When "enough" is not enough: new perspectives on optimal methadone maintenance dose.

Some methadone maintenance treatment (MMT) programs prescribe inadequate daily methadone doses. Patients complain of withdrawal symptoms and continue illicit opioid use, yet practitioners are reluctant to increase doses above certain arbitrary thresholds. Serum methadone levels (SMLs) may guide practitioners dosing decisions, especially for those patients who have low SMLs despite higher methadone doses. Such variation is due in part to the complexities of methadone metabolism. The medication itself is a racemic (50:50) mixture of 2 enantiomers: an active "R" form and an essentially inactive "S" form. Methadone is metabolized primarily in the liver, by up to five cytochrome P450 isoforms, and individual differences in enzyme activity help explain wide ranges of active R-enantiomer concentrations in patients given identical doses of racemic methadone. Most clinical research studies have used methadone doses of less than 100 mg/day [d] and have not reported corresponding SMLs. New research suggests that doses ranging from 120 mg/d to more than 700 mg/d, with correspondingly higher SMLs, may be optimal for many patients. Each patient presents a unique clinical challenge, and there is no way of prescribing a single best methadone dose to achieve a specific blood level as a "gold standard" for all patients. Clinical signs and patient-reported symptoms of abstinence syndrome, and continuing illicit opioid use, are effective indicators of dose inadequacy. There does not appear to be a maximum daily dose limit when determining what is adequately "enough" methadone in MMT.

Influence of the timing of low-dose aspirin on tolerability of prolonged-release nicotinic acid in patients at elevated cardiovascular risk

OBJECTIVES: To investigate the effect of low-dose aspirin administered in the morning or evening on the rate of discontinuation of prolonged-release nicotinic acid (Niaspan) due to flushing in patients at elevated cardiovascular risk. RESEARCH DESIGN AND METHODS: This was an observational, non-interventional study in patients at elevated cardiovascular risk due to cardiovascular disease or type 2 diabetes. Patients received prolonged-release nicotinic acid and aspirin under the usual care of their physician for 15 weeks. MAIN OUTCOME MEASURES: The main outcome measure was the rate of treatment discontinuation for flushing. Other adverse drug reactions (ADRs) were also recorded. Lipid parameters were also measured. RESULTS: The patient population included 539 subjects (70% male); 36% had type 2 diabetes, 80% had prior cardiovascular disease, and 37% had a family history of cardiovascular disease. The rate of treatment discontinuation due to flushing did not differ (p = 0.3375) between the morning aspirin group (10.6%) and the evening aspirin group (13.8%). The overall incidence of flushing was 57%. Most flushes were of mild or moderate severity and decreases occurred over time in both frequency and intensity. ADRs unrelated to flushing occurred in 6.6% of the morning aspirin group and 7.4% of the evening aspirin group. HDL-cholesterol increased by +21.3% in the overall population, together with moderate improvements in other lipid parameters. CONCLUSIONS: Flushing was the most common ADR with prolonged-release nicotinic acid treatment, as expected. The timing of aspirin administration did not influence the rate of treatment discontinuations for flushing. Marked increases in HDL-cholesterol were observed.

Integration of Pore Features into the Evaluation of Fingerprint Evidence

Fingerprint practitioners rely on level 3 features to make decisions in relation to the source of an unknown friction ridge skin impression. This research proposes to assess the strength of evidence associated with pores when shown in (dis)agreement between a mark and a reference print. Based upon an algorithm designed to automatically detect pores, a metric is defined in order to compare different impressions. From this metric, the weight of the findings is quantified using a likelihood ratio. The results obtained on four configurations and 54 donors show the significant contribution of the pore features and translate into statistical terms what latent fingerprint examiners have developed holistically through experience. The system provides LRs that are indicative of the true state under both the prosecution and the defense propositions. Not only such a system brings transparency regarding the weight to assign to such features, but also forces a discussion in relation to the risks of such a model to mislead.

La mediació i l'arbitratge de consum: explorar sistemes d'ODR

La utilització dels mitjans alternatius de resolució de conflictes (ADR) en l'àmbit de les reclamacions de consum té un marc legal específic a Espanya -i també a la UE- des del 1993, que deriva de les seves característiques especials. Algunes són d'encuny exclusivament jurídic: es tracta de reclamacions en què el marc legal aplicable és el denominat dret de consum; d'altres tenen un suport bàsicament fàctic: solen tenir poca entitat econòmica, és a dir, entren en la categoria del que denominem small claims, i el fet que les reclamacions -en alguns casos que van en augment- siguin transfrontereres condiciona l'opció entre jurisdicció tradicional i ADR, com també tindrem ocasió d'analitzar. Cal afegir a aquests elements jurídics i fàctics un element important de política legislativa en un àmbit de la UE: els ADR s'entenen com un instrument bàsic per a garantir l'accés dels consumidors a la justícia, però alhora, en l'àmbit del comerç electrònic, són un element de gran transcendència en la creació de la denominada confiança electrònica o e-confidence. Per aquest motiu, s'exploren contínuament proces- sos de resolució en línia de conflictes (on-line dispute resolution, ODR). Els ODR pretenen la màxima eficàcia oferint un suport tècnic capaç de solucionar una controvèrsia amb la intervenció d'un tercer o sense, i dins o fora de l'organització de l'empresari. D'aquesta manera, s'usa un mateix expedient tècnic per a posar en marxa successivament més d'un ADR, o es potencien els mecanismes automàtics que prescindeixen dels conceptes jurídics i, en mig de l'exploració constant, Espanya aposta per l'arbitratge electrònic de consum en el RD 236/2008. A aquests temes ens referirem a continuació.

La mediación y el arbitraje de consumo: explorando sistemas de ODR

La utilización de ADR en el ámbito de las reclamaciones de consumo tiene un marco legal específico en España -y también en la UE- desde 1993, que deriva de sus características especiales. Algunas son de cuño exclusivamente jurídico: se trata de reclamaciones en las que el marco legal aplicable es el denominado derecho de consumo; otras poseen un soporte básicamente fáctico: suelen tener poca entidad económica, es decir, entran en la categoría de lo que denominamos small claims, y el hecho de que las reclamaciones -en algunos supuestos que van en aumento- sean transfronterizas condiciona la opción entre jurisdicción tradicional y ADR, como también tendremos ocasión de analizar. Hay que añadir a estos elementos jurídicos y fácticos un elemento importante de política legislativa en un ámbito de la UE; los ADR se entienden como un instrumento básico para garantizar el acceso de los consumidores a la justicia, pero al mismo tiempo, en el ámbito del comercio electrónico, son un ele- mento de gran trascendencia en la creación de la denominada e-confidence. Por este motivo, se explo- ran continuamente formas de ODR (On-line Dispute Resolution). Los ODR pretenden la mayor eficacia ofreciendo un soporte técnico capaz de solucionar una controversia con o sin la intervención de un tercero, y dentro o fuera de la organización del empresario. De este modo, se usa un mismo expediente técnico para poner en marcha sucesivamente más de un ADR, o se potencian los mecanismos automáticos que prescinden de los conceptos jurídicos y, en medio de la exploración constante, España apuesta por el arbitraje electrónico de consumo en el RD 236/2008. A estos temas vamos a referirnos a continuación.

What do we actually mean by talent in business? Does it really matter?

[spa] La conceptuación de talento ha ido cobrando cada vez más importancia tanto para académicos como profesionales, con el fin de avanzar en el estudio de la gestión del talento. De hecho, la confusión sobre el significado de talento en la realidad empresarial impide llegar a un consenso sobre el concepto y la práctica de la gestión del talento. En este estudio teórico revisamos el concepto de talento en el mundo de la empresa con el fin de resumir lo que hemos aprendido y discutir las ventajas y limitaciones de las diferentes acepciones. Concluimos con la formulación de una definición de este concepto, ya que una correcta interpretación de la gestión del talento—por no hablar de una exitosa gestión del talento— depende de tener una comprensión clara de lo que se entiende por talento en un contexto organizativo. Además, con la definición de talento propuesta delimitamos el concepto de talento evitando algunos problemas detectados en las definiciones anteriores (por ejemplo, generalidades y tautologías), y poniendo de relieve las variables importantes que le afectan y lo hacen más manejable.

How to assign a likelihood ratio in a footwear mark case: an analysis and discussion in the light of R v T

This article analyses and discusses issues that pertain to the choice of relevant databases for assigning values to the components of evaluative likelihood ratio procedures at source level. Although several formal likelihood ratio developments currently exist, both case practitioners and recipients of expert information (such as judiciary) may be reluctant to consider them as a framework for evaluating scientific evidence in context. The recent ruling R v T and ensuing discussions in many forums provide illustrative examples for this. In particular, it is often felt that likelihood ratio-based reasoning amounts to an application that requires extensive quantitative information along with means for dealing with technicalities related to the algebraic formulation of these approaches. With regard to this objection, this article proposes two distinct discussions. In a first part, it is argued that, from a methodological point of view, there are additional levels of qualitative evaluation that are worth considering prior to focusing on particular numerical probability assignments. Analyses will be proposed that intend to show that, under certain assumptions, relative numerical values, as opposed to absolute values, may be sufficient to characterize a likelihood ratio for practical and pragmatic purposes. The feasibility of such qualitative considerations points out that the availability of hard numerical data is not a necessary requirement for implementing a likelihood ratio approach in practice. It is further argued that, even if numerical evaluations can be made, qualitative considerations may be valuable because they can further the understanding of the logical underpinnings of an assessment. In a second part, the article will draw a parallel to R v T by concentrating on a practical footwear mark case received at the authors' institute. This case will serve the purpose of exemplifying the possible usage of data from various sources in casework and help to discuss the difficulty associated with reconciling the depth of theoretical likelihood ratio developments and limitations in the degree to which these developments can actually be applied in practice.

What do we actually mean by talent in business? Does it really matter?

[spa] La conceptuación de talento ha ido cobrando cada vez más importancia tanto para académicos como profesionales, con el fin de avanzar en el estudio de la gestión del talento. De hecho, la confusión sobre el significado de talento en la realidad empresarial impide llegar a un consenso sobre el concepto y la práctica de la gestión del talento. En este estudio teórico revisamos el concepto de talento en el mundo de la empresa con el fin de resumir lo que hemos aprendido y discutir las ventajas y limitaciones de las diferentes acepciones. Concluimos con la formulación de una definición de este concepto, ya que una correcta interpretación de la gestión del talento—por no hablar de una exitosa gestión del talento— depende de tener una comprensión clara de lo que se entiende por talento en un contexto organizativo. Además, con la definición de talento propuesta delimitamos el concepto de talento evitando algunos problemas detectados en las definiciones anteriores (por ejemplo, generalidades y tautologías), y poniendo de relieve las variables importantes que le afectan y lo hacen más manejable.

Overweight and eating disorders in primary care: a sentinella reporting in 2-20 years old patients

Aims: To describe overweight or eating disorders in primary care consultations of Swiss children or adolescents and analyze responses by physicians. Methods: 150 to 200 primary care physicians participating in the Swiss Sentinel Surveillance Network in collaboration with the Swiss Federal Office of Public Health register their consultations over one year for selected health conditions. We describe reports of consultations where overweight or eating disorders were identified in subjects aged 2-20 years by physicians, patients or their relatives, or referring professionals, between 29.12.2007 and 15.2.2008. Results: 189 consultations were registered in the first 7 weeks of declaration. A short majority concerned female (58%) and 12-20 years old (53%) patients. Half were reported by pediatricians, one third by general practitioners and the remaining minority by internists. The sample included two thirds of Swiss-German and one third of Swiss-French cases. In the male subgroup aged 2-20 and in female children aged 2-11, almost all reported consultations were characterized by overweight. Among female teenagers, underweight was reported in 29% whilst overweight was recorded in 60%. Anorexia was noted in 68% of reported consultations of underweight female teenagers. In underweight patients, advice given by physicians frequently covered both nutrition and physical activity (38%) or nutrition only (29%), while no specific recommendations were recorded for the remaining third. In case of overweight, for one half of consultations patients received both nutritional and physical activity recommendations, for 12% nutritional only, and for one quarter patients were not advised in these domains. No specific treatment was usually proposed to overweight patients (65%), except when bulimia was diagnosed; in such case, one third of patients were proposed a psychological/psychiatric treatment, whereas both psychological and pharmacological treatments were frequently offered for underweight teenagers. Therapy was most often motivated by physicians (50%) or by relatives (44%), more rarely by patients themselves (7%). Conclusions: These preliminary data indicate that in some primary care consultations of young patients with overweight or eating disorders, advice was not given on nutrition and physical activity. This observation needs to be later confirmed with the totality of the consultations registered in 2008 and reasons will be further investigated.

E-learning initiatives in forensic interpretation: report on experiences from current projects and outlook

This paper reports on the purpose, design, methodology and target audience of E-learning courses in forensic interpretation offered by the authors since 2010, including practical experiences made throughout the implementation period of this project. This initiative was motivated by the fact that reporting results of forensic examinations in a logically correct and scientifically rigorous way is a daily challenge for any forensic practitioner. Indeed, interpretation of raw data and communication of findings in both written and oral statements are topics where knowledge and applied skills are needed. Although most forensic scientists hold educational records in traditional sciences, only few actually followed full courses that focussed on interpretation issues. Such courses should include foundational principles and methodology - including elements of forensic statistics - for the evaluation of forensic data in a way that is tailored to meet the needs of the criminal justice system. In order to help bridge this gap, the authors' initiative seeks to offer educational opportunities that allow practitioners to acquire knowledge and competence in the current approaches to the evaluation and interpretation of forensic findings. These cover, among other aspects, probabilistic reasoning (including Bayesian networks and other methods of forensic statistics, tools and software), case pre-assessment, skills in the oral and written communication of uncertainty, and the development of independence and self-confidence to solve practical inference problems. E-learning was chosen as a general format because it helps to form a trans-institutional online-community of practitioners from varying forensic disciplines and workfield experience such as reporting officers, (chief) scientists, forensic coordinators, but also lawyers who all can interact directly from their personal workplaces without consideration of distances, travel expenses or time schedules. In the authors' experience, the proposed learning initiative supports participants in developing their expertise and skills in forensic interpretation, but also offers an opportunity for the associated institutions and the forensic community to reinforce the development of a harmonized view with regard to interpretation across forensic disciplines, laboratories and judicial systems.

Interim Guide for Optimum Joint Performance of Concrete Pavements, September 2011

The purpose of this guide is to help practitioners understand how to optimize concrete pavement joint performance through the identification, mitigation, and prevention of joint deterioration. It summarizes current knowledge from research and practice to help practitioners access the latest knowledge and implement proven techniques. Emphasizing that water is the common factor in most premature joint deterioration, this guide describes various types of joint deterioration that can occur. Some distresses are caused by improper joint detailing or construction, and others can be attributed to inadequate materials or proportioning. D cracking is a form of joint distress that results from the use of poor-quality aggregates. A particular focus in this guide is joint distress due to freeze-thaw action. Numerous factors are at play in the occurrence of this distress, including the increased use of a variety of deicing chemicals and application strategies. Finally, this guide provides recommendations for minimizing the potential for joint deterioration, along with recommendations for mitigation practices to slow or stop the progress of joint deterioration.

Guide to Dowel Load Transfer Systems for Jointed Concrete Roadway Pavements, September 2011

This guide provides a summary of the factors and design theories that should be considered when designing dowel load transfer systems for concrete pavement systems (including dowel basket design and fabrication) and presents recommendations for widespread adoption (i.e., standardization). Development of the guide was sponsored by the National Concrete Consortium with the goal of helping practitioners develop and implement dowel load transfer designs based on knowledge about current research and best practices.

Substitutable Concrete Pavements: A Manual of Practice, August 2011

Developed as a more detailed follow up at a 2009 briefing document,Building Sustainable Pavement with Concrete, this guide provides a clear, concise and cohesive discussion of pavement sustainability concepts and of recommended practices for maximizing the sustainability of concrete pavements. The intended audience includes decisions makers and practitioners in both owner-agencies and supply, manufacturing consulting and contractor businesses. Readers will find individual chapters with the most recent technical information and best practices related to concrete pavement deign, materials, construction, use/operations, renewal and recycling. In addition, they will find chapters addressing issues specific to pavement sustainability in the urban environment and to the evaluation of pavement sustainability.

Guide to Cement-Based Integrated Pavement Solutions, August 2011

This guide provides a clear, concise, and cohesive presentation of cement-bound materials options for 10 specific engineering pavement applications: new concrete pavements, concrete overlays, previous concrete, precast pavements, roller-compacted concrete, cement-treated base, full-depth reclamation with cement, cement-modified soils, recycled concrete aggregates, and repair and restoration. Each application is presented as a method for meeting specific design and construction objectives that today’s pavement practitioners must accomplish. The benefits, considerations, brief description, and summary of materials, design, and construction requirements, as well as a list of sustainable attributes, are provided for every solution. This guide is intended to be short, simple, and easy to understand. It was designed so that the most up-to-date and relevant information is easily extractable. It is not intended to be used as a design guide for any of the applications identified herein. Recommendations for additional information that can provide such details are given at the end of each solution discussion. The intended audience is practitioners, including engineers and managers who face decisions regarding what materials to specify in the pavement systems they design or manage. The audience also includes city and county engineers, along with the A/E firms that often represent them, and state DOT engineers at all levels who are seeking alternatives in this era of changing markets.

Diagnosis and management of chronic obstructive pulmonary disease: the swiss guidelines: official guidelines of the Swiss Respiratory Society.

The new Swiss Chronic Obstructive Pulmonary Disease (COPD) Guidelines are based on a previous version, which was published 10 years ago. The Swiss Respiratory Society felt the need to update the previous document due to new knowledge and novel therapeutic developments about this prevalent and important disease. The recommendations and statements are based on the available literature, on other national guidelines and, in particular, on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. Our aim is to advise pulmonary physicians, general practitioners and other health care workers on the early detection and diagnosis, prevention, best symptomatic control, and avoidance of COPD as well as its complications and deterioration.