"I’ll call you when we are ready" (One family’s experience of critical care and end of life decision making)

The purpose of this paper is to explore through narrative accounts one family's expérience of critical care, after the admission of a family member to an Intensive Care Unit (ICU) and their subséquent death five weeks later. Numerous studies support the need for effective communication and clear information to be given to the family. In this instance it was évident from their stories that there were numerous barriers to communication, including language and a lack of insight into the needs of the family. Many families do not understand the complexities of nursing care in an ICU so lack of communication by nursing staff was identified as uncaring behavior and encounters. Facilitating a family's proximity to a dying patient and encouraging them to participate in care helps to maintain some sensé of personal control. Despite a commitment to involving family members in care, which was enshrined in the Unit Philosophy, relatives were banished to the waiting room for hours. They experienced feelings of powerlessness and helplessness as they waited with other relatives for news following investigations or until 'the doctor had completed his rounds'. Explanations of "we must make 'the patient' comfortable" was no consolation for those who wished to be involved in care. The words "I'il call you when we are ready" became a mantra to the forgotten families who waited patiently for those with power to admit them to the ICU. Implications are this family felt they were left alone to cope with the traumatic expériences leading up to and surrounding the death. They felt mainly supported by the priest, who not only administered the last rites but provided spiritual support to the family and dealt sensitively with many issues. Paternalism in décision making when there is a moral obligation to ensure that discussions on end of life dilemmas are an inclusive process with families, doctors, nurses was not understood, therefore it caused conflict within the family over EOL décision making. The family felt that the opportunity to share expériences through telling and retelling their stories would enable them to reconfigure the past and create purpose in the future.

Greater Miami: Stories

GREATER MIAMI: STORIES is a collection of short stories about the disparity between the hoped-for expectations of life in America—as seen through the prism of South Florida—and the reality of a life lived on the margins. The characters, ranging in age from early adulthood to the elderly, attempt to navigate the perils of a new and unfamiliar existence—physical and/or psychological—while seeking to recoup the losses of home and country, love and language. The collection uses Miami as its setting due to the wide demographic range of its inhabitants, and the stories address themes of memory, love, sex, opportunity and privilege, the mayhem born of disinformation, and the anxiety of displacement. Each story in the collection describes a pivotal moment when the characters encounter a truth that had previously eluded them and then must deal with the repercussions of that knowledge.

The modern state and the re-creation of the indigenous other: The case of the authentic Sami in Sweden and the white man's Indian in the United States of America

The present study comparatively examined the socio-political and economic transformation of the indigenous Sámi in Sweden and the Indian American in the United States of America occurring first as a consequence of colonization and later as a product of interaction with the modern territorial and industrial state, from approximately 1500 to 1900. ^ The first colonial encounters of the Europeans with these autochthonous populations ultimately created an imagery of the exotic Other and of the noble savage. Despite these disparaging representations, the cross-cultural settings in which these interactions took place also produced the hybrid communities and syncretic life that allowed levels of cultural accommodation, autonomous space, and indigenous agency to emerge. By the nineteenth century, however, the modern territorial and industrial state rearranges the dynamics and reaches of power across a redefined territorial sovereign space, consequently, remapping belongingness and identity. In this context, the status of indigenous peoples, as in the case of Sámi and of Indian Americans, began to change at par with industrialization and with modernity. At this point in time, indigenous populations became a hindrance to be dealt with the legal re-codification of Indigenousness into a vacuumed limbo of disenfranchisement. It is, thus, the modern territorial and industrial state that re-creates the exotic into an indigenous Other. ^ The present research showed how the initial interaction between indigenous and Europeans changed with the emergence of the modern state, demonstrating that the nineteenth century, with its fundamental impulses of industrialism and modernity, not only excluded and marginalized indigenous populations because they were considered unfit to join modern society, it also re-conceptualized indigenous identity into a constructed authenticity.^

What Is a Firm’s Life Expectancy? Empirical Evidence in the Context of Portuguese Companies

It is a fact that the uncertainty about a firm’s future has to be measured and incorporated into a company’s valuation throughout the explicit analysis period – in the continuing or terminal value within valuation models. One of the concerns that can influence the continuing value of enterprises, which is not explicitly considered in traditional valuation models, is a firm’s average life expectancy. Although the literature has studied the life cycle of a firm, there is still a considerable lack of references on this topic. If we ignore the period during which a company has the ability to produce future cash flows, the valuations can fall into irreversible errors, leading to results markedly different from market values. This paper aims to provide a contribution in this area. Its main objective is to construct a mortality table for non-listed Portuguese enterprises, showing that the use of a terminal value through a mathematical expression of perpetuity of free cash flows is not adequate. We provide the use of an appropriate coefficient to perceive the number of years in which the company will continue to operate until its theoretical extinction. If well addressed regarding valuation models, this issue can be used to reduce or even to eliminate one of the main problems that cause distortions in contemporary enterprise valuation models: the premise of an enterprise’s unlimited existence in time. Besides studying the companies involved in it, from their existence to their demise, our study intends to push knowledge forward by providing a consistent life and mortality expectancy table for each age of the company, presenting models with an explicitly and different survival rate for each year. Moreover, we show that, after reaching a certain age, firms can reinvent their business, acquiring maturity and consequently postponing their mortality through an additional life period.

Early life exposure to chronic intermittent hypoxia primes increased susceptibility to hypoxia-induced weakness in rat sternohyoid muscle during adulthood

Intermittent hypoxia is a feature of apnea of prematurity (AOP), chronic lung disease, and sleep apnea. Despite the clinical relevance, the long-term effects of hypoxic exposure in early life on respiratory control are not well defined. We recently reported that exposure to chronic intermittent hypoxia (CIH) during postnatal development (pCIH) causes upper airway muscle weakness in both sexes, which persists for several weeks. We sought to examine if there are persistent sex-dependent effects of pCIH on respiratory muscle function into adulthood and/or increased susceptibility to re-exposure to CIH in adulthood in animals previously exposed to CIH during postnatal development. We hypothesized that pCIH would cause long-lasting muscle impairment and increased susceptibility to subsequent hypoxia. Within 24 h of delivery, pups and their respective dams were exposed to CIH: 90 s of hypoxia reaching 5% O2 at nadir; once every 5 min, 8 h per day for 3 weeks. Sham groups were exposed to normoxia in parallel. Three groups were studied: sham; pCIH; and pCIH combined with adult CIH (p+aCIH), where a subset of the pCIH-exposed pups were re-exposed to the same CIH paradigm beginning at 13 weeks. Following gas exposures, sternohyoid and diaphragm muscle isometric contractile and endurance properties were examined ex vivo. There was no apparent lasting effect of pCIH on respiratory muscle function in adults. However, in both males and females, re-exposure to CIH in adulthood in pCIH-exposed animals caused sternohyoid (but not diaphragm) weakness. Exposure to this paradigm of CIH in adulthood alone had no effect on muscle function. Persistent susceptibility in pCIH-exposed airway dilator muscle to subsequent hypoxic insult may have implications for the control of airway patency in adult humans exposed to intermittent hypoxic stress during early life.

Landscape strategies in Bronze Age Southwestern Cyprus (2500-1100 B.C.)

This thesis concerns the analysis of the socio-economic transformation of communities in Bronze Age southwestern Cyprus. Through the adoption of a dialectical perspective of analysis, individuals and environment are considered part of the same unity: they are cooperating agents in shaping society and culture. The Bronze Age is a period of intense transformation in the organization of local communities, made of a continuous renegotiation of the socio-economic roles and interactions. The archaeological record from this portion of the island allows one to go beyond the investigation of the complex and articulated transition from the EBA-MBA agro-pastoral and self-sufficient communities to the LBA centralized and trade-oriented urban-centres. Through a shifting of analytical scales, the emerging picture suggests major transformations in the individual-community-territory dialectical relations. A profound change in the materials conditions of social life, as well as in the superstructural realm, was particularly entailed by the dissolution of the relation to the earth, due to the emergence of new forms of land exploitation/ownership and to the shift of the settlement pattern in previously unknown areas. One of the key points of this thesis is the methodological challenge of working with legacy survey data as I re-analysed a diverse archaeological legacy, which is the result of more than fifty years of survey projects, rescue and research-oriented excavations, as well as casual discoveries. Source critique and data evaluation are essential requirements in an integrative and cross-disciplinary regional perspective, in the comprehensive processing of heterogeneous archaeological and environmental datasets. Through the estimation of data precision and certainty, I developed an effective - but simple - method to critically evaluate existing datasets and to inter-correlate them without losing their original complexity. This powerful method for data integration can be applied to similar datasets belonging to other regions and other periods as it originates from the evaluation of larger methodological and theoretical issues that are not limited to my spatial and temporal focus. As I argue in this thesis, diverse archaeological legacies can be efficiently re-analysed through an integrative and regional methodology. The adoption of a regional scale of analysis can provide an excellent perspective on the complexity of transformations in ancient societies, thus creating a fundamental bridge between the local stories and grand landscape narratives.

Richard Yates: re-writing postwar American culture

This thesis explores the fiction of American author Richard Yates to propose that his work provides an insistent questioning and alternative vision of postwar American culture. Such an approach is informed by a revisionist account of four distinct yet interconnected areas of postwar culture: the role of the non-heroic soldier stepping in and out of World War II; suburbanisation and fashioning of anti-suburban performance; demarcation of gender roles and unraveling of sexual conservatism in the 1950s; consideration of what constituted the normative within postwar discourse and representations of mental illness in Yates’ work. These four spheres of interest form the backbone to this study in its combined aim of reclaiming Yates’ fiction in line with a more progressive historical framework while shaping a new critical appreciation of his fiction. Such analysis will be primed by an opening discussion that illustrates how Yates’ fiction has frequently been ensconced in a limited interpretative lens: an approach, that I argue, has kept Yates on the periphery of the canon and ultimately resulted in the neglect of an author who provided a rich, progressive and historically significant dialogue of postwar American life. This PhD arrives at a point when Yatesian scholarship is finally gaining momentum after the cumulative impact of a comprehensive biography, a faithful film adaptation of his seminal text Revolutionary Road (1961), plus the recent re-issue of his catalogue of work. An assessment as to why he remained on the margins of success for the duration of his career is therefore of pressing interest in light of this recent critical and commercial recognition.

The difference of Being in the early modern world: a relational-material approach to life in Scotland in the period of the witch trials

This thesis investigates how ways of being in different ontologies emerge from material and embodied practice. This general concern is explored through the particular case study of Scotland in the period of the witch trials (the 16th and 17th centuries C.E.). The field of early modern Scottish witchcraft studies has been active and dynamic over the past 15 years but its prioritisation of what people said over what they did leaves a clear gap for a situated and relational approach focusing upon materiality. Such an approach requires a move away from the Cartesian dichotomies of modern ontology to recognise past beliefs as real to those who experienced them, coconstitutive of embodiment and of the material worlds people inhabited. In theory, method and practice, this demands a different way of exploring past worlds to avoid flattening strange data. To this end, the study incorporates narratives and ‘disruptions’ – unique engagements with Contemporary Art which facilitate understanding by enabling the temporary suspension of disbelief. The methodology is iterative, tacking between material and written sources in order to better understand the heterogeneous assemblages of early modern (counter-) witchcraft. Previously separate areas of discourse are (re-)constituted into alternative ontic categories of newly-parallel materials. New interpretations of things, places, bodies and personhoods emerge, raising questions about early modern experiences of the world. Three thematic chapters explore different sets of collaborative agencies as they entwine into new things, co-fabricating a very different world. Moving between witch trial accounts, healing wells, infant burial grounds, animals, discipline artefacts and charms, the boundaries of all prove highly permeable. People, cloth and place bleed into one another through contact; trees and water emerge as powerful agents of magical-place-making; and people and animals meet to become single, hybrid-persons spread over two bodies. Life and death consistently emerge as protracted processes with the capacity to overlap and occur simultaneously in problematic ways. The research presented in this thesis establishes a new way of looking at the nature of Being as experienced by early modern Scots. This provides a foundation for further studies, which can draw in other materials not explored here such as communion wares and metal charms. Comparison with other early modern Western societies may also prove fruitful. Furthermore, the methodology may be suitable for application to other interdisciplinary projects incorporating historical and material evidence.

Un aporte a la comprensión de las estrategias emergentes en las organizaciones a través del concepto de improvisación y la metáfora musical

Este trabajo se inscribe en uno de los grandes campos de los estudios organizacionales: la estrategia. La perspectiva clásica en este campo promovió la idea de que proyectarse hacia el futuro implica diseñar un plan (una serie de acciones deliberadas). Avances posteriores mostraron que la estrategia podía ser comprendida de otras formas. Sin embargo, la evolución del campo privilegió en alguna medida la mirada clásica estableciendo, por ejemplo, múltiples modelos para ‘formular’ una estrategia, pero dejando en segundo lugar la manera en la que esta puede ‘emerger’. El propósito de esta investigación es, entonces, aportar al actual nivel de comprensión respecto a las estrategias emergentes en las organizaciones. Para hacerlo, se consideró un concepto opuesto —aunque complementario— al de ‘planeación’ y, de hecho, muy cercano en su naturaleza a ese tipo de estrategias: la improvisación. Dado que este se ha nutrido de valiosos aportes del mundo de la música, se acudió al saber propio de este dominio, recurriendo al uso de ‘la metáfora’ como recurso teórico para entenderlo y alcanzar el objetivo propuesto. Los resultados muestran que 1) las estrategias deliberadas y las emergentes coexisten y se complementan, 2) la improvisación está siempre presente en el contexto organizacional, 3) existe una mayor intensidad de la improvisación en el ‘como’ de la estrategia que en el ‘qué’ y, en oposición a la idea convencional al respecto, 4) se requiere cierta preparación para poder improvisar de manera adecuada.

Infección por virus sincitial respiratorio y su relación con valores de IGG en niños críticos

Antecedente: La infección por el virus sincitial respiratorio (VSR) representa una elevada morbimortalidad, y en algunos casos necesidad de manejo en unidades de cuidado intensivo pediátrico (UCIP). La respuesta inmunológica influye de manera directa en la expresión de la severidad y pronóstico de los pacientes con infección respiratoria. Metodología: Estudio de una cohorte retrospectiva de pacientes con infección respiratoria grave secundaria a VSR, sin historia de inmunodeficiencia, atendidos en la UCIP del Hospital Universitario Clínica San Rafael. Se realizó análisis descriptivoglobaly de acuerdo a la categorización de las prueba de IgG. Resultados: De 188 pacientes que ingresaron a la UCIP, 13% presentaron infección por VSR (24), con una edad promedio de 7,3 (DE=3,6) meses. Pertenecían al sexo masculino79,83%. Se encontró que 12,5% tenían un valor de IgGbajo para su edad, 58,33% tenían valores en límite inferior y el 29,17% dentro de rangos normales para su edad. En los pacientes con IgG baja, fue mayor la presentación de choque séptico que no responde a líquidos (100 vs 92 vs 86%), la mediana de días de ventilación mecánica fue mayor (8 vs 6 vs 5 respectivamente), así como la mortalidad (67 vs 7,1 vs 0%). Conclusión: Nuestra serie encontró que aquellos pacientes con niveles bajos o valores en el límite inferior de IgG sérica tuvieron mayor compromiso sistémico, mayor duración de ventilación mecánica y mayor mortalidad. Se necesitan estudios prospectivos que relaciones niveles bajos de IgG con severidad y pronostico en estos pacientes con infección grave por VSR.

The Scored Patient-Generated Subjective Global Assessment (PG-SGA) and its Association with Quality of Life in Ambulatory Patients Receiving Radiotherapy

OBJECTIVE: To evaluate the scored Patient-generated Subjective Global Assessment (PG-SGA) tool as an outcome measure in clinical nutrition practice and determine its association with quality of life (QoL). DESIGN: A prospective 4 week study assessing the nutritional status and QoL of ambulatory patients receiving radiation therapy to the head, neck, rectal or abdominal area. SETTING: Australian radiation oncology facilities. SUBJECTS: Sixty cancer patients aged 24-85 y. INTERVENTION: Scored PG-SGA questionnaire, subjective global assessment (SGA), QoL (EORTC QLQ-C30 version 3). RESULTS: According to SGA, 65.0% (39) of subjects were well-nourished, 28.3% (17) moderately or suspected of being malnourished and 6.7% (4) severely malnourished. PG-SGA score and global QoL were correlated (r=-0.66, P<0.001) at baseline. There was a decrease in nutritional status according to PG-SGA score (P<0.001) and SGA (P<0.001); and a decrease in global QoL (P<0.001) after 4 weeks of radiotherapy. There was a linear trend for change in PG-SGA score (P<0.001) and change in global QoL (P=0.003) between those patients who improved (5%) maintained (56.7%) or deteriorated (33.3%) in nutritional status according to SGA. There was a correlation between change in PG-SGA score and change in QoL after 4 weeks of radiotherapy (r=-0.55, P<0.001). Regression analysis determined that 26% of the variation of change in QoL was explained by change in PG-SGA (P=0.001). CONCLUSION: The scored PG-SGA is a nutrition assessment tool that identifies malnutrition in ambulatory oncology patients receiving radiotherapy and can be used to predict the magnitude of change in QoL.