Developing a framework to support the delivery of effective pain management for children: an exploratory qualitative study

Two million children are admitted to hospital every year in the UK and between 59 and 94% will experience pain, with 27-40% of them experiencing moderate to severe pain. Currently there are a number of well researched guidelines on children’s pain available, yet pain prevalence is high. Despite the guidelines there is a lack of an overall framework that includes the necessary components to deliver effective pain management. This study built on previous work about key elements that support children’s pain management, by exploring their relevance and practical application with 43 health care practitioners. We carried out focus groups with Band 5 nurses (n=6), Advanced Nurse Practitioners (n=11), and semi structured interviews with Pain Nurses (n=16), and Consultants (n=10). We also presented and discussed our findings with an Advisory Group. Findings demonstrated that the following elements were considered to be important: delivering pain management with confidence, supporting colleagues with protocols and guidance, empowering parents to be involved in pain management and adopting an individual approach to a child and family. These elements formed the basis of a framework for children’s pain management. Some practitioners indicated that pain management required education as well as more resources and that the culture of an area could influence pain management practice. The framework brings together elements that have the potential to improve the management of children’s pain through its use as an education tool in facilitating the development of skilled confident pain practitioners, who empower parents to engage in their child’s pain care. Each interrelated element of the framework plays an important part in the overall management of children’s pain. Information sheets, posters and an animation have been developed to support the dissemination of the findings to health care practitioners, parents and educators

Governors as CEOs: An Evolution

This paper examines the emergence of American governors as modern day CEOs from the historical perspective. In the 1960s, the shift in the power of the governorship was beginning, and by the 1970s, the trend toward stronger chief executives was reinforced by various federalism initiatives and the increasing complexity of managing state government. As the 1980s arrived, shifts in federal responsibilities to state governments, economic challenges and competitiveness, increased urbanization, demands for additional services and programs, and accelerating technologies have required a new kind of leadership in the governor’s office. Such leadership requires not only authority, but a managerial expertise and information to be successful and effective as a governor. With this emergence of a “new breed” of governors, the office has acquired a growth in respect and power. Over the last forty years, five out of the last seven U.S presidents were state governors before becoming the country’s chief executive. This is unprecedented in American history. During the first half of the twentieth century, governors mostly functioned in the traditional role as state figurehead in a strongly political framework. They were often not known beyond their state’s boundaries, and they spent an estimated 15% of their time on traditional management and administration. Today, if states were considered corporations, most would be among the Fortune 500 companies! Now governors are functioning more like corporate chief executive officers than traditional politicians. This paper seeks to explain this shift toward governors becoming influential, effective and powerful organizational leaders

The First Law for Boosted Kaluza-Klein Black Holes

We study the thermodynamics of Kaluza-Klein black holes with momentum along the compact dimension, but vanishing angular momentum. These black holes are stationary, but non-rotating. We derive the first law for these spacetimes and find that the parameter conjugate to variations in the length of the compact direction is an effective tension, which generally differs from the ADM tension. For the boosted black string, this effective tension is always positive, while the ADM tension is negative for large boost parameter. We also derive two Smarr formulas, one that follows from time translation invariance, and a second one that holds only in the case of exact translation symmetry in the compact dimension. Finally, we show that the `tension first law' derived by Traschen and Fox in the static case has the form of a thermodynamic Gibbs-Duhem relation and give its extension in the stationary, non-rotating case.Comment: 20 pages, 0 figures; v2 - reference adde

Perspectives of the barriers and enablers to nutritional adherence in professional male academy football players

Background Nutritional intake is important for young football players; however, little is known about the factors that influence their nutritional adherence. Purpose The aim of this study was to investigate players’, sports nutritionists’,and coaches’ perspectives of the barriers and enablers to adhering to nutritional recommendations within a professional football club. Method Individual interviews, based on the Capability, Opportunity, Motivation – Behaviour (COM-B) model and Theoretical Domains Framework (TDF), were conducted with 13 players (18 ± 1.3 years), 12 sports nutritionists, and 10 coaches from 2, 12, and 10 professional football clubs, respectively. Thematic analysis was used to interpret the data. Results Seven key themes were generated relating to the players’ barriers and enablers to nutritional adherence: (1) Capability: (a) Nutritional Knowledge; (b) Cooking Skills; (2) Opportunity: (c) Training Venue Food Provision; (d) Nutritionist Accessibility and Approachability; (e) Living Status: (3) Motivation: (f) Performance Implications; and (g) Role Modelling. Conclusion Inadequate food provision within the training and home environment, and limited time with the sports nutritionist were key barriers to nutritional adherence in youth football players. Football clubs should allocate more time for sports nutritionists to deliver nutrition support and sports nutritionists should aim to control the players environment to support optimal nutritional intake

Enthalpy and the Mechanics of AdS Black Holes

We present geometric derivations of the Smarr formula for static AdS black holes and an expanded first law that includes variations in the cosmological constant. These two results are further related by a scaling argument based on Euler's theorem. The key new ingredient in the constructions is a two-form potential for the static Killing field. Surface integrals of the Killing potential determine the coefficient of the variation of the cosmological constant in the first law. This coefficient is proportional to a finite, effective volume for the region outside the AdS black hole horizon, which can also be interpreted as minus the volume excluded from a spatial slice by the black hole horizon. This effective volume also contributes to the Smarr formula. Since the cosmological constant is naturally thought of as a pressure, the new term in the first law has the form of effective volume times change in pressure that arises in the variation of the enthalpy in classical thermodynamics. This and related arguments suggest that the mass of an AdS black hole should be interpreted as the enthalpy of the spacetime.Comment: 21 pages; v2 references adde

Tension Perturbations of Black Brane Spacetimes

We consider black-brane spacetimes that have at least one spatial translation Killing field that is tangent to the brane. A new parameter, the tension of a spacetime, is defined. The tension parameter is associated with spatial translations in much the same way that the ADM mass is associated with the time translation Killing field. In this work, we explore the implications of the spatial translation symmetry for small perturbations around a background black brane. For static charged black branes we derive a law which relates the tension perturbation to the surface gravity times the change in the the horizon area, plus terms that involve variations in the charges and currents. We find that as a black brane evaporates the tension decreases. We also give a simple derivation of a first law for black brane spacetimes. These constructions hold when the background stress-energy is governed by a Hamiltonian, and the results include arbitrary perturbative stress-energy sources.Comment: 21 pages, o figures, harvma

Significant Changes in Resting Metabolic Rate Over a Competitive Match Week Are Accompanied by an Absence of Nutritional Periodization in Male Professional Soccer Players.

Resting metabolic rate (RMR) is an important component of total daily energy expenditure; however, it is currently not understood how it varies across a typical competitive match week in professional soccer players. For the first time, we aimed to assess RMR throughout an in-season competitive week in professional soccer players. Additionally, we aimed to assess energy and carbohydrate intake across the same week. Twenty-four professional soccer players from an English Premier League club (age: 18 ± 1.6 years) completed the study. RMR was assessed each morning of a typical competitive match week (match day [MD] -3, -2, -1, +1, +2, and + 3), and dietary intake (including MD) was assessed daily via the remote food photography method and 24-hr recall. Daily training load was quantified using Global Positioning System, daily muscle soreness ratings were recorded, and body composition was assessed via dual-energy X-ray absorptiometry. There was a significant (p = .0004) increase in mean RMR of ∼261 kcal/day on MD + 1, compared with MD - 1. Additionally, volume of oxygen consumed significantly increased at MD + 1 (p = .0002) versus MD - 1. There were no significant differences in daily energy or carbohydrate intake across the competitive week (p > .05), with inadequate carbohydrate intakes on MD - 1 (∼3.9 g/kg body mass), MD (∼4.2 g/kg body mass), and MD + 1 (∼3.6 g/kg body mass) in relation to current recommendations. We report, for the first time, that RMR is significantly increased following a competitive match in professional soccer players. In addition, we confirm previous findings to reinforce that players exhibit inadequate nutrition periodization practices, which may impair physical performance and recovery

Codimension Two Branes and Distributional Curvature

In general relativity, there is a well-developed formalism for working with the approximation that a gravitational source is concentrated on a shell, or codimension one surface. By contrast, there are obstacles to concentrating sources on surfaces that have a higher codimension, for example, a string in a spacetime with dimension greater than or equal to four. Here it is shown that, by giving up some of the generality of the codimension one case, curvature can be concentrated on submanifolds that have codimension two. A class of metrics is identified such that (1) the scalar curvature and Ricci densities exist as distributions with support on a co-dimension two submanifold, and (2) using the Einstein equation, the distributional curvature corresponds to a concentrated stress-energy with equation of state p equals minus the energy density, where p is the isotropic pressure tangent to the submanifold. This is the appropriate stress-energy to describe a self-gravitating brane that is governed by an area action, or a brane world deSitter cosmology. The possibility of having a different equation of state arise from a wider class of metrics is discussed.Comment: 18 pages; v2 references added; typos corrected, references added; additional references adde

Activation of NF-κB and p300/CBP potentiates cancer chemoimmunotherapy through induction of MHC-I antigen presentation

Many cancers evade immune rejection by suppressing major histocompatibility class I (MHC-I) antigen processing and presentation (AgPP). Such cancers do not respond to immune checkpoint inhibitor therapies (ICIT) such as PD-1/PD-L1 [PD-(L)1] blockade. Certain chemotherapeutic drugs augment tumor control by PD-(L)1 inhibitors through potentiation of T-cell priming but whether and how chemotherapy enhances MHC-I-dependent cancer cell recognition by cytotoxic T cells (CTLs) is not entirely clear. We now show that the lysine acetyl transferases p300/CREB binding protein (CBP) control MHC-I AgPPM expression and neoantigen amounts in human cancers. Moreover, we found that two distinct DNA damaging drugs, the platinoid oxaliplatin and the topoisomerase inhibitor mitoxantrone, strongly up-regulate MHC-I AgPP in a manner dependent on activation of nuclear factor kappa B (NF-κB), p300/CBP, and other transcription factors, but independently of autocrine IFNγ signaling. Accordingly, NF-κB and p300 ablations prevent chemotherapy-induced MHC-I AgPP and abrogate rejection of low MHC-I-expressing tumors by reinvigorated CD8+ CTLs. Drugs like oxaliplatin and mitoxantrone may be used to overcome resistance to PD-(L)1 inhibitors in tumors that had "epigenetically down-regulated," but had not permanently lost MHC-I AgPP activity

Onset and Progression of Behavioral and Molecular Phenotypes in a Novel Congenic R6/2 Line Exhibiting Intergenerational CAG Repeat Stability

In the present study we report on the use of speed congenics to generate a C57BL/6J congenic line of HD-model R6/2 mice carrying 110 CAG repeats, which uniquely exhibits minimal intergenerational instability. We also report the first identification of the R6/2 transgene insertion site. The relatively stable line of 110 CAG R6/2 mice was characterized for the onset of behavioral impairments in motor, cognitive and psychiatric-related phenotypes as well as the progression of disease-related impairments from 4 to 10 weeks of age. 110Q mice exhibited many of the phenotypes commonly associated with the R6/2 model including reduced activity and impairments in rotarod performance. The onset of many of the phenotypes occurred around 6 weeks and was progressive across age. In addition, some phenotypes were observed in mice as early as 4 weeks of age. The present study also reports the onset and progression of changes in several molecular phenotypes in the novel R6/2 mice and the association of these changes with behavioral symptom onset and progression. Data from TR-FRET suggest an association of mutant protein state changes (soluble versus aggregated) in disease onset and progression