46 CFR 153.312 - Ventilation system standards.

Code of Federal Regulations, 2014 CFR

2014-10-01

... CARRYING BULK LIQUID, LIQUEFIED GAS, OR COMPRESSED GAS HAZARDOUS MATERIALS Design and Equipment Cargo Handling Space Ventilation § 153.312 Ventilation system standards. A cargo handling space ventilation... (approx. 32.8 ft) from openings into or ventilation intakes for, accommodation or service spaces. (b) A...

46 CFR 153.312 - Ventilation system standards.

Code of Federal Regulations, 2010 CFR

2010-10-01

... CARRYING BULK LIQUID, LIQUEFIED GAS, OR COMPRESSED GAS HAZARDOUS MATERIALS Design and Equipment Cargo Handling Space Ventilation § 153.312 Ventilation system standards. A cargo handling space ventilation... (approx. 32.8 ft) from openings into or ventilation intakes for, accommodation or service spaces. (b) A...

Association Between Noninvasive Ventilation and Mortality Among Older Patients With Pneumonia

PubMed Central

Valley, Thomas S.; Walkey, Allan J.; Lindenauer, Peter K.; Wiener, Renda Soylemez; Cooke, Colin R.

2016-01-01

Objective Despite increasing use, evidence is mixed as to the appropriate use of noninvasive ventilation in patients with pneumonia. We aimed to determine the relationship between receipt of noninvasive ventilation and outcomes for patients with pneumonia in a real-world setting. Design, Setting, Patients We performed a retrospective cohort study of Medicare beneficiaries (aged > 64 yr) admitted to 2,757 acute-care hospitals in the United States with pneumonia, who received mechanical ventilation from 2010 to 2011. Exposures Noninvasive ventilation versus invasive mechanical ventilation. Measurement and Main Results The primary outcome was 30-day mortality with Medicare reimbursement as a secondary outcome. To account for unmeasured confounding associated with noninvasive ventilation use, an instrumental variable was used—the differential distance to a high noninvasive ventilation use hospital. All models were adjusted for patient and hospital characteristics to account for measured differences between groups. Among 65,747 Medicare beneficiaries with pneumonia who required mechanical ventilation, 12,480 (19%) received noninvasive ventilation. Patients receiving noninvasive ventilation were more likely to be older, male, white, rural-dwelling, have fewer comorbidities, and were less likely to be acutely ill as measured by organ failures. Results of the instrumental variable analysis suggested that, among marginal patients, receipt of noninvasive ventilation was not significantly associated with differences in 30-day mortality when compared with invasive mechanical ventilation (54% vs 55%; p = 0.92; 95% CI of absolute difference, –13.8 to 12.4) but was associated with significantly lower Medicare spending ($18,433 vs $27,051; p = 0.02). Conclusions Among Medicare beneficiaries hospitalized with pneumonia who received mechanical ventilation, noninvasive ventilation use was not associated with a real-world mortality benefit. Given the wide CIs, however, substantial harm associated with noninvasive ventilation could not be excluded. The use of noninvasive ventilation for patients with pneumonia should be cautioned, but targeted enrollment of marginal patients with pneumonia could enrich future randomized trials. PMID:27749319

46 CFR 28.840 - Means for stopping pumps, ventilation, and machinery.

Code of Federal Regulations, 2014 CFR

2014-10-01

... pumps, ventilation, and machinery. All electrically driven fuel oil transfer pumps, fuel oil unit and service pumps, and ventilation fans shall be fitted with remote controls from a readily accessible... 46 Shipping 1 2014-10-01 2014-10-01 false Means for stopping pumps, ventilation, and machinery. 28...

46 CFR 28.840 - Means for stopping pumps, ventilation, and machinery.

Code of Federal Regulations, 2010 CFR

2010-10-01

... pumps, ventilation, and machinery. All electrically driven fuel oil transfer pumps, fuel oil unit and service pumps, and ventilation fans shall be fitted with remote controls from a readily accessible... 46 Shipping 1 2010-10-01 2010-10-01 false Means for stopping pumps, ventilation, and machinery. 28...

46 CFR 28.840 - Means for stopping pumps, ventilation, and machinery.

Code of Federal Regulations, 2013 CFR

2013-10-01

... pumps, ventilation, and machinery. All electrically driven fuel oil transfer pumps, fuel oil unit and service pumps, and ventilation fans shall be fitted with remote controls from a readily accessible... 46 Shipping 1 2013-10-01 2013-10-01 false Means for stopping pumps, ventilation, and machinery. 28...

46 CFR 28.840 - Means for stopping pumps, ventilation, and machinery.

Code of Federal Regulations, 2012 CFR

2012-10-01

... pumps, ventilation, and machinery. All electrically driven fuel oil transfer pumps, fuel oil unit and service pumps, and ventilation fans shall be fitted with remote controls from a readily accessible... 46 Shipping 1 2012-10-01 2012-10-01 false Means for stopping pumps, ventilation, and machinery. 28...

46 CFR 28.840 - Means for stopping pumps, ventilation, and machinery.

Code of Federal Regulations, 2011 CFR

2011-10-01

... pumps, ventilation, and machinery. All electrically driven fuel oil transfer pumps, fuel oil unit and service pumps, and ventilation fans shall be fitted with remote controls from a readily accessible... 46 Shipping 1 2011-10-01 2011-10-01 false Means for stopping pumps, ventilation, and machinery. 28...

Bedside end-tidal CO2 tension as a screening tool to exclude pulmonary embolism.

PubMed

Hemnes, A R; Newman, A L; Rosenbaum, B; Barrett, T W; Zhou, C; Rice, T W; Newman, J H

2010-04-01

End tidal carbon dioxide tension (P(ET,CO(2))) is a surrogate for dead space ventilation which may be useful in the evaluation of pulmonary embolism (PE). We aimed to define the optimal P(ET,CO(2)) level to exclude PE in patients evaluated for possible thromboembolism. 298 patients were enrolled over 6 months at a single academic centre. P(ET,CO(2)) was measured within 24 h of contrast-enhanced helical computed tomography, lower extremity duplex or ventilation/perfusion scan. Performance characteristics were measured by comparing test results with clinical diagnosis of PE. PE was diagnosed in 39 (13%) patients. Mean P( ET,CO(2)) in healthy volunteers did not differ from P( ET,CO(2)) in patients without PE (36.3+/-2.8 versus 35.5+/-6.8 mmHg). P(ET,CO(2 )) in patients with PE was 30.5+/-5.5 mmHg (p<0.001 versus patients without PE). A P(ET,CO(2)) of >or=36 mmHg had optimal sensitivity and specificity (87.2 and 53.0%, respectively) with a negative predictive value of 96.6% (95% CI 92.3-98.5). This increased to 97.6% (95% CI 93.2-99.) when combined with Wells score <4. A P(ET,CO(2)) of >or=36 mmHg may reliably exclude PE. Accuracy is augmented by combination with Wells score. P( ET,CO(2)) should be prospectively compared to D-dimer in accuracy and simplicity to exclude PE.

Ethical challenges in home mechanical ventilation: a secondary analysis.

PubMed

Dybwik, Knut; Nielsen, Erik Waage; Brinchmann, Berit Støre

2012-03-01

The aim of this study was to explore the ethical challenges in home mechanical ventilation based on a secondary analysis of qualitative empirical data. The data included perceptions of healthcare professionals in hospitals and community health services and family members of children and adults using home mechanical ventilation. The findings show that a number of ethical challenges, or dilemmas, arise at all levels in the course of treatment: deciding who should be offered home mechanical ventilation, respect for patient and family wishes, quality of life, dignity and equal access to home mechanical ventilation. Other challenges were the impacts home mechanical ventilation had on the patient, the family, the healthcare services and the allocation of resources. A better and broader understanding of these issues is crucial in order to improve the quality of care for both patient and family and assist healthcare professionals involved in home mechanical ventilation to make decisions for the good of the patient and his or her family.

Variation in ventilation time after coronary artery bypass grafting: an analysis from the society of thoracic surgeons adult cardiac surgery database.

PubMed

Jacobs, Jeffrey P; He, Xia; O'Brien, Sean M; Welke, Karl F; Filardo, Giovanni; Han, Jane M; Ferraris, Victor A; Prager, Richard L; Shahian, David M

2013-09-01

Short postoperative ventilation times are accepted as a marker of quality. This analysis assesses center level variation in postoperative ventilation time in a subset of patients undergoing isolated coronary artery bypass grafting (CABG). In 2009 and 2010, 325,129 patients in the STS Adult Cardiac Surgery Database underwent isolated CABG. Patients were excluded if they were intubated before entering the operating room, required ventilation for greater than 24 hours, or had missing data on key covariates. The final study cohort was 274,231 isolated CABG patients from 1,008 centers. Bayesian hierarchical models were used to assess between-center variation in ventilation time and to explore the effect of center-level covariates. Analyses were performed with and without adjusting for case mix. After adjusting for case mix, the ratio of median ventilator time at the 90th percentile of the center-level distribution compared with the tenth percentile was 9.0:5.0=1.8 (95% credible interval: 1.79 to 1.85). This ratio illustrates the scale of between-center differences: centers above the 90th percentile have a ventilation time of at least 1.8 times that of centers below the tenth percentile. Smaller hospital volume, presence of a residency program, and some census regions were associated with longer ventilation times. After adjustment for severity of illness, substantial inter-center variation exists in postoperative ventilation time in this subset of patients undergoing isolated CABG. This finding represents an opportunity for multi-institutional quality improvement initiatives designed to limit variations in ventilator management and achieve the shortest possible ventilation times for all patients, thus benefiting both clinical outcomes and resource utilization. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Efficacy of continuous versus intermittent subglottic secretion drainage in preventing ventilator-associated pneumonia in patients requiring mechanical ventilation: A single-center randomized controlled trial.

PubMed

Fujimoto, Hiroko; Yamaguchi, Osamu; Hayami, Hajime; Shimosaka, Mika; Tsuboi, Sayaka; Sato, Mitsunori; Takebayashi, Shigeo; Morita, Satoshi; Saito, Mari; Goto, Takahisa; Kurahashi, Kiyoyasu

2018-03-23

Aspiration of subglottic secretion is a widely used intervention to prevent ventilator-associated pneumonia (VAP). This study aimed to compare the efficacy of continuous and intermittent subglottic secretion drainage (SSD) in preventing VAP. A single-center randomized controlled trial was conducted on adult postoperative patients who were expected to undergo mechanical ventilation for more than 48 hours. Primary outcome measure was incidence of VAP and secondary outcome measures were length of mechanical ventilation and intensive-care unit (ICU) stay. Fifty-nine patients received continuous SSD, while 60 patients received intermittent SSD. Of these 119 patients, 88 (74%) were excluded and 15 and 16 patients were allocated to receive continuous and intermittent SSD, respectively. VAP was detected in 4 (26.7%) and 7 (43.8%) patients in the continuous and intermittent groups, respectively, (p=0.320). The length of mechanical ventilation was significantly shorter (p=0.034) in the continuous group (99.5±47.1 h) than in the intermittent group (159.9±94.5 h). The length of ICU stay was also shorter (p=0.0097) in the continuous group (6.3±2.1 days) than the intermittent group (9.8±4.8 days). Although continuous SSD did not reduce the incidence of VAP, it reduced the length of mechanical ventilation and ICU stay when compared to intermittent SSD.

Service bay area, pump room level, showing ventilation fans and ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

Service bay area, pump room level, showing ventilation fans and ducts association with evaporative-cooling system. Note battery bank at far right. View to the east - Wellton-Mohawk Irrigation System, Pumping Plant No. 3, South of Interstate 8, Wellton, Yuma County, AZ

Iatrogenic pneumothorax related to mechanical ventilation

PubMed Central

Hsu, Chien-Wei; Sun, Shu-Fen

2014-01-01

Pneumothorax is a potentially lethal complication associated with mechanical ventilation. Most of the patients with pneumothorax from mechanical ventilation have underlying lung diseases; pneumothorax is rare in intubated patients with normal lungs. Tension pneumothorax is more common in ventilated patients with prompt recognition and treatment of pneumothorax being important to minimize morbidity and mortality. Underlying lung diseases are associated with ventilator-related pneumothorax with pneumothoraces occurring most commonly during the early phase of mechanical ventilation. The diagnosis of pneumothorax in critical illness is established from the patients’ history, physical examination and radiological investigation, although the appearances of a pneumothorax on a supine radiograph may be different from the classic appearance on an erect radiograph. For this reason, ultrasonography is beneficial for excluding the diagnosis of pneumothorax. Respiration-dependent movement of the visceral pleura and lung surface with respect to the parietal pleura and chest wall can be easily visualized with transthoracic sonography given that the presence of air in the pleural space prevents sonographic visualization of visceral pleura movements. Mechanically ventilated patients with a pneumothorax require tube thoracostomy placement because of the high risk of tension pneumothorax. Small-bore catheters are now preferred in the majority of ventilated patients. Furthermore, if there are clinical signs of a tension pneumothorax, emergency needle decompression followed by tube thoracostomy is widely advocated. Patients with pneumothorax related to mechanical ventilation who have tension pneumothorax, a higher acute physiology and chronic health evaluation II score or PaO2/FiO2 < 200 mmHg were found to have higher mortality. PMID:24834397

[Pulmonary complications associated with mechanical ventilation in neonates].

PubMed

Torres-Castro, Cristabel; Valle-Leal, Jaime; Martínez-Limón, Alba J; Lastra-Jiménez, Zaira; Delgado-Bojórquez, Lesvia Carmina

To determine the incidence of0 associated with mechanical ventilation in patients admitted to a service in a second level hospital NICU. Retrospective analytical study records of newborns admitted to NICU room and receiving mechanical ventilation in a secondary hospital health care. Demographic data, of mechanical ventilation, intubation and complications reported in the clinical record were collected and analyzed in SPSS 20. 53 patients selected a total of 40 complications found. The annual incidence of pulmonary complications associated with mechanical ventilation in the area of service neonatology NICU, at a second level hospital at Sonora was 49.05% (95% CI 0.35 to 0.62). The most frequent pulmonary complications were atelectasis 35%, pneumonia 27.5%, pneumothorax 15%, bronchopulmonary dysplasia 15%, pneumomediastinum 15% and pulmonary hemorrhage 2.5%. The presentation of pulmonary complications secondary to mechanical ventilation in neonatal patients is similar to that reported in developing countries. Atelectasis is the most common pulmonary complication in neonatal patients undergoing mechanical ventilation. Copyright © 2016 Hospital Infantil de México Federico Gómez. Publicado por Masson Doyma México S.A. All rights reserved.

Feasibility of Protective Ventilation During Elective Supratentorial Neurosurgery: A Randomized, Crossover, Clinical Trial.

PubMed

Ruggieri, Francesco; Beretta, Luigi; Corno, Laura; Testa, Valentina; Martino, Enrico A; Gemma, Marco

2017-06-30

Traditional ventilation approaches, providing high tidal volumes (Vt), produce excessive alveolar distention and lung injury. Protective ventilation, employing lower Vt and positive end-expiratory pressure (PEEP), is an attractive alternative also for neuroanesthesia, when prolonged mechanical ventilation is needed. Nevertheless, protective ventilation during intracranial surgery may exert dangerous effects on intracranial pressure (ICP). We tested the feasibility of a protective ventilation strategy in neurosurgery. Our monocentric, double-blind, 1:1 randomized, 2×2 crossover study aimed at studying the effect size and variability of ICP in patients undergoing elective supratentorial brain tumor removal and alternatively ventilated with Vt 9 mL/kg-PEEP 0 mm Hg and Vt 7 mL/kg-PEEP 5 mm Hg. Respiratory rate was adjusted to maintain comparable end-tidal carbon dioxide between ventilation modes. ICP was measured through a subdural catheter inserted before dural opening. Forty patients were enrolled; 8 (15%) were excluded after enrollment. ICP did not differ between traditional and protective ventilation (11.28±5.37, 11 [7 to 14.5] vs. 11.90±5.86, 11 [8 to 15] mm Hg; P=0.541). End-tidal carbon dioxide (28.91±2.28, 29 [28 to 30] vs. 28.00±2.17, 28 [27 to 29] mm Hg; P<0.001). Peak airway pressure (17.25±1.97, 17 [16 to 18.5] vs. 15.81±2.87, 15.5 [14 to 17] mm Hg; P<0.001) and plateau airway pressure (16.06±2.30, 16 [14.5 to 17] vs. 14.19±2.82, 14 [12.5 to 16] mm Hg; P<0.001) were higher during protective ventilation. Blood pressure, heart rate, and body temperature did not differ between ventilation modes. Dural tension was "acceptable for surgery" in all cases. ICP differences between ventilation modes were not affected by ICP values under traditional ventilation (coefficient=0.067; 95% confidence interval, -0.278 to 0.144; P=0.523). Protective ventilation is a feasible alternative to traditional ventilation during elective neurosurgery.

20 CFR 404.1313 - World War II service excluded.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 20 Employees' Benefits 2 2011-04-01 2011-04-01 false World War II service excluded. 404.1313... DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services World War II Veterans § 404.1313 World War II service excluded. Your service was not in the active service of the United...

20 CFR 404.1313 - World War II service excluded.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false World War II service excluded. 404.1313... DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services World War II Veterans § 404.1313 World War II service excluded. Your service was not in the active service of the United...

20 CFR 404.1313 - World War II service excluded.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 20 Employees' Benefits 2 2012-04-01 2012-04-01 false World War II service excluded. 404.1313... DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services World War II Veterans § 404.1313 World War II service excluded. Your service was not in the active service of the United...

20 CFR 404.1313 - World War II service excluded.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false World War II service excluded. 404.1313... DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services World War II Veterans § 404.1313 World War II service excluded. Your service was not in the active service of the United...

Ventilator-dependent children and the health services system. Unmet needs and coordination of care.

PubMed

Hefner, Jennifer L; Tsai, Wan Chong

2013-10-01

Children dependent on mechanical ventilation are a vulnerable population by virtue of their chronic disability and are therefore at increased risk for health disparities and access barriers. The present study is the first, to our knowledge, to conduct a large-scale survey of caregivers of ventilator-dependent children to develop a comprehensive socio-demographic profile. To describe the demographic and health status profile of ventilator-dependent children, to identify the types of unmet needs families caring for a child on a ventilator face, and to determine the correlates of access to care coordination. A survey was administered to 122 parents whose children attended a pediatric home ventilator clinic at a large tertiary Midwestern medical center (84% of the clinic population). Half of the patient population had severe functional limitations, and 70% had one or more comorbidities. One quarter of caregivers reported current financial struggles, and 16% screened positive for a probable depressive disorder. More than half of families reported unmet needs for care, most frequently therapeutic services and skilled nursing care. Of those reporting an unmet need for skilled nursing care, lack of adequate staffing was the main barrier (71.1%). Financial struggles and a probable caregiver depressive disorder were significantly associated with an unmet need for care coordination. This is the first large-scale quantitative study to investigate the themes of unmet need and care coordination within this vulnerable population. The results suggest these families face barriers accessing therapeutic and skilled nursing services, and caregiver mental health and financial struggles may be important points of intervention for service providers through the inclusion of multidisciplinary care teams and the strengthening of social services referral networks.

TU-G-BRA-04: Changes in Regional Lung Function Measured by 4D-CT Ventilation Imaging for Thoracic Radiotherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nakajima, Y; Kadoya, N; Kabus, S

Purpose: To test the hypothesis: 4D-CT ventilation imaging can show the known effects of radiotherapy on lung function: (1) radiation-induced ventilation reductions, and (2) ventilation increases caused by tumor regression. Methods: Repeat 4D-CT scans (pre-, mid- and/or post-treatment) were acquired prospectively for 11 thoracic cancer patients in an IRB-approved clinical trial. A ventilation image for each time point was created using deformable image registration and the Hounsfield unit (HU)-based or Jacobian-based metric. The 11 patients were divided into two subgroups based on tumor volume reduction using a threshold of 5 cm{sup 3}. To quantify radiation-induced ventilation reduction, six patients whomore » showed a small tumor volume reduction (<5 cm{sup 3}) were analyzed for dose-response relationships. To investigate ventilation increase caused by tumor regression, two of the other five patients were analyzed to compare ventilation changes in the lung lobes affected and unaffected by the tumor. The remaining three patients were excluded because there were no unaffected lobes. Results: Dose-dependent reductions of HU-based ventilation were observed in a majority of the patient-specific dose-response curves and in the population-based dose-response curve, whereas no clear relationship was seen for Jacobian-based ventilation. The post-treatment population-based dose-response curve of HU-based ventilation demonstrated the average ventilation reductions of 20.9±7.0% at 35–40 Gy (equivalent dose in 2-Gy fractions, EQD2), and 40.6±22.9% at 75–80 Gy EQD2. Remarkable ventilation increases in the affected lobes were observed for the two patients who showed an average tumor volume reduction of 37.1 cm{sup 3} and re-opening airways. The mid-treatment increase in HU-based ventilation of patient 3 was 100.4% in the affected lobes, which was considerably greater than 7.8% in the unaffected lobes. Conclusion: This study has demonstrated that 4D-CT ventilation imaging shows the known effects of radiotherapy on lung function: radiation-induced ventilation reduction and ventilation increase caused by tumor regression, providing validation for 4D-CT ventilation imaging. This study was supported in part by a National Lung Cancer Partnership Young Investigator Research grant.« less

Contributing Factors for Morbidity and Mortality in Patients with Organophosphate Poisoning on Mechanical Ventilation: A Retrospective Study in a Teaching Hospital

PubMed Central

Patil, Gurulingappa; Nikhil, M.

2016-01-01

Introduction One of the most common causes of poisoning in agricultural based developing countries like India is due to Organophosphorus (OP) compound. Its widespread use and easy availability has increased the likelihood of poisoning with these compounds. Aim To study the morbidity and mortality in patients with acute OP poisoning requiring mechanical ventilation. Materials and Methods This was a retrospective study constituting patients of all age groups admitted to the Intensive Care Unit (ICU) with diagnosis of OP poisoning between January 2015 to December 2015. Of 66 OP poisoning cases those patients who went against medical advice, 20 were excluded from the study and thus 46 patients were included. Diagnosis was performed from the history taken either from the patient or from the patient’s relatives and presenting symptoms. Demographic data, month of the year, age of patient, mode of poisoning, cholinesterase levels, duration of mechanical ventilation and mortality were recorded. Data are presented as mean±SD. Results A 97.83% (45/46) of cases were suicidal. Out of 46, 9 were intubated and mechanically ventilated. Duration of mechanical ventilation varied from less than 48 hours to more than 7 days. Mortality rate was 50%, 0% and 100% in those who required mechanical ventilation for more than 7 days, 2 to 7 days and <2days respectively. None of the predictors like age, severity of poisoning, cholinesterase levels and duration of ventilation were independent predictors of death and all of them contributed to the mortality. Overall mortality rate in those who required mechanical ventilation was 22.22%. Conclusion Morbidity and mortality due to OP poisoning is directly proportional to the age, severity of poisoning and duration of mechanical ventilation and inversely proportional to serum cholinesterase level. PMID:28208980

20 CFR 404.1323 - Post-World War II service excluded.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 20 Employees' Benefits 2 2011-04-01 2011-04-01 false Post-World War II service excluded. 404.1323... DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services Post-World War II Veterans § 404.1323 Post-World War II service excluded. Your service was not in the active service...

20 CFR 404.1323 - Post-World War II service excluded.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false Post-World War II service excluded. 404.1323... DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services Post-World War II Veterans § 404.1323 Post-World War II service excluded. Your service was not in the active service...

20 CFR 404.1323 - Post-World War II service excluded.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 20 Employees' Benefits 2 2012-04-01 2012-04-01 false Post-World War II service excluded. 404.1323... DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services Post-World War II Veterans § 404.1323 Post-World War II service excluded. Your service was not in the active service...

20 CFR 404.1323 - Post-World War II service excluded.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false Post-World War II service excluded. 404.1323... DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services Post-World War II Veterans § 404.1323 Post-World War II service excluded. Your service was not in the active service...

Burden of Obesity on Pediatric Inpatients with Acute Asthma Exacerbation in the United States.

PubMed

Okubo, Yusuke; Nochioka, Kotaro; Hataya, Hiroshi; Sakakibara, Hiroshi; Terakawa, Toshiro; Testa, Marcia

Obesity and asthma are common health problems in the United States. The objective of this study was to evaluate the clinical and economic burdens of obesity on hospitalized children with acute asthma exacerbation in 2012. Hospital discharge records of patients aged 2 to 18 years with a diagnosis of asthma were obtained from the 2012 Kids' Inpatient Database, wherein the data were compiled by the Agency for Healthcare Research and Quality. The discharge records were weighted to estimate the number of hospitalizations because of asthma exacerbations in the United States. To classify whether the patient was obese or not, we used the International Classification of Diseases, Ninth Revision, Clinical Modification code 278.0x. We compared the odds of using noninvasive or invasive mechanical ventilation, mean total charges for inpatient service, and length of hospital stay between obese and nonobese patients. A total of 74,338 patient discharges were extracted. Of these, 3,494 discharges were excluded because of chronic medical conditions. Using discharge weight variables, we estimated a total of 100,157 hospitalizations with asthma exacerbations among children aged between 2 and 18 years in 2012. Obesity was significantly associated with higher odds of using mechanical ventilation (odds ratio 1.59, 95% CI 1.28-1.99), higher mean total hospital charges (adjusted difference: $1588, 95% CI $802-$2529), and longer mean length of hospital stay (0.24 days, 95% CI 0.17-0.32 days) compared with nonobesity. These findings suggest that obesity is a significant risk factor of severe asthma exacerbation that requires mechanical ventilation, and obesity is an economically complicating factor. Copyright © 2016 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

9 CFR 354.226 - Lighting and ventilation.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 9 Animals and Animal Products 2 2011-01-01 2011-01-01 false Lighting and ventilation. 354.226 Section 354.226 Animals and Animal Products FOOD SAFETY AND INSPECTION SERVICE, DEPARTMENT OF AGRICULTURE... Facilities § 354.226 Lighting and ventilation. There shall be ample light, either natural or artificial or...

SU-E-J-87: Ventilation Weighting Effect On Mean Doses of Both Side Lungs for Patients with Advanced Stage Lung Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Qu, H; Xia, P; Yu, N

Purpose: To study ventilation weighting effect on radiation doses to both side lungs for patients with advanced stage lung cancer. Methods: Fourteen patients with advanced stage lung cancer were included in this retrospective study. Proprietary software was developed to calculate the lung ventilation map based on 4DCT images acquired for radiation therapy. Two phases of inhale (0%) and exhale (50%) were used for the lung ventilation calculations. For each patient, the CT images were resampled to the same dose calculation resolution of 3mmx3mmx3mm. The ventilation distribution was then normalized by the mean value of the ventilation. The ventilation weighted dosemore » was calculated by applying linearly weighted ventilation to the dose of each pixel. The lung contours were automatically delineated from patient CT image with lung window, excluding the tumor and high density tissues. For contralateral and ipsilateral lungs, the mean lung doses from the original plan and ventilation weighted mean lung doses were compared using two tail t-Test. Results: The average of mean dose was 6.1 ±3.8Gy for the contralateral lungs, and 26.2 ± 14.0Gy for the ipsilateral lungs. The average of ventilation weighted dose was 6.3± 3.8Gy for the contralateral lungs and 24.6 ± 13.1Gy for the ipsilateral lungs. The statistics analysis shows the significance of the mean dose increase (p<0.015) for the contralateral lungs and decrease (p<0.005) for the ipsilateral lungs. Conclusion: Ventilation weighted doses were greater than the un-weighted doses for contralateral lungs and smaller for ipsilateral lungs. This Result may be helpful to understand the radiation dosimetric effect on the lung function and provide planning guidance for patients with advance stage lung cancer.« less

Significance of Prior Digestive Colonization With Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Patients With Ventilator-Associated Pneumonia.

PubMed

Bruyère, Rémi; Vigneron, Clara; Bador, Julien; Aho, Serge; Toitot, Amaury; Quenot, Jean-Pierre; Prin, Sébastien; Charles, Pierre Emmanuel

2016-04-01

Ventilator-associated pneumonia is frequent in ICUs. Extended-spectrum β-lactamase-producing Enterobacteriaceae are difficult-to-treat pathogens likely to cause ventilator-associated pneumonia. We sought to assess the interest of screening for extended-spectrum β-lactamase-producing Enterobacteriaceae rectal carriage as a way to predict their involvement in ventilator-associated pneumonia. A retrospective cohort study of patients with suspected ventilator-associated pneumonia in a medical ICU was conducted. Every patient admitted between January 2006 and August 2013 was eligible if subjected to mechanical ventilation for more than 48 hours. Each patient with suspected ventilator-associated pneumonia was included in the cohort. Active surveillance culture for extended-spectrum β-lactamase-producing Enterobacteriaceae detection was routinely performed in all patients at admission and then weekly throughout the study period. Extended-spectrum β-lactamase colonization was defined by the isolation of at least one extended-spectrum β-lactamase-producing Enterobacteriaceae from rectal swab culture. None. Among 587 patients with suspected ventilator-associated pneumonia, 40 (6.8%) were colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae prior to the development of pneumonia. Over the study period, 20 patients (3.4%) had ventilator-associated pneumonia caused by extended-spectrum β-lactamase-producing Enterobacteriaceae; of whom, 17 were previously detected as being colonized with extended-spectrum β-lactamase-producing Enterobacteriaceae. Sensitivity and specificity of prior extended-spectrum β-lactamase-producing Enterobacteriaceae colonization as a predictor of extended-spectrum β-lactamase-producing Enterobacteriaceae involvement in ventilator-associated pneumonia were 85.0% and 95.7%, respectively. The positive and negative predictive values were 41.5% and 99.4%, respectively. The positive likelihood ratio was 19.8. Screening for extended-spectrum β-lactamase-producing Enterobacteriaceae digestive colonization by weekly active surveillance cultures could reliably exclude the risk of the involvement of such pathogens in patients with ventilator-associated pneumonia in low-prevalence area.

Mechanical ventilation weaning and extubation after spinal cord injury: a Western Trauma Association multicenter study.

PubMed

Kornblith, Lucy Z; Kutcher, Matthew E; Callcut, Rachael A; Redick, Brittney J; Hu, Charles K; Cogbill, Thomas H; Baker, Christopher C; Shapiro, Mark L; Burlew, Clay C; Kaups, Krista L; DeMoya, Marc A; Haan, James M; Koontz, Christopher H; Zolin, Samuel J; Gordy, Stephanie D; Shatz, David V; Paul, Doug B; Cohen, Mitchell J

2013-12-01

Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI were compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy and development of acute lung injury and ventilator-associated pneumonia. A total of 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of the patients with cervical SCI were ventilator free by discharge. One hundred forty-nine patients (43.3%) underwent tracheostomy, and 53.7% of them were successfully weaned from the ventilator, compared with an 85.6% success rate among those with no tracheostomy (p < 0.05). Patients who underwent tracheostomy had significantly higher rates of ventilator-associated pneumonia (61.1% vs. 20.5%, p < 0.05) and acute lung injury (12.8% vs. 3.6%, p < 0.05) and fewer ventilator-free days (1 vs. 24 p < 0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (odds ratio, 14.1; 95% confidence interval, 2.78-71.67; p < 0.05). While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned before discharge. In patients with SCI, tracheostomy is associated with major morbidity, and its use, especially among patients with cervical SCI, deserves further study. Prognostic study, level III.

Venting of attics & cathedral ceilings

Treesearch

William B. Rose; Anton TenWolde

2002-01-01

Current building codes typically call for attic ventilation to minimize condensation on the underside of roof sheathing. Summer cooling of attic air, minimizing ice dams, and extending the service life of the roof materials often are cited as additional benefits of attic ventilation. In fact, most asphalt shingle manufacturers warrant their products only for ventilated...

Workplace air-conditioning and health services attendance among French middle-aged women: a prospective cohort study.

PubMed

Preziosi, P; Czernichow, S; Gehanno, P; Hercberg, S

2004-10-01

To assess the relationship between type of ventilation in the workplace, health services attendance, and sickness absence among middle-aged women. In a national sample of 920 professionally active women aged 49-65 yr from the SU.VI.MAX cohort, recruited from the general population in France, health services attendance and sickness absence were assessed prospectively during 1999. Being exposed to heating, ventilation, and air-conditioning (HVAC) systems in the workplace proved to be a risk factor for attendance at global and several specialist medical services. The adjusted odds ratio for otorhinolaryngologist attendance was 2.33 (95% CI = 1.35-4.04) in the HVAC group compared with the natural ventilation group, and 1.70 (1.13-2.58) for sickness absence. Dermatologist and global medical services attendance rates may also be higher in this group (P = 0.06 in both cases). Exposure to HVAC systems was a strong and significant risk factor for otorhinolaryngologist attendance and sickness absence. HVAC systems are prevalent in recent office buildings and have been shown to be associated with several adverse health effects in terms of morbidity and mortality. From a public-health perspective, our results outline the need for a quantitative assessment of the health impact of ventilation systems, taking into account the possible loss of production that exists in addition to the direct costs of medical services use.

Variation in Definition of Prolonged Mechanical Ventilation.

PubMed

Rose, Louise; McGinlay, Michael; Amin, Reshma; Burns, Karen Ea; Connolly, Bronwen; Hart, Nicholas; Jouvet, Philippe; Katz, Sherri; Leasa, David; Mawdsley, Cathy; McAuley, Danny F; Schultz, Marcus J; Blackwood, Bronagh

2017-10-01

Consistency of definitional criteria for terminology applied to describe subject cohorts receiving mechanical ventilation within ICU and post-acute care settings is important for understanding prevalence, risk stratification, effectiveness of interventions, and projections for resource allocation. Our objective was to quantify the application and definition of terms for prolonged mechanical ventilation. We conducted a scoping review of studies (all designs except single-case study) reporting a study population (adult and pediatric) using the term prolonged mechanical ventilation or a synonym. We screened 5,331 references, reviewed 539 full-text references, and excluded 120. Of the 419 studies (representing 38 countries) meeting inclusion criteria, 297 (71%) reported data on a heterogeneous subject cohort, and 66 (16%) included surgical subjects only (46 of those 66, 70% cardiac surgery). Other studies described COPD (16, 4%), trauma (22, 5%), neuromuscular (17, 4%), and sepsis (1, 0.2%) cohorts. A total of 741 terms were used to refer to the 419 study cohorts. The most common terms were: prolonged mechanical ventilation (253, 60%), admission to specialized unit (107, 26%), and long-term mechanical ventilation (79, 19%). Some authors (282, 67%) defined their cohorts based on duration of mechanical ventilation, with 154 studies (55%) using this as the sole criterion. We identified 37 different durations of ventilation ranging from 5 h to 1 y, with > 21 d being the most common (28 of 282, 7%). For studies describing a surgical cohort, minimum ventilation duration required for inclusion was ≥ 24 h for 20 of 66 studies (30%). More than half of all studies (237, 57%) did not provide a reason/rationale for definitional criteria used, with only 28 studies (7%) referring to a consensus definition. We conclude that substantial variation exists in the terminology and definitional criteria for cohorts of subjects receiving prolonged mechanical ventilation. Standardization of terminology and definitional criteria is required for study data to be maximally informative. Copyright © 2017 by Daedalus Enterprises.

Cost of treating ventilator-associated pneumonia post cardiac surgery in the National Health Service: Results from a propensity-matched cohort study.

PubMed

Luckraz, Heyman; Manga, Na'ngono; Senanayake, Eshan L; Abdelaziz, Mahmoud; Gopal, Shameer; Charman, Susan C; Giri, Ramesh; Oppong, Raymond; Andronis, Lazaros

2018-05-01

Ventilator-associated pneumonia is associated with significant morbidity, mortality and healthcare costs. Most of the cost data that are available relate to general intensive care patients in privately remunerated institutions. This study assessed the cost of managing ventilator-associated pneumonia in a cardiac intensive care unit in the National Health Service in the United Kingdom. Propensity-matched study of prospectively collected data from the cardiac surgical database between April 2011 and December 2014 in all patients undergoing cardiac surgery (n = 3416). Patients who were diagnosed as developing ventilator-associated pneumonia, as per the surveillance definition for ventilator-associated pneumonia (n = 338), were propensity score matched with those who did not (n = 338). Costs of treating post-op cardiac surgery patients in intensive care and cost difference if ventilator-associated pneumonia occurred based on Healthcare Resource Group categories were assessed. Secondary outcomes included differences in morbidity, mortality and cardiac intensive care unit and in-hospital length of stay. There were no significant differences in the pre-operative characteristics or procedures between the groups. Ventilator-associated pneumonia developed in 10% of post-cardiac surgery patients. Post-operatively, the ventilator-associated pneumonia group required longer ventilation (p < 0.01), more respiratory support, longer cardiac intensive care unit (8 vs 3, p < 0.001) and in-hospital stay (16 vs 9) days. The overall cost for post-operative recovery after cardiac surgery for ventilator-associated pneumonia patients was £15,124 compared to £6295 for non-ventilator-associated pneumonia (p < 0.01). The additional cost of treating patients with ventilator-associated pneumonia was £8829. Ventilator-associated pneumonia was associated with significant morbidity to the patients, generating significant costs. This cost was nearer to the lower end for the cost for general intensive care unit patients in privately reimbursed systems.

20 CFR 404.1313 - World War II service excluded.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false World War II service excluded. 404.1313 Section 404.1313 Employees' Benefits SOCIAL SECURITY ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services World War II Veterans § 404.1313 World War II service exclude...

Influences of meteorological parameters on indoor radon concentrations (222Rn) excluding the effects of forced ventilation and radon exhalation from soil and building materials.

PubMed

Schubert, Michael; Musolff, Andreas; Weiss, Holger

2018-06-13

Elevated indoor radon concentrations ( 222 Rn) in dwellings pose generally a potential health risk to the inhabitants. During the last decades a considerable number of studies discussed both the different sources of indoor radon and the drivers for diurnal and multi day variations of its concentration. While the potential sources are undisputed, controversial opinions exist regarding their individual relevance and regarding the driving influences that control varying radon indoor concentrations. These drivers include (i) cyclic forced ventilation of dwellings, (ii) the temporal variance of the radon exhalation from soil and building materials due to e.g. a varying moisture content and (iii) diurnal and multi day temperature and pressure patterns. The presented study discusses the influences of last-mentioned temporal meteorological parameters by effectively excluding the influences of forced ventilation and undefined radon exhalation. The results reveal the continuous variation of the indoor/outdoor pressure gradient as key driver for a constant "breathing" of any interior space, which affects the indoor radon concentration with both diurnal and multi day patterns. The diurnally recurring variation of the pressure gradient is predominantly triggered by the day/night cycle of the indoor temperature that is associated with an expansion/contraction of the indoor air volume. Multi day patterns, on the other hand, are mainly due to periods of negative air pressure indoors that is triggered by periods of elevated wind speeds as a result of Bernoulli's principle. Copyright © 2018 Elsevier Ltd. All rights reserved.

The accuracy of Gram stain of respiratory specimens in excluding Staphylococcus aureus in ventilator-associated pneumonia.

PubMed

Gottesman, Tamar; Yossepowitch, Orit; Lerner, Evgenia; Schwartz-Harari, Orna; Soroksky, Arie; Yekutieli, Daniel; Dan, Michael

2014-10-01

To evaluate the Gram stain of deep tracheal aspirate as a tool to direct empiric antibiotic therapy, and more specifically as a tool to exclude the need for empiric antibiotic coverage against Staphylococcus aureus in ventilator-associated pneumonia (VAP). A prospective, single-center, observational, cohort study. All wards at a community hospital. Adult patients requiring mechanical ventilation, identified as having VAP in a 54-month prospective surveillance database. Sampling of lower airway secretions by deep endotracheal aspiration was taken from each patient who developed VAP. Samples were sent immediately for Gram stain and qualitative bacterial cultures. Demographic and relevant clinical data were collected; Gram stain, culture, and antibiotic susceptibility results were documented; and outcome was followed prospectively. The analysis included 114 consecutive patients with 115 episodes of VAP from June 2007 to January 2012. Sensitivity of Gram stain compared with culture was 90.47% for gram-positive cocci, 69.6% for gram-negative rods, and 50% for sterile cultures. Specificity was 82.5%, 77.8%, and 79%, respectively. Negative predictive value was high for gram-positive cocci (97%) and sterile cultures (96%) but low for gram-negative rods (20%). Acinetobacter baumanii (45%) and Pseudomonas aeruginosa (38 %) were the prevailing isolates. S aureus was found in 18.3% of the patients. Most isolates were multiresistant. Absence of gram-positive bacteria on Gram stain had a high negative predictive value. These data can be used to narrow the initial empiric antibiotic regimen and to avoid unnecessary exposure of patients to vancomycin and other antistaphyloccocal agents. Copyright © 2014 Elsevier Inc. All rights reserved.

42 CFR 412.29 - Excluded rehabilitation units: Additional requirements.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Costs and Inpatient Capital-Related Costs § 412.29 Excluded rehabilitation units: Additional..., social services, psychological services (including neuropsychological services), and orthotic and...

9 CFR 130.19 - User fees for other veterinary diagnostic services or materials provided at NVSL (excluding FADDL).

Code of Federal Regulations, 2011 CFR

2011-01-01

... 9 Animals and Animal Products 1 2011-01-01 2011-01-01 false User fees for other veterinary... User fees for other veterinary diagnostic services or materials provided at NVSL (excluding FADDL). (a) User fees for other veterinary diagnostic services or materials available from NVSL (excluding FADDL...

9 CFR 130.19 - User fees for other veterinary diagnostic services or materials provided at NVSL (excluding FADDL).

Code of Federal Regulations, 2010 CFR

2010-01-01

... 9 Animals and Animal Products 1 2010-01-01 2010-01-01 false User fees for other veterinary... User fees for other veterinary diagnostic services or materials provided at NVSL (excluding FADDL). (a) User fees for other veterinary diagnostic services or materials available from NVSL (excluding FADDL...

Early Rehabilitation in the Medical and Surgical Intensive Care Units for Patients With and Without Mechanical Ventilation: An Interprofessional Performance Improvement Project.

PubMed

Corcoran, John R; Herbsman, Jodi M; Bushnik, Tamara; Van Lew, Steve; Stolfi, Angela; Parkin, Kate; McKenzie, Alison; Hall, Geoffrey W; Joseph, Waveney; Whiteson, Jonathan; Flanagan, Steven R

2017-02-01

Most early mobility studies focus on patients on mechanical ventilation and the role of physical and occupational therapy. This Performance Improvement Project (PIP) project examined early mobility and increased intensity of therapy services on patients in the intensive care unit (ICU) with and without mechanical ventilation. In addition, speech-language pathology rehabilitation was added to the early mobilization program. We sought to assess the efficacy of early mobilization of patients with and without mechanical ventilation in the ICU on length of stay (LOS) and patient outcomes and to determine the financial viability of the program. PIP. Prospective data collection in 2014 (PIP) compared with a historical patient population in 2012 (pre-PIP). Medical and surgical ICUs of a Level 2 trauma hospital. There were 160 patients in the PIP and 123 in the pre-PIP. Interprofessional training to improve collaboration and increase intensity of rehabilitation therapy services in the medical and surgical intensive care units for medically appropriate patients. Demographics; intensity of service; ICU and hospital LOS; medications; pain; discharge disposition; functional mobility; and average cost per day were examined. Rehabilitation therapy services increased from 2012 to 2014 by approximately 60 minutes per patient. The average ICU LOS decreased by almost 20% from 4.6 days (pre-PIP) to 3.7 days (PIP) (P = .05). A decrease of over 40% was observed in the floor bed average LOS from 6.0 days (pre-PIP) to 3.4 days (PIP) (P < .01). An increased percentage of PIP patients, 40.5%, were discharged home without services compared with 18.2% in the pre-PIP phase (P < .01). Average cost per day in the ICU and floor bed decreased in the PIP group, resulting in an annualized net cost savings of $1.5 million. The results of the PIP indicate that enhanced rehabilitation services in the ICU is clinically feasible, results in improved patient outcomes, and is fiscally sound. Most early mobility studies focus on patients on mechanical ventilation. The results of this PIP project demonstrate that there are significant benefits to early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. Benefits include reduced hospitalization LOS, decreased health care costs, and decreased need for postacute care services. III. Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

42 CFR 410.102 - Excluded services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Excluded services. 410.102 Section 410.102 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS Comprehensive Outpatient Rehabilitation Facility (CORF) Services...

Outcome of ventilated infants born at term without major congenital abnormalities.

PubMed

Ramadan, Ghada; Paul, Nicola; Morton, Margaret; Peacock, Janet L; Greenough, Anne

2012-02-01

The longer-term outcome of term-born infants without congenital anomalies requiring ventilation in the first 24 h after birth has rarely been reported. Our aims were to determine the mortality and long-term morbidity of such infants and identify risk factors for adverse outcome. The outcomes of 43 of 45 infants born at term consecutively requiring mechanical ventilation were reviewed. The infants had: meconium aspiration syndrome (n = 11), hypoxic ischaemic encephalopathy (HIE) (n = 11), respiratory depression (n = 12), sepsis (n = 5), persistent pulmonary hypertension of the newborn (n = 3) and middle cerebral artery infarction (n = 1). Eleven infants developed seizures (26%), 13 (30%) had abnormal electroencephalograms and 11 (26%) had abnormal MRI scans; 26% had an adverse outcome: six died, and five had severe neurodisability at 2 years. The infants with congenital toxoplasmosis and a middle cerebral artery infarction were excluded from the prediction analysis. In the remaining 41 patients, requirement for anticonvulsants (relative risk, RR = 4.44, 95% CI = 1.48 to 12.70; p = 0.014) and prolonged ventilation (longer than 3 days) (RR 4.83, 95% CI 1.51 to 15.64) predicted adverse outcome. Infants with HIE had an increased risk of adverse outcome (relative risk 5.45, 95% CI 1.01 to 33.85), but an adverse outcome occurred in infants with other diagnoses. Mortality and neurodisability at follow-up were common in infants born at term without major congenital anomalies who required mechanical ventilation in the first 24 h after birth, particularly in those who developed seizures requiring treatment and prolonged ventilation.

Clinical Correlates of Surveillance Events Detected by National Healthcare Safety Network Pneumonia and Lower Respiratory Infection Definitions—Pennsylvania, 2011–2012

PubMed Central

See, Isaac; Chang, Julia; Gualandi, Nicole; Buser, Genevieve L.; Rohrbach, Pamela; Smeltz, Debra A.; Bellush, Mary Jo; Coffin, Susan E.; Gould, Jane M.; Hess, Debra; Hennessey, Patricia; Hubbard, Sydney; Kiernan, Andrea; O’Donnell, Judith; Pegues, David A.; Miller, Jeffrey R.; Magill, Shelley S.

2017-01-01

Objective To determine the clinical diagnoses associated with National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events. Design Retrospective chart review. Setting Eight acute care hospitals in Pennsylvania. Patients All patients hospitalized during 2011–2012. Methods Medical records were reviewed from a random sample of patients reported to NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU/LRI events were recorded. Results We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to NHSN; 29 (12%) of reported events fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassification. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia, of which 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or non-infectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator-associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI, 84% were in mechanically-ventilated patients, and 21% had no corresponding clinical diagnosis documented. Conclusions In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded to compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015. PMID:27072043

Effect of type II diabetes mellitus on outcomes in patients with acute respiratory distress syndrome.

PubMed

Singla, Abhishek; Turner, Paul; Pendurthi, Madhu Kalyan; Agrawal, Vrinda; Modrykamien, Ariel

2014-02-01

The acute respiratory distress syndrome (ARDS) is a life-threatening condition, whereas the presence of diabetes has been shown to be protective in its development. We undertook this study to assess the association of type II diabetes mellitus with clinical outcomes in patients with ARDS. We retrospectively examined the medical records of consecutive series of patients with ARDS requiring mechanical ventilation from January 2008 to March 2011. Patients with type I diabetes were excluded from the study. Clinical outcomes such as ventilator-free days, mortality, length of stay in the hospital and intensive care unit (ICU), and reintubations were compared based on the presence of diabetes. Multivariate regression model was used to find if the presence of type II diabetes mellitus predicts ventilator-free days at day 28. Two hundred forty-nine patients with ARDS were admitted to the ICU during the study period. Fifty (20%) subjects had type II diabetes mellitus. Differences in ventilator-free days, in-hospital mortality, reintubation rate, and length of stay in the hospital or ICU were not statistically significant between diabetic and nondiabetic patients with ARDS. Acute Physiologic and Chronic Health Evaluation II, ICU specialty, use of vasopressors, and the need for reintubation were predictors of ventilator-free days at day 28. The presence of type II diabetes mellitus and its adjustment by body mass index did not show association with ventilator-free days at day 28. The presence of type II diabetes mellitus is not associated with clinical outcomes in ARDS, even when its presence is adjusted by body mass index. © 2013.

Clinical Correlates of Surveillance Events Detected by National Healthcare Safety Network Pneumonia and Lower Respiratory Infection Definitions-Pennsylvania, 2011-2012.

PubMed

See, Isaac; Chang, Julia; Gualandi, Nicole; Buser, Genevieve L; Rohrbach, Pamela; Smeltz, Debra A; Bellush, Mary Jo; Coffin, Susan E; Gould, Jane M; Hess, Debra; Hennessey, Patricia; Hubbard, Sydney; Kiernan, Andrea; O'Donnell, Judith; Pegues, David A; Miller, Jeffrey R; Magill, Shelley S

2016-07-01

OBJECTIVE To determine the clinical diagnoses associated with the National Healthcare Safety Network (NHSN) pneumonia (PNEU) or lower respiratory infection (LRI) surveillance events DESIGN Retrospective chart review SETTING A convenience sample of 8 acute-care hospitals in Pennsylvania PATIENTS All patients hospitalized during 2011-2012 METHODS Medical records were reviewed from a random sample of patients reported to the NHSN to have PNEU or LRI, excluding adults with ventilator-associated PNEU. Documented clinical diagnoses corresponding temporally to the PNEU and LRI events were recorded. RESULTS We reviewed 250 (30%) of 838 eligible PNEU and LRI events reported to the NHSN; 29 reported events (12%) fulfilled neither PNEU nor LRI case criteria. Differences interpreting radiology reports accounted for most misclassifications. Of 81 PNEU events in adults not on mechanical ventilation, 84% had clinician-diagnosed pneumonia; of these, 25% were attributed to aspiration. Of 43 adult LRI, 88% were in mechanically ventilated patients and 35% had no corresponding clinical diagnosis (infectious or noninfectious) documented at the time of LRI. Of 36 pediatric PNEU events, 72% were ventilator associated, and 70% corresponded to a clinical pneumonia diagnosis. Of 61 pediatric LRI patients, 84% were mechanically ventilated and 21% had no corresponding clinical diagnosis documented. CONCLUSIONS In adults not on mechanical ventilation and in children, most NHSN-defined PNEU events corresponded with compatible clinical conditions documented in the medical record. In contrast, NHSN LRI events often did not. As a result, substantial modifications to the LRI definitions were implemented in 2015. Infect Control Hosp Epidemiol 2016;37:818-824.

Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions.

PubMed

Dennis, Bradley M; Gondek, Stephen P; Guyer, Richard A; Hamblin, Susan E; Gunter, Oliver L; Guillamondegui, Oscar D

2017-04-01

Concerted management of the traumatic hemothorax is ill-defined. Surgical management of specific hemothoraces may be beneficial. A comprehensive strategy to delineate appropriate patients for additional procedures does not exist. We developed an evidence-based algorithm for hemothorax management. We hypothesize that the use of this algorithm will decrease additional interventions. A pre-/post-study was performed on all patients admitted to our trauma service with traumatic hemothorax from August 2010 to September 2013. An evidence-based management algorithm was initiated for the management of retained hemothoraces. Patients with length of stay (LOS) less than 24 hours or admitted during an implementation phase were excluded. Study data included age, Injury Severity Score, Abbreviated Injury Scale chest, mechanism of injury, ventilator days, intensive care unit (ICU) LOS, total hospital LOS, and interventions required. Our primary outcome was number of patients requiring more than 1 intervention. Secondary outcomes were empyema rate, number of patients requiring specific additional interventions, 28-day ventilator-free days, 28-day ICU-free days, hospital LOS, all-cause 6-month readmission rate. Standard statistical analysis was performed for all data. Six hundred forty-two patients (326 pre and 316 post) met the study criteria. There were no demographic differences in either group. The number of patients requiring more than 1 intervention was significantly reduced (49 pre vs. 28 post, p = 0.02). Number of patients requiring VATS decreased (27 pre vs. 10 post, p < 0.01). Number of catheters placed by interventional radiology increased (2 pre vs. 10 post, p = 0.02). Intrapleural thrombolytic use, open thoracotomy, empyema, and 6-month readmission rates were unchanged. The "post" group more ventilator-free days (median, 23.9 vs. 22.5, p = 0.04), but ICU and hospital LOS were unchanged. Using an evidence-based hemothorax algorithm reduced the number of patients requiring additional interventions without increasing complication rates. Defined criteria for surgical intervention allows for more appropriate utilization of resources. Therapeutic study, level IV.

42 CFR 403.768 - Excluded services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... a RNHCI. (c) A nurse who is not providing RNHCI home nursing services under arrangement with a RNHCI... 42 Public Health 2 2010-10-01 2010-10-01 false Excluded services. 403.768 Section 403.768 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL...

Impact of noninvasive ventilation (NIV) trial for various types of acute respiratory failure in the emergency department; decreased mortality and use of the ICU.

PubMed

Tomii, Keisuke; Seo, Ryutaro; Tachikawa, Ryo; Harada, Yuka; Murase, Kimihiko; Kaji, Reiko; Takeshima, Yoshimi; Hayashi, Michio; Nishimura, Takashi; Ishihara, Kyosuke

2009-01-01

Trial of noninvasive ventilation (NIV) in the emergency department (ED) for heterogeneous acute respiratory failure (ARF) has been optional and its clinical benefit unclear. We conducted a retrospective cohort study comparing between two periods, October 2001-September 2003 and October 2004-September 2006, i.e., before and after adopting an NIV-trial strategy in which NIV was applied in the ED to any noncontraindicated ARF patients needing ventilatory support and was then continued in the intermediate-care-unit. During these two periods, we retrieved cases of ARF treated either invasively or with NIV, and compared the patients' in-hospital mortalities and the length of ICU and intermediate-care-unit stay. Compared were 73 (invasive 56, NIV 17) and 125 cases (invasive 31, NIV 94) retrieved from 271 and 415 emergent admissions with proper pulmonary etiologies for mechanical ventilation, respectively. Of their respiratory failures, type (hypercapnic/non-hypercapnic, 0.97 vs. 0.98) and severity (pH 7.23 vs. 7.21 for hypercapnic; PaO(2)/FiO(2) 133 vs. 137 for non-hypercapnic) were similar, and the rate of predisposing etiologies was not significantly different. However, excluding those with recurrent aspiration pneumonia for whom NIV was mostly used as "ceiling" treatment, significant reductions in both overall in-hospital mortality (38%-19%, risk ratio 0.51, 95% CI 0.31-0.84), and median length of ICU and intermediate-care-unit stay (12 vs. 5 days, P<0.0001) were found. NIV-trial in the ED for all possible patients with ARF of pulmonary etiologies, excluding those with recurrent aspiration pneumonia, may reduce overall in-hospital mortality and ICU stays.

Increasing the inspiratory time and I:E ratio during mechanical ventilation aggravates ventilator-induced lung injury in mice.

PubMed

Müller-Redetzky, Holger C; Felten, Matthias; Hellwig, Katharina; Wienhold, Sandra-Maria; Naujoks, Jan; Opitz, Bastian; Kershaw, Olivia; Gruber, Achim D; Suttorp, Norbert; Witzenrath, Martin

2015-01-28

Lung-protective ventilation reduced acute respiratory distress syndrome (ARDS) mortality. To minimize ventilator-induced lung injury (VILI), tidal volume is limited, high plateau pressures are avoided, and positive end-expiratory pressure (PEEP) is applied. However, the impact of specific ventilatory patterns on VILI is not well defined. Increasing inspiratory time and thereby the inspiratory/expiratory ratio (I:E ratio) may improve oxygenation, but may also be harmful as the absolute stress and strain over time increase. We thus hypothesized that increasing inspiratory time and I:E ratio aggravates VILI. VILI was induced in mice by high tidal-volume ventilation (HVT 34 ml/kg). Low tidal-volume ventilation (LVT 9 ml/kg) was used in control groups. PEEP was set to 2 cm H2O, FiO2 was 0.5 in all groups. HVT and LVT mice were ventilated with either I:E of 1:2 (LVT 1:2, HVT 1:2) or 1:1 (LVT 1:1, HVT 1:1) for 4 hours or until an alternative end point, defined as mean arterial blood pressure below 40 mm Hg. Dynamic hyperinflation due to the increased I:E ratio was excluded in a separate group of animals. Survival, lung compliance, oxygenation, pulmonary permeability, markers of pulmonary and systemic inflammation (leukocyte differentiation in lung and blood, analyses of pulmonary interleukin-6, interleukin-1β, keratinocyte-derived chemokine, monocyte chemoattractant protein-1), and histopathologic pulmonary changes were analyzed. LVT 1:2 or LVT 1:1 did not result in VILI, and all individuals survived the ventilation period. HVT 1:2 decreased lung compliance, increased pulmonary neutrophils and cytokine expression, and evoked marked histologic signs of lung injury. All animals survived. HVT 1:1 caused further significant worsening of oxygenation, compliance and increased pulmonary proinflammatory cytokine expression, and pulmonary and blood neutrophils. In the HVT 1:1 group, significant mortality during mechanical ventilation was observed. According to the "baby lung" concept, mechanical ventilation-associated stress and strain in overinflated regions of ARDS lungs was simulated by using high tidal-volume ventilation. Increase of inspiratory time and I:E ratio significantly aggravated VILI in mice, suggesting an impact of a "stress/strain × time product" for the pathogenesis of VILI. Thus increasing the inspiratory time and I:E ratio should be critically considered.

Poor Adherence to Lung-Protective Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome.

PubMed

Ward, Shan L; Quinn, Carson M; Valentine, Stacey L; Sapru, Anil; Curley, Martha A Q; Willson, Douglas F; Liu, Kathleen D; Matthay, Michael A; Flori, Heidi R

2016-10-01

To determine the frequency of low-tidal volume ventilation in pediatric acute respiratory distress syndrome and assess if any demographic or clinical factors improve low-tidal volume ventilation adherence. Descriptive post hoc analysis of four multicenter pediatric acute respiratory distress syndrome studies. Twenty-six academic PICU. Three hundred fifteen pediatric acute respiratory distress syndrome patients. All patients who received conventional mechanical ventilation at hours 0 and 24 of pediatric acute respiratory distress syndrome who had data to calculate ideal body weight were included. Two cutoff points for low-tidal volume ventilation were assessed: less than or equal to 6.5 mL/kg of ideal body weight and less than or equal to 8 mL/kg of ideal body weight. Of 555 patients, we excluded 240 for other respiratory support modes or missing data. The remaining 315 patients had a median PaO2-to-FIO2 ratio of 140 (interquartile range, 90-201), and there were no differences in demographics between those who did and did not receive low-tidal volume ventilation. With tidal volume cutoff of less than or equal to 6.5 mL/kg of ideal body weight, the adherence rate was 32% at hour 0 and 33% at hour 24. A low-tidal volume ventilation cutoff of tidal volume less than or equal to 8 mL/kg of ideal body weight resulted in an adherence rate of 58% at hour 0 and 60% at hour 24. Low-tidal volume ventilation use was no different by severity of pediatric acute respiratory distress syndrome nor did adherence improve over time. At hour 0, overweight children were less likely to receive low-tidal volume ventilation less than or equal to 6.5 mL/kg ideal body weight (11% overweight vs 38% nonoverweight; p = 0.02); no difference was noted by hour 24. Furthermore, in the overweight group, using admission weight instead of ideal body weight resulted in misclassification of up to 14% of patients as receiving low-tidal volume ventilation when they actually were not. Low-tidal volume ventilation is underused in the first 24 hours of pediatric acute respiratory distress syndrome. Age, Pediatric Risk of Mortality-III, and pediatric acute respiratory distress syndrome severity were not associated with improved low-tidal volume ventilation adherence nor did adherence improve over time. Overweight children were less likely to receive low-tidal volume ventilation strategies in the first day of illness.

12 CFR 1291.5 - Competitive application program.

Code of Federal Regulations, 2014 CFR

2014-01-01

... (excluding the value of sweat equity), provided that the project's uses of funds also include or exclude... project. Cash costs do not include in-kind donations, voluntary professional labor or services, or sweat... services (excluding the value of sweat equity) committed to the project as part of the total development...

12 CFR 1291.5 - Competitive application program.

Code of Federal Regulations, 2012 CFR

2012-01-01

... (excluding the value of sweat equity), provided that the project's uses of funds also include or exclude... project. Cash costs do not include in-kind donations, voluntary professional labor or services, or sweat... services (excluding the value of sweat equity) committed to the project as part of the total development...

12 CFR 1291.5 - Competitive application program.

Code of Federal Regulations, 2011 CFR

2011-01-01

... (excluding the value of sweat equity), provided that the project's uses of funds also include or exclude... project. Cash costs do not include in-kind donations, voluntary professional labor or services, or sweat... services (excluding the value of sweat equity) committed to the project as part of the total development...

12 CFR 1291.5 - Competitive application program.

Code of Federal Regulations, 2013 CFR

2013-01-01

... (excluding the value of sweat equity), provided that the project's uses of funds also include or exclude... project. Cash costs do not include in-kind donations, voluntary professional labor or services, or sweat... services (excluding the value of sweat equity) committed to the project as part of the total development...

Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study

PubMed Central

Seymour, Christopher W; Kahn, Jeremy M; Schwab, C William; Fuchs, Barry D

2008-01-01

Introduction Patients triaged to tertiary care centers frequently undergo rotary-wing transport and may be exposed to additional risk for adverse events. The incidence of physiologic adverse events and their predisposing factors in mechanically ventilated patients undergoing aeromedical transport are unknown. Methods We performed a retrospective review of flight records of all interfacility, rotary-wing transports to a tertiary care, university hospital during 2001 to 2003. All patients receiving mechanical ventilation via endotracheal tube or tracheostomy were included; trauma, scene flights, and fixed transports were excluded. Data were abstracted from patient flight and hospital records. Adverse events were classified as either major (death, arrest, pneumothorax, or seizure) or minor (physiologic decompensation, new arrhythmia, or requirement for new sedation/paralysis). Bivariate associations between hospital and flight characteristics and the presence of adverse events were examined. Results Six hundred eighty-two interfacility flights occurred during the period of review, with 191 patients receiving mechanical ventilation. Fifty-eight different hospitals transferred patients, with diagnoses that were primarily cardiopulmonary (45%) and neurologic (37%). Median flight distance and time were 42 (31 to 83) km and 13 (8 to 22) minutes, respectively. No major adverse events occurred during flight. Forty patients (22%) experienced a minor physiologic adverse event. Vasopressor requirement prior to flight and flight distance were associated with the presence of adverse events in-flight (P < 0.05). Patient demographics, time of day, season, transferring hospital characteristics, and ventilator settings before and during flight were not associated with adverse events. Conclusion Major adverse events are rare during interfacility, rotary-wing transfer of critically ill, mechanically ventilated patients. Patients transferred over a longer distance or transferred on vasopressors may be at greater risk for minor adverse events during flight. PMID:18498659

Thirteen years of invasive and noninvasive home ventilation for children in a developing country: A retrospective study.

PubMed

Nathan, Anna Marie; Loo, Hui Yan; de Bruyne, Jessie Anne; Eg, Kah Peng; Kee, Sze Ying; Thavagnanam, Surendran; Bouniu, Marilyn; Wong, Jiat Earn; Gan, Chin Seng; Lum, Lucy Chai See

2017-04-01

Home ventilation (HV) for children is growing rapidly worldwide. The aim was to describe (1) the sociodemographic characteristics of children on HV and (2) the indications for, means and outcome of initiating HV in children from a developing country. This retrospective study included patients sent home on noninvasive or invasive ventilation, over 13 years, by the pediatric respiratory unit in a single center. Children who declined treatment were excluded. Seventy children were initiated on HV: 85.7% on noninvasive ventilation, 14.3% on invasive ventilation. There was about a threefold increase from 2001-2008 (n = 18) to 2009-2014 (n = 52). Median (range) age of initiating HV was 11 (1-169) months and 73% of children were <2 years old. Common indications for HV were respiratory (57.2%), chest/spine anomalies (11.4%), and neuromuscular (10.0%). Fifty-two percent came off their devices with a median (interquartile range) usage duration of 12 (4.8, 21.6) months. Ten children (14.3%) died with one avoidable death. Children with neuromuscular disease were less likely to come off their ventilator (0.0%) compared to children with respiratory disease (62.1%). Forty-one percent of parents bought their equipment, whereas 58.6% borrowed their equipment from the medical social work department and other sources. HV in a resource-limited country is possible. Children with respiratory disease made up a significant proportion of those requiring HV and were more likely to be weaned off. The mortality rate was low. The social work department played an important role in facilitating early discharge. Pediatr Pulmonol. 2017;52:500-507. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Biomarker kinetics in the prediction of VAP diagnosis: results from the BioVAP study.

PubMed

Póvoa, Pedro; Martin-Loeches, Ignacio; Ramirez, Paula; Bos, Lieuwe D; Esperatti, Mariano; Silvestre, Joana; Gili, Gisela; Goma, Gema; Berlanga, Eugenio; Espasa, Mateu; Gonçalves, Elsa; Torres, Antoni; Artigas, Antonio

2016-12-01

Prediction of diagnosis of ventilator-associated pneumonia (VAP) remains difficult. Our aim was to assess the value of biomarker kinetics in VAP prediction. We performed a prospective, multicenter, observational study to evaluate predictive accuracy of biomarker kinetics, namely C-reactive protein (CRP), procalcitonin (PCT), mid-region fragment of pro-adrenomedullin (MR-proADM), for VAP management in 211 patients receiving mechanical ventilation for >72 h. For the present analysis, we assessed all (N = 138) mechanically ventilated patients without an infection at admission. The kinetics of each variable, from day 1 to day 6 of mechanical ventilation, was assessed with each variable's slopes (rate of biomarker change per day), highest level and maximum amplitude of variation (Δ (max)). A total of 35 patients (25.4 %) developed a VAP and were compared with 70 non-infected controls (50.7 %). We excluded 33 patients (23.9 %) who developed a non-VAP nosocomial infection. Among the studied biomarkers, CRP and CRP ratio showed the best performance in VAP prediction. The slope of CRP change over time (adjusted odds ratio [aOR] 1.624, confidence interval [CI]95% [1.206, 2.189], p = 0.001), the highest CRP ratio concentration (aOR 1.202, CI95% [1.061, 1.363], p = 0.004) and Δ (max) CRP (aOR 1.139, CI95% [1.039, 1.248], p = 0.006), during the first 6 days of mechanical ventilation, were all significantly associated with VAP development. Both PCT and MR-proADM showed a poor predictive performance as well as temperature and white cell count. Our results suggest that in patients under mechanical ventilation, daily CRP monitoring was useful in VAP prediction. Trial registration NCT02078999.

42 CFR 460.96 - Excluded services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Excluded services. 460.96 Section 460.96 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

42 CFR 460.96 - Excluded services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 4 2011-10-01 2011-10-01 false Excluded services. 460.96 Section 460.96 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) PROGRAMS OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE...

[Anesthesia ventilators].

PubMed

Otteni, J C; Beydon, L; Cazalaà, J B; Feiss, P; Nivoche, Y

1997-01-01

To review anaesthesia ventilators in current use in France by categories of ventilators. References were obtained from computerized bibliographic search. (Medline), recent review articles, the library of the service and personal files. Anaesthesia ventilators can be allocated into three groups, depending on whether they readminister expired gases or not or allow both modalities. Contemporary ventilators provide either constant volume ventilation, or constant pressure ventilation, with or without a pressure plateau. Ventilators readministering expired gases after CO2 absorption, or closed circuit ventilators, are either of a double- or a single-circuit design. Double-circuit ventilators, or pneumatical bag or bellows squeezers, or bag-in-bottle or bellows-in-bottle (or box) ventilators, consist of a primary, or driving circuit (bottle or box) and a secondary or patient circuit (including a bag or a bellows or membrane chambers). Bellows-in-bottle ventilators have either standing bellows ascending at expiration, or hanging bellows, descending at expiration. Ascending bellows require a positive pressure of about 2 cmH2O throughout exhalation to allow the bellows to refill. The expired gas volume is a valuable indicator for leak and disconnection. Descending bellows generate a slight negative pressure during exhalation. In case of leak or disconnection they aspirate ambient air and cannot act therefore as an indicator for integrity of the circuit and the patient connection. Closed circuit ventilators with a single-circuit (patient circuit) include a insufflating device consisting either in a bellows or a cylinder with a piston, operated by a electric or pneumatic motor. As the hanging bellows of the double circuit ventilators, they generate a slight negative pressure during exhalation and aspirate ambient air in case of leak or disconnection. Ventilators not designed for the readministration of expired gases, or open circuit ventilators, are generally stand-alone mechanical ventilators modified to allow the administration of inhalational anaesthetic agents.

21 CFR 211.46 - Ventilation, air filtration, air heating and cooling.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 4 2010-04-01 2010-04-01 false Ventilation, air filtration, air heating and cooling. 211.46 Section 211.46 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) DRUGS: GENERAL CURRENT GOOD MANUFACTURING PRACTICE FOR FINISHED PHARMACEUTICALS...

Multi-slice Fractional Ventilation Imaging in Large Animals with Hyperpolarized Gas MRI

PubMed Central

Emami, Kiarash; Xu, Yinan; Hamedani, Hooman; Xin, Yi; Profka, Harrilla; Rajaei, Jennia; Kadlecek, Stephen; Ishii, Masaru; Rizi, Rahim R.

2012-01-01

Noninvasive assessment of regional lung ventilation is of critical importance in quantifying the severity of disease and evaluating response to therapy in many pulmonary diseases. This work presents for the first time the implementation of a hyperpolarized (HP) gas MRI technique for measuring whole-lung regional fractional ventilation (r) in Yorkshire pigs (n = 5) through the use of a gas mixing and delivery device in supine position. The proposed technique utilizes a series of back-to-back HP gas breaths with images acquired during short end-inspiratory breath-holds. In order to decouple the RF pulse decay effect from ventilatory signal build-up in the airways, regional distribution of flip angle (α) was estimated in the imaged slices by acquiring a series of back-to-back images with no inter-scan time delay during a breath-hold at the tail-end of the ventilation sequence. Analysis was performed to assess the multi-slice ventilation model sensitivity to noise, oxygen and number of flip angle images. The optimal α value was determined based on minimizing the error in r estimation; αopt = 5–6° for the set of acquisition parameters in pigs. The mean r values for the group of pigs were 0.27±0.09, 0.35±0.06, 0.40±0.04 for ventral, middle and dorsal slices, respectively, (excluding conductive airways r > 0.9). A positive gravitational (ventral-dorsal) ventilation gradient effect was present in all animals. The trachea and major conductive airways showed a uniform near-unity r value, with progressively smaller values corresponding to smaller diameter airways, and ultimately leading to lung parenchyma. Results demonstrate the feasibility of measurements of fractional ventilation in large species, and provides a platform to address technical challenges associated with long breathing time scales through the optimization of acquisition parameters in species with a pulmonary physiology very similar to that of human beings. PMID:22290603

Diagnostic accuracy of pulmonary host inflammatory mediators in the exclusion of ventilator-acquired pneumonia

PubMed Central

Hellyer, Thomas P; Conway Morris, Andrew; McAuley, Daniel F; Walsh, Timothy S; Anderson, Niall H; Singh, Suveer; Dark, Paul; Roy, Alistair I; Baudouin, Simon V; Wright, Stephen E; Perkins, Gavin D; Kefala, Kallirroi; Jeffels, Melinda; McMullan, Ronan; O'Kane, Cecilia M; Spencer, Craig; Laha, Shondipon; Robin, Nicole; Gossain, Savita; Gould, Kate; Ruchaud-Sparagano, Marie-Hélène; Scott, Jonathan; Browne, Emma M; MacFarlane, James G; Wiscombe, Sarah; Widdrington, John D; Dimmick, Ian; Laurenson, Ian F; Nauwelaers, Frans; Simpson, A John

2015-01-01

Background Excessive use of empirical antibiotics is common in critically ill patients. Rapid biomarker-based exclusion of infection may improve antibiotic stewardship in ventilator-acquired pneumonia (VAP). However, successful validation of the usefulness of potential markers in this setting is exceptionally rare. Objectives We sought to validate the capacity for specific host inflammatory mediators to exclude pneumonia in patients with suspected VAP. Methods A prospective, multicentre, validation study of patients with suspected VAP was conducted in 12 intensive care units. VAP was confirmed following bronchoscopy by culture of a potential pathogen in bronchoalveolar lavage fluid (BALF) at >104 colony forming units per millilitre (cfu/mL). Interleukin-1 beta (IL-1β), IL-8, matrix metalloproteinase-8 (MMP-8), MMP-9 and human neutrophil elastase (HNE) were quantified in BALF. Diagnostic utility was determined for biomarkers individually and in combination. Results Paired BALF culture and biomarker results were available for 150 patients. 53 patients (35%) had VAP and 97 (65%) patients formed the non-VAP group. All biomarkers were significantly higher in the VAP group (p<0.001). The area under the receiver operator characteristic curve for IL-1β was 0.81; IL-8, 0.74; MMP-8, 0.76; MMP-9, 0.79 and HNE, 0.78. A combination of IL-1β and IL-8, at the optimal cut-point, excluded VAP with a sensitivity of 100%, a specificity of 44.3% and a post-test probability of 0% (95% CI 0% to 9.2%). Conclusions Low BALF IL-1β in combination with IL-8 confidently excludes VAP and could form a rapid biomarker-based rule-out test, with the potential to improve antibiotic stewardship. PMID:25298325

20 CFR 404.1209 - Mandatorily excluded services.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Mandatorily excluded services. 404.1209 Section 404.1209 Employees' Benefits SOCIAL SECURITY ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND... unemployment; (b) Services performed in an institution by a patient or inmate of the institution; (c...

Technology evaluation of heating, ventilation, and air conditioning for MIUS application

NASA Technical Reports Server (NTRS)

Gill, W. L.; Keough, M. B.; Rippey, J. O.

1974-01-01

Potential ways of providing heating, ventilation, and air conditioning for a building complex serviced by a modular integrated utility system (MIUS) are examined. Literature surveys were conducted to investigate both conventional and unusual systems to serve this purpose. The advantages and disadvantages of the systems most compatible with MIUS are discussed.

46 CFR 154.1205 - Mechanical ventilation system: Standards.

Code of Federal Regulations, 2011 CFR

2011-10-01

... openings to accommodations, service, control station, and other gas-safe spaces. (c) Each ventilation system under § 154.1200 (a) and (b)(1) must change the air in that space and its adjoining trunks at... top of each space that personnel enter during cargo handling operations. (b) The discharge end of each...

Continuous High-Frequency Oscillation Therapy in Invasively Ventilated Pediatric Subjects in the Critical Care Setting.

PubMed

Morgan, Stephen; Hornik, Christoph P; Patel, Niyati; Williford, Walter L; Turner, David A; Cheifetz, Ira M

2016-11-01

Continuous high-frequency oscillation (CHFO) creates a pressure gradient in the small airways that accelerates expiratory flow. The intended use of CHFO therapy is to facilitate secretion removal and treat atelectasis. Our objective was to assess the feasibility, safety, and efficacy of CHFO in the mechanically ventilated pediatric population. After institutional review board approval, we retrospectively reviewed medical records of mechanically ventilated children treated with CHFO (the MetaNeb system) at our institution from July 1, 2007 through August 31, 2012. Patients supported with extracorporeal membrane oxygenation were excluded. We evaluated changes in ventilator settings in subjects with ventilator data documented within 6 h pre- and post-treatment. We evaluated arterial blood gas (ABG) results for individual treatments, comparing ABG results within 8 h pre-therapy to ABG results within 3 h post-treatment. Oxygen index and P aO 2 /F IO 2 were calculated. Demographic data, blood pressure, heart rate, and development of new air leak while being treated with CHFO were recorded. Pre- and post-CHFO measurements were compared using Wilcoxon signed-rank testing. Our cohort included 59 invasively ventilated subjects. Median age was 2 y (range 1 month to 19 y), and median weight was 14 kg (2-81 kg). We evaluated data on 528 total treatments (range per subject 1-39 treatments). Peak inspiratory pressure significantly decreased with CHFO, whereas other parameters, including P aCO 2 and breathing frequency, remained stable. There was no significant change in systolic blood pressure, diastolic blood pressure, or heart rate following treatment with CHFO. One subject (2%) developed a clinically insignificant pneumothorax during CHFO. CHFO is feasible and seems safe in our cohort of mechanically ventilated pediatric subjects. The rate of pneumothorax was consistent with that seen in similar pediatric ICU populations. These preliminary results suggest that CHFO may be beneficial by improving lung compliance in pediatric subjects with secretion-induced atelectasis. Prospective clinical studies are needed to further evaluate the clinical efficacy and safety of CHFO in children receiving invasive mechanical ventilation. Copyright © 2016 by Daedalus Enterprises.

Congenital central hypoventilation syndrome: diagnostic and management challenges.

PubMed

Kasi, Ajay S; Perez, Iris A; Kun, Sheila S; Keens, Thomas G

2016-01-01

Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder with failure of central control of breathing and of the autonomic nervous system function due to a mutation in the paired-like homeobox 2B (PHOX2B) gene. Affected patients have absent or negligible ventilatory sensitivity to hypercapnia and hypoxemia, and they do not exhibit signs of respiratory distress when challenged with hypercarbia or hypoxia. The diagnosis of CCHS must be confirmed with PHOX2B gene mutation. Generally, the PHOX2B mutation genotype can aid in anticipating the severity of the phenotype. They require ventilatory support for life. Home assisted ventilation options include positive pressure ventilation via tracheostomy, noninvasive positive pressure ventilation, and diaphragm pacing via phrenic nerve stimulation, but each strategy has its associated limitations and challenges. Since all the clinical manifestations of CCHS may not manifest at birth, periodic monitoring and early intervention are necessary to prevent complications and improve outcome. Life-threatening arrhythmias can manifest at different ages and a normal cardiac monitoring study does not exclude future occurrences leading to the dilemma of timing and frequency of cardiac rhythm monitoring and treatment. Given the rare incidence of CCHS, most health care professionals are not experienced with managing CCHS patients, particularly those with diaphragm pacers. With early diagnosis and advances in home mechanical ventilation and monitoring strategies, many CCHS children are surviving into adulthood presenting new challenges in their care.

Causes Of Low Efficiency Of Combined Ventilation System In Coal Mines In Resolving The Problem Of Air Leaks (Inflows) Between Levels And Surface

NASA Astrophysics Data System (ADS)

Popov, Valeriy; Filatov, Yuriy; Lee, Hee; Golik, Anatoliy

2017-11-01

The paper discusses the problem of the underground mining safety control. The long-term air intake to coal accumulations is reviewed as one of the reasons of endogenous fires during mining. The methods of combating air leaks (inflows) in order to prevent endogenous fires are analyzed. The calculations showing the discrepancy between the design calculations for the mine ventilation, disregarding a number of mining-andgeological and mining-engineering factors, and the actual conditions of mining are given. It is proved that the conversion of operating mines to combined (pressure and exhaust) ventilation system in order to reduce the endogenous fire hazard of underground mining is unreasonable due to impossibility of providing an optimal distribution of aerodynamic pressure in mines. The conversion does not exclude the entry of air into potentially hazardous zones of endogenous fires. The essence of the combined application of positive and negative control methods for the distribution of air pressure is revealed. It consists of air doors installation in easily ventilated airways and installation of pressure equalization chambers equipped with auxiliary fans near the stoppings, working sections and in parallel airways.The effectiveness of the combined application of negative and positive control methods for the air pressure distribution in order to reduce endogenous fire hazard of mining operations is proved.

Pseudocalcification on chest CT scan.

PubMed

Tiruvoipati, R; Balasubramanian, S K; Entwisle, J J; Firmin, R K; Peek, G J

2007-07-01

Liquid ventilation with perfluorocarbons is used in severe respiratory failure that cannot be managed by conventional methods. Very little is known about the use of liquid ventilation in paediatric patients with respiratory failure and there are no reports describing the distribution and excretion of perfluorocarbons in paediatric patients with severe respiratory failure. The aim of this report is to highlight the prolonged retention of perfluorocarbons in a paediatric patient, mimicking pulmonary calcification and misleading the interpretation of the chest CT scan. A 10-year-old girl was admitted to our intensive care unit with severe respiratory failure due to miliary tuberculosis. Extracorporeal membrane oxygenation (ECMO) was used to support gas exchange and partial liquid ventilation (PLV) with perfluorodecalin was used to aid in oxygenation, lavage the lungs and clear thick secretions. The patient developed a pneumothorax (fluorothorax) on the next day and PLV was discontinued. Multiple bronchoalveolar lavages were performed to clear thick secretions. With no improvement in lung function over the next month a CT scan of the chest was performed. This revealed extensive pulmonary fibrosis and multiple high attenuation lesions suggestive of pulmonary calcification. To exclude perfluorodecalin as the cause for high attenuation lesions, a sample of perfluorodecalin was scanned to estimate the Hounsfield unit density, which was similar to the density of high attenuation lesions on chest CT scan. High-density opacification should be interpreted with caution, especially following liquid ventilation.

20 CFR 404.1015 - Family services.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Family services. 404.1015 Section 404.1015... Family services. (a) General. If you work as an employee of a relative, the work is excluded from.... (b) Family work for other than sole proprietor. Work for a corporation is not excluded under this...

Right Atrial Anomalous Muscle Bundle Presenting with Acute Superior Vena Cava Syndrome and Pulmonary Embolism: Surgical Management.

PubMed

Madjarov, Jeko M; Katz, Michael G; Madjarova, Sophia; Madzharov, Svetozar; Arko, Frank R; Miller, David W; Robicsek, Francis

2018-05-21

An anomalous muscle bundle crossing the right atrial cavity represents a pathological finding with unproved clinical significance. This congenital anomaly may be difficult to recognize via echocardiography and could be confused with other intra-cavitary lesions. We report a case of a 53-year-old female presented to the cardio-vascular service with acute superior vena cava syndrome and sub-massive pulmonary embolism. The patient underwent venography confirming superior vena cava stenosis. A ventilation/perfusion lung scan showed two sizable perfusion defects due to pulmonary embolism. MRI and echocardiography imaging demonstrated right atrium mass. Surgery was then carried out using standard cardiopulmonary bypass; right atrial muscle bundle was excised and superior vena cava reconstruction was performed. The patient was discharged uneventfully and remains symptom-free at two years follow-up. In cases of nonmalignant pathology of superior vena cava syndrome, appropriate studies should be conducted to exclude potential congenital abnormalities such as this anomalous muscle bundle in the right atrium. Open heart surgery is a viable treatment option in select cases. Published by Elsevier Inc.

Detection of early subclinical lung disease in children with cystic fibrosis by lung ventilation imaging with hyperpolarised gas MRI.

PubMed

Marshall, Helen; Horsley, Alex; Taylor, Chris J; Smith, Laurie; Hughes, David; Horn, Felix C; Swift, Andrew J; Parra-Robles, Juan; Hughes, Paul J; Norquay, Graham; Stewart, Neil J; Collier, Guilhem J; Teare, Dawn; Cunningham, Steve; Aldag, Ina; Wild, Jim M

2017-08-01

Hyperpolarised 3 He ventilation-MRI, anatomical lung MRI, lung clearance index (LCI), low-dose CT and spirometry were performed on 19 children (6-16 years) with clinically stable mild cystic fibrosis (CF) (FEV 1 >-1.96), and 10 controls. All controls had normal spirometry, MRI and LCI. Ventilation-MRI was the most sensitive method of detecting abnormalities, present in 89% of patients with CF, compared with CT abnormalities in 68%, LCI 47% and conventional MRI 22%. Ventilation defects were present in the absence of CT abnormalities and in patients with normal physiology, including LCI. Ventilation-MRI is thus feasible in young children, highly sensitive and provides additional information about lung structure-function relationships. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

The role of lung imaging in pulmonary embolism

PubMed Central

Mishkin, Fred S.; Johnson, Philip M.

1973-01-01

The advantages of lung scanning in suspected pulmonary embolism are its diagnostic sensitivity, simplicity and safety. The ability to delineate regional pulmonary ischaemia, to quantitate its extent and to follow its response to therapy provides valuable clinical data available by no other simple means. The negative scan effectively excludes pulmonary embolism but, although certain of its features favour the diagnosis of embolism, the positive scan inherently lacks specificity and requires angiographic confirmation when embolectomy, caval plication or infusion of a thrombolytic agent are contemplated. The addition of simple ventilation imaging techniques with radioxenon overcomes this limitation by providing accurate analog estimation or digital quantitation of regional ventilation: perfusion (V/Q) ratios fundamental to understanding the pathophysiologic consequences of embolism and other diseases of the lung. ImagesFig. 1Fig. 2Fig. 3Fig. 4Fig. 5Fig. 6Fig. 7p495-bFig. 8Fig. 9Fig. 10Fig. 11Fig. 12Fig. 13 PMID:4602128

29 CFR 1471.135 - May the Federal Mediation and Conciliation Service exclude a person who is not currently...

Code of Federal Regulations, 2010 CFR

2010-07-01

... 29 Labor 4 2010-07-01 2010-07-01 false May the Federal Mediation and Conciliation Service exclude....135 Labor Regulations Relating to Labor (Continued) FEDERAL MEDIATION AND CONCILIATION SERVICE GOVERNMENTWIDE DEBARMENT AND SUSPENSION (NONPROCUREMENT) General § 1471.135 May the Federal Mediation and...

Chemical Emissions of Residential Materials and Products: Review of Available Information

DOE Office of Scientific and Technical Information (OSTI.GOV)

Willem, Henry; Singer, Brett

2010-09-15

This report is prepared in the context of a larger program whose mission is to advance understanding of ventilation and indoor air quality in U.S. homes. A specific objective of this program is to develop the scientific basis ? through controlled experiments, monitoring and analysis ? for health risk-based ventilation standards. Appropriate and adequate ventilation is a basic element of a healthy home. Ventilation provides outdoor air and in the process removes indoor odors and contaminants including potentially unhealthful chemicals emitted by indoor materials, products and activities. Ventilation traditionally was assured to occur via infiltration of outdoor air through cracksmore » and other leakage pathways in the residential building envelope. As building air tightness is improved for energy efficiency, infiltration can be reduced to inadequate levels. This has lead to the development of standards requiring mechanical ventilation. Though nominally intended to ensure acceptable indoor air quality, the standards are not explicitly tied to health risk or pollutant exposure targets. LBNL is currently designing analyses to assess the impact of varying ventilation standards on pollutant concentrations, health risks and energy use. These analyses require information on sources of chemical pollutant emissions, ideally including emission rates and the impact of ventilation on emissions. Some information can be obtained from recent studies that report measurements of various air contaminants and their concentrations in U.S. residences. Another way to obtain this information is the bottom-up approach of collecting and evaluating emissions data from construction and interior materials and common household products. This review contributes to the latter approach by summarizing available information on chemical emissions from new residential products and materials. We review information from the scientific literature and public sources to identify and discuss the databases that provide information on new or low-emission materials and products. The review focuses on the primary chemical or volatile organic compound (VOC) emissions from interior surface materials, furnishings, and some regularly used household products; all of these emissions are amenable to ventilation. Though it is an important and related topic, this review does not consider secondary pollutants that result from reactions of ozone and unsaturated organics bound to or emitted from material surfaces. Semi-volatile organic compounds (SVOCs) have been largely excluded from this review because ventilation generally is not an effective way to control SVOC exposures. Nevertheless, health concerns about exposures to SVOCs emitted from selected materials warrant some discussion.« less

Unloading work of breathing during high-frequency oscillatory ventilation: a bench study

PubMed Central

van Heerde, Marc; Roubik, Karel; Kopelent, Vitek; Plötz, Frans B; Markhorst, Dick G

2006-01-01

Introduction With the 3100B high-frequency oscillatory ventilator (SensorMedics, Yorba Linda, CA, USA), patients' spontaneous breathing efforts result in a high level of imposed work of breathing (WOB). Therefore, spontaneous breathing often has to be suppressed during high-frequency oscillatory ventilation (HFOV). A demand-flow system was designed to reduce imposed WOB. Methods An external gas flow controller (demand-flow system) accommodates the ventilator fresh gas flow during spontaneous breathing simulation. A control algorithm detects breathing effort and regulates the demand-flow valve. The effectiveness of this system has been evaluated in a bench test. The Campbell diagram and pressure time product (PTP) are used to quantify the imposed workload. Results Using the demand-flow system, imposed WOB is considerably reduced. The demand-flow system reduces inspiratory imposed WOB by 30% to 56% and inspiratory imposed PTP by 38% to 59% compared to continuous fresh gas flow. Expiratory imposed WOB was decreased as well by 12% to 49%. In simulations of shallow to normal breathing for an adult, imposed WOB is 0.5 J l-1 at maximum. Fluctuations in mean airway pressure on account of spontaneous breathing are markedly reduced. Conclusion The use of the demand-flow system during HFOV results in a reduction of both imposed WOB and fluctuation in mean airway pressure. The level of imposed WOB was reduced to the physiological range of WOB. Potentially, this makes maintenance of spontaneous breathing during HFOV possible and easier in a clinical setting. Early initiation of HFOV seems more possible with this system and the possibility of weaning of patients directly on a high-frequency oscillatory ventilator is not excluded either. PMID:16848915

Increased risk of pneumonia among ventilated patients with traumatic brain injury: every day counts!

PubMed

Hui, Xuan; Haider, Adil H; Hashmi, Zain G; Rushing, Amy P; Dhiman, Nitasha; Scott, Valerie K; Selvarajah, Shalini; Haut, Elliott R; Efron, David T; Schneider, Eric B

2013-09-01

Patients with traumatic brain injury (TBI) frequently require mechanical ventilation (MV). The objective of this study was to examine the association between time spent on MV and the development of pneumonia among patients with TBI. Patients older than 18 y with head abbreviated injury scale (AIS) scores coded 1-6 requiring MV in the National Trauma Data Bank 2007-2010 data set were included. The study was limited to hospitals reporting pneumonia cases. AIS scores were calculated using ICDMAP-90 software. Patients with injuries in any other region with AIS score >3, significant burns, or a hospital length of stay >30 d were excluded. A generalized linear model was used to determine the approximate relative risk of developing all-cause pneumonia (aspiration pneumonia, ventilator-associated pneumonia [VAP], and infectious pneumonia identified by the International Classification of Disease, Ninth Revision, diagnosis code) for each day of MV, controlling for age, gender, Glasgow coma scale motor score, comorbidity (Charlson comorbidity index) score, insurance status, and injury type and severity. Among the 24,525 patients with TBI who required MV included in this study, 1593 (6.5%) developed all-cause pneumonia. After controlling for demographic and injury factors, each additional day on the ventilator was associated with a 7% increase in the risk of pneumonia (risk ratio 1.07, 95% confidence interval 1.07-1.08). Patients who have sustained TBIs and require MV are at higher risk for VAP than individuals extubated earlier; therefore, shortening MV exposure will likely reduce the risk of VAP. As patients with TBI frequently require MV because of neurologic impairment, it is key to develop aggressive strategies to expedite ventilator independence. Copyright © 2013 Elsevier Inc. All rights reserved.

Chlorhexidine and tooth-brushing as prevention strategies in reducing ventilator-associated pneumonia rates.

PubMed

Roberts, Nesta; Moule, Pam

2011-01-01

Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation after endotracheal intubation. The role of chlorhexidine and tooth-brushing has been considered as a clinical intervention to reduce infection rates, however, evidence to inform this needs appraising. This paper presents a critical review on the effect of chlorhexidine gluconate (CHX) and tooth-brushing in decreasing rates of VAP in mechanically ventilated adult patients cared for in intensive care settings. A literature search was conducted using a number of bibliographic databases (n = 6). A number of parameters were used to exclude irrelevant papers. A total n = 17 papers were located and accessed, which were directly related to the field. Eight studies that met the criteria and addressed the study aims were reviewed. CHX was successful in reducing the rate of VAP and using a combination of CHX and colistine resulted in better oropharyngeal decontamination which reduced and delayed VAP. Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the potential to reduce nosocomial infections. Results of studies investigating the use of tooth-brushing in reducing VAP incidence proved inconsistent, although all recommend tooth-brushing as important in maintaining good oral hygiene. The use of chlorhexidine has been proven to be of some value in reducing VAP, although may be more effective when used with a solution which targets gram-negative bacteria. Tooth-brushing is recommended in providing a higher standard of oral care to mechanically ventilated patients and reducing VAP when used with chlorhexidine. However, limitations in study design and inconsistency in results suggest that further research is required into the effects of tooth-brushing. © 2011 The Authors. Nursing in Critical Care © 2011 British Association of Critical Care Nurses.

The prevalence and impact of prescription controlled substance use among injured patients at a Level I trauma center.

PubMed

Cannon, Robert; Bozeman, Matthew; Miller, Keith Roy; Smith, Jason Wayne; Harbrecht, Brian; Franklin, Glen; Benns, Matthew

2014-01-01

There has been increasing attention focused on the epidemic of prescription drug use in the United States, but little is known about its effects in trauma. The purpose of this study was to define the prevalence of prescription controlled substance use among trauma patients and determine its effects on outcome. A retrospective review of all patients admitted to a Level 1 trauma center from January 1, 2011, to December 31, 2011, was performed. Patients dying within 24 hours or without home medication reconciliations were excluded. Data review included preexisting benzodiazepine or narcotic use, sex, age, mechanism of injury, Injury Severity Scores (ISSs), intensive care unit (ICU) and overall length of stay, ventilator days, and overall cost. SAS version 9.3 was used for the analysis, and p ≤ 0.05 was considered significant. A total of 1,700 patients met inclusion criteria. Of these, 340 (20.0%) were on prescription narcotics and/or benzodiazepines at the time of admission. Patients in the narcotic/benzodiazepine group were significantly older (48 years vs. 43 years) and more likely to be women (43.7% vs. 28.9%). There was no difference in mechanism, ISS, or the presence of head injury between groups. Both ICU length of stay (3.3 days vs. 2.1 days) and total length of stay (7.8 days vs. 6.1 days) were significantly longer in patients on outpatient narcotics and/or benzodiazepines. Excluding severely injured patients, the need for mechanical ventilation was also increased among outpatient controlled substance users (15.8% vs. 11.0%). There is a substantial prevalence of preexisting controlled substance use (20%) among patients at our Level 1 trauma center. Preexisting controlled substance use is associated with longer total hospital and ICU stays. Among mildly to moderately injured patients, preinjury controlled substance is also associated with the need for mechanical ventilation. Prognostic study, level III.

Home Mechanical Ventilation: A 12-Year Population-Based Retrospective Cohort Study.

PubMed

Povitz, Marcus; Rose, Louise; Shariff, Salimah Z; Leonard, Sean; Welk, Blayne; Jenkyn, Krista Bray; Leasa, David J; Gershon, Andrea S

2018-04-01

Increasing numbers of individuals are being initiated on home mechanical ventilation, including noninvasive (bi-level) and invasive mechanical ventilation delivered via tracheostomy due to chronic respiratory failure to enable symptom management and promote quality of life. Given the high care needs of these individuals, a better understanding of the indications for home mechanical ventilation, and health-care utilization is needed. We performed a retrospective cohort study using provincial health administrative data from Ontario, Canada (population ∼13,000,000). Home mechanical ventilation users were characterized using health administrative data to determine the indications for home mechanical ventilation, the need for acute care at the time of ventilation approval, and their health service use and mortality rates following approval. The annual incidence of home mechanical ventilation approval rose from 1.8/100,000 in 2000 to 5.0/100,000 in 2012, or an annual increase of approximately 0.3/100,000 persons/y. The leading indications were neuromuscular disease, thoracic restriction, and COPD. The indication for the remainder could not be determined due to limitations of the administrative databases. Of the 4,670 individuals, 23.0% commenced home mechanical ventilation following an acute care hospitalization. Among individuals who survived at least 1 y, fewer required hospitalization in the year that followed home mechanical ventilation approval (29.9% vs 39.8%) as compared with the year prior. Utilization of home mechanical ventilation is increasing in Ontario, Canada, and further study is needed to clarify the factors contributing to this and to further optimize utilization of health-care resources. Copyright © 2018 by Daedalus Enterprises.

20 CFR 404.1323 - Post-World War II service excluded.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Post-World War II service excluded. 404.1323 Section 404.1323 Employees' Benefits SOCIAL SECURITY ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Wage Credits for Veterans and Members of the Uniformed Services Post-World War II Veterans § 404.1323 Post-World War II...

5 CFR 919.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2010 CFR

2010-01-01

... person as a principal under a covered transaction? 919.315 Section 919.315 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) GOVERNMENTWIDE DEBARMENT... with Other Persons § 919.315 May I use the services of an excluded person as a principal under a...

Ventilator-associated pneumonia rates at major trauma centers compared with a national benchmark: a multi-institutional study of the AAST.

PubMed

Michetti, Christopher P; Fakhry, Samir M; Ferguson, Pamela L; Cook, Alan; Moore, Forrest O; Gross, Ronald

2012-05-01

Ventilator-associated pneumonia (VAP) rates reported by the National Healthcare Safety Network (NHSN) are used as a benchmark and quality measure, yet different rates are reported from many trauma centers. This multi-institutional study was undertaken to elucidate VAP rates at major trauma centers. VAP rate/1,000 ventilator days, diagnostic methods, institutional, and aggregate patient data were collected retrospectively from a convenience sample of trauma centers for 2008 and 2009 and analyzed with descriptive statistics. At 47 participating Level I and II centers, the pooled mean VAP rate was 17.2 versus 8.1 for NHSN (2006-2008). Hospitals' rates were highly variable (range, 1.8-57.6), with 72.3% being above NHSN's mean. Rates differed based on who determined the rate (trauma service, 27.5; infection control or quality or epidemiology, 11.9; or collaborative effort, 19.9) and the frequency with which VAP was excluded based on aspiration or diagnosis before hospital day 5. In 2008 and 2009, blunt trauma patients had higher VAP rates (17.3 and 17.6, respectively) than penetrating patients (11.0 and 10.9, respectively). More centers used a clinical diagnostic strategy (57%) than a bacteriologic strategy (43%). Patients with VAP had a mean Injury Severity Score of 28.7, mean Intensive Care Unit length of stay of 20.8 days, and a 12.2% mortality rate. 50.5% of VAP patients had a traumatic brain injury. VAP rates at major trauma centers are markedly higher than those reported by NHSN and vary significantly among centers. Available data are insufficient to set benchmarks, because it is questionable whether any one data set is truly representative of most trauma centers. Application of a single benchmark to all centers may be inappropriate, and reliable diagnostic and reporting standards are needed. Prospective analysis of a larger data set is warranted, with attention to injury severity, risk factors specific to trauma patients, diagnostic method used, VAP definitions and exclusions, and reporting guidelines. III, prognostic study.

Impact of a Palliative Care Program on Tracheostomy Utilization in a Community Hospital.

PubMed

Pan, Cynthia X; Gutierrez, Cristina; Maw, Min M; Kansler, Amanda L; Gross, Liam; He, Jie; Kanta, Romana; Paul, Subroto

2015-12-01

Tracheostomies are typically provided to wean patients off the ventilator. However, in many circumstances tracheostomies are placed in patients who are at the end of their life with little hope of meaningful recovery. Palliative care teams decrease utilization of aggressive medical interventions in patients who are at the end of life. The study objective was to determine the impact of a palliative care team on tracheostomy utilization in a community hospital setting. The study was a four-year retrospective analysis of adult patients undergoing elective tracheostomy two years before and after the establishment of a palliative care program. The study in an ethnically diverse community hospital included patients older than 18 years old, with patients undergoing a tracheostomy due to trauma excluded. Before and after comparisons were made of demographics, in-hospital mortality, length of stay, and discharge status of patients undergoing tracheostomy. Seven hundred ninety patients undergoing tracheostomy were identified (n = 406, n = 384 before and after September 10, 2010, respectively). Patients were ethnically diverse (Caucasian 43%, Asian 23%, African American 11%, Hispanic 7%). The number of hospital admissions slightly increased during these two time periods (n = 58,926; n = 60,662, respectively). There were no statistical differences in age (73 versus 72, p = 0.827); gender (n = 218 [54%] versus n = 217 [57%] male, p = 0.426); or race (n = 187 [46%] versus n = 150 [39%] Caucasian, p = 0.073) in the two time periods. Patients who underwent tracheostomy after a palliative care service was established had less incidence of comorbid disease (Charlson Comorbidity Index score [CCIS]: 2 versus 3, p = 0.025); lower inpatient mortality (n = 107 [28%] versus n = 148 [37%], p = 0.009]); greater discharge to home or rehabilitation (n = 262 [68%] versus n = 249 [62%], p = 0.01); and lower rates of palliative weaning from mechanical ventilation (n = 61[16%] versus n = 113 [28%], p < 0.001). In an ethnically diverse community hospital, the institution of a palliative care program appears to have improved patient selection for tracheostomy with lower rates of inpatient mortality, improved rates of home discharge, and lower rates of palliative weaning from mechanical ventilation.

Spontaneous Breathing Trials and Conservative Sedation Practices Reduce Mechanical Ventilation Duration in Subjects With ARDS.

PubMed

Kallet, Richard H; Zhuo, Hanjing; Yip, Vivian; Gomez, Antonio; Lipnick, Michael S

2018-01-01

Spontaneous breathing trials (SBTs) and daily sedation interruptions (DSIs) reduce both the duration of mechanical ventilation and ICU length of stay (LOS). The impact of these practices in patients with ARDS has not previously been reported. We examined whether implementation of SBT/DSI protocols reduce duration of mechanical ventilation and ICU LOS in a retrospective group of subjects with ARDS at a large, urban, level-1 trauma center. All ARDS survivors from 2002 to 2016 ( N = 1,053) were partitioned into 2 groups: 397 in the pre-SBT/DSI group (June 2002-December 2007) and 656 in the post-SBT/DSI group (January 2009-April 2016). Patients from 2008, during the protocol implementation period, were excluded. An additional SBT protocol database (2008-2010) was used to assess the efficacy of SBT in transitioning subjects with ARDS to unassisted breathing. Comparisons were assessed by either unpaired t tests or Mann-Whitney tests. Multiple comparisons were made using either one-way analysis of variance or Kruskal-Wallis and Dunn's tests. Linear regression modeling was used to determine variables independently associated with mechanical ventilation duration and ICU LOS; differences were considered statistically significant when P < .05. Compared to the pre-protocol group, subjects with ARDS managed with SBT/DSI protocols experienced pronounced reductions both in median (IQR) mechanical ventilation duration (14 [6-29] vs 9 [4-17] d, respectively, P < .001) and median ICU LOS (18 [8-33] vs 13 [7-22] d, respectively P < .001). In the final model, only treatment in the SBT/DSI period and higher baseline respiratory system compliance were independently associated with reduced mechanical ventilation duration and ICU LOS. Among subjects with ARDS in the SBT performance database, most achieved unassisted breathing with a median of 2 SBTs. Evidenced-based protocols governing weaning and sedation practices were associated with both reduced mechanical ventilation duration and ICU LOS in subjects with ARDS. However, higher respiratory system compliance in the SBT/DSI cohort also contributed to these improved outcomes. Copyright © 2018 by Daedalus Enterprises.

Non-invasive quantitative pulmonary V/Q imaging using Fourier decomposition MRI at 1.5T.

PubMed

Kjørstad, Åsmund; Corteville, Dominique M R; Henzler, Thomas; Schmid-Bindert, Gerald; Zöllner, Frank G; Schad, Lothar R

2015-12-01

Techniques for quantitative pulmonary perfusion and ventilation using the Fourier Decomposition method were recently demonstrated. We combine these two techniques and show that ventilation-perfusion (V/Q) imaging is possible using only a single MR acquisition of less than thirty seconds. The Fourier Decomposition method is used in combination with two quantification techniques, which extract baselines from within the images themselves and thus allows quantification. For the perfusion, a region assumed to consist of 100% blood is utilized, while for the ventilation the zero-frequency component is used. V/Q-imaging is then done by dividing the quantified ventilation map with the quantified perfusion map. The techniques were used on ten healthy volunteers and fifteen patients diagnosed with lung cancer. A mean V/Q-ratio of 1.15 ± 0.22 was found for the healthy volunteers and a mean V/Q-ratio of 1.93 ± 0.83 for the non-afflicted lung in the patients. Mean V/Q-ratio in the afflicted (tumor-bearing) lung was found to be 1.61 ± 1.06. Functional defects were clearly visible in many of the patient images, but 5 of 15 patient images had to be excluded due to artifacts or low SNR, indicating a lack of robustness. Non-invasive, quantitative V/Q-imaging is possible using Fourier Decomposition MRI. The method requires only a single acquisition of less than 30 seconds, but robustness in patients remains an issue. Copyright © 2015. Published by Elsevier GmbH.

BreathDx - molecular analysis of exhaled breath as a diagnostic test for ventilator-associated pneumonia: protocol for a European multicentre observational study.

PubMed

van Oort, Pouline M P; Nijsen, Tamara; Weda, Hans; Knobel, Hugo; Dark, Paul; Felton, Timothy; Rattray, Nicholas J W; Lawal, Oluwasola; Ahmed, Waqar; Portsmouth, Craig; Sterk, Peter J; Schultz, Marcus J; Zakharkina, Tetyana; Artigas, Antonio; Povoa, Pedro; Martin-Loeches, Ignacio; Fowler, Stephen J; Bos, Lieuwe D J

2017-01-03

The diagnosis of ventilator-associated pneumonia (VAP) remains time-consuming and costly, the clinical tools lack specificity and a bedside test to exclude infection in suspected patients is unavailable. Breath contains hundreds to thousands of volatile organic compounds (VOCs) that result from host and microbial metabolism as well as the environment. The present study aims to use breath VOC analysis to develop a model that can discriminate between patients who have positive cultures and who have negative cultures with a high sensitivity. The Molecular Analysis of Exhaled Breath as Diagnostic Test for Ventilator-Associated Pneumonia (BreathDx) study is a multicentre observational study. Breath and bronchial lavage samples will be collected from 100 and 53 intubated and ventilated patients suspected of VAP. Breath will be analysed using Thermal Desorption - Gas Chromatography - Mass Spectrometry (TD-GC-MS). The primary endpoint is the accuracy of cross-validated prediction for positive respiratory cultures in patients that are suspected of VAP, with a sensitivity of at least 99% (high negative predictive value). To our knowledge, BreathDx is the first study powered to investigate whether molecular analysis of breath can be used to classify suspected VAP patients with and without positive microbiological cultures with 99% sensitivity. UKCRN ID number 19086, registered May 2015; as well as registration at www.trialregister.nl under the acronym 'BreathDx' with trial ID number NTR 6114 (retrospectively registered on 28 October 2016).

Full-Scale Schlieren Visualization of Commercial Kitchen Ventilation Aerodynamics

NASA Astrophysics Data System (ADS)

Miller, J. D.; Settles, G. S.

1996-11-01

The efficient removal of cooking effluents from commercial kitchens has been identified as the most pressing energy-related issue in the food service industry. A full-scale schlieren optical system with a 2.1x2.7m field-of-view, described at previous APS/DFD meetings, images the convective airflow associated with a typical gas-fired cooking griddle and ventilation hood. Previous attempts to visualize plumes from cooking equipment by smoke and neutrally-buoyant bubbles were not sufficiently keyed to thermal convection. Here, the point where the ventilation hood fails to capture the effluent plume is clearly visible, thus determining the boundary condition for a balanced ventilation system. Further, the strong influence of turbulent entrainment is seen in the behavior of the combustion products vented by the griddle and the interference caused by a makeup-air outlet located too close to the lip of the ventilation hood. Such applications of traditional fluid dynamics techniques and principles are believed to be important to the maturing of ventilation technology. (Research supported by EPRI and IFMA, Inc.)

A Contemporary Assessment of Acute Mechanical Ventilation in Beijing: Description, Costs, and Outcomes.

PubMed

Ye, Yanping; Zhu, Bo; Jiang, Li; Jiang, Qi; Wang, Meiping; Hua, Lin; Xi, Xiuming

2017-07-01

To evaluate the contemporary practice, outcomes, and costs related to mechanical ventilation among ICUs in China. A prospective observational cohort study. Fourteen ICUs among 13 hospitals in Beijing, China. Seven hundred ninety-three patients who received at least 24 hours of mechanical ventilation within the first 48 hours of ICU stay. None. The mean age was 64 years. Sixty-three percent were male. New acute respiratory failure accounted for 85.5% of mechanical ventilation cases. Only 4.7% of the patients received mechanical ventilation for acute exacerbation of chronic obstructive pulmonary disease. The most widely used ventilation mode was the combination of synchronized intermittent mandatory ventilation and pressure support (43.6%). Use of lung-protective ventilation is widespread with tidal volumes of 7.1 mL/kg (2.1 mL/kg). The ICU/hospital mortality was 27.6%/29.3%, respectively (8.5%/9.7% for surgical patients and 41.3%/43.2% for medical patients, respectively). The mean level of ICU/hospital cost per patient was $15,271 (18,940)/$22,946 (25,575), respectively. The mean daily ICU cost per patient was $1,212. For the first time, we obtained a preliminary epidemiology data of mechanical ventilation in Beijing, China, through the study. Compared with the other nations, our patients are older, predominantly male, and treated according to prevailing international guidelines yet at a relatively high cost and high mortality. The expanding elderly population predicts increase demand for mechanical ventilation that must be met by continuous improvement in quality and efficiency of critical care services.

Reduction of duration and cost of mechanical ventilation in an intensive care unit by use of a ventilatory management team.

PubMed

Cohen, I L; Bari, N; Strosberg, M A; Weinberg, P F; Wacksman, R M; Millstein, B H; Fein, I A

1991-10-01

To test the hypothesis that a formal interdisciplinary team approach to managing ICU patients requiring mechanical ventilation enhances ICU efficiency. Retrospective review with cost-effectiveness analysis. A 20-bed medical-surgical ICU in a 450-bed community referral teaching hospital with a critical care fellowship training program. All patients requiring mechanical ventilation in the ICU were included, comparing patients admitted 1 yr before the inception of the ventilatory management team (group 1) with those patients admitted for 1 yr after the inception of the team (group 2). Group 1 included 198 patients with 206 episodes of mechanical ventilation and group 2 included 165 patients with 183 episodes of mechanical ventilation. A team consisting of an ICU attending physician, nurse, and respiratory therapist was formed to conduct rounds regularly and supervise the ventilatory management of ICU patients who were referred to the critical care service. The two study groups were demographically comparable. However, there were significant reductions in resource use in group 2. The number of days on mechanical ventilation decreased (3.9 days per episode of mechanical ventilation [95% confidence interval 0.3 to 7.5 days]), as did days in the ICU (3.3 days per episode of mechanical ventilation [90% confidence interval 0.3 to 6.3 days]), numbers of arterial blood gases (23.2 per episode of mechanical ventilation; p less than .001), and number of indwelling arterial catheters (1 per episode of mechanical ventilation; p less than .001). The estimated cost savings from these reductions was $1,303 per episode of mechanical ventilation. We conclude that a ventilatory management team, or some component thereof, can significantly and safely expedite the process of "weaning" patients from mechanical ventilatory support in the ICU.

Effects of ventilation behaviour on indoor heat load based on test reference years.

PubMed

Rosenfelder, Madeleine; Koppe, Christina; Pfafferott, Jens; Matzarakis, Andreas

2016-02-01

Since 2003, most European countries established heat health warning systems to alert the population to heat load. Heat health warning systems are based on predicted meteorological conditions outdoors. But the majority of the European population spends a substantial amount of time indoors, and indoor thermal conditions can differ substantially from outdoor conditions. The German Meteorological Service (Deutscher Wetterdienst, DWD) extended the existing heat health warning system (HHWS) with a thermal building simulation model to consider heat load indoors. In this study, the thermal building simulation model is used to simulate a standardized building representing a modern nursing home, because elderly and sick people are most sensitive to heat stress. Different types of natural ventilation were simulated. Based on current and future test reference years, changes in the future heat load indoors were analyzed. Results show differences between the various ventilation options and the possibility to minimize the thermal heat stress during summer by using an appropriate ventilation method. Nighttime ventilation for indoor thermal comfort is most important. A fully opened window at nighttime and the 2-h ventilation in the morning and evening are more sufficient to avoid heat stress than a tilted window at nighttime and the 1-h ventilation in the morning and the evening. Especially the ventilation in the morning seems to be effective to keep the heat load indoors low. Comparing the results for the current and the future test reference years, an increase of heat stress on all ventilation types can be recognized.

Effects of ventilation behaviour on indoor heat load based on test reference years

NASA Astrophysics Data System (ADS)

Rosenfelder, Madeleine; Koppe, Christina; Pfafferott, Jens; Matzarakis, Andreas

2016-02-01

Since 2003, most European countries established heat health warning systems to alert the population to heat load. Heat health warning systems are based on predicted meteorological conditions outdoors. But the majority of the European population spends a substantial amount of time indoors, and indoor thermal conditions can differ substantially from outdoor conditions. The German Meteorological Service (Deutscher Wetterdienst, DWD) extended the existing heat health warning system (HHWS) with a thermal building simulation model to consider heat load indoors. In this study, the thermal building simulation model is used to simulate a standardized building representing a modern nursing home, because elderly and sick people are most sensitive to heat stress. Different types of natural ventilation were simulated. Based on current and future test reference years, changes in the future heat load indoors were analyzed. Results show differences between the various ventilation options and the possibility to minimize the thermal heat stress during summer by using an appropriate ventilation method. Nighttime ventilation for indoor thermal comfort is most important. A fully opened window at nighttime and the 2-h ventilation in the morning and evening are more sufficient to avoid heat stress than a tilted window at nighttime and the 1-h ventilation in the morning and the evening. Especially the ventilation in the morning seems to be effective to keep the heat load indoors low. Comparing the results for the current and the future test reference years, an increase of heat stress on all ventilation types can be recognized.

[New possibilities in emergency medical transportation and emergency services of Polish Medical Air Rescue].

PubMed

Gałazkowski, Robert

2010-01-01

In Poland, two types of medical services are accomplished by the Medical Air Rescue (MAR) operating all over the country: emergency transport from the incident scene to hospital and inter-hospital transport. Helicopters or planes are used for this purpose. In 2009, helicopters performed 4359 flights to incidents and 1537 inter-hospital transports whereas planes performed 589 inter-hospital ambulance and 196 rescue flights. MAR operates from 17 bases of the Helicopter Emergency Medical Service (HEMS) and one airbase. Helicopters are mainly used when medical transport is emergent, within the operational region of a given base whereas planes when the distance between the present and target airports exceeds 250 km. In 2008, new modern aircraft were introduced to HEMS-helicopters EC 135. They fulfil all requirements of air transport regulations and are adjusted to visual (VFR) and instrumental (IFR) flights rules, at day and night. The medical cabin of EC 135 is ergonomic and functional considering the majority of rescue activities under life-saving circumstances. It is equipped with ventilator, defibrillator, infusion pumps etc. Defibrillators have 12-lead ECG, E(T)CO2, SpO2, NIBP, and IBP modules. Transport ventilators can work in a variety of ventilation modes including CMV, SIMV, SVV, BILEVEL, PCV, ASB, PPV and CPAP. The purchase of helicopters with modern avionic and medical configuration ensures high quality services of MAR for many years to come.

Building America Case Study: Sealed Crawl Spaces with Integrated Whole-House Ventilation in a Cold Climate, Ithaca, New York

DOE Office of Scientific and Technical Information (OSTI.GOV)

"9One method of code-compliance for crawlspaces is to seal and insulate the crawlspace, rather than venting to the outdoors. However, codes require mechanical ventilation; either via conditioned supply air from the HVAC system, or a continuous exhaust ventilation strategy. As the CARB's building partner, Ithaca Neighborhood Housing Services, intended to use the unvented crawlspace in a recent development, CARB was interested in investigating a hybrid ventilation method that includes the exhaust air from the crawlspace as a portion of an ASHRAE 62.2 compliant whole-house ventilation strategy. This hybrid ventilation method was evaluated through a series of long-term monitoring tests thatmore » observed temperature, humidity, and pressure conditions through the home and crawlspace. Additionally, CARB worked with NREL to perform multi-point tracer gas testing on six separate ventilation strategies - varying portions of 62.2 required flow supplied by the crawlspace fan and an upstairs bathroom fan. The intent of the tracer gas testing was to identify effective Reciprocal Age of Air (RAoA), which is equivalent to the air change rate in well-mixed zones, for each strategy while characterizing localized infiltration rates in several areas of the home.« less

Knowledge levels of intensive care nurses on prevention of ventilator-associated pneumonia.

PubMed

Akın Korhan, Esra; Hakverdioğlu Yönt, Gülendam; Parlar Kılıç, Serap; Uzelli, Derya

2014-01-01

Ventilator-associated pneumonia constitutes a significant concern for ventilated patients in the intensive care unit. This study was planned to evaluate the knowledge of nurses working in general intensive care units concerning evidence-based measures for the prevention of ventilator-associated pneumonia. This study design is cross-sectional. It was carried out on nurses working in the general intensive care units of anesthiology and re-animation clinics. Collection of research data was performed by means of a Nurse Identification Form and a Form of Evidence-Based Knowledge concerning the Prevention of Ventilator-Associated Pneumonia. Characterization statistics were shown by percentage, median and interquartile range. Chi-square and Wilcoxon tests and Kruskal-Wallis tests were used as appropriate. The median value of total points scored by nurses on the questionnaire was 4.00 ± 2.00. The difference between the nurses' education levels, duration of work experience and participation in in-service training programmes on ventilator-associated pneumonia prevention and the median value of their total scores on the questionnaire was found to be statistically significant (p < 0.05). The conclusion of the study was that critical care nurses' knowledge about ventilator-associated pneumonia prevention is poor. © 2013 British Association of Critical Care Nurses.

A new system for continuous and remote monitoring of patients receiving home mechanical ventilation

NASA Astrophysics Data System (ADS)

Battista, L.

2016-09-01

Home mechanical ventilation is the treatment of patients with respiratory failure or insufficiency by means of a mechanical ventilator at a patient's home. In order to allow remote patient monitoring, several tele-monitoring systems have been introduced in the last few years. However, most of them usually do not allow real-time services, as they have their own proprietary communication protocol implemented and some ventilation parameters are not always measured. Moreover, they monitor only some breaths during the whole day, despite the fact that a patient's respiratory state may change continuously during the day. In order to reduce the above drawbacks, this work reports the development of a novel remote monitoring system for long-term, home-based ventilation therapy; the proposed system allows for continuous monitoring of the main physical quantities involved during home-care ventilation (e.g., differential pressure, volume, and air flow rate) and is developed in order to allow observations of different remote therapy units located in different places of a city, region, or country. The developed remote patient monitoring system is able to detect various clinical events (e.g., events of tube disconnection and sleep apnea events) and has been successfully tested by means of experimental tests carried out with pulmonary ventilators typically used to support sick patients.

A new system for continuous and remote monitoring of patients receiving home mechanical ventilation.

PubMed

Battista, L

2016-09-01

Home mechanical ventilation is the treatment of patients with respiratory failure or insufficiency by means of a mechanical ventilator at a patient's home. In order to allow remote patient monitoring, several tele-monitoring systems have been introduced in the last few years. However, most of them usually do not allow real-time services, as they have their own proprietary communication protocol implemented and some ventilation parameters are not always measured. Moreover, they monitor only some breaths during the whole day, despite the fact that a patient's respiratory state may change continuously during the day. In order to reduce the above drawbacks, this work reports the development of a novel remote monitoring system for long-term, home-based ventilation therapy; the proposed system allows for continuous monitoring of the main physical quantities involved during home-care ventilation (e.g., differential pressure, volume, and air flow rate) and is developed in order to allow observations of different remote therapy units located in different places of a city, region, or country. The developed remote patient monitoring system is able to detect various clinical events (e.g., events of tube disconnection and sleep apnea events) and has been successfully tested by means of experimental tests carried out with pulmonary ventilators typically used to support sick patients.

The Integrative Weaning Index in Elderly ICU Subjects.

PubMed

Azeredo, Leandro M; Nemer, Sérgio N; Barbas, Carmen Sv; Caldeira, Jefferson B; Noé, Rosângela; Guimarães, Bruno L; Caldas, Célia P

2017-03-01

With increasing life expectancy and ICU admission of elderly patients, mechanical ventilation, and weaning trials have increased worldwide. We evaluated a cohort with 479 subjects in the ICU. Patients younger than 18 y, tracheostomized, or with neurologic diseases were excluded, resulting in 331 subjects. Subjects ≥70 y old were considered elderly, whereas those <70 y old were considered non-elderly. Besides the conventional weaning indexes, we evaluated the performance of the integrative weaning index (IWI). The probability of successful weaning was investigated using relative risk and logistic regression. The Hosmer-Lemeshow goodness-of-fit test was used to calibrate and the C statistic was calculated to evaluate the association between predicted probabilities and observed proportions in the logistic regression model. Prevalence of successful weaning in the sample was 83.7%. There was no difference in mortality between elderly and non-elderly subjects ( P = .16), in days of mechanical ventilation ( P = .22) and days of weaning ( P = .55). In elderly subjects, the IWI was the only respiratory variable associated with mechanical ventilation weaning in this population ( P < .001). The IWI was the independent variable found in weaning of elderly subjects that may contribute to the critical moment of this population in intensive care. Copyright © 2017 by Daedalus Enterprises.

77 FR 47528 - International Trademark Classification Changes

Federal Register 2010, 2011, 2012, 2013, 2014

2012-08-09

..., ventilating, water supply and sanitary purposes. 12. Vehicles; apparatus for locomotion by land, air or water.... Treatment of materials. 41. Education; providing of training; entertainment; sporting and cultural... providing food and drink; temporary accommodation. 44. Medical services; veterinary services; hygienic and...

Patient Views on Three Key Service Areas within Hospital COPD Care

ERIC Educational Resources Information Center

Roberts, C. Michael; Seiger, Anil; Ingham, Jane

2009-01-01

Objective: The views of patients with Chronic Obstructive Pulmonary Disease (COPD) about three key services (non-invasive ventilation [NIV], early discharge schemes and rehabilitation) were sought in order to inform recommendations for the delivery of optimum care within a national programme of hospital COPD service development. Design: Four focus…

45 CFR 263.0 - What definitions apply to this part?

Code of Federal Regulations, 2010 CFR

2010-10-01

...) Management information systems not related to the tracking and monitoring of TANF requirements (e.g., for a... example, it excludes costs of providing diversion benefits and services, providing program information to... services, work supports, and case management. It also excludes costs for contracts devoted entirely to such...

Extravasation from venous catheter: a serious complication potentially missed by lung imaging

DOE Office of Scientific and Technical Information (OSTI.GOV)

Spicer, K.M.; Gordon, L.

Three patients were referred for lung ventiliation and perfusion (V/Q) imaging with symptoms strongly suggestive of pulmonary embolus (PE). Chest roentgenograms and xenon ventilation studies on all three were normal, save for prominent mediastinal silhouettes and effusions. Technetium-99m macroaggregated albumin(Tc-99m MAA), when injected through the central venous catheter (CVP), revealed mediastinal localization, whereas antecubital injections showed normal pulmonary perfusion. Contrast fluoroscopy introduced through the venous catheter in the first patient defined the extravasation. For patients under strong suspicion of PE, with a venous catheter whose distal tip is seen about the level of the heart on chest radiograph, the authorsmore » recommend administering the perfusion agent slowly through the central catheter to exclude catheter-induced complications. When extravasation is detected, injection of Tc-99m MAA by peripheral vein should be used to exclude PE.« less

[Cases and duration of mechanical ventilation in German hospitals : An analysis of DRG incentives and developments in respiratory medicine].

PubMed

Biermann, A; Geissler, A

2016-09-01

Diagnosis-related groups (DRGs) have been used to reimburse hospitals services in Germany since 2003/04. Like any other reimbursement system, DRGs offer specific incentives for hospitals that may lead to unintended consequences for patients. In the German context, specific procedures and their documentation are suspected to be primarily performed to increase hospital revenues. Mechanical ventilation of patients and particularly the duration of ventilation, which is an important variable for the DRG-classification, are often discussed to be among these procedures. The aim of this study was to examine incentives created by the German DRG-based payment system with regard to mechanical ventilation and to identify factors that explain the considerable increase of mechanically ventilated patients in recent years. Moreover, the assumption that hospitals perform mechanical ventilation in order to gain economic benefits was examined. In order to gain insights on the development of the number of mechanically ventilated patients, patient-level data provided by the German Federal Statistical Office and the German Institute for the Hospital Remuneration System were analyzed. The type of performed ventilation, the total number of ventilation hours, the age distribution, mortality and the DRG distribution for mechanical ventilation were calculated, using methods of descriptive and inferential statistics. Furthermore, changes in DRG-definitions and changes in respiratory medicine were compared for the years 2005-2012. Since the introduction of the DRG-based payment system in Germany, the hours of ventilation and the number of mechanically ventilated patients have substantially increased, while mortality has decreased. During the same period there has been a switch to less invasive ventilation methods. The age distribution has shifted to higher age-groups. A ventilation duration determined by DRG definitions could not be found. Due to advances in respiratory medicine, new ventilation methods have been introduced that are less prone to complications. This development has simultaneously improved survival rates. There was no evidence supporting the assumption that the duration of mechanical ventilation is influenced by the time intervals relevant for DRG grouping. However, presumably operational routines such as staff availability within early and late shifts of the hospital have a significant impact on the termination of mechanical ventilation.

45 CFR 2506.4 - What types of debts are excluded from these regulations?

Code of Federal Regulations, 2010 CFR

2010-10-01

... 45 Public Welfare 4 2010-10-01 2010-10-01 false What types of debts are excluded from these...) CORPORATION FOR NATIONAL AND COMMUNITY SERVICE COLLECTION OF DEBTS Introduction § 2506.4 What types of debts are excluded from these regulations? The following types of debts are excluded: (a) Debts or claims...

45 CFR 2506.4 - What types of debts are excluded from these regulations?

Code of Federal Regulations, 2011 CFR

2011-10-01

... 45 Public Welfare 4 2011-10-01 2011-10-01 false What types of debts are excluded from these...) CORPORATION FOR NATIONAL AND COMMUNITY SERVICE COLLECTION OF DEBTS Introduction § 2506.4 What types of debts are excluded from these regulations? The following types of debts are excluded: (a) Debts or claims...

The Relationship of Housing and Population Health: A 30-Year Retrospective Analysis

PubMed Central

Jacobs, David E.; Wilson, Jonathan; Dixon, Sherry L.; Smith, Janet; Evens, Anne

2009-01-01

Objective We analyzed the relationship between health status and housing quality over time. Methods We combined data from two nationally representative longitudinal surveys of the U.S. population and its housing, the National Health and Nutrition Examination Survey and the American Housing Survey, respectively. We identified housing and health trends from approximately 1970 to 2000, after excluding those trends for which data were missing or where we found no plausible association or change in trend. Results Changes in housing include construction type, proportion of rental versus home ownership, age, density, size, moisture, pests, broken windows, ventilation and air conditioning, and water leaks. Changes in health measures include asthma, respiratory illness, obesity and diabetes, and lead poisoning, among others. The results suggest ecologic trends in childhood lead poisoning follow housing age, water leaks, and ventilation; asthma follows ventilation, windows, and age; overweight trends follow ventilation; blood pressure trends follow community measures; and health disparities have not changed greatly. Conclusions Housing trends are consistent with certain health trends over time. Future national longitudinal surveys should include health, housing, and community metrics within a single integrated design, instead of separate surveys, in order to develop reliable indicators of how housing changes affect population health and how to best target resources. Little progress has been made in reducing the health and housing disparities of disadvantaged groups, with the notable exception of childhood lead poisoning caused by exposure to lead-based paint hazards. Use of these and other data sets to create reliable integrated indicators of health and housing quality are needed. PMID:19440499

Adult respiratory distress syndrome in Leptospira canicola infection.

PubMed Central

Zaltzman, M; Kallenbach, J M; Goss, G D; Lewis, M; Zwi, S; Gear, J H

1981-01-01

A man was admitted to the Johannesburg Hospital with a history of fever, diarrhoea, and dry cough for four days. He began to produce bloodstained sputum and was found to have severe arterial hypoxaemia. Radiography showed widespread opacification over both lung fields, and the clinical and haemodynamic features were consistent with the adult respiratory distress syndrome. Serology for Leptospira canicola was positive. Despite antibiotics, supportive therapy, and ventilation the patient died. Necropsy excluded cardiac disease. This case shows that leptospirosis may cause the adult respiratory distress syndrome. Images p520-a PMID:6790049

PREVENTIVE MAINTENANCE. HONEYWELL PLANNING GUIDE.

ERIC Educational Resources Information Center

Honeywell, Inc., Minneapolis, Minn.

THIS HONEYWELL PAMPHLET DISCUSSES SOME ASPECTS OF PREVENTIVE MAINTENANCE OF AUTOMATIC CONTROLS, HEATING, VENTILATING, AND AIR CONDITIONING, AND COMPARES IN-PLANT WITH CONTRACT SERVICE, CONCLUDING THAT CONTRACT SERVICE IS PREFERABLE AND DESCRIBING A NUMBER OF MAINTENANCE PLANS WHICH THEY FURNISH. PREVENTIVE MAINTENANCE PROVIDES--(1) MORE EFFICIENT…

Constipation in intensive care unit: incidence and risk factors.

PubMed

Nassar, Antonio Paulo; da Silva, Fernanda Maria Queiroz; de Cleva, Roberto

2009-12-01

Although gastrointestinal motility disorders are common in critically ill patients, constipation and its implications have received very little attention. We aimed to determine the incidence of constipation to find risk factors and its implications in critically ill patients During a 6-month period, we enrolled all patients admitted to an intensive care unit from an universitary hospital who stayed 3 or more days. Patients submitted to bowel surgery were excluded. Constipation occurred in 69.9% of the patients. There was no difference between constipated and not constipated in terms of sex, age, Acute Physiology and Chronic Health Evaluation II, type of admission (surgical, clinical, or trauma), opiate use, antibiotic therapy, and mechanical ventilation. Early (<24 hours) enteral nutrition was associated with less constipation, a finding that persisted at multivariable analysis (P < .01). Constipation was not associated with greater intensive care unit or mortality, length of stay, or days free from mechanical ventilation. Constipation is very common among critically ill patients. Early enteral nutrition is associated with earlier return of bowel function.

42 CFR 402.208 - Factors considered in determining whether to exclude, and the length of exclusion.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 2 2014-10-01 2014-10-01 false Factors considered in determining whether to exclude, and the length of exclusion. 402.208 Section 402.208 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS CIVIL MONEY PENALTIES...

42 CFR 412.130 - Retroactive adjustments for incorrectly excluded hospitals and units.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under the Prospective Payment Systems § 412.130 Retroactive adjustments for... hospital that was excluded from the prospective payment systems specified in § 412.1(a)(1) or paid under...

17 CFR 256.01-4 - Construction or service contracts, and centralized procurement accounting.

Code of Federal Regulations, 2010 CFR

2010-04-01

... expenses directly attributable to construction work shall be excluded from the accounting system of the... companies. Cost of goods procured shall be excluded from the accounting system of the service company and... contracts, and centralized procurement accounting. 256.01-4 Section 256.01-4 Commodity and Securities...

British Thoracic Society Quality Standards for acute non-invasive ventilation in adults

PubMed Central

Davies, Michael; Allen, Martin; Bentley, Andrew; Bourke, Stephen C; Creagh-Brown, Ben; D’Oliveiro, Rachel; Glossop, Alastair; Gray, Alasdair; Jacobs, Phillip; Mahadeva, Ravi; Moses, Rachael; Setchfield, Ian

2018-01-01

Introduction The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for the provision of acute non-invasive ventilation in adults together with measurable markers of good practice. Methods Development of British Thoracic Society (BTS) Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. Results 6 quality statements have been developed, each describing a standard of care for the provision of acute non-invasive ventilation in the UK, together with measurable markers of good practice. Conclusion BTS Quality Standards for acute non-invasive ventilation in adults form a key part of the range of supporting materials that the Society produces to assist in the dissemination and implementation of guideline’s recommendations. PMID:29636979

Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger: a randomized controlled trial [ISRCTN88724583].

PubMed

Lorente, Leonardo; Lecuona, María; Jiménez, Alejandro; Mora, María L; Sierra, Antonio

2006-01-01

Some guidelines to prevent ventilator-associated pneumonia (VAP) do not establish a recommendation for the preferential use of either heat and moisture exchangers (HMEs) or heated humidifiers (HHs), while other guidelines clearly advocate the use of HMEs. The aim of this study was to determine the incidence of VAP associated with HHs or HMEs. A randomized study was conducted in the intensive care unit of a university hospital involving patients expected to require mechanical ventilation for >5 days. Patients were assigned to two groups; one group received HH and the other group received HME. Tracheal aspirate samples were obtained on endotracheal intubation, then twice a week, and finally on extubation, in order to diagnose VAP. Throat swabs were taken on admission to the intensive care unit, then twice a week, and finally at discharge from the intensive care unit in order to classify VAP as primary endogenous, secondary endogenous, or exogenous. A total of 120 patients were assigned to HMEs (60 patients) and HHs (60 patients); 16 patients received mechanical ventilation for less than five days and were excluded from the analysis. Data analysis of the remaining 104 patients (53 HMEs and 51 HHs) showed no significant differences between groups regarding sex, age, Acute Physiology and Chronic Health Evaluation II score, pre-VAP use of antibiotics, days on mechanical ventilation, and diagnosis group. VAP was found in eight of 51 (15.69%) patients in the HH group and in 21 of 53 (39.62%) patients in the HME group (P = 0.006). The median time free of VAP was 20 days (95% confidence interval, 13.34-26.66) for the HH group and was 42 days (95% confidence interval, 35.62-48.37) for the HME group (P <0.001). Cox regression analysis showed the HME as a risk factor for VAP (hazard rate, 16.2; 95% confidence interval, 4.54-58.04; P < 0.001). The patients mechanically ventilated during more than 5 days developed a lower incidence of VAP with a heated humidifier than heat and moisture exchanger.

Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger: a randomized controlled trial [ISRCTN88724583

PubMed Central

Lorente, Leonardo; Lecuona, María; Jiménez, Alejandro; Mora, María L; Sierra, Antonio

2006-01-01

Introduction Some guidelines to prevent ventilator-associated pneumonia (VAP) do not establish a recommendation for the preferential use of either heat and moisture exchangers (HMEs) or heated humidifiers (HHs), while other guidelines clearly advocate the use of HMEs. The aim of this study was to determine the incidence of VAP associated with HHs or HMEs. Methods A randomized study was conducted in the intensive care unit of a university hospital involving patients expected to require mechanical ventilation for >5 days. Patients were assigned to two groups; one group received HH and the other group received HME. Tracheal aspirate samples were obtained on endotracheal intubation, then twice a week, and finally on extubation, in order to diagnose VAP. Throat swabs were taken on admission to the intensive care unit, then twice a week, and finally at discharge from the intensive care unit in order to classify VAP as primary endogenous, secondary endogenous, or exogenous. Results A total of 120 patients were assigned to HMEs (60 patients) and HHs (60 patients); 16 patients received mechanical ventilation for less than five days and were excluded from the analysis. Data analysis of the remaining 104 patients (53 HMEs and 51 HHs) showed no significant differences between groups regarding sex, age, Acute Physiology and Chronic Health Evaluation II score, pre-VAP use of antibiotics, days on mechanical ventilation, and diagnosis group. VAP was found in eight of 51 (15.69%) patients in the HH group and in 21 of 53 (39.62%) patients in the HME group (P = 0.006). The median time free of VAP was 20 days (95% confidence interval, 13.34–26.66) for the HH group and was 42 days (95% confidence interval, 35.62–48.37) for the HME group (P <0.001). Cox regression analysis showed the HME as a risk factor for VAP (hazard rate, 16.2; 95% confidence interval, 4.54–58.04; P < 0.001). Conclusion The patients mechanically ventilated for more than five days developed a lower incidence of VAP with a HH than with a HME. PMID:16884530

Temporal Changes in Prescription of Neuropharmacologic Drugs and Utilization of Resources Related to Neurologic Morbidity in Mechanically Ventilated Children With Bronchiolitis.

PubMed

Shein, Steven L; Slain, Katherine; Wilson-Costello, Deanne; McKee, Bryan; Rotta, Alexandre T

2017-12-01

Critically ill children with bronchiolitis may require neuropharmacologic medications and support for neuro-functional sequelae, but current practices are not well described. We aimed to describe recent trends in neuropharmacology and utilization of neuro-rehabilitation resources in mechanically ventilated children with bronchiolitis. Analysis of the multicenter Pediatric Health Information System database. Forty-seven U.S. children's hospitals. PICU patients less than 2 years old with bronchiolitis undergoing mechanical ventilation between 2006 and 2015. None. Annual rates of utilization of neuropharmacologic medications (sedatives, analgesics, etc) and of neuro-rehabilitation services (physical therapy, neurologic consultation, etc) over the 10-year study period were compared. Neuropharmacologic medications prescribed on greater than or equal to 2 days were extracted. Utilization of MRI of the brain, neurologic consultation, swallow evaluation, occupational therapy, and physical therapy was also extracted. Among 12,508 subjects, the median age was 2.8 months, ~50% had comorbid conditions, and the median duration of mechanical ventilation was 7 days. The percentage of children prescribed greater than or equal to five drugs/drug classes increased over the study period from 36.5% to 55.8% (p < 0.001). There were significant increases over time in utilization of 10 of the 15 individual drugs/drug classes analyzed. More than half of subjects (6,294 [50.3%]) received at least one service that evaluates/treats neurologic morbidity. There were significant increases in the use of greater than or equal to one service (36.3% in 2006 to 59.6% in 2015; p < 0.001) and in the use of greater than or equal to two services (20.8% to 34.8%; p < 0.001). Utilization of each of the five individual resources increased significantly during the study period, but use of vasoactive medications and mortality did not. Prescription of neuropharmacologic agents increased over time using metrics of both overall drug burden and specific drug usage. Concurrently, the utilization of services that evaluate and/or treat neurologic morbidity was common and also increased over time.

[Factors associated with the prognosis of mechanically ventilated infants and children. An international study].

PubMed

Farias, J A; Frutos-Vivar, F; Casado Flores, J; Siaba, A; Retta, A; Fernández, A; Baltodano, A; Ko, I J; Johnson, M; Esteban, A

2006-12-01

Identify factors associated with the survival of pediatric patients who are submitted to mechanical ventilation (MV) for more than 12 hours. International prospective cohort study. It was performed between April 1 and May 31 1999. All patients were followed-up during 28 days or discharge to pediatric intensive care unit (PICU). 36 PICUs from 7 countries. A total of 659 ventilated patients were enrolled but 15 patients were excluded because their vital status was unknown on discharge. Overall in-UCIP mortality rate was 15,6%. Recursive partitioning and logistic regression were used and an outcome model was constructed. The variables significantly associated with mortality were: peak inspiratory pressure (PIP), acute renal failure (ARF), PRISM score and severe hypoxemia (PaO2/FiO2 < 100). The subgroup with best outcome (mortality 7%) included patients who were ventilated with a PIP < 35 cmH2O, without ARF, or PaO2/FiO2 > 100 and PRISM < 27. In patients with a mean PaO2/FiO2 < 100 during MV mortality increased to 26% (OR: 4.4; 95% CI 2.0 to 9.4). Patients with a PRISM score > 27 on admission to PICU had a mortality of 43% (OR: 9.6; 95% CI 4,2 to 25,8). Development of acute renal failure was associated with a mortality of 50% (OR: 12.7; 95% CI 6.3 to 25.7). Finally, the worst outcome (mortality 58%) was for patients with a mean PIP >/= 35 cmH2O (OR 17.3; 95% CI 8.5 to 36.3). In a large cohort of mechanically ventilated pediatric patients we found that severity of illness at admission, high mean PIP, development of acute renal failure and severe hypoxemia over the course of MV were the factors associated with lower survival rate.

Multi Service Tactics, Techniques, and Procedures for Treatment of Chemical Warfare Agent Casualties and Conventional Military Chemical Injuries

DTIC Science & Technology

2016-08-02

at mechanical ventilation of a severely exposed casualty until atropine takes effect . Administering supplemental oxygen as available. Chapter 3 3-10...Scavengers; hydroxocobalamin, and dicobalt edetate (2) Provision of S-Groups, thiosulfate (3) Assisted ventilation (4) Oxygen cyanogen... temperature index for light work. Refer to table 1-3 on page 1-12 for work and rest cycles and also water consumption chart. Chapter 1 1-12 ATP 4

Prolonged mechanical ventilation in Canadian intensive care units: a national survey.

PubMed

Rose, Louise; Fowler, Robert A; Fan, Eddy; Fraser, Ian; Leasa, David; Mawdsley, Cathy; Pedersen, Cheryl; Rubenfeld, Gordon

2015-02-01

We sought to describe prevalence and care practices for patients experiencing prolonged mechanical ventilation (PMV), defined as ventilation for 21 or more consecutive days and medical stability. We provided the survey to eligible units via secure Web link to a nominated unit champion from April to November 2012. Weekly telephone and e-mail reminders were sent for 6 weeks. Response rate was 215 (90%) of 238 units identifying 308 patients requiring PMV on the survey day occupying 11% of all Canadian ventilator-capable beds. Most units (81%) used individualized plans for both weaning and mobilization. Weaning and mobilization protocols were available in 48% and 38% of units, respectively. Of those units with protocols, only 25% reported weaning guidance specific to PMV, and 11% reported mobilization content for PMV. Only 30% of units used specialized mobility equipment. Most units referred to speech language pathologists (88%); use of communication technology was infrequent (11%). Only 29% routinely referred to psychiatry/psychology, and 17% had formal discharge follow-up services. Prolonged mechanical ventilation patients occupied 11% of Canadian acute care ventilator bed capacity. Most units preferred an individualized approach to weaning and mobilization with considerable variation in weaning methods, protocol availability, access to specialized rehabilitation equipment, communication technology, psychiatry, and discharge follow-up. Copyright © 2014 Elsevier Inc. All rights reserved.

26 CFR 1.552-4 - Certain excluded banks.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 26 Internal Revenue 7 2011-04-01 2009-04-01 true Certain excluded banks. 1.552-4 Section 1.552-4 Internal Revenue INTERNAL REVENUE SERVICE, DEPARTMENT OF THE TREASURY (CONTINUED) INCOME TAX (CONTINUED) INCOME TAXES (CONTINUED) Foreign Personal Holding Companies § 1.552-4 Certain excluded banks. (a) A...

46 CFR 154.805 - Vent masts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... ventilation intake or other opening to an accommodation, service, control station, or other gas-safe space... to an accommodation, service, control station, or other gas-safe space; (g) Has drains to remove any liquid that may accumulate; and (h) Prevents accumulations of liquid at the relief valves. [CGD 74-289...

46 CFR 154.805 - Vent masts.

Code of Federal Regulations, 2013 CFR

2013-10-01

... ventilation intake or other opening to an accommodation, service, control station, or other gas-safe space... to an accommodation, service, control station, or other gas-safe space; (g) Has drains to remove any liquid that may accumulate; and (h) Prevents accumulations of liquid at the relief valves. [CGD 74-289...

46 CFR 153.201 - Openings to accommodation, service or control spaces.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 46 Shipping 5 2011-10-01 2011-10-01 false Openings to accommodation, service or control spaces... DANGEROUS CARGOES SHIPS CARRYING BULK LIQUID, LIQUEFIED GAS, OR COMPRESSED GAS HAZARDOUS MATERIALS Design... spaces. (a) Except as allowed in paragraph (b) of this section, entrances, ventilation intakes and...

46 CFR 153.201 - Openings to accommodation, service or control spaces.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 5 2010-10-01 2010-10-01 false Openings to accommodation, service or control spaces... DANGEROUS CARGOES SHIPS CARRYING BULK LIQUID, LIQUEFIED GAS, OR COMPRESSED GAS HAZARDOUS MATERIALS Design... spaces. (a) Except as allowed in paragraph (b) of this section, entrances, ventilation intakes and...

46 CFR 154.805 - Vent masts.

Code of Federal Regulations, 2011 CFR

2011-10-01

... ventilation intake or other opening to an accommodation, service, control station, or other gas-safe space... to an accommodation, service, control station, or other gas-safe space; (g) Has drains to remove any liquid that may accumulate; and (h) Prevents accumulations of liquid at the relief valves. [CGD 74-289...

46 CFR 153.201 - Openings to accommodation, service or control spaces.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 5 2014-10-01 2014-10-01 false Openings to accommodation, service or control spaces... DANGEROUS CARGOES SHIPS CARRYING BULK LIQUID, LIQUEFIED GAS, OR COMPRESSED GAS HAZARDOUS MATERIALS Design... spaces. (a) Except as allowed in paragraph (b) of this section, entrances, ventilation intakes and...

46 CFR 153.201 - Openings to accommodation, service or control spaces.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 5 2013-10-01 2013-10-01 false Openings to accommodation, service or control spaces... DANGEROUS CARGOES SHIPS CARRYING BULK LIQUID, LIQUEFIED GAS, OR COMPRESSED GAS HAZARDOUS MATERIALS Design... spaces. (a) Except as allowed in paragraph (b) of this section, entrances, ventilation intakes and...

46 CFR 153.201 - Openings to accommodation, service or control spaces.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 5 2012-10-01 2012-10-01 false Openings to accommodation, service or control spaces... DANGEROUS CARGOES SHIPS CARRYING BULK LIQUID, LIQUEFIED GAS, OR COMPRESSED GAS HAZARDOUS MATERIALS Design... spaces. (a) Except as allowed in paragraph (b) of this section, entrances, ventilation intakes and...

41 CFR 105-68.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 41 Public Contracts and Property Management 3 2010-07-01 2010-07-01 false May I use the services of an excluded person as a principal under a covered transaction? 105-68.315 Section 105-68.315 Public Contracts and Property Management Federal Property Management Regulations System (Continued...

Randomized intubation with polyurethane or conical cuffs to prevent pneumonia in ventilated patients.

PubMed

Philippart, François; Gaudry, Stéphane; Quinquis, Laurent; Lau, Nicolas; Ouanes, Islem; Touati, Samia; Nguyen, Jean Claude; Branger, Catherine; Faibis, Frédéric; Mastouri, Maha; Forceville, Xavier; Abroug, Fekri; Ricard, Jean Damien; Grabar, Sophie; Misset, Benoît

2015-03-15

The occurrence of ventilator-associated pneumonia (VAP) is linked to the aspiration of contaminated pharyngeal secretions around the endotracheal tube. Tubes with cuffs made of polyurethane rather than polyvinyl chloride or with a conical rather than a cylindrical shape increase tracheal sealing. To test whether using polyurethane and/or conical cuffs reduces tracheal colonization and VAP in patients with acute respiratory failure. We conducted a multicenter, prospective, open-label, randomized study in four parallel groups in four intensive care units between 2010 and 2012. A cohort of 621 patients with expected ventilation longer than 2 days was included at intubation with a cuff composed of cylindrical polyvinyl chloride (n = 148), cylindrical polyurethane (n = 143), conical polyvinyl chloride (n = 150), or conical polyurethane (n = 162). We used Kaplan-Meier estimates and log-rank tests to compare times to events. After excluding 17 patients who secondarily refused participation or had met an exclusion criterion, 604 were included in the intention-to-treat analysis. Cumulative tracheal colonization greater than 10(3) cfu/ml at Day 2 was as follows (median [interquartile range]): cylindrical polyvinyl chloride, 0.66 (0.58-0.74); cylindrical polyurethane, 0.61 (0.53-0.70); conical polyvinyl chloride, 0.67 (0.60-0.76); and conical polyurethane, 0.62 (0.55-0.70) (P = 0.55). VAP developed in 77 patients (14.4%), and postextubational stridor developed in 28 patients (6.4%) (P = 0.20 and 0.28 between groups, respectively). Among patients requiring mechanical ventilation, polyurethane and/or conically shaped cuffs were not superior to conventional cuffs in preventing tracheal colonization and VAP. Clinical trial registered with clinicaltrials.gov (NCT01114022).

Reinnervation of the diaphragm by the inferior laryngeal nerve to the phrenic nerve in ventilator-dependent tetraplegic patients with C3-5 damage.

PubMed

Verin, Eric; Morelot-Panzini, Capucine; Gonzalez-Bermejo, Jesus; Veber, Benoit; Perrouin Verbe, Brigitte; Soudrie, Brigitte; Leroi, Anne Marie; Marie, Jean Paul; Similowski, Thomas

2017-10-01

The aim of this study was to evaluate the feasibility of unilateral diaphragmatic reinnervation in humans by the inferior laryngeal nerve. This pilot study included chronically ventilated tetraplegic patients with destruction of phrenic nerve motoneurons. Five patients were included. They all had a high level of tetraplegia, with phrenic nerve motor neuron destruction. They were highly dependent on ventilation, without any possibility of weaning. They did not have other chronic pathologies, especially laryngeal disease. They all had diaphragmatic explorations to diagnose the destruction of the motoneurons of the phrenic nerves and nasoendoscopy to be sure that they did not have laryngeal or pharyngeal disease. Then, surgical anastomosis of the right phrenic nerve was performed with the inferior laryngeal nerve, by a cervical approach. A laryngeal reinnervation was performed at the same time, using the ansa hypoglossi. One patient was excluded because of a functional phrenic nerve and one patient died 6 months after the surgery of a cardiac arrest. The remaining three patients were evaluated after the anastomosis every 6 months. They did not present any swallowing or vocal alterations. In these three patients, the diaphragmatic explorations showed that there was a recovery of the diaphragmatic electromyogram of the right and left hemidiaphragms after 1 year. Two patients had surgical diaphragmatic explorations for diaphragmatic pacing 18-24 months after the reinnervation with excellent results. At 36 months, none of the patients could restore their automatic ventilation. In conclusion, this study demonstrated that diaphragmatic reinnervation by the inferior laryngeal nerve is effective, without any vocal or swallowing complications.

Reinnervation of the diaphragm by the inferior laryngeal nerve to the phrenic nerve in ventilator-dependent tetraplegic patients with C3-5 damage

PubMed Central

Morelot-Panzini, Capucine; Gonzalez-Bermejo, Jesus; Veber, Benoit; Perrouin Verbe, Brigitte; Soudrie, Brigitte; Leroi, Anne Marie; Marie, Jean Paul; Similowski, Thomas

2017-01-01

The aim of this study was to evaluate the feasibility of unilateral diaphragmatic reinnervation in humans by the inferior laryngeal nerve. This pilot study included chronically ventilated tetraplegic patients with destruction of phrenic nerve motoneurons. Five patients were included. They all had a high level of tetraplegia, with phrenic nerve motor neuron destruction. They were highly dependent on ventilation, without any possibility of weaning. They did not have other chronic pathologies, especially laryngeal disease. They all had diaphragmatic explorations to diagnose the destruction of the motoneurons of the phrenic nerves and nasoendoscopy to be sure that they did not have laryngeal or pharyngeal disease. Then, surgical anastomosis of the right phrenic nerve was performed with the inferior laryngeal nerve, by a cervical approach. A laryngeal reinnervation was performed at the same time, using the ansa hypoglossi. One patient was excluded because of a functional phrenic nerve and one patient died 6 months after the surgery of a cardiac arrest. The remaining three patients were evaluated after the anastomosis every 6 months. They did not present any swallowing or vocal alterations. In these three patients, the diaphragmatic explorations showed that there was a recovery of the diaphragmatic electromyogram of the right and left hemidiaphragms after 1 year. Two patients had surgical diaphragmatic explorations for diaphragmatic pacing 18–24 months after the reinnervation with excellent results. At 36 months, none of the patients could restore their automatic ventilation. In conclusion, this study demonstrated that diaphragmatic reinnervation by the inferior laryngeal nerve is effective, without any vocal or swallowing complications. PMID:29181382

Design Characteristics and Tobacco Metal Concentrations in Filtered Cigars.

PubMed

Caruso, Rosalie V; O'Connor, Richard J; Travers, Mark J; Delnevo, Cristine D; Stephens, W Edryd

2015-11-01

While U.S. cigarette consumption has declined, cigar use has steadily increased, for reasons including price compared to cigarettes and the availability of filtered varieties resembling cigarettes, and flavors that have been banned in cigarettes (excluding menthol). Little published data exists on the design characteristics of such cigars. A variety of filtered cigar brands were tested for design characteristics such as whole cigar weight, ventilation, and per-cigar tobacco weight. Cigar sticks were then sent to the University of St. Andrews for metal concentration testing of As, Pb, Cr, Ni, and Cd. Large and small cigars were statistically different between cigar weight (p ≤ .001), per-cigar tobacco weight (p = .001), rod diameter (p = .006), and filter diameter (p = .012). The differences in mean ventilation (overall mean = 19.6%, min. = 0.84%, max. = 57.6%) across filtered cigar brands were found to be statistically significant (p = .031), and can be compared to the ventilation of the average of 2013 U.S. Marlboro Red, Gold, and Silver packs at 29% ventilation. There were no significant differences for metal concentrations between cigar types (p = .650), with Pb and As levels being similar to U.S. 2009 cigarette concentrations, Cd cigar levels being slightly higher, and Cr and Ni levels much lower than cigarette levels. With cigar use rising, and filtered cigars displaying substantial similarities to filtered cigarettes, more research on product characteristics is warranted. Future plans include testing tobacco alkaloid and more observation of cigar weight for tax bracket purposes. © The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Cumulative Probability and Time to Reintubation in U.S. ICUs.

PubMed

Miltiades, Andrea N; Gershengorn, Hayley B; Hua, May; Kramer, Andrew A; Li, Guohua; Wunsch, Hannah

2017-05-01

Reintubation after liberation from mechanical ventilation is viewed as an adverse event in ICUs. We sought to describe the frequency of reintubations across U.S. ICUs and to propose a standard, appropriate time cutoff for reporting of reintubation events. We conducted a cohort study using data from the Project IMPACT database of 185 diverse ICUs in the United States. We included patients who received mechanical ventilation and excluded patients who received a tracheostomy, had a do-not-resuscitate order placed, or died prior to first extubation. We assessed the percentage of patients extubated who were reintubated; the cumulative probability of reintubation, with death and do-not-resuscitate orders after extubation modeled as competing risks, and time to reintubation. Among 98,367 patients who received mechanical ventilation without death or tracheostomy prior to extubation, 9,907 (10.1%) were reintubated, with a cumulative probability of 10.0%. Median time to reintubation was 15 hours (interquartile range, 2-45 hr). Of patients who required reintubation in the ICU, 90% did so within the first 96 hours after initial extubation; this was consistent across various patient subtypes (89.3% for electives surgical patients up to 94.8% for trauma patients) and ICU subtypes (88.6% for cardiothoracic ICUs to 93.5% for medical ICUs). The reintubation rate for ICU patients liberated from mechanical ventilation in U.S. ICUs is approximately 10%. We propose a time cutoff of 96 hours for reintubation definitions and benchmarking efforts, as it captures 90% of ICU reintubation events. Reintubation rates can be reported as simple percentages, without regard for deaths or changes in goals of care that might occur.

[Effectiveness of implementing the reiki method to reduce the weaning failure. A clinical trial].

PubMed

Saiz-Vinuesa, M D; Rodríguez-Moreno, E; Carrilero-López, C; García Vitoria, J; Garrido-Moya, D; Claramonte-Monedero, R; Piqueras-Carrión, A M

2016-01-01

Admission to intensive care unit (ICU) is a difficult and stressful time for the patient, with the application of different techniques, such as intubation and ventilation support withdrawal or "weaning", which may fail due to anxiety. To determine whether Reiki is useful in reducing weaning failure, as well as reducing the number of days of mechanical ventilation (MV), length of stay in ICU, amount of sedatives, amines, and antipsychotics. Randomized clinical trial. ICU of a Level III University Hospital. ICU patients connected to Mechanical Ventilation for more than 48hours, with a signed informed consent. Patients in a terminal condition or potential organ donors were excluded. 256 patients divided into two groups: intervention group (GI) and placebo (GP). The intervention involves the application of Reiki, and a simulated technique within the placebo group. An analysis was made of the absolute and relative frequencies, with a significance level of P<.05, 95% CI RESULTS: The percentage of failures at weaning was 9% in GI and 9.5% in GP (P=.42). The mean number of days on MV was 8.85 days for GI and 9.66 for the GP (P=.53). The mean dose of sedatives: GI 1078mg and 1491mg GP. The dose of Haloperidol was lower in the GI (5.30mg vs 16.81mg GP) (P=.03, 95% CI; -21.9 to -1.13). Reiki reduces the agitation of patients. A decrease was objectively observed in the number of days of Mechanical Ventilation, length of stay, lower doses of sedatives, and a slight decrease in the weaning failure in the GI. No statistically significant difference was found in the main variable. Copyright © 2015 Elsevier España, S.L.U. y SEEIUC. All rights reserved.

Combination of Extracorporeal Life Support and Mesenchymal Stem Cell Therapy for Treatment of ARDS in Combat Casualties and Evacuation of Service Members with ARDS

DTIC Science & Technology

2017-10-01

invasiveness of mechanical ventilation and inflammatory mediators as well as improvement in oxygenation and functional outcome. 4 Keywords Acute...The Clark system is allowing us to measure the mitochondrial activity by the oxygen consumption during activation. Because the LPS-induced injury we... Ventilation • Tidal Volume • Respiratory Rate • Peak inspiratory Pressure • Positive End Expiratory Pressure (PEEP) • Fraction of inspired oxygen

No air leak on PPV does not exclude tracheobronchial injury after blunt chest trauma.

PubMed

Ong, Victor Yeok Kein; Tan, Kenneth Hock Soon

2008-04-01

Tracheobronchial injuries are commonly associated with persistent air leak with pneumothoraces especially when on positive pressure ventilation (PPV). Injuries with absence of these features together with collapse of the lung and consequent low arterial oxygen tension while on PPV are less well recognised. We present a patient with traumatic aortic dissection and preoperatively undiagnosed complete transaction of the left main bronchus following blunt chest trauma. He had no persistent air leak with lower lung lobe collapse despite undergoing PPV and had low arterial oxygen tension which failed to respond to appropriate oxygen therapy.

Improved lung recruitment and oxygenation during mandatory ventilation with a new expiratory ventilation assistance device: A controlled interventional trial in healthy pigs.

PubMed

Schmidt, Johannes; Wenzel, Christin; Mahn, Marlene; Spassov, Sashko; Cristina Schmitz, Heidi; Borgmann, Silke; Lin, Ziwei; Haberstroh, Jörg; Meckel, Stephan; Eiden, Sebastian; Wirth, Steffen; Buerkle, Hartmut; Schumann, Stefan

2018-05-04

In contrast to conventional mandatory ventilation, a new ventilation mode, expiratory ventilation assistance (EVA), linearises the expiratory tracheal pressure decline. We hypothesised that due to a recruiting effect, linearised expiration oxygenates better than volume controlled ventilation (VCV). We compared the EVA with VCV mode with regard to gas exchange, ventilation volumes and pressures and lung aeration in a model of peri-operative mandatory ventilation in healthy pigs. Controlled interventional trial. Animal operating facility at a university medical centre. A total of 16 German Landrace hybrid pigs. The lungs of anaesthetised pigs were ventilated with the EVA mode (n=9) or VCV (control, n=7) for 5 h with positive end-expiratory pressure of 5 cmH2O and tidal volume of 8 ml kg. The respiratory rate was adjusted for a target end-tidal CO2 of 4.7 to 6 kPa. Tracheal pressure, minute volume and arterial blood gases were recorded repeatedly. Computed thoracic tomography was performed to quantify the percentages of normally and poorly aerated lung tissue. Two animals in the EVA group were excluded due to unstable ventilation (n=1) or unstable FiO2 delivery (n=1). Mean tracheal pressure and PaO2 were higher in the EVA group compared with control (mean tracheal pressure: 11.6 ± 0.4 versus 9.0 ± 0.3 cmH2O, P < 0.001 and PaO2: 19.2 ± 0.7 versus 17.5 ± 0.4 kPa, P = 0.002) with comparable peak inspiratory tracheal pressure (18.3 ± 0.9 versus 18.0 ± 1.2 cmH2O, P > 0.99). Minute volume was lower in the EVA group compared with control (5.5 ± 0.2 versus 7.0 ± 1.0 l min, P = 0.02) with normoventilation in both groups (PaCO2 5.4 ± 0.3 versus 5.5 ± 0.3 kPa, P > 0.99). In the EVA group, the percentage of normally aerated lung tissue was higher (81.0 ± 3.6 versus 75.8 ± 3.0%, P = 0.017) and of poorly aerated lung tissue lower (9.5 ± 3.3 versus 15.7 ± 3.5%, P = 0.002) compared with control. EVA ventilation improves lung aeration via elevated mean tracheal pressure and consequently improves arterial oxygenation at unaltered positive end-expiratory pressure (PEEP) and peak inspiratory pressure (PIP). These findings suggest the EVA mode is a new approach for protective lung ventilation.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.

42 CFR 409.49 - Excluded services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... under Part B are excluded from home health coverage. Catheters, catheter supplies, ostomy bags, and supplies relating to ostomy care are not considered prosthetic devices if furnished under a home health...

31 CFR 19.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2012 CFR

2012-07-01

... 31 Money and Finance: Treasury 1 2012-07-01 2012-07-01 false May I use the services of an excluded person as a principal under a covered transaction? 19.315 Section 19.315 Money and Finance: Treasury...) Responsibilities of Participants Regarding Transactions Doing Business with Other Persons § 19.315 May I use the...

31 CFR 19.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2013 CFR

2013-07-01

... 31 Money and Finance: Treasury 1 2013-07-01 2013-07-01 false May I use the services of an excluded person as a principal under a covered transaction? 19.315 Section 19.315 Money and Finance: Treasury...) Responsibilities of Participants Regarding Transactions Doing Business with Other Persons § 19.315 May I use the...

31 CFR 19.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2011 CFR

2011-07-01

... 31 Money and Finance: Treasury 1 2011-07-01 2011-07-01 false May I use the services of an excluded person as a principal under a covered transaction? 19.315 Section 19.315 Money and Finance: Treasury...) Responsibilities of Participants Regarding Transactions Doing Business with Other Persons § 19.315 May I use the...

31 CFR 19.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2014 CFR

2014-07-01

... 31 Money and Finance: Treasury 1 2014-07-01 2014-07-01 false May I use the services of an excluded person as a principal under a covered transaction? 19.315 Section 19.315 Money and Finance: Treasury...) Responsibilities of Participants Regarding Transactions Doing Business with Other Persons § 19.315 May I use the...

31 CFR 19.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 31 Money and Finance: Treasury 1 2010-07-01 2010-07-01 false May I use the services of an excluded person as a principal under a covered transaction? 19.315 Section 19.315 Money and Finance: Treasury...) Responsibilities of Participants Regarding Transactions Doing Business with Other Persons § 19.315 May I use the...

Kennedy Space Center Environmental Health Program

NASA Technical Reports Server (NTRS)

Creech, Joanne W.

1997-01-01

Topic considered include: environmental health services; health physics; ionizing radiation; pollution control; contamination investigations; natural resources; surface water; health hazard evaluations; combustion gas; launch support; asbestos; hazardous noise; and ventilation.

14 CFR 158.15 - Project eligibility at PFC levels of $1, $2, or $3.

Code of Federal Regulations, 2010 CFR

2010-01-01

..., ventilation, plumbing, and electrical service), and aircraft fueling facilities next to the gate; (7) A... service airport to low-emission technology certified or verified by the Environmental Protection Agency to... equipment that include low-emission technology or use cleaner burning fuels. (c) An eligible project must be...

Looking southwest in the service bay area, pump room level, ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

Looking southwest in the service bay area, pump room level, at the ventilation fan ducts associated with the evaporative cooling system. Stairs to the operating deck above the intakes are at the far left - Wellton-Mohawk Irrigation System, Pumping Plant No. 2, Bounded by Interstate 8 to south, Wellton, Yuma County, AZ

14 CFR 158.15 - Project eligibility at PFC levels of $1, $2, or $3.

Code of Federal Regulations, 2012 CFR

2012-01-01

..., ventilation, plumbing, and electrical service), and aircraft fueling facilities next to the gate; (7) A... service airport to low-emission technology certified or verified by the Environmental Protection Agency to... equipment that include low-emission technology or use cleaner burning fuels. (c) An eligible project must be...

76 FR 15052 - Proposed Information Collection (Application for Exclusion of Children's Income); Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-18

... whether children's incomes can be excluded from consideration in determining a parent's eligibility for... be excluded from consideration in determining a parent's eligibility for non-service connected...

Creation and Validation of an Automated Algorithm to Determine Postoperative Ventilator Requirements After Cardiac Surgery.

PubMed

Gabel, Eilon; Hofer, Ira S; Satou, Nancy; Grogan, Tristan; Shemin, Richard; Mahajan, Aman; Cannesson, Maxime

2017-05-01

In medical practice today, clinical data registries have become a powerful tool for measuring and driving quality improvement, especially among multicenter projects. Registries face the known problem of trying to create dependable and clear metrics from electronic medical records data, which are typically scattered and often based on unreliable data sources. The Society for Thoracic Surgery (STS) is one such example, and it supports manually collected data by trained clinical staff in an effort to obtain the highest-fidelity data possible. As a possible alternative, our team designed an algorithm to test the feasibility of producing computer-derived data for the case of postoperative mechanical ventilation hours. In this article, we study and compare the accuracy of algorithm-derived mechanical ventilation data with manual data extraction. We created a novel algorithm that is able to calculate mechanical ventilation duration for any postoperative patient using raw data from our EPIC electronic medical record. Utilizing nursing documentation of airway devices, documentation of lines, drains, and airways, and respiratory therapist ventilator settings, the algorithm produced results that were then validated against the STS registry. This enabled us to compare our algorithm results with data collected by human chart review. Any discrepancies were then resolved with manual calculation by a research team member. The STS registry contained a total of 439 University of California Los Angeles cardiac cases from April 1, 2013, to March 31, 2014. After excluding 201 patients for not remaining intubated, tracheostomy use, or for having 2 surgeries on the same day, 238 cases met inclusion criteria. Comparing the postoperative ventilation durations between the 2 data sources resulted in 158 (66%) ventilation durations agreeing within 1 hour, indicating a probable correct value for both sources. Among the discrepant cases, the algorithm yielded results that were exclusively correct in 75 (93.8%) cases, whereas the STS results were exclusively correct once (1.3%). The remaining 4 cases had inconclusive results after manual review because of a prolonged documentation gap between mechanical and spontaneous ventilation. In these cases, STS and algorithm results were different from one another but were both within the transition timespan. This yields an overall accuracy of 99.6% (95% confidence interval, 98.7%-100%) for the algorithm when compared with 68.5% (95% confidence interval, 62.6%-74.4%) for the STS data (P < .001). There is a significant appeal to having a computer algorithm capable of calculating metrics such as total ventilator times, especially because it is labor intensive and prone to human error. By incorporating 3 different sources into our algorithm and by using preprogrammed clinical judgment to overcome common errors with data entry, our results proved to be more comprehensive and more accurate, and they required a fraction of the computation time compared with manual review.

42 CFR 460.96 - Excluded services.

Code of Federal Regulations, 2013 CFR

2013-10-01

... nursing services (unless medically necessary), and nonmedical items for personal convenience such as... procedures. (e) Services furnished outside of the United States, except as follows: (1) In accordance with...

42 CFR 460.96 - Excluded services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... nursing services (unless medically necessary), and nonmedical items for personal convenience such as... procedures. (e) Services furnished outside of the United States, except as follows: (1) In accordance with...

42 CFR 460.96 - Excluded services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... nursing services (unless medically necessary), and nonmedical items for personal convenience such as... procedures. (e) Services furnished outside of the United States, except as follows: (1) In accordance with...

National Trends (2009-2013) for Palliative Care Utilization for Patients Receiving Prolonged Mechanical Ventilation.

PubMed

Chatterjee, Kshitij; Goyal, Abhinav; Kakkera, Krishna; Harrington, Sarah; Corwin, Howard L

2018-05-04

Patients requiring mechanical ventilation have high morbidity and mortality. Providing palliative care services has been suggested as a way to improve comprehensive management of critically ill patients. We examined the trend in the utilization of palliative care among adults who require prolonged mechanical ventilation. Primary objectives were to determine the trend in palliative care utilization over time, predictors for palliative care utilization, and palliative care impact on hospital length of stay. Retrospective, cross-sectional study. The National Inpatient Sample data between 2009 and 2013 was used for this study. Adults (age ≥ 18 yr) who underwent prolonged mechanical ventilation (≥ 96 consecutive hr) were studied. Palliative care and mechanical ventilation were identified using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes. A total of 1,751,870 hospitalizations with prolonged mechanical ventilation were identified between 2009 and 2013. The utilization of palliative care increased yearly from 6.5% in 2009 to 13.1% in 2013 (p < 0.001). Among the mechanically ventilated patients who died, palliative care increased from 15.9% in 2009 to 33.3% in 2013 (p < 0.001). Median hospital length of stay for patients with and without palliative care was 13 and 17 days, respectively (p < 0.001). Patients discharged to either short- or long-term care facilities had a shorter length of stay if palliative care was provided (15 vs 19 d; p < 0.001). The factors associated with a higher palliative care utilization included older age, malignancy, larger hospitals in urban areas, and teaching hospitals. Non-Caucasian race was associated with lower palliative care utilization. Among patients who undergo prolonged mechanical ventilation, palliative care utilization is increasing, particularly in patients who die during hospitalization. Using palliative care for mechanically ventilated patients who are discharged to either short- or long-term care facilities is associated with a shorter hospital length of stay.

26 CFR 1.911-3 - Determination of amount of foreign earned income to be excluded.

Code of Federal Regulations, 2011 CFR

2011-04-01

... income to be excluded. 1.911-3 Section 1.911-3 Internal Revenue INTERNAL REVENUE SERVICE, DEPARTMENT OF... Residents of United States § 1.911-3 Determination of amount of foreign earned income to be excluded. (a) Definition of foreign earned income. For purposes of section 911 and the regulations thereunder, the term...

Do We Still Have a Digital Divide in Mental Health? A Five-Year Survey Follow-up.

PubMed

Robotham, Dan; Satkunanathan, Safarina; Doughty, Lisa; Wykes, Til

2016-11-22

Nearly everyone in society uses the Internet in one form or another. The Internet is heralded as an efficient way of providing mental health treatments and services. However, some people are still excluded from using Internet-enabled technology through lack of resources, skills, and confidence. Five years ago, we showed that people with severe mental illness were at risk of digital exclusion, especially middle-aged patients with psychosis and/or people from black or minority ethnic groups with psychosis. An understanding of the breadth of potential digital exclusion is vital for the implementation of digital health services. The aim of this study is to understand the context of digital exclusion for people who experience mental illness. We conducted a survey involving people with a primary diagnosis of psychosis or depression in London, United Kingdom. A total of 241 participants were recruited: 121 with psychosis and 120 with depression. The majority of surveys were collected face-to-face (psychosis: n=109; depression: n=71). Participants answered questions regarding familiarity, access, use, motivation, and confidence with Internet-enabled technologies (ie, computers and mobile phones). Variables predicting digital exclusion were identified in regression analyses. The results were compared with the survey conducted in 2011. Digital exclusion has declined since 2011. Online survey collection introduced biases into the sample, masking those who were likely to be excluded. Only 18.3% (20/109) of people with psychosis in our sample were digitally excluded, compared with 30% (28/93) in 2011 (χ 2 1 =3.8, P=.04). People with psychosis had less confidence in using the Internet than people with depression (χ 2 1 =7.4, P=.004). Only 9.9% (24/241) of participants in the total sample were digitally excluded, but the majority of these people had psychosis (n=20). Those with psychosis who were digitally excluded were significantly older than their included peers (t 30 =3.3, P=.002) and had used services for longer (t 97 =2.5, P=.02). Younger people were more likely to use mobile phones. Digitally excluded participants cited a lack of knowledge as a barrier to digital inclusion, and most wanted to use the Internet via computers (rather than mobile phones). Digital exclusion is lower, but some remain excluded. Facilitating inclusion among this population means helping them develop skills and confidence in using technology, and providing them with access. Providing mobile phones without basic information technology training may be counterproductive because excluded people may be excluded from mobile technology too. An evidence-based digital inclusion strategy is needed within the National Health Service to help digitally excluded populations access Internet-enabled services. ©Dan Robotham, Safarina Satkunanathan, Lisa Doughty, Til Wykes. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 22.11.2016.

Automated interpretation of ventilation-perfusion lung scintigrams for the diagnosis of pulmonary embolism using artificial neural networks.

PubMed

Holst, H; Aström, K; Järund, A; Palmer, J; Heyden, A; Kahl, F; Tägil, K; Evander, E; Sparr, G; Edenbrandt, L

2000-04-01

The purpose of this study was to develop a completely automated method for the interpretation of ventilation-perfusion (V-P) lung scintigrams used in the diagnosis of pulmonary embolism. An artificial neural network was trained for the diagnosis of pulmonary embolism using 18 automatically obtained features from each set of V-P scintigrams. The techniques used to process the images included their alignment to templates, the construction of quotient images based on the ventilation and perfusion images, and the calculation of measures describing V-P mismatches in the quotient images. The templates represented lungs of normal size and shape without any pathological changes. Images that could not be properly aligned to the templates were detected and excluded automatically. After exclusion of those V-P scintigrams not properly aligned to the templates, 478 V-P scintigrams remained in a training group of consecutive patients with suspected pulmonary embolism, and a further 87 V-P scintigrams formed a separate test group comprising patients who had undergone pulmonary angiography. The performance of the neural network, measured as the area under the receiver operating characteristic curve, was 0.87 (95% confidence limits 0.82-0.92) in the training group and 0.79 (0.69-0.88) in the test group. It is concluded that a completely automated method can be used for the interpretation of V-P scintigrams. The performance of this method is similar to others previously presented, whereby features were extracted manually.

Translation and cultural adaptation of the Brazilian Portuguese version of the Behavioral Pain Scale.

PubMed

Morete, Márcia Carla; Mofatto, Sarah Camargo; Pereira, Camila Alves; Silva, Ana Paula; Odierna, Maria Tereza

2014-01-01

The objective of this study was to translate and culturally adapt the Behavioral Pain Scale to Brazilian Portuguese and to evaluate the psychometric properties of this scale. This study was conducted in two phases: the Behavioral Pain Scale was translated and culturally adapted to Brazilian Portuguese and the psychometric properties of this scale were subsequently assessed (reliability and clinical utility). The study sample consisted of 100 patients who were older than 18 years of age, admitted to an intensive care unit, intubated, mechanically ventilated, and subjected or not to sedation and analgesia from July 2012 to December 2012. Pediatric and non-intubated patients were excluded. The study was conducted at a large private hospital that was situated in the city of São Paulo (SP). Regarding reproducibility, the results revealed that the observed agreement between the two evaluators was 92.08% for the pain descriptor "adaptation to mechanical ventilation", 88.1% for "upper limbs", and 90.1% for "facial expression". The kappa coefficient of agreement for "adaptation to mechanical ventilation" assumed a value of 0.740. Good agreement was observed between the evaluators with an intraclass correlation coefficient of 0.807 (95% confidence interval: 0.727-0.866). The Behavioral Pain Scale was easy to administer and reproduce. Additionally, this scale had adequate internal consistency. The Behavioral Pain Scale was satisfactorily adapted to Brazilian Portuguese for the assessment of pain in critically ill patients.

Comparison of intraoperative volume and pressure-controlled ventilation modes in patients who undergo open heart surgery.

PubMed

Hoşten, Tülay; Kuş, Alparslan; Gümüş, Esra; Yavuz, Şadan; İrkil, Serhat; Solak, Mine

2017-02-01

Respiratory problems occur more frequently in patients who undergo open heart surgery. Intraoperative and postoperative ventilation strategies can prevent these complications and reduce mortality. We hypothesized that PCV would have better effects on gas exchange, lung mechanics and hemodynamics compared to VCV in CABG surgery. Our primary outcome was to compare the PaO 2 /FiO 2 ratio. Patients were randomized into two groups, (VCV, PCV) consisting of 30 individuals each. Two patients were excluded from the study. I/E ratio was adjusted to 1:2 and, RR:10/min fresh air gas flow was set at 3L/min in all patients. In the VCV group TV was set at 8 mL/kg of the predicted body weight. In the PCV group, peak inspiratory pressure was adjusted to the same tidal volume with the VCV group. PaO2/FiO2 was found to be higher with PCV at the end of the surgery. Time to extubation and ICU length of stay was shorter with PCV. Ppeak was similar in both groups. Pplateau was lower and Pmean was higher at the and of the surgery with PCV compared to VCV. The hemodynamic effects of both ventilation modes were found to be similar. PVC may be preferable to VCV in patients who undergo open heart surgery. However, it would be convenient if our findings are supported by similar studies.

Lung-protective ventilation initiated in the emergency department (LOV-ED): a study protocol for a quasi-experimental, before-after trial aimed at reducing pulmonary complications.

PubMed

Fuller, Brian M; Ferguson, Ian; Mohr, Nicholas M; Stephens, Robert J; Briscoe, Cristopher C; Kolomiets, Angelina A; Hotchkiss, Richard S; Kollef, Marin H

2016-04-11

In critically ill patients, acute respiratory distress syndrome (ARDS) and ventilator-associated conditions (VACs) are associated with increased mortality, survivor morbidity and healthcare resource utilisation. Studies conclusively demonstrate that initial ventilator settings in patients with ARDS, and at risk for it, impact outcome. No studies have been conducted in the emergency department (ED) to determine if lung-protective ventilation in patients at risk for ARDS can reduce its incidence. Since the ED is the entry point to the intensive care unit for hundreds of thousands of mechanically ventilated patients annually in the USA, this represents a knowledge gap in this arena. A lung-protective ventilation strategy was instituted in our ED in 2014. It aims to address the parameters in need of quality improvement, as demonstrated by our previous research: (1) prevention of volutrauma; (2) appropriate positive end-expiratory pressure setting; (3) prevention of hyperoxia; and (4) aspiration precautions. The lung-protective ventilation initiated in the emergency department (LOV-ED) trial is a single-centre, quasi-experimental before-after study testing the hypothesis that lung-protective ventilation, initiated in the ED, is associated with reduced pulmonary complications. An intervention cohort of 513 mechanically ventilated adult ED patients will be compared with over 1000 preintervention control patients. The primary outcome is a composite outcome of pulmonary complications after admission (ARDS and VACs). Multivariable logistic regression with propensity score adjustment will test the hypothesis that ED lung-protective ventilation decreases the incidence of pulmonary complications. Approval of the study was obtained prior to data collection on the first patient. As the study is a before-after observational study, examining the effect of treatment changes over time, it is being conducted with waiver of informed consent. This work will be disseminated by publication of full-length manuscripts, presentation in abstract form at major scientific meetings and data sharing with other investigators through academically established means. NCT02543554. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses.

PubMed

Bourdeaux, Christopher P; Thomas, Matthew Jc; Gould, Timothy H; Malhotra, Gaurav; Jarvstad, Andreas; Jones, Timothy; Gilchrist, Iain D

2016-05-26

Low tidal volume (TVe) ventilation improves outcomes for ventilated patients, and the majority of clinicians state they implement it. Unfortunately, most patients never receive low TVes. 'Nudges' influence decision-making with subtle cognitive mechanisms and are effective in many contexts. There have been few studies examining their impact on clinical decision-making. We investigated the impact of 2 interventions designed using principles from behavioural science on the deployment of low TVe ventilation in the intensive care unit (ICU). University Hospitals Bristol, a tertiary, mixed medical and surgical ICU with 20 beds, admitting over 1300 patients per year. Data were collected from 2144 consecutive patients receiving controlled mechanical ventilation for more than 1 hour between October 2010 and September 2014. Patients on controlled mechanical ventilation for more than 20 hours were included in the final analysis. (1) Default ventilator settings were adjusted to comply with low TVe targets from the initiation of ventilation unless actively changed by a clinician. (2) A large dashboard was deployed displaying TVes in the format mL/kg ideal body weight (IBW) with alerts when TVes were excessive. TVe in mL/kg IBW. TVe was significantly lower in the defaults group. In the dashboard intervention, TVe fell more quickly and by a greater amount after a TVe of 8 mL/kg IBW was breached when compared with controls. This effect improved in each subsequent year for 3 years. This study has demonstrated that adjustment of default ventilator settings and a dashboard with alerts for excessive TVe can significantly influence clinical decision-making. This offers a promising strategy to improve compliance with low TVe ventilation, and suggests that using insights from behavioural science has potential to improve the translation of evidence into practice. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Effectiveness of heat and moisture exchangers in preventing ventilator-associated pneumonia in critically ill patients: a meta-analysis.

PubMed

Menegueti, Mayra Gonçalves; Auxiliadora-Martins, Maria; Nunes, Altacílio Aparecido

2014-01-01

Patients may acquire ventilator-associated pneumonia (VAP) by aspirating the condensate that originates in the ventilator circuit upon use of a conventional humidifier. The bacteria that colonize the patients themselves can proliferate in the condensate and then return to the airways and lungs when the patient aspirates this contaminated material. Therefore, the use of HME might contribute to preventing pneumonia and lowering the VAP incidence. The aim of this study was to evaluate how the use of HME impacts the probability of VAP occurrence in critically ill patients. On the basis of the acronym "PICO" (Patient, Intervention, Comparison, Outcome), the question that guided this review was "Do critically ill patients under invasive mechanical ventilation present lower VAP incidence when they use HME as compared with HH?". Two of the authors of this review searched the databases PUBMED/Medline, The Cochrane Library, and Latin-American and Caribbean Literature in Health Sciences, LILACS independently; they used the following keywords: "heat and moisture exchanger", AND "heated humidifier", AND "ventilator-associated pneumonia prevention". This review included papers in the English language published from January 1990 to December 2012. This review included ten studies. Comparison between the use of HME and HH did not reveal any differences in terms of VAP occurrence (OR = 0.998; 95% CI: 0.778-1.281). Together, the ten studies corresponded to a total sample of 1077 and 953 patients in the HME and HH groups, respectively; heterogeneity among the investigations was low (I(2) < 50%). Information about the outcome mortality was available in only eight of the ten studies. The use of HME and HH did not afford different results in terms of mortality (OR = 1.09; 95% CI: 0.864-1.376). The total sample size was 884 and 762 patients, respectively. Heterogeneity among the studies was low (I(2) = 0.0%). Current meta-analysis was not sufficient to definitely exclude an associate between heat and moisture exchangers and VAP. Despite the methodological limitations found in selected clinical trials, the current meta-analysis suggests that HME does not decrease VAP incidence or mortality in critically ill patients.

Indoor Air Quality Assessment of the San Francisco Federal Building

DOE Office of Scientific and Technical Information (OSTI.GOV)

Apte, Michael; Bennett, Deborah H.; Faulkner, David

2008-07-01

An assessment of the indoor air quality (IAQ) of the San Francisco Federal Building (SFFB) was conducted on May 12 and 14, 2009 at the request of the General Services Administration (GSA). The purpose of the assessment was for a general screening of IAQ parameters typically indicative of well functioning building systems. One naturally ventilated space and one mechanically ventilated space were studied. In both zones, the levels of indoor air contaminants, including CO2, CO, particulate matter, volatile organic compounds, and aldehydes, were low, relative to reference exposure levels and air quality standards for comparable office buildings. We found slightlymore » elevated levels of volatile organic compounds (VOCs) including two compounds often found in"green" cleaning products. In addition, we found two industrial solvents at levels higher than typically seen in office buildings, but the levels were not sufficient to be of a health concern. The ventilation rates in the two study spaces were high by any standard. Ventilation rates in the building should be further investigated and adjusted to be in line with the building design. Based on our measurements, we conclude that the IAQ is satisfactory in the zone we tested, but IAQ may need to be re-checked after the ventilation rates have been lowered.« less

Extracorporeal membrane oxygenation support in a situation of diagnostic dilemma.

PubMed

Elahi, Maqsood M; Houng, Chew; Trahair, Toby; Ravindranathan, Hari; Grant, Peter W

2012-12-01

Severe acute respiratory distress syndrome (ARDS) in children carries a high morbidity and mortality. High frequency ventilation and extracorporeal membrane oxygenation (ECMO) are used as rescue modes of support in difficult situations. Malignancy may be considered to be a relative contraindication to ECMO support. We report a case where the decision was made to support the patient with ECMO for fulminant Epstein-Barr (EBV) infection while investigations were being done to exclude an underlying malignancy. Copyright © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.

48 CFR 9.501 - Definition.

Code of Federal Regulations, 2010 CFR

2010-10-01

... consultant when rendering— (1) Services excluded in subpart 37.2; (2) Routine engineering and technical services (such as installation, operation, or maintenance of systems, equipment, software, components, or facilities); (3) Routine legal, actuarial, auditing, and accounting services; and (4) Training services. [55...

The power of local action in occupational health: the adoption of local exhaust ventilation in the Chicago tuckpointing trade.

PubMed

Weinstein, Marc; Susi, Pam; Goldberg, Mark

2016-04-01

Silica is a pervasive and potentially deadly occupational hazard in construction. The occupational risk posed by silica has long been known, but efforts to use engineering controls to minimize dust generation in tuckpointing operations, a masonry restoration specialty, have been slow. The objective of this study is to explore how local innovation in occupational safety and health may emerge, absent the establishment of national standards. This study uses a case study to explore the adoption of local exhaust ventilation in tuckpointing operations in the Chicago area. Sources of data for this research include interviews with a diverse range of key informants and the review of archival material. This case study found local unions, municipal regulators, contractors, and major public users of construction services played a central role in the events and milestones that led to the early adoption of local exhaust ventilation in Chicago. The adoption of local exhaust ventilation technology in Chicago demonstrates the potential for local actors to fill an important void when rulemaking in vital areas of occupational of health impedes effective national regulation.

5 CFR 919.310 - What must I do if a Federal agency excludes a person with whom I am already doing business in a...

Code of Federal Regulations, 2010 CFR

2010-01-01

... excludes a person with whom I am already doing business in a covered transaction? 919.310 Section 919.310 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED... Doing Business with Other Persons § 919.310 What must I do if a Federal agency excludes a person with...

5 CFR 919.415 - What must I do if a Federal agency excludes the participant or a principal after I enter into a...

Code of Federal Regulations, 2010 CFR

2010-01-01

... excludes the participant or a principal after I enter into a covered transaction? 919.415 Section 919.415 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED... § 919.415 What must I do if a Federal agency excludes the participant or a principal after I enter into...

7 CFR 58.15 - Accessibility and condition of product.

Code of Federal Regulations, 2013 CFR

2013-01-01

... be made available for verification. The room or area where the service is to be performed shall be clean and sanitary, free from foreign odors, and shall be provided with adequate lighting, ventilation...

7 CFR 58.15 - Accessibility and condition of product.

Code of Federal Regulations, 2012 CFR

2012-01-01

... be made available for verification. The room or area where the service is to be performed shall be clean and sanitary, free from foreign odors, and shall be provided with adequate lighting, ventilation...

7 CFR 58.15 - Accessibility and condition of product.

Code of Federal Regulations, 2011 CFR

2011-01-01

... be made available for verification. The room or area where the service is to be performed shall be clean and sanitary, free from foreign odors, and shall be provided with adequate lighting, ventilation...

7 CFR 58.15 - Accessibility and condition of product.

Code of Federal Regulations, 2010 CFR

2010-01-01

... be made available for verification. The room or area where the service is to be performed shall be clean and sanitary, free from foreign odors, and shall be provided with adequate lighting, ventilation...

7 CFR 58.15 - Accessibility and condition of product.

Code of Federal Regulations, 2014 CFR

2014-01-01

... be made available for verification. The room or area where the service is to be performed shall be clean and sanitary, free from foreign odors, and shall be provided with adequate lighting, ventilation...

78 FR 59701 - Medicare Program; Approval of Accrediting Organization for Suppliers of Advanced Diagnostic...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-27

... imaging services, including services described in section 1848(b)(4)(B) (excluding X-ray, ultrasound, and... imaging services,'' including x-ray, ultrasound (including echocardiography), nuclear medicine (including...

National review of use of extracorporeal membrane oxygenation as respiratory support in thoracic surgery excluding lung transplantation.

PubMed

Rinieri, Philippe; Peillon, Christophe; Bessou, Jean-Paul; Veber, Benoît; Falcoz, Pierre-Emmanuel; Melki, Jean; Baste, Jean-Marc

2015-01-01

Extracorporeal membrane oxygenation (ECMO) for respiratory support is increasingly used in intensive care units (ICU), but rarely during thoracic surgical procedures outside the transplantation setting. ECMO can be an alternative to cardiopulmonary bypass for major trachea-bronchial surgery and single-lung procedures without in-field ventilation. Our aim was to evaluate the intraoperative use of ECMO as respiratory support in thoracic surgery: benefits, indications and complications. This was a multicentre retrospective study (questionnaire) of use of ECMO as respiratory support during the thoracic surgical procedure. Lung transplantation and lung resection for tumour invading the great vessels and/or the left atrium were excluded, because they concern respiratory and circulatory support. From March 2009 to September 2012, 17 of the 34 centres in France applied ECMO within veno-venous (VV) (n=20) or veno-arterial (VA) (n=16) indications in 36 patients. Ten VA ECMO were performed with peripheral cannulation and 6 with central cannulation; all VV ECMO were achieved through peripheral cannulation. Group 1 (total respiratory support) was composed of 28 patients without mechanical ventilation, involving 23 tracheo-bronchial and 5 single-lung procedures. Group 2 (partial respiratory support) was made up of 5 patients with respiratory insufficiency. Group 3 was made up of 3 patients who underwent thoracic surgery in a setting of acute respiratory distress syndrome (ARDS) with preoperative ECMO. Mortality at 30 days in Groups 1, 2 and 3 was 7, 40 and 67%, respectively (P<0.05). In Group 1, ECMO was weaned intraoperatively or within 24 h in 75% of patients. In Group 2, ECMO was weaned in ICU over several days. In Group 1, 2 patients with VA support were converted to VV support for chronic respiratory indications. Bleeding was the major complication with 17% of patients requiring return to theatre for haemostasis. There were two cannulation-related complications (6%). VV or VA ECMO is a satisfactory alternative to in-field ventilation in complex tracheo-bronchial surgery or in single-lung surgery. ECMO should be considered and used in precarious postoperative respiratory conditions. Full respiratory support can be achieved with VV ECMO. Indications for and results of ECMO during surgery in patients with ARDS warrant further careful investigation. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Characteristics and outcome of mechanically ventilated patients with 2009 H1N1 influenza in Bosnia and Herzegovina and Serbia: impact of newly established multidisciplinary intensive care units.

PubMed

Kojicić, Marija; Kovacević, Pedja; Bajramović, Nermina; Batranović, Uros; Vidović, Jadranka; Aganović, Kenana; Gavrilović, Srdjan; Zlojutro, Biljana; Thiery, Guillaume

2012-12-01

To describe characteristics and outcome of mechanically ventilated patients admitted to three newly established intensive care units (ICU) in Bosnia-Herzegovina and Serbia for 2009 H1N1 influenza infection. The retrospective observational study included all mechanically ventilated adult patients of three university-affiliated hospitals between November 1, 2009 and March 1 2010 who had 2009 H1N1 influenza infection confirmed by real-time reverse transcriptase-polymerase-chain-reaction (RT-PCR) from nasopharyngeal swab specimens and respiratory secretions. The study included 50 patients, 31 male (62%), aged 43±13 years. Median time from hospital to ICU admission was 1 day (range 1-2). Sixteen patients (30%) presented with one or more chronic medical condition: 8 (16%) with chronic lung disease, 5 (10%) with chronic heart failure, and 3 (6%) with diabetes mellitus. Thirty-two (64%) were obese. Forty-eight patients (96%) experienced acute respiratory distress syndrome (ARDS), 28 (56%) septic shock, and 27 (54%) multiorgan failure. Forty-five patients (90%) were intubated and mechanically ventilated, 5 received non-invasive mechanical ventilation, 7 (14%) high-frequency oscillatory ventilation, and 7 (14%) renal replacement therapy. The median duration of mechanical ventilation was 7 (4-14) days. Hospital mortality was 52%. Influenza 2009 H1N1 infection in three southeast European ICUs affected predominantly healthy young patients and was associated with rapid deterioration after hospital admission and severe respiratory and multiorgan failure. These emerging ICUs provided contemporary ICU services, resulting in case-fatality rate comparable to reports from well-established ICU settings.

Reduced survival in patients with ALS with upper airway obstructive events on non-invasive ventilation.

PubMed

Georges, Marjolaine; Attali, Valérie; Golmard, Jean Louis; Morélot-Panzini, Capucine; Crevier-Buchman, Lise; Collet, Jean-Marc; Tintignac, Anne; Morawiec, Elise; Trosini-Desert, Valery; Salachas, François; Similowski, Thomas; Gonzalez-Bermejo, Jesus

2016-10-01

Non-invasive ventilation (NIV) is part of standard care in amyotrophic lateral sclerosis (ALS). Intolerance or unavailability of NIV, as well as the quality of correction of nocturnal hypoventilation, has a direct impact on prognosis. We describe the importance of NIV failure due to upper airway obstructive events, the clinical characteristics, as well as their impact on the prognosis of ALS. Retrospective analysis of the data of 190 patients with ALS and NIV in a single centre for the period 2011-2014. 179 patients tolerating NIV for more than 4 h per night without leaks were analysed. Among the 179 patients, after correction of leaks, 73 remained inadequately ventilated at night (defined as more than 5% of the night spent at <90% of SpO2), as a result of obstructive events in 67% of cases (n=48). Patients who remained inadequately ventilated after optimal adjustment of ventilator settings presented with shorter survival than adequately ventilated patients. Unexpectedly, patients with upper airway obstructive events without nocturnal desaturation and in whom no adjustment of treatment was therefore performed also presented with shorter survival. On initiation of NIV, no difference was demonstrated between patients with and without upper airway obstructive events. In all patients, upper airway obstruction was concomitant with reduction of ventilatory drive. This study shows that upper airway obstruction during NIV occurs in patients with ALS and is associated with poorer prognosis. Such events should be identified as they can be corrected by adjusting ventilator settings. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

42 CFR 412.20 - Hospital services subject to the prospective payment systems.

Code of Federal Regulations, 2010 CFR

2010-10-01

... payment systems. 412.20 Section 412.20 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Hospital Services Subject to and Excluded From the Prospective Payment Systems for Inpatient...

Effectiveness of haloperidol prophylaxis in critically ill patients with a high risk of delirium: a systematic review.

PubMed

Santos, Eduardo; Cardoso, Daniela; Neves, Hugo; Cunha, Madalena; Rodrigues, Manuel; Apóstolo, João

2017-05-01

Delirium is associated with increased intensive care unit and hospital length of stay, prolonged duration of mechanical ventilation, unplanned removal of tubes and catheters, and increased morbidity and mortality. Prophylactic treatment with low-dose haloperidol may have beneficial effects for critically ill patients with a high risk of delirium. To identify the effectiveness of haloperidol prophylaxis in critically ill patients with a high risk for delirium. Patients with a predicted high risk of delirium, aged 18 years or over, and in intensive care units. Patients with a history of concurrent antipsychotic medication use were excluded. Haloperidol prophylaxis for preventing delirium. Experimental and epidemiological study designs. Primary outcome is the incidence of delirium. Secondary outcomes are duration of mechanical ventilation, incidence of re-intubation, incidence of unplanned/accidental removal of tubes/lines and catheters, intensive care unit and hospital length of stay, and re-admissions to both settings. An initial search of MEDLINE and CINAHL was undertaken, followed by a second search for published and unpublished studies from January 1967 to September 2015 in major healthcare-related electronic databases. Studies in English, Spanish and Portuguese were included. Two independent reviewers assessed the methodological quality of five studies using the standardized critical appraisal instrument from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. There was general agreement among the reviewers to exclude one relevant study due to methodological quality. Data were extracted using the JBI data extraction form for experimental studies and included details about the interventions, populations, study methods and outcomes of significance to the review questions. Significant differences were found between participants, interventions, outcome measures (clinical heterogeneity) and designs (methodological heterogeneity). For these reasons, we were unable to perform a meta-analysis. Therefore, the results have been described in a narrative format. Five studies met the inclusion criteria. One of these studies was excluded due to poor methodological quality. The remaining four original studies (total of 1142 patients) were included in this review. Three studies were randomized controlled trials and one was a cohort study.Two studies confirmed the effectiveness of haloperidol prophylaxis in critically ill patients with a high risk of delirium. These studies showed that short-term prophylactic administration of low-dose intravenous haloperidol significantly decreased the incidence of delirium in elderly patients admitted to intensive care units after non-cardiac surgery and in general intensive care unit patients with a high risk of delirium.However, the two remaining studies showed contradictory results in mechanically ventilated critically ill adults, revealing that the administration of haloperidol reduced delirium prevalence, delayed its occurrence, and/or shorten its duration. The evidence related to the effectiveness of haloperidol prophylaxis in critically ill patients with a high risk of delirium is contradictory. However, balancing the benefits and low side effects associated with haloperidol prophylaxis, this preventive intervention may be useful to reduce the incidence of delirium in critically ill adults in intensive care units.

Ventilation.

PubMed

Turner, W A; Bearg, D W; Brennan, T

1995-01-01

This chapter begins with an overview of the history of ventilation guidelines, which has led to the guidelines that are in effect today. Of particular interest is the most recent return in the past 5 years to ventilation rates that more closely reflect a mean or average of the range of guidelines that have existed over the past century. OSHA's and the EPA's recognition of the need to operate ventilation systems in buildings in an accountable manner is also of note. Of even more interest is the resurgence of the concept of minimum mixing and once-through ventilation air that has been pursued in parts of Northern Europe for the past 10 years, and in a school that is being designed with this concept in New Hampshire. In addition, the design concept of equipping office buildings with low pressure drop high efficiency particle filtration to remove fine particles from all of the air that is supplied to the occupants is being used increasingly in the U.S. This chapter also presents an overview of the various types of ventilation systems found in homes and commercial office buildings and the common indoor air quality problems that may be associated with them. It also offers an overview of common HVAC evaluation techniques that can be used to determine if a ventilation system is performing in a manner that makes sense for the use of the space and the needs of the occupants. Are the occupants receiving a reasonable supply of outdoor air? Is the air that they receive of reasonable quality? Are obvious pollutants being exhausted? Ventilation systems have become extremely complex and more difficult to run and maintain over the past 40 years. This trend will continue to drive the need for professionally maintained HVAC equipment that is serviced and run by individuals who are accountable for the quality of the air that the system delivers.

14 CFR 158.15 - Project eligibility at PFC levels of $1, $2, or $3.

Code of Federal Regulations, 2014 CFR

2014-01-01

... of the airport. These areas do not include restaurants, car rental and automobile parking facilities..., ventilation, plumbing, and electrical service), and aircraft fueling facilities next to the gate; (7) A...

42 CFR 35.61 - Applicability.

Code of Federal Regulations, 2012 CFR

2012-10-01

... PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND... hospital or station of the Public Health Service, excluding outpatient clinics. Such contributions are...) gifts to the United States to support Public Health Service functions under section 501 of the Public...

42 CFR 35.61 - Applicability.

Code of Federal Regulations, 2011 CFR

2011-10-01

... PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND... hospital or station of the Public Health Service, excluding outpatient clinics. Such contributions are...) gifts to the United States to support Public Health Service functions under section 501 of the Public...

42 CFR 35.61 - Applicability.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND... hospital or station of the Public Health Service, excluding outpatient clinics. Such contributions are...) gifts to the United States to support Public Health Service functions under section 501 of the Public...

42 CFR 35.61 - Applicability.

Code of Federal Regulations, 2013 CFR

2013-10-01

... PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND... hospital or station of the Public Health Service, excluding outpatient clinics. Such contributions are...) gifts to the United States to support Public Health Service functions under section 501 of the Public...

42 CFR 35.61 - Applicability.

Code of Federal Regulations, 2014 CFR

2014-10-01

... PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL CARE AND EXAMINATIONS HOSPITAL AND... hospital or station of the Public Health Service, excluding outpatient clinics. Such contributions are...) gifts to the United States to support Public Health Service functions under section 501 of the Public...

Novel avulsion pattern of the left principal bronchus with involvement of the carina and caudal thoracic trachea in a cat.

PubMed

Schmierer, Philipp A; Schwarz, Andrea; Bass, Danielle A; Knell, Sebastian Christoph

2014-08-01

A 2-year-old, 4.5 kg, neutered male domestic shorthair cat was presented to the emergency service with dyspnoea, anorexia and apathetic behaviour. Thoracic radiographs showed typical signs for a thoracic trauma and a tracheal lesion in the region of the carina, consistent with pseudoairway formation. Computed tomography (CT) was performed in the conscious cat to avoid aggravation of air leakage associated with ventilation. The additional CT findings were consistent with a novel pattern of a traumatic avulsion of the left principal bronchus expanding into the carina and caudal thoracic trachea. Despite the complex avulsion pattern, successful treatment was achieved surgically by performing an end-to-end anastomosis via a fifth right intercostal lateral thoracotomy. The cat was ventilated with a feeding tube and jet ventilation throughout. The cat showed excellent recovery 6 months after surgery. © ISFM and AAFP 2013.

47 CFR 54.501 - Eligibility for services provided by telecommunications carriers.

Code of Federal Regulations, 2012 CFR

2012-10-01

...) COMMON CARRIER SERVICES (CONTINUED) UNIVERSAL SERVICE Universal Service Support for Schools and Libraries...) Libraries. (1) Only libraries eligible for assistance from a State library administrative agency under the Library Services and Technology Act (Pub. L. 104-208) and not excluded under paragraphs (b)(2) or (3) of...

7 CFR 2045.1754 - Scope of gratuitous services performed.

Code of Federal Regulations, 2010 CFR

2010-01-01

... County Office level and conform to a standard FmHA or its successor agency under Public Law 103-354... Gratuitous Services § 2045.1754 Scope of gratuitous services performed. (a) Gratuitous services accepted in... successor agency under Public Law 103-354 employees (excluding Committee members). Such services must not...

Two-year survival of severe chronic obstructive pulmonary disease subjects requiring invasive mechanical ventilation and the factors affecting survival.

PubMed

Asker, Selvi; Ozbay, Bulent; Ekin, Selami; Yildiz, Hanifi; Sertogullarindan, Bunyamin

2016-05-01

To investigate two-year survival rates and the factors affecting survival in patients of severe chronic obstructive pulmonary disease requiring invasive mechanical ventilation. The retrospective study was conducted at Yuzuncuy?l University, Van, Turkey, and comprised record of in-patients with moderate to severe chronic obstructive pulmonary disease who required invasive mechanical ventilation in the intensive care unit of the Pulmonary Diseases Department between January 2007 and December 2010. Correlation between survival and parameters such as age, gender, duration of illness, history of smoking, arterial blood gas values, pulmonary artery pressure, left ventricular ejection fraction, body mass index and laboratory findings were investigated. SPSS 19 was used for statistical analysis. Of the 69 severe COPD subjects available, 20 (29%) were excluded as they did not meet the inclusion criteria. Overall in-hospital mortality rate was 42% (n:29). Of the remaining 20 (29%) who comprised the study group, 14(70%) were men and 6(30%) were women. The mortality rates at the end of 3rd, 6th, 12th and 24th months were 61%, 76%, 84% and 85.5% respectively. There was no correlation between gender and survival in time point (p>0.05). The only factor that affected the rate of mortality at the end of the 3rd month was age (p<0.05). Mortality was high in subjects with advanced ages (p<0.05). Duration of illness affected the survival at the end of the six month (p<0.05). Survival rates were high in subjects with longer illness durations (p<0.05). Haematocrit level was the only factor that affected mortality rates at the end of 12th and 24th months (p<0.05). Subjects with higher haematocrit levels had higher survival rates (p<0.05). Age, duration of illness and haematocrit levels were the most important factors that affected survival in chronic obstructive pulmonary disease patients requiring mechanical ventilation.

EVALUATION OF THORACOSCOPY IN THE DIAGNOSIS OF DIAPHRAGMATIC INJURIES IN PENETRATING THORACOABDOMINAL TRAUMA WITHOUT LUNG DEFLATION AT DR GEORGE MUKHARI ACADEMIC HOSPITAL.

PubMed

Nsakala, L

2017-06-01

With a mortality estimated at 25% when missed, diaphragmatic injuries due to penetrating thoracoabdominal trauma present a diagnostic challenge for both the radiologist and the surgeon. In the current literature, chest x-ray has a sensitivity of 27-60% for left-sided injuries and only 17% for right-sided injuries while, CT scan has a sensitivity of 14-61% and a specificity of 76-99%. Thoracoscopy using a single lung ventilation is one of the modalities of choice for the diagnosis of these injuries with a specificity of 100% and a sensitivity of 87.5%. This was a prospective study; all stable trauma patients with penetrating thoracoabdominal injury aged 18 years and above admitted to the trauma unit at Dr George Mukhari Academic Hospital during the period of the study were included. All patients with penetrating thoracoabdominal trauma who were unstable, or necessitating prompt management and all paediatric patients were excluded from the study. In theatre, under general anaesthesia, we first performed thoracoscopy without single lung ventilation followed by laparoscopy as control on each patient. Data was collected using a standard proforma by the attending surgeon and was analysed by a statistician using IBM SPSS 22 software. A total of 32 patients met the inclusion criteria of which 4 were female (12.5%) and 28 male (87.5%) with the median age of 29 years. Of the 32 patients, 27 had thoracoabdominal stab wounds (84.3%) and 5 had gunshot wounds (15.6%). Fourteen patients (43.75%) had left sided injury and 18 patients (56.25%) had injury to the right side. The incidence of diaphragmatic injury was 37.5% (n = 12). No injuries were missed on thoracoscopy; there was no mortality or morbidity. Thoracoscopy without single lung ventilation is safe and comparable to thoracoscopy with single lung ventilation as a diagnostic tool for diaphragmatic injuries in stable patients with penetrating thoracoabdominal trauma.

Effects of fentanyl administration before induction of anesthesia and placement of the Laryngeal Mask Airway: a randomized, placebo-controlled trial.

PubMed

Joshi, Girish P; Kamali, Amin; Meng, Jin; Rosero, Eric; Gasanova, Irina

2014-03-01

To assess the effects of fentanyl administered before induction of anesthesia on movement and airway responses during desflurane anesthesia via the Laryngeal Mask Airway (LMA). Randomized, double-blinded, controlled trial. Tertiary-care academic center. 100 adult, ASA physical status 1, 2, and 3 patients undergoing ambulatory surgery. Patients were administered fentanyl 1 μg/kg (n=51) or saline (n=49) 3 to 5 minutes before induction with propofol 2-2.5 mg/kg intravenously (IV), followed by LMA placement. Anesthesia was maintained with desflurane titrated to a bispectral index (BIS) of 50-60 and 50% nitrous oxide in oxygen, and fentanyl 25 μg boluses were titrated to respiratory rate. Apnea occurrence and duration of manual ventilation, as well as frequency and severity of movement, coughing, breath holding, and laryngospasm were recorded. Two patients in each group were excluded from analysis. The fentanyl pretreatment group had a higher frequency of apnea (94% vs 64%; P=0.0003) and longer duration of manual ventilation (3 [interquartile range (IQR), 1.5-5] min vs 1 [0-1.5] min; P<0.0001) at induction. In contrast, the fentanyl pretreatment group had a lower frequency of movements (16% vs 51%;P=0.0001). The rates of intraoperative breath holding (6.1% vs 8.5%) and laryngospasm (2% vs 4.3%) in the two groups were similar. All subjects experiencing laryngospasm were smokers. Adjusting for smoking status did not affect the differences noted in apnea, duration of manual ventilation, or movement between groups; however, coughing occurrence was statistically higher in the placebo group (P=0.043). Preinduction fentanyl increased the frequency of apnea at induction and duration of manual ventilation, but reduced the frequency of movements. In addition, it reduced intraoperative coughing in smokers. Copyright © 2014 Elsevier Inc. All rights reserved.

Prone position improves lung mechanical behavior and enhances gas exchange efficiency in mechanically ventilated chronic obstructive pulmonary disease patients.

PubMed

Mentzelopoulos, Spyros D; Zakynthinos, Spyros G; Roussos, Charris; Tzoufi, Maria J; Michalopoulos, Argyris S

2003-06-01

Pronation might favorably affect respiratory system (rs) mechanics and function in volume-controlled, mode-ventilated chronic obstructive pulmonary disease (COPD) patients. We studied 10 COPD patients, initially positioned supine (baseline supine [supine(BAS)]) and then randomly and consecutively changed to protocol supine (supine(PROT)), semirecumbent, and prone positions. Rs mechanics and inspiratory work (W(I)) were assessed at baseline (0.6 L) (all postures) and sigh (1.2 L) (supine(BAS) excluded) tidal volume (V(T)) with rapid airway occlusion during constant-flow inflation. Hemodynamics and gas exchange were assessed in all postures. There were no complications. Prone positioning resulted in (a) increased dynamic-static chest wall (cw) elastance (at both V(Ts)) and improved oxygenation versus supine(BAS), supine(PROT), and semirecumbent, (b) decreased additional lung (L) resistance-elastance versus supine(PROT) and semirecumbent at sigh V(T), (c) decreased L-static elastance (at both V(Ts)) and improved CO(2) elimination versus supine(BAS) and supine(PROT), and (d) improved oxygenation versus all other postures. Semirecumbent positioning increased mainly additional cw-resistance versus supine(BAS) and supine(PROT) at baseline. V(T) W(I)-sub-component changes were consistent with changes in rs, cw, and L mechanical properties. Total rs-W(I) and hemodynamics were unaffected by posture change. After pronation, five patients were repositioned supine (supine(POSTPRO)). In supine(POSTPRO), static rs-L elastance were lower, and oxygenation was still improved versus supine(BAS). Pronation of mechanically ventilated COPD patients exhibits applicability and effectiveness and improves oxygenation and sigh-L mechanics versus semirecumbent ("gold standard") positioning. By assessing respiratory mechanics, inspiratory work, hemodynamics, and gas exchange, we showed that prone positioning of mechanically ventilated chronic obstructed pulmonary disease patients improves oxygenation and lung mechanics during sigh versus semirecumbent positioning. Furthermore, certain pronation-related benefits versus preprone-supine positioning (reduced lung elastance and improved oxygenation) are maintained in the postprone supine position.

Ventilator-associated pneumonia, like real estate: location really matters.

PubMed

Eckert, Matthew J; Davis, Kimberly A; Reed, R Lawrence; Esposito, Thomas J; Santaniello, John M; Poulakidas, Stathis; Gamelli, Richard L; Luchette, Fred A

2006-01-01

Previous work has demonstrated an increased risk of ventilator-associated pneumonia (VAP) in trauma patients after prehospital (field) intubation as compared with emergency department (ED) intubations. However, this population was not compared with patients intubated as inpatients, making data interpretation difficult. We sought to further examine predictors for the development of VAP after trauma. A 10-year retrospective review of all patients mechanically ventilated greater than 24 hours after injury was performed. In all, 1,628 patients were identified, of which 1,213 (75%) were intubated as inpatients and 415 were emergently intubated (353 ED, 62 field). Overall, those intubated emergently were younger (p = 0.03) and less injured as seen by higher Glasgow Coma Scale scores (p = 0.0002), lower Injury Severity Scores (p = 0.01) and higher Revised Trauma Scores (p < 0.0001). Despite a lower injury severity, those patients emergently intubated were more likely to develop pneumonia as 22% of ED intubations and 15% of field intubations developed pneumonia, as compared with the inpatient rate of 6.5%. Pneumonia after field intubation was more likely to be community-acquired (p < 0.0001) with a significantly lower percentage of infecting enteric gram-negative rods (p < 0.0001) as compared with the inpatient and ED groups. Forward logistic regression analysis (with VAP = 1) identified inpatient intubation as protective against VAP (odds ratio 0.28, 95% CI = 0.2-0.4). Backwards logistic regression analysis further identified both field airway (odds ratio 2.29, 95% CI = 1.1-4.9) and ED airway (odds ratio 3.61, 95% CI = 2.5-5.2) as predictive of VAP. Compared with a population of trauma patients as inpatients, and excluding those patients mechanically ventilated less than 24 hours, patients intubated in the ED or field have a higher incidence of pneumonia, despite equivalent or lower injury severity.

Survival in amyotrophic lateral sclerosis with home mechanical ventilation: the impact of systematic respiratory assessment and bulbar involvement.

PubMed

Farrero, Eva; Prats, Enric; Povedano, Mónica; Martinez-Matos, J Antonio; Manresa, Frederic; Escarrabill, Joan

2005-06-01

To analyze (1) the impact of a protocol of early respiratory evaluation of the indications for home mechanical ventilation (HMV) in patients with amyotrophic lateral sclerosis (ALS), and (2) the effects of the protocol and of bulbar involvement on the survival of patients receiving noninvasive ventilation (NIV). Retrospective study in a tertiary care referral center. HMV was indicated in 86 patients with ALS, with 22 patients (25%) presenting with intolerance to treatment associated with bulbar involvement. Treatment with HMV had been initiated in 15 of 64 patients prior to initiating the protocol (group A) and in the remaining 49 patients after protocol initiation (group B). In group A, the majority of patients began treatment with HMV during an acute episode requiring ICU admission (p = 0.001) and tracheal ventilation (p = 0.025), with a lower percentage of patients beginning HMV treatment without respiratory insufficiency (p = 0.013). No significant differences in survival rates were found between groups A and B among patients treated with NIV. Greater survival was observed in group B (p = 0.03) when patients with bulbar involvement were excluded (96%). Patients without bulbar involvement at the start of therapy with NIV presented a significantly better survival rate (p = 0.03). Multivariate analysis showed bulbar involvement to be an independent prognostic factor for survival (relative risk, 1.6; 95% confidence interval, 1.01 to 2.54; p = 0.04). No significant differences in survival were observed between patients with bulbar involvement following treatment with NIV and those with intolerance, except for the subgroup of patients who began NIV treatment with hypercapnia (p = 0.0002). Early systematic respiratory evaluation in patients with ALS is necessary to improve the results of HMV. Further studies are required to confirm the benefits of NIV treatment in patients with bulbar involvement, especially in the early stages.

42 CFR 50.302 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Abortions and Related Medical Services in Federally Assisted Programs of the Public Health Service § 50.302... medical service, including an abortion, performed for the purpose of preventing or terminating a pregnancy... of abortions is specifically excluded from this definition. ...

42 CFR 50.302 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Abortions and Related Medical Services in Federally Assisted Programs of the Public Health Service § 50.302... medical service, including an abortion, performed for the purpose of preventing or terminating a pregnancy... of abortions is specifically excluded from this definition. ...

42 CFR 50.302 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Abortions and Related Medical Services in Federally Assisted Programs of the Public Health Service § 50.302... medical service, including an abortion, performed for the purpose of preventing or terminating a pregnancy... of abortions is specifically excluded from this definition. ...

42 CFR 50.302 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Abortions and Related Medical Services in Federally Assisted Programs of the Public Health Service § 50.302... medical service, including an abortion, performed for the purpose of preventing or terminating a pregnancy... of abortions is specifically excluded from this definition. ...

42 CFR 50.302 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Abortions and Related Medical Services in Federally Assisted Programs of the Public Health Service § 50.302... medical service, including an abortion, performed for the purpose of preventing or terminating a pregnancy... of abortions is specifically excluded from this definition. ...

48 CFR 9.501 - Definition.

Code of Federal Regulations, 2012 CFR

2012-10-01

... consultant when rendering— (1) Services excluded in subpart 37.2; (2) Routine engineering and technical services (such as installation, operation, or maintenance of systems, equipment, software, components, or...

48 CFR 9.501 - Definition.

Code of Federal Regulations, 2014 CFR

2014-10-01

... consultant when rendering— (1) Services excluded in subpart 37.2; (2) Routine engineering and technical services (such as installation, operation, or maintenance of systems, equipment, software, components, or...

48 CFR 9.501 - Definition.

Code of Federal Regulations, 2013 CFR

2013-10-01

... consultant when rendering— (1) Services excluded in subpart 37.2; (2) Routine engineering and technical services (such as installation, operation, or maintenance of systems, equipment, software, components, or...

48 CFR 9.501 - Definition.

Code of Federal Regulations, 2011 CFR

2011-10-01

... consultant when rendering— (1) Services excluded in subpart 37.2; (2) Routine engineering and technical services (such as installation, operation, or maintenance of systems, equipment, software, components, or...

42 CFR 419.1 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE... system. Subpart B sets forth the categories of hospitals and services that are subject to the outpatient hospital prospective payment system and those categories of hospitals and services that are excluded from...

Medical Services: Preventive Medicine

DTIC Science & Technology

1990-10-15

and comfort.Barracks are ventilated to dilute unpleasant odors , tobacco smoke, airborne microorganisms and dusts, and to reduce tempera- ture and...injury in cold climates by wearing proper cold-weather clothing and frequently changing socks to keep feet dry, by careful handling of gasoline-type...that refugee enclaves and prisoner compounds do not become foci of epidemic disease. (4) Environmental engineering service, LC teams. The LC teams will

26 CFR 1.552-4 - Certain excluded banks.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Internal Revenue INTERNAL REVENUE SERVICE, DEPARTMENT OF THE TREASURY (CONTINUED) INCOME TAX (CONTINUED) INCOME TAXES (CONTINUED) Foreign Personal Holding Companies § 1.552-4 Certain excluded banks. (a) A... United States income taxes which would otherwise be imposed on its shareholders. If this is established...

Automated ventilator testing.

PubMed

Ghaly, J; Smith, A L

1994-06-01

A new era has arrived for the Biomedical Engineering Department at the Royal Women's Hospital in Melbourne. We have developed a system to qualitatively test for intermittent or unconfirmed faults, associated with Bear Cub ventilators. Where previous testing has been inadequate, computer logging is now used to interface the RT200 Timeter Calibration Analyser (TCA) to obtain a real time display of data, which can be stored and graphed. Using Quick Basic version 4.5, it was possible to establish communication between the TCA and an IBM compatible computer, such that meaningful displays of machine performance were produced. From the parameters measured it has been possible to obtain data on Peak Pressure, Inspiratory to Expiratory ratio (I:E ratio) Peak Flow and Rate. Monitoring is not limited to these parameters, though these were selected for our particular needs. These parameters are plotted in two ways: 1. Compressed average versus time, up to 24 hours on one screen 2. Raw data, 36 minutes displayed on each screen. The compressed data gives an overview which allows easy identification of intermittent faults. The uncompressed data confirms that the averaged signal is a realistic representation of the situation. One of the major benefits of this type of data analysis, is that ventilator performance may be monitored over a long period of time without requiring the presence of a service technician. It also allows individual ventilator performance to be graphically compared to other ventilators.

Factors Associated with Failure of Non-invasive Positive Pressure Ventilation in a Critical Care Helicopter Emergency Medical Service.

PubMed

Lee, James S; O'Dochartaigh, Domhnall; MacKenzie, Mark; Hudson, Darren; Couperthwaite, Stephanie; Villa-Roel, Cristina; Rowe, Brian H

2015-06-01

Non-invasive positive pressure ventilation (NIPPV) is used to treat severe acute respiratory distress. Prehospital NIPPV has been associated with a reduction in both in-hospital mortality and the need for invasive ventilation. The authors of this study examined factors associated with NIPPV failure and evaluated the impact of NIPPV on scene times in a critical care helicopter Emergency Medical Service (HEMS). Non-invasive positive pressure ventilation failure was defined as the need for airway intervention or alternative means of ventilatory support. A retrospective chart review of consecutive patients where NIPPV was completed in a critical care HEMS was conducted. Factors associated with NIPPV failure in univariate analyses and from published literature were included in a multivariable, logistic regression model. From a total of 44 patients, NIPPV failed in 14 (32%); a Glasgow Coma Scale (GCS)<15 at HEMS arrival was associated independently with NIPPV failure (adjusted odds ratio 13.9; 95% CI, 2.4-80.3; P=.003). Mean scene times were significantly longer in patients who failed NIPPV when compared with patients in whom NIPPV was successful (95 minutes vs 51 minutes; 39.4 minutes longer; 95% CI, 16.2-62.5; P=.001). Patients with a decreased level of consciousness were more likely to fail NIPPV. Furthermore, patients who failed NIPPV had significantly longer scene times. The benefits of NIPPV should be balanced against risks of long scene times by HEMS providers. Knowing risk factors of NIPPV failure could assist HEMS providers to make the safest decision for patients on whether to initiate NIPPV or proceed directly to endotracheal intubation prior to transport.

The value of pretest probability and modified clinical pulmonary infection score to diagnose ventilator-associated pneumonia.

PubMed

Lauzier, François; Ruest, Annie; Cook, Deborah; Dodek, Peter; Albert, Martin; Shorr, Andrew F; Day, Andrew; Jiang, Xuran; Heyland, Daren

2008-03-01

The aim of the study was to assess the utility of pretest probability and modified clinical pulmonary infection score CPIS in the diagnosis of late-onset ventilator-associated pneumonia (VAP). In 740 adults enrolled in a multicenter randomized trial, intensivists prospectively rated the pretest probability of VAP as low, moderate, or high based on their clinical judgment. The modified CPIS was calculated without considering culture results. Ventilator-associated pneumonia diagnosis was determined by 2 adjudicators using standardized definitions. We analyzed the relationship between pretest likelihood, CPIS, and VAP diagnosis. Among the 739 patients analyzed, 14.5%, 39.6%, and 45.9% had low, moderate, and high pretest probability of VAP. Patients with high pretest probability had a lower PaO2/FiO2 ratio and a larger volume of secretions. High or moderate vs low pretest probability had high sensitivity (0.88; 95% confidence interval [CI], 0.87-0.89) and positive predictive value (0.87; 95% CI, 0.86-0.88) but low specificity (0.27; 95% CI, 0.21-0.35) and negative predictive value (0.29; 95% C,: 0.22-0.37) for the diagnosis of VAP. Therefore, 71% of patients who had a low pretest probability were actually infected (1 - negative predictive value). The area under the receiver operating characteristic curve for the modified CPIS was not significant (0.47; 95% CI, 0.42-0.53), meaning that no score threshold was clinically useful. Pretest probability and a modified CPIS, which excludes culture results, are of limited utility in the diagnosis of late-onset VAP.

Aerophagia increases the risk of ventilator-associated pneumonia in critically-ill patients.

PubMed

Destrebecq, A L; Elia, G; Terzoni, S; Angelastri, G; Brenna, G; Ricci, C; Spanu, P; Umbrello, M; Iapichino, G

2014-04-01

Gastric residual volume in ventilated critically ill may complicate gut function. Over the years studies suggested to tolerate progressively higher residuals. The relationship between such volumes and the development of ventilator-associated pneumonia (VAP) is still under debate. No reports deal with the relevant anecdotal finding of air in the stomach. Aim of the present study is to test the role of air in the development of VAPs. Prospective observational trial in consecutive patients with a predicted length of ICU stay >3 days. The first 8 days of stay were studied. Sedation was targeted to have awake/cooperative patients. Early enteral nutrition was attempted. Gastric content was measured every 4 hours by 60 mL-syringe suction. Upper digestive intolerance (UDI) was defined as >2 consecutive findings of liquid >200 mL, aerophagia was defined as >2 consecutive findings of air >150 mL. Three hundred sixty-four patients enrolled, 43 developed VAP (11.8%). Patients were sedated with enteral (76% total time), intravenous (6%) or both (28%) drugs. Conscious sedation was achieved in 54% of the observations. 326 patients began enteral nutrition during the first 24 hours (1000 kcal median calorie intake). 10% developed UDI, 15% had aerophagia. No association was found between VAP and UDI (P=0.78), while significant association was found between VAP and aerophagia (OR=2.88, P<0.01). A sensitivity analysis, excluding patients admitted with respiratory infection, confirmed the results. High volumes of air in the stomach significantly increased the risk of developing VAP, while gastric residual volumes were not associated with the incidence of pneumonia.

14 CFR 1215.101 - Scope.

Code of Federal Regulations, 2011 CFR

2011-01-01

... (TDRSS) Use and Reimbursement Policy for Non-U.S. Government Users § 1215.101 Scope. This subpart sets forth the policy governing TDRSS services provided to non-U.S. government users and the reimbursement for rendering such services. It excludes TDRSS services provided as standard or optional services to...

An Evaluation of Air Force Food Service Operations at Travis Air Force Base

DTIC Science & Technology

1974-06-01

food service system as represented by food service operations...was base level feeding requirements, excluding non-appropriated fund food service activities, hospital dining facilities and patient feeding, and...inflight food service . Following completion of these studies, proposed solutions to the problems were actually implemented and evaluated in a food service experiment at Travis

32 CFR 220.6 - Certain payers excluded.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 32 National Defense 2 2012-07-01 2012-07-01 false Certain payers excluded. 220.6 Section 220.6 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES § 220.6 Certain...

32 CFR 220.6 - Certain payers excluded.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 32 National Defense 2 2011-07-01 2011-07-01 false Certain payers excluded. 220.6 Section 220.6 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES § 220.6 Certain...

32 CFR 220.6 - Certain payers excluded.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 32 National Defense 2 2010-07-01 2010-07-01 false Certain payers excluded. 220.6 Section 220.6 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES § 220.6 Certain...

32 CFR 220.6 - Certain payers excluded.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 32 National Defense 2 2014-07-01 2014-07-01 false Certain payers excluded. 220.6 Section 220.6 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES § 220.6 Certain...

32 CFR 220.6 - Certain payers excluded.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 32 National Defense 2 2013-07-01 2013-07-01 false Certain payers excluded. 220.6 Section 220.6 National Defense Department of Defense (Continued) OFFICE OF THE SECRETARY OF DEFENSE (CONTINUED) MISCELLANEOUS COLLECTION FROM THIRD PARTY PAYERS OF REASONABLE CHARGES FOR HEALTHCARE SERVICES § 220.6 Certain...

5 CFR 894.302 - What is an excluded position?

Code of Federal Regulations, 2010 CFR

2010-01-01

... 5 Administrative Personnel 2 2010-01-01 2010-01-01 false What is an excluded position? 894.302 Section 894.302 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES DENTAL AND VISION INSURANCE PROGRAM Eligibility § 894.302 What is an...

5 CFR 894.302 - What is an excluded position?

Code of Federal Regulations, 2011 CFR

2011-01-01

... 5 Administrative Personnel 2 2011-01-01 2011-01-01 false What is an excluded position? 894.302 Section 894.302 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES DENTAL AND VISION INSURANCE PROGRAM Eligibility § 894.302 What is an...

20 CFR 628.535 - Limitations on job search assistance.

Code of Federal Regulations, 2010 CFR

2010-04-01

.... Job search assistance is designed to give a participant skills in acquiring full time employment. (See... excluding tutoring, standalone skill assessment, counseling, work experience and case management. (See § 627... training services listed in JTPA section 204(b)(1) of the Act, excluding standalone skill assessment...

The power of local action in occupational health: the adoption of local exhaust ventilation in the Chicago tuckpointing trade

PubMed Central

2016-01-01

Background Silica is a pervasive and potentially deadly occupational hazard in construction. The occupational risk posed by silica has long been known, but efforts to use engineering controls to minimize dust generation in tuckpointing operations, a masonry restoration specialty, have been slow. Objectives The objective of this study is to explore how local innovation in occupational safety and health may emerge, absent the establishment of national standards. Method This study uses a case study to explore the adoption of local exhaust ventilation in tuckpointing operations in the Chicago area. Sources of data for this research include interviews with a diverse range of key informants and the review of archival material. Results This case study found local unions, municipal regulators, contractors, and major public users of construction services played a central role in the events and milestones that led to the early adoption of local exhaust ventilation in Chicago. The adoption of local exhaust ventilation technology in Chicago demonstrates the potential for local actors to fill an important void when rulemaking in vital areas of occupational of health impedes effective national regulation. PMID:27362634

5 CFR 550.708 - Creditable service.

Code of Federal Regulations, 2010 CFR

2010-01-01

... (e) Service performed with the government of the District of Columbia by an individual first employed by that government before October 1, 1987, excluding service as a teacher or librarian of the public... 5 Administrative Personnel 1 2010-01-01 2010-01-01 false Creditable service. 550.708 Section 550...

20 CFR 404.1210 - Optionally excluded services.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Section 404.1210 Employees' Benefits SOCIAL SECURITY ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND... selectively by coverage groups. They are: (a) Services in any class or classes of elective positions; (b) Services in any class or classes of part-time positions; (c) Services in any class or classes of positions...

20 CFR 404.1026 - Work for a church or qualified church-controlled organization.

Code of Federal Regulations, 2012 CFR

2012-04-01

... OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1026 Work for a church or qualified church-controlled... in this section, your employer may elect to have your services excluded from employment. You would...

20 CFR 404.1026 - Work for a church or qualified church-controlled organization.

Code of Federal Regulations, 2014 CFR

2014-04-01

... OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1026 Work for a church or qualified church-controlled... in this section, your employer may elect to have your services excluded from employment. You would...

20 CFR 404.1026 - Work for a church or qualified church-controlled organization.

Code of Federal Regulations, 2013 CFR

2013-04-01

... OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1026 Work for a church or qualified church-controlled... in this section, your employer may elect to have your services excluded from employment. You would...

20 CFR 404.1026 - Work for a church or qualified church-controlled organization.

Code of Federal Regulations, 2011 CFR

2011-04-01

... OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1026 Work for a church or qualified church-controlled... in this section, your employer may elect to have your services excluded from employment. You would...

20 CFR 404.1026 - Work for a church or qualified church-controlled organization.

Code of Federal Regulations, 2010 CFR

2010-04-01

... OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1026 Work for a church or qualified church-controlled... in this section, your employer may elect to have your services excluded from employment. You would...

75 FR 10174 - Source-Specific Federal Implementation Plan for Navajo Generating Station; Navajo Nation

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-05

... Reclamation, the Los Angeles Department of Water and Power, the Arizona Public Service, the Nevada Power... over any normal 6 minute period, excluding condensed water vapour, and 40% opacity, averaged over 6 minutes, during absorber upset transition periods. The final opacity standard excludes uncombined water...

29 CFR 552.102 - Live-in domestic service employees.

Code of Federal Regulations, 2014 CFR

2014-07-01

.... But this exemption does not excuse the employer from paying the live-in worker at the applicable... employee and the employer may exclude, by agreement between themselves, the amount of sleeping time, meal... relating to meals and sleeping) to be excluded from hours worked, the periods must be of sufficient...

75 FR 77666 - General Motors Company, Formerly Known as General Motors Corporation, Technical Center, Including...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-13

.../Professional Services, Excluding Workers of the Global Purchasing and Supply Chain Division, Warren, MI...., and Tek Systems, excluding workers of the Global Purchasing and Supply Chain Division, Warren... Purchasing and Supply Chain Division, Warren, Michigan, who became totally or partially separated from...

20 CFR 668.650 - Can INA grantees exclude segments of the eligible population?

Code of Federal Regulations, 2014 CFR

2014-04-01

... eligible population? 668.650 Section 668.650 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION... eligible population? (a) No, INA grantees cannot exclude segments of the eligible population. INA grantees... population within the service area for which the grantee was designated an equitable opportunity to receive...

20 CFR 668.650 - Can INA grantees exclude segments of the eligible population?

Code of Federal Regulations, 2012 CFR

2012-04-01

... eligible population? 668.650 Section 668.650 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION... eligible population? (a) No, INA grantees cannot exclude segments of the eligible population. INA grantees... population within the service area for which the grantee was designated an equitable opportunity to receive...

20 CFR 668.650 - Can INA grantees exclude segments of the eligible population?

Code of Federal Regulations, 2013 CFR

2013-04-01

... eligible population? 668.650 Section 668.650 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION... eligible population? (a) No, INA grantees cannot exclude segments of the eligible population. INA grantees... population within the service area for which the grantee was designated an equitable opportunity to receive...

Study of Effort to Exclude Planned Parenthood from Participation in Combined Federal Campaign. Report Prepared by the Staff of the Subcommittee on Civil Service of the Committee on Post Office and Civil Service. House of Representatives, 98th Congress, 1st Session. Committee Print No. 98-8.

ERIC Educational Resources Information Center

1983

Presented in this report is an account of the attempt made by the Director of the United States Office of Personnel Managment (OPM) to exclude the Planned Parenthood Federation of America (PPFA) from participation in the Combined Federal Campaign (CFC). The CFC is the annual charitable fundraising drive conducted among federal employees and…

42 CFR 411.15 - Particular services excluded from coverage.

Code of Federal Regulations, 2014 CFR

2014-10-01

... magnification of images for impaired vision. (2) Exceptions. (i) Post-surgical prosthetic lenses customarily... condition and clinical status. (j) Personal comfort services, except as necessary for the palliation or...

42 CFR 411.15 - Particular services excluded from coverage.

Code of Federal Regulations, 2013 CFR

2013-10-01

... magnification of images for impaired vision. (2) Exceptions. (i) Post-surgical prosthetic lenses customarily... condition and clinical status. (j) Personal comfort services, except as necessary for the palliation or...

42 CFR 411.15 - Particular services excluded from coverage.

Code of Federal Regulations, 2012 CFR

2012-10-01

... magnification of images for impaired vision. (2) Exceptions. (i) Post-surgical prosthetic lenses customarily... condition and clinical status. (j) Personal comfort services, except as necessary for the palliation or...

42 CFR 411.15 - Particular services excluded from coverage.

Code of Federal Regulations, 2011 CFR

2011-10-01

... magnification of images for impaired vision. (2) Exceptions. (i) Post-surgical prosthetic lenses customarily... condition and clinical status. (j) Personal comfort services, except as necessary for the palliation or...

37 CFR 6.1 - International schedule of classes of goods and services.

Code of Federal Regulations, 2010 CFR

2010-07-01

... generating, cooking, refrigerating, drying, ventilating, water supply and sanitary purposes. 12. Vehicles; apparatus for locomotion by land, air or water. 13. Firearms; ammunition and projectiles; explosives... goods; travel arrangement. 40. Treatment of materials. 41. Education; providing of training...

37 CFR 6.1 - International schedule of classes of goods and services.

Code of Federal Regulations, 2011 CFR

2011-07-01

... generating, cooking, refrigerating, drying, ventilating, water supply and sanitary purposes. 12. Vehicles; apparatus for locomotion by land, air or water. 13. Firearms; ammunition and projectiles; explosives... goods; travel arrangement. 40. Treatment of materials. 41. Education; providing of training...

Continuous aspiration of subglottic secretions in the prevention of ventilator-associated pneumonia in the postoperative period of major heart surgery.

PubMed

Bouza, Emilio; Pérez, María Jesús; Muñoz, Patricia; Rincón, Cristina; Barrio, José María; Hortal, Javier

2008-11-01

Aspiration of endotracheal secretions is a major step in the prevention of ventilator-associated pneumonia (VAP). We compared conventional and continuous aspiration of subglottic secretions (CASS) procedures in ventilated patients after major heart surgery (MHS). Randomized comparison during a 2-year period. A total of 714 patients were randomized (24 patients were excluded from the study; 359 CASS patients; 331 control subjects). The results for CASS patients and control subjects (per protocol and intention-to-treat analysis) were as follows: VAP incidence, 3.6% vs 5.3% (p = 0.2) and 3.8% vs 5.1%, respectively; incidence density, 17.9 vs 27.6 episodes per 1,000 days of mechanical ventilation (MV) [p = 0.18] and 18.9 vs 28.7 episodes per 1,000 days of MV, respectively; hospital antibiotic use in daily defined doses (DDDs), 1,213 vs 1,932 (p < 0.001) and 1,392 vs 1,932, respectively (p < 0.001). In patients who had received mechanical ventilation for > 48 h, the comparisons of CASS patients and control subjects were as follows: VAP incidence, 26.7% vs 47.5% (p = 0.04), respectively; incidence density, 31.5 vs 51.6 episodes per 1,000 days of MV, respectively (p = 0.03); median length of ICU stay, 7 vs 16.5 days (p = 0.01), respectively; hospital antibiotic use, 1,206 vs 1,877 DDD (p < 0.001), respectively; Clostridium difficile-associated diarrhea, 6.7% vs 12.5% (p = 0.3), respectively; and overall mortality rate, 44.4% vs 52.5% (p = 0.3), respectively. Reintubation increased the risk of VAP (relative risk [RR], 6.07; 95% confidence interval [CI], 2.20 to 16.60; p < 0.001), while CASS was the only significant protective factor (RR, 0.40; 95% CI, 0.16 to 0.99; p = 0.04). No complications related to CASS were observed. The cost of the CASS tube was 9 vs 1.5 euro for the conventional tube. CASS is a safe procedure that reduces the use of antimicrobial agents in the overall population and the incidence of VAP in patients who are at risk. CASS use should be encouraged, at least in patients undergoing MHS.

The dynamics of the pulmonary microbiome during mechanical ventilation in the intensive care unit and the association with occurrence of pneumonia.

PubMed

Zakharkina, Tetyana; Martin-Loeches, Ignacio; Matamoros, Sébastien; Povoa, Pedro; Torres, Antoni; Kastelijn, Janine B; Hofstra, Jorrit J; de Wever, B; de Jong, Menno; Schultz, Marcus J; Sterk, Peter J; Artigas, Antonio; Bos, Lieuwe D J

2017-09-01

Ventilator-associated pneumonia (VAP) is the most common nosocomial infections in patients admitted to the ICU. The adapted island model predicts several changes in the respiratory microbiome during intubation and mechanical ventilation. We hypothesised that mechanical ventilation and antibiotic administration decrease the diversity of the respiratory microbiome and that these changes are more profound in patients who develop VAP. Intubated and mechanically ventilated ICU-patients were included. Tracheal aspirates were obtained three times a week. 16S rRNA gene sequencing with the Roche 454 platform was used to measure the composition of the respiratory microbiome. Associations were tested with linear mixed model analysis and principal coordinate analysis. 111 tracheal aspirates were obtained from 35 patients; 11 had VAP, 18 did not have VAP. Six additional patients developed pneumonia within the first 48 hours after intubation. Duration of mechanical ventilation was associated with a decrease in α diversity (Shannon index; fixed-effect regression coefficient (β): -0.03 (95% CI -0.05 to -0.005)), but the administration of antibiotic therapy was not (fixed-effect β: 0.06; 95% CI -0.17 to 0.30). There was a significant difference in change of β diversity between patients who developed VAP and control patients for Bray-Curtis distances (p=0.03) and for Manhattan distances (p=0.04). Burkholderia, Bacillales and, to a lesser extent, Pseudomonadales positively correlated with the change in β diversity. Mechanical ventilation, but not antibiotic administration, was associated with changes in the respiratory microbiome. Dysbiosis of microbial communities in the respiratory tract was most profound in patients who developed VAP. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

26 CFR 31.3121(c)-1 - Included and excluded services.

Code of Federal Regulations, 2011 CFR

2011-04-01

... enrolled and is regularly attending classes at a university, to perform domestic service for the club and to keep the club's books. The domestic services performed by D for the AB Club do not constitute employment, and his services as the club's bookkeeper constitute employment. D receives a payment at the end...

26 CFR 31.3121(c)-1 - Included and excluded services.

Code of Federal Regulations, 2013 CFR

2013-04-01

... enrolled and is regularly attending classes at a university, to perform domestic service for the club and to keep the club's books. The domestic services performed by D for the AB Club do not constitute employment, and his services as the club's bookkeeper constitute employment. D receives a payment at the end...

26 CFR 31.3121(c)-1 - Included and excluded services.

Code of Federal Regulations, 2010 CFR

2010-04-01

... enrolled and is regularly attending classes at a university, to perform domestic service for the club and to keep the club's books. The domestic services performed by D for the AB Club do not constitute employment, and his services as the club's bookkeeper constitute employment. D receives a payment at the end...

26 CFR 31.3121(c)-1 - Included and excluded services.

Code of Federal Regulations, 2014 CFR

2014-04-01

... enrolled and is regularly attending classes at a university, to perform domestic service for the club and to keep the club's books. The domestic services performed by D for the AB Club do not constitute employment, and his services as the club's bookkeeper constitute employment. D receives a payment at the end...

26 CFR 31.3121(c)-1 - Included and excluded services.

Code of Federal Regulations, 2012 CFR

2012-04-01

... enrolled and is regularly attending classes at a university, to perform domestic service for the club and to keep the club's books. The domestic services performed by D for the AB Club do not constitute employment, and his services as the club's bookkeeper constitute employment. D receives a payment at the end...

Assessment of a respiratory face mask for capturing air pollutants and pathogens including human influenza and rhinoviruses.

PubMed

Zhou, S Steve; Lukula, Salimatu; Chiossone, Cory; Nims, Raymond W; Suchmann, Donna B; Ijaz, M Khalid

2018-03-01

Prevention of infection with airborne pathogens and exposure to airborne particulates and aerosols (environmental pollutants and allergens) can be facilitated through use of disposable face masks. The effectiveness of such masks for excluding pathogens and pollutants is dependent on the intrinsic ability of the masks to resist penetration by airborne contaminants. This study evaluated the relative contributions of a mask, valve, and Micro Ventilator on aerosol filtration efficiency of a new N95 respiratory face mask. The test mask was challenged, using standardized methods, with influenza A and rhinovirus type 14, bacteriophage ΦΧ174, Staphylococcus aureus ( S . aureus ), and model pollutants. The statistical significance of results obtained for different challenge microbial agents and for different mask configurations (masks with operational or nonoperational ventilation fans and masks with sealed Smart Valves) was assessed. The results demonstrate >99.7% efficiency of each test mask configuration for exclusion of influenza A virus, rhinovirus 14, and S . aureus and >99.3% efficiency for paraffin oil and sodium chloride (surrogates for PM 2.5 ). Statistically significant differences in effectiveness of the different mask configurations were not identified. The efficiencies of the masks for excluding smaller-size (i.e., rhinovirus and bacteriophage ΦΧ174) vs. larger-size microbial agents (influenza virus, S . aureus ) were not significantly different. The masks, with or without features intended for enhancing comfort, provide protection against both small- and large-size pathogens. Importantly, the mask appears to be highly efficient for filtration of pathogens, including influenza and rhinoviruses, as well as the fine particulates (PM 2.5 ) present in aerosols that represent a greater challenge for many types of dental and surgical masks. This renders this individual-use N95 respiratory mask an improvement over the former types of masks for protection against a variety of environmental contaminants including PM 2.5 and pathogens such as influenza and rhinoviruses.

Assessment of a respiratory face mask for capturing air pollutants and pathogens including human influenza and rhinoviruses

PubMed Central

Zhou, S. Steve; Lukula, Salimatu; Chiossone, Cory; Nims, Raymond W.; Suchmann, Donna B.

2018-01-01

Background Prevention of infection with airborne pathogens and exposure to airborne particulates and aerosols (environmental pollutants and allergens) can be facilitated through use of disposable face masks. The effectiveness of such masks for excluding pathogens and pollutants is dependent on the intrinsic ability of the masks to resist penetration by airborne contaminants. This study evaluated the relative contributions of a mask, valve, and Micro Ventilator on aerosol filtration efficiency of a new N95 respiratory face mask. Methods The test mask was challenged, using standardized methods, with influenza A and rhinovirus type 14, bacteriophage ΦΧ174, Staphylococcus aureus (S. aureus), and model pollutants. The statistical significance of results obtained for different challenge microbial agents and for different mask configurations (masks with operational or nonoperational ventilation fans and masks with sealed Smart Valves) was assessed. Results The results demonstrate >99.7% efficiency of each test mask configuration for exclusion of influenza A virus, rhinovirus 14, and S. aureus and >99.3% efficiency for paraffin oil and sodium chloride (surrogates for PM2.5). Statistically significant differences in effectiveness of the different mask configurations were not identified. The efficiencies of the masks for excluding smaller-size (i.e., rhinovirus and bacteriophage ΦΧ174) vs. larger-size microbial agents (influenza virus, S. aureus) were not significantly different. Conclusions The masks, with or without features intended for enhancing comfort, provide protection against both small- and large-size pathogens. Importantly, the mask appears to be highly efficient for filtration of pathogens, including influenza and rhinoviruses, as well as the fine particulates (PM2.5) present in aerosols that represent a greater challenge for many types of dental and surgical masks. This renders this individual-use N95 respiratory mask an improvement over the former types of masks for protection against a variety of environmental contaminants including PM2.5 and pathogens such as influenza and rhinoviruses. PMID:29707364

[Sleep-apnea syndrome, mechanical ventilation and critical care in Archivos de Bronconeumología (December 2009-December 2010)].

PubMed

Abad Fernández, Araceli; Pumarega, Irene Cano; Hernández, Concepción; Sampol, Gabriel; Terán-Santos, Joaquín

2011-01-01

The present study aims to review all the major articles on respiratory sleep disorders, mechanical ventilation, and respiratory critical care published in the last year in Archivos de bronconeumología. Between December 2009 and November 2010, 15 studies on these topics were published in Archivos de bronconeumología. Ten of these studies dealt with respiratory sleep disorders, consisting of six original articles, one special article, one review article, one letter to the editor and one supplement on chronic obstructive pulmonary disease and its association with sleep apneas. Five articles were published on non-invasive mechanical ventilation: one editorial, one special article, one article in a supplement and two original articles. As in previous years, there was a marked difference in the number of articles published on non-invasive mechanical ventilation and sleep-apnea syndrome, with a greater number of articles being published on the latter. Although some articles highlight the importance of the place where ventilation is commenced, no study specifically dealing with intermediate care units was published in Archivos de bronconeumología in 2010. This absence could be interpreted as a result of the low implantation of this type of unit in Spain, contrasting with the high activity undertaken in this field by pneumology services. Copyright © 2011 Sociedad Española de Neumología y Cirugía Torácica. Published by Elsevier Espana. All rights reserved.

Testing of mechanical ventilators and infant incubators in healthcare institutions.

PubMed

Badnjevic, Almir; Gurbeta, Lejla; Jimenez, Elvira Ruiz; Iadanza, Ernesto

2017-01-01

The medical device industry has grown rapidly and incessantly over the past century. The sophistication and complexity of the designed instrumentation is nowadays rising and, with it, has also increased the need to develop some better, more effective and efficient maintenance processes, as part of the safety and performance requirements. This paper presents the results of performance tests conducted on 50 mechanical ventilators and 50 infant incubators used in various public healthcare institutions. Testing was conducted in accordance to safety and performance requirements stated in relevant international standards, directives and legal metrology policies. Testing of output parameters for mechanical ventilators was performed in 4 measuring points while testing of output parameters for infant incubators was performed in 7 measuring points for each infant incubator. As performance criteria, relative error of output parameters for mechanical ventilators and absolute error of output parameters for infant incubators was calculated. The ranges of permissible error, for both groups of devices, are regulated by the Rules on Metrological and Technical Requirements published in the Official Gazette of Bosnia and Herzegovina No. 75/14, which are defined based on international recommendations, standards and guidelines. All ventilators and incubators were tested by etalons calibrated in an ISO 17025 accredited laboratory, which provides compliance to international standards for all measured parameters.The results show that 30% of the tested medical devices are not operating properly and should be serviced, recalibrated and/or removed from daily application.

[Basic life support in pediatrics].

PubMed

Calvo Macías, A; Manrique Martínez, I; Rodríguez Núñez, A; López-Herce Cid, J

2006-09-01

Basic life support (BLS) is the combination of maneuvers that identifies the child in cardiopulmonary arrest and initiates the substitution of respiratory and circulatory function, without the use of technical adjuncts, until the child can receive more advanced treatment. BLS includes a sequence of steps or maneuvers that should be performed sequentially: ensuring the safety of rescuer and child, assessing unconsciousness, calling for help, positioning the victim, opening the airway, assessing breathing, ventilating, assessing signs of circulation and/or central arterial pulse, performing chest compressions, activating the emergency medical service system, and checking the results of resuscitation. The most important changes in the new guidelines are the compression: ventilation ratio and the algorithm for relieving foreign body airway obstruction. A compression/ ventilation ratio of 30:2 will be recommended for lay rescuers of infants, children and adults. Health professionals will use a compression: ventilation ratio of 15:2 for infants and children. If the health professional is alone, he/she may also use a ratio of 30:2 to avoid fatigue. In the algorithm for relieving foreign body airway obstruction, when the child becomes unconscious, the maneuvers will be similar to the BLS sequence with chest compressions (functioning as a deobstruction procedure) and ventilation, with reassessment of the mouth every 2 min to check for a foreign body, and evaluation of breathing and the presence of vital signs. BLS maneuvers are easy to learn and can be performed by anyone with adequate training. Therefore, BLS should be taught to all citizens.

7 CFR 225.5 - Payments to State agencies and use of Program funds.

Code of Federal Regulations, 2013 CFR

2013-01-01

... agencies for the administration of Child Nutrition Programs, and exclude such funds from State budget... NUTRITION SERVICE, DEPARTMENT OF AGRICULTURE CHILD NUTRITION PROGRAMS SUMMER FOOD SERVICE PROGRAM State...

7 CFR 225.5 - Payments to State agencies and use of Program funds.

Code of Federal Regulations, 2014 CFR

2014-01-01

... agencies for the administration of Child Nutrition Programs, and exclude such funds from State budget... NUTRITION SERVICE, DEPARTMENT OF AGRICULTURE CHILD NUTRITION PROGRAMS SUMMER FOOD SERVICE PROGRAM State...

7 CFR 225.5 - Payments to State agencies and use of Program funds.

Code of Federal Regulations, 2012 CFR

2012-01-01

... agencies for the administration of Child Nutrition Programs, and exclude such funds from State budget... NUTRITION SERVICE, DEPARTMENT OF AGRICULTURE CHILD NUTRITION PROGRAMS SUMMER FOOD SERVICE PROGRAM State...

[Changes in respiratory function tests of healthy miners in accordance with length of service].

PubMed

Shishkin, G S; Ustiuzhaninova, N V; Krasulina, G P

2010-01-01

The study covered respiratory function tests in healthy miners with variable length of service. Findings are that the first year of mining is characterized by slower interchange of gases in respiratory parts of lungs, by induced protective reaction that increases dilution of inspired air. The years from second to fifth demonstrate stabilized changes and external respiratory system fixed in new functional state kept over next 15-18 years. After 20 years of service in mine, the external respiration system becomes overstrained with intensified compensatory pulmonary ventilation and protective reaction.

Keep Kids in School: A Collaborative Community Effort to Increase Compliance With State-Mandated Health Requirements.

PubMed

Rogers, Valerie; Salzeider, Christine; Holzum, Laura; Milbrandt, Tracy; Zahnd, Whitney; Puczynski, Mark

2016-05-01

It is important that collaborative relationships exist in a community to improve access to needed services for children. Such partnerships foster preventive services, such as immunizations, and other services that protect the health and well-being of all children. A collaborative relationship in Illinois involving an academic health center, a school district, and county health department to address noncompliance with health examination and immunization requirements was formed. Parents were additional partners. Examinations, screenings, and immunizations increased from previous year baselines. Greater fulfillment of health exam mandates resulted in fewer students (39% fewer) excluded from admission to school. The type of partnerships described is feasible and can result in improved health care for school-aged children who otherwise might be excluded both from health services and from school. © 2016, American School Health Association.

45 CFR 30.3 - Antitrust, fraud, exception in the account of an accountable official, and interagency claims...

Code of Federal Regulations, 2010 CFR

2010-10-01

... accountable official, and interagency claims excluded. 30.3 Section 30.3 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CLAIMS COLLECTION General Provisions § 30.3 Antitrust, fraud, exception in the account of an accountable official, and interagency claims excluded. (a) Claims involving...

5 CFR 894.303 - What happens to my enrollment if I transfer to an excluded position?

Code of Federal Regulations, 2010 CFR

2010-01-01

... 5 Administrative Personnel 2 2010-01-01 2010-01-01 false What happens to my enrollment if I transfer to an excluded position? 894.303 Section 894.303 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES DENTAL AND VISION INSURANCE...

5 CFR 894.303 - What happens to my enrollment if I transfer to an excluded position?

Code of Federal Regulations, 2011 CFR

2011-01-01

... 5 Administrative Personnel 2 2011-01-01 2011-01-01 false What happens to my enrollment if I transfer to an excluded position? 894.303 Section 894.303 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) FEDERAL EMPLOYEES DENTAL AND VISION INSURANCE...

Pump room level, looking west in the service bay area. ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

Pump room level, looking west in the service bay area. Cable trays and two ventilation fans (part of the evaporative-cooling system) are visible at right. The vacuum pump is in the center in front of a concrete partition, and a water discharge pipe is visible beyond the partition at left - Wellton-Mohawk Irrigation System, Pumping Plant No. 1, Bounded by Gila River & Union Pacific Railroad, Wellton, Yuma County, AZ

48 CFR 552.270-9 - Inspection-Right of Entry.

Code of Federal Regulations, 2010 CFR

2010-10-01

... for asbestos fibers; (2) Inspecting the heating, ventilation and air conditioning system, maintenance... 48 Federal Acquisition Regulations System 4 2010-10-01 2010-10-01 false Inspection-Right of Entry. 552.270-9 Section 552.270-9 Federal Acquisition Regulations System GENERAL SERVICES ADMINISTRATION...

42 CFR 419.22 - Hospital outpatient services excluded from payment under the hospital outpatient prospective...

Code of Federal Regulations, 2010 CFR

2010-10-01

...) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (c) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act. (d) Certified nurse-midwife services, as defined in section 1861(gg) of the Act. (e) Services of qualified...

42 CFR 419.22 - Hospital outpatient services excluded from payment under the hospital outpatient prospective...

Code of Federal Regulations, 2012 CFR

2012-10-01

... basis. (b) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (c) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act. (d) Certified nurse-midwife services, as defined in section 1861(gg) of the Act. (e) Services of...

42 CFR 419.22 - Hospital outpatient services excluded from payment under the hospital outpatient prospective...

Code of Federal Regulations, 2011 CFR

2011-10-01

...) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (c) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act. (d) Certified nurse-midwife services, as defined in section 1861(gg) of the Act. (e) Services of qualified...

47 CFR 54.501 - Eligible recipients.

Code of Federal Regulations, 2011 CFR

2011-10-01

... SERVICE Universal Service Support for Schools and Libraries § 54.501 Eligible recipients. (a) Schools. (1... discounts under this subpart. (b) Libraries. (1) Only libraries eligible for assistance from a State library administrative agency under the Library Services and Technology Act (Pub. L. 104-208) and not excluded under...

42 CFR 409.49 - Excluded services.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... an aid in the diagnosis, treatment or prevention of disease or other condition or for the relief of pain or suffering or to control or improve any physiological pathologic condition. (2) A biological is...

42 CFR 409.49 - Excluded services.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... an aid in the diagnosis, treatment or prevention of disease or other condition or for the relief of pain or suffering or to control or improve any physiological pathologic condition. (2) A biological is...

42 CFR 409.49 - Excluded services.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... an aid in the diagnosis, treatment or prevention of disease or other condition or for the relief of pain or suffering or to control or improve any physiological pathologic condition. (2) A biological is...

42 CFR 409.49 - Excluded services.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM... an aid in the diagnosis, treatment or prevention of disease or other condition or for the relief of pain or suffering or to control or improve any physiological pathologic condition. (2) A biological is...

77 FR 12848 - Medicare Program; Solicitation of Independent Accrediting Organizations To Participate in the...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-02

...)(4)(B) (excluding x-ray, ultrasound, and fluoroscopy), as specified by the Secretary in consultation... imaging services as ``imaging and computer-assisted imaging services, including x-ray, ultrasound...

Acquisition and retention of basic life support skills in an untrained population using a personal resuscitation manikin and video self-instruction (VSI).

PubMed

Nielsen, Anne Møller; Henriksen, Mikael J V; Isbye, Dan Lou; Lippert, Freddy K; Rasmussen, Lars Simon

2010-09-01

Video-based self-instruction (VSI) with a 24-min DVD and a personal resuscitation manikin solves some of the barriers associated with traditional basic life support (BLS) courses. No accurate assessment of the actual improvement in skills after attending a VSI course has been determined, and in this study we assess the skill improvement in laypersons undergoing VSI. The BLS skills of 68 untrained laypersons (high school students, their teachers and persons excluded from mainstream society) were assessed using the Laerdal ResusciAnne and PC Skill Reporting System 2.0 in a 3 min test. A total score (12-48 points) was calculated and 12 different variables were recorded. The participants attended a 24-min VSI course (MiniAnne, Laerdal) and took home the DVD and manikin for optional subsequent self-training. We repeated the test 3 1/2-4 months later. There was a significant increase in the total score (p<0.0001) from 26.5 to 34 points. The participants performed significantly better in checking responsiveness, opening the airway, checking for respiration and using the correct compression/ventilation ratio (all p-values<0.001). The compression depth improved from 38 mm to 49.5 mm and the total number of compressions increased from 67 to 141. The ventilation volume and the total number of ventilations increased, and total "hands-off" time decreased from 120.5 s to 85 s. Untrained laypersons attending a 24 min DVD-based BLS course have a significantly improved BLS performance after 3 1/2-4 months compared to pre-test skill performance. Especially the total number of compressions improved and the hands-off time decreased. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

[The role of endotracheal aspiration in the diagnosis of ventilator associated pneumonia].

PubMed

Gürgün, Alev; Korkmaz Ekren, Pervin; Bacakoğlu, Feza; Başoğlu, Ozen Kaçmaz; Dirican, Nigar; Aydemir, Şöhret; Nart, Deniz; Sayıner, Abdullah

2013-01-01

Ventilator associated pneumonia (VAP) is one of the most important causes of mortality in patients treated with invasive mechanical ventilation (IMV) in intensive care unit (ICU). Microbiological examinations are required as clinical and radiological findings are usually insufficient in the diagnosis. Twenty four patients who were receiving IMV because of respiratory failure, had a Clinical Pulmonary Infection Score (CPIS) of ≥ 6 in the follow-up and died with the suspicion of VAP were enrolled in our study. Six patients were excluded as post-mortem biopsy could not be performed. The patients who had pre-mortem CPIS ≥ 6, in whom a causative organism was identified from the culture of post-mortem lung biopsy and/or histopathological examination of lung biopsy was compatible with pneumonia were diagnosed as VAP. In the 18 patients in whom a post-mortem lung biopsy was performed, quantitative culture results of endotracheal aspirate performed 48 hours prior to death were compared with microbiological and histopathological results of post-mortem lung biopsy specimens, and the role of endotracheal aspirate in the diagnosis of VAP was evaluated retrospectively. Out of 18 patients (12 men, mean age 67.0 ± 13.0 years) included in the study, 11 (61.1%) were diagnosed as VAP. The quantitative culture of endotracheal aspirate was positive in 9 (81.8%) out of 11 patients diagnosed as VAP. The sensitivity, specificity, positive and negative predictive values of endotracheal aspirate culture for identifying VAP were found to be 81.8%, 14.3%, 60.0% and 33.3%, respectively. Our study shown that quantitative culture of endotracheal aspirate is a practical and reliable method that can be used for the diagnosis of VAP in patients receiving IMV in ICU and having CPIS ≥ 6.

Ultrafine particles and nitrogen oxides generated by gas and electric cooking.

PubMed

Dennekamp, M; Howarth, S; Dick, C A; Cherrie, J W; Donaldson, K; Seaton, A

2001-08-01

To measure the concentrations of particles less than 100 nm diameter and of oxides of nitrogen generated by cooking with gas and electricity, to comment on possible hazards to health in poorly ventilated kitchens. Experiments with gas and electric rings, grills, and ovens were used to compare different cooking procedures. Nitrogen oxides (NO(x)) were measured by a chemiluminescent ML9841A NO(x) analyser. A TSI 3934 scanning mobility particle sizer was used to measure average number concentration and size distribution of aerosols in the size range 10-500 nm. High concentrations of particles are generated by gas combustion, by frying, and by cooking of fatty foods. Electric rings and grills may also generate particles from their surfaces. In experiments where gas burning was the most important source of particles, most particles were in the size range 15-40 nm. When bacon was fried on the gas or electric rings the particles were of larger diameter, in the size range 50-100 nm. The smaller particles generated during experiments grew in size with time because of coagulation. Substantial concentrations of NO(X) were generated during cooking on gas; four rings for 15 minutes produced 5 minute peaks of about 1000 ppb nitrogen dioxide and about 2000 ppb nitric oxide. Cooking in a poorly ventilated kitchen may give rise to potentially toxic concentrations of numbers of particles. Very high concentrations of oxides of nitrogen may also be generated by gas cooking, and with no extraction and poor ventilation, may reach concentrations at which adverse health effects may be expected. Although respiratory effects of exposure to NO(x) might be anticipated, recent epidemiology suggests that cardiac effects cannot be excluded, and further investigation of this is desirable.

The effect of flow limitation on the cardiorespiratory response to arousal from sleep under controlled conditions of chemostimulation in healthy older adults.

PubMed

Goff, Elizabeth A; Nicholas, Christian L; Kleiman, Jan; Spear, Owen; Morrell, Mary J; Trinder, John

2012-12-01

The influence of flow limitation on the magnitude of the cardiorespiratory response to arousal from sleep is of interest in older people, because they experience considerable flow limitation and frequent arousals from sleep. We studied older flow-limiting subjects, testing the hypothesis that the cardiorespiratory activation response would be larger when arousal occurred during flow limitation, compared to no flow limitation, and chemical stimuli were controlled. In 11 older adults [mean ± standard deviation (SD) age: 68 ± 5 years] ventilation was stabilized using continuous positive airway pressure, and flow limitation was induced by dialling down the pressure. Partial pressure of end-tidal carbon dioxide (PetCO(2)) was maintained by titration of the inspired CO(2) and hyperoxia was maintained using 40% O(2) balanced with nitrogen. Flow limitation at the time of arousal did not augment cardiovascular activation response (heart rate P = 0.7; systolic blood pressure P = 0.6; diastolic blood pressure P = 0.3), whereas ventilation was greater following arousals during flow limitation compared to no flow limitation (P < 0.001). The pre-post-arousal differences in ventilation reflected significant pre-arousal suppression (due to flow limitation) plus post-arousal activation. In summary, the cardiovascular response to arousal from sleep is not influenced by flow limitation at the time of arousal, when chemical stimuli are controlled in older adults. This finding may contribute to the decreased cardiovascular burden associated with sleep-disordered breathing reported in older adults, although our data do not exclude the possibility that flow limitation in the presence of mild hypoxic hypercapnia could increase the cardiovascular response to arousal. © 2012 European Sleep Research Society.

Nebulization of Antiinfective Agents in Invasively Mechanically Ventilated Adults: A Systematic Review and Meta-analysis.

PubMed

Solé-Lleonart, Candela; Rouby, Jean-Jacques; Blot, Stijn; Poulakou, Garyfallia; Chastre, Jean; Palmer, Lucy B; Bassetti, Matteo; Luyt, Charles-Edouard; Pereira, Jose M; Riera, Jordi; Felton, Tim; Dhanani, Jayesh; Welte, Tobias; Garcia-Alamino, Jose M; Roberts, Jason A; Rello, Jordi

2017-05-01

Nebulization of antiinfective agents is a common but unstandardized practice in critically ill patients. A systematic review of 1,435 studies was performed in adults receiving invasive mechanical ventilation. Two different administration strategies (adjunctive and substitute) were considered clinically relevant. Inclusion was restricted to studies using jet, ultrasonic, and vibrating-mesh nebulizers. Studies involving children, colonized-but-not-infected adults, and cystic fibrosis patients were excluded. Five of the 11 studies included had a small sample size (fewer than 50 patients), and only 6 were randomized. Diversity of case-mix, dosage, and devices are sources of bias. Only a few patients had severe hypoxemia. Aminoglycosides and colistin were the most common antibiotics, being safe regarding nephrotoxicity and neurotoxicity, but increased respiratory complications in 9% (95% CI, 0.01 to 0.18; I = 52%), particularly when administered to hypoxemic patients. For tracheobronchitis, a significant decrease in emergence of resistance was evidenced (risk ratio, 0.18; 95% CI, 0.05 to 0.64; I = 0%). Similar findings were observed in pneumonia by susceptible pathogens, without improvement in mortality or ventilation duration. In pneumonia caused by resistant pathogens, higher clinical resolution (odds ratio, 1.96; 95% CI, 1.30 to 2.96; I = 0%) was evidenced. These findings were not consistently evidenced in the assessment of efficacy against pneumonia caused by susceptible pathogens. Performance of randomized trials evaluating the impact of nebulized antibiotics with more homogeneous populations, standardized drug delivery, predetermined clinical efficacy, and safety outcomes is urgently required. Infections by resistant pathogens might potentially have higher benefit from nebulized antiinfective agents. Nebulization, without concomitant systemic administration of the drug, may reduce nephrotoxicity but may also be associated with higher risk of respiratory complications.

Tumor necrosis factor receptor 1 (TNFRI) for ventilator-associated pneumonia diagnosis by cytokine multiplex analysis.

PubMed

Martin-Loeches, Ignacio; Bos, Lieuwe D; Povoa, Pedro; Ramirez, Paula; Schultz, Marcus J; Torres, Antoni; Artigas, Antonio

2015-12-01

The diagnosis of ventilator-associated pneumonia (VAP) is challenging. An important aspect to improve outcome is early recognition of VAP and the initiation of the appropriate empirical treatment. We hypothesized that biological markers in plasma can rule out VAP at the moment of clinical suspicion and could rule in VAP before the diagnosis can be made clinically. In this prospective study, patients with VAP (n = 24, microbiology confirmed) were compared to controls (n = 19) with a similar duration of mechanical ventilation. Blood samples from the day of VAP diagnosis and 1 and 3 days before were analyzed with a multiplex array for markers of inflammation, coagulation, and apoptosis. The best biomarker combination was selected and the diagnostic accuracy was given by the area under the receiver operating characteristic curve (ROC-AUC). TNF-receptor 1 (TNFRI) and granulocyte colony-stimulating factor (GCSF) were selected as optimal biomarkers at the day of VAP diagnosis, which resulted in a ROC-AUC of 0.96, with excellent sensitivity. Three days before the diagnosis TNFRI and plasminogen activator inhibitor-1 (PAI-1) levels in plasma predicted VAP with a ROC-AUC of 0.79. The slope of IL-10 and PAI-1 resulted in a ROC-AUC of 0.77. These biomarkers improved the classification of the clinical pulmonary infection score when combined. Concentration of TNFRI and PAI-1 and the slope of PAI-1 and IL-10 may be used to predict the development of VAP as early as 3 days before the diagnosis made clinically. TNFRI and GCSF may be used to exclude VAP at the moment of clinical suspicion. Especially TNFRI seems to be a promising marker for the prediction and diagnosis of VAP.

38 CFR 59.80 - Amount of grant.

Code of Federal Regulations, 2011 CFR

2011-07-01

... to the heating, ventilating, air conditioning, or other service distributed through the building via ducts, pipes, wires, or other connecting device. Fixed equipment must be installed during construction... under this part may not include the cost of: (1) Land acquisition; (2) Maintenance or repair work; or (3...

38 CFR 59.80 - Amount of grant.

Code of Federal Regulations, 2013 CFR

2013-07-01

... to the heating, ventilating, air conditioning, or other service distributed through the building via ducts, pipes, wires, or other connecting device. Fixed equipment must be installed during construction... under this part may not include the cost of: (1) Land acquisition; (2) Maintenance or repair work; or (3...

38 CFR 59.80 - Amount of grant.

Code of Federal Regulations, 2012 CFR

2012-07-01

... to the heating, ventilating, air conditioning, or other service distributed through the building via ducts, pipes, wires, or other connecting device. Fixed equipment must be installed during construction... under this part may not include the cost of: (1) Land acquisition; (2) Maintenance or repair work; or (3...

38 CFR 59.80 - Amount of grant.

Code of Federal Regulations, 2014 CFR

2014-07-01

... to the heating, ventilating, air conditioning, or other service distributed through the building via ducts, pipes, wires, or other connecting device. Fixed equipment must be installed during construction... under this part may not include the cost of: (1) Land acquisition; (2) Maintenance or repair work; or (3...

7. DETAIL OF UPPER SECTIONS OF WEST SIDE SHOWING WHITE ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

7. DETAIL OF UPPER SECTIONS OF WEST SIDE SHOWING WHITE INSULATED DUCTWORK VENTILATING CLEAN ROOM AT TOP LEVELS OF MOBILE SERVICE STRUCTURE; VIEW TO NORTHEAST. - Cape Canaveral Air Station, Launch Complex 17, Facility 28417, East end of Lighthouse Road, Cape Canaveral, Brevard County, FL

Ventilation/perfusion single-photon emission computed tomography: a service evaluation.

PubMed

Parekh, Amit; Graham, Richard; Redman, Stewart

2017-08-01

To identify the positive rate and negative predictive value (NPV) of our ventilation/perfusion (V/Q) single-photon emission computed tomography (SPECT) service as respective markers of overcalling (false positives) and undercalling (false negatives). We also identified the indeterminate rate as an indicator of the technical quality of the scans and reporter confidence. V/Q SPECT studies carried out over 5 years were classified into positive, negative and indeterminate results. Patients who had died or had pulmonary emboli on imaging within 3 months of a negative V/Q SPECT were identified as false negatives, from which the NPV was calculated. The total number of positive and indeterminate studies as a proportion of all studies was calculated as the positive and indeterminate rates. The positive rate, NPV and indeterminate rates in nonpregnant patients were 24, 98.7-100 and 3.6%, respectively. The positive rate, NPV and indeterminate rates in pregnant patients were 6.8, 100 and 2.3%, respectively. The positive rate and NPV for nonpregnant patients were similar to the published literature. This suggests that we provide a safe service. The indeterminate rate was slightly higher than the stated guidelines. The study shows that the positive rate and NPV are achievable indicators of potential overcalling and undercalling in a V/Q SPECT service.This is also one of the first studies to report a positive rate in pregnant patients undergoing V/Q SPECT that other institutions can use as a standard when evaluating their services.

[Perioperative stroke following transurethral resection of prostate: high index of suspicion and stabilization of physiological parameters can save lives].

PubMed

Nag, Deb Sanjay; Chatterjee, Abhishek; Samaddar, Devi Prasad; Agarwal, Ajay

2017-01-09

We report a case of a 72 year old hypertensive male who developed severe hypertension followed by neurological deterioration in the immediate postoperative period after transurethral resection of prostate. While arterial blood gas and laboratory tests excluded transurethral resection of prostate syndrome or any other metabolic cause, reduction of blood pressure failed to ameliorate the symptoms. A cranial CT done 4hours after the onset of neurological symptoms revealed bilateral gangliocapsular and right thalamic infarcts. Oral aspirin was advised to prevent early recurrent stroke. Supportive treatment and mechanical ventilation ensured physiological stability and the patient recovered completely over the next few days without any residual neurological deficit. Copyright © 2016. Publicado por Elsevier Editora Ltda.

41 CFR 105-68.325 - What happens if I do business with an excluded person in a covered transaction?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 41 Public Contracts and Property Management 3 2010-07-01 2010-07-01 false What happens if I do business with an excluded person in a covered transaction? 105-68.325 Section 105-68.325 Public Contracts and Property Management Federal Property Management Regulations System (Continued) GENERAL SERVICES...

31 CFR 359.32 - What definitive Series I savings bonds are excluded from the computation?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 31 Money and Finance: Treasury 2 2010-07-01 2010-07-01 false What definitive Series I savings bonds are excluded from the computation? 359.32 Section 359.32 Money and Finance: Treasury Regulations Relating to Money and Finance (Continued) FISCAL SERVICE, DEPARTMENT OF THE TREASURY BUREAU OF THE PUBLIC...

NGO Provision of Basic Education: Alternative or Complementary Service Delivery to Support Access to the Excluded?

ERIC Educational Resources Information Center

Rose, Pauline

2009-01-01

This paper focuses on approaches by non-government organisations (NGOs) to reach primary school-aged children excluded from access to the conventional state education system. It highlights recent shifts in international literature and agency priorities from the portrayal of NGO provision as a (non-formal) "alternative" to (formal) state…

78 FR 22880 - Privacy Act of 1974; Notice of cancellation of System of Record Notice (SORN)

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-17

... Administration (GSA). ACTION: Withdrawal of GSA/GOV-8 Excluded Parties List System (EPLS) System of Record Notice... Services Administration (GSA), is canceling the following system of record notice: GSA/GOV-8 Excluded... or email the GSA Privacy Act Officer: telephone 202-208-1317; email [email protected]gov...

26 CFR 1.411(a)-5 - Service included in determination of nonforfeitable percentage.

Code of Federal Regulations, 2010 CFR

2010-04-01

... service. A year of service which is not required to be taken into account by reason of a break in service... on the last day of the year is a break in service rule because employees can lose benefits by reason..., such year may not be excluded by reason of this subparagraph. In the case of a plan utilizing the...

47 CFR 36.162 - Intangible assets-Account 2690.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 36.162 Telecommunication FEDERAL COMMUNICATIONS COMMISSION (CONTINUED) COMMON CARRIER SERVICES... the operations on the basis of the separation of the cost of Telecommunications Plant In Service, Account 2001, excluding the Intangible Assets, Account 2690. Telecommunications Plant—Other ...

47 CFR 87.45 - Time in which station is placed in operation.

Code of Federal Regulations, 2011 CFR

2011-10-01

... SPECIAL RADIO SERVICES AVIATION SERVICES Applications and Licenses § 87.45 Time in which station is placed..., excluding radionavigation land test stations. When a new license has been issued or additional operating...

47 CFR 36.162 - Intangible assets-Account 2690.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 36.162 Telecommunication FEDERAL COMMUNICATIONS COMMISSION (CONTINUED) COMMON CARRIER SERVICES... the operations on the basis of the separation of the cost of Telecommunications Plant In Service, Account 2001, excluding the Intangible Assets, Account 2690. Telecommunications Plant—Other ...

LOFT. Containment and service building (TAN650). South elevation, details, section. ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

LOFT. Containment and service building (TAN-650). South elevation, details, section. Shows part of duct enclosure, railroad door opening, roof ventilators, shielded personnel entrance, and change room. Section F shows view from west looking toward shielding around airlock door on main floor. Kaiser engineers 6413-11-STEP/LOFT-650-A-9. Date: October 1964. INEEL index code no. 036-650-00-486-122221 - Idaho National Engineering Laboratory, Test Area North, Scoville, Butte County, ID

Clinical cure and survival in Gram-positive ventilator-associated pneumonia: retrospective analysis of two double-blind studies comparing linezolid with vancomycin.

PubMed

Kollef, Marin H; Rello, Jordi; Cammarata, Sue K; Croos-Dabrera, Rodney V; Wunderink, Richard G

2004-03-01

To assess the effect of baseline variables, including treatment, on clinical cure and survival rates in patients with Gram-positive, ventilator-associated pneumonia (VAP). Retrospective analysis of two randomized, double-blind studies. Multinational study with 134 sites. 544 patients with suspected Gram-positive VAP, including 264 with documented Gram-positive VAP and 91 with methicillin-resistant S. aureus (MRSA) VAP. Linezolid 600 mg or vancomycin 1 g every 12 h for 7-21 days, each with aztreonam. Clinical cure rates assessed 12-28 days after the end of therapy and excluding indeterminate or missing outcomes significantly favored linezolid in the Gram-positive and MRSA subsets. Logistic regression showed that linezolid was an independent predictor of clinical cure with odds ratios of 1.8 for all patients, 2.4 for Gram-positive VAP, and 20.0 for MRSA VAP. Kaplan-Meier survival rates favored linezolid in the MRSA subset. Logistic regression showed that linezolid was an independent predictor of survival with odds ratios of 1.6 for all patients, 2.6 for Gram-positive VAP, and 4.6 for MRSA VAP. Initial linezolid therapy was associated with significantly better clinical cure and survival rates than was initial vancomycin therapy in patients with MRSA VAP.

Respiratory and psychiatric abnormalities in chronic symptomatic hyperventilation.

PubMed Central

Bass, C; Gardner, W N

1985-01-01

Many physicians believe that the hyperventilation syndrome is invariably associated with anxiety or undiagnosed organic disease such as asthma and pulmonary embolus, or both. Twenty one patients referred by specialist physicians with unexplained somatic symptoms and unequivocal chronic hypocapnia (resting end tidal Pco2 less than or equal to 4 kPa (30 mm Hg) on repeated occasions during prolonged measurement) were investigated. All but one complained of inability to take a satisfying breath. Standard lung function test results and chest radiographs were normal in all patients, but histamine challenge showed bronchial hyper-reactivity in two of 20 patients tested, and skin tests to common allergens were positive in three of 18. Ventilation-perfusion scanning was abnormal in a further three of 15 patients studied, with unmatched perfusion defects in two and isolated ventilation defects in one. None of the 21 had thyrotoxicosis, severe coronary heart disease, or other relevant cardiovascular abnormalities. Ten of the 21 patients were neurotic and suffered from chronic psychiatric disturbance characterised by anxiety, panic, and phobic symptoms. The remainder had no detectable psychiatric disorders but reported proportionately more somatic than anxiety symptoms. Severe hyperventilation can occur in the absence of formal psychiatric or detectable respiratory or other organic abnormalities. Asthma and pulmonary embolus must be specifically excluded. PMID:3922504

[Outcomes and predictors of mortality in elderly patients requiring artificial ventilation].

PubMed

Murai, Y; Matsumiya, H; Takemura, H; Koinuma, M

2000-07-01

We retrospectively examined the outcomes and the predictors of mortality in 97 patients aged 70 years and over (mean: 79.3 years) who required artificial ventilation for more than 3 hours. The median duration of artificial ventilation was 16 days (range: 1-85). Of these patients, 61% survived ventilator weaning and 37% were discharged from hospital alive. We performed univariate and logistic regression analysis to determine the predictors of dying before weaning and hospital discharge using severity of illness data. The predictors of hospital mortality were examined in 86 patients, excluding those who had malignant disease, all of whom died in hospital. Activities of daily living (ADL) were ranked as "bedridden", "in wheelchair", or "independent". In the three age groups-up to 70 years, 75 to 84 years and 85 years and over-the respective survival rates were 63% (weaned) and 67% (discharged), 69% (weaned) and 39% (discharged), and 33% (weaned) and 12% (discharged); the overall p values being 0.026 (weaned) and 0.003 (discharged). The predictors of dying before weaning according to univariate analysis were as follows: age (p = 0.026), respiratory or cardiac arrest on admission (p = 0.003), acute physiology score (APS) of 25 or more on admission (p = 0.000), systolic blood pressure below 90 mmHg on admission (p = 0.001), hemoglobin less than 11 g/dl (p = 0.044), and total protein less than 6 g/dl (p = 0.007). The predictors of hospital mortality by univariate analysis were as follows: age (p = 0.003), limited ADL (p = 0.001), respiratory or cardiac arrest on admission (p = 0.011), APS 25 or more on admission (p = 0.049), systolic blood pressure less than 90 mmHg on admission (p = 0.002), hemoglobin less than 11 g/dl (p = 0.028), and GOT or GPT more than 50 IU (p = 0.038). The relative risk of dying before weaning decreased in the order: respiratory or cardiac arrest on admission, systolic blood pressure less than 90 mmHg on admission, total protein less than 6 g/dl (Odds ratios: 6.04, 3.90, 3.51, respectively), or, respiratory or cardiac arrest on admission, APS more than 25 in admission, total protein less than 6 g/dl (Odds ratio: 6.94, 3.99, 3.76, respectively). The relative risk of hospital mortality decreased in the order: "bedridden", systolic blood pressure less than 90 mmHg on admission, "with wheel chair" (Odds ratios: 11.76, 6.44, 3.57, respectively). In the older patients, successful ventilator weaning was not indicative of hospital discharge. Ventilator weaning depended mainly on acute health status on admission, but hospital discharge depended also on the presence of limited ADL and preexisting malignant disease.

Case Study for the ARRA-funded Ground Source Heat Pump (GSHP) Demonstration at Wilders Grove Solid Waste Service Center in Raleigh, NC

DOE Office of Scientific and Technical Information (OSTI.GOV)

Liu, Xiaobing; Malhotra, Mini; Xiong, Zeyu

High initial costs and lack of public awareness of ground-source heat pump (GSHP) technology are the two major barriers preventing rapid deployment of this energy-saving technology in the United States. Under the American Recovery and Reinvestment Act (ARRA), 26 GSHP projects have been competitively selected and carried out to demonstrate the benefits of GSHP systems and innovative technologies for cost reduction and/or performance improvement. This paper highlights the findings of a case study of one of the ARRA-funded GSHP demonstration projects, a distributed GSHP system for providing all the space conditioning, outdoor air ventilation, and 100% domestic hot water tomore » the Wilders Grove Solid Waste Service Center of City of Raleigh, North Carolina. This case study is based on the analysis of measured performance data, construction costs, and simulations of the energy consumption of conventional central heating, ventilation, and air-conditioning (HVAC) systems providing the same level of space conditioning and outdoor air ventilation as the demonstrated GSHP system. The evaluated performance metrics include the energy efficiency of the heat pump equipment and the overall GSHP system, pumping performance, energy savings, carbon emission reductions, and cost-effectiveness of the GSHP system compared with conventional HVAC systems. This case study also identified opportunities for reducing uncertainties in the performance evaluation and improving the operational efficiency of the demonstrated GSHP system.« less

Procedure Guidelines for Health Care of Special Needs Students in the School Setting.

ERIC Educational Resources Information Center

Viele, Elizabeth; Hertel, Victoria

This manual presents detailed instructions for delivering health care services to students with special health needs within the school setting. Individual chapters address the following areas: dressing; vital signs; height and weight; fluids/nourishment; medications; oxygen and use of the respirator/ventilator; suctioning; respiratory therapy;…

Thermal Standard for Small Rural Schools.

ERIC Educational Resources Information Center

Strandberg (J.S.) Consulting Engineering, Fairbanks, AK.

The Standard's purpose is to provide design requirements that will improve energy utilization in new State of Alaska owned rural educational facilities ranging in size from 7,000 to 12,000 square feet. The Standard covers exterior envelopes and selection of heating, ventilating and air conditioning systems, service water systems, energy…

Maximize Benefits, Minimize Risk: Selecting the Right HVAC Firm.

ERIC Educational Resources Information Center

Golden, James T.

1993-01-01

An informal survey of 20 major urban school districts found that 40% were currently operating in a "break down" maintenance mode. A majority, 57.9%, also indicated they saw considerable benefits in contracting for heating, ventilating, and air conditioning (HVAC) maintenance services with outside firms. Offers guidelines in selecting…

Association between Hyperglycaemia with Neurological Outcomes Following Severe Head Trauma.

PubMed

Khajavikhan, Javaher; Vasigh, Aminolah; Kokhazade, Taleb; Khani, Ali

2016-04-01

Head Trauma (HT) is a major cause of death, disability and important public health problem. HT is also the main cause of hyperglycaemia that can increase mortality. The aim of this study was to assess the correlation between hyperglycaemia with neurological outcomes following severe Traumatic Brain Injury (TBI). This is a descriptive and correlation study that was carried out at the Imam Khomeini Hospital affiliated with Ilam University of Medical Sciences, Ilam, IR, during March 2014-March 2015 on patients with severe TBI. Data were collected from the patient records on mortality, Intensive Care Unit (ICU) length of stay, hospital length of stay, admission GCS score, Injury Severity Score (ISS), mechanical ventilation, Ventilation Associated Pneumonia (VAP) and Acute Respiratory Distress Syndrome (ARDS). Random Blood Sugar (RBS) level on admission was recorded. Patients with diabetes mellitus (to minimize the overlap between acute stress hyperglycaemia and diabetic hyperglycaemia) were excluded. About 34(40%) of patients were admitted with hyperglycaemia (RBS ≥ 200 mg/dl) over the study period. The mortality rate, length of ICU stay, hospital stay, ISS and VAP & ARDS in patients with RBS levels ≥ 200 mg was significantly higher than patients with RBS levels below ≤ 200mg (p<0.05, p<0.001). A significant correlation was found between RBS with GCS arrival, length of ICU stay, length of hospital stay, ISS, mechanical ventilation and VAP & ARDS (p<0.05, p< 0.001). RBS is a predicate factor for ISS (p <0.05, OR : 1.36), GCS (p <0.001, OR : 1.69), mechanical ventilation (p< 0.05, OR : 1.27), VAP & ARDS (p <0.001, OR : 1.68), length of ICU stay (p <0.001, OR : 1.87) and length of hospital stay (p <0.05, OR : 1.24). Hyperglycaemia after severe TBI (RBS ≥ 200) is associated with poor outcome. It can be a predictive factor for mortality rate, ICU stay, GCS arrival, VAP & RDS, hospital stay and ISS. Management of hyperglycaemia with insulin protocol in cases with value >200mg/dl, is critical in improving the outcome of patients with TBI.

Air pollution in Boston bars before and after a smoking ban.

PubMed

Repace, James L; Hyde, James N; Brugge, Doug

2006-10-27

We quantified the air quality benefits of a smoke-free workplace law in Boston Massachusetts, U.S.A., by measuring air pollution from secondhand smoke (SHS) in 7 pubs before and after the law, comparing actual ventilation practices to engineering society (ASHRAE) recommendations, and assessing SHS levels using health and comfort indices. We performed real-time measurements of respirable particle (RSP) air pollution and particulate polycyclic aromatic hydrocarbons (PPAH), in 7 pubs and outdoors in a model-based design yielding air exchange rates for RSP removal. We also assessed ventilation rates from carbon dioxide concentrations. We compared RSP air pollution to the federal Air Quality Index (AQI) and the National Ambient Air Quality Standard (NAAQS) to assess health risks, and assessed odor and irritation levels using published SHS-RSP thresholds. Pre-smoking-ban RSP levels in 6 pubs (one pub with a non-SHS air quality problem was excluded) averaged 179 microg/m3, 23 times higher than post-ban levels, which averaged 7.7 microg/m3, exceeding the NAAQS for fine particle pollution (PM2.5) by nearly 4-fold. Pre-smoking ban levels of fine particle air pollution in all 7 of the pubs were in the Unhealthy to Hazardous range of the AQI. In the same 6 pubs, pre-ban indoor carcinogenic PPAH averaged 61.7 ng/m3, nearly 10 times higher than post-ban levels of 6.32 ng/m3. Post-ban particulate air pollution levels were in the Good AQI range, except for 1 venue with a defective gas-fired deep-fat fryer, while post-ban carcinogen levels in all 7 pubs were lower than outdoors. During smoking, although pub ventilation rates per occupant were within ASHRAE design parameters for the control of carbon dioxide levels for the number of occupants present, they failed to control SHS carcinogens or RSP. Nonsmokers' SHS odor and irritation sensory thresholds were massively exceeded. Post-ban air pollution measurements showed 90% to 95% reductions in PPAH and RSP respectively, differing little from outdoor concentrations. Ventilation failed to control SHS, leading to increased risk of the diseases of air pollution for nonsmoking workers and patrons. Boston's smoking ban eliminated this risk.

Fluid Overload and Renal Angina Index at Admission Are Associated With Worse Outcomes in Critically Ill Children.

PubMed

Sethi, Sidharth K; Raghunathan, Veena; Shah, Shilpi; Dhaliwal, Maninder; Jha, Pranaw; Kumar, Maneesh; Paluri, Sravanthi; Bansal, Shyam; Mhanna, Maroun J; Raina, Rupesh

2018-01-01

Objectives: We investigated the association of fluid overload and oxygenation in critically sick children, and their correlation with various outcomes (duration of ventilation, ICU stay, and mortality). We also assessed whether renal angina index (RAI) at admission can predict mortality or acute kidney injury (AKI) on day 3 after admission. Design and setting: Prospective study, pediatric intensive care in a tertiary hospital. Duration: June 2013-June 2014. Patients: Patients were included if they needed invasive mechanical ventilation for >24 h and had an indwelling arterial catheter. Patients with congenital heart disease or those who received renal replacement therapy (RRT) were excluded. Methods: Oxygenation index, fluid overload percent (daily, cumulative), RAI at admission and pediatric logistic organ dysfunction (PELOD) score were obtained in all critically ill children. KDIGO classification was used to define AKI, using both creatinine and urine output criteria. Admission data for determination of RAI included the use of vasopressors, invasive mechanical ventilation, percent fluid overload, and change in kidney function (estimated creatinine clearance). Univariable and multivariable approaches were used to assess the relations between fluid overload, oxygenation index and clinical outcomes. An RAI cutoff >8 was used to predict AKI on day 3 of admission and mortality. Results: One hundred and two patients were recruited. Fluid overload predicted oxygenation index in all patients, independent of age, gender and PELOD score ( p < 0.05). Fluid overload was associated with longer duration of ventilation ( p < 0.05), controlled for age, gender, and PELOD score. Day-3 AKI rates were higher in patients with a RAI of 8 or more, and higher areas under the RAI curve had better prediction rates for Day-3 AKI. An RAI <8 had high negative predictive values (80-95%) for Day-3 AKI. RAI was better than traditional markers of pediatric severity of illness (PELOD) score for prediction of AKI on day 3. Conclusions: This study emphasizes that positive fluid balance adversely affects intensive care in critically ill children. Further, the RAI prediction model may help optimize treatment and improve clinical prediction of AKI.

Health-Related Quality of Life in Australasian Survivors of H1N1 Influenza Undergoing Mechanical Ventilation. A Multicenter Cohort Study.

PubMed

Skinner, Elizabeth H; Haines, Kimberley J; Howe, Belinda; Hodgson, Carol L; Denehy, Linda; McArthur, Colin J; Seller, Daniel; Di Marco, Emma; Mulvany, Kate; Ryan, Danielle T; Berney, Sue

2015-06-01

Patients surviving acute respiratory distress syndrome suffer decrements in physical function and health-related quality of life (HR-QoL); however, it is unclear whether HR-QoL is disproportionately affected in those with H1N1 influenza. The objective was to compare the HR-QoL of patients with a diagnosis of H1N1 influenza who were mechanically ventilated, 12 months after intensive care unit (ICU) discharge with healthy population data and ICU survivor data. A prospective, observational, binational, multicenter cohort study was conducted in 11 ICUs in Australia and New Zealand during June-September 2009. Eligible participants were mechanically ventilated in the ICU with a confirmed diagnosis of H1N1 influenza. People were excluded if they were less than 18 years of age or could not speak English. Two validated HR-QoL questionnaires (Short Form-36 version 2 [SF-36], and Assessment of Quality of Life [AQoL]) were administered 1 year after ICU discharge. Sixty-two patients (48% male) had a median (interquartile range) age of 42 (29-53) years and an APACHE II score of 18.0 (14-20); ventilation days, 10.0 (4-23); and ICU and hospital length of stay, 12.5 (7-27) and 20.0 (15-38) days, respectively. Hospital mortality was 7%, and 31% of the cohort received a tracheostomy. The mean (SD) health utility score at 1 year was 0.68 (0.30) compared with the healthy age-matched population (0.81 [0.23]). The mean (SD) SF-36 physical and mental component summary scores were within population normal ranges at 44.4 (12.3) and 45.5 (12.5), respectively. Health-related quality of life of Australasian survivors of severe H1N1 influenza was comparable to the healthy population 1 year after ICU discharge. Consensus should be sought on standardization of follow-up time points and outcome measurement. Clinical trial registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12609001037291).

Effects of peep on lung injury, pulmonary function, systemic circulation and mortality in animals with uninjured lungs—a systematic review

PubMed Central

Pisani, Luigi; Chaves, Renato Carneiro de Freitas; Amorim, Thiago Chaves; Cherpanath, Thomas; Determann, Rogier; Dongelmans, Dave A.; Paulus, Frederique; Tuinman, Pieter Roel; Pelosi, Paolo; Gama de Abreu, Marcelo; Schultz, Marcus J.; Serpa Neto, Ary

2018-01-01

It is well-known that positive end-expiratory pressure (PEEP) can prevent ventilator-induced lung injury (VILI) and improve pulmonary physiology in animals with injured lungs. It’s uncertain whether PEEP has similar effects in animals with uninjured lungs. A systematic review of randomized controlled trials (RCTs) comparing different PEEP levels in animals with uninjured lungs was performed. Trials in animals with injured lungs were excluded, as were trials that compared ventilation strategies that also differed with respect to other ventilation settings, e.g., tidal volume size. The search identified ten eligible trials in 284 animals, including rodents and small as well as large mammals. Duration of ventilation was highly variable, from 1 to 6 hours and tidal volume size varied from 7 to 60 mL/kg. PEEP ranged from 3 to 20 cmH2O, and from 0 to 5 cmH2O, in the ‘high PEEP’ or ‘PEEP’ arms, and in the ‘low PEEP’ or ‘no PEEP’ arms, respectively. Definitions used for lung injury were quite diverse, as were other outcome measures. The effects of PEEP, at any level, on lung injury was not straightforward, with some trials showing less injury with ‘high PEEP’ or ‘PEEP’ and other trials showing no benefit. In most trials, ‘high PEEP’ or ‘PEEP’ was associated with improved respiratory system compliance, and better oxygen parameters. However, ‘high PEEP’ or ‘PEEP’ was also associated with occurrence of hypotension, a reduction in cardiac output, or development of hyperlactatemia. There were no differences in mortality. The number of trials comparing ‘high PEEP’ or ‘PEEP’ with ‘low PEEP’ or ‘no PEEP’ in animals with uninjured lungs is limited, and results are difficult to compare. Based on findings of this systematic review it’s uncertain whether PEEP, at any level, truly prevents lung injury, while most trials suggest potential harmful effects on the systemic circulation. PMID:29430442

Fluid Overload and Renal Angina Index at Admission Are Associated With Worse Outcomes in Critically Ill Children

PubMed Central

Sethi, Sidharth K.; Raghunathan, Veena; Shah, Shilpi; Dhaliwal, Maninder; Jha, Pranaw; Kumar, Maneesh; Paluri, Sravanthi; Bansal, Shyam; Mhanna, Maroun J.; Raina, Rupesh

2018-01-01

Objectives: We investigated the association of fluid overload and oxygenation in critically sick children, and their correlation with various outcomes (duration of ventilation, ICU stay, and mortality). We also assessed whether renal angina index (RAI) at admission can predict mortality or acute kidney injury (AKI) on day 3 after admission. Design and setting: Prospective study, pediatric intensive care in a tertiary hospital. Duration: June 2013-June 2014. Patients: Patients were included if they needed invasive mechanical ventilation for >24 h and had an indwelling arterial catheter. Patients with congenital heart disease or those who received renal replacement therapy (RRT) were excluded. Methods: Oxygenation index, fluid overload percent (daily, cumulative), RAI at admission and pediatric logistic organ dysfunction (PELOD) score were obtained in all critically ill children. KDIGO classification was used to define AKI, using both creatinine and urine output criteria. Admission data for determination of RAI included the use of vasopressors, invasive mechanical ventilation, percent fluid overload, and change in kidney function (estimated creatinine clearance). Univariable and multivariable approaches were used to assess the relations between fluid overload, oxygenation index and clinical outcomes. An RAI cutoff >8 was used to predict AKI on day 3 of admission and mortality. Results: One hundred and two patients were recruited. Fluid overload predicted oxygenation index in all patients, independent of age, gender and PELOD score (p < 0.05). Fluid overload was associated with longer duration of ventilation (p < 0.05), controlled for age, gender, and PELOD score. Day-3 AKI rates were higher in patients with a RAI of 8 or more, and higher areas under the RAI curve had better prediction rates for Day-3 AKI. An RAI <8 had high negative predictive values (80–95%) for Day-3 AKI. RAI was better than traditional markers of pediatric severity of illness (PELOD) score for prediction of AKI on day 3. Conclusions: This study emphasizes that positive fluid balance adversely affects intensive care in critically ill children. Further, the RAI prediction model may help optimize treatment and improve clinical prediction of AKI. PMID:29765932

Advanced Hybrid Spacesuit Concept Featuring Integrated Open Loop and Closed Loop Ventilation Systems

NASA Technical Reports Server (NTRS)

Daniel, Brian A.; Fitzpatrick, Garret R.; Gohmert, Dustin M.; Ybarra, Rick M.; Dub, Mark O.

2013-01-01

A document discusses the design and prototype of an advanced spacesuit concept that integrates the capability to function seamlessly with multiple ventilation system approaches. Traditionally, spacesuits are designed to operate both dependently and independently of a host vehicle environment control and life support system (ECLSS). Spacesuits that operate independent of vehicle-provided ECLSS services must do so with equipment selfcontained within or on the spacesuit. Suits that are dependent on vehicle-provided consumables must remain physically connected to and integrated with the vehicle to operate properly. This innovation is the design and prototype of a hybrid spacesuit approach that configures the spacesuit to seamlessly interface and integrate with either type of vehicular systems, while still maintaining the ability to function completely independent of the vehicle. An existing Advanced Crew Escape Suit (ACES) was utilized as the platform from which to develop the innovation. The ACES was retrofitted with selected components and one-off items to achieve the objective. The ventilation system concept was developed and prototyped/retrofitted to an existing ACES. Components were selected to provide suit connectors, hoses/umbilicals, internal breathing system ducting/ conduits, etc. The concept utilizes a lowpressure- drop, high-flow ventilation system that serves as a conduit from the vehicle supply into the suit, up through a neck seal, into the breathing helmet cavity, back down through the neck seal, out of the suit, and returned to the vehicle. The concept also utilizes a modified demand-based breathing system configured to function seamlessly with the low-pressure-drop closed-loop ventilation system.

"Fighting the system": Families caring for ventilator-dependent children and adults with complex health care needs at home

PubMed Central

2011-01-01

Background An increasing number of individuals with complex health care needs now receive life-long and life-prolonging ventilatory support at home. Family members often take on the role of primary caregivers. The aim of this study was to explore the experiences of families giving advanced care to family members dependent on home mechanical ventilation. Methods Using qualitative research methods, a Grounded Theory influenced approach was used to explore the families' experiences. A total of 15 family members with 11 ventilator-dependent individuals (three children and eight adults) were recruited for 10 in-depth interviews. Results The core category, "fighting the system," became the central theme as family members were asked to describe their experiences. In addition, we identified three subcategories, "lack of competence and continuity", "being indispensable" and "worth fighting for". This study revealed no major differences in the families' experiences that were dependent on whether the ventilator-dependent individual was a child or an adult. Conclusions These findings show that there is a large gap between family members' expectations and what the community health care services are able to provide, even when almost unlimited resources are available. A number of measures are needed to reduce the burden on these family members and to make hospital care at home possible. In the future, the gap between what the health care can potentially provide and what they can provide in real life will rapidly increase. New proposals to limit the extremely costly provision of home mechanical ventilation in Norway will trigger new ethical dilemmas that should be studied further. PMID:21726441

42 CFR 419.22 - Hospital services excluded from payment under the hospital outpatient prospective payment system.

Code of Federal Regulations, 2014 CFR

2014-10-01

... chapter for payment on a fee schedule basis. (b) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (c) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act. (d) Certified nurse-midwife services, as defined in section 1861(gg...

Pandemic influenza-implications for critical care resources in Australia and New Zealand.

PubMed

Anderson, Therese A; Hart, Graeme K; Kainer, Marion A

2003-09-01

To quantify resource requirements (additional beds and ventilator capacity), for critical care services in the event of pandemic influenza. Cross-sectional survey about existing and potential critical care resources. Participants comprised 156 of the 176 Australasian (Australia and New Zealand) critical care units on the database of the Australian and New Zealand Intensive Care Society (ANZICS) Research Centre for Critical Care Resources. The Meltzer, Cox and Fukuda model was adapted to map a range of influenza attack rate estimates for hospitalisation and episodes likely to require intensive care and to predict critical care admission rates and bed day requirements. Estimations of ventilation rates were based on those for community-acquired pneumonia. The estimated extra number of persons requiring hospitalisation ranged from 8,455 (10% attack rate) to 150,087 (45% attack rate). The estimated number of additional admissions to critical care units ranged from 423 (5% admission rate, 10% attack rate) to 37,522 (25% admission rate, 45% attack rate). The potential number of required intensive care bed days ranged from 846 bed days (2 day length of stay, 10% attack rate) to 375,220 bed days (10 day length of stay, 45% attack rate). The number of persons likely to require mechanical ventilation ranged from 106 (25% of projected critical care admissions, 10% attack rate) to 28,142 (75% of projected critical care admissions, 45% attack rate). An additional 1,195 emergency ventilator beds were identified in public sector and 248 in private sector hospitals. Cancellation of elective surgery could release a potential 76,402 intensive care bed days (per annum), but in the event of pandemic influenza, 31,150 bed days could be required over an 8- to 12-week period. Australasian critical care services would be overwhelmed in the event of pandemic influenza. More work is required in relation to modelling, contingency plans, and resource allocation.

A Retrospective Analysis of Direct Medical Cost and Cost of Drug Therapy in Hospitalized Patients at Private Hospital in Western India

PubMed Central

Kumbar, Shivaprasad Kalakappa

2015-01-01

Background Pharmacoeconomics is analytical tool to know cost of hospitalization and its effect on health care system and society. In India, apart from the government health services, private sector also play big role to provide health care services. Objective To study the direct medical cost and cost of drug therapy in hospitalized patients at private hospital. Materials and Methods A retrospective study was conducted at private hospital in a metro city of Western India. Total 400 patients’ billing records were selected randomly for a period from 01/01/2013 to 31/12/2014. Data were collected from medical record of hospital with permission of medical director of hospital. Patients’ demographic profile age, sex, diagnosis and various costs like ICU charge, ventilator charge, diagnostic charge, etc. were noted in previously formed case record form. Data were analysed by Z, x2 and unpaired t-test. Result Patients were divided into less than 45 years and more than 45 year age group. They were divided into medical and surgical patients according to their admission in medical or surgical ward. Mortality, Intensive Care Unit (ICU) admission, patients on ventilator were significantly (p<0.05) higher in medical patients. Direct medical cost, ward bed charge, ICU bed charge, ventilator charge and cost of drug therapy per patient were significantly (p<0.05) higher in medical patients while operation theatre and procedural charge were significantly (p<0.05) higher in surgical patients. Cost of fibrinolytics, anticoagulants, cardiovascular drugs were significantly (p<0.05) higher in medical patients. Cost of antimicrobials, proton pump inhibitors (PPIs), antiemetics, analgesics, were significantly (p<0.05) higher in surgical patients. Conclusion Ward bed charge, ICU bed charge, ventilator charge accounted more than one third cost of direct medical cost in all the patients. Cost of drug therapy was one fourth of direct medical cost. Antimicrobials cost accounted 33% of cost of drug therapy. PMID:26675983

Who is missing from the measures? Trends in the proportion and treatment of patients potentially excluded from publicly reported quality measures.

PubMed

Bernheim, Susannah M; Wang, Yongfei; Bradley, Elizabeth H; Masoudi, Frederick A; Rathore, Saif S; Ross, Joseph S; Drye, Elizabeth; Krumholz, Harlan M

2010-11-01

The Centers for Medicare and Medicaid Services provides public reporting on the quality of hospital care for patients with acute myocardial infarction (AMI). The Centers for Medicare and Medicaid Services Core Measures allow discretion in excluding patients because of relative contraindications to aspirin, β-blockers, and angiotensin-converting enzyme inhibitors. We describe trends in the proportion of patients with AMI with contraindications that could lead to discretionary exclusion from public reporting. We completed cross-sectional analyses of 3 nationally representative data cohorts of AMI admissions among Medicare patients in 1994-1995 (n = 170,928), 1998-1999 (n = 27,432), and 2000-2001 (n = 27,300) from the national Medicare quality improvement projects. Patients were categorized as ineligible (eg, transfer patients), automatically excluded (specified absolute medical contraindications), discretionarily excluded (potentially excluded based on relative contraindications), or "ideal" for treatment for each measure. For 4 of 5 measures, the percentage of discretionarily excluded patients increased over the 3 periods (admission aspirin 15.8% to 16.9%, admission β-blocker 14.3% to 18.3%, discharge aspirin 10.3% to 12.3%, and angiotensin-converting enzyme inhibitors 2.8% to 3.9%; P < .001). Of patients potentially included in measures (those who were not ineligible or automatically excluded), the discretionarily excluded represented 25.5% to 69.2% in 2000-2001. Treatment rates among patients with discretionary exclusions also increased for 4 of 5 measures (all except angiotensin-converting enzyme inhibitors). A sizeable and growing proportion of patients with AMI have relative contraindications to treatments that may result in discretionary exclusion from publicly reported quality measures. These patients represent a large population for which there is insufficient evidence as to whether measure exclusion or inclusion and treatment represents best care. Copyright © 2010 Mosby, Inc. All rights reserved.

42 CFR 1001.701 - Excessive claims or furnishing of unnecessary or substandard items and services.

Code of Federal Regulations, 2010 CFR

2010-10-01

... substandard items and services. (a) Circumstance for exclusion. The OIG may exclude an individual or entity... financial impact on program beneficiaries or other individuals; (iii) Whether the individual or entity has a... substandard items and services. 1001.701 Section 1001.701 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH...

21 CFR 1.362 - What records are excluded from this subpart?

Code of Federal Regulations, 2010 CFR

2010-04-01

... 21 Food and Drugs 1 2010-04-01 2010-04-01 false What records are excluded from this subpart? 1.362 Section 1.362 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL... as required by this subpart does not extend to recipes for food as defined in § 1.328; financial data...

Corporate social responsibility initiatives addressing social exclusion in Bangladesh.

PubMed

Werner, Wendy J

2009-08-01

The private sector is often seen as a driver of exclusionary processes rather than a partner in improving the health and welfare of socially-excluded populations. However, private-sector initiatives and partnerships- collectively labelled corporate social responsibility (CSR) initiatives-may be able to positively impact social status, earning potential, and access to services and resources for socially-excluded populations. This paper presents case studies of CSR projects in Bangladesh that are designed to reduce social exclusion among marginalized populations and explores whether CSR initiatives can increase economic and social capabilities to reduce exclusion. The examples provide snapshots of projects that (a) increase job-skills and employment opportunities for women, disabled women, and rehabilitated drug-users and (b) provide healthcare services to female workers and their communities. The CSR case studies cover a limited number of people but characteristics and practices replicable and scaleable across different industries, countries, and populations are identified. Common success factors from the case studies form the basis for recommendations to design and implement more CSR initiatives targeting socially-excluded groups. The analysis found that CSR has potential for positive and lasting impact on developing countries, especifically on socially-excluded populations. However, there is a need for additional monitoring and critical evaluation.

[Efficiency of novel splash-proof ventilator circuit component on VAP and the colonization of multiple-drug resistant bacteria prevention in patients undergoing mechanical ventilation: a prospective randomized controlled intervention study with 318 patients].

PubMed

Xu, Songao; Yu, Huijie; Sun, Hui; Zhu, Xiangyun; Xu, Xiaoqin; Xu, Jun; Cao, Weizhong

2017-01-01

To investigate the efficiency of closed tracheal suction system (CTSS) using novel splash-proof ventilator circuit component on ventilator-associated pneumonia (VAP) and the colonization of multiple-drug resistant bacteria (MDR) in patients undergoing mechanical ventilation (MV) prevention. A prospective single-blinded randomized parallel controlled intervention study was conducted. 330 severe patients admitted to the intensive care unit (ICU) of the First Hospital of Jiaxing from January 2014 to May 2016 were enrolled, and they were divided into open tracheal suction group, closed tracheal suction group, and splash-proof suction group on average by random number table. The patients in the three groups used conventional ventilator circuit component, conventional CTSS, and CTSS with a novel splash-proof ventilator circuit component for MV and sputum suction, respectively. The incidence of VAP, airway bacterial colonization rate, MDR and fungi colonization rate, duration of MV, length of ICU and hospitalization stay, and financial expenditure during hospitalization, as well as the in-hospital prognosis were recorded. After excluding patients who did not meet the inclusion criteria, incomplete data, backed out and so on, 318 patients were enrolled in the analysis finally. Compared with the open tracheal suction group, the total incidence of VAP was decreased in the closed tracheal suction group and splash-proof suction group [20.95% (22/105), 21.90% (23/105) vs. 29.63% (32/108)], but no statistical difference was found (both P > 0.05), and the incidence of VAP infections/1 000 MV days showed the same change tendency (cases: 14.56, 17.35 vs. 23.07). The rate of airway bacterial colonization and the rate of MDR colonization in the open tracheal suction group and splash-proof suction group were remarkably lower than those of closed tracheal suction group [32.41% (35/108), 28.57% (30/105) vs. 46.67% (49/105), 20.37% (22/108), 15.24% (16/105) vs. 39.05% (41/105)] with significantly statistical differences (all P < 0.05). Besides, no significantly statistical difference was found in the fungi colonization rate among open tracheal group, closed tracheal group, and splash-proof suction group (4.63%, 3.81% and 6.67%, respectively, P > 0.05). Compared with the closed tracheal suction group, the duration of MV, the length of ICU and hospitalization stay were shortened in the open tracheal suction group and splash-proof suction group [duration of MV (days): 8.00 (4.00, 13.75), 8.00 (5.00, 13.00) vs. 9.00 (5.00, 16.00); the length of ICU stay (days): 10.00 (6.00, 16.00), 11.00 (7.00, 19.00) vs. 13.00 (7.50, 22.00); the length of hospitalization stay (days): 16.50 (9.25, 32.00), 19.00 (10.50, 32.50) vs. 21.00 (10.00, 36.00)], and financial expenditure during hospitalization was lowered [10 thousand Yuan: 4.95 (3.13, 8.62), 5.47 (3.84, 9.41) vs. 6.52 (3.99, 11.02)] without significantly statistical differences (all P > 0.05). Moreover, no significantly statistical difference was found in the in-hospital prognosis among the three groups. CTSS performed using novel splash-proof ventilator circuit component shared similar advantages in preventing VAP with the conventional CTSS. Meanwhile, it is superior because it prevented the colonization of MDR and high price in the conventional CTSS.Clinical Trail Registration Chinese Clinical Trial Registry, ChiCTR-IOR-16009694.

20 CFR 404.1019 - Work as a member of a uniformed service of the United States.

Code of Federal Regulations, 2011 CFR

2011-04-01

... FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1019 Work as a member of a uniformed service of the...

20 CFR 404.1019 - Work as a member of a uniformed service of the United States.

Code of Federal Regulations, 2012 CFR

2012-04-01

... FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1019 Work as a member of a uniformed service of the...

20 CFR 404.1019 - Work as a member of a uniformed service of the United States.

Code of Federal Regulations, 2014 CFR

2014-04-01

... FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1019 Work as a member of a uniformed service of the...

20 CFR 404.1019 - Work as a member of a uniformed service of the United States.

Code of Federal Regulations, 2013 CFR

2013-04-01

... FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1019 Work as a member of a uniformed service of the...

Effect of fee-for-service air-conditioning management in balancing thermal comfort and energy usage.

PubMed

Chen, Chen-Peng; Hwang, Ruey-Lung; Shih, Wen-Mei

2014-11-01

Balancing thermal comfort with the requirement of energy conservation presents a challenge in hot and humid areas where air-conditioning (AC) is frequently used in cooling indoor air. A field survey was conducted in Taiwan to demonstrate the adaptive behaviors of occupants in relation to the use of fans and AC in a school building employing mixed-mode ventilation where AC use was managed under a fee-for-service mechanism. The patterns of using windows, fans, and AC as well as the perceptions of students toward the thermal environment were examined. The results of thermal perception evaluation in relation to the indoor thermal conditions were compared to the levels of thermal comfort predicted by the adaptive models described in the American Society of Heating, Refrigerating, and Air-Conditioning Engineers Standard 55 and EN 15251 and to that of a local model for evaluating thermal adaption in naturally ventilated buildings. A thermal comfort-driven adaptive behavior model was established to illustrate the probability of fans/AC use at specific temperature and compared to the temperature threshold approach to illustrate the potential energy saving the fee-for-service mechanism provided. The findings of this study may be applied as a reference for regulating the operation of AC in school buildings of subtropical regions.

46 CFR 11.435 - Service requirements for master of inland steam or motor vessels of any gross tons.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 1 2010-10-01 2010-10-01 false Service requirements for master of inland steam or motor... Deck Officers § 11.435 Service requirements for master of inland steam or motor vessels of any gross... (excluding the Great Lakes) steam or motor vessels of any gross tons is: (a) One year of service as first...

Effect of body position and ventilation on umbilical artery and venous blood flows during delayed umbilical cord clamping in preterm lambs.

PubMed

Hooper, Stuart B; Crossley, Kelly J; Zahra, Valerie A; van Vonderen, Jeroen; Moxham, Alison; Gill, Andrew W; Kluckow, Martin; Te Pas, Arjan B; Wallace, Euan M; Polglase, Graeme R

2017-07-01

While delayed umbilical cord clamping (UCC) is thought to facilitate placental to infant blood transfusion, the physiological factors regulating flow in the umbilical arteries and veins during delayed UCC is unknown. We investigated the effects of gravity, by changing fetal height relative to the placenta, and ventilation on umbilical blood flows and the cardiovascular transition during delayed UCC at birth. Catheters and flow probes were implanted into preterm lambs (128 days) prior to delivery to measure pulmonary, carotid, umbilical artery (UaBF) and umbilical venous (UvBF) blood flows. Lambs were placed either 10 cm below or 10 cm above the ewe. Ventilation commenced 2-3 min before UCC and continued for 30 min after UCC. Gravity reduced umbilical and cerebral flows when lambs were placed below the midline, but the reduction in UaBF and UvBF was similar. Ventilation during delayed UCC reduced UvBF and UaBF by similar amounts, irrespective of the lamb's position, such that flows into and out of the placenta remained balanced. The effects of ventilation on umbilical flows were much greater than the effects of gravity, but no net placental to lamb blood transfusion could be detected under any condition. Cardiovascular parameters, cerebral oxygen kinetics and final blood volumes were similar in both groups 5 min after UCC. Gravity caused small transient effects on umbilical and cerebral flow, but given changes were similar in umbilical arteries and veins, no net placental transfusion was detected. Ventilation during delayed UCC has a markedly greater influence on cardiovascular function in the newborn. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Influence of taekwondo as security martial arts training on anaerobic threshold, cardiorespiratory fitness, and blood lactate recovery.

PubMed

Kim, Dae-Young; Seo, Byoung-Do; Choi, Pan-Am

2014-04-01

[Purpose] This study was conducted to determine the influence of Taekwondo as security martial arts training on anaerobic threshold, cardiorespiratory fitness, and blood lactate recovery. [Subjects and Methods] Fourteen healthy university students were recruited and divided into an exercise group and a control group (n = 7 in each group). The subjects who participated in the experiment were subjected to an exercise loading test in which anaerobic threshold, value of ventilation, oxygen uptake, maximal oxygen uptake, heart rate, and maximal values of ventilation / heart rate were measured during the exercise, immediately after maximum exercise loading, and at 1, 3, 5, 10, and 15 min of recovery. [Results] At the anaerobic threshold time point, the exercise group showed a significantly longer time to reach anaerobic threshold. The exercise group showed significantly higher values for the time to reach VO2max, maximal values of ventilation, maximal oxygen uptake and maximal values of ventilation / heart rate. Significant changes were observed in the value of ventilation volumes at the 1- and 5-min recovery time points within the exercise group; oxygen uptake and maximal oxygen uptake were significantly different at the 5- and 10-min time points; heart rate was significantly different at the 1- and 3-min time points; and maximal values of ventilation / heart rate was significantly different at the 5-min time point. The exercise group showed significant decreases in blood lactate levels at the 15- and 30-min recovery time points. [Conclusion] The study results revealed that Taekwondo as a security martial arts training increases the maximal oxygen uptake and anaerobic threshold and accelerates an individual's recovery to the normal state of cardiorespiratory fitness and blood lactate level. These results are expected to contribute to the execution of more effective security services in emergencies in which violence can occur.

Randomised comparison of two neonatal resuscitation bags in manikin ventilation.

PubMed

Thallinger, Monica; Ersdal, Hege Langli; Ombay, Crescent; Eilevstjønn, Joar; Størdal, Ketil

2016-07-01

To compare ventilation properties and user preference of a new upright neonatal resuscitator developed for easier cleaning, reduced complexity, and possibly improved ventilation properties, with the standard Laerdal neonatal resuscitator. Eighty-seven Tanzanian and Norwegian nursing and medical students without prior knowledge of newborn resuscitation were briefly trained in bag-mask ventilation. The two resuscitators were used in random order on a manikin connected to a test lung with normal or low lung compliance. Data were collected with the Laerdal Newborn Resuscitation Monitor. The students graded mask seal and ease of air entry on a four-point scale ranging from 1 ('difficult') to 4 ('easy') and stated which device they preferred. (Equipment from Laerdal Global Health and Laerdal Medical). For upright versus standard resuscitator and normal lung compliance, mean expiratory lung volume was 15.5 mL vs 13.9 mL (p=0.001), mean mask leakage 48% vs 58% (p<0.001), and mean airway pressure 20 cm H2O vs 19 cm H2O (p=0.003), respectively. For low lung compliance, mean expiratory lung volume was 8.6 mL vs 8.1 mL (p=0.045), mean mask leakage 53% vs 62% (p<0.001), and mean airway pressure 21 cm H2O vs 20 cm H2O (p=0.004) for upright versus standard. The upright resuscitator was preferred by 82% and 68% of students during ventilation with normal and low lung compliance, respectively (p=0.001). Expiratory volumes were higher, mask leakage lower, and mean airway pressure slightly higher with upright versus standard resuscitator when ventilating a manikin. The majority of students preferred the upright resuscitator. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Exposure to nitrogen dioxide in an indoor ice arena - New Hampshire, 2011.

PubMed

2012-03-02

In January 2011, the New Hampshire Department of Health and Human Services (NHDHHS) investigated acute respiratory symptoms in a group of ice hockey players. The symptoms, which included cough, shortness of breath, hemoptysis, and chest pain or tightness, were consistent with exposure to nitrogen dioxide gas (NO), a byproduct of combustion. Environmental and epidemiologic investigations were begun to determine the source of the exposure and identify potentially exposed persons. This report summarizes the results of those investigations, which implicated a local indoor ice arena that had hosted two hockey practice sessions during a 24-hour period when the arena ventilation system was not functioning. A total of 43 exposed persons were interviewed, of whom 31 (72.1%) reported symptoms consistent with NO exposure. The highest attack rate was among the hockey players (87.9%). After repair of the ventilation system, no additional cases were identified. To prevent similar episodes, ice arena operators should ensure ventilation systems and alarms are operating properly and that levels of NO and carbon monoxide (CO) are monitored continuously for early detection of increased gas levels.

Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials.

PubMed

Guérin, Claude; Papazian, Laurent; Reignier, Jean; Ayzac, Louis; Loundou, Anderson; Forel, Jean-Marie

2016-11-29

Driving pressure (ΔPrs) across the respiratory system is suggested as the strongest predictor of hospital mortality in patients with acute respiratory distress syndrome (ARDS). We wonder whether this result is related to the range of tidal volume (V T ). Therefore, we investigated ΔPrs in two trials in which strict lung-protective mechanical ventilation was applied in ARDS. Our working hypothesis was that ΔPrs is a risk factor for mortality just like compliance (Crs) or plateau pressure (Pplat,rs) of the respiratory system. We performed secondary analysis of data from 787 ARDS patients enrolled in two independent randomized controlled trials evaluating distinct adjunctive techniques while they were ventilated as in the low V T arm of the ARDSnet trial. For this study, we used V T , positive end-expiratory pressure (PEEP), Pplat,rs, Crs, ΔPrs, and respiratory rate recorded 24 hours after randomization, and compared them between survivors and nonsurvivors at day 90. Patients were followed for 90 days after inclusion. Cox proportional hazard modeling was used for mortality at day 90. If colinearity between ΔPrs, Crs, and Pplat,rs was verified, specific Cox models were used for each of them. Both trials enrolled 805 patients of whom 787 had day-1 data available, and 533 of these survived. In the univariate analysis, ΔPrs averaged 13.7 ± 3.7 and 12.8 ± 3.7 cmH 2 O (P = 0.002) in nonsurvivors and survivors, respectively. Colinearity between ΔPrs, Crs and Pplat,rs, which was expected as these variables are mathematically coupled, was statistically significant. Hazard ratios from the Cox models for day-90 mortality were 1.05 (1.02-1.08) (P = 0.005), 1.05 (1.01-1.08) (P = 0.008) and 0.985 (0.972-0.985) (P = 0.029) for ΔPrs, Pplat,rs and Crs, respectively. PEEP and V T were not associated with death in any model. When ventilating patients with low V T , ΔPrs is a risk factor for death in ARDS patients, as is Pplat,rs or Crs. As our data originated from trials from which most ARDS patients were excluded due to strict inclusion and exclusion criteria, these findings must be validated in independent observational studies in patients ventilated with a lung protective strategy. Clinicaltrials.gov NCT00299650 . Registered 6 March 2006 for the Acurasys trial. Clinicaltrials.gov NCT00527813 . Registered 10 September 2007 for the Proseva trial.

A Simple “Blood-Saving Bundle” Reduces Diagnostic Blood Loss and the Transfusion Rate in Mechanically Ventilated Patients

PubMed Central

Riessen, Reimer; Behmenburg, Melanie; Blumenstock, Gunnar; Guenon, Doris; Enkel, Sigrid; Schäfer, Richard; Haap, Michael

2015-01-01

Introduction Aim of this study was to reduce blood loss caused by diagnostic blood sampling and to minimize the development of anemia in a high-risk group of mechanically ventilated medical intensive care patients. We therefore implemented a “blood-saving bundle” (BSB) combining a closed-loop arterial blood sampling system, smaller sampling tubes, reduced frequency of blood drawings, and reduced sample numbers. Methods The study included all patients from our medical ICU who were ventilated for more than 72 hours. Exclusion criteria were: acute or chronic anemia on admission, bleeding episode(s) during the ICU stay, or end-of-life therapy. The BSB was introduced in 2009 with training and educational support. Patients treated in 2008, before the introduction of the BSB, served as a control group (n = 41, 617 observation days), and were compared with patients treated in 2010 after the introduction of the BSB (BSB group, n = 50, 559 observation days). Primary endpoints were blood loss per day, and development of anemia. Secondary endpoints were numbers of blood transfusions, number of days on mechanical ventilation, and length of the ICU stay. Results Mean blood loss per ICU day was decreased from 43.3 ml (95% CI: 41.2 to 45.3 ml) in the controls to 15.0 ml (14.3 to 15.7 ml) in the BSB group (P < 0.001). The introduction of a closed-loop arterial blood sampling system was the major contributor to this effect. Mean hemoglobin concentrations showed no significant differences in both groups during the ICU stay. Hemoglobin values <9 g/dl, however, were recorded in 21.2% of observation days in the controls versus 15.4% in the BSB group (P = 0.01). Units of transfused red blood cells per 100 observation days decreased from 7 to 2.3 (P < 0.001). The mean number of ventilation days was 7.1 days (6.1 to 8.3 days) in the controls and 7.5 days (6.6 to 8.5 days) in the BSB group (P = NS). In total, patients in the BSB group stayed in ICU for a mean of 9.9 days (8.6 to 11.3 days), compared to a mean ICU stay of 13.0 days (10.9 to 15.4 days) in the control group (P = 0.014). Due to the longitudinal study design, however, we cannot exclude uncontrolled confounders affecting the transfusion frequency and mean ICU stay. Conclusion Our BSB could be easily implemented and was able to reduce diagnostic blood loss. PMID:26421920

E-education in Refrigeration Technologies for Students and Technicians in the Workplace

ERIC Educational Resources Information Center

Lenaerts, Marnik; Schreurs, Marc; Reulens, Walter

2011-01-01

The demand for broadly educated engineers, installers and service technicians is growing because of the strong growth in refrigeration, air conditioning and heating. The rapid technological evolution makes it impossible for a school or training centre to invest in all HVAC (heating ventilation and air conditioning) and refrigeration fields. It is…

14 CFR 23.853 - Passenger and crew compartment interiors.

Code of Federal Regulations, 2012 CFR

2012-01-01

... ventilation expected in service must be demonstrated by test. A placard containing the legible words “No... side of each lavatory door served. The placards must have red letters at least 1/2 inch high on a white... crew or passengers must meet the following test criteria as applicable: (i) Interior ceiling panels...

[Decrease in paO2 following intratracheal application of a local anesthetic and a 0.9% sodium chloride solution. A prospective study on the use of fiberoptic bronchoscopy in ventilated patients during local anesthesia].

PubMed

Konrad, F; Deller, A; Diatzko, J; Schmitz, J E; Kilian, J

1989-04-01

Flexible fiberoptic bronchoscopy of intubated patients can be performed in general or local anesthesia (LA). Up to now, no results have been published on the effects of LA for bronchoscopy in ventilated patients. We studied the hemodynamic changes caused by bronchoscopy under LA in mechanically ventilated patients and the effect of LA on the endoscopic decline in arterial pO2. Differences between the widely used agents lidocaine and oxybuprocaine hydrochloride were also studied. We found a decline in paO2 after the administration of LA and further investigated the influence of bronchial lavage on paO2. METHOD. A total of 70 ventilator patients, excluding patients with atelectasis, massive mucous-plug retention, and those under muscle relaxants, were examined in a surgical intensive care unit. In 40 long-term ventilator patients bronchoscopy was performed with either oxybuprocaine hydrochloride 1% (Novesin) (group 1; n = 20) or Lidocaine 1% (Xylocaine) (group 2; n = 20) (2-3 ml LA in repeated doses into the trachea and main bronchi; total amount 10 ml). We looked for hemodynamic changes and effects of LA on the bronchoscopic decline in paO2. In 15 long-term ventilator patients (group 3), LA was applied without bronchoscopy to investigate the duration of the LA-caused decline in paO2. In 15 intubated patients (group 4), the influence of intratracheal administration of 10 ml normal saline was examined. Patient data are shown in Table 2. Measurements were performed in groups 1 and 2 before and after LA, immediately after bronchoscopy and 15, 30, and 60 min after bronchoscopy and in groups 3 and 4 before and 5, 15, 30, and 60 min after LA. RESULTS. There was no effect on cardiocirculatory function during bronchoscopy in LA, but we found a decrease in paO2 after administration of LA in all patients (median in group 1 from 100 to 78 mmHg in group 2 from 104 to 86 mmHg). The subsequent bronchoscopy caused only a small, nonsignificant further decline in paO2. The administration of LA without bronchoscopy (group 3) was followed by a fall in paO2 from 86 +/- 12.5 to 69 +/- 11.7 mmHg (mean +/- SD) with oxybuprocaine hydrochloride and from 87 +/- 12.4 to 72 +/- 8.7 mmHg with lidocaine. Even after 30 min the paO2 had not returned to the initial value. The intratracheal application of 10 ml 0.9% NaCl caused a decline in paO2 from 101 +/- 20 to 78 +/- 12 mmHg (mean +/- SD), which also persisted for more than 30 min. CONCLUSIONS. The study shows that in ventilator patients undergoing fiberoptic bronchoscopy in LA, the administration of the LA is an essential factor in the decline in paO2 associated with bronchoscopy. A similar fall in paO2 is observed by intratracheal

42 CFR 456.51 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... institution for mental disease, as defined in § 440.10; (2) [Reserved] (3) Services provided in specialty hospitals and (b) Exclude services provided in mental hospitals. Utilization control requirements for mental... ASSISTANCE PROGRAMS UTILIZATION CONTROL Utilization Control: Hospitals § 456.51 Definitions. As used in this...

49 CFR 398.6 - Hours of service of drivers; maximum driving time.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Hours of service of drivers; maximum driving time... REGULATIONS TRANSPORTATION OF MIGRANT WORKERS § 398.6 Hours of service of drivers; maximum driving time. No... or operate for more than 10 hours in the aggregate (excluding rest stops and stops for meals) in any...

49 CFR 398.6 - Hours of service of drivers; maximum driving time.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 5 2010-10-01 2010-10-01 false Hours of service of drivers; maximum driving time... REGULATIONS TRANSPORTATION OF MIGRANT WORKERS § 398.6 Hours of service of drivers; maximum driving time. No... or operate for more than 10 hours in the aggregate (excluding rest stops and stops for meals) in any...

Scholarly Service and the Scholarship of Service

ERIC Educational Resources Information Center

Lee, E. Suzanne

2009-01-01

The scholarship of teaching has received a considerable amount of attention in recent years, with new recognition that faculty members' research does not necessarily exclude their pedagogy. But research and teaching are not the only parts of their lives as faculty members. Much of what they do on their campuses comes under the heading of service.…

A Management Study of the MCPS Accounting System and Certain Related Financial Services Functions. Final Report.

ERIC Educational Resources Information Center

Young (Arthur) and Co., Washington, DC.

Several years ago, Montgomery County Public Schools (MCPS) began a Management Operations Review and Evaluation (MORE) of the entire school system, excluding school-based instruction. This MORE study is an evaluation of MCPS's current accounting system and certain related financial services functions within the Department of Financial Services. In…

Analysis of USDA Forest Service fire-related expenditures 1970-1995

Treesearch

Ervin G. Schuster; David A. Cleaves; Enoch F. Bell

1997-01-01

Forest Service expenditures for fire presuppression and suppression activities increased from $61 million in FY 1970 to $951 million in FY 1994. Yet, real (net of inflation) expenditures have not increased significantly since FY 1970, if FY 1994 expenditures are excluded. During any given year, 56 percent of suppression expenditures are spent on supplies and services,...

50 CFR Figure 5 to Part 223 - Net Diagram for the Excluder Panel of the Parker Soft TED

Code of Federal Regulations, 2011 CFR

2011-10-01

... 50 Wildlife and Fisheries 9 2011-10-01 2011-10-01 false Net Diagram for the Excluder Panel of the Parker Soft TED 5 Figure 5 to Part 223 Wildlife and Fisheries NATIONAL MARINE FISHERIES SERVICE, NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION, DEPARTMENT OF COMMERCE MARINE MAMMALS THREATENED MARINE AND ANADROMOUS SPECIES Pt. 223, Fig. 5 Figure 5...

'To each according to his needs': public libraries and socially excluded people.

PubMed

Hicken, Mandy

2004-09-01

To deliver a comprehensive and efficient service to all the community, public libraries must first identify needs and allocate an appropriate level of resources. This article focuses on public libraries in England. It outlines: the Government's policy on social inclusion; the needs of the various socially excluded groups; partnerships and funding; staff training and motivation; and examples of good practice.

50 CFR Figure 5 to Part 223 - Net Diagram for the Excluder Panel of the Parker Soft TED

Code of Federal Regulations, 2014 CFR

2014-10-01

... 50 Wildlife and Fisheries 10 2014-10-01 2014-10-01 false Net Diagram for the Excluder Panel of the Parker Soft TED 5 Figure 5 to Part 223 Wildlife and Fisheries NATIONAL MARINE FISHERIES SERVICE, NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION, DEPARTMENT OF COMMERCE MARINE MAMMALS THREATENED MARINE AND ANADROMOUS SPECIES Pt. 223, Fig. 5 Figure ...

50 CFR Figure 5 to Part 223 - Net Diagram for the Excluder Panel of the Parker Soft TED

Code of Federal Regulations, 2012 CFR

2012-10-01

... 50 Wildlife and Fisheries 10 2012-10-01 2012-10-01 false Net Diagram for the Excluder Panel of the Parker Soft TED 5 Figure 5 to Part 223 Wildlife and Fisheries NATIONAL MARINE FISHERIES SERVICE, NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION, DEPARTMENT OF COMMERCE MARINE MAMMALS THREATENED MARINE AND ANADROMOUS SPECIES Pt. 223, Fig. 5 Figure ...

50 CFR Figure 5 to Part 223 - Net Diagram for the Excluder Panel of the Parker Soft TED

Code of Federal Regulations, 2013 CFR

2013-10-01

... 50 Wildlife and Fisheries 10 2013-10-01 2013-10-01 false Net Diagram for the Excluder Panel of the Parker Soft TED 5 Figure 5 to Part 223 Wildlife and Fisheries NATIONAL MARINE FISHERIES SERVICE, NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION, DEPARTMENT OF COMMERCE MARINE MAMMALS THREATENED MARINE AND ANADROMOUS SPECIES Pt. 223, Fig. 5 Figure ...

50 CFR Figure 5 to Part 223 - Net Diagram for the Excluder Panel of the Parker Soft TED

Code of Federal Regulations, 2010 CFR

2010-10-01

... 50 Wildlife and Fisheries 7 2010-10-01 2010-10-01 false Net Diagram for the Excluder Panel of the Parker Soft TED 5 Figure 5 to Part 223 Wildlife and Fisheries NATIONAL MARINE FISHERIES SERVICE, NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION, DEPARTMENT OF COMMERCE MARINE MAMMALS THREATENED MARINE AND ANADROMOUS SPECIES Pt. 223, Fig. 5 Figure 5...

Increased ICU resource needs for an academic emergency general surgery service*.

PubMed

Lissauer, Matthew E; Galvagno, Samuel M; Rock, Peter; Narayan, Mayur; Shah, Paulesh; Spencer, Heather; Hong, Caron; Diaz, Jose J

2014-04-01

ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. Retrospective database review. Academic, tertiary care, nontrauma surgical ICU. All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. None. Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (13.5 ± 17.4 d) versus general surgery (8.7 ± 12.9), transplant (7.8 ± 11.6), oral-maxillofacial surgery (5.5 ± 4.2), and neurosurgery (4.47 ± 9.8) (all p< 0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 10.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.001 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p < 0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources.

Pleural Puncture that Excludes the Ablation Zone Decreases the Risk of Pneumothorax after Percutaneous Microwave Ablation in Porcine Lung

PubMed Central

Lee, Kyungmouk Steve; Takaki, Haruyuki; Yarmohammadi, Hooman; Srimathveeravalli, Govindarajan; Luchins, Kerith; Monette, Sébastien; Nair, Sreejit; Kishore, Sirish; Erinjeri, Joseph P.

2017-01-01

Purpose To test the hypothesis that the geometry of probe placement with respect to the pleural puncture site affects the risk of pneumothorax after microwave (MW) ablation in the lung. Materials and Methods Computed tomography–guided MW ablation of the lung was performed in 8 swine under general anesthesia and mechanical ventilation. The orientation of the 17-gauge probe was either perpendicular (90°) or parallel (< 30°) with respect to the pleural puncture site, and the ablation power was 30 W or 65 W for 5 minutes. After MW ablation, swine were euthanized, and histopathologic changes were assessed. Frequency and factors affecting pneumothorax were evaluated by multivariate analysis. Results Among 62 lung MW ablations, 13 (21%) pneumothoraces occurred. No statistically significant difference was noted in the rate of pneumothorax between the perpendicular and the parallel orientations of the probe (31% vs 14%; odds ratio [OR], 2.8; P = .11). The pneumothorax rate was equal for 65-W and 30-W ablation powers (21% and 21%; OR, 1.0; P = .94). Under multivariate analysis, 2 factors were independent positive predictors of pneumothorax: ablation zone inclusive of pleural insertion point (OR, 7.7; P = .02) and time since intubation (hours) (OR, 2.7; P = .02). Conclusions Geometries where the pleural puncture site excluded the ablation zone decreased pneumothorax in swine undergoing MW ablation in the lung. Treatment planning to ensure that the pleural puncture site excludes the subsequent ablation zone may reduce the rate of pneumothorax in patients undergoing MW ablation in the lung. PMID:25753501

[Amyotrophic lateral sclerosis--diagnosis and treatment].

PubMed

Jung, H H; Neumann, M; Bloch, K E

2012-07-04

Amyotrophic lateral sclerosis (ALS) represents the most common motoneuron disorder in adulthood. It is characterized by selective degeneration of the motoneurons. About 10% of patients have a genetically determined ALS. Clinically, ALS is characterized by coexistence of signs of the first motoneuron, such as spasticity and hyperreflexia, as well as the second motoneuron, such as muscular atrophy and fasciculations. If such signs are present in at least three regions and if other possible causes have been excluded, a definite diagnosis of ALS can be made based on the revised El-Escorial criteria. Initial manifestations are often focalized and generalization develops during the course. The glutamate antagonist riluzole is worldwide the only approved ALS treatment. However, symptomatic treatments to ameliorate spasticity, drooling, speech and swallowing problems, and assisted ventilation to treat respiratory failure are essential.

Case Report: Bilateral reexpansion pulmonary edema following treatment of a unilateral hemothorax

PubMed Central

de Wolf, Steven P; Deunk, Jaap; Cornet, Alexander D; Elbers, Paul WG

2014-01-01

Bilateral re-expansion pulmonary edema (RPE) is an extremely rare entity. We report the unique case of bilateral RPE following a traumatic, unilateral hemopneumothorax in a young healthy male. Bilateral RPE occurred only one hour after drainage of a unilateral hemopneumothorax. The patient was treated with diuretics and supplemental oxygen. Diagnosis was confirmed by excluding other causes, using laboratory findings, chest radiography, pulmonary and cardiac ultrasound and high resolution computed tomography. His recovery was uneventful. The pathophysiology of bilateral RPE is not well known. Treatment is mainly supportive and consists of diuretics, mechanical ventilation, inotropes and steroids. In case of a pulmonary deterioration after the drainage of a traumatic pneumothorax, bilateral RPE should be considered after exclusion of more common causes of dyspnea. PMID:25713699

Performance of cardiopulmonary resuscitation during prolonged basic life support in military medical university students: A manikin study.

PubMed

Wang, Juan; Zhuo, Chao-Nan; Zhang, Lei; Gong, Yu-Shun; Yin, Chang-Lin; Li, Yong-Qin

2015-01-01

The quality of chest compressions can be significantly improved after training of rescuers according to the latest national guidelines of China. However, rescuers may be unable to maintain adequate compression or ventilation throughout a response of average emergency medical services because of increased rescuer fatigue. In the present study, we evaluated the performance of cardiopulmonary resuscitation (CPR) in training of military medical university students during a prolonged basic life support (BLS). A 3-hour BLS training was given to 120 military medical university students. Six months after the training, 115 students performed single rescuer BLS on a manikin for 8 minutes. The qualities of chest compressions as well as ventilations were assessed. The average compression depth and rate were 53.7±5.3 mm and 135.1±15.7 compressions per minute respectively. The proportion of chest compressions with appropriate depth was 71.7%±28.4%. The average ventilation volume was 847.2±260.4 mL and the proportion of students with adequate ventilation was 63.5%. Compared with male students, significantly lower compression depth (46.7±4.8 vs. 54.6±4.8 mm, P<0.001) and adequate compression rate (35.5%±26.5% vs. 76.1%±25.1%, P<0.001) were observed in female students. CPR was found to be related to gender, body weight, and body mass index of students in this study. The quality of chest compressions was well maintained in male students during 8 minutes of conventional CPR but declined rapidly in female students after 2 minutes according to the latest national guidelines. Physical fitness and rescuer fatigue did not affect the quality of ventilation.

Performance of cardiopulmonary resuscitation during prolonged basic life support in military medical university students: A manikin study

PubMed Central

Wang, Juan; Zhuo, Chao-nan; Zhang, Lei; Gong, Yu-shun; Yin, Chang-lin; Li, Yong-qin

2015-01-01

BACKGROUND: The quality of chest compressions can be significantly improved after training of rescuers according to the latest national guidelines of China. However, rescuers may be unable to maintain adequate compression or ventilation throughout a response of average emergency medical services because of increased rescuer fatigue. In the present study, we evaluated the performance of cardiopulmonary resuscitation (CPR) in training of military medical university students during a prolonged basic life support (BLS). METHODS: A 3-hour BLS training was given to 120 military medical university students. Six months after the training, 115 students performed single rescuer BLS on a manikin for 8 minutes. The qualities of chest compressions as well as ventilations were assessed. RESULTS: The average compression depth and rate were 53.7±5.3 mm and 135.1±15.7 compressions per minute respectively. The proportion of chest compressions with appropriate depth was 71.7%±28.4%. The average ventilation volume was 847.2±260.4 mL and the proportion of students with adequate ventilation was 63.5%. Compared with male students, significantly lower compression depth (46.7±4.8 vs. 54.6±4.8 mm, P<0.001) and adequate compression rate (35.5%±26.5% vs. 76.1%±25.1%, P<0.001) were observed in female students. CONCLUSIONS: CPR was found to be related to gender, body weight, and body mass index of students in this study. The quality of chest compressions was well maintained in male students during 8 minutes of conventional CPR but declined rapidly in female students after 2 minutes according to the latest national guidelines. Physical fitness and rescuer fatigue did not affect the quality of ventilation. PMID:26401177

26 CFR 1.468B-0 - Table of contents.

Code of Federal Regulations, 2011 CFR

2011-04-01

... Internal Revenue INTERNAL REVENUE SERVICE, DEPARTMENT OF THE TREASURY (CONTINUED) INCOME TAX (CONTINUED... services. (2) CERCLA liabilities. (g) Excluded liabilities. (h) Segregation requirement. (1) In general. (2... settlement fund. (f) Distribution of property. (g) Other taxes. (h) Denial of credits against tax. (i...

47 CFR 22.717 - Procedure for mutually exclusive applications in the Rural Radiotelephone Service.

Code of Federal Regulations, 2010 CFR

2010-10-01

... channel in the same area, or the technical proposals are otherwise in conflict. See § 22.567. (b) A... exclusive applications of any type in either service to be “cut off” (excluded from a same-day filing group...

12 CFR 618.8040 - Authorized insurance services.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 618.8040 Banks and Banking FARM CREDIT ADMINISTRATION FARM CREDIT SYSTEM GENERAL PROVISIONS Member Insurance § 618.8040 Authorized insurance services. (a) Farm Credit System banks (excluding banks for... member's or borrower's farm or aquatic unit is permitted, but limited to hail and multiple-peril crop...

12 CFR 618.8040 - Authorized insurance services.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 618.8040 Banks and Banking FARM CREDIT ADMINISTRATION FARM CREDIT SYSTEM GENERAL PROVISIONS Member Insurance § 618.8040 Authorized insurance services. (a) Farm Credit System banks (excluding banks for... member's or borrower's farm or aquatic unit is permitted, but limited to hail and multiple-peril crop...

12 CFR 618.8040 - Authorized insurance services.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 618.8040 Banks and Banking FARM CREDIT ADMINISTRATION FARM CREDIT SYSTEM GENERAL PROVISIONS Member Insurance § 618.8040 Authorized insurance services. (a) Farm Credit System banks (excluding banks for... member's or borrower's farm or aquatic unit is permitted, but limited to hail and multiple-peril crop...

[Descriptive Analysis of Health Economics of Intensive Home Care of Ventilated Patients].

PubMed

Lehmann, Yvonne; Ostermann, Julia; Reinhold, Thomas; Ewers, Michael

2018-05-14

Long-term ventilated patients in Germany receive intensive care mainly in the patients' home or in assisted-living facilities. There is a lack of knowledge about the nature and extent of resource use and costs associated with care of this small, heterogeneous but overall growing patient group. A sub-study in the context of a research project SHAPE analyzed costs of 29 patients descriptively from a social perspective. Direct and indirect costs of intensive home care over a period of three months were recorded and analyzed retrospectively. Standardized recorded written self-reports from patients and relatives as well as information from the interviewing of nursing staff and from nursing documentation were the basis for this analysis. There was an average total cost of intensive home care for three months per patient of 61194 € (95% CI 53 884-68 504) including hospital stays. The main costs were directly linked to outpatient medical and nursing care provided according to the Code of Social Law V and XI. Services provided by nursing home care service according to § 37(2) Code of Social Law V (65%) were the largest cost item. Approximately 13% of the total costs were attributable to indirect costs. Intensive home care for ventilated patients is resource-intensive and cost-intensive and has received little attention also from a health economics perspective. Valid information and transparency about the cost structures are required for an effective and economic design and management of the long-term care of this patient group. © Georg Thieme Verlag KG Stuttgart · New York.

Calibration of an In-Ear Dosimeter for a Single Hearing Protection Device

DTIC Science & Technology

2014-02-01

history of ototoxic medication use, audiological history of tinnitus , etc. A total of 54 subjects were screened to participate in this study.1 subject...was excluded from this study based on a history of seizures. 18 subjects were excluded based on hearing threshold results. 15 subjects were...Military Service: Implications for hearing loss and tinnitus ”, Washington, DC, National Academies Press. 7. United States Government Accountability Office

Forest products from Latin America : annotated bibliography of world literature on research, industry, and resource of Latin America 1915 to 1989

Treesearch

Robert R. Maeglin; R. Sidney Boone

1993-01-01

This document provides over 4,000 citations from the world literature on forest products for Latin America. Citations are grouped in 11 subject areas, with emphasis on products made directly from wood. Excluded are nonwood products such as rattan, bamboo, nuts, fruits, honey, and mushrooms. Also excluded are services from the forest, such as watershed protection,...

Corporate Social Responsibility Initiatives Addressing Social Exclusion in Bangladesh

PubMed Central

2009-01-01

The private sector is often seen as a driver of exclusionary processes rather than a partner in improving the health and welfare of socially-excluded populations. However, private-sector initiatives and partnerships—collectively labelled corporate social responsibility (CSR) initiatives—may be able to positively impact social status, earning potential, and access to services and resources for socially-excluded populations. This paper presents case studies of CSR projects in Bangladesh that are designed to reduce social exclusion among marginalized populations and explores whether CSR initiatives can increase economic and social capabilities to reduce exclusion. The examples provide snapshots of projects that (a) increase job-skills and employment opportunities for women, disabled women, and rehabilitated drug-users and (b) provide healthcare services to female workers and their communities. The CSR case studies cover a limited number of people but characteristics and practices replicable and scaleable across different industries, countries, and populations are identified. Common success factors from the case studies form the basis for recommendations to design and implement more CSR initiatives targeting socially-excluded groups. The analysis found that CSR has potential for positive and lasting impact on developing countries, especifically on socially-excluded populations. However, there is a need for additional monitoring and critical evaluation. PMID:19761088

26 CFR 1.410(b)-6 - Excludable employees.

Code of Federal Regulations, 2011 CFR

2011-04-01

... section are applied by treating all plans in the testing group as a single plan. (b) Minimum age and... greatest permissible minimum age and service requirement because the ratio percentage of that group of...)-6 Internal Revenue INTERNAL REVENUE SERVICE, DEPARTMENT OF THE TREASURY (CONTINUED) INCOME TAX...

42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Special Treatment of Certain Facilities Under the Prospective Payment System for Inpatient Operating Costs... including days and discharges from units excluded from the prospective payment system under §§ 412.25...

42 CFR 455.3 - Other applicable regulations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 4 2010-10-01 2010-10-01 false Other applicable regulations. 455.3 Section 455.3 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES.... Part 1002 of this title sets forth the following: (a) State plan requirements for excluding providers...

42 CFR § 512.210 - Included and excluded services.

Code of Federal Regulations, 2010 CFR

2017-10-01

... SERVICES (CONTINUED) HEALTH CARE INFRASTRUCTURE AND MODEL PROGRAMS EPISODE PAYMENT MODEL Scope of Episodes...) Certain PBPM payments under models tested under section 1115A of the Act that CMS determines to be... PBPM model payments funded from the Innovation Center appropriation. (c) Updating the exclusion lists...

42 CFR 402.210 - Notices.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Notices. 402.210 Section 402.210 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS CIVIL... Federal health care program in accordance with this part, notice of the proposed determination to exclude...

Adaptive servo-ventilation therapy for patients with chronic heart failure in a confirmatory, multicenter, randomized, controlled study.

PubMed

Momomura, Shin-Ichi; Seino, Yoshihiko; Kihara, Yasuki; Adachi, Hitoshi; Yasumura, Yoshio; Yokoyama, Hiroyuki; Wada, Hiroshi; Ise, Takayuki; Tanaka, Koichi

2015-01-01

Adaptive servo-ventilation (ASV) therapy is expected to be novel nonpharmacotherapy with hemodynamic effects on patients with chronic heart failure (CHF), but sufficient evidence has not been obtained. A 24-week, open-label, randomized, controlled study was performed to confirm the cardiac function-improving effect of ASV therapy on CHF patients. At 39 institutions, 213 outpatients with CHF, whose left ventricular ejection fraction (LVEF) was <40% and who had mild to severe symptoms [New York Heart Association (NYHA) class: ≥II], were enrolled. After excluding 8 patients, 102 and 103 underwent ASV plus guideline-directed medical therapy (GDMT) [ASV group] and GDMT only [control group], respectively. The primary endpoint was LVEF, and the secondary endpoints were HF deterioration, B-type natriuretic peptide (BNP), and clinical composite response (CCR: NYHA class+HF deterioration). LVEF and BNP improved significantly at completion against the baseline values in the 2 groups. However, no significant difference was found between these groups. HF deterioration tended to be suppressed. The ASV group showed a significant improvement in CCR corroborated by significant improvements in NYHA class and ADL against the control group. Under the present study's conditions, ASV therapy was not superior to GDMT in the cardiac function-improving effect but showed a clinical status-improving effect, thus indicating a given level of clinical benefit.

Temporal variation of the leak pressure of uncuffed endotracheal tubes following pediatric intubation: an observational study.

PubMed

Patel, Shreya; Lalwani, Kirk; Koh, Jeffrey; Wu, Lei; Fu, Rongwei

2014-06-01

Uncuffed endotracheal tubes are still preferred over cuffed tubes in certain situations in pediatric anesthesia. Inaccurately sized uncuffed endotracheal tubes may lead to inadequate ventilation or tracheal mucosal damage during anesthesia. Endotracheal tube size in children is usually assessed by measuring the audible leak pressure; if the fit of the tube and the leak pressure decrease significantly with time, reintubation during surgery as a result of inability to ventilate effectively may be challenging, and could lead to patient morbidity. There is no evidence to indicate whether leak pressure increases or decreases with time following endotracheal intubation with uncuffed tubes in children. We measured leak pressure for 30 min following tracheal intubation in 46 ASA I children age 0-7 years after excluding factors known to modify leak pressure. The largest mean change in leak pressure occurred between time points 0 and 15 min, an increase of 3.5 cmH2O. Endotracheal tube size and type of procedure were associated with the leak pressure. In the final linear mixed model, there were no statistically significant variations in leak pressure over time (P = 0.129) in this group of children. We did not identify a consistent change in leak pressure within 30 min following tracheal intubation with uncuffed endotracheal tubes in this group of children.

Do classroom ventilation rates in California elementary schools influence standardized test scores? Results from a prospective study.

PubMed

Mendell, M J; Eliseeva, E A; Davies, M M; Lobscheid, A

2016-08-01

Limited evidence has associated lower ventilation rates (VRs) in schools with reduced student learning or achievement. We analyzed longitudinal data collected over two school years from 150 classrooms in 28 schools within three California school districts. We estimated daily classroom VRs from real-time indoor carbon dioxide measured by web-connected sensors. School districts provided individual-level scores on standard tests in Math and English, and classroom-level demographic data. Analyses assessing learning effects used two VR metrics: average VRs for 30 days prior to tests, and proportion of prior daily VRs above specified thresholds during the year. We estimated relationships between scores and VR metrics in multivariate models with generalized estimating equations. All school districts had median school-year VRs below the California VR standard. Most models showed some positive associations of VRs with test scores; however, estimates varied in magnitude and few 95% confidence intervals excluded the null. Combined-district models estimated statistically significant increases of 0.6 points (P = 0.01) on English tests for each 10% increase in prior 30-day VRs. Estimated increases in Math were of similar magnitude but not statistically significant. Findings suggest potential small positive associations between classroom VRs and learning. Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

77 FR 28626 - Biweekly Notice, Applications and Amendments to Facility Operating Licenses and Combined Licenses...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-05-15

... Water System, the Auxiliary Building Filtered Ventilation Exhaust System, or the Diesel Generators... nuclear service water system (NSWS) for a time period of 14 days. Basis for proposed no significant... the diesel generator buildings in the event of a leak or a break in the system piping. The probability...

Integrated Utility Systems Feasibility Study and Conceptual Design at the University of Florida. Executive Summary.

ERIC Educational Resources Information Center

Kirmse, Dale W.; Manyimo, Steve B.

This executive summary presents a brief analysis of findings and recommendations. The concept of the Integrated Utility System (IUS) is to consider the interaction and mutual support of five utility subsystems needed by a campus complex of buildings. The subsystems are: (1) Electric power service; (2) Heating - ventilating - air conditioning and…

Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries).

PubMed

de Lesquen, Henri; Avaro, Jean-Philippe; Gust, Lucile; Ford, Robert Michael; Beranger, Fabien; Natale, Claudia; Bonnet, Pierre-Mathieu; D'Journo, Xavier-Benoît

2015-03-01

This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

42 CFR § 414.1440 - Qualifying APM participant determination: All-payer combination option.

Code of Federal Regulations, 2010 CFR

2017-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1440 Qualifying APM participant determination: All-payer combination option. (a) Payments excluded...

20 CFR 404.429 - Earnings; defined.

Code of Federal Regulations, 2013 CFR

2013-04-01

... the purpose of maintaining good will when such contact has a minimal effect on the ongoing operation... agricultural labor excluded under § 404.1055; (4) Remuneration, cash and non-cash, for service as a home worker... calendar year; (5) Services performed outside the United States in the Armed Forces of the United States...

20 CFR 404.429 - Earnings; defined.

Code of Federal Regulations, 2014 CFR

2014-04-01

... the purpose of maintaining good will when such contact has a minimal effect on the ongoing operation... agricultural labor excluded under § 404.1055; (4) Remuneration, cash and non-cash, for service as a home worker... calendar year; (5) Services performed outside the United States in the Armed Forces of the United States...

20 CFR 404.429 - Earnings; defined.

Code of Federal Regulations, 2011 CFR

2011-04-01

... the purpose of maintaining good will when such contact has a minimal effect on the ongoing operation... agricultural labor excluded under § 404.1055; (4) Remuneration, cash and non-cash, for service as a home worker... calendar year; (5) Services performed outside the United States in the Armed Forces of the United States...

20 CFR 404.429 - Earnings; defined.

Code of Federal Regulations, 2012 CFR

2012-04-01

... the purpose of maintaining good will when such contact has a minimal effect on the ongoing operation... agricultural labor excluded under § 404.1055; (4) Remuneration, cash and non-cash, for service as a home worker... calendar year; (5) Services performed outside the United States in the Armed Forces of the United States...

30 CFR 1220.011 - Schedule of allowable direct and allocable joint costs and credits.

Code of Federal Regulations, 2014 CFR

2014-07-01

... engineering design problems related to equipment or facilities required for NPSL operations. (4) The cost of any contract service related to research and development is specifically excluded, as are contract services calling for feasibility studies not directly related to specific engineering design problems or...

Prevalence and test characteristics of national health safety network ventilator-associated events.

PubMed

Lilly, Craig M; Landry, Karen E; Sood, Rahul N; Dunnington, Cheryl H; Ellison, Richard T; Bagley, Peter H; Baker, Stephen P; Cody, Shawn; Irwin, Richard S

2014-09-01

The primary aim of the study was to measure the test characteristics of the National Health Safety Network ventilator-associated event/ventilator-associated condition constructs for detecting ventilator-associated pneumonia. Its secondary aims were to report the clinical features of patients with National Health Safety Network ventilator-associated event/ventilator-associated condition, measure costs of surveillance, and its susceptibility to manipulation. Prospective cohort study. Two inpatient campuses of an academic medical center. Eight thousand four hundred eight mechanically ventilated adults discharged from an ICU. None. The National Health Safety Network ventilator-associated event/ventilator-associated condition constructs detected less than a third of ventilator-associated pneumonia cases with a sensitivity of 0.325 and a positive predictive value of 0.07. Most National Health Safety Network ventilator-associated event/ventilator-associated condition cases (93%) did not have ventilator-associated pneumonia or other hospital-acquired complications; 71% met the definition for acute respiratory distress syndrome. Similarly, most patients with National Health Safety Network probable ventilator-associated pneumonia did not have ventilator-associated pneumonia because radiographic criteria were not met. National Health Safety Network ventilator-associated event/ventilator-associated condition rates were reduced 93% by an unsophisticated manipulation of ventilator management protocols. The National Health Safety Network ventilator-associated event/ventilator-associated condition constructs failed to detect many patients who had ventilator-associated pneumonia, detected many cases that did not have a hospital complication, and were susceptible to manipulation. National Health Safety Network ventilator-associated event/ventilator-associated condition surveillance did not perform as well as ventilator-associated pneumonia surveillance and had several undesirable characteristics.

Economic effects of poor IAQ

DOE Office of Scientific and Technical Information (OSTI.GOV)

Haymore, C.; Odom, R.

Poor indoor air quality (IAQ) takes its toll in a variety of ways. It damages health and possessions; it lowers productivity at work; and it diverts resources to diagnosing and solving problems that result from it. Although the economic costs of some of these damages are fairly tangible and easy to quantify, a large portion are hidden. The cumulative impact can easily reach into the billions of dollars. The cost to diagnose, mitigate, and litigate IAQ problems is evidenced by the burgeoning number of businesses providing these services. A recent EPA survey indicated that over 1,500 firms specialize in IAQmore » services, a 25-percent increase from 1988. The median price for evaluating and balancing ventilation systems ranges from $250 to $1,500. The median for duct-cleaning service is about $500 and for asbestos abatement and construction/renovation, about $5,000. Costs can be as high as $50,000 for some of these services. The economic costs of poor IAQ also include the actual damages to property caused by contaminants. Indoor air pollutants can damage metals, paints, textiles, paper, and magnetic storage media and can cause increased soiling, deterioration of appearance, and reduced service life for furniture draperies, interiors, and heating, ventilation, and air conditioning (HVAC) equipment. Injury to people represent an even larger cost of poor IAQ. EPA ranks IAQ problems as one of the largest remaining health risks in the US. Health effects range from the mildly irritating, such as headaches and allergies, to the life threatening, such as cancer and heart disease. One study indicated that for every 100 white collar workers, poor IAQ would cause an extra 24 doctor visits per year. This amounts to another $288 million.« less

A randomised controlled trial evaluating a rehabilitation complex intervention for patients following intensive care discharge: the RECOVER study

PubMed Central

Salisbury, Lisa G; Boyd, Julia; Ramsay, Pamela; Merriweather, Judith; Huby, Guro; Forbes, John; Rattray, Janice Z; Griffith, David M; Mackenzie, Simon J; Hull, Alastair; Lewis, Steff; Murray, Gordon D

2012-01-01

Introduction Patients who survive an intensive care unit admission frequently suffer physical and psychological morbidity for many months after discharge. Current rehabilitation pathways are often fragmented and little is known about the optimum method of promoting recovery. Many patients suffer reduced quality of life. Methods and analysis The authors plan a multicentre randomised parallel group complex intervention trial with concealment of group allocation from outcome assessors. Patients who required more than 48 h of mechanical ventilation and are deemed fit for intensive care unit discharge will be eligible. Patients with primary neurological diagnoses will be excluded. Participants will be randomised into one of the two groups: the intervention group will receive standard ward-based care delivered by the NHS service with additional treatment by a specifically trained generic rehabilitation assistant during ward stay and via telephone contact after hospital discharge and the control group will receive standard ward-based care delivered by the current NHS service. The intervention group will also receive additional information about their critical illness and access to a critical care physician. The total duration of the intervention will be from randomisation to 3 months postrandomisation. The total duration of follow-up will be 12 months from randomisation for both groups. The primary outcome will be the Rivermead Mobility Index at 3 months. Secondary outcomes will include measures of physical and psychological morbidity and function, quality of life and survival over a 12-month period. A health economic evaluation will also be undertaken. Groups will be compared in relation to primary and secondary outcomes; quantitative analyses will be supplemented by focus groups with patients, carers and healthcare workers. Ethics and dissemination Consent will be obtained from patients and relatives according to patient capacity. Data will be analysed according to a predefined analysis plan. Trial registration The trial is registered as ISRCTN09412438 and funded by the Chief Scientist Office, Scotland. PMID:22761291

Effect of continuous oral suctioning on the development of ventilator-associated pneumonia: a pilot randomized controlled trial.

PubMed

Chow, Meyrick C M; Kwok, Shu-Man; Luk, Hing-Wah; Law, Jenny W H; Leung, Bartholomew P K

2012-11-01

Both continuous and intermittent aspiration of subglottic secretions by means of specially designed endotracheal tubes containing a separate dorsal lumen that opens into the subglottic region have been shown to be useful in reducing ventilator-associated pneumonia (VAP). However, the high cost of these tubes restricts their use. The aim of this pilot randomized controlled trial was to test the effect of a low-cost device (saliva ejector) for continuous oral suctioning (COS) on the incidence of VAP in patients receiving mechanical ventilation. The study was conducted in the six-bed medical-surgical ICU of a hospital with over 400 beds that provides comprehensive medical services to the public. The design of this study was a parallel-group randomized controlled trial. While both the experimental and control groups used the conventional endotracheal tube, the saliva ejector was only applied to patients assigned to the experimental group. The device was put between the patient's cheek and teeth, and then connected to 100mmHg of suction for the continuous drainage of saliva. Fourteen patients were randomized to receive COS and 13 patients were randomized to the control group. The two groups were similar in demographics, reasons for intubation, co-morbidity, and risk factors for acquiring VAP. VAP was found in 3 patients (23.1%; 71 episodes of VAP per 1000 ventilation days) receiving COS and in 10 patients (83.3%; 141 episodes of VAP per 1000 ventilation days) in the control group (relative risk, 0.28; 95% confidence interval, 0.10-0.77; p=0.003). The duration of mechanical ventilation in the experimental group was 3.2 days (SD 1.3), while that in the control group was 5.9 days (SD 2.8) (p=0.009); and the length of ICU stay was 4.8 days (SD 1.6) versus 9.8 days (SD 6.3) for the experimental and control groups, respectively (p=0.019). Continuous clearance of oral secretion by the saliva ejector may have an important role to play in reducing the rate of VAP, decreasing the duration of mechanical ventilation, and shortening the length of stay of patients in the ICU. Copyright © 2012 Elsevier Ltd. All rights reserved.

26 CFR 31.3401(a)(8)(A)-1 - Remuneration for services performed outside the United States by citizens of the United States.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 26 Internal Revenue 15 2010-04-01 2010-04-01 false Remuneration for services performed outside the... Tax at Source § 31.3401(a)(8)(A)-1 Remuneration for services performed outside the United States by citizens of the United States. (a) Remuneration excluded from gross income under section 911. (1) (i...

42 CFR 419.22 - Hospital services excluded from payment under the hospital outpatient prospective payment system.

Code of Federal Regulations, 2013 CFR

2013-10-01

... meet the requirements of § 415.102(a) of this chapter for payment on a fee schedule basis. (b) Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act. (c) Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Act. (d) Certified nurse-midwife...

46 CFR 11.455 - Service requirements for master of Great Lakes and inland steam or motor vessels of not more than...

Code of Federal Regulations, 2010 CFR

2010-10-01

... gross tons is one year of total service in the deck department of steam or motor, sail, or auxiliary sail vessels. To obtain authority to serve on the Great Lakes, three months of the required service... the United States (excluding the Great Lakes). (b) In order to obtain an endorsement for sail or...

46 CFR 11.454 - Service requirements for mate of Great Lakes and inland steam or motor vessels of not more than...

Code of Federal Regulations, 2011 CFR

2011-10-01

... gross tons is six months of service in the deck department of steam or motor, sail, or auxiliary sail... United States (excluding the Great Lakes). (b) In order to obtain an endorsement for sail or auxiliary sail vessels, the applicant must submit evidence of three months of service on sail or auxiliary sail...

46 CFR 11.454 - Service requirements for mate of Great Lakes and inland steam or motor vessels of not more than...

Code of Federal Regulations, 2010 CFR

2010-10-01

... gross tons is six months of service in the deck department of steam or motor, sail, or auxiliary sail... United States (excluding the Great Lakes). (b) In order to obtain an endorsement for sail or auxiliary sail vessels, the applicant must submit evidence of three months of service on sail or auxiliary sail...

46 CFR 11.455 - Service requirements for master of Great Lakes and inland steam or motor vessels of not more than...

Code of Federal Regulations, 2011 CFR

2011-10-01

... gross tons is one year of total service in the deck department of steam or motor, sail, or auxiliary sail vessels. To obtain authority to serve on the Great Lakes, three months of the required service... the United States (excluding the Great Lakes). (b) In order to obtain an endorsement for sail or...

Prevalence of wounds in a community care setting in Ireland.

PubMed

McDermott-Scales, L; Cowman, S; Gethin, G

2009-10-01

To establish the prevalence of wounds and their management in a community care setting. A multi-site, census point prevalence wound survey was conducted in the following areas: intellectual disability, psychiatry, GP practices, prisons, long-term care private nursing homes, long-term care, public nursing homes and the community/public health (district) nursing services on one randomly selected day. Acute services were excluded. Formal ethical approval was obtained. Data were collected using a pre-piloted questionnaire. Education was provided to nurses recording the tool (n=148). Descriptive statistical analysis was performed. A 97.2% response rate yielded a crude prevalence rate of 15.6% for wounds across nursing disciplines (290/1,854 total census) and 0.2% for the community area (290/133,562 population statistics for the study area). Crude point prevalence ranged from 2.7% in the prison services (7/262 total prison population surveyed) to 33.5% in the intellectual disability services (72/215 total intellectual disability population surveyed). The most frequent wounds recorded were pressure ulcers (crude point prevalence 4%, 76/1,854 total census; excluding category l crude point prevalence was 2.6%, 49/1,854 total census), leg ulcers (crude point prevalence 2.9%, 55/1,854 total census), self-inflicted superficial abrasions (crude point prevalence 2.2%, 41/1,854 total census) and surgical wounds (crude point prevalence 1.7%, 32/1,854 total census). These results support previous international research in that they identify a high prevalence of wounds in the community. The true community prevalence of wounds is arguably much higher, as this study identified only wounds known to the nursing services and excluded acute settings and was conducted on one day.

Noninvasive and invasive ventilation and enteral nutrition for ALS in Italy.

PubMed

Fini, Nicola; Georgoulopoulou, Eleni; Vinceti, Marco; Monelli, Marco; Pinelli, Giovanni; Vacondio, Paolo; Giovannini, Michele; Dallari, Rossano; Marudi, Andrea; Mandrioli, Jessica

2014-10-01

We performed a population-based study to assess amyotrophic lateral sclerosis (ALS) survival after noninvasive ventilation (NIV), invasive ventilation (IV), and enteral nutrition (EN). We included patients diagnosed from 2000 to 2009 in Modena, where a prospective registry and a Motor Neuron Diseases Centre have been active since 2000. Of the 193 incident cases, 47.7% received NIV, 24.3% received tracheostomy, and 49.2% received EN. A total of 10.4% of the patients refused NIV, 31.6% refused IV, and 8.7% refused EN. The median survival times after NIV, IV, and EN were 15, 19, and 9 months, respectively. Of the tracheostomized patients, 79.7% were discharged from the hospital; 73.0% were discharged to home. The median survival times for tracheostomized patients who were cared for at home and in nursing homes were 43 and 2 months, respectively. The multivariate analysis demonstrated that the place of discharge was the only independent prognostic factor after IV (P<0.01). Service organizations may promote adherence to NIV, IV, EN, and influence postprocedure survival. These data may be useful in defining health plans regarding advanced ALS care and in patient counseling. © 2014 Wiley Periodicals, Inc.

Expiratory rib cage compression in mechanically ventilated adults: systematic review with meta-analysis

PubMed Central

Borges, Lúcia Faria; Saraiva, Mateus Sasso; Saraiva, Marcos Ariel Sasso; Macagnan, Fabrício Edler; Kessler, Adriana

2017-01-01

Objective To review the literature on the effects of expiratory rib cage compression on ventilatory mechanics, airway clearance, and oxygen and hemodynamic indices in mechanically ventilated adults. Methods Systematic review with meta-analysis of randomized clinical trials in the databases MEDLINE (via PubMed), EMBASE, Cochrane CENTRAL, PEDro, and LILACS. Studies on adult patients hospitalized in intensive care units and under mechanical ventilation that analyzed the effects of expiratory rib cage compression with respect to a control group (without expiratory rib cage compression) and evaluated the outcomes static and dynamic compliance, sputum volume, systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, peripheral oxygen saturation, and ratio of arterial oxygen partial pressure to fraction of inspired oxygen were included. Experimental studies with animals and those with incomplete data were excluded. Results The search strategy produced 5,816 studies, of which only three randomized crossover trials were included, totaling 93 patients. With respect to the outcome of heart rate, values were reduced in the expiratory rib cage compression group compared with the control group [-2.81 bpm (95% confidence interval [95%CI]: -4.73 to 0.89; I2: 0%)]. Regarding dynamic compliance, there was no significant difference between groups [-0.58mL/cmH2O (95%CI: -2.98 to 1.82; I2: 1%)]. Regarding the variables systolic blood pressure and diastolic blood pressure, significant differences were found after descriptive evaluation. However, there was no difference between groups regarding the variables secretion volume, static compliance, ratio of arterial oxygen partial pressure to fraction of inspired oxygen, and peripheral oxygen saturation. Conclusion There is a lack of evidence to support the use of expiratory rib cage compression in routine care, given that the literature on this topic offers low methodological quality and is inconclusive. PMID:28444078

Surgery and perioperative management for post-intubation tracheoesophageal fistula: case series analysis

PubMed Central

Puma, Francesco; Santoprete, Stefano; Urbani, Moira; Cagini, Lucio; Andolfi, Marco; Potenza, Rossella; Daddi, Niccolò

2017-01-01

Background Post-intubation tracheoesophageal fistula (PITEF) is an often mistreated, severe condition. This case series reviewed for both the choice and timing of surgical technique and outcome PITEF patients. Methods This case series reviewed ten consecutive patients who had undergone esophageal defect repair and airway resection/reconstruction between 2000 and 2014. All cases were examined for patients: general condition, medical history, preparation to surgery, diagnostic work-up, timing of surgery and procedure, fistula size and site, ventilation type, nutrition, post-operative course and complications. Results All patients were treated according to Grillo’s technique. Overall, 6/10 patients had undergone a preliminary period of medical preparation. Additionally, 3 patients had already had a tracheostomy, one had had a gastrostomy and 4 had both. One patient had a Dumon stent with enlargement of the fistula. Concomitant tracheal stenosis had been found in 7 patients. The mean length of the fistulas was 20.5 mm (median 17.5 mm; range, 8–45 mm), at a median distance from the glottis of 43 mm (range, 20–68 mm). Tracheal resection was performed in all ten cases. The fistula was included in the resection in 6 patients, while it was excluded in the remaining 4 due to their distance. Post-repair tracheotomy was performed in 3 patients. The procedure was performed in 2 ventilated patients. Morbidity related to fistula and anastomosis was recorded in 3 patients (30%), with one postoperative death (10%); T-Tube placement was necessary in 3 patients, with 2/3 decannulations after long-stenting. Definitive PITEF closure was obtained for all patients. At 5-year follow-up, the 9 surviving patients had no fistula-related morbidity. Conclusions Primary esophageal closure with tracheal resection/reconstruction seemed to be effective treatment both short and long-term. Systemic conditions, mechanical ventilation, detailed preoperative assessment and appropriate preparation were associated with outcome. Indeed, the 3 patients who had received T-Tube recovered from anastomotic complications. PMID:28275475

Beneficial effect of nocturnal oximetric control on the clinical and gasometric situation and the prognosis of patients with home non-invasive mechanical ventilation.

PubMed

Hidalgo Carvajal, Raúl; Sánchez Casado, Marcelino; de Miguel-Díez, Javier; López Gabaldón, Encarnación

2018-02-28

The effectiveness of home non-invasive mechanical ventilation (NIMV) is assessed by determining blood gas values in wakefulness, the evolution of their symptoms, and the monitoring of ventilation at night. The aim of our study is to evaluate whether defined values reached with outpatient monitoring by oximetry is related to the clinical, arterial gases and survival of a sample of patients with home NIMV. Retrospective observational cohort study of a series of patients receiving home NIMV treatment for different causes. Patients with amyotrophic lateral sclerosis and less than 3 months of follow-up were excluded. The evolution of the patient's symptoms, their baseline arterial blood gases in wakefulness, and home nocturnal oximetry records, are evaluated at each outpatient visit. Good maintained oximetry control (MOC) was defined when mean O2 saturation values were reached and maintained until the last revision. Patient groups were considered, according to whether or not a good MOC was achieved during follow-up. Four hundred patients were evaluated. Three hundred and sixty four (91%) were included in the study; their median age was 68 years, 51% were male. 37.6% had a good MOC during follow-up. Compared to patients with not good MOC, a better long-term mortality was obtained (16.8% vs 28.2%, P=.013), and an improvement in symptoms (33.8% vs 18.6%, P=.002) and a lower proportion of patients with persistently>50mmHg PaCO2 (14.2% vs. 33.9%, P<.001) was observed. In the follow-up of patients with home NIMV in our context, values defined in home nocturnal oximetry (good MOC) are positively associated with clinical, gasometric and longer-term survival. Copyright © 2018 Elsevier España, S.L.U. All rights reserved.

Ultrafine particles and nitrogen oxides generated by gas and electric cooking

PubMed Central

Dennekamp, M; Howarth, S; Dick, C; Cherrie, J; Donaldson, K; Seaton, A

2001-01-01

OBJECTIVES—To measure the concentrations of particles less than 100 nm diameter and of oxides of nitrogen generated by cooking with gas and electricity, to comment on possible hazards to health in poorly ventilated kitchens.
METHODS—Experiments with gas and electric rings, grills, and ovens were used to compare different cooking procedures. Nitrogen oxides (NOx) were measured by a chemiluminescent ML9841A NOx analyser. A TSI 3934 scanning mobility particle sizer was used to measure average number concentration and size distribution of aerosols in the size range 10-500 nm.
RESULTS—High concentrations of particles are generated by gas combustion, by frying, and by cooking of fatty foods. Electric rings and grills may also generate particles from their surfaces. In experiments where gas burning was the most important source of particles, most particles were in the size range 15-40 nm. When bacon was fried on the gas or electric rings the particles were of larger diameter, in the size range 50-100 nm. The smaller particles generated during experiments grew in size with time because of coagulation. Substantial concentrations of NOX were generated during cooking on gas; four rings for 15 minutes produced 5 minute peaks of about 1000 ppb nitrogen dioxide and about 2000 ppb nitric oxide.
CONCLUSIONS—Cooking in a poorly ventilated kitchen may give rise to potentially toxic concentrations of numbers of particles. Very high concentrations of oxides of nitrogen may also be generated by gas cooking, and with no extraction and poor ventilation, may reach concentrations at which adverse health effects may be expected. Although respiratory effects of exposure to NOx might be anticipated, recent epidemiology suggests that cardiac effects cannot be excluded, and further investigation of this is desirable.


Keywords: cooking fuels; nitrogen oxides; ultrafine particles PMID:11452045

Dobutamine-induced high cardiac index did not prevent vasospasm in subarachnoid hemorrhage patients: a randomized controlled pilot study.

PubMed

Rondeau, Nelly; Cinotti, Raphaël; Rozec, Bertrand; Roquilly, Antoine; Floch, Hervé; Groleau, Nicolas; Michel, Patrick; Asehnoune, Karim; Blanloeil, Yvonnick

2012-10-01

Prevention of vasospasm is a challenging issue in subarachnoid hemorrhage (SAH) patients and the objective is to compare high dobutamine-induced cardiac index (CI) and high norepinephrine-induced hypertension for the prevention of vasospasm in SAH patients. Single center, single blind, controlled randomized study. Patients hospitalized in intensive care unit (ICU) for a moderate to severe SAH (WFNS grade ≥2) were randomized to receive dobutamine to reach a 25 % increase in cardiac index or norepinephrine to reach a mean arterial pressure ≥100 mmHg. Norepinephrine could be used in the dobutamine group to maintain a cerebral pressure perfusion ≥60 mmHg. Primary endpoint was the incidence of angiographic vasospasm in the first 14 days in the ICU setting, which was upheld by a cerebral arteriography. Secondary endpoints were the incidence of delayed ischemic deficits, duration of mechanical ventilation, and ICU length of stay (LOS). During the 3-year study, 41 patients were randomized. Six patients were excluded--3 because of consent withdrawal and 3 who did not receive the assigned treatment. Respectively, 17 and 18 patients in the dobutamine and the norepinephrine group were kept in analysis. Five (28 %) patients in the dobutamine group and 5 (27 %) patients in the norepinephrine group developed vasospasm in ICU (p = 1). Seven (41 %) patients presented a delayed ischemic deficit in the dobutamine group and 9 (50 %) in the norepinephrine group (p = 0.24). Duration of mechanical ventilation was 8 [0.5-11.5] days in the dobutamine group and 19 [2.7-23] days in the norepinephrine group (p = 0.01). ICU LOS was 11 [6-15] days in the dobutamine group and 21 [9-28] days in the norepinephrine group (p = 0.01). As compared to norepinephrine-induced hypertension, dobutamine-induced high CI did not reduce the rate of vasospasm in SAH patients. Dobutamine may reduce durations of mechanical ventilation and ICU LOS.

Characteristics of Japanese Patients with Becker Muscular Dystrophy and Intermediate Muscular Dystrophy in a Japanese National Registry of Muscular Dystrophy (Remudy): Heterogeneity and Clinical Variation.

PubMed

Mori-Yoshimura, Madoka; Mitsuhashi, Satomi; Nakamura, Harumasa; Komaki, Hirofumi; Goto, Kanako; Yonemoto, Naohiro; Takeuchi, Fumi; Hayashi, Yukiko K; Murata, Miho; Takahashi, Yuji; Nishino, Ichizo; Takeda, Shin'ichi; Kimura, En

2018-01-01

Obtaining an adequate number of patients to conduct a natural history study for rare diseases such as Becker muscular dystrophy (BMD) is difficult. The present study used data from Remudy, a national registry for neuromuscular diseases in Japan, to conduct a phenotypic analysis of BMD. We analyzed Remudy data of participants with dystrophinopathy. All participants who were aged 17 and older and were ambulant at age 13 were included in this study. Participants were divided into two groups: those with BMD who were ambulant at age 17, and those with intermediate muscular dystrophy (IMD) who lost ambulation by age 17. Frequent mutations were analyzed by age at ambulation, cardiopulmonary function, and genotype. For clinical comparisons, participants who were administered steroids were excluded. From July 2009 through September 2015, 192 participants had registered with Remudy. Mean participant age was 34.80±13.3 (range, 17-78) years, and 52.1% of participants were ambulant. Of the entire study population, 50.5% had cardiomyopathy and 35.9% had respiratory failure. Three participants required invasive ventilation and 30 required non-invasive ventilation. Nineteen of the 30 non-invasive ventilator users were part-time users. In total, 138 (71.9%) had BMD and 54 (28.1%) had IMD. The most frequent mutation was ex45_ex47del (36 participants). Among participants with frequent in-frame mutations, those with the ex45-49del mutation lost their ambulation earlier than those with the ex45_ex47del mutation. A total of 67 different exon deletions and duplications were identified in the study population. We clarified the clinical phenotypes of Japanese patients with BMD/IMD using data from Remudy. Our results suggest that not only IMD but also BMD are associated with risk of respiratory dysfunction.

Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe.

PubMed

Hortal, Javier; Muñoz, Patricia; Cuerpo, Gregorio; Litvan, Hector; Rosseel, Peter M; Bouza, Emilio

2009-01-01

Patients undergoing major heart surgery (MHS) represent a special subpopulation at risk for nosocomial infections. Postoperative infection is the main non-cardiac complication after MHS and has been clearly related to increased morbidity, use of hospital resources and mortality. Our aim was to determine the incidence, aetiology, risk factors and outcome of ventilator-associated pneumonia (VAP) in patients who have undergone MHS in Europe. Our study was a prospective study of patients undergoing MHS in Europe who developed suspicion of VAP. During a one-month period, participating units submitted a protocol of all patients admitted to their units who had undergone MHS. Overall, 25 hospitals in eight different European countries participated in the study. The number of patients intervened for MHS was 986. Fifteen patients were excluded because of protocol violations. One or more nosocomial infections were detected in 43 (4.4%) patients. VAP was the most frequent nosocomial infection (2.1%; 13.9 episodes per 1000 days of mechanical ventilation). The microorganisms responsible for VAP in this study were: Enterobacteriaceae (45%), Pseudomonas aeruginosa (20%), methicillin-resistant Staphylococcus aureus (10%) and a range of other microorganisms. We identified the following significant independent risk factors for VAP: ascending aorta surgery (odds ratio (OR) = 6.22; 95% confidence interval (CI) = 1.69 to 22.89), number of blood units transfused (OR = 1.08 per unit transfused; 95% CI = 1.04 to 1.13) and need for re-intervention (OR = 6.65; 95% CI = 2.10 to 21.01). The median length of stay in the intensive care unit was significantly longer (P < 0.001) in patients with VAP than in patients without VAP (23 days versus 2 days). Death was significantly more frequent (P < 0.001) in patients with VAP (35% versus 2.3%). Patients undergoing aortic surgery and those with complicated post-intervention courses, requiring multiple transfusions or re-intervention, constitute a high-risk group probably requiring more active preventive measures.

Anaesthesia ventilators.

PubMed

Jain, Rajnish K; Swaminathan, Srinivasan

2013-09-01

Anaesthesia ventilators are an integral part of all modern anaesthesia workstations. Automatic ventilators in the operating rooms, which were very simple with few modes of ventilation when introduced, have become very sophisticated with many advanced ventilation modes. Several systems of classification of anaesthesia ventilators exist based upon various parameters. Modern anaesthesia ventilators have either a double circuit, bellow design or a single circuit piston configuration. In the bellows ventilators, ascending bellows design is safer than descending bellows. Piston ventilators have the advantage of delivering accurate tidal volume. They work with electricity as their driving force and do not require a driving gas. To enable improved patient safety, several modifications were done in circle system with the different types of anaesthesia ventilators. Fresh gas decoupling is a modification done in piston ventilators and in descending bellows ventilator to reduce th incidence of ventilator induced volutrauma. In addition to the conventional volume control mode, modern anaesthesia ventilators also provide newer modes of ventilation such as synchronised intermittent mandatory ventilation, pressure-control ventilation and pressure-support ventilation (PSV). PSV mode is particularly useful for patients maintained on spontaneous respiration with laryngeal mask airway. Along with the innumerable benefits provided by these machines, there are various inherent hazards associated with the use of the ventilators in the operating room. To use these workstations safely, it is important for every Anaesthesiologist to have a basic understanding of the mechanics of these ventilators and breathing circuits.

Evaluation of ventilators for mouthpiece ventilation in neuromuscular disease.

PubMed

Khirani, Sonia; Ramirez, Adriana; Delord, Vincent; Leroux, Karl; Lofaso, Frédéric; Hautot, Solène; Toussaint, Michel; Orlikowski, David; Louis, Bruno; Fauroux, Brigitte

2014-09-01

Daytime mouthpiece ventilation is a useful adjunct to nocturnal noninvasive ventilation (NIV) in patients with neuromuscular disease. The aims of the study were to analyze the practice of mouthpiece ventilation and to evaluate the performance of ventilators for mouthpiece ventilation. Practice of mouthpiece ventilation was assessed by a questionnaire, and the performance of 6 home ventilators with mouthpiece ventilation was assessed in a bench test using 24 different conditions per ventilator: 3 mouthpieces, a child and an adult patient profile, and 4 ventilatory modes. Questionnaires were obtained from 30 subjects (mean age 33 ± 11 y) using NIV for 12 ± 7 y. Fifteen subjects used NIV for > 20 h/day, and 11 were totally ventilator-dependent. The subject-reported benefits of mouthpiece ventilation were a reduction in dyspnea (73%) and fatigue (93%) and an improvement in speech (43%) and eating (27%). The bench study showed that none of the ventilators, even those with mouthpiece ventilation software, were able to deliver mouthpiece ventilation without alarms and/or autotriggering in each condition. Alarms and/or ineffective triggering or autotriggering were observed in 135 of the 198 conditions. The occurrence of alarms was more common with a large mouthpiece without a filter compared to a small mouthpiece with a filter (P < .001), but it was not related to the patient profile, the ventilatory mode, or the type of ventilator. Subjects are satisfied with mouthpiece ventilation. Alarms are common with home ventilators, although less common in those with mouthpiece ventilation software. Improvements in home ventilators are needed to facilitate the expansion of mouthpiece ventilation. Copyright © 2014 by Daedalus Enterprises.

Cost-effectiveness of midwifery services vs. medical services in Quebec. LEquipe dEvaluation des Projets-Pilotes Sages-Femmes.

PubMed

Reinharz, D; Blais, R; Fraser, W D; Contandriopoulos, A P

2000-01-01

This study compared the cost-effectiveness of midwife services provided in birth centres operating as pilot projects with current hospital-based medical services in the province of Quebec. One thousand midwives' clients were matched with 1,000 physicians' clients on the basis of socio-demographic characteristics and obstetrical risk. Direct costs for the prenatal, intrapartum and postpartum periods were estimated. Effectiveness was assessed on the basis of three clinical indicators and four indices related to the individualization of care as assessed by women. Results show that the costs of midwife services were barely lower than or equal to those of physician services, but cost-effectiveness ratios were to the advantage of the midwife group, except for one clinical indicator (neonatal ventilation). Overall, this study provides rational support for the process of legalizing midwifery in the province.

Prospective observational cohort study of patients with weaning failure admitted to a specialist weaning, rehabilitation and home mechanical ventilation centre

PubMed Central

Mifsud Bonnici, Denise; Sanctuary, Thomas; Murphy, Patrick B; Steier, Joerg; Marino, Philip; Pattani, Hina; Creagh-Brown, Ben C; Hart, Nicholas

2016-01-01

Objectives According to National Health Service England (NHSE) specialist respiratory commissioning specification for complex home ventilation, patients with weaning failure should be referred to a specialist centre. However, there are limited data reporting the clinical outcomes from such centres. Setting Prospective observational cohort study of patients admitted to a UK specialist weaning, rehabilitation and home mechanical ventilation centre between February 2005 and July 2013. Participants 262 patients admitted with a median age of 64.2 years (IQR 52.6–73.2 years). 59.9% were male. Results 39.7% of patients had neuromuscular and/or chest wall disease, 21% were postsurgical, 19.5% had chronic obstructive pulmonary disease (COPD), 5.3% had obesity-related respiratory failure and 14.5% had other diagnoses. 64.1% of patients were successfully weaned, with 38.2% weaned fully from ventilation, 24% weaned to nocturnal non-invasive ventilation (NIV), 1.9% weaned to nocturnal NIV with intermittent NIV during the daytime. 21.4% of patients were discharged on long-term tracheostomy ventilation. The obesity-related respiratory failure group were most likely to wean (relative risk (RR) for weaning success=1.48, 95% CI 1.35 to 1.77; p<0.001), but otherwise weaning success rates did not significantly vary by diagnostic group. The median time-to-wean was 19 days (IQR 9–33) and the median duration of stay was 31 days (IQR 16–50), with no difference observed between the groups. Weaning centre mortality was 14.5%, highest in the COPD group (RR=2.15, 95% CI 1.19 to 3.91, p=0.012) and lowest in the neuromuscular and/or chest wall disease group (RR=0.34, 95% CI 0.16 to 0.75, p=0.007). Of all patients discharged alive, survival was 71.7% at 6 months and 61.8% at 12 months postdischarge. Conclusions Following NHSE guidance, patients with weaning delay and failure should be considered for transfer to a specialist centre where available, which can demonstrate favourable short-term and long-term clinical outcomes. PMID:26956162

HVAC [Heating, Ventilation and Air Conditioning] subsystem design description: 4 x 350 MW(t) Modular HTGR [High-Temperature Gas-Cooled Reactor] Plant

DOE Office of Scientific and Technical Information (OSTI.GOV)

NONE

1986-06-01

The HVAC system is a subsystem within the Mechanical Services Group (MSG). The HVAC system for the 4 x 350 MW(t) Modular HTGR Plant presently consists of ten, nonsafety-related subsystems located in the Nuclear Island (NI) and Energy Conversion Area (ECA) of the plant.

Potential risk for bacterial contamination in conventional reused ventilator systems and disposable closed ventilator-suction systems.

PubMed

Li, Ya-Chi; Lin, Hui-Ling; Liao, Fang-Chun; Wang, Sing-Siang; Chang, Hsiu-Chu; Hsu, Hung-Fu; Chen, Sue-Hsien; Wan, Gwo-Hwa

2018-01-01

Few studies have investigated the difference in bacterial contamination between conventional reused ventilator systems and disposable closed ventilator-suction systems. The aim of this study was to investigate the bacterial contamination rates of the reused and disposable ventilator systems, and the association between system disconnection and bacterial contamination of ventilator systems. The enrolled intubated and mechanically ventilated patients used a conventional reused ventilator system and a disposable closed ventilator-suction system, respectively, for a week; specimens were then collected from the ventilator circuit systems to evaluate human and environmental bacterial contamination. The sputum specimens from patients were also analyzed in this study. The detection rate of bacteria in the conventional reused ventilator system was substantially higher than that in the disposable ventilator system. The inspiratory and expiratory limbs of the disposable closed ventilator-suction system had higher bacterial concentrations than the conventional reused ventilator system. The bacterial concentration in the heated humidifier of the reused ventilator system was significantly higher than that in the disposable ventilator system. Positive associations existed among the bacterial concentrations at different locations in the reused and disposable ventilator systems, respectively. The predominant bacteria identified in the reused and disposable ventilator systems included Acinetobacter spp., Bacillus cereus, Elizabethkingia spp., Pseudomonas spp., and Stenotrophomonas (Xan) maltophilia. Both the reused and disposable ventilator systems had high bacterial contamination rates after one week of use. Disconnection of the ventilator systems should be avoided during system operation to decrease the risks of environmental pollution and human exposure, especially for the disposable ventilator system. ClinicalTrials.gov PRS / NCT03359148.

49 CFR 1245.3 - Employees; definition, service hours, and compensation.

Code of Federal Regulations, 2011 CFR

2011-10-01

..., holidays, absences on leave, vacations, etc., should be excluded from time actually worked, but if such... all of their employees at twelve different times each year. (c) Joint employees. Each person jointly... paid for. (The service time of all classes of employees shall be recorded in hours instead of days or...

49 CFR 1245.3 - Employees; definition, service hours, and compensation.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., holidays, absences on leave, vacations, etc., should be excluded from time actually worked, but if such... all of their employees at twelve different times each year. (c) Joint employees. Each person jointly... paid for. (The service time of all classes of employees shall be recorded in hours instead of days or...

Prairie strips improve biodiversity and the delivery of multiple ecosystem services from corn–soybean croplands

Treesearch

Lisa A. Schulte; Jarad Niemi; Matthew J. Helmers; Matt Liebman; J. Gordon Arbuckle; David E. James; Randall K. Kolka; Matthew E. O’Neal; Mark D. Tomer; John C. Tyndall; Heidi Asbjornsen; Pauline Drobney; Jeri Neal; Gary Van Ryswyk; Chris Witte

2017-01-01

Loss of biodiversity and degradation of ecosystem services from agricultural lands remain important challenges in the United States despite decades of spending on natural resource management. To date, conservation investment has emphasized engineering practices or vegetative strategies centered on monocultural plantings of nonnative plants, largely excluding native...

26 CFR 1.1402(a)-11 - Ministers and members of religious orders.

Code of Federal Regulations, 2010 CFR

2010-04-01

... remuneration for services performed in the exercise of his ministry or the rental allowance paid to him as remuneration for such services irrespective of whether such rental value or rental allowance is excluded from... director of internal revenue with whom the waiver certificate, Form 2031, is filed a written statement...

Faculty and Civil Service Salaries, Fiscal Year 1996.

ERIC Educational Resources Information Center

Illinois State Board of Higher Education, Springfield.

This report provides data on fiscal year (FY) 1996 average 9-month faculty and civil service salaries (excluding fringe benefits) and information on those salaries since FY 1980 for full-time employees at Illinois colleges and universities and the Illinois Mathematics and Science Academy. The report provides data comparing salaries with economic…

49 CFR 360.5 - Updating user fees.

Code of Federal Regulations, 2014 CFR

2014-10-01

... determined by the cost study in Regulations Governing Fees For Service, 1 I.C.C. 2d 60 (1984), or subsequent... material in the Federal Register or FMCSA Register. (This rounding procedures excludes copying, printing... determined by the cost study in Regulations Governing Fees For Service, 1 I.C.C. 2d 60 (1984), or subsequent...

20 CFR 404.1018a - Work by civilians for the United States Government or its instrumentalities-remuneration paid...

Code of Federal Regulations, 2010 CFR

2010-04-01

...' Benefits SOCIAL SECURITY ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950... was exempt from Social Security tax was also excluded. Certain other work for the United States or an... the Agriculture Marketing Service and the Commodity Stabilization Service, formerly the Production and...

22 CFR 208.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2011 CFR

2011-04-01

... INTERNATIONAL DEVELOPMENT GOVERNMENTWIDE DEBARMENT AND SUSPENSION (NONPROCUREMENT) Responsibilities of Participants Regarding Transactions Doing Business with Other Persons § 208.315 May I use the services of an... transaction unless the U.S. Agency for International Development grants an exception under § 208.120. ...

22 CFR 208.315 - May I use the services of an excluded person as a principal under a covered transaction?

Code of Federal Regulations, 2010 CFR

2010-04-01

... INTERNATIONAL DEVELOPMENT GOVERNMENTWIDE DEBARMENT AND SUSPENSION (NONPROCUREMENT) Responsibilities of Participants Regarding Transactions Doing Business with Other Persons § 208.315 May I use the services of an... transaction unless the U.S. Agency for International Development grants an exception under § 208.120. ...

12 CFR 747.10 - Filing of papers.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 12 Banks and Banking 6 2011-01-01 2011-01-01 false Filing of papers. 747.10 Section 747.10 Banks... Practice and Procedure § 747.10 Filing of papers. (a) Filing. Any papers required to be filed, excluding...) Delivering the papers to a reliable commercial courier service, overnight delivery service, or to the U.S...

12 CFR 747.10 - Filing of papers.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Filing of papers. 747.10 Section 747.10 Banks... Practice and Procedure § 747.10 Filing of papers. (a) Filing. Any papers required to be filed, excluding...) Delivering the papers to a reliable commercial courier service, overnight delivery service, or to the U.S...

29 CFR 9.3 - Coverage.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 29 Labor 1 2014-07-01 2013-07-01 true Coverage. 9.3 Section 9.3 Labor Office of the Secretary of Labor NONDISPLACEMENT OF QUALIFIED WORKERS UNDER SERVICE CONTRACTS General § 9.3 Coverage. This part applies to all service contracts and their solicitations, except those excluded by § 9.4 of this part...

29 CFR 9.3 - Coverage.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 29 Labor 1 2013-07-01 2013-07-01 false Coverage. 9.3 Section 9.3 Labor Office of the Secretary of Labor NONDISPLACEMENT OF QUALIFIED WORKERS UNDER SERVICE CONTRACTS General § 9.3 Coverage. This part applies to all service contracts and their solicitations, except those excluded by § 9.4 of this part...

24 CFR 883.302 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-04-01

... cure of substantial accumulation of deferred maintenance. Cosmetic improvements alone do not qualify as... fees or charges for management and maintenance services with respect to the space, but excluding...

24 CFR 883.302 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-04-01

... cure of substantial accumulation of deferred maintenance. Cosmetic improvements alone do not qualify as... fees or charges for management and maintenance services with respect to the space, but excluding...

24 CFR 883.302 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-04-01

... cure of substantial accumulation of deferred maintenance. Cosmetic improvements alone do not qualify as... fees or charges for management and maintenance services with respect to the space, but excluding...

24 CFR 883.302 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-04-01

... cure of substantial accumulation of deferred maintenance. Cosmetic improvements alone do not qualify as... fees or charges for management and maintenance services with respect to the space, but excluding...

If patient-reported outcome measures are considered key health-care quality indicators, who is excluded from participation?

PubMed

Kroll, Thilo; Wyke, Sally; Jahagirdar, Deepa; Ritchie, Karen

2014-10-01

Patient-reported outcome measures have received increasing attention with regard to ensuring quality improvement across the health service. However, there is a risk that people with disabilities and low literacy are systematically excluded from the development of these measures as well as their application in clinical practice. This editorial highlights some of these risks and the potential consequences of exclusion for these groups. © 2012 John Wiley & Sons Ltd.

A new system for understanding modes of mechanical ventilation.

PubMed

Chatburn, R L; Primiano, F P

2001-06-01

Numerous ventilation modes and ventilation options have become available as new mechanical ventilators have reached the market. Ventilator manufacturers have no standardized terminology for ventilator modes and ventilation options, and ventilator operator's manuals do not help the clinician compare the modes of ventilators from different manufacturers. This article proposes a standardized system for classifying ventilation modes, based on general engineering principles and a small set of explicit definitions. Though there may be resistance by ventilator manufacturers to a standardized system of ventilation terminology, clinicians and health care equipment purchasers should adopt such a system in the interest of clear communication--the lack of which prevents clinicians from fully understanding the therapies they administer and could compromise the quality of patient care.

Race, treatment preferences, and hospice enrollment. Eligibility criteria may exclude patients with the greatest needs for care

PubMed Central

Fishman, Jessica; O'Dwyer, Peter; Lu, Hien L.; Henderson, Hope; Asch, David A.; Casarett, David J.

2009-01-01

Background The requirement that patients give up curative treatment makes hospice enrollment unappealing for some patients, and may particularly limit use among African American patients. Objectives To determine whether African-American patients with cancer are more likely than white patients are to have preferences for cancer treatment that exclude them from hospice, and whether they are less likely to want specific hospice services. Methods 283 patients receiving treatment for cancer at six oncology clinics within the University of Pennsylvania Cancer Network completed conjoint interviews measuring their perceived need for five hospice services and their preferences for continuing cancer treatment. Patients were followed for six months or until death. Results African American patients had stronger preferences for continuing their cancer treatments on a 7-point scale even after adjusting for age, sex, finances, education, ECOG performance status, quality of life, and physical and psychological symptom burden (adjusted means 4.75 vs. 3.96; β coefficient 0.82; 95% confidence interval 0.22-1.41; p=0.007). African-American patients also had greater perceived needs for hospice services after adjusting for these characteristics (adjusted means 2.31 vs. 1.83) (β coefficient 0.51; 95% confidence interval 0.11-0.92; p=0.01). However, this effect disappeared after adjusting for household finances. Conclusions Hospice eligibility criteria may exclude African-American patients disproportionately despite greater perceived needs for hospice services in this population. The mechanisms driving this health disparity likely include both cultural differences and economic characteristics, and consideration should be given to redesigning hospice eligibility criteria. PMID:19107761

Potential risk for bacterial contamination in conventional reused ventilator systems and disposable closed ventilator-suction systems

PubMed Central

Li, Ya-Chi; Lin, Hui-Ling; Liao, Fang-Chun; Wang, Sing-Siang; Chang, Hsiu-Chu; Hsu, Hung-Fu; Chen, Sue-Hsien

2018-01-01

Background Few studies have investigated the difference in bacterial contamination between conventional reused ventilator systems and disposable closed ventilator-suction systems. The aim of this study was to investigate the bacterial contamination rates of the reused and disposable ventilator systems, and the association between system disconnection and bacterial contamination of ventilator systems. Methods The enrolled intubated and mechanically ventilated patients used a conventional reused ventilator system and a disposable closed ventilator-suction system, respectively, for a week; specimens were then collected from the ventilator circuit systems to evaluate human and environmental bacterial contamination. The sputum specimens from patients were also analyzed in this study. Results The detection rate of bacteria in the conventional reused ventilator system was substantially higher than that in the disposable ventilator system. The inspiratory and expiratory limbs of the disposable closed ventilator-suction system had higher bacterial concentrations than the conventional reused ventilator system. The bacterial concentration in the heated humidifier of the reused ventilator system was significantly higher than that in the disposable ventilator system. Positive associations existed among the bacterial concentrations at different locations in the reused and disposable ventilator systems, respectively. The predominant bacteria identified in the reused and disposable ventilator systems included Acinetobacter spp., Bacillus cereus, Elizabethkingia spp., Pseudomonas spp., and Stenotrophomonas (Xan) maltophilia. Conclusions Both the reused and disposable ventilator systems had high bacterial contamination rates after one week of use. Disconnection of the ventilator systems should be avoided during system operation to decrease the risks of environmental pollution and human exposure, especially for the disposable ventilator system. Trial registration ClinicalTrials.gov PRS / NCT03359148 PMID:29547638

Initial mechanical ventilator settings and lung protective ventilation in the ED.

PubMed

Wilcox, Susan R; Richards, Jeremy B; Fisher, Daniel F; Sankoff, Jeffrey; Seigel, Todd A

2016-08-01

Mechanical ventilation with low tidal volumes has been shown to improve outcomes for patients both with and without acute respiratory distress syndrome. This study aims to characterize mechanically ventilated patients in the emergency department (ED), describe the initial ED ventilator settings, and assess for associations between lung protective ventilation strategies in the ED and outcomes. This was a multicenter, prospective, observational study of mechanical ventilation at 3 academic EDs. We defined lung protective ventilation as a tidal volume of less than or equal to 8 mL/kg of predicted body weight and compared outcomes for patients ventilated with lung protective vs non-lung protective ventilation, including inhospital mortality, ventilator days, intensive care unit length of stay, and hospital length of stay. Data from 433 patients were analyzed. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Two hundred sixty-one patients (60.3%) received lung protective ventilation, but most patients were ventilated with a low positive end-expiratory pressure, high fraction of inspired oxygen strategy. Patients were ventilated in the ED for a mean of 5 hours and 7 minutes but had few ventilator adjustments. Outcomes were not significantly different between patients receiving lung protective vs non-lung protective ventilation. Nearly 40% of ED patients were ventilated with non-lung protective ventilation as well as with low positive end-expiratory pressure and high fraction of inspired oxygen. Despite a mean ED ventilation time of more than 5 hours, few patients had adjustments made to their ventilators. Copyright © 2016 Elsevier Inc. All rights reserved.

Are we fully utilizing the functionalities of modern operating room ventilators?

PubMed

Liu, Shujie; Kacmarek, Robert M; Oto, Jun

2017-12-01

The modern operating room ventilators have become very sophisticated and many of their features are comparable with those of an ICU ventilator. To fully utilize the functionality of modern operating room ventilators, it is important for clinicians to understand in depth the working principle of these ventilators and their functionalities. Piston ventilators have the advantages of delivering accurate tidal volume and certain flow compensation functions. Turbine ventilators have great ability of flow compensation. Ventilation modes are mainly volume-based or pressure-based. Pressure-based ventilation modes provide better leak compensation than volume-based. The integration of advanced flow generation systems and ventilation modes of the modern operating room ventilators enables clinicians to provide both invasive and noninvasive ventilation in perioperative settings. Ventilator waveforms can be used for intraoperative neuromonitoring during cervical spine surgery. The increase in number of new features of modern operating room ventilators clearly creates the opportunity for clinicians to optimize ventilatory care. However, improving the quality of ventilator care relies on a complete understanding and correct use of these new features. VIDEO ABSTRACT: http://links.lww.com/COAN/A47.

A randomised crossover comparison of mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation by surf lifeguards in a manikin.

PubMed

Adelborg, K; Bjørnshave, K; Mortensen, M B; Espeseth, E; Wolff, A; Løfgren, B

2014-07-01

Thirty surf lifeguards (mean (SD) age: 25.1 (4.8) years; 21 male, 9 female) were randomly assigned to perform 2 × 3 min of cardiopulmonary resuscitation on a manikin using mouth-to-face-shield ventilation (AMBU LifeKey) and mouth-to-pocket-mask ventilation (Laerdal Pocket Mask). Interruptions in chest compressions, effective ventilation (visible chest rise) ratio, tidal volume and inspiratory time were recorded. Interruptions in chest compressions per cycle were increased with mouth-to-face-shield ventilation (mean (SD) 8.6 (1.7) s) compared with mouth-to-pocket-mask ventilation (6.9 (1.2) s, p < 0.0001). The proportion of effective ventilations was less using mouth-to-face-shield ventilation (199/242 (82%)) compared with mouth-to-pocket-mask ventilation (239/240 (100%), p = 0.0002). Tidal volume was lower using mouth-to-face-shield ventilation (mean (SD) 0.36 (0.20) l) compared with mouth-to-pocket-mask ventilation (0.45 (0.20) l, p = 0.006). No differences in inspiratory times were observed between mouth-to-face-shield ventilation and mouth-to-pocket-mask ventilation. In conclusion, mouth-to-face-shield ventilation increases interruptions in chest compressions, reduces the proportion of effective ventilations and decreases delivered tidal volumes compared with mouth-to-pocket-mask ventilation. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

7 CFR 205.310 - Agricultural products produced on an exempt or excluded operation.

Code of Federal Regulations, 2010 CFR

2010-01-01

... (Continued) AGRICULTURAL MARKETING SERVICE (Standards, Inspections, Marketing Practices), DEPARTMENT OF AGRICULTURE (CONTINUED) ORGANIC FOODS PRODUCTION ACT PROVISIONS NATIONAL ORGANIC PROGRAM Labels, Labeling, and...

Factors controlling particle number concentration and size at metro stations

NASA Astrophysics Data System (ADS)

Reche, C.; Moreno, T.; Martins, V.; Minguillón, M. C.; Jones, T.; de Miguel, E.; Capdevila, M.; Centelles, S.; Querol, X.

2017-05-01

An extensive air quality campaign was performed at differently designed station platforms in the Barcelona metro system, aiming to investigate the factors governing airborne particle number (N) concentrations and their size distributions. The study of the daily trends of N concentrations by different size ranges shows that concentrations of N0.3-10 are closely related with the schedule of the metro service. Conversely, the hourly variation of N0.007-10 (mainly composed of ultrafine particles) could be partly governed by the entrance of particles from outdoor emissions through mechanical ventilation. Measurements under different ventilation settings at three metro platforms reveal that the effect on air quality linked to changes in the tunnel ventilation depends on the station design. Night-time maintenance works in tunnels are frequent activities in the metro system; and after intense prolonged works, these can result in higher N concentrations at platforms during the following metro operating hours (by up to 30%), this being especially evident for N1-10. Due to the complex mixture of factors controlling N, together with the differences in trends recorded for particles within different size ranges, developing an air quality strategy at metro systems is a great challenge. When compared to street-level urban particles concentrations, the priority in metro air quality should be dealing with particles coarser than 0.3 μm. In fact, the results suggest that at narrow platforms served by single-track tunnels the current forced tunnel ventilation during operating hours is less efficient in reducing coarse particles compared to fine.

[Cardiac efficiency in patients with Cheyne-Stokes respiration as a result of heart insufficiency during long-term nasal respiratory treatment with adaptive servo ventilation (AutoSet CS)].

PubMed

Schädlich, S; Königs, I; Kalbitz, F; Blankenburg, T; Busse, H-J; Schütte, W

2004-06-01

Cheyne-Stokes respiration (CSR) is known to be an important negative predictor of outcome in patients with congestive heart failure. The goal of this study was to investigate whether the use of adaptive servo ventilation (AutoSet CS) would permit sufficient suppression of this pathological breathing pattern and improve cardiac function in longterm use over 1 year. Inclusion criteria for the study were congestive heart failure (left ventricular ejection fraction 20-50%), proven CSR with a central apnea-hypopnea index (AHI) > 15/h and stable clinical status with standard medical therapy. Patients with obstructive sleep apnea and COPD were excluded. Twenty consecutive patients (16 male) age 65.5 years (range 48-77) were followed with full blood counts, blood gas analysis, lung function tests and questionnaires for cardiopulmonary capacities (Minnesota, MRC Scale) and sleepiness (Epworth Sleepiness Scale). In addition, we performed 6-min walk distance (6MWD), echocardiography and polysomnography just before and after adjusting to adaptive servo ventilation and 3 and 12 months later. Mean usage of adaptive servo ventilation was sufficient (4.3 +/- 2.1 h/day at 12 months). No significant changes in blood gas analysis, blood counts and pulmonary function were detectable. CSR disappeared almost completely in all patients (AHI pre-study 44.3 +/- 13.4/h vs 3.4 +/- 8.0/h at 12 months; p < 0.0001). Saturation normalized steadily over the course of the study. The desaturation index decreased from 45.3 +/- 17.8/h to 5.2 +/- 11.5/h at 12 months (p < 0.0001). Mean saturation increased with the first night of sleep with adaptive servo ventilation from 92.0 +/- 2.5% to 93.0 +/- 1.6% (p < 0.05) and then to 94.1 +/- 1.9% at 3, and 94.2 +/- 1.9% at 12 months (p < 0.001). Quality of sleep was significantly improved with an increase of slow-wave sleep from 4.5 +/- 4.6% to 13.7 +/- 6.9% at 12 months (p < 0.0001). The arousal index concomitantly decreased from 29.8 +/- 17.9/h pre-study to 12.0 +/- 10.3/h at 12 months (p < 0.01). REM-sleep and sleep efficiency remained unchanged. The Epworth Sleepiness Scale showed only a trend to improvement. Cardiac function improved significantly during the course of the study. The ejection fraction increased from mean 37.1 +/- 12.5% pre-study to 41.7 +/- 8.8% at 12 months (p < 0.05). The 6-min walk distance increased from 192 +/- 110 m to 277 +/- 130 m at 12 months (p < 0.01). The MRC and Minnesota score were not significantly different pre- and post-study. We conclude that long-term respirator therapy with adaptive servo ventilation has sufficiently suppressed CSR and improved cardiac function in patients with congestive heart failure. Thus, safety and feasibility of this respirator therapy could be demonstrated. However, due to methodological reasons (no control group, no randomization) a direct effect on cardiac function could not be confirmed.

The Applicability of Performance-Based Acquisition Techniques to Level-of-Effort Services Contracts

DTIC Science & Technology

2015-06-01

Regulation Supplement (NMCARS) Change 13-05). However, there is a large category of services acquisitions that does not mesh well with PBA’s rationale...sampled, 19 contracts (38%) were not clearly identified as LOE or completion.9 Excluding the “not clear” category , 22 of the remaining 31 contracts...attention away from important elements. For example, several contracts focused on grammatical correctness of reports. Describing a complex services

A MODEL BUILDING CODE ARTICLE ON FALLOUT SHELTERS WITH RECOMMENDATIONS FOR INCLUSION OF REQUIREMENTS FOR FALLOUT SHELTER CONSTRUCTION IN FOUR NATIONAL MODEL BUILDING CODES.

ERIC Educational Resources Information Center

American Inst. of Architects, Washington, DC.

A MODEL BUILDING CODE FOR FALLOUT SHELTERS WAS DRAWN UP FOR INCLUSION IN FOUR NATIONAL MODEL BUILDING CODES. DISCUSSION IS GIVEN OF FALLOUT SHELTERS WITH RESPECT TO--(1) NUCLEAR RADIATION, (2) NATIONAL POLICIES, AND (3) COMMUNITY PLANNING. FALLOUT SHELTER REQUIREMENTS FOR SHIELDING, SPACE, VENTILATION, CONSTRUCTION, AND SERVICES SUCH AS ELECTRICAL…

Comparison of Airway Control Methods and Ventilation Success with an Automatic Resuscitator

DTIC Science & Technology

2015-10-08

REPORT DOCUMENTATION PAGE Form Approved OMB No. 0704-0188 Public reporting burden for this collection of information is estimated to average 1 hour...completing and reviewing this collection of information . Send comments regarding this burden estimate or any other aspect of this collection of information ...including suggestions for reducing this burden to Department of Defense, Washington Headquarters Services, Directorate for Information Operations

Joint Service Chemical and Biological Defense Program: FY 06-07 Overview

DTIC Science & Technology

2006-01-01

Performers Molecular model of human plasma-derived butyryl Electronmicrograph of bacillus spores adhering to cell membrane processes 38866_BATT_TX 11...agents, and radioactive fallout. CPS is integrated with the ship’s Heating, Ventilation, and Air-Conditioning ( HVAC ) systems and provides filtered air...molecules for intervention against protein NTA. • Identify and evaluate effectiveness of spore germination inhibitors. • Expand drug discovery program

78 FR 11988 - Migratory Bird Subsistence Harvest in Alaska; Harvest Regulations for Migratory Birds in Alaska...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-21

...-management process involving the Service, the Alaska Department of Fish and Game, and Alaska Native... developed under a co-management process involving the Service, the Alaska Department of Fish and Game, and... Fish and Game's request to expand the Fairbanks North Star Borough excluded area to include the Central...

26 CFR 1.61-2 - Compensation for services, including fees, commissions, and similar items.

Code of Federal Regulations, 2011 CFR

2011-04-01

... contributions received by a clergyman for services, pay of persons in the military or naval forces of the United... excluded by law. Several special rules apply to members of the Armed Forces, National Oceanic and... regulations thereunder; (v) Miscellaneous items, see section 122. (b) Members of the Armed Forces, National...

26 CFR 1.61-2 - Compensation for services, including fees, commissions, and similar items.

Code of Federal Regulations, 2010 CFR

2010-04-01

... contributions received by a clergyman for services, pay of persons in the military or naval forces of the United... excluded by law. Several special rules apply to members of the Armed Forces, National Oceanic and... regulations thereunder; (v) Miscellaneous items, see section 122. (b) Members of the Armed Forces, National...

20 CFR 404.1014 - Domestic service by a student for a local college club, fraternity or sorority.

Code of Federal Regulations, 2014 CFR

2014-04-01

... ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1014 Domestic service by a student for..., your work is not covered as employment. (b) Explanation of terms—(1) Work of a household nature means...

20 CFR 404.1014 - Domestic service by a student for a local college club, fraternity or sorority.

Code of Federal Regulations, 2011 CFR

2011-04-01

... ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1014 Domestic service by a student for..., your work is not covered as employment. (b) Explanation of terms—(1) Work of a household nature means...

20 CFR 404.1014 - Domestic service by a student for a local college club, fraternity or sorority.

Code of Federal Regulations, 2010 CFR

2010-04-01

... ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1014 Domestic service by a student for..., your work is not covered as employment. (b) Explanation of terms—(1) Work of a household nature means...

20 CFR 404.1014 - Domestic service by a student for a local college club, fraternity or sorority.

Code of Federal Regulations, 2012 CFR

2012-04-01

... ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1014 Domestic service by a student for..., your work is not covered as employment. (b) Explanation of terms—(1) Work of a household nature means...

20 CFR 404.1014 - Domestic service by a student for a local college club, fraternity or sorority.

Code of Federal Regulations, 2013 CFR

2013-04-01

... ADMINISTRATION FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE (1950- ) Employment, Wages, Self-Employment, and Self-Employment Income Work Excluded from Employment § 404.1014 Domestic service by a student for..., your work is not covered as employment. (b) Explanation of terms—(1) Work of a household nature means...

76 FR 11363 - Defense Federal Acquisition Regulation Supplement; Government Support Contractor Access to...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-02

... management and oversight of a program or effort (rather than to directly furnish an end item or service to... prime contractor or any such first-tier subcontractor in furnishing end items or services of the type.... 2320, which applies to technical data, but not to computer software (which is expressly excluded from...

[Neurally adjusted ventilatory assist (NAVA). A new mode of assisted mechanical ventilation].

PubMed

Moerer, O; Barwing, J; Quintel, M

2008-10-01

The aim of mechanical ventilation is to assure gas exchange while efficiently unloading the respiratory muscles and mechanical ventilation is an integral part of the care of patients with acute respiratory failure. Modern lung protective strategies of mechanical ventilation include low-tidal-volume ventilation and the continuation of spontaneous breathing which has been shown to be beneficial in reducing atelectasis and improving oxygenation. Poor patient-ventilator interaction is a major issue during conventional assisted ventilation. Neurally adjusted ventilator assist (NAVA) is a new mode of mechanical ventilation that uses the electrical activity of the diaphragm (EAdi) to control the ventilator. First experimental studies showed an improved patient-ventilator synchrony and an efficient unloading of the respiratory muscles. Future clinical studies will have to show that NAVA is of clinical advantage when compared to conventional modes of assisted mechanical ventilation. This review characterizes NAVA according to current publications on this topic.

48 CFR 225.7102-1 - Policy.

Code of Federal Regulations, 2010 CFR

2010-10-01

....7102-1 Policy. When acquiring the following forging items, whether as end items or components, acquire... propulsion shafts Excludes service and landing craft shafts. Periscope tubes All. Ring forgings for bull...

Thoracic sonography for pneumothorax: The clinical evaluation of an operational space medicine spin-off

NASA Astrophysics Data System (ADS)

Kirkpatrick, Andrew W.; Nicolaou, Savvas; Rowan, Kevin; Liu, David; Cunningham, Johan; Sargsyan, Ashot E.; Hamilton, Douglas; Dulchavsky, Scott A.

2005-05-01

The recent interest in the use of ultrasound (US) to detect pneumothoraces after acute trauma in North America was initially driven by an operational space medicine concern. Astronauts aboard the International Space Station (ISS) are at risk for pneumothoraces, and US is the only potential medical imaging available. Pneumothoraces are common following trauma, and are a preventable cause of death, as most are treatable with relatively simple interventions. While pneumothoraces are optimally diagnosed clinically, they are more often inapparent even on supine chest radiographs (CXR) with recent series reporting a greater than 50% rate of occult pneumothoraces. In the course of basic scientific investigations in a conventional and parabolic flight laboratory, investigators familiarized themselves with the sonographic features of both pneumothoraces and normal pulmonary ventilation. By examining the visceral-parietal pleural interface (VPPI) with US, investigators became confident in diagnosing pneumothoraces. This knowledge was subsequently translated into practice at an American and a Canadian trauma center. The sonographic examination was found to be more accurate and sensitive than CXR (US 96% and 100% versus US 74% and 36%) in specific circumstances. Initial studies have also suggested that detecting the US features of pleural pulmonary ventilation in the left lung field may offer the ability to exclude serious endotracheal tube malpositions such as right mainstem and esophageal intubations. Applied thoracic US is an example of a clinically useful space medicine spin-off that is improving health care on earth.

Preemptive antibiotic treatment based on gram staining reduced the incidence of ARDS in mechanically ventilated patients.

PubMed

Matsushima, Asako; Tasaki, Osamu; Shimizu, Kentaro; Tomono, Kazunori; Ogura, Hiroshi; Shimazu, Takeshi; Sugimoto, Hisashi

2008-08-01

Ventilator-associated pneumonia (VAP) is one of the major complications in the intensive care unit. VAP sometimes results in acute respiratory distress syndrome (ARDS), and the associated mortality is high. We hypothesized that preemptive antibiotic therapy based on results of bedside gram staining would reduce the incidence of VAP. Patients who were endotracheally intubated in our intensive care unit for more than 72 hours were included. Patients younger than 16 years of age or patients died because of brain death were excluded. The study was divided into two periods. During the first period, we used antibiotics according to the American Thoracic Society guidelines. During the second period, antibiotics were given according to the results of bedside gram staining even before radiographic infiltrate appeared. One hundred twenty-eight patients and 133 patients were included in the first and second periods, respectively. The incidence of VAP was significantly decreased in the second period (first period, 22%; second period, 9%, p < 0.01). The incidence of ARDS was also decreased significantly in the second period (first period, 11%; second period, 3%, p < 0.01). The duration and total amount of antibiotics administered did not increase in the second period. VAP associated mortality was significantly lower in the second period (first period, 5%; second period, 0.8%, p < 0.05). Early diagnosis and treatment of respiratory infection based on results of gram staining significantly reduced the incidences of VAP and ARDS without an increase in the use of antibiotics.

Clinical profile and outcomes of acute cardiorenal syndrome type-5 in sepsis: An eight-year cohort study.

PubMed

Vallabhajosyula, Saraschandra; Sakhuja, Ankit; Geske, Jeffrey B; Kumar, Mukesh; Kashyap, Rahul; Kashani, Kianoush; Jentzer, Jacob C

2018-01-01

To evaluate the clinical features and outcomes of acute cardiorenal syndrome type-5 in patients with severe sepsis and septic shock. Historical cohort study of all adult patients with severe sepsis and septic shock admitted to the intensive care units (ICU) at Mayo Clinic Rochester from January 1, 2007 through December 31, 2014. Patients with prior renal or cardiac dysfunction were excluded. Patients were divided into groups with and without cardiorenal syndrome type-5. Acute Kidney Injury (AKI) was defined by both serum creatinine and urine output criteria of the AKI Network and the cardiac injury was determined by troponin-T levels. Outcomes included in-hospital mortality, ICU and hospital length of stay, and one-year survival. Of 602 patients meeting the study inclusion criteria, 430 (71.4%) met criteria for acute cardiorenal syndrome type-5. Patients with cardiorenal syndrome type-5 had higher severity of illness, greater vasopressor and mechanical ventilation use. Cardiorenal syndrome type-5 was associated higher unadjusted in-hospital mortality, ICU and hospital lengths of stay, and lower one-year survival. When adjusted for age, gender, severity of illness and mechanical ventilation, cardiorenal syndrome type-5 was independently associated with 1.7-times greater odds of in-hospital mortality (p = .03), but did not predict one-year survival (p = .06) compared to patients without cardiorenal syndrome. In sepsis, acute cardiorenal syndrome type-5 is associated with worse in-hospital mortality compared to patients without cardiorenal syndrome.

Endobronchial Valves for Endoscopic Lung Volume Reduction: Best Practice Recommendations from Expert Panel on Endoscopic Lung Volume Reduction.

PubMed

Slebos, Dirk-Jan; Shah, Pallav L; Herth, Felix J F; Valipour, Arschang

2017-01-01

Endoscopic lung volume reduction (ELVR) is being adopted as a treatment option for carefully selected patients suffering from severe emphysema. ELVR with the one-way endobronchial Zephyr valves (EBV) has been demonstrated to improve pulmonary function, exercise capacity, and quality of life in patients with both heterogeneous and homogenous emphysema without collateral ventilation. In this "expert best practices" review, we will highlight the practical aspects of this therapy. Key selection criteria for ELVR are hyperinflation with a residual volume >175% of predicted, forced expiratory volume <50% of predicted, and a 6-min walking distance >100 m. Patients with repeated infectious complications, severe bronchiectasis, and those with unstable cardiovascular comorbidities should be excluded from EBV treatment. The procedure may be performed with either conscious sedation or general anesthesia and positive pressure mechanical ventilation using a flexible endotracheal tube or a rigid bronchoscope. Chartis and EBV placement should be performed in 1 procedure when possible. The sequence of valve placement should be orchestrated to avoid obstruction and delivery of subsequent valves. If atelectasis has not occurred by 1 month after procedure, evaluate valve position on CT and consider replacing the valves that are not optimally positioned. Pneumothorax is a common complication and typically occurs in the first 2 days following treatment. A management algorithm for pneumothorax has been previously published. Long-term sequelae from EBV therapy do occur but are easily manageable. © 2016 The Author(s) Published by S. Karger AG, Basel.

Tracheostomy and invasive mechanical ventilation in amyotrophic lateral sclerosis: decision-making factors and survival analysis.

PubMed

Kimura, Fumiharu

2016-04-28

Invasive and/or non-invasive mechanical ventilation are most important options of respiratory management in amyotrophic lateral sclerosis. We evaluated the frequency, clinical characteristics, decision-making factors about ventilation and survival analysis of 190 people with amyotrophic lateral sclerosis patients from 1990 until 2013. Thirty-one percentage of patients underwent tracheostomy invasive ventilation with the rate increasing more than the past 20 years. The ratio of tracheostomy invasive ventilation in patients >65 years old was significantly increased after 2000 (25%) as compared to before (10%). After 2010, the standard use of non-invasive ventilation showed a tendency to reduce the frequency of tracheostomy invasive ventilation. Mechanical ventilation prolonged median survival (75 months in tracheostomy invasive ventilation, 43 months in non-invasive ventilation vs natural course, 32 months). The life-extending effects by tracheostomy invasive ventilation were longer in younger patients ≤65 years old at the time of ventilation support than in older patients. Presence of partners and care at home were associated with better survival. Following factors related to the decision to perform tracheostomy invasive ventilation: patients ≤65 years old: greater use of non-invasive ventilation: presence of a spouse: faster tracheostomy: higher progression rate; and preserved motor functions. No patients who underwent tracheostomy invasive ventilation died from a decision to withdraw mechanical ventilation. The present study provides factors related to decision-making process and survival after tracheostomy and help clinicians and family members to expand the knowledge about ventilation.

Closed-loop mechanical ventilation for lung injury: a novel physiological-feedback mode following the principles of the open lung concept.

PubMed

Schwaiberger, David; Pickerodt, Philipp A; Pomprapa, Anake; Tjarks, Onno; Kork, Felix; Boemke, Willehad; Francis, Roland C E; Leonhardt, Steffen; Lachmann, Burkhard

2018-06-01

Adherence to low tidal volume (V T ) ventilation and selected positive end-expiratory pressures are low during mechanical ventilation for treatment of the acute respiratory distress syndrome. Using a pig model of severe lung injury, we tested the feasibility and physiological responses to a novel fully closed-loop mechanical ventilation algorithm based on the "open lung" concept. Lung injury was induced by surfactant washout in pigs (n = 8). Animals were ventilated following the principles of the "open lung approach" (OLA) using a fully closed-loop physiological feedback algorithm for mechanical ventilation. Standard gas exchange, respiratory- and hemodynamic parameters were measured. Electrical impedance tomography was used to quantify regional ventilation distribution during mechanical ventilation. Automatized mechanical ventilation provided strict adherence to low V T -ventilation for 6 h in severely lung injured pigs. Using the "open lung" approach, tidal volume delivery required low lung distending pressures, increased recruitment and ventilation of dorsal lung regions and improved arterial blood oxygenation. Physiological feedback closed-loop mechanical ventilation according to the principles of the open lung concept is feasible and provides low tidal volume ventilation without human intervention. Of importance, the "open lung approach"-ventilation improved gas exchange and reduced lung driving pressures by opening atelectasis and shifting of ventilation to dorsal lung regions.

Epidemiology of Noninvasive Ventilation in Pediatric Cardiac ICUs.

PubMed

Romans, Ryan A; Schwartz, Steven M; Costello, John M; Chanani, Nikhil K; Prodhan, Parthak; Gazit, Avihu Z; Smith, Andrew H; Cooper, David S; Alten, Jeffrey; Mistry, Kshitij P; Zhang, Wenying; Donohue, Janet E; Gaies, Michael

2017-10-01

To describe the epidemiology of noninvasive ventilation therapy for patients admitted to pediatric cardiac ICUs and to assess practice variation across hospitals. Retrospective cohort study using prospectively collected clinical registry data. Pediatric Cardiac Critical Care Consortium clinical registry. Patients admitted to cardiac ICUs at PC4 hospitals. None. We analyzed all cardiac ICU encounters that included any respiratory support from October 2013 to December 2015. Noninvasive ventilation therapy included high flow nasal cannula and positive airway pressure support. We compared patient and, when relevant, perioperative characteristics of those receiving noninvasive ventilation to all others. Subgroup analysis was performed on neonates and infants undergoing major cardiovascular surgery. To examine duration of respiratory support, we created a casemix-adjustment model and calculated adjusted mean durations of total respiratory support (mechanical ventilation + noninvasive ventilation), mechanical ventilation, and noninvasive ventilation. We compared adjusted duration of support across hospitals. The cohort included 8,940 encounters from 15 hospitals: 3,950 (44%) received noninvasive ventilation and 72% were neonates and infants. Medical encounters were more likely to include noninvasive ventilation than surgical. In surgical neonates and infants, 2,032 (55%) received postoperative noninvasive ventilation. Neonates, extracardiac anomalies, single ventricle, procedure complexity, preoperative respiratory support, mechanical ventilation duration, and postoperative disease severity were associated with noninvasive ventilation therapy (p < 0.001 for all). Across hospitals, noninvasive ventilation use ranged from 32% to 65%, and adjusted mean noninvasive ventilation duration ranged from 1 to 4 days (3-d observed mean). Duration of total adjusted respiratory support was more strongly correlated with duration of mechanical ventilation compared with noninvasive ventilation (Pearson r = 0.93 vs 0.71, respectively). Noninvasive ventilation use is common in cardiac ICUs, especially in patients admitted for medical conditions, infants, and those undergoing high complexity surgery. We observed wide variation in noninvasive ventilation use across hospitals, though the primary driver of total respiratory support time seems to be duration of mechanical ventilation.

5 CFR 919.305 - May I enter into a covered transaction with an excluded or disqualified person?

Code of Federal Regulations, 2010 CFR

2010-01-01

... PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) GOVERNMENTWIDE DEBARMENT AND SUSPENSION (NONPROCUREMENT) Responsibilities of Participants Regarding Transactions Doing Business with Other...

20 CFR 404.290 - Recalculations.

Code of Federal Regulations, 2013 CFR

2013-04-01

... subpart N of this part) and for individuals interned during World War II (see subpart K of this part), not... account— (1) Earnings (including compensation for railroad service) incorrectly included or excluded in...

20 CFR 404.290 - Recalculations.

Code of Federal Regulations, 2011 CFR

2011-04-01

... subpart N of this part) and for individuals interned during World War II (see subpart K of this part), not... account— (1) Earnings (including compensation for railroad service) incorrectly included or excluded in...

20 CFR 404.290 - Recalculations.

Code of Federal Regulations, 2014 CFR

2014-04-01

... subpart N of this part) and for individuals interned during World War II (see subpart K of this part), not... account— (1) Earnings (including compensation for railroad service) incorrectly included or excluded in...

20 CFR 404.290 - Recalculations.

Code of Federal Regulations, 2012 CFR

2012-04-01

... subpart N of this part) and for individuals interned during World War II (see subpart K of this part), not... account— (1) Earnings (including compensation for railroad service) incorrectly included or excluded in...

2006 public transportation fact book

DOT National Transportation Integrated Search

2006-04-01

This book includes only public transportation data and excludes taxicab, unregulated jitney, school, sightseeing, intercity, charter, : military, and non-public service (e.g., governmental and corporate shuttles), and special application systems (e.g...

2004 public transportation fact book

DOT National Transportation Integrated Search

2004-03-01

This book includes only public transportation data and excludes taxicab, unregulated jitney, school, sightseeing, intercity, charter, : military, and non-public service (e.g., governmental and corporate shuttles), and special application systems (e.g...

2005 public transportation fact book

DOT National Transportation Integrated Search

2005-04-01

This book includes only public transportation data and excludes taxicab, unregulated jitney, school, sightseeing, intercity, charter, military, and non-public service (e.g., governmental and corporate shuttles), and special application systems (e.g.,...

Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD)

PubMed Central

2012-01-01

Executive Summary In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions. After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses. The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html. Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm. For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx. The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact. Objective The objective of this health technology assessment was to determine the effectiveness and cost-effectiveness of noninvasive ventilation for stable chronic obstructive pulmonary disease (COPD). Clinical Need: Condition and Target Population Noninvasive ventilation is used for COPD patients with chronic respiratory failure. Chronic respiratory failure in COPD patients may be due to the inability of the pulmonary system to coordinate ventilation, leading to adverse arterial levels of oxygen and carbon dioxide. Noninvasive ventilation in stable COPD patients has the potential to improve quality of life, prolong survival, and improve gas exchange and sleep quality in patients who are symptomatic after optimal therapy, have hypercapnia or nocturnal hypoventilation and mild hypercapnia, and are frequently hospitalized. Technology Noninvasive positive pressure ventilation (NPPV) is any form of positive ventilatory support without the use of an endotracheal tube. For stable COPD, the standard of care when using noninvasive ventilation is bilevel positive airway pressure (BiPAP). Bilevel positive airway pressure involves both inspiratory and expiratory pressure, high during inspiration and lower during expiration. It acts as a pressure support to accentuate a patient’s inspiratory efforts. The gradient between pressures maintains alveolar ventilation and helps to reduce carbon dioxide levels. Outpatients typically use BiPAP at night. Additional advantages of using BiPAP include resting of respiratory muscles, decreased work of breathing, and control of obstructive hypopnea. Research Question What is the effectiveness and cost-effectiveness of noninvasive ventilation, compared with no ventilation while receiving usual care, for stable COPD patients? Research Methods Literature Search Search Strategy A literature search was performed on December 3, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 2004 to December 3, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. When the reviewer was unsure of the eligibility of articles, a second clinical epidemiologist and then a group of epidemiologists reviewed these until consensus was reached. Inclusion Criteria full-text English language articles, studies published between January 1, 2004 and December 3, 2010, journal articles that report on the effectiveness or cost-effectiveness of noninvasive ventilation, clearly described study design and methods, and health technology assessments, systematic reviews, meta-analyses, randomized controlled trials (RCTs). Exclusion Criteria non-English papers animal or in vitro studies case reports, case series, or case-case studies cross-over RCTs studies on noninvasive negative pressure ventilation (e.g., iron lung) studies that combine ventilation therapy with other regimens (e.g., daytime NPPV plus exercise or pulmonary rehabilitation) studies on heliox with NPPV studies on pulmonary rehabilitation with NPPV Outcomes of Interest mortality/survival hospitalizations/readmissions length of stay in hospital forced expiratory volume arterial partial pressure of oxygen arterial partial pressure of carbon dioxide dyspnea exercise tolerance health-related quality of life Note: arterial pressure of oxygen and carbon dioxide are surrogate outcomes. Statistical Methods A meta-analysis and an analysis of individual studies were performed using Review Manager Version 5. For continuous data, a mean difference was calculated, and for dichotomous data, a relative risk ratio was calculated for RCTs. For continuous variables with mean baseline and mean follow-up data, a change value was calculated as the difference between the 2 mean values. Quality of Evidence The quality of each included study was assessed taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses. The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence: High Further research is very unlikely to change confidence in the estimate of effect. Moderate Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate. Low Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate. Very Low Any estimate of effect is very uncertain Summary of Findings Conclusions The following conclusions refer to stable, severe COPD patients receiving usual care. Short-Term Studies Based on low quality of evidence, there is a beneficial effect of NPPV compared with no ventilation on oxygen gas exchange, carbon dioxide gas exchange, and exercise tolerance measured using the 6 Minute Walking Test. Based on very low quality of evidence, there is no effect of NPPV therapy on lung function measured as forced expiratory volume in 1 second (Type II error not excluded). Long-Term Studies Based on moderate quality of evidence, there is no effect of NPPV therapy for the outcomes of mortality, lung function measured as forced expiratory volume in 1 second, and exercise tolerance measured using the 6 Minute Walking Test. Based on low quality of evidence, there is no effect of NPPV therapy for the outcomes of oxygen gas exchange and carbon dioxide gas exchange (Type II error not excluded). Qualitative Assessment Based on low quality of evidence, there is a beneficial effect of NPPV compared with no ventilation for dyspnea based on reduced Borg score or Medical Research Council dyspnea score. Based on moderate quality of evidence, there is no effect of NPPV therapy for hospitalizations. Health-related quality of life could not be evaluated. PMID:23074437

Interactive simulation system for artificial ventilation on the internet: virtual ventilator.

PubMed

Takeuchi, Akihiro; Abe, Tadashi; Hirose, Minoru; Kamioka, Koichi; Hamada, Atsushi; Ikeda, Noriaki

2004-12-01

To develop an interactive simulation system "virtual ventilator" that demonstrates the dynamics of pressure and flow in the respiratory system under the combination of spontaneous breathing, ventilation modes, and ventilator options. The simulation system was designed to be used by unexperienced health care professionals as a self-training tool. The system consists of a simulation controller and three modules: respiratory, spontaneous breath, and ventilator. The respiratory module models the respiratory system by three resistances representing the main airway, the right and left lungs, and two compliances also representing the right and left lungs. The spontaneous breath module generates inspiratory negative pressure produced by a patient. The ventilator module generates driving force of pressure or flow according to the combination of the ventilation mode and options. These forces are given to the respiratory module through the simulation controller. The simulation system was developed using HTML, VBScript (3000 lines, 100 kB) and ActiveX control (120 kB), and runs on Internet Explorer (5.5 or higher). The spontaneous breath is defined by a frequency, amplitude and inspiratory patterns in the spontaneous breath module. The user can construct a ventilation mode by setting a control variable, phase variables (trigger, limit, and cycle), and options. Available ventilation modes are: controlled mechanical ventilation (CMV), continuous positive airway pressure, synchronized intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), SIMV + PSV, pressure-controlled ventilation (PCV), pressure-regulated volume control (PRVC), proportional assisted ventilation, mandatory minute ventilation (MMV), bilevel positive airway pressure (BiPAP). The simulation system demonstrates in a graph and animation the airway pressure, flow, and volume of the respiratory system during mechanical ventilation both with and without spontaneous breathing. We developed a web application that demonstrated the respiratory mechanics and the basic theory of ventilation mode.

Plutonium Finishing Plant (PFP) HVAC System Component Index

DOE Office of Scientific and Technical Information (OSTI.GOV)

DICK, J.D.

2000-02-28

The Plutonium Finishing Plant (PFP) WAC System includes sub-systems 25A through 25K. Specific system boundaries and justifications are contained in HNF-SD-CP-SDD-005, ''Definition and Means of Maintaining the Ventilation System Confinement Portion of the PFP Safety Envelope.'' The procurement requirements associated with the system necessitates procurement of some system equipment as Commercial Grade Items in accordance with HNF-PRO-268, ''Control of Purchased Items and Services.'' This document lists safety class and safety significant components for the Heating Ventilation Air Conditioning and specifies the critical characteristics for Commercial Grade Items, as required by HNF-PRO-268 and HNF-PRO-1819. These are the minimum specifications that themore » equipment must meet in order to properly perform its safety function. There may be several manufacturers or models that meet the critical characteristics for any one item.« less

Paid carers' experiences of caring for mechanically ventilated children at home: implications for services and training.

PubMed

Maddox, Christina; Pontin, David

2013-06-01

UK survival rates for long-term mechanically ventilated children have increased and paid carers are trained to care for them at home, however there is limited literature on carers' training needs and experience of sharing care. Using a qualitative abductive design, we purposively sampled experienced carers to generate data via diaries, semi-structured interviews, and researcher reflexive notes. Research ethics approval was granted from NHS and University committees. Five analytical themes emerged - Parent as expert; Role definition tensions; Training and Continuing Learning Needs; Mixed Emotions; Support Mechanisms highlighting the challenges of working in family homes for carers and their associated learning needs. Further work on preparing carers to share feelings with parents, using burnout prevention techniques, and building confidence is suggested. Carers highlight the lack of clinical supervision during their night-working hours. One solution may be to provide access to registered nurse support when working out-of-office hours.

Bronchiolitis-associated encephalopathy in critically-ill infants: an underestimated complication?

PubMed

Antonucci, Roberto; Chiappe, Stefano; Porcella, Annalisa; Rosatelli, Daniela; Fanos, Vassilios

2010-05-01

To investigate the bronchiolitis-associated encephalopathy in critically ill infants. The records of infants with severe bronchiolitis admitted to our intensive care unit between 1991 and 2003 were reviewed. Subjects with underlying neurological disorders were excluded. Encephalopathy was defined as occurrence of seizures or at least two nonconvulsive neurologic manifestations. A semistructured telephone interview investigated long-term neurodevelopmental outcome. Twenty-one infants (11 newborns) were enrolled. All patients required oxygen supplementation and 14 required mechanical ventilation. Encephalopathy occurred in 10 infants, six of whom developed seizures. Encephalopathic infants frequently (six of nine) showed transient EEG abnormalities, and occasionally (one of nine) cranial ultrasound abnormalities. A positive respiratory syncytial virus test was found in five of nine encephalopathic infants. One encephalopathic patient died, while 20 infants clinically normalised before discharge and showed a good neurodevelopmental outcome. Acute encephalopathy was frequently observed in our patients with severe bronchiolitis. Long-term prognosis of encephalopathic infants was good.

Comparison of 4-Dimensional Computed Tomography Ventilation With Nuclear Medicine Ventilation-Perfusion Imaging: A Clinical Validation Study

DOE Office of Scientific and Technical Information (OSTI.GOV)

Vinogradskiy, Yevgeniy, E-mail: yevgeniy.vinogradskiy@ucdenver.edu; Koo, Phillip J.; Castillo, Richard

Purpose: Four-dimensional computed tomography (4DCT) ventilation imaging provides lung function information for lung cancer patients undergoing radiation therapy. Before 4DCT-ventilation can be implemented clinically it needs to be validated against an established imaging modality. The purpose of this work was to compare 4DCT-ventilation to nuclear medicine ventilation, using clinically relevant global metrics and radiologist observations. Methods and Materials: Fifteen lung cancer patients with 16 sets of 4DCT and nuclear medicine ventilation-perfusion (VQ) images were used for the study. The VQ-ventilation images were acquired in planar mode using Tc-99m-labeled diethylenetriamine-pentaacetic acid aerosol inhalation. 4DCT data, spatial registration, and a density-change-based modelmore » were used to compute a 4DCT-based ventilation map for each patient. The percent ventilation was calculated in each lung and each lung third for both the 4DCT and VQ-ventilation scans. A nuclear medicine radiologist assessed the VQ and 4DCT scans for the presence of ventilation defects. The VQ and 4DCT-based images were compared using regional percent ventilation and radiologist clinical observations. Results: Individual patient examples demonstrate good qualitative agreement between the 4DCT and VQ-ventilation scans. The correlation coefficients were 0.68 and 0.45, using the percent ventilation in each individual lung and lung third, respectively. Using radiologist-noted presence of ventilation defects and receiver operating characteristic analysis, the sensitivity, specificity, and accuracy of the 4DCT-ventilation were 90%, 64%, and 81%, respectively. Conclusions: The current work compared 4DCT with VQ-based ventilation using clinically relevant global metrics and radiologist observations. We found good agreement between the radiologist's assessment of the 4DCT and VQ-ventilation images as well as the percent ventilation in each lung. The agreement lessened when the data were analyzed on a regional level. Our study presents an important step for the integration of 4DCT-ventilation into thoracic clinical practice.« less

Impact of Room Ventilation Rates on Mouse Cage Ventilation and Microenvironment.

PubMed

Reeb, Carolyn K.; Jones, Robert B.; Bearg, David W.; Bedigian, Hendrick; Paigen, Beverly

1997-01-01

To assess the impact of room ventilation on animal cage microenvironment, intracage ventilation rate, temperature, humidity, and concentrations of carbon dioxide and ammonia were monitored in nonpressurized, bonnet-topped mouse cages. Cages on the top, middle, and bottom rows of a mouse rack were monitored at room ventilation rates of 0, 5, 10, and 20 air changes/h (ACH). Ventilation inside the animal cage increased somewhat from 12.8 to 18.9 ACH as room ventilation rate in- creased from 0 to 20 ACH, but the differences were not statistically significant, and most of the increase occurred in cages in the top row nearest to the fresh air supply. Cages containing mice had ventilation rate between 10 and 15 ACH even when room ventilation was reduced to 0 ACH; this ventilation is a result of the thermal heat load of the mice. After 6 days of soiled bedding, intracage ammonia concentration was c 3 ppm at all room ventilation rates and was not affected by increasing room ventilation. Temperature inside cages did not change with increasing ventilation. Humidity inside cages significantly decreased with increasing ventilation, from 55% relative humidity at 5 ACH to 36% relative humidity at 20 ACH. Carbon dioxide concentration decreased from 2,500 ppm to 1,900 ppm when ventilation rate increased from 5 ACH to 10 ACH, but no further significant decrease was observed at 20 ACH. In conclusion, increasing the room ventilation rate higher than 5 ACH did not result in significant improvements in the cage microenvironment.

Variable mechanical ventilation

PubMed Central

Fontela, Paula Caitano; Prestes, Renata Bernardy; Forgiarini Jr., Luiz Alberto; Friedman, Gilberto

2017-01-01

Objective To review the literature on the use of variable mechanical ventilation and the main outcomes of this technique. Methods Search, selection, and analysis of all original articles on variable ventilation, without restriction on the period of publication and language, available in the electronic databases LILACS, MEDLINE®, and PubMed, by searching the terms "variable ventilation" OR "noisy ventilation" OR "biologically variable ventilation". Results A total of 36 studies were selected. Of these, 24 were original studies, including 21 experimental studies and three clinical studies. Conclusion Several experimental studies reported the beneficial effects of distinct variable ventilation strategies on lung function using different models of lung injury and healthy lungs. Variable ventilation seems to be a viable strategy for improving gas exchange and respiratory mechanics and preventing lung injury associated with mechanical ventilation. However, further clinical studies are necessary to assess the potential of variable ventilation strategies for the clinical improvement of patients undergoing mechanical ventilation. PMID:28444076

47 CFR 101.64 - Service areas.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Commerce. The Commerce Department organizes the 50 States and the District of Columbia into 172 EAs... Islands; American Samoa and the Gulf of Mexico. A total of 175 authorizations (excluding the Gulf of...

47 CFR 101.64 - Service areas.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Commerce. The Commerce Department organizes the 50 States and the District of Columbia into 172 EAs... Islands; American Samoa and the Gulf of Mexico. A total of 175 authorizations (excluding the Gulf of...

47 CFR 101.64 - Service areas.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Commerce. The Commerce Department organizes the 50 States and the District of Columbia into 172 EAs... Islands; American Samoa and the Gulf of Mexico. A total of 175 authorizations (excluding the Gulf of...

47 CFR 101.64 - Service areas.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Commerce. The Commerce Department organizes the 50 States and the District of Columbia into 172 EAs... Islands; American Samoa and the Gulf of Mexico. A total of 175 authorizations (excluding the Gulf of...

2007 public transportation fact book

DOT National Transportation Integrated Search

2007-05-01

This book includes only public transportation data and excludes taxicab, unregulated jitney, school, sightseeing, intercity, charter, : military, and services not available to the general public, or segments of the general public (e.g., governmental ...

49 CFR 24.303 - Related nonresidential eligible expenses.

Code of Federal Regulations, 2011 CFR

2011-10-01

... improvements at the replacement site. (b) Professional services performed prior to the purchase or lease of a... limited to, soil testing, feasibility and marketing studies (excluding any fees or commissions directly...

49 CFR 24.303 - Related nonresidential eligible expenses.

Code of Federal Regulations, 2010 CFR

2010-10-01

... improvements at the replacement site. (b) Professional services performed prior to the purchase or lease of a... limited to, soil testing, feasibility and marketing studies (excluding any fees or commissions directly...

Effects of positive end-expiratory pressure and recruitment maneuvers in a ventilator-induced injury mouse model

PubMed Central

Franzi, Lisa M.; Linderholm, Angela L.; Last, Jerold A.; Adams, Jason Y.; Harper, Richart W.

2017-01-01

Background Positive-pressure mechanical ventilation is an essential therapeutic intervention, yet it causes the clinical syndrome known as ventilator-induced lung injury. Various lung protective mechanical ventilation strategies have attempted to reduce or prevent ventilator-induced lung injury but few modalities have proven effective. A model that isolates the contribution of mechanical ventilation on the development of acute lung injury is needed to better understand biologic mechanisms that lead to ventilator-induced lung injury. Objectives To evaluate the effects of positive end-expiratory pressure and recruitment maneuvers in reducing lung injury in a ventilator-induced lung injury murine model in short- and longer-term ventilation. Methods 5–12 week-old female BALB/c mice (n = 85) were anesthetized, placed on mechanical ventilation for either 2 hrs or 4 hrs with either low tidal volume (8 ml/kg) or high tidal volume (15 ml/kg) with or without positive end-expiratory pressure and recruitment maneuvers. Results Alteration of the alveolar-capillary barrier was noted at 2 hrs of high tidal volume ventilation. Standardized histology scores, influx of bronchoalveolar lavage albumin, proinflammatory cytokines, and absolute neutrophils were significantly higher in the high-tidal volume ventilation group at 4 hours of ventilation. Application of positive end-expiratory pressure resulted in significantly decreased standardized histology scores and bronchoalveolar absolute neutrophil counts at low- and high-tidal volume ventilation, respectively. Recruitment maneuvers were essential to maintain pulmonary compliance at both 2 and 4 hrs of ventilation. Conclusions Signs of ventilator-induced lung injury are evident soon after high tidal volume ventilation (as early as 2 hours) and lung injury worsens with longer-term ventilation (4 hrs). Application of positive end-expiratory pressure and recruitment maneuvers are protective against worsening VILI across all time points. Dynamic compliance can be used guide the frequency of recruitment maneuvers to help ameloriate ventilator-induced lung injury. PMID:29112971

46 CFR 111.103-1 - Power ventilation systems except machinery space ventilation systems.

Code of Federal Regulations, 2010 CFR

2010-10-01

... (CONTINUED) ELECTRICAL ENGINEERING ELECTRIC SYSTEMS-GENERAL REQUIREMENTS Remote Stopping Systems § 111.103-1 Power ventilation systems except machinery space ventilation systems. Each power ventilation system must... 46 Shipping 4 2010-10-01 2010-10-01 false Power ventilation systems except machinery space...