Oral cancer treatments and adherence: medication event monitoring system assessment for capecitabine

Background: Oncological treatments are traditionally administered via intravenous injection by qualified personnel. Oral formulas which are developing rapidly are preferred by patients and facilitate administration however they may increase non-adherence. In this study 4 common oral chemotherapeutics are given to 50 patients, who are still in the process of inclusion, divided into 4 groups. The aim is to evaluate adherence and offer these patients interdisciplinary support with the joint help of doctors and pharmacists. We present here the results for capecitabine. Materials and Methods: The final goal is to evaluate adhesion in 50 patients split into 4 groups according to oral treatments (letrozole/exemestane, imatinib/sunitinib, capecitabine and temozolomide) using persistence and quality of execution as parameters. These parameters are evaluated using a medication event monitoring system (MEMS®) in addition to routine oncological visits and semi-structured interviews. Patients were monitored for the entire duration of treatment up to a maximum of 1 year. Patient satisfaction was assessed at the end of the monitoring period using a standardized questionary. Results: Capecitabine group included 2 women and 8 men with a median age of 55 years (range: 36−77 years) monitored for an average duration of 100 days (range: 5-210 days). Persistence was 98% and quality of execution 95%. 5 patients underwent cyclic treatment (2 out of 3 weeks) and 5 patients continuous treatment. Toxicities higher than grade 1 were grade 2−3 hand-foot syndrome in 1 patient and grade 3 acute coronary syndrome in 1 patient both without impact on adherence. Patients were satisfied with the interviews undergone during the study (57% useful, 28% very useful, 15% useless) and successfully integrated the MEMS® in their daily lives (57% very easily, 43% easily) according to the results obtained by questionary at the end of the monitoring period. Conclusion: Persistence and quality of execution observed in our Capecitabine group of patients were excellent and better than expected compared to previously published studies. The interdisciplinary approach allowed us to better identify and help patients with toxicities to maintain adherence. Overall patients were satisfied with the global interdisciplinary follow-up. With longer follow up better evaluation of our method and its impact will be possible. Interpretation of the results of patients in the other groups of this ongoing trial will provide us information for a more detailed analysis.

Colonization with multiple Staphylococcus aureus strains among patients in European intensive care units.

Patients and healthy individuals intermittently and inconsistently carry different methicillin-resistant Staphylococcus aureus (MRSA) subtypes. In the present study, we assessed the clonality of methicillin-susceptible S. aureus (MSSA) and MRSA strains in patients admitted to 1 of 6 intensive care units (ICUs), using spa typing and multilocus variable number of tandem repeats analysis (MLVA).

Electroencephalogram changes during inhalation with nitric oxide in the pediatric intensive care patient--a preliminary report.

OBJECTIVES: Although endogenous nitric oxide (NO) is an excitatory mediator in the central nervous system, inhaled NO is not considered to cause neurologic side effects because of its short half-life. This study was motivated by a recent case report about neurologic symptoms and our own observation of severe electroencephalogram (EEG) abnormalities during NO inhalation. DESIGN: Blind, retrospective analyses of EEGs which were registered before, during, and after NO inhalation. EEG was classified in a 5-point rating system by an independent electroencephalographer who was blinded to the patients' clinical histories. Comparisons were made with the previous evaluation documented at recording. Other EEG-influencing parameters such as oxygen saturation, hemodynamics, electrolytes, and pH were evaluated. SETTING: Pediatric intensive care unit of a tertiary care university children's hospital. PATIENTS: Eleven ventilated, long-term paralyzed, sedated children (1 mo to 14 yrs) who had EEG or clinical assessment before NO treatment and EEG during NO inhalation. They were divided into two groups according to the NO-indication (e.g., congenital heart defect, acute respiratory distress syndrome). MEASUREMENTS AND MAIN RESULTS: All 11 patients had an abnormal EEG during NO inhalation. EEG-controls without NO showed remarkable improvement. EEG abnormalities were background slowing, low voltage, suppression burst (n = 2), and sharp waves (n = 2) independent of patients' age, NO-indication, and other EEG-influencing parameters. CONCLUSIONS: These preliminary data suggest the occurrence of EEG-abnormalities after application of inhaled NO in critically ill children. We found no correlation with other potential EEG-influencing parameters, although clinical state, medication, or hypoxemia might contribute. Comprehensive, prospective, clinical assessment regarding a causal relationship between NO-inhalation and EEG-abnormalities and their clinical importance is needed.

Hierarchic species-area relationships and the management of forest habitat islands in intensive farmland

Habitat loss and fragmentation due to land use changes are major threats to biodiversity in forest ecosystems, and they are expected to have important impacts on many taxa and at various spatial scales. Species richness and area relationships (SARs) have been used to assess species diversity patterns and drivers, and thereby in the establishment of conservation and management strategies. Here we propose a hierarchical approach to achieve deeper insights on SARs in small forest islets in intensive farmland and to address the impacts of decreasing naturalness on such relationships. In the intensive dairy landscapes of Northwest Portugal, where small forest stands (dominated by pines, eucalypts or both) represent semi-natural habitat islands, 50 small forest stands were selected and surveyed for vascular plant diversity. A hierarchical analytical framework was devised to determine species richness and inter- and intra-patch SARs for the whole set of forest patches (general patterns) and for each type of forest (specific patterns). Differences in SARs for distinct groups were also tested by considering subsets of species (native, alien, woody, and herbaceous). Overall, values for species richness were confirmed to be different between forest patches exhibiting different levels of naturalness. Whereas higher values of plant diversity were found in pine stands, higher values for alien species were observed in eucalypt stands. Total area of forest (inter-patch SAR) was found not to have a significant impact on species richness for any of the targeted groups of species. However, significant intra-patch SARs were obtained for all groups of species and forest types. A hierarchical approach was successfully applied to scrutinise SARs along a gradient of forest naturalness in intensively managed landscapes. Dominant canopy tree and management intensity were found to reflect differently on distinct species groups as well as to compensate for increasing stand area, buffering SARs among patches, but not within patches. Thus, the maintenance of small semi-natural patches dominated by pines, under extensive practices of forest management, will promote native plant diversity while at the same time contributing to limit the expansion of problematic alien invasive species.

Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians.

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment.

Primary activity measurements with a 4πβ-4πγ coincidence counting system.

The radioactive concentrations of (166m)Ho, (134)Cs and (133)Ba solutions have been standardised using a 4πβ-4πγ coincidence counting system we have recently set up. The detection in the beta channel is performed using various geometries of a UPS-89 plastic scintillator optically coupled to a selected low-noise 1in. diameter photomultiplier tube. The light-tight thin capsule that encloses this beta detector is housed within the well of a 5in.×5in. NaI(Tl) monocrystal detector. The beta detection efficiency can be varied either by optical filtering or electronic discrimination when the electrons loose all their energy in the plastic scintillator. This 4πβ-4πγ coincidence system improves on our 4πβ(PC)-γ system in that its sample preparation is less labour intensive, it yields larger beta- and gamma-counting efficiencies thus enabling the standardisation of low activity sources with good statistics in reasonable time, and it makes standardising short-lived radionuclides easier. The resulting radioactive concentrations of (166m)Ho, (134)Cs and (133)Ba are found to agree with those measured with other primary measurement methods thus validating our 4πβ-4πγ coincidence counting system.

Nursing intervention bundle for enteral nutrition in intensive care: a collective construction

Objective The collective construction of a nursing intervention bundle for patients in critical care in the hospital receiving enteral nutrition therapy, supported by evidence-based practice. Method A qualitative convergent-care study with 24 nursing professionals in an intensive care unit of a public hospital in Santa Catarina. Data collection was performed from May to August 2013, with semi-structured interviews and discussion groups. Results Four interventions emerged that constituted the bundle: bedside pH monitoring to confirm the position of the tube; stabilization of the tube; enteric position of the tube; and maintaining the head of the bed elevated at 30° to 45°.
 Conclusion The interventions chosen neither required additional professional workload nor extra charges to the institution, which are identified as improving the adoption of the bundle by nursing professionals at the ICU.

Usability of computerized nursing process from the ICNP® in intensive care units

OBJECTIVE To analyze the usability of Computerized Nursing Process (CNP) from the ICNP® 1.0 in Intensive Care Units in accordance with the criteria established by the standards of the International Organization for Standardization and the Brazilian Association of Technical Standards of systems. METHOD This is a before-and-after semi-experimental quantitative study, with a sample of 34 participants (nurses, professors and systems programmers), carried out in three Intensive Care Units. RESULTS The evaluated criteria (use, content and interface) showed that CNP has usability criteria, as it integrates a logical data structure, clinical assessment, diagnostics and nursing interventions. CONCLUSION The CNP is a source of information and knowledge that provide nurses with new ways of learning in intensive care, for it is a place that provides complete, comprehensive, and detailed content, supported by current and relevant data and scientific research information for Nursing practices.

Factors influencing Intensive Care Units nurses in end-of-life decisions

OBJECTIVETo identify the factors that influence the Intensive Care Unit nurse in the decision-making process in end-of-life situations.METHODEthnographic case study, which used the theoretical framework of medical anthropology. Data were collected through semi-structured interviews with 10 nurses.RESULTSThe inductive thematic analysis enabled us to identify four themes:The cultural context of the Intensive Care Unit: decision-making in situations of end-of-life; Beliefs and subjectivity of care in end-of-life situations; Professional experience and context characteristics of end-of-life care situations; and Humanization practices in end-of-life situations: the patient and family centered care.CONCLUSIONProfessional maturity, the ability to transmit information and the ability to negotiate are directly related to the inclusion of nurses in the decision-making process.

Family health nursing care: weaknesses and strengths in the Unified Health System

OBJECTIVETo analyze the weaknesses and strengths of nursing care in the Family Health Strategy and its interfaces with the Unified Health System network.METHODA qualitative study performed by means of semi-structured interviews and systematic observations, with the participation of a nursing team of 15 people from October of 2012 to January of 2013.RESULTSStrengths that were emphasized: the nurse's versatility in conducting users within the unit and the health system, therefore directly acting upon access to these services. The nurse is the main subject that participates in the care processes for the person, family and social groups. Weaknesses that were highlighted: fragile embracement and low resolution of users' and families' problems.CONCLUSIONThe nursing care process in health units still lacks collective articulation, involvement of the team, and decentralization of the decisions.

Cost system design and cost management in the Spanish public sector

Cost systems have been shown to have developed considerably in recent years andactivity-based costing (ABC) has been shown to be a contribution to cost management,particularly in service businesses. The public sector is composed to a very great extentof service functions, yet considerably less has been reported of the use of ABC tosupport cost management in this sector.In Spain, cost systems are essential for city councils as they are obliged to calculate thecost of the services subject to taxation (eg. waste collection, etc). City councils musthave a cost system in place to calculate the cost of services, as they are legally requirednot to profit , from these services.This paper examines the development of systems to support cost management in theSpanish Public Sector. Through semi-structured interviews with 28 subjects within oneCity Council it contains a case study of cost management. The paper contains extractsfrom interviews and a number of factors are identified which contribute to thesuccessful development of the cost management system.Following the case study a number of other City Councils were identified where activity-based techniques had either failed or stalled. Based on the factors identified inthe single case study a further enquiry is reported. The paper includes a summary usingstatistical analysis which draws attention to change management, funding and politicalincentives as factors which had an influence on system success or failure.

O Sistema Semi-Presidencialista Cabo-verdiano: A Relação entre os Poderes Executivo e Legislativo

O artigo procura analisar a relação que se estabelece entre o poder executivo e legislativo no sistema de governo cabo-verdiano, onde Investigadores buscam compreendê-lo, tendo em conta a sua configuração prática, teórica e constitucional. Há que realçar a proeminência do debate e dos estudos realizados no sentido de compreender como é que a academia científica procura debelar esta problemática. Duas questões são pertinentes neste debate: a primeira refere-se à configuração teórico-constitucional do sistema de governo cabo-verdiano e a outra à prática política e legislativa.

A behavioral ecology of shermen: hidden stories from trajectory data in the Northern Humboldt Current System

This work proposes an original contribution to the understanding of shermen spatial behavior, based on the behavioral ecology and movement ecology paradigms. Through the analysis of Vessel Monitoring System (VMS) data, we characterized the spatial behavior of Peruvian anchovy shermen at di erent scales: (1) the behavioral modes within shing trips (i.e., searching, shing and cruising); (2) the behavioral patterns among shing trips; (3) the behavioral patterns by shing season conditioned by ecosystem scenarios; and (4) the computation of maps of anchovy presence proxy from the spatial patterns of behavioral mode positions. At the rst scale considered, we compared several Markovian (hidden Markov and semi-Markov models) and discriminative models (random forests, support vector machines and arti cial neural networks) for inferring the behavioral modes associated with VMS tracks. The models were trained under a supervised setting and validated using tracks for which behavioral modes were known (from on-board observers records). Hidden semi-Markov models performed better, and were retained for inferring the behavioral modes on the entire VMS dataset. At the second scale considered, each shing trip was characterized by several features, including the time spent within each behavioral mode. Using a clustering analysis, shing trip patterns were classi ed into groups associated to management zones, eet segments and skippers' personalities. At the third scale considered, we analyzed how ecological conditions shaped shermen behavior. By means of co-inertia analyses, we found signi cant associations between shermen, anchovy and environmental spatial dynamics, and shermen behavioral responses were characterized according to contrasted environmental scenarios. At the fourth scale considered, we investigated whether the spatial behavior of shermen re ected to some extent the spatial distribution of anchovy. Finally, this work provides a wider view of shermen behavior: shermen are not only economic agents, but they are also foragers, constrained by ecosystem variability. To conclude, we discuss how these ndings may be of importance for sheries management, collective behavior analyses and end-to-end models.

Copper, zinc and manganese in soils of two watersheds in Santa Catarina with intensive use of pig slurry

Systematic pig slurry application to crop soils may lead to the accumulation of heavy metals in regions with intensive pig raising. The aim of this study was to evaluate the accumulation of Cu, Zn and Mn in soils under systematic pig slurry application. For this purpose, soil samples were collected from two of the most representative watersheds of Santa Catarina where the predominant activity is pig raising. In each watershed, 12 properties were chosen to evaluate the different systems of pig husbandry (complete cycle (CC), farrowing (FaU) and finishing units (FiU)). Based on information of the producers, soil samples were collected in areas with and without systematic manure application. To determine the total Cu, Zn and Mn content in soils and manure, a methodology proposed by the Environmental Protection Agency of the United States (USEPA), method nº 3050B, was used. For the available heavy metal content, Cu and Zn was extracted with HCl 0.1 mol L-1 and Mn with KCl 1 mol L-1. Data were subjected to multivariate analysis, using the canonical discriminant analysis to identify the metals that best differentiate the soils studied within each swine housing system. Successive pig slurry applications cause an increase in Cu, Zn and Mn availability in the soil and this indicates the need for monitoring of the metal concentrations over time. The critical values of Cu in the soil can be reached and exceeded more rapidly than Zn. The results showed that the soil type may be one of the attribute underlying the determination of public policies in pig raising and waste management because soils such as Inceptisols were shown to be more prone to possible contamination since they may more rapidly reach total critical Cu levels.

Origin of a restraining bend in an evolving strike-slip system: The Cenozoic As Pontes basin (NW Spain)

The As Pontes basin (12 km2), NW Iberian Peninsula, is bounded by a double restraining bend of a dextral strike-slip fault, which is related to the western onshore end of the Pyrenean belt. Surface and subsurface data obtained from intensive coal exploration and mining in the basin since the 1960s together with additional structural and stratigraphic sequence analysis allowed us to determine the geometric relationships between tectonic structures and stratigraphic markers. The small size of the basin and the large amount of quality data make the As Pontes basin a unique natural laboratory for improving our understanding of the origin and evolution of restraining bends. The double restraining bend is the end stage of the structural evolution of a compressive underlapping stepover, where the basin was formed. During the first stage (stepover stage), which began ca. 30 Ma ago (latest Rupelian) and lasted 3.4 My, two small isolated basins bounded by thrusts and normal faults were formed. For 1.3 My, the strike-slip faults, which defined the stepover, grew towards each other until joining and forming the double restraining bend, which bounds one large As Pontes basin (transition stage). The history of the basin was controlled by the activity of the double restraining bend for a further 3.4 My (restraining bend stage) and ended in mid-Aquitanian times (ca. 22 Ma).