Risk factors, microbiological findings and outcomes of necrotizing fasciitis in New Zealand: a retrospective chart review

Background
The incidence and mortality from necrotizing fasciitis (NF) are increasing in New Zealand (NZ). Triggered by a media report that traditional Samoan tattooing was causing NF, we conducted a chart review to investigate the role of this and other predisposing and precipitating factors and to document NF microbiology, complications and interventions in NZ.

Methods
We conducted a retrospective review of 299 hospital charts of patients discharged with NF diagnosis codes in eight hospitals in NZ between 2000 and 2006. We documented and compared by ethnicity the prevalence of predisposing and precipitating conditions, bacteria isolated, complications and interventions used.

Results
Out of 299 charts, 247 fulfilled the case definition. NF was most common in elderly males. Diabetes was the most frequent co-morbid condition, followed by obesity. Nearly a quarter of patients were taking non-steroidal anti-inflammatory drugs (NSAID). Traditional Samoan tattooing was an uncommon cause. Streptococcus pyogenes and Staphylococcus aureus were the two commonly isolated bacteria. Methicillin-resistant Staphylococcus aureus was implicated in a relatively small number of cases. Shock, renal failure, coagulation abnormality and multi-organ dysfunction were common complications. More than 90% of patients underwent surgical debridement, 56% were admitted to an intensive care unit (ICU) and slightly less than half of all patients had blood product transfusion. One in six NF cases had amputations and 23.5% died.

Conclusion
This chart review found that the highest proportion of NF cases was elderly males with co-morbidities, particularly diabetes and obesity. Tattooing was an uncommon precipitating event. The role of NSAID needs further exploration. NF is a serious disease with severe complications, high case fatality and considerable use of health care resources.

The frontotemporal-orbitozygomatic approach : reconstructive technique and outcome

Background The frontotemporal-orbitozygomatic (FTOZ) approach, also known as "the workhorse of skull base surgery," has captured the interest of many researchers throughout the years. Most of the studies published have focused on the surgical technique and the gained exposure. However, few studies have described reconstructive techniques or functional and cosmetic outcomes. The goal of this study was to describe the surgical reconstruction after the FTOZ approach and analyze the functional and cosmetic outcomes. Methods Seventy-five consecutive patients who had undergone FTOZ craniotomy for different reasons were selected. The same surgical (one-piece FTOZ) and reconstructive techniques were applied in all patients. The functional outcome was measured by complications related to the surgical approach: retro-orbital pain, exophthalmos, enophthalmos, ocular movement restriction, cranial nerve injuries, pseudomeningocele (PMC) and secondary surgeries required to attain a reconstructive closure. The cosmetic outcome was evaluated by analyzing the satisfaction of the patients and their families. Questionnaires were conducted later in the postoperative period. A statistical analysis of the data obtained from the charts and questions was performed. Results Of the 75 patients studied, 59 had no complications whatsoever. Ocular movement restriction was found in two patients (2.4 %). Cranial nerve injury was documented in seven patients (8.5 %). One patient (1.2 %) underwent surgical repair of a cerebrospinal fluid (CSF) leak from the initial surgery. Two patients (2.4 %) developed delayed postoperative pseudomenigocele. One patient (1.2 %) developed intraparenchymal hemorrhage (IPH). Full responses to the questionnaires were collected from 28 patients giving an overall response rate of 34 %. Overall, 22 patients (78.5 %) were satisfied with the cosmetic outcome of surgery. Conclusion The reconstruction after FTOZ approach is as important as the performance of the surgical technique. Attention to anatomical details and the stepwise reconstruction are a prerequisite to the successful preservation of function and cosmesis. In our series, the orbitozygomatic osteotomy did not increase surgical complications or alter cosmetic outcomes.

America’s challenges in the Greater Middle East: the Obama administration's policies

The Middle East has been the centerpiece of American foreign policy for decades. As President Barack Obama faces continuing wars in Iraq and Afghanistan, the nuclear debate in Iran, and the ever-present Israeli-Palestinian conflict, the future of this region is once again firmly in the international spotlight. America's Challenges in the Greater Middle East charts US policy towards key Middle Eastern states and evaluates the impact of the current administration's policies. This edited volume brings together scholarly opinion from a diverse range of world-recognized experts and is the definitive text on the Obama administration's engagement with this volatile, yet politically vital, part of the world.

Dynamics of childhood growth and obesity: development and validation of a quantitative mathematical model

Background
Clinicians and policy makers need the ability to predict quantitatively how childhood bodyweight will respond to obesity interventions.

Methods
We developed and validated a mathematical model of childhood energy balance that accounts for healthy growth and development of obesity, and that makes quantitative predictions about weight-management interventions. The model was calibrated to reference body composition data in healthy children and validated by comparing model predictions with data other than those used to build the model.

Findings
The model accurately simulated the changes in body composition and energy expenditure reported in reference data during healthy growth, and predicted increases in energy intake from ages 5—18 years of roughly 1200 kcal per day in boys and 900 kcal per day in girls. Development of childhood obesity necessitated a substantially greater excess energy intake than for development of adult obesity. Furthermore, excess energy intake in overweight and obese children calculated by the model greatly exceeded the typical energy balance calculated on the basis of growth charts. At the population level, the excess weight of US children in 2003—06 was associated with a mean increase in energy intake of roughly 200 kcal per day per child compared with similar children in 1971—74. The model also suggests that therapeutic windows when children can outgrow obesity without losing weight might exist, especially during periods of high growth potential in boys who are not severely obese.

Interpretation
This model quantifies the energy excess underlying obesity and calculates the necessary intervention magnitude to achieve bodyweight change in children. Policy makers and clinicians now have a quantitative technique for understanding the childhood obesity epidemic and planning interventions to control it.

Funding
Intramural Research Program of the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.

Progress Toward Robust Polymer Hydrogels

In this review we highlight new developments in tough hydrogel materials in terms of their enhanced mechanical performance and their corresponding toughening mechanisms. These mechanically robust hydrogels have been developed over the past 10 years with many now showing mechanical properties comparable with those of natural tissues. By first reviewing the brittleness of conventional synthetic hydrogels, we introduce each new class of tough hydrogel: homogeneous gels, slip-link gels, double-network gels, nanocomposite gels and gels formed using poly-functional crosslinkers. In each case we provide a description of the fracture process that may be occurring. With the exception of double network gels where the enhanced toughness is quite well understood, these descriptions remain to be confirmed. We also introduce material property charts for conventional and tough synthetic hydrogels to illustrate the wide range of mechanical and swelling properties exhibited by these materials and to highlight links between these properties and the network topology. Finally, we provide some suggestions for further work particularly with regard to some unanswered questions and possible avenues for further enhancement of gel toughness.

Slope stability analysis for cohesive materials filled on purely cohesive undrained clay

Stability charts for soil slopes were first produced by Taylor in 1937 and they continue to be used extensively as design tools and draw the attention of many investigators. From a review of literature, it was found that there is no convenient solution has been provided for cohesive materials filled on purely cohesive undrained clay. A recent study revealed that the embankment slope which has two-layered clays failed in an undrained state which shows the importance of this study. In order to obtain the solutions for this type of fill slope. A number of numerical method are employed, namely the finite element upper and lower bound limit analysis methods and limit equilibrium method. The numerical upper and lower bound limit analysis method can bracket true solutions within a small range (6%). The solutions of limit equilibrium analysis are used for comparison purpose.

Application of neural network to rock slope stability assessments

It is known that rock masses are inhomogeneous, discontinuous media composed of rock material and naturally occurring discontinuities such as joints, fractures and bedding planes. These features make any analysis very difficult using simple theoretical solutions. Generally speaking, back analysis technique can be used to capture some implicit parameters for geotechnical problems. In order to perform back analyses, the procedure of trial and error is generally required. However, it would be time-consuming. This study aims at applying a neural network to do the back analysis for rock slope failures. The neural network tool will be trained by using the solutions of finite element upper and lower bound limit analysis methods. Therefore, the uncertain parameter can be obtained, particularly for rock mass disturbance.

Trench stability under bentonite pressure in purely cohesive clay

Trench stability is a conventional geotechnical problem; however, current evaluations are often based entirely on empiricism. This paper uses numerical finite-element upper and lower bound limit analysis to produce stability charts for two-dimensional and three-dimensional homogeneous and inhomogeneous undrained diaphragm wall trenches. Using the limit theorems cannot only provide a simple and useful way of analyzing the stability of the trench, but also avoid the shortcomings and arbitrary assumptions underpinning the limit equilibrium method. By considering the effects from the bentonite slurry pressures, the collapse load in this study has been bracketed to within ±8.5 or better by the numerical upper and lower bound limit analyses. The chart solutions can be used to predict either the critical depth or the safety factor of the trench and provide a convenient tool for preliminary designs by practicing engineers. © 2014 American Society of Civil Engineers.

Obesity prevention in early life: an opportunity to better support the role of Maternal and Child Health Nurses in Australia

BACKGROUND: Because parents with young children access primary health care services frequently, a key opportunity arises for Maternal and Child Health (MCH) nurses to actively work with families to support healthy infant feeding practices and lifestyle behaviours. However, little is known regarding the extent to which MCH nurses promote obesity prevention practices and how such practices could be better supported. METHODS: This mixed methods study involved a survey of 56 MCH nurses (response rate 84.8 %), 16 of whom participated in semi-structured qualitative interviews. Both components aimed to examine the extent to which nurses addressed healthy infant feeding practices, healthy eating, active play and limiting sedentary behavior during routine consultations with young children 0-5 years. Key factors influencing such practices and how they could be best supported were also investigated. All data were collected from September to December 2013. Survey data were analysed descriptively and triangulated with qualitative interview findings, the analysis of which was guided by grounded theory principles. RESULTS: Although nurses reported measuring height/length and weight in most consultations, almost one quarter (22.2 %) reported never/rarely using growth charts to identify infants or children at risk of overweight or obesity. This reflected a reluctance to raise the issue of weight with parents and a lack of confidence in how to address it. The majority of nurses reported providing advice on aspects of infant feeding relevant to obesity prevention at most consultations, with around a third (37 %) routinely provided advice on formula preparation. Less than half of nurses routinely promoted active play and only 30 % discussed limiting sedentary behaviour such as TV viewing. Concerns about parental receptiveness and maintaining rapport were key barriers to more effective implementation. CONCLUSION: While MCH nurses are well placed to address obesity prevention in early life, there is currently a missed public health opportunity. Improving nurse skills in behaviour change counseling will be key to increasing their confidence in raising sensitive lifestyle issues with parents to better integrate obesity prevention practices into normal MCH service delivery.

Cost-effectiveness analysis of a hospital electronic medication management system

OBJECTIVE: To conduct a cost-effectiveness analysis of a hospital electronic medication management system (eMMS). METHODS: We compared costs and benefits of paper-based prescribing with a commercial eMMS (CSC MedChart) on one cardiology ward in a major 326-bed teaching hospital, assuming a 15-year time horizon and a health system perspective. The eMMS implementation and operating costs were obtained from the study site. We used data on eMMS effectiveness in reducing potential adverse drug events (ADEs), and potential ADEs intercepted, based on review of 1 202 patient charts before (n = 801) and after (n = 401) eMMS. These were combined with published estimates of actual ADEs and their costs. RESULTS: The rate of potential ADEs following eMMS fell from 0.17 per admission to 0.05; a reduction of 71%. The annualized eMMS implementation, maintenance, and operating costs for the cardiology ward were A$61 741 (US$55 296). The estimated reduction in ADEs post eMMS was approximately 80 actual ADEs per year. The reduced costs associated with these ADEs were more than sufficient to offset the costs of the eMMS. Estimated savings resulting from eMMS implementation were A$63-66 (US$56-59) per admission (A$97 740-$102 000 per annum for this ward). Sensitivity analyses demonstrated results were robust when both eMMS effectiveness and costs of actual ADEs were varied substantially. CONCLUSION: The eMMS within this setting was more effective and less expensive than paper-based prescribing. Comparison with the few previous full economic evaluations available suggests a marked improvement in the cost-effectiveness of eMMS, largely driven by increased effectiveness of contemporary eMMs in reducing medication errors.

Three-dimensional slope stability assessment of two-layered undrained clay

This paper uses the finite element upper and lower bound limit analysis methods to investigate the three-dimensional (3D) slope stability of two-layered undrained clay slopes. The solutions obtained from the slope stability analyses are bracketed to within ±10% or better. For comparison purposes, results from two-dimensional (2D) analyses based on the numerical limit analysis methods and the conventional limit equilibrium method (LEM) are also discussed. This study shows that 3D boundary of a slope can have significant effects on the slope stability. In addition, the results are presented in the form of stability charts which can be convenient tools for practicing engineers.

Generating reusable visual notations using model transformation

Visual notations are a key aspect of visual languages. They provide a direct mapping between the intended information and set of graphical symbols. Visual notations are most often implemented using the low level syntax of programming languages which is time consuming, error prone, difficult to maintain and hardly human-centric. In this paper we describe an alternative approach to generating visual notations using by-example model transformations. In our new approach, a semantic mapping between model and view is implemented using model transformations. The notations resulting from this approach can be reused by mapping varieties of input data to their model and can be composed into different visualizations. Our approach is implemented in the CONVErT framework and has been applied to many visualization examples. Three case studies for visualizing statistical charts, visualization of traffic data, and reuse of a Minard's map visualization's components, are presented in this paper. A detailed user study of our approach for reusing notations and generating visualizations has been provided. 80% of the participants in this user study agreed that the novel approach to visualization was easy and 87% stated that they quickly learned to use the tool support.

Generating reusable visual notations using model transformation

Visual notations are a key aspect of visual languages. They provide a direct mapping between the intended information and set of graphical symbols. Visual notations are most often implemented using the low level syntax of programming languages which is time consuming, error prone, difficult to maintain and hardly human-centric. In this paper we describe an alternative approach to generating visual notations using byexample model transformations. In our new approach, a semantic mapping between model and view is implemented using model transformations. The notations resulting from this approach can be reused by mapping varieties of input data to their model and can be composed into different visualisations. Our approach is implemented in the CONVErT framework and has been applied to many visualisation examples. Two case studies for visualising statistical charts and visualisation of traffic data are presented in this paper. A detailed user study of our approach for reusing notations and generating visualisations has been provided that shows good reusability and general acceptance of the novel approach.

Pore pressure effect on slope stability assessment

Slope stability assessment has been an integral problem for geotechnical engineering all these years. While stability of slopes is affected by various factors, pore pressure is one of the common naturalelements that influence slope stability analysis. This paper studies the effect of pore pressure on slope stability assessment by using Limit Equilibrium Method (LEM). The results will be compared to the solutions of Hoek and Bray charts. In this study, slopes with different levels of water table corresponding to those of Hoek and Bray charts are investigated. It’s interesting to observe that the results obtained from the Hoek and Bray charts yielded different factor of safety compare to those in the study here-in. In fact, the different between the factors of safety could be up to 30%. Hence this issue should be taken into consideration during slope design.