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

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

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

An Empirical Non-TNT Approach to Launch Vehicle Explosion Modeling

In an effort to increase crew survivability from catastrophic explosions of Launch Vehicles (LV), a study was conducted to determine the best method for predicting LV explosion environments in the near field. After reviewing such methods as TNT equivalence, Vapor Cloud Explosion (VCE) theory, and Computational Fluid Dynamics (CFD), it was determined that the best approach for this study was to assemble all available empirical data from full scale launch vehicle explosion tests and accidents. Approximately 25 accidents or full-scale tests were found that had some amount of measured blast wave, thermal, or fragment explosion environment characteristics. Blast wave overpressure was found to be much lower in the near field than predicted by most TNT equivalence methods. Additionally, fragments tended to be larger, fewer, and slower than expected if the driving force was from a high explosive type event. In light of these discoveries, a simple model for cryogenic rocket explosions is presented. Predictions from this model encompass all known applicable full scale launch vehicle explosion data. Finally, a brief description of on-going analysis and testing to further refine the launch vehicle explosion environment is discussed

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

Identification of glyceraldehyde‐3‐phosphate dehydrogenase as a Ca2+‐dependent fusogen in human neutrophil cytosol

The membrane fusion events observed during neutrophil degranulation are important aspects of the immunoregulatory system. In an attempt to understand the regulation of granule‐plasma membrane fusion, we have begun characterizing human neutrophil cytosol for fusion activity, finding that 50% of the fusogenic activity could be attributed to members of the annexin family of proteins. The major non‐annexin fusion activity (25% of the total cytosolic activity) was enriched by ion exchange chromatography after depletion of annexins by Ca2+‐dependent phospholipid affinity chromatography. The fusion activity co‐purified with a 10,14‐kDa dimer identified as leukocyte L1 (which was non‐fusogenic), along with an approximately 36‐kDa protein. This protein was identified as glyceraldehyde‐3‐phosphate dehydrogenase (GAPDH) by amino‐terminal sequencing, and the fusion activity was verified using commercially available GAPDH. GAPDH may play an important role in degranulation because it is as potent as annexin I on a mass basis and may constitute up to 25% of the total cytosolic fusion activity of the neutrophil. J. Leukoc. Biol. 63: 331–336; 1998.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142089/1/jlb0331.pd

Violence Prevention: Reaching Adolescents with the Message

To identify an effective medium for communicating with adolescents in a large-scale, cost-effective violence prevention program. A set of youth violence prevention programs was established at The Stamford Hospital, a level II trauma center. The traveling version of the program was presented to middle school students in four parts: 1) a rap music video created by our violence prevention staff, 2) a facilitated discussion about dealing with anger, 3) a video of a trauma resuscitation in our emergency department, and 4) a commercial video of a teenage boy paralyzed after a gunshot wound. A written questionnaire with a five-point rating scale (1 to 5) was used to survey the audience 1 month after the program. The survey assessed the respondents\u27 recall of each part of the program and the perceptions of the value of each part in identifying the problem of violence and reducing violent behavior. Results: Of 99 respondents, the highest ratings for retention, problem identification, and impact were given to the commercial video (combined average category ranking of 11.394) and the rap music video (11.182). The trauma resuscitation video and the discussion of anger were ranked as being less effective (10.253 and 9.383, respectively). The audience seemed to comprehend the main point of the program and ranked the program, as a whole, higher than any of the parts when measured by success at problem identification and impact. Effective communication with adolescents is possible through many avenues. Children of the video age respond well to visual material. A violence prevention program should incorporate effective multimedia presentations. A variety of methods hi combination proves to be most effective

Diversity of Artists in Major U.S. Museums

The U.S. art museum sector is grappling with diversity. While previous work has investigated the demographic diversity of museum staffs and visitors, the diversity of artists in their collections has remained unreported. We conduct the first large-scale study of artist diversity in museums. By scraping the public online catalogs of 18 major U.S. museums, deploying a sample of 10,000 artist records comprising over 9,000 unique artists to crowdsourcing, and analyzing 45,000 responses, we infer artist genders, ethnicities, geographic origins, and birth decades. Our results are threefold. First, we provide estimates of gender and ethnic diversity at each museum, and overall, we find that 85% of artists are white and 87% are men. Second, we identify museums that are outliers, having significantly higher or lower representation of certain demographic groups than the rest of the pool. Third, we find that the relationship between museum collection mission and artist diversity is weak, suggesting that a museum wishing to increase diversity might do so without changing its emphases on specific time periods and regions. Our methodology can be used to broadly and efficiently assess diversity in other fields.Comment: 15 pages, 2 figures, minor revisions of and enhancements to tex

Entangled Photons from Small Quantum Dots

We discuss level schemes of small quantum-dot turnstiles and their applicability in the production of entanglement in two-photon emission. Due to the large energy splitting of the single-electron levels, only one single electron level and one single hole level can be made resonant with the levels in the conduction band and valence band. This results in a model with nine distinct levels, which are split by the Coulomb interactions. We show that the optical selection rules are different for flat and tall cylindrically symmetric dots, and how this affects the quality of the entanglement generated in the decay of the biexciton state. The effect of charge carrier tunneling and of a resonant cavity is included in the model.Comment: 10 pages, 8 figure

PLA2 promotes fusion between PMN‐specific granules and complex liposomes

Neutrophil stimulation results in the activation of a variety of phospholipases, including phospholipase A2 (PLA2), which releases arachidonic acid from the 2 position of membrane phospholipids, leaving a lysophospholipid. Because arachidonic acid is known to be a potent fusogen in vitro, we examined the effect of metabolism by PLA2 on the fusion of complex liposomes (liposomes prepared with a phospholipid composition similar to that found in neutrophil plasma membrane). We observed that PLA2 augmented the fusion of complex liposomes with each other as well as with specific granules isolated from human neutrophils, lowering the Ca2+ requirement for fusion by three orders of magnitude. Furthermore, although lysophospholipids inhibited fusion, the incorporation of arachidonic acid into liposome membranes overcame the inhibitory effects of the lysophospholipids. Thus with PLA2 and annexins we were able to obtain fusion of complex liposomes at concentations of Ca2+ that are close to physiological. Our data suggest that the activation of PLA2 and the generation of arachidonic acid may be the major fusion‐promoting event mediating neutrophil degranulation.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141645/1/jlb0663.pd