bluuebunny/crossref_metadata_2025 huggingface dataset:
Implementing Intensive Intervention
Authors: Zumeta Rebecca O.
Published: December 2014

Despite years of school reform intended to help students reach high academic standards, students with disabilities continue to struggle, suggesting a need for more intensive intervention as a part of special education and multi-tiered systems of support. At the same time, greater inclusion of students with disabilities in large-scale assessment, expanding knowledge of evidence-based practices, and improving assessment technology in recent decades provide important points of progress. This article summarizes this progress, notes potential areas for expansion, and suggests future implementation and policy research questions as they relate to observed challenges with provision of intensive intervention for students with disabilities.
Reinforcing Success
Authors: Lloyd John Wills , Lloyd Patricia A.
Published: December 2014

Since 1966 when we began our careers in special education, we and others in our cohort have seen substantial changes in our discipline. In our personal experience, we had the opportunity to work together in situations that led us to focus on practices and procedures that produced better outcomes for our students, and better outcomes for students became our primary metric for assessing educational recommendations. Regardless of the rationale, theory, or appealing argument for them, we wanted to know whether a proposed procedure helps students with disabilities succeed. Sometimes those procedures need to be employed in special places. We explain how we came to this perspective, why we hope that perspective does not get lost amid contemporary reform efforts, and what we hope it will mean for the future.
Computerized Cognitive Testing in the Management of Youth Sports-Related Concussion
Authors: De Marco Anthony P. , Broshek Donna K.
Published: December 2014

Computerized neurocognitive testing has become a growing practice across medical populations, but particularly within sports medicine and the management of sports-related concussion. Although traditional neuropsychological measures are solely administered and interpreted by neuropsychologists, computerized cognitive tests are marketed to and utilized by a wide range of professionals involved in the management of sports-related concussions, many of whom lack specialized psychometric training. Although the benefits of computerized testing allow for many youth athletes to be evaluated quickly, professionals implementing their use should be aware of the potential pitfalls and the high potential for misuse. After briefly reviewing the recommended guidelines set forth by the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology, we review the benefits/limitations of computerized testing in the management of sports-related concussion and the basic psychometric properties of some of the more widely used computerized measures. Lastly, we discuss the practical application of these devices.
A query on research methodology and ethics: defending Citizens Advice, its work and goals
Authors: Lee Siew-Peng
Published: December 2014

This is a response to an article by Holgate et al., in which the authors argue that minority ethnic workers lack support and legal advice on employment problems; in particular they found the Citizens Advice Bureau network to be ‘not very successful’ and ‘ineffectual’. This response raises concerns about research methodology, including the integrity with which existing literature was cited and the rigour with which new data were generated and interpreted. This author uses her insight into Citizens Advice work to contextualize – and contest – some of the interpretations made by Holgate and colleagues. From a research ethics perspective, this case highlights the disparity of power between the researchers and the researched – and reiterates the impact of previous research on future research endeavours. While Open Access is good for those outside academia, those within must become more astute about the myriad contexts within which their published work might be mis/interpreted.
Topology, size and shape optimization of an automotive cross car beam
Authors: Li Chao , Kim Il Yong
Published: December 2014

An automotive cross car beam supports instrument panels including the heating, ventilation and air-conditioning system, the knee airbags, the steering-column and steering-wheel system and the central console. Avoiding resonant frequencies and improving driving comfort are major performance requirements in the design of a cross car beam. Because of the nature of mass production in the automotive industry, the consideration of manufacturability is important, and the current practice in the industry does grant detailed information on the steering-column and steering-wheel system to the cross car beam designer. The objective of this paper is to perform a complete topology, size and shape optimization of a cross car beam by using a lightweight material, by considering two practical manufacturing processes (extrusion and casting) and by assuming a realistic situation where only limited information on the steering-column and steering-wheel system is available to the cross car beam designer. First, a simplified finite element model of the steering-column and steering-wheel system was developed, and it was calibrated using optimization such that the important behaviour of the simplified finite element model agrees with that of the real steering-column and steering-wheel system. Topology optimization was performed to determine the optimal material distribution for the parts that connect the steering-column and steering-wheel system and the cross car beam. Then a geometry reinterpretation of the favourable topology result was performed to address the concerns from the viewpoints of the cost and the manufacturability. A sensitivity study was conducted subsequently to determine the size optimization design variables with significant effects on the frequency performance. Finally, size and shape optimization were performed together to optimize further the details of the cross car beam structure. The weight of the optimal aluminium design was reduced by nearly 40% compared with the steel design while the important performance requirements are met.
Oasis evolution processes and mechanisms in the lower reaches of Heihe River, Inner Mongolia, China since 1 ka ago
Authors: Zhao Hui , Sheng Yongwei , Zhang Jiawu , Zhao Yan , Li Guoqiang
Published: December 2014

Two major oases in the lower reaches of Heihe River, Inner Mongolia of China, the desertified ancient Juyanze oasis (AJO) and the modern Ejina oasis (MEO), experienced dramatic environmental changes and human migrations as documented in historic records. The processes and mechanisms of their evolution are the key for us to understand the environmental changes and human activities in this region, yet are still unclear. This study provides an evolution chronology of these two oases by analyzing the optical dating records from MEO and 14C dating records from AJO and discusses their evolution mechanisms based on drainage network analysis and field investigations. The optical dating samples collected from aeolian sands below humus layers in Populus euphratica woodlands on MEO indicate that this oasis developed between 1.05 and 0.45 ka ago, while the 14C dating samples collected from a number of dead P. euphratica trees from AJO consistently suggest that the complete desertification of AJO occurred before ~400 cal. a BP. These new dating results imply that the two oases evolved simultaneously but in opposite directions. That is, AJO desertified while MEO developed gradually in the last 1 ka. Climate change occurring over the last 1 ka in northern China cannot explain the opposite evolution directions of these two adjacent oases. The drainage network analysis based on digital elevation models (DEMs) and field observations and the dates (~0.5 ka) of the top lacustrine layer from GaxuNur Lake north of MEO suggest that the evolution of the two oases was mainly governed by Heihe River migration.
It’s agony for us as well
Authors: Green Janet , Darbyshire Philip , Adams Anne , Jackson Debra
Published: December 2014

Background:

Improved techniques and life sustaining technology in the neonatal intensive care unit have resulted in an increased probability of survival for extremely premature babies. The by-product of the aggressive treatment is iatrogenic pain, and this infliction of pain can be a cause of suffering and distress for both baby and nurse.

Research question:

The research sought to explore the caregiving dilemmas of neonatal nurses when caring for extremely premature babies. This article aims to explore the issues arising for neonatal nurses when they inflict iatrogenic pain on the most vulnerable of human beings – babies ≤24 weeks gestation.

Participants:

Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in New South Wales, Australia.

Ethical consideration:

Ethical processes and procedures set out by the ethics committee have been adhered to by the researchers.

Findings:

A qualitative approach was used to analyse the data. The theme ‘inflicting pain’ comprised three sub-themes: ‘when caring and torture are the same thing’, ‘why are we doing this!’ and ‘comfort for baby and nurse’. The results show that the neonatal nurses were passionate about the need for appropriate pain relief for extremely premature babies.

Conclusion:

The neonatal nurses experienced a profound sense of distress manifested as existential suffering when they inflicted pain on extremely premature babies. Inflicting pain rather than relieving it can leave the nurses questioning their role as compassionate healthcare professionals.
Progress in Island Health in the Asia-Pacific Region
Authors: Hokama Tomiko , Binns Colin
Published: December 2014

The Asia-Pacific region contains many islands, perhaps up to 100 000. The provision of public health and health care to small isolated groups poses particular challenges in the 21st century. The health of island populations has improved over the past 3 decades, but maintaining and improving current levels of health is made more difficult by emigration and the difficulty of maintaining communications.
A strain monitoring approach for estimating lateral displacements of concrete columns under seismic excitations
Authors: Bassam Asadollah , Ansari Farhad
Published: December 2014

This study describes development of an indirect method for reference-free monitoring of lateral displacements in concrete columns under dynamic loads. The method is independent of the material and section properties of the structure. Therefore, damage due to the change in material and section properties during seismic events does not affect the estimated displacement results. The approach involves discretization of the column elements and placement of strain sensors on opposing sides of the columns for the computation of curvature during the seismic events. Element equivalent force vectors are obtained from the measured strains and subsequently employed for the computation of lateral displacements. Fiber Bragg grating displacement sensors were employed for monitoring the strains. The experimental portion of the research involved shake table tests of a four-span bridge using the recorded ground motions of the 1994 Northridge earthquake. The objective was to verify the accuracy and efficiency of the proposed method by comparing the results with direct displacement measurements. Comparison of the proposed method with the direct measurement of the lateral displacements during the shake table tests indicated reasonable correlation between the computed and direct measurements.
Goal Orientation and Safety Climate
Authors: Drach-Zahavy Anat , Somech Anit
Published: December 2014

The study developed and tested a cross-level model for predicting individual differences in nurses’ safety compliance, integrating individual-level differences in goal orientation, unit-level safety climate, and their cross-level interactions. Three hundred nurses from 76 units completed validated questionnaires on goal orientation and safety climate; data on safety compliance were obtained through structured observations on nurses administering medications. Results showed that learning goal orientation and avoid performance goal orientation were significantly and positively associated with safety compliance. Cross-level interactions existed between an individual’s goal orientation and safety climate and his or her safety compliance: A learning goal orientation was positively related to safety compliance only when safety climate was high, thereby exhibiting an enhancing mechanism. By comparison, an individual’s prove performance goal orientation was positively related to safety compliance only when safety climate was low, thereby exhibiting a compensating mechanism. These findings carry important insights for research on person-in-situation models.
Social Communication Is Predicted by Inhibitory Ability and ADHD Traits in Preschool-Aged Children
Authors: Rints Ami , McAuley Tara , Nilsen Elizabeth S.
Published: December 2014

Objective: Given the role inhibitory control plays in both ADHD and communication, this study examined whether inattentive and hyperactive-impulsive traits mediate the impact of weak inhibitory ability upon the knowledge and application of pragmatic rules early in development. Method: Participants were 36 typically developing preschoolers and their caregivers. ADHD traits were assessed per caregiver report. Inhibition was assessed in children using a distraction task. Pragmatic language was assessed by asking children about hypothetical social situations (knowledge) and by asking caregivers to report on children’s actual communicative behaviors (application). Results: Individual differences in inhibition predicted both facets of pragmatic language development. Hyperactive-impulsive behaviors were a significant mediator of this relationship—but only with regard to children’s ability to effectively apply pragmatic rules in everyday life. Conclusion: Our findings suggest that social communication difficulties in some young children are a downstream consequence of hyperactive-impulsive behaviors that arise from poorly developed inhibitory control.
Simplified springback prediction in Al/PP/Al sandwich air bending
Authors: Mohammadi SV , Parsa MH , Aghchai A Jalali
Published: December 2014

Al/PP/Al laminated sheets have shown promising properties for different applications from aeronautics to construction. In this paper, an easy and fast springback prediction of Al3105/polypropylene/Al3105 sandwich sheets in air bending process is presented. An analytical formulation for springback prediction is developed based on a wrap around assumption and primary bending theories. Numerical simulation and experiments were carried out for verifications for the effect of punch radius, die opening, and punch stroke on springback. Results show that with an increase in either punch stroke, punch radius or die opening, springback increases. Die opening was found to be the most influential parameter.
From gendered organizations to compassionate borderspaces: Reading corporeal ethics with Bracha Ettinger
Authors: Kenny Kate , Fotaki Marianna
Published: December 2014

In this article, we propose a new way of approaching the topic of ethics for management and organization theory. We build on recent developments within critical organization studies that focus on the question of what kind of ethics is possible in organizational contexts that are inevitably beset by difference. Addressing this ‘ethics of difference’, we propose a turn to feminist theory, in which the topic has long been debated but which has been underutilized in organization theory until very recently. Specifically, we draw on the work of Bracha Ettinger to re-think and extend existing understandings. Inspired by gender studies, psychoanalysis, philosophy and art, Ettinger’s work has been celebrated for its revolutionary re-theorization of subjectivity. Drawing on a feminist ethics of the body inspired by psychoanalysis, she presents a concept of ‘trans-subjectivity’. In this, subjectivity is defined by connectedness, co-existence and compassion towards the other, and is grounded in what Ettinger terms the ‘matrixial borderspace’. An ethics of organization derived from the concept of the matrixial suggests that a different kind of ethical relation with the Other is possible. In this article, we demonstrate this through examining the issue of gender in the workplace. We conclude by outlining the implications of this perspective for rethinking ethics, embodiment and gender, and in particular for the development of a corporeal ethics for organization studies.
Changes in telemonitored physiological variables and symptoms prior to exacerbations of chronic obstructive pulmonary disease
Authors: Burton Christopher , Pinnock Hilary , McKinstry Brian
Published: December 2014

We examined symptom scores and physiological measurements from patients who were using a pilot COPD telemonitoring service. Of 33 patients recruited to the study, 19 were monitored for longer than 200 days. We identified three patterns of exacerbation, which we termed discrete (n = 5), rolling (n = 9) and over-ridden (n = 4). The association between FEV1, pulse and SpO2 and total symptom score was examined using multilevel logistic regression. The intraclass correlation coefficient for the model was high (0.36) indicating that much of the variance was due to differences between individuals, rather than within individuals. Compared to baseline, at the onset of exacerbations (n = 172) the mean pulse rate increased from 87 to 94 /min and the mean SpO2 fell from 93.6 to 92.4%. However, physiological variables did not differentiate between exacerbations and isolated bad days (n = 150). Few patient records displayed clear patterns of normality and exacerbation. Clinicians selecting patients for telemonitoring should assess the patient’s perception of variation in their symptoms and provide careful training and support whilst patients are learning to monitor their condition.
‘The Untold Story’: The mediated female ghost in England’s Blenheim Palace
Authors: Roberts Robin
Published: December 2014

Designated a World Heritage site, Blenheim Palace demonstrates the use of technology and gender in tourist destinations to re-package cultural sites. A multi-media exhibit entitled ‘The Untold Story’ updates the site by using new media not to emphasize the great public triumphs, but instead to reveal private family relationships. Told by a projected apparition of the first Duchess’ lady’s maid, Grace Ridley, the exhibit addresses the tourists by including them in intimate, behind-the-scenes views of 300 years of family stories. The ghostly female narrator stands in for the tourist, a feminized outsider fascinated by the gossipy version of family history. Examining ‘The Untold Story’ provides insight into gender negotiations within tourist sites. This particular combination of new media and a female ghost exposes the emphasis in traditional heritage sites on elites, as well as anxiety about the estate’s dependence on servants in the past and tourists in the present.
Determinants of Interest Margins of Banks in Sri Lanka
Authors: Kumari S.M. Susanthi Medha
Published: December 2014

Net interest margin (NIM) is an indicator of the level of efficiency of financial intermediation by banks. This study analyses the determinants of NIMs of domestic banks of Sri Lanka for the period of January 2002 to March 2011 based on the model developed by Ho and Saunders and its extensions using panel regression. Sri Lankan banks are inward looking in setting NIMs as operating costs, credit risk, risk aversion, non-interest income and capital adequacy requirements are determinants. Market competition, other regulations on banks, risk arising from the volatility of market prices and macroeconomic variables do not have a significant impact on the determination of NIMs.
Bordered penality: Precarious membership and abnormal justice
Authors: Aas Katja Franko
Published: December 2014

The article brings to attention, and explores, the transformations of criminal justice related to the control of unwanted mobility, looking in particular at recent Norwegian developments. It maps a gradual emergence of a differentiated, two-tier approach to criminal justice and a more exclusionary penal culture directed at non-citizens. The article suggests that the absence of formal membership is the essential factor contributing towards shifting the nature of penal intervention from reintegration into the society towards deportation and territorial exclusion, and towards the development of a particular form of penality, termed hereby bordered penality. The lack of formal citizenship status also crucially affects the procedural and substantive standards of justice afforded to non-members. While these developments are not confined to Norway alone, they cast doubt on the non-punitive image that is widely attributed to Scandinavian countries, and present a set of conceptual, epistemological and normative challenges for criminal justice in a rapidly globalizing world.
A two-person conception of freedom: The significance of Jessica Benjamin’s idea of intersubjectivity
Authors: Yeatman Anna
Published: December 2014

Jessica Benjamin offers a two-person, relational account of freedom understood in terms of intersubjectivity. She sees the conditions of possibility of this account as arising out of the historical process of challenge to the established patriarchal one-person account of freedom that is led by the feminist insistence on the feminine/maternal other as a subject in her own right. Where the patriarchal conception of freedom operates in terms of one will prevailing over the other, a relationship of domination that is structured as a subject–object dualism, the two-person account of freedom works with a subject-to-subject relationship where the tension between one subject’s will and the other’s is not resolved, but kept in play. Benjamin offers a historically contextualized phenomenological account of the reconfiguration of relationships (most particularly, those of ‘mothering’ and psychoanalysis) in terms of intersubjectivity. This is not a historicist account for there is nothing that suggests that the contest between the one-person and two-person conceptions of freedom will be resolved. Benjamin specifies intersubjectivity in terms of a two-subject interaction where both self-assertion and mutual recognition are dynamically entwined. A two-person conception of freedom enables a both/and understanding of the relationship between creativity and limit, self and other, freedom and law, and autonomy and dependency. The significance of Benjamin’s work is that she offers an excellent start for the reconstruction of our idea of freedom as a two-person rather than a one-person conception.
The Use of Research Syntheses and Nomological Networks to Develop HRD Theory
Authors: Newman Isadore , Hitchcock John H. , Newman David
Published: December 2014

The Problem

Research syntheses are rarely used in the field of human resource development (HRD). There are notable exceptions, but our search of the related literature found relatively few instances where procedures like meta-analyses are used to advance theory and empirically informed practice.

The Solution

To address this gap, this article provides a broad overview of different techniques for synthesizing literature. The article describes how research syntheses can be used to inform theory development; this is done via the description of a construct called nomological network. Such a network can be thought of as kind of minitheory, which is derived from the theoretical relationships among key constructs.

The Stakeholders

Readers interested in developing empirically informed HRD theory and practice should benefit from a description of how research syntheses can inform their work.
Roles of the WWOX in pathogenesis and endocrine therapy of breast cancer
Authors: Li Juan , Liu Jie , Ren Yu , Liu Peijun
Published: December 2014

Breast cancer is one of the most common malignancies, often with complicated etiology and poor clinical outcome. In recent years, a critical role has emerged for the WW domain-containing oxidoreductase (WWOX) in breast cancer. WWOX is a tumor suppressor; it is deleted or attenuated in 29–63.2% of breast cancer tissues and is associated with a poor prognosis of breast cancer patients. WWOX heterozygous knockout mice show a higher incidence of mammary tumors and impaired branching morphogenesis. At the molecular level, WWOX interacts with AP2γ, ErbB4, SMAD3, and WBP2 suppressing their transcription activities in breast cancer cell lines. This review provides comprehensive insights into the current knowledge of WWOX activities in the pathogenesis and endocrine therapy of breast cancer.
Control and Resilience Within the Maritime Traffic Management Domain
Authors: Praetorius Gesa , Hollnagel Erik
Published: December 2014

This article presents research conducted within the Vessel Traffic Service (VTS) domain. VTS is a service that is provided close to ports and geographically challenging areas to support merchant vessels in their navigation. Although VTS is legally an advice and assistance service, applying concepts from Cognitive Systems Engineering and Resilience Engineering can highlight how the joint human-machine system works to promote safe and efficient traffic movements. The VTS is a Joint Cognitive System that maintains control through a mixture of opportunistic and tactical control. Strategic control is only partially supported by the higher levels of system aggregation that provide the basis for defining daily operations within the settings of the VTS. To increase the VTS system’s ability to anticipate, respond, monitor, and learn, and therefore the ability to be resilient, there is a need to promote more strategic and tactical control within daily operations.
A pilot study of simple interventions to improve informed consent in clinical research: Feasibility, approach, and results
Authors: Kass Nancy E. , Taylor Holly A. , Ali Joseph , Hallez Kristina , Chaisson Lelia
Published: December 2014

Background:

Research suggests that participants do not always adequately understand studies. While some consent interventions increase understanding, methodologic challenges have been raised in studying consent outside of actual trial settings. This study examined the feasibility of testing two consent interventions in actual studies and measured effectiveness of interventions in improving understanding.

Methods:

Participants enrolling in any of eight ongoing clinical trials were sequentially assigned to one of three different informed consent strategies for enrollment in their clinical trial. Control participants received standard consent procedures for their trial. Participants in the first intervention arm received a bulleted fact sheet summarizing key study information. Participants in the second intervention arm received the bulleted fact sheet and also engaged in a feedback Q&A session. Later, patients answered closed- and open-ended questions to assess patient understanding and literacy. Descriptive statistics, Wilcoxon -Mann -Whitney and Kruskal-Wallis tests were generated to assess correlations; regression analysis determined predictors of understanding.

Results:

144 participants enrolled. Using regression analysis, participants receiving the second intervention scored 7.6 percentage points higher (p = .02) on open-ended questions about understanding than participants in the control, although unadjusted comparisons did not reach statistical significance.

Conclusions:

Our study supports the hypothesis that patients receiving both bulleted fact sheets and a Q&A session had higher understanding compared to standard consent. Fact sheets and short structured dialog are quick to administer and easy to replicate across studies and should be tested in larger samples.
UK Transplant — Update
Authors: Rudge Chris
Published: December 2014

Those of you old enough to remember the opprobrium heaped upon Norman Lamont (or was it Nigel Lawson?) for his optimistic description of “the green shoots of economic recovery” may think me foolhardy when I take a similarly optimistic view of the organ donor situation in the UK. However, I think that for the first time for many years there are grounds for optimism.
Skint
Authors: Goldhill David
Published: December 2014

We asked for your views about running Skills courses for Intensivists — SKINT for short. Thirty five ICS members replied. Many thanks for your comments.
Nutritional Practices in Scottish Intensive Care Units: Results of a 2006 Survey
Authors: McDougall Marcia
Published: December 2014

Nutritional practices in Scottish ICUs vary widely, according to a survey carried out in 2006. Most striking is the variation in the use of parenteral nutrition and naso-jejunal feeding. Nutrition teams have been recommended for all acute hospitals and may aid in the management of difficult cases. Evidence-based guidelines for critical care nutrition are available and delivery of nutrition may be improved by the use of these guidelines. Regular audit of nutritional delivery is suggested to ensure optimal feeding of intensive care patients.
Erythromycin is More Effective than Metoclopramide in the Treatment of Feed Intolerance in Critical Illness
Authors: Janossy Kate , Cairns Chris , Taylor Bruce
Published: December 2014

In intensive care patients with feed intolerance, erythromycin reduces gastric residual volume more effectively than metoclopramide (NNT 4). Both drugs rapidly become ineffective. In patients who fail monotherapy, an open-label, non-controlled extension of this study suggests combination therapy may be effective.

Level of evidence: 1+ (RCT with a low risk of bias)
The Ministerial Taskforce on Organ Donation
Authors: Smith Martin , Murphy Paul
Published: December 2014

Organ donation rates in the UK are amongst the lowest in Europe and there is a widening gap between the supply of cadaveric organ donors and the demand for solid organ transplants. The Report from the Organ Donation Taskforce has recently been published and its 14 recommendations represent a structured and systematic approach to organ donation in the UK. The proposed changes will ensure that organ donation is considered every time a potential organ donor dies, that the wishes of the potential organ donor or their family are ascertained and respected, and that every opportunity is taken to maximise the number of organs that can be transplanted successfully. Clarification of legal and ethical issues will allow clinicians to embrace these changes with confidence. Taken together, the recommendations will deliver the organ donation service that is so urgently needed in the UK.
Are Trainees Equipped to Transfer Critically Ill Patients?
Authors: Cook Caroline , Allan C
Published: December 2014

Transferring critically ill patients, whether intra- or inter-hospital, is an integral part of the daily working life of intensive care unit staff. It requires a multitude of skills, including thorough patient assessment, rigorous pre-transfer preparation, and constant vigilance throughout the transfer to ensure the safety of the patient. The development of these skills is a fundamental necessity for trainees in critical care. We investigated current critical care trainees' experience of patient transfer in one region in the UK, and assessed their views of their training in patient transfer. The results of our survey demonstrate some worrying conclusions about deficiencies in specific transfer training. We hope to encourage a discussion about the standards in transfer training which are needed and the best way to deliver such training.
Central Venous Catheters: Do we need to Review Practice on Positioning?
Authors: Sivasubramaniam Subash , Hiremath Mrityunjay
Published: December 2014

It is generally agreed that the tip of an inserted central venous catheter (CVC) should not lie within the right atrium. However, the tip of a CVC not inserted to an adequate depth could lie outside the superior vena cava, predisposing to thrombus formation and infection. A retrospective audit of the position of CVCs on chest radiographs in intensive care patients and the associated incidence of catheter-related infections was therefore undertaken. Chest radiographs of 100 patients who had central venous catheterisation were assessed using the electronic record system, measuring the distance of the CVC tip from the tracheal carina and the site of insertion. Comparisons were then made of the incidence of infection in the groups where the CVC tip was above or below the carina. In a significant proportion of patients (31%) the CVC tip lay too far below the carina. There was no significant difference in the incidence of catheter-related infections between the groups where the catheter was too far below the carina and too far above the carina. CVCs should not be placed too far below the carina as seen on the chest radiograph. Leaving a portion of CVC outside the skin does not appear to increase the incidence of infection in this small group of patients.
Delirium – Does it Matter?
Authors: Page Valerie
Published: December 2014

Delirium is a disturbance of consciousness associated with new-onset changes in cognition. It is associated with increased mortality and long-term cognitive impairment for ICU patients. This article reviews the current state of research in delirium in critical care.
Communication with Next-of-Kin: A Trigger for PTSD, a Cause for Compensation?
Authors: Bodenham Andrew , Bell Dominic
Published: December 2014

Discussions with next-of-kin about the condition, prognosis and management of a patient when death or profound disability is a likely outcome, is a delicate challenge even for senior intensivists. This is compounded when the patient is young and previously fit, and the admission attributable to unanticipated complications of anaesthesia. Some three years after such an event, a civil claim was pursued against a consultant for post-traumatic stress disorder (PTSD), allegedly induced by an inappropriately optimistic initial position on prognosis. There was neither complaint nor staff perception of communication difficulties in the intervening period. This article reviews limited case details, the growing trend of such litigation, the role of the expert witness, and gives guidance on communication and steps to protect clinicians from this new category of civil claim.

This case report should be read in conjunction with the editorial entitled ‘Communication with relatives and carers – another source of litigation?’ by Dee Kotak on pages 212–13 of this journal.
Summary of the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) – For Comment
Authors: Powell-Tuck Jeremy , Allison Simon P , Gosling Peter , Lobo Dileep N , Carlson Gordon L , Gore Marcus , Lewington Andrew J , Pearse Rupert M , Mythen Monty G
Published: December 2014

Starting in October 2006 the Association of Surgeons of Great Britain and Ireland, the Society of Academic and Research Surgery, BAPEN Medical, the Intensive Care Society, the Association for Clinical Biochemistry and the Renal Association, nominated core members of a steering committee who came together to establish consensus for good peri-operative fluid prescribing. Concern arose regarding a high incidence of postoperative sodium and water overload, and evidence to suggest that preventing or treating this, by more accurate fluid therapy, would improve outcome. The following recommendations (28 in total) are extracted from the complete document which can be found on the ICS website ( http://www.ics.ac.uk/downloads/2008112340_GIFTASUP%20FINAL_31-10-08.pdf ). Members of the steering committee used the definitions of the Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001) accessed from http://www.cebm.net/index.aspx?o=1025 to assign levels of evidence, each of which, after debate, was accepted unanimously. However, debate is on-going and you are encouraged to have your say. Please communicate your thoughts on this published summary to the editor of JICS who will seek response from the authors.
Ventilator-Associated Pneumonia; A Concise Review
Authors: Chandler Ben , Hunter John
Published: December 2014

Ventilator-associated pneumonia (VAP) continues to be the most common nosocomial infection in critically ill patients requiring mechanical ventilation. In this review data was sourced from Medline, the National Institute for Clinical Effectiveness (NICE), study authors and review articles. Development of VAP prolongs length of stay in the intensive care unit and may increase mortality. Although diagnosis is difficult, with little consensus on ideal diagnostic criteria, there is general agreement that rapid and accurate diagnosis of VAP is essential as delayed administration of appropriate antibiotic therapy increases mortality. Implementation of evidence-based strategies for the prevention of VAP may reduce morbidity, mortality and length of stay.
Prokinetic Drugs in the Intensive Care Unit: Reviewing the Evidence
Authors: Grant Katherine , Thomas Richard
Published: December 2014

Delay in gastric emptying is common in the critically ill, and can lead to abdominal distension, diarrhoea or constipation, and vomiting, and may contribute to increased incidence of reflux and nosocomial infection. Prokinetic agents increase the rate of luminal transit as well as the force of contraction, and are commonly used in the intensive care unit. This article summarises the current state of knowledge about the use of prokinetics and explores potential agents which might be used in the future in this group of patients.
The Use of Peripherally Inserted Central Catheters in Intensive Care: Should you Pick the PICC?
Authors: Tan Robert , Knowles Daniel , Streater Carmel , Johnston Andrew J
Published: December 2014

Peripherally inserted central catheters (PICCs) are useful routes for intermediate central venous access; however, there is a paucity of data regarding their use in the intensive care setting. We have been using PICCs on our ICU since 2006 and have undertaken a retrospective audit of all PICC use during one year to define complication rates. PICCs were inserted by a dedicated vascular access team (VAT). Microbiology and radiology databases were used to assess rates of line-related bacteraemias and catheter misplacements. Blockage rates were collected from VAT records. Data was available on 116 PICCs, corresponding to 1,558 line days. The median duration of placement of PICCs was 9 days (range 0–100) in situ with a misplacement rate at insertion of 12.1%. The catheter-related blood stream infection rate was zero. The blockage rate was 29.5/1,000 line days; 87% of these blockages were cleared using urokinase. We believe that PICCs can be safely used in intensive care patients.
Survival following Profound Lactic Acidosis and Cardiac Arrest: Does Metformin Really Induce Lactic Acidosis?
Authors: Spencer Craig , Randic Luka , Butler John
Published: December 2014

We report the case of a 63-year-old man who suffered a witnessed pulseless electrical activity cardiac arrest on presentation to the emergency department. Despite a profound post-arrest acidosis (pH 6.48) he went on to make an unexpectedly good recovery. He was treated for metformin-associated lactic acidosis (MALA) and septic shock, although the origin of the sepsis was never confirmed. We discuss the growing evidence against the existence of MALA as a lone diagnosis and the aetiology of post-cardiac arrest metabolic acidosis.
Positive End-Expiratory Pressure in Ventilated Non-Hypoxaemic Patients May Reduce Ventilator-Associated Pneumonia and Hypoxaemic Episodes
Authors: O'Brien Peter , Cole Stephen J
Published: December 2014

Applying PEEP to ventilated non-hypoxaemic patients may reduce ventilator-associated pneumonia (VAP) and hypoxaemic episodes.

Level of evidence: 1− (RCT with a high risk of bias)
Cardiac Intensive Care within the UK – a 2008 Survey
Authors: Rigg Christopher
Published: December 2014

Following the development of critical care services generally, and the publication of the recent NCEPOD report ‘Coronary artery bypass grafts – the heart of the matter’ specifically, a questionnaire survey was conducted into manpower services available for post-operative cardiac intensive care patients across the United Kingdom (UK). A total of 31 questionnaires were returned from the 39 units contacted (a response rate of 79%). Cardiac critical care units (CICU) vary in capacity from 7–36 beds and support a cardiac workload varying from 550–2,100 cases per annum. Most units (68%) admit some non-cardiac patients. Consultant cardiac anaesthetists are the most senior physicians managing CICU patients in 94% of units. Cardiac surgeons were reported to have clinical input only to their own patients in 90% of units, and no surgeon had sessional commitment to the CICU. Twelve units (38%) have access to an outreach service and only seven (23%) have recognition for training with the Intercollegiate Board for Training in Intensive Care Medicine (IBTICM). Cardiac anaesthetists continue to have a central role in delivering and developing CICU services.
Use of the SOFA Score in Pandemic Influenza — A Prospective Study
Authors: Williams Louise , Gannon John
Published: December 2014

It has been predicted that in the event of an influenza pandemic in the UK, there could be up to ten times the number of patients requiring critical care support than there are beds available. To aid rational, objective and ethical clinical decision making, the Department of Health recommends using the Sequential Organ Failure Assessment (SOFA) score as a tool for triaging admissions to the critical care unit. This study assessed what effect using the SOFA score would have on capacity. Daily SOFA scores were calculated for all patients on the critical care unit over a one month period. Twenty-four per cent of patients did not meet the criteria for admission to the unit, which would have freed up 36% of bed days in the event of a pandemic. Using this scoring system in conjunction with other measures recommended by the national framework may help the hospital cope with the high demand for critical care beds in the event of an influenza pandemic.
Bilateral Tension Pneumothoraces following Percutaneous Tracheostomy
Authors: Li Yat Wah , Chandan Garud S
Published: December 2014

Percutaneous tracheostomy is a relatively safe bedside alternative to surgical tracheostomy. However, there are significant risks and complications, such as pneumothorax. This case report describes what is believed to be the first example of bilateral tension pneumothorax secondary to percutaneous tracheostomy insertion which occurred despite bronchoscopic guidance.
Delivery of Inhaled Beta Agonists by Metered-Dose Inhaler in Ventilated Patients — A Survey of Current Practice
Authors: Scally Jennifer , Eusuf Ajmal , Cochran Diarmid
Published: December 2014

For many years nebulisers have been the standard method of delivering beta agonists in ventilated patients, but metered-dose inhalers are increasingly seen as an effective alternative. Metered-dose inhalers are cheaper and less likely to cause infection. Clinical studies have shown inhalers to be as effective as nebulisers, but their use demands careful attention to detail. Minor alterations in inhaler technique can alter the delivered dose six-fold, varying from 0 to 38% of the total dose. We surveyed the frequency of metered-dose inhaler use and assessed the adequacy of the techniques currently employed. Our survey showed that only a minority (25%) of units were using inhalers, but that of these, 84% were using a dose or technique that was unlikely to deliver a therapeutic dose.
Extracorporeal Membrane Oxygenation for Severe Respiratory Failure
Authors: Hawthorne Chris , McConnell Paul , Cairns Chris
Published: December 2014

Management of severe respiratory failure in a specialist centre which is capable of delivering a complex ‘bundle’ of care including a strict acute respiratory distress syndrome (ARDS) protocol, extracorporeal membrane oxygenation (ECMO), molecular adsorbent recycling system (MARS) and steroids, may improve outcomes when compared with conventional care. It is difficult to comment on the value of ECMO alone based on this study.

Level of evidence: 1+ (RCT with a low risk of bias)
The Vegetative State: Life, Death and Consciousness
Authors: Healy Justin
Published: December 2014

The three conditions that are traditionally defined as disorders of consciousness are the comatose state, the minimally conscious state and the vegetative state. Thirty years after the phrase was coined, the definition and management of patients in vegetative states continue to provoke debate. Recent advances in neuroimaging have cast doubt on the assertion that these patients are completely unaware of their environment. This article presents a case report and review of disorders of consciousness, their definition, prognosis and ethical issues in the management of patients.
Thromboprophylaxis in Intensive Care: A Nationwide, Multidisciplinary Quality Improvement Project
Authors: Morris Andrew Conway , Forrest Ruth , Campbell Alison
Published: December 2014

Patients admitted to intensive care units (ICUs) are at high risk of developing venous thromboemboli. Pharmacological thromboprophylaxis is efficacious in critically ill patients; however, prescription of such agents is often found to be suboptimal. The aim of this study was to assess the quality of pharmacoprophylaxis prescribing across Scottish ICUs, and to introduce measures to improve this. A point-prevalence survey of thromboprophylaxis was followed by a pharmacist-delivered intervention and a subsequent point-prevalence survey, in 22 Scottish ICUs. In the initial survey, 15% of eligible patients (n=94) were not receiving pharmacoprophylaxis, while 10% of ineligible patients had thromboprophylaxis prescribed. A quality improvement programme was instituted with pharmacist-delivered daily checks for thromboprophylaxis prescription, prompting of medical staff and local checklists. Following implementation of the intervention, a repeat survey of 130 patients revealed that the rate of eligible patients receiving thromboprophylaxis rose to 96%, (p=0.02, relative risk reduction 0.89). Additionally mechanoprophylaxis use increased and those receiving no prophylaxis fell to 8% (p=0.005 relative risk reduction 0.85). The rate of prescription of thromboprophylaxis to ineligible patients was 14% (p=0.65). A simple intervention led to significant improvements in the use of thromboprophylaxis in ICU, with an effect achievable on a national scale.
Ovarian Hyperstimulation Syndrome — The Role of Intra-Abdominal Pressure Monitoring
Authors: Lobo Clinton , Twigg Steven
Published: December 2014

Ovarian hyperstimulation syndrome is a condition which includes symptoms of nausea, vomiting and abdominal pain. The accumulation of ascites can lead to respiratory compromise. We present a case where intra-vesical abdominal pressure monitoring was used to guide the timing of paracentesis.
Transfusion of Stored Red Blood Cells in Critical Illness: Impact on Tissue Oxygenation
Authors: Nee Patrick A , Bonney Samantha , Madden Peter , Overfield Joyce
Published: December 2014

Blood transfusion is a common requirement in the intensive care setting. Improved tissue oxygenation is the therapeutic objective of transfusion for normovolaemic anaemia. However, the efficiency with which red blood cells (RBCs) carry oxygen to the tissues has been questioned, particularly after prolonged storage. We measured the impact on oxygen transport variables (base excess, lactate and ScvO2) of transfusion of a unit of stored RBCs in 45 critically ill adults. There were no significant changes in these variables, except for ScvO2, which increased with older units (≥ 20 days storage), suggesting impaired oxygen uptake by the tissues. The role of the storage lesion (structural and functional changes in the RBC acquired in storage media) is discussed with reference to its impact on oxygen delivery.