Managing multifunctional landscapes: Local insights from a Pacific Island Country context.

Across Pacific Island Countries, projects and policies are incorporating objectives related to managing landscape multifunctionality to sustain flows of multiple, valued ecosystem services. Strategies to manage natural resources are often not effective, or do not have intended outcomes, if they do not account for local contexts and the varied needs and constraints of stakeholders who rely upon natural resources for their livelihoods. Through fieldwork in Ba, Fiji, local insights were generated concerning the institutional, geographic, and socio-economic factors which determine and challenge i) different stakeholders' ability to access landscape resources, and ii) stakeholders' capacities to benefit from ecosystem services. The following insights were generated from this research which are important for guiding management of landscape multifunctionality. In Ba, hierarchical governance systems present barriers to effective management of landscape multifunctionality, and projects or policies with aims to manage landscapes should establish context appropriate multi-scale governance. Such governance systems should facilitate communication and interaction between different stakeholders, build upon community knowledge, and support communities as key actors in landscape management. Consideration of the spatial footprint of landscape resources, stakeholders' different physical and financial capacities, and the institutional structures that mediate access to resources should be central to landscape management and planning. Various climatic stressors affect flows of ecosystem services from the Ba landscape and people's capacity to access landscape resources; therefore, it is important that management of landscapes also builds resilience to climate stressors.

Turning down the heat: An enhanced understanding of the relationship between urban vegetation and surface temperature at the city scale.

Guiding urban planners on the cooling returns of different configurations of urban vegetation is important to protect urban dwellers from adverse heat impacts. To this end, we estimated statistical models that fused multi-temporal very fine spatial (20 cm) and vertical (1 mm) resolution imagery, that captures the complexity of urban vegetation, with remotely sensed temperature data to assess how urban vegetation configuration influences urban temperatures. Perth, Western Australia, was used as a case-study for this analysis. Panel regression models showed that within a location an increase in tree and shrub cover has a larger cooling effect than grass coverage. On average, holding all else equal, an approximate 1 km2 increase in shrub (tree) cover within a location reduces surface temperatures by 12 °C (5 °C). We included a range of robustness checks for the observed relationships between urban vegetation type and temperature. Geographically weighted regression models showed spatial variation in the cooling effect of different vegetation types; this indicates that i) unobserved factors moderate temperature-vegetation relationships across urban landscapes, and ii) that urban vegetation type and temperature relationships are complex. Machine learning models (Random Forests) were used to further explore complex and non-linear relationships between different urban vegetation configurations and temperature. The Random Forests showed that vegetation type explained 31.84% of the out-of-bag variance in summer surface temperatures, that increased cover of large vegetation within a location increases cooling, and that different configurations of urban vegetation structure can lead to cooling gains. The models in this study were trained with vegetation data capturing local detail, multiple time-periods, and entire city coverage. Thus, these models illustrate the potential to develop locally-detailed and spatially explicit tools to guide planning of vegetation configuration to optimise cooling at local- and city-scales.

A feasibility study into the use of three-dimensional printer modelling in acetabular fracture surgery.

There are a number of challenges associated with the operative treatment of acetabular fractures. The approach used is often extensive, while operative time and perioperative blood loss can also be significant. With the proliferation of 3D printer technology, we present a fast and economical way to aid the operative planning of complex fractures. We used augmented stereoscopic 3D CT reconstructions to allow for an appreciation of the normal 3D anatomy of the pelvis on the fractured side and to use the models for subsequent intraoperative contouring of pelvic reconstruction plates. This leads to a reduction in the associated soft tissue trauma, reduced intraoperative time and blood loss, minimal handling of the plate, and reduced fluoroscopic screening times. We feel that the use of this technology to customize implants, plates, and the operative procedure to a patient's unique anatomy can only lead to improved outcomes.

The costs and characteristics of occupational injuries admitted to a trauma unit.

Occupational injuries requiring admission to a trauma unit were examined to outline the events surrounding the injury and to examine the costs. Sixty-nine patients were admitted over a 12-month period, representing 4.30% of all work-related injuries attending the emergency department and 4.25% of all admissions to the trauma unit. Most were male (91%), working in skilled trade occupations (65%), with a mean age of 38.8 years. Personal protective equipment was used only by 46% of injured workers who should have been using it. Sixty-one percent of patients believed that their injury was preventable. Half of the injuries were to the upper limb, fall was the most frequent mechanism (25%) and the median duration of admission was 2 days. The direct hospital costs were estimated at over 300000 GBP. Failure to use protective equipment and to follow health and safety guidelines suggests that opportunities exist for injury prevention.

Rehabilitation regimens following surgical repair of extensor tendon injuries of the hand-a systematic review of controlled trials.

There is no consensus on the most effective rehabilitation regimen following extensor tendon repair of the hand. This systematic review evaluates the outcomes of the various regimens. The Cochrane, MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker databases were searched for any prospective randomised clinical trials comparing rehabilitation regimens for acute extensor tendon injuries in adults. Five papers met the inclusion criteria. The regimens were static immobilisation, dynamic splinting and early active motion (EAM). There was no standard format of reporting. The sample size ranged from 27 to 100 patients. The duration of follow-up ranged from 8 to 24 weeks. Overall, patients' total active motion improved with time. Early mobilisation regimens (active and passive) achieve quicker recovery of motion than static immobilisation but the long-term outcome appears similar. Given the comparable outcomes between dynamic splinting and EAM, we therefore favour EAM which is simpler and more convenient.

The differential diagnosis of foot lumps: 101 cases treated surgically in North Glasgow over 4 years.

INTRODUCTION: There are a wide variety of different lesions which present as lumps of the foot. There have been very few studies which look at the presenting characteristics or the differential diagnosis of such lesions. PATIENTS AND METHODS: All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied in order to determine patient demographics, presenting characteristics, diagnoses encountered and to assess the diagnostic accuracy of the surgeon. RESULTS: In total, 101 patients were identified. Average age was 47.3 years (range, 14-79 years); there was a marked female preponderance with 73 females and 28 males. Thirty different histological types were identified; ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the 101 lumps were correctly diagnosed prior to surgery. Certain lesions were more commonly encountered in specific zones of the foot. CONCLUSIONS: We have shown that there are a wide variety of potential diagnoses which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and, therefore, surgical excision and histological diagnosis should be sought if there is any uncertainty.

Improving hand-washing performance - a crossover study of hand-washing in the orthopaedic department.

INTRODUCTION: Effective hand-washing is essential for reducing the spread of infection in hospitals. We aimed to evaluate hand-washing performance of hospital personnel and to determine if this could be improved by education. MATERIALS AND METHODS: A total of 55 personnel working in the orthopaedic department were asked to clean their hands using an alcohol gel containing a clear fluorescent substance. They were unaware of the assessment method. Performance was assessed by examining their hands under UV light to identify areas that had been neglected. Subjects could visualise which areas they had missed and were then educated regarding hand-washing technique and retested after 7 days. RESULTS: Of the 55 subjects, 53 completed the study. Individual performance varied widely. Following a simple educational intervention, 49 out of 53 subjects improved from an average of 7.8% to 2.3% area missed (P < 0.001). CONCLUSIONS: We suggest that hand-washing effectiveness needs to be improved and that a simple educational intervention can be effective.

One plunge or two?--hand disinfection with alcohol gel.

OBJECTIVE: To compare health care workers' hand surface coverage using two different volumes of alcohol gel for hand disinfection. PARTICIPANTS: and methods. A total of 84 members of staff in our hospital were studied. Subjects were asked to disinfect their hands with alcohol gel containing a clear fluorescent substance. Performance was assessed by using UV light to identify areas which had been missed, and the total surface area missed was calculated. A total of 42 subjects received 3.5 ml of alcohol gel, and 42 age-, sex-, and job-matched subjects received 1.75 ml of alcohol gel. RESULTS: Significantly less area was missed when hand disinfecting with double the volume of alcohol gel; 1.23 versus 6.35% surface area was missed (P < 0.001). CONCLUSION: Doubling the volume of alcohol gel used for hand disinfection significantly improves the efficiency of coverage of the hands with alcohol gel. This may result in lower bacterial count on the hands and may reduce the spread of nosocomial infections including that of methicillin-resistant Staphylococcus aureus.

A new skatepark: the impact on the local hospital.

BACKGROUND: There has been a resurgence of skateboarding, rollerblading and BMX riding in recent years and in response dedicated skateparks have opened in many cities across the UK. It is acknowledged that these sports are associated with risk of injury and it is recommended that participants wear protective clothing. OBJECTIVE: We aimed to determine if the opening of a skatepark near our hospital had any effect on the number of skatepark related injuries attending the emergency department and to describe the types of injuries sustained. METHODS: All patients attending the emergency department with sports injuries were identified over 24 consecutive weeks. At the end of the 12th week a skatepark opened nearby. Data recorded prospectively included age and sex of subjects, the delay from injury to presenting to hospital, whether or not protective equipment was worn and if first aid was administered before attending hospital. The investigations performed in the emergency department, the diagnosis, treatment received and disposal from the hospital were also recorded. RESULTS: After the skatepark opened there was a significant increase in the number of skatepark related attendances from 7 to 32. Protective clothing was only worn by 9 out of 39 of those with injuries. The commonest injuries were musculoskeletal and the limbs were injured more frequently than the head and trunk. CONCLUSION: We demonstrated a significant increase in the number of skatepark related injuries attending the emergency department following the opening of a nearby skatepark.

Re-admissions to the State Hospital at Carstairs, 1992-1997.

OBJECTIVE: To examine the incidence and characteristics of re-admissions to the State Hospital over the six year inclusive period of January 1992 to December 1997. RESONS FOR THE STUDY: RISK ASSESSMENT: A re-admission to a high-security setting may be the result of a failed risk assessment at the time of discharge. An analysis of re-admissions might reveal facts that will improve risk prediction. In this context every re-admission to maximum security should qualify for critical incident appraisal. A re-admission could also indicate prudent risk management where the patient is readmitted prior to the occurrence of any new incident. Our analysis may give an indication how risk prediction and risk management is functioning in the Forensic Psychiatry setting. HEALTH ECONOMICS: Patient numbers at the State Hospital have exceeded planning predictions. In the early 1990s the prediction was that numbers would level off at around 200 patients. Instead admission rates continued to rise and the State Hospital in-patient population has on occasion reached its maximum. This trend has continued throughout the decade with the daily patient numbers averaging 236, 248, 252 and 249 in the last four years (1997-2000). In this context the role played by re-admissions is an important health economics issue. DESIGN: Data gathered from the medical records department and examination of medical case files, entered into a database, and subsequently analysed using a variety of tools. Descriptive statistics for the total State Hospital patient population between 1992-1994 were taken from a published survey. Other comparative analyses were undertaken using data from previously published studies. SETTING: The data originate from the State Hospital, Carstairs, Lanarkshire, which is the only psychiatric hospital in Scotland to offer maximum-security care. Patients are admitted from ordinary psychiatric hospitals as well as from a penal setting. The maximum number of staffed beds is currently 257. These comprise an admission unit, two rehabilitation units including one with flatlet accommodation, a specialist learning difficulties unit, an all female unit and six male wards. The Hospital is staffed by psychiatrists, GPs, psychologists, social workers, psychiatric nurses including nurse specialists, occupational therapists, and other specialist staff employed in the education, occupations and recreation departments. RESULTS AND CONCLUSIONS: Annual re-admission rate, averaged over 1992-1997 is 22.3% of all patient discharges in the hospital. This is broadly in line with other studies quoted in the literature. The re-admission rate co-varied with first admission rate at an almost constant ratio of 0.38 over the six-year period of study. There is no apparent systematic reason for this phenomenon. The most apparent risk factor was a previous admission to the State Hospital of less than a years duration. Compared with the current average length of stay of five years, this must be considered a short admission. Patients with an above average length of stay were rarely readmitted. Most re-admissions returned during the first year after discharge and nearly all had returned within a three-year period. State patients on a Restriction Order who will be subject to conditional discharge with ongoing supervision fared best and were least likely to be re-admitted. However such patients are also likely to have an above average length of stay. Convicted prisoners and remanded offenders were most likely to be readmitted. There was almost no crossover between the civil and criminal populations when their status was reviewed on re-admission. This raises the question, whether these two patient groups should be perceived and managed differently. The recent move to build medium secure units in Scotland, such as the Orchard Clinic in Edinburgh, now makes this a practical option. This finding also suggests that, in Scotland, bed closures in Mental Hospitals are not leading to a decant of mentally disordered patients into the penal system, at least at the level of more serious offending. Violence was overall the most common reason for return to the State Hospital. Violence was the predominant reason for re-admission from a local hospital whereas relapse of symptoms, where such symptoms were associated with dangerous behaviour in the past, was rarely given as a reason. In contrast, relapse was the predominant reason for return from prison. This may be related to inadequate prison hospital facilities rather than good risk prediction.

Implantable cardioverter defibrillator patch erosion in a heart transplant patient.

A 57-year-old man who had received an automatic implantable cardioverter defibrillator and subsequent orthotopic heart transplant presented to medical attention for hemoptysis. The hemoptysis was caused by the migration of the left ventricular patch of the automatic implantable cardioverter defibrillator, which had been left in place at the time of orthotopic heart transplant. The patch had eroded into the left lung. We recommend that implantable cardioverter defibrillators be removed completely at the time of heart transplantation to prevent subsequent complications.

Concomitant subclavian and coronary artery disease.

BACKGROUND: Proximal subclavian artery occlusive disease in the presence of a patent internal mammary artery used as a conduit for a coronary artery bypass graft procedure may cause reversal of internal mammary artery flow (coronary-subclavian steal) and produce myocardial ischemia. METHODS: We reviewed outcome to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal. Between 1985 and 1997, 20 patients had either concomitant subclavian and coronary artery disease diagnosed before operation (group 1, 5 patients) or symptomatic coronary-subclavian steal occurring after a previous coronary artery bypass graft procedure (group 2, 15 patients). Patients in group 1 received direct subclavian artery bypass and a simultaneous coronary artery bypass graft procedure in which the ipsilateral internal mammary artery was used for at least one of the bypass conduits. Patients in group 2 received either extrathoracic subclavian-carotid bypass (5 patients, 33.3%) or percutaneous transluminal angioplasty and stenting (10 patients, 66.7%) as treatment for symptomatic coronary-subclavian steal. RESULTS: All patients were symptom-free after intervention. One patient treated with percutaneous transluminal angioplasty and stenting died of progressive renal failure. Follow-up totaled 58.5 patient-years (mean, 3.1 years/patient). In group 1, primary patency was 100% (mean follow-up, 3.7 years). In group 2, one late recurrence was treated by operative revision, yielding a secondary patency rate of 100% (mean follow-up, 2.9 years). CONCLUSIONS: Subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal with acceptably low operative risk. Midterm follow-up demonstrates good patency.

Production of the next-generation library virtual tour.

While many libraries offer overviews of their services through their Websites, only a small number of health sciences libraries provide Web-based virtual tours. These tours typically feature photographs of major service areas along with textual descriptions. This article describes the process for planning, producing, and implementing a next-generation virtual tour in which a variety of media elements are integrated: photographic images, 360-degree "virtual reality" views, textual descriptions, and contextual floor plans. Hardware and software tools used in the project are detailed, along with a production timeline and budget, tips for streamlining the process, and techniques for improving production. This paper is intended as a starting guide for other libraries considering an investment in such a project.

A molecular phylogeny of Phytophthora and related oomycetes.

Phylogenetic relationships among 50 Phytophthora species and between Phytophthora and other oomycetes were examined on the basis of the ITS sequences of genomic rDNA. Phytophthora grouped with Pythium, Peronospora, and Halophytophthora, distant from genera in the Saprolegniales. Albugo was intermediate between these two groups. Unlike Pythium, Phytophthora was essentially monophyletic, all but three species forming a cluster of eight clades. Two clades contained only species with nonpapillate sporangia. The other six clades included either papillate and semipapillate, or semipapillate and nonpapillate types, transcending traditional morphological groupings, which are evidently not natural assemblages. Peronospora was related to P. megakarya and P. palmivora and appears to be derived from a Phytophthora that has both lost the ability to produce zoospores and become an obligate biotroph. Three other Phytophthoras located some distance from the main Phytophthora-Peronospora cluster probably represent one or more additional genera.

Cryoablation of incessant ventricular tachycardia: case report and long-term follow-up.

We report the case of a 52-year-old man who had incessant ventricular tachycardia despite treatment with antiarrhythmic agents. Placement of an implantable cardioverter/defibrillator, radiofrequency ablation, and antitachycardia pacing were ineffective. He underwent intraoperative arrhythmia mapping and cryoablation at our institution. Eighteen months later, he remained free of arrhythmia. He was in New York Heart Association functional class II with an ejection fraction of 30%.

Sinus of Valsalva aneurysm or fistula: management and outcome.

BACKGROUND: Few large or long-term series exist regarding the management of patients with sinus of Valsalva aneurysms or fistulas (SVAFs). METHODS: Between 1956 and 1997, 129 patients presented with a ruptured (64 cases; 49.6%) or nonruptured (65 cases; 50.4%) SVAF. The patients included 88 men and 41 women, with a mean age of 39.1 years. Associated findings included a history of endocarditis (42 cases; 32.6%), a bicuspid aortic valve (21 cases; 16.3%), a ventricular septal defect (15 cases; 11.6%), and Marfan's syndrome (12 cases; 9.3%). Operative procedures included simple plication (61 cases; 47.3%), patch repair (52 cases; 40.3%), aortic root replacement (16 cases; 12.4%), and aortic valve replacement/repair (75 cases; 58.1%). RESULTS: There were five in-hospital deaths (3.9%): four due to preexisting sepsis and endocarditis and one that followed dehiscence of the repair in a patient with Marfan's syndrome. Two patients (1.6%) had strokes during the early postoperative period. The survivors were followed up for 661.1 patient-years (5.3 years/patient). The following late complications occurred: prosthetic valve malfunction (5 cases; 3.9%), prosthetic valve endocarditis (3 cases; 2.3%), SVAF recurrence (2 cases; 1.6%), thrombosis (1 case; 0.8%), and anticoagulation-related bleeding (1 case; 0.8%). CONCLUSIONS: Resection and repair of SVAF entails an acceptably low operative risk and yields long-term freedom from symptoms. Early, aggressive treatment is recommended to prevent endocarditis or lesional enlargement, which causes worse symptoms and necessitates more extensive repair.

Origin of a new Phytophthora pathogen through interspecific hybridization.

Plant disease epidemics resulting from introductions of exotic fungal plant pathogens are a well known phenomenon. An associated risk-that accelerated pathogen evolution may be occurring as a consequence of genetic exchange between introduced, or introduced and resident, fungal pathogens-is largely unrecognized. This is, in part, because examples of natural, interspecific hybridization in fungi are very rare. Potential evolutionary developments range from the acquisition of new host specificities to emergence of entirely new pathogen taxa. We present evidence from cytological behavior, additive nucleotide bases in repetitive internal transcribed spacer regions of the rRNA-encoding DNA (rDNA), and amplified fragment length polymorphisms of total DNA that a new, aggressive Phytophthora pathogen of alder trees in Europe comprises a range of heteroploid-interspecific hybrids involving a Phytophthora cambivora-like species and an unknown taxon similar to Phytophthora fragariae. The hybrids' marked developmental instabilities, unusual morphological variability, and evidence for recombination in their internal transcribed spacer profiles indicates that they are of recent origin and that their evolution is continuing. The likelihood of such evolutionary events may be increasing as world trade in plants intensifies. However, routine diagnostic procedures currently in use are insufficiently sensitive to allow their detection.

Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option.

PURPOSE: Central venous obstruction is a common problem in patients with chronic renal failure who undergo maintenance hemodialysis. We studied the use of right atrial bypass grafting in nine cases of central venous obstruction associated with upper extremity venous hypertension. To better understand the options for managing this condition, we discuss the roles of surgery and percutaneous transluminal angioplasty with stent placement. METHODS: All patients had previously undergone placement of bilateral temporary subclavian vein dialysis catheters. Severe arm swelling, graft thrombosis, or graft malfunction developed because of central venous stenosis or obstruction in the absence of alternative access sites. A large-diameter (10 to 16 mm) externally reinforced polytetrafluoroethylene (GoreTex) graft was used to bypass the obstructed vein and was anastomosed to the right atrial appendage. This technique was used to bypass six lesions in the subclavian vein, two lesions at the innominate vein/superior vena caval junction, and one lesion in the distal axillary vein. RESULTS: All patients except one had significant resolution of symptoms without operative mortality. Bypass grafts remained patent, allowing the arteriovenous grafts to provide functional access for 1.5 to 52 months (mean, 15.4 months) after surgery. CONCLUSION: Because no mortality directly resulted from the procedure and the morbidity rate was acceptable, this bypass grafting technique was adequate in maintaining the dialysis access needed by these patients. Because of the magnitude of the procedure, we recommend it only for the occasional patient in whom all other access sites are exhausted and in whom percutaneous dilation and/or stenting has failed.

The Information Commons: a model for (physical) digital resource centers.

Since its planning, construction, and opening in 1996, the Information Commons, located in The University of Iowa's Hardin Library for the Health Sciences, has served as a common ground for self-directed learning, information research, hands-on class sessions, and multimedia development. Initiatives launched from the Information Commons not only have helped increase the visibility of Hardin Library as an environment well equipped to support traditional research and education needs, but have promoted the library as a campus leader and viable partner in planning and delivering digital technologies effectively. Ongoing initiatives have focused on better integrating the library's services and resources with the curricula and research needs of the university's health sciences units. This paper describes the facility, its programmatic elements, and its impact on education, communication, and technology trends in an academic health sciences setting. Particular attention is paid to initiatives launched during the first two years of operation. This paper also discusses plans for expansion of the facility.