Literature review on advance care planning of nursing home residents

Aim: Conduct a search and analytic review of literature regarding attributes of Advance Care Planning (ACP) and Advance Directive in order to identify the experiences and the best care strategies for older adults resident in nursing homes or long term institutions. Methodology: An extensive electronic search was undertaken in the following databases: Pubmed (via Ovid search), Cumulative Index of Nursing and Allied Health (CINAHL, via EBHOST), psychINFO and Cochrane. After analyzing and eliminating duplicates and professional's point of view (19), 144 titles were considered relevant: 28 opinion papers, 94 descriptive/qualitative studies or predictive studies, 17 experimental and five systematic reviews. Most of them were produced in North America and only 10 were in French. Results: With regard to European experiences, studies are scarce and further research could benefit from North American evidence. Contrary to Europe, nurses in North America play a major role in the process of care planning. The major findings were related to the poor efficacy of the completion of Advance Directives, even in presence of a substantial variety of implementation strategies. The evidence supports interventions that conceptualize ACP as a process, with an emphasis on the ascertainment of patients' values and beliefs and the necessity to include the family or loved ones from the beginning of the process in order to favor the expression and sharing of one's life perspectives and priorities in care. The most relevant findings were associated with the conceptualization of the ACP as a change in health behaviors which needs an involvement in different stages to overcome a variety of barriers. Conclusion: Rigorous research in ACP for the older adults in Swiss nursing homes that promote respect and dignity in this frail population is needed. How to best achieve patients and families goals should be the focus of nursing intervention and research in this domain.

The use of 3D planning in facial surgery: Preliminary observations.

Three-dimensional (3D) planning is becoming a more commonly used tool in maxillofacial surgery. At first used only virtually, 3D planning now also enables the creation of useful intraoperative aids such as cutting guides, which decrease the operative difficulty. In our center, we have used 3D planning in various domains of facial surgery and have investigated the advantages of this technique. We have also addressed the difficulties associated with its use. 3D planning increases the accuracy of reconstructive surgery, decreases operating time, whilst maintaining excellent esthetic results. However, its use is restricted to osseous reconstruction at this stage and once planning has been undertaken, it cannot be reversed or altered intraoperatively. Despite the attractive nature of this new tool, its uses and practicalities must be further evaluated. In particular, cost-effectiveness, hospital stay, and patient perceived benefits must be assessed.

Translating from India and the Moving Space of Translation (Illustrated by the Works of Ajñeya)

The inadequacies and obsolescence of Eurocentric theories based on a binaryand static worldview have become a staple topic of postcolonial studies, and tosome extent also of translation studies. Nonetheless, the literary texts that arecalled upon in order to show the dynamism and hybridity of (post)modern worksbelong for the most part to the languages of the former colonial powers, especiallyEnglish, and remain inserted in a system that construes literatures interms of opposition. As a consequence, there is outside India a doubly misleadingunderstanding of Indian literatures other than those written in English:firstly, that translations of works in Hindi and in the Indian bhāṣā seem to belacking, if not inexistent, and secondly, that these "minor" literatures - as theyare regularly termed - are still often viewed as being highly dependent on theidea of "tradition," in opposition to the "postmodern" hybridity of the literatureswritten in the "dominant" languages, such as English or French. Againstthese views and supported by the analysis of Ajñeya's works in Hindi togetherwith their English translations, this paper aims to show: 1) that translationsfrom Hindi, which are not in fact non-existent, are mainly carried out in India,and 2) that Ajñeya's works, while representing a significant instance of the effectivehybridity present in Indian literatures, help to illustrate the moving spaceof translation. This demonstration effectively invalidates the above-mentionedoppositional standpoint.

Effect of added dead space on sleep disordered breathing at high altitude.

OBJECTIVE: Sleep disordered breathing with central apnea or hypopnea frequently occurs at high altitude and is thought to be caused by a decrease in blood CO(2) level. The aim of this study was to assess the effects of added respiratory dead space on sleep disordered breathing.¦METHODS: Full polysomnographies were performed on 12 unacclimatized swiss mountaineers (11 males, 1 female, mean age 39±12 y.o.) in Leh, Ladakh (3500m). In random order, half of the night was spent with a 500ml increase in dead space through a custom designed full face mask and the other half without it.¦RESULTS: Baseline data revealed two clearly distinct groups: one with severe sleep disordered breathing (n=5, AHI>30) and the other with moderate to no disordered breathing (n=7, AHI<30). DS markedly improved breathing in the first group (baseline vs DS): apnea hypopnea index (AHI) 70.3±25.8 vs 29.4±6.9 (p=0.013), oxygen desaturation index (ODI): 72.9±24.1/h vs 42.5±14.4 (p=0.031), whereas it had no significant effect in the second group or in the total population. Respiratory events were almost exclusively central apnea or hypopnea. Microarousal index, sleep efficiency, and sleep architecture remained unchanged with DS. A minor increase in mean PtcCO(2) (n=3) was observed with DS.¦CONCLUSION: A 500ml increase in dead space through a fitted mask may improve nocturnal breathing in mountaineers with severe altitude-induced sleep disordered breathing.

Comme une mode urbaine : projets de régénération urbaine et patrimonialisation à Porto et Marseille

Partant de deux études de cas, le projet de Frente Ribeirinha à Porto (Portugal) et celui d'Euroméditerranée à Marseille, ce projet de thèse a pour objectif l'étude des modalités de valorisation du tissu bâti (patrimonialisation) par les acteurs institutionnels dans les projets de régénération urbaine. Suivant l'hypothèse de l'entrée dans un nouveau régime de patrimonialité, l'analyse doit expliciter les stratégies à l'oeuvre ainsi que la manière dont les autorités publiques influent sur les représentations de l'espace construit. Abordant la question des échelles d'intervention des projets de régénération urbaine à partir des deux études de cas, mais également de littératures sur des projets anglo-saxons, la thèse cherche à voir, au prisme de la construction patrimoniale, comment ces projets sont directement connectés à l'économie internationale et au phénomène de globalisation et s'ils prennent en compte l'échelle du quotidien et de la domesticité. Il s'agit de montrer les limites d'une valorisation du tissu bâti dans un objectif de retombées économiques (ville consommable) au détriment des valeurs d'usage et de signifiants du quotidien. D'où l'hypothèse de l'importance d'une prise en compte des représentations de valeurs aux différentes échelles (dimensions socio-culturelles du projet de régénération) pour un équilibre qualitatif dans la fabrication du territoire et des projets sur le long terme. La volonté est sensiblement la compréhension des nouvelles constructions patrimoniales ainsi que des pratiques de conception et de mise en oeuvre du projet urbain. - Based on two case studies, the Frente Ribeirinha project in Porto (Portugal) and Euroméditerranée in Marseille, this research project aims at studying the modes of enhancement of the built fabric by institutional actors in urban regeneration projects. Posing the idea of a new heritage regime, this analysis attempts to explain the different strategies at work and how public authorities influence the built space's representations. Looking at the different scales of intervention of regeneration projects in our two case studies, as well as Anglo-Saxon literature on projects, it seeks at seeing, through heritage processes, how these projects are directly connected to the international economy and the phenomenon of globalization. Also, it aims at investigating whether policies take into account the scale of everyday life and domesticity. It attempts to show the limit of a built fabric's valuation with economic benefits objectives (consumable city) rather than taking into account values and meanings of everyday life. Hence, the thesis suggests taking into account representations and values at different scales (socio-cultural dimensions of the regeneration project) for a qualitative balance in urban planning and urban projects' manufacturing. The aim is to broaden the understanding on heritage construction, on urban design practices and on implementation of urban projects.

The immune space: a concept and template for rationalizing vaccine development.

Abstract Empirical testing of candidate vaccines has led to the successful development of a number of lifesaving vaccines. The advent of new tools to manipulate antigens and new methods and vectors for vaccine delivery has led to a veritable explosion of potential vaccine designs. As a result, selection of candidate vaccines suitable for large-scale efficacy testing has become more challenging. This is especially true for diseases such as dengue, HIV, and tuberculosis where there is no validated animal model or correlate of immune protection. Establishing guidelines for the selection of vaccine candidates for advanced testing has become a necessity. A number of factors could be considered in making these decisions, including, for example, safety in animal and human studies, immune profile, protection in animal studies, production processes with product quality and stability, availability of resources, and estimated cost of goods. The "immune space template" proposed here provides a standardized approach by which the quality, level, and durability of immune responses elicited in early human trials by a candidate vaccine can be described. The immune response profile will demonstrate if and how the candidate is unique relative to other candidates, especially those that have preceded it into efficacy testing and, thus, what new information concerning potential immune correlates could be learned from an efficacy trial. A thorough characterization of immune responses should also provide insight into a developer's rationale for the vaccine's proposed mechanism of action. HIV vaccine researchers plan to include this general approach in up-selecting candidates for the next large efficacy trial. This "immune space" approach may also be applicable to other vaccine development endeavors where correlates of vaccine-induced immune protection remain unknown.

Three-dimensional radiobiological dosimetry of kidneys for treatment planning in peptide receptor radionuclide therapy.

PURPOSE: Peptide receptor radionuclide therapy (PRRT) delivers high absorbed doses to kidneys and may lead to permanent nephropathy. Reliable dosimetry of kidneys is thus critical for safe and effective PRRT. The aim of this work was to assess the feasibility of planning PRRT based on 3D radiobiological dosimetry (3D-RD) in order to optimize both the amount of activity to administer and the fractionation scheme, while limiting the absorbed dose and the biological effective dose (BED) to the renal cortex. METHODS: Planar and SPECT data were available for a patient examined with (111)In-DTPA-octreotide at 0.5 (planar only), 4, 24, and 48 h post-injection. Absorbed dose and BED distributions were calculated for common therapeutic radionuclides, i.e., (111)In, (90)Y and (177)Lu, using the 3D-RD methodology. Dose-volume histograms were computed and mean absorbed doses to kidneys, renal cortices, and medullae were compared with results obtained using the MIRD schema (S-values) with the multiregion kidney dosimetry model. Two different treatment planning approaches based on (1) the fixed absorbed dose to the cortex and (2) the fixed BED to the cortex were then considered to optimize the activity to administer by varying the number of fractions. RESULTS: Mean absorbed doses calculated with 3D-RD were in good agreement with those obtained with S-value-based SPECT dosimetry for (90)Y and (177)Lu. Nevertheless, for (111)In, differences of 14% and 22% were found for the whole kidneys and the cortex, respectively. Moreover, the authors found that planar-based dosimetry systematically underestimates the absorbed dose in comparison with SPECT-based methods, up to 32%. Regarding the 3D-RD-based treatment planning using a fixed BED constraint to the renal cortex, the optimal number of fractions was found to be 3 or 4, depending on the radionuclide administered and the value of the fixed BED. Cumulative activities obtained using the proposed simulated treatment planning are compatible with real activities administered to patients in PRRT. CONCLUSIONS: The 3D-RD treatment planning approach based on the fixed BED was found to be the method of choice for clinical implementation in PRRT by providing realistic activity to administer and number of cycles. While dividing the activity in several cycles is important to reduce renal toxicity, the clinical outcome of fractionated PRRT should be investigated in the future.

Partition coefficient and molecular flexibility: the concept of lipophilicity space.

The rationale of this study was to investigate molecular flexibility and its influence on physicochemical properties with a view to uncovering additional information on the fuzzy concept of dynamic molecular structure. Indeed, it is now known that computed molecular interaction fields (MIFs) such as molecular electrostatic potentials (MEPs) and lipophilicity potentials (MLPs) are conformation-dependent, as are dipole moments. A database of 125 compounds was used whose conformational space was explored, while conformation-dependent parameters were computed for each non-redundant conformer found in the conformational space of the compounds. These parameters were the virtual log P (log P(MLP), calculated by a MLP approach), the apolar surface area (ASA), polar surface area (PSA), and solvent-accessible surface (SAS). For each compound, the range taken by each parameter (its property space) was divided by the number of rotors taken as an index of flexibility, yielding a parameter termed 'molecular sensitivity'. This parameter was poorly correlated with others (i.e., it contains novel information) and showed the compounds to fall into two broad classes. 'Sensitive' molecules are those whose computed property ranges are markedly sensitive to conformational effects, whereas 'insensitive' (in fact, less sensitive) molecules have property ranges which are comparatively less affected by conformational fluctuations. A pharmacokinetic application is presented.