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Sample records for extremely difficult due

  1. Rules and technical tricks in extremely difficult laparoscopic cholecystectomies

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    Liviu Drăghici

    2017-11-01

    Full Text Available We remind you of some technical artifices required in order to resolve difficult cases, such as: antegrade laparoscopic cholecystectomy (LC, subtotal laparoscopic cholecystectomy (SLC and the “stairs” clipping of the cystic duct. Also we acknowledge the closing of the cystic duct. We analyzed the medical records of 15251 laparoscopic cholecystectomies performed during 1994-2015, with emphasis on: surgical technique, conversion rate, hemorrhage, postoperative bile leaking, iatrogenic MBD injuries and mortality. We divided the cases in 5 study groups, group 1 (1994- 2004 N= 5138, group 2 (2005-2015 N= 10113, group 3 (fundus first cholecystectomies, N=2348, group 4 (retrograde cholecystectomies, N=12889 and group 5 (subtotal laparoscopic cholecystectomy-SLC, N=14 which we compared regarding the main parameters. We prefer to perform a “step by step” clipping each time the length of the clip does not cover all the circumference of the cystic duct. This artifices, is a simple laparoscopic gesture easy to perform and has the advantage of avoiding a large excessive and risky laparoscopic dissection in the vicinity of the main biliary duct. More seldom we appeal to the suture of the cystic stump using the intracorporeal knots or a simple stump ligation with an extracorporeal preformed not. We did not encounter any late or early complications following the implementation of this technical laparoscopic artifice. Laborious laparoscopic cholecystectomies performed by a well-trained surgical team ensure the premises of a good performance even while adopting laparoscopic ingenious and difficile gestures that also respect the intraoperatory rules and principals.

  2. [Anaesthetic management in a paediatric patient with a difficult airway due to epidermolysis bullosa dystrophica].

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    Blázquez Gómez, E; Garcés Aletá, A; Monclus Diaz, E; Manen Berga, F; García-Aparicio, L; Ontanilla López, A

    2015-05-01

    Dystrophic epidermolysis bullosa (DEB) is a rare inherited disorder characterized by blistering after minimal trauma. These blisters tend to form dystrophic scars, leading to limiting and life-threatening sequelae. The anaesthetic management of patients with DEB is a challenge, even for the most experienced anaesthesiologists, but basic principles can help us prepare the plan of care. The main goals are to prevent trauma/infection of skin/mucous, and to establish a secure airway without causing bullae. Patient positioning and the instruments used to monitor vital signs and administering anaesthetic agents can cause new lesions. It is advisable to lubricate the instruments and to avoid adhesive material and shearing forces on the skin. Besides the implications of the comorbidities, there is a potential difficult intubation and difficult vascular access. Acute airway obstruction can occur due to airway instrumentation. We report the case of a patient diagnosed with EBD difficult airway and undergoing correction of syndactylyl and dental extractions. Copyright © 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

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

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    Yakup Tomak

    2012-09-01

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

  4. Airway management of a difficult airway due to prolonged enlarged goiter using loco-sedative technique

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    Divya Srivastava

    2013-01-01

    Full Text Available Appropriate airway management is an essential part of anesthesiologist′s role. Huge goiters can lead to distorted airway and difficulty in endotracheal intubation. In this report, we present a case of a 67-year-old woman with a huge toxic multinodular thyroid swelling, gradually increasing in size for last 20 years, where trachea was successfully intubated. She had a history of deferred surgery in June 2007 due to inability to intubate, despite 5-6 attempts using different laryngoscopes, bougie, and stylet. Patient was re-admitted in December 2011 for the surgery and was successfully intubated this time with help of fiberoptic intubation using loco-sedative technique. Patient was electively kept intubated postoperatively in view of chances of tracheomalacia due to prolonged large goiter. She was extubated successfully on post-op day 2 after demonstration of leak around trachea following tracheal tube cuff deflation. The different techniques of managing the difficult airway in these patients are discussed.

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

    DEFF Research Database (Denmark)

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

    2015-01-01

    INTRODUCTION: The successful outcome of a major amputation depends on several factors, including stump wound healing. The purpose of this study was to examine the criteria upon which the index amputation was based and to identify factors associated with early amputation failure after major non......-traumatic lower-extremity amputation. METHODS: We studied a consecutive one-year series of 36 men and 34 women with a median (25-75% quartiles) age of 72 (63-83) years who were treated in an acute orthopaedic ward; 44 below-knee and 26 above-knee amputees of whom 47 had an American Society of Anesthesiologists...... rating above two. Patient characteristics and other factors potentially influencing early amputation failure within 30 days were evaluated. RESULTS: Eleven patients died (16%) and 11 (16%) had a re-amputation at a higher level, whereas four (6%) had a major revision at the same level within 30 days...

  6. Extreme Wind, Rain, Storm Surge, and Flooding: Why Hurricane Impacts are Difficult to Forecast?

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    Chen, S. S.

    2017-12-01

    The 2017 hurricane season is estimated as one of the costliest in the U.S. history. The damage and devastation caused by Hurricane Harvey in Houston, Irma in Florida, and Maria in Puerto Rico are distinctly different in nature. The complexity of hurricane impacts from extreme wind, rain, storm surge, and flooding presents a major challenge in hurricane forecasting. A detailed comparison of the storm impacts from Harvey, Irma, and Maria will be presented using observations and state-of-the-art new generation coupled atmosphere-wave-ocean hurricane forecast model. The author will also provide an overview on what we can expect in terms of advancement in science and technology that can help improve hurricane impact forecast in the near future.

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

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    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.

  8. The Damage To The Armour Layer Due To Extreme Waves

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    Oztunali Ozbahceci, Berguzar; Ergin, Aysen; Takayama, Tomotsuka

    2010-05-01

    The sea waves are not regular but random and chaotic. In order to understand this randomness, it is common to make individual wave analysis in time domain or spectral analysis in frequency domain. Characteristic wave heights like Hmax, H%2,H1-10, H1-3, Hmean are obtained through individual wave analysis in time domain. These characteristic wave heights are important because they are used in the design of different type of coastal structures. It is common to use significant wave height, H1-3,for the design of rubble mound structures. Therefore, only spectrally derived or zero-crossing significant wave height is usually reported for the rubble mound breakwaters without any information on larger waves. However, even the values of H1-3are similar; some train of irregular waves may exhibit a large fluctuation of instantaneous wave energy, while another train may not show such a fluctuation (Goda, 1998). Moreover, freak or rogue wave, simply defined as the wave exceeding at least twice the significant wave height may also occur. Those larger waves were called as extreme waves in this study and the effect of extreme waves on the damage to the armour layer of rubble mound breakwaters was investigated by means of hydraulic model experiment. Rock armored rubble mound breakwater model with 1:1.5 slope was constructed in the wave channel of Hydraulics Laboratory of the Disaster Prevention Research Institute of Kyoto University, Japan. The model was consisted of a permeable core layer, a filter and armour layer with two stones thicknesses. Size of stones were same for both of the slopes as Dn50(armour)=0.034m, Dn50(filter)=0.021m and Dn50(core)=0.0148m for armour, filter and core layers, respectively. Time series which are approximately equal to 1000 waves, with similar significant wave height but different extreme wave height cases were generated. In order to generate necessary time series in the wave channel, they were firstly computed by numerically. For the numerical

  9. [Effectiveness of the GlideScope video laryngoscope in a case of unexpected difficult airway due to lingual tonsil hypertrophy].

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    Cruz, P; Alarcón, L; Del Castillo, T; Cabrerizo, P; Díaz, S

    2015-05-01

    Lingual tonsil hypertrophy can cause varying degrees of airway obstruction and is considered a risk factor for difficult mask ventilation and tracheal intubation. We report a case of unexpected difficult airway in a patient with unknown lingual tonsil hypertrophy that was solved with the use of the GlideScope video laryngoscope. Copyright © 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

  10. [Chonic diarrhea and malabsorption due to common variable immunodeficiency, gastrectomy and giardiasis infection: a difficult nutritional management].

    Science.gov (United States)

    Domínguez-López, M E; González-molero, I; Ramírez-Plaza, C P; Soriguer, F; Olveira, G

    2011-01-01

    Gastric cancer is a frequent cause of cancer-related mortality in the world. Surgery is the only potentially curative therapy, although the adverse effects of surgery are common and considerable. Common variable immunodeficiency is in many cases cause of gastrointestinal system problems such as chronic diarrhea caused by infestation with giardia lamblia, nodular lymphoid hiperplasia ad loss of villi leading frequently to malapsortion and malnutrition. Nutritional deficiencies due to malapsorption (postgastrectomy and secondary to loss of villi, giardiasis and common variable inmunodeficiency) are common. We present the case of a patient with gastric cancer who underwent a gastrectomy with common variable hipogammaglobulinemia and chronic infestation by giardia lamblia, with serious diarrhea resistant to treatment and malabsorption.

  11. Extreme hydronephrosis due to uretropelvic junction obstruction in infant (case report).

    Science.gov (United States)

    Krzemień, Grażyna; Szmigielska, Agnieszka; Bombiński, Przemysław; Barczuk, Marzena; Biejat, Agnieszka; Warchoł, Stanisław; Dudek-Warchoł, Teresa

    2016-01-01

    Hydronephrosis is the one of the most common congenital abnormalities of urinary tract. The left kidney is more commonly affected than the right side and is more common in males. To determine the role of ultrasonography, renal dynamic scintigraphy and lowerdose computed tomography urography in preoperative diagnostic workup of infant with extreme hydronephrosis. We presented the boy with antenatally diagnosed hydronephrosis. In serial, postnatal ultrasonography, renal scintigraphy and computed tomography urography we observed slightly declining function in the dilated kidney and increasing pelvic dilatation. Pyeloplasty was performed at the age of four months with good result. Results of ultrasonography and renal dynamic scintigraphy in child with extreme hydronephrosis can be difficult to asses, therefore before the surgical procedure a lower-dose computed tomography urography should be performed.

  12. What Makes Difficult History Difficult?

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    Gross, Magdalena H.; Terra, Luke

    2018-01-01

    All modern nation-states have periods of difficult history that teachers fail to address or address inadequately. The authors present a framework for defining difficult histories and understanding what makes them difficult. These events 1) are central to a nation's history, 2) contradict accepted histories or values, 3) connect with present…

  13. Deterministic and Probabilistic Analysis of NPP Communication Bridge Resistance Due to Extreme Loads

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    Králik Juraj

    2014-12-01

    Full Text Available This paper presents the experiences from the deterministic and probability analysis of the reliability of communication bridge structure resistance due to extreme loads - wind and earthquake. On the example of the steel bridge between two NPP buildings is considered the efficiency of the bracing systems. The advantages and disadvantages of the deterministic and probabilistic analysis of the structure resistance are discussed. The advantages of the utilization the LHS method to analyze the safety and reliability of the structures is presented

  14. Quantifying population exposure to airborne particulate matter during extreme events in California due to climate change

    Science.gov (United States)

    Mahmud, A.; Hixson, M.; Kleeman, M. J.

    2012-08-01

    The effect of climate change on population-weighted concentrations of particulate matter (PM) during extreme pollution events was studied using the Parallel Climate Model (PCM), the Weather Research and Forecasting (WRF) model and the UCD/CIT 3-D photochemical air quality model. A "business as usual" (B06.44) global emissions scenario was dynamically downscaled for the entire state of California between the years 2000-2006 and 2047-2053. Air quality simulations were carried out for 1008 days in each of the present-day and future climate conditions using year-2000 emissions. Population-weighted concentrations of PM0.1, PM2.5, and PM10 total mass, components species, and primary source contributions were calculated for California and three air basins: the Sacramento Valley air basin (SV), the San Joaquin Valley air basin (SJV) and the South Coast Air Basin (SoCAB). Results over annual-average periods were contrasted with extreme events. The current study found that the change in annual-average population-weighted PM2.5 mass concentrations due to climate change between 2000 vs. 2050 within any major sub-region in California was not statistically significant. However, climate change did alter the annual-average composition of the airborne particles in the SoCAB, with notable reductions of elemental carbon (EC; -3%) and organic carbon (OC; -3%) due to increased annual-average wind speeds that diluted primary concentrations from gasoline combustion (-3%) and food cooking (-4%). In contrast, climate change caused significant increases in population-weighted PM2.5 mass concentrations in central California during extreme events. The maximum 24-h average PM2.5 concentration experienced by an average person during a ten-yr period in the SJV increased by 21% due to enhanced production of secondary particulate matter (manifested as NH4NO3). In general, climate change caused increased stagnation during future extreme pollution events, leading to higher exposure to diesel engines

  15. Quantifying population exposure to airborne particulate matter during extreme events in California due to climate change

    Directory of Open Access Journals (Sweden)

    A. Mahmud

    2012-08-01

    Full Text Available The effect of climate change on population-weighted concentrations of particulate matter (PM during extreme pollution events was studied using the Parallel Climate Model (PCM, the Weather Research and Forecasting (WRF model and the UCD/CIT 3-D photochemical air quality model. A "business as usual" (B06.44 global emissions scenario was dynamically downscaled for the entire state of California between the years 2000–2006 and 2047–2053. Air quality simulations were carried out for 1008 days in each of the present-day and future climate conditions using year-2000 emissions. Population-weighted concentrations of PM0.1, PM2.5, and PM10 total mass, components species, and primary source contributions were calculated for California and three air basins: the Sacramento Valley air basin (SV, the San Joaquin Valley air basin (SJV and the South Coast Air Basin (SoCAB. Results over annual-average periods were contrasted with extreme events.

    The current study found that the change in annual-average population-weighted PM2.5 mass concentrations due to climate change between 2000 vs. 2050 within any major sub-region in California was not statistically significant. However, climate change did alter the annual-average composition of the airborne particles in the SoCAB, with notable reductions of elemental carbon (EC; −3% and organic carbon (OC; −3% due to increased annual-average wind speeds that diluted primary concentrations from gasoline combustion (−3% and food cooking (−4%. In contrast, climate change caused significant increases in population-weighted PM2.5 mass concentrations in central California during extreme events. The maximum 24-h average PM2.5 concentration experienced by an average person during a ten-yr period in the SJV increased by 21% due to enhanced production of secondary particulate matter (manifested as NH4NO3. In general, climate

  16. Quantifying the daily economic impact of extreme space weather due to failure in electricity transmission infrastructure

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    Oughton, Edward J.; Skelton, Andrew; Horne, Richard B.; Thomson, Alan W. P.; Gaunt, Charles T.

    2017-01-01

    Extreme space weather due to coronal mass ejections has the potential to cause considerable disruption to the global economy by damaging the transformers required to operate electricity transmission infrastructure. However, expert opinion is split between the potential outcome being one of a temporary regional blackout and of a more prolonged event. The temporary blackout scenario proposed by some is expected to last the length of the disturbance, with normal operations resuming after a couple of days. On the other hand, others have predicted widespread equipment damage with blackout scenarios lasting months. In this paper we explore the potential costs associated with failure in the electricity transmission infrastructure in the U.S. due to extreme space weather, focusing on daily economic loss. This provides insight into the direct and indirect economic consequences of how an extreme space weather event may affect domestic production, as well as other nations, via supply chain linkages. By exploring the sensitivity of the blackout zone, we show that on average the direct economic cost incurred from disruption to electricity represents only 49% of the total potential macroeconomic cost. Therefore, if indirect supply chain costs are not considered when undertaking cost-benefit analysis of space weather forecasting and mitigation investment, the total potential macroeconomic cost is not correctly represented. The paper contributes to our understanding of the economic impact of space weather, as well as making a number of key methodological contributions relevant for future work. Further economic impact assessment of this threat must consider multiday, multiregional events.

  17. The investigation of the Japanese black cattle as well as their rearing environment inside the 'difficult-to-return zone' due to Fukushima nuclear power plant disaster

    International Nuclear Information System (INIS)

    Okada, K.

    2016-01-01

    We are continuously investigating the effect of persistent exposure to low level radiation on Japanese Black cattle kept on 3 ranches as well as their rearing environment inside the 'difficult-to-return zone' due to Fukushima nuclear power plant disaster. The spatial radiation dose rate at 1 m above ground was 40 μSv/h in the spring of 2013 but it decreased to about 20 μSv/h after 1 year 7 months. Accumulated spatial radiation dose throughout the year of was 220 mSv and exposure dose of cattle throughout that year was 170 mSv. The effect of radiation exposure due to the nuclear power plant disaster has not been clearly recognized in cattle. (author)

  18. Scale orientated analysis of river width changes due to extreme flood hazards

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    G. Krapesch

    2011-08-01

    Full Text Available This paper analyses the morphological effects of extreme floods (recurrence interval >100 years and examines which parameters best describe the width changes due to erosion based on 5 affected alpine gravel bed rivers in Austria. The research was based on vertical aerial photos of the rivers before and after extreme floods, hydrodynamic numerical models and cross sectional measurements supported by LiDAR data of the rivers. Average width ratios (width after/before the flood were calculated and correlated with different hydraulic parameters (specific stream power, shear stress, flow area, specific discharge. Depending on the geomorphological boundary conditions of the different rivers, a mean width ratio between 1.12 (Lech River and 3.45 (Trisanna River was determined on the reach scale. The specific stream power (SSP best predicted the mean width ratios of the rivers especially on the reach scale and sub reach scale. On the local scale more parameters have to be considered to define the "minimum morphological spatial demand of rivers", which is a crucial parameter for addressing and managing flood hazards and should be used in hazard zone plans and spatial planning.

  19. EVALUATION OF DISTAL UPPER EXTREMITY (DUE MUSCULOSKELETAL DISORDERS BY STRAIN INDEX (SI IN AN IRONWORK INDUSTRY

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    Seyed-Ali Moussavi-Najarkola

    2008-04-01

    Full Text Available Background and aims:Work-related musculoskeletal disorders (WMSDS is one of the mostimportant problems in working populations of Iranian industries; so, in order to evaluate theintegrated roles and effects of various ergonomic risk factors inducing such disorders, the StrainIndex (SI methods was used.Methods: This was a cross-sectional study conducted on 448 male subjects including 63controls working in administrative jobs and 385 cases working in lathing, welding, melting andfoundry jobs using integrated procedure which includes observations, interview, NordicMusculoskeletal Questionnaire (NMQ methods and SI model. All workers were questioned.Data were analyzed using SPSS software v. 11 and Excel package.Results: The most prevalent MSDs in upper limbs were found in melting lathing, foundry andwelding respectively. There was a significant relationship between age and job groups (c2=7.33;df=16; p<0.001. One-way analysis of variance showed a significant differences among means ofcalculated Strain Indices of administrative (1.06, lathing (6.52, welding (3.68, melting (7.79and foundry (6.33 jobs (F=5.92; df=16; p=0.005. Also it was revealed that melting job wasattributed as "hazardous job" (4 risk level, lathing and foundry jobs were referred to "moderaterisk level" (3 risk level, welding job was allocated as "uncertain risk level" (2 risk level, andadministrative job was attributed as "safe risk level" (1 risk level. Moreover, there was asignificant relationship between DUE and job groups (c2=11.92; df=12; p=0.004.The paired ttestshowed significant difference with direct and relatively complete correlation between meansof Strain Indices in right (6.53 and left (4.29 hands (r=0.69; t=3.15; p<0.001.Conclusion: The Strain Index (SI model can be referred as an efficient and applicable methodfor the assessment of ergonomics risk factors inducing upper extremity musculoskeletal disorders(UEMSDs, classifying jobs, correcting and modifying work situations

  20. Will climate change increase the risk for critical infrastructure failures in Europe due to extreme precipitation?

    Science.gov (United States)

    Nissen, Katrin; Ulbrich, Uwe

    2016-04-01

    An event based detection algorithm for extreme precipitation is applied to a multi-model ensemble of regional climate model simulations. The algorithm determines extent, location, duration and severity of extreme precipitation events. We assume that precipitation in excess of the local present-day 10-year return value will potentially exceed the capacity of the drainage systems that protect critical infrastructure elements. This assumption is based on legislation for the design of drainage systems which is in place in many European countries. Thus, events exceeding the local 10-year return value are detected. In this study we distinguish between sub-daily events (3 hourly) with high precipitation intensities and long-duration events (1-3 days) with high precipitation amounts. The climate change simulations investigated here were conducted within the EURO-CORDEX framework and exhibit a horizontal resolution of approximately 12.5 km. The period between 1971-2100 forced with observed and scenario (RCP 8.5 and RCP 4.5) greenhouse gas concentrations was analysed. Examined are changes in event frequency, event duration and size. The simulations show an increase in the number of extreme precipitation events for the future climate period over most of the area, which is strongest in Northern Europe. Strength and statistical significance of the signal increase with increasing greenhouse gas concentrations. This work has been conducted within the EU project RAIN (Risk Analysis of Infrastructure Networks in response to extreme weather).

  1. Prediction and discovery of extremely strong hydrodynamic instabilities due to a velocity jump: theory and experiments

    International Nuclear Information System (INIS)

    Fridman, A M

    2008-01-01

    The theory and the experimental discovery of extremely strong hydrodynamic instabilities are described, viz. the Kelvin-Helmholtz, centrifugal, and superreflection instabilities. The discovery of the last two instabilities was predicted and the Kelvin-Helmholtz instability in real systems was revised by us. (reviews of topical problems)

  2. Changes in extreme regional sea surface height due to an abrupt weakening of the Atlantic meridional overturning circulation

    NARCIS (Netherlands)

    Brunnabend, S.-E.; Dijkstra, H. A.; Kliphuis, M. A.; van Werkhoven, B.J.C.; Bal, H. E.; Seinstra, F.; Maassen, J.; van Meersbergen, M.

    2014-01-01

    As an extreme scenario of dynamical sea level changes, regional sea surface height (SSH) changes that occur in the North Atlantic due to an abrupt weakening of the Atlantic meridional overturning circulation (AMOC) are simulated. Two versions of the same ocean-only model are used to study the effect

  3. Climate Change Impacts on Flood risk in Urban Areas due to Combined Effects of Extreme Precipitation and Sea Surges

    DEFF Research Database (Denmark)

    Larsen, A. N.; Mikkelsen, Peter Steen; Arnbjerg-Nielsen, Karsten

    Climate change will impact the hydrological cycle greatly and lead to increases in flood hazards due to both pluvial and fluvial floods as well as sea surges in many regions. The impacts of the individual effects are analysed for a catchment in Greater Copenhagen. Based on both the present...... surges. Presently the most important hazard is due to extreme precipitation. However, due to climate change impacts the future most important hazard is due to sea surges. The increase in probability of floods is substantial over a 70 year horizon and actions must be taken to decrease either the hazards...

  4. Quantifying population exposure to airborne particulate matter during extreme events in California due to climate change

    OpenAIRE

    A. Mahmud; M. Hixson; M. J. Kleeman

    2012-01-01

    The effect of climate change on population-weighted concentrations of particulate matter (PM) during extreme events was studied using the Parallel Climate Model (PCM), the Weather Research and Forecasting (WRF) model and the UCD/CIT 3-D photochemical air quality model. A "business as usual" (B06.44) global emissions scenario was dynamically downscaled for the entire state of California between the years 2000–2006 and 2047–2053. Air quality simulations were carried out for ...

  5. Quantifying population exposure to airborne particulate matter during extreme events in California due to climate change

    OpenAIRE

    A. Mahmud; M. Hixson; M. J. Kleeman

    2012-01-01

    The effect of climate change on population-weighted concentrations of particulate matter (PM) during extreme pollution events was studied using the Parallel Climate Model (PCM), the Weather Research and Forecasting (WRF) model and the UCD/CIT 3-D photochemical air quality model. A "business as usual" (B06.44) global emissions scenario was dynamically downscaled for the entire state of California between the years 2000–2006 and 2047–2053. Air quality simulations were carried out for 1008 days ...

  6. Lower-Extremity Weakness in a Teenager Due to Thyrotoxic Periodic Paralysis.

    Science.gov (United States)

    Thornton, Matthew D

    2017-04-01

    Thyrotoxic hypokalemic paralysis is the hallmark of thyrotoxic periodic paralysis (TPP). TPP is a potentially deadly complication of hyperthyroidism that occurs because of rapid and dramatic intracellular shift of potassium. This transference results in severe hypokalemia and clinically manifests itself as muscle weakness or paralysis. This condition predominantly affects males of Asian descent, and its presentation can range from mild to severe, as seen in our case. We present the case of a 15-year-old Asian-American male who presented to a tertiary-care pediatric emergency department complaining of generalized weakness and flaccid paralysis of his lower extremities. The differential for such a complaint is extremely broad, and the symptoms can result from etiologies arising from the cerebral cortex, the spinal cord, peripheral nerves, the neuromuscular junction, or even the muscles themselves. Our patient was found to have an extremely low serum potassium concentration, as well as an electrocardiogram that revealed a prolonged QT interval and right bundle branch block. The etiology of these abnormalities and the patient's symptoms was found to be undiagnosed and uncontrolled hyperthyroidism from Grave's disease, which resulted in this dramatic presentation of thyrotoxic hypokalemic paralysis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This entity is common in Asia but still somewhat rare in the United States and other Western countries. Our case illustrates that careful history taking and a focused diagnostic evaluation, in conjunction with having an awareness of this disease, can help expedite diagnosis and management, as well as avoid unnecessary and potential harmful testing in the emergency department setting. Copyright © 2016 Elsevier Inc. All rights reserved.

  7. Vegetation Cover and Furrow Erosion due to Extreme Rain Events in Semiarid Environments

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    Belén Cárceles-Rodríguez

    2017-05-01

    Full Text Available The conservation of the soil resource in semi-arid environments is one of the major challenges of agricultural systems, particularly in the Mediterranean region. In the present study, two types of soil management were compared: minimum tillage (ML and minimum tillage with spontaneous vegetation cover (MLVE. The comparison was conducted in a rainfed almond plantation at slope (35%, under an extraordinary event in 2015 (91.3 mm and EI30 of 2,719.89 mm ha-1 h-1. In this situation in MLVE plots, the development of furrows in contrast to ML were not recorded; the total soil loss was more than 12 times lower than that recorded in the latter. This fact demonstrated the effectiveness of the vegetal cover in the protection of the agricultural soil against the erosion during extreme events. Also, for ML management, furrow erosion represented more than 60% of the total soil loss, demonstrating the dominance of this type of erosion. Finally, it should be noted that this event represents the almost total loss of soil recorded in the experimental plots during the period 2012-2015; and this consequently shows the significant impact of extreme events on erosion rates in the Mediterranean region.

  8. Within-summer variation in out-of-hospital cardiac arrest due to extremely long sunshine duration.

    Science.gov (United States)

    Onozuka, Daisuke; Hagihara, Akihito

    2017-03-15

    Although several studies have reported the impacts of extremely high temperatures on cardiovascular diseases, no studies have examined whether variation in out-of-hospital cardiac arrest (OHCA) due to extremely long sunshine duration changes during the summer. We obtained daily data on all cases of OHCA and weather variations for all 47 prefectures of Japan during the summer (June to September) between 2005 and 2014. A distributed lag non-linear model combined with a quasi-Poisson regression model was used to estimate within-summer variation in OHCA due to extremely long sunshine duration for each prefecture. Then, multivariate random-effects meta-analysis was performed to derive overall effect estimates of sunshine duration at the national level. A total of 166,496 OHCAs of presumed cardiac origin met the inclusion criteria. The minimum morbidity percentile (MMP) was the 0th percentile of sunshine duration at the national level. The overall cumulative relative risk (RR) at the 99th percentile vs. the MMP was 1.15 (95% CI: 1.05-1.27) during the summer. The effect of extremely long sunshine duration on OHCA in early summer was acute and did not persist, whereas an identical effect was observed in late summer, but it was delayed and lasted for several days. During summer periods, excessive sunshine duration could increase the risk of OHCA. Timely preventive measures to reduce the OHCA risk due to extremely long sunshine duration are important in early summer, whereas these measures could include a wider time window of several days to reduce the risk in late summer. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  9. Assessing extreme sea levels due to tropical cyclones in the Atlantic basin

    Science.gov (United States)

    Muis, Sanne; Lin, Ning; Verlaan, Martin; Winsemius, Hessel; Vatvani, Deepak; Ward, Philip; Aerts, Jeroen

    2017-04-01

    Tropical cyclones (TCs), including hurricanes and typhoons, are characterised by high wind speeds and low pressure and cause dangerous storm surges in coastal areas. Over the last 50 years, storm surge incidents in the Atlantic accounted for more than 1,000 deaths in the United Stated. Recent flooding disasters, such as Hurricane Katrina in New Orleans in 2005 and, Hurricane Sandy in New York in 2012, exemplify the significant TC surge risk in the United States. In this contribution, we build on Muis et al. (2016), and present a new modelling framework to simulate TC storm surges and estimate their probabilities for the Atlantic basin. In our framework we simulate the surge levels by forcing the Global Tide and Surge Model (GTSM) with wind and pressure fields from TC events. To test the method, we apply it to historical storms that occurred between 1988 and 2015 in the Atlantic Basin. We obtain high-resolution meteorological forcing by applying a parametric hurricane model (Holland 1980; Lin and Chavas 2012) to the TC extended track data set (Demuth et al. 2006; updated), which describes the position, intensity and size of the historical TCs. Preliminary results show that this framework is capable of accurately reproducing the main surge characteristics during past events, including Sandy and Katrina. While the resolution of GTSM is limited for local areas with a complex bathymetry, the overall performance of the model is satisfactory for the basin-scale application. For an accurate assessment of risk to coastal flooding in the Atlantic basin it is essential to provide reliable estimates of surge probabilities. However, the length of observed TC tracks is too short to accurately estimate the probabilities of extreme TC events. So next steps are to statistically extend the observed record to many thousands of years (e.g., Emanuel et al. 2006), in order to force GTSM with a large number of synthetic storms. Based on these synthetic simulations, we would be able to

  10. [Malnutrition due to an extremely 'healthy' diet; a new eating disorder?].

    Science.gov (United States)

    Nauta, K; Toxopeus, K; Eekhoff, E M W

    2016-01-01

    A 71-year-old male was admitted to our hospital with heart failure, cachexia and biochemical disturbances due to a diet consisting of exclusively vegetables, oil and water. Our investigations showed that this diet was a consequence of an excessive preoccupation with health. The patient did not meet criteria for an eating disorder or other DSM-IV psychiatric disorder. We conclude that malnutrition due to health fad diets may be an underestimated medical problem. There is no specific psychopathological disorder that covers this behaviour, and there is no knowledge of its epidemiology. Popular literature is paying a great deal attention to orthorexia nervosa, an alleged eating disorder that describes a pathological obsession with healthy food. In medical literature this concept has been largely neglected, although eating disorder specialists frequently observe this behaviour in their practice. More clinical and scientific attention for this phenomenon is necessary to determine its epidemiology, validity and clinical picture.

  11. Nerve transfers for restoration of upper extremity motor function in a child with upper extremity motor deficits due to transverse myelitis: case report.

    Science.gov (United States)

    Dorsi, Michael J; Belzberg, Allan J

    2012-01-01

    Transverse myelitis (TM) may result in permanent neurologic dysfunction. Nerve transfers have been developed to restore function after peripheral nerve injury. Here, we present a case report of a child with permanent right upper extremity weakness due to TM that underwent nerve transfers. The following procedures were performed: double fascicle transfer from median nerve and ulnar nerve to the brachialis and biceps branches of the musculocutaneous nerve, spinal accessory to suprascapular nerve, and medial cord to axillary nerve end-to-side neurorraphy. At 22 months, the patient demonstrated excellent recovery of elbow flexion with minimal improvement in shoulder abduction. We propose that the treatment of permanent deficits from TM represents a novel indication for nerve transfers in a subset of patients. Copyright © 2011 Wiley Periodicals, Inc.

  12. Customized toric intraocular lens implantation for correction of extreme corneal astigmatism due to corneal scarring

    Directory of Open Access Journals (Sweden)

    R Bassily

    2010-03-01

    Full Text Available R Bassily, J LuckOphthalmology Department, Royal United Hospital, Combe Park, Bath, UKAbstract: A 76-year-old woman presented with decreased visual function due to cataract formation. Twenty-five years prior she developed right sided corneal ulceration that left her with 10.8 diopters (D of irregular astigmatism at 71.8° (steep axis. Her uncorrected visual acuity was 6/24 and could only ever wear a balanced lens due to the high cylindrical error. Cataract surgery was planned with a custom designed toric intraocular lens (IOL with +16.0 D sphere inserted via a wound at the steep axis of corneal astigmatism. Postoperative refraction was -0.75/+1.50 × 177° with a visual acuity of 6/9 that has remained unchanged at six-week follow-up with no IOL rotation. This case demonstrates the value of high power toric IOLs for the correction of pathological corneal astigmatism.Keywords: intraocular lens, corneal ulceration, visual acuity, scarring

  13. Extreme concentration fluctuations due to local reversibility of mixing in turbulent flows

    Science.gov (United States)

    Xia, Hua; Francois, Nicolas; Punzmann, Horst; Szewc, Kamil; Shats, Michael

    2018-05-01

    Mixing of a passive scalar in a fluid (e.g. a radioactive spill in the ocean) is the irreversible process towards homogeneous distribution of a substance. In a moving fluid, due to the chaotic advection [H. Aref, J. Fluid Mech. 143 (1984) 1; J. M. Ottino, The Kinematics of Mixing: Stretching,Chaos and Transport (Cambridge University Press, Cambridge, 1989)] mixing is much faster than if driven by molecular diffusion only. Turbulence is known as the most efficient mixing flow [B. I. Shraiman and E. D. Siggia, Nature 405 (2000) 639]. We show that in contrast to spatially periodic flows, two-dimensional turbulence exhibits local reversibility in mixing, which leads to the generation of unpredictable strong fluctuations in the scalar concentration. These fluctuations can also be detected from the analysis of the fluid particle trajectories of the underlying flow.

  14. Extremely elevated alpha-fetoprotein due to acute exacerbation of chronic hepatitis B without malignancy: a case report.

    Science.gov (United States)

    Yoon, Young-Min; Kang, Da-Yeong; Kim, Da-Young; Seo, Jun-Won; Lim, Hyun-Jong; Lee, Hee-Jeong; Park, Sang-Gon

    2016-06-01

    Alpha-fetoprotein is produced by a variety of tumors such as hepatocellular carcinoma, hepatoblastoma, and germ cell tumors of the ovary and testes. However, we present a case of significantly elevated serum alpha-fetoprotein without evidence of malignant disease in a patient who is a carrier of chronic hepatitis B. A 60-year-old Korean man presented with markedly increased alpha-fetoprotein (2350 ng/mL; normal 7 × 105 IU/mL). Our patient was diagnosed with acute exacerbation of chronic hepatitis B, and we presumed that this condition might be related to extremely elevated alpha-fetoprotein. When our patient was treated with entecavir, the serum alpha-fetoprotein level immediately decreased, in parallel with the hepatitis B virus deoxyribonucleic acid copy number. We report a rare case of extremely elevated alpha-fetoprotein due to acute exacerbation of chronic hepatitis B without any malignancy, and a decrease in this tumor marker simultaneous with a decrease in hepatitis B virus deoxyribonucleic acid copy number on entecavir treatment. This case report is important due to the rarity of the case; furthermore, it provides details of a diagnostic process for a variety of benign diseases and malignant tumors that should be considered in patients with elevated alpha-fetoprotein. Thus, we present a case report, along with a review, that will be helpful for diagnosis and treatment of patients with elevated alpha-fetoprotein.

  15. The application of DSA bolus chase technology in diagnosing the vascular disorders of lower extremities due to diabetes mellitus

    International Nuclear Information System (INIS)

    Ren Chongyang; Di Zhenhai; Mao Xuequn; Zou Rong; Zhang Jian; Wang Meirong; Li Quan

    2010-01-01

    Objective: To retrospectively evaluate the digital subtraction angiography (DSA) bolus chase technology in diagnosing the vascular disorders of lower extremities due to diabetes mellitus. Methods: From January 2004 to March 2010, DSA was performed in forty-five diabetes patients with suspicious vascular diseases of lower extremities. Among them, 24 cases (31 lower limbs)were examined with DSA bolus chase technology and the remaining 21 cases (21 lower limbs)were examined with traditional segmentational technique. The contrast dosage used in angiography, the total exposure time, the examination time and the imaging value for making diagnosis were analyzed and compared between two techniques. Results: For DSA bolus chase technology group, the contrast dosage used in angiography, the total exposure time and the examination time were 25.26 ml, 13.23 s and 37.26 min, respectively,with an average exposure of 101.65 pictures. For traditional segmentational technique group, the contrast dosage used in angiography, the total exposure time and the examination time were 130.00 ml, 52.38 s and 50.48 min, respectively, with an average exposure of 118.33 pictures. The percentage of high quality images in bolus chase technology group and in traditional segmentational technique group were 90.3% and 90.5%, respectively. All the images could meet the requirements for making a reliable diagnosis. Conclusion: Digital subtraction angiography by using bolus-chase technology can well demonstrate the vascular pathology of lower extremities caused by diabetes mellitus, obtain sufficient imaging information necessary for making a reliable diagnosis. DSA bolus chase technology is superior to traditional segmentational technique in shortening procedure time, reducing contrast medium dosage and decreasing radiation dose. (authors)

  16. Extreme lateral approach in a case of acute-onset quadriplegia due to high cervical neurenteric cyst.

    Science.gov (United States)

    Abhishek, Agrawal; Anushree, Agrawal; Patir, Rana; Sehgal, A D

    2007-01-01

    Spinal neurenteric cysts are very rare intradural developmental lesions, predominantly localized anterior to the cervical cord and arising from misplaced endodermal cells in the 3rd week of embryonic life. An acute onset of symptoms can occur due to hemorrhage, but has not as yet been reported in relation to infection in the cyst. We report an 18-year-old male who presented with a rapid onset of respiratory distress and quadriplegia over a period of 6 h requiring intubation and ventilatory support. There was no respiratory effort with a dense sensory level from the neck. MRI of the cervical spine revealed an intradural extramedullary ventrally located cystic lesion at the C(2-3) level. There was no evidence of systemic infection elsewhere in the body. The lesion was radically excised using an extreme lateral approach as it provided excellent visualization of the cyst, thus permitting safe dissection without retraction of the cord. The cyst was tense and the contents turbid, thick, creamy and mucinous without any evidence of fresh or altered blood. Histopathological examination confirmed the cyst to be a neurenteric cyst. The cystic fluid, which was sent for culture, grew coagulase-negative Staphylococcus aureus. This is the first documented case of rapid neurological deterioration due to infection in a neurenteric cyst. In spite of an early effective surgical management, outcome was poor due to the rapid and profound neurological deficit. Copyright (c) 2007 S. Karger AG, Basel.

  17. Conflict management: difficult conversations with difficult people.

    Science.gov (United States)

    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.

  18. Conflict Management: Difficult Conversations with Difficult People

    OpenAIRE

    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.

  19. Solving Component Structural Dynamic Failures Due to Extremely High Frequency Structural Response on the Space Shuttle Program

    Science.gov (United States)

    Frady, Greg; Nesman, Thomas; Zoladz, Thomas; Szabo, Roland

    2010-01-01

    For many years, the capabilities to determine the root-cause failure of component failures have been limited to the analytical tools and the state of the art data acquisition systems. With this limited capability, many anomalies have been resolved by adding material to the design to increase robustness without the ability to determine if the design solution was satisfactory until after a series of expensive test programs were complete. The risk of failure and multiple design, test, and redesign cycles were high. During the Space Shuttle Program, many crack investigations in high energy density turbomachines, like the SSME turbopumps and high energy flows in the main propulsion system, have led to the discovery of numerous root-cause failures and anomalies due to the coexistences of acoustic forcing functions, structural natural modes, and a high energy excitation, such as an edge tone or shedding flow, leading the technical community to understand many of the primary contributors to extremely high frequency high cycle fatique fluid-structure interaction anomalies. These contributors have been identified using advanced analysis tools and verified using component and system tests during component ground tests, systems tests, and flight. The structural dynamics and fluid dynamics communities have developed a special sensitivity to the fluid-structure interaction problems and have been able to adjust and solve these problems in a time effective manner to meet budget and schedule deadlines of operational vehicle programs, such as the Space Shuttle Program over the years.

  20. How do extreme streamflow due to hurricane IRMA compare during 1938-2017 in South Eastern US?

    Science.gov (United States)

    Anandhi, A.

    2017-12-01

    The question related to Irma, Harvey, Maria, and other hurricanes is: are hurricane more frequent and intense than they have been in the past. Recent hurricanes were unusually strong hitting the US Coastline or territories as a category 4 or 5, dropping unusually large amounts of precipitation on the affected areas creating extreme high-flow events in rivers and streams in affected areas. The objective of the study is to determine how extreme are streamflows from recent hurricanes (e.g. IRMA) when compared to streamflow's during 1938-2017 time-period. Additionally, in this study, the extreme precipitations are also compared during IRMA. Extreme high flows are selected from Indicators of Hydrologic Alteration (IHA). They are distributions, timing, duration, frequency, magnitude, pulses, and days of extreme events in rivers of the southeastern United States and Gulf of Mexico Hydrologic Region—03. Streamflow data from 30 stations in the region with at least 79 years of record (1938-2017) are used. Historical precipitation changes is obtained from meta-analysis of published literature. Our preliminary results indicate the extremeness of streamflow from recent hurricanes vary with the IHA indicator selected. Some potential implications of these extreme events on the region's ecosystem are also discussed using causal chains and loops.

  1. Psychopathology in difficult asthma

    NARCIS (Netherlands)

    Prins, L.C.; van Son, M.J.M.; Keimpema, A.R.; van Ranst, D; Pommer, A; Meijer, J.W.; Pop, V.J.M.

    2015-01-01

    OBJECTIVE: Within the asthma population, difficult asthma (DA) is a severe condition in which patients present with frequent exacerbations, hospitalizations and emergency room visits. The identification and treatment of psychopathology is included in the management of DA. Psychopathology is supposed

  2. Floor cooling. Extreme cooling efficiency due to vapour barrier? Optimized floor heating and cooling system; Flaechenkuehlung. Extreme Kuehlleistung dank Dampfsperre. Optimiertes Fussbodenheiz- und Kuehlsystem

    Energy Technology Data Exchange (ETDEWEB)

    Werner, Rolf [Wieland-Werke AG, Ulm (Germany). Technisches Marketing Haustechnik

    2010-07-01

    The active cooling of offices generally is accepted ever more. Among other things this is due to the fact that the climatic change results in a hotter summer on a long-term basis also in Germany. Also the use of computers, printing and copying machines increases the thermal load of the rooms considerably. The architecturally affected facade design with large glass areas also has an impact. The thermal comfort maintains the efficiency in offices. Thus, the efficient space cooling has become standard.

  3. Extreme total solar irradiance due to cloud enhancement at sea level of the NE Atlantic coast of Brazil

    Energy Technology Data Exchange (ETDEWEB)

    Piacentini, Ruben D. [Instituto de Fisica Rosario (CONICET-Universidad Nacional de Rosario), 27 de Febrero 210bis, 2000 Rosario (Argentina); Facultad de Ciencias Exactas, Ingenieria y Agrimensura, Universidad Nacional de Rosario, Pellegrini 250, 2000 Rosario (Argentina); Salum, Graciela M. [Instituto de Fisica Rosario (CONICET-Universidad Nacional de Rosario), 27 de Febrero 210bis, 2000 Rosario (Argentina); Facultad Regional Concepcion del Uruguay, Universidad Tecnologica Nacional, Concepcion del Uruguay (Argentina); Fraidenraich, Naum; Tiba, Chigueru [Grupo de Pesquisas em Fontes Alternativas de Energia, Universidade Federal de Pernambuco, Av. Prof. Luiz Freire, 1000 - 50.740-540, Recife, PE (Brazil)

    2011-01-15

    Extraterrestrial total solar irradiance, usually called Solar Constant, is attenuated by the atmosphere in different proportions, depending mainly on solar zenith angle and altitude of the measurement point. In this work, it is presented very high and extreme horizontal plane measurements of global solar irradiance that in some days overpassed the Solar Constant corrected by the actual Sun-Earth distance (CSC). They were obtained at sea level of the intertropical Atlantic coast, in the city of Recife, Brazil, in the period February 2008-January 2009. Extreme total solar irradiance values larger than CSC were measured during 3.4% of the days of the total registered period. This percentage increases to 7.4% for global solar irradiance within 95.1-100% of the CSC and to 15.3% within 90.1-95% of the CSC. The largest extreme total solar irradiance value, 1477 {+-} 30 W/m{sup 2}, was registered the 28th of March 2008 at 11:34 local time (UT - 3h). It overpassed by 7.9% the CSC value for this day (1369.4 W/m{sup 2}) and by 42.3% the estimated value of the clear sky Iqbal C radiation model (1037.7 W/m{sup 2}). The observation of extreme values should be taken into account in the study of solar radiation effects related to materials exposed to the outside, UV index and biological effects, among others. Also, the detailed knowledge of this interesting effect may contribute significantly to clarify physical aspects about the interaction of global solar radiation with the ecosystem and climate change. (author)

  4. Trends in the number of extreme hot SST days along the Canary Upwelling System due to the influence of upwelling

    Directory of Open Access Journals (Sweden)

    Xurxo Costoya

    2014-07-01

    Full Text Available Trends in the number of extreme hot days (days with SST anomalies higher than the 95% percentile were analyzed along the Canary Upwelling Ecosystem (CUE over the period 1982- 2012 by means of SST data retrieved from NOAA OI1/4 Degree. The analysis will focus on the Atlantic Iberian sector and the Moroccan sub- region where upwelling is seasonal (spring and summer are permanent, respectively. Trends were analyzed both near coast and at the adjacent ocean where the increase in the number of extreme hot days is higher. Changes are clear at annual scale with an increment of 9.8±0.3 (9.7±0.1 days dec-1 near coast and 11.6±0.2 (13.5±0.1 days dec-1 at the ocean in the Atlantic Iberian sector (Moroccan sub-region. The differences between near shore and ocean trends are especially patent for the months under intense upwelling conditions. During that upwelling season the highest differences in the excess of extreme hot days between coastal and ocean locations (Δn(#days dec-1 occur at those regions where coastal upwelling increase is high. Actually, Δn and upwelling trends have shown to be significantly correlated in both areas, R=0.88 (p<0.01 at the Atlantic Iberian sector and R=0.67 (p<0.01 at the Moroccan sub-region.

  5. Real-time prediction of extreme ambient carbon monoxide concentrations due to vehicular exhaust emissions using univariate linear stochastic models

    International Nuclear Information System (INIS)

    Sharma, P.; Khare, M.

    2000-01-01

    Historical data of the time-series of carbon monoxide (CO) concentration was analysed using Box-Jenkins modelling approach. Univariate Linear Stochastic Models (ULSMs) were developed to examine the degree of prediction possible for situations where only a limited data set, restricted only to the past record of pollutant data are available. The developed models can be used to provide short-term, real-time forecast of extreme CO concentrations for an Air Quality Control Region (AQCR), comprising a major traffic intersection in a Central Business District of Delhi City, India. (author)

  6. Under-reported dosimetry errors due to interplay effects during VMAT dose delivery in extreme hypofractionated stereotactic radiotherapy.

    Science.gov (United States)

    Gauer, Tobias; Sothmann, Thilo; Blanck, Oliver; Petersen, Cordula; Werner, René

    2018-06-01

    Radiotherapy of extracranial metastases changed from normofractioned 3D CRT to extreme hypofractionated stereotactic treatment using VMAT beam techniques. Random interaction between tumour motion and dynamically changing beam parameters might result in underdosage of the CTV even for an appropriately dimensioned ITV (interplay effect). This study presents a clinical scenario of extreme hypofractionated stereotactic treatment and analyses the impact of interplay effects on CTV dose coverage. For a thoracic/abdominal phantom with an integrated high-resolution detector array placed on a 4D motion platform, dual-arc treatment plans with homogenous target coverage were created using a common VMAT technique and delivered in a single fraction. CTV underdosage through interplay effects was investigated by comparing dose measurements with and without tumour motion during plan delivery. Our study agrees with previous works that pointed out insignificant interplay effects on target coverage for very regular tumour motion patterns like simple sinusoidal motion. However, we identified and illustrated scenarios that are likely to result in a clinically relevant CTV underdosage. For tumour motion with abnormal variability, target coverage quantified by the CTV area receiving more than 98% of the prescribed dose decreased to 78% compared to 100% at static dose measurement. This study is further proof of considerable influence of interplay effects on VMAT dose delivery in stereotactic radiotherapy. For selected conditions of an exemplary scenario, interplay effects and related motion-induced target underdosage primarily occurred in tumour motion pattern with increased motion variability and VMAT plan delivery using complex MLC dose modulation.

  7. Extreme oceanographic forcing and coastal response due to the 2015–2016 El Niño

    Science.gov (United States)

    Barnard, Patrick; Hoover, Daniel J.; Hubbard, David M.; Snyder, Alexander; Ludka, Bonnie C.; Allan, Jonathan; Kaminsky, George M.; Ruggiero,; Gallien, Timu W.; Gabel, Laura; McCandless, Diana; Weiner, Heather M.; Cohn, Nicholas; Anderson, Dylan L.; Serafin, Katherine A.

    2017-01-01

    The El Niño-Southern Oscillation is the dominant mode of interannual climate variability across the Pacific Ocean basin, with influence on the global climate. The two end members of the cycle, El Niño and La Niña, force anomalous oceanographic conditions and coastal response along the Pacific margin, exposing many heavily populated regions to increased coastal flooding and erosion hazards. However, a quantitative record of coastal impacts is spatially limited and temporally restricted to only the most recent events. Here we report on the oceanographic forcing and coastal response of the 2015–2016 El Niño, one of the strongest of the last 145 years. We show that winter wave energy equalled or exceeded measured historical maxima across the US West Coast, corresponding to anomalously large beach erosion across the region. Shorelines in many areas retreated beyond previously measured landward extremes, particularly along the sediment-starved California coast.

  8. Extreme oceanographic forcing and coastal response due to the 2015-2016 El Niño.

    Science.gov (United States)

    Barnard, Patrick L; Hoover, Daniel; Hubbard, David M; Snyder, Alex; Ludka, Bonnie C; Allan, Jonathan; Kaminsky, George M; Ruggiero, Peter; Gallien, Timu W; Gabel, Laura; McCandless, Diana; Weiner, Heather M; Cohn, Nicholas; Anderson, Dylan L; Serafin, Katherine A

    2017-02-14

    The El Niño-Southern Oscillation is the dominant mode of interannual climate variability across the Pacific Ocean basin, with influence on the global climate. The two end members of the cycle, El Niño and La Niña, force anomalous oceanographic conditions and coastal response along the Pacific margin, exposing many heavily populated regions to increased coastal flooding and erosion hazards. However, a quantitative record of coastal impacts is spatially limited and temporally restricted to only the most recent events. Here we report on the oceanographic forcing and coastal response of the 2015-2016 El Niño, one of the strongest of the last 145 years. We show that winter wave energy equalled or exceeded measured historical maxima across the US West Coast, corresponding to anomalously large beach erosion across the region. Shorelines in many areas retreated beyond previously measured landward extremes, particularly along the sediment-starved California coast.

  9. Extreme hypertriglyceridemia, pseudohyponatremia, and pseudoacidosis in a neonate with lipoprotein lipase deficiency due to segmental uniparental disomy.

    Science.gov (United States)

    Ashraf, Ambika P; Hurst, Anna C E; Garg, Abhimanyu

    Extreme hypertriglyceridemia is rare in the neonatal period. We report a neonate with lipoprotein lipase (LPL) deficiency who presented with diagnostic and management conundrum. A full-term 36-day-old female was noted to have "Pepto-Bismol like" blood when repeating a newborn screening. The initial plasma triglyceride level was 24,318 mg/dL. The laboratory tests revealed serum bicarbonate level of severe anemia. There were no signs of acute distress. The point of care capillary blood testing, however, demonstrated normal serum pH (7.2), bicarbonate (25.4 mmol/L), and sodium (139 mmol/L). The patient had mild elevation of serum lactic acid and no ketonuria. A diagnosis of type I hyperlipoproteinemia was made. Oral feeding was stopped, and the infant received intravenous fluids for the next 7 days resulting in lowering of serum triglyceride levels to 1016 mg/dL. Oral feeding was initiated with an amino acid-rich formula to which medium chain triglycerides were slowly added, while maintaining the total fat content to A, p.(Gly215Glu) mutation. Subsequent analysis of the parental samples revealed that only the father, but not the mother, was a heterozygous carrier of the same mutation. Analysis of 18 informative microsatellite markers on chromosome 8 revealed paternal segmental uniparental disomy with partial absence of the maternal chromosome 8p, confirmed by single-nucleotide polymorphism microarray. We conclude that besides pseudohyponatremia, extreme hypertriglyceridemia can rarely present as pseudoacidosis and uniparental disomy can be an underlying mechanism for autosomal recessive diseases such as LPL deficiency. Published by Elsevier Inc.

  10. Making marketing difficult

    DEFF Research Database (Denmark)

    Meyer, Gitte

    2005-01-01

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

  11. Why Translation Is Difficult

    DEFF Research Database (Denmark)

    Carl, Michael; Schaeffer, Moritz Jonas

    2017-01-01

    The paper develops a definition of translation literality that is based on the syntactic and semantic similarity of the source and the target texts. We provide theoretical and empirical evidence that absolute literal translations are easy to produce. Based on a multilingual corpus of alternative...... translations we investigate the effects of cross-lingual syntactic and semantic distance on translation production times and find that non-literality makes from-scratch translation and post-editing difficult. We show that statistical machine translation systems encounter even more difficulties with non-literality....

  12. Dealing with difficult pasts

    DEFF Research Database (Denmark)

    McAtackney, Laura

    2013-01-01

    develop. I argue that such politically loaded manifestations of difficult pasts are highly significant during post-conflict renegotiations of society. They act as reminders of what happened, a commentary on how far society has – or has not moved on – and the potential for future relations and directions....... Using Robben Island and Long Kesh / Maze as case-studies this paper will explore the physical manifestations of political imprisonment, their experiences in the post-conflict context and reveal contestations of meaning at these dark heritage sites....

  13. Effects of anthropogenic heat due to air-conditioning systems on an extreme high temperature event in Hong Kong

    Science.gov (United States)

    Wang, Y.; Li, Y.; Di Sabatino, S.; Martilli, A.; Chan, P. W.

    2018-03-01

    Anthropogenic heat flux is the heat generated by human activities in the urban canopy layer, which is considered the main contributor to the urban heat island (UHI). The UHI can in turn increase the use and energy consumption of air-conditioning systems. In this study, two effective methods for water-cooling air-conditioning systems in non-domestic areas, including the direct cooling system and central piped cooling towers (CPCTs), are physically based, parameterized, and implemented in a weather research and forecasting model at the city scale of Hong Kong. An extreme high temperature event (June 23-28, 2016) in the urban areas was examined, and we assessed the effects on the surface thermal environment, the interaction of sea-land breeze circulation and urban heat island circulation, boundary layer dynamics, and a possible reduction of energy consumption. The results showed that both water-cooled air-conditioning systems could reduce the 2 m air temperature by around 0.5 °C-0.8 °C during the daytime, and around 1.5 °C around 7:00-8:00 pm when the planetary boundary layer (PBL) height was confined to a few hundred meters. The CPCT contributed around 80%-90% latent heat flux and significantly increased the water vapor mixing ratio in the atmosphere by around 0.29 g kg-1 on average. The implementation of the two alternative air-conditioning systems could modify the heat and momentum of turbulence, which inhibited the evolution of the PBL height (a reduction of 100-150 m), reduced the vertical mixing, presented lower horizontal wind speed and buoyant production of turbulent kinetic energy, and reduced the strength of sea breeze and UHI circulation, which in turn affected the removal of air pollutants. Moreover, the two alternative air-conditioning systems could significantly reduce the energy consumption by around 30% during extreme high temperature events. The results of this study suggest potential UHI mitigation strategies and can be extended to

  14. Severe upper extremity polyneuropathy due to inferior brachial plexus compression as a result of left subclavian artery pseudoaneurism

    Directory of Open Access Journals (Sweden)

    George Kosmadakis

    2012-01-01

    Full Text Available In the present report, we describe the case of a 76-year-old hemodialysis patient who was admitted with clinical features of neurological thoracic exit syndrome due to subclavian artery pseudoaneurism following the insertion of a dual lumen vascular internal jugular catheter (vascath with excellent outcome after endo-arterial stent placement.

  15. Massive hemobilia due to hepatic arteriobiliary fistula during endoscopic retrograde cholangiopancretography: An extremely rare guidewir-related complication

    Energy Technology Data Exchange (ETDEWEB)

    Nam, Jeong Gu; Seo, Young Woo; Hwang, Jae Cheol; Weon, Young Cheol; Kang, Byeong Seong; Bang, Sung Jo; Bang, Min Seo [Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan (Korea, Republic of)

    2015-05-15

    Although endoscopic retrograde cholangiopancreatography (ERCP) is an effective modality for diagnosis and treatment of biliary and pancreatic diseases, the risk for procedure-related complications is high. Hemorrhage is one of major complications of ERCP. Most ERCP-associated bleeding is primarily a complication related to sphincterotomy rather than diagnostic ERCP. We are reporting a case of massive hemobilia due to hepatic arteriobiliary fistula caused by guidewire-associated injury during ERCP, which was successfully treated with transarterial embolization of the hepatic artery.

  16. Difficult diagnoses in the skeletal radiology

    International Nuclear Information System (INIS)

    Freyschmidt, Juergen

    2013-01-01

    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.

  17. Extremely large nonsaturating magnetoresistance and ultrahigh mobility due to topological surface states in the metallic Bi2Te3 topological insulator

    Science.gov (United States)

    Shrestha, K.; Chou, M.; Graf, D.; Yang, H. D.; Lorenz, B.; Chu, C. W.

    2017-05-01

    Weak antilocalization (WAL) effects in Bi2Te3 single crystals have been investigated at high and low bulk charge-carrier concentrations. At low charge-carrier density the WAL curves scale with the normal component of the magnetic field, demonstrating the dominance of topological surface states in magnetoconductivity. At high charge-carrier density the WAL curves scale with neither the applied field nor its normal component, implying a mixture of bulk and surface conduction. WAL due to topological surface states shows no dependence on the nature (electrons or holes) of the bulk charge carriers. The observations of an extremely large nonsaturating magnetoresistance and ultrahigh mobility in the samples with lower carrier density further support the presence of surface states. The physical parameters characterizing the WAL effects are calculated using the Hikami-Larkin-Nagaoka formula. At high charge-carrier concentrations, there is a greater number of conduction channels and a decrease in the phase coherence length compared to low charge-carrier concentrations. The extremely large magnetoresistance and high mobility of topological insulators have great technological value and can be exploited in magnetoelectric sensors and memory devices.

  18. Modelling the increased frequency of extreme sea levels in the Ganges-Brahmaputra-Meghna delta due to sea level rise and other effects of climate change.

    Science.gov (United States)

    Kay, S; Caesar, J; Wolf, J; Bricheno, L; Nicholls, R J; Saiful Islam, A K M; Haque, A; Pardaens, A; Lowe, J A

    2015-07-01

    Coastal flooding due to storm surge and high tides is a serious risk for inhabitants of the Ganges-Brahmaputra-Meghna (GBM) delta, as much of the land is close to sea level. Climate change could lead to large areas of land being subject to increased flooding, salinization and ultimate abandonment in West Bengal, India, and Bangladesh. IPCC 5th assessment modelling of sea level rise and estimates of subsidence rates from the EU IMPACT2C project suggest that sea level in the GBM delta region may rise by 0.63 to 0.88 m by 2090, with some studies suggesting this could be up to 0.5 m higher if potential substantial melting of the West Antarctic ice sheet is included. These sea level rise scenarios lead to increased frequency of high water coastal events. Any effect of climate change on the frequency and severity of storms can also have an effect on extreme sea levels. A shelf-sea model of the Bay of Bengal has been used to investigate how the combined effect of sea level rise and changes in other environmental conditions under climate change may alter the frequency of extreme sea level events for the period 1971 to 2099. The model was forced using atmospheric and oceanic boundary conditions derived from climate model projections and the future scenario increase in sea level was applied at its ocean boundary. The model results show an increased likelihood of extreme sea level events through the 21st century, with the frequency of events increasing greatly in the second half of the century: water levels that occurred at decadal time intervals under present-day model conditions occurred in most years by the middle of the 21st century and 3-15 times per year by 2100. The heights of the most extreme events tend to increase more in the first half of the century than the second. The modelled scenarios provide a case study of how sea level rise and other effects of climate change may combine to produce a greatly increased threat to life and property in the GBM delta by the end

  19. Clinical review: Management of difficult airways

    Science.gov (United States)

    Langeron, Olivier; Amour, Julien; Vivien, Benoît; Aubrun, Frédéric

    2006-01-01

    Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia and intensive care. A patent and secure airway is essential to manage anesthetized or critically ill patients. Oxygenation maintenance during tracheal intubation is the cornerstone of difficult airway management and is always emphasized in guidelines. The occurrence of respiratory adverse events has decreased in claims for injuries due to inadequate airway management mainly at induction of anesthesia. Nevertheless, claim reports emphasize that airway emergencies, tracheal extubation and/or recovery of anesthesia phases are still associated with death or brain damage, indicating that additional educational support and management strategies to improve patient safety are required. The present brief review analyses specific problems of airway management related to difficult tracheal intubation and to difficult mask ventilation prediction. The review will focus on basic airway management including preoxygenation, and on some oxygenation and tracheal intubation techniques that may be performed to solve a difficult airway. PMID:17184555

  20. Clinical review: management of difficult airways.

    Science.gov (United States)

    Langeron, Olivier; Amour, Julien; Vivien, Benoît; Aubrun, Frédéric

    2006-01-01

    Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia and intensive care. A patent and secure airway is essential to manage anesthetized or critically ill patients. Oxygenation maintenance during tracheal intubation is the cornerstone of difficult airway management and is always emphasized in guidelines. The occurrence of respiratory adverse events has decreased in claims for injuries due to inadequate airway management mainly at induction of anesthesia. Nevertheless, claim reports emphasize that airway emergencies, tracheal extubation and/or recovery of anesthesia phases are still associated with death or brain damage, indicating that additional educational support and management strategies to improve patient safety are required. The present brief review analyses specific problems of airway management related to difficult tracheal intubation and to difficult mask ventilation prediction. The review will focus on basic airway management including preoxygenation, and on some oxygenation and tracheal intubation techniques that may be performed to solve a difficult airway.

  1. Observation and nursing of complications due to high re-perfusion injury occurring after balloon angioplasty for diabetic vascular diseases of lower extremity

    International Nuclear Information System (INIS)

    Zhang Lingling; Zhu Yueqi; Mou Ling

    2011-01-01

    Objective: To evaluate the symptomatic nursing in treating the complications caused by high re-perfusion which develops after balloon angioplasty for the treatment of diabetic vascular diseases of lower extremity. Methods: Eighteen patients with lower limb ischemia caused by diabetes mellitus developed high re-perfusion injury complications after receiving balloon angioplasty. The patients were randomly and equally divided into study group and control group. The special nursing measures designed by the author's department, including raising the diseased lower limb, enforcing the flexion and extension movement of the leg, cold compress, wound exposure, etc. were carried out for patients of study group, while no special nursing measures were adopted for patients of control group. The clinical results, such as limb pain, swelling and subcutaneous petechia after re-perfusion injury, were evaluated and compared between two groups. Results: After the treatment, the limb pain, swelling and subcutaneous petechia due to high re-perfusion injury in study group were relieved more markedly than that in control group, the difference in evaluation score between two groups was statistically significant (P<0.01). Conclusion: The special symptomatic nursing measures are very effective in relieving the high re-perfusion injury after balloon angioplasty for the treatment of diabetic lower limb ischemia. (authors)

  2. Strain evolution in Si substrate due to implantation of MeV ion observed by extremely asymmetric x-ray diffraction

    International Nuclear Information System (INIS)

    Emoto, T.; Ghatak, J.; Satyam, P. V.; Akimoto, K.

    2009-01-01

    We studied the strain introduced in a Si(111) substrate due to MeV ion implantation using extremely asymmetric x-ray diffraction and measured the rocking curves of asymmetrical 113 diffraction for the Si substrates implanted with a 1.5 MeV Au 2+ ion at fluence values of 1x10 13 , 5x10 13 , and 1x10 14 /cm 2 . The measured curves consisted of a bulk peak and accompanying subpeak with an interference fringe. The positional relationship of the bulk peak to the subpeak and the intensity variation of those peaks with respect to the wavelengths of the x rays indicated that crystal lattices near the surface were strained; the lattice spacing of surface normal (111) planes near the surface was larger than that of the bulk. Detailed strain profiles along the depth direction were successfully estimated using a curve-fitting method based on Darwin's dynamical diffraction theory. Comparing the shapes of resultant strain profiles, we found that a strain evolution rapidly occurred within a depth of ∼300 nm at fluence values between 1x10 13 and 5x10 13 /cm 2 . This indicates that formation of the complex defects progressed near the surface when the fluence value went beyond a critical value between 1x10 13 and 5x10 13 /cm 2 and the defects brought a large strain to the substrate.

  3. Probability assessment for the incidence of extreme events due to the climatic change. Focus Germany; Berechnung der Wahrscheinlichkeiten fuer das Eintreten von Extremereignissen durch Klimaaenderungen. Schwerpunkt Deutschland

    Energy Technology Data Exchange (ETDEWEB)

    Jonas, Martin; Staeger, Tim; Schoenwiese, Christian-Dietrich [Frankfurt Univ. (Germany). Inst. fuer Atmosphaere und Umwelt, Arbeitsgruppe Klimaforschung

    2005-08-15

    The study on the probability of occurrence of extreme weather events in Germany is based on compiled data covering ground-level temperature, precipitation and wind during the time period 1901 to 2000. The data processing approach is based on two methodologies: a time-gliding extreme value analysis and a structure-oriented time-series analysis. The results show a significant increase of very hot months and at the same time a decrease of extreme cold months within the 20th century. In the time period after 1951 the probability of very high daily maximum temperatures increased for all seasons. Concerning the precipitation the increase of extreme values and higher variabilities are observed for the winter period. The results concerning the wind are not so clear. Summarizing the extreme behavior of temperature and precipitation has shown strong variations during the last century.

  4. LIHTC Difficult to Develop Areas

    Data.gov (United States)

    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)...

  5. Psychopathology in difficult asthma : Review

    NARCIS (Netherlands)

    Prins, L.C.J.; van Son, M.A.C.; van Keimpema, A.R.J.; van Ranst, D.; Antonissen-Pommer, A.M.; Meijer, J.W.G.; Pop, V.J.M.

    2015-01-01

    Objective: Within the asthma population, difficult asthma (DA) is a severe condition in which patients present with frequent exacerbations, hospitalizations and emergency room visits. The identification and treatment of psychopathology is included in the management of DA. Psychopathology is supposed

  6. Difficult to control atopic dermatitis

    NARCIS (Netherlands)

    U. Darsow (U.); A. Wollenberg (A.); D. Simon; A. Taieb; T. Werfel; A.P. Oranje (Arnold); C. Gelmetti (C.); Ã. Svensson (Ãke); M. Deleuran (M.); A.M. Calza; F. Giusti; J. Lübbe (Jann); S. Seidenari (Stefania); J. Ring (J.)

    2013-01-01

    textabstractDifficult 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

  7. Effective communication during difficult conversations.

    Science.gov (United States)

    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

  8. The contribution to future flood risk in the Severn Estuary from extreme sea level rise due to ice sheet mass loss

    Science.gov (United States)

    Quinn, N.; Bates, P. D.; Siddall, M.

    2013-12-01

    The rate at which sea levels will rise in the coming century is of great interest to decision makers tasked with developing mitigation policies to cope with the risk of coastal inundation. Accurate estimates of future sea levels are vital in the provision of effective policy. Recent reports from UK Climate Impacts Programme (UKCIP) suggest that mean sea levels in the UK may rise by as much as 80 cm by 2100; however, a great deal of uncertainty surrounds model predictions, particularly the contribution from ice sheets responding to climatic warming. For this reason, the application of semi-empirical modelling approaches for sea level rise predictions has increased of late, the results from which suggest that the rate of sea level rise may be greater than previously thought, exceeding 1 m by 2100. Furthermore, studies in the Red Sea indicate that rapid sea level rise beyond 1m per century has occurred in the past. In light of such research, the latest UKCIP assessment has included a H++ scenario for sea level rise in the UK of up to 1.9 m which is defined as improbable but, crucially, physically plausible. The significance of such low-probability sea level rise scenarios upon the estimation of future flood risk is assessed using the Somerset levels (UK) as a case study. A simple asymmetric probability distribution is constructed to include sea level rise scenarios of up to 1.9 m by 2100 which are added to a current 1:200 year event water level to force a two-dimensional hydrodynamic model of coastal inundation. From the resulting ensemble predictions an estimation of risk by 2100 is established. The results indicate that although the likelihood of extreme sea level rise due to rapid ice sheet mass loss is low, the resulting hazard can be large, resulting in a significant (27%) increase to the projected annual risk. Furthermore, current defence construction guidelines for the coming century in the UK are expected to account for 95% of the sea level rise distribution

  9. Management of the difficult airway.

    Science.gov (United States)

    Schwartz, D E; Wiener-Kronish, J P

    1991-09-01

    For clinicians involved in airway management, a plan of action for dealing with the difficult airway or a failed intubation should be developed well in advance of encountering a patient in whom intubation is not routine. When difficulty is anticipated, the equipment necessary for performing a difficult intubation should be immediately available. It also is prudent to have a surgeon skilled in performing a tracheotomy and a criothyroidotomy stand by. The intubation should be attempted in the awake state, preferably using the fiberoptic bronchoscope. The more challenging situation is when the difficult airway is confronted unexpectedly. After the first failed attempt at laryngoscopy, head position should be checked and the patient ventilated with oxygen by mask. A smaller styletted tube and possibly a different laryngoscope blade should be selected for a second attempt at intubation. The fiberoptic bronchoscope and other equipment for difficult intubation should be obtained. A second attempt should then be made. If this is unsuccessful, the patient should be reoxygenated, and assistance including a skilled anesthesiologist and surgeon should be summoned. On a third attempt, traction to the tongue can be applied by an assistant, a tube changer could be used to enter the larynx, or one of the other special techniques previously described can be used. If this third attempt fails, it may be helpful to have a physician more experienced in airway management attempt intubation after oxygen has been administered to the patient. If all attempts are unsuccessful, then invasive techniques to secure the airway will have to be performed.

  10. Clinical review: Management of difficult airways

    OpenAIRE

    Langeron, Olivier; Amour, Julien; Vivien, Benoît; Aubrun, Frédéric

    2006-01-01

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

  11. Difficult to control atopic dermatitis

    Science.gov (United States)

    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

  12. Feasibility and outcomes of a classical Pilates program on lower extremity strength, posture, balance, gait, and quality of life in someone with impairments due to a stroke.

    Science.gov (United States)

    Shea, Sarah; Moriello, Gabriele

    2014-07-01

    Pilates is a method that can potentially be used for stroke rehabilitation to address impairments in gait, balance, strength, and posture. The purpose of this case report was to document the feasibility of using Pilates and to describe outcomes of a 9-month program on lower extremity strength, balance, posture, gait, and quality of life in an individual with stroke. The participant was taught Pilates exercises up to two times per week for nine months in addition to traditional rehabilitation in the United States. Outcomes were assessed using the Berg Balance Scale (BBS), Stroke Impact Scale (SIS), GAITRite System(®), 5 repetition sit-to-stand test (STST), and flexicurve. Improvements were found in balance, lower extremity strength, and quality of life. Posture and gait speed remained the same. While these changes cannot be specifically attributed to the intervention, Pilates may have added to his overall rehabilitation program and with some modifications was feasible to use in someone with a stroke. Copyright © 2013 Elsevier Ltd. All rights reserved.

  13. Difficult airway in a patient with Coffin-Siris syndrome.

    Science.gov (United States)

    Dimaculangan, D; Lokhandwala, B; Wlody, D; Gross, R

    2001-02-01

    We report on a patient with Coffin-Siris syndrome and consider a potential association between this condition and difficult intubation. Although this inherited condition is extremely rare, anesthesiologists should be aware of its existence and prepare for potential airway management problems whenever it is encountered.

  14. Difficult physician-patient relationships.

    Science.gov (United States)

    Reifsteck, S W

    1998-01-01

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

  15. Suppressed power saturation due to optimized optical confinement in 9xx nm high-power diode lasers that use extreme double asymmetric vertical designs

    Science.gov (United States)

    Kaul, T.; Erbert, G.; Maaßdorf, A.; Knigge, S.; Crump, P.

    2018-03-01

    Broad area lasers with novel extreme double asymmetric structure (EDAS) vertical designs featuring increased optical confinement in the quantum well, Γ, are shown to have improved temperature stability without compromising series resistance, internal efficiency or losses. Specifically, we present here vertical design considerations for the improved continuous wave (CW) performance of devices operating at 940 nm, based on systematically increasing Γ from 0.26% to 1.1%, and discuss the impact on power saturation mechanisms. The results indicate that key power saturation mechanisms at high temperatures originate in high threshold carrier densities, which arise in the quantum well at low Γ. The characteristic temperatures, T 0 and T 1, are determined under short pulse conditions and are used to clarify the thermal contribution to power limiting mechanisms. Although increased Γ reduces thermal power saturation, it is accompanied by increased optical absorption losses in the active region, which has a significant impact on the differential external quantum efficiency, {η }{{diff}}. To quantify the impact of internal optical losses contributed by the quantum well, a resonator length-dependent simulation of {η }{{diff}} is performed and compared to the experiment, which also allows the estimation of experimental values for the light absorption cross sections of electrons and holes inside the quantum well. Overall, the analysis enables vertical designs to be developed, for devices with maximized power conversion efficiency at high CW optical power and high temperatures, in a trade-off between absorption in the well and power saturation. The best balance to date is achieved in devices using EDAS designs with {{Γ }}=0.54 % , which deliver efficiencies of 50% at 14 W optical output power at an elevated junction temperature of 105 °C.

  16. Difficult weaning in delayed onset diaphragmatic hernia

    Directory of Open Access Journals (Sweden)

    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.

  17. Mandelbrot's Extremism

    NARCIS (Netherlands)

    Beirlant, J.; Schoutens, W.; Segers, J.J.J.

    2004-01-01

    In the sixties Mandelbrot already showed that extreme price swings are more likely than some of us think or incorporate in our models.A modern toolbox for analyzing such rare events can be found in the field of extreme value theory.At the core of extreme value theory lies the modelling of maxima

  18. Diagnosis and management of deep vein thrombosis of the upper extremity: a review

    International Nuclear Information System (INIS)

    Baarslag, Henk J.; Reekers, Jim A.; Koopman, Maria M.W.; Beek, Edwin J.R. van

    2004-01-01

    Deep vein thrombosis of the upper extremity is an increasing clinical problem due to the use of long-term indwelling catheters for chemotherapy or long-term feeding. The clinical diagnosis is difficult to make, and various imaging modalities have been used for this purpose. The use of (interventional) radiological procedures has been advancing in recent years. This review describes the clinical background, the imaging modalities that may be employed, treatment options and outcome of patients with upper extremity thrombosis. (orig.)

  19. Extremity doses to interventional radiologists

    International Nuclear Information System (INIS)

    Wihtby, M.; Martin, C. J.

    2002-01-01

    Radiologists performing interventional procedures are often required to stand close to the patient's side when carrying out manipulations under fluoroscopic control. This can result in their extremities receiving a high radiation dose, due to scattered radiation. These doses are sometimes high enough to warrant that the radiologist in question be designated a classified radiation worker. Classification in the UK is a result of any worker receiving or likely to receive in the course of their duties in excess of 3/10ths of any annual dose limit (500mSv to extremities, skin). The doses to the legs of radiologists have received less attention than those to the hands, however the doses may be high, due to the proximity of the legs and feet to scattered radiation. The legs can be exposed to a relatively high level of scattered radiation as the radiation in produced from scatter of the un attenuated beam from the bottom of the patient couch. The routine monitoring of extremity doses in interventional radiology is difficult due to several factors. Firstly a wide range of interventional procedures in undertaken in every radiology department, and these procedures require many different techniques, equipment and skills. This means that the position the radiologist adopts in relation to scattering medium and therefore their exposure, depends heavily on the type of procedure. As the hands which manipulate the catheters within the patient are often located close to the patients side and to the area under irradiation, the distribution of dose across the hands can be variable, with very high localised doses, making routine monitoring difficult. The purpose of this study was to determine the magnitude and distribution of dose to the hands and legs of interventional radiologists carrying out a wide range of both diagnostic and therapeutic interventional procedures. To ascertain the most effective method of monitoring the highest dose in accordance with the Basic safety standards

  20. Overcoming difficult conversations in clinical supervision

    Directory of Open Access Journals (Sweden)

    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

  1. How Difficult It Is to Be God

    DEFF Research Database (Denmark)

    Wilson, Fiona

    2014-01-01

    Book review of Carlos Iván Degregori, How Difficult It Is to Be God: Shining Path's Politics of War in Peru,1980–1999 (Madison, WI: University of Wisconsin Press, 2012)......Book review of Carlos Iván Degregori, How Difficult It Is to Be God: Shining Path's Politics of War in Peru,1980–1999 (Madison, WI: University of Wisconsin Press, 2012)...

  2. The greenhouse effect and extreme weather

    International Nuclear Information System (INIS)

    Groenaas, Sigbjoern; Kvamstoe, Nils Gunnar

    2002-01-01

    The article asserts that an anthropogenic global warming is occurring. This greenhouse effect is expected to cause more occurrences of extreme weather. It is extremely difficult, however, to relate specific weather catastrophes to global warming with certainty, since such extreme weather conditions are rare historically. The subject is controversial. The article also discusses the public debate and the risk of floods

  3. Extreme cosmos

    CERN Document Server

    Gaensler, Bryan

    2011-01-01

    The universe is all about extremes. Space has a temperature 270°C below freezing. Stars die in catastrophic supernova explosions a billion times brighter than the Sun. A black hole can generate 10 million trillion volts of electricity. And hypergiants are stars 2 billion kilometres across, larger than the orbit of Jupiter. Extreme Cosmos provides a stunning new view of the way the Universe works, seen through the lens of extremes: the fastest, hottest, heaviest, brightest, oldest, densest and even the loudest. This is an astronomy book that not only offers amazing facts and figures but also re

  4. Difficult intubation: are you prepared for it?

    Science.gov (United States)

    Balcom, C

    1994-01-01

    The endotracheal intubation of a patient for surgery requires an anaesthetist who is aided by a skilled and experienced helper. This paper explores reasons why some patients are difficult to intubate. Some are predictable on pre-operative assessment and others are not. Suggestions are given on how the helper is useful to the anaesthetist in this potentially critical situation.

  5. Preoperative Ultrasonography as a Predictor of Difficult ...

    African Journals Online (AJOL)

    patient.[8]. On the basis of ultrasound findings, surgeons can select the cases appropriate for their skills aiming at reducing operative complications and minimizing the waste of operative time.[2]. Based on ... bed-more than 20 min. 4. Spillage of bile and ... gallbladder turned out to be difficult laparoscopically. The positive ...

  6. Preoperative Prediction of Difficult Laparoscopic Cholecystectomy: A ...

    African Journals Online (AJOL)

    Pujahari[2] [Table 1]. The scores were added up to get a total score and the patients were divided into categories of risks based on the total score [Table 2]. The following operative parameters ... The timing was noted from the first port site incision till the last ports closure. ..... Dhanke PS, Vgane SP. Factors predicting difficult ...

  7. Crisis management during anaesthesia: difficult intubation.

    Science.gov (United States)

    Paix, A D; Williamson, J A; Runciman, W B

    2005-06-01

    Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation. To examine the role of a specific sub-algorithm for the management of difficult intubation. The potential performance of a structured approach developed by review of the literature and analysis of each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. There were 147 reports of difficult intubation capable of analysis among the first 4000 incidents reported to AIMS. The difficulty was unexpected in 52% of cases; major physiological changes occurred in 37% of these cases. Saturation fell below 90% in 22% of cases, oesophageal intubation was reported in 19%, and an emergency transtracheal airway was required in 4% of cases. Obesity and limited neck mobility and mouth opening were the most common anatomical contributing factors. The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient's cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.

  8. The long shadows of the difficult past?

    DEFF Research Database (Denmark)

    Wolnik, Kevin; Busse, Britta; Tholen, Jochen

    2017-01-01

    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...... half of the twentieth century (e.g. parents and grandparents, schools, the media) are examined. The theoretical basis chosen for addressing these questions is the work of Mannheim (1928) on the formation of successive generations, and the theories of collective memories and identities of Eisenstadt...... and his followers. Our empirical evidence comes from a transnational comparison of young people’s memories of this difficult past in Denmark, Finland and Germany. From a historical perspective a comparison of the three countries is particularly interesting as they played different roles during the Second...

  9. Arctic sea ice, Eurasia snow, and extreme winter haze in China.

    Science.gov (United States)

    Zou, Yufei; Wang, Yuhang; Zhang, Yuzhong; Koo, Ja-Ho

    2017-03-01

    The East China Plains (ECP) region experienced the worst haze pollution on record for January in 2013. We show that the unprecedented haze event is due to the extremely poor ventilation conditions, which had not been seen in the preceding three decades. Statistical analysis suggests that the extremely poor ventilation conditions are linked to Arctic sea ice loss in the preceding autumn and extensive boreal snowfall in the earlier winter. We identify the regional circulation mode that leads to extremely poor ventilation over the ECP region. Climate model simulations indicate that boreal cryospheric forcing enhances the regional circulation mode of poor ventilation in the ECP region and provides conducive conditions for extreme haze such as that of 2013. Consequently, extreme haze events in winter will likely occur at a higher frequency in China as a result of the changing boreal cryosphere, posing difficult challenges for winter haze mitigation but providing a strong incentive for greenhouse gas emission reduction.

  10. A note on extreme sets

    Directory of Open Access Journals (Sweden)

    Radosław Cymer

    2017-10-01

    Full Text Available In decomposition theory, extreme sets have been studied extensively due to its connection to perfect matchings in a graph. In this paper, we first define extreme sets with respect to degree-matchings and next investigate some of their properties. In particular, we prove the generalized Decomposition Theorem and give a characterization for the set of all extreme vertices in a graph.

  11. Foreign body aspiration masquerading as difficult asthma

    Directory of Open Access Journals (Sweden)

    Rai S

    2007-01-01

    Full Text Available It is important to assess patients of difficult/therapy resistant asthma carefully in order to identify whether there are any correctable factors that may contribute to their poor control. It is critical to make a diagnosis of asthma and to exclude other airway diseases. A 65-years-old lady presented with repeated acute episodes of dyspnoea and wheezing. She was on regular medication for bronchial asthma for 18 years. There was no history of foreign body aspiration or loss of consciousness. Her chest radiograph was normal. She showed poor response to corticosteroids and bronchodilators. Fibreoptic bronchoscopy (FOB showed intracordal cyst of the left vocal cord and 1cm size irregular piece of betel nut in right main bronchus, which was removed endoscopically with the help of dormia basket, following which her condition improved and asthma was controlled on inhaled bronchodilators.

  12. Effective Climate Communication with Difficult Audiences

    Science.gov (United States)

    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.

  13. Chernobyl: Chronicle of difficult weeks [videorecording

    Energy Technology Data Exchange (ETDEWEB)

    Volodymyr, S

    1987-07-01

    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.

  14. The reentry catheter: a second chance for endoluminal reentry at difficult lower extremity subintimal arterial recanalizations.

    Science.gov (United States)

    Etezadi, Vahid; Benenati, James F; Patel, Parag J; Patel, Rahul S; Powell, Alex; Katzen, Barry T

    2010-05-01

    From January 2005 to July 2008, a retrospective study was conducted at a single institution to investigate technical success of the use of a reentry device (Outback LTD reentry catheter) in aortoiliac and femoropopliteal artery recanalization in 34 patients (18 men; mean age +/- SD, 72 years +/- 11) in whom the conventional guide wires and catheters failed to reenter the true lumen. True lumen reentry was achieved in 87% (n = 23) and 91% (n = 11) of patients with femoropopliteal and aortoiliac occlusions, respectively. The overall technical success rate with the device was 88% (n = 34). The device success rate in Transatlantic Inter-Society Consensus II class D lesions was significantly lower than in lower lesion classes (71.4% vs 100%; P < .05). No procedure-related complications were encountered. In conclusion, the use of the reentry catheter enhances the likelihood of successful subintimal recanalization of chronic occlusions in femoropopliteal and aortoiliac arteries.

  15. Nostalgia: retreat or support in difficult times?

    Science.gov (United States)

    Batcho, Krystine Irene

    2013-01-01

    The relationship between nostalgia and coping during difficult times was explored in 2 empirical studies. In the first, 80 undergraduates, 60 women and 20 men, completed the Nostalgia Inventory, a measure of nostalgia proneness, the COPE Inventory, a dispositional measure of strategies for coping with stressful events, and the Childhood Survey, a survey of impressions of childhood experiences. Nostalgia proneness correlated with use of adaptive coping, including emotional social support, expressing emotions, turning to religion, and suppressing competing activities, and did not correlate with escapist or avoidance strategies, including denial, behavioral disengagement, and substance abuse. Nostalgia proneness was related positively to favorable emotional and behavioral childhood experiences and did not correlate with adverse experiences. Favorable impressions of childhood correlated positively with adaptive coping strategies and inversely with dysfunctional ones, whereas unfavorable childhood experiences correlated positively with dysfunctional coping. Regression analyses suggested that the relationship between nostalgia proneness and certain coping strategies may be mediated in part by childhood experiences. In a second study, 100 undergraduates, 86 women and 14 men, completed the Nostalgia Inventory, recalled autobiographical memories that illustrated how childhood is either special or similar to their present life, and rated their likely use of strategies in dealing with 2 hypothetical problems. Nostalgia proneness correlated with emotional and instrumental social coping and with the goal-directed strategies of planning, taking action, and positive reframing. Further research is recommended to explore the role of childhood memories in coping and to identify mechanisms that mediate the relationship between nostalgia and coping.

  16. Why behavior change is difficult to sustain.

    Science.gov (United States)

    Bouton, Mark E

    2014-11-01

    Unhealthy behavior is responsible for much human disease, and a common goal of contemporary preventive medicine is therefore to encourage behavior change. However, while behavior change often seems easy in the short run, it can be difficult to sustain. This article provides a selective review of research from the basic learning and behavior laboratory that provides some insight into why. The research suggests that methods used to create behavior change (including extinction, counterconditioning, punishment, reinforcement of alternative behavior, and abstinence reinforcement) tend to inhibit, rather than erase, the original behavior. Importantly, the inhibition, and thus behavior change more generally, is often specific to the "context" in which it is learned. In support of this view, the article discusses a number of lapse and relapse phenomena that occur after behavior has been changed (renewal, spontaneous recovery, reinstatement, rapid reacquisition, and resurgence). The findings suggest that changing a behavior can be an inherently unstable and unsteady process; frequent lapses should be expected. In the long run, behavior-change therapies might benefit from paying attention to the context in which behavior change occurs. Copyright © 2014 Elsevier Inc. All rights reserved.

  17. Ductility increase in difficult to work nickel alloys due to calcium microalloying

    International Nuclear Information System (INIS)

    Shevtsov, V.A.; Grigoryan, R.A.; Aleev, V.P.; Stepanov, V.P.; Bytskij, E.V.

    1995-01-01

    Impact of calcium microadditions on mechanical properties of heat-resisting alloys Kh66VMTYu and KhN33KV is studied. It is established that the calcium additions up to 0.01% essentially increase the alloy plastic characteristics of the alloy without changing its strength characteristics.5 refs., 3 figs

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

    Directory of Open Access Journals (Sweden)

    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

  19. Combined precut in difficult biliary cannulation

    Directory of Open Access Journals (Sweden)

    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.

  20. Evolution caused by extreme events.

    Science.gov (United States)

    Grant, Peter R; Grant, B Rosemary; Huey, Raymond B; Johnson, Marc T J; Knoll, Andrew H; Schmitt, Johanna

    2017-06-19

    Extreme events can be a major driver of evolutionary change over geological and contemporary timescales. Outstanding examples are evolutionary diversification following mass extinctions caused by extreme volcanism or asteroid impact. The evolution of organisms in contemporary time is typically viewed as a gradual and incremental process that results from genetic change, environmental perturbation or both. However, contemporary environments occasionally experience strong perturbations such as heat waves, floods, hurricanes, droughts and pest outbreaks. These extreme events set up strong selection pressures on organisms, and are small-scale analogues of the dramatic changes documented in the fossil record. Because extreme events are rare, almost by definition, they are difficult to study. So far most attention has been given to their ecological rather than to their evolutionary consequences. We review several case studies of contemporary evolution in response to two types of extreme environmental perturbations, episodic (pulse) or prolonged (press). Evolution is most likely to occur when extreme events alter community composition. We encourage investigators to be prepared for evolutionary change in response to rare events during long-term field studies.This article is part of the themed issue 'Behavioural, ecological and evolutionary responses to extreme climatic events'. © 2017 The Author(s).

  1. Extreme Events in Nature and Society

    CERN Document Server

    Albeverio, Sergio; Kantz, Holger

    2006-01-01

    Significant, and usually unwelcome, surprises, such as floods, financial crisis, epileptic seizures, or material rupture, are the topics of Extreme Events in Nature and Society. The book, authored by foremost experts in these fields, reveals unifying and distinguishing features of extreme events, including problems of understanding and modelling their origin, spatial and temporal extension, and potential impact. The chapters converge towards the difficult problem of anticipation: forecasting the event and proposing measures to moderate or prevent it. Extreme Events in Nature and Society will interest not only specialists, but also the general reader eager to learn how the multifaceted field of extreme events can be viewed as a coherent whole.

  2. Lymphoscintigraphy of the lower extremity

    International Nuclear Information System (INIS)

    Abbasi, N.Z.

    1990-01-01

    Fifty one lower extremities of 26 normal healthy volunteers and 26 extremities of 13 patients with oedema have been studied. Dynamic quantitative lymphoscintigraphy using 99Tc-m antimony sulphide colloid during passive exercise as well as before and after active exercise was performed. parameters of lymphatic function including percentage of radioactivity cleared from the injection site, the percentage uptake by the inguinal lymph nodes, the time of arrival of activity at the regional lymph nodes and the lymphatic reserve index have been evaluated. The percentage clearance of activity from the injection site was found technically difficult to standardize and proved to be an unreliable parameter of lymphatic function. However, the quantitation of nodal uptake, the lymphatic transit time and the lymphatic reserve capacity accurately depicted the lymphatic functional status of an individual. The physiologic parameters of lymphatic function of the contralateral lower extremities were compared and a physiologic difference in the lymphatic capacity of the two limbs was scintigraphically documented. (author)

  3. Rosetta Structure Prediction as a Tool for Solving Difficult Molecular Replacement Problems.

    Science.gov (United States)

    DiMaio, Frank

    2017-01-01

    Molecular replacement (MR), a method for solving the crystallographic phase problem using phases derived from a model of the target structure, has proven extremely valuable, accounting for the vast majority of structures solved by X-ray crystallography. However, when the resolution of data is low, or the starting model is very dissimilar to the target protein, solving structures via molecular replacement may be very challenging. In recent years, protein structure prediction methodology has emerged as a powerful tool in model building and model refinement for difficult molecular replacement problems. This chapter describes some of the tools available in Rosetta for model building and model refinement specifically geared toward difficult molecular replacement cases.

  4. Extremely fast increase in the organic loading rate during the co-digestion of rapeseed oil and sewage sludge in a CSTR--characterization of granules formed due to CaO addition to maintain process stability.

    Science.gov (United States)

    Kasina, M; Kleyböcker, A; Michalik, M; Würdemann, H

    2015-01-01

    In a co-digestion system running with rapeseed oil and sewage sludge, an extremely fast increase in the organic loading rate was studied to develop a procedure to allow for flexible and demand-driven energy production. The over-acidification of the digestate was successfully prevented by calcium oxide dosage, which resulted in granule formation. Mineralogical analyses revealed that the granules were composed of insoluble salts of long chain fatty acids and calcium and had a porous structure. Long chain fatty acids and calcium formed the outer cover of granules and offered interfaces on the inside thereby enhancing the growth of biofilms. With granule size and age, the pore size increased and indicated degradation of granular interfaces. A stable biogas production up to the organic loading rate of 10.4 kg volatile solids m(-3) d(-1) was achieved although the hydrogen concentration was not favorable for propionic acid degradation. However, at higher organic loading rates, unbalanced granule formation and degradation were observed. Obviously, the adaption time for biofilm growth was too short to maintain the balance, thereby resulting in a low methane yield.

  5. Obstructive jaundice due to tuberculosis of distal CBD and periampullary region mimickcholangiocarcinoma

    Directory of Open Access Journals (Sweden)

    Sumantra Ray

    2012-01-01

    Full Text Available Abdominal tuberculosis (TB commonly affects the intestinal tract, lymph nodes, peritoneum, and solid organs in varying combinations. Hepatobiliary or pancreatic TB is rare and the preoperative diagnosis is difficult. Though rare, there have been a few citations of intrahepatic tuberculosis, but isolated bile duct tuberculosis is extremely rare. Here we report a case of obstructive jaundice which was initially thought to be due to lower-end cholangiocarcinoma but postoperatively it was found to be tuberculosis.

  6. Due diligence

    International Nuclear Information System (INIS)

    Sanghera, G.S.

    1999-01-01

    The Occupational Health and Safety (OHS) Act requires that every employer shall ensure the health and safety of workers in the workplace. Issues regarding the practices at workplaces and how they should reflect the standards of due diligence were discussed. Due diligence was described as being the need for employers to identify hazards in the workplace and to take active steps to prevent workers from potentially dangerous incidents. The paper discussed various aspects of due diligence including policy, training, procedures, measurement and enforcement. The consequences of contravening the OHS Act were also described

  7. Extremely Preterm Birth

    Science.gov (United States)

    ... Events Advocacy For Patients About ACOG Extremely Preterm Birth Home For Patients Search FAQs Extremely Preterm Birth ... Spanish FAQ173, June 2016 PDF Format Extremely Preterm Birth Pregnancy When is a baby considered “preterm” or “ ...

  8. Temporal changes in morality attributed to heat extremes for 57 cities in Northeast Asia.

    Science.gov (United States)

    Lee, Whanhee; Choi, Hayon Michelle; Kim, Dahye; Honda, Yasushi; Guo, Yue-Liang Leon; Kim, Ho

    2018-03-01

    Recent studies have reported that heat-related mortality decreased by adaptation during decades. However, since the frequency of extreme heat events is increasing, it is difficult to conclude with certainty that the heat mortality burden is decreasing. To examine temporal changes in mortality attributed to heat extremes in Northeast Asia, we collected temperature and mortality data covering the years 1972-2012 from 57 cities of 3 countries (Taiwan, Korea, and Japan) in Northeast Asia. Poisson regression curves were fitted to the data from each city. The temporal changes in heat-mortality association were estimated with a time-varying distributed lag non-linear model. Heat extremes were defined as temperatures greater than the 97.5th percentiles of city-specific average temperatures. Attributable deaths were calculated considering temporal variations in exposure and relative risk. The estimates were then pooled through meta-analysis. The results show that the mortality risk on extreme heat days declined during the study period in all countries. However, as summer temperatures in Japan have shown more heat extremes over time, the mortality risk attributed to heat increased during 2003-2012 (0.32%) compared with 1972-1981 (0.19%). Thus, to assess the total health burden due to heat extremes related to climate change, public health strategies should focus on the temporal variation in heat-mortality association as well as changes in the distribution of heat extremes overtime. Copyright © 2017 Elsevier B.V. All rights reserved.

  9. The Difficult Chore of Measuring Coordination by EXAFS

    International Nuclear Information System (INIS)

    Ravel, B.; Kelly, S. D.

    2007-01-01

    Neither the theory nor the interpretation of Extended X-Ray-Absorption Fine-Structure (EXAFS) spectroscopy requires assumptions of crystalline symmetry or periodicity. As a result, EXAFS is a tool applied to a wide range of scientific disciplines and to a wide variety of experimental systems. A simple enumeration of the atoms in the coordination environment of the absorber is often the primary goal of an EXAFS experiment. There are, however, a number of pitfalls in the way of an accurate determination of coordination number (CN). These include statistical limitations of the EXAFS fitting problem, empirical effects due to sample preparation, and the assumptions made about the physical structure surrounding the absorber in the course of data analysis. In this paper we examine several of these pitfalls and their effects upon the determination of CN. Where possible, we offer suggestions for avoiding or mitigating the pitfalls. We hope this paper will help guide the general EXAFS practitioner through the difficult chore of accurately determining CN

  10. Legacies from extreme drought increase ecosystem sensitivity to future extremes

    Science.gov (United States)

    Smith, M. D.; Knapp, A.; Hoover, D. L.; Avolio, M. L.; Felton, A. J.; Wilcox, K. R.

    2016-12-01

    Climate extremes, such as drought, are increasing in frequency and intensity, and the ecological consequences of these extreme events can be substantial and widespread. Although there is still much to be learned about how ecosystems will respond to an intensification of drought, even less is known about the factors that determine post-drought recovery of ecosystem function. Such knowledge is particularly important because post-drought recovery periods can be protracted depending on the extent to which key plant populations, community structure and biogeochemical processes are affected. These drought legacies may alter ecosystem function for many years post-drought and may impact future sensitivity to climate extremes. We experimentally imposed two extreme growing season droughts in a central US grassland to assess the impacts of repeated droughts on ecosystem resistance (response) and resilience (recovery). We found that this grassland was not resistant to the first extreme drought due to reduced productivity and differential sensitivity of the co-dominant C4 grass (Andropogon gerardii) and C3 forb (Solidago canadensis) species. This differential sensitivity led to a reordering of species abundances within the plant community. Yet, despite this large shift in plant community composition, which persisted post-drought, the grassland was highly resilient post-drought, due to increased abundance of the dominant C4 grass. Because of this shift to increased C4 grass dominance, we expected that previously-droughted grassland would be more resistant to a second extreme drought. However, contrary to these expectations, previously droughted grassland was more sensitive to drought than grassland that had not experienced drought. Thus, our result suggest that legacies of drought (shift in community composition) may increase ecosystem sensitivity to future extreme events.

  11. Validated questionnaires heighten detection of difficult asthma comorbidities.

    Science.gov (United States)

    Radhakrishna, Naghmeh; Tay, Tunn Ren; Hore-Lacy, Fiona; Stirling, Robert; Hoy, Ryan; Dabscheck, Eli; Hew, Mark

    2017-04-01

    Multiple extra-pulmonary comorbidities contribute to difficult asthma, but their diagnosis can be challenging and time consuming. Previous data on comorbidity detection have focused on clinical assessment, which may miss certain conditions. We aimed to locate relevant validated screening questionnaires to identify extra-pulmonary comorbidities that contribute to difficult asthma, and evaluate their performance during a difficult asthma evaluation. MEDLINE was searched to identify key extra-pulmonary comorbidities that contribute to difficult asthma. Screening questionnaires were chosen based on ease of use, presence of a cut-off score, and adequate validation to help systematically identify comorbidities. In a consecutive series of 86 patients referred for systematic evaluation of difficult asthma, questionnaires were administered prior to clinical consultation. Six difficult asthma comorbidities and corresponding screening questionnaires were found: sinonasal disease (allergic rhinitis and chronic rhinosinusitis), vocal cord dysfunction, dysfunctional breathing, obstructive sleep apnea, anxiety and depression, and gastro-oesophageal reflux disease. When the questionnaires were added to the referring clinician's impression, the detection of all six comorbidities was significantly enhanced. The average time for questionnaire administration was approximately 40 minutes. The use of validated screening questionnaires heightens detection of comorbidities in difficult asthma. The availability of data from a battery of questionnaires prior to consultation can save time and allow clinicians to systematically assess difficult asthma patients and to focus on areas of particular concern. Such an approach would ensure that all contributing comorbidities have been addressed before significant treatment escalation is considered.

  12. Therapist reactions in self-experienced difficult situations: an exploration

    NARCIS (Netherlands)

    Smith, A.J.M.; Kleijn, W.C.; Hutschemaekers, G.J.M.

    2007-01-01

    This article describes a qualitative study of 63 difficult therapeutic situations described by 26 therapists. The study was part of research on specific reactions of therapists to traumatized clients. The research questions for the current analyses focused on the categorization of difficult

  13. Unusual tumour ablations: report of difficult and interesting cases

    OpenAIRE

    Mauri, Giovanni; Nicosia, Luca; Varano, Gianluca Maria; Shyn, Paul; Sartori, Sergio; Tombesi, Paola; Di Vece, Francesca; Orsi, Franco; Solbiati, Luigi

    2017-01-01

    Image-guided ablations are nowadays applied in the treatment of a wide group of diseases and in different organs and regions, and every day interventional radiologists have to face more difficult and unusual cases of tumour ablation. In the present case review, we report four difficult and unusual cases, reporting some tips and tricks for a successful image-guided treatment.

  14. Extreme bendability of DNA double helix due to bending asymmetry

    NARCIS (Netherlands)

    Salari, H.; Eslami-Mossallam, B.; Nederi, S.; Ejtehadi, M.R.

    2015-01-01

    Experimental data of the DNA cyclization (J-factor) at short length scales exceed the theoretical expectation based on the wormlike chain (WLC) model by several orders of magnitude. Here, we propose that asymmetric bending rigidity of the double helix in the groove direction can be responsible for

  15. Impact of extreme load requirements and quality assurance on nuclear power plant costs

    International Nuclear Information System (INIS)

    Stevenson, J.D.

    1993-01-01

    Definitive costs, applicable to nuclear power plant concrete structures, as a function of National Regulatory Requirements, standardization, the effect of extreme load design associated with both design basis accidents and extreme external events and quality assurance are difficult to develop since such effects are interrelated and not only differ widely from country to country, project to project but also vary in time. Table 1 shows an estimate of the of the overall plant cost effects of external event extreme load design on nuclear power plant design for the U.S -and selected foreign countries for which experience with LWRs exist- Germany is the most expensive primarily due to a military aircraft crash resistance. However, the German requirement for 4 safeguards trains rather than 2 and the containment design requirement to consider one Steam Generator blowdown concurrent with a RCS blowdown. This presentation will concentrate on the direct current impact extreme load design and quality assurance have on concrete structures, systems and components for nuclear plants. This presentation is considered timely due to the increased interest in the c potential backfit of Eastern European nuclear power stations of the WWER 440 and WWER 1000 types which typically did not consider the extreme loads identified in Table 1 and accident loads in Table 3 and quality assurance in Table 5 in their original design. Concrete structures in particular are highlighted because they typically form the last barrier to radioactive release from the containment and other Safety Related Structures

  16. Guidelines and algorithms for managing the difficult airway.

    Science.gov (United States)

    Gómez-Ríos, M A; Gaitini, L; Matter, I; Somri, M

    2018-01-01

    The difficult airway constitutes a continuous challenge for anesthesiologists. Guidelines and algorithms are key to preserving patient safety, by recommending specific plans and strategies that address predicted or unexpected difficult airway. However, there are currently no "gold standard" algorithms or universally accepted standards. The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms. Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

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

    CERN Document Server

    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

  18. Estimation of extreme risk regions under multivariate regular variation

    NARCIS (Netherlands)

    Cai, J.; Einmahl, J.H.J.; de Haan, L.F.M.

    2011-01-01

    When considering d possibly dependent random variables, one is often interested in extreme risk regions, with very small probability p. We consider risk regions of the form {z ∈ Rd : f (z) ≤ β}, where f is the joint density and β a small number. Estimation of such an extreme risk region is difficult

  19. A Fiducial Approach to Extremes and Multiple Comparisons

    Science.gov (United States)

    Wandler, Damian V.

    2010-01-01

    Generalized fiducial inference is a powerful tool for many difficult problems. Based on an extension of R. A. Fisher's work, we used generalized fiducial inference for two extreme value problems and a multiple comparison procedure. The first extreme value problem is dealing with the generalized Pareto distribution. The generalized Pareto…

  20. Difficult management of posterior urethra gunshot wound combined with urethro-rectal fistula

    Directory of Open Access Journals (Sweden)

    Walid Kerkeni

    2015-06-01

    Full Text Available Posterior urethra gunshot wounds are poorly described in the literature. They are often associated with pelvic vital lesions making difficult early repair of urethral injuries. They can be complicated by urethro-rectal fistula, which makes their management more complicated. We report a new case of posterior urethra disruption due to a gunshot wound and complicated by urethro-rectal fistula.

  1. Difficult management of posterior urethra gunshot wound combined with urethro-rectal fistula

    OpenAIRE

    Walid Kerkeni; Ahmed Saadi; Mohamed Hédi Rebai; Abderrazak Bouzouita; Mohamed Cherif; Amine Derouiche; Tahar Khalfallah; Mohamed Riadh Ben Slama; Mohamed Chebil

    2015-01-01

    Posterior urethra gunshot wounds are poorly described in the literature. They are often associated with pelvic vital lesions making difficult early repair of urethral injuries. They can be complicated by urethro-rectal fistula, which makes their management more complicated. We report a new case of posterior urethra disruption due to a gunshot wound and complicated by urethro-rectal fistula.

  2. Students' perceptions of difficult concepts in biology in senior ...

    African Journals Online (AJOL)

    Students' perceptions of difficult concepts in biology in senior secondary schools in ... that students in Senior Secondary School Two (SSII) have difficulties in learning, the ... However, teaching strategies, students' attitude, inadequate learning ...

  3. Extreme environment electronics

    CERN Document Server

    Cressler, John D

    2012-01-01

    Unfriendly to conventional electronic devices, circuits, and systems, extreme environments represent a serious challenge to designers and mission architects. The first truly comprehensive guide to this specialized field, Extreme Environment Electronics explains the essential aspects of designing and using devices, circuits, and electronic systems intended to operate in extreme environments, including across wide temperature ranges and in radiation-intense scenarios such as space. The Definitive Guide to Extreme Environment Electronics Featuring contributions by some of the world's foremost exp

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

    OpenAIRE

    Watanabe, Hiroshi

    2013-01-01

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

  5. Technology improves upper extremity rehabilitation.

    Science.gov (United States)

    Kowalczewski, Jan; Prochazka, Arthur

    2011-01-01

    Stroke survivors with hemiparesis and spinal cord injury (SCI) survivors with tetraplegia find it difficult or impossible to perform many activities of daily life. There is growing evidence that intensive exercise therapy, especially when supplemented with functional electrical stimulation (FES), can improve upper extremity function, but delivering the treatment can be costly, particularly after recipients leave rehabilitation facilities. Recently, there has been a growing level of interest among researchers and healthcare policymakers to deliver upper extremity treatments to people in their homes using in-home teletherapy (IHT). The few studies that have been carried out so far have encountered a variety of logistical and technical problems, not least the difficulty of conducting properly controlled and blinded protocols that satisfy the requirements of high-level evidence-based research. In most cases, the equipment and communications technology were not designed for individuals with upper extremity disability. It is clear that exercise therapy combined with interventions such as FES, supervised over the Internet, will soon be adopted worldwide in one form or another. Therefore it is timely that researchers, clinicians, and healthcare planners interested in assessing IHT be aware of the pros and cons of the new technology and the factors involved in designing appropriate studies of it. It is crucial to understand the technical barriers, the role of telesupervisors, the motor improvements that participants can reasonably expect and the process of optimizing IHT-exercise therapy protocols to maximize the benefits of the emerging technology. Copyright © 2011 Elsevier B.V. All rights reserved.

  6. Atomic collisions under extreme conditions in space

    International Nuclear Information System (INIS)

    Itikawa, Yukikazu

    1987-01-01

    In space, atoms and molecules are often placed under the extreme conditions which are very difficult to be realized on Earth. For instance, extremely hot and dense plasmas are found in and around various stellar objects (e.g., neutron stars) on one hand and extremely cold and diffuse gases prevail in interstellar space on the other. There is so strong a magnetic field that electron clouds in atoms and molecules are distorted. The study of atomic collisions under the extreme conditions is not only helpful in understanding the astrophysical environment but also reveals new aspects of the physics of atoms and molecules. This paper is an invitation to the study. (References are not exhaustive but only provide a clue with which more details can be found.) (author)

  7. Extreme value distributions

    CERN Document Server

    Ahsanullah, Mohammad

    2016-01-01

    The aim of the book is to give a through account of the basic theory of extreme value distributions. The book cover a wide range of materials available to date. The central ideas and results of extreme value distributions are presented. The book rwill be useful o applied statisticians as well statisticians interrested to work in the area of extreme value distributions.vmonograph presents the central ideas and results of extreme value distributions.The monograph gives self-contained of theory and applications of extreme value distributions.

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

    OpenAIRE

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

    2015-01-01

    The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent ...

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

    Directory of Open Access Journals (Sweden)

    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.

  10. Deformation of extremal black holes from stringy interactions

    Science.gov (United States)

    Chen, Baoyi; Stein, Leo C.

    2018-04-01

    Black holes are a powerful setting for studying general relativity and theories beyond GR. However, analytical solutions for rotating black holes in beyond-GR theories are difficult to find because of the complexity of such theories. In this paper, we solve for the deformation to the near-horizon extremal Kerr metric due to two example string-inspired beyond-GR theories: Einstein-dilaton-Gauss-Bonnet and dynamical Chern-Simons theory. We accomplish this by making use of the enhanced symmetry group of NHEK and the weak-coupling limit of EdGB and dCS. We find that the EdGB metric deformation has a curvature singularity, while the dCS metric is regular. From these solutions, we compute orbital frequencies, horizon areas, and entropies. This sets the stage for analytically understanding the microscopic origin of black hole entropy in beyond-GR theories.

  11. How to manage a child with difficult asthma?

    Science.gov (United States)

    Saglani, Sejal; Fleming, Louise

    2016-08-01

    Children with difficult asthma have significant morbidity and fail to achieve asthma control despite being prescribed high dose maintenance treatment. If control remains poor after diagnostic confirmation, detailed assessments of the reasons for asthma being difficult-to-control are needed. Underlying modifiable factors including non-adherence to medication, persistent environmental exposures that trigger asthma symptoms and psychosocial factors contribute to poor control in these patients. The focus of this review is to provide a practical approach to the diagnosis and management of difficult asthma including an overview of long term assessments to identify potential progression to true, severe asthma. A multi-disciplinary team is critical to enable modifiable factors to be identified and addressed. Significant resources are required to manage paediatric difficult asthma optimally and only specialist centres should be tasked with the assessment of these patients. Although this may have an impact on healthcare resources, long term benefits for lung health are significant. Expert commentary: The management of paediatric difficult asthma is not simple and involves numerous professionals with varied expertise. However, if it is not undertaken with the appropriate skills, there is a significant risk of children receiving inappropriate invasive investigations and therapies that will have no impact on morbidity.

  12. Performance testing of extremity dosimeters, Study 2

    International Nuclear Information System (INIS)

    Harty, R.; Reece, W.D.; Hooker, C.D.

    1990-04-01

    The Health Physics Society Standards Committee (HPSSC) Working Group on Performance Testing of Extremity Dosimeters has issued a draft of a proposed standard for extremity dosimeters. The draft standard proposes methods to be used for testing dosimetry systems that determine occupational radiation dose to the extremities and the performance criterion used to determine compliance with the standard. Pacific Northwest Laboratory (PNL) has conducted two separate evaluations of the performance of extremity dosimeter processors to determine the appropriateness of the draft standard, as well as to obtain information regarding the performance of extremity dosimeters. Based on the information obtained during the facility visits and the results obtained from the performance testing, it was recommended that changes be made to ensure that the draft standard is appropriate for extremity dosimeters. The changes include: subdividing the mixture category and the beta particle category; eliminating the neutron category until appropriate flux-to-dose equivalent conversion factors are derived; and changing the tolerance level for the performance criterion to provide consistency with the performance criterion for whole body dosimeters, and to avoid making the draft standard overly difficult for processors of extremity dosimeters to pass. 20 refs., 10 figs., 6 tabs

  13. A novel cannulation technique for difficult urethral catheterization

    Directory of Open Access Journals (Sweden)

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

    Directory of Open Access Journals (Sweden)

    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.

  15. Extremal black holes in dynamical Chern–Simons gravity

    International Nuclear Information System (INIS)

    McNees, Robert; Stein, Leo C; Yunes, Nicolás

    2016-01-01

    Rapidly rotating black hole (BH) solutions in theories beyond general relativity (GR) play a key role in experimental gravity, as they allow us to compute observables in extreme spacetimes that deviate from the predictions of GR. Such solutions are often difficult to find in beyond-general-relativity theories due to the inclusion of additional fields that couple to the metric nonlinearly and non-minimally. In this paper, we consider rotating BH solutions in one such theory, dynamical Chern–Simons (dCS) gravity, where the Einstein–Hilbert action is modified by the introduction of a dynamical scalar field that couples to the metric through the Pontryagin density. We treat dCS gravity as an effective field theory and work in the decoupling limit, where corrections are treated as small perturbations from GR. We perturb about the maximally rotating Kerr solution, the so-called extremal limit, and develop mathematical insight into the analysis techniques needed to construct solutions for generic spin. First we find closed-form, analytic expressions for the extremal scalar field, and then determine the trace of the metric perturbation, giving both in terms of Legendre decompositions. Retaining only the first three and four modes in the Legendre representation of the scalar field and the trace, respectively, suffices to ensure a fidelity of over 99% relative to full numerical solutions. The leading-order mode in the Legendre expansion of the trace of the metric perturbation contains a logarithmic divergence at the extremal Kerr horizon, which is likely to be unimportant as it occurs inside the perturbed dCS horizon. The techniques employed here should enable the construction of analytic, closed-form expressions for the scalar field and metric perturbations on a background with arbitrary rotation. (paper)

  16. Extremely secure identification documents

    International Nuclear Information System (INIS)

    Tolk, K.M.; Bell, M.

    1997-09-01

    The technology developed in this project uses biometric information printed on the document and public key cryptography to ensure that an adversary cannot issue identification documents to unauthorized individuals or alter existing documents to allow their use by unauthorized individuals. This process can be used to produce many types of identification documents with much higher security than any currently in use. The system is demonstrated using a security badge as an example. This project focused on the technologies requiring development in order to make the approach viable with existing badge printing and laminating technologies. By far the most difficult was the image processing required to verify that the picture on the badge had not been altered. Another area that required considerable work was the high density printed data storage required to get sufficient data on the badge for verification of the picture. The image processing process was successfully tested, and recommendations are included to refine the badge system to ensure high reliability. A two dimensional data array suitable for printing the required data on the badge was proposed, but testing of the readability of the array had to be abandoned due to reallocation of the budgeted funds by the LDRD office

  17. Statistical techniques for modeling extreme price dynamics in the energy market

    International Nuclear Information System (INIS)

    Mbugua, L N; Mwita, P N

    2013-01-01

    Extreme events have large impact throughout the span of engineering, science and economics. This is because extreme events often lead to failure and losses due to the nature unobservable of extra ordinary occurrences. In this context this paper focuses on appropriate statistical methods relating to a combination of quantile regression approach and extreme value theory to model the excesses. This plays a vital role in risk management. Locally, nonparametric quantile regression is used, a method that is flexible and best suited when one knows little about the functional forms of the object being estimated. The conditions are derived in order to estimate the extreme value distribution function. The threshold model of extreme values is used to circumvent the lack of adequate observation problem at the tail of the distribution function. The application of a selection of these techniques is demonstrated on the volatile fuel market. The results indicate that the method used can extract maximum possible reliable information from the data. The key attraction of this method is that it offers a set of ready made approaches to the most difficult problem of risk modeling.

  18. How extreme is extreme hourly precipitation?

    Science.gov (United States)

    Papalexiou, Simon Michael; Dialynas, Yannis G.; Pappas, Christoforos

    2016-04-01

    The importance of accurate representation of precipitation at fine time scales (e.g., hourly), directly associated with flash flood events, is crucial in hydrological design and prediction. The upper part of a probability distribution, known as the distribution tail, determines the behavior of extreme events. In general, and loosely speaking, tails can be categorized in two families: the subexponential and the hyperexponential family, with the first generating more intense and more frequent extremes compared to the latter. In past studies, the focus has been mainly on daily precipitation, with the Gamma distribution being the most popular model. Here, we investigate the behaviour of tails of hourly precipitation by comparing the upper part of empirical distributions of thousands of records with three general types of tails corresponding to the Pareto, Lognormal, and Weibull distributions. Specifically, we use thousands of hourly rainfall records from all over the USA. The analysis indicates that heavier-tailed distributions describe better the observed hourly rainfall extremes in comparison to lighter tails. Traditional representations of the marginal distribution of hourly rainfall may significantly deviate from observed behaviours of extremes, with direct implications on hydroclimatic variables modelling and engineering design.

  19. Optimization with Extremal Dynamics

    International Nuclear Information System (INIS)

    Boettcher, Stefan; Percus, Allon G.

    2001-01-01

    We explore a new general-purpose heuristic for finding high-quality solutions to hard discrete optimization problems. The method, called extremal optimization, is inspired by self-organized criticality, a concept introduced to describe emergent complexity in physical systems. Extremal optimization successively updates extremely undesirable variables of a single suboptimal solution, assigning them new, random values. Large fluctuations ensue, efficiently exploring many local optima. We use extremal optimization to elucidate the phase transition in the 3-coloring problem, and we provide independent confirmation of previously reported extrapolations for the ground-state energy of ±J spin glasses in d=3 and 4

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

    Directory of Open Access Journals (Sweden)

    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.

  1. Why reference to the past is difficult for agrammatic speakers

    NARCIS (Netherlands)

    Bastiaanse, Roelien

    Many studies have shown that verb inflections are difficult to produce for agrammatic aphasic speakers: they are frequently omitted and substituted. The present article gives an overview of our search to understanding why this is the case. The hypothesis is that grammatical morphology referring to

  2. Difficult management of posterior urethra gunshot wound combined ...

    African Journals Online (AJOL)

    Posterior urethra gunshot wounds are poorly described in the literature. They are often associated with pelvic vital lesions making difficult early repair of urethral injuries. They can be complicated by urethrorectal fistula, which makes their management more complicated. We report a new case of posterior urethra disruption ...

  3. Seeking the best training model for difficult conversations in neonatology.

    Science.gov (United States)

    Lechner, Beatrice E; Shields, Robin; Tucker, Richard; Bender, G Jesse

    2016-05-01

    We hypothesize that a formal simulation curriculum prepares neonatology fellows for difficult conversations better than traditional didactics. Single-center neonatology fellowship graduates from 1999 to 2013 were sent a retrospective web-based survey. Some had been exposed to a Difficult Conversations curriculum (simulation group), others had not (no simulation group). The simulation group participated in one workshop annually, consisting of lecture, simulation, and debriefing. Scenarios were customized to year of training. Epoch comparisons were made between the simulation and no simulation groups. Self-rated baseline effectiveness at discussing difficult topics was not different. The simulation group reported more supervised family meetings and feedback after fellow-led meetings. Simulations were rated very positively. The simulation group reported increased comfort levels. Strategic pause and body positioning were specific communication skills more frequently acquired in the simulation group. In both groups, the highest ranked contributors to learning were mentor observation and clinical practice. In the simulation group, simulation and debriefing outranked didactics or other experiences. Simulation-based workshops improve communication skills in high stakes conversations. However, they do not substitute for mentor observation and experience. Establishing a structured simulation-based difficult conversations curriculum refines vital communication skills necessary for the high stakes conversations neonatologists direct in clinical practice.

  4. Percutaneous transhepatic cholelithotripsy for difficult common bile duct stones

    DEFF Research Database (Denmark)

    Stage, J G; Moesgaard, F; Grønvall, S

    1998-01-01

    or ureteroscope in ten patients and by stone removal by basket in the remaining four patients. The procedure was carried out using local anesthesia in the last 11 patients. Except for two patients with transient cholangitis, no complications occurred. CONCLUSIONS: Difficult bile duct and intrahepatic stones can...

  5. Confronting "Difficult Knowledge": Critical Aesthetics and War in the Classroom

    Science.gov (United States)

    Heybach Vivirito, Jessica A.

    2012-01-01

    This qualitative multi-site case study explores critical aesthetic experiences in teacher education classrooms, and advocates for the inclusion of theoretical and practical knowledge of "difficult knowledge," visual culture, and critical aesthetics in the classroom. Social reality consists of a perpetual stream of tragic and horrific…

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

    Science.gov (United States)

    Ruggeri, Azzurra; Gummerum, Michaela; Hanoch, Yaniv

    2014-01-01

    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. 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. 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. 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.

  7. Braving Difficult Choices Alone: Children's and Adolescents' Medical Decision Making

    Science.gov (United States)

    Ruggeri, Azzurra; Gummerum, Michaela; Hanoch, Yaniv

    2014-01-01

    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. PMID:25084274

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

    Science.gov (United States)

    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…

  9. Confusing cracks and difficult deformations : Interpreting structural damage in masonry

    NARCIS (Netherlands)

    De Vent, I.; Rots, J.G.; Van Hees, R.P.J.; Hobbelman, G.J.

    2012-01-01

    Cracks and deformatiçns in masonry are common phenomena in historical buildings. If they are interpreted correctly, they can be an extremely valuable source çf informatiçn on the load history of the premises. Nevertheless, this interpretation is not always as obvious as one may think. In the

  10. Pulmonary embolism and difficult-to-treat asthma

    Directory of Open Access Journals (Sweden)

    Catarina Teles Martins

    2007-11-01

    Full Text Available Asthma control is a key point in patient management. GINA's most recent report emphasises the need to investigate uncontrolled asthma, of which non-compliance with treatment, COPD, smoking, chronic sinusitis, gastroesophageal reflux disease and obesity are the usual causes.The aim of this work is to evaluate the role of pulmonary thromboembolism (PTE in cases of difficult-to-treat asthma. We reviewed the case reports of patients with severe persistent asthma followed in our Asthma Outpatients Clinic between 2004 and 2006. We selected the ones that maintained uncontrolled disease despite an optimal therapeutical approach and investigated the causes.In this group (n = 254, 28 (11% had severe persistent asthma and their mean age was 44 ± SD18 years old. 86% were females. Of these, 57% (n = 16 had uncontrolled disease: 35% (n = 6 due to non-compliance with treatment; 29% (n = 5 pulmonary thrombombolism (scintigraphic confirmation; 12% (n = 2 severe rhinosinusitis; 6% (n = 1 hypereosinophilic syndrome; 6% (n = 1 persistent allergen exposure and 6% (n = 1 are still being investigated.Patients with TPE (mean age 56 ± SD9 years old; 80% females; 80% Caucasians were diagnosed with asthma as adults (mean age 37 ± SD14 years old. The mean time until the diagnosis of TPE was 18 ± SD12 years. Predisposing factors for TPE were venous insufficiency (40%, hypertension (40% and deficit of functional protein C and S (20%.All these patients received anticoagulant therapy (80% are still medicated. It should be noted that after the beginning of anticoagulants, 40% of the patients achieved control of their asthma and 40% have partially controlled disease. There were no hospital admissions for asthma exacerbations after the beginning of anticoagulation in this group.This study supports the inclusion of TPE in the group of comorbidities to consider while investigating uncontrolled

  11. Human due diligence.

    Science.gov (United States)

    Harding, David; Rouse, Ted

    2007-04-01

    Most companies do a thorough job of financial due diligence when they acquire other companies. But all too often, deal makers simply ignore or underestimate the significance of people issues in mergers and acquisitions. The consequences are severe. Most obviously, there's a high degree of talent loss after a deal's announcement. To make matters worse, differences in decision-making styles lead to infighting; integration stalls; and productivity declines. The good news is that human due diligence can help companies avoid these problems. Done early enough, it helps acquirers decide whether to embrace or kill a deal and determine the price they are willing to pay. It also lays the groundwork for smooth integration. When acquirers have done their homework, they can uncover capability gaps, points of friction, and differences in decision making. Even more important, they can make the critical "people" decisions-who stays, who goes, who runs the combined business, what to do with the rank and file-at the time the deal is announced or shortly thereafter. Making such decisions within the first 30 days is critical to the success of a deal. Hostile situations clearly make things more difficult, but companies can and must still do a certain amount of human due diligence to reduce the inevitable fallout from the acquisition process and smooth the integration. This article details the steps involved in conducting human due diligence. The approach is structured around answering five basic questions: Who is the cultural acquirer? What kind of organization do you want? Will the two cultures mesh? Who are the people you most want to retain? And how will rank-and-file employees react to the deal? Unless an acquiring company has answered these questions to its satisfaction, the acquisition it is making will be very likely to end badly.

  12. Classifying Returns as Extreme

    DEFF Research Database (Denmark)

    Christiansen, Charlotte

    2014-01-01

    I consider extreme returns for the stock and bond markets of 14 EU countries using two classification schemes: One, the univariate classification scheme from the previous literature that classifies extreme returns for each market separately, and two, a novel multivariate classification scheme tha...

  13. Emotional distance to so-called difficult patients

    DEFF Research Database (Denmark)

    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....... Patients' case records were studied and four meetings with the staff were arranged to discuss the findings. Data collection lasted 18 months in all. Findings: Three strategies were identified: persuasion, avoidance (emotional distance), and compromise. Interestingly, in the relationship with a particular...... patient, the avoidance strategy did not necessarily represent the terminal stage, since a nurse could revert to the compromise strategy. Some of the nurses experienced painful emotions regarding these interactions. Conclusions: The avoidance strategy (emotional distance) resulted in important social...

  14. Difficult Tracheal Intubation in Obese Gastric Bypass patients

    DEFF Research Database (Denmark)

    Dohrn, Niclas; Sommer, Thorbjørn; Bisgaard, J.

    2016-01-01

    Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess...... the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation. This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients...... was 3.5 % and the patients with DTI were more frequently males, had higher CLC, higher American Society of Anesthesiologists physical status classification (ASA), and noticeably, a lower BMI compared to the patients with easy tracheal intubation. After adjustment with multivariable analyses body mass...

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

    DEFF Research Database (Denmark)

    Lauridsen, Karen M.; Madsen, Henning

    intercultural collaboration. The issues that arise seem to be grounded in linguistic, cultural and educational factors. This paper reports on and discusses a study of student responses to intercultural collaboration (in English) in two programmes at Aarhus University, Denmark. One conclusion...... is that the international students are more prepared to work in multicultural teams than their Danish peers. Another one tells us that once students have experience with the diversity of these teams, at least some of them become more open towards working in such teams in the future. It is interesting to discuss......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...

  16. Interesting cases which were difficult to diagnose by CT

    International Nuclear Information System (INIS)

    Ueki, Koji; Okubo, Koichi; Shinohara, Shinji

    1981-01-01

    Computed tomography (CT) clinically provides us with much more useful diagnostic informations regarding the localization, size, shape, extent and inner structure of the lesions and then in some cases the specific diagnosis can be also obtained by CT alone. However, it is usually difficult to define the longitudinal extent of the lesions, their relation to adjacent tissues, the originated site in enormous lesion and histological type also. At CT examination, it is essential to recognize these drawback and limitation on CT. From these points of view, six interesting cases (i.e. pericardial diverticulum, hepatoma with retroperitoneal metastasis, cholangiohepatoma, afferent loop syndrome, invagination and retroperitoneal malignant schwannoma) which were difficult to diagnose by CT and proved ultimately with operation or autopsy were illustrated with some reviews. (author)

  17. Distant Galaxy Clusters Hosting Extreme Central Galaxies

    Science.gov (United States)

    McDonald, Michael

    2014-09-01

    The recently-discovered Phoenix cluster harbors the most star-forming central cluster galaxy of any cluster in the known Universe, by nearly a factor of 10. This extreme system appears to be fulfilling early cooling flow predictions, although the lack of similar systems makes any interpretation difficult. In an attempt to find other "Phoenix-like" clusters, we have cross-correlated archival all-sky surveys (in which Phoenix was detected) and isolated 4 similarly-extreme systems which are also coincident in position and redshift with an overdensity of red galaxies. We propose here to obtain Chandra observations of these extreme, Phoenix-like systems, in order to confirm them as relaxed, rapidly-cooling galaxy clusters.

  18. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners

    Science.gov (United States)

    Kahanov, Leamor; Eberman, Lindsey E; Games, Kenneth E; Wasik, Mitch

    2015-01-01

    Stress fractures account for between 1% and 20% of athletic injuries, with 80% of stress fractures in the lower extremity. Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. Accurate diagnosis for stress fractures is dependent on the anatomical area. Anatomical regions such as the pelvis, sacrum, and metatarsals offer challenges due to difficulty differentiating pathologies with common symptoms. Special tests and treatment regimes, however, are similar among most stress fractures with resolution between 4 weeks to a year. The most difficult aspect of stress fracture treatment entails mitigating internal and external risk factors. Practitioners should address ongoing risk factors to minimize recurrence. PMID:25848327

  19. Radiofrequency ablation for hepatocellular carcinoma: assistant techniques for difficult cases.

    Science.gov (United States)

    Inoue, Tatsuo; Minami, Yasunori; Chung, Hobyung; Hayaishi, Sousuke; Ueda, Taisuke; Tatsumi, Chie; Takita, Masahiro; Kitai, Satoshi; Hatanaka, Kinuyo; Ishikawa, Emi; Yada, Norihisa; Hagiwara, Satoru; Ueshima, Kazuomi; Kudo, Masatoshi

    2010-07-01

    To confirm the safety and effectiveness of techniques to assist radiofrequency ablation (RFA) for difficult cases, we retrospectively evaluated successful treatment rates, early complications and local tumor progressions. Between June 1999 and April 2009, a total of 341 patients with 535 nodules were treated as difficult cases. Artificial pleural effusion assisted ablation was performed on 64 patients with 82 nodules. Artificial ascites-assisted ablation was performed on 11 patients with 13 nodules. Cooling by endoscopic nasobiliary drainage (ENBD) tube-assisted ablation was performed on 6 patients with 8 nodules. When the tumors were not well visualized with conventional B-mode ultrasonography (US), contrast-enhanced US-assisted ablation with Levovist or Sonazoid or virtual CT sonography-assisted ablation was performed. Contrast-enhanced US-assisted ablation was performed on 139 patients with 224 nodules and virtual CT sonography-assisted ablation was performed on 121 patients with 209 nodules. In total, complete ablation was achieved in 514 of 535 (96%) nodules in difficult cases. For RFA with artificial pleural effusion, artificial ascites and ENBD, complete response was confirmed in all cases. For contrast-enhanced US- and CT sonography-assisted ablation, complete response was 95%. Early complications were recognized in 24 cases (4.5%). All cases recovered with no invasive treatment. Local tumor recurrence was investigated in 377 nodules of 245 patients, and 69 (18%) nodules were positive. Tumor recurrences in each assisted technique were 14.7% in artificial pleural effusion cases, 7% in artificial ascites, 12.5% in ENBD tube cases, 31% in virtual CT sonography, and 8.5% in contrast-enhanced US. Although local tumor progression needs to be carefully monitored, assisted techniques of RFA for difficult cases are well tolerated and expand the indications of RFA. Copyright (c) 2010 S. Karger AG, Basel.

  20. Nutrition security under extreme events

    Science.gov (United States)

    Martinez, A.

    2017-12-01

    Nutrition security under extreme events. Zero hunger being one of the Sustainable Development Goal from the United Nations, food security has become a trending research topic. However extreme events impact on global food security is not yet 100% understood and there is a lack of comprehension of the underlying mechanisms of global food trade and nutrition security to improve countries resilience to extreme events. In a globalized world, food is still a highly regulated commodity and a strategic resource. A drought happening in a net food-exporter will have little to no effect on its own population but the repercussion on net food-importers can be extreme. In this project, we propose a methodology to describe and quantify the impact of a local drought to human health at a global scale. For this purpose, nutrition supply and global trade data from FAOSTAT have been used with domestic food production from national agencies and FAOSTAT, global precipitation from the Climate Research Unit and health data from the World Health Organization. A modified Herfindahl-Hirschman Index (HHI) has been developed to measure the level of resilience of one country to a drought happening in another country. This index describes how a country is dependent of importation and how diverse are its importation. Losses of production and exportation due to extreme events have been calculated using yield data and a simple food balance at country scale. Results show that countries the most affected by global droughts are the one with the highest dependency to one exporting country. Changes induced by droughts also disturbed their domestic proteins, fat and calories supply resulting most of the time in a higher intake of calories or fat over proteins.

  1. Clinicians' recognition and management of emotions during difficult healthcare conversations.

    Science.gov (United States)

    Martin, Elliott B; Mazzola, Natalia M; Brandano, Jessica; Luff, Donna; Zurakowski, David; Meyer, Elaine C

    2015-10-01

    To examine the most commonly reported emotions encountered among healthcare practitioners when holding difficult conversations, including frequency and impact on care delivery. Interprofessional learners from a range of experience levels and specialties completed self-report questionnaires prior to simulation-based communication workshops. Clinicians were asked to describe up to three emotions they experienced when having difficult healthcare conversations; subsequent questions used Likert-scales to measure frequency of each emotion, and whether care was affected. 152 participants completed questionnaires, including physicians, nurses, and psychosocial professionals. Most commonly reported emotions were anxiety, sadness, empathy, frustration, and insecurity. There were significant differences in how clinicians perceived these different emotions affecting care. Empathy and anxiety were emotions perceived to influence care more than sadness, frustration, and insecurity. Most clinicians, regardless of clinical experience and discipline, find their emotional state influences the quality of their care delivery. Most clinicians rate themselves as somewhat to quite capable of recognizing and managing their emotions, acknowledging significant room to grow. Further education designed to increase clinicians' recognition of, reflection on, and management of emotion would likely prove helpful in improving their ability to navigate difficult healthcare conversations. Interventions aimed at anxiety management are particularly needed. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  2. Medicare Home Health Services: A Difficult Program to Control

    Science.gov (United States)

    1981-09-25

    represent about one-third of all visits provided under the program. Family and friends altio provide similar services to the elderly and consequently...example, that the individual is to be confined to his or her home but that this does not necessarily mean that the patient is bedridden . At the same...34feebleness" and "insecurity" cannot be considered home- bound. We believe that in many cases (particularly for the elderly ) it would be extremely

  3. Extremal surface barriers

    International Nuclear Information System (INIS)

    Engelhardt, Netta; Wall, Aron C.

    2014-01-01

    We present a generic condition for Lorentzian manifolds to have a barrier that limits the reach of boundary-anchored extremal surfaces of arbitrary dimension. We show that any surface with nonpositive extrinsic curvature is a barrier, in the sense that extremal surfaces cannot be continuously deformed past it. Furthermore, the outermost barrier surface has nonnegative extrinsic curvature. Under certain conditions, we show that the existence of trapped surfaces implies a barrier, and conversely. In the context of AdS/CFT, these barriers imply that it is impossible to reconstruct the entire bulk using extremal surfaces. We comment on the implications for the firewall controversy

  4. A New CT-Guided Modified Trocar Technique for Drainage of Difficult Locations Abscesses

    Energy Technology Data Exchange (ETDEWEB)

    Tyng, Chiang J., E-mail: chiangjengtyng@gmail.com; Amoedo, Maurício K.; Bohrer, Yves; Bitencourt, Almir G. V.; Barbosa, Paula N. V.; Almeida, Maria Fernanda A.; Zurstrassen, Charles E. [AC Camargo Cancer Center, Department of Imaging (Brazil); Coimbra, Felipe J. F.; Costa, Wilson L. da [AC Camargo Cancer Center, Department of Abdominal Surgery (Brazil); Chojniak, Rubens [AC Camargo Cancer Center, Department of Imaging (Brazil)

    2017-05-15

    PurposeComputed tomography (CT) is commonly used to guide drainage of deep-seated abdominal fluid collections. However, in some cases, these collections seem to be inaccessible due to surrounding organs or their being in difficult locations. The aim of this study is to describe a modified Trocar technique to drain collections in difficult locations, especially those in the subphrenic space, without passing through intervening organs.Materials and MethodsThis retrospective case series study describes seven inpatients who underwent CT-guided drainage using a modified Trocar technique for abscesses that are difficult to access percutaneously. All patients provided written informed consent prior to the procedure. After placement of a 12–14F catheter inside the peritoneum, the Trocar stylet was removed so that the tip of the catheter became blunt and flexible to avoid injury to organs and structures in the catheter route, and the catheter was slowly advanced towards the collection using CT guidance and tactile sensation. After reaching the target, the stylet was reintroduced to enter the abscess wall.ResultsAll procedures were performed using an anterior abdominal wall access with adequate catheter positioning and resulted in clinical status improvement in the days after the drainage. No complications related to the procedure were identified in any of the patients.ConclusionsThe modified Trocar technique for percutaneous CT-guided drainage of abdominal abscesses may be feasible for lesions that are difficult to access with conventional methods.

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

    Energy Technology Data Exchange (ETDEWEB)

    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.)

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

    International Nuclear Information System (INIS)

    Hongisto, M.; Nikula, A.

    1996-01-01

    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.)

  7. [Intraoperative choledochoscopy usefulness in the treatment of difficult biliary stones].

    Science.gov (United States)

    Cuendis-Velázquez, A; Rojano-Rodríguez, M E; Morales-Chávez, C E; González Angulo-Rocha, A; Fernández-Castro, E; Aguirre-Olmedo, I; Torres-Ruiz, M F; Orellana-Parra, J C; Cárdenas-Lailson, L E

    2014-01-01

    Choledocholithiasis presents in 5-10% of the patients with biliary lithiasis. Numerous treatment algorithms have been considered for this disease, however, up to 10% of these therapeutic procedures may fail. Intraoperative choledochoscopy has become a useful tool in the treatment of patients with difficult-to-manage choledocholithiasis. To determine the usefulness of intraoperative choledochoscopy in the laparoendoscopic treatment of difficult stones that was carried out in our service. A cross-sectional study was conducted. The case records were reviewed of the patients that underwent intraoperative choledochoscopy during biliary tree exploration plus laparoscopic choledochoduodenal anastomosis within the time frame of March 1, 2011 and May 31, 2012, at the Hospital General Dr. Manuel Gea González. Transabdominal choledochoscopies were performed with active stone extraction when necessary, followed by peroral choledochoscopies through the recently formed bilioenteric anastomosis. The data were analyzed with descriptive statistics and measures of central tendency. The mean age was 71 years, 57% of the patients were women, and the ASA III score predominated. Active extraction of stones with 7 to 35mm diameters was carried out in 4 of the cases and the absence of stones in the biliary tract was corroborated in all the patients. The mean surgery duration was 18 minutes (range: 4 to 45min). Choledochoscopy is a safe and effective minimally invasive procedure for the definitive treatment of difficult stones. Copyright © 2013 Asociación Mexicana de Gastroenterología. Published by Masson Doyma México S.A. All rights reserved.

  8. Statistics of Extremes

    KAUST Repository

    Davison, Anthony C.; Huser, Raphaë l

    2015-01-01

    Statistics of extremes concerns inference for rare events. Often the events have never yet been observed, and their probabilities must therefore be estimated by extrapolation of tail models fitted to available data. Because data concerning the event

  9. Analysis of extreme events

    CSIR Research Space (South Africa)

    Khuluse, S

    2009-04-01

    Full Text Available ) determination of the distribution of the damage and (iii) preparation of products that enable prediction of future risk events. The methodology provided by extreme value theory can also be a powerful tool in risk analysis...

  10. Acute lower extremity ischaemia

    African Journals Online (AJOL)

    Acute lower extremity ischaemia. Acute lower limb ischaemia is a surgical emergency. ... is ~1.5 cases per 10 000 persons per year. Acute ischaemia ... Table 2. Clinical features discriminating embolic from thrombotic ALEXI. Clinical features.

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

    DEFF Research Database (Denmark)

    Witt, Flemming; Nielsen, Jørn Flohr

    The employee empowerment literature promises better organizational performance as well as more motivated and satisfied employees. However, this literature often neglects the specific context of public services in general, or the health care sector, hospitals, and nursing in particular. Nurses...... in Danish public hospitals work in a unique situation that makes the uncritical transfer of empowerment interventions intended to redesign their work difficult or even unfeasible. Analysis from an institutional perspective of the ongoing power struggle between agens of change at several levels in the Danish...

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

    International Nuclear Information System (INIS)

    Neumann, N.U.; Albert, H.H. von

    1982-01-01

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

  13. A child with a difficult airway: what do I do next?

    Science.gov (United States)

    Engelhardt, Thomas; Weiss, Markus

    2012-06-01

    Difficulties in pediatric airway management are common and continue to result in significant morbidity and mortality. This review reports on current concepts in approaching a child with a difficult airway. Routine airway management in healthy children with normal airways is simple in experienced hands. Mask ventilation (oxygenation) is always possible and tracheal intubation normally simple. However, transient hypoxia is common in these children usually due to unexpected anatomical and functional airway problems or failure to ventilate during rapid sequence induction. Anatomical airway problems (upper airway collapse and adenoid hypertrophy) and functional airway problems (laryngospasm, bronchospasm, insufficient depth of anesthesia and muscle rigidity, gastric hyperinflation, and alveolar collapse) require urgent recognition and treatment algorithms due to insufficient oxygen reserves. Early muscle paralysis and epinephrine administration aids resolution of these functional airway obstructions. Children with an 'impaired' normal (foreign body, allergy, and inflammation) or an expected difficult (scars, tumors, and congenital) airway require careful planning and expertise. Training in the recognition and management of these different situations as well as a suitably equipped anesthesia workstation and trained personnel are essential. The healthy child with an unexpected airway problem requires clear strategies. The 'impaired' normal pediatric airway may be handled by anesthetists experienced with children, whereas the expected difficult pediatric airway requires dedicated pediatric anesthesia specialist care and should only be managed in specialized centers.

  14. High Metal Removal Rate Process for Machining Difficult Materials

    Energy Technology Data Exchange (ETDEWEB)

    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.

  15. Determination of difficult to measure actinides in radioactive liquid waste

    International Nuclear Information System (INIS)

    Drabova, V.; Galanda, D.; Dulanska, S.; Remenec, B.; Kuruc, J.

    2014-01-01

    In decommissioning of a nuclear facilities and radioactive waste treatment the activity of various radionuclides need to be measured for the waste characterization. Radiochemical separation of 241 Am, 237 Np and isotopes of plutonium was tested on model solution of evaporator concentrate sample for isolation of each of them for alpha-spectrometry analysis. This paper describes use of the molecular recognition technology product AnaLig(R)Pu-01 gel from IBC Advanced technologies, Inc. to effectively and selectively pre-concentrate, separate and recover difficult-to-measure actinides from model solution of evaporator concentrate samples which belong to the most difficult matrices to analyse. The method is suitable for analysing highly contaminated samples of radioactive waste in a relatively short time. For counting the alpha activity of 241 Am, 239,240 Pu, 238 Pu and 237 Np ORTEC 576A alpha-spectrometer equipped with ULTRA TM ion implanted silicon detectors (600 mm 2 active area) was used. The spectra were processed by using the Alpha-vision TM 32-bit emulation software from the EG and G ORTEC company. (authors)

  16. Maxillofacial trauma patient: coping with the difficult airway

    Directory of Open Access Journals (Sweden)

    Barak Michal

    2009-05-01

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

  17. Multidisciplinary Difficult Airway Course: An Essential Educational Component of a Hospital-Wide Difficult Airway Response Program.

    Science.gov (United States)

    Leeper, W Robert; Haut, Elliott R; Pandian, Vinciya; Nakka, Sajan; Dodd-O, Jeffrey; Bhatti, Nasir; Hunt, Elizabeth A; Saheed, Mustapha; Dalesio, Nicholas; Schiavi, Adam; Miller, Christina; Kirsch, Thomas D; Berkow, Lauren

    2018-04-05

    A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scores and themes derived from qualitative assessments, and prepost course knowledge assessment MCQ scores. Tertiary care academic hospital center PARTICIPANTS: Students, residents, fellows, and practicing physicians from the departments of Surgery, Otolaryngology Head and Neck Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine; advanced practice providers (nurse practitioners and physician assistants), nurse anesthetists, nurses, and respiratory therapists. Totally, 23 MDACs have been conducted, including 499 participants. Course evaluations were uniformly positive with mean score of 86.9 of 95 points. Qualitative responses suggest major value from high-fidelity simulation, the hands-on skill stations, and teamwork practice. MCQ scores demonstrated significant improvement: median (interquartile range) pre: 69% (60%-81%) vs post: 81% (72%-89%), p < 0.001. Implementation of a MDAC successfully disseminated principles and protocols to all airway providers. Demonstrable

  18. Extreme Programming: Maestro Style

    Science.gov (United States)

    Norris, Jeffrey; Fox, Jason; Rabe, Kenneth; Shu, I-Hsiang; Powell, Mark

    2009-01-01

    "Extreme Programming: Maestro Style" is the name of a computer programming methodology that has evolved as a custom version of a methodology, called extreme programming that has been practiced in the software industry since the late 1990s. The name of this version reflects its origin in the work of the Maestro team at NASA's Jet Propulsion Laboratory that develops software for Mars exploration missions. Extreme programming is oriented toward agile development of software resting on values of simplicity, communication, testing, and aggressiveness. Extreme programming involves use of methods of rapidly building and disseminating institutional knowledge among members of a computer-programming team to give all the members a shared view that matches the view of the customers for whom the software system is to be developed. Extreme programming includes frequent planning by programmers in collaboration with customers, continually examining and rewriting code in striving for the simplest workable software designs, a system metaphor (basically, an abstraction of the system that provides easy-to-remember software-naming conventions and insight into the architecture of the system), programmers working in pairs, adherence to a set of coding standards, collaboration of customers and programmers, frequent verbal communication, frequent releases of software in small increments of development, repeated testing of the developmental software by both programmers and customers, and continuous interaction between the team and the customers. The environment in which the Maestro team works requires the team to quickly adapt to changing needs of its customers. In addition, the team cannot afford to accept unnecessary development risk. Extreme programming enables the Maestro team to remain agile and provide high-quality software and service to its customers. However, several factors in the Maestro environment have made it necessary to modify some of the conventional extreme

  19. Convergence of Extreme Value Statistics in a Two-Layer Quasi-Geostrophic Atmospheric Model

    Directory of Open Access Journals (Sweden)

    Vera Melinda Gálfi

    2017-01-01

    Full Text Available We search for the signature of universal properties of extreme events, theoretically predicted for Axiom A flows, in a chaotic and high-dimensional dynamical system. We study the convergence of GEV (Generalized Extreme Value and GP (Generalized Pareto shape parameter estimates to the theoretical value, which is expressed in terms of the partial information dimensions of the attractor. We consider a two-layer quasi-geostrophic atmospheric model of the mid-latitudes, adopt two levels of forcing, and analyse the extremes of different types of physical observables (local energy, zonally averaged energy, and globally averaged energy. We find good agreement in the shape parameter estimates with the theory only in the case of more intense forcing, corresponding to a strong chaotic behaviour, for some observables (the local energy at every latitude. Due to the limited (though very large data size and to the presence of serial correlations, it is difficult to obtain robust statistics of extremes in the case of the other observables. In the case of weak forcing, which leads to weaker chaotic conditions with regime behaviour, we find, unsurprisingly, worse agreement with the theory developed for Axiom A flows.

  20. Extreme Weather and Climate: Workshop Report

    Science.gov (United States)

    Sobel, Adam; Camargo, Suzana; Debucquoy, Wim; Deodatis, George; Gerrard, Michael; Hall, Timothy; Hallman, Robert; Keenan, Jesse; Lall, Upmanu; Levy, Marc; hide

    2016-01-01

    Extreme events are the aspects of climate to which human society is most sensitive. Due to both their severity and their rarity, extreme events can challenge the capacity of physical, social, economic and political infrastructures, turning natural events into human disasters. Yet, because they are low frequency events, the science of extreme events is very challenging. Among the challenges is the difficulty of connecting extreme events to longer-term, large-scale variability and trends in the climate system, including anthropogenic climate change. How can we best quantify the risks posed by extreme weather events, both in the current climate and in the warmer and different climates to come? How can we better predict them? What can we do to reduce the harm done by such events? In response to these questions, the Initiative on Extreme Weather and Climate has been created at Columbia University in New York City (extreme weather.columbia.edu). This Initiative is a University-wide activity focused on understanding the risks to human life, property, infrastructure, communities, institutions, ecosystems, and landscapes from extreme weather events, both in the present and future climates, and on developing solutions to mitigate those risks. In May 2015,the Initiative held its first science workshop, entitled Extreme Weather and Climate: Hazards, Impacts, Actions. The purpose of the workshop was to define the scope of the Initiative and tremendously broad intellectual footprint of the topic indicated by the titles of the presentations (see Table 1). The intent of the workshop was to stimulate thought across disciplinary lines by juxtaposing talks whose subjects differed dramatically. Each session concluded with question and answer panel sessions. Approximately, 150 people were in attendance throughout the day. Below is a brief synopsis of each presentation. The synopses collectively reflect the variety and richness of the emerging extreme event research agenda.

  1. Extreme meteorological conditions

    International Nuclear Information System (INIS)

    Altinger de Schwarzkopf, M.L.

    1983-01-01

    Different meteorological variables which may reach significant extreme values, such as the windspeed and, in particular, its occurrence through tornadoes and hurricanes that necesarily incide and wich must be taken into account at the time of nuclear power plants' installation, are analyzed. For this kind of study, it is necessary to determine the basic phenomenum of design. Two criteria are applied to define the basic values of design for extreme meteorological variables. The first one determines the expected extreme value: it is obtained from analyzing the recurence of the phenomenum in a convened period of time, wich may be generally of 50 years. The second one determines the extreme value of low probability, taking into account the nuclear power plant's operating life -f.ex. 25 years- and considering, during said lapse, the occurrence probabilities of extreme meteorological phenomena. The values may be determined either by the deterministic method, which is based on the acknowledgement of the fundamental physical characteristics of the phenomena or by the probabilistic method, that aims to the analysis of historical statistical data. Brief comments are made on the subject in relation to the Argentine Republic area. (R.J.S.) [es

  2. Radon mitigation experience in difficult-to-mitigate schools

    International Nuclear Information System (INIS)

    Leovic, K.W.; Craig, A.B.

    1990-01-01

    Initial radon mitigation experience in schools has shown sub-slab depressurization (SSD) to be generally effective in reducing elevated levels of radon in schools that have a continuous layer of clean, coarse aggregate underneath the slab. However, mitigation experience is limited in schools without sub-slab aggregate and in schools with characteristics such as return-air ductwork underneath the slab or unducted return-air plenums in the drop ceiling that are open to the sub-slab area (via open tops of block walls). Mitigation of schools with utility tunnels and of schools constructed over crawl spaces is also limited. Three Maryland schools exhibiting some of the above characteristics are being researched to help understand the mechanisms that control radon entry and mitigation in schools where standard SSD systems are not effective. This paper discusses specific characteristics of potentially difficult-to-mitigate schools and, where applicable, details examples from the three Maryland schools

  3. Management of difficult airway in intratracheal tumor surgery

    Directory of Open Access Journals (Sweden)

    Agarwal Surendra K

    2005-06-01

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

  4. Ploughs for difficult seams of Bergbau AG Niederrhein

    Energy Technology Data Exchange (ETDEWEB)

    Klimek, K.-H.

    1989-06-29

    Ploughs for difficult seams have been used in five panels at collieries of Bergbau AG Niederrhein. It was determined during operation that short or standard ploughs achieve a 30% higher area rate of advance than double ploughs. Differences in pitch in the plough chain lead to regenerative operation of the motor with the greater chain pitch in the case of deviations over 1.5%. An excessively high pretensioning force depending on the wire diameter may lead to an increase in the no-load power up to 100%. In future special attention must be paid to observance of a defined cutting depth; systems for load equalisation and the tensioner for the plough chain which can be used during continuous operation, must be further developed. 6 refs., 4 figs., 1 tab.

  5. U. K. storage market improves after difficult start to year

    Energy Technology Data Exchange (ETDEWEB)

    Kingston, J

    1979-07-15

    According to J. Kingston of PD Oil and Chemical Storage Ltd., the present shortage of oil and product supplies has raised storage capacity rates and some tankage expansion is being considered, but there is no prospect of new terminal construction in the short-term without considerable hardening of storage tariffs. The few tanks under construction are for the specific requirements of certain chemical producers. PD Oil and Chemical operates three storage facilities at Barry, South Wales, where many tanks are specially lined for handling difficult products, Ipswich, and Purfleet, U.K., which have a total capacity of 733,600 cu m, as well as seven others in South Africa, Australia, Spain, France, the U.S., Canary Islands, and Cape Verde Islands in conjunction with subsidiary or associated companies. A table lists PD Oil and Chemical's facilities in the U.K., including location, type of storage, capacity, and accessibility.

  6. Cylindrical plunge grinding of difficult to grind materials

    International Nuclear Information System (INIS)

    Nakajima, Toshikatsu; Uno, Yoshiyuki; Kayahara, Masayuki.

    1983-01-01

    Cylindrical plunge grinding processes of titanium alloy and nickel-base superalloys with various kinds of conventional grinding wheels, which are known as difficult to grind materials, are experimentally investigated, analyzing size generation process, grinding force, surface roughness, wheel wear, grinding ratio and so on. For grinding titanium alloy Ti-6Al-4V, GC grinding wheel yields most superior grinding results which leads to lower grinding force, smaller residual stock, less wheel wear and higher grinding ratio up to about 3 with GC 80 L 9 V wheel. Then, for grinding nickelbase superalloys Waspaloy and Rene 41, WA 150 L 9 V wheel yields better grinding results in surface roughness, wheel wear, grinding ratio without chatter vibration though grinding force is higher, and the grinding ratio about 3 is obtained. Furthermore, higher plunge speed and speed ratio result in higher grinding efficiency though grinding force, surface roughness, wheel wear increase for grinding titanium alloy and nickel-base superalloys. (author)

  7. Difficult colonoscopy: air, carbon dioxide, or water insufflation?

    Science.gov (United States)

    Chaubal, Alisha; Pandey, Vikas; Patel, Ruchir; Poddar, Prateik; Phadke, Aniruddha; Ingle, Meghraj; Sawant, Prabha

    2018-04-01

    This study aimed to compare tolerance to air, carbon dioxide, or water insufflation in patients with anticipated difficult colonoscopy (young, thin, obese individuals, and patients with prior abdominal surgery or irradiation). Patients with body mass index (BMI) less than 18 kg/m 2 or more than 30 kg/m 2 , or who had undergone previous abdominal or pelvic surgeries were randomized to air, carbon dioxide, or water insufflation during colonoscopy. The primary endpoint was cecal intubation with mild pain (less than 5 on visual analogue scale [VAS]), without use of sedation. The primary end point was achieved in 32.7%, 43.8%, and 84.9% of cases with air, carbon dioxide and water insufflation ( P carbon dioxide, and water insufflation ( P carbon dioxide for pain tolerance. This was seen in the subgroups with BMI 30 kg/m 2 .

  8. Contentious Conversations: Using Mediation Techniques in Difficult Clinical Ethics Consultations.

    Science.gov (United States)

    Fiester, Autumn

    2015-01-01

    Mediators utilize a wide range of skills in the process of facilitating dialogue and resolving conflicts. Among the most useful techniques for clinical ethics consultants (CECs)-and surely the least discussed-are those employed in acrimonious, hostile conversations between stakeholders. In the context of clinical ethics disputes or other bedside conflicts, good mediation skills can reverse the negative interactions that have prevented the creation of workable treatment plans or ethical consensus. This essay lays out the central framework mediators use in distinguishing positions from interests and describes a set of strategies for managing contentious ethics consultations or working with "difficult" patients, families, or patient-careprovider interactions. Copyright 2015 The Journal of Clinical Ethics. All rights reserved.

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

    Directory of Open Access Journals (Sweden)

    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.

  10. Taking a holistic approach to managing difficult stress fractures.

    Science.gov (United States)

    Miller, Timothy L; Best, Thomas M

    2016-09-09

    Stress fractures and other bony stress injuries occur along a spectrum of severity which can impact treatment and prognosis. When treating these injuries, it should be borne in mind that no two stress fractures behave exactly alike. Given that they are not a consistent injury, standardized treatment protocols can be challenging to develop. Treatment should be individualized to the patient or athlete, the causative activity, the anatomical site, and the severity of the injury. A holistic approach to the treatment of the most difficult stress fractures should be taken by orthopedists and sports medicine specialists. This approach is necessary to obtain optimal outcomes, minimize loss of fitness and time away from sports participation, and decrease the risk of recurrence.

  11. Acceptance issues for large items and difficult waste

    International Nuclear Information System (INIS)

    Palmer, J.; Lock, Peter

    2002-01-01

    Peter Lock described some particular cases which had given rise to difficult acceptance issues at NIREX, ranging from large size items to the impacts of chemicals used during decontamination on the mobility of radionuclides in a disposal facility: The UK strategy for intermediate level and certain low level radioactive waste disposal is based on production of cementitious waste-forms packaged in a standard range of containers as follows: 500 litre Drum - the normal container for most operational ILW (0.8 m diameter x 1.2 m high); 3 m"3 Box - a larger container for solid wastes (1.72 m x 1.72 m plan x 1.2 m high); 3 m"3 Drum - a larger container for in-drum mixing and immobilisation of sludge waste-forms (1.72 m diameter x 1.2 m high); 4 m Box - for large items of waste, especially from decommissioning (4.0 m x 2.4 m plan x 2.2 m high); 2 m LLW Box - for higher-density wastes (2.0 m x 2.4 m plan x 2.2 m high). In addition the majority of LLW is packaged by supercompaction followed by grouting in modified ISO freight containers (6 m x 2.5 m x 2.5 m). Some wastes do not fit easily into this strategy. These wastes include: very large items, (too big for the 4 m box) which, if dealt with whole, pose transport and disposal problems. These items are discussed further in Section 2; waste whose characteristics make packaging difficult. Such wastes are described in more detail in Section 3

  12. Performance specifications: the nearly impossible versus the merely difficult

    Science.gov (United States)

    Hopper, Darrel G.

    2000-08-01

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

  13. Discussion of difficult problems of early diagnosis of pancreatic cancer

    Directory of Open Access Journals (Sweden)

    GUO Xiaozhong

    2014-08-01

    Full Text Available Pancreatic cancer is a common malignant neoplasm of the pancreas with an extremely high mortality. Currently, the early diagnosis of pancreatic cancer is still not ideal. Attention should be paid to some clinical warning symptoms, such as unexplained abdominal and back pain, jaundice, and unexpected diabetes. Additionally, the combined use of CA19-9, CEA, and other tumor markers, the attention to biochemical indicators, the detection of mutation in KAI1 or p53 gene, and the exploration of the value of miRNA in clinical diagnosis are of great significance. On the other hand, ultrasound, CT, MRCP, ERCP, PET-CT, and other imaging methods, as well as effective collection of cytology specimens, should be performed. Thus, there is hope for the early diagnosis of pancreatic cancer.

  14. Acclimatization to extreme heat

    Science.gov (United States)

    Warner, M. E.; Ganguly, A. R.; Bhatia, U.

    2017-12-01

    Heat extremes throughout the globe, as well as in the United States, are expected to increase. These heat extremes have been shown to impact human health, resulting in some of the highest levels of lives lost as compared with similar natural disasters. But in order to inform decision makers and best understand future mortality and morbidity, adaptation and mitigation must be considered. Defined as the ability for individuals or society to change behavior and/or adapt physiologically, acclimatization encompasses the gradual adaptation that occurs over time. Therefore, this research aims to account for acclimatization to extreme heat by using a hybrid methodology that incorporates future air conditioning use and installation patterns with future temperature-related time series data. While previous studies have not accounted for energy usage patterns and market saturation scenarios, we integrate such factors to compare the impact of air conditioning as a tool for acclimatization, with a particular emphasis on mortality within vulnerable communities.

  15. Extremely deformable structures

    CERN Document Server

    2015-01-01

    Recently, a new research stimulus has derived from the observation that soft structures, such as biological systems, but also rubber and gel, may work in a post critical regime, where elastic elements are subject to extreme deformations, though still exhibiting excellent mechanical performances. This is the realm of ‘extreme mechanics’, to which this book is addressed. The possibility of exploiting highly deformable structures opens new and unexpected technological possibilities. In particular, the challenge is the design of deformable and bi-stable mechanisms which can reach superior mechanical performances and can have a strong impact on several high-tech applications, including stretchable electronics, nanotube serpentines, deployable structures for aerospace engineering, cable deployment in the ocean, but also sensors and flexible actuators and vibration absorbers. Readers are introduced to a variety of interrelated topics involving the mechanics of extremely deformable structures, with emphasis on ...

  16. Statistics of Extremes

    KAUST Repository

    Davison, Anthony C.

    2015-04-10

    Statistics of extremes concerns inference for rare events. Often the events have never yet been observed, and their probabilities must therefore be estimated by extrapolation of tail models fitted to available data. Because data concerning the event of interest may be very limited, efficient methods of inference play an important role. This article reviews this domain, emphasizing current research topics. We first sketch the classical theory of extremes for maxima and threshold exceedances of stationary series. We then review multivariate theory, distinguishing asymptotic independence and dependence models, followed by a description of models for spatial and spatiotemporal extreme events. Finally, we discuss inference and describe two applications. Animations illustrate some of the main ideas. © 2015 by Annual Reviews. All rights reserved.

  17. Probabilistic analysis of extreme wind events

    Energy Technology Data Exchange (ETDEWEB)

    Chaviaropoulos, P.K. [Center for Renewable Energy Sources (CRES), Pikermi Attikis (Greece)

    1997-12-31

    A vital task in wind engineering and meterology is to understand, measure, analyse and forecast extreme wind conditions, due to their significant effects on human activities and installations like buildings, bridges or wind turbines. The latest version of the IEC standard (1996) pays particular attention to the extreme wind events that have to be taken into account when designing or certifying a wind generator. Actually, the extreme wind events within a 50 year period are those which determine the ``static`` design of most of the wind turbine components. The extremes which are important for the safety of wind generators are those associated with the so-called ``survival wind speed``, the extreme operating gusts and the extreme wind direction changes. A probabilistic approach for the analysis of these events is proposed in this paper. Emphasis is put on establishing the relation between extreme values and physically meaningful ``site calibration`` parameters, like probability distribution of the annual wind speed, turbulence intensity and power spectra properties. (Author)

  18. Adventure and Extreme Sports.

    Science.gov (United States)

    Gomez, Andrew Thomas; Rao, Ashwin

    2016-03-01

    Adventure and extreme sports often involve unpredictable and inhospitable environments, high velocities, and stunts. These activities vary widely and include sports like BASE jumping, snowboarding, kayaking, and surfing. Increasing interest and participation in adventure and extreme sports warrants understanding by clinicians to facilitate prevention, identification, and treatment of injuries unique to each sport. This article covers alpine skiing and snowboarding, skateboarding, surfing, bungee jumping, BASE jumping, and whitewater sports with emphasis on epidemiology, demographics, general injury mechanisms, specific injuries, chronic injuries, fatality data, and prevention. Overall, most injuries are related to overuse, trauma, and environmental or microbial exposure. Copyright © 2016 Elsevier Inc. All rights reserved.

  19. Extremal graph theory

    CERN Document Server

    Bollobas, Bela

    2004-01-01

    The ever-expanding field of extremal graph theory encompasses a diverse array of problem-solving methods, including applications to economics, computer science, and optimization theory. This volume, based on a series of lectures delivered to graduate students at the University of Cambridge, presents a concise yet comprehensive treatment of extremal graph theory.Unlike most graph theory treatises, this text features complete proofs for almost all of its results. Further insights into theory are provided by the numerous exercises of varying degrees of difficulty that accompany each chapter. A

  20. Past and future changes in extreme sea levels and waves

    Digital Repository Service at National Institute of Oceanography (India)

    Lawe, J.A.; Woodworth, P.L.; Knutson, T.; McDonald, R.E.; Mclnnes, K.L.; Woth, K.; Von Storch, H.; Wolf, J.; Swail, V.; Bernier, N.B.; Gulev, S.; Horsburgh, K.J.; Unnikrishnan, A.S.; Hunter, J.R.; Weisse, R.

    of Extreme Sea Level 11.3.1 An Introduction to Storms Both mid-latitude and tropical storms are associated with extremes of sea level. Storm surges are generated by low atmospheric pressure and intense winds over the ocean. The latter also cause high wave... timescales, extremes and mean-sea-level change are both major factors in determining coastal evolution including the development of coastal ecosystems. It will be seen below that, although it is difficult to determine how mean sea level has changed...

  1. Extremes in random fields a theory and its applications

    CERN Document Server

    Yakir, Benjamin

    2013-01-01

    Presents a useful new technique for analyzing the extreme-value behaviour of random fields Modern science typically involves the analysis of increasingly complex data. The extreme values that emerge in the statistical analysis of complex data are often of particular interest. This book focuses on the analytical approximations of the statistical significance of extreme values. Several relatively complex applications of the technique to problems that emerge in practical situations are presented.  All the examples are difficult to analyze using classical methods, and as a result, the author pr

  2. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics

    Directory of Open Access Journals (Sweden)

    Venkateswaran Ramkumar

    2016-01-01

    Full Text Available The various physiological changes in pregnancy make the parturient vulnerable for early and rapid desaturation. Severe hypoxaemia during intubation can potentially compromise two lives (mother and foetus. Thus tracheal intubation in the pregnant patient poses unique challenges, and necessitates meticulous planning, ready availability of equipment and expertise to ensure maternal and foetal safety. The All India Difficult Airway Association (AIDAA proposes a stepwise plan for the safe management of the airway in obstetric patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists (ISA. Modified rapid sequence induction using gentle intermittent positive pressure ventilation with pressure limited to ≤20 cm H 2 O is acceptable. Partial or complete release of cricoid pressure is recommended when face mask ventilation, placement of supraglottic airway device (SAD or tracheal intubation prove difficult. One should call for early expert assistance. Maternal SpO 2 should be maintained ≥95%. Apnoeic oxygenation with nasal insufflation of 15 L/min oxygen during apnoea should be performed in all patients. If tracheal intubation fails, a second- generation SAD should be inserted. The decision to continue anaesthesia and surgery via the SAD, or perform fibreoptic-guided intubation via the SAD or wake up the patient depends on the urgency of surgery, foeto-maternal status and availability of resources and expertise. Emergency cricothyroidotomy must be performed if complete ventilation failure occurs.

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

    Science.gov (United States)

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

    2015-11-01

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

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

    DEFF Research Database (Denmark)

    Thorup, Signe Strann; Darvann, T.A.; Hermann, N.V.

    2010-01-01

    from pre- to post-surgery using thin-plate spline warping. The registration results are convincing and represent a first move towards an automatic registration method for dealing with difficult deformations due to this type of surgery. New or breakthrough work to be presented: The method provides...... was needed. We have previously demonstrated that non-rigid registration using B-splines is able to provide automated determination of point correspondences in populations of infants without cleft lip. However, this type of registration fails when applied to the task of determining the complex deformation...

  5. Stellar extreme ultraviolet astronomy

    International Nuclear Information System (INIS)

    Cash, W.C. Jr.

    1978-01-01

    The design, calibration, and launch of a rocket-borne imaging telescope for extreme ultraviolet astronomy are described. The telescope, which employed diamond-turned grazing incidence optics and a ranicon detector, was launched November 19, 1976, from the White Sands Missile Range. The telescope performed well and returned data on several potential stellar sources of extreme ultraviolet radiation. Upper limits ten to twenty times more sensitive than previously available were obtained for the extreme ultraviolet flux from the white dwarf Sirius B. These limits fall a factor of seven below the flux predicted for the star and demonstrate that the temperature of Sirius B is not 32,000 K as previously measured, but is below 30,000 K. The new upper limits also rule out the photosphere of the white dwarf as the source of the recently reported soft x-rays from Sirius. Two other white dwarf stars, Feige 24 and G191-B2B, were observed. Upper limits on the flux at 300 A were interpreted as lower limits on the interstellar hydrogen column densities to these stars. The lower limits indicate interstellar hydrogen densitites of greater than .02 cm -3 . Four nearby stars (Sirius, Procyon, Capella, and Mirzam) were observed in a search for intense low temperature coronae or extended chromospheres. No extreme ultraviolet radiation from these stars was detected, and upper limits to their coronal emisson measures are derived

  6. Extremity x-ray

    Science.gov (United States)

    ... page: //medlineplus.gov/ency/article/003461.htm Extremity x-ray To use the sharing features on this page, ... in the body Risks There is low-level radiation exposure. X-rays are monitored and regulated to provide the ...

  7. Extremity perfusion for sarcoma

    NARCIS (Netherlands)

    Hoekstra, Harald Joan

    2008-01-01

    For more than 50 years, the technique of extremity perfusion has been explored in the limb salvage treatment of local, recurrent, and multifocal sarcomas. The "discovery" of tumor necrosis factor-or. in combination with melphalan was a real breakthrough in the treatment of primarily irresectable

  8. Statistics of Local Extremes

    DEFF Research Database (Denmark)

    Larsen, Gunner Chr.; Bierbooms, W.; Hansen, Kurt Schaldemose

    2003-01-01

    . A theoretical expression for the probability density function associated with local extremes of a stochasticprocess is presented. The expression is basically based on the lower four statistical moments and a bandwidth parameter. The theoretical expression is subsequently verified by comparison with simulated...

  9. Leptospermum Honey for Wound Care in an Extremely Premature Infant.

    Science.gov (United States)

    Esser, Media

    2017-02-01

    Neonatal wound care is challenging due to the fragility and vulnerable skin structure. Neonates are often left susceptible to the forces of their environment, leaving them open to infection when skin injury occurs. Leptospermum honey has been used successfully in adult patients, with evidence lacking in the neonatal population. This case demonstrates the management of a difficult-to-heal wound in a 23-week gestation infant. Selecting the proper treatment and products for wound healing is challenging, with little evidence-based research available for the treatment of neonatal wounds. Leptospermum honey and other adult-driven dressings have been used for neonatal wound care as well as other adult-driven dressings. This case demonstrates the benefits of Leptospermum honey as an option for neonatal wounds. This case presents the treatment and healing of an extensive wound of a 23-week gestation neonate using a hydrogel product initially and then transitioning to a Leptospermum honey dressing due to suboptimal healing. Results of this treatment included quick healing time, little to no scarring, and no loss of movement or function to the affected extremities. The incorporation of Leptospermum honey for wound care has the potential to promote faster wound healing, with less scarring in the neonatal population. Adult wound care principles have been applied in the face of a weak evidence base relating to neonatal-specific cases. There is a need for continued research related to moist wound healing in the neonatal population, with resulting product and practice recommendations.

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

    International Nuclear Information System (INIS)

    VanderSchee, K.

    1998-01-01

    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

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

    Energy Technology Data Exchange (ETDEWEB)

    VanderSchee, K. [EnergyERA (Canada)

    1998-12-31

    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.

  12. Improving oncology nurses' communication skills for difficult conversations.

    Science.gov (United States)

    Baer, Linda; Weinstein, Elizabeth

    2013-06-01

    When oncology nurses have strong communication skills, they play a pivotal role in influencing patient satisfaction, adherence to plans of care, and overall clinical outcomes. However, research studies indicate that nurses tend to keep communication with patients and families at a superficial, nontherapeutic level. Processes for teaching goals-of-care communication skills and for implementing skills into clinical practice are not clearly defined. Nurses at a large comprehensive cancer center recognized the need for help with this skill set and sought out communication experts to assist in providing the needed education. An educational project was developed to improve therapeutic communication skills in oncology nurses during goals-of-care discussions and giving bad news. The program was tailored to nurses and social workers providing care to patients in a busy, urban, academic, outpatient oncology setting. Program topics included exploring the patient's world, eliciting hopes and concerns, and dealing with conflict about goals. Sharing and discussing specific difficult questions and scenarios were encouraged throughout the program. The program was well attended and well received by oncology nurses and social workers. Participants expressed interest in the continuation of communication programs to further enhance skills.

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

    Science.gov (United States)

    Fugazza, G; Bona, F

    1996-03-01

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

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

    Directory of Open Access Journals (Sweden)

    Westgren Magnus

    2010-06-01

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

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

    Science.gov (United States)

    2010-01-01

    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. PMID:20587075

  16. Simultaneous Optimization of Tallies in Difficult Shielding Problems

    International Nuclear Information System (INIS)

    Peplow, Douglas E.; Evans, Thomas M.; Wagner, John C.

    2008-01-01

    Monte Carlo is quite useful for calculating specific quantities in complex transport problems. Many variance reduction strategies have been developed that accelerate Monte Carlo calculations for specific tallies. However, when trying to calculate multiple tallies or a mesh tally, users have had to accept different levels of relative uncertainty among the tallies or run separate calculations optimized for each individual tally. To address this limitation, an extension of the CADIS (Consistent Adjoint Driven Importance Sampling) method, which is used for difficult source/detector problems, has been developed to optimize several tallies or the cells of a mesh tally simultaneously. The basis for this method is the development of an importance function that represents the importance of particles to the objective of uniform Monte Carlo particle density in the desired tally regions. This method utilizes the results of a forward discrete ordinates solution, which may be based on a quick, coarse-mesh calculation, to develop a forward-weighted source for the adjoint calculation. The importance map and the biased source computed from the adjoint flux are then used in the forward Monte Carlo calculation to obtain approximately uniform relative uncertainties for the desired tallies. This extension is called forward-weighted CADIS, or FW-CADIS

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

    Energy Technology Data Exchange (ETDEWEB)

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

    1995-11-01

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

  18. A technical solution to a difficult problem - An update

    International Nuclear Information System (INIS)

    Asselstine, J.K.

    1985-01-01

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

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

    Science.gov (United States)

    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.

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

    Science.gov (United States)

    Bickel, Janet; Rosenthal, Susan L

    2011-10-01

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

  1. Plasma hot machining for difficult-to-cut materials, 1

    International Nuclear Information System (INIS)

    Kitagawa, Takeaki; Maekawa, Katsuhiro; Kubo, Akihiko

    1987-01-01

    Machinability of difficult-to-cut materials has been a great concern to manufacturing engineers since demands for new materials in the aerospace and nuclear industries are more and more increasing. The purpose of this study is to develop a hot machining to improve machinability of high hardness materials. A plasma arc is used for heating materials cut. The surface just after being heated is removed as a chip by tungsten carbide tools. The turning experiments of high hardness steels with aid of plasma arc heating show not only the decrease in cutting forces but also the following effectiveness: (1) The application of the plasma hot machining to the condition, under which a built-up edge (BUE) appears in turning 0.46%C steel, makes the BUE disappeared, bringing less flank wear. (2) In the case of 18%Mn steel cutting, deep groove wear on the end-cutting edge diminishes, and roughness of the machined surface is improved by the prevention from chatter. (3) Although the chilled cast iron has high hardness of above HB = 350, the plasma hot machining makes it possible to cut it with tungsten carbide tools having less chipping and flank wear. (author)

  2. Nuclear energy and public opinion - a difficult relationship

    International Nuclear Information System (INIS)

    Kaase, M.

    1990-01-01

    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) [de

  3. A technical solution to a difficult problem - An update

    Energy Technology Data Exchange (ETDEWEB)

    Asselstine, J K

    1985-07-01

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

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

    International Nuclear Information System (INIS)

    Helwig, P.C.; Goosney, R.; Smith, W.L.

    1993-01-01

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

  5. Soft tissue masses of extremities: MR findings

    Energy Technology Data Exchange (ETDEWEB)

    Son, Seok Hyun; Yang, Seoung Oh; Choi, Jong Chul; Park, Byeong Ho; Lee, Ki Nam; Choi, Sun Seob; Chung, Duck Hwan [Dong-A University College of Medicine, Pusan (Korea, Republic of)

    1993-11-15

    To evaluate MR findings of soft tissue masses in extremities and to find the helpful findings of distinguish benignity from malignancy, 28 soft tissue masses (22 benign and 6 malignant) in extremities were reviewed. TI-weighted, proton density, T2-weighted and Gd-DTPA enhanced images were obtained. MR images allowed a specific diagnosis in large number of benign masses, such as hemangioma(8/9), lipoma(2/2), angiolipoma(1/1), epidermoid cyst(2/2), myositis ossificans(1/1), synovial chondromatosis(1/1) and pigmented villonodular synovitis(1/2). Specific diagnosis was difficult in the rest of the masses including malignancy. However, inhomogeneous signal intensities with necrosis and inhomogeneous enhancement may suggest malignant masses.

  6. Committee VI.1. Extreme Hull Girder Loading

    DEFF Research Database (Denmark)

    Jensen, Jørgen Juncher

    2000-01-01

    Committee Mandate. Evaluate and develop direct calculation procedures for extreme wawe loads on ship hull girders. Due consideration shall be given to stochastic and non-linear effects. The procedures shall be assessed by comparison with in-service experiences, model tests and more refined...

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

    Directory of Open Access Journals (Sweden)

    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.

  8. Species delimitation in taxonomically difficult fungi: the case of Hymenogaster.

    Directory of Open Access Journals (Sweden)

    Benjamin Stielow

    2011-01-01

    Full Text Available False truffles are ecologically important as mycorrhizal partners of trees and evolutionarily highly interesting as the result of a shift from epigeous mushroom-like to underground fruiting bodies. Since its first description by Vittadini in 1831, inappropriate species concepts in the highly diverse false truffle genus Hymenogaster has led to continued confusion, caused by a large variety of prevailing taxonomical opinions.In this study, we reconsidered the species delimitations in Hymenogaster based on a comprehensive collection of Central European taxa comprising more than 140 fruiting bodies from 20 years of field work. The ITS rDNA sequence dataset was subjected to phylogenetic analysis as well as clustering optimization using OPTSIL software.Among distinct species concepts from the literature used to create reference partitions for clustering optimization, the broadest concept resulted in the highest agreement with the ITS data. Our results indicate a highly variable morphology of H. citrinus and H. griseus, most likely linked to environmental influences on the phenology (maturity, habitat, soil type and growing season. In particular, taxa described in the 19(th century frequently appear as conspecific. Conversely, H. niveus appears as species complex comprising seven cryptic species with almost identical macro- and micromorphology. H. intermedius and H. huthii are described as novel species, each of which with a distinct morphology intermediate between two species complexes. A revised taxonomy for one of the most taxonomically difficult genera of Basidiomycetes is proposed, including an updated identification key. The (semi-automated selection among species concepts used here is of importance for the revision of taxonomically problematic organism groups in general.

  9. Techniques for assisting difficult delivery at caesarean section.

    Science.gov (United States)

    Waterfall, Heather; Grivell, Rosalie M; Dodd, Jodie M

    2016-01-31

    Caesarean section involves making an incision in the woman's abdomen and cutting through the uterine muscle. The baby is then delivered through that incision. Difficult caesarean birth may result in injury for the infant or complications for the mother. Methods to assist with delivery include vacuum or forceps extraction or manual delivery utilising fundal pressure. Medication that relaxes the uterus (tocolytic medication) may facilitate the birth of the baby at caesarean section. Delivery of the impacted head after prolonged obstructed labour can be associated with significant maternal and neonatal complication; to facilitate delivery of the head the surgeon may utilise either reverse breech extraction or head pushing. To compare the use of tocolysis (routine or selective use) with no use of tocolysis or placebo and to compare different extraction methods at the time of caesarean section for outcomes of infant birth trauma, maternal complications (particularly postpartum haemorrhage requiring blood transfusion), and long-term measures of infant and childhood morbidity. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies. All published, unpublished, and ongoing randomised controlled trials comparing the use of tocolytic agents (routine or selective) at caesarean section versus no use of tocolytic or placebo at caesarean section to facilitate the birth of the baby. Use of instrument versus manual delivery to facilitate birth of the baby. Reverse breech extraction versus head pushing to facilitate delivery of the deeply impacted fetal head. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Seven randomised controlled trials, involving 582 women undergoing caesarean section were included in this review. The risk of bias of included trials was variable, with some trials not adequately describing allocation or

  10. Maritime Military Decision Making in Environments of Extreme Information Ambiguity: An Initial Exploration

    National Research Council Canada - National Science Library

    Reeves, Andrew T

    2005-01-01

    ... to make effective decisions. An environment of extreme information ambiguity, a dependent variable, is one of the most difficult components of a battle where the decision maker may reach a confusing and debilitating point...

  11. Closure of difficult pharyngocutaneous fistula following salvage laryngectomy. Case report

    International Nuclear Information System (INIS)

    Suesada, Nobuko; Sakuraba, Minoru; Nagamatsu, Shogo; Miyamoto, Shimpei; Shinozaki, Takeshi; Hayashi, Ryuichi

    2013-01-01

    The patient was a 74-year-old man. A total laryngectomy was performed due to recurrence of laryngeal cancer after chemoradiotherapy (CRT). Postoperatively, a pharyngocutaneous fistula developed and patch-graft reconstruction using a pectoral major musculocutaneous flap was planned. However, due to expansion of the necrotic area, we needed to perform tubular reconstruction. Nevertheless, infection and pus discharge were observed and a second surgery was performed. Resection and reconstruction at the neck were considered impossible because advanced necrosis was seen at the cervical esophageal stump, and the operative procedure was changed to esophageal resection, gastric pull-up and free jejunum transfer. Although leakage was found at the jejunum-gastric anastomosis site by fluoroscopy on the 14th postoperative day, it disappeared through conservative therapy. In addition, oral ingestion was begun on the 28th postoperative day. At 6 months after the surgery, the patient was able to regularly intake food and no constriction of the tracheostoma was seen. In this case, unexpected expansion of the necrotic area was a significant problem. As for the causes, diminished blood flow to the esophagus due to total thyroidectomy and bilateral paratracheal lymph node dissection, and infection in the surrounding area, along with remarkable tissue damage with CRT were considered possible. In salvage surgery, attention will be necessary in evaluating necrotic range and selection of appropriate reconstructive procedure. (author)

  12. How Spoken Language Comprehension is Achieved by Older Listeners in Difficult Listening Situations.

    Science.gov (United States)

    Schneider, Bruce A; Avivi-Reich, Meital; Daneman, Meredyth

    2016-01-01

    Comprehending spoken discourse in noisy situations is likely to be more challenging to older adults than to younger adults due to potential declines in the auditory, cognitive, or linguistic processes supporting speech comprehension. These challenges might force older listeners to reorganize the ways in which they perceive and process speech, thereby altering the balance between the contributions of bottom-up versus top-down processes to speech comprehension. The authors review studies that investigated the effect of age on listeners' ability to follow and comprehend lectures (monologues), and two-talker conversations (dialogues), and the extent to which individual differences in lexical knowledge and reading comprehension skill relate to individual differences in speech comprehension. Comprehension was evaluated after each lecture or conversation by asking listeners to answer multiple-choice questions regarding its content. Once individual differences in speech recognition for words presented in babble were compensated for, age differences in speech comprehension were minimized if not eliminated. However, younger listeners benefited more from spatial separation than did older listeners. Vocabulary knowledge predicted the comprehension scores of both younger and older listeners when listening was difficult, but not when it was easy. However, the contribution of reading comprehension to listening comprehension appeared to be independent of listening difficulty in younger adults but not in older adults. The evidence suggests (1) that most of the difficulties experienced by older adults are due to age-related auditory declines, and (2) that these declines, along with listening difficulty, modulate the degree to which selective linguistic and cognitive abilities are engaged to support listening comprehension in difficult listening situations. When older listeners experience speech recognition difficulties, their attentional resources are more likely to be deployed to

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

    International Nuclear Information System (INIS)

    Di Lucia, Lorenzo

    2013-01-01

    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

  14. Extremes in nature

    CERN Document Server

    Salvadori, Gianfausto; Kottegoda, Nathabandu T

    2007-01-01

    This book is about the theoretical and practical aspects of the statistics of Extreme Events in Nature. Most importantly, this is the first text in which Copulas are introduced and used in Geophysics. Several topics are fully original, and show how standard models and calculations can be improved by exploiting the opportunities offered by Copulas. In addition, new quantities useful for design and risk assessment are introduced.

  15. Noninvasive carcinoma ex pleomorphic adenoma of the parotid gland: A difficult diagnosis on fine needle aspiration

    Directory of Open Access Journals (Sweden)

    Theresa Scognamiglio

    2015-01-01

    Full Text Available Carcinoma ex pleomorphic adenoma (CXPA is a rare epithelial malignancy that arises from a primary or recurrent pleomorphic adenoma (PA. It may be noninvasive (NI or invasive. NI CXPA is extremely rare. Preoperative diagnosis on fine needle aspiration (FNA of CXPA may be difficult and poses a diagnostic challenge to clinicians and pathologists. Herein, we describe the FNA findings of a case of NI-CXPA. A 69-year-old woman presented with rapid enlargement of a stable parotid mass of 25 years. Cytologically, malignant cells were focally associated with metachromatic fibromyxoid matrix that was homogeneous and dense with a vague fibrillary quality. There were cell groups, papillary-like clusters and single malignant cells. The nuclei were pleomorphic with irregularly dispersed chromatin, and the cytoplasm was ill-defined and granular. Nucleoli were small to inconspicuous. Mitoses and necrosis were not seen. Cytological features were not specific for any type of salivary gland carcinoma. The FNA diagnosis was primary high-grade adenocarcinoma of the parotid gland, not otherwise specified. Facial nerve-sparing total parotidectomy was performed, which histologically showed PA interspersed with ducts and nests composed of pleomorphic atypical nuclei surrounded by extensive hyalinization. Single cells were also noted. No capsular infiltration was seen in the entirely sampled tumor. Immunohistochemistry for Ki-67 showed a higher proliferation rate in the malignant ducts and p63 positive cells focally surrounded some of the malignant ducts. Histological diagnosis was NI-CXPA. Accurate diagnosis is important for proper surgical management; however, the preoperative diagnosis of NI-CXPA is difficult to make on FNA.

  16. Noninvasive carcinoma ex pleomorphic adenoma of the parotid gland: A difficult diagnosis on fine needle aspiration

    Science.gov (United States)

    Scognamiglio, Theresa; Joshi, Rohan; Kuhel, William I.; Tabbara, Sana O.; Rezaei, M. Katayoon; Hoda, Rana S.

    2015-01-01

    Carcinoma ex pleomorphic adenoma (CXPA) is a rare epithelial malignancy that arises from a primary or recurrent pleomorphic adenoma (PA). It may be noninvasive (NI) or invasive. NI CXPA is extremely rare. Preoperative diagnosis on fine needle aspiration (FNA) of CXPA may be difficult and poses a diagnostic challenge to clinicians and pathologists. Herein, we describe the FNA findings of a case of NI-CXPA. A 69-year-old woman presented with rapid enlargement of a stable parotid mass of 25 years. Cytologically, malignant cells were focally associated with metachromatic fibromyxoid matrix that was homogeneous and dense with a vague fibrillary quality. There were cell groups, papillary-like clusters and single malignant cells. The nuclei were pleomorphic with irregularly dispersed chromatin, and the cytoplasm was ill-defined and granular. Nucleoli were small to inconspicuous. Mitoses and necrosis were not seen. Cytological features were not specific for any type of salivary gland carcinoma. The FNA diagnosis was primary high-grade adenocarcinoma of the parotid gland, not otherwise specified. Facial nerve-sparing total parotidectomy was performed, which histologically showed PA interspersed with ducts and nests composed of pleomorphic atypical nuclei surrounded by extensive hyalinization. Single cells were also noted. No capsular infiltration was seen in the entirely sampled tumor. Immunohistochemistry for Ki-67 showed a higher proliferation rate in the malignant ducts and p63 positive cells focally surrounded some of the malignant ducts. Histological diagnosis was NI-CXPA. Accurate diagnosis is important for proper surgical management; however, the preoperative diagnosis of NI-CXPA is difficult to make on FNA. PMID:25972908

  17. Rhabdomyosarcoma of the extremity

    International Nuclear Information System (INIS)

    Rao, Bhaskar N

    1997-01-01

    Rhabdomyosarcoma is the most common soft tissue sarcoma accounting for almost 55%. These tumors arise from unsegmented mesoderm or primitive mesenchyma, which have the capacity to differentiate into muscle. Less than 5% occur in the first year of life. Extremity rhabdomyosarcoma are mainly seen in the adolescent years. The most common histologic subtype is the alveolar variant. Other characteristics of extremity rhabdomyosarcoma include a predilection for lymph node metastasis, a high local failure, and a relatively low survival rate. They often present as slow painless masses; however, lesions in the hand and foot often present as painful masses and imaging studies may show invasion of the bone. Initial diagnostic approaches include needle biopsy or incisional biopsy for larger lesions. Excisional biopsy is indicated preferably for lesions less than 2.5 cm. following this in most instances therapy is initiated with multi agent chemotherapy depending upon response, the next modality may be either surgery with intent to cure or radiation therapy. Amputation of an extremity for local control is not considered in most instances. Prognostic factors that have been determined over the years to be of significance by multi variant analysis have included age, tumor size, invasiveness, presence of either nodal or distant metastasis, and complete excision whenever feasible, with supplemental radiation therapy for local control

  18. Abdominal Cocoon: A Rare and Difficult Togetherness in Trauma Patient

    Directory of Open Access Journals (Sweden)

    Erkan Oymaci

    2016-07-01

    Full Text Available Abdominal cocoon, as known sclerosing encapsulating peritonitis, is a rare condition of mechanical intestinal obstruction due to total or partial encapsulation of the small bowel by a fibrocollagenous membrane. It has been reported mainly in young adolescent women and the majority of the cases are of unknown etiology. Awareness of this rare cause of surgical emergency may prevent delay in treatment and avoid unnecessary procedures for the patient. We are presenting an operated abdominal cocoon case which can be cause difficulty in diagnose and treatment.

  19. Plating on some difficult-to-plate metals and alloys

    International Nuclear Information System (INIS)

    Dini, J.W.; Johnson, H.R.

    1980-02-01

    Electrodeposition of coatings on metals such as beryllium, beryllium-copper, Kovar, lead, magnesium, thorium, titanium, tungsten, uranium, zirconium, and their alloys can be problematic. This is due in most cases to a natural oxide surface film that readily reforms after being removed. The procedures we recommend for plating on these metals rely on replacing the oxide film with a displacement coating, or etching to allow mechanical keying between the substrate and plated deposit. The effectiveness of the procedures is demonstrated by interface bond strengths found in ring-shear and conical-head tensile tests

  20. Defining Extreme Events: A Cross-Disciplinary Review

    Science.gov (United States)

    McPhillips, Lauren E.; Chang, Heejun; Chester, Mikhail V.; Depietri, Yaella; Friedman, Erin; Grimm, Nancy B.; Kominoski, John S.; McPhearson, Timon; Méndez-Lázaro, Pablo; Rosi, Emma J.; Shafiei Shiva, Javad

    2018-03-01

    Extreme events are of interest worldwide given their potential for substantial impacts on social, ecological, and technical systems. Many climate-related extreme events are increasing in frequency and/or magnitude due to anthropogenic climate change, and there is increased potential for impacts due to the location of urbanization and the expansion of urban centers and infrastructures. Many disciplines are engaged in research and management of these events. However, a lack of coherence exists in what constitutes and defines an extreme event across these fields, which impedes our ability to holistically understand and manage these events. Here, we review 10 years of academic literature and use text analysis to elucidate how six major disciplines—climatology, earth sciences, ecology, engineering, hydrology, and social sciences—define and communicate extreme events. Our results highlight critical disciplinary differences in the language used to communicate extreme events. Additionally, we found a wide range in definitions and thresholds, with more than half of examined papers not providing an explicit definition, and disagreement over whether impacts are included in the definition. We urge distinction between extreme events and their impacts, so that we can better assess when responses to extreme events have actually enhanced resilience. Additionally, we suggest that all researchers and managers of extreme events be more explicit in their definition of such events as well as be more cognizant of how they are communicating extreme events. We believe clearer and more consistent definitions and communication can support transdisciplinary understanding and management of extreme events.

  1. Variable effects of climate on forest growth in relation to climate extremes, disturbance, and forest dynamics

    Science.gov (United States)

    Itter, Malcolm S.; Finley, Andrew O.; D'Amato, Anthony W.; Foster, Jane R.; Bradford, John B.

    2017-01-01

    Changes in the frequency, duration, and severity of climate extremes are forecast to occur under global climate change. The impacts of climate extremes on forest productivity and health remain difficult to predict due to potential interactions with disturbance events and forest dynamics—changes in forest stand composition, density, size and age structure over time. Such interactions may lead to non-linear forest growth responses to climate involving thresholds and lag effects. Understanding how forest dynamics influence growth responses to climate is particularly important given stand structure and composition can be modified through management to increase forest resistance and resilience to climate change. To inform such adaptive management, we develop a hierarchical Bayesian state space model in which climate effects on tree growth are allowed to vary over time and in relation to past climate extremes, disturbance events, and forest dynamics. The model is an important step toward integrating disturbance and forest dynamics into predictions of forest growth responses to climate extremes. We apply the model to a dendrochronology data set from forest stands of varying composition, structure, and development stage in northeastern Minnesota that have experienced extreme climate years and forest tent caterpillar defoliation events. Mean forest growth was most sensitive to water balance variables representing climatic water deficit. Forest growth responses to water deficit were partitioned into responses driven by climatic threshold exceedances and interactions with insect defoliation. Forest growth was both resistant and resilient to climate extremes with the majority of forest growth responses occurring after multiple climatic threshold exceedances across seasons and years. Interactions between climate and disturbance were observed in a subset of years with insect defoliation increasing forest growth sensitivity to water availability. Forest growth was particularly

  2. Variable effects of climate on forest growth in relation to climate extremes, disturbance, and forest dynamics.

    Science.gov (United States)

    Itter, Malcolm S; Finley, Andrew O; D'Amato, Anthony W; Foster, Jane R; Bradford, John B

    2017-06-01

    Changes in the frequency, duration, and severity of climate extremes are forecast to occur under global climate change. The impacts of climate extremes on forest productivity and health remain difficult to predict due to potential interactions with disturbance events and forest dynamics-changes in forest stand composition, density, size and age structure over time. Such interactions may lead to non-linear forest growth responses to climate involving thresholds and lag effects. Understanding how forest dynamics influence growth responses to climate is particularly important given stand structure and composition can be modified through management to increase forest resistance and resilience to climate change. To inform such adaptive management, we develop a hierarchical Bayesian state space model in which climate effects on tree growth are allowed to vary over time and in relation to past climate extremes, disturbance events, and forest dynamics. The model is an important step toward integrating disturbance and forest dynamics into predictions of forest growth responses to climate extremes. We apply the model to a dendrochronology data set from forest stands of varying composition, structure, and development stage in northeastern Minnesota that have experienced extreme climate years and forest tent caterpillar defoliation events. Mean forest growth was most sensitive to water balance variables representing climatic water deficit. Forest growth responses to water deficit were partitioned into responses driven by climatic threshold exceedances and interactions with insect defoliation. Forest growth was both resistant and resilient to climate extremes with the majority of forest growth responses occurring after multiple climatic threshold exceedances across seasons and years. Interactions between climate and disturbance were observed in a subset of years with insect defoliation increasing forest growth sensitivity to water availability. Forest growth was particularly

  3. [Difficult Ventilation Requiring Emergency Endotracheal Intubation during Awake Craniotomy Managed by Laryngeal Mask Airway].

    Science.gov (United States)

    Matsuda, Asako; Mizota, Toshiyuki; Tanaka, Tomoharu; Segawa, Hajime; Fukuda, Kazuhiko

    2016-04-01

    We report a case of difficult ventilation requiring emergency endotracheal intubation during awake craniotomy managed by laryngeal mask airway (LMA). A 45-year-old woman was scheduled to receive awake craniotomy for brain tumor in the frontal lobe. After anesthetic induction, airway was secured using ProSeal LMA and patient was mechanically ventilated in pressure-control mode. Patient's head was fixed with head-pins at anteflex position, and the operation started. About one hour after the start of the operation, tidal volume suddenly decreased. We immediately started manual ventilation, but the airway resistance was extremely high and we could not adequately ventilate the patient. We administered muscle relaxant for suspected laryngospasm, but ventilatory status did not improve; so we decided to conduct emergency endotracheal intubation. We tried to intubate using Airwayscope or LMA-Fastrach, but they were not effective in our case. Finally trachea was intubated using transnasal fiberoptic bronchoscopy. We discuss airway management during awake craniotomy, focusing on emergency endotracheal intubation during surgery.

  4. Extreme Programming Pocket Guide

    CERN Document Server

    Chromatic

    2003-01-01

    Extreme Programming (XP) is a radical new approach to software development that has been accepted quickly because its core practices--the need for constant testing, programming in pairs, inviting customer input, and the communal ownership of code--resonate with developers everywhere. Although many developers feel that XP is rooted in commonsense, its vastly different approach can bring challenges, frustrations, and constant demands on your patience. Unless you've got unlimited time (and who does these days?), you can't always stop to thumb through hundreds of pages to find the piece of info

  5. Upper extremity golf injuries.

    Science.gov (United States)

    Cohn, Michael A; Lee, Steven K; Strauss, Eric J

    2013-01-01

    Golf is a global sport enjoyed by an estimated 60 million people around the world. Despite the common misconception that the risk of injury during the play of golf is minimal, golfers are subject to a myriad of potential pathologies. While the majority of injuries in golf are attributable to overuse, acute traumatic injuries can also occur. As the body's direct link to the golf club, the upper extremities are especially prone to injury. A thorough appreciation of the risk factors and patterns of injury will afford accurate diagnosis, treatment, and prevention of further injury.

  6. Changes in extreme regional sea level under global warming

    NARCIS (Netherlands)

    Brunnabend, S. E.; Dijkstra, H. A.; Kliphuis, Michael; Bal, Henri E.; Seinstra, Frank J.; van Werkhoven, Ben; Maassen, J.; van Meersbergen, Maarten

    2017-01-01

    An important contribution to future changes in regional sea level extremes is due to the changes in intrinsic ocean variability, in particular ocean eddies. Here, we study a scenario of future dynamic sea level (DSL) extremes using a high-resolution version of the Parallel Ocean Program and

  7. Ergotamine-induced upper extremity ischemia: a case report

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Man Deuk; Lee, Gun [Bundang CHA General Hospital, Pochon (China); Shin, Sung Wook [Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul (Korea, Republic of)

    2005-06-15

    Ergotamine-induced limb ischemia is an extremely rare case. We present a case of a 64-year-old man, who developed ischemia on the right upper extremity due to long-term use of Ergot for migraine headache. Angiography revealed diffused, smooth, and tapered narrowing of the brachial artery. The patient was successfully treated with intravenous nitroprusside.

  8. Meeting the challenge of constructing a uniquely difficult barrier wall

    International Nuclear Information System (INIS)

    Stamnes, R.L.; Orlean, H.M.; Thompson, N.E.

    1997-01-01

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

  9. [Vascular adrenal cyst causing difficult to control high blood pressure].

    Science.gov (United States)

    García Escudero, D; Torres Roca, M; Hernández Contreras, M E; Sánchez Rodríguez, C; Oñate Celdrán, J

    Hypertension is a prevalent disease in developed countries. Adrenal masses, and especially adrenal cysts, are a rare and usually asymptomatic finding, which can go unnoticed or be detected as incidental findings in imaging tests. These circumstances make the multidisciplinary approach mandatory. The case is presented on a 72 year-old woman with uncontrolled high blood pressure referred to the Urology Department due to the incidental finding of a right retroperitoneal mass. A functional and imaging study was performed, establishing a diagnosis of adrenal cyst causing hypertensive symptoms. A literature search was performed in order to assess diagnostic and therapeutic approaches. With the diagnosis of adrenal cyst causing uncontrolled high blood pressure, a right laparoscopic adrenalectomy was performed. After surgery the patient has maintained blood pressure within the normal range. A multidisciplinary approach is necessary for the management of rare diseases. The surgical approach, if possible, should be laparoscopic. Copyright © 2017 SEH-LELHA. Publicado por Elsevier España, S.L.U. All rights reserved.

  10. East-West European economic integration: Difficult to reach target

    International Nuclear Information System (INIS)

    D'Ermo, V.; Manca, S.

    1993-01-01

    The energy sector of Western Europe is now undergoing a slow growth period due largely to the socio-economic upheavals of East and West German unification and the political-economic restructuring of the countries making up Eastern Europe and the former Soviet Union. This paper evidences this fact by tabling and commenting on 1991-1992 coal, petroleum, natural gas and electric power production/consumption/export statistical data representing energy sector activities in the former COMECON member countries. The poor performance of these countries can be attributed to the effects of energy market liberalization, the restructuring of utility assets, limited production capacities and inflation. It is estimated that the adjustment time to reach economic parity with Western nations will be long but that the waiting period could be shortened through the implementation of technology transfer and financial cooperation programs with the more prosperous countries capable of providing the investment capital and know-how needed for the restructuring of production systems and resource development

  11. The 'Safari' Technique to Perform Difficult Subintimal Infragenicular Vessels

    International Nuclear Information System (INIS)

    Gandini, Roberto; Pipitone, Vincenzo; Stefanini, Matteo; Maresca, Luciano; Spinelli, Alessio; Colangelo, Vittorio; Reale, Carlo Andrea; Pampana, Enrico; Simonetti, Giovanni

    2007-01-01

    The purpose of this study was to describe the efficacy of planned combined subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to obtain the precise recanalization of the patent portion of a distal runoff vessel in critical limb ischemia (CLI) patients presenting long occlusions involving the popliteal trifurcation. Four patients at risk of limb loss due to long occlusions involving the leg vessel tree and not suitable for a surgical bypass were treated by the subintimal antegrade and retrograde (posterior tibial or anterior tibial artery) approach. The patent portion of the runoff vessel was previously assessed by magnetic resonance angiography (MRA) and directly punctured under Doppler ultrasound (US) guidance. A subintimal channel rendezvous was performed to allow snaring of the guidewires. Subsequently, a balloon dilatation was performed without stent deployment. All patients were successfully recanalized and had complete healing of the limb lesions. At the 12-month follow-up all patients showed clinical improvement with no major complications related to the procedure. This combined antegrade and retrograde subintimal approach is currently an excellent endovascular option in patients with long occlusions extending onto the leg vessels trifurcation and at risk of limb loss

  12. Difficult OptEase Filter Retrievals After Prolonged Indwelling Times

    Energy Technology Data Exchange (ETDEWEB)

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

    2013-08-01

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

  13. Difficult OptEase Filter Retrievals After Prolonged Indwelling Times

    International Nuclear Information System (INIS)

    Van Ha, Thuong G.; Kang, Lisa; Lorenz, Jonathan; Zangan, Steven; Navuluri, Rakesh; Straus, Christopher; Funaki, Brian

    2013-01-01

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

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

    Science.gov (United States)

    2015-01-01

    A clinical case reported to SENSAR is presented (www.sensar.org). A patient came to the operating room for surgery for parathyroidectomy. She had several predictors of difficult airway management, including a story of difficulties in previous intubations in other hospitals, as the patient reported. Therefore, after evaluation in preoperative consultation, fibreoptic bronchoscopy intubation was recommended. The day of surgery after induction of general anesthesia direct laryngoscopy was performed, without recognizing any glottic structure (Cormack-Lehane grade iv). Conventional laryngoscope was changed to a videolaryngoscope (Airtraq(®)) to try to improve the laryngoscopic view, but there were difficulties with handling and insertion of it, causing minor injuries to the lingual mucosa. Finally, tracheal intubation was achieved after several attempts. Analysis of the incident revealed the active error due to lack of experience of the professional who performed intubation maneuvers, favored by latent factors or contributors as were the complex pathology of the patient and the absence of protocols to difficult airway management in the hospital. Communication and analysis of this incident served to highlight the importance of the security protocols in Anesthesia, and as a result a working group that conducted the current algorithm approach to a difficult airway management was formed, established guidelines for further information patient and deals since clinical training and professional practice for the management of airway devices availables in the hospital. Copyright © 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

  15. Freight economic vulnerabilities due to flooding events.

    Science.gov (United States)

    2016-12-01

    Extreme weather events, and flooding in particular, have been occurring more often and with increased severity over the past decade, and there is reason to expect this trend will continue in the future due to a changing climate. Flooding events can u...

  16. Computational discovery of extremal microstructure families

    Science.gov (United States)

    Chen, Desai; Skouras, Mélina; Zhu, Bo; Matusik, Wojciech

    2018-01-01

    Modern fabrication techniques, such as additive manufacturing, can be used to create materials with complex custom internal structures. These engineered materials exhibit a much broader range of bulk properties than their base materials and are typically referred to as metamaterials or microstructures. Although metamaterials with extraordinary properties have many applications, designing them is very difficult and is generally done by hand. We propose a computational approach to discover families of microstructures with extremal macroscale properties automatically. Using efficient simulation and sampling techniques, we compute the space of mechanical properties covered by physically realizable microstructures. Our system then clusters microstructures with common topologies into families. Parameterized templates are eventually extracted from families to generate new microstructure designs. We demonstrate these capabilities on the computational design of mechanical metamaterials and present five auxetic microstructure families with extremal elastic material properties. Our study opens the way for the completely automated discovery of extremal microstructures across multiple domains of physics, including applications reliant on thermal, electrical, and magnetic properties. PMID:29376124

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

    International Nuclear Information System (INIS)

    Badami, Madhav G.

    2004-01-01

    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

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

    Directory of Open Access Journals (Sweden)

    G. Deslypere

    2015-01-01

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

  19. The cause of fever and pulmonary infiltrate: a difficult etiological diagnosis

    Directory of Open Access Journals (Sweden)

    Bahjat Barakat

    2017-04-01

    Full Text Available Adult-onset Still’s disease is a rare condition that typically presents itself with intermittent fever, arthralgia and salmon colored rash. The involvement of the in lung is less common and very rare. Diagnosis is relatively difficult because of the presence of non-specific symptoms and the lack of serological markers specific to the disease. We report the case of a patient having a pulmonary infiltrate/infiltration compatible with pneumonia, cutaneous/skin rash and persistence of fever with multiple admissions to the Emergency Room due to the failure of treatment with antibiotics. After an appropriate work-up, a diagnosis of adult-onset Still’s disease was made.

  20. Combustion-assisted laser cutting of a difficult-to-machine superalloy

    International Nuclear Information System (INIS)

    Molian, P.A.

    1992-01-01

    In laser cutting, the largest single application of lasers in manufacturing, the assist gas plays an important role in affecting the cutting performance. The assist gas is usually oxygen or an inert gas. In this paper acetylene and oxygen was employed to create combustion reactions during CO 2 laser cutting that enabled an improvement in the cutting speed, and cut quality of a difficult-to-machine superalloy. A comparison with laser cutting of a plain carbon steel under identical conditions was also made to determine the usefulness of combustion energy. Results indicate that both cutting speed and quality are enhanced by the reduction in the viscosity of slag formed during cutting (which assisted in ejection of the slag through the bottom of the kerf) due to the heat released by the acetylene burning inside the kerf. Correlations of experimental data with a theoretical model provided the influence of combustion power and gas-flow power on the cutting phenomena

  1. Investigating NARCCAP Precipitation Extremes via Bivariate Extreme Value Theory (Invited)

    Science.gov (United States)

    Weller, G. B.; Cooley, D. S.; Sain, S. R.; Bukovsky, M. S.; Mearns, L. O.

    2013-12-01

    We introduce methodology from statistical extreme value theory to examine the ability of reanalysis-drive regional climate models to simulate past daily precipitation extremes. Going beyond a comparison of summary statistics such as 20-year return values, we study whether the most extreme precipitation events produced by climate model simulations exhibit correspondence to the most extreme events seen in observational records. The extent of this correspondence is formulated via the statistical concept of tail dependence. We examine several case studies of extreme precipitation events simulated by the six models of the North American Regional Climate Change Assessment Program (NARCCAP) driven by NCEP reanalysis. It is found that the NARCCAP models generally reproduce daily winter precipitation extremes along the Pacific coast quite well; in contrast, simulation of past daily summer precipitation extremes in a central US region is poor. Some differences in the strength of extremal correspondence are seen in the central region between models which employ spectral nudging and those which do not. We demonstrate how these techniques may be used to draw a link between extreme precipitation events and large-scale atmospheric drivers, as well as to downscale extreme precipitation simulated by a future run of a regional climate model. Specifically, we examine potential future changes in the nature of extreme precipitation along the Pacific coast produced by the pineapple express (PE) phenomenon. A link between extreme precipitation events and a "PE Index" derived from North Pacific sea-surface pressure fields is found. This link is used to study PE-influenced extreme precipitation produced by a future-scenario climate model run.

  2. Spatial extreme value analysis to project extremes of large-scale indicators for severe weather.

    Science.gov (United States)

    Gilleland, Eric; Brown, Barbara G; Ammann, Caspar M

    2013-09-01

    Concurrently high values of the maximum potential wind speed of updrafts ( W max ) and 0-6 km wind shear (Shear) have been found to represent conducive environments for severe weather, which subsequently provides a way to study severe weather in future climates. Here, we employ a model for the product of these variables (WmSh) from the National Center for Atmospheric Research/United States National Center for Environmental Prediction reanalysis over North America conditioned on their having extreme energy in the spatial field in order to project the predominant spatial patterns of WmSh. The approach is based on the Heffernan and Tawn conditional extreme value model. Results suggest that this technique estimates the spatial behavior of WmSh well, which allows for exploring possible changes in the patterns over time. While the model enables a method for inferring the uncertainty in the patterns, such analysis is difficult with the currently available inference approach. A variation of the method is also explored to investigate how this type of model might be used to qualitatively understand how the spatial patterns of WmSh correspond to extreme river flow events. A case study for river flows from three rivers in northwestern Tennessee is studied, and it is found that advection of WmSh from the Gulf of Mexico prevails while elsewhere, WmSh is generally very low during such extreme events. © 2013 The Authors. Environmetrics published by JohnWiley & Sons, Ltd.

  3. Extreme-scale Algorithms and Solver Resilience

    Energy Technology Data Exchange (ETDEWEB)

    Dongarra, Jack [Univ. of Tennessee, Knoxville, TN (United States)

    2016-12-10

    A widening gap exists between the peak performance of high-performance computers and the performance achieved by complex applications running on these platforms. Over the next decade, extreme-scale systems will present major new challenges to algorithm development that could amplify this mismatch in such a way that it prevents the productive use of future DOE Leadership computers due to the following; Extreme levels of parallelism due to multicore processors; An increase in system fault rates requiring algorithms to be resilient beyond just checkpoint/restart; Complex memory hierarchies and costly data movement in both energy and performance; Heterogeneous system architectures (mixing CPUs, GPUs, etc.); and Conflicting goals of performance, resilience, and power requirements.

  4. The attitudes of neonatal nurses towards extremely preterm infants.

    Science.gov (United States)

    Gallagher, Katie; Marlow, Neil; Edgley, Alison; Porock, Davina

    2012-08-01

    The paper is a report of a study of the attitudes of neonatal nurses towards extremely preterm infants. Alongside advancing survival at extremely preterm gestational ages, ethical debates concerning the provision of invasive care have proliferated in light of the high morbidity. Despite nurses being the healthcare professionals who work closest with the infant and their family, their potential influence is usually ignored when determining how parents come to decisions about future care for their extremely premature infant. A Q methodology was employed to explore the attitudes of neonatal nurses towards caring for extremely preterm infants. Data were collected between 2007 and 2008 and analysed using PQMethod and Card Content Analysis. Thirty-six nurses from six neonatal units in the United Kingdom participated. Although there was consensus around the professional role of the nurse, when faced with the complexities of neonatal nursing three distinguishing factors emerged: the importance of parental choice in decision-making, the belief that technology should be used to assess response to treatment, and the belief that healthcare professionals should undertake difficult decisions. Neonatal nurses report unexpected difficulties in upholding their professionally defined role through highly complex and ever varied decision-making processes. Recognition of individual attitudes to the care of extremely preterm infants and the role of the family in the face of difficult decisions should facilitate more open communication between the nurse and the parents and improve the experience of both the nurse and the family during these emotional situations. © 2011 Blackwell Publishing Ltd.

  5. APPENDICULAR INVAGINATION DUE TO ENDOMETRIOSIS

    Directory of Open Access Journals (Sweden)

    Vasja Kruh

    2003-12-01

    Full Text Available Background. Invagination of the vermiform appendix is a very rare occurrence. We summarize epidemiologic and etiologic factors, types of classification, symtomatology, diagnostic features and treatment.Patients and treatment. The authors present 49-years old female with long-standing abdominal pains, who came in our hospital due to acute exacerbation with sever abdominal pain. Because of progressive symptoms and sensitivity in the right-lower abdominal quadrant a diagnostic laparoscopy was performed. An anomaly of cecum and the absence of appendix vermiformis have forced us to proceed with laparotomy in McBurnay point. After cecotomy an invaginated gangrenous appendix was found. The histological examination revealed endometriosis.Conclusions. By presenting this extremely rare pathology we also want to emphasize the important role of diagnostic laparoscopy in front of acute abdomen.

  6. Consideration of Task Performance for Robots Engaged in Extremely Dangerous Environment in Nuclear Power Plants

    Energy Technology Data Exchange (ETDEWEB)

    Hong, Seung Mo; Han, Kee Soo; Yi, Sung Deok; Kim, Seoung Rae [Nuclear Engineering Service and Solution Co. Ltd., Daejeon (Korea, Republic of); Choi, Young [KAERI, Daejeon (Korea, Republic of)

    2015-05-15

    After Fukushima Daiichi Nuclear Accident, it is started to pay more attention to operation and accident of nuclear power plants (NPPs). For domestic nuclear industry, it was recommended to establish corresponding strategies against accidents due to extremely dangerous natural disasters. Each nuclear power plant is also preparing to establish strategies to secure nuclear safety functions by estimating the counterplans for extreme accidents. Robots are particularly being used to access the areas where those are dangerous for human beings to access or to restore the accident. Robot technologies in NPPs are emerging cutting-edge technologies that are just a start except the developed countries like USA, Japan, etc. But they are carefully considered because they have the advantages of performing tasks in extremely dangerous environment in NPPs instead of human beings. In this study, the applicability of robots will be considered in extremely dangerous environment in NPPs. Accurate judgment of the inside situation of the plant and quick actions in the extreme condition like earthquake accompanied by loss of all AC powers should be considered as major function in terms of prevention of accident spread. According to the reported stress test results of domestic NPPs, the difficult things for operators to carry out in extreme conditions can be predictable, therefore the active use of robots as accident mitigation strategies will be helpful to reduce the unnecessary spending for facility improvement. Current trend of domestic and foreign robot technology development focuses on the information search of the inside of the plant and development of preventive maintenance of NPPs. As seen actually in Fukushima Daiichi, main roles of robots place emphasis on measuring the inside radiation level accessing to the area where operator cannot access and delivering information which can support operator's decision-making and actions. Therefore, it is considered that development of

  7. Defining difficult laryngoscopy findings by using multiple parameters: A machine learning approach

    Directory of Open Access Journals (Sweden)

    Moustafa Abdelaziz Moustafa

    2017-04-01

    Conclusion: “Alex Difficult Laryngoscopy Software” (ADLS is a machine learning program for prediction of difficult laryngoscopy. New cases can be entered to the training set thus improving the accuracy of the software.

  8. Are BALQSOs extreme accretors?

    Science.gov (United States)

    Yuan, M. J.; Wills, B. J.

    2002-12-01

    Broad Absorption Line (BAL) QSOs are QSOs with massive absorbing outflows up to 0.2c. Two hypothesis have been suggested in the past about the nature of BALQSOs: Every QSO might have BAL outflow with some covering factor. BALQSOs are those which happen to have outflow along our line of sight. BALQSOs have intrinsically different physical properties than non-BALQSOs. Based on BALQSO's optical emission properties and a large set of correlations linking many general QSO emission line and continuum properties, it has been suggested that BALQSOs might accrete at near Eddington limit with abundant of fuel supplies. With new BALQSO Hβ region spectroscopic observation conducted at UKIRT and re-analysis of literature data for low and high redshift non-BALQSOs, We confirm that BALQSOs have extreme Fe II and [O III] emission line properties. Using results derived from the latest QSO Hβ region reverberation mapping, we calculated Eddington ratios (˙ {M}/˙ {M}Edd) for our BAL and non-BALQSOs. The Fe II and [O III] strengths are strongly correlated with Eddington ratios. Those correlations link Eddington ratio to a large set of general QSO properties through the Boroson & Green Eigenvector 1. We find that BALQSOs have Eddington ratios close to 1. However, all high redshift, high luminosity QSOs have rather high Eddington ratios. We argue that this is a side effect from selecting the brightest objects. In fact, our high redshift sample might constitute BALQSO's high Eddington ratio orientation parent population.

  9. Extreme weather Events

    Indian Academy of Sciences (India)

    Resulting in deaths, disease and injury due to drowning, lack of sanitation and safe drinking water and exposure to dangerous chemical contaminants. Floods and tropical cyclones have greatest impact in South Asia; and Latin America; Increased risk of diarrhoeal diseases, cholera, cryptosporidiosis,; campylobacter and ...

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

    Science.gov (United States)

    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…

  11. Difficult Children

    DEFF Research Database (Denmark)

    Christensen, Else

    . Especially on children and their development in social relations to children at the same age, on how the mothers experience their child and on the parent’s resources concerning health, education and job situation. The paper presents results from the first two data collections (1996 and 1999) in a prospective...... in contact with their peers, more attention-related problems and less emotional or psychological resources. Furthermore the mothers experience more trouble in child rearing than what is found in an average family. The results are important in the way that they attract attention to the child’s own situation...... the family in a poor position regarding the children’s well-being, health and development, but not so severe that the child is to be placed out of home. The paper concentrates attention on differences between families with and without contact to the social service department for reasons related to the child...

  12. Likelihood estimators for multivariate extremes

    KAUST Repository

    Huser, Raphaë l; Davison, Anthony C.; Genton, Marc G.

    2015-01-01

    The main approach to inference for multivariate extremes consists in approximating the joint upper tail of the observations by a parametric family arising in the limit for extreme events. The latter may be expressed in terms of componentwise maxima, high threshold exceedances or point processes, yielding different but related asymptotic characterizations and estimators. The present paper clarifies the connections between the main likelihood estimators, and assesses their practical performance. We investigate their ability to estimate the extremal dependence structure and to predict future extremes, using exact calculations and simulation, in the case of the logistic model.

  13. Likelihood estimators for multivariate extremes

    KAUST Repository

    Huser, Raphaël

    2015-11-17

    The main approach to inference for multivariate extremes consists in approximating the joint upper tail of the observations by a parametric family arising in the limit for extreme events. The latter may be expressed in terms of componentwise maxima, high threshold exceedances or point processes, yielding different but related asymptotic characterizations and estimators. The present paper clarifies the connections between the main likelihood estimators, and assesses their practical performance. We investigate their ability to estimate the extremal dependence structure and to predict future extremes, using exact calculations and simulation, in the case of the logistic model.

  14. Further outlooks: extremely uncomfortable; Die weiteren Aussichten: extrem ungemuetlich

    Energy Technology Data Exchange (ETDEWEB)

    Resenhoeft, T.

    2006-07-01

    Climate is changing extremely in the last decades. Scientists dealing with extreme weather, should not only stare at computer simulations. They have also to turn towards psyche, seriously personal experiences, knowing statistics, relativise supposed sensational reports and last not least collecting more data. (GL)

  15. Common Bile Duct Perforation Due to Tuberculosis: A Case Report

    Directory of Open Access Journals (Sweden)

    Razman Jarmin

    2004-10-01

    Full Text Available A young man with HIV presented with biliary peritonitis secondary to spontaneous common bile duct perforation. Investigation revealed that the perforation was due to Mycobacterium tuberculosis. Tuberculosis of the bile duct is uncommon and usually presents with obstructive jaundice due to stricture. Bile duct perforation due to tuberculosis is extremely rare. Its management is discussed.

  16. Common Bile Duct Perforation Due to Tuberculosis: A Case Report

    OpenAIRE

    Razman Jarmin; Shaharin Shaharuddin

    2004-01-01

    A young man with HIV presented with biliary peritonitis secondary to spontaneous common bile duct perforation. Investigation revealed that the perforation was due to Mycobacterium tuberculosis. Tuberculosis of the bile duct is uncommon and usually presents with obstructive jaundice due to stricture. Bile duct perforation due to tuberculosis is extremely rare. Its management is discussed.

  17. Assessing Climate Variability using Extreme Rainfall and ...

    African Journals Online (AJOL)

    user1

    extreme frequency); the average intensity of rainfall from extreme events ... frequency and extreme intensity indices, suggesting that extreme events are more frequent and intense during years with high rainfall. The proportion of total rainfall from ...

  18. Effects of Extreme Events on Arsenic Cycling in Salt Marshes

    Science.gov (United States)

    Northrup, Kristy; Capooci, Margaret; Seyfferth, Angelia L.

    2018-03-01

    Extreme events such as storm surges, intense precipitation, and supermoons cause anomalous and large fluctuations in water level in tidal salt marshes, which impacts the sediment biogeochemistry that dictates arsenic (As) cycling. In addition to changes in water level, which impacts soil redox potential, these extreme events may also change salinity due to freshwater inputs from precipitation or saltwater inputs due to surge. It is currently unknown how As mobility in tidal salt marshes will be impacted by extreme events, as fluctuations in salinity and redox potential may act synergistically to mobilize As. To investigate impacts of extreme events on As cycling in tidal salt marshes, we conducted a combined laboratory and field investigation. We monitored pore water and soil samples before, during, and after two extreme events: a supermoon lunar eclipse followed by a storm surge and precipitation induced by Hurricane Joaquin in fall 2015 at the St. Jones Reserve in Dover, Delaware, a representative tidal salt marsh in the Mid-Atlantic United States. We also conducted soil incubations of marsh sediments in batch and in flow-through experiments in which redox potential and/or salinity were manipulated. Field investigations showed that pore water As was inversely proportional to redox potential. During the extreme events, a distinct pulse of As was observed in the pore water with maximum salinity. Combined field and laboratory investigations revealed that this As pulse is likely due to rapid changes in salinity. These results have implications for As mobility in the face of extreme weather variability.

  19. Diplopia due to Dacryops

    Directory of Open Access Journals (Sweden)

    Rahmi Duman

    2013-01-01

    Full Text Available Dacryops is a lacrimal ductal cyst. It is known that it can cause globe displacement, motility restriction, and proptosis because of the mass effect. Diplopia due to dacryops has not been reported previously. Here, we present a 57-year-old man with binocular horizontal diplopia that occurred during left direction gaze due to dacryops.

  20. Management of the mangled extremity

    NARCIS (Netherlands)

    Prasarn, Mark L.; Helfet, David L.; Kloen, Peter

    2012-01-01

    The management of a mangled extremity continues to be a matter of debate. With modern advances in trauma resuscitation, microvascular tissue transfer, and fracture fixation, severe traumatic extremity injuries that would historically have been amputated are often salvaged. Even if preserving a

  1. A decade of weather extremes

    NARCIS (Netherlands)

    Coumou, Dim; Rahmstorf, Stefan

    The ostensibly large number of recent extreme weather events has triggered intensive discussions, both in- and outside the scientific community, on whether they are related to global warming. Here, we review the evidence and argue that for some types of extreme - notably heatwaves, but also

  2. Attitude extremity, consensus and diagnosticity

    NARCIS (Netherlands)

    van der Pligt, J.; Ester, P.; van der Linden, J.

    1983-01-01

    Studied the effects of attitude extremity on perceived consensus and willingness to ascribe trait terms to others with either pro- or antinuclear attitudes. 611 Ss rated their attitudes toward nuclear energy on a 5-point scale. Results show that attitude extremity affected consensus estimates. Trait

  3. Consistency of extreme flood estimation approaches

    Science.gov (United States)

    Felder, Guido; Paquet, Emmanuel; Penot, David; Zischg, Andreas; Weingartner, Rolf

    2017-04-01

    Estimations of low-probability flood events are frequently used for the planning of infrastructure as well as for determining the dimensions of flood protection measures. There are several well-established methodical procedures to estimate low-probability floods. However, a global assessment of the consistency of these methods is difficult to achieve, the "true value" of an extreme flood being not observable. Anyway, a detailed comparison performed on a given case study brings useful information about the statistical and hydrological processes involved in different methods. In this study, the following three different approaches for estimating low-probability floods are compared: a purely statistical approach (ordinary extreme value statistics), a statistical approach based on stochastic rainfall-runoff simulation (SCHADEX method), and a deterministic approach (physically based PMF estimation). These methods are tested for two different Swiss catchments. The results and some intermediate variables are used for assessing potential strengths and weaknesses of each method, as well as for evaluating the consistency of these methods.

  4. Reconstruction of Lower Extremity Primary Malignant and Metastatic ...

    African Journals Online (AJOL)

    2017-10-26

    Oct 26, 2017 ... Lower extremity tumors and endoprosthesis. 1130. Nigerian Journal of Clinical Practice ¦ Volume 20 ¦ Issue 9 ¦ September 2017 renal failure, and the other patients died due to advanced metastatic disease. None of our patients who received radiotherapy and chemotherapy died due to oncologic treatment.

  5. Panhypopituitarism Due to Hemochromatosis

    OpenAIRE

    Mesut Özkaya; Kadir Gis; Ali Çetinkaya

    2013-01-01

    Hemochromatosis is an iron storage disease. Panhypopituitarism is a clinical condition in which the anterior pituitary hormones are deficient. Herein, we report a rare case of panhypopituitarism due to hemochromatosis. Turk Jem 2013; 17: 125-6

  6. Deference and Due Process

    OpenAIRE

    Vermeule, Cornelius Adrian

    2015-01-01

    In the textbooks, procedural due process is a strictly judicial enterprise; although substantive entitlements are created by legislative and executive action, it is for courts to decide independently what process the Constitution requires. The notion that procedural due process might be committed primarily to the discretion of the agencies themselves is almost entirely absent from the academic literature. The facts on the ground are very different. Thanks to converging strands of caselaw ...

  7. Prevention of Dental Damage and Improvement of Difficult Intubation Using a Paraglossal Technique With a Straight Miller Blade

    Directory of Open Access Journals (Sweden)

    Yu-Feng Huang

    2010-10-01

    Full Text Available Patients with diseased teeth, or those who are difficult to intubate, have a higher risk of dental injury during laryngoscopy. We report 3 cases of smooth endotracheal intubation using a paraglossal technique with a straight Miller blade in patients with poor dentition. Three patients with poor dentition were scheduled to undergo surgery under general anesthesia. All patients presented with extremely loose upper central incisors and had lost the other right upper teeth, while micrognathia and prominent, loose upper incisors were noted in 1 case. We elected to use a straight Miller blade using a paraglossal approach. A nasopharyngeal airway was inserted after induction of general anesthesia to facilitate mask ventilation and prevent air leakage from the mask. The Miller blade was then inserted from the right corner of the mouth, avoiding contact with the vulnerable incisors, and advanced along the groove between the tongue and tonsil. The endotracheal tube was subsequently smoothly inserted after obtaining a grade 1 Cormack and Lehane view without dental trauma in all 3 cases. Direct laryngoscopy using the paraglossal straight blade technique avoids dental damage in patients with mobile upper incisors and no right maxillary molars. It is a practical alternative method that differs from the traditional Macintosh laryngoscope in patients with a high risk of dental injury during the procedure. This technique, which provides an improved view of the larynx, might also be helpful with patients in whom intubation is difficult.

  8. The effectiveness of search dogs compared with humans in searching difficult terrain at turbine sites for bat fatalities

    Energy Technology Data Exchange (ETDEWEB)

    Mathews, Fiona

    2011-07-01

    Full text: Many wind farms in the UK and elsewhere in northern Europe are situated in habitat with dense tall vegetation such as arable fields and upland heaths. This makes surveying for bat fatalities extremely difficult. To facilitate a multi-centre study of the effects of wind turbines on British bats, we have therefore conducted controlled trials of the relative success of trained search dogs and ecologists in retrieving bat carcasses. Although dogs have been used previously in ecological surveys for bats, this is the first time they have been specifically trained for use in 'difficult to survey' habitats. Two ecologists and two Labrador dogs with handlers were each given the opportunity to retrieve up to 45 bat carcasses in a range of habitat types. Their efficiency in terms of overall search time, costs, and retrieval abilities were evaluated. Our results indicate that high rates of retrieval can be achieved by dogs, even in dense vegetation up to 75cm high. Further, a typical 100m2 search area can be surveyed in less than half the time taken by humans. The limitations of using search dogs, and their ability to detect the presence of bats that have been scavenged are also presented (presentation supported with video footage). (Author)

  9. Spatial dependence of extreme rainfall

    Science.gov (United States)

    Radi, Noor Fadhilah Ahmad; Zakaria, Roslinazairimah; Satari, Siti Zanariah; Azman, Muhammad Az-zuhri

    2017-05-01

    This study aims to model the spatial extreme daily rainfall process using the max-stable model. The max-stable model is used to capture the dependence structure of spatial properties of extreme rainfall. Three models from max-stable are considered namely Smith, Schlather and Brown-Resnick models. The methods are applied on 12 selected rainfall stations in Kelantan, Malaysia. Most of the extreme rainfall data occur during wet season from October to December of 1971 to 2012. This period is chosen to assure the available data is enough to satisfy the assumption of stationarity. The dependence parameters including the range and smoothness, are estimated using composite likelihood approach. Then, the bootstrap approach is applied to generate synthetic extreme rainfall data for all models using the estimated dependence parameters. The goodness of fit between the observed extreme rainfall and the synthetic data is assessed using the composite likelihood information criterion (CLIC). Results show that Schlather model is the best followed by Brown-Resnick and Smith models based on the smallest CLIC's value. Thus, the max-stable model is suitable to be used to model extreme rainfall in Kelantan. The study on spatial dependence in extreme rainfall modelling is important to reduce the uncertainties of the point estimates for the tail index. If the spatial dependency is estimated individually, the uncertainties will be large. Furthermore, in the case of joint return level is of interest, taking into accounts the spatial dependence properties will improve the estimation process.

  10. Causes of Glacier Melt Extremes in the Alps Since 1949

    Science.gov (United States)

    Thibert, E.; Dkengne Sielenou, P.; Vionnet, V.; Eckert, N.; Vincent, C.

    2018-01-01

    Recent record-breaking glacier melt values are attributable to peculiar extreme events and long-term warming trends that shift averages upward. Analyzing one of the world's longest mass balance series with extreme value statistics, we show that detrending melt anomalies makes it possible to disentangle these effects, leading to a fairer evaluation of the return period of melt extreme values such as 2003, and to characterize them by a more realistic bounded behavior. Using surface energy balance simulations, we show that three independent drivers control melt: global radiation, latent heat, and the amount of snow at the beginning of the melting season. Extremes are governed by large deviations in global radiation combined with sensible heat. Long-term trends are driven by the lengthening of melt duration due to earlier and longer-lasting melting of ice along with melt intensification caused by trends in long-wave irradiance and latent heat due to higher air moisture.

  11. So small, so loud: extremely high sound pressure level from a pygmy aquatic insect (Corixidae, Micronectinae).

    Science.gov (United States)

    Sueur, Jérôme; Mackie, David; Windmill, James F C

    2011-01-01

    To communicate at long range, animals have to produce intense but intelligible signals. This task might be difficult to achieve due to mechanical constraints, in particular relating to body size. Whilst the acoustic behaviour of large marine and terrestrial animals has been thoroughly studied, very little is known about the sound produced by small arthropods living in freshwater habitats. Here we analyse for the first time the calling song produced by the male of a small insect, the water boatman Micronecta scholtzi. The song is made of three distinct parts differing in their temporal and amplitude parameters, but not in their frequency content. Sound is produced at 78.9 (63.6-82.2) SPL rms re 2.10(-5) Pa with a peak at 99.2 (85.7-104.6) SPL re 2.10(-5) Pa estimated at a distance of one metre. This energy output is significant considering the small size of the insect. When scaled to body length and compared to 227 other acoustic species, the acoustic energy produced by M. scholtzi appears as an extreme value, outperforming marine and terrestrial mammal vocalisations. Such an extreme display may be interpreted as an exaggerated secondary sexual trait resulting from a runaway sexual selection without predation pressure.

  12. So small, so loud: extremely high sound pressure level from a pygmy aquatic insect (Corixidae, Micronectinae.

    Directory of Open Access Journals (Sweden)

    Jérôme Sueur

    Full Text Available To communicate at long range, animals have to produce intense but intelligible signals. This task might be difficult to achieve due to mechanical constraints, in particular relating to body size. Whilst the acoustic behaviour of large marine and terrestrial animals has been thoroughly studied, very little is known about the sound produced by small arthropods living in freshwater habitats. Here we analyse for the first time the calling song produced by the male of a small insect, the water boatman Micronecta scholtzi. The song is made of three distinct parts differing in their temporal and amplitude parameters, but not in their frequency content. Sound is produced at 78.9 (63.6-82.2 SPL rms re 2.10(-5 Pa with a peak at 99.2 (85.7-104.6 SPL re 2.10(-5 Pa estimated at a distance of one metre. This energy output is significant considering the small size of the insect. When scaled to body length and compared to 227 other acoustic species, the acoustic energy produced by M. scholtzi appears as an extreme value, outperforming marine and terrestrial mammal vocalisations. Such an extreme display may be interpreted as an exaggerated secondary sexual trait resulting from a runaway sexual selection without predation pressure.

  13. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners

    Directory of Open Access Journals (Sweden)

    Kahanov L

    2015-03-01

    Full Text Available Leamor Kahanov,1 Lindsey E Eberman,2 Kenneth E Games,2 Mitch Wasik2 1College of Health Science, Misericordia University, Dallas, PA, USA; 2Department of Applied Medicine and Rehabilitation, Indiana State University, Terre Haute, IN, USA Abstract: Stress fractures account for between 1% and 20% of athletic injuries, with 80% of stress fractures in the lower extremity. Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. Accurate diagnosis for stress fractures is dependent on the anatomical area. Anatomical regions such as the pelvis, sacrum, and metatarsals offer challenges due to difficulty differentiating pathologies with common symptoms. Special tests and treatment regimes, however, are similar among most stress fractures with resolution between 4 weeks to a year. The most difficult aspect of stress fracture treatment entails mitigating internal and external risk factors. Practitioners should address ongoing risk factors to minimize recurrence. Keywords: medial tibial stress syndrome, stress injury, nonunion stress fracture

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

    DEFF Research Database (Denmark)

    Nørskov, Anders Kehlet; Rosenstock, Charlotte Valentin; Wetterslev, Jørn

    2013-01-01

    -specific assessment. Data from patients' pre-operative airway assessment are registered in the Danish Anaesthesia Database. Objective scores for intubation and mask ventilation grade the severity of airway managements. The accuracy of predicting difficult intubation and mask ventilation is measured for each group...... the examination and registration of predictors for difficult mask ventilation with a non-specified clinical airway assessment on prediction of difficult mask ventilation.Method/Design: We cluster-randomized 28 Danish departments of anaesthesia to airway assessment either by the SARI or by usual non...... that registration of the SARI and predictors for difficult mask ventilation are mandatory for the intervention group but invisible to controls....

  15. Defining Political Extremism in the Balkans. The Case of Serbia

    Directory of Open Access Journals (Sweden)

    Babić Marko

    2015-12-01

    Full Text Available Political extremism (and particularly right wing political extremism remains relatively insufficiently explored due to the fact that the phenomenon is controversial and hard to define. Its ambiguity and variability depending on time and spatial point of view further complicates its definition. Its structure is amorphous and eclectic as it often includes elements from different ideologies and connects incompatible ideas. A multidimensional conceptualization and an interdisciplinary approach - sociological, social, psychological and historical, are the Author’s tools in explaining the phenomenon of political extremism in Serbia, hopefully contributing to its clarification and laying a foundation for its further explanatory theoretical studies.

  16. Converter-controlled belt conveyor systems under the difficult conditions; Umrichtergesteuerte Bandanlagen unter schwierigen Bedingungen

    Energy Technology Data Exchange (ETDEWEB)

    Horz, Michael-Josef [RAG Deutsche Steinkohle, Herne (Germany). Abt. Elektrotechnik unter Tage; Mueller, Uwe [RAG Deutsche Steinkohle, Herne (Germany). Servicebereich Technik- und Logistikdienste

    2010-05-15

    Panel 572 is located at a depth of 1,200 m in the Girondelle seam at the West mine. The panel has a mean thickness of 2.5 m and is designed as a shearer loader face with a length of 460 m. Coal is conveyed to the shaft by six belts with a total length of about 6 km and a total lifting height of 396 m. The main conveyor belt 1 with an installed power of 3 MW links the panel to a bunker. Conveyor belts 2 to 4 each with 500 kW drive power have operated in a stable manner since the start of working of the panel. Due to in-seam drivage with a selective-cut machine of type AM 85 an area with a marked trough was produced in the coal conveyor road. This area is traversed by belt 5. The planning and control of the conveyor belt in this difficult geological environment impose high demands on drive and control technology. To ensure stable operation under different loads a raft of measures was resolved and implemented. The contribution examines the problem and describes the implemented measures in detail. (orig.)

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2012-07-01

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

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

    International Nuclear Information System (INIS)

    Ogata, Daniel Cury; Totsugui, Joel Takashi; Ditzel Filho, Leo Fernando da Silva; Ioshii, Sergio Ossamu; Machuca, Tiago Noguchi; Ogata, Alessandro Cury

    2005-01-01

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

  19. Squint surgery in TED -- hints and fints, or why Graves' patients are difficult patients.

    Science.gov (United States)

    Nardi, M

    2009-01-01

    Endocrine ophthalmopathy is the most common cause of acute onset diplopia in middle aged or older individuals. Ocular muscle involvement is characterized by myositis followed by fibrosis: this causes a stiffness and a shortening of the muscles involved with restriction of ocular movements: so the impairment of rotation is due to a mechanical obstacle and not to a paresis. Prisms are rarely useful in relieving diplopia and the majority of symptomatic patients need squint surgery. Timing of surgery is very important and two considerations are to be kept in mind: first, the systemic disease must be in remission and the ocular deviation must be stable for at least six months; second, if more than one surgical procedure is needed for the ophthalmopathy, muscle surgery has its right place after orbital surgery and before lid surgery. Obviously dealing with restrictive disorders, surgery is based on weakening procedures of the affected muscles: identifying the affected muscles is of crucial importance and may be sometime difficult for the presence of misleading signs; great advances have been made in surgical technique with the development of adjustable sutures and of topical anesthesia. Prognosis is usually good with more than 80% of patients recovering a useful field of binocular single vision with one procedure and more than 90% with two or more procedures.

  20. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency.

    Science.gov (United States)

    Lee, Christopher H; Wira, Charles R

    2009-10-01

    Myxedema coma is the most lethal manifestation of hypothyroidism. It is a true medical emergency and can result in profound hemodynamic instability and airway compromise. Myxedema coma currently remains a diagnostic challenge due to the rarity of cases seen today, and failure to promptly initiate therapy with replacement thyroid hormone can be fatal. As thyroid hormone therapy can take days or weeks to reverse the manifestations of myxedema coma, interim supportive therapy is critical while awaiting clinical improvement. Some patients will require endotracheal intubation in the emergency department (ED), and physicians should be aware that unanticipated posterior pharyngeal edema in myxedema coma could severely complicate airway management. Although mechanical ventilation is a well-described adjunctive therapy for myxedema coma, reports of the potential difficulty in securing a definitive airway in these patients are rare. We describe a case of an unidentified woman who presented to the ED with myxedema coma requiring urgent endotracheal intubation and was found to have extensive posterior pharyngeal angioedema inconsistent with her relatively benign external examination. This case highlights the typical features of myxedema coma and discusses our necessity for a rescue device in definitive endotracheal tube placement. Emergency physicians should anticipate a potentially difficult airway in all myxedema coma patients regardless of the degree of external facial edema present.

  1. Injury due to thorotrast

    International Nuclear Information System (INIS)

    Mori, Takesaburo

    1976-01-01

    A synthetic study was performed on some of those to whom Thorotrast had been injected, in Japan. In the epidemiological study of 147 war woundeds to whom Thorotrast had been injected, it was noted that the Thorotrast injection increased the mortality rate and the incidences of malignant hepatic tumor, liver cirrhosis, and hematological diseases. Clinical study of 44 of them showed that the Thorotrast injection resulted in liver and hematopoietic hypofunctions. Analysis of the dissection of the injected area in 118 cases showed malignant hepatic tumor in 63.5%, liver cirrhosis in 14.4% and hematological diseases in 10.2%. The total of the three types of disease was 88.1%. Histological classification showed that of the malignant hepatic tumors due to Thorotrast, hepatobiliary cancer and hemangioendothelioma of the liver were frequent. By the comparison of the absorbed dose in the liver of the malignant hepatic tumors due to Thorotrast with that of the cancers developed in animal experiments, it was noted that the carcinogenic dose was a mean of 2,000 - 3,000 rad by accumulated dose. It was elucidated that carcinogenesis and fibrination were primary in injury due to Thorotrast, i.e., late injury due to Thorotrast, and that the increase in the accumulated dose in rogans and the increase of the local dose due to the gigantic growth of Thorotrast granules in organs greatly influenced carninogenesis and fibrination. (Chiba, N.)

  2. HIGH PERFORMANCE TAPS FOR CUTTING THREADS IN DIFFICULT TO MACHINE MATERIALS

    Directory of Open Access Journals (Sweden)

    M. R. Akhmedova

    2016-01-01

    Full Text Available Objectives. This article explores in detail questions of instrument operation function of tapping internal threads in hard materials. The existing relationship between vibration system amplitude and tool durability is indicated; on this basis, it is determined that the best course for improving the durability performance is increasing vibratory resistance. Based on a critical analysis of existing designs with consideration of their flaws, the development of new technological designs of taps is tasked with ensuring stable operation when handling hard materials. Methods. It is noteworthy that one of the main vibration resistance improvement methods of the tool is to reduce the contact area of the tool with the work piece in the cutting zone. Methods are proposed for improving the vibration resistance of taps, considering the correlation adjustment of tap teeth in order to completely eliminate friction at the sides of the thread cutting surface and uneven implementation flute cutting steps. Results. The idea of increasing vibration resistance has seen the new development of vibration-proof tap designs, heralded as innovations due to the accuracy of thread cutting and durability achieved by reducing the thread contact area with the work piece in the cutting zone. Increased vibration resistance is achieved in the modified taps through high correction by means of thread side downgrading of the coarse tap cone by an additional angle of 30º. In another design, the stylus provided with uneven angular spacing. Test results of designed taps machined in corrosion-resistant 1Kh18N9T steel. A manifold increase in tool durability was achieved due to its high vibration resistance. Conclusions. The redesigned taps have a number of advantages, characterised by a high resistance when processing difficult materials and an insignificant increase in the complexity of their manufacture compared with standard taps. Therefore they can be recommended for large

  3. Statistical Model of Extreme Shear

    DEFF Research Database (Denmark)

    Larsen, Gunner Chr.; Hansen, Kurt Schaldemose

    2004-01-01

    In order to continue cost-optimisation of modern large wind turbines, it is important to continously increase the knowledge on wind field parameters relevant to design loads. This paper presents a general statistical model that offers site-specific prediction of the probability density function...... by a model that, on a statistically consistent basis, describe the most likely spatial shape of an extreme wind shear event. Predictions from the model have been compared with results from an extreme value data analysis, based on a large number of high-sampled full-scale time series measurements...... are consistent, given the inevitabel uncertainties associated with model as well as with the extreme value data analysis. Keywords: Statistical model, extreme wind conditions, statistical analysis, turbulence, wind loading, statistical analysis, turbulence, wind loading, wind shear, wind turbines....

  4. Racial Extremism in the Army

    National Research Council Canada - National Science Library

    Hudson, Walter M

    1998-01-01

    ... modem phenomenon of "skinheads." I then discuss the history of white supremacist extremism in the Army, culminating in the December, 1995 murders of two black civilians by soldiers assigned to the 82d Airborne Division at Fort Bragg, North Carolina...

  5. Anaphylaxis due to caffeine

    OpenAIRE

    Sugiyama, Kumiya; Cho, Tatsurai; Tatewaki, Masamitsu; Onishi, Shogo; Yokoyama, Tatsuya; Yoshida, Naruo; Fujimatsu, Takayoshi; Hirata, Hirokuni; Fukuda, Takeshi; Fukushima, Yasutsugu

    2015-01-01

    We report a rare case of anaphylaxis due to caffeine intake. A 27-year-old woman suffered her first episode of anaphylaxis and a positive skin prick test suggested that the anaphylaxis was due to an IgE-mediated hypersensitivity reaction to caffeine. She was diagnosed with caffeine allergy and has not had an allergic reaction after avoiding foods and drinks containing caffeine. Although caffeine is known to have antiallergic effects, this case shows that caffeine can be an allergen and cause ...

  6. Interevent Time Distribution of Renewal Point Process, Case Study: Extreme Rainfall in South Sulawesi

    Science.gov (United States)

    Sunusi, Nurtiti

    2018-03-01

    The study of time distribution of occurrences of extreme rain phenomena plays a very important role in the analysis and weather forecast in an area. The timing of extreme rainfall is difficult to predict because its occurrence is random. This paper aims to determine the inter event time distribution of extreme rain events and minimum waiting time until the occurrence of next extreme event through a point process approach. The phenomenon of extreme rain events over a given period of time is following a renewal process in which the time for events is a random variable τ. The distribution of random variable τ is assumed to be a Pareto, Log Normal, and Gamma. To estimate model parameters, a moment method is used. Consider Rt as the time of the last extreme rain event at one location is the time difference since the last extreme rainfall event. if there are no extreme rain events up to t 0, there will be an opportunity for extreme rainfall events at (t 0, t 0 + δt 0). Furthermore from the three models reviewed, the minimum waiting time until the next extreme rainfall will be determined. The result shows that Log Nrmal model is better than Pareto and Gamma model for predicting the next extreme rainfall in South Sulawesi while the Pareto model can not be used.

  7. Global predictability of temperature extremes

    Science.gov (United States)

    Coughlan de Perez, Erin; van Aalst, Maarten; Bischiniotis, Konstantinos; Mason, Simon; Nissan, Hannah; Pappenberger, Florian; Stephens, Elisabeth; Zsoter, Ervin; van den Hurk, Bart

    2018-05-01

    Extreme temperatures are one of the leading causes of death and disease in both developed and developing countries, and heat extremes are projected to rise in many regions. To reduce risk, heatwave plans and cold weather plans have been effectively implemented around the world. However, much of the world’s population is not yet protected by such systems, including many data-scarce but also highly vulnerable regions. In this study, we assess at a global level where such systems have the potential to be effective at reducing risk from temperature extremes, characterizing (1) long-term average occurrence of heatwaves and coldwaves, (2) seasonality of these extremes, and (3) short-term predictability of these extreme events three to ten days in advance. Using both the NOAA and ECMWF weather forecast models, we develop global maps indicating a first approximation of the locations that are likely to benefit from the development of seasonal preparedness plans and/or short-term early warning systems for extreme temperature. The extratropics generally show both short-term skill as well as strong seasonality; in the tropics, most locations do also demonstrate one or both. In fact, almost 5 billion people live in regions that have seasonality and predictability of heatwaves and/or coldwaves. Climate adaptation investments in these regions can take advantage of seasonality and predictability to reduce risks to vulnerable populations.

  8. Incidence and predictors of difficult laryngoscopy in 11,219 pediatric anesthesia procedures.

    Science.gov (United States)

    Heinrich, Sebastian; Birkholz, Torsten; Ihmsen, Harald; Irouschek, Andrea; Ackermann, Andreas; Schmidt, Joachim

    2012-08-01

    Difficult laryngoscopy in pediatric patients undergoing anesthesia. This retrospective analysis was conducted to investigate incidence and predictors of difficult laryngoscopy in a large cohort of pediatric patients receiving general anesthesia with endotracheal intubation. Young age and craniofacial dysmorphy are predictors for the difficult pediatric airway and difficult laryngoscopy. For difficult laryngoscopy, other general predictors are not yet described. Retrospectively, from a 5-year period, data from 11.219 general anesthesia procedures in pediatric patients with endotracheal intubation using age-adapted Macintosh blades in a single center (university hospital) were analyzed statistically. The overall incidence of difficult laryngoscopy [Cormack and Lehane (CML) grade III and IV] was 1.35%. In patients younger than 1 year, the incidence of CML III or IV was significantly higher than in the older patients (4.7% vs 0.7%). ASA Physical Status III and IV, a higher Mallampati Score (III and IV) and a low BMI were all associated (P pediatric anesthesia is lower than in adults. Our results show that the risk of difficult laryngoscopy is much higher in patients below 1 year of age, in underweight patients and in ASA III and IV patients. The underlying disease might also contribute to the risk. If the Mallampati score could be obtained, prediction of difficult laryngoscopy seems to be reliable. Our data support the existing recommendations for a specialized anesthesiological team to provide safe anesthesia for infants and neonates. © 2012 Blackwell Publishing Ltd.

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

    Science.gov (United States)

    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?" and…

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

    DEFF Research Database (Denmark)

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

  11. Between Trauma and Perpetration: Psychoanalytical and Social Psychological Perspectives on Difficult Histories in the Israeli Context

    Science.gov (United States)

    Goldberg, Tsafrir

    2017-01-01

    This study explores the applicability of psychoanalytic trauma-centered perspectives and social psychological intergroup comparison perspectives to difficult histories of the Israeli context. The study describes 2 test cases of difficult histories in the Jewish-Israeli context at the levels of curriculum policy, teachers, and learners. The first…

  12. Difficult Knowledge and the English Classroom: A Catholic Framework Using Cormac McCarthy's "The Road"

    Science.gov (United States)

    Jarvie, Scott; Burke, Kevin

    2015-01-01

    In this article, the authors explore the generative possibilities of risk-taking in the Catholic school English classroom. They associate pedagogical risk with what Deborah Britzman (1998) has called "difficult knowledge"--content that causes students to consider social trauma. Incorporating difficult knowledge meaningfully requires…

  13. Footwear traction and lower extremity noncontact injury.

    Science.gov (United States)

    Wannop, John W; Luo, Geng; Stefanyshyn, Darren J

    2013-11-01

    Football is the most popular high school sport; however, it has the highest rate of injury. Speculation has been prevalent that foot fixation due to high footwear traction contributes to injury risk. Therefore, the purpose of the study was to determine whether a relationship exists between the athlete's specific footwear traction (measured with their own shoes on the field of play) and lower extremity noncontact injury in high school football. For 3 yr, 555 high school football athletes had their footwear traction measured on the actual field of play at the start of the season, and any injury the athletes suffered during a game was recorded. Lower extremity noncontact injury rates, grouped based on the athlete's specific footwear traction (both translational and rotational), were compared. For translational traction, injury rate reached a peak of 23.3 injuries/1000 game exposures within the midrange of translational traction, before decreasing to 5.0 injuries/1000 game exposures in the high range of traction. For rotational traction, there was a steady increase in injury rate as footwear traction increased, starting at 4.2 injuries/1000 game exposures at low traction and reaching 19.2 injuries/1000 game exposures at high traction. A relationship exists between footwear traction and noncontact lower extremity injury, with increases in rotational traction leading to a greater injury rate and increases in translational traction leading to a decrease in injury. It is recommended that athletes consider selecting footwear with the lowest rotational traction values for which no detriment in performance results.

  14. Dynamical properties and extremes of Northern Hemisphere climate fields over the past 60 years

    Directory of Open Access Journals (Sweden)

    D. Faranda

    2017-12-01

    Full Text Available Atmospheric dynamics are described by a set of partial differential equations yielding an infinite-dimensional phase space. However, the actual trajectories followed by the system appear to be constrained to a finite-dimensional phase space, i.e. a strange attractor. The dynamical properties of this attractor are difficult to determine due to the complex nature of atmospheric motions. A first step to simplify the problem is to focus on observables which affect – or are linked to phenomena which affect – human welfare and activities, such as sea-level pressure, 2 m temperature, and precipitation frequency. We make use of recent advances in dynamical systems theory to estimate two instantaneous dynamical properties of the above fields for the Northern Hemisphere: local dimension and persistence. We then use these metrics to characterize the seasonality of the different fields and their interplay. We further analyse the large-scale anomaly patterns corresponding to phase-space extremes – namely time steps at which the fields display extremes in their instantaneous dynamical properties. The analysis is based on the NCEP/NCAR reanalysis data, over the period 1948–2013. The results show that (i despite the high dimensionality of atmospheric dynamics, the Northern Hemisphere sea-level pressure and temperature fields can on average be described by roughly 20 degrees of freedom; (ii the precipitation field has a higher dimensionality; and (iii the seasonal forcing modulates the variability of the dynamical indicators and affects the occurrence of phase-space extremes. We further identify a number of robust correlations between the dynamical properties of the different variables.

  15. Dynamical properties and extremes of Northern Hemisphere climate fields over the past 60 years

    Science.gov (United States)

    Faranda, Davide; Messori, Gabriele; Alvarez-Castro, M. Carmen; Yiou, Pascal

    2017-12-01

    Atmospheric dynamics are described by a set of partial differential equations yielding an infinite-dimensional phase space. However, the actual trajectories followed by the system appear to be constrained to a finite-dimensional phase space, i.e. a strange attractor. The dynamical properties of this attractor are difficult to determine due to the complex nature of atmospheric motions. A first step to simplify the problem is to focus on observables which affect - or are linked to phenomena which affect - human welfare and activities, such as sea-level pressure, 2 m temperature, and precipitation frequency. We make use of recent advances in dynamical systems theory to estimate two instantaneous dynamical properties of the above fields for the Northern Hemisphere: local dimension and persistence. We then use these metrics to characterize the seasonality of the different fields and their interplay. We further analyse the large-scale anomaly patterns corresponding to phase-space extremes - namely time steps at which the fields display extremes in their instantaneous dynamical properties. The analysis is based on the NCEP/NCAR reanalysis data, over the period 1948-2013. The results show that (i) despite the high dimensionality of atmospheric dynamics, the Northern Hemisphere sea-level pressure and temperature fields can on average be described by roughly 20 degrees of freedom; (ii) the precipitation field has a higher dimensionality; and (iii) the seasonal forcing modulates the variability of the dynamical indicators and affects the occurrence of phase-space extremes. We further identify a number of robust correlations between the dynamical properties of the different variables.

  16. Ideologies and Discourses: Extreme Narratives in Extreme Metal Music

    Directory of Open Access Journals (Sweden)

    Bojana Radovanović

    2016-10-01

    Full Text Available Historically speaking, metal music has always been about provoking a strong reaction. Depending on the characteristics of different sub-genres, one can focus on the sound, technique, visual appearance, and furthermore, the ideologies and ideas that are the foundation for each of the sub-genres. Although the majority of the metal community rejects accusations of being racially intolerant, some ideologies of extreme sub-genres (such as black metal are in fact formed around the ideas of self-conscious elitism expressed through interest in pagan mythology, racism, Nazism and fascism. There has been much interest in the Nazi era within the extreme metal scene thus influencing other sub-genres and artists. The aim of this paper is to examine various appearances of extreme narratives such as Nazism and racism in  different sub-genres of metal, bearing in mind variations dependent on geographical, political, and other factors.

  17. Effect of Tracheostomy on Weaning Parameters in Difficult-to-Wean Mechanically Ventilated Patients: A Prospective Observational Study

    Science.gov (United States)

    Lim, Chor-Kuan; Ruan, Sheng-Yuan; Lin, Feng-Ching; Wu, Chao-Ling; Chang, Hou-Tai; Jerng, Jih-Shuin; Wu, Huey-Dong; Yu, Chong-Jen

    2015-01-01

    Background and Objective Weaning parameters are commonly measured through an endotracheal tube in mechanically ventilated patients recovering from acute respiratory failure, however this practice has rarely been evaluated in tracheostomized patients. This study aimed to investigate changes in weaning parameters measured before and after tracheostomy, and to explore whether the data measured after tracheostomy were associated with weaning outcomes in difficult-to-wean patients. Methods In a two-year study period, we enrolled orotracheally intubated patients who were prepared for tracheostomy due to difficult weaning. Weaning parameters were measured before and after the conversion to tracheostomy and compared, and the post-tracheostomy data were tested for associations with weaning outcomes. Results A total of 86 patients were included. After tracheostomy, maximum inspiratory pressure (mean difference (Δ) = 4.4, 95% CI, 2.7 to 6.1, Ptracheostomy than those who were unsuccessfully weaned. Conclusions In conclusion, the conversion from endotracheal tube to tracheostomy significantly improved the measured values of weaning parameters in difficult-to-wean patients who subsequently weaned successfully from the mechanical ventilator. The change was significant only for airway resistance in patients who failed weaning. Trial Registration ClinicalTrials.gov NCT01312142 PMID:26379127

  18. 3D seismic experiment in difficult area in Japan; Kokunai nanchiiki ni okeru sanjigen jishin tansa jikken

    Energy Technology Data Exchange (ETDEWEB)

    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.

  19. 38 CFR 4.58 - Arthritis due to strain.

    Science.gov (United States)

    2010-07-01

    ... 38 Pensions, Bonuses, and Veterans' Relief 1 2010-07-01 2010-07-01 false Arthritis due to strain... FOR RATING DISABILITIES Disability Ratings The Musculoskeletal System § 4.58 Arthritis due to strain. With service incurred lower extremity amputation or shortening, a disabling arthritis, developing in...

  20. Difficult behaviors in the emergency department: a cohort study of housed, homeless and alcohol dependent individuals.

    Directory of Open Access Journals (Sweden)

    Tomislav Svoboda

    Full Text Available This study contrasted annual rates of difficult behaviours in emergency departments among cohorts of individuals who were homeless and low-income housed and examined predictors of these events.Interviews in 1999 with men who were chronically homeless with drinking problems (CHDP (n = 50, men from the general homeless population (GH (n = 61, and men residing in low-income housing (LIH (n = 58 were linked to catchment area emergency department records (n = 2817 from 1994 to 1999. Interview and hospital data were linked to measures of difficult behaviours.Among the CHDP group, annual rates of visits with difficult behaviours were 5.46; this was 13.4 (95% CI 10.3-16.5 and 14.3 (95% CI 11.2-17.3 times higher than the GH and LIH groups. Difficult behaviour incidents included physical violence, verbal abuse, uncooperativeness, drug seeking, difficult histories and security involvement. Difficult behaviours made up 57.54% (95% CI 55.43-59.65%, 24% (95% CI 19-29%, and 20% (95% CI 16-24% of CHDP, GH and LIH visits. Among GH and LIH groups, 87% to 95% were never involved in verbal abuse or violence. Intoxication increased all difficult behaviours while decreasing drug seeking and leaving without being seen. Verbal abuse and violence were less likely among those housed, with odds ratios of 0.24 (0.08, 0.72 and 0.32 (0.15, 0.69, respectively.Violence and difficult behaviours are much higher among chronically homeless men with drinking problems than general homeless and low-income housed populations. They are concentrated among subgroups of individuals. Intoxication is the strongest predictor of difficult behaviour incidents.

  1. Two centuries of extreme events over the Baltic Sea and North Sea regions

    Science.gov (United States)

    Stendel, Martin; den Besselaar Else, van; Abdel, Hannachi; Jaak, Jaagus; Elizabeth, Kent; Christiana, Lefebvre; Gudrun, Rosenhagen; Anna, Rutgersson; Frederik, Schenk; der Schrier Gerard, van; Tim, Woolings

    2017-04-01

    Two centuries of extreme events over the Baltic Sea and North Sea regions In the framework of the BACC 2 (for the Baltic Sea) and NOSCCA projects (for the North Sea region), studies of past and present variability and changes in atmospheric variables within the North Sea region over the instrumental period (roughly the past 200 years) have been investigated. Findings on trends in temperature and precipitation have already been presented. Here we focus on data homogeneity issues and examine how reliable reanalyses are in this context. Unlike most other regions in the world, there is a wealth of old observations available for the Baltic and North Sea regions, most of it in handwritten form in meteorological journals and other publications. These datasets need to be carefully digitised and homogenized. For this, a thorough quality control must be applied; otherwise the digitised datasets may prove useless or even counterproductive. We present evidence that this step cannot be conducted without human interference and thus cannot be fully automated. Furthermore, inhomogeneities due to e.g. instrumentation and station relocations need to be addressed. A wealth of reanalysis products is available, which can help detect such inhomogeneities in observed time series, but at the same time are prone to biases and/or spurious trends themselves e.g. introduced by changes in the availability and quality of the underlying assimilated data. It therefore in general remains unclear in how far we can simulate the pre-satellite era with respect to homogeneity with reanalyses based only on parts of the observing system. Extreme events and changes in extreme situations are more important and of greater (societal) significance than changes in mean climate. However, changes in extreme weather events are difficult to assess not only because they are, per definition, rare events, but also due to the homogeneity issues outlined above. Taking these into account, we present evidence for changes

  2. Allergic contact dermatitis due to highly reactive halogenated compounds

    Energy Technology Data Exchange (ETDEWEB)

    Pickering, F C; Ive, F A

    1983-11-01

    Ten cases of dermatitis in a fine organic chemicals plant are reported. These cases were all due to exposure to chemical compounds with reactive bromine or chlorine atoms. This type of chemical is always extremely irritant, but evidence is put forward to suggest that these cases were the result of allergic sensitization. Chemicals with reactive halogen atoms should always be handled with extreme care and patch testing should be approached with caution.

  3. Seasonal temperature extremes in Potsdam

    Science.gov (United States)

    Kundzewicz, Zbigniew; Huang, Shaochun

    2010-12-01

    The awareness of global warming is well established and results from the observations made on thousands of stations. This paper complements the large-scale results by examining a long time-series of high-quality temperature data from the Secular Meteorological Station in Potsdam, where observation records over the last 117 years, i.e., from January 1893 are available. Tendencies of change in seasonal temperature-related climate extremes are demonstrated. "Cold" extremes have become less frequent and less severe than in the past, while "warm" extremes have become more frequent and more severe. Moreover, the interval of the occurrence of frost has been decreasing, while the interval of the occurrence of hot days has been increasing. However, many changes are not statistically significant, since the variability of temperature indices at the Potsdam station has been very strong.

  4. Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry.

    Science.gov (United States)

    Burjek, Nicholas E; Nishisaki, Akira; Fiadjoe, John E; Adams, H Daniel; Peeples, Kenneth N; Raman, Vidya T; Olomu, Patrick N; Kovatsis, Pete G; Jagannathan, Narasimhan; Hunyady, Agnes; Bosenberg, Adrian; Tham, See; Low, Daniel; Hopkins, Paul; Glover, Chris; Olutoye, Olutoyin; Szmuk, Peter; McCloskey, John; Dalesio, Nicholas; Koka, Rahul; Greenberg, Robert; Watkins, Scott; Patel, Vikram; Reynolds, Paul; Matuszczak, Maria; Jain, Ranu; Khalil, Samia; Polaner, David; Zieg, Jennifer; Szolnoki, Judit; Sathyamoorthy, Kumar; Taicher, Brad; Riveros Perez, N Ricardo; Bhattacharya, Solmaletha; Bhalla, Tarun; Stricker, Paul; Lockman, Justin; Galvez, Jorge; Rehman, Mohamed; Von Ungern-Sternberg, Britta; Sommerfield, David; Soneru, Codruta; Chiao, Franklin; Richtsfeld, Martina; Belani, Kumar; Sarmiento, Lina; Mireles, Sam; Bilen Rosas, Guelay; Park, Raymond; Peyton, James

    2017-09-01

    The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques. Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt. In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.

  5. Use of versapoint to refashion the cervical canal to overcome unusually difficult embryo transfers and improve in-vitro fertilization-embryo transfer outcome: A case series

    Directory of Open Access Journals (Sweden)

    Nalini Mahajan

    2011-01-01

    Full Text Available Background : Smooth atraumatic embryo transfer is paramount for the success of in-vitro fertilization (IVF. In difficult cases, cervical canal manipulation may be required. Aim : To see if surgical correction of the cervical canal or cervical canal refashioning could improve ease of embryo transfer. Setting : Private infertility and IVF hospital. Design : Prospective study. Materials and Methods : Patients: 11 women with failed 1-3 IVF cycles with history of extremely difficult embryo transfers (ETs despite undergoing cervical dilatation in the cycle prior to IVF. Interventions : Operative hysteroscopy using Versapoint for refashioning of the cervical canal. Main Outcome Measures : Ease of ET in the subsequent IVF cycle. Secondary outcome measure was to assess reproductive outcome. Results : Easy and atraumatic ET in the IVF cycle after procedure in 100% patients. PR was 46.5%. Conclusions : Use of Versapoint for refashioning the cervical canal can improve the quality of ET and PR.

  6. Statistical Model of Extreme Shear

    DEFF Research Database (Denmark)

    Hansen, Kurt Schaldemose; Larsen, Gunner Chr.

    2005-01-01

    In order to continue cost-optimisation of modern large wind turbines, it is important to continuously increase the knowledge of wind field parameters relevant to design loads. This paper presents a general statistical model that offers site-specific prediction of the probability density function...... by a model that, on a statistically consistent basis, describes the most likely spatial shape of an extreme wind shear event. Predictions from the model have been compared with results from an extreme value data analysis, based on a large number of full-scale measurements recorded with a high sampling rate...

  7. Automation Rover for Extreme Environments

    Science.gov (United States)

    Sauder, Jonathan; Hilgemann, Evan; Johnson, Michael; Parness, Aaron; Hall, Jeffrey; Kawata, Jessie; Stack, Kathryn

    2017-01-01

    Almost 2,300 years ago the ancient Greeks built the Antikythera automaton. This purely mechanical computer accurately predicted past and future astronomical events long before electronics existed1. Automata have been credibly used for hundreds of years as computers, art pieces, and clocks. However, in the past several decades automata have become less popular as the capabilities of electronics increased, leaving them an unexplored solution for robotic spacecraft. The Automaton Rover for Extreme Environments (AREE) proposes an exciting paradigm shift from electronics to a fully mechanical system, enabling longitudinal exploration of the most extreme environments within the solar system.

  8. Hygienic diagnosis in extreme conditions

    International Nuclear Information System (INIS)

    Sofronov, G.A.

    1997-01-01

    Review for book by M.P. Zakharchenko, S.A. Lopatin, G.N. Novozhilov, V.I. Zakharov Hygienic diagnosis in extreme conditions is presented discussing the problem of people health preservation under extreme conditions. Hygienic diagnosis is considered illustrated by cases of hostilities (Afghan War), earthquake response in Armenia (1988) and Chernobyl accident response. Attention is paid to the estimation of radiation doses to people and characteristics of main types of dosimeters. The high scientific level of the book is marked

  9. Extreme Conditions Modeling Workshop Report

    Energy Technology Data Exchange (ETDEWEB)

    Coe, R. G.; Neary, V. S.; Lawson, M. J.; Yu, Y.; Weber, J.

    2014-07-01

    Sandia National Laboratories (SNL) and the National Renewable Energy Laboratory (NREL) hosted the Wave Energy Converter (WEC) Extreme Conditions Modeling (ECM) Workshop in Albuquerque, NM on May 13th-14th, 2014. The objective of the workshop was to review the current state of knowledge on how to model WECs in extreme conditions (e.g. hurricanes and other large storms) and to suggest how U.S. Department of Energy (DOE) and national laboratory resources could be used to improve ECM methods for the benefit of the wave energy industry.

  10. Sequential algorithm analysis to facilitate selective biliary access for difficult biliary cannulation in ERCP: a prospective clinical study.

    Science.gov (United States)

    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

    2014-02-17

    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. This prospective clinical study enrolled 711 patients with naïve papillae at a tertiary referral center. If wire-guided cannulation was deemed to have failed due to the DBC criteria, then according to the cannulation algorithm early precut fistulotomy (EPF; cannulation time > 5 min, papillary contacts > 5 times, or hook-nose-shaped papilla), double-guidewire cannulation (DGC; unintentional pancreatic duct cannulation ≥ 3 times), and precut after placement of a pancreatic stent (PPS; if DGC was difficult or failed) were performed sequentially. The main outcome measurements were the technical success, procedure outcomes, and complications. Initially, a total of 140 (19.7%) patients with DBC underwent EPF (n = 71) and DGC (n = 69). Then, in DGC group 36 patients switched to PPS due to difficulty criteria. The successful biliary cannulation rate was 97.1% (136/140; 94.4% [67/71] with EPF, 47.8% [33/69] with DGC, and 100% [36/36] with PPS; P EPF, 314.8 (65.2) seconds in DGC, and 706.0 (469.4) seconds in PPS (P EPF, DGC, and PPS may be safe and feasible for DBC. The use of EPF in selected DBC criteria, DGC in unintentional pancreatic duct cannulations, and PPS in failed or difficult DGC may facilitate successful biliary cannulation.

  11. Moving in extreme environments: what's extreme and who decides?

    Science.gov (United States)

    Cotter, James David; Tipton, Michael J

    2014-01-01

    Humans work, rest and play in immensely varied extreme environments. The term 'extreme' typically refers to insufficiency or excess of one or more stressors, such as thermal energy or gravity. Individuals' behavioural and physiological capacity to endure and enjoy such environments varies immensely. Adverse effects of acute exposure to these environments are readily identifiable (e.g. heat stroke or bone fracture), whereas adverse effects of chronic exposure (e.g. stress fractures or osteoporosis) may be as important but much less discernable. Modern societies have increasingly sought to protect people from such stressors and, in that way, minimise their adverse effects. Regulations are thus established, and advice is provided on what is 'acceptable' exposure. Examples include work/rest cycles in the heat, hydration regimes, rates of ascent to and duration of stay at altitude and diving depth. While usually valuable and well intentioned, it is important to realise the breadth and importance of limitations associated with such guidelines. Regulations and advisories leave less room for self-determination, learning and perhaps adaptation. Regulations based on stress (e.g. work/rest cycles relative to WBGT) are more practical but less direct than those based on strain (e.g. core temperature), but even the latter can be substantively limited (e.g. by lack of criterion validation and allowance for behavioural regulation in the research on which they are based). Extreme Physiology & Medicine is publishing a series of reviews aimed at critically examining the issues involved with self- versus regulation-controlled human movement acutely and chronically in extreme environments. These papers, arising from a research symposium in 2013, are about the impact of people engaging in such environments and the effect of rules and guidelines on their safety, enjoyment, autonomy and productivity. The reviews will cover occupational heat stress, sporting heat stress, hydration, diving

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

    LENUS (Irish Health Repository)

    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.

  13. Implications of Age-Related Changes in Anatomy for Geriatric-Focused Difficult Airways

    Directory of Open Access Journals (Sweden)

    Shih-Yi Lee

    2017-09-01

    Full Text Available The structure and function surrounding the airway change by the age, which may ultimately result in having anatomic features of difficult airways in the elderly. Hence, we reviewed the literature focusing on the age-related anatomic changes and accordingly to compare the characteristics of difficult airways. With age, teeth wear and loss, protein and collagen synthesis reduction, and bone loss and muscle atrophy results in aged face (chin protrusion, cheek retraction and drooping, jaw restriction (temporo-madibular joint disc displacement and osteoarthritis, neck and back stiffness, and kyphotic deformities (degeneration of spinal articular cartilage, intervertebral discs, and spinal osteoporosis. These age-related changes in anatomy are compatible with the predictors of a difficult airway. We hope that these age-related anatomic approaches will prospectively allow a detailed understanding of the hallmarks resulting in geriatric-focused difficult airways in the future studies.

  14. Assessment of the Difficult Areas of the Senior Secondary School 2 ...

    African Journals Online (AJOL)

    Assessment of the Difficult Areas of the Senior Secondary School 2 (Two) ... Correlation between the students' perceived difficulty and their achievement in a test and ... Students need counseling, encouragement and enlightenment in order to ...

  15. Difficult Airway Response Team: A Novel Quality Improvement Program for Managing Hospital-Wide Airway Emergencies

    Science.gov (United States)

    Mark, Lynette J.; Herzer, Kurt R.; Cover, Renee; Pandian, Vinciya; Bhatti, Nasir I.; Berkow, Lauren C.; Haut, Elliott R.; Hillel, Alexander T.; Miller, Christina R.; Feller-Kopman, David J.; Schiavi, Adam J.; Xie, Yanjun J.; Lim, Christine; Holzmueller, Christine; Ahmad, Mueen; Thomas, Pradeep; Flint, Paul W.; Mirski, Marek A.

    2015-01-01

    Background Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. Methods We developed a quality improvement program—the Difficult Airway Response Team (DART)—to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had three core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. Results Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index > 40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous

  16. Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.

    Science.gov (United States)

    Mark, Lynette J; Herzer, Kurt R; Cover, Renee; Pandian, Vinciya; Bhatti, Nasir I; Berkow, Lauren C; Haut, Elliott R; Hillel, Alexander T; Miller, Christina R; Feller-Kopman, David J; Schiavi, Adam J; Xie, Yanjun J; Lim, Christine; Holzmueller, Christine; Ahmad, Mueen; Thomas, Pradeep; Flint, Paul W; Mirski, Marek A

    2015-07-01

    Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty

  17. Technical Due Diligence

    DEFF Research Database (Denmark)

    Jensen, Per Anker; Varano, Mattia

    2011-01-01

    carried out for buyers or sellers involved in real estate transactions. It can also be part of mergers including real estate and other assets or part of facilities management outsourcing. This paper is based on a case study and an interview survey of companies involved in TDD consulting in Denmark......Technical Due Diligence (TDD) as an evaluation of the performance of constructed facilities has become an important new field of practice for consultants. Before the financial crisis started in autumn 2008 it represented the fastest growing activity in some consulting companies. TDD is mostly...... and Italy during 2009. The research identifies the current practice and compares it with the recommended practice in international guidelines. The current practice is very diverse and could in many cases be improved by a more structured approach and stricter adherence to international guidelines. However...

  18. Evaluation of Truview evo2® Laryngoscope In Anticipated Difficult Intubation-A Comparison To Macintosh Laryngoscope

    Directory of Open Access Journals (Sweden)

    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.

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

    Directory of Open Access Journals (Sweden)

    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.

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

    Science.gov (United States)

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

    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. PMID:22144932

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

    Directory of Open Access Journals (Sweden)

    Bensghir Mustapha

    2011-01-01

    Full Text Available 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

    International Nuclear Information System (INIS)

    Durante, S; Comoglio, M; Rostagno, M

    2011-01-01

    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. [Correlation between obstructive apnea syndrome and difficult airway in ENT surgery].

    Science.gov (United States)

    Pera, Marcia Hiray; Tardelli, Maria Angela; Novo, Neil Ferreira; Juliano, Yara; Silva, Helga Cristina Almeida da

    2017-12-21

    ENT patients with obstructive sleep apnea syndrome have a tendency of collapsing the upper airways in addition to anatomical obstacles. Obstructive sleep apnea syndrome is related to the increased risk of difficult airway and also increased perioperative complications. In order to identify these patients in the preoperative period, the STOP Bang questionnaire has been highlighted because it is summarized and easy to apply. Evaluate through the STOP Bang questionnaire whether patients undergoing ENT surgery with a diagnosis of obstructive sleep apnea syndrome have a higher risk of complications, particularly the occurrence of difficult airway. Measurements of anatomical parameters for difficult airway and questionnaire application for clinical prediction of obstructive sleep apnea syndrome were performed in 48 patients with a previous polysomnographic study. The sample detected difficult airway in about 18.7% of patients, all of them with obstructive sleep apnea syndrome. This group had older age, cervical circumference > 40cm, ASA II and Cormack III/IV. Patients with obstructive sleep apnea syndrome had higher body mass index, cervical circumference, and frequent apnea. In subgroup analysis, the group with severe obstructive sleep apnea syndrome showed a significantly higher SB score compared to patients without this syndrome or with a mild/moderate obstructive sleep apnea syndrome. The STOP Bang questionnaire was not able to predict difficult airway and mild obstructive sleep apnea syndrome, but it identified marked obstructive sleep apnea syndrome. All patients with difficult airway had moderate and marked obstructive sleep apnea syndrome, although this syndrome did not involve difficult airway. The variables Cormack III/IV and BMI greater than 35 Kg.m -2 were able to predict difficult airway and obstructive sleep apnea syndrome, respectively. Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

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

    International Nuclear Information System (INIS)

    DiMaio, Frank

    2013-01-01

    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

  5. Angiography of the upper extremity

    International Nuclear Information System (INIS)

    Janevski, B.K.

    1982-01-01

    This thesis provides a description of the technical and medical aspects of arteriography of the upper extremity and an extensive analysis of the angiographic anatomy and pathology of 750 selective studies performed in more than 500 patients. A short historical review is provided of angiography as a whole and of arteriography of the hand in particular. The method of percutaneous transfemoral catheterization of the arteries of the upper extremity and particularly the arteries of the hand is considered, discussing the problems the angiographer encounters frequently, describing the angiographic complications which may occur and emphasizing the measures to keep them to a minimum. The use of vasodilators in hand angiography is discussed. A short description of the embryological patterns persisting in the arteries of the arm is included in order to understand the congenital variations of the arteries of the upper extremity. The angiographic patterns and clinical aspects of the most common pathological processes involving the arteries of the upper extremities are presented. Special attention is paid to the correlation between angiography and pathology. (Auth.)

  6. Extreme conditions (p, T, H)

    Energy Technology Data Exchange (ETDEWEB)

    Mesot, J [Lab. for Neutron Scattering ETH Zurich, Zurich (Switzerland) and Paul Scherrer Institute, Villigen (Switzerland)

    1996-11-01

    The aim of this paper is to summarize the sample environment which will be accessible at the SINQ. In order to illustrate the type of experiments which will be feasible under extreme conditions of temperature, magnetic field and pressure at the SINQ a few selected examples are also given. (author) 7 figs., 14 refs.

  7. Book review: Extreme ocean waves

    Science.gov (United States)

    Geist, Eric L.

    2011-01-01

    ‘‘Extreme Ocean Waves’’ is a collection of ten papers edited by Efim Pelinovsky and Christian Kharif that followed the April 2007 meeting of the General Assembly of the European Geosciences Union. A note on terminology: extreme waves in this volume broadly encompass different types of waves, includ- ing deep-water and shallow-water rogue waves (alternatively termed freak waves), storm surges from cyclones, and internal waves. Other types of waves such as tsunamis or rissaga (meteotsunamis) are not discussed in this volume. It is generally implied that ‘‘extreme’’ has a statistical connotation relative to the average or significant wave height specific to each type of wave. Throughout the book, in fact, the reader will find a combination of theoretical and statistical/ empirical treatment necessary for the complete examination of this subject. In the introduction, the editors underscore the importance of studying extreme waves, documenting several dramatic instances of damaging extreme waves that occurred in 2007. 

  8. Extreme Energy Events Monitoring report

    CERN Document Server

    Baimukhamedova, Nigina

    2015-01-01

    Following paper reflects the progress I made on Summer Student Program within Extreme Energy Events Monitor project I was working on. During 8 week period I managed to build a simple detector system that is capable of triggering events similar to explosions (sudden change in sound levels) and measuring approximate location of the event. Source codes are available upon request and settings described further.

  9. Astrobiology: Life in Extreme Environments

    Science.gov (United States)

    Kaur, Preeti

    2011-01-01

    Astrobiology is the study of the origin, evolution and distribution of life in the universe. It seeks to answer two important scientific questions: how did we get here and are we alone in the universe? Scientists begin by studying life on Earth and its limits. The discovery of extremophiles on Earth capable of surviving extremes encourages the…

  10. Extreme weather: Subtropical floods and tropical cyclones

    Science.gov (United States)

    Shaevitz, Daniel A.

    Extreme weather events have a large effect on society. As such, it is important to understand these events and to project how they may change in a future, warmer climate. The aim of this thesis is to develop a deeper understanding of two types of extreme weather events: subtropical floods and tropical cyclones (TCs). In the subtropics, the latitude is high enough that quasi-geostrophic dynamics are at least qualitatively relevant, while low enough that moisture may be abundant and convection strong. Extratropical extreme precipitation events are usually associated with large-scale flow disturbances, strong ascent, and large latent heat release. In the first part of this thesis, I examine the possible triggering of convection by the large-scale dynamics and investigate the coupling between the two. Specifically two examples of extreme precipitation events in the subtropics are analyzed, the 2010 and 2014 floods of India and Pakistan and the 2015 flood of Texas and Oklahoma. I invert the quasi-geostrophic omega equation to decompose the large-scale vertical motion profile to components due to synoptic forcing and diabatic heating. Additionally, I present model results from within the Column Quasi-Geostrophic framework. A single column model and cloud-revolving model are forced with the large-scale forcings (other than large-scale vertical motion) computed from the quasi-geostrophic omega equation with input data from a reanalysis data set, and the large-scale vertical motion is diagnosed interactively with the simulated convection. It is found that convection was triggered primarily by mechanically forced orographic ascent over the Himalayas during the India/Pakistan flood and by upper-level Potential Vorticity disturbances during the Texas/Oklahoma flood. Furthermore, a climate attribution analysis was conducted for the Texas/Oklahoma flood and it is found that anthropogenic climate change was responsible for a small amount of rainfall during the event but the

  11. Central Anticholinergic Syndrome due to Hypoxia-Induced Bradycardia in a Child with Difficult Intubation Undergoing Complete Dental Restoration: A Case Report.

    Directory of Open Access Journals (Sweden)

    Mohamad Gharavifard

    2014-10-01

    Full Text Available Central anticholinergic syndrome (CAS following general anesthesia (GA is a well known syndrome in children and adults. Many cases of CAS have been previously reported in the literature. However, there are only two reports of post resuscitation CAS after administration of small doses of atropine. Hereby, we report a case of CAS in a child undergoing complete dental restoration under GA after receiving a small dose of atropine to reverse hypoxia induced bradycardia. Intraoperative events such as hypoxia or cardiac arrest may play a role as triggers for CAS. However, we cannot establish a causal relationship between the occurrence of CAS and such critical events.

  12. Central Anticholinergic Syndrome due to Hypoxia-Induced Bradycardia in a Child with Difficult Intubation Undergoing Complete Dental Restoration: A Case Report.

    Science.gov (United States)

    Gharavifard, Mohamad; Razavi, Majid; Ghandehari Motlagh, Mehdi; Ziyaeifard, Mohsen

    2014-09-01

    Central anticholinergic syndrome (CAS) following general anesthesia (GA) is a well known syndrome in children and adults. Many cases of CAS have been previously reported in the literature. However, there are only two reports of post resuscitation CAS after administration of small doses of atropine. Hereby, we report a case of CAS in a child undergoing complete dental restoration under GA after receiving a small dose of atropine to reverse hypoxia induced bradycardia. Intraoperative events such as hypoxia or cardiac arrest may play a role as triggers for CAS. However, we cannot establish a causal relationship between the occurrence of CAS and such critical events.

  13. Traumatic oesophageal perforation due to haematoma

    DEFF Research Database (Denmark)

    Grønhøj Larsen, Christian; Brandt, Bodil

    2014-01-01

    . Three explanations postulated to be the cause for late perforation which might be due to esophageal wall ischemia from pressure built up between the hematoma, azygos vein and the lower part of thoracic trachea; or could be an immediate rupture walled-off until the patient became symptomatic......; or the intramural hematoma gradually lysed and causing late perforation. CONCLUSION: Although extremely rare, an oesophageal haematoma and late complications must be considered in patients on anti-coagulant therapy following blunt thoracic trauma and complaining only of chest pain....

  14. Stretch due to Penile Prosthesis Reservoir Migration

    Directory of Open Access Journals (Sweden)

    E. Baten

    2016-03-01

    Full Text Available A 43-year old patient presented to the emergency department with stretch, due to impossible deflation of the penile prosthesis, 4 years after successful implant. A CT-scan showed migration of the reservoir to the left rectus abdominis muscle. Refilling of the reservoir was inhibited by muscular compression, causing stretch. Removal and replacement of the reservoir was performed, after which the prosthesis was well-functioning again. Migration of the penile prosthesis reservoir is extremely rare but can cause several complications, such as stretch.

  15. Malignant bone tumors of the pelvis and of the extremities

    International Nuclear Information System (INIS)

    Gullotta, U.; Reiser, M.; Feuerbach, S.; Biehl, T.; Technische Univ. Muenchen

    1981-01-01

    Bone tumors of the extremities are usually diagnosed by conventional radiography. A good angiogram may render information not only about intra- and extraosseous extension of the tumor, but often also about the biological dignity. CT is usually not necessary, especially since it is sometimes difficult to define the extraosseous borders of these extremity tumors with this method. In bone tumors of the pelvis, however, neither conventional radiography nor angiography render reliable information about the extent of the tumor, which CT is very well able to do. Therefore CT is primarily indicated for evaluation of bone tumors in this region. Angiography is done only for preoperative evaluation of the vascular architecture or for potential therapeutic embolisation. (orig.) [de

  16. Determining extreme parameter correlation in ground water models

    DEFF Research Database (Denmark)

    Hill, Mary Cole; Østerby, Ole

    2003-01-01

    can go undetected even by experienced modelers. Extreme parameter correlation can be detected using parameter correlation coefficients, but their utility depends on the presence of sufficient, but not excessive, numerical imprecision of the sensitivities, such as round-off error. This work...... investigates the information that can be obtained from parameter correlation coefficients in the presence of different levels of numerical imprecision, and compares it to the information provided by an alternative method called the singular value decomposition (SVD). Results suggest that (1) calculated...... correlation coefficients with absolute values that round to 1.00 were good indicators of extreme parameter correlation, but smaller values were not necessarily good indicators of lack of correlation and resulting unique parameter estimates; (2) the SVD may be more difficult to interpret than parameter...

  17. Identification of Climate Change with Generalized Extreme Value (GEV) Distribution Approach

    International Nuclear Information System (INIS)

    Rahayu, Anita

    2013-01-01

    Some events are difficult to avoid and gives considerable influence to humans and the environment is extreme weather and climate change. Many of the problems that require knowledge about the behavior of extreme values and one of the methods used are the Extreme Value Theory (EVT). EVT used to draw up reliable systems in a variety of conditions, so as to minimize the risk of a major disaster. There are two methods for identifying extreme value, Block Maxima with Generalized Extreme Value (GEV) distribution approach and Peaks over Threshold (POT) with Generalized Pareto Distribution (GPD) approach. This research in Indramayu with January 1961-December 2003 period, the method used is Block Maxima with GEV distribution approach. The result showed that there is no climate change in Indramayu with January 1961-December 2003 period.

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

    Directory of Open Access Journals (Sweden)

    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

  19. [Blunt force injuries due to martial arts in children--a diagnostic problem? Delayed diagnosis of an infected hematoma].

    Science.gov (United States)

    Kruppa, C; Goericke, S L; Matheney, T; Ozokyay, L; Schildhauer, T A; Muhr, G; Dudda, M

    2010-10-01

    Blunt force injuries in martial arts occur frequently but isolated hematoma of muscles in the extremities is rare. Even minor trauma of the lower extremities due to throwing techniques in judo and other forms of Asian martial arts can lead to major pathologies. A 9-year-old girl presented with an unclear swelling and soreness of the calf muscle. The patient could not remember an obvious traumatic event. She was admitted 4 days later because of increased swelling, pain and erythema. The parents reported a minor trauma at judo training 1 week ago. Further investigation was performed with MRI and confirmed a massive hematoma much greater than previously shown by sonography. Histologic and microbiologic evaluation demonstrated florid inflammation and proof of Staphylococcus aureus was found intra-operatively. The diagnosis of blunt force injuries due to martial arts is difficult in childhood because often children do not remember a traumatic event. Therefore, it is important to obtain a thorough history from caregivers. Because sonography depends highly on the experience of the investigator MRI is considered to be a better diagnostic modality to diagnose and guide treatment in this age group.

  20. A new extremity dosemeter for beta and gamma radiation

    International Nuclear Information System (INIS)

    Heinzelmann, M.; Pagenkamper, M.

    1988-01-01

    An extremity dosemeter developed at the Juelich Nuclear Research Centre is very well suited for the precise and energy-independent measurement of the skin dose generated by beta or gamma radiation. This is also confirmed by the results of this intercomparison programme. The dosemeter contains three TLDs of LiF in Teflon mounted behind a window of 0.9 mg/cm 2 . The great advantage of this dosemeter is three TLD's enabling statements about the radiation quality. However, the dosemeter has two disadvantages The dosemeter is complicated to manufacture. A very thin plastic foil of 0.9 mg/cm 2 must be attached to a support. This work is difficult and time-consuming and cannot be automated. The window in front of the TLD is not sturdy enough and is occasionally destroyed when the dosemeter is being worn. These two disadvantages prevent this extremity dosemeter from being used more frequently. For this reason, work was begun on developing a new extremity dosemeter without these two disadvantages. The great advantage of the previous dosemeter of obtaining statements about the type of radiation with the aid of readings from three TLD's was to be retained. The improved extremity dosemeter has a more sturdy and thicker window with a similar response as the previous dosemeter with a thinner window

  1. Endotypes of difficult-to-control asthma in inner-city African American children.

    Directory of Open Access Journals (Sweden)

    K R Brown

    Full Text Available African Americans have higher rates of asthma prevalence, morbidity, and mortality in comparison with other racial groups. We sought to characterize endotypes of childhood asthma severity in African American patients in an inner-city pediatric asthma population. Baseline blood neutrophils, blood eosinophils, and 38 serum cytokine levels were measured in a sample of 235 asthmatic children (6-17 years enrolled in the NIAID (National Institute of Allergy and Infectious Diseases-sponsored Asthma Phenotypes in the Inner City (APIC study (ICAC (Inner City Asthma Consortium-19. Cytokines were quantified using a MILLIPLEX panel and analyzed on a Luminex analyzer. Patients were classified as Easy-to-Control or Difficult-to-Control based on the required dose of controller medications over one year of prospective management. A multivariate variable selection procedure was used to select cytokines associated with Difficult-to-Control versus Easy-to-Control asthma, adjusting for age, sex, blood eosinophils, and blood neutrophils. In inner-city African American children, 12 cytokines were significant predictors of Difficult-to-Control asthma (n = 235. CXCL-1, IL-5, IL-8, and IL-17A were positively associated with Difficult-to-Control asthma, while IL-4 and IL-13 were positively associated with Easy-to-Control asthma. Using likelihood ratio testing, it was observed that in addition to blood eosinophils and neutrophils, serum cytokines improved the fit of the model. In an inner-city pediatric population, serum cytokines significantly contributed to the definition of Difficult-to-Control asthma endotypes in African American children. Mixed responses characterized by TH2 (IL-5 and TH17-associated cytokines were associated with Difficult-to-Control asthma. Collectively, these data may contribute to risk stratification of Difficult-to-Control asthma in the African American population.

  2. Difficult incidents and tutor interventions in problem-based learning tutorials.

    Science.gov (United States)

    Kindler, Pawel; Grant, Christopher; Kulla, Steven; Poole, Gary; Godolphin, William

    2009-09-01

    Tutors report difficult incidents and distressing conflicts that adversely affect learning in their problem-based learning (PBL) groups. Faculty development (training) and peer support should help them to manage this. Yet our understanding of these problems and how to deal with them often seems inadequate to help tutors. The aim of this study was to categorise difficult incidents and the interventions that skilled tutors used in response, and to determine the effectiveness of those responses. Thirty experienced and highly rated tutors in our Year 1 and 2 medical curriculum took part in semi-structured interviews to: identify and describe difficult incidents; describe how they responded, and assess the success of each response. Recorded and transcribed data were analysed thematically to develop typologies of difficult incidents and interventions and compare reported success or failure. The 94 reported difficult incidents belonged to the broad categories 'individual student' or 'group dynamics'. Tutors described 142 interventions in response to these difficult incidents, categorised as: (i) tutor intervenes during tutorial; (ii) tutor gives feedback outside tutorial, or (iii) student or group intervenes. Incidents in the 'individual student' category were addressed relatively unsuccessfully (effective 75% of the time) by response (iii). None of the interventions worked well when used in response to problems related to 'group dynamics'. Overall, 59% of the difficult incidents were dealt with successfully. Dysfunctional PBL groups can be highly challenging, even for experienced and skilled tutors. Within-tutorial feedback, the treatment that tutors are most frequently advised to apply, was often not effective. Our study suggests that the collective responsibility of the group, rather than of the tutor, to deal with these difficulties should be emphasised.

  3. Arterial trauma of the extremities. An Ivorian surgical experience ...

    African Journals Online (AJOL)

    ... clinical and surgical experience of the arterial injuries of extremities for 23 years(1977 to ... Their case files have been reviewed and forms the subject of this study ... due to reperfusion injury (1 case) and biliary peritonitis(1 case). Conclusion Arterial injury is a true surgical emergencies and repair should be urgent to avoid ...

  4. Elastic modulus of Extreme Ultraviolet exposed single-layer graphene

    NARCIS (Netherlands)

    Mund, Baibhav Kumar; Gao, An; Sturm, Jacobus Marinus; Lee, Christopher James; Bijkerk, Frederik

    2015-01-01

    Highly transparent membranes are required for a number of applications, such as protective coatings for components in Extreme Ultraviolet (EUV) lithography, beam splitters (EUV pump-probe experiments), transmission gratings, and reticles. Graphene is an excellent candidate due to its high tensile

  5. Extreme climatic events in relation to global change and their impact on life histories

    Directory of Open Access Journals (Sweden)

    Juan MORENO, Anders Pape Møller

    2011-06-01

    Full Text Available Extreme weather conditions occur at an increasing rate as evidenced by higher frequency of hurricanes and more extreme precipitation and temperature anomalies. Such extreme environmental conditions will have important implications for all living organisms through greater frequency of reproductive failure and reduced adult survival. We review examples of reproductive failure and reduced survival related to extreme weather conditions. Phenotypic plasticity may not be sufficient to allow adaptation to extreme weather for many animals. Theory predicts reduced reproductive effort as a response to increased stochasticity. We predict that patterns of natural selection will change towards truncation selection as environmental conditions become more extreme. Such changes in patterns of selection may facilitate adaptation to extreme events. However, effects of selection on reproductive effort are difficult to detect. We present a number of predictions for the effects of extreme weather conditions in need of empirical tests. Finally, we suggest a number of empirical reviews that could improve our ability to judge the effects of extreme environmental conditions on life history [Current Zoology 57 (3: 375–389, 2011].

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

    LENUS (Irish Health Repository)

    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.

  7. Distractor dwelling, skipping, and revisiting determine target absent performance in difficult visual search

    Directory of Open Access Journals (Sweden)

    Gernot Horstmann

    2016-08-01

    Full Text Available Some targets in visual search are more difficult to find than others. In particular, a target that is similar to the distractors is more difficult to find than a target that is dissimilar to the distractors. Efficiency differences between easy and difficult searches are manifest not only in target-present trials but also in target-absent trials. In fact, even physically identical displays are searched through with different efficiency depending on the searched-for target. Here, we monitored eye movements in search for a target similar to the distractors (difficult search versus a target dissimilar to the distractors (easy search. We aimed to examine three hypotheses concerning the causes of differential search efficiencies in target-absent trials: (a distractor dwelling (b distractor skipping, and (c distractor revisiting. Reaction times increased with target similarity which is consistent with existing theories and replicates earlier results. Eye movement data indicated guidance in target trials, even though search was very slow. Dwelling, skipping, and revisiting contributed to low search efficiency in difficult search, with dwelling being the strongest factor. It is argued that differences in dwell time account for a large amount of total search time differences.

  8. Flow cytometry of duodenal intraepithelial lymphocytes improves diagnosis of celiac disease in difficult cases.

    Science.gov (United States)

    Valle, Julio; Morgado, José Mario T; Ruiz-Martín, Juan; Guardiola, Antonio; Lopes-Nogueras, Miriam; García-Vela, Almudena; Martín-Sacristán, Beatriz; Sánchez-Muñoz, Laura

    2017-10-01

    Diagnosis of celiac disease is difficult when the combined results of serology and histology are inconclusive. Studies using flow cytometry of intraepithelial lymphocytes (IELs) have found that celiac patients have increased numbers of γδ IELs, along with a decrease in CD3-CD103 + IELs. The objective of this article is to assess the role of flow cytometric analysis of IELs in the diagnosis of celiac disease in difficult cases. A total of 312 patients with suspicion of celiac disease were included in the study. Duodenal biopsy samples were used for histological assessment and for flow cytometric analysis of IELs. In 46 out of 312 cases (14.7%) the combination of serology and histology did not allow the confirmation or exclusion of celiac disease. HLA typing had been performed in 42 of these difficult cases. Taking into account HLA typing and the response to a gluten-free diet, celiac disease was excluded in 30 of these cases and confirmed in the remaining 12. Flow cytometric analysis of IELs allowed a correct diagnosis in 39 out of 42 difficult cases (92.8%) and had a sensitivity of 91.7% (95% CI: 61.5% to 99.8%) and a specificity of 93.3% (95% CI: 77.9% to 99.2%) for the diagnosis of celiac disease in this setting. Flow cytometric analysis of IELs is useful for the diagnosis of celiac disease in difficult cases.

  9. Distractor Dwelling, Skipping, and Revisiting Determine Target Absent Performance in Difficult Visual Search

    Science.gov (United States)

    Horstmann, Gernot; Herwig, Arvid; Becker, Stefanie I.

    2016-01-01

    Some targets in visual search are more difficult to find than others. In particular, a target that is similar to the distractors is more difficult to find than a target that is dissimilar to the distractors. Efficiency differences between easy and difficult searches are manifest not only in target-present trials but also in target-absent trials. In fact, even physically identical displays are searched through with different efficiency depending on the searched-for target. Here, we monitored eye movements in search for a target similar to the distractors (difficult search) versus a target dissimilar to the distractors (easy search). We aimed to examine three hypotheses concerning the causes of differential search efficiencies in target-absent trials: (a) distractor dwelling (b) distractor skipping, and (c) distractor revisiting. Reaction times increased with target similarity which is consistent with existing theories and replicates earlier results. Eye movement data indicated guidance in target trials, even though search was very slow. Dwelling, skipping, and revisiting contributed to low search efficiency in difficult search, with dwelling being the strongest factor. It is argued that differences in dwell time account for a large amount of total search time differences. PMID:27574510

  10. Pediatric lower extremity mower injuries.

    Science.gov (United States)

    Hill, Sean M; Elwood, Eric T

    2011-09-01

    Lawn mower injuries in children represent an unfortunate common problem to the plastic reconstructive surgeon. There are approximately 68,000 per year reported in the United States. Compounding this problem is the fact that a standard treatment algorithm does not exist. This study follows a series of 7 pediatric patients treated for lower extremity mower injuries by a single plastic surgeon. The extent of soft tissue injury varied. All patients were treated with negative pressure wound therapy as a bridge to definitive closure. Of the 7 patients, 4 required skin grafts, 1 required primary closure, 1 underwent a lower extremity amputation secondary to wounds, and 1 was repaired using a cross-leg flap. Function limitations were minimal for all of our patients after reconstruction. Our basic treatment algorithm is presented with initial debridement followed by the simplest method possible for wound closure using negative pressure wound therapy, if necessary.

  11. Extreme Conditions Modeling Workshop Report

    Energy Technology Data Exchange (ETDEWEB)

    Coe, Ryan Geoffrey [Sandia National Laboratories (SNL-NM), Albuquerque, NM (United States); Neary, Vincent Sinclair [Sandia National Laboratories (SNL-NM), Albuquerque, NM (United States); Lawon, Michael J. [National Renewable Energy Lab. (NREL), Golden, CO (United States); Yu, Yi-Hsiang [National Renewable Energy Lab. (NREL), Golden, CO (United States); Weber, Jochem [National Renewable Energy Lab. (NREL), Golden, CO (United States)

    2014-07-01

    Sandia National Laboratories (SNL) and the National Renewable Energy Laboratory (NREL) hosted the Wave Energy Converter (WEC) Extreme Conditions Modeling (ECM) Workshop in Albuquerque, New Mexico on May 13–14, 2014. The objective of the workshop was to review the current state of knowledge on how to numerically and experimentally model WECs in extreme conditions (e.g. large ocean storms) and to suggest how national laboratory resources could be used to improve ECM methods for the benefit of the wave energy industry. More than 30 U.S. and European WEC experts from industry, academia, and national research institutes attended the workshop, which consisted of presentations from W EC developers, invited keynote presentations from subject matter experts, breakout sessions, and a final plenary session .

  12. Extreme project. Progress report 2006

    International Nuclear Information System (INIS)

    Eyrolle, F.; Masson, O.; Charmasson, S.

    2007-01-01

    The E.X.T.R.E.M.E. project introduced in 2005 to the S.E.S.U.R.E. / L.E.R.C.M. has for objectives to acquire data on the consequences of the extreme climatic meteorological episodes on the distribution of the artificial radioisotopes within the various compartments of the geosphere. This report presents the synthesis of the actions developed in 2006 in positioning and in co financing of the project by means of regional or national research programs (C.A.R.M.A., E.X.T.R.E.M.A., E.C.C.O.R.E.V.I.), of data acquisition, valuation and scientific collaboration. (N.C.)

  13. On causality of extreme events

    Directory of Open Access Journals (Sweden)

    Massimiliano Zanin

    2016-06-01

    Full Text Available Multiple metrics have been developed to detect causality relations between data describing the elements constituting complex systems, all of them considering their evolution through time. Here we propose a metric able to detect causality within static data sets, by analysing how extreme events in one element correspond to the appearance of extreme events in a second one. The metric is able to detect non-linear causalities; to analyse both cross-sectional and longitudinal data sets; and to discriminate between real causalities and correlations caused by confounding factors. We validate the metric through synthetic data, dynamical and chaotic systems, and data representing the human brain activity in a cognitive task. We further show how the proposed metric is able to outperform classical causality metrics, provided non-linear relationships are present and large enough data sets are available.

  14. Extreme Nonlinear Optics An Introduction

    CERN Document Server

    Wegener, Martin

    2005-01-01

    Following the birth of the laser in 1960, the field of "nonlinear optics" rapidly emerged. Today, laser intensities and pulse durations are readily available, for which the concepts and approximations of traditional nonlinear optics no longer apply. In this regime of "extreme nonlinear optics," a large variety of novel and unusual effects arise, for example frequency doubling in inversion symmetric materials or high-harmonic generation in gases, which can lead to attosecond electromagnetic pulses or pulse trains. Other examples of "extreme nonlinear optics" cover diverse areas such as solid-state physics, atomic physics, relativistic free electrons in a vacuum and even the vacuum itself. This book starts with an introduction to the field based primarily on extensions of two famous textbook examples, namely the Lorentz oscillator model and the Drude model. Here the level of sophistication should be accessible to any undergraduate physics student. Many graphical illustrations and examples are given. The followi...

  15. I-Love-Q to the extreme

    Science.gov (United States)

    Silva, Hector O.; Yunes, Nicolás

    2018-01-01

    Certain bulk properties of neutron stars, in particular their moment of inertia, rotational quadrupole moment and tidal Love number, when properly normalized, are related to one another in a nearly equation of state independent way. The goal of this paper is to test these relations with extreme equations of state at supranuclear densities constrained to satisfy only a handful of generic, physically sensible conditions. By requiring that the equation of state be (i) barotropic and (ii) its associated speed of sound be real, we construct a piecewise function that matches a tabulated equation of state at low densities, while matching a stiff equation of state parametrized by its sound speed in the high-density region. We show that the I-Love-Q relations hold to 1 percent with this class of equations of state, even in the extreme case where the speed of sound becomes superluminal and independently of the transition density. We also find further support for the interpretation of the I-Love-Q relations as an emergent symmetry due to the nearly constant eccentricity of isodensity contours inside the star. These results reinforce the robustness of the I-Love-Q relations against our current incomplete picture of physics at supranuclear densities, while strengthening our confidence in the applicability of these relations in neutron star astrophysics.

  16. Impacts of Extreme Events on Human Health. Chapter 4

    Science.gov (United States)

    Bell, Jesse E.; Herring, Stephanie C.; Jantarasami, Lesley; Adrianopoli, Carl; Benedict, Kaitlin; Conlon, Kathryn; Escobar, Vanessa; Hess, Jeremy; Luvall, Jeffrey; Garcia-Pando, Carlos Perez; hide

    2016-01-01

    Increased Exposure to Extreme Events Key Finding 1: Health impacts associated with climate-related changes in exposure to extreme events include death, injury, or illness; exacerbation of underlying medical conditions; and adverse effects on mental health[High Confidence]. Climate change will increase exposure risk in some regions of the United States due to projected increases in the frequency and/or intensity of drought, wildfires, and flooding related to extreme precipitation and hurricanes [Medium Confidence].Disruption of Essential Infrastructure Key Finding 2: Many types of extreme events related to climate change cause disruption of infrastructure, including power, water, transportation, and communication systems, that are essential to maintaining access to health care and emergency response services and safeguarding human health [High Confidence].Vulnerability to Coastal Flooding Key Finding 3: Coastal populations with greater vulnerability to health impacts from coastal flooding include persons with disabilities or other access and functional needs, certain populations of color, older adults, pregnant women and children, low-income populations, and some occupational groups [High Confidence].Climate change will increase exposure risk to coastal flooding due to increases in extreme precipitation and in hurricane intensity and rainfall rates, as well as sea level rise and the resulting increases in storm surge.

  17. Extreme seismicity and disaster risks: Hazard versus vulnerability (Invited)

    Science.gov (United States)

    Ismail-Zadeh, A.

    2013-12-01

    Although the extreme nature of earthquakes has been known for millennia due to the resultant devastation from many of them, the vulnerability of our civilization to extreme seismic events is still growing. It is partly because of the increase in the number of high-risk objects and clustering of populations and infrastructure in the areas prone to seismic hazards. Today an earthquake may affect several hundreds thousand lives and cause significant damage up to hundred billion dollars; it can trigger an ecological catastrophe if occurs in close vicinity to a nuclear power plant. Two types of extreme natural events can be distinguished: (i) large magnitude low probability events, and (ii) the events leading to disasters. Although the first-type events may affect earthquake-prone countries directly or indirectly (as tsunamis, landslides etc.), the second-type events occur mainly in economically less-developed countries where the vulnerability is high and the resilience is low. Although earthquake hazards cannot be reduced, vulnerability to extreme events can be diminished by monitoring human systems and by relevant laws preventing an increase in vulnerability. Significant new knowledge should be gained on extreme seismicity through observations, monitoring, analysis, modeling, comprehensive hazard assessment, prediction, and interpretations to assist in disaster risk analysis. The advanced disaster risk communication skill should be developed to link scientists, emergency management authorities, and the public. Natural, social, economic, and political reasons leading to disasters due to earthquakes will be discussed.

  18. Promoting Exit from Violent Extremism

    DEFF Research Database (Denmark)

    Dalgaard-Nielsen, Anja

    2013-01-01

    A number of Western countries are currently adding exit programs targeting militant Islamists to their counterterrorism efforts. Drawing on research into voluntary exit from violent extremism, this article identifies themes and issues that seem to cause doubt, leading to exit. It then provides a ...... the influence attempt as subtle as possible, use narratives and self-affirmatory strategies to reduce resistance to persuasion, and consider the possibility to promote attitudinal change via behavioral change as an alternative to seek to influence beliefs directly....

  19. Racial Extremism in the Army

    Science.gov (United States)

    1998-04-01

    of Deference ...................................................................................................... 46 1. The Separation of Powers Doctrine...to the military. This deference has a two-fold basis. First, the separation of powers in the U.S. Constitution gives authority to the executive (and...Why should there be judicial deference to the Army’s policy on extremism? There are two principal reasons. First, the Constitution’s separation of powers doctrine

  20. Large Extremity Peripheral Nerve Repair

    Science.gov (United States)

    2016-12-01

    LM, de Crombrugghe B. Some recent advances in the chemistry and biology of trans- forming growth factor-beta. J Cell Biol 1987;105:1039e45. 12. Hao Y...SUPPLEMENTARY NOTES 14. ABSTRACT In current war trauma, 20-30% of all extremity injuries and >80% of penetrating injuries being associated with peripheral nerve...through both axonal advance and in revascularization of the graft following placement. We are confident that this technology may allow us to

  1. Prediction of survival after surgery due to skeletal metastases in the extremities

    DEFF Research Database (Denmark)

    Sørensen, M S; Gerds, T A; Hindsø, K

    2016-01-01

    metastases and American Society of Anaesthesiologist's score were included into a series of logistic regression models. The outcome was the survival status at three, six and 12 months respectively. Results were internally validated based on 1000 cross-validations and reported as time-dependent area under...

  2. Extreme scenarios: the tightest possible constraints on the power spectrum due to primordial black holes

    Science.gov (United States)

    Cole, Philippa S.; Byrnes, Christian T.

    2018-02-01

    Observational constraints on the abundance of primordial black holes (PBHs) constrain the allowed amplitude of the primordial power spectrum on both the smallest and the largest ranges of scales, covering over 20 decades from 1‑1020/ Mpc. Despite tight constraints on the allowed fraction of PBHs at their time of formation near horizon entry in the early Universe, the corresponding constraints on the primordial power spectrum are quite weak, typically Script PRlesssim 10‑2 assuming Gaussian perturbations. Motivated by recent claims that the evaporation of just one PBH would destabilise the Higgs vacuum and collapse the Universe, we calculate the constraints which follow from assuming there are zero PBHs within the observable Universe. Even if evaporating PBHs do not collapse the Universe, this scenario represents the ultimate limit of observational constraints. Constraints can be extended on to smaller scales right down to the horizon scale at the end of inflation, but where power spectrum constraints already exist they do not tighten significantly, even though the constraint on PBH abundance can decrease by up to 46 orders of magnitude. This shows that no future improvement in observational constraints can ever lead to a significant tightening in constraints on inflation (via the power spectrum amplitude). The power spectrum constraints are weak because an order unity perturbation is required in order to overcome pressure forces. We therefore consider an early matter dominated era, during which exponentially more PBHs form for the same initial conditions. We show this leads to far tighter constraints, which approach Script PRlesssim10‑9, albeit over a smaller range of scales and are very sensitive to when the early matter dominated era ends. Finally, we show that an extended early matter era is incompatible with the argument that an evaporating PBH would destroy the Universe, unless the power spectrum amplitude decreases by up to ten orders of magnitude.

  3. Reviewing Hit Discovery Literature for Difficult Targets: Glutathione Transferase Omega-1 as an Example.

    Science.gov (United States)

    Xie, Yiyue; Dahlin, Jayme L; Oakley, Aaron J; Casarotto, Marco G; Board, Philip G; Baell, Jonathan B

    2018-05-10

    Early stage drug discovery reporting on relatively new or difficult targets is often associated with insufficient hit triage. Literature reviews of such targets seldom delve into the detail required to critically analyze the associated screening hits reported. Here we take the enzyme glutathione transferase omega-1 (GSTO1-1) as an example of a relatively difficult target and review the associated literature involving small-molecule inhibitors. As part of this process we deliberately pay closer-than-usual attention to assay interference and hit quality aspects. We believe this Perspective will be a useful guide for future development of GSTO1-1 inhibitors, as well serving as a template for future review formats of new or difficult targets.

  4. The primary study of fistulae isolation for difficult-cured traumatic carotid cavernous by two accesses

    International Nuclear Information System (INIS)

    Wang Ziliang; Li Tianxiao; Zhai Shuiting; Cao Huicun; Xu Jiangyu; Bai Weixing; Liu Jian

    2007-01-01

    Objective: To investigate the feasibility and security of the isolation of fistulae for difficult-cured traumatic carotid cavernous by the anterio or inferior communicating artery. Methods: Five patients with difficult-cured TCCF including four males and one female. They were cathetered by both femoral arteries. Balloon-catheter directly attached to the near of fistulae and microcatheter conversely attached to the far of fistulae. Detachable balloons and micro coils were used to isolated the fistulae. Results: Five patients were cured with fistulae isolation and angiography did not show remnants fistulae in time. Clinical signs and symptoms got better and better. During follows-up no one recurred. Conclusions: The isolation of fistulae is a feasible and secure therapy for the difficult-cured traumatic direct carotid cavernous fistulae. (authors)

  5. Treatment of psychological factors in a child with difficult asthma: a case report.

    Science.gov (United States)

    Anbar, Ran D; Sachdeva, Shagun

    2011-07-01

    Difficult asthma is defined as the persistence of asthma symptoms, abnormal pulmonary function showing airway obstruction, and continued requirement for short-acting bronchodilator therapy, despite adequate treatment with inhaled corticosteroids. It calls for a thorough evaluation of the patient to look into alternate and complicating diagnoses. The authors report a case of a 9-year-old patient with difficult asthma who failed to respond to conventional therapy. Although it was recognized that he had a number of potential medical complicating factors including allergies, chronic sinusitis, and gastroesophageal reflux, a psychological intervention using hypnosis ultimately appeared to help alleviate his symptoms completely. Thus, psychological evaluation and intervention should be considered early in the course of management of a patient with difficult asthma, because it may help avoid time-consuming and expensive investigations of potential complicating factors, and it may yield rapid improvement in the patient's clinical condition.

  6. The "difficult" patient reconceived: an expanded moral mandate for clinical ethics.

    Science.gov (United States)

    Fiester, Autumn

    2012-01-01

    Between 15 and 60% of patients are considered "difficult" by their treating physicians. Patient psychiatric pathology is the conventional explanation for why patients are deemed "difficult." But the prevalence of the problem suggests the possibility of a less pathological cause. I argue that the phenomenon can be better explained as a response to problematic interactions related to health care delivery. If there are grounds to reconceive the "difficult" patient as reacting to the perception of ill treatment, then there is an ethical obligation to address this perception of harm. Resolution of such conflicts currently lies with the provider and patient. But the ethical stakes place these conflicts into the province of the ethics consult service. As the resource for addressing ethical dilemmas, there is a moral mandate to offer assistance in the resolution of these ethically charged conflicts that is no less pressing than the more familiar terrain of clinical ethics consultation.

  7. Typologies of extreme longevity myths.

    Science.gov (United States)

    Young, Robert D; Desjardins, Bertrand; McLaughlin, Kirsten; Poulain, Michel; Perls, Thomas T

    2010-01-01

    Purpose. Political, national, religious, and other motivations have led the media and even scientists to errantly accept extreme longevity claims prima facie. We describe various causes of false claims of extraordinary longevity. Design and Methods. American Social Security Death Index files for the period 1980-2009 were queried for individuals with birth and death dates yielding ages 110+ years of age. Frequency was compared to a list of age-validated supercentenarians maintained by the Gerontology Research Group who died during the same time period. Age claims of 110+ years and the age validation experiences of the authors facilitated a list of typologies of false age claims. Results. Invalid age claim rates increase with age from 65% at age 110-111 to 98% by age 115 to 100% for 120+ years. Eleven typologies of false claims were: Religious Authority Myth, Village Elder Myth, Fountain of Youth Myth (substance), Shangri-La Myth (geographic), Nationalist Pride, Spiritual Practice, Familial Longevity, Individual and/or Family Notoriety, Military Service, Administrative Entry Error, and Pension-Social Entitlement Fraud. Conclusions. Understanding various causes of false extreme age claims is important for placing current, past, and future extreme longevity claims in context and for providing a necessary level of skepticism.

  8. Moderate and extreme maternal obesity.

    LENUS (Irish Health Repository)

    Abdelmaboud, M O

    2012-05-01

    The aim of this study was to investigate the prevalence of moderate and extreme obesity among an Irish obstetric population over a 10-year period, and to evaluate the obstetric features of such pregnancies. Of 31,869 women delivered during the years 2000-2009, there were 306 women in the study group, including 173 in the moderate or Class 2 obese category (BMI 35-39.9) and 133 in the extreme or Class 3 obese category (BMI > or = 40).The prevalence of obese women with BMI > or = 35 was 9.6 per 1000 (0.96%), with an upward trend observed from 2.1 per 1000 in the year 2000, to 11.8 per 1000 in the year 2009 (P = 0.001). There was an increase in emergency caesarean section (EMCS) risk for primigravida versus multigravid women, within both obese categories (P < 0.001). However, there was no significant difference in EMCS rates observed between Class 2 and Class 3 obese women, when matched for parity. The prevalence of moderate and extreme obesity reported in this population is high, and appears to be increasing. The increased rates of abdominal delivery, and the levels of associated morbidity observed, have serious implications for such women embarking on pregnancy.

  9. Attribution of climate extreme events

    Science.gov (United States)

    Trenberth, Kevin E.; Fasullo, John T.; Shepherd, Theodore G.

    2015-08-01

    There is a tremendous desire to attribute causes to weather and climate events that is often challenging from a physical standpoint. Headlines attributing an event solely to either human-induced climate change or natural variability can be misleading when both are invariably in play. The conventional attribution framework struggles with dynamically driven extremes because of the small signal-to-noise ratios and often uncertain nature of the forced changes. Here, we suggest that a different framing is desirable, which asks why such extremes unfold the way they do. Specifically, we suggest that it is more useful to regard the extreme circulation regime or weather event as being largely unaffected by climate change, and question whether known changes in the climate system's thermodynamic state affected the impact of the particular event. Some examples briefly illustrated include 'snowmaggedon' in February 2010, superstorm Sandy in October 2012 and supertyphoon Haiyan in November 2013, and, in more detail, the Boulder floods of September 2013, all of which were influenced by high sea surface temperatures that had a discernible human component.

  10. Typologies of Extreme Longevity Myths

    Directory of Open Access Journals (Sweden)

    Robert D. Young

    2010-01-01

    Full Text Available Purpose. Political, national, religious, and other motivations have led the media and even scientists to errantly accept extreme longevity claims prima facie. We describe various causes of false claims of extraordinary longevity. Design and Methods. American Social Security Death Index files for the period 1980–2009 were queried for individuals with birth and death dates yielding ages 110+ years of age. Frequency was compared to a list of age-validated supercentenarians maintained by the Gerontology Research Group who died during the same time period. Age claims of 110+ years and the age validation experiences of the authors facilitated a list of typologies of false age claims. Results. Invalid age claim rates increase with age from 65% at age 110-111 to 98% by age 115 to 100% for 120+ years. Eleven typologies of false claims were: Religious Authority Myth, Village Elder Myth, Fountain of Youth Myth (substance, Shangri-La Myth (geographic, Nationalist Pride, Spiritual Practice, Familial Longevity, Individual and/or Family Notoriety, Military Service, Administrative Entry Error, and Pension-Social Entitlement Fraud. Conclusions. Understanding various causes of false extreme age claims is important for placing current, past, and future extreme longevity claims in context and for providing a necessary level of skepticism.

  11. Predictability and possible earlier awareness of extreme precipitation across Europe

    Science.gov (United States)

    Lavers, David; Pappenberger, Florian; Richardson, David; Zsoter, Ervin

    2017-04-01

    Extreme hydrological events can cause large socioeconomic damages in Europe. In winter, a large proportion of these flood episodes are associated with atmospheric rivers, a region of intense water vapour transport within the warm sector of extratropical cyclones. When preparing for such extreme events, forecasts of precipitation from numerical weather prediction models or river discharge forecasts from hydrological models are generally used. Given the strong link between water vapour transport (integrated vapour transport IVT) and heavy precipitation, it is possible that IVT could be used to warn of extreme events. Furthermore, as IVT is located in extratropical cyclones, it is hypothesized to be a more predictable variable due to its link with synoptic-scale atmospheric dynamics. In this research, we firstly provide an overview of the predictability of IVT and precipitation forecasts, and secondly introduce and evaluate the ECMWF Extreme Forecast Index (EFI) for IVT. The EFI is a tool that has been developed to evaluate how ensemble forecasts differ from the model climate, thus revealing the extremeness of the forecast. The ability of the IVT EFI to capture extreme precipitation across Europe during winter 2013/14, 2014/15, and 2015/16 is presented. The results show that the IVT EFI is more capable than the precipitation EFI of identifying extreme precipitation in forecast week 2 during forecasts initialized in a positive North Atlantic Oscillation (NAO) phase. However, the precipitation EFI is superior during the negative NAO phase and at shorter lead times. An IVT EFI example is shown for storm Desmond in December 2015 highlighting its potential to identify upcoming hydrometeorological extremes.

  12. Energy, entropy, environment: Why is protection of the environment objectively difficult?

    Energy Technology Data Exchange (ETDEWEB)

    Rebane, Karl K [Institute of Physics, Tartu (Estonia)

    1995-05-01

    Evolution and man`s history indicate that the winners are the species and societies that act faster and consume more high-quality energy and materials: in other words, those which cause more pollution and faster growth of entropy. This could be the reason why protection of the environment is objectively difficult and, in particular, why it is almost impossible to considerably reduce man`s consumption of energy and materials in a world of competition. To escape this fatal evolutionary outcome, fundamentally new thinking is needed, thinking which takes the survival of mankind as the primary value. The role of religion in solving this tremendously difficult task should not be neglected

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

    CERN Document Server

    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

  14. The importance of subjective facial appearance on the ability of anesthesiologists to predict difficult intubation.

    Science.gov (United States)

    Connor, Christopher W; Segal, Scott

    2014-02-01

    Previously we demonstrated that a computer algorithm based on bedside airway examinations and facial photographs accurately classified easy and difficult airways. The extent of the ability of anesthesiologists to perform the same task is unknown. We hypothesized that providing photographs would add to the predictive ability of anesthesiologists over that achieved when provided only with the Mallampati (MP) score and the thyromental distance (TMD). We further hypothesized that human observers would implicitly bias their predictions toward more sensitive determination of difficult airways, rather than more specific determination of easy airways. Residents, fellows, and attending anesthesiologists with varying levels of experience (N = 160) were presented with MP and TMD information from 80 Caucasian men subjects. The same subjects' data, accompanied by 3 facial photographs in head-on and right and left profiles, were also presented. Anesthesiologists classified the airways as easy or difficult according to specified criteria ("easy" defined as a single attempt with a Macintosh 3 blade resulting in a grade 1 laryngoscopic view; "difficult" defined as >1 attempt by an operator with at least 12 months anesthesia experience, grade 3 or 4 laryngoscopic view, need for a second operator, or nonelective use of an alternative airway device). Accuracy, sensitivity, and specificity were calculated for each anesthesiologist. We further developed a cost function to quantify a relative bias toward avoiding an unexpectedly difficult intubation versus overpreparing for an easy intubation. One hundred sixty respondents completed the study. Presenting photographs improved respondents' sensitivity and accuracy in classifying airways, though specificity decreased slightly. Overall accuracy when given photographs was 61.6% (95% confidence interval, 60.8%-62.4%), which was significantly lower than the computer's performance of 87.5% (t test, P interval, 4.9:1-8.4:1). Anesthesiologists can

  15. High levels of IGF-1 predict difficult intubation of patients with acromegaly.

    Science.gov (United States)

    Zhang, Yu; Guo, Xiaopeng; Pei, Lijian; Zhang, Zhuhua; Tan, Gang; Xing, Bing

    2017-08-01

    To investigate the characteristics of difficult intubation and identify novel efficient predictors in patients with acromegaly. Patients with either untreated acromegaly or non-functional pituitary adenomas were enrolled. Patients with acromegaly underwent hormone assays, upper airway computed tomography and magnetic resonance imaging examinations and preoperative overnight polysomnography. The modified Mallampati classification, mouth opening, neck circumference, and neck extension were assessed, and the Cormack-Lehane grades and the time of tracheal intubation were recorded. Patients with acromegaly had a higher incidence of difficult intubation (62.5%). The time of tracheal intubation was prolonged, the neck circumference was enlarged, and the neck extension was confined. In patients with acromegaly and difficult intubation, the insulin-like growth factor 1 levels and apnea/hypoxia index were significantly higher compared to patients without difficult intubation (1115.40 ± 253.73 vs. 791.67 ± 206.62 ng/ml, P = 0.020; 22.17 ± 23.25 vs. 2.47 ± 2.84, P = 0.026, respectively). The bilateral regression analysis revealed that high levels of insulin-like growth factor 1 were an independent risk factor for developing difficult intubation (p = 0.042, Exp B = 1.006). The modified Mallampati classification was positively correlated with apnea/hypoxia index and could be calculated using the following logarithmic equation: MMC = 0.2982 * ln (AHI) + 2.1836. In patients with acromegaly, neck movement is confined, the time of tracheal intubation is prolonged, and the neck circumference is enlarged, and these patients suffer from an increased incidence of difficult intubation (62.5%) during anesthesia induction. The apnea/hypoxia index and insulin-like growth factor 1 levels are both increased in acromegalic patients with difficult intubation, and elevated insulin-like growth factor 1 levels are an independent risk factor of difficult

  16. Assessment of the storz video Macintosh laryngoscope for use in difficult airways: A human simulator study.

    Science.gov (United States)

    Bair, Aaron E; Olmsted, Kalani; Brown, Calvin A; Barker, Tobias; Pallin, Daniel; Walls, Ron M

    2010-10-01

    Video laryngoscopy has been shown to improve glottic exposure when compared to direct laryngoscopy in operating room studies. However, its utility in the hands of emergency physicians (EPs) remains undefined. A simulated difficult airway was used to determine if intubation by EPs using a video Macintosh system resulted in an improved glottic view, was easier, was faster, or was more successful than conventional direct laryngoscopy. Emergency medicine (EM) residents and attending physicians at two academic institutions performed endotracheal intubation in one normal and two identical difficult airway scenarios. With the difficult scenarios, the participants used video laryngoscopy during the second case. Intubations were performed on a medium-fidelity human simulator. The difficult scenario was created by limiting cervical spine mobility and inducing trismus. The primary outcome was the proportion of direct versus video intubations with a grade I or II Cormack-Lehane glottic view. Ease of intubation (self-reported via 10-cm visual analog scale [VAS]), time to intubation, and success rate were also recorded. Descriptive statistics as well as medians with interquartile ranges (IQRs) are reported where appropriate. The Wilcoxon matched pairs signed-rank test was used for comparison testing of nonparametric data. Participants (n = 39) were residents (59%) and faculty. All had human intubation experience; 51% reported more than 100 prior intubations. On difficult laryngoscopy, a Cormack-Lehane grade I or II view was obtained in 20 (51%) direct laryngoscopies versus 38 (97%) of the video-assisted laryngoscopies (p < 0.01). The median VAS score for difficult airways was 50 mm (IQR = 28–73 mm) for direct versus 18 mm (IQR = 9–50 mm) for video (p < 0.01). The median time to intubation in difficult airways was 25 seconds (IQR = 16–44 seconds) for direct versus 20 seconds (IQR = 12–35 seconds) for video laryngoscopy (p < 0.01). All intubations were successful without

  17. Extreme pressure differences at 0900 NZST and winds across New Zealand

    Science.gov (United States)

    Salinger, M. James; Griffiths, Georgina M.; Gosai, Ashmita

    2005-07-01

    Trends in extremes in station daily sea-level pressure differences at 0900 NZST are examined, and extreme daily wind gusts, across New Zealand, since the 1960s. Annual time series were examined (with indices of magnitude and frequency over threshold percentiles) from the daily indices selected. These follow from earlier indices of normalized monthly mean sea-level pressure differences between station pairs, except the daily indices are not normalized. The frequency statistics quantify the number of extreme zonal (westerly and easterly), or extreme meridional (southerly or northerly), pressure gradient events. The frequency and magnitude of extreme westerly episodes has increased slightly over New Zealand, with a significant increase in the westerly extremes to the south of New Zealand. In contrast, the magnitude and frequency of easterly extremes has decreased over New Zealand, but increased to the south, with some trends weakly significant. The frequency and magnitude of daily southerly extremes has decreased significantly in the region.Extreme daily wind gust events at key climate stations in New Zealand and at Hobart, Australia, are highly likely to be associated with an extreme daily pressure difference. The converse was less likely to hold: extreme wind gusts were not always observed on days with extreme daily pressure difference, probably due to the strong influence that topography has on localized station winds. Significant correlations exist between the frequency indices and both annual-average mean sea-level pressures around the Australasian region and annual-average sea surface temperature (SST) anomalies in the Southern Hemisphere. These correlations are generally stronger for indices of extreme westerly or extreme southerly airflows. Annual-average pressures in the Tasman Sea or Southern Ocean are highly correlated to zonal indices (frequency of extreme westerlies). SST anomalies in the NINO3 region or on either side of the South Island are

  18. Production processes at extremely high energies

    CERN Document Server

    Gastmans, R; Wu, Tai Tsun

    2013-01-01

    The production processes are identified that contribute to the rise of the total cross section in proton-proton scattering at extremely high energies, s->~. At such energies, the scattering can be described by a black disk (completely absorptive) with a radius expanding logarithmically with energy surrounded by a gray fringe (partially absorptive). For the leading term of (lns)^2 in the increasing total cross section, the gray fringe is neglected, and geometrical optics is generalized to production processes. It is known that half of the rise in the total cross section is due to elastic scattering. The other half is found to originate from the production of jets with relatively small momenta in the center-of-mass system.

  19. Extreme scenarios for nuclear waste repositories

    Energy Technology Data Exchange (ETDEWEB)

    Brown, M J [Harvard Univ., Cambridge, MA (USA). Div. of Applied Sciences; Crouch, E [Harvard Univ., Cambridge, MA (USA). Energy and Environmental Policy Center

    1982-09-01

    Two extreme scenarios for release of radioactive waste have been constructed. In the first, a volcanic eruption releases 1 km/sup 2/ of an underground nuclear waste repository, while in the second, waste enters the drinking water reservoir of a major city. With pessimistic assumptions, upper bounds on the number of cancers due to radiation are calculated. In the volcano scenario, the effects of the waste are smaller than the effects of natural radioactivity in the volcanic dust if the delay between emplacement and eruption exceeds 2000 yr. The consequences of the waste in drinking water depend on the survival time of the canisters and the rate of leaching of the nuclides from the waste matrix. For a canister life of 400 yr and a leach time of 6300 yr the cancer rate in the affected area would increase by 25%.

  20. Extreme scenarios for nuclear waste repositories

    Energy Technology Data Exchange (ETDEWEB)

    Brown, M J; Crouch, E

    1982-09-01

    Two extreme scenarios for release of radioactive waste have been constructed. In the first, a volcanic eruption releases 1 km2 of an underground nuclear waste repository, while in the second, waste enters the drinking water reservoir of a major city. With pessimistic assumptions, upper bounds on the number of cancers due to radiation are calculated. In the volcano scenario, the effects of the water are smaller than the effects of natural radioactivity in the volcanic dust if the delay between emplacement and eruption exceeds 2000 yr. The consequences of the waste in drinking water depend on the survival time of the canisters and the rate of leaching of the nuclides from the waste matrix. For a canister life of 400 yr and a leach time of 6300 yr the cancer rate in the affected area would increase by 25%.

  1. Prospect for extreme field science

    Energy Technology Data Exchange (ETDEWEB)

    Tajima, T. [Ludwig Maximilian Univ. and Max Planck Institute for Quantum Optics, Garching (Germany); Japan Atomic Energy Agency, Kyoto and KEK, Tsukuba (Japan)

    2009-11-15

    The kind of laser extreme light infrastructure (ELI) provides will usher in a class of experiments we have only dreamed of for years. The characteristics that ELI brings in include: the highest intensity ever, large fluence, and relatively high repetition rate. A personal view of the author on the prospect of harnessing this unprecedented opportunity for advancing science of extreme fields is presented. The first characteristic of ELI, its intensity, will allow us to access, as many have stressed already, extreme fields that hover around the Schwinger field or at the very least the neighboring fields in which vacuum begins to behave as a nonlinear medium. In this sense, we are seriously probing the 'material' property of vacuum and thus the property that theory of relativity itself described and will entail. We will probe both special theory and general theory of relativity in regimes that have been never tested so far. We may see a glimpse into the reach of relativity or even its breakdown in some extreme regimes. We will learn Einstein and may even go beyond Einstein, if our journey is led. Laser-driven acceleration both by the laser field itself and by the wakefield that is triggered in a plasma is huge. Energies, if not luminosity, we can access, may be unprecedented going far beyond TeV. The nice thing about ELI is that it has relatively high repetition rate and average fluence as compared with other extreme lasers. This high fluence can be a key element that leads to applications to high energy physics, such as gamma-gamma collider driver experiment, and some gamma ray experiments that may be relevant in the frontier of photo-nuclear physics, and atomic energy applications. Needless to say, high fluence is one of most important features that industrial and medical applications may need. If we are lucky, we may see a door opens at the frontier of novel physics that may not be available by any other means. (authors)

  2. The distribution of urate deposition within the extremities in gout: a review of 148 dual-energy CT cases

    International Nuclear Information System (INIS)

    Mallinson, Paul I.; Reagan, Adrian C.; Munk, Peter L.; Ouellette, Hugue; Nicolaou, Savvas; Coupal, Tyler

    2014-01-01

    Clinical detection of gout can be difficult due to co-existent and mimicking arthropathies and asymptomatic disease. Understanding of the distribution of urate within the body can aid clinical diagnosis and further understanding of the resulting pathology. Our aim was to determine this distribution of urate within the extremities in patients with gout. All patients who underwent a four-limb dual-energy computed tomography (DECT) scan for suspected gout over a 2-year period were identified (n = 148, 121 male, 27 female, age range, 16-92 years, mean = 61.3 years, median = 63 years). The reports of the positive cases were retrospectively analyzed and the locations of all urate deposition recorded and classified by anatomical location. A total of 241 cases met the inclusion criteria, of which 148 cases were positive. Of these, 101 (68.2 %) patients had gout in the foot, 81 (56.1 %) in the knee, 79 (53.4 %) in the ankle, 41 (27.7 %) in the elbow, 25 (16.9 %) in the hand, and 25 (16.9 %) in the wrist. The distribution was further subcategorized for each body part into specific bone and soft tissue structures. In this observational study, we provide for the first time a detailed analysis of extremity urate distribution in gout, which both supports and augments to the current understanding based on clinical and microscopic findings. (orig.)

  3. The distribution of urate deposition within the extremities in gout: a review of 148 dual-energy CT cases

    Energy Technology Data Exchange (ETDEWEB)

    Mallinson, Paul I. [Vancouver General Hospital, Radiology Department, Vancouver (Canada); Vancouver General Hospital, Clinical Fellow in Musculoskeletal Radiology, Vancouver, BC (Canada); Reagan, Adrian C.; Munk, Peter L.; Ouellette, Hugue; Nicolaou, Savvas [Vancouver General Hospital, Radiology Department, Vancouver (Canada); Coupal, Tyler [McMaster University, De Groote School of Medicine, Hamilton, Ontario (Canada)

    2014-03-15

    Clinical detection of gout can be difficult due to co-existent and mimicking arthropathies and asymptomatic disease. Understanding of the distribution of urate within the body can aid clinical diagnosis and further understanding of the resulting pathology. Our aim was to determine this distribution of urate within the extremities in patients with gout. All patients who underwent a four-limb dual-energy computed tomography (DECT) scan for suspected gout over a 2-year period were identified (n = 148, 121 male, 27 female, age range, 16-92 years, mean = 61.3 years, median = 63 years). The reports of the positive cases were retrospectively analyzed and the locations of all urate deposition recorded and classified by anatomical location. A total of 241 cases met the inclusion criteria, of which 148 cases were positive. Of these, 101 (68.2 %) patients had gout in the foot, 81 (56.1 %) in the knee, 79 (53.4 %) in the ankle, 41 (27.7 %) in the elbow, 25 (16.9 %) in the hand, and 25 (16.9 %) in the wrist. The distribution was further subcategorized for each body part into specific bone and soft tissue structures. In this observational study, we provide for the first time a detailed analysis of extremity urate distribution in gout, which both supports and augments to the current understanding based on clinical and microscopic findings. (orig.)

  4. Extreme weather and climate events with ecological relevance: a review.

    Science.gov (United States)

    Ummenhofer, Caroline C; Meehl, Gerald A

    2017-06-19

    Robust evidence exists that certain extreme weather and climate events, especially daily temperature and precipitation extremes, have changed in regard to intensity and frequency over recent decades. These changes have been linked to human-induced climate change, while the degree to which climate change impacts an individual extreme climate event (ECE) is more difficult to quantify. Rapid progress in event attribution has recently been made through improved understanding of observed and simulated climate variability, methods for event attribution and advances in numerical modelling. Attribution for extreme temperature events is stronger compared with other event types, notably those related to the hydrological cycle. Recent advances in the understanding of ECEs, both in observations and their representation in state-of-the-art climate models, open new opportunities for assessing their effect on human and natural systems. Improved spatial resolution in global climate models and advances in statistical and dynamical downscaling now provide climatic information at appropriate spatial and temporal scales. Together with the continued development of Earth System Models that simulate biogeochemical cycles and interactions with the biosphere at increasing complexity, these make it possible to develop a mechanistic understanding of how ECEs affect biological processes, ecosystem functioning and adaptation capabilities. Limitations in the observational network, both for physical climate system parameters and even more so for long-term ecological monitoring, have hampered progress in understanding bio-physical interactions across a range of scales. New opportunities for assessing how ECEs modulate ecosystem structure and functioning arise from better scientific understanding of ECEs coupled with technological advances in observing systems and instrumentation.This article is part of the themed issue 'Behavioural, ecological and evolutionary responses to extreme climatic events

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

    Science.gov (United States)

    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…

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

    Directory of Open Access Journals (Sweden)

    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.

  7. Problems in psychiatric care of 'difficult patients': a Delphi-study

    NARCIS (Netherlands)

    Koekkoek, Bauke; van Meijel, Berno; Schene, Aart; Hutschemaekers, Giel

    2009-01-01

    'difficult patients' may evoke strong feelings in health professionals. The ambivalent attitude of, especially, non-psychotic chronic patients towards psychiatric care may be frustrating and burdensome to professionals. Many of these patients are cared for in non-specialized services, where

  8. Problems in psychiatric care of 'difficult patients': a Delphi-study

    NARCIS (Netherlands)

    Koekkoek, B.W.; Meijel, B.K.G. van; Schene, A.H.; Hutschemaekers, G.J.M.

    2009-01-01

    Aims - 'difficult patients' may evoke strong feelings in health professionals. The ambivalent attitude of, especially, non-psychotic chronic patients towards psychiatric care may be frustrating and burdensome to professionals. Many of these patients are cared for in non-specialized services, where

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

    Science.gov (United States)

    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.

  10. How to Handle Difficult Parents: Proven Solutions for Teachers. Second Edition

    Science.gov (United States)

    Tingley, Suzanne Capek

    2012-01-01

    "How to Handle Difficult Parents" is a funny, but practical, guide to working effectively with parents and avoiding unnecessary conflict. Whether you're a teacher (regular or special education) or a coach, this book will give you practical suggestions regarding what to say and how to say it to parents who question your lesson plans, challenge your…

  11. Prehospital prognosis is difficult in patients with acute exacerbation of chronic obstructive pulmonary disease

    DEFF Research Database (Denmark)

    Lindvig, Katrine P.; Brøchner, Anne C.; Lassen, Annmarie T.

    2017-01-01

    in the form of intubation. The emergency physician faces difficult treatment decisions, however, and prognostic tools that could assist in determining which patients would benefit from intubation and ventilator support would be helpful. The aim of the current study was to identify prehospital clinical...

  12. Which Aspects of the English Language Do Distance Learners Find Difficult?

    Science.gov (United States)

    Teoh, George Boon Sai; Lin, Agnes Liau Wei; Belaja, Kathy

    2016-01-01

    This study reports the findings of a research carried out on distance learners at the School of Distance Education (SDE), University Sains Malaysia (USM). The study was explorative in nature with the purpose identifying the aspects of the English language which distance learners found difficult to learn. A quantitative survey questionnaire design…

  13. Long-Term Memory for Pictures under Conditions of Difficult Foil Discriminability.

    Science.gov (United States)

    Homa, Donald; Viera, Cynthia

    Research has demonstrated that subjects are sensitive to both thematic and non-thematic information in pictorial stimuli. Three experiments were conducted to investigate memory for pictures under conditions of difficult foil discriminability and lengthy retention intervals. The foils differed from the studied persons in the number and quality of…

  14. Environmental risk evaluation of difficult substances in USES 2.0

    NARCIS (Netherlands)

    Beelen P van; ECO

    1998-01-01

    An inventory is given of the problems which arise when difficult substances are evaluated with the Uniform System for the Evaluation of Substances (USES). It gives an indication about the different classes of chemicals which can give problems in USES. Further, it describes the problems which occur

  15. Pharmacotherapeutic approaches for treating psoriasis in difficult-to-treat areas.

    Science.gov (United States)

    Kivelevitch, Dario; Frieder, Jillian; Watson, Ian; Paek, So Yeon; Menter, M Alan

    2018-04-01

    Despite great therapeutic advancements in psoriasis, four notable difficult-to-treat areas including the scalp, nails, intertriginous (including genitals), and palmoplantar regions, pose a challenge to both physicians and patients. Localized disease of these specific body regions inflicts a significant burden on patients' quality of life and requires an adequate selection of treatments. Areas covered: This manuscript discusses appropriate therapies and important treatment considerations for these difficult-to-treat areas based on the available clinical data from the literature. Expert opinion: Clinical trials assessing therapies for the difficult-to-treat areas have been inadequate. With the first biological clinical trial for genital psoriasis pending publication, it is with hope that other biological agents will be evaluated for region-specific psoriasis. A greater understanding of the genetic and immunologic aspects of regional psoriasis, as well as identification of unique biomarkers, will further guide management decisions. For example, the recent discovery of the IL-36 receptor gene for generalized pustular psoriasis may prove valuable for other forms of psoriasis. Ultimately, identification of the most beneficial treatments for each psoriasis subtype and difficult-to-treat area will provide patients with maximal quality of life.

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

    DEFF Research Database (Denmark)

    Skak, Morten; Bloze, Gintautas

    2013-01-01

    by increased income inequality. In this paper we present calculations of the number of month it takes for an average young wage earner family that is presently in a tenant position to save 10 per cent of the average dwelling value. Our calculations show that it has become more difficult for young families...

  17. Difficult Dialogues, Rewarding Solutions: Strategies to Expand Postsecondary Opportunities While Controlling Costs

    Science.gov (United States)

    Immerwahr, John

    2009-01-01

    This report from Public Agenda is a summary of the process and outcomes of the "Difficult Dialogues" that took place in November 2008 at the 4th annual policy summit of the Midwestern Higher Education Compact (MHEC). Nearly 200 state legislators, institutional and system-level leaders and governing board members, faculty, executive…

  18. Intraabdominal actinomycosis resulting in a difficult to diagnose intraperitoneal mass: A case report.

    Science.gov (United States)

    Tsujimura, Naoto; Takemoto, Hiroyoshi; Nakahara, Yujiro; Wakasugi, Masaki; Matsumoto, Takashi; Nishioka, Kiyonori; Takachi, Kou; Oshima, Satoshi; Yoshida, Kyotaro

    2018-01-01

    Actinomycosis is a chronic suppurative granulomatous disease caused by Actinomyces israelii. Preoperative confirmed diagnosis is very difficult, so most cases are diagnosed preoperatively as malignant tumors. We report a case of intraabdominal actinomycosis which was difficult to diagnose preoperatively. A woman, 60 years old, experienced discomfort in her lower right abdomen. She complained of nausea and anorexia and visited our hospital. Laboratory blood tests, abdominal CT, and abdominal MRI led to a diagnosis of a uterine sarcoma or primary intestinal mass, and she underwent surgery. Her histopathological diagnosis was intraabdominal actinomycosis. Actinomycosis is a chronic purulent granulomatous inflammation caused by Actinomyces israelii. No clinical symptoms or laboratory findings are characteristic of abdominal actinomycosis, so this disorder is very difficult to diagnose preoperatively. Therefore, many cases are diagnosed as malignant tumors and undergo surgery. After surgery, long-term antibiotic treatment (penicillin) is usually administered. We reported a case of intraabdominal actinomycosis that resulted in a difficult to diagnose intraperitoneal mass. When a large intraperitoneal mass is found, actinomycosis needs to be included as one of differential diagnoses. Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.

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

    Science.gov (United States)

    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…

  20. "Everything Is about Balance": Graduate Education Faculty and the Navigation of Difficult Discourses on Race

    Science.gov (United States)

    Murray-Johnson, Kayon; Ross-Gordon, Jovita M.

    2018-01-01

    The purpose of this multiple case study was to describe the experiences of graduate education faculty of varying racial/ethnic backgrounds, learning to navigate difficult discourses on race effectively over time. The study employed positionality as a theoretical framework. Findings indicate that faculty balance what we refer to as "strategies…

  1. The Difficult Patron in the Academic Library: Problem Issues or Problem Patrons?

    Science.gov (United States)

    Simmonds Patience L.; Ingold, Jane L.

    2002-01-01

    Identifies difficult patron issues in academic libraries from the librarians' perspectives and offers solutions to try and prevent them from becoming problems. Topics include labeling academic library users; eliminating sources of conflict between faculty and library staff; and conflicts between students and library staff. (Author/LRW)

  2. Difficult airways: a reliable “Plan B” | Bishop | Southern African ...

    African Journals Online (AJOL)

    Percutaneous transtracheal jet ventilation (PTJV) is an accepted method of rescue ventilation following unsuccessful attempts to secure the airway through conventional methods. Pre-emptive use of PTJV in the difficult airway has also been described as using either a specifically designed jet ventilation catheter, or other ...

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

    Science.gov (United States)

    Segall, Avner

    2014-01-01

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

  4. Successful difficult airway management of a child with Coffin-siris syndrome.

    Science.gov (United States)

    Ozkan, Ahmet Selim; Akbas, Sedat; Yalin, Mehmet Ridvan; Ozdemir, Emine; Koylu, Zeynep

    2017-08-01

    Management of airway in patients who have Coffin-Siris syndrome (CSS) is often problematic because most of these patients have difficult airway. NTI via C-MAC VL is an useful alternative to direct laryngoscope for orotracheal intubation in airway and anesthetic management in a case of CSS. Alternative airway devices should be readily available.

  5. Successful difficult airway management of a child with Coffin?siris syndrome

    OpenAIRE

    Ozkan, Ahmet Selim; Akbas, Sedat; Yalin, Mehmet Ridvan; Ozdemir, Emine; Koylu, Zeynep

    2017-01-01

    Key Clinical Message Management of airway in patients who have Coffin?Siris syndrome (CSS) is often problematic because most of these patients have difficult airway. NTI via C?MAC VL is an useful alternative to direct laryngoscope for orotracheal intubation in airway and anesthetic management in a case of CSS. Alternative airway devices should be readily available.

  6. Vulnerability as a Key Concept in Museum Pedagogy on Difficult Matters

    Science.gov (United States)

    Tinning, Katrine

    2018-01-01

    In recent years there has been an increasing interest in museum studies in exhibitions on what is termed Difficult Matters (Silvén and Björklund 2006)--such as rape and mass murder--and how such exhibitions may evoke ethical change. This raises the question about the conditions on which such exhibitions can lead to an ethical change. By developing…

  7. Assessment of risk factors responsible for difficult weaning from mechanical ventilation in adults

    Directory of Open Access Journals (Sweden)

    Yehia Khalil

    2012-07-01

    Conclusion: All potential causes of ventilator dependency should be identified when a patient is difficult-to-wean. Then, a plan should be developed that uses a multidisciplinary team approach to correct the reversible causes of weaning failure and facilitates weaning thereafter.

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

    Directory of Open Access Journals (Sweden)

    Mehmet Turan Inal

    2014-12-01

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

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

    Science.gov (United States)

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

    2006-01-01

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

  10. Why Do Disadvantaged Filipino Children Find Word Problems in English Difficult?

    Science.gov (United States)

    Bautista, Debbie; Mulligan, Joanne

    2010-01-01

    Young Filipino students are expected to solve mathematical word problems in English, a language that many encounter only in schools. Using individual interviews of 17 Filipino children, we investigated why word problems in English are difficult and the extent to which the language interferes with performance. Results indicate that children could…

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

    Science.gov (United States)

    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…

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

    Science.gov (United States)

    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…

  13. Difficult airway management of children in ambulatory anesthesia: challenges and solutions

    Directory of Open Access Journals (Sweden)

    Huang AS

    2016-11-01

    Full Text Available Andrea S Huang,1 Lindsey Rutland,2 John Hajduk,1 Narasimhan Jagannathan1,2 1Department of Pediatric Anesthesia, Ann and Robert H. Lurie Children’s Hospital of Chicago, 2Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Abstract: As the field of pediatric ambulatory anesthesia expands, anesthesiologists can anticipate encountering an increasing number of patients with expected and unexpected difficult airways. This unique setting and patient population both present challenges in making a decision whether and how to safely proceed in the case of a child with a difficult airway. A host of patient, provider, procedure, and facility-specific factors should be considered. Providers should understand the differences between the pediatric and adult airway, recognize common features and syndromes associated with difficult airways, and be comfortable with different airway equipment and techniques available in the ambulatory setting. Early anticipation, a comprehensive patient assessment, and a clear decision-making algorithm with multiple airway management plans are all critical in safely and effectively managing these patients. These issues and recommendations will be discussed in this comprehensive narrative review. Keywords: difficult airway, pediatrics, ambulatory surgery, airway devices, children

  14. Combination therapy versus monotherapy for gastroesophageal reflux in children with difficult-to-treat bronchial asthma

    Directory of Open Access Journals (Sweden)

    Adel Salah Bediwy

    2014-01-01

    Conclusions: Combination of domperidone and esomeprazole was more effective in improving the endoscopic reflux score, childhood-asthma control test (C-ACT and FEV1 (% of predicted and significantly reduced the sputum SP than the use of esomeprazole only in children with difficult-to-treat asthma.

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

    Science.gov (United States)

    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…

  16. Regional decision-makers as potential users of Extreme Weather Event Attribution - Case studies from the German Baltic Sea coast and the Greater Paris area

    Directory of Open Access Journals (Sweden)

    Maria Schwab

    2017-12-01

    Full Text Available Extreme Event Attribution has raised increasing attention in climate science in the last years. It means to judge the extent to which certain weather-related extreme events have changed due to human influences on climate with probabilistic statements. Extreme Event Attribution is often anticipated to spur more than just scientific ambition. It is able to provide answers to a commonly asked questions after extreme events, namely, ‘can we blame it on climate change’ and is assumed to support decision-making of various actors engaged in climate change mitigation and adaptation. More in-depth research is widely lacking about who these actors are; in which context they can make use of it; and what requirements they have, to be able to actually apply Extreme Event Attribution. We have therefore addressed these questions with two empirical case studies looking at regional decision-makers who deal with storm surge risks in the German Baltic Sea region and heat waves in the Greater Paris area. Stakeholder interviews and workshops reveal that fields of application and requirements are diverse, difficult to explicitly identify, and often clearly associated with stakeholders' specific mandate, the hazard background, and the regional socio-economic setting. Among the considered stakeholders in the Baltic Sea region, Extreme Event Attribution is perceived to be most useful to awareness-raising, in particular for climate change mitigation. They emphasised the importance of receiving understandable information - and that, rather later, but with smaller uncertainties than faster, but with higher uncertainties. In the Paris case, we typically talked to people engaged in adaptation with expertise in terms of climate science, but narrowly defined mandates which is typical for the Paris-centred political system with highly specialised public experts. The interviewees claimed that Extreme Event Attribution is most useful to political leverage and public

  17. Due diligence duties for an environmental liability

    International Nuclear Information System (INIS)

    Huebsch, M.

    2000-04-01

    Jurisdiction turned out well to create a basic ruling for due diligence duties. These due diligence duties are high standards for the law of torts (outside of contracts) within the Austrian civil law and represent a liability-extension for the holder of the source of danger. They establish an action for injunction in particular for preventing (further) damages. Therewith due diligence duties get a general sense in the range of a civil law for environmental liability. The responsible holder of a danger zone will therefore influence his way of acting to protect potential victims and the environment. The burden of proof is on the plaintiff (victims) under the Civil Code. Victims have specific sources of danger including high endangering special facilities in their argumentation with the so-called prima-facie-proof or first-appearance-proof. A turning back of the presentation of evidence to the polluter is wrong. The polluter himself has a continuing liability for dangerous activities and his clerks in the case of an extremely high danger of damage. All due diligence duties can be arranged in three areas: in information-, danger-avoidance- and danger-prevention-duties. The determination of range and essence of the duties has to be adjusted to each individual case. The range of the specific danger area is the essential link. The intensity of due diligence duties is increasing with the size of danger in the way of a movable system depending on the protected interest. Due diligence duties have to be kept within reasonable limits with two criterions: necessarity and demand. Proportionality of actions is a third criterion to avoid exaggeration of due diligence duties to obtain an effective protection for victims including the environment. (author)

  18. Statistical uncertainty of extreme wind storms over Europe derived from a probabilistic clustering technique

    Science.gov (United States)

    Walz, Michael; Leckebusch, Gregor C.

    2016-04-01

    Extratropical wind storms pose one of the most dangerous and loss intensive natural hazards for Europe. However, due to only 50 years of high quality observational data, it is difficult to assess the statistical uncertainty of these sparse events just based on observations. Over the last decade seasonal ensemble forecasts have become indispensable in quantifying the uncertainty of weather prediction on seasonal timescales. In this study seasonal forecasts are used in a climatological context: By making use of the up to 51 ensemble members, a broad and physically consistent statistical base can be created. This base can then be used to assess the statistical uncertainty of extreme wind storm occurrence more accurately. In order to determine the statistical uncertainty of storms with different paths of progression, a probabilistic clustering approach using regression mixture models is used to objectively assign storm tracks (either based on core pressure or on extreme wind speeds) to different clusters. The advantage of this technique is that the entire lifetime of a storm is considered for the clustering algorithm. Quadratic curves are found to describe the storm tracks most accurately. Three main clusters (diagonal, horizontal or vertical progression of the storm track) can be identified, each of which have their own particulate features. Basic storm features like average velocity and duration are calculated and compared for each cluster. The main benefit of this clustering technique, however, is to evaluate if the clusters show different degrees of uncertainty, e.g. more (less) spread for tracks approaching Europe horizontally (diagonally). This statistical uncertainty is compared for different seasonal forecast products.

  19. Cause and Properties of the Extreme Space Weather Event of 2012 July 23

    Science.gov (United States)

    Liu, Y. D.; Luhmann, J. G.; Kajdic, P.; Kilpua, E.; Lugaz, N.; Nitta, N.; Lavraud, B.; Bale, S. D.; Farrugia, C. J.; Galvin, A. B.

    2013-12-01

    Extreme space weather refers to extreme conditions in space driven by solar eruptions and subsequent disturbances in interplanetary space, or otherwise called solar superstorms. Understanding extreme space weather events is becoming ever more vital, as the vulnerability of our society and its technological infrastructure to space weather has increased dramatically. Instances of extreme space weather, however, are very rare by definition and therefore are difficult to study. Here we report and investigate an extreme event, which occurred on 2012 July 23 with a maximum speed of about 3050 km/s near the Sun. This event, with complete modern remote sensing and in situ observations from multiple vantage points, provides an unprecedented opportunity to study the cause and consequences of extreme space weather. It produced a superfast shock with a peak solar wind speed of 2246 km/s and a superstrong magnetic cloud with a peak magnetic field of 109 nT observed near 1 AU at STEREO A. The record solar wind speed and magnetic field would produce a record geomagnetic storm since the space era with a minimum Dst of -1200 - -600 nT, if this event hit the Earth. We demonstrate how successive coronal mass ejections (CMEs) can be enhanced into a solar superstorm as they interact en route from the Sun to 1 AU. These results not only provide a benchmark for studies of extreme space weather, but also present a new view of how an extreme space weather event can be generated from usual solar eruptions.

  20. Outcomes for Extremely Premature Infants

    Science.gov (United States)

    Glass, Hannah C.; Costarino, Andrew T.; Stayer, Stephen A.; Brett, Claire; Cladis, Franklyn; Davis, Peter J.

    2015-01-01

    Premature birth is a significant cause of infant and child morbidity and mortality. In the United States, the premature birth rate, which had steadily increased during the 1990s and early 2000s, has decreased annually for four years and is now approximately 11.5%. Human viability, defined as gestational age at which the chance of survival is 50%, is currently approximately 23–24 weeks in developed countries. Infant girls, on average, have better outcomes than infant boys. A relatively uncomplicated course in the intensive care nursery for an extremely premature infant results in a discharge date close to the prenatal EDC. Despite technological advances and efforts of child health experts during the last generation, the extremely premature infant (less than 28 weeks gestation) and extremely low birth weight infant (ELBW) (CPAP, mechanical ventilation, and exogenous surfactant increased survival and spurred the development of neonatal intensive care in the 1970s through the early 1990s. Routine administration of antenatal steroids during premature labor improved neonatal mortality and morbidity in the late 1990s. The recognition that chronic postnatal administration of steroids to infants should be avoided may have improved outcomes in the early 2000s. Evidence from recent trials attempting to define the appropriate target for oxygen saturation in preterm infants suggests arterial oxygen saturation between 91–95% (compared to 85–89%) avoids excess mortality. However, final analyses of data from these trials have not been published, so definitive recommendations are still pending The development of neonatal neurocognitive care visits may improve neurocognitive outcomes in this high-risk group. Long-term follow up to detect and address developmental, learning, behavioral, and social problems is critical for children born at these early gestational ages. The striking similarities in response to extreme prematurity in the lung and brain imply that agents and

  1. Gravity and Extreme Magnetism SMEX

    Science.gov (United States)

    2012-01-01

    The Gravity and Extreme Magnetism SMEX mission will be the first mission to catalogue the X-ray polarisation of many astrophysical objects including black-holes and pulsars. This first of its kind mission is enabled by the novel use of a time projection chamber as an X-ray polarimeter. The detector has been developed over the last 5 years, with the current effort charged toward a demonstration of it's technical readiness to be at level 6 prior to the preliminary design review. This talk will describe the design GEMS polarimeter and the results to date from the engineering test unit.

  2. Aplastic anemia due to radiation

    International Nuclear Information System (INIS)

    Sakai, Kunio; Saito, Akira

    1978-01-01

    The relationship between radiation exposure and aplastic anemia, clarified previously, is discussed. When persons such as radiological technicians receive whole-body irradiation in rather large doses, it is possible that aplastic anemia will result later on. However, this is difficult to determine because the irradiated region is limited despite large doses of radiation. (Bell, E.)

  3. Climate change & extreme weather vulnerability assessment framework.

    Science.gov (United States)

    2012-12-01

    The Federal Highway Administrations (FHWAs) Climate Change and Extreme Weather Vulnerability : Assessment Framework is a guide for transportation agencies interested in assessing their vulnerability : to climate change and extreme weather event...

  4. Frequently Asked Questions (FAQ) about Extreme Heat

    Science.gov (United States)

    ... Extreme Heat Older Adults (Aged 65+) Infants and Children Chronic Medical Conditions Low Income Athletes Outdoor Workers Pets Hot Weather Tips Warning Signs and Symptoms FAQs Social Media How to Stay Cool Missouri Cooling Centers Extreme ...

  5. E.X.T.R.E.M.E. project. Launch

    International Nuclear Information System (INIS)

    Eyrolle, F.; Charmasson, S.; Masson, O.

    2005-01-01

    Due to the drastic decrease in artificial radioactivity levels from primary sources such as atmospheric fallout or industrial releases, radioactive storages constituted in the past within several environmental compartments act today as non negligible secondary sources. These delayed sources are particularly active during extreme weather or climatic events such as rainfalls or atmospheric deposits, floods, storms, etc...that may remove important mass, generate activity levels higher than the predicted ones from modeling based on mean transfer process, and produce in a couple of hours or days fluxes similar to those accrued over several month or years. Extreme aims at assessing the consequences on man and its environment of natural events that generate extreme radioactive stocks and/or fluxes within several environmental compartments (atmosphere, soils, rivers, coastal marine environment and deep sea areas). (authors)

  6. Predicting extreme rainfall over eastern Asia by using complex networks

    International Nuclear Information System (INIS)

    He Su-Hong; Gong Yan-Chun; Huang Yan-Hua; Wu Cheng-Guo; Feng Tai-Chen; Gong Zhi-Qiang

    2014-01-01

    A climate network of extreme rainfall over eastern Asia is constructed for the period of 1971–2000, employing the tools of complex networks and a measure of nonlinear correlation called event synchronization (ES). Using this network, we predict the extreme rainfall for several cases without delay and with n-day delay (1 ≤ n ≤ 10). The prediction accuracy can reach 58% without delay, 21% with 1-day delay, and 12% with n-day delay (2 ≤ n ≤ 10). The results reveal that the prediction accuracy is low in years of a weak east Asia summer monsoon (EASM) or 1 year later and high in years of a strong EASM or 1 year later. Furthermore, the prediction accuracy is higher due to the many more links that represent correlations between different grid points and a higher extreme rainfall rate during strong EASM years. (geophysics, astronomy, and astrophysics)

  7. Kenyan women adult literacy learners: why their motivation is difficult to sustain.

    Science.gov (United States)

    Mwiria, K

    1993-05-01

    Kenya, like other Third World countries, has illiteracy rates for women which are twice those of men (in 1978, 35% of males and 70% of females aged 15 and above were illiterate). Since the beginning of the country's literacy campaign in 1979, women have comprised more than 70% of attendees. While this situation remains the case, the overall enrolment figures for the program have shown a gradual decline from 1979 to 1990 due to a lack of emphasis on individual motivation. Women dominate the literacy programs for several reasons: 1) women historically had less access to formal education than men; 2) the changing economy has forced women to assume extra responsibilities outside the home which make the women want to acquire formal skills; 3) women's schedules are often flexible enough to allow them to attend classes; 4) literacy classes provide women with needed socialization opportunities; and 5) in some communities cultural norms prevent men from attending classes with women. Women also have many obstacles which make their desire to become adult learners difficult to sustain. They have responsibilities which range from child-bearing to management of their family farms which leave them little time for study or class attendance. There is also little encouragement offered the women either at home or in their classes. At home they are confronted with a myriad of demands on their time. Their classes take place in conditions which are not very conducive to learning (classrooms designed for children or open air centers). The literacy teachers are, for the most part, unqualified. They must meet only minimal requirements and receive no training. The women also have less opportunities to practice their new skills outside of the classroom. Women have less time then men to read, and they are less fluent then men in English and Kiswahili, the 2 official languages of Kenya. Because Kenyan society is male-dominated, there is little encouragement given to women who attempt to

  8. Extreme Maximum Land Surface Temperatures.

    Science.gov (United States)

    Garratt, J. R.

    1992-09-01

    There are numerous reports in the literature of observations of land surface temperatures. Some of these, almost all made in situ, reveal maximum values in the 50°-70°C range, with a few, made in desert regions, near 80°C. Consideration of a simplified form of the surface energy balance equation, utilizing likely upper values of absorbed shortwave flux (1000 W m2) and screen air temperature (55°C), that surface temperatures in the vicinity of 90°-100°C may occur for dry, darkish soils of low thermal conductivity (0.1-0.2 W m1 K1). Numerical simulations confirm this and suggest that temperature gradients in the first few centimeters of soil may reach 0.5°-1°C mm1 under these extreme conditions. The study bears upon the intrinsic interest of identifying extreme maximum temperatures and yields interesting information regarding the comfort zone of animals (including man).

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

    DEFF Research Database (Denmark)

    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...

  10. Exascale Co-design for Modeling Materials in Extreme Environments

    Energy Technology Data Exchange (ETDEWEB)

    Germann, Timothy C. [Los Alamos National Lab. (LANL), Los Alamos, NM (United States)

    2014-07-08

    Computational materials science has provided great insight into the response of materials under extreme conditions that are difficult to probe experimentally. For example, shock-induced plasticity and phase transformation processes in single-crystal and nanocrystalline metals have been widely studied via large-scale molecular dynamics simulations, and many of these predictions are beginning to be tested at advanced 4th generation light sources such as the Advanced Photon Source (APS) and Linac Coherent Light Source (LCLS). I will describe our simulation predictions and their recent verification at LCLS, outstanding challenges in modeling the response of materials to extreme mechanical and radiation environments, and our efforts to tackle these as part of the multi-institutional, multi-disciplinary Exascale Co-design Center for Materials in Extreme Environments (ExMatEx). ExMatEx has initiated an early and deep collaboration between domain (computational materials) scientists, applied mathematicians, computer scientists, and hardware architects, in order to establish the relationships between algorithms, software stacks, and architectures needed to enable exascale-ready materials science application codes within the next decade. We anticipate that we will be able to exploit hierarchical, heterogeneous architectures to achieve more realistic large-scale simulations with adaptive physics refinement, and are using tractable application scale-bridging proxy application testbeds to assess new approaches and requirements. Such current scale-bridging strategies accumulate (or recompute) a distributed response database from fine-scale calculations, in a top-down rather than bottom-up multiscale approach.

  11. Observed increase in extreme daily rainfall in the French Mediterranean

    Science.gov (United States)

    Ribes, Aurélien; Thao, Soulivanh; Vautard, Robert; Dubuisson, Brigitte; Somot, Samuel; Colin, Jeanne; Planton, Serge; Soubeyroux, Jean-Michel

    2018-04-01

    We examine long-term trends in the historical record of extreme precipitation events occurring over the French Mediterranean area. Extreme events are considered in terms of their intensity, frequency, extent and precipitated volume. Changes in intensity are analysed via an original statistical approach where the annual maximum rainfall amounts observed at each measurement station are aggregated into a univariate time-series according to their dependence. The mean intensity increase is significant and estimated at + 22% (+ 7 to + 39% at the 90% confidence level) over the 1961-2015 period. Given the observed warming over the considered area, this increase is consistent with a rate of about one to three times that implied by the Clausius-Clapeyron relationship. Changes in frequency and other spatial features are investigated through a Generalised Linear Model. Changes in frequency for events exceeding high thresholds (about 200 mm in 1 day) are found to be significant, typically near a doubling of the frequency, but with large uncertainties in this change ratio. The area affected by severe events and the water volume precipitated during those events also exhibit significant trends, with an increase by a factor of about 4 for a 200 mm threshold, again with large uncertainties. All diagnoses consistently point toward an intensification of the most extreme events over the last decades. We argue that it is difficult to explain the diagnosed trends without invoking the human influence on climate.

  12. An overview on extremity dosimetry in medical applications

    International Nuclear Information System (INIS)

    Vanhavere, F.; Carinou, E.; Donadille, L.; Ginjaume, M.; Jankowski, J.; Rimpler, A.; Sans Merce, M.

    2008-01-01

    Some activities of EURADOS Working Group 9 (WG9) are presently funded by the European Commission (CONRAD project). The objective of WG9 is to promote and co-ordinate research activities for the assessment of occupational exposures to staff at workplaces in interventional radiology (IR) and nuclear medicine. For some of these applications, the skin of the fingers is the limiting organ for individual monitoring of external radiation. Therefore, sub-group 1 of WG9 deals with the use of extremity dosemeters in medical radiation fields. The wide variety of radiation field characteristics present in a medical environment together with the difficulties in measuring a local dose that is representative for the maximum skin dose, usually with one single detector, makes it difficult to perform accurate extremity dosimetry. Sub-group 1 worked out a thorough literature review on extremity dosimetry issues in diagnostic and therapeutic nuclear medicine and positron emission tomography, interventional radiology and interventional cardiology and brachytherapy. Some studies showed that the annual dose limits could be exceeded if the required protection measures are not taken, especially in nuclear medicine. The continuous progress in new applications and techniques requires an important effort in radiation protection and training. (authors)

  13. Can Concentration - Discharge Relationships Diagnose Material Source During Extreme Events?

    Science.gov (United States)

    Karwan, D. L.; Godsey, S.; Rose, L.

    2017-12-01

    Floods can carry >90% of the basin material exported in a given year as well as alter flow pathways and material sources. In turn, sediment and solute fluxes can increase flood damages and negatively impact water quality and integrate physical and chemical weathering of landscapes and channels. Concentration-discharge (C-Q) relationships are used to both describe export patterns as well as compute them. Metrics for describing C-Q patterns and inferring their controls are vulnerable to infrequent sampling that affects how C-Q relationships are interpolated and interpreted. C-Q relationships are typically evaluated from multiple samples, but because hydrological extremes are rare, data are often unavailable for extreme events. Because solute and sediment C-Q relationships likely respond to changes in hydrologic extremes in different ways, there is a pressing need to define their behavior under extreme conditions, including how to properly sample to capture these patterns. In the absence of such knowledge, improving load estimates in extreme floods will likely remain difficult. Here we explore the use of C-Q relationships to determine when an event alters a watershed system such that it enters a new material source/transport regime. We focus on watersheds with sediment and discharge time series include low-frequency and/or extreme events. For example, we compare solute and sediment patterns in White Clay Creek in southeastern Pennsylvania across a range of flows inclusive of multiple hurricanes for which we have ample ancillary hydrochemical data. TSS is consistently mobilized during high flow events, even during extreme floods associated with hurricanes, and sediment fingerprinting indicates different sediment sources, including in-channel remobilization and landscape erosion, are active at different times. In other words, TSS mobilization in C-Q space is not sensitive to the source of material being mobilized. Unlike sediments, weathering solutes in this watershed

  14. A compliant mechanism for inspecting extremely confined spaces

    Science.gov (United States)

    Mascareñas, David; Moreu, Fernando; Cantu, Precious; Shields, Daniel; Wadden, Jack; El Hadedy, Mohamed; Farrar, Charles

    2017-11-01

    We present a novel, compliant mechanism that provides the capability to navigate extremely confined spaces for the purpose of infrastructure inspection. Extremely confined spaces are commonly encountered during infrastructure inspection. Examples of such spaces can include pipes, conduits, and ventilation ducts. Often these infrastructure features go uninspected simply because there is no viable way to access their interior. In addition, it is not uncommon for extremely confined spaces to possess a maze-like architecture that must be selectively navigated in order to properly perform an inspection. Efforts by the imaging sensor community have resulted in the development of imaging sensors on the millimeter length scale. Due to their compact size, they are able to inspect many extremely confined spaces of interest, however, the means to deliver these sensors to the proper location to obtain the desired images are lacking. To address this problem, we draw inspiration from the field of endoscopic surgery. Specifically we consider the work that has already been done to create long flexible needles that are capable of being steered through the human body. These devices are typically referred to as ‘steerable needles.’ Steerable needle technology is not directly applicable to the problem of navigating maze-like arrangements of extremely confined spaces, but it does provide guidance on how this problem should be approached. Specifically, the super-elastic nitinol tubing material that allows steerable needles to operate is also appropriate for the problem of navigating maze-like arrangements of extremely confined spaces. Furthermore, the portion of the mechanism that enters the extremely confined space is completely mechanical in nature. The mechanical nature of the device is an advantage when the extremely confined space features environmental hazards such as radiation that could degrade an electromechanically operated mechanism. Here, we present a compliant mechanism

  15. Palaeoflood hydrology in Europe: towards a better understanding of extreme floods

    Science.gov (United States)

    Benito, G.; Thorndycraft, V. R.; Rico, M.; Sheffer, N.; Enzel, Y.

    2003-04-01

    Floods are the most common natural disasters in Europe and, in terms of economic damage, costs are increasing spectacularly with time. Flood risk assessment associated with extreme floods is difficult due to the scarcity of hydrological measurements, that rarely go beyond 1000 years, which is clearly not sufficient for flood management in urban and industrial areas. Besides the use of conventional hydrologic data, the pre-instrumental record can be completed from palaeoflood hydrology or from documentary flood information, or through the combined use of both these tools. Recent developments of palaeoflood hydrology in Europe provide (1) major improvements in flood risk assessment, and (2) a better understanding of long-term flood-climate relationships. Palaeoflood hydrology has been successfully applied in large, medium rivers as well as small ungauged mountain drainage basins. Long-term palaeoflood records from Spain and France show that recent extraordinary flooding (causing huge economic damages) are not the largest ones, but that similar or even greater floods occurred several times in the past. In addition, clusters of floods coinciding in time at several European rivers point out to climatic factors as responsible mechanisms, although in recent time flood magnitude can be magnified by increasing human activity.

  16. Climate extremes and challenges to infrastructure development in coastal cities in Bangladesh

    Directory of Open Access Journals (Sweden)

    Sowmen Rahman

    2015-03-01

    Full Text Available Most of the coastal cities in Bangladesh are situated on the riverbanks of low-lying tidal zones at an average elevation of 1.0–1.5 m from the sea level. Construction and management of buildings, roads, power and telecommunication transmission lines, drainage and sewerage and waste management are very difficult and vulnerable to climate change disasters. Cyclonic storms associated with tidal floods impact seriously the infrastructures and thus the livelihoods. Although coastal cities are the ultimate shelters of the coastal people during the extremes events, the coastal cities are not safe and cannot support them due to poor infrastructure. This study analyses the challenges coastal urbanization faces under different situations like cyclones, floods and water-logging, salinity, land-sliding and erosion etc. during the disasters and their effects on city lives for water supply and sanitation, power and electricity and waste management etc., and puts forward recommendations towards sustainable planning of coastal cities.

  17. Conference on Extreme Value Theory and Applications

    CERN Document Server

    Lechner, James; Simiu, Emil

    1994-01-01

    It appears that we live in an age of disasters: the mighty Missis­ sippi and Missouri flood millions of acres, earthquakes hit Tokyo and California, airplanes crash due to mechanical failure and the seemingly ever increasing wind speeds make the storms more and more frightening. While all these may seem to be unexpected phenomena to the man on the street, they are actually happening according to well defined rules of science known as extreme value theory. We know that records must be broken in the future, so if a flood design is based on the worst case of the past then we are not really prepared against floods. Materials will fail due to fatigue, so if the body of an aircraft looks fine to the naked eye, it might still suddenly fail if the aircraft has been in operation over an extended period of time. Our theory has by now penetrated the so­ cial sciences, the medical profession, economics and even astronomy. We believe that our field has come of age. In or~er to fully utilize the great progress in the the...

  18. Hypothyroid-induced acute compartment syndrome in all extremities.

    Science.gov (United States)

    Musielak, Matthew C; Chae, Jung Hee

    2016-12-20

    Acute compartment syndrome (ACS) is an uncommon complication of uncontrolled hypothyroidism. If unrecognized, this can lead to ischemia, necrosis and potential limb loss. A 49-year-old female presented with the sudden onset of bilateral lower and upper extremity swelling and pain. The lower extremity anterior compartments were painful and tense. The extensor surface of the upper extremities exhibited swelling and pain. Motor function was intact, however, limited due to pain. Bilateral lower extremity fasciotomies were performed. Postoperative Day 1, upper extremity motor function decreased significantly and paresthesias occurred. She therefore underwent bilateral forearm fasciotomies. The pathogenesis of hypothyroidism-induced compartment syndrome is unclear. Thyroid-stimulating hormone-induced fibroblast activation results in increased glycosaminoglycan deposition. The primary glycosaminoglycan in hypothyroid myxedematous changes is hyaluronic acid, which binds water causing edema. This increases vascular permeability, extravasation of proteins and impaired lymphatic drainage. These contribute to increased intra-compartmental pressure and subsequent ACS. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2016.

  19. [Algorithm for securing an unexpected difficult airway : User analysis on a simulator].

    Science.gov (United States)

    Ott, T; Truschinski, K; Kriege, M; Naß, M; Herrmann, S; Ott, V; Sellin, S

    2018-01-01

    Critical incidents in difficult airway management are still a main contributory factor for perioperative morbidity and mortality. Many national associations have developed algorithms for management of these time critical events. For implementation of these algorithms the provision of technical requirements and procedure-related training are essential. Severe airway incidents are rare events and clinical experience of the individual operators is limited; therefore, simulation is an adequate instrument for training and evaluating difficult airway algorithms. The aim of this observational study was to evaluate the application of the institutional difficult airway algorithm among anesthetists. After ethics committee approval, anesthetists were observed while treating a "cannot intubate" (CI) and a "cannot intubate, cannot ventilate" (CICV) situation in the institutional simulation center. As leader of a supportive team the participants had to deal with an unexpected difficult airway after induction of anesthesia in a patient simulator. The following data were recorded: sequence of the applied airway instruments, time to ventilation after establishing a secured airway using any instrument in the CI situation and time to ventilation via cricothyrotomy in the CICV situation. Conformity to the algorithm was defined by the sequence of the applied instruments. Analysis comprised conformity to the algorithm, non-parametric tests for time to ventilation and differences between junior and senior anesthetists. Out of 50 participants 45 were analyzed in the CI situation. In this situation 93% of the participants acted in conformity with the algorithm. In 62% the airway was secured by flexible intubation endoscopy, in 38% with another device. Data from 46 participants were analyzed in the CICV situation. In this situation 91% acted in conformity with the algorithm. The last device used prior to the decision for cricothyrotomy was flexible intubation endoscopy in 39%, a

  20. Anaesthetic management in a case of large plunging ranula with difficult airway: A case report

    Directory of Open Access Journals (Sweden)

    Surendra Kumar Sethi

    2017-04-01

    Full Text Available Plunging ranula is a mucous retention cyst found on the floor of mouth which arises from the submandibular and sublingual salivary glands extending to lateral aspect of neck, which may often cause potential airway obstruction leading to difficulty in airway management. A forty year old female patient was admitted to our hospital with large, painless swelling in the floor of mouth extending to the lateral part of body of mandible and neck. This intraoral swelling distorted the normal airway anatomy thus making airway management difficult as the patient was planned for excision of swelling under general anaesthesia. So we present a case of successful management of a difficult airway by using awake fibre optic intubation in a patient posted for excision of a large plunging ranula under general anaesthesia.

  1. Infrared Red Intubation System (IRRIS) guided flexile videoscope assisted difficult airway management

    DEFF Research Database (Denmark)

    Kristensen, M S; Fried, E; Biro, P

    2018-01-01

    BACKGROUND: Tracheal intubation with a flexible scope is a cornerstone technique in patients with severely difficult airways, but may fail. We report on a technique, Infrared Red Intubation System (IRRIS), that seems to facilitate the identification of the glottis. METHODS: The IRRIS is placed over...... the patient's cricothyroid membrane and emits blinking infrared light through the patient's skin into the subglottic space. When a flexible videoscope (one that does not filter infrared light) is introduced into the airway, it will display this as a blinking white light emerging from the glottis, retrograde...... transillumination, showing the pathway to the trachea. We have introduced this as an adjunct when managing our patients with difficult airways. We describe the technique and retrospectively report on the first ten patients where it was used. RESULTS: All ten patients had significant pathology in the airway...

  2. An anatomy of countertransference: staff reactions to difficult psychiatric hospital patients.

    Science.gov (United States)

    Colson, D B; Allen, J G; Coyne, L; Dexter, N; Jehl, N; Mayer, C A; Spohn, H

    1986-09-01

    Countertransference among hospital staff was investigated as part of ongoing research on difficult-to-treat psychiatric hospital patients. Staff's ratings of their emotional reactions to 127 patients on long-term units were analyzed by factor analysis, and the resulting factors were correlated by discipline with patient problem behaviors. Among the conclusions were that different forms of psychopathology elicit characteristic patterns of emotional reaction from staff; that some dimensions of psychopathology, particularly suicidal-depressed behavior and violence-agitation, elicit different emotional reactions among different disciplines, thus laying the groundwork for division among staff; and that the more difficult the process of hospital treatment, the more likely staff will experience a variety of emotions.

  3. The Positive Effect of Resilience on Stress and Business Outcomes in Difficult Work Environments.

    Science.gov (United States)

    Shatté, Andrew; Perlman, Adam; Smith, Brad; Lynch, Wendy D

    2017-02-01

    To examine whether resilience has a protective effect in difficult work environments. A survey of 2063 individuals measured individual resilience, stress, burnout, sleep problems, likelihood of depression, job satisfaction, intent to quit, absences, and productivity. It also measured work characteristics: job demands, job influence, and social support. Multivariate and logistic regression models examined the main effects and interactions of resilience and job characteristics. High strain work environments (high demand, low influence, and low support) have an unfavorable effect on all outcomes. Resilience has a protective effect on all outcomes. For stress, burnout, and sleep, higher resilience has a more protective effect under low-strain conditions. For depression, absence and productivity, resilience has a more protective effect when job strain is high. Workers with high resilience have better outcomes in difficult work environments.

  4. Injuries in an Extreme Conditioning Program

    Science.gov (United States)

    Aune, Kyle T.; Powers, Joseph M.

    2016-01-01

    injury incidence rate among athletes with <6 months of experience in the ECP was 2.5 times greater than that of more experienced athletes (≥6 months of experience). Of the 132 injuries, 23 (17%) required surgical intervention. Squat cleans, ring dips, overhead squats, and push presses were more likely to cause injury. Athletes reported that 35% of injuries were due to overexertion and 20% were due to improper technique. Conclusion: The estimated injury rate among athletes participating in this ECP was similar to the rate of injury in weightlifting and most other recreational activities. The shoulder or upper arm was the most commonly injured area, and previous shoulder injury predisposed to new shoulder injury. New athletes are at considerable risk of injury compared with more experienced athletes. Clinical Relevance: Extreme conditioning programs are growing in popularity, and there is disagreement between science and anecdotal reports from athletes, coaches, and physicians about their relative safety. This study estimates the incidence of injury in extreme conditioning programs, which appears to be similar to other weight-training programs. PMID:27760844

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

    DEFF Research Database (Denmark)

    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....

  6. Quality Assurance in the National Tests of English: Investigating What Makes Reading Difficult

    Directory of Open Access Journals (Sweden)

    Angela Hasselgreen

    2017-09-01

    Full Text Available This article presents a piece of research, conducted in order to validate the claims made in test results, concerning what it means – in terms of reading ability – to be placed at a particular mastery level. It will consider the question of what makes reading tasks difficult, and whether data from the National Tests of English (NTE supports the progression of subskills/reading operations as presented in the mastery level descriptors, which are the basis of test results

  7. Real life study of three years omalizumab in patients with difficult-to-control asthma.

    Science.gov (United States)

    López Tiro, J Jesús; Contreras, E Angélica Contreras; del Pozo, M Elena Ramírez; Gómez Vera, J; Larenas Linnemann, D

    2015-01-01

    Even though there are multiple options for the treatment of asthma, there still exists a fair group of patients with difficult-to-control asthma. We describe for the first time the real-world effects of three-year omalizumab treatment on patients with difficult-to-control asthma, seen in a social security hospital in a Latin American country. Difficult-to-control asthmatic patients from the out-patient clinic of a regional hospital were recruited to receive a three-year omalizumab course. Efficacy parameters were asthma control test (ACT) score; FEV1; daily beclomethasone maintenance dose; and unplanned visits for asthma exacerbations (emergency room (ER), hospitalisations, intensive care). 52 patients were recruited, 47 completed the three-year treatment (42 female, 15-67 years, mean age 43.5). Comparing efficacy parameters of the year before omalizumab with the 3rd year of omalizumab: mean ACT improved from 12.4 to 20.5, mean FEV1 from 66.3% (standard deviation (SD) 19.1%) to 88.4% (SD 16.2%) of predicted, while mean beclomethasone dose reduced from 1750 to 766 mcg/day and there was a significant reduction in patients experiencing ER visits (from 95% to 19%, pomalizumab, two because of an adverse event (anaphylaxis, severe headache, both resolved without sequelae). Omalizumab improved most clinical parameters of Mexican patients with difficult-to-control asthma. Especially the rates of ER visits and hospitalisation were significantly reduced, thus reducing costs. Omalizumab was generally well tolerated. Copyright © 2013 SEICAP. Published by Elsevier Espana. All rights reserved.

  8. Use of Adult Fibreoptic Bronchoscope for Difficult Paediatric Intubation: A Case Report

    Directory of Open Access Journals (Sweden)

    Kundan Sandugir Gosavi

    2015-06-01

    Full Text Available Difficult airway management in paediatric patients may require a technique different from the standard one. We report the use of an adult fibreoptic bronchoscope and J tipped guidewire to intubate a child having temporo-mandibular joint ankylosis. Spontaneous respiration was maintained and local anaesthesia was provided to the upper airway during the procedure and the successful use of this technique avoided the requirement of surgical airway.

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

    OpenAIRE

    Stjernstoft, Tero

    2004-01-01

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

  10. Deep Help in Complex Project Work: Guiding and Path-Clearing Across Difficult Terrain

    OpenAIRE

    Fisher, Colin M.; Pillemer, Julianna; Amabile, Teresa M.

    2017-01-01

    How do teams working on complex projects get the help they need? Our qualitative investigation of the help provided to project teams at a prominent design firm revealed two distinct helping processes, both characterized by deep, sustained engagement that far exceeds the brief interactions described in the helping literature. Such deep help consisted of (1) guiding a team through a difficult juncture by working with its members in several prolonged, tightly clustered sessions, or (2) path-clea...

  11. Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway.

    Science.gov (United States)

    Corso, Ruggero M; Cattano, Davide; Buccioli, Matteo; Carretta, Elisa; Maitan, Stefano

    2016-01-01

    Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

  12. [Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway].

    Science.gov (United States)

    Corso, Ruggero M; Cattano, Davide; Buccioli, Matteo; Carretta, Elisa; Maitan, Stefano

    2016-01-01

    Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

  13. Difficultés scolaires et séparation des parents

    OpenAIRE

    Henri-Panabière, Gaële

    2011-01-01

    Répartition des collégiens dans les classes de difficultés scolaires selon que les parents vivent ensemble ou non… …dans la population d’ensemble (N=629 sans les non-réponses) …et dans la sous-population des parents diplômé(s) du supérieur (N=251 sans les non-réponses)

  14. Creating and Understanding Hybrid Interfaces of Multifunctional Composite Laminates for Extreme Environments

    Data.gov (United States)

    National Aeronautics and Space Administration — Due to increasing needs for lightweight and multifunctional structures and materials that can operate at and sustain the extreme environment such as high temperature...

  15. Extreme Variability in a Broad Absorption Line Quasar

    Energy Technology Data Exchange (ETDEWEB)

    Stern, Daniel; Jun, Hyunsung D. [Jet Propulsion Laboratory, California Institute of Technology, 4800 Oak Grove Drive, Mail Stop 169-221, Pasadena, CA 91109 (United States); Graham, Matthew J.; Djorgovski, S. G.; Donalek, Ciro; Drake, Andrew J.; Mahabal, Ashish A.; Steidel, Charles C. [California Institute of Technology, 1200 E. California Boulevard, Pasadena, CA 91125 (United States); Arav, Nahum; Chamberlain, Carter [Department of Physics, Virginia Tech, Blacksburg, VA 24061 (United States); Barth, Aaron J. [Department of Physics and Astronomy, 4129 Frederick Reines Hall, University of California, Irvine, CA 92697 (United States); Glikman, Eilat, E-mail: daniel.k.stern@jpl.nasa.gov [Department of Physics, Middlebury College, Middlebury, VT 05753 (United States)

    2017-04-20

    CRTS J084133.15+200525.8 is an optically bright quasar at z = 2.345 that has shown extreme spectral variability over the past decade. Photometrically, the source had a visual magnitude of V ∼ 17.3 between 2002 and 2008. Then, over the following five years, the source slowly brightened by approximately one magnitude, to V ∼ 16.2. Only ∼1 in 10,000 quasars show such extreme variability, as quantified by the extreme parameters derived for this quasar assuming a damped random walk model. A combination of archival and newly acquired spectra reveal the source to be an iron low-ionization broad absorption line quasar with extreme changes in its absorption spectrum. Some absorption features completely disappear over the 9 years of optical spectra, while other features remain essentially unchanged. We report the first definitive redshift for this source, based on the detection of broad H α in a Keck/MOSFIRE spectrum. Absorption systems separated by several 1000 km s{sup −1} in velocity show coordinated weakening in the depths of their troughs as the continuum flux increases. We interpret the broad absorption line variability to be due to changes in photoionization, rather than due to motion of material along our line of sight. This source highlights one sort of rare transition object that astronomy will now be finding through dedicated time-domain surveys.

  16. The Relation Between Visual Impairment and Extremity Fractures

    Directory of Open Access Journals (Sweden)

    Berrak Şekeryapan

    2013-08-01

    Full Text Available Purpose: To evaluate the association between the development of extremity fracture and visual impairment in adults. Material and Method: This study included 56 patients (patient group aged 18 years or older who had extremity fractures due to a fall. The control group (n=42 was selected from visitors who had regular medical check-ups at our hospital. Each participant underwent a full ophthalmologic examination. Mean age was compared by Student’s t test. The other variables were compared by chi-square test. Results: The prevalence of subjects with visual impairment was significantly higher in the patients group (78.6% than in the control group (38.1% (p<0.05. The prevalence of treatable eye diseases such as cataract and refractive errors were significantly higher in the patient group than in the control group (p<0.05 for both. Twenty-eight patients (50% in the patient group and 8 subjects in the control group had visual acuities lower than 0.5 (p<0.05. Discussion: We have found that the prevalence of visual impairment was significantly higher in adults with extremity fractures due to falls than in the control group. Hence, we believe that regular ophthalmological examination in adults, providing regular use of eyeglasses in patients with refractive errors, and timely treatment of treatable eye diseases such as cataract could decrease the extremity fractures from falls in adults. (Turk J Ophthalmol 2013; 43: 250-2

  17. Automatic residue removal for high-NA extreme illumination

    Science.gov (United States)

    Moon, James; Nam, Byong-Sub; Jeong, Joo-Hong; Kong, Dong-Ho; Nam, Byung-Ho; Yim, Dong Gyu

    2007-10-01

    An epidemic for smaller node has been that, as the device architecture shrinks, lithography process requires high Numerical Aperture (NA), and extreme illumination system. This, in turn, creates many lithography problems such as low lithography process margin (Depth of Focus, Exposure Latitude), unstable Critical Dimension (CD) uniformity and restricted guideline for device design rule and so on. Especially for high NA, extreme illumination such as immersion illumination systems, above all the related problems, restricted design rule due to forbidden pitch is critical and crucial issue. This forbidden pitch is composed of numerous optical effects but majority of these forbidden pitch compose of photo resist residue and these residue must be removed to relieve some room for already tight design rule. In this study, we propose automated algorithm to remove photo resist residue due to high NA and extreme illumination condition. This algorithm automatically self assembles assist patterns based on the original design layout, therefore insuring the safety and simplicity of the generated assist pattern to the original design and removes any resist residue created by extreme illumination condition. Also we tested our automated algorithm on full chip FLASH memory device and showed the residue removal effect by using commercial verification tools as well as on actual test wafer.

  18. Stream Response to an Extreme Defoliation Event

    Science.gov (United States)

    Gold, A.; Loffredo, J.; Addy, K.; Bernhardt, E. S.; Berdanier, A. B.; Schroth, A. W.; Inamdar, S. P.; Bowden, W. B.

    2017-12-01

    Extreme climatic events are known to profoundly impact stream flow and stream fluxes. These events can also exert controls on insect outbreaks, which may create marked changes in stream characteristics. The invasive Gypsy Moth (Lymantria dispar dispar) experiences episodic infestations based on extreme climatic conditions within the northeastern U.S. In most years, gypsy moth populations are kept in check by diseases. In 2016 - after successive years of unusually warm, dry spring and summer weather -gypsy moth caterpillars defoliated over half of Rhode Island's 160,000 forested ha. No defoliation of this magnitude had occurred for more than 30 years. We examined one RI headwater stream's response to the defoliation event in 2016 compared with comparable data in 2014 and 2015. Stream temperature and flow was gauged continuously by USGS and dissolved oxygen (DO) was measured with a YSI EXO2 sonde every 30 minutes during a series of deployments in the spring, summer and fall from 2014-2016. We used the single station, open channel method to estimate stream metabolism metrics. We also assessed local climate and stream temperature data from 2009-2016. We observed changes in stream responses during the defoliation event that suggest changes in ET, solar radiation and heat flux. Although the summer of 2016 had more drought stress (PDSI) than previous years, stream flow occurred throughout the summer, in contrast to several years with lower drought stress when stream flow ceased. Air temperature in 2016 was similar to prior years, but stream temperature was substantially higher than the prior seven years, likely due to the loss of canopy shading. DO declined dramatically in 2016 compared to prior years - more than the rising stream temperatures would indicate. Gross Primary Productivity was significantly higher during the year of the defoliation, indicating more total fixation of inorganic carbon from photo-autotrophs. In 2016, Ecosystem Respiration was also higher and Net

  19. Extreme interplanetary rotational discontinuities at 1 AU

    Science.gov (United States)

    Lepping, R. P.; Wu, C.-C.

    2005-11-01

    This study is concerned with the identification and description of a special subset of four Wind interplanetary rotational discontinuities (from an earlier study of 134 directional discontinuities by Lepping et al. (2003)) with some "extreme" characteristics, in the sense that every case has (1) an almost planar current sheet surface, (2) a very large discontinuity angle (ω), (3) at least moderately strong normal field components (>0.8 nT), and (4) the overall set has a very broad range of transition layer thicknesses, with one being as thick as 50 RE and another at the other extreme being 1.6 RE, most being much thicker than are usually studied. Each example has a well-determined surface normal (n) according to minimum variance analysis and corroborated via time delay checking of the discontinuity with observations at IMP 8 by employing the local surface planarity. From the variance analyses, most of these cases had unusually large ratios of intermediate-to-minimum eigenvalues (λI/λmin), being on average 32 for three cases (with a fourth being much larger), indicating compact current sheet transition zones, another (the fifth) extreme property. For many years there has been a controversy as to the relative distribution of rotational (RDs) to tangential discontinuities (TDs) in the solar wind at 1 AU (and elsewhere, such as between the Sun and Earth), even to the point where some authors have suggested that RDs with large ∣Bn∣s are probably not generated or, if generated, are unstable and therefore very rare. Some of this disagreement apparently has been due to the different selection criteria used, e.g., some allowed eigenvalue ratios (λI/λmin) to be almost an order of magnitude lower than 32 in estimating n, usually introducing unacceptable error in n and therefore also in ∣Bn∣. However, we suggest that RDs may not be so rare at 1 AU, but good quality cases (where ∣Bn∣ confidently exceeds the error in ∣Bn∣) appear to be uncommon, and further

  20. Shocking matter to extreme conditions

    International Nuclear Information System (INIS)

    Gupta, Y.M.; Sharma, S.M.

    1997-01-01

    A good understanding of the thermodynamic response of matter at high compression and high energy densities is important to several areas of physics. Shock-wave experiments are uniquely suited for obtaining data at extreme conditions, and a shock-compressed matter can be viewed as a condensed system with or without dissociation or as a strongly coupled plasma. This article reviews work by Da Silva et al. in which irradiances ranging from 5x10 superscript 12 to 2x10 superscript 14 W/cm 2 were used to generate 8- to 10-ns square pulses in liquid deuterium. The authors demonstrated negligible pre-heating of the sample, steady propagation of the shock wave, and direct determination of the shock wave velocity along with particle velocity and density in the shocked state. Da Silva et al. results are compared with models and other experimental information, and the usefulness of the data in other areas is assessed. 11 refs., 1 fig

  1. Weather extremes could affect agriculture

    Science.gov (United States)

    Balcerak, Ernie

    2012-05-01

    As Earth's climate warms, agricultural producers will need to adapt. Changes, especially increases in extreme events, are already having an impact on food production, according to speakers at a 1 May session on agriculture and food security at the AGU Science Policy Conference. Christopher Field, director of the Department of Global Ecology at the Carnegie Institution for Science of Washington, D. C., pointed out the complex factors that come into play in understanding food security, including spatially varying controls and stresses, incomplete models, and the potential for threshold responses. Factors that are likely to cause problems include increasing population; increasing preference for meat, which needs more land and energy inputs to produce; climate change; and increasing use of agricultural lands for biomass energy.

  2. Generic Hurricane Extreme Seas State

    DEFF Research Database (Denmark)

    Wehmeyer, Christof; Skourup, Jesper; Frigaard, Peter

    2012-01-01

    Extreme sea states, which the IEC 61400-3 (2008) standard requires for the ultimate limit state (ULS) analysis of offshore wind turbines are derived to establish the design basis for the conceptual layout of deep water floating offshore wind turbine foundations in hurricane affected areas....... Especially in the initial phase of floating foundation concept development, site specific metocean data are usually not available. As the areas of interest are furthermore not covered by any design standard, in terms of design sea states, generic and in engineering terms applicable environmental background...... data is required for a type specific conceptual design. ULS conditions for different return periods are developed, which can subsequently be applied in siteindependent analysis and conceptual design. Recordings provided by National Oceanic and Atmospheric Administration (NOAA), of hurricanes along...

  3. Pneumatic tourniquets in extremity surgery.

    LENUS (Irish Health Repository)

    Wakai, A

    2012-02-03

    Pneumatic tourniquets maintain a relatively bloodless field during extremity surgery, minimize blood loss, aid identification of vital structures, and expedite the procedure. However, they may induce an ischemia-reperfusion injury with potentially harmful local and systemic consequences. Modern pneumatic tourniquets are designed with mechanisms to regulate and maintain pressure. Routine maintenance helps ensure that these systems are working properly. The complications of tourniquet use include postoperative swelling, delay of recovery of muscle power, compression neurapraxia, wound hematoma with the potential for infection, vascular injury, tissue necrosis, and compartment syndrome. Systemic complications can also occur. The incidence of complications can be minimized by use of wider tourniquets, careful preoperative patient evaluation, and adherence to accepted principles of tourniquet use.

  4. (When and where) Do extreme climate events trigger extreme ecosystem responses? - Development and initial results of a holistic analysis framework

    Science.gov (United States)

    Hauber, Eva K.; Donner, Reik V.

    2015-04-01

    a seasonal cycle for each quantile of the distribution, which can be used for a fully data-adaptive definition of extremes as exceedances above this time-dependent quantile function. (2) Having thus identified the extreme events, their distribution is analyzed in both space and time. Following a procedure recently proposed by Lloyd-Hughes (2012) and further exploited by Zscheischler et al. (2013), extremes observed at neighboring points in space and time are considered to form connected sets. Investigating the size distribution of these sets provides novel insights into the development and dynamical characteristics of spatio-temporally extended climate and ecosystem extremes. (3) Finally, the timing of such spatio-temporally extended extremes in different climatic as well as ecological variables is tested pairwise to rule out that co-occurrences of extremes have emerged solely due to chance. For this purpose, the recently developed framework of coincidence analysis (Donges et al., 2011; Rammig et al. 2014) is applied. The corresponding analysis allows identifying potential causal linkages between climatic extremes and extreme ecosystem responses and, thus, to study their mechanisms and spatial as well as seasonal distribution in great detail. In this work, the described method is exemplified by using different climate data from the ERA-Interim reanalysis as well as remote sensing-based land surface temperature data. References: Donges et al., PNAS, 108, 20422, 2011 Lloyd-Hughes, Int. J. Climatol., 32, 406, 2012 Rammig et al., Biogeosc. Disc., 11, 2537, 2014 Zscheischler et al., Ecol. Inform., 15, 66, 2013

  5. The Contribution of Extreme Precipitation to the Total Precipitation in China

    Institute of Scientific and Technical Information of China (English)

    SUN Jian-Qi

    2012-01-01

    Using daily precipitation data from weather stations in China, the variations in the contribution of extreme precipitation to the total precipitation are analyzed. It is found that extreme precipitation accounts for approximately one third of the total precipitation based on the overall mean for China. Over the past half century, extreme precipitation has played a dominant role in the year-to-year variability of the total precipitation. On the decadal time scale, the extreme precipitation makes different contributions to the wetting and drying regions of China. The wetting trends of particular regions are mainly attributed to increases in extreme precipitation; in contrast, the drying trends of other regions are mainly due to decreases in non-extreme precipitation.

  6. What is the right way to talk about extreme events?

    Science.gov (United States)

    Sobel, A. H.

    2013-12-01

    Extreme weather events draw the attention of the public. By demonstrating the vulnerability of human society to climate, extreme events can cause nonscientists -government leaders as well as the broader population - to take the danger posed by anthropogenic global warming more seriously than they otherwise might. An extreme event that draws media attention can become a 'teachable moment'. But extreme events are difficult to talk about in a way that honors both the strengths and weaknesses of the underlying science. No single event can be attributed to climate change, and some types of events are not even clearly influenced by it (or not in any ways our science can yet demonstrate). Strong, media-friendly statements that closely connect specific events to climate - designed to make best use of the moment's teachability - can easily overstate the case. This will raise the hackles of one's colleagues, at a minimum, and at worst, may damage the credibility of the field more broadly. Yet talking too much about the uncertainties runs the risk of understating the basic truth that global warming is real and dangerous, and may lend inadvertent support to anti-scientific denialism. I will discuss this tension in the context of my own experiences in the media after 'Superstorm' Sandy. I will address arguments I have heard, from social scientists and media consultants, to the effect that climate scientists should adopt communications strategies that lead to stronger, more media-friendly statements, and learn to suppress the tendency, bred into us during our scientific training, to emphasize the uncertainties.

  7. To the fringe and back: Violent extremism and the psychology of deviance.

    Science.gov (United States)

    Kruglanski, Arie W; Jasko, Katarzyna; Chernikova, Marina; Dugas, Michelle; Webber, David

    2017-04-01

    We outline a general psychological theory of extremism and apply it to the special case of violent extremism (VE). Extremism is defined as motivated deviance from general behavioral norms and is assumed to stem from a shift from a balanced satisfaction of basic human needs afforded by moderation to a motivational imbalance wherein a given need dominates the others. Because motivational imbalance is difficult to sustain, only few individuals do, rendering extreme behavior relatively rare, hence deviant. Thus, individual dynamics translate into social patterns wherein majorities of individuals practice moderation, whereas extremism is the province of the few. Both extremism and moderation require the ability to successfully carry out the activities that these demand. Ability is partially determined by the activities' difficulty, controllable in part by external agents who promote or oppose extremism. Application of this general framework to VE identifies the specific need that animates it and offers broad guidelines for addressing this pernicious phenomenon. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

  8. Vertical structure of extreme currents in the Faroe-Bank Channel

    Directory of Open Access Journals (Sweden)

    C. Carollo

    2005-09-01

    Full Text Available Extreme currents are studied with the aim of understanding their vertical and spatial structures in the Faroe-Bank Channel. Acoustic Doppler Current Profiler time series recorded in 3 deployments in this channel were investigated. To understand the main features of extreme events, the measurements were separated into their components through filtering and tidal analysis before applying the extreme value theory to the surge component. The Generalized Extreme Value (GEV distribution and the Generalized Pareto Distribution (GPD were used to study the variation of surge extremes from near-surface to deep waters. It was found that this component alone is not able to explain the extremes measured in total currents, particularly below 500 m. Here the mean residual flow enhanced by tidal rectification was found to be the component feature dominating extremes. Therefore, it must be taken into consideration when applying the extreme value theory, not to underestimate the return level for total currents. Return value speeds up to 250 cm s–1 for 50/250 years return period were found for deep waters, where the flow is constrained by the topography at bearings near 300/330° It is also found that the UK Meteorological Office FOAM model is unable to reproduce either the magnitude or the form for the extremes, perhaps due to its coarse vertical and horizontal resolution, and is thus not suitable to model extremes on a regional scale. Keywords. Oceanography: Physical (Currents; General circulation; General or miscellaneous

  9. Vertical structure of extreme currents in the Faroe-Bank Channel

    Directory of Open Access Journals (Sweden)

    C. Carollo

    2005-09-01

    Full Text Available Extreme currents are studied with the aim of understanding their vertical and spatial structures in the Faroe-Bank Channel. Acoustic Doppler Current Profiler time series recorded in 3 deployments in this channel were investigated. To understand the main features of extreme events, the measurements were separated into their components through filtering and tidal analysis before applying the extreme value theory to the surge component. The Generalized Extreme Value (GEV distribution and the Generalized Pareto Distribution (GPD were used to study the variation of surge extremes from near-surface to deep waters. It was found that this component alone is not able to explain the extremes measured in total currents, particularly below 500 m. Here the mean residual flow enhanced by tidal rectification was found to be the component feature dominating extremes. Therefore, it must be taken into consideration when applying the extreme value theory, not to underestimate the return level for total currents. Return value speeds up to 250 cm s–1 for 50/250 years return period were found for deep waters, where the flow is constrained by the topography at bearings near 300/330° It is also found that the UK Meteorological Office FOAM model is unable to reproduce either the magnitude or the form for the extremes, perhaps due to its coarse vertical and horizontal resolution, and is thus not suitable to model extremes on a regional scale.

    Keywords. Oceanography: Physical (Currents; General circulation; General or miscellaneous

  10. Adaptation to extreme climate events at a regional scale

    OpenAIRE

    Hoffmann, Christin

    2017-01-01

    A significant increase of the frequency, the intensity and the duration of extreme climate events in Switzerland induces the need to find a strategy to deal with the damages they cause. For more than two decades, mitigation has been the main objective of climate policy. However, due to already high atmospheric carbon concentrations and the inertia of the climate system, climate change is unavoidable to some degree, even if today’s emissions were almost completely cut back. Along with the high...

  11. Design, fabrication, and characterization of high-efficiency extreme ultraviolet diffusers

    Energy Technology Data Exchange (ETDEWEB)

    Naulleau, Patrick P.; Liddle, J. Alexander; Salmassi, Farhad; Anderson, Erik H.; Gullikson, Eric M.

    2004-02-19

    As the development of extreme ultraviolet (EUV) lithography progresses, interest grows in the extension of traditional optical components to the EUV regime. The strong absorption of EUV by most materials and its extremely short wavelength, however, makes it very difficult to implement many components that are commonplace in the longer wavelength regimes. One such example is the diffuser often implemented with ordinary ground glass in the visible light regime. Here we demonstrate the fabrication of reflective EUV diffusers with high efficiency within a controllable bandwidth. Using these techniques we have fabricated diffusers with efficiencies exceeding 10% within a moderate angular single-sided bandwidth of approximately 0.06 radians.

  12. Extreme Rainfall In A City

    Science.gov (United States)

    Nkemdirim, Lawrence

    Cities contain many structures and activities that are vulnerable to severe weather. Heavy precipitation cause floods which can damage structures, compromise transportation and water supply systems, and slow down economic and social activities. Rain induced flood patterns in cities must be well understood to enable effective placement of flood control and other regulatory measures. The planning goal is not to eliminate all floods but to reduce their frequency and resulting damage. Possible approaches to such planning include probability based extreme event analysis. Precipitation is normally the most variable hydrologic element over a given area. This variability results from the distribution of clouds and in cloud processes in the atmosphere, the storm path, and the distribution of topographical features on the ground along path. Some studies suggest that point rainfall patterns are also affected by urban industrial effects hence some agreement that cities are wetter than the country surrounding them. However, there are still questions regarding the intra- urban distribution of precipitation. The sealed surfaces, urban structures, and the urban heat anomaly increase convection in cities which may enhance the generation of clouds. Increased dust and gaseous aerosols loads are effective condensation and sublimation nuclei which may also enhance the generation of precipitation. Based on these associations, the greatest amount of convection type rainfall should occur at city center. A study of summer rainfall in Calgary showed that frequencies of trace amounts of rainfall and events under 0.2mm are highest downtown than elsewhere. For amounts greater than than 0.2 mm, downtown sites were not favored. The most compelling evidence for urban-industrial precipitation enhancement came from the Metromex project around St. Loius, Missouri where maximum increases of between 5 to 30 per cent in summer rainfall downwind of the city was linked to urbanization and

  13. Laparoendoscopic Rendezvous for Concomitant Cholecystocholedocholithiasis: A Successful Modality Even in the Most Difficult Presentations Including Pregnancy.

    Science.gov (United States)

    Shirah, Bader Hamza; Mikwar, Zaher Abdulaziz; Ahmad, Akram Neyaz; Dahlan, Yaser Mohammed

    2016-01-01

    Background . Laparoendoscopic rendezvous (LERV) technique is emerging as an attractive treatment option for concomitant cholecystocholedocholithiasis. In this paper, we report our experience in performing the LERV technique in patients with unusual presentations in terms of anatomical difficulty, pregnancy, multiple comorbid diseases, and postlaparotomy. We aim to highlight the effectiveness of the LERV technique in some clinical situations where conventional methods would fail or carry high risks in adequately managing concomitant cholecystocholedocholithiasis. Methods . Four patients diagnosed to have concomitant cholecystocholedocholithiasis with associated difficult presentation or comorbid diseases were treated using the LERV technique. One patient presented with difficult anatomy where ERCP failed at initial attempts. Another patient was pregnant (first trimester). A third patient had complex comorbid diseases (bronchial asthma, hypertension, congestive heart failure, and end-stage renal disease on regular hemodialysis). A fourth patient had previous laparotomy and sigmoidectomy for diverticular disease and had severe hospital phobia. Results . All patients tolerated the LERV technique very well; no intraoperative occurrence was reported. The mean operative time was 86.3 ± 17.2 minutes; mean time of the endoscopic part was 29.4 ± 3.57 minutes. The mean blood loss was 44.3 ± 18.2 mL (range 20-85). Residual stone, postoperative complications, postoperative morbidity, and postoperative mortality were 0 (0%). Postoperative short hospital stay was reported in all patients, average 3 days (range 2-4). Conclusion . LERV procedure is a safe and effective treatment option for the management of concomitant cholecystocholedocholithiasis, even in difficult situations where other methods would fail or carry high risks, or in patients presenting with severe comorbid diseases or pregnancy. This procedure may emerge as an attractive alternative option for high

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

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    Katharina eScheiter

    2014-03-01

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

  15. Laparoendoscopic Rendezvous for Concomitant Cholecystocholedocholithiasis: A Successful Modality Even in the Most Difficult Presentations Including Pregnancy

    Directory of Open Access Journals (Sweden)

    Bader Hamza Shirah

    2016-01-01

    Full Text Available Background. Laparoendoscopic rendezvous (LERV technique is emerging as an attractive treatment option for concomitant cholecystocholedocholithiasis. In this paper, we report our experience in performing the LERV technique in patients with unusual presentations in terms of anatomical difficulty, pregnancy, multiple comorbid diseases, and postlaparotomy. We aim to highlight the effectiveness of the LERV technique in some clinical situations where conventional methods would fail or carry high risks in adequately managing concomitant cholecystocholedocholithiasis. Methods. Four patients diagnosed to have concomitant cholecystocholedocholithiasis with associated difficult presentation or comorbid diseases were treated using the LERV technique. One patient presented with difficult anatomy where ERCP failed at initial attempts. Another patient was pregnant (first trimester. A third patient had complex comorbid diseases (bronchial asthma, hypertension, congestive heart failure, and end-stage renal disease on regular hemodialysis. A fourth patient had previous laparotomy and sigmoidectomy for diverticular disease and had severe hospital phobia. Results. All patients tolerated the LERV technique very well; no intraoperative occurrence was reported. The mean operative time was 86.3±17.2 minutes; mean time of the endoscopic part was 29.4±3.57 minutes. The mean blood loss was 44.3±18.2 mL (range 20–85. Residual stone, postoperative complications, postoperative morbidity, and postoperative mortality were 0 (0%. Postoperative short hospital stay was reported in all patients, average 3 days (range 2–4. Conclusion. LERV procedure is a safe and effective treatment option for the management of concomitant cholecystocholedocholithiasis, even in difficult situations where other methods would fail or carry high risks, or in patients presenting with severe comorbid diseases or pregnancy. This procedure may emerge as an attractive alternative option for high

  16. Multimodal treatment in difficult sialolithiasis: Role of extracorporeal shock-wave lithotripsy and intraductal pneumatic lithotripsy.

    Science.gov (United States)

    Koch, Michael; Schapher, Mirco; Mantsopoulos, Konstantinos; von Scotti, Felix; Goncalves, Miguel; Iro, Heinrich

    2017-12-15

    To assess results after treatment of difficult/complex sialolithiasis with extracorporeal shock-wave lithotripsy (ESWL) and intraductal pneumatic lithotripsy (IPL). Retrospective study in a tertiary referral center. Altogether, 63 stones were diagnosed in 38 patients with difficult/complex sialolithiasis. Forty-nine stones were treated with fragmentation using both ESWL and IPL. Stones accessible with the sialendoscope were treated primarily with IPL in multiple sialolithiasis. Seventy-one ESWL procedures and 57 IPL were performed in our patients. Forty-nine stones were treated by 67 ESWL procedures and 52 IPL. ESWL converted sialoliths from sialendoscopically untreatable into sialendoscopically treatable cases in 94.7%; the treatment then was completed by a total of 52 IPL procedures. ESWL was performed before IPL (81.6%), in combination with IPL (7.9%) and after (10.5%). Complete fragmentation was achieved in 97.9%. Four stones each were treated with ESWL and IPL alone in multiple sialolithiasis. Altogether, 53 stones were treated by 57 IPL procedures. Complete fragmentation was achieved in 98.1% of the 53 stones. ESWL and IPL were the dominant treatment modalities in 84.1% of all 63 stones treated. Of all 38 patients, 92.1% became stone-free and all became symptom-free. All the glands were preserved. Multiple stones were treated in 34.2% of the patients; of these, 92.3% became stone-free. These results show that patients with difficult and complex sialolithiasis can be treated with high success rates of > 90% using a multimodal, minimally invasive, and gland-preserving treatment approach. ESWL and IPL played a key role in this multimodal treatment regime in > 80% of stones. 4. Laryngoscope, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

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

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    Basak Ceyda Meco

    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.

  18. Extreme Ionizing-Radiation-Resistant Bacterium

    Science.gov (United States)

    Vaishampayan, Parag A.; Venkateswaran, Kasthuri J.; Schwendner, Petra

    2013-01-01

    There is a growing concern that desiccation and extreme radiation-resistant, non-spore-forming microorganisms associated with spacecraft surfaces can withstand space environmental conditions and subsequent proliferation on another solar body. Such forward contamination would jeopardize future life detection or sample return technologies. The prime focus of NASA s planetary protection efforts is the development of strategies for inactivating resistance-bearing micro-organisms. Eradi cation techniques can be designed to target resistance-conferring microbial populations by first identifying and understanding their physiologic and biochemical capabilities that confers its elevated tolerance (as is being studied in Deinococcus phoenicis, as a result of this description). Furthermore, hospitals, food, and government agencies frequently use biological indicators to ensure the efficacy of a wide range of radiation-based sterilization processes. Due to their resistance to a variety of perturbations, the nonspore forming D. phoenicis may be a more appropriate biological indicator than those currently in use. The high flux of cosmic rays during space travel and onto the unshielded surface of Mars poses a significant hazard to the survival of microbial life. Thus, radiation-resistant microorganisms are of particular concern that can survive extreme radiation, desiccation, and low temperatures experienced during space travel. Spore-forming bacteria, a common inhabitant of spacecraft assembly facilities, are known to tolerate these extreme conditions. Since the Viking era, spores have been utilized to assess the degree and level of microbiological contamination on spacecraft and their associated spacecraft assembly facilities. Members of the non-sporeforming bacterial community such as Deinococcus radiodurans can survive acute exposures to ionizing radiation (5 kGy), ultraviolet light (1 kJ/m2), and desiccation (years). These resistive phenotypes of Deinococcus enhance the

  19. History Matters: What Happens When African Americans Confront Their Difficult Past.

    Science.gov (United States)

    Seitz, Phillip

    2016-05-01

    History and Reconstruction is an interdisciplinary project to assess the impact of African American history education for black men. Under the theory of trauma recovery, leading scholars of African American history worked with a group of ten ex-offenders, supported by the services of a psychologist and an African American cultural expert and storyteller. Results based on psychological testing and qualitative feedback showed that history can be a catalyst for personal development and transformation. It also demonstrated that difficult history can be taught and assimilated for audience benefit. History and Reconstruction was supported by the Pew Center for Arts and Heritage.

  20. Anesthetic considerations and difficult airway management in a case of Noonan syndrome

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    Sukhminder Jit Singh Bajwa

    2011-01-01

    Full Text Available Noonan syndrome is a genetically transmitted autosomal dominant disorder characterized by various anatomic anomalies and pathophysiologic derangements. Anesthetic management in such cases poses a multitude of challenges, especially related to the airway management and maintenance of cardiovascular stability. We report a case of a 9-year-old male child weighing 24 kg, who was diagnosed as a case of Noonan syndrome and had undergone ligation of patent ductus arteriosus during early childhood. The child was operated on for release of bilateral neck bands under general anesthesia. The case report pertains to the successful airway and anesthetic management in the background of difficult airway and existence of various cardiac lesions.