Chest pain in daily practice: occurrence, causes and management

QUESTIONS UNDER STUDY: We assessed the occurrence and aetiology of chest pain in primary care practice. These features differ between primary and emergency care settings, where most previous studies have been performed. METHODS: 59 GPs in western Switzerland recorded all consecutive cases presenting with chest pain. Clinical characteristics, laboratory tests and other investigations as well as the diagnoses remaining after 12 months of follow-up were systematically registered. RESULTS: Among 24,620 patients examined during a total duration of 300 weeks of observation, 672 (2.7%) presented with chest pain (52% female, mean age 55 +/- 19(SD)). Most cases, 442 (1.8%), presented new symptoms and in 356 (1.4%) it was the reason for consulting. Over 40 ailments were diagnosed: musculoskeletal chest pain (including chest wall syndrome) (49%), cardiovascular (16%), psychogenic (11%), respiratory (10%), digestive (8%), miscellaneous (2%) and without diagnosis (3%). The three most prevalent diseases were: chest wall syndrome (43%), coronary artery disease (12%) and anxiety (7%). Unstable angina (6), myocardial infarction (4) and pulmonary embolism (2) were uncommon (1.8%). Potentially serious conditions including cardiac, respiratory and neoplasic diseases accounted for 20% of cases. A large number of laboratory tests (42%), referral to a specialist (16%) or hospitalisation (5%) were performed. Twentyfive patients died during follow-up, of which twelve were for a reason directly associated with thoracic pain [cancer (7) and cardiac causes (5)]. CONCLUSIONS: Thoracic pain was present in 2.7% of primary care consultations. Chest wall syndrome pain was the main aetiology. Cardio - vascular emergencies were uncommon. However chest pain deserves full consideration because of the occurrence of potentially serious conditions.

Development of a Business Model that Supports Mobile Value-Added Services Market Creation in Emerging Countries

Tutkielman tavoitteena on luoda liiketoimintamalli, joka tukee langattomien matkaviestintäpalveluiden markkinoiden luomista kehittyvillä markkinoilla. Teoreettinen osa tarkastelee langattomien matkaviestintäpalveluiden liiketoimintamallin kehittämisen tärkeimpiä elementtejä CIS maissa. Teoreettisen kappaleen tuloksena saadaan puitteet, jonka avulla liiketoimintamalli matkaviestintäpalveluille voidaan kehittää. Tutkielman empiirinen osa on toteutettu case tutkimuksena, jonka tavoitteena on ollut langattomien matkaviestintäpalvelujen markkinoiden luominen CIS maissa. Pääasiallinen empiirisen tiedon lähde on ollut teemahaastattelut. Tuloksena saatuja empiirisen osan tietoja verrataan teoriakappaleen vastaaviin tuloksiin Tulokset osoittavat, että radikaalin korkean teknologian innovaation markkinoiden luominen on hidas prosessi, joka vaatii kärsivällisyyttä yritykseltä. Markkinoiden, teknologian ja strategian epävarmuustekijät tuovat epävarmuutta kehittyvälle toimialalle ja markkinoille, joka vaikeuttaa liiketoimintamallin kehittämistä. Tärkein tekijä on palvelujen markkinointi ennemmin kuin teknologian. Avain kyvykkyys markkinoiden luomisessa on oppiminen, ei tietäminen.

Facilitating coordination improvement efforts in cross-functional process development programs

Business process improvement is a common approach in increasing the effectiveness of an organization. It can be seen as an effort to increase coordination between units. Process improvement has proved to be challenging, and most management consultation firms facilitate organizations in this kind of initiatives. Cross-functional improvement is one of the main areas for internal consultants as well. However, the needs, challenges and means of cross-functional help have been rarely discussed in the literature. The objective of this thesis is on one hand to present a conceptual and descriptive framework to help understand the challenges of facilitating coordination improvement efforts in cross-functional improvement programs, and on the other hand to develop and test feasible solutions for some facilitation situations. The research questions are: 1. Why and in what kind of situations do organizations need help in developing coordination in cross-functional processes? 2. How can a facilitator help organizations in improving coordination to develop cross-functional processes? The study consists of two parts. The first part is an overview of the dissertation, and the second part comprises six research publications. The theoretical background for the study are the differentiation causing challenges in cross-functional settings, the coordination needed to improve processes, change management principles, methods and tools, and consultation practises. Three of the publications introduce tools for helping in developing prerequisites, planning responsibilities and supporting learning during the cross-functional program. The three other papers present frameworks to help understand and analyse the improvement situation. The main methodological approaches used in this study are design science research, action research and case research. The research data has been collected from ten cases representing different kinds of organizations, processes and developing situations. The data has been collected mainly by observation, semi-structured interviews and questionnaires. The research contributes to the rare literature combining coordination theories and process improvement practises. It also provides additional understanding of a holistic point of view in process improvement situations. The most important contribution is the addition to the theories of facilitating change in process improvement situations. From the managerial point of view, this study gives advice to managers and consultants in planning and executing cross-functional programs. The main factors increasing the need for facilitation are the challenges for differentiation, challenges of organizational change in general, and the novelty of initiatives and improvement practices concerning process development. Organizations need help in creating the prerequisites to change, in planning initiatives, easing conflict management and collaboration between groups, as well as supporting the learning of cross-functional improvement. The main challenges of facilitation are combining the different roles as a consultant, maintaining the ownership for the improvement project with the client, and supporting learning in the client organization.

Exploring the personal and professional lives of teachers in the search for authenticity /

"We teach who we are" (Palmer, 1998, p. 2). This simple, yet profound, statement was the catalyst that began my thesis journey. Using a combination of self-study and participant narratives, Palmer's idea was explored as search for authenticity. The self-study component of this narrative was enhanced by the stories of two other teachers, both women. I chose to use narrative methodology to uncover and discover the relationship between the personal and professional lives of being a teacher. Do teachers express themselves daily in their classrooms? Do any lessons from the classroom translate into teachers' personal lives? The themes of reflection, authenticity, truth, and professional development thread themselves throughout this narrative study. In order to be true to myself as a teacher/researcher, arts-based interpretations accompany my own and each participant's profile. Our conversations about our pasts, our growth as teachers and journeys as individuals were captured in poetry and photographic mosaics. Through rich and detailed stories we explored who we are as teachers and how we became this way. The symbiotic relationship between our personal and professional lives was illustrated by tales of bravery, self-discovery, and reflection. The revelations uncovered illustrate the powerful role our past plays in shaping the present and potentially the friture. It may seem indulgent to spend time exploring who we are as teachers in a time that is increasingly focused on improving student test scores. Yet, the truth remains that, "Knowing myself is as crucial to good teaching as knowing my students and my subject" (Palmer, 1998, p. 2).

Paradigms and prisons: a narrative of translation and transformation : my hero's journey from "at-risk" youth to teacher/learner in a jail setting /

All life is suffering. Life is the pursuit ofhappiness. These are two foundational Buddhist dictums that, in their simplicity, I have entirely misunderstood regarding their depth, misreading them as contradictory. Indeed, my superficial interpretations led me to Thoreau's life ofquiet desperation and deep depression. We come to know and bring understanding to our lives by storying them. My own Hero's Journey, the path from my egoic selftoward the universal Self, can be understood as the resultant translations and transformations. Inevitably each of us is involved in such a story, though most are unaware of the stages along our own Hero's journey. ' Narrative honours writing as a means of knowing. The contemplative reflection allows insight into our imprisoning paradigms, beliefs, behaviours, and blind spots. My research revisits and explores nodal experiences along my Hero's Journey through 4 categories: self, society, soil, and Self. While the value of this process of narrative inquiry lay in its ability to come to know and understand one's self, perhaps its greater value is of a more universal nature. My inquiry, while adding to the body of academic educational narrative literature, may also illuminate a path to educators, students, and all interested, encouraging a response to the call of their own Hero's journey. I am a teacher/learner in a jail setting, working with youth between the ages of 12 and 18 who have committed crimes such as armed robbery, assault, rape, and murder. As this thesis follows my continual development from egoic self/teacher/learner to universal Self/Teacher/Learner, it also enables me to both consciously and unconsciously open the ways in which I expand my care, compassion, and love to work with at-risk youth.

An Exploration of Professors’ Use of Twitter in Higher Education

Scant research has explored how professors in Canadian universities use Twitter as a teaching tool or to augment knowledge about their subject disciplines. This case study employed a mixed-method approach to examine how professors in an Ontario university use Twitter. Using a variation of the technology acceptance model, the survey (n = 17) found that professor participants—41.2% of whom use Twitter—perceive Twitter as somewhat useful as a teaching tool, not useful for finding and sharing information, and not useful for personal use. Participants’ gender and number of years teaching are not indicators of Twitter use. Furthermore, the level of support from peers and the university may be reasons why some do not use Twitter or have stopped using Twitter. Face-to-face interviews (n = 3) revealed that Twitter is not used in classrooms or lecture halls, but predominantly as a means of sharing information with students and colleagues. Another deterrent to using Twitter is not knowing who to follow. Findings indicate that some professors at this university embrace Twitter, but not necessarily as an in-class teaching tool. The challenge and the advantage of using Twitter is to discover and follow people who tweet material and to select relevant material to pass along to students and colleagues. Professor participants in the study found a use for the social network as a means to increase student engagement, create virtual information-exchange communities, and enrich their own learning.

Comparaison de deux nouvelles méthodes d’évaluation de la fertilité masculine avec le spermogramme chez des patients ayant recours à la fécondation in vitro

Des facteurs masculins sont identifiés dans près de la moitié des cas d’infertilité. À ce jour, les tests évaluant la fertilité masculine demeurent peu prédictifs de la survenue d’une grossesse. Dans le but de pallier cette lacune, nous avons mis au point deux nouveaux tests mesurant l’intégrité de l’ADN et le temps de survie des spermatozoïdes. Nous avons effectué une étude prospective portant sur 42 couples infertiles suivis en fécondation in vitro (FIV). Le spermogramme a été effectué selon les critères de l’Organisation Mondiale de la Santé (OMS) et le temps de survie des spermatozoïdes exposés à un détergent cationique a été mesuré en observant la mobilité sous microscope. L’intégrité de l’ADN des spermatozoïdes a été vérifiée par la nouvelle méthode de marquage radioenzymatique et par analyse de la structure de la chromatine (SCSA). Tous les tests ont été réalisés sur la partie des échantillons de sperme non utilisée par la clinique de fertilité. Le projet a été approuvé par le comité d’éthique du Centre Hospitalier Universitaire de Montréal (CHUM) et les patients ont préalablement signé un formulaire de consentement éclairé. L’analyse des paramètres du spermogramme et de l’intégrité de l’ADN n’a montré aucune différence statistiquement significative entre les données chez les couples avec ou sans grossesse. Cependant, le taux de grossesse biochimique était statistiquement plus élevé chez les couples dont le temps de survie des spermatozoïdes était long (>250 s) comparativement à ceux dont ce temps était court (≤250 s): 66% vs 27% respectivement (p<0,05). Les taux de grossesse clinique et d’implantation étaient aussi plus élevés, mais les différences n’atteignaient pas le seuil de signification statistique. Nos résultats confirment que le spermogramme et la mesure de la fragmentation de l’ADN des spermatozoïdes ne sont pas de bons facteurs prédictifs des résultats de la FIV. Par contre, le test de survie des spermatozoïdes serait un meilleur indicateur de la possibilité d’une grossesse en FIV. L’amélioration de sa spécificité et un plus grand nombre de sujets sont nécessaires avant de proposer son application en clinique de fertilité.

A poetics of apprehension : indeterminacy in Gertrude Stein, Emily Dickinson and Caroline Bergvall

Ce mémoire examine les poétiques de trois poètes très différentes, mais dont les œuvres peuvent être qualifiées d'indéterminées et de radicales : Emily Dickinson (1830-1886), Gertrude Stein (1874-1946) et Caroline Bergvall (née en 1962). Dickinson et Stein sont anglo-américaines, tandis que Bergvall est d’origine franco-norvégienne, bien qu'elle choisisse d’écrire en anglais. Toutes les trois rompent la structure syntaxique conventionnelle de l’anglais par leurs poétiques, ce qui comporte des implications esthétiques et politiques. Dans ce qui suit, j’analyse l’indétermination de leurs poétiques à partir de la notion, décrite par Lyn Hejinian, de la description comme appréhension qui présente l’écriture comme un mode de connaissance plutôt qu'un moyen d’enregistrer ce que le poète sait déjà. La temporalité de cette activité épistémologique est donc celle du présent de l’écriture, elle lui est concomitante. J'affirme que c'est cette temporalité qui, en ouvrant l’écriture aux événements imprévus, aux vicissitudes, aux hésitations, aux erreurs et torsions de l’affect, cause l'indétermination de la poésie. Dans le premier chapitre, j'envisage l'appréhension chez Gertrude Stein à travers son engagement, tout au long de sa carrière, envers « le présent continu » de l’écriture. Le deuxième chapitre porte sur le sens angoissé de l’appréhension dans la poésie de Dickinson, où le malaise, en empêchant ou en refoulant une pensée, suspend la connaissance. Le langage, sollicité par une expérience qu'il ne peut lui-même exprimer, donne forme à l'indétermination. Un dernier chapitre considère l’indétermination linguistique du texte et de l’exposition Say Parsley, dans lesquels Bergvall met en scène l’appréhension du langage : une appréhension qui survient plutôt chez le lecteur ou spectateur que chez la poète.

Mental health service utilization among students and staff in 18 months following Dawson College shooting

The aim of this study was to investigate service utilization by students and staff in the 18 months following the September 13, 2006, shooting at Dawson College, Montreal, as well as the determinants of this utilization within the context of Canada’s publicly managed healthcare system. Methods A sample of 948 from among the college’s 10,091 students and staff agreed to complete an adapted computer or web-based standardized questionnaire drawn from the Statistics Canada 2002 Canadian Community Health Survey cycle 1.2 on mental health and well-being. Results In the 18 months following the shooting, there was a greater incidence and prevalence not only of PTSD, but also of other anxiety disorders, depression, and substance abuse. Staff and students were as likely to consult a health professional when presenting a mental or substance use disorder, with females more likely to do so than males. Results also indicated that there was relatively high internet use for mental health reasons by students and staff (14% overall). Conclusions Following a major crisis event causing potential mass trauma, even in a society characterized by easy access to public, school and health services and when the population involved is generally well educated, the acceptability of consulting health professionals for mental health or substance use problems represents a barrier. However, safe internet access is one way male and female students and staff can access information and support and it may be useful to further exploit the possibilities afforded by web-based interviews in anonymous environments.

Essays in economics of information

Cette thèse est une collection de trois articles en économie de l'information. Le premier chapitre sert d'introduction et les Chapitres 2 à 4 constituent le coeur de l'ouvrage. Le Chapitre 2 porte sur l’acquisition d’information sur l’Internet par le biais d'avis de consommateurs. En particulier, je détermine si les avis laissés par les acheteurs peuvent tout de même transmettre de l’information à d’autres consommateurs, lorsqu’il est connu que les vendeurs peuvent publier de faux avis à propos de leurs produits. Afin de comprendre si cette manipulation des avis est problématique, je démontre que la plateforme sur laquelle les avis sont publiés (e.g. TripAdvisor, Yelp) est un tiers important à considérer, autant que les vendeurs tentant de falsifier les avis. En effet, le design adopté par la plateforme a un effet indirect sur le niveau de manipulation des vendeurs. En particulier, je démontre que la plateforme, en cachant une partie du contenu qu'elle détient sur les avis, peut parfois améliorer la qualité de l'information obtenue par les consommateurs. Finalement, le design qui est choisi par la plateforme peut être lié à la façon dont elle génère ses revenus. Je montre qu'une plateforme générant des revenus par le biais de commissions sur les ventes peut être plus tolérante à la manipulation qu'une plateforme qui génère des revenus par le biais de publicité. Le Chapitre 3 est écrit en collaboration avec Marc Santugini. Dans ce chapitre, nous étudions les effets de la discrimination par les prix au troisième degré en présence de consommateurs non informés qui apprennent sur la qualité d'un produit par le biais de son prix. Dans un environnement stochastique avec deux segments de marché, nous démontrons que la discrimination par les prix peut nuire à la firme et être bénéfique pour les consommateurs. D'un côté, la discrimination par les prix diminue l'incertitude à laquelle font face les consommateurs, c.-à-d., la variance des croyances postérieures est plus faible avec discrimination qu'avec un prix uniforme. En effet, le fait d'observer deux prix (avec discrimination) procure plus d'information aux consommateurs, et ce, même si individuellement chacun de ces prix est moins informatif que le prix uniforme. De l'autre côté, il n'est pas toujours optimal pour la firme de faire de la discrimination par les prix puisque la présence de consommateurs non informés lui donne une incitation à s'engager dans du signaling. Si l'avantage procuré par la flexibilité de fixer deux prix différents est contrebalancé par le coût du signaling avec deux prix différents, alors il est optimal pour la firme de fixer un prix uniforme sur le marché. Finalement, le Chapitre 4 est écrit en collaboration avec Sidartha Gordon. Dans ce chapitre, nous étudions une classe de jeux où les joueurs sont contraints dans le nombre de sources d'information qu'ils peuvent choisir pour apprendre sur un paramètre du jeu, mais où ils ont une certaine liberté quant au degré de dépendance de leurs signaux, avant de prendre une action. En introduisant un nouvel ordre de dépendance entre signaux, nous démontrons qu'un joueur préfère de l'information qui est la plus dépendante possible de l'information obtenue par les joueurs pour qui les actions sont soit, compléments stratégiques et isotoniques, soit substituts stratégiques et anti-toniques, avec la sienne. De même, un joueur préfère de l'information qui est la moins dépendante possible de l'information obtenue par les joueurs pour qui les actions sont soit, substituts stratégiques et isotoniques, soit compléments stratégiques et anti-toniques, avec la sienne. Nous établissons également des conditions suffisantes pour qu'une structure d'information donnée, information publique ou privée par exemple, soit possible à l'équilibre.

Inference for nonparametric high-frequency estimators with an application to time variation in betas

We consider the problem of conducting inference on nonparametric high-frequency estimators without knowing their asymptotic variances. We prove that a multivariate subsampling method achieves this goal under general conditions that were not previously available in the literature. We suggest a procedure for a data-driven choice of the bandwidth parameters. Our simulation study indicates that the subsampling method is much more robust than the plug-in method based on the asymptotic expression for the variance. Importantly, the subsampling method reliably estimates the variability of the Two Scale estimator even when its parameters are chosen to minimize the finite sample Mean Squared Error; in contrast, the plugin estimator substantially underestimates the sampling uncertainty. By construction, the subsampling method delivers estimates of the variance-covariance matrices that are always positive semi-definite. We use the subsampling method to study the dynamics of financial betas of six stocks on the NYSE. We document significant variation in betas within year 2006, and find that tick data captures more variation in betas than the data sampled at moderate frequencies such as every five or twenty minutes. To capture this variation we estimate a simple dynamic model for betas. The variance estimation is also important for the correction of the errors-in-variables bias in such models. We find that the bias corrections are substantial, and that betas are more persistent than the naive estimators would lead one to believe.

Designing in the real world is complex anyway - so what?

Designing is a heterogeneous, fuzzily defined, floating field of various activities and chunks of ideas and knowledge. Available theories about the foundations of designing as presented in "the basic PARADOX" (Jonas and Meyer-Veden 2004) have evoked the impression of Babylonian confusion. We located the reasons for this "mess" in the "non-fit", which is the problematic relation of theories and subject field. There seems to be a comparable interface problem in theory-building as in designing itself. "Complexity" sounds promising, but turns out to be a problematic and not really helpful concept. I will argue for a more precise application of systemic and evolutionary concepts instead, which - in my view - are able to model the underlying generative structures and processes that produce the visible phenomenon of complexity. It does not make sense to introduce a new fashionable meta-concept and to hope for a panacea before having clarified the more basic and still equally problematic older meta-concepts. This paper will take one step away from "theories of what" towards practice and doing and try to have a closer look at existing process models or "theories of how" to design instead. Doing this from a systemic perspective leads to an evolutionary view of the process, which finally allows to specify more clearly the "knowledge gaps" inherent in the design process. This aspect has to be taken into account as constitutive of any attempt at theory-building in design, which can be characterized as a "practice of not-knowing". I conclude, that comprehensive "unified" theories, or methods, or process models run aground on the identified knowledge gaps, which allow neither reliable models of the present, nor reliable projections into the future. Consolation may be found in performing a shift from the effort of adaptation towards strategies of exaptation, which means the development of stocks of alternatives for coping with unpredictable situations in the future.

Procedures as a Representation for Data in a Computer Program for Understanding Natural Language

This paper describes a system for the computer understanding of English. The system answers questions, executes commands, and accepts information in normal English dialog. It uses semantic information and context to understand discourse and to disambiguate sentences. It combines a complete syntactic analysis of each sentence with a "heuristic understander" which uses different kinds of information about a sentence, other parts of the discourse, and general information about the world in deciding what the sentence means. It is based on the belief that a computer cannot deal reasonably with language unless it can "understand" the subject it is discussing. The program is given a detailed model of the knowledge needed by a simple robot having only a hand and an eye. We can give it instructions to manipulate toy objects, interrogate it about the scene, and give it information it will use in deduction. In addition to knowing the properties of toy objects, the program has a simple model of its own mentality. It can remember and discuss its plans and actions as well as carry them out. It enters into a dialog with a person, responding to English sentences with actions and English replies, and asking for clarification when its heuristic programs cannot understand a sentence through use of context and physical knowledge.

Measuring Value in Product Development

“What is value in product development?” is the key question of this paper. The answer is critical to the creation of lean in product development. By knowing how much value is added by product development (PD) activities, decisions can be more rationally made about how to allocate resources, such as time and money.

Measuring Value in Product Development

“What is value in product development?” is the key question of this paper. The answer is critical to the creation of lean in product development. By knowing how much value is added by product development (PD) activities, decisions can be more rationally made about how to allocate resources, such as time and money. In order to apply the principles of Lean Thinking and remove waste from the product development system, value must be precisely defined. Unfortunately, value is a complex entity that is composed of many dimensions and has thus far eluded definition on a local level. For this reason, research has been initiated on “Measuring Value in Product Development.” This paper serves as an introduction to this research. It presents the current understanding of value in PD, the critical questions involved, and a specific research design to guide the development of a methodology for measuring value. Work in PD value currently focuses on either high-level perspectives on value, or detailed looks at the attributes that value might have locally in the PD process. Models that attempt to capture value in PD are reviewed. These methods, however, do not capture the depth necessary to allow for application. A methodology is needed to evaluate activities on a local level to determine the amount of value they add and their sensitivity with respect to performance, cost, time, and risk. Two conceptual tools are proposed. The first is a conceptual framework for value creation in PD, referred to here as the Value Creation Model. The second tool is the Value-Activity Map, which shows the relationships between specific activities and value attributes. These maps will allow a better understanding of the development of value in PD, will facilitate comparison of value development between separate projects, and will provide the information necessary to adapt process analysis tools (such as DSM) to consider value. The key questions that this research entails are: · What are the primary attributes of lifecycle value within PD? · How can one model the creation of value in a specific PD process? · Can a useful methodology be developed to quantify value in PD processes? · What are the tools necessary for application? · What PD metrics will be integrated with the necessary tools? The research milestones are: · Collection of value attributes and activities (September, 200) · Development of methodology of value-activity association (October, 2000) · Testing and refinement of the methodology (January, 2001) · Tool Development (March, 2001) · Present findings at July INCOSE conference (April, 2001) · Deliver thesis that captures a formalized methodology for defining value in PD (including LEM data sheets) (June, 2001) The research design aims for the development of two primary deliverables: a methodology to guide the incorporation of value, and a product development tool that will allow direct application.