Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia:A randomized controlled trial

Context: Nursing home residents with pneumonia are frequently hospitalized. Such transfers may be associated with multiple hazards of hospitalization as well as economic costs. Objective: To assess whether using a clinical pathway for on-site treatment of pneumonia and other lower respiratory tract infections in nursing homes could reduce hospital admissions, related complications, and costs. Design, Setting, and Participants: A cluster randomized controlled trial of 680 residents aged 65 years or older in 22 nursing homes in Hamilton, Ontario, Canada. Nursing homes began enrollment between January 2, 2001, and April 18, 2002, with the last resident follow-up occurring July 4, 2005. Residents were eligible if they met a standardized definition of lower respiratory tract infection. Interventions: Treatment in nursing homes according to a clinical pathway, which included use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse, or usual care. Main Outcome Measures: Hospital admissions, length of hospital stay, mortality, health-related quality of life, functional status, and cost. Results: Thirty-four (10%) of 327 residents in the clinical pathway group were hospitalized compared with 76 (22%) of 353 residents in the usual care group. Adjusting for clustering of residents in nursing homes, the weighted mean reduction in hospitalizations was 12% (95% confidence interval [CI], 5%-18%; P=.001). The mean number of hospital days per resident was 0.79 in the clinical pathway group vs 1.74 in the usual care group, with a weighted mean difference of 0.95 days per resident (95% CI, 0.34-1.55 days; P=.004). The mortality rate was 8% (24 deaths) in the clinical pathway group vs 9% (32 deaths) in the usual care group, with a weighted mean difference of 2.9% (95% CI, -2.0% to 7.9%; P=.23). There were no significant differences between the groups in health-related quality of life or functional status. The clinical pathway resulted in an overall cost savings of US $1016 per resident (95% CI, $207-$1824) treated. Conclusion: Treating residents of nursing homes with pneumonia and other lower respiratory tract infections with a clinical pathway can result in comparable clinical outcomes, while reducing hospitalizations and health care costs. ©2006 American Medical Association. All rights reserved.

Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes:Cluster randomised controlled trial

Objective: To assess whether a multifaceted intervention can reduce the number of prescriptions for antimicrobials for suspected urinary tract infections in residents of nursing homes. Design: Cluster randomised controlled trial. Setting: 24 nursing homes in Ontario, Canada, and Idaho, United States. Participants: 12 nursing homes allocated to a multifaceted intervention and 12 allocated to usual care. Outcomes were measured in 4217 residents. Interventions: Diagnostic and treatment algorithm for urinary tract infections implemented at the nursing home level using a multifaceted approach-small group interactive sessions for nurses, videotapes, written material, outreach visits, and one on one interviews with physicians. Main outcome measures: Number of antimicrobials prescribed for suspected urinary tract infections, total use of antimicrobials, admissions to hospital, and deaths. Results: Fewer courses of antimicrobials for suspected urinary tract infections per 1000 resident days were prescribed in the intervention nursing homes than in the usual care homes (1.17 v 1.59 courses; weighted mean difference -0.49, 95% confidence intervals -0.93 to -0.06). Antimicrobials for suspected urinary tract infection represented 28.4% of all courses of drugs prescribed in the intervention nursing homes compared with 38.6% prescribed in the usual care homes (weighted mean difference -9.6%, -16.9% to -2.4%). The difference in total antimicrobial use per 1000 resident days between intervention and usual care groups was not significantly different (3.52 v 3.93; weighed mean difference -0.37, -1.17 to 0.44). No significant difference was found in admissions to hospital or mortality between the study arms. Conclusion: A multifaceted intervention using algorithms can reduce the number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes.

Why the size structure of marine communities can require decades to recover from fishing

A dynamic food-web model of more than 1000 species was used to quantify the recovery trajectory of marine community size-structure under different hypothetical fishing regimes, using the Northeast Atlantic as an example. Size-structure was summarised by four indicators: the Large Fish Indicator (LFI), the Large Species Indicator (LSI), the biomass-weighted mean maximum length of fish species (EMBED Equation.3) and the biomass-weighted mean maturation length of fish species (EMBED Equation.3). Time-series of these indicators recorded recovery following release from fishing with various size-selectivities, intensities and durations. In model simulations, fishing-induced trophic cascades were observed to distort fish community size-structure, but these did not have a large influence on recovery level or duration as measured by the four indicators. However, simulations showed that local extinctions of large fish species increased in number with both fishing intensity and duration, and could strongly limit the recovery level. Recovery of fish community size-structure to near equilibrium frequently took multiple decades in simulations; these long transient periods suggest that management interventions for size-structure recovery may require much longer than previously thought. Our results demonstrate the need for community-level modelling to set realistic targets for management of community size-structure.

Re-engineering and Re-defining University Libraries in the context of modern Information and Communication Technologies: a study with special reference to the University Libraries in Kerala

Information and communication technologies are the tools that underpin the emerging “Knowledge Society”. Exchange of information or knowledge between people and through networks of people has always taken place. But the ICT has radically changed the magnitude of this exchange, and thus factors such as timeliness of information and information dissemination patterns have become more important than ever.Since information and knowledge are so vital for the all round human development, libraries and institutions that manage these resources are indeed invaluable. So, the Library and Information Centres have a key role in the acquisition, processing, preservation and dissemination of information and knowledge. ln the modern context, library is providing service based on different types of documents such as manuscripts, printed, digital, etc. At the same time, acquisition, access, process, service etc. of these resources have become complicated now than ever before. The lCT made instrumental to extend libraries beyond the physical walls of a building and providing assistance in navigating and analyzing tremendous amounts of knowledge with a variety of digital tools. Thus, modern libraries are increasingly being re-defined as places to get unrestricted access to information in many formats and from many sources.The research was conducted in the university libraries in Kerala State, India. lt was identified that even though the information resources are flooding world over and several technologies have emerged to manage the situation for providing effective services to its clientele, most of the university libraries in Kerala were unable to exploit these technologies at maximum level. Though the libraries have automated many of their functions, wide gap prevails between the possible services and provided services. There are many good examples world over in the application of lCTs in libraries for the maximization of services and many such libraries have adopted the principles of reengineering and re-defining as a management strategy. Hence this study was targeted to look into how effectively adopted the modern lCTs in our libraries for maximizing the efficiency of operations and services and whether the principles of re-engineering and- redefining can be applied towards this.Data‘ was collected from library users, viz; student as well as faculty users; library ,professionals and university librarians, using structured questionnaires. This has been .supplemented by-observation of working of the libraries, discussions and interviews with the different types of users and staff, review of literature, etc. Personal observation of the organization set up, management practices, functions, facilities, resources, utilization of information resources and facilities by the users, etc. of the university libraries in Kerala have been made. Statistical techniques like percentage, mean, weighted mean, standard deviation, correlation, trend analysis, etc. have been used to analyse data.All the libraries could exploit only a very few possibilities of modern lCTs and hence they could not achieve effective Universal Bibliographic Control and desired efficiency and effectiveness in services. Because of this, the users as well as professionals are dissatisfied. Functional effectiveness in acquisition, access and process of information resources in various formats, development and maintenance of OPAC and WebOPAC, digital document delivery to remote users, Web based clearing of library counter services and resources, development of full-text databases, digital libraries and institutional repositories, consortia based operations for e-journals and databases, user education and information literacy, professional development with stress on lCTs, network administration and website maintenance, marketing of information, etc. are major areas need special attention to improve the situation. Finance, knowledge level on ICTs among library staff, professional dynamism and leadership, vision and support of the administrators and policy makers, prevailing educational set up and social environment in the state, etc. are some of the major hurdles in reaping the maximum possibilities of lCTs by the university libraries in Kerala. The principles of Business Process Re-engineering are found suitable to effectively apply to re-structure and redefine the operations and service system of the libraries. Most of the conventional departments or divisions prevailing in the university libraries were functioning as watertight compartments and their existing management system was more rigid to adopt the principles of change management. Hence, a thorough re-structuring of the divisions was indicated. Consortia based activities and pooling and sharing of information resources was advocated to meet the varied needs of the users in the main campuses and off campuses of the universities, affiliated colleges and remote stations. A uniform staff policy similar to that prevailing in CSIR, DRDO, ISRO, etc. has been proposed by the study not only in the university libraries in kerala but for the entire country.Restructuring of Lis education,integrated and Planned development of school,college,research and public library systems,etc.were also justified for reaping maximum benefits of the modern ICTs.

Export of dissolved organic carbon from an upland peatland during storm events: implications for flux estimates

Most of the dissolved organic carbon (DOC) exported from catchments is transported during storm events. Accurate assessments of DOC fluxes are essential to understand long-term trends in the transport of DOC from terrestrial to aquatic systems, and also the loss of carbon from peatlands to determine changes in the source/sink status of peatland carbon stores. However, many long-term monitoring programmes collect water samples at a frequency (e.g. weekly/monthly) less than the time period of a typical storm event (typically <1–2 days). As widespread observations in catchments dominated by organo-mineral soils have shown that both concentration and flux of DOC increases during storm events, lower frequency monitoring could result in substantial underestimation of DOC flux as the most dynamic periods of transport are missed. However, our intensive monitoring study in a UK upland peatland catchment showed a contrasting response to these previous studies. Our results showed that (i) DOC concentrations decreased during autumn storm events and showed a poor relationship with flow during other seasons; and that (ii) this decrease in concentrations during autumn storms caused DOC flux estimates based on weekly monitoring data to be over-estimated, rather than under-estimated, because of over rather than under estimation of the flow-weighted mean concentration used in flux calculations. However, as DOC flux is ultimately controlled by discharge volume, and therefore rainfall, and the magnitude of change in discharge was greater than the magnitude of decline in concentrations, DOC flux increased during individual storm events. The implications for long-term DOC trends are therefore contradictory, as increased rainfall could increase flux but cause an overall decrease in DOC concentrations from peatland streams. Care needs to be taken when interpreting long-term trends in DOC flux rather than concentration; as flux is calculated from discharge estimates, and discharge is controlled by rainfall, DOC flux and rainfall/discharge will always be well correlated.

Assessment of CloudSat reflectivity measurements and ice cloud properties using ground-based and airborne cloud radar observations

A quantitative assessment of Cloudsat reflectivities and basic ice cloud properties (cloud base, top, and thickness) is conducted in the present study from both airborne and ground-based observations. Airborne observations allow direct comparisons on a limited number of ocean backscatter and cloud samples, whereas the ground-based observations allow statistical comparisons on much longer time series but with some additional assumptions. Direct comparisons of the ocean backscatter and ice cloud reflectivities measured by an airborne cloud radar and Cloudsat during two field experiments indicate that, on average, Cloudsat measures ocean backscatter 0.4 dB higher and ice cloud reflectivities 1 dB higher than the airborne cloud radar. Five ground-based sites have also been used for a statistical evaluation of the Cloudsat reflectivities and basic cloud properties. From these comparisons, it is found that the weighted-mean difference ZCloudsat − ZGround ranges from −0.4 to +0.3 dB when a ±1-h time lag around the Cloudsat overpass is considered. Given the fact that the airborne and ground-based radar calibration accuracy is about 1 dB, it is concluded that the reflectivities of the spaceborne, airborne, and ground-based radars agree within the expected calibration uncertainties of the airborne and ground-based radars. This result shows that the Cloudsat radar does achieve the claimed sensitivity of around −29 dBZ. Finally, an evaluation of the tropical “convective ice” profiles measured by Cloudsat has been carried out over the tropical site in Darwin, Australia. It is shown that these profiles can be used statistically down to approximately 9-km height (or 4 km above the melting layer) without attenuation and multiple scattering corrections over Darwin. It is difficult to estimate if this result is applicable to all types of deep convective storms in the tropics. However, this first study suggests that the Cloudsat profiles in convective ice need to be corrected for attenuation by supercooled liquid water and ice aggregates/graupel particles and multiple scattering prior to their quantitative use.

Intensive agriculture reduces soil biodiversity across Europe

Soil biodiversity plays a key role in regulating the processes that underpin the delivery of ecosystem goods and services in terrestrial ecosystems. Agricultural intensification is known to change the diversity of individual groups of soil biota, but less is known about how intensification affects biodiversity of the soil food web as a whole, and whether or not these effects may be generalized across regions. We examined biodiversity in soil food webs from grasslands, extensive, and intensive rotations in four agricultural regions across Europe: in Sweden, the UK, the Czech Republic and Greece. Effects of land-use intensity were quantified based on structure and diversity among functional groups in the soil food web, as well as on community-weighted mean body mass of soil fauna. We also elucidate land-use intensity effects on diversity of taxonomic units within taxonomic groups of soil fauna. We found that between regions soil food web diversity measures were variable, but that increasing land-use intensity caused highly consistent responses. In particular, land-use intensification reduced the complexity in the soil food webs, as well as the community-weighted mean body mass of soil fauna. In all regions across Europe, species richness of earthworms, Collembolans, and oribatid mites was negatively affected by increased land-use intensity. The taxonomic distinctness, which is a measure of taxonomic relatedness of species in a community that is independent of species richness, was also reduced by land-use intensification. We conclude that intensive agriculture reduces soil biodiversity, making soil food webs less diverse and composed of smaller bodied organisms. Land-use intensification results in fewer functional groups of soil biota with fewer and taxonomically more closely related species. We discuss how these changes in soil biodiversity due to land-use intensification may threaten the functioning of soil in agricultural production systems.

Simple measures of climate, soil properties and plant traits predict national scale grassland soil carbon stocks

1. Soil carbon (C) storage is a key ecosystem service. Soil C stocks play a vital role in soil fertility and climate regulation, but the factors that control these stocks at regional and national scales are unknown, particularly when their composition and stability are considered. As a result, their mapping relies on either unreliable proxy measures or laborious direct measurements. 2. Using data from an extensive national survey of English grasslands we show that surface soil (0-7cm) C stocks in size fractions of varying stability can be predicted at both regional and national scales from plant traits and simple measures of soil and climatic conditions. 3. Soil C stocks in the largest pool, of intermediate particle size (50-250 µm), were best explained by mean annual temperature (MAT), soil pH and soil moisture content. The second largest C pool, highly stable physically and biochemically protected particles (0.45-50 µm), was explained by soil pH and the community abundance weighted mean (CWM) leaf nitrogen (N) content, with the highest soil C stocks under N rich vegetation. The C stock in the small active fraction (250-4000 µm) was explained by a wide range of variables: MAT, mean annual precipitation, mean growing season length, soil pH and CWM specific leaf area; stocks were higher under vegetation with thick and/or dense leaves. 4. Testing the models describing these fractions against data from an independent English region indicated moderately strong correlation between predicted and actual values and no systematic bias, with the exception of the active fraction, for which predictions were inaccurate. 5. Synthesis and Applications: Validation indicates that readily available climate, soils and plant survey data can be effective in making local- to landscape-scale (1-100,000 km2) soil C stock predictions. Such predictions are a crucial component of effective management strategies to protect C stocks and enhance soil C sequestration.

Triple isotope (δD, δ17O, δ18O) study on precipitation, drip water and speleothem fluid inclusions for a central European cave (NW Switzerland)

Deuterium (dD) and oxygen (d18O) isotopes are powerful tracers of the hydrological cycle and have been extensively used for paleoclimate reconstructions as they can provide information on past precipitation, temperature and atmospheric circulation. More recently, the use of 17Oexcess derived from precise measurement of d17O and d18O gives new and additional insights in tracing the hydrological cycle whereas uncertainties surround this proxy. However, 17Oexcess could provide additional information on the atmospheric conditions at the moisture source as well as about fractionations associated with transport and site processes. In this paper we trace water stable isotopes (dD, d17O and d18O) along their path from precipitation to cave drip water and finally to speleothem fluid inclusions for Milandre cave in northwestern Switzerland. A two year-long daily resolved precipitation isotope record close to the cave site is compared to collected cave drip water (3 months average resolution) and fluid inclusions of modern and Holocene stalagmites. Amount weighted mean dD, d18O and d17O are �71.0‰, �9.9‰, �5.2‰ for precipitation, �60.3‰, �8.7‰, �4.6‰ for cave drip water and �61.3‰, �8.3‰, �4.7‰ for recent fluid inclusions respectively. Second order parameters have also been derived in precipitation and drip water and present similar values with 18 per meg for 17Oexcess whereas d-excess is 1.5‰ more negative in drip water. Furthermore, the atmospheric signal is shifted towards enriched values in the drip water and fluid inclusions (D of ~ þ 10‰ for dD). The isotopic composition of cave drip water exhibits a weak seasonal signal which is shifted by around 8e10 months (groundwater residence time) when compared to the precipitation. Moreover, we carried out the first d17O measurement in speleothem fluid inclusions, as well as the first comparison of the d17O behaviour from the meteoric water to the fluid inclusions entrapment in speleothems. This study on precipitation, drip water and fluid inclusions will be used as a speleothem proxy calibration for Milandre cave in order to reconstruct paleotemperatures and moisture source variations for Western Central Europe.

Revisão sistemática e meta-análise do uso de antidepressivos no transtorno de ansiedade generalizada

Revisão da Literatura: O Transtorno de Ansiedade Generalizada (TAG) é caracterizado por preocupação excessiva, persistente e incontrolável sobre diversos aspectos da vida do paciente. Tem prevalência entre 1,6% e 5,1% e índice de comorbidades de até 90,4%. As principais comorbidades são depressão maior (64%) e distimia (37%). Os antidepressivos podem ser eficazes no tratamento do TAG. A Medicina Baseada em Evidências (MBE) busca reunir a melhor evidência disponível com experiência clínica e conhecimentos de fisiopatologia. A melhor maneira disponível de síntese das evidências é a revisão sistemática e a meta-análise. Objetivos: Investigar a eficácia e tolerabilidade dos antidepressivos no tratamento do TAG através de uma revisão sistemática da literatura e meta-análise. Sumário do artigo científico: A revisão sistemática incluiu ensaios clínicos randomizados e controlados e excluiu estudos não-randomizados, estudos com pacientes com TAG e outro transtorno de eixo I. Os dados foram extraídos por dois revisores independentes e risco relativo, diferença da média ponderada e número necessário para tratamento (NNT) foram calculados. Antidepressivos (imipramina, paroxetina e venlafaxina) foram superiores ao placebo. O NNT calculado foi de 5,5. A evidência disponível sugere que os antidepressivos são superiores ao placebo no tratamento do TAG e bem tolerados pelos pacientes.

Thermochronology of the South American platform in the state of São Paulo, Brazil, through apatite fission tracks

The fission-track method (FTM) in apatite was applied to 45 samples collected in the Serra da Mantiqueira (Mantiqueira mountain range), the Serra do Mar (Mar mountain range), regions next to these mountain ranges and the coastal region between Ubatuba and Santos in the State of São Paulo, Brazil, to study the thermochronology of the South American Platform in southeast Brazil and its influence on Santos and Campos basins. The data presented in this work complement the previously presented data on the same region (Tello Saenz et al., 2003. J. S. Am. Earth Sci. 15, 765-774) with 31 new samples analyzed. The weighted mean of the corrected ages from high Mantiqueira (around 1000 m), (121 +/- 6) Ma, coincides with the South Atlantic opening. The fact that its thermal history starts at a relatively low temperature (similar to 80 degrees C) suggests that the age of similar to 120 Ma would be the formation age of Serra da Mantiqueira due to a rapid pulse, in which tracks had no time to be retained at the closure temperature, that is similar to 120 degrees C. The Serra do Mar presents a more complicated thermal history, with several reactivations indicated by the changes in the slope of its cooling curve. The thermal histories obtained in the regions next to these mountain ranges are compatible with the results mentioned above. The Santos Basin has unconformities that agree with changes in the slope thermal histories of the studied region. (c) 2005 Elsevier Ltd. All rights reserved.

Recombinant luteinizing hormone supplementation to recombinant follicle-stimulation hormone during induced ovarian stimulation in the GnRH-agonist protocol: A meta-analysis

Purpose: to compare the efficacy of recombinant LH supplementation for controlled ovarian stimulation in recombinant FSH and GnRH-agonist protocol.Methods: Search strategies included on-line surveys of databases. The fixed effects model was used for odds ratio and effect size (weighted mean difference). Four trials fulfilled the inclusion criteria.Results: a fewer days of stimulation (p < 0.0001), a fewer total amount of r-FSH administered (p < 0.0001) and a higher serum estradiol levels on the day of hCG administration (p < 0.0001) were observed for the r-LH supplementation protocol. However, differences were not observed in number of oocyte retrieved, number of mature oocytes, clinical pregnancy per oocyte retrieval, implantation and miscarriage rates.Conclusions: more randomized controlled trials are necessary before evidence-based recommendations regarding exogenous LH supplementation in ovarian stimulation protocols with FSH and GnRH-agonist for assisted reproduction treatment can be provided.

An algorithm for arranging response surface designs in small blocks

We consider the problem of blocking response surface designs when the block sizes are prespecified to control variation efficiently and the treatment set is chosen independently of the block structure. We show how the loss of information due to blocking is related to scores defined by Mead and present an interchange algorithm based on scores to improve a given blocked design. Examples illustrating the performance of the algorithm are given and some comparisons with other designs are made. (C) 2000 Elsevier B.V. B.V. All rights reserved.

Dose de exposição radiométrica e composição das rochas sedimentares e ígneas na bacia do Rio Corumbataí (SP)

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

Hydrochemistry and weathering rates on Corumbatai River basin, São Paulo State, Brazil

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