Weather parameters and nosocomial bloodstream infection: a case-referent study

OBJECTIVE To evaluate if temperature and humidity influenced the etiology of bloodstream infections in a hospital from 2005 to 2010.METHODS The study had a case-referent design. Individual cases of bloodstream infections caused by specific groups or pathogens were compared with several references. In the first analysis, average temperature and humidity values for the seven days preceding collection of blood cultures were compared with an overall “seven-days moving average” for the study period. The second analysis included only patients with bloodstream infections. Several logistic regression models were used to compare different pathogens and groups with respect to the immediate weather parameters, adjusting for demographics, time, and unit of admission.RESULTS Higher temperatures and humidity were related to the recovery of bacteria as a whole (versus fungi) and of gram-negative bacilli. In the multivariable models, temperature was positively associated with the recovery of gram-negative bacilli (OR = 1.14; 95%CI 1.10;1.19) or Acinetobacter baumannii (OR = 1.26; 95%CI 1.16;1.37), even after adjustment for demographic and admission data. An inverse association was identified for humidity.CONCLUSIONS The study documented the impact of temperature and humidity on the incidence and etiology of bloodstream infections. The results correspond with those from ecological studies, indicating a higher incidence of gram-negative bacilli during warm seasons. These findings should guide policies directed at preventing and controlling healthcare-associated infections.

A qualitative description of soil parameters variation due to a prescribed fire in Portuguese northwestern forests using Fuzzy Boolean Nets — The case study of Cabreira mountain

In this paper we study the modifications that occurred in some forest soil properties after a prescribed fire. The research focused on the alterations of soil pH, soil moisture and soil organic matter content during a two-year span, from 2008 to 2009. The study site is located in Anjos, Vieira do Minho municipality, a forest site that has suffered from recurrent wildfires for several decades. Furze (Ulex, sp.), broom (Cytisus, sp.), gorse (Chamaespartum tridentatum) and a very few disperse adult pine (Pinus sylvestris) are the predominant vegetation type in the study area. The average height of this shrub vegetation is around 1.5 m. The prescribed fire was conducted by the National Forestry Authority (AFN) in November 2008. Fuzzy Boolean Nets (FBN) were used to evaluate the alteration in soil parameters when compared with adjacent spots where: i) no fire occurrence was registered since 1998; ii) fire occurrence was registered in 2008; and iii) vegetation pruning by mechanical cut was done in Spring six months prior to the prescribed fire event. Results suggest that in the particular case of the studied site, Anjos, the observed soil properties alterations cannot be related with the prescribed fire.

Medication regimen complexity in institutionalized elderly people in an aging society

Background: Complex medication regimens may adversely affect compliance and treatment outcomes. Complexity can be assessed with the medication regimen complexity index (MRCI), which has proved to be a valid, reliable tool, with potential uses in both practice and research. Objective: To use the MRCI to assess medication regimen complexity in institutionalized elderly people. Setting: Five nursing homes in mainland Portugal. Methods: A descriptive, cross-sectional study of institutionalized elderly people (n = 415) was performed from March to June 2009, including all inpatients aged 65 and over taking at least one medication per day. Main outcome measure: Medication regimen complexity index. Results: The mean age of the sample was 83.9 years (±6.6 years), and 60.2 % were women. The elderly patients were taking a large number of drugs, with 76.6 % taking more than five medications per day. The average medication regimen complexity was 18.2 (±SD = 9.6), and was higher in the females (p < 0.001). The most decisive factors contributing to the complexity were the number of drugs and dosage frequency. In regimens with the same number of medications, schedule was the most relevant factor in the final score (r = 0.922), followed by pharmaceutical forms (r = 0.768) and additional instructions (r = 0.742). Conclusion: Medication regimen complexity proved to be high. There is certainly potential for the pharmacist's intervention to reduce it as part as the medication review routine in all the patients.

Perspectives of the Internal Public in a Cultural Event: the Case of Noc Noc, Guimarães - Portugal

Given the significant impact that cultural events may have in local communities and the inherent organization complexity, it is important to understand their specificities. Most of the times cultural events disregard marketing and often marketing is distant from art. Thus an analysis of an inside perspective might bring significant returns to the organization of such an event. This paper considers the three editions (2011, 2012 and 2013) of a cultural event – Noc Noc – organized by a local association in the city of Guimarães, Portugal. Its format is based in analogous events, as Noc Noc intends to convert everyday spaces (homes, commercial outlets and a number of other buildings) into cultural spaces, processed and transformed by artists, hosts and audiences. By interviewing a sample of people (20) who have hosted this cultural event, sometimes doubling as artists, and by experiencing the three editions of the event, this paper illustrates how the internal public understands this particular cultural event, analyzing specifically their motivations, ways of acting and participating, as well as their relationship with the public, with the organization of the event and with art in general. Results support that artists and hosts motivations must be identified in a timely and appropriate moment, as well as their views of this particular cultural event, in order to keep them participating, since low budget cultural events such as this one may have a key role in small scale cities.

Mapping the quality of life experience in Alfama: a case study in Lisbon, Portugal.

Dissertation submitted in partial fulfilment of the requirements for the Degree of Master of Science in Geospatial Technologies.

FIRST CASE OF HUMAN INFECTION BY Bertiella studeri (Blanchard, 1891) Stunkard,1940 (Cestoda; Anoplocephalidae) IN BRAZIL

SUMMARY Cestodes of the Bertiella genus are parasites of non-human primates found in Africa, Asia, Oceania and the Americas. Species Bertiella studeri and Bertiella mucronatacould, accidentally, infect human beings. The infection occurs from ingestion of mites from the Oribatida order containing cysticercoid larvae of the parasite. The objective of this report is to register the first case of human infection by Bertiella studeri in Brazil. Proglottids of the parasite, found in the stool sample of a two-and-a-half-year-old child, were fixed, stained and microscopically observed to evaluate its morphological characteristics. Eggs obtained from the proglottids were also studied. The gravid proglottids examined matched the description of the genus Bertiella. The eggs presented a round shape, with the average diameter of 43.7 µm, clearly showing the typical pyriform apparatus of B. studeri. The authors concluded that the child was infected with Bertiella studeri,based on Stunkard's (1940) description of the species. This is the fifth case of human Bertiellosis described in Brazil through morphometric analysis of the parasite, the third in Minas Gerais State and the first diagnosed case of Bertiella studeriin Brazil.

Tumors of the Brachial Plexus in a Tertiary Referral Center: a Case Series and Literature Review

Introduction: Brachial plexus (BP) tumors are very rare tumors, with less than 800 cases been described in the literature worldwide since 1970. These tumors often present as local or radicular pain, with scant or no neurological deficits. These symptoms are shared by many other more common rheumatologic diseases, thus making their diagnosis difficult in most cases. Additionally, these tumors often present as lumps and are therefore biopsied, which carries a significant risk of iatrogenic nerve injury. Material and Methods: In this paper the authors describe their experience with the management of 5 patients with BP tumors followed up for at least 2 years. There were 4 males and 1 female. Median follow-up time was 41 ± 21 months. Average age at diagnosis was 40,0 ± 19,9 years. The most common complaints at presentation were pain and sensibility changes. All patients had a positive Tinel sign when the lesion was percussed. In all patients surgery was undertaken and the tumors removed. In 4 patients nerve integrity was maintained. In one patient with excruciating pain a segment of the nerve had to be excised and the nerve defect was bridged with sural nerve grafts. Results: Pathology examination of the resected specimens revealed a Schwannoma in 4 cases and a neurofibroma in the patient submitted to segmental nerve resection. Two years postoperatively, no recurrences were observed. All patients revealed clinical improvement. The patient submitted to nerve resection had improvement in pain, but presented diminished strength and sensibility in the involved nerve territory. Conclusion: Surgical excision of BP tumors is not a risk free procedure. Most authors suggest surgery if the lesion is symptomatic or progressing in size. If the tumor is stationary and not associated with neurological dysfunction a conservative approach should be taken.

Barreiras e facilitadores à implementação de um modelo de gestão de cuidados em Saúde Mental

RESUMO: Enquadramento teórico - Os estudos epidemiológicos demonstram que apesar de todo o progresso científico, muitas pessoas continuam sem acesso aos Serviços de Saúde Mental (SSM) e que, em muitos casos, os cuidados não têm a qualidade suficiente. A experiência de vários países mostra que os processos de implementação de modelos de intervenção terapêutica, como é o da Gestão de Cuidados, são lentos e complexos, não dependendo somente do grau de efectividade ou da complexidade das práticas a implementar. O Modelo de Gestão de Cuidados (MGC), é definido como uma prática baseada na evidência, utilizada para ajudar os doentes nos seus processos de recuperação. As estratégias para implementar práticas baseadas na evidência são críticas para a melhoria dos serviços. Existem, apesar de toda a evidência, muitas barreiras à implementação. Ao constatarmos que as práticas validadas pela ciência estão longe de estar claramente disseminadas nos serviços de saúde mental, fundamentamos a necessidade de utilizar metodologia de implementação que, além da efectividade das práticas, permita uma efectividade da implementação. Para responder às necessidades de formação e no âmbito da implementação do Plano Nacional de Saúde Mental, foram formados, em Portugal, 170 profissionais de saúde mental provenientes de serviços públicos e do sector social, de todas as regiões de Portugal Continental. Considerando que estes profissionais adquiriram competências específicas no MGC, através de um programa de formação nacional idêntico para todos os serviços de saúde mental, investigámos o grau de implementação deste modelo, bem como os facilitadores e as barreiras à sua correcta implementação. Existem vários estudos internacionais sobre as barreiras e os facilitadores à implementação de práticas baseadas na evidência, embora a maior parte desses estudos seja baseado em entrevistas semi-estruturadas a profissionais. Por outro lado, não existem, em Portugal, estudos sobre as barreiras e os facilitadores à implementação de práticas de saúde mental. Objectivos 1. Estimar o grau da implementação do MGC nos serviços de saúde mental portugueses 2. Caracterizar as regiões onde a implementação do MGC tenha ocorrido em maior grau. 3. Identificar os factores facilitadores e as barreiras à implementação do MGC, entre as regiõesde saúde do país. 4. Explorar as relações entre a fidelidade da implementação, as barreiras e os facilitadores da implementação, a cultura organizacional e as características dos serviços de saúde mental. Metodologia Estudo observacional, transversal e descritivo, com características exploratórias. População: profissionais dos serviços de saúde mental públicos e do sector social que frequentaram o Programa Nacional de Formação em Saúde Mental Comunitária no curso “Cuidados Integrados e Recuperação”, da Coordenação Nacional para a Saúde Mental / Ministério da Saúde, entre Outubro de 2008 e Dezembro de 2009, (n=71). Avaliação Fidelidade de implementação do Modelo de Gestão de Cuidados - IMR-S (Illness Management and Recovery Scale); Qualidade das guidelines utilizadas na implementação do Modelo de Gestão de Cuidados - AGREE II-PT (Appraisal of Guidelines, for Research and Evaluation); Avaliação das Barreiras e Facilitadores à implementação do MGC - BaFAI (Barriers and Facilitators Assessment Instrument); Avaliação da Cultura Organizacional dos serviços de saúde mental - CVF-I (Competing Values Framework Instrument). Análise Estatística Para a descrição dos dados foram aplicados métodos de estatística descritiva. Para a comparação de subgrupos foram utilizados os testes de Mann Whitney e Kruskall-Wallis. Para a investigação de associações foram utilizados os métodos de correlação de Spearman e a Regressão Múltipla. O tratamento e análise dos dados foram realizados utilizando o programa estatístico IBM SPSS Statistics® para Mac/Apple® nas versões 19 e 20. Resultados Serviços: A articulação com os cuidados de saúde primários existe na maioria dos serviços (56.34%) e 77.46% dos serviços têm autonomia para definir os cuidados a prestar. A maioria dos serviços (63.38%) realiza duas ou mais reuniões clínicas por mês e a quase totalidade (95.77%) recebe estagiários e/ou internos. A área da investigação tem níveis considerados baixos, quando comparados com outros países da Europa, tanto para a globalidade das áreas de investigação (25.35%), como para as áreas psicossociais (22.54%). Considerando componentes fundamentais para a implementação de modelos de gestão de cuidados, os resultados nacionais indicam que 66.20% dos serviços fazem registos em processo clínico único. As percentagens de utilização de planos individuais de cuidados são globalmente baixas (46.48%). Por seu turno, a utilização de guidelines, nos serviços do país, tem uma percentagem média nacional de 57.75%. Profissionais: São, na sua maioria, do sexo feminino (69.01%), com idades entre os 25 e os 56 anos (média 38.9, ± 7.41). Pertencem, maioritariamente, aos grupos profissionais da enfermagem (23.94%) e da psicologia (49.30%). A formação dos profissionais é de nível superior em todos os grupos, com uma percentagem total de licenciados de 80.3%, tendo os restantes uma formação ao nível do mestrado. Apesar dos valores baixos (17%) de formação prévia em modelos de gestão de cuidados, 39% dos profissionais indicou utilizar algumas vertentes destes modelos na sua prática. Apesar de 97,18% dos profissionais ter participado em dois ou mais encontros científicos, num período de dois anos, apenas 38.03% apresentou alguma comunicação científica no mesmo intervalo. Guideline: Os resultados da avaliação da guideline do MGC indicaram percentagens mais altas, quanto à qualidade do seu desenvolvimento, nos Domínios 1 (Objectivo e finalidade, com 72.2%) e 4 (Clareza de Apresentação, 77.7%). O Domínio 5 (Aplicabilidade) foi pontuado no limite inferior do desenvolvimento com qualidade suficiente (54.1%), ao passo que a guideline obteve uma pontuação negativa nos Domínios 2 (Envolvimento das partes interessadas, com 41.6%) e 3 (Rigor do Desenvolvimento, com 28.1%). Adicionalmente não foi possível às avaliadoras cotar o Domínio 6 (Independência editorial), por ausência de referências neste contexto. A guideline teve uma avaliação global positiva (66%), com recomendação de aceitação com modificações. Cultura Organizacional: O perfil de liderança com maior frequência nos serviços de saúde mental portugueses foi o de Mentor (45.61%). As percentagens mais baixas pertenceram aos perfis Monitor e Inovador (3.51%). Na perspectiva da cultura organizacional dos serviços, apontuação mais alta foi a da Cultura das Relações Humanas (74.07%). A estratégia de liderança, com predomínio em todas as regiões, foi a estratégia de Flexibilidade (66.10%). Os resultados mostram que a única associação positivamente significativa com o grau da implementação do MGC é a do perfil Produtor, com um peso específico de 14.55% na prevalência dos perfis de liderança nos serviços de saúde mental portugueses. Barreiras: As barreiras à implementação da prática do MGC, identificadas pelos profissionais dos serviços de saúde mental, com percentagens mais altas nos totais do país, foram: o tempo (57.7%), o conhecimento sobre o modelo e a motivação (40.8%), a colaboração dos outros profissionais (33.7%), o número de contactos reduzidos com os doentes (35.2%), as insuficiências do ponto de vista dos espaços (70.4%) e dos instrumentos disponíveis (69%) para implementar o MGC. Existiu uma variação entre as regiões de saúde do país. Os resultados mostram que houve uma correlação negativa, de forma significativa, entre a implementação do MGC e as barreiras: da resistência à utilização de protocolos, do formato da prática, da necessidade de mais treino e da não cooperação dos profissionais. Foram encontradas diferenças estatisticamente significativas entre as barreiras à implementação e as características dos serviços, dos profissionais e da cultura organizacional. Implementação: A média nacional da fidelidade de implementação do MGC (41.48) teve valores aproximados aos de estudos similares. Na pontuação por regiões, a implementação com maior fidelidade ocorreu no Alentejo. Se considerarmos a implementação com fidelidade esta ocorreu em 57.75% dos serviços e uma boa implementação em 15.49%. Os métodos de regressão permitiram confirmar a capacidade preditiva das barreiras e da cultura organizacional quanto à fidelidade da implementação do MGC. Discussão: No universo das hipóteses inicialmente colocadas foi possível verificar a variação da implementação do MGC entre as regiões do país. O estudo permitiu, adicionalmente, concluir pela existência de denominadores comuns de maior sucesso da implementação do MGC. Foi ainda possível verificar uma relação significativa, existente entre o grau de implementação e as dimensões das barreiras, a cultura organizacional e os recursos dos SSM (aqui definidos pelas características dos serviços e dos profissionais). De uma forma mais conclusiva podemos afirmar que existem outros factores, que não estão relacionados com a avaliação restrita dos recursos financeiros ou humanos, associados à qualidade da implementação de práticas baseadas na evidência, como o MGC. Exemplo disso são os achados referentes à região de saúde do Alentejo, onde a distância dos grandes centros urbanos e as conhecidas dificuldades de acessibilidade, combinadas com os problemas conhecidos da falta de recursos, não impediram que fosse a região com os valores mais altos da fidelidade de implementação. Conclusões: Foram encontradas inúmeras barreiras à implementação do MGC. Existem barreiras diferentes entre regiões, que resultam das características dos serviços, dos profissionais e da cultura organizacional. Para existir implementação é necessária a consideração de metodologias próprias que vão para além dos tradicionais programas de formação. As práticas baseadas na evidência, amplamente defendidas, exigem implementações baseadas na evidência.-------------ABSTRACT: Introduction - Several epidemiological studies show that, despite all scientific progress, many people still continue to have no access to mental health services and in many situations the quality of care is poor. The experiences of several countries show that progress towards case management implementation is slow and complex, depending not only from the degree of effectiveness or the complexity of the practice. Case management is defined as an evidence-based practice used to help patients in the recovery process. Strategies to implement evidence-based practices are critical to services improvement. There are many barriers to their implementation, despite all available evidence. Realising that practices of proved scientific value are far from being clearly implemented, justifies the need to use implementation methodologies that, beyond practice effectiveness, allow implementation effectiveness. To answer training needs and in the framework of the National Mental Health Plan implementation, 170 mental health (MH) professionals from portuguese public and private sectors were trained. Considering that case management skills were acquired, as a result of this training programme, we decided to study the degree of implementation in the services.Barriers and facilitators to the implementation were studied as well. There are several studies related with barriers and facilitators to the implementation of evidence-based practices, but most of them use semi-structured interviews with professionals. Additionally, there are no studies in Portugal related with barriers and facilitators to the implementation of mental health practices. Objectives1. Estimate the degree of case management implementation in Portuguese MH Services. 2.Describe regions where implementation occurred with higher fidelity degree. 3. Identify barriers and facilitators to case management implementation across country regions. 4. Explore the relationships between implementation, barriers and facilitators, organisational culture and services characteristics. Methodology - Cross sectional, descriptive study. Assessments - Implementation fidelity - IMR-S (Illness Management and Recovery Scale); Guideline quality - AGREE II-PT (Appraisal of Guidelines, for Research and Evaluation); Barriers and facilitators assessment - BaFAI (Barriers and Facilitators Assessment Instrument); Organisational culture assessment - CVF-I (Competing Values Framework Instrument). Statistical analysis - Descriptives and cross-tabs. Subgroups comparison: Mann-Witney and Kruskall-Wallis. Associations between variables were calculated using Spearman correlation's and Multiple Regression. Results - Services: Liaison with primary care is done in most services (56.34%) and 77.46% have autonomy to determine care. Most services have regular clinical meetings and almost all give internship training (95.77%). Research activity is low compared with other European countries, for both general and psychosocial research. Considering key components for the case management implementation, 66.20% of all services use single clinical records. The use of individual care plans is globally low (46.48%) and there is a use of guidelines in 57.75% of services. Human Resources: most are women (69.01%), with age ranging from 25-56 (average 39.9, SD 7.41). The majority are psychologists (49.30%) and nurses (23.94%). All have a university degree, 19.7% have a masters degree and 83% didn’t have any case management training before the above mentioned national training. Despite the low levels of preceding case management training, 39% have used model components in day-to-day practice and although 97.18% of the workforce have attended scientific meetings in the last 2 years, only 38.03% presented communications in the same period. Guideline: Results show that higher scores were obtained in Domain 1. Scope and Purpose (72.2.%),and Domain 4. Clarity of presentation (77.7%). Domain 5. pplicability scored near low boundary (54.1%) and negative scores were found in Domain 2. Stakeholder Involvement (41.6%) and Domain 3. Rigour of Development (28.1%). Global score was 66% and the guideline was recommended with modifications. Organisational Culture: The most frequent leadership profile was the Mentor profile (45.61%). Lower scores belonged to Innovator and Monitor profiles (3.51%). On the organisational culture overall, higher scores were found in the Human Relations culture (74.07%). The higher leadership strategy was the strategy of flexibility (66.10%). The results additionally showed that the only leadership profile associated with case management implementation was the Producer profile, representing 14.55% of all leadership profiles in the country.Barriers: The barriers identified by MH professionals, with high percentages, were: lack of time (57.7%), knowledge and motivation (40.8%), other colleagues cooperation (33.7%), low number of contacts with patients (35.2%), lack of facilities (70.4%) and lack of instruments (69%) to implement case management, varying across regions. Results show that there was a negative correlation between implementation and the following barriers: using protocols, practice format, need for more training and lack of cooperation from colleagues. Additionally, statistical differences were found between barriers to implementation and: services characteristics, workforce characteristics, organisational culture. Implementation: The national average results of case management implementation fidelity was (41.48), close to values found in similar studies. In the regional scores South Region Alentejo had the highest implementation score. If we look at minimum scores to assume implementation fidelity, these occurred in 57.75% of services and a good implementation occurred in 15.49% of these. Regression methods allowed to confirm that implementation score prediction was possible using the combination of barriers and organisational culture scores. Discussion - Considering the initial study hypotheses, it was possible to confirm the variation of case management implementation across country regions. Additionally, we could conclude that common denominators exist when successful implementation occurred. It was possible to observe a significant relationship between implementation degree and the dimensions of barriers, organisational culture and services resources (defined as professionals and services characteristics). In a more conclusive way, we can say that there are factors, other than financial and human resources, that are associated with evidence based practices implementation like case management. An example is the Alentejo region, were the distance from urban centres, and the known difficulties associated with accessibility, plus the lack of financial and human resources, have not impeded the regional higher score on implementation. Conclusions: Case management implementation had several barriers to implementation. There are different barriers across country regions, resulting from organisational culture, services and professionals characteristics. To reach implementation it is necessary to consider specific methodologies that go beyond traditional training programs and evident practices, widely promoted. Evidence-based practices require evidence-based implementations.

Assessment of distinctive road runoff quality in coastal areas, based on a monitoring case study

High levels of marine salt deposition present in coastal areas have a relevant effect on road runoff characteristics. This study assesses this effect with the purpose of identifying the relationships between monitored water quality parameters and intrinsic site variables. To achieve this objective, an extensive monitoring program was conducted on a Portuguese coastal highway. The study included 30 rainfall events, in different weather, traffic, and salt deposition conditions. The evaluations of various water quality parameters were carried out in over 200 samples. In addition, the meteorological, hydrological, and traffic parameters were continuously measured. The salt deposition rates were determined by means of a wet candle device, which is an innovative feature of the monitoring program. The relation between road runoff pollutants and independent variables associated with weather, traffic, and salt deposition conditions was assessed. Significant correlations among pollutants were observed. A high salinity concentration and its influence on the road runoff were confirmed. Furthermore, the concentrations of the most relevant pollutants seemed to be very dependent on some meteorological variables, particularly the duration of the antecedent dry period prior to each rainfall event and the average wind speed.

Cantrell Syndrome. Case report of an adult

Cantrell syndrome is characterized by defects that involve the diaphragm, abdominal wall, pericardium, heart, and lower region of the sternum. It is a rare entity, usually diagnosed at birth and accompanied by high mortality due to the complexity and gravity of the anomalies. In this report, we present a 32-year-old male patient, who was diagnosed in infancy but who reached adult age asymptomatic.

Rhinitis due to acrylates : case report

Background: Acrylates and methacrylates (salts and esters of acrylic and metacrylic acid respectively), are monomers commonly found in polymer plastics, resins and glues, and are widely used in many industry sectors. The first adverse health effects described were skin reactions and asthma. Exposure to acrylates, for instance when using multicomponent glues, is now a well known cause of occupational asthma. Methods: We report the case of a rhinitis - and possible asthma - to acrylates, in a 38-year-old woman, working in a nail beauty salon. She was currently treated for hypertension, and otherwise known for obesity and seasonal rhinoconjunctivitis, but did not have any respiratory problem. Two years after starting this activity, she progressively started to complain of anosmia, rhinitis, and intermittent dyspnea. Her job consisted in decorating nails with a mixture of a polymer powder and a liquid monomer, after removing the previous artificial nail with a small sander. We assessed exposure to acrylates at her working place, both as dust (from sanded nails) and volatile compound (from the mixture described above), and she was asked to measure her peak flow values twice a day for ten days, in order to detect a possible relationship between her occupational activities, the symptoms and the peak flow values. Results: Measures made during the visit of the patient's place of work showed that the existing aspiration system was efficient for eliminating the dust produced by nail sanding, but not for eliminating the volatile components. Thus, occupational exposure to acrylates was demonstrated. Moreover, the peak flow measures showed an average decrease of almost 10 percent when the patient was at work, compared to when she stayed home. We concluded that she actually suffered from professional rhinitis and, possibly, professional asthma (not certain because of the limited number of peak flow measures per day). Conclusion: Although exposure to acrylates is a well known cause of occupational asthma, it should be emphasized that the exact mechanisms of action remain unknown, despite the abundant literature about it. Some professions, which tend to be more frequent nowadays (such as working in a nail beauty salon), can expose the worker to particular risks. This highlights the need of always inquiring not only about the profession, but also the related activities, when facing a case of suspected asthma.

Penalizing Cartels: The Case for Basing Penalties on Price Overcharge

In this paper we set out the welfare economics based case for imposing cartel penalties on the cartel overcharge rather than on the more conventional bases of revenue or profits (illegal gains). To do this we undertake a systematic comparison of a penalty based on the cartel overcharge with three other penalty regimes: fixed penalties; penalties based on revenue, and penalties based on profits. Our analysis is the first to compare these regimes in terms of their impact on both (i) the prices charged by those cartels that do form; and (ii) the number of stable cartels that form (deterrence). We show that the class of penalties based on profits is identical to the class of fixed penalties in all welfare-relevant respects. For the other three types of penalty we show that, for those cartels that do form, penalties based on the overcharge produce lower prices than those based on profit) while penalties based on revenue produce the highest prices. Further, in conjunction with the above result, our analysis of cartel stability (and thus deterrence), shows that penalties based on the overcharge out-perform those based on profits, which in turn out-perform those based on revenue in terms of their impact on each of the following welfare criteria: (a) average overcharge; (b) average consumer surplus; (c) average total welfare.

Quality assurance in the EORTC 22033-26033/CE5 phase III randomized trial for low grade glioma: the digital individual case review.

INTRODUCTION: The phase III EORTC 22033-26033/NCIC CE5 intergroup trial compares 50.4 Gy radiotherapy with up-front temozolomide in previously untreated low-grade glioma. We describe the digital EORTC individual case review (ICR) performed to evaluate protocol radiotherapy (RT) compliance. METHODS: Fifty-eight institutions were asked to submit 1-2 randomly selected cases. Digital ICR datasets were uploaded to the EORTC server and accessed by three central reviewers. Twenty-seven parameters were analysed including volume delineation, treatment planning, organ at risk (OAR) dosimetry and verification. Consensus reviews were collated and summary statistics calculated. RESULTS: Fifty-seven of seventy-two requested datasets from forty-eight institutions were technically usable. 31/57 received a major deviation for at least one section. Relocation accuracy was according to protocol in 45. Just over 30% had acceptable target volumes. OAR contours were missing in an average of 25% of cases. Up to one-third of those present were incorrectly drawn while dosimetry was largely protocol compliant. Beam energy was acceptable in 97% and 48 patients had per protocol beam arrangements. CONCLUSIONS: Digital RT plan submission and review within the EORTC 22033-26033 ICR provide a solid foundation for future quality assurance procedures. Strict evaluation resulted in overall grades of minor and major deviation for 37% and 32%, respectively.

Turnaround across diverse global supply chains using shared metrics and change methodology: The Case of Amer Sports Corporation

Purpose - The purpose of this paper is to document the outcome of a global three-year long supply chain improvement initiative at a multi-national producer of branded sporting goods that is transforming from a holding structure to an integrated company. The case company is comprised of seven internationally well-known sport brands, which form a diverse set of independent sub-cases, on which the same supply chain metrics and change project approach was applied to improve supply chain performance. Design/methodology/approach - By using in-depth case study and statistical analysis the paper analyzes across the brands how supply chain complexity (SKU count), supply chain type (make or buy) and seasonality affect completeness and punctuality of deliveries, and inventory as the change project progresses. Findings - Results show that reduction in supply chain complexity improves delivery performance, but has no impact on inventory. Supply chain type has no impact on service level, but brands with in-house production are better in improving inventory than those with outsourced production. Non-seasonal business units improve service faster than seasonal ones, yet there is no impact on inventory. Research limitations/implications - The longitudinal data used for the analysis is biased with the general business trend, yet the rich data from different cases and three-years of data collection enables generalizations to a certain level. Practical implications - The in-depth case study serves as an example for other companies on how to initiate a supply chain improvement project across business units with tangible results. Originality/value - The seven sub-cases with their different characteristics on which the same improvement initiative was applied sets a unique ground for longitudinal analysis to study supply chain complexity, type and seasonality.