Cost-effectiveness analysis of the diagnosis of meniscus tears.

BACKGROUND: Diagnostic imaging represents the fastest growing segment of costs in the US health system. This study investigated the cost-effectiveness of alternative diagnostic approaches to meniscus tears of the knee, a highly prevalent disease that traditionally relies on MRI as part of the diagnostic strategy. PURPOSE: To identify the most efficient strategy for the diagnosis of meniscus tears. STUDY DESIGN: Economic and decision analysis; Level of evidence, 1. METHODS: A simple-decision model run as a cost-utility analysis was constructed to assess the value added by MRI in various combinations with patient history and physical examination (H&P). The model examined traumatic and degenerative tears in 2 distinct settings: primary care and orthopaedic sports medicine clinic. Strategies were compared using the incremental cost-effectiveness ratio (ICER). RESULTS: In both practice settings, H&P alone was widely preferred for degenerative meniscus tears. Performing MRI to confirm a positive H&P was preferred for traumatic tears in both practice settings, with a willingness to pay of less than US$50,000 per quality-adjusted life-year. Performing an MRI for all patients was not preferred in any reasonable clinical scenario. The prevalence of a meniscus tear in a clinician's patient population was influential. For traumatic tears, MRI to confirm a positive H&P was preferred when prevalence was less than 46.7%, with H&P preferred above that. For degenerative tears, H&P was preferred until the prevalence reaches 74.2%, and then MRI to confirm a negative was the preferred strategy. In both settings, MRI to confirm positive physical examination led to more than a 10-fold lower rate of unnecessary surgeries than did any other strategy, while MRI to confirm negative physical examination led to a 2.08 and 2.26 higher rate than H&P alone in primary care and orthopaedic clinics, respectively. CONCLUSION: For all practitioners, H&P is the preferred strategy for the suspected degenerative meniscus tear. An MRI to confirm a positive H&P is preferred for traumatic tears for all practitioners. Consideration should be given to implementing alternative diagnostic strategies as well as enhancing provider education in physical examination skills to improve the reliability of H&P as a diagnostic test. CLINICAL RELEVANCE: Alternative diagnostic strategies that do not include the use of MRI may result in decreased health care costs without harm to the patient and could possibly reduce unnecessary procedures.

‘Martial races’ and ‘imperial subjects’: violence and governance in colonial India, 1857–1914

This essay explores the specificity of colonial violence in India. Although imperial and military historians are familiar with several instances of such violence—notably the rebellion in 1857 and the 1919 massacre at the Jallianwalla Bagh in Amritsar—there is a broader, and arguably more significant, history that has largely escaped attention. In contrast to metropolitan European states, where sovereignty derived, at least in principle, from a covenant between subjects and government, the sovereign power of the colonial state was always predicated on the violent subjugation of ‘the natives’. However, while violence was integral to colonialism, such violence was never a purely metropolitan agency: most of those recruited to serve in the colonial military were, themselves, Indian. Exploring the history of the imperial military in South Asia after 1857, the paper outlines the complex and rather ambiguous relationship between the colonial state and its ‘native armies’. RESUME Cet article se penche sur la spe´cificite´ de la violence coloniale. Malgre´ des exemples familiers—comme la grande re´volte de 1857 en Inde ou le massacre de Jallianwalla Bagh a` Amritsar en 1919—il y a une histoire plus large et plus importante qui a e´chappe´e a` l’attention des historiens. Contrairement aux e´tats europe´ens ou la souverainete´ de´rivait en principe du moins d’un contrat social entre les acteurs sociaux, le pouvoir souverain de l’e´tat colonial restait fonde´ sur la subjugation violente des indige`nes.

Characteristics and trends of self-harming behaviours in young people

Deliberate self-harm is recognized as a serious public health issue in young people. There is evidence that young people who self-harm are more likely to repeat self-harm, and this in turn increases their risk of completed suicide. Prevalence studies have identified that the rate of self-harm among young people is on the increase, information largely based on data arising from review and analysis of hospital attendances. However, community-based studies indicate that the prevalence is much higher, with those seen in emergency departments representing the 'tip of the iceberg' (Hawton and Rodham, 2006). Young people's motives for self-harm are discussed, as are research findings which indicate that nurses can have negative attitudes towards patients who self-harm. The article considers the implications of this for young people and identifies areas for future research.

Considering theories of aggression in an emergency department context

Internationally literature emphasises concern regarding the phenomenon of violence and aggression within the emergency field. This paper emphasises the important role education and training may play in reducing the risk of staff being exposed to violent or aggressive experiences. Furthermore, the paper emphasises, explores and discusses well recognised theories relating to aggression development. These theories can be used to explain both organisational strategies designed to minimise aggression in the emergency department and situational factors contributing to the development of aggressive interactions.

A conceptual framework for designing pharmaceutical reverse logistics networks in China

Over latest decade, Reverse Logistics (RL) has gained more and more attention from both industry and academia. In the past, most research on RL has been focused on automobile, electronic waste, computer, paper, package and package material. There is very little research and practice on drug recycling. Nevertheless, it is vital important to properly dispose expired drug because of hazardous contain which may harm to people and environment. In China, public awareness of the harmfulness of expired drugs is still very low and very few efforts have been made to recycle drugs. Therefore, this research aims to build up a conceptual framework to indentify factors of influencing drug recycling in China, from scratch borrowing from existing literature and industry practices in other recycling areas. This framework helps in designing reverse logistic (RL) network and also can provide a useful reference tool for policymakers at the local and national level. Furthermore, a primary research is planed to validate the framework and RL network.

Influences of the Oceans on Human Health and Well-Being

Human health and well-being are tied to the vitality of the global ocean and coastal systems on which so many live and rely. We engage with these extraordinary environments to enhance both our health and our well-being. But, we need to recognize that introducing contaminants and otherwise altering these ocean systems can harm human health and well-being in significant and substantial ways. These are complex, challenging, and critically important themes. How the human relationship to the oceans evolves in coming decades may be one of the most important connections in understanding our personal and social well-being. Yet, our understanding of this relationship is far too limited. This remarkable volume brings experts from diverse disciplines and builds a workable understanding of breadth and depth of the processes – both social and environmental – that will help us to limit future costs and enhance the benefits of sustainable marine systems. In particular, the authors have developed a shared view that the global coastal environment is under threat through intensified natural resource utilization, as well as changes to global climate and other environmental systems. All these changes contribute individually, but more importantly cumulatively, to higher risks for public health and to the global burden of disease. This pioneering book will be of value to advanced undergraduate and postgraduate students taking courses in public health, environmental, economic, and policy fields. Additionally, the treatment of these complex systems is of essential value to the policy community responsible for these questions and to the broader audience for whom these issues are more directly connected to their own health and well-being.

Satellite discrimination of Karenia mikimotoi and Phaeocystis harmful algal blooms in European coastal waters: Merged classification of ocean colour data

The detection of dense harmful algal blooms (HABs) by satellite remote sensing is usually based on analysis of chlorophyll-a as a proxy. However, this approach does not provide information about the potential harm of bloom, nor can it identify the dominant species. The developed HAB risk classification method employs a fully automatic data-driven approach to identify key characteristics of water leaving radiances and derived quantities, and to classify pixels into “harmful”, “non-harmful” and “no bloom” categories using Linear Discriminant Analysis (LDA). Discrimination accuracy is increased through the use of spectral ratios of water leaving radiances, absorption and backscattering. To reduce the false alarm rate the data that cannot be reliably classified are automatically labelled as “unknown”. This method can be trained on different HAB species or extended to new sensors and then applied to generate independent HAB risk maps; these can be fused with other sensors to fill gaps or improve spatial or temporal resolution. The HAB discrimination technique has obtained accurate results on MODIS and MERIS data, correctly identifying 89% of Phaeocystis globosa HABs in the southern North Sea and 88% of Karenia mikimotoi blooms in the Western English Channel. A linear transformation of the ocean colour discriminants is used to estimate harmful cell counts, demonstrating greater accuracy than if based on chlorophyll-a; this will facilitate its integration into a HAB early warning system operating in the southern North Sea.

Coelocaulon crespoae Barreno & Vázquez spec. nova (Lichenes). Notas sobre la flora liquénica de brezales españoles

Se realiza una descripción detallada del nuevo liquen Coelocaulon crespoae, epifito de brezos, jaras y pinos en la Península Ibérica, se incluye mapa de distribución e ilustraciones de la anatomía y morfología. Asimismo se ha confeccionado una tabla sintética que pone de manifiesto sus relaciones con otras especies de Cornicularia s. ampl. Se comentan otros táxones que tienen eí mismo hábitat: Protoblastenia russula (Ach.) Räsänen, Ochrolechia anomala (Harm.) Verseghy y Buellia griseovirens (Turner et Borrer) Almb. cuya presencia en España tiene marcado interés taxonómico y corológico.

The consequences of child-parent violence reflected in a life story

A process of social transformation allied with ongoing changes to the family has made possible the existence of a relatively little-known phenomenon: that of child-parent violence, which is raised as one of the most commonly experienced forms of violence in the family environment. Based on the study of this phenomenon, in our research we have used the qualitative technique of a life story, making use of a field diary in which we have taken notes on our daily work in the therapeutic context, for the purposes of mitigating the effects of such a process. The following research objectives were set: establishing the connection existing between family education style and the use of violence by the minor; and evaluating the extent to which family therapy mitigates the use of violence by the minor. The family education model, together with other dimensions, results in situations of child-parent violence occurring repeatedly, with continuing negative reinforcement from both parties in order to maintain a recurrent cycle of conduct, from which it is difficult to «escape» other than through a process of ongoing psychological therapy.

TRANSIENT LIPOPOLYSACCHARIDE-INDUCED CYTOKINE RESPONSES IN THE MATERNAL AND FETAL GUINEA PIG

The aim of this study was to further investigate the role of pro-inflammatory cytokines in the pathogenesis of fetal cererbral white matter injury associated with chorioamnionitis by charaterizing the time course of the cytokine response in the pregnant guinea pig following a maternal inflammatory insult. Chorioamnionitis increases the risk for fetal brain injury. In the guinea pig, a threshold maternal inflammatory response must be reached for significant fetal brain injury to occur. However, a previous study demonstrated that, by seven days after an acute maternal inflammatory insult, cytokine levels in both maternal and fetal compartments are not different from controls. The purpose of this study, therefore, was to test the hypothesis that a significant cytokine response occurs within the first seven days following an acute maternal inflammatory response. Pregnant guinea pigs (n=34) were injected intraperitoneally with 100µg/kg lipopolysaccharide (LPS) at 70% gestation and euthanized at 24 hours, 48 hours or 5 days following endotoxin exposure. Control animals were euthanized at 70% gestation without exposure. Concentrations of interleukin-6, interleukin 1-β and tumour necrosis factor-α (IL-6, IL-1β, TNF-α) were quantified in the maternal serum and amniotic fluid by enzyme-linked immunosorbent assay. IL-6 and IL-1β concentrations were elevated in the maternal serum at 24 hours and returned to control levels by five days. In the amniotic fluid, IL-6 peaked at 48 hours and IL-1β at 24 hours. TNF-α levels were not significantly increased. A single maternal LPS injection produces transient increases in cytokine concentrations in the maternal serum and amniotic fluid. This further implicates the cytokines as potential mediators of fetal white matter damage. Although this response might not be sufficient to produce the brain injury itself, it may initiate harmful pro-inflammatory cytokine cascades, which could even continue to harm the fetus following delivery. A human diagnostic protocol was developed to assess the use of serial serum biomarkers, including IL-6 and TNF-α, in the prediction of histological chorioamnionitis. Preliminary analysis of the pilot study suggests that certain biomarkers might be worthy of further investigation in a larger-scale study.

Indeterminate Sentences for the Severely Personality Disordered

In line with recent incapacitative efforts aimed at dealing with dangerous people in the community, the Government has proposed a new indeterminate sentence to deal with the current gap in the law which exists in relation to dangerous individuals with untreatable severe personality disorders. However, these new measures have serious civil liberty implications and are largely unworkable in practice. It is suggested that rather than introducing these new powers it would be better to consider amending deficiencies which exist in the criminal justice and mental health systems in respect of the management of violent and sexual offenders.

Flavian laws, the railway, the newspaper and Loring’s breads

It is abound the research on the formation, rise and failure of the financial and industrial network undertaken by the Loring-Heredia-Larios triangle, bourgeois families who introduced the Industrial Revolution in the south of Andalusia. On the contrary, there are almost nonexistent studies from the perspective of the mentality that sustained their business, social and ethical model in the algid decades of their action (1850-1860). In this paper we propose some hypotheses about the ideological structures of bourgeois group and point out some keys, clues and signs for a future reconstruction of this kind, which so far has not been incardinated that early and failed malaguenan industrial revolution in streams thinking of that time.

Secular Trends in Substance Use: The Conflict and Young People in Northern Ireland

The resolution of political conflict has led some to suggest that Northern Ireland will now face a range of social problems that have been ignored or suppressed by the Troubles. One such area is adolescent drug use. In this article, a review of a range of data sources shows that drug use, with few exceptions, has increased since the emergence of the ongoing peace process. Social and political changes and enhanced paramilitary involvement in the drugs trade appear to have somehow created an environment where drug use has flourished. In reviewing current drug policy and practice, the article highlights the lack of prevention, treatment, and harm reduction services established in Northern Ireland as a cause for concern.

'Dare the boist'rous main': the role of the Belfast Newsletter in the process of emigration from Ulster to North America 1760-1800

Before the mass migrations from Ireland in the nineteenth century, earlier waves of migration in the eighteenth century saw significant numbers of people leave Ireland, predominantly from Ulster, to settle in North America. This article, using as its principal data source the Belfast News Letter ( BNL), its letters, advertisements and reports, focuses firstly on reconstructing the late eighteenth-century migration process and voyage, highlighting the barriers represented by the Atlantic Ocean. In addition to the challenges of the sea, there were problems with the ships, the ever-present danger of disease and also threats from other vessels, from privateers to press gangs. The voyage was recognized as a ‘universal dread’, and the risks taken to ‘dare the boist’rous main’ were perhaps not minimized in the pages of the BNL, whose editorial stance was antipathetic to the migration for the potential harm it caused to Ulster by removing so many of its industrious young. The second part of this article goes on to consider the newspaper’s and others’ vested interests in the emigration process, demonstrates how these were manifested in the press and sets the coverage of this very significant early emigration flow within the context of contemporary religious and colonial discourses at a period of very lively transatlantic interactions.