Evidence-based recommendations for the diagnosis of ankylosing spondylitis: Results from the Australian 3E initiative in rheumatology

• As part of the 3E program, we conducted a systematic literature review and gathered consensus from 23 practising Australian rheumatologists to develop guidelines for early identification of ankylosing spondylitis and specialist referral. • In three rounds of break-out sessions followed by discussion and voting, the specialist panel addressed three questions related to diagnosis of ankylosing spondylitis: In individuals with back pain, what are the early clinical features that suggest ankylosing spondylitis? How useful is imaging in identifying early ankylosing spondylitis? Based on which clinical features should a general practitioner refer a patient to a rheumatologist for further evaluation? • The panel agreed on six recommendations related to the three questions: 1a. Early clinical features to suggest ankylosing spondylitis include inflammatory back pain and age at symptom onset < 45 years. 1b. The absence of symptomatic response to an appropriate course of non-steroidal anti-inflammatory drugs makes the diagnosis of ankylosing spondylitis less likely. 1c. Raised inflammatory markers are supportive, but their absence does not rule out the diagnosis of ankylosing spondylitis. 2a. Despite low sensitivity to detect changes of early ankylosing spondylitis, plain radiographs of the pelvis and spine are appropriate initial imaging techniques. 2b. Magnetic resonance imaging is a useful imaging modality for detecting early changes of ankylosing spondylitis. 3. Individuals with inflammatory back pain should be referred to a rheumatologist for further evaluation. • Effective dissemination and implementation of these recommendations are important to standardise the approach to early diagnosis of ankylosing spondylitis.

Evidence-based recommendations for the monitoring and treatment of ankylosing spondylitis: Results from the Australian 3E initiative in rheumatology

Aim: To develop a set of Australian recommendations for the monitoring and treatment of ankylosing spondylitis (AS) through systematic literature review combined with the opinion of practicing rheumatologists. Methods: A set of eight questions, four in each domain of monitoring and treatment, were formulated by voting and the Delphi method. The results of a systematic literature review addressing each question were presented to the 23 participants of the Australian 3E meeting. All participants were clinical rheumatologists experienced in the daily management of AS. Results: After three rounds of breakout sessions to discuss the findings of the literature review, a set of recommendations was finalized after discussion and voting. The category of evidence and strength of recommendation were determined for each proposal. The level of agreement among participants was excellent (mean 84%, range 64-100%). Conclusions: The 12 recommendations developed from evidence and expert opinion provide guidance for the daily management of AS patients. For most recommendations, we found a paucity of supportive evidence in the literature highlighting the need for additional clinical studies.

Complex crystallization dynamics in amorphous germanium observed with dynamic transmission electron microscopy

Crystallization of amorphous germanium (a-Ge) by laser or electron beam heating is a remarkably complex process that involves several distinct modes of crystal growth and the development of intricate microstructural patterns on the nanosecond to ten microsecond time scales. Here we use dynamic transmission electron microscopy (DTEM) to study the fast, complex crystallization dynamics with 10 nm spatial and 15 ns temporal resolution. We have obtained time-resolved real-space images of nanosecond laser-induced crystallization in a-Ge with unprecedentedly high spatial resolution. Direct visualization of the crystallization front allows for time-resolved snapshots of the initiation and roughening of the dendrites on submicrosecond time scales. This growth is followed by a rapid transition to a ledgelike growth mechanism that produces a layered microstructure on a time scale of several microseconds. This study provides insights into the mechanisms governing this complex crystallization process and is a dramatic demonstration of the power of DTEM for studying time-dependent material processes far from equilibrium.

In situ investigation of explosive crystallization in a-Ge: Experimental determination of the interface response function using dynamic transmission electron microscopy

The crystallization of amorphous semiconductors is a strongly exothermic process. Once initiated the release of latent heat can be sufficient to drive a self-sustaining crystallization front through the material in a manner that has been described as explosive. Here, we perform a quantitative in situ study of explosive crystallization in amorphous germanium using dynamic transmission electron microscopy. Direct observations of the speed of the explosive crystallization front as it evolves along a laser-imprinted temperature gradient are used to experimentally determine the complete interface response function (i.e., the temperature-dependent front propagation speed) for this process, which reaches a peak of 16 m/s. Fitting to the Frenkel-Wilson kinetic law demonstrates that the diffusivity of the material locally/immediately in advance of the explosive crystallization front is inconsistent with those of a liquid phase. This result suggests a modification to the liquid-mediated mechanism commonly used to describe this process that replaces the phase change at the leading amorphous-liquid interface with a change in bonding character (from covalent to metallic) occurring in the hot amorphous material.

The effect of an in–shoe orthotic heel lift on loading of the Achilles tendon during shod walking

- Study Design Controlled laboratory study - Objective To investigate the effect of a 12–mm in–shoe orthotic heel lift on Achilles tendon loading during shod walking using transmission–mode ultrasonography. - Background Orthotic heel lifts are thought to lower tension in the Achilles tendon but evidence for this effect is equivocal. - Methods The propagation speed of ultrasound, which is governed by the elastic modulus and density of tendon and is proportional to the tensile load to which it is exposed, was measured in the right Achilles tendon of twelve recreationally–active males during shod treadmill walking at matched speeds (3.4±0.7 km/h), with and without addition of a heel lift. Vertical ground reaction force and spatiotemporal gait parameters were simultaneously recorded. Data were acquired at 100Hz during 10s of steady–state walking. Statistical comparisons were made using paired t–tests (α=.05). - Results Ultrasound transmission speed in the Achilles tendon was characterized by two maxima (P1, P2) and minima (M1, M2) during walking. Addition of a heel lift to footwear resulted in a 2% increase and 2% decrease in the first vertical ground reaction force peak and the local minimum, respectively (P<.05). Peak ultrasonic velocity in the Achilles tendon (P1, P2, M2) was significantly lower with addition of an orthotic heel lift (P<.05). - Conclusions Peak ultrasound transmission speed in the Achilles tendon was lower with the addition of a 12–mm orthotic heel lift, indicating the heel lift reduced tensile load in the Achilles tendon, thereby counteracting the effect of footwear. These findings support the addition of orthotic heel lifts to footwear in the rehabilitation of Achilles tendon disorders where management aims to lower tension within the tendon. - Level of Evidence Therapy, level 2a

Regional Differences in the Influence of Irrigation on Climate

A global climate model experiment is performed to evaluate the effect of irrigation on temperatures in several major irrigated regions of the world. The Community Atmosphere Model, version 3.3, was modified to represent irrigation for the fraction of each grid cell equipped for irrigation according to datasets from the Food and Agriculture Organization. Results indicate substantial regional differences in the magnitude of irrigation-induced cooling, which are attributed to three primary factors: differences in extent of the irrigated area, differences in the simulated soil moisture for the control simulation (without irrigation), and the nature of cloud response to irrigation. The last factor appeared especially important for the dry season in India, although further analysis with other models and observations are needed to verify this feedback. Comparison with observed temperatures revealed substantially lower biases in several regions for the simulation with irrigation than for the control, suggesting that the lack of irrigation may be an important component of temperature bias in this model or that irrigation compensates for other biases. The results of this study should help to translate the results from past regional efforts, which have largely focused on the United States, to regions in the developing world that in many cases continue to experience significant expansion of irrigated land.

Is there a relationship between screening for diabetes related foot complications and limb amputation?

Background From the conservative estimates of registrants with the National Diabetes Supply Scheme, we will be soon passing 1.1 Million Australians affected by all types of diabetes. The diabetes complications of foot ulceration and amputation are costly to all. These costs can be reduced with appropriate prevention strategies, starting with identifying people at risk through primary care diabetic foot screening. Yet levels of diabetic foot screening in Australia are difficult to quantify. This presentation aims to report on foot screening rates as recorded in existing academic literature, national health surveys and national database reports. Methods Literature searches included diabetic foot screening that occurred in the primary care setting for populations over 2000 people from 2002 to 2014. Searches were performed using Medline and CINAHL as well as internet searches of Organisations for Economic Co-operation and Development (OECD) countries health databases. The focus is on type 1 and type 2 diabetes in adults, and not gestational diabetes or children. The two primary outcome measures were foot -screening rates as a percentage of adult diabetic population and major lower limb amputation incidence rates from standardised OECD data. Results The most recent and accurate level for Australian population review was in the AUSDIAB (Australian Diabetes and lifestyle survey) from 2004. This survey reported screening in primary care to be as low as 50%. Countries such as the United Kingdom and United States of America have much higher reported rates of foot screening (67-86%) recorded using national databases and web based initiatives that involve patients and clinicians. By comparison major amputation rates for Australia were similar to the United Kingdom at 6.5 versus 5.1 per 100,000 population, but dis-similar to the United States of America at 17 per 100,000 population. Conclusions Australian rates of diabetic foot screening in primary care centres is ambiguous. There is no direct relationship between foot screening levels in a primary care environment and major lower limb amputation, based on national health survey's and OECD data. Uptake of national registers, incentives and web-based systems improve levels of diabetic foot assessment, which are the first steps to a healthier diabetic population.

A note on acyclic edge coloring of complete bipartite graphs

An acyclic edge coloring of a graph is a proper edge coloring such that there are no bichromatic (2-colored) cycles. The acyclic chromatic index of a graph is the minimum number k such that there is an acyclic edge coloring using k colors and is denoted by a'(G). Let Delta = Delta(G) denote the maximum degree of a vertex in a graph G. A complete bipartite graph with n vertices on each side is denoted by K-n,K-n. Alon, McDiarmid and Reed observed that a'(K-p-1,K-p-1) = p for every prime p. In this paper we prove that a'(K-p,K-p) <= p + 2 = Delta + 2 when p is prime. Basavaraju, Chandran and Kummini proved that a'(K-n,K-n) >= n + 2 = Delta + 2 when n is odd, which combined with our result implies that a'(K-p,K-p) = p + 2 = Delta + 2 when p is an odd prime. Moreover we show that if we remove any edge from K-p,K-p, the resulting graph is acyclically Delta + 1 = p + 1-edge-colorable. (C) 2009 Elsevier B.V. All rights reserved.

Field assessment of avocado rootstock selections for resistance to Phytophthora root rot.

Phytophthora root rot (PRR), caused by P. cinnamomi, is a primary constraint on avocado productivity in Australia. Numerous field trials at sites in northern NSW and southern QLD have demonstrated significant variation in tree health amongst commercial rootstocks and recently selected material, grown under high PRR disease pressure. Selections 'SHSR-02', 'SHSR-04', ungrafted 'Hass' (rooted cuttings from clonal propagation) and the commercial rootstock 'DusaTM' were significantly healthier over time than other rootstocks, many of which died during the course of the trials. 'Reed' was consistently highly susceptible. In many cases superior tree health was associated with increased tree height and trunk girth. The trials also clearly demonstrate the negative impact of Phytophthora root rot on establishment of new avocado production blocks, and the importance of identifying and selecting avocado rootstock material that can withstand high P. cinnamomi disease pressure.

Pathogenicity studies in avocado with three nectriaceous fungi, Calonectria ilicicola, Gliocladiopsis sp and Ilyonectria liriodendri

Calonectria ilicicola, Gliocladiopsis sp. and Ilyonectria liriodendri were isolated from diseased roots of young avocado trees. Pathogenicity studies with seedlings of three avocado cultivars, Velvick, Hass and Reed, demonstrated that Calonectria ilicicola is a severe root rot pathogen, reducing the biomass of healthy roots, and reducing plant height over time. Calonectria ilicicola was re-isolated from diseased roots. Ilyonectria liriodendri and Gliocladiopsis sp. were not pathogenic and plant height was increased after Gliocladiopsis sp. amendment compared to all other treatments in trials with cvs Velvick and Hass.

Enhancing somatic embryogenesis in avocado (Persea americana Mill.) using a two-step culture system and including glutamine in the culture medium

The development of a more efficient in vitro regeneration system for somatic embryos (SEs) of avocado (Persea americana) would facilitate the development of new superior cultivars for this valuable horticultural crop. In this study, we report a new and efficient method for maintenance and regeneration of avocado SEs. Avocado SEs of four cultivars remained healthy and viable in vitro for 11 months on a medium used for mango somatic embryogenesis, compared with 3-4 months on Murashige and Skoog medium. Various supplements and media modifications were investigated to improve the low conversion rate of regenerated plants from avocado SEs reported previously. The one-step system for regeneration of white-opaque somatic embryos (WOSEs) used solid medium only over a period of 12-14 weeks (sub-culturing every 6 weeks). Addition of praline and glutamine improved the total regeneration from 0 to 17.5% and 10.5%, and plant/shoot recovery from 0 to 12.5% and 5%, respectively. A two-step culture system involving the transfer of WOSEs of cultivar 'Reed' after 6 weeks on solid to liquid medium for 12-15 days as an intermediate step, followed by subculturing again onto solid medium for 6 weeks improved total regeneration to 29% and plant/shoot recovery to 18.3 from 0% when regenerated by subculturing on solid medium only. Supplementation with proline in the solid as well as liquid medium in the two-step culture system at 0.4 g/L increased total regeneration to 35% and plant/shoot recovery to 20%. We were able to achieve highest regeneration using glutamine at 1 g/L in the two-step culture system in terms of both total regeneration (58.3%, including 43.3% bipolar regeneration) and plant/shoot recovery (36.7%) rates, which were significantly higher than in any other treatment investigated. (C) 2013 Elsevier B.V. All rights reserved.

Rectangular universal cellular array

A rectangular universal cellular array consisting of cells having three inputs and one output is described. This array is based on the Reed-Muller canonical expansion of a switching function. Although the total number of external input pins required in this array is the same as that of a rectangular array proposed in the literature, the number of cells is very much less.

A Note on Easily Testable Realizations for Logic Functions

It is shown that at most, n + 3 tests are required to detect any single stuck-at fault in an AND gate or a single faulty EXCLUSIVE OR (EOR) gate in a Reed-Muller canonical form realization of a switching function.

Coastal environmental gradients – Key to reproduction habitat mapping of freshwater fish in the Baltic Sea

Habitat requirements of fish are most strict during the early life stages, and the quality and quantity of reproduction habitats lays the basis for fish production. A considerable number of fish species in the northern Baltic Sea reproduce in the shallow coastal areas, which are also the most heavily exploited parts of the brackish marine area. However, the coastal fish reproduction habitats in the northern Baltic Sea are poorly known. The studies presented in this thesis focused on the influence of environmental conditions on the distribution of coastal reproduction habitats of freshwater fish. They were conducted in vegetated littoral zone along an exposure and salinity gradient extending from the innermost bays to the outer archipelago on the south-western and southern coasts of Finland, in the northern Baltic Sea. Special emphasis was placed on reed-covered Phragmites australis shores, which form a dominant vegetation type in several coastal archipelago areas. The main aims of this research were to (1) develop and test new survey and mapping methods, (2) investigate the environmental requirements that govern the reproduction of freshwater fish in the coastal area and (3) survey, map and model the distribution of the reproduction habitats of pike (Esox lucius) and roach (Rutilus rutilus). The white plate and scoop method with a standardized sampling time and effort was demonstrated to be a functional method for sampling the early life stages of fish in dense vegetation and shallow water. Reed-covered shores were shown to form especially important reproduction habitats for several freshwater fish species, such as pike, roach, other cyprinids and burbot, in the northern Baltic Sea. The reproduction habitats of pike were limited to sheltered reed- and moss-covered shores of the inner and middle archipelago, where suitable zooplankton prey were available and the influence of the open sea was low. The reproduction habitats of roach were even more limited and roach reproduction was successful only in the very sheltered reed-covered shores of the innermost bay areas, where salinity remained low (< 4‰) during the spawning season due to freshwater inflow. After identifying the critical factors restricting the reproduction of pike and roach, the spatial distribution of their reproduction habitats was successfully mapped and modelled along the environmental gradients using only a few environmental predictor variables. Reproduction habitat maps are a valuable tool promoting the sustainable use and management of exploited coastal areas and helping to maintain the sustainability of fish populations. However, the large environmental gradients and the extensiveness of the archipelago zone in the northern Baltic Sea demand an especially high spatial resolution of the coastal predictor variables. Therefore, the current lack of accurate large-scale, high-resolution spatial data gathered at exactly the right time is a considerable limitation for predictive modelling of shallow coastal waters.

Prevalence of foot disease and risk factors in general inpatient populations: A systematic review and meta-analysis

Objective: To systematically review studies reporting the prevalence in general adult inpatient populations of foot disease disorders (foot wounds, foot infections, collective ‘foot disease’) and risk factors (peripheral arterial disease (PAD), peripheral neuropathy (PN), foot deformity). Methods: A systematic review of studies published between 1980 and 2013 was undertaken using electronic databases (MEDLINE, EMBASE and CINAHL). Keywords and synonyms relating to prevalence, inpatients, foot disease disorders and risk factors were used. Studies reporting foot disease or risk factor prevalence data in general inpatient populations were included. Included study's reference lists and citations were searched and experts consulted to identify additional relevant studies. 2 authors, blinded to each other, assessed the methodological quality of included studies. Applicable data were extracted by 1 author and checked by a second author. Prevalence proportions and SEs were calculated for all included studies. Pooled prevalence estimates were calculated using random-effects models where 3 eligible studies were available. Results: Of the 4972 studies initially identified, 78 studies reporting 84 different cohorts (total 60 231 517 participants) were included. Foot disease prevalence included: foot wounds 0.01–13.5% (70 cohorts), foot infections 0.05–6.4% (7 cohorts), collective foot disease 0.2–11.9% (12 cohorts). Risk factor prevalence included: PAD 0.01–36.0% (10 cohorts), PN 0.003–2.8% (6 cohorts), foot deformity was not reported. Pooled prevalence estimates were only able to be calculated for pressure ulcer-related foot wounds 4.6% (95% CI 3.7% to 5.4%)), diabetes-related foot wounds 2.4% (1.5% to 3.4%), diabetes-related foot infections 3.4% (0.2% to 6.5%), diabetes-related foot disease 4.7% (0.3% to 9.2%). Heterogeneity was high in all pooled estimates (I2=94.2–97.8%, p<0.001). Conclusions: This review found high heterogeneity, yet suggests foot disease was present in 1 in every 20 inpatients and a major risk factor in 1 in 3 inpatients. These findings are likely an underestimate and more robust studies are required to provide more precise estimates.