Decision-making processes of weaning from mechanical ventilation: a comparative ethnographic insight into the dynamics of the decision-making environment

Many critical clinical conditions result in respiratory failure and precipitate the use of mechanical ventilation for their management. A prolonged period of mechanical ventilation is costly for both the patient, in terms of adverse effects, and the health care service. Therefore, immediate liberation of the patient from mechanical ventilation and constitution of spontaneous breathing, a process called weaning, is vital. This daily lifesaving practice, on which nurses are taking an increasing role with the introduction of nurse-led protocols, can become complicated requiring the effective use of assessment information through decision-making processes to improve outcomes of care. Most literature on the field fails to address that weaning decisions are affected not only by the nature of the task but also by the characteristics of the decision-maker and the decision environment. This research aimed to study nurses' decision-making processes when managing the weaning of long-term ventilated patients and to explore the impact of the diverse elements of the clinical environment on this intricate practice. An ethnographic approach was used to compare weaning decision-making processes in two different culturally intensive care units (ICU). Participant observation was used to follow the weaning practices of 10 patients in a Scottish ICU and 9 patients in a Greek ICU admitted with respiratory failure due to pneumonia or COPD exacerbation. Nurses were observed in their daily weaning practice and participated in reflective interviews at the end of their shift to extrapolate how they used the information to make their decisions. Semi-structured interviews were, then, conducted with nurses, physiotherapists and medical staff to explore their perceptions on weaning practices and the factors that influenced their decisions and clinical practice. Data were analysed thematically and concept maps were developed from the reflective interviews to analyse nurses‟ decision-making processes. The concept attainment theory was used as a framework to understand nurses' thinking processes. Nurses in all ranges of experience demonstrated a similar decision-making skill, which signifies that this cognitive process is not always related to the level of experience and knowledge. Nurses' weaning care was organised around maintaining a balance of care under the 'wean as able' medical instruction. Inconsistency in the weaning decisions led to a variability of weaning approaches followed for each patient and to long periods of weaning inactivity. Various reasons, related to the working relationships, lack of nurses‟ accountability, lack of support and unstructured information flow, were responsible for the deficiency in sustainable and consistent weaning decisions. In both settings, there was lack of culture to foster a shared decision-making approach in weaning practice and encourage nurses' autonomy in decision-making. This study concluded with proposing a collaborative decision-making framework for weaning long-term ventilated patients, which will involve and appreciate the contribution of all members of the multidisciplinary team

Effects of HOXB4 downstream targets on the haemopoietic differentiation of pluripotent stem cells

Attempts for the in vitro differentiation of reconstituting human HSCs from ESCs have been unsuccessful as key factors of HSC specification remain unclear. Enforced HOXB4 expression can enhance haemopoietic differentiation of mouse and human ESCs and generate reconstituting HSCs from mouse ESCs. We have previously shown that HOXB4 can enhance haemopoietic differentiation of mouse ESCs in a paracrine manner. Microarray analysis identified a number of secreted factors upregulated by HOXB4 potentially mediating this paracrine effect. The aim of this study was to assess whether these factors alone and/or in combination can enhance the in vitro haemopoietic differentiation of mouse and human ESCs. We first developed a defined, serum and feeder-free protocol to test the effects of these secreted factors on haemopoietic differentiation. This defined protocol allowed us to compare the haemopoietic potential of mouse ESCs with the recently derived epiblast stem cells (EpiSCs), thought to be comparable to hESCs. Haemopoietic colony forming assay and flow cytometry analysis showed that serum-free conditions generated 8- 10 fold more CD144+CD41+ and c-Kit+CD41+ haemopoietic progenitor cells (HPCs) compared to serum conditions from both ESCs and EpiSCs, with ESCs giving the most significant increase. We then validated the panel of HOXB4 target genes by QRT-PCR and selected those increased in expression by at least 2.5-fold when HOXB4 was activated. We used this defined, serum-free protocol to assess the effects of our panel of secreted factors, FGF17, RSPO3 and APLN, on the haemopoietic differentiation of mouse ESCs. We demonstrated that FGF17 can mediate HOXB4 haemopoietic activity by enhancing the generation of c-Kit+ HPCs. On the other hand increasing concentrations of RSPO3 inhibited haemopoietic development by reducing the numbers of CD41+ and CD41+CD45+ HPCs, while, APLN did not have any effects on the haemopoietic activity of the cells. We finally used the secreted factors in human ESC and iPSC differentiation cultures. We observed differences in the activity of the tested factors not only between species but also between human cell lines. These results suggest that HOXB4 haemopoietic activity is partly mediated by paracrine signalling but more complex cell interactions are probably required for it to fully exert its effects. More importantly, HOXB4 regulatory pathways differ between mouse and human cells stressing the need for careful translation of data between the two species and more detailed analysis of key human haemopoietic factors for the successful generation of reconstituting HSCs

Φυσιολογικό προφίλ Ελληνίδων αθλητριών- γυναικών καράτε

Το φυσιολογικό προφίλ αθλητριών του καράτε αποτελεί ένα από τα πιο βασικά στοιχεία ώστε οι ερευνητές που θέλουν να ασχοληθούν με το άθλημα να μπορέσουν να εντοπίσουν χαρακτηριστικά που συνθέτουν το προφίλ μίας αθλήτριας καράτε. Σκοπός της παρούσας εργασίας είναι η καταγραφή και αξιολόγηση των σωματομετρικών χαρακτηριστικών και των φυσικών ικανοτήτων που κατέχουν οι αθλήτριες του καράτε για να ανταπεξέρχονται στις απαιτήσεις του αθλήματος. Το δείγμα αποτέλεσαν αρχικά 10 γυναίκες αθλήτριες με χρονολογική ηλικία 16-26. Οι δοκιμαζόμενες είχαν σωματική μάζα 61,6±10,656 kg και σωματικό ανάστημα 1,647±0,066 m. Οι μετρήσεις πραγματοποιήθηκαν σε 2 διαδοχικές επισκέψεις. Μετρήθηκαν τα ανθρωπομετρικά χαρακτηριστικά (ύψος, βάρος, δείκτης μάζας σώματος), η δύναμη των καμπτηρών των δακτύλων με χειροδυναμομέτρηση, η ευκινησία με την δοκιμασία Τ-τεστ, η ευκαμψία με το sit&reach τεστ, η ταχύτητα με sprint 20m, η ισορροπία με την δοκιμασία flamingo και τέλος η αερόβια ικανότητα με την δοκιμασία του 1 μιλίου. Όλες οι δοκιμαζόμενες ήταν υγιείς χωρίς τραυματισμούς. Ο εξοπλισμός που χρησιμοποιήθηκε για τις δοκιμασίες ήταν κώνοι, χρονόμετρο, χειροδυναμόμετρο(Jamar Samons Preston), δαπεδοεργόμετρο, κουτί μέτρησης ευκαμψίας, ζυγαριά ακριβείας (0,1kg), επιδαπέδιο αναστημόμετρο(τύπου seca), οξυγονόμετρο και μετρητής γαλακτικού (Lactate Scout4). Ο μέσος όρος των αποτελεσμάτων για τον ΔΜΣ, την χειροδυναμομέτρηση (δεξί& αριστερό άκρο), την ευκαμψία (δεξί, αριστερό & συνδυασμό των δύο), την ταχύτητα, την ευκινησία, την ισορροπία και την αερόβια ικανότητα ήταν αντίστοιχα, 22,62±2,05, (δεξί) 29,5±6,502, (αριστερό)27,15±5,354, (δεξί) 26,6±5,796, (αριστερό)26,3±6,056, (συνδυασμό Δ+Αρ)26±4,714, 3,725±0,157, 12,445±0,815, (δεξί)2,5±2,877, (αριστερό)3±3,464, (γαλακτικό)2,81±1,414 και (VO2max) 42,035±7,056. Σύμφωνα με τα παραπάνω αποτελέσματα καταλήγουμε στο συμπέρασμα ότι το καράτε είναι ένα άθλημα όπου γυμνάζει συμμετρικά όλο το σώμα.The normal profile of female karate athletes is one of the most basic elements for researchers who want to study the sport to be able to identify characteristics that make up the profile of a female karate athlete. The purpose of this work is to record and evaluate the somatometric characteristics and the physical abilities possessed by female karate athletes to cope with the demands of the sport. The sample consisted initially of 10 female athletes with a chronological age of 16-26. The subjects had a body mass of 61.6±10.656 kg and a body height of 1.647±0.066 m. Measurements were performed in 2 consecutive visits. Anthropometric characteristics (height, weight, body mass index), finger flexor strength with hand dynamometry, agility with the T-test, flexibility with the sit&reach test, 20m sprint speed, balance with the test were measured. flamingo and finally the aerobic capacity with the 1 mile test. All subjects were healthy without injuries. The equipment used for the tests were cones, stopwatch, arm dynamometer (Jamar Samons Preston), floor ergometer, flexibility measuring box, precision scale (0.1 kg), floor staminometer (seca type), oxygen meter and lactate meter (Lactate Scout4). The mean results for BMI, dynamometry (right & left limb), flexibility (right, left & combined), speed, agility, balance and aerobic capacity were respectively, 22.62±2, 05, (right) 29.5±6.502, (left)27.15±5.354, (right) 26.6±5.796, (left)26.3±6.056, (D+R combination)26±4.714, 3.725± 0.157, 12.445±0.815, (right)2.5±2.877, (left)3±3.464, (galactic)2.81±1.414 and (VO2max) 42.035±7.056. According to the above results, we come to the conclusion that karate is a sport where the whole body is symmetrically trained

Family ward rounds in Intensive Care: an integrative review of the literature

BackgroundThe involvement of family members in the ward rounds is a novel but under-researched family-centered care intervention in adult intensive care units, with limited evidence on the impact it has on patient and family-centered outcomes.ObjectivesThis integrative review aimed to understand how family rounds are implemented in critical care and to appraise the evidence on outcomes for patients, family members, and healthcare professionals.DesignAn integrative review methodological framework permitted the inclusion of all research designs.Data sourcesMEDLINE; CINAHL; PsycINFO; Cochrane Library; Web of Science Current Contents Connect; Web of Science—Core Collection; The Joanna Briggs Institute EBP Database; ProQuest Sociological Abstracts; and ProQuest Dissertation and Theses Global, Embase were systematically searched.Review MethodsWe reviewed studies that referred to or used as an intervention the involvement of family members in daily critical care team rounds. We included primary research in adult intensive care units regardless of patients' length of stay. We excluded patients receiving end-of-life care. We considered any outcome related to the critically ill patient and/or their family member, outcomes related to the healthcare professionals, and outcomes related to clinical and/or nursing treatment. The Mixed Methods Appraisal Tool was used to appraise the quality of the studies. The review was registered in the Prospero database.ResultsFrom the 541 articles initially retrieved, 15 studies met the inclusion criteria and were included in the review. Studies originated from the United States of America and Canada since 2003, and a variety of designs were used. Four before and after studies and a non-randomized experimental study explored the impact of structured family rounds on family and staff satisfaction, showing limited improvement in satisfaction. Six cross-sectional survey studies explored family members' and clinicians' perceptions and demonstrated a positive attitude towards family-centered rounds, but some concerns were raised from the nursing staff. Three qualitative studies and a mixed-methods study identified structural and cultural factors influencing healthcare professionals' and families' acceptance of family rounds. Most studies were of poor to moderate quality, with limited confidence in the outcomes reported.ConclusionsMost studies reported improved family satisfaction as the main outcome. Future research should focus on longitudinal patient and family-centered outcomes, including mental health outcomes, and on qualitative data to understand the processes, barriers, and facilitators to implement family-centered rounds in intensive care units

Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel

Objective To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council’s complex interventions framework. MethodsA phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout.ResultsFrom numerous modifiable prescribing behaviours identified, active ‘antibiotic time-out’ was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers` capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit. ConclusionThis novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit’s feasibility and effectiveness

Challenges and barriers to optimising sedation in intensive care: a qualitative study in eight Scottish intensive care units

Objectives: Various strategies to promote light sedation are highly recommended in recent guidelines, as deep sedation is associated with suboptimum patient outcomes. Yet, the challenges met by clinicians in delivering high-quality analgosedation is rarely addressed. As part of the evaluation of a cluster-randomised quality improvement trial in eight Scottish intensive care units (ICUs), we aimed to understand the challenges to optimising sedation in the Scottish ICU settings prior to the trial. This article reports on the findings.Design: A qualitative exploratory design: We conducted focus groups (FG) with clinicians during the preintervention period.Setting and participants: Eight Scottish ICUs. Nurses, physiotherapists and doctors working in each ICU volunteered to participate. FG were recorded and verbatim transcribed and inserted in NVivo V.10 for analysis. Qualitative thematic analysis was undertaken to develop emergent themes from the patterns identified in relation to sedation practice. Ethical approval was secured by Scotland A Research ethics committee.Results: Three themes emerged from the inductive analysis: (a) a recent shift in sedation practice, (b) uncertainty in decision-making and (c) system-level factors including the ICU environment, organisational factors and educational gaps. Clinicians were challenged daily to manage agitated or difficult-to-sedate patients in the era of a progressive mantra of ‘just sedate less’ imposed by the pain–agitation–delirium guidelines.Conclusions: The current implementation of guidelines does not support behaviour change strategies to allow a patient-focused approach to sedation management, which obstructs optimum sedation–analgesia management. Recognition of the various challenges when mandating less sedation needs to be considered and novel sedation–analgesia strategies should allow a system-level approach to improve sedation–analgesia quality

Rationale, design and methodology of a trial evaluating three strategies designed to improve sedation quality in intensive care units (DESIST study)

Objectives To describe the rationale, design and methodology for a trial of three novel interventions developed to improve sedation-analgesia quality in adult intensive care units (ICUs).Participants and Setting 8 clusters, each a Scottish ICU. All mechanically ventilated sedated patients were potentially eligible for inclusion in data analysis.Design Cluster randomised design in 8 ICUs, with ICUs randomised after 45?weeks baseline data collection to implement one of four intervention combinations: a web-based educational programme (2 ICUs); education plus regular sedation quality feedback using process control charts (2 ICUs); education plus a novel sedation monitoring technology (2 ICUs); or all three interventions. ICUs measured sedation-analgesia quality, relevant drug use and clinical outcomes, during a 45-week preintervention and 45-week postintervention period separated by an 8-week implementation period. The intended sample size was >100 patients per site per study period.Main Outcome measures The primary outcome was the proportion of 12?h care periods with optimum sedation-analgesia, defined as the absence of agitation, unnecessary deep sedation, poor relaxation and poor ventilator synchronisation. Secondary outcomes were proportions of care periods with each of these four components of optimum sedation and rates of sedation-related adverse events. Sedative and analgesic drug use, and ICU and hospital outcomes were also measured.Analytic approach Multilevel generalised linear regression mixed models will explore the effects of each intervention taking clustering into account, and adjusting for age, gender and APACHE II score. Sedation-analgesia quality outcomes will be explored at ICU level and individual patient level. A process evaluation using mixed methods including quantitative description of intervention implementation, focus groups and direct observation will provide explanatory information regarding any effects observed.Conclusions The DESIST study uses a novel design to provide system-level evaluation of three contrasting complex interventions on sedation-analgesia quality. Recruitment is complete and analysis ongoing.Trial registration number NCT01634451

A Neuroprotective Bovine Colostrum Attenuates Apoptosis in Dexamethasone-Treated MC3T3-E1 Osteoblastic Cells

Glucocorticoid-induced osteoporosis (GIO) is one of the most common secondary forms of osteoporosis. GIO is partially due to the apoptosis of osteoblasts and osteocytes. In addition, high doses of dexamethasone (DEX), a synthetic glucocorticoid receptor agonist, induces neurodegeneration by initiating inflammatory processes leading to neural apoptosis. Here, a neuroprotective bovine colostrum against glucocorticoid-induced neuronal damage was investigated for its anti-apoptotic activity in glucocorticoid-treated MC3T3-E1 osteoblastic cells. A model of apoptotic osteoblastic cells was developed by exposing MC3T3-E1 cells to DEX (0–700 μM). Colostrum co-treated with DEX was executed at 0.1–5.0 mg/mL. Cell viability was measured for all treatment schedules. Caspase-3 activation was assessed to determine both osteoblast apoptosis under DEX exposure and its potential prevention by colostrum co-treatment. Glutathione reduced (GSH) was measured to determine whether DEX-mediated oxidative stress-driven apoptosis is alleviated by colostrum co-treatment. Western blot was performed to determine the levels of p-ERK1/2, Bcl-XL, Bax, and Hsp70 proteins upon DEX or DEX plus colostrum exposure. Colostrum prevented the decrease in cell viability and the increase in caspase-3 activation and oxidative stress caused by DEX exposure. Cells, upon colostrum co-treated with DEX, exhibited higher levels of p-ERK1/2 and lower levels of Bcl-XL, Bax, and Hsp70. Our data support the notion that colostrum may be able to reduce DEX-induced apoptosis possibly via the activation of the ERK pathway and modulation of the Hsp70 system. We provided preliminary evidence on how bovine colostrum, as a complex and multi-component dairy product, in addition to its neuroprotective action, may affect osteoblastic cell survival undergoing apoptosis

Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography

Background: Antimicrobial resistance poses a serious global public health threat. Hospital misuse of antibiotics hascontributed to this problem and evidence-based interventions are urgently needed to change inappropriateprescribing practices. This paper reports the first theoretical stage of a longer-term project to improve antibioticprescribing in hospitals through design of an effective behaviour-change intervention.Methods: Qualitative synthesis using meta-ethnography of primary studies reporting doctors’ views andexperiences of antibiotic prescribing in hospitals for example, their barriers to appropriate prescribing. Twentyelectronic databases were systematically searched over a 10-year period and potential studies screened againsteligibility criteria. Included studies were quality-appraised. Original participant quotes and author interpretationswere extracted and coded thematically into NVivo. All study processes were conducted by two reviewers workingindependently with findings discussed with the wider team and key stakeholders. Studies were related by findingsinto clusters and translated reciprocally and refutationally to develop a new line-of-argument synthesis andconceptual model. Findings are reported using eMERGe guidance.Results: Fifteen papers (13 studies) conducted between 2007 and 2017 reporting the experiences of 336 doctors ofvarying seniority working in acute hospitals across seven countries, were synthesised. Study findings related in fourways which collectively represented multiple challenges to appropriate antibiotic medical prescribing in hospitals:loss of ownership of prescribing decisions, tension between individual care and public health concerns, evidence-based practice versus bedside medicine, and diverse priorities between different clinical teams. The resulting newline-of-argument and conceptual model reflected how these challenges operated on both micro- and macro-level,highlighting key areas for improving current prescribing practice, such as creating feedback mechanisms,normalising input from other specialties and reducing variation in responsibility for antibiotic decisions