Variations in the management of acute illness in children with congenital adrenal hyperplasia: An audit of three paediatric hospitals

Objective: Episodes of acute adrenal insufficiency (AI)/adrenal crises (AC) are a serious consequence of congenital adrenal hyperplasia (CAH). This study aimed to assess morbidity from acute illness in CAH and identify factors associated with use of IV hydrocortisone, admission and diagnosis of an AC. Method: An audit of acute illness presentations among children with CAH to paediatric hospitals in New South Wales, Australia, between 2000 and 2015. Results: There were 321 acute presentations among 74 children with CAH. Two thirds (66.7%, n=214) of these resulted in admission and 49.2% (n=158) of the patients received intravenous (IV) hydrocortisone. An AC was diagnosed in (9.0%). Prior to presentation, 64.2% (n=206) had used oral stress dosing and 22.1% (n=71) had been given intramuscular (IM) hydrocortisone. Vomiting was recorded in 61.1% (n=196), 32.7% (n=64) of whom had used IM hydrocortisone. Admission, AC diagnosis, and use of stress dosing varied significantly between hospitals. IM use varied from 7.0% in one metropolitan hospital to 45.8% in the regional hospital. Children aged up to 12 months had the lowest levels of stress dosing and IV hydrocortisone administration. A higher number of prior hospital attendances for acute illness was associated with increased use of IM hydrocortisone. Conclusion: Pre-hospital and in-hospital management of children with CAH can vary between health services. Children under 12 months have lower levels of stress dosing prior to hospital than other age groups. Experience with acute episodes improves self-management of CAH in the context of acute illness in educated patient populations

Regional differences in business start-up rates in Australia : implications for future research and public policy

The Global Entrepreneurship Monitor (GEM) project in Australia provided both data and theoretical framework for this investigation of regional differences in entrepreneurial activity within Australia and the factors that might underlie such differences.This study found that entrepreneurial activity as measured by participation in business start-ups varied significantly between 11 defined regions of Australia. Factors found to be associated with high start-up activity were personal acquaintance with someone who had recently started a business (strong and statistically significant) and the perception of good opportunities for starting a business locally (indicative only). Participation rate by age range across region varied widely. Sample size precluded more in-depth analysis.The study indicates a need for a research program designed to produce data and analysis that might be constructively shared by those who wish to foster entrepreneurship in Australia.<br /

Adrenal crises: perspectives and research directions

Adrenal crises (AC) are life-threatening complications of adrenal insufficiency (AI). These events have an estimated incidence of between 5 and 10 ACs/100 patient years (PY) and are responsible for some of the increased morbidity and excess mortality experienced by patients with AI. Treatment involves urgent administration of IV/IM hydrocortisone and IV fluids. Patient education regarding preventive measures, such as increasing the dose of replacement therapy (“stress dosing”) when sick, using parenteral hydrocortisone as necessary and accessing medical assistance promptly, is still considered the best approach to averting the onset of an AC at times of physiological stress, most commonly an infection. However, recent evidence has demonstrated that patient education does not prevent many AC events and the reasons for this are not fully understood. Furthermore, there is no widely accepted definition of AC. Without a validated AC definition it is difficult to interpret variations in the incidence of AC and determine the effectiveness of preventive measures. This article aims to review the clinical aspects of AC events; to explore the epidemiology; and to offer a definition for an AC and to offer a perspective on future directions for research into AC prevention

Adrenal Crisis

Glucocorticoid replacement therapy, available since the 1950s, has prolonged the survival of patients with adrenal insufficiency. However, adrenal crises, which are life-threatening medical emergencies, still develop in many affected patients. Adrenal crisis appears to be increasing in frequency, despite the availability of effective preventive strategies. This review examines the definitions, pathophysiology, epidemiology, and treatment of adrenal crises

A rigorous statistical framework for spatio-temporal pollution prediction and estimation of its long-term impact on health

In the United Kingdom, air pollution is linked to around 40000 premature deaths each year, but estimating its health effects is challenging in a spatio-temporal study. The challenges include spatial misalignment between the pollution and disease data; uncertainty in the estimated pollution surface; and complex residual spatio-temporal autocorrelation in the disease data. This article develops a two-stage model that addresses these issues. The first stage is a spatio-temporal fusion model linking modeled and measured pollution data, while the second stage links these predictions to the disease data. The methodology is motivated by a new five-year study investigating the effects of multiple pollutants on respiratory hospitalizations in England between 2007 and 2011, using pollution and disease data relating to local and unitary authorities on a monthly time scale

Barthes and mouvance

In this article I consider, through the example of mouvance, both Roland Barthes’s engagement with medieval culture and the contribution that medievalists can make to Barthes studies. The term mouvance was proposed by Paul Zumthor to account for textual instability in a pre-print age of often anonymous texts. Barthes uses Zumthor’s term twice, in a lecture from Comment vivre ensemble (How to Live Together) given on February 2, 1977. Focusing on these occurrences, I show how Barthesian mouvance shares with Zumthor’s definition an emphasis on instability, while also acting as a gloss on one of Barthes’s own terms: idiorrythmie (idiorrhythmy). Barthes’s use of the term mouvance is one striking example of his own engagement with contemporary medieval scholarship. Yet I also argue that mouvance, for Barthes, is a matter of form as much as content. Accordingly, I suggest that medievalists, and the notion of mouvance, can help respond to editorial challenges surrounding Barthes’s work, especially in the case of posthumously published texts with oral origins that exist in several different versions

Virtual knot homology and concordance

We construct and investigate the properties of a new extension of Khovanov homology to virtual links, known as doubled Khovanov homology. We describe a perturbation of doubled Khovanov homology, analogous to Lee homology, and produce a doubled Rasmussen invariant; we use it obtain a number of results regarding virtual knot and link concordance. For instance, we demonstrate that the doubled Rasmussen invariant can obstruct the existance of a concordance between a virtual knot and a classical knot (i.e. a knot in the three-sphere ). Kawamura and independently Lobb defned easily-computable bounds on the Rasmussen invariant of classical knots; we generalise these bounds to both the doubled Rasmussen invariant and to a distinct concordance invariant known as the virtual Rasmussen invariant, due to Dye, Kaestner, and Kaufman. We use the new bounds to compute or estimate the slice genus of all virtual knots of 4 classical crossings or less. Finally, we use doubled Khovanov homology as a framework to construct a homology theory of links in thickened surfaces (objects closely related to, but distinct from, virtual links). This homology theory of links in thickened surfaces feeds back to the study of virtual knot concordance, as we are able to use it to investigate a refnement of the notion of sliceness of virtual knots

Soldiers and tribesmen : the Roman army and tribal society in late imperial Africa

PhD ThesisThis thesis is concerned with two groups which guarded North Africa's frontiers during the Later Roman Empire, firstly the regular army, and secondly, the gentiles, or tribesmen. The subject is introduced in Chapter I, and the academic debate on this subject summarised . In Chapter II, the continued existence of a garrison of regular soldiers, in the fourth century sector commands (limites), is demonstrated. The present consensus regarding the manning of the limites would assign a much larger role to some kind of tribal militia. The actual role of the Moorish and Libyan tribes in frontier defence is analysed in the next chapter. They are seen to be essentially an adjunct to the limitanei rather than a replacement for them. The long involvement of African tribesmen in the military service of Rome is traced in Chapter IV. The field army is examined in Chapter V. A pattern of steady growth is discerned, gradually supplanting the limitanei. In Chapters VI and VIr attention is focussed once more on the frontier troops. The location of the limites listed in the Notitia Dignitatum, and their internal organisation are analysed in Chapter VI. Chapter VIr studies the duties of the limitanei. The essentially policing nature of their work is stressed. Finally, two cases of extensive tribal integration are studied and some comments made on the relations between the imperial administration and the tribal aristocracy. In conclusion, it is noted that soldiers and tribesmen did not occupy two separate worlds, a Romanised Africa and an Afrique oubliee. On the contrary they were often one and the same, as soldiers were probably recruited from amongst tribesmen, and formed part of a single frontier society.British Academy Grant. Tessa and Mortimer Wheeler Fund