A randomized controlled proof-of-concept trial of early sedation management using Responsiveness Index monitoring in mechanically ventilated critically ill patients

INTRODUCTION: Deep sedation is associated with adverse patient outcomes. We recently described a novel sedation-monitoring technology, the Responsiveness Index (RI), which quantifies patient arousal using processed frontal facial EMG data. We explored the potential effectiveness and safety of continuous RI monitoring during early intensive care unit (ICU) care as a nurse decision-support tool. METHODS: In a parallel-group controlled single centre proof of concept trial, patients requiring mechanical ventilation and sedation were randomized via sequential sealed envelopes following ICU admission. Control group patients received hourly clinical sedation assessment and daily sedation holds; the RI monitor was connected but data were concealed from clinical staff. The intervention group received control group care, but RI monitoring was visible and nurses were asked to adjust sedation to maintain patients with an RI>20 whenever possible. Traffic-light colour coding (RI<20, Red; 20–40, Amber; >40, Green) simplified decision-making. The intervention lasted up to 48 hours. Sixteen nurses were interviewed to explore their views of the novel technology. RESULTS: We analysed 74 patients treated per protocol (36 intervention; 38 control). The proportion of patients with RI<20 was identical at the start of monitoring (54 % both groups). Overall, the proportion of time with RI<20 trended to lower values for the intervention group (median 16 % (1–3rd quartile 8–30 %) versus 33 % (10–54 %); P = 0.08); sedation and analgesic use was similar. A post hoc analysis restricted to patients with RI<20 when monitoring started, found intervention patients spent less time with low RI value (16 % (11–45 %) versus 51 % (33–72 %); P = 0.02), cumulative propofol use trended to lower values (median 1090 mg versus 2390 mg; P = 0.14), and cumulative alfentanil use was lower (21.2 mg versus 32.3 mg; P = 0.01). RASS scores were similar for both groups. Sedation related adverse event rates were similar (7/36 versus 5/38). Similar proportions of patients had sedation holds (83 % versus 87 %) and were extubated (47 % versus 44 %) during the intervention period. Nurses valued the objective visible data trends and simple colour prompts, and found RI monitoring a useful adjunct to existing practice. CONCLUSIONS: RI monitoring was safe and acceptable. Data suggested potential to modify sedation decision-making. Larger trials are justified to explore effects on patient-centred outcomes. TRIAL REGISTRATION: NCT01361230 (registered April 19, 2010) ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s13054-015-1043-1) contains supplementary material, which is available to authorized users

Arterial stiffness and vascular complications in patients with type 1 diabetes: The finnish diabetic nephropathy (FinnDiane) study

While patients with type 1 diabetes (T1D) are known to suffer from early cardiovascular disease (CVD), we examined associations between arterial stiffness and diabetic complications in a large patient group with T1D.This study included 807 subjects (622 T1D and 185 healthy volunteers (age 40.6 ± 0.7 versus 41.6 ± 1.2 years; P = NS)). Arterial stiffness was measured by pulse wave analysis from each participant. Furthermore, information on diabetic retinopathy, nephropathy, and CVD was collected. The renal status was verified from at least two out of three urine collections.Patients with T1D without signs of diabetic nephropathy had stiffer arteries measured as the augmentation index (AIx) than age-matched control subjects (17.3% ± 0.6% versus 10.0% ± 1.2%; P0.001). Moreover, AIx (OR 1.08; 95% CI 1.03-1.13; P = 0.002) was associated with diabetic laser-treated retinopathy in patients with normoalbuminuria in a multivariate logistic regression analysis. The same was true for AIx and diabetic nephropathy (1.04 (1.01-1.08); P = 0.004) as well as AIx and CVD (1.06 (1.00-1.12); P = 0.01) in patients with T1D.Arterial stiffness was associated with microvascular and macrovascular complications in patients with T1D

Sphingomyelin is associated with kidney disease in type 1 diabetes (The FinnDiane Study)

Diabetic kidney disease, diagnosed by urinary albumin excretion rate (AER), is a critical symptom of chronic vascular injury in diabetes, and is associated with dyslipidemia and increased mortality. We investigated serum lipids in 326 subjects with type 1 diabetes: 56% of patients had normal AER, 17% had microalbuminuria (20 ≤ AER < 200 μg/min or 30 ≤ AER < 300 mg/24 h) and 26% had overt kidney disease (macroalbuminuria AER ≥ 200 μg/min or AER ≥ 300 mg/24 h). Lipoprotein subclass lipids and low-molecular-weight metabolites were quantified from native serum, and individual lipid species from the lipid extract of the native sample, using a proton NMR metabonomics platform. Sphingomyelin (odds ratio 2.53, P < 10−7), large VLDL cholesterol (odds ratio 2.36, P < 10−10), total triglycerides (odds ratio 1.88, P < 10−6), omega-9 and saturated fatty acids (odds ratio 1.82, P < 10−5), glucose disposal rate (odds ratio 0.44, P < 10−9), large HDL cholesterol (odds ratio 0.39, P < 10−9) and glomerular filtration rate (odds ratio 0.19, P < 10−10) were associated with kidney disease. No associations were found for polyunsaturated fatty acids or phospholipids. Sphingomyelin was a significant regressor of urinary albumin (P < 0.0001) in multivariate analysis with kidney function, glycemic control, body mass, blood pressure, triglycerides and HDL cholesterol. Kidney injury, sphingolipids and excess fatty acids have been linked in animal models—our exploratory approach provides independent support for this relationship in human patients with diabetes

Painolastiveden käsittelylaitteiston valinta Containerships VII -alukseen

Tämän opinnäytetyön tarkoituksena oli löytää konttialukseen sopiva painolastiveden käsittelyjärjestelmä nyt markkinoilla olevista vaihtoehdoista eri rajoittavat tekijät huomioiden. Sopivimman käsittelymenetelmän valinnan lisäksi tehtiin vertailua eri valmistajien tuotteiden välillä valitun käsittelymenetelmän ja itse aluksen operoinnin ja teknisten rajoitusten pohjalta. Opinnäytetyön aikana perehdyttiin painolastin käsittelyä ja laitteistoja koskevaan vaatimusympäristöön, eri käsittelymenetelmiin, itse alukseen ja sen rajoituksiin sekä eri valmistajien laitteistoihin. Laitteistojen vertailu tehtiin tarkastelemalla ensiksi mahdollisia sopivia käsittelymenetelmiä, jonka jälkeen jäljelle jääneitä laitteistovaihtoehtoja vertailtiin keskenään. Haasteita opinnäytetyölle asettivat muutoksessa oleva vaatimusympäristö, laitteistoista saatujen tietojen vertailukelpoisuus sekä jälkiasennuksen tilavaatimukset aluksessa. Tuloksissa ja johtopäätöksissä esitetään varustamolle suositus aikaistaa seuraavaa viisivuotiskatsastusta lisäajan saamiseksi hankinnalle ja asennukselle. Samalla kehotettiin tekemään hankinnasta ja asennuksesta riskiarvio, jota tulee säännöllisesti päivittää. Laitteiston mahdolliseksi sijoituspaikaksi aluksessa saatiin kaksi vaihtoehtoa, jotka esitetään tuloksissa ja johtopäätöksissä. Molemmat vaihtoehdot sijaitsevat konehuoneen ulkopuolella, toinen makeavesitankista erotettavassa tilassa ja toinen ruumaan sijoitettavassa kontissa. Vertailluista laitteistoista oli vaikea esittää ehdottomasti parasta vaihtoehtoa. Opinnäytetyön tuloksena päädyttiin kuitenkin suosittelemaan varustamolle Alfa Lavalin PureBallast 3.1-laitteistoa.The objective of the thesis was to find a suitable ballast water management system for the containership. The scope of the study included the treatment system technologies in the market, taking account the limiting factors. In addition to the selection of the treatment system technology, the thesis compares products from different producers, based on the technology, operational aspects of the vessel and technical limitations. Regulations, treatment system technologies, the vessel itself and different producers and theirs products were studied in this thesis. First the suitable treatment system technology was reviewed, after which the remaining pieces of equipment were compared to each other. The changing regulatory environment, the comparability of information of the equipment and lack of space in the vessel for the retrofit, were the main challenges of the thesis. As a recommendation to ship owner, the IOPP renewal survey should be advanced in order to get an extension for the procurement and installation. At the same time, risk assessment including procurement and installation, should be made. As a conclusion, there are two options for the location of the equipment. Both are outside of the engine room, one uses the space in the fresh water tank and the other is a separate container in the cargo hold. It was difficult to find the absolutely best option for the vessel from the pieces of equipment compared. However, as a conclusion, Alfa Laval PureBallast 3.1 was recommended for the ship owner

Työasemien virtualisointi, käyttö ja hallinta

Virtualisoitavien palvelujen määrä lisääntyy yhä enemmän yksityisten ihmisten ja varsinkin yritysten keskuudessa, kun etsitään kustannustehokkaita ratkaisuja. Virtualisointia voidaan hyödyntää monissa eri kohteissa, kuten palvelin-, tallennus-, verkko-, työasema- ja sovellusvirtualisoinnissa. Opinnäytetyössä käsitellään virtuaalityöasemien luonti-, ylläpito- ja käyttömenetelmiä käyttäen esimerkkinä Quest vWorkspace - ja VMware-tuoteperheiden tuotteita. Toimeksiantajallani on vanhoja tuotantokäytössä olevia sellu- ja paperiteollisuuteen tehtyjä ohjelmia, jotka vaativat toimiakseen vanhan käyttöjärjestelmän. Opinnäytetyön tavoitteena oli luoda virtuaalinen työasema tällaista vanhaa ohjelmaa varten käyttäen yrityksessä jo olemassa olevia virtualisointitekniikoita. Virtuaalista työasemaa varten tehtiin pohjakone hyödyntäen VMware vSphere -ohjelmaa. Quest vWorkspace Management Console -ohjelman avulla pohjakoneen tilannevedoksesta luotiin virtuaalikoneet hyödyntäen linked clone -tekniikkaa. Opinnäytetyön aikana Salemate-ohjelma saatiin virtualisoitua onnistuneesti ja Salemate-virtuaalikoneiden ylläpitoasiat ratkaistiin. Samaa virtualisointitapaa voidaan tämän jälkeen hyödyntää myös yrityksen muissa samankaltaisissa tilanteissa. Opinnäytetyön dokumentissa esitellään toimeksiantaja, kerrotaan virtualisoinnin historista, käydään läpi työn kannalta tärkeimmät virtualisointitekniikat ja lopuksi kerrotaan työn eri vaiheista, käytetyistä työmenetelmistä ja työn tuloksena syntyneen virtuaalikoneen käyttömahdollisuuksista yrityksessä.The number of virtualization services is constantly growing among private persons and especially among companies because it is a very cost effective solution. Virtualization services can be utilized for many different purposes, such as server, storage, network, desktop and application virtualization. This thesis examined the creation, upkeep and operating method of workstation virtualization utilizing the products of Quest vWorkspace and VMware product families. The case company still uses some old programs which are made for pulp- and paper industry purposes and they require an old operating system. The objective of this study was to create a virtual workstation for the old operating system using existing virtualization techniques. A base computer was made for the virtual workspace utilizing VMware vSphere –program. With the help of Quest vWorkspace Management Console program, the virtual computers were created from the base computer’s snapshots utilizing linked clone -technique. As a result, the Salemate-program was virtualized successfully and the virtual computer’s upkeep issues were solved. The same virtualization method could be used in similar situations within the company. In this study the case company was presented, the history of virtualization was described, the most important virtualization methods for this thesis are examined and lastly the different stages of this thesis, methods and implications were described