Quantification of the risk of Phytophthora dieback in The Greater Blue Mountains World Heritage area

Biological invasions exert great pressure on natural ecosystems and conservation areas, the latter of which have been established to conserve biodiversity. The presence of invasive species in natural ecosystems disrupts evolutionary processes, alters species abundance and can potentially lead to extinction (Mack et al., 2000; Crowl et al., 2008). When an invasive species is the cause of plant disease, the potential for that pathogen to survive in a new environment and the expectation of the impacts it may cause, can be estimated from locations where it already occurs. Understanding the dynamics of disease is important for management and research alike, and will hopefully make way for a proactive rather than reactive response. Disease in natural Australian ecosystems caused by the invasive species Phytophthora cinnamomi has been recognised for nearly 100 years (Newhook and Podger, 1972); its devastating impacts have lead to the disease syndrome, Phytophthora dieback, being classified as a Key Threatening Process by the Australian Federal Government (Commonwealth of Australia, 2005). Yet, the assessment of potential disease establishment, that is, disease risk, is limited. This remains true for the globally significant Greater Blue Mountains World Heritage Area (GBMWHA) in New South Wales, a centre of plant and animal conservation. Not only is the understanding of the pathogen distribution limited, so too is knowledge of the potential impacts on flora and the influence climate change may have on disease expression. Management of Phytophthora dieback in the GBMWHA is made increasingly complex by the rugged and remote nature of much of the World Heritage Area, as well as competing demands from tourism, recreation and the impacts of fire and other introduced species. This study aims to address some of these complexities by establishing the suitability of the GBMWHA to P. cinnamomi, its current distribution and the potential for disease. Additionally, with the difficulty of accessing much of the GBMWHA and the risk of disease transmission in mind, an alternate approach to disease identification is trialed. The first task of this project, was concerned with understanding the potential distribution of P. cinnamomi within the GBMWHA using mechanistic modelling and information on the pathogen’s ecology. Most of the GBMHWA was found to be suitable, leading to the acceptance of the first hypothesis that the climatic and topographic conditions of the GBMWHA are conducive to P. cinnamomi establishment. The most conducive areas were characterised by high soil wetness, high rainfall and moderate temperatures, while the areas least conducive were conversely hotter and drier. Although iv the model appeared to overpredict into areas the pathogen was not found, increasing distribution risk was associated with increasing isolations, possibly indicating that the pathogen is yet to reach its potential niche. The modelled distribution of P. cinnamomi was then used to inform a field investigation to determine the actual distribution in the GBMWHA and assess the impact of the pathogen on vegetation communities and individuals. As an invasive species, the distribution of P. cinnamomi was hypothesised to be primarily found in locations with high anthropogenic activity; however it was isolated extensively from remote areas, leading to the rejection of this hypothesis. Disease was never the less expected, albeit sporadic, as per disease expression in other vegetation communities in New South Wales (Arentz, 1974; Walsh et al., 2006; Howard, 2008). Heathland communities that often have a higher incidence of disease (McDougall and Summerell, 2003), had a high rate of pathogen isolation, as well as clear indications of disease in the GBMWHA. Additionally, freshwater wetlands, many of which are endangered ecological communities under Commonwealth and State legislation, had a high rate of pathogen isolation also. The results collected during the field work were then utilised to assess the risk of Phytophthora dieback occurring in the GBMWHA within the context of the disease triangle. The distribution of P. cinnamomi was combined with models of over 130 individual host species to produce a spatially explicit model, quantifying the risk of disease. That a large portion of the GBMWHA is at risk of Phytophthora dieback was not the case, and as such this hypothesis was rejected. Although much of the World Heritage Area had a least some level of risk, greatest risk was associated with a few small areas that occurred at higher elevations with suitable rainfall and temperature conditions. Unfortunately, many of these locations were associated with high levels of tourism and recreation, highlighting the potential for anthropogenic dispersal of P. cinnamomi into, around and out of the GBMWHA. Disease itself has a temporal element which cannot be quantified in one set of field results and as disease spreads the results become outdated quickly (O'Gara et al., 2005). Field-based assessments of disease are expensive and time consuming, and in area as vast and rugged as the GBMWHA, difficult and potentially dangerous. Real-time information on the impacts of disease are therefore needed by land managers to efficiently deploy management strategies (O'Gara et al., 2005). Remote sensing offers an alternative means of assessment not requiring site entry. Vegetation condition can be assessed remotely in all manner of plant systems including the detection and quantification of disease. As such, it was hypothesised here that infection caused by P. cinnamomi could be detected fro

The value of clinical judgement analysis for improving the quality of doctors' prescribing decisions

Background Many initiatives are taken to improve prescribing decisions. Educational strategies for doctors have been effective in at least 50% of cases. Some reflection on one's own performance seems to be a common feature of the most effective strategies. So far, such reflections have mainly focused on the observed outcomes of the doctors' decisions, i.e. on what doctors do in practice. Studies in other fields have shown that another form of feedback based on the analysis of judgements may be useful as well. Objectives The objectives of the study were to discuss the principles underlying clinical judgement analysis, give examples of its use in the medical context, and discuss its potential for improving prescribing decisions. Results Clinical judgement analysis can look behind the outcome of a decision to the underlying decision process. Carefully constructed or selected case material is required for this analysis. Combining feedback on outcomes with feedback based on clinical judgement analysis offers doctors insight both in what they do, and why or when they do it. It may reveal determinants of decision making which are not available through unaided introspection. Interventions using this combination of feedback for improving doctors' prescribing behaviour have been (partly) successful in 4 cases and unsuccessful in one case. Conclusions Clinical judgement analysis gives doctors a structured reflection on the decision-making policy, and can help them to improve their future decisions. It may be especially useful for groups of doctors who try to work towards a consensus policy. The approach is not very helpful when simple decision rules are appropriate

Medication Adherence Affects Treatment Modifications in Patients With Type 2 Diabetes

Background: Low rates of treatment modification in patients with insufficiently controlled risk factors are common in type 2 diabetes. Although adherence problems are often mentioned in surveys as a reason for not intensifying treatment, observational studies have shown inconclusive results. Objective: To assess how medication adherence affects treatment modifications for hypertension and hyperglycemia in patients with type 2 diabetes. Methods: This was a cohort study of 11,268 primary care patients with type 2 diabetes in the Netherlands. Inclusion criteria were diagnosis before 2007, >= 1 prescription to antihypertensive or glucose-regulating medication in the preceding 6 months, and a systolic blood pressure level >= 140 mm Hg or glycosylated hemoglobin >= 7% in 2007. Patients on maximal treatment were excluded. Treatment modifications as observed from prescriptions were classified as none, dose increase, dose decrease, class switch, class addition, or class discontinuation. Refill adherence was assessed as medication possession ratio or length of last gap between refills. We performed multilevel multinomial regression analysis to test for associations. Results: We included 4980 diabetic patients with elevated blood pressure and 2945 diabetic patients with elevated glycosylated hemoglobin levels. Patients with lower adherence for antihypertensive drugs were more likely to have those medications discontinued (odds ratio [OR] for every 10% lower medication possession ratio =1.22; 95% CI, 1.11-1.33) or the dose decreased (OR = 1.14; CI 1.01-1.28). For glucose-regulating medication, dose increases (OR = 0.92; 95% CI, 0.85-0.98) and medication additions (OR = 0.90; 95% CI, 0.82-0.99) were less likely in patients with lower adherence levels. Conclusions: Low adherence inhibits the intensification of glucose-regulating but not antihypertensive medication in type 2 diabetic patients with insufficiently controlled risk factors in the Netherlands. Adherence problems may lead to diminished or even discontinued antihypertensive treatment. (Clin Ther. 2011;33:121-134) (c) 2011 Elsevier HS Journals, Inc

Limited effect of patient and disease characteristics on compliance with hospital antimicrobial guidelines

Objective: Physicians frequently deviate from guidelines that promote prudent use of antimicrobials. We explored to what extent patient and disease characteristics were associated with compliance with guideline recommendations for three common infections. Methods: In a 1-year prospective observational study, 1,125 antimicrobial prescriptions were analysed for compliance with university hospital guidelines. Results: Compliance varied significantly between and within the groups of infections studied. Compliance was much higher for lower respiratory tract infections (LRTIs; 79%) than for sepsis (53%) and urinary tract infections (UTIs; 40%). Only predisposing illnesses and active malignancies were associated with more compliant prescribing, whereas alcohol/ intravenous drug abuse and serum creatinine levels > 130 mu mol/l were associated with less compliant prescribing. Availability of culture results had no impact on compliance with guidelines for sepsis but was associated with more compliance in UTIs and less in LRTIs. Narrowing initial broad-spectrum antimicrobial therapy to cultured pathogens was seldom practised. Most noncompliant prescribing concerned a too broad spectrum of activity when compared with guideline-recommended therapy. Conclusion: Patient characteristics had only a limited impact on compliant prescribing for a variety of reasons. Physicians seemed to practise defensive prescribing behaviour, favouring treatment success in current patients over loss of effectiveness due to resistance in future patients

Perceived barriers for treatment of chronic heart failure in general practice; are they affecting performance?

BACKGROUND: The aim of this study is to determine to what extent barriers perceived by general practitioners (GPs) for prescribing angiotensin-converting enzyme inhibitors (ACE-I) in chronic heart failure (CHF) patients are related to underuse and underdosing of these drugs in actual practice. METHODS: Barriers were assessed with a semi-structured questionnaire. Prescribing data were extracted from GPs' computerised medical records for a random sample of their CHF patients. Relations between barriers and prescribing behaviour were assessed by means of Spearman rank correlation and multivariate regression modelling. RESULTS: GPs prescribed ACE-I to 45% of their patients and had previously initiated such treatment in an additional 3.5%, in an average standardised dose of 13.5 mg. They perceived a median of four barriers in prescribing ACE-I or optimising ACE-I dose. Many GPs found it difficult to change treatment initiated by a cardiologist. Furthermore, initiating ACE-I in patients already using a diuretic or stable on their current medication was perceived as barrier. Titrating the ACE-I dose was seen as difficult by more than half of the GPs. No significant relationships could be found between the barriers perceived and actual ACE-I prescribing. Regarding ACE-I dosing, the few GPs who did not agree that the ACE-I should be as high as possible prescribed higher ACE-I doses. CONCLUSION: Variation between GPs in prescribing ACE-I for CHF cannot be explained by differences in the barriers they perceive. Tailor-made interventions targeting only those doctors that perceive a specific barrier will therefore not be an efficient approach to improve quality of care

Medication Errors in Vietnamese Hospitals:Prevalence, Potential Outcome and Associated Factors

Background Evidence from developed countries showed that medication errors are common and harmful. Little is known about medication errors in resource-restricted settings, including Vietnam. Objectives To determine the prevalence and potential clinical outcome of medication preparation and administration errors, and to identify factors associated with errors. Methods This was a prospective study conducted on six wards in two urban public hospitals in Vietnam. Data of preparation and administration errors of oral and intravenous medications was collected by direct observation, 12 hours per day on 7 consecutive days, on each ward. Multivariable logistic regression was applied to identify factors contributing to errors. Results In total, 2060 out of 5271 doses had at least one error. The error rate was 39.1%(95% confidence interval 37.8%-40.4%). Experts judged potential clinical outcomes as minor, moderate, and severe in 72 (1.4%), 1806 (34.2%) and 182 (3.5%) doses. Factors associated with errors were drug characteristics (administration route, complexity of preparation, drug class; all p values <0.001), and administration time (drug round, p = 0.023; day of the week, p = 0.024). Several interactions between these factors were also significant. Nurse experience was not significant. Higher error rates were observed for intravenous medications involving complex preparation procedures and for anti-infective drugs. Slightly lower medication error rates were observed during afternoon rounds compared to other rounds. Conclusions Potentially clinically relevant errors occurred in more than a third of all medications in this large study conducted in a resource-restricted setting. Educational interventions, focusing on intravenous medications with complex preparation procedure, particularly antibiotics, are likely to improve patient safety

Heart failure guidelines and prescribing in primary care across Europe

BACKGROUND: Major international differences in heart failure treatment have been repeatedly described, but the reasons for these differences remain unclear. National guideline recommendations might be a relevant factor. This study, therefore, explored variation of heart failure guideline recommendations in Europe. METHODS: Treatment recommendations of 14 national guidelines published after 1994 were analyzed in relation to the heart failure treatment guideline of the European Society of Cardiology. To test potential relations between recommendations and prescribing, national prescribing patterns as obtained by a European study in primary care (IMPROVEMENT-HF) were related to selected recommendations in those countries. RESULTS: Besides the 14 national guidelines used by primary care physicians in the countries contacted, the European guideline was used in four countries, and separate guidelines for specialists and primary care were available in another four countries. Two countries indicated that no guideline was used up to 2000. Comprehensiveness of the guidelines varied with respect to length, literature included and evidence ratings. Relevant differences in treatment recommendations were seen only in drug classes where evidence had changed recently (β-blockers and spironolactone). The relation between recommendation and prescribing for selected recommendations was inconsistent among countries. CONCLUSION: Differences in guideline recommendations are not sufficient to explain variation of prescribing among countries, thus other factors must be considered

Going means trouble and staying makes it double: the value of licensing recorded music online

This paper discusses whether a copyright compensation system (CCS) for recorded music—endowing private Internet subscribers with the right to download and use works in return for a fee—would be welfare increasing. It reports on the results of a discrete choice experiment conducted with a representative sample of the Dutch population consisting of 4986 participants. Under some conservative assumptions, we find that applied only to recorded music, a mandatory CCS could increase the welfare of rights holders and users in the Netherlands by over €600 million per year (over €35 per capita). This far exceeds current rights holder revenues from the market of recorded music of ca. €144 million per year. A monthly CCS fee of ca. €1.74 as a surcharge on Dutch Internet subscriptions would raise the same amount of revenues to rights holders as the current market for recorded music. With a voluntary CCS, the estimated welfare gains to users and rights holders are even greater for CCS fees below €20 on the user side. A voluntary CCS would also perform better in the long run, as it could retain a greater extent of market coordination. The results of our choice experiment indicate that a well-designed CCS for recorded music would simultaneously make users and rights holders better off. This result holds even if we correct for frequently observed rates of overestimation in contingent valuation studies