Considerations for using sucrose to reduce procedural pain in preterm infants

Preterm and critically ill newborns admitted to a NICU undergo repeated skin-breaking procedures that are necessary for their survival. Sucrose is rapidly becoming the accepted clinical standard nonpharmacologic intervention for managing acute procedural pain for these infants. Although shown to be safe in single doses, only 4 studies have evaluated the effects of repeated doses of sucrose over relatively short periods of time. None has examined the use of sucrose throughout the NICU stay, and only 1 study evaluated the neurodevelopmental outcomes after repeated doses of sucrose. In that study, infants born at 10 doses per day in the first week of life were more likely to show poorer attention and motor development in the early months after discharge from the NICU. Results of studies in animal models have suggested that the mechanism of action of sucrose is through opioid pathways; however, in human infants, little has been done to examine the physiologic mechanisms involved, and the findings reported thus far have been ambiguous. Drawing from the growing animal literature of research that has examined the effects of chronic sugar exposure, we describe alternative amine and hormone pathways that are common to the processing of sucrose, attention, and motor development. In addition, a review of the latest research to examine the effects of repeated sucrose on pain processing is presented. These 2 literatures each can inform the other and can provide an impetus to initiate research to examine not only the mechanisms involved in the calming mechanisms of sucrose but also in the long-term neurodevelopmental effects of repeated sucrose in those infants born extremely preterm or critically ill.

Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia:A randomized controlled trial

Context: Nursing home residents with pneumonia are frequently hospitalized. Such transfers may be associated with multiple hazards of hospitalization as well as economic costs. Objective: To assess whether using a clinical pathway for on-site treatment of pneumonia and other lower respiratory tract infections in nursing homes could reduce hospital admissions, related complications, and costs. Design, Setting, and Participants: A cluster randomized controlled trial of 680 residents aged 65 years or older in 22 nursing homes in Hamilton, Ontario, Canada. Nursing homes began enrollment between January 2, 2001, and April 18, 2002, with the last resident follow-up occurring July 4, 2005. Residents were eligible if they met a standardized definition of lower respiratory tract infection. Interventions: Treatment in nursing homes according to a clinical pathway, which included use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse, or usual care. Main Outcome Measures: Hospital admissions, length of hospital stay, mortality, health-related quality of life, functional status, and cost. Results: Thirty-four (10%) of 327 residents in the clinical pathway group were hospitalized compared with 76 (22%) of 353 residents in the usual care group. Adjusting for clustering of residents in nursing homes, the weighted mean reduction in hospitalizations was 12% (95% confidence interval [CI], 5%-18%; P=.001). The mean number of hospital days per resident was 0.79 in the clinical pathway group vs 1.74 in the usual care group, with a weighted mean difference of 0.95 days per resident (95% CI, 0.34-1.55 days; P=.004). The mortality rate was 8% (24 deaths) in the clinical pathway group vs 9% (32 deaths) in the usual care group, with a weighted mean difference of 2.9% (95% CI, -2.0% to 7.9%; P=.23). There were no significant differences between the groups in health-related quality of life or functional status. The clinical pathway resulted in an overall cost savings of US $1016 per resident (95% CI, $207-$1824) treated. Conclusion: Treating residents of nursing homes with pneumonia and other lower respiratory tract infections with a clinical pathway can result in comparable clinical outcomes, while reducing hospitalizations and health care costs. ©2006 American Medical Association. All rights reserved.

Why Do Firms Pay Dividends?: Evidence from an Early and Unregulated Capital Market

Why do firms pay dividends? To answer this question, we use a hand-collected data set of companies traded on the London stock market between 1825 and 1870. As tax rates were effectively zero, the capital market was unregulated, and there were no institutional stockholders, we can rule out these potential determinants ex ante. We find that, even though they were legal, share repurchases were not used by firms to return cash to shareholders. Instead, our evidence provides support for the information–communication explanation for dividends, while providing little support for agency, illiquidity, catering, or behavioral explanations. © The Authors 2013. Published by Oxford University Press [on behalf of the European Finance Association]. All rights reserved.

Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute lung injury to Reduce Pulmonary dysfunction (HARP-2) trial: study protocol for a randomized controlled trial

Background: Acute lung injury (ALI) is a common devastating clinical syndrome characterized by life-threatening respiratory failure requiring mechanical ventilation and multiple organ failure. There are in vitro, animal studies and pre-clinical data suggesting that statins may be beneficial in ALI. The Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute lung injury to Reduce Pulmonary dysfunction (HARP-2) trial is a multicenter, prospective, randomized, allocation concealed, double-blind, placebo-controlled clinical trial which aims to test the hypothesis that treatment with simvastatin will improve clinical outcomes in patients with ALI.

Methods/Design: Patients fulfilling the American-European Consensus Conference Definition of ALI will be randomized in a 1: 1 ratio to receive enteral simvastatin 80 mg or placebo once daily for a maximum of 28 days. Allocation to randomized groups will be stratified with respect to hospital of recruitment and vasopressor requirement. Data will be recorded by participating ICUs until hospital discharge, and surviving patients will be followed up by post at 3, 6 and 12 months post randomization. The primary outcome is number of ventilator-free days to day 28. Secondary outcomes are: change in oxygenation index and sequential organ failure assessment score up to day 28, number of non pulmonary organ failure free days to day 28, critical care unit mortality; hospital mortality; 28 day post randomization mortality and 12 month post randomization mortality; health related quality of life at discharge, 3, 6 and 12 months post randomization; length of critical care unit and hospital stay; health service use up to 12 months post-randomization; and safety. A total of 540 patients will be recruited from approximately 35 ICUs in the UK and Ireland. An economic evaluation will be conducted alongside the trial. Plasma and urine samples will be taken up to day 28 to investigate potential mechanisms by which simvastatin might act to improve clinical outcomes.

Considering the impact of the 'Right to Bargain' Legislation in Ireland: A Review

Ireland is rare among advanced economies in not having statutory trade union recognition legislation for collective bargaining purposes. The matter has been a source of policy contention over the years with attempts to resolve it encapsulated in the so-called ‘Right to Bargain’ legislation, introduced in 2001. This legislation has sought to circumvent statutory recognition in Ireland by putting in place an alternative mechanism for unions to represent members in non-union firms where collective bargaining is not practiced. This review, based on a mixture of empirical and documentary evidence, demonstrates that this legislation was moderately successful for a short period in generating pay rises, improved employment conditions and better access to procedures for union members in non-unionised firms. Indeed, in some respects, it was a superior institutional mechanism to a statutory recognition regime.

Performance analysis of switch-and-stay combining in two-way relay systems with analog network coding and time-division broadcast protocols

In this paper, weconsider switch-and-stay combining (SSC) in two-way relay systems with two amplify-and-forward relays, one of which is activated to assist the information exchange between the two sources. The system operates in either analog network coding (ANC) protocol where the communication is only achieved with the help of the active relay or timedivision broadcast (TDBC) protocol where the direct link between two sources can be utilized to exploit more diversity gain. In both cases, we study the outage probability and bit error rate (BER) for Rayleigh fading channels. In particular, we derive closed-form lower bounds for the outage probability and the average BER, which remain tight for different fading conditions. We also present asymptotic analysis for both the outage probability and the average BER at high signalto-noise ratio. It is shown that SSC can achieve the full diversity order in two-way relay systems for both ANC and TDBC protocols with proper switching thresholds. Copyright © 2014 John Wiley & Sons, Ltd.

Development of a Short Stay Unit in an Emergency Department

In 2009, the Royal Victoria Hospital, Belfast, established a nine-bed, short-stay unit in its emergency department. This article explains the rationale for the model of care delivery adopted, and the importance of developing and working with integrated care pathways. It also discusses four areas essential to the effective running of the unit: interdisciplinary collaboration, training for clinical nurse leaders, management of change and leadership.

Increase in the pharmacological management of Type 2 diabetes with pay-for-performance in primary care in the UK

Aims To determine whether the financial incentives for tight glycaemic control, introduced in the UK as part of a pay-for-performance scheme in 2004, increased the rate at which people with newly diagnosed Type 2 diabetes were started on anti-diabetic medication.

Methods A secondary analysis of data from the General Practice Research Database for the years 1999-2008 was performed using an interrupted time series analysis of the treatment patterns for people newly diagnosed with Type 2 diabetes (n=21 197).

Results Overall, the proportion of people with newly diagnosed diabetes managed without medication 12months after diagnosis was 47% and after 24months it was 40%. The annual rate of initiation of pharmacological treatment within 12months of diagnosis was decreasing before the introduction of the pay-for-performance scheme by 1.2% per year (95% CI -2.0, -0.5%) and increased after the introduction of the scheme by 1.9% per year (95% CI 1.1, 2.7%). The equivalent figures for treatment within 24months of diagnosis were -1.4% (95% CI -2.1, -0.8%) before the scheme was introduced and 1.6% (95% CI 0.8, 2.3%) after the scheme was introduced.

Conclusion The present study suggests that the introduction of financial incentives in 2004 has effected a change in the management of people newly diagnosed with diabetes. We conclude that a greater proportion of people with newly diagnosed diabetes are being initiated on medication within 1 and 2years of diagnosis as a result of the introduction of financial incentives for tight glycaemic control.

International inter-school competition to encourage children to walk to school: a mixed methods feasibility study.

Background: Active travel to school can be an important contributor to the total physical activity of children but levels have declined and more novel approaches are required to stimulate this as an habitual behaviour. The aim of this mixed methods study was to investigate the feasibility of an international walk to school competition supported by novel swipecard technology to increase children's walking to/from school. Methods: Children aged 9-13 years old participated in an international walk to school competition to win points for themselves, their school and their country over a 4-week period. Walks to and from school were recorded using swipecard technology and a bespoke website. For each point earned by participants, 1 pence (£0.01) was donated to the charity of the school's choice. The primary outcome was number of walks to/from school objectively recorded using the swipecard tracking system over the intervention period. Other measures included attitudes towards walking collected at baseline and week 4 (post-intervention). A qualitative sub-study involving focus groups with children, parents and teachers provided further insight. Results: A total of 3817 children (mean age 11.5±SD 0.7) from 12 schools in three cities (London and Reading, England and Vancouver, Canada) took part in the intervention, representing a 95% intervention participation rate. Results show a gradual decline in the average number of children walking to and from school over the 4-week period (week 1 mean 29%±SD2.5; week 2 mean 18%±SD3.6; week 3 mean 14%±SD4.0; week 4 mean 12%±SD1.1). Post intervention, 97% of children felt that walking to school helped them stay healthy, feel happy (81%) and stay alert in class (76%). These results are supported by qualitative findings from children, parents and teachers. Key areas for improvement include the need to incorporate strategies for maintenance of behaviour change into the intervention and also to adopt novel methods of data collection to increase follow-up rates. Conclusions: This mixed methods study suggests that an international walk to school competition using innovative technology can be feasibly implemented and offers a novel way of engaging schools and motivating children to walk to school.

The Coxian phase-type distribution as a contribution to the multilevel model of in-hospital mortality

This paper presents multilevel models that utilize the Coxian phase-type distribution in order to be able to include a survival component in the model. The approach is demonstrated by modeling patient length of stay and in-hospital mortality in geriatric wards in Italy. The multilevel model is used to provide a means of controlling for the existence of possible intra-ward correlations, which may make patients within a hospital more alike in terms of experienced outcome than patients coming from different hospitals, everything else being equal. Within this multilevel model we introduce the use of the Coxian phase-type distribution to create a covariate that represents patient length of stay or stage (of hospital care). Results demonstrate that the use of the multilevel model for representing the in-patient mortality is successful and further enhanced by the inclusion of the Coxian phase-type distribution variable (stage covariate).

Using the hidden Markov model to capture quality of care in Lombardy geriatric wards

Quality of care is an important aspect of healthcare monitoring, which is used to ensure that the healthcare system is delivering care of the highest standard. With populations growing older there is an increased urgency in making sure that the healthcare delivered is of the highest standard. Healthcare providers are under increased pressure to ensure that this is the case with public and government demand expecting a healthcare system of the highest quality. Modelling quality of care is difficult to measure due to the many ways of defining it. This paper introduces a potential model which could be used to take quality of care into account when modelling length of stay. The Coxian phase-type distribution is used to model length of stay and the associated quality of care incorporated into the Coxian using a Hidden Markov model. Covariates are also introduced to determine their impact on the hidden level to find out what potentially can affect quality of care. This model is applied to geriatic patient data from the Lombardy region of Italy. The results obtained highlighted that bed numbers and the type of hospital (public or private) can have an effect on the quality of care delivered.

Content Validity in Landscape Valuation: A transdisciplinary approach to valuing the landscape of the peninsula of Sorrento, Italy.

This paper addresses the representation of landscape complexity in stated preferences research. It integrates landscape ecology and landscape economics and conducts the landscape analysis in a three-dimensional space to provide ecologically meaningful quantitative landscape indicators that are used as variables for the monetary valuation of landscape in a stated preferences study. Expected heterogeneity in taste intensity across respondents is addressed with a mixed logit model in Willingness to Pay space. The results suggest that the integration of landscape ecology metrics in a stated preferences model provides useful insights for valuing landscape and landscape changes

"Should I prioritize medical problem solving or attentive listening?": the dilemmas and challenges that medical students experience when learning to conduct consultations

Objective: Communication skills can be trained alongside clinical reasoning, history taking or clinical examination skills. This is advocated as a solution to the low transfer of communication skills. Still, students have to integrate the knowledge/skills acquired during different curriculum parts in patient consultations at some point. How do medical students experience these integrated consultations within a simulated environment and in real practice when dealing with responsibility?

Methods: Six focus groups were conducted with (pre-)/clerkship students.

Results: Students were motivated to practice integrated consultations with simulated patients and felt like 'real physicians'. However, their focus on medical problem solving drew attention away from improving their communication skills. Responsibility for real patients triggered students' identity development. This identity formation guided the development of an own consultation style, a process that was hampered by conflicting demands of role models.

Conclusion: Practicing complete consultations results in the dilemma of prioritizing medical problem solving above attention for patient communication. Integrated consultation training advances this dilemma to the pre-clerkship period. During clerkships this dilemma is heightened because real patients trigger empathy and responsibility, which invites students to define their role as doctor.

Practice Implications: When training integrated consultations, educators should pay attention to students' learning priorities and support the development of students' professional identity.

Secure Switch-and-Stay Combining (SSSC) for Cognitive Relay Networks

In this paper, we study a two-phase underlay cognitive relay network, where there exists an eavesdropper who can overhear the message. The secure data transmission from the secondary source to secondary destination is assisted by two decode-and-forward (DF) relays. Although the traditional opportunistic relaying technique can choose one relay to provide the best secure performance, it needs to continuously have the channel state information (CSI) of both relays, and may result in a high relay switching rate. To overcome these limitations, a secure switch-and-stay combining (SSSC) protocol is proposed where only one out of the two relays is activated to assist the secure data transmission, and the secure relay switching occurs when the relay cannot support the secure communication any longer. This security switching is assisted by either instantaneous or statistical eavesdropping CSI. For these two cases, we study the system secure performance of SSSC protocol, by deriving the analytical secrecy outage probability as well as an asymptotic expression for the high main-to-eavesdropper ratio (MER) region. We show that SSSC can substantially reduce the system complexity while achieving or approaching the full diversity order of opportunistic relaying in the presence of the instantaneous or statistical eavesdropping CSI.

Effectiveness of a biomarker-based exclusion of ventilator-acquired pneumonia to reduce antibiotic use: protocol for a randomised controlled trial (VAPrapid-2):Study protocol for a randomised controlled trial

Background Ventilator-acquired pneumonia (VAP) is a common reason for antimicrobial therapy in the intensive care unit (ICU). Biomarker-based diagnostics could improve antimicrobial stewardship through rapid exclusion of VAP. Bronchoalveloar lavage (BAL) fluid biomarkers have previously been shown to allow the exclusion of VAP with high confidence. Methods/Design This is a prospective, multi-centre, randomised, controlled trial to determine whether a rapid biomarker-based exclusion of VAP results in fewer antibiotics and improved antimicrobial management. Patients with clinically suspected VAP undergo BAL, and VAP is confirmed by growth of a potential pathogen at > 104 colony-forming units per millilitre (CFU/ml). Patients are randomised 1:1, to either a ‘biomarker-guided recommendation on antibiotics’ in which BAL fluid is tested for IL-1β and IL-8 in addition to routine microbiology testing, or to ‘routine use of antibiotics’ in which BAL undergoes routine microbiology testing only. Clinical teams are blinded to intervention until 6 hours after randomisation, when biomarker results are reported to the clinician. The primary outcome is a change in the frequency distribution of antibiotic-free days (AFD) in the 7 days following BAL. Secondary outcome measures include antibiotic use at 14 and 28 days; ventilator-free days; 28-day mortality and ICU mortality; sequential organ failure assessment (SOFA) at days 3, 7 and 14; duration of stay in critical care and the hospital; antibiotic-associated infections; and antibiotic-resistant pathogen cultures up to hospital discharge, death or 56 days. A healthcare-resource-utilisation analysis will be calculated from the duration of critical care and hospital stay. In addition, safety data will be collected with respect to performing BAL. A sample size of 210 will be required to detect a clinically significant shift in the distribution of AFD towards more patients having fewer antibiotics and therefore more AFD. Discussion This trial will test whether a rapid biomarker-based exclusion of VAP results in rapid discontinuation of antibiotics and therefore improves antibiotic management in patients with suspected VAP.