Expectations, Outcomes, and Medical Costs in Patients with Low Back Pain Referred to Physical Therapy

To describe treatment expectations among patients referred to physical therapy (PT) for low back pain (LBP) and to examine the relationship among expectations, outcomes, and medical care costs, 111 patients referred to PT for LBP within a managed care environment were studied in a prospective cohort study. Both χ2 and Student's t tests, as well as one-way analyses of variance, were used to assess bivariate differences in expectations, outcomes, and medical costs. A backward-stepping multivariate regression algorithm was used to assess the role of expectations, controlling for patient characteristics on (1) the change in patient-reported improvement between admission and discharge, and (2) annual medical expenditures. Patients' treatment expectations, pain levels, and functional levels were measured at the initial PT visit. Pain and functional status were also measured at PT discharge. Medical care expenditures were compiled for the 12 months following PT referral. Patients with the highest level of expectations reported the greatest level of improvement at PT discharge and had the lowest 12-month average medical care expenditures. Conversely, patients with the lowest level of expectations reported the lowest level of improvement and had the highest 12-month average medical expenditures. LBP patients' expectations about treatment were associated with outcomes, and additionally predictive of medical care expenditures. We found that among LBP patients referred to PT, patients with the highest expectation level at baseline reported the greatest improvement and the lowest medical care expenditures.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63291/1/10935070260474958.pd

Elucidating emergence and transmission of multidrug-resistant tuberculosis in treatment experienced patients by whole genome sequencing.

BACKGROUND: Understanding the emergence and spread of multidrug-resistant tuberculosis (MDR-TB) is crucial for its control. MDR-TB in previously treated patients is generally attributed to the selection of drug resistant mutants during inadequate therapy rather than transmission of a resistant strain. Traditional genotyping methods are not sufficient to distinguish strains in populations with a high burden of tuberculosis and it has previously been difficult to assess the degree of transmission in these settings. We have used whole genome analysis to investigate M. tuberculosis strains isolated from treatment experienced patients with MDR-TB in Uganda over a period of four years. METHODS AND FINDINGS: We used high throughput genome sequencing technology to investigate small polymorphisms and large deletions in 51 Mycobacterium tuberculosis samples from 41 treatment-experienced TB patients attending a TB referral and treatment clinic in Kampala. This was a convenience sample representing 69% of MDR-TB cases identified over the four year period. Low polymorphism was observed in longitudinal samples from individual patients (2-15 SNPs). Clusters of samples with less than 50 SNPs variation were examined. Three clusters comprising a total of 8 patients were found with almost identical genetic profiles, including mutations predictive for resistance to rifampicin and isoniazid, suggesting transmission of MDR-TB. Two patients with previous drug susceptible disease were found to have acquired MDR strains, one of which shared its genotype with an isolate from another patient in the cohort. CONCLUSIONS: Whole genome sequence analysis identified MDR-TB strains that were shared by more than one patient. The transmission of multidrug-resistant disease in this cohort of retreatment patients emphasises the importance of early detection and need for infection control. Consideration should be given to rapid testing for drug resistance in patients undergoing treatment to monitor the emergence of resistance and permit early intervention to avoid onward transmission

Ancient and Modern Geochemical Signatures in the 13,500-Year Sedimentary Record of Lake Cadagno

Although lake sediments are globally important organic carbon sinks and therefore important habitats for deep microbial life, the deep lacustrine biosphere has thus far been little studied compared to its marine counterpart. To investigate the impact of the underexplored deep lacustrine biosphere on the sediment geochemical environment and vice versa, we performed a comprehensive microbiological and geochemical characterization of a sedimentary sequence from Lake Cadagno covering its entire environmental history since formation following glacial retreat. We found that both geochemical gradients and microbial community shifts across the ∼13.5 kyr subsurface sedimentary record reflect redox changes in the lake, going from oxic to anoxic and sulfidic. Most microbial activity occurs within the top 20 cm of sediment, where millimolar sulfate concentrations diffusing in from the bottom water are almost completely consumed. In deeper sediment layers, organic carbon remineralization is much slower but microorganisms nonetheless subsist on fermentation, sulfur cycling, metal reduction, and methanogenesis. The most surprising finding was the presence of a deep, oxidizing groundwater source. This water source generates an inverse redox gradient at the bottom of the sedimentary sequence and could contribute to the remineralization of organic matter sequestered in the energy-limited deep subsurface

JET experience on managing radioactive waste and implications for ITER

The reduced radiotoxicity and half-life of radioactive waste arisings from nuclear fusion reactors as compared to current fission reactors is one of the key benefits of nuclear fusion. As a result of the research programme at the Joint European Torus (JET), significant experience on the management of radioactive waste has been gained which will be of benefit to ITER and the nuclear fusion community.The successful management of radioactive waste is dependent on accurate and efficient tracking and characterisation of waste streams. To accomplish this all items at JET which are removed from radiological areas are identified and pre-characterised, by recording the radiological history, before being removed from or moved between radiological areas. This system ensures a history of each item is available when it is finally consigned as radioactive waste and also allows detailed forecasting of future arisings. All radioactive waste generated as part of JET operations is transferred to dedicated, on-site, handling facilities for further sorting, sampling and final streaming for off-site disposal. Tritium extraction techniques including leaching, combustion and thermal treatment followed by liquid scintillation counting are used to determine tritium content.Recent changes to government legislation and Culham specific disposal permit conditions have allowed CCFE to adopt additional disposal routes for fusion wastes requiring new treatment and analysis techniques. Facilities currently under construction include a water de-tritiation facility and a materials de-tritiation facility, both of which are relevant for ITER. The procedures used to manage radioactive waste from generation to off-site disposal have been assessed for relevance to ITER and a number have been shown to be significant. The procedures and de-tritiation factors demonstrated by radioactive waste treatment plants currently under construction will be important to tritium recovery and waste minimisation in ITER and DEMO