808 resultados para Clinical problem-solving


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Endocrine resistance in breast cancer remains a major clinical problem and is caused by crosstalk mechanisms of growth factor receptor cascades, such as the erbB and PI3K/AKT pathways. The possibilities a single breast cancer cell has to achieve resistance are manifold. We developed a model of 4-hydroxy-tamoxifen (OHT)‑resistant human breast cancer cell lines and compared their different expression patterns, activation of growth factor receptor pathways and compared cells by genomic hybridization (CGH). We also tested a panel of selective inhibitors of the erbB and AKT/mTOR pathways to overcome OHT resistance. OHT‑resistant MCF-7-TR and T47D-TR cells showed increased expression of HER2 and activation of AKT. T47D-TR cells showed EGFR expression and activated MAPK (ERK-1/2), whereas in resistant MCF-7-TR cells activated AKT was due to loss of CTMP expression. CGH analyses revealed remarkable aberrations in resistant sublines, which were predominantly depletions. Gefitinib inhibited erbB signalling and restored OHT sensitivity in T47D-TR cells. The AKT inhibitor perifosine restored OHT sensitivity in MCF-7-TR cells. All cell lines showed expression of receptors for gonadotropin-releasing hormone (GnRH) I and II, and analogs of GnRH-I/II restored OHT sensitivity in both resistant cell lines by inhibition of erbB and AKT signalling. In conclusion, mechanisms to escape endocrine treatment in breast cancer share similarities in expression profiling but are based on substantially different genetic aberrations. Evaluation of activated mediators of growth factor receptor cascades is helpful to predict response to specific inhibitors. Expression of GnRH-I/II receptors provides multi-targeting treatment strategies.

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Global economic changes have psychological consequences and Mr. Lepeska set out to assess these changes in working adults in Lithuania between 1993 and 1997. He surveyed two groups of working adults, with a total of 200 people, randomly selected and representing different organisations and professions. In both groups around 30% of participants were managers, with the remainder working in non-managerial positions. The participants were surveyed twice, once in 1993 and the second time in 1997,using various psychodiagnostic tools to measure their psychological characteristics. The results showed that strategies for coping with stress have changed, with problem solving strategies being used more often, and avoidance behaviour or seeking social support less. Men tended to have rejected these strategy more radically than women. Attitudes towards work had become more positive, with managers' attitudes having changed more significantly than those of employees from lower levels of organisations. Younger people were more positive towards work-related changes, while situational anxiety tended to increase with age, although overall it remained low. Mr. Lepeska found that while there were some indications of an increasing individualist in relation to peers, the traditional collective orientation of Lithuanian adults had if anything increased. People have become more accepting of an unequal distribution of power, making it difficult to increase the participation of subordinates in decision making. He also noted a tendency for Lithuanians to see their organisations as traditional families, expecting them to take care of them physically and economically in return for loyalty. The strong feminine orientation with its stress on interpersonal relations and overall quality of life has also strengthened, but the ability of Lithuanians to take initiative and control their environment was relatively low. Mr. Lepeska concludes that organisations should seek to recruit people who are able to adjust more easily to changes and consider measuring dominance, individualism, and attitudes to work-related change and situational anxiety in the process of professional selection. There should also be more emphasis on team building and on training managers to maintain closer relationships with their subordinates so as to increase the latter's participation in decision making. Good interpersonal relations can be a strong work motivator, as may be special attention to the security needs of older employees.

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OBJECTIVES: Residual airspace following thoracic resections is a common clinical problem. Persistent air leak, prolonged drainage time, and reduced hemostasis extend hospital stay and morbidity. We report a trial of pharmacologic-induced diaphragmatic paralysis through continuous paraphrenic injection of lidocaine to reduced residual airspace. The objectives were confirmation of diaphragmatic paralysis and possible procedure related complications. METHODS: Six eligible patients undergoing resectional surgery (lobectomy or bilobectomy) were included. Inclusion criteria consisted of: postoperative predicted FEV1 greater than 1300 ml, right-sided resection, absence of parenchymal lung disease, no class III antiarrhythmic therapy, absence of hypersensitivity reactions to lidocaine, no signs of infection, and informed consent. Upon completion of resection an epidural catheter was attached in the periphrenic tissue on the proximal pericardial surface, externalized through a separate parasternal incision, and connected to a perfusing system injecting lidocaine 1% at a rate of 3 ml/h (30 mg/h). Postoperative ICU surveillance for 24h and daily measurement of vital signs, drainage output, and bedside spirometry were performed. Within 48 h fluoroscopic confirmation of diaphragmatic paralysis was obtained. The catheter removal coincided with the chest tube removal when no procedural related complications occurred. RESULTS: None of the patients reported respiratory impairment. Diaphragmatic paralysis was documented in all patients. Upon removal of catheter or discontinuation of lidocaine prompt return of diaphragmatic motility was noticed. Two patients showed postoperative hemodynamic irrelevant atrial fibrillation. CONCLUSION: Postoperative paraphrenic catheter administration of lidocaine to ensure reversible diaphragmatic paralysis is safe and reproducible. Further studies have to assess a benefit in terms of reduction in morbidity, drainage time, and hospital stay, and determine the patients who will profit.

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BACKGROUND: Faculties face the permanent challenge to design training programs with well-balanced educational outcomes, and to offer various organised and individual learning opportunities. AIM: To apply our original model to a postgraduate training program in rheumatology in general, and to various learning experiences in particular, in order to analyse the balance between different educational objectives. METHODS: Learning times of various educational activities were reported by the junior staff as targeted learners. The suitability of different learning experiences to achieve cognitive, affective and psychomotor learning objectives was estimated. Learning points with respect to efficacy were calculated by multiplication of the estimated learning times by the perceived appropriateness of the educational strategies. RESULTS: Out of 780 hours of professional learning per year (17.7 hours/week), 37.7% of the time was spent under individual supervision of senior staff, 24.4% in organised structured learning, 22.6% in self-studies, and 15.3% in organised patient-oriented learning. The balance between the different types of learning objectives was appropriate for the overall program, but not for each particular learning experience. Acquisition of factual knowledge and problem solving was readily aimed for during organised teaching sessions of different formats, and by personal targeted reading. Attitudes, skills and competencies, as well as behavioural and performance changes were mostly learned during caring for patients under interactive supervision by experts. CONCLUSION: We encourage other faculties to apply this approach to any other curriculum of undergraduate education, postgraduate training or continuous professional development in order to foster the development of well-balanced learning experiences.

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Civil infrastructure provides essential services for the development of both society and economy. It is very important to manage systems efficiently to ensure sound performance. However, there are challenges in information extraction from available data, which also necessitates the establishment of methodologies and frameworks to assist stakeholders in the decision making process. This research proposes methodologies to evaluate systems performance by maximizing the use of available information, in an effort to build and maintain sustainable systems. Under the guidance of problem formulation from a holistic view proposed by Mukherjee and Muga, this research specifically investigates problem solving methods that measure and analyze metrics to support decision making. Failures are inevitable in system management. A methodology is developed to describe arrival pattern of failures in order to assist engineers in failure rescues and budget prioritization especially when funding is limited. It reveals that blockage arrivals are not totally random. Smaller meaningful subsets show good random behavior. Additional overtime failure rate is analyzed by applying existing reliability models and non-parametric approaches. A scheme is further proposed to depict rates over the lifetime of a given facility system. Further analysis of sub-data sets is also performed with the discussion of context reduction. Infrastructure condition is another important indicator of systems performance. The challenges in predicting facility condition are the transition probability estimates and model sensitivity analysis. Methods are proposed to estimate transition probabilities by investigating long term behavior of the model and the relationship between transition rates and probabilities. To integrate heterogeneities, model sensitivity is performed for the application of non-homogeneous Markov chains model. Scenarios are investigated by assuming transition probabilities follow a Weibull regressed function and fall within an interval estimate. For each scenario, multiple cases are simulated using a Monte Carlo simulation. Results show that variations on the outputs are sensitive to the probability regression. While for the interval estimate, outputs have similar variations to the inputs. Life cycle cost analysis and life cycle assessment of a sewer system are performed comparing three different pipe types, which are reinforced concrete pipe (RCP) and non-reinforced concrete pipe (NRCP), and vitrified clay pipe (VCP). Life cycle cost analysis is performed for material extraction, construction and rehabilitation phases. In the rehabilitation phase, Markov chains model is applied in the support of rehabilitation strategy. In the life cycle assessment, the Economic Input-Output Life Cycle Assessment (EIO-LCA) tools are used in estimating environmental emissions for all three phases. Emissions are then compared quantitatively among alternatives to support decision making.

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As engineers, we are trained to use logical, rational problem solving to insure our mines operate at maximum efficiency. We tend to use the same technical approach to design safety into all mining systems. This works well for machines, but not so much for the human component. Recent insights in the field of behavioral economics provide useful ideas for addressing the fact that we are driven by emotions more often than by rational thought. Understanding the nonrational aspect of human behavior is an important piece of any safety system design.

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Ideally the social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance their well-being (IFSW 2004). The social work practice, however, often proves to be different. Social workers are always in the danger to make decisions for their clients or define problems according to their own interpretation and world view. In quite a number of cases, the consequence of such a social work practice is that the clients feel disempowered rather than empowered. This dilemma is multiplying when western social workers get involved in developing countries. The potential that intervention, with the intention to empower and liberate the people, turns into disempowerment is tremendously higher because of the differences in tradition, culture and society, on the one side and the power imbalance between the ‘West’ and the ‘Rest’ on the other side. Especially in developing countries, where the vast majority of people live in poverty, many Western social workers come with a lot of sympathy and the idea to help the poor and to change the world. An example is Romania. After the collapse of communism in 1989, Romania was an economically, politically and socially devastated country. The pictures of the orphanages shocked the western world. As a result many Non-Governmental Organisations (NGOs), churches and individuals were bringing humanitarian goods to Romania in order to alleviate the misery of the Romanian people and especially the children. Since then, important changes in all areas of life have occurred, mostly with foreign financial aid and support. At the political level, democratic institutions were established, a liberal market economy was launched and laws were adapted to western standards regarding the accession into the European Union and the NATO. The western world has left its marks also at the grassroots level in form of NGOs or social service agencies established through western grants and individuals. Above and beyond, the presence of western goods and investment in Romania is omnipresent. This reflects a newly-gained freedom and prosperity - Romania profits certainly from these changes. But this is only one side of the medal, as the effect of westernisation contradicts with the Romanian reality and overruns many deep-rooted traditions, thus the majority of people. Moreover, only a small percentage of the population has access to this western world. Western concepts, procedures or interpretations are often highly differing from the Romanian tradition, history and culture. Nevertheless, western ideas seem to dominate the transition in many areas of daily life in Romania. A closer look reveals that many changes take place due to pressure of western governments and are conditioned to financial support. The dialectic relationship between the need for foreign aid and the implementation becomes very obvious in Romania and often leads, despite the substantial benefits, to unpredictable and rather negative side-effects, at a political, social, cultural, ecological and/or economic level. This reality is a huge dilemma for all those involved, as there is a fine line between empowering and disempowering action. It is beyond the scope of this journal to discuss the dilemma posed by Western involvement at all levels; therefore this article focuses on the impact of Western social workers in Romania. The first part consists of a short introduction to social work in Romania, followed by the discussion about the dilemma posed by the structure of project of international social work and the organisation of private social service agencies. Thirdly the experiences of Romanian staff with Western social workers are presented and then discussed with regard to turning disempowering tendencies of Western social workers into empowerment.

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The volume consists of twenty-five chapters selected from among peer-reviewed papers presented at the CELDA (Cognition and Exploratory Learning in the Digital Age) 2013 Conference held in Fort Worth, Texas, USA, in October 2013 and also from world class scholars in e-learning systems, environments and approaches. The following sub-topics are included: Exploratory Learning Technologies (Part I), e-Learning social web design (Part II), Learner communities through e-Learning implementations (Part III), Collaborative and student-centered e-Learning design (Part IV). E-Learning has been, since its initial stages, a synonym for flexibility. While this dynamic nature has mainly been associated with time and space it is safe to argue that currently it embraces other aspects such as the learners’ profile, the scope of subjects that can be taught electronically and the technology it employs. New technologies also widen the range of activities and skills developed in e-Learning. Electronic learning environments have evolved past the exclusive delivery of knowledge. Technology has endowed e-Learning with the possibility of remotely fomenting problem solving skills, critical thinking and team work, by investing in information exchange, collaboration, personalisation and community building.

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BACKGROUND Previous meta-analyses comparing the efficacy of psychotherapeutic interventions for depression were clouded by a limited number of within-study treatment comparisons. This study used network meta-analysis, a novel methodological approach that integrates direct and indirect evidence from randomised controlled studies, to re-examine the comparative efficacy of seven psychotherapeutic interventions for adult depression. METHODS AND FINDINGS We conducted systematic literature searches in PubMed, PsycINFO, and Embase up to November 2012, and identified additional studies through earlier meta-analyses and the references of included studies. We identified 198 studies, including 15,118 adult patients with depression, and coded moderator variables. Each of the seven psychotherapeutic interventions was superior to a waitlist control condition with moderate to large effects (range d = -0.62 to d = -0.92). Relative effects of different psychotherapeutic interventions on depressive symptoms were absent to small (range d = 0.01 to d = -0.30). Interpersonal therapy was significantly more effective than supportive therapy (d = -0.30, 95% credibility interval [CrI] [-0.54 to -0.05]). Moderator analysis showed that patient characteristics had no influence on treatment effects, but identified aspects of study quality and sample size as effect modifiers. Smaller effects were found in studies of at least moderate (Δd = 0.29 [-0.01 to 0.58]; p = 0.063) and large size (Δd = 0.33 [0.08 to 0.61]; p = 0.012) and those that had adequate outcome assessment (Δd = 0.38 [-0.06 to 0.87]; p = 0.100). Stepwise restriction of analyses by sample size showed robust effects for cognitive-behavioural therapy, interpersonal therapy, and problem-solving therapy (all d>0.46) compared to waitlist. Empirical evidence from large studies was unavailable or limited for other psychotherapeutic interventions. CONCLUSIONS Overall our results are consistent with the notion that different psychotherapeutic interventions for depression have comparable benefits. However, the robustness of the evidence varies considerably between different psychotherapeutic treatments.

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Residents of the European College of Veterinary Public Health (ECVPH) carried out a survey to explore the expectations and needs of potential employers of ECVPH diplomates and to assess the extent to which the ECVPH post-graduate training program meets those requirements. An online questionnaire was sent to 707 individuals working for universities, government organizations, and private companies active in the field of public health in 16 countries. Details on the structure and activities of the participants' organizations, their current knowledge of the ECVPH, and potential interest in employing veterinary public health (VPH) experts or hosting internships were collected. Participants were requested to rate 22 relevant competencies according to their importance for VPH professionals exiting the ECVPH training. A total of 138 completed questionnaires were included in the analysis. While generic skills such as "problem solving" and "broad horizon and inter-/multidisciplinary thinking" were consistently given high grades by all participants, the importance ascribed to more specialized skills was less homogeneous. The current ECVPH training more closely complies with the profile sought in academia, which may partly explain the lower employment rate of residents and diplomates within government and industry sectors. The study revealed a lack of awareness of the ECVPH among public health institutions and demonstrated the need for greater promotion of this veterinary specialization within Europe, both in terms of its training capacity and the professional skill-set of its diplomates. This study provides input for a critical revision of the ECVPH curriculum and the design of post-graduate training programs in VPH.

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The metacognitve ability to accurately estimate ones performance in a test, is assumed to be of central importance for initializing task-oriented effort. In addition activating adequate problem-solving strategies, and engaging in efficient error detection and correction. Although school children's' ability to estimate their own performance has been widely investigated, this was mostly done under highly-controlled, experimental set-ups including only one single test occasion. Method: The aim of this study was to investigate this metacognitive ability in the context of real achievement tests in mathematics. Developed and applied by a teacher of a 5th grade class over the course of a school year these tests allowed the exploration of the variability of performance estimation accuracy as a function of test difficulty. Results: Mean performance estimations were generally close to actual performance with somewhat less variability compared to test performance. When grouping the children into three achievement levels, results revealed higher accuracy of performance estimations in the high achievers compared to the low and average achievers. In order to explore the generalization of these findings, analyses were also conducted for the same children's tests in their science classes revealing a very similar pattern of results compared to the domain of mathematics. Discussion and Conclusion: By and large, the present study, in a natural environment, confirmed previous laboratory findings but also offered additional insights into the generalisation and the test dependency of students' performances estimations.

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Background: We previously found good psychometric properties of the Inventory for assessment of stress management skills (German translation: Inventar zur Erfassung von Stressbewältigungsfertigkeiten), ISBF, a short questionnaire for combined assessment of different perceived stress management skills in the general population. Here, we investigate whether stress management skills as measured by ISBF relate to cortisol stress reactivity in two independent studies, a laboratory study (study 1) and a field study (study 2). Methods: 35 healthy non-smoking and medication-free men in study 1 (age mean±SEM:38.0±1.6) and 35 male and female employees in study 2 (age mean±SEM:32.9±1.2) underwent an acute standardized psychosocial stress task combining public speaking and mental arithmetic in front of an audience. We assessed stress management skills (ISBF) and measured salivary cortisol before and after stress and several times up to 60 min (study 2) and 120 min (study 1) thereafter. Potential confounders were controlled. Results:. General linear models controlling for potential confounders revealed that in both studies, higher stress management skills (ISBF total score) were independently associated with lower cortisol levels before and after stress (main effects ISBF: p’s<.055) and lower cortisol stress reactivity (interaction ISBF-by-stress: p’s<.029). Post-hoc-testing of ISBF subscales suggest lower cortisol stress reactivity with higher “relaxation abilities” (both studies) and higher scores in the scale “cognitive strategies and problem solving” (study 2). Conclusions: Our findings suggest blunted increases in cortisol following stress with increasing stress management skills as measured by ISBF. This suggests that the ISBF not only relates to subjective psychological but also objective physiological stress indicators which may further underscore the validity of the questionnaire.

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Introduction To be successful in a profession, persons must have mastery of professional affective behaviors in addition to that profession’s core knowledge base. Health care delivery is more than just developing a good plan of care. The effective health care provider also will have good interpersonal and communication skills, have a commitment to learning, act professionally and responsibly, and have abilities in problem solving and critical thinking. But, these behaviors and characteristics are not taught directly in a professional program. This presentation will demonstrate how these ‘generic abilities’ have been incorporated in a post-professional program and how they can be used in other professional health care, professional development, and leadership programs. [See PDF for complete abstract]

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BACKGROUND: Renal failure after thoracoabdominal aortic repair is a significant clinical problem. Distal aortic perfusion for organ and spinal cord protection requires cannulation of the left femoral artery. In 2006, we reported the finding that direct cannulation led to leg ischemia in some patients and was associated with increased renal failure. After this finding, we modified our perfusion technique to eliminate leg ischemia from cannulation. In this article, we present the effects of this change on postoperative renal function. METHODS: Between February 1991 and July 2008, we repaired 1464 thoracoabdominal aortic aneurysms. Distal aortic perfusion was used in 1088, and these were studied. Median patient age was 68 years, and 378 (35%) were women. In September 2006, we began to adopt a sidearm femoral cannulation technique that provides distal aortic perfusion while maintaining downstream flow to the leg. This was used in 167 patients (15%). We measured the joint effects of preoperative glomerular filtration rate (GFR) and cannulation technique on the highest postoperative creatinine level, postoperative renal failure, and death. Analysis was by multiple linear or logistic regression with interaction. RESULTS: The preoperative GFR was the strongest predictor of postoperative renal dysfunction and death. No significant main effects of sidearm cannulation were noted. For peak creatinine level and postoperative renal failure, however, strong interactions between preoperative GFR and sidearm cannulation were present, resulting in reductions of postoperative renal complications of 15% to 20% when GFR was <60 mL>/min/1.73 m(2). For normal GFR, the effect was negated or even reversed at very high levels of GFR. Mortality, although not significantly affected by sidearm cannulation, showed a similar trend to the renal outcomes. CONCLUSION: Use of sidearm cannulation is associated with a clinically important and highly statistically significant reduction in postoperative renal complications in patients with a low GFR. Reduced renal effect of skeletal muscle ischemia is the proposed mechanism. Effects among patients with good preoperative renal function are less clear. A randomized trial is needed.

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Molluscan preparations have yielded seminal discoveries in neuroscience, but the experimental advantages of this group have not, until now, been complemented by adequate molecular or genomic information for comparisons to genetically defined model organisms in other phyla. The recent sequencing of the transcriptome and genome of Aplysia californica, however, will enable extensive comparative studies at the molecular level. Among other benefits, this will bring the power of individually identifiable and manipulable neurons to bear upon questions of cellular function for evolutionarily conserved genes associated with clinically important neural dysfunction. Because of the slower rate of gene evolution in this molluscan lineage, more homologs of genes associated with human disease are present in Aplysia than in leading model organisms from Arthropoda (Drosophila) or Nematoda (Caenorhabditis elegans). Research has hardly begun in molluscs on the cellular functions of gene products that in humans are associated with neurological diseases. On the other hand, much is known about molecular and cellular mechanisms of long-term neuronal plasticity. Persistent nociceptive sensitization of nociceptors in Aplysia displays many functional similarities to alterations in mammalian nociceptors associated with the clinical problem of chronic pain. Moreover, in Aplysia and mammals the same cell signaling pathways trigger persistent enhancement of excitability and synaptic transmission following noxious stimulation, and these highly conserved pathways are also used to induce memory traces in neural circuits of diverse species. This functional and molecular overlap in distantly related lineages and neuronal types supports the proposal that fundamental plasticity mechanisms important for memory, chronic pain, and other lasting alterations evolved from adaptive responses to peripheral injury in the earliest neurons. Molluscan preparations should become increasingly useful for comparative studies across phyla that can provide insight into cellular functions of clinically important genes.