Should pulmonary embolism be suspected in exacerbation of chronic obstructive pulmonary disease?

BACKGROUND: The cause of acute exacerbation of chronic obstructive pulmonary disease (COPD) is often difficult to determine. Pulmonary embolism may be a trigger of acute dyspnoea in patients with COPD. AIM: To determine the prevalence of pulmonary embolism in patients with acute exacerbation of COPD. METHODS: 123 consecutive patients admitted to the emergency departments of two academic teaching hospitals for acute exacerbation of moderate to very severe COPD were included. Pulmonary embolism was investigated in all patients (whether or not clinically suspected) following a standardised algorithm based on d-dimer testing, lower-limb venous ultrasonography and multidetector helical computed tomography scan. RESULTS: Pulmonary embolism was ruled out by a d-dimer value <500 microg/l in 28 (23%) patients and a by negative chest computed tomography scan in 91 (74%). Computed tomography scan showed pulmonary embolism in four patients (3.3%, 95% confidence interval (CI), 1.2% to 8%), including three lobar and one sub-segmental embolisms. The prevalence of pulmonary embolism was 6.2% (n = 3; 95% CI, 2.3% to 16.9%) in the 48 patients who had a clinical suspicion of pulmonary embolism and 1.3% (n = 1; 95% CI, 0.3% to 7.1%) in those not suspected. In two cases with positive computed tomography scan, the venous ultrasonography also showed a proximal deep-vein thrombosis. No other patient was diagnosed with venous thrombosis. CONCLUSIONS: The prevalence of unsuspected pulmonary embolism is very low in patients admitted in the emergency department for an acute exacerbation of their COPD. These results argue against a systematic examination for pulmonary embolism in this population.

Métamorphoses identitaires en situation de mobilité

Identity metamorphoses in a context of mobility This study has its roots in the current upsurge in student mobility and in the scientific debates about the concepts of identity and intercultural communication. Based on a corpus of interviews with French Erasmus students in Finland, the study blends in theories of postmodern identity, intercultural hermeneutics and discourse analysis to examine how the students construct themselves and diverse ‘othernesses’ (included theirs) when they talk about their experiences. The use of the French pronoun on, pronoun switches, and virtual voices (ex: I said to myself...) allowed to pinpoint the students’ unstable identity metamorphoses in their discourses: integration of liquid and solid selves, infidelity in identification with the French but also with Erasmus ‘tribes’, and games of identity. Though the exchange experience appears as interesting for the students, the results show that many and varied misconceptions about identity, culture, intercultural communication, language use, and strangeness lead the students to evaluate their experiences negatively. The implication of the study is that students should be prepared for their time abroad, not so much in terms of ‘grammars of culture’ (e.g. ‘Finns behave in such and such ways’, ‘the French are...’), but through the development of competences to analyse the identity metamorphoses that take place in intercultural encounters and prevent people from meeting each other as diverse individuals. This could make study abroad one of the best training periods for postmodernity and globalization.

Symptoms Have Modest Accuracy in Detecting Endoscopic and Histologic Remission in Adults With Eosinophilic Esophagitis.

BACKGROUND & AIMS: It is not clear whether symptoms alone can be used to estimate the biologic activity of eosinophilic esophagitis (EoE). We aimed to evaluate whether symptoms can be used to identify patients with endoscopic and histologic features of remission. METHODS: Between April 2011 and June 2014, we performed a prospective, observational study and recruited 269 consecutive adults with EoE (67% male; median age, 39 years old) in Switzerland and the United States. Patients first completed the validated symptom-based EoE activity index patient-reported outcome instrument and then underwent esophagogastroduodenoscopy with esophageal biopsy collection. Endoscopic and histologic findings were evaluated with a validated grading system and standardized instrument, respectively. Clinical remission was defined as symptom score <20 (range, 0-100); histologic remission was defined as a peak count of <20 eosinophils/mm(2) in a high-power field (corresponds to approximately <5 eosinophils/median high-power field); and endoscopic remission as absence of white exudates, moderate or severe rings, strictures, or combination of furrows and edema. We used receiver operating characteristic analysis to determine the best symptom score cutoff values for detection of remission. RESULTS: Of the study subjects, 111 were in clinical remission (41.3%), 79 were in endoscopic remission (29.7%), and 75 were in histologic remission (27.9%). When the symptom score was used as a continuous variable, patients in endoscopic, histologic, and combined (endoscopic and histologic remission) remission were detected with area under the curve values of 0.67, 0.60, and 0.67, respectively. A symptom score of 20 identified patients in endoscopic remission with 65.1% accuracy and histologic remission with 62.1% accuracy; a symptom score of 15 identified patients with both types of remission with 67.7% accuracy. CONCLUSIONS: In patients with EoE, endoscopic or histologic remission can be identified with only modest accuracy based on symptoms alone. At any given time, physicians cannot rely on lack of symptoms to make assumptions about lack of biologic disease activity in adults with EoE. ClinicalTrials.gov, Number: NCT00939263.

Soldiering and the making of Finnish manhood : conscription and masculinity in interwar Finland, 1918–1939

Military conscription and peacetime military service were the subjects of heated political, social and cultural controversies during the early years of national independence in Finland. Both the critics and the supporters of the existing military system described it as strongly formative of young men’s physical and moral development into adult men and male citizens. The conflicts over conscription prompted the contemporaries to express their notions about what Finnish men were like, at their best and at their worst, and what should and could be done about it. This thesis studies military conscription as an arena for the “making of manhood” in peacetime Finnish society, 1918–1939. It examines a range of public images of conscripted soldiering, asking how soldiering was depicted and given gendered meanings in parliamentary debates, war hero myths, texts concerned with the military and civic education of conscripts, as well as in works of fiction and reminiscences about military training as a personal experience. Studying conscription with a focus on masculinity, the thesis explores the different cultural images of manliness, soldiering and male citizenship on offer in Finnish society. It investigates how political parties, officers, educators, journalists, writers and “ordinary” conscripts used and developed, embraced or rejected these notions, according to their political purposes or personal needs. The period between the two world wars can be described as a fast-forward into military modernity in Finland. In the process, European middle class gender ideologies clashed with Finnish agrarian masculinities. Nationalistic agendas for the militarisation of Finnish manhood stumbled against intense class conflicts and ideological resistance. Military propaganda used images of military heroism, civic virtue and individual success to persuade the conscripts into ways of thinking and acting that were shaped by bourgeois mentality, nationalistic ideology and religious morality. These images are further analysed as expressive of the personal experiences and emotions of their middle-aged, male authors. The efforts of these military educators were, however, actively resisted on many fronts, ranging from rural working class masculinities among the conscripted young men to ideological critiques of the standing army system in parliament. In narratives about military training, masculinity was depicted as both strengthened and contradicted by the harsh and even brutal practices of interwar Finnish military training. The study represents a combination of new military history and the historical study of men and masculinities. It approaches masculinity as a contested and highly political form of social and cultural knowledge that is actively and selectively used by historic actors. Instead of trying to identify a dominant or “hegemonic” form of masculinity within a pre-determined theoretical structure, this study examines how the meanings ascribed to manhood varied according to class, age, political ideology and social situation. The interwar period in Finland can be understood as a period of contest between different notions of militarised masculinity, yet to judge by the materials studied, there was no clear winning party in that contest. A gradual movement from an atmosphere of conflict surrounding conscription towards political and cultural compromises can be discerned, yet this convergence was incomplete and many division lines remained.

Morrey's Farmers and Business Directory, Containing the Following Valuable Information: The Name, with the Post Office Address, Lot and Concession, of each Farmer; also whether a Freeholder or a Tenant (1884/85)

The Union Publishing Co.'s farmers' and business directory for the counties of Haldimand, Lincoln, Welland & Wentworth.

Les enjeux de la translation des technologies : le cas des tests de pharmacogénétique au Québec

Problématique : L’arrivée des tests de pharmacogénétique a été annoncée dans les médias et la littérature scientifique telle une révolution, un tournant vers la médecine personnalisée. En réalité, cette révolution se fait toujours attendre. Plusieurs barrières législatives, scientifiques, professionnelles et éthiques sont décrites dans la littérature comme étant la cause du délai de la translation des tests de pharmacogénétique, du laboratoire vers la clinique. Cet optimisme quant à l’arrivée de la pharmacogénétique et ces barrières existent-elles au Québec? Quel est le contexte de translation des tests de pharmacogénétique au Québec? Actuellement, il n’existe aucune donnée sur ces questions. Il est pourtant essentiel de les évaluer. Alors que les attentes et les pressions pour l’intégration rapide de technologies génétiques sont de plus en plus élevées sur le système de santé québécois, l’absence de planification et de mécanisme de translation de ces technologies font craindre une translation et une utilisation inadéquates. Objectifs : Un premier objectif est d’éclairer et d’enrichir sur les conditions d’utilisation et de translation ainsi que sur les enjeux associés aux tests de pharmacogénétique dans le contexte québécois. Un deuxième objectif est de cerner ce qui est véhiculé sur la PGt dans différentes sources, dont les médias. Il ne s’agit pas d’évaluer si la pharmacogénétique devrait être intégrée dans la clinique, mais de mettre en perspective les espoirs véhiculés et la réalité du terrain. Ceci afin d’orienter la réflexion quant au développement de mécanismes de translation efficients et de politiques associées. Méthodologie : L’analyse des discours de plusieurs sources documentaires (n=167) du Québec et du Canada (1990-2005) et d’entretiens avec des experts québécois (n=19) a été effectuée. Quatre thèmes ont été analysés : 1) le positionnement et les perceptions envers la pharmacogénétique; 2) les avantages et les risques reliés à son utilisation; 3) les rôles et les tensions entre professionnels; 4) les barrières et les solutions de translation. Résultats : L’analyse des représentations véhiculées sur la pharmacogénétique dans les sources documentaires se cristallise autour de deux pôles. Les représentations optimistes qui révèlent une fascination envers la médecine personnalisée, créant des attentes (« Génohype ») en regard de l’arrivée de la pharmacogénétique dans la clinique. Les représentations pessimistes qui révèlent un scepticisme (« Génomythe ») envers l’arrivée de la pharmacogénétique et qui semblent imprégnés par l’historique des représentations médiatiques négatives de la génétique. Quant à l’analyse des entretiens, celle-ci a permis de mettre en lumière le contexte actuel du terrain d’accueil. En effet, selon les experts interviewés, ce contexte comporte des déficiences législatives et un dysfonctionnement organisationnel qui font en sorte que l’utilisation des tests de pharmacogénétique est limitée, fragmentée et non standardisée. S’ajoute à ceci, le manque de données probantes et de dialogue entre des acteurs mal ou peu informés, la résistance et la crainte de certains professionnels. Discussion : Plusieurs changements dans la réglementation des systèmes d’innovation ainsi que dans le contexte d’accueil seront nécessaires pour rendre accessibles les tests de pharmacogénétique dans la pratique clinique courante. Des mécanismes facilitateurs de la translation des technologies et des facteurs clés de réussite sont proposés. Enfin, quelques initiatives phares sont suggérées. Conclusion : Des efforts au niveau international, national, provincial et local sont indispensables afin de résoudre les nombreux obstacles de la translation des tests de pharmacogénétique au Québec et ainsi planifier l’avenir le plus efficacement et sûrement possible.

Why should Restrictive Clauses be applicable in Cases of Forced Selling of Limited Liability Company Shares?

In many European countries, one of the most complex and widely discussed issues addressed by legal systems with respect to forced selling of limited liability and public limited company shares is the impact of possible statutory restrictions on transfers . Thus, while some authors deny the applicability of such provisions (as a possible avenue for commission of creditor fraud) , others support their validity (on the basis of prevention of possible fraudulent actions affecting interests protected by restrictive causes). In my opinion, a solution must be found in which prosecution of creditor fraud co-exists with respect for the rights scheme. As a general rule, this solution would call for applicability of restrictive clauses to cases of forced selling, regardless of whether such statutory provisions are viewed in terms of order or alienation.

Could Staying Human in Medical Training Help Make Medicine Humane? Review of Allan D. Peterkin, Staying Human During Residency Training

Compte-rendu / Review

Índice de pulsatilidad de arteria cerebral media como predictor para desenlaces desfavorables en fetos pequeños para la edad gestacional

Introducción: La aparición de vasodilatación aislada de la arteria cerebral media en fetos pequeños para la edad gestacional sin otros cambios en el doppler puede interpretarse como fisiológica o podría ser la manifestación inicial de una restricción de crecimiento intrauterino de inicio tardío. Se pretende evaluar la asociación de la disminución del índice de pulsatibilidad de la arteria cerebral media, como predictor de desenlaces perinatales adversos, en fetos con bajo peso para edad gestacional. Metodología: Se realizó un estudio de cohorte analítica de temporalidad histórica para determinar si el hallazgo de disminución de la pulsatibilidad en el doppler de arteria cerebral media se asocia con el pronóstico perinatal adverso, en fetos pequeños para edad gestacional mediante un muestreo no probabilístico. Resultados: Se recolectaron un total de 325 flujometría doppler de fetos pequeños para edad gestacional. El riesgo de parto pretérmino fue RR 2.6 IC95% 1.6-4.1, de hospitalización fue RR 1.4 IC95%1.1-1.9 y de muerte fue 2.1 IC95%1.5-3.2 cuando hay índice de pulsatilidad alterada en la arteria cerebral media. La regresión logística mostró que el riesgo de desenlaces desfavorables con alteraciones en la arteria cerebral media fue de RR 4.2 IC95% 2.5-7.1 ajustado por edad materna, edad gestacional y bajo peso al nacer. Discusión Los pacientes expuestos presentan mayor riesgo de desenlaces desfavorables con diferencias significativas, no así en otros estudios publicados. El presente estudio muestra asociaciones significativas que debe ser evaluada con estudios más amplios.

What is Character or Moral Education All About?

Resumen basado en el del autor

Ergonomics as authoritarian or libertarian: reflections on Ward’s politics of design

Ergonomics is intrinsically connected to political debates about the good society, about how we should live. This article follows the ideas of Colin Ward by setting the practices of ergonomics and design along a spectrum between more libertarian approaches and more authoritarian. Within Anglo-American ergonomics, more authoritarian approaches tend to prevail, often against the wishes of designers who have had to fight with their employers for best possible design outcomes. The article draws on debates about the design and manufacturing of schoolchildren’s furniture. Ergonomics would benefit from embracing these issues to stimulate a broader discourse amongst its practitioners about how to be open to new disciplines, particularly those in the social sciences.

Push or pull? : The relationship between quality of care and use of complementary and alternative medicine among patients with lung cancer in Sweden

Little is known about relationships between quality of care (QoC) and use of complementary and alternative medicine (CAM) among patients with lung cancer (LC). Purpose: This study examines CAM-use among patients with LC in Sweden, associations between QoC and CAM-use among these patients, and reported aspects of LC-care perceived as particularly positive and negative by patients, as well as suggestions for improving QoC. Methods: Survey data from 94 patient members of the Swedish LC patient organization about CAM-use and QoC as measured by the instrument “Quality from the patient’s perspective” were analyzed. Results: Fifty (53%) LC-patients used CAM, with 40 of the CAM-users reporting that CAM helped them. The most common CAMs used were dietary supplements and natural remedies, followed by prayer. Significantly more patients reported using prayer and meditation for cure than was the case for other types of CAM used. Less than half the CAM-users reported having spoken with staff from the biomedical health care system about their CAM-use. Patients provided numerous suggestions for improving LC-care in a variety of areas, aiming at a more effective and cohesive care trajectory. No differences in QoC were found between CAM-users and non-CAM-users, but differences in CAM-use i.e. type of CAM, reasons for using CAM, and CAM-provider consulted could be associated with different experiences of care. Conclusions: It is important to recognize that CAM-users are not a homogeneous group but might seek different types of CAMs and CAM-providers in different situations depending on experiences of care.

Os crimes de mídia no paradigma democrático constitucional

The criminal responsibility of the media is analyzed when the criteria for production of news and events involving public safety are produced without considering the technical, legal and ethical practice of journalism in the media factors. Freedom of speech, expression of thought, necessary for professional qualifications and constitutional limits, reaching criminal constitutional principles and the possibilities of criminal liability for offenses practiced in the media are present as key factors legal dialogue in this work. The judgment of the Supreme Court on the unconstitutionality of Law nº. 5.250/67 called Media Law caused a gap in the national legal system, forcing the use of the criminal code to address issues that involve crimes produced in media professional performance. The presumption of innocence is ignored by the professional media during a police investigation where the information published does not respect, including constitutional guarantees: the right to privacy, honor and image. The right to information and the duty to inform media are worked in its constitutional aspect, considering that the same information should be produced is guided by the quality and guiding principles of truth. The constitutional concept of media is presented as information with the appropriate language of the news media, produced and disseminated through the vehicles of mass media, whether in print or digital platform. The presented model of the legal right to information is outlined from a constitutional hermeneutics, increasing the production of news as a result of the occupation of journalist in different news platforms, guaranteeing the quality of this prolific law. Under the Freedom of professional activity of the journalist, the constitutional limits are addressed in line with the reality of (non) regulation of their profession, considering the constitutional abuses committed in the exercise of that activity linked to communication fences. Jusphilosophic field reaches the limits of the duty of truth in journalism as a tool for spreading news, respect the audience and compatibility with the constitutional state. Using the conceptual and doctrinal aspects, this criminal offense is parsed from the journalistic practice and the publication of news involving public safety, with the hypothetical field consummation of that crime through the eventual intention. As a form of judgment against these crimes produced in honor media presents the court of the jury as a legitimate form of democratic decision