Physiological monitoring in the complex multimorbid heart failure patient - Conclusions.

Comorbidities are increasingly recognized as crucial components of the heart failure syndrome. Main specific challenges are polypharmacy, poor adherence to treatments, psychological aspects, and the need of monitoring after discharge. The chronic multimorbid patient therefore represents a specific heart failure phenotype that needs an appropriate and continuous management over time. This supplement issue covers the key points of a series of meeting coordinated by the Heart Failure Association of the European Society of Cardiology (ESC), that have discussed the issues surrounding the effective monitoring of our ever more complex and multimorbid heart failure patients. Here, we present an overview of the complex issues from a healthcare delivery perspective

Renal function, electrolytes, and congestion monitoring in heart failure.

Congestion, renal function, and electrolyte imbalance (particularly potassium) are common problems in the management of the complex multi-morbid patient with heart failure (HF). Poor control of these fundamental clinical features is associated with adverse outcomes. Close monitoring of serum potassium and renal function is recommended by most current guidelines during the management of an episode of acute decompensated HF, yet the recommendations remain poorly implemented. Physicians are advised to treat a state of euvolaemia after an admission with decompensated HF and residual congestion is a marker of worse outcome, yet control of congestion is poorly assessed and managed in real-world practice. This document reflects the key points discussed by a panel of experts during a Heart Failure Association meeting on physiological monitoring of the complex multi-morbid HF patient, and here, we present to aspects related to renal function, electrolyte, and congestion monitoring

Engineering and programming manual: Two-dimensional kinetic reference computer program (TDK)

The Two Dimensional Kinetics (TDK) computer program is a primary tool in applying the JANNAF liquid rocket thrust chamber performance prediction methodology. The development of a methodology that includes all aspects of rocket engine performance from analytical calculation to test measurements, that is physically accurate and consistent, and that serves as an industry and government reference is presented. Recent interest in rocket engines that operate at high expansion ratio, such as most Orbit Transfer Vehicle (OTV) engine designs, has required an extension of the analytical methods used by the TDK computer program. Thus, the version of TDK that is described in this manual is in many respects different from the 1973 version of the program. This new material reflects the new capabilities of the TDK computer program, the most important of which are described

Elemol and amyris oil repel the ticks Ixodes scapularis and Amblyomma americanum (Acari: Ixodidae) in laboratory bioassays.

The essential oil from Amyris balsamifera (Rutaceae) and elemol, a principal constituent of the essential oil of Osage orange, Maclura pomifera (Moraceae) were evaluated in in vitro and in vivo laboratory bioassays for repellent activity against host-seeking nymphs of the blacklegged tick,Ixodes scapularis, and the lone star tick, Amblyomma americanum. Both bioassays took advantage of the tendency of these host-seeking ticks to climb slender vertical surfaces. In one bioassay, the central portion of a vertical strip of filter paper was treated with test solution and ticks placed or allowed to crawl onto the untreated lower portion. In the other bioassay, a strip of organdy cloth treated with test solution was doubly wrapped (treatment on outer layer) around the middle phalanx of a forefinger and ticks released on the fingertip. Both amyris oil and elemol were repellent to both species of ticks. Elemol did not differ significantly in effectiveness against A. americanum from the widely used repellent deet. At 2 and 4 h after application to filter paper, 827 μg amyris oil/cm2 paper repelled 80 and 55%, respectively, of A. americanum nymphs. Ixodes scapularis was repelled by lower concentrations of amyris oil and elemol than A. americanum

A qualitative study of self-evaluation of junior doctor performance: is perceived ’safeness’ a more useful metric than confidence and competence?

© 2015 The Authors. Published by BMJ. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: http://dx.doi.org/10.1136/bmjopen-2015-008521Objectives: The terms confidence and competence have been poorly defined and are often misused by junior doctors. Given safe practice relies on healthcare professionals being aware of their own skill sets improving self-assessment of confidence and competence is important. The aim of this work was to explore junior doctors’ understanding of how they perceive their own performance in respect of managing feverish children in an emergency department. Setting: A children’s emergency department in a tertiary hospital in the East Midlands, UK. Participants: 22 Junior doctors volunteered to undertake focus groups via a meta-planning methodology over 2 years (14 participants in the first year and 8 in the second). Results: Although doctors were aware of the difference between confidence and competence they were not able to distinguish between them in practical terms. The feeling of being ‘safe’ emerged as a term in which there was a shared understanding compared to reported confidence and competence. Conclusions: A perception of ‘safeness’ is a concept that may aid self-evaluation and we present a matrix that might be used by supervisors and educators to examine this and its relationship with confidence and competence.NIH

Physiological and clinical consequences of relief of right ventricular outflow tract obstruction late after repair of congenital heart defects.

BACKGROUND: Right ventricular outflow tract obstruction (RVOTO) is a common problem after repair of congenital heart disease. Percutaneous pulmonary valve implantation (PPVI) can treat this condition without consequent pulmonary regurgitation or cardiopulmonary bypass. Our aim was to investigate the clinical and physiological response to relieving RVOTO. METHODS AND RESULTS: We studied 18 patients who underwent PPVI for RVOTO (72% male, median age 20 years) from a total of 93 who had this procedure for various indications. All had a right ventricular outflow tract (RVOT) gradient >50 mm Hg on echocardiography without important pulmonary regurgitation (less than mild or regurgitant fraction <10% on magnetic resonance imaging [MRI]). Cardiopulmonary exercise testing, tissue Doppler echocardiography, and MRI were performed before and within 50 days of PPVI. PPVI reduced RVOT gradient (51.4 to 21.7 mm Hg, P<0.001) and right ventricular systolic pressure (72.8 to 47.3 mm Hg, P<0.001) at catheterization. Symptoms and aerobic (25.7 to 28.9 mL.kg(-1).min(-1), P=0.002) and anaerobic (14.4 to 16.2 mL.kg(-1).min(-1), P=0.002) exercise capacity improved. Myocardial systolic velocity improved acutely (tricuspid 4.8 to 5.3 cm/s, P=0.05; mitral 4.7 to 5.5 cm/s, P=0.01), whereas isovolumic acceleration was unchanged. The tricuspid annular velocity was not maintained on intermediate follow-up. Right ventricular end-diastolic volume (99.9 to 89.7 mL/m2, P<0.001) fell, whereas effective stroke volume (43.7 to 48.3 mL/m2, P=0.06) and ejection fraction (48.0% to 56.8%, P=0.01) increased. Left ventricular end-diastolic volume (72.5 to 77.4 mL/m2, P=0.145), stroke volume (45.3 to 50.6 mL/m2, P=0.02), and ejection fraction (62.6% to 65.8%, P=0.03) increased. CONCLUSIONS: PPVI relieves RVOTO, which leads to an early improvement in biventricular performance. Furthermore, it reduces symptoms and improves exercise tolerance. These findings have important implications for the management of this increasingly common condition

Mesoscale acid deposition modeling studies

The work performed in support of the EPA/DOE MADS (Mesoscale Acid Deposition) Project included the development of meteorological data bases for the initialization of chemistry models, the testing and implementation of new planetary boundary layer parameterization schemes in the MASS model, the simulation of transport and precipitation for MADS case studies employing the MASS model, and the use of the TASS model in the simulation of cloud statistics and the complex transport of conservative tracers within simulated cumuloform clouds. The work performed in support of the NASA/FAA Wind Shear Program included the use of the TASS model in the simulation of the dynamical processes within convective cloud systems, the analyses of the sensitivity of microburst intensity and general characteristics as a function of the atmospheric environment within which they are formed, comparisons of TASS model microburst simulation results to observed data sets, and the generation of simulated wind shear data bases for use by the aviation meteorological community in the evaluation of flight hazards caused by microbursts

Percutaneous pulmonary valve implantation in humans - Results in 59 consecutive patients

Background - Right ventricular outflow tract (RVOT) reconstruction with valved conduits in infancy and childhood leads to reintervention for pulmonary regurgitation and stenosis in later life.Methods and Results - Patients with pulmonary regurgitation with or without stenosis after repair of congenital heart disease had percutaneous pulmonary valve implantation (PPVI). Mortality, hemodynamic improvement, freedom from explantation, and subjective and objective changes in exercise tolerance were end points. PPVI was performed successfully in 58 patients, 32 male, with a median age of 16 years and median weight of 56 kg. The majority had a variant of tetralogy of Fallot (n = 36), or transposition of the great arteries, ventricular septal defect with pulmonary stenosis (n = 8). The right ventricular (RV) pressure (64.4 +/- 17.2 to 50.4 +/- 14 mm Hg, P < 0.001), RVOT gradient (33 +/- 24.6 to 19.5 +/- 15.3, P < 0.001), and pulmonary regurgitation ( PR) (grade 2 of greater before, none greater than grade 2 after, P < 0.001) decreased significantly after PPVI. MRI showed significant reduction in PR fraction (21 +/- 13% versus 3 +/- 4%, P < 0.001) and in RV end-diastolic volume (EDV) (94 +/- 28 versus 82 +/- 24 mL (.) beat(-1) (.) m(-2), P < 0.001) and a significant increase in left ventricular EDV ( 64 +/- 12 versus 71 +/- 13 mL (.) beat(-1.) m(-2), P = 0.005) and effective RV stroke volume ( 37 +/- 7 versus 42 +/- 9 mL (.) beat(-1) (.) m(-2), P = 0.006) in 28 patients (age 19 +/- 8 years). A further 16 subjects, on metabolic exercise testing, showed significant improvement in V(O2)max (26 +/- 7 versus 29 +/- 6 mL (.) kg(-1) (.) min(-1), P < 0.001). There was no mortality.Conclusions - PPVI is feasible at low risk, with quantifiable improvement in MRI-defined ventricular parameters and pulmonary regurgitation, and results in subjective and objective improvement in exercise capacity