Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study

Objective : To explore attitudes and experiences of doctors and nurses regarding cardiopulmonary resuscitation for patients with end stage illness in an acute hospital. Design : Qualitative study; thematic analysis of two audio-taped focus groups and four semi-structured interviews. Setting : Acute district hospital, Northern Ireland. Participants : Seven nurses and nine doctors; varying nationality, gender and years of professional experience; involved in cardiopulmonary resuscitation decision-making. Results : Participants reported different interpretations of resuscitation policy and of what do not attempt to resuscitate (DNAR) decisions meant in relation to practical care for patients. This confusion in translating policy into practice contributed to communication difficulties in initiating, documenting and implementing cardiopulmonary resuscitation decisions. Participants were aware of how clinical conditions could change and reported uncertainty in determining end stage illness; they expressed fears of potential consequences of DNAR decisions for patients' care. The more disease-centred approach of doctors to patients' management, compared to nurses' more patient-centred approach, contributed to inter-professional conflict within teams. Doctors identified training needs in applying resuscitation policy and ethical principles in `real life' and nurses identified a need for ongoing professional support, which was perceived as being less available to junior doctors. Personal relationships between staff and patients, cultural reluctance to address sensitive issues and local community expectations of relatives being involved in decisions added to policy implementation difficulties. Conclusions : The findings indicate a need for ongoing staff support and training in applying resuscitation policy to decisions for patients with end stage illness in an acute hospital. They support suggestions that reviews of local resuscitation policy and of national guidelines should be undertaken with openness and honesty regarding the goals, opportunities and difficulties involved in trying to deliver good end of life care in local settings. Palliative Medicine 2007; 21 : 305—312 Key Words: do not attempt resuscitation (DNAR) • end stage illness • inter-professional • policy • resuscitation decisions

Designs and designers of medieval ‘new towns’ in Wales

Medieval 'new towns' seem to echo Roman towns in having a grid of streets associated with a fortress, and have often been credited with a standard plan applied by the hand of authority. Here the authors analyse the new towns founded by Edward I in Wales and find some highly significant variations. Rediscovering the original layouts by high precision survey and GIS mapping, they show that some towns, founded at the same time and on similar topography, had quite different layouts, while others, founded at long intervals, had plans that were almost identical. Documentation hints at the explanation: it was the architects, masons and ditch-diggers, not the king and aristocracy, who established and developed these blueprints of urban life.

Phenotypic diversity amongst strains of Pleurotus sajor-caju: implications for cultivation in and environments

In arid regions, biodiversity and biomass are limited by water availability, and this problem has been compounded by desertification associated with global climate change. The saprotrophic macrofungi that are indigenous to hot subtropical and tropical regions, such as Pleurotus spp., can play key roles in water sequestration, nutrient cycling, human nutrition, and bioremediation of waste materials. We studied 15 strains of Pleurotus sajor-caju, a widespread and phenotypically-diverse species, to establish variability in growth response and primordium development over a range of stress parameters: osmotic potential (-0.5 to -5 MPa), temperature (5-40 degrees C) and pH (2-12). The initiation of primordia precedes basidiome production and therefore represents a key stage in bioremediation strategies and fungi-driven nutrient cycles. Primordia were produced at low pH (4-6), at suboptimal growth temperatures (<or =25 degrees C), and under moderate water stress (-0.5 to -3.5 MPa). Although the growth windows for different strains were similar, their maximum growth rates and the optimum conditions for growth varied. We discuss the phenotypic diversity of Pleurotus strains and discuss their potential for cultivation, bioremediation and ecological regeneration.

Absolute Calibration of Atomic Density Measurements by Laser-Induced Fluorescence Spectroscopy with Two-Photon Excitation (TALIF)

The two-photon resonances of atomic hydrogen (? = 2 × 205.1 nm), atomic nitrogen (? = 2 × 206.6 nm) and atomic oxygen (? = 2 × 225.6 nm) are investigated together with two selected transitions in krypton (? = 2×204.2 nm) and xenon (? = 2×225.5 nm). The natural lifetimes of the excited states, quenching coefficients for the most important collisions partners, and the relevant ratios of the two-photon excitation cross sections are measured. These data can be applied to provide a calibration for two-photon laser-induced fluorescence measurements based on comparisons with spectrally neighbouring noble gas resonances.

Application to argon ions of a new technique to measure the two-electron contribution to the ground state energy of helium-like ions

We have measured the two-electron contribution of the ground state energy of helium-like argon ions using an electron beam ion trap (EBIT). A two-dimensional map was measured showing the intensity of x-rays from the trap passing through a krypton-filled absorption cell. The independent axes of this map were electron beam energy and x-ray energy. From this map, we deduced the two-electron contribution of the ground state of helium-like argon. This experimentally determined Value (312.4 +/- 9.5 eV) was found to be in good agreement with our calculated values (about 303.35 eV) and previous calculations of the same quantity. Based on these measurements, we have shown that a ten-day absorption spectroscopy run with a super-EBIT should be sufficient to provide a new benchmark value for the two-electron contribution to the ground state of helium-like krypton. Such a measurement would then constitute a test of quantum electrodynamics to second order.

Testing the role of expansion in the prospective control of locomotion

The constant bearing angle (CBA) strategy is a prospective strategy that permits the interception of moving objects. The purpose of the present study is to test this strategy. Participants were asked to walk through a virtual environment and to change, if necessary, their walking speed so as to intercept approaching targets. The targets followed either a rectilinear or a curvilinear trajectory and target size was manipulated both within trials (target size was gradually changed during the trial in order to bias expansion) and between trials (targets of different sizes were used). The curvature manipulation had a large effect on the kinematics of walking, which is in agreement with the CBA strategy. The target size manipulations also affected the kinematics of walking. Although these effects of target size are not predicted by the CBA strategy, quantitative comparisons of observed kinematics and the kinematics predicted by the CBA strategy showed good fits. Furthermore, predictions based on the CBA strategy were deemed superior to predictions based on a required velocity (V-REQ) model. The role of target size and expansion in the prospective control of walking is discussed.