Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities

Objective: In Australian residential aged care facilities (RACFs), the use of certain classes of high-risk medication such as antipsychotics, potent analgesics, and sedatives is high. Here, we examined the prescribed medications and subsequent changes recommended by geriatricians during comprehensive geriatric consultations provided to residents of RACFs via videoconference. Design: This is a prospective observational study. Setting: Four RACFs in Queensland, Australia, are included. Participants: A total of 153 residents referred by general practitioners for comprehensive assessment by geriatricians delivered by video-consultation. Results: Residents’ mean (standard deviation, SD) age was 83.0 (8.1) years and 64.1% were female. They had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean (SD) of 9.6 (4.2) regular medications. Ninety-one percent of patients were taking five or more medications daily. Of total medications prescribed (n=1,469), geriatricians recommended withdrawal of 9.8% (n=145) and dose alteration of 3.5% (n=51). New medications were initiated in 47.7% (n=73) patients. Of the 10.3% (n=151) medications considered as high risk, 17.2% were stopped and dose altered in 2.6%. Conclusion: There was a moderate prevalence of potentially inappropriate high-risk medications. However, geriatricians made relatively few changes, suggesting either that, on balance, prescription of these medications was appropriate or, because of other factors, there was a reluctance to adjust medications. A structured medication review using an algorithm for withdrawing medications of high disutility might help optimize medications in frail patients. Further research, including a broader survey, is required to understand these dynamics.

Prescribing for older people discharged from the acute sector to residential aged-care facilities

For frail older people, admission to hospital is an opportunity to review the indications for specific medications. This research investigates prescribing for 206 older people discharged into residential aged care facilities from 11 acute care hospitals in Australia. Patients had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean of 7.2 regular medications at admission to hospital and 8.1 medications on discharge, with hyper-polypharmacy (≥10 drugs) increasing from 24.3% to 32.5%. Many drugs were preventive medications whose time until benefit was likely to exceed the expected lifespan. In summary, frail patients continue to be exposed to extensive polypharmacy and medications with uncertain risk–benefit ratio.

Trends in therapeutic and prevention strategies for management of Bovine Mastitis: An overview

Mastitis is one of the most economically significant diseases for the dairy industry for backyard farmers in developing countries and high producing herds worldwide. Two of the major factors impeding reduction in the incidence of this disease is [a] the lack of availability of an effective vaccine capable of protecting against multiple etiological agents and [b] propensity of some of the etiological agents to develop persistent antibiotic resistance in biofilms. This is further complicated by the continuing revolving shift in the predominant etiological agents of mastitis, depending upon a multitude of factors such as variability in hygienic practices on farms, easy access leading to overuse of appropriate or inappropriate antibiotics at suboptimal concentrations, particularly in developing countries, and lack of compliance with the recommended treatment schedules. Regardless, Staphylococcus aureus and Streptococcus uberis followed by Escherichia coli, Streptococcus agalactiae has become the predominant etiological agents of bovine mastitis followed Streptococcus agalactiae, Streptococcus dysagalactiae, Klebsiella pneumonia and the newly emerging Mycoplasma bovis. Current approaches being pursued to reduce the negative economic impact of this disease are through early diagnosis of infection, immediate treatment with an antibiotic found to either inhibit or kill the pathogen(s) in vitro using planktonic cultures and the use of the currently marketed vaccines regardless of their demonstrated effectiveness. Given the limitations of breeding programs, including genetic selection to improve resistance against infectious diseases including mastitis, it is imperative to have the availability of an effective broad-spectrum, preferably cross-protective, vaccine capable of protecting against bovine mastitis for reduction in the incidence of bovine mastitis, as well as interrupting the potential cross-species transmission to humans. This overview highlights the major etiological agents, factors affecting susceptibility to mastitis, and the current status of antibiotic-based therapies and prototype vaccine candidates or commercially available vaccines against bovine mastitis as potential preventative strategies. © 2013 Tiwari JG, et al.

Official habits of Rabbi and Cantor Rabbis

Official habits of Rabbi and Cantor as introduced by the Beden Oberrat der Israeliten (Central Council of Jews) in 1843. The distinction of the Rabbi is expressed in his wearing a silk mantle over his wool coat and a white double collar, representing the tablets of Moses.

Declining trends in annual catch rates of the tiger shark (Galeocerdo cuvier) in Queensland, Australia

Suitable long term species-specific catch rate and biological data are seldom available for large shark species, particularly where historical commercial logbook reporting has been poor. However, shark control programs can provide suitable data from gear that consistently fishes nearshore waters all year round. We present an analysis of the distribution of 4757 . Galeocerdo cuvier caught in surface nets and on drumlines across 9 of the 10 locations of the Queensland Shark Control Program (QSCP) between 1993 and 2010. Standardised catch rates showed a significant decline (p<. 0.0001) in southern Queensland locations for both gear types, which contrasts with studies at other locations where increases in tiger shark catch per unit effort (CPUE) have been reported. Significant temporal declines in the average size of tiger sharks occurred at four of the nine locations analysed (p<. 0.05), which may be indicative of fishing reducing abundance in these areas. Given the long term nature of shark control programs along the Australian east coast, effects on local abundance should have been evident many years ago, which suggests that factors other than the effects of shark control programs have also contributed to the decline. While reductions in catch rate are consistent with a decline in tiger shark abundance, this interpretation should be made with caution, as the inter-annual CPUE varies considerably at most locations. Nevertheless, the overall downward trend, particularly in southern Queensland, indicates that current fishing pressures on the species may be unsustainable. © 2012 Elsevier B.V.

Land leasing, land degradation and agricultural productivity in Finland

This study analysed whether the land tenure insecurity problem has led to a decline in long-term land improvements (liming and phosphorus fertilization) under the Common Agricultural Policy (CAP) and Nordic production conditions in European Union (EU) countries such as Finland. The results suggests that under traditional cash lease contracts, which are encouraged by the existing land leasing regulations and agricultural subsidy programs, the land tenure insecurity problem on leased land reduces land improvements that have a long pay-back period. In particular, soil pH was found to be significantly lower on land cultivated under a lease contract compared to land owned by the farmers themselves. The results also indicate that land improvements could not be reversed by land markets, because land owners would otherwise have carried out land improvements even if not farming by themselves. To reveal the causality between land tenure and land improvements, the dynamic optimisation problem was solved by a stochastic dynamic programming routine with known parameters for one-period returns and transition equations. The model parameters represented Finnish soil quality and production conditions. The decision rules were solved for alternative likelihood scenarios over the continuation of the fixed-term lease contract. The results suggest that as the probability of non-renewal of the lease contract increases, farmers quickly reduce investments in irreversible land improvements and, thereafter, yields gradually decline. The simulations highlighted the observed trends of a decline in land improvements on land parcels that are cultivated under lease contracts. Land tenure has resulted in the neglect of land improvement in Finland. This study aimed to analyze whether these challenges could be resolved by a tax policy that encourages land sales. Using Finnish data, real estate tax and a temporal relaxation on the taxation of capital gains showed some potential for the restructuring of land ownership. Potential sellers who could not be revealed by traditional logit models were identified with the latent class approach. Those landowners with an intention to sell even without a policy change were sensitive to temporal relaxation in the taxation of capital gains. In the long term, productivity and especially productivity growth are necessary conditions for the survival of farms and the food industry in Finland. Technical progress was found to drive the increase in productivity. The scale had only a moderate effect and for the whole study period (1976–2006) the effect was close to zero. Total factor productivity (TFP) increased, depending on the model, by 0.6–1.7% per year. The results demonstrated that the increase in productivity was hindered by the policy changes introduced in 1995. It is also evidenced that the increase in land leasing is connected to these policy changes. Land institutions and land tenure questions are essential in agricultural and rural policies on all levels, from local to international. Land ownership and land titles are commonly tied to fundamental political, economic and social questions. A fair resolution calls for innovative and new solutions both on national and international levels. However, this seems to be a problem when considering the application of EU regulations to member states inheriting divergent landownership structures and farming cultures. The contribution of this study is in describing the consequences of fitting EU agricultural policy to Finnish agricultural land tenure conditions and heritage.

Water-use efficiency and productivity trends in Australian irrigated cotton: a review

The aim of this review is to report changes in irrigated cotton water use from research projects and on-farm practice-change programs in Australia, in relation to both plant-based and irrigation engineering disciplines. At least 80% of the Australian cotton-growing area is irrigated using gravity surface-irrigation systems. This review found that, over 23 years, cotton crops utilise 6-7ML/ha of irrigation water, depending on the amount of seasonal rain received. The seasonal evapotranspiration of surface-irrigated crops averaged 729mm over this period. Over the past decade, water-use productivity by Australian cotton growers has improved by 40%. This has been achieved by both yield increases and more efficient water-management systems. The whole-farm irrigation efficiency index improved from 57% to 70%, and the crop water use index is >3kg/mm.ha, high by international standards. Yield increases over the last decade can be attributed to plant-breeding advances, the adoption of genetically modified varieties, and improved crop management. Also, there has been increased use of irrigation scheduling tools and furrow-irrigation system optimisation evaluations. This has reduced in-field deep-drainage losses. The largest loss component of the farm water balance on cotton farms is evaporation from on-farm water storages. Some farmers are changing to alternative systems such as centre pivots and lateral-move machines, and increasing numbers of these alternatives are expected. These systems can achieve considerable labour and water savings, but have significantly higher energy costs associated with water pumping and machine operation. The optimisation of interactions between water, soils, labour, carbon emissions and energy efficiency requires more research and on-farm evaluations. Standardisation of water-use efficiency measures and improved water measurement techniques for surface irrigation are important research outcomes to enable valid irrigation benchmarks to be established and compared. Water-use performance is highly variable between cotton farmers and farming fields and across regions. Therefore, site-specific measurement is important. The range in the presented datasets indicates potential for further improvement in water-use efficiency and productivity on Australian cotton farms.

Insights into PBDE uptake, body burden, and elimination gained from Australian age–Concentration trends observed shortly after peak exposure

Background Population pharmacokinetic models combined with multiple sets of age– concentration biomonitoring data facilitate back-calculation of chemical uptake rates from biomonitoring data. Objectives We back-calculated uptake rates of PBDEs for the Australian population from multiple biomonitoring surveys (top-down) and compared them with uptake rates calculated from dietary intake estimates of PBDEs and PBDE concentrations in dust (bottom-up). Methods Using three sets of PBDE elimination half-lives, we applied a population pharmacokinetic model to the PBDE biomonitoring data measured between 2002–2003 and 2010–2011 to derive the top-down uptake rates of four key PBDE congeners and six age groups. For the bottom-up approach, we used PBDE concentrations measured around 2005. Results Top-down uptake rates of Σ4BDE (the sum of BDEs 47, 99, 100, and 153) varied from 7.9 to 19 ng/kg/day for toddlers and from 1.2 to 3.0 ng/kg/day for adults; in most cases, they were—for all age groups—higher than the bottom-up uptake rates. The discrepancy was largest for toddlers with factors up to 7–15 depending on the congener. Despite different elimination half-lives of the four congeners, the age–concentration trends showed no increase in concentration with age and were similar for all congeners. Conclusions In the bottom-up approach, PBDE uptake is underestimated; currently known pathways are not sufficient to explain measured PBDE concentrations, especially in young children. Although PBDE exposure of toddlers has declined in the past years, pre- and postnatal exposure to PBDEs has remained almost constant because the mothers’ PBDE body burden has not yet decreased substantially.

Large-scale characterization of drought pattern: a continent-wide modelling approach applied to the Australian wheatbelt – spatial and temporal trends

* Plant response to drought is complex, so that traits adapted to a specific drought type can confer disadvantage in another drought type. Understanding which type(s) of drought to target is of prime importance for crop improvement. * Modelling was used to quantify seasonal drought patterns for a check variety across the Australian wheatbelt, using 123 yr of weather data for representative locations and managements. Two other genotypes were used to simulate the impact of maturity on drought pattern. * Four major environment types summarized the variability in drought pattern over time and space. Severe stress beginning before flowering was common (44% of occurrences), with (24%) or without (20%) relief during grain filling. High variability occurred from year to year, differing with geographical region. With few exceptions, all four environment types occurred in most seasons, for each location, management system and genotype. * Applications of such environment characterization are proposed to assist breeding and research to focus on germplasm, traits and genes of interest for target environments. The method was applied at a continental scale to highly variable environments and could be extended to other crops, to other drought-prone regions around the world, and to quantify potential changes in drought patterns under future climates.

Invisible opportunities and irreversible trends

Small firms are always vulnerable to complex technological change that may render their existing business model obsolete. This paper emphasises the need to understand how the Internet's ubiquitous World Wide Web is impacting on their operating environments. Consideration of evolutionary theory and the absorptive capacity construct provides the foundation for discussion of how learning and discovery take place within individuals, firms and the environments that interact with. Small firms, we argue, face difficulties identifying what routines and competencies are best aligned with the seemingly invisible dominant designs that support pursuit of new enterprise in web-impacted environments. We argue that such difficulties largely relate to an inability to acquire external knowledge and the subsequent reliance on existing internal selection processes that may reinforce the known, at the expense of the unknown. The paper concludes with consideration as to how managers can overcome the expected difficulties through the development of internal routines that support the continual search, evaluation and acquisition of specific external knowledge.

Frost trends and their estimated impact on yield in the Australian wheatbelt

Radiant spring frosts occurring during reproductive developmental stages can result in catastrophic yield loss for wheat producers. To better understand the spatial and temporal variability of frost, the occurrence and impact of frost events on rain-fed wheat production was estimated across the Australian wheatbelt for 1957–2013 using a 0.05 ° gridded weather data set. Simulated yield outcomes at 60 key locations were compared with those for virtual genotypes with different levels of frost tolerance. Over the last six decades, more frost events, later last frost day, and a significant increase in frost impact on yield were found in certain regions of the Australian wheatbelt, in particular in the South-East and West. Increasing trends in frost-related yield losses were simulated in regions where no significant trend of frost occurrence was observed, due to higher mean temperatures accelerating crop development and causing sensitive post-heading stages to occur earlier, during the frost risk period. Simulations indicated that with frost-tolerant lines the mean national yield could be improved by up to 20 through (i) reduced frost damage (~10 improvement) and (ii) the ability to use earlier sowing dates (adding a further 10 improvement). In the simulations, genotypes with an improved frost tolerance to temperatures 1 °C lower than the current 0 °C reference provided substantial benefit in most cropping regions, while greater tolerance (to 3 °C lower temperatures) brought further benefits in the East. The results indicate that breeding for improved reproductive frost tolerance should remain a priority for the Australian wheat industry, despite warming climates.

Fauna community trends during early restoration of alluvial open forest/woodland ecosystems on former agricultural land

Vertebrate fauna was studied over 10 years following revegetation of a Eucalyptus tereticornis ecosystem on former agricultural land. We compared four vegetation types: remnant forest, plantings of a mix of native tree species on cleared land, natural regeneration of partially cleared land after livestock removal, and cleared pasture land with scattered paddock trees managed for livestock production. Pasture differed significantly from remnant in both bird and nonbird fauna. Although 10 years of ecosystem restoration is relatively short term in the restoration process, in this time bird assemblages in plantings and natural regeneration had diverged significantly from pasture, but still differed significantly from remnant. After 10 years, 70 and 66% of the total vertebrate species found in remnant had been recorded in plantings and natural regeneration, respectively. Although the fauna assemblages within plantings and natural regeneration were tracking toward those of remnant, significant differences in fauna between plantings and natural regeneration indicated community development along different restoration pathways. Because natural regeneration contained more mature trees (dbh > 30 cm), native shrub species, and coarse woody debris than plantings from the beginning of the study, these features possibly encouraged different fauna to the revegetation areas from the outset. The ability of plantings and natural regeneration to transition to the remnant state will be governed by a number of factors that were significant in the analyses, including shrub cover, herbaceous biomass, tree hollows, time since fire, and landscape condition. Both active and passive restoration produced significant change from the cleared state in the short term.

IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes

Recommendations - 1 To identify a person with diabetes at risk for foot ulceration, examine the feet annually to seek evidence for signs or symptoms of peripheral neuropathy and peripheral artery disease. (GRADE strength of recommendation: strong; Quality of evidence: low) - 2 In a person with diabetes who has peripheral neuropathy, screen for a history of foot ulceration or lower-extremity amputation, peripheral artery disease, foot deformity, pre-ulcerative signs on the foot, poor foot hygiene and ill-fitting or inadequate footwear. (Strong; Low) - 3 Treat any pre-ulcerative sign on the foot of a patient with diabetes. This includes removing callus, protecting blisters and draining when necessary, treating ingrown or thickened toe nails, treating haemorrhage when necessary and prescribing antifungal treatment for fungal infections. (Strong; Low) - 4 To protect their feet, instruct an at-risk patient with diabetes not to walk barefoot, in socks only, or in thin-soled standard slippers, whether at home or when outside. (Strong; Low) - 5 Instruct an at-risk patient with diabetes to daily inspect their feet and the inside of their shoes, daily wash their feet (with careful drying particularly between the toes), avoid using chemical agents or plasters to remove callus or corns, use emollients to lubricate dry skin and cut toe nails straight across. (Weak; Low) - 6 Instruct an at-risk patient with diabetes to wear properly fitting footwear to prevent a first foot ulcer, either plantar or non-plantar, or a recurrent non-plantar foot ulcer. When a foot deformity or a pre-ulcerative sign is present, consider prescribing therapeutic shoes, custom-made insoles or toe orthosis. (Strong; Low) - 7 To prevent a recurrent plantar foot ulcer in an at-risk patient with diabetes, prescribe therapeutic footwear that has a demonstrated plantar pressure-relieving effect during walking (i.e. 30% relief compared with plantar pressure in standard of care therapeutic footwear) and encourage the patient to wear this footwear. (Strong; Moderate) - 8 To prevent a first foot ulcer in an at-risk patient with diabetes, provide education aimed at improving foot care knowledge and behaviour, as well as encouraging the patient to adhere to this foot care advice. (Weak; Low) - 9 To prevent a recurrent foot ulcer in an at-risk patient with diabetes, provide integrated foot care, which includes professional foot treatment, adequate footwear and education. This should be repeated or re-evaluated once every 1 to 3 months as necessary. (Strong; Low) - 10 Instruct a high-risk patient with diabetes to monitor foot skin temperature at home to prevent a first or recurrent plantar foot ulcer. This aims at identifying the early signs of inflammation, followed by action taken by the patient and care provider to resolve the cause of inflammation. (Weak; Moderate) - 11 Consider digital flexor tenotomy to prevent a toe ulcer when conservative treatment fails in a high-risk patient with diabetes, hammertoes and either a pre-ulcerative sign or an ulcer on the distal toe. (Weak; Low) - 12 Consider Achilles tendon lengthening, joint arthroplasty, single or pan metatarsal head resection, or osteotomy to prevent a recurrent foot ulcer when conservative treatment fails in a high-risk patient with diabetes and a plantar forefoot ulcer. (Weak; Low) - 13 Do not use a nerve decompression procedure in an effort to prevent a foot ulcer in an at-risk patient with diabetes, in preference to accepted standards of good quality care. (Weak; Low)