Latitudinal trends in shell production cost from the tropics to the poles.

The proportion of body mass devoted to skeleton in marine invertebrates decreases along latitudinal gradients from large proportions in the tropics to small proportions in polar regions. A historical hypothesis-that latitudinal differences in shell production costs explain these trends-remains untested. Using field-collected specimens spanning a 79°N to 68°S latitudinal gradient (16,300 km), we conducted a taxonomically controlled evaluation of energetic costs of shell production as a proportion of the total energy budget in mollusks. Shell production cost was fairly low across latitudes at <10% of the energy budget and predominately <5% in gastropods and <4% in bivalves. Throughout life, shell cost tended to be lower in tropical species and increased slightly toward the poles. However, shell cost also varied with life stage, with the greatest costs found in young tropical gastropods. Low shell production costs on the energy budget suggest that shell cost may play only a small role in influencing proportional skeleton size gradients across latitudes relative to other ecological factors, such as predation in present-day oceans. However, any increase in the cost of calcium carbonate (CaCO3) deposition, including from ocean acidification, may lead to a projected ~50 to 70% increase in the proportion of the total energy budget required for shell production for a doubling of the CaCO3 deposition cost. Changes in energy budget allocation to shell cost would likely alter ecological trade-offs between calcification and other drivers, such as predation, in marine ecosystems.

Evaluation of an analytic linear Boltzmann transport equation solver for high-density inhomogeneities.

PURPOSE: Acuros external beam (Acuros XB) is a novel dose calculation algorithm implemented through the ECLIPSE treatment planning system. The algorithm finds a deterministic solution to the linear Boltzmann transport equation, the same equation commonly solved stochastically by Monte Carlo methods. This work is an evaluation of Acuros XB, by comparison with Monte Carlo, for dose calculation applications involving high-density materials. Existing non-Monte Carlo clinical dose calculation algorithms, such as the analytic anisotropic algorithm (AAA), do not accurately model dose perturbations due to increased electron scatter within high-density volumes. METHODS: Acuros XB, AAA, and EGSnrc based Monte Carlo are used to calculate dose distributions from 18 MV and 6 MV photon beams delivered to a cubic water phantom containing a rectangular high density (4.0-8.0 g/cm(3)) volume at its center. The algorithms are also used to recalculate a clinical prostate treatment plan involving a unilateral hip prosthesis, originally evaluated using AAA. These results are compared graphically and numerically using gamma-index analysis. Radio-chromic film measurements are presented to augment Monte Carlo and Acuros XB dose perturbation data. RESULTS: Using a 2% and 1 mm gamma-analysis, between 91.3% and 96.8% of Acuros XB dose voxels containing greater than 50% the normalized dose were in agreement with Monte Carlo data for virtual phantoms involving 18 MV and 6 MV photons, stainless steel and titanium alloy implants and for on-axis and oblique field delivery. A similar gamma-analysis of AAA against Monte Carlo data showed between 80.8% and 87.3% agreement. Comparing Acuros XB and AAA evaluations of a clinical prostate patient plan involving a unilateral hip prosthesis, Acuros XB showed good overall agreement with Monte Carlo while AAA underestimated dose on the upstream medial surface of the prosthesis due to electron scatter from the high-density material. Film measurements support the dose perturbations demonstrated by Monte Carlo and Acuros XB data. CONCLUSIONS: Acuros XB is shown to perform as well as Monte Carlo methods and better than existing clinical algorithms for dose calculations involving high-density volumes.

Determining water sensitive urban design project benefits using a multi-criteria assessment tool.

The integration of urban water cycle management with urban planning and design is referred to as 'Water Sensitive Urban Design' or 'WSUD' in Australia; one of the key elements of WSUD is the management of urban stormwater. In early 2006, the Victorian Government released the Yarra River Action Plan, which allocated $20 million towards tackling urban stormwater pollution. To help ensure this money is allocated in an equitable and transparent manner across all metropolitan local governments a multi-criteria assessment tool has been developed. This paper presents an overview of the multi-criteria assessment tool developed and adopted for selecting WSUD projects that are eligible for funding through Melbourne Water's Stormwater Program. This tool considers three types of indicators: environmental, engagement (engagement with stakeholders and local government capacity building) and financial. Within each category, a series of indicators of different weightings are applied to score a project. Where initial concept designs do not meet the Program criteria, additional work is undertaken to refine and improve the project. The tool and its use are illustrated with a case study.

Energetic cost of synthesizing proteins in Antarctic limpet, Nacella concinna (Strebel, 1908), is not temperature dependent.

The energetic cost of protein synthesis is thought to account for a significant proportion of total metabolism. However, attempts to estimate the energetic cost of synthesizing proteins have resulted in surprisingly variable results, particularly for the small number of polar organisms studied, where cost estimates vary by two orders of magnitude. Much of this variability is probably the result of differing methodologies and experimental designs. Here we have used two different, carefully validated methods to measure the costs of protein synthesis in Antarctic limpets. One method, which utilized a specific protein synthesis inhibitor, was used to measure the cost of protein synthesis at two temperatures to test the hypothesis that the cost of protein synthesis varies with temperature. The cost of protein synthesis measured using the inhibitor cycloheximide was 13.95 +/- 0.77 micromol O2/mg protein, while correlation of absolute protein synthesis with oxygen consumption suggested the cost of protein synthesis was 19.58 micromol O2/mg protein. Water temperature did not alter the cost of protein synthesis in Nacella concinna (Student's t-test, P = 0.849, t = 0.19, df = 12). In a meta-analysis of literature values for the cost of protein synthesis there was no significant effect of temperature, but there was a significant relationship between the concentration of cycloheximide used to inhibit protein synthesis and the measured cost.

Children’s health and the environment in Europe: a baseline assessment

This publication gives an overview of the establishment of an environment and health information system in Europe, whose aim is to provide up-to-date and reliable information about public health and the environment as well as the outcomes of methodological work. It presents information on the scientific basis, framework and scope of the system together with plans for future developments. The system’s main product is an indicator-based assessment of children’s health and the environment in the WHO European Region in the context of the Children’s Environment and Health Action Plan for Europe. This assessment provides a baseline against which the progress and effects of action taken can be evaluated at the Fifth Ministerial Conference on Environment and Health scheduled for 2009. Targeted at policy-makers, public health professionals, epidemiologists and environmental science professionals, this publication offers a basis for action to prevent diseases and promote healthy environments.

Computer-assisted total knee replacement. A controlled cadaver study using a multi-parameter quantitative CT assessment of alignment (the Perth CT Protocol).

A controlled study, comparing computer- and conventional jig-assisted total knee replacement in six cadavers is presented. In order to provide a quantitative assessment of the alignment of the replacements, a CT-based technique which measures seven parameters of alignment has been devised and used. In this a multi-slice CT machine scanned in 2.5 mm slices from the acetabular roof to the dome of the talus with the subject's legs held in a standard position. The mechanical and anatomical axes were identified, from three-dimensional landmarks, in both anteroposterior and lateral planes. The coronal and sagittal alignment of the prosthesis was then measured against the axes. The rotation of the femoral component was measured relative to the transepicondylar axis. The rotation of the tibial component was measured with reference to the posterior tibial condyles and the tibial tuberosity. Coupled femorotibial rotational alignment was assessed by superimposition of the femoral and tibial axial images. The radiation dose was 2.7 mSV. The computer-assisted total knee replacements showed better alignment in rotation and flexion of the femoral component, the posterior slope of the tibial component and in the matching of the femoral and tibial components in rotation. Differences were statistically significant and of a magnitude that support extension of computer assistance to the clinical situation.

Validity of subjective global assessment as a nutritional marker in end-stage renal disease.

Subjective global assessment (SGA) is a widely available clinical tool established to be of prognostic value in patients with end-stage renal disease (ESRD). Although it is reported to reflect a patient's nutritional status, its direct relationship to nutrition has not been determined. The aim of this study is to compare SGA with the gold standard for nutrition, total-body nitrogen (TBN) level, and thus determine the validity of SGA as a marker of nutritional status in patients with ESRD. Seventy-six consecutive dialysis patients referred from the renal service for routine measurement of TBN underwent simultaneous assessment of SGA determined by two independent examiners. Both examiners were blinded to TBN results. Only a moderate level of agreement was found in SGA score between the two examiners (weighted kappa score, 0.6). When patients were stratified into three nutritional groups determined by their SGA score, mean TBN values for each group by observer differed significantly (P = 0.0008 and P = 0.02, respectively). However, a significant statistical trend of worsening nutrition across SGA strata was found only for observer 2 (P = 0.049). Test performance of SGA as a predictor of malnutrition using a cutoff score of B (SGA = B or C) or C (SGA = C) was poor (positive likelihood ratios [LRs], 0.7 to 2.3; negative LRs, 0.5 to 1.0). Therefore, SGA appears not to improve the posttest probability of detecting malnutrition. SGA may differentiate severely malnourished patients from those with normal nutrition, but is not a reliable predictor of degree of malnutrition.

Re-validation and shortening of the Functional Assessment of Anorexia/Cachexia Therapy (FAACT) questionnaire.

PURPOSE: The original Functional Assessment of Anorexia/Cachexia Therapy (FAACT) was designed to measure general aspects of quality of life (QOL) as well as specific anorexia/cachexia-related concerns. Our primary purpose was to reduce the number of anorexia/cachexia subscale items in a manner that either retains or improves reliability, validity and precision. METHODS: The FAACT was administered using an interactive computer program that allowed immediate entry of the data. A total of 213 patients were recruited. RESULTS: A combined empirical and conceptual approach led to the reduction of the anorexia/cachexia subscale (A/CS) from 18 to 12 items. A 26-item trial outcome index (TOI) combining physical well-being (PWB), functional well-being (FWB), and the A/CS-12 was highly reliable and sensitive to change in performance status rating (PSR). We found that PWB, FWB, and A/CS-12 subscales performed differently. Specifically, PWB and FWB scores decreased in patients whose (PSR) worsened. However, although A/CS-12 scores were responsive to change in PSR over time, average A/CS-12 scores of all patients, even those whose PSR worsened, improved over the course of treatment. CONCLUSIONS: Elimination of six items from the anorexia/cachexia subscale of the FAACT was accomplished without loss of internal consistency or sensitivity to change in performance status. The A/CS-12 subscale provides unique, important information not captured by a generic chronic illness questionnaire.

Reliability and validity of the Functional Assessment of Cancer Therapy-Breast quality-of-life instrument.

PURPOSE: This is the first published report on the validation of the Functional Assessment of Cancer Therapy-Breast (FACT-B), a 44-item self-report instrument designed to measure multidimensional quality of life (QL) in patients with breast cancer. The FACT-B consists of the FACT-General (FACT-G) plus the Breast Cancer Subscale (BCS), which complements the general scale with items specific to QL in breast cancer. The FACT-B was developed with an emphasis on patients' values and brevity and is available in nine languages. METHODS AND RESULTS: Two validation samples were used for this report. The first (n = 47) was tested twice over a 2-month period to assess sensitivity to change. Significant sensitivity to change in performance status rating (PSR) was demonstrated for the FACT-B total score, the Physical Well-Being (PWB) subscale, the Functional Well-Being (FWB) subscale, and the BCS. Sensitivity to change in QL as measured by the Functional Living Index-Cancer (FLIC) was documented in the FACT-B total score, PWB, FWB, and Emotional Well-Being (EWB). Additional validity and reliability data were obtained from a larger sample (n = 295). The alpha coefficient (internal consistency) for the FACT-B total score was high (alpha = .90), with subscale alpha coefficients ranging from .63 to .86. Evidence supported test-retest reliability, as well as convergent, divergent, and known groups validity. CONCLUSION: The FACT-B is appropriate for use in oncology clinical trials, as well as in clinical practice. It demonstrates ease of administration, brevity, reliability, validity, and sensitivity to change.

Validation of the functional assessment of multiple sclerosis quality of life instrument.

Based on scientific literature and interviews with clinicians and patients, we developed a quality of life instrument for use with people with MS called the Functional Assessment of Multiple Sclerosis (FAMS). The initial item pool consisted of 88 questions: 28 from the general version of the Functional Assessment of Cancer Therapy quality of life instrument, plus 60 generated by patients, providers, and literature review. The validation samples comprised a mail survey cohort (N = 377) and a clinical cohort (N = 56). Both cohorts provides evidence for internal consistency of the derived subscales, test-retest reliability, content validity, concurrent validity, and construct validity. Principal components and Rasch measurement model analyses were applied sequentially to survey sample data, reducing test length to 44 questions, divided into six subscales: mobility, symptoms, emotional well-being (depression), general contentment, thinking/fatigue, and family/social well-being. Fifteen initially rejected questions were added back as miscellaneous (unscored) questions for their potential clinical and empirical value. The mobility subscale was strongly predictive of the Kurtzke Extended Disability Status Scale and the Scripps Neurologic Rating Scales. The other five subscales were not, indicating they measure aspects of patient quality of life not captured by the neurologic exam. The final 59-item English language instrument (FAMS version 2) is available for inclusion in clinical trials and clinical practice.

Haemophilia care in Zimbabwe.

OBJECTIVE: To review haemophilia care in Zimbabwe. DESIGN: Retrospective study. SETTING: Cases seen in both central hospitals and health centres in Harare. MAIN OUTCOME MEASURES: Home treatment hospital admission and HIV seroconversion. RESULTS: Of the expected 500 haemophilicacs in a Zimbabwean male population of five million, only 190 had been registered by mid 1993. Home treatment is effective. CONCLUSION: Haemophilia care in Zimbabwe has a good foundation. Home care is effective and needs to be expanded simultaneously with health education for the cases.

PIP: A retrospective study was conducted to evaluate the status of hemophilia care in Zimbabwe. Parirenyatwa Hospital in Harare has the only hemophilia clinic in Zimbabwe. This monthly clinic facilitates diagnosis, registration, and long-term management of hemophilia. In mid 1993, there were 190 registered hemophilia cases in Zimbabwe. During 1991-1993, only 70 patients were seen more than once in the clinic. The National Blood Transfusion Service (NTSB) supplies blood products for hemophiliacs. Solvent-detergent treated Factor VIII and IX (FVIII and FIX, respectively) concentrates are imported from South Africa. They are the most common blood products used in Harare. Laboratory staff screen fresh frozen plasma and cryoprecipitate for HIV antibody and hepatitis B surface antigen. Five NTSB branches also distribute blood products. Blood products are expensive. Most hemophiliacs are covered by a social welfare program. 45 hemophiliac cases had been receiving home care since 1987. 67% of 24 home care patients receiving FVIII did not store FVIII packs in a refrigerator. Most home care patients injected blood products 0-6 hours from onset of symptoms (e.g., nosebleed). About 33% did not know how to calculate the dose required. All home care patients were satisfied with treatment. In 1992, Parirenyatwa Hospital registered 3 deaths of hemophiliacs. When considering only the 70 regular clinic attenders, the mortality rate for 1992 was 5.7%. Of the 73 hemophiliac cases tested for HIV infection, 32% tested positive. All HIV-positive hemophiliac cases began treatment for hemophilia before 1986, the year before HIV testing of hemophiliacs started. So far, about 33% of hemophiliacs tested positive for hepatitis C. The only social support system for hemophiliacs is the Zimbabwe Hemophilia Association. None of the 38 hemophiliacs screened for coagulation factor inhibitors had any inhibitors. Hemophilia care in Zimbabwe has a good start and can be used as a model for other developing countries. Expansion and close supervision of the effective home treatment program is advised.

The Bristol-Myers Anorexia/Cachexia Recovery Instrument (BACRI): a brief assessment of patients' subjective response to treatment for anorexia/cachexia.

A brief visual analogue instrument was developed and tested in the context of a multicentre randomized double-blinded four-dose trial of megestrol acetate for the treatment of AIDS-related anorexia/cachexia. This nine-item instrument, the Bristol-Myers Anorexia/Cachexia Recovery Instrument (BACRI), was administered every 4 weeks after initiation of study drug (placebo vs 100 mg, 400 mg or 800 mg of drug). The purpose of the instrument was to quantify patient perception of benefit in areas such as decreased concern over weight, decreased concern over appearance, increased pleasure in eating and increase in global perception of quality of life. Post-trial psychometric evaluation of the instrument strongly supported the use of a seven-item index of subjective recovery from symptoms of anorexia/cachexia (BACRI-7) and a single criterion item depicting patient perception of benefit (BACRI-1). The BACRI-7 and BACRI-1 scales showed significant improvement over 12 weeks in patients who received higher dose active drug (400 and 800 mg) compared with the placebo and 100 mg doses. Further differentiation of 400 vs 800 mg arms was seen in the BACRI-7 results, consistent with dose-response improvements in weight and lean body mass changes. Quadratic trends over time in lean body mass change and provider-rated appetite grade suggested peak therapeutic effect at 8 weeks for these endpoints, whereas the absence of these trends in overall weight and patient-reported BACRI scores suggested that these benefits are more persistent. Although subjective (patient-reported) benefit is strongly associated with objective indicators of improvement, there remains the possibility that there is some added, independent benefit of megestrol acetate to subjective well-being.

Reliability and validity of the Functional Assessment of Cancer Therapy-Lung (FACT-L) quality of life instrument.

The FACT-L (version 3) is a 44-item self-report instrument which measures multidimensional quality of life. Available in eight languages, it is currently being used in several Phase II and III lung cancer clinical trials. Reliability and validity of the 33-item version 2 of the FACT-General (FACT-G) have previously been published. This paper reports further validation data on the FACT-G with a subsample of lung cancer patients from the original publication and, more importantly, presents data on the Lung Cancer Subscale (LCS). The nine LCS questions were administered along with the FACT-G to 116 patients with lung cancer. Internal consistency (coefficient alpha) was improved from 0.53 to 0.68 by dropping two questions which were uncorrelated with the others. A subset of 41 patients was tested again at 2 months to evaluate sensitivity to change in performance status rating (PSR) and to obtain estimates of a clinically meaningful change score for the FACT-G and the 7-item LCS. Using a linear test for trend, sensitivity to change in performance status rating (PSR) was obtained with the Total score (P = 0.03), the Physical Well Being (PWB) subscale (P = 0.02), the Functional Well Being (FWB) subscale (P = 0.05), and the LCS (P = 0.03). A 21-item Trial Outcome Index (TOI), combining scores on PWB, FWB and LCS, was highly reliable (coefficient a = 0.89) and sensitive to change in PSR F(1,38) = 4.84 (P = 0.01). This TOI is probably the most relevant and precise indicator of patient-reported quality of life available for lung cancer patients who complete the FACT-L while participating in an oncology clinical trial. The FACT-L may also be of benefit in evaluating quality of life in patients with lung diseases other than cancer.

Family medicine residency programs. Evaluating the need for different third-year programs.

We asked hospital chief executive officers (CEOs) and District Health Council executive directors (DHCs) to compare third-year family medicine residency programs and judge which are more needed in their communities. Care for the elderly and emergency medicine ranked highest among CEOs, while DHCs ranked care for the elderly and mental health highest. Academic family medicine and northern programs ranked lowest for both groups.

Demographic characteristics of full-time emergency physicians in Canada.

The objective of this study was to describe individual and practice characteristics of Canadian emergency physicians, and to determine if these characteristics varied with geographic region, type of certification, or method of reimbursement. The study took place in emergency departments across Canada, and all full-time physicians with certification in emergency medicine, and a random sample of Canadian Association of Emergency Physician members without certification were surveyed with a 23-item questionnaire. Descriptive statistics on individual and practice characteristics were outcome measures. Comparative statistics evaluating demographic characteristics by region, type of certification, and method of reimbursement were used. There were significant differences between responders and nonresponders based on certification (P < .001) and region of residence (P < .005). Most physicians are male (87.3%), married (83.3%), reimbursed on a fee for service basis (61%), work in teaching hospitals (65.8%), and participate in medical education (82.3%). On average physicians are 38 years of age, work of 14 shifts/month, 9 hours/shift, 11 nonclinical emergency related hours/week, and have 5 vacation weeks/year. More physicians with FRCP(EM) certification work in teaching hospitals (P < .00001), do nonclinical emergency related work (P < .0001), participate in medical education (P < .0001), and are involved in research (P < .001). There are significant differences by geographic region in gross annual salary (P < .00001), method of reimbursement (P < .00001), and independent hospital emergency department status (P < .00001). Fee-for-service reimbursement for clinical service provides a higher gross annual income than other methods (P = .028). Emergency medicine is an emerging clinical discipline with a strong academic focus.(ABSTRACT TRUNCATED AT 250 WORDS)

Advanced prostate cancer. The role of high priced hormone therapy.

OBJECTIVE: To compare the costs of the various options presently available in Australia for treatment of advanced prostatic carcinoma by androgen deprivation. DESIGN: Forty patients underwent a bilateral orchidectomy for prostatic carcinoma during the 1990/91 financial year at the Princess Alexandra Hospital, Brisbane. The Yale Cost Model, as adapted for use in Australian case-mix projects, was used to derive a diagnosis related group (DRG) cost for this procedure. This was compared with the projected cost that would be incurred in treating patients with the various medical alternatives. To enable comparison, expenses were calculated assuming a mean duration of survival of two years. RESULTS: The average cost of a bilateral orchidectomy was $2869. This compared to $11,253 for goserelin and $12,329 for cyproterone acetate when used alone in treating a single patient. Flutamide is presently only approved for combination therapy with a luteinising hormone-releasing hormone agonist, and when used with goserelin an average cost of $16,148 per patient was projected. CONCLUSIONS: Bilateral orchidectomy is clearly the cheapest means of hormone manipulation for prostatic carcinoma. Unless the costs of alternative therapies are drastically reduced in Australia, their use is difficult to justify in other than exceptional circumstances. We believe their use should be restricted presently to patients who would otherwise require a bilateral orchidectomy and have an anticipated survival of less than six months.

Public opinion and purchasing.

OBJECTIVES: To explore the use of a questionnaire to obtain representative public opinions on health services. To examine residents' priorities, knowledge, and views on the public's role in decision making. DESIGN: Self administered postal questionnaire. POPULATION: Random sample of 1500 residents in Bath District Health Authority, drawn from electoral registers. MAIN OUTCOME MEASURES: Levels of agreement or disagreement with statements provided and degree of importance given to services and aspects of services. RESULTS: 70 questionnaires were returned unopened. Completed questionnaires were returned by 704 (49.2%) of the 1430 remaining residents. Kidney dialysis was thought very important by 559 (87%) respondents and family planning by only 58 (9%). Public priorities did not seem to reflect value for money. Clear information about treatment was rated as very important by 530 (76%) and comfortable waiting areas by 70 (10%). 372 (53%) of respondents said that they would definitely travel to a hospital outside the district to reduce their wait for surgery. Knowledge of the services provided by the authority and the money available to it was poor. 446 (65%) respondents wanted greater public involvement in decision making. CONCLUSIONS: A postal questionnaire can provide useful information about public priorities and perceptions about the services provided. More information about health services and their costs and benefits should be given to the public to assist greater public participation in decision making.

Casemix and costing hospital information program, Brisbane South Regional Health Authority: a preliminary study to determine the emergency department component of DRG costs.

The issue of costs incurred for patients in the Emergency Department who are subsequently admitted was investigated by the authors to determine the significance of costs and to identify which DRGs and clinical specialties are likely to be affected. A theoretical costing study was performed in collaboration with the staff in the Emergency Department for patients admitted through this Department. The Study was a preliminary one with a number of methodological limitations. This paper describes how the costing exercise was performed. The DRGs most likely to be admitted via this route are identified and recommendations for further study are made. The study results identify a number of issues that require resolution prior to the introduction of casemix based funding.