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The sensitivity of pneumothorax diagnosis via handheld ultrasound is low, and there is no equipment suitable for use with life-threatening tension pneumothorax in a prehospital setting. This study proposes a novel technology involving optical fibers and near-infrared spectroscopy to assist in needle thoracostomy decompression. The proposed system via the optical fibers emitted dual wavelengths of 690 and 850 nm, allowing distinction among different layers of tissue in vivo. The fundamental principle is the modified Beer–Lambert law (MBLL) which is the basis of near-infrared tissue spectroscopy. Changes in optical density corresponding to different wavelengths (690 and 850 nm) and hemoglobin parameters (levels of Hb and HbO2) were examined. The Kruskal–Wallis H test was used to compare the differences in parameter estimates among tissue layers; all p-values were 2 levels relative to those observed in the vein and artery, all p-values were also

Hotel A served the boutique hotel segment. Rather than focusing on market segments in Singapore’s hotel chain scale system, the management decided to offer guests an affordable luxury experience via excellent personalized service while capitalizing on the rich and authentic cultural heritage that the hotel offered in terms of history and design. Although Hotel A had won the Best Hotel Service award three years consecutively, it was getting harder to distinguish itself from other boutique hotels and to align itself with the parent company’s (Company A) strategic long-term goals. Mr. Lim had been the manager of Hotel A for five years. He worked up the ranks, learning the ropes and garnering accolades for best service, and management skills. He had earned the respect of his staff as he empowered his staff, empathized with them and walked the talk. Since December 2019, the world had been reeling from the impact of a global pandemic caused by the coronavirus (COVID-19) which was primarily spread through physical contact and respiratory droplets. Most countries implemented very stringent measures to prevent the disease from spreading within its borders. The luxury boutique hotel category in particular had been negatively affected as the hospitality industry focused on people, personalized services and face to face interactions. One prominent change seen as a result of COVID-19 was a change in consumer behavior, influenced by risk perception (Gössling et al., 2020; Kirk & Rifkin, 2020). Guests became more cautious and concerned about safety and hygiene, preferring less human touch during registration and food delivery, and practiced safe distancing from others (Rittichainuwat & Chakraborty, 2009). Millennials had increasingly become an attractive market segment for the luxury hotel industry as they were not price conscious, preferring to “spend tomorrow’s money” and “spend ahead of income” (Wang, Sun & Song, 2011). Furthermore, as they were digital natives, products and experiences which could satisfy their luxury consumptions could be promoted easily via social media marketing. In August 2020, the Singapore government rolled out a S$45 million SingapoRediscovers campaign where Singaporeans were given S$320 million in tourism credits to drive local spending (Straits Times, August 2020). Mr. Lim is in a dilemma. How can he promote Hotel A as the preferred staycation destination to local Millennials without alienating its more traditional clientele and brand image as a heritage hotel catering to foreigners? How should Hotel A provide personalized service and maintain service quality and satisfaction with safe management measures in place in sync with Millennials’ lifestyle?

The traditional needle cricothyroidotomy procedure is performed blindly without any medical equipment. Complications including posterior tracheal wall perforation, accidental vessel puncture, and missed tracheal puncture are reported. Therefore, we proposed a dual-wavelength fiber-optic technique based on the technique of near-infrared spectroscopy to assist operators performing needle cricothyroidotomy in a swine model. We embedded optical fibers in a 16-gauge intravenous needle catheter. Real-time data were displayed on an oscilloscope, and we used the program to analyze the data immediately. The change of optical density corresponding to 690-nm and 850-nm wavelengths and hemoglobin parameters (HbO2 and Hb concentrations) was analyzed immediately using the program in the laptop. Unique and significant optical differences were presented in this experiment. We could easily identify every different tissue by the change of optical density corresponding to 690-nm and 850-nm wavelengths and hemoglobin parameters (HbO2 and Hb concentrations). Statistical method (Kruskal-Wallis H test) was used to compare differences in tissues at each time-point, respectively. The p values in every tissue in optical density change corresponding to 690 nm and 850 nm were all p values in every tissue in Hb and HbO2 were also all

For steady state visually evoked potential (SSVEP) based brain computer interfaces (BCIs), the elicited SSVEP signals always contain noises and then the performance of SSVEP-based BCIs would be greatly degraded in practical applications. Therefore, to develop an SSVEP signal enhancement would be able to increase the accuracy of SSVEP-based BCIs. In this study, a convolutional denoising autoencoder based SSVEP signal enhancement is proposed to suppress the noise components. The convolutional denoising autoencoder is applied to estimate and suppress the noise components. To effectively estimate the noise components, a sinusoid wave is designed as an ideal SSVEP signal. To ignore the effects of phase, cross correlation is adopted to estimate the phase in the training stage. The experimental results evaluated by using signal-to-noise ratio and canonical correspondence analysis showed that the proposed approaches can effectively suppress the noises components. Therefore, the proposed approach can be applied to develop robust SSVEP-based BCIs.

The communication of a patient with amyotrophic lateral sclerosis is limited and then the quality of lives would be greatly reduced. The patients still maintain the cognitive ability, thus developing an assistive communication interface would greatly help them in daily live. Recently, steady state visually evoked potential (SSVEP) based brain computer interfaces (BCIs) had been successfully developed to help patients. Increasing the accuracy of SSVEP-based BCIs is able to realize the assistive communication interfaces in practical applications. In this study, a modular continuous restricted Boltzmann machine (MCRBM) is proposed to improve the performance of SSVEP-based BCIs. To precisely represent the characteristics of elicited signals of SSVEP, the frequency magnitude, the coefficients of canonical correlation analysis, and the correlations of magnitude square coherence are selected as the features. In the first layer of MCRBM, the continuous restricted Boltzmann machine based neural networks are used as the basic units and applied to accurately estimate by using different types of features. In the second layer of MCRBM, a CRBM is then designed to fuse the decisions and find the final results. The experimental results showed that MCRBM produce higher accuracy compared to CRBM. Therefore, the proposed approach can be adopted in practical applications and then help patients in communicating with others.

Monitoring people’s blood pressure can effectively prevent blood pressure-related diseases. Therefore, providing a convenient and comfortable approach can effectively help patients in monitoring blood pressure. In this study, an attention mechanism-based convolutional long short-term memory (LSTM) neural network is proposed to easily estimate blood pressure. To easily and comfortably estimate blood pressure, electrocardiogram (ECG) and photoplethysmography (PPG) signals are acquired. To precisely represent the characteristics of ECG and PPG signals, the signals in the time and frequency domain are selected as the inputs of the proposed NN structure. To automatically extract the features, the convolutional neural networks (CNNs) are adopted as the first part of neural networks. To identify the meaningful features, the attention mechanism is used in the second part of neural networks. To model the characteristic of time series, the long short-term memory (LSTM) is adopted in the third part of neural networks. To integrate the information of previous neural networks, the fully connected networks are used to estimate blood pressure. The experimental results show that the proposed approach outperforms CNN and CNN-LSTM and complies with the Association for the Advancement of Medical Instrumentation standard.

A novel aptamer-based competitive drug screening platform for osteoporosis was devised in which fluorescence-labeled, sclerostin-specific aptamers compete with compounds from selected chemical libraries for the binding of immobilized recombinant human sclerostin to achieve high-throughput screening for potential small-molecule sclerostin inhibitors and to facilitate drug repurposing and drug discovery. Of the 96 selected inhibitors and FDA-approved drugs, six were shown to result in a significant decrease in the fluorescence intensity of the aptamer, suggesting a higher affinity toward sclerostin compared with that of the aptamer. The targets of these potential sclerostin inhibitors were correlated to lipid or bone metabolism, and several of the compounds have already been shown to be potential osteogenic activators, indicating that the aptamer-based competitive drug screening assay offered a potentially reliable strategy for the discovery of target-specific new drugs. The six potential sclerostin inhibitors suppressed the level of both intracellular and/or extracellular sclerostin in mouse osteocyte IDG-SW3 and increased alkaline phosphatase activity in IDG-SW3 cells, human bone marrow-derived mesenchymal stem cells and human fetal osteoblasts hFOB1.19. Potential small-molecule drug candidates obtained in this study are expected to provide new therapeutics for osteoporosis as well as insights into the structure–activity relationship of sclerostin inhibitors for rational drug design.

We read with interest the article regarding 97 patients who underwent thyroidectomy for Graves’ disease (1). In the retrospective study, 49 patients received open thyroidectomy (OT) and 46 patients received transoral endoscopic thyroidectomy vestibular approach (TOETVA). The outcomes of patients with TOETVA were compared to those of patients with OT. The authors discovered and concluded that patients receiving TOETVA had better cosmetic results (scare-free) than patients with OT. Also, they reported that patients receiving TOETVA experienced significantly less pain than that in patients with OT. The finding has drawn the attention of anesthesiologists who are involved in the pain management perioperatively.

Chia-Chun Chuang,1 Chien-Ching Lee,1,2 Li-Kai Wang,1 Bor-Shyh Lin,2 Wen-Ju Wu,1 Chung-Han Ho,3 Jen-Yin Chen1,4 1Department of Anesthesiology, ChiMei Medical Center, 2Department of Imaging and Biomedical Photonics, National Chiao Tung University, 3Department of Medical Research, Chi Mei Medical Center, 4Department of the Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan, Republic of China Purpose: This study aimed to evaluate whether a nonpharmacological approach through implementation of a communication improvement program (named CICARE for Connect, Introduce, Communicate, Ask, Respond and Exit) into standard operating procedure (SOP) in acute pain service (APS) improved satisfaction in patients receiving intravenous patient-controlled analgesia (IV-PCA).Patients and methods: This was a nonrandomized before–after study. Adult patients (aged between 20 and 80years) who received IV-PCA after major surgery were included. Implementing CICARE into SOP was conducted in APS. Anonymous questionnaires were used to measure outcomes in this prospective two-part survey. The first part completed by APS nurses contained patients’ characteristics, morphine dosage, delivery/demand ratios, IV-PCA side effects and pain at rest measured with an 11-point numeric rating scale (NRS, 0–10). A score of NRS ≥4 was defined as inadequately treated pain. The ten-question second part was completed by patients voluntarily after IV-PCA was discontinued. Each question was assessed with a 5-point Likert scale (1: extremely poor; 5: excellent). Patients were separated into “before” and “after” CICARE groups. Primary outcomes were patient global impression of improvement in pain (PGI-Improvement) and patient satisfaction. Secondary outcomes included quality of communication skills, instrument proficiency and accessibility/availability of IV-PCA.Results: The response rate was 55.3%, with 187 usable questionnaires. CICARE effectively improved patient global impression of improvement in pain, patient satisfaction, communication skills and accessibility/availability of IV-PCA. No significant differences were noted in instrument proficiency, morphine dosage, delivery/demand ratios, rates of inadequately treated pain at rest and side effects of IV-PCA between groups. Paradoxical findings were noted between the rates of inadequately treated pain/side effects and PGI-Improvement in pain/patient satisfaction, which were affected by psychological factors.Conclusion: Nonpharmacological interventions carried out by implementing CICARE into SOP for APS effectively improved patient satisfaction and postoperative pain management quality, but this did not affect actual pain. Keywords: acute pain service, patient–physician communication, nonpharmacological approach, patient-controlled analgesia, patient satisfaction

Medical institutions are eager to introduce new information technology to improve patient safety and clinical efficiency. However, the acceptance of new information technology by medical personnel plays a key role in its adoption and application. This study aims to investigate whether perceived organizational learning capability (OLC) is associated with user acceptance of information technology among operating room nurse staff.Nurse anesthetists and operating room nurses were recruited in this questionnaire survey. A pilot study was performed to ensure the reliability and validity of the translated questionnaire, which consisted of 14 items from the four dimensions of OLC, and 16 items from the four constructs of user acceptance of information technology, including performance expectancy, effort expectancy, social influence, and behavioral intention. Confirmatory factor analysis was applied in the main survey to evaluate the construct validity of the questionnaire. Structural equation modeling was used to test the hypothetical relationships between the four dimensions of user acceptance of information technology and the second-ordered OLC. Goodness of fit of the hypothetic model was also assessed.Performance expectancy, effort expectancy, and social influence positively influenced behavioral intention of users of the clinical information system (all p0.001) and accounted for 75% of its variation. The second-ordered OLC was positively associated with performance expectancy, effort expectancy, and social influence (all p0.001). However, the hypothetic relationship between perceived OLC and behavioral intention was not significant (p = 0.87). The fit statistical analysis indicated reasonable model fit to data (root mean square error of approximation = 0.07 and comparative fit index = 0.91).Perceived OLC indirectly affects user behavioral intention through the mediation of performance expectancy, effort expectancy, and social influence in the operating room setting.

The left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that helps in maintaining the pumping ability of a failing heart. Thromboembolism poses a significant risk during and after LVAD implantation. It occurs in up to 35% of patients with adverse sequelae. We present the case of a 75-year-old man who underwent coronary artery bypass graft surgery and LVAD implantation for acute myocardial ischemia and severe left ventricular dysfunction. However, subsequent transthoracic echocardiographic examination revealed an LVAD thrombus, and LVAD removal was suggested following the failure of thrombolytic therapy. After the LVAD cannula was removed, transesophageal echocardiography (TEE) revealed a residual thrombus in the left atrium. Thrombectomy was successfully performed by opening the left atrium with cardiopulmonary bypass. We believe that TEE monitoring aided the implantation and removal of the LVAD device. In this case, we found that TEE not only helped in monitoring the ventricular function but also in detecting other problems such as the residual thrombus. We strongly recommend TEE monitoring during the entire LVAD-removal procedure, particularly for patients who need to undergo LVAD removal because of thrombosis formation.

Patients with Hallervorden-Spatz disease may be confronted by invasive procedure, like gastrostomy and thalamotomy for care of the status of extreme dystonia and rigidity. This rare disorder possesses potential perioperative risks, such as difficult airway management, aspiration pneumonia, hyperpyrexia, dehydration, acute renal failure, and postoperative pulmonary insufficiency. As patients were usually in the state of uncontrollable dystonia and rigidity, delayed endotracheal extubation had been suggested by several previous case reports. We report the anesthetic management of a 34-year-old Hallervorden-Spatz disease woman scheduled for intrathecal baclofen pump implantation under general anesthesia. Preoperatively she had suffered from severe dystonia, confusion and repeated attacks of respiratory insufficiency and pneumonia requiring mechanical ventilation and critical care. Anesthesia was induced uneventfully and the catheter of the pump reached the CSF via T2 interspace. Intraoperative intrathecal baclofen injection mildly relieved her severe dystonia and rigidity. Hemodynamics and arterial blood gas were improved than preoperative. She was extubated after consciousness was regained. Postanesthetic visit demonstrated a fair outcome. Whether this treatment applies to every case confronted by general anesthesia needs to be elucidated. Nevertheless, we suggest intrathecal baclofen may help postanesthetic pulmonary care by attenuating dystonia and rigidity and can be an adjuvant for anesthesia care in patients with Hallervorden-Spatz disease.

This paper aims to find out two outcomes of feedback in the novice writers’ graphic organizers, which are the novice writers’ ability to align their ideas to their writing goal, and their perceived germane, metacognitive, extraneous and intrinsic cognitive loads when generating and revising ideas based on the feedback. Data was gathered from the students’ graphic organizers, mental difficulty questionnaires and focus group discussion. The findings show that the students’ relevance of ideas improved with feedback in their organizers, except for one sub‐process. In addition, the students’ metacognitive load seems to affect the amount of ideas generated. These findings have implications for media selection mix and social collaborative environments. Ruckmeldung uber graphische Organizer von Studenten unterstutzt das Schreiben – Relevanz von Anfanger Ideen und Erinnerungsnotizen Mit diesem Beitrag soll versucht werden, die Ergebnisse zweier Ruckmeldungen uber die graphischen Organizer von Anfangern zu finden: ...

In previous research about thermally and laterally driven microactuators, Guckel et al. proposed a microactuator based on the variable cross sections but the same length of two adjacent beams. Pan and Hsu presented another type of microactuator based on different lengths but the same cross sections of two adjacent beams. Here, a microactuator that combines the traits of those two designs is proposed, optimized, and fabricated. Finite element analysis is performed to obtain the optimal dimensions of the structures when the maximum lateral displacement is achieved. When the air gap is 2 μm, the optimal performance of current design is similar to Guckel's design with optimal dimensions, but it has 65% larger displacement than Pan and Hsu's design at optimal dimensions. For the case of the large air gap beneath the structure (300 μm), the microactuator of current design has more than 25% tip displacement improvement compared to Guckel's or Pan and Hsu's designs. It is also found that the proposed structure is less sensitive to the beam length variations around optimal point no matter in small or large air gap case. Experimental results also verify that the dimension of the air gap affects the thermal boundary condition, so does the performance and optimal architecture of the microactuators.

We describe the successful management of extravasation injury to the left hand by contrast medium with stellate ganglion block and intra-arterial nitroglycerin in a patient which befell during contrast-enhanced imaging. The incidence of contrast-medium extravasation injury is increasing because of the convenience and availability of contrast-enhanced imaging and ease of injection access. Extravasation of contrast medium may results in severe pain, erythema, cyanosis, and edema or even skin necrosis, which is largely related to the ionization, osmolarity, and volume of the contrast medium. The conservative treatment is often adequate in small amount extravasation, but if the extravasation is overwhelming further energetic management is mandatory. A 29-year-old man was brought to our emergency because of diffuse abdominal pain and he was arranged to receive intravenous contrast media enhanced abdominal computed tomography for diagnosis. Ruptured appendicitis with abscess formation was suspected; then the patient underwent emergent appendectomy and drainage of the abscess. However, severe swelling and cyanotic change that radiated from the intravenous catheter insertion site in every direction over the entire dorsum of the left hand were noted after the surgery. Contrast-medium extravasation injury was highly contemplated and a left stellate ganglion block was performed immediately for relief of symptoms. The consulting surgeon ruled out compartment syndrome, but advised emergent left upper limb arteriography, which revealed signs of vasospasm with high intravascular pressure of the left distal ulnar and radial arteries; thus nitroglycerin was injected into left distal ulnar and radial arteries for relief of vasospasm. The clinical symptoms were improved after the above managements and the patient was discharged 7 days later without any sequela.

This paper presented the use of the dialogic communication model to teach students how to write a report introduction. In the case study presented, the students engaged in discussions and reflections regarding the contextual complexities in the writers’ and readers’ organizational environments, which helped them adapt their writing to their readers’ needs and flow of thought. The thinking process that students go through in making their writing more reader-centered using this model could be a useful springboard to help students adopt the thinking processes of professional engineers. Accepted version