The adherence to initial processes of care in elderly patients with acute venous thromboembolism.

BACKGROUND We aimed to assess whether elderly patients with acute venous thromboembolism (VTE) receive recommended initial processes of care and to identify predictors of process adherence. METHODS We prospectively studied in- and outpatients aged ≥65 years with acute symptomatic VTE in a multicenter cohort study from nine Swiss university- and non-university hospitals between September 2009 and March 2011. We systematically assessed whether initial processes of care, which are recommended by the 2008 American College of Chest Physicians guidelines, were performed in each patient. We used multivariable logistic models to identify patient factors independently associated with process adherence. RESULTS Our cohort comprised 950 patients (mean age 76 years). Of these, 86% (645/750) received parenteral anticoagulation for ≥5 days, 54% (405/750) had oral anticoagulation started on the first treatment day, and 37% (274/750) had an international normalized ratio (INR) ≥2 for ≥24 hours before parenteral anticoagulation was discontinued. Overall, 35% (53/153) of patients with cancer received low-molecular-weight heparin monotherapy and 72% (304/423) of patients with symptomatic deep vein thrombosis were prescribed compression stockings. In multivariate analyses, symptomatic pulmonary embolism, hospital-acquired VTE, and concomitant antiplatelet therapy were associated with a significantly lower anticoagulation-related process adherence. CONCLUSIONS Adherence to several recommended processes of care was suboptimal in elderly patients with VTE. Quality of care interventions should particularly focus on processes with low adherence, such as the prescription of continued low-molecular-weight heparin therapy in patients with cancer and the achievement of an INR ≥2 for ≥24 hours before parenteral anticoagulants are stopped.

Sources and contributions of wood smoke during winter in London: assessing local and regional influences

Determining the contribution of wood smoke to air pollution in large cities such as London is becoming increasingly important due to the changing nature of domestic heating in urban areas. During winter, biomass burning emissions have been identified as a major cause of exceedances of European air quality limits. The aim of this work was to quantify the contribution of biomass burning in London to concentrations of PM2:5 and determine whether local emissions or regional contributions were the main source of biomass smoke. To achieve this, a number of biomass burning chemical tracers were analysed at a site within central London and two sites in surrounding rural areas. Concentrations of levoglucosan, elemental carbon (EC), organic carbon (OC) and K+ were generally well correlated across the three sites. At all the sites, biomass burning was found to be a source of OC and EC, with the largest contribution of EC from traffic emissions, while for OC the dominant fraction included contributions from secondary organic aerosols, primary biogenic and cooking sources. Source apportionment of the EC and OC was found to give reasonable estimation of the total carbon from non-fossil and fossil fuel sources based upon comparison with estimates derived from 14C analysis. Aethalometer-derived black carbon data were also apportioned into the contributions frombiomass burning and traffic and showed trends similar to those observed for EC. Mean wood smoke mass at the sites was estimated to range from 0.78 to 1.0 μgm-3 during the campaign in January–February 2012. Measurements on a 160m tower in London suggested a similar ratio of brown to black carbon (reflecting wood burning and traffic respectively) in regional and London air. Peaks in the levoglucosan and K+ concentrations were observed to coincide with low ambient temperature, consistent with domestic heating as a major contributing local source in London. Overall, the source of biomass smoke in London was concluded to be a background regional source overlaid by contributions from local domestic burning emissions. This could have implications when considering future emission control strategies during winter and may be the focus of future work in order to better determine the contributing local sources.

How do sport clubs recruit volunteers? Analyzing and developing a typology of decision-making processes on recruiting volunteers in sport clubs.

Effective strategies for recruiting volunteers who are prepared to make a long-term commitment to formal positions are essential for the survival of voluntary sport clubs. This article examines the decision-making processes in relation to these efforts. Under the assumption of bounded rationality, the garbage can model is used to grasp these decision-making processes theoretically and access them empirically. Based on case study framework an in-depth analysis of recruitment practices was conducted in nine selected sport clubs. Results showed that the decision-making processes are generally characterized by a reactive approach in which dominant actors try to handle personnel problems of recruitment in the administration and sport domains through routine formal committee work and informal networks. In addition, it proved possible to develop a typology that deliver an overview of different decision-making practices in terms of the specific interplay of the relevant components of process control (top-down vs. bottom-up) and problem processing (situational vs. systematic).

The Jurisprudence of the World Trade Organization 2014

In 2014, the Dispute Settlement Body (DSB) of the World Trade Organization (WTO) adopted seven panel reports and six Appellate Body rulings. Two of the cases relate to anti-dumping measures. Three cases, comprising five complaints, are of particular interest and these are summarized and discussed below. China – Rare Earths further refines the relationship between protocols of accession and the general provisions of WTO agreements, in particular the exceptions of Article XX GATT. Recourse to that provision is no longer excluded but depends on a careful case-by-case analysis. While China failed to comply with the conditions for export restrictions, the case reiterates the problem of insufficiently developed disciplines on export restrictions on strategic minerals and other commodities in WTO law. EC – Seals Products is a landmark case for two reasons. Firstly, it limits the application of the Agreement on Technical Barriers to Trade (TBT Agreement) resulting henceforth in a narrow reading of technical regulations. Normative rules prescribing conditions for importation are to be dealt with under the rules of the General Agreement on Tariffs and Trade (GATT) instead. Secondly, the ruling permits recourse to public morals in justifying import restrictions essentially on the basis of process and production methods (PPMs). Meanwhile, the more detailed implications for extraterritorial application of such rules and for the concept of PPMs remain open as these key issues were not raised by the parties to the case. Peru – Agricultural Products adds to the interpretation of the Agreement on Agriculture (AoA), but most importantly, it confirms the existing segregation of WTO law and the law of free trade agreements. The case is of particular importance for Switzerland in its relations with the European Union (EU). The case raises, but does not fully answer, the question whether in a bilateral agreement, Switzerland or the EU can, as a matter of WTO law, lawfully waive their right of lodging complaints against each other under WTO law within the scope of their bilateral agreement, for example the Agreement on Agriculture where such a clause exists.

Microscopic theory of cooperative spin crossover: Interaction of molecular modes with phonons

In this article, we present a new microscopic theoretical approach to the description of spin crossover in molecular crystals. The spin crossover crystals under consideration are composed of molecular fragments formed by the spin-crossover metal ion and its nearest ligand surrounding and exhibiting well defined localized (molecular) vibrations. As distinguished from the previous models of this phenomenon, the developed approach takes into account the interaction of spin-crossover ions not only with the phonons but also a strong coupling of the electronic shells with molecular modes. This leads to an effective coupling of the local modes with phonons which is shown to be responsible for the cooperative spin transition accompanied by the structural reorganization. The transition is characterized by the two order parameters representing the mean values of the products of electronic diagonal matrices and the coordinates of the local modes for the high- and low-spin states of the spin crossover complex. Finally, we demonstrate that the approach provides a reasonable explanation of the observed spin transition in the [Fe(ptz)6](BF4)2 crystal. The theory well reproduces the observed abrupt low-spin → high-spin transition and the temperature dependence of the high-spin fraction in a wide temperature range as well as the pronounced hysteresis loop. At the same time within the limiting approximations adopted in the developed model, the evaluated high-spin fraction vs. T shows that the cooperative spin-lattice transition proves to be incomplete in the sense that the high-spin fraction does not reach its maximum value at high temperature.

Mechanical circulatory support as a bridge to heart transplantation: what remains? Long-term emotional sequelae in patients and spouses

Implantation of a ventricular assist device (VAD) reduces short-term mortality and morbidity and provides patients with reasonable quality of life even though it may also be a long-lasting emotional burden. This study was conducted to analyze the long-time emotional consequences of VAD implantation, followed by heart transplantation in patients and spouses.

Computer technology applications in surgical implant dentistry: a systematic review

PURPOSE: To assess the literature on accuracy and clinical performance of computer technology applications in surgical implant dentistry. MATERIALS AND METHODS: Electronic and manual literature searches were conducted to collect information about (1) the accuracy and (2) clinical performance of computer-assisted implant systems. Meta-regression analysis was performed for summarizing the accuracy studies. Failure/complication rates were analyzed using random-effects Poisson regression models to obtain summary estimates of 12-month proportions. RESULTS: Twenty-nine different image guidance systems were included. From 2,827 articles, 13 clinical and 19 accuracy studies were included in this systematic review. The meta-analysis of the accuracy (19 clinical and preclinical studies) revealed a total mean error of 0.74 mm (maximum of 4.5 mm) at the entry point in the bone and 0.85 mm at the apex (maximum of 7.1 mm). For the 5 included clinical studies (total of 506 implants) using computer-assisted implant dentistry, the mean failure rate was 3.36% (0% to 8.45%) after an observation period of at least 12 months. In 4.6% of the treated cases, intraoperative complications were reported; these included limited interocclusal distances to perform guided implant placement, limited primary implant stability, or need for additional grafting procedures. CONCLUSION: Differing levels and quantity of evidence were available for computer-assisted implant placement, revealing high implant survival rates after only 12 months of observation in different indications and a reasonable level of accuracy. However, future long-term clinical data are necessary to identify clinical indications and to justify additional radiation doses, effort, and costs associated with computer-assisted implant surgery.

Investigating the consistency between proxy-based reconstructions and climate models using data assimilation: a mid-Holocene case study

The mid-Holocene (6 kyr BP; thousand years before present) is a key period to study the consistency between model results and proxy-based reconstruction data as it corresponds to a standard test for models and a reasonable number of proxy-based records is available. Taking advantage of this relatively large amount of information, we have compared a compilation of 50 air and sea surface temperature reconstructions with the results of three simulations performed with general circulation models and one carried out with LOVECLIM, a model of intermediate complexity. The conclusions derived from this analysis confirm that models and data agree on the large-scale spatial pattern but the models underestimate the magnitude of some observed changes and that large discrepancies are observed at the local scale. To further investigate the origin of those inconsistencies, we have constrained LOVECLIM to follow the signal recorded by the proxies selected in the compilation using a data-assimilation method based on a particle filter. In one simulation, all the 50 proxy-based records are used while in the other two only the continental or oceanic proxy-based records constrain the model results. As expected, data assimilation leads to improving the consistency between model results and the reconstructions. In particular, this is achieved in a robust way in all the experiments through a strengthening of the westerlies at midlatitude that warms up northern Europe. Furthermore, the comparison of the LOVECLIM simulations with and without data assimilation has also objectively identified 16 proxy-based paleoclimate records whose reconstructed signal is either incompatible with the signal recorded by some other proxy-based records or with model physics.

Rib fractures at postmortem computed tomography (PMCT) validated against the autopsy

To evaluate the sensitivity of postmortem computed tomography (PMCT) in rib fracture detection validated against autopsy. Fifty-one forensic cases underwent a postmortem CT prior to forensic autopsy. Two image readers (radiologist and forensic pathologist) assessed high resolution CT data sets for rib fractures. Correct recognition rates (CRR), sensitivity and specificity values were calculated over all observations as well as individually for every rib and region. Additionally, for partial rib fractures the sensitivity of autopsy was calculated vice versa. 3876 entries in each study protocol (autopsy, PMCT radiologist and PMCT forensic pathologist) were investigated. A total of 690 fractures (autopsy), 491 (PMCT and radiologist) and 559 (PMCT and forensic pathologist) were detected. The CRR was 0.85. Sensitivity and specificity of PMCT for rib fracture detection were 0.63 (0.58 radiologist, 0.68 forensic pathologist) and 0.97 (both readers 0.97), respectively. Low CRR and sensitivity values were obtained for antero-lateral fractures. Partial rib fractures were better detected by PMCT. PMCT has a rather low sensitivity for rib fracture detection when validated against autopsy and indicates that clinical CT may also demonstrate a reasonable number of false negatives. Partial rib fractures often remain undetected at autopsy.

Volunteering in sport clubs

Volunteers are the most important resource for non-profit sport clubs seeking to bolster their viability (e.g. sporting programs). Although many people do voluntary work in sport clubs, stable voluntary engagement can no longer be granted. This difficulty is confirmed by existing research across various European countries. From a club management point of view, a detailed understanding of how to attract volunteers and retain them in the long term is becoming a high priority. The purpose of this study is (1) to analyse the influence of individual characteristics and corresponding organisational conditions on volunteering in sports clubs as well as (2) to examine the decision-making processes in relation to implement effective strategies for recruiting volunteers. For the first perspective a multi-level framework for the investigation of the factors of voluntary engagement in sports clubs is developed. The individual and context factors are estimated in different multi-level models based on a sample of n = 1,434 sport club members from 36 sport clubs in Switzerland. Results indicate that volunteering is not just an outcome of individual characteristics such as lower workloads, higher income, children belonging to the sport club, longer club memberships, or a strong commitment to the club. It is also influenced by club-specific structural conditions; volunteering is more probable in rural sports clubs whereas growth-oriented goals in clubs have a destabilising effect. Concerning decision-making processes an in-depth analysis of recruitment practices for volunteers was conducted in nine selected sport clubs (case study design) based on the garbage can model. Results show that the decision-making processes are generally characterised by a reactive approach in which dominant actors try to handle personnel problems of recruitment in the administration and sport domains through routine formal committee work and informal networks. In addition, it proved possible to develop a typology that deliver an overview of different decision-making practices in terms of the specific interplay of the relevant components of process control (top-down vs. bottom-up) and problem processing (situational vs. systematic). Based on the findings some recommendations for volunteer management in sport clubs are worked out.

Radical cystectomy and ileal orthotopic bladder substitution after radical retropubic prostatectomy: functional and oncological results

Men with good functional results following radical retropubic prostatectomy (RRP) and requiring radical cystectomy (RC) for subsequent bladder carcinoma seldom receive orthotopic bladder substitution. Four patients aged 62-72 years (median 67 years), who had undergone RRP for prostate cancer of stage pT2bN0M0 Gleason score 6 (n = 1), pT2cN0M0 Gleason score 5 and 6 (n = 2) and pT3bN0M0 Gleason score 7 (n = 1) 27 to 104 months before, developed urothelial bladder carcinoma treated with RC and ileal orthotopic bladder substitution. After radical prostatectomy three were continent and one had grade I stress incontinence, and three achieved intercourse with intracavernous alprostadil injections. Follow-up after RC ranged between 27 and 42 months (median 29 months). At the 24-month follow-up visit after RC daily urinary continence was total (0 pad) in one patient, two used one pad for mild leakage, and one was incontinent following endoscopic incision of anastomotic stricture. One patient died of progression of bladder carcinoma, while the other three are alive without evidence of disease. The three surviving patients continued to have sexual intercourse with intracavernous alprostadil injections. Men with previous RRP have a reasonable chance of maintaining a satisfactory functional outcome following RC and ileal orthotopic bladder substitution.

Motive-Oriented Psychotherapeutic Relationship Facing a Patient Presenting with Narcissistic Personality Disorder: A Case Study

Motive-oriented therapeutic relationship (MOTHER), a prescriptive concept based on an integrative form of case formulation, the Plan Analysis (PA) method (Caspar, in: Eells (ed.), Handbook of psychotherapy case formulations, 2007), has shown to be of particular relevance for the treatment of patients presenting with personality disorders, in particular contributing to better therapeutic outcome and to a more constructive development of the therapeutic alliance over time (Kramer et al., J Nerv Ment Dis 199:244–250, 2011). Several therapy models refer to MOTHER as intervention principle with regard to borderline and Narcissistic Personality Disorder (NPD) (Sachse et al., Clarification-oriented psychotherapy of narcissistic personality disorder, 2011; Caspar and Berger, in: Dulz et al. (eds.), Handbuch der Borderline-Störungen, 2011). The present case study discusses the case of Mark, a 40-year-old patient presenting with NPD, along with anxious, depressive and anger problems. This patient underwent a seven-session long pre-therapy process, based on psychiatric and psychotherapeutic principles complemented with PA and MOTHER, in preparation for further treatment. MOTHER will be illustrated with patient–therapist verbatim from session 4 and the links between MOTHER and confrontation techniques will be discussed in the context of process-outcome hypotheses, in particular the effect of MOTHER on symptom reduction.

Why evolutionary biologists should get seriously involved in ecological monitoring and applied biodiversity assessment programs

While ecological monitoring and biodiversity assessment programs are widely implemented and relatively well developed to survey and monitor the structure and dynamics of populations and communities in many ecosystems, quantitative assessment and monitoring of genetic and phenotypic diversity that is important to understand evolutionary dynamics is only rarely integrated. As a consequence, monitoring programs often fail to detect changes in these key components of biodiversity until after major loss of diversity has occurred. The extensive efforts in ecological monitoring have generated large data sets of unique value to macro-scale and long-term ecological research, but the insights gained from such data sets could be multiplied by the inclusion of evolutionary biological approaches. We argue that the lack of process-based evolutionary thinking in ecological monitoring means a significant loss of opportunity for research and conservation. Assessment of genetic and phenotypic variation within and between species needs to be fully integrated to safeguard biodiversity and the ecological and evolutionary dynamics in natural ecosystems. We illustrate our case with examples from fishes and conclude with examples of ongoing monitoring programs and provide suggestions on how to improve future quantitative diversity surveys.

Water-use efficiency and transpiration across European forests during the Anthropocene

The Earth’s carbon and hydrologic cycles are intimately coupled by gas exchange through plant stomata1, 2, 3. However, uncertainties in the magnitude4, 5, 6 and consequences7, 8 of the physiological responses9, 10 of plants to elevated CO2 in natural environments hinders modelling of terrestrial water cycling and carbon storage11. Here we use annually resolved long-term δ13C tree-ring measurements across a European forest network to reconstruct the physiologically driven response of intercellular CO2 (Ci) caused by atmospheric CO2 (Ca) trends. When removing meteorological signals from the δ13C measurements, we find that trees across Europe regulated gas exchange so that for one ppmv atmospheric CO2 increase, Ci increased by ~0.76 ppmv, most consistent with moderate control towards a constant Ci/Ca ratio. This response corresponds to twentieth-century intrinsic water-use efficiency (iWUE) increases of 14 ± 10 and 22 ± 6% at broadleaf and coniferous sites, respectively. An ensemble of process-based global vegetation models shows similar CO2 effects on iWUE trends. Yet, when operating these models with climate drivers reintroduced, despite decreased stomatal opening, 5% increases in European forest transpiration are calculated over the twentieth century. This counterintuitive result arises from lengthened growing seasons, enhanced evaporative demand in a warming climate, and increased leaf area, which together oppose effects of CO2-induced stomatal closure. Our study questions changes to the hydrological cycle, such as reductions in transpiration and air humidity, hypothesized to result from plant responses to anthropogenic emissions.