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This chapter develops and defends the merited response argument for ethicism. Less satisfactory versions of the argument due to Hume and Noöl Carroll are criticized. The favoured version of the argument developed here holds, roughly, that when works prescribe responses to the events that they represent, their aesthetic success partly depends on these responses being merited, and that whether this is so partly depends on whether the responses are ethical. Several objections to this argument, including some by Jacobson, are discussed and rejected. The chapter also discusses at length the case of dark humour, including black comedies and satire. It is shown that dark humour does not undermine the merited response argument or ethicism.

The feasibility conditions for a physical system often mandate specific structural stipulations on the inverse problems. This chapter focuses on eight selected structures: Jacobi matrices, Toeplitz matrices, nonnegative matrices, stochastic matrices, unitary matrices, matrices with prescribed entries, matrices with prescribed singular values, and matrices with prescribed singular values and eigenvalues.

In practice, it is often the case that only partial information on eigenvalues and eigenvectors is available. In many cases, just a few eigenpairs can determine much of the desirable reconstruction. This chapter illustrates this point by concentrating on the Toeplitz structure and the self-adjoint quadratic pencils. The possibility of model updating or tuning applications is discussed.

This chapter looks at developments of new fire management models during the 1970s and 1980s. Across the national park system, fire management planning moved to the forefront. A significant number of plans were written at parks as diverse as Mammoth Cave National Park and Antietam National Battlefield. The new emphasis on fire plans produced a higher caliber of document than ever seen before. Leading scholars played a key role, with many plan concepts stemming from their research.

The management of forests can affect their vulnerability to attack by pests and pathogens, but the effects may be complex. This chapter introduces the subject by discussing the influence of the structure and species composition of semi-natural forests on outbreaks of the spruce budworm in North America. Silvicultural operations can also be a tool of pest management at different stages in the rotation. Practical examples are discussed under the headings of planting and establishment, thinning and pruning, fertilisation, prescribed burning, felling and post-harvest, and salvage and long-term storage of trees killed in outbreaks or following extensive windblow.

This chapter begins with a summary of discussions in the preceding chapters. It concludes by speculating about the issues underlying the problems of inappropriate antibiotic prescribing, particularly in developed countries, but also as it contributes to the global problem of bacterial resistance to antibiotics.

Our knowledge of ancient festivals is rather extensive, the evidence telling much about what people were doing, but not why they were doing it, for example, in some cases the ritual process can be captured. Greek festivals can be defined as facts of culture. By including theories about the neurophysiological bases of cultural phenomena, anthropological understanding of festive social action are applied, and liminality, symbolism, cultural performances, prescribed sentiments, and power aspects are discussed. Departing from these theoretical viewpoints, the festivals of the Olympia and the Heraia at Olympia are analysed as manifestations of elaborating symbols, establishing the ‘nature’ of male and female, while the Olympia generated the summarising symbol of Hellenic ethnicity. In contrast, the Dionysia at Athens gathered the community in an atmosphere of Dionysiac disorder. Its programme manifested a liminal phase, including expressions arousing comic and tragic fascinations — sentiments aimed at provoking the audience’s cultural sense of normality.

This chapter discusses several efforts to use indicators within the law of international human rights. It identifies the criticisms made to these efforts, and states that there is an increasing potential for suitable tempered indicators to play valuable roles. It then takes a look at the project of the UN Office of the High Commissioner for Human Rights, which is aimed to create internationally-prescribed indicators for a number of primary UN human rights treaties. It determines that these indicators may help in addressing the concerns of the perceived legitimacy of the supervisory committees under these treaties. This chapter also suggests that indicators may play a role in assisting peoples and publics to use the kinds of pressures and constraints on governments that human rights advocates have long sought after.

This chapter discusses the shift in fire policy adopted by the United States at the beginning of the twenty-first century. It describes the Healthy Forests Initiative, a policy that advocates fuel reduction as a means of protecting communities from wildfire and for restoring the health of mismanaged forests. It also discusses some policy and regulation changes associated with the Healthy Forests Initiative. The Healthy Forests Restoration Act (HFRA), in particular, facilitated fuel reduction through mechanical thinning and prescribed burning. The chapter also considers the ecological effects of fuel-reduction treatments and mechanical thinning projects and how they differ from commercial logging.

This chapter defines a new set of goals for fire management: protection of human life, maintenance and restoration of native biological diversity, and protection of private property from fire. It discusses how fire management can be improved by placing higher priority on the protection of human life and biological diversity of native species than on protecting property from fire. It also describes how these goals can be accomplished by the application of the following techniques: fire suppression, fuel reduction, and prescribed burning.

Pregnant women and their fetuses are more likely than ever to be exposed to antipsychotic medications; perhaps to the newer agents in particular. Drugs like clozapine, olanzapine, risperidone, and quetiapine are increasingly used in women of reproductive age for a range of psychiatric and behavioural disorders other than schizophrenia (Buchanan et al. 2009). Reproductive safety data remain surprisingly incomplete and guideline recommendations lend limited support to clinical risk-benefit analyses (Howard 2005; McKenna et al. 2005; NICE 2007). This is a problem not least because the gold standard randomized controlled trial is considered unethical for assessing psychotropic medication use during pregnancy, while other available observational studies are generally underpowered, with biased samples and therefore remain unfit for purpose in a rapidly changing prescribing landscape (NICE 2007). In a UK population approaching 66 million, –3,000–4,000 births per year may be exposed to antipsychotics or other psychotropic medications. This chapter provides a critical summary of current knowledge about potential risks of fetal antipsychotic and antiepileptic drug exposure and proposes how future observational studies might fill crucial gaps in the evidence. Most incident cases of severe mental illness (schizophrenia, related disorders, and bipolar disorder) occur during the reproductive years and most are treated with continuous psychotropic pharmacotherapy (Buchanan et al. 2009). Better care, deinstitutionalization and the use of newer agents with fewer effects on fertility means that women with psychotic disorders maybe increasingly likely to become pregnant (Howard 2005; NICE 2007), while the use of newer ‘atypical’ antipsychotics for other mental disorders common among women of childbearing age is also expanding (McKenna et al. 2005). For these reasons, psychotropic medications is increasingly likely to be prescribed to mothers during pregnancy (Newport et al. 2007). It is surprising then that reproductive safety data for psychotropic agents remains so incomplete (Barnes 2008; Webb et al. 2004) and guideline recommendations lend limited support to women, their partners and their treating clinicians in difficult clinical risk-benefit analyses (NICE 2007). Recent reports conclude that prospective studies are needed which can access unbiased, reliable (large enough) samples of ill mothers exposed to psychotropic medication and take account of key maternal characteristics (e.g. psychiatric diagnosis, smoking, pregnancy weight) in the estimation of risk (Barnes 2008; NICE 2007).

Medication administration is a key skill and it is vital that you are able to demonstrate safety in all aspects of the medication administration process in order to avoid harm or death to your patient. The NMC (2004, 2010) reiterates this point, highlighting that the administration of medicines is an important aspect of a nurse’s professional practice. They argue that it is not simply a mechanistic task, but one that requires thought, exercise and professional judgement. Studies suggest that medicine administration is one of the highest risk processes that a nurse will undertake in clinical practice (NPSA 2007b; Elliot and Lui 2010). Medication administration errors are one of the most common errors reported to the National Patient Safety Agency (NPSA). Indeed in a 12-month period in 2007, 72,482 medication errors were reported with 100 of these causing either death or severe harm to the patient (NPSA 2009). The frequency of these errors has led to a number of changes in the medication administration process. Alongside these important recommendations, most higher education establishments will want to ensure safety of medicine administration and may test this vital skill using an OSCE to ensure that you are adequately prepared for safe administration of medication in practice. There are a number of important laws and key documents that relate to the administration of medication and it is important that you understand these as they all impact upon your practice when administering medication to a patient. You may also be tested on your knowledge in relation to these areas so it is important that you have read these. Important documents you will need to know include: ● The laws that relate to medication in the UK, ● NMC Standards for Medicines Management (2010) (www.nmc-uk.org), ● Local policies related to hospital/Primary Care Trust (PCT) regulation of medication (refer to local guidance). There are a number of laws that influence the manufacturing, prescription, supply, storage and administration of medication. Whilst you will not need to study the intricacies of these laws you will need to understand the main issues each law covers.

Prescription drug monitoring programs (PDMPs) are secure, online, state-based databases that contain information about controlled substance prescriptions written by clinicians and dispensed by pharmacists within a jurisdiction. In this chapter, current and future trends impacting PDMPs are reviewed and the implication of these trends for the future development of even more effective PDMPs is discussed. Uses of PDMPs by public health partners are also reviewed. For example, law enforcement officials may use data collected by PDMPs when investigating unusual prescribing patterns. Law enforcement officials may also use PMDP data in drug courts and other criminal diversion programs. Medical licensing boards use PMDP data to assess aberrant prescribing practices. Health systems, insurers, and public health officials use aggregated PDMP data as part of their efforts to evaluate a quality improvement initiative, an opioid stewardship program to improve opioid prescribing system-wide, or broad changes to prescribing patterns across a city, county, or state.

Antimicrobial stewardship (AMS) is a healthcare- system- wide approach to promoting and monitoring the judicious use of antimicrobials (including antibiotics) to preserve their future effectiveness and optimize outcomes for patients. Put simply, it is using the right antibiotic, at the right dose, via the right route, at the right time, for the right duration (Centres for Disease Control, 2010). Antimicrobial resistance (AMR) is a serious and growing global public health concern. Antibiotics are a unique class of drug as their use in individual patients may have an impact on others through the spread of resistant organisms. Antibiotics are essential for saving lives in conditions such as sepsis, and without effective antibiotics even minor operations could be life-threatening due to the risk of resistant infections. Across Europe approximately 25,000 people die each year as a result of hospital infections caused by resistant bacteria, and others have more prolonged and complicated illness. By 2050, AMR is predicted to be one of the major causes of death worldwide. Protecting the use of currently available antibiotics is crucial as discovery of new antimicrobials has stalled. Studies consistently demonstrate that 30–50% of antimicrobial prescriptions are unnecessary or inappropriate. Figure 18.1 shows some of the reasons behind this. As well as driving increasing resistance, unnecessary prescribing leads to unwanted adverse effects, including avoidable drug reactions and interactions, Clostridium difficile-associated diarrhoea, and healthcare-associated infections with resistant micro-organisms, all of which are associated with adverse clinical outcomes, including increased length of hospital stay and mortality, with increased cost to healthcare systems. Prudent use of antibiotics improves patient care and clinical outcomes, reduces the spread of antimicrobial resistance, and saves money. There are a number of global and national guidelines outlining what a robust AMS programme should consist of (see Further reading and useful resources), including: ● Infectious Diseases Society of America (IDSA): Guidelines for Developing an Institutional Programme to Enhance Antimicrobial Stewardship. ● National Institute for Health and Care Excellence (NICE): Antimicrobial Stewardship: Systems and Processes for Effective Antimicrobial Medicine Use [NG15]. ● Department of Health (DoH): Start Smart Then Focus, updated 2015. ● DoH: UK 5- Year Antimicrobial Resistance Strategy 2013 to 2018.

Sepsis is defined as life- threatening organ dysfunction caused by a detrimental host response to infection. Septic shock is a subset of sepsis in which underlying circulatory and cellular abnormalities are profound enough to substantially increase mortality. Septic shock is characterized by: ● The need for vasopressors to maintain mean arterial pressure (MAP) > 65mmHg despite adequate volume resuscitation. ● A serum lactate > 2mmol/L In lay terms, it is hypoperfusion with evidence of metabolic derangement. The mortality for both criteria is ~40%, compared to 20–30% for a single item. Please also refer to: https:// www.nice.org.uk/ guidance/indevelopment/gid-cgwave0686 The old definitions of sepsis described a heterogeneous group of patients and did not discriminate between infectious and non- infectious causes such as pancreatitis and trauma. The new definitions also allow easier recognition, based on a combination of symptoms and signs. Key parameters include: decreased level of consciousness, rigors, severe myalgia, high or low temperature, pulse > 130/min, systolic blood pressure < 90mmHg, respiratory rate (RR) > 25/ min, creatinine > 170μmol/ L, platelets < 100 x 109/l and bilirubin > 33μmol/ L. The Clinical Quality Commission recommend that NHS trusts use the national early warning score (NEWS), and a score > 5 is an indication to consider moving a patient to critical care. SIRS is defined as any of the two following criteria: acutely altered mental state, temperature < 36°C or > 38°C, pulse > 90/ min, RR > 20/ min, WCC > 12 or < 4 x 109/L and hyperglycaemia in the absence of diabetes mellitus. In the former definitions (1991 and 2001), sepsis was defined as infection plus SIRS. SIRS, however, was not good at separating infected patients who died from those who recovered from infection. SIRS was often an appropriate reaction to infection and many hospitalized patients meet the SIRS criteria. Also, as many as one in eight patients admitted to critical care units with infection and new organ failure did not have two SIRS criteria required to fulfil the sepsis definition. SIRS is no longer part of the new definitions.

By the end of this chapter, you should understand… ● The range of possible sources of information about medicines ● Their positive and negative characteristics ● Some trustworthy sources of evidence ● The role of medicines information departments ● Some basic principles of critical analysis of evidence ● How the British National Formulary (BNF) is structured ● How to read a BNF monograph ● A selection of terms used in the literature about medicines…. While nurses will not usually be selecting medicines, they still need information to make the best use of the medicines prescribed for their patients. Information of all kinds is much more readily available today than it was a generation ago when the authors were students, but much of it is of low quality and today’s student must learn to test the quality of the evidence offered to see if it can be relied upon. In all fields of healthcare it has become usual to insist that practice must be evidence based. This is very desirable, but it begs the question—what is evidence? This chapter will examine some of the sources of evidence about medicines that are available and give some guidance on their reliability. Later, there will be an introduction to critical analysis of sources, and a description of some of the key terms used in evaluating clinical evidence about medicines. Sources of information may be conveniently divided into two main types—people and publications. It is natural that many healthcare professionals should rely upon their mentors and instructors to supplement the knowledge they gain in formal teaching. Indeed, for many years much of the practical information about medicines that junior doctors received came from participation in ward rounds under the tutelage of a consultant. In medical school they learned some general pharmacology, but the actions of many drugs were learned following graduation (Maxwell and Walley, 2009 ) The same will be true for nurses, and it will continue to be true throughout their careers. New medicines will come into use, and nurses will have to learn about them. It is therefore important to realize that pharmacology will be a lifelong study and does not end with registration as a nurse.

This chapter offers some final thoughts on the relationships between religious culture and outgroup altruism. It suggests that collectivist culture is more predisposed towards outward altruism compared to individualistic culture and explains that altruistic behavior in collectivist cultures is motivated by prescribed norms, the violation of which may result in the loss of group identification. It also contends that consequential altruism is altruistic inasmuch as it benefits the other and it may be the highest normative level most cultures can reach.

This article argues that virtue ethics provides a deeper and more compelling analysis of the ethical problems raised by conflicts of interest in physician prescribing than do other ethical perspectives. The author argues that disclosure requirements fail to address specifically medical vices, such as physician maleficence and betrayal, which are shown when physicians’ industry ties lead them to engage in harmful prescribing behaviour, or to redefine their therapeutic relationships with patients as business relationships. The author also evaluates proposals to use financial incentives for physicians to avoid biased prescribing, and indicates how such an analysis can also help the development of a virtue ethics model for regulatory interventions more generally. The author then highlights a moral cost to the use of financial incentives here that, while justifiable on utilitarian cost-effectiveness grounds, is a moral cost that on a virtue ethics approach to policy should not be paid in efforts to improve health outcomes.