• Back to school Post Covid-19: Rebuilding a better future for all children

      Lalli, Gurpinder; Defeyter, Greta; Shinwell, Jackie; von Hippel, Paul; Henderson, Emily; Brownlee, Iain; Pepper, Gillian; Stretesky, Paul; Long, Michael; McKenna, Jim; et al. (Education Committee, UK Parliament, 2020-06-10)
      This paper provides a summary of the key academic papers for the following areas: learning loss and academic attainment; EdTech interventions and home schooling; physical activity, food insecurity and obesity; and mental health and wellbeing. For each area, the findings from peer-reviewed academic papers are summarised and discussed in terms of relevance to the current Covid-19 pandemic. The latter half of the paper provides, for each area, a range of research informed short-, mid- and long-term school based strategies, policies and interventions to advise the UK government for pupils returning to school. The early adoption of these proposals will support teachers, parents and children and provide positive messaging to pupils and hence, increase public confidence. Finally, the authors appeal to the concept of human capital, and discuss how schools provide an excellent platform to narrow mid-to-long term health and educational inequalities. The suggestions in this paper converge with action at the international level; with many key agencies (UNESCO, UNICEF, World Bank and World Food Programme) making the case for the key role of school food in supporting the back to school movement.
    • “Back to square one”: The experience of straddling adolescence and early adulthood in unemployed UK university graduates with common mental health issues

      Cockshott, Christopher J.; Kiemle, Gundi; Byrne, Paula; Gabbay, Mark B.; Institute of Psychology, Faculty of Education, Health, and Wellbeing, University of Wolverhampton, Wolverhampton, UK; Doctorate in Clinical Psychology, University of Liverpool, Liverpool, UK; Institute of Psychology, Health, and Society, University of Liverpool, Liverpool, UK; Institute of Psychology, Health, and Society, University of Liverpool, Liverpool, UK (Sage, 2017-09-25)
      We investigated the experiences of unemployed university graduates with common mental health issues. After conducting semistructured interviews with 12 unemployed bachelor’s degree graduates with common mental health issues, we used interpretative phenomenological analysis to generate three superordinate themes: “fall from grace,” “vulnerability,” and “life on hold.” Our focus in this article is life on hold and its constituent themes: “stagnation,” “moving backward,” and “feeling left behind.” Graduates struggled to complete the broader structural life transition from university student to the adult world of work, experiencing a nebulous state of straddling adolescence and early adulthood. This undermined their sense of adult maturity, leaving them vulnerable to becoming entrenched in their mental health-related difficulties. We discuss these findings in relation to the developmental perspectives of life-course theory, status passages, and separation–individuation in early adulthood, which raise important issues for the applicability of life-course frameworks for these graduates, who are a disadvantaged minority group.
    • Balanced forced-diuresis compared to control as a reno-protective approach in cardiac surgery: secondary outcome of a randomized controlled trial, assessment of neutrophil gelatinase-associated lipocalin levels

      Luckraz, Heyman; Giri, Ramesh; Wrigley, Benjamin; Nagarajan, Kumaresan; Senanayake, Eshan; Sharman, Emma; Beare, Lawrence; Nevill, Alan; Heart-Centre, American Hospital, PO Box 5566, Dubai, UAE. HeymanLuckraz@aol.com. (Springer Science and Business Media LLC, 2021-08-24)
      Background: Neutrophil gelatinase-associated lipocalin (NGAL) is a recognised biomarker for acute kidney injury (AKI).This study investigated the impact of balanced forced-diuresis using RenalGuard® system (RG), in reducing acute kidney injury (AKI) rates and the associated NGAL levels (6-h post-CPB plasma level) post adult cardiac surgery with cardiopulmonary bypass (CPB). Methods: Patients included in the study were at high-risk for AKI post cardiac surgery, namely history of diabetes and/or anaemia, e-GFR 20–60 ml/min/1.73 m2, Logistic EuroScore > 5, anticipated CPB time > 120 min. Patients were randomized to either RG (n = 110) or managed as per current practice (control = 110). RIFLE-defined AKI rate (based on serum creatinine level increase) within first 3 days of surgery and 6-h post CPB NGAL levels were the primary and secondary end-points. Results: Pre and intra-operative characteristics between the two groups were similar (p > 0.05) including the pre-op NGAL levels, the oxygen delivery (ecDO2i) and the carbon dioxide production (ecVCO2i) during CPB. Patients in the RG group had a significantly lower post-operative RIFLE-defined AKI rate compared to control (10% (11/110) v/s 20.9% (23/110), p = 0.03). Overall, median 6-h post CPB NGAL levels in patients with AKI were significantly higher than those who did not develop AKI (211 vs 150 ng/ml, p < 0.001). Patients managed by balanced forced-diuresis had lower post-operative NGAL levels (146 vs 178 ng/ml, p = 0.09). Using previously reported NGAL cut-off level for AKI (142 ng/ml), binary logistic regression analysis confirmed a beneficial effect of the RG system, with an increased risk of AKI of 2.2 times in the control group (OR 2.2, 95% CI 1.14–4.27, p = 0.02). Conclusions: Overall, the 6-h post-CPB plasma NGAL levels were significantly higher in patients who developed AKI. Patients managed with the novel approach of balanced forced-diuresis, provided by the RenalGuard® system, had a lower AKI rate and lower NGAL levels indicating a lesser degree of renal tissue injury. Trial registration ClinicalTrials.gov website, NCT02974946, https://clinicaltrials.gov/ct2/show/NCT02974946.
    • Balanced forced‐diuresis as a renal protective approach in cardiac surgery: Secondary outcomes of electrolyte changes

      Luckraz, Heyman; Giri, Ramesh; Wrigley, Benjamin; Nagarajan, Kumaresan; Senanayake, Eshan; Sharman, Emma; Beare, Lawrence; Nevill, Alan (Wiley, 2021-08-19)
      Objectives Forced-diuresis during cardiopulmonary bypass (CPB) can be associated with significant electrolyte shifts. This study reports on the serum electrolyte changes during balanced forced-diuresis with the RenalGuard® system (RG) during CPB. Methods Patients at risk of acute kidney injury (AKI)—(history of diabetes &/or anaemia, e-GFR 20–60 ml/min/1.73 m2, anticipated CPB time >120 min, Log EuroScore >5)—were randomized to either RG (study group) or managed as per current practice (control group). Results The use of RG reduced AKI rate (10% for RG and 20.9% in control, p = .03). Mean urine output was significantly higher in the RG group during surgery (2366 ± 877 ml vs. 765 ± 549 ml, p < .001). The serum potassium levels were maintained between 3.96 and 4.97 mmol/L for the RG group and 4.02 and 5.23 mmol/L for the controls. Median potassium supplemental dose was 60 (0–220) mmol (RG group) as compared to 30 (0–190) mmol for control group over first 24 h (p < .001). On Day 1 post-op, there were no significant differences in the serum sodium, potassium, calcium, magnesium, phosphate, and chloride levels between the two groups. Otherwise, postoperative clinical recovery was also similar. Conclusions Balanced forced-diuresis with the RG reduced AKI rates after on-pump cardiac surgery compared to controls. Although the RG group required higher doses of IV potassium replacement in the postoperative period, normal serum levels of potassium were maintained by appropriate intravenous potassium supplementation and the clinical outcomes between groups were similar.
    • Balancing hope and despair at the end of life: The contribution of organ and tissue donation.

      Walker, Wendy; Sque, Magi (Elsevier, 2015-12-09)
      PURPOSE: Concern for the grieving family can moderate the intentions of critical care staff to advocate deceased organ and tissue donation. Conversely, benevolent actions may provoke distress through missed opportunities to save or transform lives. This article provides insight into the perceived benefits of organ and tissue donation for grieving families who experienced end-of-life care in the intensive care unit. METHODS: Data were collected via semistructured, face-to-face or telephone interviews with 43 participants from 31 donor families. Audio recordings were transcribed verbatim and subjected to qualitative content analysis. RESULTS: The study findings affirmed the importance of person-centered end-of-life care. Donor families shared examples of good-quality care and communication that contained the hallmarks of compassion, respect, dignity, and choice. We uncovered a trajectory of hope and despair in which the option of organ and tissue donation appeared to give meaning to the life and death of the deceased person and was comforting to some families in their bereavement. CONCLUSIONS: Our study findings underlined the significance of donation decision making for grieving families. Organ and tissue donation has the potential to balance hope and despair at the end of life when the wishes of the dying, deceased, and bereaved are fulfilled.
    • Balancing safety and enjoyment: current practice when recommending tastes for people with intellectual disabilities who are non-orally fed

      Chadwick, Darren (Elsevier, 2014-06-13)
      Eating and drinking problems are common among people with intellectual disabilities. Having a compromised swallow or being at risk of inadequate nutrition are two reasons for introducing non-oral feeding. Such procedures involve the creation of an external opening for food and drink to be delivered directly into the stomach through a tube. In recent years maintenance of the swallow and quality of life issues have led to introduction of small amounts of food and drink (oral tastes) for people who are non-orally fed. Little evidence exists about the reasoning used to inform this decision or the types of oral tastes offered. This study aims to address these omissions. An exploratory survey, distributed via email, was used to gather information from speech and language therapists and dietitians about their current practice and their decision-making processes when offering oral tastes to people who are non-orally fed. Data presented here reflect the responses from respondents working primarily with people with intellectual disabilities (55 out of 158 respondents). Oral tastes were being offered and clinical decision-making around this centred on balancing the wellbeing and wishes of the person with intellectual disabilities and their carers with the risks to wellbeing inherent in implementing and supporting an oral taste programme.
    • Ballet injuries: injury incidence and severity over 1 year.

      Allen, Nick; Nevill, Alan; Brooks, John; Koutedakis, Yiannis; Wyon, Matthew (Lippincott, Williams & Wilkin, 2012-09)
      STUDY DESIGN: Prospective, descriptive single-cohort study. OBJECTIVE: To assess the incidence and severity of injuries to a professional ballet company over 1 year. METHODS: Data for an elite-level ballet company of 52 professional dancers were collected by an in-house medical team using a time-loss injury definition. RESULTS: A total of 355 injuries were recorded, with an overall injury incidence of 4.4 injuries per 1000 hours (female, 4.1; male, 4.8; P>.05) and a mean of 6.8 injuries per dancer (female, 6.3; male, 7.3; P>.05). Mean injury severity was 7 days (female, 4; male, 9; P<.05). Most injuries were classified as overuse (64%; female, 68%; male, 60%; P>.05); mean severity of injury was 3 days for females and 9 days for males (P<.05). The percentage of traumatic injuries was 32% for females and 40% for males (P<.05); the corresponding severity was 6 and 10 days, respectively (P<.05). CONCLUSION: The relatively high number of injuries reported and the resulting loss of dance time support the need to introduce interventions to reduce the risk of injury in professional dancers.
    • Barriers and solutions to HE progression for Early Years’ practitioners

      Kendall, Alexandra; Carey, Danielle; Cramp, Andy; Perkins, Helen (Routledge, 2012-10-12)
      Shifts in UK social and economic policy have focused on education and care in the Early Years as key to improving social inclusion, skills acquisition and longer term social and economic prosperity. The implications for practitioners in the sector have been significant as roles, functions and foci have been renegotiated through the processes of professionalising the workforce. Drawing on the outcomes of a qualitative study of the career trajectories and aspirations of Early Years educators working in the private, voluntary and independent sector, this paper explores the processes of professionalisation as they collide with the lived experiences of practitioners at the chalk face. The project, funded by the Lifelong Learning Network, aimed to achieve understanding of the influence on career development decision making, particularly in relation to progression to higher education. Our findings suggest that many practitioners fall into the category of ‘non-traditional learners’ and that socio-cultural issues may be key factors in determining decision-making about career development. By bearing witness to the lived experience of practitioners we argue that the processes of workforce development must place greater emphasis on the contestable nature of professionalism and the plurality of professional identity and that Universities are key to achieving this.
    • Barriers to early presentation of self-discovered breast cancer in Singapore and Malaysia: a qualitative multicentre study

      Lim, Jennifer N. W.; Potrata, Barbara; Simonella, Leonardo; Ng, Celene WQ; Aw, Tar-Ching; Dahlui, Maznah; Hartman, Mikael; Mazlan, Rifhan; Taib, Nur Aishah (BMJ Publishing Group Ltd., 2015-12-21)
      Objective To explore and compare barriers to early presentation of self-discovered breast cancer in Singapore and Malaysia. Design A qualitative interview study with thematic analysis of transcripts. Participants 67 patients with self-discovered breast symptoms were included in the analysis. Of these, 36% were of Malay ethnicity, 39% were Chinese and 25% Indian, with an average age of 58 years (range 24–82 years). The number of women diagnosed at early stages of cancer almost equalled those at advanced stages. Approximately three-quarters presented with a painless lump, one-quarter experienced a painful lump and 10% had atypical symptoms. Setting University hospital setting in Singapore and Malaysia. Results Patients revealed barriers to early presentation not previously reported: the poor quality of online website information about breast symptoms, financial issues and the negative influence of relatives in both countries, while perceived poor quality of care and services in state-run hospitals and misdiagnosis by healthcare professionals were reported in Malaysia. The pattern of presentation by ethnicity remained unchanged where more Malay delayed help-seeking and had more advanced cancer compared to Chinese and Indian patients. Conclusions There are few differences in the pattern of presentation and in the reported barriers to seek medical care after symptom discovery between Singapore and Malaysia despite their differing economic status. Strategies to reduce delayed presentation are: a need to improve knowledge of disease, symptoms and causes, quality of care and services, and quality of online information; and addressing fear of diagnosis, treatment and hospitalisation, with more effort focused on the Malay ethnic group. Training is needed to avoid missed diagnoses and other factors contributing to delay among health professionals.
    • Barriers to utilisation of cervical cancer screening in Sub Sahara Africa: a systematic review

      Lim, Jennifer N. W.; Ojo, A A (2017-01-23)
      Cervical cancer is the commonest cause of cancer-related death in Sub Sahara Africa (SSA). Both primary and secondary preventive services are available but utilisation remain low. This systematic review aims to summarise reported barriers preventing women from utilising cervical cancer screening services in SSA.
    • ‘Because it’s fun’: English and American girls’ counter-hegemonic stories of alcohol and marijuana use

      Arnull, E; Ryder, J (Informa UK Limited, 2019-02-20)
      Girls’ alcohol and other drug (AOD) use are depicted culturally as problematic. In this comparative, qualitative, study the voices of 59 English and American justice-involved girls give a counter-hegemonic portrayal of their alcohol and marijuana use. In their stories, we see how their AOD use is pleasurable and boundaried. AOD use involves negotiated risk within the situated context of shared experience and friendship networks that heighten and promote pleasure and fun. The findings offer the opportunity to address the ‘credibility gap’ in international health promotion policy. Our aim is to promote the adoption of policy approaches that recognize the complexity of girls’ lives and draw on strategies they have devised.
    • Becoming an eportfolio teacher.

      Hughes, Julie (Washington, DC: Stylus Publishing, 2009)
      This book: Higher education institutions of all kinds - across the United States and around the world - have rapidly expanded the use of electronic portfolios in a broad range of applications including general education, the major, personal planning, freshman learning communities, advising, assessing, and career planning. Widespread use creates an urgent need to evaluate the implementation and impact of e-portfolios. Using qualitative and quantitative methods, the contributors to this book—all of whom have been engaged with the Inter/National Coalition for Electronic Portfolio Research—have undertaken research on how e-portfolios influence learning and the learning environment for students, faculty members, and institutions. This book features emergent results of studies from 20 institutions that have examined effects on student reflection, integrative learning, establishing identity, organizational learning, and designs for learning supported by technology. It also describes how institutions have responded to multiple challenges in e-portfolio development, from engaging faculty to going to scale. These studies exemplify how e-portfolios can spark disciplinary identity, increase retention, address accountability, improve writing, and contribute to accreditation. The chapters demonstrate the applications of e-portfolios at community colleges, small private colleges, comprehensive universities, research universities, and a state system.
    • The behaviour and wellbeing of children and adults with severe intellectual disability and complex needs: the Be-Well checklist for carers and professionals

      Oliver, Chris; Adams, Dawn; Allen, Debbie; Crawford, Hayley; Heald, Mary; Moss, Jo; Richards, Caroline; Waite, Jane; Welham, Alice; Wilde, Lucy; et al. (Elsevier, 2020-10-13)
      Children and adults with severe intellectual disability and complex needs often show behaviours and distress that carers and professionals find difficult to identify causes for, manage and decrease. The prevailing view is that these behaviours and distress are learned and consequently interventions focus on behavioural techniques. In this article we summarise the findings of research that indicate that behaviour and distress in this population are influenced by transient and stable characteristics or conditions that can interact with aspects of learning, be independent of learning, and interact with each other. These transient and stable characteristics or conditions are: pain and discomfort, sensory sensitivity, anxiety and low mood, sleep problems, atypical emotional regulation, specific cognitive difference, and differences in social behaviour. To aid carers and professionals, we present a checklist of the elements of an assessment process that covers these transient and stable characteristics or conditions and other relevant influences on behaviour and distress such as seizures, medication, learning and communication. We also draw attention to the benefit of identifying the cause of intellectual disability to inform the assessment process.
    • Behavioural economics, motivating psycho-education improvements; a mobile technology initiative in South Africa

      Forsythe, Alexandra; Venter, Catherine (Frontiers Media S.A., 2019-07-10)
      Here we report on a health behavioural support project, using incentivised behaviour on a mobile platform through M4JAM. This was a proof of concept study to support further developments, more specifically targeted at the management of Tuberculosis and Human Immunodeficiency Virus. The study reported here examines the impact of financial rewards and app towards improving mental health outcomes in South Africa. 136 participants were recruited from a database and dichotomized into self-determined and heteronomous groups based on self-report scores. Overall the findings highlighted that personal financial incentives have a role in motivating behaviour and that individuals with higher levels of self-determinate motivation. The findings are discussed in light of the usefulness of an incentivized mobile platform in real-world practice to encourage mental health improvements in a low to middle-income countries.
    • Being a girl who gets into trouble: narratives of girlhood

      Arnull, E (Berghahn Journals, 2019-07-01)
      In this article I focus on the narratives of girls who describe the events that shape their lives and get them into trouble. The narratives are explored against Darrell Steffensmeier and Emilie Allan's (1996) proffered Gender Theory, to consider whether it offers an adequate explanatory framework. The article adds to the body of knowledge about girlhood, gender norms, and transgression and provides fresh insight into the relevance of physical strength to girls' violence. I conclude that girls are defining girlhood as they live it and it is the disjuncture with normative concepts that leads them into conflict with institutions of social control.
    • Beliefs about medicines and non-adherence in patients with stroke, diabetes mellitus and rheumatoid arthritis: A cross-sectional study in China

      Wei, Li; Champman, Sarah; Li, Xiaomei; Li, Xin; Li, Sumei; Chen, Ruoling; Bo, Nie; Chater, Angel; Horne, Robert; Department of Practice and Policy, University College London School of Pharmacy, London, UK. (BMJ, 2017-10-05)
      © 2017 author(s). Objectives To investigate beliefs about medicines and their association with medicine adherence in patients with chronic diseases in China. Design A cross-sectional questionnaire-based study Setting Two large urban hospitals in Hefei and Tianjin, China Participants Hospital inpatients (313 stroke patients) and outpatients (315 diabetic patients and 339 rheumatoid arthritis (RA) patients) were recruited between January 2014 and September 2014. Outcome measures The Beliefs about Medicines Questionnaire (BMQ), assessing patients' beliefs about the specific medicine (Specific-Necessity and Specific-Concerns) prescribed for their conditions (stroke/diabetes/RA) and more general background beliefs about pharmaceuticals as a class of treatment (BMQ-General Benefit, Harm and Overuse); the Perceived Sensitivity to Medicines scale (PSM) assessed patients' beliefs about how sensitive they were to the effects of medicines and the Medication Adherence Report Scale. The association between non-adherence and beliefs about medicines was assessed using a logistic regression model. Results Patients with diabetes mellitus had a stronger perceived need for treatment (mean (SD) Specific-Necessity score, 3.75 (0.40)) than patients with stroke (3.69 (0.53)) and RA (3.66 (0.44)) (p=0.049). Moderate correlations were observed between Specific-Concerns and General-Overuse, General-Harm and PSM (Pearson correlation coefficients, 0.39, 0.49 and 0.49, respectively, p<0.01). Three hundred and eleven patients were non-adherent to their medicine (159 (51.0%) in the stroke group, 60 (26.7%) in the diabetes mellitus group and 62 (19.8%) in the RA group, p<0.01). Across the whole sample, after adjusting for demographic characteristics, non-adherence was associated with patients who had higher concerns about their medicines (OR, 1.35, 95% CI 1.07 to 1.71) and patients who believed that they were personally sensitive to the effects of medications (OR 1.44, 95% CI 1.16 to 1.85). Conclusion The BMQ is a useful tool to identify patients at risk of non-adherence. In the future, adherence intervention studies may use the BMQ to screen for patients who are at risk of non-adherence and to map interventional support.
    • Beneficial changes in energy expenditure and lipid profile after eccentric exercise in overweight and lean women

      Paschalis, V; Nikolaidis, Michalis G.; Giakas, Giannis; Theodorou, A. A.; Sakellariou, G. K.; Fatouros, I. G.; Koutedakis, Yiannis; Jamurtas, Athanasios Z. (Wiley-Blackwell, 2010)
      The aim was to compare lean and overweight females in regard to the effects of eccentric exercise on muscle damage indices, resting energy expenditure (REE) and respiratory quotient (RQ) as well as blood lipid and lipoprotein profile. Lean and overweight females (deviated by their body mass index) performed an eccentric exercise session. Muscle damage, energy cost and lipid profile were assessed pre-exercise and up to 72 h post-exercise. After eccentric exercise (i) muscle damage indices were affected more in the overweight subjects compared with the lean subjects; (ii) the elevation of absolute and relative REE was larger and more prolonged in the overweight group compared with the lean group; (iii) after 24 h, RQ had significantly declined, with the overweight subjects exhibiting a larger reduction compared with the lean group; and (iv) the blood lipid profile was favorably modified, with the overweight group exhibiting more favorable responses compared with the lean group. The differences between the lean and the overweight subjects may be partly due to the fact that overweight individuals experienced greater muscle damage than lean individuals. Eccentric exercise may be a promising lifestyle factor to combat obesity and dyslipidemias.
    • Beneficial effect of higher dietary fiber intake on plasma HDL-C and TC/HDL-C ratio among Chinese rural-to-urban migrant workers

      Zhou, Quan; Wu, Jiang; Tang, Jie; Wang, Jia-Ji; Lu, Chu-Hong; Wang, Pei-Xi (MDPI AG, 2015-04-29)
      Research has shown that high-dose supplemental dietary fiber intake has beneficial effects on cardiovascular risk factors. To clarify such a relationship, we examined the association between daily dietary fiber intake and plasma lipids using a cross-sectional design including 1034 (M 502, F 532) rural-to-urban workers in China. We found a dose-response relationship between increased dietary fiber intakes and increase of HDL cholesterol in male workers. There was also a dose-response relationship between increased dietary fiber intake and decreased total cholesterol to HDL cholesterol (TC/HDL-C) ratio in both male and female workers, after adjusting for potential confounders (p for trend, all p < 0.05). When the average dietary fiber intake increased from less than 18 g/day to over 30 g/day, the average HDL cholesterol level increased by 10.1%, and the TC/HDL-C ratio decreased by 14.4% for males (p = 0.020) and by 11.1% for females (p = 0.048). In conclusion, higher daily dietary fiber consumption is associated with beneficial effect on cholesterol for rural-to-urban workers in China, suggesting its potential beneficial effect on decreasing the risk of cardiovascular diseases.
    • Bereaved donor families' experiences of organ and tissue donation, and perceived influences on their decision making

      Sque, Magi; Walker, Wendy; Long-Sutehall, Tracy; Morgan, Myfanwy; Randhawa, Gurch; Rodney, Amanda (2018-01-16)
      Purpose To elicit bereaved families' experiences of organ and tissue donation. A specific objective was to determine families' perceptions of how their experiences influenced donation decision-making. Methods Retrospective, qualitative interviews were undertaken with 43 participants of 31 donor families to generate rich, informative data. Participant recruitment was via 10 National Health Service Trusts, representative of five regional organ donation services in the UK. Twelve families agreed to DBD, 18 agreed to DCD, 1 unknown. Participants' responses were contextualised using a temporal framework of ‘The Past’, which represented families' prior knowledge, experience, attitudes, beliefs, and intentions toward organ donation; ‘The Present’, which incorporated the moment in time when families experienced the potential for donation; and ‘The Future’, which corresponded to expectations and outcomes arising from the donation decision. Results Temporally interwoven experiences appeared to influence families' decisions to donate the organs of their deceased relative for transplantation. Conclusions The influence of temporality on donation-decision making is worthy of consideration in the planning of future education, policy, practice, and research for improved rates of family consent to donation.