How Well Do Medical Students Understand the Consequences of the Debt They Are Accumulating?

No abstract available

Action modelling research for sociotechnical transitions

Transitions are multi-actor, multilevel, multi-factor processes that involve periods of instability that may result in changes to social, political and economic structures. This means that society is faced with a very high level of uncertainty as to the possible pathways of change and the impacts of policy actions. These challenges mean that there is a need to consider not just the structure and theory of analysis, but the ways in which research can reach across policy makers and other transition stakeholders. These two points define a spectrum of engagement for transition research between macro level, policy-oriented transition studies carried out with modelling and simulation and case specific work that involves direct engagement with stakeholders and focuses on local or regional issues, such as urban transitions. A middle of the way approach is action-based research. The research question addressed by this paper is: how can action modelling of sustainability transitions enable stakeholders to address the high level of uncertainty in considering sustainability transitions? The paper explores the potential that lies at the intersection of action research practice, transition research, and transition modelling and simulation. We review current research methods that involve modelling research and stakeholders and identify areas where this combination has something to offer: (i) participatory modelling and organizational change, (ii) expert based modelling for policy making and negotiation, (iii) renewable energy communities, (iv) interactive models for role playing games. We discuss some of the approaches used and draw conclusions for future climate mitigation processes

Predictors associated with mortality of extracorporeal life support therapy for acute heart failure: single-center experience with 679 patients

Background: Extracorporeal life support (ECLS) therapy is increasingly used for cardiac and respiratory support postcardiotomy, refractory cardiogenic shock and cardiopulmonary resuscitation. This study aims to describe in-hospital mortality of patients requiring ECLS, identify independent predictors associated with mortality and analyze changes of mortality over time. Methods: This retrospective study includes all adult ECLS cases at the University Hospital Zurich, a designated ECLS center in Switzerland, in the period 2007 to 2019. Results: ECLS therapy was required in 679 patients (median age 60 years, 27.5% female). In-hospital mortality was 55.5%. Cubic spline interpolation did not detect evidence for a change in mortality over the whole period of 13 years. In-hospital mortality significantly varied between ECLS indications: 70.7% (152/215) for postcardiotomy, 67.9% (108/159) for cardiopulmonary resuscitation, 47.0% (110/234) for refractory cardiogenic shock, and 9.9% (7/71) for lung transplantation and expansive thoracic surgery (P<0.001). Logistic regression modelling showed excellent discrimination in the receiver operating characteristic (ROC) area under the curve (AUC) of 0.89 [95% confidence interval (CI): 0.87-0.92] and identified significant mortality predictors: age, simplified acute physiology score (SAPS) II, as well as new liver failure and each allogenic blood transfusion unit given per day. ECLS after cardiopulmonary resuscitation was associated with significantly higher mortality compared to ECLS for refractory cardiogenic shock. Conclusions: In-hospital mortality of patients treated with ECLS therapy is high. Outcomes have not changed significantly in the observed period. We identified age, SAPS II, new liver failure and each allogenic blood transfusion unit given per day as independent mortality predictors. Knowledge of predictors strongly associated with in-hospital mortality may affect future decisions about ECLS indications and the respective management to use this elaborate therapy more effectively. Keywords: Extracorporeal circulation; extracorporeal life support (ECLS)/extracorporeal membrane oxygenation (ECMO); mortality; outcome; predictor

Altered interaction of physiological activity and behavior affects risky decision-making in ADHD

BackgroundAdult attention-deficit/hyperactivity disorder (ADHD) is often associated with risky decision-making behavior. However, current research studies are often limited by the ability to adequately reflect daily behavior in a laboratory setting. Over the lifespan impairments in cognitive functions appear to improve, whereas affective functions become more severe. We assume that risk behavior in ADHD arises predominantly from deficits in affective processes. This study will therefore aim to investigate whether a dysfunction in affective pathways causes an abnormal risky decision-making (DM) behavior in adult ADHD.MethodsTwenty-eight participants with ADHD and twenty-eight healthy controls completed a battery of questionnaires regarding clinical symptoms, self-assessment of behavior and emotional competence. Furthermore, skin conductance responses were measured during the performance in a modified version of the Balloon Analogue Risk Task. A linear mixed-effects model analysis was used to analyze emotional arousal prior to a decision and after feedback display.ResultsResults showed higher emotional arousal in ADHD participants before decision-making (β = −0.12, SE = 0.05, t = −2.63, p &lt; 0.001) and after feedback display (β = −0.14, SE = 0.05, t = −2.66, p = 0.008). Although risky behavior was greater in HC than in ADHD, we found a significant interaction effect of group and anticipatory skin conductance responses regarding the response behavior (β = 107.17, SE = 41.91, t = 2.56, p = 0.011). Post hoc analyses revealed a positive correlation between anticipatory skin conductance responses and reaction time in HC, whereas this correlation was negative in ADHD. Self-assessment results were in line with the objective measurements.ConclusionWe found altered changes in physiological activity during a risky decision-making task. The results confirm the assumption of an aberrant relationship between bodily response and risky behavior in adult ADHD. However, further research is needed with respect to age and gender when considering physiological activities

Effectiveness and acceptability of progestogens in combined oral contraceptives – a systematic review

BACKGROUND: The progestogen component of oral contraceptives (OCs) has undergone changes since it was recognized that their chemical structure can influence the spectrum of minor adverse and beneficial effects. METHODS: The objective of this review was to evaluate currently available low-dose OCs containing ethinylestradiol and different progestogens in terms of contraceptive effectiveness, cycle control, side effects and continuation rates. The Cochrane Controlled Trials Register, MEDLINE and EMBASE databases were searched. Randomized trials reporting clinical outcomes were considered for inclusion and were assessed for methodological quality and validity. RESULTS: Twenty–two trials were included in the review. Eighteen were sponsored by pharmaceutical companies and in only 5 there was an attempt for blinding. Most comparisons between different interventions included one to three trials, involving usually less than 500 women. Discontinuation was less with second-generation progestogens compared to first–generation (RR 0.79; 95% CI 0.69–0.91). Cycle control appeared to be better with second-compared to first-generation progestogens for both, mono-and triphasic preparations (RR 0.69; 95% CI 0.52–0.91) and (RR 0.61; 95% CI 0.43–0.85), respectively. Intermenstrual bleeding was less with third- compared to second-generation pills (RR 0.71; 95% CI 0.55–0.91). Contraceptive effectiveness of gestodene (GSD) was comparable to that of levonorgestrel (LNG), and had similar pattern of spotting, breakthrough bleeding and absence of withdrawal bleeding). Drospirenone (DRSP) was similar compared to desogestrel (DSG) regarding contraceptive effectiveness, cycle control and side effects. CONCLUSION: The third- and second-generation progestogens are preferred over first generation in all indices of acceptability. Current evidence suggests that GSD is comparable to LNG in terms of contraceptive effectiveness and for most cycle control indices. GSD is also comparable to DSG. DRSP is comparable to DSG. Future research should focus on independently conducted well designed randomized trials comparing particularly the third- with second-generation progestogens

Preclinical safety and efficacy of a therapeutic antibody that targets SARS-CoV-2 at the sotrovimab face but is escaped by Omicron

The recurrent emerging of novel viral variants of concern (VOCs) with evasion of preexisting antibody immunity upholds severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) case numbers and maintains a persistent demand for updated therapies. We selected the patient-derived antibody CV38-142 based on its potency and breadth against the VOCs Alpha, Beta, Gamma, and Delta for preclinical development into a therapeutic. CV38-142 showed in vivo efficacy in a Syrian hamster VOC infection model after post-exposure and therapeutic application and revealed a favorable safety profile in a human protein library screen and tissue cross-reactivity study. Although CV38-142 targets the same viral surface as sotrovimab, which maintains activity against Omicron, CV38-142 did not neutralize the Omicron lineages BA.1 and BA.2. These results highlight the contingencies of developing antibody therapeutics in the context of antigenic drift and reinforce the need to develop broadly neutralizing variant-proof antibodies against SARS-CoV-2

Planowanie zarządzania zasobami wodnymi w intensywnie użytkowanej rolniczo zlewni Quebec, Kanada, z wykorzystniem modelu dynamicznego uwzględniającego interesariuszy

The participation of stakeholders is an important component in integrated and adaptive watershed planning and management. In Quebec, Canada watershed organizations are in the process of implementing participatory based watershed planning and management schemes. However, there is a lack of simple and readily implementable frameworks and methods to explicitly involve stakeholders, as well as integrate physical and social processes, in watershed planning and management in Quebec. This paper describes the application of the first three stages of a newly proposed five stage stepwise Participatory Model Building framework that was developed to help facilitate the participatory investigation of problems in watershed planning and management through the use of qualitative system dynamics models. In the agriculturally intensive Du Chene watershed in Québec, eight individual stakeholder interviews were conducted in cooperation with the local watershed organization to develop qualitative system dynamics models that represent the main physical and social processes in the Du Chene watershed. The proposed Participatory Model Building framework was found to be accessible for all the interviewees, and was deemed to be very useful by the watershed organization to develop an overview of the different perspectives of the main stakeholders in the watershed, as well as to help develop watershed policies and strategies. The individual qualitative system dynamics models developed in this study can subsequently be converted into an overall group built system dynamics model (describing the socio-economic-political components of the watershed), which in turn can be quantified and coupled with a physically based model such as HEC-HMS or SWAT (describing the physical components of the watershed).Rola interesariuszy jest ważnym elementem w zintegrowanym zarządzaniu zasobami wodnymi zlewni. Organizacje zajmujące się zagospodarowaniem zlewni rzecznych, w prowincji Quebec wdrążają obecnie system zarządzania zasobami wodnymi zlewni oparty na partycypacji interesariuszy, którzy zainteresowani są wykorzystaniem zasobów wodnych. Obecnie brakuje nieskomplikowanej i wygodnej we wdrożeniu metodyki uwzględnienia interesariuszy w zintegrowanym zarządzaniu zlewnią, w którym rozpatruje się ponadto zachodzące procesy społeczne i fizyczne. W pracy opisano zastosowanie pierwszych trzech, z pięciu etapów, nowo zaproponowanej metodyki stworzenia dynamicznego modelu partycypacyjnego, stosowanego w celu ułatwienia rozstrzygania problemów zarządzania zlewnią poprzez partycypację interesariuszy korzystających z jej zasobów. W intensywnie użytkowanej rolniczo zlewni Du Chene w prowincji Quebec, przeprowadzono 8 wywiadów z interesariuszami, a następnie, przy współpracy lokalnego zarządu wodnego, przystąpiono do zbudowania ilościowego modelu dynamicznego, który uwzględnia główne procesy fizyczne i społeczne w zlewni – Du Chene. Zaproponowany model partycypacji został oceniony przez interesariuszy jako przystępny oraz okazał się być użyteczny dla zarządów wodnych w celu przeglądu różnych perspektyw wkładu interesariuszy w zarządzanie zlewnią, a także ułatwił opracowanie strategii i polityki zarządzania zasobami zlewni. Model dynamicznego systemu udziałowców, zbudowany dla indywidualnych udziałowców w badanej zlewni i opisany w tym artykule, może zostać stopniowo rozbudowany do ogólnego, zbiorczego modelu, opisującego socjologiczne, ekonomiczne i polityczne procesy, istotne dla zarządzania zlewnią, oraz może zostać zintegrowany z modelami matematycznymi, takimi jak HEC-HMS lub SWAT, opisującymi fizyczne komponenty zlewni

Towards adaptive and integrated management paradigms to meet the challenges of water governance

Integrated Water Resource Management (IWRM) aims at finding practical and sustainable solutions to water resource issues. Research and practice have shown that innovative methods and tools are not sufficient to implement IWRM - the concept needs to also be integrated in prevailing management paradigms and institutions. Water governance science addresses this human dimension by focusing on the analysis of regulatory processes that influence the behavior of actors in water management systems. This paper proposes a new methodology for the integrated analysis of water resources management and governance systems in order to elicit and analyze case-specific management paradigms. It builds on the Management and Transition Framework (MTF) that allows for the examination of structures and processes underlying water management and governance. The new methodology presented in this paper combines participatory modeling and analysis of the governance system by using the MTF to investigate case-specific management paradigms. The linking of participatory modeling and research on complex management and governance systems allows for the transfer of knowledge between scientific, policy, engineering and local communities. In this way, the proposed methodology facilitates assessment and implementation of transformation processes towards IWRM that require also the adoption of adaptive management principles. A case study on flood management in the Tisza River Basin in Hungary is provided to illustrate the application of the proposed methodology