Incidence of violent behavior among patients in Psychiatric Intensive Care Units

Background and Objectives: Both psychiatric acute units and psychiatric intensive care units (PICUs) focus on acute treatment of behavioral disturbances such as violence and aggressive threats and acts. The aim of the present study is to describe the frequency of violent behavior; such as verbal or physical threats and physical attacks, among patients admitted to psychiatric intensive care unit (PICU). In addition the relationship between the episodes of threats and/or attacks in relation to time of the day, days of the week, and their seasonal variations was explored. Methods: All violent behavior was continuously assessed at the psychiatric emergency department. Data were collected during the period from May 2010 to May 2012. Results: Patients with only one hospitalization were less violent than those who have had two hospitalizations. There was a statistically significant difference in violence among patients without formal secondary education and those who have not formal education. Violent behavior showed two peaks during the day; the first occurring at 1 pm and the second at 8 pm. In regard to seasonality, summer had a higher incidence of violence. The most peaceful seasons of the year were spring and autumn. Conclusions: Violent behavior shows variation in daytime, days of the week and season in acute psychiatric intensive care. Daytime variation shows two peaks of violence at 1 pm and 8 pm, Sundays and Wednesdays being the quietest days regarding violence both in winter and summer. Patient's level of education and hospitalization status partially explain the variation.

Anthropometric indicators of nutritional status and growth in very low birth-weight premature infants hospitalized in a neonatal intensive care unit

Background: Anthropometric indicators are difficult to interpret in very low birth weight (VLBW) premature infants, including both appropriate for gestational age (AGA) and small for gestational age (SGA) infants. Therefore, the purpose was to describe the anthropometric indicators of growth and nutritional status in VLBW premature infants AGA and SGA, hospitalized in a neonatal intensive care unit (NICU). Study design: The descriptive and prospective study design included 114 preterm infants, adequate for gestational age/small for gestational age hospitalized in the intensive care unit. Head, thigh, mid upper arm circumference, skin-fold measurements and weight/age, length/ age, and weight/length indices were obtained. Correlations were made among the anthropometric indices, and a multivariate regression analysis with weight/age as dependent variable was performed. Results: Weight/age in AGA premature infants had high number of significant anthropometric correlations. The SGA premature infants had few and weak correlations. The regression analysis showed that anthropometric indices better explain changes in the weight/age index in adequate for gestational age premature infants. Conclusion: Weight/age in the VLBW/AGA premature infants could reflect growth, nutritional status and energy stored as fat, but in the VLBW/SGA premature infants, thigh circumference and mid arm circumference would be better indicators just of nutritional status.

Priorities for future intensive care research in the UK: results of a James Lind Alliance Priority Setting Partnership.

This James Lind Alliance (JLA) Priority Setting Partnership aimed to identify and prioritise unanswered questions about adult intensive care that are important to people who have been critically ill, their families, and the health professionals who care for them. Consensus techniques (modified Delphi and Nominal Group) were used to generate suggestions using online and postal surveys. Following verification and iterative editorial review, research topics were constructed from these suggestions. These topics were presented in a second online and postal survey for rating. A Nominal Group of 21 clinicians, patients and family representatives subsequently met to rank the most important research topics and produce a prioritised list. The project was coordinated by a representative Steering Group and independently overseen by the JLA. The initial survey and review of the literature generated over 1,300 suggestions. Preliminary editing and verification permitted us to encapsulate these suggestions within 151 research topics. Iterative review by members of the Steering Group produced 37 topic statements, subsequently rated by participants. Using the mode to determine importance, 19 topics were presented to the group from which a ‘top three’ intensive care research priorities were identified and a further nine topics were prioritised. By applying and adapting the JLA methodology to focus on an area of care rather than to a single disease, we have provided a means to ensure that patients, their families and professionals materially contribute to the prioritisation of intensive care research in the UK.

Intensive care survivors’ experiences of ward-based care: Meleis’ theory of nursing transitions and role development among critical care outreach services.

Aims and objectives. To explore the psychosocial needs of patients discharged from intensive care, the extent to which they are captured using existing theory on transitions in care and the potential role development of critical care outreach, follow-up and liaison services. Background. Intensive care patients are at an increased risk of adverse events, deterioration or death following ward transfer. Nurse-led critical care outreach, follow-up or liaison services have been adopted internationally to prevent these potentially avoidable sequelae. The need to provide patients with psychosocial support during the transition to ward-based care has also been identified, but the evidence base for role development is currently limited. Design and methods. Twenty participants were invited to discuss their experiences of ward-based care as part of a broader study on recovery following prolonged critical illness. Psychosocial distress was a prominent feature of their accounts, prompting secondary data analysis using Meleis et al.’s mid-range theory on experiencing transitions. Results. Participants described a sense of disconnection in relation to profound debilitation and dependency and were often distressed by a perceived lack of understanding, indifference or insensitivity among ward staff to their basic care needs. Negotiating the transition between dependence and independence was identified as a significant source of distress following ward transfer. Participants varied in the extent to which they were able to express their needs and negotiate recovery within professionally mediated boundaries. Conclusion. These data provide new insights into the putative origins of the psychosocial distress that patients experience following ward transfer. Relevance to clinical practice. Meleis et al.’s work has resonance in terms of explicating intensive care patients’ experiences of psychosocial distress throughout the transition to general ward–based care, such that the future role development of critical care outreach, follow-up and liaison services may be more theoretically informed.

A rehabilitation intervention to promote physical recovery following intensive care: a detailed description of construct development, rationale and content together with proposed taxonomy to capture processes in a randomised controlled trial.

Background: increasing numbers of patients are surviving critical illness, but survival may be associated with a constellation of physical and psychological sequelae that can cause on going disability and reduced health-related quality of life. Limited evidence currently exists to guide the optimum structure, timing, and content of rehabilitation programmes. There is a need to both develop and evaluate interventions to support and expedite recovery during the post-ICU discharge period. This paper describes the construct development for a complex rehabilitation intervention intended to promote physical recovery following critical illness. The intervention is currently being evaluated in a randomised trial (ISRCTN09412438; funder Chief Scientists Office, Scotland). Methods: the intervention was developed using the Medical Research Council (MRC) framework for developing complex healthcare interventions. We ensured representation from a wide variety of stakeholders including content experts from multiple specialties, methodologists, and patient representation. The intervention construct was initially based on literature review, local observational and audit work, qualitative studies with ICU survivors, and brainstorming activities. Iterative refinement was aided by the publication of a National Institute for Health and Care Excellence guideline (No. 83), publicly available patient stories (Healthtalkonline), a stakeholder event in collaboration with the James Lind Alliance, and local piloting. Modelling and further work involved a feasibility trial and development of a novel generic rehabilitation assistant (GRA) role. Several rounds of external peer review during successive funding applications also contributed to development. Results: the final construct for the complex intervention involved a dedicated GRA trained to pre-defined competencies across multiple rehabilitation domains (physiotherapy, dietetics, occupational therapy, and speech/language therapy), with specific training in post-critical illness issues. The intervention was from ICU discharge to 3 months post-discharge, including inpatient and post-hospital discharge elements. Clear strategies to provide information to patients/families were included. A detailed taxonomy was developed to define and describe the processes undertaken, and capture them during the trial. The detailed process measure description, together with a range of patient, health service, and economic outcomes were successfully mapped on to the modified CONSORT recommendations for reporting non-pharmacologic trial interventions. Conclusions: the MRC complex intervention framework was an effective guide to developing a novel post-ICU rehabilitation intervention. Combining a clearly defined new healthcare role with a detailed taxonomy of process and activity enabled the intervention to be clearly described for the purpose of trial delivery and reporting. These data will be useful when interpreting the results of the randomised trial, will increase internal and external trial validity, and help others implement the intervention if the intervention proves clinically and cost effective.

A randomised controlled trial evaluating a rehabilitation complex intervention for patients following intensive care discharge: the RECOVER study.

Introduction: Patients who survive an intensive care unit admission frequently suffer physical and psychological morbidity for many months after discharge. Current rehabilitation pathways are often fragmented and little is known about the optimum method of promoting recovery. Many patients suffer reduced quality of life. Methods and analysis: The authors plan a multicentre randomised parallel group complex intervention trial with concealment of group allocation from outcome assessors. Patients who required more than 48 h of mechanical ventilation and are deemed fit for intensive care unit discharge will be eligible. Patients with primary neurological diagnoses will be excluded. Participants will be randomised into one of the two groups: the intervention group will receive standard ward-based care delivered by the NHS service with additional treatment by a specifically trained generic rehabilitation assistant during ward stay and via telephone contact after hospital discharge and the control group will receive standard ward-based care delivered by the current NHS service. The intervention group will also receive additional information about their critical illness and access to a critical care physician. The total duration of the intervention will be from randomisation to 3 months postrandomisation. The total duration of follow-up will be 12 months from randomisation for both groups. The primary outcome will be the Rivermead Mobility Index at 3 months. Secondary outcomes will include measures of physical and psychological morbidity and function, quality of life and survival over a 12-month period. A health economic evaluation will also be undertaken. Groups will be compared in relation to primary and secondary outcomes; quantitative analyses will be supplemented by focus groups with patients, carers and healthcare workers. Ethics and dissemination: Consent will be obtained from patients and relatives according to patient capacity. Data will be analysed according to a predefined analysis plan.

Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial.

Importance: critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. Objective: to evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post–intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. Design, Setting, and Participants: a parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. Interventions: during the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. Main Outcomes and Measures: the Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). Results: median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, −0.2 [95% CI, −1.3 to 0.9; P = .71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, −0.1 [95% CI, −3.3 to 3.1; P = .96]; and in the Mental Component Summary score, 0.2 [95% CI, −3.4 to 3.8; P = .91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. Conclusions and Relevance: post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery.

Do simple ventilation and gas exchange measurements predict early successful weaning from respiratory support in unselected general intensive care patients?

Background. The value of respiratory variables as weaning predictors in the intensive care unit (ICU) is controversial. We evaluated the ability of tidal volume (Vtexp), respiratory rate ( f ), minute volume (MVexp), rapid shallow breathing index ( f/Vt), inspired–expired oxygen concentration difference [(I–E)O2], and end-tidal carbon dioxide concentration (PE′CO2) at the end of a weaning trial to predict early weaning outcomes. Methods. Seventy-three patients who required .24 h of mechanical ventilation were studied. A controlled pressure support weaning trial was undertaken until 5 cm H2O continuous positive airway pressure or predefined criteria were reached. The ability of data from the last 5 min of the trial to predict whether a predefined endpoint indicating discontinuation of ventilator support within the next 24 h was evaluated. Results. Pre-test probability for achieving the outcome was 44% in the cohort (n¼32). Non-achievers were older, had higher APACHE II and organ failure scores before the trial, and higher baseline arterial H+ concentrations. The Vt, MV, f, and f/Vt had no predictive power using a range of cut-off values or from receiver operating characteristic (ROC) analysis. The [I–E]O2 and PE′CO2 had weak discriminatory power [areaunder the ROC curve: [I–E]O2 0.64 (P¼0.03); PE′CO2 0.63 (P¼0.05)]. Using best cut-off values for [I–E]O2 of 5.6% and PE′CO2 of 5.1 kPa, positive and negative likelihood ratios were 2 and 0.5, respectively, which only changed the pre- to post-test probability by about 20%. Conclusions. In unselected ICU patients, respiratory variables predict early weaning from mechanical ventilation poorly.

KANGAROO CARE: MATERNAL PERCEPTION OF THE EXPERIENCE IN THE NEONATAL INTENSIVE CARE UNIT

Objective: To investigate the maternal perception of the experience in the first phase of the Kangaroo Mother Care Method in the Neonatal Intensive Care Unit (NICU). Methods: Descriptive, exploratory and qualitative study, conducted in the period from August to October 2014, with 10 mothers of newborn preterm (NP) infants, who were admitted to the Maternity School Assis Chateaubriand (MEAC) in Fortaleza, Brazil, and had received skin-to-skin contact through the Kangaroo Care Method during hospitalization in the NICU. Data was collected by semi-structured interview, directed by guiding questions. Content analysis was used for processing the data, being established four categories: “The bond and the attachment”, “Maternal competence”, “The fear of losing the baby” and “The importance of the multidisciplinary team”. Results: The Kangaroo Care Method is a safe and pleasurable practice for mothers and relatives, in addition to providing social and psychoaffective benefits, found in the imagery of the method institutionalization and in the mothers’ experience when properly supported. The meanings of the maternal feelings of apprehension as a result of the first physical contact with the hospitalized child can be evidenced. Regarding the evaluation of its clinical practice, this method has provided better development of the newborn infant and a reduction in hospital stay. Conclusion: The study shows relevance, since the evidence of the maternal perception of this method supports its establishment as a mandatory practice in maternity hospitals, in view of the benefits to the mother and the neonate.

Learning strategies implemented by the students of Advanced Intensive English I courses for improving oral discourse in the Bachelor of Arts in English Teaching, Department of Foreign Languages, University of El Salvador, year 2014.

There are many learning strategies some, more successful than others when they are applied in a correct way. “Strategies are most successful when they are implemented in a system that encourages collaboration among staff and students, and in which each is a part of a well-planned whole system” (Johns Hopkins, 2000). Additionally, Learning strategies have become an effective instrument in the field of education because students can make use of several strategies in order to enhance their English level in terms of communication. To communicate in a meaningful way, it is important to express ideas inside and outside the classroom; it is part of the development and improvement of speaking.

XML-Intensive software development

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INVESTIGATIONS INTO MECHANISMS UNDERLYING EXTREME WAVE FORMATIONS AND COMPUTATIONALLY INTENSIVE SIMULATIONS

Various mechanisms have been proposed to explain extreme waves or rogue waves in an oceanic environment including directional focusing, dispersive focusing, wave-current interaction, and nonlinear modulational instability. The Benjamin-Feir instability (nonlinear modulational instability), however, is considered to be one of the primary mechanisms for rogue-wave occurrence. The nonlinear Schrodinger equation is a well-established approximate model based on the same assumptions as required for the derivation of the Benjamin-Feir theory. Solutions of the nonlinear Schrodinger equation, including new rogue-wave type solutions are presented in the author's dissertation work. The solutions are obtained by using a predictive eigenvalue map based predictor-corrector procedure developed by the author. Features of the predictive map are explored and the influences of certain parameter variations are investigated. The solutions are rescaled to match the length scales of waves generated in a wave tank. Based on the information provided by the map and the details of physical scaling, a framework is developed that can serve as a basis for experimental investigations into a variety of extreme waves as well localizations in wave fields. To derive further fundamental insights into the complexity of extreme wave conditions, Smoothed Particle Hydrodynamics (SPH) simulations are carried out on an advanced Graphic Processing Unit (GPU) based parallel computational platform. Free surface gravity wave simulations have successfully characterized water-wave dispersion in the SPH model while demonstrating extreme energy focusing and wave growth in both linear and nonlinear regimes. A virtual wave tank is simulated wherein wave motions can be excited from either side. Focusing of several wave trains and isolated waves has been simulated. With properly chosen parameters, dispersion effects are observed causing a chirped wave train to focus and exhibit growth. By using the insights derived from the study of the nonlinear Schrodinger equation, modulational instability or self-focusing has been induced in a numerical wave tank and studied through several numerical simulations. Due to the inherent dissipative nature of SPH models, simulating persistent progressive waves can be problematic. This issue has been addressed and an observation-based solution has been provided. The efficacy of SPH in modeling wave focusing can be critical to further our understanding and predicting extreme wave phenomena through simulations. A deeper understanding of the mechanisms underlying extreme energy localization phenomena can help facilitate energy harnessing and serve as a basis to predict and mitigate the impact of energy focusing.

Impacto ambiental associado à utilização intensive de algumas energies renováveis – Pequeno contributo

A utilização da energia hídrica, obtida em grandes barragens, é uma prática muito antiga, em Portugal. Nas ultimas décadas de anos , o seu número tem aumentado, existindo ou estando em fase de conclusão, 57 grandes barragens, no Alentejo. Os problemas associados a este tipo de barragens são conhecidos. Iremos falar de um, extremamente importante, na região. Devido à profundidade atingida, existe pouco oxigénio no fundo destes reservatórios, e a decomposição de matéria morta origina grandes quantidades de metano. Em termos de efeito de estufa o metano é 30 vezes mais potente que o CO2. O facto de não ter havido limpeza do solo antes do enchimento das albufeiras e de algumas se encontrarem com problemas de eutrofização, vem aumentar este problema. Outro tipo de energia muito utilizada é a energia solar, existindo grandes centrais fotovoltaicas em funcionamento e prevendo-se a construção de novas centrais com uma potência total de 1300 MW para o país. Em Évora, Ourique, Alcoutim e Nisa já foi anunciada a construção de novas centrais com uma potência total de 155 MW. Os problemas associados a este tipo de centrais, são de vários tipos. Iremos debruçar-nos sobre os produtos tóxicos que as células solares contêm e que variam com o tipo de célula. Estando algumas centrais já em funcionamento e outras em fase de montagem, importa refletir sobre o que fazer depois de a central deixar de funcionar. O que fazer com os resíduos tóxicos, as toneladas de aço e outros materiais envolvidos, formação de pessoal que saiba manusear os produtos tóxicos, custos associados às soluções possíveis, etc. Não se conhecendo informação relativa a estes problemas, por parte da comunicação social, importa refletir sobre a informação fornecida à população e autoridades locais envolvidas.

Impacto ambiental associado à utilização intensive de algumas energies renováveis – Pequeno contributo

A utilização da energia hídrica, obtida em grandes barragens, é uma prática muito antiga, em Portugal. Nas ultimas décadas de anos , o seu número tem aumentado, existindo ou estando em fase de conclusão, 57 grandes barragens, no Alentejo. Os problemas associados a este tipo de barragens são conhecidos. Iremos falar de um, extremamente importante, na região. Devido à profundidade atingida, existe pouco oxigénio no fundo destes reservatórios, e a decomposição de matéria morta origina grandes quantidades de metano. Em termos de efeito de estufa o metano é 30 vezes mais potente que o CO2. O facto de não ter havido limpeza do solo antes do enchimento das albufeiras e de algumas se encontrarem com problemas de eutrofização, vem aumentar este problema. Outro tipo de energia muito utilizada é a energia solar, existindo grandes centrais fotovoltaicas em funcionamento e prevendo-se a construção de novas centrais com uma potência total de 1300 MW para o país. Em Évora, Ourique, Alcoutim e Nisa já foi anunciada a construção de novas centrais com uma potência total de 155 MW. Os problemas associados a este tipo de centrais, são de vários tipos. Iremos debruçar-nos sobre os produtos tóxicos que as células solares contêm e que variam com o tipo de célula. Estando algumas centrais já em funcionamento e outras em fase de montagem, importa refletir sobre o que fazer depois de a central deixar de funcionar. O que fazer com os resíduos tóxicos, as toneladas de aço e outros materiais envolvidos, formação de pessoal que saiba manusear os produtos tóxicos, custos associados às soluções possíveis, etc. Não se conhecendo informação relativa a estes problemas, por parte da comunicação social, importa refletir sobre a informação fornecida à população e autoridades locais envolvidas.