Country differences in the diagnosis and management of coronary heart disease : a comparison between the US, the UK and Germany

Background The way patients with coronary heart disease (CHD) are treated is partly determined by non-medical factors. There is a solid body of evidence that patient and physician characteristics influence doctors' management decisions. Relatively little is known about the role of structural issues in the decision making process. This study focuses on the question whether doctors' diagnostic and therapeutic decisions are influenced by the health care system in which they take place. This non-medical determinant of medical decision-making was investigated in an international research project in the US, the UK and Germany. Methods Videotaped patients within an experimental study design were used. Experienced actors played the role of patients with symptoms of CHD. Several alternative versions were taped featuring the same script with patients of different sex, age and social status. The videotapes were shown to 384 randomly selected primary care physicians in the three countries under study. The sample was stratified on gender and duration of professional experience. Physicians were asked how they would diagnose and manage the patient after watching the video vignette using a questionnaire with standardised and open-ended questions. Results Results show only small differences in decision making between British and American physicians in essential aspects of care. About 90% of the UK and US doctors identified CHD as one of the possible diagnoses. Further similarities were found in test ordering and lifestyle advice. Some differences between the US and UK were found in the certainty of the diagnoses, prescribed medications and referral behaviour. There are numerous significant differences between Germany and the other two countries. German physicians would ask fewer questions, they would order fewer tests, prescribe fewer medications and give less lifestyle advice. Conclusion Although all physicians in the three countries under study were presented exactly the same patient, some disparities in the diagnostic and patient management decisions were evident. Since other possible influences on doctors treatment decisions are controlled within the experimental design, characteristics of the health care system seem to be a crucial factor within the decision making process

Gamma-ray bursts and terrestrial planetary atmospheres

We describe results of modeling the effects on Earth-like planets of long-duration gamma-ray bursts (GRBs) within a few kiloparsecs. A primary effect is generation of nitrogen oxide compounds which deplete ozone. Ozone depletion leads to an increase in solar UVB radiation at the surface, enhancing DNA damage, particularly in marine microorganisms such as phytoplankton. In addition, we expect increased atmospheric opacity due to buildup of nitrogen dioxide produced by the burst and enhanced precipitation of nitric acid. We review here previous work on this subject and discuss recent developments, including further discussion of our estimates of the rates of impacting GRBs and the possible role of short-duration bursts.Comment: 12 pages including 5 figures (4 in color). Added discussion of GRB rates and biological effects. Accepted for publication in New Journal of Physics, for special issue "Focus on Gamma-Ray Bursts

‘He's a Cracking Wee Geezer from Pakistan’: Lay Accounts of Refugee Integration Failure and Success in Scotland

Previous research on the integration of asylum seekers and refugees has aimed to develop conceptual frameworks for understanding integration or to measure the extent to which people are integrated. However, this research tends to pay insufficient attention to the rhetorical functions of integration discourse. The current study addresses this gap through a discursive analysis of ‘lay’ accounts of asylum seeker and refugee integration in Glasgow, Scotland. The analysis highlights that accounts of integration ‘failure’ may support ‘two-way’ conceptions of integration while still blaming asylum seekers for any lack of integration. Furthermore, accounts of integration ‘success’ may reinforce assimilationist policies or otherwise function to reinforce the view that adult asylum seekers generally do not integrate. The analysis highlights the importance of attending to the rhetorical functions of integration discourse in order to understand how particular policies and practices are supported or criticised at the community level at which integration takes place

Dental Amalgam Restorations and Children’s Neuropsychological Function: The New England Children’s Amalgam Trial

BACKGROUND: A concern persists that children’s exposure to mercury vapor from dental amalgams produces neurotoxicity. OBJECTIVE: Our goal was to compare the neuropsychological function of children, without prior exposure to dental amalgam, whose caries were repaired using either dental amalgam or mercury-free composite materials. METHODS: We conducted a randomized controlled trial involving 534 6- to 10-year-old urban and rural children who were assessed yearly for 5 years using a battery of tests of intelligence, achievement, language, memory, learning, visual–spatial skills, verbal fluency, fine motor function, problem solving, attention, and executive function. RESULTS: Although the mean urinary mercury concentration was greater among children in the amalgam group than the composite group (0.9 vs. 0.6 μg/g creatinine), few significant differences were found between the test scores of children in the two groups. The differences found were inconsistent in direction. Analyses using two cumulative exposure indices—surface years of amalgam and urinary mercury concentration—produced similar results. CONCLUSIONS: Exposure to elemental mercury in amalgam at the levels experienced by the children who participated in the trial did not result in significant effects on neuropsychological function within the 5-year follow-up period

The Electromyographic Threshold in Girls and Women.

BACKGROUND: The electromyographic threshold (EMGTh) is thought to reflect increased high-threshold/type-II motor-unit (MU) recruitment and was shown higher in boys than in men. Women differ from men in muscular function. PURPOSE: Establish whether females' EMGTh and girls‒women differences are different than males'. METHODS: Nineteen women (22.9±3.3yrs) and 20 girls (10.3±1.1yrs) had surface EMG recorded from the right and left vastus lateralis muscles during ramped cycle-ergometry to exhaustion. EMG root-mean-squares were averaged per pedal revolution. EMGTh was determined as the least residual sum of squares for any two regression-line data divisions, if the trace rose ≥3SD above its regression line. EMGTh was expressed as % final power-output (%Pmax) and %VO2pk power (%PVO2pk). RESULTS: EMGTh was detected in 13 (68%) of women, but only 9 (45%) of girls (p<0.005) and tended to be higher in the girls (%Pmax= 88.6±7.0 vs. 83.0±6.9%, p=0.080; %PVO2pk= (101.6±17.6 vs. 90.6±7.8%, p=0.063). When EMGTh was undetected it was assumed to occur at 100%Pmax or beyond. Consequently, EMGTh values turned significantly higher in girls than in women (94.8±7.4 vs. 88.4±9.9 %Pmax, p=0.026; and 103.2±11.7 vs. 95.2±9.9 %PVO2pk, p=0.028). CONCLUSIONS: During progressive exercise, girls appear to rely less on higher-threshold/type-II MUs than do women, suggesting differential muscle activation strategy

Sources of Variation in Physician Adherence with Clinical Guidelines: Results from a Factorial Experiment

BACKGROUND: Health services research has documented the magnitude of health care variations. Few studies focus on provider level sources of variation in clinical decision making-for example, which primary care providers are likely to follow clinical guidelines, with which types of patient. OBJECTIVES: To estimate: (1) the extent of primary care provider adherence to practice guidelines and the unconfounded influence of (2) patient attributes and (3) physician characteristics on adherence with clinical practice guidelines. DESIGN: In a factorial experiment, primary care providers were shown clinically authentic video vignettes with actors portrayed different “patients” with identical signs of coronary heart disease (CHD). Different types of providers were asked how they would manage the different “patients” with identical CHD symptoms. Measures were taken to protect external validity. RESULTS: Adherence to some guidelines is high (over 50% of physicians would follow a third of the recommended actions), yet there is low adherence to many of them (less than 20% would follow another third). Female patients are less likely than males to receive 4 of 5 types of physical examination (p < .03); older patients are less likely to be advised to stop smoking (p < .03). Race and SES of patients had no effect on provider adherence to guidelines. A physicians’ level of experience (age) appears to be important with certain patients. CONCLUSIONS: Physician adherence with guidelines varies with different types of “patient” and with the length of clinical experience. With this evidence it is possible to appropriately target interventions to reduce health care variations by improving physician adherence with clinical guidelines

English as the International Language of Research

The annual world output of research papers and scholarly ar ticles is large and increasing, and there is little doubt that English is the medium of publication for the majority of such papers. However, closer analyses of the available data reveal rather few papers from non- native speakers, especially from the Third World. This imbalance sug gests that English is only the International Language of Research in a receptive sense. It needs to become so in a productive sense as well if Third World investment in doctoral scholarship etc. is to remain justified. Unfortunately, the ESP profession has concentrated on undergraduate teaching programmes and rather neglected the teaching of Research English. However, there are now welcome signs of change, which may therefore aid a process of making English a truly international language rather than one over-restricted in terms of publication sources to the Northern Hemisphere.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68423/2/10.1177_003368828501600101.pd

Blood lead level and dental caries in school-age children.

The association between blood lead level and dental caries was evaluated in cross-sectional analyses of baseline data for 543 children 6-10 years old screened for enrollment in the Children's Amalgam Trial, a study designed to assess potential health effects of mercury in silver fillings. Approximately half of the children were recruited from an urban setting (Boston/Cambridge, MA, USA) and approximately half from a rural setting (Farmington, ME, USA). Mean blood lead level was significantly greater among the urban subgroup, as was the mean number of carious tooth surfaces. Blood lead level was positively associated with number of caries among urban children, even with adjustment for demographic and maternal factors and child dental practices. This association was stronger in primary than in permanent dentition and stronger for occlusal, lingual, and buccal tooth surfaces than for mesial or distal surfaces. In general, blood lead was not associated with caries in the rural subgroup. The difference between the strength of the associations in the urban and rural settings might reflect the presence of residual confounding in the former setting, the presence of greater variability in the latter setting in terms of important caries risk factors (e.g., fluoride exposure), or greater exposure misclassification in the rural setting. These findings add to the evidence supporting a weak association between children's lead exposure and caries prevalence. A biologic mechanism for lead cariogenicity has not been identified, however. Our data are also consistent with residual confounding by factors associated with both elevated lead exposure and dental caries