Challenges, Strengths and Opportunities Related to Implementing Comprehensive Evidence-Based Guidelines on Breast Cancer Survivorship Care by Primary Care Physicians and Nurse Practitioners in Southeastern Ontario

Background Many breast cancer survivors continue to have a broad range of physical and psychosocial problems after breast cancer treatment. As cancer centres move forward with earlier discharge of stable breast cancer survivors to primary care follow-up it is important that comprehensive evidence-based breast cancer survivorship care is implemented to effectively address these needs. Research suggests primary care providers are willing to provide breast cancer survivorship care but many lack the knowledge and confidence to provide evidence-based care. Purpose The overall purpose of this thesis was to determine the challenges, strengths and opportunities related to implementing comprehensive evidence-based breast cancer survivorship guidelines by primary care physicians and nurse practitioners in southeastern Ontario. Methods This mixed-methods research was conducted in three phases: (1) synthesis and appraisal of clinical practice guidelines relevant to provision of breast cancer survivorship care within the primary care practice setting; (2) a brief quantitative survey of primary care providers to determine actual practices related to provision of evidence-based breast cancer survivorship care; and (3) individual interviews with primary care providers about the challenges, strengths and opportunities related to provision of comprehensive evidence-based breast cancer survivorship care. Results and Conclusions In the first phase, a comprehensive clinical practice framework was created to guide provision of breast cancer survivorship care and consisted of a one-page checklist outlining breast cancer survivorship issues relevant to primary care, a three-page summary of key recommendations, and a one-page list of guideline sources. The second phase identified several knowledge and practice gaps, and it was determined that guideline implementation rates were higher for recommendations related to prevention and surveillance aspects of survivorship care and lowest related to screening for and management of long-term effects. The third phase identified three major challenges to providing breast cancer survivorship care: inconsistent educational preparation, provider anxieties, and primary care burden; and three major strengths or opportunities to facilitate implementation of survivorship care guidelines: tools and technology, empowering survivors, and optimizing nursing roles. A better understanding of these challenges, strengths and opportunities will inform development of targeted knowledge translation interventions to provide support and education to primary care providers.

Modelleren en formaliseren in de rekenwiskundeles

Lenferink, M. (2016).Modelleren en formaliseren in de rekenwiskundeles: Versterken van de kwaliteit van de rekenwiskunde-instructie door vakspecifieke feedback. Juli, 25, 2016, Heerlen, Nederland:Open Universiteit.

Extracting Patterns from Educational Traces via Clustering and Associated Quality Metrics

Clustering algorithms, pattern mining techniques and associated quality metrics emerged as reliable methods for modeling learners’ performance, comprehension and interaction in given educational scenarios. The specificity of available data such as missing values, extreme values or outliers, creates a challenge to extract significant user models from an educational perspective. In this paper we introduce a pattern detection mechanism with-in our data analytics tool based on k-means clustering and on SSE, silhouette, Dunn index and Xi-Beni index quality metrics. Experiments performed on a dataset obtained from our online e-learning platform show that the extracted interaction patterns were representative in classifying learners. Furthermore, the performed monitoring activities created a strong basis for generating automatic feedback to learners in terms of their course participation, while relying on their previous performance. In addition, our analysis introduces automatic triggers that highlight learners who will potentially fail the course, enabling tutors to take timely actions.

Selective serotonin reuptake inhibitor antidepressant use in first trimester pregnancy and risk of specific congenital anomalies: a European register-based study

Evidence of an association between early pregnancy exposure to selective serotonin reuptake inhibitors (SSRI) and congenital heart defects (CHD) has contributed to recommendations to weigh benefits and risks carefully. The objective of this study was to determine the specificity of association between first trimester exposure to SSRIs and specific CHD and other congenital anomalies (CA) associated with SSRI exposure in the literature (signals). A population-based case-malformed control study was conducted in 12 EUROCAT CA registries covering 2.1 million births 1995-2009 including livebirths, fetal deaths from 20 weeks gestation and terminations of pregnancy for fetal anomaly. Babies/fetuses with specific CHD (n = 12,876) and non-CHD signal CA (n = 13,024), were compared with malformed controls whose diagnosed CA have not been associated with SSRI in the literature (n = 17,083). SSRI exposure in first trimester pregnancy was associated with CHD overall (OR adjusted for registry 1.41, 95% CI 1.07-1.86, fluoxetine adjOR 1.43 95% CI 0.85-2.40, paroxetine adjOR 1.53, 95% CI 0.91-2.58) and with severe CHD (adjOR 1.56, 95% CI 1.02-2.39), particularly Tetralogy of Fallot (adjOR 3.16, 95% CI 1.52-6.58) and Ebstein's anomaly (adjOR 8.23, 95% CI 2.92-23.16). Significant associations with SSRI exposure were also found for ano-rectal atresia/stenosis (adjOR 2.46, 95% CI 1.06-5.68), gastroschisis (adjOR 2.42, 95% CI 1.10-5.29), renal dysplasia (adjOR 3.01, 95% CI 1.61-5.61), and clubfoot (adjOR 2.41, 95% CI 1.59-3.65). These data support a teratogenic effect of SSRIs specific to certain anomalies, but cannot exclude confounding by indication or associated factors.

The Outer Solar Systems Origins Survey. I. Design and First-quarter Discoveries

We report the discovery, tracking, and detection circumstances for 85 trans-Neptunian objects (TNOs) from the first 42 deg2 of the Outer Solar System Origins Survey. This ongoing r-band solar system survey uses the 0.9 deg2 field of view MegaPrime camera on the 3.6 m Canada–France–Hawaii Telescope. Our orbital elements for these TNOs are precise to a fractional semimajor axis uncertainty <0.1%. We achieve this precision in just two oppositions, as compared to the normal three to five oppositions, via a dense observing cadence and innovative astrometric technique. These discoveries are free of ephemeris bias, a first for large trans-Neptunian surveys. We also provide the necessary information to enable models of TNO orbital distributions to be tested against our TNO sample. We confirm the existence of a cold "kernel" of objects within the main cold classical Kuiper Belt and infer the existence of an extension of the "stirred" cold classical Kuiper Belt to at least several au beyond the 2:1 mean motion resonance with Neptune. We find that the population model of Petit et al. remains a plausible representation of the Kuiper Belt. The full survey, to be completed in 2017, will provide an exquisitely characterized sample of important resonant TNO populations, ideal for testing models of giant planet migration during the early history of the solar system.

Wenn Kinder töten (müssen) : eine kindheitswissenschaftliche Betrachtung von Schutzmöglichkeiten und Lebensrealitäten von Kindersoldaten

[s.c.]

Politics and protestant Lordship in North East Scotland during the reign of James VI: The life of George Keith, fourth Earl Marischal, 1554-1623

George Keith, fourth Earl Marischal is a case study of long-term, quietly successful and stable lordship through the reign of James VI. Marischal’s life provides a wholly underrepresented perspective on this era, where the study of rebellious and notorious characters has dominated. He is also a counter-example to the notion of a general crisis among the European nobility, at least in the Scottish context, as well as to the notion of a ‘conservative’ or ‘Catholic’ north east. In 1580 George inherited the richest earldom in Scotland, with a geographical extent stretching along the east coast from Caithness to East Lothian. His family came to be this wealthy as a long term consequence of the Battle of Flodden (1513) where a branch of the family, the Inverugie Keiths had been killed. The heiress of this branch was married to the third earl and this had concentrated a large number of lands, and consequently wealth, in the hands of the earls. This had, however, also significantly decreased the number of members and hence power of the Keith kindred. The third earl’s conversion to Protestantism in 1544 and later his adherence to the King’s Party during the Marian Civil War forced the Keiths into direct confrontation with their neighbours in the north east, the Gordons (led by the Earls of Huntly), a Catholic family and supporters of the Queen’s Party. Although this feud was settled for a time at the end of the war, the political turmoil caused by a succession of short-lived factional regimes in the early part of the personal reign of James VI (c.1578-1585) led the new (fourth) Earl Marischal into direct confrontation with the new (sixth) Earl of Huntly. Marischal was outclassed, outmanoeuvred and outgunned at both court and in the locality in this feud, suffering considerably. However, Huntly’s over-ambition in wider court politics meant that Marischal was able to join various coalitions against his rival, until Huntly was exiled in 1595. Marischal also came into conflict briefly with Chancellor John Maitland of Thirlestane as a consequence of Marischal’s diplomatic mission to Denmark in 1589-1590, but was again outmatched politically and briefly imprisoned. Both of these feuds reveal Marischal to be relatively cautious and reactionary, and both reveal the limitations of his power. Elsewhere, the study of Marischal’s activities in the centre of Scottish politics reveal him to be unambitious. He was ready to serve King James, the two men having a healthy working relationship, but Marischal showed no ambition as a courtier, to woo the king’s favour or patronage, instead delegating interaction with the monarch to his kinsmen. Likewise, in government, Marischal rarely attended any of the committees he was entitled to attend, such as the Privy Council, although he did keep a keen eye on the land market and the business conducted under the Great Seal. Although personally devout and a committed Protestant, the study of Marischal’s interaction with the national Kirk and the parishes of which he was patron reveal that he was at times a negligent patron and exercised his right of ministerial presentation as lordly, not godly patronage. The notion of a ‘conservative North East’ is, however, rejected. Where Marischal was politically weak at court and weak in terms of force in the locality, we see him pursuing sideways approaches to dealing with this. Thus he was keen to build up his general influence in the north and in particular with the burgh of Aberdeen (one result of this being the creation of Marischal College in 1593), pursued disputes through increasing use of legal methods rather than bloodfeud (thus exploiting his wealth and compensating for his relative lack of force) and developed a sophisticated system of maritime infrastructure, ultimately expressed through the creating of the burghs of Peterhead and Stonehaven. Although his close family caused him a number of problems over his lifetime, he was able to pass on a stable and enlarged lordship to his son in 1623.

Otimização e validação de métodos empregando DLLME e DLLME-SFO para a extração simultânea de agrotóxicos multiclasse em água mineral

O Rio Grande Sul destaca-se no cenário nacional como grande produtor de diversas culturas, as quais demandam grande quantidade de agrotóxicos das mais diversas classes químicas e toxicidades. No entanto a intensa utilização destes compostos torna-se uma preocupação devido a possíveis contaminações das águas superficiais e subterrâneas. Em virtude da degradação dos mananciais a água mineral passou a ser uma das fontes mais utilizadas para o consumo humano, pois tem-se a percepção de que a mesma possui melhor qualidade que a água tratada, além disso acredita-se que a mesma esta isenta de substâncias orgânicas prejudiciais à saúde humana. Neste trabalho, foi realizada a determinação dos agrotóxicos atrazina, simazina, imazapique, imazetapir, imidacloprido, ciproconazol, tebuconazol e epoxiconazol em água mineral empregando a Microextração Líquido-Líquido Dispersiva (DLLME), Microextração Líquido-Líquido Dispersiva com Solidificação da Gota Orgânica Flutuante (DLLME-SFO) e Cromatografia Líquida acoplada à Espectrometria de Massas em série com fonte de ionização por Eletronebulização (LC-ESI-MS/MS). Para o método empregando DLLME e LC-ESI-MS/MS foram otimizados alguns fatores como o tipo e volume de solvente extrator e dispersor e pH. Após a otimização dos parâmetros de extração, fragmentação dos compostos e separação cromatográfica, o método foi validado avaliando-se curva analítica, linearidade, limites de detecção e quantificação, precisão (repetitividade e precisão intermediária) e exatidão (recuperação). Todas as curvas analíticas apresentaram valores de r maiores que 0,999. Os Limites de Quantificação (LOQs) para o método estiveram na faixa de 5 a 500 ng L-1. Foram obtidas recuperações entre 102 - 120% para a repetibilidade e entre 92 e 110% para a precisão intermediária, com RSD de 2 a 10% para todos os compostos. Para o método empregando DLLME-SFO e LC-ESI-MS/MS foram avaliados alguns parâmetros que afetam a eficiência da extração como, tipo e volume de solvente extrator e dispersor, força iônica e pH. Nas condições ótimas de extração todas as curvas analíticas apresentaram valores de r maiores que 0,997. Os LOQs para o método variaram entre 12,5 - 125 ng L-1. As recuperações foram entre 70 e 118% para a repetitividade e entre 76 e 95% para a precisão intermediária, com RSD de 2 a 18% para todos os compostos. Com relação ao Efeito Matriz (EM) avaliado para todos os compostos pelos dois métodos, foi observado baixo EM. Isso indicou que não é necessário utilizar a curva analítica preparada no extrato branco da matriz para a quantificação destes analitos. Ambos os métodos foram aplicados para a determinação de resíduos de agrotóxicos em amostras de água mineral provenientes de diferentes regiões do estado do Rio Grande do Sul e não foram encontrados resíduos de agrotóxicos nas amostras analisadas. Os métodos validados apresentaram como principais vantagens baixo consumo de solventes orgânicos e amostra, rapidez, altos fatores de concentração e recuperações dentro da faixa aceitável. Os limites de quantificação dos métodos ficaram abaixo dos limites máximos de resíduos permitidos pela legislação brasileira para agrotóxicos em água mineral.

Aparycje współczesności

Książka zawiera opisy i rozważania dotyczące kultury współczesnej, jej przejawów oraz zagrożeń.

De la cooperativa agroalimentaria a la “Learning Netchain". Hacia un planteamiento teórico interorganizativo e interpersonal

Se propone un planteamiento teórico/conceptual para determinar si las relaciones interorganizativas e interpersonales de la netchain de las cooperativas agroalimentarias evolucionan hacia una learning netchain. Las propuestas del trabajo muestran que el mayor grado de asociacionismo y la mayor cooperación/colaboración vertical a lo largo de la cadena están positivamente relacionados con la posición horizontal de la empresa focal más cercana del consumidor final. Esto requiere una planificación y una resolución de problemas de manera conjunta, lo que está positivamente relacionado con el mayor flujo y diversidad de la información/conocimiento obtenido y diseminado a lo largo de la netchain. Al mismo tiempo se necesita desarrollar un contexto social en el que fluya la información/conocimiento y las nuevas ideas de manera informal y esto se logra con redes personales y, principalmente, profesionales y con redes internas y, principalmente, externas. Todo esto permitirá una mayor satisfacción de los socios de la cooperativa agroalimentaria y de sus distribuidores y una mayor intensidad en I+D, convirtiéndose la netchain de la cooperativa agroalimentaria, así, en una learning netchain.

El vínculo en Arteterapia médica.

Este trabajo de investigación tiene como tema central el vínculo en sesiones de arteterapia con niños hospitalizados. Su objetivo principal es identificar aquellos elementos que favorezcan la relación entre terapeuta y paciente que se han podido comprobar en el ejercicio de la práctica académica en hospitales infantiles de la Comunidad de Madrid. Se ha elaborado siguiendo los planteamientos de la metodología cualitativa y concretamente los paradigmas fenomenológico y reflexivo y el método de estudio de casos múltiple. Para acercar al lector a la comprensión de estas temáticas se ha revisado la teoría de Winnicott, y Melanie Klein, fundamentalmente, considerando la teoría de las relaciones objetales y la constitución del Yo como piedras angulares para la fundamentación teórica del mismo. Así mismo, se expone el perfil de paciente pediátrico y el concepto de hospitalismo que define los posibles efectos que causa la hospitalización en los niños. También, se revisan las cualidades del arteterapia y se analiza su indicación en el contexto hospitalario donde el arteterapeuta ayudará a constituir un ambiente de sostén y posibilidad creadora que permitirá al paciente conectar con la capacidad y por tanto, reconectar con la salud. Como conclusión se afirma que existen elementos favorecedores del vínculo en arteterapia médica y que este está condicionado en gran medida por el marco institucional y sus profesionales, así como por los familiares del paciente y la salud del paciente.

High bandwidth freestanding semipolar (11–22) InGaN/GaN light-emitting diodes

Freestanding semipolar (11–22) indium gallium nitride (InGaN) multiplequantum-well light-emitting diodes (LEDs) emitting at 445 nm have been realized by the use of laser lift-off (LLO) of the LEDs from a 50- m-thick GaN layer grown on a patterned (10–12) r -plane sapphire substrate (PSS). The GaN grooves originating from the growth on PSS were removed by chemical mechanical polishing. The 300 m × 300 m LEDs showed a turn-on voltage of 3.6 V and an output power through the smooth substrate of 0.87 mW at 20 mA. The electroluminescence spectrum of LEDs before and after LLO showed a stronger emission intensity along the [11–23]InGaN/GaN direction. The polarization anisotropy is independent of the GaN grooves, with a measured value of 0.14. The bandwidth of the LEDs is in excess of 150 MHz at 20 mA, and back-to-back transmission of 300 Mbps is demonstrated, making these devices suitable for visible light communication (VLC) applications.

Evaluation of two methods for computational HLA haplotypes inference using a real dataset

info:eu-repo/semantics/publishedVersion

Evaluation of two methods for computational HLA haplotypes inference using a real dataset

info:eu-repo/semantics/publishedVersion