Surgical treatment approaches and reimbursement costs of surgical site infections post hip arthroplasty in Australia : a retrospective analysis

BACKGROUND: The treatment for deep surgical site infection (SSI) following primary total hip arthroplasty (THA) varies internationally and it is at present unclear which treatment approaches are used in Australia. The aim of this study is to identify current treatment approaches in Queensland, Australia, show success rates and quantify the costs of different treatments. METHODS: Data for patients undergoing primary THA and treatment for infection between January 2006 and December 2009 in Queensland hospitals were extracted from routinely used hospital databases. Records were linked with pathology information to confirm positive organisms. Diagnosis and treatment of infection was determined using ICD-10-AM and ACHI codes, respectively. Treatment costs were estimated based on AR-DRG cost accounting codes assigned to each patient hospital episode. RESULTS: A total of n=114 patients with deep surgical site infection were identified. The majority of patients (74%) were first treated with debridement, antibiotics and implant retention (DAIR), which was successful in eradicating the infection in 60.3% of patients with an average cost of $13,187. The remaining first treatments were 1-stage revision, successful in 89.7% with average costs of $27,006, and 2-stage revisions, successful in 92.9% of cases with average costs of $42,772. Multiple treatments following 'failed DAIR' cost on average $29,560, for failed 1-stage revision were $24,357, for failed 2-stage revision were $70,381 and were $23,805 for excision arthroplasty. CONCLUSIONS: As treatment costs in Australia are high primary prevention is important and the economics of competing treatment choices should be carefully considered. These currently vary greatly across international settings.

Development and validation of the ankle fracture outcome of rehabilitation measure (A-FORM)

Study Design Delphi panel and cohort study. Objective To develop and refine a condition-specific, patient-reported outcome measure, the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), and to examine its psychometric properties, including factor structure, reliability, and validity, by assessing item fit with the Rasch model. Background To our knowledge, there is no patient-reported outcome measure specific to ankle fracture with a robust content foundation. Methods A 2-stage research design was implemented. First, a Delphi panel that included patients and health professionals developed the items and refined the item wording. Second, a cohort study (n = 45) with 2 assessment points was conducted to permit preliminary maximum-likelihood exploratory factor analysis and Rasch analysis. Results The Delphi panel reached consensus on 53 potential items that were carried forward to the cohort phase. From the 2 time points, 81 questionnaires were completed and analyzed; 38 potential items were eliminated on account of greater than 10% missing data, factor loadings, and uniqueness. The 15 unidimensional items retained in the scale demonstrated appropriate person and item reliability after (and before) removal of 1 item (anxious about footwear) that had a higher-than-ideal outfit statistic (1.75). The “anxious about footwear” item was retained in the instrument, but only the 14 items with acceptable infit and outfit statistics (range, 0.5–1.5) were included in the summary score. Conclusion This investigation developed and refined the A-FORM (Version 1.0). The A-FORM items demonstrated favorable psychometric properties and are suitable for conversion to a single summary score. Further studies utilizing the A-FORM instrument are warranted. J Orthop Sports Phys Ther 2014;44(7):488–499. Epub 22 May 2014. doi:10.2519/jospt.2014.4980

Bayesian designs with frequentist and Bayesian error rate considerations

So far, most Phase II trials have been designed and analysed under a frequentist framework. Under this framework, a trial is designed so that the overall Type I and Type II errors of the trial are controlled at some desired levels. Recently, a number of articles have advocated the use of Bavesian designs in practice. Under a Bayesian framework, a trial is designed so that the trial stops when the posterior probability of treatment is within certain prespecified thresholds. In this article, we argue that trials under a Bayesian framework can also be designed to control frequentist error rates. We introduce a Bayesian version of Simon's well-known two-stage design to achieve this goal. We also consider two other errors, which are called Bayesian errors in this article because of their similarities to posterior probabilities. We show that our method can also control these Bayesian-type errors. We compare our method with other recent Bayesian designs in a numerical study and discuss implications of different designs on error rates. An example of a clinical trial for patients with nasopharyngeal carcinoma is used to illustrate differences of the different designs.

Alkaloid production by isolates of the sorghum ergot pathogen (Claviceps africana) from Australia and other countries

Isolates of Claviceps africana from Australia, Africa, Asia, and America were tested for the production of dihydroergosine (DHES), and its biogenic precursors dihydroelymoclavine (DHEL) and festuclavine (FEST), in culture. Several growth media were evaluated to optimise alkaloid production with little success. The best of these involved 2-stage culturing on high-sucrose substrate. Australian C. africana isolates varied widely and inconsistently in alkaloid production, with DHES concentrations in mycelium ranging from: <0.1 to 9 mg DHES/kg; <0.1 to 1.6 mg DHEL/kg; and <0.1 to 0.4 mg FEST/kg. In a separate experiment using similar culturing techniques, DHES was produced by 2 of 3 Australian isolates, 1 of 3 USA isolates, 1 of 4 Indian isolates, the sole Puerto Rican isolate, the sole Japanese isolate, but not the sole South African isolate. In this experiment, DHES concentrations detected in mycelium of Australian isolates (0.1-1.0 mg DHES/kg) were of similar magnitude to isolates from other countries (0.2-1.8 mg DHES/kg). Three C. africana isolates, including one that produced only traces of alkaloid in culture after 8 weeks, were inoculated onto panicles of sterile male sorghum plants. After 8 weeks, all 3 isolates produced 10-19 mg DHES/kg in the panicles, demonstrating that the growing plant favoured more consistent alkaloid production than culture medium.

Assessing the sustainability of wheat-based cropping systems using APSIM: Model parameterisation and evaluation

Assessing the sustainability of crop and soil management practices in wheat-based rotations requires a well-tested model with the demonstrated ability to sensibly predict crop productivity and changes in the soil resource. The Agricultural Production Systems Simulator (APSIM) suite of models was parameterised and subsequently used to predict biomass production, yield, crop water and nitrogen (N) use, as well as long-term soil water and organic matter dynamics in wheat/chickpea systems at Tel Hadya, north-western Syria. The model satisfactorily simulated the productivity and water and N use of wheat and chickpea crops grown under different N and/or water supply levels in the 1998-99 and 1999-2000 experimental seasons. Analysis of soil-water dynamics showed that the 2-stage soil evaporation model in APSIM's cascading water-balance module did not sufficiently explain the actual soil drying following crop harvest under conditions where unused water remained in the soil profile. This might have been related to evaporation from soil cracks in the montmorillonitic clay soil, a process not explicitly simulated by APSIM. Soil-water dynamics in wheat-fallow and wheat-chickpea rotations (1987-98) were nevertheless well simulated when the soil water content in 0-0.45 m soil depth was set to 'air dry' at the end of the growing season each year. The model satisfactorily simulated the amounts of NO3-N in the soil, whereas it underestimated the amounts of NH 4-N. Ammonium fixation might be part of the soil mineral-N dynamics at the study site because montmorillonite is the major clay mineral. This process is not simulated by APSIM's nitrogen module. APSIM was capable of predicting long-term trends (1985-98) in soil organic matter in wheat-fallow and wheat-chickpea rotations at Tel Hadya as reported in literature. Overall, results showed that the model is generic and mature enough to be extended to this set of environmental conditions and can therefore be applied to assess the sustainability of wheat-chickpea rotations at Tel Hadya.

Osseointegrated total knee replacement connected to a lower limb prosthesis: 4 cases

Background and purpose — Osseointegrated implants are an alternative for prosthetic attachment in individuals with amputation who are unable to wear a socket. However, the load transmitted through the osseointegrated fixation to the residual tibia and knee joint can be unbearable for those with transtibial amputation and knee arthritis. We report on the feasibility of combining total knee replacement (TKR) with an osseointegrated implant for prosthetic attachment. Patients and methods — We retrospectively reviewed all 4 cases (aged 38–77 years) of transtibial amputations managed with osseointegration and TKR in 2012–2014. The below-the-knee prosthesis was connected to the tibial base plate of a TKR, enabling the tibial residuum and knee joint to act as weight-sharing structures. A 2-stage procedure involved connecting a standard hinged TKR to custom-made implants and creation of a skin-implant interface. Clinical outcomes were assessed at baseline and after 1–3 years of follow-up using standard measures of health-related quality of life, ambulation, and activity level including the questionnaire for transfemoral amputees (Q-TFA) and the 6-minute walk test. Results — There were no major complications, and there was 1 case of superficial infection. All patients showed improved clinical outcomes, with a Q-TFA improvement range of 29–52 and a 6-minute walk test improvement range of 37–84 meters. Interpretation — It is possible to combine TKR with osseointegrated implants.

Genome-wide meta-analysis identifies five new susceptibility loci for cutaneous malignant melanoma

Thirteen common susceptibility loci have been reproducibly associated with cutaneous malignant melanoma (CMM). We report the results of an international 2-stage meta-analysis of CMM genome-wide association studies (GWAS). This meta-analysis combines 11 GWAS (5 previously unpublished) and a further three stage 2 data sets, totaling 15,990 CMM cases and 26,409 controls. Five loci not previously associated with CMM risk reached genome-wide significance (P < 5 × 10−8), as did 2 previously reported but unreplicated loci and all 13 established loci. Newly associated SNPs fall within putative melanocyte regulatory elements, and bioinformatic and expression quantitative trait locus (eQTL) data highlight candidate genes in the associated regions, including one involved in telomere biology.

Wireless network-coded accumulate-compute and forward two-way relaying

The design of modulation schemes for the physical layer network-coded two way wireless relaying scenario is considered. It was observed by Koike-Akino et al. for the two way relaying scenario, that adaptively changing the network coding map used at the relay according to the channel conditions greatly reduces the impact of multiple access interference which occurs at the relay during the MA Phase and all these network coding maps should satisfy a requirement called exclusive law. We extend this approach to an Accumulate-Compute and Forward protocol which employs two phases: Multiple Access (MA) phase consisting of two channel uses with independent messages in each channel use, and Broadcast (BC) phase having one channel use. Assuming that the two users transmit points from the same 4-PSK constellation, every such network coding map that satisfies the exclusive law can be represented by a Latin Square with side 16, and conversely, this relationship can be used to get the network coding maps satisfying the exclusive law. Two methods of obtaining this network coding map to be used at the relay are discussed. Using the structural properties of the Latin Squares for a given set of parameters, the problem of finding all the required maps is reduced to finding a small set of maps. Having obtained all the Latin Squares, the set of all possible channel realizations is quantized, depending on which one of the Latin Squares obtained optimizes the performance. The quantization thus obtained, is shown to be the same as the one obtained in [7] for the 2-stage bidirectional relaying.

Surface markers of regionalization in the vertebrate nervous system

In order to identify new molecules that might play a role in regional specification of the nervous system, we generated and characterized monoclonal antibodies (mAbs) that have positionally-restricted labeling patterns.

The FORSE-1 mAb was generated using a strategy designed to produce mAbs against neuronal cell surface antigens that might be regulated by regionally-restricted transcription factors in the developing central nervous system (CNS). FORSE-1 staining is enriched in the forebrain as compared to the rest of the CNS until E18. Between E11.5-E13.5, only certain areas of the forebrain are labeled. There is also a dorsoventrally-restricted region of labeling in the hindbrain and spinal cord. The mAb labels a large proteoglycan-like cell-surface antigen (>200 kD). The labeling pattern of FORSE-1 is conserved in various mammals and in chick.

To determine whether the FORSE-1 labeling pattern is similar to that of known transcription factors, the expression of BF-1 and Dlx-2 was compared with FORSE-1. There is a striking overlap between BF-1 and FORSE-1 in the telencephalon. In contrast, FORSE-1 and Dlx-2 have very different patterns of expression in the forebrain, suggesting that regulation by Dlx-2 alone cannot explain the distribution of FORSE-1. They do, however, share some sharp boundaries in the diencephalon. In addition, FORSE-1 identifies some previously unknown boundaries in the developing forebrain. Thus, FORSE-1 is a new cell surface marker that can be used to subdivide the embryonic forebrain into regions smaller than previously described, providing further complexity necessary for developmental patterning.

I also studied the expression of the cell surface protein CD9 in the developing and adult rat nervous system. CD9 is implicated in intercellular signaling and cell adhesion in the hematopoetic system. In the nervous system, CD9 may perform similar functions in early sympathetic ganglia, chromaffin cells, and motor neurons, all of which express the protein. The presence of CD9 on the surfaces of Schwann cells and axons at the appropriate time may allow the protein to participate in the cellular interactions involved in myelination.

Desenvolvimento de técnica de análise de imagens digitais para avaliação do estágio da fibrose em biópsias hepáticas de pacientes portadores de hepatite crônica por vírus da hepatite B e C

As hepatites crônicas por vírus são as mais frequentes, destacando-se os vírus das hepatites B (VHB) e C (VHC). O estudo anatomopatológico da biópsia hepática é considerado o padrão ouro para avaliar com precisão a distorção arquitetural e o grau de fibrose do parênquima do fígado, importantes fatores prognósticos para os pacientes portadores de hepatites crônicas virais. Na avaliação histopatológica atual, em adição aos relatos subjetivos das alterações histológicas, escores semiquantitativos que correlacionam achados morfológicos com graus numéricos são usados, tais como os reconhecidos escores de Ishak e METAVIR. Entretanto, em todos estes sistemas há a desvantagem da subjetividade do examinador e da incorporação de alterações categóricas, sem referências às mudanças quantitativas do colágeno hepático. Técnicas de análise de imagens digitais (AID) que fornecem quantificação objetiva dos graus de fibrose em amostras histológicas têm sido desenvolvidas. Todavia, o alto custo e dificuldade ao acesso das tecnologias descritas restringem seu uso a poucos centros especializados. Este estudo visa o desenvolvimento de uma técnica de custo acessível para a análise de imagens digitais da fibrose hepática em hepatites crônicas virais. Foram estudadas 304 biópsias de pacientes com hepatite crônica por vírus B e C, obtidas através de agulhas Menghini. Todas as amostras tinham pelo menos 15 mm de comprimento ou cinco espaços-porta completos e foram coradas pelo método Tricrômico de Masson. O estadiamento foi feito por um único hepatopatologista experiente, sem o conhecimento dos dados clínicos dos pacientes. Os escores de Ishak e METAVIR foram aplicados. As imagens microscópicas foram digitalizadas. Os índices de fibrose foram determinados de forma automatizada, em técnica desenvolvida no programa Adobe Photoshop. Para o escore de Ishak, observamos os seguintes índices de Fibrose (IF) médios: 0,8% 0,0 (estágio 0), 2.4% 0,6 (estágio 1), 4,7% 1,6 (estágio 2), 7,4% 1,4 (estágio 3), 14,9% 3,7 (estágio 4), 23,4% 2,9 (estágio 5) e 34,5% 1,5 (estágio 6). Para a classificação METAVIR: 0,8% 0,1 (estágio F0), 3,8% 1,8 (estágio F1), 7,4% 1,4 (estágio F2), 20,4% 5,2 (estágio F3) e 34,5% 1,5 (estágio F4). Observamos uma excelente correlação entre os índices de fibrose da AID e os escores de Ishak (r=0,94; p<0,001) e METAVIR (r=0,92; p<0,001). Em relação à indicação de tratamento antiviral, foi observado IF médio de 16,4%. Em relação ao diagnóstico de cirrose, foi observado IF médio de 26,9%, para o escore de Ishak, e 34,5% para a classificação METAVIR. A reprodutibilidade intra-observador foi excelente. Este novo método de análise de imagens digitais para a quantificação de fibrose hepática tem custo acessível e foi desenvolvido com tecnologia que está disponível em todo o mundo, permitindo identificar com precisão todos os estágios de fibrose, com excelente reprodutibilidade intra-observador.

The development of aerodynamic performance measurements in a transient test facility

Transient test facilities offer the potential for the simultaneous study of turbine aerodynamic performance, unsteady flow phenomena and the heat transfer characteristics of a turbine stage. This paper describes the development of aerodynamic performance measurement techniques in the Oxford Rotor Facility (ORF). The solutions to the technological issues involved with transient testing presented in this paper are expected to achieve levels of precision uncertainty comparable with traditional steady flow test rigs. The theoretical background to the measurement of aerodynamic performance is presented together with a comprehensive pre-test uncertainty analysis. The instrumentation scheme for the measurement of stage mass flow rate is discussed in detail, the measurements of shaft power, total inlet enthalpy, and stage pressure ratio are also outlined. The current working section features a 62% scale, 1-1/2 stage, high-pressure shroudless transonic turbine. The required inlet flow conditions are provided by an Isentropic Light Piston Tunnel (ILPT) with a quasi-steady state run time of approximately 70ms. The testing is conducted at engine representative specific speed, pressure ratio, gas-to-wall temperature ratio, Mach number and Reynolds number.

A COMPARATIVE-STUDY OF KARYOTYPES OF MUNTJACS BY CHROMOSOME PAINTING

We have used a combination of chromosome sorting, degenerate oligonucleotide-primed polymerase chain reaction (DOP-PCR), chromosome painting and digital image capturing and processing techniques for comparative chromosome analysis of members of the genus Muntiacus. Chromosome-specific ''paints'' from a female Indian muntjac were hybridised to the metaphase chromosomes of the Gongshan, Black, and Chinese muntjac by both single and three colour chromosome painting. Karyotypes and idiograms for the Indian, Gongshan, Black and Chinese muntjac were constructed, based on enhanced 4', 6-diamidino-2-phenylindole (DAPI) banding patterns. The hybridisation signal for each paint was assigned to specific bands or chromosomes for all of the above muntjac species. The interspecific chromosomal homology was demonstrated by the use of both enhanced DAPI banding and comparative chromosome painting. These results provide direct molecular cytogenetic evidence for the tandem fusion theory of the chromosome evolution of muntjac species.

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Breeding behavior under temporal risk of predation in male root voles (Microtus oeconomus)

We examined breeding behavior responses of male root votes (Microtus oeconomus) to temporal risk of predation by using acute and chronic exposure to predator odor. The 2 series of exposure experiments provided 2 types of temporal patterns of risk: continuous safety with a brief period of risk and Sustained risk with a brief period of safety. Male root votes that were acutely exposed to predator odor for I h suppressed their breeding behavior, but bred immediately after exposure to control odor for I h. Those chronically exposed to predator odor for 20 days maintained behavioral suppression during the 1-h period of exposure to control odor. Acutely exposed males did not change their physiological patterns of breeding, but those chronically exposed to predator odor had reduced testosterone concentration and epididymis index. Our results indicate that breeding behavior in a given situation depends on the overall patterns of risk experienced by male root votes, and the acute and chronic stress responses that affect reproduction are responsible for different behavioral responses to the 2 types of temporal patterns of risk. We also discuss the reasons for conflicting results about breeding suppression of votes between previous studies in the laboratory and the field.

Metacognition in monkeys during an oculomotor task.

This study investigated whether rhesus monkeys show evidence of metacognition in a reduced, visual oculomotor task that is particularly suitable for use in fMRI and electrophysiology. The 2-stage task involved punctate visual stimulation and saccadic eye movement responses. In each trial, monkeys made a decision and then made a bet. To earn maximum reward, they had to monitor their decision and use that information to bet advantageously. Two monkeys learned to base their bets on their decisions within a few weeks. We implemented an operational definition of metacognitive behavior that relied on trial-by-trial analyses and signal detection theory. Both monkeys exhibited metacognition according to these quantitative criteria. Neither external visual cues nor potential reaction time cues explained the betting behavior; the animals seemed to rely exclusively on internal traces of their decisions. We documented the learning process of one monkey. During a 10-session transition phase, betting switched from random to a decision-based strategy. The results reinforce previous findings of metacognitive ability in monkeys and may facilitate the neurophysiological investigation of metacognitive functions.