Bronchoscopic Management of COPD and Advances in Therapy

Chronic Obstructive Pulmonary Disease (COPD) is a highly prevalent and morbid disease marked by irreversible structural changes in the lungs. Bronchoscopic therapies have significantly expanded the treatment armamentarium for patients with persistent symptoms by reducing the physiologic detriments of hyperinflation in a less invasive fashion than surgical lung volume reduction. The spectrum of bronchoscopic techniques to reduce hyperinflation includes endobronchial valves, coils, thermal ablation, and biologic sealants. Other therapies focus on reducing parasympathetic tone and mucus hypersecretion and include targeted lung denervation, bronchial rheoplasty, and cryospray techniques. In this article, we will review the variety of techniques for bronchoscopic lung volume reduction, both established and investigational, along with their respective benefits and complications and will briefly review other investigational therapies for COPD

Optimal scheduling of an integrated batch and continuous process system

Bibliography: leaves 136-139.An industrial problem has been posed involving the determination of the optimal scheduling and sequencing of a batch process system. The plant incorporates both batch and continuous units and is further complicated by the existence of a nonlinear relationship between the processing rate and the lot size in the continuous plant. The primary goal of this project is to investigate the application of a rigorous mathematical approach to determine the optimal operating policy of a complex processing system. In broad terms, scheduling involves the allocation of a limited number of resources to ensure the completion of a set of tasks, in an optimal way. The problem is formulated as a mathematical model through the use of mixed-integer programming. The difficulty associated with this type of work is in describing the plant using constraints to develop a mathematical model which both accurately reflects the plant and renders the problem solvable. The model must incorporate the connectivity of the plant and prevent resource-task allocation conflicts. A survey of the pertinent literature has been conducted and is reviewed in Chapter 2. Here the principles of batch scheduling are addressed. The focus of the literature review is on the formulation of such problems into a mathematical representation. A description of two fundamentally different approaches for the formulation of short-term scheduling problems is presented. Other aspects of the review include the commercially available software used in the solution of these problems, campaign planning and on-line scheduling. The work in this thesis initially focuses on the scheduling of a simplified version of the industrial plant. The simplified version consists exclusively of batch processing units. The motivation for this was to develop a formulation which incorporated the unique characteristics of the full problem but was computationally easier to solve. A number of scenarios were conducted which show both the flexibility of the formulation and the ability of the formulation to reschedule tasks when faced with different operating conditions. In the discussion of these scenarios, issues such as the computational efficiency and the implications of the results are addressed. The next step was to add a continuous plant upstream to the simplified batch process. The continuous plant exhibits a nonlinear relationship between the processing rate and the efficiency of operation. An approximation of the non-linearity is proposed and further scenario studies are carried out. Finally, the full problem is tackled but due to the great computational expense required to solve the problem an alternative method is proposed. This method is based on a series of random-type scenarios, which serve as an alternative as well as benchmark to the solutions obtained via rigorous optimization

Pleural Fluid Resolution Is Associated with Improved Survival in Patients with Malignant Pleural Effusion

Malignant pleural effusion is associated with a poor prognosis and, while risk stratification models exist, prior studies have not evaluated pleural fluid resolution and its association with survival. We performed a retrospective review of patients diagnosed with malignant pleural effusion between 2013 and 2017, evaluating patient demographics, pleural fluid and serum composition, and procedural and treatment data using Cox regression analysis to evaluate associations with survival. In total, 123 patients were included in the study, with median survival from diagnosis being 4.8 months. Resolution of malignant pleural fluid was associated with a significant survival benefit, even when accounting for factors such as placement of an indwelling pleural catheter, anti-cancer therapy, pleural fluid cytology, cancer pheno/genotypes, and pleural fluid characteristics. Elevated fluid protein, placement of an indwelling pleural catheter, and treatment with targeted or hormone therapies were associated with pleural fluid resolution. We conclude that the resolution of pleural fluid accumulation in patients with malignant pleural effusion is associated with a survival benefit possibility representing a surrogate marker for treatment of the underlying metastatic cancer. These findings support the need to better understand the mechanism of fluid resolution in patients with malignant pleural effusion as well as the tumor–immune interplay occurring with the malignant pleural space

Growth, profits and technological choice: The case of the Lancashire cotton textile industry

Using Lancashire textile industry company case studies and financial records, mainly from the period just before the First World War, the processes of growth and decline are re-examined. These are considered by reference to the nature of Lancashire entrepreneurship and the impact on technological choice. Capital accumulation, associated wealth distributions and the character of Lancashire business organisation were sybiotically linked to the success of the industry before 1914. However, the legacy of that accumulation in later decades, chronic overcapacity, formed a barrier to reconstruction and enhanced the preciptious decline of a once great industry

Corporate governance and financial constraints on strategic turnarounds

The paper extends the Robbins and Pearce (1992) two-stage turnaround response model to include governance factors. In addition to the retrenchment and recovery, the paper proposes the addition of a realignment stage, referring specifically to the re-alignment of expectations of principal and agent groups. The realignment stage imposes a threshold that must be crossed before the retrenchment and hence recovery stage can be entered. Crossing this threshold is problematic to the extent that the interests of governance-stakeholder groups diverge in a crisis situation. The severity of the crisis impacts on the bases of strategy contingent asset valuation leading to the fragmentation of stakeholder interests. In some cases the consequence may be that management are prevented from carrying out turnarounds by governance constraints. The paper uses a case study to illustrate these dynamics, and like the Robbins and Pearce study, it focuses on the textile industry. A longitudinal approach is used to show the impact of the removal of governance constraints. The empirical evidence suggests that such financial constraints become less serious to the extent that there is a functioning market for corporate control. Building on governance research and turnaround literature, the paper also outlines the general case necessary and sufficient conditions for successful turnarounds

Feasibility of a prototype carbon nanotube enabled stationary digital chest tomosynthesis system for identification of pulmonary nodules by pulmonologists

Background: Screen detected and incidental pulmonary nodules are increasingly common. Current guidelines recommend tissue sampling of solid nodules >8 mm. Bronchoscopic biopsy poses the lowest risk but is paired with the lowest diagnostic yield when compared to CT-guided biopsy or surgery. A need exists for a safe, mobile, low radiation dose, intra-procedural method to localize biopsy instruments within target nodules. This retrospective cross sectional reader feasibility study evaluates the ability of clinicians to identify pulmonary nodules using a prototype carbon nanotube radiation enabled stationary digital chest tomosynthesis system. Methods: Patients with pulmonary nodules on prior CT imaging were recruited and consented for imaging with stationary digital chest tomosynthesis. Five pulmonologists of varying training levels participated as readers. Following review of patient CT and a thoracic radiologist’s interpretation of nodule size and location the readers were tasked with interpreting the corresponding tomosynthesis scan to identify the same nodule found on CT. Results: Fifty-five patients were scanned with stationary digital chest tomosynthesis. The median nodule size was 6 mm (IQR =4–13 mm). Twenty nodules (37%) were greater than 8 mm. The radiation entrance dose for s-DCT was 0.6 mGy. A significant difference in identification of nodules using s-DCT was seen for nodules <8 vs. ≥8 mm in size (57.7% vs. 90.9%, CI: −0.375, −0.024; P<0.001). Inter-reader agreement was fair, and better for nodules ≥8 mm [0.278 (SE =0.043)]. Conclusions: With system and carbon nanotube array optimization, we hypothesize the detection rate for nodules will improve. Additional study is needed to evaluate its use in target and tool co-localization and target biopsy

Electromagnetic Transthoracic Nodule Localization for Minimally Invasive Pulmonary Resection

Background: Increased use of chest computed tomography and the institution of lung cancer screening have increased the detection of ground-glass and small pulmonary nodules. Intraoperative localization of these lesions via a minimally invasive thoracoscopic approach can be challenging. We present the feasibility of perioperative transthoracic percutaneous nodule localization using a novel electromagnetic navigation platform. Methods: This is a multicenter retrospective analysis of a prospectively collected database of patients who underwent perioperative electromagnetic transthoracic nodule localization before attempted minimally invasive resection between July 2016 and March 2018. Localization was performed using methylene blue or a mixture of methylene blue and the patient's blood (1:1 ratio). Patient, nodule, and procedure characteristics were collected and reported. Results: Thirty-one nodules were resected from 30 patients. Twenty-nine of 31 nodules (94%) were successfully localized. Minimally invasive resection was successful in 93% of patients (28/30); 7% (2/30) required conversion to thoracotomy. The median nodule size was 13 mm (interquartile range 25%-75%, 9.5-15.5), and the median depth from the surface of the visceral pleura to the nodule was 10 mm (interquartile range 25%-75%, 5.0-15.9). Seventy-one percent (22/31) of nodules were malignant. No complications associated with nodule localization were reported. Conclusions: The use of intraoperative electromagnetic transthoracic nodule localization before thoracoscopic resection of small and/or difficult to palpate lung nodules is safe and effective, potentially eliminating the need for direct nodule palpation. Use of this technique aids in minimally invasive localization and resection of small, deep, and/or ground-glass lung nodules

The industrial meaning of "gradualism": the Labour party and industry, 1918-1931

In the period from 1918 until 1931, the British Labour party adhered to the precepts of "gradualism": incrementally and by degrees, the party would gain support and pass legislation in an inexorable progress toward the socialist millennium. For a while, it seemed that this strategy would carry all before it. Emerging from the First World War with a "socialist" commitment, it became the largest opposition party at the 1918 general election. In 1922 it became the clear opposition to the Conservatives, and Ramsay MacDonald was reelected leader after an eight-year break. A short-lived minority Labour government in 1924 was followed by heavy electoral defeat, but the party was able to form its second minority government in 1929. However, its credibility was destroyed by soaring unemployment, and the ministry collapsed in the summer of 1931 after failing to agree on public expenditure cuts. MacDonald and the chancellor of the Exchequer, Philip Snowden, led a small Labour cohort into a "National" government, which went on to crush Labour at the polls that October. Detailed work on this complex period of Labour's history is hard to find, however. Little work has been done on policy: in particular, it is surprising that, given the party's symbiotic link with trade unionism and the central role of industry in Labour leaders' conception of the transformation to socialism, so little attention has been paid to the party's industrial policy in this period