Changing healthcare: stakeholder perceptions of the burden of chronic disease and the value of teams, measurements and communication.

Canadian healthcare is changing. Over the course of the past decade, the Health Care in Canada Survey (HCIC) has annually measured the reactions of the public and professional stakeholders to many of these change forces. In HCIC 2008, for the first time, the public's perception of their health status and all stakeholders' views of the burden and effective management of chronic diseases were sought. Overall, Canadians perceive themselves as healthy, with 84% of adults reporting good-to-excellent health. However, good health decreased with age as the occurrence of chronic illness rose, from 12% in the age group 18-24 to 65% for the population =65 years. More than 70% of all stakeholders were strongly or somewhat supportive of the implementation of coordinated care, or disease management programs, to improve the care of patients with chronic illnesses. Concordant support was also expressed for key disease management components, including coordinated interventions to improve home, community and self-care; increased wellness promotion; and increased use of clinical measurements and feedback to all stakeholders. However, there were also important areas of non-concordance. For example, the public and doctors consistently expressed less support than other stakeholders for the value of team care, including the use of non-physician professionals to provide patient care; increased patient involvement in decision-making; and the use of electronic health records to facilitate communication. The actual participation in disease management programs averaged 34% for professionals and 25% for the public. We conclude that chronic diseases are common, age-related and burdensome in Canada. Disease management or coordinated intervention often delivered by teams is also relatively common, despite its less-than-universal acceptance by all stakeholders. Further insights are needed, particularly into the variable perceptions of the value and efficacy of team-delivered healthcare and its important components.

Transnational authority in the knowledge-based economy: Who sets the standards of ICT training and certification?

This article examines the extent and limits of nonstate forms of authority in international relations. It analyzes how the information and communication technology (ICT) infrastructure for the tradability of services in a global knowledge-based economy relies on informal regulatory practices for the adjustment of ICT-related skills. By focusing on the challenge that highly volatile and short-lived cycles of demands for this type of knowledge pose for ensuring the right qualification of the labor force, the article explores how companies and associations provide training and certification programs as part of a growing market for educational services setting their own standards. The existing literature on non-conventional forms of authority in the global political economy has emphasized that the consent of actors, subject to informal rules and some form of state support, remains crucial for the effectiveness of those new forms of power. However, analyses based on a limited sample of actors tend toward a narrow understanding of the issues concerned and fail to fully explore the differentiated space in which non state authority is emerging. This article develops a three-dimensional analytical framework that brings together the scope of the issues involved, the range of nonstate actors concerned, and the spatial scope of their authority. The empirical findings highlight the limits of these new forms of nonstate authority and shed light on the role of the state and international governmental organizations in this new context.

Comprehensive Expression Analyses of Neural Cell-Type-Specific miRNAs Identify New Determinants of the Specification and Maintenance of Neuronal Phenotypes.

MicroRNAs (miRNAs) have been shown to play important roles in both brain development and the regulation of adult neural cell functions. However, a systematic analysis of brain miRNA functions has been hindered by a lack of comprehensive information regarding the distribution of miRNAs in neuronal versus glial cells. To address this issue, we performed microarray analyses of miRNA expression in the four principal cell types of the CNS (neurons, astrocytes, oligodendrocytes, and microglia) using primary cultures from postnatal d 1 rat cortex. These analyses revealed that neural miRNA expression is highly cell-type specific, with 116 of the 351 miRNAs examined being differentially expressed fivefold or more across the four cell types. We also demonstrate that individual neuron-enriched or neuron-diminished RNAs had a significant impact on the specification of neuronal phenotype: overexpression of the neuron-enriched miRNAs miR-376a and miR-434 increased the differentiation of neural stem cells into neurons, whereas the opposite effect was observed for the glia-enriched miRNAs miR-223, miR-146a, miR-19, and miR-32. In addition, glia-enriched miRNAs were shown to inhibit aberrant glial expression of neuronal proteins and phenotypes, as exemplified by miR-146a, which inhibited neuroligin 1-dependent synaptogenesis. This study identifies new nervous system functions of specific miRNAs, reveals the global extent to which the brain may use differential miRNA expression to regulate neural cell-type-specific phenotypes, and provides an important data resource that defines the compartmentalization of brain miRNAs across different cell types.

Global regulation of the knowledge-based economy: The rise of standards in educational services

This article examines the extent and limits of non-state forms of authority in international relations. It analyses how the information and communication technology (ICT) infrastructure for the tradability of services in a global knowledge-based economy relies on informal regulatory practices for adjustment of ICT-related skills. Companies and associations provide training and certification programmes as part of a growing market for educational services setting their own standards. The existing literature on non-conventional forms of authority in the global political economy has emphasised that the consent of actors subject to informal rules and explicit or implicit state recognition remains crucial for the effectiveness of those new forms of power. However, analyses based on a limited sample of actors tend toward a narrow understanding of the issues and fail to fully explore the differentiated space in which non-state authority is emerging. This paper examines the form of authority underpinning the global knowledge-based economy within the broader perspective of the issues likely to be standardised by technical ICT specification, the wide range of actors involved, and the highly differentiated space where standards become authoritative. The empirical findings highlight the role of different private actors in establishing international educational norms in this field. They also pinpoint the limits of profit-oriented standard-settings, notably with regard to generic norms.

Evaluation of email alerts in practice: Part 2. Validation of the information assessment method.

RATIONALE AND OBJECTIVE:. The information assessment method (IAM) permits health professionals to systematically document the relevance, cognitive impact, use and health outcomes of information objects delivered by or retrieved from electronic knowledge resources. The companion review paper (Part 1) critically examined the literature, and proposed a 'Push-Pull-Acquisition-Cognition-Application' evaluation framework, which is operationalized by IAM. The purpose of the present paper (Part 2) is to examine the content validity of the IAM cognitive checklist when linked to email alerts. METHODS: A qualitative component of a mixed methods study was conducted with 46 doctors reading and rating research-based synopses sent on email. The unit of analysis was a doctor's explanation of a rating of one item regarding one synopsis. Interviews with participants provided 253 units that were analysed to assess concordance with item definitions. RESULTS AND CONCLUSION: The content relevance of seven items was supported. For three items, revisions were needed. Interviews suggested one new item. This study has yielded a 2008 version of IAM.

Stereological analysis of the rat and monkey amygdala

The amygdala is part of a neural network that contributes to the regulation of emotional behaviors. Rodents, especially rats, are used extensively as model organisms to decipher the functions of specific amygdala nuclei, in particular in relation to fear and emotional learning. Analysis of the role of the nonhuman primate amygdala in these functions has lagged work in the rodent but provides evidence for conservation of basic functions across species. Here we provide quantitative information regarding the morphological characteristics of the main amygdala nuclei in rats and monkeys, including neuron and glial cell numbers, neuronal soma size, and individual nuclei volumes. The volumes of the lateral, basal, and accessory basal nuclei were, respectively, 32, 39, and 39 times larger in monkeys than in rats. In contrast, the central and medial nuclei were only 8 and 4 times larger in monkeys than in rats. The numbers of neurons in the lateral, basal, and accessory basal nuclei were 14, 11, and 16 times greater in monkeys than in rats, whereas the numbers of neurons in the central and medial nuclei were only 2.3 and 1.5 times greater in monkeys than in rats. Neuron density was between 2.4 and 3.7 times lower in monkeys than in rats, whereas glial density was only between 1.1 and 1.7 times lower in monkeys than in rats. We compare our data in rats and monkeys with those previously published in humans and discuss the theoretical and functional implications that derive from our quantitative structural findings.

Angiotensin converting enzyme inhibitor induced angio-oedema: a review of the pathophysiology and risk factors.

Angio-oedema (AE) is a known adverse effect of angiotensin converting enzyme inhibitor (ACE-I) therapy. Over the past several decades, evidence of failure to diagnose this important and potentially fatal reaction is commonly found in the literature. Because this reaction is often seen first in the primary care setting, a review was undertaken to analyse and document the keys to both diagnostic criteria as well as to investigate potential risk factors for ACE-I AE occurrence. A general review of published literature was conducted through Medline, EMBASE, and the Cochrane Database, targeting ACE-I-related AE pathomechanism, diagnosis, epidemiology, risk factors, and clinical decision making and treatment. The incidence and severity of AE appears to be on the rise and there is evidence of considerable delay in diagnosis contributing to significant morbidity and mortality for patients. The mechanism of AE due to ACE-I drugs is not fully understood, but some genomic and metabolomic information has been correlated. Additional epidemiologic data and clinical treatment outcome predictors have been evaluated, creating a basis for future work on the development of clinical prediction tools to aid in risk identification and diagnostic differentiation. Accurate recognition of AE by the primary care provider is essential to limit the rising morbidity associated with ACE-I treatment-related AE. Research findings on the phenotypic indicators relevant to this group of patients as well as basic research into the pathomechanism of AE are available, and should be used in the construction of better risk analysis and clinical diagnostic tools for ACE-I AE.

Ingénieur pédagogique et démarche projet : facteurs clés de succès pour l'intégration des technologies dans la pratique enseignante?

Résumé: Les gouvernements des pays occidentaux ont dépensé des sommes importantes pour faciliter l'intégration des technologies de l'information et de la communication dans l'enseignement espérant trouver une solution économique à l'épineuse équation que l'on pourrait résumer par la célèbre formule " faire plus et mieux avec moins ". Cependant force est de constater que, malgré ces efforts et la très nette amélioration de la qualité de service des infrastructures, cet objectif est loin d'être atteint. Si nous pensons qu'il est illusoire d'attendre et d'espérer que la technologie peut et va, à elle seule, résoudre les problèmes de qualité de l'enseignement, nous croyons néanmoins qu'elle peut contribuer à améliorer les conditions d'apprentissage et participer de la réflexion pédagogique que tout enseignant devrait conduire avant de dispenser ses enseignements. Dans cette optique, et convaincu que la formation à distance offre des avantages non négligeables à condition de penser " autrement " l'enseignement, nous nous sommes intéressé à la problématique du développement de ce type d'applications qui se situent à la frontière entre les sciences didactiques, les sciences cognitives, et l'informatique. Ainsi, et afin de proposer une solution réaliste et simple permettant de faciliter le développement, la mise-à-jour, l'insertion et la pérennisation des applications de formation à distance, nous nous sommes impliqué dans des projets concrets. Au fil de notre expérience de terrain nous avons fait le constat que (i)la qualité des modules de formation flexible et à distance reste encore très décevante, entre autres parce que la valeur ajoutée que peut apporter l'utilisation des technologies n'est, à notre avis, pas suffisamment exploitée et que (ii)pour réussir tout projet doit, outre le fait d'apporter une réponse utile à un besoin réel, être conduit efficacement avec le soutien d'un " champion ". Dans l'idée de proposer une démarche de gestion de projet adaptée aux besoins de la formation flexible et à distance, nous nous sommes tout d'abord penché sur les caractéristiques de ce type de projet. Nous avons ensuite analysé les méthodologies de projet existantes dans l'espoir de pouvoir utiliser l'une, l'autre ou un panachage adéquat de celles qui seraient les plus proches de nos besoins. Nous avons ensuite, de manière empirique et par itérations successives, défini une démarche pragmatique de gestion de projet et contribué à l'élaboration de fiches d'aide à la décision facilitant sa mise en oeuvre. Nous décrivons certains de ses acteurs en insistant particulièrement sur l'ingénieur pédagogique que nous considérons comme l'un des facteurs clé de succès de notre démarche et dont la vocation est de l'orchestrer. Enfin, nous avons validé a posteriori notre démarche en revenant sur le déroulement de quatre projets de FFD auxquels nous avons participé et qui sont représentatifs des projets que l'on peut rencontrer dans le milieu universitaire. En conclusion nous pensons que la mise en oeuvre de notre démarche, accompagnée de la mise à disposition de fiches d'aide à la décision informatisées, constitue un atout important et devrait permettre notamment de mesurer plus aisément les impacts réels des technologies (i) sur l'évolution de la pratique des enseignants, (ii) sur l'organisation et (iii) sur la qualité de l'enseignement. Notre démarche peut aussi servir de tremplin à la mise en place d'une démarche qualité propre à la FFD. D'autres recherches liées à la réelle flexibilisation des apprentissages et aux apports des technologies pour les apprenants pourront alors être conduites sur la base de métriques qui restent à définir. Abstract: Western countries have spent substantial amount of monies to facilitate the integration of the Information and Communication Technologies (ICT) into Education hoping to find a solution to the touchy equation that can be summarized by the famous statement "do more and better with less". Despite these efforts, and notwithstanding the real improvements due to the undeniable betterment of the infrastructure and of the quality of service, this goal is far from reached. Although we think it illusive to expect technology, all by itself, to solve our economical and educational problems, we firmly take the view that it can greatly contribute not only to ameliorate learning conditions but participate to rethinking the pedagogical approach as well. Every member of our community could hence take advantage of this opportunity to reflect upon his or her strategy. In this framework, and convinced that integrating ICT into education opens a number of very interesting avenues provided we think teaching "out of the box", we got ourself interested in courseware development positioned at the intersection of didactics and pedagogical sciences, cognitive sciences and computing. Hence, and hoping to bring a realistic and simple solution that could help develop, update, integrate and sustain courseware we got involved in concrete projects. As ze gained field experience we noticed that (i)The quality of courseware is still disappointing, amongst others, because the added value that the technology can bring is not made the most of, as it could or should be and (ii)A project requires, besides bringing a useful answer to a real problem, to be efficiently managed and be "championed". Having in mind to propose a pragmatic and practical project management approach we first looked into open and distance learning characteristics. We then analyzed existing methodologies in the hope of being able to utilize one or the other or a combination to best fit our needs. In an empiric manner and proceeding by successive iterations and refinements, we defined a simple methodology and contributed to build descriptive "cards" attached to each of its phases to help decision making. We describe the different actors involved in the process insisting specifically on the pedagogical engineer, viewed as an orchestra conductor, whom we consider to be critical to ensure the success of our approach. Last but not least, we have validated a posteriori our methodology by reviewing four of the projects we participated to and that we think emblematic of the university reality. We believe that the implementation of our methodology, along with the availability of computerized cards to help project managers to take decisions, could constitute a great asset and contribute to measure the technologies' real impacts on (i) the evolution of teaching practices (ii) the organization and (iii) the quality of pedagogical approaches. Our methodology could hence be of use to help put in place an open and distance learning quality assessment. Research on the impact of technologies to learning adaptability and flexibilization could rely on adequate metrics.

Indications for cardiovascular magnetic resonance in children with congenital and acquired heart disease: an expert consensus paper of the Imaging Working Group of the AEPC and the Cardiovascular Magnetic Resonance Section of the EACVI.

This article provides expert opinion on the use of cardiovascular magnetic resonance (CMR) in young patients with congenital heart disease (CHD) and in specific clinical situations. As peculiar challenges apply to imaging children, paediatric aspects are repeatedly discussed. The first section of the paper addresses settings and techniques, including the basic sequences used in paediatric CMR, safety, and sedation. In the second section, the indication, application, and clinical relevance of CMR in the most frequent CHD are discussed in detail. In the current era of multimodality imaging, the strengths of CMR are compared with other imaging modalities. At the end of each chapter, a brief summary with expert consensus key points is provided. The recommendations provided are strongly clinically oriented. The paper addresses not only imagers performing CMR, but also clinical cardiologists who want to know which information can be obtained by CMR and how to integrate it in clinical decision-making.

Twenty years of research into Chlamydia-like organisms: a revolution in our understanding of the biology and pathogenicity of members of the phylum Chlamydiae.

Chlamydiae are obligate intracellular bacteria that share a unique but remarkably conserved biphasic developmental cycle that relies on a eukaryotic host cell for survival. Although the phylum was originally thought to only contain one family, the Chlamydiaceae, a total of nine families are now recognized. These so-called Chlamydia-like organisms (CLOs) are also referred to as 'environmental chlamydiae', as many were initially isolated from environmental sources. However, these organisms are also emerging pathogens, as many, such as Parachlamydia sp., Simkania sp. and Waddlia sp., have been associated with human disease, and others, such as Piscichlamydia sp. and Parilichlamydia sp., have been documented in association with diseases in animals. Their strict intracellular nature and the requirement for cell culture have been a confounding factor in characterizing the biology and pathogenicity of CLOs. Nevertheless, the genomes of seven CLO species have now been sequenced, providing new information on their potential ability to adapt to a wide range of hosts. As new isolation and diagnostic methods advance, we are able to further explore the richness of this phylum with further research likely to help define the true pathogenic potential of the CLOs while also providing insight into the origins of the 'traditional' chlamydiae.

Indications for cardiovascular magnetic resonance in children with congenital and acquired heart disease: an expert consensus paper of the Imaging Working Group of the AEPC and the Cardiovascular Magnetic Resonance Section of the EACVI.

This article provides expert opinion on the use of cardiovascular magnetic resonance (CMR) in young patients with congenital heart disease (CHD) and in specific clinical situations. As peculiar challenges apply to imaging children, paediatric aspects are repeatedly discussed. The first section of the paper addresses settings and techniques, including the basic sequences used in paediatric CMR, safety, and sedation. In the second section, the indication, application, and clinical relevance of CMR in the most frequent CHD are discussed in detail. In the current era of multimodality imaging, the strengths of CMR are compared with other imaging modalities. At the end of each chapter, a brief summary with expert consensus key points is provided. The recommendations provided are strongly clinically oriented. The paper addresses not only imagers performing CMR, but also clinical cardiologists who want to know which information can be obtained by CMR and how to integrate it in clinical decision-making.

Fingermark age determinations: legal considerations, review of the literature and practical propositions

The question of the age of fingermarks is often raised in investigations and trials when suspects admit that they have left their fingermarks at a crime scene but allege that the contact occurred at a different time than the crime and for legal reasons. In the first part of this review article, examples from American appellate court cases will be used to demonstrate that there is a lack of consensus among American courts regarding the admissibility and weight of testimony from expert witnesses who provide opinions about the age of fingermarks. Of course, these issues are not only encountered in America but have also been reported elsewhere, for example in Europe. The disparity in the way fingermark dating cases were managed in these examples is probably due to the fact that no methodology has been validated and accepted by the forensic science community so far. The second part of this review article summarizes the studies reported on fingermark dating in the literature and highlights the fact that most proposed methodologies still suffer from limitations preventing their use in practice. Nevertheless, several approaches based on the evolution of aging parameters detected in fingermark residue over time appear to show promise for the fingermark dating field. Based on these approaches, the definition of a formal methodological framework for fingermark dating cases is proposed in order to produce relevant temporal information. This framework identifies which type of information could and should be obtained about fingermark aging and what developments are still required to scientifically address dating issues.