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Using 2018 Medicare data, we examined the relationship between dual eligibility and injury-related emergency department use among a cohort of assisted living residents (n=116,754). We fit multilevel models with random intercepts at the assisted living community and license type levels. The baseline rate of injury-related emergency department emergency department use was 0.17. After controlling for resident characteristics (i.e., age, sex, race, and chronic conditions), license type characteristics (i.e., dementia care licensure, staffing regulations), and assisted living community characteristics (i.e., size and percentage of residents with dementia), being dually eligible for Medicare and Medicaid was associated with a 12% increase in the probability of having an injury-related emergency department visit (b=.02; p

This article examines how a resurgent clash of Arab and Israeli nationalisms created tensions within New Labour as the leadership sought to reconcile claims of duplicity in its Middle East ...

There is an increasing body of research suggesting that low body weight is associated with scoliosis, but this is based on case-control studies, which are prone to bias. No studies have investigated the components of body weight: fat and lean mass. We have therefore carried out the first population-based prospective study of the association between fat and lean mass at age 10 years assessed by dual-energy X-ray absorptiometry (DXA), with presence of scoliosis at age 15 years using the Avon Longitudinal Study of Parents and Children (ALSPAC). All children with scoliosis at age 10 years were excluded. Of 5299 children at age 15 years, 312 (5.9%) had scoliosis. Our results show a negative association between body mass index (BMI)/body weight at age 10 years and scoliosis at age 15 years, with a 20% reduced risk of scoliosis per SD increase in BMI (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.70–0.92; p = 0.001). This association with BMI/body weight reflects associations with both fat mass and lean mass. After adjustment for age, gender, leg length, and fat mass per SD increase in lean mass, there was a 20% reduced risk of scoliosis (OR, 0.80; 95% CI, 0.65–0.97) and per SD increase in fat mass there was a 13% reduced risk of scoliosis (OR, 0.87; 95% CI, 0.74–1.03). In terms of adipocyte function, an inverse association was seen between leptin at age 10 years and scoliosis (OR for scoliosis per SD increase in leptin of 0.78; 95% CI, 0.63–0.99), and a positive association between adiponectin at age 10 years and scoliosis (OR for scoliosis per SD increase in adiponectin of 1.44; 95% CI, 0.99–2.10). This is the first study to address the association between the individual components of body weight and scoliosis in a prospective cohort study, and shows altered body composition that is present before the onset of clinically detected scoliosis. © 2014 American Society for Bone and Mineral Research.

This article reconstructs the evolution of New Labour's foreign policy towards the Israeli–Palestinian question and the Middle East Peace Process. It argues that between 1997 and 1999 the approach became personalised when differences in substance and style emerged as Tony Blair (Prime Minister), and Robin Cook (Foreign Secretary), sought to define Britain's positions in a declining process. At the core of this divergence was Cook's preference for a greater Euro-centred multilateralist role in the trilateral negotiating template (bilateral Arab–Israeli talks overseen by the USA) and Blair's more pragmatic focus on Anglo-American relations. Yet the trigger for Blair's decision to control Middle East policy—Cook's Jerusalem visit during Britain's EU presidency—ran contrary to USA initiatives designed to augment peace efforts, and later formed a basis of contradiction between the criteria for humanitarian intervention in the Blair doctrine and his policy towards the Israeli–Palestinian conflict.

The report outlines the overall data collection and analysis process for developing airport terminal building energy use intensity (ATB-EUI) benchmarks. Individual chapters highlight: defining annual EUI per ATB zone; annual EU calculation per ATB system; estimation of ATB’s measured annual EU based on utility information; the complete ATB annual EU/EUI table; the input form; and site visits. The report complements CD-ROM 178: Airport Terminal Building Energy Use Intensity (ATB-EUI) Benchmarking Tool.

Objective: Selective serotonin reuptake inhibitors (SSRIs) treat depression by antagonizing the serotonin (5-hydroxytryptamine) transporter (5-HTT). These drugs may also have skeletal effects given the presence of functional serotonergic pathways in bone and evidence demonstrating detrimental effects of SSRIs on postmenopausal bone changes. This study aimed to explore the influence of an SSRI (fluoxetine hydrochloride) on the bone changes associated with estrogen deficiency in adult mice. Design: Adult, female, Swiss-Webster mice underwent ovariectomy (OVX) or sham OVX and were treated daily for 4 weeks with either fluoxetine hydrochloride (5 or 20 mg/kg) or a vehicle solution (control). In vivo assessments of hindlimb areal and tibial volumetric bone mineral density were performed at baseline and after 4 weeks of intervention. Femurs and lumbar vertebrae were subsequently removed and assessed ex vivo for bone mineral density and trabecular bone architecture and turnover. Results: In vivo and ex vivo skeletal measures found no interactions between OVX (estrogen deficiency) and 5-HTT inhibition, indicating that the skeletal effects of these interventions were independent. 5-HTT inhibition had detrimental skeletal effects, with the fluoxetine-treated groups having reduced bone mineral density and altered trabecular architecture. These changes resulted from both a decrease in bone formation and increase in bone resorption. Conclusions: These data indicate that a commonly prescribed SSRI has a negative influence on the adult skeleton, independent of estrogen deficiency. This finding supports clinical data demonstrating SSRI use to be associated with accelerated bone loss after menopause and highlights a need for further research into the skeletal effects of SSRIs.

Short-term exercise in growing rodents provided lifelong benefits to bone structure, strength, and fatigue resistance. Consequently, exercise when young may reduce the risk for fractures later in life, and the old exercise adage of “use it or lose it” may not be entirely applicable to the skeleton. Introduction: The growing skeleton is most responsive to exercise, but low-trauma fractures predominantly occur in adults. This disparity has raised the question of whether exercised-induced skeletal changes during growth persist into adulthood where they may have antifracture benefits. This study investigated whether brief exercise during growth results in lifelong changes in bone quantity, structure, quality, and mechanical properties. Materials and Methods: Right forearms of 5-week-old Sprague-Dawley rats were exercised 3 days/week for 7 weeks using the forearm axial compression loading model. Left forearms were internal controls and not exercised. Bone quantity (mineral content and areal density) and structure (cortical area and minimum second moment of area [IMIN]) were assessed before and after exercise and during detraining (restriction to home cage activity). Ulnas were removed after 92 weeks of detraining (at 2 years of age) and assessed for bone quality (mineralization) and mechanical properties (ultimate force and fatigue life). Results: Exercise induced consistent bone quantity and structural adaptation. The largest effect was on IMIN, which was 25.4% (95% CI, 15.6–35.3%) greater in exercised ulnas compared with nonexercised ulnas. Bone quantity differences did not persist with detraining, whereas all of the absolute difference in bone structure between exercised and nonexercised ulnas was maintained. After detraining, exercised ulnas had 23.7% (95% CI, 13.0–34.3%) greater ultimate force, indicating enhanced bone strength. However, exercised ulnas also had lower postyield displacement (−26.4%; 95% CI, −43.6% to −9.1%), indicating increased brittleness. This resulted from greater mineralization (0.56%; 95% CI, 0.12–1.00%), but did not influence fatigue life, which was 10-fold greater in exercised ulnas. Conclusions: These data indicate that exercise when young can have lifelong benefits on bone structure and strength, and potentially, fracture risk. They suggest that the old exercise adage of “use it or lose it” may not be entirely applicable to the skeleton and that individuals undergoing skeletal growth should be encouraged to perform impact exercise.

s / International Journal of Surgery 12 (2014) S13eS117 S67 12 months. Both insertional and non-insertional tendinopathies were found to be improved after surgical treatment. Conclusions: Our series shows surgical treatment of Achilles tendinopathies can be successful in patients who fail conservative treatment. 1396: ‘TIERS OF DELAY’: WARFARIN, HIP FRACTURES AND TARGET DRIVEN CARE Will Eardley , Hannah Freeman, Kirsty MacLeod, Anne Tate. Jaems Cook University Hospital, Middlesbrough, UK. Introduction: Anticoagulation reversal causes operative delays and loss of Best Practice Tariff (BPT). We sought to establish the impact on BPT for hip fracture patients admitted on warfarin. Methods: Patients undergoing surgery for a hip fracture over a 32-month period were reviewed. Time to theatre, length of stay and mortality were subject to independent samples t-tests. Results: 83 patients on warfarin had a mean time to theatre of 49.74 hrs (1.71-121.88), a 79% breach of BPT. In the control group, 908patients tookon average 24.51 hrs (1.2-287.48), a 28% breach of BPT (p 50degrees) demonstrateda significant improvement in correction with the CoCr constructs (0.81 vs 0.69, P1⁄40.02). Sagittal balancewas improved in both (CoCr 27.8, Ti 28.0) without significant difference (p1⁄40.84). Preoperative kyphosiswas normal in 49% and 43% of the CoCr and Ti Groups respectively (p1⁄40.63). 12 Ti patients moved from normal kyphosis to abnormal. 9 moved from abnormal to normal (p1⁄40.66). 10 CoCr patients were normalised with only 2 becoming abnormal (p1⁄40.04). Conclusions: Stiffer CoCr rods improve coronal correction for patients with large curves and normalise hypokyphotic deformities more effectively. Improvements weren't seen in sagittal balance or coronal curves less than 40 degrees.

There is an increasing body of research suggesting that low body weight is associated with scoliosis, but this is based on case-control studies, which are prone to bias. No studies have investigated the components of body weight: fat and lean mass. We have therefore carried out the first population-based prospective study of the association between fat and lean mass at age 10 years assessed by dual-energy X-ray absorptiometry (DXA), with presence of scoliosis at age 15 years using the Avon Longitudinal Study of Parents and Children (ALSPAC). All children with scoliosis at age 10 years were excluded. Of 5299 children at age 15 years, 312 (5.9%) had scoliosis. Our results show a negative association between body mass index (BMI)/body weight at age 10 years and scoliosis at age 15 years, with a 20% reduced risk of scoliosis per SD increase in BMI (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.70-0.92; p = 0.001). This association with BMI/body weight reflects associations with both fat mass and lean mass. After adjustment for age, gender, leg length, and fat mass per SD increase in lean mass, there was a 20% reduced risk of scoliosis (OR, 0.80; 95% CI, 0.65-0.97) and per SD increase in fat mass there was a 13% reduced risk of scoliosis (OR, 0.87; 95% CI, 0.74-1.03). In terms of adipocyte function, an inverse association was seen between leptin at age 10 years and scoliosis (OR for scoliosis per SD increase in leptin of 0.78; 95% CI, 0.63-0.99), and a positive association between adiponectin at age 10 years and scoliosis (OR for scoliosis per SD increase in adiponectin of 1.44; 95% CI, 0.99-2.10). This is the first study to address the association between the individual components of body weight and scoliosis in a prospective cohort study, and shows altered body composition that is present before the onset of clinically detected scoliosis.

PURPOSE: To evaluate the efficacy and utility of SPECT/CT as a diagnostic modality and preoperative planning tool in patients undergoing fusion surgery for low back pain and/or leg pain. STUDY DESIGN/SETTING: A prospective cohort study (n525) performed over a 2-year period. PATIENT SAMPLE: All consecutive patients requiring lumbar spondylodesis for back pain and/or leg pain included. OUTCOME MEASURES: Clinical outcome measures included EQ-5D, EQ-5D VAS, ODI and VAS Pain Scores. METHODS: SPECT/CT fusion imaging was performed in conjunction with standard CT and MRI preoperatively to guide patient selection and surgical planning. Clinical outcome measures were collected preoperatively and at 6 weeks, 6 months and 1 year postoperatively. RESULTS: SPECT/CT fusion imaging demonstrated increased sensitivity for facet degeneration when compared to MRI. No difference was identified when comparing SPECT/CT to standard CT to assess disc degeneration. There was a significant improvement in all clinical outcome measures assessed preoperatively and followed out to 1-year postoperatively. Mean ODI score improved from 58.92 to 12.0; VAS back pain score improved from 7.46 preoperatively to 1.0; VAS leg pain score improved from 4.15 to 0.25. CONCLUSIONS: SPECT/CT fusion imaging is an excellent adjunct to existing imaging modalities, facilitating accurate level selection in patients undergoing lumbar fusion surgery for low back pain and/or leg pain. Lumbar fusion surgery guided by SPECT/CT fusion imaging was associated with excellent postoperative health related quality of life (HRQOL) outcome measures. CONFLICTS OF INTEREST: None. FUNDING SOURCES: None.

We demonstrate spin-exchange optical pumping of 3He using a "hybrid" K-Rb vapor mixture. The Rb atoms absorb light from a standard laser at 795 nm, then collisionally polarize the potassium atoms. Spin-exchange collisions of K and 3He atoms then transfer the angular momentum to the 3He with much greater efficiency than Rb-3He. For a K-rich vapor, the efficiency of the hybrid spin-exchange collisions approaches 1/4, an order of magnitude greater than achieved by pure Rb pumping. We present the first measurements of actual photon efficiencies (polarized nuclei produced per absorbed photon), and show that a new parasitic absorption process limits the total efficiencies for both hybrid and pure Rb pumping.

OBJECTIVE: To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments. DESIGN: Randomised controlled trial. SETTING: Orthopaedic outpatient departments in two hospitals. SUBJECTS: 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion. INTERVENTIONS: Initial assessment and management undertaken by post- Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists). MAIN OUTCOME MEASURES: Patient centred measures of pain, functional disability and perceived handicap. RESULTS: A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238). CONCLUSIONS: On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.