The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes

A Monte Carlo Approach to Modeling the Breakup of the Space Launch System EM-1 Core Stage with an Integrated Blast and Fragment Catalogue

The Liquid Propellant Fragment Overpressure Acceleration Model (L-FOAM) is a tool developed by Bangham Engineering Incorporated (BEi) that produces a representative debris cloud from an exploding liquid-propellant launch vehicle. Here it is applied to the Core Stage (CS) of the National Aeronautics and Space Administration (NASA) Space Launch System (SLS launch vehicle). A combination of Probability Density Functions (PDF) based on empirical data from rocket accidents and applicable tests, as well as SLS specific geometry are combined in a MATLAB script to create unique fragment catalogues each time L-FOAM is run-tailored for a Monte Carlo approach for risk analysis. By accelerating the debris catalogue with the BEi blast model for liquid hydrogen / liquid oxygen explosions, the result is a fully integrated code that models the destruction of the CS at a given point in its trajectory and generates hundreds of individual fragment catalogues with initial imparted velocities. The BEi blast model provides the blast size (radius) and strength (overpressure) as probabilities based on empirical data and anchored with analytical work. The coupling of the L-FOAM catalogue with the BEi blast model is validated with a simulation of the Project PYRO S-IV destruct test. When running a Monte Carlo simulation, L-FOAM can accelerate all catalogues with the same blast (mean blast, 2 blast, etc.), or vary the blast size and strength based on their respective probabilities. L-FOAM then propagates these fragments until impact with the earth. Results from L-FOAM include a description of each fragment (dimensions, weight, ballistic coefficient, type and initial location on the rocket), imparted velocity from the blast, and impact data depending on user desired application. LFOAM application is for both near-field (fragment impact to escaping crew capsule) and far-field (fragment ground impact footprint) safety considerations. The user is thus able to use statistics from a Monte Carlo set of L-FOAM catalogues to quantify risk for a multitude of potential CS destruct scenarios. Examples include the effect of warning time on the survivability of an escaping crew capsule or the maximum fragment velocities generated by the ignition of leaking propellants in internal cavities

Solid Rocket Launch Vehicle Explosion Environments

Empirical explosion data from full scale solid rocket launch vehicle accidents and tests were collected from all available literature from the 1950s to the present. In general data included peak blast overpressure, blast impulse, fragment size, fragment speed, and fragment dispersion. Most propellants were 1.1 explosives but a few were 1.3. Oftentimes the data from a single accident was disjointed and/or missing key aspects. Despite this fact, once the data as a whole was digitized, categorized, and plotted clear trends appeared. Particular emphasis was placed on tests or accidents that would be applicable to scenarios from which a crew might need to escape. Therefore, such tests where a large quantity of high explosive was used to initiate the solid rocket explosion were differentiated. Also, high speed ground impacts or tests used to simulate such were also culled. It was found that the explosions from all accidents and applicable tests could be described using only the pressurized gas energy stored in the chamber at the time of failure. Additionally, fragmentation trends were produced. Only one accident mentioned the elusive "small" propellant fragments, but upon further analysis it was found that these were most likely produced as secondary fragments when larger primary fragments impacted the ground. Finally, a brief discussion of how this data is used in a new launch vehicle explosion model for improving crew/payload survival is presented

Forty-five revolutions per minute:a qualitative study of Hybrid Order use in forensic psychiatric practice

Psychiatrists who recommend a Hybrid Order (Section 45A) as a disposal option at the point of sentencing accept that the convicted individual, as well as being mentally disordered and in need of treatment, is also culpable and deserving of criminal punishment. Ethical and clinical concerns have typically limited its clinical use. However, in 2015 the Court of Appeal specified in R v Vowles and others that the Hybrid Order disposal should be considered first in terms of potential mental health disposals. This judgement sets a high threshold for the use of the hospital order which has been the bedrock of inpatient forensic psychiatric practice since 1983. This study sought to explore the attitudes of consultant forensic psychiatrists towards the use of the Hybrid Order in the wake of the Vowles judgement. We interviewed 12 consultant forensic psychiatrists with longstanding experience of psychiatric sentencing recommendations. We found that the majority of consultants considered the Hybrid Order to be a valuable disposal option when used under specific circumstances. However, significant concerns were raised about its use in those with an enduring psychotic illness. Community aftercare arrangements for Hybrid Order disposals were viewed as inferior to community aftercare arrangements for Section 37/41 patients

Spin Injection and Relaxation in Ferromagnet-Semiconductor Heterostructures

We present a complete description of spin injection and detection in Fe/Al_xGa_{1-x}As/GaAs heterostructures for temperatures from 2 to 295 K. Measurements of the steady-state spin polarization in the semiconductor indicate three temperature regimes for spin transport and relaxation. At temperatures below 70 K, spin-polarized electrons injected into quantum well structures form excitons, and the spin polarization in the quantum well depends strongly on the electrical bias conditions. At intermediate temperatures, the spin polarization is determined primarily by the spin relaxation rate for free electrons in the quantum well. This process is slow relative to the excitonic spin relaxation rate at lower temperatures and is responsible for a broad maximum in the spin polarization between 100 and 200 K. The spin injection efficiency of the Fe/Al_xGa_{1-x}As Schottky barrier decreases at higher temperatures, although a steady-state spin polarization of at least 6 % is observed at 295 K.Comment: 3 Figures Submitted to Phys. Rev. Let

Exfiltration from sewers - is it a serious problem?

This paper contends that estimates of exfiltration leakage from sewers, and the problems arising from it may be too high due to an underestimation of the “self-repairing” action of sewage and sewage sediments in raw sewage. Two aspects of a continuing programme of research are reported;(i) the measurement of exfiltration rates from a range of defects in a sewer pipe with pipe bedding effects simulated by a dry gravel trench surround to the pipe, and (ii) an assessment of the persistence of pathogens in the gravel and soil beneath the test rig pipe, using coliforms as a biological indicator. The results show that the introduction of a gravel surround resulted in more rapid and effective sealing across the entire range of defects tested compared to previously performed experiments with the defects discharging to air. Complete sealing eventually occurred on every run for a 10 mm x 10 mm defect situated at the invert of the sewer and the lowest recorded levels in each experiment for a 10 mm wide radial defect were of the order 10-3 to 10-4 ls-1. These results have been scaled-up to estimate leakage rates in lengths of sewers and sub-catchments and levels significantly lower than previously estimated are indicated. Additionally, the pilot experiment to investigate the fate of biological contaminants in the exfiltrate suggests rapid reduction in microorganisms levels beneath the sewer pipe

Technological aids for the rehabilitation of memory and executive functioning in children and adolescents with acquired brain injury (Review).

No abstract available

Spin flip from dark to bright states in InP quantum dots

We report measurements of the time for spin flip from dark (non-light emitting) exciton states in quantum dots to bright (light emitting) exciton states in InP quantum dots. Dark excitons are created by two-photon excitation by an ultrafast laser. The time for spin flip between dark and bright states is found to be approximately 200 ps, independent of density and temperature below 70 K. This is much shorter than observed in other quantum dot systems. The rate of decay of the luminescence intensity, approximately 300 ps, is not simply equal to the radiative decay rate from the bright states, because the rate of decay is limited by the rate of conversion from dark excitons into bright excitons. The dependence of the luminescence decay time on the spin flip time is a general effect that applies to many experiments.Comment: 3 figure

The provision of adult intensive care in Northern Ireland with reference to the role of high dependency care.

In 1991 an audit of Intensive Care Services was carried out by the Northern Ireland Intensive Care Group. In conjunction with this regional overview, all patients in the Regional Intensive Care Unit, (RICU) in the Royal Victoria Hospital were assessed daily, over a 10 month period in 1990-91 and classified as conforming to either intensive care or high dependency status. These data were then used to compare adult intensive care service in Northern Ireland with recent national and international recommendations on intensive care. Ten units in Northern Ireland were surveyed. In regard to national or international guidelines, all ten were deficient to some degree. Four units had significant deficiencies; small patient numbers, lack of 'dedicated' 24 hr medical cover and or deficiencies in the provision of appropriate monitoring and or equipment. There was a large diversity in casemix among the ten units surveyed which suggested differing admission criteria. The bed occupancy of RICU was 100%. Refused admissions constituted a further 13% of unresourced workload. The lack of physically separate, dedicated high dependency unit facilities meant that 26% of bed days were devoted to HDU care (usually for "improved" intensive care unit patients not yet ready for discharge to a general ward. Achieving nationally recommended intensive care standards (on a regional basis) is probably only possible if a number of the smaller intensive care units are redesignated as high dependency units, and patients requiring intensive care are concentrated in a smaller number of larger ICUs. This will increase the frequency of interhospital transfer of critically ill patients