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Although chylothorax is an uncommon complication following paediatric cardiothoracic surgery, it has significant associated morbidities and increased in-hospital mortality, as well as results in higher costs. A lack of prospective evidence or consensus guidelines for management of chylothorax further hinders optimal management. The aim of this survey was to characterise variations in practice in the management of chylothorax and to identify areas for future research.
Materials and methods:
A descriptive, observational survey investigating conservative management practices of chylothorax was distributed internationally to health-care professionals in paediatric intensive care and cardiology units. The survey investigated five domains: the first providing general information about health-care professionals and four domains focusing on clinical practice including diet composition and duration.
In total, sixty-four health-care professionals completed the survey, representing 38 organisations from 16 countries. The respondents were dietitians (80%), physicians (19%), and nurses (1%). In Australia and New Zealand, management was most commonly directed by physicians’ preference (67%) as compared to unit protocols in Europe (67%), United States of America (67%), and Other regions (55%). Dietitians in Australia/New Zealand, United Kingdom, and Ireland followed the most restrictive diet therapy recommending <5 g long chain triglyceride fat per day (p < 0.00001). The duration of diet therapy significantly varied between regions: Australia/New Zealand: 4 weeks (36%) and 6 weeks (43%); Europe: 4 weeks (25%) and 6 weeks (57%); and North America: 4 weeks (18%) and 6 weeks (75%) (p < 0.00001).
This survey highlights international variations in practice in the management of chylothorax, particularly with respect to treatment duration and dietary fat restriction. Future research should include a multi-centre randomised controlled trial to inform evidence-based practice and reduce morbidity, particularly poor growth.
This paper presents a combined experimental and large-eddy simulation study to characterise the effect of aspect ratio on the near-wake structure of a square finite wall-mounted cylinder (FWMC). The cylinder aspect ratios (span
) investigated in the experiments were
$1.4\leqslant L/W\leqslant 21.4$
and the oncoming boundary-layer thicknesses were
at a Reynolds number based on cylinder width of
, respectively. In complementary simulations, the cylinder aspect ratios investigated were 1.4, 4.3, 10 and 18.6. The cylinder wake structure was visualised in three-dimensional space using a vortex core detection method and decomposed to its oscillation modes using the spectral proper orthogonal decomposition (SPOD) technique. A parametric diagram is proposed to predict whether the time-averaged wake structure is a dipole or a quadrupole pattern, based on oncoming boundary-layer height and aspect ratio. Cellular shedding occurs when the aspect ratio is high with up to three shedding cells occurring across the span for aspect ratios
. Each of these cells sheds at a distinct frequency, as evidenced by the spectral content of the surface pressure measured on the side face and the near-wake velocity. Amplitude modulation is also observed in the vortex shedding, which explains the amplitude modulation of the acoustic pressure emitted by square FWMCs. SPOD is shown to be a viable method to identify the occurrence of cellular shedding in the wake.
This paper presents the results of an experimental study that relates the flow structures in the wake of a square finite wall-mounted cylinder with the radiated noise. Acoustic and hot-wire measurements were taken in an anechoic wind tunnel. The cylinder was immersed in a near-zero-pressure gradient boundary layer whose thickness was 130 % of the cylinder width,
. Aspect ratios were in the range
$0.29\leqslant L/W\leqslant 22.9$
is the cylinder span), and the Reynolds number, based on width, was
. Four shedding regimes were identified, namely R0 (
), RI (
), RII (
) and RIII (
), with each shedding regime displaying an additional acoustic tone as the aspect ratio was increased. At low aspect ratios (R0 and RI), downwash dominated the wake, creating a highly three-dimensional shedding environment with maximum downwash at
. Looping vortex structures were visualised using a phase eduction technique. The principal core of the loops generated the most noise perpendicular to the cylinder. For higher aspect ratios in RII and RIII, the main noise producing structures consisted of a series of inclined vortex filaments, where the angle of inclination varied between vortex cells.
Consecutive, adult, non–intensive care unit (non-ICU) inpatients triggering an institutional clinical sepsis pathway from May to August 2015.
All patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger.
In total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04–1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant.
Sepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation. Further studies are needed to evaluate clinical outcomes.
The flow and noise created by sawtooth trailing-edge serrations has been studied experimentally at a low Reynolds number. Experiments have been performed on a flat-plate model with an elliptical leading edge and an asymmetrically bevelled trailing edge at Reynolds numbers of Rec = 1 × 105–1.3 × 105, based on chord. Wide serrations with a wavelength (λs) to amplitude (2h) ratio of λs/h = 0.6 were found to reduce the overall sound pressure level by up to 11dB. In contrast, narrower serrations with λs/h = 0.2 produce tonal noise and increase the overall noise level by up to 4dB. Intense vortices across the span of the trailing edge with narrow serrations are shown to be the source of tonal noise. Wide serrations reduce turbulent velocity fluctuations at low frequencies which explains the lower radiated noise. The narrow serrations that produce low Reynolds number tonal noise were shown previously to be effective at higher Reynolds numbers (Rec > 2 × 105), demonstrating that care is needed to fully understand the flow field over serrations for all intended operating conditions.
Immunomics is a relatively new field of research which integrates the disciplines of immunology, genomics, proteomics, transcriptomics and bioinformatics to characterize the host-pathogen interface. Herein, we discuss how rapid advances in molecular immunology, sophisticated tools and molecular databases are facilitating in-depth exploration of the immunome. In our opinion, an immunomics-based approach presides over traditional antigen and vaccine discovery methods that have proved ineffective for highly complex pathogens such as the causative agents of malaria, tuberculosis and schistosomiasis that have evolved genetic and immunological host-parasite adaptations over time. By using an integrative multidisciplinary approach, immunomics offers enormous potential to advance 21st century antigen discovery and rational vaccine design against complex pathogens such as the Plasmodium parasite.
The aim of this study was to assess the feasibility of radiographer led verification of cone-beam computed tomography (CBCT) images for patients with solitary lung tumours treated with stereotactic body radiotherapy treatment (SBRT).
Material and methods
CBCT setup images of 20 patients from the first fraction of each patient were retrospectively registered by therapeutic radiographers. The displacements recorded were compared with the clinical oncologist’s original online match. The time taken by radiographers to verify the CBCT images was also recorded.
Overall agreement for all radiographers when compared with the clinical oncologist match was 91%. Interobserver variations between radiographers were X plane 0·87 (0·76–0·94); Y plane 0·74 (0·51–0·88); and Z plane 0·88 (0·78–0·95) intraclass correlation coefficient and 95% confidence interval. The average time taken for verification was 128 seconds.
Therapeutic radiographers are able to verify CBCT images for thorax SBRT with results comparable to the ‘gold standard’ clinical oncologists’ match, however additional training will be provided for online verification. The time taken was within acceptable limits.
The incentive sensitisation model of obesity suggests that modification of the dopaminergic associated reward systems in the brain may result in increased awareness of food-related visual cues present in the current food environment. Having a heightened awareness of these visual food cues may impact on food choices and eating behaviours with those being most aware of or demonstrating greater attention to food-related stimuli potentially being at greater risk of overeating and subsequent weight gain. To date, research related to attentional responses to visual food cues has been both limited and conflicting. Such inconsistent findings may in part be explained by the use of different methodological approaches to measure attentional bias and the impact of other factors such as hunger levels, energy density of visual food cues and individual eating style traits that may influence visual attention to food-related cues outside of weight status alone. This review examines the various methodologies employed to measure attentional bias with a particular focus on the role that attentional processing of food-related visual cues may have in obesity. Based on the findings of this review, it appears that it may be too early to clarify the role visual attention to food-related cues may have in obesity. Results however highlight the importance of considering the most appropriate methodology to use when measuring attentional bias and the characteristics of the study populations targeted while interpreting results to date and in designing future studies.