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Sample records for conditions including difficult

  1. Full-face excavation of large tunnels in difficult conditions

    Giovanni Barla

    2016-06-01

    Full Text Available Following a few preliminary remarks on the tunneling methods at the beginning of the 20th century, the successful applications of the full-face method also in difficult conditions are underlined. The attention is posed on the use of a systematic reinforcement of the face and of the ground, by means of fiber-glass elements. A selection of tunnels where this method was used successfully is reported with the purpose of illustrating the wide spectrum of ground conditions where it has been applied. Then, following a description of the main concepts behind the method, the attention moves from the so-called “heavy method”, where deformations are restrained, to the “light method”, where deformations are allowed with the intention to decrease the stresses acting on the primary and final linings. The progress in the application of the “light method” is underlined, up to the development of a novel technique, which relies on the use of a yielding support composed of top head steel sets with sliding joints and special deformable elements inserted in the primary lining. The well-known case study of the Saint Martin La Porte access adit, along the Lyon-Turin Base Tunnel, is described. In this tunnel, a yield-control support system combined with full-face excavation has been adopted successfully in order to cope with the large deformations experienced during face advance through the Carboniferous formation. The monitoring results obtained during excavation are illustrated, together with the modeling studies performed when paying attention to the rock mass time-dependent behavior.

  2. Full-face excavation of large tunnels in difficult conditions

    Giovanni Barla

    2016-01-01

    Following a few preliminary remarks on the tunneling methods at the beginning of the 20th century, the successful applications of the full-face method also in difficult conditions are underlined. The attention is posed on the use of a systematic reinforcement of the face and of the ground, by means of fiber-glass elements. A selection of tunnels where this method was used successfully is reported with the pur-pose of illustrating the wide spectrum of ground conditions where it has been applied. Then, following a description of the main concepts behind the method, the attention moves from the so-called “heavy method”, where deformations are restrained, to the “light method”, where deformations are allowed with the intention to decrease the stresses acting on the primary and final linings. The progress in the application of the“light method”is underlined, up to the development of a novel technique, which relies on the use of a yielding support composed of top head steel sets with sliding joints and special deformable elements inserted in the primary lining. The well-known case study of the Saint Martin La Porte access adit, along the Lyon-Turin Base Tunnel, is described. In this tunnel, a yield-control support system combined with full-face excavation has been adopted successfully in order to cope with the large deformations experienced during face advance through the Carboniferous formation. The monitoring results obtained during excavation are illustrated, together with the modeling studies performed when paying attention to the rock mass time-dependent behavior.

  3. TAKRAF bucket wheel excavators for difficult operating conditions

    Harta, H.; Jurisch, H.

    1987-04-01

    Design, performance and technical specifications are explained for bucket wheel excavators, built by TAKRAF Lauchhammerwerk, GDR. The SRs (K) 2000 excavator (capacity 3000 m/sup 3//h, digging height 28 m) has been built since 1972 and operates in Ehkibastuz black coal surface mines at a temperature range of +/- 40 C. A total of nine such excavators are in operation, two more are being built. The SRs 2000 excavator (42 are in operation, 5 more are being built) operates in the Greek Ptolemais brown coal mine with 4000 m/sup 3//h capacity and at 30 m bench height. The SRs 4000 excavator (7600 m/sup 3//h capacity, 36 m digging height) is new and being assembled at Ptolemais and at Kansk-Achinsk. The largest excavation type is the SRs 6300 for 13,000 m/sup 3//h overburden removal. Smaller equipment includes the SRs 400 operating in the Austrian Oberdorf brown coal mine and also in Yugoslavia, among other places, the SRs 700 and the SRs 1500, the latter two being developed for hard, cohesive overburden, 17 to 22 m digging height and with 2400 to 3000 m/sup 3//h capacity. Photographs of excavators operating in various surface mines are provided. 3 refs.

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

    Sirvinskiene Giedre

    2012-04-01

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

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

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

    2008-05-15

    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.)

  6. Relationships between young people and labour market: a difficult condition in the Southern Italy

    De Santis M.

    2008-01-01

    This paper aims at identifying individual and family features that represent advantage or disadvantage factors in the participation of young people to labour market. In particular, the difficult condition of the Southern Italy is analysed. First, we will compare the participation of young people to labour market in Italy to the one of the main European countries. The European Union and its main countries represent a natural benchmark for the conditions of labour market in our country. Subsequ...

  7. Difficult asthma.

    Ahmet Uslu; Tülay Özdemir

    1989-01-01

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

  8. Consolidating the budget under difficult conditions: Ten guidelines viewed against Europe's beginning consolidation programme

    Aiginger, Karl; Schratzenstaller, Margit

    2011-01-01

    There is evidence that a budget consolidation strategy can work with only a small and shortlived negative impact on growth. However, many countries are currently trying to consolidate at the same time as firms and consumers are deleveraging. We develop ten guidelines for consolidation during such a difficult economic period and cross-check whether the upcoming consolidation programmes being implemented in the EU countries comply with our guidelines. We propose following a 'high road' on cutti...

  9. Adnexectomy Versus Ovarian Conservation During Total Hysterectomy for Benign Conditions. A Difficult Dilemma

    Ion Păun

    2014-09-01

    Full Text Available Introduction: Bilateral adnexectomy is a surgical procedure that is frequently associated with total hysterectomy performed for benign uterine conditions. Given the relatively wide range of indications for the aforementioned type of salpingo-ooforectomy which in it self is not devoid of potential risks the patients' and physicians' decision-making should take into account several parameters (most helpful to individualize treatment such as published ratio of removal versus conservation of uterine adnexae, patients' age, pre/postmenopausal status at the time of surgery, relevant family and personal history including current use of hormonal replacement therapy. Material and Method: This retrospective cohort study was conducted among 457 women aged 18 years or older who underwent abdominal total hysterectomies for benign uterine conditions between 2000 and 2011. The study patients were stratified by age for better characterization and according to recent publications. Results: Uni- or bilateral oophorectomy was performed in 50% of the subgroup of hysterectomized women younger than 35 years old whereas in the other half of the same age category of patients the uterine adnexas were conserved. Among the study patients aged between 35 and 45 years in 50.5% of the cases the unilateral type of oophorectomy was undertaken while for the other 49.5% of women the bilateral adnexectomy was the rule. Finally, in all patients older than age 45 years the bilateral salpingo-oophorectomy was the procedure of choice. Moreover, out of the 55 study patients in which at least one ovary was preserved, 30.9% of cases underwent the removal of the remaining adnexa when affected de novo by malignant (n=3 or benign (n=14 pathology. Last but not least, in order to reduce both cancer risks and early menopause hazards, our analysis based on recent literature attempted to identify patient characteristics (relevant factors associated with or without bilateral oophorectomy at the

  10. The difficult path of the Southern economy in 2000s and the conditions for development relaunching

    Bianchi L; Padovani R.

    2009-01-01

    Some months after the presentation of 2009 SVIMEZ's Annual Report on Mezzogiorno's economy, the analysis it proposes shows the dramatic effects of crisis in the South of Italy. Despite expectations, it was unavoidable since Mezzogiorno was in crisis before crisis would arise. Over 2009, then, anti-cyclical policies have been funded by resources allocated for South development, thus worsening the conditions of such regions. The reasons of breaking down a convergence trend, though very slight, ...

  11. Coping with difficult weather and snow conditions: Reindeer herders’ views on climate change impacts and coping strategies

    Minna T. Turunen

    2016-01-01

    Full Text Available Winter is a critical season for reindeer herding, with the amount and quality of snow being among the most important factors determining the condition of reindeer and the annual success of the livelihood. Our first aim was to model the future (2035–2064 snow conditions in northern Finland, especially the quantities related to ground ice and/or ice layers within the snow pack, exceptionally deep snow and late snow melt. Secondly, we studied the strategies by which herders cope with the impacts of difficult weather and snow conditions on herding by interviewing 21 herders. SNOWPACK simulations indicate that snow cover formation will be delayed by an average of 19 days and snow will melt 16 days earlier during the period 2035–2064 when compared to 1980–2009. There will be more frequent occurrence of ground ice that persists through the winter and the ice layers in open environments will be thicker in the future. The snow cover will be 26–40% thinner and snow in open environments will be denser. Variability between winters will grow. In interviews, herders indicated that a longer snowless season and thin snow cover would be advantageous for herding due to increased availability of forage, but more frequent icing conditions would cause problems. The most immediate reaction of reindeer to the decreased availability of forage caused by difficult snow conditions is to disperse. This effect is intensified when the lichen biomass on the pastures is low. To cope with the impacts of adverse climatic conditions, herders increase control over their herds, intensify the use of pasture diversity, take reindeer into enclosures and/or start or intensify supplementary feeding. The research also reveals that predators, competing land uses and the high prices of supplementary feed and fuel were the major threats to the herders’ coping capacity. Coping capacity was facilitated by, among other factors, the herders’ experience-based traditional knowledge

  12. Difficult thyroidectomies

    Pelizzo, M.R.

    2015-01-01

    The “difficult thyroidectomies” (DT) are motivated by several factors that, alone or in association with each other, make surgery more laborious and increase the related risks. Topographical, technical and anatomical criteria have been used by us to classify DT with a view to illustrating specific problems and suggesting appropriate strategies. According to topographical criteria we considered mediastinal goiter and resurgery; according to technical criteria we considered the presence of auto...

  13. Difficult thyroidectomies.

    Pellizzo, M R

    2015-01-01

    The "difficult thyroidectomies" (DT) are motivated by several factors that, alone or in association with each other, make surgery more laborious and increase the related risks. Topographical, technical and anatomical criteria have been used by us to classify DT with a view to illustrating specific problems and suggesting appropriate strategies. According to topographical criteria we considered mediastinal goiter and resurgery; according to technical criteria we considered the presence of auto-immune thyroiditis and locally advanced malignancies; on the basis of anatomical criteria, we considered the presence of "non recurrent" laryngeal nerve and of a pre-operatory vocal cord palsy. PMID:26017102

  14. Conquering the difficult airway.

    Gandy, William E

    2008-01-01

    Every medic should practice regularly for the inevitable difficult airway case. Practice should include review of the causes of difficult airways, as well as skill practice. Having a preassembled airway kit can make your response to an unexpected difficult situation easier. Of all the devices mentioned, the bougie is the airway practitioner's best friend. Using the BURP technique, if not contraindicated, together with the bougie will enable you to intubate many difficult patients with confidence. Remember, "If your patient cannot breathe, nothing else matters. PMID:18251307

  15. Conflict Management: Difficult Conversations with Difficult People

    Overton, Amy R.; Lowry, Ann C.

    2013-01-01

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

  16. Conflict management: difficult conversations with difficult people.

    Overton, Amy R; Lowry, Ann C

    2013-12-01

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

  17. The Physiologically Difficult Airway

    Jarrod M. Mosier

    2015-12-01

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

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

    Flouris, Triant; Walker, Thomas

    2005-01-01

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

  19. Preanalytical conditions that affect coagulation testing, including hormonal status and therapy

    BLOMBÄCK, M; Konkle, B A; Manco-Johnson, M. J.; Bremme, K.; HELLGREN, M; Kaaja, R.

    2007-01-01

    Preanalytical conditions, be they due to the individual's physiologic state or to exogenous factors, can affect coagulation factors, in either a transient or a persistent manner, and need to be considered in laboratory testing. These conditions include physical and mental stress, diurnal variation, hormone levels and posture at the time of blood drawing. While testing of these factors has not been exhaustive and some results are conflicting, guidelines for testing conditions can be given.

  20. Difficult wounds: an update.

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

    2005-01-01

    intraseptal connective tissue grafts. More recently, surgeons have repaired large septal perforations with a radial forearm free flap. Because of its availability and deep emotional significance, the skin is a common site for self-destructive behavior with the development of factitious skin wounds. When suspected, psychiatric care must proceed immediately. Second, the ulcer can then be healed by appropriate techniques and wound repair. It is important to emphasize that the treating physician must first confront the patient, and then a psychiatrist should provide appropriate psychotherapy. Hidradenitis suppurativa is an inflammatory disease of the skin and subcutaneous tissue that occurs in apocrine-gland-bearing areas distributed in the axilla, mammary nipple areola, mons pubis, groin, scrotum, perineum, perianal region, and umbilicus. The condition has an insidious onset. The susceptibility of women's axillary skin to hidradenitis suppurativa may be related, in part, to the practice of axillary removal of hair with a safety razor. Consequently, the use of safety razors must be avoided and replaced with the use of an electric razor. The method of treatment will vary with the stage of the disease. Treatment of the chronic stage of axillary hidradenitis suppurativa is primarily surgical. More recently, carbon dioxide laser treatment, with healing by secondary intention, is proving to be a rapid, efficient, and economic treatment of this difficult wound. PMID:16022640

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

    Åström, Peter

    2013-01-01

    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...

  2. A Three-Dimensional Thermal Model Including Thermal Boundary Conditions for High Power IGBT Modules

    Bahman, Amir Sajjad; Ma, Ke; Ghimire, Pramod;

    2016-01-01

    Accurate thermal dynamics of high power IGBT modules is important information for the reliability analysis and thermal design of the power electronics system. However, the existing thermal models have their limits to correctly predict these complicated thermal behaviors in the IGBTs: The typically...... used thermal model based on one-dimensional RC lumps have limits to provide temperature distributions inside the device, moreover some variable factors in the real-field applications like the cooling and heating conditions of converter cannot be adapted. On the other hand, the more advanced three...... the critical thermal distribution under long-term analysis. Meanwhile the boundary conditions for thermal analysis are modelled and included, which can be adapted to different real field applications of power electronic converter. Finally, the accuracy of the proposed thermal model is verified by both...

  3. Difficult conversations in orthopaedics.

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

    2015-01-01

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

  4. Difficult to control atopic dermatitis

    Darsow, U.; Wollenberg, A.; Simon, D; A. Taïeb; Werfel, T.; A. Oranje; C. Gelmetti; Svensson, A; Deleuran, M.; A. Calza; Giusti, F.; Lübbe, J; Seidenari, S; Ring, J.

    2013-01-01

    Difficult to control atopic dermatitis (AD) presents a therapeutic challenge and often requires combinations of topical and systemic treatment. Anti-inflammatory treatment of severe AD most commonly includes topical glucocorticosteroids and topical calcineurin antagonists used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, the topical calcineurin inhibitors tacrolimus and pimecrolimus are preferred...

  5. The Genus Aloe: Phytochemistry and Therapeutic Uses Including Treatments for Gastrointestinal Conditions and Chronic Inflammation.

    Cock, I E

    2015-01-01

    Plants of the genus Aloe have perhaps the longest recorded history of medicinal usage and are amongst the most widely used plants for traditional medicinal purposes worldwide. Aloe vera, Aloe ferox, Aloe arborescens and Aloe perryi are the best known and most widely used, but many other species are also used for their therapeutic properties. The Aloes have been used since ancient times, particularly for the treatment of microbial infections, gastrointestinal disorders and inflammatory conditions. In addition to their myriad uses in traditional therapeutics, the Aloes have also been used as components of cosmetic formulations, and in the food and beverage industries. Despite their wide acceptance, studies from different laboratories often report wide variations in the therapeutic bioactivities from within the same Aloe species, even when the same extraction procedures are used. Furthermore, leaves from individual Aloe plants within the same species may have widely varying levels of the bioactive phytochemicals. Phytochemical analyses have shown that many Aloe species contain various carbohydrate polymers (notably glucomannans) and a range of other low molecular weight phenolic compounds including alkaloids, anthraquinones, anthrones, benzene and furan derivatives, chromones, coumarins, flavonoids, phytosterols, pyrans and pyrones. There has been a wealth of information published about the phytochemistry and therapeutic potential of the Aloes (especially Aloe vera). Much of this has been contradictory. Intra- and interspecies differences in the redox state of the individual Aloe components and in the ratios of these components may occur between individual plants. These factors may all affect the physiological properties of Aloe extracts. Due to the structure and chemical nature of many of the Aloe phytochemicals, it is likely that many of the reported medicinal properties are due to antioxidant or prooxidant effects. The antioxidant/prooxidant activities of many Aloe

  6. Making marketing difficult

    Meyer, Gitte

    2005-01-01

    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...... 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 fulfil that 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....

  7. Management of difficult urticaria

    Yadav Sudha

    2009-01-01

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

  8. A difficult beginning

    Suneth Agampodi

    2013-10-01

    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!

  9. Upgrading during difficult times

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

  10. Difficult to control atopic dermatitis.

    Darsow, Ulf; Wollenberg, Andreas; Simon, Dagmar; Taïeb, Alain; Werfel, Thomas; Oranje, Arnold; Gelmetti, Carlo; Svensson, Ake; Deleuran, Mette; Calza, Anne-Marie; Giusti, Francesca; Lübbe, Jann; Seidenari, Stefania; Ring, Johannes

    2013-01-01

    Difficult to control atopic dermatitis (AD) presents a therapeutic challenge and often requires combinations of topical and systemic treatment. Anti-inflammatory treatment of severe AD most commonly includes topical glucocorticosteroids and topical calcineurin antagonists used for exacerbation management and more recently for proactive therapy in selected cases. Topical corticosteroids remain the mainstay of therapy, the topical calcineurin inhibitors tacrolimus and pimecrolimus are preferred in certain locations. Systemic anti-inflammatory treatment is an option for severe refractory cases. Microbial colonization and superinfection contribute to disease exacerbation and thus justify additional antimicrobial / antiseptic treatment. Systemic antihistamines (H1) may relieve pruritus but do not have sufficient effect on eczema. Adjuvant therapy includes UV irradiation preferably of UVA1 wavelength. "Eczema school" educational programs have been proven to be helpful. PMID:23663504

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

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

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

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

    2011-10-15

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

  13. LIHTC Difficult to Develop Areas

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

  14. Effective communication during difficult conversations.

    Polito, Jacquelyn M

    2013-06-01

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

  15. DIFFICULT AIRWAY IN THYROID SURGERY

    Cuello-Azcárate JJ

    2011-12-01

    Full Text Available Background: Thyroid surgery has been considered as a risk factor for the management of difficult airway.Method: We review the relevant literature related to the difficult airway and thyroid surgery.Comments: Endothoracic goiter, deformity of the airway, compression of the airway and thyroid cancer do not appear to have an influence on the difficulty for intubation.Classical parameters have a better predictive value: mouth opening less than 35 mm, Mallampati II-IV, short neck, neck movility less than 80 degrees, thyromental distance less than 60 mm, retrognathia, Cormack index III-IV, macroglossia, inability to protude the teeth and body mass index (BMI greater than 35 Kg/m2.Conclusions: According to the literature, thyroid disease does not increase the risk for a difficult airway (ventilation / intubation.The risk of an unexpected difficult airway (false negative cannot be eliminated.All patients must undergo an assessment of the airway

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

    Afanasyev, A.

    2011-12-01

    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

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

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

    2013-12-15

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

  18. Textpresso Site-Specific Recombinases: a text-mining server for the recombinase literature including Cre mice and conditional alleles

    Urbanski, William M.; Condie, Brian G.

    2016-01-01

    Textpresso Site Specific Recombinases (http://ssrc.genetics.uga.edu/) is a text-mining web server for searching a database of over 9000 full-text publications. The papers and abstracts in this database represent a wide range of topics related to site-specific recombinase (SSR) research tools. Included in the database are most of the papers that report the characterization or use of mouse strains that express Cre recombinase as well as papers that describe or analyze mouse lines that carry conditional (floxed) alleles or SSR-activated transgenes/knockins. The database also includes reports describing SSR-based cloning methods such as the Gateway or the Creator systems, papers reporting the development or use of SSR-based tools in systems such as Drosophila, bacteria, parasites, stem cells, yeast, plants, zebrafish and Xenopus as well as publications that describe the biochemistry, genetics or molecular structure of the SSRs themselves. Textpresso Site Specific Recombinases is the only comprehensive text-mining resource available for the literature describing the biology and technical applications of site-specific recombinases. PMID:19882667

  19. Overcoming difficult conversations in clinical supervision

    Williams B

    2016-06-01

    Full Text Available Brett Williams,1 Christine King,1 Tanya Edlington,21Department of Community Emergency Health and Paramedic Practice, Monash University, Franskton, VIC, 2The Conversation Clinic Pty Ltd, Melbourne, VIC, Australia Background: Clinical supervisors are responsible for managing many facets of clinical learning and face a range of challenges when the need for "difficult" conversations arises, including the need to manage conflict and relationships. Methods: Spotlight on Conversations Workshop was developed to improve the capacity of clinical supervisors to engage in difficult conversations. They were designed to challenge the mindset of clinical supervisors about difficult conversations with students, the consequences of avoiding difficult conversations, and to offer activities for practicing difficult conversations. Preworkshop, postworkshop, and 4-month follow-up evaluations assessed improvements in knowledge, intent to improve, and confidence along with workshop satisfaction. Results: Nine workshops were delivered in a range of locations across Victoria, Australia, involving a total of 117 clinical supervisors. Preworkshop evaluations illustrated that more than half of the participants had avoided up to two difficult conversations in the last month in their workplace. Postworkshop evaluation at 4 months showed very high levels of satisfaction with the workshop's relevancy, content, and training, as well as participants' intention to apply knowledge and skills. Also shown were significant changes in participants' confidence to have difficult conversations not only with students but also with other peers and colleagues. In follow-up in-depth interviews with 20 of the 117 participants, 75% said they had made definite changes in their practice because of what they learned in the workshop and another 10% said they would make changes to their practice, but had not had the opportunity yet to do so. Conclusion: We conclude that the Spotlight on

  20. Adenomyosis: Difficult to Diagnose, and Difficult to Treat

    Wood, C.

    2001-01-01

    Drug therapy may be effective in controlling symptoms but the frequent coexistence of endometriosis and the lack of controlled studies make their efficacy difficult to quantify. Danazol IUD has been shown to reduce symptoms. Conservative surgery involving endomyometrial ablation, laparoscopic myometrial electrocoagulation or excision has proven to be effective in more than 50% of patients, although follow up has been restricted to three years. Arterial uterine artery embolization is a new tec...

  1. Teaching Difficult Topics with Primary Sources

    Potter, Lee Ann

    2011-01-01

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

  2. 40 CFR 142.307 - What terms and conditions must be included in a small system variance?

    2010-07-01

    ... requirements, for the contaminant for which a small system variance is sought, as specified in 40 CFR part 141... included in a small system variance? 142.307 Section 142.307 Protection of Environment ENVIRONMENTAL... IMPLEMENTATION Variances for Small System Review of Small System Variance Application § 142.307 What terms...

  3. Maxillofacial Injury-Not Always a Difficult Airway.

    Glasheen, John; Hennelly, David; Cusack, Stephen

    2015-08-01

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

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

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

    1971-01-01

    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.

  5. Working in a difficult regime

    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

  6. Current Trends in the Management of Difficult Urinary Catheterizations

    Willette, Paul A.; Coffield, Scott K

    2012-01-01

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

  7. Dealing with the difficult utility

    STS HydroPower, Ltd. (STS) is an independent hydroelectric power developer involved in the full scope of hydroelectric activities. This includes the permitting, design, financing, turbine design and manufacturing, site construction and operation of small to mid-sized hydroelectric sites across the United States. At the present time, STS owns and operates nine sites in four states with a combined capacity of 20 megawatts. In dealing with the implementation of these sites, STS has dealt with five different utilities. In addition, in pursuing additional development opportunities throughout the United States, STS has had contact with numerous other utilities. During this time it would be fair to conclude that each of these utilities has exhibited its own personality with respect to dealing with independent developers. To the credit of the utility industry, the majority of these utilities have been helpful and supportive of independent projects, but a small number of utilities have approached projects from an initial and continuing adversarial position. The purpose of this paper is to examine those options and procedures available to the developer when a utility is encountered with a negative predisposition

  8. Parathyroid cancer - difficult diagnosis - a case report.

    Pyzik, Aleksandra Joanna; Matyjaszek-Matuszek, Beata; Zwolak, Agnieszka; Chrapko, Beata; Pyzik, Dawid; Strawa-Zakościelna, Katarzyna

    2016-01-01

    Parathyroid cancer is a rare disorder of unclear etiology that is difficult to diagnose and treat. It is most often diagnosed incidentally based on multi-organ non-specific symptoms of hypercalcemia as a consequence of parathyroid hormone oversecretion. We present a case of a male with primary hyperparathyroidism who was diagnosed with parathyroid cancer ectopically located in the mediastinum only after the third surgery. However, due to chronic hypercalcemia, problems with localization and a bad clinical condition, the patient was not able to undergo a radical resection and one year after the first pathological fracture died. Taking into consideration the whole clinical picture we want to emphasize the need to apply comprehensive differential diagnosis of hypercalcemia and localization diagnosis of parathyroid tissue with a use of MIBI scintigraphy accompanied by the computed tomography and magnetic resonance imaging, as the most specific diagnostic tools employed in this pathology. PMID:26838944

  9. Review article: Extubation of the difficult airway and extubation failure.

    Cavallone, Laura F; Vannucci, Andrea

    2013-02-01

    Respiratory complications after tracheal extubation are associated with significant morbidity and mortality, suggesting that process improvements in this clinical area are needed. The decreased rate of respiratory adverse events occurring during tracheal intubation since the implementation of guidelines for difficult airway management supports the value of education and guidelines in advancing clinical practice. Accurate use of terms in defining concepts and describing distinct clinical conditions is paramount to facilitating understanding and fostering education in the treatment of tracheal extubation-related complications. As an example, understanding the distinction between extubation failure and weaning failure allows one to appreciate the need for pre-extubation tests that focus on assessing airway patency in addition to evaluating the ability to breathe spontaneously. Tracheal reintubation after planned extubation is a relatively rare event in the postoperative period of elective surgeries, with reported rates of reintubation in the operating room and postanesthesia care unit between 0.1% and 0.45%, but is a fairly common event in critically ill patients (0.4%-25%). Conditions such as obesity, obstructive sleep apnea, major head/neck and upper airway surgery, and obstetric and cervical spine procedures carry significantly increased risks of extubation failure and are frequently associated with difficult airway management. Extubation failure follows loss of upper airway patency. Edema, soft tissue collapse, and laryngospasm are among the most frequent mechanisms of upper airway obstruction. Planning for tracheal extubation is a critical component of a successful airway management strategy, particularly when dealing with situations at increased risk for extubation failure and in patients with difficult airways. Adequate planning requires identification of patients who have or may develop a difficult airway, recognition of situations at increased risk of

  10. Biomarkers in the Management of Difficult Asthma.

    Schleich, Florence; Sophie, Demarche; Renaud, Louis

    2016-01-01

    Difficult asthma is a heterogeneous disease of the airways including various types of bronchial inflammation and various degrees of airway remodeling. Therapeutic response of severe asthmatics can be predicted by the use of biomarkers of Type2-high or Type2-low inflammation. Based on sputum cell analysis, four inflammatory phenotypes have been described. As induced sputum is timeconsuming and expensive technique, surrogate biomarkers are useful in clinical practice. Eosinophilic phenotype is likely to reflect ongoing adaptive immunity in response to allergen. Several biomarkers of eosinophilic asthma are easily available in clinical practice (blood eosinophils, serum IgE, exhaled nitric oxyde, serum periostin). Neutrophilic asthma is thought to reflect innate immune system activation in response to pollutants or infectious agents while paucigranulocytic asthma is thought to be not inflammatory and characterized by smooth muscle dysfunction. We currently lack of user-friendly biomarkers of neutrophilic asthma and airway remodeling. In this review, we summarize the biomarkers available for the management of difficult asthma. PMID:26467509

  11. Current Trends in the Management of Difficult Urinary Catheterizations

    Willette, Paul A.; Coffield, Scott

    2012-01-01

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

  12. The 'difficult' polyp: pitfalls for endoscopic removal.

    Jung, M

    2012-01-01

    Adenomatous polyps are early neoplasias of colorectal cancer (adenoma-carcinoma sequence). The majority of adenomas or early invasive cancers (T1sm1) can be resected by endoscopy. Endoscopic resection techniques include classic loop polypectomy, endoscopic mucosectomy with preceding lifting of the (almost flat) lesion, endoscopic submucosal dissection and transanal microsurgical resection, an alternative to endoscopic submucosal dissection in the rectum. Endoscopic polyp removal should always aim to resect the lesion in 'one piece' and avoid, whenever possible, 'piecemeal resection'. One-piece polypectomy is the basis for a precise histopathological analysis and for proving complete removal of the lesion. Preceding injection of saline solution into the submucosa to lift the targeted polyp is a therapeutic modality to remove even-flat and flat-depressed adenomas. In addition, a positive lifting sign is regarded as a criterion of lower superficial malignancy. Lifting of a polyp can be negatively influenced by an already advanced cancer (T1sm3/T2) in the deep parts of the submucosa as well as by scars and connective tissue in the upper two layers of the colorectal wall. Hence, a negative lifting sign may lead to incorrect macroscopic evaluation of the lesion before removal. Endoscopic submucosal dissection is mostly performed in large laterally spreading tumors in the rectum and in the preanal region. The technique has a relatively long learning curve and is somewhat time consuming. A 'difficult polyp' may be characterized by: (1) the size (>3 cm), pedunculated or sessile (Ip/Is); (2) morphological type (classification of Paris 2003), in particular the flat type II lesions IIa-c flat, flat depressed; laterally spreading tumors and the large sessile-serrated lesions; and (3) the difficult assessment of the grade of malignancy before removal [e.g. dysplasia-associated lesions or masses (DALMs), sporadic adenoma, colitis carcinoma]. Chromoendoscopy (with indigo carmine

  13. Predicting Difficult Laparoscopic Cholecystectomy Based on Clinicoradiological Assessment

    Udachan, Tejaswini V; Sasnur, Prasad; Baloorkar, Ramakanth; Sindgikar, Vikram; Narasangi, Basavaraj

    2015-01-01

    Introduction Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic cholelithiasis. However, of all Laparoscopic cholecystectomies, 1-13% requires conversion to an open for various reasons. Thus, for surgeons it would be helpful to establish criteria that would predict difficult laparoscopic cholecystectomy and conversion preoperatively. But there is no clear consensus among the laparoscopic surgeons regarding the parameters predicting the difficult dissection and conversion to open cholecystectomy. Aim To assess the clinical and radiological parameters for predicting the difficult laparoscopic cholecystectomy and its conversion. Materials and Methods This was a prospective study conducted from October 2010 to October 2014. Total of 180 patients meeting the inclusion criteria undergoing LC were included in the study. Four parameters were assessed to predict the difficult LC. These parameters were: 1) Gallbladder wall thickness; 2) Pericholecystic fluid collection; 3) Number of attacks; 4) Total leucocyte count. The statistical analysis was done using Z-test. Results Out of 180 patients included in this study 126 (70%) were easy, 44 (24.44%) were difficult and 3 (5.56%) patients required conversion to open cholecystectomy. The overall conversion rate was 5.6%. The TLC>11000, more than 2 previous attacks of cholecystitis, GB wall thickness of >3mm and Pericholecystic collection were all statistically significant for predicting the difficult LC and its conversion. Conclusion The difficult laparoscopic cholecystectomy and conversion to open surgery can be predicted preoperatively based on number of previous attacks of cholecystitis, WBC count, Gall bladder wall thickness and Pericholecystic collection. PMID:26816942

  14. Management of the difficult airway in children. A case report

    Magaly Álvarez Bárzaga

    2011-03-01

    Full Text Available The anesthesiologist plays a unique role in the health care of all patients who will undergo a surgical procedure. In this sense, he is a key factor in the appropriate and timely management of the airway. There are special situations that condition a difficult airway and can have a profound impact on anesthetic morbidity and mortality. These risks increases in the case of children, that is why the case of a pediatric patient with a difficult airway caused by limitation of mouth opening, scheduled for elective surgery in order to treat this condition in the Pediatric University Hospital ¨Paquito González Cueto " in Cienfuegos, is presented.

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

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

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

    Pruess, K.

    2011-05-15

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

  17. Single particle ICP-MS as a tool for determining the stability of silver nanoparticles in aquatic matrixes under various environmental conditions, including treatment by ozonation.

    Telgmann, Lena; Nguyen, Michael Thanh Khoa; Shen, Li; Yargeau, Viviane; Hintelmann, Holger; Metcalfe, Chris D

    2016-07-01

    Silver nanoparticles (AgNPs) are used in a large number of consumer products due to their antimicrobial and antifungal properties, and these materials may be discharged into municipal wastewater. Wastewater treatment, including advanced oxidation processes (AOPs), may modify the forms of silver in wastewater before they are discharged into surface waters. In addition, little is known about the changes in AgNPs that occur in natural waters under different environmental conditions. In this project, we utilized single particle ICP-MS (spICP-MS) and dynamic light scattering (DLS) analytical techniques to evaluate changes in the number and size of AgNPs in laboratory experiments with milliQ water under different environmental conditions, as well as during ozonation. Changes in the number and size of AgNPs determined by spICP-MS were evidence of altered stability of the nanoparticles. Increased rates of dissolution occurred under extremes of pH. Lower temperature decreased the rate of dissolution of AgNP relative to the dissolution in treatments at room temperature. The addition of chloride resulted in the loss of AgNPs from suspension due to agglomeration and precipitation. Ozonation led to a rapid decline in the number and size of AgNPs, as indicated by both spICP-MS and DLS analysis. An increase in the concentration of dissolved silver in the ozone treatments was evidence that changes in particle size were a result of oxidative dissolution of AgNPs to silver ion. Graphical abstract Single particle ICP-MS is used to evaluate dissolution of silver nanoparticles under different environmental conditions, including water treatment by ozonation. PMID:27311958

  18. Novel reinforcement learning approach for difficult control problems

    Becus, Georges A.; Thompson, Edward A.

    1997-09-01

    We review work conducted over the past several years and aimed at developing reinforcement learning architectures for solving difficult control problems and based on and inspired by associative control process (ACP) networks. We briefly review ACP networks able to reproduce many classical instrumental conditioning test results observed in animal research and to engage in real-time, closed-loop, goal-seeking interactions with their environment. Chronologically, our contributions include the ideally interfaced ACP network which is endowed with hierarchical, attention, and failure recognition interface mechanisms which greatly enhanced the capabilities of the original ACP network. When solving the cart-pole problem, it achieves 100 percent reliability and a reduction in training time similar to that of Baird and Klopf's modified ACP network and additionally an order of magnitude reduction in number of failures experienced for successful training. Next we introduced the command and control center/internal drive (Cid) architecture for artificial neural learning systems. It consists of a hierarchy of command and control centers governing motor selection networks. Internal drives, similar hunger, thirst, or reproduction in biological systems, are formed within the controller to facilitate learning. Efficiency, reliability, and adjustability of this architecture were demonstrated on the benchmark cart-pole control problem. A comparison with other artificial learning systems indicates that it learns over 100 times faster than Barto, et al's adaptive search element/adaptive critic element, experiencing less failures by more than an order of magnitude while capable of being fine-tuned by the user, on- line, for improved performance without additional training. Finally we present work in progress on a 'peaks and valleys' scheme which moves away from the one-dimensional learning mechanism currently found in Cid and shows promises in solving even more difficult learning control

  19. Difficult laryngoscopy made easy with a "BURP".

    Knill, R L

    1993-03-01

    Displacement of the larynx by backward, upward and rightward pressure on the thyroid cartilage or "BURP" may improve visualization of the glottis in some cases of difficult direct laryngoscopy. In a patient with the Treacher-Collins syndrome in whom conventional laryngoscopy had proved impossible and tracheal intubation extremely difficult, this manoeuvre exposed the entire glottis and made tracheal intubation under direct vision easy. In a patient with protruding upper incisors and a prominent premaxilla which precluded a view of the glottis by conventional laryngoscopy, "BURP" again revealed the glottic opening and simplified the placement of an endotracheal tube. This experience suggests that "BURP" be considered as a potential aid in the management of difficult direct laryngoscopy. PMID:8467551

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

    Veretelnikova Yu.Ya.

    2013-03-01

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

  1. Engaging Men in Difficult Dialogues about Privilege

    Loschiavo, Chris; Miller, David S.; Davies, Jon

    2007-01-01

    Male privilege is one aspect of social inequality that underlies much of the oppression and violence that occurs on college campuses. Mad Skills, a program addressing power and privilege with college men, is described along with general recommendations about how to engage men in difficult dialogues. The PIE Model is used to describe defensive…

  2. The difficult encounter between inspector and farmer

    Anneberg, Inger; Sørensen, Jan Tind; Vaarst, Mette

    2012-01-01

    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....

  3. Resistance, Reactance, and the Difficult Client.

    Dowd, E. Thomas; Sanders, Daniel

    1994-01-01

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

  4. Qualitative analysis of unanticipated difficult airway management

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

    2006-01-01

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

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

    Goodwin, Alan

    2003-01-01

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

  6. Qualitative analysis of unanticipated difficult airway management

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

    2006-01-01

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

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

    Radwanek-Bąk, Barbara; Nieć, Marek

    2014-05-01

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

  8. Why Evaluating Semantic Web Applications is Difficult

    Ossenbruggen, van, Jacco; Amin, Alia; Hildebrand, Michiel

    2008-01-01

    This position paper discusses our experience in evaluating our cultural search and annotation engine. We identify three aspects that determine the quality of a semantic web application as a whole, namely: the quality of data set, the quality of underlying search and inference software and the quality of the user interface. We argue that evaluation of semantic web applications is particularly difficult because of the strong interdependency between the three aspects.

  9. Listening: the most difficult skill to teach

    WALKER, Natasha

    2014-01-01

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

  10. Difficult treatment decisions in autoimmune hepatitis

    Albert; J; Czaja

    2010-01-01

    Treatment decisions in autoimmune hepatitis are complicated by the diversity of its clinical presentations,uncertainties about its natural history,evolving opinions regarding treatment end points,varied nature of refractory disease,and plethora of alternative immu-nosuppressive agents. The goals of this article are to review the difficult treatment decisions and to provide the bases for making sound therapeutic judgments. The English literature on the treatment problems in au-toimmune hepatitis were identif...

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

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

    2013-01-01

    discrete groundwater inflow supports streamflow during low-flow conditions along the entire 18-kilometer stream reach. Concentrations of dissolved selenium within all subreaches of Toll Gate Creek exceeded the Colorado aquatic-life standard of 4.6 micrograms per liter in 2007. Concentrations of selenium in the upper portion of the Toll Gate Headwaters subreach (TGH) remained close to the aquatic-life standard at about 5 micrograms per liter. Downstream from a concrete-lined channel section, inflows with selenium concentrations greater than the stream contribute selenium load to surface water. However, stream selenium concentrations were less than 20 micrograms per liter all along Toll Gate Creek. Concentrations of selenium in groundwater were in general substantially greater than the Colorado aquatic-life standard of 4.6 micrograms per liter and at some locations were greater than the U.S. Environmental Protection Agency primary drinking-water standard for selenium of 50 micrograms per liter. The distribution of selenium concentrations in groundwater, springs, and the 11 inflows with the greatest selenium concentrations indicates that shallow groundwater in surficial materials and the Denver Formation bedrock is a source of selenium loading to Toll Gate Creek and that selenium loading is distributed along the entire length of the study reach downstream from the concrete-lined channel. Water-quality and solids-sampling results from this study indicate weathering processes release water-soluble selenium from the underlying Denver Formation claystone bedrock with subsequent cycling of selenium in the aquatic environment of Toll Gate Creek. Exposure of the Denver Formation selenium-bearing bedrock to oxidizing atmospheric conditions, surface water, and groundwater, oxidizes selenide, held as a trace element in pyrite or in complexes with organic matter, to selenite and selenate. Secondary weathering products including iron oxides and selenium-bearing salts have accumulated in

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

    Veretelnikova Yu.Ya.; Chernyshkova E.V.; Belyakov A.Ye.

    2013-01-01

    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 copi...

  13. [Difficult teenagers: the challenges of interdisciplinarity].

    Saint-Andrté, Stéphane; Botbola, Michel

    2013-01-01

    The adolescents in great distress, because of ruptures in the course of their lives and of their chaotic family environment, need educational and social actions. The consensual point of view is that responding to the needs of the so called "difficult adolescents" implies the involvement of educational, therapeutic and judicial services. Nevertheless, the usual tendency to categorize the users with the idea it will permit to guide them to the appropriate skill field and the transgressive characteristic of these adolescents' behaviours lead all these services to reject them and send them to the two other services. PMID:24450000

  14. Laparoscopic management of difficult recurrent choledocholithiasis.

    Dixit, Anupam; Wynne, Kamal S; Harris, Adrian M

    2007-01-01

    The management of common bile duct stones has traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of the last century, endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration has become the mainstream treatment for common bile duct stones in most medical centers around the world. However, in some patients, endoscopic retrograde cholangiopancreatography is difficult and laparoscopy is challenging because of previous surgery. These facts are highlighted in this report. PMID:17651582

  15. Difficult male urethral catheterization: a review of different approaches

    Carlos Villanueva

    2008-08-01

    Full Text Available PURPOSE: To review and compare the different methods for difficult male urethral catheterization described in selected literature. MATERIALS AND METHODS: A PubMed search was done with the terms "difficult", "failed", or "complications" and "urethral catheterization", "transurethral catheterization", "Foley catheter", "urethral catheter" or "filiforms and followers". All articles addressing the issue of difficult adult male urethral catheterization were included. RESULTS: Six main approaches were identified on the 14 articles included for review: 1 Passage of either a Glidewire, guide wire or filiform under direct vision; 2 Blind passage of a filiform, guide wire, Glidewire or hydrophilic catheter; 3 "The Peel-away® sheath placed on a cystoscope/resectoscope technique"; 4 "The rigid ureteroscope placed inside the 22F Foley technique"; 5 Suprapubic catheterization; and 6 "The instillation of 60 cc of saline through the catheter as it is advanced technique". CONCLUSION: There is a paucity of prospective data comparing the benefits, risks, success rates and complications of the different approaches for difficult Foley catheter placement. Our suggested approach starts with the initial attempt at urethral catheterization with an 18F coude and a 12F silicone catheter. If these fail, using a flexible cystoscope or the blind Glidewire technique are reasonable alternatives. If dilatation of a stricture is necessary, ureteric dilatators or a urethral balloon dilatator are recommended.

  16. Braving difficult choices alone: children's and adolescents' medical decision making.

    Azzurra Ruggeri

    Full Text Available OBJECTIVE: What role should minors play in making medical decisions? The authors examined children's and adolescents' desire to be involved in serious medical decisions and the emotional consequences associated with them. METHODS: Sixty-three children and 76 adolescents were presented with a cover story about a difficult medical choice. Participants were tested in one of four conditions: (1 own informed choice; (2 informed parents' choice to amputate; (3 informed parents' choice to continue a treatment; and (4 uninformed parents' choice to amputate. In a questionnaire, participants were asked about their choices, preference for autonomy, confidence, and emotional reactions when faced with a difficult hypothetical medical choice. RESULTS: Children and adolescents made different choices and participants, especially adolescents, preferred to make the difficult choice themselves, rather than having a parent make it. Children expressed fewer negative emotions than adolescents. Providing information about the alternatives did not affect participants' responses. CONCLUSIONS: Minors, especially adolescents, want to be responsible for their own medical decisions, even when the choice is a difficult one. For the adolescents, results suggest that the decision to be made, instead of the agent making the decision, is the main element influencing their emotional responses and decision confidence. For children, results suggest that they might be less able than adolescents to project how they would feel. The results, overall, draw attention to the need to further investigate how we can better involve minors in the medical decision-making process.

  17. Chernobyl: Chronicle of difficult weeks [videorecording

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

  18. Difficult weaning in delayed onset diaphragmatic hernia

    Ahmed Syed

    2009-01-01

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

  19. Effective Climate Communication with Difficult Audiences

    Denning, S.

    2015-12-01

    Climate communication is often fraught with ideological baggage ("noise") that makes it very difficult to connect to audiences. In these cases, it is helpful to use "best practices" known from other fields of communication. Engaging audiences with authenticity, using plain language, respecting cultural and political differences, and a sprinkling of humor can go a long way toward establishing a connection. It's important to avoid common but polarizing tropes from popular media, and often quite helpful to frame climate issues in novel or unexpected ways that cut across entrenched political discourse. Emerging social science research Beyond ideology, climate change is Simple, Serious, and Solvable. Effective communication of these three key ideas can succeed when the science argument is carefully framed to avoid attack of the audience's ethical identity. Simple arguments from common sense and everyday experience are more successful than data. Serious consequences to values that resonate with the audience can be avoided by solutions that don't threaten those values.

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

    Naim Jerliu

    2015-12-01

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

  1. A gene-derived SNP-based high resolution linkage map of carrot including the location of QTL conditioning root and leaf anthocyanin pigmentation

    Cavagnaro, Pablo F; Iorizzo, Massimo; Yildiz, Mehtap; Senalik, Douglas; Parsons, Joshua; Ellison, Shelby; Simon, Philipp W

    2014-01-01

    Background Purple carrots accumulate large quantities of anthocyanins in their roots and leaves. These flavonoid pigments possess antioxidant activity and are implicated in providing health benefits. Informative, saturated linkage maps associated with well characterized populations segregating for anthocyanin pigmentation have not been developed. To investigate the genetic architecture conditioning anthocyanin pigmentation we scored root color visually, quantified root anthocyanin pigments by...

  2. Soaring Cotton Prices to Make Manufacturing Difficult

    2009-01-01

    With manufacturing slowly recovering amid improving economic condi-tions, cotton demand has increased prompting more orders among mills. However, with a deficient supply of cotton in the market, prices extend gains

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

    Krock, Bernd; Borel, C. Marcela; Barrera, Facundo; Tillmann, Urban; Fabro, Elena; Almandoz, Gastón O.; Ferrario, Martha E.; Garzón Cardona, John E.; Koch, Boris P; Alonso, Cecilia; Lara, Rubén J.

    2015-01-01

    The overlay of cooler nutrient enriched Beagle–Magellan water with warmer nutrient depleted shelf water and a strong stratification of the water column in the San Jorge Gulf region, Argentina, coincided with relatively high dinoflagellate abundances in April 2012, up to 34,000 cells L− 1. This dinoflagellate proliferation was dominated by Ceratium spp., but environmental conditions also favored to a lesser amount the occurrence of toxigenic dinoflagellates, such as Alexandrium tamarense and P...

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

    Piepho Tim

    2009-07-01

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

  5. Combined precut in difficult biliary cannulation

    Jesús Espinel-Díez

    2013-06-01

    Full Text Available 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 session. 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.

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

    Scott, Hazel J.; Gale, Alastair G.

    2005-04-01

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

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

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

    2015-08-01

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

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

    Andresen, Elisa, E-mail: Elisa.Andresen@uni-konstanz.de [University of Konstanz, Department of Biology, D-78457 Konstanz (Germany); Opitz, Judith, E-mail: Daniela.Opitz@uni-konstanz.de [University of Konstanz, Department of Biology, D-78457 Konstanz (Germany); Thomas, George, E-mail: George.Thomas@uni-konstanz.de [University of Konstanz, Department of Biology, D-78457 Konstanz (Germany); 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 České Budejovice (Czech Republic)

    2013-10-15

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

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

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

  10. The Difficult Stoma: Challenges and Strategies.

    Strong, Scott A

    2016-06-01

    The problems that a patient experiences after the creation of a temporary or permanent stoma can result from many factors, but a carefully constructed stoma located in an ideal location is typically associated with appropriate function and an acceptable quality of life. The construction of the stoma can be confounded by many concomitant conditions that increase the distance that the bowel must traverse or shorten the bowel's capacity to reach. Stomas can be further troubled by a variety of problems that potentially arise early in the recovery period or months later. Surgeons must be familiar with these obstacles and complications to avoid their occurrence and minimize their impact. PMID:27247541

  11. Abdominal Wall Modification for the Difficult Ostomy

    Beck, David E.

    2008-01-01

    A select group of patients with major stomal problems may benefit from operative modification of the abdominal wall. Options may include a modified abdominoplasty (abdominal wall contouring), localized flaps, or liposuction. Although frequently successful, these techniques have the potential for significant morbidity.

  12. Childhood Bipolar Disorder: A Difficult Diagnosis

    Sutton, Kimberly Kode

    2014-01-01

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

  13. Management of difficult airway in intratracheal tumor surgery

    Agarwal Surendra K

    2005-06-01

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

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

    Viet Q. Tran

    2008-01-01

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

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

    Stendell, Line; Lundstrøm, Lars H; Wetterslev, Jørn;

    2015-01-01

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

  16. Implications of the KONVERGENCE Model for Difficult Cleanup Decisions

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

    2002-08-04

    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.

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

    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-users relative to other supply/transport options which may now be viable economic alternatives. figs

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

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

    2015-12-01

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

  19. Usefulness of Percutaneous Transhepatic Cholangioscopic Lithotomy for Removal of Difficult Common Bile Duct Stones

    Lee, Jae Hyung; Kim, Hyung Wook; Kang, Dae Hwan; Choi, Cheol Woong; Park, Su Bum; Kim, Suk Hun; Jeon, Ung Bae

    2013-01-01

    Background/Aims Approximately 5% to 10% of common bile duct (CBD) stones are difficult to remove by conventional endoscopic methods. Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) can be an alternative method for this condition, but is not well established yet. The aim of this study was to evaluate the clinical efficacy and safety of PTCSL for removal of difficult CBD stones. Methods This study is a retrospective review of 34 consecutive patients who underwent unsuccessful remova...

  20. Difficult Airway Management in A Case of Thalassaemia Major

    Neerja Bharti

    2008-01-01

    Full Text Available Difficult to ventilate, difficult to intubate cases are the most challenging to anaesthesiologists. We present a case of thalassaemia with difficult airway who underwent splenectomy surgery. The severe maxillary prominence with protruded upper incisors, limited mouth opening, depressed nasal bridge and narrow anterior nares posed a problem in mask ventilation and subsequent tracheal intubation. The patient was intubated successfully using fibreoptic bronchoscope aided with intubating laryngeal mask airway (Fastrach.

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

    Pruess, K.

    2011-04-01

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

  2. Incidence and predictors of difficult mask ventilation and intubation

    Prerana N Shah

    2012-01-01

    Conclusions: The predictive score may lead to a better anticipation of difficult airway management, potentially deceasing the morbidity and mortality resulting from hypoxia or anoxia with failed ventilation.

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

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

    2009-04-01

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

  4. 困难企业子弟学校高中学生心理卫生状况的相关分析%Analysis about Psychological Health of Students of the Senier Middle Sc hool Attached to the Enterprise on Difficult Conditions

    李晓东; 周于川; 周远华; 杨世文

    2001-01-01

    Using SCL-90 clinal table,188 senier middle school stud ents of a certain enterprise sons and daughters school were tested.The result sh ows that:①The psychological health level of the difficult enterprise school is much lower than that of the norm students in our country.21.3% of the senier students have diff erent kinds of problems about the health.②The change of the psychological healt h level of the enterprise school students shows grade character.Among them,the h ealth level of Grade Ⅱ is even lower than that of Grade Ⅰand Grade Ⅲ.③The re ason of the health problem that has formed to the students of the difficult ente rprise school is that they can't fit in their study and the obsessment of the development of their self-consciouness trouble themselves too.%采用SCL-90临床自评量表,对某企业子弟学校三年制高中188名学 生进行测试。结 果表明:①困难企业子弟学校高中生心理健康水平总体上低于全国中学生常模,有21.3%的 高 中生存在各种明显的心理健康问题。②困难企业子弟学校高中生心理健康水平其变化表现出 年 级特征,其中,二年级水平较低,一、三年级较高。③困难企业子弟学校高中生心理健康问 题产生的主要原因是学习上的不适应,学生自我意识发展问题的困扰

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

    Chiara Bozzano

    2013-03-01

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

  6. Management of difficult inflammatory bowel disease: where are we now?

    D.S. Rampton

    2000-01-01

    Management of inflammatory bowel disease includes not only drug, endoscopic and surgical therapy but alsopsychosocial support, dietary and specific nutritional measures: a multidisciplinary medical, surgical, nursingand dietetic approach is essential for all patients, particularly those with complex or refractory disease. Inthis paper, current treatment of acute severe ulcerative colitis and steroid-refractory or -dependent Crohn'sdisease is reviewed. Adjunctive intravenous cyclosporin is an alternative to urgent colectomy in steroid-refractory patients with acute severe ulcerative colitis, while the place of intravenous heparin for thisindication awaits clarification. Azathioprine or 6-mercaptopurine are useful options in chronically active,steroid-refractory or -dependent Crohn's disease, but may take up to 4 months to work. Methotrexate is amore recent immunomodulatory alternative. Of new therapies selectively aimed at specific pathophysiologicaltargets, the first to reach clinical application is anti-TNF-alpha antibody (infliximab) for refractory Crohn'sdisease: its benefits are promising, but experience with it is limited to date, its cost is high and there areuncertainties about long-term safety. In view of the increasing variety and complexity of management optionsin inflammatory bowel disease, whether apparently responsive or difficult to treat, patients must participatein decisions about which therapies they are to be given.

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

    Westgren Magnus

    2010-06-01

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

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

    Stern, David

    2013-01-01

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

  9. Corticosteroid responsiveness and clinical characteristics in childhood difficult asthma

    Bossley, C.J.; Saglani, S; Kavanagh, C.; Payne, D.N.R.; Wilson, N; Tsartsali, L.; Rosenthal, M; Balfour-Lynn, I M; Nicholson, A.G.; Bush, A

    2009-01-01

    This study describes the clinical characteristics and corticosteroid responsiveness of children with difficult asthma (DA). We hypothesised that complete corticosteroid responsiveness (defined as improved symptoms, normal spirometry, normal exhaled nitric oxide fraction (FeNO) and no bronchodilator responsiveness (BDR

  10. Social support and support of children in difficult situations

    Lavrenova T. I.; Lygina M. A.

    2011-01-01

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

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

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

    2013-11-01

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

  12. Clustering is difficult only when it does not matter

    Daniely, Amit; Saks, Michael

    2012-01-01

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

  13. A novel cannulation technique for difficult urethral catheterization

    Mehmet Kaynar

    2016-03-01

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

  14. Cricothyrotomy can be hazardous in a difficult airway scenario

    Reema Ray

    2007-01-01

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

  15. Complicated jejunal diverticulitis: A challenging diagnosis and difficult therapy

    Erik Schloericke

    2012-01-01

    Full Text Available Background/Aim: In contrast to diverticulosis of the colon, jejunal diverticulosis is a rare entity that often becomes clinically relevant only after exacerbations occur. The variety of symptoms and low incidence make this disease a difficult differential diagnosis. Patients and Methods: Data from all patients who were treated in our surgical department for complicated jejunal diverticulitis, that is, gastrointestinal hemorrhage or a diverticula perforation were collected prospectively over a 6-year period (January 2004 to January 2010 and analyzed retrospectively. Results: The median age among the 9 patients was 82 years (range: 54-87. Except for 2 cases (elective operation for a status postjejunal peridiverticulitis and a re-perforation of a diverticula in a patient s/p segment resection with free perforation, the diagnosis could only be confirmed with an exploratory laparotomy. Perforation was observed in 5 patients, one of which was a retroperitoneal perforation. The retroperitoneal perforation was associated with transanal hemorrhage. Hemodynamically relevant transanal hemorrhage requiring transfusion were the reason for an exploratory laparotomy in 2 further cases. In one patient, the hemorrhage was the result of a systemic vasculitis with resultant gastrointestinal involvement. A singular jejunal diverticulum caused an adhesive ileus in one patient. The extent of jejunal diverticulosis varied between a singular diverticulum to complete jejunal involvement. A tangential, transverse excision of the diverticulum was carried out in 3 patients. The indication for segment resection was made in the case of a perforation with associated peritonitis (n=4 as well as the presence of 5 or more diverticula (n=2. Histological analysis revealed chronic pandiverticulitis in all patients. Median operating time amounted to 142 minutes (range: 65-210 and the median in-hospital stay was 12 days (range: 5-45. Lethality was 0%. Major complications included

  16. Assessment of Risk Factors for Conversion from Difficult Laparoscopic to Open Cholecystectomy - A Hospital Based Prospective Study

    Roman Kidwai

    2016-07-01

    Full Text Available Background: Laparoscopic cholecystectomy is the gold standard in the treatment of gallstones. It has proved to be an effective and safe procedure both in elective and emergency conditions; however, conversion to open surgery is inevitable in some cases. Hence the present study was carried out to identify various factors which can predict the difficult laparoscopic cholecystectomy so that an early conversion to open cholecystectomy can be considered. Material and Methods: A prospective st st study was conducted from 1 February 2011 to 31 January 2012 that included 63 patients of all age groups and both sexes who were found to have symptomatic gallstones and were scheduled for laparoscopic cholecystectomy at Nepalgunj Medical College and Teaching Hospital, Nepal. Age, sex, body mass index, previous abdominal surgery and past history of acute attack of cholecystitis of the patients were recorded. A pre-operative ultrasound was performed just prior to surgery, and three ultrasonographic parameters were analyzed, namely gall bladder wall thickness, number of stones and stone impacted in Hartmann's pouch. Intra-operative causes for difficult laparoscopic cholecystectomy like adhesions in Calot's triangle and gall bladder perforation with bile leak were also evaluated. Results: Total number of patients in this study was 63; out of which difficult laparoscopic cholecystectomy was seen in 25(39.7 patients and 7(11.1 patients required conversion to open cholecystectomy. Ultrasonography was good at predicting difficulty in each component with exception of gall bladder wall thickness which was not statistically significant. Conclusion: BMI, ultrasonographic finding of presence of multiple stone or stones impacted in Hartmann's pouch, adhesion in Calot's triangle and gall bladder perforations are predictors of difficult laparoscopic cholecystectomy.

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

    Lauridsen, Karen M.; Madsen, Henning

    Team Work in International Programs: Why is it so difficult? And what can we do about it? It is common knowledge that students often find it difficult to collaborate on assignments, projects, etc., but we require that they do so for a number of reasons, e.g. to learn how to work in teams or take...... the pedagogical and didactic implications of these findings. What can we as lecturers/teachers do in order to have students buy into the added value of diversity and multicultural teams from the beginning? The presenter will reflect on this in order to facilitate a discussion and exchange of experience among...

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

    Murthy

    2014-08-01

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

  19. What Highly Effective Leaders Do during Difficult Times

    Raisor, Michael Louis

    2011-01-01

    The purpose of this study was to determine what the most highly effective leaders do during difficult times to be successful. The backdrop of the study was the 2009 $300 million cuts to the Indiana K-12 education budget, a uniform crisis that affected all 293 public school districts at the same time. The subjects in this study were those…

  20. Difficult Temperament, Parental Relationships, and Adolescent Alcohol Use Disorder Symptoms.

    Neighbors, Bryan D.; Clark, Duncan B.; Donovan, John E.; Brody, Gene H.

    2000-01-01

    Study tested the hypothesis that the quality of the parent-adolescent relationship mediates the association between difficult temperament and alcohol use disorder (AUD) symptoms. Results suggest that alcohol abuse prevention and treatment programs should consider the role of basic temperamental characteristics in pathological drinking, and the…

  1. Cultural Differences in Children's Emotional Reactions to Difficult Situations.

    Cole, Pamela M.; Bruschi, Carole J.; Tamang, Babu L.

    2002-01-01

    Two studies examined beliefs about revealing emotion among children from Brahman, Tamang and American cultures. Findings indicated three distinct cultural patterns: Tamang were more likely to appraise difficult situations in terms of shame, while the others endorsed anger. Brahmins were more likely not to communicate negative emotion. Americans…

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

    Tesař, Václav

    2013-01-01

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

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

    Mah, Ronald

    2006-01-01

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

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

    Teena Bansal

    2016-04-01

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

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

    Debasis Pradhan

    2015-01-01

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

  6. An unanticipated difficult airway in Lesch-Nyhan syndrome

    Rashmi Salhotra

    2012-01-01

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

  7. Emotional distance to so-called difficult patients

    Michaelsen, Jette Joost

    2012-01-01

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

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

    Efiaty A. Soepardi

    2005-03-01

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

  9. Development of New Tools for the Synthesis of "Difficult Peptides"

    Paradís Bas, Marta

    2015-01-01

    Tesi realitzada a l'Institut de Recerca Biomèdica de Barcelona (IRBB) The known as "difficult peptides", as well as those sequences that aggregate in solution, are some of those molecules with high applicability as nanomaterials or even in medicine field. This thesis has addressed to overcome the synthetic, as well as, the peptide manipulation in solution drawbacks associated to this kind of peptides. The strategies proposed and evaluated in the present work have been divided in three chap...

  10. Difficult to control asthma in the patient with pseudoachondroplasia

    Wilczynska, Maria; Ching, Teresa

    2011-01-01

    Pseudoachondroplasia (PsA) is a type of short-limbed dwarfism resulting from mutations in the cartilage oligomeric matrix protein gene. Skeletal involvement in the PsA is well-described but there are not any published cases reporting airways involvement. The authors present a case of a female with the PsA and congenital anomalies of the respiratory tract resulting in the tracheobronchomalacia and a difficult to control asthma.

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

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

    1996-01-01

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

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

    Walsh, K

    2012-02-03

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

  13. High Metal Removal Rate Process for Machining Difficult Materials

    Bates, Robert; McConnell, Elizabeth

    2016-06-29

    Machining methods across many industries generally require multiple operations to machine and process advanced materials, features with micron precision, and complex shapes. The resulting multiple machining platforms can significantly affect manufacturing cycle time and the precision of the final parts, with a resultant increase in cost and energy consumption. Ultrafast lasers represent a transformative and disruptive technology that removes material with micron precision and in a single step manufacturing process. Such precision results from athermal ablation without modification or damage to the remaining material which is the key differentiator between ultrafast laser technologies and traditional laser technologies or mechanical processes. Athermal ablation without modification or damage to the material eliminates post-processing or multiple manufacturing steps. Combined with the appropriate technology to control the motion of the work piece, ultrafast lasers are excellent candidates to provide breakthrough machining capability for difficult-to-machine materials. At the project onset in early 2012, the project team recognized that substantial effort was necessary to improve the application of ultrafast laser and precise motion control technologies (for micromachining difficult-to-machine materials) to further the aggregate throughput and yield improvements over conventional machining methods. The project described in this report advanced these leading-edge technologies thru the development and verification of two platforms: a hybrid enhanced laser chassis and a multi-application testbed.

  14. Laryngeal mask airway: an alternative for the difficult airway.

    Jones, J R

    1995-10-01

    The laryngeal mask airway (LMA) was invented by Dr. Archie Brain at the London Hospital, Whitechapel, in 1981. Dr. Brain's main objective for the LMA was that it would provide a better method of maintaining a patient's airway than by face mask. Also, the LMA would be less hemodynamically stressful than with insertion of an endotracheal tube. The LMA consists of a silicone rubber tube connected to a miniature silicone mask. The perimeter of the mask consists of an inflatable elliptical cuff, which forms a tip at the distal aspect of the LMA. The aperture bars in the dome of the mask lift the epiglottis away, so the lumen remains unobstructive. The LMA forms a low pressure seal around the larynx. The LMA is contraindicated in any situation where the patient is at risk for pulmonary aspiration. The LMA is not a substitute for a properly placed endotracheal tube in this situation. The American Society of Anesthesiologists' difficult airway algorithm recommends the insertion of an LMA when ventilation and/or intubation are difficult. The distal aperture of the LMA is in close approximation to the vocal cords, so a 6.0-mm internal diameter endotracheal tube can be passed over an intubating stylet or a pediatric fiberoptic bronchoscope to secure a patient's airway. PMID:7502644

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

    Philippe Davezies

    2012-11-01

    Full Text Available L’intensification du travail oblige les salariés de tous secteurs et de tous niveaux hiérarchiques à des arbitrages serrés entre les différents objectifs du travail. Faute d’espace de discussion, chacun se débrouille seul, avec comme conséquence une individualisation des questions, une montée des conflits et une dégradation de la performance. Cette situation appelle la mise en place des espaces d’expression sur le travail, prévus dans la loi française. Cette orientation se heurte cependant à une difficulté : l’activité du travailleur est en avance sur sa conscience et beaucoup plus riche que ce qu’il est capable d’exprimer. Des espaces autonomes d’élaboration des enjeux du travail sont nécessaires pour créer les conditions d’une discussion avec la hiérarchie susceptible de porter ses fruits dans le domaine de la santé au travail et dans celui de la performance globale de l’entreprise.Regardless of the job sector or hierarchical position, work intensification forces workers to make hard choices between the different goals they are expected to meet. Due to a lack of discussion, people have to manage by themselves. The consequences are a rising tide of interpersonal conflicts and occupational stress associated with a deterioration in overall performance. This situation requires that time and places be set aside for work disputes, in keeping with French law. Nevertheless, there is a serious difficulty in actualizing this law: the worker’s tacit knowledge of his work is much richer than his conscious ability to verbalize and describe the work activity. Self-governed, employee-reserved times and places for working out the stakes at issue are necessary before discussing with the administration if we are to arrive at favourable results for occupational health and overall company performance.La intensificación del trabajo obliga a los empleados, independientemente del sector o del nivel jerárquico al que

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

    Barış Bulunmnaz

    2012-03-01

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

  17. The bogeyman cometh: a strategic approach for difficult adolescents.

    O'Connor, J J; Hoorwitz, A N

    1984-06-01

    Unpredictable and threatening events can sometimes alter one's view of reality. The altered perception may in turn result in altered forms of behavior and interaction with others. Deliberate efforts to facilitate this altered perception is sometimes attempted by invoking mythical forces such as the Bogeyman, Death, Satan, a shaman, or a sorcerer. Anthropological observations of shamanic magic suggest a number of components that appear to be responsible for these reality-altering experiences. These can be employed to create such experiences in the treatment of difficult adolescents for whom usual solutions have been ineffective. The experience results in systemic changes that render the adolescent accessible to more usual forms of treatment and more functional interactions with adults. The crafting of this kind of experience is illustrated in a case example. Parallels with other clinical practices as well as ethical considerations are discussed. PMID:6734794

  18. How difficult is it to obtain restricted release authorization

    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)

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

    Fabíola Maria Sabino Meireles

    2013-03-01

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

  20. Antiviral therapy for "difficult-to-treat" hepatitis C virus-infected patients

    Tatsuo Kanda; Osamu Yokosuka; Masao Omata

    2013-01-01

    Objective To review the updated research on direct antiviral agents (DAAs)-including regimens for hepatitis C virus (HCV),and focus on "difficult-to-treat" HCV-infected patients.Data sources The literature concerning DAAs and hepatitis C cited in this review was collected from PubMed and Google Scholar databases published in English up to July 2013.Study selection Data from published articles regarding HCV and DAAs in clinical trials and in clinical use were identified and reviewed.Results It was recognized that some "difficult-to-treat" patients would still exist,even though stronger treatments using such as DAAs,including telaprevir and boceprevir,which lead to higher sustained virological response rates,are available.Such patients include those with advanced fibrosis/cirrhosis,elderly persons,children,HCV-human immunodeficiency virus co-infected patients,HCV-infected recipients,and so on.Conclusions Certain "difficult-to-treat" patients would still exist,even though stronger treatment is available.Although evidence from clinical trials is still lacking,interferon-sparing regimens could have stronger effects for eradicating HCV in such cases.

  1. Comparison of Mallampati test with lower jaw protrusion maneuver in predicting difficult laryngoscopy and intubation

    Muhammad Irfan Ul Haq

    2013-01-01

    Full Text Available Background: Failure to maintain a patent airway is one of the commonest causes of anesthesia-related morbidity and mortality. Many protocols, algorithms, and different combinations of tested methods for airway assessment have been developed to predict difficult laryngoscopy and intubation. The reported incidence of a difficult intubation varies from 1.5% to 13%. The objective of this study was to compare Mallampati test (MT with lower jaw protrusion (LJP maneuver in predicting difficult laryngoscopy and intubation. Materials and Methods: Seven hundred and sixty patients were included in the study. All the patients underwent MT and LJP maneuver for their airway assessment. After a standardized technique of induction of anesthesia, primary anesthetist performed laryngoscopy and graded it according to the grades described by Cormack and Lehane. Sensitivity, specificity, accuracy, and positive predictive value (PPV and negative predictive value (NPV were calculated for both these tests with 95% confidence interval (CI using conventional laryngoscopy as gold standard. Area under curve was also calculated for both, MT and LJP maneuver. A P < 0.05 was taken as significant. Results: LJP maneuver had higher sensitivity (95.9% vs. 27.1%, NPV (98.7% vs. 82.0%, and accuracy (90.1% vs. 80.3% when compared to MT in predicting difficult laryngoscopy and intubation. Both tests, however, had similar specificity and PPV. There was marked difference in the positive and negative likelihood ratio between LJP and MT. Similarly, the area under the curve favored LJP maneuver over MT. Conclusion: The results of this study show that LJP maneuver is a better test to predict difficult laryngoscopy and tracheal intubation. We recommend the addition of this maneuver to the routine preoperative evaluation of airway.

  2. Comparison of Mallampati test with lower jaw protrusion maneuver in predicting difficult laryngoscopy and intubation

    Ul Haq, Muhammad Irfan; Ullah, Hameed

    2013-01-01

    Background: Failure to maintain a patent airway is one of the commonest causes of anesthesia-related morbidity and mortality. Many protocols, algorithms, and different combinations of tested methods for airway assessment have been developed to predict difficult laryngoscopy and intubation. The reported incidence of a difficult intubation varies from 1.5% to 13%. The objective of this study was to compare Mallampati test (MT) with lower jaw protrusion (LJP) maneuver in predicting difficult laryngoscopy and intubation. Materials and Methods: Seven hundred and sixty patients were included in the study. All the patients underwent MT and LJP maneuver for their airway assessment. After a standardized technique of induction of anesthesia, primary anesthetist performed laryngoscopy and graded it according to the grades described by Cormack and Lehane. Sensitivity, specificity, accuracy, and positive predictive value (PPV) and negative predictive value (NPV) were calculated for both these tests with 95% confidence interval (CI) using conventional laryngoscopy as gold standard. Area under curve was also calculated for both, MT and LJP maneuver. A P < 0.05 was taken as significant. Results: LJP maneuver had higher sensitivity (95.9% vs. 27.1%), NPV (98.7% vs. 82.0%), and accuracy (90.1% vs. 80.3%) when compared to MT in predicting difficult laryngoscopy and intubation. Both tests, however, had similar specificity and PPV. There was marked difference in the positive and negative likelihood ratio between LJP and MT. Similarly, the area under the curve favored LJP maneuver over MT. Conclusion: The results of this study show that LJP maneuver is a better test to predict difficult laryngoscopy and tracheal intubation. We recommend the addition of this maneuver to the routine preoperative evaluation of airway. PMID:24106353

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

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

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

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

    2008-03-15

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

  5. Interactive removal and ground truth for difficult shadow scenes.

    Gong, Han; Cosker, Darren

    2016-09-01

    A user-centric method for fast, interactive, robust, and high-quality shadow removal is presented. Our algorithm can perform detection and removal in a range of difficult cases, such as highly textured and colored shadows. To perform detection, an on-the-fly learning approach is adopted guided by two rough user inputs for the pixels of the shadow and the lit area. After detection, shadow removal is performed by registering the penumbra to a normalized frame, which allows us efficient estimation of nonuniform shadow illumination changes, resulting in accurate and robust removal. Another major contribution of this work is the first validated and multiscene category ground truth for shadow removal algorithms. This data set containing 186 images eliminates inconsistencies between shadow and shadow-free images and provides a range of different shadow types such as soft, textured, colored, and broken shadow. Using this data, the most thorough comparison of state-of-the-art shadow removal methods to date is performed, showing our proposed algorithm to outperform the state of the art across several measures and shadow categories. To complement our data set, an online shadow removal benchmark website is also presented to encourage future open comparisons in this challenging field of research. PMID:27607503

  6. QUALIFYING LEGACY BY PARTICULAR TITLE – A DIFFICULT TASK

    Ilioara GENOIU

    2014-05-01

    Full Text Available The current Civil Code in force, unlike the previous one, succeeds into making a clear and natural distinction between will – as a whole – and legacy – as the main testamentary provision. Unfortunately, it does not also provide flawless regulations in terms of the categories of legacies, which are classified according to their object (universal legacies, legacies by universal title, legacies by particular title. In what the legacy by universal title is concerned, the Civil Code in force contains some controversial provisions at article 1056 paragraph (2 letter c, which interfere also with the correct qualification of legacy by particular title. Then, the regulations of the legal regime applicable to the legatee by particular title also evince flaws, for instance at article 1114 article (3 letter b of the Civil Code, so that it becomes more and more difficult to qualify certain legacies, as being by particular or by universal title. The current work aims to point out the provisions of the Civil Code mentioned before, which generate or can generate potential controversies, but also to propose certain remedies.

  7. QUALIFYING LEGACY BY PARTICULAR TITLE – A DIFFICULT TASK

    Ilioara GENOIU

    2014-06-01

    Full Text Available The current Civil Code in force, unlike the previous one, succeeds into making a clear and natural distinction between will – as a whole – and legacy – as the main testamentary provision. Unfortunately, it does not also provide flawless regulations in terms of the categories of legacies, which are classified according to their object (universal legacies, legacies by universal title and legacies by particular title. In what the legacy by universal title is concerned, the Civil Code in force contains some controversial provisions at article 1056 paragraph (2 letter c, which interfere also with the correct qualification of legacy by particular title. Then, the regulations of the legal regime applicable to the legatee by particular title also evince flaws, for instance at article 1114 article (3 letter b of the Civil Code, so that it becomes more and more difficult to qualify certain legacies, as being by particular or by universal title. The current work aims to point out the provisions of the Civil Code mentioned before, which generate or can generate potential controversies, but also to propose certain remedies.

  8. Nuclear energy and public opinion - a difficult relationship

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

  9. Bronchogenic Cyst in a Patient with Difficult Asthma

    Soheil Ben Razavi

    2010-03-01

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

  10. How difficult is inference of mammalian causal gene regulatory networks?

    Djordje Djordjevic

    Full Text Available Gene regulatory networks (GRNs play a central role in systems biology, especially in the study of mammalian organ development. One key question remains largely unanswered: Is it possible to infer mammalian causal GRNs using observable gene co-expression patterns alone? We assembled two mouse GRN datasets (embryonic tooth and heart and matching microarray gene expression profiles to systematically investigate the difficulties of mammalian causal GRN inference. The GRNs were assembled based on > 2,000 pieces of experimental genetic perturbation evidence from manually reading > 150 primary research articles. Each piece of perturbation evidence records the qualitative change of the expression of one gene following knock-down or over-expression of another gene. Our data have thorough annotation of tissue types and embryonic stages, as well as the type of regulation (activation, inhibition and no effect, which uniquely allows us to estimate both sensitivity and specificity of the inference of tissue specific causal GRN edges. Using these unprecedented datasets, we found that gene co-expression does not reliably distinguish true positive from false positive interactions, making inference of GRN in mammalian development very difficult. Nonetheless, if we have expression profiling data from genetic or molecular perturbation experiments, such as gene knock-out or signalling stimulation, it is possible to use the set of differentially expressed genes to recover causal regulatory relationships with good sensitivity and specificity. Our result supports the importance of using perturbation experimental data in causal network reconstruction. Furthermore, we showed that causal gene regulatory relationship can be highly cell type or developmental stage specific, suggesting the importance of employing expression profiles from homogeneous cell populations. This study provides essential datasets and empirical evidence to guide the development of new GRN inference

  11. How difficult is inference of mammalian causal gene regulatory networks?

    Djordjevic, Djordje; Yang, Andrian; Zadoorian, Armella; Rungrugeecharoen, Kevin; Ho, Joshua W K

    2014-01-01

    Gene regulatory networks (GRNs) play a central role in systems biology, especially in the study of mammalian organ development. One key question remains largely unanswered: Is it possible to infer mammalian causal GRNs using observable gene co-expression patterns alone? We assembled two mouse GRN datasets (embryonic tooth and heart) and matching microarray gene expression profiles to systematically investigate the difficulties of mammalian causal GRN inference. The GRNs were assembled based on > 2,000 pieces of experimental genetic perturbation evidence from manually reading > 150 primary research articles. Each piece of perturbation evidence records the qualitative change of the expression of one gene following knock-down or over-expression of another gene. Our data have thorough annotation of tissue types and embryonic stages, as well as the type of regulation (activation, inhibition and no effect), which uniquely allows us to estimate both sensitivity and specificity of the inference of tissue specific causal GRN edges. Using these unprecedented datasets, we found that gene co-expression does not reliably distinguish true positive from false positive interactions, making inference of GRN in mammalian development very difficult. Nonetheless, if we have expression profiling data from genetic or molecular perturbation experiments, such as gene knock-out or signalling stimulation, it is possible to use the set of differentially expressed genes to recover causal regulatory relationships with good sensitivity and specificity. Our result supports the importance of using perturbation experimental data in causal network reconstruction. Furthermore, we showed that causal gene regulatory relationship can be highly cell type or developmental stage specific, suggesting the importance of employing expression profiles from homogeneous cell populations. This study provides essential datasets and empirical evidence to guide the development of new GRN inference methods for

  12. Optical modulator including grapene

    Liu, Ming; Yin, Xiaobo; Zhang, Xiang

    2016-06-07

    The present invention provides for a one or more layer graphene optical modulator. In a first exemplary embodiment the optical modulator includes an optical waveguide, a nanoscale oxide spacer adjacent to a working region of the waveguide, and a monolayer graphene sheet adjacent to the spacer. In a second exemplary embodiment, the optical modulator includes at least one pair of active media, where the pair includes an oxide spacer, a first monolayer graphene sheet adjacent to a first side of the spacer, and a second monolayer graphene sheet adjacent to a second side of the spacer, and at least one optical waveguide adjacent to the pair.

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

    Sonia Fleury

    2004-01-01

    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 incr...

  14. Metaphors as Second Labels: Difficult for Preschool Children?

    Rubio-Fernández, Paula; Grassmann, Susanne

    2016-08-01

    This study investigates the development of two cognitive abilities that are involved in metaphor comprehension: implicit analogical reasoning and assigning an unconventional label to a familiar entity (as in Romeo's 'Juliet is the sun'). We presented 3- and 4-year-old children with literal object-requests in a pretense setting (e.g., 'Give me the train with the hat'). Both age-groups succeeded in a baseline condition that used building blocks as props (e.g., placed either on the front or the rear of a train engine) and only required spatial analogical reasoning to interpret the referential expression. Both age-groups performed significantly worse in the critical condition, which used familiar objects as props (e.g., small dogs as pretend hats) and required both implicit analogical reasoning and assigning second labels. Only the 4-year olds succeeded in this condition. These results offer a new perspective on young children's difficulties with metaphor comprehension in the preschool years. PMID:26162307

  15. Intravascular Large B-Cell Lymphoma: A Difficult Diagnostic Challenge.

    Khan, Maria S; McCubbin, Mark; Nand, Sucha

    2014-01-01

    anemic. About 20% have hepatic and renal dysfunction. The treatment consists of systemic chemotherapy with cyclophosphamide, doxorubicin, vincristine, prednisone plus rituximab (CHOP-R) and central nervous system prophylaxis. Retrospective data suggests that, with treatment, 51% to 82% of the patients achieve a complete remission and 27% to 56% are alive at 2-year follow-up. Conclusion. IVLBCL is a difficult diagnosis to make as the disease remains confined to the vascular lumen. It may be associated with certain viral illnesses, and this association needs to be explored further. It is important to consider this diagnosis in the appropriate settings because patients may achieve durable remissions with therapy. PMID:26425595

  16. Does ultrasonographic volume of the thyroid gland correlate with difficult intubation? An observational study

    Basak Ceyda Meco

    2015-06-01

    Full Text Available BACKGROUND AND OBJECTIVES: Preoperative ultrasonographic evaluation of the thyroid gland done by surgeons could let us foresee airway management challenges. The aim of this observational study was to evaluate the effects of thyroid-related parameters assessed preoperatively by surgeons via ultrasonography and chest X-ray on intubation conditions. METHODS: Fifty patients undergoing thyroid surgery were enrolled. Thyromental distance, Mallampati score, neck circumference and range of neck movement were evaluated before the operation. Thyroid volume, signs of invasion or compression and tracheal deviation on chest X-ray were also noted. The intubation conditions were assessed with Cormack and Lehane score and the intubation difficulty scale. Statistical analyses were done with SPSS 15.0 software. RESULTS: The mean thyroid volume of the patients was 26.38 ± 14 mL. The median intubation difficulty scale was 1 (0-2. Thyromental distance (p = 0.011; r = 0.36; 95% CI 0.582-0.088, Mallampati score (p = 0.041; r = 0.29; 95% CI 0.013-0.526, compression or invasion signs (p = 0.041; r = 0.28; 95% CI 0.006-0.521 and tracheal deviation on chest X-ray (p = 0.041; r = 0.52; 95% CI 0.268-0.702 were correlated with intubation difficulty scale. Also patients were classified into two groups related to their intubation difficulty scale (Group I, n = 19: intubation difficulty scale = 0; Group II, n = 31: 1 < intubation difficulty scale ≤ 5 and difficult intubation predictors and thyroid-related parameters were compared. Only Mallampati score was significantly different between groups (p = 0.025. CONCLUSION: The thyroid volume is not associated with difficult intubation. However clinical assessment parameters may predict difficult intubation.

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

    Eduardo Macoto Kosugi

    2016-04-01

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

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

    Cimer, Atilla

    2012-01-01

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

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

    Joanne Lester

    2015-03-01

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

  20. Analytic device including nanostructures

    Di, Fabrizio, E.

    2015-07-02

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

  1. The difficult transition to national health insurance in Bulgaria

    Bistra Vladimirova Datzova

    2006-01-01

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

  2. Aging clinical problems: a difficult balance between age and frailty.

    Rozzini, Renzo

    2016-01-01

    Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. Frailty is a condition associated with ageing with associated weakness, slowing, decreased energy, lower activity, and, when severe, unintended weight loss. As a population ages, a central focus of geriatricians and public health practitioners is to understand, and then beneficially intervene on, the factors and processes that put elders at such risk, especially the increased vulnerability to stressors (e.g. extremes of heat and cold, infection, injury, or even changes in medication) that characterizes many older adults. The syndrome of geriatric frailty is hypothesized to reflect impairments in the regulation of multiple physiologic systems, embodying a lack of resilience to physiologic challenges and thus elevated risk for a range of deleterious endpoints. The empirical assessment of geriatric frailty in individuals seeks to capture this or related features. PMID:27374041

  3. Sea Ice Prediction Has Easy and Difficult Years

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

    2014-01-01

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

  4. Prediction is difficult, preparation is critical and possible

    Zilli, Romano; Dalton, Luke; Ooms, Wim;

    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...

  5. The Dounreay silver destruction process for difficult organic wastes

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

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

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

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

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

    2013-12-01

    Biomineralized exo- or endoskeletons of fossil marine invertebrates are widespread and diverse components of the Phanerozoic rock record of Earth's past and present oceans. Exoskeletons serve as protection against environmental pressure or predators, whilst endoskeletons can act as support or serve as an attachment for muscles and ligaments and hence as a mechanism for transmitting muscular forces. Biogenic hard parts represent sophisticated products resulting from the hierarchical interaction of inorganic minerals (95%) and macromolecular organic matrices, forming commonly less than 5%. The significance of many biogenic carbonate archives lies in the time-resolved growth patterns and their ability to record ambient environmental conditions in the form of multiple geochemical properties (multi-proxy archives) that have been widely used to assess past oceanic seawater properties. Here, we compile and review published work dealing with crystallization pathways of skeletal hard parts secreted by mollusks (i.e., bivalves and cephalopods) as well as brachiopods as widely used archives of ancient neritic epeiric settings. Bivalves and cephalopods (e.g., extinct ammonoids and belemnites and extant Sepia, Nautilus and Spirula) all form accretionary calcitic, aragonitic or vateritic skeletal hard parts. Despite the fact that mollusks and brachiopods form part of very different branches of the animal phylogenetic tree, their biomineralization strategies are surprisingly similar. Our main focus lies in a critical assessment of the complex pathways of ions and aquo-complexes from their source (seawater) to the final product (biomineral). We do this as an attempt to critically test the commonly held hypothesis that many fossil hard parts precipitated (under favorable conditions and pending subsequent diagenetic alteration) in equilibrium with seawater. Two main observations stand out: (1) the present knowledge on pathways and mechanisms (e.g., ion channel trans-membrane or

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

    Sonia Fleury

    2004-05-01

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

  9. Peristomal skin complications are common, expensive, and difficult to manage

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

    2012-01-01

    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......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...... 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...

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

    Monali Bhosle

    2009-06-01

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

  11. METHODOLOGY OF DETERMINATION OF ADMISSIBLE SPEEDS OF TRAIN MOVEMENT ON DIFFICULT SECTIONS OF RAILROAD PLAN

    M. B. Kurhan

    2014-03-01

    Full Text Available Purpose. Determination of improvement ways of admissible speeds of train movement on the difficult sections of а railroad plan. Methodology. Mathematical modeling of the train traffic is used to achieve the purpose of research. The average weighted speed and elevation of outer rail is predicted on this basis. Findings. The case analysis of the speeds determination in curved sections of track was carried out. The above mentioned track sections adversely affect the ride comfort and the intensity of the way disorder, as well as the reasons that contribute to the speed limits traffic on the railways of Ukraine. The technique of performing the calculations for determining the permissible train speeds was developed and tested on real curves of railways, were the accelerated movement of trains was introduced. Proposals on automate calculations in distances and services by way of determining the permissible speeds in curves were developed. Originality. Methodology of determining the permissible motion speeds and elevation of outer rails on the difficult sections of the railway plan was developed. This approach allows you to get a rational decisions on reorganization of plan based on local conditions. Practical value. The developed technique of definition of admissible speeds of motion in curves was implemented as a program DopShvid. The program was tested on real railway sections, where the accelerated train motion was introduced.

  12. The depsipeptide method for solid-phase synthesis of difficult peptides.

    Coin, Irene

    2010-05-01

    After about one century of peptide chemistry, the main limitation to the accessibility of peptides and proteins via chemosynthesis is the arising of folding and aggregation phenomena. This is true not only for sequences above a critical length but also for several biologically relevant substrates that are relatively short yet form either highly folded structures (e.g. WW domains) or fibrils and aggregates after final deprotection (beta-amyloid peptide). Such so-called difficult sequences may be more easily obtained via their corresponding depsipeptides (O-acyl isopeptides), ester isomers that are often easier to assemble and purify, and are smoothly converted to the parent amides under mild conditions. The depsipeptide method is the most recent technique to improve the outcome of difficult syntheses, applicable to sequences containing residues of serine or threonine. A brief overview is presented about chemical aspects of the method, the steps that have been undertaken for its optimization, and the evaluation of its efficiency. Further applications of analogous principles to other critical topics in peptide synthesis such as condensation of peptide segments and solid-phase synthesis of naturally occurring cyclodepsipeptides are addressed as well. PMID:20401924

  13. Prediction is Difficult, Especially the Future: A Progress Report

    Andrew Booth

    2007-03-01

    Full Text Available Objective This paper reviews developments in the consolidation and diversification of the evidence based library and information practice (EBLIP paradigm since publication of the authors’ book Evidence Based Practice for Information Professionals: a Handbook in 2004.Methods The authors provide an updated narrative review of key themes in the development of evidence based librarianship within the context of the new consensual term ‘EBLIP.’ Sources for this thematic framework included professional literature, Internet searches, and the authors’ personal experiences.Results ‐ While considerable achievements have been realized within a three‐year period, most notably the instigation of the journal known as EBLIP, a broadening of the paradigm to other library sectors, and increased availability of implementation studies, many challenges remain. Of particular concern is the lack of international strategic foresight in determining rotation of the biennial international conferences and distribution of influential EBLIP infrastructures and initiatives.Conclusion ‐ While the enthusiasms and energies of individual practitioners and work teams have made considerable progress in meeting short‐term objectives, uncertainty remains concerning how longer‐term objectives requiring infrastructure and resources might be realized. From its faltering steps as a toddler EBLIP has developed to a ‘prepubescent’ stage with the promise of ‘growth spurts’ and ‘emotional crises.’ The next three years should prove both challenging and demanding.

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

    Simson Tarigan

    2007-03-01

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

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

    Hongisto, M.; Nikula, A.

    1996-11-01

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

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

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

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

    Yakup Tomak

    2012-09-01

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

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

    MCCARTHY, EDWARD H.

    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…

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

    Hernandez, Luis; Smith, Connie Jo

    2009-01-01

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

  20. Predictive factors of difficult procedure in octogenarians undergoing elective laparoscopic cholecystectomy: a single center experience

    GUIDA, F.; MONACO, L.; SCHETTINO, M.; PORFIDIA, R.; IAPICCA, G.

    2016-01-01

    Aim To assess the feasibility and safety of laparoscopic cholecystectomy (LC) in very elderly patients with particular attention to the predicitive factors of difficulty. Patients and methods All patients aged ≥ 80 undergoing elective LC for lithiasis at our institution since 1st January 2015 to 31st December 2015 were included in the study. Exclusion criteria were: a) acute cholecystitis; b) biliary pancreatitis; c) biliary tract neoplasms; d) urgent procedure. Pre-, intra- and postoperative data were recorded. Results During the study period, we performed 72 LC and we enrolled 17 patients aged ≥ 80 with a M:F = 5:12. Of these, 10 patients had a “difficult” cholecystectomy. In seven cases an intraoperative cholangiography (IOC) was performed. Postoperative course was regular but in two patients we had an Oddian spasm in 1st postoperative day. Female sex (p=0.03) and preoperative high level of serum amylase (p= 0.02) were significantly associated to difficult cholecystectomy in elderly patients. Conclusion LC in octogenarians is feasible and safe. However, sex and serum amylase can help the surgeon to predict a more difficult procedure in elective LC. In this group of patients an approach based on the individual risk is desirable and the patient could be referred to a multidisciplinary approach. PMID:27381691

  1. Being a therapist in difficult therapeutic impasses: A hermeneutic-phenomenological analysis of skilled psychotherapists’ experiences, needs, and strategies in difficult therapies ending well

    Moltu, Christian

    2011-01-01

    The aim of this thesis is to explore from the first person perspective the experiences of processes involved in difficult therapies that are resolved constructively. The methodological approach towards this aim is qualitative inquiry. The participants are twelve highly skilled psychotherapists from various theoretical affiliations, who were interviewed in-depth about their experiences. The data material of the thesis comprises the recalled experiences from specific difficult therapy processes...

  2. A case of meningococcal meningitis that was difficult to treat owing to concurrent ventriculitis.

    Nakahara, Hiroaki; Oda, Toshimi; Fukao, Eri; Horiuchi, Izumi; Honma, Yutaka; Uchigata, Masanobu

    2016-05-31

    A 64-year-old male came to our hospital emergency department with fever and consciousness disturbance. Culture tests of blood and spinal fluid samples revealed meningococci (Neisseria meningitidis), and we made a diagnosis of meningococcal meningitis. Brain magnetic resonance imaging (MRI) findings revealed ventriculitis. Ceftriaxone was administered for 17 days, however, relapse was noted after that was discontinued, with neutropenia and renal impairment thought to be adverse reactions to the beta-lactam antibiotic. Hence, treatment was switched to oral administration of moxifloxacin for a total of 12 weeks, including in an outpatient setting. After moxifloxacin was discontinued, no side effects or relapse were seen, and treatment was ended. Although antibacterial agents generally show favorable effects for meningococcal meningitis, we consider that sufficient antimicrobial therapy is difficult in cases complicated with ventriculitis. PMID:27151225

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

    Yeh, Pin-Hung; Hsu, Po-Kai

    2016-04-01

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

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

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

    2013-06-01

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

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

    Jeremy P Harris

    2015-12-01

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

  6. Hook removal from a loggerhead sea turtle (Caretta caretta):Report of a tricky surgery under difficult conditions

    João Pedro Barreiros

    2015-01-01

    A sub adult Caretta caretta was found on the 23rd August, 2014 ca. 16 nautical miles south off S. Miguel Island, Azores (Northeast Atlantic), with a large pelagic trawl hook inside its mouth. The individual was kept in a basin of sea water and sent by boat to Terceira Island following instructions by the Azores Regional Government via the Environmental Authority in order to be examined by the author and, if possible, undergo the necessary hook removal procedures. In this note, we describe the surgical procedures and how the turtle was evaluated both pre- and post-surgery.

  7. The Effect of a Gluten-Free Diet in Children With Difficult-to-Manage Nephrotic Syndrome

    Lemley, Kevin V.; Faul, Christian; Schramm, Karla; Meyers, Kevin; Kaskel, Frederick; Dell, Katherine M.; Gipson, Debbie S.; Gibson, Keisha; Trachtman, Howard

    2016-01-01

    Case reports have linked childhood nephrotic syndrome to food sensitivity, including gluten. We report our experience with 8 children (6 boys, 2 girls; age at implementation of special diet 2–14 years) with difficult-to-manage nephrotic syndrome who were placed on a gluten-free diet for 3.4 ± 4.3 years (range, 0.6–14 years) and who had clinical improvement enabling reduction or discontinuation in steroid dosage. PMID:27338701

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

    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

    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.

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

    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

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

    Sidarus, Nura; Haggard, Patrick

    2016-05-01

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

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

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

    2007-01-01

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

  12. Deciphering the Distance between Distance Education and Working Professionals in Difficult Geographies

    Pandey, Jatin; Singh, Manjari

    2015-01-01

    This study investigates the factors that draw working professionals towards distance education programs, and the factors that sustain their distance education experience. The study is conducted in difficult terrains of Uttarakhand, a hilly state in India which helps us investigate the phenomenon in difficult geographies. Through interviews of ten…

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

    Culpepper, Larry

    2013-01-01

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

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

    Smita Prakash

    2013-01-01

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

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

    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)

  16. Predictive value of preoperative tests in estimating difficult intubation in patients who underwent direct laryngoscopy in ear, nose, and throat surgery

    Osman Karakus

    2015-04-01

    Full Text Available BACKGROUND AND OBJECTIVES: Predictive value of preoperative tests in estimating difficult intubation may differ in the laryngeal pathologies. Patients who had undergone direct laryngoscopy (DL were reviewed, and predictive value of preoperative tests in estimating difficult intubation was investigated. METHODS: Preoperative, and intraoperative anesthesia record forms, and computerized system of the hospital were screened. RESULTS: A total of 2611 patients were assessed. In 7.4% of the patients, difficult intubations were detected. Difficult intubations were encountered in some of the patients with Mallampati scoring (MS system Class 4 (50%, Cormack-Lehane classification (CLS Grade 4 (95.7%, previous knowledge of difficult airway (86.2%, restricted neck movements (cervical ROM (75.8%, short thyromental distance (TMD (81.6%, vocal cord mass (49.5% as indicated in parentheses (p < 0.0001. MS had a low sensitivity, while restricted cervical ROM, presence of a vocal cord mass, short thyromental distance, and MS each had a relatively higher positive predictive value. Incidence of difficult intubations increased 6.159 and 1.736-fold with each level of increase in CLS grade and MS class, respectively. When all tests were considered in combination difficult intubation could be classified accurately in 96.3% of the cases. CONCLUSION: Test results predicting difficult intubations in cases with DL had observedly overlapped with the results provided in the literature for the patient populations in general. Differences in some test results when compared with those of the general population might stem from the concomitant underlying laryngeal pathological conditions in patient populations with difficult intubation.

  17. Hyomental distance in the different head positions and hyomental distance ratio in predicting difficult intubation

    Nevena Kalezić

    2016-06-01

    Full Text Available The hyomental distance ratio (HMDR is the ratio between the hyomental distance (HMD (the distance between the hyoid bone and the tip of the chin at the extreme of head extension (HMDe and the one in the neutral position (HMDn. The objective of the study was to examine the predictive value, sensitivity, and specificity of HMDe, HMDn, and HMDR in predicting difficult endotracheal intubation (DI. A prospective study included 262 patients that underwent elective surgical operations. The following parameters were observed as possible predictors of DI: HMDR, HMDe, HMDn, Mallampati score, and body mass index (BMI. The cut-off points for the DI predictors were HMDe <5.3 cm, HMDn ≤5.5 cm, and HMDR ≤1.2. The assessment that DI existed was made by the anesthesiologist while performing laryngoscopy by applying the Cormack-Lehane classification. DI was present in 13 patients (5%. No significant difference was observed in the frequency of DI with regard to the sex, age, and BMI of the patients. Our research indicated HMDR as the best predictor of DI with a sensitivity of 95.6% and specificity of 69.2%. HMDR can be used in the everyday work of anesthesiologists because HMDR values ≤1.2 may reliably predict DI.

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

    Meltem Türkay

    2014-12-01

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

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

    Malik, M A

    2009-11-01

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

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

    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...

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

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

    2011-01-01

    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.

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

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

  3. Low-Dose Isotretinoin: An Option for Difficult-to-Treat Papulopustular Rosacea.

    van Zuuren, Esther J; Fedorowicz, Zbys

    2016-06-01

    Rosacea is a chronic disease with a profound impact on quality of life. Although there are a range of treatments for its many manifestations, some cases are difficult to treat. Sbidian et al. show in this double-blind, randomized, placebo-controlled trial that low-dose isotretinoin can be effective in treating difficult-to-treat and frequently relapsing papulopustular rosacea. PMID:27212646

  4. The prediction of difficult intubation in obese patients using mirror indirect laryngoscopy: A prospective pilot study

    Arne O Budde

    2013-01-01

    Full Text Available Background: The incidence of difficult laryngoscopy and intubation in obese patients is higher than in the general population. Classical predictors of difficult laryngoscopy and intubation have been shown to be unreliable. We prospectively evaluated indirect mirror laryngoscopy as a predictor of difficult laryngoscopy in obese patients. Materials and Methods: 60 patients with a body mass index (BMI greater than 30, scheduled to undergo general anesthesia, were enrolled. Indirect mirror laryngoscopy was performed and was graded 1-4 according to Cormack and Lehane. A view of grade 3-4 was classified as predicting difficult laryngoscopy. Additional assessments for comparison were the Samsoon and Young modification of the Mallampati airway classification, Wilson Risk Sum Score, neck circumference, and BMI. The view obtained upon direct laryngoscopy after induction of general anesthesia was classified according to Cormack and Lehane as grade 1-4. Results: Sixty patients met the inclusion criteria; however, 8 (13.3% patients had an excessive gag reflex, and examination of the larynx was not possible. 15.4% of patients who underwent direct laryngoscopy had a Cormack and Lehane grade 3 or 4 view and were classified as difficult. Mirror laryngoscopy had a tendency toward statistical significance in predicting difficult laryngoscopy in these patients. Conclusions: This study is consistent with previous studies, which have demonstrated that no one individual traditional test has proven to be adequate in predicting difficult airways in the obese population. However, the new application of an old test - indirect mirror laryngoscopy - could be a useful additional test to predict difficult laryngoscopy in obese patients.

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

    Giuseppe De Benedittis

    2005-01-01

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

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

    Neamat I. Abdel rahman

    2016-01-01

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

  7. A comparison of Mallampati scoring, upper lip bite test and sternomental distance in predicting difficult intubation

    Arun Varghese; Taznim Mohamed

    2016-01-01

    Background: Difficult or failed tracheal intubation has been identified as one of the most important causes of death or permanent brain damage during anaesthesia. The present study has aimed to compare modified Mallampati score, Upper lip bite test and sternomental distance for predicting difficult intubation in adult patients. Methods: In this study 199 patients aged 18-60 years were recruited who were undergoing elective surgeries requiring endotracheal intubation. All patients were eva...

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

    Seema

    2016-03-01

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

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

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

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

    Mohan

    2015-10-01

    Full Text Available BACKGROUND AND RATIONALE : Preoperative evaluation is important in the detection of patients at risk for difficult tracheal intubation. Thyromental distance (TMD is often used for these purposes, but its value as an indicator for difficult intubation is questionable, as it varies with patient size and body proportions. The purpose of the present study was to evaluate and compare the accuracies of th e Ratio o f Patient’s Height t o TMD (ratio of height to TMD=RHTMD, with TMD and Modified Mallampati classification (MP in the prediction of difficult tracheal intubation. OBJECTIVE : This study is an attempt in finding an airway index by making simple measurements to anticipate difficult airway and compare RHTMD with TMD and MP classification for predicting difficult airway. METHODS : 170 apparently normal ASA I & II patients who were u ndergoing elective surgeries under General Anaesthesia (GA were included in the study. The MP, TMD and RHTMD were determined in each patient preoperatively and Cormack – Lehane (CL grading was assessed during laryngoscopy. TMD ≤6.5cm, RHTMD > 25 and MP c lass III & IV were considered difficult intubation; these values were compared with CL grading. CL grade III&IV were considered as difficult intubation. The optimal predictive value was chosen using a receiver operating characteristic (ROC curve. The area s under the ROC curves (AUC of TMD and RHTMD were compared to determine the performance of the different predictive tests used. The sensitivity, specificity, and positive and negative predictive values of each of the predictive tests were calculated accor ding to standard formulae. RESULTS : Difficult intubation occurred in 6 out of 170 patients (3.5% in the study. The sensitivity of Modified Mallampati classification was 33.3% and specificity was 90.8%. The test has a positive predictive value of 11.7%, ne gative predictive value of 97.3% and overall accuracy of 88.8%. The sensitivity of TMD was 33.3% and

  11. Conditional Sampling for Max-Stable Random Fields

    Wang, Yizao

    2010-01-01

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

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

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

    2013-01-01

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

  13. Assessing the effects of different dielectrics on environmentally conscious powder-mixed EDM of difficult-to-machine material (WC-Co)

    Singh, Jagdeep; Sharma, Rajiv Kumar

    2016-06-01

    Electrical discharge machining (EDM) is a well-known nontraditional manufacturing process to machine the difficult-to-machine (DTM) materials which have unique hardness properties. Researchers have successfully performed hybridization to improve this process by incorporating powders into the EDM process known as powder-mixed EDM process. This process drastically improves process efficiency by increasing material removal rate, micro-hardness, as well as reducing the tool wear rate and surface roughness. EDM also has some input parameters, including pulse-on time, dielectric levels and its type, current setting, flushing pressure, and so on, which have a significant effect on EDM performance. However, despite their positive influence, investigating the effects of these parameters on environmental conditions is necessary. Most studies demonstrate the use of kerosene oil as dielectric fluid. Nevertheless, in this work, the authors highlight the findings with respect to three different dielectric fluids, including kerosene oil, EDM oil, and distilled water using one-variable-at-a-time approach for machining as well as environmental aspects. The hazard and operability analysis is employed to identify the inherent safety factors associated with powder-mixed EDM of WC-Co.

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

    Brunero, Scott; Lamont, Scott

    2010-06-01

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

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

    Giuseppe De Benedittis

    2005-05-01

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

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

    Shaw, Peter J A

    2010-01-01

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

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

    Mary Breheny

    2011-01-01

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

  18. A Randomized-Controlled Trial of Oral Low-Dose Isotretinoin for Difficult-To-Treat Papulopustular Rosacea.

    Sbidian, Emilie; Vicaut, Éric; Chidiack, Henri; Anselin, Elie; Cribier, Bernard; Dréno, Brigitte; Chosidow, Olivier

    2016-06-01

    Rosacea is a chronic inflammatory facial skin disease with psychosocial impact. Oral cyclines are recommended for moderate-to-severe papulopustular rosacea. Oral isotretinoin was found valuable for difficult-to-treat cases in several reports. This multicenter, double-blind, randomized-placebo-controlled trial compared oral isotretinoin (0.25 mg/kg/day) with placebo (2:1 ratio) for difficult-to-treat papulopustular rosacea. Included patients had at least eight papulopustular lesions. The primary endpoint after the 4-month treatment period was the response rate: at least 90% reduction of the number of papules/pustules compared with baseline. Secondary outcomes included measures on quality of life (Skindex score). Between February 2007 and August 2009, 156 patients were randomized to receive either isotretinoin (n = 108) or placebo (n = 48). In the intention-to-treat population, 57.4% of isotretinoin recipients reached the primary endpoint, compared with 10.4% of those taking the placebo (absolute difference, 47 percentage points; 95% confidence interval, 34.3-59.7; P Rosacea relapsed in 27 (58.3%) of 51 patients who accepted 4 months of continued follow-up, with a median of 15 weeks to recurrence. The percentages of patients in each arm who stopped their treatment because of adverse event(s) did not differ. Low-dose isotretinoin was an effective therapeutic option for difficult-to-treat papulopustular rosacea. Further studies should investigate the value of a minimal effective isotretinoin dose to maintain these remissions. PMID:26854486

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

    Rosenstock, Charlotte Vallentin; Thøgersen, Bente; Afshari, Arash;

    2012-01-01

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

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

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

    2016-01-01

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

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

    Mehmet Turan Inal

    2014-12-01

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

  2. Generalization of Changes in Children's Preferences for Easy or Difficult Goals Induced through Peer Modeling.

    Sagotsky, Gerald; Lepper, Mark R.

    1982-01-01

    Explores the generalization of changes in children's preferences for easy or difficult goals, when their preferences are induced by exposure to peer models playing a novel athletic game. Subjects played the same game immediately after exposure, participated in a "spelling bee" three weeks later, and chose puzzles of differing levels of difficulty…

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

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

    2010-01-01

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

  4. When I Whisper, Nobody Listens: Helping Young People Write about Difficult Issues.

    Frost, Helen

    This book offers guidance on how teachers can help their students write about sensitive topics or provide pragmatic suggestions for developing the skill and sensitivity necessary to venture into such difficult terrain. The book addresses students' need to articulate their thoughts and feelings about violence, anger, drug use, peer pressure, and…

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

    Vadasy, Patricia F.; Sanders, Elizabeth A.

    2015-01-01

    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…

  6. LARYNGEAL CHONDROSARCOMA: SUCCESSFUL USE OF VIDEO LARYNGOSCOPE IN ANTICIPATED DIFFICULT AIRWAY MANAGEMENT.

    Dolinaj, Vladimir; Milošev, Sanja; Janjević, Dušanka

    2016-03-01

    Laryngeal chondrosarcoma is a rare mesenchymal tumor, most frequently affecting cricoid cartilage. The objective of this report is to present successful video laryngoscope usage in a patient with anticipated difficult airway who refused awake fiberoptic endotracheal intubation (AFOI). A 59-year-old male patient was admitted in our hospital due to difficulty breathing and swallowing. On clinical examination performed by ENT surgeon, preoperative endoscopic airway examination (PEAE) could not be performed properly due to the patient's uncooperativeness. Computed tomography revealed a spherical tumor that obstructed the subglottic area almost entirely. Due to the narrowed airway, the first choice for the anticipated difficult airway management was AFOI, which the patient refused. Consequently, we decided to perform endotracheal intubation with indirect laryngoscope using a C-MAC video laryngoscope (Karl Storz, Tuttlingen, Germany). Reinforced endotracheal tube (6.0 mm internal diameter) was placed gently between the tumor mass and the posterior wall of the trachea in the first attempt. Confirmation of endotracheal intubation was done by capnography. In a patient with subglottic area chondrosarcoma refusing PEAE and AFOI, video laryngoscope is a particularly helpful device for difficult airway management when difficult airway is anticipated. PMID:27276783

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

    Mintz, Avi I.

    2010-01-01

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

  8. Inappropriate fixation of an endotracheal tube causing cuff malfunction resulting in difficult extubation.

    Nag, Deb Sanjay; Samaddar, Devi Prasad

    2016-01-01

    We discuss a case of difficult extubation, due to inadequate deflation of the tracheal tube cuff, despite collapse of the pilot balloon, on its aspiration. This was caused by inadvertent kinking of the pilot balloon tubing due to inappropriate tape fixation of the endotracheal tube. PMID:27591469

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

    Keller, Eric

    2010-01-01

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

  10. Relapsing and difficult to control hypokalemia in a patient with acute lymphoid leukemia

    Nieto-Ríos, John Fredy; Serna-Higuita, Lina María; Valencia-Chicué, Libardo Humberto; Ocampo-Kohn, Catalina; Aristizábal-Alzate, Arbey; Zuluaga-Valencia, Gustavo Adolfo

    2015-01-01

    Hypokalemia is an electrolytic disorder, in some occasions difficult to control. When severe, it may be life-threatening. We report the case of a patient with relapse of acute lymphoid leukemia, who presented to the hospital with flaccid paralysis associated with severe hypokalemia. The cause was a tubulopathy associated with leukemic infiltration of the kidneys.

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

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

    2015-01-01

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

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

    Segall, Avner

    2014-01-01

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

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

    Wolke, Dieter; St. James-Roberts, Ian

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

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

    A. Lesco

    2006-01-01

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

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

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

    2009-07-01

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

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

    Vidal-Fernández, Ana; Megías, Jesús L

    2014-01-01

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

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

    M. Gharebaghian

    2006-08-01

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

  18. Laryngoscope and a new tracheal tube assist lightwand intubation in difficult airways due to unstable cervical spine.

    Cai-neng Wu

    Full Text Available The WEI Jet Endotracheal Tube (WEI JET is a new tracheal tube that facilitates both oxygenation and ventilation during the process of intubation and assists tracheal intubation in patients with difficult airway. We evaluated the effectiveness and usefulness of the WEI JET in combination with lightwand under direct laryngoscopy in difficult tracheal intubation due to unstable cervical spine.Ninety patients with unstable cervical spine disorders (ASA I-III with general anaesthesia were included and randomly assigned to three groups, based on the device used for intubation: lightwand only, lightwand under direct laryngoscopy, lightwand with WEI JET under direct laryngoscopy.No statistically significant differences were detected among three groups with respect to demographic characteristics and C/L grade. There were statistically significant differences between three groups for overall intubation success rate (p = 0.015 and first attempt success rate (p = 0.000. The intubation time was significantly longer in the WEI group (110.8±18.3 s than in the LW group (63.3±27.5 s, p = 0.000 and DL group (66.7±29.4 s, p = 0.000, but the lowest SpO2 in WEI group was significantly higher than other two groups (p<0.01. The WEI JET significantly reduced successful tracheal intubation attempts compared to the LW group (p = 0.043. The severity of sore throat was similar in three groups (p = 0.185.The combined use of WEI JET under direct laryngoscopy helps to assist tracheal intubation and improves oxygenation during intubation in patients with difficult airway secondary to unstable spine disorders.Chinese Clinical Trial Registry ChiCTR-TRC-14005141.

  19. Pediatric Interstitial Lung Disease Masquerading as Difficult Asthma: Management Dilemmas for Rare Lung Disease in Children

    EY Chan

    2005-01-01

    Full Text Available Idiopathic nontransplant-related childhood bronchiolitis obliterans is an uncommon disease. Most patients present with chronic recurrent dyspnea, cough and wheezing, which are also features of asthma, by far a much more common condition. The present case study reports on a six-year-old girl who presented to a tertiary care centre with recurrent episodes of respiratory distress on a background of baseline tachypnea, chronic hypoxemia and exertional dyspnea. Her past medical history revealed significant lung disease in infancy, including respiratory syncytial virus bronchiolitis and repaired gastroesophageal reflux. She was treated for 'asthma exacerbations' throughout her early childhood years. Bronchiolitis obliterans was subsequently diagnosed with an open lung biopsy. She did not have sustained improvement with systemic corticosteroids, hydroxychloroquine or clarithromycin. Cardiac catheterization confirmed the presence of secondary pulmonary hypertension. Treatment options remain a dilemma for this patient because there is no known effective treatment for this condition, and the natural history is not well understood. The present case demonstrates the need for careful workup in 'atypical asthma', and the urgent need for further research into the rare lung diseases of childhood.

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

    Halttunen, Jorma; Meisner, Søren; Aabakken, Lars;

    2014-01-01

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

  1. Perinatal risk factors including malformation

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

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

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

    2015-10-01

    Solitary fibrous tumor (SFT) is a rare neoplasm that commonly originates in the pleura. Extrapleural locations are rare and for this reason sometimes difficult to diagnose. Malignant forms with local recurrence or distant metastases have been reported, also as a consequence of inappropriate treatment. In this article, we report the case of an SFT of the lower leg in a 37-year-old man. Leg SFT is a rare occurrence, and differential diagnosis may be difficult because they can mimic a variety of benign and malignant mesenchymal tumors; immunohistochemical analysis for CD34, CD99, vimentin, and Bcl-2 is necessary. Misdiagnosis carries a significant risk of inadequate removal with subsequent increased risk of recurrence and distant metastases. PMID:26579334

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

    Marčinko, Darko

    2015-09-01

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

  4. Potassium permanganate toxicity: A rare case with difficult airway management and hepatic damage

    Vijay Kumar Agrawal

    2014-01-01

    Full Text Available Potassium permanganate (KMnO 4 is rarely used for suicidal attempt. Its ingestion can lead to local as well as systemic toxicities due to coagulation necrosis and damage, caused by free radicals of permanganate. We recently managed a case of suicidal ingestion of KMnO 4 in a lethal dose. She had significant narrowing of upper airway leading to difficult intubation as well as hepatic dysfunction and coagulopathy as systemic manifestation. We suggest to keep ourselves ready to handle difficult airway with the aid of fiber optic bronchoscope or surgical airway management in such patients. Upper gastrointestinal (GI endoscopy should be done at the earliest to determine the extent of upper GI injury and further nutrition planning.

  5. Solid-phase peptide synthesis: from standard procedures to the synthesis of difficult sequences.

    Coin, Irene; Beyermann, Michael; Bienert, Michael

    2007-01-01

    This protocol for solid-phase peptide synthesis (SPPS) is based on the widely used Fmoc/tBu strategy, activation of the carboxyl groups by aminium-derived coupling reagents and use of PEG-modified polystyrene resins. A standard protocol is described, which was successfully applied in our lab for the synthesis of the corticotropin-releasing factor (CRF), >400 CRF analogs and a countless number of other peptides. The 41-mer peptide CRF is obtained within approximately 80 working hours. To achieve the so-called difficult sequences, special techniques have to be applied in order to reduce aggregation of the growing peptide chain, which is the main cause of failure for peptide chemosynthesis. Exemplary application of depsipeptide and pseudoproline units is shown for synthesizing an extremely difficult sequence, the Asn(15) analog of the WW domain FBP28, which is impossible to obtain using the standard protocol. PMID:18079725

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

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

    1982-03-01

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

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

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

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

    Nunn, Heidi, E-mail: heidi@imageinterpretation.co.uk [Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY (United Kingdom); Nunn, David L. [Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY (United Kingdom)

    2011-11-15

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

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

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

    2014-01-01

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

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

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

    2014-01-01

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

  11. The causes of difficult tracheal intubation and preoperative assessments in different age groups

    Moon, Hyoung-Yong; Baek, Chong Wha; Kim, Jin-Seo; Koo, Gill Hoi; Kim, Jin-Yun; Woo, Young-Cheol; Jung, Yong Hun; Kang, Hyun; Shin, Hwa-Yong; Yang, So-Young

    2013-01-01

    Background We studied the differences in airway assessment factors among old, middle, and young age groups, and evaluated the frequency and causes of difficult intubation among these groups. Methods Patients were divided into young (< 40 yr, n = 75 ), middle (40-59 yr, n = 83), and old (≥ 60 yr, n = 89) group. Airway assessment factors such as head and neck movement, thyromental distance, interincisor gap, dentition, Mallampati score, and Arné score were assessed. After muscle relaxation, cer...

  12. The Origin and Age of Scallop Floodplain Benches from Difficult Run, Fairfax County, Virginia.

    Scamardo, J. E.; Pizzuto, J. E.; Skalak, K.; Benthem, A.

    2015-12-01

    Sediment is deposited within scallop-shaped erosional scarps that form between trees armoring the banks of Difficult Run, a suburban watershed with a forested riparian zone. These deposits create small (surface area 85 m2, volume 300 m3), low-lying floodplain landforms this group terms Scallop Floodplain Benches (SFB). It is hypothesized that SFB formed within the past couple decades initially forming as transversal accretion deposits and eventually gaining floodplain features dominated by vertical accretion. Stratigraphic data supports that SFB deposits begin laterally as sand and gravel bars approximately 100 cm thick, and continue to grow by vertical accretion of sand, silt, and clay. As a SFB reaches its maximum height, a distinctive levee develops adjacent to the channel, and fine-grained silt and clay are deposited behind the levee. Core samples to a depth of 118 cm and additional samples from an overbank event that occurred on June 20, 2015 were collected from one of two SFB on Difficult Run near Leesburg Pike. The grain size distribution was measured using a Coulter Counter and activities of Pb-210, Cs-137, and Be-7 were measured using High Purity Germanium Detectors. Cs-137 activities are relatively constant with depth without a well-defined peak, suggesting that the SFB was deposited after 1963. Be-7 is present in the recent flood deposits, but is absent below the surface, suggesting that the SFB deposits are at least several years old. Excess Pb-210 activities decrease exponentially with depth, and can be fit using the Constant Rate of Supply method to determine an average age of approximately 13.5 years for the SFB. The SFB is storing sediment at a rate of 27 tons/year, which is equal to 0.35% of the annual sediment load of Difficult Run, based on this average age. SFB appear to be a significant component of the sediment storage of Difficult Run and therefore should be considered in the sediment budget.

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

    Vudayagiri, Sindhu; Skov, Anne Ladegaard

    2014-01-01

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

  14. Les formes terrestres de jussies : de nouvelles difficultés de gestion ?

    Dutartre, A.

    2013-01-01

    Presentation of the forms of water primrose growing in wet meadows in West France, specific problems with their management and control experiments of their development. / Présentation des formes de jussies se développant dans les prairies humides, des difficultés particulières de leur gestion et des expérimentations de régulation de leur développement.

  15. Neural Processing of Respiratory Sensations when Breathing Becomes More Difficult and Unpleasant

    AndreasVon Leupoldt

    2010-01-01

    The accurate perception of respiratory sensations is important for the successful management and treatment of respiratory diseases. Previous studies demonstrated that external stimuli such as affective pictures and distracting films can impact the perception and neural processing of respiratory sensations. This study examined the neural processing of respiratory sensations when breathing as an internal stimulus is manipulated and becomes more difficult and unpleasant. Sustained breathing thro...

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

    Wolfgram, Mark A.

    2015-01-01

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

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

    Kouhei Iwashita

    2014-07-01

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

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

    Ashok Kumar; Himanshu Gupta; Chandra Shekhar Yadav; Shah Alam Khan; Shishir Rastogi

    2013-01-01

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

  19. Which Cicadellid Species (Homoptera) are Difficult to Find in a Heterogeneous Habitat?

    Kamitani, Satoshi; Saito, Aya

    2001-01-01

    The factors that determine which cicadellid species are easy or difficult to find in a heterogeneous habitat are discussed. The probability of finding a cicadellid and the estimated true species richness were computed by the randomized species accumulation curve. The mean observed richness and estimated true species richness were 15.1 and 27.0 species, respectively. incidence, temporal abundance, annual abundance, and host plant type were used for the analyses. The most influential factor was...

  20. Ambivalent connections. Improving community mental health care for non-psychotic chronic patients perceived as 'difficult'

    Koekkoek, Bauke

    2011-01-01

    Depression is a widespread psychiatric disorder, which becomes chronic in 25-30% of cases. When psychiatric and psychological treatments are ineffective, chronic depressive patients are often assigned to long-term care which is mostly provided by mental health nurses. Due to factors strongly associated with chronicity (like dependency, demoralization and hopelessness) long-term care is a difficult undertaking both for patients and mental health nurses. Areas in which major problems occur are ...

  1. Potassium permanganate toxicity: A rare case with difficult airway management and hepatic damage

    Vijay Kumar Agrawal; Abhishek Bansal; Ranjeet Kumar; Bhanwar Lal Kumawat; Parul Mahajan

    2014-01-01

    Potassium permanganate (KMnO 4 ) is rarely used for suicidal attempt. Its ingestion can lead to local as well as systemic toxicities due to coagulation necrosis and damage, caused by free radicals of permanganate. We recently managed a case of suicidal ingestion of KMnO 4 in a lethal dose. She had significant narrowing of upper airway leading to difficult intubation as well as hepatic dysfunction and coagulopathy as systemic manifestation. We suggest to keep ourselves ready to handle difficul...

  2. Biodiversity conservation including uncharismatic species

    Muñoz, Joaquin

    2007-01-01

    (Chapron 2006; Schwartz 2006), and the main threats to biodiversity (including invasive species) (Bawa 2006). I suggest, however, that these articles do not really deal with biodiversity. Rather, they all focus on a few obviously charismatic groups (mammals, birds, some plants, fishes, human culture......). Mammals and birds have traditionally been proposed as umbrella or flagship species (‘‘species that needs such large tracts of habitat that saving it will automatically save many other species’’––Simberloff 1998), to identify areas suitable as nature reserves (Kerr 1997; Sergio et al. 2005)....

  3. "Passive-bending colonoscope" significantly improves cecal intubation in difficult cases

    Takeshi Mizukami; Haruhiko Ogata; Toshihumi Hibi

    2012-01-01

    Colonoscopy sometimes causes pain during insertion,especially in difficult cases.Over-insufflation of air causes elongation or acute angulations of the colon,making passage of the scope difficult and causing pain.We previously reported a sedative-risk-free colonoscopy insertion technique,namely,"Water Navigation Colonoscopy".Complete air suction after water infusion not only improves the vision,but also makes water flow down to the descending colon,while the sigmoid colon collapses and shortens.While non-sedative colonoscopy can be carried out without pain in most cases,some patients do complain of pain.Most of these patients have abnormal colon morphology,and the pain is caused while negotiating the "hairpin" bends of the colon.The "hairpin" bends of the colon should be negotiated by gently pushing the full-angled colonoscope.The proximal 10-20 cm from the angulated part of the conventional colonoscope is stiff,with a wide turning radius,therefore,a conventional colonoscope cannot be negotiated through the "hairpin" bends of the colon without stretching them and causing pain.The "passive-bending colonoscope" has a flexible tip with a narrow turning radius,so that the scope can be negotiated through the "hairpin" bends of the colon with a minimum turning radius and minimal discomfort.Therefore,the intubation and pain-reducing performance of the "passive-bending colonoscope" was assessed in difficult cases.

  4. [Combined Use of a Videolaryngoscope and a Transilluminating Device for Intubation with Two Difficult Airways].

    Saima, Shunsuke; Asai, Takashi; Kimura, Rie; Terada, Satoshi; Arai, Takerou; Okuda, Yasuhisa

    2015-10-01

    Videolaryngoscope is useful in patients with difficult airways, but it may not be in some patients. We report the use of a lighted stylet to facilitate tracheal intubation in 2 patients in whom laryngoscopy with a videolaryngoscope was difficult. Case 1: A 52-year-old female with loose teeth and lockjaw presented for a scoliosis surgery under general anesthesia. Laryngoscopy using a blade 3 of a Glide-Scope® (Laerdal Medical Corporation, New York, NY, USA) videolaryngoscope (GVL) showed a Cormack-Lehanne grade 3 view. Bag mask ventilation was easily achieved. By using the Trachilight™ (Saturn Biomedical System Burnaby, BC, Canada) with the GVL, we could intubate the trachea succesfully. Case 2: A 16-year-old male with a history of difficult tracheal intubation due to a limited cervical spine movement presented for an external fixation of a femur under general anesthesia. After induction of anaesthesia, bag mask ventilation was easily achieved but the GVL laryngoscopy did not provide a good view of the glottis (Cormack-Lehanne grade 3). Combined use of the Trachilight™ with the GVL, facilitated tracheal intubation. The Trachilight™ is a recognized aid to facilitate trachal intubation but the device is now commercially not available. Neverthless, we believe that a lighted stylet is potentially useful for tracheal intubation when the view of the glottis with a videolaryngoscopy is not ideal. PMID:26742405

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

    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

  6. Theory including future not excluded

    Nagao, K.; Nielsen, H.B.

    2013-01-01

    We study a complex action theory (CAT) whose path runs over not only past but also future. We show that, if we regard a matrix element defined in terms of the future state at time T and the past state at time TA as an expectation value in the CAT, then we are allowed to have the Heisenberg equation......, Ehrenfest's theorem, and the conserved probability current density. In addition,we showthat the expectation value at the present time t of a future-included theory for large T - t and large t - T corresponds to that of a future-not-included theory with a proper inner product for large t - T. Hence, the CAT...... with future explicitly present in the formalism and influencing in principle the past is not excluded phenomenologically, because the effects are argued to be very small in the present era. Furthermore, we explicitly derive the Hamiltonian for the future state via a path integral, and confirm that it...

  7. Families classification including multiopposition asteroids

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

    2016-01-01

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

  8. Identification of abnormal operating conditions and intelligent decision system

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

    2011-12-01

    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.

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

    Miguel A García-Pérez

    2014-06-01

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

  10. Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem

    Callstrom, Matthew R.; Charboneau, J. William; Atwell, Thomas D.; Farrell, Michael A.; Welch, Timothy J.; Maus, Timothy P. [Mayo Clinic, Department of Radiology, Rochester, MN (United States); Goetz, Matthew P.; Rubin, Joseph [Mayo Clinic, Department of Oncology, Rochester, MN (United States)

    2006-01-01

    Painful skeletal metastases are a common problem in cancer patients. Although external beam radiation therapy is the current standard of care for cancer patients who present with localized bone pain, 20-30% of patients treated with this modality do not experience pain relief, and few further options exist for these patients. For many patients with painful metastatic skeletal disease, analgesics remain the only alternative treatment option. Recently, image-guided percutaneous methods of tumor destruction have proven effective for treatment of this difficult problem. This review describes the application, limitations, and effectiveness of percutaneous ablative methods including ethanol, methyl methacrylate, laser-induced interstitial thermotherapy (LITT), cryoablation, and percutaneous radiofrequency ablation (RFA) for palliation of painful skeletal metastases. (orig.)

  11. Brake assembly including torque monitor

    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

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

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

    2014-01-01

    on the frequency of unanticipated difficult airway management.To prevent outcome bias and selective reporting, we hereby present a detailed statistical analysis plan as an amendment (update) to the previously published protocol for the DIFFICAIR trial. METHOD/DESIGN: The DIFFICAIR trial is a...... stratified, parallel group, cluster (cluster = department) randomized multicenter trial involving 28 departments of anesthesia in Denmark randomized to airway assessment either by the Simplified Airway Risk Index (SARI) or by a usual non-specific assessment. Data from patients' preoperative airway assessment...

  13. Percutaneous treatment of Lutembacher syndrome in a case with difficult mitral valve crossing.

    Bhambhani, Anupam; Somanath, H S

    2012-03-01

    Most cases of combination congenital cardiac anomalies are treated with open-heart surgeries because the coexisting anomalies change the cardiac anatomy in an adverse way, making catheter manipulations complex. Lutembacher syndrome is a combination of acquired mitral stenosis and congenital ostium secundum atrial septal defect. The large defect in the septum makes an Inoue balloon catheter unstable, which provides excessive space for free floatation of the catheter, making its passage into the left ventricle difficult by Inoue technique. We present a case of elective definitive percutaneous treatment of Lutembacher syndrome, discussing the technical difficulties faced in mitral valve crossing and reviewing the possible strategies to improve chances of success. PMID:22388316

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

    E.E. Craythorne; Lawrence, C M

    2008-01-01

    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,...

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

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

    2016-01-01

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

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

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

  17. Difficult diagnosis of the fragile X syndrome made possible by direct detection of DNA mutations.

    Tarleton, J; Wong, S.; Heitz, D.; Schwartz, C.

    1992-01-01

    Genetic recombination near the fragile X locus (Xq27.3) has frequently been a problem in linkage studies of families in which the fragile X is segregating. This case report illustrates the resolution of a difficult situation in a fragile X family for whom cytogenetic studies were inconclusive and where recombination had twice confounded attempts at prenatal DNA diagnosis by RFLP analysis. Using a newly developed DNA probe, StB12.3, for direct detection of DNA instability in the fragile X locu...

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

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

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

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

    Maharaj, C H

    2008-02-01

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

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

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

  1. Les difficultés de la replantation. Quel avenir pour le cacao en Côte d’Ivoire ?

    Ruf François

    2001-11-01

    Full Text Available La conférence internationale sur le thème « Quel avenir pour les cultures pérennes ? » est née de deux préoccupations. La première recouvre le champ des difficultés de la replantation, difficultés techniques, économiques mais aussi environnementales, sociales et politiques : comment replanter 1 ? La seconde est la baisse des cours, probablement structurelle, de la plupart des matières premières agricoles, notamment de celles produites par des cultures pérennes. Si les prix restent aussi bas de façon aussi durable, pourquoi replanter ? De même qu’il est toujours de bon aloi d’acheter des actions quand la bourse s’écroule, les économistes recommandent de planter quand les cours des matières premières sont à leur plancher. Toutefois, si des centaines de milliers d’hectares sont plantés par des producteurs qui anticipent une remontée des cours, celle-ci peut alors être fort retardée. Cette capacité à anticiper un retour à des prix élevés est ainsi une des causes du prolongement de la phase des très bas prix du cacao jusqu’en 2001, ce qui semble bien relever d’un échec du marché 2. Le pourquoi et le comment de la replantation sont bien indissociables. Face aux enjeux, de nombreux pays détenteurs du patrimoine « cultures pérennes tropicales » ne manquent-ils pas d’une véritable politique de replantation prenant acte des changements nécessaires dans les conditions de production, se remettant en cause, tout en faisant face aux difficultés à interpréter les marchés ? Les problèmes de replantation ne peuvent se surmonter qu’à partir d’une compréhension des processus en œuvre, sur le terrain, en commençant par les décisions des producteurs. Les exemples, les études de cas, par village, par région, restent donc des fondamentaux pour une réflexion globale, pour une anticipation des problèmes, une action nationale, voire internationale, sur la replantation. En même temps, la question de

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

    Władysław Jagiełło

    2014-03-01

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

  3. Assets for policy making in health promotion: overcoming political barriers inhibiting women in difficult life situations to access sport facilities.

    Rütten, Alfred; Abu-Omar, Karim; Frahsa, Annika; Morgan, Antony

    2009-12-01

    Although the need for intersectoral policy making in health promotion has been commonplace and a high priority for several decades, there is still a lack of appropriate methods available to assess the inputs, processes, and outcomes associated with the effectiveness of such approaches, particularly in relation to sectors outside of health. This paper demonstrates how asset based models to intersectoral policy making in health promotion can improve the effectiveness of projects aiming to improve health and related outcomes. In particular, it summarises how asset based approaches to the planning and implementation of health promotion programmes can be used to develop our methods for assessing intersectorial actions. The paper is based on the findings from a local neighbourhood project based in Erlangen, Germany, aiming to improve the opportunities for physical activity among women in difficult life situations. The neighbourhood was characterised by high rates of unemployment, social welfare recipients, and migrants. Ethnographic methods enabled us to highlight the range of health related assets available in the neighbourhood which could be activated to improve access to and uptake of physical activity amongst the target population. Results indicate that intersectoral policies seeking to improve health outcomes, are more likely to be successful if they maximise the opportunities for making the most of the assets that exist in individuals, communities and organisations. This study demonstrates how the asset model was used to create the supportive environments which facilitated women from the target population to work with policy makers on an equal footing. Their involvement in project planning and implementation helped to achieve the structural changes required to achieve the aims of the project. These included the establishment of a new job position at the city office for sports and improved access to sport facilities for women in difficult life situations. PMID

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

    Karagiaridi, Olga

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

  5. Conditions Affecting Treatment of Pertrochanteric Osteomyelitis

    Steven Wen-Neng Ueng

    2007-10-01

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

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

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

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

    Damgaard, Christian

    2011-01-01

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

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

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

    2015-09-01

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

  9. Pulmonary arteriovenous malformations presenting as difficult-to-control asthma: a case report

    Navratil Marta

    2013-01-01

    Full Text Available Abstract Introduction Although pulmonary arteriovenous malformations are relatively rare disorders, they are an important part of the differential diagnosis of common pulmonary problems, such as hypoxemia, dyspnea on exertion and pulmonary nodules. Case presentation An 11-year-old Croatian boy of Mediterranean origin with a history of asthma since childhood was admitted to our hospital for evaluation of difficult-to-control asthma during the previous six months. A chest X-ray showed a homogeneous soft tissue mass in the lingual area. Computed tomography angiography of the thorax showed two pulmonary arteriovenous malformations, one on each side of the lungs. Diagnosis of hereditary hemorrhagic telangiectasia was made clinically by Curaçao criteria. Genetic analysis revealed a mutation in the endoglin gene. The patient was treated with embolotherapy with good clinical outcome. Conclusion We present a case of pulmonary arteriovenous malformations masquerading as refractory asthma.

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

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

    2016-08-01

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

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

    Shiv PS Rana

    2011-01-01

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

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

    Tolman JA

    2011-09-01

    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

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

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

    2010-01-01

    (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...... 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...

  14. Pityriasis Rosea: An Update on Etiopathogenesis and Management of Difficult Aspects.

    Mahajan, Khushbu; Relhan, Vineet; Relhan, Aditi Kochhar; Garg, Vijay Kumar

    2016-01-01

    Pityriasis rosea (PR) is a benign papulosquamous disorder seen commonly in clinical practice. Despite its prevalence and benign nature, there are still times when this common disorder presents in an uncommon way or course posing diagnostic or management problems for the treating physician. The etiopathogenesis of PR has always been a dilemma, and extensive research is going on to elicit the exact cause. This review focuses mainly on the difficult aspects of this benign common disorder such as etiopathogenesis, atypical manifestations, recurrent cases, differential diagnosis, therapy and pregnancy considerations. Although we could not find a black and white solution to all these problems, we have tried to compile the related literature to draw out some conclusions. PMID:27512182

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

    Matteucci, Elena; Giampietro, Ottavio

    2016-01-01

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

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

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

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

    Deslypere, G; Cuppens, K; Pat, K; Aumann, J; Demuynck, K; Spaas, L

    2015-01-01

    We describe a patient with acute respiratory insufficiency and difficult ventilator weaning in the ICU ward, leading to diagnosis of small cell lung cancer with superior vena cava superior syndrome. Bilateral vocal cord paralysis caused his respiratory distress and weaning difficulties. Thyroidectomy and neurological problems (such as Parkinson disease and Guillain Barré syndrome) are more common causes of bilateral vocal cord paralysis. Lung cancer patients are also at risk due to mediastinal invasion. The left recurrent laryngeal nerve is more prone to paralysis because of the typical anatomy. In contrary, bilateral vocal cord paralysis is rare and doesn't result in speech problems but rather breathing difficulties. Tracheostomy is the classic therapy, but laser cordectomy and Botulinum toxin injection in the laryngeal muscles are alternatives. PMID:26744682

  18. 980nm laser for difficult-to-treat basal cell carcinoma

    Derjabo, A. D.; Cema, I.; Lihacova, I.; Derjabo, L.

    2013-06-01

    Begin basal cell carcinoma (BCC) is most common skin cancer over the world. There are around 20 modalities for BCC treatment. Laser surgery is uncommon option. We demonstrate our long term follow up results. Aim: To evaluate long term efficacy of a 980nm diode laser for the difficult-to-treat basal cell carcinoma. Materials and Methods: 167 patients with 173 basal cell carcinoma on the nose were treated with a 980 nm diode laser from May 1999 till May 2005 at Latvian Oncology center. All tumors were morphologically confirmed. 156 patients were followed for more than 5 years. Results: The lowest recurrence rate was observed in cases of superficial BCC, diameterConclusions: 980 nm diode laser is useful tool in dermatology with high long term efficacy, good acceptance by the patients and good cosmetics results.

  19. [Prenatal care protocol: actions and the easy and difficult aspects dealt by Family Health Strategy nurses].

    Rodrigues, Edilene Matos; do Nascimento, Rafaella Gontijo; Araújo, Alisson

    2011-10-01

    The objective of this study was to learn the perception that nurses have about the protocol of their attributions in prenatal care, identifying the health actions they develop, as well as the easy and difficult aspects in using the referred protocol. This qualitative study was developed with Family Health Strategy nurses in Divinópolis, Minas Gerais. The data survey was performed through interviews with five nurses. The data was submitted to thematic content analysis. Results showed the need for investments in professional qualification for women's health care in the pregnancy-postpartum cycle, as well as to create and implement protocols that promote a better interaction between the medical and nursing work. PMID:22031361

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

    Sunohara, Mari; Okada, Toshiki

    2015-12-01

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

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

    Butyrin Andrey Yur'evich

    2014-02-01

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

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

    Vitart M. J.

    2006-11-01

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

  3. Visual relations children find easy and difficult to process in figural analogies.

    Stevenson, Claire E; Alberto, Rosa A; van den Boom, Max A; de Boeck, Paul A L

    2014-01-01

    Analogical reasoning, the ability to learn about novel phenomena by relating it to structurally similar knowledge, develops with great variability in children. Furthermore, the development of analogical reasoning coincides with greater working memory efficiency and increasing knowledge of the entities and relations present in analogy problems. In figural matrices, a classical form of analogical reasoning assessment, some features, such as color, appear easier for children to encode and infer than others, such as orientation. Yet, few studies have structurally examined differences in the difficulty of visual relations across different age-groups. This cross-sectional study of figural analogical reasoning examined which underlying rules in figural analogies were easier or more difficult for children to correctly process. School children (N = 1422, M = 7.0 years, SD = 21 months, range 4.5-12.5 years) were assessed in analogical reasoning using classical figural matrices and memory measures. The visual relations the children had to induce and apply concerned the features: animal, color, orientation, position, quantity and size. The role of age and memory span on the children's ability to correctly process each type of relation was examined using explanatory item response theory models. The results showed that with increasing age and/or greater memory span all visual relations were processed more accurately. The "what" visual relations animal, color, quantity and size were easiest, whereas the "where" relations orientation and position were most difficult. However, the "where" visual relations became relatively easier with age and increased memory efficiency. The implications are discussed in terms of the development of visual processing in object recognition vs. position and motion encoding in the ventral ("what") and dorsal ("where") pathways respectively. PMID:25140160

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

    Claire E Stevenson

    2014-08-01

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

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

    Abdusamad, Ayad

    2013-01-01

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

  6. Assesment of Macintosh Laryngoscope and Truview EVO2 Video-laryngoscope With Respect to Hemodynamic and Intubation Quality in Patients With Presumptive Difficult Intubation

    ÇAĞLAR TORUN, Aysun; TÜR, Ayla; Özkan, Fatih; KELSAKA, Ebru; Karakaya, Deniz; Sarihasan, Binnur; TORTOP, Emişe

    2011-01-01

    ABSTRACT This study aims to compare Macintosh laryngoscope and Truview EVO2 video- laryngoscope with respect to the quality of glottic image, the success rate of intubation and their impact on the duration of intubation, hemodynamic responses and also related complications in patients with expected difficult intubation according to the Mallampati scoring system. Sixty patients in ASA I-II group ranging from 18-65 years of age were included in the study. Patients were randomly divided into ...

  7. Chromosomal Conditions

    ... labor & premature birth The newborn intensive care unit (NICU) Birth defects & other health conditions Loss & grief Tools & ... labor & premature birth The newborn intensive care unit (NICU) Birth defects & other health conditions Loss & grief Ask ...

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

    Kryukov, V. I.

    2012-01-01

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

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

    Hicks, Marilyn M.

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

  10. Sensitivity of palm print, modified mallampati score and 3-3-2 rule in prediction of difficult intubation

    Ata Mahmoodpoor

    2013-01-01

    Full Text Available Background: This study evaluated the performance of modified Mallampati score, 3-3-2 rule and palm print in prediction of difficult intubation. Methods: In a prospective descriptive study, data from 500 patients scheduled for elective surgery under general anesthesia were collected. An anesthesiologist evaluated the airway using mentioned tests and another anesthesiologist evaluated difficult intubation. Laryngoscopic views were determined by Cormack and Lehane score. Grades 3 and 4 were defined as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were determined for all tests. Results: Difficult intubation was reported in 8.9% of the patients. There was a significant correlation between body mass index and difficult intubation (P : 0.004; however, other demographic characteristics didn′t have a significant correlation with difficult intubation. Among three tests, palm print was of highest specificity (96.46% and modified Mallampati of highest sensitivity (98.40%. In a combination of the tests, the highest specificity, sensitivity and Youden index were observed when using all three tests together. Conclusions: Palm print has a high specificity for prediction of difficult intubation, but the best way for prediction of difficult intubation is using all three tests together.

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

    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.

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

    Kirschfink Michael

    2010-07-01

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

  13. New precut sphincterotomy for endoscopic retrograde cholangiopancreatography in difficult biliary duct cannulation

    2007-01-01

    AIM: To retrospectively investigate the effect and safety of various new type precut sphincterotomy techniques (VNTPST) in endoscopic retrograde cholangiopancreatography (ERCP) due to difficult biliary duct cannulation (DBC).METHODS: A plough-like pull-type sphincterotome (PLPTS) or improved short nose sphincterotome or improved needle knife was applied. VNTPST was carried out in 30 of 280 patients, whose biliary tract could not be exposed well or deep cannulation was difficult to perform during ERCP with traditional methods. Patients were followed up for short-term complications and the therapeutic effect of VNTPS was observed and compared with that of traditional endoscopic sphincterotomy (EST).RESULTS: A total 280 patients underwent ERCP, of which 3 failed in operation because of pathological features in stomch or duodenum, 247 successfully underwent traditional ERCP (89.1%, 247/277), 30 failed (10.8%, 30/277). VNTPS technique succeeded in 24(80%, 24/30) of 30 cases. The successful rate of deep biliary duct cannulation increased 8.6% (24/277), the total cannulation successful rate following precut was 97.7%. There was a significant difference between the two groups (97.7% vs 89.1%, χ2= 17.1, P < 0.01).The incidence of complications was 9.3% (26/277) for traditional ERCP group and 13.3% (4/30) for VNTPS technique group. Guideline tip was broken in pancreatic duct (KPDGP) of one patient, and there was no pancreatitis, slight or moderate bleeding postoperatively occurred in 2 patients, 1 patient had bleeding during operation (PDWN). There were no differences between VNTPS technique group and traditional ERCP(TRERCP)group (13.3% vs 9.3%,χ2 = 0.478, P > 0.05).CONCLUSION: VNTPS procedure and Deng's precut are highly effective methods to get biliary access during ERCP with DBC. With skillful techniques, it can increase the successful rate for deep cannulation of biliary duct and decrease complications. VNTPS technique, especially Deng's precut is as effective and

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

    McKee, Gabrielle

    2002-04-01

    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

  15. Difficult diagnosis: strangulated obturator hernia in an 88-year-old woman.

    Leitch, Megan Kathleen; Yunaev, Michael

    2016-01-01

    The obturator hernia is a rare type of hernia that can present a diagnostic challenge for the clinician. We report a case of an 88-year-old woman who presented with a history of right iliac fossa pain, bilious vomiting and diarrhoea. Non-specific findings on examination and blood tests made the diagnosis difficult, however, a CT scan of her abdomen revealed the site of the obstruction and the patient was taken to theatre for emergency surgery. We review the literature with focus on the diagnosis of obturator hernias and the different surgical approaches used. The authors believe that this case is of educational value to healthcare professionals, particularly those working in general practice, emergency departments and on surgical teams. It highlights to doctors that patients with incarcerated obturator hernias can present with or without overt signs of intestinal obstruction and emphasises the fact that an obturator hernia can be an important cause of intestinal obstruction in a thin, elderly woman. PMID:27358098

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

    Tamirace FAKHOURY

    2010-05-01

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

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

    N Botha

    2008-06-01

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

  18. Resilience and responses to the experience of trauma – a fascinating but difficult study area

    Szwajca, Krzysztof

    2014-06-01

    Full Text Available The notion of resilience, which attempts to explain the phenomenon of positive adaptation (coping of people exposed to adversities or traumatic events, is becoming a significant area of research in Poland. It is a complex and multidimensional notion, on the borderline between genetics, neurophysiology, anthropology of culture, sociology, medicine, political science, developmental psychology and psychiatry. The phenomenon of resilience is interactive (as it combines the experience of trauma with adaptation to it, it is difficult to measure and it raises serious methodological concerns. They tend to be so significant that some researchers consider resilience to be a construct of dubious scientific value. Such a view seems to be overly critical, however it indicates the magnitude of methodological difficulties. This article discusses some of them: problems with definitions and terminology, measurement difficulties associated with the interactive nature of resilience, the need to search for complex interactions between biological, psychological, social and environmental factors (rather than overly simplistic focus on individual factors which support good adaptation. The methodological issues have been divided into the following research areas: the nature of traumatic experiences, response to trauma, factors which impact the reporting of the reaction to trauma, developmental problems.

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

    Stephanie M Carpenter

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

  20. Difficult case of a trans-septal puncture: Use of a “SafeSept” guidewire

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

    2015-01-01

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

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

    Gansel, Yannis; Lézé, Samuel

    2015-10-01

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

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

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

    2016-01-01

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

  3. Open Boundary Conditions for Dissipative MHD

    Meier, E T

    2011-11-10

    In modeling magnetic confinement, astrophysics, and plasma propulsion, representing the entire physical domain is often difficult or impossible, and artificial, or 'open' boundaries are appropriate. A novel open boundary condition (BC) for dissipative MHD, called Lacuna-based open BC (LOBC), is presented. LOBC, based on the idea of lacuna-based truncation originally presented by V.S. Ryaben'kii and S.V. Tsynkov, provide truncation with low numerical noise and minimal reflections. For hyperbolic systems, characteristic-based BC (CBC) exist for separating the solution into outgoing and incoming parts. In the hyperbolic-parabolic dissipative MHD system, such separation is not possible, and CBC are numerically unstable. LOBC are applied in dissipative MHD test problems including a translating FRC, and coaxial-electrode plasma acceleration. Solution quality is compared to solutions using CBC and zero-normal derivative BC. LOBC are a promising new open BC option for dissipative MHD.

  4. Modeling temperature and moisture fields in conditioned spaces using zonal approach, including sorption phenomena in buildings materials; Modelisation thermo-hydro-aeraulique des locaux climatises selon l'approche zonale (prise en compte des phenomenes de sorption d'humidite)

    Cordeiro Mendoca, K.

    2004-05-15

    Building simulation models represent in our days an important tool for building conception and performance analysis. Although moisture interacts in many ways with the whole building affecting therefore its behavior, frequently these models neglects the interactions between them. In addition, in most of them, indoor air conditions are considered uniform, which is a non-realistic assumption in conditioned spaces. In this work, a model to predict temperature and moisture fields in conditioned spaces, using zonal approach, is proposed. This method is based in dividing spatially a room in a relative small number of zones, typically on the order of tens to hundreds, where the state variables of air are considered uniform, with the exception of pressure that varies hydrostatically. While not as fine-grained as CFD simulation, zonal models do give useful information about temperature and moisture distributions that is important in comfort analysis. The proposed model was structured in three groups of sub-models representing the three building domains: indoor air, envelope and HVAC system. The indoor air sub-model is related to the indoor air space, where airflow speed can be considered weak. The envelope sub-model is related to the radiation exchanges between envelope and its neighborhood, and to the simultaneous heat and mass transfers across the envelope material. This latest can be represented by four sub-models of different complexity levels, with two of them taking into account moisture adsorption and desorption by building materials. Concerning to the HVAC system model, it refers to the whole system that means equipment, control and specific airflow from equipment. All sub-models were coupled into a modular simulation environment, SPARK, well-adapted to compare different models. The applicability of the proposed model is shown by two examples. The first one shows the importance of considering moisture sorption phenomena in the prediction of indoor air conditions

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

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

    2015-08-15

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

  6. Working with "difficult" patients: an interview with Jorge García Badaracco, by Francesca Viola Borgogno.

    Badaracco, Jorge Garcia

    2010-12-01

    Jorge García Badaracco's pioneering work is well-known in his native Argentina, but not so much elsewhere. Since he was appointed as Director of a service in the Borda Buenos Aires Neuro-Psychiatric Hospital in 1959, García Badaracco started to make use of all available resources to overcome the many problems that the analysis of "difficult patients" (often psychotic) entails. In later years, he developed his ground-breaking "multifamily groups", that is, therapeutic groups that included patients, their relatives, nurses, members of the staff, and that offered the possibility to work simultaneously, in one single therapeutic intervention, on the individual, familiar, and social dimension of the mind. In this interview with García Badaracco, Francesca Viola Borgogno introduces the reader to this distinguished figure, as well as to some of his most original theoretical and clinical concepts, such as "the maddening object", "the pathological and pathogenic interdependence", "the healthy virtuality", and so on. PMID:21116289

  7. Dexmedetomidine for awake intubation and an opioid-free general anesthesia in a superobese patient with suspected difficult intubation

    Gaszynski T

    2014-07-01

    Full Text Available Tomasz Gaszynski,1 Ewelina Gaszynska,2 Tomasz Szewczyk31Department of Anesthesiology and Intensive Therapy, 2Department of Hygiene and Health Promotion, 3Department of Gastroenterology, Oncology, and General Surgery, Barlicki University Hospital, Medical University of Lodz, PolandAbstract: Super-obese patients (body mass index [BMI] >50 kg/m2 are at a particularly high risk of anesthesia-related complications during postoperative period, eg, critical respiratory events including respiratory arrest, and over-sedation leading to problems with maintaining airway open, hypoxia and hypercapnia. In this paper authors present a case of a 39-year-old super-obese (BMI 62.3 kg/m2 female patient who was admitted for surgical treatment of obesity. Preanesthesia evaluation revealed hypertension and type 2 diabetes mellitus (DM as comorbidities as well as potential for a difficult intubation– neck circumference of 46 cm, reduced neck mobility and DM type 2. Patient was intubated using "awake intubation" method using topical anesthesia and dexmedetomidine infusion. General anesthesia was maintained with sevoflurane and dexmedetomidine infusion instead of opioid administration in "opioid-free anesthesia method".Keywords: morbid obesity, non-opioid anesthesia, dexmedetomidine

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

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

  9. Why is it difficult to embed employee participation in the factory practice?

    Buhl, Henrik

    1997-01-01

    The purpose of my study is to evaluate projects with employee participation and to analyze the conditions for employee participation and the way in which it can be rooted in a factory. My hypothesis is that communicative actions have to be developed and supported as a precondition for the...... establishment of employee participation. This will propably lead to a more innovative practice, a learning organization. In this way the discussion about conditions for the establishment of participation turn in to a discussion about how to use participation to develope an innovative practice, realized in a...

  10. 物理化学难教难学的应对方法%On Coping Methods of Difficult Teaching and Learning in Physical Chemistry

    屈景年; 李俊华; 曾荣英; 刘兴; 聂雪

    2014-01-01

    该文介绍了物理化学公式多、数学推导多、公式使用条件多、抽象概念多、计算多等难教难学问题的教与学应对方法。%This paper introduced the coping methods of difficult teaching and learning in physical chemistry due to too many for-mula ,mathematical derivation ,formula using -conditions ,abstract concepts ,calculations and so on .

  11. Conditional Comonotonicity

    Napp, Clotilde; Jouini, Elyès

    2005-01-01

    In this paper we propose a generalization of the comonotonicity notion by introducing and exploring the concept of conditional comonotonicity. We characterize this notion and we show on examples that conditional comonotonicity is the natural extension of the concept of comonotonicity to dynamic settings.

  12. Assessing the Extraction Potential of Tomsk Region’s Difficult-To-Obtain Oil Reserves

    Irina Valeryevna Sharf

    2016-03-01

    Full Text Available A significant increase in oil production in the Tomsk region can be achieved by a better development of the license areas at the disposal of oil-producing companies, active prospecting, introduction of innovative technologies to increase the oil recovery, as well as active oil extraction from unconventional horizons. This article reviews the activities of the oil-producing companies of the Tomsk region for the past 10 years, and proves the potential of increasing oil production of both traditional and difficultto-obtain oil reserves, concentrated in the Bazhenov and Tyumen Formations and the Lower Jurassic sediments. Technologically, Russia is significantly lagging behind the economically developed countries in the extraction of hard unconventional hydrocarbon resources, primarily, the United States. The observed «shale revolution» was due to the complex of financial and tax breaks for oil companies, from which mainly medium and small companies were benefited. As a result, this requires an increase in investment on the part of economic entities and regional authorities, as well as additional tax benefits, considering the quality and types of actual and prospective raw materials produced in the region, in contrast to the declared benefits in Eastern Siberia. The introduction of tax incentives justified by the authors and the implementation of public-private partnership will ensure the profitability of the development of marginal and difficult-to-obtain oil deposits of the Tomsk region in the long term, which in turn should ensure the stability of economic development of the subject of the Russian Federation

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

    The CADIS and FW-CADIS hybrid Monte Carlo/deterministic techniques dramatically increase the efficiency of neutronics modeling, but their use in the accurate design analysis of very large and geometrically complex nuclear systems has been limited by the large number of processors and memory requirements for their preliminary deterministic calculations and final Monte Carlo calculation. Three mesh adaptivity algorithms were developed to reduce the memory requirements of CADIS and FW-CADIS without sacrificing their efficiency improvement. First, a macro-material approach enhances the fidelity of the deterministic models without changing the mesh. Second, a deterministic mesh refinement algorithm generates meshes that capture as much geometric detail as possible without exceeding a specified maximum number of mesh elements. Finally, a weight window coarsening algorithm de-couples the weight window mesh and energy bins from the mesh and energy group structure of the deterministic calculations in order to remove the memory constraint of the weight window map from the deterministic mesh resolution. The three algorithms were used to enhance an FW-CADIS calculation of the prompt dose rate throughout the ITER experimental facility. Using these algorithms resulted in a 23.3% increase in the number of mesh tally elements in which the dose rates were calculated in a 10-day Monte Carlo calculation and, additionally, increased the efficiency of the Monte Carlo simulation by a factor of at least 3.4. The three algorithms enabled this difficult calculation to be accurately solved using an FW-CADIS simulation on a regular computer cluster, obviating the need for a world-class super computer. (authors)

  14. [A Case of Pyoderma Gangrenosum of the Penis Difficult to Distinguish from Fournier Gangrene].

    Taguchi, Makoto; Inoue, Takaaki; Nishida, Teruhisa; Kawabata, Takashi; Kawakita, Shigenari; Muguruma, Kouei; Murota, Takashi; Kinoshita, Hidefumi; Matsuda, Tadashi

    2015-11-01

    Here, we report a case of pyoderma gangrenosum of the penis which was difficult to distinguish from Fournier gangrene. The patient was a 54-year-old male who was aware of redness and swelling of the glanspenis for 1 month prior to a consultation at our department. Although he was diagnosed with herpes and treated at a nearby hospital, his symptoms did not improve. Subsequently, the patient visited our department following the onset of pain and fever. During his initial consultation, he had a fever of 39 °C as well as redness and swelling of the glans penis with partial spontaneous purulent discharge. His blood test revealed an elevated white blood cell count (20, 000/μl) and C-reactive protein (19.1 mg/dl). Because Fournier gangrene was suspected, administration of broad-spectrum antimicrobial agents was initiated but proved to be ineffective. An abscess (2 cm in diameter) was also noted in the umbilical region.Enterococcus faecalis was detected by the bacterial culture ; and therefore, Fournier gangrene was diagnosed. A partial penectomy was performed to control the infection. Pathological findings showed only non-specific inflammation ; however, fever persisted postoperatively and blood test results showed no improvement. Furthermore, new abscess lesions emerged on the right heel and back. Because the re-performed abscess bacterial culture test result was negative, pyoderma gangrenosum was suspected, and he was started on oral prednisolone (20 mg/day). On the following day, his fever subsided and his blood test results also showed improvement. A final diagnosis of pyoderma gangrenosum was ultimately made. PMID:26699892

  15. Stepwise optimization of a low-temperature Bacillus subtilis expression system for "difficult to express" proteins.

    Welsch, Norma; Homuth, Georg; Schweder, Thomas

    2015-08-01

    In order to improve the overproduction of "difficult to express" proteins, a low-temperature expression system for Bacillus subtilis based on the cold-inducible promoter of the desaturase-encoding des gene was constructed. Selected regulatory DNA sequence elements from B. subtilis genes known to be cold-inducible were fused to different model genes. It could be demonstrated that these regulatory elements are able to mediate increased heterologous gene expression, either by improved translation efficiency or by higher messenger RNA (mRNA) stability. In case of a cold-adapted β-galactosidase from Pseudoalteromonas haloplanktis TAE79A serving as the model, significantly higher expression was achieved by fusing its coding sequence to the so-called "downstream box" sequence of cspB encoding the major B. subtilis cold-shock protein. The combination of this fusion with a cspB 5'-UTR stem-loop structure resulted in further enhancement of the β-galactosidase expression. In addition, integration of the transcription terminator of the B. subtilis cold-inducible bkd operon downstream of the target genes caused a higher mRNA stability and enabled thus a further significant increase in expression. Finally, the fully optimized expression system was validated by overproducing a B. subtilis xylanase as well as an α-glucosidase from Saccharomyces cerevisiae, the latter known for tending to form inclusion bodies. These analyses verified the applicability of the engineered expression system for extracellular and intracellular protein synthesis in B. subtilis, thereby confirming the suitability of this host organism for the overproduction of critical, poorly soluble proteins. PMID:25851716

  16. Forming Competing Fear Learning and Extinction Memories in Adolescence Makes Fear Difficult to Inhibit

    Baker, Kathryn D.; Richardson, Rick

    2015-01-01

    Fear inhibition is markedly impaired in adolescent rodents and humans. The present experiments investigated whether this impairment is critically determined by the animal's age at the time of fear learning or their age at fear extinction. Male rats (n = 170) were tested for extinction retention after conditioning and extinction at different ages.…

  17. Learning Increases the Survival of Newborn Neurons Provided that Learning Is Difficult to Achieve and Successful

    Curlik, Daniel M., II; Shors, Tracey J.

    2011-01-01

    Learning increases neurogenesis by increasing the survival of new cells generated in the adult hippocampal formation [Shors, T. J. Saving new brain cells. "Scientific American," 300, 46-52, 2009]. However, only some types of learning are effective. Recent studies demonstrate that animals that learn the conditioned response (CR) but require more…

  18. 歌唱教学难点与对策%Difficult Points and Countermeasures in Singing Teaching

    李艳婷

    2014-01-01

    Singing art is a profound,complicated and comprehensive performing art. In singing teaching,various ways need to be adopted to improve students' comprehensive quality. The difficult points in teaching lie in the abstract and professional nature of vocalization training,which determines the hard and long process of learning. The countermeasures are to teach and train students to build up confidence,know the difficulty correctly,pay great attention to basic training,have an excellent singing condition,develop a correct concept of voice,practice articulating correctly and clearly,control breath freely,feel and grasp emotions in the song,and realize the artistic distillation.%歌唱艺术是一门高深而复杂的综合性表演艺术,在教学中通过多方面的专业教学,提高学生的综合素质。发声训练的抽象性和专业性困难决定了学习过程的艰辛和漫长,让学生树立信心,正确认知难与易,注重基础训练,培养良好的歌唱状态,树立正确的声音概念,训练咬字的准确性,驾驭歌唱的气息,把握歌曲情感和艺术升华等要素是解决困难的对策。

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

    Parakh, Jal S.; Slesnick, Irwin L.

    1989-01-01

    Discusses who has the right to determine the use of animals in scientific research which includes medical experimentation and the toxicity testing of compounds, ranging from pesticides to cosmetics. Provides a list of questions for consideration and discussion. (RT)

  20. Heuristic Optimization Applied to an Intrinsically Difficult Problem: Birds Formation Flight

    Filippone, Antonino

    1996-01-01

    The birds formation flight is studied by means oftheoretical aerodynamics, heuristic methods anddistributed systems. A simplified aerodynamic analog is presented, and calculations of drag savings and flight range are shown for sometypical cases, including the line abreast flightwith various...

  1. Prolactinoma in a Diabetic Dialysis Patient with Erectile Dysfunction: A Difficult Differential Diagnosis

    Piccoli, Giorgina B.; Bermont, Francesca; Magnano, Andrea; Soragna, Giorgio; Terzolo, Massimo

    2006-01-01

    Dialysis patients often suffer from erectile dysfunction. The prevalence of this symptom in the context of dialysis is as high as 90%. Diabetes, diffuse vascular disease and pharmacological therapy are attendant causes of this condition, severely impairing the quality of life. Due to the high frequency of erectile dysfunction in uremic patients, minimalist diagnostic approaches are often used. Nevertheless, a careful differential diagnosis is also warranted in well dialyzed patients to identi...

  2. Sustaining Economic Development and the Value of Economic Production: Different Views and Difficult Problems

    Tisdell, Clement A.

    2012-01-01

    Indicates some of the different concepts of sustainable economic development and raises queries about how much present generations are concerned with future generations. A variety of conditions (ranging from very weak to very strong) have been suggested for achieving sustainable development. These are outlined. The prospect that the accumulation of man-made capital may result in unsustainable economic development is discussed and the welfare consequences of the conversion of natural capital a...

  3. Optimal for difficult roofs. East-west orientation; Optimal fuer schwierige Daecher. Ost-West-Ausrichtung

    Bouattour, Mohamed Ali [Solar Frontier Europe GmbH, Muenchen (Germany)

    2013-10-01

    With the help of CIS solar modules the unfavorable east-west roofs can be also use efficiently and profitably, since the good weak-light performance almost compensates the weak light components characterized irradiation conditions. [German] Mit Hilfe der CIS-Solarmodule lassen sich auch die unguenstige Ost-West-Daecher effizient und profitabel nutzen, da das gute Schwachlichtverhalten die hier von schwachen Lichtanteilen gepraegten Einstrahlungsverhaeltnisse nahezu kompensiert.

  4. The Reality of Myoelectric Prostheses: Understanding What Makes These Devices Difficult for Some Users to Control.

    Chadwell, Alix; Kenney, Laurence; Thies, Sibylle; Galpin, Adam; Head, John

    2016-01-01

    Users of myoelectric prostheses can often find them difficult to control. This can lead to passive-use of the device or total rejection, which can have detrimental effects on the contralateral limb due to overuse. Current clinically available prostheses are "open loop" systems, and although considerable effort has been focused on developing biofeedback to "close the loop," there is evidence from laboratory-based studies that other factors, notably improving predictability of response, may be as, if not more, important. Interestingly, despite a large volume of research aimed at improving myoelectric prostheses, it is not currently known which aspect of clinically available systems has the greatest impact on overall functionality and everyday usage. A protocol has, therefore, been designed to assess electromyographic (EMG) skill of the user and predictability of the prosthesis response as significant parts of the control chain, and to relate these to functionality and everyday usage. Here, we present the protocol and results from early pilot work. A set of experiments has been developed. First, to characterize user skill in generating the required level of EMG signal, as well as the speed with which users are able to make the decision to activate the appropriate muscles. Second, to measure unpredictability introduced at the skin-electrode interface, in order to understand the effects of the socket-mounted electrode fit under different loads on the variability of time taken for the prosthetic hand to respond. To evaluate prosthesis user functionality, four different outcome measures are assessed. Using a simple upper limb functional task prosthesis users are assessed for (1) success of task completion, (2) task duration, (3) quality of movement, and (4) gaze behavior. To evaluate everyday usage away from the clinic, the symmetricity of their real-world arm use is assessed using activity monitoring. These methods will later be used to assess a prosthesis user cohort to

  5. A Study on the Operation Strategy for Combined Accident including TLOFW accident

    It is difficult for operators to recognize the necessity of a feed-and-bleed (F-B) operation when the loss of coolant accident and failure of secondary side occur. An F-B operation directly cools down the reactor coolant system (RCS) using the primary cooling system when residual heat removal by the secondary cooling system is not available. The plant is not always necessary the F-B operation when the secondary side is failed. It is not necessary to initiate an F-B operation in the case of a medium or large break because these cases correspond to low RCS pressure sequences when the secondary side is failed. If the break size is too small to sufficiently decrease the RCS pressure, the F-B operation is necessary. Therefore, in the case of a combined accident including a secondary cooling system failure, the provision of clear information will play a critical role in the operators' decision to initiate an F-B operation. This study focuses on the how we establish the operation strategy for combined accident including the failure of secondary side in consideration of plant and operating conditions. Previous studies have usually focused on accidents involving a TLOFW accident. The plant conditions to make the operators confused seriously are usually the combined accident because the ORP only focuses on a single accident and FRP is less familiar with operators. The relationship between CET and PCT under various plant conditions is important to decide the limitation of initiating the F-B operation to prevent core damage

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

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

    2014-12-01

    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

  7. Musculoskeletal ultrasound including definitions for ultrasonographic pathology

    Wakefield, RJ; Balint, PV; Szkudlarek, Marcin;

    2005-01-01

    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...

  8. Extending Newtonian Dynamics to Include Stochastic Processes

    Zak, Michail

    2009-01-01

    A paper presents further results of continuing research reported in several previous NASA Tech Briefs articles, the two most recent being Stochastic Representations of Chaos Using Terminal Attractors (NPO-41519), [Vol. 30, No. 5 (May 2006), page 57] and Physical Principle for Generation of Randomness (NPO-43822) [Vol. 33, No. 5 (May 2009), page 56]. This research focuses upon a mathematical formalism for describing post-instability motions of a dynamical system characterized by exponential divergences of trajectories leading to chaos (including turbulence as a form of chaos). The formalism involves fictitious control forces that couple the equations of motion of the system with a Liouville equation that describes the evolution of the probability density of errors in initial conditions. These stabilizing forces create a powerful terminal attractor in probability space that corresponds to occurrence of a target trajectory with probability one. The effect in configuration space (ordinary three-dimensional space as commonly perceived) is to suppress exponential divergences of neighboring trajectories without affecting the target trajectory. As a result, the post-instability motion is represented by a set of functions describing the evolution of such statistical quantities as expectations and higher moments, and this representation is stable.

  9. 76 FR 66741 - Statutorily Mandated Designation of Difficult Development Areas and Qualified Census Tracts for 2012

    2011-10-27

    ..., rehabilitation, or new construction costs (depending on the type of LIHTC involved). These costs include amounts... by the Secretary of HUD as an area that has high construction, land, and utility costs relative to... FMR Areas as the measure of ``construction, land, and utility costs relative to area median...

  10. Difficult to predict early failure after major lower-extremity amputations

    Kristensen, Morten Tange; Holm, Gitte; Gebuhr, Peter

    2015-01-01

    INTRODUCTION: The successful outcome of a major amputation depends on several factors, including stump wound healing. The purpose of this study was to examine the criteria upon which the index amputation was based and to identify factors associated with early amputation failure after major non-tr...

  11. Asking Difficult Questions: Exploring Research Methods with Children on Painful Issues

    Leeson, Caroline

    2014-01-01

    Assumptions about a child's competence to voice an opinion often inhibit efforts to find effective methods for participation. Answers to questions are sought from the significant adults who surround a child [Morris, J. 2003. "Including All Children: Finding Out about the Experiences of Children with Communication and/or Cognitive…

  12. What works? Strategies to increase reproductive, maternal and child health in difficult to access mountainous locations: a systematic literature review.

    Abbey Byrne

    Full Text Available BACKGROUND: Geography poses serious challenges to delivery of health services and is a well documented marker of inequity. Maternal, newborn and child health (MNCH outcomes are poorer in mountainous regions of low and lower-middle income countries due to geographical inaccessibility combined with other barriers: poorer quality services, persistent cultural and traditional practices and lower socioeconomic and educational status. Reaching universal coverage goals will require attention for remote mountain settings. This study aims to identify strategies to address barriers to reproductive MNCH (RMNCH service utilisation in difficult-to-reach mountainous regions in low and lower-middle income settings worldwide. METHODS: A systematic literature review drawing from MEDLINE, Web of Science, Scopus, Google Scholar, and Eldis. Inclusion was based on; testing an intervention for utilisation of RMNCH services; remote mountain settings of low- and lower-middle income countries; selected study designs. Studies were assessed for quality and analysed to present a narrative review of the key themes. FINDINGS: From 4,130 articles 34 studies were included, from Afghanistan, Bolivia, Ethiopia, Guatemala, Indonesia, Kenya, Kyrgyzstan, Nepal, Pakistan, Papua New Guinea and Tajikistan. Strategies fall into four broad categories: improving service delivery through selected, trained and supported community health workers (CHWs to act alongside formal health workers and the distribution of critical medicines to the home; improving the desirability of existing services by addressing the quality of care, innovative training and supervision of health workers; generating demand by engaging communities; and improving health knowledge for timely care-seeking. Task shifting, strengthened roles of CHWs and volunteers, mobile teams, and inclusive structured planning forums have proved effective. CONCLUSIONS: The review highlights where known evidence-based strategies have

  13. Is less really more: Does a prefrontal efficiency genotype actually confer better performance when working memory becomes difficult?

    Ihne, Jessica L; Gallagher, Natalie M; Sullivan, Marie; Callicott, Joseph H; Green, Adam E

    2016-01-01

    Perhaps the most widely studied effect to emerge from the combination of neuroimaging and human genetics is the association of the COMT-Val(108/158)Met polymorphism with prefrontal activity during working memory. COMT-Val is a putative risk factor in schizophrenia, which is characterized by disordered prefrontal function. Work in healthy populations has sought to characterize mechanisms by which the valine (Val) allele may lead to disadvantaged prefrontal cognition. Lower activity in methionine (Met) carriers has been interpreted as advantageous neural efficiency. Notably, however, studies reporting COMT effects on neural efficiency have generally not reported working memory performance effects. Those studies have employed relatively low/easy working memory loads. Higher loads are known to elicit individual differences in working memory performance that are not visible at lower loads. If COMT-Met confers greater neural efficiency when working memory is easy, a reasonable prediction is that Met carriers will be better able to cope with increasing demand for neural resources when working memory becomes difficult. To our knowledge, this prediction has thus far gone untested. Here, we tested performance on three working memory tasks. Performance on each task was measured at multiple levels of load/difficulty, including loads more demanding than those used in prior studies. We found no genotype-by-load interactions or main effects of COMT genotype on accuracy or reaction time. Indeed, even testing for performance differences at each load of each task failed to find a single significant effect of COMT genotype. Thus, even if COMT genotype has the effects on prefrontal efficiency that prior work has suggested, such effects may not directly impact high-load working memory ability. The present findings accord with previous evidence that behavioral effects of COMT are small or nonexistent and, more broadly, with a growing consensus that substantial effects on phenotype will

  14. Natural selection and the conditions for existence: representational vs. conditional teleology in biological explanation.

    Reiss, John O

    2005-01-01

    Human intentional action, including the design and use of artifacts, involves the prior mental representation of the goal (end) and the means to achieve that goal. This representation is part of the efficient cause of the action, and thus can be used to explain both the action and the achievement of the end. This is intentional teleological explanation. More generally, teleological explanation that depends on the real existence of a representation of the goal (and the means to achieve it) can be called representational teleological explanation. Such explanations in biology can involve both external representations (e.g., ideas in the mind of God) and internal representations (souls, vital powers, entelechies, developmental programs, etc.). However, another type of explanation of intentional action (or any other process) is possible. Given that an action achieving a result occurs, the action can be explained as fulfilling the necessary conditions (means) for that result (end), and, reciprocally, the result explained by the occurrence of those necessary conditions. This is conditional teleological explanation. For organisms, natural selection is often understood metaphorically as the designer, intentionally constructing them for certain ends. Unfortunately, this metaphor is often taken rather too literally, because it has been difficult to conceive of another way to relate natural selection to the process of evolution. I argue that combining a conditional teleological explanation of organisms and of evolution provides such an alternative. This conditional teleology can be grounded in existence or survival. Given that an organism exists, we can explain its existence by the occurrence of the necessary conditions for that existence. This principle of the 'conditions for existence' was introduced by Georges Cuvier in 1800, and provides a valid, conditional teleological method for explaining organismal structure and behavior. From an evolutionary perspective, the

  15. UK Shale Gas – Hype, Reality and Difficult Questions: OIES paper

    Rogers, Howard

    2013-01-01

    The shale gas phenomenon has transformed the US from prospective LNG importer to the current expectation of it becoming a major LNG exporter. In the UK the recent upgraded estimates by the British Geological Society of shale gas resources in the north of England have unleashed a wave of speculation in the media which includes an anticipation of lower prices and eliminating the need for natural gas imports. Drawing on US data, this Comment seeks to highlight the practicalities to be faced ...

  16. Antimicrobial Drug Resistance: "Prediction Is Very Difficult, Especially about the Future"1

    Courvalin, Patrice

    2005-01-01

    Evolution of bacteria towards resistance to antimicrobial drugs, including multidrug resistance, is unavoidable because it represents a particular aspect of the general evolution of bacteria that is unstoppable. Therefore, the only means of dealing with this situation is to delay the emergence and subsequent dissemination of resistant bacteria or resistance genes. Resistance to antimicrobial drugs in bacteria can result from mutations in housekeeping structural or regulatory genes. Alternativ...

  17. Cough and dyspnoea of an asthmatic patient at Mt. Kilimanjaro: a difficult differential diagnosis.

    Goebbels, K; Gieseler, U; Schöffl, Volker; Küpper, Thomas

    2010-01-01

    This case highlights the difficulties associated with the differential diagnosis of pulmonary symptoms in patients with pre-existing diseases in extreme environmental conditions. A 58-year-old man with child-onset allergic asthma developed dyspnoea and an acute non-productive cough during a trekking expedition on Mt. Kilimanjaro (5895m) in Tanzania. The symptoms were believed initially to be linked to the high altitude exposure (high altitude pulmonary oedema (HAPE) or high altitude cough) or his pre-existing asthma. However, he was later diagnosed correctly with a reinfection of Bordetella pertussis. Pertussis is a highly communicable disease with potentially serious medical consequences that could have affected all of the expedition members. The effectiveness of a pertussis vaccine declines 4-12 years after the vaccination. Thus, it is suggested that the status of immunisation against pertussis should be checked along with those of other infections prior to travel. PMID:20188301

  18. The Difficult Diagnosis of Ischaemic Papillary Muscle Rupture; Case report from an urban emergency department

    Christian T. Braun

    2016-05-01

    Full Text Available We present a rare case of severe ischaemic papillary muscle rupture in a 67-year-old male patient who was admitted to the Emergency Department of the University Hospital Bern, Switzerland, in November 2013 with acute chest pain. On admission, the patient’s blood pressure was 60/40 mm/Hg, his pulse was 110 beats per minute and his respiratory rate was 20 breaths per minute. An electrocardiogram was normal and focused assessment with sonography in trauma was negative. Transthoracic echocardiography showed possible thickening of the mitral valve leaflet with no indications of severe mitral insufficiency or wall motion abnormalities. Triple-ruleout computed tomography angiography revealed no pulmonary emboli or aortic dissection, although coronary atherosclerosis was present. Finally, severe insufficiency of the mitral valve with rupture of the papillary muscle, likely due to ischaemia, was observed via transoesophageal echocardiography. The patient underwent a successful surgical intervention and was discharged 10 days later in stable condition.

  19. CONDITIONED SUPERPROCESSES

    LICUNHANG; WURONG

    1997-01-01

    A class of superprocesses which dies out is investigated. Under the condition of norextinction, a new superprocess is COnstructed, its life time is infinite, and its distribution isdetermined by the moment function. Several limit theorems about this superprocess and its occulpation time process are obtained.

  20. Difficult case of Cronkhite-Canada syndrome with small intestinal bacterial overgrowth, Clostridium difficile infection and polymyalgia rheumatica.

    Traussnigg, Stefan; Dolak, Werner; Trauner, Michael; Kazemi-Shirazi, Lili

    2016-01-01

    A 64-year-old woman presented with heavy diarrhoea, nausea and weight loss accompanied by alopecia and dystrophic fingernails and toenails. The preceding diagnosis of an inflammatory bowel disease, a common pitfall, was excluded by endoscopic work up. Instead, Cronkhite-Canada syndrome (CCS), a rare polyposis condition, was identified as the reason for this almost pathognomonic combination of diagnostic findings including various polyps throughout the entire intestine and ectodermal abnormalities. This case exemplifies common risks and complications in terms of gastrointestinal malabsorption, infections and small intestinal bacterial overgrowth (SIBO), including its treatment as well as a hereto unreported association with polymyalgia rheumatica. In CCS, long-term immunosuppressive therapy and close endoscopic cancer screening of the patient is essential. The treatment of vitamin deficiency and recurring SIBO helps to reduce symptoms. PMID:26818813

  1. Difficult Management of Coronary Artery Disease in a Patient with Thrombotic Thrombocytopenic Purpura

    Fatemeh Jorfi

    2015-10-01

    Full Text Available Thrombotic thrombocytopenic purpura (TTP is a rare syndrome affecting multiple organs. There is no sufficient evidence regarding the clinical cardiac manifestations of TTP. Nonetheless, pathologic cardiac involvement is quite frequent in acute TTP, which is predominantly manifested as myocardial necrosis due to coronary arteriolar microthrombosis. The present case report describes a 43-year-old man with long-standing remitted TTP, who suffered from a sequence of refractory thrombotic epicardial coronary events. Aggressive medical and interventional therapies, including long-term dual antiplatelets and coronary angioplasty, were finally successful in remitting the thrombotic events. During his two-year follow up, he has been asymptomatic.

  2. Retraction note: The prevalence of obstructive sleep apnea in patients with difficult-to-treat asthma.

    2015-12-01

    This original article, published in the Asian Pacific Journal of Allergy and Immunology, has been retracted from this journal based on an error in the analysis included a patient who has not given informed consent. The authors could not be contacted to provide the explanation. Due to the nature of the error, the Editor-in-Chief and the Associate Editors have decided to retract this article although this error does not affect the validity of the study. We apologize for any adverse consequences this may have caused. PMID:26708400

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

    Namrata Maheshwari

    2012-01-01

    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.

  4. Modeling of tamped and decoupled explosions in salt (simulation is easy. Prediction is difficult exclamation point)

    We compare predictions of the strain hardening model of Glenn (1990), with and without damage, to free field and seismic observations of SALMON, STERLING, and 64 kt (tamped) and 8 kt (decoupled) explosions in an Azgir salt dome in the former Soviet Union (FSU). We find good agreement between the model (without damage) and observations of both SALMON and STERLING. In contrast, the average spectral ratio of the tamped to decoupled Azgir explosions is systematically smaller than predicted by the strain hardening model without damage. Much better agreement is obtained when damage is included in the model of the decoupled Azgir explosion

  5. Modeling of tamped and decoupled explosions in salt (simulation is easy. Prediction is difficult!)

    Goldstein, P.; Glenn, L.A. [Lawrence Livermore National Lab., CA (United States)

    1993-11-01

    We compare predictions of the strain hardening model of Glenn (1990), with and without damage, to free field and seismic observations of SALMON, STERLING, and 64 kt (tamped) and 8 kt (decoupled) explosions in an Azgir salt dome in the former Soviet Union (FSU). We find good agreement between the model (without damage) and observations of both SALMON and STERLING. In contrast, the average spectral ratio of the tamped to decoupled Azgir explosions is systematically smaller than predicted by the strain hardening model without damage. Much better agreement is obtained when damage is included in the model of the decoupled Azgir explosion.

  6. Modeling of tamped and decoupled explosions in salt (Simulation is easy. Prediction is difficult!)

    Goldstein, P.; Glenn, L.A.

    1993-05-01

    We compare predictions of the strain hardening model of Glenn (1990), with and without damage, to free field and seismic observations of SALMON, STERLING, and 64 kt (tamped) and 8 kt (decoupled) explosions in an Azgir salt dome in the former Soviet Union (FSU). We find good agreement between the model (without damage) and observations of both SALMON and STERLING. In contrast, the average spectral ratio of the tamped to decoupled Azgir explosions is systematically smaller than predicted by the strain hardening model without damage. Much better agreement is obtained when damage is included in the model of the decoupled Azgir explosion.

  7. Modeling of tamped and decoupled explosions in salt (Simulation is easy. Prediction is difficult exclamation point)

    We compare predictions of the strain hardening model of Glenn (1990), with and without damage, to free field and seismic observations of SALMON, STERLING, and 64 kt (tamped) and 8 kt (decoupled) explosions in an Azgir salt dome in the former Soviet Union (FSU). We find good agreement between the model (without damage) and observations of both SALMON and STERLING. In contrast, the average spectral ratio of the tamped to decoupled Azgir explosions is systematically smaller than predicted by the strain hardening model without damage. Much better agreement is obtained when damage is included in the model of the decoupled Azgir explosion

  8. Experience with simulator training for emergency conditions

    The training of operators by the use of simulators is common to most countries with nuclear power plants. Simulator training programmes are generally well developed, but their value can be limited by the age, type, size and capability of the simulator. Within these limits, most full scope simulators have a capability of training operators for a range of design basis accidents. It is recognized that human performance under accident conditions is difficult to predict or analyse, particularly in the area of severe accidents. These are rare events and by their very nature, unpredictable. Of importance, therefore, is to investigate the training of operators for severe accident conditions, and to examine ways in which simulators may be used in this task. The International Nuclear Safety Advisory Group (INSAG) has reviewed this field and the associated elements of human behaviour. It has recommended that activities are concentrated on this area. Initially it is encouraging the following objectives: i) To train operators for accident conditions including severe accidents and to strongly encourage the development and use of simulators for this purpose; ii) To improve the man-machine interface by the use of computer aids to the operator; iii) To develop human performance requirements for plant operating staff. As part of this work, the IAEA convened a technical committee on 15-19 September 1986 to review the experience with simulator training for emergency conditions, to review simulator modelling for severe accident training, to examine the role of human cognitive behaviour modelling, and to review guidance on accident scenarios. A substantial deviation may be a major fuel failure, a Loss of Coolant Accident (LOCA), etc. Examples of engineered safety features are: an Emergency Core Cooling System (ECCS), and Containment Systems. This report was prepared by the participants during the meeting and reviewed further in a Consultant's Meeting. It also includes papers which were

  9. Difficult decisions: Migration from Small Island Developing States under climate change

    Kelman, Ilan

    2015-04-01

    The impacts of climate change on Small Island Developing States (SIDS) are leading to discussions regarding decision-making about the potential need to migrate. Despite the situation being well-documented, with many SIDS aiming to raise the topic to prominence and to take action for themselves, limited support and interest has been forthcoming from external sources. This paper presents, analyzes, and critiques a decision-making flowchart to support actions for SIDS dealing with climate change-linked migration. The flowchart contributes to identifying the pertinent topics to consider and the potential support needed to implement decision-making. The flowchart has significant limitations and there are topics which it cannot resolve. On-the-ground considerations include who decides, finances, implements, monitors, and enforces each decision. Additionally, views within communities differ, hence mechanisms are needed for dealing with differences, while issues to address include moral and legal blame for any climate change-linked migration, the ultimate goal of the decision-making process, the wider role of migration in SIDS communities and the right to judge decision-making and decisions. The conclusions summarize the paper, emphasizing the importance of considering contexts beyond climate change and multiple SIDS voices.

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

    Jake M Heier

    2012-01-01

    Full Text Available We report two cases of successful urgent intubation using a Seldinger technique for airway management through an anesthesia facemask, while maintaining ventilation in patients with difficult airways and grossly distorted airway anatomy. In both cases, conventional airway management techniques were predicted to be difficult or impossible, and a high likelihood for a surgical airway was present. This technique was chosen as it allows tracheal tube placement through the nares during spontaneous ventilation with the airway stented open and oxygen delivery with either continuous positive airway pressure and/or pressure support ventilation. This unhurried technique may allow intubation when other techniques are unsuitable, while maintaining control of the airway.

  11. Why is it so difficult to evaluate nursing interventions in dementia?

    Schwarzbach, Christoph; Förstl, Hans; Nocon, Marc; Mittendorf, Thomas

    2012-01-01

    Two recent health technology assessment (HTA) reports published in Germany focused on non-pharmacological interventions for patients with dementia. One of the major results was the poor methodological quality of the studies in this field. This paper concisely presents the main quantitative and qualitative findings of the HTA report published by the German Agency for HTA at the Institute of Medical Information and Documentation (dahta@DIMDI), followed by a detailed discussion of the major methodological problems observed for the inclusion criteria, interventions, the setting, number of patients included, duration of observation, comparators, clinical endpoints, health economics, and, most obvious, the impossibility of blinding and eliminating placebo effects for future clinical studies. We conclude with several suggestions addressing these challenges for future research in this field. PMID:22590475

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

    Sabol, Jozef; Hudzietzova, Jana; Rosina, Jozef, E-mail: j.sabol44@gmail.com, E-mail: hudzijan@fbmi.cvut.cz, E-mail: rosina@fbmi.cvut.cz [Faculty of Biomedical Engineering, Czech Technical University in Prague (Czech Republic)

    2013-07-01

    Current radiation protection is a very sophisticated and elaborate domain where, once the information about the exposure of persons is known in terms of the quantity of the effective dose, we can predict resulting radiological consequences related to the stochastic risk to the health of the exposed persons without a need for other details. In fact, the effective dose contains all pertinent information including the average organ dose distribution and relevant radiation and tissue weighting factors which take into account the specific effects of different types of radiation and selected tissue radiosensitivity. Since the effective dose cannot be measured directly, one has to rely on the monitoring of other appropriate measurable quantities and then do some conversions. The current structure of radiation protection quantities includes too many quantities, the definitions of some of which are not easy to understand and interpret. Moreover, there are numerous quantities based on the dose equivalent, such as the equivalent dose, effective dose, committed equivalent dose, committed effective dose, collective equivalent dose, collective effective dose, personal dose equivalent, ambient dose equivalent and directional dose equivalent, where the only unit of Sv is used.. There are a number of cases in open literature reflecting the difficulties and mistakes in the use of radiation protection quantities. Even more complicated situations are encountered in the field, where the staff responsible for personal and workplace monitoring is confused because of so many different quantities and where the staff may not be qualified and experienced enough to be able to make the relevant conversions and interpretations. The paper summarizes our experience in teaching students and lecturing in various training courses addressing radiation protection where the primary task was to ensure that all radiation protection personnel understood the quantities and units used in radiation

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

    Current radiation protection is a very sophisticated and elaborate domain where, once the information about the exposure of persons is known in terms of the quantity of the effective dose, we can predict resulting radiological consequences related to the stochastic risk to the health of the exposed persons without a need for other details. In fact, the effective dose contains all pertinent information including the average organ dose distribution and relevant radiation and tissue weighting factors which take into account the specific effects of different types of radiation and selected tissue radiosensitivity. Since the effective dose cannot be measured directly, one has to rely on the monitoring of other appropriate measurable quantities and then do some conversions. The current structure of radiation protection quantities includes too many quantities, the definitions of some of which are not easy to understand and interpret. Moreover, there are numerous quantities based on the dose equivalent, such as the equivalent dose, effective dose, committed equivalent dose, committed effective dose, collective equivalent dose, collective effective dose, personal dose equivalent, ambient dose equivalent and directional dose equivalent, where the only unit of Sv is used.. There are a number of cases in open literature reflecting the difficulties and mistakes in the use of radiation protection quantities. Even more complicated situations are encountered in the field, where the staff responsible for personal and workplace monitoring is confused because of so many different quantities and where the staff may not be qualified and experienced enough to be able to make the relevant conversions and interpretations. The paper summarizes our experience in teaching students and lecturing in various training courses addressing radiation protection where the primary task was to ensure that all radiation protection personnel understood the quantities and units used in radiation

  14. Bayesian Sampling using Condition Indicators

    Faber, Michael H.; Sørensen, John Dalsgaard

    2002-01-01

    allows for a Bayesian formulation of the indicators whereby the experience and expertise of the inspection personnel may be fully utilized and consistently updated as frequentistic information is collected. The approach is illustrated on an example considering a concrete structure subject to corrosion......The problem of control quality of components is considered for the special case where the acceptable failure rate is low, the test costs are high and where it may be difficult or impossible to test the condition of interest directly. Based on the classical control theory and the concept of...... condition indicators introduced by Benjamin and Cornell (1970) a Bayesian approach to quality control is formulated. The formulation is then extended to the case where the quality control is based on sampling of indirect information about the condition of the components, i.e. condition indicators. This...

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

    Sadreddine Ben Abid

    2012-10-01

    Full Text Available Autoimmune pancreatitis (AIP is a rare disorder, although the exact prevalence is still unkown. It is a type of pancreatitis that is presumed to have an autoimmune aetiology, and is currently diagnosed based on a combination of 5 criteria. However, in this day and age, some patients with AIP are likely to be resected for the suspicion of malignancy. The authors report a case of pseudo-tumoral autoimmune pancreatitis, reviewing some literature about it and underlining the difficulty in the diagnosis. A 56- year-old patient was referred to our unit for upper abdominal pain. In his past medical history we note mellitus diabetes. The clinical examination was unremarkable. Laboratory data showed no abnormal values. Upper endoscopy showed antral gastritis. Transabdominal ultrasonography showed a hepatic steatosis and 5 angiomas. No computed tomography scan was made. Magnetic resonance imaging (MRI showed 5 angiomas and a lesion of 20x20 mm of the pancreatic tail with decreased signal intensity on T1-weighted MR images, increased signal intensity on T2-weighted MR images. Due to concerns of pancreatic malignancy, the patient underwent open distal spleno-pancreatectomy. Histolo gical analysis of the resected specimen revealed no malignancy. Postoperatively, immunoglobulin G fraction 4 was slightly above of the upper limit of the normal range. After corticotherapy the patient is getting better. This case underlines the difficulties still encountered in the diagnosis of AIP. It has been frequently misdiagnosed as pancreatic cancer and caused unnecessary resection. In order to avoid unnecessary resections for an otherwise benign and easily treatable condition, it is urgent to refine diagnostic criteria and to reach an international consensus.

  16. Goldilocks Models of Higher-Dimensional Inflation (including modulus stabilization)

    Burgess, C P; Hayman, Peter; Patil, Subodh P

    2016-01-01

    We explore the mechanics of inflation in simplified extra-dimensional models involving an inflaton interacting with the Einstein-Maxwell system in two extra dimensions. The models are Goldilocks-like in that they are just complicated enough to include a mechanism to stabilize the extra-dimensional size, yet simple enough to solve the full 6D field equations using basic tools. The solutions are not limited to the effective 4D regime with H m_KK, but when they do standard 4D fluctuation calculations need not apply. When in a 4D regime the solutions predict eta ~ 0 hence n_s ~ 0.96 and r ~ 0.096 and so are ruled out if tensor modes remain unseen. Analysis of general parameters is difficult without a full 6D fluctuation calculation.

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

    Flanagan, R.F.; Pepe, F. Jr. [Parsons Brinckerhoff Quade & Douglas, New York, NY (United States)

    1997-12-31

    Jet grouting is being used as part of a groundwater cutoff wall system in a major New York City subway construction project to limit drawdowns in an adjacent PCB contamination plume. A circular test shaft of jet grout columns was conducted during the design phase to obtain wall installation parameters. The test program also included shaft wall mapping, and measurements of; inflows, piezometric levels, ground heave and temperature, and jet grout hydraulic conductivity. An axisymmetric finite element method groundwater model was established to back calculate the in-situ hydraulic conductivities of both the surrounding glacial soils and the jet grout walls by matching observed inflows and piezometric levels. The model also verified the use of packer permeability test as a tool in the field to evaluate the hydraulic conductivities of jet grout columns. Both the test program and analytic studies indicated that adjustments to the construction procedures would be required to obtain lower hydraulic conductivities of the jet grout walls for construction. A comparison is made with the conductivities estimated from the test program/analytic studies with those from the present construction.

  18. Total Hip Arthroplasty Using the S-ROM-A Prosthesis for Anatomically Difficult Asian Patients

    Akira Hozumi

    2015-01-01

    Full Text Available Background. The S-ROM-A prosthesis has been designed for the Asian proximal femur with a small deformed shape and narrow canal. In this study, the clinical and radiological results using the S-ROM-A prosthesis for Japanese patients with severe deformity due to dysplasia and excessive posterior pelvic tilt were examined. Methods. 94 hips were followed up for a mean of 55 months, with a mean age at surgery of 61 years. The primary diagnoses were 94 coxarthritis cases, including 51 dysplasia and 37 primary OA, 1 avascular necrosis, 2 traumatic arthritis, and 3 Perthes disease. Thirty-one hips had been treated with osteotomy of the hip joints. Preoperative intramedullary canal shapes were stovepipe in 23 hips, normal in 51 hips, and champagne-flute in 5 hips. The maximum pelvic inclination angle was 56°. Results. The mean JOA score improved from 46 points preoperatively to 80 points at final follow-up. On radiological evaluation of the fixation of the implants according to the Engh classification, 92 (97% hips were classified as “bone ingrown fixation.” Conclusion. In primary THA, using the S-ROM-A prosthesis for Asian patients with proximal femoral deformity, even after osteotomy and with posterior pelvic tilt, provided good short- to midterm results.

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

    Jet grouting is being used as part of a groundwater cutoff wall system in a major New York City subway construction project to limit drawdowns in an adjacent PCB contamination plume. A circular test shaft of jet grout columns was conducted during the design phase to obtain wall installation parameters. The test program also included shaft wall mapping, and measurements of; inflows, piezometric levels, ground heave and temperature, and jet grout hydraulic conductivity. An axisymmetric finite element method groundwater model was established to back calculate the in-situ hydraulic conductivities of both the surrounding glacial soils and the jet grout walls by matching observed inflows and piezometric levels. The model also verified the use of packer permeability test as a tool in the field to evaluate the hydraulic conductivities of jet grout columns. Both the test program and analytic studies indicated that adjustments to the construction procedures would be required to obtain lower hydraulic conductivities of the jet grout walls for construction. A comparison is made with the conductivities estimated from the test program/analytic studies with those from the present construction

  20. Difficult to Control Asthma: Epidemiology and its Link with Environmental Factors

    Sheehan, William J.; Phipatanakul, Wanda

    2015-01-01

    Purpose of review The aim of the present review is to discuss the epidemiology of inadequate asthma control with an examination of contributing environmental factors. Recent findings Despite advances in asthma therapies, a proportion of patients with asthma continue to have difficulty gaining adequate asthma control. Asthma severity and control in childhood is of particular importance as it translates to asthma morbidity in adulthood. Children with comorbid severe allergic rhinitis were more likely to have uncontrolled asthma. Recent data suggest that mouse allergen, more so than cockroach allergen, may be the most relevant urban allergen exposure. Tobacco smoke exposure, even passive exposure, leads to increased asthma symptoms and decreased response to inhaled corticosteroids. Efforts to ban smoking in public places have resulted in promising asthma results for entire populations. Energy saving efforts to tighten a home’s air leaks can lead to increased indoor pollutant levels and, therefore, must be accompanied by efforts to reduce, filter, or exchange indoor pollutants. Obesity is independently associated with decreased asthma control. Furthermore, the detrimental effects of pollutant exposure are enhanced in an overweight individual with asthma. Summary Lack of asthma control can be due to a complex web of factors including adherence, intrinsic factors, and environmental exposures. Further research on intervention strategies is needed to achieve improved rates of asthma control. PMID:26226354

  1. Can Islands of Effectiveness Thrive in Difficult Governance Settings? The Political Economy of Local-level Collaborative Governance

    Levy, Brian

    2011-01-01

    Many low-income countries contend with a governance syndrome characterized by a difficult combination of seeming openness, weak institutions, and strong inter-elite contestation for power and resources. In such countries, neither broad-based policy nor public management reforms are likely to be feasible. But are broad-based approaches necessary? Theory and evidence suggest that in such set...

  2. Fluoroscopy assisted tracheal intubation in a case of anticipated difficult airway: Fail safe devices can also fail

    Appavoo Arulvelan; Madhusudhan Soumya; Kannath Santhosh

    2015-01-01

    Difficulty in airway management is the most important cause of major anesthesia-related morbidity and mortality. Unexpected difficulties may arise even with proper preanesthesia planning. Here, we report a case of anticipated difficult airway primarily planned for flexible fibreoptic bronchoscope assisted intubation, but due to unexpected failure of light source, fluoroscopy was used, and the airway was successfully secured.

  3. Tracheal intubation with a flexible fibreoptic scope or the McGrath videolaryngoscope in simulated difficult airway scenarios

    Jepsen, Cecilie H; Gätke, Mona R; Thøgersen, Bente;

    2014-01-01

    Grath videolaryngoscope and FFE. The participants then performed tracheal intubation on a SimMan manikin once with the McGrath videolaryngoscope and once with the FFE in three difficult airway scenarios: (1) pharyngeal obstruction; (2) pharyngeal obstruction and cervical rigidity; (3) tongue oedema. MAIN OUTCOME MEASURES...

  4. Different, Difficult or Distinct? Mothers' and Fathers' Perceptions of Temperament in Children with and without Intellectual Disabilities

    Bostrom, P.; Broberg, M.; Hwang, C. P.

    2010-01-01

    Background: Can ratings of temperament be a way of identifying young children with intellectual disabilities (ID) who are at risk for being experienced as difficult? We aimed to explore parents' reports of temperament in their young children with or without ID, as well as positive and negative impact of the child on parents. Method: Mothers and…

  5. Politeness Strategies in Healthcare Communication at "Difficult Times": A Pragmatic Analysis of the "Manga" Discourse in "Nurse Aoi"

    Matsuoka, Rieko; Poole, Gregory

    2015-01-01

    This paper examines the ways in which healthcare professionals interact with patients' family members, and/or colleagues. The data are from healthcare discourses at difficult times found in the manga series entitled Nurse AOI. As the first step, we selected several communication scenes for analysis in terms of politeness strategies. From these…

  6. The long shadows of the difficult past? How young people in Denmark, Finland and Germany remember WWII

    Wolnik, Kevin; Busse, Britta; Tholen, Jochen;

    2016-01-01

    This paper focuses on the question of how young people today evaluate the Second World War today and how this ‘difficult past’ determines their political attitudes. Furthermore, the channels through which the current young generation in Europe is informed about the events dating back to the first...

  7. GlideScope Video Laryngoscope for Difficult Intubation in Emergency Patients: a Quasi-Randomized Controlled Trial.

    Ahmadi, Koorosh; Ebrahimi, Mohsen; Hashemian, Amir Masoud; Sarshar, Saeed; Rahimi-Movaghar, Vafa

    2015-12-01

    Macintosh direct laryngoscope has been the most widely used device for tracheal intubation. GlideScope video laryngoscope (GVL) has been recently introduced as an alternative device for performing intubation; however, its validity in emergency settings has not been thoroughly evaluated. The aim of this study was to compare Macintosh direct laryngoscope versus GVL for emergency endotracheal intubation. This quasi-randomized clinical trial was performed on 97 patients referred to Imam Reza Hospital whom all needed emergency intubation in 2011. Patients were divided into two groups of the easy airway and difficult airway; intubation was performed for patients with direct laryngoscopy or GVL. Then, the patients were evaluated in terms of demographic characteristics, successful intubation rate and intubation time. Data was analyzed by SPSS software 16. There was no significant difference in demographic characteristics of the patients in both easy airway and difficult airway groups who intubated with direct laryngoscopy and GVL methods (P>0.05). In difficult airway group, a significant difference was found in successful intubation at the first attempt (60.9% vs. 87.5%; P=0.036), overall intubation time (32.7 ± 14.58 vs. 22.5±7.88; PGVL. These variables were not significantly different between two methods in easy airway group. According to the results, GVL can be a useful alternative to direct laryngoscopy in emergency situations and especially in cases with a difficult airway. PMID:26749229

  8. Choice and conditioned reinforcement.

    Fantino, E; Freed, D; Preston, R. A.; Williams, W A

    1991-01-01

    A potential weakness of one formulation of delay-reduction theory is its failure to include a term for rate of conditioned reinforcement, that is, the rate at which the terminal-link stimuli occur in concurrent-chains schedules. The present studies assessed whether or not rate of conditioned reinforcement has an independent effect upon choice. Pigeons responded on either modified concurrent-chains schedules or on comparable concurrent-tandem schedules. The initial link was shortened on only o...

  9. Global Climate Change for Kids: Making Difficult Ideas Accessible and Exciting

    Fisher, D. K.; Leon, N.; Greene, M. P.

    2009-12-01

    NASA has recently launched its Global Climate Change web site (http://climate.nasa.gov), and it has been very well received. It has now also launched in preliminary form an associated site for children and educators, with a plan for completion in the near future. The goals of the NASA Global Climate Change Education site are: To increase awareness and understanding of climate change science in upper-elementary and middle-school students, reinforcing and building upon basic concepts introduced in the formal science education curriculum for these grades; To present, insofar as possible, a holistic picture of climate change science and current evidence of climate change, describing Earth as a system of interconnected processes; To be entertaining and motivating; To be clear and easy to understand; To be easy to navigate; To address multiple learning styles; To describe and promote "green" careers; To increase awareness of NASA's contributions to climate change science; To provide valuable resources for educators; To be compliant with Section 508 of the Americans with Disabilities Act. The site incorporates research findings not only on climate change, but also on effective web design for children. It is envisioned that most of the content of the site will ultimately be presented in multimedia forms. These will include illustrated and narrated "slide shows," animated expositions, interactive concept-rich games and demonstrations, videos, animated fictionalized stories, and printable picture galleries. In recognition of the attention span of the audience, content is presented in short, modular form, with a suggested, but not mandatory order of access. Empathetic animal and human cartoon personalities are used to explain concepts and tell stories. Expository, fiction, game, video, text, and image modules are interlinked for reinforcement of similar ideas. NASA's Global Climate Change Education web site addresses the vital need to impart and emphasize Earth system science

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

    Dionne Francois

    2011-07-01

    Full Text Available Abstract Objectives The aim of the project was to develop a plan to address a forecasted deficit of approximately $4.65 million for fiscal year 2010/11 in the Vancouver Communities division of the Vancouver Coastal Health Authority. For disinvestment opportunities identified beyond the forecasted deficit, a commitment was made to consider options for resource re-allocation within the Vancouver Communities division. Methods A standard approach to program budgeting and marginal analysis (PBMA was taken with a priority setting working committee and a broader advisory panel. An experienced, non-vested internal project manager worked closely with the two-member external research team throughout the process. Face to face evaluation interviews were held with 10 decision makers immediately following the process. Results The recommendations of the working committee included the implementation of 44 disinvestment initiatives with an annualized value of CAD $4.9 million, as well as consideration of possible investments if the realized savings match expectations. Overall, decision makers viewed the process favorably and the primary aim of addressing the deficit gap was met. Discussion A key challenge was the tight timeline which likely lead to less evidence informed decision making then one would hope for. Despite this, decision makers felt that better decisions were made then had the process not been in place. In the end, this project adds value in finding that PBMA can be used to cover a deficit and minimize opportunity cost through systematic application of criteria whilst ensuring process fairness through focusing on communication, transparency and decision maker engagement.

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

    Søren Meisner

    Full Text Available 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<0.00001 and from 'rarely/never' to 'sometimes' p = 0.0115. CONCLUSION: PSCs are common and troublesome and the consequences are substantial, both for the patient and from a health economic viewpoint. PSCs should be diagnosed and treated at an early stage to prevent long term, debilitating and expensive complications.

  12. Gross structure of resonance spectra (including bottomonium)

    Simple arguments are given for the explanation of the gross structure of the spectrum of particle resonances based on the shape resonance conditions, the Heisenberg uncertainty relation and the Bohr correspondence principle. 14 refs., 2 figs., 3 tabs

  13. Neuromuscular blockade for improvement of surgical conditions during laparotomy

    Madsen, Matias Vested; Scheppan, Susanne; Kissmeyer, Peter;

    2015-01-01

    INTRODUCTION: During laparotomy, surgeons frequently experience difficult surgical conditions if the patient's abdominal wall or diaphragm is tense. This issue is particularly pertinent while closing the fascia and placing the intestines into the abdominal cavity. Establishment of a deep...

  14. Static, Lightweight Includes Resolution for PHP

    Hills, M.A.; Klint, P.; Vinju, J.J.

    2014-01-01

    Dynamic languages include a number of features that are challenging to model properly in static analysis tools. In PHP, one of these features is the include expression, where an arbitrary expression provides the path of the file to include at runtime. In this paper we present two complementary analy

  15. Article Including Environmental Barrier Coating System

    Lee, Kang N. (Inventor)

    2015-01-01

    An enhanced environmental barrier coating for a silicon containing substrate. The enhanced barrier coating may include a bond coat doped with at least one of an alkali metal oxide and an alkali earth metal oxide. The enhanced barrier coating may include a composite mullite bond coat including BSAS and another distinct second phase oxide applied over said surface.

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

    Wallace Paul

    2011-01-01

    Full Text Available Abstract Background The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers -- the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives. Methods We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care, e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS in secondary care, a Community Nurse Information System (CNIS in community care, and Choose and Book (C&B across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with 'on the ground' experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT. Results Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to 'normalize' where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower

  17. The difficult challenge of a two-phase CFD modelling for all flow regimes

    Highlights: • The theoretical difficulties for modelling all flow regimes at CFD scale are identified. • The choice of the number of fields and of the time and space averaging or filtering are discussed and clarified. • Closure issues related to an all flow regime CFD model are listed and the main difficulties are identified. - Abstract: System thermalhydraulic codes model all two-phase flow regimes but they are limited to a macroscopic description. Two-phase CFD tools predict two-phase flow with a much finer space resolution but the current modelling capabilities are limited to dispersed bubbly or droplet flow and separate-phase flow. Much less experience exists on more complex flow regimes which combine the existence of dispersed fields with the presence of large interfaces such as a free surface or a film surface. A list of possible reactor issues which might benefit from an “all flow regime CFD model” is given. The first difficulty is to identify the various types of local flow configuration. It is shown that a 4-field model has much better capabilities than a two-fluid approach to identify most complex regimes. Then the choice between time averaging, space averaging, or even ensemble averaging is discussed. It is shown that only the RANS-2-fluid and a space-filtered 4-field model may be reasonably envisaged. The latter has the capabilities to identify all types of interfaces and should be privileged if a good accuracy is expected or if time fluctuations in intermittent flow have to be predicted while the former may be used when a high accuracy is not necessary and if time fluctuations in intermittent flow are not of interest. Finally the closure issue is presented including wall transfers, interfacial transfers, mass transfers between dispersed and continuous fields, and turbulent transfers. An important effort is required to model all interactions between sub-filter phenomena and the transfers from the sub-filter domain to the simulated domain. The

  18. 76 FR 9283 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...

    2011-02-17

    ... apply to hospitals exempt from the IPPS. The following is a list of the current Medicare HACs (75 FR... Healthcare Research and Quality BPM Benefit Policy Manual CABG Coronary artery bypass graft CBO Congressional... procedures as defined in the Medicare Pub. 100-02, Benefit Policy Manual (BPM), chapter 1, sections 10...

  19. 76 FR 32815 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...

    2011-06-06

    ... of the Medicare HACs for FY 2011 (75 FR 50084 through 50085): Foreign Object Retained After Surgery... infections. For a list of the items considered, see the February 17, 2011 proposed rule (76 FR 9283, 9286... Research and Quality BPM Benefit Policy Manual CABG Coronary artery bypass graft CBO Congressional...

  20. Evaluation of the novel passive sampler for cyanobacterial toxins microcystins under various conditions including field sampling

    Kohoutek, J.; Maršálek, Blahoslav; Bláha, Luděk

    2010-01-01

    Roč. 397, č. 2 (2010), s. 823-828. ISSN 1618-2642 R&D Projects: GA MŠk 1M0571 Institutional research plan: CEZ:AV0Z60050516 Keywords : passive sampler * microcystin * POCIS Subject RIV: EF - Botanics Impact factor: 3.841, year: 2010

  1. CORPORATE SOCIAL RESPONSIBILITY AS CONDITION OF INCLUDING UKRAINE IN EUROPE AND WORLD ECONOMIC SPACE

    T. Lytvynenko

    2013-09-01

    Full Text Available The thesis that companies’ activities for introduction of corporate social responsibility stimulates the speed of to the processes of the technical upgrade, modernization of company’s activity and increase of its profitability is proved within the article. Those Ukrainian companies, which have high index of activities transparency, are also the most profitable. However, we can’t observe any significant increment of number of companies joining the Global agreement. One of the explanations we could name is the unproved idea supported by some politicians and economists about a shadow (‘black’ market that allegedly allows creating workplaces and taking off social tension in society on the certain stage. Insignificant values of index of citizens’ trust to activity of industries holds on the development socially of responsible business. Trust considered as a part of the general social capital. The Government of Ukraine must support initiative of companies to introduce social responsibility of business, as many European governments do it. It is also important to inform society of advantages of CSR.

  2. Strategies for attraction and retention of health workers in remote and difficult-to-access areas of Chhattisgarh, India: Do they work?

    Suchitra Lisam

    2015-01-01

    Full Text Available Background: To address the acute shortages of health workers in underserved, remote, and difficult-to-access areas, the Government of Chhattisgarh and the National Rural Health Mission (NRHM launched the Chhattisgarh Rural Medical Corps (CRMC in 2009. CRMC has enabled provisions such as financial incentives, residential accommodation, life insurance, and extra marks during admission at the postgraduate (PG level to eligible doctors for the attraction and retention of health workers, i.e., doctors, staff nurses, auxiliary nurse midwives (ANMs, and rural medical assistants (RMAs in underserved areas. Objectives: This study aims to understand the CRMC scheme in terms of implementation, challenges, gaps, and outcome in achieving the attraction and retention of health workers in the remote and difficult-to-access areas of Chhattisgarh. Materials and Methods: The study adopts a mix of both qualitative and quantitative research methods. The purposive sampling method was used for the selection of three districts having normal, difficult, and inaccessible areas. Data were collected through key informant (KI interviews with beneficiaries and non-beneficiaries of CRMC or district and state government officials, and reviews of document were analyzed using a thematic analysis approach. Results: CRMC has made positive outcome as 1319 health workers, including doctors, have joined the service in 2010-11, reducing the vacancy of doctors from 90% to 45%. The scope of CRMC was primarily limited to payment of monthly financial incentives. The fund utilization rate of CRMC has increased (from 27% in 2009-10 to 98% in 2011-12, though there are delays in payment of incentives. The majority of staff lack awareness about CRMC during job applications. The payment of incentives based on facility performance has demotivated staff. Conclusions: Establishment of a performance management system, activating the CRMC cell to make it functional, and wide publicity of CRMC

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

    Healy David W

    2012-06-01

    Full Text Available Abstract Background Videolaryngoscopy presents a new approach for the management of the difficult and rescue airway. There is little available evidence to compare the performance features of these devices in true difficult laryngoscopy. Methods A prospective randomized crossover study was performed comparing the performance features of the Macintosh Laryngoscope, Glidescope, Storz CMAC and Storz DCI videolaryngoscope. Thirty anesthesia providers attempted intubation with each of the 4 laryngoscopes in a high fidelity difficult laryngoscopy manikin. The time to successful intubation (TTSI was recorded for each device, along with failure rate, and the best view of the glottis obtained. Results Use of the Glidescope, CMAC and Storz videolaryngoscopes improved the view of the glottis compared with use of the Macintosh blade (GEE, p = 0.000, p = 0.002, p = 0.000 respectively. Use of the CMAC resulted in an improved view compared with use of the Storz VL (Fishers, p = 0.05. Use of the Glidescope or Storz videolaryngoscope blade resulted in a longer TTSI compared with either the Macintosh (GLM, p = 0.000, p = 0.029 respectively or CMAC blades (GLM, p = 0.000, p = 0.033 respectively. Conclusions Unsurprisingly, when used in a simulated difficult laryngoscopy, all the videolaryngoscopes resulted in a better view of the glottis than the Macintosh blade. However, interestingly the CMAC was found to provide a better laryngoscopic view that the Storz DCI Videolaryngoscope. Additionally, use of either the Glidescope or Storz DCI Videolaryngoscope resulted in a prolonged time to successful intubation compared with use of the CMAC or Macintosh blade. The use of the CMAC during manikin simulated difficult laryngoscopy combined the efficacy of attainment of laryngoscopic view with the expediency of successful intubation. Use of the Macintosh blade combined expedience with success, despite a limited laryngoscopic view. The

  4. Composite Pressure Vessel Including Crack Arresting Barrier

    DeLay, Thomas K. (Inventor)

    2013-01-01

    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.

  5. Les difficultés d'exécution des contrats de Private Finance Initiative britanniques

    Marty, Frédéric; Voisin, Arnaud

    2007-01-01

    document de travail Alors que de nombreux travaux se sont penchés sur l'optimalité du recours aux partenariats public-privé ou sur les enjeux posés par la structure d'attribution des risques entre les parties, les difficultés d'exécution des contrats de partenariats public-privé n'ont fait jusqu'à présent l'objet que de rares analyses. Les principaux travaux développés sur les difficultés d'exécution des contrats de partenariat public-privé portent sur le cas des pays en développement et c...

  6. Long-standing meningomyelocele can be a predictor of difficult airway and postoperative hypoventilation: challenge to the anaesthesiologist.

    Sardar, Arijit; Khanna, Puneet; Singh, Abhishek; Sharma, Ankur

    2016-01-01

    A 15-year-old female patient presented with severe pain in the abdomen and obstructive uropathy. She underwent Yang-Monti ileovesicostomy under general anaesthesia. She is a known case of long-standing meningomyelocele (MMC) and presented with its potential complications such as difficult airway and restrictive lung disease. We describe the successful anaesthetic management of a case of anticipated difficult airway and postoperative hypoventilation as a sequel of kyphosis due to MMC. Her airway was secured with fibre optic-guided intubation in a semirecumbent position. Postoperative hypoventilation, hypercarbia and respiratory acidosis were managed conservatively, followed by staged weaning in the intensive care unit. Obstruction of the catheterisable continent channel of the neurogenic bladder itself may present with uropathy and urosepsis, which were also taken care of preoperatively. PMID:26884079

  7. Evaluation of Truview evo2® Laryngoscope In Anticipated Difficult Intubation-A Comparison To Macintosh Laryngoscope

    Ishwar Singh; Abhijit Khaund; Abhishek Gupta

    2009-01-01

    Summary The aim of the study was to assess and compare laryngoscopic view of Truview evo2 laryngoscope with that of Macintosh laryngoscope in patients with one or more predictors of difficult intubation (PDI). Moreover ease of intubation with Truview evo2 in terms of absolute time requirement was also aimed at. Patients for elective surgery requiring endotracheal intubation were initially assessed for three PDI parameters – modified Mallampati test, thyro-mental distance & Atlanto-occipital (...

  8. GlideScope Video Laryngoscope for Difficult Intubation in Emergency Patients: a Quasi-Randomized Controlled Trial

    Koorosh Ahmadi

    2015-12-01

    Full Text Available Macintosh direct laryngoscope has been the most widely used device for tracheal intubation. GlideScope video laryngoscope (GVL has been recently introduced as an alternative device for performing intubation; however, its validity in emergency settings has not been thoroughly evaluated. The aim of this study was to compare Macintosh direct laryngoscope versus GVL for emergency endotracheal intubation. This quasi-randomized clinical trial was performed on 97 patients referred to Imam Reza Hospital whom all needed emergency intubation in 2011. Patients were divided into two groups of the easy airway and difficult airway; intubation was performed for patients with direct laryngoscopy or GVL. Then, the patients were evaluated in terms of demographic characteristics, successful intubation rate and intubation time. Data was analyzed by SPSS software 16. There was no significant difference in demographic characteristics of the patients in both easy airway and difficult airway groups who intubated with direct laryngoscopy and GVL methods (P>0.05. In difficult airway group, a significant difference was found in successful intubation at the first attempt (60.9% vs. 87.5%; P=0.036, overall intubation time (32.7 ± 14.58 vs. 22.5±7.88; P<0.001 and first attempt intubation time (28.43 ± 12.51 vs. 21.48±7.8; P=0.001 between direct laryngoscopy and GVL. These variables were not significantly different between two methods in easy airway group. According to the results, GVL can be a useful alternative to direct laryngoscopy in emergency situations and especially in cases with a difficult airway.

  9. QUALIMETRIC ASPECTS OF THE SOCIO-CULTURAL FACTORS OF THE ADAPTATION OF CHILDREN IN DIFFICULT LIFE SITUATIONS

    Dudkin Artem Sergeevich

    2012-01-01

    For practical realization in the social and pedagogical work, the factors of social adaptation of minors received as a result of research in certain typical difficult life situations need analytical consideration using an analytical social qualimetric approach. The levels allocated during empirical research and degree of factors of social adaptation are described with qualimetric indicators, taking into account necessary and sufficient properties. Problems of studying and realization of quant...

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

    Šebestík, Jaroslav; Šafařík, Martin; Zawada, Zbigniew; Hlaváček, Jan

    Copenhagen : European Peptide Society, 2010, s. 204-205 ISBN 0-9715560-5-9. [Peptides 2010: Tales of Peptides. Proceedings of the European Peptide Symposium /31./. Copenhagen (DK), 05.09.2010-09.09.2010] R&D Projects: GA ČR GA203/07/1517 Institutional research plan: CEZ:AV0Z40550506 Keywords : 4-thiazolidinecarboxylic acid * difficult sequences * prion diseases * displacement Subject RIV: CC - Organic Chemistry

  11. Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study

    Lee, Tae Hoon; Hwang, Soon Oh; Choi, Hyun Jong; Jung, Yunho; Cha, Sang Woo; Chung, Il-Kwun; Moon, Jong Ho; Cho, Young Deok; Park, Sang-Heum; Kim, Sun-Joo

    2014-01-01

    Background Numerous clinical trials to improve the success rate of biliary access in difficult biliary cannulation (DBC) during ERCP have been reported. However, standard guidelines or sequential protocol analysis according to different methods are limited in place. We planned to investigate a sequential protocol to facilitate selective biliary access for DBC during ERCP. Methods This prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-g...

  12. Central venous catheter malposition in the azygos vein and difficult endotracheal intubation in severe ankylosing spondylitis: a case report

    Moon, Eunjin; Jeong, Hyungmo; Chung, Junyoung; Yi, Jaewoo

    2015-01-01

    Ankylosing spondylitis (AS) can be challenging for anesthesiologists because central venous access can be difficult, and the airway can be blocked due to the fixed flexion deformity of the spine. In this case, we attempted central access via the right subclavian vein, but the catheter was repeatedly inserted into the azygos vein, which was confirmed by radiology. After several attempts, the catheter position was corrected at the superior vena cava-atrial junction. Although several useful devi...

  13. 28 CFR 20.32 - Includable offenses.

    2010-07-01

    ... 28 Judicial Administration 1 2010-07-01 2010-07-01 false Includable offenses. 20.32 Section 20.32 Judicial Administration DEPARTMENT OF JUSTICE CRIMINAL JUSTICE INFORMATION SYSTEMS Federal Systems and Exchange of Criminal History Record Information § 20.32 Includable offenses. (a) Criminal history...

  14. Management of Difficult Airway With Laryngeal Mask in a Child With Mucopolysaccharidosis and Mitral Regurgitation: A Case Report

    Ziyaeifard, Mohsen; Azarfarin, Rasoul; Ferasatkish, Rasoul; Dashti, Majid

    2014-01-01

    Introduction: Mucopolysaccharidoses (MPSs) are a group of heredity storage diseases, transmitted in an autosomal recessive manner, associated with the accumulation of glycosaminoglycans (GAGs) in various tissues and organs. The concerned patients have multiple concomitant hereditary anomalies. Considering the craniofacial abnormality in these patients, airway management may be difficult for anesthesiologists. In these patients, preanesthetic assessment is necessary and performed with the accurate assessment of airways, consisting of the physical exam and radiography, MRI or CT of head and neck. An anesthesiologist should set up a “difficult intubation set” with a flexible fiber-optic bronchoscope and also, it may be necessary to discuss with an ear-nose and throat (ENT) specialist if required, for unpredicted emergency situations. Case Presentation: In this case-report we presented a 2-year-old boy with known MPSs with psychomotor retardation, bilateral corneal opacities, impaired hearing and vision, inguinal hernia, severe mitral regurgitation, micrognathia, coarse facial feature, stiff and short neck and restricted mouth opening. He scheduled for left inguinal hernia repair surgery. Discussion: The patient’s difficult airway was managed successfully and the anesthesia of his surgical procedure had an uneventful course. PMID:25478534

  15. Utility of a Gum-Elastic Bougie for Difficult Airway Management in Infants: A Simulation-Based Crossover Analysis

    Nobuyasu Komasawa

    2015-01-01

    Full Text Available Background. Direct laryngoscopy with the Miller laryngoscope (Mil for infant tracheal intubation is often difficult to use even for skilled professionals. We performed a simulation trial evaluating the utility of a tracheal tube introducer (gum-elastic bougie (GEB in a simulated, difficult infant airway model. Methods. Fifteen anesthesiologists performed tracheal intubation on an infant manikin at three different degrees of difficulty (normal [Cormack-Lehane grades (Cormack 1-2], cervical stabilization [Cormack 2-3], and anteflexion [Cormack 3-4] with or without a GEB, intubation success rate, and intubation time. Results. In the normal and cervical stabilization trials, all intubation attempts were successful regardless of whether or not the GEB was used. In contrast, only one participant succeeded in tracheal intubation without the GEB in the anteflexion trial; the success rate significantly improved with the GEB (P=0.005. Intubation time did not significantly change under the normal trial with or without the GEB (without, 12.7 ± 3.8 seconds; with, 13.4 ± 3.6 seconds but was significantly shorter in the cervical stabilization and anteflexion trials with the GEB. Conclusion. GEB use shortened the intubation time and improved the success rate of difficult infant tracheal intubation by anesthesiologists in simulations.

  16. Tracing the source of difficult to settle fine particles which cause turbidity in the Hitotsuse Reservoir, Japan.

    Murakami, Toshiki; Suzuki, Yoshihiro; Oishi, Hiroyuki; Ito, Kenichi; Nakao, Toshio

    2013-05-15

    A unique method to trace the source of "difficult-to-settle fine particles," which are a causative factor of long-term turbidity in reservoirs was developed. This method is characterized by cluster analysis of XRD (X-ray diffraction) data and homology comparison of major component compositions between "difficult-to-settle fine particles" contained in landslide soil samples taken from the upstream of a dam, and suspended "long-term turbid water particles" in the reservoir, which is subject to long-term turbidity. The experiment carried out to validate the proposed method, demonstrated a high possibility of being able to make an almost identical match between "difficult-to-settle fine particles" taken from landslide soils at specific locations and "long-term turbid water particles" taken from a reservoir. This method has the potential to determine substances causing long-term turbidity and the locations of soils from which those substances came. Appropriate countermeasures can then be taken at those specific locations. PMID:23500107

  17. 3D seismic experiment in difficult area in Japan; Kokunai nanchiiki ni okeru sanjigen jishin tansa jikken

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

    1997-05-27

    Difficult area in this context means an exploration-difficult area supposed to store oil/gas but retarded in exploration for the lack of knowledge about the geological structure due to poor quality of available seismic survey records. Discussed in this paper is a survey conducted into an area covering the southern part of Noshiro-shi, Akita-ken, and Yamamoto-cho, Yamamoto-gun, Akita-ken. An area size suitable for data collection at a target depth of 2500m is determined using an interpretation structure compiled on the basis of available well data and 2D seismic survey data. The plan for siting shock points and receiving points is modified case by case as restrictive factors come to the surface (resulting from the complicated hilly terrain, presence of pipes for agricultural water, etc.). The peculiarities of seismic waves in the terrain are studied through the interpretation of the available well data and 2D seismic survey data for the construction of a 3D velocity model for the confirmation of the appropriateness of the plan for siting shock points and receiving points. Efforts are exerted through enhanced coordination with the contractor to acquire data so that a technologically best design may be won within the limits of the budget. The quality of the data obtained from this experiment is in general better than those obtained from previous experiments, yet many problems remain to be settled in future studies about exploration-difficult areas. 4 refs., 4 figs., 1 tab.

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

    Objective: To determine the accuracy of Prayer's sign and Mallampatti test in predicting difficult endotracheal intubation in diabetic patients. Methods: The cross-sectional study was performed at Aga Khan University Hospital, Karachi, over a period from January 2009 to April 2010, and comprised 357 patients who required endotracheal intubation for elective surgical procedures. Prayer's sign and Mallampatti tests were performed for the assessment of airway by trained observers. Ease or difficulty of laryngoscopy after the patient was fully anaesthetised with standard technique were observed and laryngoscopic view of first attempt was rated according to Cormack-Lehan grade of intubation. SPSS 15 was used for statistical analysis. Results: Of the 357 patients, 125(35%) were classified as difficult to intubate. Prayer's sign showed significantly lower accuracy, positive and negative predictive values than Mallampatti test. The sensitivity of Prayer's sign was lower 29.6 (95% Confidence Interval, 21.9-38.5) than Mallampatti test 79.3 (95% confidence interval, 70.8-85.7) while specificity of both the tests was not found to be significantly different. Conclusion: Prayer's sign is not acceptable as a single best bedside test for prediction of difficult intubation. (author)

  19. Validation of modified Mallampati test with addition of thyromental distance and sternomental distance to predict difficult endotracheal intubation in adults

    Bhavdip Patel

    2014-01-01

    Full Text Available Background and Aims: Intubation is often a challenge for anaesthesiologists. Many parameters assist to predict difficult intubation. The present study was undertaken to assess the validity of different parameters in predicting difficult intubation for general anaesthesia (GA in adults and effect of combining the parameters on the validity. Methods: The anaesthesiologist assessed oropharynx of 135 adult patients. Modified Mallampati test (MMT was used and the thyromental distance (TMD and sternomental distances (SMD for each of the patients were also measured. The Cormack and Lehane laryngoscopic grading was assessed following laryngoscopy. The validity parameters such as sensitivity, specificity, false positive and negatives values, positive and negative predictive values were calculated. The effect of combining different measurements on the validity was also studied. Univariate analysis was performed using the parametric method. Results: The study group comprised of 135 patients. The sensitivity and specificity of MMT were 28.6% and 93%, respectively. The TMD (<6.5 CM had sensitivity and specificity of 100% and 75.8%, respectively. The SMD (<12.5 CM had sensitivity and specificity of 91% and 92.7%, respectively. Combination of MMT grading and TMD and SMD measurements increased the validity (sensitivity of 100% and specificity of 92.7%. Conclusion: MMT had high specificity. The validity of combination of MMT, SMD and TMD as compared to MMT alone was very high in predicting difficult intubation in adult patients. All parameters should be used in assessing an adult patient for surgery under GA.

  20. A Difficult Decision

    2009-01-01

    The financial outlook began to look a bit more optimistic in September,as some economic indicators,such as the DOW Jones Industrial Average and the prices of physical assets,showed signs of recovery one year after the outbreak of the financial tsunami triggered by the bankruptcy of Lehman Brothers.But does the numeric

  1. Difficult Decisions: Acid Rain.

    Miller, John A.; Slesnick, Irwin L.

    1989-01-01

    Discusses some of the contributing factors and chemical reactions involved in the production of acid rain, its effects, and political issues pertaining to who should pay for the clean up. Supplies questions for consideration and discussion. (RT)

  2. A difficult encounter

    Martinsen, Dorte Sindbjerg; Vasev, Nikolay Rumenov

    2015-01-01

    through three explanatory variables, namely, institutional misfit, salience and administrative resources. We find that Denmark and Bulgaria have transposed the Directive in protectionist and minimalistic ways, thus far leading to a low outcome, i.e. low patient outflow. The encounter between the EU and...

  3. Difficult wounds: radiation wounds

    In an era of modern radiotherapy, problems associated with the indiscriminate treatment of benign disease have largely disappeared. Skin sparing effects of super voltage radiation equipment make the problems previously seen with orthovoltage equipment less frequent. Vigilance on the part of the workers in the field, in general, protects from the disasters that befell Thomas Edison's laboratory assistant. Despite these modern advances, the reconstructive surgeon often faces problems of managing acute local radiation injury from accident following planned therapeutic radiation or the ulcerations and breakdowns seen months or years after radiation therapy. The single most serious hazard to surgery in radiated tissue is the lodgment of bacteria in this tissue rendered avascular by the radiation and secondary necrosis from the infection itself. The principles of management are no different from those used for other chronic granulating wounds: local wound care, appropriate topical antibacterial therapy, systemic antibiotics during the perioperative period and, most importantly, adequate soft tissue coverage

  4. Difficult marketing; Schwierige Vermarktung

    Rentzing, Sascha

    2013-02-15

    With the new edition of the Renewable Energy Law (EEG) at 1st January 2012, the market premium model becomes effective in order to implement the green electricity into the electricity market better. With this, the operators of photovoltaic power plants switched from the fixed EEG compensation for electricity to direct marketing. The market premium model provides that only 90% of the power generated by large photovoltaic power plants on roofs of buildings are compensated via EEG corresponding to 0.15 Euro/kWh. The remaining 10% is compensated only with 0.045 Euro/kWh which complies with the actual stock exchange value. If one is not very happy with this solution, one has to consume the excess power by its own or to sell the excess power to third parties. The own consumption would be the easier solution. But the own consumption is usually not possible because the most large photovoltaic power plants are installed on roofs of commercial and public buildings. Consequently, the operators of these photovoltaic power plants have to sell the excess power to third parties. This is associated with many imponderables and additional costs.

  5. A difficult beginning

    Suneth Agampodi; Sisira Siribaddana

    2013-01-01

    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...

  6. Difficult Decisions: Euthanasia.

    Parakh, Jal S.; Slesnick, Irwin L.

    1992-01-01

    Focuses on the moral arguments for and against the controversial topic of voluntary active euthanasia. Discusses the question of legalization and decriminalization of the practice. Provides a student worksheet with questions to stimulate discussion on the issue. (MDH)

  7. An Integrated Biochemistry Laboratory, Including Molecular Modeling

    Hall, Adele J. Wolfson Mona L.; Branham, Thomas R.

    1996-11-01

    The dilemma of designing an advanced undergraduate laboratory lies in the desire to teach and reinforce basic principles and techniques while at the same time exposing students to the excitement of research. We report here on a one-semester, project-based biochemistry laboratory that combines the best features of a cookbook approach (high success rate, achievement of defined goals) with those of an investigative, discovery-based approach (student involvement in the experimental design, excitement of real research). Individual modules may be selected and combined to meet the needs of different courses and different institutions. The central theme of this lab is protein purification and design. This laboratory accompanies the first semester of biochemistry (Structure and Function of Macromolecules, a course taken mainly by junior and senior chemistry and biological chemistry majors). The protein chosen as the object of study is the enzyme lysozyme, which is utilized in all projects. It is suitable for a student lab because it is easily and inexpensively obtained from egg white and is extremely stable, and its high isoelectric point (pI = 11) allows for efficient separation from other proteins by ion-exchange chromatography. Furthermore, a literature search conducted by the resourceful student reveals a wealth of information, since lysozyme has been the subject of numerous studies. It was the first enzyme whose structure was determined by crystallography (1). Hendrickson et al. (2) have previously described an intensive one-month laboratory course centered around lysozyme, although their emphasis is on protein stability rather than purification and engineering. Lysozyme continues to be the focus of much exciting new work on protein folding and dynamics, structure and activity (3 - 5). This lab course includes the following features: (i) reinforcement of basic techniques, such as preparation of buffers, simple enzyme kinetics, and absorption spectroscopy; (ii

  8. Operant Conditioning for Special Educators.

    Pedrini, Bonnie C.; Pedrini, D. T.

    The paper briefly explains operant conditioning as it pertains to special educators. Operant conditioning is thought to be an efficient method for modifying student behavior. Using the B. F. Skinner frame of reference, operant conditioning is said to include behavior modification and therapy, programed instruction, and computer assisted and…

  9. Haemophilus influenzae Disease (Including Hib) Symptoms

    ... is considered invasive. Symptoms of pneumonia usually include: Fever and chills Cough Shortness of breath or difficulty breathing Sweating ... the blood. It can cause symptoms such as: Fever and chills Excessive tiredness Pain in the belly Nausea with ...

  10. What Does Long-Term Care Include?

    Full Text Available Video: "What Does Long-Term Care Include?" Long-term care involves a variety of services designed to meet a person's health or personal care needs during a short or long period of ...

  11. Births and deaths including fetal deaths

    U.S. Department of Health & Human Services — Access to a variety of United States birth and death files including fetal deaths: Birth Files, 1968-2009; 1995-2005; Fetal death file, 1982-2005; Mortality files,...

  12. Include Passive Solar in Your Renovations.

    Bender, Gerald F.; Probasco, Jack F.

    1981-01-01

    A checklist covers potential energy saving modifications in a building scheduled for renovation, and includes suggestions for room utilization, landscaping, and building envelope, solar control, and active system modifications. (Author)

  13. Including Indigenous Minorities in Decision-Making

    Pristed Nielsen, Helene

    Based on theories of public sphere participation and deliberative democracy, this book presents empirical results from a study of experiences with including Aboriginal and Maori groups in political decision-making in respectively Western Australia and New Zealand......Based on theories of public sphere participation and deliberative democracy, this book presents empirical results from a study of experiences with including Aboriginal and Maori groups in political decision-making in respectively Western Australia and New Zealand...

  14. Including excitons in semiconductor solar cell modelling

    Burgelman, Marc; Minnaert, Ben

    2005-01-01

    Excitons are marginally important in classical semiconductor device physics, and their treatment is not included in standard solar cell modelling. However, in organic semiconductors and solar cells, the role of excitons is essential, as the primary effect of light absorption is exciton generation, and free electrons and holes are created by exciton dissociation. First steps to include excitons in solar cell modelling were presented by Green 1996 and Zhang 1998. Their model was restricted to a...

  15. Gas storage materials, including hydrogen storage materials

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

    2013-02-19

    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.

  16. Upper abdominal malignancies (not including esophagus)

    Objective: This course will give an overview of the role of radiation therapy in the treatment of gastrointestinal malignancies in the upper abdomen, with an emphasis on carcinomas of the stomach, pancreas and biliary tract. For each site, information will be presented related to failure patterns with conventional surgical treatment and the indications for surgery for different stages of disease. The possible uses of radiation therapy as an adjuvant to surgical resection will be discussed as well as the use of radiation therapy alone. In addition, the combination of radiation therapy with chemotherapy will be discussed for each of these sites, as well as the information available at present as to the optimal way to combine chemotherapy with radiation therapy. Radiation therapy is not generally accepted to have a role in the treatment of patients with adenocarcinomas of the stomach. This is related to the fact that gastric cancer has been standardly treated with surgical resection alone, and delivery of high dose radiation therapy to the upper abdomen can be difficult because of the sensitivity of nearby normal tissues. Nonetheless, data on failure patterns suggest that local recurrence is common in patients with disease through the gastric wall and with positive nodes. Although there is some suggestive data to indicate that radiation therapy is effective as an adjuvant, results of an ongoing trial will be necessary for determination of the exact role of radiation therapy. Possible uses of radiation therapy as preoperative therapy or given alone will also be briefly discussed. Radiation therapy has been often used in the treatment of pancreatic adenocarcinomas, either alone or combined with surgical resection. Its use is more common for this site both because of the extremely poor prognosis of standard therapies, and because of the difficulty in performing an adequate surgical resection. Data will be reviewed suggesting that radiation therapy has a role when

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

    Patel, A; Nouraei, S A R

    2015-03-01

    Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy-hypoxaemia-re-oxygenation cycles can escalate to airway loss and the 'can't intubate, can't ventilate' scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to 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 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

  18. Transmission line including support means with barriers

    Cookson, Alan H.

    1982-01-01

    A gas insulated transmission line includes an elongated outer sheath, a plurality of inner conductors disposed within and extending along the outer sheath, and an insulating gas which electrically insulates the inner conductors from the outer sheath. A support insulator insulatably supports the inner conductors within the outer sheath, with the support insulator comprising a main body portion including a plurality of legs extending to the outer sheath, and barrier portions which extend between the legs. The barrier portions have openings therein adjacent the main body portion through which the inner conductors extend.

  19. Electric Power Monthly, August 1990. [Glossary included

    1990-11-29

    The Electric Power Monthly (EPM) presents monthly summaries of electric utility statistics at the national, Census division, and State level. The purpose of this publication is to provide energy decisionmakers with accurate and timely information that may be used in forming various perspectives on electric issues that lie ahead. Data includes generation by energy source (coal, oil, gas, hydroelectric, and nuclear); generation by region; consumption of fossil fuels for power generation; sales of electric power, cost data; and unusual occurrences. A glossary is included.

  20. Le syndrome des brides amniotiques et ses difficultés diagnostiques et de prise en charge au Burkina Faso

    Nagalo, Kisito; Badiel, Roger; Kouéta, Fla; Tall, François Housséini; Yé, Diarra

    2015-01-01

    Le syndrome des brides amniotiques est une embryo-foetopathie rare, d’étiopathogénie encore inconnue, caractérisé par des malformations crânio-faciales, thoraco-abdominales, des membres et des extrémités. Afin de discuter des difficultés diagnostiques et thérapeutiques du syndrome des brides amniotiques, nous rapportons cinq cas de ce syndrome. Ces cas représentaient autant de phénotypes de la maladie mais avec quelques singularités. Les deux premiers étaient des cas de maladie des brides amn...

  1. A STUDY OF PREDICTION OF DIFFICULT INTUBATION USING MALLAMPATI AND WILSON SCORE CORRELATING WITH CORMACK LEHANE GRADING

    Vaishali Chandrashekhar

    2015-06-01

    Full Text Available BACKGROUND : This study was carried out to evaluate usefulness of preoperative Mallampati & Wilson’s score grading as a predictor for difficult laryngoscopy & intubation . AIMS : To determine the accuracy of the modified Mallampati test and Wilson score for predicting difficult tracheal intubation and correlation with Cormack Lehane grading . METHODS : This prospective randomized cross sectional Study carried out in 200 patients , posted for surgical procedure under GA with ETT intubation. Preoperative airway assessment using Mallampati grading (MPG & Wilson score done. Conventional anesthesia t echnique followed. Cormack Lehane grading done at laryngoscopy & correlated with previous scores for each patient. RESULTS : A MPG of I/II was found in 140 patients (70% , while 60 patients (30% were class III/IV. 138 patients (69% had a Wilson score of 0 /1 , while 60(30% had a score of 2/3 and 2 patients (1% scored ≥4. One hundred & eighty patients (90% were classified as Cormack - Lehane grade I/II , while 20 patients (10% were considered grade III/IV. Of the 60 patients with a Wilson score of 2/3 , 6 cas es (10% two attempts were required and in 2 cases (3.3% in spite of more than two attempts intubation proved impossible with the conventional laryngoscope , articulated McCoy blade was used. Two patients with a Wilson score ≥4 were intubated with gum elas tic bougie , using articulated McCoy blade. Overall , out of 200 , in 6 patients (3% two attempts of intubation was required and 4 patients (2% intubation required the use of some kind of gadget other than conventional laryngoscope and more than 2 attempts. The correlation between the Cormack - Lehane classification and the number of endotracheal intubation attempts showed that of the 180 patients with I / II grade , 4 patients (1.3% two attempts were required. Of the 20 patients classified as Cormack - Lehane III/IV , 4 cases (20% intubation proved impossible with conventional technique. This

  2. [ДX11538a: The remnant Dunhuang Codex's of the Classic of Difficult Issues collected in Russia].

    Shen, Shunong

    2014-07-01

    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, ДX11538a, 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

  3. Difficult identification of Haemophilus influenzae, a typical cause of upper respiratory tract infections, in the microbiological diagnostic routine.

    Hinz, Rebecca; Zautner, Andreas Erich; Hagen, Ralf Matthias; Frickmann, Hagen

    2015-03-01

    Haemophilus influenzae is a key pathogen of upper respiratory tract infections. Its reliable discrimination from nonpathogenic Haemophilus spp. is necessary because merely colonizing bacteria are frequent at primarily unsterile sites. Due to close phylogenetic relationship, it is not easy to discriminate H. influenzae from the colonizer Haemophilus haemolyticus. The frequency of H. haemolyticus isolations depends on factors like sampling site, patient condition, and geographic region. Biochemical discrimination has been shown to be nonreliable. Multiplex PCR including marker genes like sodC, fucK, and hpd or sequencing of the 16S rRNA gene, the P6 gene, or multilocus-sequence-typing is more promising. For the diagnostic routine, such techniques are too expensive and laborious. If available, matrix-assisted laser-desorption-ionization time-of-flight mass spectrometry is a routine-compatible option and should be used in the first line. However, the used database should contain well-defined reference spectra, and the spectral difference between H. influenzae and H. haemolyticus is small. Fluorescence in-situ hybridization is an option for less well-equipped laboratories, but the available protocol will not lead to conclusive results in all instances. It can be used as a second line approach. Occasional ambiguous results have to be resolved by alternative molecular methods like 16S rRNA gene sequencing. PMID:25883794

  4. 42 CFR 409.10 - Included services.

    2010-10-01

    ... 42 Public Health 2 2010-10-01 2010-10-01 false Included services. 409.10 Section 409.10 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM HOSPITAL INSURANCE BENEFITS Inpatient Hospital Services and Inpatient Critical Access Hospital...

  5. Do pigeons prefer alternatives that include near-hit outcomes?

    Stagner, Jessica P; Case, Jacob P; Sticklen, Mary F; Duncan, Amanda K; Zentall, Thomas R

    2015-07-01

    Pigeons show suboptimal choice on a gambling-like task similar to that shown by humans. Humans also show a preference for gambles in which there are near hits (losses that come close to winning). In the present research, we asked if pigeons would show a preference for alternatives with near-hit-like trials. In Experiment 1, we included an alternative that presented a near hit, in which a stimulus associated with reinforcement (a presumed conditioned reinforcer) changed to a stimulus associated with the absence of reinforcement (a presumed conditioned inhibitor). The pigeons tended to avoid this alternative. In Experiment 2, we varied the duration of the presumed conditioned reinforcer (2 vs. 8 s) that changed to a presumed conditioned inhibitor (8 vs. 2 s) and found that the longer the conditioned reinforcer was presented, the more the pigeons avoided it. In Experiment 3, the near-hit alternative involved an ambiguous stimulus for 8 s that changed to a presumed conditioned reinforcer (or a presumed conditioned inhibitor) for 2 s, but the pigeons still avoided it. In Experiment 4, we controlled for the duration of the conditioned reinforcer by presenting it first for 2 s followed by the ambiguous stimulus for 8 s. Once again, the pigeons avoided the alternative with the near-hit trials. In all 4 experiments, the pigeons tended to avoid alternatives that provided near-hit-like trials. We concluded that humans may be attracted to near-hit trials because near-hit trials give them the illusion of control, whereas this does not appear to be a factor for pigeons. PMID:26167775

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

    Jérôme Sudrial

    2010-01-01

    Full Text Available 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 primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm.

  7. Radiation treatment of organic substances which are difficult to decompose for utilizing sewage water again. Radiation decomposition of lignin

    The sewerage model projects utilizing sewage-treated water and the sewerage model project for the future city executed in Tokyo are described. It is important to obtain the treated water which is suitable to purposes by setting up the target for control and reducing the organic contamination which is difficult to decompose. In fiscal year 1995, as to the decomposing treatment of lignin by radiation, the effect of reducing coloring and the influence when actual flowing-in sewage and treated water coexist were examined. The experimental samples were lignin aqueous solution, synthetic sewage and flowing-in sewage, treated water, and the mixture of treated water and synthetic sewage. The measurement of water quality is explained. The γ ray irradiation with a Co-60 source was carried out. The results of respective samples are reported. When total organic carbon was at the level in flowing-in sewage and treated water, irradiation was effective for eliminating coloring. The soluble organic substances which are difficult to decompose were efficiently decomposed by irradiation. (K.I.)

  8. Photoactive devices including porphyrinoids with coordinating additives

    Forrest, Stephen R; Zimmerman, Jeramy; Yu, Eric K; Thompson, Mark E; Trinh, Cong; Whited, Matthew; Diev, Vlacheslav

    2015-05-12

    Coordinating additives are included in porphyrinoid-based materials to promote intermolecular organization and improve one or more photoelectric characteristics of the materials. The coordinating additives are selected from fullerene compounds and organic compounds having free electron pairs. Combinations of different coordinating additives can be used to tailor the characteristic properties of such porphyrinoid-based materials, including porphyrin oligomers. Bidentate ligands are one type of coordinating additive that can form coordination bonds with a central metal ion of two different porphyrinoid compounds to promote porphyrinoid alignment and/or pi-stacking. The coordinating additives can shift the absorption spectrum of a photoactive material toward higher wavelengths, increase the external quantum efficiency of the material, or both.

  9. Including knowledge creation & enabling in risk management

    Hop, Eirik

    2015-01-01

    As a contribution to Statoil Technical Efficiency Programme (STEP), has the thesis looked at how to improve the risk management process in Statoil ASA. Through theoretical research was the primary research question created: “How can knowledge creation & enabling improve our understanding of risk management?” To create a theoretical foundation, the thesis looked at principles, methods, and models for the adequate assessment and management of risk. This includes a new perspective on ri...

  10. Rotor assembly including superconducting magnetic coil

    Snitchler, Gregory L.; Gamble, Bruce B.; Voccio, John P.

    2003-01-01

    Superconducting coils and methods of manufacture include a superconductor tape wound concentrically about and disposed along an axis of the coil to define an opening having a dimension which gradually decreases, in the direction along the axis, from a first end to a second end of the coil. Each turn of the superconductor tape has a broad surface maintained substantially parallel to the axis of the coil.

  11. Including heavy flavour production in PDF fits

    A.M. Cooper-Sarkar

    2007-01-01

    AT HERA heavy quarks may contribute up to 30% of the structure function $F_2$. The introduction of heavy quarks requires an extension of the DGLAP formalism. The effect of using different heavy flavour number schemes, and different approaches to the running of $\\alpha_s$, are compared using the ZEUS PDF fit formalism. The potential of including charm data in the fit is explored, using $D^*$ double differential cross-sections rather than the inclusive quantity $F_2^{c\\bar{c}}$.

  12. Model for safety reports including descriptive examples

    Several safety reports will be produced in the process of planning and constructing the system for disposal of high-level radioactive waste in Sweden. The present report gives a model, with detailed examples, of how these reports should be organized and what steps they should include. In the near future safety reports will deal with the encapsulation plant and the repository. Later reports will treat operation of the handling systems and the repository

  13. Electric power monthly, September 1990. [Glossary included

    1990-12-17

    The purpose of this report is to provide energy decision makers with accurate and timely information that may be used in forming various perspectives on electric issues. The power plants considered include coal, petroleum, natural gas, hydroelectric, and nuclear power plants. Data are presented for power generation, fuel consumption, fuel receipts and cost, sales of electricity, and unusual occurrences at power plants. Data are compared at the national, Census division, and state levels. 4 figs., 52 tabs. (CK)

  14. The surgery of peripheral nerves (including tumors)

    Fugleholm, Kåre

    2013-01-01

    Surgical pathology of the peripheral nervous system includes traumatic injury, entrapment syndromes, and tumors. The recent significant advances in the understanding of the pathophysiology and cellular biology of peripheral nerve degeneration and regeneration has yet to be translated into improved...... nervous system response to injury are prerequisite to obtain the best possible outcome. Surgery continues to be the primary treatment modality for peripheral nerve tumors and advances in adjuvant oncological treatment has improved outcome after malignant peripheral nerve tumors. The present chapter...

  15. THE EFFECTS OF INCLUDING BANKRUPTCY ON DYNAMIC INVESTMENT DECISIONS

    Frank S. Novak; Schnitkey, Gary D.

    1994-01-01

    This article evaluates the effects of including the costs of bankruptcy in a dynamic model of off-farm investment decisions using a stochastic dynamic programming (SDP) model which incorporates the stochastic dynamic nature of investment returns and the interrelationships between financial structure and investment decisions. Our results suggest that in the presence of bankruptcy, optimal investment decisions are affected by financial structure and financial market conditions. Ignoring bankrup...

  16. Can Certain Genotypes Predispose to Poor Asthma Control in Children? A Pharmacogenetic Study of 9 Candidate Genes in Children with Difficult Asthma

    Basima Almomani; Hawwa, Ahmed F; Millership, Jeffrey S; Liam Heaney; Isabella Douglas; McElnay, James C.; Shields, Michael D.

    2013-01-01

    Objective: We tested the hypothesis that patients with difficult asthma have an increased frequency of certain genotypes that predispose them to asthma exacerbations and poor asthma control. Methods: A total of 180 Caucasian children with confirmed asthma diagnosis were selected from two phenotypic groups; difficult (n = 112) versus mild/moderate asthma (n = 68) groups. All patients were screened for 19 polymorphisms in 9 candidate genes to evaluate their association with difficult asthma. Ke...

  17. Fuel gas conditioning process

    Lokhandwala, Kaaeid A.

    2000-01-01

    A process for conditioning natural gas containing C.sub.3+ hydrocarbons and/or acid gas, so that it can be used as combustion fuel to run gas-powered equipment, including compressors, in the gas field or the gas processing plant. Compared with prior art processes, the invention creates lesser quantities of low-pressure gas per unit volume of fuel gas produced. Optionally, the process can also produce an NGL product.

  18. A kicked quantum system including the continuum

    The behaviour of a quantum particle in a separable one-term potential with three-dimensional form factor is investigated under the influence of an external force which alters the potential strength periodically or quasiperiodically. The unperturbed system possesses one bound state and a continuum of scattering states which has treated almost analytically. First numerical results, fully including the emission channel, indicate, for certain parameter combinations with commensurate or incommensurate frequency ratios, either a regular or an irregular dynamical behaviour of the system. 17 refs.; 3 figs

  19. Fundamentals for remote condition monitoring of offshore wind turbines

    McGugan, Malcolm; Larsen, Gunner Chr.; Sørensen, Bent F.;

    In the future, large wind turbines will be placed offshore in considerable numbers. Since access will be difficult and costly, it is preferable to use monitoring systems to reduce the reliance on manual inspection. The motivation for the effort reported here is to create the fundamental basis...... necessary for the use of sensors as a structural health monitoring system for wind turbine blades. This includes creating knowledge that will allow sensor signals to be used for remotely identifying the presence and position of any damage, the damage type and severity, and a structural condition assessment...... of the wind turbine blades that can integrate with existing SCADA tools to improve management of large offshore wind farms, and optimise the manual inspection/maintenance effort. Various sensor types, which have previously been identified as technically (and economically) capable of detecting the...

  20. Biological control of Polymyxa betae, fungal vector of rhizomania disease of sugar beets in greenhouse conditions

    Naraghi Laleh; Heydari Asghar; Askari Hassan; Pourrahim Reza; Marzban Rasoul

    2014-01-01

    Rhizomania is one of the most important diseases of sugar beet around the world – including in Iran. The disease causes a severe decrease in sugar yield and is a limiting factor in sugar beet cultivation. Control of the disease is very difficult due to the long-term survival of its fungal vector (Polymyxa betae) in the soil. In this study, we investigated the effects of antagonistic fungal isolates on the population of the resting structure (cystosorus) of P. betae, under greenhouse condition...

  1. Aerosol simulation including chemical and nuclear reactions

    Marwil, E.S.; Lemmon, E.C.

    1985-01-01

    The numerical simulation of aerosol transport, including the effects of chemical and nuclear reactions presents a challenging dynamic accounting problem. Particles of different sizes agglomerate and settle out due to various mechanisms, such as diffusion, diffusiophoresis, thermophoresis, gravitational settling, turbulent acceleration, and centrifugal acceleration. Particles also change size, due to the condensation and evaporation of materials on the particle. Heterogeneous chemical reactions occur at the interface between a particle and the suspending medium, or a surface and the gas in the aerosol. Homogeneous chemical reactions occur within the aersol suspending medium, within a particle, and on a surface. These reactions may include a phase change. Nuclear reactions occur in all locations. These spontaneous transmutations from one element form to another occur at greatly varying rates and may result in phase or chemical changes which complicate the accounting process. This paper presents an approach for inclusion of these effects on the transport of aerosols. The accounting system is very complex and results in a large set of stiff ordinary differential equations (ODEs). The techniques for numerical solution of these ODEs require special attention to achieve their solution in an efficient and affordable manner. 4 refs.

  2. Surgical options in ICH including decompressive craniectomy.

    Mitchell, Patrick; Gregson, Barbara A; Vindlacheruvu, Raghu R; Mendelow, A David

    2007-10-15

    Intracerebral haemorrhage (ICH) accounts for 15 to 20% of strokes. The condition carries a higher morbidity and mortality than occlusive stroke. Despite considerable research effort, no therapeutic modality either medical or surgical has emerged with clear evidence of benefit other than in rare aneurysmal cases. Intracerebral haemorrhages can be divided into those that arise from pre-existing macroscopic vascular lesions - so called "ictohaemorrhagic lesions", and those that do not; the latter being the commoner. Most of the research that has been done on the benefits of surgery has been in this latter group. Trial data available to date precludes a major benefit from surgical evacuation in a large proportion of cases however there are hypotheses of benefit still under investigation, specifically superficial lobar ICH treated by open surgical evacuation, deeper ICH treated with minimally invasive surgical techniques, and decompressive craniectomy. When an ICH arises from an ictohaemorrhagic lesion, therapy has two goals: to treat the effects of the acute haemorrhage and to prevent a recurrence. Three modalities are available for treating lesions to prevent recurrence: stereotactic radiosurgery, endovascular embolisation, and open surgical resection. As with ICH without an underlying lesion there is no evidence to support surgical removal of the haemorrhage in most cases. An important exception is ICHs arising from intracranial aneurysms where there is good evidence to support evacuation of the haematoma as well as repair of the aneurysm. PMID:17543995

  3. Terrorism cover in France for property damage including nuclear risks

    The obligation to include terrorism cover in all Property Damage policies issued on the French Market is ruled by an Act of 1986 and introduced under Section R 126-2 of the French Code of Insurance. This section stipulates that Property Damage policies must provide cover for damage resulting from acts of terrorism, with the same deductible and the same limit than that of the other damage covered in the policy. Soon after the dramatic events of September 11, 2001 in the United States and although reinsurers worldwide restricted their offer of capacities, French insurers recognized that they had to maintain this global cover for the benefit of their insurers. After difficult discussions between insurers, reinsurers, brokers, risk managers and representatives of the State, the creation of a new Pool, backed with a State guarantee, was decided in less than three months. Effective January 1, 2002 and called Gestion d'Assurance et de Reassurance des Risques Attentats et Actes de Terrorisme (GAREAT), the Pool offers a multiple layers stop-loss cover for Property Damage only, i.e. excluding TPL policies. Considering that nuclear risks should be treated in the same way as other industrial risks, it was decided that they would be covered by GAREAT as well. In the meantime, by a Decree of December 28, 2001 modifying Section R 126-2, a special provision, aiming at reducing the limit and thus the price of this cover, was introduced in the Code. The purpose of this paper is to expose the present situation applying through GAREAT and, after two years of operation to discuss future developments, including other sources of capacity for the coverage of acts of terrorism in nuclear risks insurance.(author)

  4. How FDG-PET helps making decision for surgery in various difficult subgroups of temporal lobe epilepsy?

    Concordant pre-surgical data are the important predictors of good surgical outcome in patients with localization-related epilepsy. Medically intractable temporal lobe epilepsy with hippocampal sclerosis (HS) and concordant pre-surgical data is straightforward and may not need functional imaging. However, in other instances for example, HS with discordant data (HSD), bilateral HS with discordant data (BHSD), temporal lobe epilepsy with dual pathology (DP), non-lesional temporal lobe epilepsy (NL) are the difficult subgroups. In these groups, functional imaging eg. brain perfusion SPECT or brain PET may play a major role for surgical decision making. To our knowledge, there was no previous data in using FDG-PET in different subgroups as mentioned. Only some previous studies in single subgroup without analyzing impact of PET findings on decision-making have been reported. We thus aim to evaluate the usefulness of FDG-PET in these 4 subgroups

  5. Criteria of an estimation statodynamic stability of sportsman body and system of bodies in difficult coordination sports.

    Boloban V.N.

    2012-04-01

    Full Text Available Criteria of an estimation statodynamic stability of sportsman body and system of bodies in difficult coordination sports are developed and experimentally proved. It is established that length of the general center of pressure trajectory of a body on a support, frequency of fluctuations of a body, a parity of amplitude of fluctuations of a body and frequency, symmetry and asymmetry of movements in the course of a body pose regulation, length of a trajectory of a control point moving on a trunk in the field of a sacrum in system of cooperating bodies are authentic signs of sports orientation, an estimation of sports technics of exercises and training by it. Criteria are a criterion of an estimation of a body balance in the course of sports exercises performance; allow to carry out effective sports preparation.

  6. ASSESSMENT OF DIFFICULT SPINAL ANAESTHESIA USING PRE PROCEDURAL ULTRASOUND COMPARED WITH CLINICAL METHODS IN YOUNG PATIENTS UNDERGOING ELECTIVE SURGERIES

    Malarvizhi

    2014-09-01

    Full Text Available Spinal anesthesia can be challenging in young obese patients and in elderly age group (>65yrs. The surface landmarks observed by clinical palpation can be less helpful in these patients (1-7.The purpose of this study is to do pre procedural ultrasound and clinical examination of the lumbar spine in the same group of patients and comparing them to space finally in which the procedure was performed. The aim is to find out the usefulness of sonography in assessing the difficulty of spinal anesthesia in young patients ( 40 years expertise is still needed in using this technique. This calls in for routine use of pre procedural sound screening for all anticipated difficult spinals.

  7. Response to eribulin in a difficult-to-treat, heavily pretreated breast cancer patient: a case report.

    Leo, Luigi; Caputo, Francesca; Sarno, Antonella Di; Garofano, Tiziana; Andreozzi, Francesca; Massaro, Maria Grazia; Montesarchio, Vincenzo

    2015-01-01

    In this short paper, we report our experience with eribulin mesylate in a heavily pretreated breast cancer patient with multiple bone metastases. The patient had been treated with doxorubicin, cyclophosphamide, methotrexate, fluorouracil, tamoxifen, letrozole, LH-RH analogs, fulvestrant, bevacizumab and paclitaxel and liposomal doxorubicin. In November 2013 treatment with eribulin ready to use solution (1.23 mg/m(2) days 1 and 8 of a 21-day cycle) was started and administered for a total of 14 courses. After six cycles of eribulin, evaluation with MRI showed a marked decrease in neoplastic involvement and replacement of osteolytic lesions with osteoblastic ones. No unexpected acute toxicity was observed. Although with all the limitations of any anecdotal report, our experience documents the efficacy and safety of eribulin in this difficult-to-treat patient who had been treated with multiple lines of chemotherapy. PMID:26235262

  8. The Experience of Using Ultrasound in Differential Diagnostics of Difficult Cases of Urgent Surgery (Mesenteric Thrombosis and Destructive Pancreatitis

    Firsova V.G.,

    2011-12-01

    Full Text Available There has been presented the experience of using ultrasound in urgent abdominal surgery. There have been demonstrated the possibilities of US in difficult cases and urgent situations. Differential and diagnostic criteria in acute disorder of the mesenteric circulation and destructive pancreatitis have been given. Revealed ultrasonographic phenomena have been correlated with the data of clinical examination, infrared thermography (CEM ThermoDiagnostic, computer and magnetic resonance tomography, selective angiography, intraoperative review of abdominal cavity organs, as well as verified morphologically (fine needle and intraoperative biopsy and assessed together with the results of surgical interference and conservative treatment. Clinical examples of using additional possibilities of the technique (performing diagnostic fine needle biopsy under US control have been shown.

  9. "Those were difficult years...": Oral accounts of Vlachophones from their captivity in Požarevac, Serbia

    Panopoulou Kalliopi

    2006-01-01

    Full Text Available Considering that the oral accounts of the people who experienced the events at a difficult period in time is the most important of all the other research material, I am attempting, with this article, to present a few phases of the captivity of the Vlachophones in Požarevac in 1916. The main objective is to depict the climate of the era throughout the time frame from 1916 -- the commencement of their captivity outside Greece - and their return in 1918 through the personal and collective experiences of ordinary people. It is an effort to highlight the value of the oral culture, incorporating the voice of the unseen protagonists into the historical data. It describes the way they reached this specific area, the two years they spent there, and the four phases of their return.

  10. ACCREDITATION FOR TECHNICAL ABILITIES INCLUDING COMPUTER SKILLS

    Halit Hami OZ

    2013-01-01

    Full Text Available Sector Skills are defined by state-sponsored, employer-led organizations that cover specific economic sectors in the European Union and other countries in the world to reduce skills gaps and shortages, improve productivity, boost the skills of their sector workforces and improve learning supply. The accreditation and registration systems used by professional bodies raise the profile of the profession. In many countries including the European Union, professional associations are beginning to accept practice-based accreditation, generally as an alternative to their mainstream systems. Besides studying the certain agencies in the European Union for assessing/accreditating practical abilities , Accreditation for practical abilities of Information Communication Technology and Business Management/Language domains developed by Accreditation Council for Practical abilities are also studied in detail as an example to establish a similar agency in Turkey.

  11. Including electronic effects in damage cascade simulations

    A method for including the effects of electronic losses and electron-phonon coupling in radiation damage simulations has been developed and implemented for 10 keV cascades in Fe. The MD simulations are coupled to a continuum model for the electronic energy and energy lost by the atoms, due to electronic friction and electron-phonon coupling, is gained by electronic system. Electronic energy transport is described by the heat diffusion equation and energy is returned to the lattice via a stochastic force. Thus the temperature of the atomic system is controlled by a Langevin thermostat at the local electronic temperature, which varies with time and space. The results of simulations with this inhomogeneous thermostat are compared with those of homogeneous (constant temperature) thermostat simulations for a range of electron-phonon coupling strengths. The residual defect concentration was found to have a non-monotonic variation with coupling strength.

  12. Input parameters and scenarios, including economic inputs

    Boklund, Anette; Hisham Beshara Halasa, Tariq

    2012-01-01

    place, a receiving herd needed to be found. The distance, in which the receiving herd should be found, was calculated from movement data for animals and from data from trucks and abattoirs for movements to slaughter and milk tankers. For persons visiting herds, we used a combination of expert opinions......Geographical locations of the farms are the core in these models. We used geographical data, number of animals and specification of herd types for the 50,853 herds in the Danish Husbandry Register (CHR) in 2007. For each herd, the daily probability of moving animals, to another herd or to the......, disease was simulated to spread via direct contacts (movements of animals), indirect contacts (trucks and persons) and local spread (mice, birds, airborne spread in limited distances). Furthermore, in some scenarios airborne spread was included. For all contact types, when a contact was simulated to take...

  13. Critical point anomalies include expansion shock waves

    Nannan, N. R., E-mail: ryan.nannan@uvs.edu [Mechanical Engineering Discipline, Anton de Kom University of Suriname, Leysweg 86, PO Box 9212, Paramaribo, Suriname and Process and Energy Department, Delft University of Technology, Leeghwaterstraat 44, 2628 CA Delft (Netherlands); Guardone, A., E-mail: alberto.guardone@polimi.it [Department of Aerospace Science and Technology, Politecnico di Milano, Via La Masa 34, 20156 Milano (Italy); Colonna, P., E-mail: p.colonna@tudelft.nl [Propulsion and Power, Delft University of Technology, Kluyverweg 1, 2629 HS Delft (Netherlands)

    2014-02-15

    From first-principle fluid dynamics, complemented by a rigorous state equation accounting for critical anomalies, we discovered that expansion shock waves may occur in the vicinity of the liquid-vapor critical point in the two-phase region. Due to universality of near-critical thermodynamics, the result is valid for any common pure fluid in which molecular interactions are only short-range, namely, for so-called 3-dimensional Ising-like systems, and under the assumption of thermodynamic equilibrium. In addition to rarefaction shock waves, diverse non-classical effects are admissible, including composite compressive shock-fan-shock waves, due to the change of sign of the fundamental derivative of gasdynamics.

  14. Critical point anomalies include expansion shock waves

    From first-principle fluid dynamics, complemented by a rigorous state equation accounting for critical anomalies, we discovered that expansion shock waves may occur in the vicinity of the liquid-vapor critical point in the two-phase region. Due to universality of near-critical thermodynamics, the result is valid for any common pure fluid in which molecular interactions are only short-range, namely, for so-called 3-dimensional Ising-like systems, and under the assumption of thermodynamic equilibrium. In addition to rarefaction shock waves, diverse non-classical effects are admissible, including composite compressive shock-fan-shock waves, due to the change of sign of the fundamental derivative of gasdynamics

  15. AMS at the ANU including biomedical applications

    Fifield, L.K.; Allan, G.L.; Cresswell, R.G.; Ophel, T.R. [Australian National Univ., Canberra, ACT (Australia); King, S.J.; Day, J.P. [Manchester Univ. (United Kingdom). Dept. of Chemistry

    1993-12-31

    An extensive accelerator mass spectrometry program has been conducted on the 14UD accelerator at the Australian National University since 1986. In the two years since the previous conference, the research program has expanded significantly to include biomedical applications of {sup 26}Al and studies of landform evolution using isotopes produced in situ in surface rocks by cosmic ray bombardment. The system is now used for the measurement of {sup 10}Be, {sup 14}C, {sup 26}Al, {sup 36}Cl, {sup 59}Ni and {sup 129}I, and research is being undertaken in hydrology, environmental geochemistry, archaeology and biomedicine. On the technical side, a new test system has permitted the successful off-line development of a high-intensity ion source. A new injection line to the 14UD has been established and the new source is now in position and providing beams to the accelerator. 4 refs.

  16. CERN Technical Training: LABVIEW courses include RADE

    HR Department

    2009-01-01

    The contents of the "LabView Basic I" and "LabView Intermediate II" courses have recently been changed to include, respectively, an introduction to and expert training in the Rapid Application Development Environment (RADE). RADE is a LabView-based application developed at CERN to integrate LabView in the accelerator and experiment control infrastructure. It is a suitable solution to developing expert tools, machine development analysis and independent test facilities. The course names have also been changed to "LabVIEW Basics I with RADE Introduction" and "LabVIEW Intermediate II with Advanced RADE Application". " LabVIEW Basics I with RADE Introduction" is designed for: Users preparing to develop applications using LabVIEW, or NI Developer Suite; users and technical managers evaluating LabVIEW or NI Developer Suite in purchasing decisions; users pursuing the Certified LabVIEW Developer certification. The course prepares participants to develop test and measurement, da...

  17. CERN Technical Training: LABVIEW courses include RADE

    HR Department

    2009-01-01

    The contents of the "LabView Basic I" and "LabView Intermediate II" courses have recently been changed to include, respectively, an introduction to and expert training in the Rapid Application Development Environment (RADE). RADE is a LabView-based application developed at CERN to integrate LabView in the accelerator and experiment control infrastructure. It is a suitable solution to developing expert tools, machine development analysis and independent test facilities. The course names have also been changed to "LabVIEW Basics I with RADE Introduction" and "LabVIEW Intermediate II with Advanced RADE Application". " LabVIEW Basics I with RADE Introduction" is designed for: Users preparing to develop applications using LabVIEW, or NI Developer Suite; users and technical managers evaluating LabVIEW or NI Developer Suite in purchasing decisions; users pursuing the Certified LabVIEW Developer certification. The course pr...

  18. CLIC expands to include the Southern Hemisphere

    Roberto Cantoni

    2010-01-01

    Australia has recently joined the CLIC collaboration: the enlargement will bring new expertise and resources to the project, and is especially welcome in the wake of CERN budget redistributions following the recent adoption of the Medium Term Plan.   The countries involved in CLIC collaboration With the signing of a Memorandum of Understanding on 26 August 2010, the ACAS network (Australian Collaboration for Accelerator Science) became the 40th member of in the multilateral CLIC collaboration making Australia the 22nd country to join the collaboration. “The new MoU was signed by the ACAS network, which includes the Australian Synchrotron and the University of Melbourne”, explains Jean-Pierre Delahaye, CLIC Study Leader. “Thanks to their expertise, the Australian institutes will contribute greatly to the CLIC damping rings and the two-beam test modules." Institutes from any country wishing to join the CLIC collaboration are invited to assume responsibility o...

  19. CERN Technical Training: LABVIEW courses include RADE

    HR Department

    2009-01-01

    The contents of "LabView Basic I" and "LabView Intermediate II" trainings have been recently changed to include, respectively, an introduction and an expert training on the Rapid Application Development Environment (RADE). RADE is a LabView-based application developed at CERN to integrate LabView in the accelerator and experiment control infrastructure. It is a suitable solution to develop expert tools, machine development analysis and independent test facilities. The course names have also been changed to "LabVIEW Basics I with RADE Introduction" and "LabVIEW Intermediate II with Advanced RADE Application". " LabVIEW Basics I with RADE Introduction" is designed for: Users preparing to develop applications using LabVIEW, or NI Developer Suite; users and technical managers evaluating LabVIEW or NI Developer Suite in purchasing decisions; users pursuing the Certified LabVIEW Developer certification. The course prepare...

  20. Evaluation of Truview evo2® Laryngoscope In Anticipated Difficult Intubation-A Comparison To Macintosh Laryngoscope

    Ishwar Singh

    2009-01-01

    Full Text Available The aim of the study was to assess and compare laryngoscopic view of Truview evo2 laryngoscope with that of Macintosh laryngoscope in patients with one or more predictors of difficult intubation (PDI. Moreover ease of intubation with Truview evo2 in terms of absolute time requirement was also aimed at. Patients for elective surgery requiring endotracheal intubation were initially assessed for three PDI parameters - modified Mallampati test, thyro-mental distance& Atlanto-occipital (AO joint extension. Patients with cumulative PDI scores of 2 to 5 (in a scale of 0 to 8 were evaluated for Cormack& Lehane (CL grading by Macintosh blade after standard induction. Cases with CL grade of two or more were further evaluated by Truview evo2 laryngoscope and corresponding CL grades were assigned. Intubation attempted under Truview evo2 vision and time required for each successful tracheal intubation (i.e. tracheal intubation completed within one minute was noted. Total fifty cases were studied. The CL grades assigned by Macintosh blade correlated well with the cumulative PDI scores assigned preoperatively, confirming there predictability. Truview evo2 improved laryngeal view in 92 % cases by one or more CL grade. Intubation with Truview evo2 was possible in 88% cases within stipulated time of one minute and mean time of 28.6 seconds with SD of 11.23 was reasonably quick. No significant complication like oro- pharyngeal trauma or extreme pressor response to laryngoscopy was noticed. To conclude, Truview evo2 proved to be a better tool than conventional laryngoscope in anticipated difficult situations.

  1. Efficacy of a Multimodal Cognitive Rehabilitation Including Psychomotor and Endurance Training in Parkinson's Disease

    Reuter, I.; Mehnert, S.; Sammer, G.; Oechsner, M.; Engelhardt, M.

    2012-01-01

    Mild cognitive impairment, especially executive dysfunction might occur early in the course of Parkinson's disease. Cognitive training is thought to improve cognitive performance. However, transfer of improvements achieved in paper and pencil tests into daily life has been difficult. The aim of the current study was to investigate whether a multimodal cognitive rehabilitation programme including physical exercises might be more successful than cognitive training programmes without motor train...

  2. Seepage Model for PA Including Drift Collapse

    stochastically simulate the 3D flow of water in the fractured host rock (in the vicinity of potential emplacement drifts) under ambient conditions. The Disturbed Drift Seepage Submodel evaluates the impact of the partial collapse of a drift on seepage. Drainage in rock below the emplacement drift is also evaluated

  3. Alternating phase focussing including space charge

    Longitudinal stability can be obtained in a non-relativistic drift tube accelerator by traversing each gap as the rf accelerating field rises. However, the rising accelerating field leads to a transverse defocusing force which is usually overcome by magnetic focussing inside the drift tubes. The radio frequency quadrupole is one way of providing simultaneous longitudinal and transverse focusing without the use of magnets. One can also avoid the use of magnets by traversing alternate gaps between drift tubes as the field is rising and falling, thus providing an alternation of focussing and defocusing forces in both the longitudinal and transverse directions. The stable longitudinal phase space area is quite small, but recent efforts suggest that alternating phase focussing (APF) may permit low velocity acceleration of currents in the 100-300 ma range. This paper presents a study of the parameter space and a test of crude analytic predictions by adapting the code PARMILA, which includes space charge, to APF. 6 refs., 3 figs

  4. Langevin simulations of QCD, including fermions

    We encounter critical slow down in updating when xi/a -> infinite and in matrix inversion (needed to include fermions) when msub(q)a -> 0. A simulation that purports to solve QCD numerically will encounter these limits, so to face the challenge in the title of this workshop, we must cure the disease of critical slow down. Physically, this critical slow down is due to the reluctance of changes at short distances to propagate to large distances. Numerically, the stability of an algorithm at short wavelengths requires a (moderately) small step size; critical slow down occurs when the effective long wavelength step size becomes tiny. The remedy for this disease is an algorithm that propagates signals quickly throughout the system; i.e. one whose effective step size is not reduced for the long wavelength conponents of the fields. (Here the effective ''step size'' is essentially an inverse decorrelation time.) To do so one must resolve various wavelengths of the system and modify the dynamics (in CPU time) of the simulation so that all modes evolve at roughly the same rate. This can be achieved by introducing Fourier transforms. I show how to implement Fourier acceleration for Langevin updating and for conjugate gradient matrix inversion. The crucial feature of these algorithms that lends them to Fourier acceleration is that they update the lattice globally; hence the Fourier transforms are computed once per sweep rather than once per hit. (orig./HSI)

  5. Bucket wheel excavators for varying mining conditions

    Schachtschneider, H.; Seliger, E.

    1987-06-01

    TAKRAF bucket wheel excavators have proven their efficiency through the achievement of daily production rates in excess of 300,000 bcm, and have accomplished this under the most difficult geological and climatic conditions. Even heavy, plastic, very sticky clays, very abrasive soils, and rocky partings have been successfully mined with bucket wheel excavators. The use of BWEs to mine the hard coal deposits at the Ekibastus surface mine in the U.S.S.R., has broadened the field of application of these machines. Based on the experience gained in heavy-duty service, the bucket wheel excavators designed in the future will be capable of successfully coping with even more difficult site conditions.

  6. Effects of using the simplified airway risk index vs usual airway assessment on unanticipated difficult tracheal intubation - a cluster randomized trial with 64,273 participants

    Kehlet Nørskov, Anders; Wetterslev, J; Rosenstock, C V;

    2016-01-01

    BACKGROUND: Unanticipated difficult intubation remains a challenge in anaesthesia. The Simplified Airway Risk Index (SARI) is a multivariable risk model consisting of seven independent risk factors for difficult intubation. Our aim was to compare preoperative airway assessment based on the SARI w...

  7. SEEPAGE MODEL FOR PA INCLUDING DRIFT COLLAPSE

    C. Tsang

    2004-09-22

    The purpose of this report is to document the predictions and analyses performed using the seepage model for performance assessment (SMPA) for both the Topopah Spring middle nonlithophysal (Tptpmn) and lower lithophysal (Tptpll) lithostratigraphic units at Yucca Mountain, Nevada. Look-up tables of seepage flow rates into a drift (and their uncertainty) are generated by performing numerical simulations with the seepage model for many combinations of the three most important seepage-relevant parameters: the fracture permeability, the capillary-strength parameter 1/a, and the percolation flux. The percolation flux values chosen take into account flow focusing effects, which are evaluated based on a flow-focusing model. Moreover, multiple realizations of the underlying stochastic permeability field are conducted. Selected sensitivity studies are performed, including the effects of an alternative drift geometry representing a partially collapsed drift from an independent drift-degradation analysis (BSC 2004 [DIRS 166107]). The intended purpose of the seepage model is to provide results of drift-scale seepage rates under a series of parameters and scenarios in support of the Total System Performance Assessment for License Application (TSPA-LA). The SMPA is intended for the evaluation of drift-scale seepage rates under the full range of parameter values for three parameters found to be key (fracture permeability, the van Genuchten 1/a parameter, and percolation flux) and drift degradation shape scenarios in support of the TSPA-LA during the period of compliance for postclosure performance [Technical Work Plan for: Performance Assessment Unsaturated Zone (BSC 2002 [DIRS 160819], Section I-4-2-1)]. The flow-focusing model in the Topopah Spring welded (TSw) unit is intended to provide an estimate of flow focusing factors (FFFs) that (1) bridge the gap between the mountain-scale and drift-scale models, and (2) account for variability in local percolation flux due to

  8. Including lifestyle medicine in undergraduate medical curricula

    Edward Phillips

    2015-02-01

    Full Text Available Purpose: Currently, there is no model to integrate the discipline of lifestyle medicine (LM into undergraduate medical education. Furthermore, there are no guidelines, validated assessment tools, or evaluation or implementation plans in place. Background: The World Health Organization predicts that by 2020, two-thirds of disease worldwide will be the result of poor lifestyle choices. Fewer than 50% of US primary care physicians routinely provide specific guidance on nutrition, physical activity, or weight control. Methods: We are establishing a plan to integrate LM into medical school education in collaboration with the investing stakeholders, including medical school deans and students, medical curriculum developers and researchers, medical societies, governing bodies, and policy institutes. Three planning and strategy meetings are being held to address key areas of focus – with a particular interest in nutrition, physical activity, student self-care, and behavior change – to develop specific implementation guidelines and landmarks. Results: After the first two meetings, the proposed areas of focus were determined to be: 1 supporting of deans and key personnel, 2 creation of federal and state policy commitments, 3 use of assessment as a driver of LM, 4 provision of high-quality evidence-based curricular material on an easily navigated site, and 5 engaging student interest. Implementation strategies for each focus area will be addressed in an upcoming planning meeting in early 2015. Conclusion: This initiative is expected to have important public health implications by efficiently promoting the prevention and treatment of non-communicable chronic disease with a scalable and sustainable model to educate physicians in training and practice.

  9. Weak energy condition violation and superluminal travel

    Lobo, Francisco; Crawford, Paulo

    2002-01-01

    Recent solutions to the Einstein Field Equations involving negative energy densities, i.e., matter violating the weak-energy-condition, have been obtained, namely traversable wormholes, the Alcubierre warp drive and the Krasnikov tube. These solutions are related to superluminal travel, although locally the speed of light is not surpassed. It is difficult to define faster-than-light travel in generic space-times, and one can construct metrics which apparently allow superluminal travel, but ar...

  10. Compact Radar Transceiver with Included Calibration

    McLinden, Matthew; Rincon, Rafael

    2013-01-01

    The Digital Beamforming Synthetic Aperture Radar (DBSAR) is an eight-channel phased array radar system that employs solid-state radar transceivers, a microstrip patch antenna, and a reconfigurable waveform generator and processor unit. The original DBSAR transceiver design utilizes connectorized electronic components that tend to be physically large and heavy. To achieve increased functionality in a smaller volume, PCB (printed circuit board) transceivers were designed to replace the large connectorized transceivers. One of the most challenging problems designing the transceivers in a PCB format was achieving proper performance in the calibration path. For a radar loop-back calibration path, a portion of the transmit signal is coupled out of the antenna feed and fed back into the receiver. This is achieved using passive components for stability and repeatability. Some signal also leaks through the receive path. As these two signal paths are correlated via an unpredictable phase, the leakage through the receive path during transmit must be 30 dB below the calibration path. For DBSAR s design, this requirement called for a 100-dB isolation in the receiver path during transmit. A total of 16 solid-state L-band transceivers on a PCB format were designed. The transceivers include frequency conversion stages, T/R switching, and a calibration path capable of measuring the transmit power-receiver gain product during transmit for pulse-by-pulse calibration or matched filtering. In particular, this calibration path achieves 100-dB isolation between the transmitted signal and the low-noise amplifier through the use of a switching network and a section of physical walls achieving attenuation of radiated leakage. The transceivers were designed in microstrip PCBs with lumped elements and individually packaged components for compactness. Each transceiver was designed on a single PCB with a custom enclosure providing interior walls and compartments to isolate transceiver

  11. Ocean storage, including costs and risks

    The long-term effectiveness of ocean storage will have to be based on theoretical understanding and models as there is no way to perform experiments on the required time and space scales for outgassing estimation. Based on observations of tracer behavior, the ventilation time of deep water has been revealed. Calibrated and constrained by these results, most of the OGCMs tell us that CO2 injected into the thermohaline circulation would not come back to the atmosphere in more than several hundred years. There are two types of concepts of ocean storage: one is a lake type concept to keep the CO2 at the ocean floor or a depression site as long as possible, and the other is to inject CO2 into the deep waters so that it is dispersed as quickly as possible. The technological concepts so far for implementation with minimum environmental impacts are much elaborated based on laboratory and computer experiments incorporating the key understanding of the CO2 clathrate properties attained in this decade. The frequently addressed concern of this technology includes the ecological modification of the ocean system. But even in the business-as-usual release of CO2 into the atmosphere, some modification might be foreseen in the deep ocean environment and could be inevitable not caused by the climate change but by the direct influence of the increase in the CO2 concentration in deep waters in future. We cannot stop the CO2 invasion into the deep ocean due to the existing of the excess CO2 in the atmosphere. Whichever release method is used, carbon dioxide we are releasing to the atmosphere now will find its way into the deep oceans. Hence, the right scientific question is whether there exist additional risks to the deep sea environment associated with this technology. If we accept the target of a stabilization level of the atmospheric concentration of CO2, our generation's commitment to the CO2 futures anyway extends to the modification of the deep sea environment induced by the

  12. Predicting difficult laryngoscopy in acromegalic patients undergoing surgery for excision of pituitary tumors: A comparison of extended Mallampati score with modified Mallampati classification

    Ashish Bindra

    2013-01-01

    Full Text Available Background: There are numerous reports of difficult laryngoscopy and intubation in patients with acromegaly. To date, no study has assessed the application of extended Mallampati score (EMS for predicting difficult intubation in acromegalics. The primary aim of this study was to compare EMS with modified Mallampati classification (MMP in predicting difficult laryngoscopy in acromegalic patients. We hypothesized that since EMS has been reported to be more specific and better predictor than MMP, it may be superior to the MMP to predict difficult laryngoscopy in acromegalic patients. Materials and Methods: For this prospective cohort study with matched controls, acromegalic patients scheduled to undergo pituitary surgery over a period of 3 years (January 2008-December 2010 were enrolled. Preoperative airway assessment was performed by experienced anesthesiologists and involved a MMP and the EMS. Under anesthesia, laryngoscopic view was assessed using Cormack-Lehane (CL grading. MMP and CL grades of I and II were defined "easy" and III and IV as "difficult". EMS grade of I and II were defined "easy" and III as "difficult". Data were used to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MMP and EMS in predicting difficult laryngoscopy. Results: Seventy eight patients participated in the study (39 patients in each group. Both MMP and EMS failed to detect difficult laryngoscopy in seven patients. Only one laryngoscopy was predicted to be difficult by both tests which was in fact, difficult. Conclusion: We found that addition of neck extension did not improve the predictive value of MMP.

  13. Gibbs conditioning extended, Boltzmann conditioning introduced

    Grendar, Marian

    2004-01-01

    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 justification to Maxi...

  14. Biomechanical conditions of walking

    Fan, Y F; Luo, L P; Li, Z Y; Han, S Y; Lv, C S; Zhang, B

    2015-01-01

    The development of rehabilitation training program for lower limb injury does not usually include gait pattern design. This paper introduced a gait pattern design by using equations (conditions of walking). Following the requirements of reducing force to the injured side to avoid further injury, we developed a lower limb gait pattern to shorten the stride length so as to reduce walking speed, to delay the stance phase of the uninjured side and to reduce step length of the uninjured side. This gait pattern was then verified by the practice of a rehabilitation training of an Achilles tendon rupture patient, whose two-year rehabilitation training (with 24 tests) has proven that this pattern worked as intended. This indicates that rehabilitation training program for lower limb injury can rest on biomechanical conditions of walking based on experimental evidence.

  15. Induced Sputum Substance P in Children with Difficult-to-Treat Bronchial Asthma and Gastroesophageal Reflux: Effect of Esomeprazole Therapy

    Adel Salah Bediwy

    2011-01-01

    Full Text Available Objectives. To assess the induced sputum substance P (ISSP levels in children having difficult-to-treat asthma (DA with and without gastroesophageal reflux (GER. We aimed also to evaluate the association of GER with childhood DA, relationship of GER severity with childhood asthma control test (C-ACT, FEV1, peak expiratory flow (PEF variability, and ISSP. Finally, we tried to evaluate esomeprazole treatment effect on C-ACT and FEV1 in children with DA. Methods. Spirometry, C-ACT, upper gastrointestinal endoscopy, and ISSP measurement were done for children with DA compared to healthy controls. Results. ISSP was high in DA with higher levels in the group having associated GER. In the latter group, ISSP and C-ACT improved significantly after esomeprazole treatment while FEV1 and PEF variability did not improve. Reflux severity was positively correlated with ISSP and negatively correlated with FEV1. Conclusions. GER was found in 49% of our patients with childhood DA. Very high ISSP levels in children with DA may be used as a marker for presence of GERD. Esomeprazole therapy improved asthma symptoms but did not improve lung function.

  16. Significance exaggerated of the activity of the construction in Spain; inflection and current decline? The difficult to their sostenibilitiy

    José María Serrano

    2010-04-01

    Full Text Available For some time the activity of the construction, in its different sections, (housings, works with non residential ends, transport, public works… has had special significance inside the productive system in Spain. During the last decade it has reached an exaggerated weight, so much in their participation in the GDP like of people occupied in her. The some regions that proportion represents exaggerated ends. The current economic crisis has affected with intensity to the group of the sector of the construction, making more intense the consequences of the economic recession. Everything it, is not only as a consequence of a crisis of the situation. Rather she is due to structural reasons. It seems probable that, from now on, the group of the Spanish economic system, it should be articulated with a new organization, a new productive model, where the construction only means a more reduced part of the same one. That is easy to say, but very difficult of getting it. It represents a great challenge face to the future.

  17. Synthesis of Gd2O3:Ho3+/Yb3+ upconversion nanoparticles for latent fingermark detection on difficult surfaces

    Kumar, A.; Tiwari, S. P.; Singh, A. K.; Kumar, K.

    2016-07-01

    Infrared to visible upconversion fluorescent nanoparticles of Gd2O3 codoped with Ho3+/Yb3+ ions are synthesized via thermal decomposition process. The X-ray diffraction analysis of as-synthesized nanoparticles and annealed sample at 1000 °C has shown body-centered cubic phase of Gd2O3. The synthesized phosphor has shown intense green emission upon 980-nm excitation. High-contrast latent fingermarks on some difficult semi-porous and non-porous surfaces under 980-nm diode laser excitation were developed through powder dusting and colloidal solution spraying techniques and the results are compared with the commercial green luminescent fingermark powder. The latent fingermarks were developed on transparent (biological glass slides), single-color (aluminum foil) and multicolor (plywood, plastic bottle and book cover page) background surfaces. The present study depicts that the upconversion-based latent fingermarks detection using Gd2O3:Ho3+/Yb3+ phosphor material is suitable over the other conventional powders and has potential for practical applications in forensic science.

  18. Using on-line video clips to enhance self-efficacy toward dealing with difficult situations among nursing students.

    McConville, Sally A; Lane, Andrew M

    2006-04-01

    The aim of the study was twofold. The first aim was to develop on-line video clip material that showed examples of nurses dealing with potentially difficult and delicate patient groups. The second aim was to evaluate the effectiveness of video clip materials for enhancing nursing student's self-efficacy to effectively communicate with the type of patients described above. The production of contextually relevant video clip material involved the identification of relevant material based on real experiences, writing appropriate scripts, recruiting actors, recording the performances and producing them in a form that could be accessed on-line. Self-report questionnaires were used to assess the effectiveness of video clip material. Level 1 (n = 145) nursing students completed a self-efficacy measure that assessed confidence to deal with situations such as breaking news of death, working with children, people with disability and aggressive behaviour at the start and the end of the module. Results indicated that student's self-efficacy increased noticeably over the course of the module. Differences between increases in self-efficacy attributed to watching videos or attending lectures were marginal. Findings suggest that using video clips that show students effectively coping with adverse situations provide an effective teaching approach for enhancing self-efficacy. Future research is needed to test the extent to which self-efficacy measures relate with nursing performance. PMID:16300862

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

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

    2014-05-01

    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

  20. Developing HYDMN code to include the transient of MNSR

    A description of the programs added to HYDMN code (a code for thermal-hydraulic steady state of MNSR) to include the transient of the same MNSR is presented. The code asks the initial conditions for the power (in k W) and the cold initial core inlet temperature (in degrees centigrade). A time-dependent study of the coolant inlet and outlet temperature, its speed, pool and tank temperatures is done for MNSR in general and for the Syrian MNSR in particular. The study solves the differential equations taken from reference (1) by using some numerical methods found in reference (3). The code becomes this way independent of any external information source. (Author)