Twelfth Annual Report for the year ended the 31st March, 1963

This is the twelfth Annual report of the Cumberland River Board on information of its activities and responsibilities on river management in its area between the beginning of April 1962, to the end of March 1963. The report contains 5 main sections on water resources, land drainage, fisheries, pollution, and finally the expenditure and income for the 12 month period. The first area that the report deals with is water resources, which includes information on the completion of gauging stations, abstraction of water and rainfall. The section on land drainage looks at work on improvement schemes, floods and information on maintenance work carried out on rivers including Wampool, Waver, Wiza, Ellen, Cocker, Greta, Marron, Ehen, Keekle, Esk, Bleng, Mite, Annas, Eden, Caldew and Petteril. The fisheries section covers 5 districts of the River Eden, Esk, Derwent, Ellen and South West Cumberland. It includes angling information and a general report for salmon and sea trout, brown trout and freshwater fish. Fish disease and fish hatchery are also covered as well as Byelaws and fisheries protection. The fourth section on pollution covers water quality and information on sewage and trade effluents. The River Boards preceded the Environment Agency which came into existence in 1996.

Thirteenth Annual Report for the year ended 31st March, 1964

This is the thirteenth Annual report of the Cumberland River Board on information of its activities and responsibilities on river management in its area between the beginning of April 1963, to the end of March 1964. The report contains 5 main sections on water resources, land drainage, fisheries, pollution, and finally the expenditure and income for the 12 month period. The first area that the report deals with is water resources, which includes information on the completion of gauging stations, abstraction of water and rainfall and river flow. The section on land drainage looks at work on improvement schemes, floods and information on maintenance work carried out on rivers including Wampool, Waver, Wiza, Derwent, Cocker, Keekle, Marron, Ehen, Irt, Esk, Mite, Lowther, Eden, Caldew and Petteril. The fisheries section covers 5 districts of the River Eden, Esk, Derwent, Ellen and South West Cumberland. It includes angling information and a general report for salmon and sea trout, brown trout and freshwater fish. Fish disease and fish hatchery are also covered as well as Byelaws and fisheries protection. The fourth section on pollution deals with water quality and information on sewage and trade effluents. The River Boards preceded the Environment Agency which came into existence in 1996.

Fourteenth Annual Report for the year ended 31st March, 1965

This is the fourteenth Annual report of the Cumberland River Board on information of its activities and responsibilities on river management in its area between the beginning of April 1964, to the end of March 1965. The report contains 5 main sections on water resources, land drainage, fisheries, pollution, and finally the expenditure and income for the 12 month period. The first area that the report deals with is water resources, which includes information on the completion of gauging stations, abstraction of water and rainfall and river flow. The section on land drainage looks at work on improvement schemes, floods and information on maintenance work carried out on rivers including Wampool, Waver, Wiza, Ellen, Cocker, Keekle, Marron, Ehen, Bleng, Esk, Mite, Caldew and Petteril. The fisheries section covers 5 districts of the River Eden, Esk, Derwent, Ellen and South West Cumberland. It includes angling information and a general report for salmon and sea trout, brown trout and freshwater fish. Fish disease and fish hatchery are also covered as well as Byelaws and fisheries protection. The fourth section on pollution deals with water quality and information on sewage and trade effluents. The River Boards preceded the Environment Agency which came into existence in 1996.

Mapping southern Florida's shallow-water coral ecosystems: an implementation plan

The Southern Florida Shallow-water Coral Ecosystem Mapping Implementation Plan (MIP) discusses the need to produce shallow-water (~0-40 m; 0-22 fm) benthic habitat and bathymetric maps of critical areas in southern Florida and moderate-depth (~40-200 m; 22 -109 fm) bathymetric maps for all of Florida. The ~0-40 m depth regime generally represents where most hermatypic coral species are found and where most direct impacts from pollution and coastal development occur. The plan was developed with extensive input from over 90 representatives of state regulatory and management agencies, federal agencies, universities, and non-governmental organizations involved in the conservation and management of Florida’s coral ecosystems. Southern Florida’s coral ecosystems are extensive. They extend from the Dry Tortugas in the Florida Keys as far north as St Lucie Inlet on the Atlantic Ocean coast and Tarpon Springs on the Gulf of Mexico coast. Using 10 fm (18 m) depth curves on nautical charts as a guide, southern Florida has as much as 84 percent (30,801 sq km) of 36,812 sq km of potential shallow-water (<10 fm; <18 m) coral ecosystems the tropical and subtropical U.S. Moreover, southern Florida’s coral ecosystems contribute greatly to the regional economy. Coral ecosystem-related expenditures generated $4.4 billion in sales, income, and employment and created over 70,000 full-time and part-time jobs in the region during the recent 12-month periods when surveys were conducted.

The role of macrophytes in the economy of the lower Sondu-Miriu river of Lake Victoria

This paper highlights the results of a 12 month's ecological study of macrophytes and their role in the economy of the lower Sondu-Miriu river of Lake Victoria. A total of 34 species of aquatic macrophytes were identified. These were grouped as emergent, floating leaved, free floating and submersed. The major community type identified were dominated by Cladium jamaicanse (Crantz) Kurk., Cyperus paprus (L.) and Cyperus latifolius (Poir). The study observed an over dependence on macrophytes by the local community for the supply of bedding, grazing fields, fuel, roofing and other building materials. The white (heart) of Typha shoot, Nile cabbage (Pistia stratiotes and a legume solanum nigrum traditionally known as "osuga" are used as vegetables by local community. The only source of protein in this arid region is the fish caught in the swamps and birds which inhabit the swamp. The swamp provides the only source of green pasture in the dry season for the animals. An export oriented economy has developed involving mat making and basket weaving with exports reaching as far as Japan. The study proposes a rational and sustainable exploitation of the littoral zone to support the adjacent rural community.

The use of transvaginal synthetic mesh for anterior vaginal wall prolapse repair: a randomized controlled trial

The aim of the study was to compare the efficacy and safety of transvaginal trocar-guided polypropylene mesh insertion with traditional colporrhaphy for treatment of anterior vaginal wall prolapse.This is a randomized controlled trial in which women with advanced anterior vaginal wall prolapse, at least stage II with Ba a parts per thousand yenaEuro parts per thousand+1 cm according to the Pelvic Organ Prolapse Quantification (POP-Q) classification, were randomly assigned to have either anterior colporrhaphy (n = 39) or repair using trocar-guided transvaginal mesh (n = 40). the primary outcome was objective cure rate of the anterior compartment (point Ba) assessed at the 12-month follow-up visit, with stages 0 and I defined as anatomical success. Secondary outcomes included quantification of other vaginal compartments (POP-Q points), comparison of quality of life by the prolapse quality of life (P-QOL) questionnaire, and complication rate between the groups after 1 year. Study power was fixed as 80 % with 5 % cutoff point (p < 0.05) for statistical significance.The groups were similar regarding demographic and clinical preoperative parameters. Anatomical success rates for colporrhaphy and repair with mesh placement groups were 56.4 vs 82.5 % (95 % confidence interval 0.068-0.54), respectively, and the difference between the groups was statistically significant (p = 0.018). Similar total complication rates were observed in both groups, with tape exposure observed in 5 % of the patients. There was a significant improvement in all P-QOL domains as a result of both procedures (p < 0.001), but they were not distinct between groups (p > 0.05).Trocar-guided transvaginal synthetic mesh for advanced anterior POP repair is associated with a higher anatomical success rate for the anterior compartment compared with traditional colporrhaphy. Quality of life equally improved after both techniques. However, the trial failed to detect differences in P-QOL scores and complication rates between the groups.

Development of process control methodology for tracking the quality and safety of pain, agitation and sedation management in critical care units

Objective: To develop sedation, pain, and agitation quality measures using process control methodology and evaluate their properties in clinical practice. Design: A Sedation Quality Assessment Tool was developed and validated to capture data for 12-hour periods of nursing care. Domains included pain/discomfort and sedation-agitation behaviors; sedative, analgesic, and neuromuscular blocking drug administration; ventilation status; and conditions potentially justifying deep sedation. Predefined sedation-related adverse events were recorded daily. Using an iterative process, algorithms were developed to describe the proportion of care periods with poor limb relaxation, poor ventilator synchronization, unnecessary deep sedation, agitation, and an overall optimum sedation metric. Proportion charts described processes over time (2 monthly intervals) for each ICU. The numbers of patients treated between sedation-related adverse events were described with G charts. Automated algorithms generated charts for 12 months of sequential data. Mean values for each process were calculated, and variation within and between ICUs explored qualitatively. Setting: Eight Scottish ICUs over a 12-month period. Patients: Mechanically ventilated patients. Interventions: None. Measurements and Main Results: The Sedation Quality Assessment Tool agitation-sedation domains correlated with the Richmond Sedation Agitation Scale score (Spearman [rho] = 0.75) and were reliable in clinician-clinician (weighted kappa; [kappa] = 0.66) and clinician-researcher ([kappa] = 0.82) comparisons. The limb movement domain had fair correlation with Behavioral Pain Scale ([rho] = 0.24) and was reliable in clinician-clinician ([kappa] = 0.58) and clinician-researcher ([kappa] = 0.45) comparisons. Ventilator synchronization correlated with Behavioral Pain Scale ([rho] = 0.54), and reliability in clinician-clinician ([kappa] = 0.29) and clinician-researcher ([kappa] = 0.42) comparisons was fair-moderate. Eight hundred twenty-five patients were enrolled (range, 59-235 across ICUs), providing 12,385 care periods for evaluation (range 655-3,481 across ICUs). The mean proportion of care periods with each quality metric varied between ICUs: excessive sedation 12-38%; agitation 4-17%; poor relaxation 13-21%; poor ventilator synchronization 8-17%; and overall optimum sedation 45-70%. Mean adverse event intervals ranged from 1.5 to 10.3 patients treated. The quality measures appeared relatively stable during the observation period. Conclusions: Process control methodology can be used to simultaneously monitor multiple aspects of pain-sedation-agitation management within ICUs. Variation within and between ICUs could be used as triggers to explore practice variation, improve quality, and monitor this over time

Invasive fungal infections among organ transplant recipients: results of the Transplant-Associated Infection Surveillance Network (TRANSNET).

BACKGROUND: Invasive fungal infections (IFIs) are a major cause of morbidity and mortality among organ transplant recipients. Multicenter prospective surveillance data to determine disease burden and secular trends are lacking. METHODS: The Transplant-Associated Infection Surveillance Network (TRANSNET) is a consortium of 23 US transplant centers, including 15 that contributed to the organ transplant recipient dataset. We prospectively identified IFIs among organ transplant recipients from March, 2001 through March, 2006 at these sites. To explore trends, we calculated the 12-month cumulative incidence among 9 sequential cohorts. RESULTS: During the surveillance period, 1208 IFIs were identified among 1063 organ transplant recipients. The most common IFIs were invasive candidiasis (53%), invasive aspergillosis (19%), cryptococcosis (8%), non-Aspergillus molds (8%), endemic fungi (5%), and zygomycosis (2%). Median time to onset of candidiasis, aspergillosis, and cryptococcosis was 103, 184, and 575 days, respectively. Among a cohort of 16,808 patients who underwent transplantation between March 2001 and September 2005 and were followed through March 2006, a total of 729 IFIs were reported among 633 persons. One-year cumulative incidences of the first IFI were 11.6%, 8.6%, 4.7%, 4.0%, 3.4%, and 1.3% for small bowel, lung, liver, heart, pancreas, and kidney transplant recipients, respectively. One-year incidence was highest for invasive candidiasis (1.95%) and aspergillosis (0.65%). Trend analysis showed a slight increase in cumulative incidence from 2002 to 2005. CONCLUSIONS: We detected a slight increase in IFIs during the surveillance period. These data provide important insights into the timing and incidence of IFIs among organ transplant recipients, which can help to focus effective prevention and treatment strategies.

Prospective surveillance for invasive fungal infections in hematopoietic stem cell transplant recipients, 2001-2006: overview of the Transplant-Associated Infection Surveillance Network (TRANSNET) Database.

BACKGROUND: The incidence and epidemiology of invasive fungal infections (IFIs), a leading cause of death among hematopoeitic stem cell transplant (HSCT) recipients, are derived mainly from single-institution retrospective studies. METHODS: The Transplant Associated Infections Surveillance Network, a network of 23 US transplant centers, prospectively enrolled HSCT recipients with proven and probable IFIs occurring between March 2001 and March 2006. We collected denominator data on all HSCTs preformed at each site and clinical, diagnostic, and outcome information for each IFI case. To estimate trends in IFI, we calculated the 12-month cumulative incidence among 9 sequential subcohorts. RESULTS: We identified 983 IFIs among 875 HSCT recipients. The median age of the patients was 49 years; 60% were male. Invasive aspergillosis (43%), invasive candidiasis (28%), and zygomycosis (8%) were the most common IFIs. Fifty-nine percent and 61% of IFIs were recognized within 60 days of neutropenia and graft-versus-host disease, respectively. Median onset of candidiasis and aspergillosis after HSCT was 61 days and 99 days, respectively. Within a cohort of 16,200 HSCT recipients who received their first transplants between March 2001 and September 2005 and were followed up through March 2006, we identified 718 IFIs in 639 persons. Twelve-month cumulative incidences, based on the first IFI, were 7.7 cases per 100 transplants for matched unrelated allogeneic, 8.1 cases per 100 transplants for mismatched-related allogeneic, 5.8 cases per 100 transplants for matched-related allogeneic, and 1.2 cases per 100 transplants for autologous HSCT. CONCLUSIONS: In this national prospective surveillance study of IFIs in HSCT recipients, the cumulative incidence was highest for aspergillosis, followed by candidiasis. Understanding the epidemiologic trends and burden of IFIs may lead to improved management strategies and study design.

The implementation of a translational study involving a primary care based behavioral program to improve blood pressure control: The HTN-IMPROVE study protocol (01295).

BACKGROUND: Despite the impact of hypertension and widely accepted target values for blood pressure (BP), interventions to improve BP control have had limited success. OBJECTIVES: We describe the design of a 'translational' study that examines the implementation, impact, sustainability, and cost of an evidence-based nurse-delivered tailored behavioral self-management intervention to improve BP control as it moves from a research context to healthcare delivery. The study addresses four specific aims: assess the implementation of an evidence-based behavioral self-management intervention to improve BP levels; evaluate the clinical impact of the intervention as it is implemented; assess organizational factors associated with the sustainability of the intervention; and assess the cost of implementing and sustaining the intervention. METHODS: The project involves three geographically diverse VA intervention facilities and nine control sites. We first conduct an evaluation of barriers and facilitators for implementing the intervention at intervention sites. We examine the impact of the intervention by comparing 12-month pre/post changes in BP control between patients in intervention sites versus patients in the matched control sites. Next, we examine the sustainability of the intervention and organizational factors facilitating or hindering the sustained implementation. Finally, we examine the costs of intervention implementation. Key outcomes are acceptability and costs of the program, as well as changes in BP. Outcomes will be assessed using mixed methods (e.g., qualitative analyses--pattern matching; quantitative methods--linear mixed models). DISCUSSION: The study results will provide information about the challenges and costs to implement and sustain the intervention, and what clinical impact can be expected.

Nurse-led behavioral management of diabetes and hypertension in community practices: a randomized trial.

BACKGROUND: Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions. OBJECTIVE: To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases. DESIGN: The study was designed as a patient-level randomized controlled trial. PARTICIPANTS: Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5%) but could have well-controlled HTN. INTERVENTIONS: All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention). MAIN OUTCOMES AND MEASURES: Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point. RESULTS: Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55% female and 50% white; the mean baseline A1c was 9.1% (SD = 1%) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69% of intervention patients and 70% of control patients reached the 24-month time point. Expressing model estimated differences as (intervention--control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (-0.3, 0.5), p = 0.51] and SBP [diff = -0.9 mmHg, 95% CI (-5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points. CONCLUSIONS: In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.

A phase 1-2 clinical trial of gene therapy for recurrent glioblastoma multiforme by tumor transduction with the herpes simplex thymidine kinase gene followed by ganciclovir.

This study has investigated the effects of herpes simplex thymidine kinase gene (HSV-tk) transfer followed by ganciclovir treatment as adjuvant gene therapy to surgical resection in patients with recurrent glioblastoma multiforme (GBM). The study was open and single-arm, and aimed at assessing the feasibility and safety of the technique and indications of antitumor activity. In 48 patients a suspension of retroviral vector-producing cells (VPCs) was administered by intracerebral injection immediately after tumor resection. Intravenous ganciclovir was infused daily 14 to 27 days after surgery. Patients were monitored for adverse events and for life by regular biosafety assaying. Tumor changes were monitored by magnetic resonance imaging (MRI). Reflux during injection was a frequent occurrence but serious adverse events during the treatment period (days 1-27) were few and of a nature not unexpected in this population. One patient experienced transient neurological disorders associated with postganciclovir MRI enhancement. There was no evidence of replication-competent retrovirus in peripheral blood leukocytes or in tissue samples of reresection or autopsy. Vector DNA was shown in the leukocytes of some patients but not in autopsy gonadal samples. The median survival time was 8.6 months, and the 12-month survival rate was 13 of 48 (27%). On MRI studies, tumor recurrence was absent in seven patients for at least 6 months and for at least 12 months in two patients, one of whom remains recurrence free at more than 24 months. Treatment-characteristic images of injection tracks and intracavity hemoglobin were apparent. In conclusion, the gene therapy is feasible and appears to be satisfactorily safe as an adjuvant to the surgical resection of recurrent GBM, but any benefit appears to be marginal. Investigation of the precise effectiveness of this gene therapy requires prospective, controlled studies.

Monitoring growth in asthmatic children treated with high dose inhaled glucocorticoids does not predict adrenal suppression

Aims: To determine whether routine outpatient monitoring of growth predicts adrenal suppression in prepubertal children treated with high dose inhaled glucocorticoid.

Methods: Observational study of 35 prepubertal children (aged 4–10 years) treated with at least 1000 µg/day of inhaled budesonide or equivalent potency glucocorticoid for at least six months. Main outcome measures were: changes in HtSDS over 6 and 12 month periods preceding adrenal function testing, and increment and peak cortisol after stimulation by low dose tetracosactrin test. Adrenal suppression was defined as a peak cortisol 500 nmol/l.

Results: The areas under the receiver operator characteristic curves for a decrease in HtSDS as a predictor of adrenal insufficiency 6 and 12 months prior to adrenal testing were 0.50 (SE 0.10) and 0.59 (SE 0.10). Prediction values of an HtSDS change of –0.5 for adrenal insufficiency at 12 months prior to testing were: sensitivity 13%, specificity 95%, and positive likelihood ratio of 2.4. Peak cortisol reached correlated poorly with change in HtSDS ( = 0.23, p = 0.19 at 6 months; = 0.33, p = 0.06 at 12 months).

Conclusions: Monitoring growth does not enable prediction of which children treated with high dose inhaled glucocorticoids are at risk of potentially serious adrenal suppression. Both growth and adrenal function should be monitored in patients on high dose inhaled glucocorticoids. Further research is required to determine the optimal frequency of monitoring adrenal function.

Evaluation of extended training for general practice in Northern Ireland: qualitative study.

Objective To evaluate participants' perceptions of the impact on them of an additional six months' training beyond the standard 12 month general practice vocational training scheme. Design Qualitative study using focus groups. Setting General practice vocational training in Northern Ireland. Participants 13 general practitioner registrars, six of whom participated in the additional six months' training, and four trainers involved in the additional six months' training. Main outcome measures: Participants' views about their experiences in 18 month and 12 month courses. Results Participants reported that the 12 month course was generally positive but was too pressurised and focused on examinations, and also that it had a negative impact on self care. The nature of the learning and assessment was reported to have left participants feeling averse to further continuing education and lacking in confidence. In contrast, the extended six month component was reported to have restimulated learning by focusing more on patient care and promoting self directed learning. It developed confidence, promoted teamwork, and gave experience of two practice contexts, and was reported as valuable by both ex-registrars and trainers. However, both the 12 and 18 month courses left participants feeling underprepared for practice management and self care. Conclusions 12 months' training in general practice does not provide doctors with the necessary competencies and confidence to enter independent practice. The extended period was reported to promote greater professional development, critical evaluation skills, and orientation to lifelong learning but does not fill all the gaps.

Numerical analysis of surface and fossil pollen spectra from northern Fennoscandia

Aim Determination of the main directions of variance in an extensive data base of annual pollen deposition, and the relationship between pollen data from modified Tauber traps and palaeoecological data. Location Northern Finland and Norway. Methods Pollen analysis of annual samples from pollen traps and contiguous high-resolution samples from a peat sequence. Numerical analysis (principal components analysis) of the resulting data. Results The main direction of variation in the trap data is due to the vegetation region in which each trap is located. A secondary direction of variation is due to the annual variability of pollen production of some of the tree taxa, especially Betula and Pinus. This annual variability is more conspicuous in ‘absolute’ data than it is in percentage data which, at this annual resolution, becomes more random. There are systematic differences, with respect to peat-forming taxa, between pollen data from traps and pollen data from a peat profile collected over the same period of time. Main conclusions Annual variability in pollen production is rarely visible in fossil pollen samples because these cannot be sampled at precisely a 12-month resolution. At near-annual resolution sampling, it results in erratic percentage values which do not reflect changes in vegetation. Profiles sampled at near annual resolution are better analysed in terms of pollen accumulation rates with the realization that even these do not record changes in plant abundance but changes in pollen abundance. However, at the coarser temporal resolution common in most fossil samples it does not mask the origin of the pollen in terms of its vegetation region. Climate change may not be recognizable from pollen assemblages until the change has persisted in the same direction sufficiently long enough to alter the flowering (pollen production) pattern of the dominant trees.