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Introduktion/Bakgrund: För att systematiskt kartlägga palliativa patienters symtom så rekommenderas att vårdpersonal använder sig av bedömningsinstrument. Ett av de rekommenderade bedömningsinstrumenten i Nationell vårdplan för palliativ vård, är Edmonton Symptom Assessment System, ESAS. Syfte: Syftet var att beskriva effekten som användningen av ESAS har vid palliativ vård. Metod: Denna litteraturstudie har genomförts i enlighet med Polit och Becks (2017) nio steg. Databaserna PubMed och CINAHL användes för att inhämta data som sedan kvalitetsgranskades enligt Polit och Becks (2017) granskningsmallar. Induktiv ansats användes. Studiens resultat utgjordes av 13 artiklar som i sin tur ledde till fyra kategorier. Resultat: ESAS kunde identifiera flera symtom, medförde att symtom inte förbisågs och påvisade symtomkluster. Instrumentet var ett samtalsstöd och medverkade till en mer personcentrerad vård. ESAS träffsäkra symtombedömning leder till mer personcentrerad vård. Fyra kategorier identifierades; “Öppnar upp för samtal,” “Personcentrerad symtombedömning,” “Stöd vid symtomhantering och fördelning av resurser” och “Förbättrad livskvalitet.” Slutsats: ESAS erbjuder systematik vid bedömningar, vid uppföljning av symtom samt vid utvärdering av interventioner. Användningen av ESAS minskar risken för att förbise symtom. Bedömningar leder till tidigare implementering att palliativa behandlingar samt reducerar risken att utveckla långvariga problematiska symtom. Bedömningar med ESAS kan leda till en mer skräddarsydd symtomhantering och ökad livskvalitet.

In 2004, President Bush addressed the nation and presented NASA's new vision for space exploration. This vision included the completion of the International Space Station, the retirement of the Space Shuttle, the development of a new crew exploration vehicle, and the return of humans to the moon by 2020. NASA's Exploration Systems Architecture Study (ESAS) produced a transportation architecture for returning humans to the moon affordably and safely. This architecture requires the development of two new Shuttle-derived launch vehicles, an in-space transportation vehicle, a lunar descent and landing vehicle, and a crew exploration vehicle for human transportation. The development of an in-space propellant transfer capability could greatly improve the performance, cost, mission success, and mission extensibility of the overall lunar architecture, providing a more optimal solution for future exploration missions. The work done in this thesis will analyze how this new capability could affect the current NASA lunar architecture, and will outline the value proposition of propellant refueling to NASA. A value proposition for propellant refueling will be provided to establish why an architecture that utilizes propellant refueling is better equipped to meet the goals of the Vision for Space Exploration than the current baseline design. The primary goal addressed in this research is the development of a sustainable and affordable exploration program. The value proposition will outline various refueling strategies that can be used to improve each of the architecture Figures of Merit. These include a decrease in the Life Cycle Cost of both the lunar and Mars exploration campaigns, the ability to more than double the mission payload that can be delivered to the lunar surface during cargo missions, improving the probability of successfully completing each lunar mission, decreasing the uncertainty, and therefore risk, experienced during the development process, and improving the extensibility of the exploration architecture by utilizing a greater portion of the lunar program for future crewed mission. The ability to improve these Figures of Merit provides NASA with a more valuable architecture because NASA is able to achieve a greater return on its large initial investment.

Introdução. Embora existam diferentes estratégias para a prestação de cuidados paliativos ao paciente com câncer, pouco se conhece sobre a efetividade desses modelos. Objetivos. Comparar os efeitos da equipe de cuidado paliativo integrada ao cuidado tradicional com o cuidado tradicional sozinho no controle de sintomas em paciente com câncer avançado hospitalizado. Método. Estudo longitudinal composto por dois grupos não randomizados. 73 pacientes foram admitidos para a equipe de cuidado paliativo integrada ao cuidado tradicional (Grupo ECP) e comparados a 75 atendidos no modelo de cuidado tradicional (Grupo CT). Os sintomas foram avaliados pela Escala de Avaliação de Sintomas de Edmonton (ESAS), a satisfação por escala numérica verbal (0-10), a funcionalidade pela Escala de Desempenho Funcional Físico Karnofsky (KPS) e a adequação analgésica pelo Índice de Manejo da Dor (IMD). Os pacientes foram avaliados na admissão, após 24 e 48 horas. O desfecho primário foi a melhora clinica significativa de 2 pontos na intensidade da dor e da náusea em 48 horas, comparados com a admissão. Os dados demográficos, os sintomas e sua redução foram comparados entre os Grupos pelo Teste Exato de Fisher ou Mann Whitney. O Teste de Wilcoxon analisou alterações dos sintomas intragrupos. A regressão múltipla de Poisson controlou fatores de confusão para a melhora do sintoma. O nível de significância adotado foi de 5%. Resultados. A prevalência de sintomas foi alta em ambos os grupos: no Grupo ECP a variação foi de 43.8% (depressão) a 87.7% (sensação de bem estar), e no Grupo CT, de 24% (dispneia) a 85.5% (dor). A magnitude dos sintomas, pelo escore da mediana, foi importante em ambos os Grupos: na admissão, no Grupo ECP, variou entre 5.5 (sensação de bem estar) a 8.0 (ansiedade, apetite, constipação e tristeza), e no Grupo CT, variou de 6.0 (sensação de bem estar e dispneia) a 9.0 (perda do apetite). A mediana de sobrecarga de sintomas, avaliada pelo ESAS, foi de 50.0 em ambos os grupos. Na análise de 24 horas (intragrupo), no Grupo ECP cinco sintomas (dor, náusea, perda do apetite, dispneia, prejuízo do sono) e sobrecarga de sintomas foram reduzidos (p<0.05), enquanto no Grupo Grupo CT três sintomas (dor, náusea e prejuízo do sono) foram reduzidos (p<0.05). Na análise de 48 horas (intragrupo), dez sintomas e sobrecarga de sintomas no Grupo ECP foram reduzidos (p<0.05), enquanto quatro sintomas melhoraram no Grupo CT (p<0.05). A regressão múltipla mostrou que a dor (RR= 2.2 [IC95%1.27-3.81]) e bem estar (RR=4.6 [IC95% 1.34-15.88]) reduziram 2 pontos e foi favorável somente no Grupo ECP. Verificou-se melhor adequação da analgesia no Grupo ECP comparado ao CT (p<0.05). A satisfação do doente foi elevada e similar em ambos os grupos. Conclusão. Os doentes de ambos os grupos mostraram grande sobrecarga de sintomas e somente o sintoma dor foi adequadamente controlado pelo Grupo ECP. Os resultados encontrados demandam análise de fatores da estratégia de tratamento que possam melhorar a efetividade das ações, como avaliação sistematizada dos sintomas em curtos períodos e estratégias que permitam ajuste rápido da terapêutica quando necessário. / Introduction. Although there are many different strategies for provision of palliative care to patients with cancer, little is known about the effectiveness of these modalities. Objective.To compare the effects of a palliative care team integrated with traditional care to traditional care alone on symptom control in inpatients with advanced cancer. Method. Longitudinal study composed of two non-randomized groups. Seventy-three patients were admitted to the palliative care team integrated to traditional care (PCT Group) and compared to 75 patients treated in the traditional care model (TC Group). Symptoms were assessed by the Edmonton Symptom Assessment Scale (ESAS), satisfaction with treatment by the verbal numeric scale (0-10), performance status by the Karnofsky Performance Status Scale (KPS) and analgesic adequacy by the Pain Management Index (PMI). Patients were assessed upon admission, and after 24 and 48 hours. The primary outcomes were significant clinical improvements of 2 points in pain intensity and nausea in 48 hours, compared to admission. The demographic data, symptoms, and reduction in symptoms were compared between the groups by using Fisher\'s or Mann Whitneys Exact Tests. The Wilcoxon test examined the intragroup alteration of symptoms. The Poisson multiple regression controlled for confounding factors of improvement in symptoms. A p-value of 0.05 indicated statistical significance for all analyses. Results. The prevalence of symptoms at admission was high in both groups. In the PCT Group, it ranged from 43.8% (depression) to 87.7% (loss of well-being) and, in the TC Group, it ranged from 24% (dyspnoea) to 85.5% (pain). The magnitude of median score of symptoms was substantial in both groups: at admission for the PCT group, it ranged from 5.5 (sense of well-being) to 8.0 (anxiety, appetite, constipation, sadness), while for the TC Group, it ranged from 6.0 (sense of well-being and dyspnoea) to 9.0 (loss of appetite). The median score of the symptom burden assessed by ESAS was 50.0 in both groups. In 24 hours (intragroup), the PCT Group had significant reductions in intensity of five symptoms (pain, nausea, loss of appetite, dyspnoea, and sleep disturbance) and symptom burden, while the TC Group had significant reductions in intensity of three symptoms (pain, nausea, and sleep disturbance). In 48 hours (intragroup), the PCT Group had significant reductions in intensity of ten symptoms and symptom burden and while the TC Group had significant improve in intensity of four symptoms. Multiple regression analysis showed that pain (RR = 2.2 [95% CI 1.27-3.81]) and loss of well-being (RR = 4.6 [95% CI 1.34-15.88]) were reduced by two points and it was significantly more favourable only in the PCT Group. The PMI revealed better adequacy of analgesia in the PCT Group. Satisfaction was high and similar in both groups. Conclusion. Patients with advanced cancer in both groups showed a pronounced burden of symptoms and only pain was properly controlled in the PCT Group. The results indicate that factors that can improve treatment strategy should be implemented to improve the effectiveness of clinical assistance. Examples of factors that can improve treatment are frequent and systematic assessment of symptoms in short periods, and strategies that allow for timely adjustment of therapy when necessary.

Introdução. Embora existam diferentes estratégias para a prestação de cuidados paliativos ao paciente com câncer, pouco se conhece sobre a efetividade desses modelos. Objetivos. Comparar os efeitos da equipe de cuidado paliativo integrada ao cuidado tradicional com o cuidado tradicional sozinho no controle de sintomas em paciente com câncer avançado hospitalizado. Método. Estudo longitudinal composto por dois grupos não randomizados. 73 pacientes foram admitidos para a equipe de cuidado paliativo integrada ao cuidado tradicional (Grupo ECP) e comparados a 75 atendidos no modelo de cuidado tradicional (Grupo CT). Os sintomas foram avaliados pela Escala de Avaliação de Sintomas de Edmonton (ESAS), a satisfação por escala numérica verbal (0-10), a funcionalidade pela Escala de Desempenho Funcional Físico Karnofsky (KPS) e a adequação analgésica pelo Índice de Manejo da Dor (IMD). Os pacientes foram avaliados na admissão, após 24 e 48 horas. O desfecho primário foi a melhora clinica significativa de 2 pontos na intensidade da dor e da náusea em 48 horas, comparados com a admissão. Os dados demográficos, os sintomas e sua redução foram comparados entre os Grupos pelo Teste Exato de Fisher ou Mann Whitney. O Teste de Wilcoxon analisou alterações dos sintomas intragrupos. A regressão múltipla de Poisson controlou fatores de confusão para a melhora do sintoma. O nível de significância adotado foi de 5%. Resultados. A prevalência de sintomas foi alta em ambos os grupos: no Grupo ECP a variação foi de 43.8% (depressão) a 87.7% (sensação de bem estar), e no Grupo CT, de 24% (dispneia) a 85.5% (dor). A magnitude dos sintomas, pelo escore da mediana, foi importante em ambos os Grupos: na admissão, no Grupo ECP, variou entre 5.5 (sensação de bem estar) a 8.0 (ansiedade, apetite, constipação e tristeza), e no Grupo CT, variou de 6.0 (sensação de bem estar e dispneia) a 9.0 (perda do apetite). A mediana de sobrecarga de sintomas, avaliada pelo ESAS, foi de 50.0 em ambos os grupos. Na análise de 24 horas (intragrupo), no Grupo ECP cinco sintomas (dor, náusea, perda do apetite, dispneia, prejuízo do sono) e sobrecarga de sintomas foram reduzidos (p<0.05), enquanto no Grupo Grupo CT três sintomas (dor, náusea e prejuízo do sono) foram reduzidos (p<0.05). Na análise de 48 horas (intragrupo), dez sintomas e sobrecarga de sintomas no Grupo ECP foram reduzidos (p<0.05), enquanto quatro sintomas melhoraram no Grupo CT (p<0.05). A regressão múltipla mostrou que a dor (RR= 2.2 [IC95%1.27-3.81]) e bem estar (RR=4.6 [IC95% 1.34-15.88]) reduziram 2 pontos e foi favorável somente no Grupo ECP. Verificou-se melhor adequação da analgesia no Grupo ECP comparado ao CT (p<0.05). A satisfação do doente foi elevada e similar em ambos os grupos. Conclusão. Os doentes de ambos os grupos mostraram grande sobrecarga de sintomas e somente o sintoma dor foi adequadamente controlado pelo Grupo ECP. Os resultados encontrados demandam análise de fatores da estratégia de tratamento que possam melhorar a efetividade das ações, como avaliação sistematizada dos sintomas em curtos períodos e estratégias que permitam ajuste rápido da terapêutica quando necessário. / Introduction. Although there are many different strategies for provision of palliative care to patients with cancer, little is known about the effectiveness of these modalities. Objective.To compare the effects of a palliative care team integrated with traditional care to traditional care alone on symptom control in inpatients with advanced cancer. Method. Longitudinal study composed of two non-randomized groups. Seventy-three patients were admitted to the palliative care team integrated to traditional care (PCT Group) and compared to 75 patients treated in the traditional care model (TC Group). Symptoms were assessed by the Edmonton Symptom Assessment Scale (ESAS), satisfaction with treatment by the verbal numeric scale (0-10), performance status by the Karnofsky Performance Status Scale (KPS) and analgesic adequacy by the Pain Management Index (PMI). Patients were assessed upon admission, and after 24 and 48 hours. The primary outcomes were significant clinical improvements of 2 points in pain intensity and nausea in 48 hours, compared to admission. The demographic data, symptoms, and reduction in symptoms were compared between the groups by using Fisher\'s or Mann Whitneys Exact Tests. The Wilcoxon test examined the intragroup alteration of symptoms. The Poisson multiple regression controlled for confounding factors of improvement in symptoms. A p-value of 0.05 indicated statistical significance for all analyses. Results. The prevalence of symptoms at admission was high in both groups. In the PCT Group, it ranged from 43.8% (depression) to 87.7% (loss of well-being) and, in the TC Group, it ranged from 24% (dyspnoea) to 85.5% (pain). The magnitude of median score of symptoms was substantial in both groups: at admission for the PCT group, it ranged from 5.5 (sense of well-being) to 8.0 (anxiety, appetite, constipation, sadness), while for the TC Group, it ranged from 6.0 (sense of well-being and dyspnoea) to 9.0 (loss of appetite). The median score of the symptom burden assessed by ESAS was 50.0 in both groups. In 24 hours (intragroup), the PCT Group had significant reductions in intensity of five symptoms (pain, nausea, loss of appetite, dyspnoea, and sleep disturbance) and symptom burden, while the TC Group had significant reductions in intensity of three symptoms (pain, nausea, and sleep disturbance). In 48 hours (intragroup), the PCT Group had significant reductions in intensity of ten symptoms and symptom burden and while the TC Group had significant improve in intensity of four symptoms. Multiple regression analysis showed that pain (RR = 2.2 [95% CI 1.27-3.81]) and loss of well-being (RR = 4.6 [95% CI 1.34-15.88]) were reduced by two points and it was significantly more favourable only in the PCT Group. The PMI revealed better adequacy of analgesia in the PCT Group. Satisfaction was high and similar in both groups. Conclusion. Patients with advanced cancer in both groups showed a pronounced burden of symptoms and only pain was properly controlled in the PCT Group. The results indicate that factors that can improve treatment strategy should be implemented to improve the effectiveness of clinical assistance. Examples of factors that can improve treatment are frequent and systematic assessment of symptoms in short periods, and strategies that allow for timely adjustment of therapy when necessary.

A broadside radiating, linearly polarized, electrically small Huygens source antenna system that has a large impedance bandwidth is reported. The bandwidth performance is facilitated by embedding non-Foster components into the near-field resonant parasitic elements of this metamaterial-inspired antenna. High-quality and stable radiation performance characteristics are achieved over the entire operational bandwidth. When the ideal non-Foster components are introduced, the simulated impedance bandwidth witnesses approximately a 17-fold enhancement over the passive case. Within this -10-dB bandwidth, its maximum realized gain, radiation efficiency, and front-to-back ratio (FTBR) are, respectively, 4.00 dB, 88%, and 26.95 dB. When the anticipated actual negative impedance convertor circuits are incorporated, the impedance bandwidth still sustains more than a 10-fold enhancement. The peak realized gain, radiation efficiency, and FTBR values are, respectively, 3.74 dB, 80%, and 28.01 dB, which are very comparable to the ideal values.

A pattern-reconfigurable, low-profile, efficient, electrically small, near-field resonant parasitic (NFRP), Huygens source antenna is presented. The design incorporates both electric and magnetic NFRP elements. The electric ones are made reconfigurable by the inclusion of a set of p-i-n diodes. By arranging these electric and magnetic NFRP elements properly, a set of three Huygens sources are attained, each covering a 120 degrees sector. Pattern reconfigurability is obtained by switching the diodes on or off; it encompasses the entire 360 degrees azimuth range. A prototype was fabricated and tested. The numerical and experimental studies are in good agreement. The experimental results indicate that in each of its instantaneous states at f(0) = 1.564 GHz, the antenna provides uniform peak realized gains, front-toback ratios, and radiation efficiencies, respectively, as high as 3.55 dBi, 17.5 dB, and 84.9%, even though it is electrically small: ka = 0.92, and low profile: 0.05 lambda(0).

In January 2005, President Bush announced the Vision for Space Exploration. This vision involved a progressive expansion of human capabilities beyond Low Earth Orbit beginning with a return to the moon no later than 2020. Current design processes utilized to meet this vision employ performance based trade studies to determine the lowest cost, highest reliability solution. The methodology implemented in this dissertation focuses on a concurrent evaluation of the performance, cost, and reliabilities of lunar architectures. This process directly addresses the top level requirements early in the design process and allows the decision maker to evaluate the highest reliability, lowest cost lunar architectures without being distracted by the performance details of the architecture. To achieve this methodology of bringing optimal cost and reliability solutions to the decision maker, parametric performance, cost, and reliability models are created to model each vehicle element. These models were combined using multidisciplinary optimization techniques and response surface equations to create parametric vehicle models which quickly evaluate the performance, reliability, and cost of the vehicles. These parametric models, known as ROSETTA models, combined with a life cycle cost calculator provide the tools necessary to create a lunar architecture simulation. The integration of the tools into an integrated framework that can quickly and accurately evaluate the lunar architectures is presented. This lunar architecture selection tool is verified and validated against the Apollo and ESAS lunar architectures. The results of this lunar architecture selection tool are then combined into a Pareto frontier to guide the decision maker to producing the highest reliability architecture for a given life cycle cost. With this presented methodology, the decision maker can transparently choose a lunar architecture solution based upon the high level design discriminators. This method can achieve significant reductions in life cycle costs (over 40%) keeping the same architecture reliability as a traditional design process. This methodology also allows the decision maker to choose a solution which achieves a significant reduction in failure rate (over 50%) while maintaining the same life cycle costs as the point solution of a traditional design process.