Objective To determine whether use of intermediate acting neuromuscular blocking agents during general anesthesia increases the incidence of postoperative respiratory complications.Design Prospective, propensity score matched cohort study.Setting General teaching hospital in Boston, Massachusetts, United States, 2006-10.Participants 18 579 surgical patients who received intermediate acting neuromuscular blocking agents during surgery were matched by propensity score to 18 579 reference patients who did not receive such agents. Main outcome measuresThe main outcome measures were oxygen desaturation after extubation (hemoglobin oxygen saturation <90% with a decrease in oxygen saturation after extubation of >3%) and reintubations requiring unplanned admission to an intensive care unit within seven days of surgery. We also evaluated effects on these outcome variables of qualitative monitoring of neuromuscular transmission (train-of-four ratio) and reversal of neuromuscular blockade with neostigmine to prevent residual postoperative neuromuscular blockade. ResultsThe use of intermediate acting neuromuscular blocking agents was associated with an increased risk of postoperative desaturation less than 90% after extubation (odds ratio 1.36, 95% confidence interval 1.23 to 1.51) and reintubation requiring unplanned admission to an intensive care unit (1.40, 1.09 to 1.80). Qualitative monitoring of neuromuscular transmission did not decrease this risk and neostigmine reversal increased the risk of postoperative desaturation less than 90% (1.32, 1.20 to 1.46) and reintubation (1.76, 1.38 to 2.26). ConclusionThe use of intermediate acting neuromuscular blocking agents during anesthesia was associated with an increased risk of clinically meaningful respiratory complications. Our data suggest that the strategies used in our trial to prevent residual postoperative neuromuscular blockade should be revisited. IntroductionTens of millions of people worldwide undergo general anesthesia every day. Anesthetists use a wide variety of drugs to establish the reversible state of anesthesia, which is characterised by hypnosis, amnesia, analgesia, hemodynamic stability with control of the stress response, and immobility.1 Deep anesthesia provides all components 2 3 ; however, to achieve immobility with lower levels of anesthetic agents, anesthetists may coadminister curare-type neuromuscular blocking agents. These drugs inhibit neuromuscular transmission from nerves to muscles by competitively blocking the binding of acetylcholine to its postsynaptic receptors at the motor end plate, thereby causing paralysis of the muscle.More than 400 million people receive neuromuscular blocking agents annually (Intercontinental Marketing Services (IMS) RESEARCHHealth, Multinational Integrated Data Analysis System (MIDAS), September 2010), either in the operating theatre to optimize surgical conditions, or in the intensive care unit to facilitate mechanical ventilation in those with patient-ventilator asynchrony. 4 Neuromuscular blocking a...

The nature and practice of sustainability is very complex, multi‐dimensional and dynamic. Traditional and reductionist approaches have shown their inability to address sustainability issues. Increasing complex issues and challenges related to sustainability requires a fresh approach to address the multi‐dimensional and multi‐disciplinary nature of complexity. In this paper, systems thinking is used in a case study in a UNESCO designated Biosphere Reserve to demonstrate its application to effectively address complex and sustainability issues. A systems model has been developed, and various tools, processes and techniques of systems thinking have been used in the study. The systems model and its associated systems archetypes are qualitatively analysed to provide insights into potential system behaviour and to facilitate the identification of leverage points and systemic intervention strategies that are required for the sustainable development of the Biosphere. The unique approach used in this study has significant potential to apply globally considering the comprehensive network of Biosphere Reserves around the world, as well as the various sustainability and other complex issues that our society is facing. Copyright © 2012 John Wiley & Sons, Ltd.

Policy makers, managers and leaders in organizations, governments and business institutions are under increasing pressure to make the right management decisions in the face of a continually changing political and socio‐economic landscape. To make matters more challenging, the complex environmental, socio‐economic, business‐financial issues that decision makers need to deal with tend to transcend the jurisdictions and capacities of any single organization. There is a multitude of difficult, long‐term global challenges ahead, almost all of which are coupled with the most pressing concerns of different countries at national and local levels. Despite many efforts to deal with these complex issues facing our society, the solutions so far have seldom been long lasting, because ‘treating the symptoms’ and ‘quick fixes’, using traditional linear thinking, are the easiest way out, but do not deliver the solutions. This paper describes the processes for unravelling complexity through participatory systems analysis and the interpretation of systems structures to identify leverage points for systemic interventions. It further demonstrates the promotion of effective change and the enhancement of cross‐sectoral communication and collaborative learning. This learning focuses on finding solutions to complex issues by applying an iterative, systems‐based approach, both locally—Evolutionary Learning Laboratory (ELLab)—and globally—Global Evolutionary Learning Laboratory (GELL). A generic framework and processes for implementing and institutionalizing ELLabs are described, and how these become part of the GELL for managing complex issues is explained. Four case studies are used to demonstrate diverse examples of the application and implementation of the ELLab approach. Copyright © 2013 John Wiley & Sons, Ltd.

African countries have comparative advantages in the production and export of primary commodities; however, they face many sustainability challenges in the agricultural sector. Since the democratization of many African countries, notably Ghana, there have been a number of interventions costing billions of dollars to overcome the challenges facing the agricultural industry but with little success. The agricultural industry is a complex system. Casual loop and Bayesian belief network modelling were used to develop systems models to determine the components and interactions between the policy and the social, environmental and economic dimensions of the industry. Insights into potential system behaviors and leverage points for systemic interventions required for sustainable agricultural development were identified. The systems models will help governments to anticipate the long‐term consequences of their decisions and actions, as well as help to avoid any unintended consequences of policies and strategies such as ‘silo mentality’ and ‘organizational myopia’. Copyright © 2014 John Wiley & Sons, Ltd.

This paper discusses the application of systems thinking concepts and tools in establishing ‘Learning Laboratories’ for Sustainable Development. It first presents a brief description of the potential value of utilising biosphere reserves for implementing the learning laboratories concept, followed by how systemic processes have been developed to establish a Learning Laboratory through a comprehensive pilot project in the Cat Ba Biosphere Reserve (CBBR) in Vietnam. In this project Causal Loop Modelling were used to determine the components and interactions between the policy, social, environmental and economic dimensions of the CBBR. The resultant model has been used to identify key leverage points and where systemic interventions will be most effective (potential research projects). The model also serves as a platform for learning and research collaboration through alliances and cross‐sectoral teams to address the various domains, leverage points, and interventions identified. The role and importance of systems thinking methodology and applications to deal with ever‐increasing complexities of sustainable development are discussed. The modelling approach and various processes that were used in this pilot project could be extended to other biosphere reserves in Vietnam and globally, in that way creating a worldwide network of ‘Learning Laboratories for Sustainable Development’. Copyright © 2010 John Wiley & Sons, Ltd.

The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.

Quantum optical coherence tomography (QOCT) makes use of an entangled-photon light source to carry out dispersion-immune axial optical sectioning. We present the first experimental QOCT images of a biological sample: an onion-skin tissue coated with gold nanoparticles. 3D images are presented in the form of 2D sections of different orientations.Comment: 16 Pages, 6 Figure

The African agricultural system is characterized by complex challenges such as famine, food insecurity, poor soil and quality standards, political instability, and inappropriate agricultural practices. The behavior over time graph revealed that as the African population increases, people explore new agricultural land that is in direct conflict with the conservation of forested areas, hence degrading the environment. These challenges in addition to the depletion of natural resources have worsened the plights of African farmers. The increasingly complex nature of the agricultural industry in Africa has necessitated an urgent need for the use of a systemic rather than a traditional approach in solving problems in agriculture. System archetypes were applied as diagnostic tools to anticipate potential problems and problem symptoms. Eleven system archetypes serve as the means for gaining insights into the underlying system structures from which the archetypal behaviors emerge. As part of a suite of tools, they are extremely valuable in developing broad understandings about agriculture and their environments and contribute to more effectively understanding the cause of a fix 'now' that gives rise to a much bigger problem to fix 'later'. The study revealed that opportunity and risk matrix as a policy tool does not solve the problems, but systemic approach would lead to the provision of the right management strategies. This approach facilitates adaptation and mitigation strategies towards the sustainable development for the agriculture in Africa.