The English National Health Service (NHS) is a public sector organisation with a longstanding objective to deliver high quality healthcare that is free at the point of use. In order to achieve this, the NHS has endured an evocative and controversial theme of reform across many decades. Despite such high levels of reform, the recent Operating Efficiency Framework declared that the NHS is about to enter its toughest ever financial climate. This paper will illustrate the complexities and tensions of implementing service improvement in the NHS in a climate of persistent policy reform, reduced budgets and tough regulation. The paper reports findings of three case studies of hospital trusts in the UK in relation to the implementation of Lean improvement methodologies, highlighting key complexities of a hospital context and the corresponding tension with service improvement activity.

The tension applied to the girth is usually based on an individual's experience rather than by scientific measurement or procedure. The equine thorax is a dynamic structure, and therefore the actual readings of girth tensions at rest and during exercise (actual tension) are likely to vary from the tension to which the girth was intended to be tightened at rest while standing (intended tension). This study was undertaken to determine the variability of girth tensions at rest and during exercise. A total of 19 Hanoverian horses were lunged on a 20 m circle in walk, trot and canter on both reins. In a randomized design, each horse was exposed to intended tensions 6, 10, 14 and 18 kg (saddle and girth at appropriate intended tensions). Girth tension was measured and recorded continuously using an in-line load cell. Intended girth tensions were not significantly different with mean actual girth tensions while standing. Actual girth tensions increased significantly (P < 0.001) between walk, trot and canter at all tensions except rest to trot at tension 6 kg, where the significance level was P < 0.01. Actual girth tension was significantly higher (P < 0.001) on the left rein at tension 14 kg in walk and trot, and at tensions 6, 10 and 14 kg during canter, and there was an overall trend for higher actual girth tensions on the left rein for the other tensions. As the thorax is a dynamic structure, girth tension variation could be due to multiple factors such as respiration, breath holding, muscular contraction, back flexion and extension, speed, gait and vertical acceleration of the saddle. Girth tension is a relatively new area of research, and as there are many opportunities for further research, a better understanding of the impact the girth has on the horse could help to improve performance and welfare.

The concept of tension is introduced and applied to a robot's trajectories, then new joint interpolation strategies are implemented. A joint interpolation strategy is proposed which uses joint variable reference data calculated from inverse kinematics, along with a polynomial equation or quintic equation as the parametric equation of the joint variables. This method can use any polynomial equation which has the C2 continuity property and has intermediate points which pass through the reference data. For the time variable, first order linear equations can be used where the number of equations is n – 1, n being the number of points in the reference data. Due to large reductions in computational burden resulting from this form, this method may be suited for real time applications.

What is the effect of punching holes at random in an infinite tensed membrane? When will the membrane still support tension? This problem was introduced by Connelly in connection with applications of rigidity theory to natural sciences. The answer clearly depends on the shapes and the distribution of the holes. We briefly outline a mathematical theory of tension based on graph rigidity theory and introduce a probabilistic model for this problem. We show that if the centers of the holes are distributed in ℝ2 according to a Poisson law with density λ > 0, and the shapes are i.i.d. and independent of the locations of their centers, the tension is lost on all of ℝ2 for any λ. After introducing a certain step-by-step dynamic for the loss of tension, we establish the existence of a nonrandom N = N(λ) such that N steps are almost surely enough for the loss of tension. Also, we prove that N(λ) > 2 almost surely for sufficiently small λ. The processes described in the paper are related to bootstrap and rigidity percolation.

To use end-tidal PCO2 as a non-invasive estimate of arterial PCO2, one adds a nominal value, representing the arterial–end-tidal PCO2 difference. How much does one add? We hypothesized that, halving the ventilator rate and simultaneously doubling tidal volume, the immediate change in end-tidal PCO2 would be proportional to the original arterial-end-tidal PCO2 difference. We ventilated 31 patients at 20 breaths per minute (bpm), sampled arterial blood, and changed the rate to 10 bpm. The change in end-tidal PCO2 was, as hypothesized, positively correlated to the original arterial–end-tidal difference at 20 bpm (r = 0.64). End-tidal PCO2 increased in 23 patients. Thus, in theory, this method could offer some improvement in the estimate of arterial PCO2 from end-tidal. However, because of the considerable spread of values, a separate study is needed for verification

The effects on mood of reducing dietary fat while keeping the energy constant were examined in ten male and ten female healthy volunteers aged between 20 and 37 years. Each volunteer consumed a diet containing 41% energy as fat for 1 month. For the second month half of the subjects changed to a low-fat diet (25% energy from fat) and the remainder continued to eat the diet containing 41% energy from fat. Changes in mood and blood lipid concentrations were assessed before, during and at the end of the study. Profile of mood states (POMS) ratings of anger–hostility significantly increased in the intervention group after 1 month on the low-fat diet, while during the same period there was a slight decline in anger–hostility in the control subjects (group F 6.72; df 1,14; P = 0.021). Tension–anxiety ratings declined in the control group consuming the higher fat diet but did not change in the group consuming the low-fat diet (group F 6.34; df 1,14; P = 0.025). There was a decline in fasting concentrations of HDL-cholesterol after the low-fat diet and a small increase in subjects consuming the medium-fat diet (group F 4.96; df 1,12; P = 0.046), but no significant changes in concentrations of total serum cholesterol, LDL-cholesterol or triacylglycerol were observed. The results suggest that a change in dietary fat content from 41 to 25% energy may have adverse effects on mood. The alterations in mood appear to be unrelated to changes in fasting plasma cholesterol concentrations.