Verhaltens- und fertigkeitenbasierte Frühinterventionen bei Kindern mit Autismus

Einleitung: Zu den autistischen Syndromen werden der frühkindliche Autismus (Kanner-Syndrom), das Asperger-Syndrom und atypische Autismusformen oder nicht-spezifizierte tiefgreifende Entwicklungsstörungen gezählt. Bei den autistischen Syndromen liegen Beeinträchtigungen (1) der Kommunikation und (2) der sozialen Interaktion vor. Weiterhin weisen (3) die Kinder in unterschiedlichem Maß stereotypes, repetitives Verhalten auf und haben bestimmte Sonderinteressen. Verhaltensbasierte Frühinterventionen bei Kindern mit Autismus basieren auf lerntheoretischen und verhaltenstherapeutischen Konzepten. Sie berücksichtigen die besonderen vorliegenden Beeinträchtigungen in der Wahrnehmung, der emotionalen Reaktionen, der sozialen Interaktionen sowie der Kommunikationsmuster. Die systematische Anwendung und Evaluation solcher Modelle in Deutschland ist aber bisher eher die Ausnahme. Fragestellungen: - Wie sind die gesundheitliche Effektivität und Sicherheit von verhaltens- oder fertigkeitenbasierten Frühinterventionen bei autistischen Syndromen untereinander und verglichen mit einer Standardbehandlung? - Gibt es Hinweise auf besondere Wirkfaktoren für die Effektivität? - Wie ist die Kosten-Effektivität? - Wie hoch sind die Kosten der verschiedenen Interventionen? - Lassen sich aus ethischen und rechtlichen Überlegungen Schlüsse für die Anwendung der betrachteten Interventionen bei Betroffenen mit autistischem Syndrom in der Praxis ziehen? Methoden: Basierend auf einer systematischen Literaturrecherche werden ab 2000 in deutscher oder englischer Sprache veröffentlichte kontrollierte Studien zu verhaltens- oder fertigkeitenbasierten Frühinterventionen bei Kindern mit Autismus im Alter von bis zu zwölf Jahren eingeschlossen und bewertet. Die Mindestzahl an Studienteilnehmern muss zehn pro Interventionsgruppe betragen. Ergebnisse: Insgesamt 15 Veröffentlichungen klinischer Primärstudien, acht systematische Reviews und eine ökonomische Veröffentlichung erfüllen die Einschlusskriterien. Die meisten Studien evaluieren intensive Frühinterventionen, die sich an das Modell von Lovaas (Early intensive behavioural treatment (EIBT), Applied behavioural analysis (ABA)) anlehnen. Einige Studien evaluieren andere Interventionen, die teilweise pragmatisch waren und teilweise einem bestimmten Modell folgen (spezifisches Elterntraining, Responsive education and prelinguistic milieu teaching (RPMT), Joint attention (JA) und symbolisches Spielen (SP), Picture exchange communication system (PECS)). Verhaltensanalytische Interventionen basierend auf dem Lovaas-Modell können weiterhin als die am besten empirisch abgesicherten Frühinterventionen angesehen werden. Vorschulkinder mit Autismus können durch verhaltensbasierte Interventionen mit einer Mindestintensität von 20 Stunden pro Woche Verbesserungen in kognitiven und funktionalen Bereichen (expressive Sprache, Sprachverständnis und Kommunikation) erreichen. Es bleibt jedoch unklar, welche Mindestintensität notwendig ist, und welche Wirkkomponenten für die Ergebnisse verantwortlich sind. Für andere umfassende Frühinterventionen bei Kindern mit Autismus liegt keine hochwertige Evidenz vor. Die für den ökonomischen Teilbereich identifizierte und einbezogene Publikation ist methodisch und thematisch nicht dazu geeignet, die Fragen nach der Kosten-Effektivität oder den Kostenwirkungen von Frühinterventionen beim Autismus auch nur ansatzweise zu beantworten. Publikationen zu rechtlichen, ethischen oder sozialen Aspekten werden nicht identifiziert. Die finanzielle Lage der Betroffenen und der Familien wird durch das Pflege-Weiterentwicklungsgesetz (Pf-WG) verbessert. Weitere rechtliche Belange betreffen die Betreuung und die Deliktfähigkeit der Menschen mit Autismus. Auch die gleichheitliche Betreuung und Versorgung sind insbesondere vor dem Hintergrund der Pflege im häuslichen Umfeld eine wichtige Frage. Diskussion: Es gibt nur wenige methodisch angemessene Studien zur Beurteilung der Wirksamkeit von Frühinterventionen bei Kindern mit Autismus. Die meisten Studien sind vergleichsweise kurz und haben teilsweise kein verblindetes Ergebnis-Rating. Der Mangel an hochwertigen vergleichenden Studien lässt keine solide Antwort auf die Frage zu, welche Frühintervention bei welchen Kindern mit Autismus am wirksamsten ist. Programme nach dem Lovaas-Modell scheinen am wirkungsvollsten zu sein. Dies gilt vor allem, wenn sie klinikbasiert durchgeführt werden. Zu einzelnen Wirkfaktoren von Frühinterventionen nach dem ABA-Modell konnte allerdings keine solide Evidenz gefunden werden. Es zeigte sich, dass ein Elterntraining hinsichtlich der Verbesserung der Kommunikation besser ist als eine Routinebehandlung, in der eine Mischung von Theapieelementen angewendet wird. Sowohl für die klinischen als auch die gesundheitsökonomischen Studien besteht das Problem unzureichender Verallgemeinerbarkeit der Studienergebnisse in den deutschen Versorgungskontext. Die ökonomischen Studien sind methodisch und thematisch nicht dazu geeignet die aufgeworfenen Fragestellungen zu beantworten. Schlussfolgerung: Basierend auf der derzeitigen Studienlage liegt für keine der untersuchten verhaltensbasierten Frühinterventionen bei Kindern mit Autismus ausreichende Evidenz vor. Die in diesem Bericht ausgewerteten Studien und Reviews legen nahe, dass Vorschulkinder mit Autismus durch verhaltensbasierte Interventionen mit einer Mindestintensität von 20 Stunden pro Woche Verbesserungen in kognitiven und funktionalen Bereichen erreichen können. Es gibt bisher keine Hinweise, dass bei einem substantiellen Anteil der Kinder eine vollständige Normalisierung der Entwicklung erreicht werden kann. Die meiste Evidenz liegt für die ABA vor. Ein Minimum an erforderlicher oder sinnvoller Behandlungsintensität kann jedoch nicht angegeben werden. Eine professionelle Umsetzung eines verhaltensbasierten Frühinterventionsprogrammes in engem und ausführlichem Kontakt mit den Kindern und unter Einbeziehung der Eltern erscheint sinnvoll. Zur Kosten-Effektivität von intensiven Frühinterventionen bei Kindern mit Autismus können keine validen Angaben gemacht werden. Effektive Frühinterventionen könnten jedoch die Gesamtkosten des Autismus langfristig reduzieren, indem die anfallenden hohen Aufwendungen durch eine spätere bessere soziale Anpassung überkompensiert werden.

Nokia- The surprising success of textbook wisdom

What is the secret behind Nokia’s phenomenal success in mobile phones? More generally, how to succeed in a turbulent high technology market? Historical and comparative studies bring understanding not only about past phenomena, but also insights about current and coming ones. In this paper we compare Ford and General Motors in the 1920s and 1930s with Motorola and Nokia in the 1980s and 1990s. The insight from this comparison is how reinvention of the product, category, relative to the market incumbent’s market conceptualization, is a recipe for success. Nokia’s success in the 1990s was based on following the guidelines pioneered by General Motors in the 1920s: market segmentation, embracing the latest technological advances, and brand management in the pursuit of consumer repurchases. The article tells how Nokia addresses both GM’s legacy and changes in the business environment. At the end of our paper, we disuss the generalizability of our findings.

Edukacja i kultura. Studium nad szkolnictwem obowiązkowym w Szwecji

Wydział Studiów Edukacyjnych

Social buffering of fear in zebrafish

Tese de Doutoramento em Biologia Comportamental apresentada ao ISPA - Instituto Universitário

Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic considerations

Background Writing therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched. Data sources Databases including: MEDLINE, EMBASE, PsychINFO, Linguistics and Language Behavior Abstracts, AMED, and CINHAL were searched from inception to March 2013. Review methods Four TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk of bias tool. Unfacilitated and facilitated TW studies were analysed separately under ICD-10 chapter headings. Meta-analyses were performed where possible using Revman 5.2. Costs were estimated from an NHS perspective and three cost-consequence case studies were prepared. Realist synthesis followed RAMESES guidelines. Objectives To review the clinical and cost-effectiveness of TW for people with long-term health conditions (LTCs) compared to no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom. Results From 14,658 unique citations, 284 full text papers were reviewed and 64 studies (58 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW, these were extremely heterogeneous with unclear or high risk of bias, but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable, or unreported, quality. Overall there was very little or no evidence of any benefit reported in the following conditions (number of studies): HIV (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity (n= 191, standardised mean difference (SMD) - 0.61 [95% confidence intervals (95% CI) -0.96, -0.26]) in the short term on meta-analysis of four studies. For all other LTCs there was either no, or sparse, data with no, or inconsistent, evidence of benefit. Meta-analyses conducted across all the LTCs provided no evidence that unfacilitated EW had any effect on depression at short term (n= 1,563, SMD -0.06, 95% CI -0.29 to 0.17, substantial heterogeneity), or long term (n= 778, SMD-0.04 95% CI -0.18 to 0.10, little heterogeneity) follow up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, none reported cost-effectiveness, twelve reported resource use; meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist review findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW. Limitations Difficulties with developing realist review programme theory meant that mechanisms operating during TW remain obscure. Conclusions Overall there is little evidence to support the effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focussed on facilitated TW in people with LTCs could be informative.

Practical considerations in the management of proton-pump inhibitors

Proton-pump inhibitors (PPIs) are one of the most active ingredients prescribed in Spain. In recent decades there has been an overuse of these drugs in both outpatient clinics and hospitals that has lead to a significant increase in healthcare spending and to an increase in the risk of possible side effects. It is important for health professionals to know the accepted indications and the correct doses for the use of these drugs. On the market there are different types of PPI: omeprazole, pantoprazole, lansoprazole, rabeprazole and esomeprazole. Omeprazole is the oldest and most used PPI, being also the cheapest. Although there are no important differences between PPIs in curing diseases, esomeprazole, a new-generation PPI, has proved to be more effective in eradicating H. pylori and in healing severe esophagitis compared to other PPIs. In recent years the use of generic drugs has spread; these drugs have the same bioavailability than the original drugs. In the case of PPIs, the few comparative studies available in the literature between original and generic drugs have shown no significant differences in clinical efficacy.

Insights into Neural Crest Evolution

Neural crest cells are unique to vertebrates and essential to the development and evolution of the craniofacial skeleton. Using a combination of DiI cell lineage tracing, transcriptomics, and analysis of key transcription factors of the Sox Family, I examined neural crest development in the sea lamprey, Petromyzon marinus, as the most basal extant vertebrate from which it is possible to get embryos. The results have uncovered distinct cranial and trunk neural crest subpopulations along the anterior-posterior axis of the lamprey embryo, with a clear separation between the two. However, no evidence of the presence of an intermediate vagal neural crest population was uncovered. Comparing cranial neural crest genes between lamprey and chick, either by examining individual candidate genes or whole genome transcriptome analysis, reveals significant changes in the cranial neural crest gene regulatory network of lamprey compared with chick. In particular, the lamprey cranial neural crest is "missing" several gnathostome cranial crest genes. We speculate that these may underlie the evolutionary divergence of craniofacial development between jawed and jawless vertebrates. Despite the absence of vagal neural crest, DiI-labeling shows that trunk neural crest-derived cells, likely homologous to mammalian Schwann cell precursors, contribute to the lamprey enteric nervous system, potentially representing the most primitive form of neural crest cells contribution to the ENS. Finally, I characterized key members of the Sox Family (Sox B-F) due to their importance in neural crest specification in other species. In comparative studies of the SoxC genes (Sox4, Sox11, and Sox12) in both lamprey and Xenopus, I found similar expression patterns and a novel key role in early neural crest specification, suggesting a conserved role of the SoxC genes amongst vertebrates. Taken together, this work represents important progress in characterizing the early evolution of the neural crest in vertebrates and its role in the transition from jawless to jawed vertebrates.

Utilização de um aplicativo de simulação computacional na avaliação de desempenho térmico de protótipo de habitação de interesse social (his)

This Masters Degree dissertation seeks to make a comparative study of internal air temperature data, simulated through the thermal computer application DesignBuilder 1.2, and data registered in loco through HOBO® Temp Data Logger, in a Social Housing Prototype (HIS), located at the Central Campus of the Federal University of Rio Grande do Norte UFRN. The prototype was designed and built seeking strategies of thermal comfort recommended for the local climate where the study was carried out, and built with panels of cellular concrete by Construtora DoisA, a collaborator of research project REPESC Rede de Pesquisa em Eficiência Energética de Sistemas Construtivos (Research Network on Energy Efficiency of Construction Systems), an integral part of Habitare program. The methodology employed carefully examined the problem, reviewed the bibliography, analyzing the major aspects related to computer simulations for thermal performance of buildings, such as climate characterization of the region under study and users thermal comfort demands. The DesignBuilder 1.2 computer application was used as a simulation tool, and theoretical alterations were carried out in the prototype, then they were compared with the parameters of thermal comfort adopted, based on the area s current technical literature. Analyses of the comparative studies were performed through graphical outputs for a better understanding of air temperature amplitudes and thermal comfort conditions. The data used for the characterization of external air temperature were obtained from the Test Reference Year (TRY), defined for the study area (Natal-RN). Thus the author also performed comparative studies for TRY data registered in the years 2006, 2007 and 2008, at weather station Davis Precision Station, located at the Instituto Nacional de Pesquisas Espaciais INPE-CRN (National Institute of Space Research), in a neighboring area of UFRN s Central Campus. The conclusions observed from the comparative studies performed among computer simulations, and the local records obtained from the studied prototype, point out that the simulations performed in naturally ventilated buildings is quite a complex task, due to the applications limitations, mainly owed to the complexity of air flow phenomena, the influence of comfort conditions in the surrounding areas and climate records. Lastly, regarding the use of the application DesignBuilder 1.2 in the present study, one may conclude that it is a good tool for computer simulations. However, it needs some adjustments to improve reliability in its use. There is a need for continued research, considering the dedication of users to the prototype, as well as the thermal charges of the equipment, in order to check sensitivity

Fotodegradação de pesticidas: caso do fenarimol

Tese dout. em Química, Unidade de Ciências Exactas e Humanas, Univ. do Algarve, 1997

A organização do processo de projeto de arquitetura no meio profissional: uma análise da produção em escritórios

This paper examines, through case studies, the organization of the production process of architectural projects in architecture offices in the city of Natal, specifically in relation to building projects. The specifics of the design process in architecture, the production of the project in a professional field in Natal, are studied in light of theories of design and its production process. The survey, in its different phases, was conducted between March 2010 and September 2012 and aimed to identify, understand, and analyze comparatively, by mapping the design process, the organization of production of building projects in two offices in Natal, checking as well the relationships of their agents during the process. The project was based on desk research and exploration, adopting, for both, data collection tools such as forms, questionnaires, and interviews. With the specific aim of mapping the design process, we adopted a technique that allows obtaining the information directly from employee agents involved in the production process. The technique consisted of registering information by completing daily, during or at the end of the workday, an individual virtual agenda, in which all agent collaborators described the tasks performed. The data collected allowed for the identification of the organizational structure of the office, its hierarchy, the responsibilities of agents, as well as the tasks performed by them during the two months of monitoring at each office. The research findings were based on analyses of data collected in the two offices and on comparative studies between the results of these analyses. The end result was a diagnostic evaluation that considered the level of organization and elaborated this perspective, as well as proposed solutions aimed at improving both the organization of the process and the relationships between the agents under the lens analyzed

L’utilisation libérale des transfusions de plaquettes dans la réanimation initiale des patients polytraumatisés

Cette revue systématique évalue l’effet d’une utilisation libérale de plaquettes (ratio élevé plaquettes:culots globulaires) en comparaison à une utilisation traditionnelle (faible ratio plaquettes:culots globulaires) dans la réanimation initiale des polytraumatisés. Parmi 6123 références identifiées, nous avons sélectionné 7 études observationnelles comparatives incluant au total 4230 patients. Quatre études ont rapporté une diminution de la mortalité avec des ratios plaquettes:culots globulaires élevés chez des patients transfusés massivement. Une étude sur des patients sans hémorragie massive et une étude sur un nouveau protocole de transfusion massive n’ont rapporté aucune différence. L’hétérogénéité clinique et les failles méthodologiques des études n’ont pas permis d’effectuer une méta-analyse. Les données probantes actuelles sont insuffisantes pour appuyer l’utilisation d’un ratio plaquettes:culots globulaires spécifique dans la réanimation des polytraumatisés, surtout en considérant le biais de survie et les hémorragies non massives. Des essais cliniques randomisés évaluant la sécurité et l’efficacité d’un ratio élevé plaquettes:culots globulaires sont nécessaires avant de recommander leur utilisation.

La actualización del modelo socialista y sus efectos en el Partido Comunista Cubano

El VI Congreso del Partido Comunista de Cuba introdujo una nueva agenda económica que el Gobierno llama la actualización del modelo socialista. Muchos piensan que en esencia se trata de una serie de reformas y reducen su importancia a su dimensión económica. Esta monografía busca explicar la actualización aplicando el análisis de sistemas-mundo de Immanuel Wallerstein, aportando una interpretación no convencional del fenómeno. Se puntualizará en las variables de poder y en los actores políticos que han determinado la nueva política económica: el Partido Comunista de Cuba (PCC) y las Fuerzas Armadas Revolucionarias (FAR). Ambos conforman lo que Wallerstein denomina un movimiento antisitémico. El argumento principal es que el movimiento ha puesto en marcha las reformas buscando fortalecer el Estado y así garantizar su supervivencia al consolidar su posición como el competidor único del poder estatal. Como se verá, estas metas han llevado al movimiento a sacrificar parte de su naturaleza antisistémica.

Los migrantes de la laguna: un estudio etnográfico sobre la construcción y configuración de los flujos migratorios de la comunidad Kichwa en Sesquilé

Esta tesis de grado se intereza por observar y análizar las red migratoria de los Kichwas de Sesquilé, especificamente en los procesos que permitieron la construcción y consolidación de las redes migratorias, las cuales se encienden o se apagan, a partir de las configuraciones políticas, religiosas, culturales y económicas que la comunidad ha experimentado.

Evaluating Theobroma grandiflorum for comparative genomic studies with Theobroma cacao

The seeds of Theobroma cacao (cacao) are the source of cocoa, the raw material for the multi-billion dollar chocolate industry. Cacao`s two most important traits are its unique seed storage triglyceride (cocoa butter) and the flavor of its fermented beans (chocolate). The genome of T. cacao is being sequenced, and to expand the utility of the genome sequence to the improvement of cacao, we are evaluating Theobroma grandiflorum, the closest economically important species of Theobroma for its potential use in a comparative genomic study. T. grandiflorum differs from cacao in important agronomic traits such as flavor of the fermented beans, disease resistance to witches` broom and abscission of mature fruits. By comparing genomic sequences and analyzing viable inter-specific hybrids, we hope to identify the key genes that regulate cacao`s most important traits. We have investigated the utility in T. grandiflorum of three types of markers (microsatellite markers, single-strand conformational polymorphism markers and single nucleotide polymorphism (SNP) markers) developed in cacao. Through sequencing of amplicons of 12 diverse individuals of both cacao and T. grandiflorum, we have identified new intra- and inter-specific SNPs. Two markers which had no overlap of alleles between the species were used to genotype putative inter-specific hybrid seedlings. Sequence conservation was significant and species-specific differences numerous enough to suggest that comparative genomics of T. grandiflorum and T. cacao will be useful in elucidating the genetic differences that lead to a variety of important agronomic trait differences.

Sex differences in heritability of BMI: A comparative study of results from twin studies in eight countries

Body mass index (BMI), a simple anthropometric measure, is the most frequently used measure of adiposity and has been instrumental in documenting the worldwide increase in the prevalence of obesity witnessed during the last decades. Although this increase in overweight and obesity is thought to be mainly due to environmental changes, i.e., sedentary lifestyles and high caloric diets, consistent evidence from twin studies demonstrates high heritability and the importance of genetic differences for normal variation in BMI. We analysed self-reported data on BMI from approximately 37,000 complete twin pairs (including opposite sex pairs) aged 20-29 and 30-39 from eight different twin registries participating in the GenomEUtwin project. Quantitative genetic analyses were conducted and sex differences were explored. Variation in BMI was greater for women than for men, and in both sexes was primarily explained by additive genetic variance in all countries. Sex differences in the variance components were consistently significant. Results from analyses of opposite sex pairs also showed evidence of sex-specific genetic effects suggesting there may be some differences between men and women in the genetic factors that influence variation in BMI. These results encourage the continued search for genes of importance to the body composition and the development of obesity. Furthermore, they suggest that strategies to identify predisposing genes may benefit from taking into account potential sex specific effects.