The Evaluation of an Interdisciplinary Pain Protocol in Long Term Care

Objectives: To evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents. Design: A controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data. Setting: Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group. Participants: Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group. Intervention: Implementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities. Measurements: Resident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews. Results: Pain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol. Conclusions: These study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents.

From Negation to Agreement: Revisiting the Problem of Sources for Socio-Historical Linguistics

In this article we review recent work on the history of French negation in relation to three key issues in socio-historical linguistics: identifying appropriate sources, interpreting scant or anomalous data, and interpreting generational differences in historical data. We then turn to a new case study, that of verbal agreement with la plupart, to see whether this can shed fresh light on these issues. We argue that organising data according to the author’s date of birth is methodologically sounder than according to date of publication. We explore the extent to which different genres and text types reflect changing patterns of usage and suggest that additional, different case-studies are required in order to make more secure generalisations about the reliability of different sources.

Optimizing antibiotics in residents of nursing homes:protocol of a randomized trial.

BACKGROUND: Antibiotics are frequently prescribed for older adults who reside in long-term care facilities. A substantial proportion of antibiotic use in this setting is inappropriate. Antibiotics are often prescribed for asymptomatic bacteriuria, a condition for which randomized trials of antibiotic therapy indicate no benefit and in fact harm. This proposal describes a randomized trial of diagnostic and therapeutic algorithms to reduce the use of antibiotics in residents of long-term care facilities. METHODS: In this on-going study, 22 nursing homes have been randomized to either use of algorithms (11 nursing homes) or to usual practise (11 nursing homes). The algorithms describe signs and symptoms for which it would be appropriate to send urine cultures or to prescribe antibiotics. The algorithms are introduced by inservicing nursing staff and by conducting one-on-one sessions for physicians using case-scenarios. The primary outcome of the study is courses of antibiotics per 1000 resident days. Secondary outcomes include urine cultures sent and antibiotic courses for urinary indications. Focus groups and semi-structured interviews with key informants will be used to assess the process of implementation and to identify key factors for sustainability.

A systematic review protocol on the use of online learning and blended learning for teaching clinical skills to undergraduate health professional students

Aim: This paper is a review protocol that will be used to identify, critically appraise and synthesize the best current evidence relating to the use of online learning and blended learning approaches in teaching clinical skills in undergraduate nursing.

Background: Although previous systematic reviews on online learning versus face to face learning have been undertaken (Cavanaugh et al. 2010, Cook et al. 2010), a systematic review on the impact of online learning and blended learning for teaching clinical skills has yet to be considered in undergraduate nursing. By reviewing nursing students’ online learning experiences, systems can potentially be designed to ensure all students’ are supported appropriately to meet their learning needs.

Methods/Design: The key objectives of the review are to evaluate how online-learning teaching strategies assist nursing students learn; to evaluate the students satisfaction with this form of teaching; to explore the variety of online-learning strategies used; to determine what online-learning strategies are more effective and to determine if supplementary face to face instruction enhances learning. A search of the following databases will be made MEDLINE, CINAHL, BREI, ERIC and AUEI. This review will follow the Joanna Briggs Institute guidance for systematic reviews of quantitative and qualitative research.

Conclusion: This review intends to report on a combination of student experience and learning outcomes therefore increasing its utility for educators and curriculum developers involved in healthcare education.

Physical activity and the rejuvenation of Connswater (PARC study): protocol for a natural experiment investigating the impact of urban regeneration on public health

Background: There is a dearth of evidence regarding the impact of urban regeneration projects on public health, particularly the nature and degree to which urban regeneration impacts upon health-related behaviour change. Natural experiment methodology enables comprehensive large-scale evaluations of such interventions. The Connswater Community Greenway in Belfast is a major urban regeneration project involving the development of a 9 km linear park, including the provision of new cycle paths and walkways. In addition to the environmental improvements, this complex intervention involves a number of programmes to promote physical activity in the regenerated area. The project affords a unique opportunity to investigate the public health impact of urban regeneration.

Methods/Design: The evaluation framework was informed by the socio-ecological model and guided by the RE-AIM Framework. Key components include: (1) a quasi-experimental before-and-after survey of the Greenway population (repeated cross-sectional design), in tandem with data from a parallel Northern Ireland-wide survey for comparison; (2) an assessment of changes in the local built environment and of walkability using geographic information systems; (3) semi-structured interviews with a purposive sample of survey respondents, and a range of community stakeholders, before and after the regeneration project; and (4) a cost-effectiveness analysis. The primary outcome is change in proportion of individuals identified as being regularly physically active, according to the current UK recommendations. The RE-AIM Framework will be used to make an overall assessment of the impact of the Greenway on the physical activity behaviour of local residents.

Discussion: The Connswater Community Greenway provides a significant opportunity to achieve long-term, population level behaviour change. We argue that urban regeneration may be conceptualised meaningfully as a complex intervention comprising multiple components with the potential, individually and interactively, to affect the behaviour of a diverse population. The development and implementation of our comprehensive evaluation framework reflects this complexity and illuminates an approach to the empirical, rigorous evaluation of urban regeneration. More specifically, this study will add to the much needed evidence-base about the impact of urban regeneration on public health as well as having important implications for the development of natural experiment methodology.

Herschel key program HERITAGE:A far-infrared source catalog for the Magellanic Clouds

Observations from the HERschel Inventory of the Agents of Galaxy Evolution (HERITAGE ) have been used to identify dusty populations of sources in the Large and Small Magellanic Clouds (LMC and SMC). We conducted the study using the HERITAGE catalogs of point sources available from the Herschel Science Center from both the Photodetector Array Camera and Spectrometer (PACS; 100 and 160 μm) and Spectral and Photometric Imaging Receiver (SPIRE; 250, 350, and 500 μm) cameras. These catalogs are matched to each other to create a Herschel band-merged catalog and then further matched to archival Spitzer IRAC and MIPS catalogs from the Spitzer Surveying the Agents of Galaxy Evolution (SAGE) and SAGE-SMC surveys to create single mid- to far-infrared (far-IR) point source catalogs that span the wavelength range from 3.6 to 500 μm. There are 35,322 unique sources in the LMC and 7503 in the SMC. To be bright in the FIR, a source must be very dusty, and so the sources in the HERITAGE catalogs represent the dustiest populations of sources. The brightest HERITAGE sources are dominated by young stellar objects (YSOs), and the dimmest by background galaxies. We identify the sources most likely to be background galaxies by first considering their morphology (distant galaxies are point-like at the resolution of Herschel) and then comparing the flux distribution to that of the Herschel Astrophysical Terahertz Large Area Survey (ATLAS ) survey of galaxies. We find a total of 9745 background galaxy candidates in the LMC HERITAGE images and 5111 in the SMC images, in agreement with the number predicted by extrapolating from the ATLAS flux distribution. The majority of the Magellanic Cloud-residing sources are either very young, embedded forming stars or dusty clumps of the interstellar medium. Using the presence of 24 μm emission as a tracer of star formation, we identify 3518 YSO candidates in the LMC and 663 in the SMC. There are far fewer far-IR bright YSOs in the SMC than the LMC due to both the SMC's smaller size and its lower dust content. The YSO candidate lists may be contaminated at low flux levels by background galaxies, and so we differentiate between sources with a high ("probable") and moderate ("possible ") likelihood of being a YSO. There are 2493/425 probable YSO candidates in the LMC/SMC. Approximately 73% of the Herschel YSO candidates are newly identified in the LMC, and 35% in the SMC. We further identify a small population of dusty objects in the late stages of stellar evolution including extreme and post-asymptotic giant branch, planetary nebulae, and supernova remnants. These populations are identified by matching the HERITAGE catalogs to lists of previously identified objects in the literature. Approximately half of the LMC sources and one quarter of the SMC sources are too faint to obtain accurate ample FIR photometry and are unclassified.

THE SAAF STUDY: evaluation of the Safeguarding Children Assessment and Analysis Framework (SAAF), compared with management as usual, for improving outcomes for children and young people who have experienced, or are at risk of, maltreatment: study protocol for a randomised controlled trial

Background: Serious case reviews and research studies have indicated weaknesses in risk assessments conducted by child protection social workers. Social workers are adept at gathering information but struggle with analysis and assessment of risk. The Department for Education wants to know if the use of a structured decision-making tool can improve child protection assessments of risk.

Methods/design: This multi-site, cluster-randomised trial will assess the effectiveness of the Safeguarding Children Assessment and Analysis Framework (SAAF). This structured decision-making tool aims to improve social workers' assessments of harm, of future risk and parents' capacity to change. The comparison is management as usual.

Inclusion criteria: Children's Services Departments (CSDs) in England willing to make relevant teams available to be randomised, and willing to meet the trial's training and data collection requirements.

Exclusion criteria: CSDs where there were concerns about performance; where a major organisational restructuring was planned or under way; or where other risk assessment tools were in use.

Six CSDs are participating in this study. Social workers in the experimental arm will receive 2 days training in SAAF together with a range of support materials, and access to limited telephone consultation post-training. The primary outcome is child maltreatment. This will be assessed using data collected nationally on two key performance indicators: the first is the number of children in a year who have been subject to a second Child Protection Plan (CPP); the second is the number of re-referrals of children because of related concerns about maltreatment. Secondary outcomes are: i) the quality of assessments judged against a schedule of quality criteria and ii) the relationship between the three assessments required by the structured decision-making tool (level of harm, risk of (re) abuse and prospects for successful intervention).

Discussion: This is the first study to examine the effectiveness of SAAF. It will contribute to a very limited literature on the contribution that structured decision-making tools can make to improving risk assessment and case planning in child protection and on what is involved in their effective implementation.

A realistic evaluation of track and trigger systems and acute care training for early recognition and treatment of deteriorating ward-based patients: research protocol.

Aim The aim of the study is to evaluate factors that enable or constrain the implementation and service delivery of early warnings systems or acute care training in practice. Background To date there is limited evidence to support the effectiveness of acute care initiatives (early warning systems, acute care training, outreach) in reducing the number of adverse events (cardiac arrest, death, unanticipated Intensive Care admission) through increased recognition and management of deteriorating ward based patients in hospital [1-3]. The reasons posited are that previous research primarily focused on measuring patient outcomes following the implementation of an intervention or programme without considering the social factors (the organisation, the people, external influences) which may have affected the process of implementation and hence measured end-points. Further research which considers the social processes is required in order to understand why a programme works, or does not work, in particular circumstances [4]. Method The design is a multiple case study approach of four general wards in two acute hospitals where Early Warning Systems (EWS) and Acute Life-threatening Events Recognition and Treatment (ALERT) course have been implemented. Various methods are being used to collect data about individual capacities, interpersonal relationships and institutional balance and infrastructures in order to understand the intended and unintended process outcomes of implementing EWS and ALERT in practice. This information will be gathered from individual and focus group interviews with key participants (ALERT facilitators, nursing and medical ALERT instructors, ward managers, doctors, ward nurses and health care assistants from each hospital); non-participant observation of ward organisation and structure; audit of patients' EWS charts and audit of the medical notes of patients who deteriorated during the study period to ascertain whether ALERT principles were followed. Discussion & progress to date This study commenced in January 2007. Ethical approval has been granted and data collection is ongoing with interviews being conducted with key stakeholders. The findings from this study will provide evidence for policy-makers to make informed decisions regarding the direction for strategic and service planning of acute care services to improve the level of care provided to acutely ill patients in hospital. References 1. Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidain A et al. Investigating the effectiveness of Critical Care Outreach Services: A systematic review. Intensive Care Medicine 2006; 32: 1713-1721 2. McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems for the prevention of Intensive Care admission and death of critically ill patients on general hospital wards. Cochrane Database of Systematic Reviews 2007, Issue 3. www.thecochranelibrary.com 3. Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ (2007) Rapid Response Systems: A systematic review. Critical Care Medicine 2007; 35 (5): 1238-43 4. Pawson R and Tilley N. Realistic Evaluation. London; Sage: 1997

Fluid strategies and outcomes in patients with acute respiratory distress syndrome, systemic inflammatory response syndrome and sepsis: a protocol for a systematic review and meta-analysis

Background
Fluid administration to critically ill patients remains the subject of considerable controversy. While intravenous fluid given for resuscitation may be life-saving, a positive fluid balance over time is associated with worse outcomes in critical illness. The aim of this systematic review is to summarise the existing evidence regarding the relationship between fluid administration or balance and clinically important patient outcomes in critical illness.

Methods
We will search Medline, EMBASE, the Cochrane Central Register of Controlled Trials from 1980 to the present and key conference proceedings from 2009 to the present. We will include studies of critically ill adults and children with acute respiratory distress syndrome (ARDS), sepsis and systemic inflammatory response syndrome (SIRS). We will include randomised controlled trials comparing two or more fluid regimens of different volumes of fluid and observational studies reporting the relationship between volume of fluid administered or fluid balance and outcomes including mortality, lengths of intensive care unit and hospital stay and organ dysfunction. Two independent reviewers will assess articles for eligibility, data extraction and quality appraisal. We will conduct a narrative and/or meta-analysis as appropriate.

Discussion
While fluid management has been extensively studied and discussed in the critical care literature, no systematic review has attempted to summarise the evidence for post-resuscitation fluid strategies in critical illness. Results of the proposed systematic review will inform practice and the design of future clinical trials.

Systematic review registration
PROSPERO CRD42013005608. (http://​www.​crd.​york.​ac.​uk/​PROSPERO/​)

Gender comparisons in non-acute cardiac symptom recognition and subsequent help-seeking decisions: a mixed methods study protocol

Introduction: Coronary heart disease (CHD) is one of the leading causes of death in both men and women worldwide. Despite the common misconception that CHD is a ‘man's disease’, it is now well accepted that women endure worse clinical outcomes than men following CHD-related events. A number of studies have explored whether or not gender differences exist in patients presenting with CHD, and specifically whether women delay seeking help for cardiac conditions. UK and overseas studies on help-seeking for emergency cardiac events are contradictory, yet suggest that women often delay help-seeking. In addition, no studies have looked at presumed cardiac symptoms outside an emergency situation. Given the lack of understanding in this area, an explorative qualitative study on the gender differences in help-seeking for a non-emergency cardiac events is needed. Methods and analysis: A purposive sample of 20–30 participants of different ethnic backgrounds and ages attending a rapid access chest pain clinic will be recruited to achieve saturation. Semistructured interviews focusing on help-seeking decision-making for apparent cardiac symptoms will be undertaken. Interview data will be analysed thematically using qualitative software (NVivo) to understand any similarities and differences between the way men and women construct help-seeking. Findings will also be used to inform the preliminary development of a cardiac help-seeking intentions questionnaire. Ethics and dissemination: Ethical approvals were sought and granted. Namely, the University of Westminster (sponsor) and St Georges NHS Trust REC, and the Trust Research and Development Office granted approval to host the study on the Queen Mary's Roehampton site. The study is low risk, with interviews being conducted on hospital premises during working hours. Investigators will disseminate findings via presentations and publications. Participants will receive a written summary of the key findings.

Dissertation protocol writing methodology

Animation with key areas of consideration includes audio. This version has a scaleable player

Colombia y el transpacific partnership agreement

Colombia, a partir de 1990, inicia un plan de gobierno enfocado en la apertura económica, con estrategias que propugnaban por un cambio en el modelo económico a través de políticas como la reducción de aranceles a las importaciones y otra serie de medidas proteccionistas, flexibilización laboral, la reducción del papel del Estado para darle protagonismo al sector privado y procesos de privatización de empresas públicas En este entorno internacional se ha adquirido conciencia de que, en un mundo globalizado y cada vez más interdependiente, no puede haber espacio para “aventuras solitarias de Estados soberanos”, lo que justifica la proliferación de organizaciones multilaterales en América Latina y el Caribe en la última década. Recientemente Colombia ha mostrado su interés en entrar a formar parte de un bloque económico de gran relevancia a nivel internacional: el "Transpacific Partnership Agreement" (TPP); tratado integrado por: Canadá, Estados Unidos, México, Perú, Chile, Japón, Vietnam, Malasia, Singapur, Brunei, Australia y Nueva Zelanda, representando el 35% del PIB mundial y el 11% de la población. El presente trabajo pretende presentar una visión objetiva del TPP, generando el espacio para la libre interpretación de sus beneficios o perjuicios. Para ello, se analiza el estado actual del TPP con sus principales indicadores, su desempeño en los últimos años y las relaciones diplomáticas y los flujos comerciales entre Colombia y los países miembros del mismo.

Doha/COP 18: gateway to a new climate change agreement. CEPS Commentary, 13 December 2012

Drawing on his recent experience in the climate negotiations in Doha as an advisor and negotiator on a wide variety of issues, Andrei Marcu offers his assessment of the progress achieved in the two weeks of intensive talks. In spite of modest results, he describes the talks as an important and necessary step in the revolution, first ignited at the Montreal negotiations in 2005, that rejected the top-down Kyoto Protocol model in favour of a bottom-up climate change regime. In his view, the decisions taken in Doha enable the start of a new negotiating process aimed at delivering a new global climate agreement.

Motivation, rationale and key results from the GERBILS Saharan dust measurement campaign

The Geostationary Earth Radiation Budget Intercomparison of Longwave and Shortwave radiation (GERBILS) was an observational field experiment over North Africa during June 2007. The campaign involved 10 flights by the FAAM BAe-146 research aircraft over southwestern parts of the Sahara Desert and coastal stretches of the Atlantic Ocean. Objectives of the GERBILS campaign included characterisation of mineral dust geographic distribution and physical and optical properties, assessment of the impact upon radiation, validation of satellite remote sensing retrievals, and validation of numerical weather prediction model forecasts of aerosol optical depths (AODs) and size distributions. We provide the motivation behind GERBILS and the experimental design and report the progress made in each of the objectives. We show that mineral dust in the region is relatively non-absorbing (mean single scattering albedo at 550 nm of 0.97) owing to the relatively small fraction of iron oxides present (1–3%), and that detailed spectral radiances are most accurately modelled using irregularly shaped particles. Satellite retrievals over bright desert surfaces are challenging owing to the lack of spectral contrast between the dust and the underlying surface. However, new techniques have been developed which are shown to be in relatively good agreement with AERONET estimates of AOD and with each other. This encouraging result enables relatively robust validation of numerical models which treat the production, transport, and deposition of mineral dust. The dust models themselves are able to represent large-scale synoptically driven dust events to a reasonable degree, but some deficiencies remain both in the Sahara and over the Sahelian region, where cold pool outflow from convective cells associated with the intertropical convergence zone can lead to significant dust production.

Identifying key knowledge needs for evidence-based conservation of wild insect pollinators: a collaborative cross-sectoral exercise

In response to evidence of insect pollinator declines, organisations in many sectors, including the food and farming industry, are investing in pollinator conservation. They are keen to ensure that their efforts use the best available science. We convened a group of 32 ‘conservation practitioners’ with an active interest in pollinators and 16 insect pollinator scientists. The conservation practitioners include representatives from UK industry (including retail), environmental non-government organisations and nature conservation agencies. We collaboratively developed a long list of 246 knowledge needs relating to conservation of wild insect pollinators in the UK. We refined and selected the most important knowledge needs, through a three-stage process of voting and scoring, including discussions of each need at a workshop. We present the top 35 knowledge needs as scored by conservation practitioners or scientists. We find general agreement in priorities identified by these two groups. The priority knowledge needs will structure ongoing work to make science accessible to practitioners, and help to guide future science policy and funding. Understanding the economic benefits of crop pollination, basic pollinator ecology and impacts of pesticides on wild pollinators emerge strongly as priorities, as well as a need to monitor floral resources in the landscape.