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Sample records for conditions including difficult

  1. APPLICATION OF INDIVIDUAL WASTEWATER TREATMENT PLANTS IN A DIFFICULT SOIL AND WATER CONDITIONS

    Beata Karolinczak

    2014-11-01

    Full Text Available The article presents technological and economic aspects of application of individual wastewater treatment plans in difficult soil and water conditions which include impermeable soils and a high level of groundwater. Technical analysis reviews available information around possible technologies applicable to sewage treatment and its discharge. Economic analysis highlights additional outlays that are associated with a construction of the treatment plant in such difficult conditions. In summary, a cost-effectiveness analysis is carried out.

  2. Red Indian Lake fishway, an innovative design for difficult conditions

    Red Indian Lake Dam is a large concrete gravity structure, 10-12 m high and 245 m long, in the Exploits River watershed in Newfoundland. The watershed is an ideal habitat for production of Atlantic salmon. Since 1985, the watershed above the dam has undergone an extensive stocking program to optimize the salmon production capacity of the upper reaches of the system. To sustain this development, a fishway was needed to permit returning salmon to bypass Red Indian Lake Dam, the last remaining migrational barrier. The difficulties with installing a fishway at the dam site included extreme variation in upstream water levels, the need to retrofit a fishway into an existing structure, and the necessity to attract fish into the fishway in competition with other flows from power plant, spillway, or waterfall. After examining several design approaches, an innovative design was developed incorporating two separate but interrelated flow ways: one to handle attraction water and the other for transportation water. The latter passage leads to a trap at the upper end of the fishway from which salmon are hoisted via a hopper/monorail system across the dam and into the lake. Construction of the fishway was staged over four phases between December 1985 and December 1988. 3 refs., 1 fig

  3. Infant difficult behaviors in the context of perinatal biomedical conditions and early child environment

    Sirvinskiene Giedre

    2012-04-01

    Full Text Available Abstract Background Problems experienced within the first year of an infant's life can be precursors of later mental health conditions. The purpose of this study was to examine the frequency and continuity of difficult behaviors in infants at 3 and 6 months of age and the associations of these difficulties with biomedical and psychosocial factors. Methods This study was a part of an ongoing prospective birth-cohort study. Study participants were 189 uniparous mothers and their full-term newborns. The index of infant difficult behavior was constructed. This index was then associated with the following factors: delivery mode, newborn function after birth, maternal emotional well-being, risk behavior, subjective evaluation of the quality of the relationship of the couple, and attitudes toward infant-rearing. Results Common difficult behaviors, including crying, sleeping and eating problems, were characteristic for 30.2% of 3 month old and for 22.2% of 6 month old full-term infants. The expression of infant difficult behaviors at the age of 3 months increased the likelihood of the expression of these difficulties at 6 months by more than 5 times. Factors including younger maternal age, poor prenatal and postnatal emotional well-being, prenatal alcohol consumption, low satisfaction with the couple's relationship before pregnancy, and deficiency of infant-centered maternal attitudes towards infant-rearing increased the likelihood of difficult behaviors in infants at the age of 3 months. Low maternal satisfaction with the relationship of the couple before pregnancy, negative emotional reactions of both parents toward pregnancy (as reported by the mother and the deficiency of an infant-centered maternal attitude towards infant-rearing increased the likelihood of infant difficult behaviors continuing between the ages of 3 to 6 months. Perinatal biomedical conditions were not related to the difficult behaviors in infants. Conclusions Our study suggests that early onset of difficult behavior highly increases the risk for the continuation of difficult behavior during infancy. In general, the impact of prenatal psychosocial environment on infant behavior decreases from the ages of 3 to 6 months; however, some prenatal and preconceptional psychosocial factors have direct associations with the continuity of difficult behaviors through the first half-year of an infant's life.

  4. Energy principle with included boundary conditions

    Earlier comments by the author on the limitations of the classical form of the extended energy principle are supported by a complementary analysis on the potential energy change arising from free-boundary displacements of a magnetically confined plasma. In the final formulation of the extended principle, restricted displacements, satisfying pressure continuity by means of plasma volume currents in a thin boundary layer, are replaced by unrestricted (arbitrary) displacements which can give rise to induced surface currents. It is found that these currents contribute to the change in potential energy, and that their contribution is not taken into account by such a formulation. A general expression is further given for surface currents induced by arbitrary displacements. The expression is used to reformulate the energy principle for the class of displacements which satisfy all necessary boundary conditions, including that of the pressure balance. This makes a minimization procedure of the potential energy possible, for the class of all physically relevant test functions which include the constraints imposed by the boundary conditions. Such a procedure is also consistent with a corresponding variational calculus. (Author)

  5. Infant difficult behaviors in the context of perinatal biomedical conditions and early child environment

    Sirvinskiene Giedre; Zemaitiene Nida; Zaborskis Apolinaras; Markuniene Egle; Jusiene Roma

    2012-01-01

    Abstract Background Problems experienced within the first year of an infant's life can be precursors of later mental health conditions. The purpose of this study was to examine the frequency and continuity of difficult behaviors in infants at 3 and 6 months of age and the associations of these difficulties with biomedical and psychosocial factors. Methods This study was a part of an ongoing prospective birth-cohort study. Study participants were 189 uniparous mothers and their full-term newbo...

  6. Difficult asthma.

    Ahmet Uslu; Tülay Özdemir

    1989-01-01

    Difficult asthma is a distinct entity of asthma, comprising approximately %5 of asthmatic patients. There is no agreed definition of difficult asthma. It will include asthma uncontrolled by new standard therapy, steroid dependent, steroid resistant and severe asthma. In this study difficult asthma; clinical features, risk factors, pathophysiology and novel therapies are summarized by literatures.

  7. Decreasing the cost of ground grid installations under difficult environmental conditions

    The purpose of a ground grid is to provide a means to carry and dissipate electrical currents into ground under normal and fault conditions. In some cases, especially in dry rock terrain, the soil resistivity can be very high, making it difficult and very expensive to install an acceptable ground grid. Usually a soil resistivity above 200 ohm-meter is considered high. This paper discusses and provides design calculations for a successful ground grid installation in a distribution substation located in one of the worst soil conditions encountered in the industry; a very rocky terrain where the resistivity is 1800 ohm-m. It is a practical application of the theories presented in ANSI/IEEE Std. 80-1986. The design application consists of bare copper combined with conventional and a new type of ground rod. The installation cost for this application was much less than the cost associated with that of a conventional installation

  8. A simplified intensity modulated radiation therapy technique for difficult clinical cancer condition

    Objective: To introduce a simplified intensity modulated radiation therapy (sIMRT) technique for certain difficult clinical cancer condition. Methods: For sIMRT, the average number of segments per beam should be no more than 5. The segment area is no less than 10 cm2, and the number of machine monitor for each segment is no fewer than 10. In its application process, treatment planning procedure and treatment delivery procedure are the same as those of IMRT. However, the treatment verification procedure could be set as that of three-dimensional conformal radiotherapy (3DCBT) because the area and number of monitor units of each segment were close to those values for CRT. The application of sIMRT was demonstrated in a patient with rectum cancer. Results: For rectal cancer case, aiming at target dose uniformity and sparing of organs at risk, sIMRT plan was obviously superior to 3DCRT plan, but slightly inferior to IMRT plan. In terms of treatment delivery time, sIMRT plan was almost the same as 3DCRT plan. Compared with 3 DCRT, sIMRT did not require the use of wedges, and consequently, it alleviated the labor intensity, fully avoiding accidents of wedge falloff. Its application in our clinic showed that it was mainly applied to thoracic and abdominal tumors (e. g. lung, esophagus and prostate cancers). Conclusions: The simplified intensity modulated radiation therapy introduced here is applicable to the situation that 3DCRT is unable to meet clinical requirements and condition for which IMRT requires more than 25 segments but still can not significantly improve the treatment outcome. It provides a clinical solution with high ratio of performance-to- cost benefit. Further check-up by radiation colleaques is advised. (authors)

  9. Conflict management: difficult conversations with difficult people.

    Overton, Amy R; Lowry, Ann C

    2013-12-01

    Conflict occurs frequently in any workplace; health care is not an exception. The negative consequences include dysfunctional team work, decreased patient satisfaction, and increased employee turnover. Research demonstrates that training in conflict resolution skills can result in improved teamwork, productivity, and patient and employee satisfaction. Strategies to address a disruptive physician, a particularly difficult conflict situation in healthcare, are addressed. PMID:24436688

  10. Conflict Management: Difficult Conversations with Difficult People

    Overton, Amy R.; Lowry, Ann C.

    2013-01-01

    Conflict occurs frequently in any workplace; health care is not an exception. The negative consequences include dysfunctional team work, decreased patient satisfaction, and increased employee turnover. Research demonstrates that training in conflict resolution skills can result in improved teamwork, productivity, and patient and employee satisfaction. Strategies to address a disruptive physician, a particularly difficult conflict situation in healthcare, are addressed.

  11. Understanding conditions for cooperation when regulating common resources:Why is climate change so difficult to govern?

    Arsenovic, Bojana

    2015-01-01

    International community has had little success in solving the problem of governing shared natural resources, of which the changing climate is the most prominent example. I wanted to know why. To answer this question I explored the conditions for achieving collective goals and providing for public goods, using the theory of collective action as a tool for analysis. First I examined collective action conditions in local settings, by looking into research conducted on local level natural resourc...

  12. The Physiologically Difficult Airway

    Jarrod M. Mosier

    2015-12-01

    Full Text Available Airway management in critically ill patients involves the identification and management of the potentially difficult airway in order to avoid untoward complications. This focus on difficult airway management has traditionally referred to identifying anatomic characteristics of the patient that make either visualizing the glottic opening or placement of the tracheal tube through the vocal cords difficult. This paper will describe the physiologically difficult airway, in which physiologic derangements of the patient increase the risk of cardiovascular collapse from airway management. The four physiologically difficult airways described include hypoxemia, hypotension, severe metabolic acidosis, and right ventricular failure. The emergency physician should account for these physiologic derangements with airway management in critically ill patients regardless of the predicted anatomic difficulty of the intubation.

  13. Confidence in Airline Performance in Difficult Market Conditions: An Analysis of JetBlue's Financial Market Results

    Flouris, Triant; Walker, Thomas

    2005-01-01

    This paper examines the stock market s reaction to JetBlue s Initial Public Offering (1PO) and subsequent price movements of the stock. In particular, w e examine whether the euphoria surrounding JetBlue s IPO carried over to other firms in the sector by testing whether the shares of JetBlue s competitors showed a significant price reaction to JetBlue s IPO. JetBlue's IPO took place just a few months following September 11, 2001. These events resulted in dramatic changes in the airline industry and had significant implications on the economic gains of airlines. We examine JetBlue s accounting and stock performance and compare it to the relative performance of Southwest Airlines (SWA), a representative of the loa-cost carrier group. In addition, we compare both JetBlue's and SWA's financial condition and the relative performance of their stock to two mainline U S. carriers, Continental and Northwest. representatives of the conventional-cost carrier group. We analyze whether there are any performance differences among the low-cost carriers and between low-cost carriers and conventional-cost carriers. In particular, we examine whether low-cost carriers were able to sustain the economic impacts of 9/11 better than the conventional-cost carriers.

  14. Lenord + Bauer: Exact position and speed metering in very difficult conditions; Lenord + Bauer: Exakte Positions- und Drehzahlmessung unter schwierigsten Bedingungen

    Fedder, Dirk [Lenord, Bauer und Co. GmbH, Oberhausen (Germany)

    2009-07-01

    For more than a decade, Lenord, Bauer and Co. GmbH have been supplying measuring and control systems to the leading companies of the wind power industry. They can look back at more than 40 years of experience with demanding customers, e.g. high shock and vibration resistance for speed metering in the undamped section of an ICE axle, multiple redundant real value monitoring in German submarines, long-term and low-maintenance control of the rotor blade position of wind power plants, or soiling-resistent implementation of sensors in modern marine propulsion systems. New information obtained from the sophisticated customer applications of Lenord + Bauer are continually integrated in new development and further development of sensors for optimization of robustness, insensitivity to disturbances, long life, and high accuracy. Since the mid-seventies, Lenord + Bauer specialized in magnetic speed sensors. Their current portfolio of magnetic sensors includes miniaturized speed sensors and length meters, incremental speed sensors and redundant high-resolution absolute value transmitters with a SIL (Safety Integrity Level). (orig.)

  15. Subtotal Cholecystectomy-"Fenestrating" vs "Reconstituting" Subtypes and the Prevention of Bile Duct Injury: Definition of the Optimal Procedure inDifficult Operative Conditions.

    Strasberg, Steven M; Pucci, Michael J; Brunt, L Michael; Deziel, Daniel J

    2016-01-01

    Less than complete cholecystectomy has been advocated for difficult operative conditions for more than 100 years. These operations are called partial or subtotal cholecystectomy, but the terms are poorly defined and do not stipulate whether a remnant gallbladder is created. This article briefly reviews the history and development of the procedures and introduces new terms to clarify the field. The term partial is discarded, and subtotal cholecystectomies are divided into "fenestrating" and "reconstituting" types. Subtotal reconstituting cholecystectomy closes off the lower end of the gallbladder, reducing the incidence of postoperative fistula, but creates a remnant gallbladder, which may result in recurrence of symptomatic cholecystolithiasis. Subtotal fenestrating cholecystectomy does not occlude the gallbladder, but may suture the cystic duct internally. It has a higher incidence of postoperative biliary fistula, but does not appear to be associated with recurrent cholecystolithiasis. Laparoscopic subtotal cholecystectomy has advantages but may require advanced laparoscopic skills. PMID:26521077

  16. Difficult wounds: an update.

    Edlich, Richard F; Winters, Kathryne L; Britt, L D; Long, William B; Gubler, K Dean; Drake, David B

    2005-01-01

    The purpose of this collective review is to describe revolutionary advances in the treatment of Gardner's syndrome (GS), pseudofolliculitis barbae, nasal septal perforation, factitious wounds, and hidradenitis suppurativa (HS). Gardner's syndrome or familial polyposis has various manifestations that appear to be controlled by a single genetic locus. Apart from the large bowel adenomas, which are always present, a common extracolonic symptom of Gardner's syndrome is the occurrence of epidermal cysts. These cysts can be seen before the intestinal polyps are evident. Because epidermal cysts in patients with Gardner's syndrome are always benign, we excise these cysts using incisions that are commonly used for rhytidectomy. Pseudofolliculitis barbae, a pseudofolliculitis caused by ingrown hairs, effects 85% of blacks who shave their beards. When this disease is allowed to progress to keloid formation, we use a surgical approach that includes excision of the keloidal scar, meticulous debridement of all residual ingrown hairs in the underlying wound, and coverage of the defect with a split-thickness skin graft. More recently, laser therapy has revolutionized the treatment of pseudofolliculitis barbae and has enabled a cure for the first time for those plagued with this disorder and for whom a beardless face is acceptable. Nasal septal perforation is a well recognized complication of septal surgery. Other iatrogenic causes of perforation include cryosurgery, electrocoagulation for epitaxis, nasotracheal intubation, or nose packing. In recent years drugs such as cocaine account for an increasing number of perforations. It has only been with the use of an external approach for the repair of the nasal septal defect that surgical closure has become easier and more reliable. The external approach allows for greater surgical closure and enables the surgeon to use both hands with the aid of binocular vision to mobilize and suture local mucosal advancement flaps and the intraseptal connective tissue grafts. More recently, surgeons have repaired large septal perforations with a radial forearm free flap. Because of its availability and deep emotional significance, the skin is a common site for self-destructive behavior with the development of factitious skin wounds. When suspected, psychiatric care must proceed immediately. Second, the ulcer can then be healed by appropriate techniques and wound repair. It is important to emphasize that the treating physician must first confront the patient, and then a psychiatrist should provide appropriate psychotherapy. Hidradenitis suppurativa is an inflammatory disease of the skin and subcutaneous tissue that occurs in apocrine-gland-bearing areas distributed in the axilla, mammary nipple areola, mons pubis, groin, scrotum, perineum, perianal region, and umbilicus. The condition has an insidious onset. The susceptibility of women's axillary skin to hidradenitis suppurativa may be related, in part, to the practice of axillary removal of hair with a safety razor. Consequently, the use of safety razors must be avoided and replaced with the use of an electric razor. The method of treatment will vary with the stage of the disease. Treatment of the chronic stage of axillary hidradenitis suppurativa is primarily surgical. More recently, carbon dioxide laser treatment, with healing by secondary intention, is proving to be a rapid, efficient, and economic treatment of this difficult wound. PMID:16022640

  17. Applications of Anova Type Decompositions for Comparisons of Conditional Variance Statistics Including Jackknife Estimates

    Karlin, Samuel; Rinott, Yosef

    1982-01-01

    Variance and bias comparisons are set forth for a sequence of nonlinear statistics based on independent random variables including jackknife and U-statistics of various orders. The analysis relies heavily on an orthogonal decomposition first introduced by Hoeffding in 1948. This ANOVA type decomposition is refined for purposes of discerning higher order convexity properties for an array of conditional variance coefficients. There is also some discussion of two-sample statistics.

  18. Difficult colon polypectomy

    Klaus Vormbrock

    2012-01-01

    Full Text Available Colorectal cancer (CRC is one of the leading causes of death from cancer in the world. We now know that 90% of CRC develop from adenomatous polyps. Polypectomy of colon adenomas leads to a significant reduction in the incidence of CRC. At present most of the polyps are removed endoscopically. The vast majority of colorectal polyps identified at colonoscopy are small and do not pose a significant challenge for resection to an appropriately trained and skilled endoscopist. Advanced polypectomy techniques are intended for the removal of difficult colon polyps. We have defined a “difficult polyp” as any lesion that due to its size, shape or location represents a challenge for the colonoscopist to remove. Although many “difficult polyps” will be an easy target for the advanced endoscopist, polyps that are larger than 15 mm, have a large pedicle, are flat and extended, are difficult to see or are located in the cecum or any angulated portion of the colon should be always considered difficult. Although very successful, advanced resection techniques can potentially cause serious, even life-threatening complications. Moreover, post polypectomy complications are more common in the presence of difficult polyps. Therefore, any endoscopist attempting advanced polypectomy techniques should be adequately supervised by an expert or have an excellent training in interventional endoscopy. This review describes several useful tips and tricks to deal with difficult polyps.

  19. [Management of the difficult airway].

    Kawamoto, Masashi

    2010-09-01

    Difficult airway management (DAM) including cannot intubate and cannot ventilate (CICV), and difficult mask ventilation is a life threatening issue during anesthesia care. Although American Society of Anesthesiologists (ASA) has presented the guideline for this purpose, it is still not available in this country. We as a specialist for airway management should be prepared this trouble any time by equipping a laryngoscope, fiberoptic bronchoscope, and novel devices such as Airway Scope and Airtraq. PMID:20857670

  20. Difficult conversations in orthopaedics.

    Marks, Michael R; Phillips, Donna; Halsey, David A; Wong, Andrew

    2015-01-01

    There is an overall lack of training in the communication skills needed by physicians to effectively navigate challenging patient encounters. So-called difficult patients have specific obstructive behaviors that make it challenging to establish a successful doctor-patient partnership and can elicit strong negative emotions in the physician. Instead of labeling the patient as difficult, it is more useful to consider encounters as difficult events and rely on diagnostic and interventional techniques similar to those used in solving any other clinical problem. In difficult interactions, patients may have the perception that the physician is less technically skilled, they were allotted inadequate time, received poor explanations, and were overall dissatisfied with the visit. Physicians who experience difficult encounters may find it difficult to communicate with patients. The physician is often not attuned to the psychosocial aspects of patient care and is frustrated and uneasy with patients. To improve patient and physician satisfaction and healthcare outcomes, it is helpful to review the skills and strategies for delivering bad news, managing angry patients, addressing financial concerns, and dealing with drug-seeking patients. PMID:25745890

  1. On one-loop corrections to matching conditions of lattice HQET including 1/mb terms

    HQET is an effective theory for QCD with Nf light quarks and a massive valence quark if the mass of the latter is much bigger than LQCD. As any effective theory, HQET is predictive only when a set of parameters has been determined through a process called matching. The non-perturbative matching procedure including 1/mb terms, developed by the ALPHA collaboration, consists of 19 carefully chosen observables which are precisely computable in lattice QCD as well as in lattice HQET. The matching conditions are then a set of 19 equations which relate the QCD and HQET values of these observables. We present a study of one-loop corrections to two generic matching observables involving correlation function with an insertion of the A0 operator. Our results enable us to quantify the quality of the relevant observables in view of the envisaged nonperturbative implementation of this matching procedure.

  2. Making marketing difficult

    Meyer, Gitte

    embraced by the market-place, while maintaining the old scientific alienation from political life. The case is made that modern science was born ambiguous towards the market-place, and that such ambivalence - relating to different interpretations of the idea of knowledge as a common good - is still to be...... encountered among scientists. Drawing on series of interviews with scientists from bioscience and biotechnology it is argued that, on the one hand, scientists are into marketing and PR exercises; but, on the other hand, they also voice a demand that journalists should make such marketing difficult. It is the...

  3. 76 FR 32815 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...

    2011-06-06

    ... of the Medicare HACs for FY 2011 (75 FR 50084 through 50085): Foreign Object Retained After Surgery... infections. For a list of the items considered, see the February 17, 2011 proposed rule (76 FR 9283, 9286... financial participation FY Fiscal year HAC Hospital-acquired condition HCAC Health care-acquired...

  4. 76 FR 9283 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...

    2011-02-17

    ... apply to hospitals exempt from the IPPS. The following is a list of the current Medicare HACs (75 FR... condition ICR Information collection requirement IPPS Inpatient prospective payment system MS-DRG Diagnosis... codes that identify a ``diagnosis-related group'' (MS-DRG). Assignment of an MS- DRG can take...

  5. Boundary conditions including sheath effects at a plasma-facing surface

    It has recently been reported that space-charge saturation occurs adjacent to almost every commonly used plasma-facing material for plasma temperatures above ∼50 eV. An electron emission coefficient, defined as the average number of surface-emitted electrons per incident plasma electron, which is near or above unity is responsible for the occurrence of space-charge saturation. With this motivation, a fully kinetic self-consistent theory capable of describing the plasma sheath under conditions of space-charge saturation is developed. The theory is then used to obtain boundary conditions which are suitable for incorporation into computer programs which simulate plasmas. copyright 1997 The American Physical Society

  6. [Management of difficult pediatric airway].

    Kinouchi, Keiko

    2006-01-01

    Anesthesiologists should be familiar with the management of airway and be able to recognize and identify potential difficult airway. These entities include congenital craniofacial deformities with micrognathia (e.g. Robin sequence, Treacher Collins, Goldenhar's, Crouzon's syndromes) and metabolic diseases causing the deposit of accumulated by-products (e.g., Hurler's, Morquio's, Beckwith-Wiedemann syndromes). Cormack and Lehane grades 3 and 4 at laryngoscopy are an indication for advanced techniques for intubation. The laryngeal mask airway (LMA) and fiberscope with a directable tip are useful and important modalities in handling difficult pediatric airway and intubation. LMA not only offers another mode of securing airway besides face mask and tracheal intubation, but also provides a conduit for tracheal intubation and a rescue airway in the CICV (cannot intubate, cannot ventilate) situations. Intubation with a fiberscope can be utilized through LMA or through a specially designed face mask. Face mask designed for fiberoptic intubation has a 15 mm port for connection with the breathing circuit and another 22 mm port covered with a rubber membrane through which the fiberscope is introduced and directed to the larynx and trachea followed by the tracheal tube while ventilating and anesthetizing the pediatric patients with inhalational anesthetics. Getting used to these two modalities, LMA and fiberoptic intubation of the trachea, gives a great advantage in handling of difficult pediatric airway and intubation. PMID:16440704

  7. Does Working Memory Training Transfer? A Meta-Analysis Including Training Conditions as Moderators

    Schwaighofer, Matthias; Fischer, Frank; Bhner, Markus

    2015-01-01

    A meta-analysis was undertaken to reexamine near- and far-transfer effects following working-memory training and to consider potential moderators more systematically. Forty-seven studies with 65 group comparisons were included in the meta-analysis. Results showed near-transfer effects to short-term and working-memory skills that were sustained at

  8. Does Working Memory Training Transfer? A Meta-Analysis Including Training Conditions as Moderators

    Schwaighofer, Matthias; Fischer, Frank; Bühner, Markus

    2015-01-01

    A meta-analysis was undertaken to reexamine near- and far-transfer effects following working-memory training and to consider potential moderators more systematically. Forty-seven studies with 65 group comparisons were included in the meta-analysis. Results showed near-transfer effects to short-term and working-memory skills that were sustained at…

  9. Management of difficult urticaria

    Yadav Sudha

    2009-01-01

    Full Text Available Chronic urticaria, a major health problem causing patient?s distress, induces often physicians? dilemma while dealing with its etiology, investigations and management. Clinical approach of such cases should include apart from clinical history and physical examination laboratory investigations like routine blood test, thyroid profile, etc. as well as sometimes special test like autologous serum skin test. Management includes reassurance, avoidance of precipitating factors, treatment of underlying disorders, and non-pharmacological approach along with pharmacotherapy. First line drug therapy comprises non-sedative and sedative antihistamines, second line doxepin, nifedipine, leukotriene-inhibitors, sulfasalazine, etc. and third line cyclosporine, dapsone, colchicin, etc.

  10. A difficult beginning

    Suneth Agampodi

    2013-10-01

    Full Text Available Anuradhapura clinical society (ACS took a momentous decision this year to improve the quality of Anuradhapura Medical Journal (AMJ, the official journal of ACS. Moving away from the tradition of appointing an editor annually with the change of office bearers of ACS, the society appointed two of us as editors for unlimited period to elevate the quality of AMJ. Previously AMJ was a part of annual scientific sessions and from this year, it was decided to go for a proper journal rather than a conference publication. For all practical reasons we are on probation now! AMJ has been in existence for six volumes. We can assume minimum of six published issues if at least one issue per volume was published, and that’s lot of work. One of the first things we have done is to obtain an International Standard serial Number (ISSN and digitalize the journal. With the help of Sioux Cumming and INASP we have managed to have the volume five and six in the Sri Lanka Journals Online (SLJOL (1. This issue (volume seven is the first issue under our stewardship. In this issue, we have two original articles, two case reports about bugs’ bites, two perspectives, and a review on rhinosporidiosis by a world-renowned expert. Volume seven will have one issue. Hopefully volume eight will at least have two issues per year, Yala and Maha.All original articles, case reports, and perspectives published in this issue are peer-reviewed but not refereed, showing the red card is our job although we are heavily influenced by the reviewers. If we acquire enough merit in this birth, we will be bestowed with reviewers who are conscious of deadlines. But, you researchers can’t wait till the next birth so please keep sending your research to us. If you have not heard from us still, it is because your manuscripts are being peer reviewed.There is a Sinhalese adage that “a devils abode is constructed according to the devil”. The quality of the journal is reflected on the articles it receives. But the manuscripts are submitted according to the quality of the journal (impact factor, indexation, circulation,. This is a vicious circle almost similar to what we and many others faced as start up researchers yesteryear. Without a grant, it is difficult to do research but to receive a grant you have to show research (publications. Journal impact factors should not be used to assess individual researcher’s contribution to science and for hiring, promotion, or funding decisions (2. Impact factors can be manipulated by journal editors and Thomson Scientific (the private company who creates impact factors is neither transparent about the process or have a clear policy (3.We are determined to elevate the quality of the journal. You will be the jury, but don’t be a silent assassin. Please let us know what you think at least by an E-mail. Otherwise, same fate that happened to our ancient kingdom of Rajarata will befall on the AMJ!

  11. Upgrading during difficult times

    The Co-op Upgrader is part of an integrated refinery and upgrader complex in Regina, Saskatchewan. The upgrader processes 50,000 bbl/d heavy sour crude oil, mostly Fosterton and dilute Lloydminster crude, via hydrogen addition and carbon rejection, desulfurization, demetallization, and denitrification to yield a synthetic crude blend. The synthetic crude is refined to produce gasoline and diesel fuel. Byproducts from the integrated operation include 100,000 tonnes/y of petroleum coke, 65,000 tonnes/y of sulfur, propane, butane, fuel oil, and metals (Ni and V) in the form of spent catalysts. Recent operational and economic challenges faced by the upgrader are reviewed. Technical challenges include operating the upgrader's high-temperature high-pressure heavy oil hydrotreating unit and distillate hydrogenation unit, removal and replacement of the desulfurization catalyst, waste management, and producing coke of sufficient quality. Economic challenges include the shrinking differential between light and heavy oil, higher prices for natural gas (the main raw material for hydrogen production for upgrading), seasonal changes in product specifications, and lower prices for sulfur and metal byproducts. The upgrader is also affected by interest rates since borrowing costs are the single largest expenditure after crude oil purchases. 4 figs

  12. Thoracic radiotherapy in stereotactic conditions: difficulties met when starting up and proposed solutions; Radiotherapie thoracique en conditions stereotaxiques: difficultes rencontrees lors de la mise en route et solutions proposees

    Halley, A.; Assouline, A.; Belghith, B.; Hemery, C.; Cuenca, X.; Lang, P.; Boisserie, G.; Simon, J.M.; Mazeron, J.J.; Feuvret, L. [Groupe hospitalier Pitie-Salpetriere, assistance Publique-Hopitaux de Paris, Paris (France)

    2011-10-15

    The authors report the study of difficulties met when starting up a thoracic irradiation in stereotactic conditions with respiratory feedback by means of a spirometry system. Eight patients have been selected. Images have been acquired in deep-inspiration breath-hold. Various dose levels have delivered in four sessions on the 80-per-cent isodose. It appears that this technique is constrained by the patient's physical capacities and the available technical means. Solutions are the use of a suitable support system, the screening of harmful positioning, and a training phase to respiratory feedback. Short communication

  13. Guide for Operational Configuration Management Program including the adjunct programs of design reconstitution and material condition and aging management

    This standard presents program criteria and implementation guidance for an operational configuration management program for DOE nuclear and non-nuclear facilities. This Part 2 includes chapters on implementation guidance for operational configuration management, implementation guidance for design reconstitution, and implementation guidance for material condition and aging management. Appendices are included on design control, examples of design information, conduct of walkdowns, and content of design information summaries

  14. Unexpected difficult airway with hypogonadotropic hypogonadism

    Yaman F

    2014-04-01

    Full Text Available Ferda Yaman,1 Bengi Arslan,2 Ercan Yuvan,3 nase Bykkoak1 1Anesthesiology and Reanimation Department, 2Otorhinolaryngology Head and Neck Surgery Department, 3Urology Department, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey Background: A critical aspect of safe general anesthesia is providing adequate ventilation and oxygenation. Failed endotracheal intubation and inadequate ventilation with insufficient oxygenation may lead to serious complications, even death. Anesthesiologists rarely encounter unexpected difficult airway problems in daily routine. Management of an unexpectedly difficult airway consists of laryngeal mask ventilation, gum-elastic bougie and video laryngoscopy-assisted intubation. Gum-elastic bougie is the easiest and cheapest tool used in case of an unexpected difficult intubation occurring in the operating room. Case: A 53-year-old male patient with hypogonadotropic hypogonadism presented as an unexpected difficult intubation after the induction of anesthesia. No pathological finding or predictor of difficult intubation was present. In addition, bag-mask ventilation was poor and inadequate. The patient was finally successfully intubated with a gum-elastic bougie. Conclusion: A difficult airway has been described in patients with a variety of endocrine disorders, including pituitary diseases, but not with hypogonadism. There may be an unrevealed relationship between hypogonadism and difficult airway. Gum-elastic bougie is still the most attainable and effective tool in the operation room in this situation. Keywords: airway management, intubation, hypogonadism

  15. Effective communication during difficult conversations.

    Polito, Jacquelyn M

    2013-06-01

    A strong interest and need exist in the workplace today to master the skills of conducting difficult conversations. Theories and strategies abound, yet none seem to have found the magic formula with universal appeal and success. If it is such an uncomfortable skill to master is it better to avoid or initiate such conversations with employees? Best practices and evidence-based management guide us to the decision that quality improvement dictates effective communication, even when difficult. This brief paper will offer some suggestions for strategies to manage difficult conversations with employees. Mastering the skills of conducting difficult conversations is clearly important to keeping lines of communication open and productive. Successful communication skills may actually help to avert confrontation through employee engagement, commitment and appropriate corresponding behavior PMID:23833841

  16. LIHTC Difficult to Develop Areas

    Department of Housing and Urban Development — A Difficult Development Area (DDA) for the Low Income Housing Tax Credit program is an area designated by the U.S. Department of Housing and Urban Development (HUD)...

  17. Drastic Measures for Difficult Times

    Galuszka, Peter

    2008-01-01

    This article discusses how colleges and universities are taking drastic measure for difficult times. Hit hard by the global financial crisis, colleges are cutting their budgets in ways that prompt fears about access and retention for minority students. Schools are considering layoffs, unpaid furloughs for faculty and staff, hiring freezes and…

  18. A novel rescue technique for difficult intubation and difficult ventilation.

    Zestos, Maria M; Daaboul, Dima; Ahmed, Zulfiqar; Durgham, Nasser; Kaddoum, Roland

    2011-01-01

    We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit. Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation. A 13 year old patient was taken to the operating room for incision and drainage of a neck abscess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations. PMID:21304457

  19. On one-loop corrections to matching conditions of lattice HQET including 1/m{sub b} terms

    Korcyl, Piotr [Deutsches Elektronen-Synchrotron (DESY), Zeuthen (Germany). John von Neumann-Inst. fuer Computing NIC

    2013-12-15

    HQET is an effective theory for QCD with N{sub f} light quarks and a massive valence quark if the mass of the latter is much bigger than LQCD. As any effective theory, HQET is predictive only when a set of parameters has been determined through a process called matching. The non-perturbative matching procedure including 1/m{sub b} terms, developed by the ALPHA collaboration, consists of 19 carefully chosen observables which are precisely computable in lattice QCD as well as in lattice HQET. The matching conditions are then a set of 19 equations which relate the QCD and HQET values of these observables. We present a study of one-loop corrections to two generic matching observables involving correlation function with an insertion of the A{sub 0} operator. Our results enable us to quantify the quality of the relevant observables in view of the envisaged nonperturbative implementation of this matching procedure.

  20. Teaching Difficult Topics with Primary Sources

    Potter, Lee Ann

    2011-01-01

    "Difficult" or "challenging" topics to teach include racism, violence, genocide, bullying, gangs, abuse (physical, emotional, and substance), slavery, suffering, hatred, terrorism, war, disease, loss, addiction, and more. But by confronting them with students, in the safety of a classroom through thoughtfully constructed lessons (ones that take…

  1. Difficult childhood asthma: management and future.

    Tillie-Leblond, Isabelle; Deschildre, Antoine; Gosset, Philippe; de Blic, Jacques

    2012-09-01

    Diagnosis and management of severe asthma implies the definition of different entities, that is, difficult asthma and refractory severe asthma, but also the different phenotypes included in the term refractory severe asthma. A complete evaluation by a physician expert in asthma is necessary, adapted for each child. Identification of mechanisms involved in different phenotypes in refractory severe asthma may improve the therapeutic approach. The quality of care and monitoring of children with severe asthma is as important as the prescription drug, and is also crucial for differentiating between severe asthma and difficult asthma, whereby expertise is required. PMID:22929097

  2. Update on Difficult Polypectomy Techniques.

    Ngamruengphong, Saowanee; Pohl, Heiko; Haito-Chavez, Yamile; Khashab, Mouen A

    2016-01-01

    Endoscopists often encounter colon polyps that are technically difficult to resect. These lesions traditionally were managed surgically, with significant potential morbidity and mortality. Recent advances in endoscopic techniques and instruments have allowed endoscopists to safely and effectively remove colorectal lesions with high technical and clinical success and potentially avoid invasive surgery. Endoscopic mucosal resection (EMR) has gained acceptance as the first-line therapy for large colorectal lesions. Endoscopic submucosal dissection (ESD) has been reported to be associated with higher rate of en bloc resection and less risk of short-time recurrence, but with an increased risk of adverse events. Therefore, the role of colorectal ESD should be restricted to lesions with high-risk morphologic features of submucosal invasion. In this article, we review the recent literature on the endoscopic management of difficult colorectal neoplasms. PMID:26714965

  3. Facilitating Endotracheal Intubation in Difficult Cases Using an External Magnet

    Mahin Seyedhejazi; Masood Banaii; Nasrin Taghizadieh; Mahni Mokaber

    2015-01-01

    Difficult airway is conventionally defined as a medical scenario in which a trained examiner faces difficulty in either facemask ventilation or tracheal intubation (1). Unlike difficult intubation, the incidence of difficult mask ventilation in adults is considerable (2, 3). Anesthesiologists and those who practice intubation should be familiar with the management of airway and be able to recognize and identify potentially difficult airways including congenital craniofacial deformities with m...

  4. Why Behavior Change is Difficult to Sustain

    Bouton, Mark E.

    2014-01-01

    Unhealthy behavior is responsible for much human disease, and a common goal of contemporary preventive medicine is therefore to encourage behavior change. However, while behavior change often seems easy in the short run, it can be difficult to sustain. This article provides a selective review of research from the basic learning and behavior laboratory that provides some insight into why. The research suggests that methods used to create behavior change (including extinction, counterconditioni...

  5. Including riparian vegetation in the definition of morphologic reference conditions for large rivers: A case study for Europe's Western Plains

    Van Looy, K.; P. Meire; Wasson, J.G.

    2008-01-01

    Methods for defining and retrieving reference conditions for large rivers were explored with emphasis on hydromorphologic and biologic quality indicators. For a set of four large rivers in the European Western Plains ecoregion, i.e., the rivers Meuse, Loire, Allier, and Dordogne, reference reaches were selected based on geomorphologic characteristics. A survey of riparian land use, vegetation, and bed geometry was done for the selected reaches. Responses of the riparian landscape to hydromorp...

  6. Maxillofacial Injury-Not Always a Difficult Airway.

    Glasheen, John; Hennelly, David; Cusack, Stephen

    2015-08-01

    The optimal method for securing the airway in injured patients is controversial. Maxillofacial injury has been shown to be a marker for difficult airway management; however, a delay in intubation may result in deterioration of intubating conditions due to further airway bleeding and swelling. Decisions on the timing and method of airway management depend on multiple factors, including patient characteristics, the skill set of the clinicians, and logistical considerations. This report describes the case of a multi-agency response to a motor-vehicle collision in a rural area in Ireland. One young male patient had sustained significant maxillofacial injuries, multiple limb injuries, and had a decreased level of consciousness. Further airway compromise occurred following extrication. Difficult intubation was predicted; however, abnormal jaw mobility from bilateral mandibular fractures enabled easy laryngoscopy and intubation. Although preparation must be made for difficult airway management in the setting of maxillofacial injury, appropriately trained and experienced practitioners should not be deterred from performing early intubation when indicated. PMID:25994879

  7. Guide for Operational Configuration Management Program including the adjunct programs of design reconstitution and material condition and aging management

    This standard presents program criteria and implementation guidance for an operational configuration management program for DOE nuclear and non-nuclear facilities in the operational phase. Portions of this standard are also useful for other DOE processes, activities, and programs. This Part 1 contains foreword, glossary, acronyms, bibliography, and Chapter 1 on operational configuration management program principles. Appendices are included on configuration management program interfaces, and background material and concepts for operational configuration management

  8. Northern Adriatic Sea hydrographic conditions from October 2002 September 2003, including the climatic heating anomaly of summer 2003

    Nastjenjka SUPI?

    2006-12-01

    Full Text Available CTD data were collected during 38 cruises in the northeastern Adriatic from October 2002 to September 2003 and were analyzed in the context of long-term variability (from data collected over a period of 38 years. A prognostic statistical model was created to fit the long-term data and predicted values were compared to those of the in situ CTD measurements. As with air temperatures, values attained by the sea in summer 2003 far exceeded those expected by predictive models and were induced by very large heat input from the atmosphere. In conditions of very low regional freshwater input and intrusions of more saline water masses from the south, salinity values in the spring/summer period lay far outside typical salinity values for the area.

  9. Current Trends in the Management of Difficult Urinary Catheterizations

    Willette, Paul A.; Coffield, Scott K

    2012-01-01

    Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands orother potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failedcatheterization and concomitant complications increase. Repeated and unsuccessful attempts aturinary cathe...

  10. Injection techniques to anesthetize the difficult tooth.

    Quinn, C L

    1998-09-01

    Failure to achieve anesthesia can be a significant problem in the day-to-day practice of dentistry. The usual strategy following an anesthetic failure is to reinject. Therefore, a good understanding of conventional anesthetic techniques is important. But the practitioner also needs to have a broad armamentarium of injection strategies available for the "difficult-to-anesthetize cases". These strategies include the use of 5 percent lidocaine, intrapulpal injection, periodontal ligament injection and intraosseous injection. This paper will be a brief discussion of those techniques with an emphasis on the intraosseous injection. PMID:9879235

  11. Difficult airway and difficult intubation in postintubation tracheal stenosis: a case report and literature review

    Zarogoulidis P

    2012-06-01

    Full Text Available Paul Zarogoulidis,1 Theodoros Kontakiotis,1 Kosmas Tsakiridis,2 Michael Karanikas,3 Christos Simoglou,4 Konstantinos Porpodis,1 Alexandros Mitrakas,3 Agisilaos Esebidis, 3 Maria Konoglou,5 Nikolaos Katsikogiannis,6 Vasilis Zervas,1 Christina Aggelopoulou,7 Dimitrios Mikroulis,4 Konstantinos Zarogoulidis11Pulmonary Department, "G Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; 2Cardiothoracic Department, Saint Luke Private Hospital, Thessaloniki, Greece; 31st University Surgery Department, 4Cardiothoracic Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; 51st Pulmonary Department, "G Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; 6Surgery Department (NHS, 7Neurology Department (NHS, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, GreeceAbstract: Management of a "difficult airway" remains one of the most relevant and challenging tasks for anesthesiologists and pulmonary physicians. Several conditions, such as inflammation, trauma, tumor, and immunologic and metabolic diseases, are considered responsible for the difficult intubation of a critically ill patient. In this case report we present the case of a 46-year-old male with postintubation tracheal stenosis. We will focus on the method of intubation used, since the patient had a "difficult airway" and had to be intubated immediately because he was in a life-threatening situation. Although technology is of utter importance, clinical examination and history-taking remain invaluable for the appropriate evaluation of the critically ill patient in everyday medical life. Every physician who will be required to perform intubation has to be familiar with the evaluation of the difficult airway and, in the event of the unanticipated difficult airway, to be able to use a wide variety of tools and techniques to avoid complications and fatality.Keywords: difficult airway, bronchoscopic intubation, predictive factors, predictive scales

  12. Clostridium difficile phages: still difficult?

    MarthaRebecca JaneClokie

    2014-04-01

    Full Text Available Phages that infect Clostridium difficile were first isolated for typing purposes in the 1980s, but their use was short lived. However, the rise of C. difficile epidemics over the last decade has triggered a resurgence of interest in using phages to combat this pathogen. Phage therapy is an attractive treatment option for C. difficile infection, however developing suitable phages is challenging. In this review we summarise the difficulties faced by researchers in this field, and we discuss the solutions and strategies used for the development of C. difficile phages for use as novel therapeutics.Epidemiological data has highlighted the diversity and distribution of C. difficile, and shown that novel strains continue to emerge in clinical settings. In parallel with epidemiological studies, advances in molecular biology have bolstered our understanding of C. difficile biology, and our knowledge of phage-host interactions in other bacterial species. These three fields of biology have therefore paved the way for future work on C. difficile phages to progress and develop. Benefits of using C. difficile phages as therapeutic agents include the fact that they have highly specific interactions with their bacterial hosts. Studies also show that they can reduce bacterial numbers in both in vitro and in vivo systems. Genetic analysis has revealed the genomic diversity among these phages and provided an insight into their taxonomy and evolution.No strictly virulent C. difficile phages have been reported and this contributes to the difficulties with their therapeutic exploitation. Although treatment approaches using the phage-encoded endolysin protein have been explored, the benefits of using “whole-phages” are such that they remain a major research focus. Whilst we don’t envisage working with C. difficile phages will be problem free, sufficient study should inform future strategies to facilitate their development to combat this problematic pathogen.

  13. [Therapeutic abortion: a difficult choice].

    Gratton-Jacob, F

    1981-01-01

    Because the primary responsibility for the care and raising of children still falls on women, they should be able to decide freely whether or not to have children. Although many women who do not initially desire their pregnancies turn out to be adequate mothers, studies have shown that unwanted children suffer disproportionately from a variety of emotional and behavioral disorders. Studies have also found that large numbers of women seeking abortions failed to use any contraception while others used less effective methods, sometimes because of lack of knowledge. Even the most reliable contraceptive methods are liable to occasional failures. According to some authors, undesired pregnancy many reflect a struggle of adolescents with authoritarian parents, the search of a lonely person for something to love or possess, a proof of femininity, an expression of conflict with the partner or an attempt to force a marriage, or ambivalence among middle-aged women at the prospect of becoming more independent when their children enter school. Women may obtain abortions at accredited hospitals in the Province of Quebec upon decision of a committee of 3 physicians that continuation of the pregnancy would result in danger to the life or health of the patient. In 1970 some 100-150,000 illegal abortions occurred, resulting in hospitalization of 20,000 women for complications. In 1972, 4 French-speaking hospitals performed 136 of the 2919 therapeutic abortions sought in the Province of Quebec. In recent years the number has increased. Reasons for obtaining an abortion are usually social or economic: poor relationship with the father, sufficient number of children already born, age of the preceding infant, economic difficulties, mother's age, or effect of pregnancy on work. Many adolescents refuse to tell their parents of their pregnancy for fear of their reaction, but others enjoy considerable parental support. A study of about 5000 French speaking adolescents conducted in 1977 showed that nurses were among the last people they would consider consulting about personal difficulties. Although fewer than 10% of women have serious psychiatric problems following an abortion, it is a stressful event for all who undergo it, and nurses can offer several types of assistance, including offering support and helping the patient to explore her feelings and reactions and to make firm decisions. Nurses should provide patients with all needed information on the procedure and subsequent contraception, and they should make themselves available after the procedure. PMID:6920614

  14. Difficult intubation--when can we predict it?

    Kamath S

    1991-01-01

    Full Text Available Anaesthetists at times encounter difficult intubation in an apparently normal individual in spite of using the best possible positioning and most profound relaxation. This study was carried out to find out the most simple and easy measurement that may predict a difficult intubation. The study was conducted in three groups of patients of twenty each. The first group consisted of patients in whom intubation was easy. Second group consisted of anticipated difficult intubation. Cases in whom very difficult intubation was encountered were analyzed retrospectively and were included in third group. An attempt has been made to predict difficult intubation with the roentgenographic study of lateral view of mandible along with the measurement of distance from chin to thyroid cartilage. Of all the parameters, ratio of effective mandibular length to posterior mandibular depth and distance from chin to thyroid cartilage were found to be important to predict difficult intubation.

  15. A documented previous difficult tracheal intubation as a prognostic test for a subsequent difficult tracheal intubation in adults

    Lundstrøm, L H; Møller, A M; Rosenstock, C; Astrup, G; Gätke, M R; Wetterslev, J

    2009-01-01

    SUMMARY: We investigated the diagnostic accuracy of a documented previous difficult tracheal intubation as a stand-alone test for predicting a subsequent difficult intubation. Our assessment included patients from the Danish Anaesthesia Database who were scheduled for tracheal intubation by direct...... documented history of previous difficult or failed intubation using direct laryngoscopy are strong predictors of a subsequent difficult or failed intubation and may identify 30% of these patients. Although previous investigators have reported predictive values that exceed our findings markedly, a documented...

  16. Current Trends in the Management of Difficult Urinary Catheterizations

    Willette, Paul A.; Coffield, Scott

    2012-01-01

    Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands or other potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failed catheterization and concomitant complications increase. Repeated and unsuccessful attempts at urinary ca...

  17. Why behavior change is difficult to sustain.

    Bouton, Mark E

    2014-11-01

    Unhealthy behavior is responsible for much human disease, and a common goal of contemporary preventive medicine is therefore to encourage behavior change. However, while behavior change often seems easy in the short run, it can be difficult to sustain. This article provides a selective review of research from the basic learning and behavior laboratory that provides some insight into why. The research suggests that methods used to create behavior change (including extinction, counterconditioning, punishment, reinforcement of alternative behavior, and abstinence reinforcement) tend to inhibit, rather than erase, the original behavior. Importantly, the inhibition, and thus behavior change more generally, is often specific to the "context" in which it is learned. In support of this view, the article discusses a number of lapse and relapse phenomena that occur after behavior has been changed (renewal, spontaneous recovery, reinstatement, rapid reacquisition, and resurgence). The findings suggest that changing a behavior can be an inherently unstable and unsteady process; frequent lapses should be expected. In the long run, behavior-change therapies might benefit from paying attention to the context in which behavior change occurs. PMID:24937649

  18. An unexpectedly difficult intubation following repeated endoscopy.

    Fitzwilliams, B; Volikas, I

    2004-04-01

    A 67-year-old man required an urgent laparotomy for a bleeding gastric ulcer. He had undergone three upper gastrointestinal endoscopies over five days since admission to hospital. Tracheal intubation was unexpectedly difficult due to marked supraglottic oedema as well as unfavourable upper airway anatomy. A fibreoptic intubation through a laryngeal mask airway was performed with difficulty. The management of this case of difficult intubation following repeated endoscopy is presented. PMID:15957728

  19. Difficult Channel Generation Using Genetic Algorithm

    Siddhartha Banerjee; Mitra Tithi Dey; Sayari Dutta

    2010-01-01

    For channel routing problems, Deutsch's channel examples were used extensively as benchmarks for testing new algorithms. However, it is also important to test the performance of channel routing algorithms on a wider variety of difficult examples. In this paper, we present a random channel routing generator which can generate difficult channel routing instances of arbitrary size. In this paper our goal is to generate those channels using Genetic Algorithm, which have maximum con...

  20. Difficult Channel Generation Using Genetic Algorithm

    Siddhartha Banerjee

    2010-10-01

    Full Text Available For channel routing problems, Deutsch's channel examples were used extensively as benchmarks for testing new algorithms. However, it is also important to test the performance of channel routing algorithms on a wider variety of difficult examples. In this paper, we present a random channel routing generator which can generate difficult channel routing instances of arbitrary size. In this paper our goal is to generate those channels using Genetic Algorithm, which have maximum constraints (both vertical and horizontal constraint.

  1. Living conditions, including life style, in primary-care patients with nonacute, nonspecific spinal pain compared with a population-based sample: a cross-sectional study

    Odd Lindell

    2010-11-01

    Full Text Available Odd Lindell, Sven-Erik Johansson, Lars-Erik Strender1Center for Family and Community Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, SwedenBackground: Nonspecific spinal pain (NSP, comprising back and/or neck pain, is one of the leading disorders behind long-term sick-listing, including disability pensions. Early interventions to prevent long-term sick-listing require the identification of patients at risk. The aim of this study was to compare living conditions associated with long-term sick-listing for NSP in patients with nonacute NSP, with a nonpatient population-based sample. Nonacute NSP is pain that leads to full-time sick-listing>3 weeks.Methods: One hundred and twenty-five patients with nonacute NSP, 2000–2004, were included in a randomized controlled trial in Stockholm County with the objective of comparing cognitive–behavioral rehabilitation with traditional primary care. For these patients, a cross-sectional study was carried out with baseline data. Living conditions were compared between the patients and 338 nonpatients by logistic regression. The conditions from univariate analyses were included in a multivariate analysis. The nonsignificant variables were excluded sequentially to yield a model comprising only the significant factors (P <0.05. The results are shown as odds ratios (OR with 95% confidence intervals.Results: In the univariate analyses, 13 of the 18 living conditions had higher odds for the patients with a dominance of physical work strains and Indication of alcohol over-consumption, odds ratio (OR 14.8 (95% confidence interval [CI] 3.2–67.6. Five conditions qualified for the multivariate model: High physical workload, OR 13.7 (CI 5.9–32.2; Hectic work tempo, OR 8.4 (CI 2.5–28.3; Blue-collar job, OR 4.5 (CI 1.8–11.4; Obesity, OR 3.5 (CI 1.2–10.2; and Low education, OR 2.7 (CI 1.1–6.8.Conclusions: As most of the living conditions have previously been insufficiently studied, our findings might contribute a wider knowledge of risk factors for long-term sick-listing for NSP. As the cross-sectional design makes causal conclusions impossible, our study should be complemented by prospective research.Keywords: nonspecific spinal pain, back pain, neck pain, long-term sick-listing, population-based sample, cross-sectional study

  2. Numerical simulation of CO2 leakage from a geologic disposal reservoir, including transitions from super- to sub-critical conditions, and boiling of liquid of CO2

    The critical point of CO2 is at temperature and pressure conditions of Tcrit = 31.04 C, Pcrit = 73.82 bar. At lower (subcritical) temperatures and/or pressures, CO2 can exist in two different phase states, a liquid and a gaseous state, as well as in two-phase mixtures of these states. Disposal of CO2 into brine formations would be made at supercritical pressures. However, CO2 escaping from the storage reservoir may migrate upwards towards regions with lower temperatures and pressures, where CO2 would be in subcritical conditions. An assessment of the fate of leaking CO2 requires a capability to model not only supercritical but also subcritical CO2, as well as phase changes between liquid and gaseous CO2 in sub-critical conditions. We have developed a methodology for numerically simulating the behavior of water-CO2 mixtures in permeable media under conditions that may include liquid, gaseous, and supercritical CO2. This has been applied to simulations of leakage from a deep storage reservoir in which a rising CO2 plume undergoes transitions from supercritical to subcritical conditions. We find strong cooling effects when liquid CO2 rises to elevations where it begins to boil and evolve a gaseous CO2 phase. A three-phase zone forms (aqueous - liquid - gas), which over time becomes several hundred meters thick as decreasing temperatures permit liquid CO2 to advance to shallower elevations. Fluid mobilities are reduced in the three-phase region from phase interference effects. This impedes CO2 upflow, causes the plume to spread out laterally, and gives rise to dispersed CO2 discharge at the land surface. Our simulation suggests that temperatures along a CO2 leakage path may decline to levels low enough so that solid water ice and CO2 hydrate phases may be formed

  3. Integrated modeling of CO2 storage and leakage scenarios including transitions between super- and sub-critical conditions, and phase change between liquid and gaseous CO2

    Pruess, K.

    2011-05-15

    Storage of CO{sub 2} in saline aquifers is intended to be at supercritical pressure and temperature conditions, but CO{sub 2} leaking from a geologic storage reservoir and migrating toward the land surface (through faults, fractures, or improperly abandoned wells) would reach subcritical conditions at depths shallower than 500-750 m. At these and shallower depths, subcritical CO{sub 2} can form two-phase mixtures of liquid and gaseous CO{sub 2}, with significant latent heat effects during boiling and condensation. Additional strongly non-isothermal effects can arise from decompression of gas-like subcritical CO{sub 2}, the so-called Joule-Thomson effect. Integrated modeling of CO{sub 2} storage and leakage requires the ability to model non-isothermal flows of brine and CO{sub 2} at conditions that range from supercritical to subcritical, including three-phase flow of aqueous phase, and both liquid and gaseous CO{sub 2}. In this paper, we describe and demonstrate comprehensive simulation capabilities that can cope with all possible phase conditions in brine-CO{sub 2} systems. Our model formulation includes: (1) an accurate description of thermophysical properties of aqueous and CO{sub 2}-rich phases as functions of temperature, pressure, salinity and CO{sub 2} content, including the mutual dissolution of CO{sub 2} and H{sub 2}O; (2) transitions between super- and subcritical conditions, including phase change between liquid and gaseous CO{sub 2}; (3) one-, two-, and three-phase flow of brine-CO{sub 2} mixtures, including heat flow; (4) non-isothermal effects associated with phase change, mutual dissolution of CO{sub 2} and water, and (de-) compression effects; and (5) the effects of dissolved NaCl, and the possibility of precipitating solid halite, with associated porosity and permeability change. Applications to specific leakage scenarios demonstrate that the peculiar thermophysical properties of CO{sub 2} provide a potential for positive as well as negative feedbacks on leakage rates, with a combination of self-enhancing and self-limiting effects. Lower viscosity and density of CO{sub 2} as compared to aqueous fluids provides a potential for self-enhancing effects during leakage, while strong cooling effects from liquid CO{sub 2} boiling into gas, and from expansion of gas rising towards the land surface, act to self-limit discharges. Strong interference between fluid phases under three-phase conditions (aqueous - liquid CO{sub 2} - gaseous CO{sub 2}) also tends to reduce CO{sub 2} fluxes. Feedback on different space and time scales can induce non-monotonic behavior of CO{sub 2} flow rates.

  4. Difficult clinical situations in the antiphospholipid syndrome.

    Rosa, Renata Ferreira; Ugolini-Lopes, Michelle Remio; Zeinad-Valim, Audrey Krse; D'Amico, Elbio; Andrade, Danieli

    2015-04-01

    Antiphospholipid syndrome (APS) is characterized by antiphospholipid antibodies (aPL) associated with thrombosis and/or pregnancy morbidity. However, there is a range of other manifestations associated with APS, called non-criteria manifestations that add significant morbidity to this syndrome and, some of them, represent difficult clinical situations to deal with. Other issues such as refractory treatment also represent challenging situations poorly addressed in the literature. Therefore, the purpose of this article is to review the management of difficult clinical situations in APS and provide information to help the readers in their decision-making process. PMID:25854490

  5. Medical Students' Personal Determinants of Overcoming Strategies in Difficult Situations

    Veretelnikova Yu.Ya.

    2013-03-01

    Full Text Available Goal of the research was to study conditionality of overcoming strategies in difficult situations of social interaction by personal representations of attitude to others among medical students. Material and methods. 134 first-year students of Saratov State Medical University n.a. V. I. Razumovsky took part in the comparative diagnostic study. Results. Comparison of average indices of various strategies evidence in coping behaviour allowed revealing statistically significant dependence of coping behaviour modi in difficult situations of social interaction upon types of personal representations of attitude toward others and gender features of forming effective strategies of coping behaviour among medical students. Conclusion. Correlation between coping behaviour modi in difficult situations of social interaction and typology of personal representations of attitudes toward others among medical students was marked.

  6. Qualitative analysis of unanticipated difficult airway management

    Rosenstock, C; Hansen, E G; Kristensen, M S; Rasmussen, L S; Skak, C; Østergaard, D

    2006-01-01

    Unanticipated difficult airway management (DAM) is a major challenge for the anaesthesiologist and is associated with a risk of severe patient damage. We analysed 24 cases of unanticipated DAM for actual case management and anaesthesiologists knowledge, technical and non-technical skills. Anaesth...

  7. Resistance, Reactance, and the Difficult Client.

    Dowd, E. Thomas; Sanders, Daniel

    1994-01-01

    Describes effect of client resistance and reactance in counseling and methods for assessing these phenomena. Conceptualizes client symptoms as ego-syntonic, where symptom is consonant with client's self-image, or ego-dystonic, where it is not. Uses concepts in deriving counseling strategies for working with difficult clients according to model…

  8. What's Difficult about Chemistry? An Irish Perspective

    Childs, Peter E.; Sheehan, Maria

    2009-01-01

    This semi-longitudinal investigation identified the chemistry topics that the majority of Irish chemistry pupils/students find difficult, from Junior Certificate level (age 15/16 years) right the way through to University level (age 18+). Pupils/students completed a five point, Likert-type questionnaire listing the topics covered in the different

  9. PRAISE: Christians Educators and the Difficult Student

    Beth E. Ackerman

    2008-05-01

    Full Text Available This article defends the role of the Christian educator in reaching the difficult student. It further offers tips for handling the challenging student from a Christian perspective, coupled with tried-and-true research using the acronym PRAISE: being proactive, using reinforcements, assessing and analyzing the intent of misbehavior, being sincere, and empowering students and the Holy Spirit in them.

  10. Difficult asthma and its treatment in pediatrics

    Hasan Yksel

    2010-05-01

    Full Text Available Difficult asthma which constitutes less than 5% of all childhood asthma cases is defined as presence of daily symptoms, frequent oral corticosteroid requirement and frequent exacerbations for longer than six months, despite the use of inhaled steroid equivalent to 500 mcg fluticasone propionate, long acting beta 2 agonist or theophylline and leukotriene antagonists. Difficult asthma is not expected in childhood due to the absence of remodelling, rapid restoration of the airway, use of efficacious inhaled techniques and steroids and absence of occupational exposures. Therefore, it may be thought that pediatric difficult asthma is a differential diagnosis and treatment adherence problem. It has been shown that difficult asthma cases that have been filtered from this aspect have a non-eosinophilic inflammatory phenotype characterized by defective beta 2 receptor responses and high steroid resistance. Increased thickness of the basal membrane supports the view that dysfunctional mechanisms play a more important role than inflammatory mechanisms. Environmental control and elimination of risk factors should be achieved in these cases and proper education for treatment modalities and inhalation techniques need to be provided. (Turk Arch Ped 2010; 45: 80th Year: 1-5

  11. Qualitative analysis of unanticipated difficult airway management

    Rosenstock, C; Hansen, E G; Kristensen, M S; Rasmussen, L S; Skak, C; Østergaard, D

    2006-01-01

    Unanticipated difficult airway management (DAM) is a major challenge for the anaesthesiologist and is associated with a risk of severe patient damage. We analysed 24 cases of unanticipated DAM for actual case management and anaesthesiologists knowledge, technical and non-technical skills....... Anaesthesiologists' opinions, as well as environmental factors of importance for DAM proficiency, were also assessed....

  12. Questions That Science Teachers Find Difficult (II).

    Goodwin, Alan

    2003-01-01

    Presents some questions that science teachers find difficult. Focuses on three further questions relating to "simple" everyday situations that are normally explained in terms of the kinetic theory of matter. Identifies looking at the difference between chemical and physical changes as the most problematic question. (Author/YDS)

  13. Solid expandable technology facilitates reaching gas reservoirs in difficult formations

    Holland, M.; Chipiuk, J. [Eventure Global Technology, Houston, TX (United States)

    2008-07-01

    Solid expandable tubulars that facilitate the reaching of gas reservoirs in difficult formations were discussed in this presentation. Several photographs of solid expandable technologies were first offered. The presentation discussed expandable casing, an overview of trends, historical approach, and expandable design. The Bossier trend and Bossier development history were illustrated. Other photographs and illustrations that were presented included the Middle Shelf versus Deep Bossier and Nikanassin Monteith Foothills. Drilling conditions were also examined. The discussion regarding the adoption of expandables focused on lower costs in high cost service market; a protective liner required for the Upper Bossier; and a minimum 4 and a half inch production casing. The expandable approach met Texas regulations for freshwater sand protection and isolated weaker openhole zones. The expandable SlimWell solution was also illustrated along with lessons learned such as pilot hole/under-reaming; hole preparation; drilling fluid maintenance; polycrystalline diamond compact bits and motors to drill out launcher shoe; accelerated field production; and reduced capital expenditures. It was concluded that keys to success involve daily and weekly team meetings; management and recognition and support of mechanical risk and economic benefit; and dedicated drilling, completion, and field personnel. figs.

  14. Protection of mineral deposits - a way towards difficult compromises

    Radwanek-Bąk, Barbara; Nieć, Marek

    2014-05-01

    Mineral deposits are non-renewable natural resources. Their protection and reasonable exploitation are crucial requests resulting from sustainable development principles. Those are also fundamental issues in frame of the intergeneration justice and fairness concept. Protection of mineral resources should be based on interrelated activities: maintaining the possibility of economic use of the identified mineral resources, reduced consumption of mineral resources and ensuring satisfactory results of new prospecting and development of innovative technologies for the mineral resources base. The main problem with guarantee to the use of mineral resources is the accessibility to sites with documented deposits and prospective areas of their occurrence. Often, this contradicts with the interests of residents, planners and needs of the biotic environment protection, thus is often a source of conflicts. Legislative regulations are necessary to mitigate such arguable matters. SWOT analysis carried out with respect to introducing such legal regulations serves to identify the sources of conflicts and difficulties associated with their solution. Consensus reaching is a difficult task, so all decision makers are required to show their mutual understanding and willingness to achieve the goals taking into consideration all benefits for the population (including future generations). Foundations for finding the middle ground are: making the communities aware of their demands on minerals and of indispensable conditions for satisfying these demands; providing complete and accessible information; factual, non-emotional negotiations between decision makers and the public.

  15. Streamflow and water-quality conditions including geologic sources and processes affecting selenium loading in the Toll Gate Creek watershed, Aurora, Arapahoe County, Colorado, 2007

    Paschke, Suzanne S.; Runkel, Robert L.; Walton-Day, Katherine; Kimball, Briant A.; Schaffrath, Keelin R.

    2013-01-01

    Toll Gate Creek is a perennial stream draining a suburban area in Aurora, Colorado, where selenium concentrations have consistently exceeded the State of Colorado aquatic-life standard for selenium of 4.6 micrograms per liter since the early 2000s. In cooperation with the City of Aurora, Colorado, Utilities Department, a synoptic water-quality study was performed along an 18-kilometer reach of Toll Gate Creek extending from downstream from Quincy Reservoir to the confluence with Sand Creek to develop a detailed understanding of streamflow and concentrations and loads of selenium in Toll Gate Creek. Streamflow and surface-water quality were characterized for summer low-flow conditions (JulyAugust 2007) using four spatially overlapping synoptic-sampling subreaches. Mass-balance methods were applied to the synoptic-sampling and tracer-injection results to estimate streamflow and develop spatial profiles of concentration and load for selenium and other chemical constituents in Toll Gate Creek surface water. Concurrent groundwater sampling determined concentrations of selenium and other chemical constituents in groundwater in areas surrounding the Toll Gate Creek study reaches. Multivariate principal-component analysis was used to group samples and to suggest common sources for dissolved selenium and major ions. Hydrogen and oxygen stable-isotope ratios, groundwater-age interpretations, and chemical analysis of water-soluble paste extractions from core samples are presented, and interpretation of the hydrologic and geochemical data support conclusions regarding geologic sources of selenium and the processes affecting selenium loading in the Toll Gate Creek watershed. Streamflow conditions observed and measured during the synoptic water-quality study represent summer base-flow conditions and rainfall conditions for July 2007. The lack of large tributary inflows and the spatial distribution of small tributary inflows, seeps, and springs indicate that diffuse and discrete groundwater inflow supports streamflow during low-flow conditions along the entire 18-kilometer stream reach. Concentrations of dissolved selenium within all subreaches of Toll Gate Creek exceeded the Colorado aquatic-life standard of 4.6 micrograms per liter in 2007. Concentrations of selenium in the upper portion of the Toll Gate Headwaters subreach (TGH) remained close to the aquatic-life standard at about 5 micrograms per liter. Downstream from a concrete-lined channel section, inflows with selenium concentrations greater than the stream contribute selenium load to surface water. However, stream selenium concentrations were less than 20 micrograms per liter all along Toll Gate Creek. Concentrations of selenium in groundwater were in general substantially greater than the Colorado aquatic-life standard of 4.6 micrograms per liter and at some locations were greater than the U.S. Environmental Protection Agency primary drinking-water standard for selenium of 50 micrograms per liter. The distribution of selenium concentrations in groundwater, springs, and the 11 inflows with the greatest selenium concentrations indicates that shallow groundwater in surficial materials and the Denver Formation bedrock is a source of selenium loading to Toll Gate Creek and that selenium loading is distributed along the entire length of the study reach downstream from the concrete-lined channel. Water-quality and solids-sampling results from this study indicate weathering processes release water-soluble selenium from the underlying Denver Formation claystone bedrock with subsequent cycling of selenium in the aquatic environment of Toll Gate Creek. Exposure of the Denver Formation selenium-bearing bedrock to oxidizing atmospheric conditions, surface water, and groundwater, oxidizes selenide, held as a trace element in pyrite or in complexes with organic matter, to selenite and selenate. Secondary weathering products including iron oxides and selenium-bearing salts have accumulated in the weathered zone in the semiarid climate and also can serve as sources or sinks of selenium. P

  16. Listening: the most difficult skill to teach

    WALKER, Natasha

    2014-01-01

    With listening skills usually requiring a considerably long period of time to acquire, normally involving the student experiencing a variety of emotions ranging from depression and frustration through to exhilaration and pride, teaching listening skills is one of the most difficult tasks that a teacher faces. The following article evaluates contemporary research with the aim of dissecting and discussing the reasons why the teaching of listening skills seems to be so complex and co...

  17. Difficult ("heartsink" patients and clinical communication difficulties

    Faustino R Pérez-López

    2010-12-01

    Full Text Available Faustino R Pérez-LópezDepartment of Obstetrics and Gynecology, Hospital Clínico de Zaragoza, Facultad de Medicina, Universidad de Zaragoza, Zaragoza, SpainAbstract: Managing the difficult patient requires a set of skills or strategies oriented at improving the physician–patient relationship and avoiding conflictive situations. There are different types of difficult patients who should be precisely identified for their management. These patients seek appropriate medical care which is not always provided. However, some may have unrecognized pathological illnesses, especially personality or psychiatry disorders. Clinical communications may be altered by professional and situational factors. In some circumstances, clinical symptoms are medically unexplainable or poorly defined as part of a disease or syndrome. Organic disease should be ruled out before patients are classified as having a somatoform disorder. Diagnosis may be delayed when symptoms are not properly evaluated therefore causing serious health consequences. Clinical competence, empathy, and high quality communication is required to succeed in difficult clinical encounters.Keywords: physician–patient communication, barriers to communication, expert patient

  18. Mind wandering while reading easy and difficult texts.

    Feng, Shi; D'Mello, Sidney; Graesser, Arthur C

    2013-06-01

    Mind wandering is a phenomenon in which attention drifts away from the primary task to task-unrelated thoughts. Previous studies have used self-report methods to measure the frequency of mind wandering and its effects on task performance. Many of these studies have investigated mind wandering in simple perceptual and memory tasks, such as recognition memory, sustained attention, and choice reaction time tasks. Manipulations of task difficulty have revealed that mind wandering occurs more frequently in easy than in difficult conditions, but that it has a greater negative impact on performance in the difficult conditions. The goal of this study was to examine the relation between mind wandering and task difficulty in a high-level cognitive task, namely reading comprehension of standardized texts. We hypothesized that reading comprehension may yield a different relation between mind wandering and task difficulty than has been observed previously. Participants read easy or difficult versions of eight passages and then answered comprehension questions after reading each of the passages. Mind wandering was reported using the probe-caught method from several previous studies. In contrast to the previous results, but consistent with our hypothesis, mind wandering occurred more frequently when participants read difficult rather than easy texts. However, mind wandering had a more negative influence on comprehension for the difficult texts, which is consistent with the previous data. The results are interpreted from the perspectives of the executive-resources and control-failure theories of mind wandering, as well as with regard to situation models of text comprehension. PMID:23288660

  19. Assessment of difficult airway predictors for predicting difficult laryngoscopy and intubation

    Srinivasa S; Vrinda Oza;; Vasantha Kumar; Vandana Parmar; Chhaya, V. A.

    2014-01-01

    Title: Assessment of difficult airway predictors for predicting difficult laryngoscopy and intubationObjectives: The aims and objectives of this study was to study and compare the sensitivity, specificity, positive predictive value, negative predictive value, odds ratio, relative risk, likelihood ratio and accuracy of the following parameters, modified Mallampati grading, interincisor gap, thyromental distance (TMD), ratio of height to thyromental distance (RHTMD), sternomental distance, neck...

  20. Chernobyl: Chronicle of difficult weeks [videorecording

    1. Chernobyl : chronicle of difficult weeks. Shevchenko's film crew was the first in the disaster zone following the meltdown of the core of the Chernobyl nuclear power plant in 1986. They shot continuously for more than three months. Portions of the film are exposed with white blotches - a radiation leakage. The film demonstrates how authorities and volunteers dealt with the accident, shows the efforts to get the fire under control, to take care of patients with radiation injuries, and to evacuate about 100,000 inhabitants of the area. 2. The BAM zone : permanent residents. The Baikal-Amur Mainline (BAM) railroad in Siberia is called the longest monument to the stagnation of the Brezhnev years. The film shows the lives and fates of the people in contrast to the marches and songs praising the project

  1. Difficult situations in anticoagulation after stroke

    Ntaios, George; Lip, Gregory Y H

    2016-01-01

    and the risk of bleeding. This article focuses on three common anticoagulant-related situations, where the stroke physician needs to find the delicate balance between the two risks. RECENT FINDINGS: Three typical case vignettes are presented and the associated dilemmas are discussed: a patient with an......PURPOSE OF REVIEW: A significant proportion of stroke patients is treated with anticoagulants for secondary stroke prevention. Often, in such patients, stroke physicians are required to make difficult clinical decisions when confronted with the dilemma to choose between the risk of thromboembolism...... anticoagulant-related intracranial hemorrhage: would you restart anticoagulation?, an anticoagulated patient with a previous stroke because of atrial fibrillation is scheduled for an elective polyp removal: how would you handle anticoagulation perioperatively?, and a patient presents with an ischemic stroke...

  2. Difficult weaning in delayed onset diaphragmatic hernia

    Ahmed Syed

    2009-01-01

    Full Text Available Diaphragmatic injuries are relatively rare and result from either blunt or penetrating trauma. Regardless of the mechanism, diagnosis is often missed and high index of suspicion is vital. The clinical signs associated with a diaphragmatic hernia can range from no outward signs to immediately life-threatening respiratory compromise. Establishing the clinical diagnosis of diaphragmatic injuries (DI can be challenging as it is often clinically occult. Accurate diagnosis is critical since missed DI may result in grave sequelae due to herniation and strangulation of displaced intra-abdominal organs. We present a case of polytrauma with rib fracture and delayed appearance of diaphragmatic hernia manifesting as difficult weaning from ventilatory support.

  3. Public health in Kosovo after five difficult years of independence

    Naim Jerliu

    2015-12-01

    administration. Regarding the health status, five years after independence, compared with other European countries, post-war transitional Kosovo is still characterized by higher mortality rates including traditional public health problems pertinent to infant mortality and maternal deaths. In parallel, however, Kosovo is undergoing a rapid process of epidemiological transition characterized by an aging trend which is inevitably coupled with high cardiovascular and cancer mortality and morbidity along with an excess mortality in external causes of death and injuries among the adult population. Adoption of the new Health Law in December 2012 by the Kosovo Assembly aims the transition from centralized health care system established under emergency conditions of the post-war period towards a contemporary modern health care system with a clear purchaser-provider split based on a high transparency and accountability of the health care providers and their contractors. The health care reform, leading eventually to significant changes within the health sector in Kosovo, consists of two main pillars: (i structural and functional reorganization of the health care system through establishment of Kosovo Health Service (an autonomous and non-for-profit public enterprise at central level of the health care sector, and; (ii establishment for the first time of the public health insurance system with a Health Insurance Fund as its main body. Nevertheless, five years after declaration of independence, Kosovo, the newest state in Europe consisting of the youngest population, is currently facing a particularly difficult socioeconomic and political transition and is additionally struggling and mainstreaming all energies and efforts in order to get full international recognition.

  4. Facilitating Endotracheal Intubation in Difficult Cases Using an External Magnet

    Mahin Seyedhejazi

    2015-04-01

    Full Text Available Difficult airway is conventionally defined as a medical scenario in which a trained examiner faces difficulty in either facemask ventilation or tracheal intubation (1. Unlike difficult intubation, the incidence of difficult mask ventilation in adults is considerable (2, 3. Anesthesiologists and those who practice intubation should be familiar with the management of airway and be able to recognize and identify potentially difficult airways including congenital craniofacial deformities with micrognathia (e.g. Pier Robin, Treacher Collins, Goldenhar's, and Crouzon's syndromes and metabolic diseases causing the deposition of accumulated by-products (e.g., Hurler's, Morquio's, and Beckwith-Wiedemann syndromes. Cormack and Lehane grades 3 and 4 at laryngoscopy are an indication for advanced techniques for intubation. Laryngeal mask airway (LMA and fiberscope with a directable tip are useful and important modalities in handling difficult airway and intubation (5.Even normal pediatric airway could become critical due to the anatomical and physiological differences between pediatric and adult airway; this particularly becomes a concern in infants, i.e. children younger than one year old. This hazard is augmented in the presence of congenital or acquired difficulties affecting airway. Consequently, proper preoperative assessment is considered as the cornerstone of pediatric difficult airway management. Every anesthetic plan should be tailored according to patients considering the scenario and also the expertise of the practitioner. Opting for spontaneous respiration maintenance and intervening in a step-wise manner are strongly suggested (6.Multiple airway devices have been and are developed that all of which can be placed under direct vision or blindly; most of these devices consistently both provide and maintain safe oxygenation and ventilation. Furthermore, a wide range of ancillary devices have also been introduced to be of assistance in the management of difficult airway; most of them are available in varied sizes suitable for use in children and incorporate a variety of different types of endotracheal tubes, supraglottic devices, fiber-optic, video, optical, and mechanical technologies. Some of these devices (e.g. video laryngoscope are expensive and not suitable for developing countries with limited financial reserve; some others need high levels of experiences  or learning courses which is not possible for anesthesiologist that are not working  in university hospitals or are less experienced. Some of these devices cannot be used in small children or neonates. Therefore, we were encouraged to look for a device that is easy to use and carry, inexpensive, small in size, and available in all sizes for children, and also does not need special training.

  5. Rigid fibrescope Bonfils: use in simulated difficult airway by novices

    Piepho Tim

    2009-07-01

    Full Text Available Abstract Background The Bonfils intubation fibrescope is a promising alternative device for securing the airway. We examined the success rate of intubation and the ease of use in standardized simulated difficult airway scenarios by physicians. We compared the Bonfils to a classical laryngoscope with Macintosh blade. Methods 30 physicians untrained in the use of rigid fibrescopes but experienced in airway management performed endotracheal intubation in an airway manikin (SimMan, Laerdal, Kent, UK with three different airway conditions. We evaluated the success rate using the Bonfils (Karl Storz, Tuttlingen, Germany or the Macintosh laryngoscope, the time needed for securing the airway, and subjective rating of both techniques. Results In normal airway all intubations were successful using laryngoscope (100% vs. 82% using the Bonfils (p Conclusion The Bonfils can be successfully used by physicians unfamiliar with this technique in an airway manikin. The airway could be secured with at least the same success rate as using a Macintosh laryngoscope in difficult airway scenarios. Use of the Bonfils did not delay intubation in the presence of a difficult airway. These results indicate that intensive special training is advised to use the Bonfils effectively in airway management.

  6. A Moessbauer spectrometer for difficult isotopes

    The parameters of some Moessbauer isotopes present experimental difficulties either because high velocities, low frequencies, low temperatures, or any combination of these conditions, are needed. A simple approach to easing these difficulties is described, using a mechanical resonant system and a phase locked loop. (author)

  7. Breast screening technologists: When is a difficult case truly difficult and for whom?

    Scott, Hazel J.; Gale, Alastair G.

    2005-04-01

    Each year almost all film readers in the UK Breast Screening Programme voluntarily read a set of difficult mammographic cases as a means of self-assessing their film reading skills. We set out to investigate what case characteristics, if any, actually constituted a 'difficult' or 'easy' case in the opinion of radiological experts. We also examined how UK Breast Screening personnel performed on those cases which the experts deemed were difficult, in order to build up a profile of the types of cases that provide film readers with the most problems. We examined two main elements of case diagnosis, case classification and case features and investigated if there were any group differences in terms of case difficulty and the percentage of incorrectly reported cases. Data from over 15 radiological experts and approximately 400 film readers were compared on 180 cases. Significant differences were found between the expert and screening populations (p < .05) in terms of these case characteristics. These data contribute to the understanding of just what constitutes a difficult case as considered by experts and other film-readers, with a view to elucidating the type of cases most appropriate for advanced mammographic training.

  8. Road to Sobriety Is Difficult, but Possible

    ... enable scripts and reload this page. Physicians Residents Medical Students Patients Media About AOA Contact Us A A ... the influence of friends and family members on stress levels. Medical examinations include physical exams that assess signs and ...

  9. Usage of I++ Simulator to Program Coordinate Measuring Machines when Common Programming Methods are difficult to apply

    Gąska A.; Szewczyk D.; Gąska P.; Gruza M.; Sładek J.

    2014-01-01

    Nowadays, simulators facilitate tasks performed daily by the engineers of different branches, including coordinate metrologists. Sometimes it is difficult or almost impossible to program a Coordinate Measuring Machine (CMM) using standard methods. This happens, for example, during measurements of nano elements or in cases when measurements are performed on high-precision (accurate) measuring machines which work in strictly air-conditioned spaces and the presence of the operator in such room d...

  10. Childhood Bipolar Disorder: A Difficult Diagnosis

    Sutton, Kimberly Kode

    2014-01-01

    Identifying children with emotional or behavior disorders has long been problematic. In a general sense, those children who are most likely to be noticed by teachers and, therefore, referred for possible special education placement are those who exhibit externalizing behaviors, including physical aggression, noncompliance, and rule-breaking. It is…

  11. Microcatheter Use for Difficult Percutaneous Biliary Procedures

    Percutaneous biliary drainage procedures in patients with nondilated ducts are demanding, resulting in lower success rates than in patients with bile duct dilatation. Pertinent clinical settings include patients with iatrogenic bile leaks, diffuse cholangiocarcinomas, and sclerosing cholangitis. We describe a method to facilitate these procedures with the combined use of a 2.7-Fr microcatheter and a 0.018-in. hydrophilic wire.

  12. Childhood Bipolar Disorder: A Difficult Diagnosis

    Sutton, Kimberly Kode

    2014-01-01

    Identifying children with emotional or behavior disorders has long been problematic. In a general sense, those children who are most likely to be noticed by teachers and, therefore, referred for possible special education placement are those who exhibit externalizing behaviors, including physical aggression, noncompliance, and rule-breaking. It is

  13. Development of a kinetic model, including rate constant estimations, on iodine and caesium behaviour in the primary circuit of LWR's under accident conditions

    In this report, a kinetic model has been developed with the aim to try to reproduce the chemical phenomena that take place in a flowing system containing steam, hydrogen and iodine and caesium vapours. The work is divided into two different parts. The first part consists in the estimation, through the Activited Complex Theory, of the reaction rate constants, for the chosen reactions, and the development of the kinetic model based on the concept of ideal tubular chemical reactor. The second part deals with the application of such model to several cases, which were taken from the Phase B 'Scoping Calculations' of the Phebus-FP Project (sequence AB) and the SFD-ST and SFD1.1 experiments. The main conclusion obtained from this work is that the assumption of instantaneous equilibrium could be inacurrate in order to estimate the iodine and caesium species distribution under severe accidents conditions

  14. Phlebosclerotic colitis that was difficult to distinguish from collagenous colitis.

    Hozumi, Hideaki; Hokari, Ryota; Shimizu, Motonori; Maruta, Koji; Narimatsu, Kazuyuki; Sato, Hirokazu; Sato, Shingo; Ueda, Toshihide; Higashiyama, Masaaki; Watanabe, Chikako; Komoto, Shunsuke; Tomita, Kengo; Kawaguchi, Atsushi; Nagao, Shigeaki; Miura, Soichiro

    2014-07-01

    Phlebosclerotic colitis is a rare and recently known disease entity and its etiology is still to be elucidated. Some phlebosclerotic colitis cases are difficult to distinguish from collagenous colitis because of the similarity of pathological findings. In all Japanese case reports of phlebosclerotic colitis in which an association with the use of Chinese herbal medicine is suspected, sansisi (gardenia fruit) was included, suggesting pathogenesis of this disease. We report a case of phlebosclerotic colitis that wasdifficult to be distinguished from collagenous colitis, and an association with the use of Chinese herbal medicine was suspected as the cause of the disease. PMID:23902595

  15. Analysis of the hydrographic conditions and cyst beds in the San Jorge Gulf, Argentina, that favor dinoflagellate population development including toxigenic species and their toxins

    Krock, Bernd; Borel, C. Marcela; Barrera, Facundo; Tillmann, Urban; Fabro, Elena; Almandoz, Gastn O.; Ferrario, Martha; Garzn Cardona, John E.; Koch, Boris P.; Alonso, Cecilia; Lara, Rubn

    2015-08-01

    The overlay of cooler nutrient enriched Beagle-Magellan water with warmer nutrient depleted shelf water and a strong stratification of the water column in the San Jorge Gulf region, Argentina, coincided with relatively high dinoflagellate abundances in April 2012, up to 34,000 cells L- 1. This dinoflagellate proliferation was dominated by Ceratium spp., but environmental conditions also favored to a lesser amount the occurrence of toxigenic dinoflagellates, such as Alexandrium tamarense and Protoceratium reticulatum, whose toxins were hardly detected in any other areas along the expedition transect of the R/V Puerto Deseado between 38 and 56S (Ushuaia-Mar del Plata) in March/April 2012. Generally vegetative cells of A. tamarense and P. reticulatum co-occurred with their respective phycotoxins in the water column and their cysts in the upper sediment layers. Two strains of A. tamarense were isolated from the bloom sample and morphologically characterized. Their PSP toxin profiles consisted of C1/2, gonyautoxins 1/4 and to a lesser amount of neosaxitoxin and confirmed earlier data from this region. The ratios between autotrophic picoplankton and heterotrophic bacteria were higher in shelf waters in the north than in Beagle-Magellan waters in the south of San Jorge Gulf.

  16. Effects of Cd and Ni toxicity to Ceratophyllum demersum under environmentally relevant conditions in soft and hard water including a German lake

    Andresen, Elisa, E-mail: Elisa.Andresen@uni-konstanz.de [University of Konstanz, Department of Biology, D-78457 Konstanz (Germany); Opitz, Judith, E-mail: Daniela.Opitz@uni-konstanz.de [University of Konstanz, Department of Biology, D-78457 Konstanz (Germany); Thomas, George, E-mail: George.Thomas@uni-konstanz.de [University of Konstanz, Department of Biology, D-78457 Konstanz (Germany); Strk, Hans-Joachim, E-mail: Ha-Jo.Staerk@ufz.de [UFZ Helmholtz Centre for Environmental Research, Department of Analytical Chemistry, Permoserstr. 15, D-04318 Leipzig (Germany); Dienemann, Holger, E-mail: Holger.Dienemann@smul.sachsen.de [Saxon State Company for Environment and Agriculture, Business Domain 5 (Laboratory), Department 53, Bitterfelder Str. 25, D-04849 Bad Dben (Germany); Jenemann, Kerstin, E-mail: Kerstin.Jenemann@smul.sachsen.de [Schsisches Landesamt fr Umwelt, Landwirtschaft und Geologie, Abteilung Wasser, Boden, Wertstoffe, Zur Wetterwarte 11, D-01109 Dresden (Germany); Dickinson, Bryan C., E-mail: Bryan.Dickinson@gmail.com [Harvard University, Department of Chemistry and Chemical Biology, 12 Oxford Street, Cambridge, MA 02138 (United States); Kpper, Hendrik, E-mail: Hendrik.Kuepper@uni-konstanz.de [University of Konstanz, Department of Biology, D-78457 Konstanz (Germany); University of South Bohemia, Faculty of Biological Sciences and Institute of Physical Biology, Braniovsk 31, CZ-370 05 ?esk Budejovice (Czech Republic)

    2013-10-15

    Highlights: Hardly any macrophytic growth occurred in an oligotrophic hard water lake in Germany. All parameters were optimal, besides elevated, nanomolar concentrations of Ni and Cd. We cultivated submerged macrophytes in real and simulated hard and soft lake water. Nanomolar Cd and Ni inhibited the plants photosynthetic light reactions in soft water. The inhibition was synergistic, i.e. stronger than the addition of Cd and Ni effects. -- Abstract: Even essential trace elements are phytotoxic over a certain threshold. In this study, we investigated whether heavy metal concentrations were responsible for the nearly complete lack of submerged macrophytes in an oligotrophic lake in Germany. We cultivated the rootless aquatic model plant Ceratophyllum demersum under environmentally relevant conditions like sinusoidal light and temperature cycles and a low plant biomass to water volume ratio. Experiments lasted for six weeks and were analysed by detailed measurements of photosynthetic biophysics, pigment content and hydrogen peroxide production. We established that individually non-toxic cadmium (3 nM) and slightly toxic nickel (300 nM) concentrations became highly toxic when applied together in soft water, severely inhibiting photosynthetic light reactions. Toxicity was further enhanced by phosphate limitation (75 nM) in soft water as present in many freshwater habitats. In the investigated lake, however, high water hardness limited the toxicity of these metal concentrations, thus the inhibition of macrophytic growth in the lake must have additional reasons. The results showed that synergistic heavy metal toxicity may change ecosystems in many more cases than estimated so far.

  17. Osteogenesis from Dental Pulp Derived Stem Cells: A Novel Conditioned Medium Including Melatonin within a Mixture of Hyaluronic, Butyric, and Retinoic Acids

    Maioli, Margherita; Basoli, Valentina; Santaniello, Sara; Cruciani, Sara; Delitala, Alessandro Palmerio; Pinna, Roberto; Milia, Egle; Grillari-Voglauer, Regina; Fontani, Vania; Rinaldi, Salvatore; Muggironi, Roberta; Pigliaru, Gianfranco; Ventura, Carlo

    2016-01-01

    Human dental pulp stem cells (hDPSCs) have shown relevant potential for cell therapy in the orthopedic and odontoiatric fields. The optimization of their osteogenic potential is currently a major challenge. Vascular endothelial growth factor A (VEGF A) has been recently reported to act as a major conductor of osteogenesis in vitro and in vivo. Here, we attempted to prime endogenous VEGF A expression without the need for viral vector mediated gene transfer technologies. We show that hDPSCs exposure to a mixture of hyaluronic, butyric, and retinoic acids (HA + BU + RA) induced the transcription of a gene program of osteogenesis and the acquirement of an osteogenic lineage. Such response was also elicited by cell exposure to melatonin, a pleiotropic agent that recently emerged as a remarkable osteogenic inducer. Interestingly, the commitment to the osteogenic fate was synergistically enhanced by the combinatorial exposure to a conditioned medium containing both melatonin and HA + BU + RA. These in vitro results suggest that in vivo osteogenesis might be improved and further studies are needed.

  18. Effects of Cd and Ni toxicity to Ceratophyllum demersum under environmentally relevant conditions in soft and hard water including a German lake

    Highlights: •Hardly any macrophytic growth occurred in an oligotrophic hard water lake in Germany. •All parameters were optimal, besides elevated, nanomolar concentrations of Ni and Cd. •We cultivated submerged macrophytes in real and simulated hard and soft lake water. •Nanomolar Cd and Ni inhibited the plants’ photosynthetic light reactions in soft water. •The inhibition was synergistic, i.e. stronger than the addition of Cd and Ni effects. -- Abstract: Even essential trace elements are phytotoxic over a certain threshold. In this study, we investigated whether heavy metal concentrations were responsible for the nearly complete lack of submerged macrophytes in an oligotrophic lake in Germany. We cultivated the rootless aquatic model plant Ceratophyllum demersum under environmentally relevant conditions like sinusoidal light and temperature cycles and a low plant biomass to water volume ratio. Experiments lasted for six weeks and were analysed by detailed measurements of photosynthetic biophysics, pigment content and hydrogen peroxide production. We established that individually non-toxic cadmium (3 nM) and slightly toxic nickel (300 nM) concentrations became highly toxic when applied together in soft water, severely inhibiting photosynthetic light reactions. Toxicity was further enhanced by phosphate limitation (75 nM) in soft water as present in many freshwater habitats. In the investigated lake, however, high water hardness limited the toxicity of these metal concentrations, thus the inhibition of macrophytic growth in the lake must have additional reasons. The results showed that synergistic heavy metal toxicity may change ecosystems in many more cases than estimated so far

  19. Temperature and moisture conditions for life in the extreme arid region of the Atacama desert: four years of observations including the El Nino of 1997-1998

    McKay, Christopher P.; Friedmann, E. Imre; Gomez-Silva, Benito; Caceres-Villanueva, Luis; Andersen, Dale T.; Landheim, Ragnhild

    2003-01-01

    The Atacama along the Pacific Coast of Chile and Peru is one of the driest and possibly oldest deserts in the world. It represents an extreme habitat for life on Earth and is an analog for life in dry conditions on Mars. We report on four years (September 1994-October 1998) of climate and moisture data from the extreme arid region of the Atacama. Our data are focused on understanding moisture sources and their role in creating suitable environments for photosynthetic microorganisms in the desert surface. The average air temperature was 16.5 degrees C and 16.6 degrees C in 1995 and 1996, respectively. The maximum air temperature recorded was 37.9 degrees C, and the minimum was -5.7 degrees C. Annual average sunlight was 336 and 335 W m(-2) in 1995 and 1996, respectively. Winds averaged a few meters per second, with strong fohn winds coming from the west exceeding 12 m s(-1). During our 4 years of observation there was only one significant rain event of 2.3 mm, which occurred near midnight local time. We suggest that this event was a rainout of a heavy fog. It is of interest that the strong El Nino of 1997-1998 brought heavy rainfall to the deserts of Peru, but did not bring significant rain to the central Atacama in Chile. Dew occurred at our station frequently following high nighttime relative humidity, but is not a significant source of moisture in the soil or under stones. Groundwater also does not contribute to surface moisture. Only the one rain event of 2.3 mm resulted in liquid water in the soil and beneath stones for a total of only 65-85 h over 4 years. The paucity of liquid water under stones is consistent with the apparent absence of hypolithic (under-stone) cyanobacteria, the only known primary producers in such extreme deserts.

  20. Nonadherence in difficult asthma facts, myths, and a time to act

    Lindsay JT

    2013-04-01

    Full Text Available John T Lindsay, Liam G HeaneyCentre for Infection and Immunity, Queens University Belfast, Belfast, UKAbstract: Nonadherence to prescribed treatment is an important cause of difficult asthma. Rates of nonadherence amongst asthmatic patients have been shown to range between 30% and 70%. This is associated with poor health care outcomes and increased health care costs. There is no such thing as a "typical" nonadherent patient. The reasons driving nonadherence are multifactorial. Furthermore, adherence is a variable behavior and not a trait characteristic. Adherence rates can vary between the same individual across treatments for different conditions. There is no consistent link between socioeconomic status and nonadherence, and although some studies have shown that nonadherence is more common amongst females, this is not a universal finding. The commonly held perception that better adherence is driven by greater disease severity has been demonstrated to not be the case, in both pediatric and adult patients. Identification of nonadherence is the first step. If adherence is not checked, it is likely that poor adherence will be labeled as refractory disease. Failure to identify poor adherence may lead to inappropriate escalation of therapy, including the potential introduction of complex biological therapies. Surrogate measures, such as prescription counting, are not infallible. Nonadherence can be difficult to identify in clinical practice, and a systematic approach using a variety of tools is required. Nonadherence can be successfully addressed. Therefore, assessment of adherence is of paramount importance in difficult asthma management, in order to reduce exacerbations and steroid-related side effects as well as hospital and intensive care admissions, health care cost, and inappropriate treatment escalation. In this paper, we present an overview of the literature surrounding nonadherence in difficult asthma. We explore the facts and myths surrounding the factors driving nonadherence as well as how it can be identified and addressed.Keywords: concordance, compliance, inhaled corticosteroids, drug monitoring

  1. Facial Image Analysis for Fully-Automatic Prediction of Difficult Endotracheal Intubation

    Cuendet, Gabriel Louis; Schoettker, Patrick; Yuce, Anil; Sorci, Matteo; GAO Hua; Perruchoud, Christophe; Thiran, Jean-Philippe

    2015-01-01

    Goal: Difficult tracheal intubation is a major cause of anesthesia related injuries with potential life threatening complications. Detection and anticipation of difficult airway in the preoperative period is thus crucial for the patients safety. We propose an automatic face analysis approach to detect morphological traits related to difficult intubation and improve its prediction. Methods: For this purpose, we have collected a database of 970 patients including photos, videos and ground trut...

  2. Maxillofacial trauma patient: coping with the difficult airway

    Barak Michal

    2009-05-01

    Full Text Available Abstract Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.

  3. Management of difficult airway in intratracheal tumor surgery

    Agarwal Surendra K

    2005-06-01

    Full Text Available Abstract Background Tracheal malignancies are usual victim of delay in diagnosis by virtue of their symptoms resembling asthma. Sometimes delayed diagnosis may lead to almost total airway obstruction. For difficult airways, not leaving any possibility of manipulation into neck region or endoscopic intervention, femorofemoral cardiopulmonary bypass can be a promising approach. Case Presentation We are presenting a case of tracheal adenoid cystic carcinoma (cylindroma occupying about 90% of the tracheal lumen. It was successfully managed by surgical excision of mass by sternotomy and tracheotomy under femorofemoral cardiopulmonary bypass (CPB. Conclusion Any patient with recurrent respiratory symptoms should be evaluated by radiological and endoscopic means earlier to avoid delay in diagnosis of such conditions. Femorofemoral cardiopulmonary bypass is a relatively safe way of managing certain airway obstructions.

  4. Thermoelastic stresses in non-uniform geological environments difficult outline

    ?.?. ??????

    2010-01-01

    Full Text Available Thermal stresses concern not renewed type of stresses, that is once having liberated, they cannot accumulate more. The estimation of purely thermoelastic contribution to a lithosphere stress state gives the additional information, allowing to predict the danger connected with such natural factors, as seismic and volcanic activity. Some theoretical thermoelastic problems for the geological environment of a difficult outline with non-uniform thermophysical characteristics are considered. The decision is received on the basis of a numerical finite elements method. Influence of the model fixation, the geometrical factor and boundary conditions on distribution of thermal stresses and dislocation is investigated. Computing experiments have shown, that the size of the maximum thermal stresses reaches 500 bar. The maximum values of vertical dislocation are reached by 90 m, and horizontal 50 m. Neutral plane position are precisely defined.

  5. Penile Corporeal Reconstruction during Difficult Placement of a Penile Prosthesis

    Sherif R. Aboseif

    2008-11-01

    Full Text Available For some patients with impotence and concomitant severe tunical/corporeal tissue fibrosis, insertion of a penile prosthesis is the only option to restore erectile function. Closing the tunica over an inflatable penile prosthesis in these patients can be challenging. We review our previous study which included 15 patients with severe corporeal or tunical fibrosis who underwent corporeal reconstruction with autologous rectus fascia to allow placement of an inflatable penile prosthesis. At a mean follow-up of 18 months (range 12 to 64, all patients had a prosthesis that was functioning properly without evidence of separation, herniation, or erosion of the graft. Sexual activity resumed at a mean time of 9 weeks (range 8 to 10. There were no adverse events related to the graft or its harvest. Use of rectus fascia graft for coverage of a tunical defect during a difficult penile prosthesis placement is surgically feasible, safe, and efficacious.

  6. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.

    Frerk, C; Mitchell, V S; McNarry, A F; Mendonca, C; Bhagrath, R; Patel, A; O'Sullivan, E P; Woodall, N M; Ahmad, I

    2015-12-01

    These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team. PMID:26556848

  7. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics.

    Mushambi, M C; Kinsella, S M; Popat, M; Swales, H; Ramaswamy, K K; Winton, A L; Quinn, A C

    2015-11-01

    The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training. PMID:26449292

  8. Cricothyrotomy can be hazardous in a difficult airway scenario

    Reema Ray

    2007-01-01

    Difficult and compromised airway poses a significant challenge to the anaesthesiologist. The following is a report of management of a case of difficult airway caused by injury of a prior deliberate acid ingestion. A previous uneventful anaesthetic course gave us a false sense of security while proceeding with the next surgical procedure under anaesthesia. After administration of neuromuscular blocking agent, mask ventilation became increasingly difficult and under direct laryngoscopy, visuali...

  9. Racial microaggressions and difficult dialogues on race in the classroom.

    Sue, Derald Wing; Lin, Annie I; Torino, Gina C; Capodilupo, Christina M; Rivera, David P

    2009-04-01

    A qualitative study supports the observation that difficult dialogues on race and racism are often triggered by racial microaggressions that make their appearance in classroom encounters or educational activities and materials. Difficult dialogues are filled with strong powerful emotions that may prove problematic to both students and teachers. When poorly handled by teachers, difficult dialogues can assail the personal integrity of students of color while reinforcing biased worldviews of White students. The success or failure of facilitating difficult dialogues on race is intimately linked to the characteristics and actions of instructors and their ability to recognize racial microaggressions. Implications regarding specific education and training recommendations are presented. PMID:19364205

  10. Emotional distance to so-called difficult patients

    Michaelsen, Jette Joost

    2012-01-01

    Scand J Caring Sci; 2011 Emotional distance to so-called difficult patients Purpose: To explore nurses' relationships with patients they regard as being difficult. How do nurses feel about such patients and relate to them, and what are the consequences for nurse and patient? Design and methods: A...

  11. ECO2M: A TOUGH2 Fluid Property Module for Mixtures of Water, NaCl, and CO2, Including Super- and Sub-Critical Conditions, and Phase Change Between Liquid and Gaseous CO2

    Pruess, K.

    2011-04-01

    ECO2M is a fluid property module for the TOUGH2 simulator (Version 2.0) that was designed for applications to geologic storage of CO{sub 2} in saline aquifers. It includes a comprehensive description of the thermodynamics and thermophysical properties of H{sub 2}O - NaCl - CO{sub 2} mixtures, that reproduces fluid properties largely within experimental error for temperature, pressure and salinity conditions in the range of 10 C {le} T {le} 110 C, P {le} 600 bar, and salinity from zero up to full halite saturation. The fluid property correlations used in ECO2M are identical to the earlier ECO2N fluid property package, but whereas ECO2N could represent only a single CO{sub 2}-rich phase, ECO2M can describe all possible phase conditions for brine-CO{sub 2} mixtures, including transitions between super- and sub-critical conditions, and phase change between liquid and gaseous CO{sub 2}. This allows for seamless modeling of CO{sub 2} storage and leakage. Flow processes can be modeled isothermally or non-isothermally, and phase conditions represented may include a single (aqueous or CO{sub 2}-rich) phase, as well as two-and three-phase mixtures of aqueous, liquid CO{sub 2} and gaseous CO{sub 2} phases. Fluid phases may appear or disappear in the course of a simulation, and solid salt may precipitate or dissolve. TOUGH2/ECO2M is upwardly compatible with ECO2N and accepts ECO2N-style inputs. This report gives technical specifications of ECO2M and includes instructions for preparing input data. Code applications are illustrated by means of several sample problems, including problems that had been previously solved with TOUGH2/ECO2N.

  12. Use of the Flugelman index for identifying patients who are difficult to discharge from the hospital

    Chiara Bozzano

    2013-03-01

    Full Text Available Introduction: To evaluate the use of multidimensional assessment based on the Fluegelman Index (FI to identify internal medicine patients who are likely to be difficult to discharge from the hospital. Materials and methods: Have been evaluated all patients admitted to the medical wards of the District General Hospital of Arezzo from September 1 to October 31, 2007. We collected data on age, sex, socioeconomic condition, cause of admission, comorbidity score preadmission functional status (Barthel Index, incontinence, feeding problems, length of hospitalization, condition at discharge, and type of discharge. The FI cut off for difficult discharge was > 17. Results: Of the 413 patients (mean age 80 + 11.37 years; percentage of women, 56.1% included in the study, 109 (26.39% had Flugelman Index > 17. These patients were significantly older than the patients with lower FIs (85 + 9.35 vs 78 + 11.58 years, p < 0.001, more likely to be admitted for pneumonia (22% vs. 4.9% of those with lower FIs; p < 0,001. They also had more comorbidity, loss of autonomy, cognitive impairment, social frailty, and nursing care needs. The subgroup with FIs>17 had significantly higher in-hospital mortality (30.28% vs 6.25%, p < 0.001, longer hospital stay (13 vs. 10 days, p < 0.05, and higher rates of discharge to nursing homes. Conclusions: Evaluation of internal medicine patients with the Flugelman Index may be helpful for identifying more critical patients likely to require longer hospitalization and to detect factors affecting the hospital stay. This information can be useful for more effective discharge planning.

  13. Difficult issues in mentoring: recommendations on making the "undiscussable" discussable.

    Bickel, Janet; Rosenthal, Susan L

    2011-10-01

    Many mentoring relationships do not reach fruition because the individuals fail to bridge a critical difference. When a difference prevents a learning partnership from achieving its potential, the loss is multidimensional for the individuals and the institution--wasting opportunities for the fostering of current and future talent. Insights into when such impasses are likely to arise may help both mentors and mentees address what feels "undiscussable." The authors offer numerous examples of how differences related to ethnicity, language, gender, and generation may interfere with the development of mentoring relationships. Next, the authors offer recommendations on preparing for and handling difficult conversations, including creating safety, noticing assumptions and emotions, and raising sensitive issues. Virtually all faculty can become more effective at communicating across differences and addressing difficulties that prevent mentoring relationships from achieving their potential. The pay-offs for these efforts are indisputable: increased effect in the limited time available for mentoring, an expanded legacy of positive influence, and enhanced communication and leadership skills. The honing of these relational skills enhances the colleagueship and teamwork on which virtually all research, clinical, and educational enterprises depend. Academic health centers that systematically support mentoring enhance institutional stability, talent development, and leadership capacity. PMID:21869662

  14. Genetic evidence of multiple loci in dystocia - difficult labour

    Westgren Magnus

    2010-06-01

    Full Text Available Abstract Background Dystocia, difficult labour, is a common but also complex problem during childbirth. It can be attributed to either weak contractions of the uterus, a large infant, reduced capacity of the pelvis or combinations of these. Previous studies have indicated that there is a genetic component in the susceptibility of experiencing dystocia. The purpose of this study was to identify susceptibility genes in dystocia. Methods A total of 104 women in 47 families were included where at least two sisters had undergone caesarean section at a gestational length of 286 days or more at their first delivery. Study of medical records and a telephone interview was performed to identify subjects with dystocia. Whole-genome scanning using Affymetrix genotyping-arrays and non-parametric linkage (NPL analysis was made in 39 women exhibiting the phenotype of dystocia from 19 families. In 68 women re-sequencing was performed of candidate genes showing suggestive linkage: oxytocin (OXT on chromosome 20 and oxytocin-receptor (OXTR on chromosome 3. Results We found a trend towards linkage with suggestive NPL-score (3.15 on chromosome 12p12. Suggestive linkage peaks were observed on chromosomes 3, 4, 6, 10, 20. Re-sequencing of OXT and OXTR did not reveal any causal variants. Conclusions Dystocia is likely to have a genetic component with variations in multiple genes affecting the patient outcome. We found 6 loci that could be re-evaluated in larger patient cohorts.

  15. How libraries make tough choices in difficult times purposeful abandonment

    Stern, David

    2013-01-01

    Contemporary library managers face the need to make difficult choices regarding resource allocation in the modern business environment. How Libraries Make Tough Choices in Difficult Times is a practical guide for library managers, offering techniques to analyze existing and potential services, implement best practices for maximizing existing resources, and utilize pressing financial scenarios in order to justify making difficult reallocation decisions. The book begins by asking the fundamental questions of why, what, and how, moving on to look at how to manage expectations and report to both a

  16. Social support and support of children in difficult situations

    Lavrenova T. I.; Lygina M. A.

    2011-01-01

    The article describes the results of sociological investigation. It is devoted to the problem of social assistance for the children in difficult life situation. Social accompaniment and social support are very important either for the children or their families.

  17. Dealing with the difficult student in emergency medicine

    Ronan-Bentle, Sarah E; Avegno, Jennifer; Hegarty, Cullen B.; Manthey, David E

    2011-01-01

    Dealing with a student who is perceived as difficult to work with or teach is inevitable in any academic physician's career. This paper will outline the basic categories of these difficulties pertinent to Emergency Medicine rotations in order to facilitate appropriate identification of problems. Strategies for evaluation and reporting of the difficult student are presented. Remediation, based on the type of difficulty, is addressed. Timeliness of reporting, evaluation, and feedback are invalu...

  18. Difficult Sudoku Puzzles Created by Replica Exchange Monte Carlo Method

    Watanabe, Hiroshi

    2013-01-01

    An algorithm to create difficult Sudoku puzzles is proposed. An Ising spin-glass like Hamiltonian describing difficulty of puzzles is defined, and difficult puzzles are created by minimizing the energy of the Hamiltonian. We adopt the replica exchange Monte Carlo method with simultaneous temperature adjustments to search lower energy states efficiently, and we succeed in creating a puzzle which is the world hardest ever created in our definition, to our best knowledge. (Added on Mar. 11, the ...

  19. Clustering is difficult only when it does not matter

    Daniely, Amit; Linial, Nati; Saks, Michael

    2012-01-01

    Numerous papers ask how difficult it is to cluster data. We suggest that the more relevant and interesting question is how difficult it is to cluster data sets {\\em that can be clustered well}. More generally, despite the ubiquity and the great importance of clustering, we still do not have a satisfactory mathematical theory of clustering. In order to properly understand clustering, it is clearly necessary to develop a solid theoretical basis for the area. For example, from the perspective of...

  20. Difficult diagnoses in the skeletal radiology; Schwierige Diagnosen in der Skelettradiologie

    Freyschmidt, Juergen [Klinikum Bremen-Mitte (Germany). Beratungsstelle und Referenz-Zentrum fuer Osteoradiologie

    2013-11-01

    The book on difficult diagnoses in the skeletal radiology discusses the path from symptom to diagnoses including image interpretation. Specific case studies concern the skull, the spinal cord, pelvis, shoulder and chest, upper and lower extremities. The used radiological techniques include projecting radiography, computerized tomography, scintiscanning, PET/CT, NNR imaging and ultrasonography.

  1. A novel cannulation technique for difficult urethral catheterization

    Mehmet Kaynar

    2016-03-01

    Full Text Available Introduction: To propose a novel cannulation technique for difficult urethral catheterization procedures. Technique: The sheath tip of an intravenous catheter is cut off, replaced to the needle tip and pushed through the distal drainage side hole to Foley catheter tip, and finally withdrawn for cannulation. In situations making urethral catheterization difficult, a guide wire is placed under direct vision. The modified Foley catheter is slid successfully over the guide wire from its distal end throughout the urethral passage into the bladder. Results: The modified Foley catheter was used successfully in our clinic in cases requiring difficult urethral catheterization. Conclusions: This easy and rapid modification of a Foley catheter may minimize the potential complications of blind catheter placement in standard catheterization.

  2. Cricothyrotomy can be hazardous in a difficult airway scenario

    Reema Ray

    2007-01-01

    Full Text Available Difficult and compromised airway poses a significant challenge to the anaesthesiologist. The following is a report of management of a case of difficult airway caused by injury of a prior deliberate acid ingestion. A previous uneventful anaesthetic course gave us a false sense of security while proceeding with the next surgical procedure under anaesthesia. After administration of neuromuscular blocking agent, mask ventilation became increasingly difficult and under direct laryngoscopy, visualization of glottis revealed gross fibrosis with no opening visible at all. It was a ′cannot intubate, cannot ventilate (CICV′ scenario. Percutaneous transtracheal jet ventilation (PTJV also could not be set up as canula could not be negotiated. Surgical (′stab′ cricothyroidotomy allowed rapid restoration of ventilation and oxygenation in this CICV situation but not without its complications and compromised airway was imminent. Surgical airway in the form of definite tracheostomy offered the only solution and complications averted.

  3. Dissolution method for difficult-to-dissolve nuclear fuel

    Difficult-to-dissolve nuclear fuels like e.g. ThO2, PuO2 are brought into a metallic dissolution vessel together with a nitric solven initially containing only small amounts of fissionable material. To the solvent an equimolar amount of fluoride ions is added that will form a complex compound with the fissionable material, thus only traces of the fluoride ions can be catalytically effective. In this way the difficult-to-dissolve fuels will be dissolved within a few hours. (orig.)

  4. A MODIFIED TECHNIQUE OF RETROGRADE INTUBATION IN A DIFFICULT INTUBATION CASE

    Murthy

    2014-08-01

    Full Text Available Anaesthesiologists will be facing difficult intubating conditions, anticipated or unanticipated, quite frequently, whenever they anaesthetize patients with facio- maxillary injuries, temporo mandibular joint ankylosis, obesity, pregnancy, congenital air-way abnormalities, etc. A large number of aids are available now for intubating in such difficult situations and a lot of techniques have been described in literature for giving anaesthesia for such patients. (1 Use of Bullard laryngoscope in difficult air-way situation was described by Dullenkopf et al 2003, (2 Lighted Wand by Agro et al 2004, (3 Shikani flexible seeing stylet by Agro et al 2005(4 Blind nasal intubation, L M A, Fiber optic laryngoscope by Levitan et al1999. (5 Glydoscope by Lim et al 2005(6 . In this case report, we have given one more alternate solution for this problem

  5. Privileged Identity Exploration: Examining Counselor Trainees' Reactions to Difficult Dialogues

    Watt, Sherry K.; Curtis, Gregg C.; Drummond, Jerri; Kellogg, Angela H.; Lozano, Adele; Nicoli, Gina Tagliapietra; Rosas, Marisela

    2009-01-01

    In this qualitative study, the authors examined master's-level counselor trainees' reactions to difficult dialogues in the classroom regarding racism, heterosexism/homophobia, and ableism over a 3-year period. Using the Consensual Qualitative Research method as introduced by C. E. Hill, B. J. Thompson, and E. N. Williams (1997), the data analysis

  6. Free emission quotas for the industry - a difficult topic

    The Norwegian Parliament wants to establish a Norwegian market for emission quota trading and a public committee are evaluating the possibility of establishing a market. Free quotas as a means of securing the existence of industrial working places constitute a difficult issue. This publication discusses some of the issues

  7. Do stressful conditions make adaptation difficult? Guppies in the oil-polluted environments of southern Trinidad.

    Rolshausen, Gregor; Phillip, Dawn A T; Beckles, Denise M; Akbari, Ali; Ghoshal, Subhasis; Hamilton, Patrick B; Tyler, Charles R; Scarlett, Alan G; Ramnarine, Indar; Bentzen, Paul; Hendry, Andrew P

    2015-10-01

    The ability of populations to rapidly adapt to new environments will determine their future in an increasingly human-modified world. Although meta-analyses do frequently uncover signatures of local adaptation, they also reveal many exceptions. We suggest that particular constraints on local adaptation might arise when organisms are exposed to novel stressors, such as anthropogenic pollution. To inform this possibility, we studied the extent to which guppies (Poecilia reticulata) show local adaptation to oil pollution in southern Trinidad. Neutral genetic markers revealed that paired populations in oil-polluted versus not-polluted habitats diverged independently in two different watersheds. Morphometrics revealed some divergence (particularly in head shape) between these environments, some of which was parallel between rivers. Reciprocal transplant experiments in nature, however, found little evidence of local adaptation based on survival and growth. Moreover, subsequent laboratory experiments showed that the two populations from oil-polluted sites showed only weak local adaptation even when compared to guppies from oil-free northern Trinidad. We conclude that guppies show little local adaptation to oil pollution, which might result from the challenges associated with adaptation to particularly stressful environments. It might also reflect genetic drift owing to small population sizes and/or high gene flow between environments. PMID:26495039

  8. INFORMATION TECHNOLOGY SECURITY AIRCRAFT FLIGHT IN DIFFICULT CONDITIONS BASED MULTIFACTORIAL FUZZY MODELS

    Nadir Bafadin oqlu Agayev

    2013-12-01

    Full Text Available The proposed method is designed for situations where the original information that characterizes the state of the aircraft, clearly defined and numerical variables and the so-called “linguistic variables” This simple relationship between the variables are described by means of fuzzy statements, and the complex relationship between the concepts with fuzzy algorithms

  9. Development of a no-moving-part blower for difficult operating conditions

    Tesař, Václav

    2013-01-01

    Roč. 91, č. 12 (2013), s. 2401-2411. ISSN 0263-8762 R&D Projects: GA ČR GA13-23046S Institutional research plan: CEZ:AV0Z20760514 Keywords : blower * fluidics * hazardous fluids Subject RIV: BK - Fluid Dynamics Impact factor: 2.281, year: 2013 http://www.sciencedirect.com/science/article/pii/S0263876213001081

  10. Do stressful conditions make adaptation difficult? Guppies in the oil-polluted environments of southern Trinidad

    Rolshausen, Gregor; Phillip, Dawn A T; Beckles, Denise M.; Akbari, Ali; Ghoshal, Subhasis; Hamilton, Patrick B; Tyler, Charles R; Scarlett, Alan G.; Ramnarine, Indar; Bentzen, Paul; Hendry, Andrew P.

    2015-01-01

    The ability of populations to rapidly adapt to new environments will determine their future in an increasingly human-modified world. Although meta-analyses do frequently uncover signatures of local adaptation, they also reveal many exceptions. We suggest that particular constraints on local adaptation might arise when organisms are exposed to novel stressors, such as anthropogenic pollution. To inform this possibility, we studied the extent to which guppies (Poecilia reticulata) show local ad...

  11. Pneumatic conveyance of stowing material under difficult conditions in the Asse research mine

    The Asse mine as a former potash and rock salt mine has been used for research work in the field of final storage of radioactive waste since 1965. Because of the prevailing rock pressure the pillars between the individual chambers were loaded to such an extent that extensive spalling and increased caving of pillars occurred over the years. As the chambers could no longer be entered without risk, the BGR considered that the backfilling of the southern flank to improve the stability of the mine with a view to continued use was urgently required. The paper deals with selection of the conveying method and stowing material and also provides information on the operating experience already acquired. (orig.)

  12. Difficult Behavior in Early Childhood: Positive Discipline for PreK-3 Classrooms and Beyond

    Mah, Ronald

    2006-01-01

    Creating a classroom of attentive learners takes more than swift discipline. "Difficult Behavior" can help inspire positive behavioral change and healthy, productive development. Following Acknowledgments, About the Author and Introduction, the book is divided into five sections. Part I, The Role of Discipline, includes: (1) Discipline in

  13. Effects of Multi-Tier Academic and Behavior Instruction on Difficult-to-Teach Students

    Algozzine, Bob; Wang, Chuang; White, Richard; Cooke, Nancy; Marr, Mary Beth; Algozzine, Kate; Helf, Shawnna S.; Duran, Grace Zamora

    2012-01-01

    This article addresses the effects of 3-tiered comprehensive reading and behavior interventions on K-3 student outcomes in 7 urban elementary schools with a high prevalence of students considered difficult to teach. Specific features of each level of the implementation are described including screening and tier placement procedures, scheduling and

  14. Experimental validation of a numerical model for predicting the trajectory of blood drops in typical crime scene conditions, including droplet deformation and breakup, with a study of the effect of indoor air currents and wind on typical spatter drop trajectories.

    Kabaliuk, N; Jermy, M C; Williams, E; Laber, T L; Taylor, M C

    2014-10-18

    Bloodstain Pattern Analysis (BPA) provides information about events during an assault, e.g. location of participants, weapon type and number of blows. To extract the maximum information from spatter stains, the size, velocity and direction of the drop that produces each stain, and forces acting during flight, must be known. A numerical scheme for accurate modeling of blood drop flight, in typical crime scene conditions, including droplet oscillation, deformation and in-flight disintegration, was developed and validated against analytical and experimental data including passive blood drop oscillations, deformation at terminal velocity, cast-off and impact drop deformation and breakup features. 4th order Runge-Kutta timestepping was used with the Taylor Analogy Breakup (TAB) model and Pilch and Erdman's (1987) expression for breakup time. Experimental data for terminal velocities, oscillations, and deformation was obtained via digital high-speed imaging. A single model was found to describe drop behavior accurately in passive, cast off and impact scenarios. Terminal velocities of typical passive drops falling up to 8m, distances and times required to reach them were predicted within 5%. Initial oscillations of passive blood drops with diameters of 1mmpatterns are affected by winds and draughts. PMID:25447183

  15. Edward’s syndrome: A rare cause of difficult intubation-utility of left molar approach

    Teena Bansal

    2016-04-01

    Full Text Available Edward’s syndrome (trisomy 18 is an autosomal abnormality with dysmorphic face, visceral deformities and delayed mental and motor development including congenital heart disease. Challenges may arise during mask ventilation, laryngoscopy and/or intubation of the trachea due to dysmorphic face. Difficult airway cart should be kept ready. Left molar approach using a standard Macintosh blade improves the laryngoscopic view in patients with difficult midline laryngoscopy. We hereby present a case report of a 2 year old male child with Edward’s syndrome posted for evacuation and drainage of brain abscess, intubated successfully using left molar approach.

  16. An unanticipated difficult airway in Lesch-Nyhan syndrome

    Rashmi Salhotra

    2012-01-01

    Full Text Available An 11-year-old boy with Lesch-Nyhan syndrome presented to the emergency for fixation of a fractured femur. During induction of general anesthesia, unexpected difficult intubation was encountered with a 6.5-mm ID endotracheal tube and successively smaller tubes, also failing to pass 1 cm beyond the vocal cords. Intubation was finally achieved with a 4.5-mm ID tube. The surgery was completed uneventfully. A tracheal diverticulum was found in the computerized tomography (CT scan performed postoperatively to account for this unexpected difficult intubation. This case highlights the anesthetic concerns in Lesch-Nyhan syndrome and also reports the rare occurrence of a tracheal diverticulum associated with it.

  17. Endoscopic management of difficult common bile duct stones

    Guru Trikudanathan

    2013-01-01

    Full Text Available Endoscopy is widely accepted as the first treatment option in the management of bile duct stones. In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones. Most biliary stones can be removed with an extraction balloon, extraction basket or mechanical lithotripsy after endoscopic sphincterotomy. Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients. Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed. Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

  18. Team Work in International Programs: Why is it so difficult?

    Lauridsen, Karen M.; Madsen, Henning

    Team Work in International Programs: Why is it so difficult? And what can we do about it? It is common knowledge that students often find it difficult to collaborate on assignments, projects, etc., but we require that they do so for a number of reasons, e.g. to learn how to work in teams or take...... international students are more prepared to work in multicultural teams than their Danish peers. Another one tells us that once students have experience with the diversity of these teams, at least some of them become more open towards working in such teams in the future. It is interesting to discuss the...... advantage of the diversity represented by team members. In programmes that accept international students, these difficulties seem to increase. Home students are often reluctant to enter into collaboration with their international peers, whereas the international students tend to be much more open towards...

  19. Emotional distance to so-called difficult patients

    Michaelsen, Jette Joost

    2012-01-01

    social and health problems of some patients not being recognized, and some nurses using it expressed the fear of losing contact with their emotional lives. The compromise strategy gave possibilities for dialogue. Study limitations: The focus was mainly on the nurses and their perspectives. It would be......Scand J Caring Sci; 2011 Emotional distance to so-called difficult patients Purpose: To explore nurses' relationships with patients they regard as being difficult. How do nurses feel about such patients and relate to them, and what are the consequences for nurse and patient? Design and methods: A...... nurses. Patients' case records were studied and four meetings with the staff were arranged to discuss the findings. Data collection lasted 18 months in all. Findings: Three strategies were identified: persuasion, avoidance (emotional distance), and compromise. Interestingly, in the relationship with a...

  20. Difficult airway management from Emergency Department till Intensive Care Unit.

    Pradhan, Debasis; Bhattacharyya, Prithwis

    2015-09-01

    We report a case of "can ventilate but can't intubate" situation which was successfully managed in the Emergency Department and Intensive Care Unit by the use of ProSeal laryngeal mask airway and Frova Intubating Introducer as bridging rescue devices. Use of appropriate technique while strictly following the difficult airway algorithm is the mainstay of airway management in unanticipated difficult airway situations. Although the multiple airway devices were used but each step took not more than 2 min and "don't struggle, skip to the next step principle" was followed. With the availability of many advanced airway management tools, the intensivists should have a training and experience along with preparedness in order to perform such lifesaving airway managements. PMID:26430345

  1. Management of difficult airway in penetrating cervical spine injury

    Mukesh Kumar Prasad

    2010-01-01

    Full Text Available Management of airway in trauma victim with penetrating cervical/thoracic spine injury has always been a challenge to the anaesthesiologist. Stabilisation of spine during airway manipulation, to prevent any further neural damage, is of obvious concern to the anaesthesiologist. Most anaesthesiologists are not exposed to direct laryngoscopy and intubation in lateral position during their training period. Tracheal intubation in the lateral position may be unavoidable in some circumstances. Difficult airway in an uncooperative patient compounds the problem to secure airway in lateral position. We present a 46-year-old alcoholic, hypertensive, morbidly obese person who suffered a sharp instrument (screwdriver spinal injury with anticipated difficult intubation; the case was managed successfully.

  2. Difficult airway management from Emergency Department till Intensive Care Unit

    Debasis Pradhan

    2015-01-01

    Full Text Available We report a case of "can ventilate but can′t intubate" situation which was successfully managed in the Emergency Department and Intensive Care Unit by the use of ProSeal laryngeal mask airway and Frova Intubating Introducer as bridging rescue devices. Use of appropriate technique while strictly following the difficult airway algorithm is the mainstay of airway management in unanticipated difficult airway situations. Although the multiple airway devices were used but each step took not more than 2 min and "don′t struggle, skip to the next step principle" was followed. With the availability of many advanced airway management tools, the intensivists should have a training and experience along with preparedness in order to perform such lifesaving airway managements.

  3. Odor naming is difficult, even for wine and coffee experts

    Croijmans, I.; Majid, A.

    2015-01-01

    Odor naming is difficult for people, but recent cross-cultural research suggests this difficulty is culture-specific. Jahai speakers (hunter-gatherers from the Malay Peninsula) name odors as consistently as colors, and much better than English speakers (Majid & Burenhult, 2014). In Jahai the linguistic advantage for smells correlates with a cultural interest in odors. Here we ask whether sub-cultures in the West with odor expertise also show superior odor naming. We tested wine and coffee exp...

  4. Acute urinary retention and the difficult catheterization: current emergency management.

    Sliwinski, Ania; D'Arcy, Frank T; Sultana, Ron; Lawrentschuk, Nathan

    2016-04-01

    Acute urinary retention (AUR) is a common presentation to emergency departments. This article updates the reader on the appropriate management, investigations and guidelines for AUR. It looks at the mechanism of normal micturition and describes the theories of AUR. It outlines urethral catheterization techniques for difficult cases, reviews suprapubic catheterization procedures and describes the management of AUR in polytrauma. Although emergency management is by bladder drainage, key points in the history and examination may expose significant, latent pathologies. PMID:26479738

  5. Carbon monoxide poisoning: easy to treat but difficult to recognise.

    Balzan, M. V.; Agius, G.; Galea Debono, A.

    1996-01-01

    Carbon monoxide (CO) poisoning is a common medical emergency and a frequent cause of deliberate or accidental death. It can cause acute and chronic central nervous system damage which may be minimised by prompt treatment with 100% oxygen or hyperbaric oxygen therapy. However, recognition of this intoxication can be difficult. Failure to diagnose it may have disastrous effects on the patient, and other members of the household who could subsequently become intoxicated. Guidance on the correct ...

  6. The road to the synthesis of "difficult peptides".

    Paradís-Bas, Marta; Tulla-Puche, Judit; Albericio, Fernando

    2016-02-01

    The last decade has witnessed a renaissance of peptides as drugs. This progress, together with advances in the structural behavior of peptides, has attracted the interest of the pharmaceutical industry in these molecules as potential APIs. In the past, major peptide-based drugs were inspired by sequences extracted from natural structures of low molecular weight. In contrast, nowadays, the peptides being studied by academic and industrial groups comprise more sophisticated sequences. For instance, they consist of long amino acid chains and show a high tendency to form aggregates. Some researchers have claimed that preparing medium-sized proteins is now feasible with chemical ligation techniques, in contrast to medium-sized peptide syntheses. The complexity associated with the synthesis of certain peptides is exemplified by the so-called "difficult peptides", a concept introduced in the 80's. This refers to sequences that show inter- or intra-molecular β-sheet interactions significant enough to form aggregates during peptide synthesis. These structural associations are stabilized and mediated by non-covalent hydrogen bonds that arise on the backbone of the peptide and-depending on the sequence-are favored. The tendency of peptide chains to aggregate is translated into a list of common behavioral features attributed to "difficult peptides" which hinder their synthesis. In this regard, this manuscript summarizes the strategies used to overcome the inherent difficulties associated with the synthesis of known "difficult peptides". Here we evaluate several external factors, as well as methods to incorporate chemical modifications into sequences, in order to describe the strategies that are effective for the synthesis of "difficult peptides". These approaches have been classified and ordered to provide an extensive guide for achieving the synthesis of peptides with the aforementioned features. PMID:26612670

  7. Management of difficult airway in intratracheal tumor surgery

    Agarwal Surendra K; Tewari Prabhat; Tyagi Isha; Goyal Amit; Syal Rajan

    2005-01-01

    Abstract Background Tracheal malignancies are usual victim of delay in diagnosis by virtue of their symptoms resembling asthma. Sometimes delayed diagnosis may lead to almost total airway obstruction. For difficult airways, not leaving any possibility of manipulation into neck region or endoscopic intervention, femorofemoral cardiopulmonary bypass can be a promising approach. Case Presentation We are presenting a case of tracheal adenoid cystic carcinoma (cylindroma) occupying about 90% of th...

  8. How can schools build learning organisations in difficult education contexts?

    Kholeka Constance Moloi

    2010-01-01

    There is paucity in the study of learning organisations within the education sector and particularly in schools working in difficult socio-economic contexts, such as those studied in this investigation. In this qualitative study I therefore sought evidence from teachers, in one of the districts of Gauteng province, through in-depth, semi-structured focus group interviews to establish what a learning organisation is. Using data obtained through two in-depth, semi-structured focus group intervi...

  9. Dexmedetomidine for conscious sedation in difficult awake fiberoptic intubation cases.

    Bergese, Sergio D; Khabiri, Babak; Roberts, William D; Howie, Michael B; McSweeney, Thomas D; Gerhardt, Mark A

    2007-03-01

    Currently used methods of sedation for fiberoptic intubation such as benzodiazepines, propofol, or opioids have their limitations. Dexmedetomidine (DEX) is a selective alpha-2 adrenergic agonist that has been used clinically for its sympatholytic, analgesic, and sedative properties. We report on 4 patients with particularly difficult airways who underwent successful awake fiberoptic intubation with DEX. Dexmedetomidine was used to provide a moderate level of conscious sedation without causing respiratory distress or hemodynamic instability during fiberoptic intubation. PMID:17379129

  10. Difficult factors in Management of Impacted Dental Prosthesis in Esophagus

    Efiaty A. Soepardi

    2005-03-01

    Full Text Available A dental prosthesis which ingested and impacted in esophagus, is an emergency case and life threatening, so require immediate esophagoscopy intervention for removing. The objective of this study is to assess some factors can caused dtfficulties in diagnosing and treating the ingested and impacted dental prosthesis in the esophagus and their complications. This retrospective study analyzed patient’s chart whose underwent esophagoscopy for removing the impacted dental prosthesis in Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia during a period between January 1997 and December 2003. Neck-chest X-ray and esophagoscopy were performed in all patients to identify the existence of the dental prosthesis as a diagnostic and treatment procedure. The length of time for removing the dental prosthesis was recorded and stated as a less difficult esophagoscopy when it takes time less than 60 minutes and as a difficult  esophagoscopy takes 60 minutes or longer. Some risk difficulties factors were statistically analyzed. There were 53 patients of ingested dental prosthesis in esophagus. Only 51 cases were analyzed According to the length of time for removing the dental prosthesis by esophagoscopy, 22 patients were recorded as less difficult cases and 29 patients as difficult cases. Two cases among the cases needed cervicotomy after unsuccessful esophagoscopy removal. The difficulties to diagnose an impacted dental prosthesis in the esophagus caused by unreliable clinical history, unclear signs and symptoms, unable to be detected by X-ray and was not found during esophagoscopy. The difficulties in treating due to mucosal laceration, edema, bleeding, failure of the first extraction and conformity with the size and shape, the wire outside the dental prosthesis and the length of time stayed in the esophagus. (Med J Indones 2005; 14: 33-6Keywords: ingested dental prosthesis, radioluscent foreign body, length of time of esophagoscopy

  11. Difficult airway equipment in departments of emergency medicine in Ireland: results of a national survey.

    Walsh, K

    2012-02-03

    BACKGROUND AND OBJECTIVE: Adverse effects associated with difficult airway management can be catastrophic and include death, brain injury and myocardial injury. Closed-malpractice claims have shown prolonged and persistent attempts at endotracheal intubation to be the most common situation leading to disastrous respiratory events. To date, there has been no evaluation of the types of difficult airway equipment currently available in Irish departments of emergency medicine. The objective of this survey was to identify the difficult airway equipment available in Irish departments of emergency medicine. METHODS: Departments of emergency medicine in the Republic of Ireland with at least one dedicated Emergency Medicine consultant were surveyed via telephone. RESULTS: All of the departments contacted held at least one alternative device on site for both ventilation and intubation. The most common alternative ventilation device was the laryngeal mask airway (89%). The most common alternative intubating device was the surgical airway device (100%). CONCLUSIONS: Irish departments of emergency medicine compare well with those in the UK and USA, when surveyed concerning difficult airway equipment. However, we believe that this situation could be further improved by training inexperienced healthcare providers in the use of the laryngeal mask airway and intubating laryngeal mask airway, by placing greater emphasis on the ready availability of capnography and by the increased use of portable difficult airway storage units.

  12. 34 CFR 303.15 - Include; including.

    2010-07-01

    ... 34 Education 2 2010-07-01 2010-07-01 false Include; including. 303.15 Section 303.15 Education Regulations of the Offices of the Department of Education (Continued) OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES, DEPARTMENT OF EDUCATION EARLY INTERVENTION PROGRAM FOR INFANTS AND TODDLERS...

  13. Hemorrhagic herpes encephalitis: A difficult diagnosis in computed tomography

    Herpes simplex encephalitis (HSE) is the most common sporadically appearing encephalitis in Central Europe. Differential diagnosis to brain tumors or spontaneous intercerebral hemorrhage is difficult. There are CT scan findings which are characteristic of HSE but there are no pathognomonic patterns. These characteristic findings are helpful in differential diagnosis to neoplastic or vascular processes. Thus, other diagnostic procedures (i.e. brain biopsy) to confirm diagnosis of HSE and effective therapy may be carried out in time. The difficulties in differential diagnosis are shown by the presented case. (orig.)

  14. Does "difficult patient" status contribute to de facto demedicalization? The case of borderline personality disorder.

    Sulzer, Sandra H

    2015-10-01

    A diagnosis of Borderline Personality Disorder (BPD) often signals the quintessential "difficult patient" status to clinicians, with at least one scholar arguing the condition itself was created to name and group difficult patients. While patients who are deemed difficult are often dispreferred for care, does this have an impact on their overall status as medicalized patients who have successfully achieved a sick role? This study relies on (n = 22) in-depth interviews with mental health clinicians in the United States from 2012 to evaluate how they describe patients with BPD, how the diagnosis of BPD affects the treatment clinicians are willing to provide, and the implications for patients. My findings suggest patients with BPD are routinely labeled "difficult," and subsequently routed out of care through a variety of direct and indirect means. This process creates a functional form of demedicalization where the actual diagnosis of BPD remains de jure medicalized, but the de facto or treatment component of medicalization is harder to secure for patients. PMID:26298091

  15. Enjeux, difficultés et modalités de l’expression sur le travail : point de vue de la clinique médicale du travail Concerns in occupational medicine about stakes, difficulties and conditions of dispute about work Retos, dificultades y modalidades de la expresión sobre el trabajo : punto de vista de la clínica médica del trabajo

    Philippe Davezies

    2012-11-01

    Full Text Available L’intensification du travail oblige les salariés de tous secteurs et de tous niveaux hiérarchiques à des arbitrages serrés entre les différents objectifs du travail. Faute d’espace de discussion, chacun se débrouille seul, avec comme conséquence une individualisation des questions, une montée des conflits et une dégradation de la performance. Cette situation appelle la mise en place des espaces d’expression sur le travail, prévus dans la loi française. Cette orientation se heurte cependant à une difficulté : l’activité du travailleur est en avance sur sa conscience et beaucoup plus riche que ce qu’il est capable d’exprimer. Des espaces autonomes d’élaboration des enjeux du travail sont nécessaires pour créer les conditions d’une discussion avec la hiérarchie susceptible de porter ses fruits dans le domaine de la santé au travail et dans celui de la performance globale de l’entreprise.Regardless of the job sector or hierarchical position, work intensification forces workers to make hard choices between the different goals they are expected to meet. Due to a lack of discussion, people have to manage by themselves. The consequences are a rising tide of interpersonal conflicts and occupational stress associated with a deterioration in overall performance. This situation requires that time and places be set aside for work disputes, in keeping with French law. Nevertheless, there is a serious difficulty in actualizing this law: the worker’s tacit knowledge of his work is much richer than his conscious ability to verbalize and describe the work activity. Self-governed, employee-reserved times and places for working out the stakes at issue are necessary before discussing with the administration if we are to arrive at favourable results for occupational health and overall company performance.La intensificación del trabajo obliga a los empleados, independientemente del sector o del nivel jerárquico al que pertenezcan, a un arbitraje difícil entre los diferentes objetivos del trabajo. Falta de espacios de discusión, cada cual de desenvuelve solo, lo que tiene como consecuencia una individualización, un aumento de los conflictos interpersonales y una degradación del rendimiento laboral. Esta situación requiere que se creen espacios de expresión sobre el trabajo según estipula la ley francesa. No obstante, esta orientación se enfrenta a una dificultad : la actividad del trabajador es anterior a su consciencia y mucho más rica que lo que el trabajador puede expresar. Por lo tanto, espacios autónomos de elaboración de las cuestiones del trabajo son necesarios para crear las condiciones de una discusión con los niveles jerárquicos. Discusión que sea fructífera desde el punto de vista de la salud laboral y del rendimiento global de la empresa.

  16. [Anesthetic management of Menkes disease infant with difficult vascular access].

    Yoshida, Takayuki; Furutani, Kenta; Hashimoto, Takeshi; Taneoka, Miki; Tobita, Toshiyuki; Baba, Hiroshi

    2010-10-01

    We report anesthetic management of a 6-month-old boy with Menkes disease who underwent three surgeries for vesicoureteral reflux, rupture of the bladder diverticulum, inguinal hernia, and gastroesophageal reflux. Menkes disease is a rare sex-linked disorder of copper absorption and metabolism. Anesthetic management of such patients is rather challenging because of high incidence of seizures, gastroesophageal reflux with the risk of aspiration, hypothermia, airway and vascular complications. In our patient general anesthesia was uneventfully maintained by sevoflurane combined with intravenous remifentanil and fentanyl. We experienced no major complications except some difficulties with intravenous and arterial cannulation. It was especially difficult to establish intravenous and invasive blood pressure lines because of tortuous blood vessels in this patient. We conclude that in patients with Menkes disease scheduled for surgery intravenous access should be established before the induction of general anesthesia. The necessity of invasive blood pressure monitoring should be also carefully considered beforehand. PMID:20960903

  17. A Difficult Choice for Newspapers: Advertisers or Readers?

    Barış Bulunmnaz

    2012-03-01

    Full Text Available Almost entire advertisement revenues are acquired by newspapers in print media. Along with rapid technological developments and the intensive competitive climate in newspaper sector; the gulf between high cost and low revenue has widened, and newspapers are obliged to subsidize this deficit with advertisement revenues. Newspapers in Turkey have two separate groups of customers. The first one of those groups is the advertisers and the other is the readers of that newspaper. Due to economic reasons, this compulsory dependency on advertisement revenue causes newspapers to fall into a paradox between advertisers and readers. In this article we will firstly explain advertisement and its place in marketing; then give information about the advertising sector and the distribution of Turkish advertising pie among media. Later, the relation between advertisers and readers that place newspapers in difficult circumstances will be explicated in detail, analysis and assessments will be made regarding about it.

  18. Assessing the risk factors for difficult-to-treat depression and treatment-resistant depression.

    Gaynes, Bradley

    2016-02-01

    Depression is the leading cause of disability among people across the globe, according to the World Health Organization. Among those who have been diagnosed, many fail to achieve remission after following recommended antidepressant medication and psychosocial therapies. In particular, difficult-to-treat and treatment-resistant depression may cause severe impairments for patients, including diminished cognitive functioning, increased medical bills, and decreased workplace performance, as well as an increased risk of developing comorbid illnesses. However, many tools are available to clinicians for identifying treatment-resistant depression, including rating scales such as the 9-question Patient Health Questionnaire (PHQ-9) and the Quick Inventory of Depressive Symptomatology (QIDS-SR16), as well as clinical evidence related to risk factors for difficult-to-treat or treatment-resistant depression. Accurately identifying treatment-resistant depression is the first step toward changing treatment regimens to help patients achieve remission. PMID:26829431

  19. Characterization of parameters and strategies used by physical therapists in difficult mechanical ventilation weaning

    Fabíola Maria Sabino Meireles

    2013-03-01

    Full Text Available Objective: To characterize the main strategies and parameters used by physical therapists in difficult mechanical ventilation weaning. Methods: Cross-sectional study including all the physical therapists working in adult Intensive Care Units in three public hospitals in Fortaleza-CE. A questionnaire with closed questions related to difficult mechanical ventilation weaning was applied, with either one or multiple answers. The data was treated with descriptive and non-parametric analysis. Results: Among the parameters mostly used by the 56 interviewed physical therapists for the difficult weaning, were found: current volume reduction (26 - 46.4% and desaturation during aspiration (17 - 30.4%. It was observed that 38 (67.9% alternate T-tube and continuous positive airway pressure (CPAP as strategies for difficult weaning, and 28 (50% reported reducing the pressure support. There was no statistical difference between the strategies used in the studied hospitals, neither correlation between strategies and parameters. Conclusion: It was found that physical therapists have been performing similar strategies, which are also shown in the literature, but this is not the case with the parameters. The parameters used are not supported by the literature.

  20. Importance of nutrient supply (N, P, K) for yield formation and nutrient use efficiency of safflower (Carthamus tinctorius L.) compared to sunflower (Helianthus annuus L.) including an assessment to grow safflower under north German conditions

    Abbadi, Jehad

    2007-01-01

    Safflower represents an important oil crop internationally and may have a certain production potential under German conditions, particularly in organic farming where the putatively low nutrient requirement is highly welcomed. Current knowledge regarding the nutrient require-ments of safflower as compared to similar oil crops is limited. However safflower was held worthy under German conditions in the beginning of this century, it was thus the aim of this study to determine the response of saf...

  1. Usage of I++ Simulator to Program Coordinate Measuring Machines when Common Programming Methods are difficult to apply

    G?ska, A.; Szewczyk, D.; G?ska, P.; Gruza, M.; S?adek, J.

    2014-02-01

    Nowadays, simulators facilitate tasks performed daily by the engineers of different branches, including coordinate metrologists. Sometimes it is difficult or almost impossible to program a Coordinate Measuring Machine (CMM) using standard methods. This happens, for example, during measurements of nano elements or in cases when measurements are performed on high-precision (accurate) measuring machines which work in strictly air-conditioned spaces and the presence of the operator in such room during the programming of CMM could cause an increase in temperature, which in turn could make it necessary to wait some time until conditions stabilize. This article describes functioning of a simulator and its usage during Coordinate Measuring Machine programming in the latter situation. Article also describes a general process of programming CMMs which ensures the correct machine performance after starting the program on a real machine. As an example proving the presented considerations, measurement of exemplary workpiece, which was performed on the machine working in the strictly air-conditioned room, was described

  2. Usage of I++ Simulator to Program Coordinate Measuring Machines when Common Programming Methods are difficult to apply

    Gąska A.

    2014-02-01

    Full Text Available Nowadays, simulators facilitate tasks performed daily by the engineers of different branches, including coordinate metrologists. Sometimes it is difficult or almost impossible to program a Coordinate Measuring Machine (CMM using standard methods. This happens, for example, during measurements of nano elements or in cases when measurements are performed on high-precision (accurate measuring machines which work in strictly air-conditioned spaces and the presence of the operator in such room during the programming of CMM could cause an increase in temperature, which in turn could make it necessary to wait some time until conditions stabilize. This article describes functioning of a simulator and its usage during Coordinate Measuring Machine programming in the latter situation. Article also describes a general process of programming CMMs which ensures the correct machine performance after starting the program on a real machine. As an example proving the presented considerations, measurement of exemplary workpiece, which was performed on the machine working in the strictly air-conditioned room, was described

  3. Radionuclides difficult to measure in waste packages. Final report

    In this study nuclide specific correlation analyses between key nuclides that can be easily measured and nuclides that are difficult to measure are presented. Data are taken from studies and data compilations from various countries. The results of this study can serve to perform assays of the nuclide specific radionuclide contents in waste packages by gamma measurements of 60Co and 137Cs and calculation of the contents of other nuclides via the correlation analyses, sometimes referred to as 'scaling factor method'. It can thus be avoided to have to take samples from the waste for separate analysis. An attempt is made to also investigate the physical and chemical backgrounds behind the proposed correlations. For example, a formation pathway common to the two nuclides to be correlated can be regarded as an explanation, if a good correlation is found. On the other hand, if the observed correlation is of poor quality, reasons may possibly lie in different behaviour of the two nuclides in the water system of the nuclear plant. This implies not only chemical solubility, transfer constants etc. in the water system, which would not only affect the proportionality between the two nuclides, but a different behavior in different parts of the water system must be assumed (e.g. different filter efficiencies etc). 47 refs, 57 figs, 40 tabs

  4. Nuclear energy and public opinion - a difficult relationship

    Nuclear energy remains an explosive subject. Less people demand to give up nuclear energy at once but the emotional and cognitive environment of attitudes to nuclear energy makes this relative 'peaceabilty' seem a very precarious issue. The Chernobyl shock is still active. The future will depend on whether new accidents will occur in nuclear power stations and how dangerous they will be. The highly political nature and the polarization of the subject together with an assumingly still negative coverage by the mass media and a general distrust of the people in established politics will make it very difficult to influence attitudes by means of information. We should attempt to bring sober facts and objectiveness to the discussion of nuclear energy and to involve citizens more actively than in the past while ensuring that there is less auto-selectivity (bias). What we also need is the basic and credible readiness of all participants to accept the results of a democratic process of the development of opinion. (orig./HSCH)

  5. Percutaneous lithotripsy for removing difficult bile duct stones using endoscopy

    To describe efficacy of percutaneous lithotripsy for removing difficult bile duct stones using endoscopy. A total of 88 patients with difficulties for the removal of bile duct stones using endoscopy (an impacted stone, stone size > 15 mm, intrahepatic duct (IHD) stone, stone size to bile duct diameter ratio > 1.0), were enrolled in this study. A 12 Fr sheath was inserted through the percutaneous transhepatic biliary drainage (PTBD) tract, and then nitrol stone baskets and a 0.035' snare wire were used to capture, fragment and remove the stones. The technical and clinical success rates were analyzed, together with an analysis of any complications. The overall technical success rate of stone removal was achieved in 79 of 88 patients (89.8%). In five of nine patients with failed stone removal, small residual IHD stones were noted on a cholangiogram. Even if stone removal failed in these cases, cholangitic symptoms were improved and the drainage catheter was successfully removed. Therefore, clinical success was achieved in 84 of 88 patients (95.5%). There were no significant procedure-related complications, except for sepsis in one case. Billiary stone removal using the stone basket and guide-wire snare technique through the PTBD tract is a safe and effective procedure that can be used as a primary method in patients with difficulties for the removal of bile duct stones using endoscopy

  6. Percutaneous lithotripsy for removing difficult bile duct stones using endoscopy

    Kim, See Hyung; Sohn, Chul Ho; Kim, Young Hwan [Dongsan Medical Center, Keimyung University College of Medicine, Daegu (Korea, Republic of)

    2008-03-15

    To describe efficacy of percutaneous lithotripsy for removing difficult bile duct stones using endoscopy. A total of 88 patients with difficulties for the removal of bile duct stones using endoscopy (an impacted stone, stone size > 15 mm, intrahepatic duct (IHD) stone, stone size to bile duct diameter ratio > 1.0), were enrolled in this study. A 12 Fr sheath was inserted through the percutaneous transhepatic biliary drainage (PTBD) tract, and then nitrol stone baskets and a 0.035' snare wire were used to capture, fragment and remove the stones. The technical and clinical success rates were analyzed, together with an analysis of any complications. The overall technical success rate of stone removal was achieved in 79 of 88 patients (89.8%). In five of nine patients with failed stone removal, small residual IHD stones were noted on a cholangiogram. Even if stone removal failed in these cases, cholangitic symptoms were improved and the drainage catheter was successfully removed. Therefore, clinical success was achieved in 84 of 88 patients (95.5%). There were no significant procedure-related complications, except for sepsis in one case. Billiary stone removal using the stone basket and guide-wire snare technique through the PTBD tract is a safe and effective procedure that can be used as a primary method in patients with difficulties for the removal of bile duct stones using endoscopy.

  7. The Barnes case: taking difficult futility cases public.

    Mickelsen, Ruth A; Bernstein, Daniel S; Marshall, Mary Faith; Miles, Steven H

    2013-01-01

    Futility disputes are increasing and courts are slowly abandoning their historical reluctance to engage these contentious issues, particularly when confronted with inappropriate surrogate demands for aggressive treatment. Use of the judicial system to resolve futility disputes inevitably brings media attention and requires clinicians, hospitals, and families to debate these deep moral conflicts in the public eye. A recent case in Minnesota, In re Emergency Guardianship of Albert Barnes, explores this emerging trend and the complex responsibilities of clinicians and hospital administrators seeking to replace an unfaithful surrogate demanding aggressive therapy. Use of the courts requires the coordinated commitment of significant institutional resources, management of intense media scrutiny and individual and organizational courage to enter the unpredictable world of litigation. Given the dearth of legislative guidance on medical futility, individual clinicians and institutions will continue to bear the difficult responsibility for resolution of individual futility disputes. The Barnes case illustrates how one institution successfully used the judicial system to replace an unfaithful surrogate, cease the provision of inappropriate aggressive care, and stimulate a community dialogue about appropriate care at the end of life. PMID:23581679

  8. Abatacept in difficult-to-treat juvenile idiopathic arthritis

    Jasmin B Kuemmerle-Deschner

    2009-02-01

    Full Text Available Jasmin B Kuemmerle-Deschner1, SM Benseler21Pediatric Rheumatology Clinics, Dept of Pediatrics, University Hospital Tbingen, Germany; 2Dept of Pediatric Rheumatology, The Hospital for Sick Children, Toronto, CanadaAbstract: Juvenile idiopathic arthritis (JIA is the most common chronic rheumatic disease in children and an important cause of short-term and long-term disability. Gene changes in the immune system can predispose to JIA and regulation of the immune system is crucial in the pathogenesis. The goal of therapy is complete disease control using disease-modifying antirheumatic drugs (DMARDS. Activated T-cells may play a role in the immunopathology of JIA. Therefore, targeting T-cell activation is a rational approach for the treatment of JIA. Abatacept (ABA, a selective co-stimulation modulator, has been shown to be effective in treating all JIA subtypes and is generally safe and well tolerated in JIA. Neutralizing antibodies were found in 6/9 (67% of seropositive patients, but anti-ABA antibodies did not appear to be associated with disease flare, serious adverse events, acute infusional adverse events, hypersensitivity, autoimmune disorders, or low ABA serum concentrations. Anti-ABA antibodies were more frequent when ABA concentrations were below therapeutic levels. Although information on ABA in JIA is still limited, available data suggest a potential role in difficult to treat JIA patients previously treated with other biologic agents and for non-responders to TNF-blockade.Keywords: abatacept, juvenile idiopathic arthritis (JIA, biologics

  9. Bronchogenic Cyst in a Patient with Difficult Asthma

    Soheil Ben Razavi

    2010-03-01

    Full Text Available Difficult to treat asthma is an asthma syndrome that brings in our mind other differentials. Mediastinal masses are not common findings, but are important variables. Bronchogenic cyst is a congenital anomaly of the foregut that is typically found in the mediastinum and diagnosed accidentally. We present a 4-year-old girl with allergic asthma that began at 8-months of age and finally a bronchogenic cyst was detected in this patient. The patient had history of asthma since she was eight months old. She had a history of several asthma attacks which had partly responded to asthma management. During the last episodes of asthma attacks, she was hospitalized in Pediatric Intensive Care Unit. Imaging studies showed a 4×3 cm mass in the posterior part of the thoracic cavity that had led to tracheal narrowing was found for which the patient underwent thoracotomy and in surgical exploration a cyst that had compressed the thoracic trachea. Pathological examination of the cyst revealed a bronchogenic cyst. Bronchogenic cyst is an uncommon developmental abnormality but in a patient with obstructive pattern of airways it should be considered in differential diagnosis of asthma, especially if the asthma management is not successful.

  10. Precut sphincterotomy: A reliable salvage for difficult biliary cannulation

    Ulku Saritas

    2013-01-01

    Full Text Available Even experienced endoscopists have 90% success in achieving deep biliary cannulation with standard methods. Biliary cannulation may become difficult in 10%-15% of patients with biliary obstruction and precut (access sphincterotomy is frequently chosen as a rescue treatment in these cases. Generally, precut sphincterotomy ensures a rate of 90%-100% successful deep biliary cannulation. The precut technique has been performed as either a fistulotomy with a needle knife sphincterotome or as a transpapillary septotomy with a standard sphincterotome. Both methods have similar efficacy and complication rates when administered to the proper patient. Although precut sphincterotomy ensures over 90% success of biliary cannulation, it has been characterized as an independent risk factor for pancreatitis. The complications of the precut technique are not limited to pancreatitis. Two more important ones, bleeding and perforation, are also reported in some publications as being observed more commonly than during standard sphincterotomy. It is also reported that precut sphincterotomy increases morbidity when performed in patients without dilatation of their biliary tract. Nevertheless, precut sphincterotomy is a good alternative as a rescue method in the setting of a failed standard cannulation method. This paper discusses the technical details, timing, efficacy and potential complications of precut sphincterotomy.

  11. Atrophic Vaginitis in Breast Cancer Survivors: A Difficult Survivorship Issue

    Joanne Lester; Gaurav Pahouja; Barbara Andersen; Maryam Lustberg

    2015-01-01

    Management of breast cancer includes systematic therapies including chemotherapy and endocrine therapy can lead to a variety of symptoms that can impair the quality of life of many breast cancer survivors. Atrophic vaginitis, caused by decreased levels of circulating estrogen to urinary and vaginal receptors, is commonly experienced by this group. Chemotherapy induced ovarian failure and endocrine therapies including aromatase inhibitors and selective estrogen receptor modulators can trigger ...

  12. Why is it so difficult to measure big G?

    Faller, James

    2015-04-01

    The determination of the Newtonian constant of gravitation, big G, continues to be one of Nature's greatest challenges to the skills and cunning of experimental physicists. The reasons: Big G is small, scientists are human, and error budgets are flawed. In spite of the fact that on the scale of the Universe, big G's effects are so big as to single handedly hold everything together, on the scale of a single research laboratory, big G's effects are so small that they go unnoticed. And, it is this ``smallness'' that makes the determination of this (seemingly unrelated to the rest of physics) fundamental constant so difficult. Furthermore, because they are human, scientists want to get the ``right'' (read previously obtained) answer; and this goal can affect their otherwise good judgment. Finally, error budgets are fundamentally flawed because they cannot make allowances for error sources that have not been thought of. During its nearly 300 year measurement history, the accuracy with which G is known has barely increased by three orders of magnitude; during the past 30 years the progress, measured by agreement rather than claimed accuracy of individual measurements, has been essentially zero. Nevertheless, this Mount Everest of precision measurement continues to provide an experimental challenge upon which metrologists can hone their laboratory skills for generations to come. Finally, this presentation will be understandable and interesting for ``students of all ages.'' In this year of GR100, Einstein will be mentioned more than once, and my hope is that some of you who would not normally ``risk'' attending a talk outside of your own specialty or discipline will consider coming to this one.

  13. Prediction is difficult, preparation is critical and possible

    Zilli, Romano; Dalton, Luke; Ooms, Wim; Schobesberger, Hermann; Imberechts, Hein; Egan, John; Møller, Kristian; 'Astiz, Susanna; Black, Peter; Renwick, Shane; Nunn, Mike; Bagni, Marina

    2014-01-01

    Problem Statement: Animal disease challenges appear to be ever increasing with new and emerging conditions rapidly becoming global problems due to factors such as climate change and globalisation of trade. Avian Influenza, Ebola, African Swine Fever and Porcine Epidemic Diarrhoea are just a few of the many transboundary diseases for which global cooperation in research is vital. These diseases can cause serious social, economic and environmental damage and in some cases also threaten human he...

  14. Including All the Lines

    Kurucz, Robert L.

    2009-01-01

    I present a progress report on including all the lines in the linelists, including all the lines in the opacities, including all the lines in the model atmosphere and spectrum synthesis calculations, producing high-resolution, high-signal-to-noise atlases that show (not quite) all the lines, so that finally we can determine the properties of stars from a few of the lines.

  15. Topical therapy with high-volume budesonide nasal irrigations in difficult-to-treat chronic rhinosinusitis

    Eduardo Macoto Kosugi

    2016-04-01

    Full Text Available ABSTRACT INTRODUCTION: Chronic rhinosinusitis (CRS is termed difficult-to-treat when patients do not reach acceptable level of control despite adequate surgery, intranasal corticosteroid treatment and up to 2 short courses of systemic antibiotics or corticosteroids in the preceding year. Recently, high-volume corticosteroid nasal irrigations have been recommended for CRS treatment. OBJECTIVE: To assess high-volume budesonide nasal irrigations for difficult-to-treat CRS. METHODS: Prospective uncontrolled intervention trial. Participants were assessed before- and 3 months after nasal irrigation with 1 mg of budesonide in 500 mL of saline solution daily for 2 days. Subjective (satisfactory clinical improvement and objective (SNOT-22 questionnaire and Lund-Kennedy endoscopic scores assessments were performed. RESULTS: Sixteen patients were included, and 13 (81.3% described satisfactory clinical improvement. SNOT-22 mean scores (50.2-29.6; p = 0.006 and Lund-Kennedy mean scores (8.8-5.1; p = 0.01 improved significantly. Individually, 75% of patients improved SNOT-22 scores, and 75% improved Lund-Kennedy scores after high volume budesonide nasal irrigations. CONCLUSION: High-volume corticosteroid nasal irrigations are a good option in difficult-to-treat CRS control of disease, reaching 81.3% success control and significant improvement of SNOT-22 and Lund-Kennedy scores.

  16. [Inadequate management of a difficult airway. Case SENSAR of the trimester].

    2015-01-01

    A clinical case reported to SENSAR is presented (www.sensar.org). A patient came to the operating room for surgery for parathyroidectomy. She had several predictors of difficult airway management, including a story of difficulties in previous intubations in other hospitals, as the patient reported. Therefore, after evaluation in preoperative consultation, fibreoptic bronchoscopy intubation was recommended. The day of surgery after induction of general anesthesia direct laryngoscopy was performed, without recognizing any glottic structure (Cormack-Lehane grade iv). Conventional laryngoscope was changed to a videolaryngoscope (Airtraq()) to try to improve the laryngoscopic view, but there were difficulties with handling and insertion of it, causing minor injuries to the lingual mucosa. Finally, tracheal intubation was achieved after several attempts. Analysis of the incident revealed the active error due to lack of experience of the professional who performed intubation maneuvers, favored by latent factors or contributors as were the complex pathology of the patient and the absence of protocols to difficult airway management in the hospital. Communication and analysis of this incident served to highlight the importance of the security protocols in Anesthesia, and as a result a working group that conducted the current algorithm approach to a difficult airway management was formed, established guidelines for further information patient and deals since clinical training and professional practice for the management of airway devices availables in the hospital. PMID:25766373

  17. Segmental Darier's disease: a presentation of difficult diagnosis.

    Medeiros, Paula Mota; Alves, Natália Ribeiro de Magalhães; Trujillo, Jeniffer Muñoz; Silva, Cássia Camarinha da; Faria, Paula Carolina Pessanha de; Silva, Roberto Souto da

    2015-01-01

    Darier's disease is a rare autosomal dominant genodermatosis. It has an estimated prevalence of 1 in 55,000 to 100,000 individuals, regardless of gender. It is characterized by multiple keratotic papules on the seborrheic areas of the trunk, scalp, forehead and flexures, and the clinical picture is worsened by heat, sun exposure, perspiration and mechanical trauma. Histopathology observed loss of epithelial adhesion and abnormal keratinization. About 10% of cases present in the localized form of the disease. We report a case of segmental Darier's Disease Type I and discuss the main characteristics of this condition. PMID:26312676

  18. Segmental Darier's disease: a presentation of difficult diagnosis*

    Medeiros, Paula Mota; Alves, Natália Ribeiro de Magalhães; Trujillo, Jeniffer Muñoz; da Silva, Cássia Camarinha; de Faria, Paula Carolina Pessanha; da Silva, Roberto Souto

    2015-01-01

    Darier's disease is a rare autosomal dominant genodermatosis. It has an estimated prevalence of 1 in 55,000 to 100,000 individuals, regardless of gender. It is characterized by multiple keratotic papules on the seborrheic areas of the trunk, scalp, forehead and flexures, and the clinical picture is worsened by heat, sun exposure, perspiration and mechanical trauma. Histopathology observed loss of epithelial adhesion and abnormal keratinization. About 10% of cases present in the localized form of the disease. We report a case of segmental Darier's Disease Type I and discuss the main characteristics of this condition. PMID:26312676

  19. Pump apparatus including deconsolidator

    Sonwane, Chandrashekhar; Saunders, Timothy; Fitzsimmons, Mark Andrew

    2014-10-07

    A pump apparatus includes a particulate pump that defines a passage that extends from an inlet to an outlet. A duct is in flow communication with the outlet. The duct includes a deconsolidator configured to fragment particle agglomerates received from the passage.

  20. Atrophic Vaginitis in Breast Cancer Survivors: A Difficult Survivorship Issue

    Joanne Lester

    2015-03-01

    Full Text Available Management of breast cancer includes systematic therapies including chemotherapy and endocrine therapy can lead to a variety of symptoms that can impair the quality of life of many breast cancer survivors. Atrophic vaginitis, caused by decreased levels of circulating estrogen to urinary and vaginal receptors, is commonly experienced by this group. Chemotherapy induced ovarian failure and endocrine therapies including aromatase inhibitors and selective estrogen receptor modulators can trigger the onset of atrophic vaginitis or exacerbate existing symptoms. Symptoms of atrophic vaginitis include vaginal dryness, dyspareunia, and irritation of genital skin, pruritus, burning, vaginal discharge, and soreness. The diagnosis of atrophic vaginitis is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Lifestyle modifications can be helpful but are usually insufficient to significantly improve symptoms. Non-hormonal vaginal therapies may provide additional relief by increasing vaginal moisture and fluid. Systemic estrogen therapy is contraindicated in breast cancer survivors. Continued investigations of various treatments for atrophic vaginitis are necessary. Local estrogen-based therapies, DHEA, testosterone, and pH-balanced gels continue to be evaluated in ongoing studies. Definitive results are needed pertaining to the safety of topical estrogens in breast cancer survivors.

  1. What Makes Biology Learning Difficult and Effective: Students' Views

    Cimer, Atilla

    2012-01-01

    The present study aims to determine the biological topics that students have difficulties learning, the reasons why secondary school students have difficulties in learning biology, and ways to improve the effectiveness of students' biology learning. For these purposes, a self-administered questionnaire including three open-ended questions was

  2. What Makes Biology Learning Difficult and Effective: Students' Views

    Cimer, Atilla

    2012-01-01

    The present study aims to determine the biological topics that students have difficulties learning, the reasons why secondary school students have difficulties in learning biology, and ways to improve the effectiveness of students' biology learning. For these purposes, a self-administered questionnaire including three open-ended questions was…

  3. The difficult transition to national health insurance in Bulgaria

    Bistra Vladimirova Datzova

    2006-01-01

    Health sector reform in Bulgaria aims to enhance sector efficiency, increase resources allocated to the health sector and target public resources to the most cost-effective interventions. The health system is however currently being changed in two directions-social and commercial. Transition processes in health include the simultaneous creation of market-based behaviour of all participants in the health market, and the establishment of a national social insurance system that should prevent so...

  4. Sea Ice Prediction Has Easy and Difficult Years

    Hamilton, Lawrence C.; Bitz, Cecilia M.; Blanchard-Wrigglesworth, Edward; Cutler, Matthew; Kay, Jennifer; Meier, Walter N.; Stroeve, Julienne; Wiggins, Helen

    2014-01-01

    Arctic sea ice follows an annual cycle, reaching its low point in September each year. The extent of sea ice remaining at this low point has been trending downwards for decades as the Arctic warms. Around the long-term downward trend, however, there is significant variation in the minimum extent from one year to the next. Accurate forecasts of yearly conditions would have great value to Arctic residents, shipping companies, and other stakeholders and are the subject of much current research. Since 2008 the Sea Ice Outlook (SIO) (http://www.arcus.org/search-program/seaiceoutlook) organized by the Study of Environmental Arctic Change (SEARCH) (http://www.arcus.org/search-program) has invited predictions of the September Arctic sea ice minimum extent, which are contributed from the Arctic research community. Individual predictions, based on a variety of approaches, are solicited in three cycles each year in early June, July, and August. (SEARCH 2013).

  5. Prediction is difficult, preparation is critical and possible

    Zilli, Romano; Dalton, Luke; Ooms, Wim; Schobesberger, Hermann; Imberechts, Hein; Egan, John; Møller, Kristian; 'Astiz, Susanna; Black, Peter; Renwick, Shane; Nunn, Mike; Bagni, Marina

    Problem Statement: Animal disease challenges appear to be ever increasing with new and emerging conditions rapidly becoming global problems due to factors such as climate change and globalisation of trade. Avian Influenza, Ebola, African Swine Fever and Porcine Epidemic Diarrhoea are just a few of...... the many transboundary diseases for which global cooperation in research is vital. These diseases can cause serious social, economic and environmental damage and in some cases also threaten human health. Various social, technological, economic, environmental, political and biological driving forces...... act at the level of the source of infection, transmission pathways, and the outcomes. Changes to such challenges and uncertainties are inevitable and foresight in identifying strategies is required for us to prepare for a sustainable future. The EU-funded Global Network on Infectious Diseases of...

  6. The Dounreay silver destruction process for difficult organic wastes

    State disposal of organic waste is a requirement throughout the chemical process industry, incineration being used both in the nuclear sector to reduce the volume of some low-level radioactive contaminated wastes before storage and in the non-nuclear sector along with landfill methods. The problem of the ultimate disposal of radioactivity contaminated organic wastes, particularly those containing actinides, has not been resolved however, and the incineration of organic industrial wastes has been shown to result in the formation of even more toxic substances under less than perfectly controlled conditions. This paper reports on the UKAEA at Dounreay. which has been developing a process to treat intractable plutonium dioxide and solvent from the nuclear fuel reprocessing plants

  7. Asthma of difficult handling, not all that hiss is asthma

    The paper tries about a patient of masculine sex 13 years old who consults initially for square that begins in February of 1999, consistent in cough, breathlessness and difficulty to breathe, he consults to one hospital where it is managed with beta two micronebulized, corticoids endovenous and oxygen being obtained improvement, reason why they give exit. Three days later he consults again for similar square; receiving the same treatment; a week later he presents cough and severe breathing difficulty, for that again consult and he is remitted to the Hospital San Rafael (Bogota) for no-improvement of the square. The paper includes the antecedents, exams, clinical evolution and paraclinics

  8. Risk Factors for and Prediction of a Difficult Neuraxial Block

    Stendell, Line; Lundstrøm, Lars H; Wetterslev, Jørn; Itenov, Theis S; Rosenstock, Charlotte V

    2015-01-01

    DNB. METHODS: A consecutive cohort of 73,579 patients was retrieved. A predefined DNB score and information on patient-related and organizational factors were included in the analyses. Logistic regression analysis was performed. We evaluated the diagnostic accuracy of an accumulated weighted point...... score of the patient-related risk factors of DNB. RESULTS: The prevalence of DNB and abandoned neuraxial block was 3.9 (95% confidence interval [95% CI], 3.7-4.0) and 0.2 (95% CI, 0.16-0.22), respectively. Body mass index of 35 or higher and previous DNB were associated with DNB, with 3.23 (95% CI, 2...

  9. Biogenic hardparts: Difficult archives of the geological past (Invited)

    Immenhauser, A.; Schone, B. R.; Hoffmann, R.; Niedermayr, A.

    2013-12-01

    Biomineralized exo- or endoskeletons of fossil marine invertebrates are widespread and diverse components of the Phanerozoic rock record of Earth's past and present oceans. Exoskeletons serve as protection against environmental pressure or predators, whilst endoskeletons can act as support or serve as an attachment for muscles and ligaments and hence as a mechanism for transmitting muscular forces. Biogenic hard parts represent sophisticated products resulting from the hierarchical interaction of inorganic minerals (95%) and macromolecular organic matrices, forming commonly less than 5%. The significance of many biogenic carbonate archives lies in the time-resolved growth patterns and their ability to record ambient environmental conditions in the form of multiple geochemical properties (multi-proxy archives) that have been widely used to assess past oceanic seawater properties. Here, we compile and review published work dealing with crystallization pathways of skeletal hard parts secreted by mollusks (i.e., bivalves and cephalopods) as well as brachiopods as widely used archives of ancient neritic epeiric settings. Bivalves and cephalopods (e.g., extinct ammonoids and belemnites and extant Sepia, Nautilus and Spirula) all form accretionary calcitic, aragonitic or vateritic skeletal hard parts. Despite the fact that mollusks and brachiopods form part of very different branches of the animal phylogenetic tree, their biomineralization strategies are surprisingly similar. Our main focus lies in a critical assessment of the complex pathways of ions and aquo-complexes from their source (seawater) to the final product (biomineral). We do this as an attempt to critically test the commonly held hypothesis that many fossil hard parts precipitated (under favorable conditions and pending subsequent diagenetic alteration) in equilibrium with seawater. Two main observations stand out: (1) the present knowledge on pathways and mechanisms (e.g., ion channel trans-membrane or endocytosis and vesicle transport, precursor mineralogies etc.) is surprisingly incomplete and in many cases based on descriptive rather than mechanistic approaches; (2) in analogy to all metazoans, biomineralization processes of mollusks and brachiopods are complex and involve different mechanisms for different elements. The combined uptake of specific elements both from inorganic and metabolic sources represents a major problem. Despite all of these problems, field experiments document that these biominerals respond to the aquatic geochemistry and the physical properties (temperature, salinity, pH etc.) of their environment, albeit in a more complex manner than conventionally assumed. Significant advances in multi-proxy research, however, require a more holistic view of the physico-chemical and biological processes involved. The present contribution represents a first tentative step towards this goal.

  10. Newer trends in the management of psoriasis at difficult to treat locations: Scalp, palmoplantar disease and nails

    Handa Sanjeev

    2010-01-01

    Full Text Available Psoriasis is a common, chronic, inflammatory disease with a wide range of clinical presentations. The disease severity ranges from mild to severe. Plaque type of psoriasis is the most common. A number of factors like previous treatment history and comorbid conditions influence the treatment of psoriasis in an individual patient. Location of the lesions is also an important consideration. Psoriasis localized to certain areas of the body like scalp, nails, palms and soles remains difficult to treat. These sites have been referred to as the difficult locations in literature. This article covers the management of psoriasis limited to these special areas.

  11. Difficult-to-treat-pediatric Crohn's disease: focus on adalimumab

    Zeisler B

    2015-04-01

    Full Text Available Bella Zeisler, Jeffrey S Hyams Division of Digestive Diseases, Hepatology, and Nutrition, Connecticut Children's Medical Center Hartford, University of Connecticut School of Medicine, Department of Pediatrics, Farmington, CT, USA Abstract: Adalimumab is a fully humanized anti-tumor necrosis factor alpha monoclonal antibody that was recently granted regulatory approval in the USA for the treatment of moderate to severe Crohn’s disease (CD in children. Like infliximab, the first biologic agent used to treat pediatric CD, regulatory approval was secured many years following approval for adults. The long delay between adult and pediatric approval has led to many years of off-label use of adalimumab, although it is anticipated that the use of adalimumab may further increase with official regulatory approval. To date, pediatric literature on the use of adalimumab for treatment of CD is limited, and pediatric practitioners have mostly extrapolated from research and experience provided by the adult literature. The aim of this paper is to review the literature regarding adalimumab for the treatment of pediatric CD, and includes a review of landmark adult studies as well as the pivotal pediatric study that facilitated regulatory approval. We also discuss the role of anti-tumor necrosis factor alpha agents including adalimumab in the current treatment paradigm for pediatric CD. Keywords: pediatrics, Crohn's disease, adalimumab, biologic agent

  12. The Lula Government’s First Year: The Difficult Transition

    Sonia Fleury

    2004-05-01

    Full Text Available In this article, the author analyses the first year of Luiz Inácio Lula da Silva’s Government and highlights the importance of this Government for the process of democratic consolidation in Brazil. The contradiction between maintaining an orthodox economic policy and the expectations of creating conditions for development and social inclusion have marked the first year of this Government, subordinating all public policies to the logic of controlling inflation, paying off public debt, and increasing credibility in the international market. The reality of this macroeconomic policy and the costs imposed on the Brazilian society reveal the discrepancies between the financial economy and the real economy. The public policies of the Lula Government have been marked by economic restrictions and conflicts between the different forces that make up the governing coalition. The Government introduced innovative measures with the creation of different channels of participation and social agreement. In 2004, the Government will have to confront the challenges involved in going from a monetarist policy to a policy ofdevelopment and distribution of income.

  13. Radioactivity [includes radioactivity levels

    The Environmental Digest for Wales is prepared on a regular basis by the Welsh Office and brings together data on the Welsh environment from a number of sources. Most of the information contained in the tables is collected as part of continuous monitoring programmes and will be updated in future editions. Some tables contain information collected only once as part of a survey or study, and will not be included in future volumes of the series. The section on Radioactivity includes tables of concentration in air, rainwater, milk, fish and gives details of the liquid radioactive wastes discharged from Welsh nuclear power stations (at Wylfa and Trawsfynydd) and the gamma dose rates around Welsh nuclear power stations. An appendix includes a glossary of terms used, the units of radioactivity and a list of radionuclides present in the environment. (author)

  14. Radiocarbon Dating of Difficult Samples: Natural and Laboratory Effects

    Radiocarbon dating by accelerator mass spectrometry (AMS) is routine in many laboratories around the world. The applications of 14C measurements based on the nuclide produced in the atmosphere are vast and generally easy to interpret, as the 14C value at the time of initial incorporation to the material is established. Clearly, the initial assumptions of the 14C composition are important. However, certain types of samples including bones, sediments, and lacustrine samples present special problems, since the basic assumptions can be different. These assumptions need to be treated carefully. We also encounter similar questions in the initial 14C when the nuclide is incorporated into rock surfaces or meteorites in space by direct “in situ” production of 14C in the silicate. In this talk, I will highlight some examples of these problems using some specific examples. (author)

  15. Distraction during learning with hypermedia: difficult tasks help to keep task goals on track.

    Scheiter, Katharina; Gerjets, Peter; Heise, Elke

    2014-01-01

    In educational hypermedia environments, students are often confronted with potential sources of distraction arising from additional information that, albeit interesting, is unrelated to their current task goal. The paper investigates the conditions under which distraction occurs and hampers performance. Based on theories of volitional action control it was hypothesized that interesting information, especially if related to a pending goal, would interfere with task performance only when working on easy, but not on difficult tasks. In Experiment 1, 66 students learned about probability theory using worked examples and solved corresponding test problems, whose task difficulty was manipulated. As a second factor, the presence of interesting information unrelated to the primary task was varied. Results showed that students solved more easy than difficult probability problems correctly. However, the presence of interesting, but task-irrelevant information did not interfere with performance. In Experiment 2, 68 students again engaged in example-based learning and problem solving in the presence of task-irrelevant information. Problem-solving difficulty was varied as a first factor. Additionally, the presence of a pending goal related to the task-irrelevant information was manipulated. As expected, problem-solving performance declined when a pending goal was present during working on easy problems, whereas no interference was observed for difficult problems. Moreover, the presence of a pending goal reduced the time on task-relevant information and increased the time on task-irrelevant information while working on easy tasks. However, as revealed by mediation analyses these changes in overt information processing behavior did not explain the decline in problem-solving performance. As an alternative explanation it is suggested that goal conflicts resulting from pending goals claim cognitive resources, which are then no longer available for learning and problem solving. PMID:24723907

  16. Distraction during learning with hypermedia: Difficult tasks help to keep task goals on track

    KatharinaScheiter

    2014-03-01

    Full Text Available In educational hypermedia environments, students are often confronted with potential sources of distraction arising from additional information that, albeit interesting, is unrelated to their current task goal. The paper investigates the conditions under which distraction occurs and hampers performance. Based on theories of volitional action control it was hypothesized that interesting information, especially if related to a pending goal, would interfere with task performance only when working on easy, but not on difficult tasks. In Experiment 1, 66 students learned about probability theory using worked examples and solved corresponding test problems, whose task difficulty was manipulated. As a second factor, the presence of interesting information unrelated to the primary task was varied. Results showed that students solved more easy than difficult probability problems correctly. However, the presence of interesting, but task-irrelevant information did not interfere with performance. In Experiment 2, 68 students again engaged in example-based learning and problem solving in the presence of task-irrelevant information. Problem-solving difficulty was varied as a first factor. Additionally, the presence of a pending goal related to the task-irrelevant information was manipulated. As expected, problem-solving performance declined when a pending goal was present during working on easy problems, whereas no interference was observed for difficult problems. Moreover, the presence of a pending goal reduced the time on task-relevant information and increased the time on task-irrelevant information while working on easy tasks. However, as revealed by mediation analyses these changes in overt information processing behavior did not explain the decline in problem-solving performance. As an alternative explanation it is suggested that goal conflicts resulting from pending goals claim cognitive resources, which are then no longer available for learning and problem solving.

  17. Difficult to swallow: patient preferences for alternative valproate pharmaceutical formulations

    Monali Bhosle

    2009-06-01

    Full Text Available Monali Bhosle,1 Joshua S Benner,1 Mitch DeKoven,1 Jeff Shelton21Health Economics and Outcomes Research, IMS Health Inc, Falls Church, VA, USA; 2Answers and Insights Market Research, Inc, Indianapolis, IN, USAObjective: To determine the degree to which swallowing valproate (VP tablets is an issue, the proportion of patients who would prefer an alternative formulation, and the predictors of preference.Methods: A quantitative telephone survey of eligible adults (n = 400, ≥18 years old who currently take (n = 236 or previously took (n = 164 VP tablets within the past 6 months was conducted.Results: More than half of the patients indicated that VP tablets were ‘uncomfortable to swallow’ (68.5%, n = 274 and were ‘very interested’ (65.8%, n = 263 in medications that were easier to swallow. When choosing conceptually between taking VP tablet once/day or an equally safe and effective but significantly smaller soft gel capsule twice per day, the 82.8%, (n = 331 preferred the soft gel capsule. In the multivariate regression analysis, perceiving soft gel capsules to be easier to swallow (OR = 73.54; 95% CI = 15.01 to 360.40 and taking VP more frequently (OR = 2.02; 95% CI = 1.13 to 3.61 were significant predictors of soft gel capsule treatment preference.Conclusion: VP users would prefer a formulation that is easier to swallow, even if it is needed to be taken twice per day. When choosing between medications with similar efficacy and safety, physicians can consider patient preferences to optimize conditions for medication adherence.Keywords: patient preference, valproate formulations, tablet characteristics

  18. Why Is the Overheating Problem Difficult: the Role of Entropy

    Liou, Meng-Sing

    2013-01-01

    The development of computational fluid dynamics over the last few decades has yielded enormous successes and capabilities being routinely employed today; however there remain some open problems to be properly resolved-some are fundamental in nature and some resolvable by operational changes. These two categories are distinguished and broadly explored previously. One, that belongs to the former, is the so-called overheating problem, especially in rarefying flow. This problem up to date still dogs every method known to the author; a solution to it remains elusive. The study in this paper concludes that: (1) the entropy increase is quantitatively linked to the increase in the temperature increase, (2) it is argued that the overheating is inevitable in the current shock capturing or traditional finite difference framework, and (3) a simple hybrid method is proposed that removes the overheating problem in the rarefying problems, but also retains the property of accurate shock capturing. This remedy (enhancement of current numerical methods) can be included easily in the present Eulerian codes.

  19. Difficult OptEase Filter Retrievals After Prolonged Indwelling Times

    PurposeThe OptEase vena cave filter (Cordis, Piscataway, NJ) is commercially available as a retrievable or permanent filter with short recommended indwelling time, presumably due to extensive contact of the filter side struts with the inferior vena cava wall and subsequent neointimal hyperplasia leading to incorporation. Our purpose was to evaluate OptEase filter retrievals with a long indwelling time period that required unconventional retrieval techniques.Materials and MethodsWe retrospectively reviewed patients who underwent OptEase filter retrieval with long undwelling times requiring additional maneuvers for retrieval. Techniques used included rigid endobronchial forceps dissection and wire-through-loop snare. Each patient underwent postretrieval venogram to evaluate for possible complications. In addition, patients had clinical follow-up 2 weeks after the retrieval procedure.ResultsThere were three patients (2 women, 1 man; average age 64 years) who underwent OptEase filter retrieval. The mean indwelling time was 6.4 months. The indwelling filters were successfully retrieved. There were no complications. Postprocedural follow-up showed no clinical pathology.ConclusionUnconventional techniques aided in the retrieval of OptEase filters with long indwelling times

  20. Difficult OptEase Filter Retrievals After Prolonged Indwelling Times

    Van Ha, Thuong G., E-mail: tgvanha@radiology.bsd.uchicago.edu; Kang, Lisa; Lorenz, Jonathan; Zangan, Steven; Navuluri, Rakesh; Straus, Christopher; Funaki, Brian [University of Chicago, Section of Interventional Radiology, Department of Radiology (United States)

    2013-08-01

    PurposeThe OptEase vena cave filter (Cordis, Piscataway, NJ) is commercially available as a retrievable or permanent filter with short recommended indwelling time, presumably due to extensive contact of the filter side struts with the inferior vena cava wall and subsequent neointimal hyperplasia leading to incorporation. Our purpose was to evaluate OptEase filter retrievals with a long indwelling time period that required unconventional retrieval techniques.Materials and MethodsWe retrospectively reviewed patients who underwent OptEase filter retrieval with long undwelling times requiring additional maneuvers for retrieval. Techniques used included rigid endobronchial forceps dissection and wire-through-loop snare. Each patient underwent postretrieval venogram to evaluate for possible complications. In addition, patients had clinical follow-up 2 weeks after the retrieval procedure.ResultsThere were three patients (2 women, 1 man; average age 64 years) who underwent OptEase filter retrieval. The mean indwelling time was 6.4 months. The indwelling filters were successfully retrieved. There were no complications. Postprocedural follow-up showed no clinical pathology.ConclusionUnconventional techniques aided in the retrieval of OptEase filters with long indwelling times.

  1. Analytic device including nanostructures

    Di, Fabrizio, E.

    2015-07-02

    A device for detecting an analyte in a sample comprising: an array including a plurality of pixels, each pixel including a nanochain comprising: a first nanostructure, a second nanostructure, and a third nanostructure, wherein size of the first nanostructure is larger than that of the second nanostructure, and size of the second nanostructure is larger than that of the third nanostructure, and wherein the first nanostructure, the second nanostructure, and the third nanostructure are positioned on a substrate such that when the nanochain is excited by an energy, an optical field between the second nanostructure and the third nanostructure is stronger than an optical field between the first nanostructure and the second nanostructure, wherein the array is configured to receive a sample; and a detector arranged to collect spectral data from a plurality of pixels of the array.

  2. Scabies Vaccine is Required, but Difficult to be Made

    Simson Tarigan

    2007-03-01

    Full Text Available Sarcoptes scabiei, the mite causing scabies, infests human and at least 40 species of animals. The losses associated with the disease as a public health burden and economic losses are enormous because its prevalence is very high. The current available control by treating individuals diagnosed to have the disease is both ineffective and unpractical. Besides, dissatisfaction with the pharmacological control is escalating due to the development of resistance in the mites and rejection by consumers for animals products contaminated with drug residues. Vaccination is considered to be most the attractive alternative control although the availability of vaccine is still a long way off. Control of scabies by vaccination is considered to be feasible since animals recovered from the disease posses protective immunity against mite reinfestation. In addition, despite the fact that the mites reside not deeper than the unvascularised stratum corneum and they are not blood sucking parasites, they do ingest their host immunoglobulin. Vaccine for scabies, as for other ectoparasitic diseases, includes subunit vaccine developed from mite protective antigen produced by recombinant technology. Identification of sarcoptic protective antigen which comprise the first step in the vaccine development impede by the lability and low abundance of the protective antigen, and the difficulty in obtaining sufficient amount of mites. Identification of sarcoptic protective antigen by conventional biochemical technique, although the technique has been successful for other parasites, has been unsatisfactory for S. scabiei. Identifying the protective antigen just among proteins having vital functions in the survival of mites and accessible by the effector arms of the host immune system seems to be a more feasible alternative. The allergens and membrane proteins lining the digestive tract of the mites seem to fulfil the criteria.

  3. Sugammadex use in difficult intubation due to ankylosing spondylitis and severe restrictive respiratory disease

    Yakup Tomak

    2012-09-01

    Full Text Available We describe anesthesia management of a 50-year-old man scheduled for thoracic spinal reconstruction, presenting with severe restrictive respiratory disease and difficult airway due to ankylosing spondilitis. The patient was unable to extend his head, had difficulty in breathing and sleeping in supine position due to thoracal deformities. The patient was intubated using intubating laryngeal mask airway to overcome the difficulties of limited mouth opening and head extension. He was extubated following administration of sugammadex to obtain optimal conditions in terms of respiratory muscle function and to prevent hypersecretion and bronchospasm. J Clin Exp Invest 2012; 3 (3: 398-400Key words: Restrictive lung disease, airway management, laryngeal masks, sugammadex, ankylosing spondylitis

  4. Diversity of life. Effects of power generation and transmission on biodiversity difficult to assess

    Hongisto, M.; Nikula, A.

    1996-11-01

    Scientific theories do not necessarily enable us to forecast the consequences of our actions on wildlife. Presumably, nature is able to adapt to environmental changes through variations on the genetic, species and ecosystem level; i.e. by means of biodiversity. The first studies conducted within the electricity sector show that the effects of emissions form an individual power plant on biodiversity are extremely difficult to assess because of long-range dispersion of the emission and many other factors simultaneously acting on the environment. Some concrete information about the impact of power transmission lines on biodiversity was obtained. These effects were primarily reversible. Some transmission line zones may even have favourable effects on biodiversity and on the living conditions of certain endangered species. (orig.)

  5. Diversity of life. Effects of power generation and transmission on biodiversity difficult to assess

    Scientific theories do not necessarily enable us to forecast the consequences of our actions on wildlife. Presumably, nature is able to adapt to environmental changes through variations on the genetic, species and ecosystem level; i.e. by means of biodiversity. The first studies conducted within the electricity sector show that the effects of emissions form an individual power plant on biodiversity are extremely difficult to assess because of long-range dispersion of the emission and many other factors simultaneously acting on the environment. Some concrete information about the impact of power transmission lines on biodiversity was obtained. These effects were primarily reversible. Some transmission line zones may even have favourable effects on biodiversity and on the living conditions of certain endangered species. (orig.)

  6. Initial clinical assessment of a novel multifunctional topical ointment for difficult-to-heal wounds: a case series.

    Reyzelman, Alexander M; Bazarov, Irina

    2012-12-01

    Chronic wounds are characterized by prolonged inflammation, bacterial bioburden, and ischemia. These factors represent the barriers to wound healing that need to be addressed in order to achieve wound closure. The authors performed the initial clinical testing of WinVivo Wound Ointment ("WinVivo"), a novel topical ointment containing several botanicals that have been previously shown to promote favorable wound environment and advance wound healing. In this series of 13 patients with difficult-to-heal lower-extremity wounds, WinVivo was well tolerated and demonstrated the ability to simultaneously support granulation tissue formation; decrease the amount of exudate, edema, and malodor; and reduce pain. The ulcers included in this study have been present for a minimum of 3 weeks and a maximum of 5 years prior to the start of treatment with WinVivo. Eight of 13 wounds have previously been treated with at least 1 type of advanced wound healing modality, such as dermal substitutes or negative-pressure wound therapy. Treatment with WinVivo lasted for 3 to 12 weeks and resulted in a mean 88% wound closure, with 4 wounds healing completely. In addition to significant reduction in wound size, all patients have exhibited other clinical benefits, suggesting overall improvement in wound conditions. Future studies in a larger population, as well as case-control studies comparing WinVivo with a standard of care, are therefore warranted to further evaluate the efficacy of this new treatment. PMID:23151766

  7. A Qualitative Study of the Types and Characteristics of Difficult Patrons in University Libraries

    Chen Su-may Sheih

    2009-12-01

    Full Text Available The phrase “difficult patron” is often associated with troubles and habitually abnormal behavior from patrons. From the viewpoint of organization, the existence of difficult patrons might signal dissatisfaction with services, collections, facilities, or with specific individual librarians. But difficult patron’s complaints may also be regarded as valuable opportunities to improve customer service and satisfaction. Hence, for the circulation librarians, learning how to interact with difficult patrons is quite important. This article reports findings from a qualitative study which investigated types and behavioral characteristics of difficult patrons in university libraries in Taiwan. Semi-structured interviewing method was used to investigate 23 circulation librarians’ experiences with difficult patrons. Based on the findings, this article discusses why some patrons are difficult as well as service strategies for dealing with difficult patrons in university libraries.

  8. Disarming Contankerous People: Coping with Difficult Personalities in ECE Work Settings

    Hernandez, Luis; Smith, Connie Jo

    2009-01-01

    Difficult personalities come in a variety of roles in just about every setting. While types have been identified in the typical corporate and business culture, difficult work personalities also inhabit the world of early childhood education (ECE) workplaces. Because difficult people have an impact on workplace morale and productivity, the topic…

  9. Difficult times

    Grunwald, Markus

    2012-11-01

    Silicon and wafer prices continue to plunge. Traditional solar markets cooling off and global overcapacities are the reasons, say market analysts at IMS Research. While the situation is becoming serious for many wafer manufacturers, the major suppliers of silicon have been able to keep up their production volumes.

  10. Easy and Difficult Performance-Approach Goals: Their moderating effect on the link between task interest and performance attainment

    Monica Blaga

    2008-06-01

    Full Text Available The purpose of this study was to demonstrate that the positive link between task interest and performance attainment can be negatively affected by the pursuit of difficult performance-approach goals. This was tested in a sample of 60 undergraduate students at a Dutch university. In line with expectations, for difficult performance-approach goals there was no link between task interest and performance attainment. Furthermore, among women this relation turned out to be negative. In an easy performance-approach goal condition, a positive link between task interest and performance attainment was found for both men and women, while in the control condition the same expected positive relation was not found. Theoretical and practical implications of these findings are discussed.

  11. Newer trends in the management of psoriasis at difficult to treat locations: Scalp, palmoplantar disease and nails

    Handa Sanjeev

    2010-01-01

    Psoriasis is a common, chronic, inflammatory disease with a wide range of clinical presentations. The disease severity ranges from mild to severe. Plaque type of psoriasis is the most common. A number of factors like previous treatment history and comorbid conditions influence the treatment of psoriasis in an individual patient. Location of the lesions is also an important consideration. Psoriasis localized to certain areas of the body like scalp, nails, palms and soles remains difficult to t...

  12. Statistical optimization of gold recovery from difficult leachable sulphide minerals using bacteria

    Ahmed, Hussin A.M. [King Abdulaziz Univ., Jeddah (Saudi Arabia). Mining Engineering Dept.; El-Midany, Ayman A. [King Saud Univ., Riyadh (Saudi Arabia)

    2012-07-01

    Some of refractory gold ores represent one of the difficult processable ores due to fine dissemination and interlocking of the gold grains with the associated sulphide minerals. This makes it impossible to recover precious metals from sulphide matrices by direct cyanide leaching even at high consumption of cyanide solution. Research to solve this problem is numerous. Application of bacteria shows that, some types of bacteria have great affect on sulphides bio-oxidation and consequently facilitate the leaching process. In this paper, leaching of Saudi gold ore, from Alhura area, containing sulphides before cyanidation is studied to recover gold from such ores applying bacteria. The process is investigated using stirred reactor bio-leaching rather than heap bio-leaching. Using statistical analysis the main affecting variables under studied conditions were identified. The design results indicated that the dose of bacteria, retention time and nutrition K{sub 2}SO{sub 4} are the most significant parameters. The higher the bacterial dose and the bacterial nutrition, the better is the concentrate grade. Results show that the method is technically effective in gold recovery. A gold concentrate containing > 100 g/t gold was obtained at optimum conditions, from an ore containing < 2 g/t gold i.e., 10 ml bacterial dose, 6 days retention time, and 6.5 kg/t K{sub 2}SO{sub 4}as bacteria nutrition. (orig.)

  13. An alternative method to achieve one-lung ventilation by surgical pneumothorax in difficult lung isolation patient: a case report.

    Yeh, Pin-Hung; Hsu, Po-Kai

    2016-04-01

    It is challenging to establish one-lung ventilation in difficult airway patients. Surgical pneumothorax under spontaneous breathing to obtain well-collapsed lung is a feasible method for thoracic surgery. A 76-year-old man with right empyema was scheduled for decortication. The patient had limited mouth opening due to facial cellulitis extending from the left cheek to neck. Generally, lung isolation is achieved by double-lumen endotracheal tube or bronchial blocker. Double-lumen tube insertion is difficult for patients with limited mouth opening and right-side placement of bronchial blocker usually causes insufficient deflation. We introduce an alternative lung isolation technique by surgical pneumothorax under spontaneous breathing simply with an endotracheal tube placement. This technique has never been applied into the management of difficult one-lung ventilation. By this method, we provide an ideal surgical condition with safer, less time-consuming, and less skill-demanding anesthesia. It would be an alternative choice for management of one-lung ventilation in the difficult lung isolation patient. PMID:26721826

  14. Difficult embryo transfers or blood on catheter and assisted reproductive outcomes: a systematic review and meta-analysis.

    Phillips, James A S; Martins, Wellington P; Nastri, Carolina O; Raine-Fenning, Nicholas J

    2013-06-01

    We performed a systematic review and meta-analysis to examine whether a difficult embryo transfer or the presence of blood on the transfer catheter affects assisted reproduction outcomes. We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). We aimed to determine the risk ratio (RR) associated with difficult embryo transfer or the presence of blood on the transfer catheter for the following outcomes: live birth, clinical pregnancy, and miscarriage. We identified 3066 papers, of which 194 were reviewed and nine were included. The outcome of live birth was not reported in any of the included studies and the effect on miscarriage was too imprecise for any conclusions. Pooled analysis of five studies demonstrated lower clinical pregnancy rates following a non-easy embryo transfer (RR=0.75; 95% CI=0.66-0.86). This included three studies showing subjectively difficult transfers reducing clinical pregnancies (RR=0.67; 95% CI=0.51-0.87) and two studies in which the need for additional manoeuvers reduced clinical pregnancies (RR=0.78; 95% CI=0.67-0.91). The presence of blood on the transfer catheter did not affect clinical pregnancy rates (RR=0.96; 95% CI=0.82-1.14) in five studies. We concluded that low quality evidence suggests that a difficult embryo transfer but not a bloody catheter reduces the chance of achieving a clinical pregnancy. More good quality studies are needed to evaluate the effect of difficult embryo transfer and the presence of blood on the catheter on the main outcomes of assisted reproduction. PMID:23347607

  15. Otolith morphometrics distinguish difficult species of rockfishes in the Gulf of Alaska

    Jeremy P Harris

    2015-12-01

    Full Text Available The oceans around Alaska are home to at least 40 species of rockfishes (Sebastidae. A number of these species are commercially important and are subject to strict catch limitations. However, regulators are hindered by the fact that some species are difficult to distinguish based on external characteristics and can only be conclusively identified using genetics. The rougheye (S. aleutianus and blackspotted (S. melanostictus rockfishes are one such example. Survey evidence suggests that these species segregate by depth, and that the shallower blackspotted is more prevalent in the fishery, raising concern that managing the species as a mixed stock might mask detrimental effects to the blackspotted population. This study examines otolith shape and morphometric analysis as tools for distinguishing these closely related species. Seven hundred and thirty-eight rockfish specimens were collected, their identity verified via genetic analysis, and their ages read. We then analyzed the data using several procedures including simple morphometrics and non-dimensional shape indices. We found that simple logistic regression across eight parameters was sufficient to correctly identify the species for more than 90% of the specimens. The use of shape indices did not improve prediction accuracy, but did eliminate allometric correlations among the predictor variables, which may be useful in some cases. A crucial aspect of the analysis is the inclusion of interactions with age in the model, which improved discrimination success. This may suggest an unrecognized difference in the growth rates of these species. Overall, we are capable of predicting species identity with fewer than 5% errors, which is sufficient to allow for separate management plans for the species. As such, we recommend that otolith stock discrimination techniques like these could provide an easy and effective way to discriminate many difficult-to-identify stocks, and further recommend that age data may be a useful addition to standard morphometric analyses.

  16. Difficult conversations: teaching medical oncology trainees communication skills one hour at a time.

    Epner, Daniel E; Baile, Walter F

    2014-04-01

    Difficult conversations about prognosis, end of life, and goals of care arise commonly in medical oncology practice. These conversations are often highly emotional. Medical oncologists need outstanding, patient-centered communication skills to build trust and rapport with their patients and help them make well-informed decisions. Key skills include exploring patients' perspectives, responding to emotion with empathy, and maintaining mindfulness during highly charged conversations. These skills can be taught and learned. Most previously described communication skills training curricula for oncology providers involve multiday retreats, which are costly and can disrupt busy clinical schedules. Many curricula involve a variety of oncology providers, such as physicians and nurses, at various stages of their careers. The authors developed a monthly, one-hour communication skills training seminar series exclusively for physicians in their first year of medical oncology subspecialty training. The curriculum involved a variety of interactive and engaging educational methods, including sociodramatic techniques, role-play, reflective writing, and Balint-type case discussion groups. Medical oncologists in their second and third years of training served as teaching assistants and peer mentors. Learners had the opportunity to practice skills during sessions and with patients between sessions. Learners acquired important skills and found the curriculum to be clinically relevant, judging by anonymous surveys and anonymous responses on reflective writing exercises. Results from the current curriculum are preliminary but lay the foundation for enhanced and expanded communication skills training programs in the future. PMID:24556763

  17. Difficult action decisions reduce the sense of agency: A study using the Eriksen flanker task.

    Sidarus, Nura; Haggard, Patrick

    2016-05-01

    The sense of agency refers to the feeling that we are in control of our actions and, through them, of events in the outside world. Much research has focused on the importance of retrospectively matching predicted and actual action outcomes for a strong sense of agency. Yet, recent studies have revealed that a metacognitive signal about the fluency of action selection can prospectively inform our sense of agency. Fluent, or easy, action selection leads to a stronger sense of agency over action outcomes than dysfluent, or difficult, selection. Since these studies used subliminal priming to manipulate action selection, it remained unclear whether supraliminal stimuli affecting action selection would have similar effects. We used supraliminal flankers to manipulate action selection in response to a central target. Experiment 1 revealed that conflict in action selection, induced by incongruent flankers and targets, led to reduced agency ratings over an outcome that followed the participant's response, relative to neutral and congruent flanking conditions. Experiment 2 replicated this result, and extended it to free choice between alternative actions. Finally, Experiment 3 varied the stimulus onset asynchrony (SOA) between flankers and target. Action selection performance varied with SOA. Agency ratings were always lower in incongruent than congruent trials, and this effect did not vary across SOAs. Sense of agency is influenced by a signal that tracks conflict in action selection, regardless of the visibility of stimuli inducing conflict, and even when the timing of the stimuli means that the conflict may not affect performance. PMID:27017411

  18. [A difficult to treat case of malignant peritoneal mesothelioma with peritoneal metastasis].

    Ojima, Toshihiko; Takai, Yuuki; Yamazaki, Keisuke; Kamata, Toru; Kanno, Masahiro

    2013-11-01

    A 57-year-old man presented with abdominal discomfort. A computed tomography (CT) scan revealed a tumor, with a maximum diameter of approximately 5 cm, in the transverse mesocolon near the splenic flexure as well as a small nodular shadow suggestive of peritoneal dissemination on the greater omentum. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed marked accumulations of FDG at the same sites. Laparoscopic examination revealed an elastic hard tumor, with a maximum diameter of slightly over 5 cm, at the posterior sheath of the transverse mesocolon and a small nodule on the greater omentum with apparent dissemination. Since radical surgery was considered to be difficult to perform, we only resected the disseminated nodule for diagnostic purposes. The final pathological diagnosis was biphasic- type (mixed epithelial and sarcomatoid type) malignant mesothelioma arising from the peritoneum. Approximately 20 days postoperatively, the patient received combination therapy with pemetrexed and cisplatin with a 3-week interval between the courses. Image assessment after completion of the third course revealed enlargement of the tumor mass and worsening of the peritoneal dissemination. Therefore, the treatment was switched to paclitaxel, which has been reported to be effective as a second-line therapy. The drug was scheduled to be administered on days 1, 8, and 15. However, after the first course on day 1, the patient's condition gradually deteriorated and he subsequently died. PMID:24394145

  19. Reducing the Burden of Difficult-to-Treat Major Depressive Disorder: Revisiting Monoamine Oxidase Inhibitor Therapy

    Culpepper, Larry

    2013-01-01

    Objective: Difficult-to-treat depression (eg, depression with atypical or anxious symptoms, treatment-resistant depression, or depression with frequent recurrence) is a challenging real-world health issue. This critical review of the literature focuses on monoamine oxidase inhibitor (MAOI) therapy and difficult-to-treat forms of depression.

  20. Identifying and Investigating Difficult Concepts in Engineering Mechanics and Electric Circuits. Research Brief

    Streveler, Ruth; Geist, Monica; Ammerman, Ravel; Sulzbach, Candace; Miller, Ronald; Olds, Barbara; Nelson, Mary

    2007-01-01

    This study extends ongoing work to identify difficult concepts in thermal and transport science and measure students' understanding of those concepts via a concept inventory. Two research questions provided the focal point: "What important concepts in electric circuits and engineering mechanics do students find difficult to learn?"…

  1. The Study of Difficult Temperament: A Reply to Kagan, Rothbart, and Plomin.

    Thomas, Alexander

    1982-01-01

    Based on comments by Kagan (1982), Rothbart (1982), and Plomin (1982) in response to an article on difficult temperament by Thomas, Chess, and Korn (1982), the author concludes that the study of temperamentally difficult children has a favorable prognosis. (Author/MP)

  2. The predictors of difficult tracheal intubations in patients undergoing thyroid surgery for euthyroid goitre

    To evaluate the influence of goitre on anatomic features and the correlation of these changes with difficulty in intubation. Methods: A questionnaire was employed to assess 139 patients scheduled for elective surgery of euthyroid goitre to predict the potential of difficult intubation. These measurements were later correlated with the patients who eventually had difficult intubations. Neck circumference, mouth width, lip test, sternomental distance, thymomental distance, Mallampati score and laryngeal palpation were evaluated. Results: All predictors were found to be significant as single predictors but on logistic regression analysis it was found that the circumference of the neck alone, was the independent predictor for difficult intubation. Conclusion: Neck thickness in patients with goitre is a significant predictor of difficult intubation and should be used in preoperative assessment to anticipate difficult intubations. (author)

  3. Difficult laryngoscopy and intubation in the Indian population: An assessment of anatomical and clinical risk factors

    Smita Prakash

    2013-01-01

    Full Text Available Background and Aim: Differences in patient characteristics due to race or ethnicity may influence the incidence of difficult airway. Our purpose was to determine the incidence of difficult laryngoscopy and intubation, as well as the anatomical features and clinical risk factors that influence them, in the Indian population. Methods: In 330 adult patients receiving general anaesthesia with tracheal intubation, airway characteristics and clinical factors were determined and their association with difficult laryngoscopy (Cormack and Lehane grade 3 and 4 was analysed. Intubation Difficulty Scale score was used to identify degree of difficult laryngoscopy. Results: The incidence of difficult laryngoscopy and intubation was 9.7% and 4.5%, respectively. Univariate analysis showed that increasing age and weight, male gender, modified Mallampati class (MMC 3 and 4 in sitting and supine positions, inter-incisor distance (IID ?3.5 cm, thyromental (TMD and sternomental distance, ratio of height and TMD, short neck, limited mandibular protrusion, decreased range of neck movement, history of snoring, receding mandible and cervical spondylosis were associated with difficult laryngoscopy. Multivariate analysis identified four variables that were independently associated with difficult laryngoscopy: MMC class 3 and 4, range of neck movement <80, IID ? 3.5 cm and snoring. Conclusions: We found an incidence of 9.7% and 4.5% for difficult laryngoscopy and difficult intubation, respectively, in Indian patients with apparently normal airways. MMC class 3 and 4, range of neck movement <80, IID ? 3.5 cm and snoring were independently related to difficult laryngoscopy. There was a high incidence (48.5% of minor difficulty in intubation.

  4. A Comparison of Cormeck-Lehane and Mallampati Tests with Mandibular and Neck Measurements for Predicting Difficult Intubation

    Niyazi Acer

    2011-06-01

    Full Text Available Objective: Various prediction tests were formulated to forecast difficult intubation. The Mallampati test, Wilson score, Cormack-Lehane test and thyromental distance are the most commonly used tests pre-operatively to assess the airway. The objective of the present study was to investigate whether a combination of the Mallampati and Cormack-Lehane’s classification to predict difficult intubation compared with sternomental and thyromental distances, mandibular length, width and neck length and circumference. Material and Methods: Two hundred twenty seven cases between 17 and 70 years old undergoing elective surgery were included in the study. Age, gender, body weight, body height and BMI were noted preoperatively. The pharyngeal structures were examined before the operation. At the time of intubation, laryngoscopic evaluation was performed according to the Cormack-Lehane’s laryngoscopic classification.Results: For analysis, Mallampati and Cormack-Lehane’s laryngoscopic classification were grouped as difficult (grades III and IV or easy (grades I and II. Whereas Mallampati scoring were class 1 and 2 (easy in 72.7% cases, Cormack-Lehane’s laryngoscopic scoring 90.7% of the cases were in class 1 and 2. The combination of the Cormeck-Lehane classification with neck circumference had the highest sensitivity (94.74%, but this combination decreased the positive predictive value. The combination of the Mallampati classification with neck length had the highest sensitivity (67.86%, but this combination decreased the positive predictive value.Conclusion: The findings suggest that the Mallampati and Cormeck-Lehane classification by itself is insufficient for predicting difficult intubation so should be used in conjunction with measurement of neck circumference and Cormeck-lehane test. Mallampati test with sternomental and thyromental distances in addition with neck length may be useful in routine test for preoperative prediction of difficult intubation.

  5. Lung Disease Including Asthma and Adult Vaccination

    ... Vaccine Finder . Lung Disease including Asthma and Adult Vaccination Recommend on Facebook Tweet Share Compartir Vaccines are ... have immunity to this disease Learn about adult vaccination and other health conditions Asplenia Diabetes Type 1 ...

  6. Kenyan women adult literacy learners: Why their motivation is difficult to sustain

    Mwiria, Kilemi

    1993-05-01

    Women comprise more than seventy per cent of those enrolled in the Kenya literacy programme. The reasons for this include: the limited formal educational opportunities available to females; the demands of a changing economy which have forced women to acquire extra responsibilities outside the home; the socializing opportunity made possible by literacy class attendance; flexible work schedules; and cultural beliefs which in some Kenyan communities discourage men from enrolling in the same literacy classes as women. Women literacy learners may find it difficult to sustain their interest in literacy learning because of: their multiple responsibilities; having to operate in environments not particularly conducive to learning; having to contend with professionally unqualified teachers; their limited exposure to reading materials and other learning aids; their very limited mastery of the two languages of official communication in Kenya; as well as the fact that the literacy programme is mainly administered by men. Although changes at the wider societal level still will, to the most part, determine the extent of women's participation in the Kenyan literacy programme, much could be accomplished through involving more of them in the programme's administration and by improving the quality of literacy instruction.

  7. A Delayed Complication of Temporal Craniotomy Leading to a Potentially Difficult Airway.

    Rayadurg, Vivek; Bhadrinarayan, V; Gopalakrishna, K N; Savardekar, Amey

    2016-04-01

    Pseudoankylosis of the temporomandibular joint may occur as a complication of frontotemporal craniotomy. We report a patient who presented for surgery with a restricted mouth opening resulting from an infectious complication after frontotemporal craniotomy. Early identification of the potentially difficult airway helped manage this patient. We explain the mechanism of this late complication that may result in a difficult airway. If this is not identified preoperatively when a patient presents for emergency surgery or when the patient is in altered sensorium, it may lead to an unanticipated difficult airway. PMID:26825991

  8. Observational Study of Topical Imiquimod Immunotherapy in the Treatment of Difficult Lentigo Maligna

    E.E. Craythorne

    2008-01-01

    Full Text Available Lentigo Maligna (LM typically presents at sun-exposed sites in elderly patients as an asymmetric, slow-growing, irregularly pigmented macule with an irregular indented border. With changes in sun exposure behaviour LM is becoming more prevalent in middle-aged and younger adults.1The risk of melanoma developing in LM increases with duration of the disease and therefore age,2 and is difficult to quantify, estimates range from 2.2%2 to 50%3 over a lifetime, once invasive disease is established, the tumour carries the same prognosis as other types of cutaneous malignant melanoma as defined by Breslow thickness and presence of ulceration.LM presents a difficult clinical problem and generally there is little consensus on the optimum form of management. The recommended guidelines for treatment of LM are surgical excision with excision margins into clinically normal skin of 25 mm.4,5 Others have suggested that up to 20% of cases of LM would require margins greater than this.6 However, lesions are commonly large and located on cosmetically important head and neck sites. Excision may result in a poor cosmetic outcome and it is dif? cult to justify this approach when the risk of malignant transformation may well be low. Amelanotic lentigo maligna also remains a signi? cant problem and inevitably results in incomplete excision since clinical identi? cation of disease extent is impossible.7Non-surgical treatment options are used in 50% of U.K. patients over the age of 70, these include radiotherapy, retinoids,8 5-FU and azelaic acid. Cryotherapy, once popular, has fallen from favour because of reports of invasive melanoma occurring after cryotherapy ablation.9 Commonly a watch and wait policy is adopted.Imiquimod (Aldara, Meda Pharmaceuticals Ltd is a topical immune response modifier. The drug causes an increase in interferon locally and therefore may have a place in the management of superficial interferon sensitive malignancy. There are several reports of its use to treat lentigo maligna.10-12 We describe our experience with the use of imiquimod in a group of patients with LM on the head and neck where surgery was not an option.

  9. Sensitivity and noise in GC-MS: Achieving low limits of detection for difficult analytes

    Fialkov, Alexander B.; Steiner, Urs; Lehotay, Steven J.; Amirav, Aviv

    2007-01-01

    Gas chromatography-mass spectrometry (GC-MS) instrument limit of detection (LOD) is typically listed by major vendors as that of octafluoronaphthalene (OFN). Most current GC-MS instruments can achieve LODs in the low femtogram range. However, GC-MS LODs for realistic analytes in actual samples are often a few orders of magnitude higher than OFN's. Users seldom encounter 1 pg LOD in the single ion monitoring mode in their applications. We define this detectability difference as the "OFN gap." In this paper, we demonstrate and discuss how the OFN gap can be significantly reduced by the use of GC-MS with supersonic molecular beams (SMB). Experimental results were obtained with a recently developed GC-MS with SMB named 1200-SMB, that is based on the conversion of the Varian 1200 system into a GC-MS-MS with SMB. With this 1200-SMB system, the LOD of all types of analytes, including OFN, in real samples is significantly improved through the combination of: (a) enhanced molecular ion; (b) elimination of vacuum background noise; (c) elimination of mass independent noise; (d) elimination of ion source peak tailing and degradation; (e) significantly increased range of thermally labile and low volatility compounds that are amenable for analysis through lower sample elution temperatures; (f) reduced column bleed and ghost peaks through sample elution at lower temperatures; (g) improved compatibility with large volume injections; and (h) reduced matrix interferences through the combination of enhanced molecular ion and MS-MS. As a result, the 1200-SMB LODs of common and/or difficult compounds are much closer to its OFN LOD, even in complex matrices. We crossed the permethrin, >400 for methomyl, and >2000 for C32H66. In general, the harder the compound analysis, the greater is the gain in sample detectability using the 1200-SMB versus traditional GC-MS. Thus, the 1200-SMB lowers LOD, particularly for difficult analytes that are normally sacrificed in methods, and the detectability gains can amount to a few orders of magnitude over traditional GC-MS in real-world applications.

  10. Condition Number Regularized Covariance Estimation.

    Won, Joong-Ho; Lim, Johan; Kim, Seung-Jean; Rajaratnam, Bala

    2013-06-01

    Estimation of high-dimensional covariance matrices is known to be a difficult problem, has many applications, and is of current interest to the larger statistics community. In many applications including so-called the "large p small n" setting, the estimate of the covariance matrix is required to be not only invertible, but also well-conditioned. Although many regularization schemes attempt to do this, none of them address the ill-conditioning problem directly. In this paper, we propose a maximum likelihood approach, with the direct goal of obtaining a well-conditioned estimator. No sparsity assumption on either the covariance matrix or its inverse are are imposed, thus making our procedure more widely applicable. We demonstrate that the proposed regularization scheme is computationally efficient, yields a type of Steinian shrinkage estimator, and has a natural Bayesian interpretation. We investigate the theoretical properties of the regularized covariance estimator comprehensively, including its regularization path, and proceed to develop an approach that adaptively determines the level of regularization that is required. Finally, we demonstrate the performance of the regularized estimator in decision-theoretic comparisons and in the financial portfolio optimization setting. The proposed approach has desirable properties, and can serve as a competitive procedure, especially when the sample size is small and when a well-conditioned estimator is required. PMID:23730197

  11. Difficult airway in a patient with H1N1 pneumonia in intensive care unit

    Meltem Türkay

    2014-12-01

    Full Text Available The difficult airway is a frequent problem among adult patients in intensive care unit. All critical patients should initially be evaluated as a potential difficult airway cases. Development of a serious desaturation should be considered since these patients have less physiological reserve compared to those with difficult airway due to elective surgery. Development of respiratory failure with H1N1 associated pneumonia is likely and support of intubation and mechanic ventilator shall be needed. The objective of this report is to present the management of a patient with H1N1 associated pneumonia who required intubation however could not be intubated due to difficult airway. J Clin Exp Invest 2014; 5 (4: 617-619

  12. Communicating Difficult and Taboo Information: A How-To Guide for Commanders.

    Moosey, Matthew

    2016-01-01

    Military commanders frequently mention that communicating difficult or taboo information is especially challenging. In the context of gender-integrated ground combat service there may be additional communication challenges for military commanders who may be unaccustomed to leading both men and women. Often, military commanders must communicate and deliver difficult information, or information that causes a negative emotional response from the communicator or the intended audience. This article is intended to identify some of these challenges and present practical examples and tips for military commanders to effectively communicate difficult or taboo topics and information. In addition, this article is a call for communication experts to reach out to military leaders and offer appropriate assistance in facilitating and delivering difficult communication. PMID:26741900

  13. Airway inflammation in children with difficult asthma: relationships with airflow limitation and persistent symptoms

    D. Payne(University of Liverpool); Qiu, Y.; Zhu, J.; Peachey, L; Scallan, M; Bush, A.; Jeffery, P

    2004-01-01

    Background: The effective management and development of new treatments for children with difficult asthma requires investigation of the underlying airway pathology and its relationships with persistent symptoms and airflow limitation.

  14. The Stanford Prison Experiment: Implications for the Care of the "Difficult" Patient.

    Onishi, So L; Hebert, Randy S

    2016-02-01

    Approximately 15% of patients are perceived by clinicians as "difficult." Early theories about difficult patients focused on patients' and clinicians' characteristics, often underemphasizing the influence of the environment on patients' behavior. The Stanford Prison Experiment, a classic experiment in the psychology of human behavior, provides a broader systems approach for understanding the environmental influences on patient behavior. A systems approach to the care of the difficult patient takes into consideration not only the patient's characteristics but also the health care environment and the more distal environments (ie, familial, societal, and cultural). Clinicians who are aware of the multilevel impact of these various environments on the behavior of patients are better equipped to understand, address, and hopefully even prevent difficult patient encounters. PMID:25248307

  15. Easy and difficult nasal intubation--a randomised comparison of Macintosh vs Airtraq laryngoscopes.

    St Mont, G; Biesler, I; Pfrtner, R; Mohr, C; Groeben, H

    2012-02-01

    A new Airtraq() laryngoscope has been developed for nasal intubation. We prospectively compared tracheal intubation efficiency of the Airtraq for nasotracheal intubation vs that of the Macintosh laryngoscope in 200 patients. Depending on pre-operative airway evaluation, the patients were allocated to expected easy (n = 100) or difficult (n = 100) intubation groups, on the basis of mouth opening ? 2.5 cm, modified Mallampati score of 4, history of difficult intubation, obvious tumour or swelling. Patients were randomly allocated to the Macintosh or nasotracheal Airtraq technique. All easy intubations were successfully performed with the respective technique. In the expected difficult intubation group, the success rate was higher (47/50 vs 33/50; p Airtraq compared with the Macintosh, respectively. For difficult nasal intubations, the nasotracheal Airtraq is more effective than the Macintosh laryngoscope. PMID:22251105

  16. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation.

    Malik, M A

    2009-11-01

    The purpose of this study was to determine the potential for the Pentax AWS and the Glidescope to reduce the difficulty of tracheal intubation in patients at increased risk for difficult tracheal intubation, in a randomized, controlled clinical trial.

  17. New Methodologies for Development of High Efficient Machining of Difficult to Cut Materials

    The article focuses on the automotive and aerospace industries. In these industries the need for enhanced materials performance is necessary if they are to remain competitive in global terms. Unfortunately the material properties, which make them so attractive to the aerospace and automotive industry can also make them difficult to machine. This paper will discuss integrated developments in machining techniques and cutting tools, which are emerging to cope with difficult to cut materials.

  18. Can donepezil facilitate weaning from mechanical ventilation in difficult to wean patients? An interventional pilot study

    Abbasi, Saeed; Farsaei, Shadi; Fazel, Kamran; Golzari, Samad EJ; Mahmoodpoor, Ata

    2015-01-01

    Background Management of difficult to wean patients is a dilemma for health care system. Recently published studies demonstrated efficacy of donepezil to counteract respiratory depression in sleep apnea. However, to the best of our knowledge, pharmaceutical interventions with donepezil to facilitate weaning have not been tested so far. Therefore in the present study, we evaluated the efficacy of using donepezil on weaning course in difficult to wean patients. Methods In this non-randomized in...

  19. Difficult intubation in a parturient with syringomyelia and ArnoldChiari malformation: Use of Airtraq laryngoscope

    Mustapha, Bensghir; Chkoura, K.; Elhassani, M.; Ahtil, R.; Azendour, H.; Kamili, N. Drissi

    2011-01-01

    Anesthetic technique in parturient with syringomyelia and ArnoldChiari malformation is variable depending on the teams. Difficult intubation is one of the risks when general anesthesia is opted. Different devices have been used to manage the difficult intubation in pregnant women. We report the use of Airtraq laryngoscope after failed standard laryngoscopy in a parturient with syringomyelia and ArnoldChiari type I malformation.

  20. Difficult airway management patterns among anesthesiologists practicing in Cairo University Hospitals

    Neamat I. Abdel rahman

    2016-01-01

    Conclusion: The practice of anesthesiologists in Cairo university hospitals is close to the recommendations of the ASA guidelines for management of difficult airway. There is increased skills in fiberoptic bronchoscopes and SGA with increased frequency of difficult airway managements training courses; however, they need to improve their skills in awake fiberoptic intubations technique and they need to be trained on invasive airway management access to close the discrepancy between their theoretical choices in different situations and their actual skills.

  1. The difficult patients in pain therapy: How to recognize and manage them

    Giuseppe De Benedittis

    2005-01-01

    When physicians experience negative reactions to patients, they often perceive the patients as "difficult". Such patients make up 15% to 30% of primary care practice populations. They are those whom most physicians dread. The dependency of difficult patients heavily influences the doctor-patient relationship and the outcome of the treatment. These patients often present with physical symptoms that could not be medically explained. Pain is the most frequent complaint, though unrecognized ps...

  2. Videolaryngoscopes: The solution for difficult airway management or just another strategy? Non-systematic review

    Katheryne Chaparro-Mendoza

    2015-07-01

    Full Text Available Introduction: Difficult airway management remains a challenge and is a pillar of anesthesia training. At present, unsuccessful management of the difficult airway is a leading cause of complications in the practice of anesthesia, something that has led to regular updates to the management algorithms and the development of new technologies. Objectives: To review the current state of videolaryngoscopy and its impact on difficult airway management. Methods: With the keywords Videotape Recording; Laryngoscopy; Airway Management; Intubation; Intratracheal; Obesity; Anesthesia. A non-systematic review in the following databases was conducted: Pubmed/Medline, SciElo, LILACS. Results: Videolaryngoscopes are a new technology for the management of difficult airways that so far have not replaced the standard airway management algorithm devices. Its main impact is better visualization of the laryngeal structures. However, there are still controversies regarding the ease and success of tracheal intubation. Evidence of its usefulness in difficult airway management is weak. Conclusion: Knowledge of these devices and their limitations is an alternative in difficult airway scenario, but its real value and safety for the patient is still not defined and continues to be researched.

  3. Advances in Rosetta structure prediction for difficult molecular-replacement problems

    Modeling advances using Rosetta structure prediction to aid in solving difficult molecular-replacement problems are discussed. Recent work has shown the effectiveness of structure-prediction methods in solving difficult molecular-replacement problems. The Rosetta protein structure modeling suite can aid in the solution of difficult molecular-replacement problems using templates from 15 to 25% sequence identity; Rosetta refinement guided by noisy density has consistently led to solved structures where other methods fail. In this paper, an overview of the use of Rosetta for these difficult molecular-replacement problems is provided and new modeling developments that further improve model quality are described. Several variations to the method are introduced that significantly reduce the time needed to generate a model and the sampling required to improve the starting template. The improvements are benchmarked on a set of nine difficult cases and it is shown that this improved method obtains consistently better models in less running time. Finally, strategies for best using Rosetta to solve difficult molecular-replacement problems are presented and future directions for the role of structure-prediction methods in crystallography are discussed

  4. STUDY OF VARIOUS MEASUREMENTS OF INTUBATION IN INFANTS AND THEIR CORRELATION WITH PREDICTION OF DIFFICULT INTUBATION

    Seema

    2016-03-01

    Full Text Available BACKGROUND & AIMS Several pre-operative screening tools are used in adult. Wide range of pediatric anatomical & developmental differences (especially with infants makes uses of adult clinical predictors in challenge. The aim of our study is to assess various measurements of intubation in infants and their correlation with difficult laryngoscopy. MATERIAL AND METHODS This prospective randomized study conducted in 100 infants. We assessed the usefulness of neck length (NL, neck circumference (NC, Head Circumference, (HC ratio of NC/NL and introduced length of laryngoscope blade as predictors of difficult laryngoscopy and intubation. RESULT NC, NL, HC and ratio of NC/NL were significantly associated with incidence of difficult laryngoscopy and intubation. As this ratio increases difficulty at laryngoscopy increases (p<.001. Difficult laryngoscopy was assessed using Cormack Lehane grading. We found as age increases laryngoscopy becomes easier. (p<0.05 CONCLUSION There is no single anatomical measurement of intubation in infants in our study we measured NC, NL, NC/NL, HC and introduced length of laryngoscope blade which were found to be important predictors of difficult laryngoscopy and intubation. Statistical significant correlation was found between age and Cormack Lehane grades. In infants, various congenital malformations are highly associated with difficult laryngoscopy and intubation.

  5. Frequency of difficult and failed intubation in apparently normal patients undergoing elective surgery

    To find the frequency of difficult and failed intubation in apparently normal patients undergoing elective surgery. We also aimed to look at sensitivity and specificity of Mallampatti classification in our population. Study Design: Cross sectional study. Place and Duration of Study: Combined Military Hospital, Rawalpindi and Multan from 1st May 2013 to 1st June 2013. Patients and Methods: There were 467 patients, who underwent elective surgery with general anesthesia and endotracheal intubation. During their pre-anesthetic visit, we assessed the airway according to Mallampatti score. After endotracheal intubations, frequency of difficult intubations was evaluated (i.e. Grade III and Grade IV) with special emphasis on intubation done by consultant anaesthetist and post graduate rainees followed by frequency of failure of intubation and other complications during intubation were also noted. Furthermore, comparison of Mallampatti with Cormack and Lehane's classification of difficult intubation was done. Results: Difficult intubation in these centers was 4.28% (20/467). Sensitivity of mallampatti was 98.2%. Incidence of failure of intubation was 0.42% in our study. Conclusion: The frequency of difficult intubation is 4.28% whereas failure of intubation is very low (0.42%) and was observed in special cases only. In our study, the sensitivity of Mallampatti to Cormack and Lehane's classification of intubation was 98.2% which suggests that it is a sensitive predictor of difficult intubation but complete accuracy cannot be determined by using the Mallampatti score. (author)

  6. RATIO OF PATIENTS HEIGHT TO THYROMENTAL DISTANCE ( RHTMD COMPARED TO THYROMENTAL DISTANCE FOR PREDICTION OF DIFFICULT INTUBATION

    Mohan

    2015-10-01

    Full Text Available BACKGROUND AND RATIONALE : Preoperative evaluation is important in the detection of patients at risk for difficult tracheal intubation. Thyromental distance (TMD is often used for these purposes, but its value as an indicator for difficult intubation is questionable, as it varies with patient size and body proportions. The purpose of the present study was to evaluate and compare the accuracies of th e Ratio o f Patient’s Height t o TMD (ratio of height to TMD=RHTMD, with TMD and Modified Mallampati classification (MP in the prediction of difficult tracheal intubation. OBJECTIVE : This study is an attempt in finding an airway index by making simple measurements to anticipate difficult airway and compare RHTMD with TMD and MP classification for predicting difficult airway. METHODS : 170 apparently normal ASA I & II patients who were u ndergoing elective surgeries under General Anaesthesia (GA were included in the study. The MP, TMD and RHTMD were determined in each patient preoperatively and Cormack – Lehane (CL grading was assessed during laryngoscopy. TMD ≤6.5cm, RHTMD > 25 and MP c lass III & IV were considered difficult intubation; these values were compared with CL grading. CL grade III&IV were considered as difficult intubation. The optimal predictive value was chosen using a receiver operating characteristic (ROC curve. The area s under the ROC curves (AUC of TMD and RHTMD were compared to determine the performance of the different predictive tests used. The sensitivity, specificity, and positive and negative predictive values of each of the predictive tests were calculated accor ding to standard formulae. RESULTS : Difficult intubation occurred in 6 out of 170 patients (3.5% in the study. The sensitivity of Modified Mallampati classification was 33.3% and specificity was 90.8%. The test has a positive predictive value of 11.7%, ne gative predictive value of 97.3% and overall accuracy of 88.8%. The sensitivity of TMD was 33.3% and specificity was 79.2%. The test has a positive predictive value of 5.5%, negative predictive value of 97% and overall accuracy of 77.6%. The sensitivity of RHTMD was 83.3% and specificity was 97.5%. The test has a positive predictive value of 55.5%, negative predictive value of 99.3% and overall accuracy of 97%. In our study the Area Under Curve (AUC of RHTMD was 0.87, it is significantly higher than TMD (0 .184 and MP test (0.726, indicating a more accurate prediction of RHTMD.A p value was calculated based on AUC, it shows that RHTMD had a higher and significantly better predictive value than MP classification and TMD with p value of 0.028. CONCLUSION : Th e Ratio of Height to Thyromental Distance has a better predictive value than Thyromental Distance and Modified mallampati classification. Ratio of Height to Thyromental Distance may represent a useful means of achieving a faster, simpler and more accurate predictor of difficult airway

  7. Utility of serum thymidine kinase activity measurements for cases of bovine leukosis with difficult clinical diagnoses.

    Tawfeeq, Mohammad Monir; Miura, Saori; Horiuchi, Noriyuki; Kobayashi, Yoshiyasu; Furuoka, Hidefumi; Inokuma, Hisashi

    2013-01-01

    This study evaluated the clinical usefulness of serum thymidine kinase (TK) activity for diagnosing bovine leukosis cases for which clinical diagnosis was difficult ('BL with difficult diagnosis'). Median TK activity values in 24 'BL with difficult diagnosis' and 36 cattle for which BL was clinically confirmed by cytology findings of enlarged superficial lymph nodes ('clinically confirmed BL') were 36.8 and 39.4 U/l, respectively (no significant difference). The percentage with positive TK activity (> 5.4 U/l) was also similar in both groups (83.3% for 'BL with difficult diagnosis' and 97.2% for 'clinically confirmed BL'). TK activity was significantly higher in cows with 'BL with difficult diagnosis' compared to those with other tumors (N = 13) and those with inflammatory diseases (N = 14). Maximum TK activity in cows with other tumors and inflammatory diseases was not high (cows with other tumors and those with inflammatory diseases were 1.8 and 1.4 IU/l, respectively. Positive TK activity was found in a significantly higher percentage of cows with 'BL with difficult diagnosis' (83.3%) relative to the percentages of cows with other tumors (15.3%) and inflammatory diseases (21.4%). Thus, TK activity is an appropriate marker for detecting BL onset in cows with 'BL with difficult diagnosis' as well as 'clinically confirmed BL' group. While the specificity of TK activity required for BL diagnosis is not clear, simultaneous evaluation of serum lactate dehydrogenase activity may assist in the differential diagnoses of other tumors and inflammatory diseases from BL. PMID:23628971

  8. Characterization methodology for Difficult To Measure nuclides in the Type B rad waste from the ITER

    Ji, Youngyong; Hong, Kwonpyo; Oh, Wanho; Kang, Munja; Na, Byungchan [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

    2012-10-15

    In general, it is not possible to directly detect beta rays from the rad waste in the field measurement due to their extremely low penetration through the materials. Only lab-scale measurements with proper shield and detecting system are available for the nondestructive assay. However, the disposal sites in many countries require the determination of inventories of the difficult to-measure (DTM) nuclides in the waste before their acceptance for disposal. Many sites that generate rad wastes thus are adapting the indirect method to characterize the DTM nuclides in the rad waste to be disposed. The rad waste from the operation of an international thermonuclear experimental reactor (ITER) will be sent to the hot cell building (HCB) after packing it to the basket and they are then treated into the disposal form as well as characterized through the nondestructive assay. The rad waste properties from the ITER are that high density material such as a steel, a copper, and a tungsten accounts for the main substance and many nuclides due to the neutron irradiation including the DTM nuclides exists in that waste. Therefore, the ITER is also facing with the problem for the characterization of DTM nuclides. The scaling factor for the radiological relationship between the gamma and the beta nuclides is one of the indirect measurements to characterize the DTM nuclides in the waste. The methodology of the scaling factor to apply this method to the characterization the Type B rad waste from the ITER are presented in this paper. There are several types of the in-vessel components (IVCs) in a Tokamak which will be activated by neutron and they will be divided into different types of the rad waste such as the divertor cassette, blanket module, and port plugs. In this paper, the characterization of DTM nuclides will be focused on the rad waste from a blanket module out of IVCs.

  9. Characterization methodology for Difficult To Measure nuclides in the Type B rad waste from the ITER

    In general, it is not possible to directly detect beta rays from the rad waste in the field measurement due to their extremely low penetration through the materials. Only lab-scale measurements with proper shield and detecting system are available for the nondestructive assay. However, the disposal sites in many countries require the determination of inventories of the difficult to-measure (DTM) nuclides in the waste before their acceptance for disposal. Many sites that generate rad wastes thus are adapting the indirect method to characterize the DTM nuclides in the rad waste to be disposed. The rad waste from the operation of an international thermonuclear experimental reactor (ITER) will be sent to the hot cell building (HCB) after packing it to the basket and they are then treated into the disposal form as well as characterized through the nondestructive assay. The rad waste properties from the ITER are that high density material such as a steel, a copper, and a tungsten accounts for the main substance and many nuclides due to the neutron irradiation including the DTM nuclides exists in that waste. Therefore, the ITER is also facing with the problem for the characterization of DTM nuclides. The scaling factor for the radiological relationship between the gamma and the beta nuclides is one of the indirect measurements to characterize the DTM nuclides in the waste. The methodology of the scaling factor to apply this method to the characterization the Type B rad waste from the ITER are presented in this paper. There are several types of the in-vessel components (IVCs) in a Tokamak which will be activated by neutron and they will be divided into different types of the rad waste such as the divertor cassette, blanket module, and port plugs. In this paper, the characterization of DTM nuclides will be focused on the rad waste from a blanket module out of IVCs

  10. Conditional Sampling for Max-Stable Random Fields

    Wang, Yizao

    2010-01-01

    Max-stable random fields play a central role in modeling extreme value phenomena. Their conditional distributions, however, are notoriously difficult to handle. This makes the prediction problem for such random fields a formidable challenge. Here, we obtain an explicit formula for the conditional probability in general max-linear models, which include a large class of max-stable random fields. As a consequence, we develop an algorithm for efficient and exact sampling from the conditional distributions. Our method provides a computational solution to the difficult prediction problem for max-stable random fields with discrete spectrum. This work offers new tools and a new perspective to many statistical inference problems for spatial extremes, arising, for example, in meteorology, geology, and environmental applications. The results are illustrated with simulated and real data.

  11. The 'difficult' nurse-patient relationship: development and evaluation of an e-learning package.

    Brunero, Scott; Lamont, Scott

    2010-06-01

    Nurses in most clinical settings experience difficult 'nurse patient relationships' at various times. Attempts to describe and articulate how to manage such difficult relationships can be found, but often lay blame at the patient level and ultimately leave the nurse less confident to improve patient care. This study uses an action research approach in working with nurses in a generalist setting in developing an educational strategy that helped to improve their knowledge, skills and confidence in working within the 'difficult nurse patient relationship' paradigm. Through the experiential style learning methodology of scenario based learning and applying this via e-learning, an effective educational approach has been developed. Using a quasi-experimental design to evaluate the e-learning package, significant increases in knowledge, skill, confidence and reduced nurse stress as measured on the 'difficult patient stress scale' were shown. This approach allows nurses to reflect on their own behaviour and improve their ability to enhance patient care in difficult to manage nursing care situations. PMID:20950195

  12. The difficult patients in pain therapy: How to recognize and manage them

    Giuseppe De Benedittis

    2005-05-01

    Full Text Available When physicians experience negative reactions to patients, they often perceive the patients as "difficult". Such patients make up 15% to 30% of primary care practice populations. They are those whom most physicians dread. The dependency of difficult patients heavily influences the doctor-patient relationship and the outcome of the treatment. These patients often present with physical symptoms that could not be medically explained. Pain is the most frequent complaint, though unrecognized psychopatological disorders are more prevalent among these patients. Conversely, difficult patients are rather common in chronic pain syndromes, particularly in back pain, failed back syndrome and atypical facial pain. Diagnosis can be achieved on phenomenological, psychopathological and psychodynamic grounds. The management of difficult patients can prove to be a tough task for both physicians and nurses, as they are time-consuming, draining the emotional resources of the therapist, and evoke feelings of aversion and frustration. Appropriate use of patient-doctor communication skills and an effort to improve relations with the patient through empathy, tolerance and non-judgemental listening are suggested as ways of transform a difficult encounter into a workable patient-doctor relationship.

  13. Computed tomography as an aid to planning intubation in the difficult airway.

    Grimes, David; MacLeod, Iain; Taylor, Timothy; O'Connor, Mary; Sidebottom, Andrew

    2016-01-01

    Patients having oral and maxillofacial operations often require nasal intubation, but limited mouth opening and unfavourable nasal anatomy can make it difficult. We aimed to find out whether there is an association between the prediction of difficult nasal intubation on computed tomography (CT) and actual problems. We retrospectively reviewed the imaging and anaesthetic records of 77 patients who had replacement of the temporomandibular joint (TMJ) as these patients often have limited mouth opening and have had a preoperative CT. There was a positive correlation between a radiographically-assessed difficult nostril and difficulty of intubation (p<0.001). The positive predictive value was 71.4%. As a consequence, our radiologists now routinely report on the nasal cavity in these patients, and their report and the scan are then reviewed by the anaesthetist before intubation. Our results suggest that review of the CT before planned nasal intubation should be part of routine practice. PMID:26530731

  14. Diagnostic accuracy of anaesthesiologists' prediction of difficult airway management in daily clinical practice

    Nørskov, A K; Rosenstock, C V; Wetterslev, J; Astrup, G; Afshari, A; Lundstrøm, L H

    2015-01-01

    Both the American Society of Anesthesiologists and the UK NAP4 project recommend that an unspecified pre-operative airway assessment be made. However, the choice of assessment is ultimately at the discretion of the individual anaesthesiologist. We retrieved a cohort of 188 064 cases from the Dani...... management difficulties in daily routine practice. Prediction of airway difficulties remains a challenging task, and our results underline the importance of being constantly prepared for unexpected difficulties....... difficult intubation. Likewise, difficult mask ventilation was unanticipated in 808 of 857 (94%) cases, and when anticipated (218 cases), difficult mask ventilation actually occurred in 49 (22%) cases. We present a previously unpublished estimate of the accuracy of anaesthesiologists' prediction of airway...

  15. Incidence of unanticipated difficult airway using an objective airway score versus a standard clinical airway assessment

    Nørskov, Anders Kehlet; Rosenstock, Charlotte Valentin; Wetterslev, Jørn; Lundstrøm, Lars Hyldborg

    2013-01-01

    risk reduction equalling a number needed to treat of 180. Sample size estimation is adjusted for the study design and based on standards for randomization on cluster-level. With an average cluster size of 2,500 patients, 70,000 patients will be enrolled over a 1-year trial period. The database is...... examination and registration of predictors for difficult mask ventilation with a non-specified clinical airway assessment on prediction of difficult mask ventilation.Method/Design: We cluster-randomized 28 Danish departments of anaesthesia to airway assessment either by the SARI or by usual non......-specific assessment. Data from patients' pre-operative airway assessment are registered in the Danish Anaesthesia Database. Objective scores for intubation and mask ventilation grade the severity of airway managements. The accuracy of predicting difficult intubation and mask ventilation is measured for each group...

  16. CONDITIONAL DISTANCE CORRELATION

    Wang, Xueqin; Pan, Wenliang; Wenhao HU; Tian, Yuan; Zhang, HePing

    2015-01-01

    Statistical inference on conditional dependence is essential in many fields including genetic association studies and graphical models. The classic measures focus on linear conditional correlations, and are incapable of characterizing non-linear conditional relationship including non-monotonic relationship. To overcome this limitation, we introduces a nonparametric measure of conditional dependence for multivariate random variables with arbitrary dimensions. Our measure possesses the necessar...

  17. The Bonds and Burdens of Family Life: Using Narrative Analysis to Understand Difficult Relationships

    Mary Breheny

    2011-01-01

    Full Text Available Attempts to understand difficult family relationships have ignored the inextricable links between positive and negative relationships. Narrative analysis provides insight into complex relationships within social context. We analysed interviews with older people in New Zealand using levels of narrativity to reveal the negotiations required to manage personal identity at the intersection of competing public narratives. Participants and interviewers used public narratives of family life that reinforce family roles while simultaneously drawing upon alternative narratives of identity and morality. Investigating narratives of difficult family relationships reveals the influence of dominant social norms on the negotiation of social identities through personal stories.

  18. Maxillary tumor in a child: An expected case of difficult airway.

    Reena; Vikram, A

    2016-01-01

    Craniofacial abnormalities in pediatric population fall under the category of expected case of difficult airway. We present here a case of large maxillary tumor in a 9-year-old girl where the relative difficulty was further compounded due to her noncooperation which was again expected from a child. Local anesthetic topicalization of airway followed by slow inhalational induction with gradually increasing sevoflurane, while maintaining her spontaneous breathing, we secured her airway using fiber optic bronchoscopy. The surgery and the extubation went uneventful. In conclusion a planned airway management using fiber optic bronchoscope after airway topicalization and sevoflurane induction is the ideal technique in an expected case of difficult pediatric airway. PMID:27051379

  19. Solitary Fibrous Tumor of the Lower Leg: A Rare and Difficult Diagnosis

    D’Arpa, Salvatore; Rossi, Matteo; Montesano, Luigi; Florena, Ada Maria; Moschella, Francesco; Cordova, Adriana

    2015-01-01

    Summary: Solitary fibrous tumor (SFT) is a rare neoplasm that commonly originates in the pleura. Extrapleural locations are rare and for this reason sometimes difficult to diagnose. Malignant forms with local recurrence or distant metastases have been reported, also as a consequence of inappropriate treatment. In this article, we report the case of an SFT of the lower leg in a 37-year-old man. Leg SFT is a rare occurrence, and differential diagnosis may be difficult because they can mimic a v...

  20. Making difficult decisions how to be decisive and get the business done

    Shaw, Peter J A

    2010-01-01

    You are faced with so many difficult decisions. Often your decision making seems random. It can be swayed by different situations and emotions. You need to be more rigorous in the way you make decisions and yet you have very little time to do so. Experience from others who have made tough decisions and a framework to help you do so would be invaluable. The courage to make decisions is sometimes a bit elusive. It is difficult to find the calmness to be able to make and live with those decisions. There is so much that can be learned from the experience of others. After working through this boo

  1. [Increased dose of remifentanil caused difficult ventilation at emergence from general anesthesia].

    Honda, Takashi; Takenami, Tamie; Itou, Nobuo; Suzuki, Kaoruko; Okamoto, Takashi; Hoka, Sumio

    2009-08-01

    Remifentanil induces a higher incidence of respiratory rigidity than other opioids, especially when it is given at bolus injection for anesthetic induction. A 71-year-old man underwent pharyngo-laryngeal surgery under general anesthesia with remifentanil and sevoflurane. At the end of surgery, the ventilation through a tracheal tube became difficult due to muscle rigidity simultaneously with the increased dose of remifentanil and the decreased sevoflurane concentration. It should be kept in mind that increased doses of remifentanil during as well as at the end of surgery cause difficult ventilation associated with muscle rigidity. PMID:19702212

  2. High-precision Penning trap mass measurements of 'difficult' elements produced via projectile fragmentation with LEBIT

    Ringle, R., E-mail: ringle@nscl.msu.edu; Bachelet, C.; Barquest, B. R.; Block, M.; Bollen, G.; Campbell, C. M.; Facina, M.; Ferrer, R.; III, C. M. Folden; Guenaut, C.; Kwan, E.; Kwiatkowski, A. A.; Lincoln, D. L.; Morrissey, D. J.; Pang, G. K.; Prinke, A. M.; Savory, J.; Schury, P.; Schwarz, S.; Sumithrarachchi, C. S. [National Superconducting Cyclotron Laboratory (United States)

    2011-07-15

    Rare isotope beams of many elements can be difficult or impossible to obtain at ISOL facilities due to their high melting points or chemical reactivity, but they are easily produced by projectile fragmentation and in-flight separation, a technique that rapidly produces fragments lighter than the projectile in a chemistry-free manner. Until recently, such high-energy projectile fragments could not be reduced to the thermal energies necessary for precision mass measurements in Penning traps. The Low Energy Beam and Ion Trap (LEBIT) facility at the National Superconducting Cyclotron Laboratory (NSCL) has demonstrated that projectile fragment beams can be thermalized and measured in a high-precision Penning trap. Since 2005, over 30 isotopes have been measured with LEBIT, including several isotopes of elements which are difficult for ISOL facilities to produce, such as Fe, Co, Si, Br, and S. These measurements have contributed to our understanding of nuclear structure, nuclear astrophysics, and fundamental symmetries. Some recent highlights include the discovery of an isomeric state in {sup 65}Fe, testing the Isobaric Mass Multiplet Equation (IMME) with the A = 32, T = 2 quintet with a measurement of {sup 32}Si, probing out to the proton dripline with {sup 70m}Br, and studying the N = 28 shell closure with measurements of {sup 40 - 44}S. Results of these measurements will be discussed, along with the technical developments which made them possible.

  3. Making Difficult History Public: The Pedagogy of Remembering and Forgetting in Two Washington DC Museums

    Segall, Avner

    2014-01-01

    In this article, Avner Segall explores some pedagogical processes in the context of two museums in Washington, DC, that focus on difficult knowledge, the National Museum of the American Indian (NMAI) and the United States Holocaust Memorial Museum. In doing so, Segall's aim is not to explore the museums as a whole or provide a comprehensive…

  4. Sensory Correlates of Difficult Temperament Characteristics in Preschool Children with Autism

    Chuang, I-Ching; Tseng, Mei-Hui; Lu, Lu; Shieh, Jeng-Yi

    2012-01-01

    This study was aimed to investigate the rate of co-occurring sensory processing (SP) dysfunction in children with autism who had a difficult temperament characteristics, and the relationship between SP dysfunction and temperament characteristics in preschool children with autism. A total of 111 children aged 48-84 months, 67 children with autism

  5. Cutting Costs, Keeping Quality: Financing Strategies for Youth-Serving Organizations in a Difficult Economy

    Keller, Eric

    2010-01-01

    This research brief highlights three effective financing strategies that successful youth-serving organizations are using to maintain quality services despite difficult economic times. The brief provides examples of how organizations have implemented these strategies and offers tips to help leaders consider how best to adapt these strategies to…

  6. Maternal Affective-Cognitive Processes in the Perception of Newborn Difficultness.

    Wolke, Dieter; St. James-Roberts, Ian

    A short-term longitudinal study investigated the way parents come to perceive their infant's temperament as difficult, and to identify factors influencing parents' impression formation. Subjects were 40 middle and lower middle class breastfeeding mothers and their singleton newborns of 38 weeks gestation and 2500 grams birth weight. All mothers…

  7. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management

    Rosenstock, Charlotte Vallentin; Thøgersen, Bente; Afshari, Arash; Christensen, Anne-Lise; Eriksen, Claus; Gätke, Mona R

    2012-01-01

    Awake flexible fiberoptic intubation (FFI) is the gold standard for management of anticipated difficult tracheal intubation. The purpose of this study was to compare awake FFI to awake McGrath® video laryngoscope, (MVL), (Aircraft Medical, Edinburgh, Scotland, United Kingdom) intubation in patients...

  8. Comparison of different tests to determine difficult intubation in pediatric patients

    Mehmet Turan Inal

    2014-12-01

    Full Text Available Background: The difficulties with airway management is the main reason for pediatric anesthesia-related morbidity and mortality. Objective: To assess the value of modified Mallampati test, Upper-Lip-Bite test, thyromental distance and the ratio of height to thyromental distance to predict difficult intubation in pediatric patients. Design: Prospective analysis. Measurements and results: Data were collected from 5 to 11 years old 250 pediatric patients requiring tracheal intubation. The Cormack and Lehane classification was used to evaluate difficult laryngoscopy. Sensitivity, specificity, positive predictive value and AUC values for each test were measured. Results: The sensitivity and specificity of modified Mallampati test were 76.92% and 95.54%, while those for ULBT were 69.23% and 97.32%. The optimal cutoff point for the ratio of height to thyromental distance and thyromental distance for predicting difficult laryngoscopy was 23.5 (sensitivity, 57.69%; specificity, 86.61% and 5.5 cm (sensitivity, 61.54%; specificity, 99.11%. The modified Mallampati was the most sensitive of the tests. The ratio of height to thyromental distance was the least sensitive test. Conclusion: These results suggested that the modified Mallampati and Upper-Lip-Bite tests may be useful in pediatric patients for predicting difficult intubation.

  9. 2010 ASCO Annual Meeting: progress in difficult-to-treat cancers

    Günther J Wiedemann

    2010-01-01

    Full Text Available The 46th Annual Meeting of the American Society of Clinical Oncology took place in June 2010 in Chicago, USA. More than 30,000 specialists discussed the latest innovations in research, quality, practice and technology in cancer. Here we highlight the most significant advances in difficult-to-treat cancers [2].

  10. Regional anesthesia in difficult airway: The quest for a solution continues.

    Khetarpal, Ranjana; Chatrath, Veena; Dhawan, Akshay; Attri, Joginder Pal

    2016-01-01

    Difficult airway, a scenario with potentially life threatening outcome, is routinely encountered by an anesthesiologist leaving him with the dilemma of whether to use regional anesthesia (RA) or general anesthesia. Our study aims to look into this problem. The literature search was performed in the Google, PubMed, and Medscape using key words "regional anesthesia, difficult airway, pregnancy, ventilation, intubation, epidural anesthesia, nerve blocks." More than 38 free full articles and books published from the year 1987 to 2014 were retrieved and studied. At first sight, RA may appear to offer an ideal solution as it helps to avoid the problem of difficult airway. However, the possibility of a total spinal block, failed or incomplete RA, local anesthetic toxicity or unforeseen surgical complication may make it imperative that the airway is secured. The correct decision can only be made by the anesthetist when all the relevant clinical information is taken into account. It is also important to ensure that before considering RA in a patient of difficult airway, an anesthesiologist must have a preformulated strategy for intubation. PMID:27212743

  11. Do Early Difficult Temperament and Harsh Parenting Differentially Predict Reactive and Proactive Aggression?

    Vitaro, Frank; Barker, Edward Dylan; Boivin, Michel; Brendgen, Mara; Tremblay, Richard E.

    2006-01-01

    The goal of this study was to examine the links between difficult temperament (i.e., negative emotionality) and harsh parental discipline during toddlerhood, and reactive and proactive aggression in kindergarten. These links were assessed on a longitudinal population-based study of 1516 boys and girls followed longitudinally from the age of 17…

  12. Dealing with difficult deformations: Construction of a knowledge-based deformation atlas

    Thorup, Signe Strann; Darvann, T.A.; Hermann, N.V.; Larsen, P.; Olafsdottir, H.; Paulsen, Rasmus Reinhold; Kane, A.A.; Govier, D.; Lo, L.J.; Kreiborg, S.; Larsen, Rasmus

    2010-01-01

    from pre- to post-surgery using thin-plate spline warping. The registration results are convincing and represent a first move towards an automatic registration method for dealing with difficult deformations due to this type of surgery. New or breakthrough work to be presented: The method provides a...

  13. 2010 ASCO Annual Meeting: progress in difficult-to-treat cancers

    Günther J Wiedemann; Wolfgang Wagner

    2010-01-01

    The 46th Annual Meeting of the American Society of Clinical Oncology took place in June 2010 in Chicago, USA. More than 30,000 specialists discussed the latest innovations in research, quality, practice and technology in cancer. Here we highlight the most significant advances in difficult-to-treat cancers [2].

  14. Sensory Correlates of Difficult Temperament Characteristics in Preschool Children with Autism

    Chuang, I-Ching; Tseng, Mei-Hui; Lu, Lu; Shieh, Jeng-Yi

    2012-01-01

    This study was aimed to investigate the rate of co-occurring sensory processing (SP) dysfunction in children with autism who had a difficult temperament characteristics, and the relationship between SP dysfunction and temperament characteristics in preschool children with autism. A total of 111 children aged 48-84 months, 67 children with autism…

  15. Complications after using the Airtraq laryngoscope for a predicted difficult intubation.

    ?asi?ska-Kowara, Magdalena; Karwacki, Zbigniew; ?api?ski, Mariusz

    2013-01-01

    Although standard management of an expected difficult intubation is based on fibre-optic techniques, the application of optical laryngoscopes such as Airtraq is gaining widespread acceptance. We here describe a case where an intubation attempt with the Airtraq laryngoscope was not only unsuccessful, but negatively influenced subsequent use of a flexible fibroscopic approach. PMID:23572307

  16. Prior Knowledge and Difficult Vocabulary in the Comprehension of Unfamiliar Text.

    Stahl, Steven A.; And Others

    1989-01-01

    Examines the effect of prior knowledge and difficult vocabulary on students' recall of a passage from a social studies text. Concludes that vocabulary difficulty may affect microprocessing (development of coherent text base) while prior knowledge may affect macroprocessing (summarizing), and that these effects function independently, not…

  17. Martin Award Paper: Development of Interactive Virtual Laboratories to Help Students Learn Difficult Concepts in Thermodynamics

    Bowen, Alec S.; Reid, Daniel R.; Koretsky, Milo D.

    2015-01-01

    In this project, we explore the use of threshold concept theory as a design basis for development of Interactive Virtual Laboratories in thermodynamics. Thermodynamics is a difficult subject for chemical and biological engineering students to master. One reason for the difficulty is the diverse and challenging set of threshold concepts that they…

  18. Information-Limited Parallel Processing in Difficult Heterogeneous Covert Visual Search

    Dosher, Barbara Anne; Han, Songmei; Lu, Zhong-Lin

    2010-01-01

    Difficult visual search is often attributed to time-limited serial attention operations, although neural computations in the early visual system are parallel. Using probabilistic search models (Dosher, Han, & Lu, 2004) and a full time-course analysis of the dynamics of covert visual search, we distinguish unlimited capacity parallel versus serial

  19. "Chalepa Ta Kala," "Fine Things Are Difficult": Socrates' Insights into the Psychology of Teaching and Learning

    Mintz, Avi I.

    2010-01-01

    The proverb "chalepa ta kala" ("fine things are difficult") is invoked in three dialogues in the Platonic corpus: "Hippias Major," "Cratylus" and "Republic." In this paper, I argue that the context in which the proverb arises reveals Socrates' considerable pedagogical dexterity as he uses the proverb to rebuke his interlocutor in one dialogue but…

  20. LAPAROSCOPIC CHOLECYSTECTOMY AT THE PATIENTS WITH THE ASSOCIATE PATHOLOGY AND DIFFICULT SURGICAL TECHNIQUES

    A. Lesco

    2006-01-01

    Full Text Available This paper present an analysis made on 1210 cases of laparoscopic cholecystectomies (LC. From these, 88 patients had associated pathology. The age of the patients was 11 – 82 yo. The indication for LC was large. In the study group (88 cases, the Acid-Base Balance (ABB, blood gasses, blood pressure, the central venous pressure (CVP, intra-cranial pressure (ICP, inspiratory resistance, temperature changes and also peritoneal biopsy were analysed. Methods: The multilateral study clinic-instrumental examinations of associate pathology in preoperative period were determined. Determination of the risk group and patients for LC has been allowed. Results: The CO2 pneumoperitoneum (PP (7-12 mmHg determines changes of the: 1 ABB (intra operator blood pH was 7.37 before and 7.25 after the procedure; 2 partial carbon dioxide (before 40, after 47; 3 blood pressure; 4 mean CVP (before operation - 6.67±0.17 and 10.73±0.29 after procedure (p<0.01; 5 ICP (8.65±0.19 mm, p<0.01; 6 inspiratory resistance; 7 temperature changes (due to the CO2 temperature. The conversion rate was (0,41%: complicated acute cholecystites (1, dense multiple adhesions (1, the incidence of significant hemorrhage (2, bile duct injury (1. The postoperative mortality were 0,33% (4 cases due to pulmonary artery tromboemboly. Billiary lesions during LC occur with a frequency of 0,41% (5 patients: four bile duct injuries and leaks and one case – right billiary accessory duct, were solved following another operation three days after the initial procedure. Wound infection was more frequently, occurring in 21 cases (1,74%. The other complications (14 cases include: subcutaneous emphysema and insufflations of the pro-peritoneal space, omentum, or mesentery. Conclusions: LC is a safety technique even in the patients with associated pathology, but the morbidity and mortality are high. No presumed ductal or vascular structure should be divided until its anatomical features have been completely demonstrated. If the ductal and vascular structures are so obscured by dense inflammation then the procedure should be converted to an open laparotomy. Intra-operative cholangiography will supply the surgeon with accurate details concerning the juncture of the cystic and common bile ducts. To avoid intra-operative bleeding during emergency cholecystectomy it is important to carefully dissect and identify both branches of the cystic artery as well as the main trunk before any suspected vascular structures are divided. Often the most difficult sources of bleeding to avoid in patients with acute cholecystitis is bleeding from the gallbladder fossa.

  1. Identificacin de factores predictores de tcnica epidural dificultosa en la paciente obsttrica / Identifying predictors of difficult epidural technique in pregnant

    L. M., Charco Roca; V. E., Ortiz Snchez; P., Cuesta Montero; A., Soria Quiles; L., Bonmati Garca.

    2013-10-01

    Full Text Available Introduccin: Los intentos repetidos de puncin son factores de riesgo para la aparicin de complicaciones neurolgicas secundarias a la prctica de la analgesia espinal y aumentan la ansiedad del paciente. El objetivo de este estudio es determinar qu factores son mejores predictores de la colocaci [...] n dificultosa del catter epidural en la paciente obsttrica. Material y mtodo: Estudio observacional y prospectivo en 120 gestantes a trmino que solicitan la analgesia epidural para el trabajo de parto. Se recogen variables demogrficas y antecedentes de anestesia espinal previa no exitosa o considerada dificultosa por la paciente. Se identifican variables anatmicas y se clasifica la calidad de los puntos de referencia anatmicos segn los criterios publicados por Chien en cuatro grados. Las condiciones de la tcnica y la experiencia del anestesilogo son similares en todos casos. Consideramos puncin dificultosa si se necesita ms de una puncin en la piel o una puncin pero ms de un cambio de direccin de aguja en el espacio interespinoso. Se recoge el xito obtenido y las complicaciones de la tcnica. Resultados: Fueron calificadas de puncin difcil segn los criterios del estudio en el 36,67 % de los casos. En la mayora de los casos la tcnica fue efectiva obteniendo una adecuada analgesia. La incidencia de repuncin epidural fue de 5 %. En las pacientes clasificadas en el grado 4, la tasa de puncin epidural considerada dificultosa supuso un 90 %, necesitando en el 80 % de esos casos 3 o ms intentos. En las pacientes con antecedentes personales de tcnica neuroaxial dificultosa se encontr dificultad de puncin epidural en un 28,57 % de los casos. El hbito corporal no tuvo efecto significativo sobre la tasa de xito con el primer intento. Discusin: Nuestro estudio representa una buena estimacin de la dificultad tcnica de un bloqueo neuroaxial. Seria difcil saber si los datos reflejados seran extrapolables a la realizacin de la tcnica en decbito lateral, donde los puntos de referencia anatmicos son ms difciles de identificar. Conclusiones: Nuestra recogida concluye que el mtodo ms fiable para determinar de antemano la posibilidad de una dificultad tcnica de colocacin del catter epidural lumbar es un examen de la espalda de la paciente para identificar la calidad de los puntos de referencia anatmicos e identificar la deformidad obvia de la columna vertebral. Abstract in english Introduction: Repeated attempts punctureare risk factors for the appearance of neurologic complications caused by the practice of spinal analgesia and increase patient anxiety. The purpose of this study is to determine which factor sare better predictors of difficult epidural catheter placement in t [...] he obstetric patient. Material and methods: Prospective observational study in 120 pregnant women at term who request edepidural analgesia during labor. Demographic variables and history of difficult or unsuccessful spinal anesthesia were collected. Anatomical variables were identified and the quality of anatomical landmarks was classified according to criteria published by Chien in four grades. The conditions of the technique and the experience of anesthesiologists were similar in all cases. It was considered as difficult puncture that in which was made more than one attempt on skin or more than one change of direction with the epidural needle in interspinous space. We collected the successand complications of the technique. Results: 36.67 % of cases were classified as difficult punctures according to the criteria of the study. In most cases the technique was effective obtaining asuccessful analgesia. The incidence of repeat epidural puncture was 5 %. In patients classified in grade 4, the percentage of difficult epidural puncture was 90 %, requiring in 80 % of the cases 3 or more attempts. In patients with a history of difficult neuraxial technique in 28.57 % of the cases was found difficulty in epidural puncture. Body habitus had no signif

  2. Methods of corrosion diagnosis for purposes of combustion of difficult fuels; Methoden der Korrosionsdiagnose bei der Verbrennung schwieriger Brennstoffe

    Beckmann, Michael; Krueger, Sascha; Gebauer, Kathrin; Pohl, Martin [Technische Univ. Dresden (Germany). Fakultaet Maschinenwesen; Spiegel, Wolfgang; Mueller, Wolfgang [CheMin GmbH Chemische und Mineralogische Untersuchungen, Augsburg (Germany)

    2009-07-01

    Biomasses and substitute fuels classify as difficult fuels on account of their high scale formation and corrosion potential. The methods used for assessing this damage potential can be divided into three categories: diagnosis based on the fuel itself; diagnosis during operation of the energy production plant; and diagnosis by regular monitoring during downtimes. For the final assessment it is important to give due consideration to the characteristics of both the fuel and the firing process. Study of the fuel alone would not give a sufficiently accurate picture of the real situation. Setting the assessment on a broader basis provides greater leeway in decisions of fuel selection, conditioning and mix, selection and combination of protective measures, firing control and selection of parameters used to steer plant output and thus ultimately contributes to optimising energy efficiency.

  3. "DIFFICULT AIRWAY MANAGEMENT IN A PATIENT WITH TREACHER-COLLIN’S SYNDROME WITH INTUBATING LARYNGEAL MASK AIRWAY "

    M. Gharebaghian

    2006-08-01

    Full Text Available Treacher Collin’s syndrome (TCS is a rare inherited condition characterized by bilateral and symmetric abnormalities of structures within the first and second bronchial arches. Patients with TCS present a serious problem to anesthetists maintaining their airway as upper airway obstruction and difficult tracheal intubation due to severe facial deformity. Because of retrognathia, airway management of these patients is often challenging. We report the case of a 25-yr-old patient with TCS undergoing microtia repair under general anesthesia twice. In the first time he could not be intubated via direct laryngoscopy and was intubated via blind nasal intubation. In the second time, he was intubated through an ILMA using endotracheal tube.

  4. Attributions of blame to battered women when they are perceived as feminists or as "difficult to deal with".

    Vidal-Fernández, Ana; Megías, Jesús L

    2014-01-01

    This study aimed to analyze the influence of victim-related and observer-related factors in victim blaming of battered women. Two hundred and forty six college students participated. They were asked to read a scenario describing a hypothetical case of physical violence perpetrated by a man against his partner. Depending on the experimental condition, the victim was described either as a feminist and/or as exhibiting difficulties in her relationship with others or not. A hierarchical regression analysis was performed with victim blaming as dependent variable. Participants' hostile sexism positively predicted victim blaming when the victim was described as a feminist and as a "difficult to deal with" woman (p sexist attitudes placed more blame on the victim when she was presented as a feminist woman (p < .001). These results underscore the importance of victim-related and observer-related factors, and of their interaction, in blaming the victim of gender-based violence. PMID:25011491

  5. Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs

    Halttunen, Jorma; Meisner, Søren; Aabakken, Lars; Arnelo, Urban; Grönroos, Juha; Hauge, Truls; Kleveland, Per M; Nordblad Schmidt, Palle; Saarela, Arto; Swahn, Fredrik; Toth, Ervin; Mustonen, Harri; Löhr, J-Matthias

    2014-01-01

    BACKGROUND: The definition of a "difficult" cannulation varies considerably in reports of endoscopic retrograde cholangiopancreatography (ERCP). AIMS: To define a difficult cannulation, which translates into higher risk of post-ERCP pancreatitis. PATIENTS AND METHODS: Prospective consecutive reco...

  6. Endoscopic papillary balloon dilation after sphincterotomy for difficult choledocholithiasis: A case-controlled study

    Bruno Rosa

    2013-01-01

    Full Text Available AIM: To evaluate the efficacy and safety of endoscopic sphincterotomy (EST + endoscopic papillary large balloon dilation (EPLBD vs isolated EST. METHODS: We conducted a retrospective single center study over two years, from February 2010 to January 2012. Patients with large (? 10 mm, single or multiple bile duct stones (BDS, submitted to endoscopic retrograde cholangio-pancreatography (ERCP were included. Patients in Group A underwent papillary large balloon dilation after limited sphincterotomy (EST+EPLBD, using a through-the-scope balloon catheter gradually inflated to 12-18 mm according to the size of the largest stone and the maximal diameter of the distal bile duct on the cholangiogram. Patients in Group B (control group underwent isolated sphincterotomy. Stones were removed using a retrieval balloon catheter and/or a dormia basket. When necessary, mechanical lithotripsy was performed. Complete clearance of the bile duct was documented with a balloon catheter cholangiogram at the end of the procedure. In case of residual lithiasis, a double pigtail plastic stent was placed and a second ERCP was planned within 4-6 wk. Some patients were sent for extracorporeal lithotripsy prior to subsequent ERCP. Outcomes of EST+EPLBD (Group A vs isolated EST (Group B were compared regarding efficacy (complete stone clearance, number of therapeutic sessions, mechanical and/or extracorporeal lithotripsy, biliary stent placement and safety (frequency, type and grade of complications. Statistical analysis was performed using ?2 or Fishers exact tests for the analysis of categorical parameters and Students t test for continuous variables. A P-value of less than 0.05 was considered statistically significant. RESULTS: One hundred and eleven patients were included, 68 (61.3% in Group A and 43 (38.7% in Group B. The mean diameter of the stones was similar in the two groups (16.8 4.4 and 16.0 6.7 in Groups A and B, respectively. Forty-eight (70.6% patients in Group A and 21 (48.8% in Group B had multiple BDS (P = 0.005. Overall, balloon dilation was performed up to 12 mm in 10 (14.7% patients, 13.5 mm in 17 (25.0%, 15 mm in 33 (48.6%, 16.5 mm in 2 (2.9% and 18 mm in 6 (8.8% patients, taking into account the diameter of the largest stone and that of the bile duct. Complete stone clearance was achieved in sixty-five (95.6% patients in Group A vs 30 (69.8% patients in Group B, and was attained within the first therapeutic session in 82.4% of patients in Group A vs 44.2% in Group B (P < 0.001. Patients submitted to EST+EPLBD underwent fewer therapeutic sessions (1.1 0.3 vs 1.8 1.1, P < 0.001, and fewer required mechanical (14.7% vs 37.2%, P = 0.007 or extracorporeal (0 vs 18.6%, P < 0.001 lithotripsy, as well as biliary stenting (17.6% vs 60.5%, P < 0.001. The rate of complications was not significantly different between the two groups. CONCLUSION: EST+EPLBD is a safe and effective technique for treatment of difficult BDS, leading to high rates of complete stone clearance and reducing the need for lithotripsy and biliary stenting.

  7. Psychodynamics and psychopharmacotherapy in the treatment of difficult patients with personality and eating disorders.

    Marčinko, Darko

    2015-09-01

    The complex inter-relationship between external and internal reality, a source of interest and controversy in psychiatry, has come to the foreground more prominently in the context of more integrative understanding of psychopharmacotherapy. This paper discusses the meaning and clinical applications of the psychodynamic related to psychopharmacotherapy for difficult personality and eating disorders patients. The one of the psychodynamic explanations for patients' being difficult is related to their perceived lack of mentalizing (reflective) capacities. Lack of mentalizing capacity implies disturbed view of psychopharmacotherapy. Therapeutic relationship and optimal alliance offers the frame for acceptance of psychiatric drugs as positive and useful for personality and eating disorder patients. Mentalization and intersubjectivity theories have direct implications for clinical practice, and that the notion of the third is particularly useful in understanding what happens in the patient-doctor relationship. PMID:26400147

  8. Difficult topics in junior secondary school mathematics: practical aspect of teaching and learning trigonometry

    M.A. Yusha'u

    2013-04-01

    Full Text Available This paper presented the practical aspect of teaching and learning Trigonometry to serve as a guide to both teachers and students of Mathematics. It is aimed at reducing the level of difficulties teachers and students of mathematics are facing in terms of delivery and comprehension. The paper identifies Trigonometry as a difficult topic alongside simultaneous linear equation, word problems and change of subject of a formula that causes challenges to both Mathematics teachers and educators. Problems of teaching and learning as well as the strategies that could be employed in teaching and learning of Sine, Cosine and Tangent of a triangle were explicitly explained and discussed. The paper recommends that Mathematics teachers should endeavor to teach difficult topics concretely and explicitly.

  9. Individual factors related to chronic condition in Portuguese adolescents: Highlights from the HBSC/WHO study

    Teresa Santos; Margarida Gaspar de Matos; Maria Celeste Simões; Helena Fonseca; Maria do Céu Machado

    2013-01-01

    Background: Adolescence includes a period (10 to 19 years) of profound biopsychosocial changes, constituting potentially difficult challenges, which may become more pronounced in the presence of a chronic condition and its limitations. Responses are not homogeneous and can be quite variable, depending on various specific individual factors. Research comparing adolescents with or without chronic illness, or comparing across different conditions, has been contradictory, not confirming a di...

  10. Some origins of the 'difficult' child: the Brazelton scale and the mother's view of her new-born's character.

    Meares, R; Penman, R; Milgrom-Friedman, J; Baker, K

    1982-03-01

    Thirty-two mothers and their new-born babies were studied in order to consider, in a limited way, the manner in which a mother comes to attribute personality traits to her infant. The child's expected 'difficulty' was rated by means of a standardized inventory. In addition, a semi-structured interview was conducted with the mother, and her baby was examined by means which have been described by Brazelton. The circumstances of birth were taken from hospital records. Mothers who did not expect the child to be difficult showed a 'general flexibility' which probably related to coping ability. Babies who were seen as unlikely to be difficult had high scores on 'state control' and 'physiological response to stress'. These measures include ratings for habituation and seem to reflect an efficient means of dealing with stimuli. These infantile factors did not correlate with the maternal one, suggesting that a genetic explanation of the findings was not likely. The effect of the circumstances of birth was not strong, but medication level seemed important. The transcripts of the mothers' interviews were consistent with the view that the mother's assessment of her infant's character was not only influenced by a fine observation of the infant's behaviour but also by something like 'projective identification'. The transcripts also suggested that mechanisms which have been seen as important in the development of identity in adolescence may be operating from the first days of life. PMID:7059536

  11. Determination of difficult concepts in the interpretation of musculoskeletal radiographs using a web-based learning/teaching tool

    Aim: To identify which aspects of musculoskeletal radiograph image interpretation users of a web-based learning resource found to be most difficult. Method: The resource provides modular online training, based on twelve musculoskeletal anatomical and pathological areas. At the end of each module is a multiple choice self-test, which users can utilize to consolidate their learning. There are 217 questions within the tests. The results for all questions answered on or before 1st February 2011 were analyzed, and the lowest scoring 25% of questions subsequently reviewed. A low-scoring question implies that the subject was difficult. Results: Users provided a total of 117,097 answers. The range of scores provided by the test questions varied significantly (P < 0.0001), from 15.8% to 93.8%. Topics appearing in the lowest quartile were analyzed in detail. They included interpretation of paediatric radiographs, the Salter-Harris classification, soft-tissue signs and the identification of multiple injuries. The lowest scoring modules were the shoulder and ankle. Conclusion: The results of this study will help to guide educators both within radiography and other health professions in providing more targeted teaching in musculoskeletal image interpretation.

  12. Detailed statistical analysis plan for the difficult airway management (DIFFICAIR) trial

    Nørskov, Anders Kehlet; Lundstrøm, Lars Hyldborg; Rosenstock, Charlotte Vallentin; Wetterslev, Jørn

    2014-01-01

    on the frequency of unanticipated difficult airway management.To prevent outcome bias and selective reporting, we hereby present a detailed statistical analysis plan as an amendment (update) to the previously published protocol for the DIFFICAIR trial. METHOD/DESIGN: The DIFFICAIR trial is a...... analyses regarding the DIFFICAIR trial by an a priori publication of a statistical analysis plan. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01718561....

  13. Comparison of different tests to determine difficult intubation in pediatric patients

    Mehmet Turan Inal; Dilek Memi?; Sevtap Hekimoglu Sahin; Is?l Gunday

    2014-01-01

    Background: The difficulties with airway management is the main reason for pediatric anesthesia-related morbidity and mortality. Objective: To assess the value of modified Mallampati test, Upper-Lip-Bite test, thyromental distance and the ratio of height to thyromental distance to predict difficult intubation in pediatric patients. Design: Prospective analysis. Measurements and results: Data were collected from 5 to 11 years old 250 pediatric patients requiring tracheal intubation. The ...

  14. Machining of Some Difficult-to-Cut Materials with Rotary Cutting Tools

    Stjernstoft, Tero

    2004-01-01

    Automobile and aero industries have an increasing interestin materials with improved mechanical properties. However, manyof these new materials are classified as difficult-to-cut withconventional tools. It is obvious that tools, cutting processesand cutting models has to be devel-oped parallel to materialsscience. In this thesis rotary cutting tools are tested as analternative toexpensive diamond or cubic bore nitridetools. Metal matrix composites mostly consist of a light metalalloy (such as...

  15. Analysis of residual stresses induced by dry turning of difficult-to-machine materials

    Outeiro, J.C.; Pina, J. C.; M'Saoubi, R.; Puavec, Franci; Jawahir, I. S.

    2015-01-01

    Critical issues in machining of difficult-to-cut materials are often associated with short tool-life and poor surface integrity, where the resulting tensile residual stresses on the machined surface significantly affect the component's fatigue life. This study presents the influence of cutting process parameters on machining performance and surface integrity generated during dry turning of Inconel 718 and austenitic stainless steel AISI 316L with coated and uncoated carbide tools. A three-dim...

  16. The relationship between the predictors of obstructive sleep apnea and difficult intubation

    Lee, Sang-Jun; Lee, Jong Nam; Kim, Tae-Sung; Park, Young-chul

    2011-01-01

    Background The study was performed in order to determine the risk factors for difficult tracheal intubation in obstructive sleep apnea patients. Methods For 115 male patients with obstructive sleep apnea syndrome and who were undergoing palatal muscle resection (PMR), we investigated the correlation between their age, height, weight, body mass index (BMI), their Epworth Sleepiness Scale (ESS), their apnea-hypopnea index (AHI), their neck circumference and the difficulty of tracheal intubation...

  17. Role of locking plates in treatment of difficult ununited fractures: a clinical study

    Kumar Ashok

    2013-02-01

    Full Text Available 【Abstract】Objective: To present our experience in treatment of difficult ununited long bone fractures with locking plate. Methods: Retrospective evaluation of locking plate fixation in 10 difficult nonunions of long bone fractures was done. Fixation was done with locking plate for femoral shaft fracture (3 patients, supracondylar fracture of femur (gap nonunion, fracture of clavicle, fracture of both forearm bones (radius and ulna fracture of ulna, fracture of shaft of humerus, fracture of tibial diaphysis and supracondylar frac-ture of humerus (one patient each. Five fractures had more than one previous failed internal fixation. One patient had infected nonunion which was managed by debridement with cast immobilization followed by fixation with locking plate at six weeks. Seven fractures were atrophic, two were oligotrophic, and one was hypertrophic. Fibular autograft was used in 2 cases and iliac crest cancellous bone graft used in all the patients. Results: Minimum follow-up was 6 months (range, 6 months to 2.5 years. Average time for union was 3.4 months (range 2.5 to 6 months. None of the patients had plate-related complications or postoperative wound infections. Conclusion: Along with achieving stability with lock-ing compression plate, meticulous soft tissue dissection, acceptable reduction, good fixation technique and bone grafting can help achieve union in difficult nonunion cases. Though locking plate does not by itself ensure bony union, we have found it to be another useful addition to our arma-mentarium for treating difficult fracture nonunions. Key words: Fractures, bone; Fractures, ununited; Bone plates; Orthopedic fixation devices

  18. Difficult Airway due to Retropharyngeal Hematoma after Stabbing to the Neck

    Kouhei Iwashita

    2014-07-01

    Full Text Available Reports of retropharyngeal hematoma have been scarce in the anesthesiology literature. We report a patient whose trachea was difficult to intubate due to retropharyngeal hematoma after stabbing to the neck. A woman with a knife injury to the common carotid artery required emergency carotid arterioplasty. When tracheal intubation was attempted, marked swelling of the posterior pharyngeal wall made the vocal cords impossible to visualize. Preoperative computed tomography showed a retropharyngeal hematoma. The patient required mechanical ventilation for 2 days.

  19. Environmental risk evaluation of difficult substances in USES 2.0

    van Beelen P; ECO

    1998-01-01

    An inventory is given of the problems which arise when difficult substances are evaluated with the Uniform System for the Evaluation of Substances (USES). It gives an indication about the different classes of chemicals which can give problems in USES. Further, it describes the problems which occur when the physicochemical properties of these compounds are entered into USES. Many default estimations of sorption or bioaccumulation in USES are not valid for these compounds. In comparison with ne...

  20. A Model for Comparative Collective Memory Studies: Regime Types, Cultural Traditions, and Difficult Histories

    Wolfgram, Mark A.

    2015-01-01

    Collective memory research examines how the process of individual memory formation is a social and collective experience, rather than one that is wholly psychological and individual. The stories that societies tell about themselves are an important part of this process, as they seek to socialize new members into the national community. But sometimes that national history is very difficult to deal with. Most collective memory research is based on a single case study approach. What is lacking i...

  1. Methods to ease the release of thin polydimethylsiloxane films from difficult substrates

    Vudayagiri, Sindhu; Skov, Anne Ladegaard

    2014-01-01

    permissible thickness is around 25–50 µm. The relatively small Young's modulus for these elastomers is a requirement for actuation capabilities. However, peeling and release of such films during manufacture processes are very difficult. To ease the release of the films, techniques such as the use of release....... Polysorbate-20, a non-ionic surfactant, fulfills all requirements and gives the lowest peel forces for the films....

  2. The Difficult Conceptualisation of Circular Migration between the EU and the MENA Region

    FAKHOURY, Tamirace

    2010-01-01

    This article examines the extent to which circular migration (CM) can be framed first as a useful migration typology and second as an efficient migration strategy in the MENA region and between the latter and the EU. After discussing the difficult conceptualisation of the circular migration model, it alludes to the inherent discrepancies between the normative, empirical and prescriptive connotations of the concept, then it analyses different examples of circularity in the MENA region and betw...

  3. Analysis of residual stresses induced by dry turning of difficult-to-machine materials

    Outeiro, J.C.; Pina, J. C.; Saoubi, R. M'; F. Pusavec; Jawahir, I. S.

    2008-01-01

    Critical issues in machining of difficult-to-cut materials are often associated with short tool-life and poor surface integrity, where the resulting tensile residual stresses on the machined surface significantly affect the component's fatigue life. This study presents the influence of cutting process parameters on machining performance and surface integrity generated during dry turning of Inconel 718 and austenitic stainless steel AISI 316L with coated and uncoated carbide tools. A three-dim...

  4. Application of cyanoacrylate in difficult-to-arrest acute non-variceal gastrointestinal bleeding

    Kurek, Krzysztof; Baniukiewicz, Andrzej; Świdnicka-Siergiejko, Agnieszka; Dąbrowski, Andrzej

    2014-01-01

    Gastrointestinal bleeding is a common medical emergency. Although endoscopic treatment is effective in controlling non-variceal upper gastrointestinal bleeding, in cases of persistent bleeding radiological or surgical interventions are required. Application of cyanoacrylate for treatment of difficult-to-arrest non-variceal upper gastrointestinal bleeding is poorly investigated. We describe patients in whom cyanoacrylate for acute non-variceal gastrointestinal bleeding was used to stop the ble...

  5. Cyanoacrylate spray as treatment in difficult-to-manage gastrointestinal bleeding

    Toapanta-Yanchapaxi, Liz; Chavez-Tapia, Norberto; Téllez-Ávila, Félix

    2014-01-01

    Gastrointestinal bleeding can be a life-treating event that is managed with standard endoscopic therapy in the majority of cases. However, up to 5%-10% of patients may have persistent bleeding that does not respond to conventional measures. Several endoscopic treatment techniques have been proposed as strategies to control such cases, such as epinephrine injection, hemoclips or argon plasma coagulation, but there are certain clinical scenarios where it is difficult to achieve hemostasis even ...

  6. Difficult Airway Management Methods:A Survey in Medical Colleges in India

    Sahay, B. M.; Sudha Jain; Sucheta Tidke; P S Dhande; B Premendran; Sanjot Dahake

    2008-01-01

    Presence of appropriate equipment and actual procedure employed, greatly affect the outcome in Difficult Airway situation. Medical Colleges being torchbearers in this, have been studied. Consultant presence during intubation in 54% Medical Colleges is commendable. Gum Elastic Bougie is rejected as first choice option by 71% Medical Colleges, though 88% Medical Colleges have mentioned Metal or PVC stylets as first choice options. Blind Nasal Intubation at 33% is the highest 2 nd choice opt...

  7. The intubation scoop (i-scoop) - a new type of laryngoscope for difficult and normal airways.

    Raymondos, K; Seidel, T; Sander, B; Gerdes, A; Goetz, F; Helmstdter, V; Panning, B; Dieck, T

    2014-09-01

    The i-scoop is an intubation device with a curved guiding bar with laterally located lenses at its tip, rather than a blade. Twenty-five anaesthesiologists intubated a manikin that simulated first a normal and then a difficult airway. All participants were able to intubate the difficult airway with a good view of the glottis using the i-scoop. None was able to intubate using seven other laryngoscopes (Macintosh laryngoscope, GlideScope() GVL and AVL, McGrath() (Series 5/MAC), C-MAC() , A.P. Advance() ). Intubation was successful only with the Airtraq() (n = 10), the Airway Scope (n = 5), the C-MAC D-Blade (n = 2), the A.P. Advance DAB (n = 1) and the GlideScope DL Trainer (n = 1) (p < 0.001, success rate of i-scoop vs all 12 laryngoscopes combined). In contrast to all other videolaryngoscopes, intubation of the normal airway with the i-scoop was achieved even faster than with the Macintosh laryngoscope (p < 0.02). The i-scoop outperformed all other laryngoscopes in both difficult and normal airways, and therefore has potential as an easier and safer alternative to present devices. PMID:24894025

  8. [Perioperative management of a case of myasthenic crisis with unexpected difficult airway].

    Uchida, Shinya; Nishikawa, Koichi; Mizukami, Tatsuji; Saito, Shigeru

    2009-07-01

    Myasthenia gravis (MG) is an autoimmune disorder characterized by loss of acetylcholine receptors (AChR) due primarily to the production of anti-AChR autoantibodies. We report here a case of anesthetic management of MG patient associated with difficult airway. A 58-year-old woman, 150 cm in height and 43 kg in weight, was scheduled for elective thymectomy. Preoperative evaluation using Mallampati classification, mouth opening, and thyromental distance did not predict airway difficulty. After anesthetic induction with propofol and sevoflurane, mask ventilation was performed easily. However, tracheal intubation using Macintosh type laryngoscope was unexpectedly difficult. This was largely due to transformation of the epiglottis and thereby Cormack classification was grade III. Tracheal intubation was eventually performed by blindly with a gum elastic bougie after some trials. Postoperative day two, she was diagnosed as postoperative myasthenic crisis and needed re-intubation. We used fiberscope intubation for her because it was difficult to intubate."Cannot intubate, cannot ventilate (CICV)" scenario is very rare, but it sometimes leads to serious morbidity and mortality. Therefore, we need to deal with this emergency situation by using a variety of equipments and techniques. Careful examination of the airway and a carefully considered plan for re-intubation are prerequisites for this type of surgery. PMID:19618835

  9. [Cannot intubate, cannot ventilate: airway management of difficult airways in adults].

    Asai, Takashi

    2006-01-01

    Cannot intubate, cannot ventilate (CICV) is one major cause of death associated with general anesthesia and thus proper airway management plans are necessary. To achieve safe airway management, it is necessary first to predict if the patient's trachea can be difficult to intubate or the lungs difficult to ventilate. When difficulty is predicted, the following factors should be considered: (1) if general anesthesia is truly necessary; (2) if tracheal intubation is mandatory; (3) if muscle relaxation is required; (4) if awake intubation is safer; (5) if surgical airway is required; and (6) if tracheal intubation can prevent airway obstruction. When CICV occurred after general anesthesia, it is important to remember that the primary task is to oxygenate the patient, and not to intubate the trachea: the patient may need to be awaken, surgical airway obtained, or cardiopulmonary bypass established. To make a right decision, it is necessary to know the advantages and disadvantages of each option, as well as of each airway device, and to be acquainted with these devices during routine anesthesia. In this article, I will present six typical cases of difficult airways, and will discuss appropriate options for safer airway management. PMID:16440703

  10. Cannot intubate-cannot ventilate and difficult intubation strategies: results of a Canadian national survey.

    Wong, David T; Lai, Kevin; Chung, Frances F; Ho, Ranee Y

    2005-05-01

    The purpose of this study was to determine the preferences of Canadian anesthesiologists in difficult intubation and cannot intubate-cannot ventilate (CICV) situations. Using a mailed survey, we asked anesthesiologists their preferences for and comfort level in using (a) alternative airway devices in a difficult intubation scenario and (b) infraglottic airway in a CICV scenario. Chi-square analysis and Student's t-test were used for categorical and continuous variables. Nine-hundred-seventy-one of 2066 surveys were returned. In the difficult intubation scenario, the preferred alternative airway devices were lighted stylet (45%), fiberoptic bronchoscope (26%), and intubating laryngeal mask airway (20%). Only 57% of respondents had encountered a CICV situation in real life. In the CICV scenario, preferred infraglottic airways were cricothyroidotomy by IV catheter (51%), percutaneous cricothyroidotomy (28%), and tracheostomy by surgeon (14%). Anesthesiologists had little experience and were uncomfortable with open surgical infraglottic airways. Anesthesiologists with experience using infraglottic airways on mannequins were more comfortable using them in patients (P CICV scenario, respondents preferred cricothyroidotomy by IV catheter, followed by percutaneous cricothyroidotomy and tracheostomy by surgeon. Practice on mannequins was associated with improved comfort in using infraglottic airways in patients. PMID:15845702

  11. Does time ever fly or slow down? The difficult interpretation of psychophysical data on time perception

    Miguel A García-Pérez

    2014-06-01

    Full Text Available Time perception is studied with subjective or semi-objective psychophysical methods. With subjective methods, observers provide quantitative estimates of duration and data depict the psychophysical function relating subjective duration to objective duration. With semi-objective methods, observers provide categorical or comparative judgments of duration and data depict the psychometric function relating the probability of a certain judgment to objective duration. Both approaches are used to study whether subjective and objective time run at the same pace or whether time flies or slows down under certain conditions. We analyze theoretical aspects affecting the interpretation of data gathered with the most widely used objective methods, including single-presentation and paired-comparison methods. For this purpose, a formal model of psychophysical performance is used in which subjective duration is represented via a psychophysical function and the scalar property. This provides the timing component of the model, which is invariant across methods. A decisional component that varies across methods reflects how observers use subjective durations to make judgments and give the responses requested under each method. Application of the model shows that psychometric functions in single-presentation methods are uninterpretable because the various influences on observed performance are inextricably confounded in the data. In contrast, data gathered with paired-comparison methods permit separating out those influences. Prevalent approaches to fitting psychometric functions to data are also discussed and shown to be inconsistent with widely accepted principles of time perception, implicitly assuming instead that subjective time equals objective time and that observed differences across conditions do not reflect differences in perceived duration but criterion shifts. These analyses prompt evidence-based recommendations for best methodological practice in studies on time perception.

  12. Theory including future not excluded

    Nagao, K.; Nielsen, H.B.

    2013-01-01

    We study a complex action theory (CAT) whose path runs over not only past but also future. We show that, if we regard a matrix element defined in terms of the future state at time T and the past state at time TA as an expectation value in the CAT, then we are allowed to have the Heisenberg equation......, Ehrenfest's theorem, and the conserved probability current density. In addition,we showthat the expectation value at the present time t of a future-included theory for large T - t and large t - T corresponds to that of a future-not-included theory with a proper inner product for large t - T. Hence, the CAT...

  13. Perinatal risk factors including malformation

    The study gives a survey of the factors most frequently mentioned in the literature as factors likely to adversely affect a pregnancy. One essential aspect is the discussion of those factors that can be counted among the causes of malformations, as among others, prenatal radiation exposure. The study prepared within the framework of the research project 'Radiobiological environmental monitoring in Bavaria' is intended to serve as a basis for a retrospective and prospective evaluation of infant mortality, perinatal conditions and occurrence of malformations in Bavaria, with the principal idea of drawing up an environment - related health survey. The study therefore, in addition to ionizing radiation also takes into account other detectable risks within the ecologic context, as e.g. industrial installations, refuse incineration plants or waste dumps, or urbanity. (orig./MG)

  14. Spectral synthesis including massive binaries

    Eldridge, John J; Stanway, Elizabeth R

    2009-01-01

    We have constructed a new code to produce synthetic spectra of stellar populations that includes massive binaries. We have tested this code against the broadband colours of unresolved young massive stellar clusters in nearby galaxies, the equivalent widths of the Red and Blue Wolf-Rayet bumps in star-forming SDSS galaxies and the UV and optical spectra of the star forming regions Tol-A and B in NGC5398. In each case we find a good agreement between our models and observations. We find that in...

  15. Side-branch technique for difficult guidewire placement in coronary bifurcation lesion.

    He, Xingwei; Gao, Bo; Liu, Yujian; Li, Zhuxi; Zeng, Hesong

    2016-01-01

    Despite tremendous advances in technology and skills, percutaneous coronary intervention (PCI) of bifurcation lesion (BL) remains a particular challenge for the interventionalist. During bifurcation PCI, safe guidewire placement in the main branch (MB) and the side branch (SB) is the first step for successful procedure. However, in certain cases, the complex pattern of vessel anatomy and the mix of plaque distribution may make target vessel wiring highly challenging. Therefore, specific techniques are required for solving this problem. Hereby, we describe a new use of side-branch technique for difficult guidewire placement in BL. PMID:25842349

  16. Relationships and their potential for change developed in difficult type 1 diabetes

    Zoffmann, Vibeke; Kirkevold, Marit

    2007-01-01

    Few researchers have explored how relationships between patients and providers might change problem solving in clinical practice. The authors used grounded theory to study dyads of 11 people with diabetes and poor glycemic control, and 8 nurses interacting in diabetes teams. Relational Potential...... proved more effective than the others in exploiting the Relational Potential for Change. The three types of relationship differed in (a) scope of problem solving, (b) the roles assigned to the patient and the professionals, (c) use of difficult feelings and different points of view, and (d) quality of...

  17. Difficult airway management with bonfils fiberscope in case of emergency: acute abdomen with ileus.

    Maldini, Branka; Novotny, Zdenko; Letica-Brnadi?, Renata; Brkljaci?, Ana; Bartolek, Dubravka

    2012-09-01

    This clinical report describes an emergency case of a 49-year-old man, ASA E III status, with clinical symptoms of acute abdomen and ileus, who was scheduled for urgent surgery. Predictors of difficult intubation (Mallampati test Class III, short thyro-mental (distance (arrest developed. Successful intubation with oxygenation was followed by cardiopulmonary resuscitation. Upon stabilization of the patient's vital functions, urgent surgery was performed. In the emergency case presented, we succeeded quickly to secure the airway with Bonfils fiberoptic intubation, which allowed for appropriate oxygenation and starting resuscitation. The high risk of the possible aspiration was avoided by timely provision of airway in the experienced anesthetist's hands. PMID:23330419

  18. Decontamination estimate and demonstration test results on road in the return difficult area

    This paper compared evaluation results of decontamination simulation with the actual decontamination result. One of the major factors that decontamination does not proceed, is that the decontamination results are unpredictable. JAEA has developed the software that can be predictive simulation of decontamination with a simple user interface. The purpose of this study is that to evaluate the simulation accuracy. JAEA evaluated accuracies that compared simulation results of decontamination simulation with the actual decontamination result using ultra-high water jet in the returning difficult area. Prediction accuracy was consistent with the range of ±50%. (author)

  19. Recycling management including transportation experience

    The nuclear industry, at least in advanced countries such as Japan, France and other European countries, has developed for years a global strategy of fuel utilization which implies an extensive recycling and reuse of spent fuel. Such recycling strategies are now increasingly required from the industry in general by the various Governments and international organizations. Nuclear fuel recycling and waste management are the two faces of the same policy: the closed fuel cycle, whereby reprocessing of spent fuel makes available for recycling the energetic contents : uranium and plutonium, while segregating the real waste in categories for their specific treatment, conditioning, storage, transportation and final disposal. Plutonium recycling is performed through the fabrication of the so-called mixed oxide fuel (MOX), where fissile plutonium replaces the U 235 isotope used in UO2 fuel. The international trade of nuclear materials and services, under close control of IAEA and other national and international organization, has let to the circulation of materials between the producers of uranium and enrichment fuel, fabrication, reprocessing and recycling services, and the customers worldwide. The industrial transport experience now accumulated shows an excellent record in terms of safety and quality. This communication will describe the current situation and future trends of the recycling route mainly through COGEMA industrial experience. 1 fig

  20. Dying with Dignity: Difficult Times, Difficult Choices. Hearing before the Select Committee on Aging. House of Representatives, Ninety-Ninth Congress, First Session.

    Congress of the U.S., Washington, DC. House Select Committee on Aging.

    This document contains witness testimonies and prepared statements from the Congressional hearing called to examine the dilemma faced by the terminally ill. Opening statements are included from Congressmen Roybal, Henry, Hughes, Gordon, Wortley, Hammerschmidt, and Snowe. Jacob Javits, former United States Senator, testifies, as a terminally ill…

  1. Families classification including multiopposition asteroids

    Milani, Andrea; Spoto, Federica; Knežević, Zoran; Novaković, Bojan; Tsirvoulis, Georgios

    2016-01-01

    In this paper we present the results of our new classification of asteroid families, upgraded by using catalog with > 500,000 asteroids. We discuss the outcome of the most recent update of the family list and of their membership. We found enough evidence to perform 9 mergers of the previously independent families. By introducing an improved method of estimation of the expected family growth in the less populous regions (e.g. at high inclination) we were able to reliably decide on rejection of one tiny group as a probable statistical fluke. Thus we reduced our current list to 115 families. We also present newly determined ages for 6 families, including complex 135 and 221, improving also our understanding of the dynamical vs. collisional families relationship. We conclude with some recommendations for the future work and for the family name problem.

  2. Neoclassical transport including collisional nonlinearity.

    Candy, J; Belli, E A

    2011-06-10

    In the standard δf theory of neoclassical transport, the zeroth-order (Maxwellian) solution is obtained analytically via the solution of a nonlinear equation. The first-order correction δf is subsequently computed as the solution of a linear, inhomogeneous equation that includes the linearized Fokker-Planck collision operator. This equation admits analytic solutions only in extreme asymptotic limits (banana, plateau, Pfirsch-Schlüter), and so must be solved numerically for realistic plasma parameters. Recently, numerical codes have appeared which attempt to compute the total distribution f more accurately than in the standard ordering by retaining some nonlinear terms related to finite-orbit width, while simultaneously reusing some form of the linearized collision operator. In this work we show that higher-order corrections to the distribution function may be unphysical if collisional nonlinearities are ignored. PMID:21770513

  3. Chromosomal Conditions

    ... babies by preventing birth defects, premature birth and infant mortality. Solving premature birth Stanford University Prematurity Research Center ... so closely related, chromosomal conditions are also called genetic ... causes chromosomal conditions? Chromosomal conditions are caused by two ...

  4. On the Improvement of Multi-Legged Locomotion over Difficult Terrains using a Balance Stabilization Method

    Javaid Iqbal

    2012-03-01

    Full Text Available This paper deals with the real?time walking of a multi-legged robot over difficult terrains using a balance stabilization method in order to achieve a fast speed and robust locomotion with minimal tracking errors. The stabilization method is described through a ZMP?based online pattern?generation scheme inspired by bio?mimetic stepping leg transferences with an active balance control so as to reduce the propagation of instability while performing rapid stepping actions for a fast walking gait in the presence of external disturbances. The proposed control system uses a force?position controller [14] which takes impact dynamics into consideration to compensate for the effect of external perturbations during walking by estimating impulsive forces in real?time. Using the proposed stabilization method, the robot plans appropriate footholds on the ground in order to achieve a reasonable average walking speed over difficult terrains in a natural environment. The success and performance of the proposed method is realized through dynamic simulations and real?world experiments using a six?legged hexapod robot.

  5. Evaluation of the Airtraq and Macintosh laryngoscopes in patients at increased risk for difficult tracheal intubation.

    Maharaj, C H

    2008-02-01

    The Airtraq, a novel single use indirect laryngoscope, has demonstrated promise in the normal and simulated difficult airway. We compared the ease of intubation using the Airtraq with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation, in a randomised, controlled clinical trial. Forty consenting patients presenting for surgery requiring tracheal intubation, who were deemed to possess at least three characteristics indicating an increased risk for difficulty in tracheal intubation, were randomly assigned to undergo tracheal intubation using a Macintosh (n = 20) or Airtraq (n = 20) laryngoscope. All patients were intubated by one of three anaesthetists experienced in the use of both laryngoscopes. Four patients were not successfully intubated with the Macintosh laryngoscope, but were intubated successfully with the Airtraq. The Airtraq reduced the duration of intubation attempts (mean (SD); 13.4 (6.3) vs 47.7 (8.5) s), the need for additional manoeuvres, and the intubation difficulty score (0.4 (0.8) vs 7.7 (3.0)). Tracheal intubation with the Airtraq also reduced the degree of haemodynamic stimulation and minor trauma compared to the Macintosh laryngoscope.

  6. Management of difficult intubation in a patient with ankylosing spondylitis--a case report.

    Ahmad, N; Channa, A B; Mansoor, A; Hussain, A

    2005-06-01

    We describe a case of difficult intubation in a patient suffering from ankylosing spondylitis undergoing total hip replacement surgery. The anesthetic management of 42 year old patient with difficult airway is discussed. Failure of epidural anesthesia procedure necessitated general anesthesia. The problems of performing awake fibreoptic intubation and other alternative techniques to secure the airway are described. Cervical spine involvement in ankylosing spondylitis is of great concern for the anesthetist. Longstanding progressive course of this disease leads to fibrosis, ossification and ankylosis of entire spine and sacroiliac joints. Cervical spine mobility is decreased and in severe cases total fixity occurs in a flexed position. Patient may also have atlanto-occipital and temporo-mandibular joint involvement as well. Cricoarytenoid cartilages involvement may result in upper airway compromise. Furthermore cervical spine vertebrae are prone to fractures, especially on hyperextension and may lead to spinal cord transection and quadriplegia. In this case report we describe the airway management of such patient with fixed rigidity of cervical spine and thoracolumbar kyphosis. PMID:16438012

  7. The Human and Economic Burden of Difficult-to-Treat Gouty Arthritis.

    Bardin, Thomas; Voshaar, Martijn A H Oude; van de Laar, Martinus A F J

    2015-10-01

    Gouty arthritis, one of the most painful and common forms of adult arthritis, is caused by monosodium urate crystal deposits in joints, most often in the lower extremities. Crystals trigger an inflammatory response leading to acute flares characterized by a rapid onset of pain, warmth, swelling, and redness in involved joints. Over time, continued monosodium urate crystal deposits and inflammation can lead to chronic tophaceous gout that result in bone erosion, progressing to joint destruction and significant disability. The goal of therapy in an acute gout flare is prompt and safe termination of pain and inflammation. Acute gouty arthritis is usually treated with nonsteroidal anti-inflammatory drugs, colchicine, or corticosteroids. However, for a growing number of patients, current standard treatments are ineffective or are contraindicated, largely due to the presence of comorbidities. Gouty arthritis can have a major negative impact of health-related quality of life, especially in patients with difficult-to-treat disease, as revealed by recent studies comparing health-related quality of life with that of the general population. Additionally, gouty arthritis also constitutes an important economic burden through absence from work and medical costs. This burden is even greater in patients with difficult-to-treat disease. PMID:26717799

  8. Navigating diversity with nursing students through difficult dialogues: A qualitative study

    Deirdre E. van Jaarsveldt

    2015-01-01

    Full Text Available The Difficult Dialogues project is an international initiative that promotes the development of the art and skill of civil discourse as an essential outcome of higher education. At the University of the Free State, South Africa, the project is implemented by the Centre for Teaching and Learning. When intergroup conflict started disrupting the academic performance of first year nursing students, the School of Nursing consulted with the centre to facilitate a Difficult Dialogues session. This article describes the engineering of a session programme to facilitate learning about navigating diversity and responding to conflict in a constructive way. The rich data of a qualitative inquiry conducted via the Critical Incident Questionnaire are triangulated with literature and other feedback provided to describe to what extent the session contributed towards student learning. A number of participants indicated that they had learnt to respect diversity and had realised that they could co-operate as a team in spite of individual differences. As additional evidence, the students listed specific skills that could aid them in navigating diversity and conflict in future. Considering that the School strives to establish inclusion during the orientation of students, this case raises questions about the sufficiency of such endeavours. In conclusion it is asked to what extent nurse educators should be expected to implement strategies to address issues of diversity in the classroom on a continuous basis.

  9. Evaluation of the Airtraq and Macintosh laryngoscopes in patients at increased risk for difficult tracheal intubation.

    Maharaj, C H; Costello, J F; Harte, B H; Laffey, J G

    2008-02-01

    The Airtraq, a novel single use indirect laryngoscope, has demonstrated promise in the normal and simulated difficult airway. We compared the ease of intubation using the Airtraq with the Macintosh laryngoscope, in patients at increased risk for difficult tracheal intubation, in a randomised, controlled clinical trial. Forty consenting patients presenting for surgery requiring tracheal intubation, who were deemed to possess at least three characteristics indicating an increased risk for difficulty in tracheal intubation, were randomly assigned to undergo tracheal intubation using a Macintosh (n = 20) or Airtraq (n = 20) laryngoscope. All patients were intubated by one of three anaesthetists experienced in the use of both laryngoscopes. Four patients were not successfully intubated with the Macintosh laryngoscope, but were intubated successfully with the Airtraq. The Airtraq reduced the duration of intubation attempts (mean (SD); 13.4 (6.3) vs 47.7 (8.5) s), the need for additional manoeuvres, and the intubation difficulty score (0.4 (0.8) vs 7.7 (3.0)). Tracheal intubation with the Airtraq also reduced the degree of haemodynamic stimulation and minor trauma compared to the Macintosh laryngoscope. PMID:18211450

  10. The clinical practice with difficult patients in the collective imaginary of psychology students

    Heloisa Aguetoni Cambuí

    2014-06-01

    Full Text Available The conducts that occur in the context of intersubjectivity are arranged from unconscious psychological fields which influence individual and collective practices. Therefore, it becomes important to consider the collective imagination of psychology students as this may interfere about the exercise of their clinical practice. The aim of this study was to investigate the collective imaginary of psychology students about the clinical practice with patients considered difficult in the analytic setting. Based on the psychoanalytic method, this research utilized the Procedure of Drawings-Stories with Theme in group interview, for the purpose of discuss on the vicissitudes of contemporary clinical work with these patients. In the present study, participated eight undergraduates of the eighth semester of a psychology course.The resulting material of the interview constituted by drawings-stories and the narrative was psychoanalytically analyzed, in the light of the Multiple Fields Theory proposed by Herrmann and in dialogue with the winnicottian thought, allowing to apprehend the follows fields of affective-emotional meaning: “Insecurity”, “Perfect Therapist”, “Mutuality”, “Experience”, “Negation of Madness” and “Madness as tal”. In general the imaginary manifestations of psychology students constitute the analytic relationship with the difficult patients by mobilizing feelings of insecurity, distress, anxiety, incapacity and helplessness.

  11. Too difficult to govern? An assessment of the governability of transport biofuels in the EU

    Transport biofuels are currently the subject of heated debate in the EU. In the past decade the deployment of these technologies has been justified by claims of attractive environmental, geopolitical and rural development benefits. However, expectations have rapidly turned into deep criticism regarding the sustainability of these technologies and the desirability of pursuing the biofuel path. This situation has generated an on-going controversy and policy deadlock at EU level. This study explores these issues from a governance perspective. Employing the concept of system governability, derived from interactive governance theory, it attempts to shed some light on the problems facing the governance of biofuels and on how the quality of the governance system could be improved. The analysis showed that the governability of the system decreased substantially in the period 2003–2012 due to increasing governing needs and decreasing governing capacity. The quality of the governance system can be improved by (i) improving governing capacity by reducing conflicts among governing actors, advancing consistency among institutions and creating capacity at international and global level; and (ii) promoting advanced technologies and adjusting societal ambitions and expectations regarding biofuels. - highlights: • Biofuels in the EU are significantly more difficult to govern today than in 2003. • This is due to the qualities of the system to be governed and the governing system. • Sustainable biofuel systems are inherently difficult to govern

  12. Optimal body balance disturbance tolerance skills as a methodological basis for selection of firefighters to solve difficult rescue tasks

    Władysław Jagiełło

    2014-03-01

    Full Text Available The aim of this study is the methodology of optimal choice of firefighters to solve difficult rescue tasks. 27 firefighters were analyzed: aged from 22–50 years of age, and with 2–27 years of work experience. Body balance disturbance tolerance skills (BBDTS measured by the ‘Rotational Test’ (RT and time of transition (back and forth on a 4 meter beam located 3 meters above the ground, was the criterion for simulation of a rescue task (SRT. RT and SRT were carried out first in a sports tracksuit and then in protective clothing. A total of 4 results of the RT and SRT is the substantive base of the 4 rankings. The correlation of the RT and SRT results with 3 criteria for estimating BBDTS and 2 categories ranged from 0.478 (p<0.01 – 0.884 (p<0.01 and the results of SRT 0.911 (p<0.01. The basic ranking very highly correlated indicators of SRT (0.860 and 0.844, while the 6 indicators of RT only 2 (0.396 and 0.381; p<0.05. There was no correlation between the results of the RT and SRT, but there was an important partial correlation of these variables, but only then was the effect stabilized. The Rotational Test is a simple and easy to use tool for measuring body balance disturbance tolerance skills. However, the BBDTS typology is an accurate criteria for forecasting on this basis, including the results of accurate motor simulations, and the periodic ability of firefighters to solve the most difficult rescue tasks.

  13. Synthesis and Characterization of Metal-Organic Frameworks (MOFs) That Are Difficult to Access De Novo

    Karagiaridi, Olga

    Metal-organic frameworks (MOFs) are a class of intriguing hybrid materials, comprised of metal-based nodes joined by organic linkers into a crystalline, porous, three-dimensional lattice. Their signature properties (well-defined surfaces, tailorability and ultra-high porosity) render them promising candidates for many applications, including, but not limited to, gas storage, gas separation, catalysis and sensing. One of the greatest challenges associated with MOF synthesis lies in the fact that obtaining a desired MOF structure that is tailored to perform a specific application is often not trivial. Traditional synthetic pathways termed "de novo synthesis" (typically one-pot reactions between the MOF structural building blocks under solvothermal conditions) often give rise to side products that do not possess the desired structure. To circumvent this problem, we have studied in depth two powerful MOF synthetic techniques -- solvent-assisted linker exchange (SALE) and transmetalation. These are heterogeneous reactions of parent MOF crystals with concentrated solutions of organic linkers and inorganic metal salts, respectively, that lead to the replacement of the linkers or metal nodes within the parent MOFs by the desired components, while the overall framework topology is preserved. The projects described in this dissertation have aimed to apply these techniques to transform simple (unfunctionalized) and easy to synthesize representative materials from various MOF systems to structurally and functionally interesting daughter products. Examples include synthesis of MOFs that are energetically "unfavorable", extension of MOF cages by longer linker incorporation, functionalization of MOF pores and endowment of MOFs with permanent and persistent porosity. Through these projects, we have been able to formulate a set of rules that can be applied to predict the successful outcome of SALE. Since the allure of MOFs lies in their applications, expanding the range of accessible MOF structures translates into potentially solving more relevant problems - especially those related to alternative energy and sustainability, which urgently need to be addressed given our current energy demands. We hope that SALE and transmetalation can provide alternative routes towards the synthesis of many new and exciting MOFs that can provide creative solutions to many of the problems that we face.

  14. Neuroimagen en nios con epilepsia de difcil control Children with epilepsy of difficult control: Neuroimaging

    Ileana Valdivia lvarez

    2009-09-01

    Full Text Available INTRODUCCIN. Los actuales estudios de neuroimagen representan un gran avance para el diagnstico etiolgico y pronstico de la epilepsia infantil. El objetivo del presente estudio fue describir los hallazgos por tomografa axial y resonancia magntica en nios con epilepsias de difcil control y comparar los resultados de estas tcnicas. MTODOS. Se realiz un estudio descriptivo, longitudinal prospectivo, de 108 nios con diagnstico de epilepsia de difcil control, ingresados en el Servicio de Neuropediatra del Hospital Peditrico Docente Juan Manuel Mrquez entre enero de 2002 y junio de 2006. Se realizaron tcnicas imagenolgicas por tomografa computarizada (TC y resonancia magntica nuclear (RM. RESULTADOS. Se encontraron alteraciones estructurales del cerebro en el 88 % de los nios, y hubo predominio de lesiones prenatales en la fosa posterior, trastornos de la migracin y atrofias secundarias a hipoxia perinatal. Se diagnostic atrofia cortical localizada, mediante RM, hasta en el 28 % de los nios. CONCLUSIONES. La RM es la tcnica de eleccin para el estudio de pacientes con epilepsia de difcil control, por su especificidad, mayor resolucin y relativa inocuidad. Los pacientes con zonas localizadas de atrofia requieren estudios funcionales del cerebro para descartar displasias corticales focales.INTRODUCTION: Current studies of Neuroimaging are a great advance to etiologic and prognostic diagnosis of children epilepsy. The aim of present paper was to describe findings by axial tomography (AT and magnetic resonance (MR in children with epilepsy of difficult control, and to compare results of both techniques. METHODS: A descriptive, longitudinal and prospective study was made in 108 children diagnosed with epilepsy of difficult control, admitted in Neuropediatrics Service of "Jun Manual Mrquez" Teaching Children Hospital from January, 2002 to June, 2006. The techniques used were: computed tomography (CT and nuclear magnetic resonance (NMR. RESULTS: There were brain structural alterations in 88% of children and predominance of prenatal lesions in posterior fossa, migration disorders and atrophies secondary to perinatal hypoxia. They had a diagnosis of localized cortical atrophy by MR up to 28% of children. CONCLUSIONS: MR is the choice technique to study patients with epilepsy of difficult control due to its specificity, a great resolution, and relative harmless. Patients with located zones of epilepsy need brain functional studies to rule out focal cortical dysplasias.

  15. Motor imagery beyond the motor repertoire: Activity in the primary visual cortex during kinesthetic motor imagery of difficult whole body movements.

    Mizuguchi, N; Nakata, H; Kanosue, K

    2016-02-19

    To elucidate the neural substrate associated with capabilities for kinesthetic motor imagery of difficult whole-body movements, we measured brain activity during a trial involving both kinesthetic motor imagery and action observation as well as during a trial with action observation alone. Brain activity was assessed with functional magnetic resonance imaging (fMRI). Nineteen participants imagined three types of whole-body movements with the horizontal bar: the giant swing, kip, and chin-up during action observation. No participant had previously tried to perform the giant swing. The vividness of kinesthetic motor imagery as assessed by questionnaire was highest for the chin-up, less for the kip and lowest for the giant swing. Activity in the primary visual cortex (V1) during kinesthetic motor imagery with action observation minus that during action observation alone was significantly greater in the giant swing condition than in the chin-up condition within participants. Across participants, V1 activity of kinesthetic motor imagery of the kip during action observation minus that during action observation alone was negatively correlated with vividness of the kip imagery. These results suggest that activity in V1 is dependent upon the capability of kinesthetic motor imagery for difficult whole-body movements. Since V1 activity is likely related to the creation of a visual image, we speculate that visual motor imagery is recruited unintentionally for the less vivid kinesthetic motor imagery of difficult whole-body movements. PMID:26701295

  16. Successful management of a difficult cancer pain patient by appropriate adjuvant and morphine titration.

    Rana, Shiv Ps; Ahmed, Arif; Kumar, Vindo; Chaudhary, Prakash K; Khurana, Deepa; Mishra, Seema

    2011-05-01

    Morphine has been used for many years to relieve cancer pain. Oral morphine (in either immediate release or modified release form) remains the analgesic of choice for moderate or severe cancer pain. The dose of oral morphine is titrated up to achieve adequate relief from pain with minimal side effects. Antidepressant and anticonvulsant drugs, when used in addition to conventional analgesics, give excellent relief from cancer pain. Most cancer pain responds to pharmacological measures with oral morphine but some pain like neuropathic and bony pain, pain in children and elderly age group, and advanced malignancy pain are very difficult to treat. Here, we report the management of a similar patient of severe cancer pain and the difficulty that we came across during dose titration of oral morphine and adjuvant analgesic. PMID:21976860

  17. China in the Copenhagen process: the difficult inclusion of an emerging power

    The authors propose an analysis of the Chinese assets and posture before the Copenhagen Conference. They evoke the environmental consequences of the rapid development of the Chinese economy and demography: urban pollution, acid rains, and desertification. They note that the Chinese government had to acknowledge these environmental concerns by specifying energetic performance objectives in its economic planning, by publishing a National Climate Change Programme and a middle and long term development plan for renewable energies. They outline that the different objectives related to energy performance, renewable energy production or greenhouse gas emissions are still difficult to implement at the local level as Chinese provinces are wishing to preserve their competitiveness. The authors comment China's posture in international negotiations as an emerging country or developing country which sets it free of any constraining objective. They examine the possibilities for changing this situation and involve China in reduction obligations. Then they try to foresee China's attitude in Copenhagen and to identify the possible scenarios

  18. Evidence for the a1 meson being a difficult messenger for the restoration of chiral symmetry

    We perform a theoretical analysis of the a1 resonance mass spectrum in ultrarelativistic heavy ion collisions within a hadron/string transport approach. Predictions for the a1 yield and its mass distribution are given for the GSI-FAIR and the critRHIC energy regime. The potential of the a1 meson as a signal for chiral symmetry restoration is explored. In view of the latest discussion, we investigate the decay channel a1??? in detail and find a strong bias toward low a1 masses. This apparent mass shift of the a1, if observed in the ?? channel, might render a possible mass shift due to chiral symmetry restoration very difficult to disentangle from the decay kinematics

  19. Diabetes and Pancreas: Why So Difficult? Potential Mechanisms of Elevated Serum Pancreatic Enzymes.

    Matteucci, Elena; Giampietro, Ottavio

    2016-01-01

    Diabetes mellitus has been associated with a higher risk of exocrine pancreas disorders despite inconsistencies among studies, presumably due to the presence of several (often unmeasured) confounding factors. As a direct consequence of this uncertainty, the relationship between anti-diabetic therapies and pancreatic adverse reactions is difficult to evaluate and remains far from being clarified. Indeed, the on going debate on the safety of incretin-based therapies does not lie in any definite conclusion. Serum level of amylases and lipase reflects the balance between production from different tissues and clearance, but it may be also influenced by numerous molecular, cellular, and systems mechanisms. The present review tries to provide an overview of potential biochemical pathways that may underlie pancreatic hyperenzymemia in health and diabetes mellitus. PMID:26639098

  20. An unusual cause of difficult weaning in a patient with newly diagnosed small cell lung cancer

    G. Deslypere

    2015-01-01

    Full Text Available We describe a patient with acute respiratory insufficiency and difficult ventilator weaning in the ICU ward, leading to diagnosis of small cell lung cancer with superior vena cava superior syndrome. Bilateral vocal cord paralysis caused his respiratory distress and weaning difficulties. Thyroidectomy and neurological problems (such as Parkinson disease and Guillain Barré syndrome are more common causes of bilateral vocal cord paralysis. Lung cancer patients are also at risk due to mediastinal invasion. The left recurrent laryngeal nerve is more prone to paralysis because of the typical anatomy. In contrary, bilateral vocal cord paralysis is rare and doesn't result in speech problems but rather breathing difficulties. Tracheostomy is the classic therapy, but laser cordectomy and Botulinum toxin injection in the laryngeal muscles are alternatives.

  1. Environmental policy-making in a difficult context: motorized two-wheeled vehicle emissions in India

    Motor vehicle activity is growing rapidly in India and other less-industrialized countries in Asia. This growth is contributing to serious health and welfare effects due to vehicle emissions, and energy insecurity, acidification and climate change. This paper applies the problem-structuring tools of 'value-focused thinking' to inform policy-making and implementation related to this complex problem in a difficult context, with specific reference to motorized two-wheeled vehicles, which play an important role in transport air pollution but also provide affordable mobility to millions with few other attractive options. The paper describes the process used to elicit and structure objectives and measures, based on interviews conducted by the author, and demonstrates how the objectives and measures can be used to more effectively characterize policy impacts, and create policy packages that have a better chance of long-term success

  2. Case report of clival tuberculoma. Difficult to diagnose by means of a CT scan

    Ichikawa, F.; Tachibana, S.; Miyasaka, Y.; Suwa, T.; Iida, H.; Kan, S.; Matsuda, Y.

    1987-02-01

    A patient with tuberculoma at the skull base was reported. Twenty-two years old, she had complained for ten years of amenorrhea, headache, and visual disturbance. On neurological examination, bitemporal hemianopsia, bilateral sixth nerve palsy, and recent right-side facial palsy were demonstrated. On radiological examination, a destructive lesion was found at the clivus. CT and MRI demonstrated, a space-taking lesion expanding to the floor of the third ventricle anteriorly, to the cerebello-pontine angle superiorly, and to the epipharynx inferiorly, and a marked swelling of the cerebellum, though no confirmative diagnosis could be obtained without a biopsy of the epipharyngeal tumor. The histological examination revealed that the tumor was tuberculoma. Medical treatment with INH, RFP, and steroids was effective. Although tuberculoma involving the skull base is very rare and rather difficult to diagnose, the authors would like to stress that early accurate diagnosis is very important because the lesion is curable with appropriate medical treatment.

  3. Parent perspectives on biomarkers for OCD: Talking of difficult presents, desired pasts, and imagined futures

    Whiteley, Louise Emma; Borgelt, Emily L; Stewart, S Evelyn; Illes, Judy

    2015-01-01

    This paper investigates parent perspectives on potential future applications of neuroimaging and genetic research in the obsessive-compulsive disorder (OCD) clinic: for prediction, diagnosis, and treatment choice. It does so with a reflective eye on parental motivations for discussing near but...... situate parent discussions of imagined futures in their projections from difficult presents and into desired pasts. Parents reported apparently high receptivity to potential future technological scenarios, connected to central challenges they faced in relation to OCD. Yet when parents responded to...... questions about biomarker tests with the reply, 'yes, anything that helps', uncertainty, caution, and resistance were expressed in implicit negotiations over what it means to 'help'. This paper further considers what the analysis of parent perspectives can contribute to ongoing attempts to situate questions...

  4. Cyclopropane derivatives as potential human serine racemase inhibitors: unveiling novel insights into a difficult target.

    Beato, Claudia; Pecchini, Chiara; Cocconcelli, Chiara; Campanini, Barbara; Marchetti, Marialaura; Pieroni, Marco; Mozzarelli, Andrea; Costantino, Gabriele

    2016-08-01

    d-Serine is the co-agonist of NMDA receptors and binds to the so-called glycine site. d-Serine is synthesized by human serine racemase (SR). Over activation of NMDA receptors is involved in many neurodegenerative diseases and, therefore, the inhibition of SR might represent a novel strategy for the treatment of these pathologies. SR is a very difficult target, with only few compounds so far identified exhibiting weak inhibitory activity. This study was aimed at the identification of novel SR inhibitor by mimicking malonic acid, the best-known SR inhibitor, with a cyclopropane scaffold. We developed, synthesized, and tested a series of cyclopropane dicarboxylic acid derivatives, complementing the synthetic effort with molecular docking. We identified few compounds that bind SR in high micromolar range with a lack of significant correlation between experimental and predicted binding affinities. The thorough analysis of the results can be exploited for the development of more potent SR inhibitors. PMID:26133542

  5. Evolving Dynamic Change and Exchange of Genotype Encoding in Genetic Algorithms for Difficult Optimization Problems

    Bercachi, Maroun; Clergue, Manuel; Verel, Sébastien

    2008-01-01

    The application of genetic algorithms (GAs) to many optimization problems in organizations often results in good performance and high quality solutions. For successful and efficient use of GAs, it is not enough to simply apply simple GAs (SGAs). In addition, it is necessary to find a proper representation for the problem and to develop appropriate search operators that fit well to the properties of the genotype encoding. The representation must at least be able to encode all possible solutions of an optimization problem, and genetic operators such as crossover and mutation should be applicable to it. In this paper, serial alternation strategies between two codings are formulated in the framework of dynamic change of genotype encoding in GAs for function optimization. Likewise, a new variant of GAs for difficult optimization problems denoted {\\it Split-and-Merge} GA (SM-GA) is developed using a parallel implementation of an SGA and evolving a dynamic exchange of individual representation in the context of Dual...

  6. Measuring competition in plant communities where it is difficult to distinguish individual plants

    Damgaard, Christian

    2011-01-01

    A novel method for measuring plant-plant interactions in undisturbed semi-natural and natural plant communities where it is difficult to distinguish individual plants is discussed. It is assumed that the ecological success of the different plant species in the plant community may be adequately...... method allows direct measurements of the competitive effects of neighbouringzplants on plant performance and the estimation of parameters that describe the ecological processes of plantplant interactions during the growing season as well as the process of survival and recruitment between growing seasons...... measured by plant cover and vertical density (a measure that is correlated to the 3-dimensional space occupancy and biomass). Both plant cover and vertical density are measured in a standard pin-point analysis in the beginning and at the end of the growing season. In the outlined competition model the...

  7. Impact of online training on delivering a difficult medical diagnosis: Acquiring communication skills.

    Saint-Dizier de Almeida, Valérie; Agnoletti, Marie-France

    2015-09-01

    This paper deals with developing and assessing the training of physicians to deliver a difficult diagnosis to patients. The training is provided by a web-based self-training package. This online training emphasizes the structural, functional and relational dimensions of interviews delivering a serious diagnosis, and a logical set of recommendations for behavior towards the patient. The content is illustrated by numerous delivery interview sequences that are described and for which commentary is provided. This online package was expected to enable physicians to acquire new skills and change their mental picture of diagnosis delivery. Here we discuss the assessment of training in managing the delivery of a serious diagnosis. The approach taken and the methods used to measure knowledge and skills are presented. PMID:25959340

  8. Successful management of a difficult cancer pain patient by appropriate adjuvant and morphine titration

    Shiv PS Rana

    2011-01-01

    Full Text Available Morphine has been used for many years to relieve cancer pain. Oral morphine (in either immediate release or modified release form remains the analgesic of choice for moderate or severe cancer pain. The dose of oral morphine is titrated up to achieve adequate relief from pain with minimal side effects. Antidepressant and anticonvulsant drugs, when used in addition to conventional analgesics, give excellent relief from cancer pain. Most cancer pain responds to pharmacological measures with oral morphine but some pain like neuropathic and bony pain, pain in children and elderly age group, and advanced malignancy pain are very difficult to treat. Here, we report the management of a similar patient of severe cancer pain and the difficulty that we came across during dose titration of oral morphine and adjuvant analgesic.

  9. Establishment of dual C/S systems at Monju difficult-to-access area

    The Prototype Fast Breeder Reactor 'Monju' is designed to use plutonium for fuel and sodium for coolant to avoid moderating neutrons while effectively utilizing fast neutrons. There are two areas, core and Ex-Vessel Fuel Storage Tank, where fuel assemblies are in liquid sodium and this design makes safeguards for Monju unique. Since the fuel assemblies in these areas cannot be visually confirmed, these areas are designated as a difficult-to-access-area' by the IAEA. To satisfy the inspection goal specified in 1991-1995 IAEA Safeguards Criteria, a dual C/S system consisting of two monitoring devices that are functionally independent has been requested. In this paper, efforts and development of two radiation monitors installed in Monju, Core Monitor and Ex-Vessel Fuel Storage Tank Monitor, are presented. (author)

  10. Tectonique globale. Quelques difficultés Global Tectonics. a Few Problems

    Vitart M. J.

    2006-11-01

    Full Text Available On constate que malgré la brillante démonstration apportée par les forages dans le fond des océans, les praticiens de la géologie observent une certaine réserve face aux concepts de la Tectonique globale. C'est que d'une part, certaines hypothèses de base sont difficiles à comprendre et que d'autre part, la théorie aide assez peu à la résolution des problèmes qui se présentent au géologue praticien. Nous prendrons comme exemple - la difficulté de l'interprétation des anomalies magnétiques des océans; - le problème des « structures reliques » en milieu océanique; - le problème du changement de plaque et de l'inversion du mouvement; - les bassins intraplaques transverses aux ouvertures. Despite the brilliant demonstration of drilling into ocean beds, geologists seems ta be maintaining a certain reserve when confronted with concepts of global tectonics. On one hand, some basic assumptions are difficult ta understand, and on the other the theory is of relatively little help in solving the problems faced by practicing geologists. A few examples of such problems are - the difficulty in interpreting magnetic anomalies in oceans; - the problem of « relic structures » in on oceanic environment; - the problem of plate changes and inversion of movements; - intraplate basins bridging openings.

  11. Characteristic aspects of the housing and utilitiescomplex as a difficult organizational and economic system

    Butyrin Andrey Yur'evich

    2014-02-01

    Full Text Available The existing system of housing and utility services functioning is carried out for providing the relevant living environment standards to the population by means of effective functioning of the system of uninterrupted providing housing and utility services according to existing requirements of the Russian standards. Today there is a number of problems, which doesn't allow housing and utility services to function effectively. The main of them is providing high-quality housing and utility services to the population and system of their objective cost assessment. This problem is solved by means of reforming the housing and utility sphere with the possibility of attracting financial resources from private investors. Housing and Utility of the Russian Federation, the basis of which is the housing stock, has a very high specific weight in fixed assets of all the economy.Thus, Housing and Utility is a typical difficult organizational and economic system possessing characteristic features of openness, nonlinearity and dissipativity. In this re-gard, the reasonable approach to Housing and Utility development assumes the need to account for the principles of systemacity, focus and complexity, and also can be based on the existing in the theory and practice of management methodology by difficult organizational and economic systems.Now Housing and Utility development and financing investment programs of the municipal complex organizations is carried out according to the relevant Federal law, according to which the establishment system of limit indexes of change of tariffs and investment extra charges to tariffs for services of the organizations of a municipal complex. Also, innovative ways of energy efficiency increase and decrease in wear of funds is an attempt of the state to develop effective mechanisms of attracting private funds from investors.

  12. Double guidewire technique vs transpancreatic precut sphincterotomy in difficult biliary cannulation

    Young Wook Yoo

    2013-01-01

    Full Text Available AIM: To compare the outcomes between double-guidewire technique (DGT and transpancreatic precut sphincterotomy (TPS in patients with difficult biliary cannulation. METHODS: This was a prospective, randomized study conducted in single tertiary referral hospital in Korea. Between January 2005 and September 2010. A total of 71 patients, who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved, were randomized into DGT (n = 34 and TPS (n = 37 groups. DGT or TPS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation, median cannulation time, and procedure related complications. RESULTS: The distribution of patients after randomization was balanced, and both groups were comparable in baseline characteristics, except the higher percentage of endoscopic nasobiliary drainage in the DGT group (55.9% vs 13.5%, P < 0.001. Successful cannulation rate and mean cannulation times in DGT and TPS groups were 91.2% vs 91.9% and 14.1 13.2 min vs 15.4 17.9 min, P = 0.732, respectively. There was no significant difference between the two groups. The overall incidence of post- endoscopic retrograde cholangiopancreatography (ERCP pancreatitis was 38.2% vs 10.8%, P < 0.011 in the DGT group and the TPS group; post-procedure pancreatitis was significantly higher in the DGT group. But the overall incidence of post-ERCP hyperamylasemia was no significant difference between the two groups; DGT group vs TPS group: 14.7% vs 16.2%, P < 1.0. CONCLUSION: When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved, DGT and TPS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis was significantly higher in the DGT group.

  13. Categories children find easy and difficult to process in figural analogies

    ClaireEStevenson

    2014-08-01

    Full Text Available Analogical reasoning, the ability to learn about novel phenomena by relating it to structurally similar knowledge, develops with great variability in children. Furthermore, the development of analogical reasoning coincides with greater working memory efficiency and increasing knowledge of the objects and rules present in analogy problems. In figural matrices, a classical form of analogical reasoning assessment, some categories, such as color, appear easier for children to encode and infer than others, such as orientation. Yet, few studies have structurally examined differences in the difficulty of rule-types across different age-groups. This cross-sectional study of figural analogical reasoning examined which underlying rules in figural analogies were easier or more difficult for children to correctly process. School children (N=1422, M=7.0 years, SD=21 months, range 4.5-12.5 years were assessed in analogical reasoning using classical figural matrices and memory measures. The transformations the children had to induce and apply concerned the categories: animal, color, orientation, position, quantity and size. The role of age and memory span on the children’s ability to correctly process each type of transformation was examined using explanatory item response theory models. The results showed that with increasing age and/or greater memory span all transformations were processed more accurately. The “what” transformations animal, color, quantity and size were easiest, whereas the “where” transformations orientation and position were most difficult. However, animal, orientation and position became relatively easier with age and increased memory efficiency. The implications are discussed in terms of the development of visual processing in object recognition versus position and motion encoding, the ventral (“what” and dorsal (“where” pathways respectively.

  14. Application of the Akinfiev-Diamond equation of state to neutral hydroxides of metalloids (B(OH)3, Si(OH)4, As(OH)3) at infinite dilution in water over a wide range of the state parameters, including steam conditions

    Akinfiev, Nikolay N.; Plyasunov, Andrey V.

    2014-02-01

    The Akinfiev and Diamond (2003) equation of state (EoS) for aqueous nonelectrolytes was employed to describe hydroxides of metalloids (B(OH)3, Si(OH)4, As(OH)3) over a wide temperature and pressure ranges, including steam conditions. The EoS is based on the accurate knowledge of solvent (H2O) properties and requires only three empirical parameters to be fitted to experimental data, and these are independent of temperature and pressure. For nonvolatile components thermodynamic properties of species in the ideal gas state were evaluated using quantum chemical computations. The proposed approach has been tested to predict the whole set of thermodynamic properties of solutes (the chemical potential, entropy, molar volume, and molar heat capacity) over a wide range of temperatures (273-1200 K) and pressures (0.1-1000 MPa), including the near-critical region and both low and high density regions of the solvent. Thus it can be used for modeling various geochemical processes over a whole range of solvent densities, including processes in boiling fluids and a vapor phase as well. solubility data in a low density aqueous fluid (ρ1∗ values (mSi(OH)4 > 1 mol kg-1) where polymerization effects may take place (Newton and Manning, 2003); the rest of data, containing the majority of quartz solubility points at 293-1273 K, 0.1-1000 MPa. Only the 3rd part of experimental quartz solubility data has been used in the fitting procedure. Thermodynamic properties of Si(OH)4 in the ideal gas state were recently determined by the analysis of the relevant experimental data in Plyasunov (2011b). The temperature dependence of heat capacity of the molecule was adopted from comprehensive study of Rutz and Bockhorn (2005)where DFT calculations at different levels of theory including CBS-QBS and G3MP2 methods, as well as corrections for hindered rotations and scaling for vibration frequencies were employed. The adopted Cpo (T = 300-1500 K) values for gaseous Si(OH)4 were approximated by a function and used in the treatment of data, see Table 1. The fitting procedure to evaluate the parameters of the Akinfiev-Diamond model also included the values of ΔfGo and S° of Si(OH)4 in ideal gas state at standard state conditions.First, to fit the EoS parameters, the dataset for g2∞ (Si(OH)4(aq)) has been generated using accepted experimental data on quartz solubility in water according to the reaction SiO2(quartz) + 2H2O = Si(OH)4(aq), as g2∞(SiOH(aq)(T,P)=g(quartz)(T,P)+2g(HO)(T,P)-RTlnm, where mSi corresponds to the molality of silica in the solution. Thermodynamic properties of quartz were adopted from SUPCRT database (Johnson et al., 1992), while g(H2O)(T, P) was computed using the Hill (1990) and/or Wagner and Pruß (2002) formulations.The fitting procedure was organized as described below. It is known that partial molar properties of dilute solutes close to the critical point of water are governed by the Krichevskii parameter, AKr (Levelt Sengers, 1991). Plyasunov (2012) recommended for Si(OH)4AKr = -190 ± 10 MPa evaluated from the available relevant data. We have used this value as an anchor while fitting. So, the fitting procedure was iterative. After any initial approximation for ξ, values of the a, b parameters of the EoS together with ΔfGo298(g) and So298(g) of Si(OH)4 were determined by a linear regression of the available g2∞ (Si(OH)4(aq)) experimental data. Then the ξ parameter was modified in compliance with the adopted AKr value (Eq. A7), and the fitting cycle was repeated until ξ ceased changing.The finally retrieved values for gaseous Si(OH)4 are ΔfGo298 = -1239.66 ± 1.7 kJ mol-1, So298 = 346.37 ± 3.5 J mol-1 K-1, and the EoS parameters are ξ = -1.8933; a = 0.9285 ± 1.1 cm3 g-1; b = -0.9409 ± 0.97 cm3 K0.5 g-1 (2σ confidence) (Table 1). Evaluated in this work values of ΔfGo298 and So298 for Si(OH)4 in the ideal gas state are very close to the data given in Plyasunov (2011b) on the basis of the analysis of the solubility amorphous silica and quartz in low-density steam: -1238.51 ± 3.5 kJ mol-1, and So298 = 347.78 ± 6.2 J mol-1 K-1, correspondingly.A comparison of experimental data and the results of the Akinfiev-Diamond EoS are shown in Fig. 3, while the detailed comparison is given in the Electronic Annex. As seen in Fig. 3, the whole set of experimental data included into the regression procedure (293 0.2 g cm-3) is fairly well described by the model.It is interesting to compare the Akinfiev-Diamond (2003) model predictions with the Manning's (1994) correlating equation (see Electronic Annex). The average absolute difference in lgm between all the 664 experimental and calculated solubilities is 0.060 with a standard deviation of 0.080 (for the Manning equation these numbers are 0.055 and 0.072, respectively). Note that the Manning equation contains 7 fitting parameters vs. 5 (counting ΔfGo298 and So298 as parameters, although they can be determined independently) for the Akinfiev-Diamond model.The constant of the distribution of silica between coexisting aqueous liquid and vapor phases of water is described by the model very well (Fig. 4). The Krichevskii parameter, fixed in the fitting procedure at the value, recommended in (Plyasunov, 2012b), is equal to AKr = -190 MPa.It is now possible to test model's abilities to predict quartz solubility in low density (ρ1∗ values is given in the Electronic Annex. It should be noted that despite the fact, that steam solubilities data were not used in the regression procedure, they are reproduced by the Akinfiev-Diamond (2003) model fairly well, although there is a tendency to overestimate the solubilites. The average absolute difference in lgmSi between all 60 accepted experimental and calculated solubilities is 0.100 with a standard deviation of 0.133. On the other hand the Manning (1994) equation in general strongly underestimates steam solubilities, with the average absolute difference in lgmSi equal to 0.495 and a standard deviation of 0.582.At very high temperatures (>1273 K) or pressures (>1 GPa), where solubility of quartz in water exceed 1 mol kg-1, predicted by the model solubility values are significantly smaller than the experimental ones. This result is expected. The presented model predicts the activity of monomeric Si(OH)4, and the conversion to the molality is done assuming that the activity coefficients of silica are equal to 1 at all temperatures, pressures, and concentrations of silica. However, at high total concentrations of silica in solution there are attractive interactions between silica monomers, resulting in formation of a number of polymeric forms via bridging oxygens (Hunt et al., 2011). The formation of new forms can be described either through activity coefficients that are significantly less than 1, or through an explicit consideration of polymerization constant. However this problem goes beyond the scope of the current study.

  15. [An Adult Case of Difficult Intubation Caused by Late Complications of Radiotherapy for Pediatric Neck Malignancy, as well as a Later Laryngeal Elevation Surgery].

    Sunohara, Mari; Okada, Toshiki

    2015-12-01

    We present a case of a 32-year-old female who underwent endoscopic sinus surgery under general anesthesia. She had been diagnosed as rhabdomyosarcoma of her neck at 5 years of age, and received tumor resection and chemoradiotherapy. Afterwards, she was suffering from dysphagia as a late complication of radiotherapy. She received laryngeal elevation surgery at 24 years of age, in order to improve swallowing disturbance. With rapid induction of anesthesia, she was easily ventilated with mask and bag. However, it was difficult to visualize her vocal cord with various intubating apparatus, because of her mandible hypoplasia, small oral cavity, and laryngeal elevation. After all, we were able to intubate her trachea using Pentax Airway-scope (AWS) with a Pediatric-type INTLOCK Blade (ITL-P). Radiotherapy for head and neck malignancy at childhood causes various late complications, leading to difficult intubation. Meanwhile, laryngeal elevation surgery for dysphagia anatomically makes intubation more difficult An adult who has such past history should be expected as an extremely difficult intubation case, and we must be prepared with various intubating apparatus including AWS with ITL-P. PMID:26790331

  16. Evaluation of Rapid Molecular Detection Assays for Salmonella in Challenging Food Matrices at Low Inoculation Levels and Using Difficult-to-Detect Strains.

    Ryan, Gina; Roof, Sherry; Post, Laurie; Wiedmann, Martin

    2015-09-01

    Assays for detection of foodborne pathogens are generally initially evaluated for performance in validation studies carried out according to guidelines provided by validation schemes (e.g., AOAC International or the International Organization for Standardization). End users often perform additional validation studies to evaluate the performance of assays in specific matrices (e.g., specific foods or raw material streams of interest) and with specific pathogen strains. However, these types of end-user validations are typically not well defined. This study was conducted to evaluate a secondary end user validation of four AOAC-validated commercial rapid detection assays (an isothermal nucleic acid amplification, an immunoassay, and two PCR-based assays) for their ability to detect Salmonella in two challenging matrices (dry pet food and dark chocolate). Inclusivity was evaluated with 68 diverse Salmonella strains at low population levels representing the limit of detection (LOD) for each assay. One assay detected all strains at the LOD, two assays detected multiple strains only at 10 times the LOD, and the fourth assay failed to detect two strains (Salmonella bongori and S. enterica subsp. houtenae) even at 1,000 times the LOD; this assay was not further evaluated. The three remaining assays were subsequently evaluated for their ability to detect five selected Salmonella strains in food samples contaminated at fractional levels. Unpaired comparisons revealed no significant difference between the results for each given assay and the results obtained with the reference assay. However, analysis of paired culture-confirmed results revealed assay false-negative rates of 4 to 26% for dry pet food and 12 to 16% for dark chocolate. Overall, our data indicate that rapid assays may have high false-negative rates when performance is evaluated under challenging conditions, including low-moisture matrices, strains that are difficult to detect, injured cells, and low inoculum levels. PMID:26319716

  17. Supporting clinical management of the difficult-to-treat TB cases: the ERS-WHO TB Consilium.

    D'Ambrosio, Lia; Tadolini, Marina; Centis, Rosella; Duarte, Raquel; Sotgiu, Giovanni; Aliberti, Stefano; Dara, Masoud; Migliori, Giovanni Battista

    2015-03-01

    Multi-drug and extensively drug-resistant tuberculosis (MDR/XDR-TB) are considered a serious threat for TB control and elimination. The outcome of these patients is still largely unsatisfactory as of today, with treatment success rates being consistently below 50% at global level. The World Health Organization (WHO) recommends that management of MDR-TB cases is supported by a specialized team, including complementary medical professionals able to cover several perspectives (clinical, both for adults and children; surgical; radiological; public health; psychological; nursing, among others). Implementation of such a body (known as Consilium in most of the former Soviet Union countries) is often a pre-requisite to apply for international TB control funding and concessionally priced medicines to treat M/XDR-TB cases. The primary objective of the ERS/WHO TB Consilium is to provide clinical consultation for drug-resistant TB and other difficult-to-treat TB cases, including co-infection with HIV and paediatric cases. Through technical guidance to clinicians managing complex TB cases, the main contribution and outcome of the initiative will be a public health response aimed at achieving correct treatment of affected patients and preventing further development of drug resistance. The Consilum's secondary objective is to ensure monitoring and evaluation of clinical practices on the ground (diagnosis, treatment and prevention). PMID:25809773

  18. Conditions Affecting Treatment of Pertrochanteric Osteomyelitis

    Steven Wen-Neng Ueng

    2007-10-01

    Full Text Available Background: Although osteomyelitis following treatment of pertrochanteric fractures israre, management can be difficult and often results in several physical andeconomic difficulties. Data regarding treatment of patients withpertrochanteric osteomyelitis is currently limited. This retrospective studyevaluates the management of pertrochanteric osteomyelitis and presents ourexperience using a two-stage treatment protocol.Methods: From 1984 to 1998, twenty-three pertrochanteric osteomyelitis cases weretreated with a two-stage protocol comprising of an external skeletal fixator orBuck traction after radical debridement in the first stage and reconstructionin the second stage. The study included sixteen males and seven femaleswith a mean age of 48.3 years (range 16-82 years. Patients were categorizedas “successful” or “difficult” according to the number of operations they hadundergone. Conditions including patient age, compromised host, intervalbefore treatment, fracture severity, nonunion, hip joint involvement, multipleorganisms and the presence of oxacillin-resistant Staphylococcus aureuswere recorded for analysis.Results: Only twelve of the twenty-three (52% cases were successfully managed andinfection recurred in four (17.4% cases at final follow-up. Difficult casesmanaged by the two-stage protocol were more likely to be characterized byyounger age (p = 0.03, unstable fractures (p = 0.003 and nonunions (p =0.027.Conclusion: The use of external skeletal fixation is not recommended for managingpertrochanteric osteomyelitis. Success using a two-stage protocol was difficultto achieve. Initial fracture severity should be carefully assessed whendevising a treatment protocol for pertrochanteric osteomyelitis.

  19. Analyzing the Option Effects of Difficult TOEFL Items with Low Biserials: Methods Developed for Use by Test Assemblers.

    Hicks, Marilyn M.

    Several exploratory analyses of the fifths data generated by Test of English as a Foreign Language (TOEFL) item analyses were developed in order to evaluate the effects of options on the discriminability of difficult items and to identify difficult items with low, unreliable biserials that had been rejected by test developers, but for which…

  20. Mapping Extensible Mark-up Language (XML) Documents into Rational DataBase Management System (RDBMS) for Condition Monitoring (CM)

    Abdusamad, Ayad

    2013-01-01

    Condition based maintenance is to implement plant overall based on the information sources including condition monitoring, plant production productivity, machine design characteristics and machine failure history data sets. However, because of high diversity of these information sources it makes difficult to unify different data in for optimal maintenance decision making. In addition, the rapid growth in amount of such information sources also create more problems in applying convention...

  1. Fibrin glue: its use for skin grafting of contaminated burn wounds in areas difficult to immobilize.

    Vedung, S; Hedlung, A

    1993-01-01

    A human fibrin glue was used in patients with burns for fixation of skin grafts on slightly infected wounds in the axillas, perineum, and the gluteal folds. These areas had been left open after previous skin transplantations. There was stable and safe adhesion and little inflammatory reaction between the graft and the recipient area, resulting in favorable conditions for graft incorporation. By using the glue the last wounds in our patients healed earlier, and the patients' general condition improved. PMID:8360243

  2. Chimerical conditionals

    Itamar Francez

    2015-01-01

    This paper introduces and analyzes chimerical conditionals, a class of conditionals that are puzzling vis--vis the distinction between so-called 'biscuit' and hypothetical conditionals. An analysis of this distinction is developed which draws on the pragmatic account of Franke 2009. Building on this analysis, chimericity is then shown to derive from a systematic ambiguity of a definite and often implicit argument in the consequent of chimerical conditionals, between a rigid designator and an...

  3. Interactive film scenes for tutor training in problem-based learning (PBL: dealing with difficult situations

    Kirschfink Michael

    2010-07-01

    Full Text Available Abstract Background In problem-based learning (PBL, tutors play an essential role in facilitating and efficiently structuring tutorials to enable students to construct individual cognitive networks, and have a significant impact on students' performance in subsequent assessments. The necessity of elaborate training to fulfil this complex role is undeniable. In the plethora of data on PBL however, little attention has been paid to tutor training which promotes competence in the moderation of specific difficult situations commonly encountered in PBL tutorials. Methods Major interactive obstacles arising in PBL tutorials were identified from prior publications. Potential solutions were defined by an expert group. Video clips were produced addressing the tutor's role and providing exemplary solutions. These clips were embedded in a PBL tutor-training course at our medical faculty combining PBL self-experience with a non-medical case. Trainees provided pre- and post-intervention self-efficacy ratings regarding their PBL-related knowledge, skills, and attitudes, as well as their acceptance and the feasibility of integrating the video clips into PBL tutor-training (all items: 100 = completely agree, 0 = don't agree at all. Results An interactive online tool for PBL tutor training was developed comprising 18 video clips highlighting difficult situations in PBL tutorials to encourage trainees to develop and formulate their own intervention strategies. In subsequent sequences, potential interventions are presented for the specific scenario, with a concluding discussion which addresses unresolved issues. The tool was well accepted and considered worth the time spent on it (81.62 16.91; 62.94 16.76. Tutors considered the videos to prepare them well to respond to specific challenges in future tutorials (75.98 19.46. The entire training, which comprised PBL self-experience and video clips as integral elements, improved tutor's self-efficacy with respect to dealing with problematic situations (pre: 36.47 26.25, post: 66.99 21.01; p Conclusions The interactive tool with instructional video clips is designed to broaden the view of future PBL tutors in terms of recognizing specific obstacles to functional group dynamics and developing individual intervention strategies. We show that this tool is well accepted and can be successfully integrated into PBL tutor-training. Free access is provided to the entire tool at http://www.medizinische-fakultaet-hd.uni-heidelberg.de/fileadmin/PBLTutorTraining/player.swf.

  4. Towards a unified model of pavlovian conditioning: short review of trace conditioning models

    Kryukov, V. I.

    2012-01-01

    There are three basic paradigms of classical conditioning: delay, trace and context conditioning where presentation of a conditioned stimulus (CS) or a context typically predicts an unconditioned stimulus (US). In delay conditioning CS and US normally coterminate, whereas in trace conditioning an interval of time exists between CS termination and US onset. The modeling of trace conditioning is a rather difficult computational problem and is a challenge to the behavior and connectionist approa...

  5. PREDICTING DIFFICULT INTUBATION IN SURGICAL PATIENT S SCHEDULED FOR GENERAL ANAESTHESIA: A PROSPECTIVE ST UDY OF 435 PATIENTS

    Udita

    2013-04-01

    Full Text Available ABSTRACT: BACKGROUND: Unanticipated difficult tracheal intubation is a si gnificant source of morbidity and mortality in anaesthetic practice whic h can be reduced by identification of potential difficult intubation. OBJECTIVE: We aimed the present study to know the incidence of difficult intubation, factors associated with it an d the predictive value of various airway predictors in anticipating difficult visualization of larynx and difficult intubation. METHODS: 435 adult patients (>18 year undergoing general ana esthesia with intubation were examined preoperatively for demographic details (age, sex, weig ht, dentition, airway pathology and six airway predictors i.e. Inter Incisor Gap (IIG, Modif ied Mallampatti Grading (MMPG, Upper lip bite test (ULBT, Thyromental distance (TMD, Stern omental distance (SMD and subluxation of mandible (SLM. All patients were anaesthetized usi ng standard protocol with thiopentone (5mg/kg and succinylcholine (1.5 mg/kg. On direct laryngoscopy, Cormack Lehane (CL grading was noted. CL grade I, II was defined as ea sy visualization of larynx (EVL and CL grade III, IV as difficult visualization of larynx (DVL. Difficult intubation score (DIS was calculated as sum of CL grade and number of intubation attempts. D IS of less than or equal to 4 was defined as easy intubation (EI and DIS > 4 was defined as difficult intubation (DI.Sensitivity, specificity, positive and negative predictive value, po sitive and negative likelihood ratios(LR and odds ratio value for six airway predictor tests was calculated by standard formulae. RESULTS: Incidence of DVL was 12.65% (n=55 and DI was 9.65 % (n=42, with no failed intubation. All airway tests had very high negative predictive value (>90% which implicates they identify easy intubations more precisely. MMPG and ULBT were found as nearly perfect airway predictors for difficult intubation having od ds ratio of 85.23 (95% CI 25.42- 285.89% and 65.45 (95% CI 25.69-166.7% respectively, along with very high sensitivity of 92.80% and 85.7% respectively. Presence of ULBT III is the best predictor of difficult intubation (+LR 21.97 and absence of MMPG III, IV is the best predictor of difficult intubation (-LR 0.091. Abnormal dentition and airway pathology also increase the ris k of difficult intubation, P<0.001. CONCLUSION: We conclude that ULBT and MMPG are nearly perfect airway predictors and should be used routinely during pre-anesthetic visit for screening of difficult intubation.

  6. Physical constraint as psychological holding: Mental-health treatment for difficult and violent adolescents in France.

    Gansel, Yannis; Lézé, Samuel

    2015-10-01

    The phrase "Contraindre est thérapeutique"--constraining is therapeutic--underpins the principle of numerous interventions within the field of mental health in France, ranging from traditional psychiatric units to the courthouse to violence management and prevention of dangerousness. The treatment of violence in "difficult and violent adolescents" provides a paradigmatic and revealing example of this tendency. The aim of this article is to understand how the clinical category--contenir, or "to contain"--was formed and is used. The perspective taken is that of the political anthropology of mental health and the article combines a genealogical approach of the notion with a multisite ethnographical study (conducted between September 2008 and June 2012 in three facilities for adolescent care). This study will show how "psychological holding" is used to justify "physical constraint" in the treatment of adolescent crisis and violence. Furthermore, we will see how this "dirty work", delegated to front-line professionals (educators, social workers, nurses), is used within a moral economy of suffering that promotes care and control measures in a population largely from immigrant backgrounds, judged to be both potentially vulnerable and dangerous. PMID:26048583

  7. The Difficult Conceptualisation of Circular Migration between the EU and the MENA Region

    Tamirace FAKHOURY

    2010-05-01

    Full Text Available This article examines the extent to which circular migration (CM can be framed first as a useful migration typology and second as an efficient migration strategy in the MENA region and between the latter and the EU. After discussing the difficult conceptualisation of the circular migration model, it alludes to the inherent discrepancies between the normative, empirical and prescriptive connotations of the concept, then it analyses different examples of circularity in the MENA region and between the latter and the EU. It concludes that since the very concept of circular migration (as proposed by the EU is still in its exploratory and genesis phases, it is advisable to refrain from conferring an overvalued significance on the CM approach and to consider it rather as a strategy inherent to a more global approach to labour migration in the EU-MENA context. On a more theoretical level, and beyond the specificities of the EU and MENA, this article would suggest caution in the normative use of circular migration. As much contention prevails over circular migration as a migration typology, it would be recommendable that CM be rather considered an option, a policy initiative suitable for some countries more than others, or a strategy to manage migration trends in transnational contexts.

  8. The Brain Mechanisms Underlying the Cognitive Benefits of Bilingualism may be Extraordinarily Difficult to Discover

    Kenneth R. Paap

    2014-12-01

    Full Text Available The hypothesis that coordinating two or more languages leads to an enhancement in executive functioning has been intensely studied for the past decade with very mixed results. The purpose of this review and analysis is to consider why it has been (and will continue to be difficult to discover the brain mechanisms underlying any cognitive benefits to bilingualism. Six reasons are discussed: 1 the phenomenon may not actually exist; 2 the cognitive neuroscientists investigating bilingual advantages may have been studying the wrong component of executive functioning; 3 most experiments use risky small numbers of participants and are underpowered; 4 the neural differences between groups do not align with the behavioral differences; 5 neural differences sometimes suffer from valence ambiguity, that is, disagreements whether “more” implies better or worse functioning and 6 neural differences often suffer from kind ambiguity, that is, disagreements regarding what type of mental events the pattern of activation in a region-of-interest actually reflects.

  9. Fourteen nuclear genes provide phylogenetic resolution for difficult nodes in the turtle tree of life.

    Barley, Anthony J; Spinks, Phillip Q; Thomson, Robert C; Shaffer, H Bradley

    2010-06-01

    Advances in molecular biology have expanded our understanding of patterns of evolution and our ability to infer phylogenetic relationships. Despite many applications of molecular methods in attempts at resolving the evolutionary relationships among the major clades of turtles, some nodes in the tree have proved to be extremely problematic and have remained unresolved. In this study, we use 14 nuclear loci to provide an in depth look at several of these troublesome nodes and infer the systematic relationships among 11 of the 14 turtle families. We find strong support for two of the most problematic nodes in the deep phylogeny of turtles that have traditionally defied resolution. In particular, we recover strong support for a sister relationship between the Emydidae and the monotypic bigheaded-turtle, Platysternon megacephalum. We also find strong support for a clade consisting of sea turtles, mud and musk turtles, and snapping turtles. Within this clade, snapping turtles (Chelydridae) and mud/musk turtles (Kinosternidae) are sister taxa, again with strong support. Our results emphasize the utility of multi-locus datasets in phylogenetic analyses of difficult problems. PMID:19913628

  10. Computer tomography prototyping and virtual procedure simulation in difficult cases of hip replacement surgery.

    Parchi, Paolo Domenico; Ferrari, Vincenzo; Piolanti, Nicola; Andreani, Lorenzo; Condino, Sara; Evangelisti, Gisberto; Lisanti, Michele

    2013-09-01

    Each year approximately 1 million total hip replacements (THR) are performed worldwide. A percentage of failure due to surgical approach and imprecise implant placement still exists. These result in several serious complications. We propose an approach to plan, to simulate, and to assist prosthesis implantation for difficult cases of THR based on 3-D virtual models, generated by segmenting patients' CT images, 3-D solid models, obtained by rapid prototyping (RP), and virtual procedure simulation. We carried out 8 THR with the aid of 3-D reconstruction and RP. After each procedure a questionnaire was submitted to the surgeon to assess the perceived added value of the technology. In all cases, the surgeon evaluated the 3-D model as useful in order to perform the planning. The clinical results showed a mean increase in the Harris Hip Score of about 42.5 points. The mean time of prototyping was 7.3 hours, (min 3.5 hours, max 9.3 hours). The mean surgery time was 65 minutes (min 50 minutes, max 88 minutes). Our study suggests that meticulous preoperative planning is necessary in front of a great aberration of the joint and in absence of normal anatomical landmarks, CT scan is mandatory, and 3-D reconstruction with solid model is useful. PMID:23975443

  11. Why do Family Physicians find it difficult to apply clinical guidelines?

    Andrea Pizzini

    2007-06-01

    Full Text Available The aging of the population, in Italy as well as in all the countries of the European Union, and the increasing prevalence of chronic diseases pose challenges to the development and application of clinical guidelines. Guidelines have been developed to improve the quality of health care. Anyway, Family Physicians sometimes find many obstacles in integrating guidelines into medical practice. In the care of older individuals with several comorbid diseases, application of clinical guidelines is not only difficult, but may also lead to undesirable effects. In this article, the Author take a review, published in JAMA, as a starting point to discuss the role and the importance of guidelines in patients with comorbid disease in the Italian context. The review analyses the hypothetical case of a 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension and osteoarthritis, and describes the situation of the aggregated recommendations from the most relevant guidelines. The conclusion is that, to improve the care of older patients with complex comorbidities, developing new measures and new guidelines is extremely necessary.

  12. Regulating Emotions during Difficult Multiattribute Decision Making: The Role of Pre-Decisional Coherence Shifting

    Carpenter, Stephanie M.; Yates, J. Frank; Preston, Stephanie D.; Chen, Lydia

    2016-01-01

    Almost all real-life decisions entail attribute conflict; every serious choice alternative is better than its competitors on some attribute dimensions but worse on others. In pre-decisional “coherence shifting,” the decision maker gradually softens that conflict psychologically to the point where one alternative is seen as dominant over its competitors, or nearly so. Specifically, weaknesses of the eventually chosen alternative come to be perceived as less severe and less important while its strengths seem more desirable and significant. The research described here demonstrates that difficult multiattribute decision problems are aversive and that pre-decisional coherence shifting aids individuals in regulating that emotional discomfort. Across three studies, attribute conflict was confirmed to be aversive (Study 1), and skin conductance responses and ratings of decision difficulty both decreased in participants who coherence shifted (Study 2). Coherence shifting was also diminished among decision makers who were depleted of regulatory resources, known to be required for common emotion regulation mechanisms. Further, coherence shifting was shown to be relatively common among people who reported strong suppression tendencies in everyday emotion regulation (Study 3). Overall, the data suggest that, at least in part, coherence shifting serves as a tool that helps decision makers manage the pre-decisional discomfort generated by attribute conflict. Theoretical and practical implications are discussed. PMID:26986752

  13. Difficult case of a trans-septal puncture: Use of a "SafeSept" guidewire.

    Zucchetti, Martina; Casella, Michela; DelloRusso, Antonio; Fassini, Gaetano; Carbucicchio, Corrado; Russo, Eleonora; Marino, Vittoria; Catto, Valentina; Tondo, Claudio

    2015-08-26

    A 69-year-old man was admitted to our center to undergo catheter ablation of paroxysmal atrial fibrillation refractory to antiarrhythmic drug therapy. This procedure required access to the left atrium through the interatrial septum. During hospitalization, the patient performed routinely pre-procedure transthoracic echocardiography and gadolinium-enhanced cardiac magnetic resonance showing a normal anatomy of both the fossa ovalis and the interatrial septum. Access to the left atrium proved difficult and several unsuccessful attempts to perform the trans-septal puncture were made under both fluoroscopy and intracardiac echocardiography guidance, even with radiofrequency energy delivery. Finally, trans-septal puncture was successfully carried out using a novel nitinol J-shaped "SafeSept" trans-septal guidewire, designed to cross the interatrial septum through the trans-septal needle thanks to a special sharp tip. Moreover, thanks to its rounded J shape that reduces the risk of atrial perforation, the "SafeSept" guidewire, when advanced into the left atrium, becomes atraumatic. PMID:26322190

  14. A Method for Preparing Difficult Plant Tissues for Light and Electron Microscopy.

    Clode, Peta L

    2015-08-01

    Although the advent of microwave technologies has both improved and accelerated tissue processing for microscopy, there still remain many limitations in conventional chemical fixation, dehydration, embedding, and sectioning, particularly with regard to plant materials. The Proteaceae, a family of plants widely distributed in the Southern Hemisphere and well adapted to harsh climates and nutrient-poor soils, is a perfect example; the complexity of Proteaceae leaves means that almost no ultrastructural data are available as these are notoriously difficult to both infiltrate and section. Here, a step-by-step protocol is described that allows for the successful preparation of Banksia prionotes (Australian Proteaceae) leaves for both light and transmission electron microscopy. The method, which applies a novel combination of vibratome sectioning, microwave processing and vacuum steps, and the utilization of an ultra low viscosity resin, results in highly reproducible, well-preserved, sectionable material from which very high-quality light and electron micrographs can be obtained. With this, cellular ultrastructure from the level of a leaf through to organelle substructure can be studied. This approach will be widely applicable, both within and outside of the plant sciences, and can be readily adapted to meet specific sample requirements and imaging needs. PMID:26189464

  15. A Cascade Optimization Strategy for Solution of Difficult Multidisciplinary Design Problems

    Patnaik, Surya N.; Coroneos, Rula M.; Hopkins, Dale A.; Berke, Laszlo

    1996-01-01

    A research project to comparatively evaluate 10 nonlinear optimization algorithms was recently completed. A conclusion was that no single optimizer could successfully solve all 40 problems in the test bed, even though most optimizers successfully solved at least one-third of the problems. We realized that improved search directions and step lengths, available in the 10 optimizers compared, were not likely to alleviate the convergence difficulties. For the solution of those difficult problems we have devised an alternative approach called cascade optimization strategy. The cascade strategy uses several optimizers, one followed by another in a specified sequence, to solve a problem. A pseudorandom scheme perturbs design variables between the optimizers. The cascade strategy has been tested successfully in the design of supersonic and subsonic aircraft configurations and air-breathing engines for high-speed civil transport applications. These problems could not be successfully solved by an individual optimizer. The cascade optimization strategy, however, generated feasible optimum solutions for both aircraft and engine problems. This paper presents the cascade strategy and solutions to a number of these problems.

  16. Strontium isotopes as an indicator of human migration – easy questions, difficult answers

    Szostek Krzysztof

    2015-06-01

    Full Text Available Isotope analyses of bones and teeth allow us to study phenomena which occurred in the history of human species and which are difficult to capture by traditional anthropological methods. Measuring oxygen, nitrogen and carbon isotope levels in the skeleton makes it possible to reconstruct climatic changes, diet and/or the weaning process. Among isotopes used in such analyses are strontium isotopes, helpful in analysing migration and studying the mobility of historical and prehistoric human populations. In this respect, the proportion of two isotopes, the heavier 87Sr and the lighter 86Sr, is measured, following their extraction from the bioapatite of the bone mineral. Released from rocks in the weathering process, strontium permeates individual components of inanimate and animate environments, and then finds its way, together with food, to the human body. Thanks to comprehensive environmental studies and the measurement of the strontium ratio 87Sr/86Sr in various animal tissues it is possible to determine the local isotope background for the environment. Values obtained by analysing human skeletons referenced against the range of environmental isotope variability enable researchers to trace back the location inhabited by the individual or group.

  17. Regulating Emotions during Difficult Multiattribute Decision Making: The Role of Pre-Decisional Coherence Shifting.

    Carpenter, Stephanie M; Yates, J Frank; Preston, Stephanie D; Chen, Lydia

    2016-01-01

    Almost all real-life decisions entail attribute conflict; every serious choice alternative is better than its competitors on some attribute dimensions but worse on others. In pre-decisional "coherence shifting," the decision maker gradually softens that conflict psychologically to the point where one alternative is seen as dominant over its competitors, or nearly so. Specifically, weaknesses of the eventually chosen alternative come to be perceived as less severe and less important while its strengths seem more desirable and significant. The research described here demonstrates that difficult multiattribute decision problems are aversive and that pre-decisional coherence shifting aids individuals in regulating that emotional discomfort. Across three studies, attribute conflict was confirmed to be aversive (Study 1), and skin conductance responses and ratings of decision difficulty both decreased in participants who coherence shifted (Study 2). Coherence shifting was also diminished among decision makers who were depleted of regulatory resources, known to be required for common emotion regulation mechanisms. Further, coherence shifting was shown to be relatively common among people who reported strong suppression tendencies in everyday emotion regulation (Study 3). Overall, the data suggest that, at least in part, coherence shifting serves as a tool that helps decision makers manage the pre-decisional discomfort generated by attribute conflict. Theoretical and practical implications are discussed. PMID:26986752

  18. Va area difcil en pediatra: signos predictores. Artculo de revisin Difficult airway in pediatrics. Predicting signs

    Judith Prez Lara

    2007-03-01

    Full Text Available El manejo de la Va Area es la A del ABC de la medicina moderna y representa un reto para el anestesilogo experto, y an ms para el que se encuentra en entrenamiento. Una intubacin difcil no anticipada es una emergencia mdica, si no es tratada con rapidez y de forma apropiada, puede condicionar problemas serios y hasta la muerte del paciente. En el presente artculo se hace una revisin del diagnstico precoz de esta entidad, mediante signos predictores, teniendo en cuenta algunas de las caractersticas principales de la va area del nio que la diferencian del adulto.The management of the airway is the A in the ABC of current medicine, and represents a challenge for an expert in anestesiology, and much more for those in the training process. An anticipated difficult intubation is a medical emergency which must be treated rapidly and properly because it can result in serious problems and lead to death. In this article a review of the early diagnosis of this entity through predicting signs , considering some main features at the child airway which are different from the adult's was carried out.

  19. Dealing with difficult deformations: construction of a knowledge-based deformation atlas

    Thorup, S. S.; Darvann, T. A.; Hermann, N. V.; Larsen, P.; lafsdttir, H.; Paulsen, R. R.; Kane, A. A.; Govier, D.; Lo, L.-J.; Kreiborg, S.; Larsen, R.

    2010-03-01

    Twenty-three Taiwanese infants with unilateral cleft lip and palate (UCLP) were CT-scanned before lip repair at the age of 3 months, and again after lip repair at the age of 12 months. In order to evaluate the surgical result, detailed point correspondence between pre- and post-surgical images was needed. We have previously demonstrated that non-rigid registration using B-splines is able to provide automated determination of point correspondences in populations of infants without cleft lip. However, this type of registration fails when applied to the task of determining the complex deformation from before to after lip closure in infants with UCLP. The purpose of the present work was to show that use of prior information about typical deformations due to lip closure, through the construction of a knowledge-based atlas of deformations, could overcome the problem. Initially, mean volumes (atlases) for the pre- and post-surgical populations, respectively, were automatically constructed by non-rigid registration. An expert placed corresponding landmarks in the cleft area in the two atlases; this provided prior information used to build a knowledge-based deformation atlas. We model the change from pre- to post-surgery using thin-plate spline warping. The registration results are convincing and represent a first move towards an automatic registration method for dealing with difficult deformations due to this type of surgery.

  20. Reconciliation as narrative: Witnessing against a too easy and a too difficult reconciliation

    N Botha

    2008-06-01

    Full Text Available Reconciliation as narrative: Witnessing against a too easy and a too difficult reconciliationAfter the dawn of democracy in South Africa in 1994 diverse paradigms on reconciliation have appeared on the scene. In this article these paradigms are not discredited so much for being downright unproductive, but they are found to be either too prescriptive as is the case with the TRC or too limited as is the case with the three paradigms of which mere sketches are offered.The main thrust of the article is a proposal on developing reconciliation as narrative in contradistinction to a dogmatic, technical approach to reconciliation as something to be organised, to be prescribed and engineered. The basic thesis of the article is that narrative can potentially create vast space for story-telling and for many more voices to be heard on the issue of reconciliation. The notion of narrative is advanced as a serious academic category and not an intellectual fad. A further issue is illustrating how issues like remembering, forgiveness and justice need to be brought into discourse with reconciliation.

  1. Fluoroscopy-guided lumbar drainage of cerebrospinal fluid for patients in whom a blind beside approach is difficult

    Chee, Choong Guen; Lee, Guen Young; Lee, Joon Woo; Lee, Eu Gene; Kang, Heung Sik [Dept. of Radiology, Seoul National University Bundang Hospital, Seongnam (Korea, Republic of)

    2015-08-15

    To evaluate the rates of technical success, clinical success, and complications of fluoroscopy-guided lumbar cerebrospinal fluid drainage. This retrospective study was approved by the Institutional Review Board of our hospital, and informed consent was waived. Ninety-six procedures on 60 consecutive patients performed July 2008 to December 2013 were evaluated. The patients were referred for the fluoroscopy-guided procedure due to failed attempts at a bedside approach, a history of lumbar surgery, difficulty cooperating, or obesity. Fluoroscopy-guided lumbar drainage procedures were performed in the lateral decubitus position with a midline puncture of L3/4 in the interspinous space. The catheter tip was positioned at the T12/L1 level, and the catheter was visualized on contrast agent-aided fluoroscopy. A standard angiography system with a rotatable C-arm was used. The definitions of technical success, clinical success, and complications were defined prior to the study. The technical and clinical success rates were 99.0% (95/96) and 89.6% (86/96), respectively. The mean hospital stay for an external lumbar drain was 4.84 days. Nine cases of minor complications and eight major complications were observed, including seven cases of meningitis, and one retained catheter requiring surgical removal. Fluoroscopy-guided external lumbar drainage is a technically reliable procedure in difficult patients with failed attempts at a bedside procedure, history of lumbar surgery, difficulties in cooperation, or obesity.

  2. I-123 iofetamine single photon emission tomography in school-age children with difficult-to-control seizures

    Interictal I-123 iofetamine (IMP) single photon emission tomography (SPECT) was performed in 15 children with difficult-to-control partial or generalized seizures. SPECT studies were compared with magnetic resonance imaging and CT in seven patients, with magnetic resonance imaging only in five, and with CT only in three. Electroencephalography was performed on all subjects, including invasive studies in nine. SPECT was abnormal in six patients. Magnetic resonance and/or CT studies were abnormal in two of the six patients. The other four patients with abnormal SPECT imaging studies had four magnetic resonance and two CT studies that were normal. The SPECT abnormality corresponded to EEG localization in each of the six cases. Lesions localized on SPECT were in or near the temporal lobes. Five other patients with normal SPECT had well-localized abnormalities on EEG. Four magnetic resonance and five CT studies were also negative in these five cases. Four patients whose EEGs did not show adequate lateralization had four normal SPECT, two normal CT, and three normal magnetic resonance studies. In children as in adults, IMP SPECT imaging shows promise in the localization of seizure foci in or near the temporal lobes

  3. Fluoroscopy-guided lumbar drainage of cerebrospinal fluid for patients in whom a blind beside approach is difficult

    To evaluate the rates of technical success, clinical success, and complications of fluoroscopy-guided lumbar cerebrospinal fluid drainage. This retrospective study was approved by the Institutional Review Board of our hospital, and informed consent was waived. Ninety-six procedures on 60 consecutive patients performed July 2008 to December 2013 were evaluated. The patients were referred for the fluoroscopy-guided procedure due to failed attempts at a bedside approach, a history of lumbar surgery, difficulty cooperating, or obesity. Fluoroscopy-guided lumbar drainage procedures were performed in the lateral decubitus position with a midline puncture of L3/4 in the interspinous space. The catheter tip was positioned at the T12/L1 level, and the catheter was visualized on contrast agent-aided fluoroscopy. A standard angiography system with a rotatable C-arm was used. The definitions of technical success, clinical success, and complications were defined prior to the study. The technical and clinical success rates were 99.0% (95/96) and 89.6% (86/96), respectively. The mean hospital stay for an external lumbar drain was 4.84 days. Nine cases of minor complications and eight major complications were observed, including seven cases of meningitis, and one retained catheter requiring surgical removal. Fluoroscopy-guided external lumbar drainage is a technically reliable procedure in difficult patients with failed attempts at a bedside procedure, history of lumbar surgery, difficulties in cooperation, or obesity

  4. Effects of repeated exposure to JP-8 jet fuel vapor on learning of simple and difficult operant tasks by rats.

    Ritchie, G D; Rossi, J; Nordholm, A F; Still, K R; Carpenter, R L; Wenger, G R; Wright, D W

    2001-11-01

    Groups of 16 Sprague-Dawley rats each were exposed by whole-body inhalation methods to JP-8 jet fuel at the highest vapor concentration without formation of aerosol (1,000 +/- 10% mg/m3); to 50% of this concentration (500 +/- 10% mg/m3); or to treated room air (70 +/- 81 L/min) for 6 h/d, 5 d/wk, for 6 wk (180 h). Although two subjects died of apparent kidney complications during the study, no other change in the health status of exposed rats was observed, including rate of weight gain. Following a 65-d period of rest, rats were evaluated for their capacity to learn and perform a series of operant tasks. These tasks ranged in difficulty from learning of a simple food-reinforced lever pressing response, to learning a task in which subjects were required to emit up to four-response chains of pressing three different levers (e.g., press levers C, R, L, then C). It was shown that repeated exposure to 1,000 mg/m3 JP-8 vapor induced significant deficits in acquisition or performance of moderately difficult or difficult tasks, but not simple learning tasks, as compared to those animals exposed to 500 mg/m3. Learning/performance of complex tasks by the 500-mg/m3 exposure group generally exceeded the performance of control animals, while learning by the 1,000-mg/m3 group was nearly always inferior to controls, indicating possible "neurobehavioral" hormesis. These findings appear consistent with some previously reported data for operant performance following acute exposure to certain hydrocarbon constituents of JP-8 (i.e., toluene, xylenes). There has, however, been little previously published research demonstrating long-term learning effects for repeated hydrocarbon fuel exposures. Examination of regional brain tissues from vapor-exposed rats indicated significant changes in levels of dopamine in the cerebral cortex and DOPAC in the brainstem, measured as long as 180 d postexposure, as compared to controls. PMID:11700005

  5. Forty month follow-up of persistent and difficultly controlled acromegalic patients treated with depot long acting somatostatin analog octreotide

    The objective of the present study was to investigate the effects of octreotide long acting release (S-LAR) preparation on growth hormone (GH) and insulin-like growth factor (IGF)-1 serum concentrations and pituitary tumor size in patients with persistent and difficultly controlled acromegaly even after adjuvant irradiation and/or dopamine agonists. Thirty-three patients with active acromegaly (26 female and 7 male, mean age; 43.94±14.01 standard deviation (SD) years) were included in this study. Patients were evaluated at baseline and at 6, 12, 30 and 40 months for GH, IGF-1, and GH response to oral glucose tolerance test (OGTT) and biliary ultrasonography. Sella MRI was performed at initial and at 40 months. All patients received 20 mg S-LAR. Afterwards, the dosage was titrated to improve individual GH response and reduction of IGF-1 into normal ranges. Basal serum IGF-1 levels decreased from median: 530 μg/l [IQR: 420-600] to 340 μg/l [IQR: 230-460] at 6 months (p=0.01), to 400 μg/l [IQR: 222.4-600] at 12 months (p=0.48), to 396 μg/l [IQR: 318-468] at 30 months (p=0.49), to 482 μg/l [308-580] at 40 months (p=0.47). Nadir GH levels in OGTT fell from 2.70 ng/ml [IQR: 1.35-6.90] to 1.60 ng/ml [IQR: 0.36-4.10] at 6 months (p=0.03), to 0.31 ng/ml [IQR: 0.18-0.65] at 12 months (p<0.0001), to 1.50 ng/ml [IQR: 0.83-4.00] at 30 months (p=0.398) and to 0.89 ng/ml [IQR: 0.58-1.35] at 40 months (p<0.0001). Initially, pituitary adenoma volume was median: 1.18 ml [IQR: 0.08-3.50] and it shrank to 0.21 ml [IQR: 0-2.1] at 40 months (p=0.08). Gallstones were detected in 12 patients and six of them underwent cholecystectomy. S-LAR is an effective treatment regimen in reducing GH and IGF-1 concentrations and as well as in shrinking tumor volume in persistent and difficultly controlled acromegalic patients. (author)

  6. Study of issues in difficult-to-weld thick materials by hybrid laser arc welding

    Mazar Atabaki, Mehdi

    There is a high interest for the high strength-to-weight ratio with good ductility for the welds of advanced alloys. The concern about the welding of thick materials (Advanced high strength steels (AHSS) and 5xxx and 6xxx series of aluminum alloys) has stimulated the development of manufacturing processes to overcome the associated issues. The need to weld the dissimilar materials (AHSS and aluminum alloys) is also required for some specific applications in different industries. Hence, the requirement in the development of a state-of-the-art welding procedure can be helpful to fulfill the constraints. Among the welding methods hybrid laser/arc welding (HLAW) has shown to be an effective method to join thick and difficult-to-weld materials. This process benefits from both advantages of the gas metal arc welding (GMAW) and laser welding processes. The interaction of the arc and laser can help to have enough penetration of weld in thick plates. However, as the welding of dissimilar aluminum alloys and steels is very difficult because of the formation of brittle intermetallics the present work proposed a procedure to effectively join the alloys. The reports showed that the explosively welded aluminum alloys to steels have the highest toughness, and that could be used as an "insert" (TRICLAD) for welding the thick plates of AHSS to aluminum alloys. Therefore, the HLAW of the TRICLAD-Flange side (Aluminum alloy (AA 5456)) to the Web side (Aluminum alloys (AA 6061 and AA 5456)) and the TRICLAD-Flange side (ASTM A516) to the Web side (AHSS) was studied in the present work. However, there are many issues related to HLAW of the dissimilar steels as well as dissimilar aluminum alloys that have to be resolved in order to obtain sound welds. To address the challenges, the most recent welding methods for joining aluminum alloys to steels were studied and the microstructural development, mechanical properties, and on-line monitoring of the welding processes were discussed as well. The heat and mass transfer and the issues in joining of dissimilar alloys by the hybrid laser/arc welding process (HLAW) were explicitly explained in details. A finite element model was developed to simulate the heat transfer in HLAW of the aluminum alloys. Two double-ellipsoidal heat source models were considered to describe the heat input of the gas metal arc welding and laser welding processes. An experimental procedure was also developed for joining thick advanced high strength steel plates by using the HLAW, by taking into consideration different butt joint configurations. The geometry of the weld groove was optimized according to the requirements of ballistic test, where the length of the softened heat affected zone should be less than 15.9 mm measured from the weld centerline. Since the main issue in HLAW of the AHSS was the formation of the pores, the possible mechanisms of the pores formation and their mitigation methods during the welding process were investigated. Mitigation methods were proposed to reduce the pores inside in the weld area and the influence of each method on the process stability was investigated by an on-line monitoring system of the HLAW process. The groove angle was optimized for the welding process based on the allowed amount of heat input along the TRICLADRTM interface generated by an explosive welding. The weld was fractured in the heat affected zone of the aluminum side in the tensile test. The microharness was shown that the temperature variation caused minor softening in the heat affected zone satisfying the requirement that the width of the softened heat affected zone in the steel side falls within 15.9 mm far away from the weld centerline. The microstructure analysis showed the presence of tempered martensite at the vicinity of the weld area, which it was a cause of softening in the heat affected zone.

  7. Automatic mesh adaptivity for CADIS and FW-CADIS neutronics modeling of difficult shielding problems

    The CADIS and FW-CADIS hybrid Monte Carlo/deterministic techniques dramatically increase the efficiency of neutronics modeling, but their use in the accurate design analysis of very large and geometrically complex nuclear systems has been limited by the large number of processors and memory requirements for their preliminary deterministic calculations and final Monte Carlo calculation. Three mesh adaptivity algorithms were developed to reduce the memory requirements of CADIS and FW-CADIS without sacrificing their efficiency improvement. First, a macro-material approach enhances the fidelity of the deterministic models without changing the mesh. Second, a deterministic mesh refinement algorithm generates meshes that capture as much geometric detail as possible without exceeding a specified maximum number of mesh elements. Finally, a weight window coarsening algorithm de-couples the weight window mesh and energy bins from the mesh and energy group structure of the deterministic calculations in order to remove the memory constraint of the weight window map from the deterministic mesh resolution. The three algorithms were used to enhance an FW-CADIS calculation of the prompt dose rate throughout the ITER experimental facility. Using these algorithms resulted in a 23.3% increase in the number of mesh tally elements in which the dose rates were calculated in a 10-day Monte Carlo calculation and, additionally, increased the efficiency of the Monte Carlo simulation by a factor of at least 3.4. The three algorithms enabled this difficult calculation to be accurately solved using an FW-CADIS simulation on a regular computer cluster, obviating the need for a world-class super computer. (authors)

  8. Intralesional immunotherapy for difficult to treat warts with Mycobacterium w vaccine

    Shilpa Garg

    2014-01-01

    Full Text Available Background: Immunotherapy is an evolving therapeutic modality for the treatment of warts. We conducted a study to assess the efficacy and safety of intralesional Mycobacterium w vaccine for the treatment of warts at sites that were difficult to treat. Materials and Methods: Thirty patients with at least one wart present on either the plantar surface of their feet, palms, volar aspect of their fingers, or periungual or subungual region, were treated with 0.1 ml of killed Mycobacterium w vaccine given intralesionally in a single wart, without any prior sensitisation dose. Thereafter, a single injection of 0.1 ml of vaccine was given at intervals of four weeks in a single wart till there was complete resolution of the warts or a maximum of 10 injections. Treatment was stopped if there was no response after three injections. The patients were followed up for at least six months. Results: Out of the 30 patients, 28 (93.33% patients had complete resolution of their warts, both at the injected and distant sites. The mean (SD time for complete clearance of warts was 43.71(32.82 days and the mean (SD dose of vaccine that was required for complete clearance of warts was 0.186 ml (0.101. Four patients (14.28% had a recurrence of warts. The treatment was well-tolerated and the side effects were reversible in the majority of the patients. Conclusion: In comparison to the earlier studies using Mycobacterium w vaccine for the treatment of warts, our study was different in the following aspects: No sensitisation dose was given, only a single wart was injected at a time and the duration between the period of injections was increased to four weeks. With all these changes we eliminated the complications due to the sensitisation dose and achieved good results. This study provides new insight into the dose and schedule of treatment of this evolving therapeutic modality.

  9. Risk Factors and Complications Associated with Difficult Retrieval of Embolic Protection Devices in Carotid Artery Stenting

    Purpose: This study was designed to investigate the risk factors and complications of difficult retrieval (DR) of embolic protection devices (EPDs) in carotid artery stenting (CAS). Methods: A total of 195 consecutive patients who underwent CAS between December 2007 and March 2010 in a general hospital were enrolled and divided into two groups: with DR and without DR. The risk factors of DR were analyzed with univariate and multivariate analyses. The complications of DR were recorded and analyzed. Results: A total of 30 (15.4%) patients with DR of EPDs were observed, of whom EPDs were successfully retrieved in 29, and in 1 was it taken out by surgical treatment. The retrieval time was significantly longer in patients with DR (490.5 ± 143.9 s) than in patients without DR (157.2 ± 15.7 s, p = 0.000). Vasospasm was observed more frequently in patients with DR than in patients without DR (55.2% vs. 14.5%, p = 0.000). Intracranial compilations were more frequent in patients with DR than in those without DR (17.2% vs. 0.6%, p = 0.000). Calcified plaques, degree of residual stenosis, types of the stents, and tortuosity index (TI > 80°) were all associated with DR. A logistic regression analysis indicated that calcified plaques (odds ratio (OR) = 6.5; p = 0.000) and TI > 80° (OR = 18.8; p = 0.000) were independent predictors of DR. Conclusions: Calcified plaques and TI > 80° may be related to DR in patients with CAS. DR may lengthen the retrieving time and increase the complications of the procedure.

  10. Assessing the Extraction Potential of Tomsk Region’s Difficult-To-Obtain Oil Reserves

    Irina Valeryevna Sharf

    2016-03-01

    Full Text Available A significant increase in oil production in the Tomsk region can be achieved by a better development of the license areas at the disposal of oil-producing companies, active prospecting, introduction of innovative technologies to increase the oil recovery, as well as active oil extraction from unconventional horizons. This article reviews the activities of the oil-producing companies of the Tomsk region for the past 10 years, and proves the potential of increasing oil production of both traditional and difficultto-obtain oil reserves, concentrated in the Bazhenov and Tyumen Formations and the Lower Jurassic sediments. Technologically, Russia is significantly lagging behind the economically developed countries in the extraction of hard unconventional hydrocarbon resources, primarily, the United States. The observed «shale revolution» was due to the complex of financial and tax breaks for oil companies, from which mainly medium and small companies were benefited. As a result, this requires an increase in investment on the part of economic entities and regional authorities, as well as additional tax benefits, considering the quality and types of actual and prospective raw materials produced in the region, in contrast to the declared benefits in Eastern Siberia. The introduction of tax incentives justified by the authors and the implementation of public-private partnership will ensure the profitability of the development of marginal and difficult-to-obtain oil deposits of the Tomsk region in the long term, which in turn should ensure the stability of economic development of the subject of the Russian Federation

  11. Stepwise optimization of a low-temperature Bacillus subtilis expression system for "difficult to express" proteins.

    Welsch, Norma; Homuth, Georg; Schweder, Thomas

    2015-08-01

    In order to improve the overproduction of "difficult to express" proteins, a low-temperature expression system for Bacillus subtilis based on the cold-inducible promoter of the desaturase-encoding des gene was constructed. Selected regulatory DNA sequence elements from B. subtilis genes known to be cold-inducible were fused to different model genes. It could be demonstrated that these regulatory elements are able to mediate increased heterologous gene expression, either by improved translation efficiency or by higher messenger RNA (mRNA) stability. In case of a cold-adapted β-galactosidase from Pseudoalteromonas haloplanktis TAE79A serving as the model, significantly higher expression was achieved by fusing its coding sequence to the so-called "downstream box" sequence of cspB encoding the major B. subtilis cold-shock protein. The combination of this fusion with a cspB 5'-UTR stem-loop structure resulted in further enhancement of the β-galactosidase expression. In addition, integration of the transcription terminator of the B. subtilis cold-inducible bkd operon downstream of the target genes caused a higher mRNA stability and enabled thus a further significant increase in expression. Finally, the fully optimized expression system was validated by overproducing a B. subtilis xylanase as well as an α-glucosidase from Saccharomyces cerevisiae, the latter known for tending to form inclusion bodies. These analyses verified the applicability of the engineered expression system for extracellular and intracellular protein synthesis in B. subtilis, thereby confirming the suitability of this host organism for the overproduction of critical, poorly soluble proteins. PMID:25851716

  12. Forming Competing Fear Learning and Extinction Memories in Adolescence Makes Fear Difficult to Inhibit

    Baker, Kathryn D.; Richardson, Rick

    2015-01-01

    Fear inhibition is markedly impaired in adolescent rodents and humans. The present experiments investigated whether this impairment is critically determined by the animal's age at the time of fear learning or their age at fear extinction. Male rats (n = 170) were tested for extinction retention after conditioning and extinction at different ages.

  13. Learning Increases the Survival of Newborn Neurons Provided that Learning Is Difficult to Achieve and Successful

    Curlik, Daniel M., II; Shors, Tracey J.

    2011-01-01

    Learning increases neurogenesis by increasing the survival of new cells generated in the adult hippocampal formation [Shors, T. J. Saving new brain cells. "Scientific American," 300, 46-52, 2009]. However, only some types of learning are effective. Recent studies demonstrate that animals that learn the conditioned response (CR) but require more…

  14. Open Boundary Conditions for Dissipative MHD

    Meier, E T

    2011-11-10

    In modeling magnetic confinement, astrophysics, and plasma propulsion, representing the entire physical domain is often difficult or impossible, and artificial, or 'open' boundaries are appropriate. A novel open boundary condition (BC) for dissipative MHD, called Lacuna-based open BC (LOBC), is presented. LOBC, based on the idea of lacuna-based truncation originally presented by V.S. Ryaben'kii and S.V. Tsynkov, provide truncation with low numerical noise and minimal reflections. For hyperbolic systems, characteristic-based BC (CBC) exist for separating the solution into outgoing and incoming parts. In the hyperbolic-parabolic dissipative MHD system, such separation is not possible, and CBC are numerically unstable. LOBC are applied in dissipative MHD test problems including a translating FRC, and coaxial-electrode plasma acceleration. Solution quality is compared to solutions using CBC and zero-normal derivative BC. LOBC are a promising new open BC option for dissipative MHD.

  15. Tracheal intubation with a flexible fibreoptic scope or the McGrath videolaryngoscope in simulated difficult airway scenarios

    Jepsen, Cecilie H; Gtke, Mona R; Thgersen, Bente; Mollerup, Lene T; Ruhnau, Birgitte; Rewers, Mikael; Rosenstock, Charlotte V

    2014-01-01

    BACKGROUND: Flexible fibreoptic endoscopic (FFE) intubation is considered the 'gold-standard' when difficult airway management is anticipated. Several videolaryngoscopes have been developed to facilitate intubation by laryngoscopy. OBJECTIVE: The aim of the study was to compare the performance of...

  16. Condition Monitoring

    Avenas, Yvan; Dupont, Laurent; Baker, Nick; Zara, Henri; Barruel, Franck

    2015-01-01

    Power conversion systems are dependent on the performance and reliability of static converters. However, they are subject to frequent functional and environmental strains, which can induce failures. The anticipation of these failures is difficult but important so the operation of a system can be...... failures can often be tolerated and not lead to a total breakdown of the entire array, whereas a single component failure in the inverter can lead to a collapse of the entire system. Furthermore, solar panel/module manufacturers often offer warranties of up to 20 years, while warranties for inverters...... rarely reach the ten-year mark [1]. As such, the overall cost of a PV inverter can increase by a factor of two or three if it undergoes one or two failures during the life of the system. Although the market competition between PV inverter manufacturers has traditionally focused on the efficiency of their...

  17. Difficult Decisions: Animal Rights--Do We Have the Right to Do Research on Animals?

    Parakh, Jal S.; Slesnick, Irwin L.

    1989-01-01

    Discusses who has the right to determine the use of animals in scientific research which includes medical experimentation and the toxicity testing of compounds, ranging from pesticides to cosmetics. Provides a list of questions for consideration and discussion. (RT)

  18. Three Activities To Assist Biology Teachers in Presenting Conceptually Difficult Topics.

    Taylor, Neil; Tulip, David

    1997-01-01

    Outlines three activities for different areas of biology that can serve as motivators for students or as demonstrations. Each activity is easy to organize and uses available materials. Topics include evolution, anaerobic respiration, and heat loss. (DDR)

  19. Conditional Comonotonicity

    Napp, Clotilde; Jouini, Elyès

    2005-01-01

    In this paper we propose a generalization of the comonotonicity notion by introducing and exploring the concept of conditional comonotonicity. We characterize this notion and we show on examples that conditional comonotonicity is the natural extension of the concept of comonotonicity to dynamic settings.

  20. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways

    Patel, A; S. A. R. Nouraei

    2014-01-01

    Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy–hypoxaemia–re-oxygenation cycles can escalate to airway loss and the ‘can't intubate, can't ventilate’ scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to pro...

  1. Easy and Difficult Performance-Approach Goals: Their moderating effect on the link between task interest and performance attainment

    Monica Blaga; Van Yperen, Nico W

    2008-01-01

    The purpose of this study was to demonstrate that the positive link between task interest and performance attainment can be negatively affected by the pursuit of difficult performance-approach goals. This was tested in a sample of 60 undergraduate students at a Dutch university. In line with expectations, for difficult performance-approach goals there was no link between task interest and performance attainment. Furthermore, among women this relation turned out to be negative. In an easy perf...

  2. A Comparison of Cormeck-Lehane and Mallampati Tests with Mandibular and Neck Measurements for Predicting Difficult Intubation

    Niyazi Acer; Akcan Akkaya; Baki Umut Tuğay; Ahmet Öztürk

    2011-01-01

    Objective: Various prediction tests were formulated to forecast difficult intubation. The Mallampati test, Wilson score, Cormack-Lehane test and thyromental distance are the most commonly used tests pre-operatively to assess the airway. The objective of the present study was to investigate whether a combination of the Mallampati and Cormack-Lehane’s classification to predict difficult intubation compared with sternomental and thyromental distances, mandibular length, width and neck length and...

  3. Nasal Endotracheal Intubation under Fibreoptic Endoscopic Control in Difficult Oral Intubation, Two Pediatric Cases of Submandibular Abscess

    Raval, Chetan; Rashiduddin, Mohammed

    2009-01-01

    Securing an airway in children with trismus is challenging and dangerous. Sound clinical judgment is critical for timing and for selecting the method for airway intervention. We present two pediatric cases of submandibular abscess with difficult oral intubation who underwent incision and drainage. Large facial (jaw) swelling, trismus-limited mouth opening, edema, protruding teeth, and altered airway anatomy makes airway management more difficult. Chances of rupture of abscess intraorally and ...

  4. Chimerical conditionals

    Itamar Francez

    2015-01-01

    Full Text Available This paper introduces and analyzes chimerical conditionals, a class of conditionals that are puzzling vis--vis the distinction between so-called 'biscuit' and hypothetical conditionals. An analysis of this distinction is developed which draws on the pragmatic account of Franke 2009. Building on this analysis, chimericity is then shown to derive from a systematic ambiguity of a definite and often implicit argument in the consequent of chimerical conditionals, between a rigid designator and an individual concept reading. This ambiguity is argued to arise from different ways in which context can resolve familiarity presuppositions. One consequence of the inquiry is that the notion of (independence employed in much work on conditionals cannot be viewed as a relation between propositions, but must be made sensitive to the dynamics of information flow. http://dx.doi.org/10.3765/sp.8.2 BibTeX info

  5. Sustaining Economic Development and the Value of Economic Production: Different Views and Difficult Problems

    Tisdell, Clement A.

    2012-01-01

    Indicates some of the different concepts of sustainable economic development and raises queries about how much present generations are concerned with future generations. A variety of conditions (ranging from very weak to very strong) have been suggested for achieving sustainable development. These are outlined. The prospect that the accumulation of man-made capital may result in unsustainable economic development is discussed and the welfare consequences of the conversion of natural capital a...

  6. Prolactinoma in a Diabetic Dialysis Patient with Erectile Dysfunction: A Difficult Differential Diagnosis

    Piccoli, Giorgina B; Bermont, Francesca; Magnano, Andrea; Soragna, Giorgio; Terzolo, Massimo

    2006-01-01

    Dialysis patients often suffer from erectile dysfunction. The prevalence of this symptom in the context of dialysis is as high as 90%. Diabetes, diffuse vascular disease and pharmacological therapy are attendant causes of this condition, severely impairing the quality of life. Due to the high frequency of erectile dysfunction in uremic patients, minimalist diagnostic approaches are often used. Nevertheless, a careful differential diagnosis is also warranted in well dialyzed patients to identi...

  7. Distraction during learning with hypermedia: Difficult tasks help to keep task goals on track

    KatharinaScheiter; ElkeHeise

    2014-01-01

    In educational hypermedia environments, students are often confronted with potential sources of distraction arising from additional information that, albeit interesting, is unrelated to their current task goal. The paper investigates the conditions under which distraction occurs and hampers performance. Based on theories of volitional action control it was hypothesized that interesting information, especially if related to a pending goal, would interfere with task performance only when workin...

  8. Distraction during learning with hypermedia: difficult tasks help to keep task goals on track

    Scheiter, Katharina; Gerjets, Peter; Heise, Elke

    2014-01-01

    In educational hypermedia environments, students are often confronted with potential sources of distraction arising from additional information that, albeit interesting, is unrelated to their current task goal. The paper investigates the conditions under which distraction occurs and hampers performance. Based on theories of volitional action control it was hypothesized that interesting information, especially if related to a pending goal, would interfere with task performance only when workin...

  9. Modeling temperature and moisture fields in conditioned spaces using zonal approach, including sorption phenomena in buildings materials; Modelisation thermo-hydro-aeraulique des locaux climatises selon l'approche zonale (prise en compte des phenomenes de sorption d'humidite)

    Cordeiro Mendoca, K.

    2004-05-15

    Building simulation models represent in our days an important tool for building conception and performance analysis. Although moisture interacts in many ways with the whole building affecting therefore its behavior, frequently these models neglects the interactions between them. In addition, in most of them, indoor air conditions are considered uniform, which is a non-realistic assumption in conditioned spaces. In this work, a model to predict temperature and moisture fields in conditioned spaces, using zonal approach, is proposed. This method is based in dividing spatially a room in a relative small number of zones, typically on the order of tens to hundreds, where the state variables of air are considered uniform, with the exception of pressure that varies hydrostatically. While not as fine-grained as CFD simulation, zonal models do give useful information about temperature and moisture distributions that is important in comfort analysis. The proposed model was structured in three groups of sub-models representing the three building domains: indoor air, envelope and HVAC system. The indoor air sub-model is related to the indoor air space, where airflow speed can be considered weak. The envelope sub-model is related to the radiation exchanges between envelope and its neighborhood, and to the simultaneous heat and mass transfers across the envelope material. This latest can be represented by four sub-models of different complexity levels, with two of them taking into account moisture adsorption and desorption by building materials. Concerning to the HVAC system model, it refers to the whole system that means equipment, control and specific airflow from equipment. All sub-models were coupled into a modular simulation environment, SPARK, well-adapted to compare different models. The applicability of the proposed model is shown by two examples. The first one shows the importance of considering moisture sorption phenomena in the prediction of indoor air conditions, while the second shows the impact of the external environment in the behavior of a conditioned space and in its HVAC system performance. (author)

  10. Power Flow Study Including FACTS Devices

    T.THYAGARAJAN; Dash, S.S.; Sahoo, A. K.

    2010-01-01

    The electric power industry is undergoing the most profound technical, economic and organizational changes since, its inception some one hundred years ago. This paradigm is the result of the liberalization process, stipulated by politics and followed up by industry. In countries like India with fast growing demand of electric power it is difficult to extend the transmission system in time by either building new lines or by introduction of a new voltage level. Power is therefore transmitted th...

  11. Conditional Punishment

    Kamei, Kenju

    2014-01-01

    We elicit human conditional punishment types by conducting experiments. We find that their punishment decisions to an individual are on average significantly positively proportional to other members punishment decisions to that individual.

  12. Asking Difficult Questions: Exploring Research Methods with Children on Painful Issues

    Leeson, Caroline

    2014-01-01

    Assumptions about a child's competence to voice an opinion often inhibit efforts to find effective methods for participation. Answers to questions are sought from the significant adults who surround a child [Morris, J. 2003. "Including All Children: Finding Out about the Experiences of Children with Communication and/or Cognitive…

  13. GEOTHERMAL AIR CONDITIONING

    Rahul Vadher; Hiren Prajapati

    2015-01-01

    This paper discusses the use of geothermal energy in air - conditioning system. Geothermal energy is an interesting alternative concerning the production of energy for air conditioning of building (heating or c ooling). The content of the paper includes a description of the Geothermal cooling system . In this paper includes the experimental analysis of the system and the heat transfer calculations. This paper will helpful for those who wish to...

  14. Is less really more: Does a prefrontal efficiency genotype actually confer better performance when working memory becomes difficult?

    Ihne, Jessica L; Gallagher, Natalie M; Sullivan, Marie; Callicott, Joseph H; Green, Adam E

    2016-01-01

    Perhaps the most widely studied effect to emerge from the combination of neuroimaging and human genetics is the association of the COMT-Val(108/158)Met polymorphism with prefrontal activity during working memory. COMT-Val is a putative risk factor in schizophrenia, which is characterized by disordered prefrontal function. Work in healthy populations has sought to characterize mechanisms by which the valine (Val) allele may lead to disadvantaged prefrontal cognition. Lower activity in methionine (Met) carriers has been interpreted as advantageous neural efficiency. Notably, however, studies reporting COMT effects on neural efficiency have generally not reported working memory performance effects. Those studies have employed relatively low/easy working memory loads. Higher loads are known to elicit individual differences in working memory performance that are not visible at lower loads. If COMT-Met confers greater neural efficiency when working memory is easy, a reasonable prediction is that Met carriers will be better able to cope with increasing demand for neural resources when working memory becomes difficult. To our knowledge, this prediction has thus far gone untested. Here, we tested performance on three working memory tasks. Performance on each task was measured at multiple levels of load/difficulty, including loads more demanding than those used in prior studies. We found no genotype-by-load interactions or main effects of COMT genotype on accuracy or reaction time. Indeed, even testing for performance differences at each load of each task failed to find a single significant effect of COMT genotype. Thus, even if COMT genotype has the effects on prefrontal efficiency that prior work has suggested, such effects may not directly impact high-load working memory ability. The present findings accord with previous evidence that behavioral effects of COMT are small or nonexistent and, more broadly, with a growing consensus that substantial effects on phenotype will not emerge from candidate gene studies. PMID:26649915

  15. UK Shale Gas – Hype, Reality and Difficult Questions: OIES paper

    Rogers, Howard

    2013-01-01

    The shale gas phenomenon has transformed the US from prospective LNG importer to the current expectation of it becoming a major LNG exporter. In the UK the recent upgraded estimates by the British Geological Society of shale gas resources in the north of England have unleashed a wave of speculation in the media which includes an anticipation of lower prices and eliminating the need for natural gas imports. Drawing on US data, this Comment seeks to highlight the practicalities to be faced ...

  16. Automated plough technology - a reliable and efficient extraction method even under difficult conditions; Automatisierte Hobeltechnik - Eine zuverlaessige und leistungsfaehige Gewinnungstechnik auch unter schwierigen Bedingungen

    Paschedag, U. [DBT GmbH, Luenen (Germany)

    2001-08-30

    Nowadays predominantly stripping extraction methods are used in the underground working of coal by the longwall method with seam thicknesses of less than 1,8 m - regardless of the dip or hardness of the coal. High coal yield and the small proportions of enclosing rock also stripped by the plough are important factors in determination of the profitability. The contribution describes the state of plough technology in 2001. Special attention is paid to the automation of the plough horizon control. (orig.) [German] Im untertaegigen Abbau von Steinkohle im Langfrontbau werden heute bei Floezmaechtigkeit von unter 1,8 m - unabhaengig vom Einfallen oder Haerte der Kohle - vornehmlich schaelende Abbautechniken angewandt. Hohe Kohlenausbeute und geringe Anteile an mitgeschnittenem Nebengestein bestimmen dabei die Wirtschaftlichkeit massgeblich. Im Beitrag wird der Stand der Hobeltechnik im Jahr 2001 vorgestellt. Dabei wird das Hauptaugenmerk auf die Automatisierung der Hobel-Horizont-Steuerung gerichtet. (orig.)

  17. Alternative method of inservice hydraulic testing of difficult to test pumps

    The pump test codes require that system resistance be varied until the independent variable (either the pump flow rate or differential pressure) equals its reference value. Variance from this fixed reference value is not specifically allowed. However, the design of many systems makes it impractical to set the independent variable to an exact value. Over a limited range of pump operation about the fixed reference value, linear interpolation between two points of pump operation can be used to accurately determine degradation at the reference value without repeating reference test conditions. This paper presents an overview of possible alternatives for hydraulic testing of pumps and a detailed discussion of the linear interpolation method. The approximation error associated with linear interpolation is analyzed. Methods to quantify and minimize approximation error are presented

  18. Difficult case of Cronkhite-Canada syndrome with small intestinal bacterial overgrowth, Clostridium difficile infection and polymyalgia rheumatica.

    Traussnigg, Stefan; Dolak, Werner; Trauner, Michael; Kazemi-Shirazi, Lili

    2016-01-01

    A 64-year-old woman presented with heavy diarrhoea, nausea and weight loss accompanied by alopecia and dystrophic fingernails and toenails. The preceding diagnosis of an inflammatory bowel disease, a common pitfall, was excluded by endoscopic work up. Instead, Cronkhite-Canada syndrome (CCS), a rare polyposis condition, was identified as the reason for this almost pathognomonic combination of diagnostic findings including various polyps throughout the entire intestine and ectodermal abnormalities. This case exemplifies common risks and complications in terms of gastrointestinal malabsorption, infections and small intestinal bacterial overgrowth (SIBO), including its treatment as well as a hereto unreported association with polymyalgia rheumatica. In CCS, long-term immunosuppressive therapy and close endoscopic cancer screening of the patient is essential. The treatment of vitamin deficiency and recurring SIBO helps to reduce symptoms. PMID:26818813

  19. Modeling of tamped and decoupled explosions in salt (simulation is easy. Prediction is difficult exclamation point)

    We compare predictions of the strain hardening model of Glenn (1990), with and without damage, to free field and seismic observations of SALMON, STERLING, and 64 kt (tamped) and 8 kt (decoupled) explosions in an Azgir salt dome in the former Soviet Union (FSU). We find good agreement between the model (without damage) and observations of both SALMON and STERLING. In contrast, the average spectral ratio of the tamped to decoupled Azgir explosions is systematically smaller than predicted by the strain hardening model without damage. Much better agreement is obtained when damage is included in the model of the decoupled Azgir explosion

  20. Difficult Management of Coronary Artery Disease in a Patient with Thrombotic Thrombocytopenic Purpura

    Fatemeh Jorfi

    2015-10-01

    Full Text Available Thrombotic thrombocytopenic purpura (TTP is a rare syndrome affecting multiple organs. There is no sufficient evidence regarding the clinical cardiac manifestations of TTP. Nonetheless, pathologic cardiac involvement is quite frequent in acute TTP, which is predominantly manifested as myocardial necrosis due to coronary arteriolar microthrombosis. The present case report describes a 43-year-old man with long-standing remitted TTP, who suffered from a sequence of refractory thrombotic epicardial coronary events. Aggressive medical and interventional therapies, including long-term dual antiplatelets and coronary angioplasty, were finally successful in remitting the thrombotic events. During his two-year follow up, he has been asymptomatic.

  1. Modeling of tamped and decoupled explosions in salt (Simulation is easy. Prediction is difficult exclamation point)

    We compare predictions of the strain hardening model of Glenn (1990), with and without damage, to free field and seismic observations of SALMON, STERLING, and 64 kt (tamped) and 8 kt (decoupled) explosions in an Azgir salt dome in the former Soviet Union (FSU). We find good agreement between the model (without damage) and observations of both SALMON and STERLING. In contrast, the average spectral ratio of the tamped to decoupled Azgir explosions is systematically smaller than predicted by the strain hardening model without damage. Much better agreement is obtained when damage is included in the model of the decoupled Azgir explosion

  2. Modeling of tamped and decoupled explosions in salt (Simulation is easy. Prediction is difficult!)

    Goldstein, P.; Glenn, L.A.

    1993-05-01

    We compare predictions of the strain hardening model of Glenn (1990), with and without damage, to free field and seismic observations of SALMON, STERLING, and 64 kt (tamped) and 8 kt (decoupled) explosions in an Azgir salt dome in the former Soviet Union (FSU). We find good agreement between the model (without damage) and observations of both SALMON and STERLING. In contrast, the average spectral ratio of the tamped to decoupled Azgir explosions is systematically smaller than predicted by the strain hardening model without damage. Much better agreement is obtained when damage is included in the model of the decoupled Azgir explosion.

  3. Retraction note: The prevalence of obstructive sleep apnea in patients with difficult-to-treat asthma.

    2015-12-01

    This original article, published in the Asian Pacific Journal of Allergy and Immunology, has been retracted from this journal based on an error in the analysis included a patient who has not given informed consent. The authors could not be contacted to provide the explanation. Due to the nature of the error, the Editor-in-Chief and the Associate Editors have decided to retract this article although this error does not affect the validity of the study. We apologize for any adverse consequences this may have caused. PMID:26708400

  4. Investigation of the radiochromic dye film dosimeter under process conditions, including stability, precision, accuracy, the influence of dose rate, and the influence of the environment. Part of a coordinated programme on high-dose standardization and intercomparison for industrial radiation processing

    In the course of the work irradiations have been performed with both Cobalt-60 gamma and electron accelerators. Readout of radiation induced optical densities has been made on various spectrophotometers. Irradiations have been performed under changing conditions of temperature, relative humidity and dose rate, investigating various types of the polyvinyl butyral dosimeters with respect to their sensitivity, stability and optical and mechanical properties. A new formulation of the solution from which dosimeters are cast has been developed. The dosimeter has been found to be rather independent of changes in absorbed dose rate. Maximum deviations are 15% in the range of 0.2 Gy/sec to 1012 Gy/sec. It has been shown that a short heat treatment after irradiation stabilizes the response and enhances it slightly. The plastic film dosimeter consisting of a radiochromic dye precursor (hexa(hydroxyethyl)pararosaniline cyanide) dissolved in a plastic matrix has been investigated and further developed. The dosimeter has been shown to be highly usable for industrial purposes, but suffers still from drawbacks, namely sensitivity to UV light and the need of frequent recalibrations, factors, however, which future work may be able to eliminate

  5. Extending Newtonian Dynamics to Include Stochastic Processes

    Zak, Michail

    2009-01-01

    A paper presents further results of continuing research reported in several previous NASA Tech Briefs articles, the two most recent being Stochastic Representations of Chaos Using Terminal Attractors (NPO-41519), [Vol. 30, No. 5 (May 2006), page 57] and Physical Principle for Generation of Randomness (NPO-43822) [Vol. 33, No. 5 (May 2009), page 56]. This research focuses upon a mathematical formalism for describing post-instability motions of a dynamical system characterized by exponential divergences of trajectories leading to chaos (including turbulence as a form of chaos). The formalism involves fictitious control forces that couple the equations of motion of the system with a Liouville equation that describes the evolution of the probability density of errors in initial conditions. These stabilizing forces create a powerful terminal attractor in probability space that corresponds to occurrence of a target trajectory with probability one. The effect in configuration space (ordinary three-dimensional space as commonly perceived) is to suppress exponential divergences of neighboring trajectories without affecting the target trajectory. As a result, the post-instability motion is represented by a set of functions describing the evolution of such statistical quantities as expectations and higher moments, and this representation is stable.

  6. Simulation of containment jet flows including condensation

    The validation of a CFD code for light-water reactor containment applications requires among others the presence of steam in the different flow types like jets or buoyant plumes and leads to the need to simulate condensation phenomena. In this context the paper addresses the simulation of two 'HYJET' experiments from the former Battelle Model Containment by the CFD code CFX. These experiments involve jet releases into the multi-compartment geometry of the test facility accompanied by condensation of steam at walls and in the bulk gas. In both experiments mixtures of helium and steam are injected. Helium is used to simulate hydrogen. One experiment represents a fast jet whereas in the second test a slow release of helium and steam is investigated. CFX was earlier extended by bulk and wall condensation models and is able to model all relevant phenomena observed during the experiments. The paper focuses on the simulation of the two experiments employing an identical model set-up. This provides together with other validation exercises the information on how well a wider range of flowing conditions in a full containment simulation can be covered with a single set of models (e.g. turbulence and condensation model). Some aspects related to numerical and modelling uncertainties of CFD calculations are included in the paper by investigating different turbulence models together with the modelling errors of the differencing schemes applied.

  7. Can Health Trainers Make a Difference With Difficult-to-Engage Clients? A Multisite Case Study.

    Bailey, Di; Kerlin, Lianne

    2015-09-01

    A political attempt in the United Kingdom to address health inequalities in the past decade has been the government's initiative to employ local health trainers (HTs) or health trainer champions (HTCs) to support disadvantaged individuals with aspects of their health-related behaviors. HT/HTCs provide health-related information and support to individuals with healthy eating, physical activity, and smoking cessation. They undertake community engagement and direct individuals to relevant health services. They differ in that HTs are trained to provide health interventions to individuals or groups and to make referrals to specialist health care services when necessary. This article provides an evaluation of HT/HTCs interventions across three sites, including one prison, one probation service (three teams), and one mental health center. An evaluation framework combining process and outcome measures was employed that used mixed methods to capture data relating to the implementation of the service, including the context of the HT/HTCs interventions, the reactions of their clients, and the outcomes reported. It was found that HT/HTCs interventions were more effective in the prison and mental health center compared with the probation site largely as a result of contextual factors. PMID:25794692

  8. Difficult decisions: Migration from Small Island Developing States under climate change

    Kelman, Ilan

    2015-04-01

    The impacts of climate change on Small Island Developing States (SIDS) are leading to discussions regarding decision-making about the potential need to migrate. Despite the situation being well-documented, with many SIDS aiming to raise the topic to prominence and to take action for themselves, limited support and interest has been forthcoming from external sources. This paper presents, analyzes, and critiques a decision-making flowchart to support actions for SIDS dealing with climate change-linked migration. The flowchart contributes to identifying the pertinent topics to consider and the potential support needed to implement decision-making. The flowchart has significant limitations and there are topics which it cannot resolve. On-the-ground considerations include who decides, finances, implements, monitors, and enforces each decision. Additionally, views within communities differ, hence mechanisms are needed for dealing with differences, while issues to address include moral and legal blame for any climate change-linked migration, the ultimate goal of the decision-making process, the wider role of migration in SIDS communities and the right to judge decision-making and decisions. The conclusions summarize the paper, emphasizing the importance of considering contexts beyond climate change and multiple SIDS voices.

  9. German is not Necessarily more Difficult than English: Evidence from a comparison among English, German and Hanyu Pinyin

    Jian-xiong WU layout editor

    2007-01-01


    In the area of foreign language learning in China, it is a widely-received view that German is more difficult to learn than English. Few people have realized that the factors that make German difficult to learn can in fact make it easier to learn. This article argues that it is not necessarily the case. Through comparing three pairs of relations in German, English and Hanyu-Pinyin, the author shows that there is a similarity between German and Hanyu-Pinyin in terms of pronunciatio...

  10. Wire-guided (Seldinger technique intubation through a face mask in urgent, difficult and grossly distorted airways

    Jake M Heier

    2012-01-01

    Full Text Available We report two cases of successful urgent intubation using a Seldinger technique for airway management through an anesthesia facemask, while maintaining ventilation in patients with difficult airways and grossly distorted airway anatomy. In both cases, conventional airway management techniques were predicted to be difficult or impossible, and a high likelihood for a surgical airway was present. This technique was chosen as it allows tracheal tube placement through the nares during spontaneous ventilation with the airway stented open and oxygen delivery with either continuous positive airway pressure and/or pressure support ventilation. This unhurried technique may allow intubation when other techniques are unsuitable, while maintaining control of the airway.

  11. Conditional Extremals

    Noakes, Lyle

    2011-01-01

    Imagine that measurements are made at times $t_0$ and $t_1$ of the trajectory of a physical system whose governing laws are given approximately by a class ${\\cal A}$ of so-called {\\em prior vector fields}. Because the physical laws are not known precisely, it might be that the measurements are not realised by the integral curve of any prior field. We want to estimate the behaviour of the physical system between times $t_0$ and $t_1$. An integral curve of an arbitrary vector field $X$ is said to be {\\em feasible} when it interpolates the measurements. When $X$ is critical for $L^2$ distance to ${\\cal A}$, the feasible curve is called a {\\em conditional extremum}. When the distance to ${\\cal A}$ is actually minimal, the conditional extremum is a best estimate for the intermediate behaviour of the system. The present paper does some of basic groundwork for investigating mathematical properties of conditional extrema, focusing on cases where ${\\cal A}$ comprises a single prior field $A$. When $A={\\bf 0}$ a condit...

  12. Difficult to predict early failure after major lower-extremity amputations

    Kristensen, Morten Tange; Holm, Gitte; Gebuhr, Peter

    2015-01-01

    INTRODUCTION: The successful outcome of a major amputation depends on several factors, including stump wound healing. The purpose of this study was to examine the criteria upon which the index amputation was based and to identify factors associated with early amputation failure after major non......-traumatic lower-extremity amputation. METHODS: We studied a consecutive one-year series of 36 men and 34 women with a median (25-75% quartiles) age of 72 (63-83) years who were treated in an acute orthopaedic ward; 44 below-knee and 26 above-knee amputees of whom 47 had an American Society of Anesthesiologists...... rating above two. Patient characteristics and other factors potentially influencing early amputation failure within 30 days were evaluated. RESULTS: Eleven patients died (16%) and 11 (16%) had a re-amputation at a higher level, whereas four (6%) had a major revision at the same level within 30 days...

  13. Education and training in radiation protection: a challenge in passing on a difficult and intricate message

    Current radiation protection is a very sophisticated and elaborate domain where, once the information about the exposure of persons is known in terms of the quantity of the effective dose, we can predict resulting radiological consequences related to the stochastic risk to the health of the exposed persons without a need for other details. In fact, the effective dose contains all pertinent information including the average organ dose distribution and relevant radiation and tissue weighting factors which take into account the specific effects of different types of radiation and selected tissue radiosensitivity. Since the effective dose cannot be measured directly, one has to rely on the monitoring of other appropriate measurable quantities and then do some conversions. The current structure of radiation protection quantities includes too many quantities, the definitions of some of which are not easy to understand and interpret. Moreover, there are numerous quantities based on the dose equivalent, such as the equivalent dose, effective dose, committed equivalent dose, committed effective dose, collective equivalent dose, collective effective dose, personal dose equivalent, ambient dose equivalent and directional dose equivalent, where the only unit of Sv is used.. There are a number of cases in open literature reflecting the difficulties and mistakes in the use of radiation protection quantities. Even more complicated situations are encountered in the field, where the staff responsible for personal and workplace monitoring is confused because of so many different quantities and where the staff may not be qualified and experienced enough to be able to make the relevant conversions and interpretations. The paper summarizes our experience in teaching students and lecturing in various training courses addressing radiation protection where the primary task was to ensure that all radiation protection personnel understood the quantities and units used in radiation protection in the correct way consistent with their latest definitions and ICRP recommendations. (author)

  14. Education and training in radiation protection: a challenge in passing on a difficult and intricate message

    Sabol, Jozef; Hudzietzova, Jana; Rosina, Jozef, E-mail: j.sabol44@gmail.com, E-mail: hudzijan@fbmi.cvut.cz, E-mail: rosina@fbmi.cvut.cz [Faculty of Biomedical Engineering, Czech Technical University in Prague (Czech Republic)

    2013-07-01

    Current radiation protection is a very sophisticated and elaborate domain where, once the information about the exposure of persons is known in terms of the quantity of the effective dose, we can predict resulting radiological consequences related to the stochastic risk to the health of the exposed persons without a need for other details. In fact, the effective dose contains all pertinent information including the average organ dose distribution and relevant radiation and tissue weighting factors which take into account the specific effects of different types of radiation and selected tissue radiosensitivity. Since the effective dose cannot be measured directly, one has to rely on the monitoring of other appropriate measurable quantities and then do some conversions. The current structure of radiation protection quantities includes too many quantities, the definitions of some of which are not easy to understand and interpret. Moreover, there are numerous quantities based on the dose equivalent, such as the equivalent dose, effective dose, committed equivalent dose, committed effective dose, collective equivalent dose, collective effective dose, personal dose equivalent, ambient dose equivalent and directional dose equivalent, where the only unit of Sv is used.. There are a number of cases in open literature reflecting the difficulties and mistakes in the use of radiation protection quantities. Even more complicated situations are encountered in the field, where the staff responsible for personal and workplace monitoring is confused because of so many different quantities and where the staff may not be qualified and experienced enough to be able to make the relevant conversions and interpretations. The paper summarizes our experience in teaching students and lecturing in various training courses addressing radiation protection where the primary task was to ensure that all radiation protection personnel understood the quantities and units used in radiation protection in the correct way consistent with their latest definitions and ICRP recommendations. (author)

  15. Pseudotumoral autoimmune pancreatitis mimicking a pancreatic cancer: a very difficult disease to diagnose

    Sadreddine Ben Abid

    2012-10-01

    Full Text Available Autoimmune pancreatitis (AIP is a rare disorder, although the exact prevalence is still unkown. It is a type of pancreatitis that is presumed to have an autoimmune aetiology, and is currently diagnosed based on a combination of 5 criteria. However, in this day and age, some patients with AIP are likely to be resected for the suspicion of malignancy. The authors report a case of pseudo-tumoral autoimmune pancreatitis, reviewing some literature about it and underlining the difficulty in the diagnosis. A 56- year-old patient was referred to our unit for upper abdominal pain. In his past medical history we note mellitus diabetes. The clinical examination was unremarkable. Laboratory data showed no abnormal values. Upper endoscopy showed antral gastritis. Transabdominal ultrasonography showed a hepatic steatosis and 5 angiomas. No computed tomography scan was made. Magnetic resonance imaging (MRI showed 5 angiomas and a lesion of 20x20 mm of the pancreatic tail with decreased signal intensity on T1-weighted MR images, increased signal intensity on T2-weighted MR images. Due to concerns of pancreatic malignancy, the patient underwent open distal spleno-pancreatectomy. Histolo gical analysis of the resected specimen revealed no malignancy. Postoperatively, immunoglobulin G fraction 4 was slightly above of the upper limit of the normal range. After corticotherapy the patient is getting better. This case underlines the difficulties still encountered in the diagnosis of AIP. It has been frequently misdiagnosed as pancreatic cancer and caused unnecessary resection. In order to avoid unnecessary resections for an otherwise benign and easily treatable condition, it is urgent to refine diagnostic criteria and to reach an international consensus.

  16. Making a task difficult: evidence that device-oriented steps are effortful and error-prone.

    Ament, Maartje G A; Cox, Anna L; Blandford, Ann; Brumby, Duncan P

    2013-09-01

    Errors in the execution of procedural tasks can have severe consequences. Attempts to ameliorate these slip errors through increased training and motivation have been shown to be ineffective. Instead, we identified the steps in a task procedure on which errors are most likely to occur, so that these might be designed out of the task procedure in the first place. Specifically, we considered whether device-oriented steps (i.e., steps in the task procedure that do not directly contribute to the achievement of the task goal) are more error-prone than task-oriented steps (i.e., steps that do directly contribute to the task goal). Two experiments are reported in which participants were trained to perform a novel procedural task. Across conditions, we manipulated the extent to which each step in the task procedure appeared to contribute to the achievement of the task goal (i.e., alternating the assignment of a task step between device- and task-oriented), while keeping the interface and underlying task procedure the same. Results show that participants made more errors and took longer to complete a task step when it played a device-oriented role rather than a task-orientated role. These effects were exacerbated by the introduction of a secondary task designed to increase working memory load, suggesting that when a task step plays a device-oriented role it is more weakly represented in memory. We conclude that device-oriented task steps are inherently problematic and should be avoided where possible in the design of task procedures. PMID:24059822

  17. Experience with simulator training for emergency conditions

    The training of operators by the use of simulators is common to most countries with nuclear power plants. Simulator training programmes are generally well developed, but their value can be limited by the age, type, size and capability of the simulator. Within these limits, most full scope simulators have a capability of training operators for a range of design basis accidents. It is recognized that human performance under accident conditions is difficult to predict or analyse, particularly in the area of severe accidents. These are rare events and by their very nature, unpredictable. Of importance, therefore, is to investigate the training of operators for severe accident conditions, and to examine ways in which simulators may be used in this task. The International Nuclear Safety Advisory Group (INSAG) has reviewed this field and the associated elements of human behaviour. It has recommended that activities are concentrated on this area. Initially it is encouraging the following objectives: i) To train operators for accident conditions including severe accidents and to strongly encourage the development and use of simulators for this purpose; ii) To improve the man-machine interface by the use of computer aids to the operator; iii) To develop human performance requirements for plant operating staff. As part of this work, the IAEA convened a technical committee on 15-19 September 1986 to review the experience with simulator training for emergency conditions, to review simulator modelling for severe accident training, to examine the role of human cognitive behaviour modelling, and to review guidance on accident scenarios. A substantial deviation may be a major fuel failure, a Loss of Coolant Accident (LOCA), etc. Examples of engineered safety features are: an Emergency Core Cooling System (ECCS), and Containment Systems. This report was prepared by the participants during the meeting and reviewed further in a Consultant's Meeting. It also includes papers which were presented during the meeting. A separate abstract was prepared for each of these 9 papers. Refs, figs, tabs

  18. Total Hip Arthroplasty Using the S-ROM-A Prosthesis for Anatomically Difficult Asian Patients

    Hozumi, Akira; Kobayashi, Kyousuke; Tsuru, Nobuhisa; Miyamoto, Chikara; Maeda, Jyunichiro; Chiba, Ko; Goto, Hisataka; Osaki, Makoto

    2015-01-01

    Background. The S-ROM-A prosthesis has been designed for the Asian proximal femur with a small deformed shape and narrow canal. In this study, the clinical and radiological results using the S-ROM-A prosthesis for Japanese patients with severe deformity due to dysplasia and excessive posterior pelvic tilt were examined. Methods. 94 hips were followed up for a mean of 55 months, with a mean age at surgery of 61 years. The primary diagnoses were 94 coxarthritis cases, including 51 dysplasia and 37 primary OA, 1 avascular necrosis, 2 traumatic arthritis, and 3 Perthes disease. Thirty-one hips had been treated with osteotomy of the hip joints. Preoperative intramedullary canal shapes were stovepipe in 23 hips, normal in 51 hips, and champagne-flute in 5 hips. The maximum pelvic inclination angle was 56. Results. The mean JOA score improved from 46 points preoperatively to 80 points at final follow-up. On radiological evaluation of the fixation of the implants according to the Engh classification, 92 (97%) hips were classified as bone ingrown fixation. Conclusion. In primary THA, using the S-ROM-A prosthesis for Asian patients with proximal femoral deformity, even after osteotomy and with posterior pelvic tilt, provided good short- to midterm results. PMID:26582575

  19. Jet grouting for a groundwater cutoff wall in difficult glacial soil deposits

    Jet grouting is being used as part of a groundwater cutoff wall system in a major New York City subway construction project to limit drawdowns in an adjacent PCB contamination plume. A circular test shaft of jet grout columns was conducted during the design phase to obtain wall installation parameters. The test program also included shaft wall mapping, and measurements of; inflows, piezometric levels, ground heave and temperature, and jet grout hydraulic conductivity. An axisymmetric finite element method groundwater model was established to back calculate the in-situ hydraulic conductivities of both the surrounding glacial soils and the jet grout walls by matching observed inflows and piezometric levels. The model also verified the use of packer permeability test as a tool in the field to evaluate the hydraulic conductivities of jet grout columns. Both the test program and analytic studies indicated that adjustments to the construction procedures would be required to obtain lower hydraulic conductivities of the jet grout walls for construction. A comparison is made with the conductivities estimated from the test program/analytic studies with those from the present construction

  20. Critical appraisal of pralatrexate in the management of difficult-to-treat peripheral T cell lymphoma

    Casanova M

    2011-10-01

    Full Text Available M Casanova, A Medina-Pérez, M Moreno-Beltran, M Mata-Vazquez, A RuedaOncohematology Service, Hospital Costa del Sol, Marbella, SpainAbstract: Aggressive T cell lymphomas are a subgroup of lymphomas with a particularly poor prognosis. This is especially true for patients with recurrent or refractory disease, who typically have limited response to salvage therapy and extremely poor overall survival. For this reason, there is a strong need to develop potentially active drugs for these malignancies. Pralatrexate is a novel antifolate designed to have high affinity for reduced folate carrier type 1. Preclinical and clinical studies have demonstrated that pralatrexate has significant activity against T cell lymphomas. The dose-limiting toxicity for pralatrexate is mucositis, which can be abrogated with folic acid and vitamin B12 supplementation. Pralatrexate is the first single agent approved for the treatment of patients with relapsed or refractory peripheral T cell lymphoma. This approval was based on an overall objective response rate observed in the pivotal study. The overall response rate was 29%, with a median duration of 10.1 months. This article reviews the biochemistry, preclinical experience, metabolism, and pharmacokinetics of pralatrexate, including the clinical experience with this agent in lymphoma. Future areas of development are now focused on identifying synergistic combinations of pralatrexate with other agents and the evaluation of predictive markers for clinical benefit.Keywords: pralatrexate, peripheral T cell lymphoma

  1. Meniere′s disease: Still a mystery disease with difficult differential diagnosis

    Vassiliou A

    2011-01-01

    Full Text Available One hundred and forty-six years after its first description, the differential diagnosis of Meniere′s disease remains very challenging. The aim of the present study is to review the current knowledge on the advantages and disadvantages of the new diagnostic methods for Meniere′s disease. The importance of accurate diagnosis for primary healthcare systems is also discussed. An extensive search of the literature was performed in Medline and other available database sources. Information from electronic links and related books were also included. Controlled clinical studies, prospective cohort studies, retrospective cohort studies, cross-sectional studies, case reports, written guidelines, systematic reviews, and books were selected. The typical clinical triad of symptoms from the vestibular and cochlear systems (recurrent vertigo, fluctuating sensorineural hearing loss and tinnitus is usually the key for clinical diagnosis. Glycerol dehydration test and electrocochleography are the main diagnostic tests in current practice, while vestibular evoked myogenic potentials may be used in disease staging. Imagine techniques are not specific enough to set alone the diagnosis of Meniere′s disease, although they may be necessary to exclude other pathologies. Recently developed 3D MRI protocols can delineate the perilymphatic/endolymphatic spaces of the inner ear and aid diagnosis. Meniere′s disease is a continuous problem for the patients and affects their quality of life. Taking into account the frequent nature of the disease in certain countries, efforts for reliable diagnosis, prompt referral, and successful management are undoubtedly cost-effective for healthcare systems.

  2. Difficult to Control Asthma: Epidemiology and its Link with Environmental Factors

    Sheehan, William J.; Phipatanakul, Wanda

    2015-01-01

    Purpose of review The aim of the present review is to discuss the epidemiology of inadequate asthma control with an examination of contributing environmental factors. Recent findings Despite advances in asthma therapies, a proportion of patients with asthma continue to have difficulty gaining adequate asthma control. Asthma severity and control in childhood is of particular importance as it translates to asthma morbidity in adulthood. Children with comorbid severe allergic rhinitis were more likely to have uncontrolled asthma. Recent data suggest that mouse allergen, more so than cockroach allergen, may be the most relevant urban allergen exposure. Tobacco smoke exposure, even passive exposure, leads to increased asthma symptoms and decreased response to inhaled corticosteroids. Efforts to ban smoking in public places have resulted in promising asthma results for entire populations. Energy saving efforts to tighten a homes air leaks can lead to increased indoor pollutant levels and, therefore, must be accompanied by efforts to reduce, filter, or exchange indoor pollutants. Obesity is independently associated with decreased asthma control. Furthermore, the detrimental effects of pollutant exposure are enhanced in an overweight individual with asthma. Summary Lack of asthma control can be due to a complex web of factors including adherence, intrinsic factors, and environmental exposures. Further research on intervention strategies is needed to achieve improved rates of asthma control. PMID:26226354

  3. Jet grouting for a groundwater cutoff wall in difficult glacial soil deposits

    Flanagan, R.F.; Pepe, F. Jr. [Parsons Brinckerhoff Quade & Douglas, New York, NY (United States)

    1997-12-31

    Jet grouting is being used as part of a groundwater cutoff wall system in a major New York City subway construction project to limit drawdowns in an adjacent PCB contamination plume. A circular test shaft of jet grout columns was conducted during the design phase to obtain wall installation parameters. The test program also included shaft wall mapping, and measurements of; inflows, piezometric levels, ground heave and temperature, and jet grout hydraulic conductivity. An axisymmetric finite element method groundwater model was established to back calculate the in-situ hydraulic conductivities of both the surrounding glacial soils and the jet grout walls by matching observed inflows and piezometric levels. The model also verified the use of packer permeability test as a tool in the field to evaluate the hydraulic conductivities of jet grout columns. Both the test program and analytic studies indicated that adjustments to the construction procedures would be required to obtain lower hydraulic conductivities of the jet grout walls for construction. A comparison is made with the conductivities estimated from the test program/analytic studies with those from the present construction.

  4. Environmental Sustainability - Including Land and Water Use

    Assessments of environmental sustainability can be conducted in many ways with one of the most quantitative methods including Life Cycle Impact Assessment (LCIA). While historically LCIA has included a comprehensive list of impact categories including: ozone depletion, global c...

  5. Politeness Strategies in Healthcare Communication at "Difficult Times": A Pragmatic Analysis of the "Manga" Discourse in "Nurse Aoi"

    Matsuoka, Rieko; Poole, Gregory

    2015-01-01

    This paper examines the ways in which healthcare professionals interact with patients' family members, and/or colleagues. The data are from healthcare discourses at difficult times found in the manga series entitled Nurse AOI. As the first step, we selected several communication scenes for analysis in terms of politeness strategies. From these

  6. Why Is Statistics Perceived as Difficult and Can Practice during Training Change Perceptions? Insights from a Prospective Mathematics Teacher

    Fitzmaurice, Olivia; Leavy, Aisling; Hannigan, Ailish

    2014-01-01

    An investigation into prospective mathematics/statistics teachers' (n = 134) conceptual understanding of statistics and attitudes to statistics carried out at the University of Limerick revealed an overall positive attitude to statistics but a perception that it can be a difficult subject, in particular that it requires a great deal of discipline…

  7. Difficult Dialogues, Privilege and Social Justice: Uses of the Privileged Identity Exploration (PIE) Model in Student Affairs Practice

    Watt, Sherry K.

    2007-01-01

    This article will introduce the Privileged Identity Exploration (PIE) Model. This model identifies eight (8) defense modes associated with behaviors individuals display when engaged in difficult dialogues about social justice issues. Implications for the model and ways it can be used to assist facilitators as they engage participants in…

  8. Why Is Statistics Perceived as Difficult and Can Practice during Training Change Perceptions? Insights from a Prospective Mathematics Teacher

    Fitzmaurice, Olivia; Leavy, Aisling; Hannigan, Ailish

    2014-01-01

    An investigation into prospective mathematics/statistics teachers' (n = 134) conceptual understanding of statistics and attitudes to statistics carried out at the University of Limerick revealed an overall positive attitude to statistics but a perception that it can be a difficult subject, in particular that it requires a great deal of discipline

  9. Different, Difficult or Distinct? Mothers' and Fathers' Perceptions of Temperament in Children with and without Intellectual Disabilities

    Bostrom, P.; Broberg, M.; Hwang, C. P.

    2010-01-01

    Background: Can ratings of temperament be a way of identifying young children with intellectual disabilities (ID) who are at risk for being experienced as difficult? We aimed to explore parents' reports of temperament in their young children with or without ID, as well as positive and negative impact of the child on parents. Method: Mothers and…

  10. Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome.

    Bhat, Ravi; Mane, Rajesh S; Patil, Manjunath C; Suresh, S N

    2014-07-01

    The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel's deformity (wherein the scapulae ride high on the back), synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA). After intubation, we used second smaller endotracheal tube (ETT) to stabilize and elongate the first ETT while removing the LMA. PMID:25191201

  11. Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome

    Ravi Bhat

    2014-01-01

    Full Text Available The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel′s deformity (wherein the scapulae ride high on the back, synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA. After intubation, we used second smaller endotracheal tube (ETT to stabilize and elongate the first ETT while removing the LMA.

  12. Novel use of an exchange catheter to facilitate intubation with an Aintree catheter in a tall patient with a predicted difficult airway: a case report

    Gruenbaum Shaun E

    2012-04-01

    Full Text Available Abstract Introduction The Aintree intubating catheter (Cook Medical Inc., Bloomington, IN, USA has been shown to successfully facilitate difficult intubations when other methods have failed. The Aintree intubating catheter (Cook Medical Inc., Bloomington, IN, USA has a fixed length of 56 cm, and it has been suggested in the literature that it may be too short for safe use in patients who are tall. Case presentation We present the case of a 32-year-old, 180 cm tall Caucasian woman with a predicted difficult airway who presented to our facility for an emergency cesarean section. After several failed intubation attempts via direct laryngoscopy, an airway was established with a laryngeal mask airway. After delivery of a healthy baby, our patient's condition necessitated tracheal intubation. A fiber-optic bronchoscope loaded with an Aintree intubating catheter (Cook Medical Inc., Bloomington, IN, USA was passed through the laryngeal mask airway into the trachea until just above the carina, but was too short to safely allow for the passage of an endotracheal tube. Conclusions We present a novel technique in which the Aintree intubating catheter (Cook Medical Inc., Bloomington, IN, USA was replaced with a longer (100 cm exchange catheter, over which an endotracheal tube was passed successfully into the trachea.

  13. Bayesian Sampling using Condition Indicators

    Faber, Michael H.; Sørensen, John Dalsgaard

    2002-01-01

    allows for a Bayesian formulation of the indicators whereby the experience and expertise of the inspection personnel may be fully utilized and consistently updated as frequentistic information is collected. The approach is illustrated on an example considering a concrete structure subject to corrosion......The problem of control quality of components is considered for the special case where the acceptable failure rate is low, the test costs are high and where it may be difficult or impossible to test the condition of interest directly. Based on the classical control theory and the concept of...... condition indicators introduced by Benjamin and Cornell (1970) a Bayesian approach to quality control is formulated. The formulation is then extended to the case where the quality control is based on sampling of indirect information about the condition of the components, i.e. condition indicators. This...

  14. Difficult decisions in times of constraint: Criteria based Resource Allocation in the Vancouver Coastal Health Authority

    Dionne Francois

    2011-07-01

    Full Text Available Abstract Objectives The aim of the project was to develop a plan to address a forecasted deficit of approximately $4.65 million for fiscal year 2010/11 in the Vancouver Communities division of the Vancouver Coastal Health Authority. For disinvestment opportunities identified beyond the forecasted deficit, a commitment was made to consider options for resource re-allocation within the Vancouver Communities division. Methods A standard approach to program budgeting and marginal analysis (PBMA was taken with a priority setting working committee and a broader advisory panel. An experienced, non-vested internal project manager worked closely with the two-member external research team throughout the process. Face to face evaluation interviews were held with 10 decision makers immediately following the process. Results The recommendations of the working committee included the implementation of 44 disinvestment initiatives with an annualized value of CAD $4.9 million, as well as consideration of possible investments if the realized savings match expectations. Overall, decision makers viewed the process favorably and the primary aim of addressing the deficit gap was met. Discussion A key challenge was the tight timeline which likely lead to less evidence informed decision making then one would hope for. Despite this, decision makers felt that better decisions were made then had the process not been in place. In the end, this project adds value in finding that PBMA can be used to cover a deficit and minimize opportunity cost through systematic application of criteria whilst ensuring process fairness through focusing on communication, transparency and decision maker engagement.

  15. Global Climate Change for Kids: Making Difficult Ideas Accessible and Exciting

    Fisher, D. K.; Leon, N.; Greene, M. P.

    2009-12-01

    NASA has recently launched its Global Climate Change web site (http://climate.nasa.gov), and it has been very well received. It has now also launched in preliminary form an associated site for children and educators, with a plan for completion in the near future. The goals of the NASA Global Climate Change Education site are: To increase awareness and understanding of climate change science in upper-elementary and middle-school students, reinforcing and building upon basic concepts introduced in the formal science education curriculum for these grades; To present, insofar as possible, a holistic picture of climate change science and current evidence of climate change, describing Earth as a system of interconnected processes; To be entertaining and motivating; To be clear and easy to understand; To be easy to navigate; To address multiple learning styles; To describe and promote "green" careers; To increase awareness of NASA's contributions to climate change science; To provide valuable resources for educators; To be compliant with Section 508 of the Americans with Disabilities Act. The site incorporates research findings not only on climate change, but also on effective web design for children. It is envisioned that most of the content of the site will ultimately be presented in multimedia forms. These will include illustrated and narrated "slide shows," animated expositions, interactive concept-rich games and demonstrations, videos, animated fictionalized stories, and printable picture galleries. In recognition of the attention span of the audience, content is presented in short, modular form, with a suggested, but not mandatory order of access. Empathetic animal and human cartoon personalities are used to explain concepts and tell stories. Expository, fiction, game, video, text, and image modules are interlinked for reinforcement of similar ideas. NASA's Global Climate Change Education web site addresses the vital need to impart and emphasize Earth system science concepts at or near the beginning of the education pipeline.

  16. Extubation of the perioperative patient with a difficult airway / Extubacin del paciente perioperatorio con una va area difcil

    Carin A., Hagberg; Carlos A., Artime.

    2014-10-01

    Full Text Available Existe un volumen importante de literatura dedicada al tema del manejo de la va area difcil, y se han desarrollado una serie de algoritmos y recomendaciones para el manejo seguro de pacientes en riesgo de una intubacin difcil. Sin embargo, solo recientemente se ha despertado una mayor concienci [...] a acerca de la extubacin de la va area difcil, pues aun cuando sea un procedimiento programado, suele estar plagado de complicaciones. La importancia de desarrollar estrategias pre-programadas para la extubacin de la va area difcil a fin de aumentar la seguridad del paciente y sus desenlaces se hace evidente a partir de los datos del ASA Closed Claims Analysis y del reciente Cuarto Proyecto Nacional de Auditora del Reino Unido sobre complicaciones mayores en el manejo de la va area. La clave para un manejo exitoso de los pacientes en riesgo de extubacin difcil es efectuar una evaluacin precisa de riesgo, aplicar estrategias apropiadas y la preparacin tanto del mdico como de la institucin. Abstract in english A considerable amount of literature has been dedicated to the topic of difficult airway management and a number of algorithms and recommendations have been established to safely manage patients at risk for difficult intubation. Only recently, however, has extubation of the difficult airway gained mo [...] re awareness since this procedure, although elective, is often fraught with complications. The importance of developing pre-planned strategies for extubation of the difficult airway to improve patient safety and outcomes is apparent from data from both the ASA Closed Claims Analysis and the UK's recent Fourth National Audit Project of major complications of airway management. The key to successful management of patients at risk for difficult extubation is accurate risk assessment, application of appropriate strategies, and preparedness by both the individual practitioner and the institution.

  17. The difficult challenge of a two-phase CFD modelling for all flow regimes

    Highlights: • The theoretical difficulties for modelling all flow regimes at CFD scale are identified. • The choice of the number of fields and of the time and space averaging or filtering are discussed and clarified. • Closure issues related to an all flow regime CFD model are listed and the main difficulties are identified. - Abstract: System thermalhydraulic codes model all two-phase flow regimes but they are limited to a macroscopic description. Two-phase CFD tools predict two-phase flow with a much finer space resolution but the current modelling capabilities are limited to dispersed bubbly or droplet flow and separate-phase flow. Much less experience exists on more complex flow regimes which combine the existence of dispersed fields with the presence of large interfaces such as a free surface or a film surface. A list of possible reactor issues which might benefit from an “all flow regime CFD model” is given. The first difficulty is to identify the various types of local flow configuration. It is shown that a 4-field model has much better capabilities than a two-fluid approach to identify most complex regimes. Then the choice between time averaging, space averaging, or even ensemble averaging is discussed. It is shown that only the RANS-2-fluid and a space-filtered 4-field model may be reasonably envisaged. The latter has the capabilities to identify all types of interfaces and should be privileged if a good accuracy is expected or if time fluctuations in intermittent flow have to be predicted while the former may be used when a high accuracy is not necessary and if time fluctuations in intermittent flow are not of interest. Finally the closure issue is presented including wall transfers, interfacial transfers, mass transfers between dispersed and continuous fields, and turbulent transfers. An important effort is required to model all interactions between sub-filter phenomena and the transfers from the sub-filter domain to the simulated domain. The main difficulties are expected in modelling the transfer of sub-filter interfaces to predicted interfaces and the multiple effects of sub-filter deformations of large interfaces on inter-field transfers

  18. Why is it difficult to implement e-health initiatives? A qualitative study

    Wallace Paul

    2011-01-01

    Full Text Available Abstract Background The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers -- the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives. Methods We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care, e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS in secondary care, a Community Nurse Information System (CNIS in community care, and Choose and Book (C&B across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with 'on the ground' experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT. Results Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to 'normalize' where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization. Conclusions Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners' attention to potential problems with a view to addressing them during implementation planning.

  19. Including gauge corrections to thermal leptogenesis

    This thesis provides the first approach of a systematic inclusion of gauge corrections to leading order to the ansatz of thermal leptogenesis. We have derived a complete expression for the integrated lepton number matrix including all resummations needed. For this purpose, a new class of diagram has been invented, namely the cylindrical diagram, which allows diverse investigations into the topic of leptogenesis such as the case of resonant leptogenesis. After a brief introduction of the topic of the baryon asymmetry in the universe and a discussion of its most promising solutions as well as their advantages and disadvantages, we have presented our framework of thermal leptogenesis. An effective model was described as well as the associated Feynman rules. The basis for using nonequilibrium quantum field theory has been built in chapter 3. At first, the main definitions have been presented for equilibrium thermal field theory, afterwards we have discussed the Kadanoff-Baym equations for systems out of equilibrium using the example of the Majorana neutrino. The equations have also been solved in the context of leptogenesis in chapter 4. Since gauge corrections play a crucial role throughout this thesis, we have also repeated the naive ansatz by replacing the free equilibrium propagator by propagators including thermal damping rates due to the Standard Model damping widths for lepton and Higgs fields. It is shown that this leads to a comparable result to the solutions of the Boltzmann equations for thermal leptogenesis. Thus it becomes obvious that Standard Model corrections are not negligible for thermal leptogenesis and therefore need to be included systematically from first principles. In order to achieve this we have started discussing the calculation of ladder rung diagrams for Majorana neutrinos using the HTL and the CTL approach in chapter 5. All gauge corrections are included in this framework and thus it has become the basis for the following considerations. Furthermore, we have computed the Majorana neutrino production rate itself in chapter 6 to test our numerical procedure. In this context we have calculated the tree-level result as well as the gauge corrected result for the Majorana neutrino production rate. Finally in chapter 7, we have implemented the Majorana neutrino ladder rung diagram into our setup for leptogenesis: As a first consideration, we have collected all gauge corrected diagrams up to three-loop order for the asymmetry-causing two-loop diagrams. However, the results of chap. 5 showed that it is not sufficient to just include diagrams up to three-loop level. Due to the necessity of resumming all n-loop diagrams, we have constructed a cylindrical diagram that fulfils this condition. This diagram is the link between the Majorana neutrino ladder rung diagram calculated before on the one hand and the lepton asymmetry on the other. Therefore we have been able to derive a complete expression for the integrated lepton number matrix including all leading order corrections. The numerical analysis of this lepton number matrix needs a great computational effort since for the resulting eight-dimensional integral two ordinary differential equations have to be computed for each point the routine evaluates. Thus the result remains yet inaccessible. Research perspectives: Summarising, this thesis provides the basis for a systematic inclusion of gauge interactions in thermal leptogenesis scenarios. As a next step, one should evaluate the expression for the integrated lepton number numerically to gain a value, which can be used for comparison to earlier results such as the solutions of the Boltzmann equations as well as the Kadanoff-Baym ansatz with the implemented Standard Model widths. This numerical result would be the first quantitative number, which contains leading order corrections due to all interactions of the Majorana neutrino with the Standard Model particles. Further corrections by means of including washout effects and the Hubble expansion are expected to be reasonably small. Furthermore, it is very interesting to apply this result to the case of resonant leptogenesis. This is is the scenario where there is degeneracy or quasi-degeneracy of the Majorana masses, thus none of the heavy neutrino masses can be integrated out. By using the versatile cylindrical diagram first described in this thesis, it is not far to seek that this case can be considered easily. For the sake of completeness one has to mention that it is also possible to give constraints of the gravitino production and, thus, to test supersymmetric theories. If the lightest superparticle is the gravitino, which can be a dominant component of dark matter, also supergravity might be tested at the LHC in the near future.

  20. Strategies for attraction and retention of health workers in remote and difficult-to-access areas of Chhattisgarh, India: Do they work?

    Suchitra Lisam

    2015-01-01

    Full Text Available Background: To address the acute shortages of health workers in underserved, remote, and difficult-to-access areas, the Government of Chhattisgarh and the National Rural Health Mission (NRHM launched the Chhattisgarh Rural Medical Corps (CRMC in 2009. CRMC has enabled provisions such as financial incentives, residential accommodation, life insurance, and extra marks during admission at the postgraduate (PG level to eligible doctors for the attraction and retention of health workers, i.e., doctors, staff nurses, auxiliary nurse midwives (ANMs, and rural medical assistants (RMAs in underserved areas. Objectives: This study aims to understand the CRMC scheme in terms of implementation, challenges, gaps, and outcome in achieving the attraction and retention of health workers in the remote and difficult-to-access areas of Chhattisgarh. Materials and Methods: The study adopts a mix of both qualitative and quantitative research methods. The purposive sampling method was used for the selection of three districts having normal, difficult, and inaccessible areas. Data were collected through key informant (KI interviews with beneficiaries and non-beneficiaries of CRMC or district and state government officials, and reviews of document were analyzed using a thematic analysis approach. Results: CRMC has made positive outcome as 1319 health workers, including doctors, have joined the service in 2010-11, reducing the vacancy of doctors from 90% to 45%. The scope of CRMC was primarily limited to payment of monthly financial incentives. The fund utilization rate of CRMC has increased (from 27% in 2009-10 to 98% in 2011-12, though there are delays in payment of incentives. The majority of staff lack awareness about CRMC during job applications. The payment of incentives based on facility performance has demotivated staff. Conclusions: Establishment of a performance management system, activating the CRMC cell to make it functional, and wide publicity of CRMC benefits are likely to improve attraction and retention of staff.

  1. Choice and conditioned reinforcement.

    Fantino, E; Freed, D; Preston, R. A.; Williams, W A

    1991-01-01

    A potential weakness of one formulation of delay-reduction theory is its failure to include a term for rate of conditioned reinforcement, that is, the rate at which the terminal-link stimuli occur in concurrent-chains schedules. The present studies assessed whether or not rate of conditioned reinforcement has an independent effect upon choice. Pigeons responded on either modified concurrent-chains schedules or on comparable concurrent-tandem schedules. The initial link was shortened on only o...

  2. Neuromuscular blockade for improvement of surgical conditions during laparotomy

    Madsen, Matias Vested; Scheppan, Susanne; Kissmeyer, Peter; Mørk, Emilie; Rosenberg, Jacob; Gätke, Mona Ring

    2015-01-01

    INTRODUCTION: During laparotomy, surgeons frequently experience difficult surgical conditions if the patient's abdominal wall or diaphragm is tense. This issue is particularly pertinent while closing the fascia and placing the intestines into the abdominal cavity. Establishment of a deep...

  3. Goldilocks Models of Higher-Dimensional Inflation (including modulus stabilization)

    Burgess, C P; Hayman, Peter; Patil, Subodh P

    2016-01-01

    We explore the mechanics of inflation in simplified extra-dimensional models involving an inflaton interacting with the Einstein-Maxwell system in two extra dimensions. The models are Goldilocks-like in that they are just complicated enough to include a mechanism to stabilize the extra-dimensional size, yet simple enough to solve the full 6D field equations using basic tools. The solutions are not limited to the effective 4D regime with H m_KK, but when they do standard 4D fluctuation calculations need not apply. When in a 4D regime the solutions predict eta ~ 0 hence n_s ~ 0.96 and r ~ 0.096 and so are ruled out if tensor modes remain unseen. Analysis of general parameters is difficult without a full 6D fluctuation calculation.

  4. Comparison of the glidescope, CMAC, storz DCI with the Macintosh laryngoscope during simulated difficult laryngoscopy: a manikin study

    Healy David W

    2012-06-01

    Full Text Available Abstract Background Videolaryngoscopy presents a new approach for the management of the difficult and rescue airway. There is little available evidence to compare the performance features of these devices in true difficult laryngoscopy. Methods A prospective randomized crossover study was performed comparing the performance features of the Macintosh Laryngoscope, Glidescope, Storz CMAC and Storz DCI videolaryngoscope. Thirty anesthesia providers attempted intubation with each of the 4 laryngoscopes in a high fidelity difficult laryngoscopy manikin. The time to successful intubation (TTSI was recorded for each device, along with failure rate, and the best view of the glottis obtained. Results Use of the Glidescope, CMAC and Storz videolaryngoscopes improved the view of the glottis compared with use of the Macintosh blade (GEE, p = 0.000, p = 0.002, p = 0.000 respectively. Use of the CMAC resulted in an improved view compared with use of the Storz VL (Fishers, p = 0.05. Use of the Glidescope or Storz videolaryngoscope blade resulted in a longer TTSI compared with either the Macintosh (GLM, p = 0.000, p = 0.029 respectively or CMAC blades (GLM, p = 0.000, p = 0.033 respectively. Conclusions Unsurprisingly, when used in a simulated difficult laryngoscopy, all the videolaryngoscopes resulted in a better view of the glottis than the Macintosh blade. However, interestingly the CMAC was found to provide a better laryngoscopic view that the Storz DCI Videolaryngoscope. Additionally, use of either the Glidescope or Storz DCI Videolaryngoscope resulted in a prolonged time to successful intubation compared with use of the CMAC or Macintosh blade. The use of the CMAC during manikin simulated difficult laryngoscopy combined the efficacy of attainment of laryngoscopic view with the expediency of successful intubation. Use of the Macintosh blade combined expedience with success, despite a limited laryngoscopic view. The limitations of a manikin model of difficult laryngoscopy limits the conclusions for extrapolation into clinical practice.

  5. Condition Monitoring and Diagnostics for Complex System using Neural Networks

    Zhong Yang; Haifei Si; Hui Zhao

    2013-01-01

    A rule-based expert system is a traditional approach in condition monitoring and diagnostics for complex system. However, the rule-based expert system is not only difficult to be established but also difficult to be renewed along with the changed circumstances. Neural networks provide a data based approach to condition monitoring and diagnostics for complex system such as rotating machinery. By developing associations between neural networks and a rotating ...

  6. Tracheal intubation with a flexible fibreoptic scope or the McGrath videolaryngoscope in simulated difficult airway scenarios

    Jepsen, Cecilie H; Gätke, Mona R; Thøgersen, Bente; Mollerup, Lene T; Ruhnau, Birgitte; Rewers, Mikael; Rosenstock, Charlotte V

    2014-01-01

    the McGrath series 5 videolaryngoscope (McGrath videolaryngoscope) and the FFE for tracheal intubation in manikins with a simulated difficult airway, hypothesizing that the McGrath videolaryngoscope intubation would prove faster than FFE intubation. DESIGN: A randomised controlled study. SETTING: The...... Danish Institute for medical simulation between December 2009 and June 2010. PARTICIPANTS: Twenty-eight anaesthesia residents participating in the Danish mandatory 3-day airway management course. INTERVENTIONS: All participants received instructions and training in the use of the McGrath...... videolaryngoscope and FFE. The participants then performed tracheal intubation on a SimMan manikin once with the McGrath videolaryngoscope and once with the FFE in three difficult airway scenarios: (1) pharyngeal obstruction; (2) pharyngeal obstruction and cervical rigidity; (3) tongue oedema. MAIN OUTCOME MEASURES...

  7. Central venous catheter malposition in the azygos vein and difficult endotracheal intubation in severe ankylosing spondylitis: a case report

    Moon, Eunjin; Jeong, Hyungmo; Chung, Junyoung; Yi, Jaewoo

    2015-01-01

    Ankylosing spondylitis (AS) can be challenging for anesthesiologists because central venous access can be difficult, and the airway can be blocked due to the fixed flexion deformity of the spine. In this case, we attempted central access via the right subclavian vein, but the catheter was repeatedly inserted into the azygos vein, which was confirmed by radiology. After several attempts, the catheter position was corrected at the superior vena cava-atrial junction. Although several useful devices have been developed to address difficult intubation, in this case, fiberoptic bronchoscopy was the only applicable safe alternative because of the patients extremely severe chin on chest deformity and temporomandibular joint disease. We report a successful awake fiberoptic bronchoscopic intubation in a patient with extremely severe AS and recommend that the catheter placement should be confirmed with radiology to ensure proper positioning for severe AS patients.

  8. Long-standing meningomyelocele can be a predictor of difficult airway and postoperative hypoventilation: challenge to the anaesthesiologist.

    Sardar, Arijit; Khanna, Puneet; Singh, Abhishek; Sharma, Ankur

    2016-01-01

    A 15-year-old female patient presented with severe pain in the abdomen and obstructive uropathy. She underwent Yang-Monti ileovesicostomy under general anaesthesia. She is a known case of long-standing meningomyelocele (MMC) and presented with its potential complications such as difficult airway and restrictive lung disease. We describe the successful anaesthetic management of a case of anticipated difficult airway and postoperative hypoventilation as a sequel of kyphosis due to MMC. Her airway was secured with fibre optic-guided intubation in a semirecumbent position. Postoperative hypoventilation, hypercarbia and respiratory acidosis were managed conservatively, followed by staged weaning in the intensive care unit. Obstruction of the catheterisable continent channel of the neurogenic bladder itself may present with uropathy and urosepsis, which were also taken care of preoperatively. PMID:26884079

  9. Haemophilus influenzae Disease (Including Hib) Complications

    ... Search The CDC Cancel Submit Search The CDC Haemophilus influenzae Disease (Including Hib) Note: Javascript is disabled ... on Facebook Tweet Share Compartir Most strains of Haemophilus influenzae bacteria, including Hib, usually live in a ...

  10. Haemophilus influenzae Disease (Including Hib) Symptoms

    ... Search The CDC Cancel Submit Search The CDC Haemophilus influenzae Disease (Including Hib) Note: Javascript is disabled ... Sepsis Symptoms Recommend on Facebook Tweet Share Compartir Haemophilus influenzae disease, including Hib disease, causes different symptoms ...

  11. Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study

    Lee, Tae Hoon; Hwang, Soon Oh; Choi, Hyun Jong; Jung, Yunho; Cha, Sang Woo; Chung, Il-Kwun; Moon, Jong Ho; Cho, Young Deok; Park, Sang-Heum; Kim, Sun-Joo

    2014-01-01

    Background Numerous clinical trials to improve the success rate of biliary access in difficult biliary cannulation (DBC) during ERCP have been reported. However, standard guidelines or sequential protocol analysis according to different methods are limited in place. We planned to investigate a sequential protocol to facilitate selective biliary access for DBC during ERCP. Methods This prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-g...

  12. Breaking the cycle: how I manage difficult atopic dermatitis Romper o ciclo: minha conduta em casos difceis de dermatite atpica

    Hanifin, Jon M.

    2007-01-01

    This review summarizes the general approach and philosophy of managing difficult atopic dermatitis. There are as many regimens as there are physicians, but too many fail to provide patients with adequate relief. This leads to the wasteful alternative - an allergy-seeking behavior that makes caring for these patients even more complicated. If we, as dermatologists, provide rational counseling on prevention and skin care along with effective, stable, anti-inflammatory therapy, our patients may ...

  13. Difficult diagnosis of gout: the benefit of dual energy computed tomography, initial experience in routine clinical practice

    Vera Löckmann; Patrick Veit-Haibach; Lukas Schmid

    2013-01-01

    Gout, one of the most common inflammatory arthritides in humans, is still difficult to diagnose in challenging situations, when fluid for arthrocentesis or an apparent tophus are absent and, for example, an infection as differential diagnosis has to be ruled out. Dual energy computed tomography (DECT) is an established tool for detection and characterisation of uric acid stones in the urinary tract and has recently been used to detect and display urate deposits. Our first experiences with DEC...

  14. Convergent Syntheses of HuPrP106-126 (Difficult Sequence) Using Native Chemical Ligation and Desulfurization/Deselenization

    Šebestík, Jaroslav; Šafařík, Martin; Zawada, Zbigniew; Hlaváček, Jan

    Copenhagen : European Peptide Society, 2010, s. 204-205 ISBN 0-9715560-5-9. [Peptides 2010: Tales of Peptides. Proceedings of the European Peptide Symposium /31./. Copenhagen (DK), 05.09.2010-09.09.2010] R&D Projects: GA ČR GA203/07/1517 Institutional research plan: CEZ:AV0Z40550506 Keywords : 4-thiazolidinecarboxylic acid * difficult sequences * prion diseases * displacement Subject RIV: CC - Organic Chemistry

  15. When care situations evoke difficult emotions in nursing staff members: an ethnographic study in two Norwegian nursing homes

    Sandvoll, Anne Marie; Grov, Ellen Karine; Kristoffersen, Kjell; Hauge, Solveig

    2015-01-01

    Background Caring practice in nursing homes is a complex topic, especially the challenges of meeting the basic needs of residents when their behaviour evokes difficult emotions. Cognitive and physical changes related to aging and disability can contribute to behaviours considered to be unacceptable. For example, resident behaviours such as spitting, making a mess with food or grinding teeth are behaviours that most people do not want to see, hear or experience. The aim of this study was t...

  16. QUALIMETRIC ASPECTS OF THE SOCIO-CULTURAL FACTORS OF THE ADAPTATION OF CHILDREN IN DIFFICULT LIFE SITUATIONS

    Dudkin Artem Sergeevich

    2012-01-01

    For practical realization in the social and pedagogical work, the factors of social adaptation of minors received as a result of research in certain typical difficult life situations need analytical consideration using an analytical social qualimetric approach. The levels allocated during empirical research and degree of factors of social adaptation are described with qualimetric indicators, taking into account necessary and sufficient properties. Problems of studying and realization of quant...

  17. Modular Robotics for Delivering On-Site contamination Sensors and Mapping Systems to Difficult-to-Access Locations

    Presently, characterization operations are scheduled for thousands of facilities and pieces of equipment throughout DOE sites, each of which requires manual surveying with handheld instruments and manual record keeping. Such work, particularly in difficult-to-access-areas, results in significant amounts of worker exposure, long timelines and additional secondary waste generation. Therefore, a distinct need exists for remote tools that can quickly deploy sensors and automated contamination mapping systems into these areas

  18. GlideScope Video Laryngoscope for Difficult Intubation in Emergency Patients: a Quasi-Randomized Controlled Trial

    Koorosh Ahmadi

    2015-12-01

    Full Text Available Macintosh direct laryngoscope has been the most widely used device for tracheal intubation. GlideScope video laryngoscope (GVL has been recently introduced as an alternative device for performing intubation; however, its validity in emergency settings has not been thoroughly evaluated. The aim of this study was to compare Macintosh direct laryngoscope versus GVL for emergency endotracheal intubation. This quasi-randomized clinical trial was performed on 97 patients referred to Imam Reza Hospital whom all needed emergency intubation in 2011. Patients were divided into two groups of the easy airway and difficult airway; intubation was performed for patients with direct laryngoscopy or GVL. Then, the patients were evaluated in terms of demographic characteristics, successful intubation rate and intubation time. Data was analyzed by SPSS software 16. There was no significant difference in demographic characteristics of the patients in both easy airway and difficult airway groups who intubated with direct laryngoscopy and GVL methods (P>0.05. In difficult airway group, a significant difference was found in successful intubation at the first attempt (60.9% vs. 87.5%; P=0.036, overall intubation time (32.7 ± 14.58 vs. 22.5±7.88; P<0.001 and first attempt intubation time (28.43 ± 12.51 vs. 21.48±7.8; P=0.001 between direct laryngoscopy and GVL. These variables were not significantly different between two methods in easy airway group. According to the results, GVL can be a useful alternative to direct laryngoscopy in emergency situations and especially in cases with a difficult airway.

  19. A study of physicians’ intention to quit: the role of burnout, commitment and difficult doctor-patient interactions

    Moreno Jiménez, Bernardo; Gálvez Herrer, Macarena; Rodríguez Carvajal, Raquel; Sanz Vergel, Ana Isabel

    2012-01-01

    Research on burnout and turnover intentions offers some inconsistent findings about the effects of commitment. In addition, a factor which is insufficiently studied in the turnover field is the relationship with the recipient of physicians’ work, that is, the patient. This study contributes to the research literature by examining how the moderating effect of commitment depends on difficult doctor-patient relations. A total of 480 physicians, representative of Madrid, completed the survey....

  20. Difficult life situations of the minors and the parent involvement in interdepartmental interaction addressing to solving problems of children

    Dudkin A. S.

    2011-03-01

    Full Text Available The article examines the theoretical and methodological problems of establishing inter-agency cooperation in providing social assistance to minors. The author proposes a principles for the model of the mobilization of parents to solve problems of their children. To analyze the structure of social and pedagogical work, distinguished types of difficult life situations that require special efforts to ensure children's education. Proceedings of the publication permit to develop and implement social technologies.

  1. Gross structure of resonance spectra (including bottomonium)

    Simple arguments are given for the explanation of the gross structure of the spectrum of particle resonances based on the shape resonance conditions, the Heisenberg uncertainty relation and the Bohr correspondence principle. 14 refs., 2 figs., 3 tabs

  2. Article Including Environmental Barrier Coating System

    Lee, Kang N. (Inventor)

    2015-01-01

    An enhanced environmental barrier coating for a silicon containing substrate. The enhanced barrier coating may include a bond coat doped with at least one of an alkali metal oxide and an alkali earth metal oxide. The enhanced barrier coating may include a composite mullite bond coat including BSAS and another distinct second phase oxide applied over said surface.

  3. To compare the accuracy of Prayer's sign and Mallampatti test in predicting difficult intubation in Diabetic patients

    Objective: To determine the accuracy of Prayer's sign and Mallampatti test in predicting difficult endotracheal intubation in diabetic patients. Methods: The cross-sectional study was performed at Aga Khan University Hospital, Karachi, over a period from January 2009 to April 2010, and comprised 357 patients who required endotracheal intubation for elective surgical procedures. Prayer's sign and Mallampatti tests were performed for the assessment of airway by trained observers. Ease or difficulty of laryngoscopy after the patient was fully anaesthetised with standard technique were observed and laryngoscopic view of first attempt was rated according to Cormack-Lehan grade of intubation. SPSS 15 was used for statistical analysis. Results: Of the 357 patients, 125(35%) were classified as difficult to intubate. Prayer's sign showed significantly lower accuracy, positive and negative predictive values than Mallampatti test. The sensitivity of Prayer's sign was lower 29.6 (95% Confidence Interval, 21.9-38.5) than Mallampatti test 79.3 (95% confidence interval, 70.8-85.7) while specificity of both the tests was not found to be significantly different. Conclusion: Prayer's sign is not acceptable as a single best bedside test for prediction of difficult intubation. (author)

  4. Tracing the source of difficult to settle fine particles which cause turbidity in the Hitotsuse Reservoir, Japan.

    Murakami, Toshiki; Suzuki, Yoshihiro; Oishi, Hiroyuki; Ito, Kenichi; Nakao, Toshio

    2013-05-15

    A unique method to trace the source of "difficult-to-settle fine particles," which are a causative factor of long-term turbidity in reservoirs was developed. This method is characterized by cluster analysis of XRD (X-ray diffraction) data and homology comparison of major component compositions between "difficult-to-settle fine particles" contained in landslide soil samples taken from the upstream of a dam, and suspended "long-term turbid water particles" in the reservoir, which is subject to long-term turbidity. The experiment carried out to validate the proposed method, demonstrated a high possibility of being able to make an almost identical match between "difficult-to-settle fine particles" taken from landslide soils at specific locations and "long-term turbid water particles" taken from a reservoir. This method has the potential to determine substances causing long-term turbidity and the locations of soils from which those substances came. Appropriate countermeasures can then be taken at those specific locations. PMID:23500107

  5. [Management of difficult airway with inhalation induction in a patient with Lennox-Gastaut syndrome and neck injury].

    Rey, J; Encabo, C M; Pizarro, N E; San Martn, J L; Lpez-Timoneda, F

    2015-11-01

    Lennox-Gastaut syndrome is a childhood epileptic encephalopathy, and is characterized by frequent and difficult to treat seizures associated with mental retardation. The case is presented of a 21 year-old male with Lennox-Gastaut syndrome, with bilateral cervical facet joint dislocation fracture at C6-C7 and spinal canal compression as a result of a fall during a seizure. In this case the management of the difficult airway expected in an awake and uncooperative patient, with cervical spinal cord injury is described. An airway management strategy was proposed, that allowed a rapid and safe airway control with the best possible tolerance and maintaining the neck immobilised, so as not to increase neurological injury. Within this strategy, plan A was defined as inhalation induction with sevoflurane to maintain spontaneous breathing and tracheal intubation with Airtraq. We believe that the Airtraq video laryngoscope with inhalational induction with sevoflurane is a valid and effective alternative in the management of expected difficult airway. PMID:25687944

  6. The Difficult Airway Society 'ADEPT' guidance on selecting airway devices: the basis of a strategy for equipment evaluation.

    Pandit, J J; Popat, M T; Cook, T M; Wilkes, A R; Groom, P; Cooke, H; Kapila, A; O'Sullivan, E

    2011-08-01

    Faced with the concern that an increasing number of airway management devices were being introduced into clinical practice with little or no prior evidence of their clinical efficacy or safety, the Difficult Airway Society formed a working party (Airway Device Evaluation Project Team) to establish a process by which the airway management community within the profession could itself lead a process of formal device/equipment evaluation. Although there are several national and international regulations governing which products can come on to the market and be legitimately sold, there has hitherto been no formal professional guidance relating to how products should be selected (i.e. purchased). The Airway Device Evaluation Project Team's first task was to formulate such advice, emphasising evidence-based principles. Team discussions led to a definition of the minimum level of evidence needed to make a pragmatic decision about the purchase or selection of an airway device. The Team concluded that this definition should form the basis of a professional standard, guiding those with responsibility for selecting airway devices. We describe how widespread adoption of this professional standard can act as a driver to create an infrastructure in which the required evidence can be obtained. Essential elements are that: (i) the Difficult Airway Society facilitates a coherent national network of research-active units; and (ii) individual anaesthetists in hospital trusts play a more active role in local purchasing decisions, applying the relevant evidence and communicating their purchasing decisions to the Difficult Airway Society. PMID:21707562

  7. 3D seismic experiment in difficult area in Japan; Kokunai nanchiiki ni okeru sanjigen jishin tansa jikken

    Minegishi, M.; Nakagami, K.; Tanaka, H. [Japan National Oil Corp., Tokyo (Japan). Technology Research Center

    1997-05-27

    Difficult area in this context means an exploration-difficult area supposed to store oil/gas but retarded in exploration for the lack of knowledge about the geological structure due to poor quality of available seismic survey records. Discussed in this paper is a survey conducted into an area covering the southern part of Noshiro-shi, Akita-ken, and Yamamoto-cho, Yamamoto-gun, Akita-ken. An area size suitable for data collection at a target depth of 2500m is determined using an interpretation structure compiled on the basis of available well data and 2D seismic survey data. The plan for siting shock points and receiving points is modified case by case as restrictive factors come to the surface (resulting from the complicated hilly terrain, presence of pipes for agricultural water, etc.). The peculiarities of seismic waves in the terrain are studied through the interpretation of the available well data and 2D seismic survey data for the construction of a 3D velocity model for the confirmation of the appropriateness of the plan for siting shock points and receiving points. Efforts are exerted through enhanced coordination with the contractor to acquire data so that a technologically best design may be won within the limits of the budget. The quality of the data obtained from this experiment is in general better than those obtained from previous experiments, yet many problems remain to be settled in future studies about exploration-difficult areas. 4 refs., 4 figs., 1 tab.

  8. CORPORATE SOCIAL RESPONSIBILITY AS CONDITION OF INCLUDING UKRAINE IN EUROPE AND WORLD ECONOMIC SPACE

    T. Lytvynenko

    2013-09-01

    Full Text Available The thesis that companies’ activities for introduction of corporate social responsibility stimulates the speed of to the processes of the technical upgrade, modernization of company’s activity and increase of its profitability is proved within the article. Those Ukrainian companies, which have high index of activities transparency, are also the most profitable. However, we can’t observe any significant increment of number of companies joining the Global agreement. One of the explanations we could name is the unproved idea supported by some politicians and economists about a shadow (‘black’ market that allegedly allows creating workplaces and taking off social tension in society on the certain stage. Insignificant values of index of citizens’ trust to activity of industries holds on the development socially of responsible business. Trust considered as a part of the general social capital. The Government of Ukraine must support initiative of companies to introduce social responsibility of business, as many European governments do it. It is also important to inform society of advantages of CSR.

  9. A Pseudo-Three-Dimensional Thermal Model Including Thermal Boundary Conditions for High Power IGBT Modules

    Bahman, Amir Sajjad; Ma, Ke; Ghimire, Pramod; Iannuzzo, Francesco; Blaabjerg, Frede

    2016-01-01

    Accurate thermal dynamics of high power IGBT modules is important information for the reliability analysis and thermal design of the power electronics system. However, the existing thermal models have their limits to correctly predict these complicated thermal behaviors in the IGBTs: The typicall...

  10. Probabilistic analysis of limiting conditions for operation action requirements including risk of shutdown

    When the systems needed to shut down a nuclear power plant are inoperable or degraded, the risk of shutting down the plant may be comparable to, or even higher than, that of continuing power operation with the equipment inoperable but giving priority to repairs. This concern arises because the plant may have insufficient capability for removing decay heat during the shutdown. However, in many cases, plant technical specifications require immediate shutdown of the plant. Risk-based analyses for various alternatives of operational policy available in such situations are examined. These analyses can be used to define the risk-effective requirements for those standby safety systems

  11. Evaluation of the novel passive sampler for cyanobacterial toxins microcystins under various conditions including field sampling

    Kohoutek, J.; Maršálek, Blahoslav; Bláha, Luděk

    2010-01-01

    Roč. 397, č. 2 (2010), s. 823-828. ISSN 1618-2642 R&D Projects: GA MŠk 1M0571 Institutional research plan: CEZ:AV0Z60050516 Keywords : passive sampler * microcystin * POCIS Subject RIV: EF - Botanics Impact factor: 3.841, year: 2010

  12. Difficult Decisions: Euthanasia.

    Parakh, Jal S.; Slesnick, Irwin L.

    1992-01-01

    Focuses on the moral arguments for and against the controversial topic of voluntary active euthanasia. Discusses the question of legalization and decriminalization of the practice. Provides a student worksheet with questions to stimulate discussion on the issue. (MDH)

  13. Difficult wounds: radiation wounds

    In an era of modern radiotherapy, problems associated with the indiscriminate treatment of benign disease have largely disappeared. Skin sparing effects of super voltage radiation equipment make the problems previously seen with orthovoltage equipment less frequent. Vigilance on the part of the workers in the field, in general, protects from the disasters that befell Thomas Edison's laboratory assistant. Despite these modern advances, the reconstructive surgeon often faces problems of managing acute local radiation injury from accident following planned therapeutic radiation or the ulcerations and breakdowns seen months or years after radiation therapy. The single most serious hazard to surgery in radiated tissue is the lodgment of bacteria in this tissue rendered avascular by the radiation and secondary necrosis from the infection itself. The principles of management are no different from those used for other chronic granulating wounds: local wound care, appropriate topical antibacterial therapy, systemic antibiotics during the perioperative period and, most importantly, adequate soft tissue coverage

  14. Difficult Decisions: Acid Rain.

    Miller, John A.; Slesnick, Irwin L.

    1989-01-01

    Discusses some of the contributing factors and chemical reactions involved in the production of acid rain, its effects, and political issues pertaining to who should pay for the clean up. Supplies questions for consideration and discussion. (RT)

  15. Difficult marketing; Schwierige Vermarktung

    Rentzing, Sascha

    2013-02-15

    With the new edition of the Renewable Energy Law (EEG) at 1st January 2012, the market premium model becomes effective in order to implement the green electricity into the electricity market better. With this, the operators of photovoltaic power plants switched from the fixed EEG compensation for electricity to direct marketing. The market premium model provides that only 90% of the power generated by large photovoltaic power plants on roofs of buildings are compensated via EEG corresponding to 0.15 Euro/kWh. The remaining 10% is compensated only with 0.045 Euro/kWh which complies with the actual stock exchange value. If one is not very happy with this solution, one has to consume the excess power by its own or to sell the excess power to third parties. The own consumption would be the easier solution. But the own consumption is usually not possible because the most large photovoltaic power plants are installed on roofs of commercial and public buildings. Consequently, the operators of these photovoltaic power plants have to sell the excess power to third parties. This is associated with many imponderables and additional costs.

  16. Difficult Decisions: Reproductive Technologies.

    Parakh, Jal S.; Slesnick, Irwin L.

    1988-01-01

    Presents the arguments for and against artificial insemination and in-vitro fertilization. Cites various legal, moral, and ethical questions which can be used to promote discussion. Some people feel that the natural bond between parent and child could be weakened as a result of this new technology. (RT)

  17. Difficult wounds: radiation wounds

    Krizek, T.J.

    1979-10-01

    In an era of modern radiotherapy, problems associated with the indiscriminate treatment of benign disease have largely disappeared. Skin sparing effects of super voltage radiation equipment make the problems previously seen with orthovoltage equipment less frequent. Vigilance on the part of the workers in the field, in general, protects from the disasters that befell Thomas Edison's laboratory assistant. Despite these modern advances, the reconstructive surgeon often faces problems of managing acute local radiation injury from accident following planned therapeutic radiation or the ulcerations and breakdowns seen months or years after radiation therapy. The single most serious hazard to surgery in radiated tissue is the lodgment of bacteria in this tissue rendered avascular by the radiation and secondary necrosis from the infection itself. The principles of management are no different from those used for other chronic granulating wounds: local wound care, appropriate topical antibacterial therapy, systemic antibiotics during the perioperative period and, most importantly, adequate soft tissue coverage.

  18. Condition Monitoring and Diagnostics for Complex System using Neural Networks

    Zhong Yang

    2013-01-01

    Full Text Available A rule-based expert system is a traditional approach in condition monitoring and diagnostics for complex system. However, the rule-based expert system is not only difficult to be established but also difficult to be renewed along with the changed circumstances. Neural networks provide a data based approach to condition monitoring and diagnostics for complex system such as rotating machinery. By developing associations between neural networks and a rotating machine consisting of gears, bearings and shafts for the first time, a number of advantageous aspects are identified in this study. Fundamental and harmonic frequencies relating to the components, as well as sideband and cepstrum information, were used as input parameters. Outputs of the networks were given as severity levels of system components. Neural networks demonstrated the capability for use in identifying the location and severity of numerous different machinery faults, including multiple component faults. And neural network is not just easy to be established but also easy to be renewed along with the changed circumstances.

  19. Power Flow Study Including FACTS Devices

    T. Thyagarajan

    2010-01-01

    Full Text Available The electric power industry is undergoing the most profound technical, economic and organizational changes since, its inception some one hundred years ago. This paradigm is the result of the liberalization process, stipulated by politics and followed up by industry. In countries like India with fast growing demand of electric power it is difficult to extend the transmission system in time by either building new lines or by introduction of a new voltage level. Power is therefore transmitted through weak system leading to unsatisfactory quality and reliability of power supply. So, the need for new power flow controllers capable of increasing transmission capacity and controlling power flows through predefined transmission corridors will certainly increase. For this reason, as well known in recent years a new class of controllers, Flexible AC Transmission System (FACTS controllers have rapidly met with favor. Considering the practical application of the FACTS controller, it is of importance to investigate the benefits as well as model these devices for power system steady state operation. We have performed the comprehensive modeling of most popular FACTS devices for power flow study. The effectiveness of modeling and convergence is tested with a five bus study system without any FACTS devices and further analyzed it with different FACTS controllers. The de facto standard Newton-Raphson method is used to solve the nonlinear power flow equation. Also, the study is extended for IEEE 30 bus and IEEE 118 bus system. Programming of the power flow studies stated above is implemented with MATLAB.

  20. Syngas Conditioning

    Dagle, Robert A.; Karim, Ayman M.; Li, Guosheng; Su, Yu; King, David L.

    2011-04-29

    A brief review of water gas shift (WGS) catalysis is provided. An overview of the four general classes of WGS catalysts is presented, which include: 1) high temperature shift (HTS), 2) low temperature shift (LTS), 3) sulfur-tolerant shift catalysts, and 4) precious metal-based shift catalysts. A review of WGS utilizing monoliths or other reactor technologies that pertain to fuel cell applications, an area of increasing interest over the past several years, is also presented. Ratnasamy and Wagner have recently provided an outstanding and comprehensive review of WGS catalysis. A particular emphasis of that work is catalyst surface structures, active sites, reaction intermediates, and mechanisms, particularly for noble metal-based catalysts1. The summary provided here is a succinct review of water gas shift catalysis and reactors, with an emphasis on fuel processing applications for fuel cells, and is not intended to provide a comprehensive review of WGS technology.