Is the Use of Apixaban or Enoxaparin, More Effective in the Prophylaxis of Venous Thromboembolism Post-Orthopedic Surgery?

OBJECTIVE: The objective of this selective EBM review is to determine whether or not the use of Apixaban or Enoxaparin is more effective in the prophylaxis of venous thromboembolism post-orthopedic surgery. STUDY DESIGN: Review of three English language randomized, double-blind, placebo-controlled clinical trials from 2009-2010. DATA SOURCES: Randomized, double-blind placebo controlled, clinical trials comparing the effectiveness of Apixaban and Enoxaparin in the prophylaxis of Venous Thromboembolism (VTE) post-orthopedic surgery were found using PubMed, the Cochrane Database of Randomized Controlled Trials, and the Cochrane Databases of Systematic Reviews. OUTCOMES MEASURED: Development of venous thromboembolism (VTE) post-orthopedic surgery including Total Knee Replacement (TKR) and Total Hip Replacement (THR) compared to preoperative baseline was measured using four different modes of detection: Bilateral Venography, Ventilation Perfusion Scan, Spiral CT, Pulmonary Angiography, and bleeding during the treatment phase. RESULTS: ADVANCE-1 (Apixaban Dose Orally vs. Anticoagulation with Enoxaparin) compared the efficacy of 2.5mg of Apixaban twice daily with that of Enoxaparin 30mg subcutaneous dosing twice daily post-TKR. Both regimens were initiated 12-24 hrs post surgery. No clear VTE rate reduction was evident with either drug, both exhibited similar results of 8.8% Enoxaparin, 9.0% Apixaban. However, reduced bleeding with Apixaban was observed. ADVANCE-2 focused on the two interventions, Apixaban 2.5mg twice daily initiated 12-24 hrs post surgery in comparison to Enoxaparin regimen of 40 mg subcutaneously 12 hrs prior and continued 10-14 days post-TKR. It was observed that Apixaban was superior to Enoxaparin post-TKR with a 9.3% relative reduction rate in VTE formation and 1% decline in bleeding episode. ADVANCE-3 evaluated the efficacy of Apixaban and Enoxaparin post-THR at the same dosage and administration as ADVANCE-2 TKR trial, however the treatment regimen was continued 35 days post-THR surgery. ADVANCE-3 trial concluded Apixaban was far more effective at VTE rate reduction with 1.4% compared with 3.9% of Enoxaparin use. CONCLUSIONS:The use of Apixaban 2.5 mg orally twice daily is an appropriate, safe and effectivealternative to the traditional Enoxaparin for thromboprophylaxis post-orthopedic surgery

Myocardial infarction and mortality following joint surgery in patients with rheumatoid arthritis: a retrospective cohort study

Summary of patient level comparing those with rheumatoid arthritis to those without rheumatoid arthritis. (DOCX 14 kb

A Social-Ecological systems perspective on water management in South Africa

Conventional approaches to water management have traditionally treated social systems and ecosystems as distinct, and to a large degree have failed to achieve outcomes that are simultanously efficient, equitable, and sustainable. Perhaps nowhere has the need to reform the way water is managed and even conceived been more apparent than in South Africa in the last decade, where a tremendous opportunity for change has been created in the form of the National Water Act of 1998. In this thesis I propose that water management in South Africa – which encompasses its water resources, ecosystems and their services, people they support, and institutions that govern them – is a social-ecological system: a coupled, inseparable system of human beings and nature. Using a combination of approaches, I demonstrate that a social-ecological systems perspective is needed to understand the true nature of these challenges. First, drawing from the experience of the Southern African Millennium Ecosystem Assessment (SAfMA), I construct and apply a framework for evaluating past water management responses. Second, I review a scenario planning exercise as an approach for identifying robust decisions amid high levels of uncertainty about future ecosystem services. Third, I use an agent-based model to explore the evolution of decision-making and learning by water managers under alternative paradigms. Lastly, I compare the ability of two existing frameworks to increase understanding of resilience as it applies to South African water management. Results of this work indicate that: congruence of impacts, awareness, and power is key to achieving effective water management in South Africa; future water management planning needs to take account of cross-scale trade-offs; decentralisation holds most promise when supported by a national policy framework but which allows for local learning; learning may be constrained by temporal variability, water stress, access to learning networks, and use of inappropriate indicators; and the concept of resilience may provide a mechanism for uniting social and ecological research on water management. As most past water management failures have resulted from a misunderstanding of social-ecological system dynamics, work of this kind can make a significant contribution at this pivotal point in South Africa’s water management history. Copyright 2006, University of Pretoria. All rights reserved. The copyright in this work vests in the University of Pretoria. No part of this work may be reproduced or transmitted in any form or by any means, without the prior written permission of the University of Pretoria. Please cite as follows: Bohensky, EL 2006, A Social-Ecological systems perspective on water management in South Africa, PhD thesis, University of Pretoria, Pretoria, viewed yymmdd Thesis (PhD (Environmental Studies))--University of Pretoria, 2006.Zoology and Entomologyunrestricte

The Social and Economic Long Term Monitoring Program (SELTMP) 2014: Recreation in the Great Barrier Reef

[Extract] Introduction.\ud People love to spend their recreational time visiting the Great Barrier Reef World Heritage Area (GBRWHA), (GBRMPA, 2009), and many people are doing it! The recent SELTMP surveys revealed that 95% of residents of coastal town adjacent to the GBR had visited the GBRWHA for recreation at least once, and 87% had visited in the previous 12 months. Many of these visits appeared to be to a mainland beach to walk, swim, and relax. However, 68% of people who told us about their recent trips had been beyond the mainland beach to islands, reefs, shoals, etc., to take part in activities such as fishing, snorkelling and diving. Other activities include boating, sailing, jet skiing, camping, kayaking, sight-seeing, photography, and wildlife viewing, to name a few. Recreational visitors are currently very satisfied with their use of the Marine Park.\ud \ud While most trips beyond the beach were made by ferry, about a third of these trips were accessed by residents' own or someone else's boat. While not everyone is using their vessel very frequently, vessel registration by coastal residents has increased substantially in recent years (Old Department of Transport, unpublished data, 2011).\ud \ud Given all of this activity, it is not surprising that recreation in the GBRWHA provides significant social and cultural benefits as well as many health and wellbeing benefits associated with the psychological interaction with nature (Synergies Economic Consulting, 2012). In economic terms, recreation (defined by Deloitte Access Economics as GBR catchment residents visiting an island, sailing, boating and fishing), contributed $126m in direct value or$243.9m value added to the Australian economy in 2011/12 (Deloitte Access Economics, 2013). This estimate did not include beach visits.\ud Importantly, recreation differs from tourism. The Great Barrier Reef Marine Park Authority define recreation as an independent visit for enjoyment that is not part of a commercial operation (GBRMPA, 2012). For the purposes of the SELTMP Surveys (outline following), any resident of the GBR catchment who visits the GBRWHA is included within recreation; while tourists are defined as those residing outside of the GBR catchment

Advances in monitoring the human dimension of natural resource systems: an example from the Great Barrier Reef

The aim of this paper is to demonstrate the feasibility and potential utility of decision-centric social-economic monitoring using data collected from Great Barrier Reef (Reef) region. The social and economic long term monitoring program (SELTMP) for the Reef is a novel attempt to monitor the social and economic dimensions of social-ecological change in a globally and nationally important region. It represents the current status and condition of the major user groups of the Reef with the potential to simultaneously consider trends, interconnections, conflicts, dependencies and vulnerabilities. Our approach was to combine a well-established conceptual framework with a strong governance structure and partnership arrangement that enabled the co-production of knowledge. The framework is a modification of the Millennium Ecosystem Assessment and it was used to guide indicator choice. Indicators were categorised as; (i) resource use and dependency, (ii) ecosystem benefits and well-being, and (iii) drivers of change. Data were collected through secondary datasets where existing and new datasets were created where not, using standard survey techniques. Here we present an overview of baseline results of new survey data from commercial-fishers (n =210), marine-based tourism operators (n =119), tourists (n =2877), local residents (n =3181), and other Australians (n =2002). The indicators chosen describe both social and economic components of the Reef system and represent an unprecedented insight into the ways in which people currently use and depend on the Reef, the benefits that they derive, and how they perceive, value and relate to the Reef and each other. However, the success of a program such as the SELTMP can only occur with well-translated cutting-edge data and knowledge that are collaboratively produced, adaptive, and directly feeds into current management processes. We discuss how data from the SELTMP have already been incorporated into Reef management decision-making through substantial inclusion in three key policy documents

The extra resource burden of in-hospital falls: A cost of falls study

Objective: To quantify the additional hospital length of stay (LOS) and costs associated with in-hospital falls and fall injuries in acute hospitals in Australia. Design, setting and participants: A multisite prospective cohort study conducted during 2011–2013 in the control wards of a falls prevention trial (6-PACK). The trial included all admissions to 12 acute medical and surgical wards of six Australian hospitals. In-hospital falls data were collected from medical record reviews, daily verbal reports by ward nurse unit managers, and hospital incident reporting and administrative databases. Clinical costing data were linked for three of the six participating hospitals to calculate patient-level costs. Outcome measures: Hospital LOS and costs associated with in-hospital falls and fall injuries for each patient admission. Results: We found that 966 of a total of 27 026 hospital admissions (3.6%) involved at least one fall, and 313 (1.2%) at least one fall injury, a total of 1330 falls and 418 fall injuries. After adjustment for age, sex, cognitive impairment, admission type, comorbidity and clustering by hospital, patients who had an in-hospital fall had a mean increase in LOS of 8 days (95% CI, 5.8–10.4; P < 0.001) compared with non-fallers, and incurred mean additional hospital costs of $6669 (95$3888–$9450; P < 0.001). Patients with a fall-related injury had a mean increase in LOS of 4 days (95$4727; 95% CI, −$568 to$10 022; P = 0.080). Conclusion: Patients who experience an in-hospital fall have significantly longer hospital stays and higher costs. Programs need to target the prevention of all falls, not just the reduction of fall-related injuries

Principle 4 – foster complex adaptive systems thinking

The social–ecological systems that provide ecosystem services to society can be viewed as complex adaptive systems (CAS), characterized by a high level of interconnectedness, potential for non-linear change, and inherent uncertainty and surprise. This chapter focuses on whether resilience of ecosystem services is enhanced by management based on what we refer to as ‘CAS thinking’, meaning a mental model for interpreting the world that recognizes these CAS properties. We present evidence that CAS thinking has contributed to change in management approaches in the Kruger National Park, Great Barrier Reef, Tisza river basin and Chile among other places. However, attempts to introduce CAS thinking may compromise resilience when complexity is not effectively communicated, when uncomfortable institutional change is required or when CAS thinking is not able to evolve with changing contexts or is not equitably shared. We suggest that CAS thinking can be fostered by the following: adopting a systems framework; tolerating and embracing uncertainty; investigating critical thresholds and non-linearities; acknowledging epistemological pluralism; matching institutions to CAS processes; and recognizing barriers to cognitive change. Key questions for future research on this principle relate to communicating CAS thinking, the role of power, the importance of an organizational level of CAS thinking, and institutional barriers