Assessment of Intervention Fidelity and Recommendations for Researchers Conducting Studies on the Diagnosis and Treatment of Chronic Cough in the Adult: CHEST Guideline and Expert Panel Report

BACKGROUND: Successful management of chronic cough has varied in the primary research studies in the reported literature. One of the potential reasons relates to a lack of intervention fidelity to the core elements of the diagnostic and/or therapeutic interventions that were meant to be used by the investigators.

METHODS: We conducted a systematic review to summarize the evidence supporting intervention fidelity as an important methodologic consideration in assessing the effectiveness of clinical practice guidelines used for the diagnosis and management of chronic cough. We developed and used a tool to assess for five areas of intervention fidelity. Medline (PubMed), Scopus, and the Cochrane Database of Systematic Reviews were searched from January 1998 to May 2014. Guideline recommendations and suggestions for those conducting research using guidelines or protocols to diagnose and manage chronic cough in the adult were developed and voted upon using CHEST Organization methodology.

RESULTS: A total of 23 studies (17 uncontrolled prospective observational, two randomized controlled, and four retrospective observational) met our inclusion criteria. These articles included 3,636 patients. Data could not be pooled for meta-analysis because of heterogeneity. Findings related to the five areas of intervention fidelity included three areas primarily related to the provider and two primarily related to the patients. In the area of study design, 11 of 23 studies appeared to be underpinned by a single guideline/protocol; for training of providers, two of 23 studies reported training, and zero of 23 reported the use of an intervention manual; and for the area of delivery of treatment, when assessing the treatment of gastroesophageal reflux disease, three of 23 studies appeared consistent with the most recent guideline/protocol referenced by the authors. For receipt of treatment, zero of 23 studies mentioned measuring concordance of patient-interventionist understanding of the treatment recommended, and zero of 23 mentioned measuring enactment of treatment, with three of 23 measuring side effects and two of 23 measuring adherence. The overall average intervention fidelity score for all 23 studies was poor (20.74 out of 48).

CONCLUSIONS: Only low-quality evidence supports that intervention fidelity strategies were used when conducting primary research in diagnosing and managing chronic cough in adults. This supports the contention that some of the variability in the reporting of patients with unexplained or unresolved chronic cough may be due to lack of intervention fidelity. By following the recommendations and suggestions in this article, researchers will likely be better able to incorporate strategies to address intervention fidelity, thereby strengthening the validity and generalizability of their results that provide the basis for the development of trustworthy guidelines.

Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review

BACKGROUND: Care of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan(®), AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel(®), Roche) and lorazepam (Ativan(®), Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor(®), Orion Corporation) and clonidine (Catapres(®), Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents.

OBJECTIVES: To conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs.

DATA SOURCES: We searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014.

METHODS: Evidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls(®), Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second reviewer cross-checked all the data extracted. Random-effects meta-analyses were used for data synthesis.

RESULTS: Eighteen RCTs (2489 adult patients) were included. One trial at unclear risk of bias compared dexmedetomidine with clonidine and found that target sedation was achieved in a higher number of patients treated with dexmedetomidine with lesser need for additional sedation. The remaining 17 trials compared dexmedetomidine with propofol or benzodiazepines (midazolam or lorazepam). Trials varied considerably with regard to clinical population, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded outcome assessors. Compared with propofol or benzodiazepines (midazolam or lorazepam), dexmedetomidine had no significant effects on mortality [risk ratio (RR) 1.03, 95% confidence interval (CI) 0.85 to 1.24, I (2) = 0%; p = 0.78]. Length of ICU stay (mean difference -1.26 days, 95% CI -1.96 to -0.55 days, I (2) = 31%; p = 0.0004) and time to extubation (mean difference -1.85 days, 95% CI -2.61 to -1.09 days, I (2) = 0%; p < 0.00001) were significantly shorter among patients who received dexmedetomidine. No difference in time to target sedation range was observed between sedative interventions (I (2) = 0%; p = 0.14). Dexmedetomidine was associated with a higher risk of bradycardia (RR 1.88, 95% CI 1.28 to 2.77, I (2) = 46%; p = 0.001).

LIMITATIONS: Trials varied considerably with regard to participants, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded assessors.

CONCLUSIONS: Evidence on the use of clonidine in ICUs is very limited. Dexmedetomidine may be effective in reducing ICU length of stay and time to extubation in critically ill ICU patients. Risk of bradycardia but not of overall mortality is higher among patients treated with dexmedetomidine. Well-designed RCTs are needed to assess the use of clonidine in ICUs and identify subgroups of patients that are more likely to benefit from the use of dexmedetomidine.

STUDY REGISTRATION: This study is registered as PROSPERO CRD42014014101.

FUNDING: The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.

Implantation de l'approche orientante dans une école secondaire état de la situation

Ce mémoire porte sur l'évaluation de l'implantation de l'approche orientante dans une école secondaire de l'Estrie. Les données ont été recueillies auprès des membres du personnel scolaire à l'aide d'un questionnaire développé en concertation avec le comité d'approche orientante de ce milieu. Les résultats indiquent d'une part, que le processus d'implantation de l'approche orientante est en cours mais qu'il n'est pas encore terminé et, d'autre part, qu'il existe des conditions gagnantes à l'implantation de ce concept dont une conception commune, la collaboration entre les acteurs, la formation du personnel, la mise en place de ressources et une évaluation continue des efforts entrepris.

Interventions propres à influencer l'engagement actif de l'élève dans la tâche proposée

Le présent projet de recherche vise à trouver et à valider des moyens pour diminuer les prétextes d’évitement des tâches d’élèves du primaire, autant en classe régulière qu’en éducation physique. Nous sommes deux enseignantes de champs différents qui cherchent à résoudre ce problème récurrent qui nuit au développement moteur de certains élèves en éducation physique et au développement académique d’élèves de classes régulières. Notre expérience nous indique qu’un choix d’activités stimulantes, variées et innovatrices ne semble pas suffisant pour favoriser l’engagement de tous les élèves d’un même groupe. Donc, il apparaît judicieux de trouver une ou plusieurs façons de résoudre ce problème, car il s’observe dans toutes les sphères d’enseignement. Avant d’expérimenter, nous allons déterminer quels peuvent être les prétextes d’évitement qu’évoquent les enfants pour refuser de réaliser les tâches demandées. Nous consulterons différents auteurs en psychologie de la motivation et en pédagogie de la motivation, autant dans le domaine de l’éducation physique qu’au niveau d’une classe régulière. Dans chacun des deux champs d’enseignement nous expérimenterons des moyens d’intervention afin de déterminer les possibilités d’actions communes utilisables pour tous les enseignants.

Argyrosomus regius (Asso, 1801) fishery and ecology in portuguese waters, with reference to its relationships to other european and african populations

Tese de doutoramento, Biologia (Biologia Marinha e Aquacultura), Universidade de Lisboa, Faculdade de Ciências, 2014

The role and performance of Herodotus as Narrator of the Histories

Thesis (Ph. D.)--University of Washington, 1987

Autumn Concert, November 11, 1990

Concert program for Autumn Concert, November 11, 1990

The Pirates of Penzance, March 10, 1987

Concert Program for The Pirates of Penzance, March 10, 1987

The Tales of Hoffmann November 10, 11, 12, 13, 1988

Concert Program for The Tales of Hoffmann November 10, 11, 12, 13 1988

Julietta May 12, 14, 15, 1988

Concert Program for Julietta May 12, 14, 15 1988

Chronique de l'histoire du monde, allant jusqu'au règne de Louis XII.

Elle est divisée en huit livres ; le dernier seul (fol. 71-79) est consacré aux rois de France. Elle commence (fol. 1) par : « Le premier livre de ceste presente cronique. De la creation du monde. Le premier jour Dieu crea les anges... » et finit (fol. 79 v°) par : «... Loys XIIe de ce non... qui a present regne en l'an de grace mil Ve et quatre ». A la fin du volume (fol. 80-84) est une traduction abrégée des Enseignements de saint Louis, commençant par : « Pour accomplissement de nostre euvre, j'ay redigé par escrit, selon la cronique latine, les beaux et bons enseignemens que le tres illustre et noble roy sainct Loys, roy de France... donnoit à son filz Philippes IIIe de ce non, jusques au nombre de XXXI... ». Au fol. A v° sont les armes d'Orléans, avec les deux vers suivants pour devise : « Cynthia, cresce, sua coeant tua cornua luce Aurea ; gryneis stabis adulta comis » .

Chronique de l'histoire du monde, allant jusqu'au règne de Louis XII.

Elle est divisée en huit livres ; le dernier seul (fol. 71-79) est consacré aux rois de France. Elle commence (fol. 1) par : « Le premier livre de ceste presente cronique. De la creation du monde. Le premier jour Dieu crea les anges... » et finit (fol. 79 v°) par : «... Loys XIIe de ce non... qui a present regne en l'an de grace mil Ve et quatre ». A la fin du volume (fol. 80-84) est une traduction abrégée des Enseignements de saint Louis, commençant par : « Pour accomplissement de nostre euvre, j'ay redigé par escrit, selon la cronique latine, les beaux et bons enseignemens que le tres illustre et noble roy sainct Loys, roy de France... donnoit à son filz Philippes IIIe de ce non, jusques au nombre de XXXI... ». Au fol. A v° sont les armes d'Orléans, avec les deux vers suivants pour devise : « Cynthia, cresce, sua coeant tua cornua luce Aurea ; gryneis stabis adulta comis » .

Analyses, persistence an degradation of the synthetic pyrethroid insecticides permethrin and fenvalerate

Studies on persistence and degradation of the synthetic pyrethroid insecticides, permethrin and fenvalerate, were carried out under natural environmental conditions of the Niagara Peninsula. Permethrin and fenvalerate were treated on apple foliage atrat~s of 0.21 kg(AI)!ha and 0.14 kg(AI)/ha, respectively. The initial cis- and trans-permethrin spray deposits were found to be 13.5 ppm and 19.2 ppm, respectively and 38.0 ppm was observed for the fenvalerate treated sample. Twenty-three days and 84 days after spray application, permethrin residues were 4.0 ppm and 2.7 ppm for the cis-isomer, whereas they were 7.9 ppm and 4.7 ppm for the trans-isomer, respectively. Residues of fenvalerate 23 days and 84 days after spray application were 13.4 ppm and 8.0 ppm, respectively. The values of observed half-life of cis-permethrin, trans-permethrin and fenvalerate were found to be 42 days, 46 days and 51 days, respectively. Studies were extended to quantitatively determine some of the major degradation compounds of permethrin and fenvalerate, which were expected to be produced as results of ester cleavage of the parent compounds. A permethrin treated sample, 84 days after initial spray application, showed 0.25 and 0.8 ppm of cis- and trans-3-(2,2-dichlorovinyl)-2,2-dimethylcyclopropanecarboxylic acid (C12CA (18), respectively. These two acids were not found as free acids, but found as conjugated compounds. The other expected degradation compounds, 3-phenoxybenzyl alcohol (PBalc (~)),3-phenoxybenz.aldehyde (PBald (38)) and 2- (4-chlorophenyl) isovaleric acid (CPIA (31)) were not detected by the methods employed in this study. The results indicate that these degradation compounds were not present, or, if they were present, their concentrations were too low to detect by the methods used.

Canada/U.S. border crossing: facilitation and constraint

Abstract The aim of this research project is to draw on accounts of experiences ofborder crossing and regulation at the Canada/U.S. border at Niagara in order to illuminate the dynamics of differentiation and inequality at this site. The research is informed by claims that the world is turning into a global village due to transnational flows oftechnology, infonnation, capital and people. Much of the available literature on globalization shows that while the transfer of technology, information, and capital are enhanced, the transnational movement of people is both facilitated and constrained in complex and unequal ways. In this project, the workings of facilitation and constraint were explored through an analysis often interviews with people who had spent a substantial portion oftheir childhood (e.g. 5 years) in a Canadian border community. The interviewees were at the time ofthe research between the ages of 19 and 25. Because most ofthe respondents were 'white' Canadians of working to upper middle class status, my focus was to explore how 'whiteness' as privilege may translate into enhanced movement across borders and how 'white' people may internalize and enjoy this privilege but may often deny its reality. I was also interested in how inequality is perceived, understood, and legitimated by these relatively privileged people. My analysis ofthe ten accounts ofborder crossing and regulation suggests that differentially situated people experience border crossing differently. An important finding is that while relatively privileged border crossers perceived and often problernatized differential treatment based on external factors such as physical appearance, and especially race, most did not challenge such treatment but rather saw it as acceptable. These findings are located within newer literature that addresses the increasing securitization ofborders and migration in western societies.