THE SHORT- AND LONG-TERM EFFECTS OF A HANDBOOK ON THE ANTIMICROBIAL PRESCRIBING PATTERNS OF HOSPITAL PHYSICIANS

This study evaluates the effect of a specially designed, physician-oriented handbook of antimicrobial use on the prescribing patterns of a group of fifty doctors at a university hospital. Data were evaluated over a peroid of one-and-one-half years, before and after the distribution of the handbook. For the purposes of this study, antimicrobial therapy was classified: (1) inappropriate if it violated one of a number of recognized principles of antimicrobial therapy, (2) appropriate if it agreed with specific recommendations or alternatives given in the distributed reference handbook, and (3) acceptable if it was neither inappropriate nor appropriate as defined by the handbook. An initial survey of antimicrobial prescribing patterns was made. Five months later the handbook was distributed and a two-week orientation program, consisting of the distribution and promotion of the problem-oriented, pocket-size handbook of appropriate antimicrobial therapy, was conducted. The handbook, which was developed by the authors and reviewed and approved by a panel of infectious disease specialists, presented guidelines for appropriate and efficacious usage of antimicrobial agents as most currently accepted in common clinical infections. Subsequent surveys were then conducted two weeks, three months, and six months after distribution of the handbook. A statistically significant difference (p < 0.01) in antimicrobial prescribing patterns was noted between the survey conducted two weeks after the introduction of the handbook and the other surveys. In this survey, while therapy classified inappropriate decreased from 44% to 28%, therapy appropriate as recommended increased from 31% to 53%. The findings of this study demonstrate that the introduction and promotion of the handbook decreases abuse and increases proper use of antimicrobial therapy, although the effect is sustainable for only a short duration--no longer than three months. These results indicate the need for a vigorous, updated program to achieve and maintain current appropriate antibotic therapy in clinical medicine. ^

FACTORS INFLUENCING THE PATTERNS OF PHYSICIAN VISITS TO NURSING HOME RESIDENTS

This study was designed to identify some of the factors related to patterns of physician visits to nursing home residents. The relationship of ten resident and organizational characteristics to patterns of physician visits was investigated through secondary analysis of data abstracted from the 1973-74 National Nursing Home Survey of the National Center for Health Statistics. The study sample was composed of 11,135 of the 19,013 nursing home residents who participated in the survey.^ The analytic results revealed that all ten variables had a statistically significant relationship to patterns of physician visits, mainly due to the large sample size. The degrees of association between the variables, measured by the Cramer's V statistic, ranged from moderate to very weak.^ Certification status of the nursing home under Medicare and/or Medicaid was shown to be most strongly related to patterns of physician visits, followed by primary source of payment for nursing home care, and residence prior to nursing home admission. Several variables thought to be related to patterns of physician visits were found to have a very weak relationship: age of the resident, marital status, length of stay, primary diagnosis, number of chronic conditions, activities of daily living status, and levels of care.^ In order to get a more precise picture of the relative influence of certification status and primary source of payment when the other variables were statistically controlled, these two variables were combined into a single variable. The results revealed that the combined effects of certification status and primary source of payment were sustained, regardless of differences in the residents' personal, utilization, and health status characteristics, and the levels of care that they received. The results also indicated that the five groups created by combining the two variables differed in patterns of physician visits. For example, private pay residents in intermediate care facilities (ICF's) and non-certified facilities were more likely to receive unscheduled visits than private pay residents in skilled nursing homes (SNH's), residents in SNH's supported by Medicare or Medicaid, and residents in ICF's supported by Medicaid. ^

GROWTH PATTERNS OF CHILDREN OF MOTHERS WITH EPILEPSY

The extent to which antiepileptic drugs (AED) in utero exposure are related to prenatal and postnatal growth is investigated in an retrospective, cohort study of children of AED treated mothers with epilepsy (N = 89) and children of women without epilepsy (N = 89). The study groups were obtained from a population based health care facility.^ Major finding was that birth head circumference of AED exposed children are significantly smaller than control children, notably male children. Other findings include birth length and weight of exposed children was slightly but not significantly smaller. Postnatal growth as measured by two velocity terms, rate of growth, and deceleration, was not significantly different between exposed and control children for height, weight, and head circumference, indicating no catch up growth. Morphologic defects, neonatal and infant mortality was more frequent in exposed children. Mothers with epilepsy reported significantly fewer spontaneous abortions. ^

Assessing the patterns of colorectal cancer treatment, adherence to treatment guidelines and survival in Texas

Colorectal cancer (CRC) is the third leading cancer in both incidence and mortality in Texas. This study investigated the adherence of CRC treatment to standard treatment guidelines and the association between standard treatment and CRC survival in Texas. The author used Texas Cancer Registry (TCR) and Medicare linked data to study the CRC treatment patterns and factors associated with standard treatment in patients who were more than 65 years old and were diagnosed in 2001 through 2007. We also determined whether adherence to standard treatment affect patients' survival. Multiple logistic regression and Cox regression analysis were used to analyze our data. Both regression models are adjusted for demographic characteristics and tumor characteristics. We found that for the 3977 regional colon cancer patients 80 years old or younger, 60.2% of them received chemotherapy, in adherence to the recommended treatment guidelines. People with younger age, female gender, higher education and lower comorbidity score are more likely adherent to this surgery guideline. Patients' adherence to chemotherapy in this cohort have better survival compared to those who are not (HR: 0.76, 95% CI: 0.68-0.84). For the 12709 colon cancer patients treated with surgery, 49.3% have more than 12 lymph nodes removed, in adherence to the treatment guidelines. People with younger age, female gender, higher education, regional stage, lager tumor size and lower comorbidity score are more likely to adherent to this surgery guideline. Patients with more than 12 lymph nodes removed in this cohort have better survival (HR: 0.86, 95% CI: 0.82-0.91). For the 1211 regional rectal cancer patients 80 years old or younger, 63.2% of them were adherent to radiation treatment. People with smaller tumor size and lower comorbidity score are more likely to adherent to this radiation guideline. There is no significant survival difference between radiation adherent patients and non-adherent patients (HR: 1.03, 95% CI: 0.82-1.29). For the 1122 regional rectal cancer patients 80 years old or younger who were treated with surgery, 76.0% of them received postoperative chemotherapy, in adherence to the treatment guidelines. People with younger age and smaller comorbidity score are related with higher adherence rate. Patients adherent with adjuvant chemotherapy in this cohort have better survival than those were not adherent (HR: 0.60, 95% CI: 0.45-0.79).^

Constraints on the magnitude and patterns of ocean cooling at the Last Glacial Maximum - Supplementary material

Observation-based reconstructions of sea surface temperature from relatively stable periods in the past, such as the Last Glacial Maximum, represent an important means of constraining climate sensitivity and evaluating model simulations. The first quantitative global reconstruction of sea surface temperatures during the Last Glacial Maximum was developed by the Climate Long-Range Investigation, Mapping and Prediction (CLIMAP) project in the 1970s and 1980s. Since that time, several shortcomings of that earlier effort have become apparent. Here we present an updated synthesis of sea surface temperatures during the Last Glacial Maximum, rigorously defined as the period between 23 and 19 thousand years before present, from the Multiproxy Approach for the Reconstruction of the Glacial Ocean Surface (MARGO) project. We integrate microfossil and geochemical reconstructions of surface temperatures and include assessments of the reliability of individual records. Our reconstruction reveals the presence of large longitudinal gradients in sea surface temperature in all of the ocean basins, in contrast to the simulations of the Last Glacial Maximum climate available at present.

Seasonal production patterns of planktonic foraminifera in the NE Atlantic Ocean

Sediment trap samples from OMEX 2 (49°N, 13°W) provide a continuous record of the seasonal succession of planktonic foraminifera in the midlatitude North Atlantic and reveal a complex relationship between periods of production and specific hydrographic conditions. Neogloboquadrina pachyderma dextral coiling (d.), Globigerina bulloides, and Globorotalia inflata are found in great numbers during both the spring and summer seasons, whereas Globigerina quinqueloba, Globorotalia hirsuta, Globorotalia scitula, and Globigerinita glutinata are associated predominantly with the increase in productivity during the spring bloom. Globigerinella aequilateralis, Orbulina universa, and Globigerinoides sacculifer are restricted to late summer conditions following the establishment of a warm, well-stratified surface ocean. An annually integrated fauna from the sediment trap, comprising ~13,000 individuals, is used to evaluate the accuracy of five faunal-based statistical methods of paleotemperature estimation. All of the temperature reconstruction techniques produce estimates of ~16°C and ~11°C for summer and winter surface temperature, respectively, which are in excellent agreement with regional hydrographic data and suggest that the sediment trap assemblage is well represented in the core top faunas. Analysis of the key species that dominate the OMEX 2 sediment trap fauna, G. bulloides, G. inflata, and N. pachyderma d., based on d18O derived temperatures from North Atlantic core top samples, suggests that seasonal variations in planktonic foraminiferal production are nonuniform across the midlatitudes and that this is likely to complicate reconstructing past seasonal hydrographic dynamics using these taxa.

Amount and patterns of beluga sightings in the eastern Beaufort Sea

An understanding of the adaptability of belugas (Delphinapterus leucas) to changing ice conditions is required to interpret and predict possible changes in habitat selection in response to projected loss of sea ice throughout the circumpolar Arctic. We analyzed beluga observations made during spring aerial surveys for ringed seals conducted from 1975 to 1979 in the eastern Beaufort Sea. Despite interannual variability in the extent and distribution of sea ice, belugas consistently selected areas with water depths of 200-500 m and heavy ice concentrations (8/10 to 10/10) while areas of open water to light ice concentrations (0/10 to 1/10) were not selected. Belugas were also found in proximity to regions with >0.5 degrees seafloor slope which include the continental slope and other areas with the potential for oceanographic upwellings. In most years (4 of 5), fast-ice edges and coastal areas were not selected. In the lightest ice year analyzed, belugas showed less specificity in habitat selection as their distribution expanded and shifted shoreward to fast-ice edges. The observed distribution is discussed in terms of predator-prey relationships particularly with reference to beluga feeding on polar cod (Boreogadus saida). More research is required to examine and compare possible changes in distribution since the late 1970s and to investigate the factors driving the patterns described.

Multiproxy sedimentation patterns of sediment cores from the continental margin off northeast Brazil

Tropical regions have been reported to play a key role in climate dynamics. To date, however, there are uncertainties in the timing and the amplitude of the response of tropical ecosystems to millennial-scale climate change. We present evidence of an asynchrony between terrestrial and marine signals of climate change during Heinrich events preserved in marine sediment cores from the Brazilian continental margin. The inferred time lag of about 1000 to 2000 years is much larger than the ecological response to recent climate change and appears to be related to the nature of hydrological changes.