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Barbara Bonvento,1 Sarah Wallace,1,2 James Lynch,1 Barry Coe,1 Brendan A McGrath1 1Acute Intensive Care Unit, University Hospital South Manchester, Manchester, 2Royal College of Speech and Language Therapists, London, UK Abstract: Tracheostomies are used to provide artificial airways for increasingly complex patients for a variety of indications. Patients and their families are dependent on knowledgeable multidisciplinary staff, including medical, nursing, respiratory physiotherapy and speech and language therapy staff, dieticians and psychologists, from a wide range of specialty backgrounds. There is increasing evidence that coordinated tracheostomy multidisciplinary teams can influence the safety and quality of care for patients and their families. This article reviews the roles of these team members and highlights the potential for improvements in care. Keywords: tracheotomy, physiotherapist, Speech & Language, Nursing

Nous avons étudié, par microscopie électronique à transmission, la structure tridimensionnelle des particules métalliques de catalyseurs Pd/Al2O3. Un modèle de cuboctaèdre tronqué est proposé pour des particules de taille de l'ordre de 30 nm. Pour des particules de taille inférieure (~ 5 nm) l'observation des profils et des orientations cristallographiques vis-à-vis du support sont compatibles avec un modèle cuboctaédrique. Transmission electron microscopy has been used to study the three dimensional structure of metal particles in Pd/Al2O3 catalysts. A model in the form of a truncated cuboctahedron is proposed for particles of size about 30 nm. For smaller (~ 5 nm) particles observations of profiles and crystallographic orientations with respect to the support are compatible with a cuboctahedron model.

Les techniques de visualisation des supports et des particules métalliques en microscopie conventionnelle à haute résolution sont précisées. On discute l'apport des principales méthodes de microanalyse en microscopie à balayage (STEM), c'est-à-dire analyse par émission X, microdiffraction et spectroscopie de pertes d'énergie, aussi bien que de la combinaison électronique des images. On examine les améliorations techniques qui sont à attendre à moyen terme. Available imaging techniques for supports and small metal particles in conventional electron microscopy are presented. The advantages of the methods of microanalysis in the scanning transmission electron microscope (STEM) are discussed. These include X-ray emission analysis, microdiffraction and electron energy loss spectroscopy as well as the electronic mixing of images. Improvements to be expected in these techniques in the near future are considered.

Cet article présente les différentes techniques de débitmétrie polyphasique non intrusive décrites dans la littérature du domaine public. Ces techniques sont considérées du point de vue de leur application dans le cadre de la production pétrolière sous-marine (mélange eau/huile/gaz). A partir d'une analyse des différentes méthodes physiques qui peuvent être utilisées, des perspectives d'avenir sont proposées. Several operations in the oil reservoir exploitation industry call for flowmeters capable of delivering information on the quantity and rate of flow of the different phases (gas, oil, water, solids . . . ) present in a pipeline. Amongst these are the estimation of remaining reserves and of well performance, control of production units such as multiphase pumping systems and fiscal monitoring in the case of pipeline networking. Existing methods, based on phase separation, require separate test lines and thus tend to be cumbersome, give only intermittent values of flow parameters and need to be calibrated due to the intrusive nature of the measurements. These drawbacks are seen to be all the more critical in subsea production where the ideal flowmeter would be compact, require little maintenance and supply precise real time data for network and multiphase pump control. In recent years flow measurement in two or more phase systems has received increasing attention both in laboratory studies and for applications in a variety of industries (for example : nuclear power production and food processing as well as of course oil production). We review here the many methods considered for non-intrusive flow metering with two or more components from the point of view of an industrial (in particular subsea oil production) application. The situation is rendered delicate, in particular for density measurement, by the uncontrolled nature of the flow which may occur in any of several regimes with differing spatial distributions of the components. Parameters permitting the various phases to be discriminated are identified in order to evaluate the various techniques. The latter are classified in two major families of interaction for which a range of frequencies are explored : mechanical interactions from ultrasound to simple pressure and noisemeasurement and electromagnetic interactions from the use of gamma rays to the measurement of static electrical properties. Consideration is also given to two techniques of special interest falling outside this classification : the use of neutron bombardment and that of nuclear magnetic resonance (NMR). Most of the techniques considered give only partial responses to the question of measuring the quantites and velocities of each of the three major components : oil water and gas. Some, such as visible light or infrared spectroscopy, are eliminated entirely due to the local nature of the measurements in the system considered. Methods such as acoustic or pressure measurement, providing a rapid and simple means of detecting major events such as the passage of slugs and gas pockets and of measuring their velocity in favorable cases, may be incorporated into the final system. Little information is however furnished as to the flow rates of individual components. Four types of measurement have been selected as presenting particular advantages in all or part of the range of parameters for which information is required. Neutron based methods, particularly when coupled to induced gamma ray spectroscopy, promise to provide useful information on water/oil ratios and on salinity although the development of practical sources is as yet only in its earliest stage. NMR is potentially capable of providing independant measurements of both the quantity and velocity of the two liquid phases although the size of such a flowmeter would be prohibitive in the application envisaged. A restricted application (both in terms of size and in the number of measured parameters) may however be advantageous in combination with other techniques. Two regions of the electromagnetic spectrum are identified as of particular interest. The first is the hard X-ray to gamma ray region where the use of two energies would allow evaluation of three phases : oil water and gas. Velocity measurement is however intrinsically difficult and, for industrial applications, detector technology still has to be improved. In the microwave region (including high frequency capacitance and resistivity measurements) most of the necessary parameters appear to be attainable by combining absorption and reflection measurements with the easy tunability of sources. Although this technology is already used in a wide variety of applications from food processing to traffic control, the range of conditions for which it will be applicable in multiphase oil production is not yet clear. A successful industrial flowmeter may imply a combination of several of these techniques incorporating intelligent use of more classical measurements such as temperature and pressure for auto calibration. Further work on evaluating the range of attainable measurements in a compact, reliable and economic system is likely to further stimulate the development of subsea multiphase production systems.

The effect of wetting on the structure and localisation of cobalt species on various supports (Al2O3, SiO2, TiO2, HZSM-5 zeolite) was studied using X-ray diffraction, Fourier transform infrared spectroscopy with CO as a molecular probe, X-ray photoelectron spectroscopy and extended X-ray absorption fine structure analysis. Aqueous impregnation to incipient wetness of reduced and passivated cobalt catalysts results, even in the absence of any promoter, in a considerable decrease in the concentration of Co crystalline phases and modifies the surface sites. The decrease in the concentration of Co3O4 crystallites was especially pronounced on silica supported catalysts prepared via impregnation of cobalt and on a mixture of Co3O4 and HZSM-5 zeolite. Saturation with water of the passivated Co/SiO2 sample results in an amorphous solid with a local structure close to that of Co2SiO4. For Co/Al2O3 and Co/TiO2 catalysts, the effect of wetting on the concentration of Co3O4 crystalline phase was considerably smaller.

Ten micrometers resolution 3D representations of different media, were obtained with a laboratory computer microtomograph developed from an electron microprobe column. From the original electron microprobe, only minor modifications have been required, indeed several of the utilities of the microprobe have been used to ensure high resolution radiography (2 micrometers). The impact of the electron beam focused onto a thin film is used to form a pointX-ray source and the radiographic image of the sample is acquired on a CCD camera. A specimen rotation mechanism allows multiple radiograph acquisition and reconstruction of the X-ray attenuation 3D cartography. Since X-ray attenuation is directly related to density and atomic number, the microscanner provides 3D cartographs of the different phases present in the sample. System performances have been evaluated on various samples, mainly rocks and composites. Comparison with scanning electron micrographs was used when possible to validate the reconstructions. Results are mostly qualitative but already show the potential of the technique in describing 3D connectivity and topology of pore networks or 3D orientation of fibres in composites.

ObjectiveStatistical shape modelling (SSM) of radiographs has been used to explore relationships between altered joint shape and hip osteoarthritis (OA). We aimed to apply SSM to Dual-energy X-ray Absorptiometry (DXA) hip scans, and examine associations between resultant hip shape modes (HSMs), radiographic hip OA (RHOA), and hip pain, in a large population based cohort.MethodSSM was performed on baseline hip DXA scans from the Osteoporotic Fractures in Men (MrOS) Study. Associations between the top ten HSMs, and prevalent RHOA from pelvic radiographs obtained 4.6 years later, were analysed in 4100 participants. RHOA was defined as Croft score ≥2. Hip pain was based on pain on walking, hip pain on examination, and Western Ontario and McMaster Universities Arthritis Index (WOMAC).ResultsThe five HSMs associated with RHOA showed features of either pincer- or cam-type deformities. HSM 1 (increased pincer-type deformity) was positively associated with RHOA [1.23 (1.09, 1.39)] [odds ratio (OR) and 95% CI]. HSM 8 (reduced pincer-type deformity) was inversely associated with RHOA [0.79 (0.70, 0.89)]. HSM 10 (increased cam-type deformity) was positively associated with RHOA [1.21 (1.07, 1.37)]. HSM 3 and HSM 4 (reduced cam-type deformity) were inversely associated with RHOA [0.73 (0.65, 0.83) and 0.82 (0.73, 0.93), respectively]. HSM 3 was inversely related to pain on examination [0.84 (0.76, 0.92)] and walking [0.88, (0.81, 0.95)], and to WOMAC score [0.87 (0.80, 0.93)].ConclusionsDXA-derived measures of hip shape are associated with RHOA, and to a lesser extent hip pain, possibly reflecting their role in the pathogenesis of hip OA.

ObjectiveTo determine the association of different types of meniscal pathology with knee pain, bone marrow lesion (BML) volume, and end-stage knee osteoarthritis (esKOA).DesignParticipants were selected from an ancillary project to the Osteoarthritis Initiative (OAI) who had at least one knee with symptomatic osteoarthritis. Baseline magnetic resonance images (MRI) were evaluated for meniscal pathology using a modified International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine (ISAKOS) classification system. We collapsed 10 types of meniscal pathology into five categories: normal, intrameniscal signal, morphological deformity/extrusion (altered meniscal shape and/or extrusion but no apparent substance loss), tear, and maceration. Outcomes included Western Ontario and McMaster Universities osteoarthritis index (WOMAC) knee pain and BML volume at baseline and after 2 years. We defined the prevalence of esKOA based on a validated algorithm. We performed logistic regression and adjusted for age, sex, and body mass index (BMI).ResultsThe 463 participants (53% male) included in the analysis had mean age 63 (9.2) years, BMI 29.6 (4.6) kg/m2, and 71% had Kellgren-Lawrence grade ≥2. Morphological deformity/extrusion and maceration, but no other types of meniscal pathology, were associated with BML volume (morphological deformity/extrusion odds ratio [OR] = 2.47, 95% CI: 1.49, 4.09, maceration OR = 5.85, 95% CI: 3.40, 10.06) and change in BML volume (morphological deformity/extrusion OR = 2.17, 95% CI: 1.37, 3.45, maceration OR = 3.12, 95% CI: 1.87, 5.19). Only maceration was associated with baseline WOMAC knee pain (OR = 2.82, 95% CI: 1.79, 4.43) and prevalence of esKOA (OR = 7.53, 95% CI: 4.25, 13.31).ConclusionsBased on MRI, morphologic deformity/extrusion and maceration rather than intrameniscal signal or tear were associated with osteoarthritis severity and progression, which highlights the importance of differentiating distinct types of meniscal pathology.

ObjectivesThe purpose of this study was to assess the concurrent validity and sensitivity to change of three knee osteoarthritis (OA) grading scales. The Kellgren-Lawrence (KL) and the Osteoarthritis Research Society International (OARSI) joint space narrowing (JSN) grading scales are well-established. The third scale, the compartmental grading scale for OA (CG) is a novel scale which grades JSN, femoral osteophytes, tibial erosion and subluxation to create a total score.MethodsOne sample of 72 posteroanterior (PA) fixed-flexion radiographs displaying mild to moderate knee OA was selected from the Multicenter Osteoarthritis Study (MOST) to study validity. A second sample of 75 radiograph pairs, which showed an increase in OA severity over 30 months, was selected to study sensitivity to change. The three radiographic grading scales were applied to each radiograph in both samples. Spearman's rank correlation coefficients were used to correlate the radiographic grades and the change in grades over 30 months with a Whole-organ Magnetic Resonance Imaging Score (WORMS)-based composite score which included five articular features of knee OA.ResultsCorrelations between the KL, OARSI JSN and CG grading scales and the magnetic resonance image (MRI)-based score were 0.836, 0.840 and 0.773 (P < 0.0001) respectively while correlations between change in the radiographic grading scales and change in the MRI-based score were 0.501, 0.525 and 0.492 (P < 0.0001).ConclusionsAll three radiographic grading scales showed high validity and are suitable to assess knee OA severity. They showed moderate sensitivity to change; therefore caution should be taken when using ordinal radiographic grading scales to monitor knee OA over time.

ObjectiveTo determine what MRI-detectable osteoarthritis features that are not visualized on radiography demonstrate progression longitudinally in Kellgren and Lawrence (KL) grade 4 knees.MethodsWe studied subjects from the Multicenter Osteoarthritis Study who had KL grade 4 knees at baseline and had baseline and 30-month MRI. Cartilage damage, bone marrow lesions (BMLs), meniscal damage, synovitis (signal changes in Hoffa fat pad), and effusion (fluid equivalent signal in the joint cavity) were semiquantitatively scored using the Whole Organ MRI Score (WORMS) system in five subregions of the medial and lateral tibiofemoral (TF) compartments. Analysis was performed for the compartment showing bone-on-bone appearance ("index") on radiograph and also for the other TF compartment of the same knee. Synovitis and effusion were assessed for the whole knee. Changes in scores at follow-up were noted for each feature. For cartilage and BML, within-grade changes were also recorded.Results140 subjects (164 knees) were included (50% women, mean age 66.0 ± 8.6 years, mean BMI 30.4 ± 5.1 kg/m(2)). Longitudinally, 51 index compartments (34%) showed an increase in the sum of cartilage scores from all subregions. In the other compartment, 25% showed an increase in the sum score for cartilage damage. For BMLs in the index compartment, 50 knees (33%) showed an increase in maximum score and 32 (21%) showed a decrease. Meniscal status mostly remained stable. Effusion worsened in 36 knees (25%) and improved in 13 knees (9%). Synovitis worsened in 14 knees (10%) and improved in six knees (4%).ConclusionIn KL grade 4 knees, MRI-detected cartilage loss and fluctuation of BMLs, effusion, and synovitis occurred frequently over a 30-month period.

ObjectiveTo determine the predictive value of unicompartimental joint space narrowing (JSN) for MRI-based cartilage thickness loss in the narrowed and the non-narrowed femorotibial compartment.Methods922 knees from 922 Osteoarthritis Initiative (OAI) participants (62.2 ± 9.0 years, 61% females) with radiographic OA (158 without JSN [noJSN], 175 with lateral JSN [latJSN], 589 with medial JSN [medJSN]) were analyzed using 3 T MRI. One-year cartilage thickness change was determined in the lateral (LFTC) and medial femorotibial compartment (MFTC), and in femorotibial subregions. The probability of subsequent cartilage loss was calculated using predefined thresholds. The predictive value of JSN for the probability and magnitude of cartilage loss was compared between latJSN, medJSN and noJSN knees using Fisher's exact and Mann-Whitney-U tests.ResultsThe probability of cartilage loss was greater in the narrowed compartment of latJSN/medJSN knees (34.9%/32.4%) than in noJSN knees (13.3%/12.7%, P ≤ 6.4 × 10(-6)) and so was the magnitude of cartilage thickness change (P ≤ 8.2 × 10(-6)). No significant differences were observed between the narrowed compartments of latJSN vs. medJSN knees (probability: P = 0.58, magnitude: P = 0.19) or between the non-narrowed compartment of latJSN/medJSN vs. noJSN knees (probability: P ≥ 0.35, magnitude: P = ≥0.23). These results were confirmed by the location-independent ordered value (OV) analyses of femorotibial subregions.ConclusionThe predictive value of latJSN for lateral compartment cartilage loss was comparable to that of medJSN for medial compartment cartilage loss, whereas cartilage loss in the non-narrowed compartment was similar to that in noJSN knees. These findings provide important clues to predicting progression of knee OA, and in tailoring inclusion criteria for clinical trials.

ObjectivesTo determine protease mutations that develop at viral failure for protease inhibitor (PI)-naive patients on a regimen containing the PI atazanavir.MethodsResistance tests on patients failing atazanavir, conducted as part of routine clinical care in a multicentre observational study, were randomly matched by subtype to resistance tests from PI-naive controls to account for natural polymorphisms. Mutations from the consensus B sequence across the protease region were analysed for association and defined using the IAS-USA 2011 classification list.ResultsFour hundred and five of 2528 (16%) patients failed therapy containing atazanavir as a first PI over a median (IQR) follow-up of 1.76 (0.84-3.15) years and 322 resistance tests were available for analysis. Recognized major atazanavir mutations were found in six atazanavir-experienced patients (P < 0.001), including I50L and N88S. The minor mutations most strongly associated with atazanavir experience were M36I, M46I, F53L, A71V, V82T and I85V (P < 0.05). Multiple novel mutations, I15S, L19T, K43T, L63P/V, K70Q, V77I and L89I/T/V, were also associated with atazanavir experience.ConclusionsViral failure on atazanavir-containing regimens was not common and major resistance mutations were rare, suggesting that adherence may be a major contributor to viral failure. Novel mutations were described that have not been previously documented.

Background: Acute exacerbation of idiopathic pulmonary fibrosis has become an important outcome measure in clinical trials. This study aimed to explore the concept of suspected acute exacerbation as an outcome measure.Methods: Three investigators retrospectively reviewed subjects enrolled in the Sildenafil Trial of Exercise Performance in IPF who experienced a respiratory serious adverse event during the course of the study. Events were classified as definite acute exacerbation, suspected acute exacerbation, or other, according to established criteria.Results: Thirty-five events were identified. Four were classified as definite acute exacerbation, fourteen as suspected acute exacerbation, and seventeen as other. Definite and suspected acute exacerbations were clinically indistinguishable. Both were most common in the winter and spring months and were associated with a high risk of disease progression and short-term mortality.Conclusions: In this study one half of respiratory serious adverse events were attributed to definite or suspected acute exacerbations. Suspected acute exacerbations are clinically indistinguishable from definite acute exacerbations and represent clinically meaningful events. Clinical trialists should consider capturing both definite and suspected acute exacerbations as outcome measures. © 2013 Collard et al.; licensee BioMed Central Ltd.

ObjectiveAs cartilage loss and bone marrow lesions (BMLs) are associated with knee joint pain and structural worsening, this study assessed whether non-invasive estimates of articular contact stress may longitudinally predict risk for worsening of knee cartilage morphology and BMLs.DesignThis was a longitudinal cohort study of adults aged 50-79 years with risk factors for knee osteoarthritis. Baseline and follow-up measures included whole-organ magnetic resonance imaging score (WORMS) classification of knee cartilage morphology and BMLs. Tibiofemoral geometry was manually segmented on baseline magnetic resonance imaging (MRI), and three-dimensional (3D) tibiofemoral point clouds were registered into subject-specific loaded apposition using fixed-flexion knee radiographs. Discrete element analysis (DEA) was used to estimate mean and peak contact stresses for the medial and lateral compartments. The association of baseline contact stress with worsening cartilage and BMLs in the same subregion over 30 months was assessed using conditional logistic regression.ResultsSubjects (N = 38, 60.5% female) had a mean ± standard deviation (SD) age and body mass index (BMI) of 63.5 ± 8.4 years and 30.5 ± 3.7 kg/m2 respectively. Elevated mean articular contact stress at baseline was associated with worsening cartilage morphology and worsening BMLs by 30 months, with odds ratio (OR) [95% confidence interval (CI)] of 4.0 (2.5, 6.4) and 6.6 (2.7, 16.5) respectively. Peak contact stress also was significantly associated with worsening cartilage morphology and BMLs {1.9 (1.5, 2.3) and 2.3 (1.5, 3.6)}(all P < 0.0001).ConclusionsDetection of higher contact stress 30 months prior to structural worsening suggests an etiological role for mechanical loading. Estimation of articular contact stress with DEA is an efficient and accurate means of predicting subregion-specific knee joint worsening and may be useful in guiding prognosis and treatment.