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

Belief, Knowledge and Expertise. The emergence of the lay expert in medical sociology

The paper has three main aims. First, to trace – through the pages of the Journal – the changing ways in which lay understandings of health and illness have been represented during the 1979-2002 period. Second, to say something about the limits of lay knowledge (and particularly lay expertise) in matters of health and medicine. Third, to call for a re-assessment of what lay people can offer to a democratised and customer sensitive system of health care and to attempt to draw a boundary around the domain of expertise. In following through on those aims, the author calls upon data derived from three current projects. These latter concern the diagnosis of Alzheimer’s disease in people with Down’s syndrome; the development of an outcome measure for people who have suffered a traumatic brain injury; and a study of why older people might reject annual influenza vaccinations. Key words: Lay health beliefs, lay expertise, Alzheimer’s, Traumatic Brain Injury, Vaccinations

Deep sampling and testing in soft stratified clay

A 37-m thick layer of stratified clay encountered during a site investigation at Swann's Bridge, near the sea-coast at Limavady, Northern Ireland, is one of the deepest and thickest layers of this type of material recorded in Ireland. A study of the relevant literature and stratigraphic evidence obtained from the site investigation showed that despite being close to the current shoreline, the clay was deposited in a fresh-water glacial lake formed approximately 13 000 BP. The 37-m layer of clay can be divided into two separate zones. The lower zone was deposited as a series of laminated layers of sand, silt, and clay, whereas the upper zone was deposited as a largely homogeneous mixture. A comprehensive series of tests was carried out on carefully selected samples from the full thickness of the deposit. The results obtained from these tests were complex and confusing, particularly the results of tests done on samples from the lower zone. The results of one-dimensional compression tests, unconsolidated undrained triaxial tests, and consolidated undrained triaxial compression tests showed that despite careful sampling, all of the specimens from the lower zone exhibited behaviour similar to that of reconstituted clays. It was immediately clear that the results needed explanation. This paper studies possible causes of the results from tests carried out on the lower Limavady clay. It suggests a possible mechanism based on anisotropic elasticity, yielding, and destructuring that provides an understanding of the observed behaviour.Key words: clay, laminations, disturbance, yielding, destructuring, reconstituted.

Exploring eye movement analysis as a measure of selective visual attention in brain injured individuals

Primary Objective: To investigate the utility of using a new method of assessment for deficits in selective visual attention (SVA). Methods and Procedures: An independent groups design compared six participants with brain injuries with six participants from a non-brain injured control group. The Sensomotoric Instruments Eye Movement system with remote eye-tracking device (eye camera), and 2 sets of eight stimuli were employed to determine if the camera would be a sensitive discriminator of SVA in these groups. Main Outcomes and Results: The attention profile displayed by the brain injured group showed that they were slower, made more errors, were less accurate, and more indecisive than the control group. Conclusions: The utility of eye movement analysis as an assessment method was established, with implications for rehabilitation requiring further development. Key words: selective visual attention, eye movement analysis, brain injury

The influence of aetiology and blame on prejudice towards survivors of brain injury.

The purpose of the present work was to investigate if a hierarchy of aetiology exists which would influence attitudes towards survivors of brain injury. An independent groups design utilised four independent variables; aetiology (measured at five levels: ‘Road Traffic Accident’ (RTA), ‘Alcohol’, ‘Drug Use’, ‘Aneurism’ and ‘Recreation’), blame (blame and no-blame), group (psychology students and members of the public) and gender to explore attitudes towards survivors of brain injury. The dependent variables were measured using the Prejudicial Evaluation Scale (PES) and Social Interaction Scale (SIS). Three hundred and twenty-five participants (173 students and 152 members of the public) were randomly allocated to one of ten possible conditions. Among individuals who contributed to receiving their injury greater prejudice was displayed towards those in the ‘Drugs’ condition followed by ‘Recreation’, ‘RTA’, ‘Alcohol’ and ‘Aneurism’. Findings suggest that a hierarchy of aetiology exists, which results in prejudicial attitudes, and is influenced by issues of blame. Key words: prejudice, blame, brain injury

Energy levels, radiative rates, and electron impact excitation rates for transitions in OVII

Aims.
In this paper we report calculations for energy levels, radiative rates, and electron impact excitation rates for transitions in O vii.
Methods.
The grasp (general-purpose relativistic atomic structure package) is adopted for calculating energy levels and radiative
rates. For determining the collision strengths and subsequently the excitation rates, the Dirac atomic R-matrix code (darc) and the
flexible atomic code (fac) are used.
Results.
Oscillator strengths, radiative rates, and line strengths are reported for all E1, E2, M1, and M2 transitions among the lowest
49 levels of O vii. Collision strengths have been averaged over a Maxwellian velocity distribution, and the resulting effective collision
strengths are reported over a wide temperature range below 2 × 106 K. Additionally, lifetimes are also listed for all levels.
Key words.

Targeting death receptors in bladder, prostate and renal cancer

PURPOSE: We describe key components of normal and aberrant death receptor pathways, the association of these abnormalities with tumorigenesis in bladder, prostate and renal cancer, and their potential application in novel therapeutic strategies targeted toward patients with cancer.

MATERIALS AND METHODS: A MEDLINE literature search of the key words death receptors, TRAIL (tumor necrosis factor related apoptosis inducing ligand), FAS, bladder, prostate, renal and cancer was done to obtain information for review. A brief overview of the TRAIL and FAS death receptor pathways, and their relationship to apoptosis is described. Mechanisms that lead to nonfunction of these pathways and how they may contribute to tumorigenesis are linked. Current efforts to target death receptor pathways as a therapeutic strategy are highlighted.

RESULTS: Activation of tumor cell expressing death receptors by cytotoxic immune cells is the main mechanism by which the immune system eliminates malignant cells. Death receptor triggering induces a caspase cascade, leading to tumor cell apoptosis. Receptor gene mutation or hypermethylation, decoy receptor or splice variant over expression, and downstream inhibitor interference are examples of the ways that normal pathway functioning is lost in cancers of the bladder and prostate. Targeting death receptors directly through synthetic ligand administration and blocking downstream inhibitor molecules with siRNA or antisense oligonucleotides represent novel therapeutic strategies under development.

CONCLUSIONS: Research into the death receptor pathways has demonstrated the key role that pathway aberrations have in the initiation and progression of malignancies of the bladder, prostate and kidney. This new understanding has resulted in exciting approaches to restore the functionality of these pathways as a novel therapeutic strategy.

Do non-native invasive fish support elevated lamprey populations?

Summary
1: Managing populations of predators and their prey to achieve conservation or resource management goals is usually technically challenging and frequently socially controversial. This is true even in the simplest ecosystems but can be made much worse when predator–prey relationships are in?uenced by complex interactions, such as biological invasions, population trends or animal movements.
2: Lough Neagh in Northern Ireland is a European stronghold for pollan Coregonus autumnalis, a coregonine ?sh and for river lampreyLampetra ?uviatilis, which feeds parasitically as an adult. Both species are of high conservation importance. Lampreys are known to consume pollan but detailed knowledge of their interactions is scant. While pollan is well known to be a landlocked species in Ireland, the life cycle of normally anadromous river lamprey in Lough Neagh has been unclear. The Lough is also a highly perturbed ecosystem, supporting several invasive, non-native ?sh species that have the potential to in?uence lamprey–pollan interactions.
3: We applied stable isotope techniques to resolve both the movement patterns of lamprey and trophic interactions in this complex community. Recognizing that stable isotope studies are often hampered by high-levels of variability and uncertainty in the systems of interest, we employed novel Bayesian mixing models, which incorporate variability and uncertainty.
4: Stable isotope analyses identi?ed troutSalmo trutta and non-native breamAbramis brama as the main items in lamprey diet. Pollan only represented a major food source for lamprey between May and July.
5: Stable isotope ratios of carbon in tissues from 71 adult lamprey showed no evidence of marine carbon sources, strongly suggesting that Lough Neagh is host to a highly unusual, nonanadromous freshwater population. This ?nding marks out the Lough’s lamprey population as of particular scienti?c interest and enhances the conservation signi?cance of this feature of the Lough.
6: Synthesis and applications.Our Bayesian isotopic mixing models illustrate an unusual pattern of animal movement, enhancing conservation interest in an already threatened population. We have also revealed a complex relationship between lamprey and their food species that is suggestive of hyperpredation, whereby non-native species may sustain high lamprey populations that may in turn be detrimental to native pollan.Long-term conservation of lamprey and pollan in this system is likely to require management intervention, but in light of this exceptional complexity, no simple management options are currently supported. Conservation plans will require better characterization ofpopulation-level interactions and simulation modelling of interventions. More generally, our study demonstrates the importance of considering a full range of possible trophic interactions, particularly in complex ecosystems, and highlights Bayesian isotopic mixing models as powerful tools in resolving trophic relationships.
Key-words: Bayesian, conservation dilemma, Coregonus autumnalis, hyperpredation, Lampetra ?uviatilis, pollan, potamodromous, River lamprey, stable isotope analysis in R, stable isotope

Epidemiology of Adolescent Rugby Injuries: A Systematic Review

OBJECTIVE: Despite recent increases in the volume of research in professional rugby union, there is little consensus on the epidemiology of injury in adolescent players. We undertook a systematic review to determine the incidence, severity, and nature of injury in adolescent rugby union players.

DATA SOURCES: In April 2009, we performed a computerized literature search on PubMed, Embase, and Cochrane Controlled Trials Register (via Ovid). Population-specific and patient-specific search terms were combined in the form of MEDLINE subject headings and key words (wound$ and injur$, rugby, adolescent$). These were supplemented with related-citation searches on PubMed and bibliographic tracking of primary and review articles.

STUDY SELECTION: Prospective epidemiologic studies in adolescent rugby union players.

DATA SYNTHESIS: A total of 15 studies were included, and the data were analyzed descriptively. Two independent reviewers extracted key study characteristics regarding the incidence, severity, and nature of injuries and the methodologic design.

CONCLUSIONS: Wide variations existed in the injury definitions and data collection procedures. The incidence of injury necessitating medical attention varied with the definition, from 27.5 to 129.8 injuries per 1000 match hours. The incidence of time-loss injury (>7 days) ranged from 0.96 to 1.6 per 1000 playing hours and from 11.4/1000 match hours (>1 day) to 12-22/1000 match hours (missed games). The highest incidence of concussion was 3.3/1000 playing hours. No catastrophic injuries were reported. The head and neck, upper limb, and lower limb were all common sites of injury, and trends were noted toward greater time loss due to upper limb fractures or dislocations and knee ligament injuries. Increasing age, the early part of the playing season, and the tackle situation were most closely associated with injury. Future injury-surveillance studies in rugby union must follow consensus guidelines to facilitate interstudy comparisons and provide further clarification as to where injury-prevention strategies should be focused.

The Diffusion of Risks in Public Private Partnership Contracts

Purpose The UK government argues that the benefits of public private partnership (PPP) in delivering public infrastructure stem from: transferring risks to the private sector within a structure in which financiers put their own capital at risk; and, the performance based payment mechanism, reinforced by the due diligence requirements imposed by the lenders financing the projects (HM Treasury, 2010). Prior studies of risk in PPPs have investigated ‘what’ risks are allocated and to ‘whom’, that is to the public or the private sector. The purpose of this study is to examine ‘how’ and ‘why’ PPP risks are diffused by their financiers. Design/methodology/approach This study focuses on the financial structure of PPPs and on their financiers. Empirical evidence comes from interviews conducted with equity and debt financiers. Findings The findings show that the financial structure of the deals generates risk aversion in both debt and equity financiers and that the need to attract affordable finance leads to risk diffusion through a network of companies using various means that include contractual mitigation through insurance, performance support guarantees, interest rate swaps and inflation hedges. Because of the complexity this process generates, both procurers and suppliers need expensive expert advice. The risk aversion and diffusion and the consequent need for advice add cost to the projects impacting on the government’s economic argument for risk transfer. Limitations and implications The empirical work covers the private finance initiative (PFI) type of PPP arrangements and therefore the risk diffusion mechanisms may not be generalisable to other forms of PPP, especially those that do not involve the use of high leverage or private finance. Moreover, the scope of this research is limited to exploring the diffusion of risk in the private sector. Further research is needed on how risk is diffused in other settings and on the value for money implication of risk diffusion in PPP contracts. Originality/value The expectation inherent in PPP is that the private sector will better manage those risks allocated to it and because private capital is at risk, financiers will perform due diligence with the ultimate outcome that only viable projects will proceed. This paper presents empirical evidence that raises questions about these expectations. Key words: public private partnership, risk management, diffusion, private finance initiative, financiers

Performance of Unsaturated Compacted Clay Under Repeated Loading Effects of Confining Pressure, Initial Compaction Effort and Water Content

While a significant number of geotechnical structures are subjected to static loading, many, such as avement subgrade, also are subjected to cyclic or dynamic loading. While the performance of saturated soils under repeated, cyclic or dynamic loading conditions is still a topic of research, similar interests are growing when the soilcondition is unsaturated. This paper examines the performance of unsaturated soils under repeated loading. As part of the research, a triaxial system was developed which incorporates small strain measurements using Hall-effect transducers, in addition to suction measurements taken using a psychrometer. Tests were conducted on samples of kaolin under constant water mass conditions. The results address the effects of compaction effort and water content at the time of compaction on the overall performance of unsaturated soils, under different amplitudes of loading and different confining pressures. The results show that suction in the sample reduced with increasing number of loading cycles of the same magnitude. The resilient modulus initially increased with increasing water content up to approximately optimum water content, and substantially reduced with further increase in water content. Key Words: suction, resilient modulus, subgrade, repeated loading, small strain measurements, compaction.

Visualising Textual Knowledge about Risks to Aid Risk Communication

This paper demonstrates a potential application for latent semantic analysis and similar techniques in visualising the differences between two levels of knowledge about a risk issue. The HIV/AIDS risk issue will be examined and the semantic clusters of key words in a technical corpora derived from specific literature about HIV/AIDS will be compared with the semantic clusters of those in more general corpora. It is hoped that these comparisons will create a fast and efficient complementary approach to the articulation of mental models of risk issues that could be used to target possible inconsistencies between expert and lay mental models.

Guideline for the diagnosis and management of myelofibrosis

The guideline group regarding the diagnosis and management of myelofibrosis was selected to be representative of UK-based medical experts, together with a contribution from a single expert from the USA. MEDLINE and EMBASE were searched systematically for publications in English from 1966 until August 2011 using a variety of key words. The writing group produced the draft guideline, which was subsequently revised by consensus of the members of the General Haematology and Haemato-oncology Task Forces of the British Committee for Standards in Haematology (BCSH). The guideline was then reviewed by a sounding board of UK haematologists, the BCSH and the British Society for Haematology Committee and comments incorporated where appropriate. The criteria used to state levels and grades of evidence are as outlined in the Procedure for Guidelines commissioned by the BCSH; the 'GRADE' system was used to score strength and quality of evidence. The objective of this guideline is to provide healthcare professionals with clear guidance on the investigation and management of primary myelofibrosis, as well as post-polycythaemic myelofibrosis (post-PV MF) and post-thrombocythemic myelofibrosis (post-ET MF) in both adult and paediatric patients.

Adherence to antiepileptic medicines in children: A multiple-methods assessment involving dried blood spot sampling

Purpose: To evaluate adherence to prescribed antiepileptic drugs (AEDs) in children with epilepsy using a combination of adherence-assessment methods.
Methods: A total of 100 children with epilepsy (=17 years old) were recruited. Medication adherence was determined via parental and child self-reporting (=9 years old), medication refill data from general practitioner (GP) prescribing records, and via AED concentrations in dried blood spot (DBS) samples obtained from children at the clinic and via self- or parental-led sampling in children's own homes. The latter were assessed using population pharmacokinetic modeling. Patients were deemed nonadherent if any of these measures were indicative of nonadherence with the prescribed treatment. In addition, beliefs about medicines, parental confidence in seizure management, and the presence of depressed mood in parents were evaluated to examine their association with nonadherence in the participating children.
Key Findings: The overall rate of nonadherence in children with epilepsy was 33%. Logistic regression analysis indicated that children with generalized epilepsy (vs. focal epilepsy) were more likely (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.37-15.81) to be classified as nonadherent as were children whose parents have depressed mood (OR 3.6, 95% CI 1.16-11.41).
Significance: This is the first study to apply the novel methodology of determining adherence via AED concentrations in clinic and home DBS samples. The present findings show that the latter, with further development, could be a useful approach to adherence assessment when combined with other measures including parent and child self-reporting. Seizure type and parental depressed mood were strongly predictive of nonadherence. © 2013 International League Against Epilepsy.
Key Words: Adherence, Epilepsy, Dried blood spots, MARS, Depressed mood.

Terry Eagleton, Postmodernism and Ireland

Terry Eagleton devoted considerable thought to the nature of postmodernism during the heyday of the postmodernist debate in the Eighties and Nineties, and always expressed strong reservations about it.1 It is worth noting that these reservations do not imply any hostility to formal experimentation, or to the registering of alienation in its postmodern form. Rather, he seeks to show how there might be a politically and morally engaged art which was very much of our time. His position is consistent with those he adopts in dealing with other subjects, and may be illuminated by reference to those works where he does so. Of all these other subjects, the most illuminating for understanding his work is that of Irish literature, for it was during this period that Eagleton became a major figure in Irish studies, and his thinking on postmodernist relativism was developed alongside his critique of revisionism in Irish historiography.