Characterisation of manual chest physiotherapy and respiratory response in mechanically ventilated children

Chest physiotherapy is integral to the management of mechanically ventilated children and previous research has confirmed that chest wall vibrations are the manual techniques used most frequently by physiotherapists in this population. Chest wall vibrations involve the application of a compressive force to the chest during expiration, with the aim of removing accumulated secretions and improving lung aeration. However, these techniques are largely unquantified and may vary greatly between practitioners and clinical units, with any significance of such variability remaining unknown.In order to evaluate the effectiveness of any therapy it is important to have a means of quantifying the treatment. It is challenging to measure techniques which involve manual contact between the therapist and patient, and at the inception of this project no means existed of directly measuring the force applied through the hand during treatments. The effectiveness of chest physiotherapy in mechanically ventilated patients is likely to be influenced by the interactions between different treatment components, such as the magnitude and pattern of the chest wall vibrations and the accompanying lung inflations. It is therefore essential to assess both the forces applied during the vibrations with the simultaneous changes in air flow, recording the ventilatory pattern throughout the treatment.The study hypotheses were:1. It is possible to create a technique to measure chest wall vibration forces during clinical treatments, and to relate such forces to simultaneous changes in respiratory flows, volumes and pressures2. Maximum and mean force applied during chest wall vibrations increase with the size and age of the child3. Manual lung hyperinflations with chest wall vibrations result in an increase in peak expiratory flow above that observed during baseline mechanical ventilation4. After adjusting for inflation volume, application of chest wall vibrations result in an increase in peak expiratory flow above that obtained during manual lung inflations aloneThe primary objectives of this research were to:1. Develop a method of quantifying chest wall vibration forces and a means of evaluating simultaneous changes in force with those of respiratory flow and pressure in ventilated infants and children of all ages2. Estimate the variability over time, within and between individual physiotherapists when treating the same and different subjects with chest wall vibrations3. Conduct a study to:i) Assess the feasibility of measuring force and respiration in a population of critically ill, mechanically ventilated childrenii) Characterise the magnitude and pattern of forces applied during chest wall vibrations and evaluate the direct effects of these manoeuvres on flow and pressure changes in the lungsiii) Determine the relative contribution of manual lung inflations and chest wall vibrations to any observed increase in expiratory airflow A secondary objective was to explore the short term effects of chest physiotherapy, by recording changes in ventilation, respiratory system mechanics and blood gases following treatment.The thesis comprises four chapters:Chapter 1 contains a comprehensive literature review of published studies demonstrating the current knowledge base of the respiratory problems of mechanical ventilation in children, chest physiotherapy in intensive care and the relationship of chest physiotherapy to normal mechanisms of airway clearance.Chapter 2 describes the process of creating a dynamic force-sensing technique to characterise manual chest physiotherapy, detailing protocol and analysis refinement during pilot force and respiratory data collection. Assessment of the variability within and between physiotherapists is also assessed.Chapter 3 details a clinical study undertaken in intensive care units at Great Ormond Street Hospital for Children NHS Trust, London. The results are presented and interpreted.Chapter 4 discusses the findings of the thesis in relation to earlier research, highlights the strengths and limitations of the current study, interprets the clinical implications of the research and suggests future work

Riding the waves of policy? The case of basic skills in adult and community learning in England

This paper draws on data from secondary sources and in-depth interviews to explore the question: What is the impact of policy on teaching, learning, assessment and inclusion in Adult and Community Learning (ACL) Skills for Life (SfL) provision? In particular, it focuses on the government’s use of five policy steering mechanisms - funding, inspection, planning, targets and policy initiatives (in this case SfL). The design of the study1 allows us to use evidence from four sets of interviews with teachers, learners and managers of ACL in eight sites of learning (four in London and four in the North East) over a period of twenty-six months of considerable policy turbulence. We argue first, that there is a symbiotic relationship between ACL and SfL provision and second, that while the combined effects of targets and funding have the most powerful effects on tutor and manager actions, inspection, planning and tutors’ and managers’ own professional values also have an important role in shaping the teaching of literacy and numeracy in ACL sites. We conclude by suggesting that professionals at the local level should be allowed to play a greater role in SfL policy-making to ensure effective policy and practice

Everything in common? The theology and practice of the sharing of possessions in community in the New Testament with particular reference to Jesus and his Disciples, the earliest Christians, and Paul

This thesis examines the theology and practice of the sharing of possessions, including food, in community in the New Testament. A significant proportion of the New Testament addresses questions around money, possessions and sharing, and provides a range of examples of ways of sharing possessions. This thesis looks at six diverse examples of sharing possessions in the New Testament, from the Gospels, Acts, and the Pauline literature. It considers each example in its social context and then compares it to other examples of sharing in the surrounding cultures to find similarities and differences between the example and surrounding practice and thought. It then examines the comparisons to see whether there are ways in which Christians developed sharing possessions that were consistently similar to or different from surrounding practice. The thesis highlights a number of common characteristics across the New Testament examples of how Christians shared possessions. In the New Testament examples, sharing: is practical and responsive; is based on communal identity; includes people from different backgrounds and various ways of contributing; is voluntary and yet includes assumptions; is both individual and communal; often responds to need; and includes eating together. This thesis analyses similarities and differences between each example and its comparators. It also identifies ways that Christians were consistently distinctive from the surrounding culture in how they shared possessions, as well as areas where Christians were similar to, and may have been influenced by the surrounding practices. The consistent distinctives include: subverting patronage expectations; greater social diversity; more flexibility; a greater emphasis on the voluntary nature of contributing; each person being involved in giving; more frequent eating together; and stronger intra-community relational bonds. This thesis demonstrates a possible approach for examining areas where there is a diverse witness within the New Testament texts

Compassion satisfaction, burnout and secondary traumatic stress in UK therapists

Section A: A literature review was conducted to identify the negative and positive impact that working with adult trauma clients has on therapists. Key theoretical concepts and possible causal mechanisms are summarised and the research evidence supporting these concepts is reviewed. The key limitations to the extant literature and future research are discussed. Section B: Background: Therapists who work with trauma clients are impacted by this work both positively and negatively. However, most studies have tended to focus on the negative impact of the work, the quantitative evidence has been inconsistent, and the research has primarily been conducted outside the UK. Method: An online questionnaire was developed which used a standardised measure to assess compassion satisfaction (CS), burnout, and secondary traumatic stress (STS) in 253 UK therapists working with adult trauma clients. Results: Whilst the majority of therapists scored within the average range for CS and burnout, 70% of scores indicated that they were at high risk of STS. Maturity, time spent engaging in R&D activities, and a higher perceived supportiveness of management and supervision predicted higher potential for CS. Youth and a lower perceived supportiveness of management predicted higher risk of burnout. Higher risk of STS was predicted in therapists engaging in more individual supervision and self-care activities, as well as those who had a personal trauma history. Discussion: These results are discussed in light of previous research. Of particular note is that exposure to trauma stories did not significantly predict STS scores as suggested by STS theory. Contextual and methodological limitations and ideas for future research are highlighted. Section C: A critical appraisal of the research process is summarised which answers the four set questions. A final personal reflection is also given

The association between graded physical activity in postmenopausal British women, and the prevalence and incidence of hip and wrist fractures.

BACKGROUND: physical activity is promoted for older women as a means of maintaining health and avoiding falls and fractures. Findings relating physical activity of older women to risk of falls and fracture are contradictory. The association between level of physical activity and prevalent and incident hip and wrist fractures was examined in a large representative sample of postmenopausal British women. METHODS: data from the British Women's Heart and Health Study, a cohort study of 4286 postmenopausal women aged 60-79, from 23 UK towns were used. Information on physical activity, anthropometry, falls and hip and wrist fractures from baseline examination and questionnaire (1999-2001) and follow-up questionnaire (2007) were available. Cross-sectional baseline prevalence data were analysed using logistic regression and cohort incidence data using a Cox proportional hazards model examining the association of physical activity with fracture outcomes. RESULTS: 3003 (70%) women, with complete baseline data, were studied. 13.6% had previously fractured a wrist and 1.3% a hip. Analyses unadjusted for confounders showed moderate protective associations between activity and fracture risk. After adjustment for confounders there was a weak trend towards fewer hip fractures (adjusted OR 0.13 [0.01, 1.18]) and more wrist fractures (adjusted OR 1.35 [0.76, 2.48]), amongst most active compared with inactive women. The crude incidence rate of wrist and/or hip fracture was 7.0 [5.9, 8.2] per 1000 person-years. No evidence was found for an association between physical activity and combined incident hip and/or wrist fracture (adjusted rate ratio inactive versus most active 1.69 [0.67, 4.24]). CONCLUSION: no clear associations between graded physical activity and hip/wrist fractures were seen but estimates were imprecise. Physical activities are heterogeneous and individual fracture types and mechanisms differ. Very large prospective observational studies are required to disentangle the precise effects of different activity patterns on different fracture types

A Compressive Multi-Mode Superresolution Display

Compressive displays are an emerging technology exploring the co-design of new optical device configurations and compressive computation. Previously, research has shown how to improve the dynamic range of displays and facilitate high-quality light field or glasses-free 3D image synthesis. In this paper, we introduce a new multi-mode compressive display architecture that supports switching between 3D and high dynamic range (HDR) modes as well as a new super-resolution mode. The proposed hardware consists of readily-available components and is driven by a novel splitting algorithm that computes the pixel states from a target high-resolution image. In effect, the display pixels present a compressed representation of the target image that is perceived as a single, high resolution image.Comment: Technical repor