Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses

OBJECTIVES: To evaluate the evidence for strategies to prevent falls or fractures in residents in care homes and hospital inpatients and to investigate the effect of dementia and cognitive impairment. DESIGN: Systematic review and meta-analyses of studies grouped by intervention and setting (hospital or care home). Meta-regression to investigate the effects of dementia and of study quality and design. DATA SOURCES: Medline, CINAHL, Embase, PsychInfo, Cochrane Database, Clinical Trials Register, and hand searching of references from reviews and guidelines to January 2005. RESULTS: 1207 references were identified, including 115 systematic reviews, expert reviews, or guidelines. Of the 92 full papers inspected, 43 were included. Meta-analysis for multifaceted interventions in hospital (13 studies) showed a rate ratio of 0.82 (95% confidence interval 0.68 to 0.997) for falls but no significant effect on the number of fallers or fractures. For hip protectors in care homes (11 studies) the rate ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on falls and not enough studies on fallers. For all other interventions (multifaceted interventions in care homes; removal of physical restraints in either setting; fall alarm devices in either setting; exercise in care homes; calcium/vitamin D in care homes; changes in the physical environment in either setting; medication review in hospital) meta-analysis was either unsuitable because of insufficient studies or showed no significant effect on falls, fallers, or fractures, despite strongly positive results in some individual studies. Meta-regression showed no significant association between effect size and prevalence of dementia or cognitive impairment. CONCLUSION: There is some evidence that multifaceted interventions in hospital reduce the number of falls and that use of hip protectors in care homes prevents hip fractures. There is insufficient evidence, however, for the effectiveness of other single interventions in hospitals or care homes or multifaceted interventions in care homes.

Comparative performance of UK PFI and non-PFI hospitals

Since the first PFI hospital was established in 1994, many debates centred on the value for money and risk transfer in PFIs. Little concern is shown with PFI hospitals’ performance in delivering healthcare. Exploratory research was carried out to compare PFI with non‐PFI hospital performance. Five performance indicators were analysed to compare differences between PFI and non‐PFI hospitals, namely the length of waiting, the length of stay, MRSA infection rate, C difficile infection rate and patient experience. Data was collected from various government bodies. The results show that only some indexes measuring patient experience emerge statistically significant. This leads to a conclusion that PFI hospitals may not perform better than non‐PFI hospitals but they are not worse than non‐PFI hospitals in the delivery of services. However, future research needs to pay attention to reliability and validity of data sets currently available to undertake comparison.

A buffering layer to support derived types and proprietary networks for Java HPC

MPJ Express is our implementation of MPI-like bindings for Java. In this paper we discuss our intermediate buffering layer that makes use of the so-called direct byte buffers introduced in the Java New I/O package. The purpose of this layer is to support the implementation of derived datatypes. MPJ Express is the first Java messaging library that implements this feature using pure Java. In addition, this buffering layer allows efficient implementation of communication devices based on proprietary networks such as Myrinet. In this paper we evaluate the performance of our buffering layer and demonstrate the usefulness of direct byte buffers. Also, we evaluate the performance of MPJ Express against other messaging systems using Myrinet and show that our buffering layer has made it possible to avoid the overheads suffered by other Java systems such as mpiJava that relies on the Java Native Interface.

A buffering layer to support derived types and proprietary networks for Java HPC

MPJ Express is our implementation of MPI-like bindings for Java. In this paper we discuss our intermediate buffering layer that makes use of the so-called direct byte buffers introduced in the Java New I/O package. The purpose of this layer is to support the implementation of derived datatypes. MPJ Express is the first Java messaging library that implements this feature using pure Java. In addition, this buffering layer allows efficient implementation of communication devices based on proprietary networks such as Myrinet. In this paper we evaluate the performance of our buffering layer and demonstrate the usefulness of direct byte buffers. Also, we evaluate the performance of MPJ Express against other messaging systems using Myrinet and show that our buffering layer has made it possible to avoid the overheads suffered by other Java systems such as mpiJava that relies on the Java Native Interface.

Understanding unconscionability in proprietary estoppel

In a series of recent cases, courts have reasserted unconscionability as the basis of proprietary estoppel and in doing so have moved away from the structured form of discretion envisaged in the classic Taylors Fashions formula. In light of these developments, this paper traces the use of unconscionability in estoppel and examines the changing role attributed to the concept. In a parallel development, in exercising their remedial discretion once a claim to estoppel has been established, the courts have emphasised the foundation of estoppel in unconscionability to assert the need for proportionality between the detriment and remedy as ‘the most essential requirement’. Collectively, the cases demonstrate a lack of transparency or consistency, which raises concerns that the courts are descending into a form of individualised discretion. These developments are of particular concern as they come at a time when commentators are predicting a ‘boom’ in estoppel to follow the introduction of electronic conveyancing.

Proprietary estoppel: a functional analysis

This article argues in favour of a functional analysis of proprietary estoppel which focuses on the role of the doctrine in enabling claims to the informal acquisition of property rights in land. The article shows that adopting such an analysis both assists our understanding of two recent decisions of the English House of Lords and helps to resolve issues of taxonomy that arise in relation to the doctrine. A functional analysis both unites the sub-categories of proprietary estoppel into a single principle and distinguishes this principle from other types of estoppel claim. It is suggested, however, that the unification of common law and equitable estoppel remains both possible and desirable as long as ‘unification’ is understood broadly and is not confined to the recognition of a doctrine that is identical in its scope and operation in all cases. It is further shown that despite a lack of discussion of the concept in the House of Lords, unconscionability continues to play a key role in proprietary estoppel and therefore in the informal acquisition of property rights. Unconscionability may now benefit from a closer connection with the other elements of claims which should prevent abuse of the concept and allay concerns of ‘palm-tree justice’.