Time-differentiated target temperature management after out-of-hospital cardiac arrest: a multicentre, randomised, parallel-group, assessor-blinded clinical trial (the TTH48 trial): study protocol for a randomised controlled trial

BACKGROUND The application of therapeutic hypothermia (TH) for 12 to 24 hours following out-of-hospital cardiac arrest (OHCA) has been associated with decreased mortality and improved neurological function. However, the optimal duration of cooling is not known. We aimed to investigate whether targeted temperature management (TTM) at 33 ± 1 °C for 48 hours compared to 24 hours results in a better long-term neurological outcome. METHODS The TTH48 trial is an investigator-initiated pragmatic international trial in which patients resuscitated from OHCA are randomised to TTM at 33 ± 1 °C for either 24 or 48 hours. Inclusion criteria are: age older than 17 and below 80 years; presumed cardiac origin of arrest; and Glasgow Coma Score (GCS) <8, on admission. The primary outcome is neurological outcome at 6 months using the Cerebral Performance Category score (CPC) by an assessor blinded to treatment allocation and dichotomised to good (CPC 1-2) or poor (CPC 3-5) outcome. Secondary outcomes are: 6-month mortality, incidence of infection, bleeding and organ failure and CPC at hospital discharge, at day 28 and at day 90 following OHCA. Assuming that 50 % of the patients treated for 24 hours will have a poor outcome at 6 months, a study including 350 patients (175/arm) will have 80 % power (with a significance level of 5 %) to detect an absolute 15 % difference in primary outcome between treatment groups. A safety interim analysis was performed after the inclusion of 175 patients. DISCUSSION This is the first randomised trial to investigate the effect of the duration of TTM at 33 ± 1 °C in adult OHCA patients. We anticipate that the results of this trial will add significant knowledge regarding the management of cooling procedures in OHCA patients. TRIAL REGISTRATION NCT01689077.

Association of oliguria with the development of acute kidney injury in the critically ill

Urine output (UO) criterion may increase the sensitivity of the definition of acute kidney injury (AKI). We determined whether the empirically derived definition for oliguria(<0.5 ml/kg/h) is independently associated with adverse outcome. Data analysis included hourly recorded UO from the prospective, multicenter FINNAKI study conducted in 16 Finnish intensive care units. Confounder-adjusted association of oliguria of different severity and duration primarily with the development of AKI defined by creatinine criterion (Cr-AKI) or renal replacement therapy(RRT) was assessed. Secondarily, we determined the association of oliguria with 90-day mortality. Of the 1966 patients analyzed for the development of AKI, 454 (23.1%) reached this endpoint. Within this AKI cohort, 312 (68.7%)developed Cr-AKI, 21 (4.6%) commenced RRT without Cr-AKI, and 121 (26.7%) commenced RRT with Cr-AKI. Episodes of severe oliguria (<0.1 ml/kg/h) for more than 3 h were independently associated with the development of Cr-AKI or RRT. The shortest periods of consecutive oliguria independently associated with an increased risk for 90-day mortality were 6–12 h of oliguria from 0.3 to <0.5 ml/kg/h, over 6 h of oliguria from 0.1 to <0.3 ml/kg/h, and severe oliguria lasting over 3 h.Thus, our findings underlie the importance of hourly UO measurements.

Mean arterial pressure and vasopressor load after out-of-hospital cardiac arrest: Associations with one-year neurologic outcome

THE AIM OF THE STUDY There are limited data on blood pressure targets and vasopressor use following cardiac arrest. We hypothesized that hypotension and high vasopressor load are associated with poor neurological outcome following out-of-hospital cardiac arrest (OHCA). METHODS We included 412 patients with OHCA included in FINNRESUSCI study conducted between 2010 and 2011. Hemodynamic data and vasopressor doses were collected electronically in one, two or five minute intervals. We evaluated thresholds for time-weighted (TW) mean arterial pressure (MAP) and outcome by receiver operating characteristic (ROC) curve analysis, and used multivariable analysis adjusting for co-morbidities, factors at resuscitation, an illness severity score, TW MAP and total vasopressor load (VL) to test associations with one-year neurologic outcome, dichotomized into either good (1-2) or poor (3-5) according to the cerebral performance category scale. RESULTS Of 412 patients, 169 patients had good and 243 patients had poor one-year outcomes. The lowest MAP during the first six hours was 58 (inter-quartile range [IQR] 56-61) mmHg in those with a poor outcome and 61 (59-63) mmHg in those with a good outcome (p<0.01), and lowest MAP was independently associated with poor outcome (OR 1.02 per mmHg, 95% CI 1.00-1.04, p=0.03). During the first 48h the median (IQR) of the TW mean MAP was 80 (78-82) mmHg in patients with poor, and 82 (81-83) mmHg in those with good outcomes (p=0.03) but in multivariable analysis TWA MAP was not associated with outcome. Vasopressor load did not predict one-year neurologic outcome. CONCLUSIONS Hypotension occurring during the first six hours after cardiac arrest is an independent predictor of poor one-year neurologic outcome. High vasopressor load was not associated with poor outcome and further randomized trials are needed to define optimal MAP targets in OHCA patients.

Prognostic Value of Secretoneurin in Critically Ill Patients With Infections.

OBJECTIVES Secretoneurin is produced in neuroendocrine cells, and the myocardium and circulating secretoneurin levels provide incremental prognostic information to established risk indices in cardiovascular disease. As myocardial dysfunction contributes to poor outcome in critically ill patients, we wanted to assess the prognostic value of secretoneurin in two cohorts of critically ill patients with infections. DESIGN Two prospective, observational studies. SETTING Twenty-four and twenty-five ICUs in Finland. PATIENTS A total of 232 patients with severe sepsis (cohort #1) and 94 patients with infections and respiratory failure (cohort #2). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We measured secretoneurin levels by radioimmunoassay in samples obtained early after ICU admission and compared secretoneurin with other risk indices. In patients with severe sepsis, admission secretoneurin levels (logarithmically transformed) were associated with hospital mortality (odds ratio, 3.17 [95% CI, 1.12-9.00]; p = 0.030) and shock during the hospitalization (odds ratio, 2.17 [1.06-4.46]; p = 0.034) in analyses that adjusted for other risk factors available on ICU admission. Adding secretoneurin levels to age, which was also associated with hospital mortality in the multivariate model, improved the risk prediction as assessed by the category-free net reclassification index: 0.35 (95% CI, 0.06-0.64) (p = 0.02). In contrast, N-terminal pro-B-type natriuretic peptide levels were not associated with mortality in the multivariate model that included secretoneurin measurements, and N-terminal pro-B-type natriuretic peptide did not improve patient classification on top of age. Secretoneurin levels were also associated with hospital mortality after adjusting for other risk factors and improved patient classification in cohort #2. In both cohorts, the optimal cutoff for secretoneurin levels at ICU admission to predict hospital mortality was ≈ 175 pmol/L, and higher levels were associated with mortality also when adjusting for Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores. CONCLUSIONS Secretoneurin levels provide incremental information to established risk indices for the prediction of mortality and shock in critically ill patients with severe infections.

The origins of art; a psychological & sociological inquiry,

"Authorities quoted": p. [307]-322.

An activity theory approach to strategy as practice

This chapter introduces activity theory as an approach for studying strategy as practice. Activity theory conceptualizes the ongoing construction of activity as a product of activity systems, comprising the actor, the community with which that actor interacts and those symbolic and material tools that mediate between actors, their community and their pursuit of activity. The focus on the mediating role of tools and cultural artefacts in human activity seems especially promising for advancing the strategy-as-practice agenda, for example as a theoretical resource for the growing interest in sociomateriality and the role of tools and artefacts in (strategy) practice (for example, Balogun et al. 2014; Lanzara 2009; Nicolini 2009; Spee and Jarzabkowski 2009; Stetsenko 2005). Despite its potential, in a recent review Vaara and Whittington (2012) identified only three strategy-as-practice articles explicitly applying an activity theory lens. In the wider area of practice-based studies in organizations, activity theory has been slightly more popular (for example, Blackler 1993; 1995; Blackler, Crump and McDonald 2000; Engeström, Kerosuo and Kajamaa 2007; Groleau 2006; Holt 2008; Miettinen and Virkkunen 2005). It still lags behind its potential, however, primarily because of its origins as a social psychology theory developed in Russia with little initial recognition outside the Russian context, particularly in the area of strategy and organization theory, until recently (Miettinen, Samra-Fredericks and Yanow 2009). This chapter explores activity theory as a resource for studying strategy as practice as it is socially accomplished by individuals in interaction with their wider social group and the artefacts of interaction. In particular, activity theory’s focus on actors as social individuals provides a conceptual basis for studying the core question in strategy-as-practice research: what strategy practitioners do. The chapter is structured in three parts. First, an overview of activity theory is provided. Second, activity theory as a practice-based approach to studying organizational action is introduced and an activity system conceptual framework is developed. Third, the elements of the activity system are explained in more detail and explicitly linked to each of the core SAP concepts: practitioners, practices and praxis. In doing so, links are made to existing strategy-as-practice research, with brief empirical examples of topics that might be addressed using activity theory. Throughout the chapter, we introduce key authors in the development of activity theory and its use in management and adjacent disciplinary fields, as further resources for those wishing to make greater use of activity theory.

Lyyli: viisinäytöksinen näytelmä

Nimiösivulla myös: Ensimmäisen kerran esitetty Suomen kansallisteatterissa 25 p. helmikuuta 1903.

Rakkautta

Lisäpainokset: 2. p. 1908 (179 s.).

Water sorption-induced crystallization, structural relaxations and strength analysis of relaxation times in amorphous lactose/whey protein systems

Water sorption-induced crystallization, α-relaxations and relaxation times of freeze-dried lactose/whey protein isolate (WPI) systems were studied using dynamic dewpoint isotherms (DDI) method and dielectric analysis (DEA), respectively. The fractional water sorption behavior of lactose/WPI mixtures shown at aw ≤ 0.44 and the critical aw for water sorption-related crystallization (aw(cr)) of lactose were strongly affected by protein content based on DDI data. DEA results showed that the α-relaxation temperatures of amorphous lactose at various relaxation times were affected by the presence of water and WPI. The α-relaxation-derived strength parameter (S) of amorphous lactose decreased with aw up to 0.44 aw but the presence of WPI increased S. The linear relationship for aw(cr) and S for lactose/WPI mixtures was also established with R2 > 0.98. Therefore, DDI offers another structural investigation of water sorption-related crystallization as governed by aw(cr), and S may be used to describe real time effects of structural relaxations in noncrystalline multicomponent solids.

Djurens roll i förskolan : En fallstudie om två förskolor med djurinriktning

Studiens syfte är att, genom observationer, undersöka djurens roll i förskolans verksamhet. Syftet är således att skildra de pedagogiska lärprocesser som förekommer i förskolor som involverar djur i sin dagliga verksamhet, bidra med kunskaper om hur djur kan påverka förskolans verksamhet och hur djurhållning kan tillämpas i den traditionella förskolan. Vårt teoretiska ramverk utgår ifrån sociokulturellt perspektiv med inriktning mot Vygotskijs och Leontyevs ”Aktivitetstrianglar” som Engeström sedan utformade grafiskt. Ramverket möjliggör användningen av begrepp som till exempel artefakter, mediering, objekt och subjekt vilket skapar en röd tråd genom hela studien. Metoden som valts är en kvalitativ fallstudie och genom denna metod kan fördjupning göras av hur två specifika förskolor med djur i verksamheten fungerar. Studiens frågeställningar bygger på ett kunskaps intresse och har fungerat som en vägledning genom studien. Frågeställningarna är: hur är djur involverade i lärandeaktiviteterna på lantbruksförskolan och hur är djur involverade i lärandeaktiviteterna på djurparksförskolan. Observationerna skedde på två olika förskolor och för att komplettera data genomfördes också samtal med förskollärarna i verksamheten. Observationerna och samtalen analyserades utifrån en tematisk analysmetod som kompletterades med en narrativ analysmetod för att ge ett djupare resultat. Resultatet visade på att det fanns både skillnader och likheter mellan förskolorna som observerades. Baserat på resultatet fördes en diskussion kring hur skillnaderna och likheterna på förskolorna med djurinriktning kunde appliceras på en traditionell förskola. Slutsatsen visar att det är möjligt att använda djur i en traditionell förskola men att tillämpningen beror på den enskilda förskolans förutsättningar.

A formação inicial e desenvolvimento profissional de educadores/professores monodocentes: os desafios do isomorfismo pedagógico

Neste texto trazemos a campo uma reflexão sobre o modo como concebemos a docência e desenvolvemos o trabalho na formação inicial e contínua de educadores-professores na Universidade de Évora. Fazemo-la a partir das nossas vivências e práticas, na formação inicial e contínua de educadores de infância (EI) e professores do 1º Ciclo do Ensino Básico (1º CEB) ao longo dos últimos quinze anos. Invocamos a nossa participação enquanto membros integrados numa equipa mais alargada de docentes, partilhando a adequação do que vamos fazendo face ao perfil de educador/professor para o qual pretendemos contribuir, não apenas porque ele está legislado, mas também porque nos pautamos pela mais recente investigação em educação infantil, perseguindo nesta etapa da construção da profissionalidade docente, aquelas que consideramos serem as mais prementes necessidades da sociedade no séc. XXI. Focalizamos esta reflexão no caso particular dos educadores de infância (professores da educação infantil dos 0 aos 6 anos) e dos professores do 1.º ciclo do ensino básico (CEB) (1ª a 4ª série do ensino fundamental dos 6 aos 10 anos), ou seja, monodocentes porque são professores que se encarregam das aprendizagens curriculares das crianças contemplando várias áreas do saber, cuja abordagem integradora é da sua responsabilidade. Iniciamos com uma breve apresentação, daqueles que pensamos serem os desafios do mundo atual que se colocam aos professores e à sua formação profissionalizante. Fundamentamos a nossa análise da formação inicial de educadores/professores na Teoria da Atividade (TA) de Leontiev (1978), mais tarde desenvolvida por Engeström (2001), entre outros, a partir das ideias de Vygostsky (1994). Partindo do pressuposto que a aprendizagem se dá por um processo de participação em práticas sociais que contêm o conhecimento construído ao longo da história dos homens, recorremos ao conceito de isomorfismo pedagógico (Niza, 2009) para (re)pensar os contextos e os processos em que os estudantes de formação de professores se apropriam e constroem o conhecimento profissional. Nesta partilha sobre a formação para a docência evidenciamos igualmente a importância das interacções que mantemos com o Movimento da Escola Moderna (MEM) portuguesa, um movimento de professores com um património único na construção do saber profissional: “O Movimento da Escola Moderna tem procurado investir a experiência dos professores, do ponto de vista teórico e conceptual, contribuindo para o desenvolvimento científico da profissão docente” (Nóvoa, 1992, p. 25 ). Apontamos assim para as opções estratégicas que temos vindo a desenvolver no sentido de procurar o isomorfismo pedagógico, capaz de sustentar esta formação de educadores/professores, de os estimular para um papel novo no contexto actual e de, enquanto docentes neste percurso profissionalizante, nos desafiarmos a reflexões permanentes em desejadas e construções de conhecimento tornadas possíveis porque realizadas em conjunto com os nossos alunos, docentes cooperantes e parcerias institucionais.