Tinker Air Force Base

One hundred twenty-two consecutive patients (104 men; 18 women) were studied to determine the incidence and natural history of pericardial effusion occurring 2, 5, 10, and 20 to 50 days after cardiac surgery. Three patients had pericardial effusions before and 103 patients (91 men; three women) had effusions after surgery. Effusions were first recorded on the second postoperative day in 72 patients, on the fifth postoperative day in 29 patients, and on the tenth postoperative day in two patients. In 96 of these patients, effusions reached their maximum size by postoperative day 10. Of the 103 patients with effusions, 66 (64%) were followed to complete resolution. A specific pattern was observed in most resolving effusions. The echo-free space diagnostic of pericardial effusion became progressively more echo-dense as the effusion diminished in size. As the effusion became echo-dense, the posterior pericardium, which had been motionless, resumed its normal systolic anterior motion. One patient developed cardiac tamponade on postoperative day 3. We conclude that pericardial effusion occurs frequently after cardiac surgery, but that associated complications are rare.

AIM: The aim of this paper is to explicate the concept of complex adaptive systems through an analysis that provides a description, antecedents, consequences, and a model case from the nursing and health care literature. BACKGROUND: Life is more than atoms and molecules--it is patterns of organization. Complexity science is the latest generation of systems thinking that investigates patterns and has emerged from the exploration of the subatomic world and quantum physics. A key component of complexity science is the concept of complex adaptive systems, and active research is found in many disciplines--from biology to economics to health care. However, the research and literature related to these appealing topics have generated confusion. A thorough explication of complex adaptive systems is needed. METHODS: A modified application of the methods recommended by Walker and Avant for concept analysis was used. FINDINGS: A complex adaptive system is a collection of individual agents with freedom to act in ways that are not always totally predictable and whose actions are interconnected. Examples include a colony of termites, the financial market, and a surgical team. It is often referred to as chaos theory, but the two are not the same. Chaos theory is actually a subset of complexity science. Complexity science offers a powerful new approach--beyond merely looking at clinical processes and the skills of healthcare professionals. CONCLUSION: The use of complex adaptive systems as a framework is increasing for a wide range of scientific applications, including nursing and healthcare management research. When nursing and other healthcare managers focus on increasing connections, diversity, and interactions they increase information flow and promote creative adaptation referred to as self-organization. Complexity science builds on the rich tradition in nursing that views patients and nursing care from a systems perspective.

We conducted a prospective, blind study to determine whether a difficult endotracheal intubation could be predicted preoperatively by evaluation of one or more anatomic features of the head. In 471 adults presenting for elective surgery, the size of the tongue relative to the oral cavity was assessed according to the Mallampati classification (oropharyngeal class), and the distance between the chin and thyroid cartilage (thyromental distance) and the angle at full extension of the head (head extension) were measured. At laryngoscopy, the difficulty in visualizing the larynx was determined by a different observer. Assignment to oropharyngeal Class 3, a thyromental distance < or = 7 cm, and a head extension < or = 80 degrees, considered either alone or in various combinations, had low sensitivity and positive predictive values in identifying patients with airways that were difficult to intubate, but high specificity and negative predictive values. We conclude that these three tests are of little value in predicting difficult intubation in adults, although the likelihood of an easy endotracheal intubation is high when they yield negative results.

Why do international comparisons have an impact on some countries while other countries do not respond? This article examines the power of international ratings and rankings (R&R) using the OECD's PISA study and its differential impact on education policymaking as a case study. It argues that international R&R have an impact when two conditions are simultaneously fulfilled: the evaluated topic is framed as crucial in the national discourse, and a substantial gap between national self-perception and the empirical results can be observed. After assessing the media impact of PISA on 21 OECD countries, the theoretical argument is illustrated by an evaluation of the differing reactions of two similarly poorly performing countries: Germany and the US. While the German system of secondary education was strongly affected by the international comparison, beginning with the first PISA study in 2000, and underwent comprehensive changes, the US first responded noticeably in the public and the political discourse only in 2010 to its below-average ranking.

OBJECTIVE: To formulate an evaluation system and authenticate the levator ani subdivisions visible on endovaginal three-dimensional ultrasonography. METHODS: A three-dimensional endovaginal ultrasound examination was performed on five fresh-frozen female pelves. The location of the pubovaginalis, puboperinealis, puboanalis, puborectalis, and iliococcygeus muscles was identified. Three-dimensional endovaginal ultrasound scans of 22 nulliparous women with normal pelvic floors were obtained, and a three-level evaluation system was constructed. Level 1 contained the muscles as they insert into the perineal body. Level 2 evaluated the insertions into the retropubic area and typically contained the pubovaginalis, puboperinealis, puboanalis, and puborectalis. Level 3 contained muscles that were cephalad to the pubic bone. Two blinded reviewers assessed levator ani subdivision visualization at each level and individual muscle visualization by the origin-insertion points. RESULTS: There was 98%, 96%, and 92% agreement for levels 1, 2, and 3 muscles, with 95% confidence intervals (CIs) of 0.92-1, 0.95-0.99, and 0.88-0.95, respectively. Kappa values (95% CI) for agreement were calculated for individual muscles as follows: superficial transverse perinei and puborectalis were seen by both raters 100%, puboperinealis, pubovaginalis, and puboanalis 0.645 (0.1-1), and iliococcygeus 0.9 (0.6-1). CONCLUSION: The location of the pubovaginalis, puboperinealis, puboanalis, puborectalis, and iliococcygeus as seen by three-dimensional endovaginal ultrasonography was confirmed through anatomic dissection of fresh-frozen pelves. Subdivisions of the levator ani muscle were visualized reliably with three-dimensional ultrasonography using a systematic approach. LEVEL OF EVIDENCE: III.

The choice of construction delivery system is one of the most important decisions that a public highway agency will make with regard to a highway, bridge, or transit construction project. Although several research projects have been conducted on the subject of comparing costs and project duration, there has been no study that statistically analyzes these factors specifically for transportation projects, much less one that eliminates the largest variable of all: different public agencies. The objective of the research reported in this paper was to determine which of two delivery methods, design-bid-build (DBB) and design-build (DB), delivers highway and bridge construction projects at the lowest cost and in the shortest time period, and to back up the findings with a rigorous statistical analysis of the data. Data were taken from the databases of the Florida Department of Transportation (FDOT) and arithmetically and statistically compared through Levene’s test, the independent samples t-test, the Welch unequal variances t-test, and the Mann-Whitney U test. In fact, this paper’s unique contribution is its rigorous statistical analysis of data gathered directly from FDOT, comparing the performance of the two delivery systems in Florida over a finite period of time. In this comparison, DBB projects performed significantly better in terms of cost according to all statistical and arithmetic tests. DBB projects did not compare as favorably in terms of duration. Some tests showed a statistically insignificant advantage to the use of DB over DBB, whereas other tests showed no difference between the two. Other public agencies can replicate the research and determine whether the same findings hold true in their situation.

Hemodynamic effects of dobutamine and dopamine (both 5, 10, 15 microgram/kg/min) and epinephrine (0.04 microgram/kg/min) were studied immediately following cessation of cardiopulmonary bypass in 34 patients with preoperative evidence of left ventricular dysfunction. Significant increases in mean cardiac index were seen with dobutamine (15, 25, and 26% respectively), and epinephrine (30%). The largest increases occurred with dopamine (44, 53, and 64 percent respectively). Responses varied from patient to patient, however. Seven patients developed marked output increases without concomitant increases in arterial pressure, whereas seven others showed "satisfying" increases in arterial pressure without appreciable output increases. Heart rate increases were small and few arrhythmias were noted. We conclude that dopamine, epinephrine, and dobutamine all are effective inotropic agents during the immediate post-bypass period, with variations discussed in detail. None possess the disturbing chronotropic and arrhythmogenic effects of isoproterenol (previously studied). Efficacy of administration of inotropic drugs seems best assessed by serial output measurements during this period.

Three types of airmasses in which tornadoes form are identified from consideration of 286 representative soundings and a median sounding for each type presented and discussed. Previously published descriptions of tornadic airmasses are identified as being of TYPE I, the most common TYPE, and some refinement is given. Two other TYPES are described and it is contended that all tornadoes and water spouts of the continental United States and adjacent waters form in airmasses that fit one of the three classifications. Finally, the weather phenomena that most commonly accompany tornadoes in each TYPE of airmass are described and related to the height of the wet-bulb freezing level above the terrain.

The frequency distribution of tornadoes in the United States is discussed briefly and an empirical method of forecasting these and allied severe local storms is described. It is shown that the formation of such storms can be forecast by evaluating certain empirical criteria related to the stability of the air column, the horizontal and vertical distributions of the moisture content and the wind. A typical tornado development is discussed from a synoptic point of view. An unusual situation and the verification of 35 experimental forecasts are briefly described.

Abstract One primary goal of annual Spring Forecasting Experiments (SFEs), which are coorganized by NOAA’s National Severe Storms Laboratory and Storm Prediction Center and conducted in the National Oceanic and Atmospheric Administration’s (NOAA) Hazardous Weather Testbed, is documenting performance characteristics of experimental, convection-allowing modeling systems (CAMs). Since 2007, the number of CAMs (including CAM ensembles) examined in the SFEs has increased dramatically, peaking at six different CAM ensembles in 2015. Meanwhile, major advances have been made in creating, importing, processing, verifying, and developing tools for analyzing and visualizing these large and complex datasets. However, progress toward identifying optimal CAM ensemble configurations has been inhibited because the different CAM systems have been independently designed, making it difficult to attribute differences in performance characteristics. Thus, for the 2016 SFE, a much more coordinated effort among many collaborators was made by agreeing on a set of model specifications (e.g., model version, grid spacing, domain size, and physics) so that the simulations contributed by each collaborator could be combined to form one large, carefully designed ensemble known as the Community Leveraged Unified Ensemble (CLUE). The 2016 CLUE was composed of 65 members contributed by five research institutions and represents an unprecedented effort to enable an evidence-driven decision process to help guide NOAA’s operational modeling efforts. Eight unique experiments were designed within the CLUE framework to examine issues directly relevant to the design of NOAA’s future operational CAM-based ensembles. This article will highlight the CLUE design and present results from one of the experiments examining the impact of single versus multicore CAM ensemble configurations.

Abstract. The effective applications of land surface models (LSMs) and hydrologic models pose a varied set of data input and processing needs, ranging from ensuring consistency checks to more derived data processing and analytics. This article describes the development of the Land surface Data Toolkit (LDT), which is an integrated framework designed specifically for processing input data to execute LSMs and hydrological models. LDT not only serves as a preprocessor to the NASA Land Information System (LIS), which is an integrated framework designed for multi-model LSM simulations and data assimilation (DA) integrations, but also as a land-surface-based observation and DA input processor. It offers a variety of user options and inputs to processing datasets for use within LIS and stand-alone models. The LDT design facilitates the use of common data formats and conventions. LDT is also capable of processing LSM initial conditions and meteorological boundary conditions and ensuring data quality for inputs to LSMs and DA routines. The machine learning layer in LDT facilitates the use of modern data science algorithms for developing data-driven predictive models. Through the use of an object-oriented framework design, LDT provides extensible features for the continued development of support for different types of observational datasets and data analytics algorithms to aid land surface modeling and data assimilation.

All upper-air soundings in the United States have been evaluated since January 1, 1950 and 274 selected as representative of air in which hailstones of known size formed. These soundings are summarized and several parameters which are or may be useful in forecasting are discussed. A graph is presented, which permits the translation of a forecast of air structure into one of hailstone size and two groups of forecasts are summarized to show the validity of this forecasting tool. The forecasts discussed were prepared in practical situations by meteorologists on regular forecasting duty and issued before the storms occurred. They therefore constitute a real test of the method under working conditions. Evidence is presented to show a very striking relation between the incidence of surface hail and the height of the wet bulb freezing level above the terrain. It was found that in 91.6% of the 274 representative soundings, the wet bulb freezing levels were between 5000 and 12,000 feet above the surface and the larger the reported surface hail, the greater the concentration of these levels near 8000 feet. It is emphasized that the method of hail forecasting discussed is not susceptible to machine methods, but depends on accurate prognostication of the thermodynamic structure of the air column as it changes in time and space.

PURPOSE: This study examined how to improve dietary habits of individuals from the general public. DESIGN: The Eating for a Healthy Life project was a randomized trial. SETTING: The study was conducted among members of religious organizations (ROs). SUBJECTS: Participants were a sample of RO members. INTERVENTION: The intervention was a multilevel package, based on our previous experience, designed to lower fat and increase fruit and vegetable consumption. MEASURES: The Eating Behaviors Questionnaire was administered preintervention and postintervention, together with 24-hour food recalls in a randomly selected subset. Analysis. Linear mixed models were used to evaluate the study's intervention, incorporating the design effects of blocking, intraclass correlation within RO, and correlation between the preintervention and postintervention points. RESULTS: Participants (n = 2175) reported significantly healthier dietary behaviors in intervention ROs at the 12-month follow-up period, compared to participants in the comparison ROs, for a fat scale change of .08 summary scale points and an adjusted intervention effect of .06 overall. CONCLUSION: Dietary intervention through ROs is a positive and successful method of changing dietary habits.

This paper reports measurements of the chemical composition of exhaust from two aircraft turbine engines. The two engines are the F101, used on the B-1B aircraft, and the F110, used on the F-16C and F-16D aircraft. Samples were collected from each engine using a probe positioned just behind the exhaust nozzle. The measurements reported here were made at four power settings from idle to intermediate power. Exhaust composition measurements included carbon monoxide, carbon dioxide, nitrogen oxides, total hydrocarbons, and individual organic species. The principal focus of this paper is on the detailed organic species results.

Incidents of counterfeit products harming humans have been widely reported in the western press. Counterfeit handbags and jeans are easily obtainable at several well-known locations around the world, including many in the United States. The construction industry is not immune from the worldwide problems of counterfeiting. Research reported on by this paper identified the center of the problem as the People’s Republic of China (PRC). In addition, the research concluded that there are significant differences in the attitudes toward counterfeiting exhibited by people living and working in North America and those living and working in the PRC. The research, based on almost 200 interviews, revealed that most Chinese manufacturers believe that “close enough is good enough” and many Chinese have a hard time understanding why that is not acceptable to the U.S. market. Of course, many U.S. and Canadian companies have had great success procuring quality material and products from China, but most have achieved this success through extensive education and training of the Chinese manufacturer and supplier, and excruciating diligence in the oversight of their entire supply chain.

Background— The P wave on an ECG is a measure of atrial electric function, and its characteristics may serve as predictors for atrial arrhythmias. Increased mean P-wave duration and P-wave terminal force traditionally have been used as markers for left atrial enlargement, and both have been associated with increased risk of atrial fibrillation. Here, we explore the genetic basis of P-wave morphology through meta-analysis of genome-wide association study results for P-wave duration and P-wave terminal force from 12 cohort studies. Methods and Results— We included 44 456 individuals, of which 6778 (16%) were of African ancestry. Genotyping, imputation, and genome-wide association study were performed at each study site. Summary-level results were meta-analyzed centrally using inverse-variance weighting. In meta-analyses of P-wave duration, we identified 6 significant ( P &lt;5×10 − 8 ) novel loci and replicated a prior association with S CN10A. We identified 3 loci at SCN5A , TBX5 , and CAV1/CAV2 that were jointly associated with the PR interval, PR segment, and P-wave duration. We identified 6 novel loci in meta-analysis of P-wave terminal force. Four of the identified genetic loci were significantly associated with gene expression in 329 left atrial samples. Finally, we observed that some of the loci associated with the P wave were linked to overall atrial conduction, whereas others identified distinct phases of atrial conduction. Conclusions— We have identified 6 novel genetic loci associated with P-wave duration and 6 novel loci associated with P-wave terminal force. Future studies of these loci may aid in identifying new targets for drugs that may modify atrial conduction or treat atrial arrhythmias.

OBJECTIVE: To investigate potential sources and risks associated with multidrug-resistant (MDR) bacteria in a deployed US military hospital. DESIGN: Retrospective analysis of factors associated with recovery of MDR bacteria, supplemented by environmental sampling. SETTING: The largest US military hospital in Afghanistan. PATIENTS: US and Afghan patients with positive bacterial culture results, from September 2007 through August 2008. METHODS: Microbiologic, demographic, and clinical data were analyzed. Potential risk factors included admission diagnosis or mechanism of injury, length of stay, gender, age, and nationality (US or Afghan). Environmental sampling of selected hospital high-touch surfaces and equipment was performed to help elucidate whether environmental MDR bacteria were contributing to nosocomial spread. RESULTS: A total of 266 patients had 411 bacterial isolates that were identified during the study period, including 211 MDR bacteria (51%). Gram-negative bacteria were common among Afghan patients (241 [76%] of 319), and 70% of these were classified as MDR. This included 58% of bacteria recovered from Afghan patients within 48 hours of hospital admission. The most common gram-negative bacteria were Escherichia coli (53% were MDR), Acinetobacter (90% were MDR), and Klebsiella (63% were MDR). Almost one-half of potential extended-spectrum β-lactamase (ESBL) producers were community acquired. Of 100 environmental swab samples, 18 yielded MDR bacteria, including 10 that were Acinetobacter, but no potential ESBL-producing bacteria. CONCLUSIONS: Gram-negative bacteria from Afghan patients had high rates of antimicrobial resistance. Patients experiencing complex trauma and prolonged hospital stays likely contribute to the presence of MDR bacteria in this facility. However, many of these patients had community-acquired cases, which implies high rates of colonization prior to hospital admission.

From sixty-two cases of non-frontal thunderstorms passing over reporting stations, a relation is found between peak wind gusts and the temperature difference between the surface air underneath and in advance of the thunderstorm. The temperature under the thunderstorm is forecast by lowering the wet-bulb temperature at the freezing level to the surface along a saturation adiabat on a pseudoadiabatic chart, permitting use of the relation as an aid to thunderstorm gust forecasting.

BACKGROUND: Continuation of intrathecal anesthesia into the postoperative period has been limited by important safety concerns. Principal among these has been the assumption that extended intrathecal therapy leads to spinal (epidural and intrathecal) space infections. To address the role of extended intrathecal catheter therapy as a cause of infections, we cultured all intrathecal catheters used to provide postoperative analgesia. METHODS: All intrathecal catheters were inserted in the operating room using sterile technique. The catheters were used either for the duration of the patients stay in the intensive care unit or until they were no longer judged to provide a therapeutic advantage. They were removed without skin preparation. The distal 2-3 cm of the catheters was cultured using semiquantitative culture methods. Results were divided into four groups: group 1, negative culture results; group 2, ten or fewer colonies of growth; group 3, more than 10 colonies on initial plates and/or growth from broth cultures; and group 4, any bacterial growth, along with evidence of local or central nervous system infections. RESULTS: Cultures were obtained from 139 patients with a mean indwelling catheter time of 66.1 h. Group 1 (102 patients) had a mean indwelling duration of 55 h. Group 2 (26 patients) and group 3 (11 patients) had significantly longer indwelling duration (83.2 h P = .0023, 129.6 h P = < .0001, respectively) than group 1. Cultures of cerebrospinal fluid obtained simultaneously with catheter cultures in 9 cases (5 in group 2 and 4 in group 3) showed no growth. No patient had evidence of local or central nervous system infection. Difficulty of catheter placement (number of attempts made and the number of levels explored), antibiotic administration, the composition of the postoperative infusions and the number of catheter breaks in the postoperative period were similar in each group. With the exception of two catheters in group 3, (cultured at 49 and 54 h), significant bacterial growth (more than ten colonies) was observed only after more than 96 h of indwelling duration. CONCLUSIONS: Application of semiquantitative culture methods assisted in explaining the results seen in group 2 as secondary to contamination of the catheter that occurred on removal. Higher numbers of bacteria (group 3) may define a population at increased risk for infectious complications. The results of this study do not absolutely resolve the issue of infectious risk associated with postoperative intrathecal catheter use, nor do they define a safe period beyond which the risk of continued catheter use would be unacceptable. However, it appears that limited periods of use (96 h or less) is not associated with either frequent local or spinal infections. Semiquantitative culture methods may help identify individuals (with catheter cultures yielding more than ten colonies) at increased risk for infectious complications and in need of closer observation.

We present six patients with chronic dislocation of the elbow who were treated by primary semiconstrained total elbow arthroplasty. All were women with a mean age of 65 years (51 to 76), the mean interval between dislocation and surgery was 17 weeks (5 to 52) and the mean follow-up 58 months (24 to 123). The most dramatic improvement was in function. The mean American Shoulder and Elbow Surgeon score was 5.2 times better (p < 0.001) and the mean total range of movement increased from 33 degrees to 121 degrees (p < 0.001) after operation. Three patients developed wear of polyethylene. One required revision for a periprosthetic fracture, and another required a bushing exchange. Primary semiconstrained elbow arthroplasty provides significant, predictable functional improvement. Potential solutions for wear of polyethylene include a different operative technique or design of implant. Despite the high incidence of such wear, total elbow arthroplasty should be considered as a viable treatment option for chronic dislocation of the elbow in elderly patients.