Challenges to patient-centred care in a general internal medicine context: findings from an exploratory study

Introduction. If we are to promote more patient-centred approaches in care delivery, we have to better characterize the situations in which being patient-centred is difficult to achieve. Data from professionals in health and social care are important because they are the people charged with operationalizing patient-centred care (PCC) in their daily practice. However, empirical accounts from frontline care providers are still lacking, and it is important to gather experiences not only from doctors but also from the other care providers. Indeed, experiences from different professions can help inform our understanding of patient care, which is expected to be both patient-centred and collaborative. Methods. This study was based on the following research question: What factors make the provision of PCC difficult to achieve? Sample and setting. A purposeful sampling technique was used, allowing for a series of choices about the participants and their professional affiliation. Because patient-centredness is the focus, 3 professions appeared to be of special interest: general internists, nurses and social workers. The study was undertaken in the General Internal Medicine Division of a teaching hospital located in a North American context. Data Collection. To answer the research question, a methodological approach based on a theory called phenomenology was chosen. Accordingly, semi-structured interviews were used since they generate understanding of the meanings different individuals have of their lived world. Interviews with 8 physicians, 10 nurses and 10 social workers were eventually conducted. Data analysis. An inductive thematic analysis was employed to make sense of the interview data. Results. The thematic analysis allowed identifying various types of challenges to PCC. Although most of the challenges were perceived by all three groups of professionals, they were perceived to a different degree across the professions, which likely reflected the scope of practice of each profession. The challenges and their distribution across the professions are illustrated in Table 1. Examples of challenges are provided in Table 2. Discussion. There is a tension between what is supposed to be done - what stands in the philosophy of patient -centredness - and what is currently done - the real life with all the challenges to PCC. According to some participants' accounts, PCC clearly risks becoming a mere illusion for health care professionals on which too great pressures are imposed.

Complete internal audit of a mammography service in a reference institution for breast imaging

Objective Undertaking of a complete audit of the service of mammography, as recommended by BI-RADS®, in a private reference institution for breast cancer diagnosis in the city of São Paulo, SP, Brazil, and comparison of results with those recommended by the literature. Materials and Methods Retrospective, analytical and cross-sectional study including 8,000 patients submitted to mammography in the period between April 2010 and March 2011, whose results were subjected to an internal audit. The patients were followed-up until December 2012. Results The radiological classification of 7,249 screening mammograms, according to BI-RADS, was the following: category 0 (1.43%), 1 (7.82%), 2 (80.76%), 3 (8.35%), 4 (1.46%), 5 (0.15%) and 6 (0.03%). The breast cancer detection ratio was 4.8 cases per 1,000 mammograms. Ductal carcinoma in situ was found in 22.8% of cases. Positive predictive values for categories 3, 4 and 5 were 1.3%, 41.3% and 100%, respectively. In the present study, the sensitivity of the method was 97.1% and specificity, 97.4%. Conclusion The complete internal audit of a service of mammography is essential to evaluate the quality of such service, which reflects on an early breast cancer detection and reduction of mortality rates.

GENETIC ARCHITECTURE, EVOLUTION AND MAINTENANCE OF A COLOR CLINE AT A CONTINENTAL SCALE

On a geological time scale the conditions on earth are very variable and biological patterns (for example the distributions of species) are very dynamic. Understanding large scale patterns of variation observed today thus requires a deep understanding of the historical factors that drove their evolution. In this thesis, we reevaluated the evolution and maintenance of a continental color cline observed in the European barn owl (Tyto alba) using population genetic tools. The colour cline spans from south-est Europe where most individual have pure white underparts to north and east Europe where most individuals have rufous-brown underparts. Our results globally showed that the old scenario, stipulating that the color cline evolved by secondary contact of two color morphs (white and rufous) that evolved in allopatry during the last ice age has to be revised. We collected samples of about 700 barn owls from the Western Palearctic to establish the first population genetic data set for this species. Individuals were genotyped at 22 microsatellites markers, at one mitochondrial gene, and at a candidate color gene. The color of each individuals was assessed and their sex determined by molecular methods. We first showed that the genetic variation in Western Europe is very limited compared to the heritable color variation. We found no evidences of different glacial lineages, and showed that selection must be involved in the maintenance of the color cline (chapter 1). Using computer simulations, we demonstrated that the post-glacial colonization of Europe occurred from the Iberian Peninsula and that the color cline could not have evolved by neutral demographic processes during this colonization (chapter 2). Finally we reevaluated the whole history of the establishment of the Western Palearctic variation of the barn owl (chapter 3): This study showed that all Western European barn owls descend from white barn owls phenotypes from the Middle East that colonized the Iberian Peninsula via North-Africa. Following the end of the last ice age (20'000 years ago), these white barn owls colonized Western Europe and under selection a novel rufous phenotype evolved (during or after the colonization). An important part of the color variation could be explained by a single mutation in the melanocortin-1-receptor (MC1R) gene that appeared during or after the colonization. The colonization of Europe reached until Greece, where the rufous birds encountered white ones (which reached Greece from the Middle East over the Bosporus) in a secondary contact zone. Our analyses show that white and rufous barn owls in Greece interbreed only to a limited extent. This suggests that barn owls are at the verge of becoming two species in Greece and demonstrates that European barn owls represent an incipient ring species around the Mediterranean. The revisited history of the establishment of the European barn owl color cline makes this model system remarkable for several aspects. It is a very clear example of strong local adaptation that can be achieved despite high gene flow (strong color and MC1R differentiation despite almost no neutral genetic differentiation). It also offers a wonderful model system to study the interactions between colonization processes and selection processes which have, for now, been remarkably understudied despite their potentially ubiquitous importance. Finally it represents a very interesting case in the speciation continuum and appeals for further studying the amount of gene flow that occurs between the color morphs in Greece. -- Sur l'échelle des temps géologiques, les conditions sur terre sont très variables et les patrons biologiques (telle que la distribution des espèces) sont très dynamiques. Si l'on veut comprendre des patrons que l'on peut observer à large échelle aujourd'hui, il est nécessaire de d'abord comprendre les facteurs historiques qui ont gouverné leur établissement. Dans cette thèse, nous allons réévaluer, grâce à des outils modernes de génétique des populations, l'évolution et la maintenance d'un cline de couleur continental observé chez l'effraie des clochers européenne (Tyto alba). Globalement, nos résultats montrent que le scenario accepté jusqu'à maintenant, qui stipule que le cline de couleur a évolué à partir du contact secondaire de deux morphes de couleur (blanches et rousses) ayant évolué en allopatrie durant les dernières glaciations, est à revoir. Afin de constituer le premier jeu de données de génétique des populations pour cette espèce, nous avons récolté des échantillons d'environ 700 effraies de l'ouest Paléarctique. Nous avons génotypé tous les individus à 22 loci microsatellites, sur un gène mitochondrial et sur un autre gène participant au déterminisme de la couleur. Nous avons aussi mesuré la couleur de tous les individus et déterminé leur sexe génétiquement. Nous avons tout d'abord pu montrer que la variation génétique neutre est négligeable en comparaison avec la variation héritable de couleur, qu'il n'existe qu'une seule lignée européenne et que de la sélection doit être impliquée dans le maintien du cline de couleur (chapitre 1). Grâce à des simulations informatiques, nous avons démontré que l'ensemble de l'Europe de l'ouest a été recolonisé depuis la Péninsule Ibérique après les dernières glaciations et que le cline de couleur ne peut pas avoir évolué par des processus neutre durant cette colonisation (chapitre 2). Finalement, nous avons réévalué l'ensemble de l'histoire postglaciaire de l'espèce dans l'ouest Paléarctique (chapitre 3): l'ensemble des effraies du Paléarctique descendent d'effraie claire du Moyen-Orient qui ont colonisé la péninsule ibérique en passant par l'Afrique du nord. Après la fin de la dernière glaciation (il y a 20'000 ans), ces effraies claires ont colonisé l'Europe de l'ouest et ont évolués par sélection le phénotype roux (durant ou après la colonisation). Une part importante de la variation de couleur peut être expliquée par une mutation sur le gène MC1R qui est apparue durant ou juste après la colonisation. Cette vague de colonisation s'est poursuivie jusqu'en Grèce où ces effraies rousses ont rencontré dans une zone de contact secondaire des effraies claires (qui sont remontées en Grèce depuis le Moyen-Orient via le Bosphore). Nos analyses montrent que le flux de gènes entre effraies blanches et rousses est limité en Grèce, ce qui suggère qu'elles sont en passe de former deux espèces et ce qui montre que les effraies constituent un exemple naissant de spéciation en anneaux autour de la Méditerranée. L'histoire revisitée des effraies des clochers de l'ouest Paléarctique en fait un système modèle remarquable pour plusieurs aspects. C'est un exemple très claire de forte adaptation locale maintenue malgré un fort flux de gènes (différenciation forte de couleur et sur le gène MC1R malgré presque aucune structure neutre). Il offre également un très bon système pour étudier l'interaction entre colonisation et sélection, un thème ayant été remarquablement peu étudié malgré son importance. Et il offre finalement un cas très intéressant dans le « continuum de spéciation » et il serait très intéressant d'étudier plus en détail l'importance du flux de gènes entre les morphes de couleur en Grèce.

The internal wave field in Sau reservoir : Observation and modeling of a third vertical mode

Water withdrawal from Mediterranean reservoirs in summer is usually very high. Because of this, stratification is often continuous and far from the typical two-layered structure, favoring the excitation of higher vertical modes. The analysis of wind, temperature, and current data from Sau reservoir (Spain) shows that the third vertical mode of the internal seiche (baroclinic mode) dominated the internal wave field at the beginning of September 2003. We used a continuous stratification two-dimensional model to calculate the period and velocity distribution of the various modes of the internal seiche, and we calculated that the period of the third vertical mode is ;24 h, which coincides with the period of the dominating winds. As a result of the resonance between the third mode and the wind, the other oscillation modes were not excited during this period

The seasonal evolution of high vertical–mode internal waves in a deep reservoir

The causal mechanism and seasonal evolution of the internal wave field in a deep, warm, monomictic reservoirare examined through the analysis of field observations and numerical techniques. The study period extends fromthe onset of thermal stratification in the spring until midsummer in 2005. During this time, wind forcing wasperiodic, with a period of 24 h (typical of land–sea breezes), and the thermal structure in the lake wascharacterized by the presence of a shallow surface layer overlying a thick metalimnion, typical of small to mediumsized reservoirs with deep outtakes. Basin-scale internal seiches of high vertical mode (ranging from mode V3 toV5) were observed in the metalimnion. The structure of the dominant modes of oscillation changed asstratification evolved on seasonal timescales, but in all cases, their periods were close to that of the local windforcing (i.e., 24 h), suggesting a resonant response. Nonresonant oscillatory modes of type V1 and V2 becamedominant after large frontal events, which disrupted the diurnal periodicity of the wind forcing

An architecture for decentralized service deployment

Peer-reviewed

Tan cerca, tan lejos: Aldo Rossi y el Grupo 2C. Arquitectura, ideología y disidencias en la Barcelona de los 70 = So close, so far : Aldo Rossi and the 2C Group. Architecture, ideology and dissents in the Barcelona of the 70s

The Catalan reception of the 1966 manifestos by Robert Venturi and Aldo Rossi marks the scenario of a breakup: while North America debates about the architectural shape as a linguistic structure, Italy dips its roots in the Modern Movement tradition as an origin for a new temporal and ideological architectural dimension. The first contacts between Rossi and Spain verify this search and allow the Italian to construct common itineraries with some architects from Barcelona. From these exchanges the 2C group will be born, taking part on typical vanguardist mechanisms: they will publish the magazine, 2C. The construction of the city (1972-1985), they will attend the XV Triennale di Milano in 1973 with the Torres Clavé Plan (1971) and the Aldo Rossi + 21 Spanish architects exhibition (1975) while he will organize the three issues of the Seminarios Internacionales de Arquitectura Contemporánea (S.I.AC.) which took place in Santiago, Sevilla and Barcelona between 1976 and 1980. In front of the unfolding of the firsts, the American contacts of Federico Correa, Oriol Bohigas, Lluís Domènech and the PER studio or the teaching work of Rafael Moneo from Barcelona since 1971, allow to draw replica itineraries with the foundation of the magazine Arquitecturas Bis (1974-1985), the organization of the meetings between international publications such as Lotus and Oppositions in Cadaqués (1975) and New York (1977), while stablishing exchanges with members of the Five Architects. Replicas that in 1976 conduct the initial ideological affirmations between Rossi and the 2C group towards irreconcilable distancing. Verifying the itinerary of the journey that the Italian leads from the Italian resistance towards the American backing down is part of the aim of this article

DAI-DEPUR: an integrated and distributed architecture for wastewater treatment plants supervision

The activated sludge process - the main biological technology usually applied towastewater treatment plants (WWTP) - directly depends on live beings (microorganisms), and therefore on unforeseen changes produced by them. It could be possible to get a good plant operation if the supervisory control system is able to react to the changes and deviations in the system and can take thenecessary actions to restore the system’s performance. These decisions are oftenbased both on physical, chemical, microbiological principles (suitable to bemodelled by conventional control algorithms) and on some knowledge (suitable to be modelled by knowledge-based systems). But one of the key problems in knowledge-based control systems design is the development of an architecture able to manage efficiently the different elements of the process (integrated architecture), to learn from previous cases (spec@c experimental knowledge) and to acquire the domain knowledge (general expert knowledge). These problems increase when the process belongs to an ill-structured domain and is composed of several complex operational units. Therefore, an integrated and distributed AIarchitecture seems to be a good choice. This paper proposes an integrated and distributed supervisory multi-level architecture for the supervision of WWTP, that overcomes some of the main troubles of classical control techniques and those of knowledge-based systems applied to real world systems

Architecture as a landscape

Postprint (published version)

IT architecture for category driven corporate procurement measurement

The purpose of this thesis was to investigate creating and improving category purchasing visibility for corporate procurement by utilizing financial information. This thesis was a part of the global category driven spend analysis project of Konecranes Plc. While creating general understanding for building category driven corporate spend visibility, the IT architecture and needed purchasing parameters for spend analysis were described. In the case part of the study three manufacturing plants of Konecranes Standard Lifting, Heavy Lifting and Services business areas were examined. This included investigating the operative IT system architecture and needed processes for building corporate spend visibility. The key findings of this study were the identification of the needed processes for gathering purchasing data elements while creating corporate spend visibility in fragmented source system environment. As an outcome of the study, roadmap presenting further development areas was introduced for Konecranes.

Developing A Knowledge Management Process Model for Internal IT Organization, Case: Stora Enso Oyj, Corporate IT

The objectives of this Master’s Thesis were to find out what kind of knowledge management strategy would fit best an IT organization that uses ITIL (Information Technology Infrastructure Library) framework for IT Service Management and to create a knowledge management process model to support chosen strategy. The empirical material for this research was collected through qualitative semi-structured interviews of a case organization Stora Enso Corporate IT. The results of the qualitative interviews indicate that codification knowledge management strategy would fit best for the case organization. The knowledge management process model was created based on earlier studies and a literature of knowledge management. The model was evaluated in the interview research and the results showed that the created process model is realistic, useful, and it responds to a real life phenomenon.

El juego y su estructura interna en relación con el trabajo de la condición física en primaria = Games and their internal structure in relation to the work of physical condition in Primary Education

One of the methodological resources that teachers use in a generalised way in Physical Education classes is the game. Inthis article we define the concept of game and analyse the characteristics of their internal structure. On the other hand welook at the concepts of physical condition and conditional skills and describe the objectives of its work in Primary Education.Finally, we relate these concepts and propose two practical examples of modifying the internal structure of the game so asto produce variations in the implied conditional skills