Gamma distribution function to understand anaerobic digestion kinetics: Kinetic constants are not constant

The Gamma model is a novel approach to characterise the complex degradation dynamics taking place during anaerobic digestion. This three parameters model results from combining the first-order kinetic model and the Gamma distribution function. In contrast to conventional models, where the kinetic constant is considered invariant, the Gamma model allows analysing the variability of the kinetic constant using a probability density function. The kinetic constant of mono-digestion and co-digestion batch tests of different wastes were modelled using the Gamma model and two common first-order models: one-step one-fraction model and one-step two-fraction model. The Gamma distribution function approximates three distinct probability density functions, i.e. exponential, log-normal, and delta Dirac. Specifically, (i) cattle paunch and pig manure approximated a log-normal distribution; (ii) cattle manure and microalgae approximated an exponential distribution, and (iii) primary sludge and cellulose approximated a delta Dirac distribution. The Gamma model was able to characterise two distinct waste activated sludge, one approximated to a log-normal distribution and the other to an exponential distribution. The same cellulose was tested with two different inocula; in both tests, the Gamma distribution function approximated a delta Dirac function but with a different kinetic value. The potential and consistency of Gamma model were also evident when analysing pig manure and microalgae co-digestion batch tests since (i) the mean k of the co-digestion tests were within the values of the mono-digestion tests, and (ii) the profile of the density function transitioned from log-normal to exponential distribution as the percentage of microalgae in the mixture increased.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines

BACKGROUND

Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines.

OBJECTIVE

To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine.

METHODS

The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and  recommendations were provided.

RESULTS

In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections.

LIMITATIONS

The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain.

CONCLUSIONS

These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.

Digital and innovation skills in health care professionals in Europe

Background

Rising life expectancy and ageing population are current phenomena that European society is facing and these are challenges for the European healthcare systems. To face them, several e-health solutions are already designed to optimize resources of the healthcare provider system. However, most of them are not being implemented or deployed. Some of the reasons are the lack of digital skills and innovation readiness in staff, and existing barriers to changing organizational practices.

Objectives

The DISH project (601008-EPP-1-2018-1-DK-EPPKA2-SSA) will develop 3 concepts to improve the digitalization of healthcare staff to help them in the use of e-health solutions already developed: 1)Learning Innovation Units, where healthcare staff, SMEs and educational institutions work together for improving the e-health solutions development and implementation; 2)On the job training, where healthcare staff will be trained in e-health and digital competences; 3)Assessment, where competences accomplished by healthcare staff will be recognized. All these concepts will be tested in 6 EU countries.

Results

The development of the 3 concepts is based on a needs analysis on present and future competences required to support the implementation of e-health solutions in Denmark, Norway, UK, Germany, Spain and Poland. Also, each country will test the 3 concepts and train 100 healthcare staff in the use of an e-solution/innovation already developed but not being fully implemented. An evaluation of the achieved skills/competences by the staff will be also conducted.

Conclusions

Healthcare workers and SMEs show willingness and motivation in contributing to the digitalization but there is a clear lack of digital skills (although this is different from country to country) to make easier the adoption in daily practice of such solutions. The project looks for promoting close collaboration between the interested parties to work together in overcoming the stated deficiency.

Key messages

The DISH concepts will facilitate a training framework for healthcare professionals in the use of digital solutions. The DISH project will promote the use of several innovations already available in the market.

Effect of a Suicide Prevention Centre for young people with suicidal behaviour in Copenhagen

Background

In the 1980s, suicide rates in Denmark were among the highest in the world. In 1992, a Suicide Prevention Centre was opened in Copenhagen with a 2-week programme of social and psychological treatment. The aim of the study was to evaluate the effect of the Suicide Prevention Centre.

Methods

In a quasi-experimental study, 362 patients in the Suicide Prevention Centre and a parallel comparison group of 39 patients were interviewed with European Parasuicide Study Interviewer Schedule I (EPSIS I), which is a comprehensive interview including several validated scales. All patients were invited to follow-up interviews with EPSIS II and followed in the National Patients Register and the Cause of Death Register.

Results

At the 1-year follow-up, 59% of patients in the intervention group and 53% of patients in the comparison groups were interviewed with EPSIS II. The intervention group obtained a significantly greater improvement in Beck’s Depression Inventory, Hopelessness Scale, Rosenberg’s Self-Esteem Scale and CAGE-score and a significantly lower repetition rate.

Discussions

Although the design cannot exclude selection bias, it seems likely that the improvement in the intervention group was facilitated by the treatment.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

The Reference Site Collaborative Network of the European Innovation Partnership on Active and Healthy Ageing

Seventy four Reference Sites of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) have been recognised by the European Commission in 2016 for their commitment to excellence in investing and scaling up innovative solutions for active and healthy ageing. The Reference Site Collaborative Network (RSCN) brings together the EIP on AHA Reference Sites awarded by the European Commission, and Candidate Reference Sites into a single forum. The overarching goals are to promote cooperation, share and transfer good practice and solutions in the development and scaling up of health and care strategies, policies and service delivery models, while at the same time supporting the action groups in their work. The RSCN aspires to be recognized by the EU Commission as the principal forum and authority representing all EIP on AHA Reference Sites. The RSCN will contribute to achieve the goals of the EIP on AHA by improving health and care outcomes for citizens across Europe, and the development of sustainable economic growth and the creation of jobs.

Development of anti-CD30 radioimmunoconstructs (RICs) for treatment of Hodgkin's lymphoma

Objectives: Comparison of the binding affinity to a CD30-positive Hodgkin lymphoma (HL) cell line and biodistribution in HL bearing mice of new anti-CD30 radioimmunoconjugates (RICs) of varying structure and labelling nuclides. Methods: The antibodies Ki-4 and 5F11 were radioiodinated by the chloramine T method or labelled with 111In via p-NCSBenzyl- DOTA. In addition, the Ki-4-dimer was investigated in the iodinated form. The RICs were analyzed for retained immunoreactivity by immunochromatography. In-vitro binding studies were performed on CD30-positive L540 cell lines. For in-vivo biodistribution studies, SCID mice bearing human HL xenografts were injected with the various radioimmunoconjugates. After 24 h, activities in the organs and tumour were measured for all 5 RICs. Tumour-free animals were studied in the same way with 131I- Ki-4 24 h p. i. The three RICs with the highest tumour/background ratios 24 h p.i. (131I-Ki-4, 131I–5F11, 111In-bz- DOTA-Ki-4) were analysed further at 48 h and 72 h. Results: All the RICs were successfully labelled with high specific activities (28–47 TBq/ mmol) and sufficient radiochemical yields (> 80%). Scatchard plot analysis proved high tumour affinity (KD = 20–220 nmol/l). In-vivo tumour accumulation in % of injected dose per g tissue (%ID/g) lay between 2.6 (131I-5F11) and 12.3 % ID/g (131I-Ki-4) with permanently high background in blood. Tumour/blood-ratios of all RICs were below one at all time points. Conclusions: In-vitro tumour cell affinities of all RICs were promising. However, in-vivo biokinetics tested in the mouse model did not meet expectations. This highlights the importance of developing and testing further new anti-CD30 conjugates.

Are hybrids between Atlantic salmon and brown trout suitable long-term hosts of Gyrodactylus salaris during winter?

The monogenean parasite Gyrodactylus salaris poses serious threats to many Atlantic salmon populations and presents many conservation and management questions/foci and challenges. It is therefore critical to identify potential vectors for infection. To test whether hybrids of native Atlantic salmon (Salmo salar) × brown trout (Salmo trutta) are suitable as reservoir hosts for G. salaris during winter, infected hybrid parr were released into a natural subarctic brook in the autumn. Six months later, 23.9% of the pit-tagged fish were recaptured. During the experimental period, the hybrids had a sixfold increase in mean intensity of G. salaris, while the prevalence decreased from 81% to 35%. There was high interindividual hybrid variability in susceptibility to infections. The maximum infrapopulation growth rate (0.018 day^-1 ) of G. salaris throughout the winter was comparable to earlier laboratory experiments at similar temperatures. The results confirm that infrapopulations of G. salaris may reproduce on a hybrid population for several generations at low water temperatures (~1 °C). Wild salmon-trout hybrids are undoubtedly susceptible to G. salaris and represent an important reservoir host for the parasite independent of other co-occurring susceptible hosts. Consequently, these hybrids may pose a serious risk for G. salaris transmission to nearby, uninfected rivers by migratory individuals.

Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines

BACKGROUND

Opioid use, abuse, and adverse consequences, including death, have escalated at an alarming rate since the 1990s. In an attempt to control opioid abuse, numerous regulations and guidelines for responsible opioid prescribing have been developed by various organizations. However, the US opioid epidemic is continuing and drug dose deaths tripled during 1999 to 2015. Recent data show a continuing increase in deaths due to natural and semisynthetic opioids, a decline in methadone deaths, and an explosive increase in the rates of deaths involving other opioids, specifically heroin and illicit synthetic fentanyl. Contrary to scientific evidence of efficacy and negative recommendations, a significant proportion of physicians and patients (92%) believe that opioids reduce pain and a smaller proportion (57%) report better quality of life. In preparation of the current guidelines, we have focused on the means to reduce the abuse and diversion of opioids without jeopardizing access for those patients suffering from non-cancer pain who have an appropriate medical indication for opioid use.

OBJECTIVES

To provide guidance for the prescription of opioids for the management of chronic non-cancer pain, to develop a consistent philosophy among the many diverse groups with an interest in opioid use as to how appropriately prescribe opioids, to improve the treatment of chronic non-cancer pain and to reduce the likelihood of drug abuse and diversion. These guidelines are intended to provide a systematic and standardized approach to this complex and difficult arena of practice, while recognizing that every clinical situation is unique.

METHODS

The methodology utilized included the development of objectives and key questions. The methodology also utilized trustworthy standards, appropriate disclosures of conflicts of interest, as well as a panel of experts from various specialties and groups. The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed, with a best evidence synthesis of the available literature, and utilized grading for recommendation as described by the Agency for Healthcare Research and Quality (AHRQ).Summary of Recommendations:i. Initial Steps of Opioid Therapy 1. Comprehensive assessment and documentation. (Evidence: Level I; Strength of Recommendation: Strong) 2. Screening for opioid abuse to identify opioid abusers. (Evidence: Level II-III; Strength of Recommendation: Moderate) 3. Utilization of prescription drug monitoring programs (PDMPs). (Evidence: Level I-II; Strength of Recommendation: Moderate to strong) 4. Utilization of urine drug testing (UDT). (Evidence: Level II; Strength of Recommendation: Moderate) 5. Establish appropriate physical diagnosis and psychological diagnosis if available. (Evidence: Level I; Strength of Recommendation: Strong) 6. Consider appropriate imaging, physical diagnosis, and psychological status to collaborate with subjective complaints. (Evidence: Level III; Strength of Recommendation: Moderate) 7. Establish medical necessity based on average moderate to severe (≥ 4 on a scale of 0 - 10) pain and/or disability. (Evidence: Level II; Strength of Recommendation: Moderate) 8. Stratify patients based on risk. (Evidence: Level I-II; Strength of Recommendation: Moderate) 9. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: Level I-II; Strength of Recommendation: Moderate) 10. Obtain a robust opioid agreement, which is followed by all parties. (Evidence: Level III; Strength of Recommendation: Moderate)ii. Assessment of Effectiveness of Long-Term Opioid Therapy 11. Initiate opioid therapy with low dose, short-acting drugs, with appropriate monitoring. (Evidence: Level II; Strength of Recommendation: Moderate) 12. Consider up to 40 morphine milligram equivalent (MME) as low dose, 41 to 90 MME as a moderate dose, and greater than 91 MME as high dose. (Evidence: Level II; Strength of Recommendation: Moderate) 13. Avoid long-acting opioids for the initiation of opioid therapy. (Evidence: Level I; Strength of Recommendation: Strong) 14. Recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses, within FDA recommended doses. (Evidence: Level I; Strength of Recommendation: Strong) 15. Understand and educate the patients of the effectiveness and adverse consequences. (Evidence: Level I; Strength of Recommendation: Strong) 16. Similar effectiveness for long-acting and short-acting opioids with increased adverse consequences of long-acting opioids. (Evidence: Level I-II; Strength of recommendation: Moderate to strong) 17. Periodically assess pain relief and/or functional status improvement of ≥ 30% without adverse consequences. (Evidence: Level II; Strength of recommendation: Moderate) 18. Recommend long-acting or high dose opioids only in specific circumstances with severe intractable pain. (Evidence: Level I; Strength of Recommendation: Strong)iii. Monitoring for Adherence and Side Effects 19. Monitor for adherence, abuse, and noncompliance by UDT and PDMPs. (Evidence: Level I-II; Strength of Recommendation: Moderate to strong) 20. Monitor patients on methadone with an electrocardiogram periodically. (Evidence: Level I; Strength of Recommendation: Strong). 21. Monitor for side effects including constipation and manage them appropriately, including discontinuation of opioids when indicated. (Evidence: Level I; Strength of Recommendation: Strong)iv. Final Phase 22. May continue with monitoring with continued medical necessity, with appropriate outcomes. (Evidence: Level I-II; Strength of Recommendation: Moderate) 23. Discontinue opioid therapy for lack of response, adverse consequences, and abuse with rehabilitation. (Evidence: Level III; Strength of Recommendation: Moderate) CONCLUSIONS: These guidelines were developed based on comprehensive review of the literature, consensus among the panelists, in consonance with patient preferences, shared decision-making, and practice patterns with limited evidence, based on randomized controlled trials (RCTs) to improve pain and function in chronic non-cancer pain on a long-term basis. Consequently, chronic opioid therapy should be provided only to patients with proven medical necessity and stability with improvement in pain and function, independently or in conjunction with other modalities of treatments in low doses with appropriate adherence monitoring and understanding of adverse events.Key words: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversionDisclaimer: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."

Regional variations of perceived problems in ambulatory care from the perspective of general practitioners and their patients - an exploratory focus group study in urban and rural regions of northern Germany

BACKGROUND

Patients from rural and urban regions should have equitable access to health care. In Germany, the physician-patient-ratio and the supply of medical services vary greatly between urban and rural areas. The aim of our study was to explore the regional variations of the perceived health care problems in ambulatory care from the perspective of affected professionals and laypersons i.e. general practitioners and their patients.

METHODS

We conducted 27 focus groups with general practitioners (n = 65) and patients (n = 145) from urban areas, environs and rural areas in northern Germany. Discussions were facilitated by two researchers using a semi-structured guideline. The transcripts were content analyzed using deductive and inductive categories.

RESULTS

General practitioners and patients reported problems due to demographic change and patient behaviour, through structural inequalities and the ambulatory reimbursement system as well as with specialist care and inpatient care. A high physician density, associated with high competition between general practitioners, a high fluctuation of patients and a low status of general practitioners were the main problems reported in urban areas. In contrast, participants from rural areas reported an insufficient physician density, a lack of young recruits in primary care and a resulting increased workload as problematic. All regions are concerned with subjectively inadequate general practitioners' budgets, insufficiently compensated consultations and problems in the cooperation with specialists and inpatient care institutions. Most problems were mentioned by GPs and patients alike, but some (e.g. high competition rates in urban regions and problems with inpatient care) were only mentioned by GPs.

CONCLUSIONS

While many problems arise in urban regions as well as in rural regions, our results support the notion that there is an urgent need for action in rural areas. Possible measures include the support of telemedicine, delegation of medical services and reoccupation of vacant practices. The attractiveness of working in rural areas for general practitioners, specialists and clinicians must be increased by consolidating and expanding rural infrastructure (e.g. child care and cultural life). The above mentioned results also indicate that the ambulatory reimbursement system should be examined regarding the reported inequalities. Measures to further enhance the cooperation between general practitioners, specialists and inpatient care should be taken to solve supra-regionally reported problems. Problems showing regional variations indicate the need for measures to balance these variations between the regions. This is the first German study to analyze subjective views of the stakeholders concerned on regionally variating problems in ambulatory care. Further studies are needed to quantify the extent of the identified problems and differences. A corresponding survey is currently under way.

Truth or Consequences

What follows is a collectively improvised story that emerged as four authors set out to explore their experiences and thoughts concerning organizational stories. The story is a reflection of their collective, creative, improvisational sense making via the construction of a narrative. The authors were selected because of their experience in the fields of organizational storytelling, narrative theory, and improvisation. They began by asking themselves “What would happen if we engaged in improvisation to collectively create a story that makes sense of organizational research?” After several rounds of reviews, they added reader voices, along with their own insights gained from their experience in constructing “Truth or Consequences.”

The Organizational Story as Leadership

Leaders are often noted for providing a compelling vision that inspires followers to act to fulfill the vision, often by telling stories. Here, we begin a separation of the notion of `leader as person' from the notion of leadership as the discourse that represents such a vision. We transcend the notion that leaders tell stories, to the proposition that stories themselves operate like leaders. We suggest that people follow the story as much as they follow the storyteller or author, hence the story becomes the leader. In discussing the characteristics that stories share with leadership, we generate two propositions. First, within the context of organizational development, leadership development can move from `people' development to the development of the narratives that resonate within organizations. Second, we decouple leader as person or position, from leadership as process in order to illustrate stories as leaders. We conclude with specific messages that individuals can take away.

Structural Competency in the U.S. Healthcare Crisis: Putting Social and Policy Interventions Into Clinical Practice

This symposium of the Journal of Bioethical Inquiry illustrates structural competency: how clinical practitioners can intervene on social and institutional determinants of health. It will require training clinicians to see and act on structural barriers to health, to adapt imaginative structural approaches from fields outside of medicine, and to collaborate with disciplines and institutions outside of medicine. Case studies of effective work on all of these levels are presented in this volume. The contributors exemplify structural competency from many angles, from the implications of epigenetics for environmental intervention in personalized medicine to the ways clinicians can act on fundamental causes of disease, address abuses of power in clinical training, racially desegregate cities to reduce health disparities, address the systemic causes of torture by police, and implement harm-reduction programs for addiction in the face of punitive drug laws. Together, these contributors demonstrate the unique roles that clinicians can play in breaking systemic barriers to health and the benefit to the U.S. healthcare system of adopting innovations from outside of the United States and outside of clinical medicine.

Co-infection of Nucleospora cyclopteri (Microsporidia) and Kudoa islandica (Myxozoa) in farmed lumpfish, Cyclopterus lumpus L., in Norway: a case report

This study describes a co-infection of Kudoa islandica (Myxozoa) and Nucleospora cyclopteri (Microsporida) in farmed lumpfish, Cyclopterus lumpus L., in Norway. Several other parasites (Cryptocotyle sp., protozoan ciliates and Gyrodactylus sp.) were also found in gills. In June 2013, the mortality in a farmed lumpfish population increased to 65%. Lumpfish showed erratic swimming behaviour and loss of weight. At necropsy, nodules in the kidney were the only visible lesions. Histologically, all fish showed severe changes with gill inflammation and necrosis in the spleen, kidney and liver. Haemorrhages and necrosis were observed in some hearts. Intracellular microsporidians associated with the lesions were detected in most organs using histological examination and Calcofluor White. Kudoa spores were diagnosed in the skeletal muscle, but no inflammatory response was associated with the presence of the plasmodia. Comparison of 18S ribosomal DNA sequences showed 100% similarity to Kudoa islandica and Nucleospora cyclopteri. Kudoa islandica and N. cyclopteri have previously been described associated with lesions in wild lumpfish in Iceland. In the present case, N. cyclopteri is believed to be the main cause of systemic pathology. This is the first description of K. islandica and N. cyclopteri causing pathology in farmed lumpfish in Norway.

This Is Going to Hurt

As compassion has become established in the organizational literature as an important area of study, calls for increased compassion in our own work and research have increased. Compassion can take many forms in academic work, but in this article we propose a framework for compassionate research methods. Not only driven by caring for others and a desire for improving their lot, compassionate research methods actually immerse the researcher in compassionate work. We propose that compassionate research methods include three important elements: ethnography, aesthetics, and emotionality. Together, these provide opportunities for emergent theoretical experimentation that can lead to both the alleviation of suffering in the immediate research context and new theoretical insights. To show the possibilities of this method, we use empirical data from a unique setting—the first U.S. permanent death penalty defense team.

[Morbidity differences according to nursing stage and nursing setting in long-term care patients: Results of a claims data based study]

BACKGROUND

We analyzed the differences in morbidity patterns of chronic diseases between long-term care dependent persons in nursing homes compared to those dwelling in the community. We also investigated morbidity differences between long-term care need stages in Germany.

MATERIALS AND METHODS

The study included claims data of one nationwide operating statutory health insurance in 2006. Inclusion criteria were age ≥ 65 years, minimum 1 out of 46 diagnoses in at least 3 quarters of the year (n = 8,670). A comparison population was formed with n = 114,962. Prevalences, relative risks, and odds ratios for the risk of nursing home care were calculated.

RESULTS

In the bivariate analysis, only three chronic diseases - dementia, urinary incontinence, and chronic heart failure - showed a higher risk for nursing home care. Regression analysis revealed that only dementia showed higher odds related to the stage of nursing needs.

CONCLUSION

Among the chronic diseases, only dementia shows a substantially elevated risk for nursing home care. Risk studies on other chronic diseases associated with higher risks of long-term care dependency and specific intervention strategies aiming at delaying or preventing nursing home admission should be developed.

Effect of light-emitting diode (LED) vs. fluorescent (FL) lighting on laying hens in aviary hen houses: Part 2 - Egg quality, shelf-life and lipid composition

In this 60-wk study, egg quality, egg shelf-life, egg cholesterol content, total yolk lipids, and yolk fatty acid composition of eggs produced by Dekalb white laying hens in commercial aviary houses with either light-emitting diode (LED) or fluorescent (FL) lighting were compared. All parameters were measured at 27, 40, and 60 wk of age, except for egg shelf-life, which was compared at 50 wk of age. The results showed that, compared to the FL regimen, the LED regimen resulted in higher egg weight, albumen height, and albumen weight at 27 wk of age, thicker shells at 40 wk of age, but lower egg weight at 60 wk of age. Egg quality change was similar between the lighting regimens during the 62-d egg storage study, indicating that LED lighting did not influence egg shelf-life. Eggs from both lighting regimens had similar cholesterol content. However, cholesterol concentration of the yolk (15.9 to 21.0 mg cholesterol/g wet weight yolk) observed in this study was higher than that of United States Department of Agriculture (USDA) database (10.85 mg/g). No significant differences in total lipids or fatty acid composition of the yolks were detected between the two lighting regimens.

Institutional judo: how entrepreneurs use institutional forces to create change

Purpose

– The purpose of this paper is to examine an entrepreneur’s attempt to gain legitimacy and change institutions in a multiple institutions setting.

Design/methodology/approach

– The authors conducted a qualitative case study to track an entrepreneur’s efforts to create a new financial instrument and get it accepted and traded on the New York Stock Exchange.

Findings

– The authors introduce the concept of institutional judo, analogous to the martial art where a fighter uses his opponent’s forces against him. While institutional theory has focussed on how institutional pressures force actors to conform, the term judo refers to an actor using institutional pressures to their advantage in changing those very institutions.

Research limitations/implications

– This qualitative research involves a single case study, but is most suited to revealing extensions of theory and subtle processes.

Practical implications

– The approach allowed the authors to provide a nuanced look at the actual change efforts by an entrepreneur to gain legitimacy.

Social implications

– This study provides a nuanced look at actual attempts to change institutions.

Originality/value

– Institutional judo offers a new change mechanism within institutional theory.

[Use and potential risks of over-the-counter analgesics]

BACKGROUND AND AIM

We investigated the use of prescription and non-prescription (over-the-counter, OTC) analgesics and the associated risks in elderly patients with multiple morbidities.

METHODS

Pain medication use was evaluated from the baseline data (2008/2009) of the MultiCare cohort enrolling elderly patients with multiple morbidities who were treated by primary care physicians (trial registration: ISRCTN89818205). We considered opioids (N02A), other analgesics, and antipyretics (N02B) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; M01A). OTC use, duplicate prescription, dosages, and interactions were examined for acetylsalicylic acid, diclofenac, (dex)ibuprofen, naproxen, and acetaminophen.

RESULTS

Of 3,189 patients with multiple morbidities aged 65-85 years, 1,170 patients reported to have taken at least one prescription or non-prescription analgesic within the last 3 months (36.7 %). Of these, 289 patients (24.7 % of 1,170) took at least one OTC analgesic. Duplicate prescription was observed in 86 cases; 15 of these cases took the analgesics regularly. In two cases, the maximum daily dose of diclofenac was exceeded due to duplicate prescription. In 235 cases, patients concurrently took a drug with a potentially clinically relevant interaction. In 43 cases (18.3 % of 235) an OTC analgesic, usually ibuprofen, was involved.

DISCUSSION

About one third of the elderly patients took analgesics regularly or as needed. Despite the relatively high use of OTC analgesics, the proportions of duplicate prescription, medication overdoses, and adverse interactions due to OTC products was low.

Tocopherol and annatto tocotrienols distribution in laying-hen body

The impact of supplementing laying-hen feed with annatto tocotrienols (T3s) and alpha-tocopherol on the distribution of various forms of vitamin E and cholesterol throughout the hen's body was evaluated. A total of 18 organs or tissues (skin, fat pad, liver and gall bladder, heart, oviduct, forming yolk, laid yolk, lungs, spleen, kidney, pancreas, gizzard, digestive tract, brain, thigh, breast, manure, and blood) were collected after 7 wk of feeding on diets enriched with various levels of alpha-tocopherol and annatto extract that contained gamma-T3 and delta-T3. Tissue weights, contents of lipid, alpha-tocopherol, gamma-T3, delta-T3, cholesterol, and fatty acid composition of extracted lipids from the collected organs and tissues were determined. Tissue weight and lipid content did not change significantly with feed supplementation treatments, except that the liver became heavier with increased levels of supplementation. Overall, the main organs that accumulated the supplemented vitamin E were fat pad, liver and gall bladder, oviduct, forming yolks, laid yolks, kidney, brain, thigh, and breast. Much of annatto gamma-T3 and delta-T3 (> 90%) was found in the manure, indicating poor uptake. In some tissues (brain and oviduct,) a significant increase in polyunsaturated fatty acids was seen with increased supplementation. Alpha-tocopherol impacted the transfer of gamma-T3 to forming and laid yolks, but did not impact delta-T3 transfer. No significant differences were found in most of the tissues in cholesterol, except a reduction in heart, based on tissue as-is. Blood samples showed large variations in individual hens with no significant differences in total and HDL cholesterol, or total triacylglycerols. Supplementing feed with annatto T3s and alpha-tocopherol showed that the vitamin E profile and distribution of the laying-hen body can be altered, but to different extents depending on tissue. The result of this research has significance in enhancing meat nutrient content.

High-Throughput Assay Development for Cystine-Glutamate Antiporter (xc-) Highlights Faster Cystine Uptake than Glutamate Release in Glioma Cells

The cystine-glutamate antiporter (system x_c^-) is a Na⁺-independent amino acid transporter that exchanges extracellular cystine for intracellular glutamate. It is thought to play a critical role in cellular redox processes through regulation of intracellular glutathione synthesis via cystine uptake. In gliomas, system x_c^- expression is universally up-regulated while that of glutamate transporters down-regulated, leading to a progressive accumulation of extracellular glutamate and excitotoxic cell death of the surrounding non-tumorous tissue. Additionally, up-regulation of system x_c^- in activated microglia has been implicated in the pathogenesis of several neurodegenerative disorders mediated by excess glutamate. Consequently, system x_c^- is a new drug target for brain cancer and neuroinflammatory diseases associated with excess extracellular glutamate. Unfortunately no potent and selective small molecule system x_c^- inhibitors exist and to our knowledge, no high throughput screening (HTS) assay has been developed to identify new scaffolds for inhibitor design. To develop such an assay, various neuronal and non-neuronal human cells were evaluated as sources of system x_c^-. Human glioma cells were chosen based on their high system x_c^- activity. Using these cells, [¹⁴C]-cystine uptake and cystine-induced glutamate release assays were characterized and optimized with respect to cystine and protein concentrations and time of incubation. A pilot screen of the LOPAC/NINDS libraries using glutamate release demonstrated that the logistics of the assay were in place but unfortunately, did not yield meaningful pharmacophores. A larger, HTS campaign using the 384-well cystine-induced glutamate release as primary assay and the 96-well ¹⁴C-cystine uptake as confirmatory assay is currently underway. Unexpectedly, we observed that the rate of cystine uptake was significantly faster than the rate of glutamate release in human glioma cells. This was in contrast to the same rates of cystine uptake and glutamate release previously reported in normal human fibroblast cells.

Presence of Anisakis simplex (Rudolphi, 1809 det. Krabbe, 1878) and Hysterothylacium aduncum (Rudolphi, 1802) (Nematoda; Anisakidae) in runts of farmed Atlantic salmon, Salmo salar L

One hundred farmed Atlantic salmon, Salmo salar L., were examined for the presence of nematodes by digestion of tissue in HCl-pepsin solution. All fish were sampled from one cage in a fish farm on the Norwegian south-west coast. Fifty harvest quality salmon, that is, salmon for human consumption (mean 5.4 kg, variation 3.0-7.6 kg), were sampled at the processing line while 50 salmon runts (mean 1.1 kg, variation 0.4-1.8 kg), discarded due to poor performance, were sampled from the discard bin after the grading station. Runts are individual fish with clear signs of poor performance over time and abnormal appearance and are thus not processed for human consumption. No nematodes were found in the musculature or viscera of the 50 harvest quality salmon. In total, 75 nematodes were found in 10 (20%) of the runts; 53 nematodes in the viscera and 22 in the musculature. Nematodes in the musculature were identified as Anisakis simplex (Rudolphi, 1809 det. Krabbe, 1878), while nematodes in the viscera were identified as A. simplex and Hysterothylacium aduncum (Rudolphi, 1802).