Existing evidence related to soil retention of phosphorus from on-site wastewater treatment systems in boreal and temperate climate zones: a systematic map

BackgroundIn Sweden there are nearly one million soil-based on-site wastewater treatment systems (OWTSs). OWTSs may contribute to eutrophication of surface waters, due to the discharge of phosphorus (P). Hence, in certain cases, a high P removal rate (up to 90%) of OWTSs is required by Swedish authorities. Since these requirements may have costly consequences to property owners, it is debated whether they are too strict. In this debate, it is often claimed that the soil retention of P occurring in the natural environments may be underestimated by authorities. Soil retention is the inhibition of the transport of P through the ground, due to different chemical, physical and biological processes occurring there. These processes make the P transport slower, which may reduce the unwanted impact on receiving water bodies. However, the efficiency of soil retention of P remains unclear. The objective of this systematic map was to collect, code, organise and elucidate the relevant evidence related to the topic, to be able to guide stakeholders through the evidence base, and to support future research synthesising, commissioning, and funding. The systematic map was carried out in response to needs declared by the Swedish Agency for Marine and Water Management but the conclusions should be valid for a wider range of countries across boreo-temperate regions.MethodsSearches were made for peer-reviewed and grey literature using bibliographic databases, search engines, specialist websites, and stakeholder contacts. The references were screened for relevance according to a predefined set of eligibility criteria. A detailed database of the relevant studies was compiled. Data and metadata that enable evaluation and discussion of the character and quality of the evidence base were extracted and coded. Special focus was placed on assessing if existing evidence could contribute to policy and practice decision making. Descriptive information about the evidence base was presented in tables and figures. An interactive evidence atlas and a choropleth were created, displaying the locations of all studies.Review findings234 articles out of 10,797 screened records fulfilled the eligibility criteria. These articles contain 256 studies, performed in the field or in the laboratory. Six different study types were identified, based on where the measurements were conducted. Most studies, including laboratory studies, lack replicates. Most field studies are observational case studies.ConclusionsIt is not possible to derive valid generic measures of the efficiency of soil retention of P occurring in the natural soil environment from available research. Neither does the evidence base allow for answering the question of the magnitude of the potential impact of OWTSs on the P concentration in recipients on a general basis, or under what conditions OWTSs generally have such an impact. A compilation of groundwater studies may provide examples of how far the P may reach in x years, but the number of groundwater studies is insufficient to draw any general conclusions, given the complexity and variability of the systems. Future research should strive for replicated study designs, more elaborate reporting, and the establishment of a reporting standard

Quantum effects on Lagrangian points and displaced periodic orbits in the Earth-Moon system

Recent work in the literature has shown that the one-loop long distance quantum corrections to the Newtonian potential imply tiny but observable effects in the restricted three-body problem of celestial mechanics, i.e., at the Lagrangian libration points of stable equilibrium the planetoid is not exactly at equal distance from the two bodies of large mass, but the Newtonian values of its coordinates are changed by a few millimeters in the Earth-Moon system. First, we assess such a theoretical calculation by exploiting the full theory of the quintic equation, i.e., its reduction to Bring-Jerrard form and the resulting expression of roots in terms of generalized hypergeometric functions. By performing the numerical analysis of the exact formulas for the roots, we confirm and slightly improve the theoretical evaluation of quantum corrected coordinates of Lagrangian libration points of stable equilibrium. Second, we prove in detail that also for collinear Lagrangian points the quantum corrections are of the same order of magnitude in the Earth-Moon system. Third, we discuss the prospects to measure, with the help of laser ranging, the above departure from the equilateral triangle picture, which is a challenging task. On the other hand, a modern version of the planetoid is the solar sail, and much progress has been made, in recent years, on the displaced periodic orbits of solar sails at all libration points, both stable and unstable. The present paper investigates therefore, eventually, a restricted three-body problem involving Earth, Moon and a solar sail. By taking into account the one-loop quantum corrections to the Newtonian potential, displaced periodic orbits of the solar sail at libration points are again found to exist

The role of guidelines and the patient's life-style in GPs' management of hypercholesterolaemia

BACKGROUND: Recent Swedish and joint European guidelines on hyperlipidaemia stress the high coronary risk for patients with already established arterio-sclerotic disease (secondary prevention) or diabetes. For the remaining group, calculation of the ten-year risk for coronary events using the Framingham equation is suggested. There is evidence that use of and adherence to guidelines is incomplete and that tools for risk estimations are seldom used. Intuitive risk estimates are difficult and systematically biased. The purpose of the study was to examine how GPs use knowledge of guidelines in their decisions to recommend or not recommend a cholesterol-lowering drug and the reasons for their decisions. METHODS: Twenty GPs were exposed to six case vignettes presented on a computer. In the course of six screens, successively more information was added to the case. The doctors were instructed to think aloud while processing the cases (Think-Aloud Protocols) and finally to decide for or against drug treatment. After the six cases they were asked to describe how they usually reason when they meet patients with high cholesterol values (Free-Report Protocols). The two sets of protocols were coded for cause-effect relations that were supposed to reflect the doctors' knowledge of guidelines. The Think-Aloud Protocols were also searched for reasons for the decisions to prescribe or not to prescribe. RESULTS: According to the protocols, the GPs were well aware of the importance of previous coronary heart disease and diabetes in their decisions. On the other hand, only a few doctors mentioned other arterio-sclerotic diseases like stroke and peripheral artery disease as variables affecting their decisions. There were several instances when the doctors' decisions apparently deviated from their knowledge of the guidelines. The arguments for the decisions in these cases often concerned aspects of the patient's life-style like smoking or overweight- either as risk-increasing factors or as alternative strategies for intervention. CONCLUSIONS: Coding verbal protocols for knowledge and for decision arguments seems to be a valuable tool for increasing our understanding of how guidelines are used in the on treatment of hypercholesterolaemia. By analysing arguments for treatment decisions it was often possible to understand why departures from the guidelines were made. While the need for decision support is obvious, the current guidelines may be too simple in some respects

The ruptured Achilles tendon: operative and non-operative treatment options

The Achilles tendon is the strongest and thickest tendon in the human body. Like any other tendon in the body, however, it is susceptible to rupture. Many surgeons advocate early operative repair of the ruptured Achilles tendon, citing decreased re-rupture rates and improved functional outcome. Waiting for surgical repair for longer than one month may lead to inferior functional results postoperatively. Non-operative treatment has higher re-rupture rates as compared to surgically repaired tendons, but may be the treatment of choice in some patients. While for many years, patients were rigidly immobilized in a non-weightbearing cast for 6–8 weeks postoperatively, newer studies have shown excellent results with early weightbearing, and this is quickly becoming the standard of care amongst many physicians

GPs' decisions on drug treatment for patients with high cholesterol values: A think-aloud study

BACKGROUND: The purpose was to examine how General Practitioners (GPs) use clinical information and rules from guidelines in their decisions on drug treatment for high cholesterol values. METHODS: Twenty GPs were presented with six case vignettes and were instructed to think aloud while successively more information about a case was presented, and finally to decide if a drug should be prescribed or not. The statements were coded for the clinical information to which they referred and for favouring or not favouring prescription. RESULTS: The evaluation of clinical information was compatible with decision-making as a search for reasons or arguments. Lifestyle-related information like smoking and overweight seemed to be evaluated from different perspectives. A patient's smoking favoured treatment for some GPs and disfavoured treatment for others. CONCLUSIONS: The method promised to be useful for understanding why doctors differ in their decisions on the same patient descriptions and why rules from the guidelines are not followed strictly

Measurement properties of the Minimal Insomnia Symptom Scale (MISS) in an elderly population in Sweden

<p>Abstract</p> <p>Background</p> <p>Insomnia is common among elderly people and associated with poor health. The Minimal Insomnia Symptom Scale (MISS) is a three item screening instrument that has been found to be psychometrically sound and capable of identifying insomnia in the general population (20-64 years). However, its measurement properties have not been studied in an elderly population. Our aim was to test the measurement properties of the MISS among people aged 65 + in Sweden, by replicating the original study in an elderly sample.</p> <p>Methods</p> <p>Data from a cross-sectional survey of 548 elderly individuals were analysed in terms of assumptions of summation of items, floor/ceiling effects, reliability and optimal cut-off score by means of ROC-curve analysis and compared with self-reported insomnia criteria.</p> <p>Results</p> <p>Corrected item-total correlations ranged between 0.64-0.70, floor/ceiling effects were 6.6/0.6% and reliability was 0.81. ROC analysis identified the optimal cut-off score as ≥7 (sensitivity, 0.93; specificity, 0.84; positive/negative predictive values, 0.256/0.995). Using this cut-off score, the prevalence of insomnia in the study sample was 21.7% and most frequent among women and the oldest old.</p> <p>Conclusions</p> <p>Data support the measurement properties of the MISS as a possible insomnia screening instrument for elderly persons. This study make evident that the MISS is useful for identifying elderly people with insomnia-like sleep problems. Further studies are needed to assess its usefulness in identifying clinically defined insomnia.</p

General practitioners' reasoning when considering the diagnosis heart failure: a think-aloud study

BACKGROUND: Diagnosing chronic heart failure is difficult, especially in mild cases or early in the course of the disease, and guidelines are not easily implemented in everyday practice. The aim of this study was to investigate general practitioners' diagnostic reasoning about patients with suspected chronic heart failure in comparison with recommendations in European guidelines. METHODS: Think-aloud technique was used. Fifteen general practitioners reasoned about six case vignettes, representing authentic patients with suspected chronic heart failure. Information about each case was added successively in five steps. The general practitioners said their thoughts aloud while reasoning about the probability of the patient having chronic heart failure, and tried to decide about the diagnosis. Arguments for and against chronic heart failure were analysed and compared to recommendations in guidelines. RESULTS: Information about ejection fraction was the most frequent diagnostic argument, followed by information about cardiac enlargement or pulmonary congestion on chest X-ray. However, in a third of the judgement situations, no information about echocardiography was utilized in the general practitioners' diagnostic reasoning. Only three of the 15 doctors used information about a normal electrocardiography as an argument against chronic heart failure. Information about other cardio-vascular diseases was frequently used as a diagnostic argument. CONCLUSIONS: The clinical information was not utilized to the extent recommended in guidelines. Some implications of our study are that 1) general practitioners need more information about how to utilize echocardiography when diagnosing chronic heart failure, 2) guidelines ought to give more importance to information about other cardio-vascular diseases in the diagnostic reasoning, and 3) guidelines ought to treat the topic of diastolic heart failure in a clearer way

A Call for Urgent Monitoring of Food and Water Security Based on Relevant Indicators for the Arctic

This perspective paper argues for an urgent need to monitor a set of 12 concrete, measurable indicators of food and water security in the Arctic over time. Such a quantitative indicator approach may be viewed as representing a reductionist rather than a holistic perspective, but is nevertheless necessary for actually knowing what reality aspects to monitor in order to accurately understand, quantify, and be able to project critical changes to food and water security of both indigenous and non-indigenous people in the Arctic. More relevant indicators may be developed in the future, taking us further toward reconciliation between reductionist and holistic approaches to change assessment and understanding. However, the potential of such further development to improved holistic change assessment is not an argument not to urgently start to monitor and quantify the changes in food and water security indicators that are immediately available and adequate for the Arctic context

A three-group study, internet-based, face-to-face based and standard- management after acute whiplash associated disorders (WAD) – choosing the most efficient and cost-effective treatment: study protocol of a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>The management of Whiplash Associated Disorders is one of the most complicated challenges with high expenses for the health care system and society. There are still no general guidelines or scientific documentation to unequivocally support any single treatment for acute care following whiplash injury.</p> <p>The main purpose of this study is to try a new behavioural medicine intervention strategy at acute phase aimed to reduce the number of patients who have persistent problems after the whiplash injury. The goal is also to identify which of three different interventions that is most cost-effective for patients with Whiplash Associated Disorders. In this study we are controlling for two factors. First, the effect of behavioural medicine approach is compared with standard care. Second, the manner in which the behavioural medicine treatment is administered, Internet or face-to-face, is evaluated in it's effectiveness and cost-effectiveness.</p> <p>Methods/Design</p> <p>The study is a randomized, prospective, experimental three-group study with analyses of cost-effectiveness up to two-years follow-up. <it>Internet – based programme </it>and <it>face-to-face group treatment programme </it>are compared to <it>standard-treatment </it>only. Patient follow-ups take place three, six, twelve and 24 months, that is, short-term as well as long-term effects are evaluated. Patients will be enrolled via the emergency ward during the first week after the accident.</p> <p>Discussion</p> <p>This new self-help management will concentrate to those psychosocial factors that are shown to be predictive in long-term problems in Whiplash Associated Disorders, i.e. the importance of self-efficacy, fear of movement, and the significance of catastrophizing as a coping strategy for restoring and sustaining activities of daily life. Within the framework of this project, we will develop, broaden and evaluate current physical therapy treatment methods for acute Whiplash Associated Disorders. The project will contribute to the creation of a cost-effective behavioural medicine approach to management of acute Whiplash Associated Disorders. The results of this study will answer an important question; on what extent and how should these patients be treated at acute stage and how much does the best management cost.</p> <p>Trial registration number</p> <p>Current Controlled Trials ISRCTN61531337</p