Use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: Cochrane systematic review and meta-analysis.

Objective To investigate the effects of weaning protocols on the total duration of mechanical ventilation, mortality, adverse events, quality of life, weaning duration, and length of stay in the intensive care unit and hospital.

Design Systematic review.

Data sources Cochrane Central Register of Controlled Trials, Medline, Embase, CINAHL, LILACS, ISI Web of Science, ISI Conference Proceedings, Cambridge Scientific Abstracts, and reference lists of articles. We did not apply language restrictions.

Review methods We included randomised and quasi-randomised controlled trials of weaning from mechanical ventilation with and without protocols in critically ill adults.

Data selection Three authors independently assessed trial quality and extracted data. A priori subgroup and sensitivity analyses were performed. We contacted study authors for additional information.

Results Eleven trials that included 1971 patients met the inclusion criteria. Compared with usual care, the geometric mean duration of mechanical ventilation in the weaning protocol group was reduced by 25% (95% confidence interval 9% to 39%, P=0.006; 10 trials); the duration of weaning was reduced by 78% (31% to 93%, P=0.009; six trials); and stay in the intensive care unit length by 10% (2% to 19%, P=0.02; eight trials). There was significant heterogeneity among studies for total duration of mechanical ventilation (I(2)=76%, P

Conclusion There is evidence of a reduction in the duration of mechanical ventilation, weaning, and stay in the intensive care unit when standardised weaning protocols are used, but there is significant heterogeneity among studies and an insufficient number of studies to investigate the source of this heterogeneity. Some studies suggest that organisational context could influence outcomes, but this could not be evaluated as it was outside the scope of this review.

International perspectives on the influence of structure and process of weaning from mechanical ventilation.

Background 
Recently, clinical and research attention has been focused on refining weaning processes to improve outcomes for critically ill patients who require mechanical ventilation. One such process, use of a weaning protocol, has yielded conflicting results, arguably because of the influence of existing context and processes.

Objective 
To compare international data to assess differences in context and processes in intensive care units that could influence weaning.  

Methods 
Review of existing national data on provision of care for critically ill patients, including structure, staffing, skill mix, education, roles, and responsibilities for weaning in intensive care units of selected countries.

Results 
Australia, New Zealand, Denmark, Norway, Sweden, and the United Kingdom showed similarities in critical care provision, structure, skill mix, and staffing ratios in intensive care units. Weaning in these countries is generally a collaborative process between nurses and physicians. Notable differences in intensive care units in the United States were the frequent use of an open structure and inclusion of respiratory therapists on the intensive care unit’s health care team. Nurses may be excluded from direct management of ventilator weaning in some institutions, as this role is primarily assumed by respiratory therapists guided by medical directives. Availability of critical care beds was highest in the United States and lowest in the United Kingdom.

Conclusion 
Context and processes of care that could influence ventilator weaning outcomes varied considerably across countries. Further quantification of these contextual influences should be considered when translating research findings into local clinical practice and when designing randomized, controlled trials.

Exploring the adoption and implementation of discrete and integrated IT systems: A Framework for analysis

Despite the substantial organisational benefits of integrated IT, the implementation of such systems – and particularly Enterprise Resource Planning (ERP) systems – has tended to be problematic, stimulating an extensive body of research into ERP implementation. This research has remained largely separate from the main IT implementation literature. At the same time, studies of IT implementation have generally adopted either a factor or process approach; both have major limitations. To address these imitations, factor and process perspectives are combined here in a unique model of IT implementation. We argue that • the organisational factors which determine successful implementation differ for integrated and traditional, discrete IT • failure to manage these differences is a major source of integrated IT failure. The factor/process model is used as a framework for proposing differences between discrete and integrated IT.

Ankle disease in juvenile idiopathic arthritis: ultrasound findings in clinically swollen ankles

The ankle joint is frequently involved in juvenile idiopathic arthritis (JIA), but it is unclear whether this is predominantly due to synovitis, tenosynovitis, or both. We performed clinic-based ultrasound examination to assess the prevalence of synovitis and tenosynovitis in children with JIA felt clinically to have active inflammatory disease of the ankle.

An interprofessional approach to improving paediatric medication safety.

BACKGROUND: Safe drug prescribing and administration are essential elements within undergraduate healthcare curricula, but medication errors, especially in paediatric practice, continue to compromise patient safety. In this area of clinical care, collective responsibility, team working and communication between health professionals have been identified as key elements in safe clinical practice. To date, there is limited research evidence as to how best to deliver teaching and learning of these competencies to practitioners of the future.

METHODS: An interprofessional workshop to facilitate learning of knowledge, core competencies, communication and team working skills in paediatric drug prescribing and administration at undergraduate level was developed and evaluated. The practical, ward-based workshop was delivered to 4th year medical and 3rd year nursing students and evaluated using a pre and post workshop questionnaire with open-ended response questions.

RESULTS: Following the workshop, students reported an increase in their knowledge and awareness of paediatric medication safety and the causes of medication errors (p < 0.001), with the greatest increase noted among medical students. Highly significant changes in students' attitudes to shared learning were observed, indicating that safe medication practice is learnt more effectively with students from other healthcare disciplines. Qualitative data revealed that students' participation in the workshop improved communication and teamworking skills, and led to greater awareness of the role of other healthcare professionals.

CONCLUSION: This study has helped bridge the knowledge-skills gap, demonstrating how an interprofessional approach to drug prescribing and administration has the potential to improve quality and safety within healthcare.

Fully hardware based WFQ architecture for high-speed QoS packet scheduling

A full hardware implementation of a Weighted Fair Queuing (WFQ) packet scheduler is proposed. The circuit architecture presented has been implemented using Altera Stratix II FPGA technology, utilizing RLDII and QDRII memory components. The circuit can provide fine granularity Quality of Service (QoS) support at a line throughput rate of 12.8Gb/s in its current implementation. The authors suggest that, due to the flexible and scalable modular circuit design approach used, the current circuit architecture can be targeted for a full ASIC implementation to deliver 50 Gb/s throughput. The circuit itself comprises three main components; a WFQ algorithm computation circuit, a tag/time-stamp sort and retrieval circuit, and a high throughput shared buffer. The circuit targets the support of emerging wireline and wireless network nodes that focus on Service Level Agreements (SLA's) and Quality of Experience.

Holothurians – potential biomonitors for metal levels in deep-sea sediments

Levels of cadmium, copper, aluminium, iron, manganese and zinc (Cd, Cu, Al, Fe, Mn and Zn) in deep-sea sediments and sediment-feeding holothurians are reported. Profiles of metals were found to vary with depth in the sediment. Holothurian foregut metal values are generally closer to surficial sediment levels, whereas body wall levels, with the exception of Cd and Cu, were generally lower. Holothurians are presented as potential biomonitors of metal concentrations in the deep-sea floor environment.

Composition profiling of seized ecstasy tablets by Raman spectroscopy

Raman spectroscopy with far-red excitation has been investigated as a simple and rapid technique for composition profiling of seized ecstasy (MDMA, N-methyl-3,4-methylenedioxyamphetamine) tablets. The spectra obtained are rich in vibrational bands and allow the active drug and excipient used to bulk the tablets to be identified. Relative band heights can be used to determine drug/excipient ratios and the degree of hydration of the drug while the fact that 50 tablets per hour can be analysed allows large numbers of spectra to be recorded. The ability of Raman spectroscopy to distinguish between ecstasy tablets on the basis of their chemical composition is illustrated here by a sample set of 400 tablets taken from a large seizure of > 50000 tablets that were found in eight large bags. The tablets are all similar in appearance and carry the same logo. Conventional analysis by GC-MS showed they contained MDMA. Initial Raman studies of samples from each of the eight bags showed that despite some tablet-to-tablet variation within each bag the contents could be classified on the basis of the excipients used. The tablets in five of the bags were sorbitol-based, two were cellulose-based and one bag contained tablets with a glucose excipient. More extensive analysis of 50 tablets from each of a representative series of sample bags gave distribution profiles that showed the contents of each bag were approximately normally distributed about a mean value, rather than being mixtures of several discrete types. Two of the sorbitol-containing sample sets were indistinguishable while a third was similar but not identical to these, in that it contained the same excipient and MDMA with the same degree of hydration but had a slightly different MDMA/sorbitol ratio. The cellulose-based samples were badly manufactured and showed considerable tablet-to-tablet variation in their drug/excipient ratio while the glucose-based tablets had a tight distribution in their drug/excipient ratios. The degree of hydration in the MDMA feedstocks used to manufacture the cellulose-, glucose- and sorbitol-based tablets were all different from each other. This study, because it centres on a single seizure of physically similar tablets with the same active drug, highlights the fact that simple physical descriptions coupled with active drug content do not in themselves fully characterize the nature of the seized materials. There is considerable variation in the composition of the tablets within this single seizure and the fact that this variation can be detected from Raman spectra demonstrates that the potential benefits of obtaining highly detailed spectra can indeed translate into information that is not readily available from other methods but would be useful for tracing of drug distribution networks.

Rapid analysis of ecstasy and related phenethylamines in seized tablets by Raman spectroscopy

Raman spectroscopy with far-red excitation has been used to study seized, tableted samples of MDMA (N-methyl-3,4-methylenedioxyamphetamine) and related compounds (MDA, MDEA, MBDB, 2C-B and amphetamine sulfate), as well as pure standards of these drugs. We have found that by using far-red (785 nm) excitation the level of fluorescence background even in untreated seized samples is sufficiently low that there is little difficulty in obtaining good quality data with moderate 2 min data accumulation times. The spectra can be used to distinguish between even chemically-similar substances, such as the geometrical isomers MDEA and MBDB, and between different polymorphic/hydrated forms of the same drug. Moreover, these differences can be found even in directly recorded spectra of seized samples which have been bulked with other materials, giving a rapid and non-destructive method for drug identification. The spectra can be processed to give unambiguous identification of both drug and excipients (even when more than one compound has been used as the bulking agent) and the relative intensities of drug and excipient bands can be used for quantitative or at least semi-quantitative analysis. Finally, the simple nature of the measurements lends itself to automatic sample handling so that sample throughputs of 20 samples per hour can be achieved with no real difficulty.