When "enough" is not enough: new perspectives on optimal methadone maintenance dose.

Some methadone maintenance treatment (MMT) programs prescribe inadequate daily methadone doses. Patients complain of withdrawal symptoms and continue illicit opioid use, yet practitioners are reluctant to increase doses above certain arbitrary thresholds. Serum methadone levels (SMLs) may guide practitioners dosing decisions, especially for those patients who have low SMLs despite higher methadone doses. Such variation is due in part to the complexities of methadone metabolism. The medication itself is a racemic (50:50) mixture of 2 enantiomers: an active "R" form and an essentially inactive "S" form. Methadone is metabolized primarily in the liver, by up to five cytochrome P450 isoforms, and individual differences in enzyme activity help explain wide ranges of active R-enantiomer concentrations in patients given identical doses of racemic methadone. Most clinical research studies have used methadone doses of less than 100 mg/day [d] and have not reported corresponding SMLs. New research suggests that doses ranging from 120 mg/d to more than 700 mg/d, with correspondingly higher SMLs, may be optimal for many patients. Each patient presents a unique clinical challenge, and there is no way of prescribing a single best methadone dose to achieve a specific blood level as a "gold standard" for all patients. Clinical signs and patient-reported symptoms of abstinence syndrome, and continuing illicit opioid use, are effective indicators of dose inadequacy. There does not appear to be a maximum daily dose limit when determining what is adequately "enough" methadone in MMT.

Performance of mechanical ventilators at the patient's home: a multicentric quality control study

Background: Quality control procedures vary considerably among the providers of equipment for home mechanical ventilation (HMV). Methods: A multicentre quality control survey of HMV was performed at the home of 300 patients included in the HMV programmes of four hospitals in Barcelona. It consisted of three steps: (1) the prescribed ventilation settings, the actual settings in the ventilator control panel, and the actual performance of the ventilator measured at home were compared; (2) the different ventilator alarms were tested; and (3) the effect of differences between the prescribed settings and the actual performance of the ventilator on non-programmed readmissions of the patient was determined. Results: Considerable differences were found between actual, set, and prescribed values of ventilator variables; these differences were similar in volume and pressure preset ventilators. The percentage of patients with a discrepancy between the prescribed and actual measured main ventilator variable (minute ventilation or inspiratory pressure) of more than 20% and 30% was 13% and 4%, respectively. The number of ventilators with built in alarms for power off, disconnection, or obstruction was 225, 280 and 157, respectively. These alarms did not work in two (0.9%), 52 (18.6%) and eight (5.1%) ventilators, respectively. The number of non-programmed hospital readmissions in the year before the study did not correlate with the index of ventilator error. Conclusions: This study illustrates the current limitations of the quality control of HMV and suggests that improvements should be made to ensure adequate ventilator settings and correct ventilator performance and ventilator alarm operation.

Late and post-Hercyniam low temperature veins in the Catalonian Coastal Ranges

Many of the veins enclosed within the Paleozoic basement of the Catalonian Coastal Ranges show severa1 common characteristics: low temperature of formation (between 75 and 200C), the presence of complex polisaline fluids and a certain relationship to the pretriassic paleosurface. Mineralogical composition and age are variable, ranging from Pb-Zn veins with carbonate gangue of late Hercynian age through metal poor fluorite rich veins to barite rich veins of Triasssic age. Mineralizing fluids are not related to late Hercynianmagmatism and deposition took place in active fractures developed either in extensional as in compressive regimes.

The Hercynian ore deposits from the Catalonian Coastal Ranges

Many mineralizations, showings and geochemical anomalies have been found in the Hercynian of the Catalonian Coastal Ranges during the last ten years. Many of them are enclosed in the Paleozoic sediments and volcanics and display pre-metamorphic syngenetic characteristics. The lower carboniferous manganese and base meta1 deposits appear to be formed from hydrothermal fluids springing up in the sea floor through active fractures controlling the filling of the basins in a extensional geotectonic setting. Although less evidence and more controversy is available, similar ore forming processes could have taken place in older Paleozoic times. The deformation and metamorphism have not played an important remobilization role, and most epigenetic deposits of Hercynian age are related to the hydrothermal cells induced by the post-metamorphic granitic intrusives.

Consumer Advisory Bulletin, Credit Cards vs. Nailing Down Home Repair Rip-Offs & Disputes, April 2011

The Attorney General’s Consumer Protection Division receives hundreds of calls and consumer complaints every year. Follow these tips to avoid unexpected expense and disappointments. This record is about: Nailing Down Home Repair Rip-Offs & Disputes

A territorial model of commuting in Catalonia, 1986-1996

Commuting consists in the fact that an important fraction of workers in developed countries do not reside close to their workplaces but at long distances from them, so they have to travel to their jobs and then back home daily. Although most workers hold a job in the same municipality where they live or in a neighbouring one, an important fraction of workers face long daily trips to get to their workplace and then back home.Even if we divide Catalonia (Spain) in small aggregations of municipalities, trying to make them as close to local labour markets as possible, we will find out that some of them have a positive commuting balance, attracting many workers from other areas and providing local jobs for almost all their resident workers. On the other side, other zones seem to be mostly residential, so an important fraction of their resident workers hold jobs in different local labour markets. Which variables influence an area¿s role as an attraction pole or a residential zone? In previous papers (Artís et al, 1998a, 2000; Romaní, 1999) we have brought out the main individual variables that influence commuting by analysing a sample of Catalan workers and their commuting decisions. In this paper we perform an analysis of the territorial variables that influence commuting, using data for aggregate commuting flows in Catalonia from the 1991 and 1996 Spanish Population Censuses.These variables influence commuting in two different ways: a zone with a dense, welldeveloped economical structure will have a high density of jobs. Work demand cannot be fulfilled with resident workers, so it spills over local boundaries. On the other side, this economical activity has a series of side-effects like pollution, congestion or high land prices which make these areas less desirable to live in. Workers who can afford it may prefer to live in less populated, less congested zones, where they can find cheaper land, larger homes and a better quality of life. The penalty of this decision is an increased commuting time. Our aim in this paper is to highlight the influence of local economical structure and amenities endowment in the workplace-residence location decision. A place-to-place logit commuting models is estimated for 1991 and 1996 in order to find the economical and amenities variables with higher influence in commuting decisions. From these models, we can outline a first approximation to the evolution of these variables in the 1986-1996 period. Data have been obtained from aggregate flow travel-matrix from the 1986, 1991 and 1996 Spanish Population Censuses

Delirium in elderly patients hospitalized in an acute care unit.

Introduction: Delirium is frequent in hospitalized older people, with incidence rate up to 40% in acute care. Delirium is associated with several adverse consequences, including increased mortality and institutionalization. This study aims to investigate the prevalence, incidence, and consequences of delirium in patients hospitalized in an acute care unit for elderly (ACE unit). Methods: Over a 3 months period, every patient (N = 93, mean age 84.1 ± 7.8 years, 66/93(71%) women) admitted to a 28-bed ACE unit were systematically assessed for delirium. Trained nurses used the Confusion Assessment Method (CAM) instrument to determine the presence of delirium at admission and on each subsequent day over patients' stay. Delirium prevalence rate was defined as the proportion of patients with a positive CAM within 24 hours of admission to the ACE unit. Delirium incidence rate was defined as the proportion of patients with a negative CAM at admission whose CAM became positive at least once during their stay. This evaluation was part of a functional assessment, including Basic Activities of Daily Life (Katz BADL, from 0 to 6, higher score indicating better function). Delirium prevention interventions and specific treatment was provided if needed. Results: Overall,25/93(27%)patients had delirium during their stay. Prevalence of delirium at admission was 10/93 (11%), with an incidence of 15/83(18%). Compared with non-delirious patients, those with delirium were more frequently men (10/25(40%) vs 17/68(25%), p <.001) and had reduced functional status at admission(BADL 2.0 ± 1.9 vs 3.6 ± 2.1, p = .004). They tended to be older (86.0 ± 6.7 vs 83.3 ± 8.1 years, p = .110). At discharge, delirium was associated with reduced functional status (BADL 2.0 ± 2.1 vs 4.3 ± 1.9, p <.001), lower rate of home discharge (6/20(30%) vs 28/65 (43%), p = .009) and increased mortality (5/25 (20%) vs 3/68 (5%), p <.001). On average, patients with delirium stayed 5.7 days longer (17.0 ± 9.8 vs 11.31 ± 6.3, p = .011). Conclusion: Delirium occurred in almost a third of these older patients, even though its incidence was relatively low in this frail population. Despite specific management, delirium remained associated with higher risk for adverse outcomes at discharge. These results suggest that early preventive interventions, implemented as soon as possible after hospital admission, might be needed in similar population to achieve better outcomes. Effectiveness of such interventions will be evaluated in future studies.

Positional therapy for obstructive sleep apnea: an objective measurement of patients' usage and efficacy at home.

BACKGROUND: Positional therapy that prevents patients from sleeping supine has been used for many years to manage positional obstructive sleep apnea (OSA). However, patients' usage at home and the long term efficacy of this therapy have never been objectively assessed.¦METHODS: Sixteen patients with positional OSA who refused or could not tolerate continuous positive airway pressure (CPAP) were enrolled after a test night study (T0) to test the efficacy of the positional therapy device. The patients who had a successful test night were instructed to use the device every night for three months. Nightly usage was monitored by an actigraphic recorder placed inside the positional device. A follow-up night study (T3) was performed after three months of positional therapy.¦RESULTS: Patients used the device on average 73.7 ± 29.3% (mean ± SD) of the nights for 8.0 ± 2.0 h/night. 10/16 patients used the device more than 80% of the nights. Compared to the baseline (diagnostic) night, mean apnea-hypopnea index (AHI) decreased from 26.7 ± 17.5 to 6.0 ± 3.4 with the positional device (p<0.0001) during T0 night. Oxygen desaturation (3%) index also fell from 18.4 ± 11.1 to 7.1 ± 5.7 (p = 0.001). Time spent supine fell from 42.8 ± 26.2% to 5.8 ± 7.2% (p < 0.0001). At three months (T3), the benefits persisted with no difference in AHI (p = 0.58) or in time spent supine (p = 0.98) compared to T0 night. The Epworth sleepiness scale showed a significant decrease from 9.4 ± 4.5 to 6.6 ± 4.7 (p = 0.02) after three months.¦CONCLUSIONS: Selected patients with positional OSA can be effectively treated by a positional therapy with an objective compliance of 73.7% of the nights and a persistent efficacy after three months.

A territorial model of commuting in Catalonia, 1986-1996

Commuting consists in the fact that an important fraction of workers in developed countries do not reside close to their workplaces but at long distances from them, so they have to travel to their jobs and then back home daily. Although most workers hold a job in the same municipality where they live or in a neighbouring one, an important fraction of workers face long daily trips to get to their workplace and then back home.Even if we divide Catalonia (Spain) in small aggregations of municipalities, trying to make them as close to local labour markets as possible, we will find out that some of them have a positive commuting balance, attracting many workers from other areas and providing local jobs for almost all their resident workers. On the other side, other zones seem to be mostly residential, so an important fraction of their resident workers hold jobs in different local labour markets. Which variables influence an area¿s role as an attraction pole or a residential zone? In previous papers (Artís et al, 1998a, 2000; Romaní, 1999) we have brought out the main individual variables that influence commuting by analysing a sample of Catalan workers and their commuting decisions. In this paper we perform an analysis of the territorial variables that influence commuting, using data for aggregate commuting flows in Catalonia from the 1991 and 1996 Spanish Population Censuses.These variables influence commuting in two different ways: a zone with a dense, welldeveloped economical structure will have a high density of jobs. Work demand cannot be fulfilled with resident workers, so it spills over local boundaries. On the other side, this economical activity has a series of side-effects like pollution, congestion or high land prices which make these areas less desirable to live in. Workers who can afford it may prefer to live in less populated, less congested zones, where they can find cheaper land, larger homes and a better quality of life. The penalty of this decision is an increased commuting time. Our aim in this paper is to highlight the influence of local economical structure and amenities endowment in the workplace-residence location decision. A place-to-place logit commuting models is estimated for 1991 and 1996 in order to find the economical and amenities variables with higher influence in commuting decisions. From these models, we can outline a first approximation to the evolution of these variables in the 1986-1996 period. Data have been obtained from aggregate flow travel-matrix from the 1986, 1991 and 1996 Spanish Population Censuses

Testing the bivariate distribution of daily equity returns using copulas: an application to the Spanish stock market

In this paper we deal with the identification of dependencies between time series of equity returns. Marginal distribution functions are assumed to be known, and a bivariate chi-square test of fit is applied in a fully parametric copula approach. Several families of copulas are fitted and compared with Spanish stock market data. The results show that the t-copula generally outperforms other dependence structures, and highlight the difficulty in adjusting a significant number of bivariate data series