Adherence to clinical practice guidelines among three primary contact professions: A best evidence synthesis of the literature for the management of acute and subacute low back pain

Aim: To determine adherence to clinical practice guidelines in the medical, physiotherapy and chiropractic professions for acute and subacute mechanical low back pain through best-evidence synthesis of the healthcare literature. Methods: A structured best-evidence synthesis of the relevant literature through a literature search of relevant databases for peer-reviewed papers on adherence to clinical practice guidelines from 1995 to 2013. Inclusion of papers was based on selection criteria and appraisal by two reviewers who independently applied a modified Downs & Black appraisal tool. The appraised papers were summarized in tabular form and analysed by the authors. Results: The literature search retrieved 23 potentially relevant papers that were evaluated for methodological quality, of which 11 studies met the inclusion criteria. The main finding was that no profession in the study consistently attained an overall high concordance rating. Of the three professions examined, 73% of chiropractors adhered to current clinical practice guidelines, followed by physiotherapists (62%) and then medical practitioners (52%). Conclusions: This review showed that quality papers in this area of research are very limited. Notwithstanding, chiropractors appear to adhere to clinical practice guidelines more so than physiotherapists and medical practitioners, although there is scope for improvement across all three professions

Subclinical Thyroid Dysfunction and Fracture Risk: A Meta-analysis

IMPORTANCE Associations between subclinical thyroid dysfunction and fractures are unclear and clinical trials are lacking. OBJECTIVE To assess the association of subclinical thyroid dysfunction with hip, nonspine, spine, or any fractures. DATA SOURCES AND STUDY SELECTION The databases of MEDLINE and EMBASE (inception to March 26, 2015) were searched without language restrictions for prospective cohort studies with thyroid function data and subsequent fractures. DATA EXTRACTION Individual participant data were obtained from 13 prospective cohorts in the United States, Europe, Australia, and Japan. Levels of thyroid function were defined as euthyroidism (thyroid-stimulating hormone [TSH], 0.45-4.49 mIU/L), subclinical hyperthyroidism (TSH <0.45 mIU/L), and subclinical hypothyroidism (TSH ≥4.50-19.99 mIU/L) with normal thyroxine concentrations. MAIN OUTCOME AND MEASURES The primary outcome was hip fracture. Any fractures, nonspine fractures, and clinical spine fractures were secondary outcomes. RESULTS Among 70,298 participants, 4092 (5.8%) had subclinical hypothyroidism and 2219 (3.2%) had subclinical hyperthyroidism. During 762,401 person-years of follow-up, hip fracture occurred in 2975 participants (4.6%; 12 studies), any fracture in 2528 participants (9.0%; 8 studies), nonspine fracture in 2018 participants (8.4%; 8 studies), and spine fracture in 296 participants (1.3%; 6 studies). In age- and sex-adjusted analyses, the hazard ratio (HR) for subclinical hyperthyroidism vs euthyroidism was 1.36 for hip fracture (95% CI, 1.13-1.64; 146 events in 2082 participants vs 2534 in 56,471); for any fracture, HR was 1.28 (95% CI, 1.06-1.53; 121 events in 888 participants vs 2203 in 25,901); for nonspine fracture, HR was 1.16 (95% CI, 0.95-1.41; 107 events in 946 participants vs 1745 in 21,722); and for spine fracture, HR was 1.51 (95% CI, 0.93-2.45; 17 events in 732 participants vs 255 in 20,328). Lower TSH was associated with higher fracture rates: for TSH of less than 0.10 mIU/L, HR was 1.61 for hip fracture (95% CI, 1.21-2.15; 47 events in 510 participants); for any fracture, HR was 1.98 (95% CI, 1.41-2.78; 44 events in 212 participants); for nonspine fracture, HR was 1.61 (95% CI, 0.96-2.71; 32 events in 185 participants); and for spine fracture, HR was 3.57 (95% CI, 1.88-6.78; 8 events in 162 participants). Risks were similar after adjustment for other fracture risk factors. Endogenous subclinical hyperthyroidism (excluding thyroid medication users) was associated with HRs of 1.52 (95% CI, 1.19-1.93) for hip fracture, 1.42 (95% CI, 1.16-1.74) for any fracture, and 1.74 (95% CI, 1.01-2.99) for spine fracture. No association was found between subclinical hypothyroidism and fracture risk. CONCLUSIONS AND RELEVANCE Subclinical hyperthyroidism was associated with an increased risk of hip and other fractures, particularly among those with TSH levels of less than 0.10 mIU/L and those with endogenous subclinical hyperthyroidism. Further study is needed to determine whether treating subclinical hyperthyroidism can prevent fractures

Características químicas de um latossolo adubado com uréia e cloreto de potássio em ambiente protegido

A produção de vegetais mais sadios e de boa qualidade e o fornecimento contínuo no mercado são fatores que têm determinado a adoção do sistema de cultivo protegido por um número maior de produtores. Porém, devido ao pouco conhecimento sobre o manejo do solo nessas condições, tem-se aplicado altas doses de fertilizantes, ocasionando problemas de salinidade e desequilíbrio nutricional. O objetivo desse trabalho foi avaliar os efeitos da aplicação da uréia e do cloreto de potássio nas características químicas de um LATOSSOLO VERMELHO Destrófico, principalmente nos índices de acidez e saturação em potássio. O N e o K foram aplicados em cobertura, nas doses equivalentes de 13,3 e 39,9 g m-2 de N e 5,5 e 16,6 g m-2 de K, em esquema fatorial (2x2+1), com tratamento adicional, sem a aplicação dos nutrientes. Cultivou-se pimentão, cultivar Mayata, em condições de ambiente protegido, durante 34 semanas. Após o pegamento das mudas, foi aplicado 1/6 dos nutrientes a cada dez dias. Ao final do ciclo, as formas de N nítrico e N amoniacal representaram melhor as doses do nutriente aplicados ao solo e não houve acidificação. As raízes tiveram significativo crescimento após a aplicação de N, enquanto que o aumento da dose de K, aplicado como KCl, prejudicou o crescimento radicular, provavelmente associado à alta concentração de K no solo e possíveis efeitos salinos, correspondendo a mais de 5,0 mmol c dm-3 e mais que 5,3% de saturação do K no complexo de troca, na camada superficial do solo

Performance of a localized tree splitting criterion in tree averaging

This paper explores the performance of the local splitting criterion devised by Bremner & Taplin for classification and regression trees when multiple trees are averaged to improve performance. The criterion is compared with the deviance used by Clark & Pregibon's method, which is a global splitting criterion typically used to grow trees. The paper considers multiple trees generated by randomly selecting splits with probability proportional to the likelihood for the split, and by bagging where bootstrap samples from the data are used to grow trees. The superiority of the localized splitting criterion often persists when multiple trees are grown and averaged for six datasets. Tree averaging is known to be advantageous when the trees being averaged produce different predictions, and this can be achieved by choosing splits where the splitting criterion is locally optimal. The paper shows that use of locally optimal splits gives promising results in conjunction with both local and global splitting criteria, and with and without random selection of splits. The paper also extends the local splitting criterion to accommodate categorical predictors

Performance of localized regression tree splitting criteria on data with discontinuities

Properties of the localized regression tree splitting criterion, described in Bremner & Taplin (2002) and referred to as the BT method, are explored in this paper and compared to those of Clark & Pregibon's (1992) criterion (the CP method). These properties indicate why the BT method can result in superior trees. This paper shows that the BT method exhibits a weak bias towards edge splits, and the CP method exhibits a strong bias towards central splits in the presence of main effects. A third criterion, called the SM method, that exhibits no bias towards a particular split position is introduced. The SM method is a modification of the BT method that uses more symmetric local means. The BT and SM methods are more likely to split at a discontinuity than the CP method because of their relatively low bias towards particular split positions. The paper shows that the BT and SM methods can be used to discover discontinuities in the data, and that they offer a way of producing a variety of different trees for examination or for tree averaging methods

Modified classification and regression tree splitting criteria for data with interactions

This paper proposes modified splitting criteria for classification and regression trees by modifying the definition of the deviance. The modified deviance is based on local averaging instead of global averaging and is more successful at modelling data with interactions. The paper shows that the modified criteria result in much simpler trees for pure interaction data (no main effects) and can produce trees with fewer errors and lower residual mean deviances than those produced by Clark & Pregibon’s (1992) method when applied to real datasets with strong interaction effects

Hunger in the UK classroom

This chapter starts by presenting a historical account of school food policy in the United Kingdom, including the introduction of free school meals, nutritional policies, and school food standards. Following this, the current research literature on school meals in the United Kingdom is discussed in terms of diet and nutrition, body weight, mental health and wellbeing, educational attainment, and behaviour. Next, this chapter presents research findings relating to school breakfast clubs and cognition, educational attainment, diet and nutrition, and behaviour. This chapter concludes by presenting policy recommendations for how school programmes can enhance the health, wellbeing, and educational attainment of children across the world