Vancomycin-resistant enterococcus outbreak in a pediatric intensive care unit: report of successful interventions for control and prevention

The objective of this study is to retrospectively report the results of interventions for controlling a vancomycin-resistant enterococcus (VRE) outbreak in a tertiary-care pediatric intensive care unit (PICU) of a University Hospital. After identification of the outbreak, interventions were made at the following levels: patient care, microbiological surveillance, and medical and nursing staff training. Data were collected from computer-based databases and from the electronic prescription system. Vancomycin use progressively increased after March 2008, peaking in August 2009. Five cases of VRE infection were identified, with 3 deaths. After the interventions, we noted a significant reduction in vancomycin prescription and use (75% reduction), and the last case of VRE infection was identified 4 months later. The survivors remained colonized until hospital discharge. After interventions there was a transient increase in PICU length-of-stay and mortality. Since then, the use of vancomycin has remained relatively constant and strict, no other cases of VRE infection or colonization have been identified and length-of-stay and mortality returned to baseline. In conclusion, we showed that a bundle intervention aiming at a strict control of vancomycin use and full compliance with the Hospital Infection Control Practices Advisory Committee guidelines, along with contact precautions and hand-hygiene promotion, can be effective in reducing vancomycin use and the emergence and spread of vancomycin-resistant bacteria in a tertiary-care PICU.

Safety and outcome of coronary interventions with special reference to anticoagulation and stent type

University of Turku, Faculty of Medicine, Department of Cardiology and Cardiovascular Medicine, Doctoral Programme of Clinical Investigation, Heart Center, Turku University Hospital, Turku, Finland Division of Internal Medicine, Department of Cardiology, Seinäjoki Central Hospital, Seinäjoki, Finland Heart Center, Satakunta Central Hospital, Pori, Finland Annales Universitatis Turkuensis Painosalama Oy, Turku, Finland 2015 Antithrombotic therapy during and after coronary procedures always entails the challenging establishment of a balance between bleeding and thrombotic complications. It has been generally recommended to patients on long-term warfarin therapy to discontinue warfarin a few days prior to elective coronary angiography or intervention to prevent bleeding complications. Bridging therapy with heparin is recommended for patients at an increased risk of thromboembolism who require the interruption of anticoagulation for elective surgery or an invasive procedure. In study I, consecutive patients on warfarin therapy referred for diagnostic coronary angiography were compared to control patients with a similar disease presentation without warfarin. The strategy of performing coronary angiography during uninterrupted therapeutic warfarin anticoagulation appeared to be a relatively safe alternative to bridging therapy, if the international normalized ratio level was not on a supratherapeutic level. In-stent restenosis remains an important reason for failure of long-term success after a percutaneous coronary intervention (PCI). Drug-eluting stents (DES) reduce the problem of restenosis inherent to bare metal stents (BMS). However, a longer delay in arterial healing may extend the risk of stent thrombosis (ST) far beyond 30 days after the DES implantation. Early discontinuation of antiplatelet therapy has been the most important predisposing factor for ST. In study II, patients on long-term oral anticoagulant (OAC) underwent DES or BMS stenting with a median of 3.5 years’follow-up. The selective use of DESs with a short triple therapy seemed to be safe in OAC patients, since late STs were rare even without long clopidogrel treatment. Major bleeding and cardiac events were common in this patient group irrespective of stent type. In order to help to predict the bleeding risk in patients on OAC, several different bleeding risk scorings have been developed. Risk scoring systems have also been used also in the setting of patients undergoing a PCI. In study III, the predictive value of an outpatient bleeding risk index (OBRI) to identify patients at high risk of bleeding was analysed. The bleeding risk seemed not to modify periprocedural or long-term treatment choices in patients on OAC after a percutaneous coronary intervention. Patients with a high OBRI often had major bleeding episodes, and the OBRI may be suitable for risk evaluation in this patient group. Optical coherence tomography (OCT) is a novel technology for imaging intravascular coronary arteries. OCT is a light-based imaging modality that enables a 12–18 µm tissue axial resolution to visualize plaques in the vessel, possible dissections and thrombi as well as, stent strut appositions and coverage, and to measure the vessel lumen and lesions. In study IV, 30 days after titanium-nitride-oxide (TITANOX)-coated stent implantation, the binary stent strut coverage was satisfactory and the prevalence of malapposed struts was low as evaluated by OCT. Long-term clinical events in patients treated with (TITANOX)-coated bio-active stents (BAS) and paclitaxel-eluting stents (PES) in routine clinical practice were examined in study V. At the 3-year follow-up, BAS resulted in better long-term outcome when compared with PES with an infrequent need for target vessel revascularization. Keywords: anticoagulation, restenosis, thrombosis, bleeding, optical coherence tomography, titanium

Climate Change and Ethics of Geoengineering -- Implications Of Climate Emergency Ethics

Global climate change and intentional climate modification, i.e. geoengineering include various ethical problems which are entangled as a complex ensemble of questions regarding the future of the biosphere. The possibilities of catastrophic effects of climate change which are also called “climate emergency” have led to the emergence of the idea of modifying the atmospheric conditions in the form of geoengineering. The novel issue of weather ethics is a subdivision of climate ethics, and it is interested in ethical and political questions surrounding weather and climate control and modification in a restricted spatio-temporal scale. The objective of geoengineering is to counterbalance the adverse effects of climate change and its diverse corollaries in various ways on a large scale. The claim of this dissertation is that there are ethical justifications to claim that currently large-scale interventions to the climate system are ethically questionable. The justification to pursue geoengineering on the basis of considering its pros and cons, is inadequate. Moral judgement can still be elaborated in cases where decisions have to be made urgently and the selection of desirable choices is severely limited. The changes needed to avoid severe negative impacts of climate change requires commitment to mitigation as well as social changes because technical solutions cannot address the issue of climate change altogether. The quantitative emphasis of consumerism should shift to qualitative focus on the aspiration for simplicity in order to a move towards the objective of the continuation of the existence of humankind and a flourishing, vital biosphere.

Finance-Led Growth Regime no Brasil: estatuto teórico, evidências empíricas e consequências macroeconômicas

This paper analyzes the Brazilian growth pattern during the post-liberalization period, emphasizing the structural links between finance and productive capital accumulation. The results indicate a finance-led growth regime in the period 2004-2008, under a very specific financialization process. The first part is a survey of the international literature, which defines the financialization concept and its relevance for understanding Brazilian economic problems. The next part provides a historical overview on the structural changes that made possible the development of financial-led regimes. The paper also applies an empirical analysis of some selected Brazilian macroeconomic indicators.

Consumer-led new product development. Case: Dairy Industry

This thesis focuses on consolidation the recommendations on the integration of consumer in new product development (NPD) given in the academic literature, and on the example of the three NPD projects in the case company. The empirical findings advocate that the case company fulfills the principles of consumer-led NPD, and it is only one-step away of the full consumer empowerment strategy. Therefore, its NPD can be seen as an example of consumer-led NPD implementation. The findings also suggest that the product can be developed in consumer-led way regardless of the source of an idea (product- or need-driven), the target audience and resources assigned, in case when consumer mindset is integrated on all levels of organisation: strategic, cultural, operational and process. It is possible with top-management commitment, internal consumer research group, and the sophisticated consumer research methods. The specific managerial recommendations are given on developing consumer-led culture, strategy, NPD process and the appropriate consumer research methods and techniques.

Histoire, par JEAN LE FERON, de la maison d'Harcourt, depuis Bernard, seigneur d'Harcourt, qui est donné comme vivant sous Rollon, premier duc de Normandie, jusqu'à Claude, sire de Rieux, sixième comte d'Harcourt, lequel vivait sous François Ier, roi de France. Premiers mots : « Chacune nation se donne la gloire et honneur d'estre produite et yssue de la noblesse des Troyens... ». Derniers mots : « ... led. sieur Claude de Ryeux, delivré de l'emprisonnement moyennant sa ransson par luy payée ». (Fol. 1 à 36 et 39 à 52).

Contient : « Extraict tiré de Longey, 5 lieues de Falaize, autour d'une salle », concernant « messire Jehan de Harcourt, dict le preuxdhomme, conte d'Aresecot,... messire Robert de Harcourt, conte d'Aresecot,... messire Richard de Harcourt, conte d'Aresecot,... messire Raoul d'Harcourt, conte d'Aresecot... » ; « Genealogie de Harcourt » ; Un acte de HENRI IV, roi de France, portant « erection du marquisat de La Motte Harcourt » au bailliage de Caen, en faveur de « Pierre de Ha[r]court », gentilhomme de sa chambre et capitaine de cinquante hommes d'armes de ses ordonnances, et des héritiers dudit Pierre d'Harcourt. St-Denis en France, août 1593. Copie

« Extrait de l'amortissement general fait par le roy François I, roy de France, des biens des ecclesiastiques non amortis, sceans et scituez ez dioceses de Sens, Chartres, Orleans et Meaux, moyennant le prix et somme pour lesd. quatre diocezes de 63,000 livres tournois, sçavoir pour le dioceze de Sens 20,000, pour celuy de Chartres 24,000, pour celluy d'Orleans 12,000 et pour celluy de Meaux 7,000 », contenant seulement « une Declaration tirée de la chambre des comptes de Paris, du revenu, terres et heritages de l'abbaye du Pont aux Dames, qui fut taxée, pour sa part et cotization, à la somme de 120 livres, etc., led. amortissement fait le 3 septembre 1522 ». (Fol. 4).

Contient : Ce premier extrait est suivi de la « coppie de tiltres et admortissemens de l'eglise et abbaye N. D. du Pont aux Dames, de l'ordre de Cisteaulx, ou diocese de Meauls en Brye, faicte par l'ordonnance du roy, en l'an 1547 »

Early detection and intervention for infants at risk of autism spectrum disorders

Autism is a developmental disorder that is characterized by abnonnal social interactions and communications as well as repetitive and restricted activities and interests. There is evidence of a genetic component, as 5% of younger siblings are diagnosed if their older sibling has been diagnosed. Autism is generally not diagnosed until age 3 at the earliest, yet it has been shown that early intervention for children with autism can greatly increase their functioning. Because of this, it is important that symptoms of autism are identified as early as possible so that diagnosis can occur as soon as possible to allow these children the earliest intervention. This thesis was divided into two parts. The first looked at the psychometrics of two proposed measures, the Parent Observation Checklist (POC), administered monthly, and the Infant Behavior Summary Evaluation (mSE), administered bimonthly, to see if they can be used with the infant population to identify autistic symptoms in infants who are at high risk for autism or related problems because they have an older sibling with autism. Study 1 reported acceptable psychometric properties of both the POC and IBSE in terms of test-retest reliability, internal consistency, construct validity and predictive validity. These results provide preliminary evidence that parent report measures can help to detect early symptoms of ASD in infants. The POC was shown to differentiate infants who were diagnosed from a matched group that was not diagnosed by 3 years of age. The second part of this thesis involved a telephone interview of parents who reported developmental and/or behavior problems in their high-risk infants that may be early signs of Autism Spectrum Disorder (ASD). During the interview, a service questionnaire was administered to see what interventions (including strategies recommended by the researchers) their at risk infants and affected older siblings were receiving, how satisfied the parents were with them and how effective they felt the interventions were. 3 Study 2 also yielded promising results. Parents utilized a variety of services for at risk infants and children with ASD. The interventions included empirically validated early intervention (e.g., ABA) to non-empirically validated treatments (e.g., diet therapy). The large number of nonempirically validated treatments parents used was surprising, yet parents reported being involved and satisfied, and thought that the services were effective. Parents' perceptions of their stress levels went down slightly and feelings of competence rose when they accessed services for their infants. Overall, the results of this thesis provide new evidence that parent-report methods hold promise as early detection instruments for ASD in at-risk infants. More research is needed to further validate these instruments as well as to understand the variables related to the parents' choice of early intervention for their at risk and affected children.

Changing roles of nurse educators employed in acute and chronic care settings : the impact of professional and statutory mandates in Ontario at four sites of one hospital corporation /

The role of the hospital-employed nurse educator is evolving. Factors influencing this change include the introduction of standards for nurse educators by the College of Nurses of Ontario (CNO), a change in the way nurses are educated, the emergence of nursing as a profession, and hospital restructuring as a result of budgetary constraints. Two of these influencing factors: the introduction of the updated Standards of Practice for Registered Nurses and Registered Practical Nurses (1996) and hospital restructuring occurred over the last 7 years at several hospitals in southern Ontario. Current literature as well as the Standards of Practice (1996) were utilized to examine the current roles and responsibilities of nurse educators and subsequently develop a questionnaire to study the impact of these influencing factors on the role of the nurse educator. This questionnaire was piloted and revised before its distribution at 4 hospitals in southern Ontario. Twenty-five of the 41 surveys (61%) distributed were returned for analysis. The data reflected that the Standards of Practice had a positive influence on the role of the nurse educator, while hospital restructuring had a negative impact. In addition, many of the roles and responsibilities identified in the literature were indeed part of the current role of nurse educators, as well as several responsibilities not captured in the literature. The predictions for the future of this role in its current state were not positive given the financial status of the health care system as well as the lack of clarity for the role and the current level ofjob satisfaction among practicing nurse educators. However, a list of recommendations were generated which, if implemented, could add clarity to the role and improve job satisfaction. This could enhance the retention of current nurse educators and the possibility of recruiting competent nurse educators to the role in the future.

Learning to be literate : parental empowerment in early literacy interventions

Considerable research has focused on the success of early intervention programs for children. However, minimal research has focused on the effect these programs have on the parents of targeted children. Many current early intervention programs champion family-focused and inclusive programming, but few have evaluated parent participation in early interventions and fewer still have evaluated the impact of these programs on beliefs and attitudes and parenting practices. Since parents will continue to play a key role in their child's developmental course long after early intervention programs end, it is vital to examine whether these programs empower parents to take action to make changes in the lives of their children. The goal of this study was to understand parental influences on the early development of literacy, and in particular how parental attitudes, beliefs and self efficacy impact parent and child engagement in early literacy intervention activities. A mixed method procedure using quantitative and qualitative strategies was employed. A quasi-experimental research design was used. The research sample, sixty parents who were part of naturally occurring community interventions in at- risk neighbourhoods in a south-western Ontario city participated in the quantitative phase. Largely individuals whose home language was other than English, these participants were divided amongst three early literacy intervention groups, a Prescriptive Interventionist type group, a Participatory Empowering type group and a drop-in parent- child neighbourhood Control group. Measures completed pre and post a six session literacy intervention, on all three literacy and evidence of change in parental empowerment. Parents in all three groups, on average, held beliefs about early literacy that were positive and that were compatible with current approaches to language development and emergent literacy. No significant change in early literacy beliefs and attitudes for pre to post intervention was found. Similarly, there was no significant difference between groups on empowerment scores, but there was a significant change post intervention in one group's empowerment score. There was a drop in the empowerment score for the Prescriptive Interventionist type group, suggesting a drop in empowerment level. The qualitative aspect of this study involved six in-depth interviews completed with a sub-set of the sixty research participants. Four similar themes emerged across the groups: learning takes place across time and place; participation is key; success is achieved by taking small steps; and learning occurs in multiple ways. The research findings have important implications for practitioners and policy makers who target at risk populations with early intervention programming and wish to sustain parental empowerment. Study results show the value parents place on early learning and point to the importance of including parents in the development and delivery of early intervention programs. groups, were analyzed for evidence of change in parental attitudes and beliefs about early literacy and evidence of change in parental empowerment. Parents in all three groups, on average, held beliefs about early literacy that were positive and that were compatible with current approaches to language development and emergent literacy. No significant change in early literacy beliefs and attitudes for pre to post intervention was found. Similarly, there was no significant difference between groups on empowerment scores, but there was a significant change post intervention in one group's empowerment score. There was a drop in the empowerment score for the Prescriptive Interventionist type group, suggesting a drop in empowerment level. The qualitative aspect of this study involved six in-depth interviews completed with a sub-set of the sixty research participants. Four similar themes emerged across the groups: learning takes place across time and place; participation is key; success is achieved by taking small steps; and learning occurs in multiple ways. The research findings have important implications for practitioners and policy makers who target at risk populations with early intervention programming and wish to sustain parental empowerment. Study results show the value parents place on early learning and point to the importance of including parents in the development and delivery of early intervention programs.

Opening a can of worms : perceptions and practices of teachers in Newfoundland and Labrador incorporating the role of a therapist

Educational trends of inclusion and collaboration have led to changing roles of teachers, including an emphasis on personal support. To provide for social, emotional, and behavioural needs, teachers may adopt a therapeutic role. Many models for such support are proposed, with most models including the importance of student-teacher relationships, a focus on social, emotional, and behavioural development, and direct instruction of related skills. This study includes 20 interview participants. In addition, 4 of the 20 interview participants also took part in a case study. It examines whether participants adopt a therapeutic role, their beliefs about student-teacher relationships, whether they provide interventions in personal issues, and instructed social, emotional, and behaviour skills. Findings show that teachers adopt an academic role as well as a therapeutic role, believe student-teacher relationships are important, are approached about personal issues, and instruct social, emotional, and behavioural skills. Talking and listening are commonly used to provide support, typically exclusive of formal curricular goals. The challenges in providing front-line support issues that may be shared within an established student-teacher relationship are considered. Support in turn for teachers who choose to provide support for personal issues in the classroom within a therapeutic role are suggested, including recommendations for support and referral related to specific social, emotional, or behavioural scenarios that may arise in the school community.

Reflective practice and the novice nurse /

The importance of reflective practice to the novice nurse was explored in this study. The novice nurse, for the purpose of this study, was defined as a Registered Nurse who graduated from an accredited nursing program within a 1 2-month period prior to the data collection date and who had no prior experience as a Registered Nurse before graduation. All of the nurses enrolled in this study were female. This study explored the perceived link between transformational learning and reflective practice, and whether there may be a need to standardize a conceptual framework and definition for reflective practice in nursing academia. The literature that was reviewed for this study indicated that there were inconsistencies in the application of reflective practice within academic curriculums. The literature did identify that the majority of academic scholars have agreed that reflection is paramount in the development of critical thinking skills, self-awareness, and selfdirection. And, while all of these skills drive professional practice and effect excellent patient care, institutional health care has been reticent to support the value of reflective practice because of a lack of empirical data sets. The 4 novice Registered Nurses who participated in this study were asked 4 openended questions that provided a foundation for comparing the novice nurses' experiences, interpretations, and perceptions of reflective practice. These nurses participated in individual audiotaped interviews with the researcher. The study was based upon Heath's (1998) model of "Theory hitegration via Reflective Practice." The results demonstrated that reflective practice was significant to the novice nurse and was used as a tool to identify further learning needs. Transformational learning through reflection was described by the study participants. The findings within this study are consistent with previous work done in the area of reflection and the novice nurse.

Facilitating self-directed learning: the nurse educators' perspective

The concept of self-directed learning was examined from the nurse educators' perspective. One structured interview, lasting between one and one-and-a half hours, was conducted with each of 14 nurse educators in two community college continuing education programs in nursing. One community college program encourages selfdirected learning; the other encourages self-study and active participation in the teaching/learning process. All 14 interviews were tape-recorded and transcribed verbatim. Verbatim transcripts were analyzed for themes, patterns, and relationships utilizing analyst-constructed typologies. six prerequisites or necessary conditions for facilitating self-directed learning in a community college continuing education program in nursing were identified. ~he crucial issue in facilitating self-directed learning was found to be the issue of teacher-control.