New vertebral fractures after vertebroplasty: 2-year results from a randomised controlled trial

Summary: A randomised controlled trial of vertebroplasty (VP) versus placebo assessed the effect of VP on the risk of further vertebral fractures. While no statistically significant between-group differences for new or progressed fracture risk at 12 and 24 months were observed, we observed a consistent trend towards higher risk of any type of fracture in the group undergoing VP. Our analysis was underpowered, and further adequately powered studies are needed to be able to draw firm conclusions about further vertebral risk with vertebroplasty. Purpose: This study seeks to assess the effect of VP on the risk of further radiologically apparent vertebral fracture within two years of the procedure. Methods: We conducted a randomised placebo-controlled trial of VP in people with acute osteoporotic vertebral fracture. Eligible participants were randomly assigned to VP (n = 38) or placebo (n = 40). Cement volume and leakage were recorded for the VP group. Plain thoracolumbar radiographs were taken at baseline, 12 and 24 months. Two independent radiologists assessed these for new and progressed fractures at the same, adjacent and non-adjacent levels. Results: At 12 and 24 months, radiographs were available for 45 (58 %) and 47 (60 %) participants, respectively. There were no between-group differences for new or progressed fractures: 32 and 40 in the VP group after 12 and 24 months compared with 21 and 33 in the placebo group (hazard ratio (HR) 1.80, 95 % confidence interval (CI) 0.82 to 3.94). Similar results were seen when considering only adjacent (HR (95 % CI) 2.30 (0.57 to 9.29)) and non-adjacent (HR (95 % CI) 1.45 (0.55 to 3.81) levels. In all comparisons, there was a consistent trend towards higher risk of any type of fracture in the group undergoing VP. Within the VP group, fracture risk was unrelated to total (HR (95 % CI) 0.91 (0.71 to 1.17)) or relative (HR (95 % CI) 1.31 (0.15 to 11.48)) cement volume or cement leakage (HR (95 % CI) 1.20 (0.63 to 2.31)). Conclusion: For patients undergoing VP, our study did not demonstrate significant increases in subsequent fracture risk beyond that experienced by those with vertebral fractures who did not undergo the procedure. However, because of the non-significant numerical increases observed, studies with adequate power are needed to draw definite conclusions about fracture risk.

East and West, past and present: rekindle old principles for new management practices

This paper explores the sayings and stories of the ancient Chinese philosophers Guanzi, Hanfeizi, Xunzi and Yanzi. Their way of ruling the state and managing the people are analysed and discussed in line with thoughts from the mainstream and modern Western management gurus, such as Warren Bennis, Peter Drucker, Mary Parker Follett, Douglas McGregor, Rosabeth Moss Kanter, Elton Mayo, and Jeffrey Pfeffer. Striking similarities call for addressing key issues in human resource management. East and west thinkers across 3000 years are identified. The principles-based ruling and management were found difficult to be taken seriously in ancient times as it is today. However, these principles must be rekindled to protect organisations and the world from mischievous behaviour that has caused much human suffering.

New approaches for studies of Muslim women and sport

This article offers a new approach for examining Muslim women in sport, which combines the domains of sporting participation, consumption and representation. It proposes moving beyond a sports development paradigm and deficit model of sports participation, whereby marginal communities are incorporated into the mainstream by playing sport, to take account of other ways that people engage with sport as consumers and fans. Conceptually, this approach is informed by transnational feminist perspectives, which foreground the role of power hierarchies in the production of knowledge about the sporting female Other. It suggests that sport practitioners, scholars and policy makers pay greater theoretical attention to how Muslim women are constructed within sport discourses. By widening the research focus to consider consumption and representation, possibilities emerge to expand on the narrow research and policy fields of ‘ethnicity’ and ‘well-being’ focused on physical health outcomes through which Muslim women’s engagement with sport is commonly framed.

The experiences and needs of family carers of people with diabetes at the end of life

ABSTRACT
Diabetes is a common, increasingly prevalent chronic disease. Many people requiring palliative care have diabetes. Diabetes requires lifelong self-care tasks. Family carers frequently perform these tasks when the person with diabetes is no longer able to perform them, but there is a lack of information about carers’ needs to enable them to undertake their new care tasks. The study aimed to collect information from family carers of people with diabetes requiring palliative care about their views and experiences of managing a family member’s diabetes at the end of life and identify their needs to enable them to undertake diabetes care tasks. Data were collected during individual, semistructured interviews with 10 family members caring for a person with diabetes receiving palliative care. The 4 key themes identified were as follows: I didn’t know what to do: it’s a big responsibility; I need education; and it’s important to manage diabetes. Family members/carers feel anxious about their increasing responsibility when caring for their family member’s diabetes and need information and education to help them monitor and interpret blood glucose levels, mange high or low blood glucose levels, and administer glucose-lowering medicines safely and confidently.

Understanding quality of life in medicine : a new approach

This article introduces the subjective side of quality of life as it has evolved within the discipline of psychology. Subjective well-being is also of special interest within medicine due to its links to pathology and the fact that it is managed by a homeostatic system. This form of management offers an explanation for the unusual properties of subjective well-being, including its normal positivity, stability, and nonlinear relationship to objective variables, such as physical health. Central to understanding is the proposition that subjective well-being mainly consists of a specific form of trait mood. This homeostatically protected mood has a genetic set point and it is the experience of this set-point mood that homeostasis is defending. The resources required to maintain normal homeostatic control are described. If these resources are inadequate to protect the experience of set-point mood, mood positivity falls, and there is a high probability of depression. In this article, the process of homeostasis is shown to assist understanding of intervention effectiveness within both psychology and medicine. This concerns matters of resilience, the nonlinear relationship between levels of subjective well-being, and the strength of challenging agents, and the important understanding that interventions designed to raise subjective well-being are critically dependent on its level at baseline. Key teaching points: • The physiological process of homeostasis has a parallel in psychology in the homeostatic management of subjective well-being. • Subjective well-being is a more globally informative construct than health-related quality of life. • How people feel about themselves and their lives cannot be simply predicted through measures of health. • When subjective well-being homeostasis is defeated, there is a high probability of depression.

Patterns of general practitioner usage among Pacific people: indicative results from the Waikato Medical Care Survey 1991-2

AIMS: To report patterns of medical contact in a representative sample of Pacific people attending the general practitioner. METHODS: The data were drawn from a survey of general practice in the Waikato region representing a one per cent sample of all weekday encounters. In total, 12,833 patient encounter forms were completed. Just over one per cent of all encounters were recorded for patients of Pacific Islands background. RESULTS: Rates of medical contact for Pacific patients were lower-3.4 visits per year versus 4.5 for the whole sample-fewer follow up visits were requested (71% versus 76.2%), presentation was delayed (4.9 days from onset versus 3.7 for the sample) and there was an apparently lower level of rapport achieved. CONCLUSION: Overall levels of medical contact and return visits among Pacific patients appear to be lower and presentation delayed in this Waikato sample.

Nurse-led titration of angiotensin converting enzyme inhibitors, beta-adrenergic blocking agents, and angiotensin receptor blockers for people with heart failure with reduced ejection fraction

BACKGROUND: Heart failure is associated with high mortality and hospital readmissions. Beta-adrenergic blocking agents, angiotensin converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) can improve survival and reduce hospital readmissions and are recommended as first-line therapy in the treatment of heart failure. Evidence has also shown that there is a dose-dependent relationship of these medications with patient outcomes. Despite this evidence, primary care physicians are reluctant to up-titrate these medications. New strategies aimed at facilitating this up-titration are warranted. Nurse-led titration (NLT) is one such strategy. OBJECTIVES: To assess the effects of NLT of beta-adrenergic blocking agents, ACEIs, and ARBs in patients with heart failure with reduced ejection fraction (HFrEF) in terms of safety and patient outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL Issue 11 of 12, 19/12/2014), MEDLINE OVID (1946 to November week 3 2014), and EMBASE Classic and EMBASE OVID (1947 to 2014 week 50). We also searched reference lists of relevant primary studies, systematic reviews, clinical trial registries, and unpublished theses sources. We used no language restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing NLT of beta-adrenergic blocking agents, ACEIs, and/or ARBs comparing the optimisation of these medications by a nurse to optimisation by another health professional in patients with HFrEF. DATA COLLECTION AND ANALYSIS: Two review authors (AD & JC) independently assessed studies for eligibility and risk of bias. We contacted primary authors if we required additional information. We examined quality of evidence using the GRADE rating tool for RCTs. We analysed extracted data by risk ratio (RR) with 95% confidence interval (CI) for dichotomous data to measure effect sizes of intervention group compared with usual-care group. Meta-analyses used the fixed-effect Mantel-Haenszel method. We assessed heterogeneity between studies by Chi(2) and I(2). MAIN RESULTS: We included seven studies (1684 participants) in the review. One study enrolled participants from a residential care facility, and the other six studies from primary care and outpatient clinics. All-cause hospital admission data was available in four studies (556 participants). Participants in the NLT group experienced a lower rate of all-cause hospital admissions (RR 0.80, 95% CI 0.72 to 0.88, high-quality evidence) and fewer hospital admissions related to heart failure (RR 0.51, 95% CI 0.36 to 0.72, moderate-quality evidence) compared to the usual-care group. Six studies (902 participants) examined all-cause mortality. All-cause mortality was also lower in the NLT group (RR 0.66, 95% CI 0.48 to 0.92, moderate-quality evidence) compared to usual care. Approximately 27 deaths could be avoided for every 1000 people receiving NLT of beta-adrenergic blocking agents, ACEIs, and ARBs. Only three studies (370 participants) reported outcomes on all-cause and heart failure-related event-free survival. Participants in the NLT group were more likely to remain event free compared to participants in the usual-care group (RR 0.60, 95% CI 0.46 to 0.77, moderate-quality evidence). Five studies (966 participants) reported on the number of participants reaching target dose of beta-adrenergic blocking agents. This was also higher in the NLT group compared to usual care (RR 1.99, 95% CI 1.61 to 2.47, low-quality evidence). However, there was a substantial degree of heterogeneity in this pooled analysis. We rated the risk of bias in these studies as high mainly due to a lack of clarity regarding incomplete outcome data, lack of reporting on adverse events associated with the intervention, and the inability to blind participants and personnel. Participants in the NLT group reached maximal dose of beta-adrenergic blocking agents in half the time compared with participants in usual care. Two studies reported on adverse events; one of these studies stated there were no adverse events, and the other study found one adverse event but did not specify the type or severity of the adverse event. AUTHORS' CONCLUSIONS: Participants in the NLT group experienced fewer hospital admissions for any cause and an increase in survival and number of participants reaching target dose within a shorter time period. However, the quality of evidence regarding the proportion of participants reaching target dose was low and should be interpreted with caution. We found high-quality evidence supporting NLT as one strategy that may improve the optimisation of beta-adrenergic blocking agents resulting in a reduction in hospital admissions. Despite evidence of a dose-dependent relationship of beta-adrenergic blocking agents, ACEIs, and ARBs with improving outcomes in patients with HFrEF, the translation of this evidence into clinical practice is poor. NLT is one strategy that facilitates the implementation of this evidence into practice.

The establishment and development of neurosurgery services in Papua New Guinea

BACKGROUND: Papua New Guinea (PNG) is a developing Pacific Nation of 7.3 million people. Although neurosurgery training was introduced to PNG in the year 2000, it was in 2003 that a neurosurgery service was established. Prior to this time, neurosurgery in PNG was performed by general surgeons, with some assistance from visiting Australian neurosurgeons. Neurosurgical training was introduced to PNG in 2000. The model involved a further 3 years of training for a surgeon who had already completed 4 years of general surgical training. We aim to review the output, outcomes and impact achieved by training the first national neurosurgeon. METHODS: The data on activity (output) and outcomes were collected prospectively from 2003-2012. Ongoing mentoring and continuing professional development were provided through annual neurosurgical visits from Australia. There were serious limitations in the provision of equipment, with a lack of computerized tomographic or MR imaging, and adjuvant oncological services. RESULTS: There were 1618 neurosurgery admissions, 1020 neurosurgical procedures with a 5.74 % overall mortality. Seventy percent of cases presented as emergencies. There were improved outcomes, particularly for head injuries, whilst hydrocephalus was managed with an acceptable morbidity and revision rate. CONCLUSIONS: The training of a neurosurgeon resulted in PNG patients receiving a better range of surgical services, with a lower mortality. The outcomes able to be delivered were limited by late presentations of patients and lack of resources including imaging. These themes are familiar to all low- and middle-income countries (LMICs) and this may serve as a model for other LMIC neurosurgical services to adopt as they consider whether to establish and develop neurosurgical and other sub-specialist surgical services.

Action research in a remote district in Papua New Guinea: final report

This project investigated whether action research could be used to address ‘grassroots’ community problems in a remote district of PNG. The research team introduced, supported and researched the implementation of a pilot action research project from April to November 2015 in Abau, Central Province. The project was funded by the Australian Government and commissioned through the Economic and Public Sector Program (EPSP) managed by Coffey. The action research participants comprised people from throughout Abau with interests in women’s and gender equity issues from community groups and agencies in the district. The action research teams developed evidence-based understandings of the causes and consequences of the problems that they were addressing through their actions. The research team provided each participant with a mobile phone connected to a ‘common user group’ (CUG). This enabled each participant unlimited phone calls and SMS messaging to other participants and to the research team. The research team sent weekly sets of SMS messages to all participants to assist their action research work. The use of mobile phones to support action research in remote communities was an important element of both facilitating the action research and of the research on the pilot project itself. With such knowledge they were strengthened in purpose and intention to help their own community. This suggests that an extension of this work in other remote areas of PNG may be successful.

Smartphone apps to improve fitness and increase physical activity among young people: protocol of the Apps for IMproving FITness (AIMFIT) randomized controlled trial

BACKGROUND: Physical activity is a modifiable behavior related to many preventable non-communicable diseases. There is an age-related decline in physical activity levels in young people, which tracks into adulthood. Common interactive technologies such as smartphones, particularly employing immersive features, may enhance the appeal and delivery of interventions to increase levels of physical activity in young people. The primary aim of the Apps for IMproving FITness (AIMFIT) trial is to evaluate the effectiveness of two popular "off-the-shelf" smartphone apps for improving cardiorespiratory fitness in young people.

METHODS/DESIGN: A three-arm, parallel, randomized controlled trial will be conducted in Auckland, New Zealand. Fifty-one eligible young people aged 14-17 years will be randomized to one of three conditions: 1) use of an immersive smartphone app, 2) use of a non-immersive app, or 3) usual behavior (control). Both smartphone apps consist of an eight-week training program designed to improve fitness and ability to run 5 km, however, the immersive app features a game-themed design and adds a narrative. Data are collected at baseline and 8 weeks. The primary outcome is cardiorespiratory fitness, assessed as time to complete the one mile run/walk test at 8 weeks. Secondary outcomes are physical activity levels, self-efficacy, enjoyment, psychological need satisfaction, and acceptability and usability of the apps. Analysis using intention to treat principles will be performed using regression models.

DISCUSSION: Despite the proliferation of commercially available smartphone applications, there is a dearth of empirical evidence to support their effectiveness on the targeted health behavior. This pragmatic study will determine the effectiveness of two popular "off-the-shelf" apps as a stand-alone instrument for improving fitness and physical activity among young people. Adherence to app use will not be closely controlled; however, random allocation of participants, a heterogeneous group, and data analysis using intention to treat principles provide internal and external validity to the study. The primary outcome will be objectively assessed with a valid and reliable field-based test, as well as the secondary outcome of physical activity, via accelerometry. If effective, such applications could be used alongside existing interventions to promote fitness and physical activity in this population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12613001030763. Registered 16 September 2013.

New models of old(?) payment questions

Is private money feasible and desirable? In its absence, is there a central bank policy that partially or fully substitutes for private money? In this paper, some recent modeling ideas about how to address these questioned are reviewed and applied. The main ideas are that people cannot commit to future actions and that their histories are to some extent unknown - are not common knowledge. Under the additional assumption that the private monies issued by diferent people are distinct, a strong recognizability assumption, it is shown that there is a role for private money.

Access to knoledge in Brazil: new research on intellectual property, innovation and development

The present volume is the fruit of a research initiative on Access to Knowledge begun in 2004 by Yochai Benkler, Eddan Katz, and myself. Access to Knowledge is both a social movement and an approach to international and domestic policy. In the present era of globalization, intellectual property and information and communications technology are major determinants of wealth and power. The principle of access to knowledge argues that we best serve both human rights and economic development through policies that make knowledge, knowledge-creating tools, and nowledgeembedded goods as widely available as possible for decentralized innovation and use. Open technological standards, a balanced approach to intellectual property rights, and expansion of an open telecommunications infrastructure enable ordinary people around the world to benefit from the technological advances of the information age and allow them to generate a vibrant, participatory and democratic culture. Law plays a crucial role in securing access to knowledge, determining whether knowledge and knowledge goods are shared widely for the benefit of all, or controlled and monopolized for the benefit of a few.

Effects of aerobic exercise on the blood pressure, oxidative stress and eNOS gene polymorphism in pre-hypertensive older people

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Alien fishes in lakes of the Doce river basin (Brazil): Range, new occurrences and conservation of native communities

The present study shows the distribution of alien fish species in tropical lakes in the middle Doce river basin, southeastern Brazil, obtained from a rapid assessment program. The causes for their introductions were sport-fishing improvement in some specific lakes and aquaculture in the studied basin. Presently, these species have a wide distribution occurring in 41 of the 54 lakes studied, representing an actual threat to regional native fish community. The natural connection among lakes and streams during the rainy season and the dispersal mediated by local people are the main invasion agents for alien fishes. The success of these invaders is probably due to absence of pre-existing effective competitors or top-predators in the invaded communities. We consider that the eradication of alien fishes by means of the available management tools may be very difficult due to the large number of lakes invaded and to the wide spectrum of lake conditions and resources exploited by these alien species. We recommend the use of environmental education as a tool to stop the human-mediated dispersion of aliens and to improve conservation of native fish community in lakes where these alien species are not present yet. © 2004 Instituto de Ciências Biológicas - UFMG.