bluuebunny/crossref_metadata_2025 huggingface dataset:
Experimental Investigations of the Film Cooling Performance of a Micro-Tangential-Jet Scheme on a Gas Turbine Vane: Part 2 — Heat Transfer Coefficient
Authors: Hassan O. , Hassan I.
Published: October 2013

This paper presents experimental investigations of the Heat Transfer Coefficient (HTC) performance of a Micro-Tangential-Jet (MTJ) Film cooling scheme on a gas turbine vane using transient Thermochromic Liquid Crystal (TLC) technique. In part I of this paper, the film cooling effectiveness performance of the MTJ scheme was presented. The MTJ scheme is a micro-shaped scheme designed so that the secondary jet is supplied parallel to the vane surface. In order to supply the jet in a direction parallel to the vane surface, extra material was added on both pressure and suction sides. The added material is expected to produce more turbulence and hence increase the HTC values. The investigations showed that the increase in the HTC due to the presence of the MTJ scheme is very close to that resulting from the presence of normal traditional shaped schemes on the pressure side. Meanwhile, reduction in the HTC is recorded on the suction side. Such performance is attributed to the small overall height of the scheme which helped keeping the resulting turbulence at minimum. Moreover, the HTC distribution downstream the MTJ scheme is uniform in the lateral directions, which helps minimize the thermal stresses. To judge the overall performance of the MTJ scheme, the Net Heat Flux Reduction (NHFR) parameter is used. The NHFR represents a combination of the effects of both the cooling effectiveness and the HTC. Great enhancement in the NHFR performance of the MTJ was observed compared to traditional shaped schemes. The investigation showed that a blowing ratio close to unity, based on the scheme exit area, could be considered optimal for the MTJ scheme.
A Thermoresponsive Hydrogel Based Controlled Drug Delivery Device
Authors: Blanco Letia , Shiakolas Panos S. , Aswath Pranesh B. , Alberts Christopher B. , Grace Chris , Godfrey Kyle , Patin Drew
Published: October 2013

Thermoresponsive hydrogels exhibit the unique property of volume change as a function of change in temperature as they transition between hydrophilic and hydrophobic states. These hydrogels can be loaded with drug/protein and serve as reservoirs for drug/protein delivery applications. A hydrogel based device for controlled drug delivery is designed with a number of subsystems that are interfaced with LabVIEW for development of a functional device. The device was designed using analytical and finite element analysis procedures and fabricated. In this manuscript, the device design will be reviewed and discussed. A parametric study was performed to examine the device operation and performance as function of hydrogel heating/cooling temperature profiles. Subsequently, the device was employed in a series of experiments to examine the delivery of a protein as a function of thermal stimuli. The matrix used in this study was poly(ethylene glycol) diacrylate (PEGDA) and the drug delivery nanoparticles carriers were poly(N-isopropylacrylamide-co-acrylamide (PNIPAM) with a lower critical solution temperature (LCST) around 40°C. The protein of choice was bovine serum albumin (BSA). The results of this study illustrate that the development of a multi-drug or therapeutic delivery device is possible and that individual drugs can be delivered on demand using a closed loop control system.
Dynamic Response of Human Legs due to Horizontal Jump
Authors: Ravuri Srikanth , Barez Fred , Wagner David , Kao Jim
Published: October 2013

Jumping is a coordinated extension of the human body through combined strength and agility to perform a leap motion far enough for the feet to land on the ground. However, the repeated reaction forces and the resulting stresses on the ankle, knee and hip joints may cause injuries to a person. A primary mechanism of such injuries is suggested to be the acute high impact loads experienced during the landing in a horizontal jump. The goal of this study is to determine the reaction force distribution at the joints in the lower extremities during the horizontal jump. A detailed biomechanical system was constructed to calculate the reaction forces generated during the horizontal jump. The horizontal jump kinematics of a participant was measured using a three-dimensional motion capture system and the landing forces were measured using two force plates. Biomechanical simulation software was used to calculate the internal joint reaction forces at the ankle, knee, and hip. It was determined that the maximum reaction forces primarily occurred in the proximo/distal direction of the hip, 2,300 N; and ankle, 2,700 N. However, at the knee joint, the maximum reaction force was determined to be in antero/posterior direction, at 2,000 N; and proximo/distal direction, at 2,100 N, respectively.
A New High-Precision Bearing Measuring System for Non-Repetitive Run-Out (NRRO)
Authors: Yang Zhaohui , Hong Jun , Zhang Jinhua , Wang Michael Yu , Liu Jian
Published: October 2013

As ultra-precision index of high-precision ball bearings, the value of non-repetitive run-out (NRRO) directly influences the rotation accuracy in complex mechanical system. Reducing NRRO contributes to improve the quality of manufacturing in machining tools. This paper developed a new high-precision bearing measuring system to analyze the NRRO of an angular contact ball bearing caused by geometrical errors of bearings’ parts. The characteristic of measuring system as follows:

(1) The air-bearing spindle that is drive by servomotor is used to support the test bearing to ensure the system accuracy and continuously variable;

(2) The air-bearing of flat is used to load of non-contact on the test bearing along axial direction for simulation conditions of bearings;

(3) The multi-capacitive displacement sensors are used to measure run-out of the air-bearing spindle vibration of the radial direction, then the run-out is separated as system error;

(4) The NRRO of axial and radial directions caused by geometrical errors of the rings raceways and the balls could be analyzed.
Design of a Fuel Cell Powered Blended Wing Body UAV
Authors: Verstraete Dries , Lehmkuehler Kai , Wong K. C.
Published: October 2013

Small-scale electrically powered Unmanned Aerial Vehicles (UAVs) are currently in use for a variety of reconnaissance and remote sensing missions. For these missions, electrical propulsion is generally preferred over small internal combustion engines because of the low noise and IR signature, low vibration levels, ease of operational support, and physical robustness. A desire for longer endurance than is available from the current generation of batteries has motivated the development of fuel cell based hybrid electrical propulsion systems. These advanced powerplant designs often include implementation challenges that will require new development methods and tools. Fuel cells generally lead to very low fuel weight at a high specific energy (Wh/kg) but have low specific power (W/kg). A high specific power is required to improve aircraft performance and manoeuvrability. Aircraft concepts powered solely by fuel cells therefore require both extremely lightweight airframes with a large internal volume and low-power payloads, which remains a challenge for conventional airframe designs. A blended-wing-body (BWB) airframe has high aerodynamic and structural efficiencies, which therefore seem ideally suited for this new generation of power-plants.

This paper presents the development and testing of a novel BWB fuel-cell powered UAV. The paper first describes the initial design steps that led to the current airframe design. The Mark 1 platform has been developed, with a half-scale model built and currently being flight-tested. Based on the flight test results, the airframe will be scaled up and optimised to accommodate the fuel-cell and its associated systems. This aircraft will then be tested with a standard electrical propulsion system to determine the airworthiness with the restricted fuel cell power output as well as the design of the take-off boost system. This paper reports on the design, analyses, and preliminary testing of a fuel cell powered BWB UAV.
Evaluation of Dynamic Performance of Aircraft Seats for Larger Passenger Population Using Finite Element Analysis
Authors: Bhonge Prasannakumar S. , Moradi Rasoul , Lankarani Hamid M.
Published: October 2013

Dynamic aircraft seat regulations are identified in the Code of Federal Regulations (CFR), 14 CFR Parts § XX.562 for crashworthy evaluation of a seat in dynamic crash environment. The regulations specify full-scale dynamic testing on production seats. The dynamic tests are designed to demonstrate the structural integrity of the seat to withstand an emergency landing event and occupant safety. These tests are carried out on a 50th percentile Hybrid II Anthropomorphic Test Device (ATD) representing average 50 percent of human population. In this study, the dynamic performance of seats are evaluated for larger passenger population for both transport and general aviation seats. For this, Finite Element Analysis (FEA) of an aircraft seat model is analyzed by utilizing a 50th percentile e-ATD and validated with a 50th percentile ATD sled test results. Then the effect of a 95th percentile standard ATD in an aircraft passenger seat is investigated using FEA. Comparison of the 50th percentile and the 95th percentile electronic ATD models (e-ATDs) is carried out on the test parameters. This includes the restraint loads, the floor reactions and the head paths. Based on the comparison it is concluded that the seat loads go up in the range of 20 to 30% if designed for larger passenger population.
A Variational Asymptotic Method for Unit Cell Homogenization of Elastoplastic Heterogeneous Materials
Authors: Zhang Liang , Yu Wenbin
Published: October 2013

The variational asymptotic method for unit cell homogenization (VAMUCH) is a unified micromechanical numerical method that is able to predict the effective properties of heterogeneous materials and to recover the microscopic stress/strain field. The objective of this paper is to incorporate elastoplastic material behaviors into the VAMUCH to predict the nonlinear macroscopic/microscopic response of elastoplastic heterogeneous materials. The constituents are assumed to exhibit various behaviors including elastic/plastic anisotropy, isotropic/kinematic hardening, and plastic non-normality. The constitutive relations for the constituents are derived and implemented into the theory of VAMUCH. This theory is implemented using the finite element method, and an engineering code, VAMUCH, is developed for the micromechanical analysiso of unit cells. The applicability, power, and accuracy of the theory and code of VAMUCH are validated using several examples including predicting the initial and subsequent yield surfaces, stress-strain curves, and stress-strain hysteresis loops of fiber reinforced composites. The VAMUCH code is also ready to be implemented into many more sophisticated user-defined material models.
FEA Analysis of a Portable Knee Rehabilitation Device Using Mechanical Loading
Authors: Fitzwater Daric , Rophie Andrew , Schroeder Benjamin , Dole Andrew , Solano Juan , Keith Joshua , Anwar Sohel , Yokota Hiroki , Chien Stanley
Published: October 2013

In this paper, a solid model has been created with CAD software and analyzed with FEA software to obtain the deformed geometry, stress distribution, modal frequencies, temperature distribution, and life expectancy of a knee loading device that will be used in a combined biomedical and mechanical engineering research initiative. The purpose of this device is to mechanically load the end of the long bone of the human leg, causing movement of the fluids within the bone that can stimulate increased growth of bone tissues. This could potentially be used to speed the healing process of bone fractures. The CAD model of the device was constructed in Pro/ENGINEER and then exported to ANSYS Workbench where it was then meshed and solved using the finite element method.
Turbine Blade Aerodynamic Optimization on Unstructured Grids Using a Continuous Adjoint Method
Authors: Zeinalpour M. , Mazaheri K. , Irannejad A.
Published: October 2013

A gradient based optimization using the continuous adjoint method for inverse design of a turbine blade cascade is presented. The advantage of the adjoint method is that the objective function gradients can be evaluated by solving the adjoint equations with coefficients depending on the flow variables. This method is particularly suitable for aerodynamic design optimization for which the number of design variables is large. Bezier polynomials are used to parameterize suction side of the turbine blade. The numerical convective fluxes of both flow and adjoint equations are computed by using a Roe-type approximate Riemann solver. An approximate linearization is applied to simplify the calculation of the numerical flux of adjoint variables on the faces of computational cell. The problem examined is that of the inverse design of NASA C3X blade that reproduces a given pressure distributions over its surfaces. Adjoint results show a good agreement with those obtained by finite-difference method.
Sizing Optimization of Lightweight Multilayer Thermal Protection Structures for Hypersonic Aircraft
Authors: Wang Qi , Xie Gongnan , Xiao Manyu , Zhang Weihong , Sundén Bengt
Published: October 2013

In the context of hypersonic aircraft design, the major issue of the thermal protection system (TPS) is to obtain the optimal thickness of the insulation layers due to intense aerodynamic heating during re-entering earth’s atmosphere. In this study, an idea combining a transient heat transfer model and an efficient optimization model is introduced for multi-layer insulation of TPS. The TPS geometric dimensions in the thickness direction are particularly considered as the design variables and the objective function is the mass of the thermal protection structure with the limitation of the extreme temperatures of the hypersonic vehicle structure. In order to decrease the computational complexity, the Globally Convergent Method of Moving Asymptotes (GCMMA) method is specially used to search the optimal solution. The results show that the usage of multilayer insulation materials for the TPS can save more than 25% weight compared to a single-layer TPS. The detailed analysis and comparison indicate the advantages of the presented optimization model.
Adhesiveless Composite Structures With Carbon Fiber Prepregs for Aircraft Primary Structural Applications
Authors: Gandy H. T. N. , Asmatulu R.
Published: October 2013

The present work was focused on the properties of adhesiveless honeycomb sandwich structures with carbon fiber prepreg, while assessing the properties with adhesive films at the skin-to-core interface simultaneously. In this work, laminate and honeycomb sandwich panels were fabricated and tested with consistent lay-up, curing, and testing processes. The test specimens from the panels were tested for physical properties at room, hot, and cold temperatures, as well as different moisture absorption performances. The results confirmed that the self-adhesive prepreg physical properties met the components and void content recommendations used in primary structures of aircraft. The mechanical tests showed comparable results to panels, with prepreg and adhesive film at the skin-to-core interface, commonly used for primary structures.
Hippo Gains Weight: Added Insights and Complexity to Pathway Control
Authors: Enderle Leonie , McNeill Helen
Published: October 2013

Multiple regulatory inputs govern Hippo pathway activity and tissue growth.
A New PERKspective on Neurodegeneration
Authors: Scheper Wiep , Hoozemans Jeroen J. M.
Published: October 2013

Targeting stress-induced kinases that regulate protein synthesis may be a new therapeutic strategy for treating neurodegenerative diseases.
Creating Refuge
Authors: Ghajar Cyrus M.
Published: October 2013

EGF receptor inhibition causes lung cancer cells to make fibronectin, which in turn promotes therapeutic resistance.
Clostridium perfringensgas gangrene at a wrist intravenous line insertion
Authors: Determann Catherine , Walker Craig Andrew
Published: October 2013

A patient admitted to the intensive care unit for management of hypotension following a multiple medications overdose subsequently deteriorated rapidly with sepsis. A cannula site was noted to be bruised, swollen and erythematous and the X-ray demonstrated gas sitting within the tissues surrounding the metacarpal bones. The patient was referred to the orthopaedic surgeons and quickly taken for debridement of the affected area and fasciotomies of the forearm. Microbiological investigation confirmedClostridium perfringensto be present in multiple fluid samples taken from the affected site.
Role of serial MRI assessment in the management of an abdominal pregnancy
Authors: Renfroe Shyann , Dajani Nafisa K , Pandey Tarun , Magann Everett F
Published: October 2013

A 33-year-old woman was admitted to the hospital with an abdominal pregnancy at a gestational age of 20 weeks. An initial MRI mapping of fetal location and placental vascular invasion was obtained. The patient refused surgical intervention until fetal survival would be possible. Serial MRIs were essential in timing delivery and avoiding an emergency surgical situation. The baby was delivered at 24 weeks with the assistance of a multidisciplinary surgical team. The mother as well as the baby survived. This case report highlights the role of serial MRI evaluations in the diagnosis and expectant management of an abdominal pregnancy. It also highlights the importance of interdisciplinary communication for a successful outcome.
Improving documentation of treatment escalation decisions in acute care
Authors: Dahill Mark , Powter Louise , Garland Lynn , Mallett Mark , Nolan Jerry
Published: October 2013

The aim of this project was to improve the documentation of treatment escalation decisions at a district general hospital in southwest England. A pilot ‘Ceiling of Treatment’ proforma was trialled on the care of the elderly wards at the Royal United Hospital (RUH), Bath. Successive PDSA cycles enabled revision of the proforma for use across the Trust. Data were collected on the proportion of patients with a documented treatment escalation decision. Formative feedback was collected via questionnaire from trainees and discussion with special interest groups of consultants within the hospital. This approach involved collaboration between acute medicine, intensive care, elderly care, the resuscitation department, palliative care and the legal department. Documentation of ceiling of treatment decisions rose from 30% to 90% during the study. A survey of medical trainees showed 67% (n=36) had seen the ceiling of treatment form, of which, 100% found it useful on on-call shifts. Initiating a proforma to record treatment escalation decisions and combining this with the existing ‘Do not attempt cardiopulmonary resuscitation’ (DNAR) paperwork, increased decision making and documentation. This intervention ensures patients receive the appropriate level of care, as indicated by their consultant, and reduces anxiety for junior doctors during on-call shifts.
Post-acute surgical ward round proforma improves documentation
Authors: Al-Mahrouqi Haitham , Oumer Ramadan , Tapper Richard , Roberts Ross
Published: October 2013

In health care, record keeping of doctor-patient encounters is vital for quality patient care and medico-legal reasons. We audited the documentation of post-acute consultant ward round (PACWR) in our department before and six months after an introduction of a proforma (standard form).

The clinical notes of all patients admitted acutely under General Surgery over a period of one week before and one week after the introduction of a proforma were reviewed to note whether time and date, signature, impression and dietary plan were documented after PACWR. The nurses were also surveyed on the day of the PACWR for their certainty regarding the dietary plan of their patients and whether they had to contact the surgical team for clarification.

There were 108 and 103 patients eligible for the first and second study periods respectively. After the introduction of the proforma, there was a statistically significant improvement in the documentation of time and date (37% vs. 72%, p-value <0.01) and impression (40% vs. 61%, p-value <0.01). Improvement in the documentation of the dietary plan reached statistical significant only when the analysis was restricted to the cases where a proforma was filled out (78 out of 103 patients). Introduction of the proforma had no statistically significant impact on the nurses' certainty regarding their patients' dietary plan and the number of times they had to contact the surgical teams.

In conclusion, PACWR proforma improves overall documentation. This will help in avoiding adverse effects on patient care and medico-legal ramifications.
Reducing short-stay hospital admissions by ruling out non-ST elevation myocardial infarction and estimating coronary artery disease likelihood on an emergency department observation ward
Authors: Wiese Martin
Published: October 2013

Chest pain is an important presentation in adult patients attending emergency departments (ED). The process of ruling out an acute coronary syndrome (ACS) conventionally requires a short in-patient stay. This places a significant burden on healthcare systems. Recent developments have encouraged us to explore the role of an ED observation ward in the management of these patients.

We designed and implemented two proformas ('flowformas'). The first provides integrated guidance and documentation for the management of chest pain in the ED. In patients determined to be at low risk of short-term adverse outcomes the ACS rule-out process is now completed on the ED observation ward rather than on the cardio-respiratory admission ward. The second proforma is used before discharge to determine the likelihood of underlying coronary artery disease (CAD), thereby allowing risk-based follow-up arrangements to be made. We collected data on all patients admitted to EDU on the NSTEMI rule-out pathway over a 12-month period.

Between Feb 2012 and Feb 2013, 816 patients fulfilling the criteria were admitted on the pathway. 67 patients (8%) required admission due to ACS. 15 patients were admitted on two, and one on three occasions.

In conclusion, it is possible to deliver ACS rule-out on an emergency observation ward. This reduces healthcare costs and shortens hospital stay.
Helping children stop or avoid enteral feeding
Authors: Wright Charlotte
Published: October 2013

Long term enteral feeding is widely used to provides vital support for infants and children unable to feed orally, but once medically stable the transition to a normal diet can be difficult. Other children may need to commence tube feeding later in childhood because of difficulties associated with neurodisability, but recognising which children will benefit from tube feed is not straightforward. The Royal Hospital for Sick Children, Yorkhill set up a multidisciplinary feeding team in 2002 to help avoid unnecessary tube feeding.

We accept only children who are either artificially fed or with severe nutritional problems and only after attempted uni-disciplinary management. The team members are a clinical psychologist, paediatric dietitian and consultant paediatrician, supported by a specialist paediatric registrar, assistant psychologist and administrative support. We can see only a small proportion of all with complex feeding problems, but aim to improve the care of such children generally. We disseminate the lessons learned within the Feeding Clinic via education locally and nationally and have an active programme of research.

Over the first ten years of the clinic we have seen 222 patients of whom 67% were initially either tube or oral supplement fed, while only 29% remain so at follow up. In the first three years of the clinic tube fed children had spent a median of seven years on feeds before they were successfully weaned, but since then that has fallen to a median of 2.7 years. Of 53 other children referred for possibly tube feeding, 32 (60%) remain well on a normal diet and only ten (19%) have needed to start tube feeding.

The service is highly cost effective. Salary costs are only around £65,000 per year, while weaning five children per year, reducing their years on feeds by four years, saves the NHS £130,000.
Implementing scientific evidence to improve the quality of Child Protection
Authors: Cowley Laura , Tempest Vanessa , Maguire Sabine , Mann Mala , Naughton Aideen , Wain Laura , Kemp Alison
Published: October 2013

In contrast to other areas of medical practice, there was a lack of a clear, concise and accessible synthesis of scientific literature to aid the recognition and investigation of suspected child abuse, and no national training program or evidence based guidelines for clinicians. The project's aim was to identify the current scientific evidence for the recognition and investigation of suspected child abuse and neglect and to disseminate and introduce this into clinical practice.

Since 2003 a comprehensive program of Systematic Reviews of all aspects of physical abuse, emotional abuse, and neglect of children, has been developed. Based on NHS Centre for Reviews and Dissemination standards, methodology was devised and reviewers trained. Dissemination was via peer reviewed publications, a series of leaflets highlighting key points in a Question and Answer format, and a website.

To date, 21 systematic reviews have been completed, generating 28 peer reviewed publications, and six leaflets around each theme (eg fractures, bruising). More than 250,000 have been distributed to date. Our website generates more than 10,000 hits monthly. It hosts primary reviews that are updated annually, links to all included studies, publications, and detailed methodology. The reviews have directly informed five national clinical guidelines, and the first evidence based training in Child Maltreatment.

Child abuse is every health practitioner's responsibility, and it is vital that the decisions made are evidence based, as it is expected in all other fields of medicine. Although challenging, this project demonstrates that it is possible to conduct high quality systematic reviews in this field. For the first time a clear concise synthesis of up to date scientific evidence is available to all practitioners in a range of accessible formats. This has underpinned high quality national guidance and training programs. It ensures all professionals have the appropriate knowledge base in this difficult and challenging field.
Prospective management of end-stage renal failure within a conservative care programme
Authors: Dhaun Neeraj , Mackenzie Johanna , Goddard Jane , Whitworth Caroline
Published: October 2013

Progression to end-stage renal disease (ESRD) is a major issue for heath care systems both clinically and financially. Given dialysis may not prolong life, and may indeed impair quality of life, alternative options for these patients such as conservative care are urgently needed. We appointed a dialysis charge nurse who had many years of experience of working with patients on dialysis to spearhead the newly set up Conservative Care Programme (CCP) in the Edinburgh Renal Unit. The rationale was to work as part of the renal multidisciplinary team to support patients and their families to make an informed shared decision whether to opt for dialysis or to follow the CCP.

From the perspective of the patients, their families and carers we have received positive feedback since starting the CCP - thank you cards; phone calls both to the CCP Nurse Specialist and the renal unit affirming the positive experience patients had during the conservative management of their renal failure. Whilst continuing to provide the best quality of care to renal patients in NHS Lothian and Borders, the number of prevalent dialysis patients in our catchment area has fallen significantly over the last few years as demonstrated by Scottish Renal Registry data. These benefits are potentially applicable to other renal units across the UK.
How creation of a parent satisfaction questionnaire improved multidisciplinary service delivery in a paediatric day surgery unit.
Authors: Bradley Alison
Published: October 2013

Auditing patient satisfaction has become a keystone of quality patient centred healthcare. A plethora of patient satisfaction studies exist but only a few studies have been evaluated for their validity, reliability, specificity or psychometric properties. And the majority focus on adult health care. However, if validated tools are not utilised, then inaccurate results could stymie service improvement.

The level of satisfaction with the paediatric day surgery service at Tayside Children's Hospital was unknown. Our objective was to measure parent satisfaction with the paediatric day surgery by creating a parent satisfaction questionnaire which has undergone satisfactory testing for validity, reliability, specificity and psychometric properties. A Likert-style questionnaire was constructed through literature review and focus group meetings with professionals, parents and patient groups to establish content validity. Statements worded in positive phrasing were re-worded in negative phrasing to ensure intra-rater reliability. A pilot study was conducted and responses analysed for construct validity and inter-rater agreement. Internal reliability was established using Chronbach's alpha analysis, which produced scores for each part of the questionnaire between 0.7 and 0.9.

Overall parent satisfaction was high. 95.48% either strongly agreed or agreed with positively worded statements regarding pre-operative clinic service. In particular 100% satisfaction was reported with the pre-operative phone call which only 70% of participants received. 96.60% strongly agreed or agreed with positive statements regarding service provided on the ward and 87.50% strongly agreed or agreed with positive statements regarding the discharge process. 5% specifically requested improved information giving.

In conclusion the parent satisfaction questionnaire was found to have proven validity, reliability, specificity and psychometric properties. Overall parent satisfaction was found to be high. Areas identified for improvement included delivering pre-operative phone call to all parents who have children undergoing day surgery and further exploration of sources and methods of information giving.
Quality improvement in Respiratory Medicine: Designing and implementing a bronchoscopy checklist at Southend University Hospital
Authors: Thillai Muhunthan , Powrie Duncan
Published: October 2013

There is currently no standardised procedure checklist for bronchoscopies in the United Kingdom. Furthermore, very few hospitals appear to routinely use any form of checklist for these procedures. Conversely, the World Health Organisation surgical checklist has become standard practice in most hospitals, our own included, for all surgical procedures. Based on our own needs, we decided to create a bronchoscopy checklist which could be used at our hospital with the primary emphasis on ensuring patient safety and improving clinical outcomes. We surveyed local surgical checklists as well as endoscopic checklists used in hospitals around the world. We then created an initial draft which was sent out to consultation to all Respiratory Physicians in our hospital. Comments were also taken from the endoscopy nursing staff. After a series of consultations, a checklist was trialled over the course of two weeks. Feedback from use in the endoscopy suite resulted in further modifications and a final version of the checklist came into use in May 2013. It is now used for all bronchoscopic procedures carried out by Respiratory Physicians in the hospital. An audit is planned for later this year to monitor uptake of the checklist and to determine if it has changed outcomes.
Improving safety of sedation for transoesophageal echocardiography
Authors: Patel Amour , Katarey Dev R
Published: October 2013

This project aimed to develop solutions for optimal, safe sedation, in transoesophageal echocardiagraphy (TOE). Prescription and dosage errors arise from physicians failing to approach experienced operators for assistance, and lack of familiarity with Trust TOE guidelines. We conducted a retrospective analysis of 319 patients who were referred for TOE over a nine-month period. Data was obtained from the hospital medical records and database. Midazolam doses exceeding Trust guidelines were being administered, posing unnecessary risks for under 18 and over 60 year-olds especially. This quality improvement project intervened by: 1. Adding a paediatric section with sedation dosage advice to Trust guidelines; 2. Increasing awareness of the need for lower sedation doses in over 60 year-olds, by updating the pre-procedure checklist with an age and maximum recommended midazolam dose section. These changes were accepted following presentation of the audit at the monthly Clinical Governance Meeting, and early indications reported increased confidence in midazolam dosing and awareness of the risks of not following the guidelines. Operator confidence in these changes requires re-audit, in order to confirm the findings, and continue improvement to the Trust TOE guidelines and patient safety.
Improving patient access at a movement disorder clinic by participating in a Process Improvement Program
Authors: Goodridge Alan , Woodhouse Douglas , Barbour Janet
Published: October 2013

Our multi-disciplinary neurology team were dissatisfied with long access times for consultation for new referrals. We participated in a rapid process improvement workshop and a structured improvement process. Over a six-month period we were able to reduce our access time for initial appointment for patients with suspected movement disorders from 133 to 20 days. We implemented a 'carousel' multi-disciplinary appointment and a standardised clinic form that improved the flow of patients and that we estimate will save 150 hours of physician time and 320 hours of administrative time per year.
Decreasing the risk of iatrogenic lymphoedema after axillary surgery: a threefold intervention
Authors: Bates Sophie , Sedgwick Rosemary
Published: October 2013

Procedures such as venepuncture and cannulation can precipitate Breast Cancer Related Lymphoedema (BCRL) in patients who have undergone axillary surgery. We noted that procedures were inadvertently being performed on the side of surgery at our hospital, as susceptible patients were not clearly identifiable to staff.

An online anonymous staff survey at our hospital revealed that 26.9% of responders had seen procedures being performed on at risk arms in non-emergency settings. 83.3% of responders felt an intervention to allow easy identification of at risk arms would be useful.

Our intervention was threefold. Firstly, we created an 'At Risk Arm' alert on the computerised records system. Secondly, we produced a warning sign for each susceptible patient's bed. The signs are displayed above beds, and returned to notes for use if the patient is re-admitted. Thirdly, we informed GPs via discharge summaries of the need to perform procedures on the opposite side to surgery.

A second staff survey was conducted after implementation. 46.2%of responders felt that the new interventions would decrease the chance of patients developing BCRL. 61.5% felt that susceptible patients being more identifiable to staff would decrease the likelihood of procedures being performed on at risk arms.

Our project showed the importance of ensuring axillary surgery patients are clearly identifiable to hospital staff during admission. Further interventions could include wristbands or patient alert cards. This work could be extended to include primary care and outpatient settings.
Improving out-of-hours intravenous fluid prescribing for junior doctors: a prescription label
Authors: Hartridge-Lambert Sidonie , Moore Lorna , Walker Oliver , Wilkinson Dominic
Published: October 2013

Junior doctors are routinely asked to prescribe intravenous fluids (IVF) out-of-hours. Given time constraints and the number of unfamiliar patients, there is uncertainty about their prescription accuracy and safety, particularly in patients who have specific fluid balance requirements. An IVF prescription label was devised for the fluids section of the adult drug chart indicating important patient identifiers and diagnoses such as chronic heart/renal failure. The audit was carried out over a 16 day period, covering three weekends. A qualitative pre- and post-audit questionnaire assessed the confidence of junior doctors in out-of-hours IVF prescribing. All doctors based on the ward during that specific time period were targeted for the post-audit questionnaire. Post-audit, 58% (n=7) saw the label. 86% of those seven doctors stated the label had prompted them to do the following: a) examine the patient b) check blood results and c) urine output. 100% stated that the label improved their confidence in prescribing IVF. In addition, 71% felt the label made them more cautious in prescribing IVF and 43% felt they prescribed less. Overall, all seven (100%) doctors stated that the IVF prescription label was a useful addition to the drug chart. In conclusion, pressurised junior doctors would feel more confident prescribing IVF for unfamiliar patients if crucial information was readily visible on the drug chart. This would improve the accuracy of fluid prescribing and patient safety.
Cardiovascular health monitoring in patients with psychotic illnesses: A project to investigate and improve performance in primary and secondary care
Authors: Modi Rakesh Narendra , Ledingham David
Published: October 2013

Patients with psychotic illnesses are predicted to die 15 years younger than the national average. The chief cause is cardiovascular disease (1). Evidence-based guidelines including those produced by the National Institute of Health and clinical Excellence and the Quality Outcomes Framework, recommend regular monitoring of their cardiovascular risk (2,3,4).

Primary health care audits were undertaken in an urban and a rural setting. These looked at the proportion of patients who had their physical health regularly monitored in line with NICE guidelines. Following an audit in general practice, it became clear that there was a group of patients that were chronic non-attenders. It was not clear whether these patients were the responsibility of the general practices or psychiatric services. An audit in secondary care then looked at the level of cardiovascular health monitoring in that setting, and the communication of results to primary care. These audits demonstrated that monitoring of cardiovascular health did not meet standards as set by NICE. Further to this, communication of findings between primary and secondary care was also poor.

Primary care interventions included setting up Alert reminder boxes on the computer system and sending invitations for clinic attendance to 'at risk' patients. In secondary care interventions included redesign of the patient lists to include a way of monitoring cardiovascular health and generation of a new discharge summary to facilitate communication of cardiovascular indicators to primary care.

These interventions have resulted in marked improvements in cardiovascular health monitoring in primary care, however, there is still room for considerable improvement. Discussions about further intervention strategies, and further audit cycles, are ongoing.
A medication workshop for patients with schizophrenia living in community care homes
Authors: Perry Jennifer , Bashir Khaver , Lingwood Susie
Published: October 2013

Psychoeducation for patients with schizophrenia can improve a range of outcomes. Our aim was to test a workshop intervention enabling service users to learn more about mental illness and their medication. A Quality Improvement Project was undertaken to create a workshop for patients with a diagnosis of schizophrenia within the Haringey Community Rehabilitation Team (HCRT) . The response was tested using anonymous questionnaires after each workshop. We held ten workshops (total of 47 participants), after which 83% of patients felt that the workshop had helped them to understand more about their mental health, 77% felt they were able to understand the purpose of their medication, 79% felt they were able to understand the side effects, and 70% felt they could have a say in prescribing. Objectives for the Quality Improvement Project were met. This workshop will be used for other patients within the HCRT and is transferable to other community mental health teams.
Genistein Suppresses the Isoproterenol-Treated H9c2 Cardiomyoblast Cell Apoptosis Associated with P-38, Erk1/2, JNK, and NFκB Signaling Protein Activation
Authors: Hu Wei-Syun , Lin Yueh-Min , Ho Tsung-Jung , Chen Ray-Jade , Li Yi-Hui , Tsai Fuu-Jen , Tsai Chang-Hai , Day Cecilia Hsuan , Chen Tung-Sheng , Huang Chih-Yang
Published: October 2013

Heart disease (HD) is associated with estrogen and therefore gender and menopausal status. In addition, clinical evidence shows that increased serum norepinephrine is found in patients with HD. Therefore, this study aimed to investigate the cardio-protective effect of genistein, a selective estrogen receptor modulator (SERM) from soy bean extract, in H9c2 cardiomyoblast cells treated with isoproterenol (ISO), a norepinephrine analog. In this in vitro model, image data and results from western blotting shown that ISO treatment was capable of inducing cellular apoptosis, especially the mitochondrial dependent pathway. Treatment of genistein could suppress the expression of mitochondrial pro-apoptotic proteins including Bad, caspase-8, caspase-9, and caspase-3 in H9c2 treated with ISO. By contrast, several survival proteins were expressed in H9c2 treated with genistein, such as phosphor (p)-Akt, p-Bad, and p-Erk1/2. Furthermore, we confirmed that the protective role of genistein was partially mediated through the expression of Erk1/2, Akt, and NF κ B proteins by adding several pathway inhibitors. These in vitro data suggest that genistein may be a safe and natural SERM alternative to hormone therapy in cardio-protection.
20(S)-Protopanaxadiol Triggers Mitochondrial-Mediated Apoptosis in Human Lung Adenocarcinoma A549 Cells via Inhibiting the PI3K/Akt Signaling Pathway
Authors: Zhang Yun-Long , Zhang Rui , Xu Hua-Li , Yu Xiao-Feng , Qu Shao-Chun , Sui Da-Yuan
Published: October 2013

20(S)-Protopanaxadiol (PPD), an aglycone saponin ginsenoside isolated from Panax quinquefolium L, has been shown to inhibit the growth and proliferation in several cancer lines. However, the underlying molecular mechanisms remain poorly understood. In this study, we investigated the apoptosis-induced effects and the mechanism of 20(S)-PPD on human lung adenocarcinoma A549 cells. 20(S)-PPD showed a potent antiproliferative activity against A549 cells by triggering apoptosis. 20(S)-PPD-induced apoptosis was characterized by a dose-dependent loss of the mitochondrial membrane, release of cytochrome c, second mitochondria-derived activator of caspase (Smac) and apoptosis-inducing factor (AIF), activation of caspase-9/-3, and cleavage of poly (ADP-ribose) polymerase (PARP). Caspase-dependence was indicated by the ability of the pan-caspase inhibitor z-VAD-fmk to attenuate 20(S)-PPD-induced apoptosis. After treatment with 20(S)-PPD, the proportion of A549 cells at the G0/G1 phase increased, while cells at the S and G2/M phases decreased. Furthermore, 20(S)-PPD also triggered down-regulation of phosphorylated Akt (Ser473/Thr308) and glycogen synthase kinase 3β (GSK 3β). Knockdown of GSK 3β with siRNA promoted the apoptotic effects of 20(S)-PPD. These results revealed an unexpected mechanism of action for this unique ginsenoside: triggering a mitochondrial-mediated, caspase-dependent apoptosis via down-regulation of the PI3K/Akt signaling pathway in A549 cells. Our findings encourage further studies of 20(S)-PPD as a promising chemopreventive agent against lung cancer.
Cytotoxic Effect and Induction of Apoptosis in Human Cervical Cancer Cells by Antrodia camphorata
Authors: Yang Pei-Yu , Hu Dan-Ning , Liu Fu-Shing
Published: October 2013

Antrodia camphorata is a Chinese herb indigenous to Taiwan. Previous reports demonstrated that it could induce apoptosis in some cancer cells. The purpose of this study was to investigate the apoptotic effect of the crude extract of A. camphorata in cervical cancer cells. Two human cervical cancer cell lines, HeLa and C-33A, were treated with extract of A. camphorata (10–1000 μg/mL). We found that A. camphorata extract was cytotoxic to both cervical cancer cells in a dose- and time-dependent manner as examined by MTT assay. Treatment with A. camphorata extract at 400 μg/mL induced a 2.3- and 4.4-fold increase in oligonucleosome formation from the cleaved chromosomal DNA in HeLa and C-33A cells, respectively. A. camphorata extract also activated caspase-3, -8, and -9 activities and increased the cytosolic level of cytochrome c in both cell lines as the dosage increased. Furthermore, A. camphorata extract increased expressions of Bak, Bad and Bim, while decreasing expressions of Bcl-2 and Bcl-xL of the Bcl-2 family proteins in HeLa and C-33A cells. The expression of IAP proteins, XIAP and survivin, was also decreased in both cervical cancer cells after treatment with A. camphorata. Our in vitro study suggests that A. camphorata is cytotoxic to cervical cancer cells through both extrinsic and intrinsic apoptotic mechanisms. It could be used as a novel phytotherapeutic agent or auxiliary therapy in the treatment of cervical cancer.
Rapid Identification of Chemical Constituents in Traditional Chinese Medicine Fufang Preparation Xianling Gubao Capsule by LC-linear Ion Trap/Orbitrap Mass Spectrometry
Authors: Dai Yi , Tu Feng-Juan , Yao Zhi-Hong , Ding Bo , Xu Wen , Qiu Xiao-Hui , Yao Xin-Sheng
Published: October 2013

The traditional Chinese medicine fufang preparation "Xian-Ling-Gu-Bao" capsule (XLGB), which is composed of six herbal medicines, is popularly used for the treatment of osteoporosis. A reliable and effective method using LC-linear ion trap (LTQ)/Orbitrap mass spectrometry for rapid screening and identification of chemical constituents in "Xian-Ling-Gu-Bao" capsule is described in this paper. Based on the UV spectrum, mass spectrum, and the chemical components isolated from the original plants of XLGB, 118 compounds were identified or tentatively characterized, including 58 flavonoid glycosides, six prenylated flavonones, five prenylated isoflavones, six prenylated chalcones, four xanthone C-glycosides, 13 saponins, eight phenolic acids, five coumarins, three lignans, three iridoids, five phenethyl alcohol glycosides, one tanshinone and one alkaloid. This work might be helpful for the quality control and further pharmacokinetic studies of XLGB, and provided a good example for the rapid identification of chemical constituents in traditional Chinese medicine fufang preparation. Moreover, the identification strategy for the linkages of sugar residues in flavonol O-glycosides was summarized in the study. The diagnostic fragment ions at m/z 185 [ C 12 H 9 O 2] and 157 [ C 11 H 9 O ], which distinguish C -6 and C -8 prenylated flavonoids, were reported for the first time.