Undergraduate palliative care teaching in Swiss medical faculties: a nationwide survey and improved learning objectives

BACKGROUND In 2007, a first survey on undergraduate palliative care teaching in Switzerland has revealed major heterogeneity of palliative care content, allocation of hours and distribution throughout the 6 year curriculum in Swiss medical faculties. This second survey in 2012/13 has been initiated as part of the current Swiss national strategy in palliative care (2010 - 2015) to serve as a longitudinal monitoring instrument and as a basis for redefinition of palliative care learning objectives and curriculum planning in our country. METHODS As in 2007, a questionnaire was sent to the deans of all five medical faculties in Switzerland in 2012. It consisted of eight sections: basic background information, current content and hours in dedicated palliative care blocks, current palliative care content in other courses, topics related to palliative care presented in other courses, recent attempts at improving palliative care content, palliative care content in examinations, challenges, and overall summary. Content analysis was performed and the results matched with recommendations from the EAPC for undergraduate training in palliative medicine as well as with recommendations from overseas countries. RESULTS There is a considerable increase in palliative care content, academic teaching staff and hours in all medical faculties compared to 2007. No Swiss medical faculty reaches the range of 40 h dedicated specifically to palliative care as recommended by the EAPC. Topics, teaching methods, distribution throughout different years and compulsory attendance still differ widely. Based on these results, the official Swiss Catalogue of Learning Objectives (SCLO) was complemented with 12 new learning objectives for palliative and end of life care (2013), and a national basic script for palliative care was published (2015). CONCLUSION Performing periodic surveys of palliative care teaching at national medical faculties has proven to be a useful tool to adapt the national teaching framework and to improve the recognition of palliative medicine as an integral part of medical training.

[Pilot Project: Improved Lung Deposition via a New Nasal Inhalation Procedure].

INTRODUCTION Inhaled drugs can only be effective if they reach the middle and small airways. This study introduces a system that combines a trans-nasal application of aerosols with noninvasive pressure support ventilation. METHODS In a pilot study, 7 COPD patients with GOLD stages II and III inhaled a radiolabeled marker dissolved in water via a trans-nasal route. The mean aerosol particle size was 5.5 µm. Each patient took part in two inhalation sessions that included two application methods and were at least 70 hours apart. During the first session ("passive method"), the patient inhaled the aerosol through an open tube system. The second session ("active method") included pressure support ventilation during the inhalation process. A gamma camera and planar scintigraphy was used to determine the distribution of aerosol particles in the patient's body and lung. RESULTS The pressure supported inhalation ("active method") results in an increased aerosol lung deposition compared to the passive method. Above all, we could demonstrate deposition in the lung periphery with relatively large aerosol particles (5.5 µm). DISCUSSION The results prove that the combination of trans-nasal inhalation with noninvasive pressure support ventilation leads to significantly increased particle deposition in the lung.

Twenty years' experience with the Swiss data registry for assisted reproductive medicine: outcomes, key trends and recommendations for improved practice.

QUESTIONS UNDER STUDY The impact of assisted reproductive technology (ART) on Swiss demography was quantified. From 1993 to 2012 the number of deliveries, including multiples, generated by ART was compared with overall delivery numbers. Swiss experts in ART collaborated in a consensus to increase successful outcomes, to reduce the incidence of complications of ART and to validate recommendations through statistical review of available data. METHODS Data generated between 1993 and 2012 and published by the Federal Office of Statistics (BfS) were compared with the Swiss database on ART (FIVNAT-CH) as organised by the Swiss Society of Reproductive Medicine (SGRM). From these analyses a panel of Swiss experts in ART extracted recommendations to improve current practice, to prevent complications related to ART and to recommend changes in current Swiss legislation dealing with ART. RESULTS Since 1993 the age of women giving birth rose together with the number of women asking for ART. This demographic trend was reflected in a rise in the number of deliveries generated by ART (in 2012: 2.2%) and the proportion of multiple births (in 2012: 17.6%). The outcome of ART was most negatively influenced by the age of the treated patient. The number of retrieved oocytes decisively impacted the likelihood of delivery, the risk of multiple births and the incidence of ovarian hyperstimulation syndrome. CONCLUSIONS Optimal ovarian stimulation should be designed for the retrieval of 10 to 15 oocytes per treatment. Swiss legislation should enable and stimulate a policy of elective single embryo transfer to avoid multiple births.

Corrigendum: reduced IFNλ4 activity is associated with improved HCV clearance and reduced expression of interferon-stimulated genes

Erratum for Reduced IFNλ4 activity is associated with improved HCV clearance and reduced expression of interferon-stimulated genes. [Nat Commun. 2014]

An improved single-plaquette gauge action

We describe and test a nonperturbatively improved single-plaquette lattice action for 4-d SU(2) and SU(3) pure gauge theory, which suppresses large fluctuations of the plaquette, without requiring the naive continuum limit for smooth fields. We tune the action parameters based on torelon masses in moderate cubic physical volumes, and investigate the size of cut-off effects in other physical quantities, including torelon masses in asymmetric spatial volumes, the static quark potential, and gradient flow observables. In 2-d O(N) models similarly constructed nearest-neighbor actions have led to a drastic reduction of cut-off effects, down to the permille level, in a wide variety of physical quantities. In the gauge theories, we find significant reduction of lattice artifacts, and for some observables, the coarsest lattice result is very close to the continuum value. We estimate an improvement factor of 40 compared to using the Wilson gauge action to achieve the same statistical accuracy and suppression of cut-off effects.

Antimicrobial drug use and risk factors associated with treatment incidence and mortality in Swiss veal calves reared under improved welfare conditions

Ninety-one Swiss veal farms producing under a label with improved welfare standards were visited between August and December 2014 to investigate risk factors related to antimicrobial drug use and mortality. All herds consisted of own and purchased calves, with a median of 77.4% of purchased calves. The calves' mean age was 29±15days at purchasing and the fattening period lasted at average 120±28 days. The mean carcass weight was 125±12kg. A mean of 58±33 calves were fattened per farm and year, and purchased calves were bought from a mean of 20±17 farms of origin. Antimicrobial drug treatment incidence was calculated with the defined daily dose methodology. The mean treatment incidence (TIADD) was 21±15 daily doses per calf and year. The mean mortality risk was 4.1%, calves died at a mean age of 94±50 days, and the main causes of death were bovine respiratory disease (BRD, 50%) and gastro-intestinal disease (33%). Two multivariable models were constructed, for antimicrobial drug treatment incidence (53 farms) and mortality (91 farms). No quarantine, shared air space for several groups of calves, and no clinical examination upon arrival at the farm were associated with increased antimicrobial treatment incidence. Maximum group size and weight differences >100kg within a group were associated with increased mortality risk, while vaccination and beef breed were associated with decreased mortality risk. The majority of antimicrobial treatments (84.6%) were given as group treatments with oral powder fed through an automatic milk feeding system. Combination products containing chlortetracycline with tylosin and sulfadimidine or with spiramycin were used for 54.9%, and amoxicillin for 43.7% of the oral group treatments. The main indication for individual treatment was BRD (73%). The mean age at the time of treatment was 51 days, corresponding to an estimated weight of 80-100kg. Individual treatments were mainly applied through injections (88.5%), and included administration of fluoroquinolones in 38.3%, penicillines (amoxicillin or benzylpenicillin) in 25.6%, macrolides in 13.1%, tetracyclines in 12.0%, 3th and 4th generation cephalosporines in 4.7%, and florfenicol in 3.9% of the cases. The present study allowed for identifying risk factors for increased antimicrobial drug treatment and mortality. This is an important basis for future studies aiming at reducing treatment incidence and mortality in veal farms. Our results indicate that improvement is needed in the selection of drugs for the treatment of veal calves according to the principles of prudent use of antibiotics.

Non-metastatic castrate-resistant prostate cancer: a call for improved guidance on clinical management.

BACKGROUND Guidelines on the clinical management of non-metastatic castrate-resistant prostate cancer (nmCRPC) generally focus on the need to continue androgen deprivation therapy and enrol patients into clinical trials of investigational agents. This guidance reflects the lack of clinical trial data with established agents in the nmCRPC patient population and the need for trials of new agents. AIM To review the evidence base and consider ways of improving the management of nmCRPC. CONCLUSION Upon the development of castrate resistance, it is essential to rule out the presence of metastases or micrometastases by optimising the use of bone scans and possibly newer procedures and techniques. When nmCRPC is established, management decisions should be individualised according to risk, but risk stratification in this diverse population is poorly defined. Currently, prostate-specific antigen (PSA) levels and PSA doubling time remain the best method of assessing the risk of progression and response to treatment in nmCRPC. However, optimising imaging protocols can also help assess the changing metastatic burden in patients with CRPC. Clinical trials of novel agents in nmCRPC are limited and have problems with enrolment, and therefore, improved risk stratification and imaging may be crucial to the improved management. The statements presented in this paper, reflecting the views of the authors, provide a discussion of the most recent evidence in nmCRPC and provide some advice on how to ensure these patients receive the best management available. However, there is an urgent need for more data on the management of nmCRPC.

Assessing the improved discriminatory power of a new biomarker in prognostic models

Although the area under the receiver operating characteristic (AUC) is the most popular measure of the performance of prediction models, it has limitations, especially when it is used to evaluate the added discrimination of a new biomarker in the model. Pencina et al. (2008) proposed two indices, the net reclassification improvement (NRI) and integrated discrimination improvement (IDI), to supplement the improvement in the AUC (IAUC). Their NRI and IDI are based on binary outcomes in case-control settings, which do not involve time-to-event outcome. However, many disease outcomes are time-dependent and the onset time can be censored. Measuring discrimination potential of a prognostic marker without considering time to event can lead to biased estimates. In this dissertation, we have extended the NRI and IDI to survival analysis settings and derived the corresponding sample estimators and asymptotic tests. Simulation studies were conducted to compare the performance of the time-dependent NRI and IDI with Pencina’s NRI and IDI. For illustration, we have applied the proposed method to a breast cancer study.^ Key words: Prognostic model, Discrimination, Time-dependent NRI and IDI ^

Improved Techniques for Acquisition and Analysis of Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Detecting Vascular Permeability in the Central Nervous System

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a noninvasive technique for quantitative assessment of the integrity of blood-brain barrier and blood-spinal cord barrier (BSCB) in the presence of central nervous system pathologies. However, the results of DCE-MRI show substantial variability. The high variability can be caused by a number of factors including inaccurate T1 estimation, insufficient temporal resolution and poor contrast-to-noise ratio. My thesis work is to develop improved methods to reduce the variability of DCE-MRI results. To obtain fast and accurate T1 map, the Look-Locker acquisition technique was implemented with a novel and truly centric k-space segmentation scheme. In addition, an original multi-step curve fitting procedure was developed to increase the accuracy of T1 estimation. A view sharing acquisition method was implemented to increase temporal resolution, and a novel normalization method was introduced to reduce image artifacts. Finally, a new clustering algorithm was developed to reduce apparent noise in the DCE-MRI data. The performance of these proposed methods was verified by simulations and phantom studies. As part of this work, the proposed techniques were applied to an in vivo DCE-MRI study of experimental spinal cord injury (SCI). These methods have shown robust results and allow quantitative assessment of regions with very low vascular permeability. In conclusion, applications of the improved DCE-MRI acquisition and analysis methods developed in this thesis work can improve the accuracy of the DCE-MRI results.

Improved digital elevation model (DEM) for Lake Eyre, Australia

Here we demonstrate the applicability of using altimetry data and Landsat imagery to provide the most accurate digital elevation model (DEM) of Australia's largest playa lake - Lake Eyre. We demonstrate through the use of geospatial techniques a robust assessment of lake area and volume of recent lake-filling episodes whilst also providing the most accurate estimates of area and volume for larger lake filling episodes that occurred throughout the last glacial cycle. We highlight that at a depth of 25 m Lake Mega-Eyre would merge with the adjacent Lake Mega-Frome to form an immense waterbody with a combined area of almost 35,000 km**2 and a combined volume of ~520 km**3. This would represent a vast water body in what is now the arid interior of the Australian continent. The improved DEM is more reliable from a geomorphological and hydrological perspective and allows a more accurate assessment of water balance under the modern hydrological regime. The results presented using GLAS/ICESat data suggest that earlier historical soundings were correct and the actual lowest topographic point in Australia is -15.6 m below sea level. The results also contrast nicely the different basin characteristics of two adjacent lake systems; Lake Eyre and Lake Frome.

Improved geoid solution for the Weddell Sea region

We present a geoid solution for the Weddell Sea and adjacent continental Antarctic regions. There, a refined geoid is of interest, especially for oceanographic and glaciological applications. For example, to investigate the Weddell Gyre as a part of the Antarctic Circumpolar Current and, thus, of the global ocean circulation, the mean dynamic topography (MDT) is needed. These days, the marine gravity field can be inferred with high and homogeneous resolution from altimetric height profiles of the mean sea surface. However, in areas permanently covered by sea ice as well as in coastal regions, satellite altimetry features deficiencies. Focussing on the Weddell Sea, these aspects are investigated in detail. In these areas, ground-based data that have not been used for geoid computation so far provide additional information in comparison with the existing high-resolution global gravity field models such as EGM2008. The geoid computation is based on the remove-compute-restore approach making use of least-squares collocation. The residual geoid with respect to a release 4 GOCE model adds up to two meters and more in the near-coastal and continental areas of the Weddell Sea region, also in comparison with EGM2008. Consequently, the thus refined geoid serves to compute new estimates of the regional MDT and geostrophic currents.

Improved ore processing assessed by digital image análisis of the ores: a key to the sustainable development of the Iberian Pyrite Belt

Mining in the Iberian Pyrite Belt (IPB), the biggest VMS metallogenetic province known in the world to date, has to face a deep crisis in spite of the huge reserves still known after ≈5 000 years of production. This is due to several factors, as the difficult processing of complex Cu-Pb-Zn-Ag- Au ores, the exhaustion of the oxidation zone orebodies (the richest for gold, in gossan), the scarce demand for sulphuric acid in the world market, and harder environmental regulations. Of these factors, only the first and the last mentioned can be addressed by local ore geologists. A reactivation of mining can therefore only be achieved by an improved and more efficient ore processing, under the constraint of strict environmental controls. Digital image analysis of the ores, coupled to reflected light microscopy, provides a quantified and reliable mineralogical and textural characterization of the ores. The automation of the procedure for the first time furnishes the process engineers with real-time information, to improve the process and to preclude or control pollution; it can be applied to metallurgical tailings as well. This is shown by some examples of the IPB.

An improved way for evaluating competences: A different approach to project management learning .;

This paper presents a formal initiative for monitoring the competence acquisition by a team of students with different backgrounds facing the experience of being working by projects and in a project. These students are inexperienced in the project management field and they play this game on a time-shared manner along with other activities. The goal of this experience is to make some improvements in determining the competence levels acquired by means of how the work is being done. The use of this information, which is out of the scope of this particular work, could make possible to bring additional information to the students involved in terms of their individual competencies and the identification of new opportunities of personal improvement.