Pain measurement and management in elderly patients : Clinical studies in long term hospital care and after cardiac surgery

The proportion of patients over 75 years of age, receiving all different types of healthcare, is constantly increasing. The elderly undergo surgery and anaesthetic procedures more often than middle-aged patients. Poor pain management in the elderly is still an issue. Although the elderly consumes the greatest proportion of prescribed medicines in Western Europe, most clinical pharmacological studies have been performed in healthy volunteers or middle-aged patients. The aim of this study was to investigate pain measurement and management in cognitively impaired patients in long term hospital care and in cognitively normal elderly patients after cardiac surgery. This thesis incorporated 366 patients, including 86 home-dwelling or hospitalized elderly with chronic pain and 280 patients undergoing cardiac surgery with acute pain. The mean age of patients was 77 (SD ± 8) years and approximately 8400 pain measurements were performed with four pain scales: Verbal Rating Scale (VRS), the Visual Analogue Scale (VAS), the Red Wedge Scale (RWS), and the Facial Pain Scale (FPS). Cognitive function, depression, functional ability in daily life, postoperative sedation and postoperative confusion were assessed with MMSE, GDS, Barthel Index, RASS, and CAM-ICU, respectively. The effects and plasma concentrations of fentanyl and oxycodone were measured in elderly (≥ 75 years) and middle-aged patients (≤ 60 years) and the opioid-sparing effect of pregabalin was studied after cardiac surgery. The VRS pain scores after movement correlated with the Barthel Index. The VRS was most successful in the groups of demented patients (MMSE 17-23, 11-16 and ≤ 10) and in elderly patients on the first day after cardiac surgery. The elderly had a higher plasma concentration of fentanyl at the end of surgery than younger patients. The plasma concentrations of oxycodone were comparable between the groups. Pain intensity on the VRS was lower and the sedation scores were higher in the elderly. Total oxycodone consumption during five postoperative days was reduced by 48% and the CAM-ICU scores were higher on the first postoperative day in the pregabalin group. The incidence of postoperative pain during movement was lower in the pregabalin group three months after surgery. This investigation demonstrates that chronic pain did not seem to impair daily activities in home-dwelling Finnish elderly. The VRS appeared to be applicable for elderly patients with clear cognitive dysfunction (MMSE ≤17) and it was the most feasible pain scale for the early postoperative period after cardiac surgery. After cardiac surgery, plasma concentrations of fentanyl in elderly were elevated, although oxycodone concentrations were at similar level compared to middle-aged patients. The elderly had less pain and were more sedated after doses of oxycodone. Therefore, particular attention must be given to individual dosing of the opioids in elderly surgical patients, who often need a smaller amount for adequate analgesia than middle-aged patients. The administration of pregabalin reduced postoperative oxycodone consumption after cardiac surgery. Pregabalin-treated patients had less confusion, and additionally to less postoperative pain on the first postoperative day and during movement at three months post-surgery. Pregabalin might be a new alternative as analgesic for acute postoperative and chronic pain management in the elderly. Its clinical role and safety remains to be verified in large-scale randomized and controlled studies. In the future, many clinical trials in the older category of patients will be needed to facilitate improvements in health care methods.

Facilitated advocacy: supporting farmers to have a voice in policy making and the development of service provision

Listening to people, especially those who are poor, and involving them in policy making and decisions about service delivery processes are logical steps in building better services and improving policies aimed at poverty alleviation. This case describes a facilitated advocacy that helped to negotiate and support a role for poor people who farm and fish, to contribute recommendations for changes in services and policies that impact on their lives. The national Government of India’s Department of Animal Husbandry and Dairying and the Indian Council for Agricultural Research, both in the capital Delhi, have been linking with farmers and fishers and state government officials in the eastern states of Jharkhand, Orissa and West Bengal, in partnership with the STREAM Initiative of the intergovernmental Network of Aquaculture Centers in Asia Pacific and with the support of the UK Government Department for International Development, Natural resources Systems Program supporting farmers to have a voice(13 p.)

Panel Discussion - Management of Eurasian watermilfoil in the United States using native insects: State regulatory and management issues

While researchers have evaluated the potential of native insect herbivores to manage nonindigenous aquatic plant species such as Eurasian watermilfoil ( Myriophyllum spicatum L.), the practical matters of regulatory compliance and implementation have been neglected. A panel of aquatic nuisance species program managers from three state natural resource management agencies (Minnesota, Vermont and Washington) discussed their regulatory and policy concerns. In addition, one ecological consultant attempting to market one of the native insects to manage Eurasian watermilfoil added his perspective on the special challenges of distributing a native biological control agent for management of Eurasian watermilfoil.

A briefing on development and management of aquaculture-based fisheries enhancements

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National policy framework and strategy for fisheries and aquaculture development in Pakistan: final national workshop Islamabad, 30-31 Oct. 2006

The Final National Workshop was held from 30-31 October 2006 in Islamabad, Pakistan, with the objectives to:

Políticas sobre la integración de las TIC en la escuela de la Comunidad Autónoma del País Vasco

[ES]En la Comunidad Autónoma Vasca se han tomado una serie de decisiones estratégicas materializadas en diversas políticas, planes institucionales e iniciativas con el objeto de integrar, usar e innovar con TIC en las escuelas. Desde iniciativas pretéritas centradas básicamente en la dotación de infraestructuras, pasando por el perfeccionamiento del profesorado, actualmente existe un modelo que intenta unir de facto la política de infraestructura y la formación del los docentes para una utilización eficiente de las TIC. La descripción y el análisis del impacto de las mismas en el entorno escolar es el objetivo de esta investigación. En este estudio se ha llevado a cabo una metodología de corte cualitativo basada en la recogida de ideas, opiniones y valoraciones de políticos, técnicos, directores de centros, así como de profesores mediante entrevistas en profundidad (N=25). Los diferentes agentes educativos entrevistados reconocen que a día de hoy el modelo propuesto que unifica lo tecnológico, lo psicopedagógico y lo organizativo adolece de falta de información eficaz y de financiación impidiendo claramente un impacto real en las escuelas.

A review of the biology, ecology and management of Scirpus Olneyi. Volume 1: An annotated bibliography of selected references

This annotated bibliography of selected literature on Olney's three7square (Scirpus olneyi Gray )compiled basically for two reasons: 1) to assist a task force in its pursuit of an explanation for the substantial reduction in marsh acreage at the Blackwater National Wildlife Refuge in Dorchester County, Maryland, and 2) to serve as the author's foundation for the initiation of ecological research on this species as partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Botany Department of the University of Maryland. Both purposes are directly related in that the Author's research will be of use to the task force, along I with its other technical information and research results, in under-standing and possibly correcting the marshland loss problem at the Refuge. (PDF contains 100 pages)

The California Red Sea Urchin, Strongylocentrotus franciscanus, Fishery: Catch, Effort, and Management Trends

California's red sea urchin, Strongylocentrotus franciscanus, catch peaked at 23,577 metric tons (t) in 1988. Since then, catches and CPUE have trended downward at different rates in northern and southern California, with 10,086 t landed statewide in 1995. West coast sea urchin catches and CPUE from British Columbia, Can., to Baja California, Mex., have generally declined during this period which followed a decade of rapid fishery expansion. This expansion was in response to increasing demand from Japan fueled by rising prices based largely on a more favorable export currency exchange rate. West coast stock assessment methods have been based on integrating a combination of fisheries dependent data and population surveys into models at various levels of complexity. California management policy has centered on technical measures such as size limits and seasonal closures and has been largely ineffective in stabilizing declining catches.

Mesophotic coral ecosystems research strategy: international workshop to prioritize research and management needs for mesophotic coral ecosystems, Jupiter, Florida, 12-15 July 2008

On July 12-15, 2008, researchers and resource managers met in Jupiter, Florida to discuss and review the state of knowledge regarding mesophotic coral ecosystems, develop a working definition for these ecosystems, identify critical resource management information needs, and develop a Mesophotic Coral Ecosystems Research Strategy to assist the U.S. National Oceanic and Atmospheric Administration (NOAA) and other agencies and institutions in their research prioritization and strategic planning for mesophotic coral ecosystems. Workshop participants included representatives from international, Federal, and state governments; academia; and nongovernmental organizations. The Mesophotic Coral Ecosystems Workshop was hosted by the Perry Institute for Marine Science (PIMS) and organized by NOAA and the U.S. Geological Survey (USGS). The workshop goals, objectives, schedule, and products were governed by a Steering Committee consisting of members from NOAA (National Centers for Coastal Ocean Science’s Center for Sponsored Coastal Ocean Research, the Office of Ocean Exploration and Research’s NOAA Undersea Research Program, and the National Marine Fisheries Service), USGS, PIMS, the Caribbean Coral Reef Institute, and the Bishop Museum.

Agriculture, irrigation and poverty reduction in Cambodia: Policy narratives and ground realities compared

This report is a contribution to an assessment of the current status of agriculture in Cambodia, focusing on the linkages between agriculture and water, mainly in the form of irrigation. It seeks to view current government policies on agriculture and irrigation in the context of experiences on the ground, as communicated through the many field studies that cover varied aspects of performance in the agriculture sector and irrigation schemes. In an effort to identify future research areas, this review examines the status quo, and connects or disconnects with stated policy through a broad lens to capture strengths and challenges across crop production, irrigation management and post-harvest contexts. It places irrigation under scrutiny in terms of its value as a major area of government expenditure in recent years, and asks whether it presents the best potential for future gains in productivity, when compared with the prospects offered by investments in other aspects of agriculture. The fieldwork and review of current literature that form the basis of this report were undertaken at the request of, and partly funded by, the Australian Centre for International Agricultural Research (ACIAR). It is also intended to contribute knowledge to the CGIAR Research Program on Aquatic Agricultural Systems (AAS) led by WorldFish, who co-funded the activities.

Workshop on assessing governance in the Bay of Bengal Large Marine Ecosystem, Bangkok, Thailand, October 28-30, 2014: workshop summary and messages for Bay of Bengal marine resource policy-makers and other stakeholders

This brochure suggests casting a wider net when dealing with governance assessment to include other players.

Pretty good governance: balancing policy drivers and stakeholder interests in developing fisheries ecosystem plans

The central research question that this thesis addresses is whether there is a significant gap between fishery stakeholder values and the principles and policy goals implicit in an Ecosystem Approach to Fisheries Management (EAFM). The implications of such a gap for fisheries governance are explored. Furthermore an assessment is made of what may be practically achievable in the implementation of an EAFM in fisheries in general and in a case study fishery in particular. The research was mainly focused on a particular case study, the Celtic Sea Herring fishery and its management committee, the Celtic Sea Herring Management Advisory Committee (CSHMAC). The Celtic Sea Herring fishery exhibits many aspects of an EAFM and the fish stock has successfully recovered to healthy levels in the past 5 years. However there are increasing levels of governance related conflict within the fishery which threaten the future sustainability of the stock. Previous research on EAFM governance has tended to focus either on higher levels of EAFM governance or on individual behaviour but very little research has attempted to link the two spheres or explore the relationship between them. Two main themes within this study aimed to address this gap. The first was what role governance could play in facilitating EAFM implementation. The second theme concerned the degree of convergence between high-level EAFM goals and stakeholder values. The first method applied was governance benchmarking to analyse systemic risks to EAFM implementation. This found that there are no real EU or national level policies which provide stakeholders or managers with clear targets for EAFM implementation. The second method applied was the use of cognitive mapping to explore stakeholders understandings of the main ecological, economic and institutional driving forces in the Celtic Sea Herring fishery. The main finding from this was that a long-term outlook can and has been incentivised through a combination of policy drivers and participatory management. However the fundamental principle of EAFM, accounting for ecosystem linkages rather than target stocks was not reflected in stakeholders cognitive maps. This was confirmed in a prioritisation of stakeholders management priorities using Analytic Hierarchy Process which found that the overriding concern is for protection of target stock status but that wider ecosystem health was not a priority for most management participants. The conclusion reached is that moving to sustainable fisheries may be a more complex process than envisioned in much of the literature and may consist of two phases. The first phase is a transition to a long-term but still target stock focused approach. This achievable transition is mainly a strategic change, which can be incentivised by policies and supported by stakeholders. In the Celtic Sea Herring fishery, and an increasing number of global and European fisheries, such transitions have contributed to successful stock recoveries. The second phase however, implementation of an ecosystem approach, may present a greater challenge in terms of governability, as this research highlights some fundamental conflicts between stakeholder perceptions and values and those inherent in an EAFM. This phase may involve the setting aside of fish for non-valued ecosystem elements and will require either a pronounced mind-set and value change or some strong top-down policy incentives in order to succeed. Fisheries governance frameworks will need to carefully explore the most effective balance between such endogenous and exogenous solutions. This finding of low prioritisation of wider ecosystem elements has implications for rights based management within an ecosystem approach, regardless of whether those rights are individual or collective.

Education and Poverty: Confronting the Evidence

Current U.S. policy initiatives to improve the U.S. education system, including No Child Left Behind, test-based evaluation of teachers, and the promotion of competition are misguided because they either deny or set to the side a basic body of evidence documenting that students from disadvantaged households on average perform less well in school than those from more advantaged families. Because these policy initiatives do not directly address the educational challenges experienced by disadvantaged students, they have contributed little-and are not likely to contribute much in the future-to raising overall student achievement or to reducing achievement and educational attainment gaps between advantaged and disadvantaged students. Moreover, such policies have the potential to do serious harm. Addressing the educational challenges faced by children from disadvantaged families will require a broader and bolder approach to education policy than the recent efforts to reform schools. © 2012 by the Association for Public Policy Analysis and Management.