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Sample records for making reallocation difficult

  1. What Makes Difficult History Difficult?

    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…

  2. Making marketing difficult

    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...

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

    Stern, David

    2013-01-01

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

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

    Azzurra Ruggeri

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

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

    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.

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

    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

  7. Respecting an Individual's Privacy Critical in Making Difficult Journalistic Judgments.

    Adams, Julian

    1984-01-01

    Discusses the criteria of "newsworthy" regarding news reporting and the right to privacy. Examines the thin line between what is legal and what is ethical to print and some components of the law to consider when making such decisions. (HTH)

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

    Bickel, Janet; Rosenthal, Susan L

    2011-10-01

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

  9. Figure 4, Cropland Reallocation

    U.S. Environmental Protection Agency — This is a netCDF formatted data file. All data values are reported as grid cell area percent (%). Since all simulation grid cells are of uniform area. Reallocation...

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

    Shaw, Peter J A

    2010-01-01

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

  11. 24 CFR 791.405 - Reallocations of budget authority.

    2010-04-01

    ... 24 Housing and Urban Development 4 2010-04-01 2010-04-01 false Reallocations of budget authority... Allocation of Budget Authority for Housing Assistance § 791.405 Reallocations of budget authority. (a) The field office shall make every reasonable effort to use the budget authority made available for each...

  12. Quality Assurance in the National Tests of English: Investigating What Makes Reading Difficult

    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

  13. Difficult to wean patients: cultural factors and their impact on weaning decision-making.

    Kydonaki, Kalliopi; Huby, Guro; Tocher, Jennifer

    2014-03-01

    To examine the elements of the intensive care environment and consider the impact on nurses' involvement in decision-making when weaning from mechanical ventilation. Optimal management of difficult to wean patients requires the dynamic collaboration of all clinicians and the contribution of their knowledge and skills. The introduction of weaning protocols has increased nurses' input in decision-making, but there are various elements of the decision environment that impact on their involvement, which have been given little consideration. Ethnography was used as the research design for this study. Fieldwork took place in two tertiary hospitals in Greece and Scotland for five months each to unveil clinicians' behaviour and interactions during the weaning practice. Observation was based on the weaning process of 10 Scottish and 9 Greek long-term ventilated patients. Semi-structured interviews followed with nurses (n = 33) and doctors (n = 9) in both settings to understand nurses' perceived involvement in weaning decision-making. Thematic analysis of interviews and field notes followed using the Qualitative Data Analysis software NVivo. Clinicians' participation was voluntary. The main themes identified were the (1) organisation of the units (time and structure of the ward rounds, staff levels and staff allocation system), (2) the inter- professional relationships, (3) the ownership and accountability in weaning decision-making and (4) the role of the weaning protocols. These elements described the culture of the ICUs and defined nurses' role in weaning decision-making. Clinical decision-making is a multi-dynamic process specifically in complex clinical situations such as weaning from mechanical ventilation. This paper suggests that weaning practice should be considered in relation to the elements of the clinical environment to provide an individualised and patient-centred weaning approach. Methods to enhance nurses' role in teamwork and collaborative decision-making

  14. Authoritarian physicians and patients' fear of being labeled 'difficult' among key obstacles to shared decision making.

    Frosch, Dominick L; May, Suepattra G; Rendle, Katharine A S; Tietbohl, Caroline; Elwyn, Glyn

    2012-05-01

    Relatively little is known about why some patients are reluctant to engage in a collaborative discussion with physicians about their choices in health care. To explore this issue further, we conducted six focus-group sessions with forty-eight people in the San Francisco Bay Area. In the focus groups, we found that participants voiced a strong desire to engage in shared decision making about treatment options with their physicians. However, several obstacles inhibit those discussions. These include the fact that even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations; that physicians can be authoritarian; and that the fear of being categorized as "difficult" prevents patients from participating more fully in their own health care. We argue that physicians may not be aware of a need to create a safe environment for open communication to facilitate shared decision making. Rigorous measures of patient engagement, and of the degree to which health care decisions truly reflect patient preferences, are needed to advance shared decision making in clinical practice.

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

    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

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

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

    2009-04-15

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

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

    Segall, Avner

    2014-01-01

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

  18. Insider trading: regulation, risk reallocation, and welfare

    Estrada, Javier

    1995-01-01

    I argue in this paper that the imposition of insider trading regulations on a securities market generates not on1y a reallocation of wealth from insiders to liquidity traders, but also a reallocation of risk from the former to the latter. I further argue that, although the wealth reallocation has no impact on social welfare, under plausible assumptions, the risk reallocation imposes a cost on society.

  19. Success nonetheless : Making public utilities work in small-scale democracies despite difficult capital conditions

    Douglas, Scott

    2011-01-01

    A large part of the study of politics is dedicated to identifying the circumstances under which democracy will flourish. Putnam made a major contribution to this field through his concept of social capital as developed in Making Democracy Work. Putnam found that communities with a high number of

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

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

    2016-01-01

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

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

    Stephanie M Carpenter

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

  2. What makes it so difficult for nurses to coach patients in shared decision making? A process evaluation.

    Lenzen, Stephanie Anna; Daniëls, Ramon; van Bokhoven, Marloes Amantia; van der Weijden, Trudy; Beurskens, Anna

    2018-04-01

    Primary care nurses play a crucial role in coaching patients in shared decision making about goals and actions. This presents a challenge to practice nurses, who are frequently used to protocol-based working routines. Therefore, an approach was developed to support nurses to coach patients in shared decision making. To investigate how the approach was implemented and experienced by practice nurses and patients. A process evaluation was conducted using quantitative and qualitative methods. Fifteen female practice nurses (aged between 28 and 55 years), working with people suffering from diabetes, COPD, asthma and/or cardiovascular diseases, participated. Nurses were asked to apply the approach to their chronically ill patients and to recruit patients (n = 10) willing to participate in an interview or an audio-recording of a consultation (n = 13); patients (13 women, 10 men) were aged between 41 and 88 years and suffered from diabetes, COPD or cardiovascular diseases. The approach involved a framework for shared decision making about goals and actions, a tool to explore the patient perspective, a patient profiles model and a training course. Interviews (n = 15) with nurses, a focus group with nurses (n = 9) and interviews with patients (n = 10) were conducted. Nurses filled in a questionnaire about their work routine before, during and after the training course. They were asked to deliver audiotapes of their consultations (n = 13). Overall, nurses felt that the approach supported them to coach patients in shared decision making. Nurses had become more aware of their own attitudes and learning needs and reported to have had more in-depth discussions with patients. The on-the-job coaching was experienced as valuable. However, nurses struggled to integrate the approach in routine care. They experienced the approach as different to their protocol-based routines and expressed the importance of receiving support and the need for integration of the

  3. WHAT MAKES CHEMISTRY DIFFICULT?

    IICBA01

    School of Natural and Computational Science Dire Dawa University, Ethiopia,. 2 ... lack of teaching aids and the difficulty of the language of chemistry. ... lab every other week consisting of concept pretests on the web, hand-written homework, ...

  4. How FDG-PET helps making decision for surgery in various difficult subgroups of temporal lobe epilepsy?

    Tepmongkol, S [Division of Nuclear Medicine, Department of Radiology and Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok (Thailand); Locharernkul, C [Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University and Chulalongkorn Comprehensive Epilepsy Program under the patronage of Professor Doctor HRH Princess Chulabhorn, Bangkok (Thailand); Chaiwatanarat, T; Kingpetch, K; Sirisalipoch, S [Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok (Thailand); Limotai, C; Loplumlert, J [Chulalongkorn Comprehensive Epilepsy Program under the patronage of Professor Doctor HRH Princess Chulabhorn, Bangkok (Thailand)

    2007-07-01

    Concordant pre-surgical data are the important predictors of good surgical outcome in patients with localization-related epilepsy. Medically intractable temporal lobe epilepsy with hippocampal sclerosis (HS) and concordant pre-surgical data is straightforward and may not need functional imaging. However, in other instances for example, HS with discordant data (HSD), bilateral HS with discordant data (BHSD), temporal lobe epilepsy with dual pathology (DP), non-lesional temporal lobe epilepsy (NL) are the difficult subgroups. In these groups, functional imaging eg. brain perfusion SPECT or brain PET may play a major role for surgical decision making. To our knowledge, there was no previous data in using FDG-PET in different subgroups as mentioned. Only some previous studies in single subgroup without analyzing impact of PET findings on decision-making have been reported. We thus aim to evaluate the usefulness of FDG-PET in these 4 subgroups.

  5. 24 CFR 92.606 - Reallocations.

    2010-04-01

    ... 24 Housing and Urban Development 1 2010-04-01 2010-04-01 false Reallocations. 92.606 Section 92.606 Housing and Urban Development Office of the Secretary, Department of Housing and Urban Development HOME INVESTMENT PARTNERSHIPS PROGRAM American Dream Downpayment Initiative § 92.606 Reallocations. If...

  6. Citric Acid and Quinine Share Perceived Chemosensory Features Making Oral Discrimination Difficult in C57BL/6J Mice

    Treesukosol, Yada; Mathes, Clare M.

    2011-01-01

    Evidence in the literature shows that in rodents, some taste-responsive neurons respond to both quinine and acid stimuli. Also, under certain circumstances, rodents display some degree of difficulty in discriminating quinine and acid stimuli. Here, C57BL/6J mice were trained and tested in a 2-response operant discrimination task. Mice had severe difficulty discriminating citric acid from quinine and 6-n-propylthiouracil (PROP) with performance slightly, but significantly, above chance. In contrast, mice were able to competently discriminate sucrose from citric acid, NaCl, quinine, and PROP. In another experiment, mice that were conditioned to avoid quinine by pairings with LiCl injections subsequently suppressed licking responses to quinine and citric acid but not to NaCl or sucrose in a brief-access test, relative to NaCl-injected control animals. However, mice that were conditioned to avoid citric acid did not display cross-generalization to quinine. These mice significantly suppressed licking only to citric acid, and to a much lesser extent NaCl, compared with controls. Collectively, the findings from these experiments suggest that in mice, citric acid and quinine share chemosensory features making discrimination difficult but are not perceptually identical. PMID:21421543

  7. The lack of homogeneity in the product (LHP) in the ceramic tile industry and its impact on the reallocation of inventories

    Alarcon, F.; Alemany, M. M. E.; Lario, F. C.; Oltra, R. F.

    2011-01-01

    The allocation of the product available- to-promise (ATP) in make-to-stock (MTS) contexts is of the utmost importance as it can influence customer satisfaction and profits of the company. However, a proper initial allocation may become inadequate for several reasons. In these case, it is necessary the reallocation of inventory, which will be more complex the more ambitious goals to achieve with it and increased the amount of information to use. In this regard, it is noteworthy that the lack of homogeneity in the product (LHP), present in different industrial sectors, causes the atomization of the inventory and increases the complexity of the reallocation, difficult to obtain optimal solutions. This paper describes the problems of the LHP, first under a generic perspective and then, particularized to MTS ceramic companies. Subsequently, situations in which a specific allocation of ATP can no longer be appropriate in this context are identified and the reassignment, as a way to search for new valid assignments, is proposed. Finally, through a case study of a ceramic company, the impact of the LHP in each of the situations identified is analyzed, noting that the LHP causes some of these situations and in all of them, complicates the reallocation of inventory to orders. (Authors) 31 refs.

  8. Economics and computer science of a radio spectrum reallocation.

    Leyton-Brown, Kevin; Milgrom, Paul; Segal, Ilya

    2017-07-11

    The recent "incentive auction" of the US Federal Communications Commission was the first auction to reallocate radio frequencies between two different kinds of uses: from broadcast television to wireless Internet access. The design challenge was not just to choose market rules to govern a fixed set of potential trades but also, to determine the broadcasters' property rights, the goods to be exchanged, the quantities to be traded, the computational procedures, and even some of the performance objectives. An essential and unusual challenge was to make the auction simple enough for human participants while still ensuring that the computations would be tractable and capable of delivering nearly efficient outcomes.

  9. Dynamic reallocation of marketable nitrogen emission permits in Danish freshwater aquaculture

    Nielsen, Rasmus; Andersen, Jesper Levring; Bogetoft, Peter

    2014-01-01

    farms are gradually introduced to the industry over 10 years. The new industry structure, production, and profitability gains are investigated, and the effect of changing the overall level of nitrogen emission is analyzed. Our results show that there is scope for a more efficient allocation of resources...... to either increase the production level or to reduce the emission level. This article adds to the literature by extending previous static reallocation models to a dynamic model, which allows for a gradual introduction of new firms. This makes it possible for managers to analyze the effects of reallocating...

  10. Difficult decisions: A qualitative exploration of the statistical decision making process from the perspectives of psychology students and academics

    Peter James Allen

    2016-02-01

    Full Text Available Quantitative research methods are essential to the development of professional competence in psychology. They are also an area of weakness for many students. In particular, students are known to struggle with the skill of selecting quantitative analytical strategies appropriate for common research questions, hypotheses and data types. To begin understanding this apparent deficit, we presented nine psychology undergraduates (who had all completed at least one quantitative methods course with brief research vignettes, and asked them to explicate the process they would follow to identify an appropriate statistical technique for each. Thematic analysis revealed that all participants found this task challenging, and even those who had completed several research methods courses struggled to articulate how they would approach the vignettes on more than a very superficial and intuitive level. While some students recognized that there is a systematic decision making process that can be followed, none could describe it clearly or completely. We then presented the same vignettes to 10 psychology academics with particular expertise in conducting research and/or research methods instruction. Predictably, these ‘experts’ were able to describe a far more systematic, comprehensive, flexible and nuanced approach to statistical decision making, which begins early in the research process, and pays consideration to multiple contextual factors. They were sensitive to the challenges that students experience when making statistical decisions, which they attributed partially to how research methods and statistics are commonly taught. This sensitivity was reflected in their pedagogic practices. When asked to consider the format and features of an aid that could facilitate the statistical decision making process, both groups expressed a preference for an accessible, comprehensive and reputable resource that follows a basic decision tree logic. For the academics in

  11. Difficult Decisions: A Qualitative Exploration of the Statistical Decision Making Process from the Perspectives of Psychology Students and Academics.

    Allen, Peter J; Dorozenko, Kate P; Roberts, Lynne D

    2016-01-01

    Quantitative research methods are essential to the development of professional competence in psychology. They are also an area of weakness for many students. In particular, students are known to struggle with the skill of selecting quantitative analytical strategies appropriate for common research questions, hypotheses and data types. To begin understanding this apparent deficit, we presented nine psychology undergraduates (who had all completed at least one quantitative methods course) with brief research vignettes, and asked them to explicate the process they would follow to identify an appropriate statistical technique for each. Thematic analysis revealed that all participants found this task challenging, and even those who had completed several research methods courses struggled to articulate how they would approach the vignettes on more than a very superficial and intuitive level. While some students recognized that there is a systematic decision making process that can be followed, none could describe it clearly or completely. We then presented the same vignettes to 10 psychology academics with particular expertise in conducting research and/or research methods instruction. Predictably, these "experts" were able to describe a far more systematic, comprehensive, flexible, and nuanced approach to statistical decision making, which begins early in the research process, and pays consideration to multiple contextual factors. They were sensitive to the challenges that students experience when making statistical decisions, which they attributed partially to how research methods and statistics are commonly taught. This sensitivity was reflected in their pedagogic practices. When asked to consider the format and features of an aid that could facilitate the statistical decision making process, both groups expressed a preference for an accessible, comprehensive and reputable resource that follows a basic decision tree logic. For the academics in particular, this aid

  12. Difficult Decisions: A Qualitative Exploration of the Statistical Decision Making Process from the Perspectives of Psychology Students and Academics

    Allen, Peter J.; Dorozenko, Kate P.; Roberts, Lynne D.

    2016-01-01

    Quantitative research methods are essential to the development of professional competence in psychology. They are also an area of weakness for many students. In particular, students are known to struggle with the skill of selecting quantitative analytical strategies appropriate for common research questions, hypotheses and data types. To begin understanding this apparent deficit, we presented nine psychology undergraduates (who had all completed at least one quantitative methods course) with brief research vignettes, and asked them to explicate the process they would follow to identify an appropriate statistical technique for each. Thematic analysis revealed that all participants found this task challenging, and even those who had completed several research methods courses struggled to articulate how they would approach the vignettes on more than a very superficial and intuitive level. While some students recognized that there is a systematic decision making process that can be followed, none could describe it clearly or completely. We then presented the same vignettes to 10 psychology academics with particular expertise in conducting research and/or research methods instruction. Predictably, these “experts” were able to describe a far more systematic, comprehensive, flexible, and nuanced approach to statistical decision making, which begins early in the research process, and pays consideration to multiple contextual factors. They were sensitive to the challenges that students experience when making statistical decisions, which they attributed partially to how research methods and statistics are commonly taught. This sensitivity was reflected in their pedagogic practices. When asked to consider the format and features of an aid that could facilitate the statistical decision making process, both groups expressed a preference for an accessible, comprehensive and reputable resource that follows a basic decision tree logic. For the academics in particular, this aid

  13. 75 FR 75693 - Tax Credit Assistance Program-Reallocation of Funds

    2010-12-06

    ... DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT [Docket No. FR-5448-N-01] Tax Credit Assistance... the Reallocation of Tax Credit Assistance Program (TCAP) funds. This funding opportunity makes approximately $16 million available to assist housing projects that received Low Income Housing Tax Credit...

  14. Electricity market integration: Redistribution effect versus resource reallocation

    Finon, Dominique; Romano, Elliot

    2009-01-01

    Summary: In countries with a significant amount of low variable cost generation capacity, the integration of electricity markets poses a real problem with respect to consumers' interests. In such cases, consumers face a significant price rise compared with consumers in countries where low-cost capacities are lacking. This paper analyses this problem both in the short and long term, focusing on a market dominated by nuclear and hydro production. When there are too many restrictions on new capacity developments in low-cost technologies, market integration will lead to surplus redistribution without any production reallocation. This really makes it legitimate to contemplate redistributive compensations towards local consumers in countries which benefited from low variable cost generators at the moment of liberalisation. This paper examines two alternative ways of rent reallocation, one by income with a windfall tax on nuclear producers and the allocation of this revenue to energy efficiency policy funds, and another by price by giving drawing rights on the existing nuclear generators' production to small commercial and domestic consumers, at a level equivalent to the one necessary to maintain regulated prices.

  15. Remote Sensing of Aerosols from Satellites: Why Has It Been Do Difficult to Quantify Aerosol-Cloud Interactions for Climate Assessment, and How Can We Make Progress?

    Kahn, Ralph A.

    2015-01-01

    The organizers of the National Academy of Sciences Arthur M. Sackler Colloquia Series on Improving Our Fundamental Understanding of the Role of Aerosol-Cloud Interactions in the Climate System would like to post Ralph Kahn's presentation entitled Remote Sensing of Aerosols from Satellites: Why has it been so difficult to quantify aerosol-cloud interactions for climate assessment, and how can we make progress? to their public website.

  16. The lack of homogeneity in the product (LHP) in the ceramic tile industry and its impact on the reallocation of inventories; La falta de homogeneidad del producto (FHP) en las empresas ceramicas y su impacto en la reasignacion del inventario

    Alarcon, F.; Alemany, M. M. E.; Lario, F. C.; Oltra, R. F.

    2011-07-01

    The allocation of the product available- to-promise (ATP) in make-to-stock (MTS) contexts is of the utmost importance as it can influence customer satisfaction and profits of the company. However, a proper initial allocation may become inadequate for several reasons. In these case, it is necessary the reallocation of inventory, which will be more complex the more ambitious goals to achieve with it and increased the amount of information to use. In this regard, it is noteworthy that the lack of homogeneity in the product (LHP), present in different industrial sectors, causes the atomization of the inventory and increases the complexity of the reallocation, difficult to obtain optimal solutions. This paper describes the problems of the LHP, first under a generic perspective and then, particularized to MTS ceramic companies. Subsequently, situations in which a specific allocation of ATP can no longer be appropriate in this context are identified and the reassignment, as a way to search for new valid assignments, is proposed. Finally, through a case study of a ceramic company, the impact of the LHP in each of the situations identified is analyzed, noting that the LHP causes some of these situations and in all of them, complicates the reallocation of inventory to orders. (Authors) 31 refs.

  17. Development of shared decision-making resources to help inform difficult healthcare decisions: An example focused on dysvascular partial foot and transtibial amputations.

    Quigley, Matthew; Dillon, Michael P; Fatone, Stefania

    2018-02-01

    Shared decision making is a consultative process designed to encourage patient participation in decision making by providing accurate information about the treatment options and supporting deliberation with the clinicians about treatment options. The process can be supported by resources such as decision aids and discussion guides designed to inform and facilitate often difficult conversations. As this process increases in use, there is opportunity to raise awareness of shared decision making and the international standards used to guide the development of quality resources for use in areas of prosthetic/orthotic care. To describe the process used to develop shared decision-making resources, using an illustrative example focused on decisions about the level of dysvascular partial foot amputation or transtibial amputation. Development process: The International Patient Decision Aid Standards were used to guide the development of the decision aid and discussion guide focused on decisions about the level of dysvascular partial foot amputation or transtibial amputation. Examples from these shared decision-making resources help illuminate the stages of development including scoping and design, research synthesis, iterative development of a prototype, and preliminary testing with patients and clinicians not involved in the development process. Lessons learnt through the process, such as using the International Patient Decision Aid Standards checklist and development guidelines, may help inform others wanting to develop similar shared decision-making resources given the applicability of shared decision making to many areas of prosthetic-/orthotic-related practice. Clinical relevance Shared decision making is a process designed to guide conversations that help patients make an informed decision about their healthcare. Raising awareness of shared decision making and the international standards for development of high-quality decision aids and discussion guides is important

  18. The Patient Feedback Response Framework - Understanding why UK hospital staff find it difficult to make improvements based on patient feedback: A qualitative study.

    Sheard, Laura; Marsh, Claire; O'Hara, Jane; Armitage, Gerry; Wright, John; Lawton, Rebecca

    2017-04-01

    Patients are increasingly being asked for feedback about their healthcare experiences. However, healthcare staff often find it difficult to act on this feedback in order to make improvements to services. This paper draws upon notions of legitimacy and readiness to develop a conceptual framework (Patient Feedback Response Framework - PFRF) which outlines why staff may find it problematic to respond to patient feedback. A large qualitative study was conducted with 17 ward based teams between 2013 and 2014, across three hospital Trusts in the North of England. This was a process evaluation of a wider study where ward staff were encouraged to make action plans based on patient feedback. We focus on three methods here: i) examination of taped discussion between ward staff during action planning meetings ii) facilitators notes of these meetings iii) telephone interviews with staff focusing on whether action plans had been achieved six months later. Analysis employed an abductive approach. Through the development of the PFRF, we found that making changes based on patient feedback is a complex multi-tiered process and not something that ward staff can simply 'do'. First, staff must exhibit normative legitimacy - the belief that listening to patients is a worthwhile exercise. Second, structural legitimacy has to be in place - ward teams need adequate autonomy, ownership and resource to enact change. Some ward teams are able to make improvements within their immediate control and environment. Third, for those staff who require interdepartmental co-operation or high level assistance to achieve change, organisational readiness must exist at the level of the hospital otherwise improvement will rarely be enacted. Case studies drawn from our empirical data demonstrate the above. It is only when appropriate levels of individual and organisational capacity to change exist, that patient feedback is likely to be acted upon to improve services. Copyright © 2017 The Authors. Published

  19. Excel-based scheduling for reallocation of nursing staff.

    2016-10-19

    Outi Annelli Tuominen and colleagues write in Nursing Management about the use of an Excel-based scheduling system for reallocation of nursing staff, which was trialled on ward managers and assistant ward managers.

  20. Job Creation and Job Destruction, Worker Reallocation, and Wages.

    Belzil, Christian

    2000-01-01

    Using Danish firm (workplace) data on employment reallocation merged with individual records, the effects of job creation/destruction and worker reallocation on wages are estimated using fixed effects techniques. After controlling for business cycle fluctuations, job creation is found to increase male wages. The effect of net job creation seems present at all phases of the business cycle. Entry wages as well as wages of low tenure workers appear much more sensitive to idiosyncratic job creati...

  1. Why Translation Is Difficult

    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....

  2. Job creation and destruction, worker reallocation and wages

    Belzil, Christian

    1997-01-01

    Using Danish firm level data on employment dynamics merged with individual records on all workers in a given firm, various measures of employment and worker reallocation used in the macroeconomics literature are incorporated in a wage equation framework. The effects of job creation/destruction an......Using Danish firm level data on employment dynamics merged with individual records on all workers in a given firm, various measures of employment and worker reallocation used in the macroeconomics literature are incorporated in a wage equation framework. The effects of job creation...

  3. Financial Globalisation and Sectoral Reallocation of Capital in South Africa

    Ziv Chinzara; Radhika Lahiri; En Te chen

    2012-01-01

    The study examines the impact of financial globalisation on intra-sector and inter-sector firm level reallocation of capital in South Africa using panel data for the period 1991-2008. The measure of efficient reallocation of capital is based on the variation of firm's marginal returns to capital around the optimal level, while the measure of financial globalisation is constructed by tracing the financial reforms/restrictions that took place in South Africa since the 1970s. We find that financ...

  4. Destruction and reallocation of skills following large company closures

    Holm, Jacob Rubæk; Østergaard, Christian Richter; Olesen, Thomas Roslyng

    2017-01-01

    This paper analyzes what happens to redundant skills and workers when large companies close down and whether their skills are destroyed or reallocated. The analysis is based on a combination of qualitative and quantitative data of the closure of four companies. Getting a job in a skill......-related industry or moving to a spinoff firm leads to skill reallocation. Thus, the result depends on regional idiosyncrasies such as industry structure and urbanization. If local policy makers and the owners exert a coordinated effort, it is possible to create success stories of less skill destruction in urban...

  5. Managing and reallocating inventory across two markets with local information

    Spiliotopoulou, E.

    2018-01-01

    Consider a firm that controls inventory centrally for two separate markets that are managed by regional managers having local demand information. The central planner provides a dedicated inventory level to each market, to ensure a minimum service level, but can reallocate inventory once associated

  6. Zinc allocation and re-allocation in rice

    Stomph, T.J.; Jiang, W.; Putten, van der P.E.L.; Struik, P.C.

    2014-01-01

    Aims: Agronomy and breeding actively search for options to enhance cereal grain Zn density. Quantifying internal (re-)allocation of Zn as affected by soil and crop management or genotype is crucial. We present experiments supporting the development of a conceptual model of whole plant Zn allocation

  7. Reallocating resources to focused factories: a case study in chemotherapy

    Vanberkel, P.T.; Boucherie, Richardus J.; Hans, Elias W.; Hurink, Johann L.; Litvak, Nelli; van Lent, W.A.M.; van Harten, Willem H.; van Harten, Wim H.; Blake, J.; Carter, M.

    2010-01-01

    This study investigates the expected service performance associated with a proposal to reallocate resources from a centralized chemotherapy department to a breast cancer focused factory. Using a slotted queueing model we show that a decrease in performance is expected and calculate the amount of

  8. Reallocation and nutrient use efficiency in Antioquia central forests

    Leon Pelaez, Juan; Gonzalez Hernandez, Maria; Gallardo Lancho, Juan

    2009-01-01

    We have studied nutrient related variables such as reallocation, nutrient use efficiency (NUE) and fine litter fall for three years in an oak forest Quercus humboldtii Bonpl. and also in some other forest plantations like pine, Pinus patula, and cypress, Cupressus lusitanica, in Antioquia, Colombia. Leaf litter quantities returned to the soil followed a falling sequence: oak (5313.3 kg ha-1 year-1) > pine (4866.5 kg ha-1 year-1) > cypress (2460.3 kg ha-1 year-1). The coniferous species showed the highest NUE for the majority of elements that were examined, except for P, which reached its absolute maximum in the oak forest -where a clear reallocation of this nutrient was also recorded-, probably because of its reduced availability in these volcanic ash-derived soils. Nutrient reallocation allows the conservation of the nutrients by reducing its loss from leaching and litter-fall, thereby closing the nutrient cycle in this native forest. In fact, P gains from net deposition were found there -this includes foliar leaching and atmospheric deposition-, which indicates that the species absorbs the P contained in rainfall from the leaves before it reaches the forest ground. N slow-efficiency use was probably due to its low availability in soil, given its low mineralization rates in these montane forests. K showed the highest reallocation values. Such figures are influenced by its clearly mobile character, according to the highest net deposition levels also verified for this element. With the exception of Mg, there was no clear relationship between the reallocation process and NUE.

  9. Making Things Difficult in Lexical Decision: The Impact of Pseudohomophones and Transposed-Letter Nonwords on Frequency and Semantic Priming Effects

    Lupker, Stephen J.; Pexman, Penny M.

    2010-01-01

    Performance in a lexical decision task is crucially dependent on the difficulty of the word-nonword discrimination. More wordlike nonwords cause not only a latency increase for words but also, as reported by Stone and Van Orden (1993), larger word frequency effects. Several current models of lexical decision making can explain these types of…

  10. Conflict management: difficult conversations with difficult people.

    Overton, Amy R; Lowry, Ann C

    2013-12-01

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

  11. Conflict Management: Difficult Conversations with Difficult People

    Overton, Amy R.; Lowry, Ann C.

    2013-01-01

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

  12. Differences in Multitask Resource Reallocation After Change in Task Values

    Matton , Nadine; Paubel , Pierre-Vincent; Cegarra , Julien; Raufaste , Éric

    2016-01-01

    International audience; Objective The objective was to characterize multitask resource reallocation strategies when managing subtasks with various assigned values.Background When solving a resource conflict in multitasking, Salvucci and Taatgen predict a globally rational strategy will be followed that favors the most urgent subtask and optimizes global performance. However, Katidioti and Taatgen identified a locally rational strategy that optimizes only a subcomponent of the whole task, lead...

  13. What Makes a Beam Shaping Problem Difficult

    Romero, Louis; Dickey, Fred M.

    2000-01-01

    The authors have discussed the three factors that they believe are the most important in determining the difficulty of a beam shaping problem: scaling, smoothness, and coherence. The arguments have been almost completely based on considering how these factors influence beam shaping lenses that were designed using geometrical optics. However, they believe that these factors control the difficulty of beam shaping problems even if one does not base ones design strategy on geometrical optics. For example, they have shown that a lens designed using geometrical optics will not work well unless β is large. However, they have also shown that if β is small the uncertainty principle shows that it is impossible to do a good job of beam shaping no matter how one designs ones lens

  14. Psychopathology in difficult asthma

    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

  15. Zinc allocation and re-allocation in rice

    Stomph, Tjeerd Jan; Jiang, Wen; Van Der Putten, Peter E. L.; Struik, Paul C.

    2014-01-01

    Aims: Agronomy and breeding actively search for options to enhance cereal grain Zn density. Quantifying internal (re-)allocation of Zn as affected by soil and crop management or genotype is crucial. We present experiments supporting the development of a conceptual model of whole plant Zn allocation and re-allocation in rice. Methods: Two solution culture experiments using 70Zn applications at different times during crop development and an experiment on within-grain distribution of Zn are reported. In addition, results from two earlier published experiments are re-analyzed and re-interpreted. Results: A budget analysis showed that plant zinc accumulation during grain filling was larger than zinc allocation to the grains. Isotope data showed that zinc taken up during grain filling was only partly transported directly to the grains and partly allocated to the leaves. Zinc taken up during grain filling and allocated to the leaves replaced zinc re-allocated from leaves to grains. Within the grains, no major transport barrier was observed between vascular tissue and endosperm. At low tissue Zn concentrations, rice plants maintained concentrations of about 20 mg Zn kg−1 dry matter in leaf blades and reproductive tissues, but let Zn concentrations in stems, sheath, and roots drop below this level. When plant zinc concentrations increased, Zn levels in leaf blades and reproductive tissues only showed a moderate increase while Zn levels in stems, roots, and sheaths increased much more and in that order. Conclusions: In rice, the major barrier to enhanced zinc allocation towards grains is between stem and reproductive tissues. Enhancing root to shoot transfer will not contribute proportionally to grain zinc enhancement. PMID:24478788

  16. 24 CFR 92.451 - Reallocation of HOME funds from a jurisdiction that is not designated a participating...

    2010-04-01

    ... Development HOME INVESTMENT PARTNERSHIPS PROGRAM Reallocations § 92.451 Reallocation of HOME funds from a... that the jurisdiction has failed to: (i) Meet the participation threshold amount in § 92.102; (ii...

  17. Making decisions at the end of life when caring for a person with dementia: a literature review to explore the potential use of heuristics in difficult decision-making.

    Mathew, R; Davies, N; Manthorpe, J; Iliffe, S

    2016-07-19

    Decision-making, when providing care and treatment for a person with dementia at the end of life, can be complex and challenging. There is a lack of guidance available to support practitioners and family carers, and even those experienced in end of life dementia care report a lack of confidence in decision-making. It is thought that the use of heuristics (rules of thumb) may aid decision-making. The aim of this study is to identify whether heuristics are used in end of life dementia care, and if so, to identify the context in which they are being used. A narrative literature review was conducted taking a systematic approach to the search strategy, using the Centre for Reviews and Dissemination guidelines. Rapid appraisal methodology was used in order to source specific and relevant literature regarding the use of heuristics in end of life dementia care. A search using terms related to dementia, palliative care and decision-making was conducted across 4 English language electronic databases (MEDLINE, EMBASE, PsycINFO and CINAHL) in 2015. The search identified 12 papers that contained an algorithm, guideline, decision tool or set of principles that we considered compatible with heuristic decision-making. The papers addressed swallowing and feeding difficulties, the treatment of pneumonia, management of pain and agitation, rationalising medication, ending life-sustaining treatment, and ensuring a good death. The use of heuristics in palliative or end of life dementia care is not described in the research literature. However, this review identified important decision-making principles, which are largely a reflection of expert opinion. These principles may have the potential to be developed into simple heuristics that could be used in practice. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  18. Dealing with difficult pasts

    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....

  19. The effects of lane width, shoulder width, and road cross-sectional reallocation on drivers' behavioral adaptations.

    Mecheri, Sami; Rosey, Florence; Lobjois, Régis

    2017-07-01

    Previous research has shown that lane-width reduction makes drivers operate vehicles closer to the center of the road whereas hard-shoulder widening induces a position farther away from the road's center. The goal of the present driving-simulator study was twofold. First, it was aimed at further investigating the respective effects of lane and shoulder width on in-lane positioning strategies, by examining vehicle distance from the center of the lane. The second aim was to assess the impact on safety of three possible cross-sectional reallocations of the width of the road (i.e., three lane-width reductions with concomitant shoulder widening at a fixed cross-sectional width) as compared to a control road. The results confirmed that lane-width reduction made participants drive closer to the road's center. However, in-lane position was affected differently by lane narrowing, depending on the traffic situation. In the absence of oncoming traffic, lane narrowing gave rise to significant shifts in the car's distance from the lane's center toward the edge line, whereas this distance remained similar across lane widths during traffic periods. When the shoulders were at least 0.50m wide, participants drove farther away from both the road center and the lane center. Road reallocation operations resulted in vehicles positioned farther away from the edge of the road and less swerving behavior, without generating higher driving speeds. Finally, it is argued that road-space reallocation may serve as a good low-cost tool for providing a recovery area for steering errors, without impairing drivers' behavior. Copyright © 2017 Elsevier Ltd. All rights reserved.

  20. Lack of Annual Reports Make it Difficult to Analyze Library Strategic Credibility. A Review of: Staines, G. (2009. Towards an assessment of strategic credibility in academic libraries. Library Management, 30(3, 148-162.

    Kirsty Thomson

    2011-06-01

    Full Text Available Objective – To investigate whether libraries achieve strategic credibility by assessing if strategic planning goals match the achievements described in annual reports.Design – Content analysis of annual reports and strategic plans from a sample of Association of Research Libraries (ARL.Setting – Academic libraries in Canada and the United States of America.Subjects – A random sample of 12 Canadian and 16 American academic libraries. All libraries were members of ARL.Methods – The researcher contacted the directors of 28 ARL libraries and asked for copies of their strategic plans and annual reports. She also visited the websites of libraries to obtain the reports. The contents of the strategic plans and annual reports were analyzed, and trends in the Canadian and American strategic plans were identified.Main Results – This study found that only 39% of ARL libraries produce annual reports, making it difficult to assess if libraries have strategic credibility, as their strategic plans cannot be assessed against annual reports. The strategic plans gathered in this study were analyzed and emerging themes were identified. These included physical library space (renovations, expansions or new buildings; offsite storage; assessment (both of the libraries’ services, and of information literacy training; development activities such as fundraising and marketing; and personnel issues. Cultural differences also were found inthe strategic plans, with American libraries being more focused on trends such as digitization and institutional repositories, andCanadian libraries’ plans being more focused on users’ needs. Trends in annual reports were not reported due to the small number ofannual reports in the sample.Conclusion – This study gives a snapshot ofthe trends in strategic plans of ARL members. It shows that many ARL members do not produce an annual report, and that it istherefore difficult to assess if their strategicplans are

  1. On System Engineering a Barter-Based Re-allocation of Space System Key Development Resources

    Kosmann, William J.

    NASA has had a decades-long problem with cost growth during the development of space science missions. Numerous agency-sponsored studies have produced average mission level development cost growths ranging from 23 to 77%. A new study of 26 historical NASA science instrument set developments using expert judgment to re-allocate key development resources has an average cost growth of 73.77%. Twice in history, during the Cassini and EOS-Terra science instrument developments, a barter-based mechanism has been used to re-allocate key development resources. The mean instrument set development cost growth was -1.55%. Performing a bivariate inference on the means of these two distributions, there is statistical evidence to support the claim that using a barter-based mechanism to re-allocate key instrument development resources will result in a lower expected cost growth than using the expert judgment approach. Agent-based discrete event simulation is the natural way to model a trade environment. A NetLogo agent-based barter-based simulation of science instrument development was created. The agent-based model was validated against the Cassini historical example, as the starting and ending instrument development conditions are available. The resulting validated agent-based barter-based science instrument resource re-allocation simulation was used to perform 300 instrument development simulations, using barter to re-allocate development resources. The mean cost growth was -3.365%. A bivariate inference on the means was performed to determine that additional significant statistical evidence exists to support a claim that using barter-based resource re-allocation will result in lower expected cost growth, with respect to the historical expert judgment approach. Barter-based key development resource re-allocation should work on science spacecraft development as well as it has worked on science instrument development. A new study of 28 historical NASA science spacecraft

  2. Optimal production resource reallocation for CO2 emissions reduction in manufacturing sectors

    Fujii, Hidemichi; Managi, Shunsuke

    2015-01-01

    To mitigate the effects of climate change, countries worldwide are advancing technologies to reduce greenhouse gas emissions. This paper proposes and measures optimal production resource reallocation using data envelopment analysis. This research attempts to clarify the effect of optimal production resource reallocation on CO2 emissions reduction, focusing on regional and industrial characteristics. We use finance, energy, and CO2 emissions data from 13 industrial sectors in 39 countries from...

  3. Differences in Multitask Resource Reallocation After Change in Task Values.

    Matton, Nadine; Paubel, Pierre; Cegarra, Julien; Raufaste, Eric

    2016-12-01

    The objective was to characterize multitask resource reallocation strategies when managing subtasks with various assigned values. When solving a resource conflict in multitasking, Salvucci and Taatgen predict a globally rational strategy will be followed that favors the most urgent subtask and optimizes global performance. However, Katidioti and Taatgen identified a locally rational strategy that optimizes only a subcomponent of the whole task, leading to detrimental consequences on global performance. Moreover, the question remains open whether expertise would have an impact on the choice of the strategy. We adopted a multitask environment used for pilot selection with a change in emphasis on two out of four subtasks while all subtasks had to be maintained over a minimum performance. A laboratory eye-tracking study contrasted 20 recently selected pilot students considered as experienced with this task and 15 university students considered as novices. When two subtasks were emphasized, novices focused their resources particularly on one high-value subtask and failed to prevent both low-value subtasks falling below minimum performance. On the contrary, experienced people delayed the processing of one low-value subtask but managed to optimize global performance. In a multitasking environment where some subtasks are emphasized, novices follow a locally rational strategy whereas experienced participants follow a globally rational strategy. During complex training, trainees are only able to adjust their resource allocation strategy to subtask emphasis changes once they are familiar with the multitasking environment. © 2016, Human Factors and Ergonomics Society.

  4. Reallocation of water in the state of New Mexico based on cooperative game theory

    Rouhi Rad, M.

    2011-12-01

    Water allocation models often aim to maximize net benefits in the river basin based on the water rights, thus there is no motivation to use water efficiently by the users with lower marginal value for water. Water markets not only could help increase the net benefits over the basin but also will encourage the stakeholders to save the water and use it in transfer markets and increase their income. This issue can be viewed as a game in which stakeholders can play non-cooperatively and try to increase their own benefits using the amount of water assigned to them or they could cooperate and make coalitions in order to increase the total benefits in the coalition and the whole basin. The aim of this study is to reallocate the water based on cooperation among different stakeholders, namely agricultural, municipal and industrial and environmental, in the Upper Rio Grande river basin in the state of New Mexico in order to increase efficiency, sustainability and equity of water distribution in the basin using different game theory schemes such as Nucleolus and the Shapley Value.

  5. Priority setting in practice: participants opinions on vertical and horizontal priority setting for reallocation.

    Waldau, Susanne; Lindholm, Lars; Wiechel, Anna Helena

    2010-08-01

    In the Västerbotten County Council in Sweden a priority setting process was undertaken to reallocate existing resources for funding of new methods and activities. Resources were created by limiting low priority services. A procedure for priority setting was constructed and fully tested by engaging the entire organisation. The procedure included priority setting within and between departments and political decision making. Participants' views and experiences were collected as a basis for future improvement of the process. Results indicate that participants appreciated the overall approach and methodology and wished to engage in their improvement. Among the improvement proposals is prolongation of the process in order to improve the knowledge base quality. The procedure for identification of new items for funding also needs to be revised. The priority setting process was considered an overall success because it fulfilled its political goals. Factors considered crucial for success are a wish among managers for an economic strategy that addresses existing internal resource allocation; process management characterized by goal orientation and clear leadership; an elaborate communications strategy integrated early in the process and its management; political unity in support of the procedure, and a strong political commitment throughout the process. Generalizability has already been demonstrated by several health care organisations that performed processes founded on this working model. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

  6. SIMPLE HEURISTIC ALGORITHM FOR DYNAMIC VM REALLOCATION IN IAAS CLOUDS

    Nikita A. Balashov

    2018-03-01

    Full Text Available The rapid development of cloud technologies and its high prevalence in both commercial and academic areas have stimulated active research in the domain of optimal cloud resource management. One of the most active research directions is dynamic virtual machine (VM placement optimization in clouds build on Infrastructure-as-a-Service model. This kind of research may pursue different goals with energy-aware optimization being the most common goal as it aims at a urgent problem of green cloud computing - reducing energy consumption by data centers. In this paper we present a new heuristic algorithm of dynamic reallocation of VMs based on an approach presented in one of our previous works. In the algorithm we apply a 2-rank strategy to classify VMs and servers corresponding to the highly and lowly active VMs and solve four tasks: VM classification, host classification, forming a VM migration map and VMs migration. Dividing all of the VMs and servers into two classes we attempt to implement the possibility of risk reduction in case of hardware overloads under overcommitment conditions and to reduce the influence of the occurring overloads on the performance of the cloud VMs. Presented algorithm was developed based on the workload profile of the JINR cloud (a scientific private cloud with the goal of maximizing its usage, but it can also be applied in both public and private commercial clouds to organize the simultaneous use of different SLA and QoS levels in the same cloud environment by giving each VM rank its own level of overcommitment.

  7. Ad valorem versus unit taxes: Monopolistic competition, heterogeneous firms, and intra-industry reallocations

    Schröder, Philipp; Sørensen, Allan

    a general equilibrium monopolistic competition model with heterogeneous firms and intra-industry reallocations. We show that the welfare superiority of ad valorem over unit taxes under imperfect competition is not only preserved but amplified. The additional difference between the tools arises because unit...... taxes distort relative prices, which in turn reduces average industry productivity through reallocations (the survival and increased market share of lower productivity firms). Importantly, numerical solutions of the model reveal that the relative welfare loss from using the unit tax increases...

  8. A violência nas relações afetivas dificulta a prevenção de DST/AIDS? Does violence in the emotional relationships make STD/AIDS prevention more difficult?

    Maria Helena Ruzany

    2003-08-01

    Full Text Available OBJETIVOS: identificar a ocorrência de situações de violência no cotidiano de adolescentes e jovens de comunidades de baixa renda; pesquisar a relação entre uso de drogas e comportamentos de risco de DST/AIDS; e verificar se a violência nas relações afetivas entre adolescentes e jovens dificulta a prevenção de DST/AIDS. MÉTODOS: estudo epidemiológico com adolescentes e jovens de dois bairros da cidade do Rio de Janeiro, a partir dos dados obtidos de um questionário estruturado que versava sobre perfil da clientela, informações sobre a família, uso de drogas, situações de violência do cotidiano, experiência sexual, entre outras. Para o presente artigo, somente as variáveis que particularizavam agressividade, uso de drogas, comportamentos sexuais de risco e violência nas relações afetivas foram analisadas. Em particular, destacou-se a associação da variável "eu usei camisinha na última relação sexual" com as questões que indicavam ou não atitudes violentas nas relações afetivas. RESULTADOS: participaram 1.041 indivíduos na faixa etária entre 14 e 22 anos, sendo 53,6% do sexo feminino. Entre os resultados mais relevantes, observou-se uma relação estatisticamente significativa entre o não uso de preservativo (pOBJECTIVES: to identify violent situations in the daily life of adolescents and young people of low-income communities; to establish a relation between the use of drugs and STD/AIDS risk behavior; and to verify if violence in the emotional relationships between adolescents and young people make the STD/AIDS prevention more difficult. METHOD: epidemiological study with adolescents and young people of two neighborhoods in the city of Rio de Janeiro, based on the results obtained from a structured questionnaire that dealt with subjects' profile, information about the family, use of drugs, daily violent situations, sexual experience, among others. For the present article, only the variables that dealt with

  9. 15 CFR 303.6 - Allocation and reallocation of exemptions among producers.

    2010-01-01

    ... 15 Commerce and Foreign Trade 2 2010-01-01 2010-01-01 false Allocation and reallocation of exemptions among producers. 303.6 Section 303.6 Commerce and Foreign Trade Regulations Relating to Commerce and Foreign Trade (Continued) INTERNATIONAL TRADE ADMINISTRATION, DEPARTMENT OF COMMERCE MISCELLANEOUS...

  10. The importance of reallocation for productivity growth: Evidence from European and US banking

    Bos, J.W.B.; van Santen, P.C.; Schilp, P.

    2013-01-01

    This paper quantifies the effect of reallocation dynamics on aggregate productivity developments in the banking sectors of Europe and the United States. We document an increase in productivity over the period 1995-2009, on the order of 11% in the US and 19% in Europe. At an annual frequency,

  11. 77 FR 42486 - Intent To Prepare an Integrated Water Supply Storage Reallocation Report; Environmental Impact...

    2012-07-19

    ... Water Supply Storage Reallocation Report; Environmental Impact Statement for Missouri River Municipal... Policy Act of 1969 (NEPA), as amended and the 1958 Water Supply Act, as amended, the U.S. Army Corps of... purpose of the study is to determine if changes to the current allocation of storage for M&I water supply...

  12. Trade openness, real exchange rates and job reallocation : Evidence from Belgium

    I. Colantone (Italo)

    2012-01-01

    textabstractThis paper investigates the impact of real exchange rate movements on job reallocation at the industry level. The analysis focuses on the manufacturing sector of Belgium, using data for 82 NACE 3-digit industries, over the time span 1996-2002. I find that real exchange rate changes do

  13. Unemployment dynamics, and propagation of aggregate and reallocation shocks in the Netherlands

    van Montfort, C.A.G.M.; den Butter, F.A.G.; Weitenberg, G.

    2003-01-01

    This paper models the propagation at the macro level of four types of shocks using the SVAR approach. Time series data for the Netherlands on job creation, job destruction, the number of vacancies and labour supply are used to identify aggregate demand and supply shocks, and reallocation demand and

  14. Distributed Services with Foreseen and Unforeseen Tasks: The Mobile Re-allocation Problem

    J.A. Larco Martinelli (Jose); R. Dekker (Rommert); U. Kaymak (Uzay)

    2007-01-01

    textabstractIn this paper we deal with a common problem found in the operations of security and preventive/corrective maintenance services: that of routing a number of mobile resources to serve foreseen and unforeseen tasks during a shift. We define the (Mobile Re-Allocation Problem) MRAP as the

  15. Overcoming difficult conversations in clinical supervision

    Williams B

    2016-06-01

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

  16. LIHTC Difficult to Develop Areas

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

  17. Psychopathology in difficult asthma : Review

    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

  18. Difficult to control atopic dermatitis

    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

  19. Effective communication during difficult conversations.

    Polito, Jacquelyn M

    2013-06-01

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

  20. Make

    Frauenfelder, Mark

    2012-01-01

    The first magazine devoted entirely to do-it-yourself technology projects presents its 29th quarterly edition for people who like to tweak, disassemble, recreate, and invent cool new uses for technology. MAKE Volume 29 takes bio-hacking to a new level. Get introduced to DIY tracking devices before they hit the consumer electronics marketplace. Learn how to build an EKG machine to study your heartbeat, and put together a DIY bio lab to study athletic motion using consumer grade hardware.

  1. Management of the difficult airway.

    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.

  2. A Rational Approach to Estimating the Surgical Demand Elasticity Needed to Guide Manpower Reallocation during Contagious Outbreaks

    Tsao, Hsiao-Mei; Sun, Ying-Chou; Liou, Der-Ming

    2015-01-01

    Background Emerging infectious diseases continue to pose serious threats to global public health. So far, however, few published study has addressed the need for manpower reallocation needed in hospitals when such a serious contagious outbreak occurs. Aim To quantify the demand elasticity of the major surgery types in order to guide future manpower reallocation during contagious outbreaks. Materials and Methods Based on a nationwide research database in Taiwan, we extracted the monthly volume...

  3. NPP-VIIRS DNB-based reallocating subpopulations to mercury in Urumqi city cluster, central Asia

    Zhou, X.; Feng, X. B.; Dai, W.; Li, P.; Ju, C. Y.; Bao, Z. D.; Han, Y. L.

    2017-02-01

    Accurate and update assignment of population-related environmental matters onto fine grid cells in oasis cities of arid areas remains challenging. We present the approach based on Suomi National Polar-orbiting Partnership (S-NPP) -Visible Infrared Imaging Radiometer Suite (VIIRS) Day/Night Band (DNB) to reallocate population onto a regular finer surface. The number of potential population to the mercury were reallocated onto 0.1x0.1 km reference grid in Urumqi city cluster of China’s Xinjiang, central Asia. The result of Monte Carlo modelling indicated that the range of 0.5 to 2.4 million people was reliable. The study highlights that the NPP-VIIRS DNB-based multi-layered, dasymetric, spatial method enhances our abilities to remotely estimate the distribution and size of target population at the street-level scale and has the potential to transform control strategies for epidemiology, public policy and other socioeconomic fields.

  4. Nitrogen and carbon reallocation in fungal mycelia during decomposition of boreal forest litter.

    Johanna B Boberg

    Full Text Available Boreal forests are characterized by spatially heterogeneous soils with low N availability. The decomposition of coniferous litter in these systems is primarily performed by basidiomycete fungi, which often form large mycelia with a well-developed capacity to reallocate resources spatially- an advantageous trait in heterogeneous environments. In axenic microcosm systems we tested whether fungi increase their biomass production by reallocating N between Pinus sylvestris (Scots pine needles at different stages of decomposition. We estimated fungal biomass production by analysing the accumulation of the fungal cell wall compound chitin. Monospecific systems were compared with systems with interspecific interactions. We found that the fungi reallocated assimilated N and mycelial growth away from well-degraded litter towards fresh litter components. This redistribution was accompanied by reduced decomposition of older litter. Interconnection of substrates increased over-all fungal C use efficiency (i.e. the allocation of assimilated C to biomass rather than respiration, presumably by enabling fungal translocation of growth-limiting N to litter with higher C quality. Fungal connection between different substrates also restricted N-mineralization and production of dissolved organic N, suggesting that litter saprotrophs in boreal forest ecosystems primarily act to redistribute rather than release N. This spatial integration of different resource qualities was hindered by interspecific interactions, in which litters of contrasting quality were colonised by two different basidiomycete species. The experiments provide a detailed picture of how resource reallocation in two decomposer fungi leads to a more efficient utilisation of spatially separated resources under N-limitation. From an ecosystem point of view, such economic fungal behaviour could potentially contribute to organic matter accumulation in the litter layers of boreal forests.

  5. Labor reallocation and firm growth: Benchmarking transition countries against mature market economies

    Mitra, Pradeep; Muravyev, Alexander; Schaffer, Mark E.

    2014-01-01

    This paper uses firm-level survey data to study labor reallocation and firm growth in the transition countries over 1996 - 2005, including benchmarking against developed market economies. The data shows rapid growth of the new private sector and of the micro- and small-firm sectors, with the size distribution of firms moving towards the pattern observed in comparable surveys of developed market economies. Throughout, the regional patterns suggest greater convergence in the transition countrie...

  6. Nitrogen and carbon reallocation in fungal mycelia during decomposition of boreal forest litter.

    Boberg, Johanna B; Finlay, Roger D; Stenlid, Jan; Ekblad, Alf; Lindahl, Björn D

    2014-01-01

    Boreal forests are characterized by spatially heterogeneous soils with low N availability. The decomposition of coniferous litter in these systems is primarily performed by basidiomycete fungi, which often form large mycelia with a well-developed capacity to reallocate resources spatially- an advantageous trait in heterogeneous environments. In axenic microcosm systems we tested whether fungi increase their biomass production by reallocating N between Pinus sylvestris (Scots pine) needles at different stages of decomposition. We estimated fungal biomass production by analysing the accumulation of the fungal cell wall compound chitin. Monospecific systems were compared with systems with interspecific interactions. We found that the fungi reallocated assimilated N and mycelial growth away from well-degraded litter towards fresh litter components. This redistribution was accompanied by reduced decomposition of older litter. Interconnection of substrates increased over-all fungal C use efficiency (i.e. the allocation of assimilated C to biomass rather than respiration), presumably by enabling fungal translocation of growth-limiting N to litter with higher C quality. Fungal connection between different substrates also restricted N-mineralization and production of dissolved organic N, suggesting that litter saprotrophs in boreal forest ecosystems primarily act to redistribute rather than release N. This spatial integration of different resource qualities was hindered by interspecific interactions, in which litters of contrasting quality were colonised by two different basidiomycete species. The experiments provide a detailed picture of how resource reallocation in two decomposer fungi leads to a more efficient utilisation of spatially separated resources under N-limitation. From an ecosystem point of view, such economic fungal behaviour could potentially contribute to organic matter accumulation in the litter layers of boreal forests.

  7. Optimal inventory reallocation to customer orders in ceramic tile companies characterized by the lack of homogeneity in the product (LHP)

    Alemany, M. M. E.; Alarcon, F.; Oltra, R. F.; Lario, B. C.

    2013-01-01

    The lack of homogeneity in the product (LHP) is defined as the lack of uniformity required by the customer in the products. The LHP appears in companies where the final products obtained are not homogeneous, leading to the existence of different references (subtypes) of the same product. This lack of homogeneity is a problem when the client needs to be served through homogeneous units of a product and commit orders are based on planned quantities, whose final homogeneity characteristics are unknown at the time of acquiring the customer commitments. The frequent discrepancies caused by the LHP between planned homogeneous amounts and those actually obtained and available, can prevent the delivery of committed orders. To solve this problem, we propose a mathematical programming model for the reallocation of inventory in Make to Stock (MTS) ceramic tile companies characterized by the LHP that combines multiple objectives. The proposed mathematical model has been validated by its application to a real case of a ceramic company. The analysis of the obtained results indicates significant improvements in the number of orders completed on time and in sales revenue achieved. (Author) 33 refs.

  8. Difficult to control atopic dermatitis

    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

  9. What makes listening difficult? Factors affecting second language listening comprehension

    2010-04-01

    idioms in the passage on listening comprehension. The American Heritage Dictionary (2000) defines idiom as “an expression consisting of two or more...years of age and spoke English without a noticeable foreign accent had significantly poorer word recognition scores than monolingual listeners for...of reference: The experience of the Dutch CEFR Construct Project. Language Assessment Quarterly, 3(1), 3–30. American Heritage Dictionary of the

  10. Difficult physician-patient relationships.

    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.

  11. Difficult to foresee tomorrow's world

    Anon.

    2016-01-01

    Some countries like Italy or Kazakhstan have given up nuclear power but others (Viet-Nam, Bangladesh, Egypt, Turkey) have the willingness to enter the nuclear world to sustain their development while complying with their environmental obligations. Others like United Arab Emirates, Belarus have their first reactor being built and other countries like France, Finland, United States, Slovakia, Brazil, Pakistan, India, Taiwan, South-Korea, China, Russia, Ukraine are reinforcing their reactor fleet by building new reactors. A total of 62 reactors is being built throughout the world with 22 in China. New construction of reactors, the dismantling of decommissioned installations and the integration of nuclear power in new economic models make the future brighter for nuclear industry. (A.C.)

  12. A Dynamic Reallocation Based Window Access Scheme for Enhancing QoS of Vehicular Ad-hoc Networks (VANETs

    Md. Amirul Islam

    2018-01-01

    Full Text Available This article proposes a new MAC scheme for Vehicle-to-Infrastructure (V2I communications that dynamically reallocates unused TDMA slots. By maintaining a balanced waiting time, the proposed TDMA based scheduling scheme allocates TDMA slots in a rational way to minimize merging and one-hop neighboring collision. The proposed scheme ensures dynamic reallocation of unused slots by using “time slot reassignment” mechanism. The scheme has been simulated in VEINS framework of OMNET++ network simulator and its performance has been compared with other conventional protocols. Experimental results show that our scheme performs better than existing schemes in terms of successfully transmitted data packets.

  13. Task set induces dynamic reallocation of resources in visual short-term memory.

    Sheremata, Summer L; Shomstein, Sarah

    2017-08-01

    Successful interaction with the environment requires the ability to flexibly allocate resources to different locations in the visual field. Recent evidence suggests that visual short-term memory (VSTM) resources are distributed asymmetrically across the visual field based upon task demands. Here, we propose that context, rather than the stimulus itself, determines asymmetrical distribution of VSTM resources. To test whether context modulates the reallocation of resources to the right visual field, task set, defined by memory-load, was manipulated to influence visual short-term memory performance. Performance was measured for single-feature objects embedded within predominantly single- or two-feature memory blocks. Therefore, context was varied to determine whether task set directly predicts changes in visual field biases. In accord with the dynamic reallocation of resources hypothesis, task set, rather than aspects of the physical stimulus, drove improvements in performance in the right- visual field. Our results show, for the first time, that preparation for upcoming memory demands directly determines how resources are allocated across the visual field.

  14. Multiscale energy reallocation during low-frequency steady-state brain response.

    Wang, Yifeng; Chen, Wang; Ye, Liangkai; Biswal, Bharat B; Yang, Xuezhi; Zou, Qijun; Yang, Pu; Yang, Qi; Wang, Xinqi; Cui, Qian; Duan, Xujun; Liao, Wei; Chen, Huafu

    2018-05-01

    Traditional task-evoked brain activations are based on detection and estimation of signal change from the mean signal. By contrast, the low-frequency steady-state brain response (lfSSBR) reflects frequency-tagging activity at the fundamental frequency of the task presentation and its harmonics. Compared to the activity at these resonant frequencies, brain responses at nonresonant frequencies are largely unknown. Additionally, because the lfSSBR is defined by power change, we hypothesize using Parseval's theorem that the power change reflects brain signal variability rather than the change of mean signal. Using a face recognition task, we observed power increase at the fundamental frequency (0.05 Hz) and two harmonics (0.1 and 0.15 Hz) and power decrease within the infra-slow frequency band ( .955) of their spatial distribution and brain-behavior relationship at all frequency bands. Additionally, the reallocation of finite energy was observed across various brain regions and frequency bands, forming a particular spatiotemporal pattern. Overall, results from this study strongly suggest that frequency-specific power and variability may measure the same underlying brain activity and that these results may shed light on different mechanisms between lfSSBR and brain activation, and spatiotemporal characteristics of energy reallocation induced by cognitive tasks. © 2018 Wiley Periodicals, Inc.

  15. Real-Time Track Reallocation for Emergency Incidents at Large Railway Stations

    Wei Liu

    2015-01-01

    Full Text Available After track capacity breakdowns at a railway station, train dispatchers need to generate appropriate track reallocation plans to recover the impacted train schedule and minimize the expected total train delay time under stochastic scenarios. This paper focuses on the real-time track reallocation problem when tracks break down at large railway stations. To represent these cases, virtual trains are introduced and activated to occupy the accident tracks. A mathematical programming model is developed, which aims at minimizing the total occupation time of station bottleneck sections to avoid train delays. In addition, a hybrid algorithm between the genetic algorithm and the simulated annealing algorithm is designed. The case study from the Baoji railway station in China verifies the efficiency of the proposed model and the algorithm. Numerical results indicate that, during a daily and shift transport plan from 8:00 to 8:30, if five tracks break down simultaneously, this will disturb train schedules (result in train arrival and departure delays.

  16. A real-time Excel-based scheduling solution for nursing staff reallocation.

    Tuominen, Outi Anneli; Lundgren-Laine, Heljä; Kauppila, Wiveka; Hupli, Maija; Salanterä, Sanna

    2016-09-30

    Aim This article describes the development and testing of an Excel-based scheduling solution for the flexible allocation and reallocation of nurses to cover sudden, unplanned absences among permanent nursing staff. Method A quasi-experimental, one group, pre- and post-test study design was used ( Box 1 ) with total sampling. Participants (n=17) were selected purposefully by including all ward managers (n=8) and assistant ward managers (n=9) from one university hospital department. The number of sudden absences among the nursing staff was identified during two 4-week data collection periods (pre- and post-test). Results During the use of the paper-based scheduling system, 121 absences were identified; during the use of the Excel-based system, 106 were identified. The main reasons for the use of flexible 'floating' nurses were sick leave (n=66) and workload (n=31). Other reasons (n=29) included patient transfer to another hospital, scheduling errors and the start or end of employment. Conclusion The Excel-based scheduling solution offered better support in obtaining substitute labour inside the organisation, with smaller employment costs. It also reduced the number of tasks ward managers had to carry out during the process of reallocating staff.

  17. Chronicle of a difficult relationship

    Kroker, Holger

    2011-01-01

    50 years ago, the first German nuclear power plant went online in Kahl on the Main. Visions were high in the early days of this industry, and during its first years it seemed to be headed for success. By the mid-1970s 21 reactors had been commissioned, or were already operating. But then the winds changed, people began to turn against nuclear power, public discussion was marked by heated disputes around projects such as Brokdorf, Kalkar, Wackersdorf and Gorleben. In the face of these problems, the nuclear sector failed to develop an effective strategy for regaining public support on a permanent basis. The accidents in the power plants of Harrisburg, USA, and Chernobyl contributed to making nuclear power unpopular in society. At the time of its domestic crisis, German nuclear technology achieved successes abroad. The French-German AREVA group became a world market leader in the fields of reactor design and construction, servicing, maintenance and modernization. In the domestic market, however, all signs seem to point to an end of nuclear energy in the medium run. (orig.)

  18. Foreign body aspiration masquerading as difficult asthma

    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.

  19. Effective Climate Communication with Difficult Audiences

    Denning, S.

    2015-12-01

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

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

    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 ...

  1. Reallocating Human Resources to Maximize Student Achievement: A Critical Case Study of a Southern California School District

    Glazener, Adrianna Kathleen

    2013-01-01

    This study applied the Evidence-Based Model (Odden & Picus, 2008) as a framework for determining how district leadership could potentially reallocate human resources to maximize the opportunity for student achievement, relying heavily on the ten strategies for doubling student performance (Odden, 2009; Odden & Archibald, 2009) and the…

  2. 76 FR 12293 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2011-03-07

    ... fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from jig... fishery is currently open, it is important to immediately inform the industry as to the revised... this fishery, to allow the industry to plan for the fishing season, and to avoid potential disruption...

  3. 77 FR 53152 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2012-08-31

    ... fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from other... fishery is currently open, it is important to immediately inform the industry as to the revised... this fishery, to allow the industry to plan for the fishing season, and to avoid potential disruption...

  4. 75 FR 13444 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2010-03-22

    ... the most recent fisheries data in a timely fashion and would delay the reallocation of Pacific cod.... Since the fishery is currently open, it is important to immediately inform the industry as to the... operation of this fishery, to allow the industry to plan for the fishing season, and to avoid potential...

  5. 78 FR 73454 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Western...

    2013-12-06

    ... fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from catcher... is currently ongoing, it is important to immediately inform the industry as to the revised... this fishery, to allow the industry to plan for the fishing season, and to avoid potential disruption...

  6. 78 FR 14932 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pollock in the Bering Sea...

    2013-03-08

    ... most recent fisheries data in a timely fashion and would delay the reallocation of AI pollock. Since the pollock fishery is currently open, it is important to immediately inform the industry as to the... orderly conduct and efficient operation of this fishery; allow the industry to plan for the fishing season...

  7. 77 FR 61300 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Atka Mackerel in the Bering...

    2012-10-09

    ... from responding to the most recent fisheries data in a timely fashion and would delay the reallocation... is currently open, it is important to immediately inform the industry as to the revised allocations..., to allow the industry to plan for the fishing season, and to avoid potential disruption to the...

  8. 77 FR 76425 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Central...

    2012-12-28

    ... fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from catcher...-line gear. Since the fishery is currently open, it is important to immediately inform the industry as... efficient operation of this fishery, to allow the industry to plan for the fishing season, and to avoid...

  9. 78 FR 9327 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2013-02-08

    ... fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from jig... fishery is currently open, it is important to immediately inform the industry as to the revised... this fishery, to allow the industry to plan for the fishing season, and to avoid potential disruption...

  10. 77 FR 67579 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Central...

    2012-11-13

    ... from responding to the most recent fisheries data in a timely fashion and would delay the reallocation... using jig gear. Since the fishery is currently open, it is important to immediately inform the industry... and efficient operation of this fishery, to allow the industry to plan for the fishing season, and to...

  11. 78 FR 53076 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2013-08-28

    ... the most recent fisheries data in a timely fashion and would delay the reallocation of Pacific cod... industry as to the revised allocations. Immediate notification is necessary to allow for the orderly conduct and efficient operation of this fishery, to allow the industry to plan for the fishing season, and...

  12. 75 FR 55689 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Yellowfin Sole in the Bering...

    2010-09-14

    ... fisheries data in a timely fashion and would delay the reallocation of yellowfin sole from the BSAI trawl... is important to immediately inform the industry as to the revised allocations. Immediate notification... industry to plan for the fishing season, and to avoid potential disruption to the fishing fleet as well as...

  13. 77 FR 8176 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2012-02-14

    ... fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from jig... fishery is currently open, it is important to immediately inform the industry as to the revised... this fishery, to allow the industry to plan for the fishing season, and to avoid potential disruption...

  14. 78 FR 49200 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pollock in the Bering Sea...

    2013-08-13

    ... most recent fisheries data in a timely fashion and would delay the reallocation of Aleutian Islands... industry as to the final Bering Sea subarea pollock allocations. Immediate notification is necessary to allow for the orderly conduct and efficient operation of this fishery; allow the industry to plan for...

  15. 77 FR 66564 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Western...

    2012-11-06

    ... fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from catcher... open, it is important to immediately inform the industry as to the revised allocations. Immediate... the industry to plan for the fishing season, and to avoid potential disruption to the fishing fleet as...

  16. 75 FR 19562 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2010-04-15

    ... fisheries data in a timely fashion and would delay the reallocation of Pacific cod specified from jig... fishery is currently open, it is important to immediately inform the industry as to the revised... this fishery, to allow the industry to plan for the fishing season, and to avoid potential disruption...

  17. 76 FR 76903 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2011-12-09

    ... the most recent fisheries data in a timely fashion and would delay the reallocation of Pacific cod... industry as to the revised allocations. Immediate notification is necessary to allow for the orderly conduct and efficient operation of this fishery, to allow the industry to plan for the fishing season, and...

  18. 78 FR 5143 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pollock in the Bering Sea...

    2013-01-24

    ... a timely fashion and would delay the reallocation of AI pollock. Since the pollock fishery opens January 20, 2013, it is important to immediately inform the industry as to the final Bering Sea subarea... operation of this fishery; allow the industry to plan for the fishing season and avoid potential disruption...

  19. 75 FR 52478 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pacific Cod in the Bering...

    2010-08-26

    ... a timely fashion and would delay the reallocation of Pacific cod specified from trawl catcher... catcher vessel Pacific cod fishery is currently open, it is important to immediately inform the industry... and efficient operation of this fishery, to allow the industry to plan for the fishing season, and to...

  20. 75 FR 51185 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Rock Sole in the Bering Sea...

    2010-08-19

    ... 600 and 50 CFR part 679. The 2010 rock sole TAC specified for the Bering Sea and Aleutian Islands ICA... Amendment 80 Allocations of The Aleutian Islands Pacific Ocean Perch, And BSAI Flathead Sole, Rock Sole, And.... 0910131363-0087-02] RIN 0648-XY29 Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Rock...

  1. Talk the Walk: Does Socio-Cognitive Resource Reallocation Facilitate the Development of Walking?

    Ronny Geva

    Full Text Available Walking is of interest to psychology, robotics, zoology, neuroscience and medicine. Human's ability to walk on two feet is considered to be one of the defining characteristics of hominoid evolution. Evolutionary science propses that it emerged in response to limited environmental resources; yet the processes supporting its emergence are not fully understood. Developmental psychology research suggests that walking elicits cognitive advancements. We postulate that the relationship between cognitive development and walking is a bi-directional one; and further suggest that the initiation of novel capacities, such as walking, is related to internal socio-cognitive resource reallocation. We shed light on these notions by exploring infants' cognitive and socio-communicative outputs prospectively from 6-18 months of age. Structured bi/tri weekly evaluations of symbolic and verbal development were employed in an urban cohort (N = 9 for 12 months, during the transition from crawling to walking. Results show links between preemptive cognitive changes in socio-communicative output, symbolic-cognitive tool-use processes, and the age of emergence of walking. Plots of use rates of lower symbolic play levels before and after emergence of new skills illustrate reductions in use of previously attained key behaviors prior to emergence of higher symbolic play, language and walking. Further, individual differences in age of walking initiation were strongly related to the degree of reductions in complexity of object-use (r = .832, p < .005, along with increases, counter to the general reduction trend, in skills that serve recruitment of external resources [socio-communication bids before speech (r = -.696, p < .01, and speech bids before walking; r = .729, p < .01]. Integration of these proactive changes using a computational approach yielded an even stronger link, underscoring internal resource reallocation as a facilitator of walking initiation (r = .901, p<0

  2. Evidence of endothelial inflammation, T cell activation, and T cell reallocation in uncomplicated Plasmodium falciparum malaria

    Elhassan, I M; Hviid, L; Satti, G

    1994-01-01

    endothelium. We measured plasma levels of soluble markers of endothelial inflammation and T cell activation in 32 patients suffering from acute, uncomplication P. falciparum malaria, as well as in 10 healthy, aparasitemic control donors. All donors were residents of a malaria-endemic area of Eastern State...... Sudan. In addition, we measured the T cell surface expression of the interleukin-2 receptor (CD25) and the lymphocyte function-associated antigen (LFA-1; CD11a/CD18). We found that the plasma levels of all inflammation and activation markers were significantly increased in the malaria patients compared...... with the control donors. In addition, we found a disease-induced depletion of T cells with high expression of the LFA-1 antigen, particularly in the CD4+ subset. The results obtained provide further support for the hypothesis of T cell reallocation to inflamed endothelium in acute P. falciparum malaria....

  3. Talk the Walk: Does Socio-Cognitive Resource Reallocation Facilitate the Development of Walking?

    Geva, Ronny; Orr, Edna

    2016-01-01

    Walking is of interest to psychology, robotics, zoology, neuroscience and medicine. Human's ability to walk on two feet is considered to be one of the defining characteristics of hominoid evolution. Evolutionary science propses that it emerged in response to limited environmental resources; yet the processes supporting its emergence are not fully understood. Developmental psychology research suggests that walking elicits cognitive advancements. We postulate that the relationship between cognitive development and walking is a bi-directional one; and further suggest that the initiation of novel capacities, such as walking, is related to internal socio-cognitive resource reallocation. We shed light on these notions by exploring infants' cognitive and socio-communicative outputs prospectively from 6-18 months of age. Structured bi/tri weekly evaluations of symbolic and verbal development were employed in an urban cohort (N = 9) for 12 months, during the transition from crawling to walking. Results show links between preemptive cognitive changes in socio-communicative output, symbolic-cognitive tool-use processes, and the age of emergence of walking. Plots of use rates of lower symbolic play levels before and after emergence of new skills illustrate reductions in use of previously attained key behaviors prior to emergence of higher symbolic play, language and walking. Further, individual differences in age of walking initiation were strongly related to the degree of reductions in complexity of object-use (r = .832, p developments, form an integrated adaptable composite, which possibly enables proactive internal resource reallocation, designed to support the emergence of new developmental milestones, such as walking.

  4. Public health and the economy could be served by reallocating medical expenditures to social programs.

    Tran, Linda Diem; Zimmerman, Frederick J; Fielding, Jonathan E

    2017-12-01

    As much as 30% of US health care spending in the United States does not improve individual or population health. To a large extent this excess spending results from prices that are too high and from administrative waste. In the public sector, and particularly at the state level, where budget constraints are severe and reluctance to raise taxes high, this spending crowds out social, educational, and public-health investments. Over time, as spending on medical care increases, spending on improvements to the social determinants of health are starved. In California the fraction of General Fund expenditures spent on public health and social programs fell from 34.8% in fiscal year 1990 to 21.4% in fiscal year 2014, while health care increased from 14.1% to 21.3%. In spending more on healthcare and less on other efforts to improve health and health determinants, the state is missing important opportunities for health-promoting interventions with a strong financial return. Reallocating ineffective medical expenditures to proven and cost-effective public health and social programs would not be easy, but recognizing its potential for improving the public's health while saving taxpayers billions of dollars might provide political cover to those willing to engage in genuine reform. National estimates of the percent of medical spending that does not improve health suggest that approximately $5 billion of California's public budget for medical spending has no positive effect on health. Up to 10,500 premature deaths could be prevented annually by reallocating this portion of medical spending to public health. Alternatively, the same expenditure could help an additional 418,000 high school students to graduate.

  5. Public health and the economy could be served by reallocating medical expenditures to social programs

    Linda Diem Tran

    2017-12-01

    Full Text Available As much as 30% of US health care spending in the United States does not improve individual or population health. To a large extent this excess spending results from prices that are too high and from administrative waste. In the public sector, and particularly at the state level, where budget constraints are severe and reluctance to raise taxes high, this spending crowds out social, educational, and public-health investments. Over time, as spending on medical care increases, spending on improvements to the social determinants of health are starved. In California the fraction of General Fund expenditures spent on public health and social programs fell from 34.8% in fiscal year 1990 to 21.4% in fiscal year 2014, while health care increased from 14.1% to 21.3%. In spending more on healthcare and less on other efforts to improve health and health determinants, the state is missing important opportunities for health-promoting interventions with a strong financial return. Reallocating ineffective medical expenditures to proven and cost-effective public health and social programs would not be easy, but recognizing its potential for improving the public's health while saving taxpayers billions of dollars might provide political cover to those willing to engage in genuine reform. National estimates of the percent of medical spending that does not improve health suggest that approximately $5 billion of California's public budget for medical spending has no positive effect on health. Up to 10,500 premature deaths could be prevented annually by reallocating this portion of medical spending to public health. Alternatively, the same expenditure could help an additional 418,000 high school students to graduate.

  6. Quantitative health impact assessment of transport policies: two simulations related to speed limit reduction and traffic re-allocation in the Netherlands.

    Schram-Bijkerk, D; van Kempen, E; Knol, A B; Kruize, H; Staatsen, B; van Kamp, I

    2009-10-01

    Few quantitative health impact assessments (HIAs) of transport policies have been published so far and there is a lack of a common methodology for such assessments. To evaluate the usability of existing HIA methodology to quantify health effects of transport policies at the local level. Health impact of two simulated but realistic transport interventions - speed limit reduction and traffic re-allocation - was quantified by selecting traffic-related exposures and health endpoints, modelling of population exposure, selecting exposure-effect relations and estimating the number of local traffic-related cases and disease burden, expressed in disability-adjusted life-years (DALYs), before and after the intervention. Exposure information was difficult to retrieve because of the local scale of the interventions, and exposure-effect relations for subgroups and combined effects were missing. Given uncertainty in the outcomes originating from this kind of missing information, simulated changes in population health by two local traffic interventions were estimated to be small (<5%), except for the estimated reduction in DALYs by less traffic accidents (60%) due to speed limit reduction. Quantitative HIA of transport policies at a local scale is possible, provided that data on exposures, the exposed population and their baseline health status are available. The interpretation of the HIA information should be carried out in the context of the quality of input data and assumptions and uncertainties of the analysis.

  7. A rational approach to estimating the surgical demand elasticity needed to guide manpower reallocation during contagious outbreaks.

    Tsao, Hsiao-Mei; Sun, Ying-Chou; Liou, Der-Ming

    2015-01-01

    Emerging infectious diseases continue to pose serious threats to global public health. So far, however, few published study has addressed the need for manpower reallocation needed in hospitals when such a serious contagious outbreak occurs. To quantify the demand elasticity of the major surgery types in order to guide future manpower reallocation during contagious outbreaks. Based on a nationwide research database in Taiwan, we extracted the monthly volumes of major surgery types for the period 1998-2003, which covered the SARS period, in order to carry out a time series analysis. The demand elasticity of each surgery type was then estimated by autoregressive integrated moving average (ARIMA) analysis. During the study period, the surgical volumes of most selected surgery types either increased or remained steady. We categorized these surgery types into low-, moderate- and high-elastic groups according to their demand elasticity. Appendectomy, 'open reduction of fracture with internal fixation' and 'free skin graft' were in the low demand elasticity group. Transurethral prostatectomy and extracorporeal shockwave lithotripsy (ESWL) were in the high demand elasticity group. The manpower of the departments carrying out the surgeries with low demand elasticity should be maintained during outbreaks. In contrast, departments in charge of surgeries mainly with high demand elasticity, like urology departments, may be in a position to have part of their staff reallocated. Taking advantage of the demand variation during the SARS period in 2003, we adopted the concept of demand elasticity and used a time series approach to figure out an effective index of demand elasticity for various types of surgery that could be used as a rational reference to carry out manpower reallocation during contagious outbreak situations.

  8. Thermosensitivity of growth is determined by chaperone-mediated proteome reallocation

    Chen, Ke; Gao, Ye; Mih, Nathan; O’Brien, Edward J.; Yang, Laurence; Palsson, Bernhard O.

    2017-01-01

    Maintenance of a properly folded proteome is critical for bacterial survival at notably different growth temperatures. Understanding the molecular basis of thermoadaptation has progressed in two main directions, the sequence and structural basis of protein thermostability and the mechanistic principles of protein quality control assisted by chaperones. Yet we do not fully understand how structural integrity of the entire proteome is maintained under stress and how it affects cellular fitness. To address this challenge, we reconstruct a genome-scale protein-folding network for Escherichia coli and formulate a computational model, FoldME, that provides statistical descriptions of multiscale cellular response consistent with many datasets. FoldME simulations show (i) that the chaperones act as a system when they respond to unfolding stress rather than achieving efficient folding of any single component of the proteome, (ii) how the proteome is globally balanced between chaperones for folding and the complex machinery synthesizing the proteins in response to perturbation, (iii) how this balancing determines growth rate dependence on temperature and is achieved through nonspecific regulation, and (iv) how thermal instability of the individual protein affects the overall functional state of the proteome. Overall, these results expand our view of cellular regulation, from targeted specific control mechanisms to global regulation through a web of nonspecific competing interactions that modulate the optimal reallocation of cellular resources. The methodology developed in this study enables genome-scale integration of environment-dependent protein properties and a proteome-wide study of cellular stress responses. PMID:29073085

  9. Clinical review: Management of difficult airways

    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

  10. Clinical review: management of difficult airways.

    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.

  11. How Difficult It Is to Be God

    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)...

  12. Climate change convention : reallocation of carbon dioxide emissions; Convenzione sui cambiamenti climatici: ipotesi per una assegnazione di quote di emissioni di anidride carbonica

    Turchetti, P; Venanzi, M [ENEA, Centro Ricerche Casaccia, Rome (Italy). Dip. Ambiente

    1995-07-01

    In 1992, during the United Nation`s Conference on Environment and Development, held in Rio de Janeiro, the Framework Convention on Climate Change was signed. The ultimate objective of this Convention is the control and the reduction of greenhouse gas releases from human activities, to achieve stabilization of greenhouse gas concentrations in the atmosphere. The purpose of this research is to provide a reallocation of carbon dioxide important greenhouse gas, among nine countries representing the different geopolitical worldwide situations. Demographic, socioeconomic and environmental criteria have been taken into account. Some of these issues have been proposed in the international negotiating context. In order to apportion emissions the Analytic Hierarchy Process (AHP) has been used. The AHP is a multi objective decision-making technique employing a method of pairwise comparisons to rank order alternatives of a problem formulated in a hierarchic structure by computing the largest eigenvalue of the pairwise comparisons matrix. Moreover, the AHP approach enables one to deal with both quantitative and qualitative factors in a logical fashion. The findings summarize the different indicators considered representing the proposals of the parties involved in the international debate.

  13. A novel cannulation technique for difficult urethral catheterization

    Mehmet Kaynar

    2016-03-01

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

  14. Difficult intubation: are you prepared for it?

    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.

  15. Difficult diagnoses in the skeletal radiology

    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.

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

    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 ...

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

    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 ...

  18. Crisis management during anaesthesia: difficult intubation.

    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.

  19. End-user GHG emissions from energy. Reallocation of emissions from energy industries to end users 2005-2010

    Fernandez, R. [European Environment Agency (EEA), Copenhagen (Denmark); Watterson, J. [AEA Technology plc - EEA' s European Topic Centre on Air Pollution and Climate Change Mitigation (ETC/ACM) (United Kingdom)

    2012-12-15

    The objective of this report is to help improve the understanding of past GHG emission trends in the energy sector from the demand or end-user side. To do this, the report develops a methodology to redistributes emissions from energy industries to the final users (by sector) of that energy. This reallocation is done on the basis of Eurostat's energy balances and GHG inventories for the energy sector as reported to the United Nations Framework Convention on Climate Change (UNFCCC), for the period 2005-2010. (Author)

  20. End-user GHG emissions from energy. Reallocation of emissions from energy industries to end users 2005-2009

    Fernandez, R. (European Environment Agency (EEA), Copenhagen (Denmark)); Watterson, J. (AEA Technology plc - EEA' s European Topic Centre on Air Pollution and Climate Change Mitigation (ETC/ACM) (United Kingdom))

    2011-12-15

    The objective of this report is to help improve the understanding of past greenhouse gas (GHG) emission trends in the energy sector from the demand or end-user side. To do this, the report develops a methodology to redistributes emissions from energy industries to the final users (by sector) of that energy. This reallocation is done on the basis of Eurostat's energy balances and GHG inventories for the energy sector as reported to the United Nations Framework Convention on Climate Change (UNFCCC), for the period 2005-2009. (Author)

  1. The long shadows of the difficult past?

    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...

  2. Clinical review: Management of difficult airways

    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...

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

    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...

  4. Difficult weaning in delayed onset diaphragmatic hernia

    Ahmed Syed

    2009-01-01

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

  5. Chernobyl: Chronicle of difficult weeks [videorecording

    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.

  6. Improving Web Search for Difficult Queries

    Wang, Xuanhui

    2009-01-01

    Search engines have now become essential tools in all aspects of our life. Although a variety of information needs can be served very successfully, there are still a lot of queries that search engines can not answer very effectively and these queries always make users feel frustrated. Since it is quite often that users encounter such "difficult…

  7. Reallocation of resources between generations and genders in the market and non-market economy. The case of Italy

    Zannella, Marina

    2015-01-01

    In this article the National Transfer Accounts (NTA) method is used to develop a comprehensive account of resource reallocations between population members in Italy, encompassing the age and the gender perspective, the public and the familial institutional sectors as well as the market and non-market dimensions of the economy. The inclusion of the non-market economy, referring to household and care time, allows for an insight into the gender division of labour and the strength of intergenerational obligations in the Italian familistic welfare regime. Results highlight the existence of large flows of resources within the family both between genders and toward young generations, with men and women giving rise to considerable monetary and time transfers, respectively. PMID:26110106

  8. Nostalgia: retreat or support in difficult times?

    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.

  9. Why behavior change is difficult to sustain.

    Bouton, Mark E

    2014-11-01

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

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

    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.

  11. Combined precut in difficult biliary cannulation

    Jesús Espinel-Díez

    2013-06-01

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

  12. Difficult relationships: critical pedagogies and curriculum

    María Verónica Di Caudo Villoslada

    2013-07-01

    Full Text Available This paper reviews the proposals of the ‘critical pedagogies’ and presents some difficulties in the realization of their principles in the context of current public policies in Latin America. Distances between discourses and practices, absence of radically democratic educational policies, lack of awareness of critical pedagogies by teachers, lack of contextual production and indiscriminate use of the word critical—that ends up opposing everything that is considered as traditional pedagogy—makes us wonder about the real possibility of transformation in order to fight against the dominant power relationships through counter-hegemonic and destabilizing practices in education.

  13. THE DIFFICULT TASK OF MAINTAINING CREDIBILITY

    Lucian Croitoru

    2003-07-01

    Full Text Available During the past two years the main features of the Romanian economy were the strong economic growth and the presence of a relatively high surplus on the foreign exchange market. Among the direct consequences of that surplus were the gradually declining depreciation rate, the tendency towards real appreciation of the leu against the euro-USD basket as compared to 2000, the generalization of anticipations regarding that appreciation and the decreases in the interest rates. The decreases in the interest rates and elimination of the well-known costs of high and volatile inflation brought about important benefits in terms of economic growth. Indeed, the lower inflation stimulated investments by contributing to the extension of decision-making horizons. Is it possible to repeat the same trend also in 2003?

  14. [Waldheim--the difficult task of investigation].

    Beine, K; Schmitz, F; Schumann, V; Trenckmann, U

    1991-03-01

    This is a report on a mental hospital--or, rather, a department of a mental hospital--called "Waldheim", (literal meaning: "hostal, or home in the woods") which is a section of the mental hospital at Hochweitzschen in Saxony in the former German Democratic Republic (GDR). Public opinion had been aroused some time ago by an article published in the German weekly "Stern" in which it was stated that psychotic patients were being subjected to leukotomy or stereotactic surgery, and that castration by x-ray treatment was being performed in mentally handicapped women, in that hospital. The article prompted the then Ministery of Health of the GDR to constitute an "expert committee" to investigate into the matter. The magazine's allegations were partly confirmed by the committee. The GDR parliament then constituted a "special parliamentary commission" for another inquiry. Again several allegations were confirmed. It was stated that the events and actions in that hospital had been unsatisfactorily assessed and digested. The authors undertake to make the procedures followed by the medical and nursing staff, accessible to a wider public and to render them more lucid. Important structural characteristics of the patterns that developed there, were the governmentally prescribed segregation of severely diseased persons to "treat" them far away from their residential community, the absence of a critical general public, and the amalgamation of supervisory institutions with those that require to be supervised.(ABSTRACT TRUNCATED AT 250 WORDS)

  15. Maxillofacial trauma patient: coping with the difficult airway

    Barak Michal

    2009-05-01

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

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

    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.

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

    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.

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

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

    2015-11-01

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

  19. 24 CFR 576.45 - Reallocation of grant amounts; returned or unused amounts.

    2010-04-01

    ... with the provisions of § 576.5 of this part. (e) Selection criteria. HUD will award grants under... to be made. (b) FEMA boards. HUD may use State and local boards established under the Emergency Food... will rank the applications using the criteria in paragraph (e) of this section. (7) HUD may make a...

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

    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

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

    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

    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

    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. Acceptance issues for large items and difficult waste

    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

  5. Optimal inventory reallocation to customer orders in ceramic tile companies characterized by the lack of homogeneity in the product (LHP); Reasignacion optima del inventario a pedidos en empresas ceramicas caracterizadas por la falta de homogeneidad en el producto (FHP)

    Alemany, M. M. E.; Alarcon, F.; Oltra, R. F.; Lario, B. C.

    2013-02-01

    The lack of homogeneity in the product (LHP) is defined as the lack of uniformity required by the customer in the products. The LHP appears in companies where the final products obtained are not homogeneous, leading to the existence of different references (subtypes) of the same product. This lack of homogeneity is a problem when the client needs to be served through homogeneous units of a product and commit orders are based on planned quantities, whose final homogeneity characteristics are unknown at the time of acquiring the customer commitments. The frequent discrepancies caused by the LHP between planned homogeneous amounts and those actually obtained and available, can prevent the delivery of committed orders. To solve this problem, we propose a mathematical programming model for the reallocation of inventory in Make to Stock (MTS) ceramic tile companies characterized by the LHP that combines multiple objectives. The proposed mathematical model has been validated by its application to a real case of a ceramic company. The analysis of the obtained results indicates significant improvements in the number of orders completed on time and in sales revenue achieved. (Author) 33 refs.

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

    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.

  7. Efficient similarity-based data clustering by optimal object to cluster reallocation.

    Rossignol, Mathias; Lagrange, Mathieu; Cont, Arshia

    2018-01-01

    We present an iterative flat hard clustering algorithm designed to operate on arbitrary similarity matrices, with the only constraint that these matrices be symmetrical. Although functionally very close to kernel k-means, our proposal performs a maximization of average intra-class similarity, instead of a squared distance minimization, in order to remain closer to the semantics of similarities. We show that this approach permits the relaxing of some conditions on usable affinity matrices like semi-positiveness, as well as opening possibilities for computational optimization required for large datasets. Systematic evaluation on a variety of data sets shows that compared with kernel k-means and the spectral clustering methods, the proposed approach gives equivalent or better performance, while running much faster. Most notably, it significantly reduces memory access, which makes it a good choice for large data collections. Material enabling the reproducibility of the results is made available online.

  8. Reallocating risks and returns to scale up adoption of distributed electricity resources

    Kulatilaka, Nalin; Santiago, Leonardo; Vakili, Pirooz

    2014-01-01

    Deployment of distributed electricity resources requires bringing together assets that belong to diverse and geographically diffuse owners. Using the example of distributed solar PV, we analyze the schemes used to encourage/induce owners of distributed assets to make them available for electricity generation. The dominant model in the U.S. is long term power purchase agreements (PPA) offered to owners/consumers by solar developers. We show that these agreements (mis)allocate the electricity price risk to owners/consumers and impose limitations on the scale up of distributed solar. By proper use of financial markets it is possible to shift the electricity price risk from owners/consumers to parties that are better positioned to manage it. The proposed contracts simplify the adoption decision for owners/consumers and can lead to a wider adoption. Removing barriers to scale up requires (i) eliminating the tight coupling between consumers and owners and (ii) rewarding the owners unambiguously for the assets they provide. These necessitate the transformation of the current intermediary firms into full-fledged distributed generators. We discuss the implications of such a transformation and argue that the broad outline of our analysis can be used to assess scale up schemes in other domains of distributed electricity resources as well. - Highlights: • We analyze schemes used to induce owners of distributed assets to make them available for electricity generation. • We show that power purchase agreements used in solar PV “misallocate” electricity price risk to owners/consumers. • We propose new contracts forms that shift price risk from consumers to parties that are better able to manage it. • Full-fledged distributed generators are created by unambiguously rewarding owners and de-coupling consumption/ownership. • We argue that our analysis can be used to assess scale up schemes in other domains of distributed electricity resources

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

    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

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

    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.

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

    Radwanek-Bąk, Barbara; Nieć, Marek

    2014-05-01

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

  12. Climate Change Will Make Recovery from Eutrophication More Difficult in Shallow Danish Lake Søbygaard

    Rolighed, Jonas; Jeppesen, Erik; Søndergaard, Martin

    2016-01-01

    . The nutrient loading reduction scenarios predicted increased diatom dominance, accompanied by an increase in the zooplankton:phytoplankton biomass ratio. Simulations generally showed phytoplankton to benefit from a warmer climate and the fraction of cyanobacteria to increase. In the 6 ◦C warming scenario...

  13. Addiction surplus: the add-on margin that makes addictive consumptions difficult to contain.

    Adams, Peter J; Livingstone, Charles

    2015-01-01

    Addictive consumptions generate financial surpluses over-and-above non-addictive consumptions because of the excessive consumption of addicted consumers. This add-on margin or 'addiction surplus' provides a powerful incentive for beneficiaries to protect their income by ensuring addicted consumers keep consuming. Not only that, addiction surplus provides the financial base that enables producers to sponsor activities which aim to prevent public health initiatives from reducing consumption. This paper examines the potency of addiction surplus to engage industry, governments and communities in an on-going reliance on addiction surplus. It then explores how neo-liberal constructions of a rational consumer disguise the ethical and exploitative dynamics of addiction surplus by examining ways in which addictive consumptions fail to conform to notions of autonomy and rationality. Four measures are identified to contain the distorting effects of addiction surplus. Copyright © 2014 Elsevier B.V. All rights reserved.

  14. Do Questions Written in the Target Language Make Foreign Language Listening Comprehension Tests More Difficult?

    Filipi, Anna

    2012-01-01

    The Assessment of Language Competence (ALC) certificates is an annual, international testing program developed by the Australian Council for Educational Research to test the listening and reading comprehension skills of lower to middle year levels of secondary school. The tests are developed for three levels in French, German, Italian and…

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

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

    2009-12-01

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

  16. What makes interdisciplinarity difficult? Some consequences of domain specificity in interdisciplinary practice

    MacLeod, Miles Alexander James

    2018-01-01

    Research on interdisciplinary science has for the most part concentrated on the institutional obstacles that discourage or hamper interdisciplinary work, with the expectation that interdisciplinary interaction can be improved through institutional reform strategies such as through reform of peer

  17. Making difficult decisions: the role of quality of care in choosing a nursing home.

    Pesis-Katz, Irena; Phelps, Charles E; Temkin-Greener, Helena; Spector, William D; Veazie, Peter; Mukamel, Dana B

    2013-05-01

    We investigated how quality of care affects choosing a nursing home. We examined nursing home choice in California, Ohio, New York, and Texas in 2001, a period before the federal Nursing Home Compare report card was published. Thus, consumers were less able to observe clinical quality or clinical quality was masked. We modeled nursing home choice by estimating a conditional multinomial logit model. In all states, consumers were more likely to choose nursing homes of high hotel services quality but not clinical care quality. Nursing home choice was also significantly associated with shorter distance from prior residence, not-for-profit status, and larger facility size. In the absence of quality report cards, consumers choose a nursing home on the basis of the quality dimensions that are easy for them to observe, evaluate, and apply to their situation. Future research should focus on identifying the quality information that offers the most value added to consumers.

  18. Forming competing fear learning and extinction memories in adolescence makes fear difficult to inhibit

    Baker, Kathryn D.; Richardson, Rick

    2015-01-01

    Fear inhibition is markedly impaired in adolescent rodents and humans. The present experiments investigated whether this impairment is critically determined by the animal's age at the time of fear learning or their age at fear extinction. Male rats (n = 170) were tested for extinction retention after conditioning and extinction at different ages. We examined neural correlates of impaired extinction retention by detection of phosphorylated mitogen-activated protein kinase immunoreactivity (pMA...

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

    Baker, Kathryn D.; Richardson, Rick

    2015-01-01

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

  20. The central odontogenic fibroma: How difficult can be making a preliminary diagnosis

    Pippi, Roberto; Santoro, Marcello; Patini, Romeo

    2016-01-01

    Central odontogenic fibroma (COF) is a rare benign odontogenic tumor derived from the dental ectomesenchymal tissues. A 16-year-old Caucasian female patient was referred by her dentist for a radiolucent asymptomatic area associated with the crown of the impacted lower right third molar. A preliminary diagnosis of a follicular cyst was supposed. The lesion was surgically removed under general anesthesia together with the impacted tooth. The microscopic diagnosis of the excised tissue revealed ...

  1. Validated questionnaires heighten detection of difficult asthma comorbidities.

    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.

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

    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

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

    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.

  4. Inspiratory muscle training in difficult to wean patients: work it harder, make it better, do it faster, makes us stronger.

    Nava, Stefano; Fasano, Luca

    2011-01-01

    Weaning from prolonged mechanical ventilation is a complex, time-consuming process that involves the loss of force/generating capacity of the inspiratory muscle. In their study 'Inspiratory muscle strength training improves the outcome in failure to wean patients: a randomized trial', Martin and colleagues showed that the use of an inspiratory muscle strength program increased the maximal inspiratory pressure and improved weaning success compared to a control group. The study was performed mainly in post-surgical patients, however, and the results, therefore, may not be generalizable to other subsets of patients, such as those with chronic obstructive pulmonary disease or congestive heart failure. Indeed, the study applied so-called 'strength training' and not 'endurance training', which may be more appropriate in certain circumstances.

  5. Guidelines and algorithms for managing the difficult airway.

    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.

  6. Techniques for assisting difficult delivery at caesarean section.

    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

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

    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 ...

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

    Watanabe, Hiroshi

    2013-01-01

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

  9. Achieving a Risk-Informed Decision-Making Environment at NASA: The Emphasis of NASA's Risk Management Policy

    Dezfuli, Homayoon

    2010-01-01

    This slide presentation reviews the evolution of risk management (RM) at NASA. The aim of the RM approach at NASA is to promote an approach that is heuristic, proactive, and coherent across all of NASA. Risk Informed Decision Making (RIDM) is a decision making process that uses a diverse set of performance measures along with other considerations within a deliberative process to inform decision making. RIDM is invoked for key decisions such as architecture and design decisions, make-buy decisions, and budget reallocation. The RIDM process and how it relates to the continuous Risk Management (CRM) process is reviewed.

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

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

    2015-01-01

    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 ...

  11. How to manage a child with difficult asthma?

    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. Difficult airway management of children in ambulatory anesthesia: challenges and solutions

    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

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

    Veretelnikova Yu.Ya.

    2013-03-01

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

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

    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

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

    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.

  16. Percutaneous transhepatic cholelithotripsy for difficult common bile duct stones

    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...

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

    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…

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

    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.

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

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

    2000-01-01

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

  20. Emotional distance to so-called difficult patients

    Michaelsen, Jette Joost

    2012-01-01

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

  1. Difficult Tracheal Intubation in Obese Gastric Bypass patients

    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...

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

    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...

  3. Interesting cases which were difficult to diagnose by CT

    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)

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

    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.

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

    Efiaty A. Soepardi

    2005-03-01

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

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

    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.

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

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

    2016-01-01

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

  8. Anaesthetic management in a case of large plunging ranula with difficult airway: A case report

    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.

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

    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.

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

    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

  11. High Metal Removal Rate Process for Machining Difficult Materials

    Bates, Robert; McConnell, Elizabeth

    2016-06-29

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

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

    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)

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

    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

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

    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

  15. Management of difficult airway in intratracheal tumor surgery

    Agarwal Surendra K

    2005-06-01

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

  16. Ploughs for difficult seams of Bergbau AG Niederrhein

    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.

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

    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.

  18. Cylindrical plunge grinding of difficult to grind materials

    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)

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

    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 .

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

    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.

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

    Viet Q. Tran

    2008-01-01

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

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

    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.

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

    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.

  4. Flexible lot sizing in hybrid make-to-order/make-to-stock production planning

    Beemsterboer, Bart; Land, Martin; Teunter, Ruud

    2017-01-01

    Hybrid make-to-order/make-to-stock production systems are difficult to control. Batch production of make-to-stock products allows for efficient capacity usage, but fixed batch sizes can make the system less responsive to make-to-order customers. Using Markov Decision Process modeling, we show that

  5. The Difficult Chore of Measuring Coordination by EXAFS

    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

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

    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.

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

    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.

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

    Westgren Magnus

    2010-06-01

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

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

    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

  10. Simultaneous Optimization of Tallies in Difficult Shielding Problems

    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

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

    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.

  12. Rules and technical tricks in extremely difficult laparoscopic cholecystectomies

    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.

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

    Naim Jerliu

    2015-12-01

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

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

    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.

  15. [Productive restructuring and the reallocation of work and employment: a survey of the "new" forms of social inequality].

    Marques, Ana Paula Pereira

    2013-06-01

    The scope of this paper is to question the inevitability of the processes of segmentation and increased precariousness of the relations of labor and employment, which are responsible for the introduction of "new" forms of social inequality that underpin the current model of development of economies and societies. It seeks to criticize the limits of global financial and economic logic, which constitute a "new spirit of capitalism," namely a kind of reverence for the natural order of things. It is therefore necessary to conduct an analytical survey of the ongoing changes in the labor market, accompanied by epistemological vigilance which makes it possible to see neoliberal (di)visions and dominant techno-deterministic theses in context. The enunciation of scenarios on the future of work will conclude this survey and will make it possible to draw attention to both the historical and temporal constraints and to the urgent need to unveil what is ideological and political in the prevailing logic of rationalization and processes to reinstate work and employment as a "central social experience" in contemporary times.

  16. Decision Making

    Pier Luigi Baldi

    2006-06-01

    Full Text Available This article points out some conditions which significantly exert an influence upon decision and compares decision making and problem solving as interconnected processes. Some strategies of decision making are also examined.

  17. Retrievability - A too simple answer to a difficult question?

    Odhnoff, C.

    2002-01-01

    Near to Stockholm in October, 1999, KASAM and IAEA held a joint seminar on Retrievability. There were some 40 participants from about ten countries. Consensus was not the objective, moreover, the discussions were conducted in a friendly spirit of respect and wish to understand different opinions. The retrievability option was incorporated into into broader concepts by a stepwise procedure designed to allow the possibility of steps being reversed, thereby reducing the dramatic difference between open and closed repositories. Each step would give you time to consider and best if the repository concept so far was up to expectations. Retrievability is not a simple answer, but it helps to make this question less complicated. (author)

  18. Methods for measuring denitrification: Diverse approaches to a difficult problem

    Groffman, Peter M.; Altabet, Mark A.; Böhlke, J. K.

    2006-01-01

    , and global scales. Unfortunately, this process is very difficult to measure, and existing methods are problematic for different reasons in different places at different times. In this paper, we review the major approaches that have been taken to measure denitrification in terrestrial and aquatic environments...... based on stable isotopes, (8) in situ gradients with atmospheric environmental tracers, and (9) molecular approaches. Our review makes it clear that the prospects for improved quantification of denitrification vary greatly in different environments and at different scales. While current methodology allows...... for the production of accurate estimates of denitrification at scales relevant to water and air quality and ecosystem fertility questions in some systems (e.g., aquatic sediments, well-defined aquifers), methodology for other systems, especially upland terrestrial areas, still needs development. Comparison of mass...

  19. Pulmonary embolism and difficult-to-treat asthma

    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

  20. Use of programme budgeting and marginal analysis as a framework for resource reallocation in respiratory care in North Wales, UK.

    Charles, J M; Brown, G; Thomas, K; Johnstone, F; Vandenblink, V; Pethers, B; Jones, A; Edwards, R T

    2016-09-01

    Since the global financial crisis, UK NHS spending has reduced considerably. Respiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Under the remit of 'prudent healthcare' championed by the Welsh Health Minister, a Programme Budgeting Marginal Analysis (PBMA) of the North Wales respiratory care pathway was conducted. A PBMA panel of directors of medicines management, therapies finance, planning, public health and healthcare professionals used electronic voting to establish criteria for decision-making and vote on candidate interventions in which to disinvest and invest. A sum of £86.9 million was spent on respiratory care in 2012-13. Following extensive discussion of 13 proposed candidate interventions facilitated by a chairperson, 4 candidates received recommendations to disinvest, 7 to invest and 2 to maintain current activity. Marginal analysis prioritized mucolytics and high antibiotic prescribing as areas for disinvestment, and medicines waste management and pulmonary rehabilitation for investment. This exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and investment decisions. Initial progress has begun with communication from the Medical Director in relation to the disinvestment in mucolytics prescribing and possible redirection of funding options being explored. © The Author 2015. Published by Oxford University Press on behalf of Faculty of Public Health.

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

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

    2016-01-01

    facilitate lexical access, making it difficult for them to fully engage higher-order cognitive abilities in support of listening comprehension.

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

    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.

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

    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

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

    Sonia Fleury

    2004-05-01

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

  5. Jungle Giants: Assessing Sustainable Harvesting in a Difficult-to-Survey Species (Python reticulatus.

    Daniel J D Natusch

    Full Text Available Sustainability of wildlife harvests is critical but difficult to assess. Evaluations of sustainability typically combine modelling with the measurement of underlying abundances. For many taxa harvested in developing countries, however, abundances are near-impossible to survey and a lack of detailed ecological information impedes the reliability of models. In such cases, repeated surveys of the attributes of harvested individuals may provide more robust information on sustainability. If the numbers, sizes and other demographic attributes of animals taken for the commercial trade do not change over biologically significant time intervals (decades, there is a prima facie case that the harvest is indeed sustainable. Here, we report the results of examinations of > 4,200 reticulated pythons (Python reticulatus taken for the commercial leather industry in northern and southern Sumatra, Indonesia. The numbers, mean body sizes, clutch sizes, sizes at maturity and proportion of giant specimens have not decreased between our first surveys (1995 and repeat surveys (2015. Thus, despite assumptions to the contrary, the harvest appears to be sustainable. We use our data to inform the design of future monitoring programs for this species. Our study underpins the need for robust science to inform wildlife trade policy and decision-making, and urges wildlife managers to assess sustainability of difficult-to-survey terrestrial wildlife by drawing inferences directly from the harvest itself.

  6. Jungle Giants: Assessing Sustainable Harvesting in a Difficult-to-Survey Species (Python reticulatus).

    Natusch, Daniel J D; Lyons, Jessica A; Mumpuni; Riyanto, Awal; Shine, Richard

    2016-01-01

    Sustainability of wildlife harvests is critical but difficult to assess. Evaluations of sustainability typically combine modelling with the measurement of underlying abundances. For many taxa harvested in developing countries, however, abundances are near-impossible to survey and a lack of detailed ecological information impedes the reliability of models. In such cases, repeated surveys of the attributes of harvested individuals may provide more robust information on sustainability. If the numbers, sizes and other demographic attributes of animals taken for the commercial trade do not change over biologically significant time intervals (decades), there is a prima facie case that the harvest is indeed sustainable. Here, we report the results of examinations of > 4,200 reticulated pythons (Python reticulatus) taken for the commercial leather industry in northern and southern Sumatra, Indonesia. The numbers, mean body sizes, clutch sizes, sizes at maturity and proportion of giant specimens have not decreased between our first surveys (1995) and repeat surveys (2015). Thus, despite assumptions to the contrary, the harvest appears to be sustainable. We use our data to inform the design of future monitoring programs for this species. Our study underpins the need for robust science to inform wildlife trade policy and decision-making, and urges wildlife managers to assess sustainability of difficult-to-survey terrestrial wildlife by drawing inferences directly from the harvest itself.

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

    Miranda, E.P.

    1992-01-01

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

  8. Drugs that modulate aging: the promising yet difficult path ahead.

    Kennedy, Brian K; Pennypacker, Juniper K

    2014-05-01

    Once a backwater in medical sciences, aging research has emerged and now threatens to take the forefront. This dramatic change of stature is driven from 3 major events. First and foremost, the world is rapidly getting old. Never before have we lived in a demographic environment like today, and the trends will continue such that 20% percent of the global population of 9 billion will be over the age of 60 by 2050. Given current trends of sharply increasing chronic disease incidence, economic disaster from the impending silver tsunami may be ahead. A second major driver on the rise is the dramatic progress that aging research has made using invertebrate models such as worms, flies, and yeast. Genetic approaches using these organisms have led to hundreds of aging genes and, perhaps surprisingly, strong evidence of evolutionary conservation among longevity pathways between disparate species, including mammals. Current studies suggest that this conservation may extend to humans. Finally, small molecules such as rapamycin and resveratrol have been identified that slow aging in model organisms, although only rapamycin to date impacts longevity in mice. The potential now exists to delay human aging, whether it is through known classes of small molecules or a plethora of emerging ones. But how can a drug that slows aging become approved and make it to market when aging is not defined as a disease. Here, we discuss the strategies to translate discoveries from aging research into drugs. Will aging research lead to novel therapies toward chronic disease, prevention of disease or be targeted directly at extending lifespan? Copyright © 2014 Mosby, Inc. All rights reserved.

  9. Productive friction: how difficult business partnerships can accelerate innovation.

    Hagel, John; Brown, John Seely

    2005-02-01

    Companies are becoming more dependent on business partners, but coordinating with outsiders takes its toll. Negotiating terms, monitoring performance, and, if needs are not being met, switching from one partner to another require time and money. Such transaction costs, Ronald Coase explained in his 1937 essay "The Nature of the Firm," drove many organizations to bring their activities in-house. But what if Coase placed too much emphasis on these costs? What if friction between companies can be productive? Indeed, as John Hagel and John Seely Brown point out, interactions between organizations can yield benefits beyond the goods or services contracted for. Companies get better at what they do--and improve faster than their competitors--by working with outsiders whose specialized capabilities complement their own. Different enterprises bring different perspectives and competencies. When these enterprises tackle a problem together, they dramatically increase the chances for innovative solutions. Of course, misunderstandings often arise when people with different backgrounds and skill sets try to collaborate. Opposing sides may focus on the distance that separates them rather than the common challenges they face. How can companies harness friction so that it builds capabilities? Start by articulating performance goals that everyone buys into. Then make sure people are using tangible prototypes to wrangle over. Finally, assemble teams with committed people who bring different perspectives to the table. As individual problems are being addressed, take care that the underpinnings of shared meaning and trust are also being woven between the companies. Neither can be dictated--but they can be cultivated. Without them, the performance fabric quickly unravels, and business partnerships disintegrate into rivalrous competition.

  10. Model : making

    Bottle, Neil

    2013-01-01

    The Model : making exhibition was curated by Brian Kennedy in collaboration with Allies & Morrison in September 2013. For the London Design Festival, the Model : making exhibition looked at the increased use of new technologies by both craft-makers and architectural model makers. In both practices traditional ways of making by hand are increasingly being combined with the latest technologies of digital imaging, laser cutting, CNC machining and 3D printing. This exhibition focussed on ...

  11. [Epidermoid cyst of the testis difficult to make a preoperative diagnosis on the echoic examination: a case report].

    Yamamoto, Keisuke; Takada, Tsuyoshi; Momohara, Chikahiro; Komori, Kazuhiko; Honda, Masahito; Fujioka, Hideki

    2003-04-01

    A case of epidermoid cyst of the testis is presented. The patient was a 64-year-old man who complained of a painless mass in the left scrotum. Physical examination revealed a hen-egg sized enlargement of the left scrotal contents. The ultrasonographic appearance did not show a hyperechoic partition, which is called echogenic rim, a characteristic of this tumor on the echoic examination, and was homogeneous, almost similar to that of a normal testis. Because malignant testicular tumors could not be excluded preoperatively, excisional biopsy of the left testis was performed first. Histological diagnosis was an epidermoid cyst of the testis. As the left testis was almost completely occupied by the tumor and no normal testicular tissue was recognized, we performed orchiectomy additionally. Epidermoid cyst of the testis is a rare benign tumor that accounts for about 1 percent of all testicular tumors. It clinically resembles malignant testicular tumors, and orchiectomy is often performed for treatment. About 154 cases of testicular epidermoid cyst have been reported in the Japanese literature and are reviewed briefly here.

  12. Achieving Operational Flexibility Through Task Organization: How the American Forces in Europe Beat Nazi Germany by Making the Difficult Routine

    2013-05-23

    the ABied invasion of Southern France). August 19: Resistance uprising in Paris . 20: Allies encircle Germans in the Falaise Pocket. Key Changes I...34 Army Group) for 1\\.farker-Garden (note Ridgeway bad no tactical cmd) August 25: Liberation of Paris . ~ Eisenhower Assumes Command on Continent...A.irborne Divisions) September 17-25: Operntioo Market Garden (A.Died aibome assault on HoDand). September 18: The U.S. Ninth Army finally takes Brest

  13. Temporal perspective and other psychological factors making it difficult to adapt to requirements of treatment in chronic dialysis patients

    Zawadzka, Barbara; Byrczek, Magdalena; Zawadzka, Sara

    2014-01-01

    Aim. The study analyzed the relationship between temporal perspective, selected personal resources, and unhealthy behavior, manifesting in problems with adherence to fluid intake restrictions, in chronic hemodialyzis patients. The authors tried to answer the question whether there is temporal perspective and other psychological factors increasing the risk of non-adaptive behaviors. Methods. Sixty-one patients, aged 23–81 years (M = 59; SD = 13,9) on chronic hemodialysis at the Departmen...

  14. [Temporal perspective and other psychological factors making it difficult to adapt to requirements of treatment in chronic dialysis patients].

    Zawadzka, Barbara; Byrczek, Magdalena; Zawadzka, Sara

    2014-01-01

    The study analyzed the relationship between temporal perspective, selected personal resources, and unhealthy behavior, manifesting in problems with adherence to fluid intake restrictions, in chronic.hemodialyzis patients. The authors tried to answer the question whether there is temporal perspective and other psychological factors increasing the risk of non-adaptive behaviors. Sixty-one patients, aged 23-81 years (m = 59; SD = 13,9) on chronic hemodialysis at the Department of Nephrology University Hospital were qualified to the study. The study group consisted of 30 patients with poorer fluid regimen adherence and 31 con- trols, who maintained fluid regimen. The patients were qualified on the bases of the average interdialysis weight gains measured nine times during three weeks. The following research tools were used: P. Zimbardo and J. Boyd ZTPI test; P.T. Costa and R.R. McCrae NEO-FFI Inventory; J. Strelau Temperament Inventory, R. Schwarzer GSES; M. F. Scheier; C. S. Carver and M. W. Bridges LOT-R; M. Watson and S. Greer CECS; BJ. Felton, TA. Revenson, GA. Hinrichsen AIS. Difficulties in adapting to the fluid intake restrictions are significantly associated with temporal orientation towards negative aspects of the present and the past. Non-adaptive health behaviors are typical for patients with temperamental lack of balance between agitation and inhibition processes and are characterized by high agreeableness and low conscientious- ness. The association between excessive anger control and the risk of non-adherence medical recommendations. Time perception and other personality factors form mechanisms regulating health behaviors in chronically treatment patients.

  15. Steel making

    Chakrabarti, A K

    2014-01-01

    "Steel Making" is designed to give students a strong grounding in the theory and state-of-the-art practice of production of steels. This book is primarily focused to meet the needs of undergraduate metallurgical students and candidates for associate membership examinations of professional bodies (AMIIM, AMIE). Besides, for all engineering professionals working in steel plants who need to understand the basic principles of steel making, the text provides a sound introduction to the subject.Beginning with a brief introduction to the historical perspective and current status of steel making together with the reasons for obsolescence of Bessemer converter and open hearth processes, the book moves on to: elaborate the physiochemical principles involved in steel making; explain the operational principles and practices of the modern processes of primary steel making (LD converter, Q-BOP process, and electric furnace process); provide a summary of the developments in secondary refining of steels; discuss principles a...

  16. Making smarter decisions in urban environments

    Velthausz, D

    2015-10-01

    Full Text Available Increasing urbanisation has introduced and exacerbated challenges related to the management of service delivery, resources and hazards. Making informed decisions for a city and its inhabitants is difficult because a city is an extremely complex...

  17. New possibilities using additive manufacturing with materials that are difficult to process and with complex structures

    Olsson, Anders; Hellsing, Maja S.; Rennie, Adrian R.

    2017-05-01

    Additive manufacturing (or 3D printing) opens the possibility of creating new designs and manufacturing objects with new materials rapidly and economically. Particularly for use with polymers and polymer composites, simple printers can make high quality products, and these can be produced easily in offices, schools and in workshops and laboratories. This technology has opened a route for many to test ideas or to make custom devices. It is possible to easily manufacture complex geometries that would be difficult or even impossible to create with traditional methods. Naturally this technology has attracted attention in many fields that include the production of medical devices and prostheses, mechanical engineering as well as basic sciences. Materials that are highly problematic to machine can be used. We illustrate process developments with an account of the production of printer parts to cope with polymer fillers that are hard and abrasive; new nozzles with ruby inserts designed for such materials are durable and can be used to print boron carbide composites. As with other materials, complex parts can be printed using boron carbide composites with fine structures, such as screw threads and labels to identify materials. General ideas about design for this new era of manufacturing customised parts are presented.

  18. New possibilities using additive manufacturing with materials that are difficult to process and with complex structures

    Olsson, Anders; Hellsing, Maja S; Rennie, Adrian R

    2017-01-01

    Additive manufacturing (or 3D printing) opens the possibility of creating new designs and manufacturing objects with new materials rapidly and economically. Particularly for use with polymers and polymer composites, simple printers can make high quality products, and these can be produced easily in offices, schools and in workshops and laboratories. This technology has opened a route for many to test ideas or to make custom devices. It is possible to easily manufacture complex geometries that would be difficult or even impossible to create with traditional methods. Naturally this technology has attracted attention in many fields that include the production of medical devices and prostheses, mechanical engineering as well as basic sciences. Materials that are highly problematic to machine can be used. We illustrate process developments with an account of the production of printer parts to cope with polymer fillers that are hard and abrasive; new nozzles with ruby inserts designed for such materials are durable and can be used to print boron carbide composites. As with other materials, complex parts can be printed using boron carbide composites with fine structures, such as screw threads and labels to identify materials. General ideas about design for this new era of manufacturing customised parts are presented. (invited comment)

  19. Make Sense?

    Gyrd-Jones, Richard; Törmälä, Minna

    Purpose: An important part of how we sense a brand is how we make sense of a brand. Sense-making is naturally strongly connected to how we cognize about the brand. But sense-making is concerned with multiple forms of knowledge that arise from our interpretation of the brand-related stimuli......: Declarative, episodic, procedural and sensory. Knowledge is given meaning through mental association (Keller, 1993) and / or symbolic interaction (Blumer, 1969). These meanings are centrally related to individuals’ sense of identity or “identity needs” (Wallpach & Woodside, 2009). The way individuals make...... sense of brands is related to who people think they are in their context and this shapes what they enact and how they interpret the brand (Currie & Brown, 2003; Weick, Sutcliffe, & Obstfeld, 2005; Weick, 1993). Our subject of interest in this paper is how stakeholders interpret and ascribe meaning...

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

    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.

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

    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.

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

    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

  3. Re-allocating Public Space

    Figueroa, Maria J.

    values such as reciprocity and mutual help, as critical components in the formation of new narratives in the use of space. In this way unlocking practices and demonstrating new possibilities within which the use of bicycles became merely a social instrument demonstrating visions of the common good...

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

    Hernandez, Luis; Smith, Connie Jo

    2009-01-01

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

  5. Difficult Children

    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...

  6. Decision making.

    Chambers, David W

    2011-01-01

    A decision is a commitment of resources under conditions of risk in expectation of the best future outcome. The smart decision is always the strategy with the best overall expected value-the best combination of facts and values. Some of the special circumstances involved in decision making are discussed, including decisions where there are multiple goals, those where more than one person is involved in making the decision, using trigger points, framing decisions correctly, commitments to lost causes, and expert decision makers. A complex example of deciding about removal of asymptomatic third molars, with and without an EBD search, is discussed.

  7. Making Connections

    Pien, Cheng Lu; Dongsheng, Zhao

    2011-01-01

    Effective teaching includes enabling learners to make connections within mathematics. It is easy to accord with this statement, but how often is it a reality in the mathematics classroom? This article describes an approach in "connecting equivalent" fractions and whole number operations. The authors illustrate how a teacher can combine a common…

  8. Oral to nasal tube exchange under fibroscopic view: a new technique for nasal intubation in a predicted difficult airway.

    Monclus, Enric; Garcés, Antonio; Artés, David; Mabrock, Maged

    2008-07-01

    For a predicted difficult airway, oral intubation techniques are well established in pediatric anesthesia, but nasotracheal intubation remains a problem. There are many reports concerning this, but the risk of bleeding, added to the lack of cooperation make this procedure difficult and hazardous. We describe a modification of the nasal intubation technique in two stages. First an oral intubation and then exchanging the oral for a nasal tube, in the case of a 13-year-old boy affected by an advanced stage of cherubism. Oral intubation using a laryngeal mask technique has already been reported, but problems appear during the exchange procedure and even more when direct laryngoscopy is impossible. Fiberscopic control of the exchange, and the introduction of a Cook Exchange Catheter into the trachea through the oral tube before withdrawal, permits oxygenation of the patient and acts as a guide for oral tube reintroduction if required.

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

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

    2012-07-01

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

  10. Incision extension is the optimal method of difficult gallbladder extraction at laparoscopic cholecystectomy.

    Bordelon, B M; Hobday, K A; Hunter, J G

    1992-01-01

    An unsolved problem of laparoscopic cholecystectomy is the optimal method of removing the gallbladder with thick walls and a large stone burden. Proposed solutions include fascial dilatation, stone crushing, and ultrasonic, high-speed rotary, or laser lithotripsy. Our observation was that extension of the fascial incision to remove the impacted gallbladder was time efficient and did not increase postoperative pain. We reviewed the narcotic requirements of 107 consecutive patients undergoing laparoscopic cholecystectomy. Fifty-two patients required extension of the umbilical incision, and 55 patients did not have their fascial incision enlarged. Parenteral meperidine use was 39.5 +/- 63.6 mg in the patients requiring fascial incision extension and 66.3 +/- 79.2 mg in those not requiring fascial incision extension (mean +/- standard deviation). Oral narcotic requirements were 1.1 +/- 1.5 doses vs 1.3 +/- 1.7 doses in patients with and without incision extension, respectively. The wide range of narcotic use in both groups makes these apparent differences not statistically significant. We conclude that protracted attempts at stone crushing or expensive stone fragmentation devices are unnecessary for the extraction of a difficult gallbladder during laparoscopic cholecystectomy.

  11. A nuclear-armed Iran: a difficult but not impossible policy problem - Lecture note

    Sitt, Bernard

    2006-01-01

    This lecture note makes an analysis of a report by Barry R. Posen from The Century Foundation (TCF) and entitled: 'A nuclear-armed Iran: a difficult but not impossible policy problem' (28 Dec 2006). In this report, the author believes that diplomacy would be the ideal outcome in handling the nuclear bomb situation in Iran, but containment and deterrence will be effective if diplomacy fails. He challenges the common fears that arise from Iran's potential possession of a bomb: The fear that Iran would use nuclear threats against nonnuclear neighbors; The fear that Iran would use nuclear weapons to annihilate the state of Israel. To ensure effective deterrence, the United States would need to pursue a strategy of coexistence with a nuclear Iran. In order to do so, the US would have to renew its commitment to the security of the Middle East; US involvement would be required to prevent regional proliferation and to ensure the protection of Iran's neighbors. The present Lecture note analyzes and discusses the 4 threats of a nuclear Iran that need to be dissuaded: a risky and more violent foreign policy; the blackmailing of some neighbor countries; the supply of nuclear weapons to non-state actors; and nuclear strikes against Israel despite inevitable retaliatory measures

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

    Epner, Daniel E; Baile, Walter F

    2014-04-01

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

  13. Making Yugoslavs

    Nielsen, Christian Axboe

    . By the time Aleksandar was killed by an assassin’s bullet five years later, he not only had failed to create a unified Yugoslav nation but his dictatorship had also contributed to an increase in interethnic tensions.   In Making Yugoslavs, Christian Axboe Nielsen uses extensive archival research to explain...... the failure of the dictatorship’s program of forced nationalization. Focusing on how ordinary Yugoslavs responded to Aleksandar’s nationalization project, the book illuminates an often-ignored era of Yugoslav history whose lessons remain relevant not just for the study of Balkan history but for many...

  14. THE MAKING OF DECISION MAKING

    Leonardo Yuji Tamura

    2016-04-01

    Full Text Available Quantum Electronics was a Brazilian startup in the 1990's that was acquired by an American equity fund in 2012. They are currently the largest manufacturer of vehicle tracking and infotainment systems. The company was founded by three college friends, who are currently executives at the company: Camilo Santos, Pedro Barbosa and Luana Correa. Edward Hutter was sent by the equity fund to take over the company’s finances, but is having trouble making organizational decisions with his colleagues. As a consultant, I was called to help them improve their decision making process and project prioritization. I adapted and deployed our firm's methodology, but, in the end, its adequacy is shown to be very much in question. The author of this case study intends to explore how actual organizational decisions rely on different decision models and their assumptions, .as well as demonstrate that a decision model is neither absolutely good nor bad as its quality is context dependent.

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

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

    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....

  16. Human Factors Influencing Decision Making

    1998-07-01

    and Einhom (1991); Zeelenberg et al. (1997). This environmental context also makes it difficult to associate measured personality traits with specific... Zeelenberg and Beattie5 (1997): People are motivated to minimize post-decision regret. As a result people can become risk averse or risk seeking...188-201), Ablex, Norwood NJ, 1993. 5 Zeelenberg M. and J. Beattie. "Consequences of regret aversion 2: additional evidence for effects of feedback on

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

    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.

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

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

    2007-01-01

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

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

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

    2012-01-01

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

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

    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…

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

    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…

  2. When care situations evoke difficult emotions in nursing staff members: an ethnographic study in two Norwegian nursing homes.

    Sandvoll, Anne Marie; Grov, Ellen Karine; Kristoffersen, Kjell; Hauge, Solveig

    2015-01-01

    Caring practice in nursing homes is a complex topic, especially the challenges of meeting the basic needs of residents when their behaviour evokes difficult emotions. Cognitive and physical changes related to aging and disability can contribute to behaviours considered to be unacceptable. For example, resident behaviours such as spitting, making a mess with food or grinding teeth are behaviours that most people do not want to see, hear or experience. The aim of this study was to gain a deeper understanding of how nursing home staff members deal with such behaviours in care situations. This article draws on ethnographic data to describe how nursing home staff members manage unpleasant resident behaviours. The study was based on two long-term units in two Norwegian public nursing homes. The Region's Medical Ethics Committee and the Norwegian Social Science Data Services granted approval. In total, 45 participants (37 nursing aides and eight nurses) agreed to participate in this study. Ten of the participants were interviewed at the end of the field study. This study indicates that nursing home staff members experience difficult emotions related to some residents' behaviours. However, they found these feelings difficult to express and rarely verbalized them openly. In addition, they were characterized by a strong obligation to help all residents, despite their own feelings. Therefore, it appears that an inner struggle occurs as a part of everyday practice. Despite these difficult emotions, nursing staff members believed that they needed to manage their responses and continued to offer good care to all residents. These findings extend our understanding of this unarticulated part of nursing home practice.

  3. Use of a Flexible Intubating Scope in Combination with a Channeled Video Laryngoscope for Managing a Difficult Airway in the Emergency Department.

    Sowers, Nicholas; Kovacs, George

    2016-02-01

    Difficulty with intubation is not uncommon in the emergency setting. Video laryngoscopes (VLs) are commonly used to manage the difficult airway in the emergency department (ED). Intubation using a flexible bronchoscope, while considered the gold standard for managing the anticipated difficult airway in the operating room, is not commonly used in the ED. We present a case describing VL-assisted flexible scope intubation performed in the ED as a novel feasible approach to managing the difficult airway. A 65-year-old male, post cardiac arrest, with multiple unsuccessful attempts at prehospital intubation had rapid sequence intubation (RSI) performed and, despite obtaining a view with a King Vision™ VL, the skilled operator was unable to advance the endotracheal tube (ETT). An Ambu™ aScope3 flexible intubating scope (FIS) was placed through the ETT loaded in the channel of the King Vision and advanced through the cords to a position proximal to the carina. The ETT was then advanced easily over the FIS and down the trachea. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although video laryngoscopy is commonly used in the ED, intubation can prove difficult, despite having an adequate view of the glottis. Use of an FIS, however, through a channeled VL makes navigation of the ETT easier and facilitates tube advancement, which can be difficult with VL. Channeled VL-assisted use of an FIS is a viable option for managing the difficult airway. Copyright © 2016 Elsevier Inc. All rights reserved.

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

    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.

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

    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.

  6. Decision making regarding multifetal reduction.

    Maifeld, Michelle; Hahn, Sandra; Titler, Marita G; Mullen, Meredithe

    2003-01-01

    To identify salient variables that influence decision making regarding multifetal reduction (MFR) and describe their effect on individuals over time. Prospective, exploratory, descriptive design, using qualitative and quantitative methods. Midwestern tertiary care center. A convenience sample of 11 consecutive consenting couples with triplet or higher-order pregnancies who elected to undergo MFR. Semistructured audiotaped telephone interviews at three points: (a) 2 weeks postreduction, (b) 6 weeks postpartum, and (c) 6 months postpartum; a demographic and marital adjustment questionnaire. Themes identified by content analysis and compared via matrix analysis between males and females and at three points in time; trends in marital adjustment. Dominant variables influencing MFR decision making were risks associated with higher-order pregnancies and preservation of infants' and mothers' health. Most participants identified emotional issues, including moral and ethical dilemmas, as the most difficult aspect of reduction. Over time, participants reported feeling more positive about their decision; nonetheless, negative feelings emerged progressively. Risk aversion favored MFR decision making. Yet, both making and living with the decision were emotionally difficult for this sample. Interventions are needed to assist couples with this decision and its consequences.

  7. Kenyan women adult literacy learners: why their motivation is difficult to sustain.

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

    Malik, M A

    2009-11-01

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

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

    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.

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

    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 ...

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

    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

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

    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

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

    Neamat I. Abdel rahman

    2016-01-01

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

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

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

    2011-01-01

    Anesthetic technique in parturient with syringomyelia and 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

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

    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.

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

    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.

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

    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

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

    Sirvinskiene Giedre

    2012-04-01

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

  19. Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery.

    Kosins, Aaron M; Obagi, Zein E

    2017-02-01

    The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue. This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures. Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue. Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer. The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively

  20. Analysis of Production, Impact, and Scientific Collaboration on Difficult Airway Through the Web of Science and Scopus (1981-2013).

    García-Aroca, Miguel Ángel; Pandiella-Dominique, Andrés; Navarro-Suay, Ricardo; Alonso-Arroyo, Adolfo; Granda-Orive, José Ignacio; Anguita-Rodríguez, Francisco; López-García, Andrés

    2017-06-01

    Bibliometrics, the statistical analysis of written publications, is an increasingly popular approach to the assessment of scientific activity. Bibliometrics allows researchers to assess the impact of a field, or research area, and has been used to make decisions regarding research funding. Through bibliometric analysis, we hypothesized that a bibliometric analysis of difficult airway research would demonstrate a growth in authors and articles over time. Using the Web of Science (WoS) and Scopus databases, we conducted a search of published manuscripts on the difficult airway from January 1981 to December 2013. After removal of duplicates, we identified 2412 articles. We then analyzed the articles as a group to assess indicators of productivity, collaboration, and impact over this time period. We found an increase in productivity over the study period, with 37 manuscripts published between 1981 and 1990, and 1268 between 2001 and 2010 (P 9% for both WoS and Scopus, and CAGR for anesthesiology as a whole =0.64% in WoS, and =3.30% in Scopus. Furthermore, we found a positive correlation between the number of papers published per author and the number of coauthored manuscripts (P < .001). We also found an increase in the number of coauthored manuscripts, in international cooperation between institutions, and in the number of citations for each manuscript. For any author, we also identified a positive relationship between the number of citations per manuscript and the number of papers published (P < .001). We found a greater increase over time in the number of difficult airway manuscripts than for anesthesiology research overall. We found that collaboration between authors increases their impact, and that an increase in collaboration increases citation rates. Publishing in English and in certain journals, and collaborating with certain authors and institutions, increases the visibility of manuscripts published on this subject.

  1. The Difficult Airway Society 'ADEPT' guidance on selecting airway devices: the basis of a strategy for equipment evaluation.

    Pandit, J J; Popat, M T; Cook, T M; Wilkes, A R; Groom, P; Cooke, H; Kapila, A; O'Sullivan, E

    2011-08-01

    Faced with the concern that an increasing number of airway management devices were being introduced into clinical practice with little or no prior evidence of their clinical efficacy or safety, the Difficult Airway Society formed a working party (Airway Device Evaluation Project Team) to establish a process by which the airway management community within the profession could itself lead a process of formal device/equipment evaluation. Although there are several national and international regulations governing which products can come on to the market and be legitimately sold, there has hitherto been no formal professional guidance relating to how products should be selected (i.e. purchased). The Airway Device Evaluation Project Team's first task was to formulate such advice, emphasising evidence-based principles. Team discussions led to a definition of the minimum level of evidence needed to make a pragmatic decision about the purchase or selection of an airway device. The Team concluded that this definition should form the basis of a professional standard, guiding those with responsibility for selecting airway devices. We describe how widespread adoption of this professional standard can act as a driver to create an infrastructure in which the required evidence can be obtained. Essential elements are that: (i) the Difficult Airway Society facilitates a coherent national network of research-active units; and (ii) individual anaesthetists in hospital trusts play a more active role in local purchasing decisions, applying the relevant evidence and communicating their purchasing decisions to the Difficult Airway Society. © 2011 The Authors. Anaesthesia © 2011 The Association of Anaesthetists of Great Britain and Ireland.

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

    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.

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

    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.

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

    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)

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

    Walsh, K

    2012-02-03

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

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

    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.

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

    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.

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

    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

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

    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.

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

    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)

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

    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.

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

    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.

  13. Sketching is more than making correct drawings

    Waanders, Remko Martijn; Eggink, Wouter; Mulder-Nijkamp, Maaike; Kovacevic, A.; Ion, W.; McMahon, C.; Buck, C.; Hogarth, P.

    2011-01-01

    Sketching in the context of a design process is not a goal in itself, but can be considered as a tool to make better designs. Sketching as a design tool has several useful effects as: ordering your thoughts, better understanding of difficult shapes, functioning as a communication tool, and providing

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

    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

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

    Teena Bansal

    2016-04-01

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

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

    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.

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

    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

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

    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

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

    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

  20. Towards a Future Reallocation of Work between Humans and Machines – Taxonomy of Tasks and Interaction Types in the Context of Machine Learning

    Traumer, Fabian; Oeste-Reiß, Sarah; Leimeister, Jan Marco

    2017-01-01

    In today’s race for competitive advantages, more and more companies implement innovations in artificial intelligence and machine learning (ML). Although these machines take over tasks that have been executed by humans, they will not make human workforce obsolete. To leverage the potentials of ML, collaboration between humans and machines is necessary. Before collaboration processes can be developed, a classification of tasks in the field of ML is needed. Therefore, we present a taxonomy for t...

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

    Wolke, Dieter; St. James-Roberts, Ian

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

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

    Fabíola Maria Sabino Meireles

    2013-03-01

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

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

    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

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

    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

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

    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…

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

    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...

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

    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…

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

    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…

  9. Environmental risk evaluation of difficult substances in USES 2.0

    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

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

    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.

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

    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...

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

    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…

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

    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.

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

    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.

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

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

    2010-01-01

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

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

    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…

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

    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)

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

    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 ...

  19. Successful difficult airway management of a child with Coffin-siris syndrome.

    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.

  20. Successful difficult airway management of a child with Coffin?siris syndrome

    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.

  1. Vulnerability as a Key Concept in Museum Pedagogy on Difficult Matters

    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…

  2. Assessment of risk factors responsible for difficult weaning from mechanical ventilation in adults

    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.

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

    Mehmet Turan Inal

    2014-12-01

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

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

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

    2006-01-01

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

  5. Why Do Disadvantaged Filipino Children Find Word Problems in English Difficult?

    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…

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

    Mintz, Avi I.

    2010-01-01

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

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

    Keller, Eric

    2010-01-01

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

  8. Combination therapy versus monotherapy for gastroesophageal reflux in children with difficult-to-treat bronchial asthma

    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.

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

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

    2015-01-01

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

  10. "Best Case/Worst Case": Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-Moment Surgical Decisions.

    Kruser, Jacqueline M; Nabozny, Michael J; Steffens, Nicole M; Brasel, Karen J; Campbell, Toby C; Gaines, Martha E; Schwarze, Margaret L

    2015-09-01

    To evaluate a communication tool called "Best Case/Worst Case" (BC/WC) based on an established conceptual model of shared decision-making. Focus group study. Older adults (four focus groups) and surgeons (two focus groups) using modified questions from the Decision Aid Acceptability Scale and the Decisional Conflict Scale to evaluate and revise the communication tool. Individuals aged 60 and older recruited from senior centers (n = 37) and surgeons from academic and private practices in Wisconsin (n = 17). Qualitative content analysis was used to explore themes and concepts that focus group respondents identified. Seniors and surgeons praised the tool for the unambiguous illustration of multiple treatment options and the clarity gained from presentation of an array of treatment outcomes. Participants noted that the tool provides an opportunity for in-the-moment, preference-based deliberation about options and a platform for further discussion with other clinicians and loved ones. Older adults worried that the format of the tool was not universally accessible for people with different educational backgrounds, and surgeons had concerns that the tool was vulnerable to physicians' subjective biases. The BC/WC tool is a novel decision support intervention that may help facilitate difficult decision-making for older adults and their physicians when considering invasive, acute medical treatments such as surgery. © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.

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

    Halttunen, Jorma; Meisner, Søren; Aabakken, Lars

    2014-01-01

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

  12. Incomplete adherence to the ASA difficult airway algorithm is unchanged after a high-fidelity simulation session.

    Borges, Bruno C R; Boet, Sylvain; Siu, Lyndon W; Bruppacher, Heinz R; Naik, Viren N; Riem, Nicole; Joo, Hwan S

    2010-07-01

    Although guidelines for difficult airway management have been published, the extent to which consultant anesthesiologists follow these guidelines has not been determined. The purpose of this study is to observe how consultant anesthesiologists manage a "cannot intubate, cannot ventilate" (CICV) scenario in a high-fidelity simulator and to evaluate whether a simulation teaching session improves their adherence to the American Society of Anesthesiologists (ASA) difficult airway algorithm. With Ethics Board approval and informed consent, all staff anesthesiologists in a single tertiary care institution were invited to enrol in this study where they managed a simulated unanticipated CICV scenario in a high-fidelity simulator. The scenario involved a patient with a difficult airway whose trachea could not be intubated and where it was impossible to ventilate the patient's lungs. Airway management options, including laryngeal mask airway, a fibreoptic bronchoscope, and a Glidescope were available for use but scripted to fail. A percutaneous cricothyroidotomy was required to re-establish adequate ventilation. Following the scenario, there was a personalized one-hour video-assisted expert debriefing focusing on the ASA difficult airway guidelines and "hands-on" cricothyroidotomy teaching. The second scenario followed immediately with an identical CICV scenario. The content to either scenario was not revealed beforehand. Outcome measures included: 1) major deviations from the ASA difficult airway guidelines; 2) time to start cricothyroidotomy; and 3) time to achieve ventilation. Thirty-eight anesthesiologists agreed to participate. The number of major deviations from the ASA algorithm was similar in the first and second sessions. These deviations included: multiple laryngoscopies (0 vs 2 pre-post; P = 0.49), use of fibreoptic bronchoscope (8 vs 7 pre-post; P = 1.0), bypass of laryngeal mask airway attempt (7 vs 13 pre-post; P = 0.19), and failure to call for anesthetic help

  13. [Algorithm for securing an unexpected difficult airway : User analysis on a simulator].

    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

  14. Infrared Red Intubation System (IRRIS) guided flexile videoscope assisted difficult airway management

    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...

  15. An anatomy of countertransference: staff reactions to difficult psychiatric hospital patients.

    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.

  16. The Positive Effect of Resilience on Stress and Business Outcomes in Difficult Work Environments.

    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.

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

    Vudayagiri, Sindhu; Skov, Anne Ladegaard

    2014-01-01

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

  18. Real life study of three years omalizumab in patients with difficult-to-control asthma.

    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.

  19. Use of Adult Fibreoptic Bronchoscope for Difficult Paediatric Intubation: A Case Report

    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.

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

    Stjernstoft, Tero

    2004-01-01

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

  1. Deep Help in Complex Project Work: Guiding and Path-Clearing Across Difficult Terrain

    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...

  2. Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway.

    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.

  3. [Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway].

    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.

  4. Difficultés scolaires et séparation des parents

    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)

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

    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.

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

    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.

  7. Increasing Cognitive Inhibition with a Difficult Prior Task: Implications for Mathematical Thinking

    Attridge, Nina; Inglis, Matthew

    2015-01-01

    Dual-process theories posit two distinct types of cognitive processing: Type 1, which does not use working memory making it fast and automatic, and Type 2, which does use working memory making it slow and effortful. Mathematics often relies on the inhibition of pervasive Type 1 processing to apply new skills or knowledge that require Type 2…

  8. Hard To Find and Difficult To Manage: The Effects of Child Care on the Workplace.

    Emlen, Arthur C.; Koren, Paul E.

    This study, which focused on effects of child care on the workplace, addressed several questions: (1) What kinds of child care arrangements do employed parents make, and why do they make them? (2) Are these parents having difficulty finding child care? (3) Does their ability to manage child care affect their absenteeism and stress? (4) What roles…

  9. The Impact of Oregon's Pension Legacy Costs on New Teacher Turnover and Quality. CEDR Working Paper. WP #2016-5

    Cahill, Kevin E.; Dyke, Andrew; Tapogna, John

    2016-01-01

    Pension legacy costs can restrict the amount of resources available for current public education, potentially making it more difficult to attract and retain high-quality teachers. Oregon provides a useful case study in pension legacy costs because many school districts in the state are now reallocating General Fund expenditures to cover sizeable…

  10. Tragic Choices in Humanitarian Aid : A Framework of Organizational Determinants of NGO Decision Making

    Heyse, Liesbet

    Humanitarian NGOs face difficult choices about whom to help and whom not on a daily basis. The research question in this article is how humanitarian NGOs make these difficult decisions and why in a particular way. March's study on consequential and appropriate decision-making processes is used to

  11. Laparoendoscopic Rendezvous for Concomitant Cholecystocholedocholithiasis: A Successful Modality Even in the Most Difficult Presentations Including Pregnancy.

    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

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

    2015-01-01

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

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

    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

  14. Laparoendoscopic Rendezvous for Concomitant Cholecystocholedocholithiasis: A Successful Modality Even in the Most Difficult Presentations Including Pregnancy

    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

  15. Multimodal treatment in difficult sialolithiasis: Role of extracorporeal shock-wave lithotripsy and intraductal pneumatic lithotripsy.

    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.

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

    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.

  17. History Matters: What Happens When African Americans Confront Their Difficult Past.

    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.

  18. Anesthetic considerations and difficult airway management in a case of Noonan syndrome

    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.

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

    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...

  20. Making healthy choices easy choices: the role of empowerment

    Koelen, M.A.; Lindström, B.

    2005-01-01

    An important goal of health promotion is to make it easier for people to make healthy choices. However, this may be difficult if people do not feel control over their environment and their personal circumstances. An important concept in relation to this is empowerment. Health professionals are

  1. Shared decision making

    ... page: //medlineplus.gov/ency/patientinstructions/000877.htm Shared decision making To use the sharing features on this page, ... treatment you both support. When to use Shared Decision Making Shared decision making is often used when you ...

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

    Gąska A.

    2014-02-01

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

  3. Vital lines drawn from books: difficult feelings in Alison Bechdel's Fun Home and Are You My Mother?

    Bauer, Heike

    2014-01-01

    This article examines the representation of a transnational archive of queer books in Alison Bechdel's graphic memoirs Fun Home and Are You My Mother? for the insights it provides into the role of reading in making sense of the often difficult "felt experiences" of lesbian life. In both memoirs, books serve an important narrative function in the portrayal of Alison's lesbian identification and its complex emotional entanglements with the lives of parents who are trapped-killed even, in the case of the father-in the wastelands of patriarchy and heterosexual expectation. The article argues that in this complex family dynamic in which "sexual identity" itself is a problem and emotions remain largely unspoken, books act as fragile conduits of feelings, shaping familial relationships even as they allow Alison to contextualize her life in relation to historical events and social norms. Reading books allows her to understand the apparently U.S.-specific history of her family in relation to a wider queer history in the West.

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

    M. B. Kurhan

    2014-03-01

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

  5. "Difficult-to treat" ulcers management: use of pulse dose radiofrequency.

    Quarto, Gennaro; Solimeno, G; Furino, E; Sivero, Luigi; Bucci, Luigi; Massa, Salvatore; Benassai, Giacomo; Apperti, M

    2013-01-01

    In this paper we wanted to evaluate the impact of pain reduction on the evolution of "difficult-to treat" ulcers, using Radiofrequency analgesia in pulse-dose modality. We have performed a randomized trial to evaluate the efficacy of the RF in PD mode to reduce the healing time of ulcers of difficult management as outpatient for spontaneous and provoked pain. We enrolled 23 patients, including 7 males (30%) and 16 females (70%), aged between 53 and 79 years (mean age = 67.2) sorted according to the first letter of the last name in ascending order and assigned alternately to one or another group. In Group A healing was obtained in 33% of patients (4/12), with an average healing time of 6 months while in Group B healing has been obtained in 81% of patients (9/11) with an average time of 3 months (range 1-5 months) Student's T was performed to compare the average recovery time among the two groups; moreover we have analyzed the proportions of healed patients in the group A and B. Healing time significantly decreased in group B (p = 0,013079). Even the cure rate has changed favorably, in a statistically significant way. According to the literature related to the use of the RF pulse dose, there is a greater effectiveness of this technique in respect of the classical PRF, in terms of immediate and long-term reduction of pain and this impacts positively on the course of ulcer healing.

  6. Why are the Mathematics National Examination Items Difficult and What Is Teachers’ Strategy to Overcome It?

    Heri Retnawati

    2017-07-01

    Full Text Available The quality of national examination items plays an enormous role in identifying students’ competencies mastery and their difficulties. This study aims to identify the difficult items in the Junior High School Mathematics National Examination, to find the factors that cause students’ difficulty and to reveal the strategies that the teachers and the students might implement in order to overcome them. The study is phenomenological research with the mixed methods. The data were collected using documentation of students’ responses and focus group discussion (FGD of teachers. The data analysis was conducted using Milles & Hubberman steps. The results of the study showed that there were 4 difficult items of the 40 test items for the students. The students’ difficulties were the lack of concept understanding, difficulties in calculating, difficulties in selecting information, being deceived by the distractors, being unaccustomed to completing complex and non-integers test items, and completing contextual test items that have been presented in the form of figures or narrative texts.

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

    Deirdre E. van Jaarsveldt

    2015-01-01

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

  8. Does ego development increase during midlife? The effects of openness and accommodative processing of difficult events.

    Lilgendahl, Jennifer Pals; Helson, Ravenna; John, Oliver P

    2013-08-01

    Although Loevinger's model of ego development is a theory of personality growth, there are few studies that have examined age-related change in ego level over developmentally significant periods of adulthood. To address this gap in the literature, we examined mean-level change and individual differences in change in ego level over 18 years of midlife. In this longitudinal study, participants were 79 predominantly White, college-educated women who completed the Washington University Sentence Completion Test in early (age 43) and late (age 61) midlife as well as measures of the trait of Openness (ages 21, 43, 52, and 61) and accommodative processing (assessed from narratives of difficult life events at age 52). As hypothesized, the sample overall showed a mean-level increase in ego level from age 43 to age 61. Additionally, a regression analysis showed that both the trait of Openness at age 21 and accommodative processing of difficult events that occurred during (as opposed to prior to) midlife were each predictive of increasing ego level from age 43 to age 61. These findings counter prior claims that ego level remains stable during adulthood and contribute to our understanding of the underlying processes involved in personality growth in midlife. © 2012 Wiley Periodicals, Inc.

  9. Multi-Stream Saline-Jet Dissection Using a Simple Irrigation System Defines Difficult Tissue Planes

    Ng, Philip CH

    2010-01-01

    Introduction: Single-stream hydro-jet dissection is increasingly used in various laparoscopic procedures, but its use requires special equipment. We describe a simple method for using an irrigation system for saline-jet tissue dissection as a useful adjunct prior to adhesiolysis. Material and Methods: Intraabdominal adhesions prolong laparoscopic procedures, because tissue planes are difficult to identify. We performed multi-jet saline dissection (MSSJ) between 2000 and 2009 in more than 500 patients during laparoscopy involving hernias, gallbladders, appendices, and intestinal obstructions. We use a standard suction irrigation probe, which is attached to a 1-liter saline bag with an inflatable cuff around to create a pressure of 250mm Hg to 300mm Hg. In effect, this is the standard setup generally used for irrigation. After using saline dissection, tissue planes can be better defined and the structures can then be separated. Result and Discussion: Using this method, we have successfully identified tissue planes in spite of dense adhesions, and our conversion rates to open have been reduced dramatically. This method is relatively safer than other modalities of tissue dissection, such as diathermy, ultrasonic, blunt or sharp dissection. The disadvantage is that with tissues saturated with saline it becomes more difficult to use diathermy hemostasis. Care has to be exercised in monitoring the temperature and volume of the fluid used. PMID:20529528

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

    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

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

    Maharaj, C H

    2008-02-01

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

  12. The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data

    Garrett Joanne M

    2006-10-01

    Full Text Available Abstract Background Literature on difficult doctor-patient relationships has focused on the "difficult patient." Our objective was to determine physician and practice characteristics associated with greater physician-reported frustration with patients. Methods We conducted a secondary analysis of the Physicians Worklife Survey, which surveyed a random national sample of physicians. Participants were 1391 family medicine, general internal medicine, and medicine subspecialty physicians. The survey assessed physician and practice characteristics, including stress, depression and anxiety symptoms, practice setting, work hours, case-mix, and control over administrative and clinical practice. Physicians estimated the percentage of their patients who were "generally frustrating to deal with." We categorized physicians by quartile of reported frustrating patients and compared characteristics of physicians in the top quartile to those in the other three quartiles. We used logistic regression to model physician characteristics associated with greater frustration. Results In unadjusted analyses, physicians who reported high frustration with patients were younger (p 55 per week, higher stress, practice in a medicine subspeciality, and greater number of patients with psychosocial problems or substance abuse. Conclusion Personal and practice characteristics of physicians who report high frustration with patients differ from those of other physicians. Understanding factors contributing to physician frustration with patients may allow us to improve the quality of patient-physician relationships.

  13. Nickel: makes stainless steel strong

    Boland, Maeve A.

    2012-01-01

    Nickel is a silvery-white metal that is used mainly to make stainless steel and other alloys stronger and better able to withstand extreme temperatures and corrosive environments. Nickel was first identified as a unique element in 1751 by Baron Axel Fredrik Cronstedt, a Swedish mineralogist and chemist. He originally called the element kupfernickel because it was found in rock that looked like copper (kupfer) ore and because miners thought that "bad spirits" (nickel) in the rock were making it difficult for them to extract copper from it. Approximately 80 percent of the primary (not recycled) nickel consumed in the United States in 2011 was used in alloys, such as stainless steel and superalloys. Because nickel increases an alloy's resistance to corrosion and its ability to withstand extreme temperatures, equipment and parts made of nickel-bearing alloys are often used in harsh environments, such as those in chemical plants, petroleum refineries, jet engines, power generation facilities, and offshore installations. Medical equipment, cookware, and cutlery are often made of stainless steel because it is easy to clean and sterilize. All U.S. circulating coins except the penny are made of alloys that contain nickel. Nickel alloys are increasingly being used in making rechargeable batteries for portable computers, power tools, and hybrid and electric vehicles. Nickel is also plated onto such items as bathroom fixtures to reduce corrosion and provide an attractive finish.

  14. Counter Traction Makes Endoscopic Submucosal Dissection Easier

    Oyama, Tsuneo

    2012-01-01

    Poor counter traction and poor field of vision make endoscopic submucosal dissection (ESD) difficult. Good counter traction allows dissections to be performed more quickly and safely. Position change, which utilizes gravity, is the simplest method to create a clear field of vision. It is useful especially for esophageal and colon ESD. The second easiest method is clip with line method. Counter traction made by clip with line accomplishes the creation of a clear field of vision and suitable co...

  15. Welfare Reform: Tribal TANF Allows Flexibility To Tailor Programs, but Conditions on Reservations Make It Difficult To Move Recipients into Jobs. Report to Congressional Requesters.

    General Accounting Office, Washington, DC.

    The 1996 Personal Responsibility and Work Opportunity Reconciliation Act gave American Indian and Alaska Native tribes the option to administer Temporary Assistance for Needy Families (TANF) programs either alone or in a tribal consortium. The law also granted tribal TANF programs more flexibility in program design than it gave to state programs.…

  16. Ongoing outbreak with well over 4,000 measles cases in Italy from January to end August 2017 - what is making elimination so difficult?

    Filia, Antonietta; Bella, Antonino; Del Manso, Martina; Baggieri, Melissa; Magurano, Fabio; Rota, Maria Cristina

    2017-09-14

    We report an ongoing measles outbreak in Italy, with over 4,400 cases reported in 20 Regions from January to August 2017. Median age was 27 years, 88% of the cases were unvaccinated. The highest incidence was in infants below one year of age and 7% of cases occurred among healthcare workers. Three deaths occurred and two cases of encephalitis were reported. Wide immunity gaps and nosocomial transmission are major challenges to measles elimination in Italy. This article is copyright of The Authors, 2017.

  17. Publication Bias Currently Makes an Accurate Estimate of the Benefits of Enrichment Programs Difficult: A Postmortem of Two Meta-Analyses Using Statistical Power Analysis

    Warne, Russell T.

    2016-01-01

    Recently Kim (2016) published a meta-analysis on the effects of enrichment programs for gifted students. She found that these programs produced substantial effects for academic achievement (g = 0.96) and socioemotional outcomes (g = 0.55). However, given current theory and empirical research these estimates of the benefits of enrichment programs…

  18. Severe Hypertriglyceridemia Possibly Masked Acute Pancreatitis and Led to a Difficult Diagnosis in an Obese Patient with Ketoacidosis-onset Type 2 Diabetes.

    Fujishiro, Midori; Horita, Akiko; Nakagawara, Hiroshi; Mawatari, Takayuki; Kishigami, Yoshifusa; Tominaga, Yoshiteru; Moriyama, Mitsuhiko; Ishihara, Hisamitsu

    2017-10-01

    A young obese man with ketoacidosis-onset type 2 diabetes mellitus, associated with severe hypertriglyceridemia, was admitted to a local hospital complaining of abdominal pain. Although the abdominal pain worsened, his serum amylase level remained normal with persistent severe hypertriglyceridemia until the second day of hospitalization. The next day, computed tomography showed severe acute pancreatitis (AP) with serum amylase elevation, while the patient's triglyceride level decreased to 558 mg/dL. He was transferred to our hospital and recovered after intensive care. AP accompanied by diabetic ketoacidosis is not rare but an early diagnosis can be difficult to make due to normal amylase levels in the presence of severe hypertriglyceridemia.

  19. Medical decision making

    Stiggelbout, A.M.; Vries, M. de; Scherer, L.; Keren, G.; Wu, G.

    2016-01-01

    This chapter presents an overview of the field of medical decision making. It distinguishes the levels of decision making seen in health-care practice and shows how research in judgment and decision making support or improve decision making. Most of the research has been done at the micro level,

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

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

    2015-01-01

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

  1. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access.

    Costantino, Thomas G; Parikh, Aman K; Satz, Wayne A; Fojtik, John P

    2005-11-01

    We assess the success rate of emergency physicians in placing peripheral intravenous catheters in difficult-access patients who were unsuccessfully cannulated by emergency nurses. A technique using real-time ultrasonographic guidance by 2 physicians was compared with traditional approaches using palpation and landmark guidance. This was a prospective, systematically allocated study of all patients requiring intravenous access who presented to 2 university hospitals between October 2003 and March 2004. Inclusion criterion was the inability of any available nurse to obtain intravenous access after at least 3 attempts on a subgroup of patients who had a history of difficult intravenous access because of obesity, history of intravenous drug abuse, or chronic medical problems. Exclusion criterion was the need for central venous access. Patients presenting on odd days were allocated to the ultrasonographic-guided group, and those presenting on even days were allocated to the traditional-approach group. Endpoints were successful cannulation, number of sticks, time, and patient satisfaction. Sixty patients were enrolled, 39 on odd days and 21 on even days. Success rate was greater for the ultrasonographic group (97%) versus control (33%), difference in proportions of 64% (95% confidence interval [CI] 39% to 71%). The ultrasonographic group required less overall time (13 minutes versus 30 minutes, for a difference of 17 [95% CI 0.8 to 25.6]), less time to successful cannulation from first percutaneous puncture (4 minutes versus 15 minutes, for a difference of 11 [95% CI 8.2 to 19.4]), and fewer percutaneous punctures (1.7 versus 3.7, for a difference of 2.0 [95% CI 1.27 to 2.82]) and had greater patient satisfaction (8.7 versus 5.7, for a difference of 3.0 [95% CI 1.82 to 4.29]) than the traditional landmark approach. Ultrasonographic-guided peripheral intravenous access is more successful than traditional "blind" techniques, requires less time, decreases the number of

  2. Decision Making and Cancer

    Reyna, Valerie F.; Nelson, Wendy L.; Han, Paul K.; Pignone, Michael P.

    2015-01-01

    We review decision-making along the cancer continuum in the contemporary context of informed and shared decision making, in which patients are encouraged to take a more active role in their health care. We discuss challenges to achieving informed and shared decision making, including cognitive limitations and emotional factors, but argue that understanding the mechanisms of decision making offers hope for improving decision support. Theoretical approaches to decision making that explain cogni...

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

    Hongisto, M.; Nikula, A.

    1996-11-01

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

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

    Maldini, Branka; Novotny, Zdenko; Letica-Brnadić, Renata; Brkljacić, Ana; Bartolek, Dubravka

    2012-09-01

    This clinical report describes an emergency case of a 49-year-old man, ASA E III status, with clinical symptoms of acute abdomen and ileus, who was scheduled for urgent surgery. Predictors of difficult intubation (Mallampati test Class III, short thyro-mental (management decided on one attempt of Bonfils fiberoptic intubation as primary intervention and urgent tracheotomy, if needed, as secondary intervention. Immediately after assuming supine position on the operating table, the patient lost consciousness and cardiac arrest developed. Successful intubation with oxygenation was followed by cardiopulmonary resuscitation. Upon stabilization of the patient's vital functions, urgent surgery was performed. In the emergency case presented, we succeeded quickly to secure the airway with Bonfils fiberoptic intubation, which allowed for appropriate oxygenation and starting resuscitation. The high risk of the possible aspiration was avoided by timely provision of airway in the experienced anesthetist's hands.

  5. 980nm laser for difficult-to-treat basal cell carcinoma

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

    2013-06-01

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

  6. Technology of magnetic abrasive finishing in machining of difficult-to-machine alloy complex surface

    Fujian MA

    2016-10-01

    Full Text Available The technology of magnetic abrasive finishing is one of the important finishing technologies. Combining with low-frequency vibration and ultrasonic vibration, it can attain higher precision, quality and efficiency. The characteristics and the related current research of magnetic abrasive finishing, vibration assisted magnetic abrasive finishing and ultrasonic assisted magnetic abrasive finishing are introduced. According to the characteristics of the difficult-to-machine alloy's complex surface, the important problems for further study are presented to realize the finishing of complex surface with the technology of magnetic abrasive finishing, such as increasing the machining efficiency by enhancing the magnetic flux density of machining gap and compounding of magnetic energy and others, establishing of the control function during machining and the process planning method for magnetic abrasive finishing of complex surface under the space geometry restraint of complex surface on magnetic pole, etc.

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

    Yakup Tomak

    2012-09-01

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

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

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

    2015-09-01

    This paper deals with developing and assessing the training of physicians to deliver a difficult diagnosis to patients. The training is provided by a web-based self-training package. This online training emphasizes the structural, functional and relational dimensions of interviews delivering a serious diagnosis, and a logical set of recommendations for behavior towards the patient. The content is illustrated by numerous delivery interview sequences that are described and for which commentary is provided. This online package was expected to enable physicians to acquire new skills and change their mental picture of diagnosis delivery. Here we discuss the assessment of training in managing the delivery of a serious diagnosis. The approach taken and the methods used to measure knowledge and skills are presented. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

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

    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.)

  10. [Facing the difficult experience even with support: the underage adolescent experiencing motherhood].

    Andrade, Paula Rosenberg de; Ohara, Conceição Vieira da Silva; Borba, Regina Issuzu Hirooka de; Ribeiro, Circéa Amalia

    2015-01-01

    To understand the meaning of childcare for the underage adolescent mother, to reveal the demands of care and to build a theoretical model based on this experience. Qualitative research with symbolic interactionism as the theoretical framework and the grounded theory as the methodological framework; nine adolescents participated in the study. The semi-structured interview was used to collect data from September 2008 to September 2011, during paediatric nursing consultation at the Centro Assistencial Cruz de Malta, a philanthropic institution in the city of São Paulo/Brazil. Data analysis led to the construction of the theoretical model,Facing a difficult experience even with support. The experience shows that the difficulties to care for a child, even with help, are not met, only mitigated, and that underage adolescents do not have the maturity to cope with this experience.

  11. Health activism: the way forward to improve health in difficult times.

    Laverack, Glenn

    2013-09-01

    Health activism is an action on behalf of a cause, action that goes beyond what is conventional or routine in society. It involves a challenge to the existing order whenever it is perceived to lead to a social injustice or inequality. Today social injustice is killing people on a grand scale and it is timely for health activism to be used as a way forward to improve health during difficult economic and political times. Health activism is essential because it can create the necessary conditions for people to take control over their own lives when others cannot or will not act on their behalf. Health promotion agencies and the practitioners that they employ, professional organisations and researchers can also play an important role. What is clear is that if greedy corporations and complacent governments are not challenged, we will continue to have limited success in improving health.

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

    G. Deslypere

    2015-01-01

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

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

    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.

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

    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

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

    Zoffmann, Vibeke; Kirkevold, Marit

    2007-01-01

    Few researchers have explored how relationships between patients and providers might change problem solving in clinical practice. The authors used grounded theory to study dyads of 11 people with diabetes and poor glycemic control, and 8 nurses interacting in diabetes teams. Relational Potential...... for Change was identified as a core category that involved three types of relationships. Professionals mostly shifted between less effective relationships characterized by I-you-distant provider dominance and I-you-blurred sympathy. Although rarely seen, a third relationship, I-you-sorted mutuality proved...... more effective than the others in exploiting the Relational Potential for Change. The three types of relationship differed in (a) scope of problem solving, (b) the roles assigned to the patient and the professionals, (c) use of difficult feelings and different points of view, and (d) quality...

  16. Effect of Ultrasound-Guided Placement of Difficult-to-Place Peripheral Venous Catheters

    Partovi-Deilami, Kohyar; Nielsen, Jesper K.; Møller, Ann M.

    2016-01-01

    operated by nurse anesthetists for these patients. This prospective observational study with a pre/post design focused on inpatients with DIVA referred for PVC placement, a service provided by nurse anesthetists in most Scandinavian hospitals. The rate of success, procedure time, number of skin punctures......) with ultrasound. Procedure time was reduced from 20 to 10 minutes, discomfort was unchanged, and the median number of skin punctures decreased from 3 to 2. The incidence of central venous catheter placement dropped from 34% to 7%. Implementation of a training program and a mobile service in which nurse......, discomfort, catheter size, location, and incidence of central venous catheter placement are reported before and after implementation of a training program and a mobile service using ultrasound to place difficult-to-place PVCs. The success rate increased from 0% (0 of 33 patients) to 83% (58 of 70 patients...

  17. Anterior cysts of the spine: a difficult differential diagnosis to amyotrophic lateral sclerosis.

    Schmalbach, S; Petri, S; Götz, F; Dengler, R; Krampfl, K

    2008-11-01

    We describe three patients referred to our ALS/MND clinic with suspected diagnosis of amyotrophic lateral sclerosis (ALS). The patients were all male, middle aged, and their initial symptoms were weakness and fasciculations in upper limb muscles. Results of clinical and electrophysiological examination in all cases were in accordance with possible ALS according to the revised El Escorial criteria. Other conditions mimicking ALS appeared to be excluded by extensive technical examinations and laboratory tests. Only repeated MRI examinations revealed anterior spinal cysts several years after symptom onset. This report intends to highlight this rare and difficult differential diagnosis of ALS and underlines the value of the revised El Escorial criteria in conjunction with electrophysiology to asses the certainty of the diagnosis ALS.

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

    Damgaard, Christian

    2011-01-01

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

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

    Shiv PS Rana

    2011-01-01

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

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

    2009-06-01

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

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

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

    1987-02-01

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

  2. The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit

    Sheila Nainan Myatra

    2016-01-01

    Full Text Available Tracheal intubation (TI is a routine procedure in the Intensive Care Unit (ICU and is often life-saving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with a suboptimal evaluation of the airway and limited oxygen reserves despite adequate pre-oxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxaemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA proposes a stepwise plan for safe management of the airway in critically ill 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. Non-invasive positive pressure ventilation during pre-oxygenation improves oxygen stores in patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnoea before the occurrence of hypoxaemia. High-flow nasal cannula oxygenation at 60-70 L/min may also increase safety during TI in critically ill patients. Stable haemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

  3. Undergoing an immunization is effortlessly, manageable or difficult according to five-year-old children.

    Harder, Maria; Christensson, Kyllike; Söderbäck, Maja

    2015-06-01

    To prevent diseases among children they regularly undergo immunizations. Previous research show different approaches available to facilitate immunization-procedures for children to protect them from harm. To complement this research and provide care suited for children, research recognizing their perceptions of undergoing such a procedure is needed. The aim of this study was to describe 5-year-old children's perceptions of undergoing an immunization. A phenomenographic approach and analysis was used to describe the children's (n = 21) various perceptions. The data-collection was accomplished directly after the immunization to grasp the children's immediate perceptions. Drawings and reflective talks were used as they are considered as suitable methods when involving young children in research. The right to conduct research with children was approved by the appropriate research ethics committee and also by each child and the parents. The findings show that children's perceptions of an immunization-procedure may vary from effortlessly, to manageable or difficult. Regardless of how the child perceive the immunization-procedure each perception embrace the children's descriptions of actors and articles in the situation, their feelings in the situation and also their actions to deal with the immunization. Nevertheless, these descriptions vary according to how the children perceive the immunization as effortlessly, manageable or difficult. Children's and adults' perceptions of medical procedures may differ and children need guidance, time and space to deal with them. Recognizing children's perceptions of undergoing an immunization contributes to the promotion of their right to be involved in their own health care and towards the development of child-centred care. © 2014 Nordic College of Caring Science.

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

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

    2014-01-01

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

  5. Percutaneous sonographically assisted endoscopic gastrostomy for difficult cases with interposed organs.

    Moriwaki, Yoshihiro; Otani, Jun; Okuda, Junzo; Zotani, Hitomi; Kasuga, So

    2018-03-27

    The aim of this retrospective observational study was to clarify the usefulness and safety of percutaneous sonographically assisted endoscopic gastrostomy or duodenostomy (PSEGD) using the introduction method. The information for the sequential 22 patients who could not undergo standard percutaneous endoscopic gastrostomy (PEG) and underwent PSEGD for 3 y was extracted and was reviewed. In standard PEG, we performed pushing out of the stomach from the mediastinum and full distention to adhere the gastric wall to the peritoneal wall without interposing of the intraperitoneal tissues by air inflation and a turning-over procedure of the endoscope, four-point square fixation of the stomach to the peritoneal wall by using a Funada-style gastric wall fixation kit under diaphanoscopy, extracorporeal thumb pushing, and in difficult cases extracorporeal ultrasound guidance, and if necessary confirmation of fixation of the gastric wall to the peritoneal wall and placement of the PEG tube without any interposed tissues by using ultrasound. Twenty-one patients (95.5%) successfully underwent PSEGD. Early complications (more than grade 2 in Clavien-Dindo classification) just after the procedure occurred in one case (active oozing). We did not encounter a case with mispuncture of the intraperitoneal organs and tissues. Delayed complications occurring within 1 mo were pneumonia in five patients, including death in three cases; bleeding from puncture site in two patients; and atrial fibrilation in one patient. PSEGD using the introduction method is a useful procedure for difficult patients in whom intraperitoneal organ or tissue is suspected to be interposed between the abdominal wall and stomach. Copyright © 2018 Elsevier Inc. All rights reserved.

  6. "Stiction Syndrome": Non-Operative Management of Patients With Difficult AMS 700 Series Inflation.

    Kavoussi, Nicholas L; Viers, Boyd R; VanDyke, Maia E; Pagliara, Travis J; Morey, Allen F

    2017-09-01

    Static friction (stiction) is a mechanical phenomenon in which a state of increased resistance exists across a control valve mechanism. To present a strategy for non-operative management of inflatable penile prosthesis (IPP) cases with pump malfunction from pump valve stiction. All patients had American Medical Systems (AMS; Minnetonka, MN, USA) 700 series Momentary Squeeze IPPs with transient pump malfunction owing to pump valve stiction after extended periods of device inactivity. Our evolving non-operative management experience with the "forced deflation" maneuver is described. This technique has successfully prevented the need for surgical pump replacement. Of patients with IPP who were instructed to inflate and deflate daily to prevent stiction recurrence, none have re-presented with difficult inflation. Of 306 patients receiving the AMS 700 series IPP at our institution from 2007 through 2015, 6 (1.9%) presented with difficulty activating the Momentary Squeeze pump (from 2011 through 2015). Four additional patients were referred from outside institutions with the same complaint. All patients (10 of 10, 100%) presented after a prolonged period of inactivity (minimum = 6 weeks) during which the IPP was not cycled and remained stagnant. Although the initial four patients (40%) underwent surgical exploration with pump mobilization and replacement, the six most recent patients (60%) were successfully instructed in the forced deflation maneuver in the office, which enabled the device to cycle normally thereafter. Device inactivity, for as little as 6 weeks, can predispose to Momentary Squeeze pump valve malfunction; and a regimen of daily IPP cycling could prevent stiction-related malfunction. Our findings should encourage practitioners to attempt conservative management of patients with "stiction syndrome" whenever possible, thereby avoiding unnecessary surgery. Kavoussi NL, Viers BR, VanDyke ME, et al. "Stiction Syndrome": Non-Operative Management of Patients

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

    Chiara Bozzano

    2013-03-01

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

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

    Butyrin Andrey Yur'evich

    2014-02-01

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

  9. A case difficult to diagnose in adults: High sinus venous atrial septal defect

    Ozge Cetinarslan

    2018-01-01

    Full Text Available Sinus venous atrial septal defect (SVD is highly difficult to diagnose because of its location. Below, we report a case of SVD which is misdiagnosed as pulmonary hypertension and anomalous pulmonary venous return. A 57-year-old female patient was referred to congenital disease outpatient clinic of a tertiary center. She was admitted to the hospital with complaints of fatigue and exercise dyspnea which had started a year ago. She had transthoracic echocardiography (TTE examination done in another hospital which showed dilated right heart chambers and pulmonary hypertension. She underwent transesophageal echocardiography (TEE examination with the suspicion of atrial septal defect (ASD, but no defect was seen. As her symptoms persisted, we repeated the TTE and TEE examination in our center. TEE revealed 0.6 cm ASD on the upper side of the interatrial septum. All four pulmonary veins were draining into the left atrium. Right heart catheterization (RHC confirmed the diagnosis. A left-to-right shunt was detected and localized by a significant step-up in blood oxygen saturation found between mid and upper segments of the right atrium. According to our TEE and RHC results, we planned the surgical closure of the defect. Sinus venous ASD is deficiency of the superior portion of atrial septum adjacent to superior vena cava. Diagnosis of SVD is often more difficult than other forms of ASD and may require special imaging such as TEE, magnetic resonance imaging, or computed tomographic scanning. In conclusion, cardiologists must be aware about the possibility of SVD patients who have unexplained exertional dyspnea and fatigue, dilated right atrium and ventricle, pulmonary hypertension, paradoxical embolism, or atrial arrhythmias in their respective populations.

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

    Claire E Stevenson

    2014-08-01

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

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

    Vitart M. J.

    2006-11-01

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

  12. Crisis Management: Psychological and Sociological Factors in Decision Making

    1975-03-01

    Section A. Cognitive Prooeaes While what has been a Ued the " rational model" of decision - making may not adequately account for the operation of the...obstacles blocking rational decision - making . 7. What part does fatigue play in reacting to a crisis? Fatigue results from two factors. First...further important question of the impact of these variables on decision - making . It is a difficult theoretical problem to link the maladaptive emotional

  13. Alphabet soup: making sense of genetic testing in CMT.

    Lawson, Victoria; Gharibshahi, Shahram

    2010-09-01

    The diagnosis of inherited neuropathies can be challenging in several ways. First, a hereditary neuropathy must be suspected. Although some family histories are clear with multiple members affected, other families require directed inquiry. Second, even when a hereditary neuropathy is clear, it can be difficult to make a genetic characterization. The field of genotyping is expanding so rapidly, it is difficult to know what tests to order. The authors share their guidelines for the diagnosis of inherited neuropathies. © Thieme Medical Publishers.

  14. Hospice decision making: diagnosis makes a difference.

    Waldrop, Deborah P; Meeker, Mary Ann

    2012-10-01

    This study explored the process of decision making about hospice enrollment and identified factors that influence the timing of that decision. This study employed an exploratory, descriptive, cross-sectional design and was conducted using qualitative methods. In-depth in-person semistructured interviews were conducted with 36 hospice patients and 55 caregivers after 2 weeks of hospice care. The study was guided by Janis and Mann's conflict theory model (CTM) of decision making. Qualitative data analysis involved a directed content analysis using concepts from the CTM. A model of hospice enrollment decision making is presented. Concepts from the CTM (appraisal, surveying and weighing the alternatives, deliberations, adherence) were used as an organizing framework to illustrate the dynamics. Distinct differences were found by diagnosis (cancer vs. other chronic illness, e.g., heart and lung diseases) during the pre-encounter phase or before the hospice referral but no differences emerged during the post-encounter phase. Differences in decision making by diagnosis suggest the need for research about effective means for tailored communication in end-of-life decision making by type of illness. Recognition that decision making about hospice admission varies is important for clinicians who aim to provide person-centered and family-focused care.

  15. Self-Assessment of Governance Teams in an Argentine Private University: Adapting to Difficult Times

    Durand, Julio; Pujadas, Carlos

    2004-01-01

    Argentine Universities like similar institutions all around the world are facing a complex and challenging environment that demands a more sophisticated leadership and the development of complex managerial skills. In this paper we propose that enhancing the quality of collective decision making, and building more complex teams as a way to preserve…

  16. Personality affects learning performance in difficult tasks in a sex-dependent way

    Titulaer, M.; Oers, van K.; Naguib, M.

    2012-01-01

    Animals constantly need to cope with changes in their environment. Coping with changes in cues that are associated with the location and abundance of food is essential for being able to adjust behaviourally to a variable environment. The use of cues in decision making requires appropriate levels of

  17. 76 FR 66741 - Statutorily Mandated Designation of Difficult Development Areas and Qualified Census Tracts for 2012

    2011-10-27

    ... poverty data is not available for 2010 census tract boundaries. The most recent data for which household... not match the geography of the income and poverty rate information. This makes the most recent data... metropolitan areas that have never been DDAs in the history of the program get one or more SADDAs. Under SADDAs...

  18. The Neural Bases of Difficult Speech Comprehension and Speech Production: Two Activation Likelihood Estimation (ALE) Meta-Analyses

    Adank, Patti

    2012-01-01

    The role of speech production mechanisms in difficult speech comprehension is the subject of on-going debate in speech science. Two Activation Likelihood Estimation (ALE) analyses were conducted on neuroimaging studies investigating difficult speech comprehension or speech production. Meta-analysis 1 included 10 studies contrasting comprehension…

  19. How do patients come to be seen as 'difficult'?: a mixed-methods study in community mental health care

    Koekkoek, B.; Hutschemaekers, G.; van Meijel, B.; Schene, A.

    2011-01-01

    Across all health care settings, certain patients are perceived as 'difficult' by clinicians. This paper's aim is to understand how certain patients come to be perceived and labelled as 'difficult' patients in community mental health care, through mixed-methods research in The Netherlands between

  20. When Your Child Is Difficult: Solve Your Toughest Child-Raising Problems with a Four-Step Plan That Works.

    Silberman, Mel

    Written for parents, this book discusses four steps for dealing with children's difficult behavior. The book is divided into two parts. Part 1, "The Building Blocks," discusses baseline perspectives parents need to establish in order to effectively deal with difficult behavior. Topics covered include: (1) parents' dual roles as caregivers and…

  1. Recent and historic sediment dynamics along Difficult Run, a suburban Virginia Piedmont stream

    Hupp, Cliff R.; Noe, Gregory B.; Schenk, Edward R.; Bentham, Adam J.

    2012-01-01

    Suspended sediment is one of the major concerns regarding the quality of water entering the Chesapeake Bay. Some of the highest suspended-sediment concentrations occur on Piedmont streams, including Difficult Run, a tributary of the Potomac River draining urban and suburban parts of northern Virginia. Accurate information on catchment level sediment budgets is rare and difficult to determine. Further, the sediment trapping portion of sediment budget represents an important ecosystem service that profoundly affects downstream water quality. Our objectives, with special reference to human alterations to the landscape, include the documentation and estimation of floodplain sediment trapping (present and historic) and bank erosion along an urbanized Piedmont stream, the construction of a preliminary sediment balance, and the estimation of legacy sediment and recent development impacts. We used white feldspar markers to measure floodplain sedimentation rates and steel pins to measure erosion rates on floodplains and banks, respectively. Additional data were collected for/from legacy sediment thickness and characteristics, mill pond impacts, stream gaging station records, topographic surveying, and sediment density, texture, and organic content. Data were analyzed using GIS and various statistical programs. Results are interpreted relative to stream equilibrium affected by both post-colonial bottomland sedimentation (legacy) and modern watershed hardening associated with urbanization. Six floodplain/channel sites, from high to low in the watershed, were selected for intensive study. Bank erosion ranges from 0 to 470 kg/m/y and floodplain sedimentation ranges from 18 to 1369 kg/m/y (m refers to meters of stream reach). Upstream reaches are net erosional, while downstream reaches have a distinctly net depositional flux providing a watershed sediment balance of 2184 kg/m/y trapped within the system. The amounts of both deposition and erosion are large and suggest

  2. Recent and historic sediment dynamics along Difficult Run, a suburban Virginia Piedmont stream

    Hupp, Cliff R.; Noe, Gregory B.; Schenk, Edward R.; Benthem, Adam J.

    2013-01-01

    Suspended sediment is one of the major concerns regarding the quality of water entering the Chesapeake Bay. Some of the highest suspended-sediment concentrations occur on Piedmont streams, including Difficult Run, a tributary of the Potomac River draining urban and suburban parts of northern Virginia. Accurate information on catchment level sediment budgets is rare and difficult to determine. Further, the sediment trapping portion of sediment budget represents an important ecosystem service that profoundly affects downstream water quality. Our objectives, with special reference to human alterations to the landscape, include the documentation and estimation of floodplain sediment trapping (present and historic) and bank erosion along an urbanized Piedmont stream, the construction of a preliminary sediment balance, and the estimation of legacy sediment and recent development impacts. We used white feldspar markers to measure floodplain sedimentation rates and steel pins to measure erosion rates on floodplains and banks, respectively. Additional data were collected for/from legacy sediment thickness and characteristics, mill pond impacts, stream gaging station records, topographic surveying, and sediment density, texture, and organic content. Data were analyzed using GIS and various statistical programs. Results are interpreted relative to stream equilibrium affected by both post-colonial bottomland sedimentation (legacy) and modern watershed hardening associated with urbanization. Six floodplain/channel sites, from high to low in the watershed, were selected for intensive study. Bank erosion ranges from 0 to 470 kg/m/y and floodplain sedimentation ranges from 18 to 1369 kg/m/y (m refers to meters of stream reach). Upstream reaches are net erosional, while downstream reaches have a distinctly net depositional flux providing a watershed sediment balance of 2184 kg/m/y trapped within the system. The amounts of both deposition and erosion are large and suggest

  3. Make Better Food Choices

    10 tips Nutrition Education Series make better food choices 10 tips for women’s health Fruits Grains Dairy Vegetables Protein Make yourself a priority and take time to care for yourself. ChooseMyPlate. gov ...

  4. Categorization = Decision Making + Generalization

    Seger, Carol A; Peterson, Erik J.

    2013-01-01

    We rarely, if ever, repeatedly encounter exactly the same situation. This makes generalization crucial for real world decision making. We argue that categorization, the study of generalizable representations, is a type of decision making, and that categorization learning research would benefit from approaches developed to study the neuroscience of decision making. Similarly, methods developed to examine generalization and learning within the field of categorization may enhance decision making research. We first discuss perceptual information processing and integration, with an emphasis on accumulator models. We then examine learning the value of different decision making choices via experience, emphasizing reinforcement learning modeling approaches. Next we discuss how value is combined with other factors in decision making, emphasizing the effects of uncertainty. Finally, we describe how a final decision is selected via thresholding processes implemented by the basal ganglia and related regions. We also consider how memory related functions in the hippocampus may be integrated with decision making mechanisms and contribute to categorization. PMID:23548891

  5. Managing government employees: how to motivate your people, deal with difficult issues, and achieve tangible results

    Liff, Stewart

    2007-01-01

    ..., Benefits, and Retirement They Want the Job Security Offered by Government The Government Can Offer the Right Job and Training The Government Offers Many Opportunities to Advance Why Do Government Personnel Systems Make Things So Difficult? 1 1 2 3 4 4 5 7 8 9 10 11 11 12 12 12 13 vii ... 16220$ CNTS 11-14-06 08:22:32 PS PAGE viiviii Contents History of t...

  6. Implementing accountable management reforms in public sector : the difficult travel from intentions to effects

    Pettersen, Inger Johanne

    2000-01-01

    Over the last decade a number of management accounting practices and techniques have appeared to improve the quality and reliability of management accounting information in public sector. The aim of this paper is to gain more insight into the link between management accounting reforms and organizational learning and change in the hospital sector. Especially, the focus is put on the processes of defining, interpreting and sense-making of accounting information in this complex public sector man...

  7. The reallocation of [ʝ] in cypriot greek

    Pappas, Panayiotis A.

    2016-01-01

    This  article examines the variation between lateral palatal ([ʎ]) and fricative palatal ([ʝ])  instantiations of the variable (liV) in Cypriot Greek. Through the analysis of two datasets, one based on  sociolinguistic interviews, and one based on elicitation task s, it is shown that the fricative variant, which  used to be associated mainly with the city of Ammochostos (Famagusta), is now present in all three major  urban centres of the island, and that young men are leading the change. The ...

  8. Reallocating attention during multiple object tracking.

    Ericson, Justin M; Christensen, James C

    2012-07-01

    Wolfe, Place, and Horowitz (Psychonomic Bulletin & Review 14:344-349, 2007) found that participants were relatively unaffected by selecting and deselecting targets while performing a multiple object tracking task, such that maintaining tracking was possible for longer durations than the few seconds typically studied. Though this result was generally consistent with other findings on tracking duration (Franconeri, Jonathon, & Scimeca Psychological Science 21:920-925, 2010), it was inconsistent with research involving cuing paradigms, specifically precues (Pylyshyn & Annan Spatial Vision 19:485-504, 2006). In the present research, we broke down the addition and removal of targets into separate conditions and incorporated a simple performance model to evaluate the costs associated with the selection and deselection of moving targets. Across three experiments, we demonstrated evidence against a cost being associated with any shift in attention, but rather that varying the type of cue used for target deselection produces no additional cost to performance and that hysteresis effects are not induced by a reduction in tracking load.

  9. Efficient and confidential reallocation of contracts

    Bogetoft, Peter; Nielsen, Kurt

    2012-01-01

    The first Danish exchange for sugar beet contracts was established in January 2008. It was also the world’s first major application of a new technology, secure multiparty computation (SMC), which ensures the security and cost-effectiveness of such exchanges. The technology can potentially be used...

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

    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.)

  11. Primary Hepatic Lymphoma Is Difficult to Discriminate from a Liver Abscess

    Nobuhiro Takeuchi

    2014-01-01

    Full Text Available An 82-year-old woman presented with a high-grade fever of 40°C and was admitted to our institution for intensive examination and treatment. Noncontrast abdominal computed tomography (CT revealed low-density masses at segments 5 and 8, suggestive of a liver abscess. On further examination, a contrast-enhanced abdominal CT showed a 30×30 mm mass with an enhanced margin at segment 8 in the arterial phase; the contrast agents were washed out in the venous phase. In addition, a 63×52 mm mass with a density lower than that of liver parenchyma was observed at segment 8 in the portal phase. On the basis of these findings, either a liver abscess or hepatocellular carcinoma was suspected. To confirm the diagnosis, a fine needle biopsy was scheduled. Histopathological analysis of the biopsied specimens confirmed the diagnosis of diffuse large B-cell lymphoma. Chemotherapy was not indicated owing to the patient’s age and poor performance status; thus, best supportive care was planned. On day 22 after admission, the patient died of pneumonia. We experienced a case of PHL that was difficult to discriminate from a liver abscess. Imaging alone is insufficient to diagnose PHL; therefore, fine needle biopsy is recommended for a definitive diagnosis.

  12. Gold nanoparticles as scaffolds for poor water soluble and difficult to vehiculate antiparkinson codrugs

    Di Crescenzo, A.; Cacciatore, I.; Petrini, M.; D'Alessandro, M.; Petragnani, N.; Del Boccio, P.; Di Profio, P.; Boncompagni, S.; Spoto, G.; Turkez, H.; Ballerini, P.; Di Stefano, A.; Fontana, A.

    2017-01-01

    We report the facile and non-covalent preparation of gold nanoparticles (AuNPs) stabilized by an antiparkinson codrug based on lipoic acid (LA). The obtained AuNPs appear stable in both dimethyl sulfoxide and fetal bovine serum and able to load an amount of codrug double the weight of gold. These NPs were demonstrated to be safe and biocompatible towards primary human blood cells and human neuroblastoma cells, one of the most widely used cellular models to study dopaminergic neural cells, therefore are ideal drug carriers for difficult to solubilize molecules. Very interestingly, the codrug-stabilized AuNPs were shown to reduce the accumulation of reactive oxygen species in SH-SY5Y cells treated with LD and did not change total oxidant status levels in cultured human blood cells, thus confirming the antioxidant role of LA although bound to AuNPs. The characterization of AuNPs in terms of loading and stability paves the way for their use in biomedical and pharmacological applications.

  13. Difficult Myotomy Is Not Determined by Preoperative Therapy and Does Not Impact Outcome

    Villadolid, Desiree V.; Al-Saadi, Sam; Rosemurgy, Alexander S.

    2007-01-01

    Objectives: The impact of preoperative endoscopic therapy on the difficulty of laparoscopic Heller myotomy and the impact of the difficulty of the myotomy on long-term outcome has not been determined. This study was undertaken to determine whether preoperative therapy impacts the difficulty of laparoscopic Heller myotomy and whether preoperative therapy or difficulty of myotomy impacts long-term outcomes. Methods: Since 1992, 305 patients, 56% male, median age 49 years, underwent laparoscopic Heller myotomy and were prospectively followed. The difficulty of the laparoscopic Heller myotomy was scored by the operating surgeon for the most recent 170 consecutive patients on a scale of 1 (easiest) to 5 (most difficult). Patients scored their symptoms before and after myotomy using a Likert scale from 0 (never/not bothersome) to 10 (always/very bothersome). Results: Before myotomy, 66% of patients underwent endoscopic therapy: 33% dilation, 11% Botox, and 22% both. Preoperative endoscopic therapy did not correlate with the difficulty of the myotomy (P=NS). Median follow-up was 25 months. Regardless of the difficulty of the myotomy, dysphagia improved with myotomy (Pmyotomy. Conclusions: Laparoscopic Heller myotomy improves the frequency and severity of dysphagia. The difficulty of laparoscopic Heller myotomy is not impacted by preoperative therapy, and neither preoperative therapy nor difficulty of the myotomy impact long-term outcome. PMID:17931516

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

    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.

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

    Kenneth R. Paap

    2014-12-01

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

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

    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.

  17. Critical care nurses' experiences of performing successful peripheral intravenous catheterization in difficult situations.

    Forsberg, Angelica; Engström, Åsa

    2018-06-01

    The aim of this study is to describe the experiences of critical care nurses (CCNs) when performing successful peripheral intravenous catheterization (PIVC) on adult inpatients in difficult situations. This study uses a descriptive design with a qualitative approach. Semistructured interviews were given to CCNs (n = 22) at a general central county hospital in northern Sweden. The interview text was analyzed with qualitative thematic content analysis. Three themes emerged: "releasing time and creating peace," "feeling self-confidence in the role of expert nurse," and "technical interventions promoting success." CCNs stated that apart from experience, releasing enough time is the most crucial factor for a successful PIVC. They emphasized the importance of identifying the kinds of difficulties that may occur during the procedure, for example, fragile or/and invisible veins. CCNs explained that compared to when they were newly graduated, the difference in their approach nowadays has changed to using their hands more than their eyes and that they feel comfortable with bodily palpations. To further optimize PIVC performing skills, continued possibilities to train and learn in hospital settings are necessary, even after formal education has been completed. Copyright © 2018 Society for Vascular Nursing, Inc. Published by Elsevier Inc. All rights reserved.

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

    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. A case of desmoplastic melanoma that was difficult to distinguish from malignant peripheral nerve sheath tumor

    Kenji Yorita

    2018-03-01

    Full Text Available The clinical and pathological diagnosis of desmoplastic melanoma is difficult, because almost 50% of desmoplastic melanoma cases involve non-pigmented lesions and the tumor cells can resemble fibroblasts or Schwannian cells based on their frequent amelanotic features. Moreover, desmoplastic melanoma typically has low positive rates for melanoma markers, with the exception of the S-100 protein. We report the case of an 81-year-old Japanese man with an 8-mm desmoplastic melanoma. He initially noticed a painless and non-pigmented skin lesion that did not grow noticeably for 6 months. It was unlikely that he had von Recklinghausen disease, and the mass was initially considered a dermatofibroma. Excisional biopsy revealed an intradermal mass, with the superficial portion mimicking neurofibroma and the deeper portion exhibiting nodular growth of sarcomatoid spindle cells. The tumor region lacked intradermal proliferation of atypical melanocytic cells, intracytoplasmic melanin, and expression of melanoma markers (except S-100 protein and Sox10. Although a malignant peripheral nerve sheath tumor derived from neurofibroma was possible, the slow growth with diffuse and strong immunoreactivity to the S-100 protein and Sox10 favored a diagnosis of desmoplastic melanoma. Pathologists should recognize that desmoplastic melanoma may not involve in situ lesions or the immunohistochemical expression of standard melanoma markers.

  20. Frontal sinus osteoma: a difficult surgical decision in the era of endoscopic sinus surgery.

    Hazarika, Produl; Zachariah, Plavilayl Koruthu Joyse; Victor, John; Punnoose, Seema E; Sharma, Santosh; Devi, Chitra

    2011-01-01

    A slow-growing frontal sinus osteoma has been followed up since the year 2001 by clinical, endoscopic, and radiological examination in the Department of Otolaryngology, New Medical Centre Specialty Hospital, Abu Dhabi, for 10 years until the year 2010. The last computed tomography scan of paranasal sinuses was done on April 5, 2010, which revealed increasing size of the osteoma by 38.1 mm; and it has become symptomatic. No specific cause of the sudden change of growth of the osteoma could be evaluated from the history and clinical examination. There was an increase in the frequency of headache and feeling of pressure in the forehead. Choice of surgical approach was difficult in this popular era of endonasal endoscopic sinus approach. A great deal of effort was made after reviewing the literature and consultation with the radiologist and neurosurgeon to accept the bicoronal osteoplastic flap approach. A broad-based posterior frontal sinus is found to be ideal for external approach. Copyright © 2011 Elsevier Inc. All rights reserved.

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

    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.

  2. Diagnosis of depression in children and adolescents. Clinical pointers to a difficult diagnosis.

    2010-04-01

    It is now accepted that depression can also affect children and adolescents, but its diagnosis is not straightforward. We examined review articles published on this subject over the last 15 years by large specialist groups and multidisciplinary teams. Most studies of symptoms of psychological distress and depression in children are mainly based on clinical experience of specialists and therefore provide only modest evidence. Isolated, transient unhappiness is not in itself a symptom of depression, but recurrent and persistent mood disorders constitute important warning signs. A French consensus jury recommended attentive listening to potentially depressed children, and those closest to them, focusing on phrases that might reflect a loss of interest, enjoyment, self-esteem and self-confidence; feelings of guilt, shame, loss of affection and hope; and morbid or suicidal ideas. British clinical practice guidelines recommend evaluating the severity of a depressive episode on the basis of the type and number of symptoms, and the family context. Scores designed to diagnose depression and assess its severity are controversial. In practice, diagnosis of depression in children and adolescents with persistent psychological distress is not based on a simple list of symptoms. In difficult cases, it is better to adopt a multidisciplinary approach in order to gauge severity and to determine the most appropriate treatment, which, in most cases, does not involve the use of drugs.

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

    Tamirace FAKHOURY

    2010-05-01

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

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

    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.

  5. Teachers' Grading Decision Making

    Isnawati, Ida; Saukah, Ali

    2017-01-01

    This study investigated teachers' grading decision making, focusing on their beliefs underlying their grading decision making, their grading practices and assessment types, and factors they considered in grading decision making. Two teachers from two junior high schools applying different curriculum policies in grade reporting in Indonesian…

  6. I: Making Art

    Rosenfeld, Malke; Johnson, Marquetta; Plemons, Anna; Makol, Suzanne; Zanskas, Meghan; Dzula, Mark; Mahoney, Meg Robson

    2014-01-01

    Writing about the teaching artist practice should mean writing about art making. As both teacher and artist, the authors are required to be cognizant of their own art-making processes, both how it works and why it is important to them, in order to make this process visible to their students. They also need the same skills to write about how and…

  7. Elements of Making

    Rodriguez, Shelly; Harron, Jason; Fletcher, Steven; Spock, Hannah

    2018-01-01

    While there is no official definition, making is generally thought of as turning ideas into products through design, invention, and building. Support is growing for integrating making into science, technology, engineering, and mathematics (STEM) education. Making can help high school students explore science concepts and phenomena, yet, lacking…

  8. Making the Silence Visible

    Keshavarz, Fatemeh

    2006-01-01

    This article discusses the vulnerability of U.S. professors of Islamic and Near Eastern studies, particularly if they are of Muslim origin. The author, a scholar of subjects related to literatures and cultures of the Muslim world, who is herself of Muslim origin, has found it more difficult in recent years to bring many topics to the classroom.…

  9. Focused Science Delivery makes science make sense.

    Rachel W. Scheuering; Jamie. Barbour

    2004-01-01

    Science does not exist in a vacuum, but reading scientific publications might make you think it does. Although the policy and management implications of their findings could often touch a much wider audience, many scientists write only for the few people in the world who share their area of expertise. In addition, most scientific publications provide information that...

  10. Making detailed predictions makes (some) predictions worse

    Kelly, Theresa F.

    In this paper, we investigate whether making detailed predictions about an event makes other predictions worse. Across 19 experiments, 10,895 participants, and 415,960 predictions about 724 professional sports games, we find that people who made detailed predictions about sporting events (e.g., how many hits each baseball team would get) made worse predictions about more general outcomes (e.g., which team would win). We rule out that this effect is caused by inattention or fatigue, thinking too hard, or a differential reliance on holistic information about the teams. Instead, we find that thinking about game-relevant details before predicting winning teams causes people to give less weight to predictive information, presumably because predicting details makes information that is relatively useless for predicting the winning team more readily accessible in memory and therefore incorporated into forecasts. Furthermore, we show that this differential use of information can be used to predict what kinds of games will and will not be susceptible to the negative effect of making detailed predictions.

  11. Making strategy: learning by doing.

    Christensen, C M

    1997-01-01

    Companies find it difficult to change strategy for many reasons, but one stands out: strategic thinking is not a core managerial competence at most companies. Executives hone their capabilities by tackling problems over and over again. Changing strategy, however, is not usually a task that they face repeatedly. Once companies have found a strategy that works, they want to use it, not change it. Consequently, most managers do not develop a competence in strategic thinking. This Manager's Tool Kit presents a three-stage method executives can use to conceive and implement a creative and coherent strategy themselves. The first stage is to identify and map the driving forces that the company needs to address. The process of mapping provides strategy-making teams with visual representations of team members' assumptions, those pictures, in turn, enable managers to achieve consensus in determining the driving forces. Once a senior management team has formulated a new strategy, it must align the strategy with the company's resource-allocation process to make implementation possible. Senior management teams can translate their strategy into action by using aggregate project planning. And management teams that link strategy and innovation through that planning process will develop a competence in implementing strategic change. The author guides the reader through the three stages of strategy making by examining the case of a manufacturing company that was losing ground to competitors. After mapping the driving forces, the company's senior managers were able to devise a new strategy that allowed the business to maintain a competitive advantage in its industry.

  12. Making and Changing Wills

    Cheryl Tilse

    2016-02-01

    Full Text Available Wills are important social, economic, and legal documents. Yet little is known about current will making practices and intentions. A comprehensive national database on the prevalence of will making in Australia was developed to identify who is or is not most likely to draw up a will and triggers for making and changing wills. A national survey of 2,405 adults aged above 18 years was administered by telephone in August and September 2012. Fifty-nine percent of the Australian adult population has a valid will, and the likelihood of will making increases with age and estate value. Efforts to get organized, especially in combination with life stage and asset changes trigger will making; procrastination, rather than a strong resistance, appears to explain not making a will. Understanding will making is timely in the context of predicted significant intergenerational transfers of wealth, changing demographics, and a renewed emphasis on retirement planning.

  13. Improving working equine welfare in 'hard-win' situations, where gains are difficult, expensive or marginal.

    Pritchard, Joy; Upjohn, Melissa; Hirson, Tamsin

    2018-01-01

    Brooke is a non-government organisation with working equine welfare programmes across Africa, Asia and Latin America. In 2014, staff from ten country programmes were asked to identify 'no-win' situations (subsequently reframed as 'hard-wins')-where improving equine welfare is proving difficult, expensive and/or marginal-in order to inform strategic decisions on how to approach, manage and mitigate for such situations. The Delphi-type consultation process had three phases. Round 1 posed five questions in the form of a workshop, survey and semi-structured interviews. Round 2 re-presented key themes and sense-checked initial conclusions. Round 3 reviewed the nature and prevalence of hard-win situations at an international meeting of all participants. Reasons given for hard-win situations included: no economic or social benefit from caring for working animals; poor resource availability; lack of empathy for working equids or their owners among wider stakeholders; deep-seated social issues, such as addiction or illegal working; areas with a high animal turnover or migratory human population; lack of community cooperation or cohesion; unsafe areas where welfare interventions cannot be adequately supported. Participants estimated the prevalence of hard-win situations as 40-70% of their work. They suggested some current ways of working that may be contributing to the problem, and opportunities to tackle hard-wins more effectively. Respondents agreed that if equine welfare improvements are to span generations of animals, interventions cannot rely on relatively simple, technical knowledge-transfer strategies and quick-wins alone. Programmes need to be more flexible and iterative and less risk-averse in their approaches to embedding good equine welfare practices in all relevant actors. Consultation recommendations informed development of Brooke's new global strategy, a revised organisational structure and redefinition of roles and responsibilities to streamline ways to

  14. Examination of decontamination of various materials at houses in difficult-to-return zone

    Mori, Airi; Tanabe, Tsutomu; Kato, Mitsugu; Wada, Takao

    2017-03-01

    Large quantities of radioactive materials were released into the environment as a result of the TEPCO Fukushima Daiichi Nuclear Power Station accident. Residential areas and forest areas near the power station were contaminated with the radioactive materials. Outside of the houses, schools and the other buildings are being decontaminated by national authority and local government. On the other hand, the materials (such as walls, floors, or windows) which constitute the houses are not decontaminated officially. In order to prepare decontamination methods that can be applied easily, we conducted examinations of decontamination for various materials in houses. Fibrous materials, woods, glasses, concretes, plastics, vinyl chloride materials, metals and synthetic leathers were used in our examinations. These materials were collected from houses in difficult-to-return zone, and were contaminated by radioactive materials released by the accident. Dry methods (suction, wiping, adsorption and peelable coating), wet methods (wiping, brushing, polishing and washing) and physical method (peeling of materials) were used for decontamination. As a result of our examinations, materials with low water permeability, such as glasses, concretes, vinyl chloride materials and metals, were able to be decontaminated efficiently (about 90% reduction) by using wet methods. Materials with high water permeability like woods were relatively well decontaminated by peelable coating (about 60%–70% reduction). However, any methods except for physical method were not effective for tatami. It seems the most reasonable way to replace old surface of tatami with new one. In addition to the examination described above, the difference of contamination reduction effect between chemical properties of detergents and the effect of rubbing of peelable coating were also examined. Finally, the most effective method was summarized based on these examinations. (author)

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

    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

  16. Safety of Temporary Discontinuation of Antihypertensive Medication in Patients With Difficult-to-Control Hypertension.

    Beeftink, Martine M A; van der Sande, Nicolette G C; Bots, Michiel L; Doevendans, Pieter A; Blankestijn, Peter J; Visseren, Frank L J; Voskuil, Michiel; Spiering, Wilko

    2017-05-01

    Successful control of blood pressure relies on identification of secondary causes and contributing factors of hypertension. As antihypertensive medication can interfere with diagnostic investigations, temporary discontinuation of medication is advised. However, there are concerns about the safety of temporary discontinuation of antihypertensive medication in patients with difficult-to-control hypertension. We assessed the occurrence of adverse cardiovascular and cerebrovascular events potentially attributable to temporary discontinuation of antihypertensive medication between February 2010 and March 2016 (n=604) in our Analysis of Complicated Hypertension screening program. A reference group (n=604) was extracted from the SMART study (Second Manifestations of Arterial Disease) cohort (comprising a similar cohort at our hospital in whom medication was not stopped) and individually matched for blood pressure, age, sex, and history of cardiovascular disease. Discontinuation of medication was well tolerated; 62% reported no complaints, 24% had mild discomfort that could be left untreated, and 14% experienced complaints that required prescription of antihypertensive escape medication. Three major adverse events were observed in the Analysis of Complicated Hypertension group between discontinuation of medication and 30 days after restart of medication (event rate=31.2 events per 1000 patient-year). In the reference cohort, 5 cardiovascular events were observed during a similar follow-up period (event rate=51.2 events per 1000 patient-year). In conclusion, discontinuation of antihypertensive medication for the diagnostic evaluation of hypertension does not increase the acute risk of cardiovascular events when performed in a well-controlled setting in specialized hospitals with appropriate protocols for monitoring safety. © 2017 American Heart Association, Inc.

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

    Ibrahim, A. M.; Peplow, D. E.; Mosher, S. W.; Wagner, J. C.; Evans, T. M.; Wilson, P. P.; Sawan, M. E.

    2013-01-01

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

  18. Automatic mesh adaptivity for hybrid Monte Carlo/deterministic neutronics modeling of difficult shielding problems

    Ibrahim, Ahmad M.; Wilson, Paul P.H.; Sawan, Mohamed E.; Mosher, Scott W.; Peplow, Douglas E.; Wagner, John C.; Evans, Thomas M.; Grove, Robert E.

    2015-01-01

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

  19. Grief symptoms and difficult patient loss for oncologists in response to patient death.

    Granek, Leeat; Ben-David, Merav; Shapira, Shahar; Bar-Sela, Gil; Ariad, Samuel

    2017-07-01

    The study aimed to explore oncologist's grief symptoms over patient death and to identify why and which losses are particularly challenging when patients die. The grounded theory method was used to collect and analyze the data. Twenty-two oncologists were interviewed between March 2013 and June 2014 from three adult oncology centers in the north, center, and south of Israel. Oncologists were at different stages of their careers and varied in their sub-specialties, gender, and personal and professional backgrounds. Grief begun when the patient died, in anticipation of the patient's death, many days after the death, or when the patient received a poor prognosis. The phenomenological experience of grief for oncologists included behavioral, cognitive, physical, and emotional symptoms in response to patient death. Behavioral symptoms included crying and difficulties sleeping. Cognitive symptoms included self-doubt and rumination about the patient and the care the patient had received before death. Physical symptoms included chest pain, fatigue, and general physical discomfort. Emotional symptoms included sadness, anxiety, helplessness, guilt, relief, irritability, and loss. Difficult patient loss was caused by patient-related factors, family-related factors, and disease-related factors. Patient deaths result in behavioral, cognitive, physical, and emotional symptoms of grief in oncologists. These symptoms become particularly intense in the context of patient, family, and disease-related factors. Educational and supportive interventions for managing grief related to patient death are needed in order to support oncologists in their emotionally and mentally taxing work. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  20. Still a difficult business? Negotiating alcohol-related problems in general practice consultations.

    Rapley, Tim; May, Carl; Frances Kaner, Eileen

    2006-11-01

    This paper describes general practitioners' (GPs) experiences of detecting and managing alcohol and alcohol-related problems in consultations. We undertook qualitative research in two phases in the North-East of England. Initially, qualitative interviews with 29 GPs explored their everyday work with patients with alcohol-related issues. We then undertook group interviews--two with GPs and one with a primary care team--where they discussed and challenged findings of the interviews. The GPs reported routinely discussing alcohol with patients with a range of alcohol-related problems. GPs believed that this work is important, but felt that until patients were willing to accept that their alcohol consumption was problematic they could achieve very little. They tentatively introduced alcohol as a potential problem, re-introduced the topic periodically, and then waited until the patient decided to change their behaviour. They were aware that they could identify and manage more patients. A lack of time and having to work with the multiple problems that patients brought to consultations were the main factors that stopped GPs managing more risky drinkers. Centrally, we compared the results of our study with [Thom, B., & Tellez, C. (1986). A difficult business-Detecting and managing alcohol-problems in general-practice. British Journal of Addiction, 81, 405-418] seminal study that was undertaken 20 years ago. We show how the intellectual, moral, emotional and practical difficulties that GPs currently face are quite similar to those faced by GPs from 20 years ago. As the definition of what could constitute abnormal alcohol consumption has expanded, so the range of consultations that they may have to negotiate these difficulties in has also expanded.

  1. A Difficult Journey: Reflections on Driving and Driving Cessation From a Team of Clinical Researchers.

    Liddle, Jacki; Gustafsson, Louise; Mitchell, Geoffrey; Pachana, Nancy A

    2017-02-01

    Recognizing the clinical importance and safety and well-being implications for the population, a multidisciplinary team has been researching older drivers and driving cessation issues for more than 15 years. Using empirical approaches, the team has explored quality of life and participation outcomes related to driving and nondriving for older people and has developed interventions to improve outcomes after driving cessation. The team members represent occupational therapists, medical practitioners, and clinical and neuropsychologists. While building the evidence base for driving- and driving cessation-related clinical practice, the researchers have also had first-hand experiences of interruptions to their own or parents' driving; involvement of older family members in road crashes; and provision of support during family members' driving assessment and cessation. This has led to reflection on their understandings and re-evaluation and refocusing of their perspectives in driving cessation research. This work will share the narratives of the authors and note their developing perspectives and foci within research as well as their clinical practice. Personal reflections have indicated the far-reaching implications for older drivers and family members of involvement in road crashes: the potential for interruptions to driving as a time for support and future planning and the conflicting and difficult roles of family members within the driving cessation process. Overall the lived, personal experience of the authors has reinforced the complex nature of driving and changes to driving status for the driver and their support team and the need for further research and support. © The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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

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

    2015-11-01

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

  3. What is good medical ethics? A very personal response to a difficult question.

    Farsides, Bobbie

    2015-01-01

    A personal reflection upon a career in medical ethics leads to four conclusions on what makes for 'good medical ethics'. Good medical ethics is practical in approach, philosophically well grounded, cross disciplinary, and while it might not be a necessary feature, the experience of the author suggests that it is the work of 'good people'. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

  4. Reason, Consent and Contract The Difficult Least Common Denominator of Contractualist Theories

    Felipe Schwember Augier Felipe Schwember Augier

    2014-12-01

    Full Text Available “Contractualism” refers to the diverse theories that maintain that the obligatory nature of norms rests on the consent of those bound by them. However, this general characterization overlooks crucial differences among the different contractualist theories. The article analyzes diverse typologies in order to highlight these differences and reach a more precise characterization of contractualism. It concludes that the distinction between hypothetical and ideal consent made by some of these versions makes it impossible to formulate a univocal definition of contractualism.

  5. Data for decision making: strategic information tools for hospital management during a pandemic.

    Farias, Daniel R; Raffo, Lucrecia; Bacigalupo, Silvia; Cremaschi, Maria; Vence, Liliana; Ramos, Susana; Salguero, Ana; Claudio, Martin; Meites, Elissa; Cubito, Alejandro

    2010-10-01

    During the 2009 influenza A (H1N1) pandemic, Argentina's Hospital Nacional Profesor Alejandro Posadas, a referral center in the capital province of Buenos Aires, treated a large urban patient population. Beginning in April, after severe influenza had been reported in North America but before any suspected cases of H1N1 had been reported in Argentina, the authors formed a pandemic planning committee to direct our hospital's response. An important strategy of the management team was to create a single daily monitoring tool that could integrate multiple information sources. We describe our pandemic planning strategy so that it may serve as a template for other hospitals. We describe our integrated data management system and the indicators it measured. We also describe the iterative process used to develop these tools and the current versions we use in surveillance for possible new waves of pandemic influenza. We present 3 examples of strategic decision making applied to data from our integrated information system. Daily pandemic surveillance data motivated the planning committee to reallocate hospital resources to care for patients during the peak pandemic period. This report illustrates the importance of pandemic planning and advanced integrated information tools for management of a health care facility during a pandemic.

  6. Doppler Effect-Based Automatic Landing Procedure for UAV in Difficult Access Environments

    Jan M. Kelner

    2017-01-01

    Full Text Available Currently, almost unrestricted access to low-lying areas of airspace creates an opportunity to use unmanned aerial vehicles (UAVs, especially those capable of vertical take-off and landing (VTOL, in transport services. UAVs become increasingly popular for transporting postal items over small, medium, and large distances. It is forecasted that, in the near future, VTOL UAVs with a high take-off weight will also deliver goods to very distant and hard-to-reach locations. Therefore, UAV navigation plays a very important role in the process of carrying out transport services. At present, during the flight phase, drones make use of the integrated global navigation satellite system (GNSS and the inertial navigation system (INS. However, the inaccuracy of GNSS + INS makes it unsuitable for landing and take-off, necessitating the guidance of a human UAV operator during those phases. Available navigation systems do not provide sufficiently high positioning accuracy for an UAV. For this reason, full automation of the landing approach is not possible. This paper puts forward a proposal to solve this problem. The authors show the structure of an autonomous system and a Doppler-based navigation procedure that allows for automatic landing approaches. An accuracy evaluation of the developed solution for VTOL is made on the basis of simulation studies.

  7. Business making decisions

    Enrique Benjamín Franklin Fincowsky

    2011-06-01

    Full Text Available People and organizations make better or get wrong as consequence of making decisions. Sometimes making decisions is just a trial and error process. Some others, decisions are good and the results profitable with a few of mistakes, most of the time because it’s considered the experience and the control of a specific field or the good intention of who makes them. Actually, all kinds of decisions bring learning. What is important is the intention, the attitude and the values considered in this process. People from different scenes face many facts and circumstances—almost always out of control—that affect the making decisions process. There is not a unique way to make decisions for all companies in many settings. The person who makes a decision should identify the problem, to solve it later using alternatives and solutions. Even though, follow all the steps it’s not easy as it seems. Looking back the conditions related to the decisions, we can mention the followings: uncertainty, risk and certainty. When people identify circumstances and facts, as well as its effects in a possible situation, they will make decisions with certainty. As long as the information decreases and it becomes ambiguous the risk becomes an important factor in the making decisions process because they are connected to probable objectives (clear or subjective (opinion judgment or intuition. To finish, uncertainty, involves people that make a decision with no or little information about circumstances or criteria with basis

  8. Counter traction makes endoscopic submucosal dissection easier.

    Oyama, Tsuneo

    2012-11-01

    Poor counter traction and poor field of vision make endoscopic submucosal dissection (ESD) difficult. Good counter traction allows dissections to be performed more quickly and safely. Position change, which utilizes gravity, is the simplest method to create a clear field of vision. It is useful especially for esophageal and colon ESD. The second easiest method is clip with line method. Counter traction made by clip with line accomplishes the creation of a clear field of vision and suitable counter traction thereby making ESD more efficient and safe. The author published this method in 2002. The name ESD was not established in those days; the name cutting endoscopic mucosal resection (EMR) or EMR with hook knife was used. The other traction methods such as external grasping forceps, internal traction, double channel scope, and double scopes method are introduced in this paper. A good strategy for creating counter traction makes ESD easier.

  9. Cricotracheostomy for a patient with difficult airway access for an aberrant common carotid artery: A case report

    Hiroshi Hasegawa

    2017-03-01

    Although there is a need to resolve the long-term sequelae, we believe that cricotracheostomy is likely to be as useful for establishment of an open airway as tracheostomy or cricothyrotomy, especially in emergency or difficult situations.

  10. What's 'difficult'? A multi-stage qualitative analysis of secondary care specialists' experiences with medically unexplained symptoms.

    Maatz, Anke; Wainwright, Megan; Russell, Andrew J; Macnaughton, Jane; Yiannakou, Yan

    2016-11-01

    The term 'difficult' is pervasively used in relation to medically unexplained symptoms (MUS) and patients with MUS. This article scrutinises the use of the term by analysing interview data from a study of secondary care specialists' experiences with and attitudes towards patients suffering from MUS. Qualitative design employing semi-structured open-ended interviews systematically analysed in three stages: first, data were analysed according to the principles of content analysis. The analysis subsequently focused on the use of the term 'difficult'. Iterations of the term were extracted by summative analysis and thematic coding revealed its different meanings. Finally, alternative expressions were explored. Three NHS trust secondary care hospitals in North-East England. 17 senior clinicians from seven medical and two surgical specialities. Unsolicited use of the term 'difficult' was common. 'Difficult' was rarely used as a patient characteristic or to describe the therapeutic relationship. Participants used 'difficult' to describe their experience of diagnosing, explaining, communicating and managing these conditions and their own emotional reactions. Health care system deficits and the conceptual basis for MUS were other facets of 'difficult'. Participants also reported experiences that were rewarding and positive. This study shows that blanket statements such as 'difficult patients' mask the complexity of doctors' experiences in the context of MUS. Our nuanced analysis of the use of 'difficult' challenges preconceived attitudes. This can help counter the unreflexive perpetuation of negative evaluations that stigmatize patients with MUS, encourage greater acknowledgement of doctors' emotions, and lead to more appropriate conceptualizations and management of MUS. Copyright © 2016 Elsevier Inc. All rights reserved.

  11. Teaching Vacancies and Difficult-to-Staff Teaching Positions in Public Schools. Stats in Brief. NCES 2015-065

    Malkus, Nat; Hoyer, Kathleen Mulvaney; Sparks, Dinah

    2015-01-01

    This brief investigates teaching vacancies and difficult-to-staff teaching positions (i.e., positions for which the principals reported that it was very difficult to fill a vacancy or that they could not fill a vacancy in a specific subject area) in public schools in four school years (1999-2000, 2003-04, 2007-08, and 2011-12). This Statistics in…

  12. Beyond Psychometrics: The Difference between Difficult Problem Solving and Complex Problem Solving

    Jens F. Beckmann

    2017-10-01

    Full Text Available In this paper we argue that a synthesis of findings across the various sub-areas of research in complex problem solving and consequently progress in theory building is hampered by an insufficient differentiation of complexity and difficulty. In the proposed framework of person, task, and situation (PTS, complexity is conceptualized as a quality that is determined by the cognitive demands that the characteristics of the task and the situation impose. Difficulty represents the quantifiable level of a person’s success in dealing with such demands. We use the well-documented “semantic effect” as an exemplar for testing some of the conceptual assumptions derived from the PTS framework. We demonstrate how a differentiation between complexity and difficulty can help take beyond a potentially too narrowly defined psychometric perspective and subsequently gain a better understanding of the cognitive mechanisms behind this effect. In an empirical study a total of 240 university students were randomly allocated to one of four conditions. The four conditions resulted from contrasting the semanticity level of the variable labels used in the CPS system (high vs. low and two instruction conditions for how to explore the CPS system’s causal structure (starting with the assumption that all relationships between variables existed vs. starting with the assumption that none of the relationships existed. The variation in the instruction aimed at inducing knowledge acquisition processes of either (1 systematic elimination of presumptions, or (2 systematic compilation of a mental representation of the causal structure underpinning the system. Results indicate that (a it is more complex to adopt a “blank slate” perspective under high semanticity as it requires processes of inhibiting prior assumptions, and (b it seems more difficult to employ a systematic heuristic when testing against presumptions. In combination, situational characteristics, such as the

  13. A new spiral dental implant: a tool for oral rehabilitation of difficult cases.

    Balan, I; Calcaterra, R; Lauritano, D; Grecchi, E; Carinci, F

    2017-01-01

    Spiral dental implant (SDI) is an implant with a conical internal helix that confers the characteristic of self-drilling, self-tapping, and self-bone condensing. These proprieties offer better control during insertion of SDI giving a high primary stabilization, even in poor quality bone. A shorter diameter of SDI results in reduced drilling during insertion and consequently less trauma and minimal bone loss. To address the research purpose, the investigators designed a retrospective cohort study. The study population was composed of 25 patients, 11 males and 14 females that have been treated by Dr. Balan with 187 SDI positioned in mandible and into maxilla bone. The implants were placed during the years 2013 to 2014 in Dr. Balan clinic. All patients underwent the same surgical protocol. Several variables are investigated: demographic (age and gender), anatomic (upper/lower jaws and tooth site), implant (length and diameter and type) variables, edentulism (partial or total), and comorbid status of health (i.e.: hypothyroidism, parodontitis, hypertension, diabetes, presence of cancer, heart disease, hepatitis and rheumatologic disease). Pearson Chi-Square test was used to investigate variables and p < 0.05 was considered statistically significant. Statistically it has been shown that females have a higher possibility of unsuccessful respect of male, with a "p value" of 0.014. Another important impact factor for success of implant insertion has been represented by concomitants pathologies: cancer represents the most negative high factor risk with a percentage of unsuccessful of 50%, followed by heart disease (15%), and diabetes (3.7%). SDIs are reliable tools for difficult cases of oral rehabilitation. They have a higher success and survival rate, which means stable results over time. No differences were detected among SDI lengths, implant/crown ratio. In addition, the insertion of SDIs in banked bone can be performed without adverse effects. Finally, flapless and

  14. Endotracheal intubation in patients with difficult airway: Using laryngeal mask airway with bougie versus video laryngoscopy

    Hesameddin Modir

    2017-01-01

    Full Text Available Airway management is essential for safe anesthesia and endotracheal intubation is the most important procedure by which critically ill patients can be better managed, especially if done quickly and successfully. This study aimed to compare the techniques of intubation through laryngeal mask airway (LMA using a bougie versus video laryngoscopy (VL regarding to intubation success and the quality of intubation indices in patients with difficult airways. This randomized clinical trial was performed on 96 patients aged 16–76 years with Mallampati class 3 or 4 who underwent elective surgery. Once the demographics were recorded, patients were randomly divided into two groups and the first group intubated with VL, and the second group intubated through laryngeal mask using a bougie. Then vital signs, arterial oxygen saturation, the time required for successful intubation, and ease of intubation were recorded. Here t-tests, chi-square, Fisher exact tests, and analysis of variance for repeated measurement were used to analyze the data in SPSS software. The overall success rates of intubation in VL and LMA groups were 46 (96% and 44 (92%, respectively. The mean duration of intubation for the LMA and VL groups was 18.70 ± 6.73 and 14.21 ± 4.14 seconds, respectively (P < 0.001. Moreover, visual analogue scale score for pain in throat was significantly lower in VL group than LMA (1.65 ± 0.76 vs. 1.33 ± 0.52. Moreover, easy intubation in bougie group was 50%, while the easy intubation in VL was 73% (P = 0.023. In addition, incidence of cough was 31% in the LMA with bougie group and 9% in VL group (P = 0.005. The VL technique is an easier method and has a shorter intubation time than LMA using bougie, and causes a lower incidence of coughing, laryngospasm in patients that need intubation. Moreover, cough and discomfort in the throat tend to be less in VL, and the LMA could be used as replacement of VL in hard situations.

  15. Improving working equine welfare in 'hard-win' situations, where gains are difficult, expensive or marginal.

    Joy Pritchard

    Full Text Available Brooke is a non-government organisation with working equine welfare programmes across Africa, Asia and Latin America. In 2014, staff from ten country programmes were asked to identify 'no-win' situations (subsequently reframed as 'hard-wins'-where improving equine welfare is proving difficult, expensive and/or marginal-in order to inform strategic decisions on how to approach, manage and mitigate for such situations.The Delphi-type consultation process had three phases. Round 1 posed five questions in the form of a workshop, survey and semi-structured interviews. Round 2 re-presented key themes and sense-checked initial conclusions. Round 3 reviewed the nature and prevalence of hard-win situations at an international meeting of all participants.Reasons given for hard-win situations included: no economic or social benefit from caring for working animals; poor resource availability; lack of empathy for working equids or their owners among wider stakeholders; deep-seated social issues, such as addiction or illegal working; areas with a high animal turnover or migratory human population; lack of community cooperation or cohesion; unsafe areas where welfare interventions cannot be adequately supported. Participants estimated the prevalence of hard-win situations as 40-70% of their work. They suggested some current ways of working that may be contributing to the problem, and opportunities to tackle hard-wins more effectively.Respondents agreed that if equine welfare improvements are to span generations of animals, interventions cannot rely on relatively simple, technical knowledge-transfer strategies and quick-wins alone. Programmes need to be more flexible and iterative and less risk-averse in their approaches to embedding good equine welfare practices in all relevant actors. Consultation recommendations informed development of Brooke's new global strategy, a revised organisational structure and redefinition of roles and responsibilities to

  16. Decision Making Under Uncertainty

    2010-11-01

    A sound approach to rational decision making requires a decision maker to establish decision objectives, identify alternatives, and evaluate those...often violate the axioms of rationality when making decisions under uncertainty. The systematic description of such observations may lead to the...which leads to “anchoring” on the initial value. The fact that individuals have been shown to deviate from rationality when making decisions

  17. Making Collaborative Innovation Accountable

    Sørensen, Eva

    The public sector is increasingly expected to be innovative, but the prize for a more innovative public sector might be that it becomes difficult to hold public authorities to account for their actions. The article explores the tensions between innovative and accountable governance, describes...... the foundation for these tensions in different accountability models, and suggest directions to take in analyzing the accountability of collaborative innovation processes....

  18. Disseminated Intracranial Ewing’s Sarcoma in an Adult:A Rare and Difficult Diagnosis

    Emil Lou

    2012-06-01

    Full Text Available The Ewing sarcoma family of tumors comprises a rare class of cancers of mesenchymal origin. Cases of Ewing’s sarcoma in the central nervous system – specifically, intracranial Ewing’s – are extremely rare. Almost all reported cases have occurred in children. However, this rare presentation can also occur in the adult population. It is important to distinguish these tumors from primitive neuroectodermal tumors at the time of diagnosis. Testing for EWSR1(22q12 gene rearrangement using fluorescence in situ hybridization is a useful tool for making the distinction between these 2 similar but distinct entities. We present here the case of a middle-aged male patient with intracranial Ewing’s sarcoma, and discuss diagnostic challenges and potential new treatment approaches for this rare disease.

  19. Alternative method of inservice hydraulic testing of difficult to test pumps

    Stockton, N.B.; Shangari, S.

    1994-01-01

    The pump test codes require that system resistance be varied until the independent variable (either the pump flow rate or differential pressure) equals its reference value. Variance from this fixed reference value is not specifically allowed. However, the design of many systems makes it impractical to set the independent variable to an exact value. Over a limited range of pump operation about the fixed reference value, linear interpolation between two points of pump operation can be used to accurately determine degradation at the reference value without repeating reference test conditions. This paper presents an overview of possible alternatives for hydraulic testing of pumps and a detailed discussion of the linear interpolation method. The approximation error associated with linear interpolation is analyzed. Methods to quantify and minimize approximation error are presented

  20. Intelligent Information System to support decision making.

    Kathrin Rodríguez Llanes

    2010-06-01

    Full Text Available Making decisions is complicated in a generalized way, the materials and humans resources of the entity we belong to depends on it, such as the fulfillment of its goals. But when the situations are complex, making decisions turns into a very difficult work, due to the great amount of aspects to consider when making the right choice. To make this efficiently the administration must to consult an important volume of information, which generally, is scattered and in any different formats. That’s why appears the need of developing software that crowd together all that information and be capable of, by using powerful search engines and process algorithms improve the good decisions making process. Considering previous explanation, a complete freeware developed product is proposed, this constitutes a generic and multi-platform solution, that using artificial intelligence techniques, specifically the cases based reasoning, gives the possibility to leaders of any institution or organism of making the right choice in any situation.With client-server architecture, this system is consumed from web as a service and it can be perfectly integrated with a management system or the geographic information system to facilitate the business process.