Again: An account of demoralisation in patients and families experiencing recurrence of cancer

AIMS The aims of this thesis are to provide understanding of the psychosocial impact of recurrent cancer on patients and family members and to develop a substantive theory that explains the phenomenon of recurrence from a psychosocial perspective. BACKGROUND Cancer survival is increasing, and as people live longer, cancer recurrence is a real possibility. Recurrence has been described as one of the most stressful phases of cancer. Despite this reality, recurrence is poorly understood from a psychosocial perspective. Nurses, caring for patients and family members through their cancer trajectory, need to develop new understanding of how families experience recurrence in order to help them adapt to this phase of cancer. METHODS This grounded theory study was conducted in four cancer units of two hospitals in North of Spain. The sample consisted of 15 patients, 13 relatives, and 14 nurses. Triangulation of sources of data including family interviews, individual interviews, memos, and literature was used to provide a different but complementary view of the impact of cancer recurrence. Data collection and analysis were based on the constant comparative method of grounded theory. RESULTS A core category and three main categories have emerged from the data. The first main category, “again”- when fear of recurrence becomes reality, shows the suffering of cancer survivors and their family members after a diagnosis of recurrent cancer. The term “again” symbolises past suffering due to the fear of recurrence and new sufferings as a result of the diagnosis of recurrent cancer; it also implies a re-encounter with health services and nurses. Suffering has been found to take on a social dimension in that recurrence was not an individual experience, but also a family experience. In addition, the social construction of suffering impacted on the nurses caring for the patients and families. The second main category, identified as demoralisation as a response to the suffering of recurrence, refers to the nature of suffering after the families knew that cancer had come back. Demoralisation has been found to be an emotional reaction characterised by feelings of exhaustion, uncertainty, and a resurgence of the fear of death. Such a condition posed great challenges to the nurses who described caring for these patients as harder than caring for newly diagnosed cancer patients. The third main category, identified as rebuilding morale in the experience of recurrence, highlights families’ search for meaning in their experience of recurrence and how nurses shifted the focus of care when caring for patients with recurrent cancer. The core category of this study is demoralisation in cancer recurrence. It is the foundation of a proposed theory for family nursing which explains what the experience of cancer recurrence involves for patients and families, and proposes a psychosocial framework for the management of demoralisation in families facing recurrent cancer. CONCLUSIONS This thesis contributes to new understanding of the psychosocial impact of cancer recurrence on families and the nurses’ experiences of caring during the recurrent phase of cancer. The re-conceptualisation of demoralisation brings an original understanding of the concept, which has been unpublished and unexplored in cancer nursing so far

Effect of soiling in CPV systems

The effect of soiling in flat PV modules has been already studied, causing a reduction of the electrical output of 4% on average. For CPV's, as far as soiling produces light scattering at the optical collector surface, the scattered rays should be definitively lost because they cannot be focused onto the receivers again. While the theoretical study becomes difficult because soiling is variable at different sites, it becomes easier to begin the monitoring of the real field performance of concentrators and then raise the following question: how much does the soiling affect to PV concentrators in comparison with flat panels?? The answers allow to predict the PV concentrator electrical performance and to establish a pattern of cleaning frequency. Some experiments have been conducted at the IES-UPM and CSES-ANU sites, consisting in linear reflective concentration systems, a point focus refractive concentrator and a flat module. All the systems have been measured when soiled and then after cleaning, achieving different increases of ISC. In general, results show that CPV systems are more sensitive to soiling than flat panels, accumulating losses in ISC of about 14% on average in three different tests conducted at IESUPM and CSES-ANU test sites in Madrid (Spain) and Canberra (Australia). Some concentrators can reach losses up to 26% when the system is soiled for 4 months of exposure

Perfil sociodemográfico y caracterización en salud de mujeres víctimas de trata de personas en Chile. 2012-2017. / Sociodemographic profile and characterization in health of women victims of human trafficking in Chile. 2012-2017.

Actualmente, el fenómeno de la trata de personas tensiona los países del mundo a dirigir sus políticas hacia esta forma de esclavitud moderna, enfatizando la detección, prevención, reparación y protección de las víctimas. En Chile, los escasos estudios existentes respecto a la trata de personas se limitan a las variables descriptivas y geográficas de la caracterización del delito, sin tener en cuenta las variables de acceso, atención y tratamientos de salud en profundidad. Este estudio pretende conocer y describir las características sociodemográficas y el estado de salud de las víctimas de trata de personas en Chile, entre 2012 y el primer semestre de 2017, mediante los ingresos formales a la única casa de protección en Chile. El estudio es cuantitativo de tipo descriptivo y de corte transversal de los registros de las víctimas. Las participantes fueron 43 mujeres víctimas de trata, de 32 años de media y con uno/a o más hijos/ as. Se constata un multidiagnóstico de las víctimas, debido a la cantidad de enfermedades y programas de salud a los que ingresan. Por último, se evidencia una falta de protocolo entre la casa de protección y el sistema de salud, el cual es de vital importancia para definir la calidad de salud de las víctimas de trata de personas. Nowadays, the phenomenon of human trafficking is pressuring countries around the world to direct policies towards this form of modern slavery, emphasizing the detection, prevention, reparation and protection of victims. In Chile, the few existing studies about human trafficking are limited to the descriptive and geographical variables of the crime characterization, without taking into account the variables of access, care and health treatments. This study pretends to know and describe the sociodemographic characteristics and health status of human trafficking victims in Chile, between 2012 and the first half of 2017, considering only the registered admissions into the only human trafficking protection home in Chile. The study is quantitative of a descriptive and cross-sectional nature of the victims’ records. The participants were 43 women victims of trafficking, 32 years old on average and with one or more children. A multidiagnosis of the victims is identified due to the number of diseases and health programs they register into. Finally, there is evidence of a lack of protocol between the protection home and the health system, which is of vital importance to determine the health of the human trafficking victims

Modern machine-learning can support diagnostic differentiation of central and peripheral acute vestibular disorders

BACKGROUND Diagnostic classification of central vs. peripheral etiologies in acute vestibular disorders remains a challenge in the emergency setting. Novel machine-learning methods may help to support diagnostic decisions. In the current study, we tested the performance of standard and machine-learning approaches in the classification of consecutive patients with acute central or peripheral vestibular disorders. METHODS 40 Patients with vestibular stroke (19 with and 21 without acute vestibular syndrome (AVS), defined by the presence of spontaneous nystagmus) and 68 patients with peripheral AVS due to vestibular neuritis were recruited in the emergency department, in the context of the prospective EMVERT trial (EMergency VERTigo). All patients received a standardized neuro-otological examination including videooculography and posturography in the acute symptomatic stage and an MRI within 7~days after symptom onset. Diagnostic performance of state-of-the-art scores, such as HINTS (Head Impulse, gaze-evoked Nystagmus, Test of Skew) and ABCD2 (Age, Blood, Clinical features, Duration, Diabetes), for the differentiation of vestibular stroke vs. peripheral AVS was compared to various machine-learning approaches: (i) linear logistic regression (LR), (ii) non-linear random forest (RF), (iii) artificial neural network, and (iv) geometric deep learning (Single/MultiGMC). A prospective classification was simulated by ten-fold cross-validation. We analyzed whether machine-estimated feature importances correlate with clinical experience. RESULTS Machine-learning methods (e.g., MultiGMC) outperform univariate scores, such as HINTS or ABCD2, for differentiation of all vestibular strokes vs. peripheral AVS (MultiGMC area-under-the-curve (AUC): 0.96 vs. HINTS/ABCD2 AUC: 0.71/0.58). HINTS performed similarly to MultiGMC for vestibular stroke with AVS (AUC: 0.86), but more poorly for vestibular stroke without AVS (AUC: 0.54). Machine-learning models learn to put different weights on particular features, each of which is relevant from a clinical viewpoint. Established non-linear machine-learning methods like RF and linear methods like LR are less powerful classification models (AUC: 0.89 vs. 0.62). CONCLUSIONS Established clinical scores (such as HINTS) provide a valuable baseline assessment for stroke detection in acute vestibular syndromes. In addition, machine-learning methods may have the potential to increase sensitivity and selectivity in the establishment of a correct diagnosis

Archaeological ceramic amphorae from underwater marine environments: Influence of firing temperature on salt crystallization decay

Non-desalinated and desalinated fragments of Iberian, Italic and Tarraconensian amphorae sherds, found in different underwater marine environments, were compared to determine the decay caused by salt crystallization. Polarizing light and fluorescence optical microscopy, scanning electron microscopy coupled to energy dispersive X-ray spectroscopy, X-ray diffraction, ion chromatography and mercury intrusion porosimetry tests were conducted on the samples. Non-desalinated samples exhibit a variety of signs of degradation, especially those samples fired at lower temperature. Sherds fired at higher temperatures have a lower surface area and less connected porosity, which entail a lower absorption of soluble salts containing water and eventually less decay than those fired at lower temperatures. The composition and texture reached with the firing temperature is a key factor on salt crystallization decay and hence on the durability of these artefacts. This should be taken into account during desalination procedures that have to be optimized in order to be successful

The diversity of Triassic South American sphenodontians: a new basal form, clevosaurs, and a revision of rhynchocephalian phylogeny

Rhynchocephalians are a group of lizard-like diapsid reptiles that were very diverse during the Mesozoic but are now restricted to a single extant genus in New Zealand. Recent cladistic analyses have revealed two major clades, Eusphenodontia and the more crownward Neosphenodontia, but relationships of individual taxa have remained difficult to determine because of missing data and an unrevised data matrix. Here we drastically revise the established data matrix on rhynchocephalians by reassessing, evaluating, and adding new characters and operational taxonomic units, differing from any previous analyses in our goal to consider all known rhynchocephalians. In addition, we describe a new genus and species of an early eusphenodontian taxon from the Norian of southern Brazil, with a unique mosaic of plesiomorphic and apomorphic traits, and we re-examine the craniodental anatomy of the eusphenodontian Clevosaurus brasiliensis with µCT imaging, revealing a unique form of acrodonty amongst rhynchocephalians.Fil: Chambi Trowell, Sofia A. V.. University of Bristol; Reino UnidoFil: Martinelli, Agustín Guillermo. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Museo Argentino de Ciencias Naturales "Bernardino Rivadavia"; ArgentinaFil: Whiteside, David I.. University of Bristol; Reino UnidoFil: Romo de Vivar Martínez, Paulo Rodrigo. Universidade Federal do Rio Grande do Sul; BrasilFil: Bento Soares, Marina. Universidade Federal do Rio Grande do Sul; BrasilFil: Schultz, Cesar. Universidade Federal do Rio Grande do Sul; BrasilFil: Gill, Pamela G.. University of Bristol; Reino UnidoFil: Benton, Michael J.. University of Bristol; Reino UnidoFil: Rayfield, Emily J.. University of Bristol; Reino Unid

SISTEMADE INDICADORES DE CALIDAD I

The present essay deals with a Quality Indicators System likely to be adopted in organizations implementing their continuous quality and improvement systems. Relations among criterion, indicator and standard and their own examples, as well as the different kinds of indicators is shown.El presente ensayo trata sobre un sistema de indicadores de la calidad que puede ser implantado en organizaciones que están implementando sistemas de calidad y mejora continua, mostrándose la relación entre criterio, indicador y estándar con sus respectivos ejemplos así como los diferentes tipos de indicadores

Latent Patient Network Learning for Automatic Diagnosis

Recently, Graph Convolutional Networks (GCNs) has proven to be a powerful machine learning tool for Computer Aided Diagnosis (CADx) and disease prediction. A key component in these models is to build a population graph, where the graph adjacency matrix represents pair-wise patient similarities. Until now, the similarity metrics have been defined manually, usually based on meta-features like demographics or clinical scores. The definition of the metric, however, needs careful tuning, as GCNs are very sensitive to the graph structure. In this paper, we demonstrate for the first time in the CADx domain that it is possible to learn a single, optimal graph towards the GCN's downstream task of disease classification. To this end, we propose a novel, end-to-end trainable graph learning architecture for dynamic and localized graph pruning. Unlike commonly employed spectral GCN approaches, our GCN is spatial and inductive, and can thus infer previously unseen patients as well. We demonstrate significant classification improvements with our learned graph on two CADx problems in medicine. We further explain and visualize this result using an artificial dataset, underlining the importance of graph learning for more accurate and robust inference with GCNs in medical applications

Hospederos intermediarios de Fasciola hepática en el Perú

Se demostró la infección natural y experimental de los caracoles limneídos peruanos con estadios larvales de Fasciola hepatica. Los índices de infección natural y experimental fueron del 12% y 28% en Lymnaea columella y del 27% y 70% en Lymnaea viatrix, respectivamente. Lymnaea diaphana y Lymnaea cousini no presentaron infección natural y demostraron no ser susceptibles a la infección experimenta

Deciding case by case on family presence in the emergency care service

Objective: To understand how physicians and nurses experience and perceive the presence of families in the emergency care service. Methods: This was a qualitative study that used symbolic interactionism as a theoretical reference, and grounded theory as a methodological reference. Twenty professionals participated – equally representing physicians and nurses - working in two emergency rooms located in the south of Brazil. Data were collected between October of 2016 and February of 2017, by means of interviews. Results: The existence of a social culture of family exclusion was identifi ed, widely diffused and practiced by professionals. However, families sometimes remain with their loved ones in the emergency room, since professionals analyze and decide “case by case”, considering different aspects throughout the care process. Conclusion: Multiple aspects are related in determining family presence during emergency care for physicians and nurses. Thus, a single directive on the presence of the family is not prudent. In fact, it is suggested that each health unit develop its protocols, considering local particularities.Objetivo: Compreender como médicos e enfermeiros vivenciam e percebem a presença da família no serviço de atendimento emergencial. Métodos: Estudo qualitativo que utilizou o Interacionismo Simbólico como referencial teórico e a Teoria Fundamentada nos Dados como referencial metodológico. Participaram 20 profi ssionais – divididos equitativamente entre médicos e enfermeiros – que atuavam em duas Salas de Emergência localizadas no Sul do Brasil. Os dados foram coletados entre outubro de 2016 e fevereiro de 2017, por meio de entrevistas. Resultados: Identifi cou-se a existência de uma cultura social de exclusão familiar, amplamente difundida e praticada pelos profi ssionais. Contudo, às vezes, as famílias permanecem com seus entes queridos na Sala de Emergência, visto que os profi ssionais analisam e decidem “caso a caso”, considerando diferentes aspectos ao longo do processo assistencial. Conclusão: Para médicos e enfermeiros múltiplos aspectos estão relacionados na determinação da presença familiar durante o atendimento emergencial. Assim, não é aconselhável uma diretiva única para a presença da família. Em realidade, sugere-se que cada unidade de saúde elabore seus protocolos considerando as particularidades locais.Objetivo: Comprender cómo médicos y enfermeros experimentan y perciben la presencia familiar en el servicio de atención de urgencias. Métodos: Estudio cualitativo, aplicando el Interaccionismo Simbólico como referencial teórico, y la Teoría Fundamentada en los Datos como referencial metodológico. Participaron 20 profesionales –equitativamente divididos entre médicos y enfermeros– actuantes en dos Servicios de Urgencias del Sur de Brasil. Datos recolectados de octubre 2016 a febrero 2017 mediante entrevistas. Resultados: Se identifi có la existencia de una cultura social de exclusión familiar, ampliamente difundida y practicada por los profesionales. Igualmente, a veces, las familias permanecen con sus seres queridos en el Servicio de Urgencias, dado que los profesionales analizan y deciden “caso por caso”, considerando diferentes aspectos a lo largo del proceso de atención. Conclusión: Para médicos y enfermeros, múltiples aspectos se relacionan con la determinación de la presencia familiar durante la atención de urgencia. Por ello, no es aconsejable una directiva única sobre presencia familiar. En realidad, se sugiere que cada unidad de salud elabore sus protocolos considerando sus propias características