Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study

BACKGROUND: Stent thrombosis is a safety concern associated with use of drug-eluting stents. Little is known about occurrence of stent thrombosis more than 1 year after implantation of such stents. METHODS: Between April, 2002, and Dec, 2005, 8146 patients underwent percutaneous coronary intervention with sirolimus-eluting stents (SES; n=3823) or paclitaxel-eluting stents (PES; n=4323) at two academic hospitals. We assessed data from this group to ascertain the incidence, time course, and correlates of stent thrombosis, and the differences between early (0-30 days) and late (>30 days) stent thrombosis and between SES and PES. FINDINGS: Angiographically documented stent thrombosis occurred in 152 patients (incidence density 1.3 per 100 person-years; cumulative incidence at 3 years 2.9%). Early stent thrombosis was noted in 91 (60%) patients, and late stent thrombosis in 61 (40%) patients. Late stent thrombosis occurred steadily at a constant rate of 0.6% per year up to 3 years after stent implantation. Incidence of early stent thrombosis was similar for SES (1.1%) and PES (1.3%), but late stent thrombosis was more frequent with PES (1.8%) than with SES (1.4%; p=0.031). At the time of stent thrombosis, dual antiplatelet therapy was being taken by 87% (early) and 23% (late) of patients (p<0.0001). Independent predictors of overall stent thrombosis were acute coronary syndrome at presentation (hazard ratio 2.28, 95% CI 1.29-4.03) and diabetes (2.03, 1.07-3.83). INTERPRETATION: Late stent thrombosis was encountered steadily with no evidence of diminution up to 3 years of follow-up. Early and late stent thrombosis were observed with SES and with PES. Acute coronary syndrome at presentation and diabetes were independent predictors of stent thrombosis.

Feasibility and acceptance of electronic quality of life assessment in general practice: an implementation study

Background Patients' health related quality of life (HRQoL) has rarely been systematically monitored in general practice. Electronic tools and practice training might facilitate the routine application of HRQoL questionnaires. Thorough piloting of innovative procedures is strongly recommended before the conduction of large-scale studies. Therefore, we aimed to assess i) the feasibility and acceptance of HRQoL assessment using tablet computers in general practice, ii) the perceived practical utility of HRQoL results and iii) to identify possible barriers hindering wider application of this approach. Methods Two HRQoL questionnaires (St. George's Respiratory Questionnaire SGRQ and EORTC QLQ-C30) were electronically presented on portable tablet computers. Wireless network (WLAN) integration into practice computer systems of 14 German general practices with varying infrastructure allowed automatic data exchange and the generation of a printout or a PDF file. General practitioners (GPs) and practice assistants were trained in a 1-hour course, after which they could invite patients with chronic diseases to fill in the electronic questionnaire during their waiting time. We surveyed patients, practice assistants and GPs regarding their acceptance of this tool in semi-structured telephone interviews. The number of assessments, HRQoL results and interview responses were analysed using quantitative and qualitative methods. Results Over the course of 1 year, 523 patients filled in the electronic questionnaires (1–5 times; 664 total assessments). On average, results showed specific HRQoL impairments, e.g. with respect to fatigue, pain and sleep disturbances. The number of electronic assessments varied substantially between practices. A total of 280 patients, 27 practice assistants and 17 GPs participated in the telephone interviews. Almost all GPs (16/17 = 94%; 95% CI = 73–99%), most practice assistants (19/27 = 70%; 95% CI = 50–86%) and the majority of patients (240/280 = 86%; 95% CI = 82–91%) indicated that they would welcome the use of electronic HRQoL questionnaires in the future. GPs mentioned availability of local health services (e.g. supportive, physiotherapy) (mean: 9.4 ± 1.0 SD; scale: 1 – 10), sufficient extra time (8.9 ± 1.5) and easy interpretation of HRQoL results (8.6 ± 1.6) as the most important prerequisites for their use. They believed HRQoL assessment facilitated both communication and follow up of patients' conditions. Practice assistants emphasised that this process demonstrated an extra commitment to patient centred care; patients viewed it as a tool, which contributed to the physicians' understanding of their personal condition and circumstances. Conclusion This pilot study indicates that electronic HRQoL assessment is technically feasible in general practices. It can provide clinically significant information, which can either be used in the consultation for routine care, or for research purposes. While GPs, practice assistants and patients were generally positive about the electronic procedure, several barriers (e.g. practices' lack of time and routine in HRQoL assessment) need to be overcome to enable broader application of electronic questionnaires in every day medical practice.

The role of specialisation in the promotion of young football talents: A person-oriented study

This paper investigates the controversial question whether it is more effective to promote specialisation in a specific sport at the beginning of a career or whether to encourage a broad range of sports when promoting competitive sports talents in order for them to achieve a high level of performance in adulthood. The issue of promoting talents depends on human developmental processes and therefore raises developmental scientific questions. Based on recent, dynamic-interactionist concepts of development, we assume a person-oriented approach focussing on the person as a whole rather than individual features. Theoretical considerations lead to four interacting factors being summarised to form a subsystem: childhood training. The relative weights of these factors lead to patterns. By relating these to a performance criterion at the age of peak performance, particularly promising developmental patterns may be identified. One hundred fifty-nine former Swiss football talents were retrospectively interviewed about their career and the data analysed using the LICUR method. Two early career patterns were identified as having a favourable influence on adult performance. Both are characterised by an above-average amount of in-club training. One pattern also exhibits an above-average amount of informal football played outside the club, the other above-average scores for activity in other sports. Hence, comprehensive training and practice inside and outside the club form the basis for subsequent football expertise.

Perceived risk and outcome expectancy on the practice of home infusion technique in a hemophilia population

This study described home infusion techniques and practices, measured the perceived risk of HIV and hepatitis transmission to self and others, and measured the outcome expectancy of following risk reduction guidelines for 90 hemophilia patients and/or their infusion assistants. It also assessed general knowledge of HIV and hepatitis information for the same population.^ The study subjects were hemophilia patients or their infusion assistants from the Gulf States Hemophilia Center in Houston, the El Paso Satellite Hemophilia Clinic in El Paso, or Texas members of the Women Outreach Network of the National Hemophilia Foundation (WONN) group. Each subject was interviewed either by telephone or in person. The questionnaire used was developed for the study and consisted of 60 items. These items assessed general demographics for the patients and assistants, including questions about their training to do infusions as well as the actual practices, measured perceived personal risk for the transmission of HIV or hepatitis to the assistants, perceived risk of transmission of HIV or hepatitis to others for assistants and self-infusers, and the outcome expectancy for following recommended risk reduction guidelines also for both groups.^ The theoretical framework used assumed that perceived risk and outcome expectancy would be predictive of behavior. The findings did not support this theory. Instead, the findings suggest that infusion behavior is habitual in nature; most respondents perform exactly the same behavior for every infusion. Since none of the variables selected were predictive of the compliance behavior for home infusion the teaching method should be directed towards mastery learning, or learning that will incorporate the correct behavior into a habitual pattern of home infusion. ^

Merging person-specific bio-markers for predicting oral cancer recurrence through an ontology

One of the major problems related to cancer treatment is its recurrence. Without knowing in advance how likely the cancer will relapse, clinical practice usually recommends adjuvant treatments that have strong side effects. A way to optimize treatments is to predict the recurrence probability by analyzing a set of bio-markers. The NeoMark European project has identified a set of preliminary bio-markers for the case of oral cancer by collecting a large series of data from genomic, imaging, and clinical evidence. This heterogeneous set of data needs a proper representation in order to be stored, computed, and communicated efficiently. Ontologies are often considered the proper mean to integrate biomedical data, for their high level of formality and for the need of interoperable, universally accepted models. This paper presents the NeoMark system and how an ontology has been designed to integrate all its heterogeneous data. The system has been validated in a pilot in which data will populate the ontology and will be made public for further research.

Jerónimo Sánchez Carranza y la Escuela Española de Esgrima

El deporte de la esgrima no siempre ha sido considerado como actualmente se conoce, ni tampoco el empleo de las armas ha sido el mismo en las diferentes épocas de la historia. Si nos centramos en la española, podemos decir que se hablaba de una forma particular de hacer esgrima, la cual era muy apreciada por el resto de los países europeos. También lo era la que se hacía en Italia. Como cualquier actividad que se desarrolla a lo largo del tiempo debe generarse desde unos comienzos. Estos comienzos siempre están en relación a alguna causa. Para centrarnos en nuestro estudio, los comienzos del manejo de la espada, de una manera lógica y razonada, se une en la persona y en la vida de Jerónimo Sánchez Carranza porque hasta que él no se decide a estudiar en profundidad la ciencia de las armas, no se ve con claridad si todo lo que se hacía con ellas era correcto o no y si todo lo que la inmensa mayoría hacía cuando tenía que utilizarlas estaba revestido de cierta coherencia y fundamento, es decir, tenía su verdad que se pudiera demostrar. Carranza estudia la esgrima que se empleaba en su época y en las anteriores y se da cuenta que tiene que dar una nueva visión de la forma de usar las armas, diferente a lo que la gran mayoría entendía hasta entonces. A Carranza se le ha considerado por muchos autores como el inventor de la esgrima española, hecho que se puede leer con bastante facilidad si se hojea algún tratado que hable de la esgrima española, sin embargo también se habla de Luis Pacheco de Narváez asignándole el mismo calificativo, aunn- ;o es posteriora Carranza. or tanto nuestro estudio se ha centrado en la vida de Jerónimo Sánchez Carranza y en ueva forma de emplear las armas por lo que hace que la tesis sea una tesis biográfica de dicho personaje, donde se ha resaltado mucho más el aspecto del manejo de las armas, de la Destreza. Partimos de las siguientes hipótesis: Carranza es el que sienta los principios técnicos dando forma y coherencia a la escuela de esgrima española gracias a sus aportaciones en los distintos aspectos metodológicos, técnicos y tácticos. La escuela de esgrima española tiene una estructura interna, responde a unas características determinadas y sirve de base a la esgrima que posteriormente se practica. Para que el estudio se pudiera llevar a cabo tuvimos que diseñar un esquema donde se pudieran recoger todos los aspectos que estuvieran relacionados con nuestro autor, de ahí surge el porqué de cada uno de los capítulos que hemos confeccionado. Dicho esquema responde a la visión actual de diferentes facetas de lo que hoy se estudia en diversas ciencias y que cuando Carranza vivía aún no se conocían. Para recoger información sobre su persona y su obra tuvimos en cuenta los distintos lugares donde se podía localizar la documentación necesaria, sobre todo Bibliotecas y Archivos, para ir confeccionando el método de trabajo que consistió en la recopilación de fuentes de todo tipo referidas al tema, pasando luego a la interpretación de las mismas. Esto nos dio una visión de conjunto que hizo que nos adentráramos en aquellos aspectos que más tarde tendríamos que analizar con mucho más detenimiento. En la tesis se puede observar dos partes bien diferenciadas que son las relacionadas; por un lado, a su vida y su tratado y, por otro, al contenido de sus teorías que son realmente las que se deben analizar necesariamente bajo unos conocimientos específicos de la actividad de la esgrima. En cuanto a su vida, se han destacado y estudiado los hechos más importantes de los que hay que resaltar, sobre todo, el que fuera considerado como el inventor de la destreza y de la manera tan particular de concebir dicho arte, diferente a lo que hasta ahora se venía haciendo y que dio paso a lo que se entendió por esgrima científica, quedando plasmada de tal manera que dio pie a la creación de una doctrina y una nueva forma de entender la esgrima la cual generó una línea de actuación que fue continuada por numerosos seguidores. Para todo ello tuvo mucho que ver el que Carranza fuera militar, la cultura y los estudios que poseía, así como la situación en la que se encontraba España además de la gente con quien se relacionaba, que por lo general, era gente culta y de clase social alta. Se ha estudiado también dentro del mismo apartado de su vida unos hechos que se le imputan y que en nuestra opinión son erróneos. Hemos considerado como más relevantes el que Carranza no fue quien riñó con Quevedo como se afirma en algunas de las obras que hemos tratado, sino que fue Pacheco quien tuvo dicha riña, ya que más bien Quevedo se mostraba partidario de las enseñanzas de Carranza, estando en contra de Pacheco. Tampoco fue quien inventó el florete como se dice en algunas ocasiones, ya que el florete aparece posteriormente como un arma de estudio de la técnica de la esgrima. Con respecto al apartado de su obra, se debe decir que tan solo escribió un único tratado que se publicó en 1582, aunque estaba acabado desde el año 1569. En el apartado de su escuela se debe destacar los fundamentos en los que basó sus postulados para que la destreza alcanzara el mismo nivel de las demás artes liberales y que lo hizo a través del estudio de la propia destreza. A lo largo del estudio que hemos realizado se puede apreciar cómo se está generando un arte que hasta ahora no había sido estudiado, viéndose los problemas que ello suponía, desde la organización de la materia a tratar, hasta cómo se debía enseñar, pasando a veces a tener que denominar conceptos de nueva aparición o renombrar y modificar antiguos que estaban anclados en puntos de partida equivocados, siendo éstos los que mayor trabajo le supuso. Diferencia bien dos aspectos básicos que debían existir en cualquier arte y más concretamente en la destreza que son: la teoría y la práctica, ambas deben estar en base a la razón ya que sería una de las formas por la que la destreza perduraría en el tiempo, junto con que esta razón estuviera apoyada en otras ciencias y con los principios de ellas. Carranza fue de la opinión de que el diestro debía conocer mediante el estudio, los elementos fundamentales con los que había que trabajar la destreza, estos elementos son el cuerpo del diestro y las armas, porque ambos van a intervenir en cualquier gesto o acción que se vaya a realizar. Del cuerpo estudió cada una de las partes que más importancia tiene cada vez que el diestro interviene y lo hace sobre todo en base a la medicina, relacionándolo con las matemáticas para poder sacar el máximo provecho, aconsejando que por el conocimiento del propio cuerpo, como el del contrario, se podrá emplear en determinadas situaciones, que si no se supiera de ello, no se sacaría el mismo resultado. De las armas lo que más resaltó fue, por un lado, que la espada debía ser el único arma que el diestro debía utilizar y, por otro, el hecho de que la espada la graduara para poder demostrar que no se hacia todo igual con las distintas partes de la misma porque no todo el arma tenía las mismas propiedades cuando se actuaba con ella. Una de las recomendaciones que dio fue que con la parte más próxima a la empuñadura se debía practicar la defensa por tener más fuerza con esta parte que con la punta y lo demostró con principios matemáticos. Se puede ver con la lectura de la tesis cómo Carranza aporta una nueva forma de trabajo en la que le da mucha importancia a la aplicación de los conocimientos, que previamente se han adquirido y para ello, es importante conocer bien los puntos fuertes y débiles del adversario. La adquisición de la práctica se debe realizar a través de la repetición para crear el hábito necesario que haga que el gesto salga fluido en cada uno de los movimientos que el diestro ejecute. Todo esto no sería posible si quien lo enseña no conoce cada uno de los elementos que intervienen en la destreza, por tanto, a la figura del maestro le da un lugar de una gran relevancia, ya que va a ser él quien tenga que guiar a los alumnos que enseñe. Lo primero que debe hacer los maestros es procurar saber lo máximo de la materia que va a enseñar, por lo que el maestro debe saber casi todo sobre la teoría y la práctica de la destreza, pero además esta teoría y práctica debe ser la correcta. Carranza persigue con su estudio, establecer los principios de la destreza, por lo menos, los más importantes, aunque fueran elementales, para que posteriormente se siguiera trabajando sobre ellos y poder conseguir que la destreza tenga cuerpo y forma de arte liberal, pudiéndose estudiar como cualquier otra, así de esta manera se haría un bien público, ya que los jóvenes se instruirían eficazmente en el uso de las armas, aunque el verdadero fin se encuentra en la conservación de la vida como manda la Fe Católica, siendo la destreza uno de los medios más eficaces para conseguirlo. Hemos dedicado un apartado de técnica y de táctica donde se refleja todo lo relacionado con las posiciones y movimientos que debe realizar el diestro para llegar a conseguir su objetivo, que es herir sin ser herido. Se han analizado las distintas tretas y el porqué de cada una desde el punto de vista del gesto y del movimiento. Si lo que se hace en destreza se relaciona con el adversario, nos adentramos en el terreno de la táctica donde se han estudiado como más importantes los conceptos del tiempo y la distancia, así como las energías que debe conservar el diestro para poder llevar a cabo un combate y del mismo salir victorioso sin llegar al agotamiento. Concluimos diciendo que de todo el estudio que se ha realizado, se ha podido comprobar que Carranza fue quien dotó a la destreza de unos principios técnicos, tácticos y metodológicos, por su forma de concebir este nuevo arte, así como que por la manera en que estableció sus teorías hizo que la destreza que se practicaba en España disfrutara de una estructura interna coherente que perduró a través de los años. SUMMARY The sport of fencing has not always been the respected sport that we know it to be today ñor has the use of weapons been the same throughout history. If we concéntrate on Spainish weapons, we can say that one particular type of sword ¡s spoken about. this sword being very respected by outher European countries, it was also the one that was respected and used in Italy. As with any activity that develops in time, it must evlove from some simple beginnings. Such basics beginnings are always in relation to a cause. To concéntrate on our study, the beginnings are, the use of the sword in a reasoned and logical manner, brought together in the life and times of Jerónimo Sánchez Carranza because until he decided to study in depth the science of weapons, we cannot see with calrity if their use was correct or not and if the vast majority , when they had to use them, used any foundation or coherence, that ¡s to say if any exactness of logical use could be demonstrated. Carranza studied the sword used in his time and those that had gone before, bearing in mind that he had a new visión of the form of use of weapons, different to what the vast majority had until then understood. Carranza has been considered by many historians as the inventor of the Spanish sword, a fact which can be seen with relative ease if one flicks through any work which deals with the Spanish sword, however, they also speak of Luis Pacheco de Narváez affording him the same title, even though he followed Carranza. In ar H our study has been centred on the life of Jerónimo Sánchez Carranza and his ne-" use of weapons. In effect this thesis is a biographical thesis of the said wherein the aspect of the use of weapons stands out more than their mastery. Given the following hypothesis: It was Carranza who evolved the first techniques giving form and coherence to the .Spanish School of Fencing, thanks to his contributions to the different aspects of method, íechnique and tactic. The Spanish School of Fencing had an ¡nternal structure anaswerable to pre-detremined characteristics and served as a base for the fencing that was to, in later days, be practised. For this study to come to a head, we had to design a plan wherein we could collate all of the aspects we could, related to our inventor. From there springs the reason for each of the chapters that we have put together. The said plan responding to the actual visión of different facets that are studied today in different sciences, that were not known in Carranza's lifetime. To collect information on his person and his works we bore in mind the different places in which we could lócate the necessary documentation, above all in libraries and archives. Developing the work-method that consisted in extracing from every source, every thing relative to the theme, re-writing later our interpretation of the same. This brought us closer and made us focus of those aspects that much later we would have to analize in greater detail. In the thesis one can observe two defferent parts that are related; on the one hand his life and works and on the other his theories, which are those that should be really analised and as such, necessarily analised within the confines of a specific knowledge of fencing. In that his life has been isolated and studied the most important facts that stand out above all, is that he was considered to be the inventor of swordmanship and the particular manner of interpreting the said art, different to its interpretaion uptil then. It gave a footing to what they understood as scientific fencing, giving shape and form to the creation of a doctrine and a new form of fencing which developed a line of action that was continued by numerious followers. For all that, much had to do with the facts that Carranza was a military man, the culture, the level of studies he had and the situation in which he found himself. What's more the people with whom he mixed were, in general, cultured and of high social standing. We have also seen in the same article on his life some dubious facts which in our opinión are erróneos. We have considered the most relevent to be that it wasnt Carranza who was in dispute with Quevedo as is stated in some of the works with which we have dealt but rather it was with Pacheco he had such disputes. What's more Quevedo demonstrated his partiality to the teachings of Carranza, going against Pacheco ñor was it him who invented The Florete, a famous Spanish sword, as was said on some ocassions, eventhough the florete appeared later as a weapon in the study of fencing technique. With respect to the article on his works, we must say that there was only one article which was published in 1582, even though it was finished in 1569. In the article on his life one must distinguish between the foundations on which he based his teachings in which swordmanship reached the same levéis as other libral art forms and what he did through the study of the self same mastery. Throughout the study which we have done, one can appreciate how he was developing an art which uptill then had not been studied, seeing for himself the problems he had fortold, from the organisation of materials at hand to how it should be taught, at times having to domínate comparative concepts again or clarify and modify ones which were anchored in erróneos points of a fencing match, feeling these to be the main forseeable jobs-at-hand. Differenciating between two basic concepts which must exist in whatever arte form and more concretly in the skill that is; the theory and practice , both being fundamental to the reason why the skill endured through time, together with this reason he was supported by other sciences and the beginnings of such. Carranza was of the opinión that the swordsman must acquired by way of study, the fundemental elements with which he had to work, these elements being the body of the swordsman and the weapons, because both were going to intervene in whatever movement or action that was going to be taken. The body studied, each of the parts having more importance each time the skill intervened and above all what it did based on medicne relating it to matemathics to exact the máximum advantage, one could employ in certain circumstances, that if they were not employed, the same advantages would not result. On weapons, what resulted best was, on the one hand, the sword should be the only weapon that the swordsman should use and on the other hand, the sword should be graded to show that one cannot do the same with the different parts of the same because not all of the weapon had the same properties when used. One of the recomendations he made was that the part nearest to the hand-guard should be used for defence because one could use more forcé with it than the point and he demonstrated this with mathematical principies. One can see on reading this thesis how Carranza brought forth a new work form, in which he put much importance on the application of experience that had previously been acquired and because of it, it was important to know well the strenghts and weaknesses of an adversery. The acquisition of technique should be realised through repetition to form the habit necessary for movement to flow freely each time the swordsman executed a movement. None of this would be possible if whoever was teaching did not know each one of the elements that intervened, affording the fencing master a great reverence, in that it was he who had to guide the students he was to teach. The first thing that the master had to do was to make sure he had the maximun knowledge over which he was going to teach, to that end, the master had to know almost everything about the theory and practice of the skill of fencing but what's more that such theory and practice had to be the correct one. Carranza persued his studies, establishing the principies of technique, at least, the most important ones even though they were elementary, so that later they could continué working on them and it could be seen that the technique had a shape and form of any other art form, allowing it to be studied like any other form, as such it had a good following, even young people could be instructed in the correct use of weapons, however the real end could be found in the conservaron of life as ordered by the Catholic Church, feeling that skill with the sword was one of the most effective methods for assuring it. We have dedicated an article to technique and tactics wherein is reflected everything related to positions and movement that the swordsman must do to achieve his objective, that is, wound without being wounded. We have analised the different tricks and the reasons from every point of view of movement and action. If what is done by technique is related with the adversery we enter in the territory of tactics wherein we have studied, most importantly, the concepts of time and distance just as, the energy the swordsman muse conserve to bring to a head a bout and arrive victorious without being exhausted. We conclude by saying that everything that has been realised by this study, has shown that it was Carranza who gave to the skill, the first basic techniques, tactics and methodology, by his conception of this new art form, just as the manner in which he established his theories, made possible the tecnhiques practiced in Spain would enjoy an intemal coherent structure, which would endure throughout the years.

Paisaje de energías: conocimiento estético en el enfoque ambiental del proyecto

Desde hace ya varias décadas la praxis de la ecología ha venido reconociendo la necesidad de estudiar los múltiples sistemas de interacción del ser humano, como especie viva, y su entorno. Entidades espaciales como el paisaje geográfico son empleadas para delimitar sistemas territoriales operados por la sociedad, precisando campos concretos de su acción física, biológica y cultural. La ecología aborda así el conocimiento científico del territorio como asentamiento humano, rastrea sus patrones espaciales y analiza su compleja estructura funcional. En ese contexto, la transferencia de herramientas e instrumentos desde la ecología al ámbito proyectivo posee ya un bagaje de más de cinco décadas. Cada vez con más frecuencia el proyecto emplea parámetros, inventarios, fórmulas, indicadores y tecnologías que tratan de dar una respuesta ambientalmente adecuada a los condicionantes de contorno, por ejemplo aprovechando las condiciones climáticas en la optimización energética o proponiendo programas de usos del suelo que eviten perturbaciones en ecosistemas de interés. Con todo, en el momento presente surgen voces que, ante el dominio indiscutible de los enfoques netamente deterministas, tratan de recordar que los principios del pensamiento ecológico van más allá del mero control cuantitativo de los procesos biofísicos. Recuerdan que la etología demostró a principios del XX que el ser humano, como ser consciente, inviste una relación de intimidad con su entorno que supera tales perspectivas: a través de la correspondencia entre percepción y significación, entre lo físico y lo psíquico, entre interioridad y exterioridad, las personas abrazan la plenitud de aquello que les rodea en un acto de profunda conciliación afectiva. De tal ligadura de intimidad depende, sí o sí, y en toda su profundidad, la aceptación humana del entorno construido. A través de la noción de ambiente [Umwelt] se demuestra que la relación del hombre con su entorno es inseparable, bidireccional y coordinada y, por lo tanto, desde una posición coherente, la experiencia del espacio puede ser examinada a partir de la reciprocidad que constituyen, en continuidad, la persona y el lugar. De esta forma, la tesis dirige su objetivo principal a explorar y considerar, desde el proyecto, el significado y la influencia de la experiencia ambiental del espacio construido en la vida humana. Es más que probable que buena parte de los problemas de desafección del hombre con los paisajes transformados de su contemporaneidad tenga que ver con que tanto las intensidades de la experiencia y percepción humana, como la potestad interpretativa de sus productos culturales, incluyendo la arquitectura, han sido fuertemente reducidas. Ante este problema, la investigación toma como hipótesis la oportunidad que ofrece el pensamiento ecológico de reformular la experiencia estética como un acto de conocimiento, como un evento donde se da el encuentro físico y se construyen significados, donde se sancionan valores sociales y se mira hacia el futuro. Se ha de señalar que la presente tesis doctoral arranca en el Laboratorio de Paisaje del Grupo de Investigación Paisaje Cultural de la Universidad Politécnica de Madrid dirigido por Concha Lapayese y Darío Gazapo, y por tanto hace suyos para el estado del arte los principales conceptos e ideas bajo los que el trabajo teórico y práctico del grupo se viene orientando desde hace años: la consideración del paisaje como acontecimiento; la oscilación de la interpretación entre un paisaje específico y un paisaje genérico en un mundo globalizado; el reconocimiento de la experiencia estética del paisaje como una toma de conciencia social; y en definitiva, la reivindicación de la interioridad en el proyecto contemporáneo. La investigación profundiza en una línea de oportunidad que se abre al promover lo que se ha llamado un conocimiento por lo sentido como estrategia ambiental que permite contrarrestar mitos profundamente arraigados en las estructuras sociales. El primer paso en ese recorrido sería explorar ecológicamente el aporte de la experiencia estética; esto es, su consideración como forma de conocimiento específico. Resultaría pertinente impulsar la idea de la inmersión en el paisaje como fenómeno experiencial, sensual y corporal, y enfrentar, desde ahí, el problema de la aceptación social de lo nuevo y lo trasformado de acuerdo con el momento actual. La exploración sobre la afectividad en el ambiente no es, en cualquier caso, un asunto nuevo. Sin pretensiones de historiografía, dos momentos del siglo XX concentran el interés de la investigación. La primera se corresponde fundamentalmente con la segunda década del siglo, en relación a una serie de influencias que desde los avances científicos determinaron singulares aventuras del arte más experimental. La segunda se posiciona en el entorno de 1970, época en la que es conocido el interés que despertaron las cuestiones ambientales. En ambos casos se han estudiado aportaciones que desvelan conceptos determinantes en la definición de la experiencia estética como un evento de adquisición de conocimiento por lo sentido. Es conveniente adelantar el rol de centralidad que para la investigación tiene el concepto de energía, tal como el propio título subraya. La energía como realidad material y sensible es el sustrato que permite navegar por el principio de unidad epistemológica que subyace al pensamiento ecológico. Sus continuas referencias simbólicas, físicas y metafóricas entre los artistas estudiados no son un mero recurso iconográfico: mantienen inherente el principio de continuidad ambiental en el cual el ser humano y la inmensidad del cosmos navegan indisociables. Un discurso unificado y consistente sobre los aportes de la experiencia estética enfocada como forma de conocimiento por lo sentido hila la lectura histórica, conceptual y práctica de toda la investigación. Con ello se alcanza a hilvanar un diagrama conceptual, modelo de análisis proyectivo, que recoge ideas científicas, filosóficas y proyectivas. De alguna manera, el diagrama trata de dibujar, desde los principios del pensamiento ecológico, la correlación de continuidad que, vacilante, tensa, sutil y frágil se desplaza incesante e irresuelta entre interioridad y exterioridad. ABSTRACT Over the last few decades ecological practice has come to acknowledge a need for studying the multiple systems of interaction between the human being - inasmuch as it is a living species - and its environment. Spatial entities such as the geographic notion of landscape have been used to delimitate the territorial systems operated by society and to describe in detail specific fields of its physical, biological and cultural action. Ecology has thus managed to address the scientific knowledge of the territory as a human settlement, tracking its spatial patterns and analysing its complex functional structure. In this context, the transfer of tools and instruments from the field of ecology to that of design has a tradition already going back more than fifty years. Increasingly more often, design makes use of parameters, inventories, formulas, indicators and technologies to give an environmentally sound response to contour conditions: for instance, taking advantage of the local climate for the optimisation of energy consumption or proposing land uses that avoid disturbing valuable ecosystems. Yet in the present day some voices have arisen that, against the uncontested domination of purely positivistic approaches, are trying to draw attention to the fact that the principles of ecological thought go beyond mere quantitative control of biophysical processes. They point out that, in the early 20th century, ethology proved that the human being, as a conscious entity, invests itself into a relationship of intimacy with its environment that surpasses such perspectives: through the correspondences between perception and signification, between physical and psychological or between inside and outside, people embrace the entirety of their surroundings in an action of deep affective conciliation. It is on this link of intimacy that - fully and unquestionably - human acceptance of the built environment depends. Through the notion of environment [Umwelt] it can be proven that the relationship between the human being and its environment is inseparable, bidirectional and coordinated; and that, therefore, from a coherent position the experience of space can be examined through the reciprocity constituted continuously by person and place. Thus, the main goal in this thesis is to explore and acknowledge, from the standpoint of design, the meaning and influence of the environmental experience in human life. It is extremely likely that many of the issues with mankind’s alienation from the transformed landscapes of the present day arise from the fact that both the intensity of human perception and experience and the interpretive capacity of its cultural products –including architecture - have been greatly reduced. Facing this issue, research has taken as hypothesis the opportunity offered by ecological thought of reformulating aesthetic experience as an act of knowledge – as an event where physical encounter takes place and meanings are constructed; where social values are sanctioned and the path towards the future is drawn. This notwithstanding, the present thesis began in the Landscape Laboratory of the Technical University of Madrid Cultural Landscape Research Group (GIPC-UPM), led by Concha Lapayese and Darío Gazapo; and has therefore appropriated for its state of the art the main concepts and ideas that have been orienting the practical and theoretical work of the latter: the understanding of landscape as an event, the oscillation of interpretation between a specific and a generic landscape within a globalised world; the acknowledgement of the aesthetic experience of landscape as a way of acquiring social awareness; and, all in all, a vindication of interiority in contemporary design. An exploration has been made of the line of opportunity that is opened when promoting what has been termed knowledge through the senses as an environmental strategy allowing to counter myths deeply rooted in social structures. The first step in this path would be an ecological exploration of the contribution of the aesthetic experience; that is, its consideration as a type of specific knowledge. It would be pertinent to further the idea of immersion into the landscape as an experiential, sensual and corporeal phenomenon and, from that point, to face the issue of social acceptance of what is new and transformed according to the values of the present day. The exploration of affectivity in the environment is not, at any rate, a new topic. Without aspiring to make a history of it, we can mark two points in the 20th century that have concentrated the interest of this research. The first coincides with the second decade of the century and relates to a number of influences that, arising from scientific progress, determined the singular adventures of the more experimental tendencies in art. The second is centred around 1970: a period in which the interest drawn by environmental matters is well known. In both cases, contributions have been studied that reveal crucial concepts in defining the aesthetic experience as an event for the acquisition of knowledge through the senses. It is necessary to highlight the role of centrality that the concept of energy has throughout this research, as is evident even in its title. Energy as a material, sensitive reality is the substrate making it possible to navigate through the principle of epistemological unity underlying ecological thought. The continuous symbolic, physical and metaphorical references to it among the artists studied here are not a mere iconographic source: they remind of the inherency of the principle of environmental continuity within which the human being and the immensity of cosmos travel indissociably. A unified, consistent discourse on the contributions of the aesthetic experience addressed as knowledge through the senses weaves together the historic, conceptual and practical reading of the whole research. With it, a conceptual diagram is constructed – a model of design analysis – gathering together scientific, philosophical and design ideas. Somehow, the diagram tries to draw from the principles of ecological thought the correlation of continuity that, vacillating, tense, subtle and fragile, shifts incessantly and unresolved between interiority and exteriority.

Predicting Children’s Early School Outcomes from their Social-Regulatory Profiles: A Person-Centered Approach

Thesis (Ph.D.)--University of Washington, 2016-06

Family centred care: a review of qualitative studies

Aim. To review systematically qualitative studies, which were found during a literature search for a Cochrane systematic review of the use of family centred care in children's hospitals. Background. Family centred care has become a cornerstone of paediatric practice, however, its effectiveness is not known. No single definition exists, rather a list of elements that constitute family centred care. However, it is recognized to involve the parents in care planning for a child in health services. A new definition is presented here. Methods. The papers were found in wide range of databases, by hand searching and by contacting the authors where necessary, using terms given in detail in the protocol in the Cochrane Library, in 2004. Qualitative studies could not be used for statistical analysis, but are still important to the review and so are described separately in this paper. Results. Negotiation between staff and families, perceptions held by both parents and staff roles influenced the delivery of family centred care. A sub-theme of cost of family centred care to families and staffs was discovered and this included both financial and emotional costs. Conclusion. Further research is needed to generate evidence about family centred care in situations arising from modern models of care in which family centred care is thought to be an inherent part, but which leave families with the care of sick children with little or no support. Relevance to clinical practice. Family centred care is said to be used widely in practice. More research is needed to ensure that is it being implemented correctly.

Balancing curriculum processes and content in a project centred curriculum - In pursuit of graduate attributes

Chemical engineering education is challenged around the world by demands and rapid changes encompassing a wide range of technical and social drivers. Graduates must be prepared for practice in increasingly diverse workplace environments in which generic or transferable attributes such as communication and teamwork together with technical excellence are mandated by prospective employers and society at large. If academe is to successfully deliver on these graduate attributes, effective curriculum design needs to include appropriate educational processes as well as course content. Conventional teacher centred approaches, stand-alone courses and retro-fitted remedial modules have not delivered the desired outcomes. Development of the broader spectrum of attributes is more likely when students are engaged with realistic and relevant experiences that demand the integration and practice of these attributes in contexts that the students find meaningful. This paper describes and evaluates The University of Queensland's Project Centred Curriculum in Chemical Engineering (PCC), a programme-wide approach to meeting these requirements. PCC strategically integrates project-based learning with more traditional instruction. Data collected shows improved levels of student attainment of generic skills with institutional and nationally benchmarked indicators showing significant increases in student perceptions of teaching quality, and overall satisfaction with the undergraduate experience. Endorsements from Australian academic, professional and industry bodies also support the approach as more effectively aligning engineering education with professional practice requirements.

Marcelian charm in nursing practice: The unity of agape and eros as the foundation of an ethic of care

Abstract In the nursing literature, a number of qualities are associated with loving care. Reference is made to, among other things, humility, attentiveness, responsibility and duty, compassion, and tenderness. The author attempts to show that charm, in the Marcelian sense, also plays a central role. It is argued that the moral foundation of charm is a unity of agape and eros. An impartial giving of the self for others is clearly of fundamental importance in an ethic of care. Including charm in the discussion points to the fact that eros also plays a crucial role. Eros produces a passion for people and for life. It is a physical and spiritual energy that animates a person in all facets of her life, including her caring work.

Small firm internationalisation; understanding the practice through an interpretive approach

The unit of analysis in firm internationalisation studies is the firm but this overlooks the importance of the individual in the internationalisation process. An evaluation of the dominant theories of firm internationalisation highlights an implicit dualistic ontology, that is, where research subject and object are considered to be separate and independent. Implications of this assumption are discussed after reviewing the dominant literatures on firm internationalisation. An alternative approach is proposed that focuses on understanding internationalisation of the firm from an individual practitioner’s perspective. It is suggested that contemporary firm internationalisation research has been hindered by its basic assumptions and its inherent researcher orientation. An interpretive phenomenographic approach is proposed as a means of achieving a first-person, practitioner’s perspective of the process of firm internationalisation, specifically in the context of the small firm. Preliminary interpretations of interviews with owners/managers of small Australian wineries are presented.

Exploring individuals' experiences of time-sensitive practice in rural Newfoundland and Labrador: a qualitative study

Rural residents of NL face some of the most complex and challenging mental health issues including depression, schizophrenia, and risk of suicide with inadequate and hard to access treatment services. Due to the increasing demands for mental health services, government officials have been emphasizing the need for more responsive and person-centered services to meet client needs. Time-sensitive counselling, an alternative approach to long-term counselling, provides more timely and focused interventions. Mental Health services in Bonavista, a rural community in NL, recently began offering time-sensitive counselling services to its residents, entitled the “Change Clinic.” This phenomenological qualitative research study explored individuals’ experiences of time-sensitive counselling services as offered by mental health services in Bonavista. The results of this research study are detailed and suggest that time-sensitive counselling services can assist in meeting the service needs of rural residents of NL.

Measuring Scope of Practice Enactment among Primary Care Registered Nurses in Ontario

Background: Primary care is the sector of health care in which patients first establish contact with the health system, are provided person-focused care over time for all new or common needs, and receive coordinated integrated health services provided elsewhere by other members of the health care team. Registered Nurses (RNs) in Canada provide care within this sector in varying roles. The extent to which RNs enact their full scope of practice in primary care settings in Canada is not known. The Actual Scope of Practice questionnaire (ASCOP) is a 26 item Likert scale questionnaire developed by researchers in Canada and validated in the acute care setting to measure the extent to which RNs apply the knowledge, skills and competencies of the professional full scope of practice. Similar to the acute care setting, there is a need to measure scope of practice enactment in the primary care setting. Objectives: The overall aim of this thesis was to measure scope of practice enactment in the primary care setting. Two research objectives were addressed: (1) to revise and adapt the ASCOP questionnaire for use in the primary care setting, and (2) to determine internal consistency, construct validity, and sensitivity of the modified instrument, the ASCOP-PC. Methods: To address the first objective, a narrative literature review and synthesis and an expert panel review was conducted. To address the second objective a cross-sectional survey of 178 RNs working in primary care organizations in Ontario was conducted Results: The ASCOP, with few modifications, addressed key attributes of nursing scope of practice in the primary care setting. The ASCOP-PC yielded acceptable alpha coefficients ranging from 0.66 to 0.91 and explained variances from 44.2 to 62.6. Total mean score of 5.16 suggests that RNs within these models of care almost always engage in activities reflected in the ASCOP-PC. Interpretation: Findings from this study support the use of a the modified ASCOP questionnaire as a reliable and valid measure of scope of practice enactment among primary care nurses in the primary care setting.

IMPLEMENTING BACK PAIN TREATMENT PATHWAYS IN CLINICAL PRACTICE: QUALITATATIVE ANALYSIS OF STAKEHOLDER PERCEPTIONS

Background
Evidence-based practice advocates utilising best current research evidence, while reflecting patient preference and clinical expertise in decision making. Successfully incorporating this evidence into practice is a complex process. Based on recommendations of existing guidelines and systematic evidence reviews conducted using the GRADE approach, treatment pathways for common spinal pain disorders were developed.

Aims
The aim of this study was to identify important potential facilitators to the integration of these pathways into routine clinical practice.

Methods
A 22 person stakeholder group consisting of patient representatives, clinicians, researchers and members of relevant clinical interest groups took part in a series of moderated focus groups, followed up with individual, semi-structured interviews. Data were analysed using content analysis.

Results
Participants identified a number of issues which were categorized into broad themes. Common facilitators to implementation included continual education and synthesis of research evidence which is reflective of everyday practice; as well as the use of clear, unambiguous messages in recommendations. Meeting additional training needs in new or extended areas of practice was also recognized as an important factor. Different stakeholders identified specific areas which could be associated with successful uptake. Patients frequently defined early involvement in a shared decision making process as important. Clinicians identified case based examples and information on important prognostic indicators as useful tools to aiding decisions.

Conclusion
A number of potential implementation strategies were identified. Further work will examine the impact of these and other important factors on the integration of evidence-based treatment recommendations into clinical practice.