Precautionary actions such as withdrawal of a vaccine from the market, or the use of black box warnings must be proportionate to the degree of scientific certainty, the severity of possible harm, the size and nature of the affected population, and the cost of the actions [29] and [30]. Decisions should also be subject to review in light of new information [20]. Anticipatory decision making

can be fostered by the collection of the highest quality of evidence possible. It should be noted, however, that the premature or complete withdrawal of a vaccine from the market can also cause harm under certain circumstances, and thus a precautionary approach may not always be ethically appropriate. Regulators have the duty to warn people when safety and/or effectiveness Protease Inhibitor Library issues are present with a vaccine. This can include important reminders about waning immunity requiring a booster in order that people remain protected from disease. For vaccines where long-term effectiveness is unknown this is particularly

important, because other measures such as screening may become even more important for people in order to prevent morbidity and mortality. Warnings need to be communicated in a timely and appropriate manner. It must be noted, however, that the social context of immunization programs may be such that premature, or overly alarmist warnings may negatively impact vaccine acceptance in the population as a whole or in particular sub-populations. Thus, while there is a moral obligation to provide all relevant information about vaccine safety and effectiveness to the HTS assay public in the interests of respecting individual autonomy and promoting informed consent, this must be balanced with the need to prevent the spread of disease. many Thus, the burden of disease needs to be taken into consideration when warning

the public of possible harm when evidence of harm is uncertain. This consideration speaks to the need to ensure that monitoring activities are proportionate in scope to what is known about the risk-benefit profile of a particular vaccine, as well as to the vulnerability of the population being immunized (see Section 3.5 below). Also, the scale of use (is the vaccine being used in a collective immunization campaign?) should also be taken into consideration when deciding what kind of monitoring activities are necessary to protect the public from harm. Proportionality should inform decisions around whether active or passive monitoring is needed, and whether targeted or universal monitoring is needed. Transparency requires that the rationale for regulatory decisions, as well as the decisions themselves need to be communicated to the public. In addition, risk communication around safety issues with vaccines needs to be made accessible and understandable in a timely manner.

Biochemical parameters like Serum Glutamic Oxaloacetic Transaminase (SGOT) and Serum Glutamic Pyruvic Transaminase (SGPT), Serum Alkaline Phosphatase (ALP), Serum Total bilirubin (T. Bil) were estimated by using commercial reagent kits in autoanalyzer (RM4000, Biochemical systems International, Italy). 15, 16, 17 and 18 Acute toxicity studies in mice

revealed that the extracts up to 2000 mg/kg produced no sign of Venetoclax toxicity or mortality. Qualitative phytochemical screening for different extracts of G. gynandra revealed the presence of steroids, terpenoids, glycosides, tannins, alkaloids, flavonoids, phenols and carbohydrates ( Table 1). The phenolic content of various extracts of G. gynandra were ranging from 13.21 ± 0.66 to 72.80 ± 0.22 (mg/g). The hydroalcoholic extract has more phenolic content (72.80 ± 0.22 mg/g) than other extracts. The alkaloidal content of extracts was ranging from 8.91 ± 0.10 to 16.68 ± 0.21 (mg/g). Temozolomide nmr The methanolic extract has more alkaloidal content (16.68 ± 0.21 mg/g) than other extracts ( Table 2). The different extracts of G. gynandra were found to possess concentration dependent free radical scavenging activity on tested free radicals ( Table 3). The mean IC50 values for superoxide radical scavenging activity of hydroalcoholic, methanolic, ethyl acetate and hexane extracts G. gynandra were found to be 150.5 ± 1.5 μg,

126.5 ± 1.3 μg, 259.2 ± 2.1 μg and 575.0 ± 2.3 μg. The mean IC50 values for hydroxyl radical scavenging activity of hydroalcoholic, methanolic, ethyl acetate and hexane extracts of G. gynandra were found to be 226.5 ± 2.1, 164.3 ± 1.8, 452.0 ± 2.5 and 709.5 ± 3.2 μg. The mean IC50 values for DPPH radical scavenging activity of hydroalcoholic, methanolic, ethyl acetate and hexane extracts of G. gynandra were found to be 108.25 ± 2.3,

87.9 ± 1.1, 239.4 ± 2.3 and 340.0 ± 2.2 μg. The order of activity as follows: ascorbic acid > methanolic extract > hydroalcoholic extract > ethyl acetate extract > Resminostat hexane extract. The CCl4-induced hepatotoxicity model is widely used to evaluate the hepatoprotective activity of drugs and plant extracts. The hepatoprotective effect of different extracts of G. gynandra at dose of 100, 200 and 400 mg/kg assessed (percentage protection) by measuring liver related biochemical parameters (SGOT, SGPT, ALP and total serum bilirubin) following CCl4-induced hepatotoxicity. In our studies, CCl4-damaged rats that were previously treated with extracts showed a significant decrease in serum GOT, GPT, ALP and T. bilirubin. This is evidence that both stabilization of the plasma membrane and repair of CCl4-induced hepatic tissue damage. The standard drug silymarin and higher dosages of extracts showed a strong hepatoprotective effect against CCl4-induced liver injury. Group I showed no significant change in the biomarkers of enzymes (SGOT, SGPT, ALP and total serum bilirubin) levels.

Similar issues exist for the broader health workforce, as outlined in the National Pain XAV-939 cell line Strategy (Australian and New Zealand College of Anaesthetists 2010). We need to better prepare the emerging workforce to manage

the predicted substantial increase in this global area of need over the next 30 years (March and Woolf, 2010, Woolf et al 2010). These epidemiologic data are consistent with Australian projections for chronic health conditions generally and chronic pain specifically (KPMG, 2009). While we agree that there is need to provide consistent evidence-based and interdisciplinary education in preregistration physiotherapy programs in Australia, it is also imperative to optimise the evidence-informed practical

skills and knowledge of clinicians currently in the workforce and who are likely to remain working for some time. These clinicians are likely to play an important role in shaping the beliefs and practice behaviours of the emerging workforce. Initiating a shift in beliefs and practice behaviours in any area is challenging and can only be sustained when supported by parallel changes in systems and policy. Reform strategies, therefore, need to be developed and implemented in a multi-stakeholder partnership framework, such as a network or community of practice model, in order to be effective and sustainable (Ranmuthugala et al 2011). In this regard, there Galunisertib order are many opportunities for collaboration among researchers, clinicians, consumers, and other stakeholders such as universities, health departments, rural health services, and policy makers to drive much-needed reform in this area. While Jones and

Hush (2011) review important curriculum reform in Canada and the US, we feel it is timely to highlight some of the initiatives currently being undertaken in Western Org 27569 Australia (WA) to help close this gap and improve service delivery to consumers who live the experience of pain. The key platform that has enabled implementation of these initiatives is the WA Health Networks, integrated into the Department of Health, WA. The aim of the of the WA Health Networks is to involve all stakeholders who share a common interest in health to interact and share information to collaboratively plan and facilitate implementation of consumer-centred health services through development of evidence-informed policy and programs. The Spinal Pain Working Group, as part of the Musculoskeletal Health Network, has been proactive in developing, implementing, and evaluating a number of projects to address state policy for service delivery in the context of spinal pain (Spinal Pain Model of Care 2009).

4 Visual impairment has been found to be an independent risk factor for falls, particularly with relation to impaired edge-contrast sensitivity and depth perception.5 and 6 People with visual impairment this website are at a particularly high risk of falls due to impaired balance7 and difficulty detecting environmental hazards. With normal ageing, conduction speed and central nervous system processing slows down,8 forcing balance control mechanisms to rely more heavily on visual input to maintain stability,9 particularly during single limb balance.10 This has obvious implications for older adults with visual impairments. Deterioration

in balance control in older people is primarily in the medio-lateral direction11 and reduced visual input has been shown to have a greater impact on lateral balance control,12 which amplifies the deterioration

in the older population with visual impairments on mobility tasks involving single-limb balance. Travel in the community presents additional hazards for older people with visual impairment. Environmental preview involves scanning the environment ahead with sufficient time to recognise potential hazards and avoid them. Glare can interfere with environmental preview in people with visual impairment. High levels of glare sensitivity are reported in individuals with glaucoma13 and recovery from glare exposure is slower in people with age-related macular degeneration.14 Fluctuations in environmental light can VE-821 price divide attention and reduce the available reaction time to hazards for this population. When attention is divided, older adults have Ribonucleotide reductase a decreased ability to avoid obstacles in the environment, compared to younger adults.15 Individuals with visual impairments may also rely on memorised aspects of the environment and

often employ a mobility aid as they travel. If the individual is using a long cane as a mobility aid, the cane is detecting the next footfall, giving little warning before a hazard is encountered. Attention allocated to route memory and mobility-aid use, in addition to postural stability and hazard avoidance, could thus overload attention resources and further increase the risk of falls in people with visual impairment. A Cochrane review by Gillespie et al16 identified several effective approaches to fall prevention for the general population of older adults living in the community, including exercise, home safety, medication management and interventions targeting multiple risk factors. The latest update of that review included no new trials that provided physical training for community-dwelling older adults with untreatable visual impairments. A Cochrane review by Cameron et al17 identified that Vitamin D prescription reduces falls in residential care facilities and that interventions targeting multiple risk factors may also do so, but it included no trials that provided physical training for older adults with visual impairments in care facilities and hospitals.

This high quality,

large multi-centre trial by Van de Port and colleagues (2012) is the latest contribution to the body of evidence. The study confirms that taskoriented circuit class training in small groups is as effective as individual intervention in improving mobility in people who require outpatient rehabilitation within the first six months after stroke. More important, Selleckchem Autophagy Compound Library the efficiency in terms of staff resources of small groups suggests that where possible circuit class intervention should be used. Specifically, for the same healthcare costs, classes could afford more therapy for the individual either through increases in amount delivered in one day or by increasing the time over which services can be delivered. The differences between the groups in terms of walking speed and 6 minute walk distance were modest but in favour of the circuit class intervention. Without more detail of the interventions Depsipeptide research buy delivered to both groups it is hard to discuss the reasons for this result. For example there is evidence that treadmill training improves walking in both ambulatory (Ada et al, in press) and non-ambulatory (Dean et al 2010, Ada et al 2010) people after stroke. Similarly the use of biofeedback has been found to improve outcome (Stanton et al 2010). The trial also had a large number of secondary

outcomes measures some of which were redundant. Omitting some redundant measures and including a measure of free-living physical activity would have been useful to see if benefits had carried over into everyday life. Alzahrani and colleagues (2009) have shown stair ability

MYO10 predicts free living physical activity after stroke. Inclusion of a free-living activity measure could have allowed subsequent analysis of this relationship in a Dutch sample. “
“Summary of: Vivodtzev I et al (2012) Functional and muscular effects of neuromuscular electrical stimulation in patients with severe COPD: a randomised clinical trial. Chest 141: 716–725. [Prepared by Kylie Hill, CAP Editor.] Question: In patients with chronic obstructive pulmonary disease (COPD), what effect does neuromuscular electrical stimulation (NMES) have on muscle function and walking endurance? Design: Randomised, controlled trial in which the patients and those who collected outcome measures were blinded to group allocation. Setting: Home-based intervention with outcomes collected at a hospital in Quebec City, Canada. Participants: Patients who were clinically stable, sedentary and able to travel to the hospital with: (a) a smoking history > 20 pack-years, (b) severe airflow obstruction, and (c) a 6-minute walk distance < 400 m. Exclusion criteria comprised any co-morbid condition associated with muscle wasting. Randomisation of 22 patients allocated 13 to the intervention group and 9 to the control group. Interventions: Both groups received electrical stimulation 5 times a week for 6 weeks.

The mixture was stirred for 0.5 h at RT and then ethyl/benzyl halides

(0.01 mol) was added to the mixture and the solution was further stirred for 3–4 h. After Panobinostat in vivo the reaction completion, verified by TLC, the product was precipitated after the addition of cold distilled water. 2–3 mL aq. Na2CO3 was added to make basic pH of 9. The product was filtered off, washed with distilled water and recrystallized from methanol. Light brown amorphous solid; Yield: 79%; M.P. 84–86 °C; Molecular formula: C19H24ClNO3S; Molecular weight: 381; IR (KBr, ѵmax/cm−1): 3078 (Ar C H stretching), 1621 (Ar C C stretching), 1369 (S O stretching); 1H NMR (400 MHz, CDCl3, ppm): δ 7.76 (d, J = 8.8 Hz, 2H, H-2′ & H-6′), 7.60 (d, J = 2.0 Hz, 1H, H-6), 7.49 (d, J = 8.8 Hz, 2H, H-3′ & H-5′), 6.99 (dd, J = 8.8, 2.0 Hz, 1H, H-4), 6.64 (d, J = 8.8 Hz,

1H, H-3), 3.57 (s, 3H, CH3O-2), 3.60 (q, J = 7.2 Hz, 2H, H-1′’), 1.19 (s, 9H, (CH3)3C-4′), INCB024360 order 0.99 (t, J = 7.2 Hz, 3H, H-2′’); EI-MS: m/z 383 [M + 2]+, 381 [M]+, 366 [M-CH3]+, 350 [M-OCH3]+, 317 [M-SO2]+, 197 [C10H13SO2]+, 156 [C7H7ClNO]+. Light grey amorphous solid; Yield: 81%; M.P. 118–120 °C; Molecular formula: C18H22ClNO3S; Molecular weight: 367; IR (KBr, ѵmax/cm−1): 3080 (Ar C H stretching), 1614 (Ar C C stretching), 1367 (S O stretching); 1H NMR (400 MHz, CDCl3, ppm): δ 7.35 (d, J = 2.8 Hz, 1H, H-6), 6.95 (dd, J = 8.8, 2.8 Hz, 1H, H-4), 6.79 (s, 2H, H-3′ & H-5′), 6.66 (d, J = 8.8 Hz, 1H, H-3), 3.76 (s, 3H, CH3O-2), 3.39 (q, J = 7.2 Hz, 2H, H-1′’), 2.57 (s, 6H, CH3-2′ & CH3-6′), 2.28 (s, 3H, CH3-4′), 0.99 (t, J = 7.2 Hz, 3H, H-2′’); EI-MS: m/z 369 [M + 2]+, 367 [M]+, 352 [M-CH3]+, 336 [M-OCH3]+,

303 [M-SO2]+, 183 [C9H11SO2]+, 156 [C7H7ClNO]+. Dark grey amorphous solid; Yield: 89%; M.P. 102–104 °C; Molecular formula: C16H18ClNO4S; Molecular weight: 355; IR (KBr, ѵmax/cm−1): 3056 (Ar C H stretching), 1603 (Ar C C stretching), 1369 (S O stretching); 1H NMR (400 MHz, CDCl3, ppm): δ 7.62 (d, J = 8.8 Hz, L-NAME HCl 2H, H-2′ & H-6′), 7.18–7.22 (m, 2H, H-4 & H-6), 6.90 (d, J = 8.8 Hz, 2H, H-3′ & H-5′), 6.71 (d, J = 8.4 Hz, 1H, H-3), 3.84 (s, 3H, CH3O-4′), 3.56 (q, J = 7.2 Hz, 2H, H-1′’), 3.45 (s, 3H, CH3O-2), 1.02 (t, J = 7.2 Hz, 3H, H-2′’); EI-MS: m/z 357 [M + 2]+, 355 [M]+, 340 [M-CH3]+, 324 [M-OCH3]+, 291 [M-SO2]+, 171 [C7H7OSO2]+, 156 [C7H7ClNO]+. Blackish grey amorphous solid; Yield: 66%; M.P. 86–88 °C; Molecular formula: C17H19ClNO4S; Molecular weight: 367; IR (KBr, ѵmax/cm−1): 3084 (Ar C H stretching), 1607 (Ar C C stretching), 1351 (S O stretching), 1719 (C O stretching); 1H NMR (400 MHz, CDCl3, ppm): δ 7.99 (d, J = 8.0 Hz, 2H, H-2′ & H-6′), 7.78 (d, J = 8.0 Hz, 2H, H-3′ & H-5′), 7.48 (d, J = 2.4 Hz, 1H, H-6), 7.03 (dd, J = 8.0, 2.4 Hz, 1H, H-4), 6.71 (d, J = 8.0 Hz, 1H, H-3), 3.41 (s, 3H, CH3O-2), 3.30 (q, J = 7.2 Hz, 2H, H-1′’), 2.50 (s, 3H, CH3CO-4′), 1.00 (t, J = 7.

Rewards for healthy behaviours was widely perceived to be a feasible intervention, but of doubtful effectiveness. Involvement of children in the planning of delivery of interventions through mechanisms such as school councils was felt to be feasible and an important facilitator to intervention. The importance of adult role models in influencing healthy behaviour was a repeated theme. Potential role models included parents, teachers, celebrities, and faith leaders. The central role of religion in the predominantly Muslim communities was seen as an

opportunity for intervention, Selleck SB431542 therefore faith leaders were a particular focus of discussion. Several participants (but not all) felt that faith leaders would not engage with interventions targeting health-related

behaviours as they GSK1210151A mouse would not identify this as part of their ‘faith’ role. There was a general perception that the community setting provided an unexploited opportunity. The provision of local low cost physical activity and healthy eating sessions were suggested and prioritised as potential interventions. Existing community resources were identified as a potential opportunity and effective signposting to these was a suggested intervention. Quotations from participants illustrating emergent themes are shown in Table 2. In addition to the specific facilitators and barriers discussed, several global barriers to intervention emerged. Children’s expectations and demand for choice was a perceived barrier; children expect to have a choice of food at home and school, and prefer sedentary

activities such as television and computers. Cultural norms within South Asian communities were highlighted. Practical barriers such as language were perceived to make intervention more challenging, but a more fundamental barrier identified was the perception that overweight children are healthy, and underweight is of more concern. The lack of parental time was identified as a barrier (see Discussion). This would impact on any interventions involving parental engagement. A further perceived barrier was the cost of commodities such as healthy food and leisure time Thymidine kinase activities. The major barriers identified for schools were curricular pressures and competing priorities. Quotations from participants relating to intervention barriers are shown in Table 3. After consideration of the FG data, the Professionals defined a set of underlying principles to guide intervention design and delivery. These were: development of an inclusive (suitable for all ethnic groups), sustainable intervention; a focus on developing practical skills; delivery of the intervention in a predominantly verbal format; and involvement of children in the implementation planning. The group then agreed a shortlist of components to be considered for the final programme.

7 The results showed that levels of circulating antibodies are increased if the test animals are pretreated with the extract. Cellular immunity involves effector mechanisms carried out by T lymphocytes and their products (lymphokines). DTH requires the specific recognition of a given antigen by activated T lymphocytes, which subsequently proliferate and release cytokines. These

in turn increase vascular permeability, induce vasodilatation promoting increased phagocytic activity. A subsequent exposure to the SRBCs antigen induces the effector phase of the DTH response, AP24534 where TH1 cells secrete a variety of cytokines that recruits and activates macrophages and other non-specific inflammatory mediators.15 Therefore, increase in DTH reaction in mice in response to T cell dependent antigen revealed the stimulatory effect of MLHT on T cells. MLHT has shown dose dependent activity. MLHT with low dose has less effect on hematological parameters especially on RBC but the high dose of the crude extract showed significant increase in the WBC count compared to the RBC count and hemoglobin. Estimation of the liver enzymes did not reflect any toxicity, the effect of MLHT on LFT enzymes may be due to

the flavonoids and coumarins which UMI-77 cost accomplish the hepatoprotective nature of the plant.16 In conclusion, the results obtained in the present study show that H. tiliaceus methanolic leaf extract produces stimulatory effect on the humoral and cell mediated immune response in the experimental animals and suggest its therapeutic usefulness in disorders of immunological origin. Further studies to identify the active constituents and elucidation of mechanism of action are recommended since it is not possible to single out the most effective

immunostimulatory constituents of this plant. All authors have none to declare. The authors thank JPR solutions for providing the partial funding to publish this research work. “
“Elephant foot yam (Amorphophallus PD184352 (CI-1040) paeoniifolius) is a plant, which is found as underground, hemispherical, depressed, dark brown corm. It is normally grown in north–eastern part of India. It is an underground, unbranched plant. Leaves are compound, large, solitary, petiole, and stout, mottled. Leaflets are 5–12.5 cm long of variable width, obovate or oblong, acute, strongly & many nerved. It is contiguous, neuters absent, appendage of spadix, subglobose or amorphous, equally or longer than the fertile region, spathe campanulate, pointed, strongly, closely veined, greenish-pink externally, base within purple, margins recurved, undulate, & crisped, male inflorescence sub turbinate, female 7.5 cm or more long. Fruits are obovoid 2–3 seeded and red berries. The fruit is known as corm and this part is used as active part of the plant. The corm has been used as the sources of the various medicines.

For protein quantification, the BCA assay was shown to be superior Selleckchem GDC 0199 for the determination of protein

concentration while the Bradford assay offers an adequate assay when specific interferences exclude the BCA assay. Using the differential signal from these two protein assays, a method was conceived and demonstrated to be capable of estimating the amount of a reducing sugar present. When neither fine accuracy nor precision is required, this method may offer a less experimentally demanding and more streamlined approach for reducing sugar determination than the PHS assay. In conjunction with well-established methods for quantifying DNA, these methods comprise the core analytical techniques needed to support purification process development. The described suite of analytics enables the rapid quantitation of key molecular classes in a microplate-based format that is amenable to automation. The deployment of these analytics will enable learn more the development of high throughput processing platforms to speed the development of polysaccharide manufacturing processes. Bernie Violand, Sa Ho, Khurram Sunasara, and Tom Emmons were invaluable in shaping the direction of this work and in providing useful suggestions for experiments and interpretation. Pfizer generously supported this research through an Eng. D. sponsorship and the Engineering and Physical Sciences Research Council

provided critical backing. “
“Vaccine adjuvants augment the immune response by promoting more effective antigen processing, presentation, and/or delivery [1]. Aluminum salts (alum) were first introduced as vaccine adjuvants over 80 years ago when little was known about the cellular or molecular mechanisms of the immune response [2], yet alum remains Methisazone the most widely used adjuvant today due to its demonstrated safety profile and effectiveness when combined with many clinically important antigens [3] and [4]. However, alum is not sufficiently potent to attain protective responses to poorly immunogenic entities [5], [6], [7], [8] and [9]. Additionally, alum preferentially promotes Th2 type responses [2], [3], [4] and [10],

which may exacerbate adverse inflammatory reactions to some respiratory pathogens, such as the respiratory syncytial virus (RSV) [11], and does not efficiently augment cytotoxic T cell responses, which are necessary to provide protective immunity against many viral antigens or therapeutic immunity against cancer-related antigens [12]. One of the main challenges of current vaccine development is to advance the clinical application of newly developed and potent adjuvants without compromising safety [12] and [13]. Novel adjuvant candidates have emerged from the discovery of pattern recognition receptors (PRR) that recognize pathogen-associated molecular patterns (PAMP) and damage-associated molecular patterns (DAMP) [14], [15], [16] and [17].

These results can facilitate the adoption of this approach in Canada as well as elsewhere. The U.S. has recently adopted the Canadian vaccine barcode standards to promote harmonization, and consequently vaccine manufacturers are beginning to alter their U.S. product labeling to include 2D barcodes [23]. Investigators at the Centers for Disease Control and Prevention have initiated a pilot project designed to determine best practices for labeling and tracking vaccines using 2D barcodes [24]. Our study had several limitations. First, we did not examine the effect of vaccine packaging type on outcomes. Packaging

types can vary, with single-dose vials, multi-dose vials, and prefilled syringes. Non-barcoded vaccines for Kinase Inhibitor Library price both study sites were single-dose

vials or pre-filled syringes. For Study Site 1, all of the barcoded vaccines used were single-dose, while for Study Site 2, influenza vaccines in multi-dose vials were used, in addition to single-dose vials and pre-filled syringes. Given that single-dose vials are smaller than multi-dose vials, and therefore have greater curvature, it is possible that the observed difference between the two arms in Study Site 2 may have been larger than it would have NVP-BGJ398 clinical trial been if only vaccines with single-dose vials were used. Second, APH had adopted Profile only three months prior to the study, therefore the time required to record vaccine data may have been greater due to unfamiliarity with a new system. Third, the number of vaccinations at APH during the pre-determined data collection period was lower than anticipated, and therefore we were unable to meet our sample size requirements for barcoded vaccines. This may have resulted in our inability

to detect a significant difference in data quality between barcode scanning and manual methods. Fourth, we included nurse trainees in our observation ADAMTS5 period at APH, and it is possible that their times to record vaccine data may be higher than for nurses, due to their limited experience; however, given that only five of the 346 observations for non-barcode vials were based on data recording by trainees, the impact on our study results was minimal. Fifth, in the FN study, one of the scanners was an older unit, which may have caused delays. Sixth, several nurses in the FN study did not respond to our interview requests. Although there were nine nurses observed in the FN study, there were additional nurses in the two participating communities in which we conducted interviews only without doing on-site observations. Therefore, there were several nurses that did not respond to our request for an interview. These individuals may have different opinions than those who responded.