Surrogate decision making for patients with end-stage dementia.

OBJECTIVE: We aim to explore how health surrogates of patients with dementia proceed in decision making, which considerations are decisive, and whether family surrogates and professional guardians decide differently. METHODS: We conducted an experimental vignette study using think aloud protocol analysis. Thirty-two family surrogates and professional guardians were asked to decide on two hypothetical case vignettes, concerning a feeding tube placement and a cardiac pacemaker implantation in patients with end-stage dementia. They had to verbalize their thoughts while deciding. Verbalizations were audio-recorded, transcribed, and analyzed according to content analysis. By experimentally changing variables in the vignettes, the impact of these variables on the outcome of decision making was calculated. RESULTS: Although only 25% and 31% of the relatives gave their consent to the feeding tube and pacemaker placement, respectively, 56% and 81% of the professional guardians consented to these life-sustaining measures. Relatives decided intuitively, referred to their own preferences, and focused on the patient's age, state of wellbeing, and suffering. Professional guardians showed a deliberative approach, relied on medical and legal authorities, and emphasized patient autonomy. Situational variables such as the patient's current behavior and the views of health care professionals and family members had higher impacts on decisions than the patient's prior statements or life attitudes. CONCLUSIONS: Both the process and outcome of surrogate decision making depend heavily on whether the surrogate is a relative or not. These findings have implications for the physician-surrogate relationship and legal frameworks regarding surrogacy. Copyright © 2011 John Wiley & Sons, Ltd.

Mobile phone use and brain tumors in children and adolescents: a multicenter case-control study.

Background It has been hypothesized that children and adolescents might be more vulnerable to possible health effects from mobile phone exposure than adults. We investigated whether mobile phone use is associated with brain tumor risk among children and adolescents. Methods CEFALO is a multicenter case-control study conducted in Denmark, Sweden, Norway, and Switzerland that includes all children and adolescents aged 7-19 years who were diagnosed with a brain tumor between 2004 and 2008. We conducted interviews, in person, with 352 case patients (participation rate: 83%) and 646 control subjects (participation rate: 71%) and their parents. Control subjects were randomly selected from population registries and matched by age, sex, and geographical region. We asked about mobile phone use and included mobile phone operator records when available. Odds ratios (ORs) for brain tumor risk and 95% confidence intervals (CIs) were calculated using conditional logistic regression models. Results Regular users of mobile phones were not statistically significantly more likely to have been diagnosed with brain tumors compared with nonusers (OR = 1.36; 95% CI = 0.92 to 2.02). Children who started to use mobile phones at least 5 years ago were not at increased risk compared with those who had never regularly used mobile phones (OR = 1.26, 95% CI = 0.70 to 2.28). In a subset of study participants for whom operator recorded data were available, brain tumor risk was related to the time elapsed since the mobile phone subscription was started but not to amount of use. No increased risk of brain tumors was observed for brain areas receiving the highest amount of exposure. Conclusion The absence of an exposure-response relationship either in terms of the amount of mobile phone use or by localization of the brain tumor argues against a causal association.

An overview of conservative treatment for lower back pain

This article summarizes the available evidence on the management of patients with subacute or chronic low back pain. The largest part is devoted to nonspecific low back pain but the models of spinal stenosis and disk herniation/sciatica are also specifically addressed. The authors point out the limited evidence available and the importance of a tailored approach for the individual patient. As the effect sizes of most therapies are rather small (close to that of a placebo), patients' preferences and other variables important for individualized management are highlighted. The task for the practitioner is difficult and awareness of this is important. Some speculation regarding potential future ways of improving patient care are presented.

Precise U-Pb age constraints for end-Triassic mass extinction, its correlation to volcanism and Hettangian post-extinction recovery

New precise zircon U-Pb ages are proposed for the Triassic-Jurassic (Rhetian-Hettangian) and the Hettangian-Sinemurian boundaries, The ages were obtained by ID-TIMS dating of single chemical-abraded zircons from volcanic ash layers within the Pucara Group, Aramachay Formation in the Utcubamba valley, northern Peru. Ash layers situated between last and first occurrences of boundary-defining ammonites yielded Pb-206/U-238 ages of 201.58 +/- 0.17/0.28 Ma (95% c.l., uncertainties without/with decay constant errors, respectively) for the Triassic-Jurassic and of 199.53 +/- 0.19/0.29 Ma for the Hettangian-Sinemurian boundaries. The former is established on a tuff located 1 m above the last local occurrence of the topmost Triassic genus Choristoceras, and 5 m below the Hettangian genus Psiloceras. The latter sample was obtained from a tuff collected within the Badouxia canadensis beds. Our new ages document total duration of the Hettagian of no more than c. 2 m.y., which has fundamental implications for the interpretation and significance of the ammonite recovery after the topmost Triassic extinction. The U-Pb age is about 0.8 +/- 0.5% older than Ar-40-Ar-39 dates determined on flood basalts of the Central Atlantic Magmatic Province (CAMP). Given the widely accepted hypothesis that inaccuracies in the K-40 decay constants or physical constants create a similar bias between the two dating methods, our new U-Pb zircon age determination for the T/J boundary corroborates the hypothesis that the CAMP was emplaced at the same time and may be responsible for a major climatic turnover and mass extinction. The zircon Pb-206/U-238 age for the T/J boundary is marginally older than the North Mountain Basalt (Newark Supergroup, Nova Scotia, Canada), which has been dated at 201.27 +/- 0.06 Ma [Schoene et al., 2006. Geochim. Cosmochim. Acta 70, 426-445]. It will be important to look for older eruptions of the CAMP and date them precisely by U-Pb techniques while addressing all sources of systematic uncertainty to further test the hypothesis of volcanic induced climate change leading to extinction. Such high-precision, high-accuracy data will be instrumental for constraining the contemporaneity of geological events at a 100 kyr level. (C) 2007 Elsevier B.V. All rights reserved.

There and back again? Combining habitat suitability modelling and connectivity analyses to assess a potential return of the otter to Switzerland

After a steady decline in the early 20th century, several terrestrial carnivore species have recently recovered in Western Europe, either through reintroductions or natural recolonization. Because of the large space requirements of these species and potential conflicts with human activities, ensuring their recovery requires the implementation of conservation and management measures that address the environmental, landscape and social dimensions of the problem. Few examples exist of such integrated management. Taking the case of the otter (Lutra lutra) in Switzerland, we propose a multi-step approach that allows to (1) identify areas with potentially suitable habitat, (2) evaluate their connectivity, (3) verify the potentiality of the species recolonization from populations in neighbouring countries. We showed that even though suitable habitat is available for the species and the level of structural connectivity within Switzerland is satisfactory, the level of connectivity with neighbouring populations is crucial to prioritize strategies that favour the species recovery in the field. This research is the first example integrating habitat suitability and connectivity assessment at different scales with other factors in a multi-step assessment for species recovery.

A joint back calculation model for the imputation of the date of HIV infection in a prevalent cohort.

In studies of the natural history of HIV-1 infection, the time scale of primary interest is the time since infection. Unfortunately, this time is very often unknown for HIV infection and using the follow-up time instead of the time since infection is likely to provide biased results because of onset confounding. Laboratory markers such as the CD4 T-cell count carry important information concerning disease progression and can be used to predict the unknown date of infection. Previous work on this topic has made use of only one CD4 measurement or based the imputation on incident patients only. However, because of considerable intrinsic variability in CD4 levels and because incident cases are different from prevalent cases, back calculation based on only one CD4 determination per person or on characteristics of the incident sub-cohort may provide unreliable results. Therefore, we propose a methodology based on the repeated individual CD4 T-cells marker measurements that use both incident and prevalent cases to impute the unknown date of infection. Our approach uses joint modelling of the time since infection, the CD4 time path and the drop-out process. This methodology has been applied to estimate the CD4 slope and impute the unknown date of infection in HIV patients from the Swiss HIV Cohort Study. A procedure based on the comparison of different slope estimates is proposed to assess the goodness of fit of the imputation. Results of simulation studies indicated that the imputation procedure worked well, despite the intrinsic high volatility of the CD4 marker.

Disentangling the Hettangian carbon isotope record: Implications for the aftermath of the end-Triassic mass extinction

This study provides an organic carbon stable isotope (delta(13)C(org)) record calibrated with detailed ammonite biostratigraphy, following the end-Triassic biological crisis. Precise correlation between this crucial fossil group and the delta(13)C(org) record is key to understanding feedbacks between biological and environmental events following mass extinction. The latest Triassic and Hettangian delta(13)C(org) record shows several negative and positive excursions. The end-Triassic negative shift coinciding with the mass extinction interval is followed by a positive excursion in the earliest Hettangian Psiloceras spelae beds, which marks the onset of recovery in the marine ecosystem. This positive trend is interrupted by a second negative delta(13)C(org) excursion in the P. pacificum beds related to a minor ammonite extinction event. This pattern of the delta(13)C(org) curve culminates in the uppermost Hettangian Angulata Zone major positive excursion. This indicates that both the ecosystem and the carbon cycle remained in a state of perturbation for at least 2 Ma, although the recovery of some pelagic taxa already began at the base of Jurassic. The early and late Hettangian positive delta(13)C(org) excursions have been confused in several recent papers. Here, we show that during the Hettangian there are indeed two distinct positive delta(13)C(org) excursions. Phases of anoxia and further pulses of Central Atlantic Magmatic Province volcanism during the Hettangian might have inhibited the full recovery for that interval of time. The main Liasicus-Angulata organic positive CIE (carbon isotope excursion) during the Late Hettangian might be related to gradual decreasing of pCO(2) due to protracted high organic burial, and coincides with a second phase of recovery, as indicated by a pulse of ammonoid diversification.

Endoleak and in-stent thrombus detection with CT angiography in a thoracic aortic aneurysm phantom at different tube energies using filtered back projection and iterative algorithms.

PURPOSE: To determine the lower limit of dose reduction with hybrid and fully iterative reconstruction algorithms in detection of endoleaks and in-stent thrombus of thoracic aorta with computed tomographic (CT) angiography by applying protocols with different tube energies and automated tube current modulation. MATERIALS AND METHODS: The calcification insert of an anthropomorphic cardiac phantom was replaced with an aortic aneurysm model containing a stent, simulated endoleaks, and an intraluminal thrombus. CT was performed at tube energies of 120, 100, and 80 kVp with incrementally increasing noise indexes (NIs) of 16, 25, 34, 43, 52, 61, and 70 and a 2.5-mm section thickness. NI directly controls radiation exposure; a higher NI allows for greater image noise and decreases radiation. Images were reconstructed with filtered back projection (FBP) and hybrid and fully iterative algorithms. Five radiologists independently analyzed lesion conspicuity to assess sensitivity and specificity. Mean attenuation (in Hounsfield units) and standard deviation were measured in the aorta to calculate signal-to-noise ratio (SNR). Attenuation and SNR of different protocols and algorithms were analyzed with analysis of variance or Welch test depending on data distribution. RESULTS: Both sensitivity and specificity were 100% for simulated lesions on images with 2.5-mm section thickness and an NI of 25 (3.45 mGy), 34 (1.83 mGy), or 43 (1.16 mGy) at 120 kVp; an NI of 34 (1.98 mGy), 43 (1.23 mGy), or 61 (0.61 mGy) at 100 kVp; and an NI of 43 (1.46 mGy) or 70 (0.54 mGy) at 80 kVp. SNR values showed similar results. With the fully iterative algorithm, mean attenuation of the aorta decreased significantly in reduced-dose protocols in comparison with control protocols at 100 kVp (311 HU at 16 NI vs 290 HU at 70 NI, P ≤ .0011) and 80 kVp (400 HU at 16 NI vs 369 HU at 70 NI, P ≤ .0007). CONCLUSION: Endoleaks and in-stent thrombus of thoracic aorta were detectable to 1.46 mGy (80 kVp) with FBP, 1.23 mGy (100 kVp) with the hybrid algorithm, and 0.54 mGy (80 kVp) with the fully iterative algorithm.

System-level Support for Mobile Ad hoc Communications: an Algorithmic & Practical Approach

A mobile ad hoc network (MANET) is a decentralized and infrastructure-less network. This thesis aims to provide support at the system-level for developers of applications or protocols in such networks. To do this, we propose contributions in both the algorithmic realm and in the practical realm. In the algorithmic realm, we contribute to the field by proposing different context-aware broadcast and multicast algorithms in MANETs, namely six-shot broadcast, six-shot multicast, PLAN-B and ageneric algorithmic approach to optimize the power consumption of existing algorithms. For each algorithm we propose, we compare it to existing algorithms that are either probabilistic or context-aware, and then we evaluate their performance based on simulations. We demonstrate that in some cases, context-aware information, such as location or signal-strength, can improve the effciency. In the practical realm, we propose a testbed framework, namely ManetLab, to implement and to deploy MANET-specific protocols, and to evaluate their performance. This testbed framework aims to increase the accuracy of performance evaluation compared to simulations, while keeping the ease of use offered by the simulators to reproduce a performance evaluation. By evaluating the performance of different probabilistic algorithms with ManetLab, we observe that both simulations and testbeds should be used in a complementary way. In addition to the above original contributions, we also provide two surveys about system-level support for ad hoc communications in order to establish a state of the art. The first is about existing broadcast algorithms and the second is about existing middleware solutions and the way they deal with privacy and especially with location privacy. - Un réseau mobile ad hoc (MANET) est un réseau avec une architecture décentralisée et sans infrastructure. Cette thèse vise à fournir un support adéquat, au niveau système, aux développeurs d'applications ou de protocoles dans de tels réseaux. Dans ce but, nous proposons des contributions à la fois dans le domaine de l'algorithmique et dans celui de la pratique. Nous contribuons au domaine algorithmique en proposant différents algorithmes de diffusion dans les MANETs, algorithmes qui sont sensibles au contexte, à savoir six-shot broadcast,six-shot multicast, PLAN-B ainsi qu'une approche générique permettant d'optimiser la consommation d'énergie de ces algorithmes. Pour chaque algorithme que nous proposons, nous le comparons à des algorithmes existants qui sont soit probabilistes, soit sensibles au contexte, puis nous évaluons leurs performances sur la base de simulations. Nous montrons que, dans certains cas, des informations liées au contexte, telles que la localisation ou l'intensité du signal, peuvent améliorer l'efficience de ces algorithmes. Sur le plan pratique, nous proposons une plateforme logicielle pour la création de bancs d'essai, intitulé ManetLab, permettant d'implémenter, et de déployer des protocoles spécifiques aux MANETs, de sorte à évaluer leur performance. Cet outil logiciel vise à accroître la précision desévaluations de performance comparativement à celles fournies par des simulations, tout en conservant la facilité d'utilisation offerte par les simulateurs pour reproduire uneévaluation de performance. En évaluant les performances de différents algorithmes probabilistes avec ManetLab, nous observons que simulateurs et bancs d'essai doivent être utilisés de manière complémentaire. En plus de ces contributions principales, nous fournissons également deux états de l'art au sujet du support nécessaire pour les communications ad hoc. Le premier porte sur les algorithmes de diffusion existants et le second sur les solutions de type middleware existantes et la façon dont elles traitent de la confidentialité, en particulier celle de la localisation.

High-precision satellite positioning system as a new tool to study the biomechanics of human locomotion.

New Global Positioning System (GPS) receivers allow now to measure a location on earth at high frequency (5Hz) with a centimetric precision using phase differential positioning method. We studied whether such technique was accurate enough to retrieve basic parameters of human locomotion. Eight subjects walked on an athletics track at four different imposed step frequencies (70-130steps/min) plus a run at free pace. Differential carrier phase localization between a fixed base station and the mobile antenna mounted on the walking person was calculated. In parallel, a triaxial accelerometer, attached to the low back, recorded body accelerations. The different parameters were averaged for 150 consecutive steps of each run for each subject (total of 6000 steps analyzed). We observed a perfect correlation between average step duration measured by accelerometer and by GPS (r=0.9998, N=40). Two important parameters for the calculation of the external work of walking were also analyzed, namely the vertical lift of the trunk and the velocity variation per step. For an average walking speed of 4.0km/h, average vertical lift and velocity variation were, respectively, 4.8cm and 0.60km/h. The average intra-individual step-to-step variability at a constant speed, which includes GPS errors and the biological gait style variation, were found to be 24. 5% (coefficient of variation) for vertical lift and 44.5% for velocity variation. It is concluded that GPS technique can provide useful biomechanical parameters for the analysis of an unlimited number of strides in an unconstrained free-living environment.

Prevalence of Joint Hypermobility and Joint Hypermobility Syndrome in a Swiss population with Chronic Low Back Pain

Objective¦Joint hypermobility (JH) and Joint Hypermobility Syndrome (JHS) are often underdiagnosed¦and were never specifically assessed in a selected population of chronic low back pain¦(LBP). This study aimed to assess JH and JHS among a population with chronic LBP using the¦Beighton and the Brigthon criteria.¦Methods¦We conducted a retrospective cross-sectional study based on a prospective data base¦among 143 patients with non-specific chronic LBP. Patients were seen by the same rheumatologist,¦who looked for JH and JHS and took their medical history. Data were analysed using logistic¦regression.¦Results¦We found a JH prevalence of 33,3% (CI 95% 22.0-44.6) among women and 21,4% (11.7-¦31.2) among men, and for JHS, of 37,9% (26.0-49.8) among women and 30,9% (19.7-42.0) among¦men. JH was less frequent among people older than fifty (P < 0.02). JHS was more prevalent among¦Swiss individuals (P < 0.01) and among individuals having a non-manual job (P<0.03) compared to¦there opposites. Patients having an important limitation for daily living activities were four times¦more likely to have JHS. Degenerative spinal disorders were negatively associated with JH (OR¦0.31 (0.13-0.73) and JHS (OR 0.31 (0.14-0.68).¦Conclusion¦A high prevalence of joint hypermobility was found in our population. JHS should be¦part of differential diagnosis in individuals with chronic non-specific LBP.