Endocarditis due to Tropheryma whipplei: rapid detection, limited genetic diversity, and long-term clinical outcome in a local experience

The characteristic features of Whipple's disease include abdominal pain, diarrhoea, wasting, and arthralgias, with the causative agent, Tropheryma whipplei, being detected mainly in intestinal biopsies. PCR technology has led to the identification of T. whipplei in specimens from various other locations, including the central nervous system and the heart. T. whipplei is now recognized as one of the causes of culture-negative endocarditis, and endocarditis can be the only manifestation of the infection with T. whipplei. Although it is considered a rare disease, the true incidence of endocarditis due to T. whipplei is not clearly established. With the increasing use of molecular methods, it is likely that T. whipplei will be more frequently identified. Questions also remain about the genetic variability of T. whipplei strains, optimal diagnostic procedures and therapeutic options. In the present study, we provide clinical data on four new patients with documented endocarditis due to T. whipplei in the context of the available published literature. There was no clinical involvement of the gastrointestinal tract. Genetic analysis of the T. whipplei strains with DNA isolated from the excised heart valves revealed little to no genetic variability. In a selected case, we describe acridine orange staining for early detection of the disease, prompting early adaptation of the antibiotic therapy. We provide long-term follow-up data on the patients. In our hands, an initial 2-week course of intravenous antibiotics followed by cotrimoxazole for at least 1 year was a suitable treatment option for T. whipplei endocarditis.

Towards optimal treatment with growth hormone in short children and adolescents: evidence and theses

Treatment with growth hormone (GH) has become standard practice for replacement in GH-deficient children or pharmacotherapy in a variety of disorders with short stature. However, even today, the reported adult heights achieved often remain below the normal range. In addition, the treatment is expensive and may be associated with long-term risks. Thus, a discussion of the factors relevant for achieving an optimal individual outcome in terms of growth, costs, and risks is required. In the present review, the heterogenous approaches of treatment with GH are discussed, considering the parameters available for an evaluation of the short- and long-term outcomes at different stages of treatment. This discourse introduces the potential of the newly emerging prediction algorithms in comparison to other more conventional approaches for the planning and evaluation of the response to GH. In rare disorders such as those with short stature, treatment decisions cannot easily be deduced from personal experience. An interactive approach utilizing the derived experience from large cohorts for the evaluation of the individual patient and the required decision-making may facilitate the use of GH. Such an approach should also lead to avoiding unnecessary long-term treatment in unresponsive individuals.

Randomised controlled trials of homeopathy in hyperactive children: treatment procedure leads to an unconventional study design. Experience with open-label homeopathic treatment preceding the Swiss ADHD placebo controlled, randomised, double-blind, cross-over trial

BACKGROUND: Treatment of patients with attention deficit hyperactivity disorder (ADHD) with homeopathy is difficult. The Swiss randomised, placebo controlled, cross-over trial in ADHD patients (Swiss ADHD trial) was designed with an open-label screening phase prior to the randomised controlled phase. During the screening phase, the response of each child to successive homeopathic medications was observed until the optimal medication was identified. Only children who reached a predefined level of improvement participated in the randomised, cross-over phase. Although the randomised phase revealed a significant beneficial effect of homeopathy, the cross-over caused a strong carryover effect diminishing the apparent difference between placebo and verum treatment. METHODS: This retrospective analysis explores the screening phase data with respect to the risk of failure to demonstrate a specific effect of a randomised controlled trial (RCT) with randomisation at the start of the treatment. RESULTS: During the screening phase, 84% (70/83) of the children responded to treatment and reached eligibility for the randomised trial after a median time of 5 months (range 1-18), with a median of 3 different medications (range 1-9). Thirteen children (16%) did not reach eligibility. Five months after treatment start, the difference in Conners Global Index (CGI) rating between responders and non-responders became highly significant (p = 0.0006). Improvement in CGI was much greater following the identification of the optimal medication than in the preceding suboptimal treatment period (p < 0.0001). CONCLUSIONS: Because of the necessity of identifying an optimal medication before response to treatment can be expected, randomisation at the start of treatment in an RCT of homeopathy in ADHD children has a high risk of failure to demonstrate a specific treatment effect, if the observation time is shorter than 12 months.

Fit between situational and dispositional goal orientation, and its effects on flow experience and affective well-being during sports.

Flow represents an optimal psychological state that is intrinsically rewarding. However, to date only a few studies have investigated the conditions for flow in sports. The present research aims to expand our understanding of the psychological factors that promote the flow experience in sports, focusing on the person-goal fit, or more precisely on the athletes’ situational and dispositional goal orientations. We hypothesize that a fit between an athlete’s situational and dispositional approach versus avoidance goal orientation should promote flow, whereas a non-fit will hinder flow during sports. In addition to the flow experience, we hypothesize that an athlete’s affective well-being is also affected by the person-goal fit. Here our assumptions are theoretically rooted in research on person-environment fit. An experimental study in an ecologically valid sport setting was conducted in order to draw causal conclusions and derive useful strategies for the practice of sports. Specifically, we investigated 67 male soccer players from a regional amateur league during a regular training session. They were randomly assigned to an approach or avoidance goal group and asked to take five penalty shots. Immediately afterwards, their flow experience and affective well-being during the penalty shootout were measured. As predicted, soccer players with a strong dispositional approach goal orientation experienced more flow and reported higher affective well-being when they were assigned to the approach goal. In contrast, soccer players with a strong dispositional avoidance goal orientation benefited from being assigned an avoidance goal in terms of their flow experience and affective well-being. The results are discussed critically with respect to their theoretical and practical implications.

Glass ionomer cement in otological microsurgery: experience over 16 years

A retrospective evaluation of glass ionomer cement (GIC) in middle ear surgery with emphasis on short- and long-term safety was conducted at the tertiary referral center. GIC was applied between 1995 and 2006 in 444 patients in otologic surgery. Technical aspects, safety, benefits and complications due to GIC were analysed until 2011 (follow-up 5-16 years; mean 10 years). GIC was applied in stapes surgery (228 primary, 92 revisions), cochlear implants (108) and implantable hearing aids (7), ossiculoplasty (7), for coverage of opened mastoid air cells towards the external ear canal (1) and inner ear fistula closure (1). GIC turned out to be very handy in stapes surgery for optimal prosthesis fixation at the incus (260) and on the malleus handle (60) without complications. Results suggest that GIC may diminish the danger of incus necrosis in primary stapedotomy. In cochlear implants and implantable hearing aids, GIC was used for casing alone (74), casing and electrode fixation (27) and electrode alone fixation (14). Inflammatory reactions were observed in five cases (4.3 %), mostly after trauma. Broken cement fragments appeared to promote foreign body rejection. In seven cases an incudo-stapedial gap was repaired with GIC with excellent hearing gain; in three cases (43 %) revision surgery was needed due to cement breakage. In one case, GIC was applied for a watertight coverage of opened mastoid cells, and in the other for fistula closure of the lateral semi-circular canal over cartilage, covered with bone pathé; follow-up was uneventful. Targeted use of GIC in middle ear surgery rarely poses problems. GIC cannot be used in neuro-otosurgery in contact with cerebrospinal fluid because of possible aluminium encephalopathy.

Twenty years' experience with the Swiss data registry for assisted reproductive medicine: outcomes, key trends and recommendations for improved practice.

QUESTIONS UNDER STUDY The impact of assisted reproductive technology (ART) on Swiss demography was quantified. From 1993 to 2012 the number of deliveries, including multiples, generated by ART was compared with overall delivery numbers. Swiss experts in ART collaborated in a consensus to increase successful outcomes, to reduce the incidence of complications of ART and to validate recommendations through statistical review of available data. METHODS Data generated between 1993 and 2012 and published by the Federal Office of Statistics (BfS) were compared with the Swiss database on ART (FIVNAT-CH) as organised by the Swiss Society of Reproductive Medicine (SGRM). From these analyses a panel of Swiss experts in ART extracted recommendations to improve current practice, to prevent complications related to ART and to recommend changes in current Swiss legislation dealing with ART. RESULTS Since 1993 the age of women giving birth rose together with the number of women asking for ART. This demographic trend was reflected in a rise in the number of deliveries generated by ART (in 2012: 2.2%) and the proportion of multiple births (in 2012: 17.6%). The outcome of ART was most negatively influenced by the age of the treated patient. The number of retrieved oocytes decisively impacted the likelihood of delivery, the risk of multiple births and the incidence of ovarian hyperstimulation syndrome. CONCLUSIONS Optimal ovarian stimulation should be designed for the retrieval of 10 to 15 oocytes per treatment. Swiss legislation should enable and stimulate a policy of elective single embryo transfer to avoid multiple births.

Is Menopause Optimal?

Various theories have been put forward to explain the fact that humans experience menopause while virtually no animals do. This paper aims to investigate one such theory: children provide a savings technology into old age, but as human babies are usually large and have long gestation periods, a substantial risk of death exists for the mother as she bears children. It seems therefore appropriate to impose a stopping rule for fertility. Given an objective (support for old age) and demographics (mortality of mother and children), an optimal age for menopause can be calculated. Using demographic data from populations that have seen little influence from modern medicine, this optimal age is compared to empirical evidence.

A practice-based culminating experience with Texas Children's Hospital: A hospital's journey to baby-friendly status

Breastfeeding and the use of human milk are widely accepted as the most complete form of nutrition for infants. Breastfeeding is shown to be associated with many positive health outcomes for both infants and mothers. Healthy People 2000 goals to increase breastfeeding rates in the early postpartum period to 75% fell short, with only 64% of mothers meeting this objective. Lack of support from healthcare providers, and unsupportive hospital policies and practices are noted as barriers to the initiation and duration of breastfeeding. The purpose of this study was to evaluate implementation of the BFHI Ten Steps to Successful Breastfeeding at Texas Children's Hospital. ^ The Baby-Friendly Hospital Initiative (BFHI) was developed in 1991 by the World Health Organization and the United Nations Children's Fund (UNICEF) to ensure that healthcare facilities offering maternity services adhere to the Ten Steps of Successful Breastfeeding and the International Code of Marketing of Breast-Milk Substitutes, and create legislation to protect the rights of breastfeeding women. The instrument used in this study was the BFHI 100 Assessment Tool created by Dr. Laura Haiek, Director of Public Health in Monteregie, Quebec, and her staff at Health and Social Services Agency of Quebec. The BFHI 100 tool utilizes 100 different indicators of compliance with BFHI through questionnaires administered to staff and administrators, pregnant and postpartum mothers, and an observer. ^ The study concluded that although there is much room for improvement in educating breastfeeding mothers, overall, the mothers interviewed were satisfied with their level of care in regards to breastfeeding support. Areas of improvement include staff training, as some nursing staff admitted to relying on the lactation consultants to provide most of the breastfeeding education for mothers. Only a small percentage of mothers interviewed reported that their baby “roomed-in” on average of 22 hours per day during their hospital stay. Staff encouragement of the rooming-in practice will help to increase the proportion of mothers who allow their babies to room-in. The current breastfeeding policy will also need to be revised and strengthened to be compliant with the Ten Steps. Ideally, Baby-Friendly practices will become the norm after staff are trained and policy revisions are made. Staff training and acceptance of breastfeeding as optimal nutrition for infants are the most critical factors that will ultimately drive change for the organization. ^

Content Delivery System for Optimal VoD Streaming

The demand of video contents has rapidly increased in the past years as a result of the wide deployment of IPTV and the variety of services offered by the network operators. One of the services that has especially become attractive to the customers is real-time video on demand (VoD) because it offers an immediate streaming of a large variety of video contents. The price that the operators have to pay for this convenience is the increased traffic in the networks, which are becoming more congested due to the higher demand for VoD contents and the increased quality of the videos. As a solution, in this paper we propose a hierarchical network system for VoD content delivery in managed networks, which implements redistribution algorithm and a redirection strategy for optimal content distribution within the network core and optimal streaming to the clients. The system monitors the state of the network and the behavior of the users to estimate the demand for the content items and to take the right decision on the appropriate number of replicas and their best positions in the network. The system's objectives are to distribute replicas of the content items in the network in a way that the most demanded contents will have replicas closer to the clients so that it will optimize the network utilization and will improve the users' experience. It also balances the load between the servers concentrating the traffic to the edges of the network.

Preliminary approach to neutron instrument selecction at ESSB-Bilbao based on experience at ISIS molecular spectroscopy group

Collaborative efforts between the Neutronics and Target Design Group at the Instituto de Fusión Nuclear and the Molecular Spectroscopy Group at the ISIS Pulsed Neutron and Muon Source date back to 2012 in the context of the ESS-Bilbao project. The rationale for these joint activities was twofold, namely: to assess the realm of applicability of the low-energy neutron source proposed by ESS-Bilbao - for details; and to explore instrument capabilities for pulsed-neutron techniques in the range 0.05-3 ms, a time range where ESS-Bilbao and ISIS could offer a significant degree of synergy and complementarity. As part of this collaboration, J.P. de Vicente has spent a three-month period within the ISIS Molecular Spectroscopy Group, to gain hands-on experience on the practical aspects of neutron-instrument design and the requisite neutron-transport simulations. To date, these activities have resulted in a joint MEng thesis as well as a number of publications and contributions to national and international conferences. Building upon these previous works, the primary aim of this report is to provide a self-contained discussion of general criteria for instrument selection at ESS-Bilbao, the first accelerator-driven, low-energy neutron source designed in Spain. To this end, Chapter 1 provides a brief overview of the current design parameters of the accelerator and target station. Neutron moderation is covered in Chapter 2, where we take a closer look at two possible target-moderator-reflector configurations and pay special attention to the spectral and temporal characteristics of the resulting neutron pulses. This discussion provides a necessary starting point to assess the operation of ESSB in short- and long-pulse modes. These considerations are further explored in Chapter 3, dealing with the primary characteristics of ESS-Bilbao as a short- or long-pulse facility in terms of accessible dynamic range and spectral resolution. Other practical aspects including background suppression and the use of fast choppers are also discussed. The guiding principles introduced in the first three chapters are put to use in Chapter 4 where we analyse in some detail the capabilities of a small-angle scattering instrument, as well as how specific scientific requirements can be mapped onto the optimal use of ESS-Bilbao for condensed-matter research. Part 2 of the report contains additional supporting documentation, including a description of the ESSB McStas component, a detailed characterisation of moderator response and neutron pulses, and estimates ofparameters associated with the design and operation of neutron choppers. In closing this brief foreword, we wish to thank both ESS-Bilbao and ISIS for their continuing encouragement and support along the way.

Quality of experience and HTTP adaptive streaming: a review of subjective studies

HTTP adaptive streaming technology has become widely spread in multimedia services because of its ability to provide adaptation to characteristics of various viewing devices and dynamic network conditions. There are various studies targeting the optimization of adaptation strategy. However, in order to provide an optimal viewing experience to the end-user, it is crucial to get knowledge about the Quality of Experience (QoE) of different adaptation schemes. This paper overviews the state of the art concerning subjective evaluation of adaptive streaming QoE and highlights the challenges and open research questions related to QoE assessment.

Quality of experience of adaptive video streaming: investigation in service parameters and subjective quality assessment methodology

The usage of HTTP adaptive streaming (HAS) has become widely spread in multimedia services. Because it allows the service providers to improve the network resource utilization and user׳s Quality of Experience (QoE). Using this technology, the video playback interruption is reduced since the network and server status in addition to capability of user device, all are taken into account by HAS client to adapt the quality to the current condition. Adaptation can be done using different strategies. In order to provide optimal QoE, the perceptual impact of adaptation strategies from point of view of the user should be studied. However, the time-varying video quality due to the adaptation which usually takes place in a long interval introduces a new type of impairment making the subjective evaluation of adaptive streaming system challenging. The contribution of this paper is two-fold: first, it investigates the testing methodology to evaluate HAS QoE by comparing the subjective experimental outcomes obtained from ACR standardized method and a semi-continuous method developed to evaluate the long sequences. In addition, influence of using audiovisual stimuli to evaluate the video-related impairment is inquired. Second, impact of some of the adaptation technical factors including the quality switching amplitude and chunk size in combination with high range of commercial content type is investigated. The results of this study provide a good insight toward achieving appropriate testing method to evaluate HAS QoE, in addition to designing switching strategies with optimal visual quality.

Bidirectional, experience-dependent regulation of N-methyl-d-aspartate receptor subunit composition in the rat visual cortex during postnatal development

In the visual cortex, as elsewhere, N-methyl-d-aspartate receptors (NMDARs) play a critical role in triggering long-term, experience-dependent synaptic plasticity. Modifications of NMDAR subunit composition alter receptor function, and could have a large impact on the properties of synaptic plasticity. We have used immunoblot analysis to investigate the effects of age and visual experience on the expression of different NMDAR subunits in synaptoneurosomes prepared from rat visual cortices. NMDARs at birth are comprised of NR2B and NR1 subunits, and, over the first 5 postnatal weeks, there is a progressive inclusion of the NR2A subunit. Dark rearing from birth attenuates the developmental increase in NR2A. Levels of NR2A increase rapidly (in <2 hr) when dark-reared animals are exposed to light, and decrease gradually over the course of 3 to 4 days when animals are deprived of light. These data reveal that NMDAR subunit composition in the visual cortex is remarkably dynamic and bidirectionally regulated by sensory experience. We propose that NMDAR subunit regulation is a mechanism for experience-dependent modulation of synaptic plasticity in the visual cortex, and serves to maintain synaptic strength within an optimal dynamic range.

Improving Patients’ Experience and Outcome of Total Joint Replacement: the RESTORE Programme

BACKGROUND: Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected. OBJECTIVE: To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR. METHODS: We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement. RESULTS: Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test. CONCLUSIONS: The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

The Impact of a Simulated Clinical Experience on CEGEP Nursing Students’ Perceptions of Self-Efficacy and Achievement

Abstract : Providing high-quality clinical experiences to prepare students for the complexities of the current health-care system has become a challenge for nurse educators. Additionally, there are concerns that the current model of clinical practice is suboptimal. Consequently, nursing programs have explored the partial replacement of traditional in-hospital clinical experiences with a simulated clinical experience. Despite research demonstrating numerous benefits to students following participation in simulation activities, insufficient research conducted within Québec exists to convince the governing bodies (Ordre des infirmières et des infirmiers du Québec, OIIQ; Ministère de L’Éducation supérieur, de la Recherche, de la Science et de la Technologie) to fully embrace simulation as part of nurse training. The purpose of this study was to examine the use of a simulated clinical experience (SCE) as a viable, partial pedagogical substitute for traditional clinical experience by examining the effects of a SCE on CEGEP nursing students’ perceptions of self-efficacy (confidence), and their ability to achieve course objectives. The findings will contribute new information to the current body of research in simulation. The specific case of obstetrical practice was examined. Based on two sections of the Nursing III-Health and Illness (180-30K-AB) course, the sample was comprised of 65 students (thirty-one students from section 0001 and thirty-four students from section 0002) whose mean age was 24.8 years. With two sections of the course available, the opportunity for comparison was possible. A triangulation mixed method design was used. An adapted version of Ravert’s (2004) Nursing Skills for Evaluation tool was utilized to collect data regarding students’ perceptions of confidence related to the nursing skills required for care of mothers and their newborns. Students’ performance and achievement of course objectives was measured through an Objective Structured Clinical Examination (OSCE) consisting of three marked stations designed to test the theoretical and clinical aspects of course content. The OSCE was administered at the end of the semester following completion of the traditional clinical experience. Students’ qualitative comments on the post -test survey, along with journal entries served to support the quantitative scale evaluation. Two of the twelve days (15 hours) allocated for obstetrical clinical experience were replaced by a SCE (17%) over the course of the semester. Students participated in various simulation activities developed to address a range of cognitive, psychomotor and critical thinking skills. Scenarios incorporating the use of human patient simulators, and designed using the Jeffries Framework (2005), exposed students to the care of families and infants during the perinatal period to both reflect and build upon class and course content in achievement of course objectives and program competencies. Active participation in all simulation activities exposed students to Bandura’s four main sources of experience (mastery experiences, vicarious experiences, social persuasion, and physiologic/emotional responses) to enhance the development of students’ self-efficacy. Results of the pre-test and post-test summative scores revealed a statistically significant increase in student confidence in performing skills related to maternal and newborn care (p < .0001) following participation in the SCE. Confidence pre-test and post-test scores were not affected by the students’ section. Skills related to the care of the post-partum mother following vaginal or Caesarean section delivery showed the greatest change in confidence ratings. OSCE results showed a mean total class score (both sections) of 57.4 (70.0 %) with normal distribution. Mean scores were 56.5 (68.9%) for section 0001 and 58.3 (71.1%) for section 0002. Total scores were similar between sections (p =0.342) based on pairwise comparison. Analysis of OSCE scores as compared to students’ final course grade revealed similar distributions. Finally, qualitative analysis identified how students’ perceived the SCE. Students cited gains in knowledge, development of psychomotor skills and improved clinical judgement following participation in simulation activities. These were attributed to the « hands on » practice obtained from working in small groups, a safe and authentic learning environment and one in which students could make mistakes and correct errors as having the greatest impact on learning through simulation.