Intervention planning for Antibiotic Review Kit (ARK): a digital and behavioural intervention to safely review and reduce antibiotic prescriptions in acute and general medicine.

BACKGROUND: Hospital antimicrobial stewardship strategies, such as 'Start Smart, Then Focus' in the UK, balance the need for prompt, effective antibiotic treatment with the need to limit antibiotic overuse using 'review and revise'. However, only a minority of review decisions are to stop antibiotics. Research suggests that this is due to both behavioural and organizational factors. OBJECTIVES: To develop and optimize the Antibiotic Review Kit (ARK) intervention. ARK is a complex digital, organizational and behavioural intervention that supports implementation of 'review and revise' to help healthcare professionals safely stop unnecessary antibiotics. METHODS: A theory-, evidence- and person-based approach was used to develop and optimize ARK and its implementation. This was done through iterative stakeholder consultation and in-depth qualitative research with doctors, nurses and pharmacists in UK hospitals. Barriers to and facilitators of the intervention and its implementation, and ways to address them, were identified and then used to inform the intervention's development. RESULTS: A key barrier to stopping antibiotics was reportedly a lack of information about the original prescriber's rationale for and their degree of certainty about the need for antibiotics. An integral component of ARK was the development and optimization of a Decision Aid and its implementation to increase transparency around initial prescribing decisions. CONCLUSIONS: The key output of this research is a digital and behavioural intervention targeting important barriers to stopping antibiotics at review (see http://bsac-vle.com/ark-the-antibiotic-review-kit/ and http://antibioticreviewkit.org.uk/). ARK will be evaluated in a feasibility study and, if successful, a stepped-wedge cluster-randomized controlled trial at acute hospitals across the NHS.

Acid rain and nitrogen deposition in a sub-tropical watershed (Piracicaba): ecosystem consequences.

High levels of wet N and acidic deposition were measured in southeast Brazil. In this study we addressed the sensitivity of water bodies and soils to acidification and N deposition in the Piracicaba River basin (12,400 km2). Average acid neutralization capacity (ANC) at 23 river sampling sites varied from 350 to 1800 microeq l(-1). Therefore, rivers and streams in the Piracicaba basin are well buffered, if the lower limit of 200 microeq l(-1) is assumed as an indication of poorly buffered waters. ANC is increased by untreated wastewaters discarded into rivers and streams of the region. Average NO3 concentrations varied from 20 to 70 microeq l(-1). At the most polluted river sites, NO3 concentration is not highest, however, probably due to NO3 reduction and denitrification. Most of the nitrogen in streams is also provided by wastewaters and not by wet deposition. The majority of the soils in the basin, however, are acidic with a low base cation content and high aluminum concentration. Therefore, soils in this basin are poorly buffered and, in areas of forest over sandy soils, acidification may be a problem.

Control of cation concentrations in stream waters by surface soil processes in an Amazonian watershed.

The chemical composition of ground waters and stream waters is thought to be determined primarily by weathering of parent rock. In relatively young soils such as those occurring in most temperate ecosystems, dissolution of primary minerals by carbonic acid is the predominant weathering pathway that liberates Ca2+, Mg2+ and K+ and generates alkalinity in the hydrosphere. But control of water chemistry in old and highly weathered soils that have lost reservoirs of primary minerals (a common feature of many tropical soils) is less well understood. Here we present soil and water chemistry data from a 10,000-hectare watershed on highly weathered soil in the Brazilian Amazon. Streamwater cation concentrations and alkalinity are positively correlated to each other and to streamwater discharge, suggesting that cations and bicarbonate are mainly flushed from surface soil layers by rainfall rather than being the products of deep soil weathering carried by groundwater flow. These patterns contrast with the seasonal patterns widely recognized in temperate ecosystems with less strongly weathered soils. In this particular watershed, partial forest clearing and burning 30 years previously enriched the soils in cations and so may have increased the observed wet season leaching of cations. Nevertheless, annual inputs and outputs of cations from the watershed are low and nearly balanced, and thus soil cations from forest burning will remain available for forest regrowth over the next few decades. Our observations suggest that increased root and microbial respiration during the wet season generates CO2 that drives cation-bicarbonate leaching, resulting in a biologically mediated process of surface soil exchange controlling the streamwater inputs of cations and alkalinity from these highly weathered soils.

Seasonal variations in water quality of an oxbow lake in response to multiple short-time pulses of flooding (Jataí Ecological Station--Mogi-Guaçu River, Luiz Antonio, SP-Brazil).

Mogi-Guaçu River is a six-order floodplain river in the upper Paraná River Basin, Southern Brazil. Its yearly discharge varies from a minimum of 100 m3.s-1 to a maximum of 600 m3.s-1. Diogo Lake is a shallow lake located at its floodplain within the Jataí Ecological Station (Luiz Antonio, São Paulo State) and is connected throughout the year to the river through a narrow and shallow channel. The main finding of this study is that the river hidrology controls the annual variations in lake hydrochemistry through a series of hydraulic effects related to oscillations in river discharge. Lake water quality is a resultant of differential contribution from local and regional watersheds. During the low water period, lake water quality is determined by inputs from Cafundó Creek, which drains the local watershed into the lake. Raising the river level during the rain season results in the damming of lake and culminates with the entrance of river waters into the plain. The geochemistry of waters in this system is determined by weathering of sandstones with basalt intrusions. Waters are acidic (river pH = 6.00 to 7.02 and stream-lake pH = 5.15 to 6.7) and dominant cations are Na+ and K+. Major anions are almost exclusively represented by bicarbonate and an unknown concentration of organic acid anions. The overall ionic load of these soft waters in the system is therefore very low.

Effect of gangliosides on memory formation of a conditioned avoidance response (CAR).

The influence of ganglioside application on the memory formation of an active conditioned avoidance response in rats was examined. Gangliosides produce retardation of the memory formation if applied immediately after the training session. If an interval of 2 h posttraining was used this effect was not observed.

[Effect of gangliosides on learning a conditioned flight reaction in rats on the shuttle box]. / Einfluss von Gangliosiden auf das Erlernen einer bedingten Fluchtreaktion der Ratte an der Shuttle-Box.

The influence of ganglioside application on active conditioning avoidance response in rats was examined. Gangliosides produce an improvement of the acquisition of the conditioning avoidance response without an influence on the retention.