General Practitioner Antimicrobial Stewardship Programme Study (GAPS): protocol for a cluster randomised controlled trial

Background There is a strong link between antibiotic consumption and the rate of antibiotic resistance. In Australia, the vast majority of antibiotics are prescribed by general practitioners, and the most common indication is for acute respiratory infections. The aim of this study is to assess if implementing a package of integrated, multifaceted interventions reduces antibiotic prescribing for acute respiratory infections in general practice. Methods/design This is a cluster randomised trial comparing two parallel groups of general practitioners in 28 urban general practices in Queensland, Australia: 14 intervention and 14 control practices. The protocol was peer-reviewed by content experts who were nominated by the funding organization. This study evaluates an integrated, multifaceted evidence-based package of interventions implemented over a six month period. The included interventions, which have previously been demonstrated to be effective at reducing antibiotic prescribing for acute respiratory infections, are: delayed prescribing; patient decision aids; communication training; commitment to a practice prescribing policy for antibiotics; patient information leaflet; and near patient testing with C-reactive protein. In addition, two sub-studies are nested in the main study: (1) point prevalence estimation carriage of bacterial upper respiratory pathogens in practice staff and asymptomatic patients; (2) feasibility of direct measures of antibiotic resistance by nose/throat swabbing. The main outcome data are from Australia’s national health insurance scheme, Medicare, which will be accessed after the completion of the intervention phase. They include the number of antibiotic prescriptions and the number of patient visits per general practitioner for periods before and during the intervention. The incidence of antibiotic prescriptions will be modelled using the numbers of patients as the denominator and seasonal and other factors as explanatory variables. Results will compare the change in prescription rates before and during the intervention in the two groups of practices. Semi-structured interviews will be conducted with the general practitioners and practice staff (practice nurse and/or practice manager) from the intervention practices on conclusion of the intervention phase to assess the feasibility and uptake of the interventions. An economic evaluation will be conducted to estimate the costs of implementing the package, and its cost-effectiveness in terms of cost per unit reduction in prescribing. Discussion The results on the effectiveness, cost-effectiveness, acceptability and feasibility of this package of interventions will inform the policy for any national implementation.

Nonlinear Sliding Mode Control Design for an Air-breathing Engine with State Estimation

A modern system theory based nonlinear control design is discussed in this paper for successful operation of an air-breathing engine operating at supersonic speed. The primary objective of the control design of such an air-breathing engine is to ensure that the engine dynamically produces the thrust that tracks a commanded value of thrust as closely as possible by regulating the fuel flow to the combustion system. However, since the engine operates in the supersonic range, an important secondary objective is to manage the shock wave configuration in the intake section of the engine which is manipulated by varying the throat area of the nozzle. A nonlinear sliding mode control technique has been successfully used to achieve both of the above objectives. In this problem, since the process is faster than the actuators, independent control designs are also carried out for the actuators as well to assure the satisfactory performance of the system. Moreover, to filter out the sensor and process noises and to estimate the states for making the control design operate based on output feedback, an Extended Kalman Filter based state estimation design is also carried out. The promising simulation results suggest that the proposed control design approach is quite successful in obtaining robust performance of the air-breathing engine.

Wegener's granulomatosis in Finland in 1981-2000

Objectives: Wegener s granulomatosis (WG) is a vasculitis with a predilection for the airways and kidneys. An increasing incidence and improved prognosis of WG has been shown. The aim of this study was to evaluate the incidence, clinical presentation, diagnostic delay, risk of dialysis-dependent renal insufficiency and mortality of WG in 1981-2000. Patients and methods: Data was retrieved from the Finnish hospital discharge register and hospital case reports. Patients diagnosed with WG in 1981-2000 were included, and their demographic and clinical data recorded. The patients were crossed with the national kidney dialysis register and the national mortality statistics. Results: A total of 492 patients (243 ♂ , 249 ♀) were diagnosed at a mean age of 54 years (SD 18). The incidence increased from 1.9 to 9.3/ million/ year. The median diagnostic delay decreased from 17 to 4 months. Patients presented most often with symptoms of the ear, nose and throat (ENT) (45%), lung (36%), musculoskeletal system (22%) and kidney (11%). Initial lung involvement, constitutional symptoms, high erythrocyte sedimentation rate (ESR) and high ELK scores [(number of simultaneously involved organ groups (ENT, Lung, Kidney)] were associated with a shorter diagnostic delay. Medical treatment of WG patients remained similar in the 1980s and 1990s. Almost 90% of patients received cyclophosphamide (CYC) and more than 90% glucocorticoid medication at some point during the course of the disease. Eighty-four patients (17%) needed dialysis. Initial renal involvement and elevated serum creatinine values were related to an increased risk of dialysis-dependent kidney disease. In two-thirds of the patients, renal impairment was reversible. Dialysis became chronic (>3 months) in 32 patients (6.5%). Nineteen patients (3.9%) received a kidney transplant. Altogether 203 patients (99 men, 104 women) died before 30 June 2005. WG was the underlying cause of death in 37%. The crude one-year and five-year survival rates were 83.3% and 74.2%, respectively. The standardized mortality ratio was 3.43 (95% CI = 2.98 to 3.94). Older age and elevated creatinine level at diagnosis predicted shorter survival. ENT symptoms at presentation and treatment with CYC were associated with better outcome. There was no additional risk associated with male gender or with either of the decades (1981-1990 and 1991-2000) Conclusions: In 1981-2000, the incidence of WG increased ca. 4.5-fold and diagnostic delay decreased to ca. one-fourth, reflecting increased recognition of the disease and improved diagnostic means. WG patients are at great risk of developing dialysis-dependent renal insufficiency and an increased risk of dying. During the study period the treatment of WG did not change markedly, nor did the prognosis improve.

Snoring and sleep apnea in children

Snoring is a primary and major clinical symptom of upper airway obstruction during sleep. Sleep-disordered breathing ranges from primary snoring to significant partial upper airway obstruction, and obstructive sleep apnea. Adult snoring and obstructive sleep apnea have been extensively studied, whereas less is known about these disorders in children. Snoring and more severe obstructive sleep apnea have been shown to have a harmful effect on the neurobehavioral development of children, but the mechanisms of this effect remains unknown. Furthermore, the correlation of this effect to objective sleep study parameters remains poor. This study evaluated the prevalence of snoring in preschool-aged children in Finland. Host and environmental risk factors, and neurobehavioral and neurocognitive symptoms of children suffering from snoring or obstructive sleep apnea were also investigated. The feasibility of acoustic rhinometry in young children was assessed. The prevalence and risk factors of snoring (I) were evaluated by a questionnaire. The random sample included 2100 children aged 1-6 years living in Helsinki. All 3- to 6-year-old children whose parents reported their child to snore always, often, or sometimes were categorized as snorers, and invited to participate to the clinical study (II-IV). Non-snoring children whose parents were willing to participate in the clinical study were invited to serve as controls. Children underwent a clinical ear-nose-throat examination. Emotional, behavioral, and cognitive performances were evaluated by Child Behavioral Checklist (CBCL), Wechsler Preschool and Primary Scale of Intelligence (WPPSI-R) and NEPSY-A Developmental Neuropsychological Assessment (NEPSY). Nasal volume was measured by acoustic rhinometry, and nasal resistance by rhinomanometry. Lateral and posteroanterior cephalometry were performed. A standard overnight ambulatory polysomnography was performed in the home environment. Twenty-six healthy children were tested in order to assess the feasibility of acoustic rhinometry in young children (V). Snoring was common in children; 6.3% of children snored always or often, whereas 81.3% snored never or occasionally. No differences were apparent between snorers and non-snorers regarding age, or gender. Pediatric snoring was associated with recurrent upper respiratory infections, otitis media, and allergic rhinitis. Exposure to parental tobacco smoke, especially maternal smoking, was more common among snorers. Rhinitis was more common among children who exposured to tobacco smoke. Overnight polysomnography (PSG) was performed on 87 children; 74% showed no signs of significant upper airway obstruction during sleep. Three children had obstructive apnea/hypopnea index (OAHI) greater than 5/h. Age, gender, or a previous adenoidectomy or tonsillectomy did not correlate with OAHI, whereas tonsillar size did correlate with OAHI. Relative body weight and obesity correlated with none of the PSG parameters. In cephalometry, no clear differences or correlations were found in PSG parameters or between snorers and non-snorers. No correlations were observed between acoustic rhinometry, rhinomanometry, and PSG parameters. Psychiatric symptoms were more frequent in the snoring group than in the nonsnoring group. In particular, anxious and depressed symptoms were more prevalent in the snoring group. Snoring children frequently scored lower in language functions. However, PSG parameters correlated poorly with neurocognitive test results in these children. This study and previous studies indicate that snoring without episodes of obstructive apnea or SpO2 desaturations may cause impairment in behavioral and neurocognitive functions. The mechanism of action remains unknown. Exposure to parental tobacco smoke is more common among snorers than non-snorers, emphasizing the importance of a smoke-free environment. Children tolerated acoustic rhinometry measurements well.

Carotid Surgery : A posse ad esse non valet consequentia

According to a large body of evidence, carotid endarterectomy (CEA) can prevent strokes, provided that appropriate inclusion criteria and high-quality perioperative treatment methods are utilised with low complication rates. From the patient s perspective, it is of paramount importance that the operation is as safe and effective as possible. From the community s point of view, it is important that CEA provision prevents as many strokes as possible. In order to define the stroke preventing potential of CEA in different communities, a comparison between eight European countries and Australia was performed including 53 077 carotid interventions. A more detailed evaluation was performed in Finland, the United Kingdom and Egypt. It could be estimated that many potentially preventable strokes occur due to insufficient diagnostics and CEA provision. The number of CEAs should be at least doubled in the Helsinki region. The theoretical power of CEA provision in stroke prevention varied significantly between the countries. Delay from symptom to surgery has been identified as one of the most important factors influencing the effectiveness of CEA. In 2008 only 11% of CEAs in Helsinki university central hospital (HUCH) were performed within the recommended14 days. Registered data of 673 CEAs in HUCH during 2000-2005 was analyzed. There was no systematic error that would have changed the outcome analysis. However it is important that registers are audited regularly and cross matching of different registries is possible. A previously unpublished method of combining medial mandibulotomy, neck incision and carotid artery interposition was carried out as a collaboration of maxillofacial, ear, nose and throat and vascular surgeons. Five patients were operated on with a technique that was feasible and possible to perform with little morbidity, but due to the significant risks involved, this technique should be reserved for carefully selected cases. In stroke prevention, organisational decisions seem far more important than details in interventional procedures when CEA is performed with low complication rates, as was the case in the present study. A TIA clinic approach with close co-operation between the on-call vascular surgeons, neurologists and radiologists should be available at all centres treating these patients. Patients should have a direct and fast admission to the hospital performing CEA.

Bubble size measurement in a gas-liquid ejector for a sodium chloride-air system

A high speed photographic technique has been employed to measure the Sauter mean diameter of bubbles experimentally in a gas liquid ejector using a sodium chloride-air system. The measured values are compared with the theoretically predicted maximum bubble size diameter using Sprow's correlation. Bubble size as a function of the liquid flow rate and also of its distance from the throat of the ejector has been reported in this paper. The results obtained for this non-reactive system are also compared with those obtained earlier for the air-water system.

Towards the concept of hydrodynamic cavitation control

A careful study of the existing literature available in the field of cavitation reveals the potential of ultrasonics as a tool for controlling and, if possible, eliminating certain types of hydrodynamic cavitation through the manipulation of nuclei size present in a flow. A glass venturi is taken to be an ideal device to study the cavitation phenomenon at its throat and its potential control. A piezoelectric transducer, driven at the crystal resonant frequency, is used to generate an acoustic pressure field and is termed an �ultrasonic nuclei manipulator (UNM)�. Electrolysis bubbles serve as artificial nuclei to produce travelling bubble cavitation at the venturi throat in the absence of a UNM but this cavitation is completely eliminated when a UNM is operative. This is made possible because the nuclei, which pass through the acoustic field first, cavitate, collapse violently and perhaps fragment and go into dissolution before reaching the venturi throat. Thus, the potential nuclei for travelling bubble cavitation at the venturi throat seem to be systematically destroyed through acoustic cavitation near the UNM. From the solution to the bubble dynamics equation, it has been shown that the potential energy of a bubble at its maximum radius due to an acoustic field is negligible compared to that for the hydrodynamic field. Hence, even though the control of hydrodynamic macro cavitation achieved in this way is at the expense of acoustic micro cavitation, it can still be considered to be a significant gain. These are some of the first results in this direction.

Recombination Drives Genetic Diversification of Streptococcus dysgalactiae Subspecies equisimilis in a Region of Streptococcal Endemicity

Infection of the skin or throat by Streptococcus dysgalactiae subspecies equisimilis (SDSE) may result in a number of human diseases. To understand mechanisms that give rise to new genetic variants in this species, we used multi-locus sequence typing (MLST) to characterise relationships in the SDSE population from India, a country where streptococcal disease is endemic. The study revealed Indian SDSE isolates have sequence types (STs) predominantly different to those reported from other regions of the world. Emm-ST combinations in India are also largely unique. Split decomposition analysis, the presence of emm-types in unrelated clonal complexes, and analysis of phylogenetic trees based on concatenated sequences all reveal an extensive history of recombination within the population. The ratio of recombination to mutation (r/m) events (11:1) and per site r/m ratio (41:1) in this population is twice as high as reported for SDSE from non-endemic regions. Recombination involving the emm-gene is also more frequent than recombination involving housekeeping genes, consistent with diversification of M proteins offering selective advantages to the pathogen. Our data demonstrate that genetic recombination in endemic regions is more frequent than non-endemic regions, and gives rise to novel local SDSE variants, some of which may have increased fitness or pathogenic potential.

A new species of Raorchestes (Amphibia: Anura: Rhacophoridae) from mid-elevation evergreen forests of the southern Western Ghats, India

A new species of the shrub frog genus Raorchestes Biju, Souche, Dubois, Dutta and Bossuyt is described as Raorchestes kakachi sp. nov. from Agastyamalai hill region in the southern Western Ghats, India. The small sized Raorchestes (male: 24.7–25.8 mm, n = 3 and female: 24.3–34.1 mm, n = 3) is distinguished from all other known congeners by the following suite of characters. Snout oval in dorsal view; tympanum indistinct; head wider than long; moderate webbing in feet; colour on dorsum varying from ivory to brown, blotches of dark brown on flanks, brown mottling on throat reducing towards vent; inner and outer surface of thigh, inner surface of shank and inner surface of tarsus with a distinct dark brown horizontal band which extends upto first three toes on upper surface. A detailed description, advertisement call features, ecology, natural history notes and comparison with closely related species are provided for the new species.

Virus-sized colloid transport in a single pore: Model development and sensitivity analysis

A mathematical model is developed to simulate the transport and deposition of virus-sized colloids in a cylindrical pore throat considering various processes such as advection, diffusion, colloid-collector surface interactions and hydrodynamic wall effects. The pore space is divided into three different regions, namely, bulk, diffusion and potential regions, based on the dominant processes acting in each of these regions. In the bulk region, colloid transport is governed by advection and diffusion whereas in the diffusion region, colloid mobility due to diffusion is retarded by hydrodynamic wall effects. Colloid-collector interaction forces dominate the transport in the potential region where colloid deposition occurs. The governing equations are non-dimensionalized and solved numerically. A sensitivity analysis indicates that the virus-sized colloid transport and deposition is significantly affected by various pore-scale parameters such as the surface potentials on colloid and collector, ionic strength of the solution, flow velocity, pore size and colloid size. The adsorbed concentration and hence, the favorability of the surface for adsorption increases with: (i) decreasing magnitude and ratio of surface potentials on colloid and collector, (ii) increasing ionic strength and (iii) increasing pore radius. The adsorbed concentration increases with increasing Pe, reaching a maximum value at Pe = 0.1 and then decreases thereafter. Also, the colloid size significantly affects particle deposition with the adsorbed concentration increasing with increasing particle radius, reaching a maximum value at a particle radius of 100 nm and then decreasing with increasing radius. System hydrodynamics is found to have a greater effect on larger particles than on smaller ones. The secondary minimum contribution to particle deposition has been found to increase as the favorability of the surface for adsorption decreases. The sensitivity of the model to a given parameter will be high if the conditions are favorable for adsorption. The results agree qualitatively with the column-scale experimental observations available in the literature. The current model forms the building block in upscaling colloid transport from pore scale to Darcy scale using Pore-Network Modeling. (C) 2014 Elsevier By. All rights reserved.

Charge Transfer Induces Formation of Stimuli-Responsive, Chiral, Cohesive Vesicles-on-a-String that Eventually Turn into a Hydrogel

A charge transfer (CT) mediated two-component, multistimuli responsive supergelation involving a L-histidine-appended pyrenyl derivative (PyHisOMe) as a donor and an asymmetric bolaamphiphilic naphthalene-diimide (Asym-NDI) derivative as an acceptor in a 2: 1 mixture of H2O/MeOH was investigated. Asym-NDI alone self-assembled into pH-responsive vesicular nanostructures in water. Excellent selectivity in CT gel formation was achieved in terms of choosing amino acid appended pyrenyl donor scaffolds. Circular di-chroism and morphological studies suggested formation of chiral, interconnected vesicular assemblies resembling ``pearls-on-a-string'' from these CT mixed stacks. XRD studies revealed the formation of monolayer lipid membranes from these CT mixed stacks that eventually led to the formation of individual vesicles. Strong cohesive forces among the interconnected vesicles originate from the protrusion of the oxyethylene chains from the surfaces of the chiral vesicles.

Nonlinear control of an air-breathing engine including its validation with vehicle guidance

An implementable nonlinear control design approach is presented for a supersonic air-breathing ramjet engine. The primary objective is to ensure that the thrust generated by the engine tracks the commanded thrust without violating the operational constraints. An important constraint is to manage the shock wave location in the intake so that it neither gets detached nor gets too much inside the intake. Both the objectives are achieved by regulating the fuel flow to the combustion chamber and by varying the throat area of the nozzle simultaneously. The design approach accounts for the nonlinear cross-coupling effects and nullifies those. Also, an extended Kalman filter has been used to filter out the sensor and process noises as well as to make the states available for feedback. Furthermore, independent control design has been carried out for the actuators. To test the performance of the engine for a realistic flight trajectory, a representative trajectory is generated through a trajectory optimization process, which is augmented with a newly-developed finite-time state dependent Riccati equation technique for nullifying the perturbations online. Satisfactory overall performance has been obtained during both climb and cruise phases. (C) 2015 Elsevier Masson SAS. All rights reserved.

Characteristics of Micronozzle Gas Flows

The fluid characteristics of gas flows in the micronozzle whose throat height is 20 μm were investigated by the direct simulation Monte Carlo (DSMC) method. In a series of cases, the dependence of mass flux on the pressure difference was gained, and the DSMC's results show good agreement with the experimental data. The comparison of mass flux and the Mach number contours between the DSMC and Navier-Stokes equations adding slip boundary also reveals quantitatively that the continuum model will be invalid gradually even when the average Knudsen number is smaller than 0.01. As one focus of the present paper, the phenomenon of the multiple expansion-compression waves that comes from the nozzle's divergent part was analyzed in detailed.

Estado forestal del Pinus caribaea Morelet var. Hondurensis en el Pinal, Laguna de Perlas, RAAS

Tbe present study was carried out in the strip of land coast between Pearls Lagoon community and the Caribbean sea, in the nearness of Pinar lagoon, 25 km to the north of Bluefields. The geographical coordinates of the area are 12" 13' N and 83" 42' west. Tbe climate presents an annua! rninfall of 4 250 mm, an avera· ge temperature of 26 "C and a relative humidity of 89 %. The topography is plain and tbe elevation oscillates between O· 10 masl. The ma.in objective of the study was to evaluate the forest conditions in which forest of P. Caribaea var .. Jwndurei'ISis ealled the Pinal are found. The methodology employed consisted of gathering all information using air pllotographs and topograpbieal maps to defined the area and stands group (designed A, B, C, D, E, F and G). Two block and seven stands were found, in which invent.ory lines with sample plots of 500 m1 each one were employed to measure the indivíduals with DBH over 10 cm. The intensily it shows ís of !5% and was measured diameter, height, age and other. In tbis forest there where found seven stands with a total area covered with pine of 312.42 has. The average age is 23 years and estirnated total volume of 97.4 ms of wood. The density is of 60,61 trees hectare, with an average volume of 13.02 m3 /has and a commercial volume of 8.29 m' 1 has. Where found lndices of place 12 (stands G), 9 y 6. Besides, the 6.3.64 % of the trees has a satisfactory tendency of growlh (quality l and 2). lt can be concluded that the resource is in badly state due to intensive exploitations and annual f!fCS; is a young forest (23 years old), dotninated by índi viduals of small diameters (10-25 cm) and medium height (5-25 m); the available areas or with possibilities of being planting are: estimated in 468.64 has. This forest has a half annual increment of 1.4.3 cm/year, which is considered excellent and is c1assified with Clas P-III, FAO Classification by forests stratification.

Catalytic Cracking and Heat Sink Capacity of Aviation Kerosene Under Supercritical Conditions

Catalytic cracking of China no. 3 aviation kerosene using a zeolite catalyst was investigated under supercritical conditions. A three-stage heating/cracking system was specially designed to be capable of heating 0.8 kg kerosene to a temperature of 1050 K and pressure of 7.0 MPa with maximum mass flow rate of 80 g/s. Sonic nozzles of different diameters were used to calibrate and monitor the mass flow rate of the cracked fuel mixture. With proper experiment arrangements, the mass flow rate per unit throat area of the cracked fuel mixture was found to well correlate with the extent of fuel conversion. The gaseous products obtained from fuel cracking under different conditions were also analyzed using gas chromatography. Composition analysis showed that the average molecular weight of the resulting gaseous products and the fuel mass conversion percentage were a strong function of the fuel temperature and were only slightly affected by the fuel pressure. The fuel conversion was also shown to depend on the fuel residence time in the reactor, as expected. Furthermore, the heat sink levels due to sensible heating and endothermic cracking were determined and compared at varying test conditions. It was found that at a fuel temperature of similar to 1050 K, the total heat sink reached similar to 3.4 MJ/kg, in which chemical heat sink accounted for similar to 1.5 MJ/kg.