A fuzzy logic decision support model for climate-driven biomass loss risk in western Oregon and Washington.

Dynamic global vegetation model (DGVM) projections are often put forth to aid resource managers in climate change-related decision making. However, interpreting model results and understanding their uncertainty can be difficult. Sources of uncertainty include embedded assumptions about atmospheric CO2 levels, uncertain climate projections driving DGVMs, and DGVM algorithm selection. For western Oregon and Washington, we implemented an Environmental Evaluation Modeling System (EEMS) decision support model using MC2 DGVM results to characterize biomass loss risk. MC2 results were driven by climate projections from 20 General Circulation Models (GCMs) and Earth System Models (ESMs), under Representative Concentration Pathways (RCPs) 4.5 and 8.5, with and without assumed fire suppression, for three different time periods. We produced maps of mean, minimum, and maximum biomass loss risk and uncertainty for each RCP / +/- fire suppression / time period. We characterized the uncertainty due to RCP, fire suppression, and climate projection choice. Finally, we evaluated whether fire or climate maladaptation mortality was the dominant driver of risk for each model run. The risk of biomass loss generally increases in current high biomass areas within the study region through time. The pattern of increased risk is generally south to north and upslope into the Coast and Cascade mountain ranges and along the coast. Uncertainty from climate future choice is greater than that attributable to RCP or +/- fire suppression. Fire dominates as the driving factor for biomass loss risk in more model runs than mortality. This method of interpreting DGVM results and the associated uncertainty provides managers with data in a form directly applicable to their concerns and should prove helpful in adaptive management planning.

Risk factors for hospitalization in a national sample of medicare home health care patients.

Acute care hospitalization during or immediately following a Medicare home health care (HHC) episode is a major adverse outcome, but little has been published about HHC patient-level risk factors for hospitalization. The authors determined risk factors at HHC admission associated with subsequent acute care hospitalization in a nationally representative Medicare patient sample (N = 374,123). Hospitalization was measured using Medicare claims data; risk factors were measured using Outcome Assessment and Information Set data. Seventeen percent of sample members were hospitalized. Multivariate logistic regression analysis found that the most influential risk factors (all p < .001) were skin wound as primary HHC diagnosis, clinician-judged guarded rehabilitation prognosis, congestive heart failure as primary HHC diagnosis, presence of depressive symptoms, dyspnea severity, and Black, compared to White. HHC initiatives that minimize chronic condition exacerbations and actively treat depressive symptoms might help reduce Medicare patient hospitalizations. Unmeasured reasons for higher hospitalization rates among Black HHC patients deserve further investigation.

Anaemia is highly prevalent among unselected internal medicine inpatients and is associated with increased mortality, earlier readmission and more prolonged hospital stay: an observational retrospective cohort study.

BACKGROUND: Anaemia is associated with adverse outcomes in elderly community-dwelling individuals, but this problem is less well characterised in the inpatient setting. AIMS: To determine the prevalence of anaemia and its associations in a well-defined cohort of internal medicine inpatients. METHODS: A retrospective cohort study of non-elective admissions under internal medicine at Palmerston North Hospital, New Zealand, was conducted for 4 months of 2008 with outcome analysis on 1 March 2010. RESULTS: At admission, 497 of 1491 (33.3%) patients were anaemic by World Health Organization criteria (haemoglobin <130 g/L for males; <120 g/L for females). Anaemia was more prevalent in males (38.1%) than females (28.2%), P < 0.001, in patients aged 65 years or older (41%) than in those under 65 (21.3%), P < 0.001, in New Zealand Europeans (34.3%) than in Maori and people from the Pacific Islands (26.4%), P= 0.04, and in patients admitted primarily because of malignancy, endocrine/metabolic disease, infection, and acute coronary syndrome/congestive heart failure (P < 0.001). Anaemia was independently associated with increased length of hospital stay (7.3 days vs 5.1 days in non-anaemic patients; P < 0.001), with mortality (P < 0.001) and unplanned hospital readmission (P < 0.001) during the follow-up period. Anaemia was infrequently acknowledged or investigated. Secondary analysis using a haemoglobin threshold of 110 g/L showed similar results. CONCLUSIONS: Anaemia is highly prevalent among medical inpatients with variation because of gender, age, race and reason for admission. Anaemia independently predicts for prolonged hospital stay, increased mortality and shorter time to readmission, but is usually not documented or investigated in this setting.

Feeding ecology of early marine phase Atlantic salmon Salmo salar post-smolts.

Dietary analyses of Atlantic salmon Salmo salar post-smolt stomachs collected from 2001 to 2005 in Penobscot Bay, Maine, U.S.A., have yielded insights into the feeding ecology of early marine phase post-smolts from different rearing origins. Most stomachs contained only one or two prey types, suggesting active prey selection. Post-smolts that lived in the river longer (i.e. from naturally reared and parr-stocked origins) were smaller and consumed more fishes than invertebrates compared to larger post-smolts that emigrated immediately post-stocking (i.e. from smolt-stocked origins). Naturally reared S. salar consumed c. 84% fishes and 16% crustaceans and parr-stocked S. salar consumed 64% fishes and 34% crustaceans. Stocked smolts consumed 48% fishes and 40% crustaceans. Differences in the type and quantity of consumed prey may be indicative of behavioural differences among rearing origins that influence post-smolt survival.

Surface trawl survey for U.S. origin Atlantic salmon Salmo salar.

A surface trawl survey (2001-2005) in Penobscot Bay, Maine, U.S.A., and the nearshore Gulf of Maine waters was conducted to investigate early marine dynamics of a hatchery-dependent Atlantic salmon Salmo salar population from a severely modified river system. Data generated were used to evaluate the effect of stocking location and time on migration success and to describe the migratory pathways and environments that post-smolts traverse. Significant differences in early migration success were detected among different stocking groups, but subsequent marine survival was independent of stocking group. While the post-smolt population was primarily composed of hatchery origin smolt-stocked fish, other life-stage stocking strategies (i.e. parr stocking) represented a higher proportion of the population than previously assumed. Catch distribution suggests evidence of an initial marine migratory pathway out of the dynamic Penobscot Bay environment. The hypothesized benefits of a predator refuge based on the co-occurring species complex is considered minimal for emigrating post-smolts given a mismatch in the size overlap among species and low abundance of other co-occurring diadromous populations. These data can be used to modify current management actions to optimize S. salar recovery and inform future research agendas.

Lead contamination of surgical gloves by contact with a lead hand.

Background. "Lead hands" are frequently used to maintain hand and finger position in hand surgery. The malleability and strength of lead make it ideal for this purpose. The aim of this study was to determine the amount of lead transferred to a surgeon's glove during handling of a lead hand. Method. Sterile surgical gloves were wiped over the surface of a lead hand. The number of wipes was varied, the gloves were then sent to a trace elements laboratory, and the lead content transferred to each glove was determined. Results. The amount of lead transferred to each glove increased with increasing exposure to the lead hand. After twenty wipes, up to 2 mg of lead was transferred to the surgeon's glove. Covering the lead hand with a sterile drape markedly reduced the lead transferred to the surgeon's glove. Conclusion. Significant amount of lead is transferred on to the gloves after handling a lead hand. This risks wound contamination and a foreign body reaction. Covering the lead hand with a sterile drape may minimise the risk of surgical wound contamination.

Use of oral dimercaptosuccinic acid (succimer) in adult patients with inorganic lead poisoning.

BACKGROUND: Chelation therapy has been used as a means of reducing the body burden of lead for five decades. Intravenous sodium calcium edetate has been the preferred agent, but there is increasing evidence that dimercaptosuccinic acid (DMSA) is also a potent chelator of lead. METHODS: Oral DMSA 30 mg/kg/day was administered to adults with blood lead concentrations > or = 50 microg/dl. The impact of DMSA on urine lead excretion, on blood lead concentrations and on symptoms was observed. The incidence and severity of adverse effects was also recorded. RESULTS: Thirty-five courses were given to 17 patients. DMSA significantly (P < 0.0001) increased urine lead excretion and significantly (P < 0.0001) reduced blood lead concentrations. Mean daily urine lead excretion exceeded the pre-treatment value by a median of 12-fold with wide variation in response (IQR 8.9-14.8, 95% CI 10.1-14.6). Pre-treatment blood lead concentrations correlated well with 5-day urine lead excretion. Headache, lethargy and constipation improved or resolved in over half the patients within the first 2 days of chelation. DMSA was generally well tolerated, but one course was discontinued due to a severe mucocutaneous reaction. There was a transient increase in alanine aminotransferase (ALT) activity during 14% of chelations. DMSA caused a significant increase in urine copper (P < 0.0001) and zinc (P < 0.05) excretion. CONCLUSION: Oral DMSA 30 mg/kg/day is an effective antidote for lead poisoning, though there is a wide inter- and intra-individual variation in response.

A cancer research UK pharmacokinetic study of BPA-mannitol in patients with high grade glioma to optimise uptake parameters for clinical trials of BNCT.

This paper describes results to-date from a human pharmacokinetic study which began recruitment in December 2007. Results are presented for a single patient recruited in December 2007. A second patient was recruited in July 2008 but detailed data are not available at the time of writing. The trial is an open-label, non-comparative, non-therapeutic study of BPA-mannitol in patients with high-grade glioma, who will be undergoing stereotactic brain biopsy as part of the diagnostic process before definitive treatment. The study investigates the route of infusion (intra-venous (IV) or intra-carotid artery) and in each case will assess the effect of administration of mannitol as a blood-brain barrier disrupter. All cohorts will receive a 2 h infusion of BPA-mannitol, and for some cohorts an additional mannitol bolus will be administered at the beginning of this infusion. Measurements are made by inductively coupled plasma mass spectrometry (ICP-MS) of (10)B concentration in samples of blood, urine, extra-cellular fluid in normal brain (via a dialysis probe), brain tissue around tumour and tumour tissue. Additional analysis of the tumour tissue is performed using secondary ion mass spectrometry (SIMS). The first patient was part of the cohort having intra-venous infusion without mannitol bolus. No serious clinical problems were experienced and the assay results can be compared with available patient data from other BNCT centres. In particular we note that the peak (10)B concentration in blood was 28.1 mg/ml for a total BPA administration of 350 mg/kg which is very consistent with the previous experience with BPA-fructose reported by the Helsinki group.

Mechanisms of bone erosion in gout: a quantitative analysis using plain radiography and computed tomography.

OBJECTIVE: The underlying basis of bone erosion in gout remains speculative. The aim of this study was to understand the mechanisms of bone erosion in gout using non-invasive imaging techniques. METHODS: Paired plain radiographs and computed tomography (CT) scans of 798 individual hand and wrist joints from 20 patients with gout were analysed. Radiographs were scored for erosion (0-5) using the Sharp/van der Heijde method. CT scans were scored for the presence and diameter of bone erosions and tophi. The presence of intraosseous tophus (tophus visualised within bone) was recorded. The relationships between radiographic erosion, CT erosion and tophus scores were analysed. RESULTS: With increasing radiographic erosion scores, the percentage of joints with intraosseous tophus increased (p<0.001). For those joints with a radiographic erosion score of 4 or 5, 96/98 (98%) had CT evidence of intraosseous tophus. There was a significant relationship between the radiographic erosion scores and intraosseous tophus size (p<0.001). For those joints with CT erosion, 194/237 (81.8%) had visible intraosseous tophus. Of the joints with CT erosions greater than 5 mm, 106/112 (94.6%) had visible intraosseous tophus and all (56/56) erosions greater than 7.5 mm had intraosseous tophus. There was a strong correlation between CT erosion diameter and intraosseous tophus diameter (r = 0.93, p<0.001). Intraosseous tophi were larger than non-intraosseous tophi, but had similar density and calcification. CONCLUSION: There is a strong relationship between bone erosion and the presence of intraosseous tophus. These results strongly implicate tophus infiltration into bone as the dominant mechanism for the development of bone erosion and joint damage in gout.

Spatial analysis of colorectal cancer incidence and proportion of late-stage in Massachusetts residents: 1995-1998.

BACKGROUND: The aims of this study were to determine if observed geographic variations in colorectal cancer incidence are simply random or are statistically significant deviations from randomness, whether statistically significant excesses are temporary or persistent, and whether they can be explained by risk factors such as socioeconomic status (SES) or the percent of the population residing in an urban area rather than a rural area. Between 1995 and 1998, 6360 male and 6628 female invasive colorectal cancer cases were diagnosed in Massachusetts residents. Cases were aggregated to Census tracts and analyzed for deviations from random occurrence with respect to both location and time. RESULTS: Six geographic areas that deviated significantly from randomness were uncovered in the age-adjusted analyses of males: three with higher incidence rates than expected and eight lower than expected. In the age-adjusted analyses of females, one area with a higher incidence rate, and one area with a lower incidence rate than expected, were found. After adjustment for SES and percent urban, some of these areas were no longer significantly different. CONCLUSION: Public health practitioners can use the results of this study to focus their attention onto areas in Massachusetts that need to increase colorectal screening or have elevated risk of colorectal cancer incidence.

Macromolecule oxidation and DNA repair in mussel (Mytilus edulis L.) gill following exposure to Cd and Cr(VI).

The oxidation of DNA and lipid was analysed in the marine mussel (Mytilus edulis) in response to exposure (10microg/l and 200microg/l) to cadmium (Cd) and chromium [Cr(VI)]. Concentration dependent uptake of both metals into mussel tissues was established and levels of gill ATP were not depleted at these exposure levels. DNA strand breakage in gill cells (analysed by the comet assay) was elevated by both metals, however, DNA oxidation [measured by DNA strand breakage induced by the DNA repair enzyme formamidopyrimidine glycosylase (FPG)] was not elevated. This was despite a statistically significant increase in both malondialdehyde and 4-hydroxynonenal - indicative of lipid peroxidation - following treatment with Cd. In contrast, both frank DNA stand breaks and FPG-induced DNA strand breaks (indicative of DNA oxidation) were increased following injection of mussels with sodium dichromate (10.4microgCr(VI)/mussel). The metals also showed differential inhibitory potential towards DNA repair enzyme activity with Cd exhibiting inhibition of DNA cutting activity towards an oligonucleotide containing 8-oxo-7,8-dihydro-2'-deoxyguanosine and Cr(VI) showing inhibition of such activity towards an oligonucleotide containing ethenoadenosine, both at 200microg/l. The metals thus show DNA damage activity in mussel gill with distinct mechanisms involving both direct and indirect (oxidative) DNA damage, as well as impairing different DNA repair capacities. A combination of these activities can contribute to adverse effects in these organisms.

Umbilical cord plasma concentrations of free morphine following single-dose diamorphine analgesia and their relationship to dose-delivery time interval, Apgar scores and neonatal respiration.

OBJECTIVE: To find the effect of dose-delivery interval on cord-blood levels of diamorphine metabolites and its effect on Apgar sores and neonatal respiration. STUDY DESIGN: Pilot study conducted in labour ward of a district general hospital. One hundred women who had normal delivery and received single dose of 7.5mg of intramuscular injection of diamorphine in labour were recruited in the study. A 2.0 ml sample of umbilical venous blood was collected from the placenta after delivery of the baby. The sample was analysed using RIA method to measure free morphine. Details about the labour and baby's condition at birth were recorded. RESULTS: The concentration of free morphine in the umbilical venous blood was significantly associated with the dose-delivery interval (coefficient (95% CI)=1.08(0.99-1.18), p<0.001). Twenty neonates had low Apgar score (< or =7) at 1 min. The odds of such a low score were raised with higher log free morphine in the cord venous plasma, but not statistically significantly (OR (95% CI)=5.3 (0.84-34), p=0.08). Fourteen neonates required resuscitation. The odds of requiring resuscitation were significantly raised with higher log free morphine: OR (95% CI)=9.3 (1.0-86), p=0.05. CONCLUSION: Concentration of free morphine in the umbilical venous blood after delivery was significantly associated with the dose-delivery interval and this had significant effect on the need for resuscitation.

Risk factors for hospitalization among Medicare home care patients.

This study determined factors associated with an increased risk of ending Medicare home health care because of hospitalization and examined specific types of and reasons for hospitalization. Sample members (N = 922) were followed from admission to discharge as they received home care from Ohio Medicare-certified home care agencies between December 1999 and March 2002. Potential patient-level risk factors were predisposing, enabling, or need variables, and an agency-level variable denoting hospital affiliation or free-standing status was examined as a second-level risk factor. Among those hospitalized (18.3%), more than 80.0% experienced emergency hospitalizations, mostly for acute exacerbations of chronic diseases. Statistically significant risk factors for hospitalization included dyspnea severity, functional disability level, skin or wound problems, diabetes, case mix score, and guarded rehabilitation prognosis. Home care agencies might reduce hospitalizations by using clinical prognosis as a key resource for team communication and by helping patients and families anticipate potential acute exacerbations of chronic diseases and manage these events at home.

The geographic distribution of melanoma incidence in Massachusetts, adjusted for covariates.

BACKGROUND: The aims of this study were to determine whether observed geographic variations in melanoma cancer incidence in both gender groups are simply random or are statistically significant, whether statistically significant excesses are temporary or persistent, and whether they can be explained by risk factors such as socioeconomic status (SES) or the percent of the population residing in an urban rather than a rural area. Between 1990 and 1999, 4774 female and 5688 male melanomas were diagnosed in Massachusetts residents. Cases were aggregated to census tracts and analyzed for deviations from random occurrence with respect to both spatial location and time. RESULTS: Thirteen geographic areas that deviated significantly from randomness were uncovered in the age-adjusted analyses of males: five with higher incidence rates than expected and eight lower than expected. In the age-adjusted analyses of females, six areas with higher incidence rates and eight areas with lower than expected incidence rates were found. After adjustment for SES and percent urban, several of these areas were no longer significantly different. CONCLUSION: These analyses identify geographic areas with invasive melanoma incidence higher or lower than expected, the times of their excess, and whether or not their status is affected when the model is adjusted for risk factors. These surveillance findings can be a sound starting point for the shoe-leather epidemiologist.

Short-term recovery after anterior cruciate ligament reconstruction: a prospective comparison of three autografts.

Sixty-four patients with three different autografts were prospectively evaluated following anterior cruciate ligament (ACL) reconstruction for motion return, thigh girth, quadriceps activity, assistive device usage, and duration of pain medication usage. The quadriceps tendon group achieved knee extension sooner than the patellar tendon group. The hamstring group used assistive devices for less time than the patellar tendon group. The quadriceps group required less pain medication than either of the groups. There are significant differences in short-term pain medication requirements and restoration of function among patients following ACL reconstruction using different autografts.

A space-time analysis of the proportion of late stage breast cancer in Massachusetts, 1988 to 1997.

BACKGROUND: Early detection is the best way to control breast cancer. This observational epidemiologic study uses ten years of data, 1988-1997, to determine whether the observed variations in the proportion of breast cancers diagnosed at late stage are simply random or are statistically significant with respect to both geographical location and time. RESULTS: A total of three spatial-temporal areas were found to deviate significantly from randomness in the unadjusted analysis; one of the three areas contained statistically significant excesses in proportion of late stage, while two areas were identified as significantly lower than expected. The area of excess spanned the first three years of the study period, while the low areas spanned the last five years of the study period. Some of these areas were no longer statistically significant when adjustments were made for SES and urban/rural status. CONCLUSION: Although there was an area of excess in eastern Massachusetts, it only spanned the first three years of the study period. The low areas were fairly consistent, spanning the last five years of the study period.

The geographic distribution of breast cancer incidence in Massachusetts 1988 to 1997, adjusted for covariates.

BACKGROUND: The aims of this study were to determine whether observed geographic variations in breast cancer incidence are random or statistically significant, whether statistically significant excesses are temporary or time-persistent, and whether they can be explained by covariates such as socioeconomic status (SES) or urban/rural status? RESULTS: A purely spatial analysis found fourteen geographic areas that deviated significantly from randomness: ten with higher incidence rates than expected, four lower than expected. After covariate adjustment, three of the ten high areas remained statistically significant and one new high area emerged. The space-time analysis identified eleven geographic areas as statistically significant, seven high and four low. After covariate adjustment, four of the seven high areas remained statistically significant and a fifth high area also identified in the purely spatial analysis emerged. CONCLUSIONS: These analyses identify geographic areas with invasive breast cancer incidence higher or lower than expected, the times of their excess, and whether or not their status is affected when the model is adjusted for risk factors. These surveillance findings can be a sound starting point for the epidemiologist and has the potential of monitoring time trends for cancer control activities.

Rate of change in functional limitations for patients with rheumatoid arthritis: effects of sex, age, and duration of illness.

OBJECTIVE: To estimate the rate of change in functional limitations for patients with rheumatoid arthritis (RA) as a function of age, duration of illness, and sex. METHODS: Patients with RA (n = 700) aged 21-65 years in 1988 were interviewed yearly for 6 years in The National Rheumatoid Arthritis Study. Functional limitations scores based on a Rasch measurement model of 20 Health Assessment Questionnaire items were analyzed in mixed-effects models to estimate the rate of change in functional ability as a function of age, duration of illness, sex, and interactions. RESULTS: Models for both patient age and duration of illness significantly predicted limitations in functional ability for men and women. The model for age included a significant cubic effect; the model for duration of illness included a significant linear effect only. Sex was significant in both models and no interactions were significant in either model. The AIC index of fit, an indicator of the information value of the model, favored the model for duration of illness over the model for age. While both models showed higher levels of functional limitations in women than men, the rate of change for women was similar to men. CONCLUSION: Limitation in functional ability in RA progressed in a linear manner with duration of illness and progressed at the same rate for both men and women, but functional limitations were greater for women.

Geographic distribution of prostate cancer incidence in the era of PSA testing, Connecticut, 1984 to 1998.

OBJECTIVES: To evaluate the geographic variation of prostate cancer incidence in Connecticut during a 15-year period: before the introduction of prostate-specific antigen (PSA) testing (1984 to 1988), during its introduction (1989 to 1993), and after its widespread adoption (1994 to 1998). METHODS: A spatial scan statistic was used to detect and test the significance of the geographic rate variation among 29,944 incident cases. RESULTS: During 1984 to 1988, eight locations had incidence rates that differed significantly from the statewide level; for 1989 to 1993, only two locations were identified. By 1994 to 1998, a significant rate variation was noted for 10 locations around Connecticut. CONCLUSIONS: The observed geographic variation of incidence rates may reflect differing opportunities to uncover latent cases at given locales.