A systems-based assessment of Palestine's current and future infrastructure requirements.

The occupied Palestinian territories of West Bank and Gaza Strip are currently experiencing many challenges in the provision of infrastructure services for their inhabitants. This includes an undersupply of infrastructure services across multiple sectors - an issue exacerbated by population growth, increasing urbanisation, economic growth and climate change. We address this challenge by providing a systems-based assessment of Palestine's infrastructure requirements and identifying broad strategies for how those needs might be met. This assessment involved four key components including: 1) defining and assessing the current system and planned infrastructure investments; 2) assessing potential future demand for infrastructure services; 3) identifying alternative strategies for future infrastructure provision beyond planned investments; and 4) analysing the performance of each strategy against a series of key performance indicators. Results from the assessment highlight the magnitude of the current and future need for urgent infrastructure investment in Palestine. The most immediate need is to alleviate the water crises in Gaza Strip, which will require at least twice as much water infrastructure investment over the coming decade than is currently in the pipeline, even if the goal is only to achieve the most basic World Health Organisation water availability requirements. To move beyond this protracted state of crises will then require a doubling of investments across all sectors to bring Palestine up to the standards of services already enjoyed by its neighbours. Such investments can have even greater impact on delivery of infrastructure services through the strategic use of interdependencies between infrastructure sectors, such as water re-use and energy-from-waste. In the pursuit of global sustainable development, the systems-based approach presented here provides an important first step in the assessment of infrastructure needs and opportunities for any country. It is particularly important for states like Palestine where key resources, such as water and energy, are so acutely constrained.

Lupus-prone New Zealand Black/New Zealand White F1 mice display endothelial dysfunction and abnormal phenotype and function of endothelial progenitor cells.

Patients with systemic lupus erythematosus (SLE) have an impairment in phenotype and function of endothelial progenitor cells (EPCs) which is mediated by interferon alpha (IFN-alpha). We assessed whether murine lupus models also exhibit vasculogenesis abnormalities and their potential association with endothelial dysfunction. Phenotype and function of EPCs and type I IFN gene signatures in EPC compartments were assessed in female New Zealand Black/New Zealand White F(1) (NZB/W), B6.MRL-Fas(lpr)/J (B6/lpr) and control mice. Thoracic aorta endothelial and smooth muscle function were measured in response to acetylcholine or sodium nitropruside, respectively. NZB/W mice displayed reduced numbers, increased apoptosis and impaired function of EPCs. These abnormalities correlated with significant decreases in endothelium-dependent vasomotor responses and with increased type I IFN signatures in EPC compartments. In contrast, B6/lpr mice showed improvement in endothelium-dependent and endothelial-independent responses, no abnormalities in EPC phenotype or function and downregulation of type I IFN signatures in EPC compartments. These results indicate that NZB/W mice represent a good model to study the mechanisms leading to endothelial dysfunction and abnormal vasculogenesis in lupus. These results further support the hypothesis that type I IFNs may play an important role in premature vascular damage and, potentially, atherosclerosis development in SLE.

Functional variability of dissolved organic matter from the surface water of a productive lake.

Functional variability of dissolved organic matter (DOM) from the surface water of Esthwaite Water (N. England) was investigated using a series of 12 standardised assays, which provide quantitative information on light absorption, fluorescence, photochemical fading, pH buffering, copper binding, benzo(a)pyrene binding, hydrophilicity, and adsorption to alumina. Ten lakewater samples were collected at different times of year during 2003-2005, and DOM concentrates obtained by low-temperature rotary evaporation. Suwannee River Fulvic Acid was used as a quality control standard. For nine of the assays, variability among DOM samples was significantly (p<0.01) greater than could be explained by analytical error. Seasonal trends observed for six of the assays could be explained by a simple mixing model in which the two end-members were DOM from the catchment (allochthonous) and DOM produced within the lake (autochthonous). The fraction of autochthonous DOM predicted by the model is significantly correlated (p<0.01) with chlorophyll concentration, consistent with production from phytoplankton. Autochthonous DOM is less light-absorbing, less fluorescent, more hydrophilic, and possesses fewer proton-dissociating groups, than allochthonous material.

Functional properties of DOM in a stream draining blanket peat.

The functional properties of dissolved organic matter (DOM) from Rough Sike, a stream draining blanket peat in the northern Pennines, UK, were investigated using a series of 12 standardised assays. Nine stream samples were collected at different discharges during 2003--2006, and DOM concentrates obtained by low temperature rotary evaporation. Suwannee River Fulvic Acid was used as a quality control standard in the assays. Dissolved organic matter in high-discharge samples was more light-absorbing at 280 and 340 nm and adsorbed more strongly to alumina, than DOM characteristic of low streamflow, but was less fluorescent and hydrophilic, and poorer in proton-dissociating groups. No significant differences were found in light absorption at 254 nm, copper- or benzo(a)pyrene binding, or photochemical fading. Combination of the Rough Sike data with previously-published results for other streams and a lake yields totals of 20-23 values per assay, for a range of DOM types. For the combined data, variability in all the assays is significant (p < 0.001), as judged by comparison with variations in repeat measurements on the quality control standard. Analysis of the combined data shows that DOM hydrophilicity and adsorption are well-predicted by linear relationships with the extinction coefficient at 340 nm (E340), while good quadratic relationships exist between E340 and both buffering capacity and fluorescence.

Long-term nitrate increases in two oligotrophic lakes, due to the leaching of atmospherically-deposited N from moorland ranker soils.

During the last 50 years nitrate concentrations in Buttermere and Wastwater (Cumbria, UK) have risen significantly, by 70 and 100%, respectively. By estimating contemporary nitrate fluxes in the lakes' catchments and in sub-catchments and comparing them with the fractional areas of different soil types, it is deduced that the surface water nitrate is derived almost entirely from organic-rich ranker soils that have a limited ability to retain atmospherically-deposited nitrogen. Little or no nitrate leaches from the other major soil type, a brown podzol, despite it having a lower C:N ratio (12.0 g g(-1)) than the ranker (17.0 g g(-1)), nor is there much contribution from the small areas of improved (chemically fertilised) grassland within the catchments. Although some nitrate leaching is occurring, total N losses are appreciably smaller than atmospheric inputs, so the catchment soils are currently accumulating between 3 and 4 g N m(-2) a(-1).

WITHDRAWN: Continuous electronic heart rate monitoring for fetal assessment during labor.

BACKGROUND: Electronic fetal monitoring (EFM) is used in the management of labor and delivery in nearly three of four pregnancies in the United States. The apparent contradiction between the widespread use of EFM and expert recommendations to limit routine use indicates that a reassessment of this practice is warranted. OBJECTIVES: To compare the efficacy and safety of routine continuous EFM during labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs). SEARCH STRATEGY: We identified RCTs by searching MEDLINE and the register maintained by the Cochrane Pregnancy and Childbirth Group, and by contacting experts, and reviewing published references. Date of last search: January 2001. SELECTION CRITERIA: Randomized controlled trials. DATA COLLECTION AND ANALYSIS: Data were abstracted by one of us, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes. MAIN RESULTS: Our search identified 13 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. Four trials that did not fulfil our selection criteria were excluded. The remaining nine trials included 18,561 pregnant women and their 18,695 infants in both high- and low-risk pregnancies from seven clinical centers in the United States, Europe, and Australia. Overall, a statistically significant decrease was associated with routine EFM for neonatal seizures (relative risk (RR) 0.51, 95% confidence interval (CI) 0.32-0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below four or seven, rate of admissions to neonatal intensive care units, perinatal deaths or cerebral palsy. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30). AUTHORS' CONCLUSIONS: The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal delivery, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

Productivity in a dominant herbaceous species is largely unrelated to soil macronutrient stocks.

To predict ecosystem responses to anthropogenic change it is important to understand how and where plant productivity is limited by macronutrient availability. Nitrogen (N) is required in large quantities for plant growth, and is readily lost through leaching or gas fluxes, but reactive nitrogen can be obtained through dinitrogen fixation, and phosphorus (P) is often considered a more fundamental long-term constraint to growth and carbon sequestration in terrestrial ecosystems. Phosphorus limitation may be becoming more prevalent due to widespread pollution by atmospheric N. Assessments of the effects of macronutrient availability on productivity in natural ecosystems are however scarce. We measured standing biomass of bracken Pteridium aquilinum as a proxy for productivity across sites with similar climate but varied geology. Total above-ground biomass varied from 404 to 1947gm-2, yet despite 12-fold to 281-fold variation in soil macronutrient stocks these were remarkably poor at explaining variation in productivity. Soil total nitrogen, organic phosphorus, calcium, magnesium and zinc had no relationship with productivity, whether expressed as concentrations, stocks or element/C ratios, and nor did foliar N/P. Soil potassium (K) and molybdenum stocks both showed weak relationships with productivity. The stock of K in bracken biomass was considerably greater as a proportion of soil stock than for other nutrient elements, suggesting that this nutrient element can be important in determining productivity. Moisture availability, as indicated by environmental trait scores for plant species present, explained considerably more of the variation in productivity than did K stock, with less production in wetter sites. Soil N/C ratio and organic P stock were relatively unimportant in determining productivity across these bracken sites. It is possible that more-direct measures of N and P availability would explain variation in productivity, but the study shows the importance of considering other essential elements and other environmental factors when predicting productivity.

Effects of streptozocin-induced diabetes on glucose metabolism and lactate release by isolated fat cells from young lean and older, moderately obese rats.

Streptozocin-induced diabetes (STZ-D) was produced in male Wistar rats at two stages of development: young, lean rats, weighing 150-220 g (6-8 wk), and older, moderately obese rats, weighing 450-500 g (6-8 mo). A comparable degree of hyperglycemia (420-500 mg/dl) without ketosis was generated by injection of 50 mg/kg i.v. STZ for young, lean rats and 30 mg/kg i.v. for older, fatter rats. The animals were killed 8-11 days after injection. Insulin binding by the isolated adipocytes of both groups was not significantly altered on a per-cell basis by the presence of diabetes. Total adipocyte glucose metabolism, both basal and insulin stimulated, was reduced (63 and 88%, respectively) by the induction of diabetes in young, lean rats. In contrast, the induction of diabetes in the older, moderately obese rats had no suppressive effect on total glucose metabolism by their fat cells. Diabetes increased the relative conversion of glucose to lactate by fat cells from both groups of rats, but in absolute terms, the fat cells from the obese diabetic rats produced significantly more lactate from glucose than cells from the lean diabetic rats, both in the absence and presence of insulin. Diabetes did not alter the glucose concentration at which peak insulin response occurred in either group. We conclude that STZ-D in rats, at different stages of development and degrees of adiposity, results in quantitatively different alterations of adipocyte metabolism, which appear to be postreceptor in nature and result in an increase in glucose conversion to lactate.

Development and application of functional assays for freshwater dissolved organic matter.

A series of 11 standardised, reproducible, assays have been developed of physico-chemical functions of dissolved organic matter (DOM) in freshwaters. The assays provide quantitative information on light absorption, fluorescence, photochemical fading, pH buffering, copper binding, benzo(a)pyrene binding, hydrophilicity and adsorption to alumina. To obtain DOM for the assays, a 45 L sample of filtered freshwater was rotary-evaporated to reduce the volume to ca. 500 cm3. The concentrate was then passed through a strong cation exchanger, in the Na+ form, to remove alkaline-earth cations, and then through 0.7 and 0.2 microm filters. Eight samples, two each from a lake and three streamwaters, were processed. The yields of dissolved organic carbon (DOC) ranged from 70% to 107% (average 91%). The samples of DOM, stored in the dark at 4 degrees C, retained their functional assay characteristics for up to 7 months. When assaying the concentrates, parallel assays were performed with Suwannee River fulvic acid (SRFA), as a quality control standard. For most of the assays, the results for eight freshwater DOM samples are similar to those obtained with SRFA, the chief exception being the greater hydrophilicity of the DOM samples. For eight of the assays, variability among the DOM samples is significantly (p < 0.01) greater than can be explained by analytical error, i.e. by comparison with results for the SRFA quality standard; the three exceptional assays are photochemical fading, copper binding and benzo(a)pyrene binding. The two lakewater samples studied gave the most extreme assay results, probably because of the influence of phytoplankton-derived DOM. Significant correlations of hydrophilicity and adsorption with optical absorbance may mean that some DOM functional properties can be predicted from comparatively simple measurements.

Preliminary studies of diabetic decompensation assessed with bedside glucose-monitoring techniques.

Blood glucose-monitoring techniques originally developed to aid outpatient management of diabetic patients are now being used to facilitate hospital care. However, applications in hyperglycemic patients have been limited because many glucose-oxidase strips and meters respond only to glucose values less than or equal to 400 mg/dl. We asked if prior dilution of blood samples would permit reliable estimations. Ten consecutive decompensated diabetic patients (age 35-73, glucose 506-879, HCO3 12-28) had blood glucose determinations done simultaneously by the hospital laboratory and by Chemstrip bG after dilution of heparinized blood 1:2 in saline. Thirty-one samples were obtained before and during insulin therapy. Correlations with laboratory glucose values were 0.95 with strips read by Accu-Chek meter and 0.90 read visually, both P less than 0.001. Average deviations from laboratory values were 7.9% with Accu-Chek and 12.9% with visual readings. Accu-Chek deviations averaged 9.6% for glucose greater than 700 mg/dl, and 6.9% for glucose greater than 400 mg/dl. Over the first hour of insulin therapy, glucose fell 150 +/- 30 mg/dl by Accu-Chek, comparable to 168 +/- 29 by laboratory measurement; the decrement by visual reading was 107 +/- 32, not significantly different. We conclude that dilution of blood samples with glucose greater than 400 allows reliable estimation of elevated values by home glucose-monitoring techniques. This approach is cost-effective and provides the rapid feedback needed for the management of critically ill patients.

The role of public health surveillance: information for effective action in public health.

Public health surveillance can provide the quantitative information needed for setting priorities and establishing rational health policy. Although there are many examples of the effective use of such information, the full potential for surveillance has not yet been realized. To a large degree, failure to achieve this potential has resulted from limited perspectives regarding the role and conduct of surveillance. Both practitioners (those who conduct surveillance) and users (those who apply surveillance data in a real-world setting) have fallen victim to such myopia. Public health surveillance must be advocated as an essential part of the global health agenda if we are to achieve international goals for improving health status. As we improve our appreciation of the variety of uses for public health surveillance data, we need to understand more fully the determinants of the decision-making process. Effective dissemination of information and effective communication are as important as data collection and analysis. No longer do we have--or should we have--the luxury of collecting information for its own sake. The information collected must have a demonstrated utility. Developing and training personnel to have expertise in public health surveillance will necessarily incur opportunity costs. Bridging gaps in data methodology and coverage will force us to weigh alternatives and to compromise. We hope that the International Symposium on Public Health Surveillance will accomplish several goals. First, we wish to foster international understanding of the definition, role, and importance of surveillance in reducing morbidity and mortality, in improving quality of life, and in setting effective health priorities. Second, we hope that this symposium will serve as a springboard for identifying issues and topics that can be addressed in greater depth at future international meetings. Finally, we see the symposium as an essential step in developing a firm commitment on the part of countries, donor agencies, and multilateral organizations to develop the essential capacity for public health surveillance throughout the world. Each country should have the capacity to measure and monitor changes in health status, risk factors, and health-service access and utilization among its people. All countries should have the means to detect emerging health problems and implement measures for their control, to evaluate the impact of health policies and programs, and to communicate health information in a meaningful fashion to policymakers and the public. If we are successful in these endeavors, the long-term effects on the public's health will be well worth the struggle required to achieve them.(ABSTRACT TRUNCATED AT 400 WORDS)

Characteristics of meta-analyses related to acceptance for publication in a medical journal.

Editors of medical journals select manuscripts for publication based, in part, on the perceived quality of the manuscript submitted. The objective of this study was to describe associations between acceptance for publication and quality-related methodologic characteristics of meta-analyses. This was a prospective observational study. The setting was editorial offices of JAMA and offices of external reviewers. The manuscripts reviewed were 112 consecutive meta-analyses submitted to JAMA during 1996 and 1997 whose authors agreed to participate. The main outcome measures were ratings of 16 methodologic characteristics reflecting quality of the meta-analysis and acceptance for publication. A "high" rating for one methodologic characteristic, whether the report of the meta-analysis provided sufficient detail to enable replication, was related significantly to publication (RR = 2.79, 95% CI = 1.13-6.89). This relationship persisted when other variables were controlled for in the model. Generally, rejected manuscripts had fewer factors rated "high," but differences were not significant. We found that inclusion of sufficient detail to allow a reader to replicate meta-analytic methods was the only characteristic related to acceptance for publication.

Persistence of influenza A by continuous close-contact transmission: the effect of non-random mixing.

The interaction of two populations has variable effects on the nature and duration of epidemic activity, depending on the transmissibility of the virus, the susceptibility of the population, migration, birth and death rates, and the initial number of cases. Under circumstances where transmission stops in a single population (the infectious contact number is less than or equal to one), transmission may continue indefinitely when two populations interact under many different parameter combinations. A mass-action model was constructed using difference equations for two populations that included parameters for migration between populations and variable transmissibility between and within these populations. The limitations of extrapolating the model to actual conditions in human populations result from assumptions inherent in these models, such as fractional infection of individuals.

Applied epidemiology for the 21st Century.

BACKGROUND: Critics argue that the modern epidemiologist seems more concerned with intricately modelling complex relationships among risk factors than understanding their origins and their implications for public health. Indeed, some contend that epidemiology has reached its limits as a discipline. To address such concerns, alternatives have been proposed that integrate biological, analytical, and social approaches to epidemiological practice and training. METHODS: The published literature was reviewed to examine critical issues in current epidemiological practice and training. In addition, we reviewed records of training programmes in applied epidemiology established in 20 countries. RESULTS: We describe an existing approach to preparing epidemiologists for the emerging challenges of public health in which epidemiological research and practice are applied toward the end of improving public health and health care. Training in applied epidemiology is based on a philosophy of 'learning while doing'. Under the supervision of an experienced epidemiologist, trainees conduct field investigations, analyse large data bases, evaluate surveillance systems, publish and present scientific research, and respond to public enquiries. More than 3000 people have received intensive formal training over the past 50 years in programmes in more than 20 countries; most graduates continued to use the tools of applied epidemiology in their work. CONCLUSION: Training in applied epidemiology anchors the discipline in population-based, relevant public health practice.

Hospitalizations in a southern rural community: an application of the 'ecology model'.

The purpose of this study is to re-examine the concepts of health services utilization presented by White and his colleagues in 'The Ecology of Medical Care'. We re-test their model in a rural population in the southern United States using longitudinal instead of cross-sectional data and find that the general principles of the 'Ecology' model do, indeed, apply to rural populations like Rougemont/Bahama. Use of this model has implications for modifying and improving the organization of the health care delivery system and for a fundamental change of emphasis in medical education.

An assessment of the use of Bayes' Theorem for forecasting in public health: the case of epidemic meningitis in China.

A mathematical model based upon Bayes' Theorem (BT) was used to forecast the occurrence of epidemic cerebrospinal meningitis (ECM) in ten communities in North China. Reports of ECM from each ten-day period during the meningitis season and records of special population movement during 1960-82 were analysed to establish forecast models. Calibration, split-sample, random-sample selection, as well as actual forecast tests, were used to check the efficiency of the models. For all the tests, the theoretical occurrence of ECM forecast by the BT method was compared with the observational data. Since the BT method offers efficiency and convenience, it is recommended for use in planning for the prevention and control of ECM in China.

Efficacy and safety of intrapartum electronic fetal monitoring: an update.

OBJECTIVE: To compare the efficacy and safety of routine electronic fetal monitoring (EFM) of labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs). DATA SOURCES: We identified RCTs by searching the MED-LINE data base for the period 1966-1994, contacting experts, and reviewing published references. METHODS OF STUDY SELECTION: Our search identified 12 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. The studies included 58,855 pregnant women and their 59,324 infants in both high- and low-risk pregnancies from ten clinical centers in the United States, Europe, Australia, and Africa. DATA EXTRACTION AND SYNTHESIS: Data were abstracted, and their accuracy was confirmed independently. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of nine outcomes. Overall, a statistically significant decrease was associated with routine EFM for a 1-minute Apgar score less than 4 (relative risk [RR] 0.82, 95% confidence interval [CI] 0.65-0.98) and neonatal seizures (RR 0.5, 95% CI 0.30-0.82). The protective effect of EFM for a 1-minute Apgar score less than 4 was apparent only in the non-United States studies, and the protective effect for neonatal seizures was evident only in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores less than 7, rate of admissions to neonatal intensive care units, and perinatal death. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.33, 95% CI 1.08-1.59) and total operative delivery (RR 1.23, 95% CI 1.15-1.31). Risk of cesarean delivery was greatest in low-risk pregnancies. CONCLUSION: The only clinically significant benefit from the use of routine EFM was in the reduction of neonatal seizures. Because of the increase in cesarean and operative vaginal deliveries, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use EFM or intermittent auscultation during labor.

Relative risks and benefits of long-term estrogen replacement therapy: a decision analysis.

OBJECTIVE: To evaluate the relative risks and benefits of exogenous estrogen use among women entering the climacteric and to consider estrogen use for relief of symptoms or prevention of disease. METHODS: Decision analysis was used to assess the value of estrogen replacement therapy in a hypothetical cohort of 10,000 women assumed to be age 50 years; health outcomes were extrapolated to age 75. Risk ratios for mortality and morbidity of health outcomes associated with the use of estrogen replacement therapy were based on longitudinal studies reported in the literature. RESULTS: Estrogen use for 25 years would decrease fatal coronary heart disease events by 48% (567 cases), decrease deaths from hip fracture by 49% (75), increase deaths from breast cancer by 21% (39), and increase deaths from endometrial cancer by 207% (29 excess deaths). On balance, 25 years of estrogen replacement therapy in a cohort of 10,000 women would prevent 574 deaths. Further, women using estrogens for 25 years would gain 3951 quality-adjusted life years compared with women not using estrogens. Sensitivity analysis suggests that the benefits of estrogen replacement therapy outweight the risks under most assumptions. CONCLUSION: In a hypothetical, population-based analysis, the health benefits of postmenopausal estrogen replacement exceed the health risks incurred. Nevertheless, clinicians must still evaluate each individual's risks and needs.

The incidence of diarrheal disease in a defined population of rural Egypt.

A prospective study of diarrheal illness was conducted for 2 years in 309 families who were part of an epidemiologic research center population in rural Egypt. The rates of illness peaked in the first year of life with between 5 and 6 episodes per person year at risk. Although no seasonal variation in reported diarrhea was demonstrated for the total population, age-specific differences in seasonal occurrence were noted. The incidence did not consistently vary by village size, nor did rates vary by sex.