Avaliação na educação pré-escolar: perspetivas e práticas

Dissertação de mestrado em Ciências da Educação (área de especialização em Desenvolvimento Curricular e Inovação Educativa)

Couple's willingness to donate embryos for research: a longitudinal study

Introduction. Decision-making on embryo disposition is a source of distress and is subject to change over time. This paper analyses the willingness of couples undergoing in vitro fertilization to donate cryopreserved embryos for research from 15 days after embryo transfer to 12 months later, taking into account the influence of psychosocial, demographic, and reproductive factors. Materials and methods. Prospective longitudinal study, with 74 heterosexual couples undergoing in vitro fertilization in a public fertility centre in Portugal, recruited between 2011 and 2012. Participants were evaluated twice: 15 days after embryo transfer and 12 months later. Results. A significant decrease in patients’ willingness to donate embryos for research over time was observed [86.5% to 73.6%; relative risk (RR) = 0.85; 95% CI 0.76–0.95]. A higher education level (>12 years) [adjusted RR (RRadj) = 0.79; 95% CI 0.64–0.96], considering research on human embryos to be important (vs. very important) (RRadj = 0.59; 95% CI 0.39–0.85) and practicing a religion less than once a month (vs. at least once a month) (RRadj = 0.73; 95% CI 0.53–1.00) seemed associated with unwillingness to donate embryos for research over time. Change towards non-donation happened mainly among couples who first considered that it was better to donate than wasting the embryos. Change towards donation occurred mostly among those stating that their priority at time 1 was to have a baby and who became pregnant in the meantime. Conclusions. Quality of care guided by patients’ characteristics, values, preferences, and needs calls for considering the factors and reasons underlying couples’ willingness to donate embryos for research over time as a topic in psychosocial guidelines for infertility and medically assisted reproductive care.

The state of art of biological processes in paternal care

This review of the state of art aimed to present the most recent data on neuronal, neurochemical, hormonal and genetic bases of paternal care using MEDLINE and PsycInfo databases (1970-2013). An integrated model of biological substrates that assist men in the transition to fatherhood is presented. Guided by a genetic background, hypothalamic-midbrain-limbic-paralimbic-cortical circuits were found to be activated in fathers when infant stimuli are presented. A set of specifi c neuropeptides and steroid hormones are produced and seem to be related to brain activation, potentiating the paternal phenotype. Together, genetic, brain and hormonal processes suggest the existence of biological bases of paternal care in humans, activated and enhanced by infant stimuli and responsive to variations in the father-infant relationship.

De la vivència a l'experiència: la significació del medi aquàtic en el desenvolupament de l'infant

This work gets deeply into the comprehension of the aquatic medium as a significant space for the for a psychomotor intervention in the development of the children. Its starting point is a methodological pose of philosophical nature which uses phenomenology as the way for discovering. From this stand, the research sequence and process are justified. They both show an underlying attitude which has guided the whole process of turning the learning-by-experiencing the phenomena into experienced-knowledge of it. In this way the characteristic gnoseological reduction of the phenomenology has been used, while proceeding to the observation of children evolving in the water. Once the construction process of this work was established, the reduction of the amount of concepts and ideas began. This is its most characteristic process of the phenomenological research. First, an approach to the aquatic medium as a pluridimensional space has been made. Afterwards a study of the up to three years old child from a global perspective which includes the emotional, the social the cognitive and the psychomotor dimensions has been done. At last, the essence of the psychomotor as a model for the pedagogical action has been studied. From this three distinctive elements, and as a result of this research, a proposal of psychomotor intervention in the aquatic medium has been built.

Development of CBCT-based prostate setup correction strategies and impact of rectal distension.

BACKGROUND: Cone-beam computed tomography (CBCT) image-guided radiotherapy (IGRT) systems are widely used tools to verify and correct the target position before each fraction, allowing to maximize treatment accuracy and precision. In this study, we evaluate automatic three-dimensional intensity-based rigid registration (RR) methods for prostate setup correction using CBCT scans and study the impact of rectal distension on registration quality. METHODS: We retrospectively analyzed 115 CBCT scans of 10 prostate patients. CT-to-CBCT registration was performed using (a) global RR, (b) bony RR, or (c) bony RR refined by a local prostate RR using the CT clinical target volume (CTV) expanded with 1-to-20-mm varying margins. After propagation of the manual CT contours, automatic CBCT contours were generated. For evaluation, a radiation oncologist manually delineated the CTV on the CBCT scans. The propagated and manual CBCT contours were compared using the Dice similarity and a measure based on the bidirectional local distance (BLD). We also conducted a blind visual assessment of the quality of the propagated segmentations. Moreover, we automatically quantified rectal distension between the CT and CBCT scans without using the manual CBCT contours and we investigated its correlation with the registration failures. To improve the registration quality, the air in the rectum was replaced with soft tissue using a filter. The results with and without filtering were compared. RESULTS: The statistical analysis of the Dice coefficients and the BLD values resulted in highly significant differences (p<10(-6)) for the 5-mm and 8-mm local RRs vs the global, bony and 1-mm local RRs. The 8-mm local RR provided the best compromise between accuracy and robustness (Dice median of 0.814 and 97% of success with filtering the air in the rectum). We observed that all failures were due to high rectal distension. Moreover, the visual assessment confirmed the superiority of the 8-mm local RR over the bony RR. CONCLUSION: The most successful CT-to-CBCT RR method proved to be the 8-mm local RR. We have shown the correlation between its registration failures and rectal distension. Furthermore, we have provided a simple (easily applicable in routine) and automatic method to quantify rectal distension and to predict registration failure using only the manual CT contours.

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

OBJECTIVE: To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," published in 2004. DESIGN: Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. METHODS: We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation (1) indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost) or clearly do not. Weak recommendations (2) indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. RESULTS: Key recommendations, listed by category, include early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7-10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure > or = 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for postoperative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7-9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B), targeting a blood glucose < 150 mg/dL after initial stabilization (2C); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); and a recommendation against the use of recombinant activated protein C in children (1B). CONCLUSIONS: There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

Avaluació ambiental de la recollida de residus municipals de Sant Boi de Llobregat

La gestió dels residus municipals ha d’avançar cap a la sostenibilitat per tal de poder fer front al gran volum de residus que es generen actualment i no malmetre el medi ambient. Aquest fet motiva a l’elaboració d’aquest projecte que es centra en l’anàlisi del procés de recollida dels residus municipals. L’estudi realitza en primer lloc una avaluació ambiental de la recollida global i una avaluació ambiental específica de la recollida de la fracció Resta mitjançant el programari SIMUR (desenvolupada per l’Agència d’Ecologia Urbana de Barcelona). Amb aquesta eina de simulació de models de gestió de residus municipal es calcula el balanç de massa, el balanç energètic, el balanç d’emissions i el balanç econòmic del procés de recollida. La metodologia per al desenvolupament de la segona fase del projecte es basa en la realització de treball de camp per al disseny de taules descriptives dels circuits de recollida de la fracció Resta, que permeten comparar-los entre sí i aconseguir l’objectiu d’avaluar l’eficiència dels sistemes de recollida de càrrega lateral i posterior de la fracció. L’assoliment dels objectius permet fer-se una idea de l’estat actual de la recollida dels residus de Sant Boi, identificant-ne els punts forts i febles i plantejant propostes de millora encarades a aconseguir una futura generació i recollida de residus més respectuosa amb l’entorn.

Efficient knowledge retrieval to calibrate input variables in forest fire prediction

Forest fires are a serious threat to humans and nature from an ecological, social and economic point of view. Predicting their behaviour by simulation still delivers unreliable results and remains a challenging task. Latest approaches try to calibrate input variables, often tainted with imprecision, using optimisation techniques like Genetic Algorithms. To converge faster towards fitter solutions, the GA is guided with knowledge obtained from historical or synthetical fires. We developed a robust and efficient knowledge storage and retrieval method. Nearest neighbour search is applied to find the fire configuration from knowledge base most similar to the current configuration. Therefore, a distance measure was elaborated and implemented in several ways. Experiments show the performance of the different implementations regarding occupied storage and retrieval time with overly satisfactory results.

Adipose-derived stem cells enhance peripheral nerve regeneration.

Traumatic injuries resulting in peripheral nerve lesions often require a graft to bridge the gap. Although autologous nerve auto-graft is still the first-choice strategy in reconstructions, it has the severe disadvantage of the sacrifice of a functional nerve. Cell transplantation in a bioartificial conduit is an alternative strategy to create a favourable environment for nerve regeneration. We decided to test new fibrin nerve conduits seeded with various cell types (primary Schwann cells and adult stem cells differentiated to a Schwann cell-like phenotype) for repair of sciatic nerve injury. Two weeks after implantation, the conduits were removed and examined by immunohistochemistry for axonal regeneration (evaluated by PGP 9.5 expression) and Schwann cell presence (detected by S100 expression). The results show a significant increase in axonal regeneration in the group of fibrin seeded with Schwann cells compared with the empty fibrin conduit. Differentiated adipose-derived stem cells also enhanced regeneration distance in a similar manner to differentiated bone marrow mesenchymal stem cells. These observations suggest that adipose-derived stem cells may provide an effective cell population, without the limitations of the donor-site morbidity associated with isolation of Schwann cells, and could be a clinically translatable route towards new methods to enhance peripheral nerve repair.

Modified 'dumbbell' technique: a simple and intuitive method to position balloon-expandable stent valves.

Intraoperative cardiac imaging plays a key role during transcatheter aortic valve replacement. In recent years, new techniques and new tools for improved image quality and virtual navigation have been proposed, in order to simplify and standardize stent valve positioning and implantation. But routine performance of the new techniques may require major economic investments or specific knowledge and skills and, for this reason, they may not be accessible to the majority of cardiac centres involved in transcatheter valve replacement projects. Additionally, they still require injections of contrast medium to obtain computed images. Therefore, we have developed and describe here a very simple and intuitive method of positioning balloon-expandable stent valves, which represents the evolution of the 'dumbbell' technique for echocardiography-guided transcatheter valve replacement without angiography. This method, based on the partial inflation of the balloon catheter during positioning, traps the crimped valve in the aortic valve orifice and, consequently, very near to the ideal landing zone. It does not require specific echocardiographic knowledge; it does not require angiographies that increase the risk of postoperative kidney failure in elderly patients, and it can be also performed in centres not equipped with a hybrid operating room.

Optimisation of antiretroviral therapy : pharmacokinetic and pharmacogenetic approaches

Les progrès de la thérapie antirétrovirale ont transformé l'infection par le VIH d'une condition inévitablement fatale à une maladie chronique. En dépit de ce succès, l'échec thérapeutique et la toxicité médicamenteuse restent fréquents. Une réponse inadéquate au traitement est clairement multifactorielle et une individualisation de la posologie des médicaments qui se baserait sur les facteurs démographiques et génétiques des patients et sur les taux sanguins totaux, libres et/ou cellulaires des médicaments pourrait améliorer à la fois l'efficacité et la tolérance de la thérapie, cette dernière étant certainement un enjeu majeur pour un traitement qui se prend à vie.L'objectif global de cette thèse était de mieux comprendre les facteurs pharmacocinétiques (PK) et pharmacogénétiques (PG) influençant l'exposition aux médicaments antirétroviraux (ARVs) nous offrant ainsi une base rationnelle pour l'optimisation du traitement antiviral et pour l'ajustement posologique des médicaments chez les patients VIH-positifs. Une thérapie antirétrovirale adaptée au patient est susceptible d'augmenter la probabilité d'efficacité et de tolérance à ce traitement, permettant ainsi une meilleure compliance à long terme, et réduisant le risque d'émergence de résistance et d'échec thérapeutique.A cet effet, des méthodes de quantification des concentrations plasmatiques totales, libres et cellulaires des ARVs ainsi que de certains de leurs métabolites ont été développées et validées en utilisant la chromatographie liquide coupée à la spectrométrie de masse en tandem. Ces méthodes ont été appliquées pour la surveillance des taux d'ARVs dans diverses populations de patients HIV-positifs. Une étude clinique a été initiée dans le cadre de l'étude VIH Suisse de cohorte mère-enfant afin de déterminer si la grossesse influence la cinétique des ARVs. Les concentrations totales et libres du lopînavir, de l'atazanavir et de la névirapine ont été déterminées chez les femmes enceintes suivies pendant leur grossesse, et celles-ci ont été trouvées non influencées de manière cliniquement significative par la grossesse. Un ajustement posologique de ces ARVs n'est donc pas nécessaire chez les femmes enceintes. Lors d'une petite étude chez des patients HIV- positifs expérimentés, la corrélation entre l'exposition cellulaire et plasmatique des nouveaux ARVs, notamment le raltégravir, a été déterminée. Une bonne corrélation a été obtenue entre taux plasmatiques et cellulaires de raltégravir, suggérant que la surveillance des taux totaux est un substitut satisfaisant. Cependant, une importante variabilité inter¬patient a été observée dans les ratios d'accumulation cellulaire du raltégravir, ce qui devrait encourager des investigations supplémentaires chez les patients en échec sous ce traitement. L'efficacité du suivi thérapeutique des médicaments (TDM) pour l'adaptation des taux d'efavirenz chez des patients avec des concentrations au-dessus de la cible thérapeutique recommandée a été évaluée lors d'une étude prospective. L'adaptation des doses d'efavirenz basée sur le TDM s'est montrée efficace et sûre, soutenant l'utilisation du TDM chez les patients avec concentrations hors cible thérapeutique. L'impact des polymorphismes génétiques des cytochromes P450 (CYP) 2B6, 2A6 et 3A4/5 sur la pharmacocinétique de l'efavirenz et de ces métabolites a été étudié : un modèle de PK de population intégrant les covariats génétiques et démographiques a été construit. Les variations génétiques fonctionnelles dans les voies de métabolisation principales (CYP2B6) et accessoires {CYP2A6et 3A4/S) de l'efavirenz ont un impact sur sa disposition, et peuvent mener à des expositions extrêmes au médicament. Un? ajustement des doses guidé par le TDM est donc recommandé chez ces patients, en accord avec les polymorphismes génétiques.Ainsi, nous avons démonté qu'en utilisant une approche globale tenant compte à la fois des facteurs PK et PG influençant l'exposition aux ARVs chez les patients infectés, il est possible, si nécessaire, d'individualiser la thérapie antirétrovirale dans des situations diverses. L'optimisation du traitement antirétroviral contribue vraisemblablement à une meilleure efficacité thérapeutique à iong terme tout en réduisant la survenue d'effets indésirables.Résumé grand publicOptimisation de la thérapie antirétrovirale: approches pharmacocinétiques et pharmacogénétiquesLes progrès effectués dans le traitement de l'infection par le virus de llmmunodéficienoe humaine acquise (VIH) ont permis de transformer une affection mortelle en une maladie chronique traitable avec des médicaments de plus en plus efficaces. Malgré ce succès, un certain nombre de patients ne répondent pas de façon optimale à leur traitement etyou souffrent d'effets indésirables médicamenteux entraînant de fréquentes modifications dans leur thérapie. Il a été possible de mettre en évidence que l'efficacité d'un traitement antirétroviral est dans la plupart des cas corrélée aux concentrations de médicaments mesurées dans le sang des patients. Cependant, le virus se réplique dans la cellule, et seule la fraction des médicaments non liée aux protéines du plasma sanguin peut entrer dans la cellule et exercer l'activité antirétrovirale au niveau cellulaire. Il existe par ailleurs une importante variabilité des concentrations sanguines de médicament chez des patients prenant pourtant la même dose de médicament. Cette variabilité peut être due à des facteurs démographiques et/ou génétiques susceptibles d'influencer la réponse au traitement antirétroviral.Cette thèse a eu pour objectif de mieux comprendre les facteurs pharmacologiques et génétiques influençant l'efficacité et ta toxicité des médicaments antirétroviraux, dans le but d'individualiser la thérapie antivirale et d'améliorer le suivi des patients HIV-positifs.A cet effet, des méthodes de dosage très sensibles ont été développées pour permettre la quantification des médicaments antirétroviraux dans le sang et les cellules. Ces méthodes analytiques ont été appliquées dans le cadre de diverses études cliniques réalisées avec des patients. Une des études cliniques a recherché s'il y avait un impact des changements physiologiques liés à la grossesse sur les concentrations des médicaments antirétroviraux. Nous avons ainsi pu démontrer que la grossesse n'influençait pas de façon cliniquement significative le devenir des médicaments antirétroviraux chez les femmes enceintes HIV- positives. La posologie de médicaments ne devrait donc pas être modifiée dans cette population de patientes. Par ailleurs, d'autres études ont portés sur les variations génétiques des patients influençant l'activité enzymatique des protéines impliquées dans le métabolisme des médicaments antirétroviraux. Nous avons également étudié l'utilité d'une surveillance des concentrations de médicament (suivi thérapeutique) dans le sang des patients pour l'individualisation des traitements antiviraux. Il a été possible de mettre en évidence des relations significatives entre l'exposition aux médicaments antirétroviraux et l'existence chez les patients de certaines variations génétiques. Nos analyses ont également permis d'étudier les relations entre les concentrations dans le sang des patients et les taux mesurés dans les cellules où le virus HIV se réplique. De plus, la mesure des taux sanguins de médicaments antirétroviraux et leur interprétation a permis d'ajuster la posologie de médicaments chez les patients de façon efficace et sûre.Ainsi, la complémentarité des connaissances pharmacologiques, génétiques et virales s'inscrit dans l'optique d'une stratégie globale de prise en charge du patient et vise à l'individualisation de la thérapie antirétrovirale en fonction des caractéristiques propres de chaque individu. Cette approche contribue ainsi à l'optimisation du traitement antirétroviral dans la perspective d'un succès du traitement à long terme tout en réduisant la probabilité des effets indésirables rencontrés. - The improvement in antirétroviral therapy has transformed HIV infection from an inevitably fatal condition to a chronic, manageable disease. However, treatment failure and drug toxicity are frequent. Inadequate response to treatment is clearly multifactorial and, therefore, dosage individualisation based on demographic factors, genetic markers and measurement of total, free and/or cellular drug level may increase both drug efficacy and tolerability. Drug tolerability is certainly a major issue for a treatment that must be taken indefinitely.The global objective of this thesis aimed at increasing our current understanding of pharmacokinetic (PK) and pharmacogenetic (PG) factors influencing the exposition to antirétroviral drugs (ARVs) in HIV-positive patients. In turn, this should provide us with a rational basis for antiviral treatment optimisation and drug dosage adjustment in HIV- positive patients. Patient's tailored antirétroviral regimen is likely to enhance treatment effectiveness and tolerability, enabling a better compliance over time, and hence reducing the probability of emergence of viral resistance and treatment failure.To that endeavour, analytical methods for the measurement of total plasma, free and cellular concentrations of ARVs and some of their metabolites have been developed and validated using liquid chromatography coupled with tandem mass spectrometry. These assays have been applied for the monitoring of ARVs levels in various populations of HIV- positive patients. A clinical study has been initiated within the frame of the Mother and Child Swiss HIV Cohort Study to determine whether pregnancy influences the exposition to ARVs. Free and total plasma concentrations of lopinavir, atazanavir and nevirapine have been determined in pregnant women followed during the course of pregnancy, and were found not influenced to a clinically significant extent by pregnancy. Dosage adjustment for these drugs is therefore not required in pregnant women. In a study in treatment- experienced HIV-positive patients, the correlation between cellular and total plasma exposure to new antirétroviral drugs, notably the HIV integrase inhibitor raltegravir, has been determined. A good correlation was obtained between total and cellular levels of raltegravir, suggesting that monitoring of total levels are a satisfactory. However, significant inter-patient variability was observed in raltegravir cell accumulation which should prompt further investigations in patients failing under an integrase inhibitor-based regimen. The effectiveness of therapeutic drug monitoring (TDM) to guide efavirenz dose reduction in patients having concentrations above the recommended therapeutic range was evaluated in a prospective study. TDM-guided dosage adjustment of efavirenz was found feasible and safe, supporting the use of TDM in patients with efavirenz concentrations above therapeutic target. The impact of genetic polymorphisms of cytochromes P450 (CYP) 2B6, 2A6 and 3A4/5 on the PK of efavirenz and its metabolites was studied: a population PK model was built integrating both genetic and demographic covariates. Functional genetic variations in main (CYP2B6) and accessory (2A6, 3A4/5) metabolic pathways of efavirenz have an impact on efavirenz disposition, and may lead to extreme drug exposures. Dosage adjustment guided by TDM is thus required in those patients, according to the pharmacogenetic polymorphism.Thus, we have demonstrated, using a comprehensive approach taking into account both PK and PG factors influencing ARVs exposure in HIV-infected patients, the feasibility of individualising antirétroviral therapy in various situations. Antiviral treatment optimisation is likely to increase long-term treatment success while reducing the occurrence of adverse drug reactions.

High-throughput hydrophilic interaction chromatography coupled to tandem mass spectrometry for the optimized quantification of the anti-Gram-negatives antibiotic colistin A/B and its pro-drug colistimethate.

Colistin is a last resort's antibacterial treatment in critically ill patients with multi-drug resistant Gram-negative infections. As appropriate colistin exposure is the key for maximizing efficacy while minimizing toxicity, individualized dosing optimization guided by therapeutic drug monitoring is a top clinical priority. Objective of the present work was to develop a rapid and robust HPLC-MS/MS assay for quantification of colistin plasma concentrations. This novel methodology validated according to international standards simultaneously quantifies the microbiologically active compounds colistin A and B, plus the pro-drug colistin methanesulfonate (colistimethate, CMS). 96-well micro-Elution SPE on Oasis Hydrophilic-Lipophilic-Balanced (HLB) followed by direct analysis by Hydrophilic Interaction Liquid Chromatography (HILIC) with Ethylene Bridged Hybrid - BEH - Amide phase column coupled to tandem mass spectrometry allows a high-throughput with no significant matrix effect. The technique is highly sensitive (limit of quantification 0.014 and 0.006μg/mL for colistin A and B), precise (intra-/inter-assay CV 0.6-8.4%) and accurate (intra-/inter-assay deviation from nominal concentrations -4.4 to +6.3%) over the clinically relevant analytical range 0.05-20μg/mL. Colistin A and B in plasma and whole blood samples are reliably quantified over 48h at room temperature and at +4°C (<6% deviation from nominal values) and after three freeze-thaw cycles. Colistimethate acidic hydrolysis (1M H2SO4) to colistin A and B in plasma was completed in vitro after 15min of sonication while the pro-drug hydrolyzed spontaneously in plasma ex vivo after 4h at room temperature: this information is of utmost importance for interpretation of analytical results. Quantification is precise and accurate when using serum, citrated or EDTA plasma as biological matrix, while use of heparin plasma is not appropriate. This new analytical technique providing optimized quantification in real-life conditions of the microbiologically active compounds colistin A and B offers a highly efficient tool for routine therapeutic drug monitoring aimed at individualizing drug dosing against life-threatening infections.

Collective victimisation and collective guilt in the former Yugoslavia : the interplay between individual, local and societal levels

The thesis examines the impact of collective war victimization on individuals' readiness to accept or assign collective guilt for past war atrocities. As a complement to previous studies, its aim is to articulate an integrated approach to collective victimization, which distinguishes between individual-, communal-, and societal-level consequences of warfare. Building on a social representation approach, it is guided by the assumption that individuals form beliefs about a conflict through their personal experiences of victimization, communal experiences of warfare that occur in their proximal surrounding, and the mass- mediatised narratives that circulate in a society's public sphere. Four empirical studies test the hypothesis that individuals' beliefs about the conflict depend on the level and type of war experiences to which they have been exposed, that is, on informative and normative micro and macro contexts in which they are embedded. The studies have been conducted in the context of the Yugoslav wars that attended the breakup of Yugoslavia, a series of wars fought between 1991 and 2001 during which numerous war atrocities were perpetrated causing a massive victimisation of population. To examine the content and impact of war experiences at each level of analysis, the empirical studies employed various methodological strategies, from quantitative analyses of a representative public opinion survey, to qualitative analyses of media content and political speeches. Study 1 examines the impact of individual- and communal- level war experiences on individuals' acceptance and assignment of collective guilt. It further examines the impact of the type of communal level victimization: exposure to symmetric (i.e., violence that similarly affects members of different ethnic groups, including adversaries) and asymmetric violence. The main goal of Study 2 is to examine the structural and political circumstances that enhance collective guilt assignment. While the previous studies emphasize the role of past victimisation, Study 2 tests the assumption that the political demobilisation strategy employed by elites facing public discontent in the collective system-threatening circumstances can fuel out-group blame. Studies 3 and 4 have been conducted predominantly in the context of Croatia and examine rhetoric construction of the dominant politicized narrative of war in a public sphere (Study 3) and its maintenance through public delegitimization of alternative (critical) representations (Study 4). Study 4 further examines the likelihood that highly identified group members adhere to publicly delegitimized critical stances on war. - Cette thèse étudie l'impact de la victimisation collective de guerre sur la capacité des individus à accepter ou à attribuer une culpabilité collective liée à des atrocités commises en temps de guerre. En compléments aux recherches existantes, le but de ce travail est de définir une approche intégrative de la victimisation collective, qui distingue les conséquences de la guerre aux niveaux individuel, régional et sociétal. En partant de l'approche des représentations sociales, cette thèse repose sur le postulat que les individus forment des croyances sur un conflit au travers de leurs expériences personnelles de victimisation, de leurs expériences de guerre lorsque celle-ci se déroule près d'eux, ainsi qu'au travers des récits relayés par les mass media. Quatre études testent l'hypothèse que les croyances des individus dépendent des niveaux et des types d'expériences de guerre auxquels ils ont été exposés, c'est-à-dire, des contextes informatifs et normatifs, micro et macro dans lesquels ils sont insérés. Ces études ont été réalisées dans le contexte des guerres qui, entre 1991 et 2001, ont suivi la dissolution de la Yougoslavie et durant lesquelles de nombreuses atrocités de guerre ont été commises, causant une victimisation massive de la population. Afin d'étudier le contenu et l'impact des expériences de guerre sur chaque niveau d'analyse, différentes stratégies méthodologiques ont été utilisées, des analyses quantitatives sur une enquête représentative d'opinion publique aux analyses qualitatives de contenu de médias et de discours politiques. L'étude 1 étudie l'impact des expériences de guerre individuelles et régionales sur l'acceptation et l'attribution de la culpabilité collective par les individus. Elle examine aussi l'impact du type de victimisation régionale : exposition à la violence symétrique (i.e., violence qui touche les membres de différents groupes ethniques, y compris les adversaires) et asymétrique. L'étude 2 se penche sur les circonstances structurelles et politiques qui augmentent l'attribution de culpabilité collective. Alors que les recherches précédentes ont mis l'accent sur le rôle de la victimisation passée, l'étude 2 teste l'hypothèse que la stratégie de démobilisation politique utilisée par les élites pour faire face à l'insatisfaction publique peut encourager l'attribution de la culpabilité à l'exogroupe. Les études 3 et 4 étudient, principalement dans le contexte croate, la construction rhétorique du récit de guerre politisé dominant (étude 3) et son entretien à travers la délégitimation publique des représentations alternatives (critiques] (étude 4). L'étude 4 examine aussi la probabilité qu'ont les membres de groupe fortement identifiés d'adhérer à des points de vue sur la guerre critiques et publiquement délégitimés.

Simulation-based systematic review of imatinib population pharmacokinetics and PK-PD relationships in chronic myeloid leukemia (CML) patients

Objectives: Several population pharmacokinetic (PPK) and pharmacokinetic-pharmacodynamic (PK-PD) analyses have been performed with the anticancer drug imatinib. Inspired by the approach of meta-analysis, we aimed to compare and combine results from published studies in a useful way - in particular for improving the clinical interpretation of imatinib concentration measurements in the scope of therapeutic drug monitoring (TDM). Methods: Original PPK analyses and PK-PD studies (PK surrogate: trough concentration Cmin; PD outcomes: optimal early response and specific adverse events) were searched systematically on MEDLINE. From each identified PPK model, a predicted concentration distribution under standard dosage was derived through 1000 simulations (NONMEM), after standardizing model parameters to common covariates. A "reference range" was calculated from pooled simulated concentrations in a semi-quantitative approach (without specific weighting) over the whole dosing interval. Meta-regression summarized relationships between Cmin and optimal/suboptimal early treatment response. Results: 9 PPK models and 6 relevant PK-PD reports in CML patients were identified. Model-based predicted median Cmin ranged from 555 to 1388 ng/ml (grand median: 870 ng/ml and inter-quartile range: 520-1390 ng/ml). The probability to achieve optimal early response was predicted to increase from 60 to 85% from 520 to 1390 ng/ml across PK-PD studies (odds ratio for doubling Cmin: 2.7). Reporting of specific adverse events was too heterogeneous to perform a regression analysis. The general frequency of anemia, rash and fluid retention increased however consistently with Cmin, but less than response probability. Conclusions: Predicted drug exposure may differ substantially between various PPK analyses. In this review, heterogeneity was mainly attributed to 2 "outlying" models. The established reference range seems to cover the range where both good efficacy and acceptable tolerance are expected for most patients. TDM guided dose adjustment appears therefore justified for imatinib in CML patients. Its usefulness remains now to be prospectively validated in a randomized trial.

Review of therapeutic drug monitoring of anticancer drugs part one - Cytotoxics.

Most anticancer drugs are characterised by a steep dose-response relationship and narrow therapeutic window. Inter-individual pharmacokinetic (PK) variability is often substantial. The most relevant PK parameter for cytotoxic drugs is the area under the plasma concentration versus time curve (AUC). Thus it is somewhat surprising that therapeutic drug monitoring (TDM) is still uncommon for the majority of agents. Goals of the review were to assess the rationale for more widely used TDM of cytotoxics in oncology. There are several reasons why TDM has never been fully implemented into daily oncology practice. These include difficulties in establishing appropriate concentration target ranges, common use of combination chemotherapies for many tumour types, analytical challenges with prodrugs, intracellular compounds, the paucity of published data from pharmacological trials and 'Day1=Day21' administration schedules. There are some specific situations for which these limitations are overcome, including high dose methotrexate, 5-fluorouracil infusion, mitotane and some high dose chemotherapy regimens. TDM in paediatric oncology represents an important challenge. Established TDM approaches includes the widely used anticancer agents carboplatin, busulfan and methotrexate, with 13-cis-retinoic acid also recently of interest. Considerable effort should be made to better define concentration-effect relationships and to utilise tools such as population PK/PD models and comparative randomised trials of classic dosing versus pharmacokinetically guided adaptive dosing. There is an important heterogeneity among clinical practices and a strong need to promote TDM guidelines among the oncological community.