Factors that impact on the use of mechanical ventilation weaning protocols in critically ill adults and children: a qualitative-evidence synthesis

Background:
Prolonged mechanical ventilation is associated with a longer intensive care unit (ICU) length of stay and higher mortality. Consequently, methods to improve ventilator weaning processes have been sought. Two recent Cochrane systematic reviews in ICU adult and paediatric populations concluded that protocols can be effective in reducing the duration of mechanical ventilation, but there was significant heterogeneity in study findings. Growing awareness of the benefits of understanding the contextual factors impacting on effectiveness has encouraged the integration of qualitative evidence syntheses with effectiveness reviews, which has delivered important insights into the reasons underpinning (differential) effectiveness of healthcare interventions.

Objectives:
1. To locate, appraise and synthesize qualitative evidence concerning the barriers and facilitators of the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

2. To integrate this synthesis with two Cochrane effectiveness reviews of protocolized weaning to help explain observed heterogeneity by identifying contextual factors that impact on the use of protocols for weaning critically-ill adults and children from mechanical ventilation;

3. To use the integrated body of evidence to suggest the circumstances in which weaning protocols are most likely to be used.

Search methods:
We used a range of search terms identified with the help of the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) mnemonic. Where available, we used appropriate methodological filters for specific databases. We searched the following databases: Ovid MEDLINE, Embase, OVID, PsycINFO, CINAHL Plus, EBSCOHost, Web of Science Core Collection, ASSIA, IBSS, Sociological Abstracts, ProQuest and LILACS on the 26th February 2015. In addition, we searched: the grey literature; the websites of professional associations for relevant publications; and the reference lists of all publications reviewed. We also contacted authors of the trials included in the effectiveness reviews as well as of studies (potentially) included in the qualitative synthesis, conducted citation searches of the publications reporting these studies, and contacted content experts.

We reran the search on 3rd July 2016 and found three studies, which are awaiting classification.

Selection criteria:
We included qualitative studies that described: the circumstances in which protocols are designed, implemented or used, or both, and the views and experiences of healthcare professionals either involved in the design, implementation or use of weaning protocols or involved in the weaning of critically-ill adults and children from mechanical ventilation not using protocols. We included studies that: reflected on any aspect of the use of protocols, explored contextual factors relevant to the development, implementation or use of weaning protocols, and reported contextual phenomena and outcomes identified as relevant to the effectiveness of protocolized weaning from mechanical ventilation.

Data collection and analysis:
At each stage, two review authors undertook designated tasks, with the results shared amongst the wider team for discussion and final development. We independently reviewed all retrieved titles, abstracts and full papers for inclusion, and independently extracted selected data from included studies. We used the findings of the included studies to develop a new set of analytic themes focused on the barriers and facilitators to the use of protocols, and further refined them to produce a set of summary statements. We used the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) framework to arrive at a final assessment of the overall confidence of the evidence used in the synthesis. We included all studies but undertook two sensitivity analyses to determine how the removal of certain bodies of evidence impacted on the content and confidence of the synthesis. We deployed a logic model to integrate the findings of the qualitative evidence synthesis with those of the Cochrane effectiveness reviews.

Main results:
We included 11 studies in our synthesis, involving 267 participants (one study did not report the number of participants). Five more studies are awaiting classification and will be dealt with when we update the review.

The quality of the evidence was mixed; of the 35 summary statements, we assessed 17 as ‘low’, 13 as ‘moderate’ and five as ‘high’ confidence. Our synthesis produced nine analytical themes, which report potential barriers and facilitators to the use of protocols. The themes are: the need for continual staff training and development; clinical experience as this promotes felt and perceived competence and confidence to wean; the vulnerability of weaning to disparate interprofessional working; an understanding of protocols as militating against a necessary proactivity in clinical practice; perceived nursing scope of practice and professional risk; ICU structure and processes of care; the ability of protocols to act as a prompt for shared care and consistency in weaning practice; maximizing the use of protocols through visibility and ease of implementation; and the ability of protocols to act as a framework for communication with parents.

Authors' conclusions:
There is a clear need for weaning protocols to take account of the social and cultural environment in which they are to be implemented. Irrespective of its inherent strengths, a protocol will not be used if it does not accommodate these complexities. In terms of protocol development, comprehensive interprofessional input will help to ensure broad-based understanding and a sense of ‘ownership’. In terms of implementation, all relevant ICU staff will benefit from general weaning as well as protocol-specific training; not only will this help secure a relevant clinical knowledge base and operational understanding, but will also demonstrate to others that this knowledge and understanding is in place. In order to maximize relevance and acceptability, protocols should be designed with the patient profile and requirements of the target ICU in mind. Predictably, an under-resourced ICU will impact adversely on protocol implementation, as staff will prioritize management of acutely deteriorating and critically-ill patients.

Understanding and modelling hydrological and soil erosion processes in burnt forest catchments

Forest fires implications in overland flow and soil erosion have been researched for several years. Therefore, is widely known that fires enhance hydrological and geomorphological activity worldwide as also in Mediterranean areas. Soil burn severity has been widely used to describe the impacts of fire on soils, and has being recognized as a decisive factor controlling post-fire erosion rates. However, there is no unique definition of the term and the relationship between soil burn severity and post-fire hydrological and erosion response has not yet been fully established. Few studies have assessed post-fire erosion over multiple years, and the authors are aware of none which assess runoff. Small amount of studies concerning pre-fire management practices were also found. In the case of soil erosion models, the Revised Universal Soil Loss Equation (RUSLE) and the revised Morgan–Morgan–Finney (MMF) are well-known models, but not much information is available as regards their suitability in predicting post-fire soil erosion in forest soils. The lack of information is even more pronounced as regards post-fire rehabilitation treatments. The aim of the thesis was to perform an extensive research under the post fire hydrologic and erosive response subject. By understanding the effect of burn severity in ecosystems and its implications regarding post fire hydrological and erosive responses worldwide. Test the effect of different pre-fire land management practices (unplowed, downslope plowed and contour plowed) and time-since-fire, in the post fire hydrological and erosive response, between the two most common land uses in Portugal (pine and eucalypt). Assess the performance of two widely-known erosion models (RUSLE and Revised MMF), to predict soil erosion rates during first year following two wildfires of distinctive burn severity. Furthermore, to apply these two models considering different post-fire rehabilitation treatments in an area severely affected by fire. Improve model estimations of post-fire runoff and erosion rates in two different land uses (pine and eucalypt) using the revised MMF. To assess these improvements by comparing estimations and measurements of runoff and erosion, in two recently burned sites, as also with their post fire rehabilitation treatments. Model modifications involved: (1) focusing on intra-annual changes in parameters to incorporate seasonal differences in runoff and erosion; and (2) inclusion of soil water repellency in runoff predictions. Additionally, validate these improvements with the application of the model to other pine and eucalypt sites in Central Portugal. The review and meta-analysis showed that fire occurrence had a significant effect on the hydrological and erosive response. However, this effect was only significantly higher with increasing soil burn severity for inter-rill erosion, and not for runoff. This study furthermore highlighted the incoherencies between existing burn severity classifications, and proposed an unambiguous classification. In the case of the erosion plots with natural rainfall, land use factor affected annual runoff while land management affected both annual runoff and erosion amounts significantly. Time-since-fire had an important effect in erosion amounts among unplowed sites, while for eucalypt sites time affected both annual runoff and erosion amounts. At all studied sites runoff coefficients increase over the four years of monitoring. In the other hand, sediment concentration in the runoff, recorded a decrease during the same period. Reasons for divergence from the classic post-fire recovery model were also explored. Short fire recurrence intervals and forest management practices are viewed as the main reasons for the observed severe and continuing soil degradation. The revised MMF model presented reasonable accuracy in the predictions while the RUSLE clearly overestimated the observed erosion rates. After improvements: the revised model was able to predict first-year post-fire plot-scale runoff and erosion rates for both forest types, these predictions were improved both by the seasonal changes in the model parameters; and by considering the effect of soil water repellency on the runoff, individual seasonal predictions were considered accurate, and the inclusion of the soil water repellency in the model also improved the model at this base. The revised MMF model proved capable of providing a simple set of criteria for management decisions about runoff and erosion mitigation measures in burned areas. The erosion predictions at the validation sites attested both to the robustness of the model and of the calibration parameters, suggesting a potential wider application.

Pollen From Alder (Alnus sp.), Birch (Betula sp.) and Oak (Quercus sp.) in the UK Originate From Small Woodlands

We have analysed the pollen seasons in Worcester for the period 2005–12 for alder (Alnus), birch (Betula) and oak (Quercus) by using back trajectory calculations and produced the first detailed source maps for these three pollen types. The study shows considerable variations in the source–receptor relationship of three of the most important tree pollen types in England with respect to allergy. Long Distance Transport is observed for Quercus and Betula but not for Alnus. The new source maps show a number of high emitting areas for Betula and Quercus, mainly near London, in the Midlands and in Wales. The production of source maps is sensitive to the used type of land cover data and how well they incorporate small woodlands. Two satellite products, Corine Land Cover and Globcover, are compared with the detailed national land cover product Land Cover Map 2007. The broad scale satellite products show either up to 50% less woody coverage or a direct misplacement of woodlands. The Lagrangian back trajectory model, the pollen count observations and the source maps altogether suggest that small woodlands (below 25 ha) play a major role in the overall pollen load in urban areas in England.

Impact of an intervention to control risk associated with patient transfer.

QUESTION UNDER STUDY: Hospitals transferring patients retain responsibility until admission to the new health care facility. We define safe transfer conditions, based on appropriate risk assessment, and evaluate the impact of this strategy as implemented at our institution. METHODS: An algorithm defining transfer categories according to destination, equipment monitoring, and medication was developed and tested prospectively over 6 months. Conformity with algorithm criteria was assessed for every transfer and transfer category. After introduction of a transfer coordination centre with transfer nurses, the algorithm was implemented and the same survey was carried out over 1 year. RESULTS: Over the whole study period, the number of transfers increased by 40%, chiefly by ambulance from the emergency department to other hospitals and private clinics. Transfers to rehabilitation centres and nursing homes were reassigned to conventional vehicles. The percentage of patients requiring equipment during transfer, such as an intravenous line, decreased from 34% to 15%, while oxygen or i.v. drug requirement remained stable. The percentage of transfers considered below theoretical safety decreased from 6% to 4%, while 20% of transfers were considered safer than necessary. A substantial number of planned transfers could be "downgraded" by mutual agreement to a lower degree of supervision, and the system was stable on a short-term basis. CONCLUSION: A coordinated transfer system based on an algorithm determining transfer categories, developed on the basis of simple but valid medical and nursing criteria, reduced unnecessary ambulance transfers and treatment during transfer, and increased adequate supervision.

Agrarian revolution in Central America : a comparison of Nicaragua and Honduras using Jeffery Paige's theory of Agrarian revolution

ABSTRACT In 1979 Nicaragua, under the Sandinistas, experienced a genuine, socialist, full scale, agrarian revolution. This thesis examines whether Jeffery Paige's theory of agrarian revolutions would have been successful in predicting this revolution and ln predicting non-revolution in the neighboring country of Honduras. The thesis begins by setting Paige's theory in the tradition of radical theories of revolution. It then derives four propositions from Paige's theory which suggest the patterns of export crops, land tenure changes and class configurations which are necessary for an agrarian and socialist revolution. These propositions are tested against evidence from the twentieth century histories of economic, social and political change in Nicaragua and Honduras. The thesis concludes that Paige's theory does help to explain the occurrence of agrarian revolution in Nicaragua and non-revolution in Honduras. A fifth proposition derived from Paige's theory proved less useful in explaining the specific areas within Nicaragua that were most receptive to Sandinista revolutionary activity.

Therapeutic riding : learning and recovery for people with disabilities

The purpose ofthis study was to explore the process oftherapeutic riding as an experiential and holistic approach to learning and recovery for people with disabilities as perceived by the providers oftherapeutic riding. To enhance the connection between theory and practice and to suggest future research, the researcher endeavoured to develop a theory that contributed to the knowledge base oftherapeutic riding, animal-assisted therapy and education, experiential education, and experiential therapy in addition to contributing to connections among them. This topic was investigated because ofthe lack ofresearch about the process of therapeutic riding, particularly from learning and a recovery perspective. Few studies have addressed how therapeutic riding outcomes are achieved or how the therapeutic riding process actually works. This study was identified as grounded theory using qualitative data through interviews and narrative reflections with therapeutic riding providers, a researcher's journal, field notes, and written documents. Grounded theory analysis was used to analyze the qualitative data. This consisted ofdoing open, axial, and selective coding. This study provided detailed descriptions ofthe research approach, researcher's involvement, participant and site selection, data collection and analysis, methodological assumptions and limitations, credibility established, and ethical considerations. The findings ofthe data analysis revealed the theme ofrelationships as central to the learning and recovery process oftherapeutic riding for people with disabilities. The significance ofthe team relationships, the horse and rider relationship, and the providers and rider relationship was found. The essential components ofthe learning and recovery process were presented in a diagram in the selective coding phase. Goals oftherapeutic riding included psycho-education; behavioural and social; physical; and equestrian. Parts ofthe process ofhow outcomes were achieved included motivation; "opens new doors;" risk; task analysis; control; communication; and environmental factors. Outcomes of therapeutic riding included independence and mobility; confidence; and transfer abilities or skills. The implications ofthese findings for theory, practice, and further research were also. explored.

Autonomic regulation and blood pressure in children

Vagal baroreflex sensitivity (BRS) is a measure of short term blood pressure (BP) regulation through alterations in heart rate. Low BRS reflects impaired autonomic system regulation and has been found to be a surrogate marker for cardiovascular health. In particular, it has found to be associated with the pathogenesis of adult hypertension. However, only limited information exists as to the negative consequences of childhood BP on baroreflex function. The objective of this study was to investigate BRS in children with 2 different BP profiles while controlling for the effects of age, maturation, sex, and body composition. A preliminary subsample of 11-14 year-old children from the HBEAT (Heart Behavioural Environmental Assessment Team) Study was selected. The children were divided into 2 BP groups; high BP (HBP; 2:95tl1 percentile, n=21) and normal BP (NBP; <90th percentile, n=85). Following an initial 15 minutes of supine rest, 5 minutes of continuous beat-to-beat BP (Finapres) and RR interval (RRI) were recorded (standard ECG). Spectral indices were computed using Fast Fourier Transform and transfer function analysis was used to compute BRS. High frequency (HF) and low frequency (LF) power spectral areas were set to 0.15-0.4 Hz and 0.04-0.15 Hz, respectively. Body composition was measured using body mass index. After adjusting for body composition, maturation, age and sex ANCOV A results were as follows; LF and HF BRS, LF and HF RRI, and RRI total power were lower in the HBP versus NBP participants (p<0.05). As well, LF IHF SBP ratio was significantly higher in the HBP compared to the NBP group (p<0.05). The regression coefficients (unstandardized B) indicated that in changing groups (NBP to HBP) LF and HF BRS decreases by 4.04 and 6.18 ms/mmHg, respectively. Thus, as BP increases, BRS decreases. These data suggest that changes in autonomic activity occur in children who have HBP, regardless of age, sex, maturation, and body composition. Thus, despite their young age and relatively short amount of time having high BP compared with adults, these children are already demonstrating poor BP regulation and reduced cardiovagal activity. Given that childhood BP is associated with hypertension in adulthood, there is a growing concern in regards to the current cardiovascular health of our children and future adults.

Analyzing the learning of the taking personal and social responsibility model within a new physical education undergraduate degree program in El Salvador

EI Salvador presents an unfortunate history that includes a military regime and a civil war that together created a legacy of violence in which the country still struggle nowadays. Salud Escolar Integral (SEI) was created in 2005 as a program to combat youth violence throughout the re-formulation of physical education (PE) classes in public schools, promoting life skills learning that supports the resolution of conflicts with nonviolent ways. In 2007, SEI supported the creation of a physical e~ucation teacher education (PETE) degree at the Universidad Pedag6gica de EI Salvador (UPES), having the goal to assist pre-service teachers with a better understanding of humanistic principles. The present research analyzed if after attending all three years ofUPES PETE program, students presented high self-perception levels of competence and confidence related to attitude, skills and knowledge to teach PE within humanistic principles. Taking Personal and Social Responsibility (TPSR) was the theoretical framework used to analyze the development of humanistic principles. The study had a mixed-method longitudinal design that included questionnaires, reflection templates and interviews. In conclusion, although it is suggested that UPES should provide better support for the development of the teaching principles of empowering students and transfer learning, most of the humanistic principles were highly promoted by the program. At last, it is suggested that future research should track teachers' progress while teaching in schools, in order to analyze if the theory of promoting humanistic principles have also become a daily practice.

Effects of age on learning a spatial motor task in younger and older adults individualizing their knowledge of results schedule

Self-controlled KR practice has revealed that providing participants the opportunity to control their KR is superior for motor learning compared to participants replicating the KR schedule of a self-control participant, without the choice (e.g., yoked). The purpose of the present experiment was two-fold. First, to examine the utility of a self-controlled KR schedule for learning a spatial motor task in younger and older adults and second, to determine whether a self-controlled KR schedule facilitates an increased ability to estimate one’s performance in retention and transfer. Twenty younger adults and 20 older adults practiced in either the self-control or yoked condition and were required to push and release a slide along a confined pathway using their non-dominant hand to a target distance. The retention data revealed that as a function of age, a self-controlled KR schedule facilitated superior retention performance and performance estimations in younger adults compared to their yoked counterparts.

Baroreflex sensitivity and developmental coordination disorder

Developmental coordination disorder (DCD) is a motor coordination disorder that is characterized by impairment of motor skills which leads to challenges with performing activities of daily living. Children with DCD have been shown to be less physically active and have increased body fatness. This is an important finding since a sedentary lifestyle and obesity are risk factors for cardiovascular disease. One indicator of cardiovascular health is baroreflex sensitivity (BRS), which is a measure of short term BP regulation that is accomplished through changes in HR. Diminished BRS is predictive of cardiovascular morbidity and mortality. The purpose of this study was to investigate BRS in 117 children aged 12 to 13 years with probable DCD (pOCO) and their matched controls with normal coordination. Following 15 minutes of supine rest, five minutes of continuous beat-by-beat blood pressure (Finapres) and RR interval were recorded (standard ECG). Spectral indices were computed using Fast Fourier Transform and transfer function analysis was used to compute BRS. High frequency and low frequency power spectral areas were set to 0.15-0.6 Hz and 0.04-0.15 Hz, respectively. BRS was compared between groups with an independent t-test and the difference was not significant. It is likely that a difference in BRS was not seen between groups since the difference in BMI between groups was small. As well, differences in BRS may not have manifested yet at this early age. However, the cardiovascular health of this population still deserves attention since differences in body composition and fitness were found between groups.

Second Welland Canal - Book 2, Survey Map 4 - Locks 11, 12, 13, 14 and 15 in Grantham

Survey map of the Second Welland Canal created by the Welland Canal Company showing the Grantham Township along the outskirts of Merritton. Identified structures associated with the Canal include Locks 11, 12, 13, 14, and 15, Lock House Lot, and the towing path. The surveyors' measurements and notes can be seen in red and black ink and pencil. Several stones likely used in the measurements are identified on the map. Local area landmarks are also identified and include streets and roads(ex. Hartzel Road and Macadamized Road), the Great Western Railroad, Swing Bridge, Thorold Station and its structures (ex. freight house, office, water tank, and wood house), Gordon and Mackay Houses, Gordon and Mackay's Cotton Mill, hydraulic race, a wharf, pond, and an unnamed bridge. Properties and property owners of note are: Concession 9 Lots 12 and 13, A. Bradley, John O'Coner, G. Grant, J. Bradley, J. Vanderburgh, O. Clifford and a parcel of land leased Gordon and Mackay.

Welland Canal Survey of Lands Nathan Pawling 1826; includes map and text.

Survey map and description of Nathan Pawling's land created by The Welland Canal Company. Included is a written description of the land along with a drawing of the land. Noteable features include; the dock, pier and tow path. The original bed of 12 mile creek is also noted on the map. Surveyor notes are seen in pencil on the map. The map notes the division of land between Pawling and Robert Brown's land. Click on 'detail' to see Map.

The Transfer of Wilderness Trips to the Everyday Lives of Young People: A Case Study

There has been considerable research that investigates the outcomes, benefits, and perceptions of wilderness trip experiences. However, the transfer of learning from a wilderness trip to the everyday lives of youth trip participants, that has deliberately explored post-trip experience, is minimal. Using a qualitative multi-case study approach, methods of data collection included interviews with six youth program participants, six parents/legal guardians, and three program staff, as well as document solicitation. Reports from the participants suggested that the key content transferred to a post-wilderness trip context were interpersonal skills; life skills; and instances of personal growth. Participants applied their learning content from the wilderness trip to school; sports; community and international volunteering; work and career aspirations; family and home life; and social life contexts. Implications for adventure programming and curriculum design, instruction, and transfer are considered.

St. Catharines documents including mortgages, wills and declarations, 1871-1914 (not inclusive)

Most of these documents refer to a tract of land located on the intersection of King and Court Streets (part of the Lawrie plan) and Carter properties in St. Catharines Ontario. The Security Loan and Savings Company of St. Catharines existed between 1870 and 1906. Thomas Rodman Merritt was the president.

The effects of consistency and inconsistency between attentional focus and task objective in learning a golf putting task

Converging evidence has demonstrated learning advantages when an individual is instructed to focus their attention externally. However, many of the motor tasks utilized in past research had clear external objectives (i.e., putting accuracy), creating a compatible relationship between an external focus of attention (i.e., outcome) and an external task objective (i.e., putting accuracy). The present study examined whether or not the consistency of instructions and task objective would differentially impact the acquisition of a golf putting task. Participants performed a putting task in a control condition or in one of four experimental conditions resulting from the factorial interaction of task instructions (internal or external) and task objective (internal or external). The retention and transfer data revealed that participants who received an external task objective demonstrated superior outcome scores. Participants who received technique information paired with outcome information demonstrated superior technique scores.