Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients

Hypovolemia caused by internal hemorrhage is a major cause of death in critical care patients. However, hypovolemia is difficult to diagnose in a timely fashion, as obvious symptoms do not manifest until patients are already nearing a critical state of shock. Novel non-invasive methods for detecting hypovolemia in the literature utilize the photoplethysmogram (PPG) waveform generated by the pulse-oximeter attached to a finger or ear. Until now, PPG-based alarms have been evaluated only on healthy patients under ideal testing scenarios (e.g., motionless patients); however, the PPG is sensitive to patient health and significant artifacts manifest when patients move. Since patient health varies within the intensive care unit (ICU) and ICU patients typically do not remain motionless, this work introduces a PPG-based monitor designed to be robust to waveform artifacts and health variability in the underlying patient population. To demonstrate the promise of our approach, we evaluate the proposed monitor on a small sample of intensive care patients from the Physionet database. The monitor detects hypovolemia within a twelve hour window of nurse documentation of hypovolemia when it is present, and achieves a low false alarm rate over patients without documented hypovolemia

Robust Monitoring of Hypovolemia in Intensive Care Patients Using Photoplethysmogram Signals

The paper presents a fingertip photoplethysmography based technique to assess patient fluid status that is robust to waveform artifacts and health variability in the underlying patient population. The technique is intended for use in intensive care units, where patients are at risk for hypovolemia, and signal artifacts and inter-patient variations in health are common. Input signals are preprocessed to remove artifact, then a parameter-invariant statistic is calculated to remove effects of patient-specific physiology. Patient data from the Physionet MIMICII database was used to evaluate the performance of this technique. The proposed method was able to detect hypovolemia within 24 hours of onset in all hypovolemic patients tested, while producing minimal false alarms over non-hypovolemic patients

Clinician-in-the-Loop Annotation of ICU Bedside Alarm Data

In this work, we describe the state of clinical monitoring in the intensive care unit and operating room, where patients are at their most fragile and thus monitoring is most heightened. We describe how large amounts of data generated by monitoring patients’ physiologic signals, along with the ubiquitous aspecific threshold alarms in use today, cause dangerous alarm fatigue for medical caregivers. In order to build more specific, more useful alarms, we gathered a novel data set that would allow us to assess the number, types, and utility of alarms currently in use in the intensive care unit. To do this, we developed a system to collect physiologic monitor data, alarms, and annotations of those alarms provided electronically by clinicians. We describe the collection process for this novel data set and provide a preliminary description of the data

Elective Total Knee Replacement in a Patient With a Left Ventricular Assist Device-Navigating the Challenges With Spinal Anesthesia.

Elective joint surgery in a patient with a left ventricular assist device (LVAD) may become increasingly common as these devices become entrenched in the management of patients with heart failure. Furthermore, regional techniques may be reasonable anesthetic options in this challenging population. This case conference discusses a spinal anesthetic for an elderly female with an LVAD who presented for an elective left total knee arthroplasty. The expert case commentaries that follow the case discussion further explore the anesthetic issues in light of the existing literature

Handoffs and Transitions in Critical Care (HATRICC): Protocol for a Mixed Methods Study of Operating Room to Intensive Care Unit Handoffs

Background: Operating room to intensive care unit handoffs are high-risk events for critically ill patients. Studies in selected patient populations show that standardizing operating room to intensive care unit handoffs improves information exchange and decreases errors. To adapt these findings to mixed surgical populations, we propose to study the implementation of a standardized operating room to intensive care unit handoff process in two intensive care units currently without an existing standard process. Methods/Design: The Handoffs and Transitions in Critical Care (HATRICC) study is a hybrid effectiveness- implementation trial of operating room to intensive care unit handoffs. We will use mixed methods to conduct a needs assessment of the current handoff process, adapt published handoff processes, and implement a new standardized handoff process in two academic intensive care units. Needs assessment: We will use non-participant observation to observe the current handoff process. Focus groups, interviews, and surveys of clinicians will elicit participants’ impressions about the current process. Adaptation and implementation: We will adapt published standardized handoff processes using the needs assessment findings. We will use small group simulation to test the new process’ feasibility. After simulation, we will incorporate the new handoff process into the clinical work of all providers in the study units. Evaluation: Using the same methods employed in the needs assessment phase, we will evaluate use of the new handoff process. Data analysis: The primary effectiveness outcome is the number of information omissions per handoff episode as compared to the pre-intervention period. Additional intervention outcomes include patient intensive care unit length of stay and intensive care unit mortality. The primary implementation outcome is acceptability of the new process. Additional implementation outcomes include feasibility, fidelity and sustainability. Discussion: The HATRICC study will examine the effectiveness and implementation of a standardized operating room to intensive care unit handoff process. Findings from this study have the potential to improve healthcare communication and outcomes for critically ill patients. Trial registration: ClinicalTrials.gov identifier: NCT02267174. Date of registration October 16, 2014

A Roadmap for HEP Software and Computing R&D for the 2020s

Particle physics has an ambitious and broad experimental programme for the coming decades. This programme requires large investments in detector hardware, either to build new facilities and experiments, or to upgrade existing ones. Similarly, it requires commensurate investment in the R&D of software to acquire, manage, process, and analyse the shear amounts of data to be recorded. In planning for the HL-LHC in particular, it is critical that all of the collaborating stakeholders agree on the software goals and priorities, and that the efforts complement each other. In this spirit, this white paper describes the R&D activities required to prepare for this software upgrade.Peer reviewe

Differential cross section measurements for the production of a W boson in association with jets in proton–proton collisions at √s = 7 TeV

Measurements are reported of differential cross sections for the production of a W boson, which decays into a muon and a neutrino, in association with jets, as a function of several variables, including the transverse momenta (pT) and pseudorapidities of the four leading jets, the scalar sum of jet transverse momenta (HT), and the difference in azimuthal angle between the directions of each jet and the muon. The data sample of pp collisions at a centre-of-mass energy of 7 TeV was collected with the CMS detector at the LHC and corresponds to an integrated luminosity of 5.0 fb[superscript −1]. The measured cross sections are compared to predictions from Monte Carlo generators, MadGraph + pythia and sherpa, and to next-to-leading-order calculations from BlackHat + sherpa. The differential cross sections are found to be in agreement with the predictions, apart from the pT distributions of the leading jets at high pT values, the distributions of the HT at high-HT and low jet multiplicity, and the distribution of the difference in azimuthal angle between the leading jet and the muon at low values.United States. Dept. of EnergyNational Science Foundation (U.S.)Alfred P. Sloan Foundatio

Juxtaposing BTE and ATE – on the role of the European insurance industry in funding civil litigation

One of the ways in which legal services are financed, and indeed shaped, is through private insurance arrangement. Two contrasting types of legal expenses insurance contracts (LEI) seem to dominate in Europe: before the event (BTE) and after the event (ATE) legal expenses insurance. Notwithstanding institutional differences between different legal systems, BTE and ATE insurance arrangements may be instrumental if government policy is geared towards strengthening a market-oriented system of financing access to justice for individuals and business. At the same time, emphasizing the role of a private industry as a keeper of the gates to justice raises issues of accountability and transparency, not readily reconcilable with demands of competition. Moreover, multiple actors (clients, lawyers, courts, insurers) are involved, causing behavioural dynamics which are not easily predicted or influenced. Against this background, this paper looks into BTE and ATE arrangements by analysing the particularities of BTE and ATE arrangements currently available in some European jurisdictions and by painting a picture of their respective markets and legal contexts. This allows for some reflection on the performance of BTE and ATE providers as both financiers and keepers. Two issues emerge from the analysis that are worthy of some further reflection. Firstly, there is the problematic long-term sustainability of some ATE products. Secondly, the challenges faced by policymakers that would like to nudge consumers into voluntarily taking out BTE LEI