Monitoring the performance of residents during training in off-pump coronary surgery.

OBJECTIVE: Control charts (eg, cumulative sum charts) plot changes in performance with time and can alert a surgeon to suboptimal performance. They were used to compare performance of off-pump coronary artery bypass surgery between a consultant and four resident surgeons and to compare performance of off-pump coronary artery bypass surgery and conventional coronary artery bypass grafting within surgeons. METHODS: Data were analyzed for consecutive patients undergoing coronary artery bypass grafting who were operated on by one consultant or one of four residents. Conversions were analyzed by intention to treat. Perioperative death or one or more of 10 adverse events constituted failure. Predicted risks of failure for individual patients were derived from the study population. Variable life-adjusted displays and risk-adjusted sequential probability ratio test charts were plotted. RESULTS: Data for 1372 patients were analyzed; 769 of the procedures were off-pump coronary artery bypass operations (56.0%). The consultant operated on 382 patients (293 off-pump, 76.7%), and the residents operated on 990 (474 off-pump, 47.9%). Patients operated on by residents tended to be older, more obese, more likely to require an urgent operation, and more likely to need a circumflex artery graft but less likely to have triple-vessel disease. There were 7 conversions (consultant 5, residents 2). The overall failure rate was 8.5% (9.2% for consultant's operations and 8.2% for residents' operations), including 10 deaths (0.7%). Predicted and observed risks of failure were similar for all five surgeons. After 100 off-pump coronary artery bypass operations, performance was the same or better for the residents as for the consultant. For all surgeons, performance was the same or better for off-pump as for conventional coronary artery bypass grafting. CONCLUSIONS: Off-pump coronary artery bypass surgery can be safely taught to cardiothoracic residents. Implementation of continuous performance monitoring for residents is practicable

Analyzing real options and flexibility in engineering systems design using decision rules and deep reinforcement learning

Engineering systems provide essential services to society e.g., power generation, transportation. Their performance, however, is directly affected by their ability to cope with uncertainty, especially given the realities of climate change and pandemics. Standard design methods often fail to recognize uncertainty in early conceptual activities, leading to rigid systems that are vulnerable to change. Real Options and Flexibility in Design are important paradigms to improve a system’s ability to adapt and respond to unforeseen conditions. Existing approaches to analyze flexibility, however, do not leverage sufficiently recent developments in machine learning enabling deeper exploration of the computational design space. There is untapped potential for new solutions that are not readily accessible using existing methods. Here, a novel approach to analyze flexibility is proposed based on Deep Reinforcement Learning (DRL). It explores available datasets systematically and considers a wider range of adaptability strategies. The methodology is evaluated on an example waste-toenergy system. Low and high flexibility DRL models are compared against stochastically optimal inflexible and flexible solutions using decision rules. The results show highly dynamic solutions, with action space parametrized via artificial neural network. They show improved expected economic value up to 69% compared to previous solutions. Combining information from action space probability distributions along expert insights and risk tolerance helps make better decisions in real-world design and system operations. Out of sample testing shows that the policies are generalizable, but subject to tradeoffs between flexibility and inherent limitations of the learning process

Pulsation Period Changes as a Tool to Identify Pre-Zero Age Horizontal Branch Stars

One of the most dramatic events in the life of a low-mass star is the He flash, which takes place at the tip of the red giant branch (RGB) and is followed by a series of secondary flashes before the star settles into the zero-age horizontal branch (ZAHB). Yet, no stars have been positively identified in this key evolutionary phase, mainly for two reasons: first, this pre-ZAHB phase is very short compared to other major evolutionary phases in the life of a star; and second, these pre-ZAHB stars are expected to overlap the loci occupied by asymptotic giant branch (AGB), HB and RGB stars observed in the color-magnitude diagram (CMD). We investigate the possibility of detecting these stars through stellar pulsations, since some of them are expected to rapidly cross the Cepheid/RR Lyrae instability strip in their route from the RGB tip to the ZAHB, thus becoming pulsating stars along the way. As a consequence of their very high evolutionary speed, some of these stars may present anomalously large period change rates. We constructed an extensive grid of stellar models and produced pre-ZAHB Monte Carlo simulations appropriate for the case of the Galactic globular cluster M3 (NGC 5272), where a number of RR Lyrae stars with high period change rates are found. Our results suggest that some -- but certainly not all -- of the RR Lyrae stars in M3 with large period change rates are in fact pre-ZAHB pulsators.Comment: Conference Proceedings HELAS Workshop on 'Synergies between solar and stellar modelling', Rome, June 2009, Astrophys. Space Sci., in the pres

Age, Metallicity, and the Distance to the Magellanic Clouds From Red Clump Stars

We show that the luminosity dependence of the red clump stars on age and metallicity can cause a difference of up to < ~0.6 mag in the mean absolute I magnitude of the red clump between different stellar populations. We show that this effect may resolve the apparent ~0.4 mag discrepancy between red clump-derived distance moduli to the Magellanic Clouds and those from, e.g., Cepheid variables. Taking into account the population effects on red clump luminosity, we determine a distance modulus to the LMC of 18.36 +/- 0.17 mag, and to the SMC of 18.82 +/- 0.20 mag. Our alternate red clump LMC distance is consistent with the value (m-M){LMC} = 18.50 +/- 0.10 adopted by the HST Cepheid Key Project. We briefly examine model predictions of red clump luminosity, and find that variations in helium abundance and core mass could bring the Clouds closer by some 0.10--0.15 mag, but not by the ~0.4 mag that would result from setting the mean absolute I-magnitude of the Cloud red clumps equal to the that of the Solar neighborhood red clump.Comment: Accepted for publication in The Astrophysical Journal Letters, AASTeX 4.0, 10 pages, 1 postscript figur

Growth and subsidence of carbonate platforms: numerical modelling and application to the Dolomites, Italy

The phenomenon of subsidence induced by the growth of carbonate platforms has been investigated with the aid of numerical modelling. The research aimed to quantify the relative contribution of this process in the creation of the accommodation space required to pile up thick neritic bodies. We analysed two end-member deformation styles, namely the elastic behaviour of the lithosphere when locally loaded and the plastic-like reaction of a sedimentary succession underlying a growing carbonate buildup. The former process, analysed using a modified flexural model, generates a regional subsidence. In contrast, the latter process, simulated by considering the compaction occurring in soft sediments, generates a local subsidence. We attempted to quantify the amount and distribution of subsidence occurring below and surrounding an isolated platform and in the adjacent basin. The major parameters playing a role in the process are discussed in detail. The model is then applied to the Late Anisian-Early Ladinian generation of carbonate platforms of the Dolomites, Northern Italy, where they are spectacularly exposed. Taking also into account the Tertiary shortening that occurred in the area, both local and regional subsidence contributions of major platform bodies have been calculated aimed at a reconstruction of the map of the induced subsidence. A major outcome of this study is that the accommodation space, that allowed the accumulation of very thick shallow-water carbonate successions in the Dolomites, was only partially due to lithospheric stretching while the contribution given by the 'local' overload is as high as 20-40% of the total subsidence. Our results also shed some light on the water-depth problem of the Triassic basins as well as on the basin-depth to platform-thickness relationships

Kink propagation in a two-dimensional curved Josephson junction

We consider the propagation of sine-Gordon kinks in a planar curved strip as a model of nonlinear wave propagation in curved wave guides. The homogeneous Neumann transverse boundary conditions, in the curvilinear coordinates, allow to assume a homogeneous kink solution. Using a simple collective variable approach based on the kink coordinate, we show that curved regions act as potential barriers for the wave and determine the threshold velocity for the kink to cross. The analysis is confirmed by numerical solution of the 2D sine-Gordon equation.Comment: 8 pages, 4 figures (2 in color