BIS monitoring versus clinical assessment for sedation in mechanically ventilated adults in the intensive care unit and its impact on clinical outcomes and resource utilization.

BACKGROUND: Patients admitted to intensive care and on mechanical ventilation, are administered sedative and analgesic drugs to improve both their comfort and interaction with the ventilator. Optimizing sedation practice may reduce mortality, improve patient comfort and reduce cost. Current practice is to use scales or scores to assess depth of sedation based on clinical criteria such as consciousness, understanding and response to commands. However these are perceived as subjective assessment tools. Bispectral index (BIS) monitors, which are based on the processing of electroencephalographic signals, may overcome the restraints of the sedation scales and provide a more reliable and consistent guidance for the titration of sedation depth.The benefits of BIS monitoring of patients under general anaesthesia for surgical procedures have already been confirmed by another Cochrane review. By undertaking a well-conducted systematic review our aim was to find out if BIS monitoring improves outcomes in mechanically ventilated adult intensive care unit (ICU) patients. OBJECTIVES: To assess the effects of BIS monitoring compared with clinical sedation assessment on ICU length of stay (LOS), duration of mechanical ventilation, any cause mortality, risk of ventilator-associated pneumonia (VAP), risk of adverse events (e.g. self-extubation, unplanned disconnection of indwelling catheters), hospital LOS, amount of sedative agents used, cost, longer-term functional outcomes and quality of life as reported by authors for mechanically ventilated adults in the ICU. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, ProQuest, OpenGrey and SciSearch up to May 2017 and checked references citation searching and contacted study authors to identify additional studies. We searched trial registries, which included clinicaltrials.gov and controlled-trials.com. SELECTION CRITERIA: We included all randomized controlled trials comparing BIS versus clinical assessment (CA) for the management of sedation in mechanically ventilated critically ill adults. DATA COLLECTION AND ANALYSIS: We used Cochrane's standard methodological procedures. We undertook analysis using Revman 5.3 software. MAIN RESULTS: We identified 4245 possible studies from the initial search. Of those studies, four studies (256 participants) met the inclusion criteria. One more study is awaiting classification. Studies were, conducted in single-centre surgical and mixed medical-surgical ICUs. BIS monitor was used to assess the level of sedation in the intervention arm in all the studies. In the control arm, the sedation assessment tools for CA included the Sedation-Agitation Scale (SAS), Ramsay Sedation Scale (RSS) or subjective CA utilizing traditional clinical signs (heart rate, blood pressure, conscious level and pupillary size). Only one study was classified as low risk of bias, the other three studies were classified as high risk.There was no evidence of a difference in one study (N = 50) that measured ICU LOS (Median (Interquartile Range IQR) 8 (4 to 14) in the CA group; 12 (6 to 18) in the BIS group; low-quality evidence).There was little or no effect on the duration of mechanical ventilation (MD -0.02 days (95% CI -0.13 to 0.09; 2 studies; N = 155; I2 = 0%; low-quality evidence)). Adverse events were reported in one study (N = 105) and the effects on restlessness after suction, endotracheal tube resistance, pain tolerance during sedation or delirium after extubation were uncertain due to very low-quality evidence. Clinically relevant adverse events such as self-extubation were not reported in any study. Three studies reported the amount of sedative agents used. We could not measure combined difference in the amount of sedative agents used because of different sedation protocols and sedative agents used in the studies. GRADE quality of evidence was very low. No study reported other secondary outcomes of interest for the review. AUTHORS' CONCLUSIONS: We found insufficient evidence about the effects of BIS monitoring for sedation in critically ill mechanically ventilated adults on clinical outcomes or resource utilization. The findings are uncertain due to the low- and very low-quality evidence derived from a limited number of studies

Probabilistic Clustering of Time-Evolving Distance Data

We present a novel probabilistic clustering model for objects that are represented via pairwise distances and observed at different time points. The proposed method utilizes the information given by adjacent time points to find the underlying cluster structure and obtain a smooth cluster evolution. This approach allows the number of objects and clusters to differ at every time point, and no identification on the identities of the objects is needed. Further, the model does not require the number of clusters being specified in advance -- they are instead determined automatically using a Dirichlet process prior. We validate our model on synthetic data showing that the proposed method is more accurate than state-of-the-art clustering methods. Finally, we use our dynamic clustering model to analyze and illustrate the evolution of brain cancer patients over time

An unusual cause of alveolar hemorrhage post hematopoietic stem cell transplantation: A case report

BACKGROUND: Hematopoietic stem cell transplantation is being increasingly used in cancer therapy. Diffuse alveolar hemorrhage, an early complication of stem cell transplant, results from bacterial, viral and fungal infections, coagulopathy, and engraftment syndrome, or can be idiopathic. Diffuse alveolar hemorrhage associated with Strongyloides stercoralis hyperinfection in stem cell transplant patients has been rarely reported. CASE PRESENTATION: We describe an unusual cause of alveolar hemorrhage post hematopoietic stem cell transplant due to Strongyloides hyperinfection. Therapy with parenteral ivermectin and thiabendazole was initiated but the patient deteriorated and died of respiratory failure and septic shock. CONCLUSION: Strongyloides stercoralis hyperinfection is an unusual cause of alveolar hemorrhage early after hematopoietic stem cell transplant with very high mortality

On The Phase Structure and Thermodynamic Geometry of R-Charged Black Holes

We study the phase structure and equilibrium state space geometry of R-charged black holes in $D = 5$, 4 and 7 and the corresponding rotating $D3$, $M2$ and $M5$ branes. For various charge configurations of the compact black holes in the canonical ensemble we demonstrate new liquid-gas like phase coexistence behaviour culminating in second order critical points. The critical exponents turn out to be the same as that of four dimensional asymptotically AdS black holes in Einstein Maxwell theory. We further establish that the regions of stability for R-charged black holes are, in some cases, more constrained than is currently believed, due to properties of some of the response coefficients. The equilibrium state space scalar curvature is calculated for various charge configurations, both for the case of compact as well as flat horizons and its asymptotic behaviour with temperature is established.Comment: 1 + 33 pages, LaTeX, 25 figures. References adde

Future projections of daily haze-conducive and clear weather conditions over the North China Plain using a perturbed parameter ensemble

We examine past and future changes in both winter haze and clear weather conditions over the North China Plain (NCP) using a perturbed parameter ensemble (PPE) and elucidate the influence of model physical parameterizations on these future projections for the first time. We use a large-scale meteorology-based haze weather index (HWI) with values > 1 as a proxy for haze-conducive weather and HWI 1) is likely to increase whereas the frequency of clear weather (HWI 1) during winter over the NCP is found to be associated with an enhanced warming of the troposphere and weaker northwesterlies in the mid-troposphere over the NCP. We also examined the changes in the interannual variability of the haze-conducive and clear weather and found no marked changes in the variability during future periods. We find a clear influence of model physical parametrizations on climatological mean frequencies for both haze-conducive and clear weather. For the mid- to late 21st century (2033–2086), the parametric effect can explain up to ∼ 80 % of the variance in the climatological mean frequencies of PPE members. This shows that different model physical parameterizations lead to a different evolution of the model’s mean climate, particularly towards the end of the 21st century. Therefore, it is desirable to consider the PPE in addition to the initialized and multimodel ensembles to obtain a more comprehensive range of plausible future projections

Extending colonic mucosal microbiome analysis - Assessment of colonic lavage as a proxy for endoscopic colonic biopsies

This study was supported through GI Research funds and MRC Grant Ref: MR/M00533X/1 to GH.Peer reviewedPublisher PD

Growth characteristics in individuals with osteogenesis imperfecta in North America: results from a multicenter study.

PurposeOsteogenesis imperfecta (OI) predisposes people to recurrent fractures, bone deformities, and short stature. There is a lack of large-scale systematic studies that have investigated growth parameters in OI.MethodsUsing data from the Linked Clinical Research Centers, we compared height, growth velocity, weight, and body mass index (BMI) in 552 individuals with OI. Height, weight, and BMI were plotted on Centers for Disease Control and Prevention normative curves.ResultsIn children, the median z-scores for height in OI types I, III, and IV were -0.66, -6.91, and -2.79, respectively. Growth velocity was diminished in OI types III and IV. The median z-score for weight in children with OI type III was -4.55. The median z-scores for BMI in children with OI types I, III, and IV were 0.10, 0.91, and 0.67, respectively. Generalized linear model analyses demonstrated that the height z-score was positively correlated with the severity of the OI subtype (P < 0.001), age, bisphosphonate use, and rodding (P < 0.05).ConclusionFrom the largest cohort of individuals with OI, we provide median values for height, weight, and BMI z-scores that can aid the evaluation of overall growth in the clinic setting. This study is an important first step in the generation of OI-specific growth curves

Selection for Replicases in Protocells

PMCID: PMC3649988This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

從中文作文看學生的情意表達能力: 個案研究

本文是一個追蹤研究，首先收集研究對象中一至中三的作文103篇，並採用現象學研究法（Phenomenological Research ）的意念進行研究。現象學研究法的重點在於深入了解人類自然的生活，把沒有虛飾的生活體驗和意義呈現出來。本文主要運用兩種分析工具：威堅遜模式（Wilkinson， 1980）及內容分析（text analysis）。論文研究的目的：分析受試者初中情意表達能力的層次。 This article is a longitudinal research which monitors 103 essays of a student from F.1 to F.3 by adopting 'phenomenological research'. Phenomenological research is based on the deep understanding of human life, presenting us with the truest life experiences without disguise. The ability to express emotion of a student as reflected from his Chinese composition. Two models are employed in this research: Wilkinson’s (1980) and text analysis. The objectives of this research is to analyse the abilities of junior secondary school students to express emotions.link_to_OA_fulltex