Role Clarification Processes for Better Integration of Nurse Practitioners into Primary Healthcare Teams: A Multiple-Case Study

Cet article s'intéresse aux processus de clarification des rôles professionnels lors de l'intégration d'une infirmière praticienne spécialisée dans les équipes de première ligne au Québec.

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.

Seasonal Studies on Primary Production and Associated Environmental Parameters in the Indian EEZ

The thesis describes the importance of Indian EEZ, definition and the various factors affecting primary production, general account of phytoplankton and its importance in marine ecosystem etc. In review of literature, general oceanography of Arabian Sea and Bay of Bengal and hydrography of eastern Arabian Sea and western Bay of Bengal. It deals with the distribution patterns of primary production, chlorophyll a, phytoplankton composition and particulate organic carbon in the eastern Arabian Sea and western Bay of Bengal during different seasons. Factors that affect primary productivity are irradiance, temperature, stability of the surface waters, nutrients and zooplankton grazing. The differential biological response of eastern Arabian Sea and western Bay of Bengal to monsoonal regimes. A precise estimation on the primary production of the entire EEZ of India on a regional basis and on a seasonal scale would be the only way to achieve any kind of predictive assessment on the fish stock and their sustainable yield. This study mainly envisages the qualitative and quantitative aspects on the magnitude of phytoplankton standing crop and production of organic carbon and their relationship to environmental characteristics during summer monsoon, Inter monsoon and winter monsoon periods in the east and west coasts of the Indian EEZ.This study revealed that the seasonality exerts a great impact on the biological production in the eastern Arabian Sea and western Bay of Bengal. High biological production may be the reason why most of the fish landings are Concentrated in the west coast of India than east coast. The present data on Phytoplankton production rate and the species composition will provide a meaningful ground for evaluations of exploitable renewable resources of the IndianEEZ

Microstructural evolution of primary crystallization in diffusion-controlled grain growth

A model has been developed for evaluating grain size distributions in primary crystallizations where the grain growth is diffusion controlled. The body of the model is grounded in a recently presented mean-field integration of the nucleation and growth kinetic equations, modified conveniently in order to take into account a radius-dependent growth rate, as occurs in diffusion-controlled growth. The classical diffusion theory is considered, and a modification of this is proposed to take into account interference of the diffusion profiles between neighbor grains. The potentiality of the mean-field model to give detailed information on the grain size distribution and transformed volume fraction for transformations driven by nucleation and either interface- or diffusion-controlled growth processes is demonstrated. The model is evaluated for the primary crystallization of an amorphous alloy, giving an excellent agreement with experimental data. Grain size distributions are computed, and their properties are discussed.

Qualitative air flow modelling and analysis of data centre air conditioning as multiple jet array

This work identifies the importance of plenum pressure on the performance of the data centre. The present methodology followed in the industry considers the pressure drop across the tile as a dependant variable, but it is shown in this work that this is the only one independent variable that is responsible for the entire flow dynamics in the data centre, and any design or assessment procedure must consider the pressure difference across the tile as the primary independent variable. This concept is further explained by the studies on the effect of dampers on the flow characteristics. The dampers have found to introduce an additional pressure drop there by reducing the effective pressure drop across the tile. The effect of damper is to change the flow both in quantitative and qualitative aspects. But the effect of damper on the flow in the quantitative aspect is only considered while using the damper as an aid for capacity control. Results from the present study suggest that the use of dampers must be avoided in data centre and well designed tiles which give required flow rates must be used in the appropriate locations. In the present study the effect of hot air recirculation is studied with suitable assumptions. It identifies that, the pressure drop across the tile is a dominant parameter which governs the recirculation. The rack suction pressure of the hardware along with the pressure drop across the tile determines the point of recirculation in the cold aisle. The positioning of hardware in the racks play an important role in controlling the recirculation point. The present study is thus helpful in the design of data centre air flow, based on the theory of jets. The air flow can be modelled both quantitatively and qualitatively based on the results.

Studies on the primary production in the Indian seas

This thesis deals with the results of investigations on primary production and related aspects conducted in the Indian seas since 1957 and includes the regional and seasonal variations in the rate of production factors controlling the same and the magnitude of potential fishery resources derived from it. Data collected for various periods using oxygen and 14c techniques from the Gulf of Mannar, palk bay, the south west coast of India including laccadive sea together with other available data form the basis of these studies.

Application of ocean colour data to study the oceanographic and atmospheric features off the southwest coast of India with special reference to upwelling

Satellite remote sensing is being effectively used in monitoring the ocean surface and its overlying atmosphere. Technical growth in the field of satellite sensors has made satellite measurement an inevitable part of oceanographic and atmospheric research. Among the ocean observing sensors, ocean colour sensors make use of visible band of electromagnetic spectrum (shorter wavelength). The use of shorter wavelength ensures fine spatial resolution of these parameters to depict oceanographic and atmospheric characteristics of any region having significant spaio-temporal variability. Off the southwest coast of India is such an area showing very significant spatio-temporal oceanographic and atmospheric variability due to the seasonally reversing surface winds and currents. Consequently, the region is enriched with features like upwelling, sinking, eddies, fronts, etc. Among them, upwelling brings nutrient-rich waters from subsurface layers to surface layers. During this process primary production enhances, which is measured in ocean colour sensors as high values of Chl a. Vertical attenuation depth of incident solar radiation (Kd) and Aerosol Optical Depth (AOD) are another two parameters provided by ocean colour sensors. Kd is also susceptible to undergo significant seasonal variability due to the changes in the content of Chl a in the water column. Moreover, Kd is affected by sediment transport in the upper layers as the region experiences land drainage resulting from copious rainfall. The wide range of variability of wind speed and direction may also influence the aerosol source / transport and consequently AOD. The present doctoral thesis concentrates on the utility of Chl a, Kd and AODprovided by satellite ocean colour sensors to understand oceanographic and atmospheric variability off the southwest coast of India. The thesis is divided into six Chapters with further subdivisions

ECG Noise Removal using GA tuned Sign-Data Least Mean Square Algorithm

Adaptive filter is a primary method to filter Electrocardiogram (ECG), because it does not need the signal statistical characteristics. In this paper, an adaptive filtering technique for denoising the ECG based on Genetic Algorithm (GA) tuned Sign-Data Least Mean Square (SD-LMS) algorithm is proposed. This technique minimizes the mean-squared error between the primary input, which is a noisy ECG, and a reference input which can be either noise that is correlated in some way with the noise in the primary input or a signal that is correlated only with ECG in the primary input. Noise is used as the reference signal in this work. The algorithm was applied to the records from the MIT -BIH Arrhythmia database for removing the baseline wander and 60Hz power line interference. The proposed algorithm gave an average signal to noise ratio improvement of 10.75 dB for baseline wander and 24.26 dB for power line interference which is better than the previous reported works

Pre-Attentive Segmentation in the Primary Visual Cortex

Stimuli outside classical receptive fields have been shown to exert significant influence over the activities of neurons in primary visual cortexWe propose that contextual influences are used for pre-attentive visual segmentation, in a new framework called segmentation without classification. This means that segmentation of an image into regions occurs without classification of features within a region or comparison of features between regions. This segmentation framework is simpler than previous computational approaches, making it implementable by V1 mechanisms, though higher leve l visual mechanisms are needed to refine its output. However, it easily handles a class of segmentation problems that are tricky in conventional methods. The cortex computes global region boundaries by detecting the breakdown of homogeneity or translation invariance in the input, using local intra-cortical interactions mediated by the horizontal connections. The difference between contextual influences near and far from region boundaries makes neural activities near region boundaries higher than elsewhere, making boundaries more salient for perceptual pop-out. This proposal is implemented in a biologically based model of V1, and demonstrated using examples of texture segmentation and figure-ground segregation. The model performs segmentation in exactly the same neural circuit that solves the dual problem of the enhancement of contours, as is suggested by experimental observations. Its behavior is compared with psychophysical and physiological data on segmentation, contour enhancement, and contextual influences. We discuss the implications of segmentation without classification and the predictions of our V1 model, and relate it to other phenomena such as asymmetry in visual search.

Effect of the human papillomavirus (HPV) quadrivalent vaccine in a subgroup of women with cervical and vulvar disease: Retrospective pooled analysis of trial data

Objectives To determine the effect of human papillomavirus (HPV) quadrivalent vaccine on the risk of developing subsequent disease after an excisional procedure for cervical intraepithelial neoplasia or diagnosis of genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia. Design Retrospective analysis of data from two international, double blind, placebo controlled, randomised efficacy trials of quadrivalent HPV vaccine (protocol 013 (FUTURE I) and protocol 015 (FUTURE II)). Setting Primary care centres and university or hospital associated health centres in 24 countries and territories around the world. Participants Among 17 622 women aged 15–26 years who underwent 1:1 randomisation to vaccine or placebo, 2054 received cervical surgery or were diagnosed with genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia. Intervention Three doses of quadrivalent HPV vaccine or placebo at day 1, month 2, and month 6. Main outcome measures Incidence of HPV related disease from 60 days after treatment or diagnosis, expressed as the number of women with an end point per 100 person years at risk. Results A total of 587 vaccine and 763 placebo recipients underwent cervical surgery. The incidence of any subsequent HPV related disease was 6.6 and 12.2 in vaccine and placebo recipients respectively (46.2% reduction (95% confidence interval 22.5% to 63.2%) with vaccination). Vaccination was associated with a significant reduction in risk of any subsequent high grade disease of the cervix by 64.9% (20.1% to 86.3%). A total of 229 vaccine recipients and 475 placebo recipients were diagnosed with genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia, and the incidence of any subsequent HPV related disease was 20.1 and 31.0 in vaccine and placebo recipients respectively (35.2% reduction (13.8% to 51.8%)). Conclusions Previous vaccination with quadrivalent HPV vaccine among women who had surgical treatment for HPV related disease significantly reduced the incidence of subsequent HPV related disease, including high grade disease.

Primary Prevention and Screening Strategies for Colorectal Cancer: Which Strategy Should Take?

Objective: To explore and define the utility of different strategies for primary prevention (ASA, diet, physical activity) and strategies of screening test (FOBT, sigmoidoscopy, colonoscopy, etc.) for colorectal cancer. Data source: Databases consulted were MEDLINE (1966 to 2006), DARE (1980 to 2006), Cochrane Central Register of Controlled Trials, Cochrane Collaboration’s Registry of Clinical Trials, Cochrane Database of Systematic Reviews and LILACS. Study selection: Studies such clinical trial, cohort and case-control studies of the effectiveness of tests for screening and primary prevention adenoma and colorectal cancer were identified by two reviewers. Data Extraction: The extraction of data and its evaluation is done in most of the process so paired. Limitations: Not strictly complies with the methodology of a systematic review and therefore reproducibility is questionable, the conclusions of this study should be extrapolated with caution. Conclusions: The major strategy of screening on the effectiveness of early detection of premalignant lesions or cancer is colonoscopy every 5 years, however it is necessary to evaluate this measure cost-effectiveness studies. For primary prevention, aspirin and cyclooxygenase-2 inhibitors reduce the incidence of colorectal adenomas. Aspirin can reduce colorectal cancer incidence. However, these medications may be associated with a significant risk of cardiovascular events and gastrointestinal bleeding. The balance between risks and benefits must be evaluated in future studies.

Empowerment: model i instrument de mesura basat en les variables primàries o efectives PIEQ (Primary Items Empowerment Questionnaire)

In this thesis a review of the state of the art on empowerment is found. A proposal is put forward for a model of the effective variables of empowerment, a new theoretical model that provides a distinct classification of individual variables. The model consists of four metavariables called reciprocal, unidirectional, shared and reflexive. Finally, a measurement tool for measuring and representing these variables graphically is described, including its process of elaboration through a preliminary pilot study that served to refine and improve the questionnaire. Both the model and the instrument proposed aim to determine the state of the primary variables involved in determining the predisposition and potential of a working group towards empowerment. With the measurement tool both organisational, departmental, working group and/or individual data can be obtained. This instrument can help companies and organisations to discover the limitations existing within a working group and act in consequence.

Resources for non-english speaking parents of children who are deaf or hard of hearing and learning english as their primary language

This study examined culturally and linguistically diverse families with deaf and hard of hearing children. A literature review consisted of looking at the rate of immigration to the United States, English speaking parents of children who are deaf and hard of hearing, bilingual education, and the obstacles bilingual parents of children who are deaf and hard of hearing may face. The data obtained was used to compile a list of resources for parents of children who are deaf and hard of hearing available in languages other than English in order to assist these families.

Evaluating the efficacy of planktonic foraminifer calcite and 18O data for sea surface temperature reconstruction for the Late Miocene

This study examines the efficacy of published δ18O data from the calcite of Late Miocene surface dwelling planktonic foraminifer shells, for sea surface temperature estimates for the pre-Quaternary. The data are from 33 Late Miocene (Messinian) marine sites from a modern latitudinal gradient of 64°N to 48°S. They give estimates of SSTs in the tropics/subtropics (to 30°N and S) that are mostly cooler than present. Possible causes of this temperature discrepancy are ecological factors (e.g. calcification of shells at levels below the ocean mixed layer), taphonomic effects (e.g. diagenesis or dissolution), inaccurate estimation of Late Miocene seawater oxygen isotope composition, or a real Late Miocene cool climate. The scale of apparent cooling in the tropics suggests that the SST signal of the foraminifer calcite has been reset, at least in part, by early diagenetic calcite with higher δ18O, formed in the foraminifer shells in cool sea bottom pore waters, probably coupled with the effects of calcite formed below the mixed layer during the life of the foraminifera. This hypothesis is supported by the markedly cooler SST estimates from low latitudes—in some cases more than 9 °C cooler than present—where the gradients of temperature and the δ18O composition of seawater between sea surface and sea bottom are most marked, and where ocean surface stratification is high. At higher latitudes, particularly N and S of 30°, the temperature signal is still cooler, though maximum temperature estimates overlap with modern SSTs N and S of 40°. Comparison of SST estimates for the Late Miocene from alkenone unsaturation analysis from the eastern tropical Atlantic at Ocean Drilling Program (ODP) Site 958—which suggest a warmer sea surface by 2–4 °C, with estimates from oxygen isotopes at Deep Sea Drilling Project (DSDP) Site 366 and ODP Site 959, indicating cooler than present SSTs, also suggest a significant impact on the δ18O signal. Nevertheless, much of the original SST variation is clearly preserved in the primary calcite formed in the mixed layer, and records secular and temporal oceanographic changes at the sea surface, such as movement of the Antarctic Polar Front in the Southern Ocean. Cooler SSTs in the tropics and sub-tropics are also consistent with the Late Miocene latitude reduction in the coral reef belt and with interrupted reef growth on the Queensland Plateau of eastern Australia, though it is not possible to quantify absolute SSTs with the existing oxygen isotope data. Reconstruction of an accurate global SST dataset for Neogene time-slices from the existing published DSDP/ODP isotope data, for use in general circulation models, may require a detailed re-assessment of taphonomy at many sites.

Determining the effect of asymmetric data on the variogram. I. Underlying asymmetry

Matheron's usual variogram estimator can result in unreliable variograms when data are strongly asymmetric or skewed. Asymmetry in a distribution can arise from a long tail of values in the underlying process or from outliers that belong to another population that contaminate the primary process. This paper examines the effects of underlying asymmetry on the variogram and on the accuracy of prediction, and the second one examines the effects arising from outliers. Standard geostatistical texts suggest ways of dealing with underlying asymmetry; however, this is based on informed intuition rather than detailed investigation. To determine whether the methods generally used to deal with underlying asymmetry are appropriate, the effects of different coefficients of skewness on the shape of the experimental variogram and on the model parameters were investigated. Simulated annealing was used to create normally distributed random fields of different size from variograms with different nugget:sill ratios. These data were then modified to give different degrees of asymmetry and the experimental variogram was computed in each case. The effects of standard data transformations on the form of the variogram were also investigated. Cross-validation was used to assess quantitatively the performance of the different variogram models for kriging. The results showed that the shape of the variogram was affected by the degree of asymmetry, and that the effect increased as the size of data set decreased. Transformations of the data were more effective in reducing the skewness coefficient in the larger sets of data. Cross-validation confirmed that variogram models from transformed data were more suitable for kriging than were those from the raw asymmetric data. The results of this study have implications for the 'standard best practice' in dealing with asymmetry in data for geostatistical analyses. (C) 2007 Elsevier Ltd. All rights reserved.