Development of process control methodology for tracking the quality and safety of pain, agitation and sedation management in critical care units

Objective: To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. Design: A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Setting: Eight Scottish ICUs over a 12-month period. Patients: Mechanically ventilated patients. Interventions: None. Measurements and Main Results: The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman [rho] = 0.75) and were reliable in clinician-clinician (weighted kappa; [kappa] = 0.66) and clinician-researcher ([kappa] = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale ([rho] = 0.24) and was reliable in clinician-clinician ([kappa] = 0.58) and clinician-researcher ([kappa] = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale ([rho] = 0.54), and reliability in clinician-clinician ([kappa] = 0.29) and clinician-researcher ([kappa] = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Conclusions: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time

Critical care in childbearing for midwives

Many women who have higher–risk pregnancies, complications or medical conditions require specialist obstetric or multidisciplinary care. Increasingly women, whose condition deteriorates and becomes critical during childbirth, are being cared for by midwives in obstetric high dependency units within the labour ward, rather than being cared for by nurses in ITU. Critical Care in Childbearing for Midwives explores all aspects of management, support and care of childbearing women who become critically ill due to pre–existing conditions or who develop critical illness as a result of complications of childbearing. It examines predisposing factors which result in the need for critical care, addresses specialist monitoring technology and skills, and explores autonomous practice and team approaches to providing care for critically ill women in childbearing.

Interpersonal Aspects of Thinking Skills in an Intercultural Language Learning Context

Asking and answering certain types of questions are thought to develop thinking skills in all types of classrooms. Previous research has demonstrated that asking higher order questions and answering with elaborated responses are associated with high achievement in first, second, and foreign language contexts. Typically more attention is paid to question frequency or achievements inferred from individual performances than to the dialogues in which asking and answering occurs. This paper argues for a focus on the construction of responses in interaction as an alternative to the investigation of questions, effects of training or individual measurements of performance. Drawing on interactional data from an adult English as a Second Language classroom, it is argued that constructing an answer to a critical question appears to be a highly collaborative and evaluative affair. The thinking skills literature suggests that responding to higher order questions is an individual higher cognitive function, however it is argued in this paper that in attempting to construct evaluative answers language learners are involved not only in a cognitive task, which may or may not be helpful to language learning, but also in a complex social task in which perspectives need to be negotiated, stances taken and identities navigated. It is suggested that higher order thinking cannot be separated from the social and cultural knowledge through which it is brought into being. It is argued that any implementation of thinking skills in an English language teaching context ought to consider interpersonal and social aspects, particularly in intercultural settings.

Telling stories of 21st Century welfare: the UK Coalition Government and the neo-liberal discourse of worklessness and dependency’ Critical Social Policy

Policy documents are a useful source for understanding the privileging of particular ideological and policy preferences (Scrase and Ockwell, 2010) and how the language and imagery may help to construct society’s assumptions, values and beliefs. This article examines how the UK Coalition government’s 2010 Green Paper, 21st Century Welfare, and the White Paper, Universal Credit: Welfare that Works, assist in constructing a discourse about social security that favours a renewal and deepening of neo-liberalization in the context of threats to its hegemony. The documents marginalize the structural aspects of persistent unemployment and poverty by transforming these into individual pathologies of benefit dependency and worklessness. The consequence is that familiar neo-liberal policy measures favouring the intensification of punitive conditionality and economic rationality can be portrayed as new and innovative solutions to address Britain’s supposedly broken society and restore economic competitiveness.

Towards a Critical Ecology of Child Development: Aligning the Theories of Bronfenbrenner and Bourdieu

Bronfenbrenner’s model of bio-ecological development has been utilized widely within the social sciences, in the field of human development, and in social work. Yet, while championing the rights of marginalised families and communities, Bronfenbrenner had under-theorized the role of power, agency and structure in shaping the ‘person-context’ interrelationship, life opportunities and social well-being. To respond to this deficit, this paper firstly outlines Bronfenbrenner’s ‘person, process, context, time’ model. Secondly, it then seeks to loosely align aspects of Bronfenbrenner’s model with Bourdieu’s analytical categories of habitus, field and capital. It is argued that these latter categories enable social workers to develop a critical ecology of child development, taking account of power and the interplay between agency and structure. The implications of the alignment for child and family social work are considered in the final section.

An official American thoracic society research statement: Comparative effectiveness research in pulmonary, critical care, and sleep medicine

Background: Comparative effectiveness research (CER) is intended to inform decision making in clinical practice, and is central to patientcentered outcomes research (PCOR). Purpose: To summarize key aspects of CER definitions and provide examples highlighting the complementary nature of efficacy and CER studies in pulmonary, critical care, and sleep medicine. Methods: An ad hoc working group of the American Thoracic Society with experience in clinical trials, health services research, quality improvement, and behavioral sciences in pulmonary, critical care, and sleepmedicinewas convened. The group used an iterative consensus process, including a reviewbyAmerican Thoracic Society committees and assemblies. Results: The traditional efficacy paradigm relies on clinical trials with high internal validity to evaluate interventions in narrowly defined populations and in research settings. Efficacy studies address the question, "Can it work in optimal conditions?" The CER paradigm employs a wide range of study designs to understand the effects of interventions in clinical settings. CER studies address the question, "Does it work in practice?" The results of efficacy and CER studies may or may not agree. CER incorporates many attributes of outcomes research and health services research, while placing greater emphasis on meeting the expressed needs of nonresearcher stakeholders (e.g., patients, clinicians, and others). Conclusions: CER complements traditional efficacy research by placing greater emphasis on the effects of interventions in practice, and developing evidence to address the needs of the many stakeholders involved in health care decisions. Stakeholder engagement is an important component of CER. Copyright © 2013 by the American Thoracic Society.

Electroless nickel, alloy, composite and nano coatings - A critical review

The development of metal deposition processes based on electroless nickel, alloy and composite coatings on various surfaces has witnessed a surge in interest among researchers, with many recent applications made possible from many excellent properties. In recent years, these coatings have shown promising corrosion and wear resistance properties and large number of newer developments became most important from macro to nano level applications. After a brief review of the fundamental aspects underlying the coating processes, this paper discusses in detail about different electroless nickel alloy, composite, nano plating, bath techniques, preparation, characterization, new depositing mechanism and their recent applications, including brief notes on difficult substrate and waste treatment for green environment. Emphasis will be onto their recent progress, which will be discussed in detail and critically reviewed.

How Critical Care Nurses' Role and Education Affect Organ Donation

Organ and tissue dysfunction and failure cause high mortality rates around the world. Tissue and organs transplantation is an established, cost-effective, life-saving treatment for patients with organ failure. However, there is a large gap between the need for and the supply of donor organs. Acute and critical care nurses have a central role in the organ donation process, from identifying and assessing potential donors and supporting their families to involvement in logistics. Nurses with an in-depth knowledge of donation understand its clinical and technical aspects as well as the moral and legal considerations. Nurses have a major role to play in tackling organ and tissue shortages. Such a role cannot be adequately performed if nurses are not fully educated about donation and transplant. Such education could be incorporated into mandatory training and completed by all nurses.

Aspects of the hemes and modulation of hydrogen donors in catalases from bovine liver, yeast, and escherichia coli

Catalase is the enzyme which decomposes hydrogen peroxide to water and oxygen. Escherichia coli contains two catalases. Hydroperoxidase I (HPI) is a bifunctional catalase-peroxidase. Hydroperoxidase II (HPII) is only catalytically active toward H202. Expression of the genes encoding these proteins is controlled by different regimes. HPJI is thought to be a hexamer, having one heme d cis group per enzymatic subunit. HPII wild type protein and heme containing mutant proteins were obtained from the laboratory of P. Loewen (Univ. of Manitoba). Mutants constructed by oligonucleotidedirected mutagenesis were targeted for replacement of either the His128 residue or the Asn201 residue in the vicinity of the HPII heme crevice. His128 is the residue thought to be analogous to the His74 distal axial ligand of the heme in the bovine liver enzyme, and Asn201 is believed to be a residue critical to the function of the enzyme because of its role in orienting and interacting with the substrate molecule. Investigation of the nature of the hemes via absorption spectroscopy of the unmodified catalase proteins and their derived pyridine hemochromes showed that while the bovine and Saccharomyces cerevisiae catalase enzymes are protoheme-containing, the HPII wild type protein contains heme d, and the mutant proteins contain either solely protoheme, or heme d-protoheme mixtures. Cyanide binding studies supported this, as ligand binding was monophasic for the bovine, Saccharomyces cerevisiae, and wild type HPII enzymes, but biphasic for several of the HPII mutant proteins. Several mammalian catalases, and at least two prokaryotic catalases, are known to be NADPH binding. The function of this cofactor appears to be the prevention of inactivation of the enzyme, which occurs via formation of the inactive secondary catalase peroxide compound (compound II). No physiologically plausible scheme has yet been proposed for the NADPH mediation of catalase activity. This study has shown, via fluorescence and affinity chromatography techniques, that NADPH binds to the T (Typical) and A (Atypical) catalases of Saccharomyces cerevisiae, and that wild type HPII apparently does not bind NADPH. This study has also shown that NADPH is unlike any other hydrogen donor to catalase, and addresses its features as a unique donor by proposing a mechanism whereby NADPH is oxidized and catalase is protected from inactivation via the formation of protein radical species. Migration of this radical to a position close to the NADPH is also proposed as an adjunct hypothesis, based on similar electron migrations that are known to occur within metmyoglobin and cytochrome c peroxidase when reacted with H202. Validation of these hypotheses may be obtained in appropriate future experiments.

Multinational drug corporations, intellectual property rights and the Canadian state : a historical and critical analysis

This study critically analyzes the historical role and influence of multinational drug cotpOrations and multinational corporations in general; the u.s. government and the Canadian state in negotiating the global recognition ofIntellectual Property Rights (IPR) under GATT/NAFTA. This process began in 1969 when the Liberal government, in response to high prices for brand-name drugs amended the Patent Act to introduce compulsory licensing by reducing monopoly protection from 20 to seven years. Although the financial position ofthe multinational drug industry was not affected, it campaigned vigorously to change the 1969 legislation. In 1987, the Patent Act was amended to extend protection to 10 years as a condition for free trade talks with the u.s. Nonetheless, the drug industry was not satisfied and accused Canada of providing a bad example to other nations. Therefore, it continued to campaign for global recognition ofIPR laws under GATT. Following the conclusion of the GATTI Trade-Related aspects of Intellectual Property Rights agreement (TRIPS) in 1991, the multinational drug industry and the American government, to the surprise of many, were still not satisfied and sought to implement harsher conditions under NAFTA. The Progressive Conservative government readily agreed without any objections or consideration for the social consequences. As a result, Bill C-91 was introduced. It abandoned compulsory licenses and was made retroactive from December 21, 1991. It is the contention of this thesis that the economic survival of multinational corporations on a global scale depends on the role and functions of the modem state. Similarly, the existence of the state depends on the ideological-political and socioeconomic assistance it gives to multinational corporations on a national and international scale. This dialectical relation of the state and multinational corporations is explored in our theoretical and historical analysis of their role in public policy.

Valuing and encouraging critical reflection in pre-service teacher education

This qualitative study was designed to investigate aspects related to valuing and encouraging critical reflection in pre-service teacher education. An examination of the place and function of practicum logbooks as used at Covenant Canadian Reformed Teachers' College, a small private college which offers pre-service teacher education formed the core of the research. An analysis of the practicum logbooks written by five student teachers during three different practicum placements was performed at two levels. First, a content analysis served to identify general and specific categories within the practice teaching contextas a learning experience. Secondly, in-depth intuitive and thematic analyses of the entries which related specifically to reflection as a learning experience gave rise to critical questions. Throughout the process, the five participants formed an active and involved group of co-researchers, adding their voices to the narrative of the learning experience. Variables such as personality type, learning style and self-directedness added a dimension which deepened and emiched the study. The result of the study suggests that practicum logbooks form a valuable base for valuing and encouraging critical reflection in pre-service teacher education. The results also suggest that not all students appear to be equally capable of critical reflection. Recognizing that teacher education exists as a continuum appears to support the findings that in their journey along this continuum, student teachers not only move from reflection-on-action to reflection-in-action, but also from content to process to premise reflection. An awareness of contributing factors such as personality type, degree of risk-taking, preferred learning style and self-directedness on the part of teacher-educators will serve to create a climate of trust in which student teachers can safely develop critical reflection, using practicum logbooks as one possible medium.

Metal music as critical dystopia : humans, technology and the future in 1990s science fiction metal

Metal Music as Critical Dystopia: Humans, Technology and the Future in 1990s Science Fiction Metal seeks to demonstrate that the dystopian elements in metal music are not merely or necessarily a sonic celebration of disaster. Rather, metal music's fascination with dystopian imagery is often critical in intent, borrowing themes and imagery from other literary and cinematic traditions in an effort to express a form of social commentary. The artists and musical works examined in this thesis maintain strong ties with the science fiction genre, in particular, and tum to science fiction conventions in order to examine the long-term implications of humanity's complex relationship with advanced technology. Situating metal's engagements with science fiction in relation to a broader practice of blending science fiction and popular music and to the technophobic tradition in writing and film, this thesis analyzes the works of two science fiction metal bands, VOlvod and Fear Factory, and provides close readings of four futuristic albums from the mid to late 1990s that address humanity's relationship with advanced technology in musical and visual imagery as well as lyrics. These recorded texts, described here as cyber metal for their preoccupation with technology in subject matter and in sound, represent prime examples of the critical dystopia in metal music. While these albums identify contemporary problems as the root bf devastation yet to come, their musical narratives leave room for the possibility of hope , allowing for the chance that dystopia is not our inevitable future.

Nanostructure des particules polymériques : aspects physiques, chimiques et biologiques

Les nanotechnologies appliquées aux sciences pharmaceutiques ont pour but d’améliorer l’administration de molécules actives par l’intermédiaire de transporteurs nanométriques. Parmi les différents types de véhicules proposés pour atteindre ce but, on retrouve les nanoparticules polymériques (NP) constituées de copolymères “en bloc”. Ces copolymères permettent à la fois l’encapsulation de molécules actives et confèrent à la particule certaines propriétés de surface (dont l’hydrophilicité) nécessaires à ses interactions avec les milieux biologiques. L’architecture retenue pour ces copolymères est une structure constituée le plus fréquemment de blocs hydrophiles de poly(éthylène glycol) (PEG) associés de façon linéaire à des blocs hydrophobes de type polyesters. Le PEG est le polymère de choix pour conférer une couronne hydrophile aux NPs et son l’efficacité est directement liée à son organisation et sa densité de surface. Néanmoins, malgré les succès limités en clinique de ces copolymères linéaires, peu de travaux se sont attardés à explorer les effets sur la structure des NPs d’architectures alternatives, tels que les copolymères en peigne ou en brosse. Durant ce travail, plusieurs stratégies ont été mises au point pour la synthèse de copolymères en peigne, possédant un squelette polymérique polyesters-co-éther et des chaines de PEG liées sur les groupes pendants disponibles (groupement hydroxyle ou alcyne). Dans la première partie de ce travail, des réactions d’estérification par acylation et de couplage sur des groupes pendants alcool ont permis le greffage de chaîne de PEG. Cette méthode génère des copolymères en peigne (PEG-g-PLA) possédant de 5 à 50% en poids de PEG, en faisant varier le nombre de chaînes branchées sur un squelette de poly(lactique) (PLA). Les propriétés structurales des NPs produites ont été étudiées par DLS, mesure de charge et MET. Une transition critique se situant autour de 15% de PEG (poids/poids) est observée avec un changement de morphologie, d’une particule solide à une particule molle (“nanoagrégat polymére”). La méthode de greffage ainsi que l’addition probable de chaine de PEG en bout de chaîne principale semblent également avoir un rôle dans les changements observés. L’organisation des chaînes de PEG-g-PLA à la surface a été étudiée par RMN et XPS, méthodes permettant de quantifier la densité de surface en chaînes de PEG. Ainsi deux propriétés clés que sont la résistance à l’agrégation en conditions saline ainsi que la résistance à la liaison aux protéines (étudiée par isothermes d’adsorption et microcalorimétrie) ont été reliées à la densité de surface de PEG et à l’architecture des polymères. Dans une seconde partie de ce travail, le greffage des chaînes de PEG a été réalisé de façon directe par cyclo-adition catalysée par le cuivre de mPEG-N3 sur les groupes pendants alcyne. Cette nouvelle stratégie a été pensée dans le but de comprendre la contribution possible des chaines de PEG greffées à l’extrémité de la chaine de PLA. Cette librairie de PEG-g-PLA, en plus d’être composée de PEG-g-PLA avec différentes densités de greffage, comporte des PEG-g-PLA avec des PEG de différent poids moléculaire (750, 2000 et 5000). Les chaines de PEG sont seulement greffées sur les groupes pendants. Les NPs ont été produites par différentes méthodes de nanoprécipitation, incluant la nanoprécipitation « flash » et une méthode en microfluidique. Plusieurs variables de formulation telles que la concentration du polymère et la vitesse de mélange ont été étudiées afin d’observer leur effet sur les caractéristiques structurales et de surface des NPs. Les tailles et les potentiels de charges sont peu affectés par le contenu en PEG (% poids/poids) et la longueur des chaînes de PEG. Les images de MET montrent des objets sphériques solides et l'on n’observe pas d’objets de type agrégat polymériques, malgré des contenus en PEG comparable à la première bibliothèque de polymère. Une explication possible est l’absence sur ces copolymères en peigne de chaine de PEG greffée en bout de la chaîne principale. Comme attendu, les tailles diminuent avec la concentration du polymère dans la phase organique et avec la diminution du temps de mélange des deux phases, pour les différentes méthodes de préparation. Finalement, la densité de surface des chaînes de PEG a été quantifiée par RMN du proton et XPS et ne dépendent pas de la méthode de préparation. Dans la troisième partie de ce travail, nous avons étudié le rôle de l’architecture du polymère sur les propriétés d’encapsulation et de libération de la curcumine. La curcumine a été choisie comme modèle dans le but de développer une plateforme de livraison de molécules actives pour traiter les maladies du système nerveux central impliquant le stress oxydatif. Les NPs chargées en curcumine, montrent la même transition de taille et de morphologie lorsque le contenu en PEG dépasse 15% (poids/poids). Le taux de chargement en molécule active, l’efficacité de changement et les cinétiques de libérations ainsi que les coefficients de diffusion de la curcumine montrent une dépendance à l’architecture des polymères. Les NPs ne présentent pas de toxicité et n’induisent pas de stress oxydatif lorsque testés in vitro sur une lignée cellulaire neuronale. En revanche, les NPs chargées en curcumine préviennent le stress oxydatif induit dans ces cellules neuronales. La magnitude de cet effet est reliée à l’architecture du polymère et à l’organisation de la NP. En résumé, ce travail a permis de mettre en évidence quelques propriétés intéressantes des copolymères en peigne et la relation intime entre l’architecture des polymères et les propriétés physico-chimiques des NPs. De plus les résultats obtenus permettent de proposer de nouvelles approches pour le design des nanotransporteurs polymériques de molécules actives.

A critical study of major construction projects in kerala vis-a-vis effectiveness in project implementation

Chapter 1 presents a brief note on the state at which the construction industry stands at present, bringing into focus the significance of the critical study. Relevance of the study, area of investigation and objectives of the study are outlined in this chapter. The 2nd chapter presents a review of the literature on the relevant areas. In the third chapter an analysis on time and cost overrun in construction highlighting the major factors responsible for it has been done. A couple of case studies to estimate loss to the nation on account of delay in construction have been presented in the chapter. The need for an appropriate estimate and a competent contractor has been emphasised for improving effectiveness in the project implementation. Certain useful equations and thoughts have been formulated on this area in this chapter that can be followed in State PWD and other Govt. organisations. Case studies on project implementation of major projects undertaken by Government sponsored/supported organizations in Kerala have been dealt with in Chapter 4. A detailed description of the project of Kerala Legislature Complex with a critical analysis has been given in this chapter. A detailed account of the investigations carried out on the construction of International Stadium, a sports project of Greater Cochin Development Authority is included here. The project details of Cochin International Airport at Nedumbassery, its promoters and contractors are also discussed in Chapter 4. Various aspects of implementation which led the above projects successful have been discussed in chapter 5. The data collected were analysed through discussion and perceptions to arrive at certain conclusions. The emergence of front-loaded contract and its impact on economics of the project execution are dealt with in this chapter. Analysis of delays in respect of the various project narrated in chapter 3 has been done here. The root causes of the project time and overrun and its remedial measures are also enlisted in this chapter. Study of cost and time overrun of any construction project IS a part of construction management. Under the present environment of heavy investment on construction activities in India, the consequences of mismanagement many a time lead to excessive expenditure which are not be avoidable. Cost consciousness, therefore has to be keener than ever before. Optimization in investment can be achieved by improved dynamism in construction management. The successful completion of coristruction projects within the specified programme, optimizing three major attributes of the process - quality, schedule and costs - has become the most valuable and challenging task for the engineer - managers to perform. So, the various aspects of construction management such as cost control, schedule control, quality assurance, management techniques etc. have also been discussed in this fifth chapter. Chapter 6 summarises the conclusions drawn from the above criticalr1 of rhajor construction projects in Kerala.

Aspects of isolation underpinning mitotic behaviour in lupin protoplasts

This study reports on the influence of critical isolation factors on the subsequent culture of protoplasts of Lupinus albus L. Protoplasts were isolated from in vitro seedling cotyledons of five early maturing accessions in which protoplast yields and division frequencies appeared to be correlated as a high protoplast yield corresponded with a high division frequency. The overall difference among the accessions for mitosis was non- significant, although the highest yield and division frequency were observed in accession LA132, with Alban giving a significantly lower level. Accession Lucrop produced the lowest number of protoplasts, all of which collapsed during culture. Of the enzyme types used for tissue maceration, Pectolyase Y23, was significantly inferior to Macerase in terms of giving way to mitosis. The extent of division in Macerase- isolated protoplast population was 266% higher than that in the Pectolyase Y23- isolated one. The physiological maturity level of the explant, expressed in terms of developmental age, was optimal when 14 - 18- day- old seedling cotyledons were used for protoplast production and culture, rather than more mature ones, despite higher protoplast yields in the latter. On K8p medium, the protoplast division frequency was 129% greater when 18- day- old seedling cotyledons were used, than that with any other treatment. This work on protoplast culture of the potentially important lupin species, which is a pulse rich in dietary protein, oil and fibre, allows a further understanding of the biology, with an aim to advance lupin biotechnology.