Variations in paediatric upper respiratory surgery rates within and between two Nordic countries

Lasten ylähengitystiekirurgia (kita-nielurisojen poisto ja tärykalvon putkitus) on länsimaissa erittäin yleistä. Leikkausten lukumäärät vaihtelevat niin kansallisesti kuin kansainvälisestikin, mutta selvää syytä näille eroille ei tiedetä. Hoitosuositusten merkitys käytäntöihin on kyseenalaistettu ja voi olla, ettei hoitosuosituksia noudateta. Leikkaukset saattavat aiheuttaa lapsipotilaille psykologisen vamman, ja lisäksi niihin sisältyy komplikaatioiden, jopa kuoleman, vaara. Jotta haittoja voidaan välttää, on tärkeää tunnistaa ne lapset, jotka hyötyvät leikkauksesta. Ongelma on paitsi lääketieteellinen, myös taloudellinen: ylähengitystiekirurgiasta aiheutuu merkittäviä kuluja. Leikkausmäärien arvioiminen on tärkeää, jotta leikkauskäytäntöjä voidaan järkeistää. Tässä väitöskirjatyössä tutkittiin ylähengitystieleikkausten määriä Suomessa ja Norjassa sekä näiden kahden maan välillä. Aiempaa tutkimusta aiheesta ei kummassakaan maassa ole tehty. Kitarisanpoiston, välikorvan putkituksen, tärykalvopiston, nielurisanpoiston ja kita- ja nielurisanpoiston leikkausmäärät saatiin kansallisista tietokannoista. Lukuja verrattiin ko. maan lasten lukumäärään, maantieteelliseen sijoittumiseen sekä lasten ikään ja sukupuoleen. Lisäksi leikkausmääriä arvioitiin suhteessa korva-, nenä- ja kurkkulääkäreiden sekä yleislääkäreiden määrään, maantieteelliseen sijoittumiseen ja lääkäreiden ikään ja sukupuoleen. Leikkausten määrissä havaittiin suurta vaihtelua niin Suomessa kuin Norjassa. Suomessa suurimmat erot leikkausmäärissä löydettiin läntisen ja itäisen miljoonapiirin välillä. Läntisessä piirissä tehtiin lähes kaksin kertaa enemmän leikkauksia kuin itäisessä piirissä. Norjassa suurimmat erot olivat pohjoisen ja itäisen piirin välillä. Pohjoisessa piirissä tehtiin kaksinkertainen määrä leikkauksia itäiseen piirrin verrattuna. Suomessa tehtiin tutkimuksen koko aikavälillä enemmän kitarisanpoistoja kuin Norjassa, mutta ko. leikkausten määrä oli maassamme selvästi laskussa. Vuonna 2002 Suomessa tehtiin 2,5 kertaa enemmän kitarisanpoistoja kuin Norjassa. (Kita)nielurisanpoistoja tehtiin kuitenkin Suomessa vähemmän kuin Norjassa. Näiden leikkausten määrät pysyivät tutkimuksen aikavälillä Suomessa samalla tasolla, kun Norjassa leikkausmäärät hieman nousivat. Suomalaisia lapsia leikattiin keskimäärin paljon nuorempina kuin norjalaisia lapsia. Tutkimuksessa ei löydetty selitystä ylähengitystieleikkausten määrän suurelle vaihtelulle Suomessa ja Norjassa tai maiden välillä. Kuitenkin Suomessa tehtyjen kitarisanpoistojen huomattavan vähenemisen myötä maiden ylähengitystieleikkausten määrät lähenivät toisiaan.

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.

Relevância de exames de rotina em pacientes de baixo risco submetidos a cirurgias de pequeno e médio porte

JUSTIFICATIVA E OBJETIVOS: A avaliação pré-operatória tem como objetivos diminuir a morbimortalidade do paciente cirúrgico, o custo do atendimento perioperatório e a ansiedade pré-operatória. A partir da avaliação clínica deve-se definir a necessidade de exames complementares e estratégias para reduzir o risco anestésico-cirúrgico. O objetivo deste trabalho foi avaliar o benefício de exames de rotina pré-operatório de pacientes de baixo risco em cirurgias de pequeno e médio porte. MÉTODOS: Trata-se de um estudo descritivo, transversal, com 800 pacientes atendidos no consultório de avaliação pré-anestésica do Hospital Santo Antonio, Salvador, BA. Foram incluídos pacientes de 1 a 45 anos, estado físico ASA I, que seriam submetidos a cirurgias eletivas de pequeno e médio porte. Avaliaram-se alterações no hemograma, coagulograma, eletrocardiograma, RX de tórax, glicemia, função renal e dosagem de sódio e potássio e as eventuais mudanças de conduta que ocorreram decorrentes dessas alterações. RESULTADOS: Dos 800 pacientes avaliados, 97,5% fizeram hemograma, 89% coagulograma, 74,1% eletrocardiograma, 62% RX de tórax, 68% glicemia de jejum, 55,7% dosagens séricas de ureia e creatinina e 10,1% dosagens de sódio e potássio séricos. Desses 700 pacientes, 68 (9,71%) apresentaram alteração nos exames pré-operatórios de rotina e apenas 10 (14,7%) dos considerados alterados tiveram conduta pré-operatória modificada, ou seja, solicitação de novos exames, interconsulta ou adiamento do procedimento. Nenhuma das cirurgias foi suspensa. CONCLUSÃO: Observou-se que excessivos exames complementares são solicitados no pré-operatório, mesmo em pacientes jovens, de baixo risco cirúrgico, com pouca ou nenhuma interferência na conduta perioperatória. Exames aboratoriais padronizados não são bons instrumentos de screening de doenças, além de gerar gastos elevados e desnecessários.

Preoperative fasting procedures : let's use the evidence

Today's anaesthetic techniques are improved and pulmonary aspiration in elective surgical patients is rare. The purpose of fasting guidelines for healthy, low risk patients undergoing elective surgery is to minimize the volume of gastric contents while avoiding unnecessary thirst and dehydration. Fasting guidelines should be based on the best available evidence and in the absence of evidence, on the knowledge of gastrointestinal physiology.

Review of international procurement procedures

Contractor selection is a crucial element in construction procurement (Drew & Skitmore 1993, p. 363). Contractors are selected through the tender process, which varies according to country, state and contracting organisation and is subject to individual differences. This paper reviews a range of international tender processes, highlighting the ethical features that govern these guidelines. The paper is part of a project to develop ethical guidelines for procurement for major contracting authorities. By reviewing tender guidelines we are able to gain an indication of the type of ethical standards reserved for procurement. The need for good business ethics in the tender process stems from the belief that ‘good ethical practice’ is critical in meeting organisational goals (Vee & Skitmore 2003, p. 125). Hence, an ethical tender process will select ethical contractors who are viewed as beneficial to the contracting authority.

Difference-based meta-analytic procedures for between-participant and/or within-participant designs : a tutorial review for sports and exercise scientists

The aim of this paper is to provide a contemporary summary of statistical and non-statistical meta-analytic procedures that have relevance to the type of experimental designs often used by sport scientists when examining differences/change in dependent measure(s) as a result of one or more independent manipulation(s). Using worked examples from studies on observational learning in the motor behaviour literature, we adopt a random effects model and give a detailed explanation of the statistical procedures for the three types of raw score difference-based analyses applicable to between-participant, within-participant, and mixed-participant designs. Major merits and concerns associated with these quantitative procedures are identified and agreed methods are reported for minimizing biased outcomes, such as those for dealing with multiple dependent measures from single studies, design variation across studies, different metrics (i.e. raw scores and difference scores), and variations in sample size. To complement the worked examples, we summarize the general considerations required when conducting and reporting a meta-analysis, including how to deal with publication bias, what information to present regarding the primary studies, and approaches for dealing with outliers. By bringing together these statistical and non-statistical meta-analytic procedures, we provide the tools required to clarify understanding of key concepts and principles.

Investigation into submicrometer particle and gaseous emissions from airport ground running procedures

Emissions from airport operations are of significant concern because of their potential impact on local air quality and human health. The currently limited scientific knowledge of aircraft emissions is an important issue worldwide, when considering air pollution associated with airport operation, and this is especially so for ultrafine particles. This limited knowledge is due to scientific complexities associated with measuring aircraft emissions during normal operations on the ground. In particular this type of research has required the development of novel sampling techniques which must take into account aircraft plume dispersion and dilution as well as the various particle dynamics that can affect the measurements of the aircraft engine plume from an operational aircraft. In order to address this scientific problem, a novel mobile emission measurement method called the Plume Capture and Analysis System (PCAS), was developed and tested. The PCAS permits the capture and analysis of aircraft exhaust during ground level operations including landing, taxiing, takeoff and idle. The PCAS uses a sampling bag to temporarily store a sample, providing sufficient time to utilize sensitive but slow instrumental techniques to be employed to measure gas and particle emissions simultaneously and to record detailed particle size distributions. The challenges in relation to the development of the technique include complexities associated with the assessment of the various particle loss and deposition mechanisms which are active during storage in the PCAS. Laboratory based assessment of the method showed that the bag sampling technique can be used to accurately measure particle emissions (e.g. particle number, mass and size distribution) from a moving aircraft or vehicle. Further assessment of the sensitivity of PCAS results to distance from the source and plume concentration was conducted in the airfield with taxiing aircraft. The results showed that the PCAS is a robust method capable of capturing the plume in only 10 seconds. The PCAS is able to account for aircraft plume dispersion and dilution at distances of 60 to 180 meters downwind of moving a aircraft along with particle deposition loss mechanisms during the measurements. Characterization of the plume in terms of particle number, mass (PM2.5), gaseous emissions and particle size distribution takes only 5 minutes allowing large numbers of tests to be completed in a short time. The results were broadly consistent and compared well with the available data. Comprehensive measurements and analyses of the aircraft plumes during various modes of the landing and takeoff (LTO) cycle (e.g. idle, taxi, landing and takeoff) were conducted at Brisbane Airport (BNE). Gaseous (NOx, CO2) emission factors, particle number and mass (PM2.5) emission factors and size distributions were determined for a range of Boeing and Airbus aircraft, as a function of aircraft type and engine thrust level. The scientific complexities including the analysis of the often multimodal particle size distributions to describe the contributions of different particle source processes during the various stages of aircraft operation were addressed through comprehensive data analysis and interpretation. The measurement results were used to develop an inventory of aircraft emissions at BNE, including all modes of the aircraft LTO cycle and ground running procedures (GRP). Measurements of the actual duration of aircraft activity in each mode of operation (time-in-mode) and compiling a comprehensive matrix of gas and particle emission rates as a function of aircraft type and engine thrust level for real world situations was crucial for developing the inventory. The significance of the resulting matrix of emission rates in this study lies in the estimate it provides of the annual particle emissions due to aircraft operations, especially in terms of particle number. In summary, this PhD thesis presents for the first time a comprehensive study of the particle and NOx emission factors and rates along with the particle size distributions from aircraft operations and provides a basis for estimating such emissions at other airports. This is a significant addition to the scientific knowledge in terms of particle emissions from aircraft operations, since the standard particle number emissions rates are not currently available for aircraft activities.

An investigation into how work-related road safety can be enhanced

Despite the facts that vehicle incidents continue to be the most common mechanism for Australian compensated fatalities and that employers have statutory obligations to provide safe workplaces, very few organisations are proactively and comprehensively managing their work-related road risks. Unfortunately, limited guidance is provided in the existing literature to assist practitioners in managing work-related road risks. The current research addresses this gap in the literature. To explore how work-related road safety can be enhanced, three studies were conducted. Study one explored the effectiveness of a range of risk management initiatives and whether comprehensive risk management practices were associated with safety outcomes. Study two explored barriers to, and facilitators for, accepting risk management initiatives. Study three explored the influence of organisational factors on road safety outcomes to identify optimal work environments for managing road risks. To maximise the research sample and increase generalisability, the studies were designed to allow data collection to be conducted simultaneously drawing upon the same sample obtained from four Australian organisations. Data was collected via four methods. A structured document review of published articles was conducted to identify what outcomes have been observed in previously investigated work-related road safety initiatives. The documents reviewed collectively assessed the effectiveness of 19 work-related road safety initiatives. Audits of organisational practices and process operating within the four researched organisations were conducted to identify whether organisations with comprehensive work-related road risk management practices and processes have better safety outcomes than organisations with limited risk management practices and processes. Interviews were conducted with a sample of 24 participants, comprising 16 employees and eight managers. The interviews were conducted to identify what barriers and facilitators within organisations are involved in implementing work-related road safety initiatives and whether differences in fleet safety climate, stage of change and safety ownership relate to work-related road safety outcomes. Finally, questionnaires were administered to a sample of 679 participants. The questionnaires were conducted to identify which initiatives are perceived by employees to be effective in managing work-related road risks and whether differences in fleet safety climate, stage of change and safety ownership relate to work-related road safety outcomes. Seven research questions were addressed in the current research project. The key findings with respect to each of the research questions are presented below. Research question one: What outcomes have been observed in previously investigated work-related road safety initiatives? The structured document review indicated that initiatives found to be positively associated with occupational road safety both during and after the intervention period included: a pay rise; driver training; group discussions; enlisting employees as community road safety change agents; safety reminders; and group and individual rewards. Research question two: Which initiatives are perceived by employees to be effective in managing work-related road risks? Questionnaire findings revealed that employees believed occupational road risks could best be managed through making vehicle safety features standard, providing practical driver skills training and through investigating serious vehicle incidents. In comparison, employees believed initiatives including signing a promise card commitment to drive safely, advertising the organisation’s phone number on vehicles and consideration of driving competency in staff selection process would have limited effectiveness in managing occupational road safety. Research question three: Do organisations with comprehensive work-related road risk management practices and processes have better safety outcomes than organisations with limited risk management practices and processes? The audit identified a difference among the organisations in their management of work-related road risks. Comprehensive risk management practices were associated with employees engaging in overall safer driving behaviours, committing less driving errors, and experiencing less fatigue and distraction issues when driving. Given that only four organisations participated in this research, these findings should only be considered as preliminary. Further research should be conducted to explore the relationship between comprehensiveness of risk management practices and road safety outcomes with a larger sample of organisations. Research question four: What barriers and facilitators within organisations are involved in implementing work-related road safety initiatives? The interviews identified that employees perceived six organisational characteristics as potential barriers to implementing work-related road safety initiatives. These included: prioritisation of production over safety; complacency towards work-related road risks; insufficient resources; diversity; limited employee input in safety decisions; and a perception that road safety initiatives were an unnecessary burden. In comparison, employees perceived three organisational characteristics as potential facilitators to implementing work-related road safety initiatives. These included: management commitment; the presence of existing systems that could support the implementation of initiatives; and supportive relationships. Research question five: Do differences in fleet safety climate relate to work-related road safety outcomes? The interviews and questionnaires identified that organisational climates with high management commitment, support for managing work demands, appropriate safety rules and safety communication were associated with employees who engaged in safer driving behaviours. Regression analyses indicated that as participants’ perceptions of safety climate increased, the corresponding likelihood of them engaging in safer driving behaviours increased. Fleet safety climate was perceived to influence road safety outcomes through several avenues. Some of these included: the allocation of sufficient resources to manage occupational road risks; fostering a supportive environment of mutual responsibility; resolving safety issues openly and fairly; clearly communicating to employees that safety is the top priority; and developing appropriate work-related road safety policies and procedures. Research question six: Do differences in stage of change relate to work-related road safety outcomes? The interviews and questionnaires identified that participants’ perceptions of initiative effectiveness were found to vary with respect to their individual stage of readiness, with stage-matched initiatives being perceived most effective. In regards to safety outcomes, regression analyses identified that as participants’ progress through the stages of change, the corresponding likelihood of them being involved in vehicle crashes decreases. Research question seven: Do differences in safety ownership relate to work-related road safety outcomes? The interviews and questionnaires revealed that management of road risks is often given less attention than other areas of health and safety management in organisations. In regards to safety outcomes, regression analyses identified that perceived authority and perceived shared ownership both emerged as significant independent predictors of self-reported driving behaviours pertaining to fatigue and distractions. The regression models indicated that as participants’ perceptions of the authority of the person managing road risks increases, and perceptions of shared ownership of safety tasks increases, the corresponding likelihood of them engaging in driving while fatigued or multitasking while driving decreases. Based on the findings from the current research, the author makes several recommendations to assist practitioners in developing proactive and comprehensive approaches to managing occupational road risks. The author also suggests several avenues for future research in the area of work-related road safety.

A comparison of two procedures for increasing spontaneous requests in children with autism

The missing-item format and interrupted behaviour chain strategy have been used to increase spontaneous requests among children with developmental disabilities, but their relative effectiveness has not been compared. The present study compared the extent to which each strategy evoked spontaneous requests and challenging behaviour in three children with autism. Sessions where a needed item was withheld (missing-item format) were compared to sessions involving the removal of a needed item (interrupted behaviour chain strategy). Comparisons were conducted across three activates in an alternating treatments design. Both strategies evoked spontaneous requests with no significant difference in effectiveness. Few differences were obtained in the amount of challenging behaviour evoked but the two conditions, although a moderate inverse relationship between spontaneous requesting and challenging behaviour was observed. The results suggest that theses two procedures yield similar outcomes. Concurrent use of both strategies may enable teachers to create a greater number of opportunities for requesting.

A research opportunity : “3D-ROSE” : virtual reality preparation for children having radiotherapy or imaging procedures

Professor Christian Langton is a medical physicist at Queensland University of Technology in Brisbane. He has developed a way of preparing children who are about to have either radiotherapy or MRI imaging procedures and is seeking research partners to develop and test these further. This is a great opportunity for nurses interested in research, and who have access to a children’s hospital, to work with Professor Langton on some truly innovative, multidisciplinary research.

Beyond statistical procedures for predictive modelling: Data mining algorithms and support for university research at QUT

In a seminal data mining article, Leo Breiman [1] argued that to develop effective predictive classification and regression models, we need to move away from the sole dependency on statistical algorithms and embrace a wider toolkit of modeling algorithms that include data mining procedures. Nevertheless, many researchers still rely solely on statistical procedures when undertaking data modeling tasks; the sole reliance on these procedures has lead to the development of irrelevant theory and questionable research conclusions ([1], p.199). We will outline initiatives that the HPC & Research Support group is undertaking to engage researchers with data mining tools and techniques; including a new range of seminars, workshops, and one-on-one consultations covering data mining algorithms, the relationship between data mining and the research cycle, and limitations and problems with these new algorithms. Organisational limitations and restrictions to these initiatives are also discussed.

Ureaplasma parvum and ureaplasma urealyticum detected in semen after washing prior to assisted reproductive technology procedures

Objective: This study investigated: (i) the prevalence of ureaplasmas in semen and washed semen and (ii) the effect of ureaplasmas on semen andrology parameters. Design: Prospective study. Setting: IVF unit -private hospital, Brisbane, Australia. Patient(s): Three hundred and forty three men participating in an assisted reproductive technology (ART) treatment cycle. Intervention(s): Semen and washed semen tested by culture, PCR assays and indirect immunofluorescent antibody assays. Statistical differences were determined by a t-test, Wilcoxon or Pearson’s Chi- square test where appropriate. Main Outcome Measure(s): The prevalence of ureaplasmas in semen and washed semen and the effect of these microorganisms on semen andrology parameters. Result(s): Ureaplasmas were detected in 73/343 (22%) semen samples and 29/343 (8.5%) washed semen samples. Ureaplasmas adherent to the surface of spermatozoa were demonstrated by indirect immunofluorescent antibody testing. U. parvum serovar 6 (36.6%) and U. urealyticum (30%) were the most prevalent isolates in washed semen. A comparison of the semen andrology parameters of washed semen ureaplasma positive and negative groups demonstrated a lower proportion of non-motile sperm in the washed semen ureaplasma positive group. Conclusion(s): Ureaplasmas are not always removed from semen by a standard ART washing procedure and can remain adherent to the surface of spermatozoa.

Cognitive load and assembly tasks : effect of instructional formats on learning assembly procedures

The study investigated the effect on learning of four different instructional formats used to teach assembly procedures. Cognitive load and spatial information processing theories were used to generate the instructional material. The first group received a physical model to study, the second an isometric drawing, the third an isometric drawing plus a model and the fourth an orthographic drawing. Forty secondary school students were presented with the four different instructional formats and subsequently tested on an assembly task. The findings indicated that there may be evidence to argue that the model format which only required encoding of an already constructed three dimensional representation, caused less extraneous cognitive load compared to the isometric and the orthographic formats. No significant difference was found between the model and the isometric-plus-model formats on all measures because 80% of the students in the isometric-plus-model format chose to use the model format only. The model format also did not differ significantly from other groups in total time taken to complete the assembly, in number of correctly assembled pieces and in time spent on studying the tasks. However, the model group had significantly more correctly completed models and required fewer extra looks than the other groups.