Characterisation of manual chest physiotherapy and respiratory response in mechanically ventilated children

Chest physiotherapy is integral to the management of mechanically ventilated children and previous research has confirmed that chest wall vibrations are the manual techniques used most frequently by physiotherapists in this population. Chest wall vibrations involve the application of a compressive force to the chest during expiration, with the aim of removing accumulated secretions and improving lung aeration. However, these techniques are largely unquantified and may vary greatly between practitioners and clinical units, with any significance of such variability remaining unknown.In order to evaluate the effectiveness of any therapy it is important to have a means of quantifying the treatment. It is challenging to measure techniques which involve manual contact between the therapist and patient, and at the inception of this project no means existed of directly measuring the force applied through the hand during treatments. The effectiveness of chest physiotherapy in mechanically ventilated patients is likely to be influenced by the interactions between different treatment components, such as the magnitude and pattern of the chest wall vibrations and the accompanying lung inflations. It is therefore essential to assess both the forces applied during the vibrations with the simultaneous changes in air flow, recording the ventilatory pattern throughout the treatment.The study hypotheses were:1. It is possible to create a technique to measure chest wall vibration forces during clinical treatments, and to relate such forces to simultaneous changes in respiratory flows, volumes and pressures2. Maximum and mean force applied during chest wall vibrations increase with the size and age of the child3. Manual lung hyperinflations with chest wall vibrations result in an increase in peak expiratory flow above that observed during baseline mechanical ventilation4. After adjusting for inflation volume, application of chest wall vibrations result in an increase in peak expiratory flow above that obtained during manual lung inflations aloneThe primary objectives of this research were to:1. Develop a method of quantifying chest wall vibration forces and a means of evaluating simultaneous changes in force with those of respiratory flow and pressure in ventilated infants and children of all ages2. Estimate the variability over time, within and between individual physiotherapists when treating the same and different subjects with chest wall vibrations3. Conduct a study to:i) Assess the feasibility of measuring force and respiration in a population of critically ill, mechanically ventilated childrenii) Characterise the magnitude and pattern of forces applied during chest wall vibrations and evaluate the direct effects of these manoeuvres on flow and pressure changes in the lungsiii) Determine the relative contribution of manual lung inflations and chest wall vibrations to any observed increase in expiratory airflow A secondary objective was to explore the short term effects of chest physiotherapy, by recording changes in ventilation, respiratory system mechanics and blood gases following treatment.The thesis comprises four chapters:Chapter 1 contains a comprehensive literature review of published studies demonstrating the current knowledge base of the respiratory problems of mechanical ventilation in children, chest physiotherapy in intensive care and the relationship of chest physiotherapy to normal mechanisms of airway clearance.Chapter 2 describes the process of creating a dynamic force-sensing technique to characterise manual chest physiotherapy, detailing protocol and analysis refinement during pilot force and respiratory data collection. Assessment of the variability within and between physiotherapists is also assessed.Chapter 3 details a clinical study undertaken in intensive care units at Great Ormond Street Hospital for Children NHS Trust, London. The results are presented and interpreted.Chapter 4 discusses the findings of the thesis in relation to earlier research, highlights the strengths and limitations of the current study, interprets the clinical implications of the research and suggests future work

The association between graded physical activity in postmenopausal British women, and the prevalence and incidence of hip and wrist fractures.

BACKGROUND: physical activity is promoted for older women as a means of maintaining health and avoiding falls and fractures. Findings relating physical activity of older women to risk of falls and fracture are contradictory. The association between level of physical activity and prevalent and incident hip and wrist fractures was examined in a large representative sample of postmenopausal British women. METHODS: data from the British Women's Heart and Health Study, a cohort study of 4286 postmenopausal women aged 60-79, from 23 UK towns were used. Information on physical activity, anthropometry, falls and hip and wrist fractures from baseline examination and questionnaire (1999-2001) and follow-up questionnaire (2007) were available. Cross-sectional baseline prevalence data were analysed using logistic regression and cohort incidence data using a Cox proportional hazards model examining the association of physical activity with fracture outcomes. RESULTS: 3003 (70%) women, with complete baseline data, were studied. 13.6% had previously fractured a wrist and 1.3% a hip. Analyses unadjusted for confounders showed moderate protective associations between activity and fracture risk. After adjustment for confounders there was a weak trend towards fewer hip fractures (adjusted OR 0.13 [0.01, 1.18]) and more wrist fractures (adjusted OR 1.35 [0.76, 2.48]), amongst most active compared with inactive women. The crude incidence rate of wrist and/or hip fracture was 7.0 [5.9, 8.2] per 1000 person-years. No evidence was found for an association between physical activity and combined incident hip and/or wrist fracture (adjusted rate ratio inactive versus most active 1.69 [0.67, 4.24]). CONCLUSION: no clear associations between graded physical activity and hip/wrist fractures were seen but estimates were imprecise. Physical activities are heterogeneous and individual fracture types and mechanisms differ. Very large prospective observational studies are required to disentangle the precise effects of different activity patterns on different fracture types

A Compressive Multi-Mode Superresolution Display

Compressive displays are an emerging technology exploring the co-design of new optical device configurations and compressive computation. Previously, research has shown how to improve the dynamic range of displays and facilitate high-quality light field or glasses-free 3D image synthesis. In this paper, we introduce a new multi-mode compressive display architecture that supports switching between 3D and high dynamic range (HDR) modes as well as a new super-resolution mode. The proposed hardware consists of readily-available components and is driven by a novel splitting algorithm that computes the pixel states from a target high-resolution image. In effect, the display pixels present a compressed representation of the target image that is perceived as a single, high resolution image.Comment: Technical repor

Riding the waves of policy? The case of basic skills in adult and community learning in England

This paper draws on data from secondary sources and in-depth interviews to explore the question: What is the impact of policy on teaching, learning, assessment and inclusion in Adult and Community Learning (ACL) Skills for Life (SfL) provision? In particular, it focuses on the government’s use of five policy steering mechanisms - funding, inspection, planning, targets and policy initiatives (in this case SfL). The design of the study1 allows us to use evidence from four sets of interviews with teachers, learners and managers of ACL in eight sites of learning (four in London and four in the North East) over a period of twenty-six months of considerable policy turbulence. We argue first, that there is a symbiotic relationship between ACL and SfL provision and second, that while the combined effects of targets and funding have the most powerful effects on tutor and manager actions, inspection, planning and tutors’ and managers’ own professional values also have an important role in shaping the teaching of literacy and numeracy in ACL sites. We conclude by suggesting that professionals at the local level should be allowed to play a greater role in SfL policy-making to ensure effective policy and practice

Assessing the Efficiency of Herbivorous Fish as Nutrient Sinks in an Integrated Freshwater Cage Aquaculture System Using Phosphorus Mass Balance Model

Integrated aquaculture systems simultaneously culture multiple species to reduce waste outputs by increasing trophic efficiency and nutrient retention. Using a phosphorus (P) mass balance model, this study assessed the efficacy of an integrated aquaculture system that used herbivorous fish to reduce waste loading into a freshwater reservoir in Guizhou Province, China. Six modified cages featured the addition of a 1 m wide outer cage surrounding a 10 m square inner cage stocked with intensively fed channel catfish (Ictalarus punctatus). Outer cages were stocked with filter-feeding herbivorous fish including, bighead carp (Hypophthalmichthys nobilis), common carp (Cyprinus carpio), and Nile tilapia (Oreochromis nilocticus). These species fed on phytoplankton, particulate waste from the inner cage, and periphyton, thereby retaining nutrients and possibly improving water quality around the cages. This experiment compared phosphorus balances of modified cages with three traditional cages also stocked with channel catfish, but which did not include an outer cage. Additional experiments compared growth rates of fish in outer cages to fish in a control cage distant from any impacts of intensively fed inner cages. Water samples were also taken to measure total phosphorus concentrations inside the cages, 1 m outside cages, and at reference sites 500-1000 m away from cages. Outer cage fish retained 0.08-0.1 kg P ton-1 harvested fish or <1% of total P inputs cage-1. Catfish in traditional cages grew slower (p<0.05) than fish in modified cages. However, there was no difference in retained phosphorus, total waste, soluble waste, or solid waste ton-1 of fish cultured between the cages. Total kg P input ton-1 fish harvested ranged from 14.1-18.8. According to the 2 model, catfish retained 24-43% of total P inputs; in addition, catfish particulate waste was 38.5% and soluble waste 18-37% of total P inputs, respectively. During grow-out, bighead carp and tilapia in outer cages increased body mass by 21% and 75%, respectively, while these same species in the control cage exhibited -3% and 0% growth. This supports the hypothesis that fish in outer cages had access to surplus energy drifting out of inner cages and successfully retained nutrients from inner cages. Contrary to expectations, total phosphorus concentrations in water samples showed no difference (p>0.05) between modified cages, traditional cages, and reference sites. Even though I concluded that outer cage fish retained nutrients from inner cages, retention was not substantial enough to improve water quality around modified cages. However, since phosphorus loading from cages had no impact on reservoir water quality, this suggests that phosphorus inputs from aquaculture are rapidly diluted and dispersed in the reservoir.Master of ScienceNatural Reources and EnvironmentUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/88169/1/Hayse-Gregson_MS_Thesis_Dec2011.pd

Children's role in the community response to HIV in Zimbabwe

Introduction: Recent debates on how to achieve an optimal HIV response are dominated by intervention strategies that fail to recognize children’s role in the community response to HIV. Whilst formal responses are key to the HIV response, they must recognize and build on indigenous community resources. This study examines adult’s perspectives on the role of children in the HIV response in the Matobo District of southern Zimbabwe. Methods: Through a mix of individual interviews (n = 19) and focus group discussions (n = 9), 90 community members who were active in social groups spoke about their community response to HIV. Transcripts were subjected to a thematic analysis and coding to generate key concepts and representations. Findings: In the wake of the HIV epidemic, traditional views of children’s social value as domestic ‘‘helpers’’ have evolved into them being regarded as capable and competent actors in the care and support of people living with HIV or AIDS, and as integral to household survival. Yet concurrent representations of children with excessive caregiving responsibilities as potentially vulnerable and at risk suggest that there is a limit to the role of children in the HIV response. Conclusion: Community volunteers and health staff delivering HIV services need to recognize the ‘‘behind the scene’’ role of children in the HIV response and ensure that children are incorporated into their modus operandi — both as social actors and as individuals in need of support