Increased risk of the abdominal aortic aneurysm in carriers of the MTHFR 677T allele

Abstract. Abdominal aortic aneurysm (AAA) presents itself as a progressive dilation of the abdominal aorta, leading -if untreated -to rupture. It is a common disease of the elderly, with a complex etiology. Several genetic, biochemical and environmental factors are recognized as relevant for the pathogenesis of AAA. We determined the polymorphism of the MTHFR (methylenetetrahydrofolate reductase) gene within the fourth exon (C677T) in 63 patients with AAA and compared it to that in 75 subjects of the population sample. The frequencies of the C/C, C/T and T/T genotypes were 65%, 27%, and 8% in the population sample and 33%, 60%, and 6% in the patients. This corresponds to a 4.4-fold greater risk of AAA in subjects who have the 677C/T variant of MTHFR, as compared with those who are 677C/C (p<0.0001; 95% CI=2.11-9.34). The frequency of allele MTHFR 677T in patients (0.37) was higher than in the population sample (0.21; p < 0.007). This association between the common allele of the MTHFR gene -MTHFR 677T -and the development of AAA suggests that elevated homocysteine (Hcy) may disturb the function of the aortic wall. The disturbance may involve enhancement of elastin degradation, the process enhanced by mild hyperhomocysteinemia in minipigs. The magnitude of this effect, which refers to the AAA patients unselected for familial occurrence, indicates that the disturbance of aortic wall physiology caused by the presence of the MTHFR 677T allele is greater than the effect of the earlier described allele disequilibrium at the polymorphic alleles of the PAI1 (plasminogen activator inhibitor 1) gene seen only in familial cases of AAA

Molecular Gas in the Host Galaxy of a Quasar at Redshift z=6.42

Observations of the molecular gas phase in quasar host galaxies provide fundamental constraints on galaxy evolution at the highest redshifts. Molecular gas is the material out of which stars form; it can be traced by spectral line emission of carbon--monoxide (CO). To date, CO emission has been detected in more than a dozen quasar host galaxies with redshifts (z) larger 2, the record holder being at z=4.69. At these distances the CO lines are shifted to longer wavelengths, enabling their observation with sensitive radio and millimetre interferometers. Here we present the discovery of CO emission toward the quasar SDSS J114816.64+525150.3 (hereafter J1148+5251) at a redshift of z=6.42, when the universe was only 1/16 of its present age. This is the first detection of molecular gas at the end of cosmic reionization. The presence of large amounts of molecular gas (M(H_2)=2.2e10 M_sun) in an object at this time demonstrates that heavy element enriched molecular gas can be generated rapidly in the earliest galaxies.Comment: 12 pages, 2 figures. To appear in Nature, July, 200

The distinctiveness of employment relations within multinationals: political games and social compromises within multinationals’ subsidiaries in Germany and Belgium

This work makes a theoretical contribution to our understanding of the strategic mechanisms that enable subsidiary management and union agency to exploit ambiguities in the subnational competitive context impacting labour flexibility-security concerns. In so doing, the article contributes to the distinctiveness of employment relations through scrutiny of the internal regime competition that fosters political games in MNCs. Studying the dynamics, we identify the set of structuring conditions governing political games, and explain why some workplace regimes generate social compromises whilst others do not. We reveal a set of strategic conditions (i.e. technology, embeddedness and MNC control) upon which compromise is built in six German and Belgian subsidiaries of four MNCs. Our analysis suggests that subsidiary control modes through expatriates and local embeddedness act as key mechanisms through which the effects of wider strategic drivers influence the form of social compromise

Measurement of Scintillation and Ionization Yield and Scintillation Pulse Shape from Nuclear Recoils in Liquid Argon

We have measured the scintillation and ionization yield of recoiling nuclei in liquid argon as a function of applied electric field by exposing a dual-phase liquid argon time projection chamber (LAr-TPC) to a low energy pulsed narrow band neutron beam produced at the Notre Dame Institute for Structure and Nuclear Astrophysics. Liquid scintillation counters were arranged to detect and identify neutrons scattered in the TPC and to select the energy of the recoiling nuclei. We report measurements of the scintillation yields for nuclear recoils with energies from 10.3 to 57.3 keV and for median applied electric fields from 0 to 970 V/cm. For the ionization yields, we report measurements from 16.9 to 57.3 keV and for electric fields from 96.4 to 486 V/cm. We also report the observation of an anticorrelation between scintillation and ionization from nuclear recoils, which is similar to the anticorrelation between scintillation and ionization from electron recoils. Assuming that the energy loss partitions into excitons and ion pairs from $^{83m}$Kr internal conversion electrons is comparable to that from $^{207}$Bi conversion electrons, we obtained the numbers of excitons ($N_{ex}$) and ion pairs ($N_i$) and their ratio ($N_{ex}/N_i$) produced by nuclear recoils from 16.9 to 57.3 keV. Motivated by arguments suggesting direction sensitivity in LAr-TPC signals due to columnar recombination, a comparison of the light and charge yield of recoils parallel and perpendicular to the applied electric field is presented for the first time.Comment: v2 to reflect published versio

Keeping vigil over the profession: a grounded theory of the context of nurse anaesthesia practice

<p>Abstract</p> <p>Background</p> <p>Nurse anaesthetists in the US have faced continued, repeated challenges to their profession. Regardless, they have met these challenges and have established themselves as major anaesthesia care providers. In this paper we address the research question: How do certified registered nurse anaesthetists (CRNAs) manage the socio-political context in which they provide care for their patients?</p> <p>Methods</p> <p>Grounded theory was used to explore how nurse anaesthetists protect and promote their profession. Purposive, snowball, and theoretical sampling was used and data were collected through participant observation and interviews conducted at a conference of the professional association, an educational program, by telephone, email exchanges, and time spent in operating rooms and an outpatient surgical clinic. Analysis included coding at increasingly abstract levels and constant comparison.</p> <p>Results</p> <p>The basic social process identified was Keeping Vigil Over the Profession, which explains how nurse anaesthetists protect and promote their profession. It is comprised of three contextual categories: Establishing Public Credibility through regulatory and educational standards, Political Vigilance and taking action in governmental and policy arenas, and Tending the Flock through a continuous information loop between local and administrative/political levels.</p> <p>Conclusions</p> <p>From our study of the context of nurse anaesthesia practice, it is clear that CRNAs are dedicated to protecting their ability to provide high quality patient care by maintaining constant vigilance over their profession.</p

Usability evaluation of a clinical decision support tool for osteoporosis disease management

<p>Abstract</p> <p>Background</p> <p>Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems. Although guidelines are available, patients are not receiving appropriate diagnostic testing or treatment. Findings from a systematic review of osteoporosis interventions and a series of focus groups were used to develop a functional multifaceted tool that can support clinical decision-making in osteoporosis disease management at the point of care. The objective of our study was to assess how well the prototype met functional goals and usability needs.</p> <p>Methods</p> <p>We conducted a usability study for each component of the tool--the Best Practice Recommendation Prompt (BestPROMPT), the Risk Assessment Questionnaire (RAQ), and the Customised Osteoporosis Education (COPE) sheet--using the framework described by Kushniruk and Patel. All studies consisted of one-on-one sessions with a moderator using a standardised worksheet. Sessions were audio- and video-taped and transcribed verbatim. Data analysis consisted of a combination of qualitative and quantitative analyses.</p> <p>Results</p> <p>In study 1, physicians liked that the BestPROMPT can provide customised recommendations based on risk factors identified from the RAQ. Barriers included lack of time to use the tool, the need to alter clinic workflow to enable point-of-care use, and that the tool may disrupt the real reason for the visit. In study 2, patients completed the RAQ in a mean of 6 minutes, 35 seconds. Of the 42 critical incidents, 60% were navigational and most occurred when the first nine participants were using the stylus pen; no critical incidents were observed with the last six participants that used the touch screen. Patients thought that the RAQ questions were easy to read and understand, but they found it difficult to initiate the questionnaire. Suggestions for improvement included improving aspects of the interface and navigation. The results of study 3 showed that most patients were able to understand and describe sections of the COPE sheet, and all considered discussing the information with their physicians. Suggestions for improvement included simplifying the language and improving the layout.</p> <p>Conclusions</p> <p>Findings from the three studies informed changes to the tool and confirmed the importance of usability testing on all end users to reduce errors, and as an important step in the development process of knowledge translation interventions.</p

Validity of a self-reported measure of familial history of obesity

<p>Abstract</p> <p>Background</p> <p>Familial history information could be useful in clinical practice. However, little is known about the accuracy of self-reported familial history, particularly self-reported familial history of obesity (FHO).</p> <p>Methods</p> <p>Two cross-sectional studies were conducted. The aims of study 1 was to compare self-reported and objectively measured weight and height whereas the aims of study 2 were to examine the relationship between the weight and height estimations reported by the study participants and the values provided by their family members as well as the validity of a self-reported measure of FHO. Study 1 was conducted between 2004 and 2006 among 617 subjects and study 2 was conducted in 2006 among 78 participants.</p> <p>Results</p> <p>In both studies, weight and height reported by the participants were significantly correlated with their measured values (study 1: r = 0.98 and 0.98; study 2: r = 0.99 and 0.97 respectively; p < 0.0001). Estimates of weight and height for family members provided by the study participants were strongly correlated with values reported by each family member (r = 0.96 and 0.95, respectively; p < 0.0001). Substantial agreement between the FHO reported by the participants and the one obtained by calculating the BMI of each family members was observed (kappa = 0.72; p < 0.0001). Sensitivity (90.5%), specificity (82.6%), positive (82.6%) and negative (90.5%) predictive values of FHO were very good.</p> <p>Conclusion</p> <p>A self-reported measure of FHO is valid, suggesting that individuals are able to detect the presence or the absence of obesity in their first-degree family members.</p

Social representations of diagnosis in the consultation

Observations of physiotherapy consultations and qualitative interviews with patients were conducted to explore the clinical explanation for sciatic pain. We report three themes which illustrate the contested and negotiated order of the clinical explanation: anchoring, resistance and normalisation. We show using the theory of social representations how the social order in the physiotherapy consultation is maintained, contested and rearticulated. We highlight the importance of agency in patients’ ability to resist the clinical explanation and in turn shape the clinical discourse within the consultation. Social representations offer insights into how the world is viewed by different individuals, in our case physiotherapists and patients with sciatic pain symptoms. The negotiation about the diagnosis reveals the malleable and socially constructed nature of pain and the meaning making process underpinning it. The study has implications for understanding inequalities in the consultation and the key ingredients of consensus

Continuity and change?: Exploring reactions to a guided self-management intervention in a randomised controlled trial for IBS with reference to prior experience of managing a long term condition

Self-care interventions are promoted as effective strategies for improving the quality of life and health outcomes for individuals with long-term health conditions. Outcome measures used in evaluations using Randomised Controlled Trials (RCTs) are not designed to consider patients' prior management strategies and experience of illness. Yet the experience of illness literature suggests that adjusting to living with chronic illness, together with broader contextual influences, are likely to be relevant to understanding responses to self-management initiatives. Using group and individual interview data we attempt to illuminate the transposition of IBS from a condition unsatisfactorily managed by medicine to one successfully managed within the life worlds of individuals. If routine embedding of complex interventions depends on the accomplishment of integration and workability in patients' everyday lives then the design and evaluation of such interventions should view participation as part of a process of continuity as well as change. Responses to formal self-management can be extended beyond psychological and other quantitatively measured outcomes. A useful addendum to trial outcomes for self-management education is an understanding of change as being inextricably linked to people's previous attempts to, and experience of, managing long-term conditions. We suggest that the benefits of understanding the prior experience of managing illness and contact with health services include the acceptability and workability of complex interventions in patients' everyday lives

Development of a prototype clinical decision support tool for osteoporosis disease management: a qualitative study of focus groups

<p>Abstract</p> <p>Background</p> <p>Osteoporosis affects over 200 million people worldwide, and represents a significant cost burden. Although guidelines are available for best practice in osteoporosis, evidence indicates that patients are not receiving appropriate diagnostic testing or treatment according to guidelines. The use of clinical decision support systems (CDSSs) may be one solution because they can facilitate knowledge translation by providing high-quality evidence at the point of care. Findings from a systematic review of osteoporosis interventions and consultation with clinical and human factors engineering experts were used to develop a conceptual model of an osteoporosis tool. We conducted a qualitative study of focus groups to better understand physicians' perceptions of CDSSs and to transform the conceptual osteoporosis tool into a functional prototype that can support clinical decision making in osteoporosis disease management at the point of care.</p> <p>Methods</p> <p>The conceptual design of the osteoporosis tool was tested in 4 progressive focus groups with family physicians and general internists. An iterative strategy was used to qualitatively explore the experiences of physicians with CDSSs; and to find out what features, functions, and evidence should be included in a working prototype. Focus groups were conducted using a semi-structured interview guide using an iterative process where results of the first focus group informed changes to the questions for subsequent focus groups and to the conceptual tool design. Transcripts were transcribed verbatim and analyzed using grounded theory methodology.</p> <p>Results</p> <p>Of the 3 broad categories of themes that were identified, major barriers related to the accuracy and feasibility of extracting bone mineral density test results and medications from the risk assessment questionnaire; using an electronic input device such as a Tablet PC in the waiting room; and the importance of including well-balanced information in the patient education component of the osteoporosis tool. Suggestions for modifying the tool included the addition of a percentile graph showing patients' 10-year risk for osteoporosis or fractures, and ensuring that the tool takes no more than 5 minutes to complete.</p> <p>Conclusions</p> <p>Focus group data revealed the facilitators and barriers to using the osteoporosis tool at the point of care so that it can be optimized to aid physicians in their clinical decision making.</p