The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

The cost-effectiveness of exercise referral schemes

Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary care setting. The primary care professional refers the patient to a third party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the patient. This paper examines the cost-effectiveness of ERS in promoting physical activity compared with usual care in primary care setting. Methods A decision analytic model was developed to estimate the cost-effectiveness of ERS from a UK NHS perspective. The costs and outcomes of ERS were modelled over the patient's lifetime. Data were derived from a systematic review of the literature on the clinical and cost-effectiveness of ERS, and on parameter inputs in the modelling framework. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses investigated the impact of varying ERS cost and effectiveness assumptions. Sub-group analyses explored the cost-effectiveness of ERS in sedentary people with an underlying condition. Results Compared with usual care, the mean incremental lifetime cost per patient for ERS was £169 and the mean incremental QALY was 0.008, generating a base-case incremental cost-effectiveness ratio (ICER) for ERS at £20,876 per QALY in sedentary individuals without a diagnosed medical condition. There was a 51% probability that ERS was cost-effective at £20,000 per QALY and 88% probability that ERS was cost-effective at £30,000 per QALY. In sub-group analyses, cost per QALY for ERS in sedentary obese individuals was £14,618, and in sedentary hypertensives and sedentary individuals with depression the estimated cost per QALY was £12,834 and £8,414 respectively. Incremental lifetime costs and benefits associated with ERS were small, reflecting the preventative public health context of the intervention, with this resulting in estimates of cost-effectiveness that are sensitive to variations in the relative risk of becoming physically active and cost of ERS. Conclusions ERS is associated with modest increase in lifetime costs and benefits. The cost-effectiveness of ERS is highly sensitive to small changes in the effectiveness and cost of ERS and is subject to some significant uncertainty mainly due to limitations in the clinical effectiveness evidence base.

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.

Correlación entre la personalidad y los factores de la Teoría del Comportamiento Planeado (TCP) en adolescentes escolarizados de 11-19 años del Caribe Colombiano

The increasing rate of pregnancies in teenagers and the high incident of the infections of sexual transmission (HIV/ AIDS, for example), these are health related issues (and especially the sexual and reproductive health), which have received great attention on the part of investigators and of the public opinion in general. Recently, there has been evidenced that teenagers carry out very easily risk sexual behaviors, and those who have not presented the above mentioned behaviors also show high levels of intention to carry out them. There is the hypothesis that besides cognitive variables such as attitudes, subjective norms, perceived behavioral control and intention, the personality of the young persons is an aspect that plays an important paper in their sexual and reproductive health. Significant correlations were found between the variales of the TPB and the personality traits; the results suggest that the direction of these correlations is associated with the specific type of behavior or situation that is assessed. Keywords: personality, theory of planned behavior, adolescents, reproductive sexuality.

Cosmological Constant and Scalar Gravitons

If a cosmological term is included in the equations of general relativity, the linearized equations can be interpreted as a tensor-scalar theory of finite-range gravitation. The scalar field cannot be transformed away be a gauge transformation (general co-ordinate transformation) and so must be interpreted as a physically significant degree of freedom. The hypothesis that a massive spin-two meson (mass m2) satisfied equations identical in form to the equations of general relativity leads to the prediction of a massive spin-zero meson (mass m0), the ratio of masses being m0 / m2 = 3*3.

Evaluation of the efficacy and economics of irrigation management, plant resistance and Brassica(spot)(TM) models for management of white blister on Brassica crops

Options for the integrated management of white blister (caused by Albugo candida) of Brassica crops include the use of well timed overhead irrigation, resistant cultivars, programs of weekly fungicide sprays or strategic fungicide applications based on the disease risk prediction model, Brassica(spot)(TM). Initial systematic surveys of radish producers near Melbourne, Victoria, indicated that crops irrigated overhead in the morning (0800-1200 h) had a lower incidence of white blister than those irrigated overhead in the evening (2000-2400 h). A field trial was conducted from July to November 2008 on a broccoli crop located west of Melbourne to determine the efficacy and economics of different practices used for white blister control, modifying irrigation timing, growing a resistant cultivar and timing spray applications based on Brassica(spot)(TM). Growing the resistant cultivar, 'Tyson', instead of the susceptible cultivar, 'Ironman', reduced disease incidence on broccoli heads by 99 %. Overhead irrigation at 0400 h instead of 2000 h reduced disease incidence by 58 %. A weekly spray program or a spray regime based on either of two versions of the Brassica(spot)(TM) model provided similar disease control and reduced disease incidence by 72 to 83 %. However, use of the Brassica(spot)(TM) models greatly reduced the number of sprays required for control from 14 to one or two. An economic analysis showed that growing the more resistant cultivar increased farm profit per ha by 12 %, choosing morning irrigation by 3 % and using the disease risk predictive models compared with weekly sprays by 15 %. The disease risk predictive models were 4 % more profitable than the unsprayed control.

Low temperature exposure of root system and inflorescence affected flowering and fruit set in 'Chardonnay' grapevines (Vitis vinifera)

The mechanisms by which low temperature affects flowering and fruit set of grapevines are poorly understood, as is the specific response of the grapevine root system and inflorescence to low temperature effects that reduce fruit set. This study aimed to determine the responses of the root system and inflorescence of the grapevine 'Chardonnay' to low temperature (10 degrees C) during flowering, and considered the possible mechanisms of low temperature effects on those parts. Temperature treatments of 10 degrees C or 20 degrees C were imposed to potted 'Chardonnay' grapevines in a glasshouse for up to two weeks during the early stages of flowering. When the root system alone was exposed to 10 degrees C (with the rest of the plant at 20 degrees C) during flowering, the number of attached berries and percentage fruit set were significantly reduced by 50 % than when the root system alone was exposed to 20 degrees C. Whereas, exposure of the inflorescence alone to 10 degrees C (with the rest of the plant at 20 degrees C) delayed flowering, allowed rachis to grow longer, and increased both the number of attached berries (from 22 to 62 per vine) and fruit set (from 8 % to, 20 %), than when the inflorescence alone was exposed to 20 degrees C. This study will enhance our understanding of the possible mechanisms of low temperature effects on grapevine fruit set and productivity.

Optimizing sowing management for short duration dry seeded aman rice on the High Ganges River Floodplain of Bangladesh

Dry seeding of aman rice can facilitate timely crop establishment and early harvest and thus help to alleviate the monga (hunger) period in the High Ganges Flood Plain of Bangladesh. Dry seeding also offers many other potential benefits, including reduced cost of crop establishment and improved soil structure for crops grown in rotation with rice. However, the optimum time for seeding in areas where farmers have access to water for supplementary irrigation has not been determined. We hypothesized that earlier sowing is safer, and that increasing seed rate mitigates the adverse effects of significant rain after sowing on establishment and crop performance. To test these hypotheses, we analyzed long term rainfall data, and conducted field experiments on the effects of sowing date (target dates of 25 May, 10 June, 25 June, and 10 July) and seed rate (20, 40, and 60 kg ha−1) on crop establishment, growth, and yield of dry seeded Binadhan-7 (short duration, 110–120 d) during the 2012 and 2013 rainy seasons. Wet soil as a result of untimely rainfall usually prevented sowing on the last two target dates in both years, but not on the first two dates. Rainfall analysis also suggested a high probability of being able to dry seed in late May/early June, and a low probability of being able to dry seed in late June/early July. Delaying sowing from 25 May/10 June to late June/early July usually resulted in 20–25% lower plant density and lower uniformity of the plant stand as a result of rain shortly after sowing. Delaying sowing also reduced crop duration, and tillering or biomass production when using a low seed rate. For the late June/early July sowings, there was a strong positive relationship between plant density and yield, but this was not the case for earlier sowings. Thus, increasing seed rate compensated for the adverse effect of untimely rains after sowing on plant density and the shorter growth duration of the late sown crops. The results indicate that in this region, the optimum date for sowing dry seeded rice is late May to early June with a seed rate of 40 kg ha−1. Planting can be delayed to late June/early July with no yield loss using a seed rate of 60 kg ha−1, but in many years, the soil is simply too wet to be able to dry seed at this time due to rainfall.

The Autobiography of a Jewish Refugee 1921-1998

Charles Leigh, 1992, 1994, 1999

Efficacy and phytotoxicity of different rates of oxadiargyl and pendimethalin in dry-seeded rice (Oryza sativa L.) in Bangladesh

A field study was established to evaluate oxadiargyl and pendimethalin during the wet seasons in Bangladesh in 2012 and 2013. The study evaluated the following treatments: oxadiargyl applied at 80, 120, and 160 g ai ha−1; pendimethalin at 800, 1200, and 1600 g ai ha−1; partial weedy; and weed-free. Rice plant density was greatly affected by weed control treatment. Lower density and lower uniformity of the rice plant stand occurred as a result of increased rates of herbicides. Increased rates of pendimethalin were more toxic than increased rates of oxadiargyl. Both herbicides effectively controlled Digitaria ciliaris, Echinochloa colona, and Phyllanthus niruri; however, they were unable to control Murdannia nudiflora. Oxadiargyl controlled Cyperus rotundus across rates by 31–55%, but pendimethalin was completely ineffective on it, and higher rates of both herbicides had no effect in controlling this weed. Both herbicides at higher rates reduced total weed biomass significantly. Among herbicide treatments, the highest yield (3.7–4.0 t ha−1) was recorded in plots treated with oxadiargyl at 160 g ai ha−1 and the lowest yield (2.4–2.8 t ha−1) was in plots treated with pendimethalin at 1600 g ai ha−1. Results from our study suggest that a higher rate of oxadiargyl can increase yield by suppressing weeds in dry-seeded rice systems. Similar to the results of oxadiargyl, pendimethalin at higher rates also greatly suppressed weeds; however, yield decreased due to phytotoxicity to rice seedlings.

First detection of extended-spectrum cephalosporin- and fluoroquinolone-resistant Escherichia coli in Australian food-producing animals

This study aimed to define the frequency of resistance to critically important antimicrobials (CIAs) [i.e. extended-spectrum cephalosporins (ESCs), fluoroquinolones (FQs) and carbapenems] among Escherichia coli isolates causing clinical disease in Australian food-producing animals. Clinical E. coli isolates (n = 324) from Australian food-producing animals [cattle (n = 169), porcine (n = 114), poultry (n = 32) and sheep (n = 9)] were compiled from all veterinary diagnostic laboratories across Australia over a 1-year period. Isolates underwent antimicrobial susceptibility testing to 18 antimicrobials using the Clinical and Laboratory Standards Institute disc diffusion method. Isolates resistant to CIAs underwent minimum inhibitory concentration determination, multilocus sequence typing (MLST), phylogenetic analysis, plasmid replicon typing, plasmid identification, and virulence and antimicrobial resistance gene typing. The 324 E. coli isolates from different sources exhibited a variable frequency of resistance to tetracycline (29.0–88.6%), ampicillin (9.4–71.1%), trimethoprim/sulfamethoxazole (11.1–67.5%) and streptomycin (21.9–69.3%), whereas none were resistant to imipenem or amikacin. Resistance was detected, albeit at low frequency, to ESCs (bovine isolates, 1%; porcine isolates, 3%) and FQs (porcine isolates, 1%). Most ESC- and FQ-resistant isolates represented globally disseminated E. coli lineages (ST117, ST744, ST10 and ST1). Only a single porcine E. coli isolate (ST100) was identified as a classic porcine enterotoxigenic E. coli strain (non-zoonotic animal pathogen) that exhibited ESC resistance via acquisition of blaCMY-2. This study uniquely establishes the presence of resistance to CIAs among clinical E. coli isolates from Australian food-producing animals, largely attributed to globally disseminated FQ- and ESC-resistant E. coli lineages.

L-Tyrosyl-L-glutarnie Acid Monohydrate, C14H18N206.H20

Mr=328.32, triclinic, P1, a=5.801 (1), b=7.977(1), c=9.110(2)A, ~t=102.33 (1), fl= 97.92 (1), y= 109.82 (1) °, v= 377.2 (1) A 3 at 293 K, Z=I, D x=1.45, D m=1.45 g cm -3, 2(MoKs)= 0.7107 A, ~ = 0.74 cm -1, F(000) = 174.0. R = 0.046 for 990 unique observed [F o > 4O(Fo)] reflections. The crystal structure is stabilized by extensive hydrogen bonding involving all N and O atoms.

Ternary bismuth oxides Bi26â-xMxO40ay (M = Mg, Al, Co and Ni) related to α - Bi2O3

Reaction of Bi2O3 with MgO, NiO, Co3O4 and Al2O3 gives rise to the corresponding ternary bismuth oxides, Bi18Mg8O36, Bi18Ni8O36, Bi20Co6O39 and Bi24Al2O39. These oxides have the general formula Bi26�xMxO40�y and exhibit BCC structures related to α - Bi2O3. In the first three solids, the metal ions, M, replace bismuth randomly at the octahedral 24r sites (space group 123); in the last case, aluminium ions occupy the tetrahedral 2a sites, the phase being isostructural with Bi24Ge2O40. Starting from Bi2O3 and NiO, orthorhombic Bi2Ni2O5 has also been obtained.

The host specificity and climatic suitability of the gall flyCecidochares connexa(Diptera: Tephritidae), a potential biological control agent for Chromolaena odorata(Asteraceae) in Australia

The gall fly Cecidochares connexa (Diptera: Tephritidae) is a potential biological control agent for Chromolaena odorata in Australia. Its host specificity was determined against 18 species in the tribe Eupatorieae (Family Asteraceae) in which C. odorata belongs, in quarantine in Brisbane, Australia. Oviposition occurred and flies developed on only C. odorata and Praxelis clematidea, both of which are in the subtribe Praxelinae. P. clematidea is considered a weed outside tropical America. In both multiple-species-minus-C. odorata choice tests and single-species no-choice tests, the mean number of galls/plant was significantly greater on C. odorata (48 and 41, respectively) than on P. clematidea (2 and 9, respectively). There were also significantly more adults emerging from C. odorata (mean 129 and 169, respectively) in the two types of tests than from P. clematidea (1 and 8, respectively). Paired choice, multiple generation (continuation) and time dependent tests further clarified the extent that C. connexa could develop on P. clematidea. In these tests, the mean number of galls formed and the mean number of emerging adults were consistently less for P. clematidea than C. odorata and populations of C. connexa could not be maintained on P. clematidea. Galls were not seen on any other plant species tested. This study supports the results of host specificity testing conducted in seven other countries and confirms that C. connexa poses little risk to other plant species in Australia. C. connexa has been released in 10 countries and an application seeking approval to release in Australia has been submitted to the Australian Government.

Liquid phase hydrogenation of aniline in a trickle bed reactor

A rate equation is developed for the liquid phase hydrogenation of aniline over cylindrical catalyst pellets of 30% nickel deposited on clay in a trickle bed reactor. The equation takes into account external and internal diffusional limitations, and describes the experimental data adequately. The hydrogenation reaction is first order with respect to hydrogen and zero order with respect to aniline. Effectiveness factors are in the range 0.003-0.03. Apparent activation energy of the reaction is 12.7 kcal/mol and true activation energy is 39.6 kcal/mol.