Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study

Objective: In South Africa, many HIV-infected patients experience delays in accessing antiretroviral therapy (ART). We examined pretreatment mortality and access to treatment in patients waiting for ART. Design: Cohort of HIV-infected patients assessed for ART eligibility at 36 facilities participating in the Comprehensive HIV and AIDS Management (CHAM) program in the Free State Province. Methods: Proportion of patients initiating ART, pre-ART mortality and risk factors associated with these outcomes were estimated using competing risks survival analysis. Results: Forty-four thousand, eight hundred and forty-four patients enrolled in CHAM between May 2004 and December 2007, of whom 22 083 (49.2%) were eligible for ART; pre-ART mortality was 53.2 per 100 person-years [95% confidence interval (CI) 51.8–54.7]. Median CD4 cell count at eligibility increased from 87 cells/ml in 2004 to 101 cells/ml in 2007. Two years after eligibility an estimated 67.7% (67.1–68.4%) of patients had started ART, and 26.2% (25.6–26.9%) died before starting ART. Among patients with CD4 cell counts below 25 cells/ml at eligibility, 48% died before ART and 51% initiated ART. Men were less likely to start treatment and more likely to die than women. Patients in rural clinics or clinics with low staffing levels had lower rates of starting treatment and higher mortality compared with patients in urban/peri-urban clinics, or better staffed clinics. Conclusions: Mortality is high in eligible patients waiting for ART in the Free State Province. The most immunocompromised patients had the lowest probability of starting ART and the highest risk of pre-ART death. Prioritization of these patients should reduce waiting times and pre-ART mortality.

EVALUATING INFRASTRUCTURE PERFORMANCE TO ASSIST FACILITY MANAGEMENT TOWARD SUSTAINABLE SYSTEMS

Civil infrastructure provides essential services for the development of both society and economy. It is very important to manage systems efficiently to ensure sound performance. However, there are challenges in information extraction from available data, which also necessitates the establishment of methodologies and frameworks to assist stakeholders in the decision making process. This research proposes methodologies to evaluate systems performance by maximizing the use of available information, in an effort to build and maintain sustainable systems. Under the guidance of problem formulation from a holistic view proposed by Mukherjee and Muga, this research specifically investigates problem solving methods that measure and analyze metrics to support decision making. Failures are inevitable in system management. A methodology is developed to describe arrival pattern of failures in order to assist engineers in failure rescues and budget prioritization especially when funding is limited. It reveals that blockage arrivals are not totally random. Smaller meaningful subsets show good random behavior. Additional overtime failure rate is analyzed by applying existing reliability models and non-parametric approaches. A scheme is further proposed to depict rates over the lifetime of a given facility system. Further analysis of sub-data sets is also performed with the discussion of context reduction. Infrastructure condition is another important indicator of systems performance. The challenges in predicting facility condition are the transition probability estimates and model sensitivity analysis. Methods are proposed to estimate transition probabilities by investigating long term behavior of the model and the relationship between transition rates and probabilities. To integrate heterogeneities, model sensitivity is performed for the application of non-homogeneous Markov chains model. Scenarios are investigated by assuming transition probabilities follow a Weibull regressed function and fall within an interval estimate. For each scenario, multiple cases are simulated using a Monte Carlo simulation. Results show that variations on the outputs are sensitive to the probability regression. While for the interval estimate, outputs have similar variations to the inputs. Life cycle cost analysis and life cycle assessment of a sewer system are performed comparing three different pipe types, which are reinforced concrete pipe (RCP) and non-reinforced concrete pipe (NRCP), and vitrified clay pipe (VCP). Life cycle cost analysis is performed for material extraction, construction and rehabilitation phases. In the rehabilitation phase, Markov chains model is applied in the support of rehabilitation strategy. In the life cycle assessment, the Economic Input-Output Life Cycle Assessment (EIO-LCA) tools are used in estimating environmental emissions for all three phases. Emissions are then compared quantitatively among alternatives to support decision making.

Can decision making in general surgery be based on evidence? An empirical study of Cochrane Reviews

BACKGROUND: This empirical study analyzes the current status of Cochrane Reviews (CRs) and their strength of recommendation for evidence-based decision making in the field of general surgery. METHODS: Systematic literature search of the Cochrane Database of Systematic Reviews and the Cochrane Collaboration's homepage to identify available CRs on surgical topics. Quantitative and qualitative characteristics, utilization, and formulated treatment recommendations were evaluated by 2 independent reviewers. Association of review characteristics with treatment recommendation was analyzed using univariate and multivariate logistic regression models. RESULTS: Ninety-three CRs, including 1,403 primary studies and 246,473 patients, were identified. Mean number of included primary studies per CR was 15.1 (standard deviation [SD] 14.5) including 2,650 (SD 3,340) study patients. Two and a half (SD 8.3) nonrandomized trials were included per analyzed CR. Seventy-two (77%) CRs were published or updated in 2005 or later. Explicit treatment recommendations were given in 45 (48%). Presence of a treatment recommendation was associated with the number of included primary studies and the proportion of randomized studies. Utilization of surgical CRs remained low and showed large inter-country differences. The most surgical CRs were accessed in UK, USA, and Australia, followed by several Western and Eastern European countries. CONCLUSION: Only a minority of available CRs address surgical questions and their current usage is low. Instead of unsystematically increasing the number of surgical CRs it would be far more efficient to focus the review process on relevant surgical questions. Prioritization of CRs needs valid methods which should be developed by the scientific surgical community.

Expert opinion on toxicity profiling--report from a NORMAN expert group meeting.

This article describes the outcome and follow-up discussions of an expert group meeting (Amsterdam, October 9, 2009) on the applicability of toxicity profiling for diagnostic environmental risk assessment. A toxicity profile was defined as a toxicological "fingerprint" of a sample, ranging from a pure compound to a complex mixture, obtained by testing the sample or its extract for its activity toward a battery of biological endpoints. The expert group concluded that toxicity profiling is an effective first tier tool for screening the integrated hazard of complex environmental mixtures with known and unknown toxicologically active constituents. In addition, toxicity profiles can be used for prioritization of sampling locations, for identification of hot spots, and--in combination with effect-directed analysis (EDA) or toxicity identification and evaluation (TIE) approaches--for establishing cause-effect relationships by identifying emerging pollutants responsible for the observed toxic potency. Small volume in vitro bioassays are especially applicable for these purposes, as they are relatively cheap and fast with costs comparable to chemical analyses, and the results are toxicologically more relevant and more suitable for realistic risk assessment. For regulatory acceptance in the European Union, toxicity profiling terminology should keep as close as possible to the European Water Framework Directive (WFD) terminology, and validation, standardization, statistical analyses, and other quality aspects of toxicity profiling should be further elaborated.

Concept, design and implementation of a cardiovascular gene-centric 50 k SNP array for large-scale genomic association studies.

A wealth of genetic associations for cardiovascular and metabolic phenotypes in humans has been accumulating over the last decade, in particular a large number of loci derived from recent genome wide association studies (GWAS). True complex disease-associated loci often exert modest effects, so their delineation currently requires integration of diverse phenotypic data from large studies to ensure robust meta-analyses. We have designed a gene-centric 50 K single nucleotide polymorphism (SNP) array to assess potentially relevant loci across a range of cardiovascular, metabolic and inflammatory syndromes. The array utilizes a "cosmopolitan" tagging approach to capture the genetic diversity across approximately 2,000 loci in populations represented in the HapMap and SeattleSNPs projects. The array content is informed by GWAS of vascular and inflammatory disease, expression quantitative trait loci implicated in atherosclerosis, pathway based approaches and comprehensive literature searching. The custom flexibility of the array platform facilitated interrogation of loci at differing stringencies, according to a gene prioritization strategy that allows saturation of high priority loci with a greater density of markers than the existing GWAS tools, particularly in African HapMap samples. We also demonstrate that the IBC array can be used to complement GWAS, increasing coverage in high priority CVD-related loci across all major HapMap populations. DNA from over 200,000 extensively phenotyped individuals will be genotyped with this array with a significant portion of the generated data being released into the academic domain facilitating in silico replication attempts, analyses of rare variants and cross-cohort meta-analyses in diverse populations. These datasets will also facilitate more robust secondary analyses, such as explorations with alternative genetic models, epistasis and gene-environment interactions.

Taxonomy development and knowledge representation of nurses' personal cognitive artifacts.

Nurses prepare knowledge representations, or summaries of patient clinical data, each shift. These knowledge representations serve multiple purposes, including support of working memory, workload organization and prioritization, critical thinking, and reflection. This summary is integral to internal knowledge representations, working memory, and decision-making. Study of this nurse knowledge representation resulted in development of a taxonomy of knowledge representations necessary to nursing practice.This paper describes the methods used to elicit the knowledge representations and structures necessary for the work of clinical nurses, described the development of a taxonomy of this knowledge representation, and discusses translation of this methodology to the cognitive artifacts of other disciplines. Understanding the development and purpose of practitioner's knowledge representations provides important direction to informaticists seeking to create information technology alternatives. The outcome of this paper is to suggest a process template for transition of cognitive artifacts to an information system.

Book Review: Regulating Code : Good Governance and Better Regulation in the Information Age

Digital technologies have profoundly changed not only the ways we create, distribute, access, use and re-use information but also many of the governance structures we had in place. Overall, "older" institutions at all governance levels have grappled and often failed to master the multi-faceted and multi-directional issues of the Internet. Regulatory entrepreneurs have yet to discover and fully mobilize the potential of digital technologies as an influential factor impacting upon the regulability of the environment and as a potential regulatory tool in themselves. At the same time, we have seen a deterioration of some public spaces and lower prioritization of public objectives, when strong private commercial interests are at play, such as most tellingly in the field of copyright. Less tangibly, private ordering has taken hold and captured through contracts spaces, previously regulated by public law. Code embedded in technology often replaces law. Non-state action has in general proliferated and put serious pressure upon conventional state-centered, command-and-control models. Under the conditions of this "messy" governance, the provision of key public goods, such as freedom of information, has been made difficult or is indeed jeopardized.The grand question is how can we navigate this complex multi-actor, multi-issue space and secure the attainment of fundamental public interest objectives. This is also the question that Ian Brown and Chris Marsden seek to answer with their book, Regulating Code, as recently published under the "Information Revolution and Global Politics" series of MIT Press. This book review critically assesses the bold effort by Brown and Marsden.

Prioritizing plant defence over growth through WRKY regulation facilitates infestation by non-target herbivores

Plants generally respond to herbivore attack by increasing resistance and decreasing growth. This prioritization is achieved through the regulation of phytohormonal signaling networks. However, it remains unknown how this prioritization affects resistance against non-target herbivores. In this study, we identify WRKY70 as a specific herbivore-induced, mitogen-activated protein kinase-regulated rice transcription factor that physically interacts with W-box motifs and prioritizes defence over growth by positively regulating jasmonic acid (JA) and negatively regulating gibberellin (GA) biosynthesis upon attack by the chewing herbivore Chilo suppressalis. WRKY70-dependent JA biosynthesis is required for proteinase inhibitor activation and resistance against C. suppressalis. In contrast, WRKY70 induction increases plant susceptibility against the rice brown planthopper Nilaparvata lugens. Experiments with GA-deficient rice lines identify WRKY70-dependent GA signaling as the causal factor in N. lugens susceptibility. Our study shows that prioritizing defence over growth leads to a significant resistance trade-off with important implications for the evolution and agricultural exploitation of plant immunity.

UNDERSTANDING NURSE CREATED COGNITIVE ARTIFACTS: PERSONALLY-CREATED-COGNITIVE-ARTIFACTS AS EXTERNAL REPRESENTATIONS OF DISTRIBUTED COGNITION

Manuscript 1: “Conceptual Analysis: Externalizing Nursing Knowledge” We use concept analysis to establish that the report tool nurses prepare, carry, reference, amend, and use as a temporary data repository are examples of cognitive artifacts. This tool, integrally woven throughout the work and practice of nurses, is important to cognition and clinical decision-making. Establishing the tool as a cognitive artifact will support new dimensions of study. Such studies can characterize how this report tool supports cognition, internal representation of knowledge and skills, and external representation of knowledge of the nurse. Manuscript 2: “Research Methods: Exploring Cognitive Work” The purpose of this paper is to describe a complex, cross-sectional, multi-method approach to study of personal cognitive artifacts in the clinical environment. The complex data arrays present in these cognitive artifacts warrant the use of multiple methods of data collection. Use of a less robust research design may result in an incomplete understanding of the meaning, value, content, and relationships between personal cognitive artifacts in the clinical environment and the cognitive work of the user. Manuscript 3: “Making the Cognitive Work of Registered Nurses Visible” Purpose: Knowledge representations and structures are created and used by registered nurses to guide patient care. Understanding is limited regarding how these knowledge representations, or cognitive artifacts, contribute to working memory, prioritization, organization, cognition, and decision-making. The purpose of this study was to identify and characterize the role a specific cognitive artifact knowledge representation and structure as it contributed to the cognitive work of the registered nurse. Methods: Data collection was completed, using qualitative research methods, by shadowing and interviewing 25 registered nurses. Data analysis employed triangulation and iterative analytic processes. Results: Nurse cognitive artifacts support recall, data evaluation, decision-making, organization, and prioritization. These cognitive artifacts demonstrated spatial, longitudinal, chronologic, visual, and personal cues to support the cognitive work of nurses. Conclusions: Nurse cognitive artifacts are an important adjunct to the cognitive work of nurses, and directly support patient care. Nurses need to be able to configure their cognitive artifact in ways that are meaningful and support their internal knowledge representations.

La planificación estática-la planificación dinámica : Ausencia de planes de ordenamiento territorial municipal

Mucho ofthe towns of Mendoza have been working for years with a methodology built with traditional zoningand code of permitted uses,not permitted or conditional. With these instrument sexpectthe presentation of private enter prisesto assess whether it complies with these regulationsto authorize the works.These agencies have a plan with zoning and code application shave already considered planning. This form of work, shows clearly the lack of actions to drive urban developmentsin the department, initiatives on the issue only limited to astatic situation, waiting for proposal sand external actions,not being able to see the advantagesand /or contribution saccom panying the Land Use Plan. Une of the important elements to considerin the Plan process, is the incorporation of participatory stage allows, consensus and guidanceto policy makers, community in territorial actions. For this way are designed and constructed public works, to address concerns of the population and in some cases,works that will produce community supportat election time. A look at the performance of Cities hall suchas Granada City Council, Churriana de la Vega and Jun, you can observe that the planning can be done other wise, as articulated action from the same organism. In principle determining zoning and uses of spaceis integral to the Land Use Planand that it further comprises the development proposals,the lines of action and prioritization of programs and projects. These local governants, which manage a municipality, working withdy namic planning councilasit implements the proposed urban development, agricultural, commercial and industrialin its territory and build public work saccording to plan. Since 2009,the province has a Law of Zoningand Land Use demanded Municipal Land Management Plans, but three years after the enactmentof the 18 only has aplan.Thisis due to two reasons:the policy makersdo not understand the multiplicity of elements and facets of a plan covering the other,the plans are perceived as a limitation on their actions , a fact not willing to accept. The dissemination of know ledge and the, new ways toaddress the Land Use Planning and management of conflicts generated by the unprecedented growthwith incompatible usesin these cities that the component swhich will requirel and manager stoimplement aplanning Plans. Tusa dinámica risión Fromm te municipalitos in thais contexto de can tal abur innovación and a newway of governing

La planificación estática-la planificación dinámica : Ausencia de planes de ordenamiento territorial municipal

Mucho ofthe towns of Mendoza have been working for years with a methodology built with traditional zoningand code of permitted uses,not permitted or conditional. With these instrument sexpectthe presentation of private enter prisesto assess whether it complies with these regulationsto authorize the works.These agencies have a plan with zoning and code application shave already considered planning. This form of work, shows clearly the lack of actions to drive urban developmentsin the department, initiatives on the issue only limited to astatic situation, waiting for proposal sand external actions,not being able to see the advantagesand /or contribution saccom panying the Land Use Plan. Une of the important elements to considerin the Plan process, is the incorporation of participatory stage allows, consensus and guidanceto policy makers, community in territorial actions. For this way are designed and constructed public works, to address concerns of the population and in some cases,works that will produce community supportat election time. A look at the performance of Cities hall suchas Granada City Council, Churriana de la Vega and Jun, you can observe that the planning can be done other wise, as articulated action from the same organism. In principle determining zoning and uses of spaceis integral to the Land Use Planand that it further comprises the development proposals,the lines of action and prioritization of programs and projects. These local governants, which manage a municipality, working withdy namic planning councilasit implements the proposed urban development, agricultural, commercial and industrialin its territory and build public work saccording to plan. Since 2009,the province has a Law of Zoningand Land Use demanded Municipal Land Management Plans, but three years after the enactmentof the 18 only has aplan.Thisis due to two reasons:the policy makersdo not understand the multiplicity of elements and facets of a plan covering the other,the plans are perceived as a limitation on their actions , a fact not willing to accept. The dissemination of know ledge and the, new ways toaddress the Land Use Planning and management of conflicts generated by the unprecedented growthwith incompatible usesin these cities that the component swhich will requirel and manager stoimplement aplanning Plans. Tusa dinámica risión Fromm te municipalitos in thais contexto de can tal abur innovación and a newway of governing

La planificación estática-la planificación dinámica : Ausencia de planes de ordenamiento territorial municipal

Mucho ofthe towns of Mendoza have been working for years with a methodology built with traditional zoningand code of permitted uses,not permitted or conditional. With these instrument sexpectthe presentation of private enter prisesto assess whether it complies with these regulationsto authorize the works.These agencies have a plan with zoning and code application shave already considered planning. This form of work, shows clearly the lack of actions to drive urban developmentsin the department, initiatives on the issue only limited to astatic situation, waiting for proposal sand external actions,not being able to see the advantagesand /or contribution saccom panying the Land Use Plan. Une of the important elements to considerin the Plan process, is the incorporation of participatory stage allows, consensus and guidanceto policy makers, community in territorial actions. For this way are designed and constructed public works, to address concerns of the population and in some cases,works that will produce community supportat election time. A look at the performance of Cities hall suchas Granada City Council, Churriana de la Vega and Jun, you can observe that the planning can be done other wise, as articulated action from the same organism. In principle determining zoning and uses of spaceis integral to the Land Use Planand that it further comprises the development proposals,the lines of action and prioritization of programs and projects. These local governants, which manage a municipality, working withdy namic planning councilasit implements the proposed urban development, agricultural, commercial and industrialin its territory and build public work saccording to plan. Since 2009,the province has a Law of Zoningand Land Use demanded Municipal Land Management Plans, but three years after the enactmentof the 18 only has aplan.Thisis due to two reasons:the policy makersdo not understand the multiplicity of elements and facets of a plan covering the other,the plans are perceived as a limitation on their actions , a fact not willing to accept. The dissemination of know ledge and the, new ways toaddress the Land Use Planning and management of conflicts generated by the unprecedented growthwith incompatible usesin these cities that the component swhich will requirel and manager stoimplement aplanning Plans. Tusa dinámica risión Fromm te municipalitos in thais contexto de can tal abur innovación and a newway of governing

A return-on-investment framework to identify conservation priorities in Africa

Environmental conservation activities must continue to become more efficient and effective, especially in Africa where development and population growth pressures continue to escalate. Recently, prioritization of conservation resources has focused on explicitly incorporating the economic costs of conservation along with better defining the outcomes of these expenditures. We demonstrate how new global and continental data that spans social, economic, and ecological sectors creates an opportunity to incorporate return-on-investment (ROI) principles into conservation priority setting for Africa. We suggest that combining conservation priorities that factor in biodiversity value, habitat quality, and conservation management investments across terrestrial, freshwater, and coastal marine environments provides a new lens for setting global conservation priorities. Using this approach we identified seven regions capturing interior and coastal resources that also have high ROI values that support further investment. We illustrate how spatially explicit, yet flexible ROI analysis can help to better address uncertainty, risk, and opportunities for conservation, while making values that guide prioritization more transparent. In one case the results of this prioritization process were used to support new conservation investments. Acknowledging a clear research need to improve cost information, we propose that adopting a flexible ROI framework to set conservation priorities in Africa has multiple potential benefits.

Clusters and Innovation: Beijing's Hi-technology Industry Cluster and Guangzhou's Automobile Industry Cluster

This paper proposes a flowchart approach to the automobile industry cluster policy and the hi-technology industry cluster policy to prioritize policy measures. First, in the automobile industry cluster, suppliers of parts and components to anchor firms such as Honda, Nissan and Toyota of Japanese assembly makers in Guangzhou, China, can innovate partly because the suppliers have become independent of their anchor firms in the Japanese Keiretsu system. Second, concerning the hi-technology industry clustering in Beijing, we show that the existence of universities is a precondition for the industrial cluster policy and that the leadership of the Zhongguancun Science Park Management Committee of Beijing Municipality is crucial to the success of the industrial cluster policy. The flowchart for the hi-technology industry is different from the one for the automobile industry cluster.

The Flowchart Model of Cluster Policy: The Automobile Industry Cluster in China

This paper proposes a general model of the flowchart approach to industrial cluster policy and applies this model to Guangzhou's automobile industry cluster. The flowchart approach to industrial cluster policy is an action plan for prioritizing policy measures in a time-ordered series. We reached the following two conclusions. First,we clarified the effects of Honda, Nissan, and Toyota on agglomeration in Guangzhou's automobile industry cluster. Second, we established that local governments play a crucial role in successful industrial cluster policy, and that the mayor of the local government should be offered incentives in order to target industrial clustering and implement cluster policy.