Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

P12 Commissioning for Quality and Innovation (CQUIN) schemes—revisiting urinary tract infection (UTI) management. What worked? What lasted? What next?

Background

UK CQUIN schemes encourage an improvement focus on a specific area of care. In 2019, CQUIN CCG1a: Improving the management of lower UTI in older people1 was adopted at the RUH resulting in increased alignment with UK guidance on diagnosis and treatment.2 Our aim was to investigate whether this improvement was sustained two years later. This would help inform quality improvement interventions prior to adoption of the 2022 CQUIN, CCG2: Appropriate antibiotic prescribing for UTI in adults aged 16+.3

Objectives

Service evaluation of the UTI pathway including compliance with two of the CQUIN care processes for UTI diagnosis in patients age 65+ presenting to ED (not admitted): (i) diagnosis excludes use of urine dipstick in people aged 65+; and (ii) urine sample sent to microbiology as per UK guidance.2

Methods

A search of the electronic patient record for key terms (Table 1) identified 6076 ED attendances for patients age 65+ between 1 August and 31 October 2021 of which 40 were identified with a primary diagnosis of UTI not requiring hospital admission. Paramedic, ED and Urgent Treatment Centre notes (paper and electronic) were reviewed in detail and information gathered regarding presence/absence of UTI symptoms aligned to diagnostic guidelines;2 presence/absence of urine dipstick test; and presence/absence of urine sample for culture and susceptibility testing. Findings were compared with identical trust data for patients (admitted and non-admitted) obtained during the 2019 CQUIN: Q1 April–June; Q2 July–September; Q3 October–December. During this period improvement interventions were implemented.

Results

See Table 2.

Conclusions

Following intensive staff education improved practice regarding urine dipstick testing and appropriate urine sampling in elderly patients with possible UTI was observed during the 2019 CQUIN period. Two years later this improvement had not been sustained. When planning interventions during the 2022 CQUIN,3 consideration should be given to a bundle of interventions including education, data feedback and systems improvement, for example, computerized decision support systems (CDSS) to embed sustained change.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Risk factors for TB in Australia and their association with delayed treatment completion

BACKGROUND: Australia has a low incidence of TB and has committed to eliminating the disease. Identification of risk factors associated with TB is critical to achieving this goal.METHODS: We undertook a prospective cohort study involving persons receiving TB treatment in four Australian jurisdictions. Risk factors and their association with delayed treatment completion (treatment delayed by at least 1 month) were analysed using univariate analyses and multivariate logistic regression.RESULTS: Baseline surveys were completed for 402 persons with TB. Most (86.1%) were born overseas. Exposure to a person with TB was reported by 19.4%. Diabetes mellitus (10.2%), homelessness (9.2%), cigarette smoking (8.7%), excess alcohol consumption (6.0%) and mental illness (6.2%) were other common risk factors. At follow-up, 24.8% of patients had delayed treatment completion, which was associated with adverse events (34.1%, aOR 6.67, 95% CI 3.36-13.27), excess alcohol consumption (6.0%, aOR 21.94, 95% CI 6.03-79.85) and HIV co-infection (2.7%, aOR 8.10, 95% CI 1.16-56.60).CONCLUSIONS: We identified risk factors for TB and their association with delayed treatment completion, not all of which are routinely collected for surveillance purposes. Recognition of these risk factors should facilitate patient-centred care and assist Australia in reaching TB elimination.

Health care’s climate footprint: the health sector contribution and opportunities for action

While vastly differing in scale, each nation's health sector directly and indirectly releases greenhouse gases (GHG) through energy consumption, transport, and product manufacture, use, and disposal. Until recently, however, the health sector has not been measured as a coherent segment of the world's climate footprint. A 2019 report by Health Care Without Harm, in collaboration with Arup, provides the most comprehensive global analysis of health care's contribution to climate change to date, based on full global coverage of spending data together with detailed information from 43 countries. It identifies key sources of health care emissions while allowing for comparison between nations and among many regions of the world. Among the report's key findings are that health care's climate footprint is equivalent to 4.4% of global net emissions; that the top three health care emitters-the United States, China, and the European Union-comprise more than half of the global footprint; and that 71% of emissions are derived from the health care supply chain. The findings inform a series of international, national, and subnational policy recommendations for health care climate action, and it identifies opportunities for further research and methodological development to support the health sector in its efforts to understand and address its climate footprint. Additional findings from 2020 will also be presented. Ultimately, these estimates of health care's climate footprint provide the baseline information needed to devise pathways and track progress toward health care de-carbonization across the sector.

Applying a mechanistic model to predict interacting effects of chemical exposure and food availability on fish populations

The potential environmental impacts of chemical exposures on wildlife are of growing concern. Freshwater ecosystems are vulnerable to chemical effects and wildlife populations, including fish, can be exposed to concentrations known to cause adverse effects at the individual level. Wild fish populations are also often subjected to numerous other stressors simultaneously which in temperate climates often include sustained periods of food limitation. The potential interactive effects of chemical exposures and food limitation on fish populations are however difficult to establish in the field. Mechanistic modelling approaches can be employed to help predict how the physiological effects of chemicals and food limitation on individuals may translate to population-level effects. Here an energy budget-individual-based model was developed and the control (no chemical) model was validated for the three-spined stickleback. Findings from two endocrine active chemical (EAC) case studies, (ethinyloestradiol and trenbolone) were then used to investigate how effects on individual fecundity translated into predicted population-level effects for environmentally relevant exposures. The cumulative effects of chemical exposure and food limitation were included in these analyses. Results show that effects of each EAC on the population were dependent on energy availability, and effects on population abundance were exacerbated by food limitation. Findings suggest that chemical effects and density dependent food competition interact to determine population responses to chemical exposures. Our study illustrates how mechanistic modelling approaches might usefully be applied to account for specific chemical effects, energy budgets and density-dependent competition, to provide a more integrated evaluation of population outcomes in chemical risk assessments.

Tuberculosis preventive treatment opportunities at antiretroviral therapy initiation and follow-up visits

Setting

Twenty-two clinics providing HIV care and treatment in Botswana where tuberculosis (TB) and HIV comorbidity is as high as 49%.

Objectives

To assess eligibility of TB preventive treatment (TPT) at antiretroviral therapy (ART) initiation and at four follow-up visits (FUVs), and to describe the TB prevalence and associated factors at baseline and yield of TB diagnoses at each FUV.

Design

A prospective study of routinely collected data on people living with HIV (PLHIV) enrolled into care for the Xpert^® MTB/RIF Package Rollout Evaluation Study between 2012 and 2015.

Results

Of 6041 PLHIV initiating ART, eligibility for TPT was 69% (4177/6041) at baseline and 93% (5408/5815); 95% (5234/5514); 96% (4869/5079); and 97% (3925/4055) at FUV1, FUV2, FUV3, and FUV4, respectively. TB prevalence at baseline was 11% and 2%, 3%, 3% and 6% at each subsequent FUV. At baseline, independent risk factors for prevalent TB were CD4 <200 cells/mm³ (aOR = 1.4, P = 0.030); anemia (aOR = 2.39, P < 0.001); cough (aOR = 11.21, P < 0.001); fever (aOR = 2.15, P = 0.001); and weight loss (aOR = 2.60, P = 0.002).

Conclusion

Eligibility for TPT initiation is higher at visits post-ART initiation, while most cases of active TB were identified at ART initiation. Missed opportunities for TB further compromises TB control effort among PLHIV in Botswana.

Improving sputum collection processes to increase tuberculosis case finding among HIV-positive persons in Botswana

SETTING

Twenty-two human immunodeficiency virus (HIV) clinics in Botswana.

OBJECTIVE

To compare sputum collection rates, sputum quality and volume, and tuberculosis (TB) diagnosis rates before and after field efforts to improve sputum collection among individuals newly diagnosed with HIV with TB symptoms.

DESIGN

Newly diagnosed individuals living with HIV attending 22 HIV clinics in Botswana were screened for TB from August 2012 to March 2014. Starting in May 2013, a field intervention composed of the introduction of a tracking log for presumed TB patients, and patient instructions and sputum induction to improve sputum collection rates was implemented.

RESULTS

Prior to the intervention, sputum collection rates were 44.1% (384/870). Subsequently, sputum collection increased to 58.3% (579/993) (P < 0.001). Sputum quality and volume also improved. Although rates of TB diagnosis increased from 9.7% (84/870) to 12.5% (120/993), this difference was not significant (P = 0.143).

CONCLUSION

Sputum collection rates among presumptive TB cases, as well as sputum quality and volume improved after implementation of the field intervention. To improve sputum collection rates, efforts at the program level should be ongoing.

Treatment outcomes, diagnostic and therapeutic impact: Xpert vs. smear. A systematic review and meta-analysis

BACKGROUND

Compared with smear microscopy, Xpert^® MTB/RIF has the potential to reduce delays in tuberculosis (TB) diagnosis and treatment initiation, and improve treatment outcomes. We reviewed publications comparing treatment outcomes of drug-susceptible TB patients diagnosed using Xpert vs. smear.

METHODS

Citations (2000-2016) reporting treatment outcomes of patients diagnosed using Xpert compared with smear were selected from PubMed, Scopus and conference abstracts. We conducted a systematic review and meta-analysis. Favorable (cured, completed) and unfavorable (failure, death, loss to follow-up) outcomes were pooled for meta-analysis; we also reviewed the number of TB cases diagnosed, time to treatment and empiric treatment. The Mantel-Haenszel method with a fixed-effect model was used; I² was calculated to measure heterogeneity.

RESULTS

From 13 citations, 43 594 TB patients were included and 4825 were with known TB treatment outcome. From the pooled analysis, an unfavorable outcomes among those diagnosed using Xpert compared with smear was 20.2%, 541/2675 vs. 21.9%, 470/2150 (risk ratio 0.92, 95%CI 0.82-1.02). Statistical heterogeneity was low (I² = 0.0%, P = 0.910). Compared with smear, Xpert was reported to be superior in increasing the number of TB patients diagnosed (2/9 citations), increasing bacteriologically confirmed TB (7/9 citations), reducing empiric treatment (3/5 citations), reducing time to diagnosis (2/3 citations), and reducing time to treatment initiation (1/5 citations).

CONCLUSIONS

Xpert implementation showed no discernible impact on treatment outcomes compared with conventional smear despite reduced time to diagnosis, time to treatment or reduced level of empiric treatment. Further research is required to learn more about gaps in the existing health system.

Initiation of anti-tuberculosis treatment in children following gastric aspirate testing, Botswana, 2008-2012

SETTING

Diagnosing pediatric tuberculosis (TB) is difficult; to improve diagnosis, gastric aspiration (GA) was performed in 121 Botswana health facilities.

OBJECTIVE

To describe treatment initiation and outcomes in children with a positive GA result and those treated empirically.

METHODS

Children with smear or culture-positive GA or those clinically diagnosed were referred for anti-tuberculosis treatment. Treatment initiation and outcomes were assessed from February 2008 to December 2012 using name-based matching algorithms of the GA database; treatment initiation was captured in the electronic TB registry. Analyses included descriptive statistics and regression models.

RESULTS

GA was conducted in 1268 children. Among these, 121 (9.5%) were GA-positive; and treatment was initiated in 90 (74.3%). An additional 137 (11.9%) were treated empirically. More than a third (36.4%) had known human immunodeficiency virus status (positive or negative); this was significantly associated with TB treatment initiation (adjusted odds ratio [aOR] 1.8, 95%CI 1.3-2.5); P < 0.05). Among the 90 children with a positive GA result, nearly all either completed treatment (78.9%) or were on treatment (20.0%) at the time of data collection.

CONCLUSION

We could not find documentation of treatment for more than a quarter of the children with laboratory-confirmed TB, an important gap that calls for further examination. The failure to initiate prompt treatment requires investigation and urgent action.

Validity and reliability of a freehand 3D ultrasound system for the determination of triceps surae muscle volume in children with cerebral palsy

This study assessed the validity, intra-rater and inter-rater reliability of segmentation of in vivo medial gastrocnemius (MG), lateral gastrocnemius (LG) and soleus (SOL) muscle volume measurement using a single sweep freehand 3D ultrasound (3DUS) in children with cerebral palsy (CP). The MG, LG and SOL of both limbs of 18 children with CP (age 8 years 4 months ± 1 year 10 months, 11 males, unilateral CP = 9, bilateral CP = 9, Gross Motor Functional Classification System I = 11, II = 7) were scanned using freehand 3DUS and magnetic resonance imaging (MRI). All freehand 3DUS and MRI images were segmented and volumes rendered by two raters. Validity was assessed using limits of agreement method. Intra-rater and inter-rater reliability was assessed using intra-class correlation (ICC), coefficient of variance (CV) and minimal detectable change (MDC). Freehand 3DUS overestimated muscle volume of the MG and LG by < 0.3 mL (1%) and underestimated SOL by < 1.3 mL (1.5%) compared with MRI. ICCs for intra-rater reliability of the segmentation process for the freehand 3DUS system and MRI for muscle volume were > 0.98 and 0.99, respectively, for all muscles. ICCs for inter-rater reliability of the segmentation process for freehand 3DUS and MRI volumes were > 0.96 and 0.98, respectively, for all muscles. MDCs for single rater freehand 3DUS and MRI were < 4.0 mL (14%) and 3.2 mL (11%), respectively, in all muscles. Freehand 3DUS is a valid and reliable method for the measurement of lower leg muscle volume that can be measured with a single sweep in children with CP in vivo. It can be used as an alternative to MRI for the detection of clinically relevant changes in calf muscle volume as the result of growth and interventions.

Population Pharmacokinetics of Apixaban in Subjects With Nonvalvular Atrial Fibrillation

This analysis describes the population pharmacokinetics (PPK) of apixaban in nonvalvular atrial fibrillation (NVAF) subjects, and quantifies the impact of intrinsic and extrinsic factors on exposure. The PPK model was developed using data from phase I-III studies. Apixaban exposure was characterized by a two-compartment PPK model with first-order absorption and elimination. Predictive covariates on apparent clearance included age, sex, Asian race, renal function, and concomitant strong/moderate cytochrome P450 (CYP)3A4/P-glycoprotein (P-gp) inhibitors. Individual covariate effects generally resulted in < 25% change in apixaban exposure vs. the reference NVAF subject (non-Asian, male, aged 65 years, weighing 70 kg without concomitant CYP3A4/P-gp inhibitors), except for severe renal impairment, which resulted in 55% higher exposure than the reference subject. The dose-reduction algorithm resulted in a ~27% lower median exposure, with a large overlap between the 2.5-mg and 5-mg groups. The impact of Asian race on apixaban exposure was < 15% and not considered clinically significant.

Time to treatment for rifampicin-resistant tuberculosis: systematic review and meta-analysis

BACKGROUND:

To reduce transmission and improve patient outcomes, rapid diagnosis and treatment of rifampicin-resistant tuberculosis (RR-TB) is required.

OBJECTIVE:

To conduct a systematic review and meta-analysis assessing time to treatment for RR-TB and variability using diagnostic testing methods and treatment delivery approach.

DESIGN:

Studies from 2000 to 2015 reporting time to second-line treatment initiation were selected from PubMed and published conference abstracts.

RESULTS:

From 53 studies, 83 cohorts (13 034 patients) were included. Overall weighted mean time to treatment from specimen collection was 81 days (95%CI 70–91), and was shorter with ambulatory (57 days, 95%CI 40–74) than hospital-based treatment (86 days, 95%CI 71–102). Time to treatment was shorter with genotypic susceptibility testing (38 days, 95%CI 27–49) than phenotypic testing (108 days, 95%CI 98–117). The mean percentage of diagnosed patients initiating treatment was 76% (95%CI 70–83, range 25–100).

CONCLUSION:

Time to second-line anti-tuberculosis treatment initiation is extremely variable across studies, and often unnecessarily long. Reduced delays are associated with genotypic testing and ambulatory treatment settings. Routine monitoring of the proportion of diagnosed patients initiating treatment and time to treatment are necessary to identify areas for intervention.

Vital Statistics, and Observations on the first thousand Female Patients admitted into the Somerset County Lunatic Asylum; the Results compared with an equal number of Male Patients, together with an Analysis of the Causes of Death in both Sexes

In a previous number (39) of this Journal are recorded the statistics of the first thousand cases of male patients admitted into the Somerset Lunatic Asylum, with an analysis of the causes of death. The same method is followed in the present communication with regard to the first thousand female admissions; a comparison is made between the sexes, and a general review from some authorities on these subjects.

Statistics of Pauper Insanity

At the last annual meeting of the Medico-Psychological Association, held at the College of Physicians, London, in July, 1870, I brought forward a resolution which, after full discussion, was amended and agreed to, in these terms:— “That it is desirable to facilitate the early admission of all acute cases of pauper insanity into county (and borough) asylums, by providing for the proper care and treatment of chronic and harmless cases elsewhere.” The object of the resolution being to ensure for acute cases that prompt treatment which is so essential, and to prevent the overcrowding and overgrowth of asylums, by providing for the transfer of incurable and harmless cases to workhouses, or to lodgings, or to reside with relatives, under proper care, treatment, and supervision. In the absence of any such provision, the enlargement of asylums progresses—this will be shown by the returns of the increase of pauper insanity in England and Wales. Several institutions have attained such dimensions that the difficulty of proper management has become great. In such overgrown establishments the individuality of the curable patient is liable to become lost amongst the crowd of idiots and incurables. The delay in obtaining the forms required by the Lunacy Acts, prior to the admission of insane patients to pauper asylums, is a great hindrance to early treatment. As regards chronic cases, this delay is of little consequence, and from the comforts being greater in the asylum than in the workhouse infirmary, and it being to the interest of workhouse officials to send insane paupers to the asylum, the accumulation of chronic and incurable cases therein can easily be accounted for.

Expanding conceptualizations of harm reduction: results from a qualitative community-based participatory research study with people who inject drugs

Background

The perspectives of people who use drugs are critical in understanding why people choose to reduce harm in relation to drug use, what practices are considered or preferred in conceptualizations of harm reduction, and which environmental factors interfere with or support the use of harm reduction strategies. This study explores how people who inject drugs (PWID) think about harm reduction and considers the critical imperative of equity in health and social services delivery for this community.

Methods

This community-based participatory research study was conducted in a Canadian urban centre. Using a peer-based recruitment and interviewing strategy, semi-structured qualitative interviews were conducted by and with PWID. The Vidaview Life Story Board, an innovative tool where interviewers and participant co-construct a visual “life-scape” using a board, markers, and customized picture magnets, was used to facilitate the interviews. The topics explored included injection drug use and harm reduction histories, facilitators and barriers to using harm reduction strategies, and suggestions for improving services and supports.

Results

Twenty-three interviews with PWID (14 men and 9 women) were analysed, with a median age of 50. Results highlighted an expanded conceptualization of harm reduction from the perspectives of PWID, including motivations for adopting harm reduction strategies and a description of harm reduction practices that went beyond conventional health-focused concerns. The most common personal practices that PWID used included working toward moderation, employing various cognitive strategies, and engaging in community activities. The importance of social or peer support and improving self-efficacy was also evident. Further, there was a call for less rigid eligibility criteria and procedures in health and social services, and the need to more adequately address the stigmatization of drug users.

Conclusions

These findings demonstrated that PWID incorporate many personal harm reduction practices in their daily lives to improve their well-being, and these practices highlight the importance of agency, self-care, and community building. Health and social services are needed to better support these practices because the many socio-structural barriers this community faces often interfere with harm reduction efforts. Finally, “one size does not fit all” when it comes to harm reduction, and more personalized or de-medicalized conceptualizations are recommended.

Uraemia: an unrecognized driver of central neurohumoral dysfunction in chronic kidney disease?

Chronic kidney disease (CKD) carries a large cardiovascular burden in part due to hypertension and neurohumoral dysfunction - manifesting as sympathetic overactivity, baroreflex dysfunction and chronically elevated circulating vasopressin. Alterations within the central nervous system (CNS) are necessary for the expression of neurohumoral dysfunction in CKD; however, the underlying mechanisms are poorly defined. Uraemic toxins are a diverse group of compounds that accumulate as a direct result of renal disease and drive dysfunction in multiple organs, including the brain. Intensive haemodialysis improves both sympathetic overactivity and cardiac baroreflex sensitivity in renal failure patients, indicating that uraemic toxins participate in the maintenance of autonomic dysfunction in CKD. In rodents exposed to uraemia, immediate early gene expression analysis suggests upregulated activity of not only pre-sympathetic but also vasopressin-secretory nuclei. We outline several potential mechanisms by which uraemia might drive neurohumoral dysfunction in CKD. These include superoxide-dependent effects on neural activity, depletion of nitric oxide and induction of low-grade systemic inflammation. Recent evidence has highlighted superoxide production as an intermediate for the depolarizing effect of some uraemic toxins on neuronal cells. We provide preliminary data indicating augmented superoxide production within the hypothalamic paraventricular nucleus in the Lewis polycystic kidney rat, which might be important for mediating the neurohumoral dysfunction exhibited in this CKD model. We speculate that the uraemic state might serve to sensitize the central actions of other sympathoexcitatory factors, including renal afferent nerve inputs to the CNS and angiotensin II, by way of recruiting convergent superoxide-dependent and pro-inflammatory pathways.

Progressive vascular remodelling, endothelial dysfunction and stiffness in mesenteric resistance arteries in a rodent model of chronic kidney disease

Chronic kidney disease (CKD) and hypertension are co-morbid conditions both associated with altered resistance artery structure, biomechanics and function. We examined these characteristics in mesenteric artery together with renal function and systolic blood pressure (SBP) changes in the Lewis polycystic kidney (LPK) rat model of CKD. Animals were studied at early (6-weeks), intermediate (12-weeks), and late (18-weeks) time-points (n=21), relative to age-matched Lewis controls (n=29). At 12 and 18-weeks, LPK arteries exhibited eutrophic and hypertrophic inward remodelling characterised by thickened medial smooth muscle, decreased lumen diameter, and unchanged or increased media cross-sectional area, respectively. At these later time points, endothelium-dependent vasorelaxation was also compromised, associated with impaired endothelium-dependent hyperpolarisation and reduced nitric oxide synthase activity. Stiffness, elastic-modulus/stress slopes and collagen/elastin ratios were increased in 6 and 18-week-old-LPK, in contrast to greater arterial compliance at 12weeks. Multiple linear regression analysis highlighted SBP as the main predictor of wall-lumen ratio (r=0.536, P<0.001 n=46 pairs). Concentration-response curves revealed increased sensitivity to phenylephrine but not potassium chloride in 18-week-LPK. Our results indicate that impairment in LPK resistance vasculature is evident at 6weeks, and worsens with hypertension and progression of renal disease.

Randomized, blinded, placebo- and positive-controlled crossover study to determine the effect of multiple doses of apixaban on the QTc interval

Apixaban is an oral, direct factor Xa inhibitor indicated for the prevention and treatment of thromboembolic disease. This randomized, blinded, 4-way crossover study investigated the potential effect of apixaban on the QTc interval. Forty healthy subjects (39 completers) each received 3 days of the following treatments: blinded apixaban 10 mg once daily (QD), 50 mg QD (supratherapeutic), matched apixaban placebo QD, and a single dose of open-label moxifloxacin 400 mg on Day 3, preceded by 2 days of placebo QD. Triplicate electrocardiograms obtained over 24 hours on Days -1 (baseline) and 3 were read by a blinded third party. The mean placebo-adjusted, time-matched, Fridericia-corrected change from baseline QTc (ΔΔQTcF) for apixaban and moxifloxacin was estimated at each time point. The maximum ΔΔQTcF was 1.51 milliseconds (one-sided upper 95% confidence interval [CI] 3.71 milliseconds) after apixaban 50 mg QD, 1.36 milliseconds (one-sided upper 95%CI 3.54 milliseconds) after apixaban 10 mg QD, and 10.21 milliseconds (lower 95%CI 8.07 milliseconds) after moxifloxacin. Concentration-response analysis suggested no evidence of a positive relationship between apixaban concentration and ΔQTcF. Apixaban doses up to 50 mg QD for 3 days were well tolerated and did not prolong the QTc interval in healthy subjects.

Predictors of psychological adjustment, experienced parenting burden and chronic sorrow symptoms in parents of children with cerebral palsy

AIM

To investigate the role of child behaviour, parental coping and experiential avoidance in predicting the psychological outcomes of: (i) psychological symptoms; (ii) chronic sorrow symptoms; and (iii) experienced parenting burden in parents of children with cerebral palsy (CP).

METHOD

This study is a cross-sectional, correlational study. Ninety-four parents of children (aged 2-12 years) with CP (various levels of motor functioning GMFCS I-V) participated.

RESULTS

Together, the three predictors of child behaviour, parental coping and experiential avoidance explained 36.8% of the variance in psychological symptoms with child behavioural problems and experiential avoidance as significant unique predictors. In addition, 15.8% of the variance in chronic sorrow symptoms was explained by the three predictors with experiential avoidance alone as a significant unique predictor. Lastly, the predictors together explained 24.3% of the variance in experienced parenting burden with child behavioural problems and experiential avoidance as significant unique predictors.

CONCLUSIONS

This study demonstrates a relationship between child behavioural problems and parental psychological symptoms and experienced parenting burden as well as a relationship between experiential avoidance and parental psychological symptoms, experienced parenting burden and chronic sorrow symptoms.

Experience with high frequency oscillation ventilation during the 2009 H1N1 influenza pandemic in Australia and New Zealand

During the 2009 H1N1 pandemic, large numbers of patients had severe respiratory failure. High frequency oscillation ventilation was used as a salvage technique for profound hypoxaemia. Our aim was to compare this experience with high frequency oscillation ventilation during the 2009 H1N1 pandemic with the same period in 2008 by performing a three-month period prevalence study in Australian and New Zealand intensive care units. The main study end-points were clinical demographics, care delivery and survival. Nine intensive care units contributed data. During 2009 there were 22 H1N1 patients (17 adults, five children) and 10 non-H1N1 patients (five adults, five children), while in 2008, 18 patients (two adults, 16 children) received high frequency oscillation ventilation. The principal non-H1N1 high frequency oscillation ventilation indication was bacterial or viral pneumonia (56%). For H1N1 patients, the median duration of high frequency oscillation ventilation was 3.7 days (interquartile range 1.8 to 5) with concomitant therapies including recruitment manoeuvres (22%), prone ventilation (41%), inhaled prostacyclins (18%) and inhaled nitric oxide (36%). Seven patients received extracorporeal membrane oxygenation, six having H1N1. Three patients had extracorporeal membrane oxygenation concurrently, two as salvage therapy following the commencement of high frequency oscillation ventilation. In 2008, no high frequency oscillation ventilation patient received extracorporeal membrane oxygenation. Overall hospital survival was 77% in H1N1 patients, while survival in patients having adjunctive extracorporeal membrane oxygenation was similar to those receiving high frequency oscillation ventilation alone (65% compared to 71%, P = 1.00). Survival rates were comparable to published extracorporeal membrane oxygenation outcomes. High frequency oscillation ventilation was used successfully as a rescue therapy for severe respiratory failure. High frequency oscillation ventilation was only available in a limited number of intensive care units during the H1N1 pandemic.

Systematic review of the efficacy of parenting interventions for children with cerebral palsy

This systematic review aims to evaluate the efficacy of parenting interventions (i.e. behavioural family intervention and parent training) with parents of children with cerebral palsy (CP) on child behavioural outcomes and parenting style/skill outcomes. The following databases were searched: Medline (1950-April 2010), PubMed (1951-April 2010), PsycINFO (1840-April 2010), CINAHL (1982-April 2010) and Web of Science (1900-April 2010). No randomized clinical trials of parenting interventions with parents of children with CP were identified. Three studies were identified that involved the examination of a targeted parenting intervention via a pre-post design. Interventions utilized included the implementation of parenting interventions in conjunction with behavioural intervention and oral motor exercises for children with CP and feeding difficulties, the Hanen It Takes Two to Talk programme and a Functional Communication Training programme for parents. All studies found changes in relevant child behavioural outcomes. The studies reviewed suggest that parenting interventions may be an effective intervention for parents of children with CP. However, the current research is limited to pre-post designs of targeted parenting interventions (e.g. parenting interventions focused upon communication). A randomized controlled trial of parenting interventions for families of children with CP is urgently needed to address this paucity in the literature and provide families of children with CP with an evidence-based intervention to address child behavioural and emotional problems as well as parenting challenges.

How copying affects the amount, evenness and persistence of cultural knowledge: insights from the social learning strategies tournament

Darwinian processes should favour those individuals that deploy the most effective strategies for acquiring information about their environment. We organized a computer-based tournament to investigate which learning strategies would perform well in a changing environment. The most successful strategies relied almost exclusively on social learning (here, learning a behaviour performed by another individual) rather than asocial learning, even when environments were changing rapidly; moreover, successful strategies focused learning effort on periods of environmental change. Here, we use data from tournament simulations to examine how these strategies might affect cultural evolution, as reflected in the amount of culture (i.e. number of cultural traits) in the population, the distribution of cultural traits across individuals, and their persistence through time. We found that high levels of social learning are associated with a larger amount of more persistent knowledge, but a smaller amount of less persistent expressed behaviour, as well as more uneven distributions of behaviour, as individuals concentrated on exploiting a smaller subset of behaviour patterns. Increased rates of environmental change generated increases in the amount and evenness of behaviour. These observations suggest that copying confers on cultural populations an adaptive plasticity, allowing them to respond to changing environments rapidly by drawing on a wider knowledge base.

Five-year outcome of state-wide hip surveillance of children and adolescents with cerebral palsy

This study reports the five-year outcomes of a prospective population-based study of clinical hip surveillance for children with cerebral palsy (CP) according to evidence-based standards of care. Systematic hip surveillance commenced in Queensland, Australia as a state-wide program in 2005. Queensland represents a dispersed population across a large geographical area, creating unique challenges in terms of service delivery. Over five years, 1,115 children with CP were recruited, representing 73% of the expected population based on 1.9 to 2.1 per 1,000 live births. Standardized clinical and radiological assessments have been provided, with a median follow-up of 1.2 years (range 1 month -5(+8) yrs). Of the 1,115 children, 423 (38%) have been discharged and 692 (62%) remain on surveillance with 314 (28%) identified as having hip displacement with Migration Percentage (MP) equal to or greater than 30% (≥ 30). The incidence of marked hip displacement (MP ≥ 30) was directly related to gross motor function, classified according to the gross motor function classification system (GMFCS), with distribution of GMFCS I=10, (3%), II=40 (13%), III=53 (43%), IV=96 (59%), and V=115 (64%). This state-wide surveillance program has been successful in correctly identifying children with hip displacement (MP ≥ 30), fast tracking children for orthopedic review and discharging those at minimal risk. No child has progressed to dislocation while on surveillance without orthopedic review.

Effect of phenotypic variation on kin selection

An expression for the equilibrium of the mean phenotypic value of a quantitative character is derived for a model in which the fitness of an individual depends on its own phenotype and the mean phenotypic value of a group of related individuals. When selection is weak the equilibrium mean is well predicted by Hamilton's k > 1/r rule (k is the ratio of mean fitness gained by recipient of altruistic behavior to mean fitness lost by donor; r is mean coefficient of relationship between donor and recipient). When selection is strong, however, the equilibrium mean depends on the heritability of the character. Low heritability can lead to substantially more "altruism" than predicted by the k > 1/r rule.

Why copy others? Insights from the social learning strategies tournament

Social learning (learning through observation or interaction with other individuals) is widespread in nature and is central to the remarkable success of humanity, yet it remains unclear why copying is profitable and how to copy most effectively. To address these questions, we organized a computer tournament in which entrants submitted strategies specifying how to use social learning and its asocial alternative (for example, trial-and-error learning) to acquire adaptive behavior in a complex environment. Most current theory predicts the emergence of mixed strategies that rely on some combination of the two types of learning. In the tournament, however, strategies that relied heavily on social learning were found to be remarkably successful, even when asocial information was no more costly than social information. Social learning proved advantageous because individuals frequently demonstrated the highest-payoff behavior in their repertoire, inadvertently filtering information for copiers. The winning strategy (discountmachine) relied nearly exclusively on social learning and weighted information according to the time since acquisition.

The impact of caring for a child with cerebral palsy: quality of life for mothers and fathers

BACKGROUND

Although it is expected that caring for a child with cerebral palsy (CP) can impact on the quality of life (QOL) of caregivers, the QOL of carers' has yet to be adequately examined. The aims of this study are to: (1) explore the QOL of mothers and fathers of children with CP aged 3-18 years; and (2) examine whether the impact of caring for a child with CP changes from childhood to adolescence.

METHOD

A qualitative study was conducted utilizing a grounded theory framework. Twenty-four mothers and 13 fathers of children and adolescents with CP aged 3-7 years (n = 15), 8-12 years (n = 10) and 13-18 years (n = 12) and with varying levels of impairment (GMFCS Level I = 1, II = 4, II = 3, IV = 5, V = 12) participated in semi-structured interviews about their QOL. The transcripts were analysed to identify issues affecting parental QOL.

RESULTS

There were no differences in parental QOL among subgroups (i.e. mothers and fathers, age groups, GMFCS levels). Parental QOL ranged across a wide spectrum. Caring for a child with CP affects a parent's physical well-being, social well-being, freedom and independence, family well-being and financial stability. Parents indicated that they often feel unsupported by the services they access.

CONCLUSIONS

Caring for a child with CP can both positively and negatively impact on a parent's life. There is value for both parents and children if parental concerns and determinants of QOL are considered in overall programme planning and service delivery for children and their families.

Falls and fear of falling: burden, beliefs and behaviours

OBJECTIVES

this study estimated the frequency of recent falls and prevalence of fear of falling among adults aged 65 and older.

DESIGN

a cross-sectional, list-assisted random digit dialling telephone survey of US adults from 2001 to 2003.

SUBJECTS

1,709 adults aged 65 or older who spoke either English or Spanish.

METHODS

prevalence estimates were calculated for recent falls, fall injuries, fear of falling and fall prevention beliefs and behaviours.

RESULTS

an estimated 3.5 million, or 9.6%, of older adults reported falling at least once in the past 3 months. About 36.2% of all older adults said that they were moderately or very afraid of falling. Few older adults who fell in the past 3 months reported making any changes to prevent future falls.

CONCLUSIONS

the high prevalence of falls and fear of falling among US older adults is of concern. Both can result in adverse health outcomes including decreased quality of life, functional limitations, restricted activity and depression. Older adults' fear of falling and their reluctance to adopt behaviours that could prevent future falls should be considered when designing fall prevention programmes.

Alcohol-impaired driving and children in the household

More children in the United States are killed in motor vehicle crashes annually than by any other cause; nearly a quarter of these deaths involve alcohol. This study examines the national prevalence of alcohol-impaired driving and riding with an alcohol-impaired driver and the association of these behaviors to having at least 1 child in the household. An estimated 2.5 million adult drivers with children living in their households reported that they had been a recent alcohol-impaired driver. Evidence-based approaches, including mass media campaigns and sobriety checkpoints, continue to be critically important public health activities.

Adult seat belt use: does the presence of children in the household make a difference?

OBJECTIVE

To obtain prevalence estimates of seat belt use among adults with and without at least one child in the household and to examine whether having at least one child in the household is associated with adult seat belt use.

METHODS

The Second Injury Control and Risk Survey (ICARIS-2) was a nationwide cross-sectional, list-assisted random-digit-dialing telephone survey of individuals who were at least 18 years old and who spoke either English or Spanish. ICARIS-2 was carried out from 2001 to 2003; a similar study, ICARIS-1, had been conducted in 1994. National estimates were calculated for the prevalence of adult seat belt use and stratified according to the presence or absence of children in the household. Prevalence estimates for the two ICARIS surveys were compared using t-tests. Multivariable logistic regression was used to explore the association between having at least one child in the household and self-reported adult seat belt use.

RESULTS

Based on the 9,684 completed household interviews in ICARIS-2, an estimated 15.9% (13 million) of drivers with children in their households did not always wear their seat belt when driving, and 17.5% (15 million) of adult passengers with children in their households did not always wear their seat belt while riding. The prevalence of drivers and passengers who did not always wear their seat belt decreased between ICARIS-1 and ICARIS-2. Both driver and passenger seat belt use were associated with the respondent's age, sex, ethnicity, level of education, current marital status, and self-reported alcohol-impaired driving or riding with an alcohol-impaired driver. Drivers with children in the household, living in the Northeast, North Central, and Southern census regions of the country were significantly more likely than those in the West to report wearing their seat belt less than always.

CONCLUSIONS

While seat belt use rates are increasing, many more lives could be saved by more complete restraint use. Effective strategies for increasing seat belt use rates and decreasing the number of both fatal and nonfatal motor vehicle injuries include primary enforcement laws, enhanced enforcement of seat belt use laws, and child safety-seat distribution combined with education programs.

The relationship between quality of life and functioning for children with cerebral palsy

Given that quality of life (QOL) is commonly confused with functioning, the aim of this study was to examine the association between functioning and QOL domains for children with cerebral palsy (CP). Two hundred and five parents of children aged 4 to 12 years with CP and 53 children aged 9 to 12 years with CP, completed the Cerebral Palsy Quality of Life Questionnaire for Children. Children were distributed reasonably evenly between sex (male, 54.6%) and Gross Motor Function Classification System levels (I 17.8%, II 28.3%, III 14.1%, IV 11.2%, and V 27.3%). For parent proxy-report, all domains of QOL were significantly associated with functioning level except access to services. For child self-report, feelings about functioning, participation and physical health, and pain and feelings about disability, were significantly associated with functioning level. Physical type domains of QOL accounted for more of the variance in functioning than psychosocial type domains. Children with CP have the potential to report a high psychosocial QOL score even if they have poor functioning.

Characterization of DNA bio-bonds for meso-scale self-assembly

In this paper, we have investigated the use of DNA hybridization as the basis for the production of new mesoscale components. AFM experimental results are studied and compared to two theoretical approaches: molecular and thermodynamic. We explain how and why DNA hybridization process can provide a good bond to self assemble components, and how molecular modelling methods allow further understanding of the physical mechanism of this process. Furthermore, the strength interaction of DNA complementary strands is measured and analyzed using statistical tools. These results are then compared to the theoretical approaches.

Attitudes toward performance of endoscopic colon cancer screening by family physicians

BACKGROUND AND OBJECTIVES

This study's purpose was to examine attitudes of family physicians and gastroenterologists toward family physician performance of lower endoscopy in general practice.

METHODS

A mailed survey was sent to 1,563 board-certified physicians in Georgia (1,303 family physicians, 260 gastroenterologists). Respondents were asked to describe their practice of lower endoscopy procedures and colorectal (CRC) screening preferences.

RESULTS

Fifty-one percent (801) of the surveys were returned. For CRC screening, family physicians recommend fecal occult blood testing most frequently (51.7%), while gastroenterologists recommended colonoscopy most frequently (89.5%). Most family physicians believe that family physicians should perform flexible sigmoidoscopy (FS) (81.4%) and colonoscopy (CS) (71.3%). A total of 71.2% of surveyed gastroenterologists believe that family physicians should perform FS, but only a minority (4.5%) believe that family physicians should perform screening CSs. Approximately 28% (186) of family physicians report performing FS (mean=.8 FS per month). Only 3.7 % (25) of family physicians reported performing CS (mean=8.2 CSs per month).

CONCLUSIONS

Although most family physicians believe that they should perform lower endoscopy, only a minority of gastroenterologists believe family physicians should perform CS. Our results show that family physician performance of lower endoscopic CRC screening is limited in general practice. Future research might consider exploring these issues from both the gastroenterologist and family physician perspective.

Early developmental intervention programs post hospital discharge to prevent motor and cognitive impairments in preterm infants

BACKGROUND

Infants born preterm are at increased risk of developing cognitive and motor impairments compared with infants born at term. Early developmental interventions have been used in the clinical setting with the aim of improving the overall functional outcome for these infants. However, the benefit of these programs remains unclear.

OBJECTIVES

To review the effectiveness of early developmental intervention post-discharge from hospital for preterm (< 37 weeks) infants on motor or cognitive development.

SEARCH STRATEGY

The Cochrane Neonatal Review group search strategy was used to identify randomised and quasi-randomised controlled trials of early developmental interventions post hospital discharge. Two review authors independently searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE Advanced, CINAHL, PsychINFO and EMBASE (1966 through February 2006).

SELECTION CRITERIA

Studies included had to be randomised or quasi-randomised controlled trials of early developmental intervention programs that commenced within the first 12 months of life for infants born at < 37 weeks with no major congenital abnormalities. Intervention could commence as an inpatient; however, a post discharge component was necessary to be included in this review. The outcome measures were not pre-specified other than that they had to assess cognitive and/or motor ability. The rates of intellectual impairment, cerebral palsy and development co-ordination disorder were also documented.

DATA COLLECTION AND ANALYSIS

Data were extracted and entered by two independent review authors. Cognitive and motor outcomes were pooled in three age groups - infant (0 to 2 years), preschool (3 to < 5 years) or school age (5 to 17 years). Meta-analysis was carried out using RevMan 4.2 to determine the effects of early developmental intervention in the short (0 to 2 years), medium (3 to < 5 years) and long term (5 to 17 years). Subgroup analysis was carried out in relation to; gestational age, birthweight, brain injury, commencement of intervention, focus of intervention and study quality.

MAIN RESULTS

Sixteen studies met the inclusion criteria (2379 randomised patients). Six of these studies were RCTs and had strong methodological quality. There was variability with regard to the focus and intensity of the intervention, and in length of follow-up. Meta-analysis concluded that intervention improved cognitive outcomes at infant age (developmental quotient [DQ]: standard mean difference [SMD] 0.46 SD; 95% CI 0.36 0.57; P < 0.0001), and at preschool age (intelligence quotient [IQ]; SMD 0.46 SD; 95%CI 0.33, 0.59; P < 0.0001). However, this effect was not sustained at school age (IQ; SMD 0.02 SD; 95% CI -0.10, 0.14; P = 0.71). There was significant heterogeneity between studies for cognitive outcomes at infant and school ages. There was little evidence of an effect of early intervention on motor outcomes in the short, medium or long-term, but there were only two studies reporting outcomes beyond 2 years.

AUTHORS' CONCLUSIONS

Early intervention programs for preterm infants have a positive influence on cognitive outcomes in the short to medium term. However, there was significant heterogeneity between the interventions included in this review. Further research is needed to determine which early developmental interventions are the most effective at improving cognitive and motor outcomes, and on the longer-term effects of these programs. Cost-effectiveness and access to services should also be evaluated since they are important factors when considering implementation of an early developmental intervention program for a preterm infant.