COS-STAR: a reporting guideline for studies developing core outcome sets (protocol)

BACKGROUND: Core outcome sets can increase the efficiency and value of research and, as a result, there are an increasing number of studies looking to develop core outcome sets (COS). However, the credibility of a COS depends on both the use of sound methodology in its development and clear and transparent reporting of the processes adopted. To date there is no reporting guideline for reporting COS studies. The aim of this programme of research is to develop a reporting guideline for studies developing COS and to highlight some of the important methodological considerations in the process.

METHODS/DESIGN: The study will include a reporting guideline item generation stage which will then be used in a Delphi study. The Delphi study is anticipated to include two rounds. The first round will ask stakeholders to score the items listed and to add any new items they think are relevant. In the second round of the process, participants will be shown the distribution of scores for all stakeholder groups separately and asked to re-score. A final consensus meeting will be held with an expert panel and stakeholder representatives to review the guideline item list. Following the consensus meeting, a reporting guideline will be drafted and review and testing will be undertaken until the guideline is finalised. The final outcome will be the COS-STAR (Core Outcome Set-STAndards for Reporting) guideline for studies developing COS and a supporting explanatory document.

DISCUSSION: To assess the credibility and usefulness of a COS, readers of a COS development report need complete, clear and transparent information on its methodology and proposed core set of outcomes. The COS-STAR guideline will potentially benefit all stakeholders in COS development: COS developers, COS users, e.g. trialists and systematic reviewers, journal editors, policy-makers and patient groups.

Panning for Gold: The Standardizing Work of Filling “Autistic” Shells – Using institutional ethnography to explore textually mediated health relations in the diagnostic process of autism.

Health reform practices in Canada and elsewhere have restructured the purpose and use of diagnostic labels and the processes of naming such labels. Diagnoses are no longer only a means to tell doctors and patients what may be wrong and indicate potential courses of treatment; some diagnoses activate specialized services and supports for persons with a disability and those who provide care for them. In British Columbia, a standardized process of diagnosis with the outcome of an autism spectrum disorder gives access to government provided health care and educational services and supports. Such processes enter individuals into a complex of text mediated relations, regulated by the principles of evidence-based medicine. However, the diagnosis of autism in children is notoriously uncertain. Because of this ambiguity, standardizing the diagnostic process creates a hurdle in gaining help and support for parents who have children with problems that could lead to a diagnosis on the autism spectrum. Such processes and their organizing relations are problematized, explored and explicated below. Grounded in the epistemological and ontological shift offered by Dorothy E. Smith (1987; 1990a; 1999; 2005), this article reports on the findings of an institutional ethnographic study that explored the diagnostic process of autism in British Columbia. More specifically, this article focuses on the processes involved in going from mothers talking from their experience about their childrens problems to the formalized and standardized, and thus “virtually” produced, diagnoses that may or may not give access to services and supports in different systems of care. Two psychologists, a developmental pediatrician, a social worker – members of a specialized multidisciplinary assessment team – and several mothers of children with a diagnosis on the autism spectrum were interviewed. The implications of standardizing the diagnosis process of a disability that is not clear-cut and has funding attached are discussed. This ethnography also provides a glimpse of the implications of current and ongoing reforms in the state-supported health care system in British Columbia, and more generally in Canada, for people’s everyday doings.

Managing patient deterioration: evaluation of what works.

Background: Rapid Response Systems (RRS) have been implemented nationally and internationally to improve patient safety in hospital. However, to date the majority of the RRS research evidence has focused on measuring the effectiveness of the intervention on patient outcomes. To evaluate RRS it has been recommended that a multimodal approach is required to address the broad range of process and outcome measures required to determine the effectiveness of the RRS concept. Aim: The aim of this paper is to evaluate the official RRS programme theoretical assumptions regarding how the programme is meant to work against actual practice in order to determine what works. Methods: The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory [1]. This approach used a variety of mixed methods to test the programme theories including individual and focus group interviews with a purposive sample of 75 nurses and doctors, observation of ward practices and documentary analysis. The findings from the case studies were analysed and compared within and across cases to identify what works for whom and in what circumstances. Results: The RRS programme theories were critically evaluated and compared with study findings to develop a mid-range theory to explain what works, for whom in what circumstances. The findings of what works suggests that clinical experience, established working relationships, flexible implementation of protocols, ongoing experiential learning, empowerment and pre-emptive management are key to the success of RRS implementation.  Conclusion:These findings highlight the combination of factors that can improve the implementation of RRS and in light of this evidence several recommendations are made to provide policymakers with guidance and direction for their success and sustainability.References: 1.Pawson R and Tilley N. (1997) Realistic Evaluation. Sage Publications; LondonType of submission: Concurrent session Source of funding: Sandra Ryan Fellowship funded by the School of Nursing & Midwifery, Queen’s University of Belfast

Realist Evaluation: a theory driven approach.

Realistic Evaluation assumes that all programmes implemented in practice have an underlying theory to explain how a particular intervention is meant to work. The purpose of realist evaluation is to test the theoretical propositions underpinning the implementation of a programme in order to understand how and why it works, or might not work, in certain circumstances. The first stage of the realist evaluation is to track and articulate the programme theories to determine the evidence on the ‘official conjecture’ (Pawson et al 2004 pg 16) of how the programme is suppose to work in practice. These official conjectures are then tested and refined by gathering empirical evidence to establish causal relationships between a programme and its outcome. Evaluation of the factors and interactions between factors, supporting or hindering the implementation of a programme in practice facilitate theory refinement. Theory refinement is viewed as an iterative and cyclical process undertaken to synthesise the empirical evidence and develop mid-range theories which can be generalised and applied to other programmes to improve implementation and sustainability. In this symposium an example of realist evaluation used to test and refine the theory underpinning the implementation of Early Warning Systems (EWS) is provided to clarify how this theory driven approach can be applied in practice.

Network relationships and the internationalisation of the tourism economy: The case of Portuguese overseas investment in the hotel sector

O presente trabalho de investigação analisa a importância das redes formais e informais na internacionalização da economia do turismo, em particular do sector hoteleiro. Para tal baseia-se numa extensa revisão bibliográfica sobre as teorias que explicam o investimento directo no estrangeiro, assim como a abordagem das redes aplicada à internacionalização e o seu enquadramento no sector do turismo. Com base na revisão de literatura, uma série de hipóteses são sugeridas, as quais são testadas na parte empírica da tese através de uma análise às empresas Portuguesas com investimentos no estrangeiro na área da hotelaria até ao final de 2007 ou com projectos em curso. Esta análise baseia-se principalmente em dados obtidos através de entrevistas-questionário realizadas aos responsáveis das empresas. O inquérito obteve 40% de taxa de resposta, contendo dados relativos às características das empresas e de cada um dos projectos realizados no estrangeiro. Com base nestes resultados são sugeridas uma série de implicações, assim como algumas recomendações para investigações futuras. Adicionalmente, e de forma a investigar mercados com diferentes realidades sócio-culturais, políticas e cultura de negócios, foi analisado o caso de Goa, através de trabalho de campo que envolveu entrevistas informais e semiestruturadas a entidades-chave ligadas ao sector do turismo e aos hoteleiros de unidades de qualidade média-alta. Foi identificado um conjunto de oportunidades e desafios para as empresas Portuguesas. Ao usar uma abordagem qualitativa e quantitativa, esta tese contribui para a compreensão da natureza, determinantes e dimensões do processo de internacionalização do sector do turismo.

Interacção entre estruturas intervalares e estruturas espectrais, na música instrumental/vocal

A presente tese apresenta-se num formato bipartido, sendo a primeira parte uma investigação teórica e a segunda parte um conjunto de composições originais que procuram estabelecer, directa e indirectamente, uma relação com a temática investigada. A investigação incide sobre as diferentes relações que se podem estabelecer entre estruturas intervalares e estruturas espectrais, a partir de um conjunto representativo de obras de diferentes compositores. As obras originais da segunda parte configuram um objecto final de análise e reflexão. As composições que integram a segunda parte da tese são: Inês – sete miniaturas sobre A Castro, para soprano e orquestra, sobre excertos de “Castro”, de António Ferreira; Um sino contra o tempo, para flauta, clarinete, percussão e piano; Terra, para orquestra de cordas; Dor e Amor, para voz, flauta, clarinete, percussão, harpa, piano, violino, viola e violoncelo, sobre poemas de Nuno Júdice; e Ode a Gaia, para soprano solo, coro misto e electrónica, a partir de textos de diversos autores e épocas, desde Homero a Fernando Pessoa. Esta investigação surge a partir da convicção de que é possível e enriquecedor para a composição a coexistência e o estabelecimento de uma relação entre estruturas que valorizam as qualidades dos intervalos que as constituem e estruturas de tipo espectral. Se o pensamento intervalar pode ser relacionado com princípios de estruturação ligados a toda uma tradição musical, desde a música modal, à tonal e à atonal, o pensamento espectral relaciona-se com o estudo do fenómeno sonoro e do timbre e é integrado mais tardiamente no séc. XX como um possível modelo estruturante na composição. A investigação sobre as obras seleccionadas, sobretudo de compositores que colocam o fenómeno da percepção num plano central, procura diferentes interacções entre os dois tipos de estrutura, interrogando-se sobre em que medida é que essa interacção influencia ou é mesmo determinante para o resultado musical final. São analisadas diferentes aplicações, tais como: a procura de qualidades acústicas na criação de estruturas intervalares, a criação de timbres particulares para linhas estruturantes, a manipulação tímbrica de estruturas verticais, a inter-relação de camadas intervalares e espectrais na textura musical de forma sincrónica e diacrónica, e o surgimento de material intervalar a partir de estruturas espectrais. Os principais resultados passam pela confirmação de que o pensamento intervalar é compatível com o pensamento espectral e vice-versa, podendo-se concluir que são essenciais diferentes funções para os dois tipos de estrutura na textura musical e que quer as estruturas intervalares quer as espectrais se relacionam com diferentes aspectos da percepção, tendo, assim, uma influência determinante no resultado musical final, na eficácia da escuta e na sua fruição.

Beyond the artefact and techno-centricity: towards process-centric understanding of architecture - alternative facilitation strategies and proposals

The artefact and techno-centricity of the research into the architecture process needs to be counterbalanced by other approaches. An increasing amount of information is collected and used in the process, resulting in challenges related to information and knowledge management, as this research evidences through interviews with practicing architects. However, emerging technologies are expected to resolve many of the traditional challenges, opening up new avenues for research. This research suggests that among them novel techniques addressing how architects interact with project information, especially that indirectly related to the artefacts, and tools which better address the social nature of work, notably communication between participants, become a higher priority. In the fields associated with the Human Computer Interaction generic solutions still frequently prevail, whereas it appears that specific alternative approaches would be particularly in demand for the dynamic and context dependent design process. This research identifies an opportunity for a process-centric and integrative approach for architectural practice and proposes an information management and communication software application, developed for the needs discovered in close collaboration with architects. Departing from the architects’ challenges, an information management software application, Mneme, was designed and developed until a working prototype. It proposes the use of visualizations as an interface to provide an overview of the process, facilitate project information retrieval and access, and visualize relationships between the pieces of information. Challenges with communication about visual content, such as images and 3D files, led to a development of a communication feature allowing discussions attached to any file format and searchable from a database. Based on the architects testing the prototype and literature recognizing the subjective side of usability, this thesis argues that visualizations, even 3D visualizations, present potential as an interface for information management in the architecture process. The architects confirmed that Mneme allowed them to have a better project overview, to easier locate heterogeneous content, and provided context for the project information. Communication feature in Mneme was seen to offer a lot of potential in design projects where diverse file formats are typically used. Through empirical understanding of the challenges in the architecture process, and through testing the resulting software proposal, this thesis suggests promising directions for future research into the architecture and design process.

Evaluation of thermochemical biomass conversion in fluidized bed

Dado o aumento acelerado dos preços dos combustíveis fósseis e as incertezas quanto à sua disponibilidade futura, tem surgido um novo interesse nas tecnologias da biomassa aplicadas à produção de calor, eletricidade ou combustíveis sintéticos. Não obstante, para a conversão termoquímica de uma partícula de biomassa sólida concorrem fenómenos bastante complexos que levam, em primeiro lugar, à secagem do combustível, depois à pirólise e finalmente à combustão ou gasificação propriamente ditas. Uma descrição relativamente incompleta de alguns desses estágios de conversão constitui ainda um obstáculo ao desenvolvimento das tecnologias que importa ultrapassar. Em particular, a presença de elevados conteúdos de matéria volátil na biomassa põe em evidência o interesse prático do estudo da pirólise. A importância da pirólise durante a combustão de biomassa foi evidenciada neste trabalho através de ensaios realizados num reator piloto de leito fluidizado borbulhante. Verificou-se que o processo ocorre em grande parte à superfície do leito com chamas de difusão devido à libertação de voláteis, o que dificulta o controlo da temperatura do reator acima do leito. No caso da gasificação de biomassa a pirólise pode inclusivamente determinar a eficiência química do processo. Isso foi mostrado neste trabalho durante ensaios de gasificação num reator de leito fluidizado de 2MWth, onde um novo método de medição permitiu fechar o balanço de massa ao gasificador e monitorizar o grau de conversão da biomassa. A partir destes resultados tornou-se clara a necessidade de descrever adequadamente a pirólise de biomassa com vista ao projeto e controlo dos processos. Em aplicações de engenharia há particular interesse na estequiometria e propriedades dos principais produtos pirolíticos. Neste trabalho procurou-se responder a esta necessidade, inicialmente através da estruturação de dados bibliográficos sobre rendimentos de carbonizado, líquidos pirolíticos e gases, assim como composições elementares e poderes caloríficos. O resultado traduziu-se num conjunto de parâmetros empíricos de interesse prático que permitiram elucidar o comportamento geral da pirólise de biomassa numa gama ampla de condições operatórias. Para além disso, propôs-se um modelo empírico para a composição dos voláteis que pode ser integrado em modelos compreensivos de reatores desde que os parâmetros usados sejam adequados ao combustível ensaiado. Esta abordagem despoletou um conjunto de ensaios de pirólise com várias biomassas, lenhina e celulose, e temperaturas entre os 600 e 975ºC. Elevadas taxas de aquecimento do combustível foram alcançadas em reatores laboratoriais de leito fluidizado borbulhante e leito fixo, ao passo que um sistema termo-gravimétrico permitiu estudar o efeito de taxas de aquecimento mais baixas. Os resultados mostram que, em condições típicas de processos de combustão e gasificação, a quantidade de voláteis libertada da biomassa é pouco influenciada pela temperatura do reator mas varia bastante entre combustíveis. Uma análise mais aprofundada deste assunto permitiu mostrar que o rendimento de carbonizado está intimamente relacionado com o rácio O/C do combustível original, sendo proposto um modelo simples para descrever esta relação. Embora a quantidade total de voláteis libertada seja estabelecida pela composição da biomassa, a respetiva composição química depende bastante da temperatura do reator. Rendimentos de espécies condensáveis (água e espécies orgânicas), CO2 e hidrocarbonetos leves descrevem um máximo relativamente à temperatura para dar lugar a CO e H2 às temperaturas mais altas. Não obstante, em certas gamas de temperatura, os rendimentos de algumas das principais espécies gasosas (e.g. CO, H2, CH4) estão bem correlacionados entre si, o que permitiu desenvolver modelos empíricos que minimizam o efeito das condições operatórias e, ao mesmo tempo, realçam o efeito do combustível na composição do gás. Em suma, os ensaios de pirólise realizados neste trabalho permitiram constatar que a estequiometria da pirólise de biomassa se relaciona de várias formas com a composição elementar do combustível original o que levanta várias possibilidades para a avaliação e projeto de processos de combustão e gasificação de biomassa.

Argyrosomus regius (Asso, 1801) fishery and ecology in portuguese waters, with reference to its relationships to other european and african populations

Tese de doutoramento, Biologia (Biologia Marinha e Aquacultura), Universidade de Lisboa, Faculdade de Ciências, 2014

Patterns of cortisol and DHEA secretion and relationships with attachment style and psychosocial variables in female adolescents: a developmental psychopathology approach

This programme of research used a developmental psychopathology approach to investigate females across the adolescent period. A two-sided story is presented; first, a study of neuroendocrine and psychosocial parameters in a group of healthy female adolescents (N = 63), followed by a parallel study of female adolescents with anorexia nervosa (AN) (N = 8). A biopsychosocial, multi-method measurement approach was taken, which utilised self-report, interview and hypothalamic-pituitary-adrenocortical (HPA) axis measures. Saliva samples for the measurement of cortisol and DHEA were collected using the best-recommended methodology: multiple samples over the day, strict reference to time of awakening, and two consecutive sampling weekdays. The research was adolescent-orientated: specifically, by using creative and ageappropriate strategies to ensure participant adherence to protocol, as well as more generally by adopting various procedures to facilitate engagement with the research process. In the healthy females mean (± SD) age 13.9 (± 2.7) years, cortisol and DHEA secretion exhibited typical adult-like diurnal patterns. Developmental markers of chronological age, menarche status and body mass index (BMI) had differential associations with cortisol and DHEA secretory activity. The pattern of the cortisol awakening response (CAR) was sensitive to whether participants had experienced first menses, but not to chronological age or BMI. Those who were post-menarche generally reached their peak point of cortisol secretion at 45 minutes post-awakening, in contrast to the pre-menarche group who were more evenly spread. Subsequent daytime cortisol levels were also higher in post-menarche females, and this effect was also noted for increasing age and BMI. Both morning and evening DHEA were positively associated with developmental markers. None of the situational or self-report psychosocial variables that were measured modulated any of the key findings regarding cortisol and DHEA secretion. The healthy group of girls were within age-appropriate norms for all the self-report measures used, however just under half of this group were insecurely attached (as assessed by interview). Only attachment style was associated with neuroendocrine parameters. In particular, those with an anxious insecure style exhibited a higher awakening sample (levels were 7.16 nmol/l, 10.40 nmol/l and 7.93 nmol/l for secure, anxious and avoidant groups, respectively) and a flatter CAR (mean increases over the awakening period were 6.38 nmol/l, 2.32 nmol/l and 8.61 nmol/l for secure, anxious and avoidant groups, respectively). The afore-mentioned pattern is similar to that consistently associated with psychological disorder in adults, and so this may be a pre-clinical vulnerability factor for subsequent mental health problems. A group of females with AN, mean (± SD) age 15.1 (± 1.6) years, were recruited from a specialist residential clinic and compared to the above group of healthy control (HC) female adolescents. A general picture of cortisol and DHEA hypersecretion was revealed in those with AN. The mean (± SD) change exhibited in cortisol levels over the 30 minute post-awakening period was 7.05 nmol/l (± 5.99) and 8.33 nmol/l (± 6.41) for HC and AN groups, respectively. The mean (± SD) evening cortisol level for the HC girls was 1.95 nmol/l (± 2.11), in comparison to 6.42 nmol/l (± 11.10) for the AN group. Mean (± SD) morning DHEA concentrations were 1.47 nmol/l (± 0.85) and 2.25 nmol/l (± 0.88) for HC and AN groups, respectively. The HC group’s mean (± SD) concentration of 12 hour DHEA was 0.55 nmol/l (± 0.46) and the AN group’s mean level was 0.89 nmol/l (± 0.90). This adrenal steroid hypersecretion evidenced by the AN group was not associated with BMI or eating disorder symptomatology. Insecure attachment characterised by fearfulness and anger was most apparent; a style which was unparalleled in the healthy group of female adolescents. The causal directions of the AN group findings remain unclear. Examining some of the participants with AN as case studies one year post-discharge from the clinic illustrated that for one participant who was recovered, in terms of returning to ordinary school life and no longer exhibiting clinical levels of eating disorder symptomatology, her CARs were no longer inconsistent over sampling days and her DHEA levels were also now generally comparable to the healthy control group. For another participant who had not recovered from her AN one year later, the profile of her CAR continued to be inconsistent over sampling days and her DHEA concentrations over the diurnal period were significantly higher in comparison to the healthy control group. In its entirety, this work’s unique contribution lies in its consideration of methodological and developmental issues specifically pertaining to adolescents. Findings also contribute to knowledge of AN and understanding of vulnerability factors, and how these may be used to develop interventions dedicated to improving adolescent health.

Antioxidant properties of hydroxycinnamic acids: a review of structure- activity relationships

Hydroxycinnamic acids (HCAs) are important phytochemicals possessing significant biological properties. Several investigators have studied in vitro antioxidant activity of HCAs in detail. In this review, we have gathered the studies focused on the structure-activity relationships (SARs) of these compounds that have used medicinal chemistry to generate more potent antioxidant molecules. Most of the reports indicated that the presence of an unsaturated bond on the side chain of HCAs is vital to their activity. The structural features that were reported to be of importance to the antioxidant activity were categorized as follows: modifications of the aromatic ring, which include alterations in the number and position of hydroxy groups and insertion of electron donating or withdrawing moieties as well as modifications of the carboxylic function that include esterification and amidation process. Furthermore, reports that have addressed the influence of physicochemical properties including redox potential, lipid solubility and dissociation constant on the antioxidant activity were also summarized. Finally, the pro-oxidant effect of HCAs in some test systems was addressed. Most of the investigations concluded that the presence of ortho-dihydroxy phenyl group (catechol moiety) is of significant importance to the antioxidant activity, while, the presence of three hydroxy groups does not necessarily improve the activity. Optimization of the structure of molecular leads is an important task of modern medicinal chemistry and its accomplishment relies on the careful assessment of SARs. SAR studies on HCAs can identify the most successful antioxidants that could be useful for management of oxidative stress-related diseases.

Entre a oposição e a negociação : Um projeto de investigação-ação sobre o papel do adulto na prevenção e mediação de conflitos entre pares na infância

Esta investigação surgiu da identificação de dificuldades ao nível da interação e gestão de conflitos entre pares, que a investigadora teve a oportunidade de observar no grupo de crianças com quem desenvolvia a sua prática educativa. Este estudo tem como objetivo compreender de que forma a transformação da praxis do educador influencia os processos de prevenção e a mediação dos conflitos entre pares no jardim-de-infância. Tendo em conta as formas e as características das relações entre pares na infância bem como o desenvolvimento moral das crianças em idade préescolar, a investigadora levou a cabo um projeto de investigação-ação com um grupo de vinte e quatro crianças de cinco anos. Ao longo do projeto, a investigadora procurou conhecer e experimentar estratégias de prevenção e mediação de conflitos interpares, monitorizando esse processo através da reflexão sobre a ação, assim como compreender os efeitos dessa experimentação no desenvolvimento profissional e na aprendizagem das crianças. Os processos do projeto são apresentados através de uma descrição densa dos eixos centrais da ação: construção do quadro de regras, organização do tempo e do grupo, organização do espaço e dos materiais, experimentação de instrumentos de pilotagem, reunião de grande grupo e estratégias de resolução de conflitos. Os dados apresentados resultam da interpretação das categorias emergentes da análise das entrevistas e das notas de campo. Através dessa interpretação, foi possível constatar os efeitos positivos do projeto, não apenas ao nível das competências de escuta e de negociação das crianças, mas também para a prática profissional da investigadora, que desenvolveu competências de reflexão e de autossupervisão.

Structure-function relationships of the alpha1b-adrenergic receptor.

The alpha1b-adrenergic receptor (AR) is a member of the large superfamily of seven transmembrane domain (TMD) G protein-coupled receptors (GPCR). Combining site-directed mutagenesis of the alpha1b-AR with computational simulations of receptor dynamics, we have explored the conformational changes underlying the process of receptor activation, i.e. the transition between the inactive and active states. Our findings suggest that the structural constraint stabilizing the alpha1b-AR in the inactive form is a network of H-bonding interactions amongst conserved residues forming a polar pocket and R143 of the DRY sequence at the end of TMDIII. We have recently reported that point mutations of D142, of the DRY sequence and of A293 in the distal portion of the third intracellular loop resulted in ligand-independent (constitutive) activation of the alpha1b-AR. These constitutively activating mutations could induce perturbations resulting in the shift of R143 out of the polar pocket. The main role of R143 may be to mediate receptor activation by triggering the exposure of several basic amino acids of the intracellular loops towards the G protein. Our investigation has been extended also to the biochemical events involved in the desensitization process of alpha1b-AR. Our results indicate that immediately following agonist-induced activation, the alpha1b-AR can undergo rapid agonist-induced phosphorylation and desensitization. Different members of the G protein coupled receptor kinase family can play a role in agonist-induced regulation of the alpha1b-AR. In addition, constitutively active alpha1b-AR mutants display different phosphorylation and internalization features. The future goal is to further elucidate the molecular mechanism underlying the complex equilibrium between activation and inactivation of the alpha1b-AR and its regulation by pharmacological substances. These findings can help to elucidate the mechanism of action of various agents displaying properties of agonists or inverse agonists at the adrenergic system.

Objective analysis of gait coordination for total knee arthroplasty outcome

Introduction: Coordination is a strategy chosen by the central nervous system to control the movements and maintain stability during gait. Coordinated multi-joint movements require a complex interaction between nervous outputs, biomechanical constraints, and pro-prioception. Quantitatively understanding and modeling gait coordination still remain a challenge. Surgeons lack a way to model and appreciate the coordination of patients before and after surgery of the lower limbs. Patients alter their gait patterns and their kinematic synergies when they walk faster or slower than normal speed to maintain their stability and minimize the energy cost of locomotion. The goal of this study was to provide a dynamical system approach to quantitatively describe human gait coordination and apply it to patients before and after total knee arthroplasty. Methods: A new method of quantitative analysis of interjoint coordination during gait was designed, providing a general model to capture the whole dynamics and showing the kinematic synergies at various walking speeds. The proposed model imposed a relationship among lower limb joint angles (hips and knees) to parameterize the dynamics of locomotion of each individual. An integration of different analysis tools such as Harmonic analysis, Principal Component Analysis, and Artificial Neural Network helped overcome high-dimensionality, temporal dependence, and non-linear relationships of the gait patterns. Ten patients were studied using an ambulatory gait device (Physilog®). Each participant was asked to perform two walking trials of 30m long at 3 different speeds and to complete an EQ-5D questionnaire, a WOMAC and Knee Society Score. Lower limbs rotations were measured by four miniature angular rate sensors mounted respectively, on each shank and thigh. The outcomes of the eight patients undergoing total knee arthroplasty, recorded pre-operatively and post-operatively at 6 weeks, 3 months, 6 months and 1 year were compared to 2 age-matched healthy subjects. Results: The new method provided coordination scores at various walking speeds, ranged between 0 and 10. It determined the overall coordination of the lower limbs as well as the contribution of each joint to the total coordination. The difference between the pre-operative and post-operative coordination values were correlated with the improvements of the subjective outcome scores. Although the study group was small, the results showed a new way to objectively quantify gait coordination of patients undergoing total knee arthroplasty, using only portable body-fixed sensors. Conclusion: A new method for objective gait coordination analysis has been developed with very encouraging results regarding the objective outcome of lower limb surgery.

Adolescent Drug Abuse Diagnosis (ADAD) vs. Health of Nation Outcome Scale for Children and Adolescents (HoNOSCA) in clinical outcome measurement.

BACKGROUND: The Adolescent Drug Abuse Diagnosis (ADAD) and Health of Nation Outcome Scales for Children and Adolescents (HoNOSCA) are both measures of outcome for adolescent mental health services. AIMS: To compare the ADAD with HoNOSCA; to examine their clinical usefulness. METHODS: Comparison of the ADAD and HoNOSCA outcome measures of 20 adolescents attending a psychiatric day care unit. RESULTS: ADAD change was positively correlated with HoNOSCA change. HoNOSCA assesses the clinic's day-care programme more positively than the ADAD. The ADAD detects a group for which the mean score remains unchanged whereas HoNOSCA does not. CONCLUSIONS: A good convergent validity emerges between the two assessment tools. The ADAD allows an evidence-based assessment and generally enables a better subject discrimination than HoNOSCA. HoNOSCA gives a less refined evaluation but is more economic in time and possibly more sensitive to change. Both assessment tools give useful information and enabled the Day-care Unit for Adolescents to rethink the process of care and of outcome, which benefited both the institution and the patients.