Heterotrophic Bacteria Associated with Cyanobacteria in Recreational and Drinking Water

Cyanobacterial mass occurrences, also known as water blooms, have been associated with adverse health effects of both humans and animals. They can also be a burden to drinking water treatment facilities. Risk assessments of the blooms have generally focused on the cyanobacteria themselves and their toxins. However, heterotrophic bacteria thriving among cyanobacteria may also be responsible for many of the adverse health effects, but their role as the etiological agents of these health problems is poorly known. In addition, studies on the water purification efficiency of operating water treatment plants during cyanobacterial mass occurrences in their water sources are rare. In the present study, over 600 heterotrophic bacterial strains were isolated from natural freshwater, brackish water or from treated drinking water. The sampling sites were selected as having frequent cyanobacterial occurrences in the water bodies or in the water sources of the drinking water treatment plants. In addition, samples were taken from sites where cyanobacterial water blooms were surmised to have caused human health problems. The isolated strains represented bacteria from 57 different genera of the Gamma-, Alpha- or Betaproteobacteria, Actinobacteria, Flavobacteria, Sphingobacteria, Bacilli and Deinococci classes, based on their partial 16S rRNA sequences. Several isolates had no close relatives among previously isolated bacteria or cloned 16S rRNA genes of uncultivated bacteria. The results show that water blooms are associated with a diverse community of cultivable heterotrophic bacteria. Chosen subsets of the isolated strains were analysed for features such as their virulence gene content and possible effect on cyanobacterial growth. Of the putatively pathogenic haemolytic strains isolated in the study, the majority represented the genus Aeromonas. Therefore, the Aeromonas spp. strains isolated from water samples associated with adverse health effects were screened for the virulence gene types encoding for enterotoxins (ast, alt and act/aerA/hlyA), flagellin subunits (flaA/flaB), lipase (lip/pla/lipH3/alp-1) and elastase (ahyB) by PCR. The majority (90%) of the Aeromonas strains included one or more of the six screened Aeromonas virulence gene types. The most common gene type was act, which was present in 77% of the strains. The fla, ahyB and lip genes were present in 30 37% of the strains. The prevalence of the virulence genes implies that the Aeromonas may be a factor in some of the cyanobacterial associated health problems. Of the 183 isolated bacterial strains that were studied for possible effects on cyanobacterial growth, the majority (60%) either enhanced or inhibited growth of cyanobacteria. In most cases, they enhanced the growth, which implies mutualistic interactions. The results indicate that the heterotrophic bacteria have a role in the rise and fall of the cyanobacterial water blooms. The genetic and phenotypic characteristics and the ability to degrade cyanobacterial hepatotoxins of 13 previously isolated Betaproteobacteria strains, were also studied. The strains originated from Finnish lakes with frequent cyanobacterial occurrence. Tested strains degraded microcystins -LR and -YR and nodularin. The strains could not be assigned to any described bacterial genus or species based on their genetic or phenotypic features. On the basis of their characteristics a new genus and species Paucibacter toxinivorans was proposed for them. The water purification efficiency of the drinking water treatment processes during cyanobacterial water bloom in water source was assessed at an operating surface water treatment plant. Large phytoplankton, cyanobacterial hepatotoxins, endotoxins and cultivable heterotrophic bacteria were efficiently reduced to low concentrations, often below the detection limits. In contrast, small planktonic cells, including also possible bacterial cells, regularly passed though the water treatment. The passing cells may contribute to biofilm formation within the water distribution system, and therefore lower the obtained drinking water quality. The bacterial strains of this study offer a rich source of isolated strains for examining interactions between cyanobacteria and the heterotrophic bacteria associated with them. The degraders of cyanobacterial hepatotoxins could perhaps be utilized to assist the removal of the hepatotoxins during water treatment, whereas inhibitors of cyanobacterial growth might be useful in controlling cyanobacterial water blooms. The putative pathogenicity of the strains suggests that the health risk assessment of the cyanobacterial blooms should also cover the heterotrophic bacteria.

An exploratory study to assess the activity of the acarine growth inhibitor, fluazuron, against Sarcoptes scabei infestation in pigs

Background: The most common treatments for scabies in human and veterinary settings are topical 5% permethrin or systemic treatment with ivermectin. However, these treatments have very little activity against arthropod eggs, and therefore repeated treatment is frequently required. In-vitro, biochemical and molecular studies have demonstrated that human mites are becoming increasingly resistant to both acaricides. To identify alternate acaricides, we undertook a pilot study of the in vivo activity of the benzoylphenyl urea inhibitor of chitin synthesis, fluazuron, in pigs with sarcoptic mange. Findings: Pigs (n = 5) were infested with S. scabei var suis, and randomised to treatment at the start of peak infestation with fluazuron at a dose of 10 mg/kg/day per os for 7 days (n = 3) or no treatment (n = 2). Clinical scores, skin scrapings for mite counts and blood sampling for pharmacokinetic analysis were undertaken. Fluazuron was well absorbed in treated pigs with measureable blood levels up to 4 weeks post treatment. No adverse effects were observed. Modest acaricidal activity of the compound was observed, with a reduction in severity of skin lesions in treated pigs, as well as a reduction in number of scabies mite's early life stages. Conclusions: The moderate efficacy of fluazuron against scabies mites indicates a lead to the development of alternate treatments for scabies, such as combination therapies that maybe applicable for human use in the future.

Physiological and behavioral responses of sheep to gaseous ammonia

Ammonia can accumulate in highly stocked sheep accommodation, for example during live export shipments, and could affect sheep health and welfare. Thus, the objective of this experiment was to test the effects of 4 NH3 concentrations, 4 (control), 12, 21, and 34 mg/m(3), on the physiology and behavior of wether sheep. Sheep were held for 12 d under a micro-climate and stocking density similar to shipboard conditions recorded on voyages from Australia to the Middle East during the northern hemispheric summer. Ammonia increased macrophage activity in transtracheal aspirations, indicating active pulmonary infl ammation; however, it had no effect (P > 0.05) on hematological variables. Feed intake decreased (P = 0.002) in proportion to ammonia concentration, and BW gain decreased (P < 0.001) at the 2 greatest concentrations. Exposure to ammonia increased (P = 0.03) the frequency of sneezing, and at the greatest ammonia concentration, sheep were less active, with less locomotion, pawing, and panting. Twenty-eight days after exposure to NH3, the pulmonary macrophage activity and BW of the sheep returned to that of sheep exposed to only 4 mg/m(3). It was concluded that NH3 induced a temporary inflammatory response of the respiratory system and reduced BW gain, which together indicated a transitory adverse effect on the welfare of sheep.

Assessing infant exposure to persistent organic pollutants via dietary intake in Australia

Persistent organic pollutants (POPs) including polybrominated diphenyl ethers (PBDEs); organochlorine pesticides (OCPs); and polychlorinated biphenyls (PCBs) persist in the environment, bioaccumulate, and pose a risk of causing adverse human health effects. Typically, exposure assessments undertaken by modeling existing intake data underestimate the concentrations of these chemicals in infants. This study aimed to determine concentrations of POPs in infant foods, assess exposure via dietary intake and compare this to historical exposure. Fruit purees, meat and vegetables, dairy desserts, cereals and jelly foods (n = 33) purchased in 2013 in Brisbane, Australia were analyzed. For OCPs and PCBs, concentrations ranged up to 95 pg/g fw and for PBDEs up to 32 pg/g fw with most analytes below the limit of detection. Daily intake is dependent on type and quantity of foods consumed. Consumption of a 140 g meal would result in intake ranging from 0 to 4.2 ng/day, 4.4 ng/day and 13.3 ng/day, for OCPs, PBDEs and PCBs, respectively. PBDEs were detected in 3/33 samples, OCPs in 9/33 samples and PCBs in 13/33 samples. Results from this study indicate exposure for infants via dietary (in contrast to dust and breast milk) intake in Australia contribute only a minor component to total exposure.

The success of the diversified farm : resource-based view

Farms and rural areas have many specific valuable resources that can be used to create non-agricultural products and services. Most of the research regarding on-farm diversification has hitherto concentrated on business start-up or farm survival strategies. Resource allocation and also financial success have not been the primary focus of investigations as yet. In this study these specific topics were investigated i.e. resource allocation and also the financial success of diversified farms from a farm management perspective. The key question addressed in this dissertation, is how tangible and intangible resources of the diversified farm affect the financial success. This study’s theoretical background deals with resource-based theory, and also certain themes of the theory of learning organisation and other decision-making theories. Two datasets were utilised in this study. First, data were collected by postal survey in 2001 (n = 663). Second, data were collected in a follow-up survey in 2006 (n = 439). Data were analysed using multivariate data analyses and path analyses. The study results reveal that, diversified farms performed differently. Success and resources were linked. Professional and management skills affected other resources, and hence directly or indirectly influenced success per se. In the light of empirical analyses of this study, tangible and intangible resources owned by the diversified farm impacted on its financial success. The findings of this study underline the importance of skills and networks for entrepreneur(s). Practically speaking all respondents of this study used either agricultural resources for non-farm businesses or non-farm resources for agricultural enterprises. To share resources in this way was seen as a pragmatic opportunity recognised by farmers. One of the downsides of diversification might be the phenomenon of over-diversification, which can be defined as the situation in which a farm diversifies beyond its optimal limit. The empirical findings of this study reveal that capital and labour resource constrains did have adverse effects on financial success. The evidence indicates that farms that were capital and labour resource constrained in 2001 were still less profitable than their ‘no problems’ counterparts five years later.

Improved chemical control of Conyza bonariensis in wheat limits problems in the following fallow

Conyza bonariensis is a major weed infesting zero-tilled cropping systems in subtropical Australia, particularly in wheat and winter fallows. Uncontrolled C.bonariensis survives to become a problem weed in the following crops or fallows. As no herbicide has been registered for C.bonariensis in wheat, the effectiveness of 11 herbicides, currently registered for other broad-leaved weeds in wheat, was evaluated in two pot and two field experiments. As previous research showed that the age of C.bonariensis, and to a lesser extent, the soil moisture at spraying affected herbicide efficacy, these factors also were investigated. The efficacy of the majority of herbicide treatments was reduced when large rosettes (5-15cm diameter) were treated, compared with small rosettes (<5cm diameter). However, for the majority of herbicide treatments, the soil moisture did not affect the herbicide efficacy in the pot experiments. In the field, a delay in herbicide treatment of 2 weeks reduced the herbicide efficacy consistently across herbicide treatments, which was related to weed age but not to soil moisture differences. Across all the experiments, four herbicides controlled C.bonariensis in wheat consistently (83-100%): 2,4-D; aminopyralid + fluroxypyr; picloram + MCPA + metsulfuron; and picloram + high rates of 2,4-D. Thus, this problem weed can be effectively and consistently controlled in wheat, particularly when small rosettes are treated, and therefore C.bonariensis will have a less adverse impact on the following fallow or crop.

Structural Veneer Based Composite Products from Hardwood Thinning - Part I: Background and Manufacturing

In Australia, plantation forests have increased in area by around 50% in the last 10 years. While this expansion has seen a modest 8% increase for softwoods, hardwood plantations have dramatically increased by over 150%. Hardwood plantations grown for high quality sawn timber are slow to mature, with a crop rotation time potentially reaching 35 years. With this long lead-time, each year the risk from fire, pests and adverse weather events dramatically increases, while not translating into substantially higher financial returns to the grower. To justify continued expansion of Australia's current hardwood plantation estate, it is becoming necessary to develop higher value end-uses for both pulpwood and smaller 'sawlog' resources. The use of the low commercial value stems currently culled during thinning appears to be a necessary option to improve the industry profitability and win new markets. This paper provides background information on Australian forests and plantations and gives an overview of potential uses of Australian hardwood plantation thinning logs, as their mechanical properties. More specifically, this paper reports on the development of structural Veneer Based Composite (VBC) products from hardwood plantation thinning logs, taking advantage of a recent technology developed to optimise the processing of this resource. The process used to manufacture a range of hollow-form veneer laminated structural products is presented and the mechanical characteristics of these products are investigated in the companion paper. The market applications and future opportunities for the proposed products are also discussed, as potential benefits to the timber industry. © RILEM 2014.

Chemical mass closure and source-specific composition of atmospheric particles

It has been known for decades that particles can cause adverse health effects as they are deposited within the respiratory system. Atmospheric aerosol particles influence climate by scattering solar radiation but aerosol particles act also as the nuclei around which cloud droplets form. The principal objectives of this thesis were to investigate the chemical composition and the sources of fine particles in different environments (traffic, urban background, remote) as well as during some specific air pollution situations. Quantifying the climate and health effects of atmospheric aerosols is not possible without detailed information of the aerosol chemical composition. Aerosol measurements were carried out at nine sites in six countries (Finland, Germany, Czech, Netherlands, Greece and Italy). Several different instruments were used in order to measure both the particulate matter (PM) mass and its chemical composition. In the off-line measurements the samples were collected first on a substrate or filter and gravimetric and chemical analysis were conducted in the laboratory. In the on-line measurements the sampling and analysis were either a combined procedure or performed successively within the same instrument. Results from the impactor samples were analyzed by the statistical methods. This thesis comprises also a work where a method for the determination carbonaceous matter size distribution by using a multistage impactor was developed. It was found that the chemistry of PM has usually strong spatial, temporal and size-dependent variability. In the Finnish sites most of the fine PM consisted of organic matter. However, in Greece sulfate dominated the fine PM and in Italy nitrate made the largest contribution to the fine PM. Regarding the size-dependent chemical composition, organic components were likely to be enriched in smaller particles than inorganic ions. Data analysis showed that organic carbon (OC) had four major sources in Helsinki. Secondary production was the major source in Helsinki during spring, summer and fall, whereas in winter biomass combustion dominated OC. The significant impact of biomass combustion on OC concentrations was also observed in the measurements performed in Central Europe. In this thesis aerosol samples were collected mainly by the conventional filter and impactor methods which suffered from the long integration time. However, by filter and impactor measurements chemical mass closure was achieved accurately, and a simple filter sampling was found to be useful in order to explain the sources of PM on the seasonal basis. The online instruments gave additional information related to the temporal variations of the sources and the atmospheric mixing conditions.

Complementary forages – integration at a whole-farm level

A high proportion of the Australian and New Zealand dairy industry is based on a relatively simple, low input and low cost pasture feedbase. These factors enable this type of production system to remain internationally competitive. However, a key limitation of pasture-based dairy systems is periodic imbalances between herd intake requirements and pasture DM production, caused by strong seasonality and high inter-annual variation in feed supply. This disparity can be moderated to a certain degree through the strategic management of the herd through altering calving dates and stocking rates, and the feedbase by conserving excess forage and irrigating to flatten seasonal forage availability. Australasian dairy systems are experiencing emerging market and environmental challenges, which includes increased competition for land and water resources, decreasing terms of trade, a changing and variable climate, an increasing environmental focus that requires improved nutrient and water-use efficiency and lower greenhouse gas emissions. The integration of complementary forages has long been viewed as a means to manipulate the home-grown feed supply, to improve the nutritive value and DM intake of the diet, and to increase the efficiency of inputs utilised. Only recently has integrating complementary forages at the whole-farm system level received the significant attention and investment required to examine their potential benefit. Recent whole-of-farm research undertaken in both Australia and New Zealand has highlighted the importance of understanding the challenges of the current feedbase and the level of complementarity between forage types required to improve profit, manage risk and/or alleviate/mitigate against adverse outcomes. This paper reviews the most recent systems-level research into complementary forages, discusses approaches to modelling their integration at the whole-farm level and highlights the potential of complementary forages to address the major challenges currently facing pasture-based dairy systems.

Chemical and source characterisation of size-segregated urban air particulate matter

Recent epidemiological studies have shown a consistent association of the mass concentration of urban air thoracic (PM10) and fine (PM2.5) particles with mortality and morbidity among cardiorespiratory patients. However, the chemical characteristics of different particulate size ranges and the biological mechanisms responsible for these adverse health effects are not well known. The principal aims of this thesis were to validate a high volume cascade impactor (HVCI) for the collection of particulate matter for physicochemical and toxicological studies, and to make an in-depth chemical and source characterisation of samples collected during different pollution situations. The particulate samples were collected with the HVCI, virtual impactors and a Berner low pressure impactor in six European cities: Helsinki, Duisburg, Prague, Amsterdam, Barcelona and Athens. The samples were analysed for particle mass, common ions, total and water-soluble elements as well as elemental and organic carbon. Laboratory calibration and field comparisons indicated that the HVCI can provide a unique large capacity, high efficiency sampling of size-segregated aerosol particles. The cutoff sizes of the recommended HVCI configuration were 2.4, 0.9 and 0.2 μm. The HVCI mass concentrations were in a good agreement with the reference methods, but the chemical composition of especially the fine particulate samples showed some differences. This implies that the chemical characterization of the exposure variable in toxicological studies needs to be done from the same HVCI samples as used in cell and animal studies. The data from parallel, low volume reference samplers provide valuable additional information for chemical mass closure and source assessment. The major components of PM2.5 in the virtual impactor samples were carbonaceous compounds, secondary inorganic ions and sea salt, whereas those of coarse particles (PM2.5-10) were soil-derived compounds, carbonaceous compounds, sea salt and nitrate. The major and minor components together accounted for 77-106% and 77-96% of the gravimetrically-measured masses of fine and coarse particles, respectively. Relatively large differences between sampling campaigns were observed in the organic carbon content of the PM2.5 samples as well as the mineral composition of the PM2.5-10 samples. A source assessment based on chemical tracers suggested clear differences in the dominant sources (e.g. traffic, residential heating with solid fuels, metal industry plants, regional or long-range transport) between the sampling campaigns. In summary, the field campaigns exhibited different profiles with regard to particulate sources, size distribution and chemical composition, thus, providing a highly useful setup for toxicological studies on the size-segregated HVCI samples.

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.

Educators’ perspectives about how older hospital patients can engage in a falls prevention education programme: A qualitative process evaluation

- Objectives Falls are the most frequent adverse event reported in hospitals. Patient and staff education delivered by trained educators significantly reduced falls and injurious falls in an older rehabilitation population. The purpose of the study was to explore the educators’ perspectives of delivering the education and to conceptualise how the programme worked to prevent falls among older patients who received the education. - Design A qualitative exploratory study. - Methods Data were gathered from three sources: conducting a focus group and an interview (n=10 educators), written educator notes and reflective researcher field notes based on interactions with the educators during the primary study. The educators delivered the programme on eight rehabilitation wards for periods of between 10 and 40 weeks. They provided older patients with individualised education to engage in falls prevention and provided staff with education to support patient actions. Data were thematically analysed and presented using a conceptual framework. - Results Falls prevention education led to mutual understanding between staff and patients which assisted patients to engage in falls prevention behaviours. Mutual understanding was derived from the following observations: the educators perceived that they could facilitate an effective three-way interaction between staff actions, patient actions and the ward environment which led to behaviour change on the wards. This included engaging with staff and patients, and assisting them to reconcile differing perspectives about falls prevention behaviours. - Conclusions Individualised falls prevention education effectively provides patients who receive it with the capability and motivation to develop and undertake behavioural strategies that reduce their falls, if supported by staff and the ward environment.

Induced Variations in Brassinosteroid Genes Define Barley Height and Sturdiness, and Expand the Green Revolution Genetic Toolkit

Reduced plant height and culm robustness are quantitative characteristics important for assuring cereal crop yield and quality under adverse weather conditions. A very limited number of short-culm mutant alleles were introduced into commercial crop cultivars during the Green Revolution. We identified phenotypic traits, including sturdy culm, specific for deficiencies in brassinosteroid biosynthesis and signaling in semidwarf mutants of barley (Hordeum vulgare). This set of characteristic traits was explored to perform a phenotypic screen of near-isogenic short-culm mutant lines from the brachytic, breviaristatum, dense spike, erectoides, semibrachytic, semidwarf, and slender dwarf mutant groups. In silico mapping of brassinosteroid-related genes in the barley genome in combination with sequencing of barley mutant lines assigned more than 20 historic mutants to three brassinosteroid-biosynthesis genes (BRASSINOSTEROID-6-OXIDASE, CONSTITUTIVE PHOTOMORPHOGENIC DWARF, and DIMINUTO) and one brassinosteroid-signaling gene (BRASSINOSTEROID-INSENSITIVE1 [HvBRI1]). Analyses of F2 and M2 populations, allelic crosses, and modeling of nonsynonymous amino acid exchanges in protein crystal structures gave a further understanding of the control of barley plant architecture and sturdiness by brassinosteroid-related genes. Alternatives to the widely used but highly temperature-sensitive uzu1.a allele of HvBRI1 represent potential genetic building blocks for breeding strategies with sturdy and climate-tolerant barley cultivars.

Robust features of future climate change impacts on sorghum yields in West Africa

West Africa is highly vulnerable to climate hazards and better quantification and understanding of the impact of climate change on crop yields are urgently needed. Here we provide an assessment of near-term climate change impacts on sorghum yields in West Africa and account for uncertainties both in future climate scenarios and in crop models. Towards this goal, we use simulations of nine bias-corrected CMIP5 climate models and two crop models (SARRA-H and APSIM) to evaluate the robustness of projected crop yield impacts in this area. In broad agreement with the full CMIP5 ensemble, our subset of bias-corrected climate models projects a mean warming of +2.8 °C in the decades of 2031–2060 compared to a baseline of 1961–1990 and a robust change in rainfall in West Africa with less rain in the Western part of the Sahel (Senegal, South-West Mali) and more rain in Central Sahel (Burkina Faso, South-West Niger). Projected rainfall deficits are concentrated in early monsoon season in the Western part of the Sahel while positive rainfall changes are found in late monsoon season all over the Sahel, suggesting a shift in the seasonality of the monsoon. In response to such climate change, but without accounting for direct crop responses to CO2, mean crop yield decreases by about 16–20% and year-to-year variability increases in the Western part of the Sahel, while the eastern domain sees much milder impacts. Such differences in climate and impacts projections between the Western and Eastern parts of the Sahel are highly consistent across the climate and crop models used in this study. We investigate the robustness of impacts for different choices of cultivars, nutrient treatments, and crop responses to CO2. Adverse impacts on mean yield and yield variability are lowest for modern cultivars, as their short and nearly fixed growth cycle appears to be more resilient to the seasonality shift of the monsoon, thus suggesting shorter season varieties could be considered a potential adaptation to ongoing climate changes. Easing nitrogen stress via increasing fertilizer inputs would increase absolute yields, but also make the crops more responsive to climate stresses, thus enhancing the negative impacts of climate change in a relative sense. Finally, CO2 fertilization would significantly offset the negative climate

Reducing falls in hospital through education to change patient and staff behaviour: A stepped wedge cluster randomised controlled effectiveness trial

Background: Falls remain the most frequent adverse event reported in hospitals, particularly geriatric rehabilitation wards. Randomised trials reducing fall injuries in hospitals have been elusive. Our previous randomised trial (n = 1206) demonstrated that multimedia education with physiotherapist falls educator support reduced falls among patients with higher cognition levels, but this benefit was offset by a potential increase in falls rates among patients with poor cognition. In the previous trial, hospital staff were blinded to the allocation of individual patients, and only delivered usual care.