Not all systematic reviews are systematic : a meta-review of the quality of systematic reviews for non-invasive remote monitoring in heart failure

Remote monitoring for heart failure has been evaluated in numerous systematic reviews. The aim of this meta-review was to appraise their quality and synthesise results. We electronically searched online databases, performed a forward citation search and hand-searched bibliographies. Systematic reviews of remote monitoring interventions that were used for surveillance of heart failure patients were included. Seven (41%) systematic reviews pooled results for meta-analysis. Eight (47%) considered all non-invasive remote monitoring strategies. Five (29%) focused on telemonitoring. Four (24%) included both non-invasive and invasive technologies. According to AMSTAR criteria, ten (58%) systematic reviews were of poor methodological quality. In high quality reviews, the relative risk of mortality in patients who received remote monitoring ranged from 0.53 (95% CI=0.29-0.96) to 0.88 (95% CI=0.76-1.01). High quality reviews also reported that remote monitoring reduced the relative risk of all-cause (0.52; 95% CI=0.28-0.96 to 0.96; 95% CI=0.90–1.03) and heart failure-related hospitalizations (0.72; 95% CI=0.64–0.81 to RR 0.79; 95% CI=0.67-0.94) and, as a consequence, healthcare costs. As the high quality reviews reported that remote monitoring reduced hospitalizations, mortality and healthcare costs, research efforts should now be directed towards optimising these interventions in preparation for more widespread implementation.

Not all systematic reviews are systematic : a meta-review of the quality of current systematic reviews and meta-analyses for remote monitoring in heart failure

Background/aims: Remote monitoring for heart failure has not only been evaluated in a large number of randomised controlled trials, but also in many systematic reviews and meta-analyses. The aim of this meta-review was to identify, appraise and synthesise existing systematic reviews that have evaluated the effects of remote monitoring in heart failure. Methods: Using a Cochrane methodology, we electronically searched all relevant online databases and search engines, performed a forward citation search as well as hand-searched bibliographies. Only fully published systematic reviews of invasive and/or non-invasive remote monitoring interventions were included. Two reviewers independently extracted data. Results: Sixty-five publications from 3333 citations were identified. Seventeen fulfilled the inclusion and exclusion criteria. Quality varied with A Measurement Tool to Assess Systematic Reviews (AMSTAR scores) ranging from 2 to 11 (mean 5.88). Seven reviews (41%) pooled results from individual studies for meta-analysis. Eight (47%) considered all non-invasive remote monitoring strategies. Four (24%) focused specifically on telemonitoring. Four (24%) included studies investigating both non-invasive and invasive technologies. Population characteristics of the included studies were not reported consistently. Mortality and hospitalisations were the most frequently reported outcomes 12 (70%). Only five reviews (29%) reported healthcare costs and compliance. A high degree of heterogeneity was reported in many of the meta-analyses. Conclusions: These results should be considered in context of two negative RCTs of remote monitoring for heart failure that have been published since the meta-analyses (TIM-HF and Tele-HF). However, high quality reviews demonstrated improved mortality, quality of life, reduction in hospitalisations and healthcare costs.

Inflow cannula design for biventricular assist devices

Cardiovascular diseases are a leading cause of death throughout the developed world. With the demand for donor hearts far exceeding the supply, a bridge-to-transplant or permanent solution is required. This is currently achieved with ventricular assist devices (VADs), which can be used to assist the left ventricle (LVAD), right ventricle (RVAD), or both ventricles simultaneously (BiVAD). Earlier generation VADs were large, volume-displacement devices designed for temporary support until a donor heart was found. The latest generation of VADs use rotary blood pump technology which improves device lifetime and the quality of life for end stage heart failure patients. VADs are connected to the heart and greater vessels of the patient through specially designed tubes called cannulae. The inflow cannulae, which supply blood to the VAD, are usually attached to the left atrium or ventricle for LVAD support, and the right atrium or ventricle for RVAD support. Few studies have characterized the haemodynamic difference between the two cannulation sites, particularly with respect to rotary RVAD support. Inflow cannulae are usually made of metal or a semi-rigid polymer to prevent collapse with negative pressures. However suction, and subsequent collapse, of the cannulated heart chamber can be a frequent occurrence, particularly with the relatively preload insensitive rotary blood pumps. Suction events may be associated with endocardial damage, pump flow stoppages and ventricular arrhythmias. While several VAD control strategies are under development, these usually rely on potentially inaccurate sensors or somewhat unreliable inferred data to estimate preload. Fixation of the inflow cannula is usually achieved through suturing the cannula, often via a felt sewing ring, to the cannulated chamber. This technique extends the time on cardiopulmonary bypass which is associated with several postoperative complications. The overall objective of this thesis was to improve the placement and design of rotary LVAD and RVAD inflow cannulae to achieve enhanced haemodynamic performance, reduced incidence of suction events, reduced levels of postoperative bleeding and a faster implantation procedure. Specific objectives were: * in-vitro evaluation of LVAD and RVAD inflow cannula placement, * design and in-vitro evaluation of a passive mechanism to reduce the potential for heart chamber suction, * design and in-vitro evaluation of a novel suture-less cannula fixation device. In order to complete in-vitro evaluation of VAD inflow cannulae, a mock circulation loop (MCL) was developed to accurately replicate the haemodynamics in the human systemic and pulmonary circulations. Validation of the MCL’s haemodynamic performance, including the form and magnitude of pressure, flow and volume traces was completed through comparisons of patient data and the literature. The MCL was capable of reproducing almost any healthy or pathological condition, and provided a useful tool to evaluate VAD cannulation and other cardiovascular devices. The MCL was used to evaluate inflow cannula placement for rotary VAD support. Left and right atrial and ventricular cannulation sites were evaluated under conditions of mild and severe heart failure. With a view to long term LVAD support in the severe left heart failure condition, left ventricular inflow cannulation was preferred due to improved LVAD efficiency and reduced potential for thrombus formation. In the mild left heart failure condition, left atrial cannulation was preferred to provide an improved platform for myocardial recovery. Similar trends were observed with RVAD support, however to a lesser degree due to a smaller difference in right atrial and ventricular pressures. A compliant inflow cannula to prevent suction events was then developed and evaluated in the MCL. As rotary LVAD or RVAD preload was reduced, suction events occurred in all instances with a rigid inflow cannula. Addition of the compliant segment eliminated suction events in all instances. This was due to passive restriction of the compliant segment as preload dropped, thus increasing the VAD circuit resistance and decreasing the VAD flow rate. Therefore, the compliant inflow cannula acted as a passive flow control / anti-suction system in LVAD and RVAD support. A novel suture-less inflow cannula fixation device was then developed to reduce implantation time and postoperative bleeding. The fixation device was evaluated for LVAD and RVAD support in cadaveric animal and human hearts attached to a MCL. LVAD inflow cannulation was achieved in under two minutes with the suture-less fixation device. No leakage through the suture-less fixation device – myocardial interface was noted. Continued development and in-vivo evaluation of this device may result in an improved inflow cannulation technique with the potential for off-bypass insertion. Continued development of this research, in particular the compliant inflow cannula and suture-less inflow cannulation device, will result in improved postoperative outcomes, life span and quality of life for end-stage heart failure patients.

Modelling the failure of thin layered mortar joints in masonry

This paper deals with the failure of high adhesive, low compressive strength, thin layered polymer mortar joints in masonry through a contact modelling in finite element framework. Failure due to combined shear, tensile and compressive stresses are considered through a constitutive damaging contact model that incorporates traction–separation as a function of displacement discontinuity. The modelling method is verified using single and multiple contact analyses of thin mortar layered masonry specimens under shear, tensile and compressive stresses and their combinations. Using this verified method, the failure of thin mortar layered masonry under a range of shear to tension ratios and shear to compression ratios has been examined. Finally, this model is applied to thin bed masonry wallettes for their behaviour under biaxial tension–tension and compression–tension loadings perpendicular and parallel to the bed joints.

(De)Constructing ADHD : Critical Guidance for Teachers and Teacher Educators

Attention Deficit Hyperactivity Disorder (ADHD) has achieved celebrity status in many Western countries, yet despite considerable effort to prove its existence as a “real” disorder, ADHD still suffers from a crisis of legitimacy. Nonetheless, diagnosis and prescription of medication has grown at a phenomenal rate since the late 1980s, particularly in Western culture. Numerous accounts exist explaining how the ADHD diagnosis functions as a convenient administrative loophole, providing schools with a medical explanation for school failure, medication to sedate the “problem” into submission, or the means to eject children from mainstream classrooms. This book provides a more holistic interpretation of how to respond to children who might otherwise be diagnosed with and medicated for “ADHD”—a diagnosis which, whether scientifically valid or not, is unhelpful within the confine of the school. Training teachers to recognise and identify “ADHD symptoms” or to understand the functions of restricted pharmaceuticals will only serve to increase the number of children diagnosed and the sale of psychoactive medications. Research has shown that such activities will not help those children learn, nor will it empower their classroom teachers to take responsibility for teaching such children well. This book seeks to provide school practitioners with knowledge that is useful within the educational context to improve the educational experiences and outcomes for children who might otherwise receive a diagnosis of ADHD.

Tensile properties of pumpkin peel and flesh tissue and review of current testing methods

In South and Southeast Asia, postharvest loss causes material waste of up to 66% in fruits and vegetables, 30% in oilseeds and pulses, and 49% in roots and tubers. The efficiency of postharvest equipment directly affects industrial-scale food production. To enhance current processing methods and devices, it is essential to analyze the responses of food materials under loading operations. Food materials undergo different types of mechanical loading during postharvest and processing stages. Therefore, it is important to determine the properties of these materials under different types of loads, such as tensile, compression, and indentation. This study presents a comprehensive analysis of the available literature on the tensile properties of different food samples. The aim of this review was to categorize the available methods of tensile testing for agricultural crops and food materials to investigate an appropriate sample size and tensile test method. The results were then applied to perform tensile tests on pumpkin flesh and peel samples, in particular on arc-sided samples at a constant loading rate of 20 mm min-1. The results showed the maximum tensile stress of pumpkin flesh and peel samples to be 0.535 and 1.45 MPa, respectively. The elastic modulus of the flesh and peel samples was 6.82 and 25.2 MPa, respectively, while the failure modulus values were 14.51 and 30.88 MPa, respectively. The results of the tensile tests were also used to develop a finite element model of mechanical peeling of tough-skinned vegetables. However, to study the effects of deformation rate, moisture content, and texture of the tissue on the tensile responses of food materials, more investigation needs to be done in the future.

The benefits of thermal clothing during winter in patients with heart failure : a pilot randomised controlled trial

Background Many Australian cities experience large winter increases in deaths and hospitalisations. Flu outbreaks are only part of the problem and inadequate protection from cold weather is a key independent risk factor. Better home insulation has been shown to improve health during winter, but no study has examined whether better personal insulation improves health. Data and Methods We ran a randomised controlled trial of thermal clothing versus usual care. Subjects with heart failure (a group vulnerable to cold) were recruited from a public hospital in Brisbane in winter and followed-up at the end of winter. Those randomised to the intervention received two thermal hats and tops and a digital thermometer. The primary outcome was the number of days in hospital, with secondary outcomes of General Practitioner (GP) visits and self-rated health. Results The mean number of days in hospital per 100 winter days was 2.5 in the intervention group and 1.8 in the usual care group, with a mean difference of 0.7 (95% CI: –1.5, 5.4). The intervention group had 0.2 fewer GP visits on average (95% CI: –0.8, 0.3), and a higher self-rated health, mean improvement –0.3 (95% CI: –0.9, 0.3). The thermal tops were generally well used, but even in cold temperatures the hats were only worn by 30% of subjects. Conclusions Thermal clothes are a cheap and simple intervention, but further work needs to be done on increasing compliance and confirming the health and economic benefits of providing thermals to at-risk groups.

Failure analysis of laminated glass panels subjected to blast loads

This paper presents a rigorous and a reliable analytical procedure using finite element (FE) techniques to study the blast response of laminated glass (LG) panel and predict the failure of its components. The 1st principal stress (σ11) is used as the failure criterion for glass and the von mises stress (σv) is used for the interlayer and sealant joints. The results from the FE analysis for mid-span deflection, energy absorption and the stresses at critical locations of glass, interlayer and structural sealant are presented in the paper. These results compared well with those obtained from a free field blast test reported in the literature. The tensile strength (T) of the glass has a significant influence on the behaviour of the LG panel and should be treated carefully in the analysis. The glass panes absorb about 80% of the blast energy for the treated blast load and this should be minimised in the design.

Vision-based estimation of airborne target pseudobearing rate using hidden Markov model filters

The problem of estimating pseudobearing rate information of an airborne target based on measurements from a vision sensor is considered. Novel image speed and heading angle estimators are presented that exploit image morphology, hidden Markov model (HMM) filtering, and relative entropy rate (RER) concepts to allow pseudobearing rate information to be determined before (or whilst) the target track is being estimated from vision information.

A cohort study of Chlamydia trachomatis treatment failure in women : a study protocol

Background Chlamydia trachomatis is the most commonly diagnosed bacterial sexually transmitted infection in the developed world and diagnosis rates have increased dramatically over the last decade. Repeat infections of chlamydia are very common and may represent re-infection from an untreated partner or treatment failure. The aim of this cohort study is to estimate the proportion of women infected with chlamydia who experience treatment failure after treatment with 1 gram azithromycin. Methods/design This cohort study will follow women diagnosed with chlamydia for up to 56 days post treatment. Women will provide weekly genital specimens for further assay. The primary outcome is the proportion of women who are classified as having treatment failure 28, 42 or 56 days after recruitment. Comprehensive sexual behavior data collection and the detection of Y chromosome DNA and high discriminatory chlamydial genotyping will be used to differentiate between chlamydia re-infection and treatment failure. Azithromycin levels in high-vaginal specimens will be measured using a validated liquid chromatography – tandem mass spectrometry method to assess whether poor azithromycin absorption could be a cause of treatment failure. Chlamydia culture and minimal inhibitory concentrations will be performed to further characterize the chlamydia infections. Discussion Distinguishing between treatment failure and re-infection is important in order to refine treatment recommendations and focus infection control mechanisms. If a large proportion of repeat chlamydia infections are due to antibiotic treatment failure, then international recommendations on chlamydia treatment may need to be re-evaluated. If most are re-infections, then strategies to expedite partner treatment are necessary.

Random breath testing in Queensland and Western Australia : Examination of how the random breath testing rate influences alcohol related traffic crash rates

In this paper we explore the relationship between monthly random breath testing (RBT) rates (per 1000 licensed drivers) and alcohol-related traffic crash (ARTC) rates over time, across two Australian states: Queensland and Western Australia. We analyse the RBT, ARTC and licensed driver rates across 12 years; however, due to administrative restrictions, we model ARTC rates against RBT rates for the period July 2004 to June 2009. The Queensland data reveals that the monthly ARTC rate is almost flat over the five year period. Based on the results of the analysis, an average of 5.5 ARTCs per 100,000 licensed drivers are observed across the study period. For the same period, the monthly rate of RBTs per 1000 licensed drivers is observed to be decreasing across the study with the results of the analysis revealing no significant variations in the data. The comparison between Western Australia and Queensland shows that Queensland's ARTC monthly percent change (MPC) is 0.014 compared to the MPC of 0.47 for Western Australia. While Queensland maintains a relatively flat ARTC rate, the ARTC rate in Western Australia is increasing. Our analysis reveals an inverse relationship between ARTC RBT rates, that for every 10% increase in the percentage of RBTs to licensed driver there is a 0.15 decrease in the rate of ARTCs per 100,000 licenced drivers. Moreover, in Western Australia, if the 2011 ratio of 1:2 (RBTs to annual number of licensed drivers) were to double to a ratio of 1:1, we estimate the number of monthly ARTCs would reduce by approximately 15. Based on these findings we believe that as the number of RBTs conducted increases the number of drivers willing to risk being detected for drinking driving decreases, because the perceived risk of being detected is considered greater. This is turn results in the number of ARTCs diminishing. The results of this study provide an important evidence base for policy decisions for RBT operations.

Failure to repeatedly supercompensate muscle glycogen stores in highly trained men

Purpose: It is not known whether it is possible to repeatedly supercompensate muscle glycogen stores after exhaustive exercise bouts undertaken within several days. Methods: We evaluated the effect of repeated exercise-diet manipulation on muscle glycogen and triacylglycerol (IMTG) metabolism and exercise capacity in six well-trained subjects who completed an intermittent, exhaustive cycling protocol (EX) on three occasions separated by 48 h (i.e., days 1, 3, and 5) in a 5-d period. Twenty-four hours before day 1, subjects consumed a moderate (6 g·kg-1)-carbohydrate (CHO) diet, followed by 5 d of a high (12 g·kg-1·d -1)-CHO diet. Muscle biopsies were taken at rest, immediately post-EX on days 1, 3, and 5, and after 3 h of recovery on days 1 and 3. Results: Compared with day 1, resting muscle [glycogen] was elevated on day 3 but not day 5 (435 ± 57 vs 713 ± 60 vs 409 ± 40 mmol·kg -1, P < 0.001). [IMTG] was reduced by 28% (P < 0.05) after EX on day 1, but post-EX levels on days 3 and 5 were similar to rest. EX was enhanced on days 3 and 5 compared with day 1 (31.9 ± 2.5 and 35.4 ± 3.8 vs 24.1 ± 1.4 kJ·kg-1, P < 0.05). Glycogen synthase activity at rest and immediately post-EX was similar between trials. Additionally, the rates of muscle glycogen accumulation were similar during the 3-h recovery period on days 1 and 3. Conclusion: We show that well-trained men cannot repeatedly supercompensate muscle [glycogen] after glycogen-depleting exercise and 2 d of a high-CHO diet, suggesting that the mechanisms responsible for glycogen accumulation are attenuated as a consequence of successive days of glycogen-depleting exercise.

Financial Markets, Institutions and Money [3rd ed.]

"The financial system is a key influencer of the health and efficiency of an economy. The role of the financial system is to gather money from people and businesses that currently have more money than they need and transfer it to those that can use it for either business or consumer expenditures. This flow of funds through financial markets and institutions in the Australian economy is huge (in the billions of dollars), affecting business profits, the rate of inflation, interest rates and the production of goods and services. In general, the larger the flow of funds and the more efficient the financial system, the greater the economic output and welfare in the economy. It is not possible to have a modern, complex economy such as that in Australia, without an efficient and sound financial system. The global financial crisis (GFC) of late 2007–09 (and the ensuing European debt crisis), where the global financial market was on the brink of collapse with only significant government intervention stopping a catastrophic global failure of the market, illustrated the importance of the financial system. Financial Markets, Institutions and Money 3rd edition introduces students to the financial system, its operations, and participants. The text offers a fresh, succinct analysis of the financial markets and discusses how the many participants in the financial system interrelate. This includes coverage of regulators, regulations and the role of the Reserve Bank of Australia, that ensure the system’s smooth running, which is essential to a modern economy. The text has been significantly revised to take into account changes in the financial world."---publisher website Table of Contents 1. The financial system - an overview 2. The Monetary Authorities 3. The Reserve Bank of Australia and interest rates 4. The level of interest rates 5. Mathematics of finance 6. Bond Prices and interest rate risk 7. The Structure of Interest Rates 8. Money Markets 9. Bond Markets 10. Equity Markets

Effect of interval training intensity on fat oxidation, blood lactate and the rate of perceived exertion in obese men

Purpose The objectives of this study were to examine the effect of 4-week moderate- and high-intensity interval training (MIIT and HIIT) on fat oxidation and the responses of blood lactate (BLa) and rating of perceived exertion (RPE). Methods Ten overweight/obese men (age = 29 ±3.7 years, BMI = 30.7 ±3.4 kg/m2) participated in a cross-over study of 4-week MIIT and HIIT training. The MIIT training sessions consisted of 5-min cycling stages at mechanical workloads 20% above and 20% below 45%VO2peak. The HIIT sessions consisted of intervals of 30-s work at 90%VO2peak and 30-s rest. Pre- and post-training assessments included VO2max using a graded exercise test (GXT) and fat oxidation using a 45-min constant-load test at 45%VO2max. BLa and RPE were also measured during the constant-load exercise test. Results There were no significant changes in body composition with either intervention. There were significant increases in fat oxidation after MIIT and HIIT (p ≤ 0.01), with no effect of intensity. BLa during the constant-load exercise test significantly decreased after MIIT and HIIT (p ≤ 0.01), and the difference between MIIT and HIIT was not significant (p = 0.09). RPE significantly decreased after HIIT greater than MIIT (p ≤ 0.05). Conclusion Interval training can increase fat oxidation with no effect of exercise intensity, but BLa and RPE decreased after HIIT to greater extent than MIIT.

Positive reappraisal improves heart rate variability during stressful work

Recent developments in wearable ECG technology have seen renewed interest in the use of Heart Rate Variability (HRV) feedback for stress management. Yet, little is know about the efficacy of such interventions. Positive reappraisal is an emotion regulation strategy that involves changing the way a situation is construed to decrease emotional impact. We sought to test the effectiveness of an intervention that used feedback on HRV data to prompt positive reappraisal during a stressful work task. Participants (N=122) completed two 20-minute trials of an inbox activity. In-between the first and the second trial participants were assigned to the waitlist control condition, a positive reappraisal via psycho-education condition, or a positive reappraisal via HRV feedback condition. Results revealed that using HRV data to frame a positive reappraisal message is more effective than using psycho-education (or no intervention)–especially for increasing positive mood and reducing arousal.