Chronic disease management programmes for adults with asthma (intervention Review)

BACKGROUND: The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education. OBJECTIVES: To evaluate the effectiveness of chronic disease management programmes for adults with asthma. SEARCH METHODS: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews. SELECTION CRITERIA: We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months. DATA COLLECTION AND ANALYSIS: After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs). MAIN RESULTS: A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes. AUTHORS' CONCLUSIONS: There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.

The First International Workshop on Warning Criteria for Active Slides: technical issues, problems and solutions for managing early warning systems

Early warning systems (EWSs) rely on the capacity to forecast a dangerous event with a certain amount of advance by defining warning criteria on which the safety of the population will depend. Monitoring of landslides is facilitated by new technologies, decreasing prices and easier data processing. At the same time, predicting the onset of a rapid failure or the sudden transition from slow to rapid failure and subsequent collapse, and its consequences is challenging for scientists that must deal with uncertainties and have limited tools to do so. Furthermore, EWS and warning criteria are becoming more and more a subject of concern between technical experts, researchers, stakeholders and decision makers responsible for the activation, enforcement and approval of civil protection actions. EWSs imply also a sharing of responsibilities which is often averted by technical staff, managers of technical offices and governing institutions. We organized the First International Workshop on Warning Criteria for Active Slides (IWWCAS) to promote sharing and networking among members from specialized institutions and relevant experts of EWS. In this paper, we summarize the event to stimulate discussion and collaboration between organizations dealing with the complex task of managing hazard and risk related to active slides.

Proton pump inhibitor-responsive oesophageal eosinophilia: an entity challenging current diagnostic criteria for eosinophilic oesophagitis.

Consensus diagnostic recommendations to distinguish GORD from eosinophilic oesophagitis (EoE) by response to a trial of proton pump inhibitors (PPIs) unexpectedly uncovered an entity called 'PPI-responsive oesophageal eosinophilia' (PPI-REE). PPI-REE refers to patients with clinical and histological features of EoE that remit with PPI treatment. Recent and evolving evidence, mostly from adults, shows that patients with PPI-REE and patients with EoE at baseline are clinically, endoscopically and histologically indistinguishable and have a significant overlap in terms of features of Th2 immune-mediated inflammation and gene expression. Furthermore, PPI therapy restores oesophageal mucosal integrity, reduces Th2 inflammation and reverses the abnormal gene expression signature in patients with PPI-REE, similar to the effects of topical steroids in patients with EoE. Additionally, recent series have reported that patients with EoE responsive to diet/topical steroids may also achieve remission on PPI therapy. This mounting evidence supports the concept that PPI-REE represents a continuum of the same immunological mechanisms that underlie EoE. Accordingly, it seems counterintuitive to differentiate PPI-REE from EoE based on a differential response to PPI therapy when their phenotypic, molecular, mechanistic and therapeutic features cannot be reliably distinguished. For patients with symptoms and histological features of EoE, it is reasonable to consider PPI therapy not as a diagnostic test, but as a therapeutic agent. Due to its safety profile, ease of administration and high response rates (up to 50%), PPI can be considered a first-line treatment before diet and topical steroids. The reasons why some patients with EoE respond to PPI, while others do not, remain to be elucidated.

Exploring new criteria to design materials for online education

Peer-reviewed

Comparing multiple criteria for species identification in two recently diverged seabirds

Correct species identification is a crucial issue in systematics with key implications for prioritising conservation effort. However, it can be particularly challenging in recently diverged species due to their strong similarity and relatedness. In such cases, species identification requires multiple and integrative approaches. In this study we used multiple criteria, namely plumage colouration, biometric measurements, geometric morphometrics, stable isotopes analysis (SIA) and genetics (mtDNA), to identify the species of 107 bycatch birds from two closely related seabird species, the Balearic (Puffinus mauretanicus) and Yelkouan (P. yelkouan) shearwaters. Biometric measurements, stable isotopes and genetic data produced two stable clusters of bycatch birds matching the two study species, as indicated by reference birds of known origin. Geometric morphometrics was excluded as a species identification criterion since the two clusters were not stable. The combination of plumage colouration, linear biometrics, stable isotope and genetic criteria was crucial to infer the species of 103 of the bycatch specimens. In the present study, particularly SIA emerged as a powerful criterion for species identification, but temporal stability of the isotopic values is critical for this purpose. Indeed, we found some variability in stable isotope values over the years within each species, but species differences explained most of the variance in the isotopic data. Yet this result pinpoints the importance of examining sources of variability in the isotopic data in a case-by-case basis prior to the cross-application of the SIA approach to other species. Our findings illustrate how the integration of several methodological approaches can help to correctly identify individuals from recently diverged species, as each criterion measures different biological phenomena and species divergence is not expressed simultaneously in all biological traits.

Partner Criteria and Life Cycle Impacts: Case UPM

The study examines partner selection criteria and the life cycle impacts on them. The target is to define the relevant criteria that should be applied in case of a partnership. In this context partnership means strategic supplier relationship. It is also examined how these criteria change on the different stages of the product and business life cycle. The empirical part is a description of developing Criteria selection tool in the case company. The study is conducted as a qualitative research using constructive and action research methodologies. The Criteria selection tool is a MS Excel workbook, giving the relevant set of supplier criteria depending on the business case. The most essential criteria, the tool will suggest for partner suppliers, are related to strategic fit, development potential and collaborative aspects. On the early stages of the life cycles the criteria related to research and development and growth potential are significant. On the late stages of the life cycles cost reduction potential becomes very important.

Threshold Selection Criteria for Quantification of Lumbosacral Cerebrospinal Fluid and Root Volumes from MRI

BACKGROUND AND PURPOSE: The high variability of CSF volumes partly explains the inconsistency of anesthetic effects, but may also be due to image analysis itself. In this study, criteria for threshold selection are anatomically defined. METHODS: T2 MR images (n = 7 cases) were analyzed using 3-dimentional software. Maximal-minimal thresholds were selected in standardized blocks of 50 slices of the dural sac ending caudally at the L5-S1 intervertebral space (caudal blocks) and middle L3 (rostral blocks). Maximal CSF thresholds: threshold value was increased until at least one voxel in a CSF area appeared unlabeled and decreased until that voxel was labeled again: this final threshold was selected. Minimal root thresholds: thresholds values that selected cauda equina root area but not adjacent gray voxels in the CSF-root interface were chosen. RESULTS: Significant differences were found between caudal and rostral thresholds. No significant differences were found between expert and nonexpert observers. Average max/min thresholds were around 1.30 but max/min CSF volumes were around 1.15. Great interindividual CSF volume variability was detected (max/min volumes 1.6-2.7). CONCLUSIONS: The estimation of a close range of CSF volumes which probably contains the real CSF volume value can be standardized and calculated prior to certain intrathecal procedures

Modern recovery boiler design criteria

Engineering and pricing of large recovery boiler were studied in this work. Engineering was carried out with Anita 4.2 which is an engineering program of Andritz. Key initial values were chosen with previous studies. Primary target of this work was to find out the consequences that furnace dimensions and furnace screen vertical part has to boiler pricing. Boilers that were engineered had different rate of furnace width and depth and different heat transfer plate count. Boiler balances were invariable. Boilers with different vertical screen construction were also calculated. First variation was boiler with vertical screen up to furnace roof. Other variation was to connect vertical screen to Pre-boiler generating bank inlet tubes. Total prices were calculated to engineered boilers. Pricing was sort out to heat transfers, high pressure pipes, steel structures, auxiliary equipments and civil/structural costs. This study did not notice parts of the boiler which costs do not vary with the construction of the boiler. Heat transfers had the largest share of costs. Boiler building had the most significant differences between the boilers. Furnace screen had also significant role especially to costs of the boiler building.

Methods for assessing the sustainability of integrated municipal waste management and

The general striving to bring down the number of municipal landfills and to increase the reuse and recycling of waste-derived materials across the EU supports the debates concerning the feasibility and rationality of waste management systems. Substantial decrease in the volume and mass of landfill-disposed waste flows can be achieved by directing suitable waste fractions to energy recovery. Global fossil energy supplies are becoming more and more valuable and expensive energy sources for the mankind, and efforts to save fossil fuels have been made. Waste-derived fuels offer one potential partial solution to two different problems. First, waste that cannot be feasibly re-used or recycled is utilized in the energy conversion process according to EU’s Waste Hierarchy. Second, fossil fuels can be saved for other purposes than energy, mainly as transport fuels. This thesis presents the principles of assessing the most sustainable system solution for an integrated municipal waste management and energy system. The assessment process includes: · formation of a SISMan (Simple Integrated System Management) model of an integrated system including mass, energy and financial flows, and · formation of a MEFLO (Mass, Energy, Financial, Legislational, Other decisionsupport data) decision matrix according to the selected decision criteria, including essential and optional decision criteria. The methods are described and theoretical examples of the utilization of the methods are presented in the thesis. The assessment process involves the selection of different system alternatives (process alternatives for treatment of different waste fractions) and comparison between the alternatives. The first of the two novelty values of the utilization of the presented methods is the perspective selected for the formation of the SISMan model. Normally waste management and energy systems are operated separately according to the targets and principles set for each system. In the thesis the waste management and energy supply systems are considered as one larger integrated system with one primary target of serving the customers, i.e. citizens, as efficiently as possible in the spirit of sustainable development, including the following requirements: · reasonable overall costs, including waste management costs and energy costs; · minimum environmental burdens caused by the integrated waste management and energy system, taking into account the requirement above; and · social acceptance of the selected waste treatment and energy production methods. The integrated waste management and energy system is described by forming a SISMan model including three different flows of the system: energy, mass and financial flows. By defining the three types of flows for an integrated system, the selected factor results needed in the decision-making process of the selection of waste management treatment processes for different waste fractions can be calculated. The model and its results form a transparent description of the integrated system under discussion. The MEFLO decision matrix has been formed from the results of the SISMan model, combined with additional data, including e.g. environmental restrictions and regional aspects. System alternatives which do not meet the requirements set by legislation can be deleted from the comparisons before any closer numerical considerations. The second novelty value of this thesis is the three-level ranking method for combining the factor results of the MEFLO decision matrix. As a result of the MEFLO decision matrix, a transparent ranking of different system alternatives, including selection of treatment processes for different waste fractions, is achieved. SISMan and MEFLO are methods meant to be utilized in municipal decision-making processes concerning waste management and energy supply as simple, transparent and easyto- understand tools. The methods can be utilized in the assessment of existing systems, and particularly in the planning processes of future regional integrated systems. The principles of SISMan and MEFLO can be utilized also in other environments, where synergies of integrating two (or more) systems can be obtained. The SISMan flow model and the MEFLO decision matrix can be formed with or without any applicable commercial or free-of-charge tool/software. SISMan and MEFLO are not bound to any libraries or data-bases including process information, such as different emission data libraries utilized in life cycle assessments.

The methodological criteria of counterpropositions within the Roman social legal framework

Partiendo de la difundida distinción, entre unos ordenamientos jurídicos abiertos, como el derecho inglés y el anglo americano, que se vinculan en el pasado al Derecho Romano, y otros cerrados o codificados, como los derechos del continente europeo, y tras detenernos en el origen terminológico de ambos sistemas y en su rígida contraposición, se procura destacar en este trabajo que Roma y su Derecho tampoco abrazan en toda su pureza, un sistema abierto.

Minimum-uncertaity states and pseudoclassical dynamics. II

The set of initial conditions for which the pseudoclassical evolution algorithm (and minimality conservation) is verified for Hamiltonians of degrees N (N>2) is explicitly determined through a class of restrictions for the corresponding classical trajectories, and it is proved to be at most denumerable. Thus these algorithms are verified if and only if the system is quadratic except for a set of measure zero. The possibility of time-dependent a-equivalence classes is studied and its physical interpretation is presented. The implied equivalence of the pseudoclassical and Ehrenfest algorithms and their relationship with minimality conservation is discussed in detail. Also, the explicit derivation of the general unitary operator which linearly transforms minimum-uncertainty states leads to the derivation, among others, of operators with a general geometrical interpretation in phase space, such as rotations (parity, Fourier).

Safety Culture and Maritime Personnel’s Safety Attitudes: Interview Report

”METKU –projektissa” (Merenkulun turvallisuuskulttuurin kehittäminen) tutkitaan kansainvälisen turvallisuusjohtamiskoodin (ISM-koodin) vaikutuksia merenkulun turvallisuuteen ja etsitään kehittämiskohteita merenkulun turvallisuusjohtamisen parantamiseksi. Tämä haastatteluraportti on laadittu METKU –projektin yhteistyössä työpakettien 1 ja 2 kesken. Tähän raporttiin haastateltiin yhteensä 94 merenkulun ammattilaista. Suurimman osan haastateltavista muodostivat aktiiviset merenkulkijat: miehistön jäsenet, päällystö ja alusten päälliköt. Haastattelukohteena oli seitsemän suomalaista varustamoa. Haastatteluissa kerättiin merenkulkijoiden kokemuksia ja mielipiteitä ISM-koodin vaikutuksesta heidän käytännön työhönsä. Suomalaiset merenkulkijat uskovat, että tänä päivänä varustamoiden johtajat ovat hyvin sitoutuneita turvallisuuteen. Myös miehistön asenteet turvallisuuteen ovat ISM-koodin käytön myötä parantuneet. Haasteltavien yhteinen huoli kohdistui jatkuvan parantamisen toimivuuteen. Kaikki haastatellut ryhmät olivat samaa mieltä siitä, että poikkeamien raportointi ei ISMkoodin vaatimuksesta huolimatta toimi kunnolla. ISM-koodin käyttöön otosta on ollut merenkululle selkeää hyötyä. Haastateltavat esittivät hyötyinä parantuneen yhteistyön ja tiedonkulun alusten ja varustamon välillä sekä sen, että merenkulun toiminnan laatu on parantunut. Monet haastateltavat korostivat, että ISM-koodin selkeät turvallisuusvastuut yhtiölle on ollut merkittävä hyöty. Itse ISM-koodiin merenkulkijoilla ei ollut juurikaan huomauttamista. Sen sijaan turvallisuusjohtamisen käytännön toteutuksessa nähtiin parantamisen varaa. ISMkoodin aiheuttamina ongelmina mainittiin mm. lisääntynyt byrokratia ja liian monimutkaiset ja yksityiskohtaiset turvallisuuskäsikirjat. Monet haastateltavat toivovat, että ISM-koodin käytännön soveltamiseen laadittaisiin ohjeita.

Development of an instrument to measure the degree of critical patient's satisfaction with nursing care: research protocol

Aim: To investigate and understand patient's satisfaction with nursing care in the intensive care unit to identify the dimensions of the concept of"satisfaction" from the patient's point of view. To design and validate a questionnaire that measures satisfaction levels in critical patients. Background: There are many instruments capable of measuring satisfaction with nursing care; however, they do not address the reality for critical patients nor are they applicable in our context. Design: A dual approach study comprising: a qualitative phase employing Grounded Theory and a quantitative and descriptive phase to prepare and validate the questionnaire. Methods: Data collection in the qualitative phase will consist of: in-depth interview after theoretical sampling, on-site diary and expert discussion group. The sample size will depend on the expected theoretical saturation n = 27-36. Analysis will be based on Grounded Theory. For the quantitative phase, the sampling will be based on convenience (n = 200). A questionnaire will be designed on the basis of qualitative data. Descriptive and inferential statistics will be used. The validation will be developed on the basis of the validity of the content, the criteria of the construct and reliability of the instrument by the Cronbach's alpha and test-retest approach. Approval date for this protocol was November 2010. Discussion: Self-perceptions, beliefs, experiences, demographic, socio-cultural epistemological and political factors are determinants for satisfaction, and these should be taken into account when compiling a questionnaire on satisfaction with nursing care among critical patients.

Caracterização do mel produzido por espécies de Melipona Illiger, 1806 (apidae: meliponini) da região nordeste do Brasil: 1. Características físico-químicas

Thirty three honey samples produced by four Melipona species from different areas of the State of Bahia, were analyzed with the aim to determine their physico-chemical characteristics, contributing to the establishment of standards for quality control. The majority of the average values for physico-chemical parameters fulfilled the quality criteria established by the Brazilian and international Legislations for Apis honey, except for moisture content, which afforded higher values. Concerning the high number of samples wich did not fit the limits for reducing sugars, it is necessary to define minimum values in order to characterize Melipona honeys, as well as criteria for use of diastasic activity.