Non-traumatic Arm, Neck, and Shoulder Complaints in General Practice: Incidence, Course and Management

Non-traumatic complaints of arm, neck, and shoulder are common and can result in functional limitations in daily life and may sometimes lead to sickness absence. Reported symptoms are e.g. pain, tingling, stiffness, numbness, loss of hand coordination. When seeking medical care for these complaints, the general practitioner (GP) is usually the first person to consult. This thesis studies patients who consult their GP with a new non-traumatic complaint of arm, neck or shoulder, with a focus on incidence, course and management. The incidence study showed that a fulltime GP is consulted about 3 times every week for a new non-traumatic complaint of arm, neck, or shoulder, most frequently located at neck or shoulder. Six months after the first consultation with their GP, 46% of the patients in the cohort study reported no recovery. Next to several complaint specific variables, the psychosocial variables little social support and high score on somatization were predicitve of non-recovery at 6 months. Management upto 6 months after the first consultation most frequently consisted of prescribed analgesics and referral for physiotherapy. Specific and non-specific diagnostic subgroups differed in the frequency that corticosteroid injections were applied, and referrals to physiotherapy and to a medical specialist. In addition variables associated with five common management options within a few weeks after the first consultation were evaluated. Overall, besides diagnosis, most frequently long duration of complaints, more functional limitations but also several GP characteristics were associated with the application of a treatment option in non-traumatic arm, neck and shoulder complaints

Incident venous thromboembolic events in the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER)

<p>Background: Venous thromboembolic events (VTE), including deep venous thrombosis and pulmonary embolism, are common in older age. It has been suggested that statins might reduce the risk of VTE however positive results from studies of middle aged subjects may not be generalisable to elderly people. We aimed to determine the effect of pravastatin on incident VTE in older people; we also studied the impact of clinical and plasma risk variables.</p> <p>Methods: This study was an analysis of incident VTE using data from the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER), a randomized, double-blind, placebo-controlled trial of pravastatin in men and women aged 70-82. Mean follow-up was 3.2 years. Risk for VTE was examined in non-warfarin treated pravastatin (n = 2834) and placebo (n = 2865) patients using a Cox's proportional hazard model, and the impact of other risk factors assessed in a multivariate forward stepwise regression analysis. Baseline clinical characteristics, blood biochemistry and hematology variables, plasma levels of lipids and lipoproteins, and plasma markers of inflammation and adiposity were compared. Plasma markers of thrombosis and hemostasis were assessed in a nested case (n = 48) control (n = 93) study where the cohort was those participants, not on warfarin, for whom data were available.</p> <p>Results: There were 28 definite cases (1.0%) of incident VTE in the pravastatin group recipients and 20 cases (0.70%) in placebo recipients. Pravastatin did not reduce VTE in PROSPER compared to placebo [unadjusted hazard ratio (95% confidence interval) 1.42 (0.80, 2.52) p = 0.23]. Higher body mass index (BMI) [1.09 (1.02, 1.15) p = 0.0075], country [Scotland vs Netherlands 4.26 (1.00, 18.21) p = 0.050 and Ireland vs Netherlands 6.16 (1.46, 26.00) p = 0.013], lower systolic blood pressure [1.35 (1.03, 1.75) p = 0.027] and lower baseline Mini Mental State Examination (MMSE) score [1.19 (1.01, 1.41) p = 0.034] were associated with an increased risk of VTE, however only BMI, country and systolic blood pressure remained significant on multivariate analysis. In a nested case control study of definite VTE, plasma Factor VIII levels were associated with VTE [1.52 (1.01, 2.28), p = 0.044]. However no other measure of thrombosis and haemostasis was associated with increased risk of VTE.</p> <p>Conclusions: Pravastatin does not prevent VTE in elderly people at risk of vascular disease. Blood markers of haemostasis and inflammation are not strongly predictive of VTE in older age however BMI, country and lower systolic blood pressure are independently associated with VTE risk.</p&gt

The influence of placements on adult nursing graduates’ choice of first post

Background: This article presents findings from a study that sought to explore the extent to which clinical placements have an impact on nursing students’ decisions regarding their first staff nurse post. Within the UK, nursing is facing a recruitment crisis with particular difficulty recruiting to areas such as primary and elderly care. Transitioning into a new role is challenging in any occupation, but it is a particular problem in nursing where the realities of professional practice often differ from students’ perception of the staff nurse role as shaped by their clinical placements. Aim: This pilot study aimed to explore the influence of practice placements on final year adult nursing students’ career decisions. Method: Qualitative and quantitative data were collected in a single phase using a questionnaire distributed to nursing students on the final day of their course. A total of 35 completed questionnaires were returned (response rate 57%). Results: Half of the participants entered the course with preconceived preferences for clinical specialisms. However, only five participants (14%) applied for first destination posts in that specialism. The overall importance of placements in career choice increased across the three years of the programme. Although placements in all three years are important, the experiences in year 3 are pivotal, with 74% rankingthese as ‘significantly influential’ in their decision-making process. Analysis of the data obtained from the free-text responses from the questionnaire suggested that working environment; the level of support provided by mentors and clinical staff; the opportunity to make a difference to patients’ lives and the variety of placements, were key influences on nursing students’ decision regarding their first staff nurse post. Conclusions: This study highlights the key role of practice placements in the career choices of student nurses, particularly during the final year of their programme. It shows that students are likely to apply for posts in the placement area they found to be most supportive and developmental

Congruence of additive and non-additive effects on gene expression estimated from pedigree and SNP data

There is increasing evidence that heritable variation in gene expression underlies genetic variation in susceptibility to disease. Therefore, a comprehensive understanding of the similarity between relatives for transcript variation is warranted-in particular, dissection of phenotypic variation into additive and non-additive genetic factors and shared environmental effects. We conducted a gene expression study in blood samples of 862 individuals from 312 nuclear families containing MZ or DZ twin pairs using both pedigree and genotype information. From a pedigree analysis we show that the vast majority of genetic variation across 17,994 probes is additive, although non-additive genetic variation is identified for 960 transcripts. For 180 of the 960 transcripts with non-additive genetic variation, we identify expression quantitative trait loci (eQTL) with dominance effects in a sample of 339 unrelated individuals and replicate 31% of these associations in an independent sample of 139 unrelated individuals. Over-dominance was detected and replicated for a trans association between rs12313805 and ETV6, located 4MB apart on chromosome 12. Surprisingly, only 17 probes exhibit significant levels of common environmental effects, suggesting that environmental and lifestyle factors common to a family do not affect expression variation for most transcripts, at least those measured in blood. Consistent with the genetic architecture of common diseases, gene expression is predominantly additive, but a minority of transcripts display non-additive effects

White British researchers and internationally educated research participants: insights from reflective practices on issues of language and culture in nursing contexts

This paper explores how reflexive practices enabled researchers to achieve a more complex analysis of qualitative data generated from focus groups. Drawing upon our experiences as two White British researchers, conducting a study with internationally educated nurses from Black, Asian and Minority Ethnic backgrounds, we consider how our analysis led us to a more nuanced understanding of the data than might have occurred without reflexivity. We identified our respective standpoints, confronted our feared biases, particularly in relation to social stereotyping and prejudice, and located ourselves as co-producers of the data. This enabled us to consider how we might be representing, holding and paralleling, systemic patterns of discrimination, leading to several new insights. Reflexive practice is often referred to in theory, less often in application. We hope that sharing our reflexive process will benefit other researchers navigating the complex waters of identifying themselves in their research

Sozialstaatliche Kürzungspolitik in Deutschland: Nur eine Mär? Eine quantitative Gesetzgebungsanalyse 1974–2014

Quantitative analyses on welfare state dynamics have to cope with the “dependent variable problem”, as studies on social spending reach different conclusions than analyses of replacement rate data. This article suggests a way around this problem by presenting results from a fine-grained analysis of welfare state legislation in Germany between 1974 and 2014. We show that the German welfare state has seen both cuts and expansions occur in all decades. Moreover, we show by means of a regression analysis that partisan politics play a role. Supporting the “Nixon-in-China”-thesis, social democratic governments are associated with a higher probability of cutbacks – especially in times of budgetary pressure – whereas expansions are more likely under Christian democratic governments

The role of horizontal resolution in simulating drivers of the global hydrological cycle

The role of atmospheric general circulation model (AGCM) horizontal resolution in representing the global energy budget and hydrological cycle is assessed, with the aim of improving the understanding of model uncertainties in simulating the hydrological cycle. We use two AGCMs from the UK Met Office Hadley Centre: HadGEM1-A at resolutions ranging from 270 to 60 km, and HadGEM3-A ranging from 135 to 25 km. The models exhibit a stable hydrological cycle, although too intense compared to reanalyses and observations. This over-intensity is explained by excess surface shortwave radiation, a common error in general circulation models (GCMs). This result is insensitive to resolution. However, as resolution is increased, precipitation decreases over the ocean and increases over the land. This is associated with an increase in atmospheric moisture transport from ocean to land, which changes the partitioning of moisture fluxes that contribute to precipitation over land from less local to more non-local moisture sources. The results start to converge at 60-km resolution, which underlines the excessive reliance of the mean hydrological cycle on physical parametrization (local unresolved processes) versus model dynamics (large-scale resolved processes) in coarser HadGEM1 and HadGEM3 GCMs. This finding may be valid for other GCMs, showing the necessity to analyze other chains of GCMs that may become available in the future with such a range of horizontal resolutions. Our finding supports the hypothesis that heterogeneity in model parametrization is one of the underlying causes of model disagreement in the Coupled Model Intercomparison Project (CMIP) exercises

Understanding the rapid summer warming and changes in temperature extremes since the mid-1990s over Western Europe

Analysis of observations indicates that there was a rapid increase in summer (June-August, JJA) mean surface air temperature (SAT) since the mid-1990s over Western Europe. Accompanying this rapid warming are significant increases in summer mean daily maximum temperature, daily minimum temperature, annual hottest day temperature and warmest night temperature, and an increase in frequency of summer days and tropical nights, while the change in the diurnal temperature range (DTR) is small. This study focuses on understanding causes of the rapid summer warming and associated temperature extreme changes. A set of experiments using the atmospheric component of the state-of-the-art HadGEM3 global climate model have been carried out to quantify relative roles of changes in sea surface temperature (SST)/sea ice extent (SIE), anthropogenic greenhouse gases (GHGs), and anthropogenic aerosols (AAer). Results indicate that the model forced by changes in all forcings reproduces many of the observed changes since the mid-1990s over Western Europe. Changes in SST/SIE explain 62.2% ± 13.0% of the area averaged seasonal mean warming signal over Western Europe, with the remaining 37.8% ± 13.6% of the warming explained by the direct impact of changes in GHGs and AAer. Results further indicate that the direct impact of the reduction of AAer precursor emissions over Europe, mainly through aerosol-radiation interaction with additional contributions from aerosol-cloud interaction and coupled atmosphere-land surface feedbacks, is a key factor for increases in annual hottest day temperature and in frequency of summer days. It explains 45.5% ± 17.6% and 40.9% ± 18.4% of area averaged signals for these temperature extremes. The direct impact of the reduction of AAer precursor emissions over Europe acts to increase DTR locally, but the change in DTR is countered by the direct impact of GHGs forcing. In the next few decades, greenhouse gas concentrations will continue to rise and AAer precursor emissions over Europe and North America will continue to decline. Our results suggest that the changes in summer seasonal mean SAT and temperature extremes over Western Europe since the mid-1990s are most likely to be sustained or amplified in the near term, unless other factors intervene

Killer immunoglobulin-like Receptors (KIR) haplogroups A and B track with Natural Killer Cells and Cytokine Profile in Aged Subjects: Observations from Octo/Nonagenarians in the Belfast Elderly Longitudinal Free-living Aging STudy (BELFAST)

BACKGROUND: Natural Killer Cells (NK) play an important role in detection and elimination of virus-infected, damaged or cancer cells. NK cell function is guided by expression of Killer Immunoglobulin-like Receptors (KIRs) and contributed to by the cytokine milieu. KIR molecules are grouped on NK cells into stimulatory and inhibitory KIR haplotypes A and B, through which NKs sense and tolerate HLA self-antigens or up-regulate the NK-cytotoxic response to cells with altered HLA self-antigens, damaged by viruses or tumours. We have previously described increased numbers of NK and NK-related subsets in association with sIL-2R cytokine serum levels in BELFAST octo/nonagenarians. We hypothesised that changes in KIR A and B haplotype gene frequencies could explain the increased cytokine profiles and NK compartments previously described in Belfast Elderly Longitudinal Free-living Aging STudy (BELFAST) octo/nonagenarians, who show evidence of ageing well. RESULTS: In the BELFAST study, 24% of octo/nonagenarians carried the KIR A haplotype and 76% KIR B haplotype with no differences for KIR A haplogroup frequency between male or female subjects (23% v 24%; p=0.88) or for KIR B haplogroup (77% v 76%; p=0.99). Octo/nonagenarian KIR A haplotype carriers showed increased NK numbers and percentage compared to Group B KIR subjects (p=0.003; p=0.016 respectively). There were no KIR A/ B haplogroup-associated changes for related CD57+CD8 ((high or low)) subsets. Using logistic regression, KIR B carriers were predicted to have higher IL-12 cytokine levels compared to KIR A carriers by about 3% (OR 1.03, confidence limits CI 0.99–1.09; p=0.027) and 14% higher levels for TGF-β (active), a cytokine with an anti-inflammatory role, (OR 1.14, confidence limits CI 0.99–1.09; p=0.002). CONCLUSION: In this observational study, BELFAST octo/nonagenarians carrying KIR A haplotype showed higher NK cell numbers and percentage compared to KIR B carriers. Conversely, KIR B haplotype carriers, with genes encoding for activating KIRs, showed a tendency for higher serum pro-inflammatory cytokines compared to KIR A carriers. While the findings in this study should be considered exploratory they may serve to stimulate debate about the immune signatures of those who appear to age slowly and who represent a model for good quality survivor-hood