Time trends in statin utilization and coronary mortality in western European countries

Objectives. To determine whether there is a relation between statin utilization and coronary heart disease (CHD) mortality in populations with different levels of coronary risk, and whether the relation changes over time. Design. Ecological study using national databases on dispensed medicines and mortality rates. Setting. Western European countries with similar public health systems. Main outcome measures. Population CHD mortality rates (rate/100.000) as a proxy for population coronary risk level, and statin utilization expressed as Defined Daily Dose per one Thousand Inhabitants per Day (DDD/TID), in each country, for each year between 2000 and 2012. Pearson’s correlation coefficients between CHD mortality and statin utilization were calculated. Linear regression analysis was used to assess the relation between changes in CHD mortality and statin utilization over the years. Results. Twelve countries were included in the study. There was a wide range of CHD mortality reduction between the years 2000 and 2012 (from 25.9% in Italy to 57.9% in Denmark) and statin utilization increase (from 121% in Belgium to 1,263% in Denmark). No statistically significant relations were found between CHD mortality rates and statin utilization, nor between changes in CHD and changes in statin utilization in the countries over the years 2000 and 2012. Conclusions. Among the Western European countries studied, the large increase in statin utilization between 2000 and 2012 was not associated with CHD mortality, nor with its rate of change over the years. Factors different from the individual coronary risk, such as population ageing, health authority programs, guidelines, media attention and pharmaceutical industry marketing, may have influenced the large increase in statin utilization. These need to be re-examined with a greater emphasis on prevention strategies

Uppkomsten av strukturella förändringar vid implementering av e-handel

De senaste åren har den internetbaserade försäljningen ökat i Sverige. För företag inom detaljhandeln innebär den geografiska begränsningen ett hinder för fortsatt tillväxt. E-handel möjliggör tillgänglighet till en större marknad, vilket framförallt gynnar mindre företag. Studiens avsikt är att undersöka om e-handeln har bidragit till strukturella förändringar inom två mindre företag. Totalt har två anställda från två företag i Uppsala- Stockholmsområdet bidragit med empiriskt material. Dessa verkar inom detaljhandelsbranschen med skoförsäljning, på en lokal marknad och genom e-handel. Analysen koncentreras kring SME (små och medelstora företag), då deras bristfälliga resurser i större utsträckning kan medföra behov som inte kan uppfyllas. Metoden som används i undersökningen är en kvalitativ intervju bestående av frågor som baserats på relaterad organisationsteori. Intervjuerna innehöll öppna frågor som kompletterades med följdfrågor. Intervjuobjektens svar analyserades med hjälp av teori inom områdena marknadsföring och organisationsteori. Resultaten från den empiriska undersökningen påvisar en korrelation mellan implementeringen av e-handel och strukturella förändringar. Sambandet klargjordes ytterligare genom de empiriska resultaten som påvisade att en ökad personalstyrka, tillkomna arbetsuppgifter och klara arbetsbeskrivningar, leder till ett större behov av strukturell anpassning. Koordinering, förmedling av rutiner och kommunikation har även ett starkt samband med uppkomna strukturella förändringar. Undersökningen karaktäriseras av ett flertal avgränsningar och en definierad omfattning. Det faktum att studien har genomförts under en kort tidsperiod, samt att fallföretagen är verksamma i en unik kontext, leder till att eventuella generaliseringar bör genomföras med största försiktighet. Studiens resultat samt implikationer kan dock användas i ett större perspektiv, exempelvis då SMEs planerar att etablera en e-handel och vid ytterligare akademisk forskning.This study intends to examine how e-commerce has contributed to structural changes in two small companies. In total, two companies in the Uppsala-Stockholm region contributed with empirical material. Their businesses operate both through physical retail outlets and through e-commerce. Since structural or organisational changes arise when a company establishes e-commerce, this study aims to analyse this process. While previous research has mainly focused on large companies on an international level, this analysis concentrates on SME (Small and Medium Enterprises) with relatively limited resources. The methodology is based on a qualitative interview, consisting of questions based on organisational theory. Interviews are performed with open-ended questions, which are complemented with follow-up questions. The interviewees’ responses to the questions are later analysed using theory from the fields of marketing, change and structure. Results from this empirical study indicate that a correlation could exist between the implementation of e-commerce and structural changes. This research is characterized by several limitations and a refined scope. The study has been conducted over a short period of time and the companies within the study are characterized by a unique context. This leads to a conclusion that any generalization should be made with caution. However, the result and implications of the study can be useful for planning the establishment of e-commerce in SMEs, as well as in further academic research

GPs' decisions on drug treatment for patients with high cholesterol values: A think-aloud study

BACKGROUND: The purpose was to examine how General Practitioners (GPs) use clinical information and rules from guidelines in their decisions on drug treatment for high cholesterol values. METHODS: Twenty GPs were presented with six case vignettes and were instructed to think aloud while successively more information about a case was presented, and finally to decide if a drug should be prescribed or not. The statements were coded for the clinical information to which they referred and for favouring or not favouring prescription. RESULTS: The evaluation of clinical information was compatible with decision-making as a search for reasons or arguments. Lifestyle-related information like smoking and overweight seemed to be evaluated from different perspectives. A patient's smoking favoured treatment for some GPs and disfavoured treatment for others. CONCLUSIONS: The method promised to be useful for understanding why doctors differ in their decisions on the same patient descriptions and why rules from the guidelines are not followed strictly

The role of guidelines and the patient's life-style in GPs' management of hypercholesterolaemia

BACKGROUND: Recent Swedish and joint European guidelines on hyperlipidaemia stress the high coronary risk for patients with already established arterio-sclerotic disease (secondary prevention) or diabetes. For the remaining group, calculation of the ten-year risk for coronary events using the Framingham equation is suggested. There is evidence that use of and adherence to guidelines is incomplete and that tools for risk estimations are seldom used. Intuitive risk estimates are difficult and systematically biased. The purpose of the study was to examine how GPs use knowledge of guidelines in their decisions to recommend or not recommend a cholesterol-lowering drug and the reasons for their decisions. METHODS: Twenty GPs were exposed to six case vignettes presented on a computer. In the course of six screens, successively more information was added to the case. The doctors were instructed to think aloud while processing the cases (Think-Aloud Protocols) and finally to decide for or against drug treatment. After the six cases they were asked to describe how they usually reason when they meet patients with high cholesterol values (Free-Report Protocols). The two sets of protocols were coded for cause-effect relations that were supposed to reflect the doctors' knowledge of guidelines. The Think-Aloud Protocols were also searched for reasons for the decisions to prescribe or not to prescribe. RESULTS: According to the protocols, the GPs were well aware of the importance of previous coronary heart disease and diabetes in their decisions. On the other hand, only a few doctors mentioned other arterio-sclerotic diseases like stroke and peripheral artery disease as variables affecting their decisions. There were several instances when the doctors' decisions apparently deviated from their knowledge of the guidelines. The arguments for the decisions in these cases often concerned aspects of the patient's life-style like smoking or overweight- either as risk-increasing factors or as alternative strategies for intervention. CONCLUSIONS: Coding verbal protocols for knowledge and for decision arguments seems to be a valuable tool for increasing our understanding of how guidelines are used in the on treatment of hypercholesterolaemia. By analysing arguments for treatment decisions it was often possible to understand why departures from the guidelines were made. While the need for decision support is obvious, the current guidelines may be too simple in some respects

Standardizing Evaluation of Patient-Specific 3D Printed Models in Surgical Planning: Development of a Cross-Disciplinary Survey Tool for Physician and Trainee Feedback

Background: 3D printed models are becoming increasingly popular in healthcare as visual and tactile tools to enhance understanding of anatomy and pathology in medical trainee education, provide procedural simulation training, and guide surgical procedures. Patient-specific 3D models are currently being used preoperatively for trainee medical education in planning surgical approaches and intraoperatively to guide decision-making in several specialties. Our study group utilized a modified Delphi process to create a standardized assessment for trainees using patient-specific 3D models as a tool in medical education during pre-surgical planning. Methods: A literature review was conducted to identify survey questions administered to clinicians in published surgical planning studies regarding the use of patient-specific 3D models. A core study team reviewed these questions, removed duplicates, categorized them, mapped them to overarching themes, and, where applicable, modified individual questions into a form generalizable across surgical specialties. The core study panel included a physician, physician-scientist, social scientist, engineer/medical student, and 3D printing lab manager. A modified Delphi process was then used to solicit feedback on the clarity and relevance of the individual questions from an expert panel consisting of 12 physicians from specialties including anesthesiology, emergency medicine, radiology, urology, otolaryngology, and obstetrics/gynecology. When the Radiological Society of North America (RSNA)/American College of Radiology (ACR) 3D Printing Registry Data Dictionary was released, additional survey questions were reviewed. A final cross-disciplinary survey of the utility of 3D printed models in surgical planning medical education was developed. Results: The literature review identified 100 questions previously published in surveys assessing patient-specific 3D models for surgical planning. Following the review, generalization, and mapping of survey questions from these studies, a list of 24 questions was generated for review by the expert study team. Five additional questions were identified in the RSNA/ACR 3D Printing Registry Data Dictionary and included for review. A final questionnaire consisting of 20 questions was developed. Conclusions: As 3D printed models become more common in medical education, the need for standardized assessment is increasingly essential. The standardized questionnaire developed in this study reflects the interests of a variety of stakeholders in patient-specific 3D models across disciplines

Cyclopentenone Isoprostanes Inhibit the Inflammatory Response in Macrophages

Although both inflammation and oxidative stress contribute to the pathogenesis of many disease states, the interaction between the two is poorly understood. Cyclopentenone isoprostanes (IsoPs), highly reactive structural isomers of the bioactive cyclopentenone prostaglandins PGA2 and PGJ2, are formed non-enzymatically as products of oxidative stress in vivo. We have, for the first time, examined the effects of synthetic 15-A2- and 15-J2-IsoPs, two groups of endogenous cyclopentenone IsoPs, on the inflammatory response in RAW264.7 and primary murine macrophages. Cyclopentenone IsoPs potently inhibited lipopolysaccharide-stimulated IkappaB alpha degradation and subsequent NF-kappaB nuclear translocation and transcriptional activity. Expression of inducible nitric-oxide synthase and cyclooxygenase-2 were also inhibited by cyclopentenone IsoPs as was nitrite and prostaglandin production (IC50 approximately 360 and 210 nM, respectively). 15-J2-IsoPs potently activated peroxisome proliferator-activated receptor gamma (PPARgamma) nuclear receptors, whereas 15-A2-IsoP did not, although the anti-inflammatory effects of both molecules were PPARgamma-independent. Interestingly 15-A2-IsoPs induced oxidative stress in RAW cells that was blocked by the antioxidant 4-hydroxy-TEMPO (TEMPOL) or the mitochondrial uncoupler carbonyl cyanide p-(trifluoromethoxy)phenylhydrazone. TEMPOL also abrogated the inhibitory effect of 15-A2-IsoPs on lipopolysaccharide-induced NF-kappaB activation, inducible nitricoxide synthase expression, and nitrite production, suggesting that 15-A2-IsoPs inhibit the NF-kappaB pathway at least partially via a redox-dependent mechanism. 15-J2-IsoP, but not 15-A2-IsoP, also potently induced RAW cell apoptosis again via a PPAR gamma-independent mechanism. These findings suggest that cyclopentenone IsoPs may serve as negative feedback regulators of inflammation and have important implications for defining the role of oxidative stress in the inflammatory response

Detection of New Delhi Metallo-β-Lactamase (Encoded by \u3ci\u3ebla\u3c/i\u3e\u3csub\u3eNDM-1\u3c/sub\u3e) in \u3ci\u3eAcinetobacter schindleri\u3c/i\u3e during Routine Surveillance

A carbapenem-resistant Alcaligenes faecalis strain was isolated from a surveillance swab of a service member injured in Afghanistan. The isolate was positive for blaNDM by real-time PCR. Species identification was reevaluated on three identification systems but was inconclusive. Genome sequencing indicated that the closest relative was Acinetobacter schindleri and that blaNDM-1 was carried on a plasmid that shared \u3e99% identity with one identified in an Acinetobacter lwoffii isolate. The isolate also carried a novel chromosomally encoded class D oxacillinase

Methodological concepts for integrated assessment of agricultural and environmental policies in SEAMLESS-IF

Agricultural and Food Policy, Environmental Economics and Policy, Farm Management, Land Economics/Use,

General practitioners' reasoning when considering the diagnosis heart failure: a think-aloud study

BACKGROUND: Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not easily implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines. METHODS: Think-aloud technique was used. Fifteen general practitioners reasoned about six case vignettes, representing authentic patients with suspected chronic heart failure. Information about each case was added successively in five steps. The general practitioners said their thoughts aloud while reasoning about the probability of the patient having chronic heart failure, and tried to decide about the diagnosis. Arguments for and against chronic heart failure were analysed and compared to recommendations in guidelines. RESULTS: Information about ejection fraction was the most frequent diagnostic argument, followed by information about cardiac enlargement or pulmonary congestion on chest X-ray. However, in a third of the judgement situations, no information about echocardiography was utilized in the general practitioners' diagnostic reasoning. Only three of the 15 doctors used information about a normal electrocardiography as an argument against chronic heart failure. Information about other cardio-vascular diseases was frequently used as a diagnostic argument. CONCLUSIONS: The clinical information was not utilized to the extent recommended in guidelines. Some implications of our study are that 1) general practitioners need more information about how to utilize echocardiography when diagnosing chronic heart failure, 2) guidelines ought to give more importance to information about other cardio-vascular diseases in the diagnostic reasoning, and 3) guidelines ought to treat the topic of diastolic heart failure in a clearer way