Brief parenting intervention (Triple P) for families of children with eczema: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy and costs of a brief, group-delivered parenting intervention for families of children with eczema. METHODS: A randomized controlled trial design was used. Families attending the Queensland Children's Hospital and from the community (n = 257) were assessed for eligibility (child 2-10 years, diagnosed with eczema, prescribed topical corticosteroids). Families who consented to participate (N = 59) were assessed at baseline for clinician-rated eczema severity, parent-reported eczema symptom severity, and electronically-monitored topical corticosteroid adherence (primary outcomes); and parenting behavior, parents' self-efficacy and task performance when managing eczema, eczema-related child behavior problems, and child and parent quality of life (secondary outcomes). Families were randomized (1:1, unblinded) to intervention (n = 31) or care-as-usual (n = 28). The intervention comprised two, 2-hr Healthy Living Triple P group sessions (face-to-face/online) and 28 intervention families attended one/both sessions. All families were offered standardized eczema education. Families were reassessed at 4-weeks post-intervention and 6-month follow-up, with clinician-raters blinded to condition. Costs of intervention delivery were estimated. RESULTS: Multilevel modeling across assessment timepoints showed significant intervention effects for ineffective parenting (d = .60), self-efficacy (d = .74), task performance (d = .81), and confidence with managing eczema-related child behavior (d = .63), but not disease/symptom severity, treatment adherence or quality of life. Mean cost per participating family with parenting behavior (clinically) improved was $159. CONCLUSIONS: Healthy Living Triple P is effective in reducing ineffective parenting practices and improving parents' self-efficacy and task performance when managing children's eczema and eczema-related behavior difficulties. There was no effect on disease/symptom severity, treatment adherence, or quality of life. CLINICAL TRIAL REGISTRATION: ACTRN12618001332213.

Additional saturday occupational therapy for adults receiving inpatient physiotherapy rehabilitation: a prospective cohort study.

BACKGROUND: The first aim of this study was to investigate the impact of providing an additional four hours of Saturday occupational therapy to patients receiving Saturday physiotherapy in an inpatient setting on length of stay, functional independence, gait and balance. The second aim was to conduct an economic evaluation to determine if the introduction of a Saturday occupational therapy service in addition to physiotherapy resulted in a net cost savings for the rehabilitation facility. METHODS: A prospective cohort study with a historical control was conducted in an Australian private mixed rehabilitation unit from 2015-2017. Clinical outcomes included the Functional Independence Measure (Motor, Cognitive, Total), gait speed (10 Meter Walk test) and five balance measures (Timed Up and Go test, Step test, Functional Reach, Feet Together Eyes Closed and the Balance Outcome Measure of Elder Rehabilitation). Economic outcomes were rehabilitation unit length of stay and additional treatment costs. RESULTS: A total of 366 patients were admitted to the rehabilitation unit over two 20-week periods. The prospective cohort (receiving Saturday occupational therapy and physiotherapy) had 192 participants and the historical control group (receiving Saturday physiotherapy only) had 174 participants. On admission, intervention group participants had higher cognitive (p < 0.01) and total (p < 0.01) Functional Independence Measure scores. Participation in weekend therapy by the intervention group was 11% higher, attending more sessions (p < 0.01) for a greater length of time (p < 0.01) compared to the historical control group. After controlling for differences in admission Functional Independence Measure scores, rehabilitation length of stay was estimated to be reduced by 1.39 (p = 0.08) days. The economic evaluation identified potential cost savings of AUD1,536 per patient. The largest potential savings were attributed to neurological patients AUD4,854. Traumatic and elective orthopaedic patients realised potential patient related cost savings per admission of AUD2,668 and AUD2,180, respectively. CONCLUSIONS: Implementation of four hours of Saturday occupational therapy in addition to physiotherapy results in a more efficient service, enabling a greater amount of therapy to be provided on a Saturday over a shorter length of stay. Provision of multidisciplinary Saturday rehabilitation is potentially cost reducing for the treating hospital.

Preschool HABIT-ILE: study protocol for a randomised controlled trial to determine efficacy of intensive rehabilitation compared with usual care to improve motor skills of children, aged 2-5 years, with bilateral cerebral palsy.

INTRODUCTION: Young children with bilateral cerebral palsy (BCP) often experience difficulties with gross motor function, manual ability and posture, impacting developing independence in daily life activities, participation and quality of life. Hand Arm Bimanual Intensive Training Including Lower Extremity (HABIT-ILE) is a novel intensive motor intervention integrating upper and lower extremity training that has been developed and tested in older school-aged children with unilateral and BCP. This study aims to compare an adapted preschool version of HABIT-ILE to usual care in a randomised controlled trial. METHODS AND ANALYSIS: 60 children with BCP aged 2-5 years, Gross Motor Function Classification System (GMFCS) II-IV will be recruited. Children will be stratified by GMFCS and randomised using concealed allocation to either receive Preschool HABIT-ILE or usual care. Preschool HABIT-ILE will be delivered in groups of four to six children, for 3 hours/day for 10 days (total 30 hours). Children receiving Preschool HABIT-ILE be provided a written home programme with the aim of achieving an additional 10 hours of home practice (total dose 40 hours). Outcomes will be assessed at baseline, immediately following intervention and then retention of effects will be tested at 26 weeks. The primary outcome will be the Peabody Developmental Motors Scales-Second Edition to evaluate gross and fine motor skills. Secondary outcomes will be gross motor function (Gross Motor Function Measure-66), bimanual hand performance (Both Hands Assessment), self-care and mobility (Pediatric Evaluation of Disability Inventory-Computer Adapted Test), goal attainment (Canadian Occupational Performance Measure), global performance of daily activities (ACTIVLIM-CP), cognition and adaptive function (Behavior Rating Inventory of Executive Function-Preschool Version), habitual physical activity (ActiGraph GT3X+) and quality of life (Infant Toddler Quality of Life Questionnaire and Child Health Utility Index-9). Analyses will follow standard principles for RCTs using two-group comparisons on all participants on an intention-to-treat basis. Comparisons between groups for primary and secondary outcomes will be conducted using regression models. ETHICS AND DISSEMINATION: Ethics approval has been granted by the Medical Research Ethics Committee Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/19/QCHQ/59444) and The University of Queensland (2020000336/HREC/19/QCHQ/59444). TRIAL REGISTRATION NUMBER: ACTRN126200000719.

Effectiveness of the Non-Medical Surgical Assistant measured by patient outcome assessment.

AIMS: To investigate effectiveness of the nurse clinician as a Non-Medical Surgical Assistant compared with the Medical Surgical Assistant. BACKGROUND: Non-Medical Surgical Assistants are clinicians who are not medical practitioners. The surgical assistant works directly with the primary surgeon intraoperatively. DESIGN: A pragmatic, retrospective, observational study on patients undergoing Laparoscopic Inguinal Hernia Repair or Primary Unilateral Total Hip Arthroplasty. Each patient received intraoperative care from a consultant surgeon and a Medical Surgical Assistant or Non-Medical Surgical Assistant. All surgical assistants were registered with the Australian Health Practitioner Regulation Agency. METHODS: Data were collected between 01/07/2014 and 30/06/2017. The effect that surgical assistant choice had on patient outcomes was estimated using regression statistical models. Six dependent variables, including length of stay, for clinical outcome assessment were specified. RESULTS/FINDINGS: The groups were equivalent in age, gender, and American Society of Anaesthesiologists scores. There were more emergency procedures in the Medical Surgical Assistant group and more hip surgery in the Non-Medical Surgical Assistant group. Patient outcome assessment showed no statistically significant differences for surgical assistant types. CONCLUSION: The nurse clinician in the role of Non-Medical Surgical Assistant was shown to be effective with equivalent patient outcomes compared with the Medical Surgical Assistant.

Economic evaluation of deep-brain stimulation for Tourette's syndrome: an initial exploration.

BACKGROUND: Deep-brain stimulation (DBS) can be effective in controlling medically intractable symptoms of Tourette's syndrome (TS). There is no evidence to date, though, of the potential cost-effectiveness of DBS for this indication. OBJECTIVE: To provide the first estimates of the likely cost-effectiveness of DBS in the treatment of severe TS. METHODS: We conducted a cost-utility analysis using clinical data from 17 Australian patients receiving DBS. Direct medical costs for DBS using non-rechargeable and rechargeable batteries and for the alternative best medical treatment (BMT), and health utilities for BMT were sourced from the literature. Incremental cost-effectiveness ratios (ICERs) were estimated using a Markov models with a 10-year time horizon and 5% discount rate. RESULTS: DBS increased quality-adjusted life year (QALY) gained from 2.76 to 4.60 over a 10-year time horizon. The ICER for DBS with non-rechargeable (rechargeable) batteries, compared to BMT, was A$33,838 (A$15,859) per QALY. The ICER estimates are sensitive to DBS costs and selected time horizon. CONCLUSIONS: Our study indicates that DBS may be a cost-effective treatment for severe TS, based on the very limited clinical data available and under particular assumptions. While the limited availability of data presents a challenge, we also conduct sensitivity analyses to test the robustness of the results to the assumptions used in the analysis. We nevertheless recommend the implementation of randomised controlled trials that collect a comprehensive range of costs and the use of a widely accepted health-related quality of life instrument to enable more definitive statements about the cost-effectiveness of DBS for TS.

Protocol for a multisite randomised trial of Hand-Arm Bimanual Intensive Training Including Lower Extremity training for children with bilateral cerebral palsy: HABIT-ILE Australia.

INTRODUCTION: Children with bilateral cerebral palsy often experience difficulties with posture, gross motor function and manual ability, impacting independence in daily life activities, participation and quality of life (QOL). Hand-Arm Bimanual Intensive Training Including Lower Extremity (HABIT-ILE) is a novel intensive motor intervention integrating upper and lower extremity training. This study aimed to compare HABIT-ILE to usual care in a large randomised controlled trial (RCT) in terms of gross motor function, manual ability, goal attainment, walking endurance, mobility, self-care and QOL. A within-trial cost-utility analysis will be conducted to synthesise costs and benefits of HABIT-ILE compared with usual care. METHODS AND ANALYSIS: 126 children with bilateral cerebral palsy aged 6-16 years will be recruited across three sites in Australia. Children will be stratified by site and Gross Motor Function Classification System and randomised using concealed allocation to either receiving HABIT-ILE immediately or being waitlisted for 26 weeks. HABIT-ILE will be delivered in groups of 8-12 children, for 6.5 hours per day for 10 days (total 65 hours, 2 weeks). Outcomes will be assessed at baseline, immediately following intervention, and then retention of effects will be tested at 26 weeks. Primary outcomes will be the Gross Motor Function Measure and ABILHAND-Kids. Secondary outcomes will be brain structural integrity, walking endurance, bimanual hand performance, self-care, mobility, performance and satisfaction with individualised goals, and QOL. Analyses will follow standard principles for RCTs using two-group comparisons on all participants on an intention-to-treat basis. Comparisons between groups for primary and secondary outcomes will be conducted using regression models. ETHICS AND DISSEMINATION: Ethics approval has been granted by the Medical Research Ethics Committee of Children's Health Queensland Hospital and the Health Service Human Research Ethics Committee (HREC/17/QRCH/282) of The University of Queensland (2018000017/HREC/17/QRCH/2820), and The Cerebral Palsy Alliance Ethics Committee (2018_04_01/HREC/17/QRCH/282). TRIAL REGISTRATION NUMBER: ACTRN12618000164291.

Cost-Effectiveness of Deep Brain Stimulation With Movement Disorders: A Systematic Review.

BACKGROUND: Movement disorders (MDs) are increasingly being managed with deep brain stimulation (DBS). High-quality economic evaluations (EEs) are necessary to evaluate the cost-effectiveness of DBS. We conducted a systematic review of published EEs of the treatment of MDs with DBS. The review compares and contrasts the reported incremental cost-effectiveness ratios (ICERs) and methodology employed by trial-based evaluations (TBEs) and model-based evaluations (MBEs). METHODS: MeSH and search terms relevant to "MDs," "DBS," and "EEs" were used to search biomedical and economics databases. Studies that used a comparative design to evaluate DBS, including before-after studies, were included. Quality and reporting assessments were conducted independently by 2 authors. Seventeen studies that targeted Parkinson's disease (PD), dystonia, and essential tremor (ET), met our selection criteria. RESULTS: Mean scores for methodological and reporting quality were 73% and 76%, respectively. The ICERs for DBS compared with best medical therapy to treat PD patients obtained from MBEs had a lower mean and range compared with those obtained from TBEs ($55,461-$735,192 per quality-adjusted life-year [QALY] vs. $9,301-$65,111 per QALY). Pre-post ICER for DBS to treat dystonia was $64,742 per QALY. DBS was not cost-effective in treating ET compared with focused-ultrasound surgery. Cost-effectiveness outcomes were sensitive to assumptions in health utilities, surgical costs, battery life-span, model time horizons, and the discount rate. CONCLUSIONS: The infrequent use of randomized, controlled trials to evaluate DBS efficacy, the paucity of data reporting the long-term effectiveness and/or utility of DBS, and the uncertainty surrounding cost data limit our ability to report cost-effectiveness summaries that are robust.

Enhanced future changes in wet and dry extremes over Africa at convection-permitting scale.

African society is particularly vulnerable to climate change. The representation of convection in climate models has so far restricted our ability to accurately simulate African weather extremes, limiting climate change predictions. Here we show results from climate change experiments with a convection-permitting (4.5 km grid-spacing) model, for the first time over an Africa-wide domain (CP4A). The model realistically captures hourly rainfall characteristics, unlike coarser resolution models. CP4A shows greater future increases in extreme 3-hourly precipitation compared to a convection-parameterised 25 km model (R25). CP4A also shows future increases in dry spell length during the wet season over western and central Africa, weaker or not apparent in R25. These differences relate to the more realistic representation of convection in CP4A, and its response to increasing atmospheric moisture and stability. We conclude that, with the more accurate representation of convection, projected changes in both wet and dry extremes over Africa may be more severe.

Seasonal temperature is associated with Parkinson's disease prescriptions: an ecological study.

The aim of this study is to test what effect the weather may have on medications prescribed to treat Parkinson's disease. Twenty-three years of monthly time, series data was sourced from the Pharmaceutical Benefits Scheme (PBS) and the Bureau of Meteorology (BOM). Data were available for eight states and territories and their corresponding capital cities. The dependent variable was the aggregate levodopa equivalent dose (LED) for 51 Parkinson's medications identified on the PBS. Two explanatory variables of interest, temperature and solar exposure, were identified in the BOM data set. Linear and cosinor models were estimated with fixed and random effects, respectively. The prescribed LED was 4.2% greater in January and 4.5% lower in July. Statistical analysis showed that temperature was associated with the prescription of Parkinson medications. Our results suggest seasonality exists in Parkinson's disease symptoms and this may be related to temperature. Further work is needed to confirm these findings and understand the underlying mechanisms as a better understanding of the causes of any seasonal variation in Parkinson's disease may help clinicians and patients manage the disease more effectively.

Short-range phenotypic divergence among genetically distinct parapatric populations of an Australian funnel-web spider.

Speciation involves divergence at genetic and phenotypic levels. Where substantial genetic differentiation exists among populations, examining variation in multiple phenotypic characters may elucidate the mechanisms by which divergence and speciation unfold. Previous work on the Australian funnel-web spider Atrax sutherlandi Gray (2010; Records of the Australian Museum62, 285-392; Mygalomorphae: Hexathelidae: Atracinae) has revealed a marked genetic structure along a 110-kilometer transect, with six genetically distinct, parapatric populations attributable to past glacial cycles. In the present study, we explore variation in three classes of phenotypic characters (metabolic rate, water loss, and morphological traits) within the context of this phylogeographic structuring. Variation in metabolic and water loss rates shows no detectable association with genetic structure; the little variation observed in these rates may be due to the spiders' behavioral adaptations (i.e., burrowing), which buffer the effects of climatic gradients across the landscape. However, of 17 morphological traits measured, 10 show significant variation among genetic populations, in a disjunct manner that is clearly not latitudinal. Moreover, patterns of variation observed for morphological traits serving different organismic functions (e.g., prey capture, burrowing, and locomotion) are dissimilar. In contrast, a previous study of an ecologically similar sympatric spider with little genetic structure indicated a strong latitudinal response in 10 traits over the same range. The congruence of morphological variation with deep phylogeographic structure in Tallaganda's A. sutherlandi populations, as well as the inconsistent patterns of variation across separate functional traits, suggest that the spiders are likely in early stages of speciation, with parapatric populations independently responding to local selective forces.

Evaluation of a Skin Self-Examination Programme: a Four-Stage Recursive Model

Background: Effective skin self-examination can enable early diagnosis and treatment of skin cancer, which otherwise could result in significant morbidity and mortality. We compare the effects of watching a DVD and reading printed materials on self skin examination. Methods: Longitudinal data from the Randomized Skin Awareness Trial were analysed (n=984). The control group were provided with written materials describing how to conduct effective skin self-examination. The intervention group received additional instruction from a DVD. It was hypothesized that self skin examination may be confounded by unobserved variables. A recursive model was specified to control for this potential source of bias. Results: At six months only watching the DVD had a statistically significant effect on diagnosed skin cancer. By 12 months both interventions were statistically significant; reading the printed materials was 63% as effective as watching the DVD. Conclusion: Watching a DVD was associated with the largest increase in diagnosed skin cancer. However, reading written materials was also associated with an increase in diagnosed skin cancer. Both visual and written communication should be considered when designing an effective skin self-examination programme.

Proceedings of the Fourth Annual Deep Brain Stimulation Think Tank: A Review of Emerging Issues and Technologies.

This paper provides an overview of current progress in the technological advances and the use of deep brain stimulation (DBS) to treat neurological and neuropsychiatric disorders, as presented by participants of the Fourth Annual DBS Think Tank, which was convened in March 2016 in conjunction with the Center for Movement Disorders and Neurorestoration at the University of Florida, Gainesveille FL, USA. The Think Tank discussions first focused on policy and advocacy in DBS research and clinical practice, formation of registries, and issues involving the use of DBS in the treatment of Tourette Syndrome. Next, advances in the use of neuroimaging and electrochemical markers to enhance DBS specificity were addressed. Updates on ongoing use and developments of DBS for the treatment of Parkinson's disease, essential tremor, Alzheimer's disease, depression, post-traumatic stress disorder, obesity, addiction were presented, and progress toward innovation(s) in closed-loop applications were discussed. Each section of these proceedings provides updates and highlights of new information as presented at this year's international Think Tank, with a view toward current and near future advancement of the field.

A comparison of the direct medical costs for individuals with or without basal or squamous cell skin cancer: A study from Australia.

OBJECTIVES: The composition of the medical costs incurred by people treated for basal cell and squamous cell carcinomas (hereafter keratinocyte cancers) is not adequately understood. We sought to compare the medical costs of individuals with or without keratinocyte cancers. METHODS: We used national health insurance data to analyze the direct medical costs of 2000 cases and 2000 controls nested within the QSkin prospective cohort study (n = 43,794) conducted in Australia. We reconstructed the medical history of patients using medical and pharmaceutical item codes and then compared the health service costs of individuals treated for keratinocyte cancers with those not treated for keratinocyte cancers. RESULTS: Individuals treated for keratinocyte cancers consumed on average AUD$1320 per annum more in medical services than those without keratinocyte cancers. Only 23.2% of costs were attributed to the explicit treatment of keratinocyte cancers. The principal drivers of the residual costs were medical attendances, surgical procedures on the skin, and histopathology services. We found significant positive associations between history of treatment for keratinocyte cancers with treatments for other health conditions, including melanoma, cardiovascular disease, lipidemia, osteoporosis, rheumatoid arthritis, colorectal cancer, prostate cancer, and tuberculosis. CONCLUSION: Individuals treated for keratinocyte cancers have substantially higher medical costs overall than individuals without keratinocyte cancers. The direct costs of skin cancer excision account for only one-fifth of this difference.

A reconstruction of a medical history from administrative data: with an application to the cost of skin cancer.

The medical record is a repository of clinical data, which can greatly enhance the quality of health and healthcare analysis. Administrative data are collected for the purpose of billing and reimbursement, and are valued by health researchers because the data are routinely audited to maintain accurate financial records. However, the quantity of incorporated clinical data can be variable. In this paper we reconstruct the medical record from health service invoices to estimate the cost of treating keratinocytic cancer (KC). The data from an epidemiological survey were linked to an administrative data set supplied by the national health insurer. A matched sampling technique with multivariable analysis was used to estimate cost. A KC treatment was identified with 42 service codes which explicitly nominated treatment of a KC. Algorithms identifying comorbities potentially correlated with KC were constructed from the service codes. The annual cost of a KC treatment was estimated to be AU$667 per individual. The average cost of explicit KC treatments was AU$231, while the cost of generic procedures used to treat KC was AU$436. Our ability to accurately control for the medical history enabled our analysis to quantify and describe the constituent costs of KC treatment.

Health system costs of skin cancer and cost-effectiveness of skin cancer prevention and screening: a systematic review.

The objective of this study was to review the literature for malignant melanoma, basal and squamous cell carcinomas to understand: (a) national estimates of the direct health system costs of skin cancer and (b) the cost-effectiveness of interventions for skin cancer prevention or early detection. A systematic review was performed using Medline, Cochrane Library and the National Health Service Economic Evaluation Databases as well as a manual search of reference lists to identify relevant studies up to 31 August 2013. A narrative synthesis approach was used to summarize the data. National cost estimates were adjusted for country-specific inflation and presented in 2013 euros. The CHEERS statement was used to assess the quality of the economic evaluation studies. Sixteen studies reporting national estimates of skin cancer costs and 11 cost-effectiveness studies on skin cancer prevention or early detection were identified. Relative to the size of their respective populations, the annual direct health system costs for skin cancer were highest for Australia, New Zealand, Sweden and Denmark (2013 euros). Skin cancer prevention initiatives are highly cost-effective and may also be cost-saving. Melanoma early detection programmes aimed at high-risk individuals may also be cost-effective; however, updated analyses are needed. There is a significant cost burden of skin cancer for many countries and health expenditure for this disease will grow as incidence increases. Public investment in skin cancer prevention and early detection programmes show strong potential for health and economic benefits.

Environmental complexity and biodiversity: the multi-layered evolutionary history of a log-dwelling velvet worm in Montane Temperate Australia.

Phylogeographic studies provide a framework for understanding the importance of intrinsic versus extrinsic factors in shaping patterns of biodiversity through identifying past and present microevolutionary processes that contributed to lineage divergence. Here we investigate population structure and diversity of the Onychophoran (velvet worm) Euperipatoides rowelli in southeastern Australian montane forests that were not subject to Pleistocene glaciations, and thus likely retained more forest cover than systems under glaciation. Over a ~100 km transect of structurally-connected forest, we found marked nuclear and mitochondrial (mt) DNA genetic structuring, with spatially-localised groups. Patterns from mtDNA and nuclear data broadly corresponded with previously defined geographic regions, consistent with repeated isolation in refuges during Pleistocene climatic cycling. Nevertheless, some E. rowelli genetic contact zones were displaced relative to hypothesized influential landscape structures, implying more recent processes overlying impacts of past environmental history. Major impacts at different timescales were seen in the phylogenetic relationships among mtDNA sequences, which matched geographic relationships and nuclear data only at recent timescales, indicating historical gene flow and/or incomplete lineage sorting. Five major E. rowelli phylogeographic groups were identified, showing substantial but incomplete reproductive isolation despite continuous habitat. Regional distinctiveness, in the face of lineages abutting within forest habitat, could indicate pre- and/or postzygotic gene flow limitation. A potentially functional phenotypic character, colour pattern variation, reflected the geographic patterns in the molecular data. Spatial-genetic patterns broadly match those in previously-studied, co-occurring low-mobility organisms, despite a variety of life histories. We suggest that for E. rowelli, the complex topography and history of the region has led to interplay among limited dispersal ability, historical responses to environmental change, local adaptation, and some resistance to free admixture at geographic secondary contact, leading to strong genetic structuring at fine spatial scale.

Testing for vitamin D and other trends in the clinical management of osteoporosis.

SUMMARY: This descriptive paper identifies some salient trends in the Australian management of osteoporosis. Changes in pharmaceutical consumption and medical utilisation are analysed. The total national consumption of four pharmaceuticals is estimated. From 2001 to 2011, the consumption of bisphosphonates and vitamin D increased. After 2006, the management rate for osteoporosis decreased. PURPOSE: During the first decade of the millennia, the total cost of vitamin D tests has increased significantly within many health care jurisdictions worldwide. Australia reports a 100-fold increase. Legitimately, concerns regarding the economic effectiveness of this test exist. The purpose of this paper is to identify what other salient clinical trends could affect the efficacy of this test when treating osteoporosis. METHODS: Longitudinal data from two Australian datasets are analysed. The first are data obtained from Medicare Australia, which report pharmaceutical consumption. The second are data obtained from a national survey of general practitioners. RESULTS: The management of osteoporosis has been characterised by a movement away from single to combination formularies. The consumption of calcium carbonate has declined, and the use of bisphosphonates has increased. While the gross consumption of risedronate increased steadily over the decade (8.4 to 186.5 kg), the consumption of alendronate declined after 2007. The consumption of vitamin D (over-the-counter and prescription) has increased from 0.58 to 2.8 kg over the decade. While prescription vitamin D comprised just 10% of the total, its consumption has undergone a 20-fold increase since 2006. Importantly, we can also report that the management of osteoporosis by Australia's general practitioners increased steadily until 2007-2008, before declining by 36%. CONCLUSIONS: Further research is required to determine possible casual relationships that may exist between these data. Until a formal economic evaluation of vitamin D testing in this clinical setting is completed, no conclusions regarding its economic effectiveness should be drawn.

Implications of global warming for the climate of African rainforests.

African rainforests are likely to be vulnerable to changes in temperature and precipitation, yet there has been relatively little research to suggest how the regional climate might respond to global warming. This study presents projections of temperature and precipitation indices of relevance to African rainforests, using global climate model experiments to identify local change as a function of global temperature increase. A multi-model ensemble and two perturbed physics ensembles are used, one with over 100 members. In the east of the Congo Basin, most models (92%) show a wet signal, whereas in west equatorial Africa, the majority (73%) project an increase in dry season water deficits. This drying is amplified as global temperature increases, and in over half of coupled models by greater than 3% per °C of global warming. Analysis of atmospheric dynamics in a subset of models suggests that this could be partly because of a rearrangement of zonal circulation, with enhanced convection in the Indian Ocean and anomalous subsidence over west equatorial Africa, the Atlantic Ocean and, in some seasons, the Amazon Basin. Further research to assess the plausibility of this and other mechanisms is important, given the potential implications of drying in these rainforest regions.

Are people who claim compensation "cured by a verdict"? A longitudinal study of health outcomes after whiplash.

This study examines whether the lure of injury compensation prompts whiplash claimants to overstate their symptoms. Claim settlement is the intervention of interest, as it represents the point at which there is no further incentive to exaggerate symptoms, and neck pain at 24 months is the outcome of interest. Longitudinal data on neck pain scores and timing of claim settlement were regressed, controlling for the effect of time on recovery, to compare outcomes in claimants who had and had not settled their compensation claims. The results show clearly that removing the financial incentive to over-report symptoms has no effect on self-reported neck pain in a fault-based compensation scheme, and this finding concurs with other studies on this topic. Policy decisions to limit compensation in the belief that claimants systematically misrepresent their health status are not supported empirically Claimants do not appear to be "cured by a verdict".

Predicting local adaptation in fragmented plant populations: implications for restoration genetics.

Understanding patterns and correlates of local adaptation in heterogeneous landscapes can provide important information in the selection of appropriate seed sources for restoration. We assessed the extent of local adaptation of fitness components in 12 population pairs of the perennial herb Rutidosis leptorrhynchoides (Asteraceae) and examined whether spatial scale (0.7-600 km), environmental distance, quantitative (Q(ST)) and neutral (F(ST)) genetic differentiation, and size of the local and foreign populations could predict patterns of adaptive differentiation. Local adaptation varied among populations and fitness components. Including all population pairs, local adaptation was observed for seedling survival, but not for biomass, while foreign genotype advantage was observed for reproduction (number of inflorescences). Among population pairs, local adaptation increased with Q(ST) and local population size for biomass. Q(ST) was associated with environmental distance, suggesting ecological selection for phenotypic divergence. However, low F(ST) and variation in population structure in small populations demonstrates the interaction of gene flow and drift in constraining local adaptation in R. leptorrhynchoides. Our study indicates that for species in heterogeneous landscapes, collecting seed from large populations from similar environments to candidate sites is likely to provide the most appropriate seed sources for restoration.