DESCRIBING SLEEP AND SEDATION PRACTICES IN THE ICU: A MULTINATIONAL SURVEY

Introduction Sleep disturbances are common in critically ill patients treated in the intensive care unit (ICU) with the potential for serious consequences and long-term effects on health outcomes and patient morbidity.
Objectives Our aim was to describe sleep management and sedation practices of adult ICUs in ten countries and to evaluate roles and responsibilities of the ICU staff in relation to key sleep and sedation decisions.
Methods A multicenter, self-administered survey sent to nurse managers of adult ICUs across 10 countries. The questionnaire comprised four domains: sleep characteristics of the critically ill; sleep and sedation practices; non-pharmacological and pharmacological interventions used to improve sleep; and the autonomy and influence of nurses on sleeping practices in the ICU.
Results Overall response rate was 66% (range 32% UK to 100% Cyprus), providing data from 522 ICUs. In all countries, the most frequent patient characteristic perceived to identify sleep was lying quietly with closed eyes (N=409, 78%) (range 92% Denmark to 36% Italy). The most commonly used sedation scale was the Richmond Agitation-Sedation Score (RASS) (N=220, 42%) (range 81% UK to 0% Denmark, Cyprus where most ICUs used the Ramsay score). In most ICUs, selection of sleep medication (N=265, 51%) and assessment of effect (N=309, 59%) was performed by physicians and nurses based on collaborative discussion. In a minority of ICUs (N=161, 31%), decisions and assessments were made by physicians alone. The most commonly used (in all countries) non-pharmacological intervention to promote sleep was reducing ICU staff noise (N=473, 91%) (range 100% Denmark, Norway to 78% Canada). Only 95 ICUs (18%) used earplugs on a frequent basis (range 0% Greece, Cyprus, Denmark to 57% Sweden). Propofol was the drug used most commonly for sedation (N=359, 69%) (range 96% Sweden to 29% Canada). Chloral hydrate was used by only 63 (12%) ICUs (range 0% Greece, Cyprus, Denmark, Italy to 56% Germany). Sedation scales were used on a routine basis by 77% of the 522 ICUs. Participants scored nursing autonomy for sleep and sedation management as moderate; median score of 5 (scale of 0 to 10), range 7 (Canada, Greece, Sweden) to 4 (Norway, Poland). Nursing influence on sleep and sedation decisions was perceived considerable; median score 8, range 9 (Denmark) to 5 (Poland).
Conclusions We found considerable across country variation in sleep promotion and sedation management practices though most have adopted a sedation scale as recommended in professional society guidelines. Most ICUs in all countries used a range of pharmacological and non-pharmacological interventions to promote sleep. Most units reported inter-professional decision-making with nurses perceived to have substantial influence on sleep/sedation decisions.

Herd management and livestock productivity in the Altai region of Western Mongolia

This thesis analyses the influence of qualitative and quantitative herbage production on seasonal rangelands, and of herd and pasture use strategies on feed intake, body mass development and reproductive performance of sheep and goats in the Altai mountain region of Bulgan county (soum) in Khovd province (aimag). This westernmost county of Mongolia is characterized by a very poor road network and thus very difficult access to regional and national markets. The thesis explores in this localized context the current rural development, the economic settings and political measures that affect the traditional extensive livestock husbandry system and its importance for rural livelihoods. Livestock management practices still follow the traditional transhumant mode, fully relying on natural pasture. This renders animal feeding very vulnerable to the highly variable climatic conditions which is one of many reasons for gradually declining quantity and quality of pasture vegetation. Small ruminants, and especially goats, are the main important species securing economic viability of their owners’ livelihood, and they are well adapted to the harsh continental climate and the present low input management practices. It is likely that small ruminants will keep their vital role for the rural community in the future, since the weak local infrastructure and slow market developments currently do not allow many income diversification options. Since the profitability of a single animal is low, animal numbers tend to increase, whereas herd management does not change. Possibilities to improve the current livestock management and thus herders’ livelihoods in an environmentally, economically and socially sustainable manner are simulated through bio-economic modelling and the implications are discussed at the regional and national scale. To increase the welfare of the local population, a substantial infrastructural and market development is needed, which needs to be accompanied by suitable pasture management schemes and policies

Policy for the Provision and Management of Cleaning Services (PDF 464KB)

This policy sets out the Department’s commitment to maintaining and improving environmental cleanliness in Northern Ireland (NI). It has been developed with the aim that best management practice, staff training and continued monitoring of performance will lead to services being maintained and improved in a challenging financial climate. The detail of the policy is presented in the three sections which follow this executive summary. Section 1 – Introduction and Background. This section sets out the aims, objectives and scope of the policy. It also sets out the key principles which should apply to cleaning services. Section 2 - Developments since the launch of Cleanliness Matters Strategy in October 2005. This outlines events and progress since 2005 and indicates how these are shaping the proposed strategic direction. Section 3 - The Way Forward. This section sets out the areas for attention over the coming years.  

Diagnostic Tests and their Application in the Management of Soil- and Water-borne Oomycete Pathogen Species

Oomycete diseases cause significant losses across a broad range of crop and aquaculture commodities worldwide. These losses can be greatly reduced by disease management practices steered by accurate and early diagnoses of pathogen presence. Determinations of disease potential can help guide optimal crop rotation regimes, varietal selections, targeted control measures, harvest timings and crop post-harvest handling. Pathogen detection prior to infection can also reduce the incidence of disease epidemics. Classical methods for the isolation of oomycete pathogens are normally deployed only after disease symptom appearance. These processes are often-time consuming, relying on culturing the putative pathogen(s) and the availability of expert taxonomic skills for accurate identification; a situation that frequently results in either delayed application, or routine ‘blanket’ over-application of control measures. Increasing concerns about pesticides in the environment and the food chain, removal or restriction of their usage combined with rising costs have focussed interest in the development and improvement of disease management systems. To be effective, these require timely, accurate and preferably quantitatve diagnoses. A wide range of rapid diagnostic tools, from point of care immunodiagnostic kits to next generation nucleotide sequencing have potential application in oomycete disease management. Here we review currently-available as well as promising new technologies in the context of commercial agricultural production systems, considering the impacts of specific biotic and abiotic and other important factors such as speed and ease of access to information and cost effectiveness

Hoshin Kanri – the Japanese way of piloting : An exploratory study of a Japanese strategic management system

Strategy is a highly topical subject among managers and since the world is constantlychanging it is also an important subject for companies’ competitive advantage and survival.At the same time experts in the field of strategic management describe western techniques ascomplex and ineffective while the Japanese techniques have been seen as unambiguous andcharacterized by focus on quality, productivity and teamwork. This calls for greaterknowledge in the Japanese management systems. Hoshin Kanri is a collection of Japanesebest strategic management practices and therefore an interesting target for our study. Thus, onthe one hand this study investigates the theory of Hoshin Kanri in order to give structure to itand provide a way for practitioner into the management system. On the other hand this studyinvestigates Hoshin Kanri in order to reveal how Japanese subsidiaries based in Sweden haveimplemented this strategic management system. This is firstly done by reviewing the existingliterature on the subject and secondly by a collective case study with in-depth interviewsconducted with managers at Japanese owned subsidiaries based in Sweden. There are somelimitations in this study. One is that the results of the study do not include all Japanesesubsidiaries in Sweden as not all companies participated in the study. Moreover, the study islimited by one individuals’ knowledge and perception of Hoshin Kanri in each of the threecompanies. The study contributes to the existing literature on the topic of Hoshin Kanri by;(1) structuring the literature and the existing models under one of two categories, namelycyclical or sequential; (2) providing a model that aims at making it more understandable andattractive for practitioner to apply; (3) initiating the mapping of the spread of Hoshin Kanriamong Japanese subsidiaries in Sweden and (4) providing a Swedish model for theapplication of HK in Japanese subsidiaries.

Ecology and physical condition of red deer in the Iberian Peninsula: implications for management

The red deer (Cervus elaphus) is currently one of the most widespread and abundant wild ungulates in the Iberian Peninsula and is extremely important both ecologically, as a key species for the functioning of the ecosystems, and economically, as a major game species. In Iberia, red deer populations are subjected to different management systems that may affect the physical condition of the individuals, with further consequences for population dynamics. Studies investigating the effects of management practices and environmental conditions on the performance of red deer are still rare regarding Mediterranean ecosystems. Much of the knowledge concerning the ecology of red deer and the impact of management on its physical condition is based on studies conducted in northern and central regions of Europe, where climatological features and management practices differ from those observed in the Mediterranean areas of Iberia. Studies on a biogeographical scale can provide important insights into the relationships between species and a particular environment and contribute to the development of more targeted and appropriate management practices. The optimisation of sampling procedures and the fine-tuning of pre-existing analytical techniques are also fundamental to a more cost-effective monitoring and, therefore, are of enormous value to wildlife managers. In this context, the main aims of this thesis were: 1) to optimise the procedures used to assess the physical condition of red deer; and 2) to identify relevant management and environmental factors affecting the nutritional condition and stress physiology of red deer in the Mediterranean ecosystems of Iberia, as well as any potential interactions between those factors. Two studies with a methodological focus, presented in the first part of the thesis, demonstrated that the physical condition of red deer can be evaluated more simply, using more cost- and time-effective procedures than those traditionally used: i) it was shown that only one kidney and its associated fat is enough to assess nutritional condition in red deer; and ii) the feasibility of using near infrared spectroscopy to predict the concentrations of stress hormone metabolites was demonstrated using faeces of red deer for the first time. Subsequently, two large-scale observational studies, conducted in representative red deer populations found in Mediterranean Iberia, highlighted the importance of considering seasonal environmental variations and variables related to hunting management practices to better understand the nutritional and physiological ecology of red deer. High population densities had adverse effects on the nutritional condition of the deer and were associated with increased stress levels in natural populations without supplementary feeding. Massive hunting events involving the use of hounds were also identified as a potential source of chronic stress in red deer. The research presented in this thesis has clear implications regarding the management and monitoring of red deer populations in Mediterranean environments and is intended to help wildlife managers to implement more effective monitoring programmes and sustainable management practices.

Earnings management nas instituições particulares de solidariedade social

A manipulação contabilística constitui-se como uma problemática atual, relatada sob os mais diversos contextos. Este estudo descritivo pretende verificar a existência de Earnings Management no contexto das Instituições Particulares de Solidariedade Social (IPSS) e averiguar as razões (motivações) que levam a estas práticas. A amostra para este estudo é constituída por 14 instituições portuguesas, num total de 58 observações situadas entre os anos 2009 e 2014. Para a análise dos dados foi utilizada uma abordagem quantitativa, primeiramente através de estatística descritiva e correlacional. Para testar a existência de Earnings Management utilizou-se um modelo baseado no estudo de accruals agregados (Modelo de Jones - 1991) e um modelo complementar baseado na distribuição de frequência de resultados (Burgstahler e Dichev -1997). Os resultados permitem inferir a existência destas práticas neste setor e as motivações estarão relacionadas com a rendibilidade das instituições.

Relations entre la composition du lait et les facteurs alimentaires dans les troupeaux laitiers québécois

L’objectif général des travaux présentes dans cette thèse de doctorat était d’établir la relation entre l’alimentation et la composition du lait des vaches laitières, en mettant l’emphase sur les teneurs en matières grasses (TMG), sur l’urée du lait et sur l’efficience d’utilisation de l’azote. Pour la TMG, c’est principalement la relation entre cette teneur et la différence alimentaire cations-anions (DACA) qui a été investiguée. Une base de données de 2 142 troupeaux québécois a été utilisée et la relation entre la composition de la ration, incluant la DACA, et la TMG du lait a été déterminée à l’aide de régressions multiples. Il a été possible de prédire entre 32 et 66 % de la variation de la TMG du lait en fonction du stade de lactation. Malgré plusieurs interactions trouvées, une augmentation de la DACA, une supplémentation avec de l’acide palmitique et une distribution des aliments en ration totale mélangée ont eu une relation positive avec la TMG du lait, tandis qu’une augmentation de la proportion de concentrés dans la ration a eu un effet négatif. Les modèles développés ont montré l’importance de la gestion de l’alimentation sur la TMG du lait. En plus, ils ont démontré l’intérêt de considérer la DACA dans la formulation de rations chez la vache laitière. Dans une deuxième étude, la même base des données a été utilisée pour identifier les facteurs nutritionnels qui peuvent faire varier la teneur en urée du lait. Contrairement à ce qui est mentionné dans la littérature, tant des corrélations positives et que négatives entre les teneurs en urée du lait et en protéines des rations à l’intérieur des troupeaux sur une période de 36 mois ont été obtenues. Pour mieux comprendre ces relations, les résultats de performances et d’alimentation de 100 troupeaux avec des corrélations positives (r > 0,69) et de 100 troupeaux avec des corrélations négatives (r < -0,44) entre la teneur en urée du lait et en protéine brute de la ration ont été comparés. Les résultats n’ont pas montré de différences entre les deux groupes ni pour la composition de la ration, ni pour l’urée du lait. Ces résultats ne permettent pas d’identifier le meilleur contexte pour l’utilisation de la teneur en urée du lait comme un outil de gestion de l’alimentation. Ces observations soulèvent des questions sur la validité de l’utilisation des statistiques d’alimentation provenant de la base de données utilisée pour des évaluations nutritionnelles plus spécifiques. Considérant les résultats du projet précédent, le dernier projet visait à mieux comprendre les caractéristiques des fermes avec différentes efficiences d’utilisation de l’azote en utilisant des données plus fiables. Ainsi, 100 fermes laitières au Québec ont été visitées pour recueillir les données de production, de consommation d’aliments et de gestion de leur troupeau. Ces fermes ont été divisées en quatre groupes par une analyse en grappes selon leur efficience d’utilisation de l’azote. La comparaison entre les groupes a montré que les fermes dans les groupes avec une plus haute efficience d’utilisation d’azote ont une production laitière moyenne par vache plus élevée. Pour les stratégies d’alimentation, les fermes plus efficientes donnent plus d’énergie, mais moins de protéines brutes que les fermes des groupes moins efficients. Les résultats ont également montré l’importance de la prise alimentaire des vaches sur l’efficience d’utilisation de l’azote puisque les fermes des groupes avec la plus grande efficience étaient également celles avec la plus faible prise alimentaire. Aussi, les résultats n’ont pas permis d’établir clairement la relation entre la teneur en urée du lait et l’efficience de l’utilisation de l’azote. En effet, des valeurs différentes pour l’urée du lait étaient obtenues entre le groupe plus efficient et le moins efficient, mais la faible ampleur de variation de l’efficience d’utilisation de l’azote des groupes intermédiaires n’a pas permis d’observer de différences pour l’urée du lait. Finalement, outre une réduction des risques de pollution, les fermes des groupes plus efficaces pour l’utilisation de l’azote étaient également celles avec la marge sur les coûts d’alimentation par les vaches plus élevées. Par conséquent, il y a aussi un intérêt économique à améliorer l’efficience de l’utilisation de l’azote sur les fermes.

Some biological and ecological considerations for research in the management of the fisheries of Lakes Victoria and Kyoga

There is little doubt that the exploitation of the current fisheries of Lakes Victoria and Kyoga requires close monitoring with a view to enforce adherence to prudent management practices. Many indigenous fishes have gradually disappeared from the commercial fishery of both lakes. In the Uganda portion of Lake Victoria for instance Okaronon and Wadanya (in press) have shown that:- 1. The once preponderant haplochromiine taxon ceased to feature in the commercial catches in 1979. 2. The lung-fish (Protopterus aethiopicus) which formerly contributed significantly to the commercial landings had declined to minor species status by the mid 1980s. 3. The catfishes Clarias mossambicus and Bagrus docmac, formerly major fish species, contributed insignificant quantities to the commercial fishery since the early and mid 1980s, respectively. Similar trend have been "reported in the Kenya and Tanzania portions of Lake Victoria (Bwathondi, 1985; Mainga, 1985, Witte and Goudswaard, 1985). On the other hand since their establishment all round the lake in the early to mid 1980s some introduced fishes namely Nile perch (Lates niloticus) and Nile tilapia (Oreochromis niloticus) built up impressive stocks in Lake Victoria (Ssentongo and Welcomme, 1985, Okaronon et al. 1985; Okaronon and Wadanya, in press). Togetther with the native pelagic cyprinid Rastrineobola argentea or Dagaa/Mukene the introduced fishes have contributed unprecidented catches, stimulating vibrant commercial fisheries which have yielded significant social economic benefits to the peoples of the three states riparian to the Lake (Reynolds and Greboval, 1988; Kudhongania et al in press). The impressive landings particularly of the Nile perch and Nile tilapia have also led to rapid industrialisation of fish processing in East Africa mainly for the export market. Fish export has now the potential of a major foreign exchange enterprise in the region.

Licenciamento Ambiental: uma ferramenta de marketing - O caso de uma empresa agro-alimentar

Mestrado em Gestão e Empreendedorismo

Efeitos da vacina contra a circovirose suína sobre os parâmetros reprodutivos e produtivos em porcas reprodutoras e o seu impacto económico

Dissertação de mestrado apresentada na área Produção e Tecnologia Animal, na Escola Superior Agrária de Santarém, do Instituto Politécnico de Santarém.

Efeitos da vacina contra a circovirose suína sobre os parâmetros reprodutivos e produtivos em porcas reprodutoras e o seu impacto económico

Dissertação de mestrado apresentada na área Produção e Tecnologia Animal, na Escola Superior Agrária de Santarém, do Instituto Politécnico de Santarém.

Human Behavious Modelling for Discrete Event and Agent Based Simulation: A Case Study

This study is about the comparison of simulation techniques between Discrete Event Simulation (DES) and Agent Based Simulation (ABS). DES is one of the best-known types of simulation techniques in Operational Research. Recently, there has been an emergence of another technique, namely ABS. One of the qualities of ABS is that it helps to gain a better understanding of complex systems that involve the interaction of people with their environment as it allows to model concepts like autonomy and pro-activeness which are important attributes to consider. Although there is a lot of literature relating to DES and ABS, we have found none that focuses on exploring the capability of both in tackling the human behaviour issues which relates to queuing time and customer satisfaction in the retail sector. Therefore, the objective of this study is to identify empirically the differences between these simulation techniques by stimulating the potential economic benefits of introducing new policies in a department store. To apply the new strategy, the behaviour of consumers in a retail store will be modelled using the DES and ABS approach and the results will be compared. We aim to understand which simulation technique is better suited to human behaviour modelling by investigating the capability of both techniques in predicting the best solution for an organisation in using management practices. Our main concern is to maximise customer satisfaction, for example by minimising their waiting times for the different services provided.

Factors affecting vaccine handling and storage practices among immunization service providers in Ibadan, Oyo State, Nigeria.

Background: Improper handling has been identified as one of the major reasons for the decline in vaccine potency at the time of administration. Loss of potency becomes evident when immunised individuals contract the diseases the vaccines were meant to prevent. Objective: Assessing the factors associated with vaccine handling and storage practices. Methods: This was a cross-sectional study. Three-stage sampling was used to recruit 380 vaccine handlers from 273 health facilities from 11 Local Government areas in Ibadan. Data was analysed using SPSS version 16 Results: Seventy-three percent were aware of vaccine handling and storage guidelines with 68.4% having ever read such guidelines. Only 15.3% read a guideline less than 1 month prior to the study. About 65.0% had received training on vaccine management. Incorrect handling practices reported included storing injections with vaccines (13.7%) and maintaining vaccine temperature using ice blocks (7.6%). About 43.0% had good knowledge of vaccine management, while 66.1% had good vaccine management practices. Respondents who had good knowledge of vaccine handling and storage [OR=10.0, 95%CI (5.28 – 18.94), p < 0.001] and had received formal training on vaccine management [OR=5.3, 95%CI (2.50 – 11.14), p< 0.001] were more likely to have good vaccine handling and storage practices. Conclusion: Regular training is recommended to enhance vaccine handling and storage practices.

Internship in revenue management at Pestana

Dissertação de Mestrado, Economia do Turismo e Desenvolvimento Regional, Faculdade de Economia, Universidade do Algarve, 2016