Effect of a pharmacist-led multicomponent intervention focussing on the medication monitoring phase to prevent potential adverse drug events in nursing homes

OBJECTIVES: To determine the extent to which the use of a clinical informatics tool that implements prospective monitoring plans reduces the incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

DESIGN: Randomized cluster trial.

SETTING: Twenty-five nursing homes serviced by two long-term care pharmacies.

PARTICIPANTS: Residents living in nursing homes during 2003 (1,711 in 12 intervention; 1,491 in 13 usual care) and 2004 (1,769 in 12 intervention; 1,552 in 13 usual care).

INTERVENTION: The pharmacy automatically generated Geriatric Risk Assessment MedGuide (GRAM) reports and automated monitoring plans for falls and delirium within 24 hours of admission or as part of the normal time frame of federally mandated drug regimen review.

MEASUREMENTS: Incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

RESULTS: GRAM triggered monitoring plans for 491 residents. Newly admitted residents in the intervention homes experienced a lower rate of potential delirium onset than those in usual care homes (adjusted hazard ratio (HR)=0.42, 95% confidence interval (CI)=0.35–0.52), overall hospitalization (adjusted HR=0.89, 95% CI=0.72–1.09), and mortality (adjusted HR=0.88, 95% CI=0.66–1.16). In longer stay residents, the effects of the intervention were attenuated, and all estimates included unity.

CONCLUSION: Using health information technology in long-term care pharmacies to identify residents who might benefit from the implementation of prospective medication monitoring care plans when complex medication regimens carry potential risks for falls and delirium may reduce adverse effects associated with appropriate medication use.

Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative-evidence synthesis

Background:
Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions.

Objectives:
1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used.

Search methods:
We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.

We reran the search on 3rd July 2016 and found three studies, which are awaiting classification.

Selection criteria:
We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation.

Data collection and analysis:
At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews.

Main results:
We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.

The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as ‘low’, 13 as ‘moderate’ and five as ‘high’ confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents.

Authors' conclusions:
There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of ‘ownership’. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.

The Family Model - A transgenerational approach to mental health in families: personal, clinical, educational, research, systems and policy perspectives

The Family Model – A transgenerational approach to mental health in families This workshop will provide an overview on The Family Model (TFM) and its use in promoting and facilitating a trans­generational family focus in Mental Health services, over the past 10­ - 15 years. Each of the speakers will address a different perspective, including service user/consumer, clinical practice, education & training, research and policy. Adrian Falkov (chair) will provide an overview of TFM to set the scene and a ‘policy to practice’ perspective, based on use of TFM in Australia. Author: Heide Lloyd. The Family Model ­ A personal (consumer/patient) perspective | United Kingdom Heide will provide a description of her experiences as a child, adult, parent & grandparent, using TFM as the structure around which to ‘weave’ her story and demonstrate how TFM has assisted her in understanding the impact of symptoms on her & family and how she has used it in her management of symptoms and recovery (personal perspective). The Family Model ­ Education & training perspective ­ Marie Diggins | United Kingdom PhD Bente Weimand | Norway Authors: ­ Marie Diggins | United Kingdom PhD Bente Weimand | Norway This combined (UK & Norwegian) presentation will cover historical background to TFM and its use in eLearning (the Social Care Institute for Excellence)and a number of other UK initiatives, together with a description of the postgraduate masters course at the University Oslo/Akershus, using TFM. The Family Model ­ A research perspective PhD Anne Grant | Northern Ireland Author: PhD Anne Grant | Ireland Anne Grant will describe how she used TFM as the theoretical framework for her PhD looking at family focused (nursing) practice in Ireland. The Family Model ­ A service systems perspective ­ Mary Donaghy | Northern Ireland Authors: PhD Adrian Falkov | Australia ­ Mary Donaghy | N Ireland Mary Donaghy will discuss how TFM has been used to support & facilitate a cross service ‘whole of system’ change program in Belfast (NI) to achieve improved family focused practice. She will demonstrate its utility in achieving a broader approach to service design, delivery and evaluation.

The analysis of large-scale turbulence characteristics in the Indonesian seas derived from a regional model based on the Princeton Ocean Model

Turbulence characteristics in the Indonesian seas on the horizontal scale of order of 100 km were calculated with a regional model of the Indonesian seas circulation in the area based on the Princeton Ocean Model (POM). As is well known, the POM incorporates the Mellor–Yamada turbulence closure scheme. The calculated characteristics are: twice the turbulence kinetic energy per unit mass, <i>q</i>²; the turbulence master scale, &ell;; mixing coefficients of momentum, <i>K</i>_M; and temperature and salinity, <i>K</i>_H; etc. The analyzed turbulence has been generated essentially by the shear of large-scale ocean currents and by the large-scale wind turbulence. We focused on the analysis of turbulence around important topographic features, such as the Lifamatola Sill, the North Sangihe Ridge, the Dewakang Sill, and the North and South Halmahera Sea Sills. In general, the structure of turbulence characteristics in these regions turned out to be similar. For this reason, we have carried out a detailed analysis of the Lifamatola Sill region because dynamically this region is very important and some estimates of mixing coefficients in this area are available. <br><br> Briefly, the main results are as follows. The distribution of <i>q</i>² is quite adequately reproduced by the model. To the north of the Lifamatola Sill (in the Maluku Sea) and to the south of the Sill (in the Seram Sea), large values of <i>q</i>² occur in the deep layer extending several hundred meters above the bottom. The observed increase of <i>q</i>² near the very bottom is probably due to the increase of velocity shear and the corresponding shear production of <i>q</i>² very close to the bottom. The turbulence master scale, &ell;, was found to be constant in the main depth of the ocean, while &ell; rapidly decreases close to the bottom, as one would expect. However, in deep profiles away from the sill, the effect of topography results in the &ell; structure being unreasonably complicated as one moves towards the bottom. Values of 15 to 20 × 10^&minus;4 m² s^-1 were obtained for <i>K</i>_M and <i>K</i>_H in deep water in the vicinity of the Lifamatola Sill. These estimates agree well with basin-scale averaged values of 13.3 × 10^&minus;4 m² s^-1 found diagnostically for <i>K</i>_H in the deep Banda and Seram Seas (Gordon et al., 2003) and a value of 9.0 × 10^&minus;4 m² s^-1 found diagnostically for <i>K</i>_H for the deep Banda Sea system (van Aken et al., 1988). The somewhat higher simulated values can be explained by the presence of steep topography around the sill.

Abrasive size and concentration effects on the tribo-corrosion of cast CoCrMo alloy in simulated body fluids

Some retrieved CoCrMo hip implants have shown that abrasive wear is one of the possible wear mechanisms invoked within such joints. To date, little work has focused on the third body abrasion of CoCrMo and therefore there is a general lack of understanding of the effect of abrasive size and volume concentration on the tribo-corrosion performance of the CoCrMo alloys. The present work assessed the tribo-corrosion behaviour of cast CoCrMo (F-75) under various abrasion-corrosion conditions by using a modified microabrasion tester incorporating a three-electrode electrochemical cell. The effects of reduced abrasive size/hardness and volume concentration, as well as the role of proteins on the tribo-corrosion performance of the cast CoCrMo alloy were addressed. The correlation between electrochemical and mechanical processes for different abrasion-corrosion test conditions has been discussed in detail. Results show that the reduction in abrasive size and volume concentration can significantly affect the abrasion-corrosion wear mechanisms and the wear-induced corrosion response of the material. The finding of this study implies that the smaller/softer third body particles generated in vivo could also result in significant wear-induced corrosion and therefore potential metal ion release, which could be potentially detrimental to both the patient health and the life span of the implants. © 2009 Elsevier Ltd. All rights reserved.

On the Limits of Exceptionalism: Principles and Practice in the Pursuit of Alternatives to Full EU Membership

Few states have been less uncomfortable with the relationship they have with the EU than the United Kingdom as a member and Turkey as an associate and would-be member. Both states currently find themselves questioning the substance and future of these relationships with domestic actors and, notably in the Turkish case, external EU voices actively advocating alternatives. While much discussion, particularly in the UK case, has focused on the advantages and disadvantages of particular existing arrangements (e.g. European Economic Area, Swiss bilateralism), this paper considers the broader principles and practices that the EU has to date either explicitly developed or implicitly established to govern the nature and substance of alternatives to [full] EU membership. It assesses the principled, practical and political limitations that exist in establishing alternatives to full membership for states seeking – or having sought for them – the accommodation of their exceptionalism. In doing so the paper considers the potential limits to a renegotiated EU membership for the UK and to an alternative short of full membership for Turkey. It also reflects on the precedent-setting consequences of any new arrangements that the EU might reach with either state for what forms membership and a relationship short of membership might take in the future.

Effect of the Electrolyte Formulation on the Performances of Edlc and Li-Ion Batteries

One of the most important components in electrochemical storage devices (batteries and supercapacitors) is undoubtedly the electrolyte. The basic function of any electrolyte in these systems is the transport of ions between the positive and negative electrodes. In addition, electrochemical reactions occurring at each electrode/electrolyte interface are the origin of the current generated by storage devices. In other words, performances (capacity, power, efficiency and energy) of electrochemical storage devices are strongly related to the electrolyte properties, as well as, to the affinity for the electrolyte to selected electrode materials. Indeed, the formulation of electrolyte presenting good properties, such as high ionic conductivity and low viscosity, is then required to enhance the charge transfer reaction at electrode/electrolyte interface (e.g. charge accumulation in the case of Electrochemical Double Layer Capacitor, EDLC). For practical and safety considerations, the formulation of novel electrolytes presenting a low vapor pressure, a large liquid range temperature, a good thermal and chemical stabilities is also required.

This lecture will be focused on the effect of the electrolyte formulation on the performances of electrochemical storage devices (Li-ion batteries and supercapacitors). During which, a summary of the physical, thermal and electrochemical data obtained by our group, recently, on the formulation of novel electrolyte-based on the mixture of an ionic liquid (such as EmimNTf2 and Pyr14NTf2) and carbonate or dinitrile solvents will be presented and commented. The impact of the electrolyte formulation on the storage performances of EDLC and Li-ion batteries will be also discussed to further understand the relationship between electrolyte formulation and electrochemical performances. This talk will also be an opportunity to further discuss around the effects of additives (SEI builder: fluoroethylene carbonate and vinylene carbonate), ionic liquids, structure and nature of lithium salt (LiTFSI vs LiPF6) on the cyclability of negative electrode to then enhance the electrolyte formulation. For that, our recent results on TiSnSb and graphite negative electrodes will be presented and discussed, for example 1,2.

1-C. Marino, A. Darwiche1, N. Dupré, H.A. Wilhelm, B. Lestriez, H. Martinez, R. Dedryvère, W. Zhang, F. Ghamouss, D. Lemordant, L. Monconduit “ Study of the Electrode/Electrolyte Interface on Cycling of a Conversion Type Electrode Material in Li Batteries” J. Phys.chem. C, 2013, 117, 19302-19313

2- Mouad Dahbi, Fouad Ghamouss, Mérièm Anouti, Daniel Lemordant, François Tran-Van “Electrochemical lithiation and compatibility of graphite anode using glutaronitrile/dimethyl carbonate mixtures containing LiTFSI as electrolyte” 2013, 43, 4, 375-385.

Family functioning during the diagnosis process in families with children on the autism spectrum,

While the causes of autism spectrum disorder (ASD) still are not fully understood, increasingly research focuses on interventions and treatment of children diagnosed with ASD. Considerably less attention is paid to family systems, family functioning, and family needs. This paper takes a family system perspective exploring how families with children on the autism spectrum function during the particularly stressful period of the diagnosis process and thereafter. Recommendations made in this paper include the need for empirical studies that address in detail family systems, family needs, the assessment and diagnostic process, service provision, social support networks, and additional stressful life events. Furthermore, the development of a family functioning assessment tools is called for in order to promote child-family-centred assessment and intervention. Details of an ongoing comparative study are outlined that will make a contribution to family studies and autism research field with a specific focus on the diagnosis

Early pain experience, child and family factors, as precursors of somatization:a prospective study of extremely premature and fullterm children

In a prospective study of 36 children who were extremely low birthweight (ELBW: <1000 g) preterm infants and 36 matched full-term controls, differences were found in somatization at age 4 1/2 years. Only children who had been extremely premature, and thereby experienced prolonged hospitalization and repeated medical intervention in infancy, had clinically high somatization scores on the Personality Inventory for Children. The combination of family relations at age 4 1/2 years, neonatal intensive care experience, poor maternal sensitivity to child cues in mother-child interaction observed at age 3 years, and child avoidance of touch or holding at age 3, predicted somatization scores, prior to school entry. Due to the known higher incidence of actual medical problems among children with a history of extreme prematurity, the high somatization ELBW children were compared with the normal somatization ELBW children. There were no differences in prevalence of actual medical problems between the 2 ELBW groups, and the importance of maternal factors in relation to somatization was confirmed. Child temperament at age 3, but not personality at 4 1/2, was related to somatization. The etiology of recurrent physical complaints of no known medical cause appears to be a multi-dimensional problem. Non-optimal parenting may contribute to the development of inappropriate strategies for coping with common pains of childhood, or of chronic pain patterns, in some children who have experienced prolonged or repeated pain as neonates.

The effect of choice on motivation for young children on the autism spectrum during discrete trial teaching

Self-determination and decision-making are acknowledged internationally as key rights of persons with disabilities and should play an important role in the development of educational plans and procedures. Not only is the chance for individuals with developmental disabilities to select their own tasks, leisure activities or reinforcers a valuable way of enhancing rights-based education and personal dignity, but choice-making opportunities may also function as a useful clinical or educational tool if they actually improve the efficacy of programmes aimed at the acquisition of socially relevant behaviours and life skills or the reduction of challenging behaviours.

The study reported here assessed whether or not choice affected effectiveness of an educational procedure for three children on the autism spectrum. Following a preference assessment, a number of discrete teaching trials were conducted with each child and, contingent upon targeted responses, either the child or the therapist selected one of three preferred reinforcer items. Reinforcer choice did not affect intervention effectiveness for two of the children; however, performance and motivation improved for the third child. Results re-affirmed the importance of thorough preference assessments prior to intervention and showed that additional stimulus choice contingent on the target response may improve motivation and outcomes for some children.

The Millennium child with autism: Early childhood trajectories for health, education and economic wellbeing

Objective: Most of what we know about children with autism spectrum disorder (ASD) is based on post-diagnostic, retrospective, self-select studies. Oftentimes, there is no direct comparison between trajectories of children with ASD and children without ASD.

Methods: To circumvent both of these problems, the present secondary data analysis utilised a large-scale longitudinal general population survey of children born in the year 2000 (i.e. the Millennium Cohort Study; MCS; n=18522). Bi-annual MCS data were available from five data sweeps (children aged 9 months to 11 years of age).

Results: Pre-diagnostic data showed early health problems differentiated children later diagnosed with autism from non-diagnosed peers. Prevalence was much higher than previously estimated (3.5% for 11-year olds). Post-diagnosis, trajectories deteriorated significantly for the children with ASD and their families in relation to education, health and economic wellbeing.

Conclusion: These findings raise many issues for service delivery and the rights of persons with disabilities and their families.