A Pilot Study Of Antihypertensive Therapy In Cerebrovascular Disease

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/111248/1/j.1532-5415.1967.tb02802.x.pd

Foot health education for people with rheumatoid arthritis : the practitioner's perspective

Background: Patient education is considered to be a key role for podiatrists in the management of patients with rheumatoid arthritis (RA). Patient education has undoubtedly led to improved clinical outcomes, however no attempts have been made to optimise its content or delivery to maximise benefits within the context of the foot affected by rheumatoid arthritis. The aim of this study was to identify the nature and content of podiatrists' foot health education for people with RA. Any potential barriers to its provision were also explored. Methods: A focus group was conducted. The audio dialogue was recorded digitally, transcribed verbatim and analysed using a structured, thematic approach. The full transcription was verified by the focus group as an accurate account of what was said. The thematic analysis framework was verified by members of the research team to ensure validity of the data. Results: Twelve members (all female) of the north west Podiatry Clinical Effectiveness Group for Rheumatology participated. Six overarching themes emerged: (i) the essence of patient education; (ii) the content; (iii) patient-centred approach to content and timing; (iv) barriers to provision; (v) the therapeutic relationship; and (vi) tools of the trade. Conclusion: The study identified aspects of patient education that this group of podiatrists consider most important in relation to its: content, timing, delivery and barriers to its provision. General disease and foot health information in relation to RA together with a potential prognosis for foot health, the role of the podiatrist in management of foot health, and appropriate self-management strategies were considered to be key aspects of content, delivered according to the needs of the individual. Barriers to foot health education provision, including financial constraints and difficulties in establishing effective therapeutic relationships, were viewed as factors that strongly influenced foot health education provision. These data will contribute to the development of a patient-centred, negotiated approach to the provision of foot health education for people with RA

GEOTRACES IC1 (BATS) contamination-prone trace element isotopes Cd, Fe, Pb, Zn, Cu, and Mo intercalibration

International audienceWe report data on the isotopic composition of cadmium, copper, iron, lead, zinc, and molybdenum at the GEOTRACES IC1 BATS Atlantic intercalibration station. In general, the between lab and within-lab precisions are adequate to resolve global gradients and vertical gradients at this station for Cd, Fe, Pb, and Zn. Cd and Zn isotopes show clear variations in the upper water column and more subtle variations in the deep water; these variations are attributable, in part, to progressive mass fractionation of isotopes by Rayleigh distillation from biogenic uptake and/or adsorption. Fe isotope variability is attributed to heavier crustal dust and hydrothermal sources and light Fe from reducing sediments. Pb isotope variability results from temporal changes in anthropogenic source isotopic compositions and the relative contributions of U.S. and European Pb sources. Cu and Mo isotope variability is more subtle and close to analytical precision. Although the present situation is adequate for proceeding with GEOTRACES, it should be possible to improve the within-lab and between-lab precisions for some of these properties

Deep-Inelastic Final States in a Space-Time Description of Shower Development and Hadronization

We extend a quantum kinetic approach to the description of hadronic showers in space, time and momentum space to deep-inelastic $ep$ collisions, with particular reference to experiments at HERA. We follow the history of hard scattering events back to the initial hadronic state and forward to the formation of colour-singlet pre-hadronic clusters and their decays into hadrons. The time evolution of the space-like initial-state shower and the time-like secondary partons are treated similarly, and cluster formation is treated using a spatial criterion motivated by confinement and a non-perturbative model for hadronization. We calculate the time evolution of particle distributions in rapidity, transverse and longitudinal space. We also compare the transverse hadronic energy flow and the distribution of observed hadronic masses with experimental data from HERA, and find encouraging results. The techniques developed in this paper may be applied in the future to more complicated processes such as eA, pp, pA and AA collisions.Comment: 44 pages plus 14 postscript figure

“Being Guided”: What Oncofertility Patients’ Decisions Can Teach Us About the Efficacy of Autonomy, Agency, and Decision-Making Theory in the Contemporary Critical Encounter

Recent research on patient decision-making reveals a disconnect between theories of autonomy, agency, and decision-making and their practice in contemporary clinical encounters. This study examines these concepts in the context of female patients making oncofertility decisions in the United Kingdom in light of the phenomenon of “being guided.” Patients experience being guided as a way to cope with, understand, and defer difficult treatment decisions. Previous discussions condemn guided decision-making, but this research suggests that patients make an informed, autonomous decision to be guided by doctors. Thus, bioethicists must consider the multifaceted ways that patients enact their autonomy in medical encounters

Evaluation of the guide to action care home fall prevention programme in care homes for older people: A multi-centre, single blinded, cluster randomised controlled trial (FINCH)

BackgroundFalls in care home residents are common, unpleasant, costly and difficult to prevent. Trial DesignThe objective was to evaluate the clinical and cost effectiveness of the Guide to Action for Falls Prevention Care Homes, GtACH) in which care home staff were trained and supported in the systematic use of a multi-domain decision support tool and identify issues affecting subsequent implementation. A two-arm parallel design, multi-centre, cluster randomised controlled trial of the GtACH programme and usual falls prevention in older care home residents was conducted with embedded process evaluation and economic evaluation. MethodThe study was conducted in care homes from ten UK sites. The primary trial outcome was the rate of falls per resident participant occurring during the 90-day period between 91 days and 180 days post-randomisation. The primary outcome for the cost effectiveness analysis was the cost per fall averted and for the cost utility analysis was the incremental cost per QALY. Secondary outcomes included the rate of falls over days 0-90 and 181-360 post randomisation, activity levels, dependency, and fractures. Care homes were randomised on a 1:1 basis to the GtACH programme or usual care, via a secure web-based randomisation service. Research assistants (RAs), resident participants and staff informants were blind to allocation at recruitment. RAs were blind to allocation at follow up. Data from NHS Digital were extracted blindly. The number of falls per resident was compared between groups using a negative binomial regression model (GEE).Results84 care homes were randomised, 39 to GtACH and 45 to usual care. 1657 residents consented and provided baseline measures, mean age 85 years, 32% men. GtACH training was delivered to 1051 staff (71% of eligible staff) over 146 group sessions. Primary RCT outcome data were available for 630 of the GtACH participants and 712 usual care participants. The primary RCT outcome result showed an unadjusted Incidence Rate Ratio (IRR) of 0.57 (95% CI 0.45-0.71, p<0.01) in favour of the GtACH programme. Fall rates were also lower in the GtACH group in the period 0-90 days, but there were no other differences between groups in the secondary outcomes. Care home staff valued the training, the systematic strategies and the specialist peer support, but there was limited incorporation of the GtACH documentation into routine care home practice. No adverse events were recorded. The incremental cost per DEMQoL-based QALY was £20,889.42 and £4,543.69 per EQ-5D based QALY. Mean falls were 1.889 (sd 3.662) in the GtACH arm and 2.747 (sd 7.414) in the usual care arm. Therefore, 0.858 falls were averted. The base case incremental cost per fall averted was £190.62ConclusionThe GtACH programme significantly reduced the rate of falls in the study care homes, without restricting residents’ activity levels or increasing their dependency and was cost effective at current thresholds in the UK NHS. Widespread implementation of the programme is justified. Trial registrationTrial registration number: ISRCTN34353836. Protocol V6 14 November 2017Funding DetailsThe National Institute for Health Research (NIHR) HTA programm

Toward a 21st-century health care system: Recommendations for health care reform

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges

Transcriptional Profiling of Chondrodysplasia Growth Plate Cartilage Reveals Adaptive ER-Stress Networks That Allow Survival but Disrupt Hypertrophy

Metaphyseal chondrodysplasia, Schmid type (MCDS) is characterized by mild short stature and growth plate hypertrophic zone expansion, and caused by collagen X mutations. We recently demonstrated the central importance of ER stress in the pathology of MCDS by recapitulating the disease phenotype by expressing misfolding forms of collagen X (Schmid) or thyroglobulin (Cog) in the hypertrophic zone. Here we characterize the Schmid and Cog ER stress signaling networks by transcriptional profiling of microdissected mutant and wildtype hypertrophic zones. Both models displayed similar unfolded protein responses (UPRs), involving activation of canonical ER stress sensors and upregulation of their downstream targets, including molecular chaperones, foldases, and ER-associated degradation machinery. Also upregulated were the emerging UPR regulators Wfs1 and Syvn1, recently identified UPR components including Armet and Creld2, and genes not previously implicated in ER stress such as Steap1 and Fgf21. Despite upregulation of the Chop/Cebpb pathway, apoptosis was not increased in mutant hypertrophic zones. Ultrastructural analysis of mutant growth plates revealed ER stress and disrupted chondrocyte maturation throughout mutant hypertrophic zones. This disruption was defined by profiling the expression of wildtype growth plate zone gene signatures in the mutant hypertrophic zones. Hypertrophic zone gene upregulation and proliferative zone gene downregulation were both inhibited in Schmid hypertrophic zones, resulting in the persistence of a proliferative chondrocyte-like expression profile in ER-stressed Schmid chondrocytes. Our findings provide a transcriptional map of two chondrocyte UPR gene networks in vivo, and define the consequences of UPR activation for the adaptation, differentiation, and survival of chondrocytes experiencing ER stress during hypertrophy. Thus they provide important insights into ER stress signaling and its impact on cartilage pathophysiology