Early post-operative mortality after major lower limb amputation: A systematic review of population and regional based studies

OBJECTIVE: Lower limb amputation is often associated with a high risk of early post-operative mortality. Mortality rates are also increasingly being put forward as a possible benchmark for surgical performance. The primary aim of this systematic review is to investigate early post-operative mortality following a major lower limb amputation in population/regional based studies, and reported factors that might influence these mortality outcomes. METHODS: Embase, PubMed, Cinahl and Psycinfo were searched for publications in any language on 30 day or in hospital mortality after major lower limb amputation in population/regional based studies. PRISMA guidelines were followed. A self developed checklist was used to assess quality and susceptibility to bias. Summary data were extracted for the percentage of the population who died; pooling of quantitative results was not possible because of methodological differences between studies. RESULTS: Of the 9,082 publications identified, results were included from 21. The percentage of the population undergoing amputation who died within 30 days ranged from 7% to 22%, the in hospital equivalent was 4-20%. Transfemoral amputation and older age were found to have a higher proportion of early post-operative mortality, compared with transtibial and younger age, respectively. Other patient factors or surgical treatment choices related to increased early post-operative mortality varied between studies. CONCLUSIONS: Early post-operative mortality rates vary from 4% to 22%. There are very limited data presented for patient related factors (age, comorbidities) that influence mortality. Even less is known about factors related to surgical treatment choices, being limited to amputation level. More information is needed to allow comparison across studies or for any benchmarking of acceptable mortality rates. Agreement is needed on key factors to be reported.

HR-MAS NMR spectroscopy shows regional metabolite variation in bovine articular cartilage

Mechanical stress is an important external factor effecting the development and maintenance of articular cartilage. The metabolite profile of diseased cartilage has been well studied but there is limited information about the variation in metabolite profile of healthy cartilage. With the importance of load in maintaining healthy cartilage, regional differences in metabolite profile associated with differences in load may provide information on how load contributes to the maintenance of healthy cartilage. HR-MAS NMR spectroscopy allows the assessment of tissue samples without modification and was used for assessing the difference in metabolic profile between the load bearing and non-load bearing regions of the bovine articular cartilage. In this preliminary study, we examined cartilage from tibia and femur of four knee joints. Sixteen pairs of 1D-NOESY spectra were acquired. Principle component analysis (PCA) identified chemical shifts responsible for variance. SBASE (AMIX) and the Human Metabolome Database were used in conjunction with previous reported cartilage data for identifying metabolites associated with the PCA results. The major contributors to load-related differences in metabolite profile were N-acetyl groups, lactate and phosphocholine peaks. Integrals of these regions were further analysed using a Student's t-test. In load bearing cartilage regions. N-acetyl groups and phosphocholine were found at significantly higher concentration (p < 0.05 and p < 0.005, respectively) in both femur and tibia, while lactate was reduced in load bearing cartilage (p < 0.005). The results of this pilot HR-MAS NMR study demonstrate its ability to provide useful metabolite information for healthy cartilage.

Connecting and collaborating in regional, rural and remote Western Australia

Teachers working in regional, rural and remote areas of Western Australia often experience a strong sense of geographic and social isolation from peers, colleagues and appropriate support mechanisms due to the huge distances between towns and communities. The projects described here have focused on the use of technology to enhance both teacher and student learning; and assist with Indigenous education and teacher professional learning. Connecting and collaborating through technologies is emerging as a powerful tool for motivating and engaging both teachers and learners within schools. Coupled with the direction of the current Federal Government with the Digital Education Revolution and the Digital Regions initiatives, opportunities for better serving regional, rural and remote communities are discussed, as are some of the current issues and needs related to these schools in Western Australia. The scope of these projects has been such that three guiding principles have been implemented through contextual lenses of varying foci - at the level of an individual, a school, and a community.

Going bush: Preparing pre-service teachers to teach in regional Western Australia

This paper reports on outcomes of Phases One and Two of the ALTC Competitive Research and Development Project "Developing Strategies at the Pre-Service Level to Address Critical Teacher Attraction and Retention Issues in Australian Rural, Regional and Remote Schools." This project funded over two years aims to strengthen the capacity and credibility of universities to prepare rural, regional and remote educators, similar to the capacity and credibility that has been created in preparing Australia's rural, regional and remote health workers. There is a strong recognition of the fundamental importance of quality teaching experiences rural, regional and remote schools and throughout this project over 200 pre-service teachers have participated in a curriculum module/object and completed a survey that encourages them to consider teaching in regional Western Australia. The project has mapped current Western Australian rural, regional and remote pre-service teacher education curriculum and field experience model. This mapping completed a comparison of national information with the identification of rural, regional and remote education curriculum and/or field experience models used nationally and internationally. In particular results from Phase One and Two will be presented reporting on the findings of the first year of the project.

Regional resilience: Pre-service teacher preparation to teach in the bush

This paper reports on the outcomes of a two year ALTC Competitive Research and Development Project that aimed to "Develop Strategies at the Pre-Service Level to Address Critical Teacher Attraction and Retention Issues in Australian Rural, Regional and Remote Schools". As well as developing a ‘training framework’ and teaching guides to increase the capacity and credibility of four universities to prepare educators who might venture out of the metropolitan area to teach, data were gathered from pre-service and graduate teachers to analyse regional resilience. It was found that there was a strong likelihood to participate in a regional practicum and stay in a non-metropolitan community once they graduated from university if they had a positive attitude to regional Western Australia either through a family connection or previous experience. Recommendations from this study emphasise the importance of having pre-service students participate in positive regional experiences early in their university study.

Rethinking connectedness : an investigation into the access of teacher professional learning in regional and remote Western Australia

Many teachers working in remote and regional areas have limited access to collegial support networks. This research aimed to examine the existing strategies that were being undertaken by the Department of Education in Western Australia, to provide professional learning to teachers in regional and remote areas. It was important to establish the perceptions of teachers’ access to professional learning from those working at the coalface in geographically dispersed areas. Consequently, the possible opportunity for improving the amount and variety of professional learning, through the application of both synchronous and asynchronous technologies was proposed. The study was guided by the primary research question: “In what ways might technology be used to support professional development of regional and remote teachers in Western Australia?” Generating descriptions of current practice of professional learning along with the teacher perceptions were central to this research endeavour. The study relied on a mixed method research approach in order to attend to the research question. The data were collected in phases, referred to as an explanatory mixed methods design. Quantitative data were collected from 104 participants to provide a general picture of the research problem. To further refine this general picture, qualitative data were collected through interviews and e-interviews of 10 teachers. Participants in the study included graduate teachers, teachers who had taught more than two years, senior teachers and Level Three teachers from seven teaching districts within Western Australia. An investigation into current practice was included in this phase and technologies available to support a professional learning community over distance were documented. The final phase incorporated the formulation of a conceptual framework where a model was developed to facilitate the successful implementation of a professional learning community through the application of synchronous and asynchronous technologies. The study has identified that travel time in order to access professional development is significant and impacts on teachers’ personal time. There are limited relief teachers available in these isolated areas which impacts on the opportunities to access professional development. Teachers face inequities, in terms of promotion, because professional development is explicitly linked to promotional opportunities. Importantly, it was found that professional learning communities are valued, but are often limited by small staff numbers at the geographic locality of the school. Teachers preferred to undertake professional learning in the local context of their district, school or classroom and this professional learning must be established at the need of the individual teacher in line with the school priorities. Teachers reported they were confident in using technology and accessing professional development online if required, however, much uncertainty surrounded the use of web 2.0 technologies for this purpose. The recommendations made from the study are intended to identify how a professional learning community might be enhanced through synchronous and asynchronous technologies.

Rethinking connectedness: improving access to professional learning for regional and remote teachers

Transformation of Australian education is occurring at a rapid rate through the implementation of a number of initiatives. These initiatives include the Digital Education Revolution, the move to a National Curriculum and the implementation of a National Framework for Professional Standards for Teachers and Principals. As these initiatives are rolled out to schools across Australia, the equitable access to professional learning to support all teachers, regardless of their geographical location, is in question. A number of studies have been conducted in Australia that highlight the importance of professional learning and the difficulty faced by regional and remote teachers with regard to access (Gerard Daniels, 2007; Lysons, Cooksey, Panizzon, Parnell & Pegg 2006; Ministerial Review of Schooling, 1994, Rural and Remote Education Advisory Council, 2000; Vinson, 2002). Along with access to professional learning, has been the discussion of effective modes of delivery. Face to face professional learning, in regional and metropolitan areas, is offered in isolation, or in some cases, is complimented with virtual learning environments. The need for a more sustainable approach to professional learning is highly necessary. A mixed method research approach was utilised in order to answer the primary research question "In what ways might technology be used to support professional learning of regional and remote teachers in Western Australia?" This research paper outlines the findings from the study including the significance of travel time; impact of limited relief teachers; implications for promotion and teacher registration; professional learning communities being valued but often limited by small staff numbers; professional learning conducted in the local context being preferred; professional learning established at the teacher and school level being desirable; teachers being confident in using technology and accessing PD online if required; and social cohesiveness being valued and often limited by isolation. Further, this research has culminated in the development of a "model of rethinking connectedness" that would facilitate improving the amount and variety of professional learning available to regional and remote teachers.

See you in class: Promoting a quality program for pre-service educators in regional locations through a virtual classroom

The quality of an online university degree is paramount to the student, the reputation of the university and most importantly, the profession that will be entered. At the School of Education within Curtin University, we aim to ensure that students within rural and remote areas are provided with high quality degrees equal to their city counterparts who access face-to-face classes on campus.In 2010, the School of Education moved to flexible delivery of a fully online Bachelor of Education degree for their rural students. In previous years, the degree had been delivered in physical locations around the state. Although this served the purpose for the time, it restricted the degree to only those rural students who were able to access the physical campus. The new model in 2010 allows access for students in any rural area who have a computer and an internet connection, regardless of their geographical location. As a result enrolments have seen a positive increase in new students. Academic staff had previously used an asynchronous environment to deliver learning modules housed within a learning management system (LMS). To enhance the learning environment and to provide high quality learning experiences to students learning at a distance, the adoption of synchronous software was introduced. This software is a real-time virtual classroom environment that allows for communication through Voice over Internet Protocol (VoIP) and videoconferencing, along with a large number of collaboration tools to engage learners. This research paper reports on the professional development of academic staff to integrate a live e-learning solution into their current LMS environment. It involved professional development, including technical orientation for teaching staff and course participants simultaneously. Further, pedagogical innovations were offered to engage the students in a collaborative learning environment. Data were collected from academic staff through semi-structured interviews and participant observation. The findings discuss the perceived value of the technology, problems encountered and solutions sought.

Regional Integration and the State : The Changing Nature of Sovereignty in Southern Africa and Europe

The study explores the role of the state in regional integration processes. The question is approached through theoretical discussion and two case-studies - SADC (Southern African Development Community) and the EU. The main research question of the study is, what are the possibilities and problems of the integration process in Southern Africa and how do they differ from the possibilities and problems of the integration process in Europe. The undelrying question of the study is why do states decide to participate in an integration process where they have to limit their sovereignty. Review of the theoretical discussion of the integration studies shows that the integration process is affected by several factors on different levels of the international system. But the state plays a central role in integration processes - integration processes are inititated and carried on by the participatig states. The European integration process shows that the interests of the state can change over time. At the beginning of the integration process, the objective was to strengthen participating states. Later EU member states have decided that it is in their interest to deepen the process even if it has meant limitation of their sovereignty. The determinant factor has been that the member states have considered it to be in their interst to deepen the process. In Southern Africa the integration process is only at the beginning. SADC aims to establish a free trade area by 2008. The biggest challenge is how to implement the integration process so that it benefits all member states in a region that is economically dominated by South Africa. In practice this can be achieved through establishment of corrective mechanisms, which ensure equitable distribution of benefits. This would require deeper integration and South Africa to adapt responsibility towards its regional partners. African integration processes in general have not been as successful as for example the EU. African states have been reluctant to limit their sovereignty in favour of regional organisations.This can be explained by the differences between European and African states. The EU member states have been democracies while African states have been characterised by concentration of power in the executive branch. Furthermore the political systems in Africa have been characterised by vertical clientelist reltionships. As a result it has not been in the interest of the political elite to limit the state sovereignty in favour of regional organisations. In recent years SADC has been relatively succesful in its integration process and reforms, but a lot remains to be done before the implementation of the free trade area can be succesful. The institutional structure and treaties of SADC differ from the structures of the EU. Member states are the main actors of the integration processes. Their differences are reflected in the process and produce different kinds of integration in different parts of the world.

Regional variation in the composition and structure of mixed-species bird flocks in the Western Ghats and Sri Lanka

Mixed-species bird flocks are attractive models for the investigation of geographical variation in animal communities, as they represent a subset of the avifauna in most forested regions of the world. Yet studies of the regional variation in flock size and the composition of flocks are few, due to the predominance of studies carried out at single study site. Here, we review nine studies of mixed-species flocks conducted at 16 sites along the Western Ghats in India and in Sri Lanka. We find that flock size varies as much within this region as it does globally, with observation time being a confounding variable. Flock composition, however, is predictably related to elevation. Flocks at high elevations (>1200 m) in the Western Ghats strongly resemble flocks at high elevations in the mountain ranges of Sri Lanka in their composition, especially at the family level. We compare these flocks to flocks of other regions and make recommendations on study methodology that can facilitate comparisons across studies.

Regional variation in social isolation amongst older Australians

Regional studies globally have a strong focus on understanding the causes of variation in the economic performance and wellbeing of regions and this emphasis acknowledges that the strength of the local or regional economy plays a determinant role in shaping quality of life. Regional research has been less active in considering spatial variation in other factors that are critical to individual and societal wellbeing. For example, the regional studies community has been absent from the debate on the social determinants of health and how these influences vary spatially. This paper considers the results of a cross sectional survey of Australians aged 65 and over that focussed on social connections and wellbeing. It examines regional variations in the incidence of social isolation within the older population. It finds that while the incidence of self-reported social isolation amongst older persons is broadly consistent with earlier studies, it demonstrates a spatial patterning that is unexpected. The paper considers community-building activities in addressing the impacts of social isolation, including the role of urban design, and suggests that there is a need to supplement the national overview presented there through more detailed studies focussed on individual localities.

Regional Blocs: Building Blocks or stumbling Blocks? (Book Review)

Reviews the book `Regional Blocks: Building Blocks or Stumbling Blocks?,' by A.S. and P. Bhalla.

Evaluation of regional and distant metastases in head and neck squamous cell carcinoma patients with special reference to the assessment of regional lymph nodes in oral cancer

For optimal treatment planning, a thorough assessment of the metastatic status of mucosal squamous cell carcinoma of the head and neck (HNSCC) is required. Current imaging methods do not allow the recognition of all patients with metastatic disease. Therefore, elective treatment of the cervical lymph nodes is usually given to patients in whom the risk of subclinical metastasis is estimated to exceed 15-20%. The objective of this study was to improve the pre-treatment evaluation of patients diagnosed with HNSCC. Particularly, we aimed at improving the identification of patients who will benefit from elective neck treatment. Computed tomography (CT) of the chest and abdomen was performed prospectively for 100 patients diagnosed with HNSCC. The findings were analysed to clarify the indications for this examination in this patient group. CT of the chest influenced the treatment approach in 3% of patients, while CT of the abdomen did not reveal any significant findings. Our results suggest that CT of the chest and abdomen is not indicated routinely for patients with newly diagnosed HNSCC but can be considered in selected cases. Retrospective analysis of 80 patients treated for early stage squamous cell carcinoma of the oral tongue was performed to investigate the potential benefits of elective neck treatment and to examine whether histopathological features of the primary tumour could be used in the prediction of occult metastases, local recurrence, or/and poor survival. Patients who had received elective neck treatment had significantly fewer cervical recurrences during the follow-up when compared to those who only had close observation of the cervical lymph nodes. Elective neck treatment did not result in survival benefit, however. Of the histopathological parameters examined, depth of infiltration and pT-category (representing tumour diameter) predicted occult cervical metastasis, but only the pT-category predicted local recurrence. Depth of infiltration can be used in the identification of at risk patients but no clear cut-off value separating high-risk and low-risk patients was found. None of the histopathological parameters examined predicted survival. Sentinel lymph node (SLN) biopsy was studied as a means of diagnosing patients with subclinical cervical metastases. SLN biopsy was applied to 46 patients who underwent elective neck dissection for oral squamous cell carcinoma. In addition, SLN biopsy was applied to 13 patients with small oral cavity tumours who were not intended to undergo elective neck dissection because of low risk of occult metastasis. The sensitivity of SLN biopsy for finding subclinical cervical metastases was found to be 67%, when SLN status was compared to the metastatic status of the rest of the neck dissection specimen. Of the patients not planned to have elective neck dissection, SLN biopsy revealed cervical metastasis in 15% of the patients. Our results suggest that SLN biopsy can not yet entirely replace elective neck dissection in the treatment of oral cancer, but it seems beneficial for patients with low risk of metastasis who are not intended for elective neck treatment according to current treatment protocols.