Economic evaluation favours physiotherapy but not corticosteroid injection as a first-line intervention for chronic lateral epicondylalgia: evidence from a randomised clinical trial

Aim To determine the cost-effectiveness of corticosteroid injection, physiotherapy and a combination of these interventions, compared to a reference group receiving a blinded placebo injection

The Time to Act Is Now: Addressing the Challenges of Being a Student, Staff, or Faculty Member at DU While Also Being a Parent to Young Children

The growing number of undergraduate and graduate students who are simultaneously raising children while attending school requires the attention of institutions that want to support their students through the completion of their intended program. Compared to traditional students, these students have greater time and financial restraints, lower graduation rates, and require accommodation, support, and resources to help them maintain their academic standing. This issue is not isolated to just students however. Staff and faculty at academic institutions are also balancing their family and work responsibilities. With an increase in the number of households where one or two adults work full time, more institutional employees are having to negotiate issues of childcare, parental leave, and the ways in which their family responsibilities are perceived by colleagues and employers. In 2017, it was found that many DU community members were struggling with issues of childcare, a child friendly environment at work, and institutional policies related to childcare at the University. These findings led to a study, conducted by the Applied Anthropology class of 2018, aimed at identifying solutions and recommendations for the aforementioned challenges. The study was exploratory and utilized mixed qualitative data collection and analysis methods. The class conducted interviews, surveys, and archival research and used thematic analysis techniques to identify overarching themes that informed the findings and suggestions of this project. Through this research three major needs were identified: clear communication of policies, accommodations for students, and on-site day care. Respondents from this and previous studies at DU identified that classroom policies, policies regarding parental leave, available childcare, and Fisher were being communicated either ineffectively or inaccurately. This has led to confusion, frustration, feelings of job insecurity, and unmet expectations regarding what resources and support DU actually offers parents. There is also a lack of policies in place for student parents, which makes creating schedules and fulfilling academic requirements more challenging for these nontraditional students. The most significant issue identified however was the lack of childcare at DU and the desire for an on-site daycare center. Respondents explained that Denver has a limited number of available, convenient, and affordable daycare options, that Fisher is not meeting their needs, and that they would like to see a facility designed specifically for DU students, staff, and faculty. In response to these challenges, this study suggests the assemblage and dissemination of accurate and clearly communicated childcare related policies, the creation of policies for student parents, and an on-site daycare facility for the DU community. Research and efforts to understand and alleviate these challenges have occurred at DU since the 1970s, and many of the identified needs and desired solutions have not changed over the past fifty years. However, because previous efforts have been powered by those in need of services, the momentum behind each effort has inevitably dissolved. A way to accomplish and sustain these suggestions and actively work towards making DU a more child and family friendly campus is by creating a permanent employee position at DU to handle these issues. This would help centralize information and policies, assist with their clear communication, and focus consistent and sustainable efforts towards helping DU students, staff, and faculty balance their work and family life

Reliability and validity of two fitness tracker devices in the laboratory and home environment for older community-dwelling people

© 2018 The Author(s). Background: Two-thirds of older Australians are sedentary. Fitness trackers have been popular with younger people and may encourage older adults to become more active. Older adults may have different gait patterns and as such it is important to establish whether fitness trackers are valid and reliable for this population. The aim of the study was to test the reliability and validity of two fitness trackers (Fitbit Flex and ChargeHR) by step count when worn by older adults. Reliability and validity were tested in two conditions: 1) in the laboratory using a two-minute-walk-test (2MWT) and 2) in a free-living environment. Methods: Two 2MWTs were completed while wearing the fitness trackers. Participants were videoed during each test. Participants were then given one fitness tracker and a GENEactiv accelerometer to wear at home for 14-days. Results: Thirty-one participants completed two 2MWTs and 30 completed the free-living procedure. Intra Class Correlation's of the fitness trackers with direct observation of steps (criterion validity) was high (ICC:0.86,95%CI:0.76,0.93). However, both fitness trackers underestimated steps. Excellent test-retest reliability (ICC = 0.75) was found between the two 2MWTs for each device, particularly the ChargeHR devices. Good strength of agreement was found for total distance and steps (fitness tracker) and moderate-to-vigorous physical activity (GENEactiv) for the free-living environment (Spearman Rho's 0.78 and 0.74 respectively). Conclusion: Reliability and validity of the Flex and ChargeHR when worn by older adults is good, however both devices underestimated step count within the laboratory environment. These fitness trackers appear suitable for consumer use and promoting physical activity for older adults

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Optimising corticosteroid injection for lateral epicondylalgia with the addition of physiotherapy: A protocol for a randomised control trial with placebo comparison

<p>Abstract</p> <p>Background</p> <p>Corticosteroid injection and physiotherapy are two commonly prescribed interventions for management of lateral epicondylalgia. Corticosteroid injections are the most clinically efficacious in the short term but are associated with high recurrence rates and delayed recovery, while physiotherapy is similar to injections at 6 weeks but with significantly lower recurrence rates. Whilst practitioners frequently recommend combining physiotherapy and injection to overcome harmful effects and improve outcomes, study of the benefits of this combination of treatments is lacking. Clinicians are also faced with the paradox that the powerful anti-inflammatory corticosteroid injections work well, albeit in the short term, for a non-inflammatory condition like lateral epicondylalgia. Surprisingly, these injections have not been rigorously tested against placebo injections. This study primarily addresses both of these issues.</p> <p>Methods</p> <p>A randomised placebo-controlled clinical trial with a 2 × 2 factorial design will evaluate the clinical efficacy, cost-effectiveness and recurrence rates of adding physiotherapy to an injection. In addition, the clinical efficacy and adverse effects of corticosteroid injection beyond that of a placebo saline injection will be studied. 132 participants with a diagnosis of lateral epicondylalgia will be randomly assigned by concealed allocation to one of four treatment groups – corticosteroid injection, saline injection, corticosteroid injection with physiotherapy or saline injection with physiotherapy. Physiotherapy will comprise 8 sessions of elbow manipulation and exercise over an 8 week period. Blinded follow-up assessments will be conducted at baseline, 4, 8, 12, 26 and 52 weeks after randomisation. The primary outcome will be a participant rating of global improvement, from which measures of success and recurrence will be derived. Analyses will be conducted on an intention-to-treat basis using linear mixed and logistic regression models. Healthcare costs will be collected from a societal perspective, and along with willingness-to-pay and quality of life data will facilitate cost-effectiveness and cost-benefit analyses.</p> <p>Conclusion</p> <p>This trial will utilise high quality trial methodologies in accordance with CONSORT guidelines. Findings from this study will assist in the development of evidence based practice recommendations and potentially the optimisation of resource allocation for rehabilitating lateral epicondylalgia.</p> <p>Trial registration</p> <p>Australian New Zealand Clinical Trials Register ACTRN12609000051246</p

Vailulu’u Seamount, Samoa: Life and death on an active submarine volcano

Submersible exploration of the Samoan hotspot revealed a new, 300-m-tall, volcanic cone, named Nafanua, in the summit crater of Vailulu’u seamount. Nafanua grew from the 1,000-m-deep crater floor in <4 years and could reach the sea surface within decades. Vents fill Vailulu’u crater with a thick suspension of particulates and apparently toxic fluids that mix with seawater entering from the crater breaches. Low-temperature vents form Fe oxide chimneys in many locations and up to 1-m-thick layers of hydrothermal Fe floc on Nafanua. High-temperature (81°C) hydrothermal vents in the northern moat (945-m water depth) produce acidic fluids (pH 2.7) with rising droplets of (probably) liquid CO₂. The Nafanua summit vent area is inhabited by a thriving population of eels (Dysommina rugosa) that feed on midwater shrimp probably concentrated by anticyclonic currents at the volcano summit and rim. The moat and crater floor around the new volcano are littered with dead metazoans that apparently died from exposure to hydrothermal emissions. Acid-tolerant polychaetes (Polynoidae) live in this environment, apparently feeding on bacteria from decaying fish carcasses. Vailulu’u is an unpredictable and very active underwater volcano presenting a potential long-term volcanic hazard. Although eels thrive in hydrothermal vents at the summit of Nafanua, venting elsewhere in the crater causes mass mortality. Paradoxically, the same anticyclonic currents that deliver food to the eels may also concentrate a wide variety of nektonic animals in a death trap of toxic hydrothermal fluids.KEYWORDS: habitats, hydrothermal, eels, currents, ventsThis is the publisher’s final pdf. The published article is copyrighted by the National Academy of Sciences of the United States of America and can be found at: http://www.pnas.org

Evolving concepts on the age-related changes in “muscle quality”

The deterioration of skeletal muscle with advancing age has long been anecdotally recognized and has been of scientific interest for more than 150 years. Over the past several decades, the scientific and medical communities have recognized that skeletal muscle dysfunction (e.g., muscle weakness, poor muscle coordination, etc.) is a debilitating and life-threatening condition in the elderly. For example, the age-associated loss of muscle strength is highly associated with both mortality and physical disability. It is well-accepted that voluntary muscle force production is not solely dependent upon muscle size, but rather results from a combination of neurologic and skeletal muscle factors, and that biologic properties of both of these systems are altered with aging. Accordingly, numerous scientists and clinicians have used the term “muscle quality” to describe the relationship between voluntary muscle strength and muscle size. In this review article, we discuss the age-associated changes in the neuromuscular system—starting at the level of the brain and proceeding down to the subcellular level of individual muscle fibers—that are potentially influential in the etiology of dynapenia (age-related loss of muscle strength and power)

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability