BC Guidelines are clinical practice guidelines and protocols that provide recommendations to B.C.practitioners on delivering high quality, appropriate care to patients with specific clinical conditions or diseases.These “Made in BC” clinical practice guidelines are developed by the Guidelines and Protocol Advisory Committee (GPAC), an advisory committee to the Medical Services Commission.The primary audience for BC Guidelines is BC physicians, nurse practitioners, and medical students.However, other audiences such as health educators, health authorities, allied health organizations, pharmacists, and nurses may also find them to be a useful resource.There are several ways to find the guidelines you are looking for.BC health care professionals and relevant stakeholders are invited to participate as external reviewers for the draft version of the revised BC Guideline Frailty in Older Adults: Early Identification and Management.This guideline addresses the early identification and management of older adults with frailty or at risk of frailty.

The guideline facilitates individualized assessment for frailty and provides a framework and tools to promote patient-centred strategies to manage frailty and prevent further functional decline.The draft guideline and external review questionnaire can be accessed on the External Review of Guidelines page.vaporizer per nachnahme bestellenPlease return the questionnaire and any other guideline comments by July 15th, 2017.kleinste vaporizerWe are pleased to announce the release of our new BC Guidelines Mobile App for Android and Apple devices.vapir no2 review ukBC Guidelines has partnered with Dr. Matthew Toom, an experienced computer programmer and UBC Family Medicine Resident, to create the new BC Guidelines Mobile App.vaporizer tlumacz

The free and redesigned mobile app works even without Internet connectivity so busy practitioners can instantly access BC Guidelines on any Apple or Android mobile device no matter where they are working.We are pleased to announce the release of the revised guideline Chronic Obstructive Pulmonary Disease (COPD): Diagnosis and Management (2017).vaperite woodstock gaThe Flare-Up Action Plan, Patient Care Flow Sheet and the Resource Guide for Patients have also undergone significant revisions.vd laguna vaporizerIn collaboration with the Family Practice Oncology Network, we are also pleased to launch the revised version of the guideline Palliative Care for the Patient with Incurable Cancer or Advanced Disease: Parts 1-3.e-zigarette wegwerf

We are pleased to provide links to two new partner guidelines on our Partner Guidelines page: The British Columbia Centre on Substance Use and the Ministry of Health have released A Guideline for the Clinical Management of Opioid Use Disorder.volcano vaporizer dormThe guideline provides evidence-based recommendations to BC physicians and nurse practitioners for the clinical management of opioid use disorder.pediatric warm steam vaporizer reviewsUntil June 5, 2017, this guideline is provided for educational purposes.For clinicians wishing to prescribe buprenorphine/naloxone and/or methadone please refer to the College of Physicians and Surgeons of BC’s Methadone and Buprenorphine: Clinical Practice Guideline for Opioid Use Disorder.After June 5, 2017, this guideline will become the guideline for the province of British Columbia.

For more information on the BC Centre on Substance Use, check out the website at: www.bccsu.ca Want to learn more about the Guidelines and Protocols Advisory Committee and the BC Guidelines development process.Check out our recently updated GPAC Handbook (2017).BC Guidelines is pleased to introduce a new External Review of Guidelines page to our website.This new page allows peer reviewers to download draft guidelines and submit questionnaire feedback directly from our website.We are also happy to provide a new online questionnaire that can be submitted through your web browser.Participating as an external reviewer has never been easier!Update on Mainpro+® Credits for Family Physicians ​ With the launch of the College of Family Physicians of Canada's new Mainpro+ system, there are now more opportunities to earn credit for continuing medical education / continuing professional development through using and participating in the development of BC Guidelines.For more details, see Continuing Professional Development (CPD) Credits.

The BioGears Engine is a fully customizable collection of physiologic systems.It includes models for anatomy-based biological systems and medical equipment.We developed an advanced engine through a top-down approach, with the ability to easily increase fidelity and manipulate system models.It can be integrated with other software and hardware platforms and devices.Computational modeling and analysis of the human physiology is extremely useful for various applications.There are many approaches for simulating the body's response to various stimuli.Some existing software uses state-based calculation that can only provide a limited amount of data, by way of preprogrammed responses.Complex interactive effects are difficult with this approach because it uses additive or purely multiplicative responses.Some existing high fidelity models use more complex computational fluid dynamics (CFD).One major drawback of this approach is the significant computation resources required.Cellular, molecular, and genetic models are difficult for whole body physiology.

Using this low-level individual cell and receptor methodology often does not provide the level of data a clinician requires for informed decision-making.Physiologically-based pharmacokinetic (PBPK) modeling focuses only on drug interactions, and is generally designed to deal with specific pathophysiology.BioGears is designed to be a deterministic multiscale modeling application that can be integrated with all other types of physiologic software.Models at any anatomical level can be implemented within the existing infrastructure.The BioGears Physiology Engine is the combination of lumped parameter mathematical models that, together, simulate whole body physiology.Each system contributes to the maintenance of homeostasis.The systems are designed to be modular and each has the ability to work in isolation.They are all reliant on the Common Data Model (CDM) connections and leverage several generic solvers and transport algorithms.The system as a whole needs to be easy to use and modify, modular, and extensible to virtually any fidelities.

Envisioned end user groups include game developers, mannequin builders, educators, researchers, sensor system developers, and trainers.Several of these users implement BioGears in a way that requires faster than real time processing without access to computational resources that exceed a personal computer.There are two different types of systems defined in BioGears - physiology-based and equipment-based.Below is a list of the current BioGears Systems with links to their methodology reports: The BioGears suite of also comes with verified tools for extensibility and elimination of potential error sources: BioGears uses differential equations with control-based feedback mechanisms to dynamically respond to parameter changes.It is designed and tuned around a stable resting physiologic state, with the ability to model pathophysiology through insults and intervention action calls.Many of the system circuit elements are modified based on substance concentrations and external action (i.e., insult and intervention) modifiers.

The Anesthesia Machine is directly connected to the Respiratory System through an inter-circuit connection.The current implementation creates a combined circuit for analysis; therefore, the combined circuit is calculated as one large circuit with a single fluid.Substances can be administered by inhalation directly to the Respiratory System or through a connected Anesthesia Machine through the vaporizer component.The Respiratory System transfers substances back and forth to the Cardiovascular System using Alveoli Transfer.The only direct connections between the two systems are simple modifiers to the heart rate and a cardiovascular resistance value during the tension pneumothorax insult.The Cardiovascular System is also tied to the Endocrine System and ECG.Substances can enter directly into the Cardiovascular System through bolus injections or the administration of an IV.Interactions between systems, such as alveoli transfer and diffusion between the extravascular and vascular space are modeled in the System Interactions methodology.

This ensures each system is responsible for only its own behavior while capturing the behavior that occurs between systems.The entire BioGears Engine works off of a transient analysis time step of 0.02 s (50 Hz).All system states are recalculated every time step.The differential equations that determine changes are linearized to approximate system variables, but the small time step provides a very accurate solution.To provide the BioGears systems with sufficient information, the CDM maintains three time steps for elements and parameters.These times are: The BioGears Engine stabilizes with a multi-step process.The engine must be initialized and reach a stable state prior to modifying the patient condition.This is completed by using a dynamic stabilization protocol to execute the engine until a specified set of criteria are met, then any patient chronic conditions are applied.These conditions modify patient parameters and model values to represent the new patient state.The engine must restabilize using the dynamic protocol to achieve a stable state.

This process is outlined in Figure 3.The BioGears Engine must perform numerous cycles of the calculations to reach a point of convergence for the output values, such as heart rate, tidal volume, systolic pressure, etc. When the engine has reached this convergence point, it is considered to be stable.During the stabilization period, the majority of feedback in the engine is inactive.An exception is the Tune Circuit methodology found in the Cardiovascular System.This modifies the cardiovascular circuit parameters to achieve the mean arterial pressure specified in each patient file.For more information on this function, see the Cardiovascular Methodology.No actions or conditions can be applied during the stabilization time.Because the patient parameters may vary in the patient file, the time required for the solution to converge may vary.By using a dynamic stabilization algorithm, the engine will be fully initialized and the solution will have converged at the conclusion of the stabilization period for any patient.

This stabilization algorithm also prevents an unnecessarily long time for a solution that may be required in the time that were statically specified for all scenarios and patients.To determine the convergence time, BioGears uses a dynamic stabilization algorithm.The stable outputs were analyzed to determine the variation present in each individual output over time.This percent variation was identified for the key outputs in each system.The percent difference between the current time step and the next time step is calculated for output.The percent difference calculated must be less than the identified convergence criteria for the output.This must be maintained for the convergence time.This time is specified at approximately seven respiratory cycles (at 16 breath/min -> ~25 seconds).The respiratory cycle was chosen because it is the has the longest period.Convergence should occur over the longest periodic cycle in the engine to ensure variation is not at a low frequency.Currently, the convergence criteria and time are specified in the CDM.

In the future, the algorithm implementation will remain in the CDM, but the convergence criteria (including time) will be moved to an XML file, similar to patient and substance files, for easy manipulation by the user (see PatientData and SubstanceData for more information).Patient conditions that are persistent or recurring are chronic conditions.The human body responds differently to chronic conditions than it does to acute conditions.While the body is in an altered state, which may be weaker, the body's response to the condition becomes damped over time.In short, the body reaches a new level of homeostasis that may not be considered healthy, but does not have the same continual feedback mechanisms operating that occur when acute conditions cause a deviation from homeostasis.To implement these conditions in the BioGears Engine, a two step stabilization process was implemented.As discussed above, the dynamic stabilization criteria was required to ensure all outputs converged prior to performing any actions (insults or intervention) in a given patient.

This is true for conditions, as well.However, after a condition is applied the solution must again converge to represent the body's new homeostatic state, that while different from the healthy homeostasis, is still a stable patient state.The same convergence methodology is used for this second convergence.However, a set of convergence criteria for the outputs must be specified for each condition.This criteria reflects the new variation in outputs over time that may exist during the condition.Examples of these conditions are anemia, pericardial effusion, and arrhythmias.More information on these can be found in the Cardiovascular Methodology.There is no limit on the number of conditions that can be applied at one time.However, testing an validation of outputs when combining conditions has not been performed.In the future, when a user applies multiple conditions, a merging algorithm will be used to combine the convergence criteria.This will specify the least stringent requirements as the final convergence criteria for the combined conditions.

Preprocess is called for each system individually and is generally used to modify the circuit elements based on feedback mechanisms and actions.This is also where any system drivers are determined for the upcoming time step, such as the heart contractility or ventilatory drivers.At the start of every Preprocess step, the next time step circuit element values are initialized to the stored baseline values.Generally speaking, elements are updated by getting the next value and using multipliers before setting it again.This allows for the "stacking" of modifiers and the ability to alter the same element based on any number of mechanisms.Process generally determines the entire next time step circuit state.The generic circuit solver is leveraged to automatically calculate unknown circuit variables.Substances are also transported throughout and between systems with general equations - usually based on path flows or absorption and diffusion coefficients and renal and hepatic clearance factors.Postprocess advances time by moving the next time step values to the current time step values.

The next values are then set to the baseline values in preparation for the upcoming Preprocess call.Externally available data is defined within the BioGears Engine in three major ways: The BioGears modeling approach takes the human body and conceptually divides it into various fluid compartments that represents a real division in terms of how portions of the body's water, solutes, and suspended elements are segregated [212].Compartments can be further discretized into smaller sub-compartments with a hierarchical relationship as you drill into various systems.In BioGears, compartments can be defined to encapsulate circuit nodes that allow easy organization, access, and synchronization of all system parts.Compartments are implemented in BioGears as conceptual physical divisions of the body.Anatomical data can be pulled from each compartment through optional node and path mapping.Figure 5 shows an example of how compartments can be defined in the Cardiovascular System.Users can customize scenarios for BioGears by modifying a variety of file types.

For example, patients, substances, compound substances, and environments can all be modified via the text files provided.This allows users to customize scenarios by tailoring patients and environmental conditions to the specific circumstances of the user.As an example of this flexibility, Biogears provides a variety of patient files.These parameters in these patient files can be specified to represent different physiologic states for a patient.See Patient Methodology for details.For more details on interfacing with the BioGears Engine, see the engine documentation.BioGears uses a low fidelity clinical approach and is not necessarily for high fidelity predictive purposes.It is also assumed to be contained within the CDM.See the individual system methodology documents for more specifics.Several scenarios have been developed and validated to ensure proper interaction not only within, but also between the BioGears physiologic systems.These patients and scenarios were developed as part of the HumanSim: Sedation and Airway project funded by TATRC, contract number W81XWH-11-C-0045.

The combined effects scenarios were validated qualitatively from available literature and from the opinions of subject matter experts (SME).More detail on patient parameters can be found in the Patient Methodology documentation.A summary of the validation is shown in Table 6.Green indicates good agreement with validation data, yellow indicates agreement with a general trend with some minor disagreement, and red indicates a disagreement with the validation data.The number indicates the number of output parameters for each category of validation success or failure.Although the tidal volume is not shown for these scenarios, it should be noted that mild to moderate discrepancies between the tidal volume set on the anesthesia machine and that observed for the patient were observed in BioGears.This is also a common observation in clinical practice, because the anesthesia machine may have to overcome the patient condition and airway resistance to provide sufficient tidal volume [92] .The Cynthia scenario begins with the administration of midazolam at 50 seconds with a full severity airway obstruction occurring at 110 seconds.

At 260 seconds a ventilator mask is placed on Cynthia.Twenty seconds later, the airway obstruction is removed and 30 milligrams of ketamine are administered via a bolus injection.Rocuronium is administered one minute later, and Cynthia is intubated 40 seconds after that.The Cynthia scenario shows excellent agreement with the qualitative and expected SME trends.However, there is a minor inconsistency in the systolic and diastolic pressure decrease following the administration of midazolam.The SME validation predicted a 15-25% decrease in systolic/diastolic pressures following the administration; however, the observed decrease was approximately 10%.This decrease was considered acceptable since other references predicted varying degrees of pressure decrease.Segment Notes Action Occurrence Time (s) Sample Scenario Time (s) Heart Rate (beats/min) Systolic Pressure (mmHg) Diastolic Pressure (mmHg) Respiration Rate (mmHg) Oxygen Saturation (mmHg) Administer Midazolam - 3 mg Drug Onset in 1-3 min 30 90 Mild Increase [92]; 5-10% Decrease [188] Moderate Decrease [92]; 15-25% Decrease [188] Moderate Decrease [92]; 15-25% Decrease [188] Moderate Decrease [92]; Marked Decrease to 0 [188] Airway Obstruction of Severity 1.0 Represents an aspiration 90 240 If O2 decreases, Increase [188] If O2 decreases, Increase [188] If O2 decreases, Increase [188] Apply Mask and Turn on Ventilator 240 250 If above increased, Decrease [188] If above increased, Decrease [188] If above increased, Decrease [188] Administer Ketamine - 30 mg/ End of Airway Obstruction Drug Onset < 2 minutes 250 310 Moderate Increase [92]; 15-25% Increase [188] Moderate Increase [92]; 15-25% Increase [188] Moderate Increase [92]; 15-25% Increase [188] Administer Rocuronium - 62mg Drug Onset in 60-90 seconds 310 400 Successful Intubation 400 900 A ventilator mask is applied to Gus at 50 seconds, and succinylcholine is injected one minute later.

After an additional minute, an unsuccessful intubation occurs, leading to the endotracheal tube residing within the esophagus.After two minutes the tube is removed and correctly set in the trachea.The produced results show excellent agreement with the expected validation trends.Segment Notes Action Occurrence Time (s) Sample Scenario Time (s) Heart Rate (beats/min) Systolic Pressure (mmHg) Diastolic Pressure (mmHg) Respiration Rate (mmHg) Oxygen Saturation (mmHg) Mask Ventilate with Oxygen 30 90 Slight decrease to due anesthesia machine resistance ; NC [188] Administer Succinycholine - 100mg Drug Onset < 1 minute 90 150 Mild Increase [92]; 5-10% Decrease [188] Mild Increase [92]; 5-10% Decrease [188] Mild Increase [92]; 5-10% Decrease [188] Goes to Zero [92]; Goes to Zero [188] Esophageal Intubation 150 270 If O2 decreases, Increase [188] If O2 decreases, Increase [188] If O2 decreases, Increase [188] May slowly decrease along O2 curve [188] Successful Intubation 270 770 If above increased, Decrease [188] If above increased, Decrease [188] If above increased, Decrease [188] Begins to increase to a normal level [188] At the beginning of the scenario, a ventilator mask is applied to Hassan.

He then receives bolus injections of ketamine and succinylcholine.This leads to an increase in the heart rate and arterial pressures due to the ketamine injection.The respiration rate begins to decrease as the patient begins to lose consciousness.After the succinylcholine injection, there is a decrease in the heart rate and arterial pressures.In addition, the respiration rate falls to zero due to the neuromuscular block.At 180 seconds, an endotracheal tube is set into the right bronchi, leading to only one lung being ventilated.This leads to a minor reduction in the oxygen saturation.Due to the reduced oxygen intake, the heart rate and arterial pressures begin to increase to compensate.The tube is reset into the trachea and the vital signs begin to return to normal.All of these trends follow the expected validation trends.Segment Notes Action Occurrence Time (s) Sample Scenario Time (s) Heart Rate (beats/min) Systolic Pressure (mmHg) Diastolic Pressure (mmHg) Respiration Rate (mmHg) Oxygen Saturation (mmHg) Mask Ventilate with Oxygen 30 90 Slight decrease to due anesthesia machine resistance ; NC [188] Administer Ketamine - 168 mg Drug Onset < 1 minute 90 130 Moderate Increase [92]; 15-25% Increase [188] Moderate Increase [92]; 15-25% Increase [188] Moderate Increase [92]; 15-25% Increase [188] Mild Decrease [92]; 25-50% Decrease [188] Administer Succinycholine - 115mg Drug Onset < 1 minute 130 160 Mild Increase [92]; 5-10% Decrease [188] Mild Increase [92]; 5-10% Decrease [188] Mild Increase [92]; 5-10% Decrease [188] Begins to drop according to preoxygenated O2 curve [188] Right Mainstem Intubation Intent is to simulate tube migration 160 250 NC, If undetected and O2 level drops significantly, Mild Increase [188] NC, If undetected and O2 level drops significantly, Mild Increase [188] NC, If undetected and O2 level drops significantly, Mild Increase [188] May slowly decrease along O2 curve [188] Correct tube placement Reset the intubation tube 250 450 NC, If above result in a Mild Increase, will return to normal [188] NC, If above result in a Mild Increase, will return to normal [188] NC, If above result in a Mild Increase, will return to normal [188] Begins to increase to a normal level >97% [188] The Joel scenario begins with a full severity airway obstruction at 50 seconds.

This leads to decreasing oxygen saturation and increasing heart rate and arterial pressures due to the sympathetic (endocrine) response.At 170 seconds, the obstruction is removed and the vital signs begin to return to normal.A ventilator mask is applied to Joel at 230 seconds, and he receives a 27 mg bolus injection of etomidate at 290 seconds.This leads to decreasing arterial pressure.At 310 seconds, a bolus injection of succinylcholine occurs before an endoctracheal tube is set 30 seconds later.The administration of succinylcholine leads to immediate decreases in heart rate, arterial pressures, and oxygen saturation.After the intubation occurs, the oxygen saturation begins to return to normal due to adequate ventilation.All of these results show strong agreement with the subject matter expert's expected trends.Segment Notes Action Occurrence Time (s) Sample Scenario Time (s) Heart Rate (beats/min) Systolic Pressure (mmHg) Diastolic Pressure (mmHg) Respiration Rate (mmHg) Oxygen Saturation (mmHg) Airway Obstruction of Severity 1.0 Represents an aspiration 30 150 NC until O2 drops then increase [188] NC until O2 drops then increase [188] NC until O2 drops then increase [188] Begins to drop according to O2 curve [188] End Airway Obstruction Represents suctioning 150 210 If above increased, Decrease [188] If above increased, Decrease [188] If above increased, Decrease [188] Return to resting physiology [188] Begins to increase to a normal level >97% [188] Ventilate w/ O2 tank O2 Source is set to Tank 1 210 270 Adminster Etomidate - 27 mg No Etomidate in drug directory, so we use Katamine instead; Drug Onset < 1 minute 270 290 Mild Decrease [92]; 5-10% Decrease [188] Mild Decrease [92]; 5-10% Decrease [188] Administer Succinycholine - 115 mg Drug Onset < 1 minute 290 320 Mild Increase [92]; 5-10% Decrease [188] Mild Increase [92]; 5-10% Decrease [188] Mild Increase [92]; 5-10% Decrease [188] Begins to drop according to preoxygenated O2 curve [188] Intubate 320 520 Begins to increase to a normal level >97% [198] Nathan receives a bolus injection of fentanyl at a dose of 150 micrograms at a scenario time of 50 seconds, and a ventilator mask is placed at 140 seconds.

Due to the administration of fentanyl, there is an observed decrease in the heart rate, arterial pressures and respiration rate.There is very good agreement with the expected trends during this time period.The The respiration rate is expected to decrease by 15-25%; however, the observed increase is approximately 10%.This was acceptable due to the trend expressed in other validation resources.The oxygen wall connection loses pressure at 230 seconds.This leads to decreasing oxygen saturation and increasing heart rate and arterial pressures due to the epinephrine response.Following this, the connection is reset to a secondary oxygen tank, and the vital signs return to normal.This behavior matches the validation trends.Segment Notes Action Occurrence Time (s) Sample Scenario Time (s) Heart Rate (beats/min) Systolic Pressure (mmHg) Diastolic Pressure (mmHg) Respiration Rate (mmHg) Oxygen Saturation (mmHg) Administer Fentanyl - 150ug Drug Onset < 2 minutes 30 120 Stable [92]; 5-10% Decrease [188] Stable [92]; 5-10% Decrease [188] Stable [92]; 5-10% Decrease [188] Decrease [92]; 15-25% Decrease [188] Apply Mask and Turn on Ventilator 120 210 Slight decrease to due anesthesia machine resistance NC [188] O2 Wall Pressure Loss 210 340 If O2 decreases, Increase [188] If O2 decreases, Increase [188] If O2 decreases, Increase [188] If undetected long enough, Decrease [188] Connect O2 Bottle 1 as O2 Source 340 840 If above increased, Decrease [188] If above increased, Decrease [188] If above increased, Decrease [188] If above decreased, Increase [188] Four scenarios were created to showcase the ability of the BioGears open-source physiology engine to simulate complex and combinatory insults and interventions.

The BioGears Showcase Scenarios demonstrate the ability of the engine to fill the physiology simulation needs of the medical simulation community.A team of soldiers is conducting a patrol when an explosive device detonates, injuring one of the soldiers.The squad medic applies direct pressure to a hemorrhaging wound, and, suspecting a tension pneumothorax, performs a needle decompression.Direct pressure is not controlling the bleeding, so a tourniquet is applied.Morphine and IV fluids are administered.See Combat Multitrauma Validation Matrix for complete details on validation.A 40 year old female with a history of asthma is having an asthma attack.She arrives at the hospital ten minutes after the beginning of the attack.A doctor administers albuterol and her condition improves.See Asthma Attack Validation Matrix for complete details on validation.A 25 year old male is hiking towards a rock formation to begin a recreational free climb.During the hike, he is working at ~10% of his maximum capacity.

The man arrives at a rock formation and begins climbing at an intensity of ~1/2 of his maximum capacity.At the top of the rock formation, the man becomes dizzy and passes out.An off-duty medic takes action to treat a heat injury.See Heat Stroke Validation Matrix for complete details on validation.A 17 year old female leaves her Alaskan home in the mid-winter to retrieve a newspaper.The door closes as she exits the house.She is stuck outside for 45 minutes where it is -10oC.When the woman's housemates realize that she is outside, they bring her back in and sit her next to a fire.See Environment Exposure Validation Matrix for complete details on validation.The BioGears Engine has successfully leveraged the CDM to model and simulate whole body physiology.The interaction of the existing system models was validated by looking at the combined effects of multiple actions on a variety of patients.Virtually everything within the engine is modular and extensible.Fidelity can be changed at any level within the system.

BioGears is a fully standalone simulator, but can also implement or interface with external software.We will continue to improve system modularity.See the system specific methodology documents for more information: Anesthesia Machine Future Work BloodChemistry Future Work Cardiovascular Future Work Drugs Future Work Endocrine Future Work Energy Future Work Environment Future Work Gastrointestinal Future Work Inhaler Future Work Nervous Future Work Renal Future Work Respiratory Future Work Tissue Future Work An area of potential future advancements for the BioGears Engine includes the integration of differing time step and un-fixed time step models.This could be achieved through simple interpolation and down-sampling, where applicable.Other advanced system dynamics, adaptive step sizes, and mixed fidelity techniques could also be investigated.Investigations into the effects of biological variability and parameter (inputs and outputs) error bound and confidence intervals could be applied throughout.