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India has one of the most rapidly ageing populations on the planet. There is concern that this rate of population ageing, coupled with the decline of extended families, decreasing fertility rates, increasing life expectancy, widowhood, singlehood or strained intergenerational relationships, will have a negative impact on the availability of (family-based) care for older adults in India, resulting in poorer health and well-being. However, India is a complex and diverse country made up of different states, castes, cultures, and ethnic groups. Moreover, rates of population ageing are not uniform as Indian states are at diverse levels of demographic transition and vary to a great extent in their cultural practices, social norms and socio-political contexts. Indeed, while India’s older adult population has now risen to 8.57 per cent, in states such as Goa and Kerala the percentage of older adults is as high as 11.20 per cent and 12.55 per cent respectively. This introduction provides an overview of these issues by situating the subsequent chapters within the broad demographic trends already mentioned and gives an outline of the structure and chapters of the book. This chapter introduces the need for focus on living arrangements and care and highlight the social, economic and cultural contexts that shape the provision of care for older adults in India.

Living arrangements and the provision of care for older people in India have been affected by migration. This is particularly salient given that Indian diaspora is the largest in the world. Hence, one can expect the trends in transnational migration to have a particular impact in the Indian context. However, and perhaps more importantly, the chapter will explore the patterns of internal migration within India. This is an important corrective to the focus on transnational migration as levels of internal migration far outweigh the extent of international migration. Therefore, this chapter examines both internal and international migration to understand how families establish, maintain and retain transnational and transregional care relations. In so doing, we draw on 1) theories of migration, 2) global chains of care and 3) life course theories to frame how migration decisions are related to life-course transitions and care provision. The life-course approach focuses on life events and transitions of individuals and the ways in which these events define their life trajectories. In particular, we will draw on the concept of ‘linked-lives’ to show how older people’s life-course transitions, for example going into care, are linked to the migration decisions of their offspring. With increasing urbanisation and migration we will see emerging trends of global and transregional chains of care to supplant and complement care deficits for vulnerable populations left behind, especially older adults.

Research in diversity has failed to study the unique challenges that the fire service’s schedule, stress, and culture of tradition pose for diverse workforces. There has also been a lack of depth when researchers have studied demographics in the fire service. This case study uses the history and demographics of the Richmond (VA) Department of Fire and Emergency Services (RFES) to answer the following research question: What can homeland security agencies learn about diversity from the successes and challenges of the City of Richmond’s Department of Fire and Emergency Services? This research consists of a qualitative and quantitative study of this fire department. The qualitative study evaluates the factors that had the greatest impact on the work environment. The quantitative study compares RFES to other career departments in Virginia and nationally. The results reveal a large gap, beyond basic demographics, in promotion opportunities for minorities and women in Virginia and national datasets. These same demographic groups in RFES, however, were promoted at rates higher than or equal to their counterparts. http://archive.org/details/diversityinthefi1094562824 Civilian, City of Richmond Department of Fire and Emergency Services Approved for public release; distribution is unlimited.

SummaryBackground Tracheal follicular pattern or so-called tracheal cobblestoning is a poorly described entity in the literature and is depicted as a nodular or lumpy appearance of the tracheal wall mucosa suggesting tracheal irritation from factors like gastro-esophageal reflux (GERD) or pulmonary infection. The aim of the present study was to investigate the prevalence and characteristics of tracheal cobblestones in a large pediatric population. Methods A large database of rigid tracheoscopies recorded in children (0–6 years of age) undergoing general anesthesia with planned tracheal intubation for elective surgical procedures was retrospectively analyzed. Tracheoscopy records were reviewed by five pediatric airway experts (authors 3–7). Data were compared using the Mann–Whitney test, chi-square or Fisher exact test as appropriate (P

Manufacturers are facing an automation-related headache in 2019, unless they properly harness the technology that already sits on their shopfloor and get it working to their advantage

BACKGROUND: Tracheal bronchus (TB) is defined as an abnormal bronchus that originates directly from the lateral wall of the trachea above the carina and goes towards the upper lobe territory of the lung. We analyzed rigid endoscopies of the trachea in children to determine the incidence and characteristics of TB. METHODS: In total, 1021 rigid endoscopies of the trachea recorded from children aged 0 to 6 years were analyzed. Endoscopic examination was performed from supraglottic region to carina using a 0-degree Hopkins rod-lens telescope. Patients with a TB were identified and the site of origin of the TB and its level above the carina was noted. Data of the identified patients was reviewed for the presence of preoperative airway findings such as stridor, upper lobe pneumonia and wheezing or atelectasis, other congenital anomalies, and intraoperative complications. RESULTS: TB was detected in 11 (1.06%) of 1021 upper airway endoscopic examinations. All originated from the right lateral wall of the trachea. Six children had retained secretions in the TB, and 3 children had perioperative airway problems unrelated to the TB. One child showed right main stem bronchus narrowing as seen at the true carina, in the presence of a TB. All the children with TB exhibited at least 1 additional congenital anomaly at birth besides TB. CONCLUSIONS: TB is a relatively common congenital endoscopic lower airway anomaly in childhood, which is itself rarely symptomatic, but almost always coexists with other congenital anomalies.

Study objective: Resuscitation is a fast paced highly complex process which makes considerable demands on the resuscitation team; even minor errors and failures may reduce the chance of a successful outcome. Failure Mode Effects Analysis (FMEA) is a team-based, systematic proactive step-by-step process which identifies failure modes/hazards within the process which could compromise the progression and outcome of the process and highlights where improvements need to be implemented to mitigate failures from occurring. We applied FMEA to the resuscitation process and highlight specific areas within the currently accepted resuscitation protocol which require further assessment. Methods: We followed the procedure for FMEA outlined by the Joint Commission but with some modifications of the basic process. Our modified approach made use of 16 individual interviews with healthcare professionals experienced in resuscitation and focus groups in order to gain a more detailed understanding of the different perspectives on the resuscitation process. The interviews prioritised potential failures that exist in the on-ward resuscitation process which enabled the team to identify specific areas which require further assessment and improvements. Results: In total the FMEA found 28 failure modes that carry a degree of risk that require action. It was found that staff perceived failure modes that relate to the patient's airway, breathing or circulation as ones which would result in a severe effect on the patient's outcome, and those that relate to tasks involved in the running of the process were often perceived as likely to occur. Conclusion: The modified FMEA approach proved practical, and was well received by clinicians within the context of resuscitation and fundamentally highlighted areas where quality improvements are necessary. Our research group and design team at the Helen Hamlyn Centre used the FMEA to develop design cues and technology innovations to address current issues of design duplicity that would be incorporated into a new 'intelligent resuscitation trolley' which we foresee will support the team by improving communication, coordination and overall efficiency. © 2009 - IOS Press and the authors. All rights reserved.

This paper deals with the output losses associated with periods of restrictive monetary and fiscal policy and of declining rates of inflation. The results using data from several countries for the seventies, tend to support the findings that inflation takes about three years to come down by the number of percentage points of the cutback of monetary expansion. Also it was found that the maximum rate of loss of output comes in the second year after the year of the cutback.

The objective of this study was to report surgical results and outcomes of cochlear implantation in a large series of children with syndromes from one centre.All syndromic children who underwent cochlear implantation at Great Ormond Street Hospital, from January 2000 to December 2010 were included in this study. The surgical technique was analysed and audiological outcomes were collected.Over the 10-year period of this study, a total of 88 cochleas in 67 children with syndromes were implanted. The common syndromes implanted in this study were Ushers syndrome (23 patients, 33 cochleas), Wardenburgs syndrome (8 patients, 9 cochleas), Pendreds syndrome (4 patients, 4 cochleas), Jervell-Lange-Neilsen syndrome (3 patients, 4 cochleas), Enlarged vestibular aqueduct syndrome (4 patients, 7 cochleas), Cogans syndrome (3 patients, 4 cochleas), CHARGE (5 patients, 6 cochleas), and Branchio Oto Renal syndrome (3 patients, 4 cochleas). Pre-operative radiological inner ear anatomy was found to be abnormal in 28.4% (25/88) cochleas in this study group. Full insertion of the electrode was achieved in 93.1% (82/88) of cochleas, partial insertion in three cochleas, and insertion was abandoned in three cochleas. Early complications were seen in 6.8% (6/88) of implantations. All the 64/67 children who were implanted are still using the implant.Cochlear implantation in syndromic children is challenging in both its audiological and surgical aspects. Good surgical results and good audiological and speech outcomes were achieved in this study, and subjective improvement in quality of life was achieved in these patients.

A 3D cycling model is presented that combines bicycle dynamics, a tyre model, rider biomechanics and environmental factors into a single dynamic system. The system is constructed using Matlab toolboxes (SimMechanics/Simulink) with the aim of identifying mechanical mechanisms that can influence performance in a road cycling time trial. Initial conditions are specified and a variable step ODE solver numerically integrates solutions to the equations of motion. Initial validation compared rider-less self-stability presented in a published “benchmark” with model simulation and found an error of

Ageing is associated with geometrical changes in muscle fascicles that may lead to deteriorations in physical functions. The purpose of this study was to study the effects of ageing on fibre orientation and strength of the lumbar extensor muscles.Fifty two healthy, 26 younger (10 males and 16 females, aged from 20 to 35) and 26 older (10 males and 16 females, aged from 65 to 90) volunteers participated in this study. Ultrasound images of the lumbar extensor muscles were obtained with the participants in relaxed standing and half flexion (50% of the range of trunk flexion). The fibre angles at the mid-substance of the muscle were recorded. Lumbar extensor muscle strength was measured in the upright posture with a load cell.The mean lumbar extensor fibre angles were found to significantly decrease in the half flexion posture when compared to upright stance (P0.01). Both the fibre angle and the moment generation capability of the muscles decreased with ageing (P0.01). There was a moderate correlation between the fibre angles in the upright posture and the muscle strength measured in this posture (r=0.40, P0.01).Age-related changes in muscle geometry and posture may partly account for the deterioration in muscle function in the elderly.

Introduction: Loss of lumbar extensor muscle strength and fatigue resistance may contribute to functional disability. Methods: Two groups of subjects were recruited: young (n = 26, 20–35 years of age) and old (n = 26, ≥65 years of age) adults. Lumbar extensor muscle strength was measured with a load cell, and electromyographic activities were recorded to study muscle fatigue at 60% of maximum voluntary contraction. Results: We found that the muscle moments generated by the extensor muscles decreased with age (P 0.05). Conclusions: The changes in strength and spectral properties of the electromyographic signals of lumbar extensor muscles may be related to age-related alterations in muscle fiber composition and recruitment. These changes should be considered in clinical functional task evaluation. Muscle Nerve 44: 74–79, 2011

Educational technology provides plenty of ways to bridge the gap between homework and game play. Martin Bailey provides some hot tips for achieving the right balance.

Original article can be found at: http://www.informaworld.com/smpp/title~content=t713410544~db=all Copyright Informa / Taylor and Francis

Objective: Foreign body inhalation is a potentially life-threatening emergency and is the commonest cause of accidental death in children under one year old. There is varying opinion regarding the urgency for removal of inhaled foreign bodies; most centres in the United Kingdom will take the patient to theatre as soon as can be arranged, regardless of the time of day. At Great Ormond Street Hospital for children it has been standard practice to perform rigid bronchoscopy and removal of an inhaled foreign body on the next available daytime operating list, providing the patient is clinically stable, even if this incurs a delay until the following day. We aimed to identify if any additional morbidity resulted from delaying removal of the foreign body. Methods: Retrospective case note review of all cases of foreign body inhalation seen at our institution over an 11-year period between July 1996 and July 2007. Results: 165 patients were referred to our institution with a suspected inhaled foreign body in the study period. 14 patients were managed conservatively due to low clinical suspicion and 57 patients underwent a negative bronchoscopy: these groups were excluded from our analysis. Of the remaining 94 patients, only 7 were taken to theatre outside a scheduled daytime operating list. All of these patients had signs of severe respiratory distress and were operated upon within 4 h of their arrival. Of the remaining patients, 41 were taken to theatre on the day of presentation and 46 on the day after presentation; all within normal daytime working hours. No additional post-operative morbidity was identified as a result of our policy to delay bronchoscopy until the next available daytime operating list. Conclusions: It is our perception that delaying removal of suspected inhaled foreign bodies to allow optimal circumstances for manipulation of the paediatric airway is a safe practice at our institution. We have not identified any adverse outcomes related to delaying bronchoscopy to the next available daytime operating list in the clinically stable patient. This remains our preferred method of practice.

Summary Objective To identify and characterize food items with high risk of airway obstruction in children younger than 15 years. Methods This retrospective study collected injury data from 1989 to 1998 for 26 pediatric hospitals in the United States and Canada. Aspiration, choking, ingestion, and insertion injuries due to food items were analyzed. The data included 1429 infants and children. Results were compared with fatality data published by the American Association of Pediatrics in 1984. Results The 10 food objects with the highest frequency for both injuries and fatalities were identified. Peanuts caused the highest frequency of injury, and hot dogs were most often associated with fatal outcomes. The severity of respiratory distress prior to hospital evaluation varied for different foods. Age younger than 3 years was the highest-risk factor. Key characteristics such as bite size, shape, and texture were analyzed and found to demonstrate relationships with severity of clinical outcomes. Conclusions Children younger than 3 years remain at greatest risk of food injury and death. We found that hard, round foods with high elasticity or lubricity properties, or both, pose a significant level of risk. Consideration of the key characteristics of the most hazardous foods may greatly decrease airway obstruction injuries. Food safety education can help pediatricians and parents select, process, and supervise appropriate foods for children younger than 3 years to make them safer for this highest-risk population.

This study retrospectively reviewed compliance with the checking policy for resuscitation trolleys on medical, surgical and paediatric wards in a large UK city-based teaching hospital. Successful advanced life support (ALS) relies on the availability of a resuscitation trolley that provides the required equipment and recommended drugs. Missing or faulty equipment can significantly compromise ALS. Local policy stipulates periodic checking, and re-stocking as required, of resuscitation trolleys, and checklists are provided for this purpose. The checklist forms located on each trolley were examined between January and December 2005. The frequency of checking was compared with the arrest calls made within that period. The medical, surgical and paediatric wards had a mean checking rate of 72.2%, 68.8% and 65.9%, respectively. In December one ward checked their trolley on 11/31 (35.5%) days of the month, during which there were two cardiac arrest calls. In this hospital, basic trolley checking procedures are not being followed, leaving the trolley unchecked, and possibly unprepared, for an emergency cardiopulmonary arrest. Hospitals should regularly review compliance with policies and procedures for the checking of resuscitation equipment to ensure that appropriate and functioning equipment, and unexpired drugs are in place in all clinical areas.

Tracheostomy involves the surgical formation of a stoma between the trachea and the skin. It is classically thought of as a treatment to alleviate airway obstruction; however, its clinical applications are varied and include long-term ventilatory support, being an aid in pulmonary toilet and use as a covering procedure during airway surgery. In this article, we review the surgical aspects of tracheostomy, including preoperative considerations, tracheostomy tube choice, operative technique and postoperative complications. Postoperative care of the child with a tracheostomy will also be discussed.

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Surgical reconstruction of paediatric laryngotracheal stenosis (LTS) has only been developed over the last 30 years, but during that period great advances have been made, and the operation is now very much tailored to the needs of the individual patient. Closed (endoscopic) techniques have a very limited place in the correction of LTS. Of the open surgical techniques, laryngotracheal reconstruction (LTR) with cartilage grafting can precisely correct grade II and mild grade III stenosis with minimal morbidity and high decannulation rates. Partial cricotracheal resection (PCTR) can deliver high success rates for more severe stenoses, but it is a more complex procedure. Because LTR is more straightforward, it tends to be preferred for grade II and mild grade III stenosis. For a suitably experienced surgeon, PCTR is the preferred option for grade IV and severe grade III stenosis, especially where there is a clear margin between the stenosis and the vocal cords. The best chance for the patient lies in the first operation: this means that the surgeon managing the problem must be fully trained in paediatric airway endoscopy and laryngotracheal surgery, since inappropriate initial management of LTS may lead to permanent intractable sequelae.

Objective: to investigate whether relief of airway obstruction in laryngomalacia by aryepiglottoplasty affects gastro-oesophageal reflux. Methods: a prospective study of consecutive infants and children with suspected laryngomalacia. Gastro-oesophageal reflux was measured before and after diagnostic microlaryngobronchoscopy and aryepiglottoplasty. Results: of the six cases who underwent aryepiglottoplasty and completed the study, three had significant pre-operative reflux according to age. In this group the reflux improved significantly after aryepiglottoplasty. In the other three cases, reflux was not age-significant pre-operatively nor did it change significantly post-operatively. Conclusions: when partial airway obstruction due to laryngomalacia co-exists with gastro-oesophageal reflux, treatment of the airway problem improves respiratory symptoms in all cases and reduces gastro-oesophageal reflux in patients with age-significant reflux. This suggests that there are two clinical groups, those with severe, age-significant reflux, possibly caused by airway obstruction, whose gastro-oesophageal reflux benefits from aryepiglottoplasty; and those whose reflux is physiological and not influenced by aryepiglottoplasty. Therefore aryepiglottoplasty can be expected to reduce gastro-oesophageal reflux in those infants with laryngomalacia who have age-significant reflux.

Objectives: We reassessed the current practice and treatment options used in the management of subglottic haemangiomas (SGHs), including the place for open submucosal surgical excision, and have compared the results of different therapeutic modalities used for SGHs. Methods: The two studies were conducted as separate exercises; (1) a retrospective review of 36 patients collected over a recent 8-year period to assess the current practice and treatment options in use; (2) a retrospective comparative study of a previous cohort of 51 patients with SGHs treated in one of four groups: (a) tracheostomy alone, (b) tracheostomy and CO2 laser, (c) systemic steroids and CO2 laser (no tracheostomy) and (d) intralesional steroid injection, CO2 laser therapy, or both, followed by intubation. Results: Systemic steroids were the most commonly used modality of treatment. Resolution of the SGH was achieved in 89% of cases at a mean follow up duration of 34 months. However, tracheostomy was required in 58% of cases, with a mean time from diagnosis to decannulation of 30 months. The time to resolution of SGHs does not appear to be reduced by laser therapy compared with treatment by tracheostomy alone. Intralesional steroid injection or laser therapy together with intubation was associated with avoidance of a tracheostomy in 66% of cases. Single-stage open surgical excision in two cases resulted in successful resolution of the SGH and discharge after a mean follow up period of 3 months. Conclusions: Despite the more widespread use of steroids and other treatment modalities, the requirement for tracheostomy has remained unchanged over the last 20 years. The use of laser therapy does not appear to confer any additional therapeutic benefit over and above tracheostomy alone in bringing about resolution of SGHs. Systemic steroids may reduce the size of the haemangioma but are associated with multiple adverse effects. The decision to use the above techniques must, therefore, be made in the light of these observations. Our early experience of single-stage excision suggests that this technique represents an exciting and promising surgical alternative, and its more widespread adoption may be the only way of further improving the outcome of patients with SGHs.

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Introduction Down's syndrome is associated with poor Eustachian tube function, and an increased incidence of cholesteatoma. The only previously published case series suggests that ‘canal wall preserving’ procedures are only rarely suitable for the management of cholesteatoma in this population. Methods We conducted a retrospective review of the hospital's clinical records database to identify patients with Down's syndrome and cholesteatoma. These patients’ notes were then reviewed. Results We identified nine patients with Down's syndrome who had undergone surgical management of cholesteatoma over a twelve year period. Three patients had bilateral disease, meaning twelve ears were treated. Seven ears were initially treated with ‘canal wall down’ procedures. Four out of five of the remaining ears were successfully treated using ‘canal wall preservation’ or ‘canal wall reconstruction’, with one ear requiring subsequent conversion to a ‘canal wall down’ approach. Conclusion Canal wall preservation/reconstruction is feasible in patients with Down's syndrome, even when cholesteatoma extends into the mastoid.

Tracheal follicular pattern or so-called tracheal cobblestoning is a poorly described entity in the literature and is depicted as a nodular or lumpy appearance of the tracheal wall mucosa suggesting tracheal irritation from factors like gastro-esophageal reflux (GERD) or pulmonary infection. The aim of the present study was to investigate the prevalence and characteristics of tracheal cobblestones in a large pediatric population.A large database of rigid tracheoscopies recorded in children (0-6 years of age) undergoing general anesthesia with planned tracheal intubation for elective surgical procedures was retrospectively analyzed. Tracheoscopy records were reviewed by five pediatric airway experts (authors 3-7). Data were compared using the Mann-Whitney test, chi-square or Fisher exact test as appropriate (P 0.05).A total of 971 rigid tracheoscopy records were analyzed. The median age of the patients was 3.3 years (range 0.4-6.0 yrs). Cobblestones were present in 377 out of 971 patients (38.8%) with a male to female prevalence of 254 (40.6%)/123 (35.5%). None of the children under four months of age showed the presence of cobblestones. The prevalence of cobblestones was significantly less in patients under 3 years of age compared to over 3 years (P 0.01). There was no association between prevalence of cobblestones and GERD, current or recent respiratory infection or concomitant enlarged tonsils.The prevalence of tracheal cobblestones in otherwise healthy children is high and is not associated with GERD or respiratory infection. The gender and age related differences are novel interesting findings that require further investigations.

Titanium osseointegrated implants for bone-anchored hearing aids (BAHAs) have been in use since 1977. A series of 32 children who received implantation since 1990 is reported. The report focuses on the surgical aspects of BAHAs, predisposing factors, and prevention of complications in an unusual pediatric population. The records of 32 children who had undergone two-stage implantation of a BAHA were retrospectively reviewed. The majority of the patients had craniofacial abnormalities. Of the 32 implantees, 29 use their BAHA at present. Five children failed to achieve osseointegration, and eight patients have had revision surgery for lost abutments, trauma, or chronic skin problems. There were no differences between preimplantation and postimplantation bone or air conduction thresholds. The pediatric BAHA carries with it a unique set of challenges and problems but can be successfully implanted and maintained.