Variability of starch-based thickened drinks for patients with dysphagia in the hospital setting

Starch-based thickening agents may be prescribed for patients with dysphagia. Thickened fluids alter variables of the swallow reflex, allowing more time for bolus manipulation without compromising airway closure. This investigation explored the variation in viscosity and physical characteristics of thickened drinks prepared in different media under laboratory conditions and compared the results with those of thickened drinks presented to dysphagic patients in one hospital. The rheological characteristics were tested on a simple plastometer and a Bohlin CVOR rheometer (Malvern Instruments, Worcestershire, UK). Samples prepared to “syrup” consistency both in the laboratory and in the hospitalwere significantly different from each other (P < 0.0001). This was also the case for samples prepared to “custard” consistency. Differences existed not only in viscosity, but drinks prepared in different media produced different rheological matrices. This signifies different viscoelastic behaviors that may effect manipulation in the mouth. From this study, preparation of thickened drinks using starch-based instant thickening powders appears to be a highly variable practice.

Interferência contextual e nível de habilidade na aprendizagem do serviço do voleibol

Este estudo investigou o efeito da interferência contextual (IC) na aquisição do serviço do voleibol em adolescentes com diferentes níveis de habilidade, considerando os testes de transferência imediato e retardado. A amostra foi composta por 56 meninas com idade entre 14 e 16 anos, distribuídas em quatro grupos de prática: aleatório com nível superior de habilidade (GAS), blocos com nível superior de habilidade (GBS), aleatório com nível inferior de habilidade (GAI) e blocos com nível inferior de habilidade (GBI). A tarefa motora consistiu dos serviços por baixo e por cima direcionados a alvos na quadra. Os resultados mostraram que o efeito da IC não foi observado nos grupos GAI e GBI, por outro lado, os grupos GAS e GBS apresentaram melhor desempenho no teste de transferência imediato. A ausência de diferenças significativas no teste de transferência retardado sugere que o efeito da IC pode ser temporário.

Practice of walking and its association with perceived environment among elderly Brazilians living in a region of low socioeconomic level

Background: The aim of this study was analyze associations between the practice of walking and environmental perception among elderly Brazilians in a region of low socioeconomic level. Methods: A cross-sectional study was conducted among 385 elderly people aged 60 years and over. To evaluate walking, the International Physical Activity Questionnaire (IPAQ), long version (leisure and transport modules) was used. The environment was evaluated by means of the Neighborhood Environmental Walkability Scale (NEWS) (adapted Brazilian version). For the statistical analysis, multiple logistic regression models were created separately for men and women. The practice of at least 150 minutes a week of walking was the dependent variable, and the variables of environmental perception were the independent variables. All the models were controlled for schooling level and age. Results: The proportion of elderly people active in walking was 56.9% for the men and 26.4% for the women. The perception of the presence of soccer fields (OR = 4.12) and their proximity, within ten minutes' walk from home (OR = 3.43), were associated with the practice of walking among the men. The perception of the presence of public squares (OR = 4.70) and the proximity of primary healthcare units, within ten minutes' walk from home (OR = 3.71), were associated with the practice of walking among the women. An association with adequate perception of vehicle traffic remained at the threshold of significance for the women. Conclusion: Accessibility of leisure structures such as football fields and public squares and of health services such as primary healthcare units were important environmental variables associated with the practice of walking among elderly people living in a region of low socioeconomic level in Brazil. These variables need to be taken into consideration when aiming to promote the practice of walking among elderly people living in similar regions.

Constant-random practice and the adaptive process in motor learning with varying amounts of constant practice

The adaptive process in motor learning was examined in terms of effects of varying amounts of constant practice performed before random practice. Participants pressed five response keys sequentially, the last one coincident with the lighting of a final visual stimulus provided by a complex coincident timing apparatus. Different visual stimulus speeds were used during the random practice. 33 children (M age=11.6 yr.) were randomly assigned to one of three experimental groups: constant-random, constant-random 33%, and constant-random 66%. The constant-random group practiced constantly until they reached a criterion of performance stabilization three consecutive trials within 50 msec. of error. The other two groups had additional constant practice of 33 and 66%, respectively, of the number of trials needed to achieve the stabilization criterion. All three groups performed 36 trials under random practice; in the adaptation phase, they practiced at a different visual stimulus speed adopted in the stabilization phase. Global performance measures were absolute, constant, and variable errors, and movement pattern was analyzed by relative timing and overall movement time. There was no group difference in relation to global performance measures and overall movement time. However, differences between the groups were observed on movement pattern, since constant-random 66% group changed its relative timing performance in the adaptation phase.

Preliminary experiences with a single-patient trials service in general practice

Objective: To pilot a single-patient trials (SPTs) service in general practice, designed to improve decision-making about long-term medications for chronic conditions. Design: 12-week within-patient, randomised, double-blind, placebo-controlled, crossover comparison of ibuprofen with paracetamol for osteoarthritis, involving three pairs of two-week treatment periods for each participating patient. Setting and patients: Patients attending an academic general practice with a clinical diagnosis of osteoarthritis, with pain of at least a month's duration severe enough to warrant consideration of long-term non-steroidal anti-inflammatory drug (NSAID) use. Main outcome measures: Pain and stiffness; measures of overall arthritis compared with previous fortnight; preference for NSAID at the end of each two-week treatment period; use of escape analgesia; side effects; and management changes as a result of the SPTs. Results: Eight of 14 patients completed SPTs. One was a clear responder to NSAIDs, five were non-responders, and two were indefinite. Of the five who were using NSAIDs before the SPT, two continued and three ceased using them. Clinically useful information assisted decision-making for all eight participants. Medication management changed for six. Conclusions: Single-patient trials can be successfully implemented in general practice and might be a valuable method for GPs to identify patients who respond to medication for chronic stable conditions such as osteoarthritis, in which individual response to medication is variable.

Sustainable Tourism and Agriculture Multifunctionality by PAR: A Variable Selection Approach

Copyright © 2013 Springer Netherlands.

The development of the Quality Indicator for Rehabilitative Care (QuIRC): a measure of best practice for facilities for people with longer term mental health problems

BACKGROUND: Despite the progress over recent decades in developing community mental health services internationally, many people still receive treatment and care in institutional settings. Those most likely to reside longest in these facilities have the most complex mental health problems and are at most risk of potential abuses of care and exploitation. This study aimed to develop an international, standardised toolkit to assess the quality of care in longer term hospital and community based mental health units, including the degree to which human rights, social inclusion and autonomy are promoted. METHOD: The domains of care included in the toolkit were identified from a systematic literature review, international expert Delphi exercise, and review of care standards in ten European countries. The draft toolkit comprised 154 questions for unit managers. Inter-rater reliability was tested in 202 units across ten countries at different stages of deinstitutionalisation and development of community mental health services. Exploratory factor analysis was used to corroborate the allocation of items to domains. Feedback from those using the toolkit was collected about its usefulness and ease of completion. RESULTS: The toolkit had excellent inter-rater reliability and few items with narrow spread of response. Unit managers found the content highly relevant and were able to complete it in around 90 minutes. Minimal refinement was required and the final version comprised 145 questions assessing seven domains of care. CONCLUSIONS: Triangulation of qualitative and quantitative evidence directed the development of a robust and comprehensive international quality assessment toolkit for units in highly variable socioeconomic and political contexts

Correcting non cephalic presentation with moxibustion: study protocol for a multi-centre randomised controlled trial in general practice.

BACKGROUND Non cephalic presentation in childbirth involves various risks to both the mother and the foetus. The incidence in Spain is 3.8% of all full-term pregnancies. The most common technique used to end the gestation in cases of non cephalic presentation is that of caesarian section, and although it provokes a lower rate of morbi-mortality than does vaginal delivery in such situations, there remains the possibility of traumatic injury to the foetal head and neck, while maternal morbidity is also increased. The application of heat (moxibustion) to an acupuncture point, in order to correct non cephalic presentation, has been practised in China since ancient times, but as yet there is insufficient evidence of its real effectiveness. METHODS/DESIGN The experimental design consists of a multi-centre randomised controlled trial with three parallel arms, used to compare real moxibustion, sham moxibustion and the natural course of events, among pregnant women with a non cephalic presentation and a gestational duration of 33-35 weeks (estimated by echography). The participants in the trial will be blinded to both interventions. The results obtained will be analyzed by professionals, blinded with respect to the allocation to the different types of intervention. In addition, we intend to carry out a economic analysis. DISCUSSION This trial will contribute to the development of evidence concerning moxibustion in the correction of non cephalic presentations. The primary outcome variable is the proportion of cephalic presentations at term. As secondary outcomes, we will evaluate the proportion of cephalic presentations at week 38 of gestation, determined by echography, together with the safety of the technique, the specificity of moxibustion and the control of the blinding process. This study has been funded by the Health Ministry of the Andalusian Regional Government. TRIAL REGISTRATION Current Controlled Trials ISRCTN10634508.

Available evidence and outcome of off-label use of rituximab in clinical practice

Purpose: To analyze the therapeutic indications for off-label use of rituximab, the available evidence for its use, the outcomes, and the cost. Methods: This was a retrospective analysis of patients treated with rituximab for off-label indications from January 2007 to December 2009 in two tertiary hospitals. Information on patient characteristics, medical conditions, and therapeutic responses was collected from medical records. Available evidence for the efficacy of rituximab in each condition was reviewed, and the cost of treatment was calculated. Results: A total of 101 cases of off-label rituximab use were analyzed. The median age of the patients involved was 53 [interquartile range (IQR) 37.568.0] years; 55.4 % were women. The indications for prescribing rituximab were primarily hematological diseases (46 %), systemic connective tissue disorders (27 %), and kidney diseases (20 %). Available evidence supporting rituximab treatment for these indications mainly came from individual cohort studies (53.5 % of cases) and case series (25.7 %). The short-term outcome (median 3 months, IQR 24 months) was a complete response in 38 % of cases and partial response in 32.6 %. The highest short-term responses were observed for systemic lupus erythematosus and membranous glomerulonephritis, and the lowest was for neuromyelitis optica, idiopathic thrombocytopenic purpura, and miscellaneous indications. Some response was maintained in long-term follow-up (median 23 months IQR 1230months) in 69.2%of patients showing a short-term response. Median cost per patient was 5,187.5 (IQR 5,187.57,781.3). Conclusions: In our study, off-label rituximab was mainly used for the treatment of hematological, kidney, and systemic connective tissue disorders, and the response among our patient cohort was variable depending on the specific disease. The level of evidence supporting the use of rituximab for these indications was low and the cost was very high. We conclude that more clinical trials on the off-label use of rituximab are needed, although these may be difficult to conduct in some rare diseases. Data from observational studies may provide useful information to assist prescribing in clinical practice.

Available evidence and outcome of off-label use of rituximab in clinical practice

Purpose: To analyze the therapeutic indications for off-label use of rituximab, the available evidence for its use, the outcomes, and the cost. Methods: This was a retrospective analysis of patients treated with rituximab for off-label indications from January 2007 to December 2009 in two tertiary hospitals. Information on patient characteristics, medical conditions, and therapeutic responses was collected from medical records. Available evidence for the efficacy of rituximab in each condition was reviewed, and the cost of treatment was calculated. Results: A total of 101 cases of off-label rituximab use were analyzed. The median age of the patients involved was 53 [interquartile range (IQR) 37.5-68.0] years; 55.4 % were women. The indications for prescribing rituximab were primarily hematological diseases (46 %), systemic connective tissue disorders (27 %), and kidney diseases (20 %). Available evidence supporting rituximab treatment for these indications mainly came from individual cohort studies (53.5 % of cases) and case series (25.7 %). The short-term outcome (median 3 months, IQR 2-4 months) was a complete response in 38 % of cases and partial response in 32.6 %. The highest short-term responses were observed for systemic lupus erythematosus and membranous glomerulonephritis, and the lowest was for neuromyelitis optica, idiopathic thrombocytopenic purpura, and miscellaneous indications. Some response was maintained in long-term follow-up (median 23 months IQR 12-30months) in 69.2%of patients showing a short-term response. Median cost per patient was 5,187.5 (IQR 5,187.5-7,781.3). Conclusions: In our study, off-label rituximab was mainly used for the treatment of hematological, kidney, and systemic connective tissue disorders, and the response among our patient cohort was variable depending on the specific disease. The level of evidence supporting the use of rituximab for these indications was low and the cost was very high. We conclude that more clinical trials on the off-label use of rituximab are needed, although these may be difficult to conduct in some rare diseases. Data from observational studies may provide useful information to assist prescribing in clinical practice.

Variable structure position control of an industrial robotic manipulator

The use of a robust position controller for a robotic manipulator moving in free space is presented. The aim is to implement in practice a controller that is robust to uncertainties in the model of the system, as well as being inexpensive from a computational point of view. Variable structure theory provides the technique for the design of such controller. The design steps are presented, first from a theoretical perspective and then applied to the control of a two degree-of-freedom manipulator. Simulation results that backed the implementation are presented, followed by the experiments conducted and the results that were obtained. The conclusion is that variable structure control is readily applicable to industrial robots for the robust control of positions.

The chronic kidney disease outcomes and practice patterns study Brazil (CKDopps-Brazil): Design, data and methodology

Introduction: The chronic kidney disease outcomes and practice patterns study (CKDopps) is an international observational, prospective, cohort study involving patients with chronic kidney disease (CKD) stages 3-5 [estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2, with a major focus upon care during the advanced CKD period (eGFR < 30 ml/min/1.73 m2)]. During a 1-year enrollment period, each one of the 22 selected clinics will enroll up to 60 advanced CKD patients (eGFR < 30 ml/min/1.73 m2 and not dialysis-dependent) and 20 earlier stage CKD patients (eGFR between 30-59 ml/min/1.73 m2). Exclusion criteria: age < 18 years old, patients on chronic dialysis or prior kidney transplant. The study timeline include up to one year for enrollment of patients at each clinic starting in the end of 2013, followed by up to 2-3 years of patient follow-up with collection of detailed longitudinal patient-level data, annual clinic practice-level surveys, and patient surveys. Analyses will apply regression models to evaluate the contribution of patient-level and clinic practice-level factors to study outcomes, and utilize instrumental variable-type techniques when appropriate. Conclusion: Launching in 2013, CKDopps Brazil will study advanced CKD care in a random selection of nephrology clinics across Brazil to gain understanding of variation in care across the country, and as part of a multinational study to identify optimal treatment practices to slow kidney disease progression and improve outcomes during the transition period to end-stage kidney disease.

Verbal ability, previous practice and load on short-term memory as determiners of differences in a complex learning task: an experimental study

Traditional psychometric theory and practice classify people according to broad ability dimensions but do not examine how these mental processes occur. Hunt and Lansman (1975) proposed a 'distributed memory' model of cognitive processes with emphasis on how to describe individual differences based on the assumption that each individual possesses the same components. It is in the quality of these components ~hat individual differences arise. Carroll (1974) expands Hunt's model to include a production system (after Newell and Simon, 1973) and a response system. He developed a framework of factor analytic (FA) factors for : the purpose of describing how individual differences may arise from them. This scheme is to be used in the analysis of psychometric tes ts . Recent advances in the field of information processing are examined and include. 1) Hunt's development of differences between subjects designated as high or low verbal , 2) Miller's pursuit of the magic number seven, plus or minus two, 3) Ferguson's examination of transfer and abilities and, 4) Brown's discoveries concerning strategy teaching and retardates . In order to examine possible sources of individual differences arising from cognitive tasks, traditional psychometric tests were searched for a suitable perceptual task which could be varied slightly and administered to gauge learning effects produced by controlling independent variables. It also had to be suitable for analysis using Carroll's f ramework . The Coding Task (a symbol substitution test) found i n the Performance Scale of the WISe was chosen. Two experiments were devised to test the following hypotheses. 1) High verbals should be able to complete significantly more items on the Symbol Substitution Task than low verbals (Hunt, Lansman, 1975). 2) Having previous practice on a task, where strategies involved in the task may be identified, increases the amount of output on a similar task (Carroll, 1974). J) There should be a sUbstantial decrease in the amount of output as the load on STM is increased (Miller, 1956) . 4) Repeated measures should produce an increase in output over trials and where individual differences in previously acquired abilities are involved, these should differentiate individuals over trials (Ferguson, 1956). S) Teaching slow learners a rehearsal strategy would improve their learning such that their learning would resemble that of normals on the ,:same task. (Brown, 1974). In the first experiment 60 subjects were d.ivided·into high and low verbal, further divided randomly into a practice group and nonpractice group. Five subjects in each group were assigned randomly to work on a five, seven and nine digit code throughout the experiment. The practice group was given three trials of two minutes each on the practice code (designed to eliminate transfer effects due to symbol similarity) and then three trials of two minutes each on the actual SST task . The nonpractice group was given three trials of two minutes each on the same actual SST task . Results were analyzed using a four-way analysis of variance . In the second experiment 18 slow learners were divided randomly into two groups. one group receiving a planned strategy practioe, the other receiving random practice. Both groups worked on the actual code to be used later in the actual task. Within each group subjects were randomly assigned to work on a five, seven or nine digit code throughout. Both practice and actual tests consisted on three trials of two minutes each. Results were analyzed using a three-way analysis of variance . It was found in t he first experiment that 1) high or low verbal ability by itself did not produce significantly different results. However, when in interaction with the other independent variables, a difference in performance was noted . 2) The previous practice variable was significant over all segments of the experiment. Those who received previo.us practice were able to score significantly higher than those without it. J) Increasing the size of the load on STM severely restricts performance. 4) The effect of repeated trials proved to be beneficial. Generally, gains were made on each successive trial within each group. S) In the second experiment, slow learners who were allowed to practice randomly performed better on the actual task than subjeots who were taught the code by means of a planned strategy. Upon analysis using the Carroll scheme, individual differences were noted in the ability to develop strategies of storing, searching and retrieving items from STM, and in adopting necessary rehearsals for retention in STM. While these strategies may benef it some it was found that for others they may be harmful . Temporal aspects and perceptual speed were also found to be sources of variance within individuals . Generally it was found that the largest single factor i nfluencing learning on this task was the repeated measures . What e~ables gains to be made, varies with individuals . There are environmental factors, specific abilities, strategy development, previous learning, amount of load on STM , perceptual and temporal parameters which influence learning and these have serious implications for educational programs .

L'obligation d'information à échelle d'intensité variable: vers une théorisation de l'obligation de conseil

En 1992, la Cour suprême du Canada souligne l'importance de faire la distinction entre l'obligation principale de conseil qui est l'objet principal du contrat et l'obligation d'information qui est accessoire. L'obligation principale de conseil est reconnue à l'égard des professionnels des professions dites libérales à l'époque, comme les avocats et notaires dans un contrat de mandat. Par contre, l'évolution jurisprudentielle récente démontre que l'obligation de conseil ne se limite plus à l'objet principal du contrat, et que la notion de «professionnel» n'a plus le sens restrictif d'autrefois. Au Québec, l'obligation principale de conseil est reconnue dans un premier temps à l'égard des professionnels soumis au Code des professions, notamment avocats et notaires. On reconnaît aussi une telle obligation accessoire de conseil à l'égard d'autres personnes qui, bien qu'elles ne soient pas des «professionnels» au sens du Code des professions, exercent tout de même des activités de nature professionnelle. C'est le cas, par exemple, des courtiers en valeurs mobilières, des courtiers en assurances ou des institutions financières. D'ailleurs, une controverse semble régner dans le domaine bancaire sur l'étendue de l'obligation de conseil et d'information des institutions financières envers un client dans le cadre d'un contrat de prestation de services. Plus particulièrement, les tribunaux semblent partagés sur la reconnaissance ou non d'une obligation de conseil de la banque dans le cadre d'un emprunt. Certaines décisions sont à l'effet que seule une obligation d'information s'impose alors que d'autres préconisent le conseil. Afin d'élucider la confusion qui règne présentement en jurisprudence dans le domaine bancaire ainsi que dans le contrat de services et d'entreprise en général, il faut faire une étude jumelée de l'évolution de l'obligation de conseil accessoire et de l'obligation de conseil principale. Notre étude porte sur l'évolution jurisprudentielle qui tend vers une théorisation dans le contrat de services ou d'entreprise, de l'obligation de conseil qui devient alors une variante ou une intensité de l'obligation accessoire d'information. Par le fait même, on constate qu'une obligation de conseil principale semble également s'étendre à une catégorie plus large de professionnels. Dans ce cas, l'obligation de conseil est similaire, dans son fondement, au devoir de conseil du «professionnel» traditionnel, au sens du Code des professions. On constate alors que l'obligation principale de conseil n'est plus restreinte aux professionnels au sens classique du terme.

Supply, demand and a failure of understanding: addressing the culture clash between archaeologists' expectations for training and employment in 'academia' versus 'practice

A university degree is effectively a prerequisite for entering the archaeological workforce in the UK. Archaeological employers consider that new entrants to the profession are insufficiently skilled, and hold university training to blame. But university archaeology departments do not consider it their responsibility to deliver fully formed archaeological professionals, but rather to provide an education that can then be applied in different workplaces, within and outside archaeology. The number of individuals studying archaeology at university exceeds the total number working in professional practice, with many more new graduates emerging than archaeological jobs advertised annually. Over-supply of practitioners is also a contributing factor to low pay in archaeology. Steps are being made to provide opportunities for vocational training, both within and outside the university system, but archaeological training and education within the universities and subsequently the archaeological labour market may be adversely impacted upon by the introduction of variable top-up student fees.