May the best Tweeter win : The Twitter strategies of key campaign accounts in the 2012 US election

The 2008 US election has been heralded as the first presidential election of the social media era, but took place at a time when social media were still in a state of comparative infancy; so much so that the most important platform was not Facebook or Twitter, but the purpose-built campaign site my.barackobama.com, which became the central vehicle for the most successful electoral fundraising campaign in American history. By 2012, the social media landscape had changed: Facebook and, to a somewhat lesser extent, Twitter are now well-established as the leading social media platforms in the United States, and were used extensively by the campaign organisations of both candidates. As third-party spaces controlled by independent commercial entities, however, their use necessarily differs from that of home-grown, party-controlled sites: from the point of view of the platform itself, a @BarackObama or @MittRomney is technically no different from any other account, except for the very high follower count and an exceptional volume of @mentions. In spite of the significant social media experience which Democrat and Republican campaign strategists had already accumulated during the 2008 campaign, therefore, the translation of such experience to the use of Facebook and Twitter in their 2012 incarnations still required a substantial amount of new work, experimentation, and evaluation. This chapter examines the Twitter strategies of the leading accounts operated by both campaign headquarters: the ‘personal’ candidate accounts @BarackObama and @MittRomney as well as @JoeBiden and @PaulRyanVP, and the campaign accounts @Obama2012 and @TeamRomney. Drawing on datasets which capture all tweets from and at these accounts during the final months of the campaign (from early September 2012 to the immediate aftermath of the election night), we reconstruct the campaigns’ approaches to using Twitter for electioneering from the quantitative and qualitative patterns of their activities, and explore the resonance which these accounts have found with the wider Twitter userbase. A particular focus of our investigation in this context will be on the tweeting styles of these accounts: the mixture of original messages, @replies, and retweets, and the level and nature of engagement with everyday Twitter followers. We will examine whether the accounts chose to respond (by @replying) to the messages of support or criticism which were directed at them, whether they retweeted any such messages (and whether there was any preferential retweeting of influential or – alternatively – demonstratively ordinary users), and/or whether they were used mainly to broadcast and disseminate prepared campaign messages. Our analysis will highlight any significant differences between the accounts we examine, trace changes in style over the course of the final campaign months, and correlate such stylistic differences with the respective electoral positioning of the candidates. Further, we examine the use of these accounts during moments of heightened attention (such as the presidential and vice-presidential debates, or in the context of controversies such as that caused by the publication of the Romney “47%” video; additional case studies may emerge over the remainder of the campaign) to explore how they were used to present or defend key talking points, and exploit or avert damage from campaign gaffes. A complementary analysis of the messages directed at the campaign accounts (in the form of @replies or retweets) will also provide further evidence for the extent to which these talking points were picked up and disseminated by the wider Twitter population. Finally, we also explore the use of external materials (links to articles, images, videos, and other content on the campaign sites themselves, in the mainstream media, or on other platforms) by the campaign accounts, and the resonance which these materials had with the wider follower base of these accounts. This provides an indication of the integration of Twitter into the overall campaigning process, by highlighting how the platform was used as a means of encouraging the viral spread of campaign propaganda (such as advertising materials) or of directing user attention towards favourable media coverage. By building on comprehensive, large datasets of Twitter activity (as of early October, our combined datasets comprise some 3.8 million tweets) which we process and analyse using custom-designed social media analytics tools, and by using our initial quantitative analysis to guide further qualitative evaluation of Twitter activity around these campaign accounts, we are able to provide an in-depth picture of the use of Twitter in political campaigning during the 2012 US election which will provide detailed new insights social media use in contemporary elections. This analysis will then also be able to serve as a touchstone for the analysis of social media use in subsequent elections, in the USA as well as in other developed nations where Twitter and other social media platforms are utilised in electioneering.

Drink and drug driving in Australian young adult users and non-users of illicit stimulants

- Introduction There is limited understanding of how young adults’ driving behaviour varies according to long-term substance involvement. It is possible that regular users of amphetamine-type stimulants (i.e. ecstasy (MDMA) and methamphetamine) may have a greater predisposition to engage in drink/drug driving compared to non-users. We compare offence rates, and self-reported drink/drug driving rates, for stimulant users and non-users in Queensland, and examine contributing factors. - Methods The Natural History Study of Drug Use is a prospective longitudinal study using population screening to recruit a probabilistic sample of amphetamine-type stimulant users and non-users aged 19-23 years. At the 4 ½ year follow-up, consent was obtained to extract data from participants’ Queensland driver records (ATS users: n=217, non-users: n=135). Prediction models were developed of offence rates in stimulant users controlling for factors such as aggression and delinquency. - Results Stimulant users were more likely than non-users to have had a drink-driving offence (8.7% vs. 0.8%, p < 0.001). Further, about 26% of ATS users and 14% of non-users self-reported driving under the influence of alcohol during the last 12 months. Among stimulant users, drink-driving was independently associated with last month high-volume alcohol consumption (Incident Rate Ratio (IRR): 5.70, 95% CI: 2.24-14.52), depression (IRR: 1.28, 95% CI: 1.07-1.52), low income (IRR: 3.57, 95% CI: 1.12-11.38), and male gender (IRR: 5.40, 95% CI: 2.05-14.21). - Conclusions Amphetamine-type stimulant use is associated with increased long-term risk of drink-driving, due to a number of behavioural and social factors. Inter-sectoral approaches which target long-term behaviours may reduce offending rates.

Quantifying progressive anterior overgrowth in the thoracic vertebrae of adolescent idiopathic scoliosis patients

Study design Anterior and posterior vertebral body heights were measured from sequential MRI scans of adolescent idiopathic scoliosis (AIS) patients and healthy controls. Objective To measure changes in vertebral body height over time during scoliosis progression to assess how vertebral body height discrepancies change during growth. Summary of background data Relative anterior overgrowth has been proposed as a potential driver for AIS initiation and progression. This theory proposes that the anterior column grows faster, and the posterior column slower, in AIS patients when compared to healthy controls. There is disagreement in the literature as to whether the anterior vertebral body heights are proportionally greater than posterior vertebral body heights in AIS patients when compared to healthy controls. To some extent, these discrepancies may be attributed to methodological differences. Methods MRI scans of the major curve of 21 AIS patients (mean age 12.5 ± 1.4 years, mean Cobb 32.2 ± 12.8º) and between T4 and T12 of 21 healthy adolescents (mean age 12.1 ± 0.5 years) were captured for this study. Of the 21 AIS patients, 14 had a second scan on average 10.8 ± 4.7 months after the first. Anterior and posterior vertebral body heights were measured from the true sagittal plane of each vertebra such that anterior overgrowth could be quantified. Results The difference between anterior and posterior vertebral body height in healthy, non-scoliotic children was significantly greater than in AIS patients with mild to moderate scoliosis. However there was no significant relationship between the overall anterior-posterior vertebral body height difference in AIS and either severity of the curve or its progression over time. Conclusions Whilst AIS patients have a proportionally longer anterior column than non-scoliotic controls, the degree of anterior overgrowth was not related to the rate of progression or the severity of the scoliotic curve.

Characterisation of chicken Campylobacter jejuni isolates using resolution optimised single nucleotide polymorphisms and binary gene markers

The principal objective of this study was to determine if Campylobacter jejuni genotyping methods based upon resolution optimised sets of single nucleotide polymorphisms (SNPs) and binary genetic markers were capable of identifying epidemiologically linked clusters of chicken-derived isolates. Eighty-eight C. jejuni isolates of known flaA RFLP type were included in the study. They encompassed three groups of ten isolates that were obtained at the same time and place and possessed the same flaA type. These were regarded as being epidemiologically linked. Twenty-six unlinked C. jejuni flaA type I isolates were included to test the ability of SNP and binary typing to resolve isolates that were not resolved by flaA RFLP. The remaining isolates were of different flaA types. All isolates were typed by real-time PCR interrogation of the resolution optimised sets of SNPs and binary markers. According to each typing method, the three epidemiologically linked clusters were three different clones that were well resolved from the other isolates. The 26 unlinked C. jejuni flaA type I isolates were resolved into 14 SNP-binary types, indicating that flaA typing can be unreliable for revealing epidemiological linkage. Comparison of the data with data from a fully typed set of isolates associated with human infection revealed that abundant lineages in the chicken isolates that were also found in the human isolates belonged to clonal complex (CC) -21 and CC-353, with the usually rare C-353 member ST-524 being especially abundant in the chicken collection. The chicken isolates selected to be diverse according to flaA were also diverse according to SNP and binary typing. It was observed that CC-48 was absent in the chicken isolates, despite being very common in Australian human infection isolates, indicating that this may be a major cause of human disease that is not chicken associated.

Seed persistence in the field may be predicted by laboratory-controlled aging

Weed management is complicated by the presence of soil seed banks. The complexity of soil-seed interactions means that seed persistence in the field is often difficult to measure, let alone predict. Field trials, although accurate in their context, are time-consuming and expensive to conduct for individual species. Some ex situ techniques for estimating seed life expectancy have been proposed, but these fail to simulate the environmental complexity of the field. Also, it has been questioned whether techniques such as the controlled aging test (CAT) are useful indicators of field persistence. This study aimed to test the validity of the standard CAT (seed aging at 45 C and 60% relative humidity) in use at the Royal Botanic Gardens, Kew, U.K., for predicting field seed-persistence. Comparison of seed persistence and CAT data for 27 northwest European species suggested a significant positive correlation of 0.31. Subsequently, 13 species of emerging and common weeds of Queensland were assessed for their seed longevity using the CAT. The seed longevity data of these species in the CAT were linked with field seed-persistence data according to three broad seed-persistence categories: <1 yr, 1 to 3 yr, and >3 yr. We discuss the scope for using the CAT as a tool for rapid assignment of species to these categories. There is a need for further studies that compare predictions of seed persistence based on the CAT with seed persistence in the field for a larger range of species and environments.

Getting mad may not mean getting even: The influence of drivers' ethical ideologies on driving anger and related behaviour

The current study explored the influence of moral values (measured by ethical ideology) on self-reported driving anger and aggressive driving responses. A convenience sample of drivers aged 17-73 years (n = 280) in Queensland, Australia, completed a self-report survey. Measures included sensation seeking, trait aggression, driving anger, endorsement of aggressive driving responses and ethical ideology (Ethical Position Questionnaire, EPQ). Scores on the two underlying dimensions of the EPQ idealism (highI/lowI) and relativism (highR/lowR) were used to categorise drivers into four ideological groups: Situationists (highI/highR); Absolutists (highI/lowR); Subjectivists (lowI/highR); and Exceptionists (lowI/lowR). Mean aggressive driving scores suggested that exceptionists were significantly more likely to endorse aggressive responses. After accounting for demographic variables, sensation seeking and driving anger, ethical ideological category added significantly, though modestly to the prediction of aggressive driving responses. Patterns in results suggest that those drivers in ideological groups characterised by greater concern to avoid affecting others negatively (i.e. highI, Situationists, Absolutists) may be less likely to endorse aggressive driving responses, even when angry. In contrast, Subjectivists (lowI, HighR), reported the lowest levels of driving anger yet were significantly more likely to endorse aggressive responses. This provides further insight into why high levels of driving anger may not always translate into more aggressive driving.

Detection and characterisation of strong resistance to phosphine in Brazilian Rhyzopertha dominica (F.) (Coleoptera: Bostrychidae)

As failure to control Rhyzopertha dominica (F.) with phosphine is a common problem in the grain-growing regions of Brazil, a study was undertaken to investigate the frequency, distribution and strength of phosphine resistance in R. dominica in Brazil. Nineteen samples of R. dominica were collected between 1991 and 2003 from central storages where phosphine fumigation had failed to control this species. Insects were cultured without selection until testing in 2005. Each sample was tested for resistance to phosphine on the basis of the response of adults to discriminating concentrations of phosphine (20 and 48 h exposures) and full dose-response assays (48 h exposure). Responses of the Brazilian R. dominica samples were compared with reference susceptible, weak-resistance and strong-resistance strains from Australia in parallel assays. All Brazilian population samples showed resistance to phosphine: five were diagnosed with weak resistance and 14 with strong resistance. Five samples showed levels of resistance similar to the reference strong-resistance strain. A representative highly resistant sample was characterised by exposing mixed-age cultures to a range of constant concentrations of phosphine for various exposure periods. Time to population extinction (TPE) and time to 99.9% suppression of population (LT99.9) values of this sample were generally similar to those of the reference strong-resistance strain. For example, at 0.1, 0.5 and 1.0 mg L-1, LT99.9 values for BR33 and the reference strong-resistance strain were respectively 21, 6.4 and 3.7 days and 17, 6.2 and 3.8 days. With both strains, doubling phosphine concentrations to 2 mg L -1 resulted in increased LT99.9 and TPE. High level and frequency of resistance in all population samples, some of which had been cultured without selection for up to 12 years, suggest little or no fitness deficit associated with phosphine resistance. The present research indicates that widespread phosphine resistance may be developing in Brazil. Fumigation practices should be monitored and resistance management plans implemented to alleviate further resistance development.

Managing for rainfall variability: effect of grazing strategy on cattle production in a dry tropical savanna

Rainfall variability is a challenge to sustainable and pro. table cattle production in northern Australia. Strategies recommended to manage for rainfall variability, like light or variable stocking, are not widely adopted. This is due partly to the perception that sustainability and profitability are incompatible. A large, long-term grazing trial was initiated in 1997 in north Queensland, Australia, to test the effect of different grazing strategies on cattle production. These strategies are: (i) constant light stocking (LSR) at long-term carrying capacity (LTCC); (ii) constant heavy stocking (HSR) at twice LTCC; (iii) rotational wet-season spelling (R/Spell) at 1.5 LTCC; (iv) variable stocking (VAR), with stocking rates adjusted in May based on available pasture; and (v) a Southern Oscillation Index (SOI) variable strategy, with stocking rates adjusted in November, based on available pasture and SOI seasonal forecasts. Animal performance varied markedly over the 10 years for which data is presented, due to pronounced differences in rainfall and pasture availability. Nonetheless, lighter stocking at or about LTCC consistently gave the best individual liveweight gain (LWG), condition score and skeletal growth; mean LWG per annum was thus highest in the LSR (113 kg), intermediate in the R/Spell (104 kg) and lowest in the HSR(86 kg). MeanLWGwas 106 kg in the VAR and 103 kg in the SOI but, in all years, the relative performance of these strategies was dependent upon the stocking rate applied. After 2 years on the trial, steers from lightly stocked strategies were 60-100 kg heavier and received appreciable carcass price premiums at the meatworks compared to those under heavy stocking. In contrast, LWG per unit area was greatest at stocking rates of about twice LTCC; mean LWG/ha was thus greatest in the HSR (21 kg/ha), but this strategy required drought feeding in four of the 10 years and was unsustainable. Although LWG/ha was lower in the LSR (mean 14 kg/ha), or in strategies that reduced stocking rates in dry years like the VAR(mean 18 kg/ha) and SOI (mean 17 kg/ha), these strategies did not require drought feeding and appeared sustainable. The R/Spell strategy (mean 16 kg/ha) was compromised by an ill-timed fire, but also performed satisfactorily. The present results provide important evidence challenging the assumption that sustainable management in a variable environment is unprofitable. Further research is required to fully quantify the long-term effects of these strategies on land condition and profitability and to extrapolate the results to breeder performance at the property level.

Growth and carcass characteristics of cast-for-age Merino ewes fed sorghum-based feedlot diets

Grain feeding low bodyweight, cast-for-age (CFA) sheep from pastoral areas of eastern Australia at the end of the growing season can enable critical carcass weight grades to be achieved and thus yield better economic returns. The aim of this work was to compare growth and carcass characteristics for CFA Merino ewes consuming either simple diets based on whole sorghum grain or commercial feed pellets. The experiment also compared various sources of additional nitrogen (N) for inclusion in sorghum diets and evaluated several introductory regimes. Seventeen ewes were killed initially to provide baseline carcass data and the remaining 301 ewes were gradually introduced to the concentrate diets over 14 days before being fed concentrates and wheaten hay ad libitum for 33 or 68 days. Concentrate treatments were: (i) commercial feed pellets, (ii) sorghum mix (SM; whole sorghum grain, limestone, salt and molasses) + urea and ammonium sulfate (SMU), (iii) SMU + whole cottonseed at 286 g/kg of concentrate dry matter (DM), (iv) SM + cottonseed meal at 139 g/kg of concentrate DM, (v) SMU + virginiamycin (20 mg/kg of concentrate) for the first 21 days of feeding, and (vi) whole cottonseed gradually replaced by SMU over the first 14 days of feeding. The target carcass weight of 18 kg was achieved after only 33 days on feed for the pellets and the SM + cottonseed meal diet. All other whole grain sorghum diets required between 33 and 68 days on feed to achieve the target carcass weight. Concentrates based on whole sorghum grain generally produced significantly (P < 0.05) lower carcass weight and fat score than pellets and this may have been linked to the significantly (P < 0.05) higher faecal starch concentrations for ewes consuming sorghum-based diets (270 v. 72 g/kg DM on day 51 of feeding for sorghum-based diets and pellets, respectively). Source of N in whole grain sorghum rations and special introductory regimes had no significant (P > 0.05) effects on carcass weight or fat score of ewes with the exception of carcass weight for SMU + whole cottonseed being significantly lower than SM + cottonseed meal at day 33. Ewes finished on all diets produced acceptable carcasses although muscle pH was high in all ewe carcasses (average 5.8 and 5.7 at 33 and 68 days, respectively). There were no significant (P > 0.05) differences between diets in concentrate DM intake, rumen fluid pH, meat colour score, fat colour score, eye muscle area, meat pH or meat temperature.

Self-Concept and School Achievement of Pupils with Cleft Lip, Cleft Palate or Both : A longitudinal study

The goal of this research was to survey the self-concept and school achievement of pupils with cleft lip, cleft palate or both from juvenile age to adolescence. Longitudinal researches of self-concept and school achievement among pupils with cleft lip, cleft palate or both are uncommon. This research was the first longitudinal research ever conducted in Finland among this population. This research can be considered to be a special educational study because of the target group involved. Self-concept consists of the person s entire personality. Personality is biological and deterministic. Self-concept includes concepts, attitudes and feelings that the person has about him or her qualities, abilities and relations to the environment. The individual associates experiences to this personality with earlier observations through the social interaction. The individual will have the consciousness of the person s existence and action. The target group in this study consisted of Finnish children with clefts, who were comprised of four different age groups. The questionnaire was sent to all subjects (N1 = 419) both times. A total of 74 % of children returned the questionnaire in 1988 (N2=305). 48 % of children returned the questionnaire in 1993 (N3=203). 42% of children returned the questionnaire both times (N4=175) . These 175 children formed the research subjects. The survey was conducted in 1988, and again in 1993. In 1988, the pupils surveyed were 9 to 12 years of age, while in 1993 they were between 14 and 17 years old. The data was collected through the use of a questionnaire, which consisted of common questions and a personality inventory test that was developed for Finnish students by professor Maija-Liisa Rauste-von Wright. Quantitative analysis methods were used to examine the structure of self-concept and school achievement. Structures found in this research were observed in relation to disorder, gender and maturation. According to these results, structures of self-concepts and school achievement are in fact stable. Basic self-concept elements are seen to be formed at an early age. The developmental aspects of self-concept following puberty are observed as the stability of self-concept and as the forming of a general self. The level of school achievement is stable, but the structure of school achievement changes. From these results, it is possible to state that the gender of the child has a statistical significance regarding self-concept and school achievement. However, the experienced disorder does not have statistical significance as regards to self-concept and school achievement. Results of self-concept support the research of self-concept conducted earlier in Finland.

Wedding portrait of Hans Krakauer and Elizabeth Godshaw (Gottschalk); Hannover, Germany. Portraits Couples

In the apartment on Ruemkorffstrasse that the Gottschalks occupied after being forced to sell their house.

Portrait of Emma Hess nee Meyerhof, called "Immisch".

Emma Hess nee Meyerhof, genannt "Immisch"

Effects of dairy proteins and calcium on diet-induced obesity in mice

Diet high in dairy products is inversely associated with body mass index, risk of metabolic syndrome and prevalence of type 2 diabetes in several populations. Also a number of intervention studies support the role of increased dairy intake in the prevention and treatment of obesity. Dairy calcium has been suggested to account for the effect of dairy on body weight, but it has been repeatedly shown that the effect of dairy is superior to the effect of supplemental calcium. Dairy proteins are postulated to either enhance the effect of calcium or have an independent effect on body weight, but studies in the area are scarce. The aim of this study was to evaluate the potential of dairy proteins and calcium in the prevention and treatment of diet-induced obesity in C57Bl/6J mice. The effect of dairy proteins and calcium on the liver and adipose tissue was also investigated in order to characterise the potential mechanisms explaining the reduction of risk for metabolic syndrome and type 2 diabetes. A high-calcium diet (1.8%) in combination with dietary whey protein inhibited body weight and fat gain and accelerated body weight and fat loss in high-fat-fed C57Bl/6J mice during long-term studies of 14 to 21 weeks. α-lactalbumin, one of the major whey proteins, was the most effective whey protein fraction showing significantly accelerated weight and fat loss during energy restriction and reduced the amount of visceral fat gain during ad libitum feeding after weight loss. The microarray data suggest sensitisation of insulin signalling in the adipose tissue as a result of a calcium-rich whey protein diet. Lipidomic analysis revealed that weight loss on whey protein-based high-calcium diet was characterised by significant decreases in diabetogenic diacylglycerols and lipotoxic ceramide species. The calcium supplementation led to a small, but statistically significant decrease in fat absorption independent of the protein source of the diet. This augments, but does not fully explain the effects of the studied diets on body weight. A whey protein-containing high-calcium diet had a protective effect against a high-fat diet-induced decline of β3 adrenergic receptor expression in adipose tissue. In addition, a high-calcium diet with whey protein increased the adipose tissue leptin expression which is decreased in this obesity-prone mouse strain. These changes are likely to contribute to the inhibition of weight gain. The potential sensitisation of insulin signalling in adipose tissue together with the less lipotoxic and diabetogenic hepatic lipid profile suggest a novel mechanistic link to explain why increased dairy intake is associated with a lower prevalence of metabolic syndrome and type 2 diabetes in epidemiological studies. Taken together, the intake of a high-calcium diet with dairy proteins has a body weight lowering effect in high-fat-fed C57Bl/6J mice. High-calcium diets containing whey protein prevent weight gain and enhance weight loss, α-lactalbumin being the most effective whey protein fraction. Whey proteins and calcium have also beneficial effects on hepatic lipid profile and adipose tissue gene expression, which suggest a novel mechanistic link to explain the epidemiological findings on dairy intake and metabolic syndrome. The clinical relevance of these findings and the precise mechanisms of action remain an intriguing field of future research.

Studies on Matrix Metalloproteinase (MMP-2, -9 and -14) and β2 Integrin Targeting as Potential Anticancer Therapeutics

Proteolytic enzymes, such as matrix metalloproteinases (MMP), are associated to the progression of several cancers. They degrade extracellular components, which helps tumors to expand and cancer cells to escape from the primary site. Of all MMPs, gelatinases (MMP-2 and -9) and membrane type-1 matrix metalloproteinase (MT1-MMP, MMP-14), in particular, are often associated to more aggressive types of head and neck carcinomas as well as to a poorer outcome in patient survival. Although therapies during the last decades have advanced, the mortality of the disease is still rather high and adjuvant therapies are searched for continuously. MMP-9 and MT1-MMP are also involved in neo-angiogenesis, which is necessary for tumor expansion. For this reason, we have identified synthetic peptides-targeting gelatinases and MT1-MMP, and have also evaluated their anticancer effects in vitro and in vivo. Antigelatinolytic peptides effectively inhibited tongue-carcinoma cell invasion and reduced the growth of xenografted tumors. In tumor samples of mice that were treated with antigelatinolytic peptides, the micro-vessel density was significantly reduced. We also identified a novel MT1-MMP targeting peptide and demonstrated that it exerted anticancer effects against several malignant cell lines in vitro. The effects of MT1-MMP inhibition on tongue-squamous cell carcinomas were evaluated by using xenograft tumors, which it effectively inhibited. Tranexamic acid was also demonstrated to inhibit tongue-squamous cell carcinoma invasion, most probably due to its ability to prevent the plasmin-mediated activation of proMMP-9. Leukocyte β2 integrins are another interesting option when evaluating targets for the therapeutic intervention of inflammatory conditions or malignancies of hematopoietic origin, since β2 integrins are expressed mainly by leukocytes. We identified a novel technique for screening small-molecule libraries against β2 integrins, and by using this technique we identified a novel αMβ2 integrin-binding chemical (IMB-10). IMB-10 significantly enhances leukocyte adhesion and inhibits their motility. We also demonstrated that IMB-10 can be used to inhibit inflammation and lymphoma growth in vivo. Interestingly, IMB-10 also reduced leukocyte tumor infiltration and inhibited tumor invasion.

Evidence-based perspective on CP rehabilitation : Reviews on physiotherapy, physiotherapy-related motor-based interventions and orthotic devices

This thesis utilises an evidence-based approach to critically evaluate and summarize effectiveness research on physiotherapy, physiotherapy-related motor-based interventions and orthotic devices in children and adolescents with cerebral palsy (CP). It aims to assess the methodological challenges of the systematic reviews and trials, to evaluate the effectiveness of interventions in current use, and to make suggestions for future trials Methods: Systematic reviews were searched from computerized bibliographic databases up to August 2007 for physiotherapy and physiotherapy-related interventions, and up to May 2003 for orthotic devices. Two reviewers independently identified, selected, and assessed the quality of the reviews using the Overview Quality Assessment Questionnaire complemented with decision rules. From a sample of 14 randomized controlled trials (RCT) published between January 1990 and June 2003 we analysed the methods of sampling, recruitment, and comparability of groups; defined the components of a complex intervention; identified outcome measures based on the International Classification of Functioning, Disability and Health (ICF); analysed the clinical interpretation of score changes; and analysed trial reporting using a modified 33-item CONSORT (Consolidated Standards of Reporting Trials) checklist. The effectiveness of physiotherapy and physiotherapy-related interventions in children with diagnosed CP was evaluated in a systematic review of randomised controlled trials that were searched from computerized databases from January 1990 up to February 2007. Two reviewers independently assessed the methodological quality, extracted the data, classified the outcomes using the ICF, and considered the level of evidence according to van Tulder et al. (2003). Results: We identified 21 reviews on physiotherapy and physiotherapy-related interventions and five on orthotic devices. These reviews summarized 23 or 5 randomised controlled trials and 104 or 27 observational studies, respectively. Only six reviews were of high quality. These found some evidence supporting strength training, constraint-induced movement therapy or hippotherapy, and insufficient evidence on comprehensive interventions. Based on the original studies included in the reviews on orthotic devices we found some short-term effects of lower limb casting on passive range of movement, and of ankle-foot orthoses on equinus walk. Long term effects of lower limb orthoses have not been studied. Evidence of upper limb casting or orthoses is conflicting. In the sample of 14 RCTs, most trials used simple randomisation, complemented with matching or stratification, but only three specified the concealed allocation. Numerous studies provided sufficient details on the components of a complex intervention, but the overlap of outcome measures across studies was poor and the clinical interpretation of observed score changes was mostly missing. Almost half (48%) of the applicable CONSORT-based items (range 28 32) were reported adequately. Most reporting inadequacies were in outcome measures, sample size determination, details of the sequence generation, allocation concealment and implementation of the randomization, success of assessor blinding, recruitment and follow-up dates, intention-to-treat analysis, precision of the effect size, co-interventions, and adverse events. The systematic review identified 22 trials on eight intervention categories. Four trials were of high quality. Moderate evidence of effectiveness was established for upper extremity treatments on attained goals, active supination and developmental status, and of constraint-induced therapy on the amount and quality of hand use and new emerging behaviours. Moderate evidence of ineffectiveness was found for strength training's effect on walking speed and stride length. Conflicting evidence was found for strength training's effect on gross motor function. For the other intervention categories the evidence was limited due to the low methodological quality and the statistically insignificant results of the studies. Conclusions: The high-quality reviews provide both supportive and insufficient evidence on some physiotherapy interventions. The poor quality of most reviews calls for caution, although most reviews drew no conclusions on effectiveness due to the poor quality of the primary studies. A considerable number of RCTs of good to fair methodological and reporting quality indicate that informative and well-reported RCTs on complex interventions in children and adolescents with CP are feasible. Nevertheless, methodological improvement is needed in certain areas of the trial design and performance, and the trial authors are encouraged to follow the CONSORT criteria. Based on RCTs we established moderate evidence for some effectiveness of upper extremity training. Due to limitations in methodological quality and variations in population, interventions and outcomes, mostly limited evidence on the effectiveness of most physiotherapy interventions is available to guide clinical practice. Well-designed trials are needed, especially for focused physiotherapy interventions.