The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes

When do I wear me out? Mental simulation and the diminution of self-control.

Exerting self-control can diminish people's capacity to engage in subsequent acts of behavioral regulation, a phenomenon termed ego depletion. But what of imaginary regulatory experiences-does simulated restraint elicit comparable lapses in self-control? Here we demonstrate such effects under theoretically tractable imagery conditions. Across 3 experiments, temporal, structural, and spatial components of mental simulation were observed to drive the efficacy of imaginary self-control. In Experiment 1, lapses in restraint (i.e., financial impulsivity) were more pronounced when imaginary regulation (i.e., dietary restraint) focused on an event in the near versus distant future. In Experiment 2, comparable effects (i.e., increased stereotyping) emerged when simulated self-control (i.e., emotional suppression) was imagined from a first-person (cf. third-person) visual perspective. In Experiment 3, restraint was diminished (i.e., increased risk taking) when self-regulation (i.e., action control) centered on an event at a near versus distant location. These findings further delineate the conditions under which mental simulation impacts core aspects of social-cognitive functioning

Your space or mine? : Mapping self in time

Peer reviewedPublisher PD

Active learning and optimal climate policy

This paper develops a climate-economy model with uncertainty, irreversibility, and active learning. Whereas previous papers assume learning from one observation per period, or experiment with control variables to gain additional information, this paper considers active learning from investment in monitoring, specifically in improved observations of the global mean temperature. We find that the decision maker invests a significant amount of money in climate research, far more than the current level, in order to increase the rate of learning about climate change. This helps the decision maker make improved decisions. The level of uncertainty decreases more rapidly in the active learning model than in the passive learning model with only temperature observations. As the uncertainty about climate change is smaller, active learning reduces the optimal carbon tax. The greater the risk, the larger is the effect of learning. The method proposed here is applicable to any dynamic control problem where the quality of monitoring is a choice variable, for instance, the precision at which we observe GDP, unemployment, or the quality of education

Turning I into me: Imagining your future self

A widely endorsed belief is that perceivers imagine their present selves using a different representational format than imagining their future selves (i.e., near future=first-person; distant future=third-person). But is this really the case? Responding to the paucity of work on this topic, here we considered how temporal distance influences the extent to which individuals direct their attention outward or inward during a brief imaginary episode. Using a non-verbal measure of visual perspective taking (i.e., letter-drawing task) our results confirmed the hypothesized relation between temporal distance and conceptions of the self. Whereas simulations of an event in the near future were dominated by a first-person representation of the self, this switched to a third-person depiction when the event was located in the distant future. Critically, this switch in vantage point was restricted to self-related simulations. The theoretical and practical implications of these findings are considered

Noticing Future Me

People drastically overestimate how often others attend to them or notice their unusual features, a phenomenon termed the spotlight effect. Despite the prevalence of this egocentric bias, little is known about how to reduce the tendency to see oneself as the object of others’ attention. Here, we tested the hypothesis that a basic property of mental imagery—the visual perspective from which an event is viewed—may alleviate a future-oriented variant of the spotlight effect. The results of three experiments supported this prediction. Experiment 1 revealed a reduction in egocentric spotlighting when participants imagined an event in the far compared with near future. Experiments 2 and 3 demonstrated reduced spotlighting and feelings of embarrassment when participants viewed an impending event from a third-person (vs. first-person) vantage point. Simple changes in one’s visual perspective may be sufficient to diminish the illusion of personal salience

Photochemical activation of TRPA1 channels in neurons and animals

Optogenetics is a powerful research tool because it enables high-resolution optical control of neuronal activity. However, current optogenetic approaches are limited to transgenic systems expressing microbial opsins and other exogenous photoreceptors. Here, we identify optovin, a small molecule that enables repeated photoactivation of motor behaviors in wild type animals. Surprisingly, optovin's behavioral effects are not visually mediated. Rather, photodetection is performed by sensory neurons expressing the cation channel TRPA1. TRPA1 is both necessary and sufficient for the optovin response. Optovin activates human TRPA1 via structure-dependent photochemical reactions with redox-sensitive cysteine residues. In animals with severed spinal cords, optovin treatment enables control of motor activity in the paralyzed extremities by localized illumination. These studies identify a light-based strategy for controlling endogenous TRPA1 receptors in vivo, with potential clinical and research applications in non-transgenic animals, including humans

Intraoperative blood pressure changes as a risk factor for anastomotic leakage in colorectal surgery

Anastomotic leakage is a serious complication after colorectal surgery. Pre- and intraoperative factors may contribute to failure of colorectal anastomosis. In this study we have tried to determine risk factors for anastomotic leakage, with special emphasis on intraoperative blood pressure changes. During a 24-month period, patients receiving a colorectal anastomosis were prospectively evaluated. For each patient preoperative characteristics, intraoperative adverse events and surgical outcome data were collected. Blood pressure changes were calculated as a relative decrease (> 25% and > 40%) from preoperative baseline values. During the study period, 285 patients underwent colorectal surgery with an anastomosis. Fifteen patients developed an anastomotic leakage (5.3%). All patients who developed a leakage had a left-sided procedure (P 40% decrease in diastolic blood pressure (P = 0.049)] were identified as univariate risk factors for anastomotic leakage. The development of an anastomotic leakage after colorectal surgery is related to surgical, patient and anaesthetic risk factors. A high preoperative diastolic blood pressure and profound intraoperative hypotension combined with complex surgery, marked by a blood loss of a parts per thousand yen250 mL and the occurrence of intraoperative adverse events, is associated with an increased risk of developing anastomotic leakag

'If they don't recognise it, you've got to deal with it yourself': Gender, young caring and educational support

This articles discusses some of the findings of a small-scale, localized, qualitative study involving children and young people identified and processed as young carers, that are providing 'substantial care' for an adult while in primary and/or secondary school. It explores their views on managing to 'care more' whilst at school and the role that teachers and schools do and could play in supporting them. The voices of young carers suggest that educational support should be available 'as soon as' children become primary carers. The interviewees were critical of the factors that they perceived compromised their 'performance' at school. Some implications of these findings for implementing strategies for carers in schools are discussed