Antimicrobial management and appropriateness of treatment of urinary tract infection in general practice in Ireland

<p>Abstract</p> <p>Background</p> <p>Urinary tract infections (UTIs) are the second most common bacterial infections in general practice and a frequent indication for prescription of antimicrobials. Increasing concern about the association between the use of antimicrobials and acquired antimicrobial resistance has highlighted the need for rational pharmacotherapy of common infections in general practice.</p> <p>Methods</p> <p>Management of urinary tract infections in general practice was studied prospectively over 8 weeks. Patients presenting with suspected UTI submitted a urine sample and were enrolled with an opt-out methodology. Data were collected on demographic variables, previous antimicrobial use and urine samples. Appropriateness of different treatment scenarios was assessed by comparing treatment with the laboratory report of the urine sample.</p> <p>Results</p> <p>A total of 22 practices participated in the study and included 866 patients. Bacteriuria was established for 21% of the patients, pyuria without bacteriuria for 9% and 70% showed no laboratory evidence of UTI. An antimicrobial agent was prescribed to 56% (481) of the patients, of whom 33% had an isolate, 11% with pyuria only and 56% without laboratory evidence of UTI. When taking all patients into account, 14% patients had an isolate identified and were prescribed an antimicrobial to which the isolate was susceptible. The agents most commonly prescribed for UTI were co-amoxyclav (33%), trimethoprim (26%) and fluoroquinolones (17%). Variation between practices in antimicrobial prescribing as well as in their preference for certain antimicrobials, was observed. Treatment as prescribed by the GP was interpreted as appropriate for 55% of the patients. Three different treatment scenarios were simulated, i.e. if all patients who received an antimicrobial were treated with nitrofurantoin, trimethoprim or ciprofloxacin only. Treatment as prescribed by the GP was no more effective than treatment with nitrofurantoin for all patients given an antimicrobial or treatment with ciprofloxacin in all patients. Prescribing cost was lower for nitrofurantoin. Empirical treatment of all patients with trimethoprim only was less effective due to the higher resistance levels.</p> <p>Conclusions</p> <p>There appears to be considerable scope to reduce the frequency and increase the quality of antimicrobial prescribing for patients with suspected UTI.</p

Destabilization of the thermohaline circulation by transient perturbations to the hydrological cycle

We reconsider the problem of the stability of the thermohaline circulation as described by a two-dimensional Boussinesq model with mixed boundary conditions. We determine how the stability properties of the system depend on the intensity of the hydrological cycle. We define a two-dimensional parameters' space descriptive of the hydrology of the system and determine, by considering suitable quasi-static perturbations, a bounded region where multiple equilibria of the system are realized. We then focus on how the response of the system to finite-amplitude surface freshwater forcings depends on their rate of increase. We show that it is possible to define a robust separation between slow and fast regimes of forcing. Such separation is obtained by singling out an estimate of the critical growth rate for the anomalous forcing, which can be related to the characteristic advective time scale of the system.Comment: 37 pages, 8 figures, submitted to Clim. Dy

Potential climatic transitions with profound impact on Europe

We discuss potential transitions of six climatic subsystems with large-scale impact on Europe, sometimes denoted as tipping elements. These are the ice sheets on Greenland and West Antarctica, the Atlantic thermohaline circulation, Arctic sea ice, Alpine glaciers and northern hemisphere stratospheric ozone. Each system is represented by co-authors actively publishing in the corresponding field. For each subsystem we summarize the mechanism of a potential transition in a warmer climate along with its impact on Europe and assess the likelihood for such a transition based on published scientific literature. As a summary, the ‘tipping’ potential for each system is provided as a function of global mean temperature increase which required some subjective interpretation of scientific facts by the authors and should be considered as a snapshot of our current understanding. <br/

Identifying uncertainties in Arctic climate change projections

Wide ranging climate changes are expected in the Arctic by the end of the 21st century, but projections of the size of these changes vary widely across current global climate models. This variation represents a large source of uncertainty in our understanding of the evolution of Arctic climate. Here we systematically quantify and assess the model uncertainty in Arctic climate changes in two CO2 doubling experiments: a multimodel ensemble (CMIP3) and an ensemble constructed using a single model (HadCM3) with multiple parameter perturbations (THC-QUMP). These two ensembles allow us to assess the contribution that both structural and parameter variations across models make to the total uncertainty and to begin to attribute sources of uncertainty in projected changes. We find that parameter uncertainty is an major source of uncertainty in certain aspects of Arctic climate. But also that uncertainties in the mean climate state in the 20th century, most notably in the northward Atlantic ocean heat transport and Arctic sea ice volume, are a significant source of uncertainty for projections of future Arctic change. We suggest that better observational constraints on these quantities will lead to significant improvements in the precision of projections of future Arctic climate change

Integrating new sea-level scenarios into coastal risk and adaptation assessments: An on-going process

The release of new and updated sea-level rise information, such as from the Intergovernmental Panel on Climate Change (IPCC) Assessment Reports, needs to be better anticipated in coastal risk and adaptation assessments. This requires risk and adaptation assessments to be regularly reviewed and updated as needed, reflecting the new information but retaining useful information from earlier assessments. In this paper, updated guidance on the types of sea-level rise information available is presented, including for sea-level extremes. An inter-comparison of the evolution of the headline projected ranges across all the IPCC reports show an increase from the Fourth and Fifth assessments to the most recent ‘Special Report on the Ocean and Cryosphere in a Changing Climate’ assessment. Later IPCC reports have begun to highlight the importance of potential high-end sea-level response, mainly reflecting uncertainties in the Greenland/Antarctic ice sheet components, and how this might be considered in scenarios. The methods that are developed here are practical and consider coastal risk assessment, adaptation planning and long-term decision making to be an ongoing process and ensure that despite the large uncertainties pragmatic adaptation decisions can be made. It is concluded that new sea-level information should not be seen as an automatic reason for abandoning existing assessments, but as an opportunity to review (i) the assessment’s robustness in the light of new science, and (ii) the utility of proactive adaptation and planning strategies, especially over the more uncertain longer-term

Valuation of livestock eco-agri-food systems: poultry, beef and dairy

As input for the TEEBAgriFood study, TEEB asked for a series of studies on livestock, rice, palm oil, inland fisheries and agro-forestry. This report deals with livestock production and aims to improve decision-making in livestock production policies, to enhance its viability, not just economically but also socially and environmentally. Livestock sector is important because they have high externalities and it is expected that livestock consumption will be 76% higher in 2050 compared to 2005 (Alexandratos and Bruisma, 2012) because of population growth, income growth, urbanization and preference shifts. This report aims to provide evidence that will help to identify policy options for the transition towards increased food security with sustainable livestock production systems, with particular emphasis on the role of smallholder farmers

Effects of Fluids on the Macro- and Microcirculations.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901

Implications of climate change for shipping: Ports and supply chains

Ports are an important economic actor—at local, national, and international scales—that have been identified as being vulnerable to future changes to the climate. This paper details the findings from an international review of state‐of‐the‐art knowledge concerning climate risks, and adaptation responses, for ports and their supply chains. Evidence from both academic and gray literature indicates that there has already been major damage and disruption to ports across the world from climate‐related hazards and that such impacts are projected to increase in the years and decades to come. Findings indicate that while a substantial—and growing—body of scientific evidence on coastal risks and potential adaptation options is acting as a stimulus for port authorities to explicitly consider the risks for their assets and operations, only a notable few have actually made the next step toward implementing adaptation strategies. This paper concludes by putting forward constructive recommendations for the sector and suggestions for research to address remaining knowledge gaps. It emphasizes a call for collaboration between the research and practice communities, as well as the need to engage a broad range of stakeholders in the adaptation planning process