Patient and health care professional decision-making to commence and withdraw from renal dialysis: A systematic review of qualitative research

Background and objectives. To ensure decisions to start and stop dialysis in end stage kidney disease are shared, the factors that affect patients and healthcare professionals in making such decisions need to be understood. This systematic review aims to explore how and why different factors mediate the choices about dialysis treatment. Design, setting, participants, and measurements. Medline, Embase, CINAHL and PsychINFO were searched for qualitative studies of factors that affect patients’ and/or healthcare professionals’ decisions to commence or withdraw from dialysis. A thematic synthesis was conducted. Results. Of 494 articles screened, 12 studies (conducted: 1985-2014) were included. These involved 206 predominantly haemodialysis patients and 64 healthcare professionals (age range: patients 26-93; professionals 26-61 years). (i) Commencing dialysis: patients based their choice on ‘gut-instinct’ as well as deliberating the impact of treatment on quality-of-life and survival. How individuals coped with decision-making was influential, some tried to take control of the problem of progressive renal failure, whilst others focussed on controlling their emotions. Healthcare professionals weighed-up biomedical factors and were led by an instinct to prolong life. Both patients and healthcare professionals described feeling powerless. (ii) Dialysis withdrawal: Only after prolonged periods of time on dialysis, were the realities of life on dialysis fully appreciated and past choice questioned. By this stage however patients were physically treatment dependent. Similar to commencing dialysis, individuals coped with treatment withdrawal in a problem or emotion-controlling way. Families struggled to differentiate choosing versus allowing death. Healthcare teams avoided and queried discussions regarding dialysis withdrawal. Patients however missed the dialogue they experienced during pre-dialysis education. Conclusions. Decision-making in end stage kidney disease is complex, dynamic, and evolves over time and towards death. The factors at work are multi-faceted and operate differently for patients and health professionals. More training and research on open-communication and shared decision-making is needed

In the Interests of clients or commerce? Legal aid, supply, demand, and 'ethical indeterminacy' in criminal defence work

As a professional, a lawyer's first duty is to serve the client's best interests, before simple monetary gain. In criminal defence work, this duty has been questioned in the debate about the causes of growth in legal aid spending: is it driven by lawyers (suppliers) inducing unnecessary demand for their services or are they merely responding to increased demand? Research reported here found clear evidence of a change in the handling of cases in response to new payment structures, though in ways unexpected by the policy's proponents. The paper develops the concept of 'ethical indeterminacy' as a way of understanding how defence lawyers seek to reconcile the interests of commerce and clients. Ethical indeterminacy suggests that where different courses of action could each be said to benefit the client, the lawyer will tend to advise the client to decide in the lawyer's own interests. Ethical indeterminacy is mediated by a range of competing conceptions of 'quality' and 'need'. The paper goes on to question the very distinction between 'supply' and 'demand' in the provision of legal services

Necessary conditions for variational regularization schemes

We study variational regularization methods in a general framework, more precisely those methods that use a discrepancy and a regularization functional. While several sets of sufficient conditions are known to obtain a regularization method, we start with an investigation of the converse question: How could necessary conditions for a variational method to provide a regularization method look like? To this end, we formalize the notion of a variational scheme and start with comparison of three different instances of variational methods. Then we focus on the data space model and investigate the role and interplay of the topological structure, the convergence notion and the discrepancy functional. Especially, we deduce necessary conditions for the discrepancy functional to fulfill usual continuity assumptions. The results are applied to discrepancy functionals given by Bregman distances and especially to the Kullback-Leibler divergence.Comment: To appear in Inverse Problem

Complete Genome Sequences of Escherichia coli Strains 1303 and ECC-1470 Isolated from Bovine Mastitis

Escherichia coli is the leading causative agent of acute bovine mastitis. Here, we report the complete genome sequence of E. coli O70:H32 strain 1303, isolated from an acute case of bovine mastitis, and E. coli Ont:Hnt strain ECC-1470, isolated from a persistent infection

Nonparametric instrumental regression with non-convex constraints

This paper considers the nonparametric regression model with an additive error that is dependent on the explanatory variables. As is common in empirical studies in epidemiology and economics, it also supposes that valid instrumental variables are observed. A classical example in microeconomics considers the consumer demand function as a function of the price of goods and the income, both variables often considered as endogenous. In this framework, the economic theory also imposes shape restrictions on the demand function, like integrability conditions. Motivated by this illustration in microeconomics, we study an estimator of a nonparametric constrained regression function using instrumental variables by means of Tikhonov regularization. We derive rates of convergence for the regularized model both in a deterministic and stochastic setting under the assumption that the true regression function satisfies a projected source condition including, because of the non-convexity of the imposed constraints, an additional smallness condition

RAÇÃO FARELADA COM DIFERENTES GRANULOMETRIAS EM FRANGOS DE CORTE

Em geral, o diâmetro geométrico médio (DGM) das partículas das rações não tem afetado o desempenho de frangos de corte, em situações experimentais. Por meio deste, objetivou-se verificar se o mesmo ocorre em criações comerciais e, também, avaliar possíveis benefícios econômicos do uso da ração com maior DGM. Para isso, o presente trabalho buscou avaliar o desempenho zootécnico em frangos de corte da linhagem ROSS, do 1º ao 42º dia de idade, arraçoados com diferentes granulometrias. O experimento foi conduzido nos meses de agosto e setembro de 1998, no aviário experimental da Cooperativa Agrícola Consolata Ltda. Em delineamento em blocos casualizados, foram testados os DGMs: 0,833, 0,703 e 1,058 mm, na fase pré-inicial; 0,829, 0,703 e 1,086 mm, na fase inicial, e; 0,818, 0,649 e 0,912 mm, na fase de crescimento. O DGM dos tratamentos apresentou influência (P < 0,05) sobre o consumo de ração de pintainhos na fase pré-inicial, sendo observadas poucas modificações (P > 0,05) no desempenho das outras fases de criação e na mortalidade das aves. Entretanto, a lucratividade inerente aos tratamentos, pode ser aumentada em até 2,78%, em função da diminuição da moagem e/ou aumento do DGM. Use of mashed rations with different particle sizes for broilers Abstract In general, the average geometric diameter (AGD) of ration has not affected broilers performance in experimental situations. The objective of this experiment was to investigate if such statement is true also for commercial farms and to evaluate the possible economic benefits of using larger ration particle sizes. For that, in the present work, ROSS broilers had theis performance estimated, from the 1st up to the 42nd day of age, fed with rations of different particle sizes. The experiment was developed during August and September of 1998, in the experimental aviary from Cooperativa Agrícola Consolata Ltda. Statistical design was of random blocks and treatment were (AGD's): 0.833, 0.703 and 1.058 mm, in the pre-initial phase; 0.829, 0.703 and 1.086 mm, in the initial phase, and; 0.818, 0.649 and 0.912 mm, in the growth phase. Treatments AGDs treatment showed influence (P < 0.05) on the consumption of chick ration in the pre-initial phase. Few modifications were observed (P > 0.05) in the acting of the other feeding phases and in the mortality of the birds. However, the gross margin related to treatments can be increased up to 2.78%, as a result of the decrease of the grinding and/or AGDs increase

Response of spontaneously hypertensive rats to inhalation of fine and ultrafine particles from traffic: experimental controlled study

BACKGROUND: Many epidemiological studies have shown that mass concentrations of ambient particulate matter (PM) are associated with adverse health effects in the human population. Since PM is still a very crude measure, this experimental study has explored the role of two distinct size fractions: ultrafine (<0.15 μm) and fine (0.15- 2.5 μm) PM. In a series of 2-day inhalation studies, spontaneously hypersensitive (SH) rats were exposed to fine, concentrated, ambient PM (fCAP) at a city background location or a combination of ultrafine and fine (u+fCAP) PM at a location dominated by traffic. We examined the effect on inflammation and both pathological and haematological indicators as markers of pulmonary and cardiovascular injury. Exposure concentrations ranged from 399 μg/m(3 )to 3613 μg/m(3 )for fCAP and from 269μg/m(3 )to 556 μg/m(3 )for u+fCAP. RESULTS: Ammonium, nitrate, and sulphate ions accounted for 56 ± 16% of the total fCAP mass concentrations, but only 17 ± 6% of the u+fCAP mass concentrations. Unambiguous particle uptake in alveolar macrophages was only seen after u+fCAP exposures. Neither fCAP nor u+fCAP induced significant changes of cytotoxicity or inflammation in the lung. However, markers of oxidative stress (heme oxygenase-1 and malondialdehyde) were affected by both fCAP and u+fCAP exposure, although not always significantly. Additional analysis revealed heme oxygenase-1 (HO-1) levels that followed a nonmonotonic function with an optimum at around 600 μg/m(3 )for fCAP. As a systemic response, exposure to u+fCAP and fCAP resulted in significant decreases of the white blood cell concentrations. CONCLUSION: Minor pulmonary and systemic effects are observed after both fine and ultrafine + fine PM exposure. These effects do not linearly correlate with the CAP mass. A greater component of traffic CAP and/or a larger proportion ultrafine PM does not strengthen the absolute effects

Differential expression of DHHC9 in microsatellite stable and instable human colorectal cancer subgroups

Microarray analysis on pooled samples has previously identified ZDHHC9 (DHHC9) to be upregulated in colon adenocarcinoma compared to normal colon mucosa. Analyses of 168 samples from proximal and distal adenocarcinomas using U133plus2.0 microarrays validated these findings, showing a significant two-fold (log 2) upregulation of DHHC9 transcript (P<10(−6)). The upregulation was more striking in microsatellite stable (MSS), than in microsatellite instable (MSI), tumours. Genes known to interact with DHHC9 as H-Ras or N-Ras did not show expression differences between MSS and MSI. Immunohistochemical analysis was performed on 60 colon adenocarcinomas, previously analysed on microarrays, as well as on tissue microarrays with 40 stage I–IV tumours and 46 tumours from different organ sites. DHHC9 protein was strongly expressed in MSS compared to MSI tumours, readily detectable in premalignant lesions, compared to the rare expression seen in normal mucosa. DHHC9 was specific for tumours of the gastrointestinal tract and localised to the Golgi apparatus, in vitro and in vivo. Overexpression of DHHC9 decreased the proliferation of SW480 and CaCo2 MSS cell lines significantly. In conclusion, DHHC9 is a gastrointestinal-related protein highly expressed in MSS colon tumours. The palmitoyl transferase activity, modifying N-Ras and H-Ras, suggests DHHC9 as a target for anticancer drug design