Fluid strategies and outcomes in patients with acute respiratory distress syndrome, systemic inflammatory response syndrome and sepsis: a protocol for a systematic review and meta-analysis

Background
Fluid administration to critically ill patients remains the subject of considerable controversy. While intravenous fluid given for resuscitation may be life-saving, a positive fluid balance over time is associated with worse outcomes in critical illness. The aim of this systematic review is to summarise the existing evidence regarding the relationship between fluid administration or balance and clinically important patient outcomes in critical illness.

Methods
We will search Medline, EMBASE, the Cochrane Central Register of Controlled Trials from 1980 to the present and key conference proceedings from 2009 to the present. We will include studies of critically ill adults and children with acute respiratory distress syndrome (ARDS), sepsis and systemic inflammatory response syndrome (SIRS). We will include randomised controlled trials comparing two or more fluid regimens of different volumes of fluid and observational studies reporting the relationship between volume of fluid administered or fluid balance and outcomes including mortality, lengths of intensive care unit and hospital stay and organ dysfunction. Two independent reviewers will assess articles for eligibility, data extraction and quality appraisal. We will conduct a narrative and/or meta-analysis as appropriate.

Discussion
While fluid management has been extensively studied and discussed in the critical care literature, no systematic review has attempted to summarise the evidence for post-resuscitation fluid strategies in critical illness. Results of the proposed systematic review will inform practice and the design of future clinical trials.

Systematic review registration
PROSPERO CRD42013005608. (http://​www.​crd.​york.​ac.​uk/​PROSPERO/​)

The effect of statins on intraocular pressure and on the incidence and progression of glaucoma: A Systematic Review and Meta-analysis

Purpose: We conducted a systematic review and meta-analysis of observational studies to evaluate the effect of oral statins on intraocular pressure (IOP) and the incidence and progression of glaucoma. Methods: This was a systematic review of the literature and meta-analysis. Searches of PubMed/Medline and Embase were conducted to include all types of studies. Gray literature abstracts were also considered for inclusion. Last search date was February 2016. Risk of bias was assessed using the Newcastle-Ottawa scale independently by two reviewers. Odds ratios (OR) or hazard ratios (HR) and 95% confidence intervals (CI) were extracted from each study. Pooled ORs for incidence of glaucoma were calculated using a random-effects model. Results: We identified seven cohort studies, three case–control studies, and one cross-sectional study with a total number of 583,615 participants. No randomized controlled trials were retrieved. Pooled ORs demonstrated a statistically significant association between short-term statin use (≤2 years) and reduced incidence of glaucoma (OR 0.96, 95%CI 0.94, 0.99). Pooled ORs of long-term statin use (>2 years) did not demonstrate statistically significant reduction in incidence of glaucoma (OR 0.70, 95%CI 0.46, 1.06). There was inconsistent evidence for the protective effect of statins against the progression of glaucoma, although there was no standard definition for progression across studies. There was no significant difference in IOP associated with statin use. Conclusions: Short-term statin use is associated with a reduced incidence of glaucoma. The effect of statins on glaucoma progression and IOP is uncertain.

An Analysis of Local Wind and Air Mass Directions and Their Impact on Cladosporium Distribution Using HYSPLIT and Circular Statistics

Ecological studies that examine species-environment relationships are often limited to several meteorological parameters, i.e. mean air temperature, relative humidity, precipitation, vapour pressure deficit and solar radiation. The impact of local wind, its speed and direction are less commonly investigated in aerobiological surveys mainly due to difficulties related to the employment of specific analytical tools and interpretation of their outputs. Identification of inoculum sources of economically important plant pathogens, as well as highly allergenic bioaerosols like Cladosporium species, has not been yet explored with remote sensing data and atmospheric models such as Hybrid Single Particle Lagrangian Integrated Trajectory (HYSPLIT). We, therefore, performed an analysis of 24 h intra-diurnal cycle of Cladosporium spp. spores from an urban site in connection with both the local wind direction and overall air mass direction computed by HYSPLIT. The observational method was a volumetric air sampler of the Hirst design with 1 h time resolution and corresponding optical detection of fungal spores with light microscopy. The atmospheric modelling was done using the on-line data set from GDAS with 1° resolution and circular statistical methods. Our results showed stronger, statistically significant correlation (p ≤ 0.05) between high Cladosporium spp. spore concentration and air mass direction compared to the local wind direction. This suggested that a large fraction of the investigated fungal spores had a regional origin and must be located more than a few kilometers away from the sampling point.

Head-to-head comparison of length of stay, patients' outcome and satisfaction in Switzerland before and after SwissDRG-Implementation in 2012 in 2012: an observational study in two tertiary university centers.

On 1 January 2012 Swiss Diagnosis Related Groups (DRG), a new uniform payment system for in-patients was introduced in Switzerland with the intention to replace a "cost-based" with a "case-based" reimbursement system to increase efficiency. With the introduction of the new payment system we aim to answer questions raised regarding length of stay as well as patients' outcome and satisfaction. This is a prospective, two-centre observational cohort study with data from University Hospital Basel and the Cantonal Hospital Aarau, Switzerland, from January to June 2011 and 2012, respectively. Consecutive in-patients with the main diagnosis of either community-acquired pneumonia, exacerbation of COPD, acute heart failure or hip fracture were included. A questionnaire survey was sent out after discharge investigating changes before and after SwissDRG implementation. Our primary endpoint was LOS. Of 1,983 eligible patients 841 returned the questionnaire and were included into the analysis (429 in 2011, 412 in 2012). The median age was 76.7 years (50.8% male). Patients in the two years were well balanced in regard to main diagnoses and co-morbidities. Mean LOS in the overall patient population was 10.0 days and comparable between the 2011 cohort and the 2012 cohort (9.7 vs 10.3; p = 0.43). Overall satisfaction with care changed only slightly after introduction of SwissDRG and remained high (89.0% vs 87.8%; p = 0.429). Investigating the influence of the implementation of SwissDRG in 2012 regarding LOS patients' outcome and satisfaction, we found no significant changes. However, we observed some noteworthy trends, which should be monitored closely.

The development of a Flanders Interaction Analysis style instrument for use in educational computer mediated communication research

Please consult the paper edition of this thesis to read. It is available on the 5th Floor of the Library at Call Number: Z 9999 E38 D56 1992

An investigation into observational characteristics of rainfall and temperature in Central Northeast India—a historical perspective 1889–2008

Mann–Kendall non-parametric test was employed for observational trend detection of monthly, seasonal and annual precipitation of five meteorological subdivisions of Central Northeast India (CNE India) for different 30-year normal periods (NP) viz. 1889–1918 (NP1), 1919–1948 (NP2), 1949–1978 (NP3) and 1979–2008 (NP4). The trends of maximum and minimum temperatures were also investigated. The slopes of the trend lines were determined using the method of least square linear fitting. An application of Morelet wavelet analysis was done with monthly rainfall during June– September, total rainfall during monsoon season and annual rainfall to know the periodicity and to test the significance of periodicity using the power spectrum method. The inferences figure out from the analyses will be helpful to the policy managers, planners and agricultural scientists to work out irrigation and water management options under various possible climatic eventualities for the region. The long-term (1889–2008) mean annual rainfall of CNE India is 1,195.1 mm with a standard deviation of 134.1 mm and coefficient of variation of 11%. There is a significant decreasing trend of 4.6 mm/year for Jharkhand and 3.2 mm/day for CNE India. Since rice crop is the important kharif crop (May– October) in this region, the decreasing trend of rainfall during themonth of July may delay/affect the transplanting/vegetative phase of the crop, and assured irrigation is very much needed to tackle the drought situation. During themonth of December, all the meteorological subdivisions except Jharkhand show a significant decreasing trend of rainfall during recent normal period NP4. The decrease of rainfall during December may hamper sowing of wheat, which is the important rabi crop (November–March) in most parts of this region. Maximum temperature shows significant rising trend of 0.008°C/year (at 0.01 level) during monsoon season and 0.014°C/year (at 0.01 level) during post-monsoon season during the period 1914– 2003. The annual maximum temperature also shows significant increasing trend of 0.008°C/year (at 0.01 level) during the same period. Minimum temperature shows significant rising trend of 0.012°C/year (at 0.01 level) during postmonsoon season and significant falling trend of 0.002°C/year (at 0.05 level) during monsoon season. A significant 4– 8 years peak periodicity band has been noticed during September over Western UP, and 30–34 years periodicity has been observed during July over Bihar subdivision. However, as far as CNE India is concerned, no significant periodicity has been noticed in any of the time series.

Plasmapheresis vs. immunoglobulin in autoimmune neurologic diseases: a meta-analysis

Objectives: to evaluate the efficacy and safety of human immunoglobulin versus plasmapheresis in the management of autoimmune neurologic diseases. Likewise, length of hospital stay and duration of ventilator support were compared. Methods: Randomized controlled trials and analytical observational studies of more than 10 cases, were reviewed. Cochrane Neuromuscular Disease Group trials, MEDLINE, EMBASE, HINARI Ovid, the Database of abstracts of reviews of effectiveness and the Economic evaluation Database were searched as data source. Reference lists were examined for further relevant articles. A random-effect model was used to derive a pooled risk ratio. Results: 725 articles were found and 27 met the criteria for a population studied of 4717 cases: 14 articles were about Guillain Barré syndrome, 10 of Myasthenia Gravis, one of Sydenham Chorea, one of Chronic inflammatory demyelinating polyneuropathy, and one of PANDAS. No evidence was found in favor of any of the two treatments as regards effectiveness (OR 0.94, IC 0.63 – 1.41, p= 0.77) or ventilator support time; IGIV had a significant better safety profile than plasmapheresis (OR 0.70, IC 0.51 – 0.96, p= 0.03) and patients needed less time of hospital stay (p=0.03). Conclusions: There is no evidence for superiority in the effectiveness of immunoglobulin or plasmapheresis in the management of autoimmune neurologic diseases. Nevertheless, patients treated with immunoglobulin have statistically significant less adverse effects, a shorter hospital stay and a tendency of less ventilator support time. These premises could lead to fewer costs for health services but an economic study should be done.

Convectively coupled equatorial waves: A new methodology for identifying wave structures in observational data

Convectively coupled equatorial waves are fundamental components of the interaction between the physics and dynamics of the tropical atmosphere. A new methodology, which isolates individual equatorial wave modes, has been developed and applied to observational data. The methodology assumes that the horizontal structures given by equatorial wave theory can be used to project upper- and lower-tropospheric data onto equatorial wave modes. The dynamical fields are first separated into eastward- and westward-moving components with a specified domain of frequency–zonal wavenumber. Each of the components for each field is then projected onto the different equatorial modes using the y structures of these modes given by the theory. The latitudinal scale yo of the modes is predetermined by data to fit the equatorial trapping in a suitable latitude belt y = ±Y. The extent to which the different dynamical fields are consistent with one another in their depiction of each equatorial wave structure determines the confidence in the reality of that structure. Comparison of the analyzed modes with the eastward- and westward-moving components in the convection field enables the identification of the dynamical structure and nature of convectively coupled equatorial waves. In a case study, the methodology is applied to two independent data sources, ECMWF Reanalysis and satellite-observed window brightness temperature (Tb) data for the summer of 1992. Various convectively coupled equatorial Kelvin, mixed Rossby–gravity, and Rossby waves have been detected. The results indicate a robust consistency between the two independent data sources. Different vertical structures for different wave modes and a significant Doppler shifting effect of the background zonal winds on wave structures are found and discussed. It is found that in addition to low-level convergence, anomalous fluxes induced by strong equatorial zonal winds associated with equatorial waves are important for inducing equatorial convection. There is evidence that equatorial convection associated with Rossby waves leads to a change in structure involving a horizontal structure similar to that of a Kelvin wave moving westward with it. The vertical structure may also be radically changed. The analysis method should make a very powerful diagnostic tool for investigating convectively coupled equatorial waves and the interaction of equatorial dynamics and physics in the real atmosphere. The results from application of the analysis method for a reanalysis dataset should provide a benchmark against which model studies can be compared.

Analysis of moisture variability in the European Centre for Medium-Range Weather Forecasts 15-year reanalysis over the tropical oceans

We compare European Centre for Medium-Range Weather Forecasts 15-year reanalysis (ERA-15) moisture over the tropical oceans with satellite observations and the U.S. National Centers for Environmental Prediction (NCEP) National Center for Atmospheric Research 40-year reanalysis. When systematic differences in moisture between the observational and reanalysis data sets are removed, the NCEP data show excellent agreement with the observations while the ERA-15 variability exhibits remarkable differences. By forcing agreement between ERA-15 column water vapor and the observations, where available, by scaling the entire moisture column accordingly, the height-dependent moisture variability remains unchanged for all but the 550–850 hPa layer, where the moisture variability reduces significantly. Thus the excess variation of column moisture in ERA-15 appears to originate in this layer. The moisture variability provided by ERA-15 is not deemed of sufficient quality for use in the validation of climate models.

The precipitation climate of Central Asia: intercomparison of observational and numerical data sources in a remote semiarid region

In this study, we systematically compare a wide range of observational and numerical precipitation datasets for Central Asia. Data considered include two re-analyses, three datasets based on direct observations, and the output of a regional climate model simulation driven by a global re-analysis. These are validated and intercompared with respect to their ability to represent the Central Asian precipitation climate. In each of the datasets, we consider the mean spatial distribution and the seasonal cycle of precipitation, the amplitude of interannual variability, the representation of individual yearly anomalies, the precipitation sensitivity (i.e. the response to wet and dry conditions), and the temporal homogeneity of precipitation. Additionally, we carried out part of these analyses for datasets available in real time. The mutual agreement between the observations is used as an indication of how far these data can be used for validating precipitation data from other sources. In particular, we show that the observations usually agree qualitatively on anomalies in individual years while it is not always possible to use them for the quantitative validation of the amplitude of interannual variability. The regional climate model is capable of improving the spatial distribution of precipitation. At the same time, it strongly underestimates summer precipitation and its variability, while interannual variations are well represented during the other seasons, in particular in the Central Asian mountains during winter and spring

Global trends and factors associated with the illegal killing of elephants: a hierarchical bayesian analysis of carcass encounter data

Elephant poaching and the ivory trade remain high on the agenda at meetings of the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES). Well-informed debates require robust estimates of trends, the spatial distribution of poaching, and drivers of poaching. We present an analysis of trends and drivers of an indicator of elephant poaching of all elephant species. The site-based monitoring system known as Monitoring the Illegal Killing of Elephants (MIKE), set up by the 10th Conference of the Parties of CITES in 1997, produces carcass encounter data reported mainly by anti-poaching patrols. Data analyzed were site by year totals of 6,337 carcasses from 66 sites in Africa and Asia from 2002–2009. Analysis of these observational data is a serious challenge to traditional statistical methods because of the opportunistic and non-random nature of patrols, and the heterogeneity across sites. Adopting a Bayesian hierarchical modeling approach, we used the proportion of carcasses that were illegally killed (PIKE) as a poaching index, to estimate the trend and the effects of site- and country-level factors associated with poaching. Important drivers of illegal killing that emerged at country level were poor governance and low levels of human development, and at site level, forest cover and area of the site in regions where human population density is low. After a drop from 2002, PIKE remained fairly constant from 2003 until 2006, after which it increased until 2008. The results for 2009 indicate a decline. Sites with PIKE ranging from the lowest to the highest were identified. The results of the analysis provide a sound information base for scientific evidence-based decision making in the CITES process.

Observational tracking of the 2D structure of coronal mass ejections between the sun and 1 AU

The Solar TErrestrial RElations Observatory (STEREO) provides high cadence and high resolution images of the structure and morphology of coronal mass ejections (CMEs) in the inner heliosphere. CME directions and propagation speeds have often been estimated through the use of time-elongation maps obtained from the STEREO Heliospheric Imager (HI) data. Many of these CMEs have been identified by citizen scientists working within the SolarStormWatch project ( www.solarstormwatch.com ) as they work towards providing robust real-time identification of Earth-directed CMEs. The wide field of view of HI allows scientists to directly observe the two-dimensional (2D) structures, while the relative simplicity of time-elongation analysis means that it can be easily applied to many such events, thereby enabling a much deeper understanding of how CMEs evolve between the Sun and the Earth. For events with certain orientations, both the rear and front edges of the CME can be monitored at varying heliocentric distances (R) between the Sun and 1 AU. Here we take four example events with measurable position angle widths and identified by the citizen scientists. These events were chosen for the clarity of their structure within the HI cameras and their long track lengths in the time-elongation maps. We show a linear dependency with R for the growth of the radial width (W) and the 2D aspect ratio (χ) of these CMEs, which are measured out to ≈ 0.7 AU. We estimated the radial width from a linear best fit for the average of the four CMEs. We obtained the relationships W=0.14R+0.04 for the width and χ=2.5R+0.86 for the aspect ratio (W and R in units of AU).

Analysis of the seasonal cycle within the first international urban land-surface model comparison

A number of urban land-surface models have been developed in recent years to satisfy the growing requirements for urban weather and climate interactions and prediction. These models vary considerably in their complexity and the processes that they represent. Although the models have been evaluated, the observational datasets have typically been of short duration and so are not suitable to assess the performance over the seasonal cycle. The First International Urban Land-Surface Model comparison used an observational dataset that spanned a period greater than a year, which enables an analysis over the seasonal cycle, whilst the variety of models that took part in the comparison allows the analysis to include a full range of model complexity. The results show that, in general, urban models do capture the seasonal cycle for each of the surface fluxes, but have larger errors in the summer months than in the winter. The net all-wave radiation has the smallest errors at all times of the year but with a negative bias. The latent heat flux and the net storage heat flux are also underestimated, whereas the sensible heat flux generally has a positive bias throughout the seasonal cycle. A representation of vegetation is a necessary, but not sufficient, condition for modelling the latent heat flux and associated sensible heat flux at all times of the year. Models that include a temporal variation in anthropogenic heat flux show some increased skill in the sensible heat flux at night during the winter, although their daytime values are consistently overestimated at all times of the year. Models that use the net all-wave radiation to determine the net storage heat flux have the best agreement with observed values of this flux during the daytime in summer, but perform worse during the winter months. The latter could result from a bias of summer periods in the observational datasets used to derive the relations with net all-wave radiation. Apart from these models, all of the other model categories considered in the analysis result in a mean net storage heat flux that is close to zero throughout the seasonal cycle, which is not seen in the observations. Models with a simple treatment of the physical processes generally perform at least as well as models with greater complexity.

EOF analysis of three records of sea-ice concentration spanning the last 30 years

Several continuous observational datasets of Artic sea-ice concentration are currently available that cover the period since the advent of routine satellite observations. We report on a comparison of three sea-ice concentration datasets. These are the National Ice Center charts, and two passive microwave radiometer datasets derived using different approaches: the NASA team and Bootstrap algorithms. Empirical orthogonal function (EOF) analyses were employed to compare modes of variability and their consistency between the datasets. The analysis was motivated by the need for a reliable, realistic sea ice climatology for use in climate model simulations, for which both the variability and absolute values of extent and concentration are important. We found that, while there are significant discrepancies in absolute concentrations, the major modes of variability derived from all records were essentially the same.

Estimates of aerosol radiative forcing from the MACC re-analysis

The European Centre for Medium-range Weather Forecast (ECMWF) provides an aerosol re-analysis starting from year 2003 for the Monitoring Atmospheric Composition and Climate (MACC) project. The re-analysis assimilates total aerosol optical depth retrieved by the Moderate Resolution Imaging Spectroradiometer (MODIS) to correct for model departures from observed aerosols. The reanalysis therefore combines satellite retrievals with the full spatial coverage of a numerical model. Re-analysed products are used here to estimate the shortwave direct and first indirect radiative forcing of anthropogenic aerosols over the period 2003–2010, using methods previously applied to satellite retrievals of aerosols and clouds. The best estimate of globally-averaged, all-sky direct radiative forcing is −0.7±0.3Wm−2. The standard deviation is obtained by a Monte-Carlo analysis of uncertainties, which accounts for uncertainties in the aerosol anthropogenic fraction, aerosol absorption, and cloudy-sky effects. Further accounting for differences between the present-day natural and pre-industrial aerosols provides a direct radiative forcing estimate of −0.4±0.3Wm−2. The best estimate of globally-averaged, all-sky first indirect radiative forcing is −0.6±0.4Wm−2. Its standard deviation accounts for uncertainties in the aerosol anthropogenic fraction, and in cloud albedo and cloud droplet number concentration susceptibilities to aerosol changes. The distribution of first indirect radiative forcing is asymmetric and is bounded by −0.1 and −2.0Wm−2. In order to decrease uncertainty ranges, better observational constraints on aerosol absorption and sensitivity of cloud droplet number concentrations to aerosol changes are required.