Evidence-based chronic heart-failure management programs : myth or reality?

Background Chronic heart-failure management programmes (CHF-MPs) have become part of standard care for patients with chronic heart failure (CHF). Objective To investigate whether programmes had applied evidence-based expert clinical guidelines to optimise patient outcomes. Design A prospective cross-sectional survey was used to conduct a national audit. Setting Community setting of CHF-MPs for patients postdischarge. Sample All CHF-MPs operating during 2005–2006 (n=55). Also 10–50 consecutive patients from 48 programmes were recruited (n=1157). Main outcome measures (1) Characteristics and interventions used within each CHF-MP; and (2) characteristics of patients enrolled into these programmes. Results Overall, there was a disproportionate distribution of CHF-MPs across Australia. Only 6.3% of hospitals nationally provided a CHF-MP. A total of 8000 postdischarge CHF patients (median: 126; IQR: 26–260) were managed via CHF-MPs, representing only 20% of the potential national case load. Significantly, 16% of the caseload comprised patients in functional New York Heart Association Class I with no evidence of these patients having had previous echocardiography to confirm a diagnosis of CHF. Heterogeneity of CHF-MPs in applied models of care was evident, with 70% of CHF-MPs offering a hybrid model (a combination of heart-failure outpatient clinics and home visits), 20% conducting home visits and 16% conducting an extended rehabilitation model of care. Less than half (44%) allowed heart-failure nurses to titrate medications. The main medications that were titrated in these programmes were diuretics (n=23, 96%), β-blockers (n=17, 71%), ACE inhibitors (ACEIs) (n=14, 58%) and spironolactone (n=9, 38%). Conclusion CHF-MPs are being implemented rapidly throughout Australia. However, many of these programmes do not adhere to expert clinical guidelines for the management of patients with CHF. This poor translation of evidence into practice highlights the inconsistency and questions the quality of health-related outcomes for these patients.

Thai emergency nurses’ management of patients with severe traumatic brain injury: comparison of knowledge and clinical management with best available evidence

Background:
In Thailand, the rate of TBI-related hospitalisation is increasing, however, little is known about the evidence-based management of severe TBI in the developing world. The aim of this study was to explore Thai emergency nurses’ management of patients with severe TBI.

Methods:
An exploratory descriptive mixed method design was used to conduct this two stage study: survey methods were used to examine emergency nurses’ knowledge regarding management of patients with severe TBI (Stage 1) and observational methods were used to examine emergency nurses’ clinical management of patients with severe TBI (Stage 2). The study setting was the emergency department (ED) at a regional hospital in Southern Thailand.

Results:
34 nurses participated in Stage 1 (response rate 91.9%) and the number of correct responses ranged from 33.3% to 95.2%. In Stage 2, a total of 160 points of measurement were observed in 20 patients with severe TBI over 40 h. In this study there were five major areas identified for the improvement of care of patients with severe TBI: (i) end-tidal carbon dioxide (ETCO2) monitoring and targets; (ii) use of analgesia and sedation; (iii) patient positioning; (iv) frequency of nursing assessment; and (v) dose of Mannitol diuretic.

Conclusions:
There is variation in Thai nurses’ knowledge and care practices for patients with severe TBI. To increase consistency of evidence-based TBI care in the Thai context, a knowledge translation intervention that is ecologically valid, appropriate to the Thai healthcare context and acceptable to the multidisciplinary care team is needed.

Environmental and cultural change on the Mt Eccles lava-flow landscapes of southwest Victoria, Australia

The Gunditjmara people developed a socio-economic system based on the modification of wetland ecosystems associated with the Mt Eccles lava flow primarily for sustainable production and management of the highly nutritious shortfin eel (Anguilla australis). This paper examines the environmental history of these landscapes since their inception about 30 000 years ago, through palaeoecological analysis of sediment cores from associated lakes and swamps, in order to contribute to an understanding of the causes and timing of cultural transformation. Two records cover the whole of the 30 000 year history of the landscape while two others provide evidence of change within the Holocene. A great deal of variation within the landscape is revealed, both temporally and spatially, with opportunities for human exploitation through the whole recorded period. Although most features of the records can be explained by natural landscape development and climate change, some human modification can be suggested from around the Pleistocene—Holocene transition while more obvious indications of management relating to eel aquaculture are evident from about 4000 cal. yr BP that appear to include adaptations to the onset of a drier and more variable climate. The study has implications for the explanation of intensification of settlement in Australia more generally within the mid to late Holocene.

Performances of rainfall-runoff models calibrated over single and continuous storm flow events

Accurate parameter estimation is important for reliable rainfall-runoff modeling. Previous studies emphasize that a sufficient length of continuous events is required for model calibration to overcome the effect of initial conditions. This paper investigates the feasibility of calibrating rainfall-runoff models over a number of limited storm flow events. For a subcatchment having a moderate influence from initial soil moisture conditions, this study shows that rainfall-runoff models could still be calibrated reliably over a set of representative events provided that the events cover a wide range of peak flow, total runoff volume, and initial soil moisture conditions. This approach could provide an alternative calibration strategy for a small watershed that has a limited data length but consists of runoff events with a wide range of magnitudes. Compared to continuous-event calibration, event-based calibration appears to perform better in simulating the overall shape of hydrograph, peak flow and time to peak. However, continuous-event calibration was found to be more reliable in providing runoff volume, suggesting that continuous-event calibration should still be used when runoff volume is the main concern of a study.

A systematic review of the management and outcome of toxic epidermal necrolysis treated in burns centres

Introduction
Toxic epidermal necrolysis (TEN) is a rare condition characterised by mucocutaneous exfoliation of greater than 30% total body surface area (%TBSA), increasingly being treated in burns centres. The rate of mortality varies significantly in the literature, with recent prospective studies in non-burns centres reporting percentage mortality of approximately 45%. We undertook a systematic review of published studies that included TEN patients treated specifically in burns centres to determine a cumulative mortality rate.

Methods
Electronic searches of MEDLINE, EMBASE and The Cochrane Library (Issue 4, 2010) databases from 1966 onwards were used to identify English articles related to the treatment of TEN in burns centres.

Results
The systematic literature search identified 20 studies which specifically described patients with TEN grater than 30% %TBSA. Treatment regimens varied amongst studies, as did mortality. The overall percentage mortality of the combined populations was 30%. Risk factors commonly described as associated with mortality included age, %TBSA and delay to definitive treatment.

Conclusion
The review highlights the variation between principles of treatment and mortality amongst burns centres. It offers a standard that burns centre can use to internationally compare their mortality rates. The review supports the ongoing reporting of outcomes in TEN patients with epidermal detachment greater than 30%.

Nutrition, management and other environmental influences on the quality and production of mohair and cashmere with particular reference to mediterranean and annual temperate climatic zones : a review

Goat fibre production is affected by genetic and environmental influences. Environmental influences which are the subject of this review include bio–geophysical factors (photoperiod, climate–herbage system and soil–plant trace nutrient composition), nutrition factors and management factors. Nutrition and management influences discussed include rate of stocking, supplementary feeding of energy and protein, liveweight change, parturition and management during shearing. While experimental data suggest affects of seasonal photoperiod on the growth of mohair and cashmere are large, these results may have confounded changes in temperature with photoperiod. The nutritional variation within and among years is the most important climatic factor influencing mohair and cashmere production and quality. Mohair quality and growth is affected significantly by rate of stocking and during periods of liveweight loss by supplementary feeding of either energy or protein. Strategic use of supplements, methods for rapid introduction of cereal grains, influence of dietary roughage on intake and the economics of supplementary feeding are discussed. Cashmere production of young, low producing goats does not appear to be affected by energy supplementation, but large responses to energy supplementation have been measured in more productive cashmere goat strains. The designs of these cashmere nutrition experiments are reviewed. Evidence for the hypothesis that energy-deprived cashmere goats divert nutrients preferentially to cashmere growth is reviewed. The influence and potential use of liveweight manipulation in affecting mohair and cashmere production and quality are described. Estimates of the energy requirements for the maintenance of fibre goats and the effect of pregnancy and lactation on mohair and cashmere growth are summarised. The effects and importance of management and hygiene during fibre harvesting (shearing) in producing quality fibre is emphasised. The review concludes that it is important to assess the results of scientific experiments for the total environmental content within which they were conducted. The review supports the view that scientific experiments should use control treatments appropriate to the environment under study as well as having controls relevant for other environments. In mediterranean and annual temperate environments, appropriate controls are liveweight loss and liveweight maintenance treatments. Mohair producers must graze goats at moderate rates of stocking to maximise animal welfare, but in so doing, they will produce heavier goats and coarser mohair. In mediterranean and annual temperate environments, seasonal changes in liveweight are large and influence both quality and production of mohair and cashmere. Mohair and cashmere producers can manipulate liveweight by supplementary feeding energy during dry seasons to minimise liveweight loss, but the economics of such feeding needs to be carefully examined. Strategic benefits can be obtained by enhancing the growth of young does prior to mating and for higher producing cashmere goats.

Is alcohol and community sport a good mix? Alcohol management, consumption and social capital in community sports clubs

Objective: Community sports clubs provide an important contribution to the health and wellbeing of individuals and the community; however, they have also been associated with risky alcohol consumption. This study assessed whether a club's alcohol management strategies were related to risky alcohol consumption by members and levels of social capital, as measured in terms of participation in and perceived safety of the club. Method: A total of 723 sports club members from 33 community football clubs in New South Wales, Australia, completed a computer assisted telephone interview (CATI) and a management representative from each club also completed a CATI. The club representative reported on the club's implementation of 11 alcohol management practices, while club members reported their alcohol consumption and perceived levels of safety at the club and participation in the club. Results: A structural equation model identified having the bar open for more than four hours; having alcohol promotions; and serving intoxicated patrons were associated with increased risky alcohol consumption while at the club; which in turn was associated with lower levels of perceived club safety and member participation. Conclusion and implications: The positive contribution of community sports clubs to the community may be diminished by specific inadequate alcohol management practices. Changing alcohol management practices can reduce alcohol consumption, and possibly increase perceived aspects of social capital, such as safety and participation.

The role of lamotrigine in the management of bipolar disorder.

Lamotrigine has emerged with a distinct place in the pharmacological treatment of bipolar disorder, with the potential to treat and prevent bipolar depression, which is the dominant and arguably most disabling and under-treated phase of the illness. This review examines the published clinical trials of lamotrigine in bipolar treatment. While the data supports its tolerability and safety, the strongest evidence for its efficacy lies in the prevention of bipolar depression, with weaker evidence for the treatment of acute bipolar depression, refractory unipolar and bipolar depression, and rapid cycling bipolar disorder. The total number of published well designed trials is small, even the maintenance evidence is derived from two studies. However, this relative inadequacy compares favorably with the alternative treatment options for bipolar depression, which are marked by poor efficacy or risk of polarity switch. The designation of lamotrigine as first-line treatment for bipolar depression prophylaxis should be done in cognizance of this context, and it would seem prudent to await greater evidence of efficacy before designating lamotrigine as first-line treatment for other bipolar indications. Further randomized controlled trials are required to consolidate the available findings and to explore the boundaries of lamotrigine's efficacy, which may encompass the soft spectral disorders.

An investigation for improved home energy management

 Increasing household energy consumption and increasing primary energy cost urged to improve home energy efficiency. Improved energy management can suggest the ways to improve home energy efficiency. Various home appliances are the prime cause to the increased power demand. Appliance's energy rating information helps to develop awareness and reduce energy consumption. Load shifting can help to reduce overall cost of used energy bill by shifting peak time load to off-peak time. However most of the present appliances remains in standby mode (active or passive) for a significant part of the day, and load shifting cannot reduce the total energy consumption. Therefore investigation is required to identify any possible scopes to improve energy management at home. This paper investigated several home appliances and monitored daily time of use power consumption. It was found that by controlling standby power from a daily home load of 4.482 kWh, power demand can be reduced 12.56% moreover energy related greenhouse gas (GHG) emission can be reduced 133.08kg/year.

Latex dilution reaction during the tapping flow course of Hevea brasiliensis and the effect of Ethrel stimulation

The latex dilution reaction during the tapping flow course has been well documented and associated with the facilitation of tapping latex flow. However, its underlying mechanism has not experimentally examined. The latex total solid content, osmotic potential and phloem turgor pressure change during the tapping flow course were simultaneously measured to investigate the cause of water movement during the tapping flow course. It was found that there are three different stages for the laticifer water equilibrium during the tapping flow course. The tapping-induced rapid turgor pressure drop is the cause of the first stage water influx into laticifers, while osmoregulation prevails during water exchange in the second and third stages of tapping flow. Meanwhile, aquaporin expressions were, for the first time, investigated during the tapping flow course. The rapid transcript up-regulation of HbPIP1, HbPIP2;1 and HbPIP2;3 contributes to the latex dilution reaction. However, their activity gating cannot be ruled out. Ethrel stimulation can significantly dilute the corresponding latex fractions during the tapping flow course due to its up-regulations of HbPIP1, HbPIP2;1 and HbPIP2;3. Nevertheless, the latex dilution reaction pattern for the Ethrel treated trees did not change, except for a lower degree of dilution compared with the un-treated trees. All these results suggest that both phloem turgor pressure and aquaporins are involved in the latex dilution reaction during the tapping flow course.

Great 'app-eal' but not there yet: a review of iPhone nutrition applications relevant to child weight management

Aims: There is increasing interest in the use of smartphone applications (apps) for delivering child obesity management interventions and supporting lifestyle behaviour change; however, there has been very little academic research on their development. Our aim is to review nutrition-related apps designed for children currently available in Australia for their usefulness in education or support behavioural interventions for child obesity. Methods: Apps available for download in iTunes Australia between 2 April and 3 June 2013 which were suitable for children >12 years were identified. Key words were chosen to identify apps applicable to children, focusing on nutrition. Results: A total of 27 apps were included. Most apps (24/27) were not based on evidence-informed recommendations. A third of apps were developed in the USA (n = 10; 37%) and were free (67%), nine apps required upfront payment, with a mean cost of $A2.80 (range $A0.99-$A7.49). The most common nutrition features were the promotion of energy balance (n = 12 apps) and guidance on appropriate portion size (n = 15). The most common behaviour change feature was goal setting (n = 15). The five apps that scored most highly against the characteristics reviewed were: Calorie Counter Pro by My Net Diary, Weight Watchers, Swap It Don't Stop It, Control My Weight by CalorieKing and Rate What I Ate-Photo Diet Tracker. Conclusions: Very few apps were identified that could be used in education or support behavioural interventions for child obesity. There is a need to harness this technology and evaluate the applicability and use within childhood obesity research interventions.

Distributed multi-agent scheme for reactive power management with renewable energy

This paper presents a new distributed multi-agent scheme for reactive power management in smart coordinated distribution networks with renewable energy sources (RESs) to enhance the dynamic voltage stability, which is mainly based on controlling distributed static synchronous compensators (DSTATCOMs). The proposed control scheme is incorporated in a multi-agent framework where the intelligent agents simultaneously coordinate with each other and represent various physical models to provide information and energy flow among different physical processes. The reactive power is estimated from the topology of distribution networks and with this information, necessary control actions are performed through the proposed proportional integral (PI) controller. The performance of the proposed scheme is evaluated on a 8-bus distribution network under various operating conditions. The performance of the proposed scheme is validated through simulation results and these results are compared to that of conventional PI-based DSTATCOM control scheme. From simulation results, it is found that the distributed MAS provides excellence performance for improving voltage profiles by managing reactive power in a smarter way.

Employing sea-level rise scenarios to strategically select sea turtle nesting habitat important for long-term management at a temperate breeding area

Management strategies to protect endangered species primarily focus on safeguarding habitats currently perceived as important (due to high-density use, rarity or contribution to the biological cycle), rather than sites of future ecological importance. This discrepancy is particularly relevant for species inhabiting beaches and coastal areas that may be lost due to sea-level rise over the next 100 years through climate change. Here, we modelled four sea-level rise (SLR) scenarios (0.2, 0.6, 0.9 and 1.3 m) to determine the future vulnerability and viability of nesting habitat (six distinct nesting beaches totalling about 6 km in length) at a key loggerhead sea turtle (Caretta caretta) rookery (Zakynthos, Greece) in the Mediterranean. For each of the six nesting beaches, we identified (1) the area of beach currently used by turtles, (2) the area of the beach anticipated to become inundated under each SLR, (3) the area of beach anticipated to become unsuitable for nesting under each SLR, (4) the potential for habitat loss under the examined SLR, and (5) the extent to which the beaches may shift in relation to natural (i.e. cliffs) and artificial (i.e. beach front development) physical barriers. Even under the most conservative 0.2 m SLR scenario, about 38% (range: 31–48%) total nesting beach area would be lost, while an average 13% (range: 7–17%) current nesting beach area would be lost. About 4 km length of nesting habitat (representing 85% of nesting activity) would be lost under the 0.9 m scenario, because cliffs prevent landward beach migration. In comparison, while the other 2 km of beach (representing 15% nests) is also at high risk, it has the capacity for landward migration, because of an adjoining sand-dune system. Therefore, managers should strengthen actions on this latter area, as a climatically critical safeguard for future sea turtle nesting activity, in parallel to regularly assessing and revising measures on the current high-use nesting habitats of this important Mediterranean loggerhead population.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: a systematic review and meta-synthesis of qualitative studies

INTRODUCTION: Despite the availability of evidence-based guidelines for the management of low back pain that contain consistent messages, large evidence-practice gaps in primary care remain.

OBJECTIVES: To perform a systematic review and meta-synthesis of qualitative studies that have explored primary care clinicians' perceptions and beliefs about guidelines for low back pain, including perceived enablers and barriers to guideline adherence.

METHODS: Studies investigatingperceptions and beliefs about low back pain guidelines were included if participants were primary care clinicians and qualitative methods had been used for both data collection and analysis. We searched major databases up to July 2014. Pairs of reviewers independently screened titles and abstracts, extracted data, appraised method quality using the CASP checklist, conducted thematic analysis and synthesized the results in narrative format.

RESULTS: Seventeen studies, with a total of 705 participants, were included. We identified three key emergent themes and eight subthemes: (1) guideline implementation and adherence beliefs and perceptions; (2) maintaining the patient-clinician relationship with imaging referrals; (3) barriers to guideline implementation. Clinicians believed that guidelines were categorical, prescriptive and constrained professional practice; however popular clinical practices superseded the guidelines. Imaging referrals were used to manage consultations and to obtain definitive diagnoses. Clinicians' perceptions reflected a lack of content knowledge and understanding of how guidelines are developed.

DISCUSSION: Addressing misconceptions and other barriers to uptake of evidence-based guidelines for managing low back pain is needed to improve knowledge transfer and close the evidence-practice gap in the treatment of this common condition.

Stochastic optimization models for energy management in carbonization process of carbon fiber production

Industrial producers face the task of optimizing production process in an attempt to achieve the desired quality such as mechanical properties with the lowest energy consumption. In industrial carbon fiber production, the fibers are processed in bundles containing (batches) several thousand filaments and consequently the energy optimization will be a stochastic process as it involves uncertainty, imprecision or randomness. This paper presents a stochastic optimization model to reduce energy consumption a given range of desired mechanical properties. Several processing condition sets are developed and for each set of conditions, 50 samples of fiber are analyzed for their tensile strength and modulus. The energy consumption during production of the samples is carefully monitored on the processing equipment. Then, five standard distribution functions are examined to determine those which can best describe the distribution of mechanical properties of filaments. To verify the distribution goodness of fit and correlation statistics, the Kolmogorov-Smirnov test is used. In order to estimate the selected distribution (Weibull) parameters, the maximum likelihood, least square and genetic algorithm methods are compared. An array of factors including the sample size, the confidence level, and relative error of estimated parameters are used for evaluating the tensile strength and modulus properties. The energy consumption and N2 gas cost are modeled by Convex Hull method. Finally, in order to optimize the carbon fiber production quality and its energy consumption and total cost, mixed integer linear programming is utilized. The results show that using the stochastic optimization models, we are able to predict the production quality in a given range and minimize the energy consumption of its industrial process.