Investigation in haemodynamic stability during intermittent haemodialysis in the critically ill

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An investigation into the effects of commencing haemodialysis in the critically ill

<b>Introduction:</b> We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. <b>Methods:</b> Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of >+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. <b>Results:</b> Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (>+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. <b>Conclusions:</b> Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature

Postfledging Survival, Movements, and Dispersal of Ring Ouzels (Turdus torquatus)

We thank Invercauld Estate for cooperation with access to Glen Clunie. S. Redpath, J. Wilson, and S. Roos provided valuable comments on the manuscript. This study was funded by the Royal Society for the Protection of Birds, Scottish Natural Heritage, and the Cairngorms National Park Authority. J.L.L. was supported by the Natural Environment Research Council.Peer reviewedPublisher PD

Simulations of Electron Capture and Low-Mass Iron Core Supernovae

The evolutionary pathways of core-collapse supernova progenitors at the low-mass end of the spectrum are beset with major uncertainties. In recent years, a variety of evolutionary channels has been discovered in addition to the classical electron capture supernova channel of super-AGB stars. The few available progenitor models at the low-mass end have been studied with great success in supernova simulations as the peculiar density structure makes for robust neutrino-driven explosions in this mass range. Detailed nucleosynthesis calculations have been conducted both for models of electron capture supernovae and low-mass iron core supernovae and revealed an interesting production of the lighter trans-iron elements (such as Zn, Sr, Y, Zr) as well as rare isotopes like Ca-48 and Fe-60. We stress the need to explore the low-mass end of the supernova spectrum further and link various observables to understand the diversity of explosions in this regime.Comment: 7 page, 3 figures, proceedings of the conference "The AGB-Supernova Mass Transition", to appear in Memorie della Societ\`a Astronomica Italian

The impact of multimodal collaborative virtual environments on learning: A gamified online debate

Online learning platforms are integrated systems designed to provide students and teachers with information, tools and resources to facilitate and enhance the delivery and management of learning. In recent years platform designers have introduced gamification and multimodal interaction as ways to make online courses more engaging and immersive. Current Web-based platforms provide a limited degree of immersion in learning experiences, thereby diminishing potential learning impact. To improve immersion, it is necessary to stimulate some or all the human senses by engaging users in an environment that perceptually surrounds them and allows intuitive and rich interaction with other users and its content. Learning in these collaborative virtual environments (CVEs) can be aided by increasing motivation and engagement through the gamification of the educational task. This rich interaction that combines multimodal stimulation and gamification of the learning experience has the potential to draw students into the learning experience and improve learning outcomes. This paper presents the results of an experimental study designed to evaluate the impact of multimodal real-time interaction on user experience and learning of gamified educational tasks completed in a CVE. Secondary school teachers and students participated in the study. The multimodal CVE is an accurate reconstruction of the European Parliament in Brussels, developed using the REVERIE (Real and Virtual Engagement In Realistic Immersive Environment) framework. In the study, we compared the impact of the VR parliament to a non-multimodal control (an educational platform called Edu-Simulation) for the same educational tasks. Our results show that the multimodal CVE improves student learning performance and aspects of subjective experience when compared to the non-multimodal control. More specifically it resulted in a more positive effect on the ability of the students to generate ideas compared to a non-multimodal control. It also facilitated a sense of presence (strong emotional and a degree of spatial) for students in the VE. The paper concludes with a discussion of future work that focusses on combining the best features of both systems in a hybrid system to increase its educational impact and evaluate the prototype in real-world educational scenarios

Explaining anomalous responses to treatment in the Intensive Care Unit

The Intensive Care Unit (ICU) provides treatment to critically ill patients. When a patient does not respond as expected to such treatment it can be challenging for clinicians, especially junior clinicians, as they may not have the relevant experience to understand the patient’s anomalous response. Datasets for 10 patients from Glasgow Royal Infirmary’s ICU have been made available to us. We asked several ICU clinicians to review these datasets and to suggest sequences which include anomalous or unusual reactions to treatment. Further, we then asked two ICU clinicians if they agreed with their colleagues’ assessments, and if they did to provide possible explanations for these anomalous sequences. Subsequently we have developed a system which is able to replicate the clinicians’ explanations based on the knowledge contained in its several ontologies; further the system can suggest additional explanations which will be evaluated by the senior consultant