Home-based versus clinic-based specimen collection in the management of Chlamydia trachomatis and Neisseria gonorrhoeae infections

BACKGROUND Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most frequent causes of bacterial sexually transmitted infections (STIs). Management strategies that reduce losses in the clinical pathway from infection to cure might improve STI control and reduce complications resulting from lack of, or inadequate, treatment. OBJECTIVES To assess the effectiveness and safety of home-based specimen collection as part of the management strategy for Chlamydia trachomatis and Neisseria gonorrhoeae infections compared with clinic-based specimen collection in sexually-active people. SEARCH METHODS We searched the Cochrane Sexually Transmitted Infections Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS on 27 May 2015, together with the World Health Organization International Clinical Trials Registry (ICTRP) and ClinicalTrials.gov. We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. SELECTION CRITERIA Randomized controlled trials (RCTs) of home-based compared with clinic-based specimen collection in the management of C. trachomatis and N. gonorrhoeae infections. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. We contacted study authors for additional information. We resolved any disagreements through consensus. We used standard methodological procedures recommended by Cochrane. The primary outcome was index case management, defined as the number of participants tested, diagnosed and treated, if test positive. MAIN RESULTS Ten trials involving 10,479 participants were included. There was inconclusive evidence of an effect on the proportion of participants with index case management (defined as individuals tested, diagnosed and treated for CT or NG, or both) in the group with home-based (45/778, 5.8%) compared with clinic-based (51/788, 6.5%) specimen collection (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.60 to 1.29; 3 trials, I² = 0%, 1566 participants, moderate quality). Harms of home-based specimen collection were not evaluated in any trial. All 10 trials compared the proportions of individuals tested. The results for the proportion of participants completing testing had high heterogeneity (I² = 100%) and were not pooled. We could not combine data from individual studies looking at the number of participants tested because the proportions varied widely across the studies, ranging from 30% to 96% in home group and 6% to 97% in clinic group (low-quality evidence). The number of participants with positive test was lower in the home-based specimen collection group (240/2074, 11.6%) compared with the clinic-based group (179/967, 18.5%) (RR 0.72, 95% CI 0.61 to 0.86; 9 trials, I² = 0%, 3041 participants, moderate quality). AUTHORS' CONCLUSIONS Home-based specimen collection could result in similar levels of index case management for CT or NG infection when compared with clinic-based specimen collection. Increases in the proportion of individuals tested as a result of home-based, compared with clinic-based, specimen collection are offset by a lower proportion of positive results. The harms of home-based specimen collection compared with clinic-based specimen collection have not been evaluated. Future RCTs to assess the effectiveness of home-based specimen collection should be designed to measure biological outcomes of STI case management, such as proportion of participants with negative tests for the relevant STI at follow-up.

Management of fever and neutropenia in paediatric cancer patients: room for improvement?

PURPOSE OF REVIEW Fever and neutropenia is the most common complication in the treatment of childhood cancer. This review will summarize recent publications that focus on improving the management of this condition as well as those that seek to optimize translational research efforts. RECENT FINDINGS A number of clinical decision rules are available to assist in the identification of low-risk fever and neutropenia however few have undergone external validation and formal impact analysis. Emerging evidence suggests acute fever and neutropenia management strategies should include time to antibiotic recommendations, and quality improvement initiatives have focused on eliminating barriers to early antibiotic administration. Despite reported increases in antimicrobial resistance, few studies have focused on the prediction, prevention, and optimal treatment of these infections and the effect on risk stratification remains unknown. A consensus guideline for paediatric fever and neutropenia research is now available and may help reduce some of the heterogeneity between studies that have previously limited the translation of evidence into clinical practice. SUMMARY Risk stratification is recommended for children with cancer and fever and neutropenia. Further research is required to quantify the overall impact of this approach and to refine exactly which children will benefit from early antibiotic administration as well as modifications to empiric regimens to cover antibiotic-resistant organisms.

Decarbonization of toll plazas: impact assessment of toll collection system management

Transport climate change impacts have become a worldwide concern. The use of Intelligent Transport Systems (ITS) could contribute to a more effective use of resources in toll road networks. Management of toll plazas is central to the reduction of greenhouse gas (GHG) emissions, as it is there that bottlenecks and congestion occur. This study focuses on management strategies aimed at reducing climate change impacts of toll plazas by managing toll collection systems. These strategies are based on the use of different collection system technologies – Electronic Toll Collection (ETC) and Open Road Tolling (ORT) – and on queue management. The carbon footprint of various toll plazas is determined by a proposed integrated methodology which estimates the carbon dioxide (CO2) emissions of the different operational stages at toll plazas (deceleration, service time, acceleration, and queuing) for the different toll collection systems. To validate the methodology, two main-line toll plazas of a Spanish toll highway were evaluated. The findings reveal that the application of new technologies to toll collection systems is an effective management strategy from an environmental point of view. The case studies revealed that ORT systems lead to savings of up to 70% of CO2 emissions at toll plazas, while ETC systems save 20% comparing to the manual ones. Furthermore, queue management can offer a 16% emissions savings when queue time is reduced by 116 seconds. The integrated methodology provides an efficient environmental management tool for toll plazas. The use of new technologies is the future of the decarbonization of toll plazas.

Optimizing PV use through active demand side management

With recent technological developments within the field of power conditioning and the progressive decrease of incentives for PV electricity in grid-connected markets, new operation modes for PV systems should be explored beyond the traditional maximization of PV electri city feed-in. An example can be found in the domestic sector, where the use of modern PV hybrid systems combin ed with efficient electrical appliances and demand side management strategies can significantly enhance the PV value for the user. This paper presents an active demand side management system able to displace the consumer’s load curve in response to local (PV hybrid system, user) and external conditions (external grid). In this way, th e consumer becomes an “active consumer” that can also cooperate with others and the grid, increasing even more the PV value for the electrical system.

Molecular tools to improve chestnut management: El Bierzo as a case study

The European chestnut (Castanea sativa Mill.) is a multipurpose species that has been widely cultivated around the Mediterranean basin since ancient times. New varieties were brought to the Iberian Peninsula during the Roman Empire, which coexist since then with native populations that survived the last glaciation. The relevance of chestnut cultivation has being steadily growing since the Middle Ages, until the rural decline of the past century put a stop to this trend. Forest fires and diseases were also major factors. Chestnut cultivation is gaining momentum again due to its economic (wood, fruits) and ecologic relevance, and represents currently an important asset in many rural areas of Europe. In this Thesis we apply different molecular tools to help improve current management strategies. For this study we have chosen El Bierzo (Castile and Leon, NW Spain), which has a centenary tradition of chestnut cultivation and management, and also presents several unique features from a genetic perspective (next paragraph). Moreover, its nuts are widely appreciated in Spain and abroad for their organoleptic properties. We have focused our experimental work on two major problems faced by breeders and the industry: the lack of a fine-grained genetic characterization and the need for new strategies to control blight disease. To characterize with sufficient detail the genetic diversity and structure of El Bierzo orchards, we analyzed DNA from 169 trees grafted for nut production covering the entire region. We also analyzed 62 nuts from all traditional varieties. El Bierzo constitutes an outstanding scenario to study chestnut genetics and the influence of human management because: (i) it is located at one extreme of the distribution area; (ii) it is a major glacial refuge for the native species; (iii) it has a long tradition of human management (since Roman times, at least); and (iv) its geographical setting ensures an unusual degree of genetic isolation. Thirteen microsatellite markers provided enough informativeness and discrimination power to genotype at the individual level. Together with an unexpected level of genetic variability, we found evidence of genetic structure, with three major gene pools giving rise to the current population. High levels of genetic differentiation between groups supported this organization. Interestingly, genetic structure does not match with spatial boundaries, suggesting that the exchange of material and cultivation practices have strongly influenced natural gene flow. The microsatellite markers selected for this study were also used to classify a set of 62 samples belonging to all traditional varieties. We identified several cases of synonymies and homonymies, evidencing the need to substitute traditional classification systems with new tools for genetic profiling. Management and conservation strategies should also benefit from these tools. The avenue of high-throughput sequencing technologies, combined with the development of bioinformatics tools, have paved the way to study transcriptomes without the need for a reference genome. We took advantage of RNA sequencing and de novo assembly tools to determine the transcriptional landscape of chestnut in response to blight disease. In addition, we have selected a set of candidate genes with high potential for developing resistant varieties via genetic engineering. Our results evidenced a deep transcriptional reprogramming upon fungal infection. The plant hormones ET and JA appear to orchestrate the defensive response. Interestingly, our results also suggest a role for auxins in modulating such response. Many transcription factors were identified in this work that interact with promoters of genes involved in disease resistance. Among these genes, we have conducted a functional characterization of a two major thaumatin-like proteins (TLP) that belongs to the PR5 family. Two genes encoding chestnut cotyledon TLPs have been previously characterized, termed CsTL1 and CsTL2. We substantiate here their protective role against blight disease for the first time, including in silico, in vitro and in vivo evidence. The synergy between TLPs and other antifungal proteins, particularly endo-p-1,3-glucanases, bolsters their interest for future control strategies based on biotechnological approaches.

A total system approach to sustainable pest management

A fundamental shift to a total system approach for crop protection is urgently needed to resolve escalating economic and environmental consequences of combating agricultural pests. Pest management strategies have long been dominated by quests for “silver bullet” products to control pest outbreaks. However, managing undesired variables in ecosystems is similar to that for other systems, including the human body and social orders. Experience in these fields substantiates the fact that therapeutic interventions into any system are effective only for short term relief because these externalities are soon “neutralized” by countermoves within the system. Long term resolutions can be achieved only by restructuring and managing these systems in ways that maximize the array of “built-in” preventive strengths, with therapeutic tactics serving strictly as backups to these natural regulators. To date, we have failed to incorporate this basic principle into the mainstream of pest management science and continue to regress into a foot race with nature. In this report, we establish why a total system approach is essential as the guiding premise of pest management and provide arguments as to how earlier attempts for change and current mainstream initiatives generally fail to follow this principle. We then draw on emerging knowledge about multitrophic level interactions and other specific findings about management of ecosystems to propose a pivotal redirection of pest management strategies that would honor this principle and, thus, be sustainable. Finally, we discuss the potential immense benefits of such a central shift in pest management philosophy.

Ecological approaches and the development of “truly integrated” pest management

Recent predictions of growth in human populations and food supply suggest that there will be a need to substantially increase food production in the near future. One possible approach to meeting this demand, at least in part, is the control of pests and diseases, which currently cause a 30–40% loss in available crop production. In recent years, strategies for controlling pests and diseases have tended to focus on short-term, single-technology interventions, particularly chemical pesticides. This model frequently applies even where so-called integrated pest management strategies are used because in reality, these often are dominated by single technologies (e.g., biocontrol, host plant resistance, or biopesticides) that are used as replacements for chemicals. Very little attention is given to the interaction or compatibility of the different technologies used. Unfortunately, evidence suggests that such approaches rarely yield satisfactory results and are unlikely to provide sustainable pest control solutions for the future. Drawing on two case histories, this paper demonstrates that by increasing our basic understanding of how individual pest control technologies act and interact, new opportunities for improving pest control can be revealed. This approach stresses the need to break away from the existing single-technology, pesticide-dominated paradigm and to adopt a more ecological approach built around a fundamental understanding of population biology at the local farm level and the true integration of renewable technologies such as host plant resistance and natural biological control, which are available to even the most resource-poor farmers.

Policy Changes to the Federal and State Management of Subsistence Hunting and Fishing in Alaska

Subsistence in Alaska is currently being impacted by naturally occurring factors such as global warming, species migration shifts, and the declination of fishery and wildlife populations. Not only are external factors pressuring the debate, management strategies from the dual management operation appear to have failed. The current national focus has been centered on federal policy changes regarding subsistence. This project extends the federal subsistence review process into the state management of subsistence and provides practical solutions for enhancing both policy programs.

Intra-specific variation for host plant use in Helicoverpa armigera (Hübner) (Lepidoptera: Noctuidae): Implications for management

The polyphagous moth Helicoverpa armigera (Hubner) is one of the world's most important agricultural pests. A number of existing approaches and future designs for management of H. armigera rely on the assumption that moths do not exhibit either genetically and/or non-genetically based variation for host plant utilization. We review recent empirical evidence demonstrating that both these forms of variation influence host plant use in this moth. The significance of this variation in H. armigera in relation to current and future pest management strategies is examined. We provide recommendations on future research needs and directions for sustainable management of H. armigera, under a framework that includes consideration of intra.-specific variation for host use relevant in this and other similar pest species. (C) 2004 Elsevier Ltd. All rights reserved.

Experimental analysis of the influence of pest management practice on the efficacy of an endemic arthropod natural enemy complex of the diamondback moth.

Maximizing the contribution of endemic natural enemies to integrated pest management (IPM) programs requires a detailed knowledge of their interactions with the target pest. This experimental field study evaluated the impact of the endemic natural enemy complex of Plutella xylostella (L.) (Lepidoptera: Yponomeutidae) on pest populations in commercial cabbage crops in southeastern Queensland, Australia. Management data were used to score pest management practices at experimental sites on independent Brassica farms practicing a range of pest management strategies, and mechanical methods of natural enemy exclusion were used to assess the impact of natural enemies on introduced cohorts of P. xylostella at each site. Natural enemy impact was greatest at sites adopting IPM and least at sites practicing conventional pest management strategies. At IPM sites, the contribution of natural enemies to P. xylostella mortality permitted the cultivation of marketable crops with no yield loss but with a substantial reduction in insecticide inputs. Three species of larval parasitoids (Diadegma semiclausum Hellen [Hymenoptera: Ichneumonidae], Apanteles ippeus Nixon [Hymenoptera: Braconidae], and Oomyzus sokolowskii Kurdjumov [Hymenoptera: Eulophidae]) and one species of pupal parasitoid Diadromus collaris Gravenhorst (Hymenoptera: Ichneumonidae) attacked immature P. xylostella. The most abundant groups of predatory arthropods caught in pitfall traps were Araneae (Lycosidae) > Coleoptera (Carabidae, Coccinelidae, Staphylinidae) > Neuroptera (Chrysopidae) > Formicidae, whereas on crop foliage Araneae (Clubionidae, Oxyopidae) > Coleoptera (Coccinelidae) > Neuroptera (Chrysopidae) were most common. The abundance and diversity of natural enemies was greatest at sites that adopted IPM, correlating greater P. xylostella mortality at these sites. The efficacy of the natural enemy complex to pest mortality under different pest management regimes and appropriate strategies to optimize this important natural resource are discussed.

Management effectiveness: Assessing management of protected areas?

To maximise the potential of protected areas, we need to understand the strengths and weaknesses in their management and the threats and stresses that they face. There is increasing pressure on governments and other bodies responsible for protected areas to monitor their effectiveness. The reasons for assessing management effectiveness include the desire by managers to adapt and improve their management strategies, improve planning and priority setting and the increasing demands for reporting and accountability being placed on managers, both nationally and internationally. Despite these differing purposes for assessment, some common themes and information needs can be identified, allowing assessment systems to meet multiple uses. Protected-area management evaluation has a relatively short history. Over the past 20 years a number of systems have been proposed but few have been adopted by management agencies. In response to a recognition of the need for a globally applicable approach to this issue, the IUCN World Commission on Protected Areas developed a framework for assessing management effectiveness of both protected areas and protected area systems. This framework was launched at the World Conservation Congress in Jordan in 2000. The framework provides guidance to managers to develop locally relevant assessment systems while helping to harmonise assessment approaches around the world. The framework is strongly linked to the protected area management process and is adaptable to different types and circumstances of protected areas around the world. Examples from Fraser Island in Australia and the Congo Basin illustrate the use of the framework.

Body-mass management of Australian lightweight rowers prior to and during competition

Purpose: Although the body-mass management strategies of athletes in high-participation weight-category sports such as wrestling have been thoroughly investigated, little is known about such practices among lightweight rowers. This study examined the body-mass management practices of lightweight rowers before competition and compared these with current guidelines of the International Federation of Rowing Association (FISA). Quantification of nutrient intake in the 1-2 h between weigh-in and racing was also sought. Methods: Lightweight rowers (N = 100) competing in a national regatta completed a questionnaire that assessed body-mass management practices during the 4 wk before and throughout a regatta plus recovery strategies after weigh-in. Biochemical data were collected immediately after weigh-in to validate questionnaire responses. Responses were categorized according to gender and age category (Senior B or younger than 23 yr old, i.e., U23, Senior A or OPEN, i.e., open age limit) for competition. Results: Most athletes (male U23 76.5%, OPEN 92.3%; female U23 84.0%, OPEN 94.1%) decreased their body mass in the weeks before the regatta at rates compliant with FISA guidelines. Gradual dieting, fluid restriction, and increased training load were the most popular methods of body-mass management. Although the importance of recovery after weigh-in was recognized by athletes, nutrient intake and especially sodium (male U23 5.3 ± 4.9, OPEN 7.7 ± 5.9; female U23 5.7 ± 6.8, OPEN 10.2 ± 5.4 mg-kg(-1)) and fluid intake (male U23 12.1 ± 7.1, OPEN 13.5 ± 8.1; female U23 9.4 ± 7.4, OPEN 14.8 ± 6.9 mL.kg(-1)) were below current sports nutrition recommendations. Conclusion: Few rowers were natural lightweights; the majority reduced their body mass in the weeks before a regatta. Nutritional recovery strategies implemented by lightweight rowers after weigh-in were not consistent with current guidelines.

Farmers' strategies for managing acid upland soils in Southeast Asia: an evolutionary perspective

The acid soils of the uplands of Southeast Asia have resisted intensive agricultural use for centuries. In recent decades, however, due to rapid population growth, escalating market demand for agricultural produce, and govemment policies for land development and settlement, the acid uplands have become the focus of more intensive land-use systems, placing greater demands on farmers and requiring the development and dissemination of improved practices for soil management. In order to develop appropriate soil management technologies and plan effective interventions to facilitate their adoption, it is important to understand the goals and circumstances of farmers in the acid uplands, the range of farming systems they have developed, and the variety of socio-economic factors and trends influencing the evolution of these farming systems. Building on Boserup's model of agrarian change, an evolutionary framework is developed and applied to five case studies: a long-fallow (shifting) cultivation system in Sarawak, Malaysia; a short-fallow system in South Kalimantan, Indonesia; a continuous cropping system in Bukidnon, Philippines; a tree crop (with intercropping) system in Southern Thailand; a livestock grazing system in Daclac, Vietnam. The framework provides a useful tool to interpret and categorise farmers' evolving soil management strategies and to plan more effective soil management research and interventions. (c) 2004 Elsevier B.V. All rights reserved.

Central hypersensitivity in whiplash: Implications for physiotherapy assessment and management

It is emerging that whiplash-associated disorder (WAD) is a complex condition characterised by a variety of physical and psychological features. Generalised sensory hypersensitivity is one of these features and its presence reflects augmented central pain processing mechanisms. Whilst most studies have investigated these processes in chronic WAD, it is becoming clear that in some of the whiplash injured, sensory disturbances are present from soon after injury, and are associated with both poor recovery and recalcitrance to multimodal physiotherapy interventions. Evidence for sensory hypersensitivity in WAD and possible underlying mechanisms of these phenomena are reviewed. Physiotherapists play an important role in the evaluation and management of whiplash injury. It is important that sensory disturbances be identified early in the clinical assessment of the whiplash injured patient and that ensuing management strategies address these changes, if the aim of treatment is to prevent the transition to chronicity.