Arthroscopic repair of inferior glenoid labrum tears (Down Under lesions) produces similar outcomes to other glenoid tears.

PURPOSE: Inferior glenoid labral tears are an uncommon but distinct shoulder injury. Only a small number of studies have reported outcomes following arthroscopic repair. The aim of the current study was to report minimum 2-year outcomes following inferior labral repair and to compare outcomes and risk factors associated with the injury to non-inferior labral tears. Whether preoperative MRI or MRA identified inferior labral tears was also assessed. METHODS: A prospective study of 162 consecutive patients undergoing arthroscopic glenoid labral repair, excluding isolated superior labral tears, was conducted. Of the 130 patients available for follow-up, 18 (13.7%) had an inferior labral tear ("Down Under lesion"), the remainder had anterior, posterior or mixed anterior/posterior lesions that did not include the inferior pole. Mean follow-up time for the Down Under group was 44 months (SD 10, range 27-57), and 30 months (SD 14, range 4-60) for the non-Down Under group. Postoperative outcomes included the Oxford Shoulder Instability Score and recurrent instability. Associations between Down Under lesions and injury mechanism, instability at presentation, recurrent instability and family history were assessed with multivariable logistic regression. Preoperative MRI or MRA reports by radiologists were examined to determine if Down Under lesions were identified. RESULTS: Oxford Shoulder Instability Scores indicated that most patients in both groups had little pain or shoulder problems postoperatively (average Oxford Score 41; 48 = no symptoms). Oxford Scores were not significantly different between the Down Under and non-Down Under groups. Four patients (22.2%) in the Down Under group had recurring symptoms (pain and instability) compared to 12 (10.6%) in the non-Down Under group; this difference was not statistically significant (adjusted OR 1.09, 95% CI 0.19,4.77). Family history of shoulder instability was positively associated with a Down Under lesion (adjusted OR 5.0, 95%CI 1.51,16.7). MRI or MRA identified 52.9% of Down Under lesions. CONCLUSION: Down Under lesions were an infrequent type of glenoid labral injury, yet postoperative outcomes were similar to other labral tears. Patients with Down Under lesions had a significant risk factor due to family history of shoulder instability. MRI and MRA could not reliably identify Down Under lesions. LEVEL OF EVIDENCE: Level III.

Serious asthma events with mometasone furoate plus formoterol compared with mometasone furoate.

BACKGROUND: The safety of long-acting ß-agonists added to inhaled corticosteroids for the treatment of persistent asthma has been controversial. OBJECTIVE: We sought to determine whether administering formoterol in combination with mometasone furoate increases the risk of serious asthma outcomes (SAOs) compared with mometasone furoate alone. This clinical trial is registered as NCT01471340. METHODS: We conducted a 26-week, randomized, double-blind trial in adolescent and adult patients (≥12 years) with persistent asthma in 35 countries with the primary objective of evaluating whether mometasone furoate-formoterol increases the risk of SAOs (adjudicated hospitalization, intubation, or death) compared with mometasone furoate alone. The key efficacy end point was asthma exacerbation (composite of hospitalization of ≥24 hours, emergency department visits of <24 hours requiring systemic corticosteroids, or use of systemic corticosteroids for ≥3 consecutive days). RESULTS: Among 11,729 patients (mometasone furoate-formoterol, n = 5,868; mometasone furoate, n = 5,861), a total of 81 SAOs, all asthma-related hospitalizations, were observed in 71 patients: 45 events from 39 patients receiving mometasone furoate-formoterol and 36 events from 32 patients receiving mometasone furoate. The hazard ratio for the first SAO in the mometasone furoate-formoterol versus mometasone furoate group was 1.22 (95% CI, 0.76-1.94; P = .411). Asthma exacerbation occurred in 1,487 patients: 708 receiving mometasone furoate-formoterol and 779 receiving mometasone furoate. The hazard ratio for the first asthma exacerbation in the mometasone furoate-formoterol versus mometasone furoate group was 0.89 (95% CI, 0.80-0.98; P = .021). CONCLUSIONS: The addition of formoterol to mometasone furoate maintenance therapy did not increase the risk of serious asthma-related events and reduced the risk of asthma exacerbation.

Assessing research capacity in Victoria's south-west health service providers.

OBJECTIVE: To investigate the research interest, capacity and culture in individuals, teams and health organisations across south-western Victoria. DESIGN: Cross-sectional survey. SETTING: Eight public health services in the south-western region of Victoria. PARTICIPANTS: All staff were invited to participate. INTERVENTION: Hospital staff survey. MAIN OUTCOME MEASURE: The Research Capacity and Culture tool. RESULTS: The survey was completed by 776 staff including nurses, allied health staff and doctors. Half of the respondents were currently involved in research, while most wanted to be more involved. Respondents reported having moderate research skills and success at individual, team and organisation levels. Women and nurses reported having lower skills than comparable groups. Motivators for undertaking research were skill development (increased job satisfaction and brain stimulation) while the most commonly selected barriers were lack of time, other work taking priority and lack of funding. CONCLUSION: Health organisations in regional and rural Victoria could harness opportunities to enable staff participation in research by supporting identified strengths, addressing barriers and providing "permission" for staff to get involved in research. Efforts to improve research capacity among women and nurses could lead to the greatest overall improvement in organisations' research capacity and output-and translation of evidence into practice.

Association of body-mass index and outcomes in patients with metastatic melanoma treated with targeted therapy, immunotherapy, or chemotherapy: a retrospective, multicohort analysis.

BACKGROUND: Obesity has been linked to increased mortality in several cancer types; however, the relation between obesity and survival outcomes in metastatic melanoma is unknown. The aim of this study was to examine the association between body-mass index (BMI) and progression-free survival or overall survival in patients with metastatic melanoma who received targeted therapy, immunotherapy, or chemotherapy. METHODS: This retrospective study analysed independent cohorts of patients with metastatic melanoma assigned to treatment with targeted therapy, immunotherapy, or chemotherapy in randomised clinical trials and one retrospective study of patients treated with immunotherapy. Patients were classified according to BMI, following the WHO definitions, as underweight, normal, overweight, or obese. Patients without BMI and underweight patients were excluded. The primary outcomes were the associations between BMI and progression-free survival or overall survival, stratified by treatment type and sex. We did multivariable analyses in the independent cohorts, and combined adjusted hazard ratios in a mixed-effects meta-analysis to provide a precise estimate of the association between BMI and survival outcomes; heterogeneity was assessed with meta-regression analyses. Analyses were done on the predefined intention-to-treat population in the randomised controlled trials and on all patients included in the retrospective study. FINDINGS: The six cohorts consisted of a total of 2046 patients with metastatic melanoma treated with targeted therapy, immunotherapy, or chemotherapy between Aug 8, 2006, and Jan 15, 2016. 1918 patients were included in the analysis. Two cohorts containing patients from randomised controlled trials treated with targeted therapy (dabrafenib plus trametinib [n=599] and vemurafenib plus cobimetinib [n=240]), two cohorts containing patients treated with immunotherapy (one randomised controlled trial of ipilimumab plus dacarbazine [n=207] and a retrospective cohort treated with pembrolizumab, nivolumab, or atezolizumab [n=331]), and two cohorts containing patients treated with chemotherapy (two randomised controlled trials of dacarbazine [n=320 and n=221]) were classified according to BMI as normal (694 [36%] patients), overweight (711 [37%]), or obese (513 [27%]). In the pooled analysis, obesity, compared with normal BMI, was associated with improved survival in patients with metastatic melanoma (average adjusted hazard ratio [HR] 0·77 [95% CI 0·66-0·90] for progression-free survival and 0·74 [0·58-0·95] for overall survival). The survival benefit associated with obesity was restricted to patients treated with targeted therapy (HR 0·72 [0·57-0·91] for progression-free survival and 0·60 [0·45-0·79] for overall survival) and immunotherapy (HR 0·75 [0·56-1·00] and 0·64 [0·47-0·86]). No associations were observed with chemotherapy (HR 0·87 [0·65-1·17, pinteraction=0·61] for progression-free survival and 1·03 [0·80-1·34, pinteraction=0·01] for overall survival). The association of BMI with overall survival for patients treated with targeted and immune therapies differed by sex, with inverse associations in men (HR 0·53 [0·40-0·70]), but no associations observed in women (HR 0·85 [0·61-1·18, pinteraction=0·03]). INTERPRETATION: Our results suggest that in patients with metastatic melanoma, obesity is associated with improved progression-free survival and overall survival compared with those outcomes in patients with normal BMI, and that this association is mainly seen in male patients treated with targeted or immune therapy. These results have implications for the design of future clinical trials for patients with metastatic melanoma and the magnitude of the benefit found supports further investigation of the underlying mechanism of these associations. FUNDING: ASCO/CCF Young Investigator Award, ASCO/CCF Career Development Award, MD Anderson Cancer Center (MDACC) Melanoma Moonshot Program, MDACC Melanoma SPORE, and the Dr Miriam and Sheldon G Adelson Medical Research Foundation.

A randomised clinical trial of feedback on inhaler adherence and technique in patients with severe uncontrolled asthma.

In severe asthma, poor control could reflect issues of medication adherence or inhaler technique, or that the condition is refractory. This study aimed to determine if an intervention with (bio)feedback on the features of inhaler use would identify refractory asthma and enhance inhaler technique and adherence.Patients with severe uncontrolled asthma were subjected to a stratified-by-site random block design. The intensive education group received repeated training in inhaler use, adherence and disease management. The intervention group received the same intervention, enhanced by (bio)feedback-guided training. The primary outcome was rate of actual inhaler adherence. Secondary outcomes included a pre-defined assessment of clinical outcome. Outcome assessors were blinded to group allocation. Data were analysed on an intention-to-treat and per-protocol basis.The mean rate of adherence during the third month in the (bio)feedback group (n=111) was higher than that in the enhanced education group (intention-to-treat, n=107; 73% versus 63%; 95% CI 2.8%-17.6%; p=0.02). By the end of the study, asthma was either stable or improved in 54 patients (38%); uncontrolled, but poorly adherent in 52 (35%); and uncontrolled, but adherent in 40 (27%).Repeated feedback significantly improved inhaler adherence. After a programme of adherence and inhaler technique assessment, only 40 patients (27%) were refractory and adherent, and might therefore need add-on therapy.

Risk factors for fouling biomass: evidence from small vessels in Australia.

Invasive non-indigenous species (NIS) are a threat to marine biodiversity and marine reliant industries. Recreational vessels are recognised as an important vector of NIS translocation, particularly domestically. This paper reports on a novel application of multilevel modelling and multiple imputation in order to quantify the relationship between biofouling biomass (wet weight) and the vessel-level characteristics of recreational and fishing vessels. It was found that the number of days since the vessel was last cleaned strongly related to the biofouling biomass, yet differed dependent on vessel type. Similarly, the median number of trips undertaken was related to the biofouling biomass, and varied according to the type of antifouling paint (AF) used. No relationship was found between vessel size and biofouling biomass per sample unit. To reduce the spread of NIS, vessel owners should use an AF paint suitable to their vessel's operational profile, and follow a maintenance schedule according to the paint manufacturer's specifications.

Acute kidney injury post-major orthopaedic surgery: A single-Centre case-control study.

AIM: To identify risk factors for acute kidney injury following major orthopaedic surgery. METHODS: We included all patients undergoing major orthopaedic surgery at University Hospital Geelong between 2008 and 2014 in the study. Out of 2188 surgeries audited, we identified cases of acute kidney injury using the RIFLE criteria and matched those to controls 2:1 for age, sex, procedure and chronic kidney disease stage. We reviewed their records for risk factors of postoperative acute kidney injury, including medications such as gentamicin, diuretics, non-steroidal anti-inflammatory drugs and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use. We reviewed the patients' history of cardiovascular disease, chronic liver disease, hypertension and diabetes mellitus along with presence of sepsis and obesity. Associations of hypothetical risk factors were estimated using conditional logistic regression. RESULTS: We identified 164 cases of AKI in an elderly cohort (median age = 73 years). Controlling for baseline comorbidities, both diuretic and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use were found to be associated with a twofold risk of acute kidney injury (diuretic - OR 2.06 95% CI:1.30-3.26, P < 0.005, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use OR 2.09 95% CI:1.31-3.32, P < 0.005). A dose-effect model accounting for perioperative nonsteroidal anti-inflammatory drug administration demonstrated a linear relationship between the number of times these drugs were given and postoperative acute kidney injury risk (OR 1.35 95% CI:1.05-1.73, P = 0.02). CONCLUSIONS: We identified perioperative diuretics, non-steroidal anti-inflammatory drugs and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker to be significantly associated with postoperative AKI. Further prospective studies are required to confirm this.

When Does Poor Governance Presage Biosecurity Risk?

Border inspection, and the challenge of deciding which of the tens of millions of consignments that arrive should be inspected, is a perennial problem for regulatory authorities. The objective of these inspections is to minimize the risk of contraband entering the country. As an example, for regulatory authorities in charge of biosecurity material, consignments of goods are classified before arrival according to their economic tariff number. This classification, perhaps along with other information, is used as a screening step to determine whether further biosecurity intervention, such as inspection, is necessary. Other information associated with consignments includes details such as the country of origin, supplier, and importer, for example. The choice of which consignments to inspect has typically been informed by historical records of intercepted material. Fortunately for regulators, interception is a rare event; however, this sparsity undermines the utility of historical records for deciding which containers to inspect. In this article, we report on an analysis that uses more detailed information to inform inspection. Using quarantine biosecurity as a case study, we create statistical profiles using generalized linear mixed models and compare different model specifications with historical information alone, demonstrating the utility of a statistical modeling approach. We also demonstrate some graphical model summaries that provide managers with insight into pathway governance.

Efficacy and safety of direct switch to indacaterol/glycopyrronium in patients with moderate COPD: the CRYSTAL open-label randomised trial.

BACKGROUND: Dual bronchodilation combining a long-acting ß2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) is the preferred choice of treatment recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 guidelines for the management of patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). The once-daily (q.d.) fixed-dose combination (FDC) of LABA, indacaterol 110 µg and LAMA, glycopyrronium 50 µg (IND/GLY 110/50 µg q.d.) demonstrated superior improvements in lung function, dyspnoea and overall health status and better tolerability against LABA or LAMA monotherapies and combination of LABA and inhaled corticosteroid (ICS) in more than 11,000 patients with moderate-to-severe COPD in several randomised controlled clinical trials. METHODS: The CRYSTAL study was the first, 12-week, randomised, open-label trial that evaluated the efficacy and safety of a direct switch from previous treatments to IND/GLY 110/50 µg q.d. on lung function and dyspnoea in patients with moderate COPD and a history of up to one exacerbation in the previous year. Patients were divided into 2 groups according to their background therapy and symptom scores and were randomised (3:1) to IND/GLY or to continue with their previous treatments. RESULTS: The study included 4389 randomised patients, of whom 2160 were in groups switched to IND/GLY (intention-to-treat population). The effect of IND/GLY was superior to LABA + ICS on trough forced expiratory volume in 1 s (FEV1; treatment difference, Δ = +71 mL) and transition dyspnoea index (TDI; [Δ = 1.09 units]), and to LABA or LAMA on trough FEV1 (Δ = +101 mL) and a TDI (Δ = 1.26 units). Improvements in health status and lower rescue medication use were also observed with IND/GLY. The safety profile of the study medication was similar to that observed in previous studies. CONCLUSIONS: IND/GLY demonstrated superior improvements in lung function and dyspnoea after direct switch from previous treatments. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT01985334 .

Changes in Bone Mineral Density in the Year after Critical Illness.

RATIONALE: Critical illness may be associated with increased bone turnover and loss of bone mineral density (BMD). Prospective evidence describing long-term changes in BMD after critical illness is needed to further define this relationship. OBJECTIVES: To measure the change in BMD and bone turnover markers (BTMs) in subjects 1 year after critical illness compared with population-based control subjects. METHODS: We studied adult patients admitted to a tertiary intensive care unit (ICU) who required mechanical ventilation for at least 24 hours. We measured clinical characteristics, BTMs, and BMD during admission and 1 year after ICU discharge. We compared change in BMD to age- and sex-matched control subjects from the Geelong Osteoporosis Study. MEASUREMENTS AND MAIN RESULTS: Sixty-six patients completed BMD testing. BMD decreased significantly in the year after critical illness at both femoral neck and anterior-posterior spine sites. The annual decrease was significantly greater in the ICU cohort compared with matched control subjects (anterior-posterior spine, -1.59%; 95% confidence interval, -2.18 to -1.01; P < 0.001; femoral neck, -1.20%; 95% confidence interval, -1.69 to -0.70; P < 0.001). There was a significant increase in 10-year fracture risk for major fractures (4.85 ± 5.25 vs. 5.50 ± 5.52; P < 0.001) and hip fractures (1.57 ± 2.40 vs. 1.79 ± 2.69; P = 0.001). The pattern of bone resorption markers was consistent with accelerated bone turnover. CONCLUSIONS: Critically ill individuals experience a significantly greater decrease in BMD in the year after admission compared with population-based control subjects. Their bone turnover biomarker pattern is consistent with an increased rate of bone loss.

Factors predictive of response, disease progression, and overall survival after dabrafenib and trametinib combination treatment: a pooled analysis of individual patient data from randomised trials.

BACKGROUND: Dabrafenib plus trametinib treatment provides significant benefits over BRAF-inhibitor monotherapy in patients with BRAFV600E-mutant or BRAFV600K-mutant advanced melanoma; however, in many patients the disease progresses, leading to death. With many treatment options available, understanding clinical factors that predict long-term response and survival for treatments is important for optimisation of patient management. We aimed to identify clinical factors associated with long-term response and survival using pooled data from randomised trials of dabrafenib plus trametinib in patients with metastatic BRAF-mutant melanoma. METHODS: We did a retrospective individual data analysis based on all published randomised trials that included treatment-naive patients with BRAFV600E-mutant or BRAFV600K-mutant metastatic melanoma who received the approved dose of dabrafenib 150 mg twice daily plus trametinib 2 mg once daily. Data were pooled from patients in the BRF113220 (part C; March 26, 2010, to Jan 15, 2015), COMBI-d (May 4, 2012, to Jan 12, 2015), and COMBI-v (June 4, 2012, to March 13, 2015) randomised trials. Patients with untreated brain metastases were not permitted to enrol in these trials. Baseline factors, identified a priori based on known melanoma clinical or prognostic characteristics, were analysed for association with progression-free survival and overall survival using univariate and multivariate analyses and assessed for hierarchical effect on outcomes using regression tree analyses. We also analysed factors identified after baseline, on treatment, and at progression, for associations with survival after progression. The trials included in this analysis are registered with ClinicalTrials.gov: BRF113220, number NCT01072175; COMBI-d, number NCT01584648; COMBI-v, number NCT01597908. FINDINGS: 617 patients were included in this analysis with a median follow-up of 20·0 months (range 0-48·0, IQR 10·1-24·8); 396 patients had progression events (ie, disease progression or death) and 290 patients had died. Median progression-free survival (11·1 months [95% CI 9·7-12·9]), median overall survival (25·6 months [23·1-34·3]), 1-year progression-free survival (48% [44-52]) and overall survival (74% [71-78]), and 2-year progression-free survival (30% [26-34]) and overall survival (53% [49-57]) were consistent with those in the individual trials. Patients with normal lactate dehydrogenase (LDH) concentration and fewer than three organ sites containing metastases (n=237) had the longest 1-year progression-free survival (68% [95% CI 62-74]) and overall survival (90% [87-94]) and 2-year progression-free survival (46% [40-54]) and overall survival (75% [70-81]), whereas patients with LDH concentration at least two times the upper limit of normal (n=70) had the shortest 1-year progression-free survival (8% [3-19]) and overall survival (40% [29-55]) and 2-year progression-free survival (2% [0-13]) and overall survival (7% [3-19]). Of patients with disease progression (n=379), survival after progression was longest in those with progression in baseline or new non-CNS lesions (n=205; median 10·0 months [95% CI 7·9-12·0]) and shortest in those with new CNS lesions or concurrent progression in baseline and new lesions (n=171; median 4·0 months [3·5-4·9]). INTERPRETATION: Several patient and clinical characteristics at and after baseline are associated with outcomes with dabrafenib plus trametinib, and durable benefit is possible with targeted treatment in defined patient subsets. FUNDING: Novartis.

Refractometric micro-sensor using a mirrored capillary resonator.

We report on a flow-through optical sensor consisting of a microcapillary with mirrored channels. Illuminating the structure from the side results in a complicated spectral interference pattern due to the different cavities formed between the inner and outer capillary walls. Using a Fourier transform technique to isolate the desired channel modes and measure their resonance shift, we obtain a refractometric detection limit of (6.3 ± 1.1) x 10-6 RIU near a center wavelength of 600 nm. This simple device demonstrates experimental refractometric sensitivities up to (5.6 ± 0.2) x 102 nm/RIU in the visible spectrum, and it is calculated to reach 1540 nm/RIU with a detection limit of 2.3 x 10-6 RIU at a wavelength of 1.55 µm. These values are comparable to or exceed some of the best Fabry-Perot sensors reported to date. Furthermore, the device can function as a gas or liquid sensor or even as a pressure sensor owing to its high refractometric sensitivity and simple operation.

Few geographic and socioeconomic variations exist in primary total shoulder arthroplasty: a multi-level study of Australian registry data.

BACKGROUND: Associations between socioeconomic position (SEP) and the uptake of primary total shoulder arthroplasty (TSA) is not well understood in the Australian population, thus potentially limiting equitable allocation of healthcare resources. We used the Australian Orthopaedic Association National Joint Replacement Registry (AOA NJRR) to examine whether geographic or socioeconomic variations exist in TSA performed for a diagnosis of osteoarthritis 2007-11 for all Australians aged ≥40 years. METHODS: Primary anatomical and reverse TSA data were extracted from the AOA NJRR which captures >99 % of all TSA nationally. Residential addresses were cross-referenced to Australian Bureau of Statistics 2011 Census data to identify SEP measured at the area-level (categorised into deciles), and geographic location defined as Australian State/Territory of residence. We used a Poisson distribution for the number of TSA over the study period, and modelled the effects of age, SEP and geographic location using multilevel modelling. RESULTS: During 2007-11, we observed 6,123 TSA (62.2 % female). For both sexes, TSA showed a proportional increase with advancing age. TSA did not vary by SEP or geographic location, with the exception of greater TSA among men in New South Wales. CONCLUSIONS: Using a national registry approach we provide the first reliable picture of TSA at a national level. The uptake of TSA was equitable across SEP; however, there was some variation between the States/Territories. With an aging population, it is imperative that monitoring of major surgical procedures continues, and be focused toward determining whether TSA uptake correlates with need across different social and area-based groups.

Smart and Fast Blood Counting of Trace Volumes of Body Fluids from Various Mammalian Species Using a Compact, Custom-Built Microscope Cytometer.

We report an accurate method to count red blood cells, platelets, and white blood cells, as well as to determine hemoglobin in the blood of humans, horses, dogs, cats, and cows. Red and white blood cell counts can also be performed on human body fluids such as cerebrospinal fluid, synovial fluid, and peritoneal fluid. The approach consists of using a compact, custom-built microscope to record large field-of-view, bright-field, and fluorescence images of samples that are stained with a single dye and using automatic algorithms to count blood cells and detect hemoglobin. The total process takes about 15 min, including 5 min for sample preparation, and 10 min for data collection and analysis. The minimum volume of blood needed for the test is 0.5 µL, which allows for minimally invasive sample collection such as using a finger prick rather than a venous draw. Blood counts were compared to gold-standard automated clinical instruments, with excellent agreement between the two methods as determined by a Bland-Altman analysis. Accuracy of counts on body fluids was consistent with hand counting by a trained clinical lab scientist, where our instrument demonstrated an approximately 100-fold lower limit of detection compared to current automated methods. The combination of a compact, custom-built instrument, simple sample collection and preparation, and automated analysis demonstrates that this approach could benefit global health through use in low-resource settings where central hematology laboratories are not accessible.

The Epidemiology of Incident Fracture from Cradle to Senescence.

To reduce the burden of fracture, not only does bone fragility need to be addressed, but also injury prevention. Thus, fracture epidemiology irrespective of degree of trauma is informative. We aimed to determine age-and-sex-specific fracture incidence rates for the Barwon Statistical Division, Australia, 2006-2007. Using radiology reports, incident fractures were identified for 5342 males and 4512 females, with incidence of 210.4 (95 % CI 204.8, 216.2) and 160.0 (155.3, 164.7)/10,000/year, respectively. In females, spine (clinical vertebral), hip (proximal femoral) and distal forearm fractures demonstrated a pattern of stable incidence through early adult life, with an exponential increase beginning in postmenopausal years for fractures of the forearm followed by spine and hip. A similar pattern was observed for the pelvis, humerus, femur and patella. Distal forearm, humerus, other forearm and ankle fractures showed incidence peaks during childhood and adolescence. For males, age-related changes mimicked the female pattern for fractures of the spine, hip, ribs, pelvis and humerus. Incidence at these sites was generally lower for males, particularly among the elderly. A similar childhood-adolescent peak was seen for the distal forearm and humerus. For ankle fractures, there was an increase during childhood and adolescence but this extended into early adult life; in contrast to females, there were no further age-related increases. An adolescent-young adult peak incidence was observed for fractures of the face, clavicle, carpal bones, hand, fingers, foot and toe, without further age-related increases. Examining patterns of fracture provides the evidence base for monitoring temporal changes in fracture burden, and for identifying high-incidence groups to which fracture prevention strategies could be directed.

The effect of surgical timing on the outcome of patients with neck of femur fracture.

AIMS: To investigate the effect of surgical timing (in hours versus after hours and weekdays versus weekends) on the outcome of patients with neck of femur fracture. METHODS: Patients who were admitted to a single tertiary referral hospital for surgical management of femoral neck fractures over a continuous period from 1/11/2002 to 12/7/2012 were identified from medical records and the operating theatre database. RESULTS: A consecutive series of 2334 patients were included in the study. Of the patients who underwent surgery during the weekday and during usual hours, 18% (207/1135) experienced an adverse event, compared to 16% (193/1199) outside of these times. The difference between the two groups was not significant (p = 0.17). The same conclusion was made for the comparison between those who had surgery during the week with those who had surgery on the weekend (17%, 267/1546 and 17%, 133/788, respectively, p > 0.05). The proportion of patients who underwent surgery during hours that experienced an adverse event was significantly higher than those undergoing surgery out of hours (18%, 327/1789 and 13%, 73/545, respectively, p = 0.0081). When adjusted for age, ASA score and pre-operative stay, there was no statistical difference between those different sub-groups. CONCLUSIONS: There was no difference in the rates of adverse events between patients who had surgery during hours and weekdays with those who had surgery after hours or weekends. The careful selection of patients with appropriate hospital staff, resources and adequate theatre access, surgery during after hours and weekends may be safely considered to prevent a delay in surgical treatment for patient with neck of femur fracture.

Image reconstruction for structured-illumination microscopy with low signal level.

We report a new image processing technique for the structured illumination microscopy designed to work with low signals, with the goal of reducing photobleaching and phototoxicity of the sample. Using a pre-filtering process to estimate experimental parameters and total variation as a constraint to reconstruct, we obtain two orders of magnitude of exposure reduction while maintaining the resolution improvement and image quality compared to a standard structured illumination microscopy. The algorithm is validated on both fixed and live cell data with results confirming that we can image more than 15x more time points compared to the standard technique.

Impact of high-sensitivity cardiac troponin I assays on patients presenting to an emergency department with suspected acute coronary syndrome.

OBJECTIVE: To determine whether introduction of high-sensitivity cardiac troponin I (hscTn-I) assays affected management of patients presenting with suspected acute coronary syndrome (ACS) to the emergency department (ED) of a tertiary referral hospital. DESIGN, PATIENTS AND SETTING: A retrospective analysis of all patients presenting to the Geelong Hospital ED with suspected ACS from 23 April 2010 to 22 April 2013 -2 years before and 1 year after the changeover to hscTn-I assays on 23 April 2012. MAIN OUTCOME MEASURES: Hospital admission rates, time spent in the ED, rates of coronary angiography, rates of percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABGS), rates of discharge with a diagnosis of ACS, and rates of inhospital mortality. RESULTS: 12 360 consecutive patients presented with suspected ACS during the study period; 1897 were admitted to Geelong Hospital in the 2 years before and 944 in the 1 year after the changeover to hscTn-I assays. Comparing the two patient groups, there was no statistically significant difference in all-hospital admission rates (95% CI for the difference, - 3.1% to 0.3%; P = 0.10) or proportion of patients subsequently discharged with a diagnosis of ACS (95% CI for the difference, - 2.3% to 5.4%; P = 0.43). After the changeover, the median time patients spent in the ED was 11.5% shorter (3.85 h v 4.35 h; 95% CI for the difference, - 0.59 to - 0.43; P < 0.001) and the proportion of admitted patients undergoing coronary angiography was higher (53.4% v 45.2%; 95% CI for the difference, 4.3 to 12.0 percentage points; P < 0.001), but there was no statistically significant rise in the proportion of patients who had invasive treatment (PCI and/or CABGS) (95% CI for the difference, - 0.4% to 6.3%; P = 0.08). Inhospital mortality rates from ACS did not change significantly (95% CI for the difference, - 1.5% to 0.8%; P = 0.43). CONCLUSION: The introduction of hscTn-I assays appeared to be associated with more rapid diagnosis, resulting in less time spent in the ED, without a change in hospital admission rates. A higher proportion of patients had coronary angiographies after the changeover, but there was no significant change in rates of invasive treatment or inhospital mortality.

Associations between socioeconomic status and primary total knee joint replacements performed for osteoarthritis across Australia 2003-10: data from the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: Relatively little is known about the social distribution of total knee joint replacement (TKR) uptake in Australia. We examine associations between socioeconomic status (SES) and TKR performed for diagnosed osteoarthritis 2003-10 for all Australian males and females aged ≥ 30 yr. METHODS: Data of primary TKR (n=213,018, 57.4% female) were ascertained from a comprehensive national joint replacement registry. Residential addresses were matched to Australian Census data to identify area-level social disadvantage, and categorised into deciles. Estimated TKR rates were calculated. Poisson regression was used to model the relative risk (RR) of age-adjusted TKR per 1,000py, stratified by sex and SES. RESULTS: A negative relationship was observed between TKR rates and SES deciles. Females had a greater rate of TKR than males. Surgery utilisation was greatest for all adults aged 70-79 yr. In that age group differences in estimated TKR per 1,000py between deciles were greater for 2010 than 2003 (females: 2010 RR 4.32 and 2003 RR 3.67; males: 2010 RR 2.04 and 2003 RR 1.78). CONCLUSIONS: Identifying factors associated with TKR utilisation and SES may enhance resource planning and promote surgery utilisation for end-stage osteoarthritis.