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Carole Decker,1 Linda Garavalia,2 Brian Garavalia,1 Teresa Simon,3 Matthew Loeb,4 John Spertus6, William Daniel51Mid America Heart Institute at Saint Luke's Hospital in Kansas City Missouri, University of Missouri-Kansas City School of Nursing, 2University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, 3Bristol-Myers Squibb, Princeton, NJ, 4Plaza Primary Care and Geriatrics, 5Saint Luke's Cardiovascular Consultants, Kansas City, MO, 6Mid America Heart Institute at Saint Luke's Hospital in Kansas City Missouri, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USABackground: Warfarin, the most commonly used antithrombotic agent for stroke prophylaxis in atrial fibrillation (AF), requires regular monitoring, frequent dosage adjustments, and dietary restrictions. Clinicians' perceptions of barriers to optimal AF management are an important factor in treatment. Anticoagulation management for AF is overseen by both cardiology and internal medicine (IM) practices. Thus, gaining the perspective of specialists and generalists is essential in understanding barriers to treatment. We used qualitative research methods to define key issues in the prescription of warfarin therapy for AF by cardiology specialists and IM physicians.Methods and results: Clinicians were interviewed to identify barriers to warfarin treatment in a large Midwestern city. Interviews were conducted until thematic saturation occurred. Content analysis yielded several themes. The most salient theme that emerged from clinician interviews was use of characteristics other than the patient's CHADS2 score to enact a treatment plan, such as the patient's social situation and past medication-taking behavior. Other themes included patient knowledge, real-world problems, breakdown in communication, and clinician reluctance.Conclusion: Warfarin treatment is associated with many challenges. The barriers identified by clinicians highlight the unmet need associated with stroke prophylaxis in AF and the opportunity to improve anticoagulation treatment in AF. Social and lifestyle factors were important considerations in determining treatment.Keywords: anticoagulants, atrial fibrillation, risk factors

Individuals within complex social groups often experience reduced reproduction owing to coercive or suppressive actions of other group members. However, the nature of social and ecological environments that favour individual acceptance of such costs of sociality is not well understood. Taxa with short periods of direct social interaction, such as some communal egg layers, are interesting models for study of the cost of social interaction because opportunities to control reproduction of others are limited to brief periods of reproduction. To understand the conditions under which communal egg layers are in fitness conflict and thus likely to influence each other's reproduction, we develop an optimality model involving a brood guarding 'host' and a nonguarding disperser, or 'egg dumper'. The model shows that when, where intermediate-sized broods have highest survival, lifetime inclusive fitnesses of hosts and dumpers are often optimized with different numbers of dumped eggs. We hypothesize that resolution of this conflict may involve attempts by one party to manipulate the other's reproduction. To test model predictions we used a lace bug (Heteroptera: Tingidae) that shows both hosts and egg dumpers as well as increased offspring survival in response to communal egg laying. We found that egg-dumping lace bugs oviposit a number of eggs that very closely matches predicted fitness optimum for hosts rather than predicted optimum of dumpers. This result suggests that dumpers pay a social cost for communal egg laying, a cost that may occur through host suppression of dumper reproduction. Although dumper allocation of eggs is thus sub-optimal for dumpers, previous models show that the decision to egg dump is nevertheless evolutionarily stable, possibly because hosts permit just enough dumper oviposition to encourage commitment to the behaviour.

Cooperative care of offspring is a hallmark of animal sociality, but it is unclear how conflicts over care-giving effort are resolved in taxa that do not use dominance and physical force to induce cooperation efforts in others. To ascertain if taxa without dominance-enforcing traits such as stings or biting mouthparts show conflicts over offspring care, we used a lace bug(Heteroptera: Tingidae) that has communal guarding of young but lacks morphologies for dominance or coercion. In Leptobyrsa decora females oviposit communally and then aggressively guard communal broods from arthropod predators. Since guarding has mortality risks, we tested if individuals lower their own risk by behaving less aggressively than the partner guard. We show that effort towards protecting brood, and thus guard risk of death, is strongly positively correlated between guarding partners. This finding suggests that mechanisms other than dominance or coercion are used by L. decora to establish an equitable and possibly conflict-minimizing distribution of care-giving effort.

Impairments pose a certain degree of difficulty to disabled people, however the impact of the environment is the major cause of disability. Despite the fact that the disabling effect of environmental factors is acknowledged, little research has been done to explore the impact of the environment on varying degrees of disability and different impairments. The aim of this study was to investigate the experience of disabled people with regard to environmental barriers in an urban as opposed to a rural setting. The specific objectives were to identify which items within the International Classification of Functioning, Disability and Health (ICF) checklist of environmental factors presented people with disability with the most barriers and to see whether the barriers were different for those living in a rural as opposed to an urban setting. The study was conducted amongst Xhosa speaking people in the Eastern and Western Cape areas of South Africa which have, respectively, 5.8% and 4.1% disability prevalences. A descriptive, analytical, cross-sectional study was used to gather the data. The primary data collection tool was the Xhosa version of the ICF checklist. The sample consisted of 468 respondents, with 375 living in the Eastern Cape and 93 in the Western Cape. Physical problems were reported by 54.6 % of the sample, 14.6% had had an intellectual impairment and 9.9% had visual, hearing or speech problems. Approximately 2% of the sample reported more than one impairment. The prevalence of the different types of impairments between the two areas was similar. Respondents from the urban area reported experiencing more barriers in the categories Products and technology and the Natural and built environment, while respondents from the rural area experienced more barriers with Attitudes. An equivalent number of people in the respective areas identified barriers in the Services category. In this study the face and construct validity of the ICF appeared to be acceptable and it is recommended that further studies be conducted to establish the reliability and content and concurrent validity of the instrument. (Contains 5 tables and 2 notes.