Simulation, no problem, of course we offer this service! (observations on firms who have worked to make this true)

The paper focuses on the practical experiences of a number of professional firms striving to use simulation to deliver information of value to their clients. It exposes issues such as limitations in existing working practices and the mismatch between language routinely used by facilitators and trainees as well as their different expectations. The paper also discusses the differences observed between incremental implementation of simulation within practices and firms who wished to "jump in at the deep end". Lastly, it addresses the dilemma of how to move simulation tools into the already busy schedules and overloaded programmes of design practices successfully

Business success through process based application of simulation

Progressive design practices are increasingly cognisant of the potential of building energy simulation to assist the delivery of energy efficient, sustainable buildings. However, the success of any building performance assessment hinges on the capabilities of the tool; the collective competences of the team formed to apply it; and, crucially, the existence of an in-house framework within which simulation can be applied with confidence (McElroy and Clarke 1999). There is also a need for the professions to set up mechanisms that facilitate dialogue with vendors in order to influence tool capabilities. And on the related issues of building an in-house competency and a framework for application, the two core issues facing the professions are: i) a need for the development of in-house procedures for management of simulation; and ii) quality assurance of the related models and appraisal results

The Wall-ACE project: an overview of the in-field monitoring on the novel Aerogel-based products

The increasing demand for high energy efficient buildings has lead to a growing interest in building envelope solutions characterised by an high level of innovation. The necessity of providing new solutions for the energy retrofit of existing and – especially – old and/or listed buildings is rising great challenges. A promising perspective comes from the implementation of aerogel-based Super Insulating Materials, which can provide added value with respect to current envelope technologies. In this framework, the ongoing EU H2020 research project Wall-ACE aims at developing a suite of Aerogel-based sustainable insulation solutions for the building market. The five insulation products under development were specifically designed for both the renovation of existing buildings and for the construction of new zero energy buildings. The aim is to achieve for each product a thermal conductivity significantly lower with respect to the state-of-the-art solutions. In this paper, an overview of the research activities which led to the development of these new high insulating products is presented. The products developed were tested through laboratory tests, numerical analysis, small scale and full-scale experimental activities. Thereafter, the different large-scale test facilities and the case study buildings selected in different EU countries (Italy, United Kingdom and France) to test the different products developed are showed

Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting

Over the past two decades, the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure by mask has increased substantially for acutely ill patients. Initial case series and uncontrolled cohort studies that suggested benefit in selected patients1–13 led to many randomized controlled trials (RCTs).14–151 Both methods of ventilation have been used in the setting of acute respiratory failure to avoid endotracheal intubation in different patient populations and settings, with variable success.14–69,117–123,134–141 In addition, noninvasive positive-pressure ventilation has been used to facilitate early liberation from conventional mechanical ventilation72–82 and to prevent reintubation.70,71,83–87These guidelines were developed to answer the following questions: What evidence is available in the literature to support recommendations for the use of noninvasive positive-pressure ventilation and continuous positive airway pressure for patients who are at risk of or who have acute respiratory distress or failure, patients who have undergone surgery and patients who are being weaned from mechanical ventilation or have recently undergone extubation? In addition, how can these two modes of noninvasive ventilation be optimally applied in these settings?Consensus conference statements152,153 and guidelines154–157 exist for the use of noninvasive ventiliation (the term used throughout this paper to refer to both noninvasive positive-pressure ventilation and continuous positive airway pressure) in the acute care setting. However, since publication of the two English guidelines addressing use in the acute care setting,154,156 many new RCTs have been published. In addition, the first154 of the two previous guidelines predated the development of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group methodology,158–160 and a less rigorous methodology was used in the second.156 Accordingly, we conducted a comprehensive search and appraisal of the current literature, using the GRADE methodology to assess the quality of the research and to generate clinical recommendations

Microbial dysbiosis and mortality during mechanical ventilation: a prospective observational study

Abstract Background Host-associated microbial communities have important roles in tissue homeostasis and overall health. Severe perturbations can occur within these microbial communities during critical illness due to underlying diseases and clinical interventions, potentially influencing patient outcomes. We sought to profile the microbial composition of critically ill mechanically ventilated patients, and to determine whether microbial diversity is associated with illness severity and mortality. Methods We conducted a prospective, observational study of mechanically ventilated critically ill patients with a high incidence of pneumonia in 2 intensive care units (ICUs) in Hamilton, Canada, nested within a randomized trial for the prevention of healthcare-associated infections. The microbial profiles of specimens from 3 anatomical sites (respiratory, and upper and lower gastrointestinal tracts) were characterized using 16S ribosomal RNA gene sequencing. Results We collected 65 specimens from 34 ICU patients enrolled in the trial (29 endotracheal aspirates, 26 gastric aspirates and 10 stool specimens). Specimens were collected at a median time of 3 days (lower respiratory tract and gastric aspirates; interquartile range [IQR] 2–4) and 6 days (stool; IQR 4.25–6.75) following ICU admission. We observed a loss of biogeographical distinction between the lower respiratory tract and gastrointestinal tract microbiota during critical illness. Moreover, microbial diversity in the respiratory tract was inversely correlated with APACHE II score (r = − 0.46, p = 0.013) and was associated with hospital mortality (Median Shannon index: Discharged alive; 1.964 vs. Deceased; 1.348, p = 0.045). Conclusions The composition of the host-associated microbial communities is severely perturbed during critical illness. Reduced microbial diversity reflects high illness severity and is associated with mortality. Microbial diversity may be a biomarker of prognostic value in mechanically ventilated patients. Trial registration ClinicalTrials.gov ID NCT01782755. Registered February 4 2013