Mycobacterium tuberculosis population structure shift in a 5-year molecular epidemiology surveillance follow-up study in a low endemic agro-industrial setting in São Paulo, Brazil

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

CC98-414 Money 2000+ Setting a Goal

Money 2000+ provides you with opportunities to acquire skills and information to help you reach your money goal(s). The first step with Money 2000+ is setting your goal(s). Then, by taking more control of your spending and where your money goes, you may be surprised at what you can actually accomplish as you progress with Money 2000+ Maybe you already know what you want to accomplish. Even so, take some time to read the rest of this booklet and to think about all parts of your life to make sure you don't miss something important.

Hydrogeologic Setting and Ground-Water Flow Simulations of the Eastern High Plains Regional Study Area, Nebraska

The transport of anthropogenic and natural contaminants to public-supply wells was evaluated in a part of the High Plains aquifer near York, Nebraska, as part of the U.S. Geological Survey National Water-Quality Assessment Program. The aquifer in the Eastern High Plains regional study area is composed of Quaternary alluvial deposits typical of the High Plains aquifer in eastern Nebraska and Kansas, is an important water source for agricultural irrigation and public water supply, and is susceptible and vulnerable to contamination. A six-layer, steady-state ground-water flow model of the High Plains aquifer near York, Nebraska, was constructed and calibrated to average conditions for the time period from 1997 to 2001. The calibrated model and advective particle-tracking simulations were used to compute areas contributing recharge and travel times from recharge areas to selected public-supply wells. Model results indicate recharge from agricultural irrigation return flow and precipitation (about 89 percent of inflow) provides most of the ground-water inflow, whereas the majority of ground-water discharge is to pumping wells (about 78 percent of outflow). Particle-tracking results indicate areas contributing recharge to public-supply wells extend northwest because of the natural ground-water gradient from the northwest to the southeast across the study area. Particle-tracking simulations indicate most ground-water travel times from areas contributing recharge range from 20 to more than 100 years but that some ground water, especially that in the lower confined unit, originates at the upgradient model boundary instead of at the water table in the study area and has travel times of thousands of years.

Low mechanical ventilation times and reintubation rates associated with a specific weaning protocol in an intensive care unit setting: a retrospective study

OBJECTIVES: A number of complications exist with invasive mechanical ventilation and with the use of and withdrawal from prolonged ventilator support. The use of protocols that enable the systematic identification of patients eligible for an interruption in mechanical ventilation can significantly reduce the number of complications. This study describes the application of a weaning protocol and its results. METHODS: Patients who required invasive mechanical ventilation for more than 24 hours were included and assessed daily to identify individuals who were ready to begin the weaning process. RESULTS: We studied 252 patients with a median mechanical ventilation time of 3.7 days (interquartile range of 1 to 23 days), a rapid shallow breathing index value of 48 (median), a maximum inspiratory pressure of 40 cmH2O, and a maximum expiratory pressure of 40 cm H2O (median). Of these 252 patients, 32 (12.7%) had to be reintubated, which represented weaning failure. Noninvasive ventilation was used postextubation in 170 (73%) patients, and 15% of these patients were reintubated, which also represented weaning failure. The mortality rate of the 252 patients studied was 8.73% (22), and there was no significant difference in the age, gender, mechanical ventilation time, and maximum inspiratory pressure between the survivors and nonsurvivors. CONCLUSIONS: The use of a specific weaning protocol resulted in a lower mechanical ventilation time and an acceptable reintubation rate. This protocol can be used as a comparative index in hospitals to improve the weaning system, its monitoring and the informative reporting of patient outcomes and may represent a future tool and source of quality markers for patient care.

Survival Analysis of Patients with Heart Failure: Implications of Time-Varying Regression Effects in Modeling Mortality

Background: Several models have been designed to predict survival of patients with heart failure. These, while available and widely used for both stratifying and deciding upon different treatment options on the individual level, have several limitations. Specifically, some clinical variables that may influence prognosis may have an influence that change over time. Statistical models that include such characteristic may help in evaluating prognosis. The aim of the present study was to analyze and quantify the impact of modeling heart failure survival allowing for covariates with time-varying effects known to be independent predictors of overall mortality in this clinical setting. Methodology: Survival data from an inception cohort of five hundred patients diagnosed with heart failure functional class III and IV between 2002 and 2004 and followed-up to 2006 were analyzed by using the proportional hazards Cox model and variations of the Cox's model and also of the Aalen's additive model. Principal Findings: One-hundred and eighty eight (188) patients died during follow-up. For patients under study, age, serum sodium, hemoglobin, serum creatinine, and left ventricular ejection fraction were significantly associated with mortality. Evidence of time-varying effect was suggested for the last three. Both high hemoglobin and high LV ejection fraction were associated with a reduced risk of dying with a stronger initial effect. High creatinine, associated with an increased risk of dying, also presented an initial stronger effect. The impact of age and sodium were constant over time. Conclusions: The current study points to the importance of evaluating covariates with time-varying effects in heart failure models. The analysis performed suggests that variations of Cox and Aalen models constitute a valuable tool for identifying these variables. The implementation of covariates with time-varying effects into heart failure prognostication models may reduce bias and increase the specificity of such models.

Sedimentary rocks of the Internal Hellenides, Greece: age, source, and depositional setting

Ziel der vorliegenden Dissertation war die Untersuchung der Liefergebiete und Ablagerungsräume sedimentärer Gesteine aus ausgewählten Gebieten der inneren Helleniden Griechenlands. Die untersuchten Sedimente Nordgriechenlands gehören zu den Pirgadikia und Vertiskos Einheiten des Serbo-Makedonische Massifs, zu den Examili, Melissochori und Prinochori Formationen der östlichen Vardar Zone und zur Makri Einheit und Melia Formation des östlichen Zirkum-Rhodope-Gürtels in Thrakien. In der östlichen Ägäis lag der Schwerpunkt bei den Sedimenten der Insel Chios. Der Metamorphosegrad der untersuchten Gesteine variiert von der untersten Grünschieferfazies bis hin zur Amphibolitfazies. Das stratigraphische Alter reicht vom Ordovizium bis zur Kreide. Zur Charakterisierung der Gesteine und ihrer Liefgebiete wurden Haupt- und Spurenelementgehalte der Gesamtgesteine bestimmt, mineralchemische Analysen durchgeführt und detritische Zirkone mit U–Pb datiert. An ausgewählten Proben wurden außerdem biostratigraphische Untersuchungen zur Bestimmung des Sedimentationsalters durchgeführt. Die Untersuchungsergebnisse dieser Arbeit sind von großer Bedeutung für paläogeographische Rekonstruktionen der Tethys. Die wichtigsten Ergebnisse lassen sich wie folgt zusammenfassen: Die ältesten Sedimente Nordgriechenlands gehören zur Pirgadikia Einheit des Serbo-Makedonischen Massifs. Es sind sehr reife, quarzreiche, siliziklastische Metasedimente, die auf Grund ihrer Maturität und ihrer detritischen Zirkone mit ordovizischen overlap-Sequenzen vom Nordrand Gondwanas korreliert werden können. Die Metasedimente der Vertiskos Einheit besitzen ein ähnliches stratigraphisches Alter, haben aber einen anderen Ablagerungsraum. Das Altersspektrum detritischer Zirkone lässt auf ein Liefergebiet im Raum NW Afrikas (Hun Superterrane) schließen. Die Gesteinsassoziation der Vertiskos Einheit wird als Teil einer aktiven Kontinentalrandabfolge gesehen. Die ältesten biostratigraphisch datierten Sedimente Griechenlands sind silurische bis karbonische Olistolithe aus einer spätpaläozoischen Turbidit-Olistostrom Einheit auf der Insel Chios. Die Alter detritischer Zirkone und die Liefergebietsanalyse der fossilführenden Olistolithe lassen den Schluss zu, dass die klastischen Sedimente von Chios Material vom Sakarya Mikrokontinent in der West-Türkei und faziellen Äquivalenten zu paläozoischen Gesteinen der Istanbul Zone in der Nord-Türkei und der Balkan Region erhalten haben. Während der Permotrias wurde die Examili Formation der östlichen Vardar Zone in einem intrakontinentalen, sedimentären Becken, nahe der Vertiskos Einheit abgelagert. Untergeordnet wurde auch karbonisches Grundgebirgsmaterial eingetragen. Im frühen bis mittleren Jura wurde die Melissochori Formation der östlichen Vardar Zone am Abhang eines karbonatführenden Kontinentalrandes abgelagert. Der Großteil des detritischen Materials kam von permokarbonischem Grundgebirge vulkanischen Ursprungs, vermutlich von der Pelagonischen Zone und/oder der unteren tektonischen Einheit des Rhodope Massifs. Die Makri Einheit in Thrakien besitzt vermutlich ein ähnliches Alter wie die Melissochori Formation. Beide sedimentären Abfolgen ähneln sich sehr. Der Großteil des detritischen Materials für die Makri Einheit kam vom Grundgebirge der Pelagonischen Zone oder äquivalenten Gesteinen. Während der frühen Kreide wurde die Prinochori Formation der östlichen Vardar Zone im Vorfeld eines heterogenen Deckenstapels abgelagert, der ophiolitisches Material sowie Grundgebirge ähnlich zu dem der Vertiskos Einheit enthielt. Ebenfalls während der Kreidezeit wurde in Thrakien, vermutlich im Vorfeld eines metamorphen Deckenstapels mit Affinitäten zum Grundgebirge der Rhodopen die Melia Formation abgelagert. Zusammenfassend kann festgehalten werden, dass die Subduktion eines Teiles der Paläotethys und die anschließende Akkretion vom Nordrand Gondwanas stammender Mikrokontinente (Terranes) nahe dem südlichen aktiven Kontinentalrand Eurasiens den geodynamischen Rahmen für die Schüttung des detritischen Materials der Sedimente der inneren Helleniden im späten Paläozoikum bildeten. Die darauf folgenden frühmesozoischen Riftprozesse leiteten die Bildung von Ozeanbecken der Neotethys ein. Intraozeanische Subduktion und die Obduzierung von Ophioliten prägten die Zeit des Jura. Die spätjurassische und frühkretazische tektonische Phase wurde durch die Ablagerung von mittelkretazischen Kalksteinen besiegelt. Die endgültige Schließung von Ozeanbecken der Neotethys im Bereich der inneren Helleniden erfolgte schließlich in der späten Kreide und im Tertiär.

Advanced modelling of time domain electromagnetic data with updated hydrogeological interpretations

Several countries have acquired, over the past decades, large amounts of area covering Airborne Electromagnetic data. Contribution of airborne geophysics has dramatically increased for both groundwater resource mapping and management proving how those systems are appropriate for large-scale and efficient groundwater surveying. We start with processing and inversion of two AEM dataset from two different systems collected over the Spiritwood Valley Aquifer area, Manitoba, Canada respectively, the AeroTEM III (commissioned by the Geological Survey of Canada in 2010) and the “Full waveform VTEM” dataset, collected and tested over the same survey area, during the fall 2011. We demonstrate that in the presence of multiple datasets, either AEM and ground data, due processing, inversion, post-processing, data integration and data calibration is the proper approach capable of providing reliable and consistent resistivity models. Our approach can be of interest to many end users, ranging from Geological Surveys, Universities to Private Companies, which are often proprietary of large geophysical databases to be interpreted for geological and\or hydrogeological purposes. In this study we deeply investigate the role of integration of several complimentary types of geophysical data collected over the same survey area. We show that data integration can improve inversions, reduce ambiguity and deliver high resolution results. We further attempt to use the final, most reliable output resistivity models as a solid basis for building a knowledge-driven 3D geological voxel-based model. A voxel approach allows a quantitative understanding of the hydrogeological setting of the area, and it can be further used to estimate the aquifers volumes (i.e. potential amount of groundwater resources) as well as hydrogeological flow model prediction. In addition, we investigated the impact of an AEM dataset towards hydrogeological mapping and 3D hydrogeological modeling, comparing it to having only a ground based TEM dataset and\or to having only boreholes data.

Identification of problems in functioning of people with sleep disorders in a clinical setting using the International Classification of Functioning Disability and Health (ICF) Checklist

We conducted an explorative, cross-sectional, multi-centre study in order to identify the most common problems of people with any kind of (primary) sleep disorder in a clinical setting using the International Classification of Functioning, Disability and Health (ICF) as a frame of reference. Data were collected from patients using a structured face-to-face interview of 45-60 min duration. A case record form for health professionals containing the extended ICF Checklist, sociodemographic variables and disease-specific variables was used. The study centres collected data of 99 individuals with sleep disorders. The identified categories include 48 (32%) for body functions, 13 (9%) body structures, 55 (37%) activities and participation and 32 (22%) for environmental factors. 'Sleep functions' (100%) and 'energy and drive functions', respectively, (85%) were the most severely impaired second-level categories of body functions followed by 'attention functions' (78%) and 'temperament and personality functions' (77%). With regard to the component activities and participation, patients felt most restricted in the categories of 'watching' (e.g. TV) (82%), 'recreation and leisure' (75%) and 'carrying out daily routine' (74%). Within the component environmental factors the categories 'support of immediate family', 'health services, systems and policies' and 'products or substances for personal consumption [medication]' were the most important facilitators; 'time-related changes', 'light' and 'climate' were the most important barriers. The study identified a large variety of functional problems reflecting the complexity of sleep disorders. The ICF has the potential to provide a comprehensive framework for the description of functional health in individuals with sleep disorders in a clinical setting.

Rapid qualitative urinary tract infection pathogen identification by SeptiFast real-time PCR

Background Urinary tract infections (UTI) are frequent in outpatients. Fast pathogen identification is mandatory for shortening the time of discomfort and preventing serious complications. Urine culture needs up to 48 hours until pathogen identification. Consequently, the initial antibiotic regimen is empirical. Aim To evaluate the feasibility of qualitative urine pathogen identification by a commercially available real-time PCR blood pathogen test (SeptiFast®) and to compare the results with dipslide and microbiological culture. Design of study Pilot study with prospectively collected urine samples. Setting University hospital. Methods 82 prospectively collected urine samples from 81 patients with suspected UTI were included. Dipslide urine culture was followed by microbiological pathogen identification in dipslide positive samples. In parallel, qualitative DNA based pathogen identification (SeptiFast®) was performed in all samples. Results 61 samples were SeptiFast® positive, whereas 67 samples were dipslide culture positive. The inter-methodological concordance of positive and negative findings in the gram+, gram- and fungi sector was 371/410 (90%), 477/492 (97%) and 238/246 (97%), respectively. Sensitivity and specificity of the SeptiFast® test for the detection of an infection was 0.82 and 0.60, respectively. SeptiFast® pathogen identifications were available at least 43 hours prior to culture results. Conclusion The SeptiFast® platform identified bacterial DNA in urine specimens considerably faster compared to conventional culture. For UTI diagnosis sensitivity and specificity is limited by its present qualitative setup which does not allow pathogen quantification. Future quantitative assays may hold promise for PCR based UTI pathogen identification as a supplementation of conventional culture methods.

Population-based analysis of 4113 patients with acute cholecystitis: defining the optimal time-point for laparoscopic cholecystectomy

Objective: To compare clinical outcomes after laparoscopic cholecystectomy (LC) for acute cholecystitis performed at various time-points after hospital admission. Background: Symptomatic gallstones represent an important public health problem with LC the treatment of choice. LC is increasingly offered for acute cholecystitis, however, the optimal time-point for LC in this setting remains a matter of debate. Methods: Analysis was based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery and included patients undergoing emergency LC for acute cholecystitis between 1995 and 2006, grouped according to the time-points of LC since hospital admission (admission day (d0), d1, d2, d3, d4/5, d ≥6). Linear and generalized linear regression models assessed the effect of timing of LC on intra- or postoperative complications, conversion and reoperation rates and length of postoperative hospital stay. Results: Of 4113 patients, 52.8% were female, median age was 59.8 years. Delaying LC resulted in significantly higher conversion rates (from 11.9% at d0 to 27.9% at d ≥6 days after admission, P < 0.001), surgical postoperative complications (5.7% to 13%, P < 0.001) and re-operation rates (0.9% to 3%, P = 0.007), with a significantly longer postoperative hospital stay (P < 0.001). Conclusions: Delaying LC for acute cholecystitis has no advantages, resulting in significantly increased conversion/re-operation rate, postoperative complications and longer postoperative hospital stay. This investigation—one of the largest in the literature—provides compelling evidence that acute cholecystitis merits surgery within 48 hours of hospital admission if impact on the patient and health care system is to be minimized.

[Adapted and Standardised Patient Management in the Treatment of Neovascular AMD in the Outpatient Setting of a University Eye Hospital.]

Visual results in treating neovascular age-related macular degeneration (AMD) using intravitreal injected anti-VEGF (IVT) clearly depend on injection frequency. Regarding to the European approval Ranibizumab has to be used only in cases of recurrent visual loss after the loading phase. In contrast monthly treatment--as also provided in the ANCHOR and MARINA studies--is generally allowed in Switzerland. However, it is commonly tried to reduce the injection frequency because of the particular cost situation in all health systems and of cause also due to the necessary strict monitoring and reinjection regimes, which raise management problems with increasing patient numbers. In this article the special treatment regimes of our University Eye Hospital is presented, in which a reduced injection frequency basically leads to the same increased and stable visual results as in ANCHOR and MARINA; however, needing significantly more injections as generally provided in other countries of Europe. The main focus for achieving this in a large number of patients is placed on re-structuring our outpatient flow for IVT patients with particular emphasis on patient separation and standardisation of treatment steps leading to significantly reduced time consumption per patient. Measurements of timing and patient satisfaction before and after restructuring underline its importance in order to be able to treat more patients at a high quality even in the future. The exceptional importance of spectral domain OCT measurements as the most important criterium for indicating re-treatment is illustrated.

Robust Inferences For Covariate Effects On Survival Time With Censored Linear Regression Models

Various inference procedures for linear regression models with censored failure times have been studied extensively. Recent developments on efficient algorithms to implement these procedures enhance the practical usage of such models in survival analysis. In this article, we present robust inferences for certain covariate effects on the failure time in the presence of "nuisance" confounders under a semiparametric, partial linear regression setting. Specifically, the estimation procedures for the regression coefficients of interest are derived from a working linear model and are valid even when the function of the confounders in the model is not correctly specified. The new proposals are illustrated with two examples and their validity for cases with practical sample sizes is demonstrated via a simulation study.

Livelihoods in Transition: Changing Land Use Strategies and Ecological Implications in a Post Soviet Setting (Kyrgyzstan)

The sudden independence of Kyrgyzstan from the Soviet Union in 1991 led to a total rupture of industrial and agricultural production. Based on empirical data, this study seeks to identify key land use transformation processes since the late 1980s, their impact on people's livelihoods and the implication for natural resources in the communes of Tosh Bulak and Saz, located in the Sokuluk River Basin on the northern slope of the Kyrgyz Range. Using the concept of the sustainable livelihood approach as an analytical framework, three different livelihood strategies were identified: (1) An accumulation strategy applied by wealthy households where renting and/or buying of land is a key element; they are the only household category capable of venturing into rain fed agriculture. (2) A preserving strategy involving mainly intermediate households who are not able to buy or rent additional agricultural land; very often they are forced to return their land to the commune or sell it to wealthier households. (3) A coping strategy including mainly poor households consisting of elderly pensioners or headed by single mothers; due to their limited labour and economic power, agricultural production is very low and hardly covers subsistence needs; pensions and social allowances form the backbone of these livelihoods. Ecological assessments have shown that the forage productivity of remote high mountain pastures has increased from 5 to 22 per cent since 1978. At the same time forage productivity on pre-mountain and mountain pastures close to villages has generally decreased from 1 to 34 per cent. It seems that the main avenues for livelihoods to increase their wealth are to be found in the agricultural sector by controlling more and mainly irrigated land as well as by increasing livestock. The losers in this process are thus those households unable to keep or exploit their arable land or to benefit from new agricultural land. Ensuring access to land for the poor is therefore imperative in order to combat rural poverty and socio-economic disparities in rural Kyrgyzstan.

A multiplex real-time PCR assay for rapid detection and differentiation of 25 bacterial and fungal pathogens from whole blood samples

Early detection of bloodstream infections (BSI) is crucial in the clinical setting. Blood culture remains the gold standard for diagnosing BSI. Molecular diagnostic tools can contribute to a more rapid diagnosis in septic patients. Here, a multiplex real-time PCR-based assay for rapid detection of 25 clinically important pathogens directly from whole blood in <6 h is presented. Minimal analytical sensitivity was determined by hit rate analysis from 20 independent experiments. At a concentration of 3 CFU/ml a hit rate of 50% was obtained for E. aerogenes and 100% for S. marcescens, E. coli, P. mirabilis, P. aeruginosa, and A. fumigatus. The hit rate for C. glabrata was 75% at 30 CFU/ml. Comparing PCR identification results with conventional microbiology for 1,548 clinical isolates yielded an overall specificity of 98.8%. The analytical specificity in 102 healthy blood donors was 100%. Although further evaluation is warranted, our assay holds promise for more rapid pathogen identification in clinical sepsis.

Development of a screening tool predicting the transition from acute to chronic low back pain for patients in a GP setting: protocol of a multinational prospective cohort study

BACKGROUND: Low back pain (LBP) is by far the most prevalent and costly musculoskeletal problem in our society today. Following the recommendations of the Multinational Musculoskeletal Inception Cohort Study (MMICS) Statement, our study aims to define outcome assessment tools for patients with acute LBP and the time point at which chronic LBP becomes manifest and to identify patient characteristics which increase the risk of chronicity. METHODS: Patients with acute LBP will be recruited from clinics of general practitioners (GPs) in New Zealand (NZ) and Switzerland (CH). They will be assessed by postal survey at baseline and at 3, 6, 12 weeks and 6 months follow-up. Primary outcome will be disability as measured by the Oswestry Disability Index (ODI); key secondary endpoints will be general health as measured by the acute SF-12 and pain as measured on the Visual Analogue Scale (VAS). A subgroup analysis of different assessment instruments and baseline characteristics will be performed using multiple linear regression models. This study aims to examine: 1. Which biomedical, psychological, social, and occupational outcome assessment tools are identifiers for the transition from acute to chronic LBP and at which time point this transition becomes manifest. 2. Which psychosocial and occupational baseline characteristics like work status and period of work absenteeism influence the course from acute to chronic LBP. 3. Differences in outcome assessment tools and baseline characteristics of patients in NZ compared with CH. DISCUSSION: This study will develop a screening tool for patients with acute LBP to be used in GP clinics to access the risk of developing chronic LBP. In addition, biomedical, psychological, social, and occupational patient characteristics which influence the course from acute to chronic LBP will be identified. Furthermore, an appropriate time point for follow-ups will be given to detect this transition. The generalizability of our findings will be enhanced by the international perspective of this study. TRIAL REGISTRATION: [Clinical Trial Registration Number, ACTRN12608000520336].