Surrogate decision making for patients with end-stage dementia.

OBJECTIVE: We aim to explore how health surrogates of patients with dementia proceed in decision making, which considerations are decisive, and whether family surrogates and professional guardians decide differently. METHODS: We conducted an experimental vignette study using think aloud protocol analysis. Thirty-two family surrogates and professional guardians were asked to decide on two hypothetical case vignettes, concerning a feeding tube placement and a cardiac pacemaker implantation in patients with end-stage dementia. They had to verbalize their thoughts while deciding. Verbalizations were audio-recorded, transcribed, and analyzed according to content analysis. By experimentally changing variables in the vignettes, the impact of these variables on the outcome of decision making was calculated. RESULTS: Although only 25% and 31% of the relatives gave their consent to the feeding tube and pacemaker placement, respectively, 56% and 81% of the professional guardians consented to these life-sustaining measures. Relatives decided intuitively, referred to their own preferences, and focused on the patient's age, state of wellbeing, and suffering. Professional guardians showed a deliberative approach, relied on medical and legal authorities, and emphasized patient autonomy. Situational variables such as the patient's current behavior and the views of health care professionals and family members had higher impacts on decisions than the patient's prior statements or life attitudes. CONCLUSIONS: Both the process and outcome of surrogate decision making depend heavily on whether the surrogate is a relative or not. These findings have implications for the physician-surrogate relationship and legal frameworks regarding surrogacy. Copyright © 2011 John Wiley & Sons, Ltd.

Fictions cartographiques

Considering normal maps that geographers do, it is possible to discuss strange maps in confrontation with the status of real maps. It is by using a precise epistemological model inspired by S. Lupasco that we will examine four relevant examples of fictuous maps. We will refer explicitly to a ternary epistemological model to confront extravagant situations furnished by litterature in regard to our normal maps. By using an explicite ternary language in relation here to the structure of the map, we will refer to the two fundamental concepts of scale and legend to show how those four fictions are emblematic and help us to understand the real maps. The ternary model scale/legend/mapmaking will be the reference model to illustrate how the Captain's map in L. Carroll, the Utopia Island of T. More, the Map of China of J.-L. Borgès and the Tender Map of M. de Scudéry are referenced in our model in regard of the real map, tertium datur, the mediator in the interaction of scale and legend.

Vacancy and interstitial depth profiles in ion-implanted silicon

An experimental method of studying shifts between concentration-versus-depth profiles of vacancy- and interstitial-type defects in ion-implanted silicon is demonstrated. The concept is based on deep level transient spectroscopy measurements utilizing the filling pulse variation technique. The vacancy profile, represented by the vacancy¿oxygen center, and the interstitial profile, represented by the interstitial carbon¿substitutional carbon pair, are obtained at the same sample temperature by varying the duration of the filling pulse. The effect of the capture in the Debye tail has been extensively studied and taken into account. Thus, the two profiles can be recorded with a high relative depth resolution. Using low doses, point defects have been introduced in lightly doped float zone n-type silicon by implantation with 6.8 MeV boron ions and 680 keV and 1.3 MeV protons at room temperature. The effect of the angle of ion incidence has also been investigated. For all implantation conditions the peak of the interstitial profile is displaced towards larger depths compared to that of the vacancy profile. The amplitude of this displacement increases as the width of the initial point defect distribution increases. This behavior is explained by a simple model where the preferential forward momentum of recoiling silicon atoms and the highly efficient direct recombination of primary point defects are taken into account.

Low-loss rib waveguides containing Si nanocrystals embedded in SiO2

We report on the study and modeling of the structural and optical properties of rib-loaded waveguides working in the 600-900-nm spectral range. A Si nanocrystal (Si-nc) rich SiO2 layer with nominal Si excess ranging from 10% to 20% was produced by quadrupole ion implantation of Si into thermal SiO2 formed on a silicon substrate. Si-ncs were precipitated by annealing at 1100°C, forming a 0.4-um-thick core layer in the waveguide. The Si content, the Si-nc density and size, the Si-nc emission, and the active layer effective refractive index were determined by dedicated experiments using x-ray photoelectron spectroscopy, Raman spectroscopy, energy-filtered transmission electron microscopy, photoluminescence and m-lines spectroscopy. Rib-loaded waveguides were fabricated by photolithographic and reactive ion etching processes, with patterned rib widths ranging from 1¿to¿8¿¿m. Light propagation in the waveguide was observed and losses of 11dB/cm at 633 and 780 nm were measured, modeled and interpreted.

Size dependence of refractive index of Si nanoclusters embedded in SiO2

he complex refractive index of SiO2 layers containing Si nanoclusters (Si-nc) has been measured by spectroscopic ellipsometry in the range from 1.5 to 5.0 eV. It has been correlated with the amount of Si excess accurately measured by x-ray photoelectron spectroscopy and the nanocluster size determined by energy-filtered transmission electron microscopy. The Si-nc embedded in SiO2 have been produced by a fourfold Si+ ion implantation, providing uniform Si excess aimed at a reliable ellipsometric modeling. The complex refractive index of the Si-nc phase has been calculated by the application of the Bruggeman effective-medium approximation to the composite media. The characteristic resonances of the refractive index and extinction coefficient of bulk Si vanish out in Si-nc. In agreement with theoretical simulations, a significant reduction of the refractive index of Si-nc is observed, in comparison with bulk and amorphous silicon. The knowledge of the optical properties of these composite layers is crucial for the realization of Si-based waveguides and light-emitting devices.

White luminescence from Si+ and C+ ion-implanted SiO2 films

The microstructural and optical analysis of SiO2 layers emitting white luminescence is reported. These structures have been synthesized by sequential Si+ and C+ ion implantation and high-temperature annealing. Their white emission results from the presence of up to three bands in the photoluminescence (PL) spectra, covering the whole visible spectral range. The microstructural characterization reveals the presence of a complex multilayer structure: Si nanocrystals are only observed outside the main C-implanted peak region, with a lower density closer to the surface, being also smaller in size. This lack of uniformity in their density has been related to the inhibiting role of C in their growth dynamics. These nanocrystals are responsible for the band appearing in the red region of the PL spectrum. The analysis of the thermal evolution of the red PL band and its behavior after hydrogenation shows that carbon implantation also prevents the formation of well passivated Si/SiO2 interfaces. On the other hand, the PL bands appearing at higher energies show the existence of two different characteristics as a function of the implanted dose. For excess atomic concentrations below or equal to 10%, the spectra show a PL band in the blue region. At higher doses, two bands dominate the green¿blue spectral region. The evolution of these bands with the implanted dose and annealing time suggests that they are related to the formation of carbon-rich precipitates in the implanted region. Moreover, PL versus depth measurements provide a direct correlation of the green band with the carbon-implanted profile. These PL bands have been assigned to two distinct amorphous phases, with a composition close to elemental graphitic carbon or stoichiometric SiC.

Efficient energy transfer from Si clusters to Er3+ in complex silicate glasses

We present an extensive study of the structural and optical emission properties in aluminum silicates and soda-lime silicates codoped with Si nanoclusters (Si-nc) and Er. Si excess of 5 and 15¿at.¿% and Er concentrations ranging from 2×1019 up to 6×1020¿cm¿3 were introduced by ion implantation. Thermal treatments at different temperatures were carried out before and after Er implantation. Structural characterization of the resulting structures was performed to obtain the layer composition and the size distribution of Si clusters. A comprehensive study has been carried out of the light emission as a function of the matrix characteristics, Si and Er contents, excitation wavelength, and power. Er emission at 1540¿nm has been detected in all coimplanted glasses, with similar intensities. We estimated lifetimes ranging from 2.5¿to¿12¿ms (depending on the Er dose and Si excess) and an effective excitation cross section of about 1×10¿17¿cm2 at low fluxes that decreases at high pump power. By quantifying the amount of Er ions excited through Si-nc we find a fraction of 10% of the total Er concentration. Upconversion coefficients of about 3×10¿18¿cm¿3¿s¿1 have been found for soda-lime glasses and one order of magnitude lower in aluminum silicates.

Modificacion de las propiedades opticas y mecanicas de polimeros mediante implantacion ionica

En el presente trabajo se estudian los efectos introducidos por la implantación de Nitrógeno atómico y Silicio sobre probetas de policarbonato empleadas para usos ópticos. Distintas dosis de Nitrógeno y Silicio fueron implantadas de cara a poner de manifiesto el efecto de la dosis sobre las propiedades ópticas y mecánicas. Se llevaron a cabo ensayos mecánicos de microdureza, nanodureza, y AFM, así como ensayos ópticos de Reflexión-absorción IR y Transmitancia UV-VIS. Los resultados muestran un endurecimiento superficial para las implantaciones a dosis altas de Nitrógeno, así como cambios considerables en los espectros de transmitancia.

Cardiac re-synchronization therapy in a patient with isolated ventricular non-compaction: a case report.

Isolated ventricular non-compaction (IVNC) is a rare, congenital, unclassified cardiomyopathy characterized by prominent trabecular meshwork and deep recesses. Major clinical manifestations of IVNC are heart failure, atrial and ventricular arrhythmias, and thrombo-embolic events. We describe a case of a 69-year-old woman in whom the diagnosis of IVNC was discovered late, whereas former echocardiographic examinations were considered normal. She was known for systolic left ventricular dysfunction for 3 years and then became symptomatic (NYHA III). In the past, she suffered from multiple episodes of deep vein thrombosis and pulmonary embolism. Electrocardiogram revealed a wide QRS complex, and transthoracic echocardiography showed typical apical thickening of the left and right ventricular myocardial wall with two distinct layers. The ratio of non-compacted to compacted myocardium was >2:1. Cardiac MRI confirmed the echocardiographic images. Cerebral MRI revealed multiple ischaemic sequellae. In view of the persistent refractory, heart failure in medical treatment of patients with classical criteria for cardiac re-synchronization therapy, as well as the ventricular arrhythmias, a biventricular automatic intracardiac defibrillator (biventricular ICD) was implanted. The 2-year follow-up period was characterized by improvement of NYHA functional class from III to I and increasing in left ventricular function. We hereby present a case of IVNC with favourable outcome after biventricular ICD implantation. Cardiac re-synchronization therapy could be considered in the management of this pathology.

Sewage sludge as nitrogen and phosphorus source for cane-plant and first ratoon crops

The use of sewage sludge in Brazilian agriculture was regulated by the resolution no. 375 Conama, in 2006. However, there is a lack of research to adequate the mineral N and P fertilizer doses to be applied in agricultural fields treated with this residue. In a field experiment, the effects of application rates of sewage sludge and mineral N and P fertilizers on the productivity and technical characteristics of the cane-plant and first ratoon (residual effect) crops were evaluated. Four doses of sewage sludge (0, 3.6, 7.2 and 10.8 t ha-1, dry base), of N (0, 30, 60 and 90 kg ha-1) and of P2O5 (0, 60, 120 and 180 kg ha-1) were combined in a factorial and laid out on randomized block design, a with two replications. To evaluate the residual effect of the sludge, 120 kg ha-1 N and 140 kg ha-1 of K2O were applied in all plots. Sludge application at cane planting, with or without N and/or P fertilizer increased the stalk yield from 84 up to 118 t ha-1, with no alteration in the sugarcane quality, compared with the application of NPK fertilizer alone, resulting in a stalk yield of 91 t ha-1. The study of the response surface for stalk yield on lowfertility soil was the basis for a recommendation of mineral N and P fertilizer doses for sugarcane implantation as related to sewage sludge application rates. It was also concluded that a sludge application of 10.8 t ha-1, which is the sludge dose established based on the N criterion according to the resolution Conama nº 375, could a) reduce the use of mineral N by 100 % and of P2O5 by 30 %, with increments of 22 % in stalk yield, as a direct effect of sludge application to cane plant crop, and b) increase the stalk yield in the second harvest (first ratoon) by up to 12 % and sugar yield by up to 11 %, by the residual effect of sludge application to sugar cane.

Availability of soil water under tillage systems, mulch management and citrus rootstocks

The increased availability of soil water is important for the management of non-irrigated orange orchards. The objective of this study was to evaluate the availability of soil water in a Haplorthox (Rhodic Ferralsol) under different tillage systems used for orchard plantation, mulch management and rootstocks in a "Pêra" orange orchard in northwest Paraná, Brazil. An experiment in a split-split-plot design was established in 2002, in an area cultivated with Brachiaria brizantha grass in which three tillage systems (no tillage, conventional tillage and strip-tillage) were used for orchard plantation. This grass was mowed twice a year between the rows, representing two mulch managements in the split plots (no mulching and mulching in the plant rows). The split-split-plots were represented by two rootstocks ("Rangpur" lime and "Cleopatra" mandarin). The soil water content in the plant rows was evaluated in the 0-20 cm layer in 2007 and at 0-20 and 20-40 cm in 2008-2009. The effect of soil tillage systems prior to implantation of orange orchards on soil water availability was less pronounced than mulching and the rootstocks. The soil water availability was lower when "Pêra" orange trees were grafted on "Cleopatra" mandarin than on "Rangpur" lime rootstocks. Mulching had a positive influence on soil water availability in the sandy surface layer (0-20 cm) and sandy clay loam subsurface (20-40 cm) of the soil in the spring. The production of B. brizantha between the rows and residue disposal in the plant rows as mulch increased water availability to the "Pêra" orange trees.

Vaccinia immune globulin: current policies, preparedness, and product safety and efficacy.

In 1980 the World Health Organization declared that smallpox was eradicated from the world, and routine smallpox vaccination was discontinued. Nevertheless, samples of the smallpox virus (variola virus) were retained for research purposes, not least because of fears that terrorist groups or rogue states might also have kept samples in order to develop a bioweapon. Variola virus represents an effective bioweapon because it is associated with high morbidity and mortality and is highly contagious. Since September 11, 2001, countries around the world have begun to develop policies and preparedness programs to deal with a bioterror attack, including stockpiling of smallpox vaccine. Smallpox vaccine itself may be associated with a number of serious adverse events, which can often be managed with vaccinia immune globulin (VIG). VIG may also be needed as prophylaxis in patients for whom pre-exposure smallpox vaccine is contraindicated (such as those with eczema or pregnant women), although it is currently not licensed in these cases. Two intravenous formulations of VIG (VIGIV Cangene and VIGIV Dynport) have been licensed by the FDA for the management of patients with progressive vaccinia, eczema vaccinatum, severe generalized vaccinia, and extensive body surface involvement or periocular implantation following inadvertent inoculation.

Remplacement valvulaire percutané au moyen de stent-valves : une nouvelle approche thérapeutique [Stents valves for percutaneous valve replacement]

Stents have a long history in traditional valve surgery as both, porcine biological valves as well as pericardial valves are mounted on stents prior to implantation. Recently stent-mounted biological devices have been compressed up to the point, where they can be passed through a catheter. Various routes can be distinguished for implantation: open access, the trans-vascular route in antegrade or retrograde fashion, as well as direct trans-apical or trans-atrial access. Direct access has the potentialforvideo-endoscopic valve replacement. In theory, as well as in the experimental setting, valved stents have been implanted in tricuspid and caval position respectively, as well as in pulmonary, mitral and aortic locations. The largest clinical experience has been achieved in pulmonary position whereas current efforts target the aortic position.