Developing local guidelines for management of sepsis in adults: sepsis guidelines for Pakistan (SGP)

Background: The purpose of developing ‘Sepsis Guidelines for Pakistan’ (SGP) is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign (SSC) tailored to available resources. These recommendations are not meant to replace the SSC Guidelines. Methodology: SGP is an initiative of Pakistan Society of Critical Care Medicine (PSCCM). Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committee i.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, essential interventions to manage sepsis, and general measures for provision of a comprehensive care to patients in sepsis according to the level of education and training of healthcare providers and facilities and resources available in different levels of hospitals. The draft was presented at the 3rd Sepsis Symposium held on 13th September, 2014 in Karachi. The final document was approved by a panel of experts from across the country, representatives of relevant societies and Global Sepsis Alliance (GSA). Recommendations: Hospitals are divided into basic, intermediate and tertiary depending on the availability of diagnostic facilities and training of the medical personnel. Modified definitions of sepsis, severe sepsis, and septic shock are used given the lack of facilities to diagnose sepsis according to international definitionsand criteria in Pakistan. Essential interventions include fluid resuscitation, vasopressors to support the circulation, maintaining oxygen saturation ≥ 90% with oxygen, non-invasive ventilation or mechanical ventilation with lung protective strategies, prompt administration of antibiotics as recommended by the Medical Microbiology & Infectious Diseases Society of Pakistan (MMIDSP) and early source control. It is recommended to avoid starvation, keep an upper blood glucose ≤180 mg/dL, use daily pharmacoprophylaxis against venous thromboembolism (VTE), use stress ulcer prophylaxis, target haemoglobin of 7-9 g/dl in the absence of ischaemic heart disease, avoid sodium bicarbonate therapy as long as pH \u3e 7.20, avoid fresh frozen plasma in the absence of bleeding, transfuse platelets if indicated, not use intravenous immunoglobulins and avoid neuromuscular blocking agents (NMBAs) in the absence of ARDS, target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients and use continuous renal replacement therapy (CRRT) to facilitate management of fluid balance in hemodynamically unstable septic patients in tertiary care centers. In addition a comprehensive, meticulous and multidisciplinary general care is required to improve outcome of sepsis by reinforcing hand hygiene and other infection control measures, adequate monitoring and documentation tailored to the available resources. Goals of care and prognosis should be discussed with patients and families early and either shifting the patient to a hospital with better facilities or limiting or withdrawing therapy in case of poor prognosis should be considered

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Background Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. Methods In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283. Findings Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group. Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset. Funding London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation

Inter-node cooperation pivoting upon location for spatially distributed smart sensor networks

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Channel Equalization Using Multilayer Perceptron Networks

In most digital communication systems, bandwidth limited channel along with multipath propagation causes ISI (Inter Symbol Interference) to occur. This phenomenon causes distortion of the given transmitted symbol due to other transmitted symbols. With the help of equalization ISI can be reduced. This paper presents a solution to the ISI problem by performing blind equalization using ANN (Artificial Neural Networks). The simulated network is a multilayer feedforward Perceptron ANN, which has been trained by utilizing the error back-propagation algorithm. The weights of the network are updated in accordance with training of the network. This paper presents a very effective method for blind channel equalization, being more efficient than the pre-existing algorithms. The obtained results show a visible reduction in the noise content

Distributed Design of a Central Service to Ensure Deterministic Behavior

A central authentication service to EPC (Electronic Product Code) system architecture is proposed in our previous work. A challenge for a central service always arises that how it can ensure a certain level of delay while processing emergent data. The increasing data in the EPC system architecture is tags data. Therefore, authenticating increasing number of tag in the central authentication service with a deterministic time response is investigated and a distributed authentication service is designed in a layered approach. A distributed design of tag searching services in SOA (Service Oriented Architecture) style is also presented. Using the SOA architectural style a self-adaptive authentication service over Cloud is also proposed for the central authentication service, that may also be extended for other applications

A Novel Security Method For RFID Tags

RFID (Radio Frequency Identification) tags use light weighted security methods because of cost constraints. In this paper a lightweight security method is investigated and proved that it significantly lacks in protecting RFID tags against simple cloning attack. In order to protect RFID tag from cloning attacks a novel security method is proposed in this paper. The proposed security method provides high level computational difficulty against the three basic attacking techniques, i.e. eavesdropping, replay and man in the middle. In order to clone a tag, attacker eavesdrops the tag responses and creates a replica of the tag. The novel security method presented in this paper increases the hardness to avoid guessing tag secrets resulting in a conditional none clone able tags. The proposed security method is also evaluated using propositional logic proofs to demonstrate the level of security it can provide

Performance Evaluation of Spatial Vector Routing Protocol for Wireless Sensor Networks

WSNs (Wireless Sensor Networks) is an emerging area of research. Researchers worldwide are working on the issues faced by sensor nodes. Communication has been a major issue in wireless networks and the problem is manifolds in WSNs because of the limited resources. The routing protocol in such networks plays a pivotal role, as an effective routing protocol could significantly reduce the energy consumed in transmitting and receiving data packets throughout a network. In this paper the performance of SVR (Spatial Vector Routing) an energy efficient, location aware routing protocol is compared with the existing location aware protocols. The results from the simulation trials show the performance of SVR

Smart Sensor Network System For Environment Monitoring

SSN (Smart Sensor Network) systems could be used to monitor buildings with modern infrastructure, plant sites with chemical pollution, horticulture, natural habitat, wastewater management and modern transport system. To sense attributes of phenomena and make decisions on the basis of the sensed value is the primary goal of such systems. In this paper a Smart Spatially aware sensor system is presented. A smart system, which could continuously monitor the network to observe the functionality and trigger, alerts to the base station if a change in the system occurs and provide feedback periodically, on demand or even continuously depending on the nature of the application. The results of the simulation trials presented in this paper exhibit the performance of a Smart Spatially Aware Sensor Networks

Lightweight Context Aware Routing in Wireless Sensor Networks for Real Environments

Design and implementation of a WSN (Wireless Sensor Network) that can efficiently work for a longer time period must include identification of the deployment environment context and to conform to the behavior of the sensor nodes. The context information when treated with evaluation factor becomes a process of context awareness and the evaluation factor is called the context attribute. In this paper, we consider the context factor of energy. The paper identifies analyses and evaluates efficiency of two when used in a context aware environment. Furthermore, the study also highlights the strengths and weaknesses of sensor SPIN (Sensor Protocol for Information via Negotiation) and LEACH (Low Energy Adaptive Clustering Hierarchy) protocols with respect to the support for WSN with heavy network traffic conditions. The performance has been evaluated in terms of energy efficiency, data packet transmission, network status, data management, reliability, etc