Two knees or not two knees? Patient costs and outcomes following bilateral and unilateral total knee joint replacement surgery for OA

Aims: This study aims to address medical and non-medical direct costs and health outcomes of bilateral and unilateral total knee replacement from the patients' perspective during the first year post-surgery. Methods: Osteoarthritis patients undergoing primary unilateral total knee or bilateral total knee replacement (TKR) surgery at three Sydney hospitals were eligible. Patients completed questionnaires pre-operatively to record expenses during the previous three months and health status immediately prior to surgery. Patients then maintained detailed prospective cost diaries and completed SF-36 and WOMAC Index each three months for the first post-operative year. Results: Pre-operatively, no significant differences in health status were found between patients undergoing unilateral TKR and bilateral TKR. Both unilateral and bilateral TKR patients showed improvements in pain, stiffness and function from pre-surgery to 12 months post-surgery. Patients who had bilateral TKR spent an average of 12.3 days in acute hospital and patients who had unilateral TKR 13.6 days. Totally uncemented prostheses were used in 6% of unilateral replacements and 48% of bilateral replacements. In hospital, patients who had bilateral TKR experienced significantly more complications, mainly thromboembolic, than patients who had unilateral TKR. Regression analysis showed that for every one point increase in the pre-operative SF-36 physical score (i.e. improving physical status) out-of-pocket costs decreased by 94%. Out-of-pocket costs for female patients were 3.3 times greater than for males. Conclusion: Patients undergoing bilateral TKR and unilateral TKR had a similar length of stay in hospital and similar out-of-pocket expenditures. Bilateral replacement patients reported better physical function and general health with fewer health care visits one year post procedure. Patients requiring bilateral TKR have some additional information to aid their decision making. While their risk of peri-operative complications is higher, they have an excellent chance of good health outcomes at 12 months and are not going to be doubly 'out-of-pocket' for the experience. (C) 2004 OsteoArthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Costs of managing urinary and faecal incontinence in a sub-acute care facility: A "bottom-up" approach

Aims: To measure accurately the direct costs of managing urinary and faecal incontinence in the sub-acute care setting. Materials and Methods: Prospective observational study was undertaken in two sub-acute care units in a metropolitan hospital. A consecutive series of 29 consecutive patients with urinary and/or faecal incontinence, who were in-patients in a geriatric rehabilitation or subacute neurologic unit underwent routine timed voiding protocol, as per usual care. Face-to-face bedside recordings of all incontinence care, with detailed cost analysis, were undertaken. Results: A total of 3,621 occasions of continence care were costed. The median time per 24 hr spent caring for incontinence per patient was 109 min (interquartile range 88-140). Isolated urinary incontinence episodes occurred in 28 patients (96.5%), mixed urinary/faecal incontinence episodes observed in 79.3%, and episodes of pure faecal incontinence were seen in 62%. The median costs of incontinence care in the sub-acute setting was $49AU per 24 hr, the major share ($41) spent on staff wages. The incontinence tasks of toileting assistance, pad changes, bed changes and catheter care were spread evenly across the three 8 hr shifts of duty. Conclusions: As our population demographics include an increasingly greater portion of the elderly, for whom long term institutional care is becoming relatively more scarce, provision of care in the sub-acute unit that may allow rehabilitation and return to home warrants scrutiny. This is the first study that delineates the costs of managing urinary and faecal incontinence in the sub-acute care setting. Such costs are substantial and place a heavy burden upon night-time carets. (C) 2004 Wiley-Liss, Inc.

The roles of natural and sexual selection during adaptation to a novel environment

The net effect of sexual selection on nonsexual fitness is controversial. On one side, elaborate display traits and preferences for them can be costly, reducing the nonsexual fitness of individuals possessing them, as well as their offspring, In contrast, sexual selection may reinforce nonsexual fitness if an individual's attractiveness and quality are genetically correlated. According to recent models, such good-genes mate choice should increase both the extent and rate of adaptation. We evolved 12 replicate populations of Drosophila serrata in a powerful two-way factorial experimental design to test the separate and combined contributions of natural and sexual selection to adaptation to a novel larval food resource. Populations evolving in the presence of natural selection had significantly higher mean nonsexual fitness when measured over three generations (13-15) during the course of experimental evolution (16-23% increase). The effect of natural selection was even more substantial when measured in a standardized, monogamous mating environment at the end of the experiment (generation 16; 52% increase). In contrast, and despite strong sexual selection on display traits, there was no evidence from any of the four replicate fitness measures that sexual selection promoted adaptation. In addition, a comparison of fitness measures conducted under different mating environments demonstrated a significant direct cost of sexual selection to females, likely arising from some form of male-induced harm. Indirect benefits of sexual selection in promoting adaptation to this novel resource environment therefore appear to be absent in this species, despite prior evidence suggesting the operation of good-genes mate choice in their ancestral environment. How novel environments affect the operation of good-genes mate choice is a fundamental question for future sexual selection research.

The relative energetic costs of the larval period, larval swimming and metamorphosis for the ascidian Diplosoma listerianum

Variation in larval quality has been shown to strongly affect the post-metamorphic performance of a wide range of marine invertebrate species. Extending the larval period of non-feeding larvae strongly affects post-metamorphic survival and growth in a range of species. These 'carry-over' effects are assumed to be due to changes in larval energetic reserves but direct tests are surprisingly rare. Here, we examine the energetic costs ( relative to the costs of metamorphosis) of extending the larval period of the colonial ascidian Diplosoma listerianum. We also manipulated larval activity levels and compared the energy consumption rates of swimming larvae and inactive larvae. Larval swimming was, energetically, very costly relative to either metamorphosis or merely extending the larval period. At least 25% of the larval energetic reserves are available for larval swimming but metamorphosis was relatively inexpensive in this species and larval reserves can be used for post-metamorphic growth. The carry-over effects previously observed in this species appear to be nutritionally mediated and even short (< 3 h) periods of larval swimming can significantly deplete larval energy reserves.

Efficiency, costs and trade-offs in marine reserve system design

With marine biodiversity conservation the primary goal for reserve planning initiatives, a site's conservation potential is typically evaluated on the basis of the biological and physical features it contains. By comparison, socio-economic information is seldom a formal consideration of the reserve system design problem and generally limited to an assessment of threats, vulnerability or compatibility with surrounding uses. This is perhaps surprising given broad recognition that the success of reserve establishment is highly dependent on widespread stakeholder and community support. Using information on the spatial distribution and intensity of commercial rock lobster catch in South Australia, we demonstrate the capacity of mathematical reserve selection procedures to integrate socio-economic and biophysical information for marine reserve system design. Analyses of trade-offs highlight the opportunities to design representative, efficient and practical marine reserve systems that minimise potential loss to commercial users. We found that the objective of minimising the areal extent of the reserve system was barely compromised by incorporating economic design constraints. With a small increase in area (< 3%) and boundary length (< 10%), the economic impact of marine reserves on the commercial rock lobster fishery was reduced by more than a third. We considered also how a reserve planner might prioritise conservation areas using information on a planning units selection frequency. We found that selection frequencies alone were not a reliable guide for the selection of marine reserve systems, but could be used with approaches such as summed irreplaceability to direct conservation effort for efficient marine reserve design.

The costs of caring for patients in a tertiary referral Australian intensive care unit

We determined the direct cost of an Intensive Care Unit (ICU) bed in a tertiary referral Australian ICU and the cost drivers thereof, by retrospectively analysing a number of prospectively designed Hospital- and Unit-specific electronic databases. The study period was a financial year, from 1 July 2002 to 30 June 2003. There were 1615 patients occupying 5692 fractional occupied bed days at a total cost of A$15,915,964, with an average length of stay of 3.69 days (range 0.5-77, median 1.06, interquartile range 2.33). The main cost driver not incorporated into this analysis was blood products (paid for centrally). The average costs of an ICU day and total stay per patient were A$2670 and A$9852 respectively. Staff-related charges were 68.76%, with consumables related expenditure making up 19.65%, clinical support services 9.55% and capital equipment 2.04%. Overtime charges and nursing agency staff were 19.4% of staff-related charges (2.9% for agency staff), 3.9% lower than expenditure associated with full-time employment charges, such as pension and leave. The emergency nature of ICU means it is difficult to accurately set a nursing establishment to cater for all admissions and therefore it is hard to decide what is an acceptable percentage difference between agency/overtime costs compared with the costs associated with full-time staff appointments. Consumable expenditure is likely to increase the most with new innovation and therapies. Using protocol driven practices may tighten and control costs incurred in ICU.

Nanocomposite Nafion-Silica membranes for direct methanol fuel cells

Commercially available proton exchange membranes such as Nafion do not meet the requirements for high power density direct methanol fuel cells, partly due to their high methanol permeability. The aim of this work is to develop a new class of high-proton conductivity membranes, with thermal and mechanical stability similar to Nafion and reduced methanol permeability. Nanocomposite membranes were produced by the in-situ sol-gel synthesis of silicon dioxide particles in preformed Nafion membranes. Microstructural modification of Nafion membranes with silica nanoparticles was shown in this work to reduce methanol crossover from 7.48x10-6 cm2s^-1 for pure Nafion® to 2.86 x10-6 cm2s^-1 for nanocomposite nafion membranes (Methanol 50% (v/v) solution, 75 degrees C). Best results were achieved with a silica composition of 2.6% (w/w). We propose that silica inhibits the conduction of methanol through Nafion by blocking sites necessary for methanol diffusion through the polymer electrolyte membrane. Effects of surface chemistry, nanoparticle formation and interactions with Nafion matrix are further addressed.

The Genus Wolbachia

Numerous invertebrate species form long lasting symbioses with bacteria (Buchner, 1949; Buchner, 1965). One of the most common of these bacterial symbionts is Wolbachia pipientis, which has been estimated to infect anywhere from 15–75% of all insect species (Werren et al., 1995a; West et al., 1998; Jeyaprakash and Hoy, 2000; Werren and Windsor, 2000) as well as many species of arachnids, terrestrial crustaceans and filarial nematodes (O’Neill et al., 1997a; Bandi et al., 1998). In most arthropod associations, Wolbachia act as reproductive parasites manipulating the reproduction of their hosts to enhance their own vertical transmission. There appears to be little direct fitness cost to the infected host besides the costs arising from the reproductive manipulations. However instances have been reported where Wolbachia can be either deleterious (Min and Benzer, 1997; Bouchon et al., 1998) or beneficial (Girin and Boultreau, 1995; Stolk and Stouthamer, 1995; Wade and Chang, 1995; Vavre et al., 1999b; Dedeine et al., 2001) to their hosts. Wolbachia were first described as intracellular Rickettsia-like organisms (RLOs), infecting the gonad cells of the mosquito, Culex pipiens (Hertig and Wolbach, 1924), and were later named 'Wolbachia pipientis' (Hertig, 1936). It was not until the work of Yen and Barr (Yen and Barr, 1971; Yen and Barr, 1973) that Wolbachia were implicated in causing crossing incompatibilities between different mosquito populations (Laven, 1951; Ghelelovitch, 1952). When polymerase chain reaction (PCR) diagnostics for Wolbachia became available, it became clear that this agent was both extremely widespread and also responsible for a range of different reproductive phenotypes in the different hosts it infected (O’Neill et al., 1992; Rousset et al., 1992; Stouthamer et al., 1993). The most common of these are cytoplasmic incompatibility, inducing parthenogenesis, overriding host sex-determination, and male-killing (O’Neill et al., 1997a). As of the time of this writing, more than 450 different Wolbachia strains with unique gene sequences, different phenotypes, and infecting different hosts have been deposited in GenBank and the Wolbachia host database (http://www.wolbachia.sols. uq.edu.au).

The Y2K Scare: Causes, costs and cures.

The worldwide scare over the 'Y2K bug result in the expenditure of hundreds of billions of dollars on Y2K compliance and conversion policies. Most of this can be seen, in retrospect, to have been unproductive or, at least, misdirected. In this paper, the technological and institutional factors leading to the adoption of these policies are considered, along with suggestions as to how such policy failures could be avoided in future.

Chemical treatment of Escherichia coli. II. Direct extraction of recombinant protein from cytoplasmic inclusion bodies in intact cells

A method is presented for the direct extraction of the recombinant protein Long-R-3-IGF-I from inclusion bodies located in the cytoplasm of intact Escherichia coli cells. Chemical treatment with 6M urea, 3 mM EDTA, and 20 mM dithiothreitol (DTT) at pH 9.0 proved an effective combination for extracting recombinant protein from intact cells. Comparable levels of Long-R-3-IGF-I were recovered by direct extraction as achieved by in vitro dissolution following mechanical disruption. However, the purity of directly extracted recombinant protein was lower due to contamination by bacterial cell components. The kinetics of direct extraction are described using a first-order equation with the time constant of 3 min. Urea appears important for permeabilization of the cell and dissolution of the inclusion body. Conversely, EDTA is involved in permeabilization of the cell wall and DTT enhances protein release. pH proved to be important with lower levels of protein release achieved at low pH values (

The 1.1 angstrom resolution crystal structure of [Tyr(15)]EpI, a novel alpha-conotoxin from Conus episcopatus, solved by direct methods

Conotoxins are valuable probes of receptors and ion channels because of their small size and highly selective activity. alpha-Conotoxin EpI, a 16-residue peptide from the mollusk-hunting Conus episcopatus, has the amino acid sequence GCCSDPRCNMNNPDY(SO3H)C-NH2 and appears to be an extremely potent and selective inhibitor of the alpha 3 beta 2 and alpha 3 beta 4 neuronal subtypes of the nicotinic acetylcholine receptor (nAChR). The desulfated form of EpI ([Tyr(15)]EpI) has a potency and selectivity for the nAChR receptor similar to those of EpI. Here we describe the crystal structure of [Tyr(15)]EpI solved at a resolution of 1.1 Angstrom using SnB. The asymmetric unit has a total of 284 non-hydrogen atoms, making this one of the largest structures solved de novo try direct methods. The [Tyr(15)]EpI structure brings to six the number of alpha-conotoxin structures that have been determined to date. Four of these, [Tyr(15)]EpI, PnIA, PnIB, and MII, have an alpha 4/7 cysteine framework and are selective for the neuronal subtype of the nAChR. The structure of [Tyr(15)]EpI has the same backbone fold as the other alpha 4/7-conotoxin structures, supporting the notion that this conotoxin cysteine framework and spacing give rise to a conserved fold. The surface charge distribution of [Tyr(15)]EpI is similar to that of PnIA and PnIB but is likely to be different from that of MII, suggesting that [Tyr(15)]EpI and MII may have different binding modes for the same receptor subtype.

The currency of case management: benefits and costs

Case management models evolved as the mental health care system shifted hospital to community settings. The research evidence underscores the efficacy of certain case management models under 'ideal' conditions; what is less clear, is how these models perform in day to day clinical practice. Moreover, the economic perspective adopted by most studies is relatively narrow thus limiting a proper understanding of the costs and benefits of such models. This paper reviews recent work in the field and highlights gaps in both method and application as a focus for future work. Curr Opin Psychiatry 12:195-199, (C) 1999 Lippincott Williams & Wilkins.