Acute Renal Failure Requiring Renal Replacement Therapy in the Intensive Care Unit: Impact on Prognostic Assessment for Shared Decision-Making

A 69 year-old female was receiving renal replacement therapy (RRT) for acute renal failure (ARF) in an intensive care unit (ICU). Consultation was requested from the palliative medicine service to facilitate a shared decision-making process regarding goals of care. Clinician responsibility in shared decision-making includes the formulation and expression of a prognostic assessment providing the necessary perspective for a spokesperson to match patient values with treatment options. For this patient, ARF requiring RRT in the ICU was used as a focal point for preparing a prognostic assessment. A prognostic assessment should include the outcomes of most importance to a discussion of goals of care: mortality risk and survivor functional status, in this case including renal recovery. A systematic review of the literature was conducted to document published data regarding these outcomes for adult patients receiving RRT for ARF in the ICU. 41 studies met the inclusion criteria. The combined mean values for short-term mortality, long-term mortality, renal-function recovery of short- term survivors, and renal-function recovery of long-term survivors were 51.7%, 68.6%, 82.0%, and 88.4% respectively. This case example illustrates a process for formulating and expressing a prognostic assessment for an ICU patient requiring RRT for ARF. Data from the literature review provides baseline information that requires adjustment to reflect specific patient circumstances. The nature of the acute primary process, comorbidities, and severity of illness are key modifiers. Finally, the prognostic assessment is expressed during a family meeting using recommended principles of communication

Acute Lung Injury and Acute Respiratory Distress Syndrome Requiring Tracheal Intubation and Mechanical Ventilation in the Intensive Care Unit: Impact on Managing Uncertainty for Patient-Centered Communication

A 56 year-old male presented with symptoms of pneumonia and findings consistent with acute lung injury (ALI). Deterioration of respiratory function occurred over the first 24 hours of hospitalization leading to placement in an intensive care unit (ICU) followed by tracheal intubation and mechanical ventilation (ETMV). At that time criteria defining acute respiratory distress syndrome (ARDS) were present. The palliative medicine service was asked to address concerns expressed by the patient’s spouse reflecting uncertainty regarding outcome expectations. When interacting with families of incapacitated critically ill patients, clinicians are advised to employ a patient-centered communication process to alleviate family distress and facilitate making necessary decisions in a shared manner. Acknowledging and confronting the uncertainties of a critical illness is an essential component of patient-centered communication. Addressing and managing uncertainty for this case scenario requires consideration of both short- and long-term outcomes including mortality, ventilator independence, and adverse effects on quality of life for survivors. In this paper, ALI/ARDS requiring ETMV in the ICU was used as a focal point for preparing a prognostic assessment incorporating these issues. This assessment was based on a review of recently published literature regarding mortality and ventilator independence of survivors for adult patients receiving ETMV for ALI/ARDS in the ICU. In the studies reviewed, long-term survival reported at 60 days to 1 year was 50-73% with greater than 84% of the survivors in each study breathing independently. Selected articles discussing outcomes other than mortality or recovery of respiratory function, particularly quality of life implications for ALI/ARDS survivors, were also reviewed. This case example of ALI/ARDS requiring ETMV in the ICU is used to illustrate the situation of an incapacitated critically ill patient where the outcome is uncertain. Patient-centered communication with the patient’s representative should acknowledge and address this uncertainty. Managing uncertainty consists of effectively expressing a carefully formulated prognostic assessment and using sound communication principles to alleviate the distress associated with the uncertain outcome probabilities

Peranan Ekstrak Kulit Pisang Untuk Mengatasi Katarak Dengan Hewan Coba Tikus (Rattus Norvegicus)

This study aimed to determine the benefits of banana peel extract to prevent and cure of cataracts. Twenty four rats, 19 days old were divided into eight experimental groups. To develop cataract models, rats were induced by sodium selenites 15 μmol/kg body weight/subcutan (sc). The groups of rats that were induced by sodium selenites and banana peel extract, showed the healing progress of eyes with the thickness of the fog on eyes. The banana peel extract could prevent of cataracts at a concentration of 25% and cure of cataracts at a concentration of 50%

Long dephasing time and high temperature ballistic transport in an InGaAs open quantum dot

We report on measurements of the magnetoconductance of an open circular InGaAs quantum dot between 1.3K and 204K. We observe two types of magnetoconductance fluctuations: universal conductance fluctuations (UCFs), and 'focusing' fluctuations related to ballistic trajectories between openings. The electron phase coherence time extracted from UCFs amplitude is larger than in GaAs/AlGaAs quantum dots and follows a similar temperature dependence (between T^-1 and T^-2). Below 150K, the characteristic length associated with 'focusing' fluctuations shows a slightly different temperature dependence from that of the conductivity.Comment: 6 pages, 4 figures, proceedings of ICSNN2002, to appear in Physica

The information analysis center concept as developed by the Radiation Shielding Information Center in its computer codes activities

Information analysis center concept and computer codes for calculating radiation transport, and shield design

X-rays from Saturn: A study with XMM-Newton and Chandra over the years 2002-05

We present the results of the two most recent (2005) XMM-Newton observations of Saturn together with the re-analysis of an earlier (2002) observation from the XMM-Newton archive and of three Chandra observations in 2003 and 2004. While the XMM-Newton telescope resolution does not enable us to resolve spatially the contributions of the planet's disk and rings to the X-ray flux, we can estimate their strengths and their evolution over the years from spectral analysis, and compare them with those observed with Chandra. The spectrum of the X-ray emission is well fitted by an optically thin coronal model with an average temperature of 0.5 keV. The addition of a fluorescent oxygen emission line at ~0.53 keV improves the fits significantly. In accordance with earlier reports, we interpret the coronal component as emission from the planetary disk, produced by the scattering of solar X-rays in Saturn's upper atmosphere, and the line as originating from the Saturnian rings. The strength of the disk X-ray emission is seen to decrease over the period 2002 - 2005, following the decay of solar activity towards the current minimum in the solar cycle. By comparing the relative fluxes of the disk X-ray emission and the oxygen line, we suggest that the line strength does not vary over the years in the same fashion as the disk flux. We consider possible alternatives for the origin of the line. The connection between solar activity and the strength of Saturn's disk X-ray emission is investigated and compared with that of Jupiter. We also discuss the apparent lack of X-ray aurorae on Saturn and conclude that they are likely to lie below the sensitivity threshold of current Earth-bound observatories. A similar comparison for Uranus and Neptune leads to the same disappointing conclusion.Comment: 10 pages, 5 figures; to be published in 'Astronomy and Astrophysics

Mandibular Advancement for Obstructive Sleep Apnea: Dose Effect on Apnea, Long-Term Use and Tolerance

Background: Previous studies have documented an effect of mandibular advancement (MA) on pharyngeal airway size and collapsibility. Objectives: We aimed to describe the course of the apnea-hypopnea index (AHI) and the snoring index (SI) during progressive MA and to evaluate the long-term efficacy, tolerance and usage of MA therapy after progressive MA titration in sleep apnea patients. Methods: Sixty-six patients with obstructive sleep apnea syndrome underwent sequential sleep recordings during progressive MA titration. Long-term effectiveness, compliance and side effects of oral appliance (OA) in the titrated position were evaluated by questionnaires. Results: OA therapy was started at 80% of the maximum MA. Seventy percent of the patients had only one increment in MA with a marked decrease in mean AHI from 36 to 10. In the remaining cases, further increments in MA were associated with a progressive reduction in AHI and an increase in the number of patients responding to treatment. OA in the titrated position resulted in a 70% decrease in AHI, with 54% of patients showing complete responses, 29% partial responses and 17% no response. Daytime sleepiness and quality of life improved, too. Seventeen months after the start of treatment, 82% of the patients declared that they were still using OA almost all nights. Reported side effects including subjective occlusal changes were frequent but mild. Conclusions: Improvement in AHI during OA is dependent on the amount of MA. Sequential sleep recordings facilitate MA titration. Long-term MA therapy in the titrated position is effective and well tolerated. Reported side effects are frequent but mild