WorldWideScience
1

Rescue operations in difficult thermal conditions  

Energy Technology Data Exchange (ETDEWEB)

The paper outlines the dangers and difficulties for rescue personnel operating in abnormally high temperature conditions. Examples of such rescue operations show serious lack of discipline and breach of codes of conduct, and also the importance of speed of action, particularly in medical care. General principles for guiding rescue personnel in conditions where the temperature exceeds 33 C at a relative humidity of at least 85% are given.

Kukuczka, A.; Cwiek, B.

1984-03-01

2

Mining coal deposits under difficult mining and geologic conditions. [USSR  

Energy Technology Data Exchange (ETDEWEB)

Selected problems associated with underground coal mining in the USSR are discussed. Deteriorating mining and geologic conditions are evaluated: mining depth increase to more than 1000 m in 22 mines, high methane content in 30% of mined coal seams, rock burst hazards in 25% of mined coal seams, unstable roofs in 40% of mined coal seams, roofs difficult to break down in 25% of mined coal seams, and decreasing coal seam thickness (45% of mined coal seams is less than 1.2 m thick). The following problems associated with underground mining are analyzed: opening coal deposits, mining seams in zones of tectonic dislocations, mining seams with varying thickness, longwall mining using sets of mining equipment (70% of coal output), mining seams 0.71 to 1.25 m thick by the KM103 and the KD80 systems, mining seams 1.2 to 4.0 m thick by the UKP and the KMG systems, mining steep seams by the AShchM, the ANShch and the 2ANShch shield mining systems, manless mining of thick coal seams using scraper loaders and auger mining, hydraulic coal mining, mine drivage in coal seams and rock layers (the Soyuz and the KRT heading machines), mine surveying (using the ShSA-2 and the Tektonika seismic systems), effects of increasing mining depth on temperature in underground coal mines and air conditioning systems, coal dust control, prevention of rock bursts and methane control.

Bratczenko, B.F.

1985-01-01

3

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

Directory of Open Access Journals (Sweden)

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.

Sirvinskiene Giedre

2012-04-01

4

Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new?  

OpenAIRE

The purpose of this article is to review the fundamental aspects of obesity, pregnancy and a combination of both. The scientific aim is to understand the physiological changes, pathological clinical presentations and application of technical skills and pharmacological knowledge on this unique clinical condition. The goal of this presentation is to define the difficult airway, highlight the main reasons for difficult or failed intubation and propose a practical approach to management Throughou...

Rao Durga; Rao Venkateswara

2010-01-01

5

Mechanical pressure gages under difficult conditions; Mechanische Druckmessgeraete unter schwierigen Einsatzbedingungen  

Energy Technology Data Exchange (ETDEWEB)

In spite of electronic solutions, mechanical pressure meters still find their place in reliable in-situ process pressure monitoring without external influences. Planners and users often have difficulties selecting the optimum meter for a given application, especially where difficult operating conditions are concerned. The contribution presents a neutral and practical guide. (orig.)

Nieswandt, T. [Wika Alexander Wiegand GmbH und Co. KG, Klingenberg (Germany)

2008-05-15

6

Difficult asthma  

OpenAIRE

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.

Ahmet Uslu; Tülay Özdemir

1989-01-01

7

Difficult Silences  

Science.gov (United States)

In December 2005, the Ford Foundation awarded Hollins University and the American Association of University Professors $10,000 to participate in the foundation's Difficult Dialogues initiative. The project supported by this grant brings together a consortium of academics, including the author, from three separate institutions in Virginia and the…

Winston, Janet

2006-01-01

8

Success Nonetheless: Making public utilities work in small-scale democracies despite difficult social capital conditions  

OpenAIRE

INTRODUCTION: The fate of societies and their governments intertwined. Academics and policy makers have long sought to understand how the attributes of a people translate to the form of government that arises and survives. In particular, they have explored which key social levers can increase the success rates of democracies. One branch of this research focussed on which societal conditions are conducive to the flourishing of democracy. Prominent scholars such as Huntington, Fukuyama and S...

Douglas, S.

2011-01-01

9

Conflict management: difficult conversations with difficult people.  

Science.gov (United States)

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

Overton, Amy R; Lowry, Ann C

2013-12-01

10

Difficult and unlikeable parents.  

OpenAIRE

Children of parents who are perceived as difficult or unlikeable are at risk of receiving less good medical care. Therefore a postal questionnaire was sent to 100 hospital doctors dealing with children asking which features made them consider a parent to be difficult or unlikeable. Seventy eight responded. Most problems arose from parents who displayed aggression, disparagement of their child, unacknowledged anxiety, or fixed ideas about the medical condition and its management. Other unpopul...

Meadow, R.

1992-01-01

11

Effectiveness of cast iron vermicularization includingconditioning’ of the alloy  

OpenAIRE

The performed investigations have resulted in conclusion that the vermicularizing treatment of ‘basic’ cast iron, consisting in‘conditioning’ the alloy by means of VLCe(2) master alloy, introducing the DENODUL5 master alloy, and graphitizing with SRF75master alloy, provides for obtaining vermicular graphite precipitates in the structure of material cast within 15 minutes’ period from themodifying treatment. The cast iron has been melted in the induction crucible furnace of medium fr...

Mierzwa, P.; Soin?ski, M. S.

2011-01-01

12

Effectiveness of cast iron vermicularization includingconditioning’ of the alloy  

Directory of Open Access Journals (Sweden)

Full Text Available The performed investigations have resulted in conclusion that the vermicularizing treatment of ‘basic’ cast iron, consisting in‘conditioning’ the alloy by means of VLCe(2 master alloy, introducing the DENODUL5 master alloy, and graphitizing with SRF75master alloy, provides for obtaining vermicular graphite precipitates in the structure of material cast within 15 minutes’ period from themodifying treatment. The cast iron has been melted in the induction crucible furnace of medium frequency under industrial conditions. Thealloy has been subjected to vermicularization in the slender ladle of 1 Mg capacity. Graphitizing has been performed in the course oftransferring the cast iron from the slender ladle to the pouring ladle. A series of test coupons in the form of reversed U-blocks of test part walls 25 mm thick have been cast of the produced cast iron. Then specimens both for metallographic examination and for testing themechanical properties have been taken from the coupons. The analysis of cast iron structure has revealed, among others, that howeverpurely vermicular graphite precipitates occurred in specimens taken out of the lower parts of test coupon walls (which are cooled faster,the nodular graphite precipitates in quantity up to 10% could be observed in specimens from the upper parts of test coupon walls (located close beneath the sinkhead.

P.Mierzwa

2011-04-01

13

Photovoltaic field emulation including dynamic and partial shadow conditions  

International Nuclear Information System (INIS)

In this paper the development of a new laboratory prototype for the emulation of a photovoltaic (PV) field is presented. The proposed system is based on a DC/DC step-down converter topology and allows to obtain the solar array I-V curves, taking into account the environmental changes in solar irradiance and cell temperature. The DC/DC converter control strategy is deduced by using a comprehensive mathematical model of the PV field whose parameters are obtained from the knowledge of: (a) maximum power point data, measured when the PV plant power converter is running, (b) open circuit voltage and short-circuit current, measured off-line. This approach allows the most accurate representation of the PV source. Computer simulations and experimental results demonstrate that the proposed circuit acts as a highly accurate and efficient laboratory simulator of the photovoltaic array electrical characteristics both in steady state and transient conditions. Partial shading and fluctuating conditions can be reproduced too. Moreover the dynamic behaviour of the proposed laboratory emulator is suitable to its effective connection to power electronic interface to the utility or to load through a DC/DC boost converter.

14

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

Science.gov (United States)

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.

Flouris, Triant; Walker, Thomas

2005-01-01

15

F1 occurrence including L condition in TUCUMAN and BUENOS AIRES  

International Nuclear Information System (INIS)

An analysis of the occurrence of the F1 layer including the L condition has been done, using data from two Argentine stations: TUCUMAN and BUENOS AIRES, at different seasons and solar activity conditions. The comparisons between observations and the F1 occurrence predicted by the IRI-90 model show the need of reviewing the use of the DuCharme et al. (1973) formula adopted by the model to predict the occurrence of the intermediate F1 layer including the L condition. (author). 6 refs, 6 figs, 2 tabs

16

Difficult colon polypectomy  

Directory of Open Access Journals (Sweden)

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.

Klaus Vormbrock

2012-01-01

17

Difficult conversations in orthopaedics.  

Science.gov (United States)

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

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

2015-01-01

18

41 CFR 102-117.65 - What terms and conditions must all rate tenders or contracts include?  

Science.gov (United States)

...false What terms and conditions must all rate tenders or contracts include? 102-117.65 Section...65 What terms and conditions must all rate tenders or contracts include? All rate tenders and contracts must include, at a...

2010-07-01

19

Included yet Excluded? : Conditions for Inclusive Teaching in Physical Education and Health  

OpenAIRE

This dissertation has examined the conditions for teachers who teach Physical Education and Health (PEH) in elementary school (age 11-12) and their opportunities to pursue inclusive teaching with the aim of reaching all pupils. The compilation thesis consists of four different articles and provides knowledge from the perspectives of pupils and teachers, but it also includes teaching and learning processes that were studied in situ. The first article contributes to knowledge on how different r...

A?stro?m, Peter

2013-01-01

20

Drivage, development and support of roadways and faces in deep mines and, consequently, in more difficult mining, geological and atmospheric conditions  

Energy Technology Data Exchange (ETDEWEB)

In Spanish mining the greatest difficulties are not caused by depth but by the following factors, either individually or in combination: great tectonization in the coalfields of Asturias, Northern Leon, Palencia, Penarroya, Pedroforca etc; highly irregular and for extreme formations in the coalfields of Cinana-Matallana and El Bierzo for example; self-combustion tendency in Teruel; great plasticity of the enclosing rock in Sabero and Teruel for example. The paper describes two of these factors in detail. These are mining of very wide, irregular seams in the Cinera-Matallana coalfield and self-combustion of lignite from the Innominada mine in the Teruel coalfield. In Spain, development of heading mechanization has taken place and the paper describes one of the most important achievements in this field. This is the WVR-4.7 shielded mole which is a full section-combined loading and stoping machine designed for mines. The main design characteristic is that the stoping face working area is occluded in two shields that cover it completely, allowing transit through difficult areas, such as faults and coal seams, with great safety for staff and with no coal cave-in problems.

1986-01-28

21

Proceedings of the 3. Canada-US rock mechanics symposium and 20. Canadian rock mechanics symposium : rock engineering 2009 : rock engineering in difficult conditions  

Energy Technology Data Exchange (ETDEWEB)

This conference provided a forum for geologists, mining operators and engineers to discuss the application of rock mechanics in engineering designs. Members of the scientific and engineering communities discussed challenges and interdisciplinary elements involved in rock engineering. New geological models and methods of characterizing rock masses and ground conditions in underground engineering projects were discussed along with excavation and mining methods. Papers presented at the conference discussed the role of rock mechanics in forensic engineering. Geophysics, geomechanics, and risk-based approaches to rock engineering designs were reviewed. Issues related to high pressure and high flow water conditions were discussed, and new rock physics models designed to enhance hydrocarbon recovery were presented. The conference featured 84 presentations, of which 9 have been catalogued separately for inclusion in this database. tabs., figs.

NONE

2009-07-01

22

High mortality in an internally displaced population in Ituri, Democratic Republic of Congo, 2005: results of a rapid assessment under difficult conditions.  

Science.gov (United States)

The ongoing conflict in Ituri, Democratic Republic of Congo (DRC), has led to more than 50,000 deaths, more than 500,000 displaced civilians and continuing, unacceptably high, mortality since 1999. In February 2005, after a resurgence of violence and further displacements, Médecins Sans Frontières (MSF) launched an emergency response in three internally displaced persons (IDP) camps in Ituri. We performed a rapid health assessment in April 2005 in one of the IDP camps to evaluate mortality (due to violence or disease) and camp living conditions. The retrospective mortality survey, covering a recall period from 18 December 2004 to 27 March 2005, indicated a crude mortality rate of 4.1 deaths/10,000/day (95% CI: 2.8-5.4) and an under-five mortality rate of 6.9 deaths/10,000/day (95% CI: 4.4-9.4). Living conditions in the camp were extremely poor (average 286 persons per latrine). Despite efforts of the international community and humanitarian organizations, the security situation continues to deteriorate. Regular assessments should be undertaken to monitor the situation. PMID:19153907

Ahoua, L; Tamrat, A; Duroch, F; Grais, R F; Brown, V

2006-01-01

23

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

International Nuclear Information System (INIS)

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.

24

Making marketing difficult  

DEFF Research Database (Denmark)

A critique of conventional science journalism is offered in this paper. The convention of science journalism as science transmission is claimed to be incapable of coping with challenges emerging from the present commercialization of science - letting science into society by embracing and being 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 conlusion of the paper that journalists must break with the convention of science transmission in order to fulfilthat demand, and in order to spur a political discussion, among scientists and in public, on how to maintain the idea of knowledge as a common good.

Meyer, Gitte

2005-01-01

25

A difficult beginning  

Directory of Open Access Journals (Sweden)

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!

Suneth Agampodi

2013-10-01

26

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

Science.gov (United States)

...on Medicare or a child on Medicaid. PPCs...populations, specifically children and pregnant women...populations more characteristic of Medicaid, particularly children and pregnant women...Medicaid populations, including children and...

2011-06-06

27

A Boundary Condition Relaxation Algorithm for Strongly Coupled, Ablating Flows Including Shape Change  

Science.gov (United States)

Implementations of a model for equilibrium, steady-state ablation boundary conditions are tested for the purpose of providing strong coupling with a hypersonic flow solver. The objective is to remove correction factors or film cooling approximations that are usually applied in coupled implementations of the flow solver and the ablation response. Three test cases are considered - the IRV-2, the Galileo probe, and a notional slender, blunted cone launched at 10 km/s from the Earth's surface. A successive substitution is employed and the order of succession is varied as a function of surface temperature to obtain converged solutions. The implementation is tested on a specified trajectory for the IRV-2 to compute shape change under the approximation of steady-state ablation. Issues associated with stability of the shape change algorithm caused by explicit time step limits are also discussed.

Gnoffo, Peter A.; Johnston, Christopher O.

2011-01-01

28

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  

Energy Technology Data Exchange (ETDEWEB)

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

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

29

Stability analysis of hollow electron columns including compressional and thermal effects: Integrability condition and numerical simulations  

International Nuclear Information System (INIS)

The diocotron spectrum for a simplified fluid model of Malmberg-Penning traps that includes compressional effects due to end curvature with finite temperature is investigated. A class of length profiles for which the linearized eigenvalue equation for perturbations can be integrated by quadratures (integrable cases) has been found. In such cases, there is only algebraic growth when the effective angular frequency has a maximum away from the axis (hollow profile), and the model is mathematically equivalent to the zero curvature (two-dimensional Euler) case. Furthermore, profiles that are slightly nonintegrable (the difference being characterized by a small parameter ?) have been studied, finding that the complex frequency of the unstable l=1 mode scales as ?2/3. Analytical calculations (to be presented in a companion paper) and numerical simulations are found in agreement. For the density profile used, the growth rate of the unstable mode has a minimum at the plasma temperature of about 5 eV, which might be tested experimentally

30

Managing the Difficult Airway in Craniomaxillofacial Trauma  

OpenAIRE

Securing the airway in the patient with craniomaxillofacial trauma can be an extremely difficult challenge for health care practitioners. This article provides several approaches to airway management. Presented here are several options for securing the airway under a variety of conditions and scenarios.

Lock, Richard

2010-01-01

31

Self-Consistent Simulation of a Bunched Electron Beam Including Radiation, Space-Charge and Boundary Conditions  

CERN Document Server

High power Free Electron Laser (FEL) designs require high-brightness beams. These beams may suffer beam quality degradation during transport through bending sections from effects that were previously insignificant at low bunch charges. Potential mechanisms include microbunching from longitudinal space-charge and transverse emittance dilution from coherent synchrotron radiation. The effects are not well-understood in the transient state, in the presence of conducting boundaries or when these effects operate together and in conjunction with the beam dynamics. A simulation method applicable under the conditions of a MW-class average power FEL driver has been developed that accounts for radiation, space-charge and boundary conditions in a self-consistent manner. This simulation may be useful in evaluating design concepts under consideration including chicane bunch compressors and energy recovery bending arcs.

Gillingham, D R

2005-01-01

32

Extubation of the difficult airway.  

Science.gov (United States)

Managing the airway in the intensive care unit (ICU) is complicated by a wide array of physiologic factors. Difficult airway may be a consequence of patient’s anatomy or airway edema developed during the ICU stay and mechanical ventilation. The incidence of failed airways and of cardiac arrest related to airway instrumentation in the ICU is much higher than that of elective intubations performed in the operating room. In this article, we will provide a framework for identifying a difficult airway, criteria for safe extubation, as well as review the devices that are available for airway management in the ICU. Proficiency in identifying a potentially difficult airway and thorough familiarity with strategies and techniques of securing the airway are necessary for safe practice of critical care medicine PMID:21887863

Faris, Khaldoun; Zayaruzny, Maksim; Spanakis, Spiro

2011-01-01

33

Drastic Measures for Difficult Times  

Science.gov (United States)

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…

Galuszka, Peter

2008-01-01

34

Multiphase Binary Mixture Flows in Porous Media in a Wide Pressure and Temperature Range Including Critical Conditions  

Science.gov (United States)

Multiphase flows in porous media with a transition between sub- and supercritical thermodynamic conditions occur in many natural and technological processes (e.g. in deep regions of geothermal reservoirs where temperature reaches critical point of water or in gas-condensate fields where subject to critical conditions retrograde condensation occurs and even in underground carbon dioxide sequestration processes at high formation pressure). Simulation of these processes is complicated due to degeneration of conservation laws under critical conditions and requires non-classical mathematical models and methods. A new mathematical model is proposed for efficient simulation of binary mixture flows in a wide range of pressures and temperatures that includes critical conditions. The distinctive feature of the model lies in the methodology for mixture properties determination. Transport equations and Darcy law are solved together with calculation of the entropy maximum that is reached in thermodynamic equilibrium and determines mixture composition. To define and solve the problem only one function - mixture thermodynamic potential - is required. Such approach allows determination not only single-phase states and two-phase states of liquid-gas type as in classical models but also two-phase states of liquid-liquid type and three-phase states. The proposed mixture model was implemented in MUFITS (Multiphase Filtration Transport Simulator) code for hydrodynamic simulations. As opposed to classical approaches pressure, enthalpy and composition variables together with fully implicit method and cascade procedure are used. The code is capable of unstructured grids, heterogeneous porous media, relative permeability and capillary pressure dependence on temperature and pressure, multiphase diffusion, optional number of sink and sources, etc. There is an additional module for mixture properties specification. The starting point for the simulation is a cubic equation of state that is used for mixture thermodynamic potential - entropy - calculation in pressure, enthalpy and composition variables. A polynomial spline is implemented to save the potential for subsequent hydrodynamic simulations. At this stage the majority of complicated thermodynamic procedures are performed prior to hydrodynamic that results in sufficient acceleration of calculations. The code was used for analysis of multiphase water-carbon dioxide mixture flows in porous media. Using the developed methodology the mixture phase diagram was calculated both below and above critical point of water. A zone of three-phase state conditions was detected where the mixture splits in three phases: liquid water and liquefied and gaseous carbon dioxide. The mixture flows subjected to formation of the three-phase flow region were investigated. The work is supported by Grant of the President of the Russian Federation (575.2010.1, 4810.2010.1).

Afanasyev, A.

2011-12-01

35

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

Energy Technology Data Exchange (ETDEWEB)

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.

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

2013-12-15

36

Difficult physician-patient relationships.  

Science.gov (United States)

Changes in the delivery of health care services in the United States are proceeding so rapidly that many providers are asking how the working relationships between doctors and patients will be effected. Accelerated by cost containment, quality improvement and the growth of managed care, these changes have caused some critics to feel that shorter visits and gatekeeper systems will promote an adversarial relationship between physicians and patients. However, proponents of the changing system feel that better prevention, follow-up care and the attention to customer service these plans can offer will lead to increased patient satisfaction and improved doctor-patient communication. Dedicated to addressing these concerns, the Bayer Institute for Health Care Communication was established in 1987 as a continuing medical education program (CME) focusing on this topic. A half-day workshop on clinician-patient communication to enhance health outcomes was introduced in 1992 and a second workshop, "Difficult' Clinician-Patient Relationships," was developed two years later. The two courses discussed in this article are offered to all physicians, residents, medical students, mid-level providers and other interested staff within the Carle system. PMID:10186308

Reifsteck, S W

1998-01-01

37

Difficult Bond. Derrida and Jewishness  

DEFF Research Database (Denmark)

Watchful insomnia can be a nerve-wracking business especially if there is a question to be, if not resolved, then at least confronted; or a decision called for, not despite the famous undecidablity hypothesis, but precisely because of it. Thus it is that finally, casting off the shadows of the night, Jacques Derrida steps into the daylight, in Paris in December 2000, to address directly the question of his Jewishness. Even if his presentation remains marked by the reservations shown in the past, and in particular the casting of affiliation in the self-cancelling terms of its annulment, Derrida nevertheless here lets down his guard in a way he had not done before. And the outcome is remarkable: for the first time he ascribes the aporetic structure of his thinking to a particular propensity for indeterminacy, which he aligns –not with Judaism in any of its doctrinal forms— but with the haunting event of ‘circumcision’ and with his own, somewhat idiosyncratic, experience of being Jewish. As both theme and strategy, ‘circumcision’ has indeed become a trope of tremendous significance in Derrida’s writing as it articulates itself inside the aporia where affiliation is inevitably determined by its own effacement. It epitomizes a difficult double bond which may well have a direct bearing on Derrida’s construal of what it means to think deconstructively.

Siegumfeldt, Inge Birgitte

2013-01-01

38

The early warning system of landslides and sediment runoffs using meteorological condition including rainfall-soil moisture index (Invited)  

Science.gov (United States)

The research including observation of rain, soil moisture content and sediment discharge is conducted on a torrent in northern Kyushu whose geology consists of Paleozoic metamorphic rocks (mainly schist) and whose vegetation consists of mainly Japanese cypress and cedar. Soil depth is approximately 50cm in average and permeability k is 0.1~0.01 order. With data obtained by the observation for more than 4 years, standard rainfalls of warning and evacuation against the sudden sediment runoffs are analyzed. Then, the result was compared with the ones in Nuevo Leon Mexico (geology of schist, slate, k=0.01~0.001 order) and in southern Sulawesi Island Indonesia (volcanic geology, k=0.001~0.0001 order). Hitherto, various methods were proposed to analyze the warning critical standard for landslide disaster or large sediment discharge. In this study, we employed Hirano's element slope runoff theory, the Self Organized Criticality Assumption (SOC), and the Elementary Catastrophe Theory (ETC) to analyze the data, although the soil moisture fluctuation, meteorological condition such as upper air wind and dew point depression, the rainfall-soil moisture index provided by Japan Meteorological Agency was considered. The last one is a cutting edge technology based on the tank model calculation of soil moisture content combined with short term rainfall prediction which is a product of numerical simulation using radar image advection analysis compensated with surface rain data and with orographic rain effect. In Hirano's theory, we can describe the critical rain Rc and rain intensity Ric as following equation. Q/A/M/ cos? = Ri ?(r*cos?)dt = Ri*R (1) ? Ric*Rc = C (2) Here, Q: sediment runoff or debris flow discharge, A: watershed area, M: function concerning with sediment deposit features on the upstream torrents or slopes (porosity, torrent bed slope gradient, sediment accumulation length and depth, cohesion), t: time, ?: torrent bed or hillside slope gradient, r: instant precipitation. C: constant, given as 8000 in Fukuoka (Kyushu, Japan), as 3750 in Sierra Madere Oriental (Nuevo Leon, Mexico), as 9000 in southern Sulawesi(Indonesia). Consequently, the forecast-warning system which has enough accuracy of 80% against sediment runoffs or debris flows for both wide range region with meteorological conditions and narrow region with the critical rain standard are established. However, in the region with lower soil permeability we may revise the standard rain by the compensation with the soil moisture content response such as increasing rate.

Kubota, T.; Silva, I. C.; Hasnawir, H.

2009-12-01

39

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

Directory of Open Access Journals (Sweden)

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

Zarogoulidis P

2012-06-01

40

Working in a difficult regime  

International Nuclear Information System (INIS)

RA and RB, the two research reactors at the Vinca Institute of Nuclear sciences were built in the late 1950s. Both were designed according to the national (former Yugoslavia) plan for developing nuclear energy. Although some modifications have been successfully made, they are now suffering from problems of ageing and funding since the attitude to the country's nuclear program has changed. Some of the equipment is fit for a museum. But the problem of ageing components is only one of the difficulties faced by the operators, they also cope with the political and financial conditions prevailing in the country

41

Including Riparian Vegetation in the Definition of Morphologic Reference Conditions for Large Rivers: A Case Study for Europe's Western Plains  

Science.gov (United States)

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 hydromorphologic conditions were determined with a set of existing and newly developed measures of riparian dynamics and forest development. Strong correlations were observed at the reach and local levels between the ratios of width to depth and embankment and the developed measures of riparian dynamics and forest. Boundary conditions for riparian forest development were determined for the hydromorphologic and biologic indicators of riparian dynamics and vegetation structure. These conditions also proved useful for determining the presence of sustainable populations of Populus nigra and Salix purpurea. From this agreement between abiotic and biotic boundary conditions, a set of useful reference conditions was determined, and a framework for the definition of reference and good status conditions subsequently evolved. Finally, a proposal for assessment and monitoring the proposed indicators is discussed for its applicability.

van Looy, Kris; Meire, Patrick; Wasson, Jean-Gabriel

2008-05-01

42

Solving difficult hepatobiliary problems in children  

Scientific Electronic Library Online (English)

Full Text Available Most difficult hepatobiliary (HPB) problems in infancy and childhood result from pathological anatomical/mechanical derangements; therefore, surgery on the liver and bile ducts depends on a detailed understanding of liver structure, function and repair response to injury or disease. The surgeon must [...] be aware of the very diverse range of anatomical variations. Perhaps key to improving the outcome of paediatric HPB surgery is centralised management and associating this with a paediatric liver transplant programme, which adds expertise and, frequently, the added benefit of adult HPB surgical input to paediatric surgical care. In the United Kingdom, this has resulted in excellent measurable benefit, particularly in the management of biliary atresia, but also of choledochal cysts, portal hypertension and liver tumours. These conditions are briefly discussed here, with focus on the technical aspects of operative management.

A J W, Millar.

43

Electric scroll compressor for mobile air conditioning including heat pump; Elektrischer Scrollverdichter in PKW Klimaanlage mit Waermepumpe  

Energy Technology Data Exchange (ETDEWEB)

In a two-zone climatic chamber a refrigeration cycle for mobile air conditioning of an electric vehicle was designed by switching with multi way valves between cooling and heating cycle. As a refrigerant compressor, an electric scroll compressor is used. In experimental studies, the COPs and compressor ratios of the two modes are shown. (orig.)

Mardorf, Lutz; Menger, Peter; Heiker, Mathias [Hochschule Osnabrueck (Germany). Labor fuer Angewandte Thermodynamik

2011-04-15

44

Adaptation of Pseudomonas aeruginosa to various conditions includes tRNA-dependent formation of alanyl-phosphatidylglycerol.  

Science.gov (United States)

The opportunistic bacterium Pseudomonas aeruginosa synthesizes significant amounts of an additional phospholipid, identified as 2' alanyl-phosphatidylglycerol (A-PG), when exposed to acidic growth conditions. At pH 5.3 A-PG contributed up to 6% to the overall lipid content of the bacterium. Sequence analysis of P. aeruginosa revealed open reading frame PA0920 showing 34% sequence identity to a protein from Staphylococcus aureus involved in tRNA-dependent formation of lysyl-phosphatidylglycerol. The P. aeruginosa deletion mutant DeltaPA0920 failed to synthesize A-PG. Heterologous overproduction of PA0920 in Escherichia coli resulted in the formation of significant amounts of A-PG, otherwise not synthesized by E. coli. Consequently, the protein encoded by PA0920 was named A-PG synthase. The enzyme was identified as an integral component of the inner membrane. The protein was partially purified by detergent solubilization and subjected to an in vitro activity assay. tRNA(Ala)-dependent catalysis was demonstrated. Transcriptional analysis of the corresponding gene in P. aeruginosa using lacZ reporter gene fusion under various pH conditions indicated a 4.4-fold acid-activated transcription. A phenotype microarray analysis was used to identify further conditions for A-PG function. PMID:19087229

Klein, Stefanie; Lorenzo, Carlos; Hoffmann, Sonja; Walther, Johannes M; Storbeck, Sonja; Piekarski, Tanja; Tindall, Bryan J; Wray, Victor; Nimtz, Manfred; Moser, Jürgen

2009-02-01

45

Statistics concerning the Apollo command module water landing, including the probability of occurrence of various impact conditions, sucessful impact, and body X-axis loads  

Science.gov (United States)

Statistical information for the Apollo command module water landings is presented. This information includes the probability of occurrence of various impact conditions, a successful impact, and body X-axis loads of various magnitudes.

Whitnah, A. M.; Howes, D. B.

1971-01-01

46

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

International Nuclear Information System (INIS)

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

47

Aerodynamics of spheres for Mach numbers from 0.6 to 10.5 including some effects of test conditions  

Science.gov (United States)

Wind tunnel tests were made for spheres of various sizes over a range of Mach numbers and Reynolds numbers. The results indicated some conditions where the drag was affected by changes in the afterbody pressure due to a shock reflection from the tunnel wall. This effect disappeared when the Mach number was increased for a given sphere size or when the sphere size was decreased for a given Mach number. Drag measurements and Schlieren photographs show the possibility of obtaining inaccurate data when tests are made with a sphere too large for the test section size and Mach number. Tests were also made of an oblate spheroid. The results indicated a region at high Mach numbers where inherent positive static stability might occur with the oblate-face forward. The drag results are compared with those for a sphere and those for various other shapes. The drag results for the oblate spheriod and the sphere are also compared with some calculated results.

Spearman, M. Leroy

1991-01-01

48

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

Science.gov (United States)

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. PMID:24096235

Andresen, Elisa; Opitz, Judith; Thomas, George; Stärk, Hans-Joachim; Dienemann, Holger; Jenemann, Kerstin; Dickinson, Bryan C; Küpper, Hendrik

2013-10-15

49

Solving difficult structures with electron diffraction.  

Science.gov (United States)

Precession electron diffraction has solved a long-standing challenge in electron diffraction. Further progress promises a general technique for structure determination of difficult crystals. PMID:25610622

Zuo, J M; Rouviére, J L

2015-01-01

50

Difficult conditions, high yields; Harte Bedingungen, hoher Ertrag  

Energy Technology Data Exchange (ETDEWEB)

St. Moritz in Switzerland is a world-famous holiday resort. In the summer of 2008, the world's biggest solar thermal power system for a hotel building was commissioned, with a collector surface of 295 square meters. In September 2009, the hotel received the Swiss Solar Award. (orig./AKB)

Hartmann, Stefan

2009-11-17

51

Why behavior change is difficult to sustain.  

Science.gov (United States)

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

Bouton, Mark E

2014-11-01

52

Road to Sobriety Is Difficult, but Possible  

Science.gov (United States)

... School Health Resources Health Calculators AOA Partnerships The Road to Sobriety is Difficult, But Possible Page Content ... stop drinking again and seek immediate help. The road to sobriety is often long and bumpy, but ...

53

Difficult airway management and the novice physician  

OpenAIRE

Background: Selection of the ideal airway device in patients with difficult airways (DA) or potentially difficult airways remains controversial, especially, for a novice anesthesia physician (NP) who must deviate from conventional direct laryngoscopy with a rigid laryngoscope following a failed intubation and employ one of the several alternative devices. The author determines and compares tracheal intubation success rates, times to success and complications of a novice physician using four a...

Aikins Noble; Ganesh Rajpaul; Springmann Kurt; Lunn Jeffrey; Solis-Keus Joanne

2010-01-01

54

Difficult Channel Generation Using Genetic Algorithm  

OpenAIRE

For channel routing problems, Deutsch's channel examples were used extensively asbenchmarks for testing new algorithms. However, it is also important to test the performanceof channel routing algorithms on a wider variety of difficult examples. In this paper, wepresent a random channel routing generator which can generate difficult channel routinginstances of arbitrary size. In this paper our goal is to generate those channels using GeneticAlgorithm, which have maximum constraints (both verti...

Siddhartha Banerjee; Mitra Tithi Dey; Sayari Dutta

2010-01-01

55

Medical Students' Personal Determinants of Overcoming Strategies in Difficult Situations  

Directory of Open Access Journals (Sweden)

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.

Veretelnikova Yu.Ya.

2013-03-01

56

Protection of mineral deposits - a way towards difficult compromises  

Science.gov (United States)

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.

Radwanek-B?k, Barbara; Nie?, Marek

2014-05-01

57

Qualitative analysis of unanticipated difficult airway management  

DEFF Research Database (Denmark)

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.

Rosenstock, C; Hansen, E G

2006-01-01

58

The difficult encounter between inspector and farmer  

DEFF Research Database (Denmark)

When the inspector drives into the farmyard and asks to see the animal barns to inspect the welfare of the animals, a tense situation may arise because inspections transcend limits and are complex and difficult for many farmers to relate to. A new research project is examining the interaction between authorities and farmers.

Anneberg, Inger; SØrensen, Jan Tind

2012-01-01

59

High quality surfaces on difficult specimens  

International Nuclear Information System (INIS)

Some details of metallographic or or ceramographic preparation are considered which are of special importance for difficult specimens: 1. The lap and polisher surfaces have to remain flat during the the polishing material. 3. For certain composite materials a chemicalmechanical polishing technique is recommended. 4. A mounting jig for parallel polishing small specimes is described. (orig.)

60

Difficult airway management and the novice physician  

Directory of Open Access Journals (Sweden)

Full Text Available Background: Selection of the ideal airway device in patients with difficult airways (DA or potentially difficult airways remains controversial, especially, for a novice anesthesia physician (NP who must deviate from conventional direct laryngoscopy with a rigid laryngoscope following a failed intubation and employ one of the several alternative devices. The author determines and compares tracheal intubation success rates, times to success and complications of a novice physician using four alternative airway devices in 20 obese (BMI more than 27.5 patients who may be more difficult to intubate than normal weight patients. Materials and Methods: In this prospective randomized experimental study the author investigates a novice physician?s use of the Bullard™, Fiberoptic™, Fastrach™and Trachlight™ comparing reliability, rapidity and safety of orotracheal intubations. Following induction of anesthesia the NP was allowed up to a maximum of two attempts per device at oral intubation. Mean intubation times plus/minus SD, per cent success rates and postoperative complications were evaluated for each device. Results: The Fastrach™ was successful 100% of the time on the first attempt requiring a mean time of 55 seconds plus/minus 6.6. All intubations were unsuccessful following two attempts with the Fiberoptic™. A success rate of 20% (one of five was achieved with the Trachlight™ on first attempt after 95 seconds. The Bullard™ was successful in 40 % (two of five of the patients after a mean time 60 seconds plus/minus five, but was the only device to result in mild oral discomfort one day post operatively. Conclusions: In the hands of a novice physician managing a difficult or potentially difficult airway, often encountered in obese patients, the Fastrach™ demonstrated the highest success rate.

Aikins Noble

2010-01-01

61

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

Energy Technology Data Exchange (ETDEWEB)

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.

Pruess, K.

2011-05-15

62

Honey bees selectively avoid difficult choices  

OpenAIRE

Here we show that honey bees (Apis mellifera) can adaptively alter their behavior in a choice test in response to trial difficulty. Bees preferentially opt out of difficult trials and by doing so, improve their success rate. We discuss whether this choice involves assessing degree of uncertainty (considered a definition of basic metacognition) or whether this task might be solved by associative mechanisms. We propose a hypothesis for how uncertainty might be processed within the known circuit...

Perry, Clint J.; Barron, Andrew B.

2013-01-01

63

Clinical review: Management of difficult airways  

OpenAIRE

Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia and intensive care. A patent and secure airway is essential to manage anesthetized or critically ill patients. Oxygenation maintenance during tracheal intubation is the cornerstone of difficult airway management and is always emphasized in guidelines. The occurrence of respiratory adverse events has decreased in claims for injuries due to inadequate airway management mainl...

Langeron, Olivier; Amour, Julien; Vivien, Benoi?t; Aubrun, Fre?de?ric

2006-01-01

64

Difficult ("heartsink" patients and clinical communication difficulties  

Directory of Open Access Journals (Sweden)

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

Faustino R Pérez-López

2010-12-01

65

Genetic and epidemiological studies of Dystocia : Difficult labour  

OpenAIRE

Objective: To explore the epidemiological characteristics, the influence on reproductive health and the genetic basis of dystocia prolonged and difficult labour. Material and methods: The thesis has a retrospective design and is mainly based on a material from an entire cohort of women, extracted from the Swedish Medical Birth Register, who had their first delivery during the years 1973 to 1997. This includes totally 2 539 534 deliveries. The number of dystocia diagnos...

Algovik, Michael

2008-01-01

66

Genetic evidence of multiple loci in dystocia - difficult labour  

OpenAIRE

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...

Westgren Magnus; Kivinen Katja; Peterson Hanna; Algovik Michael; Kere Juha

2010-01-01

67

Difficult weaning in delayed onset diaphragmatic hernia  

Directory of Open Access Journals (Sweden)

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.

Ahmed Syed

2009-01-01

68

Chernobyl: Chronicle of difficult weeks [videorecording  

International Nuclear Information System (INIS)

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

69

Rigid fibrescope Bonfils: use in simulated difficult airway by novices  

Directory of Open Access Journals (Sweden)

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.

Piepho Tim

2009-07-01

70

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

Science.gov (United States)

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. PMID:23723690

Lindsay, John T; Heaney, Liam G

2013-01-01

71

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

Directory of Open Access Journals (Sweden)

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

Lindsay JT

2013-04-01

72

[Anesthesia in spontaneous ventilation for difficult intubation].  

Science.gov (United States)

Difficult intubation in children is rare and often predictable during anesthesia consultation. This allows to establish a strategy to provide fiberoptic guided tracheal intubation with spontaneous ventilation in function of age and children pathology. A good knowledge of physiologic and anatomic children particularities, of fiberoptic technique and the respect for some principles lead to ensure the security of this procedure. First principle is to use only one anesthetic inhaled or intravenous agent in order to limit an important decrease of ventilation. The anesthetic technique recommended for pediatric fiberoptic guided intubation is inhaled anesthesia with sevoflurane. But it is possible to use an intravenous agent, like propofol, with a continuous infusion (bolus of 0.1 to 0.3 mg/kg then 0.1-0.3mg/kg per hour for maintenance) or with target controlled infusion (Schnider model, initial concentration 2.5 ?g/mL, then increase by 0.5 ?g/mL steps) particularly in children older than 5 years with an anesthetic depth control. Whatever the agent, the dose must to be titrated to maintain spontaneous ventilation. Second principle is to combine an airway local anesthesia with general anesthesia to limit airway reactivity. First, a nose topical anesthesia is administered with lidocaine plus naphazoline in children older than 2 years. Then, a laryngeal topical anesthesia is realized with lidocaine 1% (1-2 mL, 2mg/kg) through operating channel of fiberoptic bronchoscope. Finally, third principle is to ensure patient oxygenation with several techniques like use of endoscopic facial mask or nasopharyngeal tube. The use of laryngeal mask is a rescue technique in case of spontaneous ventilation lost. In conclusion, each institution has to establish an algorithm with his own knowledge, constantly feasible and regularly taught. PMID:24209989

Salvi, N; Orliaguet, G

2013-12-01

73

Blood transfusion for the patient who is difficult to transfuse.  

Science.gov (United States)

There are two types of patients who are difficult to transfuse because of the presence of red cell antibodies, those patients who have an antibody reactive against an antigen of high incidence and those who have multiple antibodies. Possible sources of blood for the patient who has an antibody reactive against a high-incidence red cell antigen include the patient's family, rare donors lacking the high-incidence antigen, and self-donation. Possible sources of blood for those who have multiple antibodies are limited to rare donors lacking the appropriate combination of antigens or to self-donation. PMID:839863

Brzica, S M; Pineda, A A; Taswell, H F

1977-03-01

74

Difficult asthma: assessment and management, Part 2.  

Science.gov (United States)

Patients with severe asthma have considerable morbidity related to their asthma and are at risk for serious, life-threatening exacerbations. Their management requires an intensive and comprehensive approach, including attention to reducing exposure to environmental inciters of airway inflammation and triggers of symptoms, patient education (including an asthma action plan), and opportunity for close patient-provider communication. Approved medical options include the lipoxygenase inhibitor, zileuton; the anti-immunoglobulin E monoclonal antibody, omalizumab; and bronchial thermoplasty. Nonapproved interventions of potential benefit are ultrahigh-dose inhaled corticosteroids, anticholinergic bronchodilators (tiotropium), macrolide antibiotics, and vitamin D supplementation for the vitamin D-deficient patient. Potentially toxic, "steroid-sparing" therapies such as methotrexate, cyclosporine, and etanercept are best reserved for patients participating in clinical trials. Recognition of specific subtypes of patients with therapy-resistant asthma permits more targeted treatment approaches, such as for aspirin-sensitive asthma, persistent eosinophilic asthma, asthma complicated by allergic bronchopulmonary aspergillosis, asthma with persistent airflow obstruction, and asthma with life-threatening (near fatal) asthmatic attacks. Novel therapies based on an improved understanding of the pathobiology of therapy-resistant asthma are greatly needed. PMID:22856632

Fanta, Christopher H; Long, Aidan A

2012-01-01

75

Maxillofacial trauma patient: coping with the difficult airway  

Directory of Open Access Journals (Sweden)

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.

Barak Michal

2009-05-01

76

Thermoelastic stresses in non-uniform geological environments difficult outline  

Directory of Open Access Journals (Sweden)

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.

?.?. ??????

2010-01-01

77

Management of difficult airway in intratracheal tumor surgery  

Directory of Open Access Journals (Sweden)

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.

Agarwal Surendra K

2005-06-01

78

Difficult-to-wean: High index of suspicion  

Science.gov (United States)

Patient: Female, 57 Final Diagnosis: Syryngomyelia • cervical Symptoms: Acute respiratory insufficiency Medication: — Clinical Procedure: — Specialty: Pulmonology Objective: Rare disease Background: Failed planned extubation occurs in a minority of patients with acute respiratory failure requiring invasive mechanical ventilation. In patients presenting with acute respiratory failure with no identifiable cardiopulmonary causes, uncommon conditions, such as cervical spondylotic myelopathy, should be considered. In very rare instances, when cervical spondylotic myelopathy and syringomyelia present concomitantly, they can be devastating. Case Report: A 57-year-old woman visited the emergency room (ER) after feeling unwell for several days. She was brought to the ER with acute respiratory distress and obtunded state with GCS of 6/15. She was hypotensive and agonally breathing. Her initial neurologic evaluation was unrevealing. Based on these findings, she was intubated. Over the next several days, she was difficult to wean from the ventilator and had persistent respiratory acidosis. After a short-lived extubation, the patient was again re-intubated. This time the neurologic evaluation showed decreased movements of all muscle groups against gravity and forces, with generalized weakness. An MRI of the brain and cervical spine demonstrated moderate degenerative disc disease and syringomyelia extending from C2 to C7 level. The patient underwent de-compression laminectomy. After failing several weaning trials, she underwent bronchoscopically-assisted tracheotomy. Conclusions: Acute cardiopulmonary and intensive care unit-acquired neuromuscular conditions have been attributed as a major cause of difficult weaning and extubation. Failure to identify and correct other rare combinations (such as cervical degenerative disc disease and syringomyelia) may cause acute respiratory failure and subsequent failure to wean and extubation, resulting in high rates of mortality and morbidity. PMID:24790685

Gelaye, Alehegn; Patel, Brijesh; Farra, Wassim; Kole, Bruce

2014-01-01

79

Organizational Behavior: Coping with Difficult Co-Workers.  

Science.gov (United States)

Discusses the need for students to learn to recognize and cope with difficult co-workers. Describes a few types of personalities that exhibit difficult or disturbed behavior and offers suggestions for coping with these personalities. (JOW)

Arnold, Vanessa D.; Roach, Terry D.

1992-01-01

80

Processing a difficult urethane elastomer system  

International Nuclear Information System (INIS)

A detailed study of an adiprene/butanediol/trimethylolpropane elastomer system and the associated production process was performed to assess the importance of various processing factors on the physical properties of the system. Results indicated that control of the curing cycle, material ratio, moisture in the curing agent and elastomer, mixing, and vacuum level was necessary. Sufficient control of the manual process could not be obtained to eliminate significant physical property variability. An automatic metering, mixing and dispensing machine was purchased for laboratory evaluation. After modification, including the addition of a high shear vacuum type mixer, and with close vacuum and temperature control, material property variability was still at an unacceptable level. A tracer agent was introduced into the curing agent system to assess the distribution of the curing agent in the elastomer. Machine evaluation using the tracer agent indicated that distribution of the curing agent in the elastomer was very poor is spite of the high shear mixing configuration. The addition of an oscillating motion to the mixing configuration. The addition of an oscillating motion to the mixing system significantly improved curing agent distribution and eliminated material property variability problems. 16 figures, 3 tables

81

The approach to the patient with a difficult melanocytic lesion.  

Science.gov (United States)

Although most histological diagnoses are made with relative ease and with great specificity and reproducibility, there is a subset of cases in which a specific and reproducible diagnosis is difficult or even impossible to render. In the melanocytic system, these cases can be divided into two broad categories. The first category, 'superficial atypical melanocytic proliferations of uncertain significance' (SAMPUS), includes predominantly junctional melanocytic proliferations, and melanocytic proliferations that are confined to the epidermis and papillary dermis, without evidence of tumorigenic proliferation or mitotic activity there. The prognosis for cure of these lesions is excellent if they are completely excised. Such lesions may include, for example, dysplastic naevi, Spitz naevi or pigmented spindle cell naevi with a few atypical melanocytes above the dermal-epidermal junction, or with greater than average cytological atypia, or with mitoses, where the differential diagnosis of melanoma in situ is difficult or impossible to rule out. The other category, 'melanocytic tumours of uncertain malignant potential' (MELTUMP), is comprised of melanocytic proliferations that form tumours in the dermis, and are therefore potentially capable of metastasis. Examples of such lesions may include atypical Spitz naevi, deep penetrating naevi, possible naevoid melanomas, or cellular blue naevi, where because of increased mitotic activity or cytologic atypia, a diagnosis of invasive or tumorigenic melanoma cannot be ruled out. In managing such lesions, we follow two main principles. The first is to manage each lesion with therapy designed to be adequate for management of the most significant consideration in the differential diagnosis. The second principle is to make clinicians and patients specifically aware of the diagnostic difficulty in their lesion, so that management can be undertaken on a true informed consent basis. PMID:15370112

Elder, David E; Xu, Xiaowei

2004-10-01

82

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

OpenAIRE

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 compar...

Odd Lindell; Sven-Erik Johansson; Lars-Erik Strender

2010-01-01

83

Penile Corporeal Reconstruction during Difficult Placement of a Penile Prosthesis  

Directory of Open Access Journals (Sweden)

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.

Sherif R. Aboseif

2008-11-01

84

Implications of the KONVERGENCE Model for Difficult Cleanup Decisions  

Energy Technology Data Exchange (ETDEWEB)

Abstract—Some cleanup decisions, such as cleanup of intractable contaminated sites or disposal of spent nuclear fuel, have proven difficult to make. Such decisions face high resistance to agreement from stakeholders possibly because they do not trust the decision makers, view the consequences of being wrong as too high, etc. Our project’s goal is to improve sciencebased cleanup decision-making. This includes diagnosing intractable situations, as a step to identifying a path toward sustainable solutions. Companion papers describe the underlying philosophy of the KONVERGENCE Model for Sustainable Decisions,1 and the overall framework and process steps.2 Where knowledge, values, and resources converge (the K, V, and R in KONVERGENCE), you will find a sustainable decision – a decision that works over time. For intractable cases, serious consideration of the adaptable class of alternatives is warranted – if properly implemented and packaged.

Piet, Steven James; Dakins, Maxine Ellen; Gibson, Patrick Lavern; Joe, Jeffrey Clark; Kerr, Thomas A; Nitschke, Robert Leon

2002-08-04

85

Pipeline developments 1998 and beyond : more choices, more difficult decisions  

International Nuclear Information System (INIS)

Some of the basic economic principles that drive gas prices and gas flows across North America, and the pressures these have placed on the pipeline sector, are reviewed. Of pressing importance to the natural gas industry in Western Canada is the prospect that in the near future industrial gas users in eastern Canada will have a wider array of pipeline choices available to them than ever before. This will mean that the users will face more offerings from more pipeline providers, forcing pipeline owners to make more difficult decisions regarding new pipeline capacity. Variables such as price, terms and conditions will become increasingly negotiable. Market power concerns also remain an important issue. As a result, there is increasing call for market-based financial regulation of pipelines. 'Market gaming' a condition where a firm manipulates the market to its own market advantage is also receiving considerable attention. The latter is of particular concern in the United States. Against this background, the nature of competition (or the lack of it) in natural gas transport, the influence of short-term service revenues for pipelines, pipeline commitments through subsidiaries, and concerns over short term pipeline valuations skewing investment decisions, are issues that will continue to invite much attention. Regarding market outlook, it was noted that significantly increased export capacity from Alberta could raise the costs of Alberta supplies to eastern Canadian end-uslberta supplies to eastern Canadian end-users relative to other supply/transport options which may now be viable economic alternatives. figs

86

A pacemaker powered by an implantable biofuel cell operating under conditions mimicking the human blood circulatory system--battery not included.  

Science.gov (United States)

Biocatalytic electrodes made of buckypaper were modified with PQQ-dependent glucose dehydrogenase on the anode and with laccase on the cathode and were assembled in a flow biofuel cell filled with serum solution mimicking the human blood circulatory system. The biofuel cell generated an open circuitry voltage, Voc, of ca. 470 mV and a short circuitry current, Isc, of ca. 5 mA (a current density of 0.83 mA cm(-2)). The power generated by the implantable biofuel cell was used to activate a pacemaker connected to the cell via a charge pump and a DC-DC converter interface circuit to adjust the voltage produced by the biofuel cell to the value required by the pacemaker. The voltage-current dependencies were analyzed for the biofuel cell connected to an Ohmic load and to the electronic loads composed of the interface circuit, or the power converter, and the pacemaker to study their operation. The correct pacemaker operation was confirmed using a medical device - an implantable loop recorder. Sustainable operation of the pacemaker was achieved with the system closely mimicking human physiological conditions using a single biofuel cell. This first demonstration of the pacemaker activated by the physiologically produced electrical energy shows promise for future electronic implantable medical devices powered by electricity harvested from the human body. PMID:23519144

Southcott, Mark; MacVittie, Kevin; Halámek, Jan; Halámková, Lenka; Jemison, William D; Lobel, Robert; Katz, Evgeny

2013-05-01

87

Actual Condition of Paddy Field Levee Maintenance by Various Farm Households including Large-scale Farming in the Developed Land Renting Area  

Science.gov (United States)

The survey of interview, resource acquisition, photographic operation, and questionnaire were carried out in the “n” Community in the “y” District in Hakusan City in Ishikawa Prefecture to investigate the actual condition of paddy field levee maintenance in the area where land-renting market was proceeding, large-scale farming was dominant, and the problems of geographically scattered farm-land existed. In the study zone, 1) an agricultural production legal person rent-cultivated some of the paddy fields and maintained the levees, 2) another agricultural production legal person rent-cultivated some of the soy bean fields for crop changeover and land owners maintained the levees. The results indicated that sufficient maintenance was executed on the levees of the paddy fields cultivated by the agricultural production legal person, the soy bean fields for crop changeover, and the paddy fields cultivated by the land owners. Each reason is considered to be the managerial strategy, the economic incentive, the mutual monitoring and cross-regulatory mechanism, etc.

Sakata, Yasuyo

88

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

Energy Technology Data Exchange (ETDEWEB)

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.

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); Stärk, 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 Düben (Germany); Jenemann, Kerstin, E-mail: Kerstin.Jenemann@smul.sachsen.de [Sächsisches Landesamt für 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); Küpper, 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, Branišovská 31, CZ-370 05 ?eské Budejovice (Czech Republic)

2013-10-15

89

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

International Nuclear Information System (INIS)

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

90

Aerodynamics of a sphere and an oblate spheroid for Mach numbers from 0.6 to 10.5 including some effects of test conditions  

Science.gov (United States)

Wind-tunnel tests were made for spheres of various sizes over a range of Mach numbers and Reynolds numbers. The results indicated some conditions where the drag was affected by changes in the afterbody pressure due to a shock reflection from the tunnel wall. This effect disappeared when the Mach number was increased for a given sphere size or when the sphere size was decreased for a given Mach number. Drag measurements and Schlieren photographs are presented that show the possibility of obtaining inaccurate data when tests are made with a sphere too large for the test section size and Mach number. Tests were also made of an oblate spheroid. The results indicated a region at high Mach numbers where inherent positive static stability might occur with the oblate-face forward. The drag results are compared with those for a sphere as well as those for various other shapes. The drag results for the oblate spheroid and the sphere are also compared with some calculated results.

Spearman, M. Leroy; Braswell, Dorothy O.

1993-01-01

91

Investigation on the behaviour of Fe++ and Cu++ chemical dosimeter under process conditions, including the influence of solute concentration in the system  

International Nuclear Information System (INIS)

The reaction mechanism proposed for the Fe-Cu dosemeter in the literature has failed to explain why the yield of Fe+++ is not a linear function of dose and why there is a difference in the initial yield when the solution is oxygen saturated as opposed to oxygen depleted. In addition, an investigation of the dose-rate effect on G(Fe+++) in oxygenated and oxygen depleted solutions yields results which have not proved amenable to the introduction of new reaction mechanisms. Pulse radiolysis studies have also failed to provide insight into additional reaction mechanisms which would explain the various discrepancies in the radiological behavior of the Fe-Cu system. In the present work, the Fe-Cu system was studied under extreme conditions of solute concentration and dose-rate. The experiments were aimed at determining the influence of concentrations of O2, Fe++, Fe+++ and Cu++ on the yield of Fe+++ in the irradiated Fe++-Cu++ dosemeter solution. Rapid mixing techniques were employed and a model reaction scheme developed for computer calculations to test the understanding of the radiochemical reactions. Methods for suppressing the reactions Cu++O2?Cu+++O2- and HO2+Fe++?HO2-+Fe+++ and thus improving dosemeter performance in a gamma field were determined. However, the investigation demonstrated that the dosemeter cannot be used for high dose-rate dosimetry of pulsed electron beams

92

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  

Science.gov (United States)

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.

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

2003-01-01

93

Dealing with difficult patients in your pain practice.  

Science.gov (United States)

Pain patients can be difficult. They can provoke negative feelings of frustration and anger among clinicians and damage the doctor-patient relationship. This article helps practitioners to identify those pain patients who would be prone to difficult behavior and sheds light on some of the reasons behind the behavior that give rise to difficult feelings. Issues of comorbid psychopathology, hostility, suicidality, aberrant drug behavior, and chronic noncompliance are discussed. Specific recommendations are also given of the best ways to manage patients with difficult behavior. PMID:15765460

Wasan, Ajay D; Wootton, Joshua; Jamison, Robert N

2005-01-01

94

Uncomfortable Positions: How Policy Practitioners Negotiate Difficult Subjects  

OpenAIRE

This thesis examines how policy practitioners negotiate difficult subjects, specifically the difficult subjects entailed in negotiations around community cohesion policy. The research applies a governmentality perspective to consider how people working within government (using techniques of governmentality to govern populations) are subject to regimes of governmentality themselves. A substantial body of the research is based on detailed ethnographic work (both participant observation and exte...

Jones, Hannah

2011-01-01

95

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

Energy Technology Data Exchange (ETDEWEB)

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.

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

2013-11-01

96

Genetic evidence of multiple loci in dystocia - difficult labour  

Directory of Open Access Journals (Sweden)

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.

Westgren Magnus

2010-06-01

97

[Decubitus ulcer in the calcaneus region: rapid development, difficult recovery].  

Science.gov (United States)

Heel pressure sores frequently arise in patients kept in bed for a long time independently of their primary disease. In account of this event the authors completed a study concerning possible mutual relations between heel pressure sores and primary disease of the patients; to validate the pharmacological treatment in less severe sores and the surgical resolution in more serious cutaneous lesions. In the last 3 years (1992-1995) at the Rehabilitation Centre of Montescano the authors have treated 39 patients suffering from 63 different severe cutaneous lesions: from phlycten to deep necrosis. The therapeutic plane utilized pharmacological treatment for 1st, 2nd, 3rd degree pressure sores, and surgical treatment for 4th degree. Pharmacological treatment included: enzymatic drugs, bactericidal and bacteriostatic medicines and cicatrizing substances. Different healing times were related to different pressure sore severity. Surgical treatment consisted of transposition of flap into wound defect. This system caused considerable reduction in resolution times. The authors noticed how easily pressure sores arise in the heel region, and how difficultly they heal. This is probably connected with particular anatomical and vascular characteristics of this region. PMID:8668293

Fugazza, G; Bona, F

1996-03-01

98

Management of difficult airway by retrograde tracheal intubation  

International Nuclear Information System (INIS)

A case of difficult intubation is presented in a patient of adenoid carcinoma with a large right-sided facial defect. She was managed with radiotherapy and a myocutaneous flap reconstruction was done with retrograde tracheal intubation. (author)

99

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  

Energy Technology Data Exchange (ETDEWEB)

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.

Pruess, K.

2011-04-01

100

Part I: The Difficult Patient: Medical and Legal Approaches  

OpenAIRE

Difficult patients are defined as those who elicit strong negative emotions from their physicians. If not acknowledged and managed correctly, these feelings can lead to diagnostic errors, unpleasant confrontations, and troublesome complaints or legal claims. The author reviews common personalities and situations that are associated with difficult encounters in emergency departments and describes an approach stressing flexibility in communication and the early establishment of rapport. He disc...

Ovens, Howard

1989-01-01

101

Management of difficult bile duct cannulation in ERCP  

Directory of Open Access Journals (Sweden)

Full Text Available In Encoscopic Retrograde Cholangiopancreatography (ERCP, the main concern is to gain access into the bile duct while avoiding the pancreatic duct because of the risk of post-ERCP pancreatitis. Difficult cannulation is defined as a situation where the endoscopist, using his/her regularly used cannulation technique, fails within a certain time limit or after a certain number of unsuccessful attempts. Different methods have been developed to manage difficult cannulation. The most common solution is to perform a precut papillotomy either with a needle knife or with a sphincterotome with or without a guide wire. This review describes different methods to overcome cases of difficult cannulation. We will discuss the success rate and complication rates associated with different methods of reaching the biliary tract.

Marianne Udd

2010-03-01

102

Clustering is difficult only when it does not matter  

CERN Document Server

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 computational complexity theory the clustering problem seems very hard. Numerous papers introduce various criteria and numerical measures to quantify the quality of a given clustering. The resulting conclusions are pessimistic, since it is computationally difficult to find an optimal clustering of a given data set, if we go by any of these popular criteria. In contrast, the practitioners' perspective is much more optimistic. Our explanation for this disparity of opinions is that complexity theory concentrates on the wors...

Daniely, Amit; Saks, Michael

2012-01-01

103

This is the tricky part: When directions become difficult  

Directory of Open Access Journals (Sweden)

Full Text Available Automated route guidance systems, both web-based systems and en-route systems, have become commonplace in recent years. These systems often replace human-generated directions, which are often incomplete, vague, or in error. However, human-generated directions have the ability to differentiate between easy and complex steps through language in a way that is more difficult in automated systems. This article examines a set of human-generated verbal directions to better understand why some parts of directions are perceived as being more difficult than the remaining steps. Insights from this analysis will lead to recommendations to improve the next generation of automated route guidance systems.

Kai-Florian Richter

2010-07-01

104

Common Conditions in Newborns  

Science.gov (United States)

... in Newborns Ages & Stages Listen Common Conditions in Newborns Article Body Some physical conditions are especially common ... difficult, or when babies are very large. While newborns recover quickly from some of these injuries, others ...

105

Developing Difficult Dialogues: An Evaluation of Classroom Implementation  

Science.gov (United States)

The University of Missouri (MU) participated in the Ford Foundation's Difficult Dialogues Initiative (DDI) supporting faculty development projects at over 40 institutions of higher education from 2006-2010. This paper reports findings from an evaluation conducted with instructors who not only engaged in faculty development workshops but also…

Placier, Peggy; Kroner, Crystal; Burgoyne, Suzanne; Worthington, Roger

2012-01-01

106

Seeing the cage: stigma and its potential to inform the concept of the difficult patient.  

Science.gov (United States)

The phenomenon of the difficult patient is well known to nurses. Nursing research concerning this phenomenon is limited. The existing research focuses primarily on describing the characteristics of the difficult patient and tends to locate the problem within the patient. This has resulted in a perpetuation of the phenomenon of the difficult patient and has created a cage effect in which nurses' thinking about this phenomenon rests. The purpose of this article is to explore the concept of the difficult patient. The specific aims are to describe the attributes of the concept; arrive at a tentative definition; summarize the findings of a critical review of the nursing research on the concept, conducted within the framework of Goffman's conceptualization of stigma (Goffman E. Stigma: Notes on the Management of Spoiled Identity. New York: Simon & Schuster; 1963.); and discuss the utility of Goffman's work to further illuminate our understanding of the difficult patient. Particular emphasis was placed on the implications for nursing research. Clinical implications are also included. PMID:14986734

Macdonald, Marilyn

2003-11-01

107

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

LENUS (Irish Health Repository)

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.

Walsh, K

2012-02-03

108

Difficult intubation due to chronic hiccup: a case report  

Directory of Open Access Journals (Sweden)

Full Text Available Hiccup is described as a spasm of the diaphragm that causes a sudden inhalation followed by rapid closure of the glottis that produces a sound. Hiccup cause difficulties for medical procedures such as surgery, endoscopy or magnetic resonance imaging. In the literature, hiccup is presented as a situation that is seen due to anesthesia and most studies describe to manage anesthesia-related hiccup. The data about difficult intubation because of hiccup is lacking. Hereby, we present a case of difficult intubation due to chronic hiccup. The patient had a chronic hiccup associated with grade 3 esophagitis and hiatal hernia. Laparoscopic Nissen fundoplication and thoracoscopic phrenic nerve ablation was performed. Our patient was hiccupping during surgery. However, the severity and the frequency of the hiccup attacks were decreased after surgery.

Ismail Hakki Hamzaoglu

2011-01-01

109

Endoscopic management of difficult common bile duct stones  

Directory of Open Access Journals (Sweden)

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.

Guru Trikudanathan

2013-01-01

110

Difficult airway management of a rare case: Syngnathia  

Directory of Open Access Journals (Sweden)

Full Text Available Syngnathia with bilateral maxillo-mandibular inter-alveolar adhesion is a rare entity and a cause of difficult airway. Airway management skills and experience of the anesthetist are crucial factors in the outcome. In this case report we aimed to discuss the successful anesthetic management of a six days-old baby presenting with congenital anomaly of isolated adhesion of the mandible and the maxilla.

Ayhan Köseo?lu

2014-12-01

111

Rolling of castings of difficult to work steels on bloomer  

International Nuclear Information System (INIS)

Recommendations on heating and rolling of castings of 12Kh18N10T, 08Kh22N6T, 14 Kh17N2, 12Kh13, 09Kh17N, 20Kh23N18 steels which introduction allows to upgrade the quality of rolled products, are given. A technique for determining optimal heating and rolling temperatures of difficult to work steels and alloys is developed. Revolution number heating temperature curves have been plotted from torsion test results

112

Management of difficult airway in intratracheal tumor surgery  

OpenAIRE

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...

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

2005-01-01

113

Difficult factors in Management of Impacted Dental Prosthesis in Esophagus  

Directory of Open Access Journals (Sweden)

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

Efiaty A. Soepardi

2005-02-01

114

How can schools build learning organisations in difficult education contexts?  

OpenAIRE

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...

Kholeka Constance Moloi

2010-01-01

115

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

Directory of Open Access Journals (Sweden)

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

Nadir Bafadin oqlu Agayev

2013-12-01

116

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

Czech Academy of Sciences Publication Activity Database

Ro?. 91, ?. 12 (2013), s. 2401-2411. ISSN 0263-8762 R&D Projects: GA ?R 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

Tesa?, Václav

2013-01-01

117

Leadership and cooperation at the general medicine department of LMU Munich: Good grades despite difficult conditions  

OpenAIRE

The relevance of general medicine at German universities will increase over the next few years. Consequently, the discussion of teaching content and even more the improvement of the structures within the still small and dependent departments of general medicine are of major importance. The example of our department at LMU Munich shows which challenges for leadership and cooperation result from lack of financial and personnel structure. The project “cooperation culture” that the department...

Schelling, Jo?rg; Braun, Susanne

2011-01-01

118

Risk Factors Assessment of the Difficult Intubation using Intubation Difficulty Scale (IDS)  

Science.gov (United States)

Background: The major responsibility of anaesthesiologist is to maintain adequate gas exchange in his patients in all circumstances and this require that patency of upper airway is constantly maintained. Problems with upper airway management are among the most frequent causes of anaesthetic mishaps. Using intubation difficulty scale (IDS) we made an attempt to objectively assess the predictors of difficult intubation. We assessed classical bedside tests such as modified Mallampati test, Thyromental distance test and also neck extension test. Methods: We prospectively observed 400 patients undergoing general anaesthesia with endotracheal intubation, for each patient intubation difficulty score was recorded during intubation. Risk factors assessment of difficult intubation done using IDS. Risk factor assessed includes modified mallampati class III and IV, thyromental distance ? 6cm and neck extension < 5cm. Patients were categorised as Easy intubation (IDS, 0 to 2), slightly difficult intubation (IDS, 3 to 4) and difficult intubation (IDS 5). Preoperative airway assessment was done by thyromental distance measurement, neck extension measurement and modified mallampati test. Data was analysed using Receiver operating characteristic curve (ROC) and area under curve (AUC) for each test computed. p<0.05 was considered significant. Results: The incidence of difficult intubation was 8% and there were no failure to intubate the trachea. The AUC were as follows: modified Mallampati test 0.473 (p<0.005), Thyromental distance test 0.753 (p<0.005) and neck extension test 0.768 (p<0.005). Conclusion: The results indicate that neck extension test is strongest predictor of difficult intubation (IDS?5) in comparison to Thyromental test and modified mallampati test. PMID:25177576

K. Nasa, Vaibhav

2014-01-01

119

Emotional distance to so-called difficult patients  

DEFF Research Database (Denmark)

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 qualitative study inspired by hermeneutic phenomenology was conducted. The data were obtained through participant observation and interviewing in a home nursing unit in a Danish municipality. During an initial 3 month period, eighteen participant observations were conducted with 12 nurses during their visits to 96 patients. During the following 3 months, 12 more participant observations were made with three nurses visiting 50 patients. Four of these patients whom the three nurses found difficult were selected and six interviews conducted with these patients. Eleven interviews were conducted with five 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 particular patient, the avoidance strategy did not necessarily represent the terminal stage, since a nurse could revert to the compromise strategy. Some of the nurses experienced painful emotions regarding these interactions. Conclusions: The avoidance strategy (emotional distance) resulted in important 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 interesting to study in greater detail the perspectives of the patients.

Michaelsen, Jette Joost

2012-01-01

120

A new twist in the pediatric difficult airway.  

Science.gov (United States)

Difficult intubation of a 2.4 kg ex premature, suspected Pierre Robin Sequence with upper airway obstruction causing respiratory failure. Multiple failed intubation attempts by an experienced pediatric anesthetist using described techniques and adjuncts. A description of a simple new maneuvre using a GlideScope and a stylet. By twisting the stylet into a spiral shape, the endotracheal tube was given improved maneuverability that allowed the intubator to place the endotracheal tube tip to the glottis opening. Then by rotating the tube in a clockwise direction it could be manipulated past the vocal cords into the trachea. PMID:25267583

Lillie, Edwardina M M A; Harding, Louise; Thomas, Mark

2015-04-01

121

[Current morphofunctional studies of the optic nerve and retina in difficult diagnostic cases].  

Science.gov (United States)

Thirty-four patients (53 eyes) with suspected optic nerve and retinal diseases were examined. For differential diagnosis, the authors used current studies of the ocular neurosensory apparatus, such as retinal tomography, computer static perimetry, and electrophysiologial techniques, including multifocal electroretinography. The complex use of structural and functional studies of the retina and optic nerve established the valid diagnosis in all difficult clinical cases. PMID:20608189

Sheremet, N L; Ronzina, I A; Galoian, N S; Kazarian, E E

2010-01-01

122

Unanticipated cannot intubate situation due to difficult mouth opening  

Science.gov (United States)

We report a case of unanticipated difficult endotracheal intubation secondary to an abrupt onset of difficulty in opening the mouth in an anesthetized adult. A female aged 76 years with American Society of Anesthetists risk Class IV E with an apparently normal preoperative temporomandibular joint was scheduled for emergency laparotomy. Following rapid sequence induction, and muscle relaxation with rocuronium, the anesthesiologist noticed lock-jaw when intubation was attempted. She was ventilated with nasopharyngeal airway, but was progressively desaturating. An emergency tracheostomy was performed. Unfortunately, she sustained cardiac arrest and could not be revived. The complication of the lock-jaw is a nightmare to airway management, especially in an unprepared situation. PMID:25788786

Akasapu, Karunakara Rao; Wuduru, Sridhar; Padhy, Narmada; Durga, Padmaja

2015-01-01

123

Strategies for Managing Difficult Clinical Situations in Between Sessions.  

Science.gov (United States)

Therapists often have to deal with situations that make them uneasy to leave their clients on their own. They can go home and wonder what their clients are doing, whether they are safe, have a place to stay, even whether or not they are fighting. These thoughts can be overwhelming for the therapist. They may think about their clients' safety, they may also be worried about their own professional way of dealing with these situations, and its implications for them as clinician. The aim of this paper is to assist therapists to manage their own anxiety and to help them help their clients in between sessions in difficult situations such as suicidality, child abuse and neglect, intimate partner violence, crisis and stress management. PMID:25294951

Karakurt, Gunnur; Anderson, Amber; Badford, Alyssa; Dial, Shannon; Korkow, Hannah; Rable, Frank; Doslovich, Serife Fulya

2014-10-01

124

A Difficult Choice for Newspapers: Advertisers or Readers?  

Directory of Open Access Journals (Sweden)

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.

Bar?? Bulunmnaz

2012-03-01

125

Paradoxical pop-ups: Why are they difficult to catch?  

Science.gov (United States)

Professional baseball players occasionally find it difficult to gracefully approach seemingly routine pop-ups. We describe a set of towering pop-ups with trajectories that exhibit cusps and loops near the apex. For a normal fly ball the horizontal velocity continuously decreases due to drag caused by air resistance. For pop-ups the Magnus force is larger than the drag force. In these cases the horizontal velocity initially decreases like a normal fly ball, but after the apex, the Magnus force accelerates the horizontal motion. We refer to this class of pop-ups as paradoxical because they appear to misinform the typically robust optical control strategies used by fielders and lead to systematic vacillation in running paths, especially when a trajectory terminates near the fielder. Former major league infielders confirm that our model agrees with their experiences.

McBeath, Michael K.; Nathan, Alan M.; Bahill, A. Terry; Baldwin, David G.

2008-08-01

126

How difficult is it to obtain restricted release authorization  

International Nuclear Information System (INIS)

Setting and implementing clean up standards for nuclear facilities pose some of the most significant policy and technical challenges facing the nuclear industry and regulators today. There continue to be challenges associated with the legal infrastructure and regulations for radioactive waste management, disposal, clearance and site release. Although progress on low-level waste (LLW) disposal sites has been achieved in some areas, we are still searching for safe, reliable and cost effective disposal solutions. In particular some facilities may not be able to decommission to levels that permit unrestricted use after decommissioning, in part because of the lack of cost effective disposal alternatives. The authors have worked on a number of approaches to addressing restricted release requirements for contaminated sites, and offer some perspective on this very difficult waste management issue. (authors)

127

Performance specifications: the nearly impossible versus the merely difficult  

Science.gov (United States)

Affordability is the objective of acquisition reform. The institution of 'performance' specifications in lieu of 'design' specifications is a key strategy. Design of a cockpit display, for example, is left to the prime contractor based on a performance requirement stated by the government. The prime delegates to the integrator. The integrator develops the display and bill of materials provided by vendors. There is no feedback loop from the vendors to the ultimate customer, the government. As a result of this situation a communication gap exists: the government, primes, and integrators have concluded that they should pay commodity prices for custom displays. One step in the closing of this gap is the establishment of cross- cutting common reference performance specifications for aerospace and defense displays. The performance specification for cockpit displays is nearly impossible to achieve -- the last ounce of technology and more is required. Commodity markets, such as consumer notebook computers, are based on but a fraction of currently available technology -- companies 'bank' technology and roll it out across several 18-month product generations. Ruggedized consumer displays can be used in aerospace and defense applications other than the cockpit, such as mission crew stations. The performance specification for non-cockpit aerospace and defense applications is merely difficult. Acquisition reform has been defined by the Secretary of Defense to mean DoD should leverage the commercial market to the maximal extent possible. For the achievement of this end, an entirely different approach is wanted for cockpit displays versus large platform mission displays. That is, the nearly impossible requires a different design and business approach from the merely difficult.

Hopper, Darrel G.

2000-08-01

128

Fotodepilación: Áreas de difícil tratamiento Photoepilation: treatment of difficult areas  

Directory of Open Access Journals (Sweden)

Full Text Available La Fotodepilación, ha permitido ampliar las posibilidades de aumentar las indicaciones de la depilación; pero junto a ello, existen contraindicaciones, efectos secundarios y complicaciones a su uso que han ido delimitándose en función de los años de experiencia de esta técnica en su aplicación clínica Al igual que con otras tecnologías, la fotodepilación debe tener en cuenta que existen casos con mayor dificultad de tratamiento según la localización, riesgos, tipo de pelo y la posible patología inductora del hirsutismo o hipertricosis. El objetivo de este trabajo es exponer aquellos casos en que por su localización se genera mayor dificultad en el tratamiento del pelo, así como de qué manera plantear las posibles alternativas a la fotodepilación a fin de obtener eficacia de resultados y bajas complicaciones. Se trata de localizaciones como el área de las cejas, área periocular, nasal, auricular , anal, escrotal, vulvar y otras zonas cutáneas de especial fragilidad, buscando la máxima eficacia del tratamiento y evitando efectos secundarios o complicaciones. Este artículo aborda las limitaciones de la técnica.Photoepilation has made it possible to broad the possibilities of increasing indications of epilation. But, at the same time, some contraindications, side effects and complications have delimited in accordance with the years of experience of this technique, its clinical application. As in other technologies, photoepilation must take into account cases that are more difficult to treat, according to hair location, complications, skin type and possible associated pathology leading to hirutism of hypertrichosis. The aim of this paper is to present cases whose location leads to greater treatment difficulties as well as how to approach possible alternatives treatment in order to obtain good efficacy and few complications. Locations such as the eyebrows and periocular region, the nose, ears, anus, scrotum, vulva and prominent areas, must be regarded in photoepilation as being the most difficult ones to treat, in search of the highest efficacy, avoiding side effects and complications. This article deals with limitations of the tecnique.

M. Vélez González

2010-06-01

129

[Treatment of inguinal hernia in a difficult environment: feasibility and efficacy of ilioinguinal and iliohypogastric blocks].  

Science.gov (United States)

Hernia repair is a very frequent surgical procedure; it is estimated that one African in five undergoes this procedure during his lifetime. Patients and methods. We evaluated the feasibility of this surgery under ilioinguinal and iliohypogastric nerve blocks in difficult environments. The medical-surgical group supporting Operation Unicorn has treated 48 inguinal hernias as medical aid to population, including 34 with these nerve blocks. Results. The block did not fail in any case. The mean time until discharge was 6.85 h, which meant that outpatient surgery was possible. Discussion and conclusion. This type of anesthesia is interesting in difficult environments. It is a safe, inexpensive, and easy to learn technique. These qualities should promote its use in countries with a low GNP. PMID:23803581

Goutorbe, P; Lacroix, G; Pauleau, G; Daranda, E; Goin, G; Bordes, J; Meaudre, E; Balandraud, P

2013-05-01

130

Management of difficult intra-articular fractures or fracture dislocations of the proximal interphalangeal joint.  

Science.gov (United States)

Intra-articular fractures or fracture dislocations of the proximal interphalangeal joint are difficult clinically because the bone and soft tissue structures are small and intricate. Suboptimal treatment of intra-articular fractures typically leads to functional impairment of the hand. This article reviews the current methods of treatment, together with the senior author's experience in treating difficult proximal interphalangeal joint fractures and dislocations. Besides conservative treatments, surgical treatments include open or closed reduction with traditional Osteosynthesis, such as K-wires, screws or plates. Among recent developments are the percutaneous application of thin cannulated compression screws and novel dynamic external fixators. After a preferred minimally invasive treatment with stable reconstruction of the articular surface, sufficient aftercare is necessary to improve surgical outcomes. PMID:25427554

Liodaki, E; Xing, S G; Mailaender, P; Stang, F

2015-01-01

131

[Difficult news and the standpoint of pediatric oncologists: a bibliographical review].  

Science.gov (United States)

In order to discuss and understand the experiences of oncologists faced with the task of communicating difficult news to children and their close family members, a bibliographical review was conducted in the Virtual Health Library databases containing the literature published by PubMed, Lilacs, Scielo, Scopus and SciVerse with input on the theme. The articles available evaluated by thematic analysis reveal the following aspects: the lack of studies focusing on the perception of professionals about imparting difficult news; communication as a strategy by which psychosocial, cultural, bioethical, legal and emotional aspects are handled; that more is expected from physicians than they were trained for. It was also seen that the information and training of professionals in strategies regarding how to handle the communication of difficult news needs to be ongoing in order to keep up with the dynamism of the occurrences and the physician-patient relations in the oncological field in which patients tend to be or feel under constant life-threatening conditions. PMID:23989582

Afonso, Selene Beviláqua Chaves; Minayo, Maria Cecília de Souza

2013-09-01

132

Prediction is difficult, preparation is critical and possible  

DEFF Research Database (Denmark)

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 Animals and Zoonoses (STAR-IDAZ) conducted foresight studies as part of its objective to improve coordination of research activities on the major infectious diseases of animals (including zoonoses) to hasten the delivery of improved control methods. The aim of these studies was to identify the scientific and technological needs, including research capacity and support structures to prevent, control or mitigate animal health and zoonotic challenges for 2030 and beyond. While our ability to predict the future is often limited, being prepared to engage with whatever may happen is critical. Methods: Foresight workshops were initially conducted in the Americas involving consideration of scenarios developed in Canada, Asia and Australasia based on the seven questions method, and in Europe involving scenario building and back-casting. Following these regional exercises, critical drivers already identified in a range of other related foresight projects were classified under eight categories and the top 3 – 5 drivers in each category were ranked with the level of uncertainty noted (high/medium/low) by experts from a range of backgrounds from Europe, Africa and the Middle-East, Asia and Australasia and the Americas. The likely impact of these drivers on various disease categories was considered, a preferred future scenario agreed and back-casting conducted at a workshop held in Moscow in June 2014. More than 40 veterinarians and animal health scientists from around the world outlined priorities in terms of research capability and capacity to attain the ideal future. Results: In each of the regions, the research capacity and knowledge networks required to optimise enablers and ameliorate barriers to our ability to meet future animal disease challenges were identified then grouped and prioritised across the regions to give an overall list in which transnational data sharing, knowledge transfer, public-private partnerships, vaccinology/immunology, vector control, antimicrobial resistance, socioeconomics, genetics/bioinformatics and utilisation of big data rated highly. Conclusion: The outputs of the STAR-IDAZ Foresight study will form the basis of a Global Strategic Research Agenda with which research funders and programme managers can prioritise and coordinate national research efforts to improve global collective preparedness for future animal, human and environmental challenges.

Zilli, Romano; Dalton, Luke

133

The Difficult Way of Social Psychology in Russia  

OpenAIRE

The article describes the main stages and directions of the development of social psychology in USSR and Russia. The comparison of theoretical approaches of Russian and Western social psychology is carried out. Special emphasis is made on the problem of social cognition and coping, which are important in the conditions of changing reality. New professional tasks of social psychology are discussed. The necessity of finding a new paradigm in social psychological investigations in conditions of ...

Andreeva, Galina M.

2009-01-01

134

Fotodepilación: Áreas de difícil tratamiento / Photoepilation: treatment of difficult areas  

Scientific Electronic Library Online (English)

Full Text Available SciELO Spain | Language: Spanish Abstract in spanish La Fotodepilación, ha permitido ampliar las posibilidades de aumentar las indicaciones de la depilación; pero junto a ello, existen contraindicaciones, efectos secundarios y complicaciones a su uso que han ido delimitándose en función de los años de experiencia de esta técnica en su aplicación clíni [...] ca Al igual que con otras tecnologías, la fotodepilación debe tener en cuenta que existen casos con mayor dificultad de tratamiento según la localización, riesgos, tipo de pelo y la posible patología inductora del hirsutismo o hipertricosis. El objetivo de este trabajo es exponer aquellos casos en que por su localización se genera mayor dificultad en el tratamiento del pelo, así como de qué manera plantear las posibles alternativas a la fotodepilación a fin de obtener eficacia de resultados y bajas complicaciones. Se trata de localizaciones como el área de las cejas, área periocular, nasal, auricular , anal, escrotal, vulvar y otras zonas cutáneas de especial fragilidad, buscando la máxima eficacia del tratamiento y evitando efectos secundarios o complicaciones. Este artículo aborda las limitaciones de la técnica. Abstract in english Photoepilation has made it possible to broad the possibilities of increasing indications of epilation. But, at the same time, some contraindications, side effects and complications have delimited in accordance with the years of experience of this technique, its clinical application. As in other tech [...] nologies, photoepilation must take into account cases that are more difficult to treat, according to hair location, complications, skin type and possible associated pathology leading to hirutism of hypertrichosis. The aim of this paper is to present cases whose location leads to greater treatment difficulties as well as how to approach possible alternatives treatment in order to obtain good efficacy and few complications. Locations such as the eyebrows and periocular region, the nose, ears, anus, scrotum, vulva and prominent areas, must be regarded in photoepilation as being the most difficult ones to treat, in search of the highest efficacy, avoiding side effects and complications. This article deals with limitations of the tecnique.

M., Vélez González.

2010-06-01

135

Nuclear energy and public opinion - a difficult relationship  

International Nuclear Information System (INIS)

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)

136

Radionuclides difficult to measure in waste packages. Final report  

Energy Technology Data Exchange (ETDEWEB)

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 {sup 60}Co and {sup 137}Cs 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.

Thierfeldt, S.; Deckert, A. [Brenk Systemplanung, Aachen (Germany)

1995-11-01

137

The Difficult Empowerment in Danish Hospital: Power to the nurses!?  

DEFF Research Database (Denmark)

The employee empowerment literature promises better organizational performance as well as more motivated and satisfied employees. However, this literature often neglects the specific context of public services in general, or the health care sector, hospitals, and nursing in particular. Nurses in Danish public hospitals work in a unique situation that makes the uncritical transfer of empowerment interventions intended to redesign their work difficult or even unfeasible. Analysis from an institutional perspective of the ongoing power struggle between agens of change at several levels in the Danish health care field indicates how norms originating from the public bureaucracy and medical comminities constrain such micro-level change initiatives. According to an organizational change perspective, narrow interventions would likely be inadequate, since conflict is likely given the particular characteristics of public organizations, and the specific attitudes of physicians and politicians and their desire to control the hospital sector. At the same time, this paper also emphasizes that the empowerment concept is likely to appeal to hospital managers and nurses in the Danish public hospital sector, since it builds on the nursing professions's self-conceptualization and is associated with better organizational performance. Our analysis starts by clarifying the concept of "nursing empowerment", and then applies a field perspective on Danish hospitals in order to identify the forces that may limit the possibility of empowering nurses and nursing. Based on this analysis, we discuss how to bring about successful nursing empowerment interventions.

Witt, Flemming; Nielsen, JØrn Flohr

2005-01-01

138

Precut sphincterotomy: A reliable salvage for difficult biliary cannulation  

Directory of Open Access Journals (Sweden)

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.

Ulku Saritas

2013-01-01

139

Percutaneous lithotripsy for removing difficult bile duct stones using endoscopy  

Energy Technology Data Exchange (ETDEWEB)

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.

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

2008-03-15

140

Percutaneous lithotripsy for removing difficult bile duct stones using endoscopy  

International Nuclear Information System (INIS)

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

141

A technical solution to a difficult problem - An update  

International Nuclear Information System (INIS)

A goal of the Reduced Enrichment Research and Test Reactor Program (RERTR) established by the U.S. Department of Energy is to develop the technical means needed to utilize LEU instead of HEU fuels in research and test reactors and to do so without operational penalties and without affecting safety characteristics. This goal has been pursued now for seven years in cooperation with many of you who are participants in this conference. The program has made significant progress in the development, demonstration and application of new LEU research reactor fuels. According to recent projections, the percentage of HEU fuel in international commerce which is technically replaceable with LEU fuels has been growing steadily as research continues. There appears to be no technical barrier to eventual replacement of HEU fuel with LEU fuel in research and test reactors. While there are many politically complex and technically difficult issues involved in nonproliferation, I conclude that the use of highly enriched weapons grade uranium as a fuel in civilian research reactors stands out as one problem which has a straight forward technical solution. The technical solution is the effort you in the RERTR program are embarked on. Once that solution is in hand, the operators of research reactors are urged to take political and legal initiatives to make the conversion happen. By effecting this conversion they will help minimize the trade in highly enriched uranium and make the world a little safer

142

Vía respiratoria difícil en paciente obstétrica acondroplásica / A difficult airway in an obstetrics patient presenting with achondroplasia  

Scientific Electronic Library Online (English)

Full Text Available SciELO Cuba | Language: Spanish Abstract in spanish Introducción: La acondroplasia es la condición más común asociada a una estatura baja con grave desproporción anatómica. Las complicaciones de la vía respiratoria difícil constituyen una de las causas más frecuente de su morbilidad y mortalidad, entre las que se pueden citar: macroglosia, escasa ape [...] rtura bucal, presencia de una tráquea estrecha, limitación en la movilidad cervical, problemas pulmonares crónicos, mandíbula pequeña con aglomeración de la dentadura y mentón prominente. Objetivo: Describir la conducta anestésica de una paciente obstétrica acondroplásica con vía respiratoria difícil. Caso Clínico: Paciente del sexo femenino, de 20 años de edad, con diagnóstico de acondroplasia y asma bronquial. Embarazo gemelar de 34 semanas el cual le imposibilitaba la deambulación, la sostenibilidad, dificultad respiratoria y no tolerancia del decúbito supino. Se le practicó cesárea, abordaje de vía respiratoria difícil, intubación con máscara laríngea Fastrach colocación de tubo endotraqueal # 6.0, ventilación controlada adecuada, utilización de relajantes musculares no despolarizantes, estabilización hemodinámica intraoperatoria, recuperación. Se trasladó a Sala Recuperación Anestésica sin complicaciones. Alta médica a los 10 días de hospitalización. Conclusiones: El abordaje de la vía respiratoria de las pacientes con Acondroplasia constituye un enigma para los anestesiólogos, pero la discusión multidisciplinaria y la ejecución de un plan de actuación favoreció el buen resultado del binomio madre-feto. Abstract in english Introduction: The achondroplasia is the commonest condition associated with a low height with a severe anatomical disproportion. The complications of the difficult airway are one of the more frequent cause of morbility and mortality including: macroglossia, an scarce buccal aperture, presence of a n [...] arrow trachea, limitation of cervical mobility, chronic pulmonary problems, small mandible with teeth crowding and a prominent chin. Objective: To describe the anesthetic behavior of an obstetrics patient with achondroplasia and a difficult airway. Clinical case: A female patient aged 20 diagnosed with achondroplasia and bronchial asthma. A twin pregnancy of 34 weeks avoiding her to walk, to stand up, respiratory difficulty and no tolerance of supine decubitus. She undergoes a cesarean section, approach of the difficult airway, intubation with a Fastrach laryngeal mask, placement of the #6.0 endotracheal tube, appropriate controlled ventilation, use of non-depolarizing muscle relaxants, intraoperative hemodynamic stabilization, recovery. She was transferred to Anesthesia Recovery Ward with complications, was discharged at 10 days of hospitalization. Conclusions: The approach of the airway of patients with achondroplasia is an enigma for anesthesiologists, but the multidisciplinary discussion and the performance of action plan favored the good result of mother-fetus duo.

Lisette Elena, Llanos Palmira; Sahily Irene, López Rabasa; Alejandro, Fonseca León; Gonzalo Santos, González Rodríguez; Jorge Humberto, Díaz Rodríguez.

2012-08-01

143

Pheochromocytoma and Pregnancy: A Difficult and Dangerous Ordeal  

OpenAIRE

Pheochromocytoma during pregnancy is potentially disastrous to the mother and fetus. Its ambiguous presentation is often mistaken for pre-eclampsia, although it may imitate other problems during pregnancy. Early diagnosis and timely, appropriate management reduces possible maternal and fetal complications. We identified a case of pheochromocytoma during pregnancy; the condition was initially diagnosed as pre-eclampsia complicated with gestational diabetes. Surgical intervention via left adren...

Mohamed Ismail, Nor Azlin; Abd Rahman, Rahana; Abd Wahab, Norasyikin; Muhammad, Rohaizak; Nor Azmi, Kamaruddin

2012-01-01

144

The Minister Council decree about conditions for to bring into the Polish customs area, to take away from the Polish customs area, and to transit through this area nuclear materials, radioactive sources and device including such sources  

International Nuclear Information System (INIS)

The decree refers to conditions for to bring into the Polish customs area, to take away from the Polish customs area, and to transit through this area nuclear materials, radioactive sources and devices containing such sources

145

Occasional finding of mesenteric lipodystrophy during laparoscopy: a difficult diagnosis.  

Science.gov (United States)

Mesenteric lipodystrophy is a rare pathological condition affecting the mesentery. Its initial presentation is typically asymptomatic. Pathological characteristics are unspecific, and generally attributed to inflammation, unless the diagnosis is suspected. Laparoscopy done for other reasons has been, as in this case, unsuccessful in providing evidence for the correct diagnosis, thus requiring laparotomy due to lack of diagnostic tissue. After 6 mo no further medical therapy is required, as the patient remains asymptomatic. Discussion of this case and a brief review of the literature are presented in the following paragraphs. PMID:17879414

Vettoretto, Nereo; Diana, Domenico-Roberto; Poiatti, Roberto; Matteucci, Armando; Chioda, Caterina; Giovanetti, Maurizio

2007-10-28

146

What Makes Biology Learning Difficult and Effective: Students' Views  

Science.gov (United States)

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…

Cimer, Atilla

2012-01-01

147

High-precision Penning trap mass measurements of ‘difficult’ elements produced via projectile fragmentation with LEBIT  

International Nuclear Information System (INIS)

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 65Fe, testing the Isobaric Mass Multiplet Equation (IMME) with the A ?=? 32, T ?=? 2 quintet with a measurement of 32Si, probing out to the proton dripline with 70mBr, and studying the N ?=? 28 shell closure with measurements of 40???44S. Results of these measurements will be discussed, along with the technical developments whichnical developments which made them possible.

148

THE EFFECTS OF SONIC ENVIRONMENT OF INDIVIDUALIZED INSTRUCTION IN LEARNING DIFFICULT AND EASY TASKS BY HIGH ACHIEVERS.  

Science.gov (United States)

THE SIXTH-GRADE STUDENTS OBTAINING THE 80 HIGHEST MEAN SCORES ON THE METROPOLITAN ACHIEVEMENT TEST FORM D WERE RANDOMLY ASSIGNED TO GROUPS OF EASY OR DIFFICULT TASKS WITHIN EACH OF FIVE DECIBEL LEVEL GROUPS. THE LEARNING TASKS WERE TAKEN FROM THE MEANINGFULNESS OF ALL POSSIBLE CVC TRIGRAMS (ARCHER, 1960). THE APPARATUS INCLUDED A TAPE RECORDING OF…

MCCARTHY, EDWARD H.

149

Popliteal artery approach to difficult percutaneous vascular intervention  

International Nuclear Information System (INIS)

This paper discusses the applications and potential complications of a popliteal artery approach to femoral artery recanalization, angioplasty, and atherectomy in 13 patients. Popliteal artery puncture was performed in 13 patients in whom a conventional antegrade approach to percutaneous intervention from either the ipsilateral or contralateral groin was unsuccessful. Arterial lesions treated included 10 superficial femoral artery occlusions, two common femoral artery occlusions, and one long-segment (7-cm) superficial femoral artery stenosis. Following successful recanalization, the arterial stenosis was treated by arthrectomy in 11 patients and angioplasty in two patients

150

Difficult wrist fractures. Perilunate fracture-dislocations of the wrist.  

Science.gov (United States)

Perilunate dislocations of the wrist have a common pathway of disruption that occurs from extensive dorsiflexion injuries. Open reduction and internal fixation of these injuries is required to provide accurate alignment and the option for ligament repair. Both dorsal and palmar surgical incisions may be indicated. Associated injuries to the median nerve must be recognized. Treatment includes scaphoid and radial styloid stabilization with multiple K-wires or internal compression screw (Herbert or Association for the Study of Internal Fixation [ASIF] screws). In these injuries, the lunate must be reduced first and stabilized. The scaphoid proximal segment follows the lunate unless the scapholunate (SL) ligament is torn. The distal scaphoid fragment, capitate, and triquetrum are reduced and aligned with the lunate and need to be held with K-wires. Ligament repair and augmentation may be necessary at both scapholunate and lunotriquetal areas if there has been serious ligament injury. Palmar ligament repair is often required, and we recommend a palmar exploration in most patients along with release of the median nerve. Surgical treatment results of perilunate fracture-dislocations of the wrist appear better than conservative treatment methods, but complications following both indicate the need for improved internal fixation and fracture-dislocation realignment. These fractures are a real challenge to the treating surgeon who must use patience, precise surgical techniques, and careful roentgenographic study (including tomograms and traction views) to assure the best result. PMID:3791735

Cooney, W P; Bussey, R; Dobyns, J H; Linscheid, R L

1987-01-01

151

Lung Disease Including Asthma and Adult Vaccination  

Science.gov (United States)

... Vaccination Home Recommended Vaccines for Adults Share Compartir Lung Disease including Asthma and Adult Vaccination Vaccines are especially ... for people with chronic health conditions such as lung disease including asthma. Lung Disease including asthma Influenza vaccine ...

152

The Lula Government’s First Year: The Difficult Transition  

Directory of Open Access Journals (Sweden)

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.

Sonia Fleury

2004-05-01

153

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

International Nuclear Information System (INIS)

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.)

154

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

Directory of Open Access Journals (Sweden)

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

Yakup Tomak

2012-09-01

155

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

Energy Technology Data Exchange (ETDEWEB)

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.)

Hongisto, M.; Nikula, A.

1996-11-01

156

Radiocarbon Dating of Difficult Samples: Natural and Laboratory Effects  

International Nuclear Information System (INIS)

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)

157

Difficult to swallow: patient preferences for alternative valproate pharmaceutical formulations  

Directory of Open Access Journals (Sweden)

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

Monali Bhosle

2009-06-01

158

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

Directory of Open Access Journals (Sweden)

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.

Chen Su-may Sheih

2009-12-01

159

Meeting the challenge of constructing a uniquely difficult barrier wall  

International Nuclear Information System (INIS)

A soil-bentonite vertical barrier wall with intersecting and round corners was constructed in complex geology and steep terrain to enclose and dewater a 1.4 hectare (3.5 acre) area once used for hazardous waste lagoons and landfills at the Queen City Farms (QCF) Superfund site in Maple Valley, Washington. The barrier system, including cap and barrier wall, was designed to contain light non-aqueous phase liquid (LNAPL), in addition to subsurface soil and ground water contaminated with chromium, polychlorinated biphenyls, polyaromatic hydrocarbons, trichloroethylene, dichloroethylene and vinyl chloride in the dissolved-phase. These contaminants threaten a drinking water aquifer beneath the site. Constructing the vertical barrier was a challenge due to steep slopes of 20 percent along the alignment (19.2 meter elevation change in the top of the wall), a 22.5 meter (75 foot) design wall depth, heavily consolidated clays and silts, open works gravels (gravel without finer soils), and geologic discontinuity. The barrier wall is keyed into either a glacial till or thin clayey-silt aquitard. Extensive earth moving, stepped walls and many construction techniques were used to enable construction of this barrier wall. Commonly accepted constructability criteria would have discouraged the construction of this wall

160

[Rehabilitation of burn victims. A difficult path back to normality].  

Science.gov (United States)

The most important aims of rehabilitation in burn victims is the restitution and improvement of joint mobility, mimicry and pulmonary function, as well as of muscular endurance and strength. In addition to the management of scars, therefore, patient instruction in unsupervised training and scar care, as well as promotion of re-integration into day-to-day life are essential. Depending on the parts of the body affected, measures may include manual therapy, active exercise, treatment with ultrasound, proprioceptive neuromuscular facilitation in the case of facial burns, respiratory therapy and ergotherapy and, finally coordination training. Treatment of the scars themselves requires a combination of a number of measures, all of which should be of an "active" nature. Of proven value are manual massage of scar tissue, stretching exercises, the use of silicone, special splints and compression clothing, as well as laser therapy. Rehabilitation measures should be applied for not less than 4 weeks. Where indicated, further surgical measures should be discussed with the patient. PMID:12134722

Butz, M; Conrady, D; Baumgärtler, H; Mentzel, H E

2002-06-13

161

Busulfan 12 mg/kg plus melphalan 140 mg/m2 versus melphalan 200 mg/m2 as conditioning regimens for autologous transplantation in newly diagnosed multiple myeloma patients included in the PETHEMA/GEM2000 study  

OpenAIRE

Background The aim of this study was to compare the long-term safety and efficacy of oral busulfan 12 mg/kg plus melphalan 140 mg/m2 and melphalan 200 mg/m2 as conditioning regimens for autologous stem cell transplantation in newly diagnosed patients with multiple myeloma in the GEM2000 study. Design and Methods The first 225 patients received oral busulfan 12 mg/kg plus melphalan 140 mg/m2; because of a high frequency of veno-occlusive disease, the protocol was amended and a further 542 ...

Lahuerta, Juan Jose?; Mateos, Maria Victoria; San Miguel, Jesu?s F.

2010-01-01

162

Engineering classification of karst ground conditions  

Directory of Open Access Journals (Sweden)

Full Text Available On a world scale, the dissolution of limestone and gypsum by natural waters creates extensive karst landforms that can be very difficult ground for civil engineers. Caves threaten foundation integrity, notably where their width is greater than their roof thickness. Sinkholes pose many problems, and are classified into six types, including subsidence sinkholes formed in soil cover within karst terrains. Rockhead morphology varies from uniform to pinnacled, also creating difficult ground to excavate or found upon. A proposed engineering classification of karst defines various complexities of ground conditions by the geohazards that they provide, mainly the caves, sinkholes and rockhead relief. Ground investigation techniques and foundation design philosophies are considered so that they are appropriate to the ground conditions provided by the different classes of karst.

Waltham,A.C.

2005-01-01

163

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

Science.gov (United States)

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…

Hernandez, Luis; Smith, Connie Jo

2009-01-01

164

Including All the Lines  

OpenAIRE

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.

Kurucz, Robert L.

2009-01-01

165

Pump apparatus including deconsolidator  

Science.gov (United States)

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.

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

2014-10-07

166

Celecoxib reduces symptoms in men with difficult chronic pelvic pain syndrome (Category IIIA  

Directory of Open Access Journals (Sweden)

Full Text Available We investigated the effectiveness of celecoxib in reducing symptoms in patients with difficult chronic pelvic pain syndrome (CPPS, NIH category IIIA. Sixty-four patients with category IIIA CPPS were randomized into two groups of 32 subjects each. One group was treated with celecoxib (200 mg daily and the other with placebo. All patients underwent treatment for 6 weeks and were evaluated clinically before (baseline and after 1, 2, 4, 6, and 8 weeks of treatment. The evaluation included the NIH Chronic Prostatitis Symptom Index (NIH-CPSI and a subjective global assessment (SGA. Repeated measures analysis of variance was used to evaluate treatment and time effects and their interaction. A decrease (means ± SD in total NIH-CPSI score from 23.91 ± 5.27 to 15.88 ± 2.51 in the celecoxib group and from 24.25 ± 5.09 to 19.50 ± 2.50 in the placebo group was observed during treatment (0 to 6 weeks. A statistically significant decrease was observed in pain subscore (P < 0.006, quality of life subscore (P < 0.032 and total NIH-CPSI score (P < 0.015 after 2, 4 and 6 weeks, but not in urinary subscore. In addition, 38% of the celecoxib and 13% of the placebo subjects had at least a moderate improvement in SGA. The trend was similar for the NIH-CPSI scores. However, the response to treatment in terms of total NIH-CPSI score or subscore was not significantly different from placebo after interruption of treatment for 2 weeks. Our results show that celecoxib provides significant symptomatic improvement limited to the duration of the therapy in patients with difficult category IIIA CPPS compared to placebo.

W.P. Zhao

2009-10-01

167

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

Science.gov (United States)

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

Epner, Daniel E; Baile, Walter F

2014-04-01

168

IMRT dose fractionation for head and neck cancer: Variation in current approaches will make standardisation difficult  

International Nuclear Information System (INIS)

Introduction. Altered fractionation has demonstrated clinical benefits compared to the conventional 2 Gy/day standard of 70 Gy. When using synchronous chemotherapy, there is uncertainty about optimum fractionation. IMRT with its potential for Simultaneous Integrated Boost (SIB) adds further to this uncertainty. This survey will examine international practice of IMRT fractionation and suggest possible reasons for diversity in approach. Material and methods. Fourteen international cancer centres were surveyed for IMRT dose/fractionation practised in each centre. Results. Twelve different types of dose fractionation were reported. Conventional 70-72 Gy (daily 2 Gy/fraction) was used in 3/14 centres with concurrent chemotherapy while 11/14 centres used altered fractionation. Two centres used >1 schedule. Reported schedules and number of centres included 6 fractions/week DAHANCA regime (3), modest hypofractionation (=2.2 Gy/fraction) (3), dose-escalated hypofractionation (=2.3 Gy/fraction) (4), hyperfractionation (1), continuous acceleration (1) and concomitant boost (1). Reasons for dose fractionation variability include (i) dose escalation; (ii) total irradiated volume; (iii) number of target volumes; (iv) synchronous systemic treatment; (v) shorter overall treatment time; (vi) resources availability; (vii) longer time on treatment couch; (viii) variable GTV margins; (ix) confidence in treatment setup; (x) late tissue toxicity and (xi) use of lower neck anterior fields. d (xi) use of lower neck anterior fields. Conclusions. This variability in IMRT fractionation makes any meaningful comparison of treatment results difficult. Some standardization is needed particularly for design of multi-centre randomized clinical trials

169

IMRT dose fractionation for head and neck cancer: Variation in current approaches will make standardisation difficult  

Energy Technology Data Exchange (ETDEWEB)

Introduction. Altered fractionation has demonstrated clinical benefits compared to the conventional 2 Gy/day standard of 70 Gy. When using synchronous chemotherapy, there is uncertainty about optimum fractionation. IMRT with its potential for Simultaneous Integrated Boost (SIB) adds further to this uncertainty. This survey will examine international practice of IMRT fractionation and suggest possible reasons for diversity in approach. Material and methods. Fourteen international cancer centres were surveyed for IMRT dose/fractionation practised in each centre. Results. Twelve different types of dose fractionation were reported. Conventional 70-72 Gy (daily 2 Gy/fraction) was used in 3/14 centres with concurrent chemotherapy while 11/14 centres used altered fractionation. Two centres used >1 schedule. Reported schedules and number of centres included 6 fractions/week DAHANCA regime (3), modest hypofractionation (=2.2 Gy/fraction) (3), dose-escalated hypofractionation (=2.3 Gy/fraction) (4), hyperfractionation (1), continuous acceleration (1) and concomitant boost (1). Reasons for dose fractionation variability include (i) dose escalation; (ii) total irradiated volume; (iii) number of target volumes; (iv) synchronous systemic treatment; (v) shorter overall treatment time; (vi) resources availability; (vii) longer time on treatment couch; (viii) variable GTV margins; (ix) confidence in treatment setup; (x) late tissue toxicity and (xi) use of lower neck anterior fields. Conclusions. This variability in IMRT fractionation makes any meaningful comparison of treatment results difficult. Some standardization is needed particularly for design of multi-centre randomized clinical trials.

Ho, Kean F. (Academic Dept. of Radiation Oncology, Univ. of Manchester, Manchester (United Kingdom)); Fowler, Jack F. (Dept. of Human Oncology and Medical Physics, Univ. of Wisconsin, Wisconsin (United States)); Sykes, Andrew J.; Yap, Beng K.; Lee, Lip W.; Slevin, Nick J. (Dept. of Clinical Oncology, Christie Hospital NHS Foundation Trust, Manchester (United Kingdom))

2009-04-15

170

Including Your Child  

Science.gov (United States)

This publication, recently released by the US Department of Education, deal with special needs children and their parents. Including Your Child is a booklet for parents that deals with the first eight years of life for children with special needs. Its eight brief sections discuss the importance of the family, help and support systems, expectations, how to plan to meet expectations, inclusion, and outreach. It also contains a developmental progress chart and several sections of resource information.

171

Investigation of the automated solid-phase synthesis of a 38mer peptide with difficult sequence pattern under different synthesis strategies.  

Science.gov (United States)

Difficult peptides are a constant challenge in solid-phase peptide synthesis. In particular, hydroxyl amino acids such as serine can cause severe breakdowns in coupling yields even several amino acids after the insertion of the critical amino acid. This paper investigates several methods of improving synthesis yields of difficult peptides including the use of different resins, activators and the incorporation of a structure-breaking pseudoproline dipeptide building block both alone and in combination with each other. PMID:25595601

Winkler, Dirk F H; Tian, Kerry

2015-04-01

172

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

Science.gov (United States)

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

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

2013-11-01

173

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

Directory of Open Access Journals (Sweden)

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.

Niyazi Acer

2011-06-01

174

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

Science.gov (United States)

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?"…

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

2007-01-01

175

[Difficult airway management using the air-Q in a patient with Klippel-Feil syndrome].  

Science.gov (United States)

Patients with Klippel-Feil syndrome (KFS) frequently encounter difficult airway management due to skeletal abnormalities, including fusion of two or more vertebrae and short neck. We report successful tracheal intubation using the air-Q supraglottic airway device (air-Q). A 46-year-old woman (height, 149 cm; weight, 62 kg) with KFS was scheduled to undergo vertebral arch plasty for cervical spondylotic myelopathy. She could open her mouth sufficiently but could not tilt her head due to C1-3 fusion. Following administration of fentanyl 100 microg and propofol 120 mg, mask ventilation was achieved with jaw thrust maneuver. We then administered rocuronium 50 mg for immobilization and attempted tracheal intubation using the Pentax-AWS Airwayscope with a thin pediatric Intlock. However, we could not target the glottis, and ventilation via a size 3 i-gel or size 3.5 air-Q was unsuccessful. Using a size 2.5 air-Q, sufficient ventilation was finally achieved. We performed fiberoptic tracheal intubation through the air-Q using a tube with an internal diameter of 6.0-mm. We then exchanged the 6.0-mm tracheal tube with a 7.0-mm spiral tube using a 10 Fr tracheal tube introducer. PMID:24979859

Komasawa, Nobuyasu; Miyazaki, Shinichiro; Soen, Masako; Kusunoki, Tomohiro; Tatsumi, Shinichi; Minami, Toshiaki

2014-06-01

176

Bupropion as add-on strategy in difficult-to-treat bipolar depressive patients.  

Science.gov (United States)

Bupropion, a selective norepinephrine and dopamine reuptake inhibitor, has been suggested for the treatment of bipolar depression, not only because of its efficacy, but also because of a probably lower risk of inducing switches to hypomania or mania. Most studies on bupropion treatment in bipolar patients have been performed in moderately ill out-patients. In contrast, we report on a sample of difficult-to-treat, predominantly severely ill, co-morbid, psychotic or therapy-refractory bipolar depressive in-patients. In this open and prospective study, 13 patients were treated with bupropion as an add-on strategy mainly to other antidepressants and to various mood stabilizers. Our data support the idea that bupropion is a first-line antidepressant in the treatment of severe bipolar depression. Eight of 13 patients showed a >50% reduction of Montgomery-Asberg Depression Scale ratings within 4 weeks. Co-medication with drugs commonly used in treatment-resistant bipolar disorder including venlafaxine, clozapine, lithium, topiramate and sodium valproate was safe in our small sample. While adhering to the suggestion of Goren and Levin not to exceed a daily dose of 450 mg of bupropion when treating bipolar depressed patients, we did not observe any switch from depression to hypomania or mania. PMID:11893875

Erfurth, Andreas; Michael, Nikolaus; Stadtland, Cornelis; Arolt, Volker

2002-01-01

177

Celecoxib reduces symptoms in men with difficult chronic pelvic pain syndrome (Category IIIA)  

Scientific Electronic Library Online (English)

Full Text Available SciELO Brazil | Language: English Abstract in english We investigated the effectiveness of celecoxib in reducing symptoms in patients with difficult chronic pelvic pain syndrome (CPPS), NIH category IIIA. Sixty-four patients with category IIIA CPPS were randomized into two groups of 32 subjects each. One group was treated with celecoxib (200 mg daily) [...] and the other with placebo. All patients underwent treatment for 6 weeks and were evaluated clinically before (baseline) and after 1, 2, 4, 6, and 8 weeks of treatment. The evaluation included the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) and a subjective global assessment (SGA). Repeated measures analysis of variance was used to evaluate treatment and time effects and their interaction. A decrease (means ± SD) in total NIH-CPSI score from 23.91 ± 5.27 to 15.88 ± 2.51 in the celecoxib group and from 24.25 ± 5.09 to 19.50 ± 2.50 in the placebo group was observed during treatment (0 to 6 weeks). A statistically significant decrease was observed in pain subscore (P

W.P., Zhao; Z.G., Zhang; X.D., Li; D., Yu; X.F., Rui; G.H., Li; G.Q., Ding.

2009-10-01

178

Effect of coating materials on thermal loading in machining difficult-to-cut materials  

Science.gov (United States)

The analysis of machining of difficult-to-cut materials is a challenging problem. This is due to the hard environment through which the cutting tool has to operate. This environment includes extreme mechanical loadings coupled to intense thermal gradients. This combination limits the tool life even in the presence of several protective tool coatings. This paper deals with a study on the effect of coating materials on thermal loading and tool wear. For the purpose, the study analyzes the temperature field inside the tool and its evolution at the tool-chip interface. Results indicate that the temperature rise into the insert is depending on coating materials, in the vicinity of the tool rake face. It therefore controls cutting tool life since intensity of wear at the tool surface is directly proportional to the local efficiency of heat removal. This in turn depends on the effective values of the thermal conductivities of the tool substrate and of the coating material, as on the heat transfer coefficient.

Kone, F.; Czarnota, C.; Haddag, B.; Lazard, M.; Nouari, M.

2011-01-01

179

Techniques for demonstrating radiation pathology in aquatic organisms including histology and autoradiography  

International Nuclear Information System (INIS)

Laboratory research carried out under well-designed conditions can produce reproducible results. However, if there is any variation in the experimental conditions including physical, chemical and biological factors, it may be difficult to compare the results obtained in different laboratories. The factors affecting the manifestation of radiation pathology are specially emphasized here. Radiation effects on fish and aquatic invertebrates are also described briefly. Almost all techniques developed for radiobiological research in mammals and cultured cells can be applied to research into aquatic organisms. Histopathological examination of fish should focus on the observation of the cell-renewal systems at appropriate time intervals after irradiation. Some techniques for demonstrating radiation pathology including histology and autoradiography in aquatic organisms, especially in fish, are illustrated with examples. (author)

180

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

Directory of Open Access Journals (Sweden)

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 2–5 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.

E.E. Craythorne

2008-01-01

181

Novel drugs in the management of difficult-to-treat hepatitis C genotypes  

Science.gov (United States)

Background Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States, with approximately 3.2 million Americans being chronically infected. Rates of HCV-related end-stage liver disease and its associated morbidity and mortality have yet to peak, so there is a pressing need for more effective and tolerable HCV treatment. HCV genotypes 1, 4, 5, and 6 are considered difficult to treat, and the need for improved therapies is especially great for persons infected with these genotypes. Current strategies for HCV treatment Current therapy for genotype 1 HCV infection includes triple therapy with pegylated interferon, ribavirin, and a NS3/4A protease inhibitor. Sustained virologic response (SVR) rates with triple therapy range from 42% to 75%, a vast improvement over pegylated interferon and ribavirin therapy alone. However, response rates remain suboptimal, and triple therapy is associated with significant adverse effects and is only indicated for genotype 1 HCV infection. Novel drugs for HCV treatment HCV drug development is proceeding at a rapid pace to meet this need. Novel direct acting antiviral agents in several classes, including new NS3/4A serine protease inhibitors, NS5A replication complex inhibitors, NS5B polymerase inhibitors, interferon lambda, and microRNAs, are in varying stages of development. These new therapeutic agents promise SVR rates of up to 100% with durations as short as 12 weeks and, often, fewer adverse effects. Conclusion New drug development in HCV is proceeding at an unprecedented pace. Novel agents promise higher SVR rates, shorter duration of therapy, and fewer adverse effects than have been possible with HCV therapy to date. PMID:24696624

Cartwright, Emily J; Miller, Lesley

2013-01-01

182

Conditions Affecting Treatment of Pertrochanteric Osteomyelitis  

Directory of Open Access Journals (Sweden)

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.

Steven Wen-Neng Ueng

2007-10-01

183

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

LENUS (Irish Health Repository)

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.

Malik, M A

2009-11-01

184

A STERILIZATION STANDARD FOR ENDOSCOPES AND OTHER DIFFICULT TO CLEAN MEDICAL DEVICES  

Science.gov (United States)

An array of difficult to clean devices are used for diagnostic and surgical procedures involving various degrees of invasiveness. These range from prophylaxis angles used for cleaning and polishing teeth to flexible fiberoptic endoscopes for surgical procedures that penetrate the...

185

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

International Nuclear Information System (INIS)

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.

186

Difficult intubation in a parturient with syringomyelia and Arnold–Chiari malformation: Use of Airtraq™ laryngoscope  

OpenAIRE

Anesthetic technique in parturient with syringomyelia and Arnold–Chiari 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 Arnold–Chiari type I malformation.

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

2011-01-01

187

Guidelines on uncomplicated urinary tract infections are difficult to follow: perceived barriers and suggested interventions  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background Urinary tract infections (UTI are among the most common health problems seen in general practice. Evidence-based guidelines on UTI are available, but adherence to these guidelines varies widely among practitioners for reasons not well understood. The aim of this study was to identify the barriers to the implementation of a guideline on UTI perceived by Dutch general practitioners (GPs and to explore interventions to overcome these barriers. Methods A focus group study, including 13 GPs working in general practices in the Netherlands, was conducted. Key recommendations on diagnosis and treatment of uncomplicated UTI were selected from the guideline. Barriers to guideline adherence and possible interventions to address these barriers were discussed. The focus group session was audio-taped and transcribed verbatim. Barriers were classified according to an existing framework. Results Lack of agreement with the recommendations, unavailable and inconvenient materials (i.e. dipslides, and organisational constraints were perceived as barriers for the diagnostic recommendations. Barriers to implementing the treatment recommendations were lack of applicability and organisational constraints related to the availability of drugs in pharmacies. Suggested interventions were to provide small group education to GPs and practice staff members, to improve organisation and coordination of care in out of hour services, to improve the availability of preferred dosages of drugs, and to pilot-test guidelines regionally. Conclusions Despite sufficient knowledge of the recommendations on UTI, attitudinal and external barriers made it difficult to follow them in practice. The care concerning UTI could be optimized if these barriers are adequately addressed in implementation strategies. The feasibility and success of these strategies could be improved by involving the target group of the guideline in selecting useful interventions to address the barriers to implementation.

Zegers-van Schaick Judith M

2010-06-01

188

Local arterialized island flap coverage of difficult hand defects preserving donor digit sensibility.  

Science.gov (United States)

Small to moderate-sized defects of the hand overlying joint surfaces, flexor tendons, Silastic implants, and tactile surfaces require full-thickness skin and subcutaneous tissue either for primary coverage or in anticipation of secondary reconstruction. In this report, six difficult hand wounds are resurfaced with an arterialized island pedicle from the lateral surface of the nearby digit in lieu of multistage distant pedicle flaps. The Littler neurovascular island flap has been modified to include only the digital artery and venae comitantes at its pedicle, preserving digital nerve intact in the donor digit. Microsurgical separation of the digital artery from the digital nerve minimizes the sensory loss of the donor digit. Cortical reeducation at the recipient site is unnecessary. The lengthy pedicle allows an arc of coverage over the palm, dorsum of the hand, and adjacent digits. Results in six cases have been favorable. Flap survival has been 100 percent. Maximum flap size was 5.5 X 2.5 cm. Two-point discrimination of the donor defect averaged 4.5 mm. No significant donor morbidity was noted, with the exception of one case in which there was a mild degree of hypertrophic scarring across the volar aspect of the proximal interphalangeal joint. The one-stage procedure minimizes the number of hospitalizations and disability time. Its proximity to injury, versatility, and relative speed with which it can be raised encourages its usage for primary coverage (two cases in this series). Preservation of near normal two-point discrimination of the donor site allows either the radial or ulnar surface of the nearby digit to be used. PMID:6647608

Rose, E H

1983-12-01

189

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

Energy Technology Data Exchange (ETDEWEB)

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.

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

2012-10-15

190

Febre de etiologia indeterminada: encruzilhada de diagnósticos / Fever of unknown origin: a difficult diagnostic problem  

Scientific Electronic Library Online (English)

Full Text Available SciELO Portugal | Language: Portuguese Abstract in portuguese Introdução: Os principais diagnósticos a considerar numa febre de etiologia indeterminada incluem as causas infecciosas, reumatológicas, imunológicas e neoplásicas. Caso clínico: Apresentamos o caso de uma criança de quatro anos do sexo masculino, observada por febre, cervicalgia e claudicação da ma [...] rcha. Detectou-se anemia e marcadores inflamatórios elevados. No internamento foi-se evidenciando palidez, exantema maculo-papular em pico febril e adenomegalias cervicais. A avaliação por Cardiologia evidenciou ectasia coronária, tendo iniciado imunoglobulina intravenosa (IGIV) por suspeita de Doença de Kawasaki atípica (DKa). Por persistência da febre invocou-se o diagnóstico mais provável de Artrite Idiopática Juvenil sistémica (AIJs). Discussão: Após a exclusão de outras causas, o diagnóstico diferencial entre DKa e AIJs é difícil pela inespecificidade dos achados. A suspeita de DKa, justifica a terapêutica com IGIV, mas a refractariedade a esta não a exclui (10% de casos refractários). Por outro lado, está descrita a presença de dilatações coronárias em contexto de quadro inflamatório sistémico, tornando este achado sugestivo mas não patognomónico de Doença de Kawasaki. Abstract in english Background: The most common causes of fever of unknown origin are infectious diseases, rheumatologic or immunologic diseases, and malignancies. Case report: The case of a four years old male child with fever, neck pain and limping gait is presented. He was anemic and had elevated inflammatory marker [...] s. He developed gradual pallor, maculopapular rash appearing with fever peaks, and cervical lymphadenopathy. Echocardiographic documentation of coronary artery ectasia, lead to intravenous immunoglobulin (IVIG) therapy for suspected atypical Kawasaki disease (aKD). The most probable diagnosis of systemic-onset Juvenile Idiopathic Arthritis (sJIA) was made after fever maintenance. Discussion: It is difficult to differentiate between aKD and sJIA because there are no specific findings. The suspicion of aKD should lead to IVIG therapy, but failure to respond is not an exclusion criterion (10% of patients are refractory cases). Systemic inflammatory disorders, like sJIA, may be associated with coronary artery dilation. This finding supports a diagnosis of aKD but is not specific for the condition.

Manuel, Oliveira; Carla, Meireles; Patrícia, Costa; Margarida, Guedes; Ana Luísa, Lobo.

191

Colecistectomía laparoscópica difícil, estrategias de manejo / Difficult laparoscopic cholecystectomy, management strategies  

Scientific Electronic Library Online (English)

Full Text Available SciELO Colombia | Language: Spanish Abstract in spanish La colecistectomía laparoscópica es uno de los procedimientos quirúrgicos practicados más frecuentemente por el cirujano general y en un importante número de casos se efectúa en pacientes mayores con gran inflamación vesicular, lo que pone a prueba los conocimientos y habilidades del cirujano. Es pe [...] rfectamente posible reconocer, antes del acto quirúrgico, en cuáles pacientes este resultará difícil en mayor o menor grado, para así diseñar estrategias de manejo intraoperatorio que nos permitan resolver favorablemente estos casos. En este artículo, el cual se presenta acompañado de videos de casos clínicos publicados en la página electrónica de la Asociación Colombiana de Cirugía (http://www.ascolcirugia.org), se pretende mostrar cuáles son las opciones de manejo en aquellos pacientes cuyas colecistectomías son muy difíciles por el grado de inflamación o por las enfermedades subyacentes y que constituyen alternativas de manejo viables para la colecistectomía laparoscópica clásica o para evitar la conversión a cirugía abierta; aunque también, se llama fuertemente la atención sobre la necesidad de una conversión temprana y oportuna antes de tener complicaciones o alteraciones iatrogénicas de la vía biliar u otro órgano vecino. Abstract in english Laparoscopic cholecystectomy is one of the most commonly performed procedures by the general surgeon and an important number of cases occur in elderly patients with major inflammation of the gallbladder, a condition that challenges the knowledge and ability of the surgeon. It is perfectible possible [...] to recognize, prior to surgery, which patients will present major or minor difficulties so as to design intraoperative strategies in order to favorably resolve such situations. This article is complemented wit uploaded YouTube videos in the web page of the Asociación Colombiana de Cirugía, http://www.ascolcirugia.org. It intends to show the different management options in those patients with very difficult cholecystectomies because of the degree of inflammation or the underlying pathology that constitute viable alternatives to the classic laparoscopic cholecystectomy or to avoid conversion open surgery; however, it also strongly calls attention to the need of early and timely conversion so as to avoid complications or iatrogenic lesion of the bile duct or neighbor organs.

Luis Fernando, Álvarez; Diego, Rivera; Miguel Evaristo, Esmeral; Marta Cecilia, García; Diego Fernando, Toro; Olga Lucía, Rojas.

2013-07-01

192

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

Energy Technology Data Exchange (ETDEWEB)

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.

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

193

Identification of abnormal operating conditions and intelligent decision system  

Science.gov (United States)

In earth pressure balance (EPB) shield construction, the "plastic flow state" is difficult to form using the soil dug in the capsule because it can cause three abnormal operating conditions, including occlusion, caking in the capsule, and spewing at the outlet of the dump device. These abnormal operating conditions can, in turn, trigger failure in tunneling, cutter-device damage, and even catastrophic incidents, such as ground settlement. This present paper effectively integrates the mechanism of abnormal operating conditions and knowledge of soil conditioning, and establishes a uniform model of identifying abnormal conditions and intelligent decision support system based on the belief rule-base system. The model maximizes knowledge in improving the soil, construction experience, and data to optimize the model online. Finally, a numerical simulation with specific construction data is presented to illustrate the effectiveness of the algorithm.

Li, Xiuliang; Jiang, Junjie; Su, Hongye; Chu, Jian

2011-12-01

194

Identificación de factores predictores de técnica epidural dificultosa en la paciente obstétrica / Identifying predictors of difficult epidural technique in pregnant  

Scientific Electronic Library Online (English)

Full Text Available SciELO Spain | Language: Spanish Abstract in spanish Introducción: Los intentos repetidos de punción son factores de riesgo para la aparición de complicaciones neurológicas secundarias a la práctica de la analgesia espinal y aumentan la ansiedad del paciente. El objetivo de este estudio es determinar qué factores son mejores predictores de la colocaci [...] ón dificultosa del catéter epidural en la paciente obstétrica. Material y método: Estudio observacional y prospectivo en 120 gestantes a término que solicitan la analgesia epidural para el trabajo de parto. Se recogen variables demográficas y antecedentes de anestesia espinal previa no exitosa o considerada dificultosa por la paciente. Se identifican variables anatómicas y se clasifica la calidad de los puntos de referencia anatómicos según los criterios publicados por Chien en cuatro grados. Las condiciones de la técnica y la experiencia del anestesiólogo son similares en todos casos. Consideramos punción dificultosa si se necesita más de una punción en la piel o una punción pero más de un cambio de dirección de aguja en el espacio interespinoso. Se recoge el éxito obtenido y las complicaciones de la técnica. Resultados: Fueron calificadas de punción difícil según los criterios del estudio en el 36,67 % de los casos. En la mayoría de los casos la técnica fue efectiva obteniendo una adecuada analgesia. La incidencia de repunción epidural fue de 5 %. En las pacientes clasificadas en el grado 4, la tasa de punción epidural considerada dificultosa supuso un 90 %, necesitando en el 80 % de esos casos 3 o más intentos. En las pacientes con antecedentes personales de técnica neuroaxial dificultosa se encontró dificultad de punción epidural en un 28,57 % de los casos. El hábito corporal no tuvo efecto significativo sobre la tasa de éxito con el primer intento. Discusión: Nuestro estudio representa una buena estimación de la dificultad técnica de un bloqueo neuroaxial. Seria difícil saber si los datos reflejados serían extrapolables a la realización de la técnica en decúbito lateral, donde los puntos de referencia anatómicos son más difíciles de identificar. Conclusiones: Nuestra recogida concluye que el método más fiable para determinar de antemano la posibilidad de una dificultad técnica de colocación del catéter epidural lumbar es un examen de la espalda de la paciente para identificar la calidad de los puntos de referencia anatómicos 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 diffic

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

2013-10-01

195

Research on Difficult Family Topics: Helping New and Experienced Researchers Cope.  

Science.gov (United States)

Addresses problems associated with conducting research on difficult family topics. Issues examined are personal issues that play a role in research topic selections, problems obtaining Review Board permission to do certain research, emotional problems experienced by researchers and interviewers doing work on loss, and emotional problems of…

Kitson, Gay C.; And Others

1996-01-01

196

Incremental Learning of Difficult Words in Story Contexts: The Role of Spelling and Pronouncing New Vocabulary  

Science.gov (United States)

In this exploratory study we examine the value of exposure to the spelling and pronunciation of word forms when introducing the meanings of new and difficult vocabulary words. Kindergarten English learners were randomly assigned to one of two types of storybook reading delivered by tutors. Students in both treatments listened to short stories…

Vadasy, Patricia F.; Sanders, Elizabeth A.

2015-01-01

197

The Divide and Conquer Exercise: Finding the Essence of Difficult Readings  

Science.gov (United States)

Objective: In this exercise, students collectively summarize a long and perhaps difficult reading into a shorter, more condensed version of itself; in the process, students experience the virtues of teamwork (the divide and conquer approach), gain valuable reading and note-taking skills, and collectively distill the essence of a reading in class.…

Peterson, Valerie V.

2006-01-01

198

Advising Parents with Difficult Children and Adolescents: Managing Stress and Negative Behaviors.  

Science.gov (United States)

This paper suggests that helpers must often educate parents about the causes of stress and its effects on the parenting process. Parents with difficult children and adolescents often complain not only that their children misbehave or are unmotivated and depressed but that such behaviors create stress in the entire family. Many clinicians report…

Sheras, Peter L.

199

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

Science.gov (United States)

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…

Mintz, Avi I.

2010-01-01

200

Information-Limited Parallel Processing in Difficult Heterogeneous Covert Visual Search  

Science.gov (United States)

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…

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

2010-01-01

201

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

Directory of Open Access Journals (Sweden)

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.

A. Lesco

2006-01-01

202

Defense Waste Management Plan for buried transuranic-contaminated waste, transuranic-contaminated soil, and difficult-to-certify transuranic waste  

International Nuclear Information System (INIS)

GAO recommended that DOE provide specific plans for permanent disposal of buried TRU-contaminated waste, TRU-contaminated soil, and difficult-to-certify TRU waste; cost estimates for permanent disposal of all TRU waste, including the options for the buried TRU-contaminated waste, TRU-contaminated soil, and difficult-to-certify TRU waste; and specific discussions of environmental and safety issues for the permanent disposal of TRU waste. Purpose of this document is to respond to the GAO recommendations by providing plans and cost estimates for the long-term isolation of the buried TRU-contaminated waste, TRU-contaminated soil, and difficult-to-certify TRU waste. This report also provides cost estimates for processing and certifying stored and newly generated TRU waste, decontaminating and decommissioning TRU waste processing facilities, and interim operations

203

Resin conditioning facility  

Energy Technology Data Exchange (ETDEWEB)

The resin conditioning facility is designed to condition the spent ion exchange resins from the ponds water treatment units of the La Hague plant. Conditioning of the resins includes three successive steps: concentration, pretreatment and cementing. The activity fixed on resins is chiefly Co 60 activity. The facility is capable of conditioning the different types of resins. (N.C.)

Guerrand, P. [Societe Generale pour les Techniques Nouvelles (SGN), 50 - Equeurdreville (France); Dupuis, D. [Cogema la Hague, 50 - Beaumont Hague (France)

1998-07-01

204

Musculoskeletal ultrasound including definitions for ultrasonographic pathology  

DEFF Research Database (Denmark)

Ultrasound (US) has great potential as an outcome in rheumatoid arthritis trials for detecting bone erosions, synovitis, tendon disease, and enthesopathy. It has a number of distinct advantages over magnetic resonance imaging, including good patient tolerability and ability to scan multiple joints in a short period of time. However, there are scarce data regarding its validity, reproducibility, and responsiveness to change, making interpretation and comparison of studies difficult. In particular, there are limited data describing standardized scanning methodology and standardized definitions of US pathologies. This article presents the first report from the OMERACT ultrasound special interest group, which has compared US against the criteria of the OMERACT filter. Also proposed for the first time are consensus US definitions for common pathological lesions seen in patients with inflammatory arthritis.

Wakefield, RJ; Balint, PV

2005-01-01

205

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

OpenAIRE

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, ad...

Jt, Lindsay; Lg, Heaney

2013-01-01

206

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

OpenAIRE

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 ind...

Lindsay, John T.; Heaney, Liam G.

2013-01-01

207

Repulsive Particle Swarm Method on Some Difficult Test Problems of Global Optimization  

OpenAIRE

In this paper we test a particular variant of the (Repulsive) Particle Swarm method on some rather difficult global optimization problems. A number of these problems are collected from the extant literature and a few of them are newly introduced. First, we introduce the Particle Swarm method of global optimization and its variant called the 'Repulsive Particle Swarm' (RPS) method. Then we endow the particles with some stronger local search abilities - much like tunneling - so that each partic...

Mishra, Sk

2006-01-01

208

Successful management of difficult airway in an adult patient of Goldenhar syndrome  

OpenAIRE

The present case emphasizes on the increasing difficulty in management of patients with Goldenhar syndrome as they age. Fiberoptic intubation using high dose dexmedetomidine along with local anesthetics is a safe technique for securing the airway in a difficult situation, even if the patient dose not cooperates for awake procedure. A16-year-old Goldenhar patient with multiple facial deformities was scheduled for correction of hollowness of right cheek and was successfully managed with high do...

Sahni, Neeru; Bhatia, Nidhi

2014-01-01

209

A control structure for the locomotion of a legged robot on difficult terrain  

OpenAIRE

The control of a legged robot walking on difficult terrain demands the development of efficient and reliable algorithms to coordinate the movement of multiple legs according to a diversity of requirements. We present a control structure, implemented on a six-legged robot, in which the aspects of stability, mobility, ground accommodation, gait generation, and robot heading are integrated in a coherent and simple way.

Celaya, Enric; Porta, Josep M.

1998-01-01

210

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

OpenAIRE

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...

Stjernstoft, Tero

2004-01-01

211

Why Is It Difficult to Predict Language Impairment and Outcome in Patients with Aphasia after Stroke?  

OpenAIRE

One of the most devastating consequences of stroke is aphasia. Communication problems after stroke can severely impair the patient's quality of life and make even simple everyday tasks challenging. Despite intense research in the field of aphasiology, the type of language impairment has not yet been localized and correlated with brain damage, making it difficult to predict the language outcome for stroke patients with aphasia. Our primary objective is to present the available evidence that hi...

Charidimou, Andreas; Kasselimis, Dimitrios; Varkanitsa, Maria; Selai, Caroline; Potagas, Constantin; Evdokimidis, Ioannis

2014-01-01

212

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

OpenAIRE

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 walk...

Javaid Iqbal; Umar Asif

2012-01-01

213

[Difficult necks. Diagnosis and treatment. Retrospective study of 145 cases using the method of Feldman].  

Science.gov (United States)

To identify a neck as difficult seems an easy thing. Nevertheless, we must admit that various clinical situations are represented under this single designation. A clinical and anatomical classification is proposed regarding the surgical strategy presented in this paper. Predominant tissue laxity and predominant fat accumulation are presented as progressive forms. Short platysma muscles and low hyoid bones are presented as constitutional. According to this classification, 145 patients among 438 facial rejuvenations were designated as difficult necks. The surgical strategy was intended, in each case, to address the underlying anatomical features, using a short incision system. A combination of wide skin undermining, fat removal under direct vision and corset platysmaplasty was performed in the 145 patients between November 2003 and May 2008. The average age was 59 years old and medium follow-up at 22 months. There was only 2% of secondary touch up for aesthetic reasons. Difficult necks, as described in this article, responded adequately to the present protocol. The postoperative results on the neck were consistent with the rest of the rejuvenated face and stood the test of time. PMID:20950920

Giordano, P; Mateu, J; Rouif, M; Laurent, B

2011-02-01

214

Percutaneous balloon pulmonary valvuloplasty: a modified over-the-wire Inoue balloon technique for difficult right ventricular anatomy.  

Science.gov (United States)

Percutaneous balloon pulmonary valvuloplasty (BPV) is the mainstay of treatment for significant pulmonary stenosis with doming leaflets. Various techniques have been described in the literature including the use of Inoue Percutaneous Transseptal Mitral Commissurotomy (PTMC) catheter with standard 0.025? guidewire. But if right ventricular anatomy is not suitable, 0.025? guidewire doesn't provide enough support to track the Inoue PTMC catheter. Here, we report a case of successful BPV using a novel technique of slenderizing the Inoue Percutaneous Transseptal Mitral Commissurotomy (PTMC) catheter over an Amplatz superstiff 0.035? guidewire. This technique may be useful during BPV in difficult right ventricular inflow and outflow tract anatomy in patients with congenital pulmonary valve stenosis. PMID:24814118

Deora, Surender; Vyas, Chirayu; Shah, Sanjay; Patel, Tejas

2014-01-01

215

Classical Conditioning  

Science.gov (United States)

!!Classical Conditioning!! Classical conditioning is the use of Pavlovian conditioning procedures where a neutral stimulus becomes capable of evoking a response through pairing with an unconditioned stimulus. Click the link below to get an introduction into classical conditioning. Introduction to Classical Conditioning Now that you\\'ve been introduced to classical conditioning, view the clip at the link below, ...

Mrs. Palacios, Miss Miller, Mr. Rowser

2008-04-01

216

Efficacy and tolerability of leflunomide in difficult-to-treat polymyalgia rheumatica and giant cell arteritis: a case series.  

Science.gov (United States)

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are related inflammatory rheumatic conditions affecting adults over the age of 50 years. Both conditions respond to initial glucocorticoid (GC) therapy. However, most patients require 12-36 months of a tapering steroid regime. Adverse events at 2 years are seen in up to 65% of patients with PMR and 86% of patients with GCA with over 50% developing serious events. There is also a high incidence of relapse in both diseases -40% within 2 years for GCA and 50% of patients with PMR at some point having a relapse. Effective steroid-sparing adjuvant therapies are urgently required especially in incomplete, poorly sustained or non-responders to glucocorticoids. In this case series, we found that Leflunomide is efficacious, with 22 out of our 23 patients exhibiting a complete or partial response. It was also steroid sparing and well tolerated. It may be a useful adjunctive agent in difficult-to-treat GCA and PMR. Prospective randomised controlled trials of Leflunomide in both GCA and PMR are now required. PMID:22897467

Adizie, T; Christidis, D; Dharmapaliah, C; Borg, F; Dasgupta, B

2012-09-01

217

Multipurpose alloys with controlled set of difficult-to-combine mechanical and physico-chemical properties  

International Nuclear Information System (INIS)

The principles and the methods of production are reported which relate to metallic materials possessing a combination of many (five, six and more) properties corresponding to the level close to limit values of one-purpose materials for each individual property. The investigation results on thin atomic, crystalline and magnetic structures of Fe-Ni and Fe-Ni-C base alloys are presented. Interrelationships are established of the variations in atomic-crystalline structure, martensitic transformations to physicomechanical and thermal properties of the alloys. The composition and the methods of production are determined for multi-purpose multiple-parameter alloys with a number of difficult-to-combine high level properties

218

More efficient cutting difficult-to-machine materials by rotary tool  

Energy Technology Data Exchange (ETDEWEB)

Super-heat-resisting alloy and stainless steel used in gas turbines, aircraft components, and nuclear equipment are difficult to machine because their cutting temperatures are high compared to carbon steel. More efficient cutting is thus required. A rotary tool cuts materials without greatly increasing cutting temperature. By applying a self-propelled fabricated rotary tool for cutting super-heat-resisting alloy, cutting speed could be increased about three times for Inconel 718 and about five times for SUS304, and that minimum surface roughness was obtained when the rotary tool was tilted 30 degrees. (author)

Itakura, Katsutoshi [H.I.T. Polytechnic, Hiroshima (Japan); Kuroda, Motofumi; Myouji, Tetsuya; Tsukamoto, Hidehiko [Mitsubishi Heavy Industries Ltd., Tokyo (Japan); Itani, Hikotaro [Ryosen Engineers Co. Ltd., Hiroshima (Japan); Ariura, Yasutsune [Kyushu Univ., Fukuoka (Japan)

2000-06-01

219

More efficient cutting difficult-to-machine materials by rotary tool  

International Nuclear Information System (INIS)

Super-heat-resisting alloy and stainless steel used in gas turbines, aircraft components, and nuclear equipment are difficult to machine because their cutting temperatures are high compared to carbon steel. More efficient cutting is thus required. A rotary tool cuts materials without greatly increasing cutting temperature. By applying a self-propelled fabricated rotary tool for cutting super-heat-resisting alloy, cutting speed could be increased about three times for Inconel 718 and about five times for SUS304, and that minimum surface roughness was obtained when the rotary tool was tilted 30 degrees. (author)

220

[?X11538a: The remnant Dunhuang Codex's of the Classic of Difficult Issues collected in Russia].  

Science.gov (United States)

The finalized edition of the Classic of Difficult Issues was collected by Yang Xuancao in the early Tang dynasty and is the only extant version so far. No earlier versions were seen since then. However, ?X11538a, one of the Russian Collection of DUNHUANG remnant papers, was verified to be a segment of the said Classic. Compared with the now circulated edition, this version is randomly arranged and irregular in its text. Even so, it still reflects, to some extent, the old picture of that ancient Classic, with some points even better than the latter. This version is significant to the researchers of this Classic even today. PMID:25429882

Shen, Shunong

2014-07-01

221

Successful management of difficult airway in an adult patient of Goldenhar syndrome  

Science.gov (United States)

The present case emphasizes on the increasing difficulty in management of patients with Goldenhar syndrome as they age. Fiberoptic intubation using high dose dexmedetomidine along with local anesthetics is a safe technique for securing the airway in a difficult situation, even if the patient dose not cooperates for awake procedure. A16-year-old Goldenhar patient with multiple facial deformities was scheduled for correction of hollowness of right cheek and was successfully managed with high dose dexmedetomidine infusion along with local anesthetics to facilitate fiberoptic intubation with no untoward side-effects. PMID:25538532

Sahni, Neeru; Bhatia, Nidhi

2014-01-01

222

Has it become more difficult for young households in rental housing to become homeowners?  

DEFF Research Database (Denmark)

It has been feared that the steep rise in house prices in the 0s would reduce ownership affordability for the young generations. In fact, homeownership among young Danish households has been falling. This development can be explained partly by postponement of family formation and partly by increased income inequality. In this paper we present calculations of the number of month it takes for an average young wage earner family that is presently in a tenant position to save 10 per cent of the average dwelling value. Our calculations show that it has become more difficult for young families to save the required amount to enter into homeownership during the 0s.

Skak, Morten; Bloze, Gintautas

2013-01-01

223

[The community health agent and working as a team: the easy and difficult aspects].  

Science.gov (United States)

The objective of this study is to analyze the easy and difficult aspects of teamwork according to community health agents. Qualitative analysis was carried out from the hermeneutical and dialectic perspective; the reference point was the senses interpretation method. The strengths and weaknesses they pointed out revealed that working as a team requires emotional relationships, with emphasis on communication, respect and cooperation, and that team meetings is an important strategy to achieve this. In conclusion, there is a need for continuous investments in team member relationships. PMID:21876891

Peres, Cássia Regina Fernandes Biffe; Caldas Júnior, Antonio Luiz; da Silva, Roseli Ferreira; Marin, Maria José Sanches

2011-08-01

224

Successful management of difficult airway in an adult patient of Goldenhar syndrome.  

Science.gov (United States)

The present case emphasizes on the increasing difficulty in management of patients with Goldenhar syndrome as they age. Fiberoptic intubation using high dose dexmedetomidine along with local anesthetics is a safe technique for securing the airway in a difficult situation, even if the patient dose not cooperates for awake procedure. A16-year-old Goldenhar patient with multiple facial deformities was scheduled for correction of hollowness of right cheek and was successfully managed with high dose dexmedetomidine infusion along with local anesthetics to facilitate fiberoptic intubation with no untoward side-effects. PMID:25538532

Sahni, Neeru; Bhatia, Nidhi

2014-11-01

225

Investigation of difficult component effects on FEM vibration prediction for the AH-1G helicopter  

Science.gov (United States)

Under the NASA-sponsored Design Analysis Methods for Vibrations program, a series of ground vibration tests and NASTRAN finite element model correlations were conducted on the Bell AH-1G helicopter gunship to investigate the effects of difficult components on the vibration response of the airframe. Secondary structure and damping were found to have significant effects on the frequency response of the airframe above 15 Hz. The nonlinear effects of thrust stiffening and elastomeric mounts on the low-frequency pylon modes below the main rotor were also significant.

Dompka, Robert V.

1988-01-01

226

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

OpenAIRE

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,...

Craythorne, E. E.; Lawrence, C. M.

2008-01-01

227

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

OpenAIRE

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...

Kryukov, V. I.

2012-01-01

228

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

Science.gov (United States)

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…

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

229

Solid phase synthesis of hydrophobic difficult sequence peptides on BDDMA-PS support.  

Science.gov (United States)

This article illustrates the successful and efficient solid phase assembly of hydrophobic difficult sequence peptides following both t-Boc and Fmoc chemistry. The peptides were synthesized on an optimized 1,4-butanediol dimethacrylate-crosslinked polystyrene support (BDDMA-PS). Four difficult sequence test peptides, VAVAG, VIVIG, QVGQVELG and VQAAIDYING, were synthesized in relatively good yield and purity without any aggregation problems. The peptides were assembled on chloromethylated and 4-hydroxymethylphenoxymethyl (HMP) BDDMA-PS resins. The peptides were fabricated using Boc amino acid 1-hydroxybenzotriazolyl and Fmoc amino acid pentafluorophenyl active esters in coupling reactions. The peptides after synthesis were cleaved from the polymeric support by exposing the peptidyl resin to 90% trifluroacetic acid/5% thioanisole/5% EDT mixture. The HPLC and MALDI TOF MS studies of the peptides revealed the high homogeneity of the synthesized peptides. Chloromethylated resin having a functional group loading of 1.14 mmol Cl/g was used for the synthesis. The yield and homogeneity of these peptides synthesized using the new support were high when compared with the conventional DVB-PS resin. PMID:11798020

Ajikumar, P K; Devaky, K S

2001-12-01

230

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

LENUS (Irish Health Repository)

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.

Maharaj, C H

2008-02-01

231

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

Directory of Open Access Journals (Sweden)

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.

Javaid Iqbal

2012-03-01

232

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

International Nuclear Information System (INIS)

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

233

The source condition in neutron diffusion theory  

International Nuclear Information System (INIS)

Boundary conditions are required to obtain a particular solution of the neutron diffusion equation. One of these conditions is the source or jump condition. A systematic procedure for applying this condition has not been established. This situation makes the solution process difficult. Here, the source condition is expressed in a single expression and its application has been systematized. The source condition expression is derived from Gauss divergence theorem. Its physical meaning is related to two physical situations found during neutron diffusion: neutron leakage and neutron absorption. This source condition is applied following three straightforward steps. To show the application of the source condition, three classical problems of neutron diffusion are solved. (Author)

234

Urogynecologic conditions: interstitial cystitis/painful bladder syndrome.  

Science.gov (United States)

Interstitial cystitis, also known as painful bladder syndrome, is a debilitating condition. The diagnosis is difficult and often is one of exclusion. Cystoscopy is the best way to confirm the diagnosis, but treatment can be initiated based on symptoms alone. Most patients benefit from an array of different drugs, including pentosan polysulfate, amitriptyline, hydroxyzine, and cimetidine. These treatments must be tailored for each patient. If oral drugs are ineffective, intravesical therapy can be attempted with dimethyl sulfoxide, heparin, or an anesthetic therapeutic combination containing lidocaine. Fulguration typically is performed if Hunner ulcers are found on cystoscopy. Hydrodistention, sacral neuromodulation, and intradetrusor onabotulinumtoxinA are sometimes useful. PMID:25756373

Desrosiers, Laurephile; Garely, Alan D

2015-03-01

235

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

Science.gov (United States)

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

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

2015-03-01

236

Neuroimagen en niños con epilepsia de difícil control Children with epilepsy of difficult control: Neuroimaging  

Directory of Open Access Journals (Sweden)

Full Text Available INTRODUCCIÓN. Los actuales estudios de neuroimagen representan un gran avance para el diagnóstico etiológico y pronóstico de la epilepsia infantil. El objetivo del presente estudio fue describir los hallazgos por tomografía axial y resonancia magnética en niños con epilepsias de difícil control y comparar los resultados de estas técnicas. MÉTODOS. Se realizó un estudio descriptivo, longitudinal prospectivo, de 108 niños con diagnóstico de epilepsia de difícil control, ingresados en el Servicio de Neuropediatría del Hospital Pediátrico Docente «Juan Manuel Márquez» entre enero de 2002 y junio de 2006. Se realizaron técnicas imagenológicas por tomografía computarizada (TC y resonancia magnética nuclear (RM. RESULTADOS. Se encontraron alteraciones estructurales del cerebro en el 88 % de los niños, y hubo predominio de lesiones prenatales en la fosa posterior, trastornos de la migración y atrofias secundarias a hipoxia perinatal. Se diagnosticó atrofia cortical localizada, mediante RM, hasta en el 28 % de los niños. CONCLUSIONES. La RM es la técnica de elección para el estudio de pacientes con epilepsia de difícil control, por su especificidad, mayor resolución 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 "Juán Manual Márquez" 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.

Ileana Valdivia Álvarez

2009-09-01

237

Neuroimagen en niños con epilepsia de difícil control / Children with epilepsy of difficult control: Neuroimaging  

Scientific Electronic Library Online (English)

Full Text Available SciELO Cuba | Language: Spanish Abstract in spanish INTRODUCCIÓN. Los actuales estudios de neuroimagen representan un gran avance para el diagnóstico etiológico y pronóstico de la epilepsia infantil. El objetivo del presente estudio fue describir los hallazgos por tomografía axial y resonancia magnética en niños con epilepsias de difícil control y co [...] mparar los resultados de estas técnicas. MÉTODOS. Se realizó un estudio descriptivo, longitudinal prospectivo, de 108 niños con diagnóstico de epilepsia de difícil control, ingresados en el Servicio de Neuropediatría del Hospital Pediátrico Docente «Juan Manuel Márquez» entre enero de 2002 y junio de 2006. Se realizaron técnicas imagenológicas por tomografía computarizada (TC) y resonancia magnética nuclear (RM). RESULTADOS. Se encontraron alteraciones estructurales del cerebro en el 88 % de los niños, y hubo predominio de lesiones prenatales en la fosa posterior, trastornos de la migración y atrofias secundarias a hipoxia perinatal. Se diagnosticó atrofia cortical localizada, mediante RM, hasta en el 28 % de los niños. CONCLUSIONES. La RM es la técnica de elección para el estudio de pacientes con epilepsia de difícil control, por su especificidad, mayor resolución y relativa inocuidad. Los pacientes con zonas localizadas de atrofia requieren estudios funcionales del cerebro para descartar displasias corticales focales. Abstract in english 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 "Juán Manual Márquez" 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.

Ileana, Valdivia Álvarez; Rogelio, Odales Ibarra.

2009-09-01

238

Structured Communication: Teaching Delivery of Difficult News with Simulated Resuscitations in an Emergency Medicine Clerkship  

Science.gov (United States)

Introduction The objective is to describe the implementation and outcomes of a structured communication module used to supplement case-based simulated resuscitation training in an emergency medicine (EM) clerkship. Methods We supplemented two case-based simulated resuscitation scenarios (cardiac arrest and blunt trauma) with role-play in order to teach medical students how to deliver news of death and poor prognosis to family of the critically ill or injured simulated patient. Quantitative outcomes were assessed with pre and post-clerkship surveys. Secondarily, students completed a written self-reflection (things that went well and why; things that did not go well and why) to further explore learner experiences with communication around resuscitation. Qualitative analysis identified themes from written self-reflections. Results A total of 120 medical students completed the pre and post-clerkship surveys. Majority of respondents reported that they had witnessed or role-played the delivery of difficult news, but only few had real-life experience of delivering news of death (20/120, 17%) and poor prognosis (34/120, 29%). This communication module led to statistically significant increased scores for comfort, confidence, and knowledge with communicating difficult news of death and poor prognosis. Pre-post scores increased for those agreeing with statements (somewhat/very much) for delivery of news of poor prognosis: comfort 69% to 81%, confidence 66% to 81% and knowledge 76% to 90% as well as for statements regarding delivery of news of death: comfort 52% to 68%, confidence 57% to 76% and knowledge 76% to 90%. Respondents report that patient resuscitations (simulated and/or real) generated a variety of strong emotional responses such as anxiety, stress, grief and feelings of loss and failure. Conclusion A structured communication module supplements simulated resuscitation training in an EM clerkship and leads to a self-reported increase in knowledge, comfort, and competence in communicating difficult news of death and poor prognosis to family. Educators may need to seek ways to address the strong emotions generated in learners with real and simulated patient resuscitations. PMID:25834685

Lamba, Sangeeta; Nagurka, Roxanne; Offin, Michael; Scott, Sandra R.

2015-01-01

239

Characterization of Ontario Hydro's low and intermediate level reactor waste -- Development of scaling factors for difficult-to-measure nuclides  

International Nuclear Information System (INIS)

Ontario Hydro has in storage over 35,000 m3 of low and intermediate level radioactive waste from its nuclear program. Since the early 80's, attempts have been made to radiochemically characterize the stored wastes. Insufficient data, however, exists on characteristics of some wastes and, in particular, data on activity levels of alpha and beta emitters in all types of waste are relatively scarce. To remedy this deficiency, scaling factors are being developed to relate the activity of difficult-to-measure (DTM) alpha/beta emitters with the activity of easy-to-measure gamma emitters. For this purpose, existing data on waste characteristics and data from analyses of particulate (sampled from reactor circuits) and contamination smears obtained during in-station radiation control and health physics related programs were examined. To facilitate the assessment of measured scaling factors, theoretical estimates were calculated from radionuclide inventories of used CANDU fuel operated under typical Ontario Hydro conditions. The preliminary findings in this paper indicate that, as for BWRs and PWRs, DTM radionuclides in CANDU wastes can be reliably scaled with respect to selected gamma emitters

240

Use of Laryngeal Mask Airway in the Management of a Difficult Airway: A Case Report  

Directory of Open Access Journals (Sweden)

Full Text Available Background: Difficulty in management of the airway occurs most frequently in patients who have Mallampati grade III and IV, and other unfavourable airway findings like short neck, restriction in range of motion of the temporoman-dibular joints and inadequate neck flexion and extension. Because of unavailability of fibreoptic bronchoscopes or inexperience in their use, laryngeal mask airway (LMA has become a common and acceptable airway management option. This is a case report of a postmenopausal woman who had her airway managed with LMA following initial failed intubation necessitating a rescheduling of the operation. Result: The patient had a successful surgery and postoperative recovery was uneventful. Conclusion: The LMA is a useful option in the management of an anticipated or unexpected difficult airway, especially in resource-poor settings where fibreoptic bronchoscopes may not be readily available.

Elizabeth Ogboli-Nwasor

2013-03-01

241

Difficult airway management following severe gasoline burn injury: a case report.  

Science.gov (United States)

Airway management following severe gasoline burn injury can be difficult. Because patients with severe burns may be treated at a variety of hospitals that provide emergent care, it is valuable for Certified Registered Nurse Anesthetists who work in such facilities to have an understanding of the care of these patients. Airway management is an extremely important consideration in the care of burn victims. If not done in a timely manner, lethal complications may result. This article reports the experience of caring for a female who was involved in an altercation, doused with gasoline, and set on fire. Consequently, airway obstruction developed and progressively worsened. Airway management interventions began with bag-valve-mask-assisted ventilation and progressed through orotracheal intubation attempts, attempts to insert a laryngeal mask airway, cricothyrotomy, emergency tracheostomy, and surgical tracheostomy. PMID:23251995

Greathouse, Jeffrey S; Stuart, Jamie L; White, William A

2012-08-01

242

Difficult dual stage transcutaneous lead extraction complicated by fracture of both leads.  

Science.gov (United States)

Extraction of two long-implanted (11 year-old) active leads due to local infection was complicated by the fracture of both leads with a metal sheath. The presence of a temporary pacing lead, inserted due to pacemaker dependence, made extraction even more difficult. The fixation of both proximal extracted lead endings in the occluded subclavian vein was much stronger than the connection of the tips of the leads with the RAA and RVA endocardium. The disintegration of both leads caused by drawing upon the distal ending added additional technical complications to the final procedure. The presented case underscores the necessity of having a full set of tools to hand even during what appears to be a routine lead extraction procedure. The importance of proper lead implantation on its extraction (in what may be the distant future) is discussed. PMID:22825904

Kutarski, Andrzej; Pietura, Rados?aw; Czajkowski, Marek

2012-01-01

243

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

Energy Technology Data Exchange (ETDEWEB)

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.

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

1987-02-01

244

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

DEFF Research Database (Denmark)

Silicone elastomers are used as dielectric electroactive polymers for making actuators, generators, sensors, and as artificial muscles in medical applications. Current requirements in the actuator manufacturing put a strict limitation on the thickness of the elastomers, such that a maximum 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 agents like surfactants and detergents, incorporating resins in the silicone matrix and grafting/adding low surface energy functionalities to the silicone elastomer have been tested. The methods used are required not to interfere with the Young's modulus and the dielectric permittivity in a negative way. Polysorbate-20, a non-ionic surfactant, fulfills all requirements and gives the lowest peel forces for the films.

Vudayagiri, Sindhu; Skov, Anne Ladegaard

2014-01-01

245

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

International Nuclear Information System (INIS)

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

246

A case of hepatic angiomyolipoma difficult to distinguish from hepatocellular carcinoma  

Directory of Open Access Journals (Sweden)

Full Text Available We report a case of hepatic angiomyolipoma with uncommon clinical features. A 56-year-old man presented with a hepatic tumor in the caudate lobe. The tumor was hypoechoic on ultrasonography, showed early-phase hyperattenuation on enhanced computed tomography and did not absorb iron on superparamagnetic iron oxide-enhanced magnetic resonance imaging. Hepatocellular carcinoma was highly suspected, and the patient underwent hepatic resection. Histologically, the tumor was mainly composed of smooth muscle cells and contained small amounts of adipose cells and blood vessels. On immunohistochemical staining, the smooth muscle cells were positive for a melanocytic cell-specific monoclonal antibody. In cases with uncommon features of angiomyolipoma, it is quite difficult to distinguish angiomyolipoma from hepatocellular carcinoma.

Masahiro Takahara, Yasuhiro Miyake, Kazuyuki Matsumoto, Daisuke Kawai, Eisuke Kaji, Tatsuya Toyokawa, Morihito Nakatsu, Masaharu Ando, Mamoru Hirohata

2009-06-01

247

Some solutions to on-line radiological monitoring of difficult streams  

International Nuclear Information System (INIS)

On-line monitoring for radiological contamination of dirty, but normally not radioactive, streams is difficult. Described are several new, low-fouling units that are intended to replace the existing sensors that monitor both beta and gamma activity. A sensor was designed, using a thin-wall Geiger-Mueller tube for beta and gamma sensitivity, to monitor the influent of the sanitary sewage treatment plant. The new design eliminates dead volumes inherent in the old unit by use of a double-layer, helically wound solenoid made of 5/16-in.-OD thin-wall (0.02-in.) Teflon tubing. A 4-L Marinelli beaker-based system that used a 3 x 3 NaI(Tl) scintillator was replaced with a multilayer solenoid of 5/8-in.-OD Teflon. Two units for the detection of beta radiation are also described. 1 ref., 6 figs., 1 tab

248

Treatment options for refractory and difficult to treat seizures: focus on vigabatrin  

Directory of Open Access Journals (Sweden)

Full Text Available Justin A Tolman, Michele A FaulknerSchool of Pharmacy and Health Professions, Creighton University, Omaha, Nebraska, NE, USAAbstract: Complex partial seizures are often refractory to current pharmacological therapies. These difficult to treat seizures are typically managed using multiple antiepileptic drugs (AEDs. AEDs as a group are frequently associated with significant adverse drug effects, multiple drug interactions, and numerous potential clinical complications due to their individual pharmacokinetic profiles and unique drug properties. Recently, the approval of vigabatrin by the US Food and Drug Administration has necessitated that clinicians re-evaluate these risk-benefit relationships and determine where the drug fits within the treatment scheme for the management of complex partial seizures. This review will facilitate that re-evaluation through a brief review of AEDs used in the treatment of complex partial seizures, followed by a focused discussion on vigabatrin.Keywords: vigabatrin, complex partial seizures, refractory seizures, risk evaluation and mitigation strategy, epilepsy

Tolman JA

2011-09-01

249

Fracture nonunion: CT assessment with multiplanar reconstruction and role of CT in suspected and difficult cases  

International Nuclear Information System (INIS)

The author evaluated ten patients with suspected fracture nonunion using CT with multiplanar reconstruction. Each case represented a difficult problem in fracture management. Disparities in clinical and radiographic findings led orthopedists to request multiplanar CT to confirm or further evaluate possible nonunion. CT with multiplanar reconstruction delineated lack of bony bridging across the fracture site in multiple planes, clarifying the diagnosis of nonunion in eight of ten cases. Evaluation of nonunion in bone subjected to multiple prior operations or with remaining hardware in place was possible (six cases). Multiplanar reconstruction aided assessment of malalignment and angular deformities in multiple views and provided additional information regarding the nonviability of the femoral head in two proximal femur fractures

250

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

Directory of Open Access Journals (Sweden)

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.

Butyrin Andrey Yur'evich

2014-02-01

251

Sequential Double-Guidewire Technique and Transpancreatic Precut Sphincterotomy for Difficult Biliary Cannulation  

Science.gov (United States)

Background/Aims: The double-guidewire technique (DGT) and transpancreatic precut sphincterotomy (TPS) are introduced as alternative biliary cannulation techniques for difficult biliary cannulation. This study aimed to evaluate the sequential use of DGT and TPS compared with a needle-knife precut papillotomy (NK). Patients and Methods: Six hundred and thirty-five consecutive patients with na?ve papilla and who underwent endoscopic retrograde cholangiopancreatography (ERCP) for biliary cannulation from March 2010 to April 2014 in a single institute were analyzed. When standard techniques were unsuccessful, DGT or NK was performed. TPS was sequentially performed if DGT failed. Results: DGT and NK were attempted in 65 and 58 patients, respectively. A sequential DGT-TPS was performed in 38 patients after a failed DGT. Biliary cannulations were successful in 42%, 74%, and 66% of the DGT, sequential DGT-TPS, and NK patients, respectively (P = 0.002). The cannulation rate was higher in the DGT ± TPS patients (85%) than in the NK patients (P = 0.014). Post-ERCP pancreatitis (PEP) developed in 26% of the successful DGT patients, 37% of the sequential DGT-TPS patients, and 10% of the NK patients (P = 0.008). Of the sequential DGT-TPS patients, the incidence of PEP was significantly reduced in patients with a pancreatic duct (PD) stent compared with patients without a PD stent (24% vs. 62%, P = 0.023). Conclusions: Sequential DGT-TPS is a useful alternative method compared with NK for patients in whom biliary cannulation is difficult. In the sequential DGT-TPS patients, the incidence of PEP was significantly reduced with the use of a PD stent. PMID:25672234

Kim, Chang W.; Chang, Jae H.; Kim, Tae H.; Han, Sok W.

2015-01-01

252

Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management : a randomized clinical trial  

DEFF Research Database (Denmark)

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 with an anticipated difficult intubation. The authors examined the hypothesis that MVL intubation would be faster than FFI.

Rosenstock, Charlotte Vallentin; ThØgersen, Bente

2012-01-01

253

A Novel 'Cheese Wire' Technique for Stent Positioning Following Difficult Iliac Artery Subintimal Dissection and Aortic Re-Entry  

International Nuclear Information System (INIS)

Subintimal wire dissection is a well-established method for traversing difficult vascular occlusions. This technique relies on re-entry of the true lumen distal to the occlusion, which may be difficult in diseased vessels with significant calcification. This case report describes a novel 'cheese wire' technique to allow stent positioning without the use of proprietary re-entry devices.

254

Descriptions of Difficult Conversations between Native and Non-Native English Speakers: In-Group Membership and Helping Behaviors  

Science.gov (United States)

This study illustrated the perceptions of native English speakers about difficult conversations with non-native English speakers. A total of 114 native English speakers enrolled in undergraduate communication courses at a regional state university answered a questionnaire about a recent difficult conversation the respondent had with a non-native…

Young, Ray; Faux, William V., II

2011-01-01

255

High fidelity medical simulation in the difficult environment of a helicopter: feasibility, self-efficacy and cost  

Directory of Open Access Journals (Sweden)

Full Text Available Abstract Background This study assessed the feasibility, self-efficacy and cost of providing a high fidelity medical simulation experience in the difficult environment of an air ambulance helicopter. Methods Seven of 12 EM residents in their first postgraduate year participated in an EMS flight simulation as the flight physician. The simulation used the Laerdal SimMan™ to present a cardiac and a trauma case in an EMS helicopter while running at flight idle. Before and after the simulation, subjects completed visual analog scales and a semi-structured interview to measure their self-efficacy, i.e. comfort with their ability to treat patients in the helicopter, and recognition of obstacles to care in the helicopter environment. After all 12 residents had completed their first non-simulated flight as the flight physician; they were surveyed about self-assessed comfort and perceived value of the simulation. Continuous data were compared between pre- and post-simulation using a paired samples t-test, and between residents participating in the simulation and those who did not using an independent samples t-test. Categorical data were compared using Fisher's exact test. Cost data for the simulation experience were estimated by the investigators. Results The simulations functioned correctly 5 out of 7 times; suggesting some refinement is necessary. Cost data indicated a monetary cost of $440 and a time cost of 22 hours of skilled instructor time. The simulation and non-simulation groups were similar in their demographics and pre-hospital experiences. The simulation did not improve residents' self-assessed comfort prior to their first flight (p > 0.234, but did improve understanding of the obstacles to patient care in the helicopter (p = 0.029. Every resident undertaking the simulation agreed it was educational and it should be included in their training. Qualitative data suggested residents would benefit from high fidelity simulation in other environments, including ground transport and for running codes in hospital. Conclusion It is feasible to provide a high fidelity medical simulation experience in the difficult environment of the air ambulance helicopter, although further experience is necessary to eliminate practical problems. Simulation improves recognition of the challenges present and provides an important opportunity for training in challenging environments. However, use of simulation technology is expensive both in terms of monetary outlay and of personnel involvement. The benefits of this technology must be weighed against the cost for each institution.

Holland Carolyn

2006-10-01

256

A lack of response of the financial behaviors of biodiversity conservation nonprofits to changing economic conditions  

Science.gov (United States)

The effectiveness of conservation organizations is determined in part by how they adapt to changing conditions. Over the previous decade, economic conditions in the United States (US) showed marked variation including a period of rapid growth followed by a major recession. We examine how biodiversity conservation nonprofits in the US responded to these changes through their financial behaviors, focusing on a sample of 90 biodiversity conservation nonprofits and the largest individual organization (The Nature Conservancy; TNC). For the 90 sampled organizations, an analysis of financial ratios derived from tax return data revealed little response to economic conditions. Similarly, more detailed examination of conservation expenditures and land acquisition practices of TNC revealed only one significant relationship with economic conditions: TNC accepted a greater proportion of conservation easements as donated in more difficult economic conditions. Our results suggest that the financial behaviors of US biodiversity conservation nonprofits are unresponsive to economic conditions. PMID:25512840

Larson, Eric R; Boyer, Alison G; Armsworth, Paul R

2014-01-01

257

Difficult-to-Treat or Resistant Hypertension: Etiology, Pathophysiology, and Innovative Therapies  

OpenAIRE

Despite the many therapeutic options available today for the treatment of hypertension, a sizable number of patients still remain resistant to treatment. The prevalence of resistant hypertension in the general population under optimal conditions is about 3–5%. Although several factors and conditions can be identified and corrected a percentage of hypertensive patients remain with unacceptably high blood pressure levels. The high prevalence of hypertension in the general population renders t...

Vasilios Papademetriou; Costas Tsioufis; Alan Gradman; Henry Punzi

2011-01-01

258

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  

Science.gov (United States)

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 (?1? 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 ?fGo 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 ?, values of the a, b parameters of the EoS together with ?fGo298(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 ? parameter was modified in compliance with the adopted AKr value (Eq. A7), and the fitting cycle was repeated until ? ceased changing.The finally retrieved values for gaseous Si(OH)4 are ?fGo298 = -1239.66 ± 1.7 kJ mol-1, So298 = 346.37 ± 3.5 J mol-1 K-1, and the EoS parameters are ? = -1.8933; a = 0.9285 ± 1.1 cm3 g-1; b = -0.9409 ± 0.97 cm3 K0.5 g-1 (2? confidence) (Table 1). Evaluated in this work values of ?fGo298 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:

Akinfiev, Nikolay N.; Plyasunov, Andrey V.

2014-02-01

259

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

International Nuclear Information System (INIS)

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

260

Malignant lymphomas (including myeloproliferative disorders)  

International Nuclear Information System (INIS)

This chapter deals with the radiotherapy and cytotoxic chemotherapy of the malignant lymphomas. Included within this group are Hodgkin's disease, non-Hodgkin's lymphoma, mycosis fungoides, and chronic lymphatic leukaemia. A further section deals with the myeloproliferative disorders, including granulocytic leukaemia, polycythaemia vera, and primary thrombocythaemia. Excluded are myeloma and reticulum cell sarcoma of bone and acute leukaemia. With regard to Hodgkin's disease, the past 25 years have seen general recognition of the curative potential of radiotherapy, at least in the local stages, and, more recently, awareness of the ability to achieve long-term survival after combination chemotherapy in generalised or in recurrent disease. At the same time the importance of staging has become appreciated and the introduction of procedures such as lymphography, staging laparotomy, and computer tomography (CT) has enormously increased its reliability. Advances have not been so dramatic in the complex group of non-Hodgkins's lymphomas, but are still very real

261

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

International Nuclear Information System (INIS)

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 ?g/l [IQR: 420-600] to 340 ?g/l [IQR: 230-460] at 6 months (p=0.01), to 400 ?g/l [IQR: 222.4-600] at 12 months (p=0.48), to 396 ?g/l [IQR: 318-468] at 30 months (p=0.49), to 482 ?g/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: 0.0volume 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)

262

Perinatal risk factors including malformation  

International Nuclear Information System (INIS)

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)

263

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

DEFF Research Database (Denmark)

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 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 vertical density at the end of the growing season is assumed to be a function of the cover of all species at the start of the growing season, and the cover at the start of the growing season is assumed to be a function of the vertical density of all species at the end of the previous growing season. The 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. Additionally, the presented method is suited for testing different ecological hypothesis on competitive interactions along environmental gradients, investigating the importance of competition, as well as predicting the likelihood of different ecological scenarios.

Damgaard, Christian

2011-01-01

264

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

Directory of Open Access Journals (Sweden)

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.

Andrea Pizzini

2007-06-01

265

Desmoplastic round small cell tumor: a case report of a neoplasm of difficult diagnosis  

International Nuclear Information System (INIS)

Desmoplastic Small Round Cell Tumor (DSRCT) is a rare neoplasm of difficult diagnosis, recently described by Gerald et al. There are reports of nearly 101 cases in the literature, being the intra-abdominal region its most common location and children and young adults its preferred age group. This paper reports a case of DSRCT in a young adult of 24 years of age. This patient presented unspecific symptoms of nausea, vomiting and a single episode of haematemesis. Upon physical examination a solid mass on the epigastrium and left hypochondrium was found. Image diagnostic procedures confirmed the existence of the expansive process and also revealed enlarged retroperitoneal lymphonodes. Diagnosis was achieved through videolaparoscopic biopsy. Histologic sections stained with hematoxylin/eosin were inconclusive and immunohistochemical analysis was required to establish the diagnosis. This analysis revealed positivity to epithelial and mesenchymal markers and weak positivity to chromogranin A, characteristic results of DSRCT. Due to the fact that the disease was locally advanced, the patient was treated with chemotherapy (cyclophosphamide and paclytaxel). However, since there was only partial response to the treatment, the patient refused to undergo any second line option of therapy. Presently, the patient is being submitted only to supportive care, within an 18-month follow-up program. (author)

266

Vía aérea difícil en pediatría: signos predictores. Artículo de revisión Difficult airway in pediatrics. Predicting signs  

Directory of Open Access Journals (Sweden)

Full Text Available El manejo de la Vía Aérea es la A del ABC de la medicina moderna y representa un reto para el anestesiólogo experto, y aún más para el que se encuentra en entrenamiento. Una intubación difícil no anticipada es una emergencia médica, si no es tratada con rapidez y de forma apropiada, puede condicionar problemas serios y hasta la muerte del paciente. En el presente artículo se hace una revisión del diagnóstico precoz de esta entidad, mediante signos predictores, teniendo en cuenta algunas de las características principales de la vía aérea del niño 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.

Judith Pérez Lara

2007-03-01

267

[Mothers of visually impaired children: difficult and easy aspects faced in care].  

Science.gov (United States)

This study aimed to identify the difficult and easy aspects faced by mothers of visually impaired (VI) children in their care. It is a descriptive qualitative study, developed in the second semester of 2011, with ten mothers of children with visual impairment from an Educational Center for the Visually Impaired located in southern Brazil. Data were collected by means of semistructured interviews and submitted to thematic content analysis. The identified difficulties were the lack of knowledge regarding the disease and how to take care of the child, the lack of access to health services, overload generated by the dependence of the child and lack of support and prejudice within their own family. The easy aspects involved the desire for the child's healthy development the chance of being in touch with qualified professionals for their education, and the contact with other VI children. Therefore, it is important to qualify the family for the care of VI children so as to ensure the development of skills and competencies enabling them to live with quality. PMID:24015466

Pintanel, Aline Campelo; Gomes, Giovana Calcagno; Xavier, Daiani Modernel

2013-06-01

268

Why is biological science difficult for first-year nursing students?  

Science.gov (United States)

Many factors contribute to poor performance in examinations in nurse education. Some of these are specific to the biological science subject area. In this study the results of two cohorts of first-year nursing students' biological science examination results were analysed to see if entry criteria and study habits significantly affected examination results. chi(2) contingency tables were used. The following parameters were shown to have a significant effect on biological science examination results: 1. Studied biology previously, chi(2)=48.06, DF=20, n=112 (significant at 0.001); 2. Level of achievement in school biology, chi(2)=11.15, DF=8, n=104 (significant at 0.05); 3. Attendance in class, chi(2)=60.71, DF=36, n=201 (significant at 0.001); 4. Use of recommended readings, chi(2)=34.86, DF=20, n=119 (significant at 0.05). Are nursing students of today giving themselves a decent chance through their study and attendance behaviour in a busy demanding course? Is overloading within the curriculum leading to these behaviours? This study shows that poor previous theoretical biological science significantly influenced biological science examination results. Biological science will continue to prove difficult, particularly for students who have a poor biological background, unless appropriate strategies are put in place both within the course and prior to entry. PMID:12027607

McKee, Gabrielle

2002-04-01

269

Endoscopic papillary large balloon dilation after limited sphincterotomy for difficult biliary stones  

Directory of Open Access Journals (Sweden)

Full Text Available AIM: To assess the efficacy and safety of endoscopic papillary large balloon dilation after biliary sphincterotomy for difficult bile duct stones retrieval. METHODS: Retrospective review of consecutive patients submitted to the technique during 18 mo. The main outcomes considered were: efficacy of the procedure (complete stone clearance; number of sessions; need of lithotripsy and complications. RESULTS: A total of 30 patients with a mean age of 68 ± 10 years, 23 female (77% and 7 male (23% were enrolled. In 10 patients, a single stone was found in the common bile duct (33% and in 20 patients multiple stones (67% were found. The median diameter of the stones was 17 mm (12-30 mm. Dilations were performed with progressive diameter Through-The-Scope balloons (up to 12, 15 or 18 mm. Complete retrieval of stones was achieved in a single session in 25 patients (84% and in two sessions in 4 patients (13%. Failure occurred in 1 case (6%. Mechanical lithotripsy was performed in 6 cases (20%. No severe complications occurred. One patient (3% had mild-grade post-endoscopic retrograde cholangiopancreatography (ERCP pancreatitis. CONCLUSION: Endoscopic balloon dilatation with a large balloon after endoscopic sphincterotomy is a safe and effective technique that could be considered an alternative choice in therapeutic ERCP.

Ana Rebelo

2012-01-01

270

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

DEFF Research Database (Denmark)

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 still uncertain technological futures, and with attention to the conceptual and normative difficulties that such time-travelling talk presents. Grounded in qualitative interviews with parents whose children had participated in an OCD neuroimaging and genetic research study in the United States, we 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 about biological selfhood and the ontological status of the brain and genes in the concrete specificities of individual lived experience; where knowledge is defined in relation to both the actions and rhetorics it facilitates.

Whiteley, Louise Emma; Borgelt, Emily L

2014-01-01

271

Science Teachers’ and Students’ Perceived Difficult Topics in the Integrated Science Curriculum of Lower Secondary Schools in Barbados  

Directory of Open Access Journals (Sweden)

Full Text Available The study was designed to investigate the perception of students and teachers of the difficult topics in the lower secondary school science curriculum of Barbados; if there were statistically significant differences in (a students’ perception and teacher perception of difficult topics and (b students’ perception of difficult topics based on their gender, interest in science, study habits and school location and school category; as well as to determine the inter-relationships among the four student variables (gender, interest in science, study habits, school location.

Babalola Ogunkola

2011-10-01

272

Will GnRH antagonists provide new hope for patients considered 'difficult responders' to GnRH agonist protocols?  

Science.gov (United States)

We have assessed the use of cetrorelix, a gonadotrophin releasing hormone (GnRH) antagonist, in conjunction with clomiphene citrate and gonadotrophin in 31 in-vitro fertilization (IVF)/gamete intra-Fallopian transfer (GIFT) cycles for 25 difficult responders. Group I included 18 poor responders (24 cycles) with no live birth in 23 previous IVF cycles with GnRH agonists. Group II included seven patients (seven cycles) with polycystic ovaries. Thirteen previous IVF/GIFT cycles with GnRH agonists had resulted in one live birth and three of these patients had developed ovarian hyperstimulation syndrome (OHSS). The treatment protocol involved a daily dose of clomiphene citrate 100 mg for 5 days and gonadotrophin injections from cycle day 2. Cetrorelix 0.25 mg/day was started when the leading follicle reached 14 mm. The outcome in both groups was favourable compared to previous treatment with GnRH agonists. In group I the abandoned cycle rate was 29 versus 57% (P = 0.06). More oocytes were produced (6.4 versus 4.7 oocytes/cycle) at a lower dose of follicle-stimulating hormone (FSH) (709 versus 1163 IU/oocyte; P = 0.08) and two live births resulted (11.8%). In group II fewer oocytes were produced (10.2 versus 14.5 oocytes/cycle), using a lower dose of gonadotrophin (170 versus 189 IU/oocyte) and resulted in one ongoing pregnancy. No patients experienced OHSS. This report is preliminary and a further controlled randomized study is required. PMID:10601078

Craft, I; Gorgy, A; Hill, J; Menon, D; Podsiadly, B

1999-12-01

273

Effect of soil conditions on the behavior of atmospheric contaminants in alpine areas  

International Nuclear Information System (INIS)

The aim of this contribution based on my thesis, is to highlight the specific impact land of high mountains of the Western Carpathians to capture elements (Cd, Pb, Hg), to how individual soil conditions determine the profile dynamics of brought elements and to show that local historical resources of contamination, which are not taken into account, is necessary to include to the concept of critical loads. Because the contents of these elements exceed adopted critical limits, the concept cannot be applied in the present form because of difficult conditions of Slovakia.

274

Breaking the cycle: how I manage difficult atopic dermatitis Romper o ciclo: minha conduta em casos difíceis de dermatite atópica  

Directory of Open Access Journals (Sweden)

Full Text Available 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 stop seeking irrational approaches. The new flood of information relating to epidermal barrier provides a basis for seeking and treating xerotic conditions earlier during infancy with the hope that the increasing problems with atopic dermatitis and asthma may be lessened with simple and safe measures.Esta revisão resume a abordagem geral e a filosofia na conduta de casos difíceis de dermatite atópica. Existe uma variedade de tratamentos, assim como de médicos, mas muitos falham e não propiciam um alívio adequado aos pacientes, o que leva a uma alternativa dispendiosa, ou seja, um atitude que visa procurar alergias e complica ainda mais o tratamento desses pacientes. Se nós, como dermatologistas, oferecermos um aconselhamento racional sobre prevenção e cuidados com a pele, junto com uma terapia antiinflamatória eficaz e estável, nossos pacientes irão parar de procurar abordagens irracionais. O novo fluxo de informações sobre a barreira epidérmica propicia uma base para investigar e tratar as doenças xeróticas em uma fase mais precoce durante o primeiro ano de vida, com a esperança de que os problemas crescentes relacionados à dermatite atópica e asma possam ser atenuados com medidas simples e seguras.

Jon M. Hanifin

2007-02-01

275

Magnetic resonance spectroscopy guided brain tumor resection: differentiation between recurrent glioma and radiation change in two diagnostically difficult cases  

International Nuclear Information System (INIS)

It is often difficult to differentiate a recurrent glioma from the effects of post-operative radiotherapy by means of conventional neurodiagnostic imaging. Proton magnetic resonance spectroscopic imaging (1H-MRSI), that allows in vivo measurements of the concentratin of brain metabolites such as choline-containing phospholipids (Cho), may provide in vivo biochemical information helpful in distinguishing areas of tumor recurrence from areas of radiation effect. Two patients who had undergone resection and post-operative radiotherapy for a cerebral glioma became newly symptomatic. Computed tomographic (CT) and magnetic resonance imaging (MRI) performed after the intravenous infusion of contrast material, and in one case, [18F]fluorodeoxyglucose positron emission tomography (PET), could not differentiate between the possibilities of recurrent glioma and radiation effect. The patients underwent 1H-MRSI prior to reoperation and the 1H-MRSI results were compared to histological findings originating from the same locations. A high Cho signal measured by 1H-MRSI was seen in areas of hisologically-proven dense tumor recurrence, while low Cho signal was present where radiation changes predominated. The differentiation between the recurrence of a cerebral glioma and the effects of post-operative irradiation was achieved using 1H-MRSI in these two patients whose conventional neurodiagnostic imaging was equivocal for such a dinostic imaging was equivocal for such a distinction. Where these two conditions are present, metabolite images from 1H-MRSI, such as that based on Cho, can be co-registered with other imaging modalities much as MRI and may also be integrated with functional MRI or functional PET within a multimodal image-guided surgical navigation system to assure maximal resection of recurrent tumor while minizing the risk of added neurological damage

276

Breaking the cycle: how I manage difficult atopic dermatitis / Romper o ciclo: minha conduta em casos difíceis de dermatite atópica  

Scientific Electronic Library Online (English)

Full Text Available Esta revisão resume a abordagem geral e a filosofia na conduta de casos difíceis de dermatite atópica. Existe uma variedade de tratamentos, assim como de médicos, mas muitos falham e não propiciam um alívio adequado aos pacientes, o que leva a uma alternativa dispendiosa, ou seja, um atitude que vis [...] a procurar alergias e complica ainda mais o tratamento desses pacientes. Se nós, como dermatologistas, oferecermos um aconselhamento racional sobre prevenção e cuidados com a pele, junto com uma terapia antiinflamatória eficaz e estável, nossos pacientes irão parar de procurar abordagens irracionais. O novo fluxo de informações sobre a barreira epidérmica propicia uma base para investigar e tratar as doenças xeróticas em uma fase mais precoce durante o primeiro ano de vida, com a esperança de que os problemas crescentes relacionados à dermatite atópica e asma possam ser atenuados com medidas simples e seguras. Abstract in english 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 f [...] or 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 stop seeking irrational approaches. The new flood of information relating to epidermal barrier provides a basis for seeking and treating xerotic conditions earlier during infancy with the hope that the increasing problems with atopic dermatitis and asthma may be lessened with simple and safe measures.

Jon M., Hanifin.

2007-02-01

277

Drought Monitor: Current Conditions  

Science.gov (United States)

The US Department of Agriculture recently released these updated data summaries for temperature, precipitation, and vegetation condition in the US. Data summaries include the Palmer Drought Severity Index (PDSI), Crop Moisture Index, Standardized Precipitation Index, Drought Impacts in the US, Percent of Normal Rainfall, Daily Streamflow Map, Snowpack, Soil Moisture, Daily Soil Moisture Anomaly, and the Vegetation and the Temperature Condition Index.

278

Recycling management including transportation experience  

International Nuclear Information System (INIS)

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 figrial experience. 1 fig

279

Gold grain implants in resistant tumors- a useful modality in difficult head and neck sites  

International Nuclear Information System (INIS)

Management of resistant head and neck cancers after failure of surgery and radiation therapy is a daunting task. Treatment by interstitial implants is the only viable alternative since salvage or palliative surgery is often not feasible and external irradiation and or chemotherapy are of very limited benefit. In many events, the sites of failures are difficult to be implanted e.g. base of skull, parapharyngeal space ... etc. using standard afterloading 192Ir or the recently available permanent palladium seeds. In a comparative study of the biologic background of 103Pd. 198Au2 123I, it was shown that 198Au is the only seed that acts independently to the tumor doubling time (Tpot), with the least wasted dose 1 However problems with staff exposure and radiation safety have pushed the latter out of favor. We reviewed the charts of 94 Gold grain implant patients (1970-1995), in order to determine whether there is a continuing role of 198Au implant. Thirty seven had the implant in the head and neck region. We hereby present our experience in those cases and compare the feasibility of 198Au to 102Pa in the same cohort. Eight cases were located in supraglottic larynx, 5 in nasopharynx, 4 in retromolar trigone, 2 in oral cavity, 4 in base of tongue, 4 in maxillary antrum, 4 in palate, 2 in lymph nodes of unknown origin, 2 in tonsilar fossa, 1 in pyrifom fossa, 1 inn tonsilar fossa, 1 in pyrifom fossa, 1 in posterior pharyngeal wall, and 1 in parotid gland. Twenty eight were recurrent cases, 6 were residual locally advanced and 3 had their implants for a second primary in an area that was irradiated before. Gold grain implants were performed under general anesthesia in (35(37)) patients using the Royal-Marsden gun. The activity of the gold grains used ranged from 3.5-4.9 mci per seed. The total activity of gold grain implants ranged from 13 to 160 mci with a median of 85 mci, the median number of seeds used was 34. The total radiation dose delivered at 0.5cm margin around the target volume ranged from 90 Gy to 220 Gy with a median of 100 Gy. Out of 37 sites implanted using 198Au, it was estimated that 103Pd could have been an alternative in 14 cases only. Comparative physics plans using 103Pd and 198Au in this subset were obtained and analyzed by 2 independent radiation oncologist (blind folded at the type of seeds). Results of the 2 types of seeds plans were comparable with no statistical significant difference) (P=0.988 for 103Pd). Local control was dependent on 2 factors 1) size of the lesion implanted; In 19 tumors with a diameter > 2.5, only 2 had local control, while of 14 patients who had lesions < 2.5.9(64 %) had local control (P:0.002) 2) site of primary and histology; palatal adenocystic arcomas tumors had average progression free survival of 52 months compared to 13.9 and 4 months in nasopharyngeal, oropharyngeal and supraglottic squamous cell carcinoma. Cessation of bleeding occurred in 50%, control of pain in 88% and relief of dysphagia in 60% average length of hospital stay was 6 days and the average bed side exposure was 40 mrem/hr. We conclude that gold grain implant has a continuing role in the palliation of recurrent head and neck tumors especially in sites difficult to reach with palladium e.g. supraglottic-larynx, base of tongue, hypopharynx, and nasopharynx. Local control is best in lesions <2.5cm in greatest dimension. Homogeneity of doses delivered is comparable to similar plans utilizing palladium seeds

280

Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study  

Directory of Open Access Journals (Sweden)

Full Text Available Endoscopic band ligation is regarded as the main therapeutic option for acute esophageal variceal bleeding, while sclerotherapy may be used in the acute setting if ligation is technically difficult. The incidence of difficult-to-perform band ligation in acute esophageal variceal bleeding, as well as the outcome of patients subjected to injection sclerotherapy as an alternative treatment, has not been clearly investigated. Our aim is to study the outcome of patients subjected to injection sclerotherapy in the acute setting of esophageal variceal bleeding when endoscopic band ligation is technically difficult to perform. We included 151 patients with acute esophageal variceal bleeding originnating from medium or large sized varices. All patients were planned for EBL as the 1st treatment option (EBL group 61.6%, meanwhile, EIS using 5% ethanolamine oleate was reserved as the 2nd treatment option when EBL was technically difficult (EIS group 38.4%. The mean time to restore hemodynamic stability was significantly prolonged in the EIS group (11.5 ± 6.5 hrs versus 9.5 ± 5.0 hrs, p 0.05. Initial control of bleeding was significantly higher in the EBL group versus the EIS group (96.7% vs 84.5%, p 0.021. Re-bleeding was more among the EIS group (42.9% vs 24.2%, p 0.04. There were no significant differences as regarding mortality and duration of hospital stay. So, a considerable proportion of cases presenting with acute variceal bleeding will have difficulty in performing EBL. In these patients, sclerotherapy is not a waning procedure with an accepted success rate, without much additional complications and without deranging mortality.

Gamal E. Esmat

2013-09-01

281

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

DEFF Research Database (Denmark)

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. New or breakthrough work to be presented: The method provides a simple way of dealing with complex morphological changes using knowledge of typical deformations.

Thorup, Signe Strann; Darvann, T.A.

2010-01-01

282

A case of difficult management of fluid-electrolyte imbalance in choroid plexus papilloma.  

Science.gov (United States)

A 22-month-old boy presented with nausea and gradual deterioration of gait disturbance. Computed tomography (CT) demonstrated an intraventricular mass lesion in the right lateral ventricle. He was referred to our department 3 weeks after onset. Acute hydrocephalus gradually proceeded 4 days after admission, and external ventricular drainage (EVD) was performed. EVD revealed cerebrospinal fluid (CSF) overproduction (800-1,500 mL/day) under constant pressure of 10 cm H2O above external auditory meatus. Magnetic resonance imaging showed a multi-lobular mass in the inferior horn of the right lateral ventricle. A choroid plexus tumor was suspected. The ratio of blood urea nitrogen:creatinine (BUN:Cre) remained between 30 and 40, and hemoglobin was between 14.0-17.0 mg/dL, suggesting marked dehydration. Serum sodium varied between 117 and 140 mmol/L, and serum potassium between 2.2 mmol/L and 6.9 mmol/L. The amount of EVD was unstable and fluid balance management was difficult. Hypotonic fluid with sodium chloride supplement was used to adjust the fluid and electrolyte imbalance. Surgical removal of the tumor was performed 6 days after EVD and tumor was grossly and totally removed. The high BUN:Cre ratio decreased to about 15 and hemoglobin recovered to 7.5-9.0 mg/dL after removal. Electrolytes returned to the normal range. Overproduction of CSF also markedly improved to < 300 mL/day. Histopathological examination diagnosed choroid plexus papilloma.We experienced a case of choroid plexus papilloma associated with fluid-electrolyte imbalance due to over-drainage after EVD, which could not be effectively controlled before tumor removal. Cautious fluid management and emergent surgical resection might be required to manage the overproduction of CSF and fluid-electrolyte imbalance. PMID:24257496

Saito, Atsushi; Nishimura, Shinjitsu; Fujita, Tomoaki; Sasaki, Tatsuya; Nishijima, Michiharu

2014-01-01

283

Automatic mesh adaptivity for CADIS and FW-CADIS neutronics modeling of difficult shielding problems  

International Nuclear Information System (INIS)

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)

284

Risk Factors and Complications Associated with Difficult Retrieval of Embolic Protection Devices in Carotid Artery Stenting  

International Nuclear Information System (INIS)

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 che retrieving time and increase the complications of the procedure.

285

Combined precut in difficult biliary cannulation / Precorte combinado en la canulación biliar difícil  

Scientific Electronic Library Online (English)

Full Text Available SciELO Spain | Language: English Abstract in english Aim: precut sphincterotomy refers to a variety of endoscopic techniques that are used in order to access the bile duct when conventional methods of cannulation have failed. There are not significant data (such as efficacy, safety) about the use of different techniques of precutting at the same sessi [...] on. We have described our experience with combined precut sphincterotomy (CPS) and we have compared our results to the use of an isolated precut. Patients and methods: we have performed 247 precuts of a total of 2.390 ERCPs. Patients were distributed according to the type of precut practiced: Needle-knife, transpancreatic and combined precut sphincterotomies. "Combined precut" consisted in performing first a transpancreatic sphincterotomy and, if the access was not achieved, then performing a needle-knife sphincterotomy in the same session. The data about safety and efficacy were prospectively collected. The complications were defined according to the consensus criteria. Results: we performed precutting techniques in 247 patients. Needle-knife, transpancreatic, and combined precuts were performed in 125 (6.9%), 74 (4.1%) and 48 (2.6%) patients, respectively. Bile duct cannulation was successful in 48 patients (100%) in the group of combined precut, 121 patients (96.8%) in the transpancreatic group, and 67 patients (90.5%) in the needle-knife group (p = 0.03). There were not differences in complications rates between the three groups. There was no pancreatitis in the combined precut group. The complications were successfully managed with conservative treatment. Conclusions: combined precut sphincterotomy seems to be a safe and successful technique in those cases of difficult bile duct cannulation.

Jesús, Espinel-Díez; Eugenia, Pinedo-Ramos; Luis, Vaquero-Ayala; Begoña, Álvarez-Cuenllas; Vanesa, Ojeda-Marrero.

2013-06-01

286

Automatic mesh adaptivity for CADIS and FW-CADIS neutronics modeling of difficult shielding problems  

Energy Technology Data Exchange (ETDEWEB)

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)

Ibrahim, A. M.; Peplow, D. E.; Mosher, S. W.; Wagner, J. C.; Evans, T. M. [Oak Ridge National Laboratory, P.O. Box 2008, Oak Ridge, TN 37831 (United States); Wilson, P. P.; Sawan, M. E. [University of Wisconsin-Madison, 1500 Engineering Dr., Madison, WI 53706 (United States)

2013-07-01

287

Exposure in difficult total knee arthroplasty using coronal tibial tubercle osteotomy.  

Directory of Open Access Journals (Sweden)

Full Text Available Exposure in a total knee arthroplasty can be challenging regardless of whether it is a difficult primary or a revision. Various techniques both proximal and distal to the patella have been described and implemented to gain exposure and improve knee flexion. When patella eversion is not possible due to previous surgery or severe preoperative knee flexion contracture, a coronal tibial tubercle osteotomy may be utilized. We present successful results utilizing the coronal tibial tubercle osteotomy procedure. The technique involved in this series is based on that described by Whiteside. It involves the development of a long lateral musculoperiosteal flap incorporating the tibial tubercle and anterior tibia, and leaving the proximal tibial cortex intact. This is extended along the tibia distally for 10 cm. It finishes by gradually osteotomising the anterior surface of the tibial crest. The tubercle is reattached with wires at the end of the procedure. This technique minimizes complications that have been associated with the tibial tubercle osteotomy. The 10 knees in 9 patients, who had total knee arthroplasty with a coronal tibial tubercle osteotomy, were reviewed pre and postoperatively. All knees were assessed using the Hospital for Special Surgery knee score (HSS. The scores averaged 43.6 preoperatively (range, 29 57 and 79.2 postoperatively (range, 67 90, and the mean range of motion was 59.5 degrees preoperatively and 78.0 degrees postoperatively. There were no cases of extension lag. Fixed flexion deformity was present in 3 cases postoperatively. Average time to union at the proximal and distal ends of the osteotomy was 8 and 24 weeks respectively. There was no evidence of nonunion and no other significant complications occurred.

Bruce WJ

2000-06-01

288

Difficult choices: infant feeding experiences of HIV-positive mothers in northern Tanzania.  

Science.gov (United States)

Infant feeding represents a great challenge in the prevention of mother-to-child transmission of HIV (pMTCT). The international guidelines informing infant feeding counselling suggest feeding methods that reduce the risk of HIV transmission, and discourage mixed feeding (combining breastfeeding with other fluids and solids). The feasibility and the social acceptability of the recommended feeding methods are hotly debated currently. Through the documentation of HIV-positive women's experiences, this article aims to provide empirically grounded knowledge on the relevance of the proposed feeding methods. Drawing upon cultural theory and a view of infant feeding practices as socially and culturally embedded, the article discusses the so-called 'informed choice' of infant feeding method among women enrolled in the pMTCT programme at Kilimanjaro Christian Medical Centre in northern Tanzania.The study is based on interviews and follow-up of 20 HIV-positive mothers during the last part of pregnancy, delivery and the first six months after birth. The article details four of these cases describing the challenges linked to exclusive breastfeeding, cow's milk feeding and formula feeding. The study demonstrates the gap between intentions and infant feeding practice in a context where the social expectations to breastfeed are high, and where kin and neighbours are part of the decision-making team surrounding infant feeding. It highlights the tension between the competing concerns of the medical and social risks involved in the choice of infant feeding method, and documents that the feeding options may be difficult to adhere to, whether a mother chooses exclusive breastfeeding or replacement feeding. PMID:18040533

Leshabari, S C; Blystad, A; Moland, K M

2007-05-01

289

Advertising and the internet: the difficult convergence Publicidade e internet: a difícil convergência  

Directory of Open Access Journals (Sweden)

Full Text Available Advertising and the internet: the difficult convergence — Ever since the crisis of Fordism, competition between companies has led to an increasingly fierce quest to draw the consumer's attention to advertisements, engendering what we call audience saturation resulting from the ubiquitousness of advertising. This saturation is aggravated as the rising costs of broadcasting in the mass media continually drive advertisers to seek new forms of addressing the consumer. In this context, it would be reasonable to expect the Internet to become a privileged route of access to the consumer. However, the Internet's relevance in traditional advertising is still negligible, at least in Brazil. This article strives to demonstrate this phenomenon, analyzing some recurring opinions in the advertising sector and explaining it in the light of an understanding of a broader advertising dynamics, thus contributing to the debate on the consequences of the advent of the Internet for the communication system and for culture. Desde a crise do fordismo, a concorrência entre as empresas tem se traduzido em uma busca ainda mais frenética pela atenção do consumidor às mensagens publicitárias, o que levou ao que chamamos aqui de saturação da audiência, isto é, a banalização dos anúncios diante da sua multiplicação. Essa saturação é agravada quando o aumento dos custos de veiculação nos meios de comunicação de massa estimula os publicitários a buscarem novas formas de interpelação do consumidor. Nesse cenário, não seria de esperar que a internet despontasse como uma rota privilegiada de acesso ao consumidor? No entanto, a sua relevância para a publicidade tradicional é pequena no Brasil. Pretendemos então demonstrar esse fato, analisar algumas opiniões recorrentes a esse respeito, dentro do campo publicitário, e explicá-lo à luz de uma compreensão da dinâmica publicitária mais abrangente. Nesse percurso, poderemos dar alguma contribuição ao debate sobre as consequências do advento da internet para o sistema de comunicação e a cultura.

Maria Eduarda da Mota Rocha

2009-09-01

290

Wire-guided (Seldinger technique) intubation through a face mask in urgent, difficult and grossly distorted airways  

OpenAIRE

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 ...

Heier, Jake M.; Schroeder, Kristopher M.; Galgon, Richard E.; Arndt, George A.

2012-01-01

291

Comparison of the glidescope, CMAC, storz DCI with the Macintosh laryngoscope during simulated difficult laryngoscopy: a manikin study  

OpenAIRE

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 laryngo...

Healy David W; Picton Paul; Morris Michelle; Turner Christopher

2012-01-01

292

Condition monitoring  

International Nuclear Information System (INIS)

This paper presents an alternative method for addressing aging of equipment in nuclear power plants. Condition monitoring is the term used for an empirical surveillance technique by which the damage caused by environmental stress imposed on equipment is periodically assessed. The assessment of existing damage versus the undamaged and failed conditions allows for extrapolation of remaining life. A discussion of currently used Arrhenius and statistical techniques used to calculate useful life and their relationship to condition monitoring is given in the paper. A simple example of the condition monitoring method and the advantages of the method are discussed

293

Difficult Decisions: Animal Rights--Do We Have the Right to Do Research on Animals?  

Science.gov (United States)

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)

Parakh, Jal S.; Slesnick, Irwin L.

1989-01-01

294

Condition numbers and scale free graphs  

OpenAIRE

In this work we study the condition number of the least square matrix corresponding to scale free networks. We compute a theoretical lower bound of the condition number which proves that they are ill conditioned. Also, we analyze several matrices from networks generated with the linear preferential attachment model showing that it is very difficult to compute the power law exponent by the least square method due to the severe lost of accuracy expected from the corresponding ...

Acosta, Gabriel; Gran?a, Mati?as; Pinasco, Juan Pablo

2006-01-01

295

Difficult-to-Treat or Resistant Hypertension: Etiology, Pathophysiology, and Innovative Therapies.  

Science.gov (United States)

Despite the many therapeutic options available today for the treatment of hypertension, a sizable number of patients still remain resistant to treatment. The prevalence of resistant hypertension in the general population under optimal conditions is about 3-5%. Although several factors and conditions can be identified and corrected a percentage of hypertensive patients remain with unacceptably high blood pressure levels. The high prevalence of hypertension in the general population renders this small percentage significant, in terms of actual patient numbers. This special issue of the journal expoars a whole spectrum of topics related to resistant hypertension: several articles address pathophysiolog and secondary causes of resistant hypertension and modern approaches to therapy. Of interest is the referance to the newer interventional approaches, that is, Baroreceptor stimulation therapy and catheter based sympathetic renal denervation. PMID:21822477

Papademetriou, Vasilios; Tsioufis, Konstantinos; Gradman, Alan; Punzi, Henry

2011-01-01

296

Experience with simulator training for emergency conditions  

International Nuclear Information System (INIS)

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

297

Brake assembly including torque monitor  

International Nuclear Information System (INIS)

This patent describes a brake assembly for selectively braking rotation of an input shaft extending from a control rod drive having a longitudinal centerline axis, the shaft being rotatable for selectively inserting and withdrawing a control rod in a nuclear reactor vessel. It comprises a stationary base; an annular bearing mounted to the base; a brake mounted to the bearing; a backing plate mounted to the bearing; a first braking pad fixedly joined to the backing plate; a rotor disc fixedly connected to the input shaft and disposed adjacent to the first pad; a second braking pad disposed adjacent to the rotor disc; and means for selectively clamping the first and second pads against the rotor disc for braking the input shaft; means for torsionally restraining the brake including: a pin extending outwardly from the backing plate toward the base; and a spring extending from the base to the pin and generally perpendicular to the centerline axis; and means for monitoring the angle for monitoring braking torque capability of the brake

298

Development of a detector system for measurement of contamination at places with difficult access  

International Nuclear Information System (INIS)

The objective of this research is the development and testing of the detector system for the measurement of very low-level radioactivity, even near background level, suitable for irregularly shaped surfaces like those inside small diameter tubes. The research carried out showed essential improvement of contamination measurements under real conditions (e.g. KRB-Gundremmingen, KKW-Biblis, ALKEM) by development of an integrated portable measuring device composed by a series of round and flat gas flow detectors

299

Trombosis venosa cerebral de difícil diagnóstico / Cerebral venous thrombosis of difficult diagnosis  

Scientific Electronic Library Online (English)

Full Text Available Introducción: La trombosis venosa cerebral, una enfermedad cerebro vascular rara, afecta fundamentalmente niños y mujeres en edad fértil. Caso clínico: Paciente de sexo femenino, 45 años de edad, evaluada en otro establecimiento de salud donde le diagnosticaron fiebre tifoidea, acudió a emergencia r [...] efiriendo un tiempo de enfermedad de 14 días, con cefalea frontal de moderada intensidad, náuseas y vómitos, fue hospitalizada por una probable hemorragia subaracnoidea. Al examen físico tenía funciones vitales estables y examen neurológico normal; la tomografia cerebral mostró edema cerebral difuso, la angiotomografía cerebral y resonancia magnética de encéfalo evidenciaron trombosis del seno sagital superior, transverso y sigmoide derecha. Los exámenes de analítica sanguínea fueron normales. Se diagnosticó trombosis venosa cerebral y se inició tratamiento antiedema cerebral y anticoagulación con heparina de bajo peso molecular y después con warfarina, siendo dada de alta sin compromiso neurológico. Discusión: La Trombosis venosa cerebral es una entidad rara y presenta síntomas inespecíficos; siendo el más frecuente la cefalea recurrente, persistente y refractaria al tratamiento, algunos casos son de díficil diagnóstico, el método diagnóstico de elección es la resonancia magnética en fase venosa y su tratamiento se realiza con anticoagulantes. Abstract in english Introduction: Cerebral venous thrombosis, rarely cerebrovascular disease, affects mainly children and women of childbearing age. Case report:. Female patient, 45 years of age, evaluated at another health center where she was diagnosed with typhoid fever, she went to emergency referring a time of ill [...] ness 14 days, with frontal headache of moderate intensity, nausea and vomiting, she was hospitalized with a probable subarachnoid hemorrhage. On physical examination, she had stable vital functions and normal neurological examination, brain tomography showed diffuse cerebral edema, cerebral angiography and MRI of the brain showed thrombosis of the sagittal sinus, transverse and sigmoid. Blood tests were normal. Cerebral venous thrombosis was the diagnosis and she was treated with antiedema cerebral and started anticoagulation with low molecular weight heparin and then with warfarin, after was discharged without neurological impairment. Discussion: Cerebral venous thrombosis is a rare entity and presents inespecific symptoms, the most frequent is persistent headache refractory to treatment, some cases are of difficult diagnosis, the diagnostic method of choice is MRI in venous phase and the treatment is with anticoagulants.

David, Lira; Nilton, Custodio; Eder, Herrera-Pérez; Liza, Núñez del Prado; Erik, Guevara-Silva; Sheila, Castro-Suárez; Rosa, Montesinos.

2014-04-01

300

Assessment of difficult laryngoscopy by electronically measured maxillo-pharyngeal angle on lateral cervical radiograph: A prospective study  

Directory of Open Access Journals (Sweden)

Full Text Available Background: Difficult airway continued to be a major cause of anesthesia-related morbidity and mortality. Successful airway management depends on direct laryngoscopy and tracheal intubation. Difficult laryngoscopy is a resultant of incomplete structural arrangements during the process of head positioning. Through clinical history,examination of the patients along with craniofacial indices alerts the anesthetist for difficult laryngoscopy. But it does not predict all causes of difficult laryngoscopy during pre-anesthetic evaluation. The maxillo-pharyngeal angle, an upper airway anatomical balance, was proposed for better understanding the pathophysiology of difficult laryngoscopy. In our study we have assess difficult laryngoscopy by electronically measuring maxillo-pharyngeal angles on a lateral cervical radiograph. This angle is normally greater than 100 o . Less than 90 o angle suggests either impossible or difficult direct laryngoscopy when all known craniofacial indices were within the normal range. Cervical radiographic assessment is a simple, economical, and non-invasive predictive method for difficult laryngoscopy. It should be used routinely along with other indices as pre-anesthetic airway assessment criteria to predict the difficult laryngoscopy. Context: Difficulties with airway management continue to be a major cause of anesthesia-related morbidity, mortality, and litigation. Pre-operative assessment of difficult laryngoscopy by the simple and non-invasive radiological method can help to prevent them. Aims: To assess the difficult laryngoscopy pre operatively by a simple and non invasive radiological method by electronically measuring maxillo-pharyngeal angle on a lateral cervical radiograph and it?s correlation with Cormack and Lehane grading. Settings and Design: This is a controlled, nonrandomized, prospective, cohort observation study. Patients and Methods: The 157 adult consented patients of ASA grade I to III of either sex, scheduled for elective surgery under general anesthesia with endo-tracheal intubation, were studied. The patients with identified difficult airway indices were excluded from the study. The maxillo-pharyngeal angle was electronically measured on a lateral cervical radiograph and was correlated with ease or difficulty of laryngoscopy under general anesthesia. Their degree of laryngeal exposure according to Cormack and Lehane classification grade was also noted. Statistical Analysis used: We performed univariate analyses to evaluate the association between the covariates and direct laryngoscopy. Results: In 148 patients (94.28%, the maxillo-pharyngeal angle was more than 100 o , in 7 patients (4.45% it was less than 90 o , and in 2 patients (1.27% the M-P angle was less than 85 o with normal craniofacial indices. When the MP angle was less than 90 o , the direct laryngoscopy was difficult which could be compared with to Cormack and Lehane classification grade III and IV. Conclusions: Lateral cervical radiographic assessment should be used as pre-anesthetic airway assessment criteria to predict the difficult laryngoscopy as it is a simple, safe and non-invasive method.

Gupta Kumkum

2010-01-01

301

Pediatric nail conditions.  

Science.gov (United States)

Pediatric nail findings are plentiful and can range from benign processes to the initial signs of a systemic condition. The examination of the nail is an essential part of the pediatric physical examination. The nail unit consists of the nail plate, the nail matrix, the hyponychium, the nail bed, and the surrounding nail folds. Conditions that affect the nail unit have a variety of etiologies; these include inflammatory, congenital, and hereditary conditions as well as tumors and trauma. This review describes many of the nail conditions that are seen in the pediatric population. PMID:24079585

Wulkan, Adam J; Tosti, Antonella

2013-01-01

302

Defining Child Exposure to Domestic Violence as Neglect: Minnesota's Difficult Experience  

Science.gov (United States)

Policymakers are increasingly focusing on children exposed to domestic violence. The 1999 Minnesota legislature amended the definition of child neglect to include a child's exposure to family violence. What was initially seen as a simple change to bring more attention to children exposed to domestic violence resulted in great turmoil across…

Edleson, Jeffrey L.; Gassman-Pines, Jenny; Hill, Marissa B.

2006-01-01

303

Tromboembolismo pulmonar e asma de difícil controlo / Pulmonary embolism and difficult-to-treat asthma  

Scientific Electronic Library Online (English)

Full Text Available SciELO Portugal | Language: Portuguese Abstract in portuguese O controlo da asma é um factor crucial na abordagem do doente: a mais recente actualização do GINA considera que uma "asma difícil de tratar" é uma asma para investigar. O não cumprimento da terapêutica, a DPOC concomitante, o tabagismo, a rinossinusite, o refluxo gastroesofágico e a obesidade são c [...] onsiderados os principais motivadores da asma difícil de controlar. O presente trabalho teve por objectivo avaliar o papel do tromboembolismo pulmonar (TEP) na asma grave de difícil controlo. Foram revistos os processos clínicos de doentes asmáticos da consulta de Alergologia Respiratória do nosso Serviço, entre 2004 e 2006, com asma "persistente grave" de acordo com o GINA 2005. Foram seleccionados os que, apesar de terapêutica optimizada, apresentavam asma "não controlada" (GINA 2006) e analisadas as suas causas. Dos 254 doentes estudados, 28 (11%) preenchiam os critérios de "asma persistente grave" (idade média 44±18 anos; 86% sexo feminino); destes, 57% (n=16) tinham doença "não controlada" - 35% (n=6) por má adesão à terapêutica; 29% (n=5) por TEP (confirmado gamagraficamente); 12% (n=2) por rinossinusite grave; 6% (n=1) por síndroma hipereosinofílica; 6% (n=1) por contacto mantido com alérgenos e 6% (n=1) em estudo. Os doentes com TEP (idade média 56±9 anos; 80% sexo feminino; 80% raça branca) tiveram o diagnóstico de asma na idade adulta (média 37 anos), tendo decorrido cerca de 18 anos até ao diagnóstico de TEP. A análise dos factores predisponentes para TEP revelou: insuficiência venosa periférica (40%), HTA (40%) e deficiência de proteína C e S funcionais (20%). Todos os doentes efectuaram terapêutica anticoagulante (80% ainda mantém), referindo-se que, após o início da anticoagulação, 40% dos doentes alcançaram o controlo da doença e 40% têm, actualmente, asma "parcialmente controlada", não se tendo verificado novos internamentos por agudização da doença. Os resultados do presente trabalho apoiam a inclusão do TEP no grupo de comorbilidades possivelmente responsáveis pelo mau controlo da asma. Abstract in english Asthma control is a key point in patient management. GINA’s most recent report emphasises the need to investigate uncontrolled asthma, of which non-compliance with treatment, COPD, smoking, chronic sinusitis, gastroesophageal reflux disease and obesity are the usual causes. The aim of this work is t [...] o evaluate the role of pulmonary thromboembolism (PTE) in cases of difficult-to-treat asthma. We reviewed the case reports of patients with severe persistent asthma followed in our Asthma Outpatients Clinic between 2004 and 2006. We selected the ones that maintained uncontrolled disease despite an optimal therapeutical approach and investigated the causes. In this group (n=254), 28 (11%) had severe persistent asthma and their mean age was 44 ± SD18 years old. 86% were females. Of these, 57% (n=16) had uncontrolled disease: 35% (n=6) due to non-compliance with treatment; 29% (n=5) pulmonary thrombombolism (scintigraphic confirmation); 12% (n=2) severe rhinosinusitis; 6% (n=1) hypereosinophilic syndrome; 6% (n=1) persistent allergen exposure and 6% (n=1) are still being investigated. Patients with TPE (mean age 56 ± SD9 years old; 80% females; 80% Caucasians) were diagnosed with asthma as adults (mean age 37 ± SD14 years old). The mean time until the diagnosis of TPE was 18 ± SD12 years. Predisposing factors for TPE were venous insufficiency (40%), hypertension (40%) and deficit of functional protein C and S (20%). All these patients received anticoagulant therapy (80% are still medicated). It should be noted that after the beginning of anticoagulants, 40% of the patients achieved control of their asthma and 40% have partially controlled disease. There were no hospital admissions for asthma exacerbations after the beginning of anticoagulation in this group. This study supports the inclusion of TPE in the group of comorbidities to consider while investigating u

Catarina Teles, Martins; Carlos, Lopes; Alda, Manique; Dolores, Moniz; Renato, Sotto-Mayor; A Bugalho de, Almeida.

2007-12-01

304

Hematuria de origen papilar o medular: entidad de difícil diagnóstico / Hematuria of papillary or medullar origin: a difficult diagnosis entity  

Scientific Electronic Library Online (English)

Full Text Available Objetivo: Los hemangiomas renales de origen papilar o medular renal, es una entidad de difícil diagnóstico, siendo una de las causas más frecuentes de episodios crónicos de hematuria, por patología benigna, fundamentalmente en pacientes jóvenes (1). El objetivo de esta presentación es mostrar la dif [...] icultad de este diagnóstico y la necesidad de sospecharlo en cuadros con historia similar a la que expresan estos casos. Métodos: Se presentan 4 casos de hematuria espontánea de origen renal, con expresión clínica de dolor cólico, de la serie histórica del Servicio de Urología de la Fundación Jiménez Díaz-Capio, los dos últimos del año 2005-6. Se presenta la metodología diagnóstica y terapéutica realizada, incluidos los estudios de angioTAC y la URS (ureterorenoscopia flexible), asi como diversas opciones de tratamiento. Resultado: La hematuria se identificó como "esencial" al descartar la relación responsable con patología tumoral o litiásica, y de origen renal al señalar claramente su origen. Se interpretó relacionada con angiomas o microangiomas de origen papilar o medular. En un caso la malformación vascular fue interpretada como FAV (fístula arteriovenosa) a ese nivel. Tras la URS exploradora, la hematuria cedió espontáneamente en dos casos. El caso histórico más antiguo requirió la exploración quirúrgica de las estructuras calicilares. Conclusión: Hace años y siguiendo el desarrollo profesional de la Especialidad de Urología, todos estos casos, de gran dificultad diagnóstica, eran sometidos a cirugía convencional, en muy pocas ocasiones con actitud conservadora, basada ésta en la exploración de las cavidades renales, intentando observar y encontrar el lugar del sangrado activo. La mayoría de los casos eran sometidos finalmente a Nefrectomía total o parcial. La posibilidad actual, de poder explorar las cavidades renales en su totalidad con el ureterorenoscopio flexible, permite un mejor diagnóstico de las lesiones y un tratamiento más conservador. El diagnóstico último de angioma renal papilar es anatomo-patológico, sin existir datos patogneumónicos de diagnóstico por la imagen Se piensa en esta patología, al final del proceso diagnóstico, y al identificar la zona papilar como origen del sangrado. La serie histórica de casos clinicos, con los hallazgos anatomo-patológicos de las nefrectomías realizadas, permite señalar la entidad, como angioma papilar, en pacientes con clínica similar. Abstract in english Objectives: Renal haemangiomas of renal papillary or medullar origin are a difficult diagnosis entity, being one of the most frequent processes of chronic episodes of hematuria, secondary to benign disease, mainly in young patients (1). The objective of this paper is to show the difficulty of this d [...] iagnosis and the need to suspect it in cases with clinical history similar to the ones described in these cases. Methods: We report 4 cases of spontaneous hematuria of renal origin, with clinical presentation as renal colic, from the historical case series of the Fundacion Jimenez Díaz - Capio, the last two from the years 2005-6. We present the diagnostic and therapeutic methodology employed, including angio-CT and flexible ureterorenoscopy (URS) as well as various treatment options. Results: Hematuria was identified as "essential" when any relation with tumor or lithiasic pathologies was ruled out, and of renal origin when the source was clearly pointed. We interpreted it was related to angiomas or microangiomas of papillary or medullar origin. In one case, the vascular malformation was interpreted as an arterial venous fistula (AVF) at that level. Hematuria stopped spontaneously in two cases after exploratory URS. The eldest historical case required surgical expiration of the caliceal structures. Conclusion: Years ago, following the professional development of Urology as speciality, conventional surgery was carried out in all these cases, of very difficult diagnosis, with a very small number of cases undergoing a conservative appr

Carmen, González Enguita; Jesús, Gómez Muñoz; Cristina, Martín Vivas; Leticia, López Martín; Luis Fernándo, Susanibar Napuri; Simona, Alexandro; Carlos, Caramelo Díaz; Remigio, Vela Navarrete.

2008-06-01

305

A Difficult Laparoscopic Cholecystectomy That Requires Conversion to Open Procedure Can Be Predicted by Preoperative Ultrasonography  

OpenAIRE

A prospective study was conducted from March 1999 to April 2000 that included 73 patients who underwent elective laparoscopic cholecystectomy for uncomplicated gallstone disease. The study was conducted at one surgical unit in the Department of Surgery and Department of Radio-diagnosis and one surgical unit in the Department of Surgery, Maulana Azad Medical College and the associated Lok Nayak Hospital, which is the largest referral hospital in northern India and is located in the capital of ...

Lal, Pawan; Agarwal, Pn; Malik, Vinod Kumar; Chakravarti, Al

2002-01-01

306

Bayesian Sampling using Condition Indicators  

DEFF Research Database (Denmark)

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 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. It is shown how half-cell potential measurements may be utilized to update the probability of excessive repair after 50 years.

Faber, Michael H.; SØrensen, John Dalsgaard

2002-01-01

307

Alternative method of inservice hydraulic testing of difficult to test pumps  

International Nuclear Information System (INIS)

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

308

Thermal Decomposition of HEs Included in Industrial Perforating Systems  

International Science & Technology Center (ISTC)

Predictive Model for Estimating the Effects Produced by Thermal Decomposition of HE Included in Perforating Systems of the Oil and Gas Industry on Their Normal Operation in Boreholes under Various Temperature and Time Conditions

309

Comparison of the glidescope, CMAC, storz DCI with the Macintosh laryngoscope during simulated difficult laryngoscopy: a manikin study  

Directory of Open Access Journals (Sweden)

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.

Healy David W

2012-06-01

310

German is not Necessarily more Difficult than English: Evidence from a comparison among English, German and Hanyu Pinyin  

OpenAIRE


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...

Wu, Jian-xiong Layout Editor

2007-01-01

311

Condition Monitoring and Diagnostics for Complex System using Neural Networks  

OpenAIRE

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 ...

Zhong Yang; Haifei Si; Hui Zhao

2013-01-01

312

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  

Directory of Open Access Journals (Sweden)

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.

Gruenbaum Shaun E

2012-04-01

313

Winning of the accompanying bed of the 2{sup nd} Lusatian seam horizon in the Welzow-Sued opencast mine under difficult geo-technical and technological conditions  

Energy Technology Data Exchange (ETDEWEB)

The lower accompanying bed of the 2{sup nd} Lusatian seam horizon contains an economically mineable coal reserve of about 9.5 million tonnes. About 9% of the present raw coal output of 20.5 million tonnes in the Welzow-Sued opencast mine come from the lower accompanying bed. This illustrates the importance of the carried out geo-technical and technological activities to mine about 2 million tonnes of coal extra per year with a low additional overburden removal and drainage. Wihtin the period of 1997 to 2000 instabilities of the slopes occurred at the pre- and the total dump which questioned the winning of the accompanying bed on a bench length of more than 1000 m. To be able to guarantee a safe mining of the coal, the following investigations were carried out: - specific geological face sampling, - sampling of the slickenside areas, - shear test series in the soil-physical laboratory, - analysis of laboratory tests and determination of calculation parameters, preparing of applicable calculation models, - soil-static alternatives investigations, - soil-mechanical target of necessary geometrical parameters in connection with - consultations, contributions and joint analyses with geologists, technologists and geo-technicians. The result was the so-called 'Supporting dam technology' - a solution that proved successfully in opencast mine operation for about two years. During this period, modifications and optimizations of the single geometrical and geo-technical parameters were carried out continuously to minimize the coal losses. (orig.)

Toelzer, B.; Meinig, H.J. [Lausitzer Braunkohle AG (LAUBAG), Senftenberg (Germany)

2002-12-01

314

 Evidence Based Surgery: How Difficult is the Implication in Routine Practice?  

Directory of Open Access Journals (Sweden)

Full Text Available  Surgery as a discipline has perhaps been slower than others pecialties to embrace evidence based principles. Today, surgeons all over Asia are prepared to challenge the dogma of yesterday. Surgical science which rests on a strong foundation of laboratory and clinical research can now be broadened to include the armamentarium of evidence based practice to advance surgical knowledge. The sheer volume of easily accessed information creates a new challenge. This article discusses keeping up with new information and finding the best available answers to specific questions amidst all the other information.

Namrata Maheshwari

2012-01-01

315

The portable Glostavent: a new anaesthetic machine for use in difficult situations.  

Science.gov (United States)

A portable version of the Glostavent anaesthetic machine is described in which recent developments in draw-over technology are incorporated into a traditional draw-over anaesthetic system. The additional features include a more efficient reservoir and an improved vaporiser which have enhanced the performance and versatility. The portable Glostavent weighs less than 10 kg and is transported in a container the size of a small suitcase. It can be used to provide inhalational anaesthesia safely and economically in situations where there are no support facilities. It is ideal for use in battlefield or disaster situations and in isolated hospitals in disadvantaged regions of the world. PMID:21226442

Tully, R; Eltringham, R; Walker, I A; Bartlett, A J

2010-11-01

316

phenix.mr_rosetta: a new tool for difficult molecular replacement problems  

Energy Technology Data Exchange (ETDEWEB)

The PHENIX development team is working with the Baker laboratory at the University of Washington to combine the power of Rosetta structure modeling with PHENIX automated molecular replacement (MR), model-building, density modification, and refinement. The basic idea is to find MR solutions with phenix. automr, rebuild them with Rosetta, including electron density map information, then rebuild those models with phenix. autobuild. The combination of Rosetta rebuilding and phenix rebuilding is the key part of this method. MR solutions are found with phenix. automr (Phaser), scored with LLG (optionally following Rosetta relaxation), the best solutions are picked and rebuilt with Rosetta including map information, the resulting models are scored with Rosetta, and then rescored with LLG, and the top models are rebuilt with phenix. autobuild. It can be very useful for cases where the search model used in molecular replacement is slightly too distant to rebuild successfully with phenix. autobuild. It can also be useful in cases where the model is too distant to even find a molecular replacement solution, and prerefinement with Rosetta can yield an improved search model.

Terwilliger, Thomas C [Los Alamos National Laboratory; Read, Randy [UNIV OF CAMBRIDGE; De Maio, Frank [UNIV OF WASHINGTON; Baker, David [UNIV OF WASHINGTON

2011-01-12

317

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)  

Energy Technology Data Exchange (ETDEWEB)

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)

Cordeiro Mendoca, K.

2004-05-15

318

[A case of primary unknown cancer difficult to distinguish from lung cancer].  

Science.gov (United States)

A 26-year-old man was admitted to our hospital with dyspnea, fever, and weight loss. A chest X-ray showed multiple tumor shadows, and a computed tomography (CT) scan showed swelling of the mediastinal and hilar lymph nodes, a mass in the retroperitoneum, and an embolus in the inferior vena cava. A biopsy from the left cervical lymph node revealeda poorly differentiated adenocarcinoma. Metastatic lung cancer was suspected, but in spite of the examinations, its primary site was unknown. Serum alfa-fetoprotein(AFP)was slightly elevated, but an AFP stain of the tumor was negative. The patient's respiratory failure rapidly worsened, and therefore, additional examinations could not be performed. The patient received chemotherapy with carboplatin and paclitaxel. His condition improved, but the tumor increased in size after 5 courses of chemotherapy. He received chemotherapy with docetaxel as second-line treatment, but it was not effective. The third-line chemotherapy regimen with carboplatin and gemcitabine was effective. In total, he received 7 lines of chemotherapy, and he lived for approximately 12 months since receiving the first chemotherapy regimen. After he died, we were able to perform OCT-4 immunohistochemistry on a tumor biopsy specimen from the lymph node, which came back positive for OCT-4. Therefore, we made a final diagnosis of extragonadal germ cell cancer syndrome. PMID:24917010

Tanaka, Yoko; Tago, Kentaro; Narabayashi, Tomoko; Sasaki, Yoshiaki; Iwahashi, Eriko; Hibino, Chihiro; Iwasaki, Teruo; Watanabe, Takahiro; Kasugai, Tsutomu; Kohama, Joji; Ohno, Kiyoshi

2014-05-01

319

Perforator-based forearm and hand adipofascial flaps for the coverage of difficult dorsal hand wounds.  

Science.gov (United States)

The author presents several case studies of alternative therapy for large and small dorsal hand and finger defects. These alternatives avoid the need for a lengthy free flap procedure, avoid the meticulous dissection required by the posterior interosseous flap, and avoid the loss of radial artery required by the reverse radial forearm flap. Distally based hand and forearm adipofascial flaps consist of the subcutaneous fat and fascia of the hand and/or forearm. They are easy to elevate, with operative times typically less than 2 hours, and can cover surfaces ranging from an individual finger to the entire dorsum of the hand. The blood supply is based on the rich profusion of perforators that exist in the hand and wrist. If desired, a skin paddle can be included with these flaps. These techniques are an important addition to the plastic and hand surgeon's armamentarium. PMID:11981186

Medalie, Daniel A

2002-05-01

320

Education and training in radiation protection: a challenge in passing on a difficult and intricate message  

International Nuclear Information System (INIS)

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)

321

Efficacy of single-layer continuous suture of the posterior wall in anastomosis involving a difficult location of the digestive tract.  

Science.gov (United States)

Surgery for digestive tract disease predominantly consists of reconstruction and anastomosis. Due to the difficult location, anastomosis is extremely challenging and the risk of complication increases accordingly. Traditional manual anastomosis and the application of a stapling device are insufficient. Therefore, the aim of this study was to investigate the feasibility and safety of a novel manual method in a difficult anastomotic location, consisting of a single-layer continuous suture in the posterior wall. In total, 15 beagle dogs were included in the study; eight underwent surgery with the novel manual method for reconstruction and anastomosis of the digestive tract, while seven underwent surgery with the stapler device as a control. The subsequent postoperative complications were observed and, three months later, the anastomotic ports were excised, and the pathological formation and morphological changes were evaluated. No statistically significant differences were identified between the total (50.0 vs. 57.1%; P=0.782) and anastomotic (0.0 vs. 28.6%; P=0.200) complication rates in the manual suture and staple suture groups, respectively. Compared with the control group, the operative expenditure was lower in the manual group (1726.7±33.5 vs. 2135.7±43.1 renminbi; P=0.001), the diameter of the anastomotic port was larger in the manual group (3.04±0.07 vs. 2.24±0.25 cm; P=0.004) and the thickness of the anastomotic port (in cm) was thinner in the manual group (2.94±0.06 vs. 5.07±0.85; P=0.002). Furthermore, the pathological formation of the anastomositic port in the manual group was improved. The results of the current study suggest single-layer continuous suture of the posterior wall in anastomosis of the digestive tract to be a novel method with feasibility and safety, particularly in difficult anastomotic locations. PMID:25202369

Li, Guo-Cai; Xu, Yong; Zhang, Yu-Chun; Zhang, Fang-Cheng; Wang, Qi; Ma, Qing-Jiu

2014-10-01

322

The palm print as a sensitive predictor of difficult laryngoscopy in diabetics: a comparison with other airway evaluation indices.  

Directory of Open Access Journals (Sweden)

Full Text Available AIMS: To evaluate the ink impression made by the palm of the dominant hand as a screening tool for difficult laryngoscopy in diabetic patients. SUBJECTS AND METHODS: In this prospective study, airway of 50 adult diabetic patients, undergoing elective surgery under general anaesthesia, was assessed preoperatively using the common clinical indices such as Modified Mallampati test, thyromental distance, degree of head extension and a specific index- the palm print test. Following induction of anaesthesia and neuromuscular relaxation, laryngoscopy was performed and the laryngoscopic view scored. The sensitivity, specificity and positive predictive value of each airway evaluation index were calculated. RESULTS: The incidence of difficult laryngoscopy was 16%. The palm print test had the highest sensitivity (75% of all the indices. The thyromental distance less than six cm had the highest specificity (95.2% but was least sensitive (25%. 87% of patients with difficult laryngoscopy had two or more indices abnormal. CONCLUSION: Though the palm print test was the most sensitive index of the four indices studied, a better prediction of difficult laryngoscopy can be achieved by evaluating all the four airway indices preoperatively.

Vani V

2000-04-01

323

Changes in Interest and Affect during a Difficult Reading Task: Relationships with Perceived Difficulty and Reading Fluency  

Science.gov (United States)

This study investigated changes in middle school students' interest and affect during a moderately difficult reading task. The aim was to explore how changes in interest (topic and situational) and affect were related to students' reading fluency throughout the task and perceived difficulty. Interest and affect were recorded at four time points:…

Fulmer, Sara M.; Tulis, Maria

2013-01-01

324

Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel-Feil syndrome.  

Science.gov (United States)

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

Bhat, Ravi; Mane, Rajesh S; Patil, Manjunath C; Suresh, S N

2014-07-01

325

Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel–Feil syndrome  

Science.gov (United States)

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

Bhat, Ravi; Mane, Rajesh S.; Patil, Manjunath C.; Suresh, S. N.

2014-01-01

326

Pseudotumoral autoimmune pancreatitis mimicking a pancreatic cancer: a very difficult disease to diagnose.  

Science.gov (United States)

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 20×20 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. PMID:24765479

Abid, Sandreddine Ben; Hefaiedh, Rania; Zghab, Sameh; Miloudi, Nizar; Gharbi, Lassad; Khalfallah, Mohamed Taher

2012-10-12

327

Pseudotumoral autoimmune pancreatitis mimicking a pancreatic cancer: a very difficult disease to diagnose  

Directory of Open Access Journals (Sweden)

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.

Nizar Miloudi

2012-10-01

328

Extubation of the perioperative patient with a difficult airway / Extubación del paciente perioperatorio con una vía aérea difícil  

Scientific Electronic Library Online (English)

Full Text Available Existe un volumen importante de literatura dedicada al tema del manejo de la vía aérea difícil, y se han desarrollado una serie de algoritmos y recomendaciones para el manejo seguro de pacientes en riesgo de una intubación difícil. Sin embargo, solo recientemente se ha despertado una mayor concienci [...] a acerca de la extubación de la vía aérea difícil, pues aun cuando sea un procedimiento programado, suele estar plagado de complicaciones. La importancia de desarrollar estrategias pre-programadas para la extubación de la vía aérea difícil 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 Auditoría del Reino Unido sobre complicaciones mayores en el manejo de la vía aérea. La clave para un manejo exitoso de los pacientes en riesgo de extubación difícil es efectuar una evaluación precisa de riesgo, aplicar estrategias apropiadas y la preparación tanto del médico como de la institución. 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.

Carin A., Hagberg; Carlos A., Artime.

2014-10-01

329

Jet grouting for a groundwater cutoff wall in difficult glacial soil deposits  

International Nuclear Information System (INIS)

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

330

Meniere?s disease: Still a mystery disease with difficult differential diagnosis  

Directory of Open Access Journals (Sweden)

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.

Vassiliou A

2011-01-01

331

Critical appraisal of pralatrexate in the management of difficult-to-treat peripheral T cell lymphoma  

Science.gov (United States)

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. PMID:22076116

Casanova, M; Medina-Pérez, A; Moreno-Beltran, M; Mata-Vazquez, M; Rueda, A

2011-01-01

332

Critical appraisal of pralatrexate in the management of difficult-to-treat peripheral T cell lymphoma  

Directory of Open Access Journals (Sweden)

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

Casanova M

2011-10-01

333

Inclusion-body myositis: a difficult diagnosis? / Miosite por corpos de inclusão: um diagnóstico difícil?  

Scientific Electronic Library Online (English)

Full Text Available A miosite por corpos de inclusão (MCI) esporádica é a miopatia mais comum acima dos 55 anos de idade. No entanto, em muitos casos, o diagnóstico é negligenciado. Os principais achados incluem fraqueza muscular progressiva, níveis séricos normais ou levemente elevados de creatinoquinase (CK) e ausênc [...] ia de resposta à imunossupressão. A biópsia muscular evidencia reação inflamatória associada com alterações degenerativas das fibras musculares. Apresentamos um caso típico de MCI cujo diagnóstico foi obtido após a realização de uma terceira biopsia muscular. Discutimos os desafios para a confirmação do diagnóstico histológico e os cuidados que podem evitar repetições do exame. Abstract in english Sporadic inclusion-body myositis (IBM) is the most common myopathy in individuals over 55 years of age. However, in many cases, the diagnosis is neglected. Its main findings include progressive muscle weakness, normal or low levels of serum creatine kinase, and the absence of a response to immunosup [...] pression. Muscle biopsy shows inflammatory reaction in association with degenerative changes of the muscle fibers. We report a typical case of IBM, in which diagnosis was possible only after three muscle biopsies. The challenges to confirm histological diagnosis and the caution to avoid repeating tests are discussed.

Carolina da Cunha, Correia; Maria Clara de Oliveira, Magalhães; Pedro Lucas de Mendonça, Barbosa; Eliene Dutra, Campos; Edmar, Zanoteli.

2014-10-01

334

Juvenile recurrent respiratory papillomatosis: still a mystery disease with difficult management.  

Science.gov (United States)

Juvenile recurrent respiratory papillomatosis (RRP) is the most common benign neoplastic disease of the larynx in children and adolescents and has a significant impact on patients and the health care system with a cost ranging from $60,000 to $470,000 per patient. The aim of this paper is to review the current literature on RRP and summarize the recent advances. RRP is caused by human papillomavirus (HPV; mainly by types 6 and 11). Patients suffer from wart-like growths in the aerodigestive tract. The course of the disease is unpredictable. Although spontaneous remission is possible, pulmonary spread and malignant transformation have been reported. Surgical excision, including new methods like the microdebrider, aims to secure an adequate airway and improve and maintain an acceptable voice. Repeated recurrences are common and thus overenthusiastic attempts to eradicate the disease may cause serious complications. When papillomas recur, old and new adjuvant methods may be tried. In addition, recent advances in immune system research may allow us to improve our treatment modalities and prevention strategies. A new vaccine is under trial to prevent HPV infection in women; the strongest risk factor for juvenile RRP is a maternal history of genital warts (transmitted from mother to child during delivery). Better understanding of the etiology of the disease and the knowledge of all available therapies is crucial for the best management of the affected patients. PMID:17022088

Stamataki, Sofia; Nikolopoulos, Thomas P; Korres, Stavros; Felekis, Dimitrios; Tzangaroulakis, Antonios; Ferekidis, Eleftherios

2007-02-01

335

Power Flow Study Including FACTS Devices  

OpenAIRE

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...

Thyagarajan, T.; Dash, S. S.; Sahoo, A. K.

2010-01-01

336

Peristomal skin complications are common, expensive, and difficult to manage : A population based cost modeling study  

DEFF Research Database (Denmark)

Background: Peristomal skin complications (PSCs) are the most common post-operative complications following creation of a stoma. Living with a stoma is a challenge, not only for the patient and their carers, but also for society as a whole. Due to methodological problems of PSC assessment, the associated health-economic burden of medium to longterm complications has been poorly described. Aim: The aim of the present study was to create a model to estimate treatment costs of PSCs using the standardized assessment Ostomy Skin Tool as a reference. The resultant model was applied to a real-life global data set of stoma patients (n = 3017) to determine the prevalence and financial burden of PSCs. Methods: Eleven experienced stoma care nurses were interviewed to get a global understanding of a treatment algorithm that formed the basis of the cost analysis. The estimated costs were based on a seven week treatment period. PSC costs were estimated for five underlying diagnostic categories and three levels of severity.The estimated treatment costs of severe cases of PSCs were increased 2-5 fold for the different diagnostic categories of PSCs compared with mild cases. French unit costs were applied to the global data set. Results: The estimated total average cost for a seven week treatment period (including appliances and accessories) was 263€ for those with PSCs (n = 1742) compared to 215€ for those without PSCs (n = 1172). A co-variance analysis showed that leakage level had a significant impact on PSC cost from 'rarely/never' to 'always/often' p

Meisner, S.; Lehur, P.-A.

2012-01-01

337

An online method for diagnosis of difficult TB cases for developing countries.  

Science.gov (United States)

Optimal use of limited human, technical and financial resources is a major concern for tuberculosis (TB) control in developing nations. Further impediments include a lack of trained physicians, and logistical difficulties in arranging face-to-face (f-2-f) TB Diagnostic Committee (TBDC) consultations. Use of e-Health for virtual TBDCs (Internet and "iPath"), to address such issues is being studied in the Philippines and Pakistan. In Pakistan, radiological diagnosis of 88 sputum smear negative but suspected TB patients has been compared with the 'gold standards' (TB culture, and 2-month clinical follow up). Of 88 diagnostic decisions made by primary physicians at the spoke site and electronic TBDC (e-TBDC) at hub site, there was agreement in 71 cases and disagreement on 17 cases. The turn-around time (TAT; patient registration at spoke site for f-2-f diagnosis to receiving the electronic diagnosis), averaged 34.6 hours; ranging 9 minutes to 289.2 hours. Average TAT at the rural site (59.15 hours) was more than the urban site (15.9 hours). Comparison of e-TBDC and f-2-f diagnosis with the gold standards showed only slight differences. Using culture as the gold standard, e-TBDC decisions showed greater accuracy (sensitivity - 32.4%) as compared to f-2-f (27.6%); using 2-month clinical follow-up as the gold standard, f-2-f diagnosis showed slightly better improvement in patient symptoms and weight as compared to e-TBDC. In Philippines "iPath" was trialed and demonstrated that e-TBDCs have potential. Such groups could review cases, diagnose, and write comments remotely, reducing the diagnosis and treatment delay compared to usual care. PMID:21335706

Marcelo, Alvin; Fatmi, Zafar; Firaza, Paul Nimrod; Shaikh, Shiraz; Dandan, Alvin Joseph; Irfan, Muhammad; Bari, Vaqar; Scott, Richard E

2011-01-01

338

Difficult decisions in times of constraint: Criteria based Resource Allocation in the Vancouver Coastal Health Authority  

Directory of Open Access Journals (Sweden)

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.

Dionne Francois

2011-07-01

339

Why is it difficult to implement e-health initiatives? A qualitative study  

Directory of Open Access Journals (Sweden)

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.

Wallace Paul

2011-01-01

340

The difficult patient: drug interaction and the influence of concomitant diseases on the treatment of hypothyroidism / O paciente difícil: interação entre drogas e influência de doenças concomitantes no tratamento do hipotiroidismo  

Scientific Electronic Library Online (English)

Full Text Available Embora a maior parte dos pacientes com hipotiroidismo fique bem com um único comprimido diário de tiroxina, aproximadamente 10% não ficam satisfeitos e outro importante grupo de pacientes apresenta controle difícil. Foram revistas as causas mais comuns para necessidades frequentes de ajuste de dose [...] ou uso de dose elevadas, incluindo falta de adesão à terapia e medicação inadequada. Descartando-se essas duas causas, é necessário investigar o uso de drogas e a presença de doenças concomitantes. Existe necessidade maior de tiroxina quando diminui a secreção ácida do estômago. Inibidores de bomba de prótons, antiácidos e uma longa lista de drogas podem dificultar a absorção da tiroxina. Várias doenças, incluindo a doença celíaca e as doenças intestinais inflamatórias crônicas, além dos hábitos alimentares, são importantes no controle do paciente hipotiroideo. Finalmente, foram mencionados os efeitos de uma lista crescente de drogas e disruptores que podem afetar o metabolismo tiroidiano em diferentes níveis. Abstract in english Although most hypothyroid patients do well with one single tablet of thyroxine daily, approximately 10% are dissatisfied and another important group of patients is difficult to control. We reviewed the most common causes for frequent-dose adjustment or high-dose requirement, including poor complianc [...] e with therapy and inadequate medication. Since these two causes have been ruled out, drug interaction and other concomitant diseases need to be investigated. Requirements of thyroxine increase in all conditions characterized by impaired gastric acid secretion. Proton-pump inhibitors, antacids and a long list of drugs may decrease thyroxine absorption. In addition, a series of diseases including celiac disease and chronic inflammatory intestinal diseases, as well as nutritional habits may be important in patient control. Finally, we mention the effects of a growing list of drugs and thyroid disruptors that may also affect thyroid hormone metabolism at many levels.

Laura S., Ward.

341

Including gauge corrections to thermal leptogenesis  

International Nuclear Information System (INIS)

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 in

342

Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step  

OpenAIRE

We report a case of prehospital “cannot intubate” and “cannot ventilate” scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20?min, because for each scenario, failed p...

Amp Me Sudrial, J. Amp R.; Caroline Birlouez; Anne-Laurette Guillerm; Jean-Luc Sebbah; Roland Amathieu; Gilles Dhonneur

2010-01-01

343

Ischemic Toes after Venous Thromboembolism: A Difficult Differential Diagnosis with Good Response to Combination Therapy—A Case Report  

OpenAIRE

The obliteration of the arterial vascular system of toes is considered as a potentially catastrophic event in clinical practices. In most instances, the cessation of arterial blood flow heralds a serious underlying pathology. A definite classification of some cases is somehow difficult and subject to diagnostic challenges. The aim of the present case study is to share and discuss potentially complex and multifactorial mechanisms of some acute vascular events. In this report, we deal with a 46...

Owlia, Mohammad Bagher; Salimzadeh, Ahmad; Alishiri, Gholmhossein; Kargar, Saeed

2012-01-01

344

Minimal deviation mucinous adenocarcinoma of the uterine cervix that proved difficult to differentiate from endometrial cancer: A case report  

OpenAIRE

Minimal deviation adenocarcinoma (MDA), also known as adenoma malignum of the uterine cervix, accounts for only ~1% of uterine cervical adenocarcinomas. Adenoma malignum of the uterine cervix was initially described by Gusserow in 1870. Using magnetic resonance imaging (MRI), MDA appears as multilocular lesions with solid components that extend from the endocervical glands to the deep cervical stroma. Cytological evaluation and biopsies have low detection rates, therefore, it is difficult to ...

Nishii, Yuko; Fukuda, Takeshi; Imai, Kenji; Yamauchi, Makoto; Hashiguchi, Yasunori; Ichimura, Tomoyuki; Yasui, Tomoyo; Sumi, Toshiyuki

2014-01-01

345

Convergent Syntheses of HuPrP106-126 (Difficult Sequence) Using Native Chemical Ligation and Desulfurization/Deselenization.  

Czech Academy of Sciences Publication Activity Database

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 ?R GA203/07/1517 Institutional research plan: CEZ:AV0Z40550506 Keywords : 4-thiazolidinecarboxylic acid * difficult sequences * prion diseases * displacement Subject RIV: CC - Organic Chemistry

Šebestík, Jaroslav; Šafa?ík, Martin; Zawada, Zbigniew; Hlavá?ek, Jan

346

3D seismic experiment in difficult area in Japan; Kokunai nanchiiki ni okeru sanjigen jishin tansa jikken  

Energy Technology Data Exchange (ETDEWEB)

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.

Minegishi, M.; Nakagami, K.; Tanaka, H. [Japan National Oil Corp., Tokyo (Japan). Technology Research Center

1997-05-27

347

To compare the accuracy of Prayer's sign and Mallampatti test in predicting difficult intubation in Diabetic patients  

International Nuclear Information System (INIS)

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)

348

[An example for a practice-oriented curriculum in social medicine under conditions of the new medical licensing regulations. Experiences with practiced-oriented teaching and possibilities for including practical issues in the teaching syllabus of medicine after the introduction of new medical licensing regulations].  

Science.gov (United States)

Experience with teaching medical students the subject of Social Medicine shows that their interest can be greatly improved by including practical issues such as interviewing chronically ill patients at home, or visiting patient counselling services in the community. With the introduction of the new licensing regulations for physicians, there will be only one final examination and the medical faculties will now have to conduct the examinations themselves. In order to create legal confidence in the results, sufficient homogeneity of the teaching syllabus in Vocational and Social Medicine courses as well as in the new Health Economics courses must be assured for all students. The merger of the two medical faculties of the Free University and the Humboldt University in Berlin have increased student numbers to 400 per semester, so that 20 groups will have to be taught simultaneously. This situation makes excursions to patients or to community facilities nearly impossible. Potential alternatives to allow inclusion of practical issues in the course, even under the new circumstances, are the use of problem-based learning techniques (PBL) such as the creation of theoretical cases dealing with special problems of Social Medicine or the use of standardised patients. PMID:15918123

Erler, A; Fuchs, J

2005-05-01

349

A difficult beginning  

OpenAIRE

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 c...

Suneth Agampodi; Sisira Siribaddana

2013-01-01

350

Transitions and difficult lessons.  

Science.gov (United States)

When it comes down to it, no job is permanent, unless of course one considers parenthood a job. From an employer perspective, employees are dispensable and they will someday no longer be needed. Are these harsh words or reality? Perhaps both. Sometimes a hard dose of reality is necessary to give one perspective or the opportunity to step back, look at the big picture, and find oneself again. Through this article, I hope to alert fellow occupational health nurses to the impermanence of employment. Rather than instill fear, I hope to encourage an openness to the possibilities of change and preparation for life beyond the current job. I am happy to report there is life (and light) on the other side. PMID:20415339

Litchfield, Sheila M

2010-04-01

351

Difficult Decisions: Euthanasia.  

Science.gov (United States)

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)

Parakh, Jal S.; Slesnick, Irwin L.

1992-01-01

352

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways.  

Science.gov (United States)

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 provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25-81]) years. The median (IQR [range]) Mallampati grade was 3 (2-3 [2-4]) and direct laryngoscopy grade was 3 (3-3 [2-4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9-19 [5-65]) min. No patient experienced arterial desaturation patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9-15.3]) kPa. The rate of increase in end-tidal carbon dioxide was 0.15 kPa.min(-1) . We conclude that THRIVE combines the benefits of 'classical' apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop-start process to a smooth and unhurried undertaking. PMID:25388828

Patel, A; Nouraei, S A R

2015-03-01

353

Ischemic Toes after Venous Thromboembolism: A Difficult Differential Diagnosis with Good Response to Combination Therapy—A Case Report  

Science.gov (United States)

The obliteration of the arterial vascular system of toes is considered as a potentially catastrophic event in clinical practices. In most instances, the cessation of arterial blood flow heralds a serious underlying pathology. A definite classification of some cases is somehow difficult and subject to diagnostic challenges. The aim of the present case study is to share and discuss potentially complex and multifactorial mechanisms of some acute vascular events. In this report, we deal with a 46-year-old man with a rather gradual-onset ischemia of his toe who responded favorably to a combination of pulsed glucocorticoid and anticoagulation within a week. PMID:22489242

Owlia, Mohammad Bagher; Salimzadeh, Ahmad; Alishiri, Gholmhossein; Kargar, Saeed

2012-01-01

354

Ischemic toes after venous thromboembolism: a difficult differential diagnosis with good response to combination therapy-a case report.  

Science.gov (United States)

The obliteration of the arterial vascular system of toes is considered as a potentially catastrophic event in clinical practices. In most instances, the cessation of arterial blood flow heralds a serious underlying pathology. A definite classification of some cases is somehow difficult and subject to diagnostic challenges. The aim of the present case study is to share and discuss potentially complex and multifactorial mechanisms of some acute vascular events. In this report, we deal with a 46-year-old man with a rather gradual-onset ischemia of his toe who responded favorably to a combination of pulsed glucocorticoid and anticoagulation within a week. PMID:22489242

Owlia, Mohammad Bagher; Salimzadeh, Ahmad; Alishiri, Gholmhossein; Kargar, Saeed

2012-01-01

355

Alternativas a la intubación orotraqueal ANTE UNA VÍA Aérea difícil en nuestro medio / Alternatives for the orotracheal intubation in case of a difficult airway in our environment  

Scientific Electronic Library Online (English)

Full Text Available Introducción: El control de la vía aérea en el quirófano es una responsabilidad del anestesiólogo, por lo que al finalizar su formación debe haber desarrollado las habilidades necesarias para atender esta exigencia. El control adecuado de la vía aérea para garantizar una correcta ventilación y oxige [...] nación no sólo es indispensable en muchos procedimientos anestésico-quirúrgicos sino también en todas aquellas situaciones en las que la función respiratoria está comprometida. En los últimos años se ha producido una proliferación de nuevos dispositivos y se han mejorado las técnicas antiguas de intubación y ventilación proporcionándonos una gran ayuda en el manejo de la vía aérea difícil. Objetivo: Evaluar el empleo de nuevos instrumentales para la intubación difícil. Desarrollo: Se realizó una revisión bibliográfica sobre los nuevos instrumentos para intubación difícil recién llegados a nuestro hospital como estilete luminoso, guía de Eschmann o gum elastic bougie, combitubo, con el fin de adquirir los elementos teóricos para aplicarlo en la práctica clínica. Conclusiones. De acuerdo a la experiencia con estos instrumentos y la literatura revisada, la primera opción es la utilización del combitubo, la guía de Eschmann o gum elastic bougie en segundo lugar y el estilete luminoso en tercer lugar. Abstract in english The anesthesiologist is responsible for the control of the airway in the operating theatre who ending its training must to have developed the skills necessary to manage this demand. The appropriate control of the airway to guarantee a proper ventilation and oxygenation not only is essential in many [...] anesthetic-surgical procedures but also in all those situations where the respiratory function is involved. In past years there has been appeared new devices and an improvement in past techniques of intubation and ventilation allowing us a great help in the management of this difficult airway. Objective: To assess the use of new tools for a difficult intubation. Development: A bibliographic review was carried out on the new tools for a difficult intubation now available in our hospital including a bright stylet, Eschmann's guide or gum elastic bougie, combitube to acquire the theoretical elements to be applied in the clinical practice. Conclusions: According to experience with these tools and the reviewed literature, the first option is the use of the combitube, the Eschmann guide or gum elastic bougie in the second place, and the bright stylet in the third one.

Antonio, Cárdenas González; Humberto, Fernández Ramos; José Antonio, Pozo Romero; Mayda, Correa Borrell.

2011-08-01

356

Secretory expression of Lentinula edodes intracellular laccase by yeast high-cell-density system: sub-milligram production of difficult-to-express secretory protein.  

Science.gov (United States)

While a number of heterologous expression systems have been reported for extracellular laccases, there are few for the intracellular counterparts. The Lentinula edodes intracellular laccase Lcc4 is an industrially potential enzyme with its unique substrate specificity. The heterologous production of the intracellular laccase, however, had been difficult because of its expression-dependent toxicity. We previously demonstrated that recombinant yeast cells synthesized and, interestingly, secreted Lcc4 only when they were suspended to an inducing medium in a high cell-density (J. Biosci. Bioeng., 113, 154-159, 2012). The high cell-density system was versatile and applicable to other difficult-to-express secretory proteins. Nevertheless, the system's great dependence on aeration, which was a practical obstacle to scale-up production of the enzyme and some other proteins, left the secretion pathway and enzymatic properties of the Lcc4 uncharacterized. In this report, we demonstrate a successful production of Lcc4 by applying a jar-fermentor to the high cell-density system. The elevated yield (0.6 mg L(-1)) due to the sufficient aeration allowed us to prepare and purify the enzyme to homogeneity. The enzyme had been secreted as a hyper-glycosylated protein, resulting in smear band-formations in SDS-PAGE. The amino acid sequencing analysis suggested that the N-terminal 17 residues had been recognized as a secretion signal. The recombinant enzyme showed similar enzymatic properties to the naturally occurring Lcc4. The characteristics of the scale-upped expression system, which includes helpful information for the potential users, have also been described. PMID:24411669

Kurose, Takeshi; Saito, Yuta; Kimata, Koichi; Nakagawa, Yuko; Yano, Akira; Ito, Keisuke; Kawarasaki, Yasuaki

2014-06-01

357

Conditional E-Cash  

Science.gov (United States)

We introduce a novel conditional e-cash protocol allowing future anonymous cashing of bank-issued e-money only upon the satisfaction of an agreed-upon public condition. Payers are able to remunerate payees for services that depend on future, yet to be determined outcomes of events. Once payment complete, any double-spending attempt by the payer will reveal its identity; no double-spending by the payee is possible. Payers can not be linked to payees or to ongoing or past transactions. The flow of cash within the system is thus both correct and anonymous. We discuss several applications of conditional e-cash including online trading of financial securities, prediction markets, and betting systems.

Shi, Larry; Carbunar, Bogdan; Sion, Radu

358

Difícil manejo do paciente com distonia segmentar respiratória / The difficult management of patients with respiratory segmental dystonia  

Scientific Electronic Library Online (English)

Full Text Available SciELO Brazil | Languages: English, Portuguese Abstract in portuguese A forma respiratória da distonia laríngea é rara, de difícil diagnóstico e provoca restrição respiratória de graus variados. O objetivo deste trabalho é apresentar um caso de distonia respiratória envolvendo laringe e faringe e sua evolução em relação à intensidade dos espasmos e seu controle. ESTUD [...] O DE CASO: Paciente de 24 anos, sexo masculino, acompanhado por 5 anos: diagnóstico por nasofibroscopia e eletromiografia e tratamento com toxina botulínica conforme necessidade de controle dos sintomas. CONCLUSÃO: O difícil manejo se deve ao fato do desconhecimento da etiologia e a pouca opção de tratamento, bem como do envolvimento da função respiratória. Abstract in english Respiratory dystonia is a rare and difficult to diagnose disorder, that causes breathing restriction of various degrees. The objective of the study is to report the case of a patient with respiratory dystonia involving the larynx and the pharynx and its evolution concerning spasms intensity and cont [...] rol. CASE REPORT: A 24 year-old-man has been followed for 5 years. The diagnosis was made by means of nasofibroscopy and electromyography. Treatment was carried out with laryngeal and pharyngeal Botulin toxin injections, as it became necessary for symptoms control. CONCLUSION: The difficult management can be secondary to the lack of knowledge on the etiology and physiopathology of the impairment, and because of the limitations in the treatment of associated respiratory symptoms.

Noemi Grigoletto De, Biase; Paulo Augusto de Lima, Pontes; Vanier, Santos Junior; Vanessa Pedrosa, Vieira; Priscila, Zambonato; Reinaldo Kazuo, Yazaki.

2007-04-01

359

A site-directed mutagenesis method particularly useful for creating otherwise difficult-to-make mutants and alanine scanning.  

Science.gov (United States)

Site-directed mutagenesis has become routine in molecular biology. However, many mutants can still be very difficult to create. Complicated chimerical mutations, tandem repeats, inverted sequences, GC-rich regions, and/or heavy secondary structures can cause inefficient or incorrect binding of the mutagenic primer to the target sequence and affect the subsequent amplification. In theory, these problems can be avoided by introducing the mutations into the target sequence using mutagenic fragments and so removing the need for primer-template annealing. The cassette mutagenesis uses the mutagenic fragment in its protocol; however, in most cases it needs to perform two rounds of mutagenic primer-based mutagenesis to introduce suitable restriction enzyme sites into templates and is not suitable for routine mutagenesis. Here we describe a highly efficient method in which the template except the region to be mutated is amplified by polymerase chain reaction (PCR) and the type IIs restriction enzyme-digested PCR product is directly ligated with the mutagenic fragment. Our method requires no assistance of mutagenic primers. We have used this method to create various types of difficult-to-make mutants with mutagenic frequencies of nearly 100%. Our protocol has many advantages over the prevalent QuikChange method and is a valuable tool for studies on gene structure and function. PMID:22001375

Wan, Haisu; Li, Yongwen; Fan, Yu; Meng, Fanrong; Chen, Chen; Zhou, Qinghua

2012-01-15

360

Sommerfeld radiation condition at threshold  

CERN Document Server

We prove Besov space bounds of the resolvent at low energies in any dimension for a class of potentials that are negative and obey a virial condition with these conditions imposed at infinity only. We do not require spherical symmetry. The class of potentials includes in dimension $\\geq3$ the attractive Coulomb potential. There are two boundary values of the resolvent at zero energy which we characterize by radiation conditions. These radiation conditions are zero energy versions of the well-known Sommerfeld radiation condition.

Skibsted, Erik

2011-01-01

361

Sommerfeld radiation condition at threshold  

DEFF Research Database (Denmark)

We prove Besov space bounds of the resolvent at low energies in any dimension for a class of potentials that are negative and obey a virial condition with these conditions imposed at infinity only. We do not require spherical symmetry. The class of potentials includes in dimension ? 3 the attractive Coulomb potential. There are two boundary values of the resolvent at zero energy which we characterize by radiation conditions. These radiation conditions are zero energy versions of the well-known Sommerfeld radiation condition.

Skibsted, Erik

2011-01-01

362

Investigação de fatores associados à asma de difícil controle / Investigation of factors associated with difficult-to-control asthma  

Scientific Electronic Library Online (English)

Full Text Available SciELO Brazil | Languages: English, Portuguese Abstract in portuguese OBJETIVO: Pesquisar a freqüência dos fatores associados à asma de difícil controle. MÉTODOS: Foram selecionados pacientes com diagnóstico de asma grave do ambulatório de asma do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. Os pacientes foram classificados em dois grupos: asma gr [...] ave controlada e asma grave de difícil controle. Após nova tentativa de otimização do tratamento para o grupo de difícil controle, foram aplicados questionário e investigação complementar de fatores associados, como exposição ambiental domiciliar e ocupacional, tabagismo, fatores sociais, rinossinusite, doença do refluxo gastroesofágico (DRGE), apnéia obstrutiva do sono, insuficiência cardíaca congestiva (ICC), embolia pulmonar, fibrose cística, disfunção de cordas vocais, deficiência de alfa-1 antitripsina e vasculite de Churg-Strauss. RESULTADOS: Foram selecionados 77 pacientes com asma grave, dos quais 47 apresentavam asma de difícil controle, sendo 68,1% do sexo feminino, idade média de 44,4 anos (±14,4) e volume expiratório forçado no primeiro segundo de 54,7% (±18,3%). Dos diagnósticos encontrados em associação à asma de difícil controle, o mais freqüente foi a pouca adesão ao tratamento (68%). Outros foram as más condições ambientais (34%) e ocupacionais (17%), rinossinusite (57%), DRGE (49%), apnéia obstrutiva do sono (2%), ICC (2%) e tabagismo (10%). Em todos os casos, pelo menos um desses fatores concomitantes foi diagnosticado. CONCLUSÕES: O fator mais freqüente associado à asma de difícil controle nos indivíduos estudados é a pouca adesão à medicação prescrita. A investigação de co-morbidades é imperativa na avaliação de pacientes com esta forma da doença. Abstract in english OBJECTIVE: To determine the prevalence of factors associated with difficult-to-control asthma. METHODS: Patients with severe asthma were selected from the outpatient asthma clinic of the Ribeirão Preto School of Medicine Hospital das Clínicas. The patients were divided into two groups: controlled se [...] vere asthma and difficult-to-control severe asthma. After new attempts to optimize the severe asthma treatment, a questionnaire was applied, and additional tests for factors associated with difficult-to-control asthma, such as environmental and occupational exposure, smoking history, social factors, rhinitis/sinusitis, gastroesophageal reflux disease (GERD), obstructive sleep apnea, congestive heart failure (CHF), pulmonary embolism, cystic fibrosis, vocal cord dysfunction, alpha-1 antitrypsin deficiency, and Churg-Strauss syndrome, were performed. RESULTS: 77 patients with severe asthma were selected, of which 47 suffered from hard-to-control asthma, being 68.1% female, with mean age of 44.4 years (±14.4), and forced expiratory volume in one second of 54.7% (±18.3). The most factors most often associated with difficult-to-control asthma were noncompliance with treatment (68%), rhinitis/sinusitis (57%), GERD (49%), environmental exposure (34%), occupational exposure (17%), smoking history (10%), obstructive sleep apnea (2%), and CHF (2%). At least one of these factors was identified in every case. CONCLUSIONS: Noncompliance with treatment was the factor most often associated with difficult-to-control asthma, underscoring the need to investigate comorbidities in the evaluation of patients with this form of the disease.

Ana Carla Sousa de, Araujo; Érica, Ferraz; Marcos de Carvalho, Borges; João, Terra Filho; Elcio Oliveira, Vianna.

2007-10-01

363

Investigação de fatores associados à asma de difícil controle Investigation of factors associated with difficult-to-control asthma  

Directory of Open Access Journals (Sweden)

Full Text Available OBJETIVO: Pesquisar a freqüência dos fatores associados à asma de difícil controle. MÉTODOS: Foram selecionados pacientes com diagnóstico de asma grave do ambulatório de asma do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. Os pacientes foram classificados em dois grupos: asma grave controlada e asma grave de difícil controle. Após nova tentativa de otimização do tratamento para o grupo de difícil controle, foram aplicados questionário e investigação complementar de fatores associados, como exposição ambiental domiciliar e ocupacional, tabagismo, fatores sociais, rinossinusite, doença do refluxo gastroesofágico (DRGE, apnéia obstrutiva do sono, insuficiência cardíaca congestiva (ICC, embolia pulmonar, fibrose cística, disfunção de cordas vocais, deficiência de alfa-1 antitripsina e vasculite de Churg-Strauss. RESULTADOS: Foram selecionados 77 pacientes com asma grave, dos quais 47 apresentavam asma de difícil controle, sendo 68,1% do sexo feminino, idade média de 44,4 anos (±14,4 e volume expiratório forçado no primeiro segundo de 54,7% (±18,3%. Dos diagnósticos encontrados em associação à asma de difícil controle, o mais freqüente foi a pouca adesão ao tratamento (68%. Outros foram as más condições ambientais (34% e ocupacionais (17%, rinossinusite (57%, DRGE (49%, apnéia obstrutiva do sono (2%, ICC (2% e tabagismo (10%. Em todos os casos, pelo menos um desses fatores concomitantes foi diagnosticado. CONCLUSÕES: O fator mais freqüente associado à asma de difícil controle nos indivíduos estudados é a pouca adesão à medicação prescrita. A investigação de co-morbidades é imperativa na avaliação de pacientes com esta forma da doença.OBJECTIVE: To determine the prevalence of factors associated with difficult-to-control asthma. METHODS: Patients with severe asthma were selected from the outpatient asthma clinic of the Ribeirão Preto School of Medicine Hospital das Clínicas. The patients were divided into two groups: controlled severe asthma and difficult-to-control severe asthma. After new attempts to optimize the severe asthma treatment, a questionnaire was applied, and additional tests for factors associated with difficult-to-control asthma, such as environmental and occupational exposure, smoking history, social factors, rhinitis/sinusitis, gastroesophageal reflux disease (GERD, obstructive sleep apnea, congestive heart failure (CHF, pulmonary embolism, cystic fibrosis, vocal cord dysfunction, alpha-1 antitrypsin deficiency, and Churg-Strauss syndrome, were performed. RESULTS: 77 patients with severe asthma were selected, of which 47 suffered from hard-to-control asthma, being 68.1% female, with mean age of 44.4 years (±14.4, and forced expiratory volume in one second of 54.7% (±18.3. The most factors most often associated with difficult-to-control asthma were noncompliance with treatment (68%, rhinitis/sinusitis (57%, GERD (49%, environmental exposure (34%, occupational exposure (17%, smoking history (10%, obstructive sleep apnea (2%, and CHF (2%. At least one of these factors was identified in every case. CONCLUSIONS: Noncompliance with treatment was the factor most often associated with difficult-to-control asthma, underscoring the need to investigate comorbidities in the evaluation of patients with this form of the disease.

Ana Carla Sousa de Araujo

2007-10-01

364

Diagnostics in low-temperature plasmas by laser spectroscopy: Expensive and difficult but worth all the trouble  

International Nuclear Information System (INIS)

In recent times, novel techniques and innovations of equipment have lead to a substantial improvement of laser spectroscopic diagnostics on low-temperature plasmas. This applies especially to the detection of charged species (electrons, positive and negative ions) and neutral radicals (atoms and molecules) as well as the measurement of electric fields. Spatially and temporally resolved measurements with high spectral resolution allow the non-invasive determination of a whole list of important parameters, e.g. temperature, density, velocity distribution, degree of dissociation, diffusion and reaction rates, sticking coefficients, voltages, currents etc. Available techniques are based generally either on scattering, absorption or fluorescence. Within this general frame a large variety of alternative schemes has been developed, especially in the case of multi-photon interaction. This sometimes confusing multitude of alternatives is necessary since as a matter of fact all schemes and techniques are limited to a certain parameter range and their applicability is determined strongly by the experimental conditions. The talk intends to give an overview on recent developments by introducing selected examples. This will include basic technical aspects as well as opportunities and limits of the interpretation of raw data for understanding the physics or chemistry of the discharge under investigation. An example is given below. The discharge presented was pulsed and for each pressure the decay of the relative density in the afterglow was traced by LIF. From the exponential part of the decay curve the decay time was determined by a least mean square fit. The non-linear behavior of the pressure scaling allows the determination of the chemical reaction rate for destruction of the radical in the discharge volume. Similar measurements on CF2 in the same discharge show that quite in contrast this radical is lost only by reaction at the reactor walls. (author)

365

Cancer of the Soft Tissue including Heart  

Science.gov (United States)

... soft tissue including heart cancer is 81.4%. Percent of Cases & 5-Year Relative Survival by Stage at Diagnosis: Soft Tissue including Heart Cancer Percent of Cases by Stage Localized (56%) Confined to ...

366

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

Science.gov (United States)

...proposed rule: AHRQ Agency for Healthcare Research and Quality BPM Benefit Policy Manual CABG Coronary artery bypass graft CBO Congressional...defined in the Medicare Pub. 100-02, Benefit Policy Manual (BPM), chapter 1, sections 10 and 120 and chapter 16,...

2011-02-17

367

Current Status of Newborn Screening: Decision-Making about the Conditions to Include in Screening Programs  

Science.gov (United States)

Newborn screening is considered a highly successful public health program that has resulted in the reduction of mortality, mental retardation, and other serious disabilities in thousands of children since the introduction of screening for phenylketonuria (PKU) in the 1960s. Programs are based in state public health departments such that each state…

Watson, Michael S.

2006-01-01

368

Rock mass evaluation for predicting tunnel constructability in the preliminary investigation stage. Phenomena causing difficult tunneling and rockburst prediction  

International Nuclear Information System (INIS)

For the selection of the Detailed Investigation Areas for HLW disposal, predicting the tunnel constructability is one of the requirements together with assessing long-term safety. This report is the 1st of the three papers dealing with the evaluation of tunnel constructability. This paper deals with the geological factors relating to difficult tunneling such as squeezing, rockburst, and others. Also it deals with the prediction of rockburst. The 2nd paper will deal with the prediction of squeezing. The 3rd paper deals with the engineering characteristics of rock mass through rock mass classification. This paper about difficult tunneling has been based upon analysis of more than 500 tunneling reports about 280 tunnel constructions. The causes of difficult tunneling are related to (1) underground water, (2) mechanical properties of the rock, or (3) others such as gas. The geological factors for excessive water inflow are porous volcanic product of Quarternary, fault crush zone and hydrothermally altered zone of Green Tuff area, and degenerated mixed rock in accretionary complex. The geological factors for squeezing are solfataric clay at Quarternary volcanic zone, fault crush zone and hydrothermally altered zone of Green Tuff area, mudstone and fault crush zone of sedimentary rock of Neogene and later. Information useful for predicting rockburst has been gathered from previous reports. In the preliminary investigation stage, geological survey, geophysical survey and borlogical survey, geophysical survey and borehole survey from the surface are the source of information. Therefore rock type, P-wave velocity from seismic exploration and in-situ rock stress from hydrofracturing have been considered. Majority of rockburst events occurred at granitic rock, excluding coal mine where different kind of rockburst occurred at pillars. And P-wave velocity was around 5 km/s at the rock of rockburst events. Horizontal maximum and minimum stresses SH and Sh have been tested as a criterion for rockburst. It has been inferred that SH - Sh > 30MPa is a good criterion for rockburst occurrence. When rock stress data is not available, continuous occurrence of borehole breakout is also a good indicator of rockburst. (author)

369

Human Rights promotion in Serbia: a difficult task for the European Union / A promoção dos Direitos Humanos na Sérvia: uma difícil missão para a União Europeia  

Scientific Electronic Library Online (English)

Full Text Available SciELO Brazil | Language: English Abstract in portuguese Este artigo explora o papel da União Europeia na proteção, implementação e promoção dos direitos humanos na Sérvia. Torna-se claro que as exigências da União Europeia em matéria de democratização na região dos Balcãs Ocidentais têm sido fundamentais também ao nível dos direitos humanos. Os direitos [...] humanos como parte dos critérios da política de condicionalidade da União Europeia são uma mensagem clara para os Estados que desejam a adesão. Contudo, o progresso da Sérvia nessa área tem se debatido com questões internas. Este paper visa analisar o processo de democratização da Sérvia no seu caminho para a União Europeia, e o seu progresso (ou não) no que se refere à proteção e implementação dos direitos humanos. Abstract in english This article explores the role of the European Union in the human rights protection, implementation and promotion in Serbia. It is clear that the EU demands on democratisation in the region of Western Balkans are crucial to achieve the respect for human rights. The human rights standards as part of [...] the conditionality criteria of the EU is a clear message towards the countries aspiring membership. However, Serbia progress in the field has been difficult due to several internal constraints. This paper aims to uncover the democratisation process of Serbia on its path towards the EU, and its progress (or not) regarding human rights protection and implementation.

Teresa Maria, Cierco.

370

Gross structure of resonance spectra (including bottomonium)  

International Nuclear Information System (INIS)

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. (orig.)

371

Conditions for supernovae driven galactic winds  

OpenAIRE

We point out that the commonly assumed condition for galactic outflows, that supernovae (SNe) heating is efficient in the central regions of starburst galaxies, suffers from invalid assumptions. We show that a large filling factor of hot ($\\ge 10^6$ K) gas is difficult to achieve through SNe heating, irrespective of the initial gas temperature and density, and of its being uniform or clumpy. We instead suggest that correlated supernovae from OB associations in molecular clou...

Nath, Biman B.; Shchekinov, Yuri

2013-01-01

372

Investigating a computerised test of the Stroop effect extended by inclusion of a third, more difficult task.  

Science.gov (United States)

A validation study of a computerised test recently developed involving the Stroop effect, extended here by inclusion of a third, more difficult test series, is presented. Three groups of men belonging to the Swedish armed forces and adjudged to differ in their qualifications (20, 32, and 19 men of levels 1, 2, and 3, respectively) and a fourth group of 18 men convicted of serious crimes of violence were given this test, termed the Stress Strategy Test. Discriminant analysis of the test's 12 variables (four for each of the three test series) yielded a discriminant power of 65% for the total group, highest for the level 1 group (80%) and for the nonmilitary group (72%), results substantially better than obtained for the original version of the test with use of similar subject groups. PMID:17566434

Federmann, Rolf; Goldsmith, Robert; Bäckström, Martin

2007-04-01

373

Behaviour of actinides and other radionuclides that are difficult to measure in the melting of contaminated steel  

International Nuclear Information System (INIS)

The research work carried out confirmed the expected homogeneous distribution of the radionuclides selected for the experiments (Fe 55 and Ni 63) in the metal ingot, as was already known from the behaviour of Co 60. The latter radionuclide may be used as an indicator nuclide for Fe 55 and Ni 63 which are both difficult to measure. C 14 also showed homogeneous distribution in the ingot (carbon steel). As expected for the melt technique strontium is released to the slag. In principle this is valid for actinides too, but depends to some extent on their chemical form (elemental uranium, UO2), the added tracer quantity and the quantity of slag forming material. A direct alpha-measurement technique has been developed for steel samples and may be suitable for free release measurements of alpha-emitting steel waste decontaminated by the melt technique

374

The ultrasound-assisted paraspinous approach to lumbar neuraxial blockade: a simplified technique in patients with difficult anatomy.  

Science.gov (United States)

Pre-procedural ultrasound imaging of the spine to identify the interspinous and interlaminar space has been shown to facilitate subsequent performance of lumbar neuraxial blockade. However, adequate visualization of the vertebral canal can be challenging for less-experienced operators, and particularly in subjects with difficult anatomy. In this case report, we describe a simplified technique of ultrasound-assisted neuraxial blockade that addresses these limitations and may thus be a useful fallback option. A pre-procedural scan is performed in which the main ultrasonographic landmarks to be identified are the neuraxial midline and the spinous processes, rather than the posterior and anterior complexes of the vertebral canal. Another key difference is the use of a paraspinous (or paramedian) needle approach rather than a midline approach that is advantageous where the interspinous spaces are narrowed by disease or suboptimal patient positioning. The anatomical basis and technical performance of this novel ultrasound-assisted paraspinous approach are presented in detail. PMID:25736612

Chin, K J; Perlas, A; Chan, V

2015-05-01

375

The Comparison of Mallampati Test in Supine and Sitting Position in Traditional Approach and During Phonation for Predicting of Difficult Laryngoscopy and Intubation  

Directory of Open Access Journals (Sweden)

Full Text Available Background: Inadequate ventilation, esophageal intubation and difficult intubation are the most common adverse respiratory outcomes in patient undergoing anesthesia .The aim of this study was to compare Mallampati test in supine and sitting positions in traditional approach and during phonation for predicting difficult laryngoscopy and intubation. Methods: In this study performed in Imam Khomeini Hospital in Tehran, Iran, Mallampati test was performed on 661 patients who met the inclusion criteria for the study. The test was done in supine and sitting positions with and without phonation by a rater who was blind to Mallampati test. Subsequently, laryngoscopy view and difficult intubation were evaluated in the four aforesaid positions by Mallampati test for predicting difficult laryngoscopy and intubation. For each situations, sensitivity, specificity, positive and negative predictive values and accuracy were calculated.Results: Overall, 28 (4.2% patients had difficult laryngoscopy and 9 (1.4% patients had difficult intubation. The highest sensitivity for Mallampati test in predicting difficult laryngoscopy and intubation was in supine and sitting positions without phonation, and the highest specificity was seen in sitting position with phonation. Negative predictive values were more than 95% in all different positions for Mallampati tests and the highest positive predictive value was seen in supine position with phonation.Conclusion: According to our findings, the highest correlation between Mallampati test and different positions in predicting difficult laryngoscopy and intubation was seen in supine position with phonation. Phonation improved Mallampati score in supine rather than sitting position.

A Meysamie

2012-09-01

376

Strong nucleosomes of mouse genome including recovered centromeric sequences.  

Science.gov (United States)

Recently discovered strong nucleosomes (SNs) characterized by visibly periodical DNA sequences have been found to concentrate in centromeres of Arabidopsis thaliana and in transient meiotic centromeres of Caenorhabditis elegans. To find out whether such affiliation of SNs to centromeres is a more general phenomenon, we studied SNs of the Mus musculus. The publicly available genome sequences of mouse, as well as of practically all other eukaryotes do not include the centromere regions which are difficult to assemble because of a large amount of repeat sequences in the centromeres and pericentromeric regions. We recovered those missing sequences using the data from MNase-seq experiments in mouse embryonic stem cells, where the sequence of DNA inside nucleosomes, including missing regions, was determined by 100-bp paired-end sequencing. Those nucleosome sequences, which are not matching to the published genome sequence, would largely belong to the centromeres. By evaluating SN densities in centromeres and in non-centromeric regions, we conclude that mouse SNs concentrate in the centromeres of telocentric mouse chromosomes, with ~3.9 times excess compared to their density in the rest of the genome. The remaining non-centromeric SNs are harbored mainly by introns and intergenic regions, by retro-transposons, in particular. The centromeric involvement of the SNs opens new horizons for the chromosome and centromere structure studies. PMID:24998943

Salih, Bilal F; Teif, Vladimir B; Tripathi, Vijay; Trifonov, Edward N

2015-06-01

377

Relación entre electroencefalograma y neuroimagen en niños con epilepsia focal de difícil control Relation between electroencephalogram and neuroimaging present in children with epilepsy of difficult control  

Directory of Open Access Journals (Sweden)

Full Text Available INTRODUCCIÓN. Las epilepsias focales son las más frecuentes en los niños, y la resistencia al tratamiento farmacológico puede estar presente hasta en el 30 % de los pacientes. Se realizó este estudio con el objetivo de dirigir la atención hacia la coincidencia topográfica de los paroxismos electroencefalográficos, con lesiones estructurales demostrables por neuroimagen, para facilitar el diseño de estrategias terapéuticas futuras. MÉTODOS. Se realizó un estudio descriptivo, longitudinal prospectivo, con 44 niños con diagnóstico de epilepsia focal de difícil control, ingresados en el Servicio de Neuropediatría del Hospital Pediátrico Docente «Juan M. Márquez», entre enero de 2003 y junio de 2007. Se realizaron estudios por electroencefalograma (EEG al ingreso y videoelectroencefalograma, además de estudios de neuroimagen por tomografía axial o resonancia magnética nuclear. RESULTADOS. Los paroxismos en EEG involucraron el lóbulo frontal hasta en el 68 % de los pacientes. En el 48 % de los pacientes, los paroxismos electroencefalográficos coinciden con zonas de alteración estructural según neuroimagen, más frecuentes en el lóbulo frontal. En el 25 % no hay coincidencia topográfica y en el 27 % no se precisan alteraciones estructurales. CONCLUSIONES. En las epilepsias focales de difícil control se debe prestar especial atención a las zonas elocuentes con coincidencia entre el EEG y la neuroimagen, para evaluar de forma temprana las alternativas quirúrgicas de tratamiento.INTRODUCTION: Focal epilepsies are the more frequent conditions in children and a pharmacologic treatment resistance could be present up to 30% of patients. Aim of present paper was to direct the attention to topographic coincidence of electroencephalographic paroxysms with structural lesions by neuroimaging facilitating the future therapeutical strategies design. METHODS: A descriptive, longitudinal, prospective study was conducted in 44 children diagnosed with epilepsy of difficult control admitted in Neuropediatrics Service of "Juán Manuel Márquez" Teaching Children Hospital from January, 2003 to June, 2007. At admission, we made electroencephalogram (EEG and videoelectroencephalogram (VEEG studies as well as neuroimaging studies by axial tomography (AT or nuclear magnetic resonance (NMR. RESULTS: Paroxysms in EEG involved frontal lobule up to the 68% of patients. In 48%, electroencephalographic paroxysms coincide with structural alteration zones according neuroimaging, more frequent in frontal lobule. In 25% there is not topographic coincidence, and in 27% there are not specified structural alterations. CONCLUSIONS: In focal epilepsies of difficult control, we must to take care of eloquent zones with coincident between EEG and neuroimaging to assess in time the surgical treatment options.

Ileana Valdivia Álvarez

2009-09-01

378

Conditional path sampling of stochastic differential equations by drift relaxation  

OpenAIRE

We present an algorithm for the efficient sampling of conditional paths of stochastic differential equations (SDEs). While unconditional path sampling of SDEs is straightforward, albeit expensive for high dimensional systems of SDEs, conditional path sampling can be difficult even for low dimensional systems. This is because we need to produce sample paths of the SDE which respect both the dynamics of the SDE and the initial and endpoint conditions. The dynamics of a SDE are...

Stinis, Panagiotis

2010-01-01

379

Composite Pressure Vessel Including Crack Arresting Barrier  

Science.gov (United States)

A pressure vessel includes a ported fitting having an annular flange formed on an end thereof and a tank that envelopes the annular flange. A crack arresting barrier is bonded to and forming a lining of the tank within the outer surface thereof. The crack arresting barrier includes a cured resin having a post-curing ductility rating of at least approximately 60% through the cured resin, and further includes randomly-oriented fibers positioned in and throughout the cured resin.

DeLay, Thomas K. (Inventor)

2013-01-01

380

Power Flow Study Including FACTS Devices  

Directory of Open Access Journals (Sweden)

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.

T. Thyagarajan

2010-01-01

381

Continuity of conditional expectations  

International Nuclear Information System (INIS)

A condition over a sequence {An} of ?-subalgebras that assures Lp-convergence of the conditional expectations will be given. This condition is more general than the Martingale theorem condition and the O'Reilly-Fetter condition. (author). 3 refs

382

Server-Side Includes Made Simple.  

Science.gov (United States)

Describes server-side include (SSI) codes which allow Webmasters to insert content into Web pages without programming knowledge. Explains how to enable the codes on a Web server, provides a step-by-step process for implementing them, discusses tags and syntax errors, and includes examples of their use on the Web site for Southern Illinois…

Fagan, Jody Condit

2002-01-01

383

Plant Condition Remote Monitoring Technique  

Science.gov (United States)

This paper summarizes the results of a radiation transfer study conducted on houseplants using controlled environmental conditions. These conditions included: (1) air and soil temperature; (2) incident and reflected radiation; and (3) soil moisture. The reflectance, transmittance, and emittance measurements were conducted in six spectral bands: microwave, red, yellow, green, violet and infrared, over a period of three years. Measurements were taken on both healthy and diseased plants. The data was collected on plants under various conditions which included: variation in plant bio-mass, diurnal variation, changes in plant pathological conditions (including changes in water content), different plant types, various disease types, and incident light wavelength or color. Analysis of this data was performed to yield an algorithm for plant disease from the remotely sensed data.

Fotedar, L. K.; Krishen, K.

1996-01-01

384

Endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones  

International Nuclear Information System (INIS)

Objective: To evaluate the effectiveness of endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones. Methods: A prospective non-randomized descriptive study was conducted at the Endoscopic Service of Surgical Unit 4, Civil Hospital Karachi over a period of 2 years from February 2007 to January 2009. A total of 84 patients where the biliary calculus was either greater than 15mm or difficult to remove with standard techniques underwent ERCP with endoscopic sphincterotomy and balloon sphincteroplasty. Patients with diagnosis of cholangitis or pancreatitis were excluded from the study. Endoscopic balloon dilatation was performed after standard sphincterotomy by using standard 15-18mm Controlled Radial Expansion (CRE) balloons. All procedures were done as day case under conscious sedation. Results: There were 18 (21.4%) male and 66 (78.6%) females. Age of the study population ranged from 16-85 years with a mean of 48.38 +- 17.07 years. The size of the stone ranged from 10-32mm with a mean of 14.7 +- 0.44mm. Stones were removed with sphincteroplasty in first session in 52/84 (61.9%) patients, 11/17 (64.4%) patients in the second session and 4/4 (100%) in the third session. Patients who were lost to follow up were 14(16.7%). Surgery was advised for 2 (2.4%) patients because of failure to remove stones by sphincteroplasty. Overall success of endoscopic sphincterotomy and large balloon dilatation in our stomy and large balloon dilatation in our study was 79.76%. Complications were seen in seven patients (8.3%) while one (1.2%) died. Bleeding was encountered in 3 (3.6%) patients which was controlled by adrenaline injection in 2 patients while one patient died due to severe haemorrhage before any surgical intervention could be undertaken. Moderate pancreatitis necessitating admission was seen in 3 patients (3.6%). None of the patients had severe pancreatitis or perforation secondary to the procedure. Conclusion: Large balloon dilatation along with endoscopic sphincterotomy is a simple, safe and effective technique in removing large bile duct stones, in patients with distal common bile duct narrowing or in whom the size of stone is greater than the size of common bile duct with a complication rate if not less equal to that of endoscopic sphincterotomy alone. (author)

385

Gibbs conditioning extended, Boltzmann conditioning introduced  

OpenAIRE

Conditional Equi-concentration of Types on I-projections (ICET) and Extended Gibbs Conditioning Principle (EGCP) provide an extension of Conditioned Weak Law of Large Numbers and of Gibbs Conditioning Principle to the case of non-unique Relative Entropy Maximizing (REM) distribution (aka I-projection). ICET and EGCP give a probabilistic justification to REM under rather general conditions. mu-projection variants of the results are introduced. They provide a probabilistic jus...

Grendar, Marian

2004-01-01

386

Endophytic bacteria in plant tissue culture: differences between easy- and difficult-to-propagate Prunus avium genotypes.  

Science.gov (United States)

The endophytic bacterial communities of six Prunus avium L. genotypes differing in their growth patterns during in vitro propagation were identified by culture-dependent and culture-independent methods. Five morphologically distinct isolates from tissue culture material were identified by 16S rDNA sequence analysis. To detect and analyze the uncultivable fraction of endophytic bacteria, a clone library was established from the amplified 16S rDNA of total plant extract. Bacterial diversity within the clone libraries was analyzed by amplified ribosomal rDNA restriction analysis and by sequencing a clone for each identified operational taxonomic unit. The most abundant bacterial group was Mycobacterium sp., which was identified in the clone libraries of all analyzed Prunus genotypes. Other dominant bacterial genera identified in the easy-to-propagate genotypes were Rhodopseudomonas sp. and Microbacterium sp. Thus, the community structures in the easy- and difficult-to-propagate cherry genotypes differed significantly. The bacterial genera, which were previously reported to have plant growth-promoting effects, were detected only in genotypes with high propagation success, indicating a possible positive impact of these bacteria on in vitro propagation of P. avium, which was proven in an inoculation experiment. PMID:24812040

Quambusch, Mona; Pirttilä, Anna Maria; Tejesvi, Mysore V; Winkelmann, Traud; Bartsch, Melanie

2014-05-01

387

Difficult cannulation: what should I do before EUS guided access? / Canulación difícil: ¿qué hacer antes de acceso guiado por EUS?  

Scientific Electronic Library Online (English)

Full Text Available SciELO Peru | Language: Spanish Abstract in spanish La canulación selectiva del conducto biliar común puede ser difícil por eso se han desarrollado diferentes estrategias para disminuir esta dificultad. La presente revisión analiza el uso de papilótomos diferentes en lugar del catéter estándar, la papilotomía con pre corte usando cuchillos o papilóto [...] mos, la septotomía papilar transpancreática y el uso de stents. La canulación biliar sigue siendo el factor más importante para considerar una ERCP como exitosa. Las indicaciones de accesos biliares alternativos y su uso es muy importante si esta falla. La punción suprapapilar es una técnica promisoria. Es importante tener en cuenta que la meta de todas las técnicas es disminuir la ocurrencia de pancreatitis aguda Abstract in english Selective cannulation of the common bile duct can be difficult, so multiple strategies have been developed to overcome the situation. In this review we analize the different strategies that can be used like different papillotome instead of the standard catheter, precut papillotomy using precut needl [...] e knives or precut papillotome, transpancreatic papillary septotomy, and stenting of the pancreatic duct. Bile duct cannulation remains an important benchmark of successful ERCP. Alternative biliary access indication and its use is very important If biliary cannulation remains unsuccessful.The suprapapillary puncture is a promissory technique. It´s important to have in mind that the goal of all techniques is to provide acute pancreatitis decrease

Everson L.A, Artifon; Renata N, Moura; Jose P, Otoch.

2014-01-01

388

Soft X-ray XANES of N in ZnO:N - Why is doping so difficult?  

International Nuclear Information System (INIS)

Soft X-ray absorption near-edge experiments (XANES) were carried out at the N K-edge for both as-grown and rapid thermal annealed epitaxial N-doped ZnO samples grown on both {112-bar 0} sapphire substrates and the (0001) face of ZnO single crystal substrates. Samples were grown by plasma-assisted MBE at a growth temperature of 450 deg. C using a solid Zn source and high-purity O2 and N2 RF radical sources. Calibrated secondary ion microscopy measurements demonstrated an as-grown N chemical concentration of approximately 1020 cm-3. The location in the ZnO lattice of N was determined in concert with first-principles real-space multiple scattering simulations. For as-grown samples, it was determined that N incorporates substitutionally on oxygen sites. It was found that a short 3min rapid thermal anneal to 800 deg. C resulted in the unambiguous formation of molecular nitrogen underscoring the metastable nature of substitutional nitrogen. High resolution XANES scans clearly matched those of a N2 gas standard. These results strongly suggest that while nitrogen can be incorporated in ZnO using metastable growth processes, the small activation barrier to the formation of molecular nitrogen will make it very difficult for nitrogen to be a dopant in actual device fabrication

389

42 CFR 493.839 - Condition: Chemistry.  

Science.gov (United States)

...2010-10-01 2010-10-01 false Condition: Chemistry. 493.839 Section 493.839 Public Health...Combination of These Tests § 493.839 Condition: Chemistry. The specialty of chemistry includes for the purposes of proficiency...

2010-10-01

390

42 CFR 493.821 - Condition: Microbiology.  

Science.gov (United States)

...2010-10-01 2010-10-01 false Condition: Microbiology. 493.821 Section 493.821 Public...of These Tests § 493.821 Condition: Microbiology. The specialty of microbiology includes, for purposes of proficiency...

2010-10-01

391

Long-term conditions.  

Science.gov (United States)

Technology enabled care services (TECS), which include technologies such as telehealth, telecare, telemedicine and self-care apps, are designed to help people manage long-term conditions and retain as much independence as possible. The NHS Commissioning Assembly has published TECS Resource for Commissioners, a toolkit that raises awareness of the range of TECS available and their benefits to patients and professionals, supports commissioners to collaborate with providers to implement TECS, and advises how to create a TECS strategy, oversee implementation plans and ensure effective evaluation. The publication is at tinyurl.com/khsebyr. PMID:25806457

2015-03-25

392

Pacific herring hearing does not include ultrasound  

OpenAIRE

Recent studies have shown that some clupeid fishes, including shad and menhaden, can detect ultrasound (sound with frequencies higher than 20?kHz) and actively avoid it. However, other clupeids, including sardines and anchovies, do not detect ultrasound. The hearing abilities of herring are of particular interest because of their commercial importance, our reliance on acoustics to monitor their populations and behavioural evidence of responses to high-frequency sound by some clupeid species...

Mann, David A.; Popper, Arthur N.; Wilson, Ben

2005-01-01

393

Gas storage materials, including hydrogen storage materials  

Science.gov (United States)

A material for the storage and release of gases comprises a plurality of hollow elements, each hollow element comprising a porous wall enclosing an interior cavity, the interior cavity including structures of a solid-state storage material. In particular examples, the storage material is a hydrogen storage material, such as a solid state hydride. An improved method for forming such materials includes the solution diffusion of a storage material solution through a porous wall of a hollow element into an interior cavity.

Mohtadi, Rana F; Wicks, George G; Heung, Leung K; Nakamura, Kenji

2014-11-25

394

Reporte de caso: anestesia espinal multimodal en paciente pediátrico con vía aérea difícil / Case report: Multimodal spinal anesthesia in a pediatric patient with a difficult airway  

Scientific Electronic Library Online (English)

Full Text Available SciELO Colombia | Language: Spanish Abstract in spanish Introducción: La anestesia espinal llevamás de 100 años en la práctica anestésica pediátrica. Actualmente viene aumentando su uso por ser eficaz, eficiente y segura. Se expone un caso exitoso en paciente con vía aérea difícil. Objetivo: Reportar un caso de anestesia espinal y sedación con remifentan [...] ilo, haciendo la revisión de la literatura incluyendo fármacos alfa 2 agonistas, para procedimientos locorregionales pediátricos. Métodos: Búsqueda bibliográfica relevante en las bases bibliográficas PubMed, MD consult y BIREME. Inicialmente se obtienen 306 artículos, seleccionando 23 considerados relevantes por los autores. Resultados: Se presenta el caso de un niño de un año de edad, con vía aérea difícil predicha por un hemangioma cavernoso en labio inferior, programado para corrección quirúrgica de pie chapín bilateral. Se administra anestesia espinal con bupivacaína hiperbárica 0,5% carbonatada 5mg y clonidina 30 1g(1,3 ml total), manteniendo sedoanalgesia 3-4/6 de Ramsay con remifentanilo 0,05-0,075 1g/kg/min, con oxígeno 50% por máscara facial y ventilación espontánea sin efectos adversos hemodinámicos o respiratorios. Conclusiones: La anestesia espinal es una alternativa ante una vía aérea difícil predicha. La clonidina (alfa 2 agonista) prolonga la duración del bloqueo sin complicaciones hemodinámicas o respiratorias. El remifentanilo para sedación en los procedimientos locorregionales pediátricos es de fácil titulación, con resultados predecibles. Abstract in english Introduction: Spinal anesthesia has been part of the pediatric anesthesia practice for more than 100 years. Its use has been increasing in recent years because of its effective-ness.efficiency and safety. We report a successful case in a patient with a difficult airway. Objective: To report a case o [...] f spinal anesthesia and sedation with remifentanil, together with a review of the literature including alpha 2 agonists for locoregional procedures in pediatrics. Methods: Search of relevant references in PubMed, MD consult and BIREME. The search resulted in 306 articles, and 23 considered relevant by the authors were finally selected. Results: We present a case of a 1-year-old boy with an expected difficult airway because of the presence of a cavernous hemangioma of the lower lip, scheduled for surgical correction of bilateral club foot. Spinal anesthesia consisted of 0,5% hyperbaric carbonated bupiva-caine plus 30 g of clonidine (1.3 ml total), maintaining sedation-analgesia at 3^1/6 on the Ramsay scale with remifentanil 0,05-0,075 g/kg/min, 50% oxygen with facial mask, and spontaneous ventilation, with no hemodynamic or respiratory adverse effects. Conclusions: Spinal anesthesia is an option in cases of predicted difficult airway. Clonidine (alpha 2 agonist) prolongs blockade with no hemodynamic or respiratory complications. Remifentanil used for sedation in pediatric locoregional procedures is easy to titrate with-predictable results.

William, Diaz Herrera; Hector Fidel, Osorio Zambrano; Miguel Francisco, Sandoval Cabrera.

2013-09-01

395

Consistent boundary conditions at nonconducting surfaces of planetary bodies: Applications in a new Ganymede MHD model  

Science.gov (United States)

The interaction of planetary bodies with their surrounding magnetized plasma can often be described with the magnetohydrodynamic (MHD) equations, which are commonly solved by numerical models. For these models it is necessary to define physically correct boundary conditions for the plasma mass and energy density, the plasma velocity, and the magnetic field. Many planetary bodies have surfaces whose electrical conductivity is negligibly small and thus no electric current penetrates their surfaces. Magnetic boundary conditions, which consider that the associated radial electric current at the planetary surface is zero, are difficult to implement because they include the curl of the magnetic field. Here we derive new boundary conditions by a decomposition of the magnetic field in poloidal and toroidal parts. We find that the toroidal part of the magnetic field needs to vanish at the surface of the insulator. For the spherical harmonics coefficients of the poloidal part, we derive a Cauchy boundary condition, which also matches a possible intrinsic field by including its Gauss coefficients. Thus, we can additionally include planetary dynamo fields as well as time-variable induction fields within electrically conductive subsurface layers. We implement the nonconducting boundary condition in the MHD simulation code ZEUS-MP using spherical geometry and provide a numerical implementation in Fortran 90 as supporting information on the JGR website. We apply it to a model for Ganymede's plasma environment. Our model also includes a consistent set of boundary conditions for the other MHD variables density, velocity, and energy. With this model we can describe Galileo spacecraft observations in and around Ganymede's minimagnetosphere very well.

Duling, Stefan; Saur, Joachim; Wicht, Johannes

2014-06-01

396

On boundary conditions in lattice Boltzmann methods  

International Nuclear Information System (INIS)

A lattice Boltzmann boundary condition for simulation of fluid flow using simple extrapolation is proposed. Numerical simulations, including two-dimensional Poiseuille flow, unsteady Couette flow, lid-driven square cavity flow, and flow over a column of cylinders for a range of Reynolds numbers, are carried out, showing that this scheme is of second order accuracy in space discretization. Applications of the method to other boundary conditions, including pressure condition and flux condition are discussed. copyright 1996 American Institute of Physics

397

On boundary conditions in lattice Boltzmann methods  

Science.gov (United States)

A lattice Boltzmann boundary condition for simulation of fluid flow using simple extrapolation is proposed. Numerical simulations, including two-dimensional Poiseuille flow, unsteady Couette flow, lid-driven square cavity flow, and flow over a column of cylinders for a range of Reynolds numbers, are carried out, showing that this scheme is of second order accuracy in space discretization. Applications of the method to other boundary conditions, including pressure condition and flux condition are discussed.

Chen, Shiyi; Martínez, Daniel; Mei, Renwei

1996-09-01

398

Survey of Macrofungi (including Truffles in Qatar  

Directory of Open Access Journals (Sweden)

Full Text Available Fourteen macrofungal genera belonging to 11 families and 7 orders were identified. These were isolated from different habitats (semi- desert, gardens, park, decayed roots of dead trees and under trees in Qatar. Macrofungi are defined here as ascomycetes and basidiomycetes with large, conspicuous spore-bearing structures that form above or beneath ground. This study indicated that the distribution of macrofungi is dependent on the plant community and the environmental conditions.

Roda F Al-Thani

2010-07-01

399

Initial Cladding Condition  

Energy Technology Data Exchange (ETDEWEB)

The purpose of this analysis is to describe the condition of commercial Zircaloy clad fuel as it is received at the Yucca Mountain Project (YMP) site. Most commercial nuclear fuel is encased in Zircaloy cladding. This analysis is developed to describe cladding degradation from the expected failure modes. This includes reactor operation impacts including incipient failures, potential degradation after reactor operation during spent fuel storage in pool and dry storage and impacts due to transportation. Degradation modes include cladding creep, and delayed hydride cracking during dry storage and transportation. Mechanical stresses from fuel handling and transportation vibrations are also included. This Analysis and Model Report (AMR) does not address any potential damage to assemblies that might occur at the YMP surface facilities. Ranges and uncertainties have been defined. This analysis will be the initial boundary condition for the analysis of cladding degradation inside the repository. In accordance with AP-2.13Q, ''Technical Product Development Planning'', a work plan (CRWMS M&O 2000c) was developed, issued, and utilized in the preparation of this document. There are constraints, caveats and limitations to this analysis. This cladding degradation analysis is based on commercial Pressurized Water Reactor (PWR) fuel with Zircaloy cladding but is applicable to Boiling Water Reactor (BWR) fuel. Reactor operating experience for both PWRs and BWRs is used to establish fuel reliability from reactor operation. It is limited to fuel exposed to normal operation and anticipated operational occurrences (i.e. events which are anticipated to occur within a reactor lifetime), and not to fuel that has been exposed to severe accidents. Fuel burnup projections have been limited to the current commercial reactor licensing environment with restrictions on fuel enrichment, oxide coating thickness and rod plenum pressures. The information provided in this analysis will be used in evaluating the post-closure performance of the Monitored Geologic Repository (MGR) in relation to waste form degradation.

E. Siegmann

2000-08-22

400

Initial Cladding Condition  

International Nuclear Information System (INIS)

The purpose of this analysis is to describe the condition of commercial Zircaloy clad fuel as it is received at the Yucca Mountain Project (YMP) site. Most commercial nuclear fuel is encased in Zircaloy cladding. This analysis is developed to describe cladding degradation from the expected failure modes. This includes reactor operation impacts including incipient failures, potential degradation after reactor operation during spent fuel storage in pool and dry storage and impacts due to transportation. Degradation modes include cladding creep, and delayed hydride cracking during dry storage and transportation. Mechanical stresses from fuel handling and transportation vibrations are also included. This Analysis and Model Report (AMR) does not address any potential damage to assemblies that might occur at the YMP surface facilities. Ranges and uncertainties have been defined. This analysis will be the initial boundary condition for the analysis of cladding degradation inside the repository. In accordance with AP-2.13Q, ''Technical Product Development Planning'', a work plan (CRWMS M andO 2000c) was developed, issued, and utilized in the preparation of this document. There are constraints, caveats and limitations to this analysis. This cladding degradation analysis is based on commercial Pressurized Water Reactor (PWR) fuel with Zircaloy cladding but is applicable to Boiling Water Reactor (BWR) fuel. Reactor operating experience for both PWRs and BWRs is used to establish fuel reliability from reactor operation. It is limited to fuel exposed to normal operation and anticipated operational occurrences (i.e. events which are anticipated to occur within a reactor lifetime), and not to fuel that has been exposed to severe accidents. Fuel burnup projections have been limited to the current commercial reactor licensing environment with restrictions on fuel enrichment, oxide coating thickness and rod plenum pressures. The information provided in this analysis will be used in evaluating the post-closure performance of the Monitored Geologic Repository (MGR) in relation to waste form degradation

401

ORGANIZATION OF MANUFACTURE WORK FOR STUDENTS WITH EASY DIFFICULT IN THEIR PSIHIC DEVELOPMENT IN SPECIAL ELEMENTARY SCHOOL “IDNINA”-SKOPJE  

OpenAIRE

Some of the students in the special elementary school are unable to continue their education in higher school, because of many objective reasons.Only from that reasons elementary school is the place for their education, working education, where they will have every possible condition for that.

Petrevski, Zlatko

2000-01-01

402

Methods for estimating the content of transuranium and other difficult to measure nuclides in produced rad waste from BWRs  

International Nuclear Information System (INIS)

During operation of nuclear power reactors a large number of radionuclides are produced. Some of them are difficult to measure. These are alpha or beta emitting radionuclides with weak or no gamma transition(s). A number of them, for instance some of the transuranium isotopes, may have significant radiological impact. It is of interest to be able to estimate the activity levels of these nuclides in the reactor systems. It is also of significant importance to estimate their content in produced waste packages and their radiological impact. In the report sources and source strengths for uranium and transuranium isotopes as well as for selected activated corrosion products are provided. Models for estimating the activity levels of these nuclides in the reactor systems and in different waste types are proposed. It is shown that the only significant source of uranium and transuranium nuclides is dispersion of fuel during operation of a reactor with defected and degrading fuel. The total amount of uranium on the core surfaces (tramp uranium), for a reactor in which no severe fuel failures have occurred, is about 0.5 g U, containing 2 % fissile material. During operation with defected fuel, up to 400 g U has been dispersed in the reactor water and distributed in the primary system during one single fuel cycle. Models for estimations of the amount of tramp uranium on the core surfaces during operation with no defected rods and the accumulation of uranium during operation with degrading fuel are provided. These models form the basis for consequence analyses of fuel failures and estimations of the amount of alpha emitting nuclides in different types of waste. 19 refs