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

Energy Technology Data Exchange (ETDEWEB)

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.

Financial Globalisation and Sectoral Reallocation of Capital in South Africa

OpenAIRE

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...

Destruction and reallocation of skills following large company closures

DEFF Research Database (Denmark)

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...

Excel-based scheduling for reallocation of nursing staff.

Science.gov (United States)

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.

Zinc allocation and re-allocation in rice

NARCIS (Netherlands)

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

Optimal production resource reallocation for CO2 emissions reduction in manufacturing sectors

OpenAIRE

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...

Zinc allocation and re-allocation in rice

Science.gov (United States)

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

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

Science.gov (United States)

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...

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

DEFF Research Database (Denmark)

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...

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

Science.gov (United States)

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.

Managing and reallocating inventory across two markets with local information

NARCIS (Netherlands)

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

Reallocating resources to focused factories: a case study in chemotherapy

NARCIS (Netherlands)

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

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

Directory of Open Access Journals (Sweden)

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.

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

Science.gov (United States)

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.

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

Science.gov (United States)

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...

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

OpenAIRE

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...

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

Directory of Open Access Journals (Sweden)

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.

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

NARCIS (Netherlands)

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

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

Directory of Open Access Journals (Sweden)

Angela Hasselgreen

2017-09-01

Full Text Available This article presents a piece of research, conducted in order to validate the claims made in test results, concerning what it means – in terms of reading ability – to be placed at a particular mastery level. It will consider the question of what makes reading tasks difficult, and whether data from the National Tests of English (NTE supports the progression of subskills/reading operations as presented in the mastery level descriptors, which are the basis of test results

Differences in Multitask Resource Reallocation After Change in Task Values

OpenAIRE

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...

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

Science.gov (United States)

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.

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

NARCIS (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

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

NARCIS (Netherlands)

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

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

Science.gov (United States)

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.

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

Science.gov (United States)

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.

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

Science.gov (United States)

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.

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

NARCIS (Netherlands)

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,

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

Directory of Open Access Journals (Sweden)

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.

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

Science.gov (United States)

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.

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

Science.gov (United States)

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

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

OpenAIRE

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...

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

Directory of Open Access Journals (Sweden)

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

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

Science.gov (United States)

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...

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

Science.gov (United States)

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.

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

Science.gov (United States)

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.

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

Science.gov (United States)

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…

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

Science.gov (United States)

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…

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

Energy Technology Data Exchange (ETDEWEB)

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.

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

International Nuclear Information System (INIS)

Badami, Madhav G.

2004-01-01

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

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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...

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

Science.gov (United States)

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.

Difficult management of posterior urethra gunshot wound combined ...

African Journals Online (AJOL)

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

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

Science.gov (United States)

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...

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

Science.gov (United States)

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.

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

Science.gov (United States)

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.

Why Translation Is Difficult

DEFF Research Database (Denmark)

Carl, Michael; Schaeffer, Moritz Jonas

2017-01-01

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

Overcoming difficult conversations in clinical supervision

Directory of Open Access Journals (Sweden)

Williams B

2016-06-01

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

A novel cannulation technique for difficult urethral catheterization

Directory of Open Access Journals (Sweden)

Mehmet Kaynar

2016-03-01

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

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

Directory of Open Access Journals (Sweden)

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.

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

Science.gov (United States)

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.

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

Energy Technology Data Exchange (ETDEWEB)

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)

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

Energy Technology Data Exchange (ETDEWEB)

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)

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

International Nuclear Information System (INIS)

Durante, S; Comoglio, M; Rostagno, M

2011-01-01

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

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

Science.gov (United States)

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.

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

Directory of Open Access Journals (Sweden)

Huang AS

2016-11-01

Full Text Available Andrea S Huang,1 Lindsey Rutland,2 John Hajduk,1 Narasimhan Jagannathan1,2 1Department of Pediatric Anesthesia, Ann and Robert H. Lurie Children’s Hospital of Chicago, 2Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA Abstract: As the field of pediatric ambulatory anesthesia expands, anesthesiologists can anticipate encountering an increasing number of patients with expected and unexpected difficult airways. This unique setting and patient population both present challenges in making a decision whether and how to safely proceed in the case of a child with a difficult airway. A host of patient, provider, procedure, and facility-specific factors should be considered. Providers should understand the differences between the pediatric and adult airway, recognize common features and syndromes associated with difficult airways, and be comfortable with different airway equipment and techniques available in the ambulatory setting. Early anticipation, a comprehensive patient assessment, and a clear decision-making algorithm with multiple airway management plans are all critical in safely and effectively managing these patients. These issues and recommendations will be discussed in this comprehensive narrative review. Keywords: difficult airway, pediatrics, ambulatory surgery, airway devices, children

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

International Nuclear Information System (INIS)

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.

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

Science.gov (United States)

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

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

Science.gov (United States)

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)

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

Science.gov (United States)

Bickel, Janet; Rosenthal, Susan L

2011-10-01

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

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?

Science.gov (United States)

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.

WHAT MAKES CHEMISTRY DIFFICULT?

African Journals Online (AJOL)

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, ...

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

OpenAIRE

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

2015-01-01

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

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

Directory of Open Access Journals (Sweden)

Walid Kerkeni

2015-06-01

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

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

Energy Technology Data Exchange (ETDEWEB)

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.

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

Science.gov (United States)

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

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

Energy Technology Data Exchange (ETDEWEB)

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.

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

Science.gov (United States)

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

Differences in Multitask Resource Reallocation After Change in Task Values.

Science.gov (United States)

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.

Thermosensitivity of growth is determined by chaperone-mediated proteome reallocation

Science.gov (United States)

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

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

Science.gov (United States)

Segall, Avner

2014-01-01

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

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

Science.gov (United States)

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

2016-01-01

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

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

NARCIS (Netherlands)

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

Conflict Management: Difficult Conversations with Difficult People

OpenAIRE

Overton, Amy R.; Lowry, Ann C.

2013-01-01

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

Conflict management: difficult conversations with difficult people.

Science.gov (United States)

Overton, Amy R; Lowry, Ann C

2013-12-01

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

SIMPLE HEURISTIC ALGORITHM FOR DYNAMIC VM REALLOCATION IN IAAS CLOUDS

Directory of Open Access Journals (Sweden)

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.

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

DEFF Research Database (Denmark)

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....

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

Science.gov (United States)

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

Maxillofacial trauma patient: coping with the difficult airway

Directory of Open Access Journals (Sweden)

Barak Michal

2009-05-01

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

Effective communication during difficult conversations.

Science.gov (United States)

Polito, Jacquelyn M

2013-06-01

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

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

Directory of Open Access Journals (Sweden)

Venkateswaran Ramkumar

2016-01-01

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

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

Science.gov (United States)

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

2015-11-01

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

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

Science.gov (United States)

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

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

DEFF Research Database (Denmark)

Witt, Flemming; Nielsen, Jørn Flohr

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

Nuclear energy and public opinion - a difficult relationship

International Nuclear Information System (INIS)

Kaase, M.

1990-01-01

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

Effective Climate Communication with Difficult Audiences

Science.gov (United States)

Denning, S.

2015-12-01

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

Foreign body aspiration masquerading as difficult asthma

Directory of Open Access Journals (Sweden)

Rai S

2007-01-01

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

Clinical review: Management of difficult airways

Science.gov (United States)

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

2006-01-01

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

Clinical review: management of difficult airways.

Science.gov (United States)

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

2006-01-01

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

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

NARCIS (Netherlands)

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

Management of the difficult airway.

Science.gov (United States)

Schwartz, D E; Wiener-Kronish, J P

1991-09-01

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

Psychopathology in difficult asthma

NARCIS (Netherlands)

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

2015-01-01

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

Offices for living in : An instrument for measuring the potential for transforming offices into homes

NARCIS (Netherlands)

Geraedts, Rob P.; van der Voordt, Theo

2003-01-01

A large number of office premises seem difficult to rent out because they no longer meet the demands of the market. A solution must be found for these premises and also for office buildings that have been empty for longer periods. Reallocation or transformation to other functions such as homes can

Validated questionnaires heighten detection of difficult asthma comorbidities.

Science.gov (United States)

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

2017-04-01

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

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

International Nuclear Information System (INIS)

Kitagawa, Takeaki; Maekawa, Katsuhiro; Kubo, Akihiko

1987-01-01

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

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

Science.gov (United States)

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.

Decision making regarding multifetal reduction.

Science.gov (United States)

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.

Crisis management during anaesthesia: difficult intubation.

Science.gov (United States)

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

2005-06-01

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

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

Directory of Open Access Journals (Sweden)

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.

Acceptance issues for large items and difficult waste

International Nuclear Information System (INIS)

Palmer, J.; Lock, Peter

2002-01-01

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

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

Directory of Open Access Journals (Sweden)

Surendra Kumar Sethi

2017-04-01

Full Text Available Plunging ranula is a mucous retention cyst found on the floor of mouth which arises from the submandibular and sublingual salivary glands extending to lateral aspect of neck, which may often cause potential airway obstruction leading to difficulty in airway management. A forty year old female patient was admitted to our hospital with large, painless swelling in the floor of mouth extending to the lateral part of body of mandible and neck. This intraoral swelling distorted the normal airway anatomy thus making airway management difficult as the patient was planned for excision of swelling under general anaesthesia. So we present a case of successful management of a difficult airway by using awake fibre optic intubation in a patient posted for excision of a large plunging ranula under general anaesthesia.

LIHTC Difficult to Develop Areas

Data.gov (United States)

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

Difficult to control atopic dermatitis

NARCIS (Netherlands)

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

2013-01-01

textabstractDifficult to control atopic dermatitis (AD) presents a therapeutic challenge and often requires combinations of topical and systemic treatment. Anti-inflammatory treatment of severe AD most commonly includes topical glucocorticosteroids and topical calcineurin antagonists used for

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

NARCIS (Netherlands)

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

How Difficult It Is to Be God

DEFF Research Database (Denmark)

Wilson, Fiona

2014-01-01

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

What Makes a Beam Shaping Problem Difficult

International Nuclear Information System (INIS)

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

Psychopathology in difficult asthma : Review

NARCIS (Netherlands)

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

2015-01-01

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

Guidelines and algorithms for managing the difficult airway.

Science.gov (United States)

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

2018-01-01

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

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

OpenAIRE

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

2015-01-01

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

How to manage a child with difficult asthma?

Science.gov (United States)

Saglani, Sejal; Fleming, Louise

2016-08-01

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

Making smarter decisions in urban environments

CSIR Research Space (South Africa)

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...

Making effective links to decision-making: Key challenges for health impact assessment

International Nuclear Information System (INIS)

Elliott, Eva; Francis, Sarah

2005-01-01

This paper draws on an exploratory research study to examine the effectiveness of health impact assessments in Wales. Through the review of five case study health impact assessments the research identified a number of benefits of the process in terms of skills and knowledge development amongst participants. The indirect contributions to decision-making were also evident including the way in which health impact assessment provided useful insights into the local community's perspective and raised awareness about the wider determinants of health. The process was also useful in establishing a dialogue between different stakeholders, which indirectly assisted decision-making and implementation. The direct links between health impact assessment and decision-making were more difficult to trace and this paper puts forward a number of suggestions for making those links more transparent. Suggestions include integrating decision-makers and clarifying the intended links to decision-making at the start of the health impact assessment process. Mainstreaming health impact assessment so that it is triggered as a routine part of all decision-making would help ensure it stands the best chance of informing decisions

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)

Energy Technology Data Exchange (ETDEWEB)

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.

Making healthy choices easy choices: the role of empowerment

NARCIS (Netherlands)

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

A technical solution to a difficult problem - An update

International Nuclear Information System (INIS)

Asselstine, J.K.

1985-01-01

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

A technical solution to a difficult problem - An update

Energy Technology Data Exchange (ETDEWEB)

Asselstine, J K

1985-07-01

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

Dealing with difficult pasts

DEFF Research Database (Denmark)

McAtackney, Laura

2013-01-01

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

Advances in Rosetta structure prediction for difficult molecular-replacement problems

International Nuclear Information System (INIS)

DiMaio, Frank

2013-01-01

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

Therapist reactions in self-experienced difficult situations: an exploration

NARCIS (Netherlands)

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

2007-01-01

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

Metrics for Uncertainty in Organizational Decision-Making

National Research Council Canada - National Science Library

Lawless, W. F; Chaudron, Laurent; Abubucker, C. P

2006-01-01

... intractable. To advance the mathematics of social interaction, we propose that only bi-sided or quantum computational agents will be capable of replicating social phenomena such as the dynamics of human agents, including the more difficult problem of organizational decision-making.

Deciding on child maltreatment : A literature review on methods that improve decision-making

NARCIS (Netherlands)

Bartelink, Cora; van Yperen, Tom A.; ten Berge, Ingrid J.

2015-01-01

Assessment and decision-making in child maltreatment cases is difficult. Practitioners face many uncertainties and obstacles during their assessment and decision-making process. Research exhibits shortcomings in this decision-making process. The purpose of this literature review is to identify and

Bottom-up priority setting revised. A second evaluation of an institutional intervention in a Swedish health care organisation.

Science.gov (United States)

Waldau, Susanne

2015-09-01

Transparent priority setting in health care based on specific ethical principles is requested by the Swedish Parliament since 1997. Implementation has been limited. In this case, transparent priority setting was performed for a second time round and engaged an entire health care organisation. Objectives were to refine a bottom-up priority setting process, reach a political decision on service limits to make reallocation towards higher prioritised services possible, and raise systems knowledge. An action research approach was chosen. The national model for priority setting was used with addition of dimensions costs, volumes, gender distribution and feasibility. The intervention included a three step process and specific procedures for each step which were created, revised and evaluated regarding factual and functional aspects. Evaluations methods included analyses of documents, recordings and surveys. Vertical and horizontal priority setting occurred and resources were reallocated. Participants' attitudes remained positive, however less so than in the first priority setting round. Identifying low-priority services was perceived difficult, causing resentment and strategic behaviour. The horizontal stage served to raise quality of the knowledge base, level out differences in ranking of services and raise systems knowledge. Existing health care management systems do not meet institutional requirements for transparent priority setting. Introducing transparent priority setting constitutes a complex institutional reform, which needs to be driven by management/administration. Strong managerial commitment is required. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

eMovie: a storyboard-based tool for making molecular movies.

Science.gov (United States)

Hodis, Eran; Schreiber, Gideon; Rother, Kristian; Sussman, Joel L

2007-05-01

The 3D structures of macromolecules are difficult to grasp and also to communicate. By their nature, movies or animations are particularly useful for highlighting key features by offering a 'guided tour' of structures and conformation changes. However, high-quality movies are rarely seen because they are currently difficult and time consuming to make. By adopting the traditional movie 'storyboard' concept, which gives guidance and direction to filming, eMovie makes the creation of lengthy molecular animations much easier. This tool is a plug-in for the open-source molecular graphics program PyMOL, and enables experts and novices alike to produce informative and high-quality molecular animations.

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

Science.gov (United States)

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

Crisis Management: Psychological and Sociological Factors in Decision Making

Science.gov (United States)

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

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

Science.gov (United States)

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

2018-04-05

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

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

Directory of Open Access Journals (Sweden)

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

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

Science.gov (United States)

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

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

Science.gov (United States)

Hernandez, Luis; Smith, Connie Jo

2009-01-01

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

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

Science.gov (United States)

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

2009-09-01

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

Enhancing Undergraduate Chemistry Learning by Helping Students Make Connections among Multiple Graphical Representations

Science.gov (United States)

Rau, Martina A.

2015-01-01

Multiple representations are ubiquitous in chemistry education. To benefit from multiple representations, students have to make connections between them. However, connection making is a difficult task for students. Prior research shows that supporting connection making enhances students' learning in math and science domains. Most prior research…

Is ALARP applicable to the management of terrorist risks?

International Nuclear Information System (INIS)

Guikema, S.D.; Aven, T.

2010-01-01

In this paper, we discuss the applicability of the as low as reasonable practicable (ALARP) principle to terrorist risk management. ALARP is a commonly used framework for managing risk due to non-intelligent threats, but terrorism introduces difficult issues, both technically and socially. In particular, the probability of a terrorist attack is difficult to define, terrorist threats are adaptive, and some terrorist risk management actions raise issues of loss of civil liberties not raised by risk management measures for other types of risk. We discuss these issues and their implications for risk management. After showing how ALARP is used to manage the risk from other hazards in different economic sectors, we discuss both the benefits and difficulties associated with extending the ALARP framework for terrorist risk analysis. We conclude that the ALARP framework can be modified to make it appropriate for risk management for adaptive risks, provided that care is taken to explicitly consider adaptive reallocation of risk in response to risk management actions, to account for perceived or actual loss of civil liberties resulting from risk management actions, and to consider the difficulties associated with using probability to measure uncertainty in adversary actions.

Unusual tumour ablations: report of difficult and interesting cases

OpenAIRE

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

2017-01-01

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

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.

Science.gov (United States)

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/

Negative feedback enables fast and flexible collective decision-making in ants.

Directory of Open Access Journals (Sweden)

Christoph Grüter

Full Text Available Positive feedback plays a major role in the emergence of many collective animal behaviours. In many ants pheromone trails recruit and direct nestmate foragers to food sources. The strong positive feedback caused by trail pheromones allows fast collective responses but can compromise flexibility. Previous laboratory experiments have shown that when the environment changes, colonies are often unable to reallocate their foragers to a more rewarding food source. Here we show both experimentally, using colonies of Lasius niger, and with an agent-based simulation model, that negative feedback caused by crowding at feeding sites allows ant colonies to maintain foraging flexibility even with strong recruitment to food sources. In a constant environment, negative feedback prevents the frequently found bias towards one feeder (symmetry breaking and leads to equal distribution of foragers. In a changing environment, negative feedback allows a colony to quickly reallocate the majority of its foragers to a superior food patch that becomes available when foraging at an inferior patch is already well underway. The model confirms these experimental findings and shows that the ability of colonies to switch to a superior food source does not require the decay of trail pheromones. Our results help to resolve inconsistencies between collective foraging patterns seen in laboratory studies and observations in the wild, and show that the simultaneous action of negative and positive feedback is important for efficient foraging in mass-recruiting insect colonies.

Difficult diagnoses in the skeletal radiology

International Nuclear Information System (INIS)

Freyschmidt, Juergen

2013-01-01

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

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

Science.gov (United States)

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

2016-01-01

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

Despite Best Intentions: A Critical Analysis of Social Justice Leadership and Decision Making

Science.gov (United States)

DeMatthews, David E.; Mungal, Angus Shiva; Carrola, Paul A.

2015-01-01

The purpose of this article is to explore the relationship between social justice leadership and organizational decision making in order to make recommendations for how principals can make more socially just decisions in difficult school contexts. This article begins with a discussion of social justice leadership, facets and theories associated…

Ethical decision-making near the end of life.

Science.gov (United States)

Finucane, T E; Harper, M

1996-05-01

For ethical decision-making near the end of life, autonomy is the moral North Star. At the same time, for some treatments, the burdens so clearly outweigh benefits that physicians may make a judgment not to offer the treatment. This is often clearer in surgery. A person with colon cancer and metastases may not insist on resection of the metastases. For some reason, some treatments have escaped these logical constraints. Attempted resuscitation of a dying patient is a good example. The circumstances in which a physician may make choices on behalf of a competent, terminally-ill patient without consent, and even without notification, are hotly debated, but data suggest that physicians do so frequently. Patients who lack capacity present even more difficult challenges. Advance directives, when available, can be extremely helpful, but even with them difficult problems can remain. If advance directives have not been established, family and close friends are an obvious source of guidance. Their legal role varies in different jurisdictions; in practice, they are crucial in bedside decision-making. Guardianship and alternatives to it remain a poor last resort. Euthanasia is a very difficult problem. We believe it is semantically misleading to lump under the term "passive euthanasia" those circumstances where potentially life-sustaining treatment is withheld or withdrawn. The tension between patient autonomy and medical common sense remains unresolved within the "futility" controversy. The authors believe it serves no purpose to discuss carefully with dying patients propositions that are nonsense. At the same time, physicians must not confuse decisions about quality of life with judgements about treatment effectiveness. We believe that what many, although not all, dying patients want are physicians with intelligent compassion who can take care of them through the dying process.

Emotional distance to so-called difficult patients

DEFF Research Database (Denmark)

Michaelsen, Jette Joost

2012-01-01

Scand J Caring Sci; 2011 Emotional distance to so-called difficult patients Purpose: To explore nurses' relationships with patients they regard as being difficult. How do nurses feel about such patients and relate to them, and what are the consequences for nurse and patient? Design and methods....... Patients' case records were studied and four meetings with the staff were arranged to discuss the findings. Data collection lasted 18 months in all. Findings: Three strategies were identified: persuasion, avoidance (emotional distance), and compromise. Interestingly, in the relationship with a particular...... patient, the avoidance strategy did not necessarily represent the terminal stage, since a nurse could revert to the compromise strategy. Some of the nurses experienced painful emotions regarding these interactions. Conclusions: The avoidance strategy (emotional distance) resulted in important social...

Alphabet soup: making sense of genetic testing in CMT.

Science.gov (United States)

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.

Sketching is more than making correct drawings

NARCIS (Netherlands)

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

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

Science.gov (United States)

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

2017-12-21

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

Decreasing the cost of ground grid installations under difficult environmental conditions

International Nuclear Information System (INIS)

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

Human Factors Influencing Decision Making

Science.gov (United States)

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

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

Directory of Open Access Journals (Sweden)

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.

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

Science.gov (United States)

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.

Making interactive decision support for patients a reality.

NARCIS (Netherlands)

Evans, R.W.; Elwyn, G.; Edwards, A.

2004-01-01

Interactive decision support applications might help patients to make difficult decisions about their health care. They lie in the context of traditional decision aids, which are known to have effects on a number of patient outcomes, including knowledge and decisional conflict. The problem of

The long shadows of the difficult past?

DEFF Research Database (Denmark)

Wolnik, Kevin; Busse, Britta; Tholen, Jochen

2017-01-01

This paper focuses on the question of how young people today evaluate the Second World War today and how this ‘difficult past’ determines their political attitudes. Furthermore, the channels through which the current young generation in Europe is informed about the events dating back to the first...... half of the twentieth century (e.g. parents and grandparents, schools, the media) are examined. The theoretical basis chosen for addressing these questions is the work of Mannheim (1928) on the formation of successive generations, and the theories of collective memories and identities of Eisenstadt...... and his followers. Our empirical evidence comes from a transnational comparison of young people’s memories of this difficult past in Denmark, Finland and Germany. From a historical perspective a comparison of the three countries is particularly interesting as they played different roles during the Second...

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

Science.gov (United States)

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

2012-08-01

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

Shared Decision Making in women testing for a BRCA 1/2 mutation.

NARCIS (Netherlands)

Roosmalen, M.S van

2005-01-01

Women with a BRCA1/2 mutation have a high genetic risk of developing breast and ovarian cancer. They face the difficult choice between screening and prophylactic surgery for the breasts and ovaries. We have developed a shared decision making program to prepare these women for decision making. The

[Evidence-based Risk and Benefit Communication for Shared Decision Making].

Science.gov (United States)

Nakayama, Takeo

2018-01-01

　Evidence-based medicine (EBM) can be defined as "the integration of the best research evidence with clinical expertise and a patient's unique values and circumstances". However, even with the best research evidence, many uncertainties can make clinical decisions difficult. As the social requirement of respecting patient values and preferences has been increasingly recognized, shared decision making (SDM) and consensus development between patients and clinicians have attracted attention. SDM is a process by which patients and clinicians make decisions and arrive at a consensus through interactive conversations and communications. During the process of SDM, patients and clinicians share information with each other on the goals they hope to achieve and responsibilities in meeting those goals. From the clinician's standpoint, information regarding the benefits and risks of potential treatment options based on current evidence and professional experience is provided to patients. From the patient's standpoint, information on personal values, preferences, and social roles is provided to clinicians. SDM is a sort of "wisdom" in the context of making autonomous decisions in uncertain, difficult situations through interactions and cooperation between patients and clinicians. Joint development of EBM and SDM will help facilitate patient-clinician relationships and improve the quality of healthcare.

Designing Human-Centered Systems for Reflective Decision Making

NARCIS (Netherlands)

Pommeranz, A.

2012-01-01

Taking major life decisions, e.g. what career to follow, is difficult and sometimes emotional. One has to find out what exactly one wants, consider the long-term consequences of the decisions and be empathetic for loved ones affected by the decisions. Decision making also deals with establishing and

Clinical review: Management of difficult airways

OpenAIRE

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

2006-01-01

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

Unanimity rule and organizational decision-making : a simulation model

NARCIS (Netherlands)

Romme, A.G.L.

2004-01-01

Unanimity rule is an important benchmark for evaluating outcomes of decisions in the social sciences. However, organizational researchers tend to ignore unanimous decision making, for example, because unanimity may be difficult to realize in large groups and may suffer from individual participants

From honeybees to Internet servers: biomimicry for distributed management of Internet hosting centers.

Science.gov (United States)

Nakrani, Sunil; Tovey, Craig

2007-12-01

An Internet hosting center hosts services on its server ensemble. The center must allocate servers dynamically amongst services to maximize revenue earned from hosting fees. The finite server ensemble, unpredictable request arrival behavior and server reallocation cost make server allocation optimization difficult. Server allocation closely resembles honeybee forager allocation amongst flower patches to optimize nectar influx. The resemblance inspires a honeybee biomimetic algorithm. This paper describes details of the honeybee self-organizing model in terms of information flow and feedback, analyzes the homology between the two problems and derives the resulting biomimetic algorithm for hosting centers. The algorithm is assessed for effectiveness and adaptiveness by comparative testing against benchmark and conventional algorithms. Computational results indicate that the new algorithm is highly adaptive to widely varying external environments and quite competitive against benchmark assessment algorithms. Other swarm intelligence applications are briefly surveyed, and some general speculations are offered regarding their various degrees of success.

Data for decision making: strategic information tools for hospital management during a pandemic.

Science.gov (United States)

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.

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

Science.gov (United States)

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

2018-04-01

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

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

Science.gov (United States)

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.

Medical Students' Personal Determinants of Overcoming Strategies in Difficult Situations

Directory of Open Access Journals (Sweden)

Veretelnikova Yu.Ya.

2013-03-01

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

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

Science.gov (United States)

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

2017-08-01

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

Preoperative Ultrasonography as a Predictor of Difficult ...

African Journals Online (AJOL)

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

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

Science.gov (United States)

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.

Difficult Tracheal Intubation in Obese Gastric Bypass patients

DEFF Research Database (Denmark)

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

2016-01-01

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

Seeking the best training model for difficult conversations in neonatology.

Science.gov (United States)

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

2016-05-01

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

Difficult intubation: are you prepared for it?

Science.gov (United States)

Balcom, C

1994-01-01

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

Preoperative Prediction of Difficult Laparoscopic Cholecystectomy: A ...

African Journals Online (AJOL)

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

Protection of mineral deposits - a way towards difficult compromises

Science.gov (United States)

Radwanek-Bąk, Barbara; Nieć, Marek

2014-05-01

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

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

Directory of Open Access Journals (Sweden)

Moustafa Abdelaziz Moustafa

2017-04-01

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

Difficult Sudoku Puzzles Created by Replica Exchange Monte Carlo Method

OpenAIRE

Watanabe, Hiroshi

2013-01-01

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

Deciding Who Decides Questions at the Intersection of School Finance Reform Litigation and Standards-Based Accountability Policies

Science.gov (United States)

Superfine, Benjamin Michael

2009-01-01

Courts hearing school finance reform cases have recently begun to consider several issues related to standards-based accountability policies. This convergence of school finance reform litigation and standards-based accountability policies represents a chance for the courts to reallocate decision-making authority for each type of reform across the…

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

Directory of Open Access Journals (Sweden)

K R Brown

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

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

Science.gov (United States)

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.

An Analysis and Allocation System for Library Collections Budgets: The Comprehensive Allocation Process (CAP)

Science.gov (United States)

Lyons, Lucy Eleonore; Blosser, John

2012-01-01

The "Comprehensive Allocation Process" (CAP) is a reproducible decision-making structure for the allocation of new collections funds, for the reallocation of funds within stagnant budgets, and for budget cuts in the face of reduced funding levels. This system was designed to overcome common shortcomings of current methods. Its philosophical…

Dexterous Manipulation: Making Remote Manipulators Easy to Use

International Nuclear Information System (INIS)

HARRIGAN, RAYMOND W.; BENNETT, PHIL C.

2001-01-01

Perhaps the most basic barrier to the widespread deployment of remote manipulators is that they are very difficult to use. Remote manual operations are fatiguing and tedious, while fully autonomous systems are seldom able to function in changing and unstructured environments. An alternative approach to these extremes is to exploit computer control while leaving the operator in the loop to take advantage of the operator's perceptual and decision-making capabilities. This report describes research that is enabling gradual introduction of computer control and decision making into operator-supervised robotic manipulation systems, and its integration on a commercially available, manually controlled mobile manipulator

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

Directory of Open Access Journals (Sweden)

Shih-Yi Lee

2017-09-01

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

Expertise and decision-making in American football

OpenAIRE

Woods, Adam J.; Kranjec, Alexander; Lehet, Matt; Chatterjee, Anjan

2015-01-01

In American football, pass interference calls can be difficult to make, especially when the timing of contact between players is ambiguous. American football history contains many examples of controversial pass interference decisions, often with fans, players, and officials interpreting the same event differently. The current study sought to evaluate the influence of experience with concepts important for officiating decisions in American football on the probability (i.e., response criteria) ...

Realokace portfolia akciového fondu

OpenAIRE

Surka, Ondřej

2014-01-01

Diploma thesis deals with portfolio reallocation of actively managed open-end equity fund. The theoretical part focuses on the issue of portfolio management, active and passive investment management and alternative investment strategies. In the practical analyses risk and return in individual years. Portfolio reallocation is based on this analysis. The designed reallocation is then compared with actual fund performance. The main objective of the thesis is to reallocate portfolio to gain addit...

Irrational time allocation in decision-making.

Science.gov (United States)

Oud, Bastiaan; Krajbich, Ian; Miller, Kevin; Cheong, Jin Hyun; Botvinick, Matthew; Fehr, Ernst

2016-01-13

Time is an extremely valuable resource but little is known about the efficiency of time allocation in decision-making. Empirical evidence suggests that in many ecologically relevant situations, decision difficulty and the relative reward from making a correct choice, compared to an incorrect one, are inversely linked, implying that it is optimal to use relatively less time for difficult choice problems. This applies, in particular, to value-based choices, in which the relative reward from choosing the higher valued item shrinks as the values of the other options get closer to the best option and are thus more difficult to discriminate. Here, we experimentally show that people behave sub-optimally in such contexts. They do not respond to incentives that favour the allocation of time to choice problems in which the relative reward for choosing the best option is high; instead they spend too much time on problems in which the reward difference between the options is low. We demonstrate this by showing that it is possible to improve subjects' time allocation with a simple intervention that cuts them off when their decisions take too long. Thus, we provide a novel form of evidence that organisms systematically spend their valuable time in an inefficient way, and simultaneously offer a potential solution to the problem. © 2016 The Author(s).

Difficult physician-patient relationships.

Science.gov (United States)

Reifsteck, S W

1998-01-01

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

Intelligent Information System to support decision making.

Directory of Open Access Journals (Sweden)

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.

Interesting cases which were difficult to diagnose by CT

International Nuclear Information System (INIS)

Ueki, Koji; Okubo, Koichi; Shinohara, Shinji

1981-01-01

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

Complexity perspectives on clinical decision making in an intensive care unit

NARCIS (Netherlands)

De Bock, Ben A.; Willems, Dick L.; Weinstein, Henry C.

2017-01-01

How to clarify the implications of complexity thinking for decision making in the intensive care unit (ICU)? Retrospective qualitative empirical research. Practitioners in an ICU were interviewed on how their decisions were made regarding a particular patient in a difficult, clinical situation.

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

Science.gov (United States)

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

2017-09-01

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

Difficult to control atopic dermatitis

Science.gov (United States)

2013-01-01

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

Comparison of different tests to determine difficult intubation in pediatric patients

Directory of Open Access Journals (Sweden)

Mehmet Turan Inal

2014-12-01

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

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

African Journals Online (AJOL)

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

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

National Research Council Canada - National Science Library

Reeves, Andrew T

2005-01-01

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

The emergency patient's participation in medical decision-making.

Science.gov (United States)

Wang, Li-Hsiang; Goopy, Suzanne; Lin, Chun-Chih; Barnard, Alan; Han, Chin-Yen; Liu, Hsueh-Erh

2016-09-01

The purpose of this research was to explore the medical decision-making processes of patients in emergency departments. Studies indicate that patients should be given enough time to acquire relevant information and receive adequate support when they need to make medical decisions. It is difficult to satisfy these requirements in emergency situations. Limited research has addressed the topic of decision-making among emergency patients. This qualitative study used a broadly defined grounded theory approach to explore decision-making in an emergency department in Taiwan. Thirty emergency patients were recruited between June and December 2011 for semi-structured interviews that were audio-taped and transcribed verbatim. The study identified three stages in medical decision-making by emergency patients: predecision (interpreting the problem); decision (a balancing act) and postdecision (reclaiming the self). Transference was identified as the core category and pattern of behaviour through which patients resolved their main concerns. This transference around decision-making represents a type of bricolage. The findings fill a gap in knowledge about the decision-making process among emergency patients. The results inform emergency professionals seeking to support patients faced with complex medical decision-making and suggest an emphasis on informed patient decision-making, advocacy, patient-centred care and in-service education of health staff. © 2016 John Wiley & Sons Ltd.

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

Science.gov (United States)

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

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

Science.gov (United States)

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.

Difficult airway management patterns among anesthesiologists practicing in Cairo University Hospitals

Directory of Open Access Journals (Sweden)

Neamat I. Abdel rahman

2016-01-01

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

Pediatric oncologists' attitudes towards involving adolescents in decision-making concerning research participation.

NARCIS (Netherlands)

Vries, M.C. de; Wit, J.M.; Engberts, D.P.; Kaspers, G.J.L.; Leeuwen, E. van

2010-01-01

BACKGROUND: Various regulations and guidelines stipulate the importance of involving adolescents in decision-making concerning research participation. Several studies have shown that in the context of pediatric oncology this involvement is difficult to achieve due to emotional stress, the complexity

Counter traction makes endoscopic submucosal dissection easier.

Science.gov (United States)

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.

Techniques for assisting difficult delivery at caesarean section.

Science.gov (United States)

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

2016-01-31

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

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

Directory of Open Access Journals (Sweden)

Gernot Horstmann

2016-08-01

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

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

Science.gov (United States)

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

2016-01-01

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

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

Directory of Open Access Journals (Sweden)

Sirvinskiene Giedre

2012-04-01

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

Emotion expression, decision-making and well-being.

Science.gov (United States)

Xiao, Erte

2008-01-01

This chapter discusses the role of emotion expression in decision-making. To understand connections between emotion and decision it is helpful first to differentiate between emotion experience and emotion expression. Understanding how emotion expression influences decision-making is important as a practical matter. However, in contrast to emotion experience, economic research has paid little attention to the significance of emotion expression in decision-making. I review recent studies on emotion expression, paying specific attention to possible connections between emotion expression, punishment, fair economic exchange, and well-being. In contrast to emotions, which are typically difficult to control, I suggest that opportunities for emotion expression can feasibly be manipulated through appropriately designed policies. I further suggest that this approach may have the ability to positively affect well-being and economic outcomes. VALUE OF THE CHAPTER: The chapter provides new perspectives on how policy-makers can benefit by understanding the effect of emotion expression in decision-making. The chapter also suggests future research to improve our understanding of emotion expression.

Counter Traction Makes Endoscopic Submucosal Dissection Easier

OpenAIRE

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...

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

Science.gov (United States)

Fiester, Autumn

2012-01-01

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

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

Science.gov (United States)

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…

Difficult factors in Management of Impacted Dental Prosthesis in Esophagus

Directory of Open Access Journals (Sweden)

Efiaty A. Soepardi

2005-03-01

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

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

Science.gov (United States)

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

2010-07-01

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

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

Science.gov (United States)

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

2015-10-01

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

Robust Inventory System Optimization Based on Simulation and Multiple Criteria Decision Making

Directory of Open Access Journals (Sweden)

Ahmad Mortazavi

2014-01-01

Full Text Available Inventory management in retailers is difficult and complex decision making process which is related to the conflict criteria, also existence of cyclic changes and trend in demand is inevitable in many industries. In this paper, simulation modeling is considered as efficient tool for modeling of retailer multiproduct inventory system. For simulation model optimization, a novel multicriteria and robust surrogate model is designed based on multiple attribute decision making (MADM method, design of experiments (DOE, and principal component analysis (PCA. This approach as a main contribution of this paper, provides a framework for robust multiple criteria decision making under uncertainty.

Making It Real: Using a Collaborative Simulation to Teach Crisis Communications

Science.gov (United States)

Olson, K. S.

2012-01-01

Even seasoned public relations (PR) practitioners can find it difficult to handle communications during a crisis situation when the consequences of making poor decisions may seem overwhelming. This article shares results from using a collaborative simulation to teach college students about crisis communications in an advanced-level PR course.…

Difficult airway in a patient with Coffin-Siris syndrome.

Science.gov (United States)

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

2001-02-01

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

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.

Directory of Open Access Journals (Sweden)

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

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

Science.gov (United States)

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

2007-01-01

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

Supporting Informed Decision Making in Prevention of Prostate Cancer

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Constantino MARTINS

2015-05-01

Full Text Available Identifying and making the correct decision on the best health treatment or screening test option can become a difficult task. Therefore is important that the patients get all types of information appropriate to manage their health. Decision aids can be very useful when there is more than one reasonable option about a treatment or uncertain associated with screening tests. The decision aids tools help people to understand their clinical condition, through the description of the different options available. The purpose of this paper is to present the project “Supporting Informed Decision Making In Prevention of Prostate Cancer” (SIDEMP. This project is focused on the creation of a Web-based decision platform specifically directed to screening prostate cancer, that will support the patient in the process of making an informed decision

Percutaneous transhepatic cholelithotripsy for difficult common bile duct stones

DEFF Research Database (Denmark)

Stage, J G; Moesgaard, F; Grønvall, S

1998-01-01

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

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

Energy Technology Data Exchange (ETDEWEB)

VanderSchee, K. [EnergyERA (Canada)

1998-12-31

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

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

International Nuclear Information System (INIS)

VanderSchee, K.

1998-01-01

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

Bioenergy production and sustainable development: science base for policy-making remains limited

DEFF Research Database (Denmark)

Robledo-Abad, Carmenza; Althaus, H.J.; Berndes, G.

2017-01-01

and methodological approaches in studies differ widely and only a small share of the studies sufficiently reports on context and/or baseline conditions, which makes it difficult to get a general understanding of the attribution of impacts. Nevertheless we identified regional patterns of positive or negative impacts...

Medical futility in children's nursing: making end-of-life decisions.

Science.gov (United States)

Brien, Irene O; Duffy, Anita; Shea, Ellen O

Caring for infants at end of life is challenging and distressing for parents and healthcare professionals, especially in relation to making decisions regarding withholding or withdrawal of treatment. The concept of medical futility must be considered under these circumstances. Parents and healthcare professionals should be involved together in making these difficult decisions. However, for some parents, emotions and guilt often are unbearable and, understandably, parents can be reluctant to make a decision. Despite the recognition of parental autonomy, if parents disagree with a decision made by medical staff, the case will be referred to and solved by the courts. The courts' decisions are often based on the best interest of the child. In this article, the authors discuss the concepts of 'parental autonomy' and 'the child's best interests' when determining medical futility for infants or neonates. The role of the nurse when caring for the dying child and their family is multifaceted. While nurses do not have a legitimate role in decision making at the end of life, it is often nurses who, through their advocacy role, inform doctors about parents' wishes and it is often nurses who support parents during this difficult time. Furthermore, nurses caring for dying children should be familiar to the family, experienced in end-of-life care and comfortable talking to parents about death and dying and treatment choices. Children's nurses therefore require advanced communication skills and an essential understanding of the ethical and legal knowledge relating to medical futility in end-of-life children's nursing.

Medical futility in children's nursing: making end-of-life decisions.

LENUS (Irish Health Repository)

Brien, Irene O

2012-02-01

Caring for infants at end of life is challenging and distressing for parents and healthcare professionals, especially in relation to making decisions regarding withholding or withdrawal of treatment. The concept of medical futility must be considered under these circumstances. Parents and healthcare professionals should be involved together in making these difficult decisions. However, for some parents, emotions and guilt often are unbearable and, understandably, parents can be reluctant to make a decision. Despite the recognition of parental autonomy, if parents disagree with a decision made by medical staff, the case will be referred to and solved by the courts. The courts\\' decisions are often based on the best interest of the child. In this article, the authors discuss the concepts of \\'parental autonomy\\' and \\'the child\\'s best interests\\' when determining medical futility for infants or neonates. The role of the nurse when caring for the dying child and their family is multifaceted. While nurses do not have a legitimate role in decision making at the end of life, it is often nurses who, through their advocacy role, inform doctors about parents\\' wishes and it is often nurses who support parents during this difficult time. Furthermore, nurses caring for dying children should be familiar to the family, experienced in end-of-life care and comfortable talking to parents about death and dying and treatment choices. Children\\'s nurses therefore require advanced communication skills and an essential understanding of the ethical and legal knowledge relating to medical futility in end-of-life children\\'s nursing.

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

Energy Technology Data Exchange (ETDEWEB)

Mathews, Fiona

2011-07-01

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

What makes listening difficult? Factors affecting second language listening comprehension

Science.gov (United States)

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

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

Science.gov (United States)

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

2015-01-01

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

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

Science.gov (United States)

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

2015-07-01

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

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

Science.gov (United States)

Ott, T; Truschinski, K; Kriege, M; Naß, M; Herrmann, S; Ott, V; Sellin, S

2018-01-01

Critical incidents in difficult airway management are still a main contributory factor for perioperative morbidity and mortality. Many national associations have developed algorithms for management of these time critical events. For implementation of these algorithms the provision of technical requirements and procedure-related training are essential. Severe airway incidents are rare events and clinical experience of the individual operators is limited; therefore, simulation is an adequate instrument for training and evaluating difficult airway algorithms. The aim of this observational study was to evaluate the application of the institutional difficult airway algorithm among anesthetists. After ethics committee approval, anesthetists were observed while treating a "cannot intubate" (CI) and a "cannot intubate, cannot ventilate" (CICV) situation in the institutional simulation center. As leader of a supportive team the participants had to deal with an unexpected difficult airway after induction of anesthesia in a patient simulator. The following data were recorded: sequence of the applied airway instruments, time to ventilation after establishing a secured airway using any instrument in the CI situation and time to ventilation via cricothyrotomy in the CICV situation. Conformity to the algorithm was defined by the sequence of the applied instruments. Analysis comprised conformity to the algorithm, non-parametric tests for time to ventilation and differences between junior and senior anesthetists. Out of 50 participants 45 were analyzed in the CI situation. In this situation 93% of the participants acted in conformity with the algorithm. In 62% the airway was secured by flexible intubation endoscopy, in 38% with another device. Data from 46 participants were analyzed in the CICV situation. In this situation 91% acted in conformity with the algorithm. The last device used prior to the decision for cricothyrotomy was flexible intubation endoscopy in 39%, a

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

Science.gov (United States)

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.

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

International Nuclear Information System (INIS)

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)

Societal rationality; towards an understanding of decision making processes in society

International Nuclear Information System (INIS)

Wahlstroem, Bjoern

2001-01-01

In a search for new ways to structure decision making on complex and controversial issues it is necessary to build an understanding of why traditional decision making processes break down. One reason is connected to the issues themselves. They represent steps into the unknown and decisions should therefore be made with prudence. A second reason is connected to a track record according to which new technologies are seen as generating more problems than solutions. A third and more fundamental reason is connected to the decision making processes themselves and a need to find better ways to approach difficult questions in the society. One way to approach societal decision making processes is to investigate their hidden rationality in an attempt to understand causes of observed difficulties. The paper is based mainly on observations from the nuclear industry, but it builds also on controversies experienced in attempts to agree on global efforts towards sustainable approaches to development. It builds on an earlier paper, which discussed the basis of rationality both on an individual and a societal level. Research in societal decision making has to rely on a true multi-disciplinary approach. It is nor enough to understand the technical and scientific models by which outcomes are predicted, but it is also necessary to understand how people make sense of their environment and how they co-operate. Rationality is in this connection one of the key concepts, with an understanding that people always are rational in their own frame of action. The challenge in this connection is to understand how this subjective rationality is formed. Societal rationality has to do with the allocation of resources. There are decisions in which several conflicting views have to be considered. Spending time and resources ex ante may support a consensus ex post, but unfortunately there is no panacea for approaching difficult decisions. Decisions with an uncertain future have to be more robust than

Societal rationality; towards an understanding of decision making processes in society

Energy Technology Data Exchange (ETDEWEB)

Wahlstroem, Bjoern [Technical Research Centre of Finland, Espoo (Finland)

2001-07-01

In a search for new ways to structure decision making on complex and controversial issues it is necessary to build an understanding of why traditional decision making processes break down. One reason is connected to the issues themselves. They represent steps into the unknown and decisions should therefore be made with prudence. A second reason is connected to a track record according to which new technologies are seen as generating more problems than solutions. A third and more fundamental reason is connected to the decision making processes themselves and a need to find better ways to approach difficult questions in the society. One way to approach societal decision making processes is to investigate their hidden rationality in an attempt to understand causes of observed difficulties. The paper is based mainly on observations from the nuclear industry, but it builds also on controversies experienced in attempts to agree on global efforts towards sustainable approaches to development. It builds on an earlier paper, which discussed the basis of rationality both on an individual and a societal level. Research in societal decision making has to rely on a true multi-disciplinary approach. It is nor enough to understand the technical and scientific models by which outcomes are predicted, but it is also necessary to understand how people make sense of their environment and how they co-operate. Rationality is in this connection one of the key concepts, with an understanding that people always are rational in their own frame of action. The challenge in this connection is to understand how this subjective rationality is formed. Societal rationality has to do with the allocation of resources. There are decisions in which several conflicting views have to be considered. Spending time and resources ex ante may support a consensus ex post, but unfortunately there is no panacea for approaching difficult decisions. Decisions with an uncertain future have to be more robust than

Fluxo de empregos, fluxo de trabalhadores e fluxo de postos de trabalho no Brasil

Directory of Open Access Journals (Sweden)

Eduardo Pontual Ribeiro

2010-09-01

Full Text Available Job flows, workers flows and employment flows in Brazil. The labor market is in constant flux. When measuring labor market mobility, it is usual to estimate labor market flow statistics, such as worker reallocation and job reallocation. The goal of this paper is to present previously unknown within plant job reallocation statistics for Brazil. The within plant job reallocation is measured as changes in the occupational mix of the plant. The within plant job reallocation allows a decomposition of worker turnover decomposition into matching, technological change and labor demand factors. Using formal labor market data for Brazil, from 1996 to 2001, our results suggest that technological change accounted for a limited share of worker turnover. More than a quarter of worker turnover can be attributed to labor demand shifts and more than 50% of worker turnover is due to matching.

Supported Decision-Making for People with Cognitive Impairments: An Australian Perspective?

Directory of Open Access Journals (Sweden)

Terry Carney

2015-01-01

Full Text Available Honouring the requirement of the Convention on the Rights of Persons with Disabilities to introduce supported decision-making poses many challenges. Not least of those challenges is in writing laws and devising policies which facilitate access to formal and informal supports for large numbers of citizens requiring assistance with day-to-day issues such as dealing with welfare agencies, managing income security payments, or making health care decisions. Old measures such as representative payee schemes or “nominee” arrangements are not compatible with the CRPD. However, as comparatively routine social security or other government services become increasingly complex to navigate, and as self-managed or personalised budgets better recognise self-agency, any “off the shelf” measures become more difficult to craft and difficult to resource. This paper focuses on recent endeavours of the Australian Law Reform Commission and other local and overseas law reform and policy initiatives to tackle challenges posed both for ordinary citizens and those covered by special programs (such as Australia’s National Disability Insurance Scheme and “disability trusts” in Australia and Canada.

Seasonal weather-related decision making for cattle production in the Northern Great Plains

Science.gov (United States)

High inter-annual variability of seasonal weather patterns can greatly affect forage and therefore livestock production in the Northern Great Plains. This variability can make it difficult for ranchers to set yearly stocking rates, particularly in advance of the grazing season. To better understand ...

Clinical decision making of experienced and novice nurses.

Science.gov (United States)

Tabak, N; Bar-Tal, Y; Cohen-Mansfield, J

1996-10-01

Decision making is an important daily nursing activity. Given contradictory past findings concerning the ease of use cognitive schema for reaching decisions among experts and novices, we chose to examine consistency of information as a parameter that may clarify the process of decision making. Ninety-two experienced nurses and 65 nursing students rated their decisional difficulty and levels of certainty in reaching a diagnosis for two scenarios: one including consistent information and one providing information that was partly inconsistent with the given diagnosis. For the consistent information, students showed more difficulty and less certainty in the given diagnosis than the experienced nurses. The inconsistent scenario was perceived as more difficult by nurses in comparison to students. The cognitive processes responsible for these results are discussed.

Chernobyl: Chronicle of difficult weeks [videorecording

Energy Technology Data Exchange (ETDEWEB)

Volodymyr, S

1987-07-01

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

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

Energy Technology Data Exchange (ETDEWEB)

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

1995-05-01

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

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

Directory of Open Access Journals (Sweden)

Tomislav Svoboda

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

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

Science.gov (United States)

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

2018-01-01

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

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

Science.gov (United States)

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.

Perceived effort for motor control and decision-making.

Directory of Open Access Journals (Sweden)

Ignasi Cos

2017-08-01

Full Text Available How effort is internally quantified and how it influences both movement generation and decisions between potential movements are 2 difficult questions to answer. Physical costs are known to influence motor control and decision-making, yet we lack a general, principled characterization of how the perception of effort operates across tasks and conditions. Morel and colleagues introduce an insightful approach to that end, assessing effort indifference points and presenting a quadratic law between perceived effort and force production.

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

NARCIS (Netherlands)

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

2009-01-01

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

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

NARCIS (Netherlands)

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

2009-01-01

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

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

Science.gov (United States)

Colson, D B; Allen, J G; Coyne, L; Dexter, N; Jehl, N; Mayer, C A; Spohn, H

1986-09-01

Countertransference among hospital staff was investigated as part of ongoing research on difficult-to-treat psychiatric hospital patients. Staff's ratings of their emotional reactions to 127 patients on long-term units were analyzed by factor analysis, and the resulting factors were correlated by discipline with patient problem behaviors. Among the conclusions were that different forms of psychopathology elicit characteristic patterns of emotional reaction from staff; that some dimensions of psychopathology, particularly suicidal-depressed behavior and violence-agitation, elicit different emotional reactions among different disciplines, thus laying the groundwork for division among staff; and that the more difficult the process of hospital treatment, the more likely staff will experience a variety of emotions.

Helping Patients to Make Informed Decisions : The PARE Guide to Disseminate EULAR Recommendations Among Patients

NARCIS (Netherlands)

de Wit, M.; Bakker, M.; van Bodegom-Vos, L.; Buch, M.; Caeyers, N.; Carluccio, A.; Geenen, R.; Greiff, R.; Glüsing, B.; Gossec, L.; Kent, A.; Poldema, I.; Vliet Vlieland, T.P.M.; Wiek, D.; Schipper, K.

2015-01-01

BACKGROUND Accurate patient information is necessary to make informed health decisions. However, the traditional, scientific wording of professional recommendations is often difficult to understand for lay people. OBJECTIVES To develop a practical guide for patient organizations and health

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

Directory of Open Access Journals (Sweden)

Theresa Scognamiglio

2015-01-01

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

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

Science.gov (United States)

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

2015-01-01

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

What's 'difficult'? A multi-stage qualitative analysis of secondary care specialists' experiences with medically unexplained symptoms.

Science.gov (United States)

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.

Effect of Integrating Hydrologic Scaling Concepts on Students Learning and Decision Making Experiences

Science.gov (United States)

Najm, Majdi R. Abou; Mohtar, Rabi H.; Cherkauer, Keith A.; French, Brian F.

2010-01-01

Proper understanding of scaling and large-scale hydrologic processes is often not explicitly incorporated in the teaching curriculum. This makes it difficult for students to connect the effect of small scale processes and properties (like soil texture and structure, aggregation, shrinkage, and cracking) on large scale hydrologic responses (like…

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

DEFF Research Database (Denmark)

Lauridsen, Karen M.; Madsen, Henning

intercultural collaboration. The issues that arise seem to be grounded in linguistic, cultural and educational factors. This paper reports on and discusses a study of student responses to intercultural collaboration (in English) in two programmes at Aarhus University, Denmark. One conclusion...... is that the international students are more prepared to work in multicultural teams than their Danish peers. Another one tells us that once students have experience with the diversity of these teams, at least some of them become more open towards working in such teams in the future. It is interesting to discuss......Team Work in International Programs: Why is it so difficult? And what can we do about it? It is common knowledge that students often find it difficult to collaborate on assignments, projects, etc., but we require that they do so for a number of reasons, e.g. to learn how to work in teams or take...

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

Science.gov (United States)

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

2014-01-01

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

Evolving neural networks for strategic decision-making problems.

Science.gov (United States)

Kohl, Nate; Miikkulainen, Risto

2009-04-01

Evolution of neural networks, or neuroevolution, has been a successful approach to many low-level control problems such as pole balancing, vehicle control, and collision warning. However, certain types of problems-such as those involving strategic decision-making-have remained difficult for neuroevolution to solve. This paper evaluates the hypothesis that such problems are difficult because they are fractured: The correct action varies discontinuously as the agent moves from state to state. A method for measuring fracture using the concept of function variation is proposed and, based on this concept, two methods for dealing with fracture are examined: neurons with local receptive fields, and refinement based on a cascaded network architecture. Experiments in several benchmark domains are performed to evaluate how different levels of fracture affect the performance of neuroevolution methods, demonstrating that these two modifications improve performance significantly. These results form a promising starting point for expanding neuroevolution to strategic tasks.

Using the ACT-R architecture to specify 39 quantitative process models of decision making

NARCIS (Netherlands)

Marewski, Julian N.; Mehlhorn, Katja

Hypotheses about decision processes are often formulated qualitatively and remain silent about the interplay of decision, memorial, and other cognitive processes. At the same time, existing decision models are specified at varying levels of detail, making it difficult to compare them. We provide a

Decision making in energy policies with conflicting interests

International Nuclear Information System (INIS)

Renn, O.

1988-01-01

After the accident in Chernobyl policy making and implementation of energy decisions have become more difficult than ever. On the one hand the public reacts with fear and opposition to a possible extention of nuclear power, on the other hand the economic prosperity of a country depends on an inexpensive and non-exhaustive energy source like nuclear energy. The paper describes a concept of energy planning developed by a study group of the Nuclear Research Centre in Julich (FRG). The concept is based on the idea that in a pluralistic society different social groups should participate in the policy formulation process and that the values of the public should be incorporated in the weighting process to make choices between given options. As reference theory the basic framework of decision analysis is used. (orig./DG)

A Large Group Decision Making Approach Based on TOPSIS Framework with Unknown Weights Information

OpenAIRE

Li Yupeng; Lian Xiaozhen; Lu Cheng; Wang Zhaotong

2017-01-01

Large group decision making considering multiple attributes is imperative in many decision areas. The weights of the decision makers (DMs) is difficult to obtain for the large number of DMs. To cope with this issue, an integrated multiple-attributes large group decision making framework is proposed in this article. The fuzziness and hesitation of the linguistic decision variables are described by interval-valued intuitionistic fuzzy sets. The weights of the DMs are optimized by constructing a...

Why reference to the past is difficult for agrammatic speakers

NARCIS (Netherlands)

Bastiaanse, Roelien

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

The Importance Of Integrating Narrative Into Health Care Decision Making.

Science.gov (United States)

Dohan, Daniel; Garrett, Sarah B; Rendle, Katharine A; Halley, Meghan; Abramson, Corey

2016-04-01

When making health care decisions, patients and consumers use data but also gather stories from family and friends. When advising patients, clinicians consult the medical evidence but also use professional judgment. These stories and judgments, as well as other forms of narrative, shape decision making but remain poorly understood. Furthermore, qualitative research methods to examine narrative are rarely included in health science research. We illustrate how narratives shape decision making and explain why it is difficult but necessary to integrate qualitative research on narrative into the health sciences. We draw on social-scientific insights on rigorous qualitative research and our ongoing studies of decision making by patients with cancer, and we describe new tools and approaches that link qualitative research findings with the predominantly quantitative health science scholarship. Finally, we highlight the benefits of more fully integrating qualitative research and narrative analysis into the medical evidence base and into evidence-based medical practice. Project HOPE—The People-to-People Health Foundation, Inc.

A qualitative study of women's decision-making at the end of IVF treatment.

Science.gov (United States)

Peddie, V L; van Teijlingen, E; Bhattacharya, S

2005-07-01

The decision not to pursue further in vitro fertilization (IVF) after one or more unsuccessful attempts is an important and often difficult one for couples. Relatively little is known about the woman's perception of this decision-making process. The aim of this study was to examine patients' perspectives of decision-making, including circumstances influencing it and satisfaction with the decision-making process. Semi-structured interviews were conducted with a purposive sample of 25 women who had decided to end treatment after unsuccessful IVF treatment. Interviews were tape-recorded and transcribed by means of thematic analysis using the open coding technique. Women experienced difficulty in accepting that their infertility would remain unresolved. Many felt that they had started with unrealistic expectations of treatment success and felt vulnerable to the pressures of both the media and society. Although the decision to end treatment was difficult, it offered many women a way out of the emotional distress caused by IVF; however, the process of decision-making created a sense of 'confrontation' for the women in which they had to address issues they had previously avoided. Adoptive parents perceived less societal pressure than those who remained childless. Efforts to improve the psychological preparation of couples who decide to end IVF treatment should be directed towards examination of the existing system of consultation, which has certain limitations in terms of the quality of communication and the provision of post-treatment support. Further efforts to develop strategies, which facilitate the decision-making process, should be considered.

An agent-based simulation combined with group decision-making technique for improving the performance of an emergency department

Directory of Open Access Journals (Sweden)

M. Yousefi

Full Text Available This study presents an agent-based simulation modeling in an emergency department. In a traditional approach, a supervisor (or a manager allocates the resources (receptionist, nurses, doctors, etc. to different sections based on personal experience or by using decision-support tools. In this study, each staff agent took part in the process of allocating resources based on their observation in their respective sections, which gave the system the advantage of utilizing all the available human resources during the workday by being allocated to a different section. In this simulation, unlike previous studies, all staff agents took part in the decision-making process to re-allocate the resources in the emergency department. The simulation modeled the behavior of patients, receptionists, triage nurses, emergency room nurses and doctors. Patients were able to decide whether to stay in the system or leave the department at any stage of treatment. In order to evaluate the performance of this approach, 6 different scenarios were introduced. In each scenario, various key performance indicators were investigated before and after applying the group decision-making. The outputs of each simulation were number of deaths, number of patients who leave the emergency department without being attended, length of stay, waiting time and total number of discharged patients from the emergency department. Applying the self-organizing approach in the simulation showed an average of 12.7 and 14.4% decrease in total waiting time and number of patients who left without being seen, respectively. The results showed an average increase of 11.5% in total number of discharged patients from emergency department.

Value Application in Radiation Protection Decision-Making

International Nuclear Information System (INIS)

Bombaerts, G.; Hardeman, F.; Braeckman, J.

2001-01-01

Full text: The radiation protection (RP) community is looking for a sound philosophical basis to support their actions. The utilitarianism-egalitarianism debate of the nineties is a reference here. These ethical theories are well elaborated in philosophy throughout the past ages, making it very difficult for RP decision-makers to use these systems in all their sensitivities. Furthermore, the debate's polarisation obstructs dealing with the essence: how can concerned people be given their say? A theory of core values gives a firm basis. Cost Benefit Analysis is another common decision-making tool in RP, often reducing values to economic numbers when it is used. A 'collective willingness to pay (CWP) principle' is proposed and it avoids this reduction. The new principle can be brought in accordance with risk perception analysis. The existing cost-effectiveness differences in RP measures will be illustrated and explained. Nevertheless, there are limitations to CWP applications. A third philosophical foundation (post-materialism) is presented to state that decision-making procedures have to balance between top-down functionality and bottom-up participation. To make sure the latter has full play, the RP officers have to put out special receptors to detect the societal important core values. This mechanism is illustrated with a few examples (Doel, Belgium; ...). (author)

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

DEFF Research Database (Denmark)

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

2013-01-01

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

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

Science.gov (United States)

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

2018-05-10

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

Environmental risk evaluation of difficult substances in USES 2.0

NARCIS (Netherlands)

Beelen P van; ECO

1998-01-01

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

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

African Journals Online (AJOL)

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

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

Science.gov (United States)

Heybach Vivirito, Jessica A.

2012-01-01

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

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

Science.gov (United States)

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

2000-01-01

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

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

Science.gov (United States)

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.

Difficult weaning in delayed onset diaphragmatic hernia

Directory of Open Access Journals (Sweden)

Ahmed Syed

2009-01-01

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

Nickel: makes stainless steel strong

Science.gov (United States)

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.

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

Science.gov (United States)

Anbar, Ran D; Sachdeva, Shagun

2011-07-01

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

Impact of Robotic Surgery on Decision Making: Perspectives of Surgical Teams.

Science.gov (United States)

Randell, Rebecca; Alvarado, Natasha; Honey, Stephanie; Greenhalgh, Joanne; Gardner, Peter; Gill, Arron; Jayne, David; Kotze, Alwyn; Pearman, Alan; Dowding, Dawn

2015-01-01

There has been rapid growth in the purchase of surgical robots in both North America and Europe in recent years. Whilst this technology promises many benefits for patients, the introduction of such a complex interactive system into healthcare practice often results in unintended consequences that are difficult to predict. Decision making by surgeons during an operation is affected by variables including tactile perception, visual perception, motor skill, and instrument complexity, all of which are changed by robotic surgery, yet the impact of robotic surgery on decision making has not been previously studied. Drawing on the approach of realist evaluation, we conducted a multi-site interview study across nine hospitals, interviewing 44 operating room personnel with experience of robotic surgery to gather their perspectives on how robotic surgery impacts surgeon decision making. The findings reveal both potential benefits and challenges of robotic surgery for decision making.

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

Science.gov (United States)

Engelhardt, Thomas; Weiss, Markus

2012-06-01

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

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

Science.gov (United States)

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

2017-10-01

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

Optimization of space system development resources

Science.gov (United States)

Kosmann, William J.; Sarkani, Shahram; Mazzuchi, Thomas

2013-06-01

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 cost growths ranging from 23% to 77%. A new study of 26 historical NASA Science instrument set developments using expert judgment to reallocate key development resources has an average cost growth of 73.77%. Twice in history, a barter-based mechanism has been used to reallocate key development resources during instrument development. 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 reallocate 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 reallocation simulation was used to perform 300 instrument development simulations, using barter to reallocate 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 reallocation will result in lower expected cost growth, with respect to the historical expert judgment approach. Barter-based key development resource reallocation should work on spacecraft development as well as it has worked on instrument development. A new study of 28 historical NASA science spacecraft developments has an average cost growth of 46.04%. As barter-based key

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

Science.gov (United States)

Connor, Christopher W; Segal, Scott

2014-02-01

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

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

Energy Technology Data Exchange (ETDEWEB)

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

2012-07-01

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

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

Science.gov (United States)

Wolke, Dieter; St. James-Roberts, Ian

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

Information-Limited Parallel Processing in Difficult Heterogeneous Covert Visual Search

Science.gov (United States)

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

2010-01-01

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

A Realistic Digital Deteriorating Patient to Foster Emergency Decision-Making Skills in Medical Students

DEFF Research Database (Denmark)

Blanchard, Emmanuel G.; Wiseman, Jeffrey; Naismith, Laura

2012-01-01

and effective in improving student decision making, DPA is difficult to carry out since it requires students and medical instructors, all busy people, to be available at the same time and location. The present paper describes the “Digital” Deteriorating Patient Activity (DDPA), an agent-based tutoring system...

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

African Journals Online (AJOL)

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

Clinical decision making: how surgeons do it.

Science.gov (United States)

Crebbin, Wendy; Beasley, Spencer W; Watters, David A K

2013-06-01

Clinical decision making is a core competency of surgical practice. It involves two distinct types of mental process best considered as the ends of a continuum, ranging from intuitive and subconscious to analytical and conscious. In practice, individual decisions are usually reached by a combination of each, according to the complexity of the situation and the experience/expertise of the surgeon. An expert moves effortlessly along this continuum, according to need, able to apply learned rules or algorithms to specific presentations, choosing these as a result of either pattern recognition or analytical thinking. The expert recognizes and responds quickly to any mismatch between what is observed and what was expected, coping with gaps in information and making decisions even where critical data may be uncertain or unknown. Even for experts, the cognitive processes involved are difficult to articulate as they tend to be very complex. However, if surgeons are to assist trainees in developing their decision-making skills, the processes need to be identified and defined, and the competency needs to be measurable. This paper examines the processes of clinical decision making in three contexts: making a decision about how to manage a patient; preparing for an operative procedure; and reviewing progress during an operative procedure. The models represented here are an exploration of the complexity of the processes, designed to assist surgeons understand how expert clinical decision making occurs and to highlight the challenge of teaching these skills to surgical trainees. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.

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

Science.gov (United States)

Jarvie, Scott; Burke, Kevin

2015-01-01

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

Untested assumptions: psychological research and credibility assessment in legal decision-making

Directory of Open Access Journals (Sweden)

Jane Herlihy

2015-05-01

Full Text Available Background: Trauma survivors often have to negotiate legal systems such as refugee status determination or the criminal justice system. Methods & results: We outline and discuss the contribution which research on trauma and related psychological processes can make to two particular areas of law where complex and difficult legal decisions must be made: in claims for refugee and humanitarian protection, and in reporting and prosecuting sexual assault in the criminal justice system. Conclusion: There is a breadth of psychological knowledge that, if correctly applied, would limit the inappropriate reliance on assumptions and myth in legal decision-making in these settings. Specific recommendations are made for further study.

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

Directory of Open Access Journals (Sweden)

Fabíola Maria Sabino Meireles

2013-03-01

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

Embodiment and sense-making in autism

Directory of Open Access Journals (Sweden)

Hanne eDe Jaegher

2013-03-01

Full Text Available Traditional functionalist approaches to autism consider cognition, communication, and perception separately, and can only provide piecemeal accounts of autism. Basing an integrative explanation on a single cause or common factor has proven difficult. Traditional theories are also disembodied and methodologically individualistic. In order to overcome these problems, I propose an enactive account of autism.For the enactive approach to cognition embodiment, interaction, and personal experience are central to understanding mind and subjectivity. Enaction defines cognition as sense-making: the way cognitive agents meaningfully connect with their world, based on their needs and goals as self-organizing, self-maintaining, embodied agents. In the social realm, when we interactively coordinate our embodied sense-making, we participate in each other’s sense-making. Thus, social understanding is defined as participatory sense-making.Applying the concepts of enaction to autism, I propose that1Sensorimotor particularities in autism translate into a different sense-making and vice versa. Autistic behaviors, e.g. restricted interests, will have sensorimotor correlates, as well as specific significance for autistic people in their context. 2Socially, a reduced flexibility in interactional coordination can lead to difficulties in participatory sense-making. At the same time, however, seemingly irrelevant autistic behavior can be quite attuned to the interactive context. I illustrate this complexity in the case of echolalia. An enactive account of autism starts from the embodiment, experience, and social interactions of autistic people. Enaction brings together the cognitive, social, experiential, and affective aspects of autism in a coherent framework based on a complex, non-linear multi-causality. On this foundation, bridges can be built between autistic people and their often non-autistic context, and quality of life prospects can be improved.

Ethical Decision Making: A Teaching and Learning Model for Graduate Students and New Professionals

Science.gov (United States)

McDonald, William M.; Ebelhar, Marcus Walker; Orehovec, Elizabeth R.; Sanderson, Robyn H.

2006-01-01

Student affairs practitioners are inundated with a variety of ethical considerations when making day-to-day decisions regarding the welfare of students and colleagues. There is every reason to believe that confronting ethical issues will be an increasingly difficult issue for student affairs professionals in the future. This article provides a…

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

Energy Technology Data Exchange (ETDEWEB)

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

2017-05-15

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

Determination of difficult to measure actinides in radioactive liquid waste

International Nuclear Information System (INIS)

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

2014-01-01

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

Planning and decision making for aerial robots

CERN Document Server

Bestaoui Sebbane, Yasmina

2014-01-01

This book provides an introduction to the emerging field of planning and decision making for aerial robots. An aerial robot is the ultimate form of Unmanned Aerial Vehicle, an aircraft endowed with built-in intelligence, requiring no direct human control and able to perform a specific task. It must be able to fly within a partially structured environment, to react and adapt to changing environmental conditions and to accommodate for the uncertainty that exists in the physical world. An aerial robot can be termed as a physical agent that exists and flies in the real 3D world, can sense its environment and act on it to achieve specific goals. So throughout this book, an aerial robot will also be termed as an agent.   Fundamental problems in aerial robotics include the tasks of spatial motion, spatial sensing and spatial reasoning. Reasoning in complex environments represents a difficult problem. The issues specific to spatial reasoning are planning and decision making. Planning deals with the trajectory algori...

Issues surrounding end-of-life decision-making

Directory of Open Access Journals (Sweden)

Tejwani V

2013-08-01

Full Text Available Vickram Tejwani,1,* YiFan Wu,1,* Sabrina Serrano,2 Luis Segura,2 Michael Bannon,3 Qi Qian1 1Department of Medicine, Division of Nephrology and Hypertension, 2Mayo Graduate School, 3Department of Trauma, Critical Care, and General Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA *These authors contributed equally to this work Abstract: End-of-life decision-making is a complex process that can be extremely challenging. We describe a 42-year-old woman in an irreversible coma without an advance directive. The case serves to illustrate the complications that can occur in end-of-life decision-making and challenges in resolving difficult futility disputes. We review the role of advance directives in planning end-of-life care, the responsibility and historical performance of patient surrogates, the genesis of futility disputes, and approaches to resolving disputes. Keywords: end-of-life care, advance directive, surrogate, futility dispute, conflict resolution

Usefulness of alternative integrative assessment methodologies in public decision making

Energy Technology Data Exchange (ETDEWEB)

Erickson, L. E.; Litchfield, J. W.; Currie, J. W.; McDonald, C. L.; Adams, R. C.

1978-07-01

Many diverse social, economic, and environmental effects are associated with each of the available energy development alternatives. The assessment of the costs, risks, and benefits of these energy development options is an important function of the U. S. Department of Energy. This task is more difficult when no single alternative is better than the others in all respects. This paper compares benefit-cost and multi-attribute utility analysis as decision aids for these more difficult and more common assessment cases. PNL has developed expertise in making these assessments through its involvement since the Calvert Cliffs decision in both the preparation of Environmental Impact Statements and the development of methods to make these statements more thorough and responsive to the spirit of the National Environmental Protection Act (NEPA). Since 1973 PNL has had continuing efforts to quantify, value, and compare all of the major factors which influence the overall impacts of energy development options. An important part of this work has been the measurement and incorporation of the relative values which community groups place on these conflicting factors. Such difficult assessment problems could be approached in many ways including the use of benefit-cost or multi-attribute utility analysis. This paper addresses the following questions: (1) Should an integrative assessment methodology be used for the overall assessment of these costs, risks, and benefits. (2) If an integrative assessment methodology is to be used, what alternative methods are available and what should be the basis for selecting a method. (3) Is it possible to use one of the available alternatives for one portion of the assessment and another for another portion of the assessment. The answers to these questions presented in this report are applicable to most public decision problems.

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

LENUS (Irish Health Repository)

Walsh, K

2012-02-03

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

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

Science.gov (United States)

DiMaio, Frank

2017-01-01

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

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

Science.gov (United States)

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.

Mathematical sense-making in quantum mechanics: An initial peek

Science.gov (United States)

Dreyfus, Benjamin W.; Elby, Andrew; Gupta, Ayush; Sohr, Erin Ronayne

2017-12-01

Mathematical sense-making—looking for coherence between the structure of the mathematical formalism and causal or functional relations in the world—is a core component of physics expertise. Some physics education research studies have explored what mathematical sense-making looks like at the introductory physics level, while some historians and "science studies" have explored how expert physicists engage in it. What is largely missing, with a few exceptions, is theoretical and empirical work at the intermediate level—upper division physics students—especially when they are learning difficult new mathematical formalism. In this paper, we present analysis of a segment of video-recorded discussion between two students grappling with a quantum mechanics question to illustrate what mathematical sense-making can look like in quantum mechanics. We claim that mathematical sense-making is possible and productive for learning and problem solving in quantum mechanics. Mathematical sense-making in quantum mechanics is continuous in many ways with mathematical sense-making in introductory physics. However, in the context of quantum mechanics, the connections between formalism, intuitive conceptual schema, and the physical world become more compound (nested) and indirect. We illustrate these similarities and differences in part by proposing a new symbolic form, eigenvector eigenvalue, which is composed of multiple primitive symbolic forms.

Neural reactivation links unconscious thought to decision-making performance.

Science.gov (United States)

Creswell, John David; Bursley, James K; Satpute, Ajay B

2013-12-01

Brief periods of unconscious thought (UT) have been shown to improve decision making compared with making an immediate decision (ID). We reveal a neural mechanism for UT in decision making using blood oxygen level-dependent (BOLD) functional magnetic resonance imaging. Participants (N = 33) encoded information on a set of consumer products (e.g. 48 attributes describing four different cars), and we manipulated whether participants (i) consciously thought about this information (conscious thought), (ii) completed a difficult 2-back working memory task (UT) or (iii) made an immediate decision about the consumer products (ID) in a within-subjects blocked design. To differentiate UT neural activity from 2-back working memory neural activity, participants completed an independent 2-back task and this neural activity was subtracted from neural activity occurring during the UT 2-back task. Consistent with a neural reactivation account, we found that the same regions activated during the encoding of complex decision information (right dorsolateral prefrontal cortex and left intermediate visual cortex) continued to be activated during a subsequent 2-min UT period. Moreover, neural reactivation in these regions was predictive of subsequent behavioral decision-making performance after the UT period. These results provide initial evidence for post-encoding unconscious neural reactivation in facilitating decision making.

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

Science.gov (United States)

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.

High Metal Removal Rate Process for Machining Difficult Materials

Energy Technology Data Exchange (ETDEWEB)

Bates, Robert; McConnell, Elizabeth

2016-06-29

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

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

Science.gov (United States)

2015-01-01

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

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

Directory of Open Access Journals (Sweden)

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

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

Science.gov (United States)

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.

Difficultés scolaires et séparation des parents

OpenAIRE

Henri-Panabière, Gaële

2011-01-01

Répartition des collégiens dans les classes de difficultés scolaires selon que les parents vivent ensemble ou non… …dans la population d’ensemble (N=629 sans les non-réponses) …et dans la sous-population des parents diplômé(s) du supérieur (N=251 sans les non-réponses)

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

Science.gov (United States)

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

2010-10-01

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

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

DEFF Research Database (Denmark)

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

2012-01-01

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

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

International Nuclear Information System (INIS)

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

2007-01-01

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

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

International Nuclear Information System (INIS)

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

77 FR 12076 - Final Programmatic Environmental Impact Statement and Integrated Water Resource Management Plan...

Science.gov (United States)

2012-02-28

... water conservation and market reallocation elements. The plan elements include projects and actions... Conservation (agricultural water and municipal/ domestic conservation); and 7. Market-Based Reallocation of Water Resources (institutional improvements to facilitate market-based water transfers). Public...

Goal-Directed Decision Making with Spiking Neurons.

Science.gov (United States)

Friedrich, Johannes; Lengyel, Máté

2016-02-03

Behavioral and neuroscientific data on reward-based decision making point to a fundamental distinction between habitual and goal-directed action selection. The formation of habits, which requires simple updating of cached values, has been studied in great detail, and the reward prediction error theory of dopamine function has enjoyed prominent success in accounting for its neural bases. In contrast, the neural circuit mechanisms of goal-directed decision making, requiring extended iterative computations to estimate values online, are still unknown. Here we present a spiking neural network that provably solves the difficult online value estimation problem underlying goal-directed decision making in a near-optimal way and reproduces behavioral as well as neurophysiological experimental data on tasks ranging from simple binary choice to sequential decision making. Our model uses local plasticity rules to learn the synaptic weights of a simple neural network to achieve optimal performance and solves one-step decision-making tasks, commonly considered in neuroeconomics, as well as more challenging sequential decision-making tasks within 1 s. These decision times, and their parametric dependence on task parameters, as well as the final choice probabilities match behavioral data, whereas the evolution of neural activities in the network closely mimics neural responses recorded in frontal cortices during the execution of such tasks. Our theory provides a principled framework to understand the neural underpinning of goal-directed decision making and makes novel predictions for sequential decision-making tasks with multiple rewards. Goal-directed actions requiring prospective planning pervade decision making, but their circuit-level mechanisms remain elusive. We show how a model circuit of biologically realistic spiking neurons can solve this computationally challenging problem in a novel way. The synaptic weights of our network can be learned using local plasticity rules

Understanding business decision making on the environment

Energy Technology Data Exchange (ETDEWEB)

Gouldson, Andy [Sustainability Research Institute, University of Leeds, West Yorks, Leeds LS2 9JT (United Kingdom)

2008-12-15

This paper considers the influence of a range of factors within and around the firm on business decision making relating to the environment. Within the firm, it emphasises the importance of governance structures, corporate cultures and organisational capacities. Around the firm, it stresses the importance of the incentives, imperatives and informational pressures that emerge from governments, markets and civil society. It is argued that change is most likely where the various external pressures resonate with each other, and where they impact upon firms with receptive corporate cultures and adequate organisational capacities. It is also argued that these preconditions for change are often absent, which makes change more difficult or more expensive. It is further argued that even when these preconditions are in place, they are likely to engender only to incremental change. As prolonged periods of incremental change must eventually encounter diminishing returns, the key challenge for those seeking to promote significant changes in business behaviour is to put in place the full range of conditions needed to allow companies to make them. This can mean focusing not only on the operational but also on the strategic activities of businesses, and not only on individual businesses but also on the broader systems and networks within which they operate. (author)

Understanding business decision making on the environment

International Nuclear Information System (INIS)

Gouldson, Andy

2008-01-01

This paper considers the influence of a range of factors within and around the firm on business decision making relating to the environment. Within the firm, it emphasises the importance of governance structures, corporate cultures and organisational capacities. Around the firm, it stresses the importance of the incentives, imperatives and informational pressures that emerge from governments, markets and civil society. It is argued that change is most likely where the various external pressures resonate with each other, and where they impact upon firms with receptive corporate cultures and adequate organisational capacities. It is also argued that these preconditions for change are often absent, which makes change more difficult or more expensive. It is further argued that even when these preconditions are in place, they are likely to engender only to incremental change. As prolonged periods of incremental change must eventually encounter diminishing returns, the key challenge for those seeking to promote significant changes in business behaviour is to put in place the full range of conditions needed to allow companies to make them. This can mean focusing not only on the operational but also on the strategic activities of businesses, and not only on individual businesses but also on the broader systems and networks within which they operate. (author)

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

Science.gov (United States)

Homa, Donald; Viera, Cynthia

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

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

Science.gov (United States)

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

2011-01-01

Anesthetic technique in parturient with syringomyelia and Arnold–Chiari malformation is variable depending on the teams. Difficult intubation is one of the risks when general anesthesia is opted. Different devices have been used to manage the difficult intubation in pregnant women. We report the use of Airtraq™ laryngoscope after failed standard laryngoscopy in a parturient with syringomyelia and Arnold–Chiari type I malformation. PMID:22144932

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

Directory of Open Access Journals (Sweden)

Bensghir Mustapha

2011-01-01

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

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

Science.gov (United States)

Goldberg, Tsafrir

2017-01-01

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

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

Science.gov (United States)

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.

Decision-making Under Risk in Children, Adolescents, and Adults

Directory of Open Access Journals (Sweden)

David ePaulsen

2011-04-01

Full Text Available Adolescents often make risky and impulsive decisions. Such behavior has led to the common assumption that a dysfunction in risk-related decision-making peaks during this age. Differences in how risk has been defined across studies, however, make it difficult to draw conclusions about developmental changes in risky decision-making. Here, we developed a non-symbolic economic decision-making task that can be used across a wide age span and that uses coefficient of variation (CV in reward as an index of risk. We found that young children showed the strongest preference for risky compared to sure bet options of equal expected value, adolescents were intermediate in their risk preference, and young adults showed the strongest risk aversion. Furthermore, children’s preference for the risky option increased for larger CVs, while adolescents and young adults showed the opposite pattern, favoring the sure bet more often as CV increased. Finally, when faced with two gambles in a risk-return tradeoff, all three age groups exhibited a greater preference for the option with the lower risk and return as the disparity in risk between the two options increased. These findings demonstrate clear age-related differences in economic risk preferences that vary with choice set and risk. Importantly, adolescence appears to represent an intermediate decision-making phenotype along the transition from childhood to adulthood, rather than an age of heightened preference for economic risk.

Decision making regarding prophylactic mastectomy: stability of preferences and the impact of anticipated feelings of regret.

NARCIS (Netherlands)

Dijk, S. van; Roosmalen, M.S van; Otten, W.; Stalmeier, P.F.M.

2008-01-01

PURPOSE: Women who test positive for a BRCA1/2 mutation face difficult choices to manage their breast cancer risk; one of these choices is whether to opt for prophylactic mastectomy. Few data are available about this decision-making process. The current study provides data regarding the stability of

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

Science.gov (United States)

Bautista, Debbie; Mulligan, Joanne

2010-01-01

Young Filipino students are expected to solve mathematical word problems in English, a language that many encounter only in schools. Using individual interviews of 17 Filipino children, we investigated why word problems in English are difficult and the extent to which the language interferes with performance. Results indicate that children could…

Which elderly patients with severe aortic stenosis benefit from surgical treatment? An aid to clinical decision making

NARCIS (Netherlands)

Bouma, Berto J.; van den Brink, Renee B.; Zwinderman, K.; Cheriex, Emile C.; Hamer, Hans H.; Lie, Kong I.; Tijssen, Jan G.

2004-01-01

Background and aim of the study: Clinical decision-making in an individual elderly patient with severe aortic stenosis (AS) is difficult. The prognosis is influenced by increased age and various cardiac morbidity and comorbidity, and the benefit of surgery is uncertain because the prognosis with

A Robust Decision-Making Technique for Water Management under Decadal Scale Climate Variability

Science.gov (United States)

Callihan, L.; Zagona, E. A.; Rajagopalan, B.

2013-12-01

probability distribution of the projected flow ensembles enables the selection of appropriate decision options. This process is repeated for each year of the planning horizon--resulting in system outcomes that can be evaluated on their performance and resiliency. The research utilizes the RiverSMART suite of software modeling and analysis tools developed under the Bureau of Reclamation's WaterSMART initiative and built around the RiverWare modeling environment. A case study is developed for the Gunnison and Upper Colorado River Basins. The ability to mitigate vulnerability using the framework is gauged by system performance indicators that measure the ability of the system to meet various water demands (i.e. agriculture, environmental flows, hydropower etc.). Options and strategies for addressing vulnerabilities include measures such as conservation, reallocation and adjustments to operational policy. In addition to being able to mitigate vulnerabilities, options and strategies are evaluated based on benefits, costs and reliability. Flow ensembles are also simulated to incorporate mean and variance from climate change projections for the planning horizon and the above robust decision-making framework is applied to evaluate its performance under changing climate.

Hemorrhagic herpes encephalitis: A difficult diagnosis in computed tomography

International Nuclear Information System (INIS)

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

1982-01-01

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

How modifiable factors influence parental decision-making about organ donation.

Science.gov (United States)

Luberda, Kamila; Cleaver, Karen

2017-11-07

A global shortage of organs from children and adults available for transplantation is compounded by the failure of next of kin to consent for organs to be donated after death. Non-modifiable and modifiable factors influence decision-making in this area. Modifiable factors are of interest when examining families' decision-making about the donation of organs from their deceased child. A scoping review was undertaken to determine how modifiable factors influence parental decision-making about organ donation. Thematic analysis identified two themes: interactions with healthcare professionals and pre-disposition to organ donation. Satisfaction with experiences of hospital care, the information provided and the way it was communicated, as well as interactions pertaining to emotional support were all found to be modifiable factors that influenced decision making. Likewise, a predisposition to organ donation and knowing the deceased's wishes were associated with the consent decision. Nurses working in critical care environments need to be able to support parents during this difficult time. This article aims to raise awareness of modifiable factors that influence parental decision-making, highlighting their relevance for children's nursing practice. ©2017 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

Decision-making under risk in children, adolescents, and young adults.

Science.gov (United States)

Paulsen, David J; Platt, Michael L; Huettel, Scott A; Brannon, Elizabeth M

2011-01-01

Adolescents often make risky and impulsive decisions. Such behavior has led to the common assumption that a dysfunction in risk-related decision-making peaks during this age. Differences in how risk has been defined across studies, however, make it difficult to draw conclusions about developmental changes in risky decision-making. Here, we developed a non-symbolic economic decision-making task that can be used across a wide age span and that uses coefficient of variation (CV) in reward as an index of risk. We found that young children showed the strongest preference for risky compared to sure bet options of equal expected value, adolescents were intermediate in their risk preference, and young adults showed the strongest risk aversion. Furthermore, children's preference for the risky option increased for larger CVs, while adolescents and young adults showed the opposite pattern, favoring the sure bet more often as CV increased. Finally, when faced with two gambles in a risk-return tradeoff, all three age groups exhibited a greater preference for the option with the lower risk and return as the disparity in risk between the two options increased. These findings demonstrate clear age-related differences in economic risk preferences that vary with choice set and risk. Importantly, adolescence appears to represent an intermediate decision-making phenotype along the transition from childhood to adulthood, rather than an age of heightened preference for economic risk.

Making strategy: learning by doing.

Science.gov (United States)

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.

Non-technical factors impacting on the decision making processes in environmental remediation. Influences on the decision making process such as cost, planned land use and public perception

International Nuclear Information System (INIS)

2002-04-01

The IAEA attaches great importance to the dissemination of information that can assist Member States with the development, implementation, maintenance and continuous improvement of systems, programmes and activities that support the nuclear fuel cycle and nuclear applications, including the legacy of past practices and accidents. In response to this, the IAEA has initiated a comprehensive programme of work covering all aspects of environmental remediation: factors important for formulating a strategy for environmental remediation; site characterisation techniques and strategies; assessment of remediation technologies; assessment of technical options for cleanup of contaminated media; post-restoration compliance monitoring; assessment of the costs of remediation measures; remediation of low-level disperse radioactive contaminations in the environment. While this project mainly focus on technological aspects, non-technical factors will be influencing the decision making process in remediation decisively. Often their influence is only tacitly accepted and not explicitly acknowledged by the responsible decision makers. This makes it difficult to trace the decision making process in the event that it has to be revisited. The present publication attempts to make these factors explicit and to present methods to include them consciously into the decision making process

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

Science.gov (United States)

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

2016-01-01

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

Improving Web Search for Difficult Queries

Science.gov (United States)

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…

Trail Blazing or Jam Session? Towards a New Concept of Clinical Decision-making.

Science.gov (United States)

Risør, Torsten

2017-04-01

Clinical decision-making (CDM) is key in learning to be a doctor as the defining activity in their clinical work. CDM is often portrayed in the literature as similar to 'trail blazing'; the doctor as the core agent, clearing away obstacles on the path towards diagnosis and treatment. However, in a fieldwork of young doctors in Denmark, it was difficult connect their practice to this image. This paper presents the exploration of this discrepancy in the heart of medical practice and how an alternative image emerged; that of a 'jam session'. The exploration is represented as a case-based hypothesis-testing: first, a theoretically and empirically informed hypothesis (H0) of how doctors perform CDM is developed. In H0, CDM is a stepwise process of reasoning about clinical data, often influenced by outside contextual factors. Then, H0 is tested against a case from ethnographic fieldwork with doctors going through internship. Although the case is chosen for characteristics that make it 'most likely' to verify the hypothesis, verification proves difficult. The case challenges preconceptions in CDM literature about chronology, context, objectivity, cognition, agency, and practice. The young doctor is found not to make decisions, but rather to participate in CDM; an activity akin to the dynamics found in a jam session. Their participation circles in and through four concurrent interrelated constructions that suggest a new conceptualization of CDM; a starting point for a deeper understanding of actual practice in a changing clinical environment.

Interaction between plate make and protein in protein crystallisation screening.

Directory of Open Access Journals (Sweden)

Gordon J King

Full Text Available BACKGROUND: Protein crystallisation screening involves the parallel testing of large numbers of candidate conditions with the aim of identifying conditions suitable as a starting point for the production of diffraction quality crystals. Generally, condition screening is performed in 96-well plates. While previous studies have examined the effects of protein construct, protein purity, or crystallisation condition ingredients on protein crystallisation, few have examined the effect of the crystallisation plate. METHODOLOGY/PRINCIPAL FINDINGS: We performed a statistically rigorous examination of protein crystallisation, and evaluated interactions between crystallisation success and plate row/column, different plates of same make, different plate makes and different proteins. From our analysis of protein crystallisation, we found a significant interaction between plate make and the specific protein being crystallised. CONCLUSIONS/SIGNIFICANCE: Protein crystal structure determination is the principal method for determining protein structure but is limited by the need to produce crystals of the protein under study. Many important proteins are difficult to crystallize, so that identification of factors that assist crystallisation could open up the structure determination of these more challenging targets. Our findings suggest that protein crystallisation success may be improved by matching a protein with its optimal plate make.

Institutionalizing telemedicine applications: the challenge of legitimizing decision-making.

Science.gov (United States)

Zanaboni, Paolo; Lettieri, Emanuele

2011-09-28

During the last decades a variety of telemedicine applications have been trialed worldwide. However, telemedicine is still an example of major potential benefits that have not been fully attained. Health care regulators are still debating why institutionalizing telemedicine applications on a large scale has been so difficult and why health care professionals are often averse or indifferent to telemedicine applications, thus preventing them from becoming part of everyday clinical routines. We believe that the lack of consolidated procedures for supporting decision making by health care regulators is a major weakness. We aim to further the current debate on how to legitimize decision making about the institutionalization of telemedicine applications on a large scale. We discuss (1) three main requirements--rationality, fairness, and efficiency--that should underpin decision making so that the relevant stakeholders perceive them as being legitimate, and (2) the domains and criteria for comparing and assessing telemedicine applications--benefits and sustainability. According to these requirements and criteria, we illustrate a possible reference process for legitimate decision making about which telemedicine applications to implement on a large scale. This process adopts the health care regulators' perspective and is made up of 2 subsequent stages, in which a preliminary proposal and then a full proposal are reviewed.

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

DEFF Research Database (Denmark)

Kristensen, M S; Fried, E; Biro, P

2018-01-01

BACKGROUND: Tracheal intubation with a flexible scope is a cornerstone technique in patients with severely difficult airways, but may fail. We report on a technique, Infrared Red Intubation System (IRRIS), that seems to facilitate the identification of the glottis. METHODS: The IRRIS is placed over...... the patient's cricothyroid membrane and emits blinking infrared light through the patient's skin into the subglottic space. When a flexible videoscope (one that does not filter infrared light) is introduced into the airway, it will display this as a blinking white light emerging from the glottis, retrograde...... transillumination, showing the pathway to the trachea. We have introduced this as an adjunct when managing our patients with difficult airways. We describe the technique and retrospectively report on the first ten patients where it was used. RESULTS: All ten patients had significant pathology in the airway...

Expertise and decision-making in American football

Science.gov (United States)

Woods, Adam J.; Kranjec, Alexander; Lehet, Matt; Chatterjee, Anjan

2015-01-01

In American football, pass interference calls can be difficult to make, especially when the timing of contact between players is ambiguous. American football history contains many examples of controversial pass interference decisions, often with fans, players, and officials interpreting the same event differently. The current study sought to evaluate the influence of experience with concepts important for officiating decisions in American football on the probability (i.e., response criteria) of pass interference calls. We further investigated the extent to which such experience modulates perceptual biases that might influence the interpretation of such events. We hypothesized that observers with less experience with the American football concepts important for pass interference would make progressively more pass interference calls than more experienced observers, even when given an explicit description of the necessary criteria for a pass interference call. In a go/no-go experiment using photographs from American football games, three groups of participants with different levels of experience with American football (Football Naïve, Football Player, and Football Official) made pass interference calls for pictures depicting left-moving and right-moving events. More experience was associated with progressively and significantly fewer pass interference calls [F(2,48) = 10.4, p Football Naïve participants making the most pass interference calls, and Football Officials the least. In addition, our data replicated a prior finding of spatial biases for interpreting left-moving images more harshly than identical right-moving images, but only in Football Players. These data suggest that experience with the concepts important for making a decision may influence the rate of decision-making, and may also play a role in susceptibility to spatial biases. PMID:26217294

Expertise and Decision-making in American Football

Directory of Open Access Journals (Sweden)

Adam J Woods

2015-07-01

Full Text Available In American football, pass interference calls can be difficult to make, especially when the timing of contact between players is ambiguous. American football history contains many examples of controversial pass interference decisions, often with fans, players, and officials interpreting the same event differently. The current study sought to evaluate the influence of experience with concepts important for officiating decisions in American football on the probability (i.e., response criteria of pass interference calls. We further investigated the extent to which such experience modulates perceptual biases that might influence the interpretation of such events. We hypothesized that observers with less experience with the American football concepts important for pass interference would make progressively more pass interference calls than more experienced observers, even when given an explicit description of the necessary criteria for a pass interference call. In a go/no-go experiment using photographs from American football games, three groups of participants with different levels of experience with American football (Football Naïve, Football Player, & Football Official made pass interference calls for pictures depicting left-moving and right-moving events. More experience was associated with progressively and significantly fewer pass interference calls (F (2, 48 = 10.4, p < .001, with Football Naïve participants making the most pass interference calls, and Football Officials the least. In addition, our data replicated a prior finding of spatial biases for interpreting left-moving images more harshly than identical right-moving images, but only in Football Players. These data suggest that experience with the concepts important for making a decision may influence the rate of decision-making, and may also play a role in susceptibility to spatial biases.

Expertise and decision-making in American football.

Science.gov (United States)

Woods, Adam J; Kranjec, Alexander; Lehet, Matt; Chatterjee, Anjan

2015-01-01

In American football, pass interference calls can be difficult to make, especially when the timing of contact between players is ambiguous. American football history contains many examples of controversial pass interference decisions, often with fans, players, and officials interpreting the same event differently. The current study sought to evaluate the influence of experience with concepts important for officiating decisions in American football on the probability (i.e., response criteria) of pass interference calls. We further investigated the extent to which such experience modulates perceptual biases that might influence the interpretation of such events. We hypothesized that observers with less experience with the American football concepts important for pass interference would make progressively more pass interference calls than more experienced observers, even when given an explicit description of the necessary criteria for a pass interference call. In a go/no-go experiment using photographs from American football games, three groups of participants with different levels of experience with American football (Football Naïve, Football Player, and Football Official) made pass interference calls for pictures depicting left-moving and right-moving events. More experience was associated with progressively and significantly fewer pass interference calls [F (2,48) = 10.4, p Football Naïve participants making the most pass interference calls, and Football Officials the least. In addition, our data replicated a prior finding of spatial biases for interpreting left-moving images more harshly than identical right-moving images, but only in Football Players. These data suggest that experience with the concepts important for making a decision may influence the rate of decision-making, and may also play a role in susceptibility to spatial biases.

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

Science.gov (United States)

Ozkan, Ahmet Selim; Akbas, Sedat; Yalin, Mehmet Ridvan; Ozdemir, Emine; Koylu, Zeynep

2017-08-01

Management of airway in patients who have Coffin-Siris syndrome (CSS) is often problematic because most of these patients have difficult airway. NTI via C-MAC VL is an useful alternative to direct laryngoscope for orotracheal intubation in airway and anesthetic management in a case of CSS. Alternative airway devices should be readily available.

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

Science.gov (United States)

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...

Immune response to an endotoxin challenge involves multiple immune parameters and is consistent among the annual-cycle stages of a free-living temperate zone bird

NARCIS (Netherlands)

Hegemann, Arne; Matson, Kevin D.; Versteegh, Maaike A.; Villegas, Auxiliadora; Tieleman, B. Irene

Trade-offs between immune function and other physiological and behavioural processes are central in ecoimmunology, but one important problem is how to distinguish a reallocation of resources away from the immune system from a reallocation or redistribution within the immune system. While variation

78 FR 78824 - Gulf of Mexico Fishery Management Council; Public Meeting

Science.gov (United States)

2013-12-27

... DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration RIN 0648-XD051 Gulf of...), National Oceanic and Atmospheric Administration (NOAA), Commerce. ACTION: Notice; public meeting. SUMMARY.... Economic Effects of Reallocation in Amendment 28 3. Social Effects of Reallocation in Amendment 28 4...

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

Science.gov (United States)

Tingley, Suzanne Capek

2012-01-01

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

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

OpenAIRE

Ozkan, Ahmet Selim; Akbas, Sedat; Yalin, Mehmet Ridvan; Ozdemir, Emine; Koylu, Zeynep

2017-01-01

Key Clinical Message Management of airway in patients who have Coffin?Siris syndrome (CSS) is often problematic because most of these patients have difficult airway. NTI via C?MAC VL is an useful alternative to direct laryngoscope for orotracheal intubation in airway and anesthetic management in a case of CSS. Alternative airway devices should be readily available.

Worker Flows and Job Flows in Danish Manufacturing, 1980-91

DEFF Research Database (Denmark)

Albæk, Karsten; Sørensen, Bent

This paper examines turnover of workers and jobs on the panel of all plants in Danish manufacturing for the years 1980-1991. We relate worker turnover to job turnover with a focus on the share of worker reallocation driven by job reallocation, and we consider the behavior of job and worker flows...... over the business cycle, throwing light on some recent theories of the cyclical behavior of the labor market. The amount of job creation and job destruction is similar in Denmark and the U.S., but job reallocation in Denmark is acyclical contrary to American findings. The probability of plant closure...... covaries negatively with the business cycle whereas the amount of plant openings varies positively with the business cycle, in particular for small plants. Worker reallocation is strongly procyclical, due to strong procyclicality of replacement hirings (hiring to an existing job). Our findings...

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

Science.gov (United States)

López Tiro, J Jesús; Contreras, E Angélica Contreras; del Pozo, M Elena Ramírez; Gómez Vera, J; Larenas Linnemann, D

2015-01-01

Even though there are multiple options for the treatment of asthma, there still exists a fair group of patients with difficult-to-control asthma. We describe for the first time the real-world effects of three-year omalizumab treatment on patients with difficult-to-control asthma, seen in a social security hospital in a Latin American country. Difficult-to-control asthmatic patients from the out-patient clinic of a regional hospital were recruited to receive a three-year omalizumab course. Efficacy parameters were asthma control test (ACT) score; FEV1; daily beclomethasone maintenance dose; and unplanned visits for asthma exacerbations (emergency room (ER), hospitalisations, intensive care). 52 patients were recruited, 47 completed the three-year treatment (42 female, 15-67 years, mean age 43.5). Comparing efficacy parameters of the year before omalizumab with the 3rd year of omalizumab: mean ACT improved from 12.4 to 20.5, mean FEV1 from 66.3% (standard deviation (SD) 19.1%) to 88.4% (SD 16.2%) of predicted, while mean beclomethasone dose reduced from 1750 to 766 mcg/day and there was a significant reduction in patients experiencing ER visits (from 95% to 19%, pomalizumab, two because of an adverse event (anaphylaxis, severe headache, both resolved without sequelae). Omalizumab improved most clinical parameters of Mexican patients with difficult-to-control asthma. Especially the rates of ER visits and hospitalisation were significantly reduced, thus reducing costs. Omalizumab was generally well tolerated. Copyright © 2013 SEICAP. Published by Elsevier Espana. All rights reserved.

Consumer decision making in the individual health insurance market.

Science.gov (United States)

Marquis, M Susan; Buntin, Melinda Beeuwkes; Escarce, José J; Kapur, Kanika; Louis, Thomas A; Yegian, Jill M

2006-01-01

This paper summarizes the results from a study of consumer decision making in California's individual health insurance market. We conclude that price subsidies will have only modest effects on participation and that efforts to reduce nonprice barriers might be just as effective. We also find that there is substantial pooling in the individual market and that it increases over time because people who become sick can continue coverage without new underwriting. Finally, we show that people prefer more-generous benefits and that it is difficult to induce people in poor health to enroll in high-deductible health plans.

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

Directory of Open Access Journals (Sweden)

Teena Bansal

2016-04-01

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

Le rôle de l'information en droit des entreprises en difficulté

OpenAIRE

Ould Eba, Moussa

2013-01-01

L’information est un moyen de gestion fiable et une garantie indispensable pour la protection des intérêts des acteurs de l’activité économique. Elle joue un rôle important dans la prévention et le traitement des difficultés des entreprises. En effet, à la lumière des informations comptables, financières et sociales, les dirigeants peuvent prévenir les difficultés et prendre les décisions adaptées à la situation de l’entreprise. Toutefois, en cas de procédures collectives, le besoin de protec...

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

Science.gov (United States)

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.

[Who makes decisions--the dilemma of decision-making within the framework of job-sharing in a hospital].

Science.gov (United States)

Voglmayr, Elisabeth; Widder, Joachim

2006-05-01

By means of a case report on a 44-year-old female patient, we show how, with changing personnel and places of care, decisions as well as the kind of decision-making during illness influence the quality of care. The patient was receiving immunosuppressive therapy after kidney transplantation and then suffered from a carcinomatous ovary. At first she refused postoperative chemotherapy, but then returned with a very advanced state of metastatic growth. The lack of continuity, a missing overall interdisciplinary concept of medical case, as well as the failure to document decision processes and the patient's attitude to life and suffering made it difficult for the caring team to accompany her in the last weeks of life. A possible solution to such a complex problem will be the introduction of ethical case deliberation.

Unicriterion Model: A Qualitative Decision Making Method That Promotes Ethics

Directory of Open Access Journals (Sweden)

Fernando Guilherme Silvano Lobo Pimentel

2011-06-01

Full Text Available Management decision making methods frequently adopt quantitativemodels of several criteria that bypass the question of whysome criteria are considered more important than others, whichmakes more difficult the task of delivering a transparent viewof preference structure priorities that might promote ethics andlearning and serve as a basis for future decisions. To tackle thisparticular shortcoming of usual methods, an alternative qualitativemethodology of aggregating preferences based on the rankingof criteria is proposed. Such an approach delivers a simpleand transparent model for the solution of each preference conflictfaced during the management decision making process. Themethod proceeds by breaking the decision problem into ‘two criteria– two alternatives’ scenarios, and translating the problem ofchoice between alternatives to a problem of choice between criteriawhenever appropriate. The unicriterion model method is illustratedby its application in a car purchase and a house purchasedecision problem.

Multi-criteria decision analysis for use in transport decision making

DEFF Research Database (Denmark)

the recent years that besides the social costs and benefits associated with transport other impacts that are more difficult to monetise should also have influence on the decision making process. This is in many developed countries realised in the transport planning, which takes into account a wide range......, however, commonly agreed that the final decision making concerning transport infrastructure projects in many cases will depend on other aspects besides the monetary ones assessed in a socio-economic analysis. Nevertheless, an assessment framework such as the Danish one (DMT, 2003) does not provide any...... specific guidelines on how to include the strategic impacts; it merely suggests describing the impacts verbally and keeping them in mind during the decision process. A coherent, well-structured, flexible, straight forward evaluation method, taking into account all the requirements of a transport...

Sensitivity analysis of Portfolio Volatility: Importance of Weights, Sectors and the Impact of Trading Strategies

OpenAIRE

E. Borgonovo; PERCOCO M

2007-01-01

This work discusses the Sensitivity Analysis (SA) of portfolio volatility ( σ_{p}) and its role in the interpretation of trading/reallocation strategies. Starting from recent findings in the SA field, we show that results obtained utilizing partial derivatives (PD) or Elasticity (E) cannot be applied to the analysis of the generic trading strategy. We show that such limitations can be overcome by making use of the Differential Importance Measure (D). We also show that, thanks to D additivity ...

A study on the major influencing factors in decision-making in abnormal radiological situations

International Nuclear Information System (INIS)

Kang, B. W.; Kim, S. K.

2001-01-01

This paper describes the task of the technical advisers within the off-site emergency response organization in nuclear accident. They shall be collected and evaluated all influencing factors relevant in decision-making process. The major influencing objective factors are the results of radiological and economic consequence assessments. However, it is associated with uncertainties in predictions dependent of the phase of the accident. Important other factors emerge from subjective arguments between technical advisers in decision-making process. By theirs different opinions, the decision maker who is lack of experience and knowledge has a much more difficult to make and implement the emergency actions. Therefore, the practically considerations in a concrete emergency situation are timely implemented the emergency actions result from already existing plans. The actual process of decision-making consists in identifying in a iterative process implementing individual actions or a set of combined action

Considerations of informed consent and decision-making competence in older adults with cognitive impairment.

Science.gov (United States)

Mayo, Ann M; Wallhagen, Margaret I

2009-04-01

Including older adults with cognitive impairment in research studies is necessary to ensure that interventions designed to improve care are effective for all older adults. However, issues related to capacity to consent raise many difficult questions that nurse researchers must address. Protecting vulnerable participants while simultaneously maintaining autonomy and moving important research forward can be challenging. Assessing the decision-making abilities of understanding, appreciation, reasoning, and expressing a choice is an important aspect of determining decision-making capacity. Yet although this is the prominent rational method for judging decision-making competence, it does not take into consideration the importance of culture, values, and emotions. This article focuses on the assessment of decision-making capacity to consent, recommendations for obtaining informed consent in older adults with cognitive impairment, the use of surrogate decision makers, strategies to maximize research participation, and directions for future research. Copyright 2009, SLACK Incorporated.

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

Science.gov (United States)

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…

Vulnerability as a Key Concept in Museum Pedagogy on Difficult Matters

Science.gov (United States)

Tinning, Katrine

2018-01-01

In recent years there has been an increasing interest in museum studies in exhibitions on what is termed Difficult Matters (Silvén and Björklund 2006)--such as rape and mass murder--and how such exhibitions may evoke ethical change. This raises the question about the conditions on which such exhibitions can lead to an ethical change. By developing…

Cochlear Implant: the complexity involved in the decision making process by the family.

Science.gov (United States)

Vieira, Sheila de Souza; Bevilacqua, Maria Cecília; Ferreira, Noeli Marchioro Liston Andrade; Dupas, Giselle

2014-01-01

to understand the meanings the family attributes to the phases of the decision-making process on a cochlear implant for their child. qualitative research, using Symbolic Interactionism and Grounded Theory as the theoretical and methodological frameworks, respectively. Data collection instrument: semistructured interview. Nine families participated in the study (32 participants). knowledge deficit, difficulties to contextualize benefits and risks and fear are some factors that make this process difficult. Experiences deriving from interactions with health professionals, other cochlear implant users and their relatives strengthen decision making in favor of the implant. deciding on whether or not to have the implant involves a complex process, in which the family needs to weigh gains and losses, experience feelings of accountability and guilt, besides overcoming the risk aversion. Hence, this demands cautious preparation and knowledge from the professionals involved in this intervention.

Ploughs for difficult seams of Bergbau AG Niederrhein

Energy Technology Data Exchange (ETDEWEB)

Klimek, K.-H.

1989-06-29

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

Management of difficult airway in intratracheal tumor surgery

Directory of Open Access Journals (Sweden)

Agarwal Surendra K

2005-06-01

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

Virtual Human Role Players for Studying Social Factors in Organizational Decision Making.

Science.gov (United States)

Khooshabeh, Peter; Lucas, Gale

2018-01-01

The cyber domain of military operations presents many challenges. A unique element is the social dynamic between cyber operators and their leadership because of the novel subject matter expertise involved in conducting technical cyber tasks, so there will be situations where senior leaders might have much less domain knowledge or no experience at all relative to the warfighters who report to them. Nonetheless, it will be important for junior cyber operators to convey convincing information relevant to a mission in order to persuade or influence a leader to make informed decisions. The power dynamic will make it difficult for the junior cyber operator to successfully influence a higher ranking leader. Here we present a perspective with a sketch for research paradigm(s) to study how different factors (normative vs. informational social influence, degree of transparency, and perceived appropriateness of making suggestions) might interact with differential social power dynamics of individuals in cyber decision-making contexts. Finally, we contextualize this theoretical perspective for the research paradigms in viable training technologies.

Virtual Human Role Players for Studying Social Factors in Organizational Decision Making

Directory of Open Access Journals (Sweden)

Peter Khooshabeh

2018-03-01

Full Text Available The cyber domain of military operations presents many challenges. A unique element is the social dynamic between cyber operators and their leadership because of the novel subject matter expertise involved in conducting technical cyber tasks, so there will be situations where senior leaders might have much less domain knowledge or no experience at all relative to the warfighters who report to them. Nonetheless, it will be important for junior cyber operators to convey convincing information relevant to a mission in order to persuade or influence a leader to make informed decisions. The power dynamic will make it difficult for the junior cyber operator to successfully influence a higher ranking leader. Here we present a perspective with a sketch for research paradigm(s to study how different factors (normative vs. informational social influence, degree of transparency, and perceived appropriateness of making suggestions might interact with differential social power dynamics of individuals in cyber decision-making contexts. Finally, we contextualize this theoretical perspective for the research paradigms in viable training technologies.

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

Science.gov (United States)

Simmonds Patience L.; Ingold, Jane L.

2002-01-01

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

Performance specifications: the nearly impossible versus the merely difficult

Science.gov (United States)

Hopper, Darrel G.

2000-08-01

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

Difficult to foresee tomorrow's world

International Nuclear Information System (INIS)

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.)

Advance Directive in End of Life Decision-Making among the Yoruba of South-Western Nigeria.

Science.gov (United States)

Jegede, Ayodele Samuel; Adegoke, Olufunke Olufunsho

2016-11-01

End-of-life decision making is value-laden within the context of culture and bioethics. Also, ethics committee role is difficult to understand on this, thus need for ethnomethodological perspective in an expanding bioethical age. Anthropological approach was utilized to document Yoruba definition and perspective of death, cultural beliefs about end-of-life decision making, factors influencing it and ethics committee role. Interviews were conducted among selected Yoruba resident in Akinyele LGA, Oyo State, Nigeria. Content analytical approach was used for data analysis. Yoruba culture, death is socially constructed having spiritual, physical and social significance. Relationship between the dying and significant others influences decision making. Hierarchy of authority informs implementing traditional advance directive. Socialization, gender, patriarchy, religious belief and tradition are major considerations in end-of-life decision making. Awareness, resource allocation and advocacy are important ethics committees' roles. Further research into cultural diversity of end-of-life decision making will strengthen ethical practice in health care delivery.

Decision Making in Uncertain Rural Scenarios by means of Fuzzy TOPSIS Method

Directory of Open Access Journals (Sweden)

Eva Armero

2011-01-01

Full Text Available A great deal of uncertain information which is difficult to quantify is taken into account by farmers and experts in the enterprise when making decisions. We are interested in the problems of the implementation of a rabbit-breeding farm. One of the first decisions to be taken refers to the design or type of structure for housing the animals, which is determined by the level of environmental control sought to be maintained in its interior. A farmer was consulted, and his answers were incorporated into the analysis, by means of the fuzzy TOPSIS methodology. The main purpose of this paper is to study the problem by means of the fuzzy TOPSIS method as multicriteria decision making, when the information was given in linguistic terms.

A hybrid multiple attribute decision making method for solving problems of industrial environment

Directory of Open Access Journals (Sweden)

Dinesh Singh

2011-01-01

Full Text Available The selection of appropriate alternative in the industrial environment is an important but, at the same time, a complex and difficult problem because of the availability of a wide range of alternatives and similarity among them. Therefore, there is a need for simple, systematic, and logical methods or mathematical tools to guide decision makers in considering a number of selection attributes and their interrelations. In this paper, a hybrid decision making method of graph theory and matrix approach (GTMA and analytical hierarchy process (AHP is proposed. Three examples are presented to illustrate the potential of the proposed GTMA-AHP method and the results are compared with the results obtained using other decision making methods.

Betel quid, chewing habits and difficult intubation: A case report and critical appraisal of evidence for practice.

Science.gov (United States)

Narendra, P L; Hegde, Harihar V; Vijaykumar, T K; Nallamilli, Samson

2015-01-01

Betel quid is used by 10-20% of world of population. Oral submucus fibrosis (OSF) is a chronic premalignant disease common in South Asian countries where betel quid is chewed. It is characterized by juxtaepithelial fibrosis of oral cavity and limited mouth opening, which can cause difficult intubation. A recent study in Taiwan has revealed long-term betel nut chewing is not predictor of difficult intubation. We describe two cases of OSF and critically analyze this study and its implications for clinical practice. OSF is now seen in Saudi Arabia and western countries with use of commercial betel quid substitutes. Although betel quid without tobacco is used in Taiwan, available evidence suggests rapid and early development of OSF where commercial chewing products like Pan Masala are used in India. Effects of betel quid may vary depending on the composition of quid and chewing habits. Studies where personal habits are involved must be analyzed carefully for external validity. Even though, Taiwan study is controlled, its validity outside Taiwan is highly questionable. Since OSF can cause unanticipated difficult intubation, thus during preanesthetic assessment, history of betel quid chewing, more importantly use of commercial chewing products is more likely to give clues to severity of OSF and possible difficult intubation. Further controlled trails in populations where commercial chewing products are used is necessary to detect association of chewing habits and difficult intubation.

Approaches to end-of-life decision-making in the NICU: insights from Dostoevsky's The Grand Inquisitor.

Science.gov (United States)

Paris, J J; Graham, N; Schreiber, M D; Goodwin, M

2006-07-01

For many parents stopping life-sustaining medical treatment on their dying infant is psychologically impossible. Dostoevsky's insights into human behavior, particularly the fact that individuals do not want the anxiety and guilt associated with responsibility for making difficult decisions, might change the way physicians approach parents for permission to withdraw life-prolonging medical interventions on dying infants.

Collaborative Platforms Aid Emergency Decision Making

Science.gov (United States)

2013-01-01

Terra. Aqua. Cloudsat. Landsat. NASA runs and partners in many missions dedicated to monitoring the Earth, and the tools used in these missions continuously return data on everything from shifts in temperature to cloud formation to pollution levels over highways. The data are of great scientific value, but they also provide information that can play a critical role in decision making during times of crisis. Real-time developments in weather, wind, ocean currents, and numerous other conditions can have a significant impact on the way disasters, both natural and human-caused, unfold. "NASA has long recognized the need to make its data from real-time sources compatible and accessible for the purposes of decision making," says Michael Goodman, who was Disasters Program manager at NASA Headquarters from 2009-2012. "There are practical applications of NASA Earth science data, and we d like to accelerate the use of those applications." One of the main obstacles standing in the way of eminently practical data is the fact that the data from different missions are collected, formatted, and stored in different ways. Combining data sets in a way that makes them useful for decision makers has proven to be a difficult task. And while the need for a collaborative platform is widely recognized, very few have successfully made it work. Dave Jones, founder and CEO of StormCenter Communications Inc., which consults with decision makers to prepare for emergencies, says that "when I talk to public authorities, they say, If I had a nickel for every time someone told me they had a common operating platform, I d be rich. But one thing we ve seen over the years is that no one has been able to give end users the ability to ingest NASA data sets and merge them with their own."

Playing a role – but which one ? : how public service motivation and professionalism affect decision-making in dilemma situations

NARCIS (Netherlands)

Schott, Carina

2015-01-01

Individuals who work in the public sector see themselves confronted with conflicting values, contradictory demands, and the need to serve an at times difficult to define ‘public interest’. This book contributes to our understanding of what drives public service professionals’ decision-making in

Cutaneous lasers and skin camouflage make-up: a useful alternative intervention for periorbital hairy congenital melanocytic naevus.

Science.gov (United States)

Townley, William A; Bragg, Thomas W H; Wright, Philip A; Cole, Richard P

2013-12-01

Periorbital congenital melanocytic naevi can be very disfiguring and difficult to treat effectively. Although surgical excision and reconstruction is the most widely accepted treatment strategy, we describe a case in which cutaneous lasers treatment followed by the application of cosmetic skin camouflage make-up provided an alternative solution delivering a good cosmetic improvement.

Dark Matter: The "Gravitational Pull" of Maternalist Discourses on Politicians' Decision Making for Early Childhood Policy in Australia

Science.gov (United States)

Bown, Kathryn; Sumsion, Jennifer; Press, Frances

2011-01-01

The article reports on a study investigating influences on Australian politicians' decision making for early childhood education and care (ECEC) policy. The astronomical concept of dark matter is utilised as a metaphor for considering normalising, and therefore frequently difficult to detect and disrupt, influences implicated in politicians'…

Pediatric Trainees Managing a Difficult Airway: Comparison of Laryngeal Mask Airway, Direct, and Video-Assisted Laryngoscopy

Directory of Open Access Journals (Sweden)

Art Ambrosio MD

2017-05-01

Full Text Available Objective Difficult airway management is a key skill required by all pediatric physicians, yet training on multiple modalities is lacking. The objective of this study was to compare the rate of, and time to, successful advanced infant airway placement with direct laryngoscopy, video-assisted laryngoscopy, and laryngeal mask airway (LMA in a difficult airway simulator. This study is the first to compare the success with 3 methods for difficult airway management among pediatric trainees. Study Design Randomized crossover pilot study. Setting Tertiary academic medical center. Methods Twenty-two pediatric residents, interns, and medical students were tested. Participants were provided 1 training session by faculty using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of a Robin sequence. Success was defined as confirmed endotracheal intubation or correct LMA placement by the testing instructor in ≤120 seconds. Results Direct laryngoscopy demonstrated a significantly higher placement success rate (77.3% than video-assisted laryngoscopy (36.4%, P = .0117 and LMA (31.8%, P = .0039. Video-assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds; 95% CI, 59.4-110.1 versus direct laryngoscopy (44.9 seconds; 95% CI, 33.8-55.9 and LMA placement (36.6 seconds; 95% CI, 24.7-48.4. Conclusions Pediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway simulator model. However, given the potential lifesaving implications of advanced airway adjuncts, including video-assisted laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for trainees.

Making Sense of Gov 2.0 Strategies: “No Citizens, No Party”

Directory of Open Access Journals (Sweden)

Enrico Ferro

2010-04-01

Full Text Available One of the main factors contributing to the limited impact of eParticipation projects is the presence of a high level of social complexity that has been identified by Macintosh as one of the five challenges in the implementation of eParticipation practices. How to make sense of social complexity is still an open issue as well as the way governments can take benefit from the wealth of information that is already available on their constituencies’ collective behaviour. In this paper, we contend that the presence of a considerable variance in terms of political interests, educational level and technological skills makes it very difficult to design workable and effective systems to support participation. A modular strategy is then recommended requiring policy designers to make a step towards citizens rather than expecting the citizenry to move their content production activity onto the “official” spaces created for ad hoc participation.

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

Science.gov (United States)

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

2018-04-01

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

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

NARCIS (Netherlands)

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

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

OpenAIRE

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 ...

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

Science.gov (United States)

Corso, Ruggero M; Cattano, Davide; Buccioli, Matteo; Carretta, Elisa; Maitan, Stefano

2016-01-01

Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

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

Science.gov (United States)

Corso, Ruggero M; Cattano, Davide; Buccioli, Matteo; Carretta, Elisa; Maitan, Stefano

2016-01-01

Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

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

Science.gov (United States)

Mwiria, K

1993-05-01

Kenya, like other Third World countries, has illiteracy rates for women which are twice those of men (in 1978, 35% of males and 70% of females aged 15 and above were illiterate). Since the beginning of the country's literacy campaign in 1979, women have comprised more than 70% of attendees. While this situation remains the case, the overall enrolment figures for the program have shown a gradual decline from 1979 to 1990 due to a lack of emphasis on individual motivation. Women dominate the literacy programs for several reasons: 1) women historically had less access to formal education than men; 2) the changing economy has forced women to assume extra responsibilities outside the home which make the women want to acquire formal skills; 3) women's schedules are often flexible enough to allow them to attend classes; 4) literacy classes provide women with needed socialization opportunities; and 5) in some communities cultural norms prevent men from attending classes with women. Women also have many obstacles which make their desire to become adult learners difficult to sustain. They have responsibilities which range from child-bearing to management of their family farms which leave them little time for study or class attendance. There is also little encouragement offered the women either at home or in their classes. At home they are confronted with a myriad of demands on their time. Their classes take place in conditions which are not very conducive to learning (classrooms designed for children or open air centers). The literacy teachers are, for the most part, unqualified. They must meet only minimal requirements and receive no training. The women also have less opportunities to practice their new skills outside of the classroom. Women have less time then men to read, and they are less fluent then men in English and Kiswahili, the 2 official languages of Kenya. Because Kenyan society is male-dominated, there is little encouragement given to women who attempt to

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

Science.gov (United States)

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.

Intelligent Decision-Making System with Green Pervasive Computing for Renewable Energy Business in Electricity Markets on Smart Grid

Directory of Open Access Journals (Sweden)

Park JongHyuk

2009-01-01

Full Text Available This paper is about the intelligent decision-making system for the smart grid based electricity market which requires distributed decision making on the competitive environments composed of many players and components. It is very important to consider the renewable energy and emission problem which are expected to be monitored by wireless communication networks. It is very difficult to predict renewable energy outputs and emission prices over time horizon, so it could be helpful to catch up those data on real time basis using many different kinds of communication infrastructures. On this backgrounds this paper provides an algorithm to make an optimal decision considering above factors.

Counselling and medical decision-making in the era of personalised medicine a practice-oriented guide

CERN Document Server

Sanchini, Virginia

2016-01-01

This book offers an overview of the main questions arising when biomedical decision-making intersects ethical decision-making. It reports on two ethical decision-making methodologies, one addressing the patients, the other physicians. It shows how patients’ autonomous choices can be empowered by increasing awareness of ethical deliberation, and at the same time it supports healthcare professionals in developing an ethical sensitivity, which they can apply in their daily practice. The book highlights the importance and relevance of practicing bioethics in the age of personalized medicine. It presents concrete cases studies dealing with cancer and genetic diseases, where difficult decisions need to be made by all the parties involved: patients, physicians and families. Decisions concern not only diagnostic procedures and treatments, but also moral values, religious beliefs and ways of seeing life and death, thus adding further layers of complexity to biomedical decision-making. This book, which is strongly ro...

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

OpenAIRE

Stjernstoft, Tero

2004-01-01

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

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

Science.gov (United States)

Immerwahr, John

2009-01-01

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

The Impact of Energy Prices on Employment and Environmental Performance: Evidence from French Manufacturing Establishments

International Nuclear Information System (INIS)

Marin, Giovanni; Vona, Francesco

2017-01-01

This paper evaluates the historical influence of energy prices on a series of measures of environmental and economic performance for a panel of French manufacturing establishments over the period 1997-2010. The focus on energy prices is motivated by the fact that changes in environmental and energy policies have been dominated by substantial reductions in discounts for large consumers, making the evaluation of each policy in isolation exceedingly difficult. To identify price effects, we construct a shift-share instrument that captures only the exogenous variation in establishment-specific energy prices. Our results highlight a trade-off between environmental and economic goals: although a 10 percent increase in energy prices brings about a 6 percent reduction in energy consumption and to a 11 percent reduction in CO_2 emissions, such an increase also has a modestly negative impact on employment (-2.6 percent) and very small impact on wages and productivity. The negative employment effects are mostly concentrated in energy-intensive and trade-exposed sectors. Simulating the effect of a carbon tax, we show that job losses for the most exposed sectors can be quite large. However, these effects are upper bounds and we show that they are significantly mitigated in multi-plant firms by labor reallocation across establishments. (authors)

Extremely secure identification documents

International Nuclear Information System (INIS)

Tolk, K.M.; Bell, M.

1997-09-01

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

Cochlear Implant: the complexity involved in the decision making process by the family

Directory of Open Access Journals (Sweden)

Sheila de Souza Vieira

2014-06-01

Full Text Available OBJECTIVE: to understand the meanings the family attributes to the phases of the decision-making process on a cochlear implant for their child.METHOD: qualitative research, using Symbolic Interactionism and Grounded Theory as the theoretical and methodological frameworks, respectively. Data collection instrument: semistructured interview. Nine families participated in the study (32 participants.RESULTS: knowledge deficit, difficulties to contextualize benefits and risks and fear are some factors that make this process difficult. Experiences deriving from interactions with health professionals, other cochlear implant users and their relatives strengthen decision making in favor of the implant.CONCLUSION: deciding on whether or not to have the implant involves a complex process, in which the family needs to weigh gains and losses, experience feelings of accountability and guilt, besides overcoming the risk aversion. Hence, this demands cautious preparation and knowledge from the professionals involved in this intervention.

Variability in visual working memory ability limits the efficiency of perceptual decision making.

Science.gov (United States)

Ester, Edward F; Ho, Tiffany C; Brown, Scott D; Serences, John T

2014-04-02

The ability to make rapid and accurate decisions based on limited sensory information is a critical component of visual cognition. Available evidence suggests that simple perceptual discriminations are based on the accumulation and integration of sensory evidence over time. However, the memory system(s) mediating this accumulation are unclear. One candidate system is working memory (WM), which enables the temporary maintenance of information in a readily accessible state. Here, we show that individual variability in WM capacity is strongly correlated with the speed of evidence accumulation in speeded two-alternative forced choice tasks. This relationship generalized across different decision-making tasks, and could not be easily explained by variability in general arousal or vigilance. Moreover, we show that performing a difficult discrimination task while maintaining a concurrent memory load has a deleterious effect on the latter, suggesting that WM storage and decision making are directly linked.

76 FR 21418 - Fiscal Year 2011 Allocation of Additional Tariff-Rate Quota Volume for Raw Cane Sugar and...

Science.gov (United States)

2011-04-15

...-Rate Quota Volume for Raw Cane Sugar and Reallocation of Unused Fiscal Year 2011 Tariff-Rate Quota Volume for Raw Cane Sugar AGENCY: Office of the United States Trade Representative. ACTION: Notice...) for imported raw cane sugar and of country-by-country reallocations of the FY 2011 in-quota quantity...

77 FR 25012 - Fiscal Year 2012 Allocation of Additional Tariff-Rate Quota Volume for Raw Cane Sugar and...

Science.gov (United States)

2012-04-26

...-Rate Quota Volume for Raw Cane Sugar and Reallocation of Unused Fiscal Year 2012 Tariff-Rate Quota Volume for Raw Cane Sugar AGENCY: Office of the United States Trade Representative. ACTION: Notice...) for imported raw cane sugar and of country-by-country reallocations of the FY 2012 in-quota quantity...

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

NARCIS (Netherlands)

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

Taking a holistic approach to managing difficult stress fractures.

Science.gov (United States)

Miller, Timothy L; Best, Thomas M

2016-09-09

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

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

Directory of Open Access Journals (Sweden)

Osman Karakus

2015-04-01

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

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

Science.gov (United States)

Karakus, Osman; Kaya, Cengiz; Ustun, Faik Emre; Koksal, Ersin; Ustun, Yasemin Burcu

2015-01-01

Predictive value of preoperative tests in estimating difficult intubation may differ in the laryngeal pathologies. Patients who had undergone direct laryngoscopy (DL) were reviewed, and predictive value of preoperative tests in estimating difficult intubation was investigated. Preoperative, and intraoperative anesthesia record forms, and computerized system of the hospital were screened. A total of 2611 patients were assessed. In 7.4% of the patients, difficult intubations were detected. Difficult intubations were encountered in some of the patients with Mallampati scoring (MS) system Class 4 (50%), Cormack-Lehane classification (CLS) Grade 4 (95.7%), previous knowledge of difficult airway (86.2%), restricted neck movements (cervical ROM) (75.8%), short thyromental distance (TMD) (81.6%), vocal cord mass (49.5%) as indicated in parentheses (p<0.0001). MS had a low sensitivity, while restricted cervical ROM, presence of a vocal cord mass, short thyromental distance, and MS each had a relatively higher positive predictive value. Incidence of difficult intubations increased 6.159 and 1.736-fold with each level of increase in CLS grade and MS class, respectively. When all tests were considered in combination difficult intubation could be classified accurately in 96.3% of the cases. Test results predicting difficult intubations in cases with DL had observedly overlapped with the results provided in the literature for the patient populations in general. Differences in some test results when compared with those of the general population might stem from the concomitant underlying laryngeal pathological conditions in patient populations with difficult intubation. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

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

Directory of Open Access Journals (Sweden)

Yehia Khalil

2012-07-01

Conclusion: All potential causes of ventilator dependency should be identified when a patient is difficult-to-wean. Then, a plan should be developed that uses a multidisciplinary team approach to correct the reversible causes of weaning failure and facilitates weaning thereafter.

Emergency management: Does it have a sufficiently comprehensive understanding of decision-making, process and context?

International Nuclear Information System (INIS)

Niculae, C.; French, S.; Carter, E.

2004-01-01

It is widely recognised in the social and management sciences that the effective support of decision-making requires a multidisciplinary perspective. This trend is also clear in nuclear emergency management (EM). However, communication between disciplines is not easy to maintain in EM contexts when the decision makers (DMs) are likely to be highly stressed. Such circumstances can lead them to revert to the instinctive patterns of perception of their core disciplines, making communication between disciplines difficult and, perhaps, obscuring complex interactions that have not been rehearsed in practice exercises. This paper explores decision making in EM and the nature of the socio-technical issues that will arise, suggesting that despite the lessons of past accidents the research EM community is still not taking a broad enough view of what future incidents may entail. (authors)

Teaching Vacancies and Difficult-to-Staff Teaching Positions in Public Schools. Stats in Brief. NCES 2015-065

Science.gov (United States)

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…

Channels of social influence for decision making in restaurants: A case study

Directory of Open Access Journals (Sweden)

M. Romero-Charneco

2018-05-01

Full Text Available Consumers use the Internet to obtain information on tourism products and services. When evaluating the alternatives, they are faced with a large volume of information that makes their purchasing decision difficult. In this context, the generalized use of mobile instant messaging (MIM has led to the implementation of chatbots in these channels, to help to plan the purchase. This research explores restaurant selection through a WhatsApp mobile instant messaging (MIM chatbot. A study is made of the channels consulted by travellers on Web 2.0 as well as the search models and restaurant selection processes, and a case study is presented. The results allow the diagnosis of the main criteria of user behaviour in this type of conversational interface in the decision-making process related to gastronomic consumption.

An Attempt of Making Program-Generated Animation in a Beginners’ Programming Class

Science.gov (United States)

Matsuyama, Chieko; Nakashima, Toyoshiro; Ishii, Naohiro

In general, mathematical subjects are used for programming education in universities. In this case, many students lose the interest in the programming because the students have the preconception that is difficult to program by using the mathematical expressions. Especially beginners of the programming are a tendency to lose the interest. Therefore it is pointed out to use the subjects which do not need mathematical knowledge as much as possible. In this paper the authors have tried to make animation that are generated by programs instead of the mathematical subjects in a beginners’ programming class using C language used in a wide-ranging field. The authors discuss about improvements of the interest of students for programming by the try that is to make animation by programs in a programming class and refer to its effects.

The impacts of the power plant generation using biomass in the price of energy in Brazil and its incorporation to the mechanism for reallocation of energy; Os impactos da geracao de usinas a biomassa no preco da energia no Brasil e sua incorporacao ao mecanismo de realocacao de energia

Energy Technology Data Exchange (ETDEWEB)

Tardin, Thiago V.; Souza, Luiz Eduardo de; Ribeiro, Paulo [Universidade Federal de Juiz de Fora (UFJF), MG (Brazil)], Emails: thiago@engenho.com, luizeduardo_jf@yahoo.com.br, pfribeiro@ieee.org; Leite, Paula Beatriz Cerqueira [Engenho Pesquisa, Desenvolvimento e Consultoria Ltda, Rio de Janeiro RJ (Brazil)], E-mail: Paula@engenho.com

2009-07-01

The energy reallocation mechanism (ERM) is a compulsory scheme used to reduce the hydrology risk. The aim of this paper is to present a proposed merger of biomass power plants in ERM. This merger will bring great benefits to the power system as a whole in that the generation of biomass is complementary to the system, reducing thus, the hydrological risk and improve safety of supply, but without raising the price of energy, since that the variable cost of production of biomass is very down. Furthermore, biomass has also benefits to be incorporated into the ERM, as it may commercialize energy to a wider range of buyers, not only during the harvest period, but also in the off season, since the ERM 'donate' energy during the period between harvests, reducing the risk of exposure to the spot market.

Why behavior change is difficult to sustain.

Science.gov (United States)

Bouton, Mark E

2014-11-01

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

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

Science.gov (United States)

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…

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

DEFF Research Database (Denmark)

Halttunen, Jorma; Meisner, Søren; Aabakken, Lars

2014-01-01

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

Patient experiences of acute myeloid leukemia: A qualitative study about diagnosis, illness understanding, and treatment decision-making.

Science.gov (United States)

LeBlanc, Thomas W; Fish, Laura J; Bloom, Catherine T; El-Jawahri, Areej; Davis, Debra M; Locke, Susan C; Steinhauser, Karen E; Pollak, Kathryn I

2017-12-01

Patients with acute myeloid leukemia (AML) face a unique, difficult situation characterized by sudden changes in health, complex information, and pressure to make quick treatment decisions amid sizeable tradeoffs. Yet, little is known about patients' experiences with AML. We used qualitative methods to learn about their experiences with diagnosis and treatment decision-making to identify areas for improvement. We recruited hospitalized patients with AML to participate in semi-structured qualitative interviews about their experiences being diagnosed with AML, receiving information, and making a treatment decision. Interviews were conducted during their hospitalization for induction chemotherapy. We analyzed data by using a constant comparison approach. Thirty-two patients completed an interview. Four main themes emerged: (a) shock and suddenness, (b) difficulty processing information, (c) poor communication, and (d) uncertainty. Patients frequently described their diagnosis as shocking. They also felt that the amount of information was too great and too difficult to process, which negatively impacted their understanding. Patients frequently described a lack of emotional support from clinicians and described uncertainty about their prognosis, the number and nature of available treatments, and what to expect from treatment. Acute myeloid leukemia poses a sudden, emotionally challenging, information-laden situation, where little time is available to make important decisions. This results in difficulty processing information and is sometimes complicated by a lack of emotive communication from clinicians. Results indicate a need for targeted interventions to improve AML patients' understanding of illness and treatment options and to address their traumatic experiences around diagnosis. Copyright © 2016 John Wiley & Sons, Ltd.

Lingual traction to facilitate fiber-optic intubation of difficult airways: a single-anesthesiologist randomized trial.

Science.gov (United States)

Ching, Yiu-Hei; Karlnoski, Rachel A; Chen, Henian; Camporesi, Enrico M; Shah, Vimal V; Padhya, Tapan A; Mangar, Devanand

2015-04-01

Flexible fiber-optic bronchoscope-guided orotracheal intubation is a valuable technique with demonstrated benefits in the management of difficult airways. Despite its popularity with anesthesia providers, the technique is not fail-safe and airway-related complications secondary to failed intubation attempts remain an important problem. We sought to determine the effect of incorporating lingual traction on the success rate of fiber-optic bronchoscope-guided intubation in patients with anticipated difficult airways. In this prospective, randomized, cohort study, we enrolled 91 adult patients with anticipated difficult airways scheduled for elective surgery to undergo fiber-optic bronchoscope-guided orotracheal intubation alone or with lingual traction by an individual anesthesiologist after induction of general anesthesia and neuromuscular blockade. A total of 78 patients were randomized: 39 patients to the fiber-optic bronchoscope-guided intubation with lingual traction group and 39 patients to the fiber-optic bronchoscope-guided intubation alone group. The primary endpoint was the rate of successful first attempt intubations. The secondary outcome was sore throat grade on post-operative day 1. Fiber-optic intubation with lingual traction compared to fiber-optic intubation alone resulted in a higher success rate (92.3 vs. 74.4 %, χ (2) = 4.523, p = 0.033) and greater odds for successful first attempt intubation (OR 4.138, 95 % CI 1.041-16.444, p = 0.044). Sore throat severity on post-operative day 1 was not significantly different but trended towards worsening grades with lingual traction. In this study, lingual traction was shown to be a valuable maneuver for facilitating fiber-optic bronchoscope-guided intubation in the management of patients with anticipated difficult airways.

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

Science.gov (United States)

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.

The Difficult Chore of Measuring Coordination by EXAFS

International Nuclear Information System (INIS)

Ravel, B.; Kelly, S. D.

2007-01-01

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

Radon mitigation experience in difficult-to-mitigate schools

International Nuclear Information System (INIS)

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

1990-01-01

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

Cylindrical plunge grinding of difficult to grind materials

International Nuclear Information System (INIS)

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

1983-01-01

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

Deciding on child maltreatment: A literature review on methods that improve decision-making.

Science.gov (United States)

Bartelink, Cora; van Yperen, Tom A; ten Berge, Ingrid J

2015-11-01

Assessment and decision-making in child maltreatment cases is difficult. Practitioners face many uncertainties and obstacles during their assessment and decision-making process. Research exhibits shortcomings in this decision-making process. The purpose of this literature review is to identify and discuss methods to overcome these shortcomings. We conducted a systematic review of the published literature on decision-making using PsychINFO and MEDLINE from 2000 through May 2014. We included reviews and quantitative research studies that investigated methods aimed at improving professional decision-making on child abuse and neglect in child welfare and child protection. Although many researchers have published articles on decision-making including ideas and theories to improve professional decision-making, empirical research on these improvements is scarce. Available studies have shown promising results. Structured decision-making has created a greater child-centred and holistic approach that takes the child's family and environment into account, which has made practitioners work more systematically and improved the analysis of complex situations. However, this approach has not improved inter-rater agreement on decisions made. Shared decision-making may improve the participation of parents and children and the quality of decisions by taking client treatment preferences into account in addition to scientific evidence and clinical experience. A number of interesting developments appear in recent research literature; however, child welfare and child protection must find additional inspiration from other areas, e.g., mental health services, because research on decision-making processes in child welfare and child protection is still rare. Copyright © 2015 Elsevier Ltd. All rights reserved.

Trail Blazing or Jam Session? Towards a new Concept of Clinical Decision-Making

OpenAIRE

Risør, Torsten

2016-01-01

Manuscript. Published version available at http://dx.doi.org/10.1080/13648470.2016.1239695 Clinical decision-making (CDM) is key in learning to be a doctor as the defining activity in their clinical work. CDM is often portrayed in the literature as similar to ‘trail blazing’; the doctor as the core agent, clearing away obstacles on the path towards diagnosis and treatment. However, in a fieldwork of young doctors in Denmark, it was difficult connect their practice to this image....

Cochlear Implant: the complexity involved in the decision making process by the family1

Science.gov (United States)

Vieira, Sheila de Souza; Bevilacqua, Maria Cecília; Ferreira, Noeli Marchioro Liston Andrade; Dupas, Giselle

2014-01-01

Objective to understand the meanings the family attributes to the phases of the decision-making process on a cochlear implant for their child. Method qualitative research, using Symbolic Interactionism and Grounded Theory as the theoretical and methodological frameworks, respectively. Data collection instrument: semistructured interview. Nine families participated in the study (32 participants). Results knowledge deficit, difficulties to contextualize benefits and risks and fear are some factors that make this process difficult. Experiences deriving from interactions with health professionals, other cochlear implant users and their relatives strengthen decision making in favor of the implant. Conclusion deciding on whether or not to have the implant involves a complex process, in which the family needs to weigh gains and losses, experience feelings of accountability and guilt, besides overcoming the risk aversion. Hence, this demands cautious preparation and knowledge from the professionals involved in this intervention. PMID:25029052

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

Directory of Open Access Journals (Sweden)

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.

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

Science.gov (United States)

Shatté, Andrew; Perlman, Adam; Smith, Brad; Lynch, Wendy D

2017-02-01

To examine whether resilience has a protective effect in difficult work environments. A survey of 2063 individuals measured individual resilience, stress, burnout, sleep problems, likelihood of depression, job satisfaction, intent to quit, absences, and productivity. It also measured work characteristics: job demands, job influence, and social support. Multivariate and logistic regression models examined the main effects and interactions of resilience and job characteristics. High strain work environments (high demand, low influence, and low support) have an unfavorable effect on all outcomes. Resilience has a protective effect on all outcomes. For stress, burnout, and sleep, higher resilience has a more protective effect under low-strain conditions. For depression, absence and productivity, resilience has a more protective effect when job strain is high. Workers with high resilience have better outcomes in difficult work environments.

Difficult relationships: critical pedagogies and curriculum

Directory of Open Access Journals (Sweden)

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.

The neural basis of rationalization: cognitive dissonance reduction during decision-making.

Science.gov (United States)

Jarcho, Johanna M; Berkman, Elliot T; Lieberman, Matthew D

2011-09-01

People rationalize the choices they make when confronted with difficult decisions by claiming they never wanted the option they did not choose. Behavioral studies on cognitive dissonance provide evidence for decision-induced attitude change, but these studies cannot fully uncover the mechanisms driving the attitude change because only pre- and post-decision attitudes are measured, rather than the process of change itself. In the first fMRI study to examine the decision phase in a decision-based cognitive dissonance paradigm, we observed that increased activity in right-inferior frontal gyrus, medial fronto-parietal regions and ventral striatum, and decreased activity in anterior insula were associated with subsequent decision-related attitude change. These findings suggest the characteristic rationalization processes that are associated with decision-making may be engaged very quickly at the moment of the decision, without extended deliberation and may involve reappraisal-like emotion regulation processes.

Remodularizing Java Programs for Improved Locality of Feature Implementations in Source Code

DEFF Research Database (Denmark)

Olszak, Andrzej; Jørgensen, Bo Nørregaard

2011-01-01

Explicit traceability between features and source code is known to help programmers to understand and modify programs during maintenance tasks. However, the complex relations between features and their implementations are not evident from the source code of object-oriented Java programs....... Consequently, the implementations of individual features are difficult to locate, comprehend, and modify in isolation. In this paper, we present a novel remodularization approach that improves the representation of features in the source code of Java programs. Both forward- and reverse restructurings...... are supported through on-demand bidirectional restructuring between feature-oriented and object-oriented decompositions. The approach includes a feature location phase based of tracing program execution, a feature representation phase that reallocates classes into a new package structure based on single...

Love as a regulative ideal in surrogate decision making.

Science.gov (United States)

Stonestreet, Erica Lucast

2014-10-01

This discussion aims to give a normative theoretical basis for a "best judgment" model of surrogate decision making rooted in a regulative ideal of love. Currently, there are two basic models of surrogate decision making for incompetent patients: the "substituted judgment" model and the "best interests" model. The former draws on the value of autonomy and responds with respect; the latter draws on the value of welfare and responds with beneficence. It can be difficult to determine which of these two models is more appropriate for a given patient, and both approaches may seem inadequate for a surrogate who loves the patient. The proposed "best judgment" model effectively draws on the values incorporated in each of the traditional standards, but does so because these values are important to someone who loves a patient, since love responds to the patient as the specific person she is. © The Author 2014. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Re-allocating Public Space

DEFF Research Database (Denmark)

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...

Combined precut in difficult biliary cannulation

Directory of Open Access Journals (Sweden)

Jesús Espinel-Díez

2013-06-01

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

Food choice decision-making by women with gestational diabetes.

Science.gov (United States)

Hui, Amy Leung; Sevenhuysen, Gustaaf; Harvey, Dexter; Salamon, Elizabeth

2014-02-01

To enhance the dietary education presented to women with gestational diabetes (GDM) by exploring the reasons and experiences that women with GDM reported in making their food-choice decisions after receipt of dietary education from a healthcare professional. Food Choice Map (FCM) semi-structured in-depth interviews were conducted with 30 women with GDM living in the Winnipeg area during their pregnancies. Verbatim transcripts were generated from the interviews. A constant comparative method was used to generate common themes to answer research inquiries. Personal food preferences, hunger and cravings were the main factors affecting food choice decision-making in women with GDM. Although the information from healthcare professionals was 1 factor that affected food choice decision-making for most of the participants, more than half of the women, including all the women who were on insulin, reported difficulties in quick adaptation to dietary management in a limited time period. Information from other sources such as family members, friends, and internet were used to cope with the adaptation. These difficulties led to a sense of decreased control of GDM and were accompanied by frustration, especially for women taking insulin. Food choice decision-making varied for this group of women with GDM. Knowledge and information aided in making healthy food choices and in portion control. However, balancing individual needs and blood glucose control in a short time period was felt to be difficult and created frustration. The findings suggested that dietary consultation needs to be personalized and to be time sensitive to promote confidence in self-control. Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

The stories they tell: How third year medical students portray patients, family members, physicians, and themselves in difficult encounters.

Science.gov (United States)

Shapiro, Johanna; Rakhra, Pavandeep; Wong, Adrianne

2016-10-01

Physicians have long had patients whom they have labeled "difficult", but little is known about how medical students perceive difficult encounters with patients. In this study, we analyzed 134 third year medical students' reflective essays written over an 18-month period about difficult student-patient encounters. We used a qualitative computerized software program, Atlas.ti to analyze students' observations and reflections. Main findings include that students described patients who were angry and upset; noncompliant with treatment plans; discussed "nonmedical" problems; fearful, worried, withdrawn, or "disinterested" in their health. Students often described themselves as anxious, uncertain, confused, and frustrated. Nevertheless, they saw themselves behaving in empathic and patient-centered ways while also taking refuge in "standard" behaviors not necessarily appropriate to the circumstances. Students rarely mentioned receiving guidance from attendings regarding how to manage these challenging interactions. These third-year medical students recognized the importance of behaving empathically in difficult situations and often did so. However, they often felt overwhelmed and frustrated, resorting to more reductive behaviors that did not match the needs of the patient. Students need more guidance from attending physicians in order to approach difficult interactions with specific problem-solving skills while maintaining an empathic, patient-centered context.

APPLICABILITY OF ACTIVITY BASED COSTING IN NEW PRODUCT DEVELOPMENT PROCESSES

Directory of Open Access Journals (Sweden)

Ewa Wanda MARUSZEWSKA

2015-01-01

Full Text Available The purpose of the article is to emphasis that activity based costing is a proper tool for engineers to enhance their deci-sion-making process while developing new product. The theoretical analysis shows that variety of factors shall be en-compassed into new product decision-making process and therefore engineers and management should pay great attention to proper cost allocation. The paper suggests the usage of Activity Based Costing methodology for new product development decision-making process. Author states that application ABC in the process of rational decision-making referring to new product development enables managers and engineers to prioritize possible solutions, and reallocate resources used in production process in order to meet wider organizational goals. It would also contribute in coopera-tion of managers and engineers for the sake of organizational goal.

Making quality improvement programs more effective.

Science.gov (United States)

Shaw-Taylor, Yoku

2014-01-01

In the past 25 years, and as recent as 2011, all external evaluations of the Quality Improvement Organization (QIO) Program have found its impact to be small or difficult to discern. The QIO program costs about $200 million on average to administer each year to improve quality of healthcare for people of 65 years or older. The program was created to address questionable quality of care. QIOs review how care is provided based on performance measures. The paper aims to discuss these issues. In 2012, the author supported the production of quarterly reports and reviewed internal monitoring and evaluation protocols of the program. The task also required reviewing all previous program evaluations. The task involved many conversations about the complexities of the program, why impact is difficult to discern and possible ways for eventual improvement. Process flow charts were created to simulate the data life cycle and discrete event models were created based on the sequence of data collection and reporting to identify gaps in data flow. The internal evaluation uncovered data gaps within the program. The need for a system of specification rules for data conceptualization, collection, distribution, discovery, analysis and repurposing is clear. There were data inconsistencies and difficulty of integrating data from one instance of measurement to the next. The lack of good and reliable data makes it difficult to discern true impact. The prescription is for a formal data policy or data governance structure to integrate and document all aspects of the data life cycle. The specification rules for governance are exemplified by the Data Documentation Initiative and the requirements published by the Data Governance Institute. The elements are all in place for a solid foundation of the data governance structure. These recommendations will increase the value of program data. The model specifies which agency units must be included in the governance authority and the data team. The

What is known about parents' treatment decisions? A narrative review of pediatric decision making.

Science.gov (United States)

Lipstein, Ellen A; Brinkman, William B; Britto, Maria T

2012-01-01

With the increasing complexity of decisions in pediatric medicine, there is a growing need to understand the pediatric decision-making process. To conduct a narrative review of the current research on parent decision making about pediatric treatments and identify areas in need of further investigation. Articles presenting original research on parent decision making were identified from MEDLINE (1966-6/2011), using the terms "decision making," "parent," and "child." We included papers focused on treatment decisions but excluded those focused on information disclosure to children, vaccination, and research participation decisions. We found 55 papers describing 52 distinct studies, the majority being descriptive, qualitative studies of the decision-making process, with very limited assessment of decision outcomes. Although parents' preferences for degree of participation in pediatric decision making vary, most are interested in sharing the decision with the provider. In addition to the provider, parents are influenced in their decision making by changes in their child's health status, other community members, prior knowledge, and personal factors, such as emotions and faith. Parents struggle to balance these influences as well as to know when to include their child in decision making. Current research demonstrates a diversity of influences on parent decision making and parent decision preferences; however, little is known about decision outcomes or interventions to improve outcomes. Further investigation, using prospective methods, is needed in order to understand how to support parents through the difficult treatment decisions.

An Evolving Worldview: Making Open Source Easy

Science.gov (United States)

Rice, Z.

2017-12-01

NASA Worldview is an interactive interface for browsing full-resolution, global satellite imagery. Worldview supports an open data policy so that academia, private industries and the general public can use NASA's satellite data to address Earth science related issues. Worldview was open sourced in 2014. By shifting to an open source approach, the Worldview application has evolved to better serve end-users. Project developers are able to have discussions with end-users and community developers to understand issues and develop new features. Community developers are able to track upcoming features, collaborate on them and make their own contributions. Developers who discover issues are able to address those issues and submit a fix. This reduces the time it takes for a project developer to reproduce an issue or develop a new feature. Getting new developers to contribute to the project has been one of the most important and difficult aspects of open sourcing Worldview. After witnessing potential outside contributors struggle, a focus has been made on making the installation of Worldview simple to reduce the initial learning curve and make contributing code easy. One way we have addressed this is through a simplified setup process. Our setup documentation includes a set of prerequisites and a set of straightforward commands to clone, configure, install and run. This presentation will emphasize our focus to simplify and standardize Worldview's open source code so that more people are able to contribute. The more people who contribute, the better the application will become over time.

Predicting difficult laryngoscopy in acromegalic patients undergoing surgery for excision of pituitary tumors: A comparison of extended Mallampati score with modified Mallampati classification

Directory of Open Access Journals (Sweden)

Ashish Bindra

2013-01-01

Full Text Available Background: There are numerous reports of difficult laryngoscopy and intubation in patients with acromegaly. To date, no study has assessed the application of extended Mallampati score (EMS for predicting difficult intubation in acromegalics. The primary aim of this study was to compare EMS with modified Mallampati classification (MMP in predicting difficult laryngoscopy in acromegalic patients. We hypothesized that since EMS has been reported to be more specific and better predictor than MMP, it may be superior to the MMP to predict difficult laryngoscopy in acromegalic patients. Materials and Methods: For this prospective cohort study with matched controls, acromegalic patients scheduled to undergo pituitary surgery over a period of 3 years (January 2008-December 2010 were enrolled. Preoperative airway assessment was performed by experienced anesthesiologists and involved a MMP and the EMS. Under anesthesia, laryngoscopic view was assessed using Cormack-Lehane (CL grading. MMP and CL grades of I and II were defined "easy" and III and IV as "difficult". EMS grade of I and II were defined "easy" and III as "difficult". Data were used to determine the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MMP and EMS in predicting difficult laryngoscopy. Results: Seventy eight patients participated in the study (39 patients in each group. Both MMP and EMS failed to detect difficult laryngoscopy in seven patients. Only one laryngoscopy was predicted to be difficult by both tests which was in fact, difficult. Conclusion: We found that addition of neck extension did not improve the predictive value of MMP.

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

Directory of Open Access Journals (Sweden)

Niyazi Acer

2011-06-01

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

Development of a Support Tool for Complex Decision-Making in the Provision of Rural Maternity Care

Science.gov (United States)

Hearns, Glen; Klein, Michael C.; Trousdale, William; Ulrich, Catherine; Butcher, David; Miewald, Christiana; Lindstrom, Ronald; Eftekhary, Sahba; Rosinski, Jessica; Gómez-Ramírez, Oralia; Procyk, Andrea

2010-01-01

Context: Decisions in the organization of safe and effective rural maternity care are complex, difficult, value laden and fraught with uncertainty, and must often be based on imperfect information. Decision analysis offers tools for addressing these complexities in order to help decision-makers determine the best use of resources and to appreciate the downstream effects of their decisions. Objective: To develop a maternity care decision-making tool for the British Columbia Northern Health Authority (NH) for use in low birth volume settings. Design: Based on interviews with community members, providers, recipients and decision-makers, and employing a formal decision analysis approach, we sought to clarify the influences affecting rural maternity care and develop a process to generate a set of value-focused objectives for use in designing and evaluating rural maternity care alternatives. Setting: Four low-volume communities with variable resources (with and without on-site births, with or without caesarean section capability) were chosen. Participants: Physicians (20), nurses (18), midwives and maternity support service providers (4), local business leaders, economic development officials and elected officials (12), First Nations (women [pregnant and non-pregnant], chiefs and band members) (40), social workers (3), pregnant women (2) and NH decision-makers/administrators (17). Results: We developed a Decision Support Manual to assist with assessing community needs and values, context for decision-making, capacity of the health authority or healthcare providers, identification of key objectives for decision-making, developing alternatives for care, and a process for making trade-offs and balancing multiple objectives. The manual was deemed an effective tool for the purpose by the client, NH. Conclusions: Beyond assisting the decision-making process itself, the methodology provides a transparent communication tool to assist in making difficult decisions. While the

Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?

Science.gov (United States)

Paolini, Jean-Baptiste; Donati, François; Drolet, Pierre

2013-02-01

An adequate airway management plan is essential for patient safety. Recently, new tools have been developed as alternatives to direct laryngoscopy and intubation. Among these, video-laryngoscopy has enjoyed a rapid increase in popularity and is now considered by many as the first-line technique in airway management. This paradigm shift may have an impact on patient safety. Studies show that video-laryngoscopes are associated with better glottic visualization, a higher success rate for difficult airways, and a faster learning curve, resulting in a higher success rate for intubations by novice physicians. Thus, unanticipated difficult intubations may be less frequent if video-laryngoscopy is used as the first-line approach. In addition, on-screen viewing by the operator creates a new dynamic interaction during airway management. The entire operating room team can assess progress in real time, which enhances communication and improves teaching. However, if video-laryngoscopes become standard tools for tracheal intubation, these more costly devices will need to be widely available in all locations where airway management is conducted. Furthermore, algorithms for difficult intubation will require modification, and the question of selecting alternate devices will arise. If the incidence of difficult intubation decreases, the lack of motivation to teach and learn the use of alternative devices might adversely impact patient safety. The greater effectiveness of video-laryngoscopes associated with multi-person visualization could enhance overall patient safety during airway management. However, the routine use of video-laryngoscopy also introduces some issues that need to be addressed to avoid potentially dangerous pitfalls.

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

Science.gov (United States)

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

2006-01-01

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

Using health outcomes data to inform decision-making: formulary committee perspective.

Science.gov (United States)

Janknegt, R

2001-01-01

When healthcare resources are limited, decisions about the treatments to fund can be complex and difficult to make, involving the careful balancing of multiple factors. The decisions taken may have far-reaching consequences affecting many people. Clearly, decisions such as the choice of products on a formulary must be taken using a selection process that is fully transparent and that can be justified to all parties concerned. Although everyone would agree that drug selection should be a rational process that follows the guidelines of evidence-based medicine, many other factors may play a role in decision-making. Although some of these are explicit and rational, others are less clearly defined, and decision-makers may be unaware of the influence exerted by some of these factors. In order to facilitate transparent decision-making that makes rational use of health outcomes information, the System of Objectified Judgement Analysis (SOJA) has been developed by the author. SOJA includes interactive software that combines the quality advantages of the 'top-down' approach to drug selection, based on a thorough literature review, with the compliance advantages of a 'bottom-up' approach, where the final decision is made by the individual formulary committee and not by the authors of the review. The SOJA method, based on decision-making processes in economics, ensures that health outcomes information is given appropriate weight. Such approaches are valuable tools in discussions about product selection for formularies.

Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care.

Science.gov (United States)

Burke, Robert E; Jones, Jacqueline; Lawrence, Emily; Ladebue, Amy; Ayele, Roman; Leonard, Chelsea; Lippmann, Brandi; Matlock, Daniel D; Allyn, Rebecca; Cumbler, Ethan

2018-05-01

Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization. We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF. Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making. Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities. We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame. The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome. Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the

Complex Decision-Making in Heart Failure: A Systematic Review and Thematic Analysis.

Science.gov (United States)

Hamel, Aimee V; Gaugler, Joseph E; Porta, Carolyn M; Hadidi, Niloufar Niakosari

Heart failure follows a highly variable and difficult course. Patients face complex decisions, including treatment with implantable cardiac defibrillators, mechanical circulatory support, and heart transplantation. The course of decision-making across multiple treatments is unclear yet integral to providing informed and shared decision-making. Recognizing commonalities across treatment decisions could help nurses and physicians to identify opportunities to introduce discussions and support shared decision-making. The specific aims of this review are to examine complex treatment decision-making, specifically implantable cardiac defibrillators, ventricular assist device, and cardiac transplantation, and to recognize commonalities and key points in the decisional process. MEDLINE, CINAHL, PsycINFO, and Web of Science were searched for English-language studies that included qualitative findings reflecting the complexity of heart failure decision-making. Using a 3-step process, findings were synthesized into themes and subthemes. Twelve articles met criteria for inclusion. Participants included patients, caregivers, and clinicians and included decisions to undergo and decline treatment. Emergent themes were "processing the decision," "timing and prognostication," and "considering the future." Subthemes described how participants received and understood information about the therapy, making and changing a treatment decision, timing their decision and gauging health status outcomes in the context of their decision, the influence of a life or death decision, and the future as a factor in their decisional process. Commonalities were present across therapies, which involved the timing of discussions, the delivery of information, and considerations of the future. Exploring this further could help support patient-centered care and optimize shared decision-making interventions.

Leadership of risk decision making in a complex, technology organization: The deliberative decision making model

Science.gov (United States)

Flaming, Susan C.

2007-12-01

The continuing saga of satellite technology development is as much a story of successful risk management as of innovative engineering. How do program leaders on complex, technology projects manage high stakes risks that threaten business success and satellite performance? This grounded theory study of risk decision making portrays decision leadership practices at one communication satellite company. Integrated product team (IPT) leaders of multi-million dollar programs were interviewed and observed to develop an extensive description of the leadership skills required to navigate organizational influences and drive challenging risk decisions to closure. Based on the study's findings the researcher proposes a new decision making model, Deliberative Decision Making, to describe the program leaders' cognitive and organizational leadership practices. This Deliberative Model extends the insights of prominent decision making models including the rational (or classical) and the naturalistic and qualifies claims made by bounded rationality theory. The Deliberative Model describes how leaders proactively engage resources to play a variety of decision leadership roles. The Model incorporates six distinct types of leadership decision activities, undertaken in varying sequence based on the challenges posed by specific risks. Novel features of the Deliberative Decision Model include: an inventory of leadership methods for managing task challenges, potential stakeholder bias and debates; four types of leadership meta-decisions that guide decision processes, and aligned organizational culture. Both supporting and constraining organizational influences were observed as leaders managed major risks, requiring active leadership on the most difficult decisions. Although the company's engineering culture emphasized the importance of data-based decisions, the uncertainties intrinsic to satellite risks required expert engineering judgment to be exercised throughout. An investigation into

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

Directory of Open Access Journals (Sweden)

Kundan Sandugir Gosavi

2015-06-01

Full Text Available Difficult airway management in paediatric patients may require a technique different from the standard one. We report the use of an adult fibreoptic bronchoscope and J tipped guidewire to intubate a child having temporo-mandibular joint ankylosis. Spontaneous respiration was maintained and local anaesthesia was provided to the upper airway during the procedure and the successful use of this technique avoided the requirement of surgical airway.

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

DEFF Research Database (Denmark)

Vudayagiri, Sindhu; Skov, Anne Ladegaard

2014-01-01

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

Tectonique globale. Quelques difficultés Global Tectonics. a Few Problems

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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.

Conceptual framework of knowledge management for ethical decision-making support in neonatal intensive care.

Science.gov (United States)

Frize, Monique; Yang, Lan; Walker, Robin C; O'Connor, Annette M

2005-06-01

This research is built on the belief that artificial intelligence estimations need to be integrated into clinical social context to create value for health-care decisions. In sophisticated neonatal intensive care units (NICUs), decisions to continue or discontinue aggressive treatment are an integral part of clinical practice. High-quality evidence supports clinical decision-making, and a decision-aid tool based on specific outcome information for individual NICU patients will provide significant support for parents and caregivers in making difficult "ethical" treatment decisions. In our approach, information on a newborn patient's likely outcomes is integrated with the physician's interpretation and parents' perspectives into codified knowledge. Context-sensitive content adaptation delivers personalized and customized information to a variety of users, from physicians to parents. The system provides structuralized knowledge translation and exchange between all participants in the decision, facilitating collaborative decision-making that involves parents at every stage on whether to initiate, continue, limit, or terminate intensive care for their infant.

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

Science.gov (United States)

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.

Prediction of difficult mask ventilation using a systematic assessment of risk factors vs. existing practice - a cluster randomised clinical trial in 94,006 patients

DEFF Research Database (Denmark)

Nørskov, A K; Wetterslev, J; Rosenstock, C V

2017-01-01

We compared implementation of systematic airway assessment with existing practice of airway assessment on prediction of difficult mask ventilation. Twenty-six departments were cluster-randomised to assess eleven risk factors for difficult airway management (intervention) or to continue with their......We compared implementation of systematic airway assessment with existing practice of airway assessment on prediction of difficult mask ventilation. Twenty-six departments were cluster-randomised to assess eleven risk factors for difficult airway management (intervention) or to continue...... with their existing airway assessment (control). In both groups, patients predicted as a difficult mask ventilation and/or difficult intubation were registered in the Danish Anaesthesia Database, with a notational summary of airway management. The trial's primary outcome was the respective incidence of unpredicted...... difficult and easy mask ventilation in the two groups. Among 94,006 patients undergoing mask ventilation, the incidence of unpredicted difficult mask ventilation in the intervention group was 0.91% and 0.88% in the control group; (OR) 0.98 (95% CI 0.66-1.44), p = 0.90. The incidence of patients predicted...

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

DEFF Research Database (Denmark)

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

2010-01-01

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

The Potential of Supplemental Instruction in Engineering Education: Creating Additional Peer-Guided Learning Opportunities in Difficult Compulsory Courses for First-Year Students

Science.gov (United States)

Malm, Joakim; Bryngfors, Leif; Mörner, Lise-Lotte

2016-01-01

Supplemental Instruction (SI) can be an efficient way of improving student success in difficult courses. Here, a study is made on SI attached to difficult first-year engineering courses. The results show that both the percentage of students passing a difficult first-year engineering course, and scores on the course exams are considerably higher…

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

International Nuclear Information System (INIS)

1987-06-01

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

Should I Make or Should I Buy? Innovation Strategies and Governance Structures in the Italian Food Sector

Directory of Open Access Journals (Sweden)

Stefano Pascucci

2011-12-01

Full Text Available This paper analyses the "make or buy" decision of food firms applied to innovation strategy using 389 Italian food firms data from the Unicredit 2007 database. We develop a set of hypothesis from three theoretical perspectives such as transaction cost economics, strategic management and resource-based view. Our paper aims at highlight whether or not different firm’s features can be linked to the decision to make or buy. We found out that these two decisions are positively interlinked. Moreover we also found out that it is difficult to indicate a clear-cut behaviour for the Italian food firms if we refer to making or buying decisions. We discuss these results and use them to bring some interesting outcomes to discuss managerial implications and/or policy interventions in this highly strategic domain.

[Involving patients, the insured and the general public in healthcare decision making].

Science.gov (United States)

Mühlbacher, Axel C; Juhnke, Christin

2016-01-01

No doubt, the public should be involved in healthcare decision making, especially when decision makers from politics and self-government agencies are faced with the difficult task of setting priorities. There is a general consensus on the need for a stronger patient centeredness, even in HTA processes, and internationally different ways of public participation are discussed and tested in decision making processes. This paper describes how the public can be involved in different decision situations, and it shows how preference measurement methods are currently being used in an international context to support decision making. It distinguishes between different levels of decision making on health technologies: approval, assessment, pricing, and finally utilization. The range of participation efforts extends from qualitative surveys of patients' needs (Citizen Councils of NICE in the UK) to science-based documentation of quantitative patient preferences, such as in the current pilot projects of the FDA in the US and the EMA at the European level. Possible approaches for the elicitation and documentation of preference structures and trade-offs in relation to alternate health technologies are decision aids, such as multi-criteria decision analysis (MCDA), that provide the necessary information for weighting and prioritizing decision criteria. Copyright © 2015. Published by Elsevier GmbH.

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

Science.gov (United States)

Fiester, Autumn

2015-01-01

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

Chronicle of a difficult relationship

International Nuclear Information System (INIS)

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.)

Decision making model design for antivirus software selection using Factor Analysis and Analytical Hierarchy Process

OpenAIRE

Nurhayati Ai; Gautama Aditya; Naseer Muchammad

2018-01-01

Virus spread increase significantly through the internet in 2017. One of the protection method is using antivirus software. The wide variety of antivirus software in the market tends to creating confusion among consumer. Selecting the right antivirus according to their needs has become difficult. This is the reason we conduct our research. We formulate a decision making model for antivirus software consumer. The model is constructed by using factor analysis and AHP method. First we spread que...

“No, Gender doesn’t make a Difference…?” Studying Negotiations and Gender in Organizations

OpenAIRE

Lotte Bloksgaard

2012-01-01

This article focuses on methodological challenges and strategies with regard to studying gender in organizations. Work organizations are often thought, theorized and talked about as gender-neutral arenas and, therefore, gender is often seen as irrelevant and of no importance in modern work-life. There is also often a discrepancy in relation to gender between discourse and practice, which makes it difficult to capture the significance of gender in organizations by the interview method alone. O...

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

DEFF Research Database (Denmark)

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

2017-01-01

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

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

Directory of Open Access Journals (Sweden)

Jake M Heier

2012-01-01

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

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

International Nuclear Information System (INIS)

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

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

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Ravi Bhat

2014-01-01

Full Text Available The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel′s deformity (wherein the scapulae ride high on the back, synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA. After intubation, we used second smaller endotracheal tube (ETT to stabilize and elongate the first ETT while removing the LMA.

Mathematical knowledge for teaching: Making the tacit more explicit in mathematics teacher education

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Abdullah, Mohd Faizal Nizam Lee; Vimalanandan, Lena

2017-05-01

Teaching practice during school based experiences, afford an opportunity for pre service teachers to put into practice their knowledge for teaching mathematics. Like all knowledge, Mathematical Knowledge for Teaching (MKT) is held in both tacit and explicit form, making it especially difficult to study and map during instruction. This study investigates the tacit and explicit nature of MKT held by pre service teachers in a Malaysian Teacher Education Program and how it impacts the Mathematical Quality of their instruction (MQI). This study of three mathematics pre-service teachers (PSTs), utilised videos of mathematics lessons, reflective debriefs and interviews. The findings suggest that factors such as reflecting, peer-sharing, conferencing with mentors and observing support in making tacit knowledge more explicit during planning and instruction. Implications for preparation of mathematics teachers capable of high Mathematical Quality of Instruction are also discussed.

Making the City "Second Nature": Freegan "Dumpster Divers" and the Materiality of Morality.

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Barnard, Alex V

2016-01-01

How do people maintain deeply held moral identities in a seemingly immoral social environment? Cultural sociologists and social psychologists have focused on how individuals cope with contexts that make acting on moral motivations difficult by building supportive networks and embedding themselves in communities of like-minded people. In this article, however, the author argues that actors can achieve a moral "sense of one's place" through a habitus that leverages the material dimensions of place itself. In particular, he shows how one community of radical environmental activists make affirming moral identities centered on living "naturally" seem like "second nature," even in a seemingly unnatural and immoral urban environment, by reconfiguring their physical world. The author shows how nonhuman objects serve as proofs of moral labor, markers of moral boundaries, and reminders of moral values, playing both a facilitating and constraining role in moral life.

Using an ecological ethics framework to make decisions about the relocation of wildlife.

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McCoy, Earl D; Berry, Kristin

2008-12-01

Relocation is an increasingly prominent conservation tool for a variety of wildlife, but the technique also is controversial, even among conservation practitioners. An organized framework for addressing the moral dilemmas often accompanying conservation actions such as relocation has been lacking. Ecological ethics may provide such a framework and appears to be an important step forward in aiding ecological researchers and biodiversity managers to make difficult moral choices. A specific application of this framework can make the reasoning process more transparent and give more emphasis to the strong sentiments about non-human organisms held by many potential users. Providing an example of the application of the framework may also increase the appeal of the reasoning process to ecological researchers and biodiversity managers. Relocation as a conservation action can be accompanied by a variety of moral dilemmas that reflect the interconnection of values, ethical positions, and conservation decisions. A model that is designed to address moral dilemmas arising from relocation of humans provides/demonstrates/illustrates a possible way to apply the ecological ethics framework and to involve practicing conservationists in the overall decision-making process.

Making texts in electronic health records comprehensible to consumers: a prototype translator.

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Zeng-Treitler, Qing; Goryachev, Sergey; Kim, Hyeoneui; Keselman, Alla; Rosendale, Douglas

2007-10-11

Narrative reports from electronic health records are a major source of content for personal health records. We designed and implemented a prototype text translator to make these reports more comprehensible to consumers. The translator identifies difficult terms, replaces them with easier synonyms, and generates and inserts explanatory texts for them. In feasibility testing, the application was used to translate 9 clinical reports. Majority (68.8%) of text replacements and insertions were deemed correct and helpful by expert review. User evaluation demonstrated a non-statistically significant trend toward better comprehension when translation is provided (p=0.15).

What Is Known about Parents’ Treatment Decisions? A Narrative Review of Pediatric Decision Making

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Lipstein, Ellen A.; Brinkman, William B.; Britto, Maria T.

2013-01-01

Background With the increasing complexity of decisions in pediatric medicine, there is a growing need to understand the pediatric decision-making process. Objective To conduct a narrative review of the current research on parent decision making about pediatric treatments and identify areas in need of further investigation. Methods Articles presenting original research on parent decision making were identified from MEDLINE (1966–6/2011), using the terms “decision making,” “parent,” and “child.” We included papers focused on treatment decisions but excluded those focused on information disclosure to children, vaccination, and research participation decisions. Results We found 55 papers describing 52 distinct studies, the majority being descriptive, qualitative studies of the decision-making process, with very limited assessment of decision outcomes. Although parents’ preferences for degree of participation in pediatric decision making vary, most are interested in sharing the decision with the provider. In addition to the provider, parents are influenced in their decision making by changes in their child’s health status, other community members, prior knowledge, and personal factors, such as emotions and faith. Parents struggle to balance these influences as well as to know when to include their child in decision making. Conclusions Current research demonstrates a diversity of influences on parent decision making and parent decision preferences; however, little is known about decision outcomes or interventions to improve outcomes. Further investigation, using prospective methods, is needed in order to understand how to support parents through the difficult treatment decisions. PMID:21969136

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

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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.

Public participation and environmental impact assessment: Purposes, implications, and lessons for public policy making

International Nuclear Information System (INIS)

O'Faircheallaigh, Ciaran

2010-01-01

In recent years the need to enhance public participation in Environmental Impact Assessment (EIA), and the efficacy of alternative mechanisms in achieving this goal, have been central themes in the EIA literature. The benefits of public participation are often taken for granted, and partly for this reason the underlying rationale for greater public participation is sometimes poorly articulated, making it more difficult to determine how to pursue it effectively. The reasons for seeking public participation are also highly diverse and not always mutually consistent. There has been limited analysis of the implications of different forms and degrees of public participation for public decision making based on EIA, and little discussion of how experience with public participation in EIA relates to debates about participation in policy making generally. This paper distinguishes various purposes for public participation in EIA, and discusses their implications for decision making. It then draws on some general models of public participation in policy making to consider how approaches to participation in EIA can be interpreted and valued, and asks what EIA experience reveals about the utility of these models. It argues that the models pay insufficient attention to the interaction that can occur between different forms of public participation; and to the fact that public participation raises issues regarding control over decision making that are not subject to resolution, but must be managed through ongoing processes of negotiation.

Decision Making in Liver Transplant Selection Committees

Science.gov (United States)

Volk, Michael L; Biggins, Scott W; Huang, Mary Ann; Argo, Curtis K; Fontana, Robert J; Anspach, Renee R

2011-01-01

Background In order to receive a liver transplant, patients must first be placed on the waiting list – a decision made in most transplant centers by a multidisciplinary committee. The function of these committees has never been studied. Objectives To describe decision making in liver transplant committees and identify opportunities for process improvement. Design Observational multi-center Setting We observed 63 meetings and interviewed 50 committee members at 4 liver transplant centers. Study Subjects Transplant committee members. Measurements Recorded transcripts and field notes were analyzed using standard qualitative sociological methods. Results While the structure of meetings varied by center, the process was uniform and involved reviewing possible reasons for patient exclusion using primarily inductive reasoning. Stated justifications for excluding patients were a) too well, b) non-hepatic comorbidities or advanced age, c) too sick in the setting of advanced liver disease, d) substance abuse, or e) other psychosocial barriers. Dominant themes identified included members’ angst over deciding who lives and dies, a high correlation between psychosocial barriers to transplant and patients’ socioeconomic status, and the influence of external forces on decision making. Consistently identified barriers to effective group decision making were: 1) unwritten center policies, and 2) confusion regarding advocacy versus stewardship roles. Limitations The use of qualitative methods provides broad understanding but limits specific inferences. These four centers may not be reflective of every transplant center nationwide. Conclusion The difficult decisions made by these committees are reasonably consistent and always well-intentioned, but might be improved by more explicit written policies and clarifying roles. This process may help inform resource allocation in other areas of medicine. Primary funding source The Greenwall Foundation. PMID:22007044

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

Science.gov (United States)

Seitz, Phillip

2016-05-01

History and Reconstruction is an interdisciplinary project to assess the impact of African American history education for black men. Under the theory of trauma recovery, leading scholars of African American history worked with a group of ten ex-offenders, supported by the services of a psychologist and an African American cultural expert and storyteller. Results based on psychological testing and qualitative feedback showed that history can be a catalyst for personal development and transformation. It also demonstrated that difficult history can be taught and assimilated for audience benefit. History and Reconstruction was supported by the Pew Center for Arts and Heritage.

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

Science.gov (United States)

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

Involvement and Influence of Healthcare Providers, Family Members, and Other Mutation Carriers in the Cancer Risk Management Decision-Making Process of BRCA1 and BRCA2 Mutation Carriers.

Science.gov (United States)

Puski, Athena; Hovick, Shelly; Senter, Leigha; Toland, Amanda Ewart

2018-03-29

Deciding between increased cancer screening or prophylactic surgery and the timing of such procedures can be a difficult and complex process for women with BRCA mutations. There are gaps in our understanding of involvement of others in the decision-making process for women with BRCA mutations. This study evaluated the management decision-making process of women with BRCA mutations, focusing on the involvement of others. Grounded theory was used to analyze and code risk management decision-making information from interviews with 20 BRCA mutation carriers. Unaffected at-risk participants with a BRCA mutation, those under age 40, and those with no children described having a difficult time making risk management decisions. Physicians were an integral part of the decision-making process by providing decisional support and management recommendations. Family members and other mutation carriers filled similar yet distinct roles by providing experiential information as well as decisional and emotional support for carriers. Participants described genetic counselors as short-term providers of risk information and management recommendations. The study findings suggest that unaffected at-risk women, women under 40, and those who do not have children may benefit from additional support and information during the decision-making process. Genetic counselors are well trained to help women through this process and connect them with resources, and may be under-utilized in long-term follow-up for women with a BRCA mutation.

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

Science.gov (United States)

Keller, Eric

2010-01-01

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

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

Directory of Open Access Journals (Sweden)

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.

Improving oncology nurses' communication skills for difficult conversations.

Science.gov (United States)

Baer, Linda; Weinstein, Elizabeth

2013-06-01

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

Evaluating water management strategies with the Systems Impact Assessment Model: SIAM version 4

Science.gov (United States)

Bartholow, John M.; Heasley, John; Hanna, Blair; Sandelin, Jeff; Flug, Marshall; Campbell, Sharon; Henriksen, Jim; Douglas, Aaron

2005-01-01

Water from many of California's coastal rivers has been used for a wide variety of development ventures, including major agricultural diversions, hydropower generation, and contaminant assimilation from industry, agriculture and logging. Anthropogenic impacts often degrade water quality and decrease the quantity and quality of aquatic habitat. Reallocating streamflow away from uses that degrade water quality to uses that foster higher water quality is a critical step in restoring riverine habitat and the anadromous fish that rely on that habitat for a portion of their life cycle. Reallocation always brings with it the need to examine the economic efficiency of the proposed changes. If the dollar benefits of improving water quality are greater than the costs, the criterion of improving economic efficiency is satisfied, a fact that can be highly persuasive to decision makers contemplating reallocation.