Auscultating heart and breath sounds through patients’ gowns: who does this and does it matter?

Background Doctors are taught to auscultate with the stethoscope applied to the skin, but in practice may be seen applying the stethoscope to the gown. Objectives To determine how often doctors auscultate heart and breath sounds through patients’ gowns, and to assess the impact of this approach on the quality of the sounds heard. Methods A sample of doctors in the west of Scotland were sent an email in 2014 inviting them to answer an anonymous questionnaire about how they auscultated heart and breath sounds. Normal heart sounds from two subjects were recorded through skin, through skin and gown, and through skin, gown and dressing gown. These were played to doctors, unaware of the origin of each recording, who completed a questionnaire about the method and quality of the sounds they heard. Results 206 of 445 (46%) doctors completed the questionnaire. 124 (60%) stated that they listened to patients’ heart sounds, and 156 (76%) to patients’ breath sounds, through patients’ gowns. Trainees were more likely to do this compared with consultants (OR 3.39, 95% CI 1.74 to 6.65). Doctors of all grades considered this practice affected the quality of the sounds heard. 32 doctors listened to the recorded heart sounds. 23 of the 64 (36%) skin and 23 of the 64 (36%) gown recordings were identified. The majority of doctors (74%) could not differentiate between skin or gown recordings, but could tell them apart from the double layer recordings (p=0.02). Trainees were more likely to hear artefactual added sounds (p=0.04). Conclusions Many doctors listen to patients’ heart and breath sounds through hospital gowns, at least occasionally. In a short test, most doctors could not distinguish between sounds heard through a gown or skin. Further work is needed to determine the impact of this approach to auscultation on the identification of murmurs and added sounds

Why can't every year be a National Year of Reading? An evaluation of the NYR in Yorkshire

An evaluation of the National Year of Reading in Yorkshire was conducted by Leeds Metropolitan University in response to a brief from Museums, Libraries and Archives, Yorkshire. This paper outlines the development and planning of phase one of this small scale qualitative research project and the analysis of the initial results which looks at the impact of NYR on the organisations that delivered the campaign and their work with target groups. The Generic Social Outcomes and the National Indicators were used to develop a theoretical framework. Data were gathered via in depth interviews and focus groups with NYR steering group partners in Calderdale and North Lincolnshire, selected as the two case study authorities. The use of MAXQDA computer-assisted qualitative data analysis software (CAQDAS) enabled data and coding structures to be stored and will facilitate comparison in this longitudinal study. This evaluation will provide material that local library authorities can use for advocacy with a range of audiences including local and central government

A retrospective study on the effects of illness severity and atrial fibrillation on outcomes in the intensive care unit

Introduction: Atrial fibrillation (AF) is common in patients in the intensive care unit (ICU) and has been associated with worse outcomes. However, it is unclear whether AF itself adds to the risk of death or is merely a marker of illness severity. We aimed to record the incidence and outcomes of all patients with different categories of AF and determine whether AF was an independent predictor of death.<p></p> Methods: This retrospective cohort study was undertaken in the ICU of a tertiary-referral university hospital. Category of AF, sex, C-reactive protein (CRP) level, APACHE II score, predicted hospital mortality and survival outcomes were analysed from 1084 records. Percentages, medians and interquartile ranges were used to describe the sample. Chi-square test and the non-parametric Mann–Whitney U test were used, as appropriate, for statistical analysis. Logistic regression analyses were performed to evaluate the association of AF with death in the ICU adjusting for age, sex, CRP level and APACHE II score.<p></p> Results: Overall, 13.6% of patients developed new-onset AF during their critical illness, while 4.3% had a pre-existing history. The hospital mortality rate was higher in those with AF compared with those without (47.9% vs. 30.9%, p<0.001) and higher in those with newly diagnosed AF compared with those with a prior history (53.1% vs. 31.9%, p=0.012). CRP levels were higher in those with AF (p<0.001) compared with those without and higher in those with newly diagnosed AF compared with those with a prior history (p=0.012). On multivariate logistic regression analysis, only the APACHE II score was found to be an independent predictor of death.<p></p> Conclusion: Despite the higher mortality rate in patients with AF, the APACHE II score was the only independent predictor of death within the ICU. Prospective studies are required to explore the apparently reduced risk of dying among those with a prior history of AF.<p></p&gt

DK-1D: a drift-kinetic simulation tool for modelling the shear Alfvén wave and its interaction with collisionless plasma

We present a highly accurate tool for the simulation of shear Alfven waves (SAW) in collisionless plasma. SAW are important in space plasma environments because for small perpendicular scale lengths they can support an electric field parallel to the ambient magnetic field. Electrons can be accelerated by the parallel electric field and these waves have been implicated as the source of vibrant auroral displays. However, the parallel electric field carried by SAW is small in comparison to the perpendicular electric field of the wave, making it difficult to measure directly in the laboratory, or by satellites in the near-Earth plasma environment. In this paper, we present a simulation code that provides a means to study in detail the SAW-particle interaction in both space and laboratory plasma. Using idealised, small-amplitude propagating waves with a single perpendicular wavenumber, the simulation code accurately reproduces the damping rates and parallel electric field amplitudes predicted by linear theory for varying temperatures and perpendicular scale lengths. We present a rigorous kinetic derivation of the parallel electric field strength for small-amplitude SAW and show that commonly-used inertial and kinetic approximations are valid except for where the ratio of thermal to Alfv\'{e}n speed is between 0.7 and 1.0. We also present nonlinear simulations of large-amplitude waves and show that in cases of strong damping, the damping rates and parallel electric field strength deviate from linear predictions when wave energies are greater than only a few percent of the plasma kinetic energy, a situation which is often observed in the magnetosphere. The drift-kinetic code provides reliable, testable predictions of the parallel electric field strength which can be investigated directly in the laboratory, and will help to bridge the gap between studies of SAW in man-made and naturally occuring plasma

RF model of the distribution system as a communication channel, phase 2. Volume 3: Appendices

Program documentation concerning the design, implementation, and verification of a computerized model for predicting the steady-state sinusoidal response of radial configured distribution feeders is presented in these appendices

RF model of the distribution system as a communication channel, phase 2. Volume 4: Sofware source program and illustrations ASCII database listings

Listings of source programs and some illustrative examples of various ASCII data base files are presented. The listings are grouped into the following categories: main programs, subroutine programs, illustrative ASCII data base files. Within each category files are listed alphabetically

Self-consistent wave-particle interactions in dispersive scale long-period field-line-resonances

Using 1D Vlasov drift-kinetic computer simulations, it is shown that electron trapping in long period standing shear Alfven waves (SAWs) provides an efficient energy sink for wave energy that is much more effective than Landau damping. It is also suggested that the plasma environment of low altitude auroral-zone geomagnetic field lines is more suited to electron acceleration by inertial or kinetic scale Alfven waves. This is due to the self-consistent response of the electron distribution function to SAWs, which must accommodate the low altitude large-scale current system in standing waves. We characterize these effects in terms of the relative magnitude of the wave phase and electron thermal velocities. While particle trapping is shown to be significant across a wide range of plasma temperatures and wave frequencies, we find that electron beam formation in long period waves is more effective in relatively cold plasma