La planification anticipée du projet thérapeutique (P.A.P.T.) auprès des personnes hébergées en établissement médico-social

Introduction Les interventions proposées pour promouvoir les directives anticipées (D.A.) n'ont que partiellement atteint leurs objectifs malgré les bénéfices anticipés. L'expérience internationale montre que, quand bien même l'institutionnalisation des D.A. est importante, les pratiques n'ont que peu évolué au cours des trois dernières décennies avec un taux de rédaction entre 15 à 30 %, variant modestement selon les publics, contextes et stratégies. Ce constat nécessite un changement de paradigme car la question des D.A. a trop fréquemment été conçue dans la perspective d'une allocation de ressources, avec une sélection de traitements à envisager en fonction de l'état de santé. Le déplacement souhaité implique de mettre en oeuvre une intervention de type Planification Anticipée du Projet Thérapeutique (P.A.P.T), centrée sur les objectifs et finalités des soins, selon les valeurs et priorités singulières à chaque patient. But L'étude pilote a permis dans un premier temps de développer et tester l'effet d'une intervention de P.A.P.T. menée par une infirmière auprès de résidants nouvellement admis en établissement médico-social (EMS) et de leurs proches significatifs. Dans un deuxième temps, la faisabilité et l'acceptabilité de cette intervention infirmière pour cette population spécifique a été évaluée. Méthode Au total 44 dyades (âge résidants M = 85,01 ans et proches M = 57,42) ont été recrutées pour participer entre mai 2011 et mai 2012 avec un suivi sur six mois dès l'admission du résidant. Un devis pré-post à groupe unique a évalué la qualité de la communication avec l'infirmière sur les soins à la fin de la vie (résidant/proche), les préférences et options de soins (résidant/proche) et la perception du fardeau chez le proche à l'entrée dans l'étude (semaine 5) et trois mois après l'intervention (semaine 25 après l'admission). L'intervention de P.A.P.T. sous forme de trois entretiens a été conduite par l'infirmière, durant le premier trimestre (semaines 6 à 13). Elle a pris connaissance de l'histoire de vie, des croyances et valeurs générales du résidant, clarifié les dix priorités jugées les plus importantes à la fin de sa vie sélectionnées et classées à l'aide d'un jeu de cartes ; elle a identifié, chez le proche, les représentations qu'il se faisait des préférences du résidant et discuté les options de soins au sein de la dyade. Après l'intervention, l'existence de traces dans les dossiers sur les priorités et souhaits de soins ainsi que la présence de D.A. rédigées ont été colligées. Des analyses descriptives et bivariées des données ont été effectuées. Résultats Aucune différence significative n'a été retrouvée après l'intervention par rapport à la qualité de la communication avec l'infirmière sur les soins à la fin de la vie chez le résidant (p = 0,32) et la similitude globale dans la dyade vis-à-vis des options de soins (p = 0,50). La concordance (degré d'accord mesuré avec l'indice K) entre résidant et proche par scénario vis-à-vis des options de soins s'est améliorée pour un des cinq scénarios et a diminué pour les quatre autres (p < 0,001). Pour le proche il a été constaté une amélioration de la qualité de la communication avec l'infirmière (p = 0,000) et de la perception du fardeau global (p - 0,007). Des traces de la P.A.P.T. ont été identifiées dans deux tiers des dossiers alors que des D.A. sont signalées pour 11 résidants. L'intervention s'est avérée faisable et a été bien acceptée par les dyades et les infirmières ayant conduit les entretiens. Conclusion L'intervention infirmière de P.A.P.T. en EMS parait efficace surtout auprès du proche. D'autres études interventionnelles à large échelle sont nécessaires pour confirmer ces résultats préliminaires chez la dyade.

MDCT arthrography of the hip: value of the adaptive statistical iterative reconstruction technique and potential for radiation dose reduction.

OBJECTIVE: The purpose of this article is to assess the effect of the adaptive statistical iterative reconstruction (ASIR) technique on image quality in hip MDCT arthrography and to evaluate its potential for reducing radiation dose. SUBJECTS AND METHODS: Thirty-seven patients examined with hip MDCT arthrography were prospectively randomized into three different protocols: one with a regular dose (volume CT dose index [CTDIvol], 38.4 mGy) and two with a reduced dose (CTDIvol, 24.6 or 15.4 mGy). Images were reconstructed using filtered back projection (FBP) and four increasing percentages of ASIR (30%, 50%, 70%, and 90%). Image noise and contrast-to-noise ratio (CNR) were measured. Two musculoskeletal radiologists independently evaluated several anatomic structures and image quality parameters using a 4-point scale. They also jointly assessed acetabular labrum tears and articular cartilage lesions. RESULTS: With decreasing radiation dose level, image noise statistically significantly increased (p=0.0009) and CNR statistically significantly decreased (p=0.001). We also found a statistically significant reduction in noise (p=0.0001) and increase in CNR (p≤0.003) with increasing percentage of ASIR; in addition, we noted statistically significant increases in image quality scores for the labrum and cartilage, subchondral bone, overall diagnostic quality (up to 50% ASIR), and subjective noise (p≤0.04), and statistically significant reductions for the trabecular bone and muscles (p≤0.03). Regardless of the radiation dose level, there were no statistically significant differences in the detection and characterization of labral tears (n=24; p=1) and cartilage lesions (n=40; p≥0.89) depending on the ASIR percentage. CONCLUSION: The use of up to 50% ASIR in hip MDCT arthrography helps to reduce radiation dose by approximately 35-60%, while maintaining diagnostic image quality comparable to that of a regular-dose protocol using FBP.

Effects of sodium sulphate and potassium chloride fertilizers on the nutritive value of timothy grown on different soils

Selostus: Natrium- ja kaliumlannoituksen vaikutus timotein ravintoarvoon

P value and the theory of hypothesis testing: an explanation for new researchers.

In the 1920s, Ronald Fisher developed the theory behind the p value and Jerzy Neyman and Egon Pearson developed the theory of hypothesis testing. These distinct theories have provided researchers important quantitative tools to confirm or refute their hypotheses. The p value is the probability to obtain an effect equal to or more extreme than the one observed presuming the null hypothesis of no effect is true; it gives researchers a measure of the strength of evidence against the null hypothesis. As commonly used, investigators will select a threshold p value below which they will reject the null hypothesis. The theory of hypothesis testing allows researchers to reject a null hypothesis in favor of an alternative hypothesis of some effect. As commonly used, investigators choose Type I error (rejecting the null hypothesis when it is true) and Type II error (accepting the null hypothesis when it is false) levels and determine some critical region. If the test statistic falls into that critical region, the null hypothesis is rejected in favor of the alternative hypothesis. Despite similarities between the two, the p value and the theory of hypothesis testing are different theories that often are misunderstood and confused, leading researchers to improper conclusions. Perhaps the most common misconception is to consider the p value as the probability that the null hypothesis is true rather than the probability of obtaining the difference observed, or one that is more extreme, considering the null is true. Another concern is the risk that an important proportion of statistically significant results are falsely significant. Researchers should have a minimum understanding of these two theories so that they are better able to plan, conduct, interpret, and report scientific experiments.

Comment améliorer la reproductibilité de lecture des VFA en dépistage clinique? la cohorte OsteoLaus.

Introduction. - Les fractures ostéoporotiques entrainent une morbi-mortalité et des coûts économiques et humains grandissants. Des campagnes de dépistage se mettent en place associant questionnaire et DXA afin d'évaluer le risque fracturaire individuel et populationnel. La découverte fortuite d'une fracture vertébrale (VF), rendue possible par la réalisation d'une morphométrie vertébrale de profil (VFA par DXA) de D4 à L4, peut changer le diagnostic et le pronostic. Néanmoins sa reproductibilité de lecture est peu élevée, surtout sur le rachis dorsal et les fractures de grade 1 [1]. L'IOF/ISCD a proposé un guide pour en améliorer la lecture. Nous avons mesuré la reproductibilité de lecture des VFA avant et après application de ce guide sur une cohorte Suisse de dépistage de l'ostéoporose. Patients et méthodes. - 360 VFA (Hologic Delphi) issus aléatoirement de la cohorte OstéoLaus (femmes > 50 ans) ont été lus par 2 lecteurs indépendants avant et après application du guide de lecture. Il comporte des règles de condition de lecture (luminosité, contraste sur l'écran) et des étapes de lecture systématisées. La reproductibilité a été évaluée par le test de kappa sur : la lisibilité de chaque vertèbre, l'existence ou non d'une VF, son grade (1, 2 ou 3 selon Genant). Nous avons utilisé le Kappa de Cohen avec une technique de bootstrap pour les comparaisons avant/après sur des données corrélées. Résultats. - L'accord entre les lecteurs est élevé et s'améliore après application du guide de lecture (tableau). Le kappa de Cohen est modéré à bon selon Landis et Koch (0,4-0,7). La reproductibilité sur les grades est améliorée en regroupant les grades 0/1 et 2/3, mais pas par le guide de lecture. Conclusion. - L'utilisation du guide de lecture des VFA IOF/ISCD améliore la reproductibilité sur la lisibilité des vertèbres, la détection des VF, mais pas la classification du grade selon Genant. Ceci est principalement expliqué par le fait que le kappa de Cohen donne beaucoup d'importance à la distribution des données, qui devient asymétrique lorsque l'événement est rare. Le kappa uniforme [2] serait mieux adapté dans cette situation. Une réanalyse est en cours.

Deep crustal electromagnetic structure of Bhuj earthquake region (India) and its implications

The existence of fluids and partial melt in the lower crust of the seismically active Kutch rift basin (on the western continental margin of India) owing to underplating has been proposed in previous geological and geophysical studies. This hypothesis is examined using magnetotelluric (MT) data acquired at 23 stations along two profiles across Kutch Mainland Uplift and Wagad Uplift. A detailed upper crustal structure is also presented using twodimensional inversion of MT data in the Bhuj earthquake (2001) area. The prominent boundaries of reflection in the upper crust at 5, 10 and 20 km obtained in previous seismic reflection profiles correlate with conductive structures in our models. The MT study reveals 1-2 km thick Mesozoic sediments under the Deccan trap cover. The Deccan trap thickness in this region varies from a few meters to 1.5 km. The basement is shallow on the northern side compared to the south and is in good agreement with geological models as well as drilling information. The models for these profiles indicate that the thickness of sediments would further increase southwards into the Gulf of Kutch. Significant findings of the present study indicate 1) the hypocentre region of the earthquake is devoid of fluids, 2) absence of melt (that is emplaced during rifting as suggested from the passive seismological studies) in the lower crust and 3) a low resistive zone in the depth range of 5-20 km. The present MT study rules out fluidsand melt (magma) as the causative factors that triggered the Bhuj earthquake. The estimated porosity value of 0.02% will explain 100-500 ohm·m resistivity values observed in the lower crust. Based on the seismic velocities and geochemical studies, presence of garnet is inferred. The lower crust consists of basalts - probably generated by partial melting of metasomatised garnet peridotite at deeper depths in the lithosphere - and their composition might be modified by reaction with the spinel peridotites.

Timing of primary growth harvest affects the yield and nutritive value of timothy-red clover mixtures

Selostus: Ensimmäisen sadon korjuuaika vaikuttaa timotein ja puna-apilan seosnurmen satoon ja rehuarvoon

Trilateral retinoblastoma: neuroimaging characteristics and value of routine brain screening on admission.

Trilateral retinoblastoma (TRb) is a rare disease associating intraocular retinoblastoma with intracranial primitive neuroectodermal tumor. Treatment is difficult and prognosis is poor. This multicenter study evaluates clinical findings and MR imaging characteristics of associated intracranial tumors in Rb patients. Clinical data of 17 patients (16 TRb and 1 quadrilateral Rb patients) included time intervals between Rb and TRb diagnosis and presence of baseline brain-imaging (BBI). Two reviewers reviewed all images individually and one reviewer per center evaluated their images. Consensus was reached during a joint scoring session. Studies were reviewed for tumor location, size and imaging characteristics (signal intensity (SI) on T1- and T2-weighted images, enhancement pattern and cystic appearance). Of 18 intracranial tumors, 78 % were located in the pineal gland and 22 % suprasellar. All tumors showed well-defined borders with mostly heterogenous enhancement (72 %) and isointense SI on T1- (78 %) and T2-weighted images (72 %) compared to gray matter. The majority of pineal TRbs showed a cystic component (57 %). TRb detected synchronously with the intraocular tumors on BBI (n = 7) were significantly smaller (P = 0.02), and mainly asymptomatic than TRb detected later on (n = 10). Overall, 5-year-survival of TRb patients detected on BBI was 67 % (95 % CI 29-100 %) compared to 11 % (95 % CI 0-32 %) for the group with delayed diagnosis. TRb mainly develops in the pineal gland and frequently presents with a cystic appearance that could be misinterpreted as benign pineal cysts. Routine BBI in all newly diagnosed Rb patients can detect TRb at a subclinical stage.

High b-value Diffusion-weighted Imaging: A Sensitive Method to Reveal White Matter Changes in Schizophrenia

Background: b-value is the parameter characterizing the intensity of the diffusion weighting during image acquisition. Data acquisition is usually performed with low b value (b~1000 s/mm2). Evidence shows that high b-values (b>2000 s/mm2) are more sensitive to the slow diffusion compartment (SDC) and maybe more sensitive in detecting white matter (WM) anomalies in schizophrenia.Methods: 12 male patients with schizophrenia (mean age 35 +/-3 years) and 16 healthy male controls matched for age were scanned with a low b-value (1000 s/mm2) and a high b-value (4000 s/mm2) protocol. Apparent diffusion coefficient (ADC) is a measure of the average diffusion distance of water molecules per time unit (mm2/s). ADC maps were generated for all individuals. 8 region of interests (frontal and parietal region bilaterally, centrum semi-ovale bilaterally and anterior and posterior corpus callosum) were manually traced blind to diagnosis.Results: ADC measures acquired with high b-value imaging were more sensitive in detecting differences between schizophrenia patients and healthy controls than low b-value imaging with a gain in significance by a factor of 20- 100 times despite the lower image Signal-to-noise ratio (SNR). Increased ADC was identified in patient's WM (p=0.00015) with major contributions from left and right centrum semi-ovale and to a lesser extent right parietal region.Conclusions: Our results may be related to the sensitivity of high b-value imaging to the SDC believed to reflect mainly the intra-axonal and myelin bound water pool. High b-value imaging might be more sensitive and specific to WM anomalies in schizophrenia than low b-value imaging

The Value of the County Engineer: Strategies to Expand the Shrinking Employment Pool, HR-338, 1993

The first phase of this research involved an effort to identify the issues relevant to gaining a better understanding of the County Engineering profession. A related objective was to develop strategies to attract responsible, motivated and committed professionals to pursue County Engineering positions. In an era where a large percentage of County Engineers are reaching retirement age, the shrinking employment pool may eventually jeopardize the quality of secondary road systems not only in Iowa, but nationwide. As we move toward the 21st century, in an era of declining resources, it is likely that professional staff members in charge of secondary roads will find themselves working with less flexible budgets for the construction and maintenance of roads and bridges. It was important to understand the challenges presented to them, and the degree to which those challenges will demand greater expertise in prioritizing resource allocations for the rehabilitation and maintenance of the 10 million miles of county roads nationwide. Only after understanding what a county engineer is and what this person does will it become feasible for the profession to begin "selling itself", i.e., attracting a new generation of County Engineers. Reaching this objective involved examining the responsibilities, goals, and, sometimes, the frustrations experienced by those persons in charge of secondary road systems in the nine states that agreed to participate in the study. The second phase of this research involved addressing ways to counter the problems associated with the exodus of County Engineers who are reaching retirement age. Many of the questions asked of participants asked them to compare the advantages and disadvantages of public sector work with the private sector. Based on interviews with nearly 50 County Engineers and feedback from 268 who returned surveys for the research, issues relevant to the profession were analyzed and recommendations were made to the profession as it prepares to attract a new generation. It was concluded that both State and Regional Associations for County Engineers, and the National Association of County Engineers are most well-situated to present opportunities for continued professional development. This factor is appealing for those who are interested in competitive advantages as professionals. While salaries in the public sector may not be able to effectively compete with those offered by the private sector, it was concluded that this is only one factor of concern to those who are in the business of "public service". It was concluded, however, that Boards of Supervisors and their equivalents in other states will need to more clearly understand the value of the contributions made by County Engineers. Then the selling points the profession can hope to capitalize on can focus on the strength of state organizations and a strong national organization that act as clearinghouses of information and advocates for the profession, as well as anchors that provide opportunities for staying current on issues and technologies.

Clinical trial substantiates the predictive value of O-6-methylguanine-DNA methyltransferase promoter methylation in glioblastoma patients treated with temozolomide.

PURPOSE: In the setting of a prospective clinical trial, we determined the predictive value of the methylation status of the O-6-methylguanine-DNA methyltransferase (MGMT) promoter for outcome in glioblastoma patients treated with the alkylating agent temozolomide. Expression of this excision repair enzyme has been associated with resistance to alkylating chemotherapy. EXPERIMENTAL DESIGN: The methylation status of MGMT in the tumor biopsies was evaluated in 38 patients undergoing resection for newly diagnosed glioblastoma and enrolled in a Phase II trial testing concomitant and adjuvant temozolomide and radiation. The epigenetic silencing of the MGMT gene was determined using methylation-specific PCR. RESULTS: Inactivation of the MGMT gene by promoter methylation was associated with longer survival (P = 0.0051; Log-rank test). At 18 months, survival was 62% (16 of 26) for patients testing positive for a methylated MGMT promoter but reached only 8% (1 of 12) in absence of methylation (P = 0.002; Fisher's exact test). In the presence of other clinically relevant factors, methylation of the MGMT promoter remains the only significant predictor (P = 0.017; Cox regression). CONCLUSIONS: This prospective clinical trial identifies MGMT-methylation status as an independent predictor for glioblastoma patients treated with a methylating agent. The association of the epigenetic inactivation of the DNA repair gene MGMT with better outcome in this homogenous cohort may have important implications for the design of future trials and supports efforts to deplete MGMT by O-6-benzylguanine, a noncytotoxic substrate of this enzyme.