All mine

 Music Video for band The Dames

Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients (review)

Background : The sedation needs of critically ill patients have been recognized as a core component of critical care and meeting these is vital to assist recovery and ensure humane treatment. There is growing evidence to suggest that sedation requirements are not always optimally managed. Sub-optimal sedation incorporates both under- and over-sedation and has been linked to both short-term (e.g. length of stay) and long-term (e.g. psychological recovery) outcomes. Various strategies have been proposed to improve sedation management and address aspects of assessment as well as delivery of sedation.

Objectives : To assess the effects of protocol-directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated intensive care unit (ICU) patients. We looked at various outcomes and examined the role of bias in order to examine the level of evidence for this intervention.

Search methods : We searched the Cochrane Central Register of Controlled trials (CENTRAL) (2013; Issue 11), MEDLINE (OvidSP) (1990 to November 2013), EMBASE (OvidSP) (1990 to November 2013), CINAHL (BIREME host) (1990 to November 2013), Database of Abstracts of Reviews of Effects (DARE) (1990 to November 2013), LILACS (1990 to November 2013), Current Controlled Trials and US National Institutes of Health Clinical Research Studies (1990 to November 2013), and reference lists of articles. We re-ran the search in October 2014. We will deal with any studies of interest when we update the review.

Selection criteria : We included randomized controlled trials (RCTs) conducted in adult ICUs comparing management with and without protocol-directed sedation.

Data collection and analysis : Two authors screened the titles and abstracts and then the full-text reports identified from our electronic search. We assessed seven domains of potential risk of bias for the included studies. We examined the clinical, methodological and statistical heterogeneity and used the random-effects model for meta-analysis where we considered it appropriate. We calculated the mean difference (MD) for duration of mechanical ventilation and risk ratio (RR) for mortality across studies, with 95% confidence intervals (CI).

Main results : We identified two eligible studies with 633 participants. Both included studies compared the use of protocol-directed sedation, specifically protocols delivered by nurses, with usual care. We rated the risk of selection bias due to random sequence generation low for one study and unclear for one study. The risk of selection bias related to allocation concealment was low for both studies. We also assessed detection and attrition bias as low for both studies while we considered performance bias high due to the inability to blind participants and clinicians in both studies. Risk due to other sources of bias, such as potential for contamination between groups and reporting bias, was considered unclear. There was no clear evidence of differences in duration of mechanical ventilation (MD -5.74 hours, 95% CI -62.01 to 50.53, low quality evidence), ICU length of stay (MD -0.62 days, 95% CI -2.97 to 1.73) and hospital length of stay (MD -3.78 days, 95% CI -8.54 to 0.97) between people being managed with protocol-directed sedation versus usual care. Similarly, there was no clear evidence of difference in hospital mortality between the two groups (RR 0.96, 95% CI 0.71 to 1.31, low quality evidence). ICU mortality was only reported in one study preventing pooling of data. There was no clear evidence of difference in the incidence of tracheostomy (RR 0.77, 95% CI 0.31 to 1.89). The studies reported few adverse event outcomes; one study reported self extubation while the other study reported re-intubation; given this difference in outcomes, pooling of data was not possible. There was significant heterogeneity between studies for duration of mechanical ventilation (I2 = 86%, P value = 0.008), ICU length of stay (I2 = 82%, P value = 0.02) and incidence of tracheostomy (I2 = 76%, P value = 0.04), with one study finding a reduction in duration of mechanical ventilation and incidence of tracheostomy and the other study finding no difference.

Authors' conclusions : There is currently insufficient evidence to evaluate the effectiveness of protocol-directed sedation. Results from the two RCTs were conflicting, resulting in the quality of the body of evidence as a whole being assessed as low. Further studies, taking into account contextual and clinician characteristics in different ICU environments, are necessary to inform future practice. Methodological strategies to reduce the risk of bias need to be considered in future studies.

I me mine: Artistic self/artistic persona

"This exhibition investigates whether there are places and activities that people consider" "more private, and more authentic than others. It also seeks to discover how people actually talk about their ‘authentic’ selves without recourse to academic theorization or speculation."

I me mine: artistic self/artistic persona

This work comprises of a series of video portraits and sound recordings that explore the connections between gesture, gaze and voice in video portraiture. Most of the subjects are artists represented in the current exhibition, but the disjunction between sound and image makes it difficult to categorically identify the authors of the sound bites on the work’s soundtrack. Designed to function as an introduction to the themes and issues generated by the Self/Persona relationship in the nascent field of Persona Studies, the work is also concerned with the presentation of the artistic self, and the ‘loss of self’ that may or may not occur as a consequence of artistic practice. Formally, the piece plays with the repetition and symmetry to underscore the vulnerability and mutability of the self within contemporary culture.

Sedation protocols to reduce duration of mechanical ventilation in the ICU: a Cochrane Systematic Review

AIMS: Assess the effects of protocol-directed sedation management on the duration of mechanical ventilation and other relevant patient outcomes in mechanically ventilated intensive care unit patients. BACKGROUND: Sedation is a core component of critical care. Sub-optimal sedation management incorporates both under- and over-sedation and has been linked to poorer patient outcomes. DESIGN: Cochrane systematic review of randomized controlled trials. DATA SOURCES: Cochrane Central Register of Controlled trials, MEDLINE, EMBASE, CINAHL, Database of Abstracts of Reviews of Effects, LILACS, Current Controlled Trials and US National Institutes of Health Clinical Research Studies (1990-November 2013) and reference lists of articles were used. REVIEW METHODS: Randomized controlled trials conducted in intensive care units comparing management with and without protocol-directed sedation were included. Two authors screened titles, abstracts and full-text reports. Potential risk of bias was assessed. Clinical, methodological and statistical heterogeneity were examined and the random-effects model used for meta-analysis where appropriate. Mean difference for duration of mechanical ventilation and risk ratio for mortality, with 95% confidence intervals, were calculated. RESULTS: Two eligible studies with 633 participants comparing protocol-directed sedation delivered by nurses vs. usual care were identified. There was no evidence of differences in duration of mechanical ventilation or hospital mortality. There was statistically significant heterogeneity between studies for duration of mechanical ventilation. CONCLUSIONS: There is insufficient evidence to evaluate the effectiveness of protocol-directed sedation as results from the two randomized controlled trials were conflicting.

Successional changes in feeding activity by threatened cockatoos in revegetated mine sites

Provision of key habitat resources is essential for effectively managing species that have specific ecological requirements and occur in production landscapes. Threatened black cockatoos in the jarrah (Eucalyptus marginata) forest of Western Australia have a wide range, so their conservation requires support from all land tenures, not just reserves. Mining in the jarrah forest temporarily removes cockatoo feeding habitat, so it is important to understand how cockatoos exploit revegetated areas for food resources. Aims We aimed to determine whether there were successional patterns in cockatoo feeding activity in revegetation aged from 4 to 23 years at three mine sites in the jarrah forest in south-Western Australia. Methods We surveyed 232 plots in revegetation to document (1) structural and floristic variation in vegetation across mine sites and revegetation ages, (2) differences in cockatoo feeding activity across mine sites and revegetation ages on the basis of feeding residues and (3) any edge effect reflecting preferential use of vegetation at the interior or exterior of mine pits. We also documented the frequency of occurrence of cockatoo food plants and feeding residues in 480 plots in unmined forest to compare with revegetated areas. Key results Marri (Corymbia calophylla) and jarrah were commonly consumed in unmined forest and Banksia and Hakea species were also fed on to a lesser extent. Revegetated mine pits provided food within 4 years and continued to do so up until the oldest plots studied (23 years). The relative importance of food plants shifted from proteaceous species in young revegetation to myrtaceous species in intermediate to older revegetation. However, extent of feeding on myrtaceous species in older revegetation did not equate to feeding rates in unmined forest, with lower frequencies recorded in revegetation. Conclusions Black cockatoos fed in revegetation at all three mine sites, despite variations in vegetation age, structure and floristics. Feeding on proteaceous and myrtaceous food plants occurred within 4 and 7 years of revegetation being established, respectively, indicating that some food resources are restored quickly after mining disturbance of the jarrah forest. Implications Our results emphasise the importance of monitoring fauna recolonisation over appropriate time scales, to understand how successional processes in revegetation influence fauna population persistence in production landscapes.