Factors affecting sleep in the critically ill: An observational study

Purpose: The aims of the current study were to describe the extrinsic and intrinsic factors affecting sleep in critically ill patients and to examine potential relationships with sleep quality. Materials and Methods: Sleep was recorded using polysomnography (PSG) and self-reports collected in adult patients in intensive care. Sound and illuminance levels were recorded during sleep recording. Objective sleep quality was quantified using total sleep time divided by the number of sleep periods (PSG sleep period time ratio). A regression model was specified using the "PSG sleep period time ratio" as a dependent variable. Results: Sleep was highly fragmented. Patients rated noise and light as the most sleep disruptive. Continuous equivalent sound levels were 56 dB (A). Median daytime illuminance level was 74 lux, and nighttime levels were 1 lux. The regression model explained 25% of the variance in sleep quality (P = .027); the presence of an artificial airway was the only statistically significant predictor in the model (P = .007). Conclusions: The presence of an artificial airway during sleep monitoring was the only significant predictor in the regression model and may suggest that although potentially uncomfortable, an artificial airway may actually promote sleep. This requires further investigation. © 2014 Elsevier Inc

Qualitative research using realist evaluation to explain preparedness for doctors' memorable 'firsts'

CONTEXT: Doctors must be competent from their first day of practice if patients are to be safe. Medical students and new doctors are acutely aware of this, but describe being variably prepared. OBJECTIVES: This study aimed to identify causal chains of the contextual factors and mechanisms that lead to a trainee being capable (or not) of completing tasks for the first time. METHODS: We studied three stages of transition: anticipation; lived experience, and post hoc reflection. In the anticipation stage, medical students kept logbooks and audio diaries and were interviewed. Consenting participants were followed into their first jobs as doctors, during which they made audio diaries to capture the lived experiences of transition. Reflection was captured using interviews and focus groups with other postgraduate trainee doctors. All materials were transcribed and references to first experiences ('firsts') were analysed through the lens of realist evaluation. RESULTS: A total of 32 medical students participated. Eleven participants were followed through the transition to the role of doctor. In addition, 70 postgraduate trainee doctors from three local hospitals who were graduates of 17 UK medical schools participated in 10 focus groups. We identified three categories of firsts (outcomes): firsts that were anticipated and deliberately prepared for in medical school; firsts for which total prior preparedness is not possible as a result of the step change in responsibility between the student and doctor identities, and firsts that represented experiences of failure. Helpful interventions in preparation (context) were opportunities for rehearsal and being given responsibility as a student in the clinical team. Building self-efficacy for tasks was an important mechanism. During transition, the key contextual factor was the provision of appropriate support from colleagues. CONCLUSIONS: Transition is a step change in responsibility for which total preparedness is not achievable. This transition is experienced as a rite of passage when the newly qualified doctor first makes decisions alone. This study extends the existing literature by explaining the mechanisms involved in preparedness for firsts

Characterisation of sleep in intensive care using 24-hour polysomnography: An observational study

Introduction: Many intensive care patients experience sleep disruption potentially related to noise, light and treatment interventions. The purpose of this study was to characterise, in terms of quantity and quality, the sleep of intensive care patients, taking into account the impact of environmental factors.Methods: This observational study was conducted in the adult ICU of a tertiary referral hospital in Australia, enrolling 57 patients. Polysomnography (PSG) was performed over a 24-hour period to assess the quantity (total sleep time: hh:mm) and quality (percentage per stage, duration of sleep episode) of patients' sleep while in ICU. Rechtschaffen and Kales criteria were used to categorise sleep. Interrater checks were performed. Sound pressure and illuminance levels and care events were simultaneously recorded. Patients reported on their sleep quality in ICU using the Richards Campbell Sleep Questionnaire and the Sleep in Intensive Care Questionnaire. Data were summarised using frequencies and proportions or measures of central tendency and dispersion as appropriate and Cohen's Kappa statistic was used for interrater reliability of the sleep data analysis.Results: Patients' median total sleep time was 05:00 (IQR: 02:52 to 07:14). The majority of sleep was stage 1 and 2 (medians: 19 and 73%) with scant slow wave and REM sleep. The median duration of sleep without waking was 00:03. Sound levels were high (mean Leq 53.95 dB(A) during the day and 50.20 dB(A) at night) and illuminance levels were appropriate at night (median <2 lux) but low during the day (median: 74.20 lux). There was a median 1.7 care events/h. Patients' mean self-reported sleep quality was poor. Interrater reliability of sleep staging was highest for slow wave sleep and lowest for stage 1 sleep.Conclusions: The quantity and quality of sleep in intensive care patients are poor and may be related to noise, critical illness itself and treatment events that disturb sleep. The study highlights the challenge of quantifying sleep in the critical care setting and the need for alternative methods of measuring sleep. The results suggest that a sound reduction program is required and other interventions to improve clinical practices to promote sleep in intensive care patients.Trial registration: Australian New Zealand clinical trial registry (http://www.anzctr.org.au/): ACTRN12610000688088. © 2013 Elliott et al.; licensee BioMed Central Ltd

A new quality of life consultation template for patients with venous leg ulceration

OBJECTIVE: Chronic venous leg ulcers (CVLUs) are common and recurrent, however, care for patients predominantly has a focus which overlooks the impact of the condition on quality of life. The aim of this study was to develop a simple, evidence-based consultation template, with patients and practitioners, which focuses consultations on quality of life themes. METHOD: A nominal group was undertaken to develop a new consultation template for patients with CVLUs based on the findings of earlier qualitative study phases. RESULTS: A user-friendly two-sided A4 template was designed to focus nurse-patient consultations on the quality of life challenges posed by CVLUs. CONCLUSION: CVLUs impact negatively on the quality of life of the patient but this receives inadequate attention during current consultations. This new template will help to ensure that key concerns are effectively raised, explored and addressed during each consultation. DECLARATION OF INTEREST: The NHS West Midlands Strategic Health Authority funded this study. The authors have no conflicts of interest to declare.NHS West Midlands Health Authorit

‘What do we do, doctor?’ Transitions of identity and responsibility: a narrative analysis

Transitioning from student to doctor is notoriously challenging. Newly qualified doctors feel required to make decisions before owning their new identity. It is essential to understand how responsibility relates to identity formation to improve transitions for doctors and patients. This multiphase ethnographic study explores realities of transition through anticipatory, lived and reflective stages. We utilised Labov’s narrative framework (Labov in J Narrat Life Hist 7(1–4):395–415, 1997) to conduct in-depth analysis of complex relationships between changes in responsibility and development of professional identity. Our objective was to understand how these concepts interact. Newly qualified doctors acclimatise to their role requirements through participatory experience, perceived as a series of challenges, told as stories of adventure or quest. Rules of interaction within clinical teams were complex, context dependent and rarely explicit. Students, newly qualified and supervising doctors felt tensions around whether responsibility should be grasped or conferred. Perceived clinical necessity was a common determinant of responsibility rather than planned learning. Identity formation was chronologically mismatched to accepting responsibility. We provide a rich illumination of the complex relationship between responsibility and identity pre, during, and post-transition to qualified doctor: the two are inherently intertwined, each generating the other through successful actions in practice. This suggests successful transition requires a supported period of identity reconciliation during which responsibility may feel burdensome. During this, there is a fine line between too much and too little responsibility: seemingly innocuous assumptions can have a significant impact. More effort is needed to facilitate behaviours that delegate authority to the transitioning learner whilst maintaining true oversight

Repeated sleep-quality assessment and use of sleep-promoting interventions in ICU.

To describe sleep quality using repeated subjective assessment and the ongoing use of sleep-promoting interventions in intensive care. It is well known that the critically ill experience sleep disruption while receiving treatment in the intensive care unit. Both the measurement and promotion of sleep is challenging in the complex environment of intensive care unit. Repeated subjective assessment of patients' sleep in the intensive care unit and use of sleep-promoting interventions has not been widely reported. An observational study was conducted in a 58-bed adult intensive care unit. Sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) each morning. intensive care unit audit sleep-promoting intervention data were compared to data obtained prior to the implementation of a sleep guideline. Patients answered open-ended questions about the facilitators and deterrents of their sleep in intensive care unit. The sample (n = 50) was predominately male (76%) with a mean age: 62.6±16.9 years. Sleep quality was assessed on 2 days or more for 21 patients. The majority of patients (98%) received sleep-promoting interventions. Sleep quality had not improved significantly since the guideline was first implemented. The mean Richards-Campbell Sleep Questionnaire score was 47.9±24.1 mm. The main sleep deterrents were discomfort and noise. Frequently cited facilitators were nothing (i.e. nothing helped) and analgesia. The Richards-Campbell Sleep Questionnaire was used on repeated occasions, and sleep-promoting interventions were used extensively. There was no evidence of improvement in sleep quality since the implementation of a sleep guideline. The use of the Richards-Campbell Sleep Questionnaire for the subjective self-assessment of sleep quality in intensive care unit patients and the implementation of simple-promoting interventions by intensive care unit clinicians is both feasible and may be the most practical way to assess sleep in the intensive care unit context

The Family Name as Socio-Cultural Feature and Genetic Metaphor: From Concepts to Methods

A recent workshop entitled The Family Name as Socio-Cultural Feature and Genetic Metaphor: From Concepts to Methods was held in Paris in December 2010, sponsored by the French National Centre for Scientific Research (CNRS) and by the journal Human Biology. This workshop was intended to foster a debate on questions related to the family names and to compare different multidisciplinary approaches involving geneticists, historians, geographers, sociologists and social anthropologists. This collective paper presents a collection of selected communications

The analytical basis for the resonances and anti-resonances of loop antennas and meta-material ring resonators

Interest in the electromagnetic properties of loop structures has surged with the recent appearance of split-ring resonator meta-materials (SRRs) and nano-antennas. Understanding the resonances, anti-resonances, and harmonics of these loops is key to understanding their response to a wide range of excitation wavelengths. We present the classical analytical solution for the input impedance of a loop structure with circumference on the order of the wavelength, and we show how to identify these resonances from the function. We transform the classical solution into a new RLC formulation and show that each natural mode of the loop can be represented as a series resonant circuit, such that the full response function can be resolved by placing all of these circuits in parallel. We show how this formulation applies to SRRs.This work has been partially supported by the Australian Research Council and the Australian Solar Institute

Maximum Likelihood Estimation for Single Particle, Passive Microrheology Data with Drift

Volume limitations and low yield thresholds of biological fluids have led to widespread use of passive microparticle rheology. The mean-squared-displacement (MSD) statistics of bead position time series (bead paths) are either applied directly to determine the creep compliance [Xu et al (1998)] or transformed to determine dynamic storage and loss moduli [Mason & Weitz (1995)]. A prevalent hurdle arises when there is a non-diffusive experimental drift in the data. Commensurate with the magnitude of drift relative to diffusive mobility, quantified by a P\'eclet number, the MSD statistics are distorted, and thus the path data must be "corrected" for drift. The standard approach is to estimate and subtract the drift from particle paths, and then calculate MSD statistics. We present an alternative, parametric approach using maximum likelihood estimation that simultaneously fits drift and diffusive model parameters from the path data; the MSD statistics (and consequently the compliance and dynamic moduli) then follow directly from the best-fit model. We illustrate and compare both methods on simulated path data over a range of P\'eclet numbers, where exact answers are known. We choose fractional Brownian motion as the numerical model because it affords tunable, sub-diffusive MSD statistics consistent with typical 30 second long, experimental observations of microbeads in several biological fluids. Finally, we apply and compare both methods on data from human bronchial epithelial cell culture mucus.Comment: 29 pages, 12 figure

Expanding the role of participatory mapping to assess ecosystem service provision in local coastal environments

There has been increasing international effort to better understand the diversity and quality of marine natural capital, ecosystem services and their associated societal benefits. However, there is an evidence gap as to how these benefits are identified at the local scale, where benefits are provided and to whom, trade-offs in development decisions, and understanding how benefits support well-being. Often the benefits of conservation are poorly understood at the local scale, are not effectively integrated into policy and are rarely included meaningfully in public discourse. This paper addresses this disjuncture and responds to the demand for improving dialogue with local communities and stakeholders. Participatory GIS mapping is used as a direct means of co-producing knowledge with stakeholder and community interests. This paper drives a shift from development of participatory approaches to adaptive applications in real-world case studies of local, national and international policy relevance. The results from four sites along the UK North Sea coast are presented. This paper showcases a robust stakeholder-driven approach that can be used to inform marine planning, conservation management and coastal development. Although the demonstration sites are UK-focused, the methodology presented is of global significance and can be applied across spatial and temporal scales