Value of team approach combined with clinical pathway for diabetic foot problems: a clinical evaluation

Aims: To evaluate the effectiveness of management of diabetic foot problems (DFP) by the National University Hospital (NUH) Multidisciplinary Diabetic Foot Team combined with a clinical pathway in terms of average length of stay (ALOS), readmission rates, hospitalisation cost per patient, major reamputation rate, and complication rate. Methods: 939 patients admitted to the Department of Orthopaedic Surgery, NUH, for DFP from 2002 (before team formation) to 2007 (after team formation). It consisted of six cohorts of patients – 61 for 2002, 70 for 2003, 148 for 2004, 180 for 2005, 262 for 2006, and 218 for 2007. All patients were managed by the NUH Multidisciplinary Diabetic Foot Team combined with a clinical pathway. Statistical analyses were carried out for five parameters (ALOS, hospitalisation cost per patient, major amputation rate, readmission rate, and complication rate). Results: From 2002 to 2007, the ALOS was significantly reduced from 20.36 days to 12.20 days (p=0.0005). Major amputation rate was significantly reduced from 31.15 to 11.01% (p<0.0005). There was also a significant reduction in complication rate from 19.67 to 7.34% (p=0.005). There were reductions in the hospitalisation cost per patient and readmission rate after formation of the multidisciplinary team but they were not statistically significant. Conclusion: Our evaluation showed that a multidisciplinary team approach combined with the implementation of a clinical pathway in NUH was effective in reducing the ALOS, major amputation rate, and complication rate of DFP

Experiences of Using Generative Communications to Support Adaptive Mobile Applications

Attention has recently begun to focus on the use of asynchronous paradigms to support adaptive mobile applications. To investigate this issue the authors have developed an asynchronous distributed systems platform based on the tuple space paradigm [Gelernter,85b] coupled with extensions to support operation in mobile environments. This paper presents our experiences of developing and using this platform. The benefits of the tuple space approach are highlighted and we discuss in some detail the design, implementation and performance of our platform. We subsequently focus on the critical issues of the tuple space API and the level of support for adaptation which can be provided without compromising the elegance and simplicity of the paradigm. The paper concludes with an analysis of the suitability of platforms based on the tuple space paradigm for use in mobile environments

Limbo: A Tuple Space Based Platform for Adaptive Mobile Applications

Mobile computing environments are characterised by significant and rapid changes in their supporting infrastructure and, in particular, in the quality-of-service (QoS) available from their underlying communications channels. Applications which can operate in these environments and take advantage of changing QoS require distributed systems support platforms. The current state-of-the-art in such platforms attempt to provide synchronous connection-oriented programming paradigms reflecting their fixed network origin. In this paper we argue that these paradigms are not well suited to operation in a mobile environment and instead propose a new platform called Limbo based on the tuple space communications paradigm. The design of Limbo is presented together with details of two prototype implementations. The use of the platform to re-engineer a number of existing adaptive mobile applications is also discussed

Benthic Reef Primary Production in Response to Large Amplitude Internal Waves at the Similan Islands (Andaman Sea, Thailand)

Coral reefs are facing rapidly changing environments, but implications for reef ecosystem functioning and important services, such as productivity, are difficult to predict. Comparative investigations on coral reefs that are naturally exposed to differing environmental settings can provide essential information in this context. One prevalent phenomenon regularly introducing alterations in water chemistry into coral reefs are internal waves. This study therefore investigates the effect of large amplitude internal waves (LAIW) on primary productivity in coral reefs at the Similan Islands (Andaman Sea, Thailand). The LAIW-exposed west sides of the islands are subjected to sudden drops in water temperature accompanied by enhanced inorganic nutrient concentrations compared to the sheltered east. At the central island, Ko Miang, east and west reefs are only few hundred meters apart, but feature pronounced differences. On the west lower live coral cover (-38 %) coincides with higher turf algae cover (+64 %) and growth (+54 %) compared to the east side. Turf algae and the reef sand-associated microphytobenthos displayed similar chlorophyll a contents on both island sides, but under LAIW exposure, turf algae exhibited higher net photosynthesis (+23 %), whereas the microphytobenthos displayed reduced net and gross photosynthesis (-19 % and -26 %,respectively) accompanied by lower respiration (-42 %). In contrast, the predominant coral Porites lutea showed higher chlorophyll a tissues contents (+42 %) on the LAIW-exposed west in response to lower light availability and higher inorganic nutrient concentrations, but net photosynthesis was comparable for both sides. Turf algae were the major primary producers on the west side, whereas microphytobenthos dominated on the east. The overall primary production rate (comprising all main benthic primary producers) was similar on both island sides, which indicates high primary production variability under different environmental conditions

The effect of temperature on the size and population density of dinoflagellates in larvae of the reef coral Porites astreoides

Pre-settlement events play an important role in determining larval success in marine invertebrates with bentho-pelagic life histories, yet the consequences of these events typically are not well understood. The purpose of this study was to examine the pre-settlement impacts of different seawater temperatures on the size and population density of dinoflagellate symbionts in brooded larvae of the Caribbean coral Porites astreoides. Larvae were collected from P. astreoides at 14-20 m depth on Conch Reef (Florida) in June 2002, and incubated for 24 h at 15 temperatures spanning the range 25.1 degrees-30.0 degrees C in mean increments of 0.4 +/- 0.1 degrees C (+/- SD). The most striking feature of the larval responses was the magnitude of change in both parameters across this 5 degrees C temperature range within 24 h. In general, larvae were largest and had the highest population densities of Symbiodinium sp. between 26.4 degrees-27.7 degrees C, and were smallest and had the lowest population densities at 25.8 degrees C and 28.8 degrees C. Larval size and symbiont population density were elevated slightly (relative to the minimal values) at the temperature extremes of 25.1 degrees C and 30 degrees C. These data demonstrate that coral larvae are highly sensitive to seawater temperature during their pelagic phase, and respond through changes in size and the population densities of Symbiodinium sp. to ecologically relevant temperature signals within 24 h. The extent to which these changes are biologically meaningful will depend on the duration and frequency of exposure of coral larvae to spatio-temporal variability in seawater temperature, and whether the responses have cascading effects on larval success and their entry to the post-settlement and recruitment phase