A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

PURPOSE: To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns. METHODS: We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and$100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis. RESULTS: Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness. CONCLUSIONS: The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision analysis II

Mid-infrared luminous quasars in the GOODS–Herschel fields: a large population of heavily obscured, Compton-thick quasars at z ≈ 2

We present the infrared (IR) and X-ray properties of a sample of 33 mid-IR luminous quasars (νL6 μm ≥ 6 × 1044 erg s−1) at redshift z ≈ 1–3, identified through detailed spectral energy distribution analyses of distant star-forming galaxies, using the deepest IR data from Spitzer and Herschel in the GOODS–Herschel fields. The aim is to constrain the fraction of obscured, and Compton-thick (CT, NH > 1.5 × 1024 cm−2) quasars at the peak era of nuclear and star formation activities. Despite being very bright in the mid-IR band, ≈30 per cent of these quasars are not detected in the extremely deep 2 and 4 Ms Chandra X-ray data available in these fields. X-ray spectral analysis of the detected sources reveals that the majority (≈67 per cent) are obscured by column densities NH > 1022 cm−2; this fraction reaches ≈80 per cent when including the X-ray-undetected sources (9 out of 33), which are likely to be the most heavily obscured, CT quasars. We constrain the fraction of CT quasars in our sample to be ≈24–48 per cent, and their space density to be Φ = (6.7 ± 2.2) × 10−6 Mpc−3. From the investigation of the quasar host galaxies in terms of star formation rates (SFRs) and morphological distortions, as a sign of galaxy mergers/interactions, we do not find any direct relation between SFRs and quasar luminosity or X-ray obscuration. On the other hand, there is tentative evidence that the most heavily obscured quasars have, on average, more disturbed morphologies than the unobscured/moderately obscured quasar hosts, which preferentially live in undisturbed systems. However, the fraction of quasars with disturbed morphology amongst the whole sample is ≈40 per cent, suggesting that galaxy mergers are not the main fuelling mechanism of quasars at z ≈ 2

Mid-infrared Luminous Quasars in the GOODS–\u3cem\u3eHerschel\u3c/em\u3e Fields: A Large Population of Heavily Obscured, Compton-Thick Quasars at \u3cem\u3ez\u3c/em\u3e ≈ 2

We present the infrared (IR) and X-ray properties of a sample of 33 mid-IR luminous quasars (νL6 μm ≥ 6 × 1044 erg s−1) at redshift z ≈ 1–3, identified through detailed spectral energy distribution analyses of distant star-forming galaxies, using the deepest IR data from Spitzer and Herschel in the GOODS–Herschel fields. The aim is to constrain the fraction of obscured, and Compton-thick (CT, NH \u3e 1.5 × 1024 cm−2) quasars at the peak era of nuclear and star formation activities. Despite being very bright in the mid-IR band, ≈30 per cent of these quasars are not detected in the extremely deep 2 and 4 Ms Chandra X-ray data available in these fields. X-ray spectral analysis of the detected sources reveals that the majority (≈67 per cent) are obscured by column densities NH \u3e 1022 cm−2; this fraction reaches ≈80 per cent when including the X-ray-undetected sources (9 out of 33), which are likely to be the most heavily obscured, CT quasars. We constrain the fraction of CT quasars in our sample to be ≈24–48 per cent, and their space density to be Φ = (6.7 ± 2.2) × 10−6 Mpc−3. From the investigation of the quasar host galaxies in terms of star formation rates (SFRs) and morphological distortions, as a sign of galaxy mergers/interactions, we do not find any direct relation between SFRs and quasar luminosity or X-ray obscuration. On the other hand, there is tentative evidence that the most heavily obscured quasars have, on average, more disturbed morphologies than the unobscured/moderately obscured quasar hosts, which preferentially live in undisturbed systems. However, the fraction of quasars with disturbed morphology amongst the whole sample is ≈40 per cent, suggesting that galaxy mergers are not the main fuelling mechanism of quasars at z ≈ 2

"Engaging with birth stories in pregnancy: a hermeneutic phenomenological study of women's experiences across two generations"

BACKGROUND: The birth story has been widely understood as a crucial source of knowledge about childbirth. What has not been reported is the effect that birth stories may have on primigravid women's understandings of birth. Findings are presented from a qualitative study exploring how two generations of women came to understand birth in the milieu of other's stories. The prior assumption was that birth stories must surely have a positive or negative influence on listeners, steering them towards either medical or midwifery-led models of care. METHODS: A Heideggerian hermeneutic phenomenological approach was used. Twenty UK participants were purposively selected and interviewed. Findings from the initial sample of 10 women who were pregnant in 2012 indicated that virtual media was a primary source of birth stories. This led to recruitment of a second sample of 10 women who gave birth in the 1970s-1980s, to determine whether they were more able to translate information into knowledge via stories told through personal contact and not through virtual technologies RESULTS: Findings revealed the experience of 'being-in-the-world' of birth and of stories in that world. From a Heideggerian perspective, the birth story was constructed through 'idle talk' (the taken for granted assumptions of things, which come into being through language). Both oral stories and those told through technology were described as the 'modern birth story'. The first theme 'Stories are difficult like that', examines the birth story as problematic and considers how stories shape meaning. The second 'It's a generational thing', considers how women from two generations came to understand what their experience might be. The third 'Birth in the twilight of certainty,' examines women's experience of Being in a system of birth as constructed, portrayed and sustained in the stories being shared. CONCLUSIONS: The women pregnant in 2012 framed their expectations in the language of choice, whilst the women who birthed in the 1970s-1980s framed their experience in the language of safety. For both, however, the world of birth was the same; saturated with, and only legitimised by the birth of a healthy baby. Rather than creating meaningful understanding, the 'idle talk' of birth made both cohorts fearful of leaving the relative comfort of the 'system', and of claiming an alternative birth

Self-Similarity in General Relativity \endtitle

The different kinds of self-similarity in general relativity are discussed, with special emphasis on similarity of the ``first'' kind, corresponding to spacetimes admitting a homothetic vector. We then survey the various classes of self-similar solutions to Einstein's field equations and the different mathematical approaches used in studying them. We focus mainly on spatially homogenous and spherically symmetric self-similar solutions, emphasizing their possible roles as asymptotic states for more general models. Perfect fluid spherically symmetric similarity solutions have recently been completely classified, and we discuss various astrophysical and cosmological applications of such solutions. Finally we consider more general types of self-similar models.Comment: TeX document, 53 page

Functional Connectivity in Tactile Object Discrimination—A Principal Component Analysis of an Event Related fMRI-Study

BACKGROUND: Tactile object discrimination is an essential human skill that relies on functional connectivity between the neural substrates of motor, somatosensory and supramodal areas. From a theoretical point of view, such distributed networks elude categorical analysis because subtraction methods are univariate. Thus, the aim of this study was to identify the neural networks involved in somatosensory object discrimination using a voxel-based principal component analysis (PCA) of event-related functional magnetic resonance images. METHODOLOGY/PRINCIPAL FINDINGS: Seven healthy, right-handed subjects aged between 22 and 44 years were required to discriminate with their dominant hand the length differences between otherwise identical parallelepipeds in a two-alternative forced-choice paradigm. Of the 34 principal components retained for analysis according to the 'bootstrapped' Kaiser-Guttman criterion, t-tests applied to the subject-condition expression coefficients showed significant mean differences between the object presentation and inter-stimulus phases in PC 1, 3, 26 and 32. Specifically, PC 1 reflected object exploration or manipulation, PC 3 somatosensory and short-term memory processes. PC 26 evinced the perception that certain parallelepipeds could not be distinguished, while PC 32 emerged in those choices when they could be. Among the cerebral regions evident in the PCs are the left posterior parietal lobe and premotor cortex in PC 1, the left superior parietal lobule (SPL) and the right cuneus in PC 3, the medial frontal and orbitofrontal cortex bilaterally in PC 26, and the right intraparietal sulcus, anterior SPL and dorsolateral prefrontal cortex in PC 32. CONCLUSIONS/SIGNIFICANCE: The analysis provides evidence for the concerted action of large-scale cortico-subcortical networks mediating tactile object discrimination. Parallel to activity in nodes processing object-related impulses we found activity in key cerebral regions responsible for subjective assessment and validation

CANDELS : constraining the AGN-merger connection with host morphologies at z ~ 2

Using Hubble Space Telescope/WFC3 imaging taken as part of the Cosmic Assembly Near-infrared Deep Extragalactic Legacy Survey, we examine the role that major galaxy mergers play in triggering active galactic nucleus (AGN) activity at z ~ 2. Our sample consists of 72 moderate-luminosity (L X ~ 1042-44 erg s-1) AGNs at 1.5 < z < 2.5 that are selected using the 4 Ms Chandra observations in the Chandra Deep Field South, the deepest X-ray observations to date. Employing visual classifications, we have analyzed the rest-frame optical morphologies of the AGN host galaxies and compared them to a mass-matched control sample of 216 non-active galaxies at the same redshift. We find that most of the AGNs reside in disk galaxies (51.4+5.8 - 5.9%), while a smaller percentage are found in spheroids (27.8+5.8 - 4.6%). Roughly 16.7+5.3 - 3.5% of the AGN hosts have highly disturbed morphologies and appear to be involved in a major merger or interaction, while most of the hosts (55.6+5.6 - 5.9%) appear relatively relaxed and undisturbed. These fractions are statistically consistent with the fraction of control galaxies that show similar morphological disturbances. These results suggest that the hosts of moderate-luminosity AGNs are no more likely to be involved in an ongoing merger or interaction relative to non-active galaxies of similar mass at z ~ 2. The high disk fraction observed among the AGN hosts also appears to be at odds with predictions that merger-driven accretion should be the dominant AGN fueling mode at z ~ 2, even at moderate X-ray luminosities. Although we cannot rule out that minor mergers are responsible for triggering these systems, the presence of a large population of relatively undisturbed disk-like hosts suggests that the stochastic accretion of gas plays a greater role in fueling AGN activity at z ~ 2 than previously thought

AChBP-targeted α-conotoxin correlates distinct binding orientations with nAChR subtype selectivity

Neuronal nAChRs are a diverse family of pentameric ion channels with wide distribution throughout cells of the nervous and immune systems. However, the role of specific subtypes in normal and pathological states remains poorly understood due to the lack of selective probes. Here, we used a binding assay based on acetylcholine-binding protein (AChBP), a homolog of the nicotinic acetylcholine ligand-binding domain, to discover a novel α-conotoxin (α-TxIA) in the venom of Conus textile. α-TxIA bound with high affinity to AChBPs from different species and selectively targeted the α3β2 nAChR subtype. A co-crystal structure of Ac-AChBP with the enhanced potency analog TxIA(A10L), revealed a 20° backbone tilt compared to other AChBP–conotoxin complexes. This reorientation was coordinated by a key salt bridge formed between Arg5 (TxIA) and Asp195 (Ac-AChBP). Mutagenesis studies, biochemical assays and electrophysiological recordings directly correlated the interactions observed in the co-crystal structure to binding affinity at AChBP and different nAChR subtypes. Together, these results establish a new pharmacophore for the design of novel subtype-selective ligands with therapeutic potential in nAChR-related diseases

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London