Poor Reliability between Cochrane Reviewers and Blinded External Reviewers When Applying the Cochrane Risk of Bias Tool in Physical Therapy Trials

OBJECTIVES To test the inter-rater reliability of the RoB tool applied to Physical Therapy (PT) trials by comparing ratings from Cochrane review authors with those of blinded external reviewers. METHODS Randomized controlled trials (RCTs) in PT were identified by searching the Cochrane Database of Systematic Reviews for meta-analysis of PT interventions. RoB assessments were conducted independently by 2 reviewers blinded to the RoB ratings reported in the Cochrane reviews. Data on RoB assessments from Cochrane reviews and other characteristics of reviews and trials were extracted. Consensus assessments between the two reviewers were then compared with the RoB ratings from the Cochrane reviews. Agreement between Cochrane and blinded external reviewers was assessed using weighted kappa (κ). RESULTS In total, 109 trials included in 17 Cochrane reviews were assessed. Inter-rater reliability on the overall RoB assessment between Cochrane review authors and blinded external reviewers was poor (κ  =  0.02, 95%CI: -0.06, 0.06]). Inter-rater reliability on individual domains of the RoB tool was poor (median κ  = 0.19), ranging from κ  =  -0.04 ("Other bias") to κ  =  0.62 ("Sequence generation"). There was also no agreement (κ  =  -0.29, 95%CI: -0.81, 0.35]) in the overall RoB assessment at the meta-analysis level. CONCLUSIONS Risk of bias assessments of RCTs using the RoB tool are not consistent across different research groups. Poor agreement was not only demonstrated at the trial level but also at the meta-analysis level. Results have implications for decision making since different recommendations can be reached depending on the group analyzing the evidence. Improved guidelines to consistently apply the RoB tool and revisions to the tool for different health areas are needed.

Novel mitochondrial tRNA(Ile) m.4282A>G gene mutation leads to chronic progressive external ophthalmoplegia plus phenotype

BACKGROUND/AIM To investigate the underlying pathomechanism in a 33-year-old female Caucasian patient presenting with chronic progressive external ophthalmoplegia (CPEO) plus symptoms. METHODS Histochemical analysis of skeletal muscle and biochemical measurements of individual oxidative phosphorylation (OXPHOS) complexes. Genetic analysis of mitochondrial DNA in various tissues with subsequent investigation of single muscle fibres for correlation of mutational load. RESULTS The patient's skeletal muscle showed 20% of cytochrome c oxidase-negative fibres and 8% ragged-red fibres. Genetic analysis of the mitochondrial DNA revealed a novel point mutation in the mitochondrial tRNA(Ile) (MTTI) gene at position m.4282G>A. The heteroplasmy was determined in blood, buccal cells and muscle by restriction fragment length polymorphism (RFLP) combined with a last fluorescent cycle. The total mutational load was 38% in skeletal muscle, but was not detectable in blood or buccal cells of the patient. The phenotype segregated with the mutational load as determined by analysis of single cytochrome c oxidase-negative/positive fibres by laser capture microdissection and subsequent LFC-RFLP. CONCLUSIONS We describe a novel MTTI transition mutation at nucleotide position m.4282G>A associated with a CPEO plus phenotype. The novel variant at position m.4282G>A disrupts the middle bond of the D-stem of the tRNA(Ile) and is highly conserved. The conservation and phenotype-genotype segregation strongly suggest pathogenicity and is in good agreement with the MTTI gene being frequently associated with CPEO. This novel variant broadens the spectrum of MTTI mutations causing CPEO.

Resistance to Temptation: The Interaction of External and Internal Control on Alcohol Use During Residential Treatment for Alcohol Use Disorder

Background: There is evidence that drinking during residential treatment is related to various factors, such as patients’ general control beliefs and self-efficacy, as well as to external control of alcohol use by program’s staff and situations where there is temptation to drink. As alcohol use during treatment has been shown to be associated with the resumption of alcohol use after discharge from residential treatment, we aimed to investigate how these variables are related to alcohol use during abstinenceoriented residential treatment programs for alcohol use disorders (AUD). Methods: In total, 509 patients who entered 1 of 2 residential abstinence-oriented treatment programs for AUD were included in the study. After detoxification, patients completed a standardized diagnostic procedure including interviews and questionnaires. Drinking was assessed by patients’ selfreport of at least 1 standard drink or by positive breathalyzer testing. The 2 residential programs were categorized as high or low control according to the average number of tests per patient. Results: Regression analysis revealed a significant interaction effect between internal and external control suggesting that patients with high internal locus of control and high frequency of control by staff demonstrated the least alcohol use during treatment (16.7%) while patients with low internal locus of control in programs with low external control were more likely to use alcohol during Treatment (45.9%). No effects were found for self-efficacy and temptation. Conclusions: As alcohol use during treatment is most likely associated with poor treatment outcomes, external control may improve treatment outcomes and particularly support patients with low internal locus of control, who show the highest risk for alcohol use during treatment. High external control may complement high internal control to improve alcohol use prevention while in treatment. Key Words: Alcohol Dependence, Alcohol Use, Locus of Control, Alcohol Testing.

Total disc arthroplasty versus anterior cervical interbody fusion: use of the Spine Tango registry to supplement the evidence from randomized control trials.

BACKGROUND CONTEXT Several randomized controlled trials (RCTs) have compared patient outcomes of anterior (cervical) interbody fusion (AIF) with those of total disc arthroplasty (TDA). Because RCTs have known limitations with regard to their external validity, the comparative effectiveness of the two therapies in daily practice remains unknown. PURPOSE This study aimed to compare patient-reported outcomes after TDA versus AIF based on data from an international spine registry. STUDY DESIGN AND SETTING A retrospective analysis of registry data was carried out. PATIENT SAMPLE Inclusion criteria were degenerative disc or disc herniation of the cervical spine treated by single-level TDA or AIF, no previous surgery, and a Core Outcome Measures Index (COMI) completed at baseline and at least 3 months' follow-up. Overall, 987 patients were identified. OUTCOME MEASURES Neck and arm pain relief and COMI score improvement were the outcome measures. METHODS Three separate analyses were performed to compare TDA and AIF surgical outcomes: (1) mimicking an RCT setting, with admission criteria typical of those in published RCTs, a 1:1 matched analysis was carried out in 739 patients; (2) an analysis was performed on 248 patients outside the classic RCT spectrum, that is, with one or more typical RCT exclusion criteria; (3) a subgroup analysis of all patients with additional follow-up longer than 2 years (n=149). RESULTS Matching resulted in 190 pairs with an average follow-up of 17 months that had no residual significant differences for any patient characteristics. Small but statistically significant differences in outcome were observed in favor of TDA, which are potentially clinically relevant. Subgroup analyses of atypical patients and of patients with longer-term follow-up showed no significant differences in outcome between the treatments. CONCLUSIONS The results of this observational study were in accordance with those of the published RCTs, suggesting substantial pain reduction both after AIF and TDA, with slightly greater benefit after arthroplasty. The analysis of atypical patients suggested that, in patients outside the spectrum of clinical trials, both surgical interventions appeared to work to a similar extent to that shown for the cohort in the matched study. Also, in the longer-term perspective, both therapies resulted in similar benefits to the patients.

Reduced order modeling of three dimensional external aerodynamic flows

A method is presented to construct computationally efficient reduced-order models (ROMs) of three-dimensional aerodynamic flows around commercial aircraft components. The method is based on the proper orthogonal decomposition (POD) of a set of steady snapshots, which are calculated using an industrial solver based on some Reynolds averaged Navier-Stokes (RANS) equations. The POD-mode amplitudes are calculated by minimizing a residual defined from the Euler equations, even though the snapshots themselves are calculated from viscous equations. This makes the ROM independent of the peculiarities of the solver used to calculate the snapshots. Also, both the POD modes and the residual are calculated using points in the computational mesh that are concentrated in a close vicinity of the aircraft, which constitute a much smaller number than the total number of mesh points. Despite these simplifications, the method provides quite good approximations of the flow variables distributions in the whole computational domain, including the boundary layer attached to the aircraft surface and the wake. Thus, the method is both robust and computationally efficient, which is checked considering the aerodynamic flow around a horizontal tail plane, in the transonic range 0.4?Mach number?0.8, ?3°?angle of attack?3°.

Total glossectomy: Is it justified?

Background: The treatment of advanced malignancies of the tongue with total glossectomy is controversial. Methods: The present study retrospectively reviews 20 patients that had total glossectomy with or without laryngectomy performed at the Princess Alexandra Hospital (Woolloongabba, QLD, Australia) over the past 10 years. The clinicopathologic parameters, perioperative morbidity and mortality were assessed. Results: The 5 years disease free and disease specific survival rates were 34% and 38%, respectively. Ninety per cent of patients acquired independent oral feeding prior to discharge, while 57% of patients that had laryngeal preservation performed achieved satisfactory vocal rehabilitation. Conclusion: Total glossectomy is an oncologically sound surgical procedure that should only be performed in carefully selected patients with advanced malignancies affecting the tongue.

Theory of strongly correlated electron systems. I. Intersite coulomb interaction and the approximation of renormalized fermions in total energy calculations

The diagrammatic strong-coupling perturbation theory (SCPT) for correlated electron systems is developed for intersite Coulomb interaction and for a nonorthogonal basis set. The construction is based on iterations of exact closed equations for many - electron Green functions (GFs) for Hubbard operators in terms of functional derivatives with respect to external sources. The graphs, which do not contain the contributions from the fluctuations of the local population numbers of the ion states, play a special role: a one-to-one correspondence is found between the subset of such graphs for the many - electron GFs and the complete set of Feynman graphs of weak-coupling perturbation theory (WCPT) for single-electron GFs. This fact is used for formulation of the approximation of renormalized Fermions (ARF) in which the many-electron quasi-particles behave analogously to normal Fermions. Then, by analyzing: (a) Sham's equation, which connects the self-energy and the exchange- correlation potential in density functional theory (DFT); and (b) the Galitskii and Migdal expressions for the total energy, written within WCPT and within ARF SCPT, a way we suggest a method to improve the description of the systems with correlated electrons within the local density approximation (LDA) to DFT. The formulation, in terms of renormalized Fermions LIDA (RF LDA), is obtained by introducing the spectral weights of the many electron GFs into the definitions of the charge density, the overlap matrices, effective mixing and hopping matrix elements, into existing electronic structure codes, whereas the weights themselves have to be found from an additional set of equations. Compared with LDA+U and self-interaction correction (SIC) methods, RF LDA has the advantage of taking into account the transfer of spectral weights, and, when formulated in terms of GFs, also allows for consideration of excitations and nonzero temperature. Going beyond the ARF SCPT, as well as RF LIDA, and taking into account the fluctuations of ion population numbers would require writing completely new codes for ab initio calculations. The application of RF LDA for ab initio band structure calculations for rare earth metals is presented in part 11 of this study (this issue). (c) 2005 Wiley Periodicals, Inc.

External audit in the National Health Service in England and Wales:a study of an oversight body's control of auditor remuneration

In the National Health Service (NHS) in England and Wales an oversight body, the Audit Commission (AC), defines the scope of the external auditors’ work, appoints the auditors and has oversight of their fees and audit quality. This heavily regulated audit regime mitigates some of the deficiencies observed in high profile corporate failures. Independence, it has been argued, is influenced by the total auditor remuneration paid by the client. In this study we examine total auditor remuneration in a regulated market which seeks to ensure audit independence and audit quality. In particular we undertake rigorous analysis of auditor remuneration by the type of auditor: We place emphasis on the differentiation between private sector firms and the AC’s in-house auditors (District Audit). Individual private audit firms charge premiums (up to 16%) for particular audit work in identified locations, but no premiums were found when we examined total auditor remuneration. The regime appears to permit efficient operation of the audit market while safeguarding both audit independence and standards.

Total quality management in English language teaching:a case study in Turkish higher education

The need to improve the management of language learning organizations in the light of the trend toward mass higher education and of the use of English as a world language was the starting point of this thesis. The thesis aims to assess the relevance, adequacy and the relative success of Total Quality Management (TQM) as a management philosophy. Taking this empirical evidence a TQM-oriented management project in a Turkish Higher Education context, the thesis observes the consequences of a change of organizational culture, with specific reference to teachers' attitudes towards management. Both qualitative and quantitative devices are employed to plot change and the value of these devices for identifying such is considered. The main focus of the thesis is the Soft S's (Shared Values, Style, Staff and Skills) of an organization rather than the Hard S's (System, Structure, Strategy). The thesis is not concerned with the teaching and learning processes, though the PDCA cycle (the Action Research Cycle) did play a part in the project for both teachers and the researcher involved in this study of organizational development. Both before the management project was launched, and at the end of the research period, the external measurement devices (Harrison's Culture Specification Device and Hofstede's VSM) were used to describe the culture of the Centre. During the management project, internal measurement devices were used to record the change including middle-management style change (the researcher in this case). The time period chosen for this study was between September 1991 and June 1994. During this period, each device was administered twice within a specific time period, ranging from a year to 32 months.

Total productive maintenance implementation in the newspaper printing industry:an action research approach

The objective of Total Productive Maintenance (TPM) is to maximise plant and equipment effectiveness, to create a sense of ownership for operators, and promote continuous improvement through small group activities involving production, engineering and maintenance personnel. This paper describes and analyses a case study of TPM implementation at a newspaper printing house in Singapore. However, rather than adopting more conventional implementation methods such as employing consultants or through a project using external training, a unique approach was adopted based on Action Research using a spiral of cycles of planning, acting observing and reflecting. An Action Research team of company personnel was specially formed to undertake the necessary fieldwork. The team subsequently assisted with administering the resulting action plan. The main sources of maintenance and operational data were from interviews with shop floor workers, participative observation and reviews conducted with members of the team. Content analysis using appropriate statistical techniques was used to test the significance of changes in performance between the start and completion of the TPM programme. The paper identifies the characteristics associated with the Action Research method when used to implement TPM and discusses the applicability of the approach in related industries and processes.

Evaluating the external validity of comorbid disorders in youth using rating scales and behavior observations

To evaluate the theoretical underpinnings of current categorical approaches to classify childhood psychopathological conditions, this dissertation examined whether children with a single diagnosis of an anxiety disorder (ANX only) and children with an anxiety diagnosis comorbid with other diagnoses (i.e., anxiety + anxiety disorder [ANX + ANX], anxiety + depressive disorder [ANX + DEP], and anxiety + disruptive disorder [ANX + EXT]) could be differentiated using external validation criteria of clinical phenomenology (i.e., levels of anxiety, depression, and internalizing, externalizing and total behavior problems). This study further examined whether the four groups could be differentiated in terms of their interaction patterns with their parents and peers, respectively. The sample consisted of 129 youth and their parents who presented to the Child Anxiety and Phobia Program (CAPP) housed within the Child and Family Psychosocial Research Center at Florida International University, Miami. Youth were between the ages of 8 and 14 years old. A battery of questionnaires was used to assess participants' clinical presentation in terms of levels of anxiety, depression, and internalizing and externalizing symptoms. Family and peer interaction were evaluated through rating scales and through behavior observation tasks. Statistics based on the parameter estimates of the structured equation models indicated that all the comorbid groups were significantly different from the pure anxiety disorder group when it came to depression indices of clinical phenomenology. Further, significant differences appeared mainly in terms of the ANX + DEP comorbid group relative to the other comorbid groups. In terms of Parent-child interaction the ANX + EXT and the ANX + DEP comorbid groups were differentiated from the pure anxiety disorder and ANX + ANX comorbid group when it came to the appraisal of the parent/child relationship by the parent, and the acceptance subscale according to the mother report. In terms of peer-child interaction the ANX + EXT and the ANX + DEP comorbid groups were statistically significantly different from the pure anxiety disorder only when it came to the positive interactions and the social skills as rated by mother. Limitations and future research recommendations are discussed.

External Validation of the ProACS Score for Risk Stratification of Patients with Acute Coronary Syndromes

INTRODUCTION: The ProACS risk score is an early and simple risk stratification score developed for all-cause in-hospital mortality in acute coronary syndromes (ACS) from a Portuguese nationwide ACS registry. Our center only recently participated in the registry and was not included in the cohort used for developing the score. Our objective was to perform an external validation of this risk score for short- and long-term follow-up. METHODS: Consecutive patients admitted to our center with ACS were included. Demographic and admission characteristics, as well as treatment and outcome data were collected. The ProACS risk score variables are age (≥72 years), systolic blood pressure (≤116 mmHg), Killip class (2/3 or 4) and ST-segment elevation. We calculated ProACS, Global Registry of Acute Coronary Events (GRACE) and Canada Acute Coronary Syndrome risk score (C-ACS) risk scores for each patient. RESULTS: A total of 3170 patients were included, with a mean age of 64±13 years, 62% with ST-segment elevation myocardial infarction. All-cause in-hospital mortality was 5.7% and 10.3% at one-year follow-up. The ProACS risk score showed good discriminative ability for all considered outcomes (area under the receiver operating characteristic curve >0.75) and a good fit, similar to C-ACS, but lower than the GRACE risk score and slightly lower than in the original development cohort. The ProACS risk score provided good differentiation between patients at low, intermediate and high mortality risk in both short- and long-term follow-up (p<0.001 for all comparisons). CONCLUSIONS: The ProACS score is valid in external cohorts for risk stratification for ACS. It can be applied very early, at the first medical contact, but should subsequently be complemented by the GRACE risk score.

KEY COMPONENTS OF TEAMWORK AND THE SERVICE (TO) YOU (A) (A) DOMESTIC (A) AND EXTERNAL (A)

The article examines a range of components for the customer service from the point of view of marketing.It start with the explanation of several features that are required for a company to crystallize teamwork that finally, after all, will be provided by the success or failure of that company.These features are named: engagement, cooperation, companionship, communication, motivation and leadership.Subsequently, this article presents a section which explores human relationships and conflict management within organizations, with emphasis on attitudes, skills and personality types that present human beings as part of its essence.Finally, this text includes a section that highlights concepts related to customer service and sales techniques that exist today.

Orientation and external morphology of burrows of the mangrove crab Ucides cordatus (Crustacea: Brachyura: Ucididae)

The aim of the present study was to characterize the external morphology and the orientation of burrows constructed by the mangrove crab Ucides cordatus. Data were obtained from two mangrove forests of similar vegetation dominance (Laguncularia racemosa) but differing in flooding heights. These mangroves were located near Barra de Icapara, Iguape City (SP), Brazil, (24 degrees 50'36 '' S-47 degrees 59'53'W). A total of 221 burrows were examined (120 on the high mangrove and 101 on the low mangrove). External morphology of the burrows was recorded by photographs for categorization and description. The directions of the burrow openings were recorded using a geological compass and the declivities of the ducts were measured with a clinometer. Females constructed 70.8% at Site A and 69.4% at Site B of the occupied burrows with the opening facing the margin of the river (P < 0.001), whilst males showed no significant difference in the burrow orientation (P > 0.05) at either site. In females, the tendency for burrow orientation possibly has a reproductive connotation as larval dispersal may be favoured and enhanced by the tides. Four groups of distinct tracks related to the morphotypes and developmental stages of U. cordatus were observed, No sediment constructions associated with the burrows were recorded for this species. Declivity of the burrows from juveniles was lower than from adults (P < 0.05), probably caused by the differential growth of the chelipeds in this species.