Using a longitudinal model to estimate the effect of methicillin-resistant staphylococcus aureus infection on length of stay in an intensive care unit

Healthcare-associated methicillin-resistant Staphylococcus aureus(MRSA) infection may cause increased hospital stay or, sometimes, death. Quantifying this effect is complicated because it is a time-dependent exposure: infection may prolong hospital stay, while longer stays increase the risk of infection. We overcome these problems by using a multinomial longitudinal model for estimating the daily probability of death and discharge. We then extend the basic model to estimate how the effect of MRSA infection varies over time, and to quantify the number of excess ICU days due to infection. We find that infection decreases the relative risk of discharge (relative risk ratio = 0.68, 95% credible interval: 0.54, 0.82), but is only indirectly associated with increased mortality. An infection on the first day of admission resulted in a mean extra stay of 0.3 days (95% CI: 0.1, 0.5) for a patient with an APACHE II score of 10, and 1.2 days (95% CI: 0.5, 2.0) for a patient with an APACHE II score of 30. The decrease in the relative risk of discharge remained fairly constant with day of MRSA infection, but was slightly stronger closer to the start of infection. These results confirm the importance of MRSA infection in increasing ICU stay, but suggest that previous work may have systematically overestimated the effect size.

Intensive cognitive-behaviour therapy for depression : preliminary findings with four country residents

Describes a brief intensive program of cognitive therapy for depression that was designed for 4 adult residents of country towns in Australia, who resided some distance from treatment centers. Ss were assessed prior to treatment, at posttreatment, and at 4-wk, 8-wk, and 20-mo follow-ups. Treatments took place over 3 consecutive days for a total period of 15 hrs. Effects were highly consistent with the impact of group treatments delivered on a more traditional schedule. If confirmed in a controlled group study, these results suggest that cognitive therapy may be applied more economically and more widely than was previously realized.

A robust reactive scheduling model for intensive care units

The ICU is an integral part of any hospital and is under great load from patient arrivals as well as resource limitations. Scheduling of patients in the ICU is complicated by the two general types; elective surgery and emergency arrivals. This complicated situation is handled by creating a tentative initial schedule and then reacting to uncertain arrivals as they occur. For most hospitals there is little or no flexibility in the number of beds that are available for use now or in the future. We propose an integer programming model to handle a parallel machine reacting system for scheduled and unscheduled arrivals.

Cost effectiveness of antimicrobial catheters in the intensive care unit : Addressing uncertainty in the decision

Introduction: Some types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost-effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, antimicrobial-coated central venous catheters to use. We re-evaluated the cost-effectiveness of all commercially available antimicrobialcoated central venous catheters for prevention of catheter-related bloodstream infection in adult intensive care unit (ICU) patients. Methods: We used a Markov decision model to compare the cost-effectiveness of antimicrobial-coated central venous catheters relative to uncoated catheters. Four catheter types were evaluated; minocycline and rifampicin (MR)-coated catheters; silver, platinum and carbon (SPC)-impregnated catheters; and two chlorhexidine and silver sulfadiazine-coated catheters, one coated on the external surface (CH/SSD (ext)) and the other coated on both surfaces (CH/SSD (int/ext)). The incremental cost per qualityadjusted life-year gained and the expected net monetary benefits were estimated for each. Uncertainty arising from data estimates, data quality and heterogeneity was explored in sensitivity analyses. Results: The baseline analysis, with no consideration of uncertainty, indicated all four types of antimicrobial-coated central venous catheters were cost-saving relative to uncoated catheters. Minocycline and rifampicin-coated catheters prevented 15 infections per 1,000 catheters and generated the greatest health benefits, 1.6 quality-adjusted life-years, and cost-savings, AUD $130,289. After considering uncertainty in the current evidence, the minocycline and rifampicin-coated catheters returned the highest incremental monetary net benefits of $948 per catheter; but there was a 62% probability of error in this conclusion. Although the minocycline and rifampicin-coated catheters had the highest monetary net benefits across multiple scenarios, the decision was always associated with high uncertainty. Conclusions: Current evidence suggests that the cost-effectiveness of using antimicrobial-coated central venous catheters within the ICU is highly uncertain. Policies to prevent catheter-related bloodstream infection amongst ICU patients should consider the cost-effectiveness of competing interventions in the light of this uncertainty. Decision makers would do well to consider the current gaps in knowledge and the complexity of producing good quality evidence in this area.

Homegardening as a panacea : a case study of South Tarawa

The Republic of Kiribati is a small, highly infertile Pacific Island nation and is one of the most challenging locations to attempt to support dense urban populations. Kiribati, like other nations in the Pacific, faces an urban future where food insecurity, unemployment, waste management and malnutrition will become increasing issues. Homegardening is suggested as one way to address many of these problems. However, the most recent study on agriculture production in urban centres in Kiribati shows that, in general, intensive cultivation of homegardens is not a common practice. This disparity between theory and practice creates an opportunity to re-examine homegardening in Kiribati and, more broadly, in the Pacific. This paper examines the practice of homegardening in urban centres in Kiribati and explores reasons why change has or has not occurred through interviews with homegardeners and government/donor representives. Results show that homegardening has increased significantly in the past five years, largely because of the promotion of homegardens and organic composting systems by donor organisations. While findings further endorse homegardening as an excellent theoretical solution to many of the problems that confront urban settlements in Kiribati and the Pacific, it raises additional questions regarding the continuation of homegarden schemes beyond donor support programmes.

Methods and preliminary results for a data linkage project to determine long-term survival after intensive care unit admission

Aims: To describe a local data linkage project to match hospital data with the Australian Institute of Health and Welfare (AIHW) National Death Index (NDI) to assess longterm outcomes of intensive care unit patients. Methods: Data were obtained from hospital intensive care and cardiac surgery databases on all patients aged 18 years and over admitted to either of two intensive care units at a tertiary-referral hospital between 1 January 1994 and 31 December 2005. Date of death was obtained from the AIHW NDI by probabilistic software matching, in addition to manual checking through hospital databases and other sources. Survival was calculated from time of ICU admission, with a censoring date of 14 February 2007. Data for patients with multiple hospital admissions requiring intensive care were analysed only from the first admission. Summary and descriptive statistics were used for preliminary data analysis. Kaplan-Meier survival analysis was used to analyse factors determining long-term survival. Results: During the study period, 21 415 unique patients had 22 552 hospital admissions that included an ICU admission; 19 058 surgical procedures were performed with a total of 20 092 ICU admissions. There were 4936 deaths. Median follow-up was 6.2 years, totalling 134 203 patient years. The casemix was predominantly cardiac surgery (80%), followed by cardiac medical (6%), and other medical (4%). The unadjusted survival at 1, 5 and 10 years was 97%, 84% and 70%, respectively. The 1-year survival ranged from 97% for cardiac surgery to 36% for cardiac arrest. An APACHE II score was available for 16 877 patients. In those discharged alive from hospital, the 1, 5 and 10-year survival varied with discharge location. Conclusions: ICU-based linkage projects are feasible to determine long-term outcomes of ICU patients

Automatic grading and packing of prawns

Prawns are a substantial Australian resource but presently are processed in a very labour-intensive manner. A prototype system has been developed for automatically grading and packing prawns into single-layer 'consumer packs' in which each prawn is approximately straight and has the same orientation. The novel technology includes a machine vision system that has been specially programmed to calculate relevant parameters at high speed and a gripper mechanism that can acquire, straighten and place prawns of various sizes. The system can be implemented on board a trawler or in an onshore processing facility. © 1993.

Transforming agriculture through pervasive wireless sensor networks

A large-scale, outdoor, pervasive computing system based on the Fleck hardware platform applies sensor network technology to farming. Comprising static and animal-borne mobile nodes, the system measures the state of a complex, dynamic system comprising climate, soil, pasture, and animals. This data supports prediction of the land's future state and improved management outcomes through closed-loop control. This article is part of a special issue, Building a Sensor-Rich World.

Understanding the Aquifier : 3D Visualisation and Groundwater Time-Series Animation in Lockyer Valley

The Lockyer Valley, southeast Queensland, hosts intensive irrigated agriculture using groundwater from over 5000 alluvial bores. A current project is considering introduction of PRW (purified recycled water) to augment groundwater supplies. To assess this, a valley-wide MODFLOW simulation model is being developed plus a new unsaturated zone flow model. To underpin these models and provide a realistic understanding of the aquifer framework a 3D visualisation model has been developed using Groundwater Visualisation System (GVS) software produced at QUT.

Greenhouse Gas Fluxes in Tropical and Temperae Agriculture: The Need for a Full-Cost Accounting of Global Warming Potentials

Agriculture's contribution to radiative forcing is principally through its historical release of carbon in soil and vegetation to the atmosphere and through its contemporary release of nitrous oxide (N2O) and methane (CHM4). The sequestration of soil carbon in soils now depleted in soil organic matter is a well-known strategy for mitigating the buildup of CO2 in the atmosphere. Less well-recognized are other mitigation potentials. A full-cost accounting of the effects of agriculture on greenhouse gas emissions is necessary to quantify the relative importance of all mitigation options. Such an analysis shows nitrogen fertilizer, agricultural liming, fuel use, N2O emissions, and CH4 fluxes to have additional significant potential for mitigation. By evaluating all sources in terms of their global warming potential it becomes possible to directly evaluate greenhouse policy options for agriculture. A comparison of temperate and tropical systems illustrates some of these options.