The demands of family caregivers of elderly individuals with dementia

The purpose of this cross-sectional observational study was to identify characteristics of caregivers of elderly people with dementia, types of care demands and to relate demands to the stage of dementia. The study was carried out in 2004 with 104 older adults and 90 caregivers in Ribeirão Preto, state of São Paulo. The OARS instrument was utilized and a questionnaire answered by caregivers. Among older adults, 66.3% were female, aged 75.5 years in average and 86.5% had caregivers. Eighty percent of the caregivers were women family members, aged 52.3 years in average. They spent 15.10 hours/day with care, without help. An important relationship was observed between caregiver's burden, physical and emotional effort and stage of dementia. Emotional overburden was higher at dementia early and late stages, this difference was statistically non-significant. Results reveal the urgent need to plan formal and informal support strategies to caregivers of Brazilian elderly people with dementia.

Event-related potential analyses via single-subject topographic classification.

Introduction: Responses to external stimuli are typically investigated by averaging peri-stimulus electroencephalography (EEG) epochs in order to derive event-related potentials (ERPs) across the electrode montage, under the assumption that signals that are related to the external stimulus are fixed in time across trials. We demonstrate the applicability of a single-trial model based on patterns of scalp topographies (De Lucia et al, 2007) that can be used for ERP analysis at the single-subject level. The model is able to classify new trials (or groups of trials) with minimal a priori hypotheses, using information derived from a training dataset. The features used for the classification (the topography of responses and their latency) can be neurophysiologically interpreted, because a difference in scalp topography indicates a different configuration of brain generators. An above chance classification accuracy on test datasets implicitly demonstrates the suitability of this model for EEG data. Methods: The data analyzed in this study were acquired from two separate visual evoked potential (VEP) experiments. The first entailed passive presentation of checkerboard stimuli to each of the four visual quadrants (hereafter, "Checkerboard Experiment") (Plomp et al, submitted). The second entailed active discrimination of novel versus repeated line drawings of common objects (hereafter, "Priming Experiment") (Murray et al, 2004). Four subjects per experiment were analyzed, using approx. 200 trials per experimental condition. These trials were randomly separated in training (90%) and testing (10%) datasets in 10 independent shuffles. In order to perform the ERP analysis we estimated the statistical distribution of voltage topographies by a Mixture of Gaussians (MofGs), which reduces our original dataset to a small number of representative voltage topographies. We then evaluated statistically the degree of presence of these template maps across trials and whether and when this was different across experimental conditions. Based on these differences, single-trials or sets of a few single-trials were classified as belonging to one or the other experimental condition. Classification performance was assessed using the Receiver Operating Characteristic (ROC) curve. Results: For the Checkerboard Experiment contrasts entailed left vs. right visual field presentations for upper and lower quadrants, separately. The average posterior probabilities, indicating the presence of the computed template maps in time and across trials revealed significant differences starting at ~60-70 ms post-stimulus. The average ROC curve area across all four subjects was 0.80 and 0.85 for upper and lower quadrants, respectively and was in all cases significantly higher than chance (unpaired t-test, p<0.0001). In the Priming Experiment, we contrasted initial versus repeated presentations of visual object stimuli. Their posterior probabilities revealed significant differences, which started at 250ms post-stimulus onset. The classification accuracy rates with single-trial test data were at chance level. We therefore considered sub-averages based on five single trials. We found that for three out of four subjects' classification rates were significantly above chance level (unpaired t-test, p<0.0001). Conclusions: The main advantage of the present approach is that it is based on topographic features that are readily interpretable along neurophysiologic lines. As these maps were previously normalized by the overall strength of the field potential on the scalp, a change in their presence across trials and between conditions forcibly reflects a change in the underlying generator configurations. The temporal periods of statistical difference between conditions were estimated for each training dataset for ten shuffles of the data. Across the ten shuffles and in both experiments, we observed a high level of consistency in the temporal periods over which the two conditions differed. With this method we are able to analyze ERPs at the single-subject level providing a novel tool to compare normal electrophysiological responses versus single cases that cannot be considered part of any cohort of subjects. This aspect promises to have a strong impact on both basic and clinical research.

Systematic difference between blood pressure readings caused by cuff type.

In this study we determine whether blood pressure readings using a cuff of fixed size systematically differed from readings made with a triple-bladder cuff (Tricuff) that automatically adjusts bladder width to arm circumference and assessed subsequent clinical and epidemiological effects. Blood pressure was measured with a standard cuff or a Tricuff in 454 patients visiting an outpatient clinic in the Seychelles (Indian Ocean). Overall means of within-individual standard cuff-Tricuff differences in systolic and diastolic blood pressures were examined in relation to arm circumference and sex. The standard cuff-Tricuff difference in systolic and diastolic blood pressures increased monotonically with circumference (from 4.7 +/- 0.8/3.2 +/- 0.7 mm Hg for arm circumference of 30 to 31 cm to 10.0 +/- 1.1/8.0 +/- 0.9 mm Hg for arm circumference &gt; or = 36 cm) and was larger in women than men. Multivariate linear regression indicated independent effects of arm circumference and sex. Forty percent of subjects with a diastolic blood pressure of &gt; or = 95 mm Hg measured with a standard cuff had values less than 95 mm Hg measured with a Tricuff. Extrapolation to the entire population of the Seychelles decreased the prevalence of blood pressure greater than or equal to 160/95 mm Hg by 11.5% and 24.0% in men and women, respectively, aged 35 to 64 years. The age-adjusted effect of body mass index on systolic and diastolic blood pressures decreased twofold using blood pressure readings made with a Tricuff instead of a standard cuff.(ABSTRACT TRUNCATED AT 250 WORDS)

EU Enlargement and Technology Transfer to New Member States, November 2005

The European Union (EU) accomplished its biggest enlargement process in 2004 in terms of the number of countries, area, and population. This study focuses on the impact of enlargement, the resulting technology transfer on the grain sectors of the New Member States (NMS), and the consequent welfare implications. The study finds that EU enlargement has important implications for the EU and the NMS, but its impact on the world grain markets is minimal. The results show that producers in the NMS gain from accession because of higher prices, whereas consumers in most NMS face a welfare loss. Incorporating technology transfer into the accession increases the welfare gain of producers despite falling prices because of the larger supply shift. The loss of welfare for consumers in most NMS is lower in this case because of the decline in grain prices.

Sensing, uptake and response to c4-dicarboxylic acids in pseudomonas aeruginosa pao1

C4-dicarboxylates are one of the preferred carbon and energy sources for the growth of P. aeruginosa, a ubiquitous and metabolically versatile bacterium. However, despite their importance, C4-dicarboxylates sensing and uptake systems were poorly understood in P. aeruginosa and only little information was available in the literature. In our work, the C4-dicarboxylate transport (Dct) system in P. aeruginosa was found to be composed of a novel two-component system, called DctB/DctD, regulating together with the sigma factor RpoN the expression of two newly identified C4-dicarboxylate transporters: DctA and DctPQM. Inactivation of the dct A, dctB or dctD gene caused a growth defect of the strain in minimal media supplemented with succinate, fumarate or malate, indicating their major role in Dct. However, residual growth of the dctA mutant in these media suggested the presence of redundant C4-dicarboxylate transporter(s). Tn5 insertion mutagenesis of the kdctA mutant, combined with a screening for growth on succinate, led to the identification of a second Dct system, the DctPQM transporter, belonging to the tripartite ATP-independent periplasmic (TRAP) family of carriers. AdctAAdctPQM double mutant showed no growth on malate and fumarate albeit residual growth on succinate suggested that additional transporters for succinate are present. Competition experiments demonstrated that the DctPQM carrier was more efficient than the DctA carrier for the utilization of succinate at μΜ concentrations, whereas DctA was the major transporter at mM concentrations. For the first time, high- and low-affinity uptake systems for succinate (DctA and DctPQM) are reported to function co-ordinately to transport C4- dicarboxylates. Most probably, the presence of redundant uptake systems contributes to the versatility of this bacterium. Next, the regulation of the Dct system was investigated. While performing a parallel study about the carbon catabolite repression (CCR) phenomenon in P. aeruginosa, a link between the CCR cascade (CbrAB/CrcZ/Crc) and the Dct system was observed. Crc is a translational repressor acting when preferred carbon sources (like C4-dicarboxylates) are present. CrcZ is a small RNA acting as a functional antagonist of Crc and induced by the CbrA/CbrB two-component system when non preferred carbon sources (like mannitol) are utilized. Novel targets of the CbrAB/CrcZ/Crc system in P. aeruginosa were identified using transcriptome analysis; among them dctA and dctPQM were detected. CCR is regulating the dct transporter genes expression depending on the succinate concentrations in the medium of growth; this modulation of CCR is possible because, at the same time, succinate concentrations tune CCR. In a medium containing high succinate concentrations, CrcZ levels were low and therefore Crc inhibited the translation of mRNA targets. Whereas in a medium containing low succinate concentrations, the subsequent increase of CrcZ levels sequestered Crc, inhibiting its activity. This model shows for the first time that CCR possesses a feedback-based circuitry, a very important type of regulatory loop that confers the best adaptive response under changing environmental conditions. The expression of the dct transporter genes is also found to be regulated by the RNA chaperone protein Hfq. Hfq has the same post-transcriptional effect than Crc at high concentration of succinate, i.e. inhibiting dctP and dctR and indirectly favouring dctA expression. Moreover, an additional indirect positive regulation of dctP expression by Hfq was found. Finally, a metabolome approach was performed to investigate the internal signals modulating CCR via induction of CbrA activity in P. aeruginosa PAOl and P. putida KT2442. The results of the analysis are currently under study in the laboratory. - Les acides C4-dicarboxyliques font partie des sources de carbone et d'énergie préférés de P. aeruginosa, une bactérie versatile et ubiquitaire. Néanmoins, malgré leur importance, comment la présence des acides C4-dicarboxyliques dans le milieu est sentie par la bactérie et comment ils sont transportés dans la cellule chez P. aeruginosa n'étaient pas connus. De plus, peu d'informations sur ces procédés ont été répertoriées dans la littérature. Grace à notre travail, le système de transport des acides C4-dicarboxyliques (Dct) chez P. aeruginosa a pu être caractérisé. En effet, il est composé d'un nouveau système à deux composants, nommé DctB/DctD, qui régule, en combinaison avec le facteur sigma alternatif RpoN, l'expression des deux nouveaux transporteurs des acides C4-dicarboxyliques: DctA et DctPQM. L'inactivation des gènes dctA, dctB or dctD cause un défaut de croissance des souches mutantes dans un milieu minimum contenant du succinate, fumarate ou malate; confirmation de leur rôle dans le Dct. Cependant, une croissance résiduelle du mutant dctA dans ces milieux suggérerait une redondance des transporteurs d'acides Grdicarboxyliques. Une expérience de mutagenèse dans la souche AdctA, utilisant le transposon Tn5, combiné avec un criblage génétique sur la croissance dans le succinate, nous a permis d'identifier le deuxième transporteur DctPQM. DctPQM appartient à la famille des transporteurs TRAP (tripartite ATP-independent periplasmic). Un double mutant AdctAAdctPQM ne pousse pas dans du malate ou fumarate mais par contre présente une croissance résiduelle dans le succinate suggérant l'existence de transporteurs supplémentaires pour le succinate. En réalisant des expériences de compétitions nous avons démontré que le transporteur DctPQM est plus efficace que le transporteur DctA pour l'utilisation de succinate à une concentration de l'ordre du μΜ. Par contre, DctA est le transporteur le plus important pour une concentration de succinate de l'ordre du raM. Pour la première fois, deux systèmes de transport, un avec une forte- et un avec une faible-affinité (DctA et DctPQM) pour le succinate, sont coordonnés dans leur activité de transport des acides C4- dicarboxyliques, probablement contribuant à la versatilité de la bactérie. Ensuite, nous avons étudié la régulation du system Dct. En effectuant, en parallèle, une étude sur le phénomène de la répression catabolique (RC) chez P. aeruginosa, un lien entre la RC et le système Dct a été observé. La cascade des régulateurs formant la RC est composée de CbrA/CbrB, CrcZ et Crc. Crc est un répresseur traductionnel qui agit quand des sources de carbone préférées (comme les acides C4-dicarboxyliques) sont présentes dans le milieu. CrcZ est un petit ARN non-codant qui agit comme antagoniste de Crc. L'expression de CrcZ est induite par le système à deux composants CbrA/CbrB lorsque une source de carbone non-préférée est utilisée (comme le mannitol). Des nouvelles cibles du système CbrAB/CrcZ/Crc chez P. aeruginosa ont été identifiées grâce à une analyse du transcriptome des souches mutantes des régulateurs de la cascade. Parmi les cibles identifiées, les gènes dctA et dctPQM étaient présents. La RC régule l'expression des transporteurs dct en fonction de la concentration de succinate dans le milieu de croissance. Cette régulation est possible parce que, en même temps, les acides C4- dicarboxyliques régulent la RC. Dans un milieu contenant une grande concentration du succinate, le niveau d'expression de CrcZ est faible, donc Crc peut inhiber l'expression de ces ARN messagers cibles. Par contre, dans un milieu avec une faible concentration de succinate, l'augmentation de l'expression de CrcZ titre Crc et inhibe son activité. Ce modèle de régulation rétroactive est très important pour le phénomène de la RC, parce qu'il permet à la bactérie d'accorder une meilleure réponse à un changement environnemental. L'expression des gènes codant pour les transporteurs dct sont aussi régulés par la protéine chaperonne d'ARN Hfq. Hfq semble avoir le même effet traductionnelle que Crc, lorsqu'il y a une forte concentration de succinate. Nous avons ainsi observé une régulation négative de l'expression du gène dct Ρ et dctR, qui code pour un répresseur de la transcription de dctA. Nous avons aussi observé une régulation positive de la transcription de dctP par Hfq, probablement de façon indirecte. Enfin, une analyse du metabolome a était utilisée pour chercher les signaux internes modulant la RC et, en particulier, l'activité de la protéine senseur CbrA chez P. aeruginosa PAOl et P. putida KT2442. Les résultats de l'analyse sont en cours d'étude dans le laboratoire.

Trouver un sens à son activité professionnelle : un aspect important de la santé au travail pour les ambulanciers

Le thème de la santé mentale des intervenants de l'Aide Médicale Urgente est particulièrement important. Le sens que revêt le travail pour ces professionnels semble central pour comprendre les motivations qui permettent aux personnes de gérer des situations à forte composante relationnelle. Comment faire pour éviter la perte de sens au travail ou la retrouver ? Une étude réalisée de suisse auprès de paramédics apporte quelques pistes de réflexion. Il convient de rappeler que les ambulanciers français ne disposent pas de la même formation que les ambulanciers suisses, paramédics. [Auteurs]

Echo-time independent signal modulations for strongly coupled systems in triple echo localization schemes: an extension of S-PRESS editing.

The double spin-echo point resolved spectroscopy sequence (PRESS) is a widely used method and standard in clinical MR spectroscopy. Existence of important J-modulations at constant echo times, depending on the temporal delays between the rf-pulses, have been demonstrated recently for strongly coupled spin systems and were exploited for difference editing, removing singlets from the spectrum (strong-coupling PRESS, S-PRESS). A drawback of this method for in vivo applications is that large signal modulations needed for difference editing occur only at relatively long echo times. In this work we demonstrate that, by simply adding a third refocusing pulse (3S-PRESS), difference editing becomes possible at substantially shorter echo times while, as applied to citrate, more favorable lineshapes can be obtained. For the example of an AB system an analytical description of the MR signal, obtained with this triple refocusing sequence (3S-PRESS), is provided.

Limits on the validity of infinite length assumptions for modelling shallow landslides

The infinite slope method is widely used as the geotechnical component of geomorphic and landscape evolution models. Its assumption that shallow landslides are infinitely long (in a downslope direction) is usually considered valid for natural landslides on the basis that they are generally long relative to their depth. However, this is rarely justified, because the critical length/depth (L/H) ratio below which edge effects become important is unknown. We establish this critical L/H ratio by benchmarking infinite slope stability predictions against finite element predictions for a set of synthetic two-dimensional slopes, assuming that the difference between the predictions is due to error in the infinite slope method. We test the infinite slope method for six different L/H ratios to find the critical ratio at which its predictions fall within 5% of those from the finite element method. We repeat these tests for 5000 synthetic slopes with a range of failure plane depths, pore water pressures, friction angles, soil cohesions, soil unit weights and slope angles characteristic of natural slopes. We find that: (1) infinite slope stability predictions are consistently too conservative for small L/H ratios; (2) the predictions always converge to within 5% of the finite element benchmarks by a L/H ratio of 25 (i.e. the infinite slope assumption is reasonable for landslides 25 times longer than they are deep); but (3) they can converge at much lower ratios depending on slope properties, particularly for low cohesion soils. The implication for catchment scale stability models is that the infinite length assumption is reasonable if their grid resolution is coarse (e.g. >25?m). However, it may also be valid even at much finer grid resolutions (e.g. 1?m), because spatial organization in the predicted pore water pressure field reduces the probability of short landslides and minimizes the risk that predicted landslides will have L/H ratios less than 25. Copyright (c) 2012 John Wiley & Sons, Ltd.

Causal explanations and scientific realism in particle physics

Particle physics studies highly complex processes which cannot be directly observed. Scientific realism claims that we are nevertheless warranted in believing that these processes really occur and that the objects involved in them really exist. This dissertation defends a version of scientific realism, called causal realism, in the context of particle physics. I start by introducing the central theses and arguments in the recent philosophical debate on scientific realism (chapter 1), with a special focus on an important presupposition of the debate, namely common sense realism. Chapter 2 then discusses entity realism, which introduces a crucial element into the debate by emphasizing the importance of experiments in defending scientific realism. Most of the chapter is concerned with Ian Hacking's position, but I also argue that Nancy Cartwright's version of entity realism is ultimately preferable as a basis for further development. In chapter 3,1 take a step back and consider the question whether the realism debate is worth pursuing at all. Arthur Fine has given a negative answer to that question, proposing his natural ontologica! attitude as an alternative to both realism and antirealism. I argue that the debate (in particular the realist side of it) is in fact less vicious than Fine presents it. The second part of my work (chapters 4-6) develops, illustrates and defends causal realism. The key idea is that inference to the best explanation is reliable in some cases, but not in others. Chapter 4 characterizes the difference between these two kinds of cases in terms of three criteria which distinguish causal from theoretical warrant. In order to flesh out this distinction, chapter 5 then applies it to a concrete case from the history of particle physics, the discovery of the neutrino. This case study shows that the distinction between causal and theoretical warrant is crucial for understanding what it means to "directly detect" a new particle. But the distinction is also an effective tool against what I take to be the presently most powerful objection to scientific realism: Kyle Stanford's argument from unconceived alternatives. I respond to this argument in chapter 6, and I illustrate my response with a discussion of Jean Perrin's experimental work concerning the atomic hypothesis. In the final part of the dissertation, I turn to the specific challenges posed to realism by quantum theories. One of these challenges comes from the experimental violations of Bell's inequalities, which indicate a failure of locality in the quantum domain. I show in chapter 7 how causal realism can further our understanding of quantum non-locality by taking account of some recent experimental results. Another challenge to realism in quantum mechanics comes from delayed-choice experiments, which seem to imply that certain aspects of what happens in an experiment can be influenced by later choices of the experimenter. Chapter 8 analyzes these experiments and argues that they do not warrant the antirealist conclusions which some commentators draw from them. It pays particular attention to the case of delayed-choice entanglement swapping and the corresponding question whether entanglement is a real physical relation. In chapter 9,1 finally address relativistic quantum theories. It is often claimed that these theories are incompatible with a particle ontology, and this calls into question causal realism's commitment to localizable and countable entities. I defend the commitments of causal realism against these objections, and I conclude with some remarks connecting the interpretation of quantum field theory to more general metaphysical issues confronting causal realism.

Source wavelet estimation for waveform inversion of crosshole georadar data

AbstractFor a wide range of environmental, hydrological, and engineering applications there is a fast growing need for high-resolution imaging. In this context, waveform tomographic imaging of crosshole georadar data is a powerful method able to provide images of pertinent electrical properties in near-surface environments with unprecedented spatial resolution. In contrast, conventional ray-based tomographic methods, which consider only a very limited part of the recorded signal (first-arrival traveltimes and maximum first-cycle amplitudes), suffer from inherent limitations in resolution and may prove to be inadequate in complex environments. For a typical crosshole georadar survey the potential improvement in resolution when using waveform-based approaches instead of ray-based approaches is in the range of one order-of- magnitude. Moreover, the spatial resolution of waveform-based inversions is comparable to that of common logging methods. While in exploration seismology waveform tomographic imaging has become well established over the past two decades, it is comparably still underdeveloped in the georadar domain despite corresponding needs. Recently, different groups have presented finite-difference time-domain waveform inversion schemes for crosshole georadar data, which are adaptations and extensions of Tarantola's seminal nonlinear generalized least-squares approach developed for the seismic case. First applications of these new crosshole georadar waveform inversion schemes on synthetic and field data have shown promising results. However, there is little known about the limits and performance of such schemes in complex environments. To this end, the general motivation of my thesis is the evaluation of the robustness and limitations of waveform inversion algorithms for crosshole georadar data in order to apply such schemes to a wide range of real world problems.One crucial issue to making applicable and effective any waveform scheme to real-world crosshole georadar problems is the accurate estimation of the source wavelet, which is unknown in reality. Waveform inversion schemes for crosshole georadar data require forward simulations of the wavefield in order to iteratively solve the inverse problem. Therefore, accurate knowledge of the source wavelet is critically important for successful application of such schemes. Relatively small differences in the estimated source wavelet shape can lead to large differences in the resulting tomograms. In the first part of my thesis, I explore the viability and robustness of a relatively simple iterative deconvolution technique that incorporates the estimation of the source wavelet into the waveform inversion procedure rather than adding additional model parameters into the inversion problem. Extensive tests indicate that this source wavelet estimation technique is simple yet effective, and is able to provide remarkably accurate and robust estimates of the source wavelet in the presence of strong heterogeneity in both the dielectric permittivity and electrical conductivity as well as significant ambient noise in the recorded data. Furthermore, our tests also indicate that the approach is insensitive to the phase characteristics of the starting wavelet, which is not the case when directly incorporating the wavelet estimation into the inverse problem.Another critical issue with crosshole georadar waveform inversion schemes which clearly needs to be investigated is the consequence of the common assumption of frequency- independent electromagnetic constitutive parameters. This is crucial since in reality, these parameters are known to be frequency-dependent and complex and thus recorded georadar data may show significant dispersive behaviour. In particular, in the presence of water, there is a wide body of evidence showing that the dielectric permittivity can be significantly frequency dependent over the GPR frequency range, due to a variety of relaxation processes. The second part of my thesis is therefore dedicated to the evaluation of the reconstruction limits of a non-dispersive crosshole georadar waveform inversion scheme in the presence of varying degrees of dielectric dispersion. I show that the inversion algorithm, combined with the iterative deconvolution-based source wavelet estimation procedure that is partially able to account for the frequency-dependent effects through an "effective" wavelet, performs remarkably well in weakly to moderately dispersive environments and has the ability to provide adequate tomographic reconstructions.

Sex differences in obesity and the regulation of energy homeostasis.

Obesity prevalence is generally higher in women than in men, and there is also a sex difference in body fat distribution. Sex differences in obesity can be explained in part by the influence of gonadal steroids on body composition and appetite; however, behavioural, socio-cultural and chromosomal factors may also play a role. This review, which evolved from the 2008 Stock Conference on sex differences in obesity, summarizes current research and recommendations related to hormonal and neuroendocrine influences on energy balance and fat distribution. A number of important gaps in the research are identified, including a need for more studies on chromosomal sex effects on energy balance, the role of socio-cultural (i.e. gender) factors in obesity and the potential deleterious effects of high-fat diets during pregnancy on the foetus. Furthermore, there is a paucity of clinical trials examining sex-specific approaches and outcomes of obesity treatment (lifestyle-based or pharmacological), and research is urgently needed to determine whether current weight loss programmes, largely developed and tested on women, are appropriate for men. Last, it is important that both animal and clinical research on obesity be designed and analysed in such a way that data can be separately examined in both men and women.

Social support, socioeconomic and clinical risk: comparison between to neighborhoods in a Brazilian upcountry town

The objective of this study was to compare the perceptions of two families living in two different neighborhoods (rated according to risk levels) regarding social support. A questionnaire was designed to assess social support according to the following dimensions: instrumental, emotional, religious, and support from friends, neighbors and family. The sample was comprised as follows: considering the 114 families living in neighborhood 1, 52 families were interviewed; and among the 162 families living in neighborhood 2, 60 families were interviewed. No significant difference was found related to instrumental, religious and emotional support, including the support from relatives among the families from both neighborhoods. The results disagree with the reviewed literature, which indicated a strong association between social support and families living at socioeconomic risk. In conclusion, social support is important for families, regardless of their risk stratification.

A non-interventional phase IV Belgian survey to assess the antiviral effectiveness of pegylated interferon-alpha-2b and ribavirin treatment according to the stage of liver fibrosis in previously untreated patients with genotype 1/4/5/6 chronic hepatitis C (PRACTICE).

BACKGROUND AND STUDY AIMS: This was an observational, non-interventional, multicenter, phase IV study, in patients with genotype 1/4/5/6 chronic hepatitis C (CHC). The primary objectives were to evaluate SVR in patients with no or minimal fibrosis (METAVIR F0-F1) versus well established fibrosis (F2-F4), and to estimate response on Weeks 12, 24 and 48 on treatment in previously untreated patients with genotypes 1/4/5/6 CHC. PATIENTS AND METHODS: 538 patients treated with pegylated interferon alfa 2b 1.5 mcg/kg in combination with ribavirin 800-1200 mg/day were enrolled in 55 sites in Belgium and Luxembourg, 505 being considered for the analysis. 40% of the patients were female and 60% male, the average age was 47.5 years, 10.5% were 65 or older. RESULTS: SVR was observed in 35% of the patients, EVR in 68%, of which pEVR in 33% and cEVR in 35%. SVR was observed in 43% of the low fibrosis group (F0, F1) and 30% of the high fibrosis group (F2, F3, F4) (p = 0.005). SVR rates were 34% for genotype 1, 37% for genotype 4, and 47% for genotype 5 (NS). Multivariate analysis showed that EVR and baseline METAVIR score are independent prognostic factors for SVR. CONCLUSIONS: This trial confirms that fibrosis stage and early viral response are the most important key-factors to predict sustained response, suggesting that the earlier patients are treated, the better the outcome. Non-invasive techniques enable us to closely monitor progression of fibrosis, allowing a better selection of patients for antiviral treatment in the DAA-era.

“IF ONLY I COULD�? ~ “THERE IS ALWAYS A LOOPHOLE"? Hope and hopelessness experienced by the severely depressive and nondepressive

The aim of this research was to structure a conceptual model of hope and hopelessness based on dictionary definitions, and to verify this model on the basis of the experiences of the severely depressive and non-depressive elderly. This research has produced a substantive theory of hope and hopelessness which is based on the experiences of the depressive and non-depressive elderly, and on the concept analysis of hope and hopelessness based on English dictionary definitions. The patients who participated in the research were 65 years old and older men and women (n=22) who had been admitted to a psychiatric hospital because of major depression, and another group: the non-depressive elderly (n=21), who were recruited from the pensioners’ clubs. The data were collected in interviews using the Clinical Assessment Tool, developed by Farran, Salloway and Clark (1990) and Farran, Wilken and Popovich (1992), and it produced 553 pages of written text, which were analysed using the ATLAS/ti programme. ATLAS/ti is a tool for analysing qualitative data and is based on Grounded Theory. The medical and nursing records of the depressive elderly completed source triangulation. The concept analysis of hope and hopelessness was made on the basis of the definitions of English dictionaries (n=103), using semantic analysis and the ATLAS/ti programme. The most important hope-promoting factors were human relations, health and managing in everyday living. Autonomy, self-determination and feeling of security were highly appreciated among the elderly. Hopelessness, on the other hand, was most often associated with the same factors: human relations, health and everyday living. Especially, losses of significant others were experienced as strongly hope-diminishing. Old age had brought freedom from duties concerning others, but now, when you finally had an opportunity to enjoy yourself, you could not accomplish anything; you were clasped in the arms of total inability, depression had come. The most obvious difference in the life course of the depressive and nondepressive elderly was the abundance of traumatic experiences in the childhood and youth of the depressive elderly. The continuous circulation of fearful thoughts was almost touchable, and suicidality was described in connection with these thoughts. You were afraid to be awake and also to go to sleep. Managing day by day was the goal. The research produced the Basic Social Process (BSP) of hope: achieving - maintaining - losing, which expresses a continuous balancing between Being without and Being with. The importance of the object of hope was combined with the amount of hope and disappointment. The process of approaching defined the realisation of hope and the process of withdrawal that of losing. Joy and security versus grief and insecurity defined the Being with and Being without. Two core categories were found. The first one “If only I could�? reflects lack of energy, lack of knowledge, lack of courage and lack of ability. The other one “There is always a loophole�? reflects deliberate tracing of possibilities and the belief in finding solutions, and managing.

Clinical Learning Environment and Supervision. Development and Validation of the CLES Evaluation Scale

The purpose of the study is: (1) to describe how nursing students' experienced their clinical learning environment and the supervision given by staff nurses working in hospital settings; and (2) to develop and test an evaluation scale of Clinical Learning Environment and Supervision (CLES). The study has been carried out in different phases. The pilot study (n=163) explored the association between the characteristics of a ward and its evaluation as a learning environment by students. The second version of research instrument (which was developed by the results of this pilot study) were tested by an expert panel (n=9 nurse teachers) and test-retest group formed by student nurses (n=38). After this evaluative phase, the CLES was formed as the basic research instrument for this study and it was tested with the Finnish main sample (n=416). In this phase, a concurrent validity instrument (Dunn & Burnett 1995) was used to confirm the validation process of CLES. The international comparative study was made by comparing the Finnish main sample with a British sample (n=142). The international comparative study was necessary for two reasons. In the instrument developing process, there is a need to test the new instrument in some other nursing culture. Other reason for comparative international study is the reflecting the impact of open employment markets in the European Union (EU) on the need to evaluate and to integrate EU health care educational systems. The results showed that the individualised supervision system is the most used supervision model and the supervisory relationship with personal mentor is the most meaningful single element of supervision evaluated by nursing students. The ward atmosphere and the management style of ward manager are the most important environmental factors of the clinical ward. The study integrates two theoretical elements - learning environment and supervision - in developing a preliminary theoretical model. The comparative international study showed that, Finnish students were more satisfied and evaluated their clinical placements and supervision with higher scores than students in the United Kingdom (UK). The difference between groups was statistical highly significant (p= 0.000). In the UK, clinical placements were longer but students met their nurse teachers less frequently than students in Finland. Arrangements for supervision were similar. This research process has produced the evaluation scale (CLES), which can be used in research and quality assessments of clinical learning environment and supervision in Finland and in the UK. CLES consists of 27 items and it is sub-divided into five sub-dimensions. Cronbach's alpha coefficient varied from high 0.94 to marginal 0.73. CLES is a compact evaluation scale and user-friendliness makes it suitable for continuing evaluation.