A paediatric telecardiology service for district hospitals in south-east England: an observational study.

The attached article is a Publisher version of the final published version which may be accessed at the link below. Copyright © 2010 BMJ Publishing Group Ltd & Royal College of Paediatrics and Child Health. All rights reservedOBJECTIVES: To compare caseloads of new patients assessed by paediatric cardiologists face-to-face or during teleconferences, and assess NHS costs for the alternative referral arrangements. DESIGN: Prospective cohort study over 15 months. SETTING: Four district hospitals in south-east England and a London paediatric cardiology centre. PATIENTS: Babies and children. INTERVENTION: A telecardiology service introduced alongside outreach clinics. MEASUREMENTS: Clinical outcomes and mean NHS costs per patient. RESULTS: 266 new patients were studied: 75 had teleconsultations (19 of 42 newborns and 56 of 224 infants and children). Teleconsultation patients generally were younger (49% being under 1 year compared with 32% seen personally (p = 0.025)) and their symptoms were not as severe. A cardiac intervention was undertaken immediately or planned for five telemedicine patients (7%) and 30 conventional patients (16%). However, similar proportions of patients were discharged after being assessed (32% telemedicine and 39% conventional). During scheduled teleconferences the mean duration of time per patient in sessions involving real-time echocardiography was 14.4 min, and 8.5 min in sessions where pre-recorded videos were transmitted. Mean cost comparisons for telemedicine and face-to-face patients over 14-day and 6-month follow-up showed the telecardiology service to be cost-neutral for the three hospitals with infrequently-held outreach clinics (1519 UK pounds vs 1724 UK pounds respectively after 14 days). CONCLUSION: Paediatric cardiology centres with small cadres of specialists are under pressure to cope with ever-expanding caseloads of new patients with suspected anomalies. Innovative use of telecardiology alongside conventional outreach services should suitably, and economically, enhance access to these specialists.The Department of Health and the Charitable Funds Committee of the Royal Brompton and Harefield NHS Trust funded the project

Concussion assessment in the Emergency Department: A preliminary study for a quality improvement project

Background In sport, concussion is assessed using the Sports Concussion Assessment Tool (SCAT) 5 and managed with return to play guidelines. Similar, user-friendly tools are rarely, if ever, used in the emergency department (ED). Objectives To evaluate a modified concussion assessment tool designed for the ED (ED-CAT) in patients presenting with a head injury and to identify variables that predict 30-day reattendance. Methods A preliminary, prospective, evaluation in a quality improvement project was conducted in one hospital in South Wales. Patients were recruited if they were over 13 years, and either did not have an ED-CT head scan or had a scan with no acute changes. The primary outcome was 30-day reattendance. Results 40 patients were recruited, 18 of whom had a CT scan. 37 were discharged on the same day with advice, two discharged the next day and one was admitted. Three (7.5%) patients reattended the department. Predictors of reattendance were headache score (median 3.0 vs 5.0; p<0.05), pressure in head score (2.0 vs 5.0; p<0.05), nausea/vomiting score (1.0 vs 3.0; p<0.05), dizziness score (1.0 vs 4.0; p<0.05), blurred vision score (0 vs 4.0; p<0.01), balance problems score (0 vs 4.0; p<0.05), sensitivity to light and confusion score (0 vs 4.0; p<0.01), orientation score (1. 0 vs 0; p<0.05) and immediate memory score (5.0 vs 4.0; p<0.05). Conclusions Key symptoms and signs predicted 30-day reattendance. The ED-CAT requires validation and refinement in a larger population to produce a short, practical, user-friendly, relevant tool for ED head injury assessment

Detection of small-scale folds at a solar wind reconnection exhaust

Observations of reconnection in the solar wind over the last few years appear to indicate that the majority of large-scale reconnecting current sheets are roughly planar, and that reconnection itself is quasi-steady. Most studies of solar wind exhausts have used spacecraft with large separations and relatively low time cadence ion measurements. Here we present multipoint Cluster observations of a reconnection exhaust and the associated current sheet at ACE and Wind, enabling it to be studied on multiple length scales and at high time resolution. While analysis shows that on large scales the current sheet is planar, detailed measurements using the four closely spaced Cluster spacecraft show that the trailing edge of the reconnection jet is nonplanar with folds orthogonal to the reconnection plane, with length scales of approximately 230 ion inertial lengths. Our findings thus suggest that while solar wind current sheets undergoing reconnection may be planar on large scales, they may also exhibit complex smaller-scale structure. Such structure is difficult to observe and has rarely been detected because exhausts are rapidly convected past the spacecraft in a single cut; there is therefore a limited set of spacecraft trajectories through the exhaust which would allow the nonplanar features to be intercepted. We consider how such nonplanar reconnection current sheets can form and the processes which may have generated the 3-D structure that was observed

Generalized Least Energy of Separation for Desalination and Other Chemical Separation Processes

Increasing global demand for fresh water is driving the development and implementation of a wide variety of seawater desalination technologies driven by different combinations of heat, work, and chemical energy. This paper develops a consistent basis for comparing the energy consumption of such technologies using Second Law efficiency. The Second Law efficiency for a chemical separation process is defined in terms of the useful exergy output, which is the minimum least work of separation required to extract a unit of product from a feed stream of a given composition. For a desalination process, this is the minimum least work of separation for producing one kilogram of product water from feed of a given salinity. While definitions in terms of work and heat input have been proposed before, this work generalizes the Second Law efficiency to allow for systems that operate on a combination of energy inputs, including fuel. The generalized equation is then evaluated through a parametric study considering work input, heat inputs at various temperatures, and various chemical fuel inputs. Further, since most modern, large-scale desalination plants operate in cogeneration schemes, a methodology for correctly evaluating Second Law efficiency for the desalination plant based on primary energy inputs is demonstrated. It is shown that, from a strictly energetic point of view and based on currently available technology, cogeneration using electricity to power a reverse osmosis system is energetically superior to thermal systems such as multiple effect distillation and multistage flash distillation, despite the very low grade heat input normally applied in those systems.Center for Clean Water and Clean Energy at MIT and KFUPM (Project R13-CW-10

Enabling people, not completing tasks: patient perspectives on relationships and staff morale in mental health wards in England

BACKGROUND: Mental health inpatient wards are stressful places to work and concerns have been raised regarding quality of patient care and staff wellbeing on these wards. Recent research has suggested that robust support systems and conditions that allow staff to exercise professional autonomy in their clinical work result in better staff morale. Staff value having a voice in their organisations, and say that they would like more interaction with patients and processes to reduce violent incidents on wards. There has been little research into patients' views on staff morale and on how it may impact on their care. This study aimed to explore staff morale and staff-patient relationships from a patient perspective. METHODS: A qualitative investigation was conducted using purposive sampling to select seven inpatient wards in England representing various subspecialties. Semi-structured interviews were carried out with three patients on each ward. A thematic approach to analysis was used, supported by NVivo 10 software. RESULTS: Patients valued staff who worked together as a cohesive team, treated them as individuals, practised in a collaborative way and used enabling approaches to support their recovery. Participating patients described observing staff closely and feeling concerned at times about their well-being and the impact on them of stress and adverse incidents. They tended to perceive ward staff and patients as closely and reciprocally linked, with staff morale having a significant impact on patient well-being and vice versa. Some participants also described modifying their own behaviour because of concerns about staff well-being. Administrative duties, staff shortages and detrimental effects of violent incidents on the ward were seen as compromising staff members' ability to be involved with patients' lives and care. CONCLUSION: Patient views about the factors impacting on staff morale on inpatient wards are similar to those of staff in qualitative studies. Their accounts suggest that staff and patient morale should be seen as interlinked, suggesting there is scope for interventions to benefit both

Effect of entropy generation on the performance of humidification-dehumidification desalination cycles

This paper applies irreversibility analysis to characterize humidification-dehumidification (HD) desalination cycles and to identify how to further improve cycles and components. It is shown that minimizing specific entropy generation of the cycle maximizes the gained output ratio (GOR). It is also shown that each cycle has one limiting component that cannot be substantially improved and a second component that should be the target of efforts to minimize entropy generation. Finally, the failure of exergy analysis to yield conclusive results for on-design HD cycle analysis is discussed briefly.Center for Clean Water and Clean Energy at MIT and KFUP

Experiments and Simulations of short-pulse laser-pumped extreme ultraviolet lasers

Recent experimental work on the development of extreme ultraviolet lasers undertaken using as the pumping source the VULCAN laser at the Rutherford Appleton Laboratory is compared to detailed simulations. It is shown that short duration (similar topicosecond) pumping can produce X-ray laser pulses of a few picosecond duration and that measurement of the emission from the plasma can give an estimate of the duration of the gain coefficient. The Ehybrid fluid and atomic physics code developed at the University of York is used to simulate X-ray laser gain and plasma emission. Two postprocessors to the Ehybrid code are utilized: 1) to raytrace the X-ray laser beam amplification and refraction and 2) to calculate the radiation emission in the kiloelectronvolt photon energy range. The raytracing and spectral simulations are compared, respectively, to measured X-ray laser output and the output of two diagnostics recording transverse X-ray emission. The pumping laser energy absorbed in the plasma is examined by comparing the simulations to experimental results. It is shown that at high pumping irradiance (>10(15) Wcm(-2)), fast electrons are produced by parametric processes in the preformed long scale-length plasmas. These fast electrons do not pump the population inversion and so pumping efficiency is reduced at high irradiance

Population-weighted degree-days: The global shift between heating and cooling

Anthropogenic greenhouse gas emissions are driving global increases in temperature. This rise will likely lead to an increase in demand for cooling in the coming years. However, increasing temperatures are not the main explanatory factor for why the world is moving towards more cooling. This paper compares population and area-weighted cooling and heating degree-days derived using ERA5-Land reanalysis temperature, to show that population growth in warmer parts of the world drives cooling demand globally. The analysis shows that mean global area-weighted heating degree-days have fallen 8.46 °C days/year, whereas population-weighted heating degree-days have fallen by 12.5 °C days/year. At the same time, mean global area-weighted cooling degree-days have risen by 3.0 °C days/year, while population-weighted cooling degree-days have risen at 6.0 °C days/year. By using sub-country analysis, this paper shows that population-weighted degree-days can substantially differ from area-weighted degree-days. Finally, the findings highlight that the choice of heating and cooling degree-day base temperature is the most important parameter in the variability of degree-days and will need to be understood better in order to accurately account for future heating and cooling energy demand

An improved model for multiple effect distillation

Increasing global demand for fresh water is driving research and development of advanced desalination technologies. As a result, a detailed model of multiple effect distillation (MED) is developed that is flexible, simple to implement, and suitable for use in optimization of water and power cogeneration systems. The MED system is modeled in a modular method in which each of the subcomponents is modeled individually and then instantiated as necessary in order to piece together the complete plant model. Modular development allows for studying various MED configurations (such as forward feed, parallel feed, etc.) with minimal code duplication. Use of equation-oriented solvers, such as Engineering Equation Solver and JACOBIAN, rather than sequential solvers, simplifies the coding complexity dramatically and also reduces the number of required approximations and assumptions. The developed model is compared with four prominent forward feed MED models from literature. Through parametric analysis, it is found that the present model compares very well with the simple model provided by El-Sayed and Silver while providing substantially more detail in regard to the various temperature profiles within the MED system. Further, the model is easier to implement than the detailed El-Dessouky model while relying on fewer assumptions. The increased detail of the model allows for proper sensitivities to key variables related to input, operating, and design conditions necessary for use in a cogeneration or hybrid system optimization process.Center for Clean Water and Clean Energy at MIT and KFUPM (Project R13-CW-10