Adherence to oral anticancer treatment: focus on quality of execution during continuous schema of treatment

Background and objective: Oral anti-cancer treatments have expanded rapidly over the last years. While taking oral tablets at home ensures a better quality of life, it also exposes patients to the risk of sub-optimal adherence. The objective of this study is to assess how well ambulatory cancer patients execute their prescribed dosing regimen while they are engaged with continuous anti-cancer treatments. Design: This is an on-going longitudinal study. Consecutive patients starting an oral treatment are proposed to enter the study by the oncologist. Then they are referred to the pharmacy, where their oral anticancer treatment is dispensed in a Medication Event Monitoring System (MEMSTM), which records date and time of each opening of the drug container. Electronically compiled dosing history data from the MEMS are summarized and used as feedback during semistructured interviews with the pharmacist, which are dedicated to prevention and management of side effects. Interviews are scheduled before each medical visit. Report of the interview is available to the oncologist via an on-line secured portal. Setting: Seamless care approach between a Multidisciplinary Oncology Center and the Pharmacy of an Ambulatory Care and Community Medicine Department. Main outcome measures: For each patient, the comparison between the electronically compiled dosing history and the prescribed regimen was summarized using a daily binary indicator indicating whether yes or no the patient has taken the medication as prescribed. Results: Study started in March 2008. Among 22 eligible patients, 19 were included (11 men, median age 63 years old) and 3 (14%) refused to participate. 15 patients were prescribed a QD regimen, 3 patients a BID and 1 patient switched from QD to BID during follow-up. Median follow up was 182 days (IQR 72-252). Early discontinuation happened in four patients: side effects (n = 1), psychiatric reasons (n = 1), cancer progression (n = 1) and death (n = 1). On average, the daily number of medications was taken as prescribed in 99% of the follow-up days. Conclusions: Execution of the prescribed dosing regimens was almost perfect during the first 6 months. Maintaining this high degree of regimen execution and persistence over time might however be challenging in this population and need therefore to be confirmed in larger and longer follow-up cohort studies.

Yield and fruit quality of apple from conventional and organic production systems

The objective of this study was to assess the yield and fruit quality of apple produced with a conventional and an organic production systems in Southern Brazil. The orchards consisted of alternate rows from 10 to 12-year old 'Royal Gala' and 'Fuji' apple trees on M.7 rootstocks, grown as slender spindles, on 4x6 m spacing. Eighteen apple trees of each cultivar and management system were randomly selected and assessed for nutrition, flowering, fruit set, yield, and fruit quality during two growing seasons (2002/2003 and 2003/2004). The organic management system resulted in lower concentrations of K, Mg, and N in leaves and fruits, and in smaller fruits for both cultivars, and lower fruit yield for 'Fuji' than from the conventional production system. For both cultivars, fruits from the organic orchard harvested at commercial maturity had a more yellowish skin background color, higher percentage of blush in the fruit skin, higher soluble solids content, higher density, higher flesh firmness, and higher severity of russet than fruits from the conventional orchard. Fruit from the organic orchard had lower titratable acidity in 'Royal Gala', and higher incidence of moldy core and lower incidence of watercore in 'Fuji', than fruit from the conventional orchard. A non-trained sensory panel detected no significant differences for fruit attributes of taste, flavor and texture between fruit from the production systems for either cultivar.

La prise en charge de l'hyper- tension artériette par des médecins en formation suit-elle les recommandations actuettes [Are the guidelines for the management of hypertensive patients followed by primary care residents and fellows?]

Numerous international guidelines are published which define how hypertensive patients should be managed. Are these guidelines followed and applicable? We have assessed the quality of management of 225 hypertensive ambulatory patients followed by young fellows in teaching for primary care medicine. The control rate defined by a blood pressure < 140/90 mmHg was 32,4%. In the last three visits, 60% of hypertensive patients had a blood pressure measurement. 79% of blood pressure readings ended with 0 or 5. Blood pressure control was identical whatever the comorbidities. In conclusion, the quality of management of hypertensive patients by in teaching fellow could potentially be improved. The actual recommendations are limited in their application. The control of high risk vascular patients is not better than those with a lower risk.

Integrating Financial Perspective to Quality Orientated Management System. Case: ALSTOM Finland Oy

Tutkimuksen päätavoitteena on tutkia taloudellisen näkökulman integroimista laatuajatteluun pohjautuvaan johtamisjärjestelmään esimerkkiyrityksessä. Johtamisjärjestelmän tulee tuottaa tietoa johdon strategiselle päätöksenteolle ja lisäksi täyttää laatujärjestelmän (ISO 9001:2000) asettamat vaatimukset. Tutkimuksen kohteena oleva työkalu on balanced scorecard (tasapainotettu tuloskortti). Työn tarkoituksena on ehdottaa balanced scorecard- talouden tunnuslukuja esimerkkiyritykselle. Tutkimuksen tavoitteisiin päästään empiiristä tutkimusta varten tehdyn teoreettisen viitekehyksen avulla. Empiiristä tutkimustietoa kerätään osallistuvan havainnoinnin, haastattelujen ja keskustelujen avulla. Tutkimusmenetelmänä on laadullinen case -tutkimus. Balanced scorecardin eri näkökulmille ehdotettiin tunnuslukuja empiirisen tutkimuksen pohjalta. Lisäksi talouden näkökulmaa tutkittiin tarkemmin. Tutkimuksen johtopäätöksenä esitettiin, että taloudelliset tunnusluvut mittaavat ensisijaisesti strategiaa eivätkä laatua. Lisäksi huomioitiin, että tuloskorttien tulisi olla koekäytössä ennen bonuspalkkauksen ja balanced scorecardin yhdistämistä.

Sanitary quality of edible bivalve mollusks in Southeastern Brazil using an UV based depuration system

The increase in seafood production, especially in mariculture worldwide, has brought out the need of continued monitoring of shellfish production areas in order to ensure safety to human consumption. The purpose of this research was to evaluate pathogenic protozoa, viruses and bacteria contamination in oysters before and after UV depuration procedure, in brackish waters at all stages of cultivation and treatment steps and to enumerate microbiological indicators of fecal contamination from production site up to depuration site in an oyster cooperative located at the Southeastern estuarine area of Brazil. Oysters and brackish water were collected monthly from September 2009 to November 2010. Four sampling sites were selected for enteropathogens analysis: site 1- oyster growth, site 2- catchment water (before UV depuration procedure), site 3 - filtration stage of water treatment (only for protozoa analysis) and site 4- oyster's depuration tank. Three microbiological indicators ! were examined at sites 1, 2 and 4. The following pathogenic microorganisms were searched: Giardia cysts, Cryptosporidium oocysts, Human Adenovirus (HAdV), Hepatitis A virus (HAV), Human Norovirus (HnoV) (genogroups I and II), JC strain Polyomavirus (JCPyV) and Salmonella sp. Analysis consisted of molecular detection (qPCR) for viruses (oysters and water samples); immunomagnetic separation followed by direct immunofluorescence assay for Cryptosporidium oocysts and Giardia cysts and also molecular detection (PCR) for the latter (oysters and water samples); commercial kit (Reveal-Neogee (R)) for Salmonella analysis (oysters). Giardia was the most prevalent pathogen in all sites where it was detected: 36.3%, 18.1%, 36.3% and 27.2% of water from sites 1, 2, 3 and 4 respectively; 36.3% of oysters from site 1 and 54.5% of depurated oysters were harboring Giardia cysts. The huge majority of contaminated samples were classified as Giardia duodenalis. HAdv was detected in water and o! ysters from growth site and HnoV GI in two batches of oysters ! (site 1) in huge concentrations (2.11 x 10(13), 3.10 x 10(12) gc/g). In depuration tank site, Salmonella sp., HAV (4.84 x 10(3)) and HnoV GII (7.97 x 10(14)) were detected once in different batches of oysters. Cryptosporidium spp. oocysts were present in 9.0% of water samples from site four. These results reflect the contamination of oysters even when UV depuration procedures are employed in this shellfish treatment plant. Moreover, the molecular comprehension of the sources of contamination is necessary to develop an efficient management strategy allied to shellfish treatment improvement to prevent foodborne illnesses. (C) 2011 Elsevier Ltd. All rights reserved.

Quality of Abdominal Surgical Nursing Care

The study evaluates the quality of abdominal surgical nursing care. The data were collected from patients (n=1208) having undergone abdominal surgical operations on their last day of hospitalization and nurses (n=218) working in the same wards. Three instruments originally created in Finland and adapted to the Lithuanian context were used: (1) Good Nursing Care Scale for patients and nurses (GNCS-P, GNCS-N), (2) Nurse Competence Scale (NCS), and (3) Nurse Empowerment Scale (NES). Patient and nurses’ perceptions of the quality of nursing care were evaluated. In addition, nurses’ perceptions of their competence and empowerment were evaluated. The patient and nurses' perceptions of the quality of abdominal surgical nursing care were positive, with more criticism in the nurses’ perceptions. Both patients and nurses gave the lowest evaluation to the quality in the progress of nursing care and the co-operation with significant others. The nurses gave the highest evaluation to the self-assessed level of their competence and the frequency of using competences in practice, with the highest assessment given to situation management and their role at work and the lowest to teaching-coaching and ensuring quality. The nurse perceptions of their empowerment were positive in the qualities and performance of an empowered nurse and empowerment promoting factors, with the highest evaluation in moral principles and sociability and the lowest evaluation in the future-orientedness and expertise. The empowerment-impeding factors were evaluated as negative. The perceptions of the quality of nursing care of both patients and nurses had significant correlations with patient and nurse satisfaction and nurse job independence. The nurse perceptions of their competence and empowerment correlated with their education, the type of the nurse license, completed courses of development of their knowledge and skills, nurse job independence, and nurse satisfaction. The nurse perceptions of the quality of nursing care had a positive correlation with their perceptions of competence and empowerment. Generally, the quality of nursing care was evaluated as high and had correlations with the patients' demographic and satisfaction factors and with the nurse demographic, work-related, and satisfaction factors. The study produced the knowledge that the quality in co-operation with significant others and the progress of nursing process, surgical nurse competence in teaching-coaching, and future-orientedness of surgical nurse empowerment need to be improved in order to develop the quality of abdominal surgical nursing care. The knowledge may be used to offer better services for abdominal surgical patients and increase their satisfaction with nursing care, as well as to increase nurses' satisfaction with work and independence at work. The study suggests implications for clinical practice and management, nursing education, and nursing research.

Sanitary quality of broiler litter reused

ABSTRACT Considering the importance of the substrate to bedding in the poultry industry in Brazil, and the enormous pressure on environmental management as to the correct use and management of the waste generated by the production sector, this study aimed to analyze the effect of reuses of two types of litter on sanitary qualities and productive performance of broilers. The study was conducted with litter from 32 different broiler houses, two types of substrates and four cycles of reuses. The litter sanitary quality was verified by the identification of the presence of Escherichia coli and Salmonellaspp. and the incidence of footpad dermatitis. It was observed that the coffee hulls litter presented a reduction of 28.61 percentage points in the probability of occurrence of Salmonella spp when compared to the wood shavings litter, nevertheless, no statistical difference was observed on bacterial occurrence with Salmonella spp. for litter of different types or numbers of reutilization. The presence of Escherichia coli was detected in litter of all cycles, for both types of substrate. The occurrence of footpad lesions was detected for both types of litter, and was influenced by the number of reutilization cycles of the litter. The degree of incidence was detected only for the litter with coffee hull in which there was an increase of 30% between the first and second reuse from which tended to stabilize.

QUALITY OF PROCESSING TOMATO FRUITS IN COMPETITION WITH Solanum americanum

ABSTRACT Five experiments were conducted to evaluate the hypothesis that Solanum americanum density and time of coexistence affect the quality of processing tomato fruit. The tomato crop was established using either the direct drilling or the transplanting technique. The factors evaluated consisted of weed density (from 0 up to 6 plants m-2) and time of weed interference (early bloom stage, full flowering stage, fruit filling, and harvest time). The effects of competition on tomato fruit quality were analysed using a multiple model. Tomato variables evaluated included industrial fruit types (which depended on ripeness and disease infection) and soluble solids level(obrix). Tomato fruit quality is dependent on the factors tested. Under low densities (< 6 plants m-2) of S. americanum there was a small impact on the quality of the tomato fruits. The percentage of grade A (mature fruit with red color and without pathogen infection) tomato fruits is the variable most affect by the independent variables. The impact of these independent variables on the percentage of grade C (green and/or with more than 15% disease infection) tomato yield was of smaller magnitude and in an inverse trend as the observed for grade A. The level of soluble solids was influenced by the weed interference on only two experiments, but the impact was of small magnitude. The impact of the results on current and future crop management practices is discussed.

Relationship between the quality of life and the severity of obstructive sleep apnea syndrome

The effects of sleep disorders on the quality of life (QOL) have been documented in the literature. Excessive sleepiness and altered circadian rhythms may negatively affect ability to learn, employment, and interpersonal relations, and directly degrade QOL. The objective of the present study was to evaluate the impact of obstructive sleep apnea syndrome of varying severity on QOL. The study was conducted on 1892 patients aged 18 years or older referred by a physician to the Sleep Institute, São Paulo, with complaints related to apnea (snoring, excessive daytime sleepiness, hyperarousal, and fatigue). They were submitted to overnight polysomnography for the diagnosis of sleep disorders from August 2005 through April 2006. The patients completed the Epworth Sleepiness Scale and QOL SF-36 sleep questionnaires. They were classified as non-physically active and physically active and not-sleepy and sleepy and the results of polysomnography were analyzed on the basis of the apnea hypopnea index (AHI). The apneic subjects showed a reduction in QOL which was proportional to severity. There was a significant decrease in all domains (physical functioning, role physical problems, bodily pain, general health perceptions, vitality, social functioning, emotional problems, general mental health) for apneics with AHI >30, who generally were sleepy and did not participate in physical activities (P < 0.05). The present study provides evidence that the impact of sleep disorders on QOL in apneics is not limited to excessive daytime sleepiness and that physical activity can contribute to reducing the symptoms. Thus, exercise should be considered as an adjunct interventional strategy in the management of obstructive sleep apnea syndrome.

The impact of short daily hemodialysis on anemia and the quality of life in Chinese patients

Anemia is a frequent complication in hemodialysis patients. Compared to conventional hemodialysis (CHD), short daily hemodialysis (sDHD) has been reported to be effective in many countries except China. The aim of the present study was to determine whether sDHD could improve anemia and quality of life (QOL) for Chinese outpatients with end-stage renal disease. Twenty-seven patients (16 males/11 females) were converted from CHD to sDHD. All laboratory values were measured before conversion (baseline), at 3 months after conversion (sDHD1), and at 6 months after conversion (sDHD2). The patient's QOL was evaluated at baseline and 6 months after conversion using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Hemoglobin concentration increased significantly from 107.4±7.9 g/L at baseline to 114.4±6.8 g/L (P<0.05) at sDHD1, and 118.3±8.4 g/L (P<0.001) at sDHD2 (Student paired t-test). However, the dose requirement for erythropoietin decreased from 6847.8±1057.3 U/week at baseline to 5869.6±1094.6 U/week (P<0.05) at sDHD2. Weekly stdKt/V increased significantly from 2.05±0.13 at baseline to 2.73±0.20 (P<0.001) at sDHD1, and 2.84±0.26 (P<0.001) at sDHD2. C-reactive protein decreased from baseline to sDHD1 and sDHD2, but without statistically significant differences. Physical and mental health survey scores increased in the 6 months following conversion to sDHD. sDHD may increase hemoglobin levels, decrease exogenous erythropoietin dose requirements, and improve QOL in Chinese hemodialysis patients compared to CHD. A possible mechanism for improvement of clinical outcomes may be optimized management of uremia associated with the higher efficiency of sDHD.

Quality of outsourced IT services in different degrees of offshoring

The Finnish IT service market can be described to be at a turning point. The clients are ever more interested on services delivered from offshore but certain issues keep them cautious. There is a lack of knowledge on what implications different degrees of offshoring have on service quality. Although there has been significant amount of research related to both service quality and offshoring, several questions are unanswered, terminology remains ambivalent and research findings are inconsistent. The study focuses on the interception of these two fields. The purpose of the study is to learn more about service quality in different degrees of offshoring. At the same time it aims to contribute in narrowing the research gaps. The degree of offshoring can be divided to three delivery modes: onshore, collaboration and offshore. The study takes a mixed method approach where the quantitative and qualitative phases are executed sequentially. First data was gathered from incident management system. Resolution time in different degrees of offshoring was analyzed with Kruskal-Wallis and Jonckheere-Terpstra tests. In addition, the compliance to Service Level Agreement (SLA) in different degrees of offshoring was examined with cross tabulation. The findings from the quantitative analysis suggested that the services with offshore delivery mode perform the best in terms of promptness and SLA compliance. However, several issues were found related to the data and for that reason, the findings should be considered with prudence. After the quantitative analysis, the study moved on to qualitative data collection and analysis. Four semi-structured interviews were held. The interviewees represented different organizational roles and had experiences from different delivery modes. Several themes were covered in the interviews, including: the concept of quality, the subjectivity or objectivity of service quality, expectations and prejudices towards offshore deliveries, quality produced in India, proactiveness of offshore resources, quality indicators and the scarcity of collaborative deliveries. Several conclusions can be made from the empirical research. Firstly, the quality in different delivery modes was found to be controversial topic. Secondly, in the collaborative delivery covered in the study, the way tasks and resources are allocated seem to cause issues. On the other hand inexperienced offshore resources are assigned to the delivery and on the other hand only routine tasks are assigned to the resources. This creates a self-enforcing loop that results in low motivation, low ownership and high employee turnover in offshore. Nevertheless, this issue is not characteristic only to collaborative deliveries but rather allocation of tasks and resources. Moreover, prejudices were identified to affect the perceived service quality in non-predictable way. The research also demonstrated that there is a need in focal company for further data gathering and analysis.

Impact of different irrigation strategies on grapes and wine quality of four grapevine cultivars (Vitis sp.) in cool climate conditions. An investigation into the relationships among ABA, water status, grape cultivar and wine quality

Niagara Peninsula of Ontario is the largest viticultural area in Canada. Although it is considered to be a cool and wet region, in the last decade many water stress events occurred during the growing seasons with negative effects on grape and wine quality. This study was initiated to understand and develop the best strategies for water management in vineyards and those that might contribute to grape maturity advancement. The irrigation trials investigated the impact of time of initiation (fruit set, lag phase and veraison), water replacement level based on theoretical loss through crop evapotranspiration (ETc; 100,50 and 25%) and different irrigation strategies [partial root zone drying (PRD) versus regulated deficit irrigation (RD!)] on grape composition and wine sensory profiles. The irrigation experiments were conducted in a commercial vineyard (Lambert Vineyards Inc.) located in Niagara-on-the-Lake, Ontario, from 2005 through 2009. The two experiments that tested the combination of different water regimes and irrigation time initiation were set up in a randomized block design as follows: Baco noir - three replicates x 10 treatments [(25%, 50% and 100% of ETc) x (initiation at fruit set, lag phase and veraison) + control]; Chardonnay - three replicates x seven treatments [(25%, 50% and 100% of ETc) x (initiation at fruit set and veraison) + control]. The experiments that tested different irrigation strategies were set up on two cultivars as follows: Sauvignon blanc - four replicates x four treatments [control, fully irrigated (100% ETc), PRD (100% ETc) and RDI (25% ETc)]; Cabemet Sauvignon - four replicates x five treatments [control, fully irrigated (100% ETc), PRD (100% ETc), RDI (50% ETc) and RDI (25% ETc)]. The controls in each experiment were nonirrigated. The irrigation treatments were compared for many variables related to soil water status, vine physiology, berry composition, wine sensory profile, and hormone composition [(abscisic acid (ABA) and its catabolites]. Soil moisture profile was mostly affected by irrigation treatments between 20 and 60 em depth depending on the grapevine cultivar and the regime of water applied. Overall soil moisture was consistently higher throughout the season in 100 and 50% ETc compare to the control. Transpiration rates and leaf temperature as well as shoot growth rate were the most sensitive variables to soil water status. Drip irrigation associated with RDI treatments (50% ETc and 25% ETc) had the most beneficial effects on vine physiology, fruit composition and wine varietal typicity, mainly by maintaining a balance between vegetative and reproductive parts of the vine. Neither the control nor the 100 ETc had overall a positive effect on grape composition and wine sensory typicity. The time of irrigation initiation affected the vine physiology and grape quality, the most positive effect was found in treatments initiated at lag phase and veraison. RDI treatments were overall more consistent in their positive effect on grape composition and wine varietal typicity comparing to PRD treatment. The greatest difference between non-irrigated and irrigated vines in most of the variables studied was found in 2007, the driest and hottest season of the experimental period. Soil water status had a greater and more consistent effect on red grapevine cultivars rather than on white winegrape cultivars. To understand the relationships among soil and plant water status, plant physiology and the hormonal profiles associated with it, abscisic acid (ABA) and its catabolites [phaseic acid (PA), dihydrophaseic acid (DPA), 7-hydroxy-ABA (TOH-ABA), 8' -hydroxy-ABA, neophaseic acid and abscisic acid glucose ester (ABA-GE)] were analyzed in leaves and berries from the Baco noir and Chardonnay irrigation trials over two growing seasons. ABA and some of its catabolites accurately described the water status in the vines. Endogenous ABA and some of its catabolites were strongly affected in Baco noir and Chardonnay by both the water regime (i.e. ET level) and timing of irrigation initiation. Chardonnay grapevines produced less ABA in both leaves and berries compared to Baco noir, which indicated that ABA synthesis is also cultivar dependant. ABA-GE was the main catabolite in treatments with high water deficits, while PA and DPA were higher in treatments with high water status, suggesting that the vine produced more ABA-GE under water deficits to maintain rapid control of the stomata. These differences between irrigation treatments with respect to ABA and catabolites were particularly noticeable in the dry 2007 season. Two trials using exogenous ABA investigated the effect of different concentrations of ABA and organs targeted for spraying, on grape maturation and berry composition of Cabemet Sauvignon grapevines, in two cool and wet seasons (2008-2009). The fIrst experiment consisted of three replicates x three treatments [(150 and 300 mg/L, both applications only on clusters) + untreated control] while the second experiment consisted in three replicates x four treatments [(full canopy, only clusters, and only leaves sprayed with 300 ppm ABA) + untreated control]. Exogenous ABA was effective in hastening veraison, and improving the composition of Cabemet Sauvignon. Ability of ABA to control the timing of grape berry maturation was dependant on both solution concentration and the target organ. ABA affected not only fruit composition but also yield components. Berries treated with ABA had lower weight and higher skin dry mass, which constitutes qualitative aspects desired in the wine grapes. Temporal advancement of ripening through hormonal control can lead to earlier fruit maturation, which is a distinct advantage in cooler areas or areas with a high risk of early frost occurrence. Exogenous ABA could provide considerable benefits to wine industry in terms of grape composition, wine style and schedule activities in the winery, particularly in wet and cool years. These trials provide the ftrst comprehensive data in eastern North America on the response of important hybrid and Vitis vinifera winegrape cultivars to irrigation management. Results from this study additionally might be a forward step in understanding the ABA metabolism, and its relationship with water status. Future research should be focused on ftnding the ABA threshold required to trigger the ripening process, and how this process could be controlled in cool climates.

The influence of primary care clinic characteristics on the quality of care for depression in patients with different comorbidity profiles

Dans les services de première ligne, la majorité des personnes atteintes de dépression souffrent également d’autres maladies chroniques comorbides. Offrir des soins de haute qualité à ces patients représente un défi important pour les intervenants en première ligne ainsi que pour le système de santé. Il y a des raisons de croire que les contextes organisationnels dans lesquels les intervenants pratiquent ont une influence importante sur les soins. Cependant, peu d’études ont examiné directement la façon dont les caractéristiques des cliniques facilitent ou entravent les soins offerts aux patients atteints de dépression et de différents types de maladies chroniques comorbides. L’objectif général de ce projet de recherche était donc de mieux comprendre comment différentes caractéristiques des cliniques de première ligne influencent la qualité des soins pour la dépression chez des patients ayant différents profils de comorbidité. La thèse comporte deux études. Tout d'abord, nous avons effectué une revue systématique examinant les relations entre la comorbidité physique chronique et la qualité des soins pour la dépression dans les services de première ligne afin de clarifier la nature de ces relations et d’identifier les facteurs qui pourraient influer sur ces relations. Ensuite, nous avons effectué une étude aux méthodes mixtes ayant deux volets : (a) un volet quantitatif examinant les relations entre la qualité des soins pour la dépression, les profils de comorbidité des patients, et les caractéristiques des cliniques de première ligne par le biais d’analyses de régression multiniveaux de données issues de deux enquêtes, et (b) un volet qualitatif basé sur une étude de cas explorant les perceptions des professionnels des services de première ligne sur les facteurs organisationnels pouvant influencer la qualité des soins offerts aux patients souffrant de dépression et d’autres maladies chroniques comorbides. Les résultats de ces études ont montré que, bien que la qualité des soins de la dépression en soins primaires soit sous-optimale, certains sous-groupes de patients dépressifs sont plus à risque que d’autres de recevoir des soins pour la dépression inadéquats, notamment des patients ayant uniquement des comorbidités chroniques physiques. Cependant, plusieurs caractéristiques des cliniques de première ligne semblent faciliter l’offre de soins de qualité aux patients atteints de dépression et de maladies chroniques comorbides : les normes et les valeurs liées au travail d'équipe et le soutien mutuel, l'accès au soutien des professionnels ayant une expertise en santé mentale, l’utilisation des algorithmes de traitement et d’autres outils d’aide à la décision pour la dépression, et l’absence d’obstacles liés aux modèles de rémunération inadéquats. Une des façons dont ces caractéristiques favorisent la qualité est en facilitant la circulation des connaissances dans les cliniques de première ligne. Nos résultats suggèrent que des interventions organisationnelles ciblées sont nécessaires pour améliorer la qualité des soins pour la dépression que reçoivent les patients ayant des maladies chroniques comorbides. Ces interventions peuvent viser différents domaines organisationnels (ex : caractéristiques structurelles/stratégiques, sociales, technologies et épistémiques) mais doivent aussi prendre en compte comment les éléments de chaque domaine interagissent et comment ils pourraient influencer les soins pour des patients ayant des profils de comorbidité différents.

Studies On The Dynamics And Water Quality Of The Muvattupuzha River In Relation To Effluent Discharge

The present study aims at the investigation of the 1ysico—chemical features of a tropical tidal river viz. we Muvattupuzha river. This river is expected to receive Jderate to heavy pollution loads in years to come, from we lone industrial unit, already set up on its bank. ilike other rivers, the geographical disposition of this Lver attains unique importance as regards its dynamics for 3) availability of natural runoff water from catchment :eas, which becomes very heavy during the monsoon season 3) regular steady availability of tail race water from a /dro—electric power station throughout the yearThe study also aims at arriving at the balancing forces of inherent self~purification of the river verses pollution loads from the factory effluents. The investigation period falls ahead of actual pollution occurrence and so the ambient conditions for a period of nearly one-and-a—half years were investigated, the analyses of which providflz to formulate the inter-relations of parameters varying with seasons. Tracer experiments were carried out which revealed the dispersion and dilution characteristics of the river in the vicinity of effluent outfall. The studv covers the trial—cum-capacity production periods of the factory during which effluents of various strength and quantity were discharged into the river; a few computed values arQ’cjmpgrQdl ... with the observed values. The base data along with the profiles of Oxygen sag equation have been utilized fb develop a mathematical model of the river with regard to its water quality