How small is too small? A systematic review of center volume and outcome after cardiac transplantation

Background—The aim of this study was to assess the relationship between the volume of cardiac transplantation procedures performed in a center and the outcome after cardiac transplantation. Methods and Results—PubMed, Embase, and the Cochrane library were searched for articles on the volume–outcome relationship in cardiac transplantation. Ten studies were identified, and all adopted a different approach to data analysis and varied in adjustment for baseline characteristics. The number of patients in each study ranged from 798 to 14401, and observed 1-year mortality ranged from 12.6% to 34%. There was no association between the continuous variables of center volume and observed mortality. There was a weak association between the continuous variables of center volume and adjusted mortality up to 1 year and a stronger association at 5 years. When centers were grouped in volume categories, low-volume centers had the highest adjusted mortality, intermediate-volume centers had lower adjusted mortality, and high-volume centers had the lowest adjusted mortality but were not significantly better than intermediate-volume centers. Category limits were arbitrary and varied between studies. Conclusions—There is a relationship between center volume and mortality in heart transplantation. The existence of a minimum acceptable center volume or threshold is unproven. However, a level of 10 to 12 heart transplants per year corresponds to the upper limit of low-volume categories that may have relatively higher mortality. It is not known whether outcomes for patients treated in low-volume transplant centers would be improved by reorganizing centers to ensure volumes in excess of 10 to 12 heart transplants per year

Effect of Sand and Wood-Shavings Bedding on the Behavior of Broiler Chickens

The purpose of this study was to determine the effect of 2 different bedding types, sand and wood shavings, on the behavior of broiler chickens. In experiment 1, 6 pens were divided down the center and bedded half with sand and half with wood shavings. Male broilers (10/pen) were observed by scan sampling at 5- or 12-min intervals throughout the 6-wk growth period during the morning (between 0800 to 0900 h), afternoon (1200 to 1500 h), and night (2300 to 0600 h). There was a significant behavior x substrate x week interaction during the day (P \u3c 0.0001) and at night (P \u3c 0.0002). Drinking, dustbathing, preening, and sitting increased in frequency on the sand side but decreased on the wood shavings side during the day, as did resting at night. In general, broilers performed a greater proportion of their total behavioral time budget on the sand (P \u3c 0.0001) as they aged. Broilers used the divider between the 2 bedding types to perch; perching behavior peaked during wk 4. In experiment 2, male broilers were housed in 8 pens (50 birds/pen) bedded only in sand or wood shavings. Bedding type had no effect on behavioral time budgets (P = 0.8946), although there were age-related changes in behavior on both bedding types. These results indicate that when given a choice, broilers increasingly performed many of their behaviors on sand, but if only one bedding type was provided they performed those behaviors with similar frequency on sand or wood shavings

The current state of the use of large wood in river restoration and management

Trees fall naturally into rivers generating flow heterogeneity, inducing geomorphological features, and creating habitats for biota. Wood is increasingly used in restoration projects and the potential of wood acting as leaky barriers to deliver natural flood management by “slowing the flow” is recognised. However, wood in rivers can pose a risk to infrastructure and locally increase flood hazards. The aim of this paper is to provide an up-to-date summary of the benefits and risks associated with using wood to promote geomorphological processes to restore and manage rivers. This summary was developed through a workshop that brought together academics, river managers, restoration practitioners and consultants in the UK to share science and best-practice on wood in rivers. A consensus was developed on four key issues: (i) hydro-geomorphological effects, (ii) current use in restoration and management, (iii) uncertainties and risks, and (iv) tools and guidance required to inform process-based restoration and management

Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

Background: The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). Methods: Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. Results: A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031. Conclusions: OBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI

United Kingdom ports policy: Changing government attitudes

The United Kingdom ports industry has been at the forefront of international trade and, therefore, cargo movement since the industrial revolution. Its contribution to the wider economy is still pivotal, handling the majority of the UK's trade. At this point in time, particularly with the government in the process of reviewing the future of its policy for the ports industry through it Ports Policy Review, it is pertinent to assess the forces, which are both driving port development and seeking to restrain unfettered growth. This paper, therefore considers the role of government and how it has shaped, and is continuing to shape, the UK ports industry.United Kingdom government Ports industry Port policy

The policy implications of market failure for the land-based jobs market for British seafarers

People with seafaring experience and skills are employed in the maritime sector of the UK economy in land-based jobs as well as in seagoing ones. This paper examines the balance of supply and demand in the land-based jobs market. It then considers the likely effects of a shortfall in the supply of British ships' officers to fill net vacancies in jobs ashore, including the policy implications of this and the consequences for the economy's maritime skills base if the Government fails to act decisively now to correct market failure.UK seafarers Supply Land-based jobs Maritime skills base

Ex-seafarers shore-based employment: the current UK situation

The decline of the British shipping industry has had a significant impact on those sectors of the UK economy which have traditionally relied on ex-seafarers as a source of skilled labour. An in-depth study of the impacts of this problem was undertaken in 2003 to consider the implications of developments which have taken place in the industry since 1996. The UK economy's requirement for people with seafaring experience to fill land-based jobs was assessed, together with the implications of any shortfall. This paper considers the demand aspects of changes which have occurred since 1996.UK seafarers Demand Land-based jobs Maritime skills base

Improving port terminal operations through information sharing

Part IV: ICT and Emerging Technologies in Production ManagementInternational audiencePorts are integral parts of many supply chains and are as such a contributing factor to the overall efficiency of the supply chain. As the role of the ports is increasingly changing towards being more integrated into the supply chain, ports need to start focusing on optimising the activities and striving for low-lead time. Ports are also complex entities comprising of different companies. The dynamic nature of ports is also a problem when trying to optimise the utilisation of resources and ensure a low lead-time. Information sharing is crucial in the attempt to improve ports operations. This paper attempts to explain how information sharing is enabled in such an environment, and which considerations are relevant, both in regards to the information and required technology. The paper highlights trust, availability of data, and complexity of solutions and technology, as being the main hurdles

CHRM2, parental monitoring, and adolescent externalizing behavior: eidence for gene-environment interaction

Psychologists, with their long-standing tradition of studying mechanistic processes, can make important contributions to further characterizing the risk associated with genes identified as influencing risk for psychiatric disorders. We report one such effort with respect to CHRM2, which codes for the cholinergic muscarinic 2 receptor and was of interest originally for its association with alcohol dependence. We tested for association between CHRM2 and prospectively measured externalizing behavior in a longitudinal, community-based sample of adolescents, as well as for moderation of this association by parental monitoring. We found evidence for an interaction in which the association between the genotype and externalizing behavior was stronger in environments with lower parental monitoring. There was also suggestion of a crossover effect, in which the genotype associated with the highest levels of externalizing behavior under low parental monitoring had the lowest levels of externalizing behavior at the extreme high end of parental monitoring. The difficulties involved in distinguishing mechanisms of gene-environment interaction are discussed