Levels of selected persistent organic pollutants in blood from delivering women in seven selected areas of Sao Paulo State, Brazil

Persistent organic pollutants (POPS) present in the living environment are thought to have detrimental health effects on the population, with pregnant women and the developing foetus being at highest risk. We report on the levels of selected POPs in maternal blood of 155 delivering women residing in seven regions within the Sao Paulo State, Brazil. The following selected POPs were measured in the maternal whole blood: 12 polychlorinated biphenyls (PCBs) congeners (IUPAC Nos. 99, 101, 118, 138, 153, 156, 163, 170, 180, 183, 187, 194); dichlordiphenyltrichloroethane p,p'-DDT, diphenyldichloroethylene p,p'-DDE and other pesticides such as hexachlorocyclohexanes (alpha-HCH, beta-HCH, gamma-HCH), hexachlorobenzene (HCB), chlordane derivatives cis-chlordane, trans-chlordane. oxy-chlordane, cis-nonachlor and trans-nonachlor. Statistical comparisons between regions were performed only on compounds having concentrations above LOD in 70% of the samples. PCB118 congener was found to be highest in the industrial site (mean 4.97 ng/g lipids); PCB138 congener concentration was highest in the Urban 3 site (mean 4.27 ng/g lipids) and congener PCB153 was highest in the industrial and Urban 3 sites with mean concentration of 7.2 ng/g lipids and 5.89 ng/g lipids respectively. Large differences in levels of p,p'-DDE between regions were observed with the Urban 3 and industrial sites having the highest concentrations of 645 ng/g lipids and 417 ng/g lipids, respectively; beta-HCH was found to be highest in the Rural 1 site; the gamma-HCH in Rural 1 and industrial; the HCB in the Rural 1 and industrial sites and oxy-chlordane and t-NC in the Rural 2 sites. An association between levels of some contaminants and maternal age and parity was also found. (C) 2011 Elsevier Ltd. All rights reserved.

Gli assetti proprietari e di controllo nell'agroalimentare italiano

The recent default of important Italian agri-business companies provides a challenging issue to be investigated through an appropriate scientific approach. The events involving CIRIO, FERRUZZI or PARMALAT rise an important research question: what are the determinants of performance for Italian companies in the Italian agri – food sector? My aim is not to investigate all the factors that are relevant in explaining performance. Performance depends on a wide set of political, social, economic variables that are strongly interconnected and that are often very difficult to express by formal or mathematical tools. Rather, in my thesis I mainly focus on those aspects that are strictly related to the governance and ownership structure of agri – food companies representing a strand of research that has been quite neglected by previous scholars. The conceptual framework from which I move to justify the existence of a relationship between the ownership structure of a company, governance and performance is the model set up by Airoldi and Zattoni (2005). In particular the authors investigate the existence of complex relationships arising within the company and between the company and the environment that can bring different strategies and performances. They do not try to find the “best” ownership structure, rather they outline what variables are connected and how they could vary endogenously within the whole economic system. In spite of the fact that the Airoldi and Zattoni’s model highlights the existence of a relationship between ownership and structure that is crucial for the set up of the thesis the authors fail to apply quantitative analyses in order to verify the magnitude, sign and the causal direction of the impact. In order to fill this gap we start from the literature trying to investigate the determinants of performance. Even in this strand of research studies analysing the relationship between different forms of ownership and performance are still lacking. In this thesis, after a brief description of the Italian agri – food sector and after an introduction including a short explanation of the definitions of performance and ownership structure, I implement a model in which the performance level (interpreted here as Return on Investments and Return on Sales) is related to variables that have been previously identified by the literature as important such as the financial variables (cash and leverage indices), the firm location (North Italy, Centre Italy, South Italy), the power concentration (lower than 25%, between 25% and 50% and between 50% and 100% of ownership control) and the specific agri – food sector (agriculture, food and beverage). Moreover we add a categorical variable representing different forms of ownership structure (public limited company, limited liability company, cooperative) that is the core of our study. All those variables are fully analysed by a preliminary descriptive analysis. As in many previous contributions we apply a panel least squares analysis for 199 Italian firms in the period 1998 – 2007 with data taken from the Bureau Van Dijck Dataset. We apply two different models in which the dependant variables are respectively the Return on Investments (ROI) and the Return on Sales (ROS) indicators. Not surprisingly we find that companies located in the North Italy representing the richest area in Italy perform better than the ones located in the Centre and South of Italy. In contrast with the Modigliani - Miller theorem financial variables could be significant and the specific sector within the agri – food market could play a relevant role. As the power concentration, we find that a strong property control (higher than 50%) or a fragmented concentration (lower than 25%) perform better. This result apparently could suggest that “hybrid” forms of concentrations could create bad functioning in the decision process. As our key variables representing the ownership structure we find that public limited companies and limited liability companies perform better than cooperatives. This is easily explainable by the fact that law establishes that cooperatives are less profit – oriented. Beyond cooperatives public limited companies perform better than limited liability companies and show a more stable path over time. Results are quite consistent when we consider both ROI and ROS as dependant variables. These results should not lead us to claim that public limited company is the “best” among all possible governance structures. First, every governance solution should be considered according to specific situations. Second more robustness analyses are needed to confirm our results. At this stage we deem these findings, the model set up and our approach represent original contributions that could stimulate fruitful future studies aimed at investigating the intriguing issue concerning the effect of ownership structure on the performance levels.

Formazione e Competenze Professionali: una ricerca empirica sui Cassaintegrati in deroga della regione Emilia Romagna

The general theme of the present inquiry concerns the role of training and continuous updating of knowledge and skills in relation to the concept of employability and social vulnerability. The empirical research has affected the entire calendar year 2010, namely from 13 February 2010 to December 31, 2010: data refer to a very specific context or to the course funded by the Emilia Romagna region and targeted to employees in cassintegrazione notwithstanding domiciled in the region. The investigations were performed in a vocational training scheme accredited by the Emilia Romagna for the provision of publicly funded training courses. The quantitative data collected are limited to the region and distributed in all the provinces of Emilia Romagna; It addressed the issue of the role of continuing education throughout life and the importance of updating knowledge and skills, such as privileged instruments to address the instability of the labor market and what strategy to reduce the risk unemployment. Based on the different strategies that the employee puts in place during their professional careers, we introduce two concepts that are more common in the so-called knowledge society, namely the concept of social vulnerability and employability. In modern organizations becomes relevant knowledge they bring workers and the relationships that develop between people and allowing exponentially and disseminate such knowledge and skills. The knowledge thus becomes the first productive force, defined by Davenport and Prusak (1998) as "fluid combination of experience, values, contextual information and specialist knowledge that provides a framework for the evaluation and assimilation of new experience and new information ". Learning at work is a by stable explicit and conscious, and even enjoyable for everyone, especially outside of a training intervention. It then goes on to address the specific issue of training, under the current labor market increasingly deconstructed.

Digital marketing: le nuove opportunità di business per le aziende nell'era del web 2.0

L’elaborato ha lo scopo di presentare le nuove opportunità di business offerte dal Web. Il rivoluzionario cambiamento che la pervasività della Rete e tutte le attività correlate stanno portando, ha posto le aziende davanti ad un diverso modo di relazionarsi con i propri consumatori, che sono sempre più informati, consapevoli ed esigenti, e con la concorrenza. La sfida da accettare per rimanere competitivi sul mercato è significativa e il mutamento in rapido sviluppo: gli aspetti che contraddistinguono questo nuovo paradigma digitale sono, infatti, velocità, mutevolezza, ma al tempo stesso misurabilità, ponderabilità, previsione. Grazie agli strumenti tecnologici a disposizione e alle dinamiche proprie dei diversi spazi web (siti, social network, blog, forum) è possibile tracciare più facilmente, rispetto al passato, l’impatto di iniziative, lanci di prodotto, promozioni e pubblicità, misurandone il ritorno sull’investimento, oltre che la percezione dell’utente finale. Un approccio datacentrico al marketing, attraverso analisi di monitoraggio della rete, permette quindi al brand investimenti più mirati e ponderati sulla base di stime e previsioni. Tra le più significative strategie di marketing digitale sono citate: social advertising, keyword advertising, digital PR, social media, email marketing e molte altre. Sono riportate anche due case history: una come ottimo esempio di co-creation in cui il brand ha coinvolto direttamente il pubblico nel processo di produzione del prodotto, affidando ai fan della Pagina Facebook ufficiale la scelta dei gusti degli yogurt da mettere in vendita. La seconda, caso internazionale di lead generation, ha permesso al brand di misurare la conversione dei visitatori del sito (previa compilazione di popin) in reali acquirenti, collegando i dati di traffico del sito a quelli delle vendite. Esempio di come online e offline comunichino strettamente.

Fattori eziologici della Sindrome del Tunnel Carpale: una revisione sistematica con meta-analisi degli studi analitici

OBIETTIVO: sintetizzare le evidenze disponibili sulla relazione tra i fattori di rischio (personali e lavorativi) e l’insorgenza della Sindrome del Tunnel Carpale (STC). METODI: è stata condotta una revisione sistematica della letteratura su database elettronici considerando gli studi caso-controllo e di coorte. Abbiamo valutato la qualità del reporting degli studi con la checklist STROBE. Le stime studio-specifiche sono state espresse come OR (IC95%) e combinate con una meta-analisi condotta con un modello a effetti casuali. La presenza di eventuali bias di pubblicazione è stata valutata osservando l’asimmetria del funnel plot e con il test di Egger. RISULTATI: Sono stati selezionati 29 studi di cui 19 inseriti nella meta-analisi: 13 studi caso-controllo e 6 di coorte. La meta-analisi ha mostrato un aumento significativo di casi di STC tra i soggetti obesi sia negli studi caso-controllo [OR 2,4 (1,9-3,1); I(2)=70,7%] che in quelli di coorte [OR 2,0 (1,6-2,7); I(2)=0%]. L'eterogeneità totale era significativa (I(2)=59,6%). Risultati simili si sono ottenuti per i diabetici e soggetti affetti da malattie della tiroide. L’esposizione al fumo non era associata alla STC sia negli studi caso-controllo [OR 0,7 (0,4-1,1); I(2)=83,2%] che di coorte [OR 0,8 (0,6-1,2); I(2)=45,8%]. A causa delle molteplici modalità di valutazione non è stato possibile calcolare una stima combinata delle esposizioni professionali con tecniche meta-analitiche. Dalla revisione, è risultato che STC è associata con: esposizione a vibrazioni, movimenti ripetitivi e posture incongrue di mano-polso. CONCLUSIONI: I risultati della revisione sistematica confermano le evidenze dell'esistenza di un'associazione tra fattori di rischio personali e STC. Nonostante la diversa qualità dei dati sull'esposizione e le differenze degli effetti dei disegni di studio, i nostri risultati indicano elementi di prova sufficienti di un legame tra fattori di rischio professionali e STC. La misurazione dell'esposizione soprattutto per i fattori di rischio professionali, è un obiettivo necessario per studi futuri.

Erfolgskontrolle in der kommunalen Wirtschaftsförderung : Analyse und Modifikation einer fragwürdigen Forderung

Seit Jahren werden Diskussionen über Erfolgskontrolle in der kommunalen Wirtschaftsförderung geführt. Im Vordergrund steht dabei die Suche nach Indikatoren und Verfahren, die es den kommunalen Wirtschaftsförderungen ermöglichen sollen, Erfolge zu messen. rnDa die Wirtschaftsförderung zu den freiwilligen Leistungen einer Gemeinde zählt, erhöht sich der Druck der Rechtfertigung gegenüber der Öffentlichkeit oder der Politik, das gilt insbesondere in Zeiten knapper öffentlicher Haushalte. Firmenansiedlungen, eine positive wirtschaftliche Entwicklung oder eine geringe Arbeitslosenquote sind sowohl im öffentlichen Bewusstsein als auch in der Politik wesentliche Kriterien einer erfolgreichen Wirtschaftsförderung. Sich ständig ändernde Rahmenbedingungen im wirtschaftsstrukturellen Gefüge haben dazu geführt, dass diese klassischen Nachweise von Erfolg immer seltener als solche präsentiert werden können. Erfolge sollten dennoch gemessen werden, um Maßnahmen und Instrumente einer kommunalen Wirtschaftsförderung zu überprüfen und gegebenenfalls an die geänderten Bedingungen anzupassen. rnEs ist schon mehr als 30 Jahre her, als in den 1970er Jahren die Suche nach Methoden und Verfahren der Erfolgskontrolle in der öffentlichen Verwaltung begann. Erfolge von kommunaler Wirtschaftsförderung können nicht einfach und ausschließlich an den markantesten wirtschaftlichen Ziffern der Kommune gemessen werden, z. B. der Zahl der sozialversicherungspflichtigen Arbeitsplätze. Seit Jahren wird um einen Lösungsweg bei der Durchführung von Erfolgskontrolle in der kommunalen Wirtschaftsförderung gerungen, abschließend wurde jedoch noch kein vollends befriedigend praktikabler Weg gefunden. Zu hinterfragen ist vor dem Hintergrund, inwiefern die vier Elemente einer Erfolgskontrolle, nämlich die Zielerreichungs-, Vollzugs-, Bedingungs- und Wirkungskontrolle, tatsächlich und hinreichend zum Einsatz kommen können.rnDie vorliegenden empirischen Untersuchungen beleuchten nun das Thema aus Sicht der kommunalen Wirtschaftsförderer und liefern Ergebnisse, die zu einem veränderten Bewusstsein gegenüber der Durchführung von Erfolgskontrolle in der kommunalen Wirtschaftsförderung führen müssten. Unabhängig von der Organisationsform und der Größe einer kommunalen Wirtschaftsförderung lässt sich empirisch nachweisen, dass der Anspruch, den der Begriff der Erfolgskontrolle in seiner gängigen Beschreibung erhebt, nicht hinreichend von einer kommunalen Wirtschaftsförderung erfüllt werden kann. rnMit Hilfe des neu entwickelten Prozesses einer modifizierten Erfolgskontrolle wird in vorliegender Arbeit ein idealtypischer Ablauf für eine kommunale Wirtschaftsförderung dargestellt. Der neue Ansatz einer modifizierten Erfolgskontrolle ist eine konsequente Reduzierung der Anforderungen auf das Praktikable und führt dazu, dass Erfolge der kommunalen Wirtschaftsförderung dargestellt werden können, ohne dass das Verfahren mehr Fragen offen lässt, als es beantwortet. Durch die modifizierte Erfolgskontrolle können die spezifischen Erfolge einer kommunalen Wirtschaftsförderung dargestellt und dokumentiert werden. rnEine modifizierte Erfolgskontrolle kann zweierlei: Sie ist eine Hilfestellung für die politisch Verantwortlichen bei der Erkenntnis, dass eine Notwendigkeit nach konkreten und der Ist-Situation sowie den Randbedingungen angepassten Zielformulierungen besteht. Sie bietet aber auch eine Möglichkeit, dass die kommunalen Wirtschaftsförderungseinrichtungen dem in der öffentlichen Diskussion formulierten Anspruch nach Erfolgskontrolle mit einem hohen Grad an Praktikabilität gerecht werden können. rnBevor also viele kommunale Wirtschaftsförderungen durch die fragwürdige Forderung an eine Erfolgskontrolle aufgrund der zu hohen Anforderungen an Methodik, Zeit und Personal aufgeben, sollte ihnen die Konzentration auf das Praktikable wieder Anreiz sein, eine modifizierte Erfolgskontrolle nach dem neuen Prozessschema in Angriff zu nehmen. rnrn

L'analisi della segmentazione

L'analisi della segmentazione, viene utilizzata per identificare sottogruppi omogenei all'interno di una popolazione generale. La segmentazione è particolarmente importante se la concorrenza varia nei diversi sottomercati all'interno di un settore in modo tale che alcuni sono più attraenti di altri. Il lavoro di tesi svolto è stato organizzato in quattro capitoli. Nel primo si parla della strategia e dell'importanza che essa riveste per un'azienda, e si analizzanno le caratteristiche di una strategia di successo. Nel secondo capitolo si trattano tre aspetti vitali di un'azienda : la vision, la mission e gli obiettivi. Nel terzo capitolo si parla del modello che Porter ha sviluppato per fornire un quadro di riferimento per la comprensione della competitività strategica di un'impresa all'interno di un mercato specifico. Si definisce formalmente cosa si intende per teoria dei giochi e si presenta quello che probabilmente è l'esempio più noto di questa teoria : il dilemma del prigioniero - un gioco di cooperazione a somma zero. Nel quarto capitolo si analizza la segmentazione del mercato italiano, si fà l'analisi dell'ambiente esterno e vedremo infatti che un'azienda prima di creare piani di business o di prendere decisioni, deve conoscere l'ambiente su cui opera. Ciò può essere ottenuto attraverso un analisi PESTEL.Il capitolo si conclude con l'analisi di un campione di azende su cui calcoleremo alcuni indici medi di redditività, il Return On Assets (ROA), il Return On common Equity (ROE)e l'Earnings Before Interests Taxes and Amortization (EBITA).

Thermoelectric properties in phase-separated half-Heusler materials

The conversion of dissipated heat into electricity is the basic principle of thermoelectricity. In this context, half-Heusler (HH) compounds are promising thermoelectric (TE) materials for waste heat recovery. They meet all the requirements for commercial TE applications, ranging from good efficiencies via environmentally friendliness to being low cost materials. This work focused on the TE properties of Ti0.3Zr0.35Hf0.35NiSn-based HH materials. This compound undergoes an intrinsic phase separation into a Ti-poor and Ti-rich HH phase during a rapid solidification process. The resulting dendritic microstructure causes a drastic reduction of the thermal conductivity, leading to higher TE efficiencies in these materials. The TE properties and temperature dependence of the phase-separated Ti0.3Zr0.35Hf0.35NiSn compound were investigated. The TE properties can be adjusted depending on the annealing treatment. The extension of annealing time for 21 days at 1000 °C revealed a reduction of the thermal conductivity and thus an enhancement of the TE performance in this sample. An increase of annealing temperature caused a change of the phase fraction ratio in favor of the Ti-rich phase, leading to an improvement of the electronic properties. rnInspired by the TE properties of the Ti0.3Zr0.35Hf0.35NiSn HH compound, the performance of different n- and p-type materials, realized via site substitution with donor and acceptor elements was examined. The fabrication of a TE n- and p-type material pair based on one starting compound can guarantee similar TE and mechanical properties and is enormous beneficial for device engineering. As donor dopants V, Nb and Sb were tested. Depending on the lattice position small doping levels were sufficient to attain distinct improvement in their TE efficiency. Acceptor-induced doping with Sc, Y and Co caused a change in the transport behavior from n- to p- type conduction, revealing the highest Seebeck coefficients obtained in the MNiSn system. rnThen, the long-term stability of an exemplary n- and p-type HH compound was proven. Surprisingly, the dendritic microstructure can be maintained even after 500 cycles (1700 h) from 373 to 873 K. The TE performance of both n- and p-type materials showed no significant change under the long-term treatment, indicating the extraordinary temperature stability of these compounds. Furthermore both HH materials revealed similar temperature-dependence of their mechanical properties. This work demonstrates the excellent suitability of phase-separated HH materials for future TE applications in the moderate temperature range.rn

Strahlungsinduzierte Mukositis als Risiko der Raumfahrt : Modelluntersuchungen an Röntgen- und Schwerionen-bestrahlten organotypischen Mundschleimhaut-Modellen

Während ausgedehnter Weltraumflüge zum Mond und Mars wäre die Besatzung eines Raumschiffs dicht ionisierender Schwerionenstrahlung, der sogenannten kosmischen Strahlung, ausgesetzt. Da bei vielen Krebspatienten die orale Mukositis als eine gravierende Nebenwirkung bei der herkömmlichen Strahlentherapie auftritt, könnte diese Erkrankung ein medizinisches Problem während ausgedehnter Weltraumflüge darstellen. Allerdings liegen bislang keine Untersuchungen über eine mögliche Mukositis-induzierte Wirkung von Schwerionenstrahlung vor. Um das Risiko strahlungsinduzierter oraler Mukositis durch kosmische Strahlung abzuschätzen, wurden dreidimensionale organotypische Mundschleimhaut-Modelle 12C Schwerionen- bzw. Röntgenstrahlung ausgesetzt und nach definierten Inkubationszeiten kryokonserviert. Aus dem Material wurden Kryoschnitte gefertigt, mit denen anschließend histologische und immunhistologische Fluoreszenzfärbungen zum Nachweis von zum Beispiel Kompaktheitsverlust, Doppelstrangbrüchen der DNA und NF-κB-Aktivierung durchgeführt wurden. Die Ausschüttung von Tumornekrosefaktor α, Interleukin 1β, Interleukin 6 und Interleukin 8 wurde in Probenüberständen mittels ELISA analysiert. Das Hauptaugenmerk dieser Studie lag dabei auf den frühen durch Strahlung verursachten Effekten. rnIm Rahmen dieser Dissertation wurde ein dreidimensionales Mundschleimhaut-Modell etabliert, das verglichen mit humaner Mundschleimhaut viele organotypische Differenzierungsmarker und in vivo-ähnliche Reaktionen auf bestimmte Reize zeigte. Nach einer Bestrahlung mit schweren Kohlenstoffionen bzw. mit Röntgenstrahlung wurden strahlungsinduzierte Effekte auf mehreren Ebenen detektiert. Bereits 1 h nach Bestrahlung konnten dosisabhängig vermehrte Doppelstrangbrüche in der DNA detektiert werden, wobei bei gleicher Dosis Schwerionenstrahlung im Durchschnitt doppelt so viele DSB verursachte wie Röntgenstrahlung. Das Mundschleimhaut-Modell reagierte auf beide Strahlungsarten mit einer Aktivierung des Transkriptionsfaktors NF-κB p50, wobei Röntgenstrahlung diese Aktivierung früher induzierte als Schwerionen. Eine strahlungsinduzierte Aktivierung von NF-κB p65 wurde in den organotypischen Kulturen zu den untersuchten Zeitpunkten nicht beobachtet. Im Vergleich zu nicht bestrahlten Kulturen waren die Konzentrationen von Interleukin 6 und Interleukin 8 unabhängig von der Strahlungsqualität nach Bestrahlung signifikant erhöht. Interleukin-1β dagegen wurde nur nach Röntgenbestrahlung signifikant vermehrt ausgeschüttet. In Schwerionen-bestrahlten Proben wurden zwar tendenziell höhere Konzentrationen beobachtet, statistische Signifikanzen ergaben sich aber nicht. Die Analysen zur TNF-α- und IFN-γ-Ausschüttung in bestrahlten organotypischen Kulturen ergaben innerhalb des gewählten Beobachtungszeitraums von 48 h keine strahlungsinduzierten Effekte. Bei den Untersuchungen der Proliferation in den Zellen der bestrahlten organotypischen Kulturen wurde bereits 24 h nach Röntgenstrahlung und 3 Tage nach Schwerionenstrahlung eine deutliche verminderte Proliferation beobachtet. Des Weiteren zeigte das Mundschleimhaut-Modell unabhängig von Strahlungsqualitäten einen eindeutigen Verlust in der Zellintegrität und daraus resultierenden Kompaktheitsverlust des Gewebes, was in der in vivo-Situation wahrscheinlich einer Gewebedegeneration entspricht. rnNach Bestrahlung mit sowohl Röntgenstrahlung als auch schweren Ionen wurden im gewählten Mukosa-Modell innerhalb von 48 h nach Behandlung strahlungsinduzierte proinflammatorische Marker eindeutig und reproduzierbar detektiert. Dies deutet darauf hin, dass während langer extraterrestrischer Expeditionen das Risiko der oralen Mukositis einkalkuliert und mit den daraus folgenden Konsequenzen gerechnet werden muss.rn

[Driving ability and daytime sleepiness]

Daytime sleepiness is a complaint of about 5-10% in a normal population. The consequences, such as impaired performance and accidents at the workplace and while driving, have major impact on the affected and on society. According to Swiss federal statistics only 1-3% of all motor vehicle accidents are due to excessive daytime sleepiness, which is in great contrast to a figure of 10 to 20% of all accidents derived from scientific studies. Due to the inadequate statistical representation of the problem, insufficient countermeasures have been realized, and the state of drivers breaching traffic regulations is not adequately investigated in this respect. The most prevalent cause of microsleep induced accidents is certainly lack of sleep due to social or professional reasons. A treating physician must also consider sedating drugs and various diseases. The typical characteristics of accidents due to falling asleep at the wheel and the risk factors involved are well established, so that informing the general public, taking prophylactic countermeasures and a targeted investigation in this respect of drivers who have breached the law are all feasible. Since symptoms of sleepiness can be recognized well before any impairment of performance occurs, the most important countermeasure is information of the drivers on the risk factors and on efficient countermeasures against sleepiness at the wheel. Besides correct diagnosis and treatment, the primary goal of physicians treating patients with pathological daytime sleepiness is to inform them at an early stage about the risks of sleepiness and the large responsibility they bear while driving. This information should be written down in the patients' records. Professional drivers suffering from daytime sleepiness, drivers who have already had an accident due to microsleep and unreasonable drivers should be referred to a centre of sleep disorders for objective measurements of sleepiness.

A comparison of the original and simplified Pulmonary Embolism Severity Index

The Pulmonary Embolism Severity Index (PESI) is a validated clinical prognostic model for patients with pulmonary embolism (PE). Recently, a simplified version of the PESI was developed. We sought to compare the prognostic performance of the original and simplified PESI. Using data from 15,531 patients with PE, we compared the proportions of patients classified as low versus higher risk between the original and simplified PESI and estimated 30-day mortality within each risk group. To assess the models' accuracy to predict mortality, we calculated sensitivity, specificity, and predictive values and likelihood ratios for low- versus higher-risk patients. We also compared the models' discriminative power by calculating the area under the receiver-operating characteristic curve. The overall 30-day mortality was 9.3%. The original PESI classified a significantly greater proportion of patients as low-risk than the simplified PESI (40.9% vs. 36.8%; p<0.001). Low-risk patients based on the original and simplified PESI had a mortality of 2.3% and 2.7%, respectively. The original and simplified PESI had similar sensitivities (90% vs. 89%), negative predictive values (98% vs. 97%), and negative likelihood ratios (0.23 vs. 0.28) for predicting mortality. The original PESI had a significantly greater discriminatory power than the simplified PESI (area under the ROC curve 0.78 [95% CI: 0.77-0.79] vs. 0.72 [95% CI: 0.71-0.74]; p<0.001). In conclusion, even though the simplified PESI accurately identified patients at low-risk of adverse outcomes, the original PESI classified a higher proportion of patients as low-risk and had a greater discriminatory power than the simplified PESI.

Capitals and capabilities: linking structure and agency to reduce health inequalities

While empirical evidence continues to show that low socio-economic position is associated with less likely chances of being in good health, our understanding of why this is so remains less than clear. In this paper we examine the theoretical foundations for a structure-agency approach to the reduction of social inequalities in health. We use Max Weber's work on lifestyles to provide the explanation for the dualism between life chances (structure) and choice-based life conduct (agency). For explaining how the unequal distribution of material and non-material resources leads to the reproduction of unequal life chances and limitations of choice in contemporary societies, we apply Pierre Bourdieu's theory on capital interaction and habitus. We find, however, that Bourdieu's habitus concept is insufficient with regard to the role of agency for structural change and therefore does not readily provide for a theoretically supported move from sociological explanation to public health action. We therefore suggest Amartya Sen's capability approach as a useful link between capital interaction theory and action to reduce social inequalities in health. This link allows for the consideration of structural conditions as well as an active role for individuals as agents in reducing these inequalities. We suggest that people's capabilities to be active for their health be considered as a key concept in public health practice to reduce health inequalities. Examples provided from an ongoing health promotion project in Germany link our theoretical perspective to a practical experience.

Prospective comparison of clinical prognostic scores in elderly patients with pulmonary embolism

Background: The Geneva Prognostic Score (GPS), the Pulmonary Embolism Severity Index (PESI), and its simplified version (sPESI) are well known clinical prognostic scores for pulmonary embolism (PE).Objectives: To compare the prognostic performance of these scores in elderly patients with PE. Patients/Methods: In a multicenter Swiss cohort of elderly patients with venous thromboembolism, we prospectively studied 449 patients aged ≥65 years with symptomatic PE. The outcome was 30-day overall mortality. We dichotomized patients as low- vs. higher-risk in all three scores using the following thresholds: GPS scores ≤2 vs. >2, PESI risk classes I-II vs. III-V, and sPESI scores 0 vs. ≥1. We compared 30-day mortality in low- vs. higher-risk patients and the areas under the receiver operating characteristic curve (ROC). Results: Overall, 3.8% of patients (17/449) died within 30 days. The GPS classified a greater proportion of patients as low risk (92% [413/449]) than the PESI (36.3% [163/449]) and the sPESI (39.6% [178/449]) (P<0.001 for each comparison). Low-risk patients based on the sPESI had a mortality of 0% (95% confidence interval [CI] 0-2.1%) compared to 0.6% (95% CI 0-3.4%) for low-risk patients based on the PESI and 3.4% (95% CI 1.9-5.6%) for low-risk patients based on the GPS. The areas under the ROC curves were 0.77 (95%CI 0.72-0.81), 0.76 (95% CI 0.72-0.80), and 0.71 (95% CI 0.66-0.75), respectively (P=0.47). Conclusions: In this cohort of elderly patients with PE, the GPS identified a higher proportion of patients as low-risk but the PESI and sPESI were more accurate in predicting mortality.

Should aortic arch replacement be performed during initial surgery for aortic root aneurysm in patients with Marfan syndrome?

OBJECTIVES: The aim of this study was to investigate whether total arch replacement (TAR) during initial surgery for root aneurysm should be routinely performed in patients with Marfan syndrome (MFS). METHODS: Retrospective analysis of 94 consecutive MFS patients fulfilling Ghent criteria who underwent 148 aortic surgeries and were followed at this institution during the past 16 years. RESULTS: The mean follow-up interval was 8.8 ± 7 years. Initial presentation was acute aortic dissection (AAD) in 35% of patients (76% Type A and 24% Type B) and aneurismal disease in 65%. TAR was performed in 8% of patients during initial surgery for AAD (otherwise a hemi-arch replacement was performed) and 1.6% in elective root repair. Secondary TAR had to be performed in only 3% of patients without, but in 33% following AAD (33% Type A and 33% Type B; P = 0.0001). Thirty-day, 6-month, 1-year and overall mortalities were 3.2, 5.3, 6.4 and 11.7%, respectively. Operative and 30-day mortalities in secondary aortic arch replacement were zero. Secondary TAR after AAD did not increase the need for the replacement of the entire thoracoabdominal aorta during follow-up compared with patients without secondary TAR (37 vs 40%, P = 1.0). CONCLUSIONS: MFS patients undergoing elective root repair have small risk of reinterventions on the aortic arch, and primary prophylactic replacement does not seem to be justified. In patients with AAD, the need for reinterventions is precipitated by the dissection itself and not by limiting the procedure to the hemi-arch replacement in the emergency setting. Limiting surgery to the aortic root, ascending aorta and proximal aortic arch is associated with low mortality in MFS patients presenting with AAD.

Help-seeking pathways in early psychosis

INTRODUCTION: Understanding the help-seeking pathways of patients with a putative risk of developing psychosis helps improving development of specialised care services. This study aimed at obtaining information about: type of health professionals contacted by patients at putative risk for psychosis on their help-seeking pathways; number of contacts; type of symptoms leading to contacts with health professionals; interval between initial contact and referral to a specialised outpatient service. METHOD: The help-seeking pathways were assessed as part of a prospective study in 104 patients with suspected at-risk states for psychosis. RESULTS: The mean number of contacts prior to referral was 2.38. Patients with psychotic symptoms more often contacted mental health professionals, whereas patients with insidious and more unspecific features more frequently contacted general practitioners (GPs). CONCLUSIONS: GPs have been found to under-identify the insidious features of emerging psychosis (Simon et al. (2005) Br J Psychiatry 187:274-281). The fact that they were most often contacted by patients with exactly these features calls for focussed and specialised help for primary care physicians. Thus, delays along the help-seeking pathways may be shortened. This may be of particular relevance for patients with the deficit syndrome of schizophrenia.