The SPHERE Study: Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

Background: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.

Methods: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

The DUB/USP17 deubiquitinating enzymes, a multigene family within a tandemly repeated sequence

Here we report the identification of 10 human, 1 murine, and 2 rat ORFs, all of which represent additional members of the DUB/USP17 family of deubiquitinating enzymes. In addition, we demonstrate that this family constitutes part of a tandemly repeated sequence conserved throughout humans, mice, and rats. Furthermore, upon examination of the known family members we have found that the multiple genes observed, in contrast to other gene families, have arisen due to the independent expansion of an ancestral sequence within each species. This premise is further strengthened by the observation that the murine and rat genes span two exons while their human counterparts have one. These observations, in conjunction with previous work demonstrating that the DUB/USP17's are cytokine inducible and that they regulate both cell growth and survival, suggest that the DUB/USP17's are a large highly conserved family of genes that may play an important role in controlling cell fate.

'American hegemony after September 11: Allies, rivals and contradictions'

11 September heralded and provided a pretext for a more aggressive but increasingly contradictory American hegemony. Some of the consequences are contrary to the United States' own interests. Its new doctrine of 'preemptive strike' against other sovereign states encourages similarly belligerent behaviour by other governments, and yet more terrorism by nonstate actors, the very threats which were to be eradicated by a re-asserted US hegemony. This essay focuses on three partly overlapping themes: different strategies towards allies - multilateral and unilateral; different forms of power - civil and military; and different ideologies of globalisation - neoliberal and neo-conservative. It argues that while US policy may oscillate between such poles, it often combines the different elements. The overall strategy of the Bush administration is best characterised as unilateral multilateralism. The main issue for US hegemonists is the ways in which their hegemony might best be exercised, maintained and strengthened vis à vis allies and rivals. But for a safer, more democratic world, the choice does not lie between one faction of US hegemonists and another: we need other alternatives such as cosmopolitan democracy and a genuine internationalist movement which would give it some much-needed substance.

Strengthening an in-service reinforcement concrete bridge with prestressed CFRP bar

Carbon fiber reinforced polymer (CFRP) bars were prestressed for the structural strengthening of 8 T-shaped reinforced concrete (RC) beams of a 21-year-old bridge in China. The ultimate bearing capacity of the existing bridge after retrofit was discussed on the basis of concrete structures theory. The flexural strengths of RC beams strengthened with CFRP bars were controlled by the failure of concrete in compression and a prestressing method was applied in the retrofit. The field construction processes of strengthening with CFRP bars—including grouting cracks, cutting groove, grouting epoxy and embedding CFRP bars, surface treating, banding with the U-type CFRP sheets, releasing external prestressed steel tendons—were introduced in detail. In order to evaluate the effectiveness of this strengthening method, field tests using vehicles as live load were applied before and after the retrofit. The test results of deflection and concrete strain of the T-shaped beams with and without strengthening show that the capacity of the repaired bridge, including the bending strength and stiffness, is enhanced. The measurements of crack width also indicate that this strengthening method can enhance the durability of bridges. Therefore, the proposed strengthening technology is feasible and effective.

Half-precessional dynamics of monsoon rainfall near the East African Equator

External climate forcings-such as long-term changes in solar insolation-generate different climate responses in tropical and high latitude regions(1). Documenting the spatial and temporal variability of past climates is therefore critical for understanding how such forcings are translated into regional climate variability. In contrast to the data-richmiddle and high latitudes, high-quality climate-proxy records from equatorial regions are relatively few(2-4), especially from regions experiencing the bimodal seasonal rainfall distribution associated with twice-annual passage of the Intertropical Convergence Zone. Here we present a continuous and well-resolved climate-proxy record of hydrological variability during the past 25,000 years from equatorial East Africa. Our results, based on complementary evidence from seismic-reflection stratigraphy and organic biomarker molecules in the sediment record of Lake Challa near Mount Kilimanjaro, reveal that monsoon rainfall in this region varied at half-precessional (similar to 11,500-year) intervals in phase with orbitally controlled insolation forcing. The southeasterly and northeasterly monsoons that advect moisture from the western Indian Ocean were strengthened in alternation when the inter-hemispheric insolation gradient was at a maximum; dry conditions prevailed when neither monsoon was intensified and modest local March or September insolation weakened the rain season that followed. On sub-millennial timescales, the temporal pattern of hydrological change on the East African Equator bears clear high-northern-latitude signatures, but on the orbital timescale it mainly responded to low-latitude insolation forcing. Predominance of low-latitude climate processes in this monsoon region can be attributed to the low-latitude position of its continental regions of surface air flow convergence, and its relative isolation from the Atlantic Ocean, where prominent meridional overturning circulation more tightly couples low-latitude climate regimes to high-latitude boundary conditions.

Integrating field sports, hare population management and conservation

Conflicts between field sports, animal welfare and species conservation are frequently contentious. In Ireland, the Irish Coursing Club (ICC) competitively tests the speed and agility of two greyhounds by using a live hare as a lure. Each coursing club is associated with a number of discrete localities, known as preserves, which are managed favourably for hares including predator control, prohibition of other forms of hunting such as shooting and poaching and the maintenance and enhancement of suitable hare habitat. We indirectly tested the efficacy of such management by comparing hare abundance within preserves to that in the wider countryside. In real terms, mean hare density was 18 times higher, and after controlling for variance in habitat remained 3 times higher, within ICC preserves than the wider countryside. Whilst we cannot rule out the role of habitat, our results suggest that hare numbers are maintained at high levels in ICC preserves either because clubs select areas of high hare density and subsequently have a negligible effect on numbers or that active population management positively increases hare abundance. The Irish hare Lepus timidus hibernicus Bell, 1837 is one of the highest priority species for conservation action in Ireland and without concessions for its role in conservation, any change in the legal status Of hare coursing under animal welfare grounds, may necessitate an increase in Government subsidies for conservation on private land together with a strengthened capacity for legislation enforcement.

Palaeoclimate change recorded in Upper Cretaceous (Albian-Cenomanian) Kazhdumi Formation Borehole spectral Gamma-Ray Logs, South Pars Gas field, Persian Gulf

Th/U and Th/K data from spectral gamma-ray logs obtained from outcrop successions have been used as a rapid and inexpensive proxy for determining possible episodes of humid-arid palaeoclimate change. Such outcrop-based measurements have never been tested using spectral gamma-ray data obtained from wireline logs in subsurface boreholes. Th/K and Th/U ratios have traditionally been used to decipher sequence stratigraphic patterns, at outcrop and in borehole. The possible influence of palaeoclimate on such ratio changes has yet to be proven, especially from borehole data. In this work, we compare borehole-derived Th/K (and to a lesser extent Th/U) to palaeoenvironmental changes inferred from palynology and deduce that both sea level and changing hinterland weathering regimes caused discrete fluctuations observed in the spectral gamma-ray logs. This is the first time such subsurface information has been used in this way. Interpretation of wireline logs in terms of palaeoclimate as well as sea level may now be considered, and the use of such logs in palaeoclimate reconstruction is strengthened.

Dust and the type II-Plateau supernova 2004dj

We present mid-infrared (MIR) spectroscopy of a Type II-plateau supernova, SN 2004dj, obtained with the Spitzer Space Telescope, spanning 106--1393d after explosion. MIR photometry plus optical/near-IR observations are also reported. An early-time MIR excess is attributed to emission from non-silicate dust formed within a cool dense shell (CDS). Most of the CDS dust condensed between 50d and 165d, reaching a mass of $0.3x^(-5)Msun. Throughout the observations much of the longer wavelength (>10microns) part of the continuum is explained as an IR echo from interstellar dust. The MIR excess strengthened at later times. We show that this was due to thermal emission from warm, non-silicate dust formed in the ejecta. Using optical/near-IR line-profiles and the MIR continua, we show that the dust was distributed as a disk whose radius appeared to be slowly shrinking. The disk radius may correspond to a grain destruction zone caused by a reverse shock which also heated the dust. The dust-disk lay nearly face-on, had high opacities in the optical/near-IR regions, but remained optically thin in the MIR over much of the period studied. Assuming a uniform dust density, the ejecta dust mass by 996d was 0.5+/-0.1 x 10^(-4)Msun, and exceeded 10^(-4)Msun by 1393d. For a dust density rising toward the center the limit is higher. Nevertheless, this study suggests that the amount of freshly-synthesized dust in the SN 2004dj ejecta is consistent with that found from previous studies, and adds further weight to the claim that such events could not have been major contributors to the cosmic dust budget.

Observation of K-Shell Soft X Ray Emission of Nitrogen Irradiated by XUV-Free Electron Laser FLASH at Intensities Greater than 10(16) W/cm(2)

In the past few years, the development of light sources of the 4(th) generation, namely XUV/X-ray Free Electron Lasers provides to the scientific community outstanding tools to investigate matter under extreme conditions never obtained in laboratories so far. As theory is at its infancy, the analysis of matter via the self-emission of the target is of central importance. The characterization of such dense matter is possible if photons can escape the medium. As the absorption of K-shell X-ray transitions is minimal, it plays a key role in this study. We report here the first successful observation of K-shell emission of Nitrogen at 430 eV using an XUV-Free Electron Laser to irradiate solid Boron Nitride targets under exceptional conditions: photon energy of 92 eV, pulse duration of similar to 20 fs, micro focusing leading to intensities larger than 10(16) W/cm(2). Using a Bragg crystal of THM coupled to a CCD, we resolved K-shell line emission from different charge states. We demonstrate that the spectroscopic data allow characterization of electron heating processes when X-ray radiation is interacting with solid matter. As energy transport is non-trivial because the light source is monochromatic, these results have an important impact on the theory. (C) 2011 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim

Cigarette Smoking Increases Risk of Barrett’s Esophagus:An Analysis of the Barrett’s and Esophageal Adenocarcinoma Consortium

Background & Aims: Cigarette smoking has been implicated in the etiology of esophageal adenocarcinoma, but it is not clear if smoking is a risk factor for Barrett's esophagus. We investigated whether tobacco smoking and other factors increase risk for Barrett's esophagus.

Methods: We analyzed data from 5 case-control studies included in the international Barrett's and Esophageal Adenocarcinoma Consortium. We compared data from subjects with Barrett's esophagus (n = 1059) with those from subjects with gastroesophageal reflux disease (gastroesophageal reflux disease controls, n = 1332), and population-based controls (n = 1143), using multivariable logistic regression models to test associations with cigarette smoking. We also tested whether cigarette smoking has synergistic effects with other exposures, which might further increase risk for Barrett's esophagus.

Results: Subjects with Barrett's esophagus were significantly more likely to have ever smoked cigarettes than the population-based controls (odds ratio [OR] = 1.67; 95% confidence interval [CI]: 1.042.67) or gastroesophageal reflux disease controls (OR = 1.61; 95% CI: 1.331.96). Increasing pack-years of smoking increased the risk for Barrett's esophagus. There was evidence of a synergy between ever-smoking and heartburn or regurgitation; the attributable proportion of disease among individuals who ever smoked and had heartburn or regurgitation was estimated to be 0.39 (95% CI: 0.250.52).

Conclusions: Cigarette smoking is a risk factor for Barrett's esophagus. The association was strengthened with increased exposure to smoking until ~20 pack-years, when it began to plateau. Smoking has synergistic effects with heartburn or regurgitation, indicating that there are various pathways by which tobacco smoking might contribute to development of Barrett's esophagus.

Monitoring the moisture transport in building stones using fibre optic relative humidity sensors

Weathering of stone is one of the major reasons for the damage of stone masonry structures and it takes place due to interlinked chemical, physical and biological processes in stones. The key parameters involved in the deterioration processes are temperature, moisture and salt. It is now known that the sudden variations in temperature and moisture greatly accelerate the weathering process of the building stone fabric. Therefore, in order to monitor these sudden variations an effective and continuous monitoring system is needed. Furthermore, it must consist of robust sensors which are accurate and can survive in the harsh environments experienced in and around masonry structures. Although salt penetration is important for the rate of deterioration of stone masonry structures, the processes involved are much slower than the damage associated with temperature and moisture variations. Therefore, in this paper a novel fibre optic temperature cum relative humidity sensor is described and its applicability in monitoring building stones demonstrated. The performance of the sensor is assessed in an experiment comprising wetting and drying of limestone blocks. The results indicate that the novel fibre optic relative humidity sensor which is tailor made for applications in masonry structures performed well in wetting and drying tests, whilst commercial capacitance based sensors failed to recover during the drying regime for a long period after a wetting regime. That is, the fibre optic sensor has the capability to measure both sorption and de-sorption characteristics of stone blocks. This sensor is used in a test wall in Oxford and the data thus obtained strengthened the laboratory observations.

Caregiving at the end of life:perspectives from spousal caregivers and care recipients.

OBJECTIVE: The purpose of this study is to examine the perspectives of both the spousal caregiver and care recipient on the caregiving experience in home-based palliative care. METHODS: A qualitative research strategy involving home-based face-to-face interviews with older palliative care patients and their spousal caregivers was used to examine the caregiving experience. RESULTS: Ten spousal caregivers and care recipient dyads participated in the study. Most informal caregivers viewed caregiving as an extension of the family relationship where caregiving responsibilities evolved over time. Spousal caregivers identified many negative reactions to caregiving, such as fatigue or weariness, depression, anger and sadness, financial stresses, and lack of time. Care recipients acknowledged the emotional and financial strain and expressed concern for their spouses. Both caregivers and care recipients were appreciative of home care services although they identified the need for additional services. They also identified difficulties in communication with formal providers and poor coordination of care among the various services. Both caregivers and care recipients disclosed some challenges with informal supports, but on the whole felt that their presence was positive. Additional positive aspects of caregiving reported by spouses included strengthened relationship with their spouse and discovering emotional strength and physical abilities in managing care. SIGNIFICANCE OF RESULTS: Health care and social service professionals need to recognize and understand both caregiver and care recipient perspectives if they are to successfully meet the needs of both members of the dyad.

A sibling-controlled, prospective study of outcomes at home and school in children with severe congenital heart disease

Objectives: The objectives of this study were to compare behaviour problems and competencies, at home and school, in 7-year-old children with congenital heart disease with a sibling control group, to examine the prospective determinants of outcome from infancy, and to explore whether any gains were maintained in our sub-group of children who had participated in a previous trial of psychological interventions in infancy.
Methods: A total of 40 children who had undergone surgery to correct or palliate a significant congenital heart defect in infancy were compared (Child Behavior Checklist) with a nearest-age sibling control group (18 participants). Comparisons were made between sub-groups of children and families who had and had not participated in an early intervention trial.
Results: Problems with attention, thought and social problems, and limitations in activity and school competencies, were found in comparison with siblings. Teacher reports were consistent with parents, although problems were of a lower magnitude. Disease, surgical, and neurodevelopmental functioning in infancy were related to competence outcomes but not behaviour problems. The latter were mediated by family and maternal mental health profiles from infancy. Limited, but encouraging, gains were maintained in the sub-group that had participated in the early intervention programme.
Conclusions: The present study is strengthened by its longitudinal design, use of teacher informants, and sibling control group. The patterns of problems and limitations discerned, and differential determinants thereof, have clear implications for interventions. We consider these in the light of our previously reported intervention trial with this sample and current outcomes at the 7-year follow-up.

Lorentz TEM investigation of the switching behavior in artificial spin ice building blocks

Frustration – the inability to simultaneously satisfy all interactions – occurs in a wide range of systems including neural networks, water ice and magnetic systems. An example of the latter is the so called spin-ice in pyrochlore materials [1] which have attracted a lot of interest not least due to the emergence of magnetic monopole defects when the ‘ice rules’ governing the local ordering breaks down [2]. However it is not possible to directly measure the frustrated property – the direction of the magnetic moments – in such spin ice systems with current experimental techniques. This problem can be solved by instead studying artificial spin-ice systems where the molecular magnetic moments are replaced by nanoscale ferromagnetic islands [3-8]. Two different arrangements of the ferromagnetic islands have been shown to exhibit spin ice behaviour: a square lattice maintaining four moments at each vertex [3,8] and the Kagome lattice which has only three moments per vertex but equivalent interactions between them [4-7]. Magnetic monopole defects have been observed in both types of lattices [7-8]. One of the challenges when studying these artificial spin-ice systems is that it is difficult to arrive at the fully demagnetised ground-state [6-8].
Here we present a study of the switching behaviour of building blocks of the Kagome lattice influenced by the termination of the lattice. Ferromagnetic islands of nominal size 1000 nm by 100 nm were fabricated in five island blocks using electron-beam lithography and lift-off techniques of evaporated 18 nm Permalloy (Ni80Fe20) films. Each block consists of a central island with four arms terminated by a different number and placement of ‘injection pads’, see Figure 1. The islands are single domain and magnetised along their long axis. The structures were grown on a 50 nm thick electron transparent silicon nitride membrane to allow TEM observation, which was back-coated with a 5 nm film of Au to prevent charge build-up during the TEM experiments.
To study the switching behaviour the sample was subjected to a magnetic field strong enough to magnetise all the blocks in one direction, see Figure 1. Each block obeys the Kagome lattice ‘ice-rules’ of “2-in, 1-out” or “1-in, 2-out” in this fully magnetised state. Fresnel mode Lorentz TEM images of the sample were then recorded as a magnetic field of increasing magnitude was applied in the opposite direction. While the Fresnel mode is normally used to image magnetic domain structures [9] for these types of samples it is possible to deduce the direction of the magnetisation from the Lorentz contrast [5]. All images were recorded at the same over-focus judged to give good Lorentz contrast.
The magnetisation was found to switch at different magnitudes of the applied field for nominally identical blocks. However, trends could still be identified: all the blocks with any injection pads, regardless of placement and number, switched the direction of the magnetisation of their central island at significantly smaller magnitudes of the applied magnetic field than the blocks without injection pads. It can therefore be concluded that the addition of an injection pad lowers the energy barrier to switching the connected island, acting as a nucleation site for monopole defects. In these five island blocks the defects immediately propagate through to the other side, but in a larger lattice the monopoles could potentially become trapped at a vertex and observed [10].
References

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[3] R F Wang et al, Nature 439 (2006) 303.
[4] M Tanaka et al, Phys Rev B 73 (2006) 052411.
[5] Y Qi, T Brintlinger and J Cumings, Phys Rev B 77 (2008) 094418.
[6] E Mengotti et al, Phys Rev B 78 (2008) 144402.
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[10] The authors gratefully acknowledge funding from the EPSRC under grant number EP/D063329/1.