Auscultating heart and breath sounds through patients’ gowns: who does this and does it matter?

Background Doctors are taught to auscultate with the stethoscope applied to the skin, but in practice may be seen applying the stethoscope to the gown. Objectives To determine how often doctors auscultate heart and breath sounds through patients’ gowns, and to assess the impact of this approach on the quality of the sounds heard. Methods A sample of doctors in the west of Scotland were sent an email in 2014 inviting them to answer an anonymous questionnaire about how they auscultated heart and breath sounds. Normal heart sounds from two subjects were recorded through skin, through skin and gown, and through skin, gown and dressing gown. These were played to doctors, unaware of the origin of each recording, who completed a questionnaire about the method and quality of the sounds they heard. Results 206 of 445 (46%) doctors completed the questionnaire. 124 (60%) stated that they listened to patients’ heart sounds, and 156 (76%) to patients’ breath sounds, through patients’ gowns. Trainees were more likely to do this compared with consultants (OR 3.39, 95% CI 1.74 to 6.65). Doctors of all grades considered this practice affected the quality of the sounds heard. 32 doctors listened to the recorded heart sounds. 23 of the 64 (36%) skin and 23 of the 64 (36%) gown recordings were identified. The majority of doctors (74%) could not differentiate between skin or gown recordings, but could tell them apart from the double layer recordings (p=0.02). Trainees were more likely to hear artefactual added sounds (p=0.04). Conclusions Many doctors listen to patients’ heart and breath sounds through hospital gowns, at least occasionally. In a short test, most doctors could not distinguish between sounds heard through a gown or skin. Further work is needed to determine the impact of this approach to auscultation on the identification of murmurs and added sounds

Realistic computable error bounds for three dimensional finite element analyses in linear elasticity

We obtain a computable estimator for the energy norm of the error in piecewise affine and piecewise quadratic finite element approximations of linear elasticity in three dimensions. We show that the estimator provides guaranteed upper bounds on the energy norm of the error as well as (up to a constant and data oscillation terms) local lower bounds

The economic theories of Henry George

Thesis (M.A.)--Boston University, 1940Henry George, the champion of the single tax movement in the United States, was born in Philadelphia, September 2, 1839. After a brief schooling he tried sailoring for one voyage, and then became an apprentice printer. At the age of eighteen he migrated to California in search of better work and higher pay. He became an itinerant printer, then later gave up this end of the work to become a reporter and editor. The fact that he was in San Francisco during the boom period and saw the coming of the transcontinental railroad, led to his first economic writinJS. The article, "What the Railroad Will Bring Us," was published in the Overland Monthly, and shows his power of inductive inference, although it was not a literary masterpiece. On a business trip to New York, he was struck by the sight of filth and poverty so rampant, side by side with great wealth . Years before he had been curious as to the reason that wages are higher in new sections or countries, than they are in older sections. The two questions were combined and answered in his pamphlet Our Land and Land Policy which he published in 1871. He proposed to solve the problem of "advancing poverty with advancing wealth," by absorbing the "unearned increment" of John Stuart Mill, through a land tax. After a number of years of mulling over the pamphlet in his mind, between his job as an editor and his work as a political orator, he amplified this essay into Progress and Poverty, published in 1880. After a slow beginning, the book caught the attention of the public, and George was famous. He had moved to New York, meanwhile, and the rest of his life was spent lecturing and writing, both here and abroad. He was associated with the Irish Land Reform movement, and made two lecture tours of Great Britain in its behalf. He was a great orator, one of the best of his day. In 1886, he ran for the mayoralty of New York, on a coalition ticket, but lost by a narrow margin. He entered politics twice again, once in the race for the Secretary of the State of New York, and, just before his death, again for the mayoralty. He was not successful at any time. In the middle of his last campaign he died; the date was October 28, 1897. The chief problem always in Henry George's mind was poverty. He felt that the "wage -fund" theory (which maintained that wages tended to a minimum because there was a fixed fund of capital set aside for the payment of wages, and every increase in the number of laborers decreased the individual share of each laborer) was wrong, for he said that wages are not paid out of capital but out of product. George regarded labor and capital as but different forms of the same thing--human exertion. Only these two are productive. Rent is an unearned increment, and it reduces wages and interest by its total amount. His problem, in the final analysis, was to find the best method of freeing the real producers of wealth by dispossessing the holders of the unearned increment. The solution of the problem, as advanced by Henry George, was to remove the cause of the evil, and make land common property. Not, he says, the nationalization of land; confiscation of land is not necessary, but the purpose will be served oy the confiscation of rent. The value of land is built up by society. Therefore, the land tax is the most just of all taxes, for only those people who have received a peculiar benefit from society in the form of land will be required to turn back some of their income into the common treasury. A summary of his theory would run in this manner: Land is the creation of God and everyone of his creatures has a right to a share. Increase in value is due largely to the efforts of society, and is an unearned increment properly belonging to society. As a result, the returns from the land should be appropriated by the government in the form of a single tax, which will be economic rent. Such a plan would eliminate uoverty, and at the same time do away with monopolists of natural rights. The whole society will tend, therefore, to level off, with the two extremes being exterminated Man's ingenuity or greater skill will not be taxed, and labor will receive its just reward. None of Henry George's ideas are entirely original, but he joined his thoughts to the stream begun many years before. He had many predecessors in the land-reform movement down through the ages. However, it must be emphasized that he knew nothing of the work of Spence, Ogilvie, Paine, the Physiocrats, or Dove until after he had written Progress and Poverty. He was only slightly familiar with the classical economists, Smith, Ricardo , and the Mills, but knew a little more about Spencer than the others. The turning point of his career came with the nomination for mayor in 1887. From then on, his influence declined. Unfortunate quarrels and fancied aspersions led to his writing polemics against Pope Leo XIII and Herbert Spencer, both of which hurt his cause irreparably. His followers have carried the fight for the single tax into politics; the greatest success has come in Australasia and Great Britain, although it is impossible to say how much is due to his influence alone. Canada instituted land reform acts in the western provinces, but none proved too successful. In the United States, only a few high points can be traced directly to George, particularly an experiment in Houston, Texas, and the enclaves. All else has met with dismal failure. The stress has changed from politics to education, and through the good work of some early leaders, Shearman, McGlynn, Fels, and Fillebrown, much was accomplished. Of recent years, the gospel has been spread abroad through the Robert Schalkenbach Foundation and the Henry George School of Social Sciences. There is evident a great awakening of interest in economics and tax reform

The Returns to formality and Informality in Urban Africa

This paper addresses the question as to why we observe such large differentials in earnings in urban African labour markets after controlling for observable human capital. We first use a three year panel across Ghana and Tanzania and find common patterns for both countries assuming that movement between occupations is exogenous. Unobserved individual market ability is by far the most important factor explaining the variance of earnings. Sector differences do matter even with controls for ability and the sectoral gap between private wage employment and civil servants is about 50 per cent, once we control for unobserved time-invariant factors. Wage earners earn the same as the selfemployed in both Ghana and Tanzania. An additional important aspect of formality is enterprise size. At most half of the OLS effect of size on earnings can be explained by unobservable ability. Workers in largest firms are the high earners with wage rates which exceed those of civil servants. We then use an extension of the Ghana panel to five years to assess the extent of possible biases from the assumption of exogenous movement. We find evidence that this is important and that OLS may be understating the extent of both the size effect and the private sector wage (negative) premium. The implications of our results for understanding the nature of formal and informal employment in Africa are discussed.

Constant free error bounds for nonuniform order discontinuous Galerkin finite-element approximation on locally refined meshes with hanging nodes

We obtain fully computable constant free a posteriori error bounds on the broken energy seminorm and the discontinuous Galerkin (DG) norm of the error for nonuniform polynomial order symmetric interior penalty Galerkin, nonsymmetric interior penalty Galerkin and incomplete interior penalty Galerkin finite-element approximations of a linear second-order elliptic problem on meshes containing hanging nodes and comprised of triangular elements. The estimators are completely free of unknown constants and provide guaranteed numerical bounds on the broken energy seminorm and the DG norm of the error. These estimators are also shown to provide a lower bound for the broken energy seminorm and the DG norm of the error up to a constant and higher-order data oscillation terms

Global Response of the Space Shuttle External Tank with the Presence of Intertank Stringer Cracks and Radius Blocks

After propellant was loaded into the external tank (ET), the November 5, 2010 launch of Space Shuttle mission STS-133 was scrubbed due to a gaseous hydrogen leak located in a vent line near the ground umbilical and ET connection. Subsequent visual inspections identified cracks in the sprayed-on foam insulation in the forward end of the ET intertank segment, adjacent to the liquid oxygen (LOX) tank, as shown in Figure 1. These cracks necessitated repair of the foam due to debris concerns that violated launch constraints. As part of the repair process, the affected foam was removed to reveal cracks in the underlying external hat stiffeners on the intertank, as shown in Figure 2. Ultimately, five stiffeners were discovered to be cracked adjacent to the LOX tank. As the managing center for the ET Project, NASA Marshall Space Flight Center (MSFC) coordinated failure investigation and repair activities among multiple organizations, which included the ET prime contractor (Lockheed Martin Space Systems Michoud Operations), the Space Shuttle Program Office at the NASA Johnson Space Center (JSC), the NASA Kennedy Space Center (KSC), and the NASA Engineering and Safety Center (NESC). STS-133 utilized the external tank designated as ET-137. Many aspects of the investigation have been reported previously in Refs. 1-7, which focus on the root cause of the failures, the flight readiness rationale and the local analyses of the stringer failures and repair. This paper summarizes the global analyses that were conducted on ET-137 as part of the NESC effort during the investigation, which was conducted primarily to determine if the repairs that were introduced to the stringers would alter the global response of the ET. In the process of the investigation, a new STAGS tabular input capability was developed to more easily introduce the aerodynamic pressure loads using a method that could easily be extended to incorporate finite element property data such as skin and stiffener thicknesses and beam cross-sectional properties

Early Ascents and Geologic Exploration of Katahdin in the Nineteenth Century; Bedrock Geology of the Shin Pond Region

Guidebook for field trips in the Mount Katahdin Region, Maine: 58th annual meeting September 29, 30, October 1, 1966: title page, table of contents, introduction, essay

Post-operative atrial fibrillation is influenced by beta-blocker therapy but not by pre-operative atrial cellular electrophysiology

We investigated whether post-cardiac surgery (CS) new-onset atrial fibrillation (AF) is predicted by pre-CS atrial cellular electrophysiology, and whether the antiarrhythmic effect of beta-blocker therapy may involve pre-CS pharmacological remodeling. Atrial myocytes were obtained from consenting patients in sinus rhythm, just prior to CS. Action potentials and ion currents were recorded using whole-cell patch-clamp technique. Post-CS AF occurred in 53 of 212 patients (25%). Those with post-CS AF were older than those without (67 ± 2 vs 62 ± 1 years, P = 0.005). In cells from patients with post-CS AF, the action potential duration at 50% and 90% repolarization, maximum upstroke velocity, and effective refractory period (ERP) were 13 ± 4 ms, 217 ± 16 ms, 185 ± 10 V/s, and 216 ± 14 ms, respectively (n = 30 cells, 11 patients). Peak L-type Ca2+ current, transient outward and inward rectifier K+ currents, and the sustained outward current were −5.0 ± 0.5, 12.9 ± 2.4, −4.1 ± 0.4, and 9.7 ± 1.0 pA/pF, respectively (13-62 cells, 7-19 patients). None of these values were significantly different in cells from patients without post-CS AF (P > 0.05 for each, 60-279 cells, 29-86 patients), confirmed by multiple and logistic regression. In patients treated >7 days with a beta-blocker pre-CS, the incidence of post-CS AF was lower than in non-beta-blocked patients (13% vs 27%, P = 0.038). Pre-CS beta-blockade was associated with a prolonged pre-CS atrial cellular ERP (P = 0.001), by a similar degree (∼20%) in those with and without post-CS AF. Conclusion: Pre-CS human atrial cellular electrophysiology does not predict post-CS AF. Chronic beta-blocker therapy is associated with a reduced incidence of post-CS AF, unrelated to a pre-CS ERP-prolonging effect of this treatment