Potential impact of single-risk-factor versus total risk management for the prevention of cardiovascular events in Seychelles.

OBJECTIVE: To assess the prevalence of cardiovascular (CV) risk factors in Seychelles, a middle-income African country, and compare the cost-effectiveness of single-risk-factor management (treating individuals with arterial blood pressure >/= 140/90 mmHg and/or total serum cholesterol >/= 6.2 mmol/l) with that of management based on total CV risk (treating individuals with a total CV risk >/= 10% or >/= 20%).METHODS: CV risk factor prevalence and a CV risk prediction chart for Africa were used to estimate the 10-year risk of suffering a fatal or non-fatal CV event among individuals aged 40-64 years. These figures were used to compare single-risk-factor management with total risk management in terms of the number of people requiring treatment to avert one CV event and the number of events potentially averted over 10 years. Treatment for patients with high total CV risk (>/= 20%) was assumed to consist of a fixed-dose combination of several drugs (polypill). Cost analyses were limited to medication.FINDINGS: A total CV risk of >/= 10% and >/= 20% was found among 10.8% and 5.1% of individuals, respectively. With single-risk-factor management, 60% of adults would need to be treated and 157 cardiovascular events per 100 000 population would be averted per year, as opposed to 5% of adults and 92 events with total CV risk management. Management based on high total CV risk optimizes the balance between the number requiring treatment and the number of CV events averted.CONCLUSION: Total CV risk management is much more cost-effective than single-risk-factor management. These findings are relevant for all countries, but especially for those economically and demographically similar to Seychelles.

Characterising avian haemosporidian communities : ecological factors, parasite persistence and co-infection

Les parasites jouent un rôle clef dans l'évolution des comportements et des traits d'histoire de vie de leurs hôtes. Le parasitisme s'avère parfois dévastateur à l'échelle de population d'hôtes, et peut également altérer certains traits associés à la valeur sélective d'un individu infecté, tels que son succès reproducteur ou encore son taux de mortalité. La coévolution hôte/parasite, qui représente l'une des forces sélectives les plus puissantes dans l'évolution des organismes, peut également conduire les partenaires de l'association parasitaire à s'adapter localement à des environnements hétérogènes. Cette thèse porte sur l'étude de parasites aviaires, du genre Plasmodium, Haemopro- teus et Leucocytozoon (Haemosporidae), naturellement associés à différentes populations de mésanges charbonnières (Parus major) et d'hirondelles des fenêtres (Delichon ur- bicum). Dans un premier temps, nous avons cherché à déterminer comment se distribuent ces parasites au sein de différentes populations hôtes et si ces communautés de parasites sont structurées. Par la suite, la principale question à laquelle nous voulions répondre était de savoir comment ces parasites, et notamment après coexistence de plusieurs lignées génétiques d'Haemosporidae au sein dun même-individu (i.e. co-infection), affectent la physiologie et le succès de reproducteur des hôtes. Nos résultats suggèrent que la distribution des Haemosporidae est principalement gouvernée par la présence d'insectes vecteurs et que la persistance de l'infection chez les hôtes varie en fonction du genre d'Haemosporidae (Chapitre 1-2). Par ailleurs, nous avons trouvé que des lignées de parasite génétiquement distinctes peuvent avoir des effets contrastés sur leurs hôtes. Par exemple, les hôtes exhibent des différences de parasitémie marquées en fonction des lignées de parasites responsable de l'infection. De plus, le succès reproducteur ainsi que la charge parasitaire des mésanges infectées par Plasmodium ou Haemoproteus n'étaient pas affecté par l'infection simultanée avec Leucocytozoon (Chapitre 2-3). Dans le Chapitre 4, j'ai examiné la capacité immunitaire de mésanges charbonnières infectées par des hémosporidies. Les résultats n'ont pas été concluant, et je suggère fortement une réévaluation de ceux-ci dans de futures études. Les mésanges charbonnières ne semblent pas signaler leur statut infectieux par la coloration de leur plumage (Chapitre 5); toutefois, la coloration noire des plumes reflète l'état de stress oxydatif des mésanges, qui dépend lui-même de l'infection parasitaire. La coloration verte pourrait également indiquer la qualité des soins paxentaux délivrés par les mésanges adultes femelles à leurs petits, comme le suggère la corrélation que nous avons observée entre la masse des jeunes d'une nichée et la coloration de leur mère. Les hirondelles capturées en Algérie souffrent plus de l'infection que celles échantillon¬nées en Europe (Chapitre 6). Les similitudes observées entre les communautés de par¬asites affectant les populations européennes et celles des populations nord-africaines suggèrent que la transmission des parasites a lieu lors de la migration vers le sud. A l'instar de nos observations sur les mésanges dans les chapitres 2 et 3, les hirondelles co-infectées ne montrent pas d'altérations de leur condition physique. Cette thèse démontre qu'il existe, au sein des populations de mésanges charbonnières, des interactions antagonistes entre, d'une part, les parasites et leurs hôtes et d'autre part, entre différent parasites. Le résultat de ces interactions antagonistes varie en fonction des espèces et de la zone géographique considérée. Nous avons démontré que les interactions ne suivent pas toujours la théorie, puisque la coevolution qui, en suivant le concept de la virulence, devrait augmenter la charge parasitaire et diminuer la condition physique des hôtes, ne montre pourtant pas d'impact négatif sur les populations de mésanges. Nous pouvons maintenant concentrer nos efforts à la caractérisation des interactions antagonistes. De plus, grâce aux avancées des méthodes moléculaires, nous pouvons suivre et étudier en détails comment ces interactions se manifestent et quels sont leurs effets sur la condition physique des hôtes. - Parasites are key in shaping various behavioural and life-history traits of their hosts. The influence of parasitism on host populations varies from slight to devastating and might influence such parameters as mortality rates or reproductive success. Host-parasite coevolution is one of the most powerful selective forces in evolution and can lead to local adaptation of parasites and hosts in spatially structured environments. In this thesis, I studied haemosporidian parasites in different populations of great tits (Parus major) and house martins (Delichon urbicum). Firstly, I wanted to determine how parasites are distributed and if parasite communities are structured. The main question I wanted to address hereafter was how parasites, and specifically infection with multiple genera of parasites (i.e. co-infection) influenced host physiology and reproductive success. I found that parasite distribution is environmentally driven and could therefore be closely linked to vector prevalence; and that the stability of parasite infection over time is genus-dependent (Chapter 1 - 2). I further found that different haemosporidian lineages might interact differently with their hosts as parasitaemia was strongly lineage-specific and that the presence of Leucocytozoon parasites showed no correlation to Plasmodium or Haemoproteus parasitaemia, nor to great tit reproductive success (Chapter 2-3). In Chapter 4 I examined immune capacity of haemosporidian-infected great tits. The results proved inconclusive, and I strongly suggest re-evaluation hereof in future work. Great tits do not appear to signal parasite infection through plumage colouration (Chapter 5); however, infection did have a link to oxidative stress resistance which is strongly signalled through the black breast stripe, with darker males being more resistant and darker females less resistant. Females might incur different costs associated with darker stripes. This would allow reversal of signaling function. Green colouration could also serve as a cue for female provisioning quality as indicated by the strong correlation between colouration and chick body mass. Breeding house martins caught in Algeria suffer greater haemosporidian infection than European populations (Chapter 6). Similar parasite communities in European and North-African populations suggest transmission of parasites may occur during southward migration. Similarly to what was observed in great tits in Chapter 2 and 3, no relationship was found between parasite co-infection and Swiss house martin body condition. This thesis demonstrates that host-parasite and inter-parasite antagonistic interac¬tions exist in great tit populations. How these interactions play out is species dependent and varies geographically. I have demonstrated that interactions do not always follow the theory, as co-infection - which under the concept of virulence should increase parasitaemia and decrease body condition - showed no negative impact on great tit populations. We can now concentrate our efforts on characterising these antagonistic interactions, and with the advance in molecular methods, track and investigate how these interactions play out and what the effect on host fitness is.

Laparoscopic surgery for coeliac artery compression syndrome: current management and technical aspects.

Objectives: The study aims to assess the feasibility and midterm outcome of trans-peritoneal laparoscopy for coeliac artery compression syndrome (CACS).Design: Retrospective chart review involving four European vascular surgery departments and two surgical teams.Materials and methods: charts for patients who underwent laparoscopy for symptomatic CACS between December 2003 and November 2009 were reviewed. Preoperative computed tomography (CT) angiography and postoperative duplex scan and/or CT angiography were performed.Results: Eleven consecutive patients (nine women) with a median age of 52 years (interquartile range: 42.5-59 years) underwent trans-peritoneal laparoscopy for CACS. All patients had a history of postprandial abdominal pain; weight loss exceeded 10% of the body mass in eight cases. Preoperative CT angiography revealed coeliac trunk stenosis >70% in all cases. One patient had additional aortitis and inferior mesenteric artery occlusion, while another patient presented with an occluded superior mesenteric artery. Two conversions occurred (one difficult dissection and one aorto-hepatic bypass needed for incomplete release of CACS). The median blood loss was 195 ml (range: 50-900 ml) and median operative time was 80 min (interquartile range: 65-162.5 years). Symptoms improved immediately in 10/11 patients (no residual stenosis) while one remained unchanged despite a residual stenosis treated by a percutaneous angioplasty. Symptoms reappeared in one patient due to coeliac axis occlusion. The mean follow-up period was 35 +/- 23 months (range: 12-78 months).Conclusion: Our study demonstrates that trans-peritoneal laparoscopy for treating median arcuate ligament syndrome is safe and feasible. Additional patients and a longer follow-up are needed for long-term assessment of this laparoscopic technique. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Ätiologie und Management der Gicht [The etiology and management of gout].

Gout is an inflammatory arthritis caused by monosodium urate (MSU) crystal deposits in and around the joint. The formation of urinary calculi can also occur in gout, but are less common than arthritis. Gout usually presents with recurrent episodes of joint inflammation, which over time lead to tophus formation and joint destruction. In the last decade, significant advances have been made regarding not only the epidemiology and genetics of gout and hyperuricemia but also the mechanisms of inflammation and treatment of gout. In addition, knowledge concerning the key role of interleukin 1 (IL-1) has provided new therapeutic perspectives. However, the current management of gout is often suboptimal, with many Patienten either not receiving adequate treatment or being unable to tolerate existing treatments. New therapeutic agents provide interesting new options for Patienten with difficult-to-treat gouty arthritis.The English full-text version of this is available at SpringerLink (under "Supplemental").

Management of transitional-cell carcinoma of the renal pelvis and ureter.

Transitional-cell carcinoma of the renal pelvis or ureter is a relatively rare disease. Several risk factors are smoking, occupational carcinogens, analgesic abuse or Balkan nephropathy. The grade and stage of the disease have the most significant impact on the outcome. The treatment of renal pelvis and ureter tumours is open or laparoscopic surgery varying from conservative to more extensive surgical procedures, i.e. radical nephroureterectomy including removal of the contents of Gerota's fascia with ipsilateral ureter and a cuff of bladder at its distal extent. Most available data are from retrospective studies and surgery is the mainstay of treatment. Chemotherapy and/or radiation therapy are possible adjuvant or primary treatment for selected patients; however, prospective studies are needed to confirm their use.

Management of hepatitis C virus (HCV) infection in drug substitution programs.

BACKGROUND: In Switzerland, intravenous drug use (IDU) accounts for 80% of newly acquired hepatitis C virus (HCV) infections. Early HCV treatment has the potential to interrupt the transmission chain and reduce morbidity/mortality due to decompensated liver cirrhosis and hepatocellular carcinoma. Nevertheless, patients in drug substitution programs are often insufficiently screened and treated. OBJECTIVE/METHODS: With the aim to improve HCV management in IDUs, we conducted a cross sectional chart review in three opioid substitution programs in St. Gallen (125 methadone and 71 heroin recipients). Results were compared with another heroin substitution program in Bern (202 patients) and SCCS/SHCS data. RESULTS: Among the methadone/heroin recipients in St. Gallen, diagnostic workup of HCV was better than expected: HCV/HIV-status was unknown in only 1% (2/196), HCV RNA was not performed in 9% (13/146) of anti-HCV-positives and the genotype missing in 15% (12/78) of HCV RNA-positives. In those without spontaneous clearance (two thirds), HCV treatment uptake was 23% (21/91) (HIV-: 29% (20/68), HIV+: 4% (1/23)), which was lower than in methadone/heroin recipients and particularly non-IDUs within the SCCS/SHCS, but higher than in the, mainly psychiatrically focussed, heroin substitution program in Bern (8%). Sustained virological response (SVR) rates were comparable in all settings (overall: 50%, genotype 1: 35-40%, genotype 3: two thirds). In St. Gallen, the median delay from the estimated date of infection (IDU start) to first diagnosis was 10 years and to treatment was another 7.5 years. CONCLUSIONS: Future efforts need to focus on earlier HCV diagnosis and improvement of treatment uptake among patients in drug substitution programs, particularly if patients are HIV-co-infected. New potent drugs might facilitate the decision to initiate treatment.

Management of adenoid cystic carcinoma of the breast: a Rare Cancer Network study.

BACKGROUND: Mammary adenoid cystic carcinoma (ACC) is a rare breast cancer. The aim of this retrospective study was to assess prognostic factors and patterns of failure, as well as the role of radiation therapy (RT), in ACC.¦METHODS: Between January 1980 and December 2007, 61 women with breast ACC were treated at participating centers of the Rare Cancer Network. Surgery consisted of lumpectomy in 41 patients and mastectomy in 20 patients. There were 51(84%) stage pN0 and 10 stage cN0 (16%) patients. Postoperative RT was administered to 40 patients (35 after lumpectomy, 5 after mastectomy).¦RESULTS: With a median follow-up of 79 months (range, 6-285), 5-year overall and disease-free survival rates were 94% (95% confidence interval [CI], 88%-100%) and 82% (95% CI, 71%-93%), respectively. The 5-year locoregional control (LRC) rate was 95% (95% CI, 89%-100%). Axillary lymph node dissection or sentinel node biopsy was performed in 84% of cases. All patients had stage pN0 disease. In univariate analysis, survival was not influenced by the type of surgery or the use of postoperative RT. The 5-year LRC rate was 100% in the mastectomy group versus 93% (95% CI, 83%-100%) in the breast-conserving surgery group, respectively (p = 0.16). For the breast-conserving surgery group, the use of RT significantly correlated with LRC (p = 0.03); the 5-year LRC rates were 95% (95% CI, 86%-100%) for the RT group versus 83% (95% CI, 54%-100%) for the group receiving no RT. No local failures occurred in patients with positive margins, all of whom received postoperative RT.¦CONCLUSION: Breast-conserving surgery is the treatment of choice for patients with ACC breast cancer. Axillary lymph node dissection or sentinel node biopsy might not be recommended. Postoperative RT should be proposed in the case of breast-conserving surgery.

Effect of soil management on the white grub population and damage in soybean

To evaluate the effect of soil management systems on population of white grubs, (Phyllophaga cuyabana Moser), and on its damage in soybean, experiments were set up under no-tillage and conventional tillage (one disk plow, and a leveling disk harrow) areas. Primary tillage equipment, used in other soil management systems, such as moldboard plow, disk plow, chisel plow and heavy duty disk harrow were also tested. Fluctuation of P. cuyabana population and the extent of its damage to soybean was similar under no-tillage and conventional tillage systems. Results comparing a range of primary tillage equipment showed that it affected soil insect populations differently, depending on the time during the season in which tillage was executed. Larval mortality could mostly be attributed to their exposure to adverse factors, soon after tillage, than to changes in soil conditions. Reduction of white grub population was more evident in plots managed by heavier equipment, such as the moldboard plow. Soil tillage could be one component within the soil pest management system in soybean, however, its use can not be generalized.

Prise en charge des sténoses carotidiennes [Management of the carotid artery stenosis].

In the western world, the carotid-artery stenosis is one of the major causes of ischemic stroke in elderly people. The principal therapeutic indication is a symptomatic stenosis > 50% in the first two weeks and the surgical approach has shown the best results. Despite inferior results to carotid endarterectomy in terms of post-operative rate of stroke and/or death, except for young patients, carotid stenting remains the best choice in patients at high surgical risk. The best medical treatment, consisting in correction of cardiovascular risk factors, statin therapy and anti-aggregation led to a drastic reduction in the annual rate of stroke associated to carotid stenosis and thus limited the surgical intervention in asymptomatic patient to men with a life expectancy of at least 5 years and a stenosis > 70%.

Pharmacist interventions to improve cardiovascular disease risk factors in diabetes: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This systematic review and meta-analysis of randomized controlled trials (RCTs) assesses the effect of pharmacist care on cardiovascular disease (CVD) risk factors among outpatients with diabetes. RESEARCH DESIGN AND METHODS: MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched. Pharmacist interventions were classified, and a meta-analysis of mean changes of blood pressure (BP), total cholesterol (TC), LDL cholesterol, HDL cholesterol, and BMI was performed using random-effects models. RESULTS: The meta-analysis included 15 RCTs (9,111 outpatients) in which interventions were conducted exclusively by pharmacists in 8 studies and in collaboration with physicians, nurses, dietitians, or physical therapists in 7 studies. Pharmacist interventions included medication management, educational interventions, feedback to physicians, measurement of CVD risk factors, or patient-reminder systems. Compared with usual care, pharmacist care was associated with significant reductions for systolic BP (12 studies with 1,894 patients; -6.2 mmHg [95% CI -7.8 to -4.6]); diastolic BP (9 studies with 1,496 patients; -4.5 mmHg [-6.2 to -2.8]); TC (8 studies with 1,280 patients; -15.2 mg/dL [-24.7 to -5.7]); LDL cholesterol (9 studies with 8,084 patients; -11.7 mg/dL [-15.8 to -7.6]); and BMI (5 studies with 751 patients; -0.9 kg/m(2) [-1.7 to -0.1]). Pharmacist care was not associated with a significant change in HDL cholesterol (6 studies with 826 patients; 0.2 mg/dL [-1.9 to 2.4]). CONCLUSIONS: This meta-analysis supports pharmacist interventions-alone or in collaboration with other health care professionals-to improve major CVD risk factors among outpatients with diabetes.

Factors crítics de l'èxit d'Amazon.com

L’objectiu principal d’aquest treball és analitzar els factors claus d’èxit de l’empresa Amazon, que l’han convertit en una de les companyies de comerç electrònic més grans e importants de l’actualitat. Amazon marca la diferència entre minorista online i el model de negoci tradicional.Volem entendre què ha fet que una empresa tan similar a la seva competència hagi tingut un creixement exponencial de les seves vendes, i quin ha estat el procés que s’ha seguit per arribar a tenir el prestigi actual.Metodologia : El desenvolupament d’aquest treball segueix la pauta de les 4P del màrqueting mix proposades per Philip Kotler al 1972: Producte, Preu, Promoció/Comunicació i Distribució (Product, Price, Place and Promotion). Hem escollit aquest marc teòric ja que al divideix de manera coherent tots els factors importants que volem tractar.Utilitzarem els coneixements adquirits a diverses assignatures (Creació d’empreses i Màrqueting de Serveis entre d’altres), per aprofundir en l’estudi de cada un dels quatre apartats principals. En cada apartat estudiarem els factors més importants relacionant-los amb diverses teories estudiades durant aquests quatre anys (com per exemple la teoria de la llarga cua) i profunditzant en conceptes claus com el CRM.Finalment, a les conclusions presentarem també un canvas que resumeixi breument els factors d’èxit principals i més importants en aquesta empresa, composant tots ells el model de negoci d’Amazon.

Anemia and chronic kidney disease are potential risk factors for mortality in stroke patients: a historic cohort study.

BACKGROUND: Chronic kidney disease (CKD) is associated to a higher stroke risk. Anemia is a common consequence of CKD, and is also a possible risk factor for cerebrovascular diseases. The purpose of this study was to examine if anemia and CKD are independent risk factors for mortality after stroke. METHODS: This historic cohort study was based on a stroke registry and included patients treated for a first clinical stroke in the stroke unit of one academic hospital over a three-year period. Mortality predictors comprised demographic characteristics, CKD, glomerular filtration rate (GFR), anemia and other stroke risk factors. GFR was estimated by means of the simplified Modification of Diet in Renal Disease formula. Renal function was assessed according to the Kidney Disease Outcomes Quality Initiative (K/DOQI)-CKD classification in five groups. A value of hemoglobin < 120 g/L in women and < 130 g/L in men on admission defined anemia. Kaplan-Meier survival curves and Cox models were used to describe and analyze one-year survival. RESULTS: Among 890 adult stroke patients, the mean (Standard Deviation) calculated GFR was 64.3 (17.8) ml/min/1.73 m2 and 17% had anemia. Eighty-two (10%) patients died during the first year after discharge. Among those, 50 (61%) had K/DOQI CKD stages 3 to 5 and 32 (39%) stages 1 or 2 (p < 0.001). Anemia was associated with an increased risk of death one year after discharge (p < 0.001). After adjustment for other factors, a higher hemoglobin level was independently associated with decreased mortality one year after discharge [hazard ratio (95% CI) 0.98 (0.97-1.00)]. CONCLUSIONS: Both CKD and anemia are frequent among stroke patients and are potential risk factors for decreased one-year survival. The inclusion of patients with a first-ever clinical stroke only and the determination of anemia based on one single measure, on admission, constitute limitations to the external validity. We should investigate if an early detection and management of both CKD and anemia could improve survival in stroke patients.

An Assessment of Traffic Safety in Urban Deer Herd Management Zones in Iowa, 2010

Many states are striving to keep their deer population to a sustainable and controllable level while maximizing public safety. In Iowa, measures to control the deer population include annual deer hunts and special deer herd management plans in urban areas. While these plans may reduce the deer population, traffic safety in these areas has not been fully assessed. Using deer population data from the Iowa Department of Natural Resources and data on deer-vehicle crashes and deer carcass removals from the Iowa Department of Transportation, the authors examined the relationship between deer-vehicle collisions, deer density, and land use in three urban areas in Iowa that have deer management plans in place (Cedar Rapids, Dubuque, and Iowa City) over the period 2002 to 2007. First, a comparison of deer-vehicle crash counts and deer carcass removal counts was conducted at the county level. Further, the authors estimated econometric models to investigate the factors that influence the frequency and severity of deer-vehicle crashes in these zones. Overall, the number of deer carcasses removed on the primary roads in these counties was greater than the number of reported deervehicle crashes on those roads. These differences can be attributed to a number of reasons, including variability in data reporting and data collection practices. In addition, high rates of underreporting of crashes were found on major routes that carry high volumes of traffic. This study also showed that multiple factors affect deer-vehicle crashes and corresponding injury outcomes in urban management zones. The identified roadway and non-roadway factors could be useful for identifying locations on the transportation system that significantly impact deer species and safety and for determining appropriate countermeasures for mitigation. Efforts to reduce deer density adjacent to roads and developed land and to provide wider shoulders on undivided roads are recommended. Improving the consistency and accuracy of deer carcass and deer-vehicle collision data collection methods and practices is also desirable.

Pavement Management Performance Modeling: Evaluating the Existing PCI Equations, RB14-013 2014

The work described in this report documents the activities performed for the evaluation, development, and enhancement of the Iowa Department of Transportation (DOT) pavement condition information as part of their pavement management system operation. The study covers all of the Iowa DOT’s interstate and primary National Highway System (NHS) and non-NHS system. A new pavement condition rating system that provides a consistent, unified approach in rating pavements in Iowa is being proposed. The proposed 100-scale system is based on five individual indices derived from specific distress data and pavement properties, and an overall pavement condition index, PCI-2, that combines individual indices using weighting factors. The different indices cover cracking, ride, rutting, faulting, and friction. The Cracking Index is formed by combining cracking data (transverse, longitudinal, wheel-path, and alligator cracking indices). Ride, rutting, and faulting indices utilize the International Roughness Index (IRI), rut depth, and fault height, respectively.