Simulated Patient as Co-facilitators: Benefits and Challenges of the Interprofessional Team OSCE (Submission #9350).

Hypothesis: The quality of care for chronic patients depends on the collaborative skills of the healthcare providers.1,2 The literature lacks reports of the use of simulation to teach collaborative skills in non-acute care settings. We posit that simulation offers benefits for supporting the development of collaborative practice in non-acute settings. We explored the benefits and challenges of using an Interprofessional Team - Objective Structured Clinical Examination (IT-OSCE) as a formative assessment tool. IT-OSCE is an intervention which involves an interprofessional team of trainees interacting with a simulated patient (SP) enabling them to practice collaborative skills in non-acute care settings.5 A simulated patient are people trained to portray patients in a simulated scenario for educational purposes.6,7 Since interprofessional education (IPE) ultimately aims to provide collaborative patient-centered care.8,9 We sought to promote patient-centeredness in the learning process. Methods: The IT-OSCE was conducted with four trios of students from different professions. The debriefing was co-facilitated by the SP with a faculty. The participants were final-year students in nursing, physiotherapy and medicine. Our research question focused on the introduction of co-facilitated (SP and faculty) debriefing after an IT-OSCE: 1) What are the benefits and challenges of involving the SP during the debriefing? and 2) To evaluate the IT-OSCE, an exploratory case study was used to provide fine grained data 10, 11. Three focus groups were conducted - two with students (n=6; n=5), one with SPs (n=3) and one with faculty (n=4). Audiotapes were transcribed for thematic analysis performed by three researchers, who found a consensus on the final set of themes. Results: The thematic analysis showed little differentiation between SPs, student and faculty perspectives. The analysis of transcripts revealed more particularly, that the SP's co-facilitation during the debriefing of an IT-OSCE proved to be feasible. It was appreciated by all the participants and appeared to value and to promote patient-centeredness in the learning process. The main challenge consisted in SPs feedback, more particularly in how they could report accurate observations to a students' group rather than individual students. Conclusion: In conclusion, SP methodology using an IT-OSCE seems to be a useful and promising way to train collaborative skills, aligning IPE, simulation-based team training in a non-acute care setting and patient-centeredness. We acknowledge the limitations of the study, especially the small sample and consider the exploration of SP-based IPE in non-acute care settings as strength. Future studies could consider the preparation of SPs and faculty as co-facilitators. References: 1. Borrill CS, Carletta J, Carter AJ, et al. The effectiveness of health care teams in the National Health Service. Aston centre for Health Service Organisational Research. 2001. 2. Reeves S, Lewin S, Espin S, Zwarenstein M. Interprofessional teamwork for health and social care. Oxford: Wiley-Blackwell; 2010. 3. Issenberg S, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning - a BEME systematic review. Medical Teacher. 2005;27(1):10-28. 4. McGaghie W, Petrusa ER, Gordon DL, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Medical Education. 2010;44(1):50-63. 5. Simmons B, Egan-Lee E, Wagner SJ, Esdaile M, Baker L, Reeves S. Assessment of interprofessional learning: the design of an interprofessional objective structured clinical examination (iOSCE) approach. Journal of Interprofessional Care. 2011;25(1):73-74. 6. Nestel D, Layat Burn C, Pritchard SA, Glastonbury R, Tabak D. The use of simulated patients in medical education: Guide Supplement 42.1 - Viewpoint. Medical teacher. 2011;33(12):1027-1029. Disclosures: None (C) 2014 by Lippincott Williams & Wilkins, Inc.

Cianosis neonatal

PROTOCOLOS TERAPEUTICOS. CIANOSIS NEONATAL. 1. CONCEPTO Se considera cianosis a la coloración azulada de la piel o de las mucosas secundaria a un oscurecimiento sanguíneo producido por un aumento de la hemoglobina reducida (principalmente HbFe ++) a valores superiores a los 3-5 gr/dl. Toda cianosis neonatal que persista más de 30 minutos tras el nacimiento...

Prognostic Importance of the Cuse of Renal Failure in Patients With Cirrhosis

BACKGROUND & AIMS: The prognostic value of the different causes of renal failure in cirrhosis is not well established. This study investigated the predictive value of the cause of renal failure in cirrhosis. METHODS: Five hundred sixty-two consecutive patients with cirrhosis and renal failure (as defined by serum creatinine 1.5 mg/dL on 2 successive determinations within 48 hours) hospitalized over a 6-year period in a single institution were included in a prospective study. The cause of renal failure was classified into 4 groups: renal failure associated with bacterial infections, renal failure associated with volume depletion, hepatorenal syndrome (HRS), and parenchymal nephropathy. The primary end point was survival at 3 months. RESULTS: Four hundred sixty-three patients (82.4%) had renal failure that could be classified in 1 of 4 groups. The most frequent was renal failure associated with infections (213 cases; 46%), followed by hypovolemia-associated renal failure (149; 32%), HRS (60; 13%), and parenchymal nephropathy (41; 9%). The remaining patients had a combination of causes or miscellaneous conditions. Prognosis was markedly different according to cause of renal failure, 3-month probability of survival being 73% for parenchymal nephropathy, 46% for hypovolemia-associated renal failure, 31% for renal failure associated with infections, and 15% for HRS (P .0005). In a multivariate analysis adjusted for potentially confounding variables, cause of renal failure was independently associated with prognosis, together with MELD score, serum sodium, and hepatic encephalopathy at time of diagnosis of renal failure. CONCLUSIONS: A simple classification of patients with cirrhosis according to cause of renal failure is useful in assessment of prognosis and may help in decision making in liver transplantation.

Randomized, crossover, double-blind, placebo-controlled trial to assess the lipid lowering effect of co-formulated TDF/FTC

Abstract INTRODUCTION: Previous studies have described improvements on lipid parameters when switching from other antiretroviral drugs to tenofovir (TDF) and impairments in lipid profile when discontinuing TDF. [1-3] It is unknown, however, if TDF has an intrinsic lipid-lowering effect or such findings are due to the addition or removal of other offending agents or other reasons. MATERIALS AND METHODS: RESULTS: 46 subjects with a median age of 43 (40-48) years were enrolled in the study: 70% were male, 56% received DRV/r and 44% LPV/r. One subject withdrew the study voluntarily at week 4 and another one interrupted due to diarrhoea at week 24. Treatment with TDF/FTC decreased total, LDL and HDL-cholesterol from 235.9 to 204.9 (p<0.001), 154.7 to 127.6 (p<0.001) and 50.3 to 44.5 mg/dL (p<0.001), respectively. In comparison, total, LDL and HDL-cholesterol levels remained stable during placebo exposure. Week 12 total cholesterol (p<0.001), LDL-cholesterol (p<0.001) and HDL-cholesterol (p=0.011) levels were significantly lower in TDF/FTC versus placebo. Treatment with TDF/FTC reduced the fraction of subjects with abnormal fasting total-cholesterol (≥200 mg/dL) from 86.7% to 56.8% (p=0.001) and LDL-cholesterol (≥130 mg/dL) from 87.8% to 43.9% (p<0.001), which was not observed with placebo. There were no virological failures, and CD4 and triglyceride levels remained stable regardless of exposure. CONCLUSION: Coformulated TDF/FTC has an intrinsic lipid-lowering effect, likely attributable to TDF.

Expanding the Customer Relationship Management scope to the non-profit organizations : an analysis focused on the e-university domain

Peer-reviewed

Syväjohtamisen valmennusprosessin mukainen esimiesvalmennus osuustoiminnallisessa organisaatiossa tapaus Hankkija-Maatalous Oy

Tämän tutkielman tarkoituksena on osallistua keskusteluun S-ryhmän johtamiskulttuurista, jossa on viime vuosina alettu korostaa esimiehen ihmisten johtamisen valmiuksia yhtenä tämän päivän ja tulevaisuuden keskeisenä menestyksen tekijänä. Tässä tutkielmassa perehdytään syvä-johtamisen esimiesvalmennukseen. Kohdeorganisaatio on Hankkija-Maatalous Oy. Tutkielman tavoitteena on selvittää, mitä Syväjohtaminen DL Oy:n esimiesvalmennus syväjohtamisen keinoin on ja kuinka syvä-johtamisen mukainen esimiesvalmennusprosessi on koettu osallistujien kesken Hankkija-Maatalous Oy:n esimiehille järjestetyssä esimiesvalmennuksessa. Tutkielma on luonteeltaan laadullinen tapaustutkimus. Tutkimusaineisto koostuu yhteensä 10 Hankkija-Maatalous Oy:n ketjuohjauksen esimiehen haastattelusta sekä osuustoimintaa, kohdeorganisaatiota ja syvä-johtamista käsittelevästä kirjallisuudesta. Teemahaastattelut suoritettiin alkukesän 2006 aikana. Tutkimustulokset osoittavat, että syväjohtamisen esimiesvalmennus ei ole pelkästään teoriatasolla toimiva muoti-ilmiö, vaan se antaa konkreettisia työkaluja käytännön esimiestyötä tekeville esimiehille. Osuus-toiminnallinen yritys antaa myös hyvän pohjan pitkäjänteiseen esimiesten ihmistenjohtamisen kehittämiseen.

Thermoplastic bioactive composite – with special reference to dissolution behaviour and tissue response

Bioactive glasses are surface-active ceramic materials which support and accelerate bone growth in the body. During the healing of a bone fracture or a large bone defect, fixation is often needed. The aim of this thesis was to determine the dissolution behaviour and biocompatibility of a composite consisting of poly(ε-caprolactone-co-DL-lactide) and bioactive glass (S53P4). In addition the applicability as an injectable material straight to a bone defect was assessed. In in vitro tests the dissolution behaviour of plain copolymer and composites containing bioactive glass granules was evaluated, as well as surface reactivity and the material’s capability to form apatite in simulated body fluid (SBF). The human fibroblast proliferation was tested on materials in cell culture. In in vivo experiments, toxicological tests, material degradation and tissue reactions were tested both in subcutaneous space and in experimental bone defects. The composites containing bioactive glass formed a unified layer of apatite on their surface in SBF. The size and amount of glass granules affected the degradation of polymer matrix, as well the material’s surface reactivity. In cell culture on the test materials the human gingival fibroblasts proliferated and matured faster compared with control materials. In in vitro tests a connective tissue capsule was formed around the specimens, and became thinner in the course of time. Foreign body cell reactions in toxicological tests were mild. In experimental bone defects the specimens with a high concentration of small bioactive glass granules (<45 μm) formed a dense apatite surface layer that restricted the bone ingrowth to material. The range of large glass granules (90-315 μm) with high concentrations formed the best bonding with bone, but slow degradation on the copolymer restricted the bone growth only in the superficial layers. In these studies, the handling properties of the material proved to be good and tissue reactions were mild. The reactivity of bioactive glass was retained inside the copolymer matrix, thus enabling bone conductivity with composites. However, the copolymer was noticed to degradate too slowly compared with the bone healing. Therefore, the porosity of the material should be increased in order to improve tissue healing.

Nanosuodatuskalvojen alkalikestävyys

Tässä diplomityössä tutkittiin nanosuodatuskalvojen puhdistusta ja kestävyyttä alkalipesuissa. Työn kirjallisuusosassa käsitellään kalvojen likaantumista ja eri puhdistusmenetelmiä, sekä vertaillaan kolmen nanosuodatuskalvon erotusominaisuuksia. Kokeellisessa osassa tutkittiin emäksisten pesukemikaalien vaikutusta kirjallisuusosassa esitettyihin kalvoihin. Käytetyt suodatuskalvot olivat Dow FilmTecTM NF-270, GE Osmonics Desal-5 DL ja Trisep XN45. Kalvojen puhdistukseen käytettiin Ecolabin P3-ultasil 110 ja 112 alkalipesukemikaaleja. Suodatuskokeet tehtiin laboratoriomittakaavan tasokalvojen suodatinlaitteistolla. Alkalikäsittelyitä tehtiin sekä liottamalla kalvoja säilytysastiassa että altistamalla näitä virtauksen ja paineen alaisuudessa. Vaihdettuja muuttujia oliat: pesuainekonsentraatio, lämpötila ja vaikutusaika. Kalvoissa tapahtuneita muutoksia arvioitiin mittaamalla permeabiliteettia sekä magnesiumsulfaatti- ja glukoosiretentioita. Suodatuslämpötilan nostaminen kasvatti lineaarisesti permeabiliteettia ja vastaavasti laski lineaarisesti retentiota. Kalvojen välillä ei ollut eroja permeabiliteettien lämpötilariippuvuuksissa. DL:n retentio laski vähiten lämpötilaa nostettaessa. Liotuskokeiden perusteella kestävät DL- ja NF-270-kalvot noin 1 % P3-ultrasil 110 liuoksia, sekä XN-kalvo 1,2–1,5 %:sia liuoksia, kun lämpötilana on 44 ºC ja vaikutusaikana 50 vrk. Käytettyjen pesukemikaalien välillä ei havaittu eroja. Pienen paineen ja virtauksen alla suoritetuissa käsittelyissä havaittiin alkalihajoamisen noudattavan likimain ensimmäisen kertaluvun reaktiokinetiikkaa ja käyttäytyvän likimain Arrheniuksen yhtälön ennustamalla tavalla. Myös näissä kokeissa XN45 osoittautui kestävimmäksi. Retentioiden heikkenemistä ei pystytty luotettavasti ennustamaan permeabiliteetin perusteella. Työssä osoitettiin että kalvojen muutoksia alkalipesuissa ajan funktiona voidaan ennustaa ja näin teollisuudessa voidaan ennakoida kalvojen vaihtotarvetta.

Otimização dos parâmetros de extração para determinação multiresíduo de pesticidas em amostras de água empregando microextração em fase sólida

In this study the factors that affect the extraction of pesticide residues from water samples for their determination by solid-phase micro-extraction (SPME) and GC/MS were optimized. The fiber polymer, the extraction mode, the ionic strength, the stirring rate, the pH and the extraction time were the most significant parameters evaluated. The recovery obtained with the proposed method ranged from 94 to 110% and the sensitivity of the method, determined by calculating the detection limit (DL), ranged from 0.004 to 0.1 mug l-1. The results obtained with spiked real samples, at the 0.1 mug l-1 level, showed acceptable conformity with the expected values.

Metodologias eletroanalíticas para a determinação de herbicidas triazínicos por voltametria de onda quadrada e técnicas de deconvolução

This work describes the development of electroanalytical methodologies for the determination of atrazine, ametrine and simazine by square wave voltammetry on a mercury electrode. For pure atrazine and pure ametrine, the detection limits (DL) were 3.7 and 4.3 µg L-1, respectively, while they increased to 4.8 and 6.5 µg L-1 in the presence of 3.0 x 10-6 mol L-1 of the other component (a mathematical deconvolution program was used in the mixture cases). The voltammetric response for simazine could not be separated from that of atrazine and measurements were carried out only in pure simazine solutions (DL: 7.5 µg L-1).

Butyltin speciation in sediments from Todos os Santos Bay (Bahia, Brazil) by GC-PFPD

Butyltin compounds were investigated in surface sediments from 17 stations in Todos os Santos Bay. Analytical conditions for organotin determination in marine sediments were optimized for GC with pulsed flame photometric detection. Detection limits were: 5.4 µg kg-1 for TBT; 0.2 µg kg-1 for DBT; and 2.1 µg kg-1 for MBT, using a 610-nm filter. In general, TBT concentrations were low and in the range of

Complicacions en la fase aguda del iamest derivades de la hiperglicèmia : revisió bibliogràfica

La hiperglicèmia elevada en la fase aguda de l’Infart Agut de Miocardi amb Elevació del segment ST, està estretament relacionada amb l’elevat risc de complicacions i mal pronòstic dels pacients, independentment que presentin Diabetis Mellitus prèviament coneguda. Hi ha evidències que en pacients que han rebut teràpia de reperfusió coronària, la hiperglicèmia major de 140mg/dL en el moment de l’ingrés està associada a esdeveniments tant perjudicials com és el desenvolupament d’una Diabetis Mellitus post Infart Agut de Miocardi. El control glicèmic a llarg termini s’associa a millores en els resultats cardiovasculars. L’objectiu d’aquesta revisió ésdeterminar la influència de la hiperglicèmia en les complicacions d’un malaltamb Infart Agut de Miocardi

BIOSSENSOR ELETROQUÍMICO BASEADO NA ENZIMA TIROSINASE PARA A DETERMINAÇÃO DE FENOL EM EFLUENTES

AbstractThis work describes the development of a biosensor based on the tyrosinase enzyme (Tyr) for the determination of phenol (PHEN) in laboratory effluent samples derived from ammoniacal nitrogen analysis of the water samples from the Muquém dam in the city of Cariús, CE, using square-wave voltammetry (SWV). The electrode modification consisted of the immobilization of gold nanoparticles, multi-walled carbon nanotubes, cobalt phthalocyanine, and Tyr on a glassy carbon electrode. The electrolyte, pH, enzyme quantity, and voltammetric parameters were optimized to detect PHEN. The analytical curves presented a linear range from 4.97 × 10-6 mol L-1 to 6.10 × 10-5 mol L-1, and the detection limit (DL) and quantitation limit (QL) values were 4.81 × 10-6 mol L-1 and 4.97 × 10-6mol L-1, respectively. The repetition of measurements with the same biosensor and repetition for three other prepared biosensors exhibited a relative standard deviation (RSD) of 5.50 and 1.75%, respectively. The percentage recovery of PHEN in effluent samples varied from 86.40 to 105.04%. The stability of the biosensor was evaluated (at 21 days) with satisfactory results, showing 97.86% of the initial response. Moreover, the DL and recovery percentages agreed with the established values from CONAMA and ABNT, respectively. Thus, the electrode configuration developed seems a promising tool in the detection and quantification of PHEN in complex samples.

Efeito de dois indutores de resistência sobre a severidade do mal-do-Panamá

O mal-do-Panamá, causado por Fusarium oxysporum f. sp. cubense, é um fator limitante à cultura da bananeira (Musa spp.). A medida de controle mais eficiente para essa doença é o cultivo de variedades resistentes. A resistência induzida constitui alternativa a ser avaliada nesse patossistema. Avaliou-se o efeito indutor de resistência de acibenzolar-S-metil (ASM) e ácido DL-b-amino-n-butírico (BABA) sobre germinação e crescimento micelial de F. oxysporum f. sp. cubense in vitro nas dosagens 0; 0,050; 0,100; 0,150; 0,200; 0,250 e 0,500 mg.ml-1 e 0; 0,525; 1,050; 1,575; 2,100; 2,625 e 3,150 mg.ml-1, respectivamente, utilizando-se F. oxysporum f. sp. cubense na concentração 1 x 10³ conídios.ml-1. Os ASM e BABA foram pulverizados nas dosagens 0; 0,050; 0,100; 0,150; 0,200; 0,250 mg.ml-1 e 0; 0,525; 1,050; 1,575; 2,100; 2,625 mg.ml-1, respectivamente, sobre bananeiras 'Maçã' e 'Grande Naine' micropropagadas, mantidas em casa de vegetação. As raízes foram inoculadas por imersão em suspensão de F. oxysporum f. sp. cubense 1 x 10³ conídios.ml-1, quatro, seis e oito semanas após indução. Avaliou-se a severidade da doença 20 dias após inoculação através de escala de notas. O BABA, 2,100 mg.ml-1, propiciou 35,29% de redução na severidade de doença em banana 'Maçã', aplicado quatro semanas antes da inoculação com F. oxysporum f. sp. cubense. O ASM, 0,500 mg.ml-1, inibiu a germinação de conídios in vitro. O BABA, nas dosagens testadas, não interferiu no crescimento micelial. Em 'Grande Naine', BABA, 0,525 mg.ml-1, reduziu a severidade da doença em 21,55% independente da época de inoculação. Não se constatou efeito do ASM sobre a severidade do mal-do-Panamá.