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

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

Hardcopy quality parameters to ensure structures detection at digital mammography

Objective To develop procedures to ensure consistency of printing quality of digital images, by means of hardcopy quantitative analysis based on a standard image. Materials and Methods Characteristics of mammography DI-ML and general purpose DI-HL films were studied through the QC-Test utilizing different processing techniques in a FujiFilm®-DryPix4000 printer. A software was developed for sensitometric evaluation, generating a digital image including a gray scale and a bar pattern to evaluate contrast and spatial resolution. Results Mammography films showed maximum optical density of 4.11 and general purpose films, 3.22. The digital image was developed with a 33-step wedge scale and a high-contrast bar pattern (1 to 30 lp/cm) for spatial resolution evaluation. Conclusion Mammographic films presented higher values for maximum optical density and contrast resolution as compared with general purpose films. The utilized digital processing technique could only change the image pixels matrix values and did not affect the printing standard. The proposed digital image standard allows greater control of the relationship between pixels values and optical density obtained in the analysis of films quality and printing systems.

Development of Color Difference Equations Matching to Human Vision System

Research on color difference evaluation has been active in recent thirty years. Several color difference formulas were developed for industrial applications. The aims of this thesis are to develop the color density which is denoted by comb g and to propose the color density based chromaticity difference formulas. Color density is derived from the discrimination ellipse parameters and color positions in the xy , xyY and CIELAB color spaces, and the color based chromaticity difference formulas are compared with the line element formulas and CIE 2000 color difference formulas. As a result of the thesis, color density represents the perceived color difference accurately, and it could be used to characterize a color by the attribute of perceived color difference from this color.

Development of an instrument to measure the degree of critical patient's satisfaction with nursing care: research protocol

Aim: To investigate and understand patient's satisfaction with nursing care in the intensive care unit to identify the dimensions of the concept of"satisfaction" from the patient's point of view. To design and validate a questionnaire that measures satisfaction levels in critical patients. Background: There are many instruments capable of measuring satisfaction with nursing care; however, they do not address the reality for critical patients nor are they applicable in our context. Design: A dual approach study comprising: a qualitative phase employing Grounded Theory and a quantitative and descriptive phase to prepare and validate the questionnaire. Methods: Data collection in the qualitative phase will consist of: in-depth interview after theoretical sampling, on-site diary and expert discussion group. The sample size will depend on the expected theoretical saturation n = 27-36. Analysis will be based on Grounded Theory. For the quantitative phase, the sampling will be based on convenience (n = 200). A questionnaire will be designed on the basis of qualitative data. Descriptive and inferential statistics will be used. The validation will be developed on the basis of the validity of the content, the criteria of the construct and reliability of the instrument by the Cronbach's alpha and test-retest approach. Approval date for this protocol was November 2010. Discussion: Self-perceptions, beliefs, experiences, demographic, socio-cultural epistemological and political factors are determinants for satisfaction, and these should be taken into account when compiling a questionnaire on satisfaction with nursing care among critical patients.

Patient education to support self-management of patients with mental illness

This study explores areas which need to be improved to develop the quality of patient education to support self-management of patients with mental illness in psychiatric hospitals. The study was conducted in five phases during the period 2000 – 2007. First, patients‘ (n = 313) satisfaction with patient education were investigated. Second, patients' (n = 51) experiences of patient education were explored. Third, a national survey was conducted to investigate realisation of patient education from the staff (n = 55) viewpoint. Fourth, outcomes of patient education were investigated by evaluating the impacts of different patient education methods on patients‘ (n = 311) attitudes towards medication, knowledge level and importance of information. Fifth, patients‘ (n = 16) perceptions of different patient education methods were explored. Patients reported poor satisfaction with patient education (Phase I), and they have considerable need to receive information during their hospital stay (Phase II). Described by staff, the content of patient education covered almost all informational areas investigated. However, discrepancies related to the realisation of patient education were found. (Phase III.) Evaluation of different patient education methods indicate that patients derived benefits from structured patient education with supportive methods (Phase IV) and patients also perceived that these methods supported their information receiving (Phase V). In order to improve the quality of patient education to support self-management of patients with mental illness patient education should be systematically and individually provided to all patients by using different educational methods. Realisation of this should be ensured by providing written instructions, improving nurses‘ knowledge and skills as well ensuring operating conditions.

Bag-of-Features Approach to Unsupervised Visual Object Categorisation

The large and growing number of digital images is making manual image search laborious. Only a fraction of the images contain metadata that can be used to search for a particular type of image. Thus, the main research question of this thesis is whether it is possible to learn visual object categories directly from images. Computers process images as long lists of pixels that do not have a clear connection to high-level semantics which could be used in the image search. There are various methods introduced in the literature to extract low-level image features and also approaches to connect these low-level features with high-level semantics. One of these approaches is called Bag-of-Features which is studied in the thesis. In the Bag-of-Features approach, the images are described using a visual codebook. The codebook is built from the descriptions of the image patches using clustering. The images are described by matching descriptions of image patches with the visual codebook and computing the number of matches for each code. In this thesis, unsupervised visual object categorisation using the Bag-of-Features approach is studied. The goal is to find groups of similar images, e.g., images that contain an object from the same category. The standard Bag-of-Features approach is improved by using spatial information and visual saliency. It was found that the performance of the visual object categorisation can be improved by using spatial information of local features to verify the matches. However, this process is computationally heavy, and thus, the number of images must be limited in the spatial matching, for example, by using the Bag-of-Features method as in this study. Different approaches for saliency detection are studied and a new method based on the Hessian-Affine local feature detector is proposed. The new method achieves comparable results with current state-of-the-art. The visual object categorisation performance was improved by using foreground segmentation based on saliency information, especially when the background could be considered as clutter.

DIGITAL BUSINESS-TO-BUSINESS MARKETING COMMUNICATIONS IN EMERGING MARKETS – Developing Business Marketing in Russia

The core idea of this Master's Thesis was that five key characteristics – market heterogeneity, sociopolitical governance, chronic shortage of resources, unbranded competition, and inadequate infrastructure – of emerging markets are radically different from the traditional industrialized capitalist society and they will require us to rethink the core assumptions of business-to-business marketing, such as business relationships, marketing communication elements, and digitalization. In this research, Russia is considered to be an emerging market that reflects the aforementioned theoretical characteristics. The research was a qualitative case study and furthermore a collective case study. In the beginning three digital marketing professionals were interviewed to better understand digital B2B marketing. The actual research data was collected through seven structured theme interviews with representatives of the case companies operating in Russia. The selection of case companies included three business consulting companies and four industrial companies. The aim of this qualitative study was to understand and clarify how business marketing exploits digital marketing methods as a part of the chosen business marketing strategy under emerging markets’ special conditions. This objective was divided in three research questions: 1) How the chosen marketing strategy reflects in the business marketing process? 2) How digital marketing communication contributes to business marketing? 3) How are the emerging markets’ characteristics reflected in the business marketing process? The main research findings indicate that digital business-to-business marketing communications can be useful and effective. Moreover, business DMC can be defined and structured in a reasonable way. The company's prevalent marketing paradigm and the chosen marketing strategy reflect in the business marketing process, and in utilizing digital marketing communications. The assumption that emerging markets set an environment with special characteristics for business marketing was supported by the study. However, the business environmental aspects were not considerably disturbing digital B2B marketing, but making it even more reasonable to harness in Russia.

Adult education policy in the European Union during the Lisbon decade : the shift to vocational adult learning and work skills matching

This doctoral dissertation investigates the adult education policy of the European Union (EU) in the framework of the Lisbon agenda 2000–2010, with a particular focus on the changes of policy orientation that occurred during this reference decade. The year 2006 can be considered, in fact, a turning point for the EU policy-making in the adult learning sector: a radical shift from a wide--ranging and comprehensive conception of educating adults towards a vocationally oriented understanding of this field and policy area has been observed, in particular in the second half of the so--called ‘Lisbon decade’. In this light, one of the principal objectives of the mainstream policy set by the Lisbon Strategy, that of fostering all forms of participation of adults in lifelong learning paths, appears to have muted its political background and vision in a very short period of time, reflecting an underlying polarisation and progressive transformation of European policy orientations. Hence, by means of content analysis and process tracing, it is shown that the new target of the EU adult education policy, in this framework, has shifted from citizens to workers, and the competence development model, borrowed from the corporate sector, has been established as the reference for the new policy road maps. This study draws on the theory of governance architectures and applies a post-ontological perspective to discuss whether the above trends are intrinsically due to the nature of the Lisbon Strategy, which encompasses education policies, and to what extent supranational actors and phenomena such as globalisation influence the European governance and decision--making. Moreover, it is shown that the way in which the EU is shaping the upgrading of skills and competences of adult learners is modeled around the needs of the ‘knowledge economy’, thus according a great deal of importance to the ‘new skills for new jobs’ and perhaps not enough to life skills in its broader sense which include, for example, social and civic competences: these are actually often promoted but rarely implemented in depth in the EU policy documents. In this framework, it is conveyed how different EU policy areas are intertwined and interrelated with global phenomena, and it is emphasised how far the building of the EU education systems should play a crucial role in the formation of critical thinking, civic competences and skills for a sustainable democratic citizenship, from which a truly cohesive and inclusive society fundamentally depend, and a model of environmental and cosmopolitan adult education is proposed in order to address the challenges of the new millennium. In conclusion, an appraisal of the EU’s public policy, along with some personal thoughts on how progress might be pursued and actualised, is outlined.

The Shadow Moiré method using the phase shifting technique and digital image processing: computational implementation and application to the 3D-reconstruction of a buckled plate

The Shadow Moiré fringe patterns are level lines of equal depth generated by interference between a master grid and its shadow projected on the surface. In simplistic approach, the minimum error is about the order of the master grid pitch, that is, always larger than 0,1 mm, resulting in an experimental technique of low precision. The use of a phase shift increases the accuracy of the Shadow Moiré technique. The current work uses the phase shifting method to determine the surfaces three-dimensional shape using isothamic fringe patterns and digital image processing. The current study presents the method and applies it to images obtained by simulation for error evaluation, as well as to a buckled plate, obtaining excellent results. The method hands itself particularly useful to decrease the errors in the interpretation of the Moiré fringes that can adversely affect the calculations of displacements in pieces containing many concave and convex regions in relatively small areas.

Local Features in Image and Video Processing - Object Class Matching and Video Shot Detection

The usage of digital content, such as video clips and images, has increased dramatically during the last decade. Local image features have been applied increasingly in various image and video retrieval applications. This thesis evaluates local features and applies them to image and video processing tasks. The results of the study show that 1) the performance of different local feature detector and descriptor methods vary significantly in object class matching, 2) local features can be applied in image alignment with superior results against the state-of-the-art, 3) the local feature based shot boundary detection method produces promising results, and 4) the local feature based hierarchical video summarization method shows promising new new research direction. In conclusion, this thesis presents the local features as a powerful tool in many applications and the imminent future work should concentrate on improving the quality of the local features.

Building the ‘Digital’ Library: Routes to Managing our Institutional Digital Learning, Teaching and Research Assets Together

Presentation at Open Repositories 2014, Helsinki, Finland, June 9-13, 2014

From library repository to university-wide service: Stanford Digital Repository as a case study

Presentation at Open Repositories 2014, Helsinki, Finland, June 9-13, 2014

Matching salt intake to physiological need in rats using foraging protocols

Several studies of the quantitative relationship between sodium need and sodium intake in rats are reviewed. Using acute diuretic treatment 24 h beforehand, intake matches need fairly accurately when intake is spread out in time by using a hypotonic solution of NaCl. In contrast, using a hypertonic solution, intake is typically double the need. Using the same diuretic treatment, although the natriuresis occurs within ~1 h, the appetite appears only slowly over 24 h. Increased plasma levels of aldosterone parallel the increased intake; however, treatment with metyrapone blocks the rise in aldosterone but has no effect on appetite. Satiation of sodium appetite was studied in rats using sodium loss induced by chronic diuretic treatment and daily salt consumption sessions. When a simulated foraging cost was imposed on NaCl access in the form of a progressive ratio lever press task, rats showed satiation for NaCl (break point) after consuming an amount close to their estimated deficit. The chronic diuretic regimen produced hypovolemia and large increases in plasma aldosterone concentration and renin activity. These parameters were reversed to or toward non-depleted control values at the time of behavioral satiation in the progressive ratio protocol. Satiation mechanisms for sodium appetite thus do appear to exist. However, they do not operate quantitatively when concentrated salt is available at no effort, but instead allow overconsumption. There are reasons to believe that such a bias toward overconsumption may have been beneficial over evolutionary time, but such biasing for salt and other commodities is maladaptive in a resource-rich environment.

Advances in biliary atresia: from patient care to research

Biliary atresia, the most common cause of liver transplantation in children, remains a challenge for clinicians and investigators. The development of new therapeutic options, besides the typical hepatoportoenterostomy, depends on a greater understanding of its pathogenesis and how it relates to the clinical phenotypes at diagnosis and the rate of disease progression. In this review, we present a perspective of how recent research has advanced the understanding of the disease and has improved clinical care protocols. Molecular and morphological analyses at diagnosis point to the potential contributions of polymorphism in the CFC1 and VEGF genes to the pathogenesis of the disease, and to an association between the degree of bile duct proliferation and long-term outcome. In experimental models, cholangiocytes do not appear to have antigen-presenting properties despite a substantial innate and adaptive immune response that targets the biliary epithelium and produces duct obstruction. Initial clinical trials assessing the efficacy of corticosteroids in decreasing the inflammation and improving outcome do not show a superior effect of corticosteroids as an adjuvant treatment following hepatoportoenterostomy. The best outcome still remains linked to an early diagnosis and surgical treatment. In this regard, the Yellow Alert campaign by the Sociedade Brasileira de Pediatria and the inclusion of the Stool Color Card in the health booklet given to every neonate in Brazil have the potential to decrease the age of diagnosis, shorten the time between diagnosis and surgical treatment, and improve the long-term outcome of children with this devastating disease.

Late emergence of A594V and L595W mutations related to ganciclovir resistance in a patient with HCMV retinitis and long-term HIV progression

The emergence of ganciclovir (GCV) resistance during the treatment of human cytomegalovirus (HCMV) infection is a serious clinical challenge, and is associated with high morbidity and mortality. In this case report, we describe the emergence of two consecutive mutations (A594V and L595W) related to GCV resistance in a patient with HCMV retinitis and long-term HIV progression after approximately 240 days of GCV use. Following the diagnosis of retinitis, the introduction of GCV did not result in viral load reduction. The detected mutations appeared late in the treatment, and we propose that other factors (high initial HCMV load, previous GCV exposure, low CD4+ cell count), in addition to the presence of resistance mutations, may have contributed to the treatment failure of HCMV infection in this patient.