The individual risk for incidents in critical patients is high. Many incidents did not harm patients, some caused damage and a few were related to the patient's death. Most incidents were considered avoidable.
The river Jarama is a medium-sinuosity meandering river with gravel bedload. Throughout the Quaternary it developed a large number of terraces in a repetitive sequence of aggradation-stability-degradationstability stages, which are studied in the middle reach of the river, applying geomorphological and sedimentological methods, as well as kadiocarbon dating techniques. The Upper Terrace System of earliest Pleistocene to mid Pleistocene age forms isolated fragments vertically disconnected and colluviated, and their sequential distribution of facies implies lateral shifting of channels and a welldeveloped flood plain. The Middle Terrace System of mid-to-late Pleistocene age has differentiated levels in the upstream reaches while downstream they condense giving a thick multi-episodic series, corresponding to the tectonic tilting of the basin. Classical point bar fining-upward sequences of a medium-to high-sinuosity river (with gravels and sands as bedload) are clearly differentiated in them. A major degradation stage follows this group of terraces, with an incision of up to 30 m. Then, during a relatively long period of stability, a forest of riparian species developed, prior to the last aggradational stage of the Lower Terrace System. The aggradation resulted in a fining-upward sequence where lateral accretion is clearly visible in the gravels, due to migration of the medium-to low-sinuosity river. Sedimentation continued and was active up to the 1950s, but since then, intense anthropogenic modifications led to renewed incision of the river. Terra Nova, 6,465475, 1994.
BackgroundAdalimumab is a monoclonal antibody indicated in immunomediate inflammatory diseases for subcutaneous administration by two different devices: pre-filled syringe and auto-injection pen.PurposeTo assess injection-site pain, the ease of use and patient preference between two delivery systems of adalimumab.Material and methodsPatients were enrolled in an open-label, single-arm, sequential trial from March 2017 to September 2017.Inclusion criteriaAt least 6 months from the beginning of treatment with adalimumab pre–filled syringe and self–administration.Informed consent had to be signed (Ethics committee approval: EC1061; Protocol Number: ADAP2017).Two visits separated by an interval of 2 months were performed.Patients were informed about the change of device from pre-filled syringe to pen in Visit 1.To evaluate the ease of use, a validated questionnaire was performed. The questionnaire consisted of 15 questions about device design, inconvenients of self-administration, long injection time, handling and technique of administration (Likert-type scale: 1=very strongly disagree; 7=very strongly agree). Answers≥5 were considered acceptable (Visit 1: Syringe; Visit 2: Pen).Patients rated their pain on a visual analogue scale (VAS) (0=none, 10=the worst pain) (Visit 1: Syringe; Visit 2: Pen).Preference between devices was evaluated in Visit 2 by a single question with three possible answers (Pen/Syringe/Indifferent).Sex, birth date, diagnosis and duration of treatment were recorded. STATA® was used for statistical analysis.ResultsTwenty-seven patients were analysed:Males (67.7%).Median age: 43 years (18–73).Diagnoses: psoriasis (33.3%); spondylitis (22.2%); Crohn’s disease (40.8%); psoriatic arthritis (3.7%).Median treatment duration: 2.9 years (0.5–8.7).A reduction in injection-site pain was observed after changing the device from pre-filled syringe to pen (Mean difference: −3.04 (CI 95%–4.21 to −1.86; p<0.001).Ease of use (% acceptable answers):Device design: Syringe: 81.5%; Pen: 100%.Any inconvenience during self–administration: Syringe: 40.7%; Pen: 14.8%.Long injection time: Syringe: 29.6%; Pen: 14.8%.Ease handling: Syringe: 63.0%; Pen: 85.2%.Ease technique of administration: Syringe: 77.8%; Pen: 96.3%.Patient preferences:Pen: 81.5% (22/27).Syringe: 7.4% (2/27).Indifferent: 11.1% (3/27).ConclusionAuto-injection pen has proved superior to pre-filled syringe in injection-site pain, the ease of use and patient preference.Limitations: the pen does not contain citrate, a pain-related excipient.No conflict of interest
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