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.

Essay, The courts martial of the 1916 leaders

This website contains digital images of the 15 courtmartial files of the executed leaders. The originals, released to the public in 2001, are in the custody of The National Archives in London; the images are displayed under licence from TNA. The website has a searchable database relating to the files, which can also be browsed by name. There are also two essays, one by Dr. Fearghal McGarry on the general context of the trials, the other by Dr. Myles Dungan on their dubious legality. These are the basic records of one of the most eventful and fateful processes in modern Irish history.
Purchase of the digital images of these records was made possible by Universities Ireland, the umbrella body which promotes co-operation between all the universities on the Island of Ireland. The purchase forms part of their extensive Decade of Centenaries programme. Further details can be found at http://universitiesireland.ie/

Inflexibilidade Psicológica

O presente trabalho, destinou-se à validação do Avoidance and Fusion Questionnaire for Youth - AFQ- Y( Greco, Baer, & Lambert, 2008), traduzido por Questionário de Evitamento Experiencial e Fusão Cognitiva para Adolescentes. Isto porque, na prática clínica, se verifica uma escassez de instrumentos de auto-resposta que avaliam estes contructos, caracterizadores da inflexibilidade psicológica. A amostra do nosso estudo consiste em 461 adolescentes, com idades compreendidas entre os 12 e os 18 anos, a frequentar o 3º ciclo do ensino básio e ensino secundário de escolas situadas em meio rural e urbano. Para além do citado instrumento a validar, os jovens preencheram também outras medidas de sintomas psicopatológicos e de percepção do seu auto-conceito social; nomeadamente, o Inventário Depressivo para Crianças (CDI; Kovacs, 1985), a Escala Revista de Ansiedade Manifesta para Crianças (RCMAS; Reynolds & Richmond, 1978) e a Escala de Comparação Social (SCS; Allan, & Gilbert, 1995), bem como uma medida de um construto semelhante referente à aceitação e mindfulness em crianças(CAMM; Greco, Baer & Lambert, 2008). Os resultados obtidos mostram que o questionário possui uma boa consistência interna, uma adequada estabilidade temporal, assim como uma boa validade. Sugerem ainda tratar-se de uma escala unidimensional. Estes dados permitem o avanço da psicologia, no que diz respeito à prática clínica com adolescentes, nomeadamente no domínio das chamadas terapias de terceira geração em Portugal. São apresentados e discutidos os dados normativos para a população portuguesa. Não obstante às limitações apontadas, os resultados sugerem que o AFQ-Y é um questionário útil na avaliação da inflexibilidade psicológica em adolescentes. /

Great characters of the New Testament /

"Reprinted June 1925"--T.p. verso.

Ion transport inside charged membranes.

Mode of access: Internet.

Resources of the southern fields and forests, medical, economical, and agricultural : being also a medical botany of the Confederate States; with practical information on the useful properties of the trees, plants and shrubs /

RBC donor (copy 2): Ernest Haywood Collection.

Virginia /

Relief shown pictorially.

[A map of the state of Virginia : constructed in conformity to law from the late surveys authorized by the legislature and other original and authentic documents /

Relief shown by hachures. Depths shown by soundings.

A map of the state of Virginia, constructed in conformity to law from the late surveys authorized by the legislature and other original and authentic documents /

Relief shown by hachures. Depths shown by soundings on Drummond's Lake only.

A map of the state of Virginia, constructed in conformity to law from the late surveys authorized by the legislature and other original and authentic documents /

Relief shown by hachures. Depths shown by soundings.

A map of the state of Virginia : constructed in conformity to law from the late surveys authorized by the legislature and other original and authentic documents /

Relief shown by hachures. Depths shown by soundings.

Essays on Financial Constraints, R&D Investments, and Competition

This dissertation consists of two chapters of theoretical studies that investigate the effect of financial constraints and market competition on research and development (R&D) investments. In the first chapter, I explore the impact of financial constraints on two different types of R&D investments. In the second chapter, I examine the impact of market competition on the relationship between financial constraints and R&D investments. In the first chapter, I develop a dynamic monopoly model to study a firm’s R&D strategy. Contrary to intuition, I show that a financially constrained firm may invest more aggressively in R&D projects than an unconstrained firm. Financial constraints introduce a risk that a firm may run out of money before its project bears fruit, which leads to involuntary termination on an otherwise positive-NPV project. For a company that relies on cash flow from assets in place to keep its R&D project alive, early success can be relatively important. I find that when the discovery process can be expedited by heavier investment (“accelerable” projects), a financially constrained company may find it optimal to “over”-invest in order to raise the probability of project survival. The over-investment will not happen if the project is only “scalable” (investment scales up payoffs). The model generates several testable implications regarding over-investment and project values. In the second chapter, I study the effects of competition on R&D investments in a duopoly framework. Using a homogeneous duopoly model where two unconstrained firms compete head to head in an R&D race, I find that competition has no effect on R&D investment if the project is not accelerable, and the competing firms are not constrained. In a heterogeneous duopoly model where a financially constrained firm competes against an unconstrained firm, I discover interesting strategic interactions that lead to preemption by the constrained firm in equilibrium. The unconstrained competitor responds to its constrained rival’s investment in an inverted-U shape fashion. When the constrained competitor has high cash flow risk, it accelerates the innovation in equilibrium, while the unconstrained firm invests less aggressively and waits for its rival to quit the race due to shortage of funds.

The Proceedings of the South Carolina Historical Association

Annually, the association publishes a journal, The Proceedings, which consists of papers presented at the annual meeting. Some Municipal Fiestas and Celebrations in Colonial Hispanic America by John Preston Moore – The Citadel Jefferson Davis’s Route from Richmond, Virginia, to Irwinville, Georgia, April 2-May 10, 1865 by Nora Marshall Davis – Historical Markers Survey of South Carolina Postal Savings Banks in the United States, 1871-1939 by Nancy McIntosh – Columbia High School Legislative Domination in South Carolina by George R. Sherrill – University of South Carolina