Sedation and weaning from mechanical ventilation: time for ‘best practice’ to catch up with new realities?

Delivery of sedation in anticipation of weaning of adult patients from prolonged mechanical ventilation is an arena of critical care medicine where opinion-based practice is currently hard to avoid because robust evidence is lacking. We offer some views on this subject, hoping to stimulate debate among colleagues

Data capture by digital pen in clinical trials: A qualitative and quantitative study.

International audienceOBJECTIVES: To investigate the use of the digital pen (DP) system to collect data in a clinical trial. To assess the accuracy of the system in this setting. DESIGN: Qualitative study based on semistructured interviews and a focus group. Quantitative study comparing the DP system and a double manual data-entry system in accuracy of acquiring data by variable type (tick boxes, dates, numbers, letters). SETTING: An ongoing randomised multicentric clinical trial in tertiary care in France. PARTICIPANTS: 27 investigators involved in the trial (anaesthetists) who did or did not include patients, 4 study monitors and the study coordinator. RESULTS: Six key findings emerged: 1) the DP system was easy to use; its utilisation was intuitive, even for investigators inexperienced in informatics; 2) despite its portability, the DP was not always used in front of patients; 3) the DP system did not affect patient recruitment; 4) most of the technical problems of the system occurred during setup (compatibility, password access, antivirus software); 5) the main advantage was quickness of data availability for the study coordination staff and the main hindrance was the extra time required for online verification; and 6) all investigators were ready to use the system again. The investigators had to check 16% of data obtained by the DP system during the verification step. There is no relevant difference between the number of errors for the DP and the double manual data-entry systems: 8/5022 versus 6/5022 data entries. 5 out of 8 DP-system failures were due to the intelligent character recognition system. CONCLUSION: The DP system has a good acceptability among all investigators in a clinical setting, whether they are experienced with computers or not, and a good accuracy, as compared with double manual data entry

Dark Matter and Baryons in the Most X-ray Luminous and Merging Galaxy Cluster RX J1347.5-1145

The galaxy cluster RX J1347-1145 is one of the most X-ray luminous and most massive clusters known. Its extreme mass makes it a prime target for studying issues addressing cluster formation and cosmology. In this paper we present new high-resolution HST/ACS and Chandra X-ray data. The high resolution and sensitivity of ACS enabled us to detect and quantify several new multiply imaged sources, we now use a total of eight for the strong lensing analysis. Combining this information with shape measurements of weak lensing sources in the central regions of the cluster, we derive a high-resolution, absolutely-calibrated mass map. This map provides the best available quantification of the total mass of the central part of the cluster to date. We compare the reconstructed mass with that inferred from the new Chandra X-ray data, and conclude that both mass estimates agree extremely well in the observed region, namely within 400 / h_70 kpc of the cluster center. In addition we study the major baryonic components (gas and stars) and hence derive the dark matter distribution in the center of the cluster. We find that the dark matter and baryons are both centered on the BCG within the uncertainties (alignment is better than <10 kpc). We measure the corresponding 1-D profiles and find that dark matter distribution is consistent with both NFW and cored profiles, indicating that a more extended radial analysis is needed to pinpoint the concentration parameter, and hence the inner slope of the dark matter profile.Comment: 12 pages, Accepted for publication in ApJ, full-res version http://www.physics.ucsb.edu/~marusa/RXJ1347.pd

High Resolution XMM-Newton Spectroscopy of the Cooling Flow Cluster A3112

We examine high signal to noise XMM-Newton European Photon Imaging Camera (EPIC) and Reflection Grating Spectrometer (RGS) observations to determine the physical characteristics of the gas in the cool core and outskirts of the nearby rich cluster A3112. The XMM-Newton Extended Source Analysis Software data reduction and background modeling methods were used to analyze the XMM- Newton EPIC data. From the EPIC data we find that the iron and silicon abundance gradients show significant increase towards the center of the cluster while the oxygen abundance profile is centrally peaked but has a shallower distribution than that of iron. The X-ray mass modeling is based on the temperature and deprojected density distributions of the intra-cluster medium determined from EPIC observations. The total mass of A3112 obeys the M-T scaling relations found using XMM-Newton and Chandra observations of massive clusters at R500. The gas mass fraction f_gas= 0.149^{+0.036}_{-0.032} at R500, is consistent with the seven-year WMAP results. The comparisons of line fluxes and flux limits on the Fe XVII and Fe XVIII lines obtained from high resolution RGS spectra indicate that there is no spectral evidence for cooler gas associated with the cluster with temperature below 1.0 keV in the central <38" (\sim 52 kpc) region of A3112. High resolution RGS spectra also yield an upper limit to the turbulent motions in compact core of A3112 (206 km/s). We find that the energy contribution of turbulence to total energy is less than 6 per cent. This upper limit is consistent with the amount of energy contribution measured in recent high resolution simulations of relaxed galaxy clusters.Comment: Accepted for publication. 14 pages, 12 Figures and 9 Table

Delphi-Consensus Weights for Ischemic and Bleeding Events to Be Included in a Composite Outcome for RCTs in Thrombosis Prevention

To weight ischemic and bleeding events according to their severity to be used in a composite outcome in RCTs in the field of thrombosis prevention.Using a Delphi consensus method, a panel of anaesthesiology and cardiology experts rated the severity of thrombotic and bleeding clinical events. The ratings were expressed on a 10-point scale. The median and quartiles of the ratings of each item were returned to the experts. Then, the panel members evaluated the events a second time with knowledge of the group responses from the first round. Cronbach's a was used as a measure of homogeneity for the ratings. The final rating for each event corresponded to the median rating obtained at the last Delphi round.Of 70 experts invited, 32 (46%) accepted to participate. Consensus was reached at the second round as indicated by Cronbach's a value (0.99 (95% CI 0.98-1.00)) so the Delphi was stopped. Severity ranged from under-popliteal venous thrombosis (median = 3, Q1 = 2; Q3 = 3) to ischemic stroke or intracerebral hemorrhage with severe disability at 7 days and massive pulmonary embolism (median = 9, Q1 = 9; Q3 = 9). Ratings did not differ according to the medical specialty of experts.These ratings could be used to weight ischemic and bleeding events of various severity comprising a composite outcome in the field of thrombosis prevention

The Atacama Cosmology Telescope: Cosmology from Galaxy Clusters Detected via the Sunyaev-Zel'dovich Effect

We present constraints on cosmological parameters based on a sample of Sunyaev-Zel'dovich-selected galaxy clusters detected in a millimeter-wave survey by the Atacama Cosmology Telescope. The cluster sample used in this analysis consists of 9 optically-confirmed high-mass clusters comprising the high-significance end of the total cluster sample identified in 455 square degrees of sky surveyed during 2008 at 148 GHz. We focus on the most massive systems to reduce the degeneracy between unknown cluster astrophysics and cosmology derived from SZ surveys. We describe the scaling relation between cluster mass and SZ signal with a 4-parameter fit. Marginalizing over the values of the parameters in this fit with conservative priors gives sigma_8 = 0.851 +/- 0.115 and w = -1.14 +/- 0.35 for a spatially-flat wCDM cosmological model with WMAP 7-year priors on cosmological parameters. This gives a modest improvement in statistical uncertainty over WMAP 7-year constraints alone. Fixing the scaling relation between cluster mass and SZ signal to a fiducial relation obtained from numerical simulations and calibrated by X-ray observations, we find sigma_8 = 0.821 +/- 0.044 and w = -1.05 +/- 0.20. These results are consistent with constraints from WMAP 7 plus baryon acoustic oscillations plus type Ia supernoava which give sigma_8 = 0.802 +/- 0.038 and w = -0.98 +/- 0.053. A stacking analysis of the clusters in this sample compared to clusters simulated assuming the fiducial model also shows good agreement. These results suggest that, given the sample of clusters used here, both the astrophysics of massive clusters and the cosmological parameters derived from them are broadly consistent with current models.Comment: 12 pages, 7 figures. Submitted to Ap

Correspondências entre Joachim Le Breton e a corte portuguesa na Europa: o nascimento da Missão Artística de 1816

A series of documents kept at the National Archive of Tombo Tower in Lisbon offers us important tools to understand the origin of the 1 81 6 Artistic Mission. Although some Brazilian historians have already explored this field extensively - including Afonso d'Escragnolle Taunay, Mário Barata and Mário Pedrosa in their invaluable publications, not to mention Jean-Baptiste Debret in his writings - it is important to shed new light on this subject so that we may understand how the project of art and industrial education was conceived in Europe byJoachim Le Breton. How did the Mission's project come about? This paper proposes to review certain letters kept at the Tombo Tower and exchanged between Portuguese diplomats and Le Breton in 1815, while the latter was still in Paris, for the ultimate purpose of retracing the first steps of this story.Uma série de documentos conservados no Arquivo Nacional da Torre do Tombo, em Lisboa, oferece-nos ainda instrumentos significativos para a compreensão da origem da Missão Artística de 1816. Embora alguns historiadores brasileiros tenham já explorado intensamente este campo, dentre os quais as preciosas publicações de Afonso d'Escragnolle Taunay, Mário Barata e Mário Pedrosa - destacando-se também os escritos deJean-Baptiste Debret -, convém buscar novas luzes para entender a concepção do projeto de ensino artístico e industrial, ainda na Europa, pelas mãos de Joachim Le Breton. Como surgiu o projeto da Missão? Este artigo tem como objetivo a análise de algumas correspondências conservadas na Torre do Tombo, trocadas entre Le Breton e os diplomatas portugueses em 1815, ainda em Paris, visando à recuperação dos primeiros passos desta história

CMB-S4: Forecasting Constraints on Primordial Gravitational Waves

CMB-S4---the next-generation ground-based cosmic microwave background (CMB) experiment---is set to significantly advance the sensitivity of CMB measurements and enhance our understanding of the origin and evolution of the Universe, from the highest energies at the dawn of time through the growth of structure to the present day. Among the science cases pursued with CMB-S4, the quest for detecting primordial gravitational waves is a central driver of the experimental design. This work details the development of a forecasting framework that includes a power-spectrum-based semi-analytic projection tool, targeted explicitly towards optimizing constraints on the tensor-to-scalar ratio, $r$, in the presence of Galactic foregrounds and gravitational lensing of the CMB. This framework is unique in its direct use of information from the achieved performance of current Stage 2--3 CMB experiments to robustly forecast the science reach of upcoming CMB-polarization endeavors. The methodology allows for rapid iteration over experimental configurations and offers a flexible way to optimize the design of future experiments given a desired scientific goal. To form a closed-loop process, we couple this semi-analytic tool with map-based validation studies, which allow for the injection of additional complexity and verification of our forecasts with several independent analysis methods. We document multiple rounds of forecasts for CMB-S4 using this process and the resulting establishment of the current reference design of the primordial gravitational-wave component of the Stage-4 experiment, optimized to achieve our science goals of detecting primordial gravitational waves for $r > 0.003$ at greater than $5\sigma$, or, in the absence of a detection, of reaching an upper limit of $r < 0.001$ at $95\%$ CL.Comment: 24 pages, 8 figures, 9 tables, submitted to ApJ. arXiv admin note: text overlap with arXiv:1907.0447