Soins palliatifs en établissements médico-sociaux: Caractéristiques et spécificités [Palliative Care in Nursing Homes: Characteristics and Specificities].

Elderly patients in palliative situations residing in a nursing home present characteristics and specificities that clearly distinguish them from patients with advanced cancer. Besides the difficulty to define a precise prognosis, their many comorbidities, their communication difficulties because of cognitive disorders, their high sensitivity to primary and secondary effects of drugs render their management a real challenge for physician and caregivers. Accompanying these patients at the end of their life also raises many ethical problems, especially when they are no longer able to express their wishes and have not previously expressed advance directives.

Short Report: Spinal Cord Stimulation in Thromboangiitis Obliterans and Secondary Raynaud's-Syndrome

Introduction: Spinal cord stimulation (SCS) may be a treatment option in limb ischemia occurring as a result of Thromboangiitis obliterans (TAO) or secondary Raynaud's-Syndrome (SRS). The impact of SCS on disease progression and micro-perfusion was prospectively evaluated during a follow-up (FU) of 4 years. Report: Under SCS, a significant increase in trans-cutaneous oxygen tension (tcpO2) was observed in TAO and a significant increase in systolic perfusion pressure at plethysmography was observed in SRS. Complete limb preservation was achieved in all patients who had reduced tobacco consumption. Discussion: SCS is an efficient therapeutic tool in TAO and SRS. Patient selection criteria are crucial for success.

Current and future trens in the quality control of pharmaceuticals and biopharmaticals : impacts on Cost of Goods Sold (COGS)

[Summary] 2. Roles of quality control in the pharmaceutical and biopharmaceutical industries. - 2.1. Pharmaceutical industry. - 2.2. Biopharmaceutical industry. - 2.3. Policy and regulatory. - 2.3.1. The US Food and Drug Administration (FDA). - 2.3.2. The European Medicine Agency (EMEA). - 2.3.3. The Japanese Ministry of Work, Labor and Welfare (MHLW). - 2.3.4. The Swiss Agency for Therapeutic Products (Swissmedic). - 2.3.5. The International Conference on Harmonization (ICH). - - 3. Types of testing. - 3.1. Microbiological purity tests. - 3.2. Physiochemical tests. - 3.3. Critical to quality steps. - 3.3.1. API starting materials and excipients. - 3.3.2. Intermediates. - 3.3.3. APIs (drug substances) and final drug product. - 3.3.4. Primary and secondary packaging materials fro drug products. - - 4. Manufacturing cost and quality control. - 4.1.1. Pharmaceutical manufacturing cost breakdown. - 4.1.2. Biopharmaceutical manufacturing cost breakdown. - 4.2. Batch failure / rejection / rework / recalls. - - 5. Future trends in the quality control of pharmaceuticals and biopharmaceuticals. - 5.1. Rapid and real time testing. - 5.1.1. Physio-chemicals testing. - 5.1.2. Rapid microbiology methods

La integración de Internet en la educación escolar española : situación actual y perspectivas de futuro

The main objectives and findings of this first research report are presented in this chapter."The Implementation of the Internet in the Spanish Education System: State of Affairs and Future Prospects" is a large-scale research project that seeks to obtain relevant data about the introduction and dissemination of Information and Communication Technology, particularly the internet, in the practical and organizational general procedures of the Spanish schools and high schools. The project articulates the processes of ICT implementation on the primary and secondary education levels embracing a holistic approach, propped up by an empirical and analytical research methodology. Thus, our survey does not intend to detect which is the impact of ICT on school activities but how all the agents involved in the school community incorporate ICT and what use they make of it. We are especially interested in identifying the teachers' pedagogical and professional uses of ICT, how students use it in their activities and to what extent it contributes in reinforcing teamwork and participation proceedings in the institutions, as well as the relations between the latter and their context. It is also of our interest to know the factors that exert the strongest influence on the way teachers, head teachers and students make use of ICT. Finally, we intend to identify the ways ICT may contribute to the improvementof educational practices.

Pharmaceuticals occurrence in a WWTP with significant industrial contribution and its input into the river system

Occurrence and removal of 81 representative Pharmaceutical Active Compounds (PhACs) were assessed in a municipal WWTP located in a highly industrialized area, with partial water reuse after UV tertiary treatment and discharge to a Mediterranean river. Water monitoring was performed in an integrated way at different points in the WWTP and river along three seasons. Consistent differences between therapeutic classes were observed in terms of influent concentration, removal efficiencies and seasonal variation. Conventional (primary and secondary) treatment was unable to completely remove numerous compounds and UV-based tertiary treatment played a complementary role for some of them. Industrial activity influence was highlighted in terms of PhACs presence and seasonal distribution. Even if global WWTP effluent impact on the studied river appeared to be minor, PhACs resulted widespread pollutants in river waters. Contamination can be particularly critical in summer in water scarcity areas, when water flow decreases considerably

Implementing a Cancer Fast-track programme between primary and specialised care in Catalonia(Spain): amixed methods study

BACKGROUND: The Cancer Fast-track Programme's aim was to reduce the time that elapsed between well-founded suspicion of breast, colorectal and lung cancer and the start of initial treatment in Catalonia (Spain). We sought to analyse its implementation and overall effectiveness. METHODS: A quantitative analysis of the programme was performed using data generated by the hospitals on the basis of seven fast-track monitoring indicators for the period 2006-2009. In addition, we conducted a qualitative study, based on 83 semistructured interviews with primary and specialised health professionals and health administrators, to obtain their perception of the programme's implementation. RESULTS: About half of all new patients with breast, lung or colorectal cancer were diagnosed via the fast track, though the cancer detection rate declined across the period. Mean time from detection of suspected cancer in primary care to start of initial treatment was 32 days for breast, 30 for colorectal and 37 for lung cancer (2009). Professionals associated with the implementation of the programme showed that general practitioners faced with suspicion of cancer had changed their conduct with the aim of preventing lags. Furthermore, hospitals were found to have pursued three specific implementation strategies (top-down, consensus-based and participatory), which made for the cohesion and sustainability of the circuits. CONCLUSION: The programme has contributed to speeding up diagnostic assessment and treatment of patients with suspicion of cancer, and to clarifying the patient pathway between primary and specialised care.

Parallel-Operating Three-Phase Voltage Source Inverters – Circulating CurrentModeling, Analysis and Mitigation

The maximum realizable power throughput of power electronic converters may be limited or constrained by technical or economical considerations. One solution to this problemis to connect several power converter units in parallel. The parallel connection can be used to increase the current carrying capacity of the overall system beyond the ratings of individual power converter units. Thus, it is possible to use several lower-power converter units, produced in large quantities, as building blocks to construct high-power converters in a modular manner. High-power converters realized by using parallel connection are needed for example in multimegawatt wind power generation systems. Parallel connection of power converter units is also required in emerging applications such as photovoltaic and fuel cell power conversion. The parallel operation of power converter units is not, however, problem free. This is because parallel-operating units are subject to overcurrent stresses, which are caused by unequal load current sharing or currents that flow between the units. Commonly, the term ’circulatingcurrent’ is used to describe both the unequal load current sharing and the currents flowing between the units. Circulating currents, again, are caused by component tolerances and asynchronous operation of the parallel units. Parallel-operating units are also subject to stresses caused by unequal thermal stress distribution. Both of these problemscan, nevertheless, be handled with a proper circulating current control. To design an effective circulating current control system, we need information about circulating current dynamics. The dynamics of the circulating currents can be investigated by developing appropriate mathematical models. In this dissertation, circulating current models aredeveloped for two different types of parallel two-level three-phase inverter configurations. Themodels, which are developed for an arbitrary number of parallel units, provide a framework for analyzing circulating current generation mechanisms and developing circulating current control systems. In addition to developing circulating current models, modulation of parallel inverters is considered. It is illustrated that depending on the parallel inverter configuration and the modulation method applied, common-mode circulating currents may be excited as a consequence of the differential-mode circulating current control. To prevent the common-mode circulating currents that are caused by the modulation, a dual modulator method is introduced. The dual modulator basically consists of two independently operating modulators, the outputs of which eventually constitute the switching commands of the inverter. The two independently operating modulators are referred to as primary and secondary modulators. In its intended usage, the same voltage vector is fed to the primary modulators of each parallel unit, and the inputs of the secondary modulators are obtained from the circulating current controllers. To ensure that voltage commands obtained from the circulating current controllers are realizable, it must be guaranteed that the inverter is not driven into saturation by the primary modulator. The inverter saturation can be prevented by limiting the inputs of the primary and secondary modulators. Because of this, also a limitation algorithm is proposed. The operation of both the proposed dual modulator and the limitation algorithm is verified experimentally.

Use of botanical extracts, cassava wastewater and nematicide for the control of root-knot nematode on carrot

Aqueous extracts of several plant species have shown promising in controlling root-knot nematode, Meloidogyne incognita (Kofoid & White), one of the most limiting agents for carrot cultivation. The current study evaluated the effect of aqueous extracts from seven botanical species applied to 40, 50, 60, 70 and 80 days after sowing 'Nantes' carrots in soil infested with root-knot nematode. Three other treatments included cassava wastewater, distilled water (control), which were applied in the same periods of the extracts application, in addition to carbofuran 50G (80Kg/ha), which was applied once at 60 days after carrot sowing. Evaluations were performed at 90 days after inoculation to determine shoot and root fresh weight, as well as the diameter and the length of principal roots and the number of galls on primary and secondary roots. Plants treated with cassava wastewater, extracts of Ricinus communis L. seeds, Crotalaria juncea L. seeds, R. communis leaves + branches + fruits, Chenopodium ambrosioides L. leaves + branches + inflorescences and Azadirachta indica A. Juss. seeds showed the highest rates of total weight (root + shoot) and shoot weight. The extract of R. communis leaves + branches + fruits provides the highest total root weight and principal root diameter. Cassava wastewater and extracts of R. communis seeds provided the highest principal root weight. The extract of R. communis seeds and cassava wastewater can be considered promising for the alternative control of M. incognita.

Driver of Demand in Cargo and Passenger Traffic Between Penta Ports

Maritime transport moves around 6 billion tonnes of freight every year. The freight consists of liquid bulks (45%), dry bulks (23%) and general cargo (32%). Freight traffic and transports chains vary according to region, commodity and the origin and the destination of freight. In the European Union the ports sector handles over 90% of the trade with third countries. The share of intra-EU trade is approximately 30% of the total transportation and the number of passengers is over 200 million every year. The Baltic Sea has more than 50,000 vessels a year pass the Skaw at the northernmost tip of Denmark on their way into or out of the Baltic. Roughly 60% to 70% of these vessels are cargo vessels and 17% to 25% tankers. Ports and maritime transport play a crucial role in global commerce today. Today’s business environment is changing rapidly, and the constant changes create challenges for the transport industry and maritime traffic. Ports have to adapt to continuous changes in economic structures, logistics demands, and people’s travel and leisure patterns. In order to ensure the competitiveness of sea connections, the ports need to fully enhance multilateral cross-border understanding and cooperation. In this report the focus is on liner traffic between five ports in the Central Baltic Region: Stockholm, Tallinn, Helsinki Turku and Naantali. The report defines the drivers of the demand for cargo and passenger traffic and highlights the most important factors. The economic situation and foreign trade of each county are elaborated on with detailed information about the flows of traffic between the five ports. Based on expert interviews, the main characteristics of each port, including strengths and weaknesses, are presented. The report is based on primary and secondary data. Primary data was received through interviews and mail surveys. Secondary data was attained through a literature research, statistics, data given by the PENTA ports and webpages. The report is divided into two main parts: the drivers creating the demand for transport and the results of current cargo and passenger flows between PENTA ports.

The Structure and Function of αI Domains in Collagen Receptor and Leukocyte Integrins

Integrins are heterodimeric, signaling transmembrane adhesion receptors that connect the intracellular actin microfilaments to the extracellular matrix composed of collagens and other matrix molecules. Bidirectional signaling is mediated via drastic conformational changes in integrins. These changes also occur in the integrin αI domains, which are responsible for ligand binding by collagen receptor and leukocyte specific integrins. Like intact integrins, soluble αI domains exist in the closed, low affinity form and in the open, high affinity form, and so it is possible to use isolated αI domains to study the factors and mechanisms involved in integrin activation/deactivation. Integrins are found in all mammalian tissues and cells, where they play crucial roles in growth, migration, defense mechanisms and apoptosis. Integrins are involved in many human diseases, such as inflammatory, cardiovascular and metastatic diseases, and so plenty of effort has been invested into developing integrin specific drugs. Humans have 24 different integrins, four of which are collagen receptor (α1β1, α2β1, α10β1, α11β1) and five leukocyte specific integrins (αLβ2, αMβ2, αXβ2, αDβ2, αEβ7). These two integrin groups are quite unselective having both primary and secondary ligands. This work presents the first systematic studies performed on these integrin groups to find out how integrin activation affects ligand binding and selectivity. These kinds of studies are important not only for understanding the partially overlapping functions of integrins, but also for drug development. In general, our results indicated that selectivity in ligand recognition is greatly reduced upon integrin activation. Interestingly, in some cases the ligand binding properties of integrins have been shown to be cell type specific. The reason for this is not known, but our observations suggest that cell types with a higher integrin activation state have lower ligand selectivity, and vice versa. Furthermore, we solved the three-dimensional structure for the activated form of the collagen receptor α1I domain. This structure revealed a novel intermediate conformation not previously seen with any other integrin αI domain. This is the first 3D structure for an activated collagen receptor αI domain without ligand. Based on the differences between the open and closed conformation of the αI domain we set structural criteria for a search for effective collagen receptor drugs. By docking a large number of molecules into the closed conformation of the α2I domain we discovered two polyketides, which best fulfilled the set structural criteria, and by cell adhesion studies we showed them to be specific inhibitors of the collagen receptor integrins.

Comparison of Classical and Secondary Cytologic Criteria Relative to Hybrid Capture for Diagnosing Cervical-vaginal Infection by Human Papillomavirus

Objective To compare the diagnostic accuracy of the classic Meisels cytologic criteria and the Schneider secondary criteria relative to the hybrid capture method for diagnosing HPV infection. Methods This was a retrospective study performed at a public university hospital. A total of 41 patients with a cytologic diagnosis of HPV infection and 40 HPV-negative patients were selected for review of the cervical-vaginal smears seeking to classical and secondary criteria. A single pathologist reviewed the slides in search of the criteria. The classical and secondary cytologic criteria were compared with the hybrid capture for diagnosing HPV infection. Bartleti test was applied for the age analysis, and Fisher's exact test was used to compare proportions. The tests were considered significant when the probability of rejecting the null hypothesis was less than 5% (p < 0.05). Results The Meisels criteria were less sensitive (34.0%) than the secondary Schneider criteria (57.5%) when compared with the hybrid capture (p < 0.0001), although the specificity of the former criteria was non-significantly higher (91.2% and 67.7%, respectively). In cases of moderate or intense inflammation, the sensitivity and specificity of the Schneider criteria were decreased, 33.3% and 50.0% respectively (p = 0.0115). Conclusions Compared with hybrid capture for diagnosis of HPV infection, the sensitivity of the secondary Schneider criteria was higher than the classical Meisels criteria.Moderate or intense inflammation reduces the sensitivity and specificity of the secondary Schneider criteria for diagnosing HPV infection using the hybrid capture as the gold standard.

System-level characterization of Th2 cell development and immune cell responses to ZnO and TiO2 nanoparticles

Asthma and allergy are common diseases and their prevalence is increasing. One of the hypotheses that explains this trend is exposure to inhalable chemicals such as traffi c-related air pollution. Epidemiological research supports this theory, as a correlation between environmental chemicals and allergic respiratory diseases has been found. In addition to ambient airborne particles, one may be exposed to engineered nanosized materials that are actively produced due to their favorable physico-chemical properties compared to their bulk size counterparts. On the cellular level, improper activity of T helper (Th) cells has been connected to allergic reactions. Th cells can differentiate into functionally different effector subsets, which are identifi ed according to their characteristic cytokine profi les resulting in specifi c ability to communicate with other cells. Th2 cells activate humoral immunity and stimulate eradication of extracellular pathogens. However, persistent predominance of Th2 cells is involved in a development of number of allergic diseases. The cytokine environment at the time of antigen recognition is the major factor determining the polarization of a naïve Th cell. Th2 cell differentiation is initiated by IL4, which signals via transcription factor STAT6. Although the importance of this pathway has been evaluated in the mouse studies, the signaling components involved have been largely unknown. The aim of this thesis was to identify molecules, which are under the control of IL4 and STAT6 in Th cells. This was done by using system-level analysis of STAT6 target genes at genome, mRNA and protein level resulting in identifi cation of various genes previously not connected to Th2 cell phenotype acquisition. In the study, STAT6-mediated primary and secondary target genes were dissection from each other and a detailed transcriptional kinetics of Th2 cell polarization of naïve human CD4+ T cells was collected. Integration of these data revealed the hierarchy of molecular events that mediates the differentiation towards Th2 cell phenotype. In addition, the results highlighted the importance of exploiting proteomics tools to complement the studies on STAT6 target genes identifi ed through transcriptional profi ling. In the last subproject, the effects of the exposure with ZnO and TiO2 nanoparticles was analyzed in Jurkat T cell line and in primary human monocyte-derived macrophages and dendritic cells to evaluate their toxicity and potential to cause infl ammation. Identifi cation of ZnO-derived gene expression showed that the same nanoparticles may elicit markedly distinctive responses in different cell types, thus underscoring the need for unbiased profi ling of target genes and pathways affected. The results gave additional proof that the cellular response to nanosized ZnO is due to leached Zn2+ ions. The approach used in ZnO and TiO2 nanoparticle study demonstrated the value of assessing nanoparticle responses through a toxicogenomics approach. The increased knowledge of Th2 cell signaling will hopefully reveal new therapeutic nodes and eventually improve our possibilities to prevent and tackle allergic infl ammatory diseases.

Internationalization of small and medium-sized enterprises and impact of institutions on international entrepreneurship in emerging economies: the case of Russia

The doctoral study presents a comprehensive analysis of the impact of the institutional environment on the internationalization-based growth strategic choices of small and mediumsized enterprises (SMEs) in emerging economies. In responding to the calls for more research on institutions and international entrepreneurship, this dissertation extends the linkages between the two to the context of emerging economies. The study presents a comprehensive analysis of institutional challenges and their impact on the internationalization of SMEs in emerging economies, particularly in Russia. The research contributes to the adoption of the institution-based view in international entrepreneurship. The dissertation is presented through five research papers. Based on primary and secondary data, the study categorizes the possible sources of institutional influences on internationalization and empirically tests their impact by applying a method triangulation research design. The result of the conducted research is a proposed theoretical model of the institutional impact on the internationalization of SMEs in emerging economies. The model is specifically focused on the growth stage of the entrepreneurial process and considers only its internationalization facet. The research identifies and provides empirical support for the existence of a positive influence of a transparent and supportive regulatory environment, an institutionalized pool of general business knowledge, and collectivistic value orientation on the proclivity of SMEs to internationalize. A level of appreciation of entrepreneurial initiatives in home country and a greater positive institutional gap provide a positive impact on the international performance of SMEs. The research provides contextualized knowledge of the institutional impact on the internationalization of SMEs in Russia. The obtained results present theoretical value in terms of showing how the environmental conditions effect the entrepreneurial internationalization-based growth in emerging economies, providing the methodological insights into the measurement of the institutional effects, and empirically contextualizing the linkage between institutions and internationalization in the Russian business environment. The research also provides value for the business and policy making stakeholders by identifying ways of utilizing the conditions in the external institutional environment.

Primary and Revision Hip Replacement. A University Hospital Database and Registry Study

Large-headed total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) with metal-on-metal (MoM) bearings became popular during the last decade. Recently, it has become evident that the large-head MoM hip implants are associated with increased revision rates despite their theoretical advantages. The purpose of this study was to evaluate the early results of primary MoM hip replacements and of acetabular revisions. I analyzed retrospectively the results of four MoM implant designs and the survival rate of acetabular revisions with impaction bone grafting, as documented in the Turku University Hospital database. Further, I evaluated the correlation between femoral head size and dislocation rate, and used the Finnish Arthroplasty Register data to compare the survival of three large-head MoM THAs to analogous HRAs. The early results for the Magnum M2A–ReCap THA were good. A larger head size decreased the risk of dislocation. Articular surface replacement (ASR) THA yielded inferior results compared to analogous HRA. For two other designs the results were similar. The R3–Synergy THA yielded inferior results compared to the reference implants. The survival of acetabular reconstructions with impaction bone grafting was inferior compared to previous reports. In conclusion, the early results of the Biomet ReCap–Magnum design were promising, and large head sizes decreased the dislocation rate. The survival of different MoM hip implant designs varied. The survival of new designs and techniques may be inferior to those reported by the clinics where implants are developed. An important caveat is that early promising results of new devices may rapidly worsen. New implants need to be introduced in a controlled fashion to the market; here, arthroplasty registers are a valuable tool that needs to be used.

Chromosome number and secondary constriction variation in 51 accessions of a citrus germplasm bank

The mitotic chromosomes of 51 citrus accessions from the Centro Nacional de Pesquisa em Mandioca e Fruticultura Tropical, Cruz das Almas, BA, Brazil, were analyzed. The sample included representatives of 20 Citrus species, one of Poncirus and seven hybrids. All accessions showed 2n = 18 without any evidence of numerical variation. The most clearly variable karyotype feature was the number and position of secondary constrictions (SECs). In 19 accessions the SECs were not identified, mainly due to the degree of chromatin condensation. In the remainder they varied in number from one to three per karyotype. They were found in the proximal region of one of the three largest chromosome pairs, in the terminal/subterminal region of a smaller chromosome or, more seldom, terminally in a larger chromosome. Only in a few cases were such constrictions observed simultaneously in both homologues of the same chromosome pair. The high variability of this karyotype feature may be due to the activation of this region in the previous interphase but may also indicate a high structural variability and heterozygosity of citrus germplasms