Heart rate recovery after exercise in chronic heart failure: Role of vital exhaustion and type D personality

OBJECTIVE: Vital exhaustion and type D personality previously predicted mortality and cardiac events in patients with chronic heart failure (CHF). Reduced heart rate recovery (HRR) also predicts morbidity and mortality in CHF. We hypothesized that elevated levels of vital exhaustion and type D personality are both associated with decreased HRR. METHODS: Fifty-one patients with CHF (mean age 58+/-12 years, 82% men) and left ventricular ejection fraction (LVEF) Maastricht Vital Exhaustion Questionnaire and the 14-item type D questionnaire asking about negative affectivity and social inhibition. HRR was calculated as the difference between heart rate at the end of exercise and 1min after abrupt cessation of exercise (HRR-1). Regression analyses were adjusted for gender, age, LVEF, and maximum exercise capacity. RESULTS: Vital exhaustion explained 8.4% of the variance in continuous HRR-1 (p=0.045). For each point increase on the vital exhaustion score (range 0-18) there was a mean+/-SEM decrease of 0.54+/-0.26bpm in HRR-1. Type D personality showed a trend toward statistical significance for being associated with lower levels of HRR-1 explaining 6.5% of the variance (p<0.08). The likelihood of having HRR-1

Independent association of sleep quality, fatigue, and vital exhaustion with platelet count in patients with a previous venous thromboembolic event

Elevated platelet count might reflect increased inflammation as an etiological factor for venous thromboembolism (VTE). Poor sleep, fatigue, and exhaustion are all associated with inflammation and are also common sequelae of chronic psychological stress that previously predicted increased risk of VTE. We hypothesized that platelet count would be high in patients with VTE who sleep poorly and who are fatigued and exhausted. We investigated 205 patients scheduled for thrombophilia work-up > or =3 months after an objectively diagnosed venous thromboembolic event. They completed the Jenkins Sleep Questionnaire to rate subjective sleep quality and the short forms of the Multidimensional Fatigue Symptom Inventory and Maastricht Vital Exhaustion Questionnaire. Platelet count was determined by a mechanical Coulter counter. Analyses controlled for age, sex, body mass index, time since the index event, and medication. After taking into account these covariates, poorer sleep quality (p = 0.001; DeltaR(2)= 0.046), high fatigue (p = 0.008; DeltaR(2)= 0.032), and vital exhaustion (p = 0.050; DeltaR(2)= 0.017) were all associated with elevated platelet count. In addition, high level of fatigue mediated the relationship between poor sleep quality and elevated platelet count (p = 0.046). Poor sleep quality, high levels of fatigue, and vital exhaustion were identified as correlates of an elevated platelet count in patients with a previous episode of VTE. Given the emerging role of inflammatory processes in VTE, the findings suggest a mechanism through which behavioral and chronic psychological stressors might contribute to incident and recurrent venous thrombotic events.

Association of vital exhaustion and depressive symptoms with changes in fibrin D-dimer to acute psychosocial stress

OBJECTIVE: Vital exhaustion and depression are psychosocial risk factors of coronary artery disease. A hypercoagulable state in response to acute psychosocial stress contributes to atherothrombotic events. We aimed to investigate the hypothesis that vital exhaustion and depression correlate with stress-induced changes in the hypercoagulability marker D-dimer. METHODS: Thirty-eight healthy and nonsmoking school teachers (mean age 50+/-8 years, 55% women) completed the nine-item Maastricht Vital Exhaustion Questionnaire and the seven-item depression subscale of the Hospital Anxiety and Depression Scale. Within 1 week, subjects twice underwent the Trier Social Stress Test (i.e., preparation phase, mock job interview, and mental arithmetic that totaled 13 min). Plasma D-dimer levels were determined at five time points during the protocol. RESULTS: Vital exhaustion (P=.022; eta(2)=.080) and depressive symptoms (P=.011; eta(2)=.090) were associated with stress-induced changes in D-dimer levels over time controlling for sex and age. Elevated levels of vital exhaustion (r=-.46, P=.005) and of depression (r=-.51, P=.002) correlated with reduced D-dimer increase from pre-stress to immediately post-stress. Also, elevated vital exhaustion (r=.34, P=.044) and depression (r=.41, P=.013) were associated with increase (i.e., attenuated recovery) of D-dimer levels between 20 and 45 min post-stress. Controlling for stress hormone and blood pressure reactivity did not substantially alter these results. CONCLUSION: The findings suggest an attenuated immediate D-dimer stress response and delayed recovery of D-dimer levels post-stress with elevated vital exhaustion and depressive symptoms. In particular, the prolonged hypercoagulability after stress cessation might contribute to the atherothrombotic risk previously observed with vital exhaustion and depression, even at subclinical levels.

Approaches to Ensure Quality Standards for Standardized/ Simulated Patient Performance in High Stakes Objective Structured Clinical Exams (OSCEs)

Introduction To meet the quality standards for high-stakes OSCEs, it is necessary to ensure high quality standardized performance of the SPs involved.[1] One of the ways this can be assured is through the assessment of the quality of SPs` performance in training and during the assessment. There is some literature concerning validated instruments that have been used to assess SP performance in formative contexts but very little related to high stakes contexts.[2], [3], [4]. Content and structure During this workshop different approaches to quality control for SPs` performance, developed in medicine, pharmacy and nursing OSCEs, will be introduced. Participants will have the opportunity to use these approaches in simulated interactions. Advantages and disadvantages of these approaches will be discussed. Anticipated outcomes By the end of this session, participants will be able to discuss the rationale for quality control of SPs` performance in high stakes OSCEs, outline key factors in creating strategies for quality control, identify various strategies for assuring quality control, and reflect on applications to their own practice. Who should attend The workshop is designed for those interested in quality assurance of SP performance in high stakes OSCEs. Level All levels are welcome. References Adamo G. 2003. Simulated and standardized patients in OSCEs: achievements and challenges:1992-2003. Med Teach. 25(3), 262- 270. Wind LA, Van Dalen J, Muijtjens AM, Rethans JJ. Assessing simulated patients in an educational setting: the MaSP (Maastricht Assessment of Simulated Patients). Med Educ 2004, 38(1):39-44. Bouter S, van Weel-Baumgarten E, Bolhuis S. Construction and validation of the Nijmegen Evaluation of the Simulated Patient (NESP): Assessing Simulated Patients' ability to role-play and provide feedback to students. Acad Med: Journal of the Association of American Medical Colleges 2012. May W, Fisher D, Souder D: Development of an instrument to measure the quality of standardized/simulated patient verbal feedback. Med Educ 2012, 2(1).

Pollen record in the area of Niederrheinische Bucht, Germany

Die Niederrheinische Bucht, ein altes tektonisches Senkungsgebiet, dessen Ausdehnung durch die Orte Aachen, Bonn, Duüsseldorf und Duisburg bestimmt ist, bildete während des jüngeren Tertiärs eine Meeresbucht am Südrande des Nordseebeckens. Noch zu Beginn des Pleistocäns erstreckte sich die Nordsee bis in den Raum von Nijmegen, und im Pliocän verlief die Kuüste etwa auf der Linie Maastricht-Kleve. Im Mittelmiocän reichte die Nordsee bis in die nördliche Niederrheinische Bucht. Marines Oberoligocän mit reicher Fauna findet sich noch in der Gegend von Köln. In Verbindung mit den marinen Transgressionen kam es in den inneren Teilen der Niederrheinischen Bucht zu mehr oder weniger ausgedehnten Vermoorungen, die zur Bildung von Braunkohlenflözen führten, unter denen das miocäne Hauptbraunkohlenflöz nordwestlich von Köln eine Mächtigkeit von mehr als 90 m erreicht. Nach NW spaltet sich das Hauptflöz in drei Teilflöze auf, die von oben nach unten als Flöz Garzweiler, Flöz Frimmersdorf und Flöz Morken bezeichnet werden. Diese Flöze können, wie neue Untersuchungen ergaben, eindeutig mit dem marinen Mittelmiocän in Verbindung gebracht werden.

Multi-component assessment of chronic obstructive pulmonary disease : an evaluation of the ADO and DOSE indices and the global obstructive lung disease categories in international primary care data sets

Funding The International Primary Care Respiratory Group (IPCRG) provided funding for this research project as an UNLOCK group study for which the funding was obtained through an unrestricted grant by Novartis AG, Basel, Switzerland. The latter funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. Database access for the OPCRD was provided by the Respiratory Effectiveness Group (REG) and Research in Real Life; the OPCRD statistical analysis was funded by REG. The Bocholtz Study was funded by PICASSO for COPD, an initiative of Boehringer Ingelheim, Pfizer and the Caphri Research Institute, Maastricht University, The Netherlands.

The European Citizens‘ Initiative – Chances, Constraints and Limits. IHS Political Science Series No. 134, April 2013

In order to celebrate the 20th anniversary of the establishment of European Union citizenship under the Maastricht Treaty in 1993, the year 2013 has been designated by the European Commission as the ‘European Year of Citizens’. The European Citizen’s Initiative (ECI) – labelled by the Commission as a ‘direct gateway through which citizens can make their voices heard in Brussels’ - may emerge in the European awareness as a new appealing platform for policy-shaping and communication. The ECI, through its transnational vox civilis character, figures among the most important novelties in the Lisbon Treaty and in the long run may facilitate and accelerate the bottom-up building of a European demos. The question is, however, whether the mechanism of pan-European signature collection is strong enough to face the democratic challenges present in the EU, especially during the ongoing financial crisis.

EU immigration trends and policies: Spain and France as case studies. Jean Monnet/Robert Schuman Paper Series Vol. 13 No. 10, August 2013

From the Introduction. The Treaty on European Union, also known as the Treaty of Maastricht or the Maastricht Treaty, created the European Union (EU) from the existing European Economic Community (EEC.) It was signed by the member states on February 7, 1992, and entered into force on November 1, 1993.1 Among its many innovations was the creation of European citizenship, which would be granted to any person who was a citizen of an EU member state. Citizenship, however, is intertwined with immigration, which the Treaty also attempted to address. Policy on visas, immigration and asylum was originally placed under Pillar 3 of the EU, which dealt with Justice and Home Affairs. In 1997, however, the Amsterdam Treaty moved these policies from Pillar 3 to Pillar 1, signaling “a shift toward more supranational decision-making in this area,” as opposed to the intergovernmental method of Pillars 2 and 3.2

EU citizenship: Citizenship and identity beyond national borders. EU Centre Singapore Background Brief No. 10, October 2013

The 1992 Maastricht Treaty introduced the concept of European Union citizenship. All citizens of the 28 EU member states are also EU citizens through the very fact that their countries are members of the EU. Acquired EU citizenship gives them the right to free movement, settlement and employment across the EU, the right to vote in European elections, and also on paper the right to consular protection from other EU states' embassies when abroad. The concept of citizenship in Europe – and indeed anywhere in the world – has been evolving over the years, and continues to evolve. Against this time scale, the concept of modern citizenship as attached to the nation-state would seem ephemeral. The idea of EU citizenship therefore does not need to be regarded as a revolutionary phenomenon that is bound to mitigate against the natural inclination of European citizens towards national identities, especially in times of economic and financial crises. In fact, the idea of EU citizenship has even been criticised by some scholars as being of little substantive value in addition to whatever rights and freedoms European citizens already have. Nonetheless the ‘constitutional moment’ that the Maastricht Treaty achieved for the idea of EU citizenship has served more than just symbolic value – the EU’s Charter of Fundamental Rights is now legally binding, for instance. The idea of EU citizenship also put pressure on the Union and its leaders to address the perceived democratic deficit that the EU is often accused of. In attempts to cement the political rights of EU citizens, the citizens’ initiative was included in Lisbon Treaty allowing citizens to directly lobby the European Commission for new policy initiatives or changes.

Estonia in the eurozone - a strategic success. OSW Commentary No. 53, 2011-06-20

The adoption of the euro in January 2011 topped off Estonia’s integration policy. In the opinion of Estonian politicians, this country has never been so secure and stable in its history. Tallinn sees the introduction of the euro primarily in the political context as an entrenchment of the Estonian presence in Europe. The process of establishing increasingly close relations with Western European countries, which the country has consistently implemented since it restored independence in 1991, has been aimed at severing itself its Soviet past and at a gradual reduction of the gap existing between Estonia and the best-developed European economies. The Estonian government also prioritises the enhancement of co-operation as part of the EU and NATO as well as its principled fulfilment of the country’s undertakings. It sees these as important elements for building the country’s international prestige. The meeting of the Maastricht criteria at the time of an economic slump and the adoption of the euro during the eurozone crisis proved the determination and efficiency of the government in Tallinn. Its success has been based on strong support from the Estonian public for the pro-European (integrationist) policy of Estonia: according to public opinion polls, approximately 80% of the country’s residents declare their satisfaction with EU membership, while support for the euro ranges between 50% and 60%. Since Estonia joined the OECD in 2010 and adopted the euro at the beginning of 2011, it has become the leader of integration processes among the Baltic states. The introduction of the euro has reinforced Estonia’s international image and made it more attractive to foreign investors. The positive example of this country may be used as a strong argument by the governments in Lithuania and Latvia when they take action to meet the Maastricht criteria. Vilnius and Riga claim they want to adopt the euro in 2014. The improving economic situation in the Baltic states will contribute to the achievement of this goal, while an excessively high inflation rate, as in 2007, may be the main impediment1.

EU Democratic Legitimacy and National Parliaments. CEPS Essay No. 7, 25 November 2013

The role of national parliaments in the EU has been at the centre of a long debate. Since the Maastricht treaty, new powers to the EU level have been accompanied not only by an increasing role of the European Parliament (EP) in the legislative process, but also by a number of declarations and protocols to ensure that national parliaments received the information and documents required to effectively monitor their governments in EU affairs. The Lisbon Treaty extended the guarantees and also included new modes of direct participation. The proper use of the mechanisms in place, namely, the subsidiarity checks, the political dialogue with the Commission and the inter-parliamentary cooperation with the European Parliament, has become of vital importance in view of recent developments in EU economic policy and beyond. The choice for increasing inter-governmentalism in decision-making and the centralisation of the implementing and supervisory powers in the Commission and the Central Bank have raised questions about political accountability and the appropriate involvement of parliaments. However, the extent to which national parliaments should be more involved is also rather controversial. This essay examines the difficulty of defining and addressing the question of the democratic legitimacy in the EU. It examines the role of the national parliaments in the treaties and explores ways in which they can contribute to improving that legitimacy.