Prospective randomized controlled trial comparing dynamic hip screw and screw fixation for undisplaced subcapital hip fractures

Background
Neck of femur fractures (NOFFs) are a common cause of morbidity and mortality in our community. Minimally displaced intracapsular fractures are treated with internal fixation by a two-hole dynamic hip screw (DHS) or three partially threaded cancellous screws. Data to support the superiority of one are limited. This prospective randomized controlled trial compares outcomes with these two fixation methods.

Methods
We prospectively recruited patients over 50 years, with an acute fracture subcapital NOFF, who walked and lived independently, and were cognitively intact. They were randomized into DHS or cancellous screw groups and followed up for 2 years (overall 75.9%). Outcomes of mortality, revision, loss of fixation, avascular necrosis, surgical complications, WOMAC, Harris hip score and SF-12 were measured.

Results
We recruited 62 patients (31 DHS, 29 cancellous screws, 2 failed consent). Six deaths (19.3%) were seen in each group. A total of 3.2% of DHS (1 out of 31) and 10.3% (3 out of 29) of cancellous screw patients required re-operation (P = 0.272). There was no statistical significant difference in patient satisfaction, quality of life (QoL), radiological union or osteonecrosis. There are trends towards better functional scores and QoL in cancellous screws, particularly at 1 year (P = 0.0061), but with a higher re-operation rate. There was a combined mortality and transition to institutional care of 40.0% (24 out of 60) at 2 years.

Conclusions
This study found no difference in outcomes between DHS and cancellous screws in the treatment of subcapital NOFFs in a fit, independent population, but we found a high level of physical decline in previously fit, independently ambulating patients. A large, multicentre trial will be required to differentiate between these two fixation methods.

The pace of life under artificial selection : personality, energy expenditure, and longevity are correlated in domestic dogs

The domestic dog has undergone extensive artificial selection resulting in an extreme diversity in body size, personality, life‐history, and metabolic traits among breeds. Here we tested whether proactive personalities (high levels of activity, boldness, and aggression) are related to a fast “pace of life” (high rates of growth, mortality, and energy expenditure). Data from the literature provide preliminary evidence that artificial selection on dogs (through domestication) generated variations in personality traits that are correlated with life histories and metabolism. We found that obedient (or docile, shy) breeds live longer than disobedient (or bold) ones and that aggressive breeds have higher energy needs than unaggressive ones. These correlations could result from either human preference for particular trait combinations or, more likely, correlated responses to artificial selection on personality. Our results suggest the existence of a general pace‐of‐life syndrome arising from the coevolution of personality, metabolic, and life‐history traits.

Academic mobility, intercultural encounters and cosmopolitan knowledge creation

In this presentation, I examine contemporary international encounters and intercultural interactions in academia as a researcher and recent participant in the ever-expanding global academic mobility programs. Academic mobility is a part of the modern continuing changes in the teaching and learning processes that higher educational institutions are undergoing globally. These changes are often termed ‘internationalization of education’ and they are expressed in the transformations in both the curricula and recruitment practices of students and staff. Global scale of academic mobility opens up prosperous opportunities for intercultural knowledge interchange, knowledge creation, and knowledge enrichment, all leading to the broadening of cultural imagination and creation of shared cosmopolitan cultural meanings.

Systematic review of lifestyle interventions to limit postpartum weight retention: implications for future opportunities to prevent maternal overweight and obesity following childbirth

Postpartum weight retention can predict future weight gain and long-term obesity. Moreover, failure to lose weight gained during pregnancy can lead to increased body mass index for subsequent pregnancies, increasing the risk of adverse maternal and foetal pregnancy outcomes. This systematic review evaluates the effectiveness of lifestyle interventions aimed at reducing postpartum weight retention. Seven electronic databases were searched for intervention studies and trials enrolling women with singleton pregnancies and published in English from January 1990 to October 2012. Studies were included when postpartum weight was a main outcome and when diet and/or exercise and/or weight monitoring were intervention components. No limitations were placed on age, body mass index or parity. Eleven studies were identified as eligible for inclusion in this review, of which 10 were randomized controlled trials. Seven studies were successful in decreasing postpartum weight retention, six of which included both dietary and physical activity components, incorporated via a range of methods and delivered by a variety of health practitioners. Few studies utilized modern technologies as alternatives to traditional face-to-face support and cost-effectiveness was not assessed in any of the studies. These results suggest that postpartum weight loss is achievable, which may form an important component of obesity prevention in mothers; however, the optimal setting, delivery, intervention length and recruitment approach remains unclear.

The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation

To assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity. Seventeen electronic databases were searched [MEDLINE; EMBASE; PreMedline In-Process & Other Non-Indexed Citations; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases; Web of Knowledge Science Citation Index (SCI); Web of Knowledge ISI Proceedings; PsycInfo; CRD databases; BIOSIS; and databases listing ongoing clinical trials] from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references. Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text using a standard form. Interventions investigated were open and laparoscopic bariatric surgical procedures in widespread current use compared with one another and with non-surgical interventions. Population comprised adult patients with body mass index (BMI) > or = 30 and young obese people. Main outcomes were at least one of the following after at least 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness. Studies eligible for inclusion in the systematic review for comparisons of Surgery versus Surgery were RCTs. For comparisons of Surgery versus Non-surgical procedures eligible studies were RCTs, controlled clinical trials and prospective cohort studies (with a control cohort). Studies eligible for inclusion in the systematic review of cost-effectiveness were full cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses and cost-consequence analyses. One reviewer performed data extraction, which was checked by two reviewers independently. Two reviewers independently applied quality assessment criteria and differences in opinion were resolved at each stage. Studies were synthesised through a narrative review with full tabulation of the results of all included studies. In the economic model the analysis was developed for three patient populations, those with BMI > or = 40; BMI > or = 30 and < 40 with Type 2 diabetes at baseline; and BMI > or = 30 and < 35. Models were applied with assumptions on costs and comorbidity.

Relationship between long-term environmental fluctuations and diving effort of female Australian fur seals

For predators foraging within spatially and temporally heterogeneous marine ecosystems, environmental fluctuations can alter prey availability. Using the proportion of time spent diving and foraging trip duration as proxies of foraging effort, a multi-year dataset was used to assess the response of 58 female Australian fur seals Arctocephalus pusillus doriferus to interannual environmental fluctuations. Multiple environmental indices (remotely sensed ocean colour data and numerical weather predictions) were assessed for their influence on inter-annual variations in the proportion of time spent diving and trip duration. Model averaging revealed strong evidence for relationships between 4 indices and the proportion of time spent diving. There was a positive relationship with effort and 2 yr-lagged spring sea-surface temperature, current winter zonal wind and southern oscillation index, while a negative relationship was found with 2 yr-lagged spring zonal wind. Additionally, a positive relationship was found between foraging trip duration and 1 yr-lagged spring surface chlorophyll a. These results suggest that environmental fluctuations may influence prey availability by affecting the survival and recruitment of prey at the larval and post-larval phases while also affecting current distribution of adult prey.

Reforestation with native mixed-species plantings in a temperate continental climate effectively sequesters and stabilizes carbon within decades.

Reforestation has large potential for mitigating climate change through carbon sequestration. Native mixed-species plantings have a higher potential to reverse biodiversity loss than do plantations of production species, but there are few data on their capacity to store carbon. A chronosequence (5-45 years) of 36 native mixed-species plantings, paired with adjacent pastures, was measured to investigate changes to stocks among C pools following reforestation of agricultural land in the medium rainfall zone (400-800 mm yr(-1) ) of temperate Australia. These mixed-species plantings accumulated 3.09 ± 0.85 t C ha(-1)  yr(-1) in aboveground biomass and 0.18 ± 0.05 t C ha(-1)  yr(-1) in plant litter, reaching amounts comparable to those measured in remnant woodlands by 20 years and 36 years after reforestation respectively. Soil C was slower to increase, with increases seen only after 45 years, at which time stocks had not reached the amounts found in remnant woodlands. The amount of trees (tree density and basal area) was positively associated with the accumulation of carbon in aboveground biomass and litter. In contrast, changes to soil C were most strongly related to the productivity of the location (a forest productivity index and soil N content in the adjacent pasture). At 30 years, native mixed-species plantings had increased the stability of soil C stocks, with higher amounts of recalcitrant C and higher C : N ratios than their adjacent pastures. Reforestation with native mixed-species plantings did not significantly change the availability of macronutrients (N, K, Ca, Mg, P, and S) or micronutrients (Fe, B, Mn, Zn, and Cu), content of plant toxins (Al, Si), acidity, or salinity (Na, electrical conductivity) in the soil. In this medium rainfall area, native mixed-species plantings provided comparable rates of C sequestration to local production species, with the probable additional benefit of providing better quality habitat for native biota. These results demonstrate that reforestation using native mixed-species plantings is an effective alternative for carbon sequestration to standard monocultures of production species in medium rainfall areas of temperate continental climates, where they can effectively store C, convert C into stable pools and provide greater benefits for biodiversity.

Finite element modeling and analysis of thrombosis in middle cerebral artery

Thrombotic stroke, which is caused by blood clot in the cerebral artery, is a major source of increased mortality and morbidity. Considering as efficient and fastest methods, mathematical approaches have gained significant importance for analyzing and understanding the biological events like thrombosis. This paper presents a computational model to analyze the effects of thrombosis using the theory of coupled fluid dynamics-structure interaction. The finite element method is used for the modeling of thrombosis (blood clot) of different stages in the middle cerebral artery with physiological compliance. The developed model is used to investigate the consequences that occur due to the various sizes of clots in the artery in the form of blood flow velocity, blood pressure, and artery wall stress. Such numerical assessment will facilitate better understanding of the biophysical process in case of thrombosis and thus would support medical practitioners to take faster curing steps.

Stable feature selection for clinical prediction: Exploiting ICD tree structure using Tree-Lasso

Modern healthcare is getting reshaped by growing Electronic Medical Records (EMR). Recently, these records have been shown of great value towards building clinical prediction models. In EMR data, patients' diseases and hospital interventions are captured through a set of diagnoses and procedures codes. These codes are usually represented in a tree form (e.g. ICD-10 tree) and the codes within a tree branch may be highly correlated. These codes can be used as features to build a prediction model and an appropriate feature selection can inform a clinician about important risk factors for a disease. Traditional feature selection methods (e.g. Information Gain, T-test, etc.) consider each variable independently and usually end up having a long feature list. Recently, Lasso and related l1-penalty based feature selection methods have become popular due to their joint feature selection property. However, Lasso is known to have problems of selecting one feature of many correlated features randomly. This hinders the clinicians to arrive at a stable feature set, which is crucial for clinical decision making process. In this paper, we solve this problem by using a recently proposed Tree-Lasso model. Since, the stability behavior of Tree-Lasso is not well understood, we study the stability behavior of Tree-Lasso and compare it with other feature selection methods. Using a synthetic and two real-world datasets (Cancer and Acute Myocardial Infarction), we show that Tree-Lasso based feature selection is significantly more stable than Lasso and comparable to other methods e.g. Information Gain, ReliefF and T-test. We further show that, using different types of classifiers such as logistic regression, naive Bayes, support vector machines, decision trees and Random Forest, the classification performance of Tree-Lasso is comparable to Lasso and better than other methods. Our result has implications in identifying stable risk factors for many healthcare problems and therefore can potentially assist clinical decision making for accurate medical prognosis.

The characteristics and outcome of infective endocarditis involving implantable cardiac devices

Infection of implantable cardiac electronic devices in particular lead endocarditis (cardiac device infective endocarditis (CDIE)) is an emerging problem with significant morbidity, mortality and health care costs. The epidemiology is characterised with advanced age and health care association in cases presenting within 6 months of implantation. Risk factors include those of the patient, the procedure and the device. Staphylococcal species predominate as the causative organisms. Diagnosis is reliably made by blood cultures and transesophageal echocardiography. Complications include pulmonary and systemic emboli, persistent bacteremia and concomitant valvular involvement. Management includes complete device removal and prolonged antimicrobial therapy. With long-term follow-up to 1 year, the mortality of CDIE is as high as 23 %. It is associated with patient co-morbidities and concomitant valvular involvement and may be prevented by device removal during index admission.

Adult education and radical habitus in an environmental campaign: learning in the coal seam gas protests in Australia

Summary: This paper examines the adult learning dimensions of protestors as they participate in a campaign to stop coal seam gas exploration in Gippsland in Central Victoria, Australia. On a global level, the imposition of coal seam gas exploration by governments and mining companies has been the trigger for movements of resistance from environmental groups. They are concerned about the impact of mining on their land, food and water supplies. In central Gippsland a group of ‘circumstantial activists’ comprised of farmers, tree changers and other local residents are campaigning against coal seam gas exploration. This unlikely coalition of environmental action groups has made effective use of a variety of community education strategies. This paper commences by outlining some of the key literature on learning and activism drawing on the education tradition of adult learning. We then draw on key concepts from Bourdieu’s writing on ‘habitus’ and ‘field’ to analyse the data from this research. We outline some of the learning practices of activists; through their involvement in this campaign, and the knowledge and skills they gain as they develop a feel for the game of protest. We argue circumstantial activists learn both formally and informally in the social environment of campaigning. Of particular interest is the role of more experienced activists from Friends of the Earth (FOE), a non-government organisation (NGO), as they pass on knowledge, experience, tactics and strategies to the novice and less experienced activists in this community campaign. We explore some of the contradictions of the protestors’ identification as activists using Bourdieu’s concepts of ‘doxa’ and ‘Ilusio’. The paper concludes by arguing learning in activism is a rich tradition of adult education and practice. However, Bourdieu’s writing on field and habitus makes an added contribution to interpreting the learning that occurs in the social space of a campaign or social movement.

Individual differences in intention to fake job interviews: Personality, self-monitoring, and the theory of planned behaviour

When job applicants lie in job interviews, they can deprive a more honest candidate of a job and deprive an organisation of the best employees. To better understand job interview faking, the present study examined the effect of general dispositions and domain-specific beliefs on the intention to fake job interviews. A community sample of 313 participants completed measures of personality (i.e., extraversion, neuroticism, conscientiousness) and self-monitoring, and a domain-specific measure of beliefs about faking job interviews based on the theory of planned behaviour, which measured attitudes, subjective norms, and perceived behavioural control. Results indicated that the measure of attitudes was the strongest predictor of intention to fake. In line with the compatibility principle, the domain-specific measures based on the theory of planned behaviour correlated much more strongly with intentions to fake job interviews than did the general measures of personality or self-monitoring. Of the dispositional measures, lower conscientiousness, higher neuroticism, and higher self-monitoring was associated with greater intention to fake job interviews. The findings support a model whereby the effect of personality on intentions is partially mediated by domain-specific beliefs.

A prospective observational study of prevalence and outcomes of patients with Gold Standard Framework criteria in a tertiary regional Australian Hospital

OBJECTIVES: Report the use of an objective tool, UK Gold Standards Framework (GSF) criteria, to describe the prevalence, recognition and outcomes of patients with palliative care needs in an Australian acute health setting. The rationale for this is to enable hospital doctors to identify patients who should have a patient-centred discussion about goals of care in hospital.

DESIGN: Prospective, observational, cohort study.

PARTICIPANTS: Adult in-patients during two separate 24 h periods.

MAIN OUTCOME MEASURES: Prevalence of in-patients with GSF criteria, documentation of treatment limitations, hospital and 1 year survival, admission and discharge destination and multivariate regression analysis of factors associated with the presence of hospital treatment limitations and 1 year survival.

RESULTS: Of 626 in-patients reviewed, 171 (27.3%) had at least one GSF criterion, with documentation of a treatment limitation discussion in 60 (30.5%) of those patients who had GSF criteria. Hospital mortality was 9.9%, 1 year mortality 50.3% and 3-year mortality 70.2% in patients with GSF criteria. One-year mortality was highest in patients with GSF cancer (73%), renal failure (67%) and heart failure (60%) criteria. Multivariate analysis revealed age, hospital length of stay and presence of the GSF chronic obstructive pulmonary disease criteria were independently associated with the likelihood of an in-hospital treatment limitation. Non-survivors at 3 years were more likely to have a GSF cancer (25% vs 6%, p=0.004), neurological (10% vs 3%, p=0.04), or frailty (45% vs 3%, p=0.04) criteria. After multivariate logistic regression GSF cancer criteria, renal failure criteria and the presence of two or more GSF clinical criteria were independently associated with increased risk of death at 3 years. Patients returning home to live reduced from 69% (preadmission) to 27% after discharge.

CONCLUSIONS: The use of an objective clinical tool identifies a high prevalence of patients with palliative care needs in the acute tertiary Australian hospital setting, with a high 1 year mortality and poor return to independence in this population. The low rate of documentation of discussions about treatment limitations in this population suggests palliative care needs are not recognised and discussed in the majority of patients.

TRIAL REGISTRATION NUMBER: 11/121.

Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction

BACKGROUND: Heart failure is associated with high mortality and hospital readmissions. Beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) can improve survival and reduce hospital readmissions and are recommended as first-line therapy in the treatment of heart failure. Evidence has also shown that there is a dose-dependent relationship of these medications with patient outcomes. Despite this evidence, primary care physicians are reluctant to up-titrate these medications. New strategies aimed at facilitating this up-titration are warranted. Nurse-led titration (NLT) is one such strategy. OBJECTIVES: To assess the effects of NLT of beta-adrenergic blocking agents, ACEIs, and ARBs in patients with heart failure with reduced ejection fraction (HFrEF) in terms of safety and patient outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL Issue 11 of 12, 19/12/2014), MEDLINE OVID (1946 to November week 3 2014), and EMBASE Classic and EMBASE OVID (1947 to 2014 week 50). We also searched reference lists of relevant primary studies, systematic reviews, clinical trial registries, and unpublished theses sources. We used no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing NLT of beta-adrenergic blocking agents, ACEIs, and/or ARBs comparing the optimisation of these medications by a nurse to optimisation by another health professional in patients with HFrEF. DATA COLLECTION AND ANALYSIS: Two review authors (AD & JC) independently assessed studies for eligibility and risk of bias. We contacted primary authors if we required additional information. We examined quality of evidence using the GRADE rating tool for RCTs. We analysed extracted data by risk ratio (RR) with 95% confidence interval (CI) for dichotomous data to measure effect sizes of intervention group compared with usual-care group. Meta-analyses used the fixed-effect Mantel-Haenszel method. We assessed heterogeneity between studies by Chi(2) and I(2). MAIN RESULTS: We included seven studies (1684 participants) in the review. One study enrolled participants from a residential care facility, and the other six studies from primary care and outpatient clinics. All-cause hospital admission data was available in four studies (556 participants). Participants in the NLT group experienced a lower rate of all-cause hospital admissions (RR 0.80, 95% CI 0.72 to 0.88, high-quality evidence) and fewer hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72, moderate-quality evidence) compared to the usual-care group. Six studies (902 participants) examined all-cause mortality. All-cause mortality was also lower in the NLT group (RR 0.66, 95% CI 0.48 to 0.92, moderate-quality evidence) compared to usual care. Approximately 27 deaths could be avoided for every 1000 people receiving NLT of beta-adrenergic blocking agents, ACEIs, and ARBs. Only three studies (370 participants) reported outcomes on all-cause and heart failure-related event-free survival. Participants in the NLT group were more likely to remain event free compared to participants in the usual-care group (RR 0.60, 95% CI 0.46 to 0.77, moderate-quality evidence). Five studies (966 participants) reported on the number of participants reaching target dose of beta-adrenergic blocking agents. This was also higher in the NLT group compared to usual care (RR 1.99, 95% CI 1.61 to 2.47, low-quality evidence). However, there was a substantial degree of heterogeneity in this pooled analysis. We rated the risk of bias in these studies as high mainly due to a lack of clarity regarding incomplete outcome data, lack of reporting on adverse events associated with the intervention, and the inability to blind participants and personnel. Participants in the NLT group reached maximal dose of beta-adrenergic blocking agents in half the time compared with participants in usual care. Two studies reported on adverse events; one of these studies stated there were no adverse events, and the other study found one adverse event but did not specify the type or severity of the adverse event. AUTHORS' CONCLUSIONS: Participants in the NLT group experienced fewer hospital admissions for any cause and an increase in survival and number of participants reaching target dose within a shorter time period. However, the quality of evidence regarding the proportion of participants reaching target dose was low and should be interpreted with caution. We found high-quality evidence supporting NLT as one strategy that may improve the optimisation of beta-adrenergic blocking agents resulting in a reduction in hospital admissions. Despite evidence of a dose-dependent relationship of beta-adrenergic blocking agents, ACEIs, and ARBs with improving outcomes in patients with HFrEF, the translation of this evidence into clinical practice is poor. NLT is one strategy that facilitates the implementation of this evidence into practice.