Lower extremity amputation in people with diabetes: Trends and determinants

Introduction: The prevalence of diabetes is rising rapidly. Assessing quality of diabetes care is difficult. Lower Extremity Amputation (LEA) is recognised as a marker of the quality of diabetes care. The focus of this thesis was first to describe the trends in LEA rates in people with and without diabetes in the Republic of Ireland (RoI) in recent years and then, to explore the determinants of LEA in people with diabetes. While clinical and socio-demographic determinants have been well-established, the role of service-related factors has been less well-explored. Methods: Using hospital discharge data, trends in LEA rates in people with and without diabetes were described and compared to other countries. Background work included concordance studies exploring the reliability of hospital discharge data for recording LEA and diabetes and estimation of diabetes prevalence rates in the RoI from a nationally representative study (SLAN 2007). To explore determinants, a systematic review and meta-analysis assessed the effect of contact with a podiatrist on the outcome of LEA in people with diabetes. Finally, a case-control study using hospital discharge data explored determinants of LEA in people with diabetes with a particular focus on the timing of access to secondary healthcare services as a risk factor. Results: There are high levels of agreement between hospital discharge data and medical records for LEA and diabetes. Thus, hospital discharge data was deemed sufficiently reliable for use in this PhD thesis. A decrease in major diabetes-related LEA rates in people with diabetes was observed in the RoI from 2005-2012. In 2012, the relative risk of a person with diabetes undergoing a major LEA was 6.2 times (95% CI 4.8-8.1) that of a person without diabetes. Based on the systematic review and meta-analysis, contact with a podiatrist did not significantly affect the relative risk (RR) of LEA in people with diabetes. Results from the case-control study identified being single, documented CKD and documented hypertension as significant risk factors for LEA in people with diabetes whilst documented retinopathy was protective. Within the seven year time window included in the study, no association was detected between LEA in patients with diabetes and timing of patient access to secondary healthcare for diabetes management. Discussion: Many countries have reported reduced major LEA rates in people with diabetes coinciding with improved organisation of healthcare systems. Reassuringly, these first national estimates in people with diabetes in the RoI from 2005 to 2012 demonstrated reducing trends in major LEA rates. This may be attributable to changes in diabetes care and also, secular trends in smoking, dyslipidaemia and hypertension. Consistent with international practice, LEA trends data in Ireland can be used to monitor quality of care. Quantifying this improvement precisely, though, is problematic without robust denominator data on the prevalence of diabetes. However, a reduction in major diabetes-related LEA rates suggests improved quality of diabetes care. Much controversy exists around the reliability of hospital discharge data in the RoI. This thesis includes the first multi-site study to explore this issue and found hospital discharge data reliable for the reporting of the procedure of LEA and diagnosis of diabetes. This project did not detect protective effects of access to services including podiatry and secondary healthcare for LEA in people with diabetes. A major limitation of the systematic review and meta-analysis was the design and quality of the included studies. The data available in the area of effect of contact with a podiatrist on LEA risk are too sparse to say anything definitive about the efficacy of podiatry on LEA. Limitations of the case-control study include lack of a diabetes register in Ireland, restricted information from secondary healthcare and lack of data available from primary healthcare. Due to these issues, duration of disease could not be accounted for in the study which limits the conclusions that can be drawn from the results. The model of diabetes care in the RoI is currently undergoing a re-configuration with plans to introduce integrated care. In the future, trends in LEA rates should be continuously monitored to evaluate the effectiveness of changes to the healthcare system. Efforts are already underway to improve the availability of routine data from primary healthcare with the recent development of the iPCRN (Irish Primary Care Research Network). Linkage of primary and secondary healthcare records with a unique patient identifier should be the goal for the future.

Alpha-fetoprotein protects the developing female mouse brain from masculinization and defeminization by estrogens

Two clearly opposing views exist on the function of alpha-fetoprotein (AFP), a fetal plasma protein that binds estrogens with high affinity, in the sexual differentiation of the rodent brain. AFP has been proposed to either prevent the entry of estrogens or to actively transport estrogens into the developing female brain. The availability of Afp mutant mice (Afp-/-) now finally allows us to resolve this longstanding controversy concerning the role of AFP in brain sexual differentiation, and thus to determine whether prenatal estrogens contribute to the development of the female brain. Here we show that the brain and behavior of female Afp-/- mice were masculinized and defeminized. However, when estrogen production was blocked by embryonic treatment with the aromatase inhibitor 1,4,6-androstatriene-3,17- dione, the feminine phenotype of these mice was rescued. These results clearly demonstrate that prenatal estrogens masculinize and defeminize the brain and that AFP protects the female brain from these effects of estrogens. © 2006 Nature Publishing Group.

Changing epidemiology of serious bacterial infections in febrile infants without localizing signs.

OBJECTIVE: Historically, management of infants with fever without localizing signs (FWLS) has generated much controversy, with attempts to risk stratify based on several criteria. Advances in medical practice may have altered the epidemiology of serious bacterial infections (SBIs) in this population. We conducted this study to test the hypothesis that the rate of SBIs in this patient population has changed over time. PATIENTS AND METHODS: We performed a retrospective review of all infants meeting FWLS criteria at our institution from 1997-2006. We examined all clinical and outcome data and performed statistical analysis of SBI rates and ampicillin resistance rates. RESULTS: 668 infants met criteria for FWLS. The overall rate of SBIs was 10.8%, with a significant increase from 2002-2006 (52/361, 14.4%) compared to 1997-2001 (20/307, 6.5%) (p = 0.001). This increase was driven by an increase in E. coli urinary tract infections (UTI), particularly in older infants (31-90 days). CONCLUSIONS: We observed a significant increase in E. coli UTI among FWLS infants with high rates of ampicillin resistance. The reasons are likely to be multifactorial, but the results themselves emphasize the need to examine urine in all febrile infants <90 days and consider local resistance patterns when choosing empiric antibiotics.

Introduction: The apparel industry and North American economic integration

The economic and social consequences of international trade agreements have become a major area of inquiry in development studies in recent years. As evidenced by the energetic protests surrounding the Seattle meeting of the World Trade Organization (WTO) in December 1999 and the controversy about China's admission to the WTO, such agreements have also become a focus of political conflict in both the developed and developing countries. At issue are questions of job gains and job losses in different regions, prices paid by consumers, acceptable standards for wages and working conditions in transnational manufacturing industries, and the quality of the environment. All these concerns have arisen with regard to the North American Free Trade Agreement (NAFTA) and can be addressed through an examination of changes in the dynamics of the apparel industry in the post-NAFTA period.1 In this book, we examine the evolution of the apparel industry in North America in order to address some of these questions as they pertain to North America, with an eye toward the broader implications of our findings. We also consider the countries of the Caribbean Basin and Central America, whose textile and apparel goods are now allowed to enter the U.S. market on the same basis as those from Canada and Mexico (Odessey 2000). © 2009 by Temple University Press. All rights reserved.

Conflicts of Interest and Outcomes of Cardiovascular Trials.

Conflicts of interests have long been recognized as potential sources of influence in the conduct and reporting of clinical trials. This controversy was again rekindled after the publication of the latest statin guidelines and a series of studies regarding competing interests in leading medical journals. We investigate the association between declared author conflicts and the outcomes of large cardiovascular trials. We searched the Medline (PubMed) database to identify "phase 2" and "phase 3" clinical trials using the search term "cardiovascular" over the past decade using "10 years" as the filter. We perceived the competing interest as present regardless of the nature such as consulting fees, honoraria, travel imbursements, stock holding, and employment. Of the 699 titles retrieved, 114 studies met the inclusion criteria. Nearly 80% of studies had at least a single author with competing interests. The 114 studies had a total of 1,433 investigators, of which 725 had declared conflicts of interests (50.6%). A total of 66 studies (58%) had half or >50 percent of investigators who had some conflicts of interests. Of these studies, 54 studies had favorable outcomes and only 12 had unfavorable outcomes (p <0.001). Among the type of competing interests, consulting or personal fees was the most common present in 58 investigators (51%). This was followed by research grants present in 55 the researchers (48%). Among 25 (22%) studies, at least one investigator reported stakes in the industry, of which only 2 studies had unfavorable outcomes for the intervention being investigated. Just 1 of the 25 clinical trials with a sample size of >1,000 had no investigators with competing interests. In conclusion, authors conflicts are associated with favorable outcomes in cardiovascular outcome trials.

Guidelines on artificial nutrition versus hydration in terminal cancer patients

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step I: define the eight key elements necessary to reach a decision: Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e. improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

The Jama legal narrative. Part II: A foray into concepts of improbability

In judicial decision making, the doctrine of chances takes explicitly into account the odds. There is more to forensic statistics, as well as various probabilistic approaches which taken together form the object of an enduring controversy in the scholarship of legal evidence. In this paper, we reconsider the circumstances of the Jama murder and inquiry (dealt with in Part I of this paper: "The Jama Model. On Legal Narratives and Interpretation Patterns"), to illustrate yet another kind of probability or improbability. What is improbable about the Jama story, is actually a given, which contributes in terms of dramatic underlining. In literary theory, concepts of narratives being probable or improbable date back from the eighteenth century, when both prescientific and scientific probability was infiltrating several domains, including law. An understanding of such a backdrop throughout the history of ideas is, I claim, necessary for AI researchers who may be tempted to apply statistical methods to legal evidence. The debate for or against probability (and especially bayesian probability) in accounts of evidence has been flouishing among legal scholars. Nowadays both the the Bayesians (e.g. Peter Tillers) and Bayesioskeptics (e.g. Ron Allen) among those legal scholars whoare involved in the controversy are willing to give AI researchers a chance to prove itself and strive towards models of plausibility that would go beyond probability as narrowly meant. This debate within law, in turn, has illustrious precedents: take Voltaire, he was critical of the application or probability even to litigation in civil cases; take Boole, he was a starry-eyed believer in probability applications to judicial decision making (Rosoni 1995). Not unlike Boole, the founding father of computing, nowadays computer scientists approaching the field may happen to do so without full awareness of the pitfalls. Hence, the usefulness of the conceptual landscape I sketch here.

The Jama legal narrative part I: The JAMA Model and narrative interpretation patterns

For the purposes of starting to tackle, within artificial intelligence (AI), the narrative aspects of legal narratives in a criminal evidence perspective, traditional AI models of narrative understanding can arguably supplement extant models of legal narratives from the scholarly literature of law, jury studies, or the semiotics of law. Not only: the literary (or cinematic) models prominent in a given culture impinge, with their poetic conventions, on the way members of the culture make sense of the world. This shows glaringly in the sample narrative from the Continent-the Jama murder, the inquiry, and the public outcry-we analyse in this paper. Apparently in the same racist crime category as the case of Stephen Lawrence's murder (in Greenwich on 22 April 1993) with the ensuing still current controversy in the UK, the Jama case (some 20 years ago) stood apart because of a very unusual element: the eyewitnesses identifying the suspects were a group of football referees and linesmen eating together at a restaurant, and seeing the sleeping man as he was set ablaze in a public park nearby. Professional background as witnesses-cum-factfinders in a mass sport, and public perceptions of their required characteristics, couldn't but feature prominently in the public perception of the case, even more so as the suspects were released by the magistrate conducting the inquiry. There are sides to this case that involve different expected effects in an inquisitorial criminal procedure system from the Continent, where an investigating magistrate leads the inquiry and prepares the prosecution case, as opposed to trial by jury under the Anglo-American adversarial system. In the JAMA prototype, we tried to approach the given case from the coign of vantage of narrative models from AI.

The Jama legal narrative part II: A foray into concepts of improbability

In judicial decision making, the doctrine of chances takes explicitly into account the odds. There is more to forensic statistics, as well as various probabilistic approaches, which taken together form the object of an enduring controversy in the scholarship of legal evidence. In this paper, I reconsider the circumstances of the Jama murder and inquiry (dealt with in Part I of this paper: 'The JAMA Model and Narrative Interpretation Patterns'), to illustrate yet another kind of probability or improbability. What is improbable about the Jama story is actually a given, which contributes in terms of dramatic underlining. In literary theory, concepts of narratives being probable or improbable date back from the eighteenth century, when both prescientific and scientific probability were infiltrating several domains, including law. An understanding of such a backdrop throughout the history of ideas is, I claim, necessary for Artificial Intelligence (AI) researchers who may be tempted to apply statistical methods to legal evidence. The debate for or against probability (and especially Bayesian probability) in accounts of evidence has been flourishing among legal scholars; nowadays both the Bayesians (e.g. Peter Tillers) and the Bayesio-skeptics (e.g. Ron Allen), among those legal scholars who are involved in the controversy, are willing to give AI research a chance to prove itself and strive towards models of plausibility that would go beyond probability as narrowly meant. This debate within law, in turn, has illustrious precedents: take Voltaire, he was critical of the application of probability even to litigation in civil cases; take Boole, he was a starry-eyed believer in probability applications to judicial decision making. Not unlike Boole, the founding father of computing, nowadays computer scientists approaching the field may happen to do so without full awareness of the pitfalls. Hence, the usefulness of the conceptual landscape I sketch here.

Environmental context explains Lévy and Brownian movement patterns of marine predators

An optimal search theory, the so-called Levy-flight foraging hypothesis(1), predicts that predators should adopt search strategies known as Levy flights where prey is sparse and distributed unpredictably, but that Brownian movement is sufficiently efficient for locating abundant prey(2-4). Empirical studies have generated controversy because the accuracy of statistical methods that have been used to identify Levy behaviour has recently been questioned(5,6). Consequently, whether foragers exhibit Levy flights in the wild remains unclear. Crucially, moreover, it has not been tested whether observed movement patterns across natural landscapes having different expected resource distributions conform to the theory's central predictions. Here we use maximum-likelihood methods to test for Levy patterns in relation to environmental gradients in the largest animal movement data set assembled for this purpose. Strong support was found for Levy search patterns across 14 species of open-ocean predatory fish (sharks, tuna, billfish and ocean sunfish), with some individuals switching between Levy and Brownian movement as they traversed different habitat types. We tested the spatial occurrence of these two principal patterns and found Levy behaviour to be associated with less productive waters (sparser prey) and Brownian movements to be associated with productive shelf or convergence-front habitats (abundant prey). These results are consistent with the Levy-flight foraging hypothesis(1,7), supporting the contention(8,9) that organism search strategies naturally evolved in such a way that they exploit optimal Levy patterns.

Analysis of the footprint in school age of 8-10 years old

Biomechanical problems in children, is an important subject currently, existing controversy in different areas, for example, the majority of children have a flattened footprint, or the hypermobility joint is linked to a musculoskeletal pain. The objective of the study was to determine what kind of footprint is most frequent in school-age children (8-10 years) in the area of Plasencia. This was taken as a sign 50 children, of whom 28 were males and 22 females. All the subjects in the study underwent an assessment of footprint planted in static as well as an exploration of different parameters through inspection in a standing position (formula digital, rearfoot). The results show that excavated footprint is present in a 72% cases of the population, 16% was belonging to an excavated footprint in which we find a higher percentage of weight related.For the digital formula we find that the most common is the Egyptian foot by 40% of the cases and that the prevalence in the rearfoot, is a normal hindfoot. In relation with the hypermobility joint, we check that it is more common in girls and that none of them presents an association to musculoskeletal pain. As a future line we could establish a more comprehensive study with new techniques and valuingchild’s statics and dynamics, to have a more accurate study of the different variables in the sample population studied.

'A terrible danger to the morals of the country': The Irish hospitals' sweepstake in Great Britain, 1930-87

This paper examines the importance of British contributions to the success of the Irish hospitals sweepstake. In its early years, up to three-quarters of these tickets were sold in Britain, bringing millions of pounds into Ireland annually to improve and expand the state's hospitals. The vast amount of money leaving Britain in this way angered the British government and forced it to introduce new legislation to curtail the activities of the Irish sweep. The paper will highlight the extent to which the success of the sweepstake depended on the market for tickets in Britain; the threat to the sweep's survival posed by the restriction of its activities in Britain after 1935; the role of the sweepstake controversy in exacerbating further already strained relations between Britain and the Irish Free State in the 1930s; how the success of the sweep raised the issue of legalising a British lottery; and the eventual decline of the sweepstake as a force in British gambling in the post-war years.

Localization of follistatin in the rat testis.

The cellular localization of the activin-binding protein, follistatin, in the rat testis has been a matter of some controversy with different investigators claiming that Sertoli cells, Leydig cells or germ cells are the primary cell types containing this protein. The localization of mRNA encoding follistatin was re-examined using reverse transcription-polymerase chain reaction (RT-PCR) and in situ hybridization as well as the distribution of follistatin by immunohistochemistry. The results demonstrate that mRNA encoding follistatin is located in many germ cells including type B spermatogonia, primary spermatocytes with the exception of the late leptotene and early zygotene stages, and spermatids at steps 1 to 11. It is also found in Sertoli cells and endothelial cells but not in Leydig cells. Immunohistochemistry, using two different antisera to follistatin, showed that this protein was localized to spermatogonia, primary spermatocytes at all stages except the zygotene stage, spermatids at all stages and to endothelial cells and Leydig cells in the intratubular regions. The failure to detect mRNA for follistatin in Leydig cells using RT-PCR and in situ hybridization suggests that the immunohistochemical localization in these cells reflects binding of follistatin produced elsewhere. The widespread localization of follistatin, taken together with its capacity to neutralize the actions of activin, may indicate that follistatin modulates a range of testicular actions of activin, many of which remain unknown.

A new teaching category at the Spanish University of Franco’s regime: the appearance on the scene of the senior lecturer

The Law of 17 July 1965 on the structure of university faculties and their teaching staff placed the figure of the university senior lecturer on stage. During the sixties, the gestation process, adoption and subsequent integration of the new figure in the academic pyramid did not escape controversy, leading to a complex phenomenon to which, however, non comprehensive studies have been devoted to reveal: how, when, why and under which conditions this teacher appeared in the Spanish University of Franco’s regime. This paper aims to provide an overview of the process of materialization of the senior lecturer, the legislative framework that definitely established this new educational category and the provisions that were in charge of regulating the processes to get tenure. Also, the first approved aggregate endowments and their distribution among universities, colleges and studies will be discussed. Finally, it was a first approach to the possible motivations that led to the creation of this new educational category in a university afflicted by serious problems waiting for a solution that had been delayed sine die. Asimismo, se analizarán las primeras dotaciones de agregados aprobadas y la distribución de las mismas por universidades, facultades y estudios. Para terminar, se realiza un primer acercamiento a las posibles motivaciones que condujeron a la creación de esta nueva figura docente en una universidad aquejada de graves problemas que esperaban a una solución que venía demorándose sine die.

Revisión sistemática de la producción española sobre rendimiento académico entre 1980 y 2011

El bajo rendimiento académico sigue siendo un problema de investigación de gran impacto social. Sin embargo, los resultados científicos no están teniendo repercusión en la mejora, ni en las políticas educativas. En este trabajo nos propusimos identificar, ordenar, analizar y extraer conclusiones sobre la producción española sobre rendimiento académico, con el fin de visualizarla y derivar problemas futuros objeto de investigación. Para ello se llevó a cabo un estudio de revisión en seis etapas, en el que se combinaron procedimientos metodológicos de investigación de síntesis y de investigación bibliométrica. Se identificaron las publicaciones en cuatro bases de datos españolas; posteriormente se analizaron y codificaron los datos extraídos alrededor de nueve indicadores: título, año, tipo de documento, editorial, autor, número autores, institución, comunidad autónoma y tema. Los resultados muestran una producción constante y creciente (1595 referencias), pero dispersa, tanto por el inmenso número de autores que publican, la mayoría con un solo trabajo, como por los lugares donde publican. Las temáticas más tratadas se refieren en primer lugar a modelos explicativos, diagnóstico y tratamiento; en segundo lugar se abordan los factores y variables determinantes del bajo y alto rendimiento académico; en tercer lugar se desarrollan estudios sobre legislación y de otras variables psicológicas y educativas en relación con el rendimiento. Este estudio supone una aproximación sintetizada de la producción sobre rendimiento académico en España, y un primer paso para investigaciones de síntesis posteriores, que nos permitan identificar buenas prácticas para el ejercicio de “prácticas basadas en la evidencia”, y otros problemas de investigación.