Early clopidogrel versus prasugrel use among contemporary STEMI and NSTEMI patients in the US: insights from the National Cardiovascular Data Registry.

BACKGROUND: P2Y12 antagonist therapy improves outcomes in acute myocardial infarction (MI) patients. Novel agents in this class are now available in the US. We studied the introduction of prasugrel into contemporary MI practice to understand the appropriateness of its use and assess for changes in antiplatelet management practices. METHODS AND RESULTS: Using ACTION Registry-GWTG (Get-with-the-Guidelines), we evaluated patterns of P2Y12 antagonist use within 24 hours of admission in 100 228 ST elevation myocardial infarction (STEMI) and 158 492 Non-ST elevation myocardial infarction (NSTEMI) patients at 548 hospitals between October 2009 and September 2012. Rates of early P2Y12 antagonist use were approximately 90% among STEMI and 57% among NSTEMI patients. From 2009 to 2012, prasugrel use increased significantly from 3% to 18% (5% to 30% in STEMI; 2% to 10% in NSTEMI; P for trend <0.001 for all). During the same period, we observed a decrease in use of early but not discharge P2Y12 antagonist among NSTEMI patients. Although contraindicated, 3.0% of patients with prior stroke received prasugrel. Prasugrel was used in 1.9% of patients ≥75 years and 4.5% of patients with weight <60 kg. In both STEMI and NSTEMI, prasugrel was most frequently used in patients at the lowest predicted risk for bleeding and mortality. Despite lack of supporting evidence, prasugrel was initiated before cardiac catheterization in 18% of NSTEMI patients. CONCLUSIONS: With prasugrel as an antiplatelet treatment option, contemporary practice shows low uptake of prasugrel and delays in P2Y12 antagonist initiation among NSTEMI patients. We also note concerning evidence of inappropriate use of prasugrel, and inadequate targeting of this more potent therapy to maximize the benefit/risk ratio.

Big or fast: two strategies in the developmental control of body size.

Adult body size is controlled by the mechanisms that stop growth when a species-characteristic size has been reached. The mechanisms by which size is sensed and by which this information is transduced to the growth regulating system are beginning to be understood in a few species of insects. Two rather different strategies for control have been discovered; one favors large body size and the other favors rapid development.

Accidentes en trabajadores ganaderos en Santa Fe, Argentina

p.67-76

An acoustic correction method for extracting sound signals

Sound waves are propagating pressure fluctuations and are typically several orders of magnitude smaller than the pressure variations in the flow field that account for flow acceleration. On the other hand, these fluctuations travel at the speed of sound in the medium, not as a transported fluid quantity. Due to the above two properties, the Reynolds averaged Navier-Stokes (RANS) equations do not resolve the acoustic fluctuations. Direct numerical simulation of turbulent flow is still a prohibitively expensive tool to perform noise analysis. This paper proposes the acousticcorrectionmethod, an alternative and affordable tool based on a modified defect correction concept, which leads to an efficient algorithm for computational aeroacoustics and noise analysis.

Putting down routes: an examination of local government cultural policy shaping the development of heritage trails

This paper explores the significance of trails within local government cultural strategies by presenting the results of an audit of 1000 trails, content analysis of local cultural strategies and a series of interviews with local government cultural officers. It highlights the growing sophistication of trails as flexible and multi-faceted products promising an array of social, environmental, cultural and economic benefits. However, key issues emerge as challenges for local government cultural officers. These include the need for a realistic assessment of the relative importance of competing rationales, the design of methodologies to enable evidence-based policy making and more effective engagement with commercial organisations.

Differential contribution of diatoms and dinoflagellates to phytoplankton biomass in the NE Atlantic Ocean and the North Sea

Sampling by the continuous plankton recorder (CPR) survey over the North Atlantic Ocean and the North Sea has enabled long-term studies of phytoplankton biomass. Analysis of an index of phytoplankton biomass, the phytoplankton colour index (PCI), has previously shown an increase in phytoplankton biomass in the NE Atlantic. In the current study, further investigations were conducted to determine the contribution of diatom and dinoflagellate cell counts to the PCI, their fluctuations over the last 45 yr and their geographical variations in the eastern North Atlantic and the North Sea. An increased contribution of dinoflagellates to the PCI was revealed over the south NE Atlantic and the northern North Sea. In contrast, the contribution of diatoms decreased in the north NE Atlantic and the northern North Sea. No discernible trends were found in the other regions of the North Sea. The relative contributions of diatoms and dinoflagellates to the PCI led to the identification of 3 geographically distinct dynamic regimes in the diatom/dinoflagellate dynamics in the NE Atlantic and the North Sea. Finally, it is stressed that the discrepancy observed in the patterns of PCI and diatom and dinoflagellate cell counts suggests that changes in PCI do not reflect changes in the community structure and that the exclusive use of PCI is not adequate to investigate the long-term trends in the trophic link between phytoplankton and herbivorous zooplankton.

Questioning the role of phenology shifts and trophic mismatching in a planktonic food web

In a warming climate, differential shifts in the seasonal timing of predators and prey have been suggested to lead to trophic ‘‘mismatches’’ that decouple primary, secondary and tertiary production. We tested this hypothesis using a 25-year time-series of weekly sampling at the Plymouth L4 site, comparing 57 plankton taxa spanning 4 trophic levels. During warm years, there was a weak tendency for earlier timings of spring taxa and later timings of autumn taxa. While this is in line with many previous findings, numerous exceptions existed and only a few taxa (e.g. Gyrodinium spp., Pseudocalanus elongatus, and Acartia clausi) showed consistent, strong evidence for temperature-related timing shifts, revealed by all 4 of the timing indices that we used. Also, the calculated offsets in timing i.e. ‘‘mismatches’’) between predator and prey were no greater in extreme warm or cold years than during more average years. Further, the magnitude of these offsets had no effect on the ‘‘success’’ of the predator, in terms of their annual mean abundance or egg production rates. Instead numerous other factors override, including: inter-annual variability in food quantity, high food baseline levels, turnover rates and prolonged seasonal availability, allowing extended periods of production. Furthermore many taxa, notably meroplankton, increased well before the spring bloom. While theoretically a chronic mismatch, this likely reflects trade-offs for example in predation avoidance. Various gelatinous taxa (Phaeocystis, Noctiluca, ctenophores, appendicularians, medusae) may have reduced these predation constraints, with variable, explosive population outbursts likely responding to improved conditions. The match–mismatch hypothesis may apply for highly seasonal, pulsed systems or specialist feeders, but we suggest that the concept is being over-extended to other marine systems where multiple factors compensate.

Las infraestructuras de recarga y el despegue del vehículo eléctrico.

Este trabajo revisa la evolución y estado actual de la automoción eléctrica; analiza las ventajas ambientales, de eficiencia energética y de costes del motor eléctrico frente al de combustión interna; y presenta como limitaciones para el uso del vehículo eléctrico, el desarrollo actual de las baterías recargables y la lenta implantación de electrolineras. Con el objetivo de contribuir al desarrollo de una actividad económica respetuosa con el medio ambiente y basada en nuevas tecnologías, se proyecta, a partir de experiencias previas, una instalación de puntos de recarga para una ciudad de 50.000 habitantes con un parque de 100 vehículos eléctricos que dispone de dos plazas de recarga rápida (poste trifásico 400V CA), siete plazas de recarga lenta (postes monofásicos 230V CA) y de 50 módulos fotovoltaicos que producen diariamente la energía equivalente a la recarga lenta de un vehículo en los meses fríos y de dos en los meses cálidos.

Los diferentes tipos de láser y sus aplicaciones en podología

Los diferentes tipos de láseres, sobre todo el láser de diodo, irrumpen en la terapéutica podológica para proporcionar una alternativa más de tratamiento en muchas patologías que son el día a día de las consultas. El buen manejo y el conocimiento de sus características son requisitos imprescindibles para no tener efectos secundarios indeseados y poder llevar a cabo tratamientos poco dolorosos, minimizando el tiempo total, y muchas veces proporcionando una solución a diversas patologías.

Belief, Knowledge and Expertise. The emergence of the lay expert in medical sociology

The paper has three main aims. First, to trace – through the pages of the Journal – the changing ways in which lay understandings of health and illness have been represented during the 1979-2002 period. Second, to say something about the limits of lay knowledge (and particularly lay expertise) in matters of health and medicine. Third, to call for a re-assessment of what lay people can offer to a democratised and customer sensitive system of health care and to attempt to draw a boundary around the domain of expertise. In following through on those aims, the author calls upon data derived from three current projects. These latter concern the diagnosis of Alzheimer’s disease in people with Down’s syndrome; the development of an outcome measure for people who have suffered a traumatic brain injury; and a study of why older people might reject annual influenza vaccinations. Key words: Lay health beliefs, lay expertise, Alzheimer’s, Traumatic Brain Injury, Vaccinations

'National Antiquities' and the Law

National museums, housing â??national antiquities', were a nineteenth-century cultural phenomenon throughout Europe. In the United Kingdom, they afforded the Treasury a means of preserving relics of antiquity claimed as treasure trove. While satisfying the desire of the scientific community for the preservation of archaeological finds, and national sentiment in Scotland and Ireland, Treasury practice undermined the British Museum's eponymous mission. This paper traces the development and legal consequences of the Treasury policy of national allocation of treasure trove, including the discussion in the Museums Committee of 1898â??99 of the â??nationality' of objects and artefacts, and considers the potential wider significance of â??national antiquity' in the context of changing constitutional arrangements in the United Kingdom in the 1920s, and in the future.