How to deal with institutional barriers

Item does not contain fulltextRelatively little is known about why some patients are reluctant to engage in a collaborative discussion with physicians about their choices in health care. To explore this issue further, we conducted six focus-group sessions with forty-eight people in the San Francisco Bay Area. In the focus groups, we found that participants voiced a strong desire to engage in shared decision making about treatment options with their physicians. However, several obstacles inhibit those discussions. These include the fact that even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations; that physicians can be authoritarian; and that the fear of being categorized as "difficult" prevents patients from participating more fully in their own health care. We argue that physicians may not be aware of a need to create a safe environment for open communication to facilitate shared decision making. Rigorous measures of patient engagement, and of the degree to which health care decisions truly reflect patient preferences, are needed to advance shared decision making in clinical practice.1 mei 201

Gravitational Mesoscopic Constraints in Cosmological Dark Matter Halos

We present an analysis of the behaviour of the `coarse-grained' (`mesoscopic') rank partitioning of the mean energy of collections of particles composing virialized dark matter halos in a Lambda-CDM cosmological simulation. We find evidence that rank preservation depends on halo mass, in the sense that more massive halos show more rank preservation than less massive ones. We find that the most massive halos obey Arnold's theorem (on the ordering of the characteristic frequencies of the system) more frequently than less massive halos. This method may be useful to evaluate the coarse-graining level (minimum number of particles per energy cell) necessary to reasonably measure signatures of `mesoscopic' rank orderings in a gravitational system.Comment: LaTeX, 15 pages, 3 figures. Accepted for publication in Celestial Mechanics and Dynamical Astronomy Journa

Towards understanding crime dynamics in a heterogeneous environment:A mathematical approach

Crime data provides information on the nature and location of the crime but, in general, does not include information on the number of criminals operating in a region. By contrast, many approaches to crime reduction necessarily involve working with criminals or individuals at risk of engaging in criminal activity and so the dynamics of the criminal population is important. With this in mind, we develop a mechanistic, mathematical model which combines the number of crimes and number of criminals to create a dynamical system. Analysis of the model highlights a threshold for criminal efficiency, below which criminal numbers will settle to an equilibrium level that can be exploited to reduce crime through prevention. This efficiency measure arises from the initiation of new criminals in response to observation of criminal activity; other initiation routes - via opportunism or peer pressure - do not exhibit such thresholds although they do impact on the level of criminal activity observed. We used data from Cape Town, South Africa, to obtain parameter estimates and predicted that the number of criminals in the region is tending towards an equilibrium point but in a heterogeneous manner - a drop in the number of criminals from low crime neighbourhoods is being offset by an increase from high crime neighbourhoods

Electronic and structural properties of superconducting MgB2_2, CaSi2_2 and related compounds

We report a detailed study of the electronic and structural properties of the 39K superconductor \mgbtwo and of several related systems of the same family, namely \mgalbtwo, \bebtwo, \casitwo and \cabesi. Our calculations, which include zone-center phonon frequencies and transport properties, are performed within the local density approximation to the density functional theory, using the full-potential linearized augmented plane wave (FLAPW) and the norm-conserving pseudopotential methods. Our results indicate essentially three-dimensional properties for these compounds; however, strongly two-dimensional $\sigma$-bonding bands contribute significantly at the Fermi level. Similarities and differences between \mgbtwo and \bebtwo (whose superconducting properties have not been yet investigated) are analyzed in detail. Our calculations for \mgalbtwo show that metal substitution cannot be fully described in a rigid band model. \casitwo is studied as a function of pressure, and Be substitution in the Si planes leads to a stable compound similar in many aspects to diborides.Comment: Revised version, Phys.Rev.B in pres

Effects of exercise in breast cancer patients: implications of the trials within cohorts (TwiCs) design in the UMBRELLA Fit trial

Purpose The Trials within Cohorts (TwiCs) design aims to overcome problems faced in conventional RCTs. We evaluated the TwiCs design when estimating the effect of exercise on quality of life (QoL) and fatigue in inactive breast cancer survivors. Methods UMBRELLA Fit was conducted within the prospective UMBRELLA breast cancer cohort. Patients provided consent for future randomization at cohort entry. We randomized inactive patients 12-18 months after cohort enrollment. The intervention group (n = 130) was offered a 12-week supervised exercise intervention. The control group (n = 130) was not informed and received usual care. Six-month exercise effects on QoL and fatigue as measured in the cohort were analyzed with intention-to-treat (ITT), instrumental variable (IV), and propensity scores (PS) analyses. Results Fifty-two percent (n = 68) of inactive patients accepted the intervention. Physical activity increased in patients in the intervention group, but not in the control group. We found no benefit of exercise for dimensions of QoL (ITT difference global QoL: 0.8, 95% CI = - 2.2; 3.8) and fatigue, except for a small beneficial effect on physical fatigue (ITT difference: - 1.1, 95% CI = - 1.8; - 0.3; IV: - 1.9, 95% CI = - 3.3; - 0.5, PS: - 1.2, 95% CI = - 2.3; - 0.2). Conclusion TwiCs gave insight into exercise intervention acceptance: about half of inactive breast cancer survivors accepted the offer and increased physical activity levels. The offer resulted in no improvement on QoL, and a small beneficial effect on physical fatigue.Clinical epidemiolog

ZC4H2, an XLID gene, is required for the generation of a specific subset of CNS interneurons

Miles-Carpenter syndrome (MCS) was described in 1991 as an XLID syndrome with fingertip arches and contractures and mapped to proximal Xq. Patients had microcephaly, short stature, mild spasticity, thoracic scoliosis, hyperextendable MCP joints, rocker-bottom feet, hyperextended elbows and knees. A mutation, p.L66H, in ZC4H2, was identified in a XLID resequencing project. Additional screening of linked families and next generation sequencing of XLID families identified three ZC4H2 mutations: p.R18K, p.R213W and p.V75in15aa. The families shared some relevant clinical features. In silico modeling of the mutant proteins indicated all alterations would destabilize the protein. Knockout mutations in zc4h2 were created in zebrafish and homozygous mutant larvae exhibited abnormal swimming, increased twitching, defective eye movement and pectoral fin contractures. Because several of the behavioral defects were consistent with hyperactivity, we examined the underlying neuronal defects and found that sensory neurons and motoneurons appeared normal. However, we observed a striking reduction in GABAergic interneurons. Analysis of cell-type-specificmarkers showed a specific loss of V2 interneurons in the brain and spinal cord, likely arising from mis-specification of neural progenitors. Injected human wt ZC4H2 rescued the mutant phenotype. Mutant zebrafish injectedwith human p.L66H or p.R213W mRNA failed to be rescued, while the p.R18K mRNA was able to rescue the interneuron defect. Our findings clearly support ZC4H2 as a novel XLID gene with a required function in interneuron development. Loss of function of ZC4H2 thus likely results in altered connectivity ofmany brain and spinal circuits

Revisiting the assumptions and implementation details of the BAY model for vortex generator flows

Today, Vortex Generators (VGs) are becoming an integral part of a Wind Turbine blade design. However, the challenges involved in the computation of the flow around VGs are yet to be dealt with in a satisfactory manner. A large number of VG models for Reynolds Averaged Navier Stokes (RANS) solvers has been proposed and, among them, the Bender–Anderson–Yagle (BAY) model (ASME Pap. FEDSM99-6919) is one of the most popular, due to its ease of use and relatively low requirements for user input. In the present paper a thorough investigation on the performance and application of the BAY model for aerodynamic VG flows is presented. A fully resolved RANS simulation is validated against experiments and then used as a benchmark for the BAY model simulations. A case relevant to wind turbines is examined, which deals with the flow past a wind turbine airfoil at Reynolds number 0.87e6. When the grid related errors are excluded, it is found that the generated vortices are weaker in the BAY model simulations than in the fully resolved computation. The latter finding is linked to an inherent deficiency of the model, which is first found in this study and which is explained in detail

Rapid and highly variable warming of lake surface waters around the globe

In this first worldwide synthesis of in situ and satellite-derived lake data, we find that lake summer surface water temperatures rose rapidly (global mean = 0.34°C decade−1) between 1985 and 2009. Our analyses show that surface water warming rates are dependent on combinations of climate and local characteristics, rather than just lake location, leading to the counterintuitive result that regional consistency in lake warming is the exception, rather than the rule. The most rapidly warming lakes are widely geographically distributed, and their warming is associated with interactions among different climatic factors—from seasonally ice-covered lakes in areas where temperature and solar radiation are increasing while cloud cover is diminishing (0.72°C decade−1) to ice-free lakes experiencing increases in air temperature and solar radiation (0.53°C decade−1). The pervasive and rapid warming observed here signals the urgent need to incorporate climate impacts into vulnerability assessments and adaptation efforts for lakes.Peer reviewe