Effectiveness of individual resource-oriented joint protection education in people with rheumatoid arthritis. A randomized controlled trial

the modern joint protection (JP) concept for people with rheumatoid arthritis (RA) is an active coping strategy to improve daily tasks and role performance by changing working methods and using assistive devices. Effective group JP education includes psycho-educational interventions. The Pictorial Representation of Illness and Self Measure (PRISM) is an interactive hands-on-tool, assessing (a) the individual's perceived burden of illness and (b) relevant individual resources. Both issues are important for intrinsic motivation to take action and change behaviour. This study compared individual conventional JP education (C-JP) with PRISM-based JP education (PRISM-JP).

Sharing vs. caring--the relative impact of sharing decisions versus managing emotions on patient outcomes

To assess the relative impact of cognitive and emotional aspects of shared decision making (SDM) on patient outcomes.

Impact of the availability of an influenza virus rapid antigen test on diagnostic decision making in a pediatric emergency department

OBJECTIVES: Fever is one of the most commonly seen symptoms in the pediatric emergency department. The objective of this study was to observe how the rapid testing for influenza virus impacts on the management of children with fever. METHODS: We performed a review of our pediatric emergency department records during the 2008/2009 annual influenza season. The BinaxNow Influenza A+B test was performed on patients with the following criteria: age 1.0 to 16.0 years, fever greater than 38.5 °C, fever of less than 96 hours' duration after the onset of clinical illness, clinical signs compatible with acute influenza, and nontoxic appearance. Additional laboratory tests were performed at the treating physician's discretion. RESULTS: The influenza rapid antigen test was performed in 192 children. One hundred nine (57%) were influenza positive, with the largest fraction (101 patients) positive for influenza A. The age distribution did not differ between children with negative and positive test results (mean, 5.3 vs. 5.1 years, not statistically significant). A larger number of diagnostic tests were performed in the group of influenza-negative patients. Twice as many complete blood counts, C-reactive protein determinations, lumbar punctures, and urinalyses were ordered in the latter group. CONCLUSIONS: Rapid diagnosis of influenza in the pediatric emergency department affects the management of febrile children as the confirmation of influenza virus infection decreases additional diagnostic tests ordered.

Primary perivascular epithelioid cell tumor of the liver not related to hepatic ligaments: hepatic PEComa as an emerging entity

Primary perivascular epithelioid cell tumor (PEComa) of the liver is a very rare example of an emerging family of hepatic PEC tumors. Only few cases have been described so far. We report the case of a large but benign hepatic PEComa in a 53-year-old man without signs of tuberous sclerosis. In contrast to recently described PEC-derived liver tumors in children and young adults, this neoplasm was not related to the hepatic ligaments but had developed deeply within the liver substance. The neoplastic cells displayed the complete phenotype typical for PEComas, i.e. reactivity for several melanoma markers and for smooth muscle actin. The unique relationship of myoid tumor cells to the adventitia of blood vessels prompted us, in comparison with published findings obtained with angiomyolipomas, to comment on the possible origin of the still enigmatic perivascular epithelioid cells.

Do patients respect the line? Transgression of boundaries reported by Swiss general practitioners

OBJECTIVE: Transgression of boundaries in the relationship between physician and patient is commonly studied with patient as victim and physician as transgressor. A recent survey in the U.S. reported that almost 90% of physicians face transgression by patients over one year. Incidents happened mainly through verbal abuse, disregarding privacy, and overly affectionate behavior. Since this incidence seems to be alarmingly high, we were interested to analyze how often general practitioners in Switzerland experience transgression by patients. METHODS: 24% of the members of the Swiss Society of Internal Medicine (SGIM) and of the Swiss Society of General Medicine (SGAM) (n=675/2781) responded to an internet-based survey which asked for experiences of transgression by patients and for physicians' responses to transgression in the last 12 months. RESULTS: 81% of responding physicians experienced transgression over the period of one year. Analyzing the frequency of incidents per physician per year, the most common forms of transgression were 'use of physician's first name' (7.7/y), 'asking personal questions' (1.8/y), 'being verbally abusive' (1.5/y), and 'being overly affectionate' (1.4/y). Calculated incidence of transgression was 3 per 1000 patient contacts. 39% of physicians decided to ignore the incident, 37% discussed the event openly. Transgression led to dismissal of patients in 13% of events. CONCLUSION: Transgression even in mild and modest form is a rare phenomenon in Swiss practices. PRACTICE IMPLICATION: The Swiss data do not suggest that there is a specific risk for Swiss practitioners to be exposed to major transgression for which they should specifically be prepared for example in communication skills trainings.

Reactivity of human natural antibodies to endothelial cells from Galalpha(1,3)Gal-deficient pigs

BACKGROUND: Xenoreactive human natural antibodies (NAb) are predominantly directed against galactose-alpha(1,3)galactose (Gal). Binding of immunoglobulin (Ig) G and IgM NAb activates porcine endothelial cells (pEC) and triggers complement lysis responsible for hyperacute xenograft rejection. In vitro, IgG NAb induce human natural killer (NK) cell-mediated lysis of pEC by antibody-dependent cell-mediated cytotoxicity (ADCC). The present study examined the levels of anti-porcine NAb in a large number of individuals and addressed the functional role of non-Gal anti-porcine NAb. METHODS: Sera from 120 healthy human blood donors were analyzed for the presence of anti-porcine NAb by flow cytometry using porcine red blood cells (pRBC), lymphoblastoid cells (pLCL), and pEC derived from control or Gal-deficient pigs. Xenogeneic complement lysis was measured by flow cytometry using human serum and rabbit complement. ADCC was analyzed by chromium-release assays using human serum and freshly isolated NK cells. RESULTS: Human IgM binding to pRBC was found in 93% and IgG binding in 86% of all samples. Non-Gal NAb comprised 13% of total IgM and 36% of total IgG binding to pEC. NAb/complement-induced lysis and ADCC of Gal-deficient compared to Gal-positive pEC were 21% and 29%, respectively. The majority of anti-Gal and non-Gal IgG NAb were of the IgG2 subclass. CONCLUSIONS: The generation of Gal-deficient pigs has overcome hyperacute anti-Gal-mediated xenograft rejection in nonhuman primates. Non-Gal anti-porcine NAb represent a potentially relevant immunological hurdle in a subgroup of individuals by inducing endothelial damage in xenografts.

Internet information and medical consultations: experiences from patients' and physicians' perspectives

OBJECTIVE: Many patients use the Internet to obtain health-related information. It is assumed that health-related Internet information (HRII) will change the consultation practice of physicians. This article explores the strategies, benefits and difficulties from the patients' and physicians' perspective. METHODS: Semi-structured interviews were conducted independently with 32 patients and 20 physicians. Data collection, processing and analysis followed the core principles of Grounded Theory. RESULTS: Patients experienced difficulties in the interpretation of the personal relevance and the meaning of HRII. Therefore they relied on their physicians' interpretation and contextualisation of this information. Discussing patients' concerns and answering patients' questions were important elements of successful consultations with Internet-informed patients to achieve clarity, orientation and certainty. Discussing HRII with patients was appreciated by most of the physicians but misleading interpretations by patients and contrary views compared to physicians caused conflicts during consultations. CONCLUSION: HRII is a valuable source of knowledge for an increasing number of patients. Patients use the consultation to increase their understanding of health and illness. Determinants such as a patient-centred consultation and timely resources are decisive for a successful, empowering consultation with Internet-informed patients. PRACTICAL IMPLICATIONS: If HRII is routinely integrated in the anamnestic interview as a new source of knowledge, the Internet can be used as a link between physicians' expertise and patient knowledge. The critical appraisal of HRII during the consultation is becoming a new field of work for physicians.

Clostridium perfringens beta-toxin induces necrostatin-inhibitable, calpain-dependent necrosis in primary porcine endothelial cells

Clostridium perfringens β-toxin (CPB) is a β-barrel pore-forming toxin and an essential virulence factor of C. perfringens type C strains, which cause fatal hemorrhagic enteritis in animals and humans. We have previously shown that CPB is bound to endothelial cells within the intestine of affected pigs and humans, and that CPB is highly toxic to primary porcine endothelial cells (pEC) in vitro. The objective of the present study was to investigate the type of cell death induced by CPB in these cells, and to study potential host cell mechanisms involved in this process. CPB rapidly induced lactate dehydrogenase (LDH) release, propidium iodide uptake, ATP depletion, potassium efflux, a marked rise in intracellular calcium [Ca(2+)]i, release of high-mobility group protein B1 (HMGB1), and caused ultrastructural changes characteristic of necrotic cell death. Despite a certain level of caspase-3 activation, no appreciable DNA fragmentation was detected. CPB-induced LDH release and propidium iodide uptake were inhibited by necrostatin-1 and the two dissimilar calpain inhibitors PD150606 and calpeptin. Likewise, inhibition of potassium efflux, chelation of intracellular calcium and treatment of pEC with cyclosporin A also significantly inhibited CPB-induced LDH release. Our results demonstrate that rCPB primarily induces necrotic cell death in pEC, and that necrotic cell death is not merely a passive event caused by toxin-induced membrane disruption, but is propagated by host cell-dependent biochemical pathways activated by the rise in intracellular calcium and inhibitable by necrostatin-1, consistent with the emerging concept of programmed necrosis ("necroptosis").

The effects of IL -10 producing monocytes on T-cell activation in patients with epithelial ovarian cancer

A newly described subset of monocytes has been identified in peritoneal exudate cells (PEC) from the malignant ascites of patients with ovarian cancer. These cells were characterized by the production of IL-10 and TGF-β2, but not IL-12, IL-1α, or TNF-α, and expressed CD14, CD16, and CD54, but not HLA-DR, CD80, CD86, CD11a, CD11b, or CD25 cell surface antigens. Since this subset of monocytes could affect the modulation of tumor immune responses in vivo, studies were undertaken to determine their effect on the activation and proliferation of autologous T-cells from the peritoneal cavity of patients with ovarian carcinoma. Cytokine transcripts, including IL-2, GM-CSF, and IFN-γ were detected in T-cells isolated from patient specimens that also contained the IL-10 producing monocytes, although the IFN-γ and IL-2 proteins could not be detected in T-cells co-incubated with the IL-10 producing monocytes in vitro. Additionally, IL-10 producing monocytes co-cultured with autologous T-cells inhibited the proliferation of the T-cells in response to PHA. T-cell proliferation and cytokine protein production could be restored by the addition of neutralizing antibodies to IL-10R and TGF-β to the co-culture system. These results suggested that this subset of monocytes may modulate antitumor immune responses by inhibiting T-cell proliferation and cytokine protein production. Further studies determined that the precursors to the inhibitory monocytes were tumor-associated and only present in the peripheral blood of patients with ovarian cancer and not present in the peripheral blood of healthy donors. These precursors could be induced to the suppressor phenotype by the addition of IL-2 and GM-CSF, two cytokines detected in the peritoneal cavity of ovarian cancer patients. Lastly, it was shown that the suppressor monocytes from the peritoneal cavity of ovarian cancer patients could be differentiated to a non-inhibitory phenotype by the addition of TNF-α and IFN-γ to the culture system. The differentiated monocytes did not produce IL-10, expressed the activation antigens HLA-DR, CD80, and CD86, and were able to stimulate autologous T-cells in vitro. Since a concomitant reduction in immune function is associated with tumor growth and progression, the effects of these monocytes are of considerable importance in the context of tumor immunotherapy. ^

Caracterización de la impedancia de superficie para el cálculo del acoplo mutuo en un cilindro circular conductor cubierto por una dieléctrico multicapa

A novel formulation for the surface impedance characterization is introduced for the canonical problem of surface fields on a perfect electric conductor (PEC) circular cylinder with a dielectric coating due to a electric current source using the Uniform Theory of Diffraction (UTD) with an Impedance Boundary Condition (IBC). The approach is based on a TE/TM assumption of the surface fields from the original problem. Where this surface impedance fails, an optimization is performed to minimize the error in the SD Green's function between the original problem and the equivalent one with the IBC. This new approach requires small changes in the available UTD based solution with IBC to include the geodesic ray angle and length dependence in the surface impedance formulas. This asymptotic method, accurate for large separations between source and observer points, in combination with spectral domain (SD) Green's functions for multidielectric coatings leads to a new hybrid SD-UTD with IBC to calculate mutual coupling among microstrip patches on a multilayer dielectric-coated PEC circular cylinder. Results are compared with the eigenfunction solution in SD, where a very good agreement is met.

Development of a Uniform Theory of Diffraction for Scattered and Surface Electromagnetic Field Analysis on a Cylinder

Con esta tesis ”Desarrollo de una Teoría Uniforme de la Difracción para el Análisis de los Campos Electromagnéticos Dispersados y Superficiales sobre un Cilindro” hemos iniciado una nueva línea de investigación que trata de responder a la siguiente pregunta: ¿cuál es la impedancia de superficie que describe una estructura de conductor eléctrico perfecto (PEC) convexa recubierta por un material no conductor? Este tipo de estudios tienen interés hoy en día porque ayudan a predecir el campo electromagnético incidente, radiado o que se propaga sobre estructuras metálicas y localmente convexas que se encuentran recubiertas de algún material dieléctrico, o sobre estructuras metálicas con pérdidas, como por ejemplo se necesita en determinadas aplicaciones aeroespaciales, marítimas o automovilísticas. Además, desde un punto de vista teórico, la caracterización de la impedancia de superficie de una estructura PEC recubierta o no por un dieléctrico es una generalización de varias soluciones que tratan ambos tipos de problemas por separado. En esta tesis se desarrolla una teoría uniforme de la difracción (UTD) para analizar el problema canónico del campo electromagnético dispersado y superficial en un cilindro circular eléctricamente grande con una condición de contorno de impedancia (IBC) para frecuencias altas. Construir una solución basada en UTD para este problema canónico es crucial en el desarrollo de un método UTD para el caso más general de una superficie arbitrariamente convexa, mediante el uso del principio de localización de los campos electromagnéticos a altas frecuencias. Esta tesis doctoral se ha llevado a cabo a través de una serie de hitos que se enumeran a continuación, enfatizando las contribuciones a las que ha dado lugar. Inicialmente se realiza una revisión en profundidad del estado del arte de los métodos asintóticos con numerosas referencias. As í, cualquier lector novel puede llegar a conocer la historia de la óptica geométrica (GO) y la teoría geométrica de la difracción (GTD), que dieron lugar al desarrollo de la UTD. Después, se investiga ampliamente la UTD y los trabajos más importantes que pueden encontrarse en la literatura. As í, este capítulo, nos coloca en la posición de afirmar que, hasta donde nosotros conocemos, nadie ha intentado antes llevar a cabo una investigación rigurosa sobre la caracterización de la impedancia de superficie de una estructura PEC recubierta por un material dieléctrico, utilizando para ello la UTD. Primero, se desarrolla una UTD para el problema canónico de la dispersión electromagnética de un cilindro circular eléctricamente grande con una IBC uniforme, cuando es iluminado por una onda plana con incidencia oblicua a frecuencias altas. La solución a este problema canónico se construye a partir de una solución exacta mediante una expansión de autofunciones de propagación radial. Entonces, ésta se convierte en una nueva expansión de autofunciones de propagación circunferencial muy apropiada para cilindros grandes, a través de la transformación de Watson. De esta forma, la expresión del campo se reduce a una integral que se evalúa asintóticamente, para altas frecuencias, de manera uniforme. El resultado se expresa según el trazado de rayos descrito en la UTD. La solución es uniforme porque tiene la importante propiedad de mantenerse continua a lo largo de la región de transición, a ambos lados de la superficie del contorno de sombra. Fuera de la región de transición la solución se reduce al campo incidente y reflejado puramente ópticos en la región iluminada del cilindro, y al campo superficial difractado en la región de sombra. Debido a la IBC el campo dispersado contiene una componente contrapolar a causa de un acoplamiento entre las ondas TEz y TMz (donde z es el eje del cilindro). Esta componente contrapolar desaparece cuando la incidencia es normal al cilindro, y también en la región iluminada cuando la incidencia es oblicua donde el campo se reduce a la solución de GO. La solución UTD presenta una muy buena exactitud cuando se compara numéricamente con una solución de referencia exacta. A continuación, se desarrolla una IBC efectiva para el cálculo del campo electromagnético dispersado en un cilindro circular PEC recubierto por un dieléctrico e iluminado por una onda plana incidiendo oblicuamente. Para ello se derivan dos impedancias de superficie en relación directa con las ondas creeping y de superficie TM y TE que se excitan en un cilindro recubierto por un material no conductor. Las impedancias de superficie TM y TE están acopladas cuando la incidencia es oblicua, y dependen de la geometría del problema y de los números de onda. Además, se ha derivado una impedancia de superficie constante, aunque con diferente valor cuando el observador se encuentra en la zona iluminada o en la zona de sombra. Después, se presenta una solución UTD para el cálculo de la dispersión de una onda plana con incidencia oblicua sobre un cilindro eléctricamente grande y convexo, mediante la generalización del problema canónico correspondiente al cilindro circular. La solución asintótica es uniforme porque se mantiene continua a lo largo de la región de transición, en las inmediaciones del contorno de sombra, y se reduce a la solución de rayos ópticos en la zona iluminada y a la contribución de las ondas de superficie dentro de la zona de sombra, lejos de la región de transición. Cuando se usa cualquier material no conductor se excita una componente contrapolar que tiende a desaparecer cuando la incidencia es normal al cilindro y en la región iluminada. Se discuten ampliamente las limitaciones de las fórmulas para la impedancia de superficie efectiva, y se compara la solución UTD con otras soluciones de referencia, donde se observa una muy buena concordancia. Y en tercer lugar, se presenta una aproximación para una impedancia de superficie efectiva para el cálculo de los campos superficiales en un cilindro circular conductor recubierto por un dieléctrico. Se discuten las principales diferencias que existen entre un cilindro PEC recubierto por un dieléctrico desde un punto de vista riguroso y un cilindro con una IBC. Mientras para un cilindro de impedancia se considera una impedancia de superficie constante o uniforme, para un cilindro conductor recubierto por un dieléctrico se derivan dos impedancias de superficie. Estas impedancias de superficie están asociadas a los modos de ondas creeping TM y TE excitadas en un cilindro, y dependen de la posición y de la orientación del observador y de la fuente. Con esto en mente, se deriva una solución UTD con IBC para los campos superficiales teniendo en cuenta las dependencias de la impedancia de superficie. La expansión asintótica se realiza, mediante la transformación de Watson, sobre la representación en serie de las funciones de Green correspondientes, evitando as í calcular las derivadas de orden superior de las integrales de tipo Fock, y dando lugar a una solución rápida y precisa. En los ejemplos numéricos realizados se observa una muy buena precisión cuando el cilindro y la separación entre el observador y la fuente son grandes. Esta solución, junto con el método de los momentos (MoM), se puede aplicar para el cálculo eficiente del acoplamiento mutuo de grandes arrays conformados de antenas de parches. Los métodos propuestos basados en UTD para el cálculo del campo electromagnético dispersado y superficial sobre un cilindro PEC recubierto de dieléctrico con una IBC efectiva suponen un primer paso hacia la generalización de una solución UTD para superficies metálicas convexas arbitrarias cubiertas por un material no conductor e iluminadas por una fuente electromagnética arbitraria. ABSTRACT With this thesis ”Development of a Uniform Theory of Diffraction for Scattered and Surface Electromagnetic Field Analysis on a Cylinder” we have initiated a line of investigation whose goal is to answer the following question: what is the surface impedance which describes a perfect electric conductor (PEC) convex structure covered by a material coating? These studies are of current and future interest for predicting the electromagnetic (EM) fields incident, radiating or propagating on locally smooth convex parts of highly metallic structures with a material coating, or by a lossy metallic surfaces, as for example in aerospace, maritime and automotive applications. Moreover, from a theoretical point of view, the surface impedance characterization of PEC surfaces with or without a material coating represents a generalization of independent solutions for both type of problems. A uniform geometrical theory of diffraction (UTD) is developed in this thesis for analyzing the canonical problem of EM scattered and surface field by an electrically large circular cylinder with an impedance boundary condition (IBC) in the high frequency regime, by means of a surface impedance characterization. The construction of a UTD solution for this canonical problem is crucial for the development of the corresponding UTD solution for the more general case of an arbitrary smooth convex surface, via the principle of the localization of high frequency EM fields. The development of the present doctoral thesis has been carried out through a series of landmarks that are enumerated as follows, emphasizing the main contributions that this work has given rise to. Initially, a profound revision is made in the state of art of asymptotic methods where numerous references are given. Thus, any reader may know the history of geometrical optics (GO) and geometrical theory of diffraction (GTD), which led to the development of UTD. Then, the UTD is deeply investigated and the main studies which are found in the literature are shown. This chapter situates us in the position to state that, as far as we know, nobody has attempted before to perform a rigorous research about the surface impedance characterization for material-coated PEC convex structures via UTD. First, a UTD solution is developed for the canonical problem of the EM scattering by an electrically large circular cylinder with a uniform IBC, when it is illuminated by an obliquely incident high frequency plane wave. A solution to this canonical problem is first constructed in terms of an exact formulation involving a radially propagating eigenfunction expansion. The latter is converted into a circumferentially propagating eigenfunction expansion suited for large cylinders, via the Watson transformation, which is expressed as an integral that is subsequently evaluated asymptotically, for high frequencies, in a uniform manner. The resulting solution is then expressed in the desired UTD ray form. This solution is uniform in the sense that it has the important property that it remains continuous across the transition region on either side of the surface shadow boundary. Outside the shadow boundary transition region it recovers the purely ray optical incident and reflected ray fields on the deep lit side of the shadow boundary and to the modal surface diffracted ray fields on the deep shadow side. The scattered field is seen to have a cross-polarized component due to the coupling between the TEz and TMz waves (where z is the cylinder axis) resulting from the IBC. Such cross-polarization vanishes for normal incidence on the cylinder, and also in the deep lit region for oblique incidence where it properly reduces to the GO or ray optical solution. This UTD solution is shown to be very accurate by a numerical comparison with an exact reference solution. Then, an effective IBC is developed for the EM scattered field on a coated PEC circular cylinder illuminated by an obliquely incident plane wave. Two surface impedances are derived in a direct relation with the TM and TE surface and creeping wave modes excited on a coated cylinder. The TM and TE surface impedances are coupled at oblique incidence, and depend on the geometry of the problem and the wave numbers. Nevertheless, a constant surface impedance is found, although with a different value when the observation point lays in the lit or in the shadow region. Then, a UTD solution for the scattering of an obliquely incident plane wave on an electrically large smooth convex coated PEC cylinder is introduced, via a generalization of the canonical circular cylinder problem. The asymptotic solution is uniform because it remains continuous across the transition region, in the vicinity of the shadow boundary, and it recovers the ray optical solution in the deep lit region and the creeping wave formulation within the deep shadow region. When a coating is present a cross-polar field term is excited, which vanishes at normal incidence and in the deep lit region. The limitations of the effective surface impedance formulas are discussed, and the UTD solution is compared with some reference solutions where a very good agreement is met. And in third place, an effective surface impedance approach is introduced for determining surface fields on an electrically large coated metallic circular cylinder. Differences in analysis of rigorouslytreated coated metallic cylinders and cylinders with an IBC are discussed. While for the impedance cylinder case a single constant or uniform surface impedance is considered, for the coated metallic cylinder case two surface impedances are derived. These are associated with the TM and TE creeping wave modes excited on a cylinder and depend on observation and source positions and orientations. With this in mind, a UTD based method with IBC is derived for the surface fields by taking into account the surface impedance variation. The asymptotic expansion is performed, via the Watson transformation, over the appropriate series representation of the Green’s functions, thus avoiding higher-order derivatives of Fock-type integrals, and yielding a fast and an accurate solution. Numerical examples reveal a very good accuracy for large cylinders when the separation between the observation and the source point is large. Thus, this solution could be efficiently applied in mutual coupling analysis, along with the method of moments (MoM), of large conformal microstrip array antennas. The proposed UTD methods for scattered and surface EM field analysis on a coated PEC cylinder with an effective IBC are considered the first steps toward the generalization of a UTD solution for large arbitrarily convex smooth metallic surfaces covered by a material coating and illuminated by an arbitrary EM source.