Inconsistencies in the planning of the duration of anticoagulation among outpatients with acute deep-vein thrombosis. Results from the OTIS-DVT Registry

Three-month anticoagulation is recommended to treat provoked or first distal deep-vein thrombosis (DVT), and indefinite-duration anticoagulation should be considered for patients with unprovoked proximal, unprovoked recurrent, or cancer-associated DVT. In the prospective Outpatient Treatment of Deep Vein Thrombosis in Switzerland (OTIS-DVT) Registry of 502 patients with acute objectively confirmed lower extremity DVT (59% provoked or first distal DVT; 41% unprovoked proximal, unprovoked recurrent, or cancer-associated DVT) from 53 private practices and 11 hospitals, we investigated the planned duration of anticoagulation at the time of treatment initiation. The decision to administer limited-duration anticoagulation therapy was made in 343 (68%) patients with a median duration of 107 (interquartile range 91-182) days for provoked or first distal DVT, and 182 (interquartile range 111-184) days for unprovoked proximal, unprovoked recurrent, or cancer-associated DVT. Among patients with provoked or first distal DVT, anticoagulation was recommended for < 3 months in 11%, 3 months in 63%, and for an indefinite period in 26%. Among patients with unprovoked proximal, unprovoked recurrent, or cancer-associated DVT, anticoagulation was recommended for < 6 months in 22%, 6-12 months in 38%, and for an indefinite period in 40%. Overall, there was more frequent planning of indefinite-duration therapy from hospital physicians as compared with private practice physicians (39% vs. 28%; p=0.019). Considerable inconsistency in planning the duration of anticoagulation therapy mandates an improvement in risk stratification of outpatients with acute DVT.

Testing for sexually transmitted infections in general practice: cross-sectional study

Background Primary care is an important provider of sexual health care in England. We sought to explore the extent of testing for chlamydia and HIV in general practice and its relation to associated measures of sexual health in two contrasting geographical settings. Methods We analysed chlamydia and HIV testing data from 64 general practices and one genitourinary medicine (GUM) clinic in Brent (from mid-2003 to mid-2006) and 143 general practices and two GUM clinics in Avon (2004). We examined associations between practice testing status, practice characteristics and hypothesised markers of population need (area level teenage conception rates and Index of Multiple Deprivation, IMD scores). Results No HIV or chlamydia testing was done in 19% (12/64) of general practices in Brent, compared to 2.1% (3/143) in Avon. In Brent, the mean age of general practitioners (GPs) in Brent practices that tested for chlamydia or HIV was lower than in those that had not conducted testing. Practices where no HIV testing was done had slightly higher local teenage conception rates (median 23.5 vs. 17.4/1000 women aged 15-44, p = 0.07) and served more deprived areas (median IMD score 27.1 vs. 21.8, p = 0.05). Mean yearly chlamydia and HIV testing rates, in practices that did test were 33.2 and 0.6 (per 1000 patients aged 15-44 years) in Brent, and 34.1 and 10.3 in Avon, respectively. In Brent practices only 20% of chlamydia tests were conducted in patients aged under 25 years, compared with 39% in Avon. Conclusions There are substantial geographical differences in the intensity of chlamydia and HIV testing in general practice. Interventions to facilitate sexually transmitted infection and HIV testing in general practice are needed to improve access to effective sexual health care. The use of routinely-collected laboratory, practice-level and demographic data for monitoring sexual health service provision and informing service planning should be more widely evaluated.

Work-related behavior and experience patterns and predictors of mental health in German physicians in medical practice

Background and Objectives: Work-related stress and burnout among physicians are of increasing relevance. The aim of this study was to investigate work-related behavior and experience patterns and predictors of mental health of physicians working in medical practice in Germany. Methods: We surveyed a stratified, random sample of 900 physicians from different specialties. The questionnaire included the standardized instruments Work-related Behavior and Experience Pattern (AVEM) and the Short Form-12 Health Survey (SF-12). Results: Only one third of physicians reported high or very high general satisfaction with their job, but 64% would choose to study medicine again. Only 18% of physicians presented a healthy behavior and experience pattern. Almost 40% presented a pattern of reduced motivation to work, 21% were at risk of overexertion, and 22% at risk for burnout. Willingness to study medicine again, fulfilled job expectations, professional years, marital status, and behavior patterns were significant predictors of mental health and accounted for 35.6% of the variance in mental health scores. Job-related perceptions also had a significant effect on burnout. Conclusions: The strong influence of work-related perceptions suggests a need for realistic expectation management in medical education, as well as support in stress management and coping strategies during medical training.

Reducing vulnerability to climate change in the Swiss Alps: a study of adaptive planning

The Swiss Alps will experience pronounced effects of climate change due to the combination of their latitudinal positioning, altitude and unique ecosystems, placing socio-economic stresses on alpine communities, many of which rely on seasonal tourism. Studies into tourism adaptation within the Swiss Alps have so far focused on the technical adaptation options of alpine stakeholders, rather than perceptions of adaptation to climate change at the operational and community level. This article investigates attitudes to adaptation in two alpine regions within Switzerland's well-established decentralized political framework, through semi-structured qualitative interviews. Stakeholders focused almost entirely on maintaining the status quo of winter tourism, through technical or marketing measures, with mixed attitudes towards climatic impacts. A matrix based on the relative internal strengths and weaknesses, external opportunities and threats of adaptation measures (a SWOT framework) was used to assess the measures and suggest how stakeholders could capitalize on the new opportunities thrown up by climate change to create a competitive advantage. A comprehensive and collaborative planning approach is vital to enable policy makers and stakeholders to maximize opportunities, minimize the adverse effects of climate change on the local economy, and develop inclusive adaptation measures that benefit the entire region in order to create more sustainable social, economic and environmental structures.

Perceptions of Social Mobility in Community College Scholars at Bucknell University

While national leaders have joined the discussion more recently, scholars in the fields of education, psychology, and sociology, have been exploring the ways in which students? socioeconomic background affects the outcomes they experience as a result of their education (Lareau, Unequal Childhoods: Class, Race, and Family Life, 2003).Furthermore, the role played by the education system in creating or diminishing socioeconomic disparity has also been studied in depth (Bourdieu, 1977; Boudon, 1977). However, the journeys of students from low-income families that begin their education at community colleges and continue it, through careful planning or chance, at elite four-year institutions, has not been the subject of much attention. This thesis explores these students? perceptions of social mobility as they have been shaped by their experiences so far in life. This includes the exploration of changes in their perceptions as the contexts for their lives have been changed. Quantitative analysis of survey results and qualitative analysis of participant interviews serve as the data set for this study. The implications ofthe findings for student affairs practitioners are also explored.

Assessing Commonality and Differentiation for Packaging-Family Planning with Application to Medication Labels

This thesis presents a metric for assessing the commonality and differentiation of packaging-family planning with application to medical labels along with supporting background research and findings. Consumable products such as medications rely on the package or label to represent the contents. Package confusion has been widely recognized as a major problem for both over-the-counter and pharmacy-dispensed medications with potentially lethal consequences. It is critical to identify a medication as a member of a product family and differentiate its contributing elements based on visual features on the package or label to avoid consumer confusion and reduce dispensing errors. Indices that indicate degrees of commonality and differentiation of features in consumer products such as batteries, light bulbs, handles, etc for platforms have been shown to benefit development of engineered product families [6]. It is possible to take a similar approach for visual features in packaging such as typography, shape/form, imagery and color to benefit packaging-family development. This thesis establishes a commonality differentiation index for prominence of visual features on over-the-counter and pharmacy-dispensed medications based on occurrence, size, and location of features. It provides a quantitative measure to assist package designers in evaluating alternatives to satisfy strategic goals and improve safety. The index is demonstrated with several medications that have been identified by the Institute for Safe Medication Practice as commonly confused.

Impact of a self-developed planning and self-constructed navigation system on skull base surgery: 10 years experience

CONCLUSION: Our self-developed planning and navigation system has proven its capacity for accurate surgery on the anterior and lateral skull base. With the incorporation of augmented reality, image-guided surgery will evolve into 'information-guided surgery'. OBJECTIVE: Microscopic or endoscopic skull base surgery is technically demanding and its outcome has a great impact on a patient's quality of life. The goal of the project was aimed at developing and evaluating enabling navigation surgery tools for simulation, planning, training, education, and performance. This clinically applied technological research was complemented by a series of patients (n=406) who were treated by anterior and lateral skull base procedures between 1997 and 2006. MATERIALS AND METHODS: Optical tracking technology was used for positional sensing of instruments. A newly designed dynamic reference base with specific registration techniques using fine needle pointer or ultrasound enables the surgeon to work with a target error of < 1 mm. An automatic registration assessment method, which provides the user with a color-coded fused representation of CT and MR images, indicates to the surgeon the location and extent of registration (in)accuracy. Integration of a small tracker camera mounted directly on the microscope permits an advantageous ergonomic way of working in the operating room. Additionally, guidance information (augmented reality) from multimodal datasets (CT, MRI, angiography) can be overlaid directly onto the surgical microscope view. The virtual simulator as a training tool in endonasal and otological skull base surgery provides an understanding of the anatomy as well as preoperative practice using real patient data. RESULTS: Using our navigation system, no major complications occurred in spite of the fact that the series included difficult skull base procedures. An improved quality in the surgical outcome was identified compared with our control group without navigation and compared with the literature. The surgical time consumption was reduced and more minimally invasive approaches were possible. According to the participants' questionnaires, the educational effect of the virtual simulator in our residency program received a high ranking.

Perceptions and evaluations of biosphere reserves by local residents in Switzerland and Ukraine

In a cross-cultural study perceptions of local people living in the surroundings of biosphere reserves in Switzerland and Ukraine were examined using the method of qualitative interviews. In the UNESCO Biosphere Entlebuch in Switzerland people stated that they hoped for a better regional economic development due to the existence of the biosphere reserve. However, at the same time people feared further restrictions regarding land-use. In the Carpathian Biosphere Reserve located in Transcarpathia/Ukraine people tended to connect certain conditions – such as the high price for wood – directly to the existence of the biosphere reserve, when in fact these conditions and the biosphere reserve were separate, parallel developments. In both case studies three key-categories influencing local residents’ perceptions and evaluations of biosphere reserves could be identified. These categories are (1) the economic situation, (2) the history of nature protection, and (3) the power balance between the involved stakeholders. Paying close attention to those three categories will help planners and managers of protected areas to better understand the reasoning of local residents for or against a biosphere reserve in their area.

Hospital food: a survey of patients' perceptions

Most hospitalised patients are dependent on hospital food for their nutritional requirements. We surveyed hospitalised patients to obtain their opinions of hospital food in order to improve menu planning and food delivery.

Design-based stereology: Planning, volumetry and sampling are crucial steps for a successful study

Quantitative data obtained by means of design-based stereology can add valuable information to studies performed on a diversity of organs, in particular when correlated to functional/physiological and biochemical data. Design-based stereology is based on a sound statistical background and can be used to generate accurate data which are in line with principles of good laboratory practice. In addition, by adjusting the study design an appropriate precision can be achieved to find relevant differences between groups. For the success of the stereological assessment detailed planning is necessary. In this review we focus on common pitfalls encountered during stereological assessment. An exemplary workflow is included, and based on authentic examples, we illustrate a number of sampling principles which can be implemented to obtain properly sampled tissue blocks for various purposes.

[Cone beam computed tomography in endodontics: a review for daily clinical practice]

Since the introduction of cone beam computed tomography (CBCT), this 3-dimensional diagnostic imaging technique has been established in a growing number of fields in dental medicine. It has become an important tool for both diagnosis and treatment planning, and is also able to support endodontic treatments. However, the higher effective dose of ionizing radiation compared to conventional 2-dimensional radiographs is not justifiable in every case. CBCT allows for a more precise diagnosis of periapical lesions, root fractures as well as external and internal resorptions. Concerning the utility of CBCT in treatment planning decisions, the gain of information through 3-dimensional imaging for any of these pathologies has to be evaluated carefully on an individual basis. Moreover, radioopaque materials such as root canal filling and posts often create artefacts, which may compromise diagnosis. The aim of this review is to summarize the possibilities and limits of CBCT imaging in endodontology as well as introduce guidelines for daily clinical practice. Furthermore, the article presents possible therapeutic advantages of preexisting CBCT scans for root canal treatments.

Theories of Militancy in Practice: Explanations of Muslim Terrorism in India

This article analyzes the interaction between theories of radicalization and state responses to militancy in India. Focusing on the interpretation of the increased frequency of terrorist attacks in Indian metropolises in the last decade, the article examines the narratives surrounding those classified as terrorists in the context of rising Muslim militancy in the country. Different state agencies operate with different theories about the links between processes of radicalization and terrorist violence. The scenarios of radicalization underlying legislative efforts to prevent terrorism, the construction of motives by the police, and the interpretation of violence by the judiciary all rely on assumptions about radicalization and violence. Such narratives are used to explain terrorism both to security agencies and to the public; they inform the categories and scenarios of prevention. Prevention relies on detection of future deeds, planning, intentions, and even potential intentions. "Detection" of potential intentions relies on assumptions about specific dispositions. Identification of such dispositions in turn relies on the context-specific theories of the causes of militancy. These determine what "characteristics" of individuals or groups indicate potential threats and form the basis for their categorization as "potentially dangerous." The article explores the cultural contexts of theories of radicalization, focusing on how they are framed by societal understandings of the causes of deviance and the relation between the individual and society emerging in contemporary India. It examines the shift in the perception of threat and the categories of "dangerous others" from a focus on role to a focus on ascriptive identity.

Water harvesting: guidelines to good practice

These guidelines provide an overview of proven good practice in water harvesting from all over the world. They form a practical reference guide while providing support and specific technical expertise for the integration of water harvesting technologies into the planning and design of projects. Thus existing information and experience is strengthened. On a broader scale, the guidelines’ objective is to facilitate, share and upscale good practice in water harvesting given the state of current knowledge. Targeted end users include local and regional planners / advisors, rural development consultants, rainwater harvesting networks and communitiesof- practice, project managers, extension agents and other implementing staff. Through informing these professionals, the aim is to stimulate discussion and new thinking about improved water management in general, and water harvesting in particular, within rainfed agriculture, particularly in the drylands. The ultimate goal is to contribute to lifting 80 million rural people out of poverty by 2015: water security is a prerequisite to achieve food security for these people.

DUAL ENERGY COMPUTED TOMOGRAPHY FOR PROTON THERAPY TREATMENT PLANNING

Proton radiation therapy is gaining popularity because of the unique characteristics of its dose distribution, e.g., high dose-gradient at the distal end of the percentage-depth-dose curve (known as the Bragg peak). The high dose-gradient offers the possibility of delivering high dose to the target while still sparing critical organs distal to the target. However, the high dose-gradient is a double-edged sword: a small shift of the highly conformal high-dose area can cause the target to be substantially under-dosed or the critical organs to be substantially over-dosed. Because of that, large margins are required in treatment planning to ensure adequate dose coverage of the target, which prevents us from realizing the full potential of proton beams. Therefore, it is critical to reduce uncertainties in the proton radiation therapy. One major uncertainty in a proton treatment is the range uncertainty related to the estimation of proton stopping power ratio (SPR) distribution inside a patient. The SPR distribution inside a patient is required to account for tissue heterogeneities when calculating dose distribution inside the patient. In current clinical practice, the SPR distribution inside a patient is estimated from the patient’s treatment planning computed tomography (CT) images based on the CT number-to-SPR calibration curve. The SPR derived from a single CT number carries large uncertainties in the presence of human tissue composition variations, which is the major drawback of the current SPR estimation method. We propose to solve this problem by using dual energy CT (DECT) and hypothesize that the range uncertainty can be reduced by a factor of two from currently used value of 3.5%. A MATLAB program was developed to calculate the electron density ratio (EDR) and effective atomic number (EAN) from two CT measurements of the same object. An empirical relationship was discovered between mean excitation energies and EANs existing in human body tissues. With the MATLAB program and the empirical relationship, a DECT-based method was successfully developed to derive SPRs for human body tissues (the DECT method). The DECT method is more robust against the uncertainties in human tissues compositions than the current single-CT-based method, because the DECT method incorporated both density and elemental composition information in the SPR estimation. Furthermore, we studied practical limitations of the DECT method. We found that the accuracy of the DECT method using conventional kV-kV x-ray pair is susceptible to CT number variations, which compromises the theoretical advantage of the DECT method. Our solution to this problem is to use a different x-ray pair for the DECT. The accuracy of the DECT method using different combinations of x-ray energies, i.e., the kV-kV, kV-MV and MV-MV pair, was compared using the measured imaging uncertainties for each case. The kV-MV DECT was found to be the most robust against CT number variations. In addition, we studied how uncertainties propagate through the DECT calculation, and found general principles of selecting x-ray pairs for the DECT method to minimize its sensitivity to CT number variations. The uncertainties in SPRs estimated using the kV-MV DECT were analyzed further and compared to those using the stoichiometric method. The uncertainties in SPR estimation can be divided into five categories according to their origins: the inherent uncertainty, the DECT modeling uncertainty, the CT imaging uncertainty, the uncertainty in the mean excitation energy, and SPR variation with proton energy. Additionally, human body tissues were divided into three tissue groups – low density (lung) tissues, soft tissues and bone tissues. The uncertainties were estimated separately because their uncertainties were different under each condition. An estimate of the composite range uncertainty (2s) was determined for three tumor sites – prostate, lung, and head-and-neck, by combining the uncertainty estimates of all three tissue groups, weighted by their proportions along typical beam path for each treatment site. In conclusion, the DECT method holds theoretical advantages in estimating SPRs for human tissues over the current single-CT-based method. Using existing imaging techniques, the kV-MV DECT approach was capable of reducing the range uncertainty from the currently used value of 3.5% to 1.9%-2.3%, but it is short to reach our original goal of reducing the range uncertainty by a factor of two. The dominant source of uncertainties in the kV-MV DECT was the uncertainties in CT imaging, especially in MV CT imaging. Further reduction in beam hardening effect, the impact of scatter, out-of-field object etc. would reduce the Hounsfeld Unit variations in CT imaging. The kV-MV DECT still has the potential to reduce the range uncertainty further.

Agroecosystem resilience and farmers’ perceptions of climate change impacts on cocoa farms in Alto Beni, Bolivia

Cocoa-based small-scale agriculture is the most important source of income for most farming families in the region of Alto Beni in the sub-humid foothills of the Andes. Cocoa is grown in cultivation systems of varying ecological complexity. The plantations are highly susceptible to climate change impacts. Local cocoa producers mention heat waves, droughts, floods and plant diseases as the main impacts affecting plants and working conditions, and they associate these impacts with global climate change. From a sustainable regional development point of view, cocoa farms need to become more resilient in order to cope with the climate change related effects that are putting cocoa-based livelihoods at risk. This study assesses agroecosystem resilience under three different cocoa cultivation systems (successional agroforestry, simple agroforestry and common practice monocultures). In a first step, farmers’ perceptions of climate change impacts were assessed and eight indicators of agroecological resilience were derived in a transdisciplinary process (focus groups and workshop) based on farmers’ and scientists’ knowledge. These indicators (soil organic matter, depth of Ah horizon, soil bulk density, tree species diversity, crop varieties diversity, ant species diversity, cocoa yields and infestation of cocoa trees with Moniliophthora perniciosa) were then surveyed on 15 cocoa farms and compared for the three different cultivation systems. Parts of the socio-economic aspects of resilience were covered by evaluating the role of cocoa cooperatives and organic certification in transitioning to more resilient cocoa farms (interviews with 15 cocoa farmers combined with five expert interviews). Agroecosystem resilience was higher under the two agroforestry systems than under common practice monoculture, especially under successional agroforestry. Both agroforestry systems achieved higher cocoa yields than common practice monoculture due to agroforestry farmers’ enhanced knowledge regarding cocoa cultivation. Knowledge sharing was promoted by local organizations facilitating organic certification. These organizations were thus found to enhance the social process of farmers’ integration into cooperatives and their reorientation toward organic principles and diversified agroforestry.