Interventions to control nosocomial infections : study designs and statistical issues

There is a wide range of potential study designs for intervention studies to decrease nosocomial infections in hospitals. The analysis is complex due to competing events, clustering, multiple timescales and time-dependent period and intervention variables. This review considers the popular pre-post quasi-experimental design and compares it with randomized designs. Randomization can be done in several ways: randomization of the cluster [intensive care unit (ICU) or hospital] in a parallel design; randomization of the sequence in a cross-over design; and randomization of the time of intervention in a stepped-wedge design. We introduce each design in the context of nosocomial infections and discuss the designs with respect to the following key points: bias, control for nonintervention factors, and generalizability. Statistical issues are discussed. A pre-post-intervention design is often the only choice that will be informative for a retrospective analysis of an outbreak setting. It can be seen as a pilot study with further, more rigorous designs needed to establish causality. To yield internally valid results, randomization is needed. Generally, the first choice in terms of the internal validity should be a parallel cluster randomized trial. However, generalizability might be stronger in a stepped-wedge design because a wider range of ICU clinicians may be convinced to participate, especially if there are pilot studies with promising results. For analysis, the use of extended competing risk models is recommended.

Temporal and spatial distribution and habitat associations of an urban population of New Zealand long-tailed bats (Chalinolobus tuberculatus)

Two ultrasound survey methods were used to determine the presence and activity patterns of New Zealand long-tailed bats (Chalinolobus tuberculatus) in the city of Hamilton. First, 13 monthly surveys conducted at 18 green spaces found C. tuberculatus in only one urban forest reserve, Hammond Bush, where they were found consistently throughout the year. Bat activity was strongly related to temperature. Second, twice-yearly citywide surveys conducted over 2 years determined the distribution and habitat associations of C. tuberculatus. Bats were found only in the southern part of the city and were strongly associated with the Waikato River. Bat activity was negatively correlated with housing and street light density and positively correlated with topographical complexity. In Hamilton, topographical complexity indicates the presence of gullies. Gullies probably provide foraging and roosting opportunities and connect the river to distant forest patches. These results suggest that urban habitats can be useful for bats if gullies can link these to distant habitat fragments.

Seasonal occurrence and distribution of Bryde's whales in the Hauraki Gulf, New Zealand

The Hauraki Gulf is a large, shallow embayment located north of Auckland City (36°51′S, 174°46′E), New Zealand. Bryde's whales (Balaenoptera edeni) are the most frequently observed balaenopterid in these waters. To assess the use of the Hauraki Gulf for this species, we examined the occurrence and distribution in relation to environmental parameters. Data were collected from a platform of opportunity during 674 daily surveys between March 2003 and February 2006. A total of 760 observations of Bryde's whales were recorded throughout the study period during 371 surveys. The number of Bryde's whales sighted/day was highest in winter, coinciding with the coolest median sea-surface temperature (14.6°C). Bryde's whales were recorded throughout the Hauraki Gulf in water depths ranging from 12.1–59.8 m (mean = 42.3, SD = 5.1). Cow–calf pairs were most frequently observed during the austral autumn in water depths of 29.9–53.9 m (mean = 40.8, SD = 5.2). Data from this study suggest Bryde's whales in the Hauraki Gulf exhibit a mix of both “inshore” and “offshore” characteristics from the Bryde's whales examined off the coast of South Africa. Based on complete mitochondrial DNA sequences, Sasaki et al. (2006) recognized two sister species of Bryde's whales: Balaenoptera brydei and B. edeni, with the latter including small-type, more coastal Bryde's whales from Japan, Hong Kong, and Australia. Their samples and samples in previous analyses of small-type whales, all originated from eastern and southeastern Asia. These authors did not include the forms of Bryde's whales that occur in other regions, e.g., in the Pacific off Peru (Valdivia et al. 1981), in the Atlantic off Brazil (Best 1977) and in the western Indian Ocean off South Africa (Best 1977). Recent genetic analysis using mtDNA from the “inshore” and “offshore” forms from South Africa confirms the offshore form is B. brydei, and establishes that the inshore form is more closely related to B. brydei than to B. edeni (Penry 2010). These different forms do vary considerably in their habitat use and ecology (refer to Table 1 for a detailed comparison between the South African inshore and offshore forms, as described by Best (1967, 1977) and the Bryde's whales from New Zealand (Wiseman 2008). Recent genetic analysis on the Bryde's whales in the Hauraki Gulf suggests they are B. brydei (Wiseman 2008). However, pending resolution of the uncertainty within and between species of this genus, we follow the Society of Marine Mammal's committee on taxonomy, who state that B. edeni applies to all Bryde's whales.

Meta-analysis of prevalence

Meta-analysis is a method to obtain a weighted average of results from various studies. In addition to pooling effect sizes, meta-analysis can also be used to estimate disease frequencies, such as incidence and prevalence. In this article we present methods for the meta-analysis of prevalence. We discuss the logit and double arcsine transformations to stabilise the variance. We note the special situation of multiple category prevalence, and propose solutions to the problems that arise. We describe the implementation of these methods in the MetaXL software, and present a simulation study and the example of multiple sclerosis from the Global Burden of Disease 2010 project. We conclude that the double arcsine transformation is preferred over the logit, and that the MetaXL implementation of multiple category prevalence is an improvement in the methodology of the meta-analysis of prevalence.

The regional distribution of anxiety disorders : implications for the Global Burden of Disease Study, 2010

Anxiety disorders are increasingly acknowledged as a global health issue however an accurate picture of prevalence across populations is lacking. Empirical data are incomplete and inconsistent so alternate means of estimating prevalence are required to inform estimates for the new Global Burden of Disease Study 2010. We used a Bayesian meta-regression approach which included empirical epidemiological data, expert prior information, study covariates and population characteristics. Reported are global and regional point prevalence for anxiety disorders in 2010. Point prevalence of anxiety disorders differed by up to three-fold across world regions, ranging between 2.1% (1.8-2.5%) in East Asia and 6.1% (5.1-7.4%) in North Africa/Middle East. Anxiety was more common in Latin America; high income regions; and regions with a history of recent conflict. There was considerable uncertainty around estimates, particularly for regions where no data were available. Future research is required to examine whether variations in regional distributions of anxiety disorders are substantive differences or an artefact of cultural or methodological differences. This is a particular imperative where anxiety is consistently reported to be less common, and where it appears to be elevated, but uncertainty prevents the reporting of conclusive estimates.

The contribution of major depression to the global burden of ischemic heart disease : a comparative risk assessment

Background Cardiovascular disease and mental health both hold enormous public health importance, both ranking highly in results of the recent Global Burden of Disease Study 2010 (GBD 2010). For the first time, the GBD 2010 has systematically and quantitatively assessed major depression as an independent risk factor for the development of ischemic heart disease (IHD) using comparative risk assessment methodology. Methods A pooled relative risk (RR) was calculated from studies identified through a systematic review with strict inclusion criteria designed to provide evidence of independent risk factor status. Accepted case definitions of depression include diagnosis by a clinician or by non-clinician raters adhering to Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) classifications. We therefore refer to the exposure in this paper as major depression as opposed to the DSM-IV category of major depressive disorder (MDD). The population attributable fraction (PAF) was calculated using the pooled RR estimate. Attributable burden was calculated by multiplying the PAF by the underlying burden of IHD estimated as part of GBD 2010. Results The pooled relative risk of developing IHD in those with major depression was 1.56 (95% CI 1.30 to 1.87). Globally there were almost 4 million estimated IHD disability-adjusted life years (DALYs), which can be attributed to major depression in 2010; 3.5 million years of life lost and 250,000 years of life lived with a disability. These findings highlight a previously underestimated mortality component of the burden of major depression. As a proportion of overall IHD burden, 2.95% (95% CI 1.48 to 4.46%) of IHD DALYs were estimated to be attributable to MDD in 2010. Eastern Europe and North Africa/Middle East demonstrate the highest proportion with Asia Pacific, high income representing the lowest. Conclusions The present work comprises the most robust systematic review of its kind to date. The key finding that major depression may be responsible for approximately 3% of global IHD DALYs warrants assessment for depression in patients at high risk of developing IHD or at risk of a repeat IHD event.

Wheeze, asthma diagnosis and medication use : a national adult survey in a developing country

Background As relatively little is known about adult wheeze and asthma in developing countries, this study aimed to determine the predictors of wheeze, asthma diagnosis, and current treatment in a national survey of South African adults. Methods A stratified national probability sample of households was drawn and all adults (>14 years) in the selected households were interviewed. Outcomes of interest were recent wheeze, asthma diagnosis, and current use of asthma medication. Predictors of interest were sex, age, household asset index, education, racial group, urban residence, medical insurance, domestic exposure to smoky fuels, occupational exposure, smoking, body mass index, and past tuberculosis. Results A total of 5671 men and 8155 women were studied. Although recent wheeze was reported by 14.4% of men and 17.6% of women and asthma diagnosis by 3.7% of men and 3.8% of women, women were less likely than men to be on current treatment (OR 0.6; 95% confidence interval (CI) 0.5 to 0.8). A history of tuberculosis was an independent predictor of both recent wheeze (OR 3.4; 95% CI 2.5 to 4.7) and asthma diagnosis (OR 2.2; 95% CI 1.5 to 3.2), as was occupational exposure (wheeze: OR 1.8; 95% CI 1.5 to 2.0; asthma diagnosis: OR 1.9; 95% CI 1.4 to 2.4). Smoking was associated with wheeze but not asthma diagnosis. Obesity showed an association with wheeze only in younger women. Both wheeze and asthma diagnosis were more prevalent in those with less education but had no association with the asset index. Independently, having medical insurance was associated with a higher prevalence of diagnosis. Conclusions Some of the findings may be to due to reporting bias and heterogeneity of the categories wheeze and asthma diagnosis, which may overlap with post tuberculous airways obstruction and chronic obstructive pulmonary disease due to smoking and occupational exposures. The results underline the importance of controlling tuberculosis and occupational exposures as well as smoking in reducing chronic respiratory morbidity. Validation of the asthma questionnaire in this setting and research into the pathophysiology of post tuberculous airways obstruction are also needed.

Global variation in the prevalence and incidence of major depressive disorder : a systematic review of the epidemiological literature

Background Summarizing the epidemiology of major depressive disorder (MDD) at a global level is complicated by significant heterogeneity in the data. The aim of this study is to present a global summary of the prevalence and incidence of MDD, accounting for sources of bias, and dealing with heterogeneity. Findings are informing MDD burden quantification in the Global Burden of Disease (GBD) 2010 Study. Method A systematic review of prevalence and incidence of MDD was undertaken. Electronic databases Medline, PsycINFO and EMBASE were searched. Community-representative studies adhering to suitable diagnostic nomenclature were included. A meta-regression was conducted to explore sources of heterogeneity in prevalence and guide the stratification of data in a meta-analysis. Results The literature search identified 116 prevalence and four incidence studies. Prevalence period, sex, year of study, depression subtype, survey instrument, age and region were significant determinants of prevalence, explaining 57.7% of the variability between studies. The global point prevalence of MDD, adjusting for methodological differences, was 4.7% (4.4–5.0%). The pooled annual incidence was 3.0% (2.4–3.8%), clearly at odds with the pooled prevalence estimates and the previously reported average duration of 30 weeks for an episode of MDD. Conclusions Our findings provide a comprehensive and up-to-date profile of the prevalence of MDD globally. Region and study methodology influenced the prevalence of MDD. This needs to be considered in the GBD 2010 study and in investigations into the ecological determinants of MDD. Good-quality estimates from low-/middle-income countries were sparse. More accurate data on incidence are also required.

Queensland's film culture: The challenges of local film distribution and festival exhibition

Organisations at the centre of the state’s industry, such as Screen Queensland, have undergone substantial and ongoing changes in the last five years. Other organisations funded by Screen Queensland, such as QPIX, Queensland’s only film development centre, have recently closed. The Brisbane International Film Festival has been restructured to become the Brisbane Asia Pacific Film Festival as of 2014. In an uncertain industry currently characterised by limited funding and diminishing support structures, local emerging filmmakers require significant initiatives and a sophisticated understanding of how to best utilise fledgling distribution models as part of a tailored strategy for their content. This essay includes interviews with emerging Brisbane filmmakers who have used a combination of traditional and contemporary approaches to exhibition and distribution thus far in their careers. It argues that for these filmmakers, while film festivals do function as crucial platforms for exposure, in the current digital market they cannot be relied upon as the only platform in securing further mainstream or commercial release. They can, however, be incorporated into an alternative distribution model that shows awareness of the contemporary situation in Australia. The research findings are arguably indicative of the challenges faced by filmmakers statewide, and suggest that further support strategies need to be considered to revive Queensland’s film culture and provide immediate support for emerging filmmakers. Queensland’s film sector is currently in the midst of significant change.

Phenotyping cotton ovule fibre initiation with spatial statistics

Yield in cultivated cotton (Gossypium spp.) is affected by the number and distribution of fibres initiated on the seed surface but, apart from simple statistical summaries, little has been done to assess this phenotype quantitatively. Here we use two types of spatial statistics to describe and quantify differences in patterning of cotton ovule fibre initials (FI). The following five different species of Gossypium were analysed: G. hirsutum L., G. barbadense L., G. arboreum, G. raimondii Ulbrich. and G. trilobum (DC.) Skovsted. Scanning electron micrographs of FIs were taken on the day of anthesis. Cell centres for fibre and epidermal cells were digitised and analysed by spatial statistics methods appropriate for marked point processes and tessellations. Results were consistent with previously published reports of fibre number and spacing. However, it was shown that the spatial distributions of FIs in all of species examined exhibit regularity, and are not completely random as previously implied. The regular arrangement indicates FIs do not appear independently of each other and we surmise there may be some form of mutual inhibition specifying fibre-initial development. It is concluded that genetic control of FIs differs from that of stomata, another well studied plant idioblast. Since spatial statistics show clear species differences in the distribution of FIs within this genus, they provide a useful method for phenotyping cotton. © CSIRO 2007.

Hydrochemical evolution and groundwater flow processes in the Galilee and Eromanga basins, Great Artesian Basin, Australia: A multivariate statistical approach

The Galilee and Eromanga basins are sub-basins of the Great Artesian Basin (GAB). In this study, a multivariate statistical approach (hierarchical cluster analysis, principal component analysis and factor analysis) is carried out to identify hydrochemical patterns and assess the processes that control hydrochemical evolution within key aquifers of the GAB in these basins. The results of the hydrochemical assessment are integrated into a 3D geological model (previously developed) to support the analysis of spatial patterns of hydrochemistry, and to identify the hydrochemical and hydrological processes that control hydrochemical variability. In this area of the GAB, the hydrochemical evolution of groundwater is dominated by evapotranspiration near the recharge area resulting in a dominance of the Na–Cl water types. This is shown conceptually using two selected cross-sections which represent discrete groundwater flow paths from the recharge areas to the deeper parts of the basins. With increasing distance from the recharge area, a shift towards a dominance of carbonate (e.g. Na–HCO3 water type) has been observed. The assessment of hydrochemical changes along groundwater flow paths highlights how aquifers are separated in some areas, and how mixing between groundwater from different aquifers occurs elsewhere controlled by geological structures, including between GAB aquifers and coal bearing strata of the Galilee Basin. The results of this study suggest that distinct hydrochemical differences can be observed within the previously defined Early Cretaceous–Jurassic aquifer sequence of the GAB. A revision of the two previously recognised hydrochemical sequences is being proposed, resulting in three hydrochemical sequences based on systematic differences in hydrochemistry, salinity and dominant hydrochemical processes. The integrated approach presented in this study which combines different complementary multivariate statistical techniques with a detailed assessment of the geological framework of these sedimentary basins, can be adopted in other complex multi-aquifer systems to assess hydrochemical evolution and its geological controls.

Smart coordinated distribution system control to enable high level penetration of rooftop PVs

This thesis addresses voltage violation problem, the most critical issue associated with high level penetration of photovoltaic (PV) in electricity distribution network. A coordinated control algorithm using the reactive power from PV inverter and integrated battery energy storage has been developed and investigated in different network scenarios in the thesis. Probable variations associated with solar generation, end-user participation and network parameters are also considered. Furthermore, a unified data model and well-defined communication protocol to ensure the smooth coordination between all the components during the operation of the algorithm is described. Finally this thesis incorporated the uncertainties of solar generation using probabilistic load flow analysis.

Systematic review of interventions to improve the provision of information for adults with primary brain tumors and their caregivers

Background: Adults with primary brain tumors and their caregivers have significant information needs. This review assessed the effect of interventions to improve information provision for adult primary brain tumor patients and/or their caregivers. Methods: We included randomized or nonrandomized trials testing educational interventions that had outcomes of information provision, knowledge, understanding, recall, or satisfaction with the intervention, for adults diagnosed with primary brain tumors and/or their family or caregivers. PubMed, MEDLINE, EMBASE and Cochrane Reviews databases were searched for studies published between 1980 and June 2014. Results: Two randomized controlled, one non-randomized controlled, and 10 single group pre-post trials enrolled more than 411 participants. Five group, four practice/process change and four individual interventions assessed satisfaction (12 studies), knowledge (four studies) or information provision (2 studies). Nine studies reported high rates of satisfaction. Three studies showed statistically significant improvements over time in knowledge and two showed greater information was provided to intervention than control group participants, although statistical testing was not performed. Discussion: The trials assessed intermediate outcomes such as satisfaction, and only 4/13 reported on knowledge improvements. Few trials had a randomized controlled design and risk of bias was either evident or could not be assessed in most domains.

A supervisory load-leveling approach to improve the voltage profile in distribution network

This paper suggests a supervisory control for storage units to provide load leveling in distribution networks. This approach coordinates storage units to charge during high generation and discharge during peak load times, while utilized to improve the network voltage profile indirectly. The aim of this control strategy is to establish power sharing on a pro rata basis for storage units. As a case study, a practical distribution network with 30 buses is simulated and the results are provided.

Impact of PV units in LV feeders on distribution system reliability

Re-supplying loads on outage through cross-connect from adjacent feeders in a distribution system may cause voltage drop and hence require load shedding. However, the surplus PV generated in some of the LV feeders can prevent load shedding, and improve reliability. In order to measure these effects, this paper proposes the application of Direct Load Flow method[1] in reliability evaluation of distribution systems with PV units. As part of this study, seasonal impacts on load consumption together with surplus PV output power injection to higher voltage networks are also considered. New indices are proposed to measure yearly expected energy export, from LV to MV and from MV to higher voltage network.