Team Cognition in Handoffs: Relating System Factors, Team Cognition Functions and Outcomes in Two Handoff Processes

OBJECTIVE

This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related.

BACKGROUND

Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition.

METHOD

We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes.

RESULTS

Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task.

CONCLUSION

Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.

Disparities in the Management of Pediatric Breast Masses

INTRODUCTION

Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass.

METHODS

A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses.

RESULTS

A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis.

CONCLUSIONS

We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.

Does Use of a Feeding Protocol Change Outcomes in Gastroschisis? A Report from the Midwest Pediatric Surgery Consortium

INTRODUCTION

 Gastroschisis feeding practices vary. Standardized neonatal feeding protocols have been demonstrated to improve nutritional outcomes. We report outcomes of infants with gastroschisis that were fed with and without a protocol.

MATERIALS AND METHODS

 A retrospective study of neonates with uncomplicated gastroschisis at 11 children's hospitals from 2013 to 2016 was performed.Outcomes of infants fed via institutional-specific protocols were compared with those fed without a protocol. Subgroup analyses of protocol use with immediate versus delayed closure and with sutured versus sutureless closure were conducted.

RESULTS

 Among 315 neonates, protocol-based feeding was utilized in 204 (65%) while no feeding protocol was used in 111 (35%). There were less surgical site infections (SSI) in those fed with a protocol (7 vs. 16%, p = 0.019). There were no differences in TPN duration, time to initial oral intake, time to goal feeds, ventilator use, peripherally inserted central catheter line deep venous thromboses, or length of stay. Of those fed via protocol, less SSIs occurred in those who underwent sutured closure (9 vs. 19%, p = 0.026). Further analyses based on closure timing or closure method did not demonstrate any significant differences.

CONCLUSION

 Across this multi-institutional cohort of infants with uncomplicated gastroschisis, there were more SSIs in those fed without an institutional-based feeding protocol but no differences in other outcomes.

Care transition of trauma patients: Processes with articulation work before and after handoff

While care transitions influence quality of care, less work studies transitions between hospital units. We studied care transitions from the operating room (OR) to pediatric and adult intensive critical care units (ICU) using Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling. We interviewed twenty-nine physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) and administered the AHRQ Hospital Survey on Patient Safety Culture items about handoffs, care transitions and teamwork. Care transitions are complex, spatio-temporal processes and involve work during the transition (i.e., handoff and transport) and preparation and follow up activities (i.e., articulation work). Physicians defined the transition as starting earlier and ending later than nurses. Clinicians in the OR to adult ICU transition without a team handoff reported significantly less information loss and better cooperation, despite positive interview data. A team handoff and supporting articulation work should increase awareness, improving quality and safety of care transitions.

Low elevation of Svalbard glaciers drives high mass loss variability

Compared to other Arctic ice masses, Svalbard glaciers are low-elevated with flat interior accumulation areas, resulting in a marked peak in their current hypsometry (area-elevation distribution) at  ~450 m above sea level. Since summer melt consistently exceeds winter snowfall, these low-lying glaciers can only survive by refreezing a considerable fraction of surface melt and rain in the porous firn layer covering their accumulation zones. We use a high-resolution climate model to show that modest atmospheric warming in the mid-1980s forced the firn zone to retreat upward by  ~100 m to coincide with the hypsometry peak. This led to a rapid areal reduction of firn cover available for refreezing, and strongly increased runoff from dark, bare ice areas, amplifying mass loss from all elevations. As the firn line fluctuates around the hypsometry peak in the current climate, Svalbard glaciers will continue to lose mass and show high sensitivity to temperature perturbations.

Svalbard glaciers are among the lowest ice masses in the Arctic, with a peak in glacier area below 450 m elevation. Using a high-resolution climate model, here the authors show that a modest warming in the mid-1980s propagated meltwater runoff above the glacier area peak, amplifying Svalbard mass loss from all elevations.

Infants with esophageal atresia and right aortic arch: Characteristics and outcomes from the Midwest Pediatric Surgery Consortium

PURPOSE

Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF.

METHODS

A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up.

RESULTS

In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54-2.65) vs. 2.57 kg (2.00-3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32-37) vs. 37 weeks (35-39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p < 0.0001). The most common cardiac lesions in the RAA group were ventricular septal defect (7), tetralogy of Fallot (7) and vascular ring (5). Seventeen infants with RAA underwent successful EA repair, 12 (71%) via right thoracotomy and 5 (29%) through left thoracotomy. Anastomotic strictures trended toward a difference in RAA patients undergoing right thoracotomy for primary repair of their EA/TEF compared to left thoracotomy (50% vs. 0%, p = 0.1). Side of thoracotomy in RAA patients undergoing EA/TEF repair was not significantly associated with mortality, anastomotic leak, recurrent laryngeal nerve injury, recurrent fistula, or esophageal dehiscence (all p > 0.29).

CONCLUSION

RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach.

LEVEL OF EVIDENCE

Level III.

Negative-Mass Instability of the Spin and Motion of an Atomic Gas Driven by Optical Cavity Backaction

We realize a spin-orbit interaction between the collective spin precession and center-of-mass motion of a trapped ultracold atomic gas, mediated by spin- and position-dependent dispersive coupling to a driven optical cavity. The collective spin, precessing near its highest-energy state in an applied magnetic field, can be approximated as a negative-mass harmonic oscillator. When the Larmor precession and mechanical motion are nearly resonant, cavity mediated coupling leads to a negative-mass instability, driving exponential growth of a correlated mode of the hybrid system. We observe this growth imprinted on modulations of the cavity field and estimate the full covariance of the resulting two-mode state by observing its transient decay during subsequent free evolution.

Cavity-Assisted Measurement and Coherent Control of Collective Atomic Spin Oscillators

We demonstrate continuous measurement and coherent control of the collective spin of an atomic ensemble undergoing Larmor precession in a high-finesse optical cavity. The coupling of the precessing spin to the cavity field yields phenomena similar to those observed in cavity optomechanics, including cavity amplification, damping, and optical spring shifts. These effects arise from autonomous optical feedback onto the atomic spin dynamics, conditioned by the cavity spectrum. We use this feedback to stabilize the spin in either its high- or low-energy state, where, in equilibrium with measurement backaction heating, it achieves a steady-state temperature, indicated by an asymmetry between the Stokes and the anti-Stokes scattering rates. For sufficiently large Larmor frequency, such feedback stabilizes the spin ensemble in a nearly pure quantum state, in spite of continuous measurement by the cavity field.

Complex Squeezing and Force Measurement Beyond the Standard Quantum Limit

A continuous quantum field, such as a propagating beam of light, may be characterized by a squeezing spectrum that is inhomogeneous in frequency. We point out that homodyne detectors, which are commonly employed to detect quantum squeezing, are blind to squeezing spectra in which the correlation between amplitude and phase fluctuations is complex. We find theoretically that such complex squeezing is a component of ponderomotive squeezing of light through cavity optomechanics. We propose a detection scheme called synodyne detection, which reveals complex squeezing and allows the accounting of measurement backaction. Even with the optomechanical system subject to continuous measurement, such detection allows the measurement of one component of an external force with sensitivity only limited by the mechanical oscillator's thermal occupation.

Suitability of the microbial community composition and function in a semiarid mine soil for assessing phytomanagement practices based on mycorrhizal inoculation and amendment addition

The recovery of species composition and functions of soil microbial community of degraded lands is crucial in order to guarantee the long-term self-sustainability of the ecosystems. A field experiment was carried out to test the influence of combining fermented sugar beet residue (SBR) addition and inoculation with the arbuscular mycorrhizal (AM) fungus Funneliformis mosseae on the plant growth parameters and microbial community composition and function in the rhizosphere of two autochthonous plant species (Dorycnium pentaphyllum L. and Asteriscus maritimus L.) growing in a semiarid soil contaminated by heavy metals. We analysed the phospholipid fatty acids (PLFAs), neutral lipids fatty acids (NLFAs) and enzyme activities to study the soil microbial community composition and function, respectively. The combined treatment was not effective for increasing plant growth. The SBR promoted the growth of both plant species, whilst the AM fungus was effective only for D. pentaphyllum. The effect of the treatments on plant growth was linked to shifts in the rhizosphere microbial community composition and function. The highest increase in dehydrogenase and β-glucosidase activities was recorded in SBR-amended soil. The SBR increased the abundance of marker PLFAs for saprophytic fungi, Gram+ and Gram- bacteria and actinobacteria, whereas the AM fungus enhanced the abundance of AM fungi-related NLFA and marker PLFAs for Gram- bacteria. Measurement of the soil microbial community composition and function was useful to assess the success of phytomanagement technologies in a semiarid, contaminated soil.

The combination of compost addition and arbuscular mycorrhizal inoculation produced positive and synergistic effects on the phytomanagement of a semiarid mine tailing

A field experiment was carried out to assess the effectiveness of combining mycorrhizal inoculation with a native AM fungus (Glomus sp.) and the addition of an urban organic waste compost (OWC) applied at two rates (0.5 and 2.0% (w:w)), with regard to promoting the establishment of Anthyllis cytisoides L. seedlings in a heavy metal polluted mine tailing, as well as stimulating soil microbial functions. The results showed that the combined use of the highest dose of OWC and AM inoculation significantly increased shoot biomass - by 64% - compared to the control value. However, the separate use of each treatment had no effect on the shoot biomass of this shrub species. At the 2% rate, OWC enhanced root colonisation by the introduced fungus as well as soil nutrient content and soil dehydrogenase and ß-glucosidase activities. The combined treatment increased the uptake of Zn and Mn in shoots, although only Zn reached excessive or potentially toxic levels. This study demonstrates that the combination of organic amendment and an AM fungus is a suitable tool for the phytomanagement of degraded mine tailings, although its effectiveness is dependent on the dose of the amendment.

Influence of segmental chromosome abnormalities on survival in children over the age of 12 months with unresectable localised peripheral neuroblastic tumours without MYCN amplification

Background:

The prognostic impact of segmental chromosome alterations (SCAs) in children older than 1 year, diagnosed with localised unresectable neuroblastoma (NB) without MYCN amplification enrolled in the European Unresectable Neuroblastoma (EUNB) protocol is still to be clarified, while, for other group of patients, the presence of SCAs is associated with poor prognosis.

Methods:

To understand the role of SCAs we performed multilocus/pangenomic analysis of 98 tumour samples from patients enrolled in the EUNB protocol.

Results:

Age at diagnosis was categorised into two groups using 18 months as the age cutoff. Significant difference in the presence of SCAs was seen in tumours of patients between 12 and 18 months and over 18 months of age at diagnosis, respectively (P=0.04). A significant correlation (P=0.03) was observed between number of SCAs per tumour and age. Event-free (EFS) and overall survival (OS) were calculated in both age groups, according to both the presence and number of SCAs. In older patients, a poorer survival was associated with the presence of SCAs (EFS=46% vs 75%, P=0.023; OS=66.8% vs 100%, P=0.003). Moreover, OS of older patients inversely correlated with number of SCAs (P=0.002). Finally, SCAs provided additional prognostic information beyond histoprognosis, as their presence was associated with poorer OS in patients over 18 months with unfavourable International Neuroblastoma Pathology Classification (INPC) histopathology (P=0.018).

Conclusions:

The presence of SCAs is a negative prognostic marker that impairs outcome of patients over the age of 18 months with localised unresectable NB without MYCN amplification, especially when more than one SCA is present. Moreover, in older patients with unfavourable INPC tumour histoprognosis, the presence of SCAs significantly affects OS.

[The concept of small volume resuscitation for preclinical trauma management. Experiences in the Air Rescue Service]

BACKGROUND

Prompt hemorrhage control and adequate fluid resuscitation are the key components of early trauma care. However, the optimal resuscitation strategy remains controversial. In this context the small volume resuscitation (SVR) concept with hypertonic-hyperoncotic solutions is a new strategy.

PATIENTS AND METHODS

This was a retrospective study in the Helicopter Emergency Medical Service over a 5-year period. Included were all major trauma victims if they were candidates for SVR (initially 4 ml HyperHaes/kg body weight, followed by conventional fluid resuscitation with crystalloids and colloids). Demographic data, type and cause of injury and injury severity score (ISS) were recorded and the amount of fluid volume and the hemodynamic profile were analyzed. Negative side-effects as well as sodium chloride serum levels on hospital admission were recorded.

RESULTS

A total of 342 trauma victims (male 70.2%, mean age 39.0 ± 18.8 years, ISS 31.6 ± 16.9, ISS>16, 81.6%) underwent prehospital SVR. A blunt trauma mechanism was predominant (96.8%) and the leading cause of injury was motor vehicle accidents (61.5%) and motorcycle accidents (22.3%). Multiple trauma and polytrauma were noted in 87.4% of the cases. Predominant was traumatic brain injury (73.1%) as well as chest injury (73.1%) followed by limb injury (69.9%) and abdominal/pelvic trauma (45.0%). Within the whole study group in addition to 250 ml HyperHaes, mean volumes of 1214 ± 679 ml lactated Ringers and 1288 ± 954 ml hydroxethylstarch were infused during the prehospital treatment phase. There were no statistically significant differences in the amount of crystalloids and colloids infused regarding the subgroups multisystem trauma (ISS>16), severe traumatic brain injury (GCS<9) and entrapment trauma compared to the total study group. In patients with an initial systolic blood pressure (SBP) >80 mmHg significantly less colloids (1035 ± 659 ml vs. 1288 ± 954 ml, p<0.006) were infused, whereas in patients with an initial SBP ≤ 80 mmHg significantly more colloids were infused (1609 ± 1159 ml vs. 1288 ± 954 ml, p<0.002). There was a statistically significant increase in systolic as well as diastolic blood pressure at all times of blood pressure measurement during prehospital treatment after bolus infusion of HyperHaes within the whole study group. The same applies to the subgroups multisystem trauma, severe traumatic brain injury and entrapment trauma. Minor negative side-effects were observed in 4 cases (1.2%). The mean serum sodium chloride profile on hospital admission was 146.9 ± 5.0 mmol/l, the base excess (BE) was -5.7 ± 5.3 mmol/l) and the pH was 7.3 ± 0.1.

CONCLUSION

The concept of small volume resuscitation provides early and effective hemodynamic control. Clinical side-effects associated with bolus infusion of hypertonic-hyperoncotic solutions are rare.

Comparative effects of native filamentous and arbuscular mycorrhizal fungi in the establishment of an autochthonous, leguminous shrub growing in a metal-contaminated soil

The aim of this study was to assess the effectiveness of inoculation with a native arbuscular mycorrhizal (AM) fungus, Glomus mosseae (Nicol. and Gerd.) Gerd. and Trappe, or a filamentous fungus, Penicillium aurantiogriseum Dierckx 1901, on the establishment of Coronilla juncea L. seedlings grown in a polluted, semiarid soil. For that, root and shoot biomass, nutrient uptake, mycorrhizal colonisation and nitrate reductase (NR) and phosphatase activities were analysed. Six months after planting, the shoot biomass of C. juncea was increased only by the inoculation with G. mosseae (by about 62% compared with non-mycorrhizal plants). The shoot NR and root acid phosphatase activities were increased more by inoculation with G. mosseae than with P. aurantiogriseum inoculation. The root NR activity and foliar nutrient contents were increased only by the inoculation with the AM fungus. The root Zn and Cu decreased with the AM fungus. In conclusion, the autochthonous AM fungus was an effective inoculant with regard to stimulating growth and alleviating heavy metal toxicity for plants growing on a soil contaminated by multiple heavy metals. Inoculation with an autochthonous, filamentous fungus does not seem to be a good strategy for phytoremediation of such problematic sites.

Integrating science and business models of sustainability for environmentally-challenging industries such as secondary lead smelters: a systematic review and analysis of findings

Secondary lead smelters (SLS) represent an environmentally-challenging industry as they deal with toxic substances posing potential threats to both human and environmental health, consequently, they operate under strict government regulations. Such challenges have resulted in the significant reduction of SLS plants in the last three decades. In addition, the domestic recycling of lead has been on a steep decline in the past 10 years as the amount of lead recovered has remained virtually unchanged while consumption has increased. Therefore, one may wonder whether sustainable development can be achieved among SLS. The primary objective of this study was to determine whether a roadmap for sustainable development can be established for SLS. The following aims were established in support of the study objective: (1) to conduct a systematic review and an analysis of models of sustainable systems with a particular emphasis on SLS; (2) to document the challenges for the U.S. secondary lead smelting industry; and (3) to explore practices and concepts which act as vehicles for SLS on the road to sustainable development. An evidence-based methodology was adopted to achieve the study objective. A comprehensive electronic search was conducted to implement the aforementioned specific aims. Inclusion criteria were established to filter out irrelevant scientific papers and reports. The relevant articles were closely scrutinized and appraised to extract the required information and data for the possible development of a sustainable roadmap. The search process yielded a number of research articles which were utilized in the systematic review. Two types of models emerged: management/business and science/mathematical models. Although the management/business models explored actions to achieve sustainable growth in the industrial enterprise, science/mathematical models attempted to explain the sustainable behaviors and properties aiming at predominantly ecosystem management. As such, there are major disconnects between the science/mathematical and management/business models in terms of aims and goals. Therefore, there is an urgent need to integrate science and business models of sustainability for the industrial enterprises at large and environmentally-challenging industrial sectors in particular. In this paper, we offered examples of practices and concepts which can be used in charting a path towards sustainable development for secondary lead smelters particularly that the waste generated is much greater outside the industrial enterprise than inside. An environmentally-challenging industry such as secondary lead smelters requires a fresh look to chart a path towards sustainable development (i.e., survivability and purposive needs) for all stakeholders (i.e., industrial enterprise, individual stakeholders, and social/ecological systems). Such a path should deal with issues beyond pollution prevention, product stewardship and clean technologies.

Addition of microbially-treated sugar beet residue and a native bacterium increases structural stability in heavy metal-contaminated Mediterranean soils

A mesocosm experiment was conducted to investigate the effect of the addition of Aspergillus niger-treated sugar beet waste, in the presence of rock phosphate, and inoculation with a native, metal-tolerant bacterium, Bacillus thuringiensis, on the stabilisation of soil aggregates of two mine tailings, with differing pH values, from a semiarid Mediterranean area and on the stimulation of growth of Piptatherum miliaceum. Bacterium combined with organic amendment enhanced structural stability (38% in acidic soil and 106% in neutral soil compared with their corresponding controls). Only the organic amendment increased pH, electrical conductivity, water-soluble C, water-soluble carbohydrates and plant growth, in both soils. While in neutral soil both organic amendment and bacterium increased dehydrogenase activity, only organic amendment had a significant effect in acidic soil. This study demonstrates that the use of P. miliaceum in combination with organic amendment and bacterium is a suitable tool for the stabilisation of the soil structure of degraded mine tailings, although its effectiveness is dependent on soil pH.

Evidence-based integrated environmental solutions for secondary lead smelters: pollution prevention and waste minimization technologies and practices

An evidence-based methodology was adopted in this research to establish strategies to increase lead recovery and recycling via a systematic review and critical appraisal of the published literature. In particular, the research examines pollution prevention and waste minimization practices and technologies that meet the following criteria: (a) reduce/recover/recycle the largest quantities of lead currently being disposed of as waste, (b) technically and economically viable, that is, ready to be diffused and easily transferable, and (c) strong industry interest (i.e., industry would consider implementing projects with higher payback periods). The following specific aims are designed to achieve the study objectives: Aim 1 - To describe the recycling process of recovering refined lead from scrap; Aim 2 - To document pollution prevention and waste management technologies and practices adopted by US stakeholders along the trajectory of LAB and lead product life cycle; Aim 3 - To explore improved practices and technologies which are employed by other organizations with an emphasis on the aforementioned criteria; Aim 4 - To demonstrate the economic and environmental costs and benefits of applying improved technologies and practices to existing US smelting operations; and Aim 5 - To evaluate improved environmental technologies and practices using an algorithm that integrates quantitative and qualitative criteria. The process of identifying relevant articles and reports was documented. The description of evidence was presented for current practices and technologies used by US smelters as well as improved practices and technologies. Options for integrated environmental solutions for secondary smelters were introduced and rank ordered on the basis of costs (i.e., capital investment) and benefits (i.e., production increases, energy and flux savings, and reduction of SO(2) and slag). An example was provided to demonstrate the utility of the algorithm by detailing the costs and benefits associated with different combinations of practices and technologies. The evidence-based methodology documented in this research reveals that it is technically and economically feasible to implement integrated environmental solutions to increase lead recovery and recycling among US smelters. The working example presented in this research can be confirmed with US stakeholders and form the basis for implementable solutions in the lead smelter and product industries to help reverse the overall trend of declining life-cycle recycling rates.

An exploratory study of lead recovery in lead-acid battery lifecycle in US market: an evidence-based approach

BACKGROUND

This research examines lead recovery and recycling in lead-acid batteries (LAB) which account for 88% of US lead consumption. We explore strategies to maximize lead recovery and recycling in the LAB lifecycle. Currently, there is limited information on recycling rates for LAB in the published literature and is derived from a single source. Therefore, its recycling efforts in the US has been unclear so as to determine the maximum opportunities for metal recovery and recycling in the face of significant demands for LAB particularly in the auto industry.

OBJECTIVES

The research utilizes an evidence-based approach to: (1) determine recycling rates for lead recovery in the LAB product lifecycle for the US market; and (2) quantify and identify opportunities where lead recovery and recycling can be improved.

METHODS

A comprehensive electronic search of the published literature was conducted to gather information on different LAB recycling models and actual data used to calculate recycling rates based on product lifecycle for the US market to identify strategies for increasing lead recovery and recycling.

RESULTS

The electronic search yielded five models for calculating LAB recycling rates. The description of evidence was documented for each model. Furthermore, an integrated model was developed to identify and quantify the maximum opportunities for lead recovery and recycling. Results showed that recycling rates declined during the period spanning from 1999 to 2006. Opportunities were identified for recovery and recycling of lead in the LAB product lifecycle.

CONCLUDING REMARKS

One can deduce the following from the analyses undertaken in this report: (1) lead recovery and recycling has been stable between 1999 and 2006; (2) lead consumption has increased at an annual rate of 2.25%, thus, the values derived in this study for opportunities dealing with lead recovery and recycling underestimate the amount of lead in scrap and waste generated; and (3) the opportunities for maximizing lead recovery and recycling are centered on spent batteries left with consumers, mishandled LAB sent to auto wreckers, slag resulting from recycling technology process inefficiencies, and lead lost in municipal waste.

Impact of DOM from composted "alperujo" on soil structure, AM fungi, microbial activity and growth of Medicago sativa

Water-soluble extracts from compost may represent an alternative nutrient and organic matter source for crop production under drip irrigation. Dissolved organic matter (DOM), extracted from composted "alperujo", the main by-product from the Spanish olive oil industry, was applied to soil alone or in combination with either Glomus intraradices Schenck and Smith or a mixture of G. intraradices, Glomus deserticola (Trappe, Bloss. and Menge) and Glomus mosseae (Nicol and Gerd.) Gerd. and Trappe. Response measurements included mycorrhizal colonisation, nutrient uptake and growth of Medicago sativa and microbiological and physical properties in the rhizosphere. Dissolved organic matter was added to soil at concentrations of 0, 50, 100 or 300mgCkg(-1) substrate. During the four months of the experiment, the plants were harvested three times. Both mycorrhizal inoculation treatments significantly increased soil aggregate stability. Only the mycorrhizal inoculations increased microbial biomass C and protease and phosphatase activities and decreased water-soluble C, particularly the mixture of arbuscular mycorrhizal fungi. At the third harvest, the greatest increase in growth of M. sativa was observed in the inoculated plants with shoot biomass being 38% greater than for plants grown in the soil amended with the highest dose of DOM and 57% greater than for control plants. The addition of DOM was not sufficient to restore soil structure and microbial activity and did not affect the mycorrhizal development of introduced populations of arbuscular mycorrhizal fungi, but, depending on the dose, its fertiliser efficiency for improving plant growth was apparent.

Micronutrient supplements and mortality of HIV-infected adults with pulmonary TB: a controlled clinical trial

SETTING

Zomba and Blantyre, Malawi, Africa.

OBJECTIVES

To determine whether daily micronutrient supplementation reduces the mortality of human immunodeficiency virus (HIV) infected adults with pulmonary tuberculosis (TB).

DESIGN

A randomised, controlled clinical trial of micronutrient supplementation for HIV-positive and HIV-negative adults with pulmonary TB. Participants were enrolled at the commencement of chemotherapy for sputum smear-positive pulmonary TB and followed up for 24 months.

RESULTS

A total of 829 HIV-positive and 573 HIV-negative adults were enrolled. During follow-up, 328 HIV-positive and 17 HIV-negative participants died. The proportion of HIV-positive participants who died in the micronutrient and placebo groups was 38.7% and 40.4%, respectively (P = 0.49). Micronutrient supplementation did not reduce mortality (hazard ratio [HR] 0.93, 95%CI 0.75-1.15) among HIV-positive adults.

CONCLUSIONS

Micronutrient supplementation at the doses used in this study does not reduce mortality in HIV-positive adults with pulmonary TB in Malawi.

Environmental changes in the North Atlantic Region: SCANNET as a collaborative approach for documenting, understanding and predicting changes

The lands surrounding the North Atlantic Region (the SCANNET Region) cover a wide range of climate regimes, physical environments and availability of natural resources. Except in the extreme North, they have supported human populations and various cultures since at least the end of the last ice age. However, the region is also important at a wider geographical scale in that it influences the global climate and supports animals that migrate between the Arctic and all the other continents of the world. Climate, environment and land use in the region are changing rapidly and projections suggest that global warming will be amplified there while increasing land use might dramatically reduce the remaining wilderness areas. Because much of the region is sparsely populated--if populated at all--observational records of past environmental changes and their impacts are both few and of short duration. However, it is becoming very important to record the changes that are now in progress, to understand the drivers of these changes, and to predict future consequences of the changes. To facilitate research into understanding impacts of global change on the lands of the North Atlantic Regions, and also to monitor changes in real time, an EU-funded network of research sites and infrastructures was formed in 2000: this was called SCANNET--SCANdinavian/North European NETwork of Terrestrial Field Bases. SCANNET currently consists of 9 core sites and 5 sites within local networks that together cover the broad range of current climate and predicted change in the region. Climate observations are well replicated across the network, whereas each site has tended to select particular environmental and ecological subjects for intensive observation. This provides diversity of both subject coverage and expertise. In this paper, we summarize the findings of SCANNET to-date and outline its information bases in order to increase awareness of data on environmental change in the North Atlantic Region. We also identify important gaps in our understanding and identify where the roles of existing infrastructures and activities represented by SCANNET can facilitate future research, monitoring and ground-truthing activities.

[Early diagnosis and treatment of Alzheimer's disease. Implementation in the doctor's office]

The efficacy of antidemential agents proven in comprehensive studies and by clinical experience, now justifies an active and positive approach by the general physician to the diagnosis and treatment of patients with dementia. The proposals on how to implement diagnostic and therapeutic measures in the doctor's office comply both with medical quality criteria and the requirements for appropriateness of treatment and considerations of economy stipulated by German law. They therefore provide the basis for a modern diagnostic work-up and treatment strategy, which will also meet economical demands.

Direct interaction of a vancomycin derivative with bacterial enzymes involved in cell wall biosynthesis

BACKGROUND

The glycopeptide antibiotic vancomycin complexes DAla-DAla termini of bacterial cell walls and peptidoglycan precursors and interferes with enzymes involved in murein biosynthesis. Semisynthetic vancomycins incorporating hydrophobic sugar substituents exhibit efficacy against DAla-DLac-containing vancomycin-resistant enterococci, albeit by an undetermined mechanism. Contrasting models that invoke either cooperative dimerization and membrane anchoring or direct inhibition of bacterial transglycosylases have been proposed to explain the bioactivity of these glycopeptides.

RESULTS

Affinity chromatography has revealed direct interactions between a semisynthetic hydrophobic vancomycin (DCB-PV), and select Escherichia coli membrane proteins, including at least six enzymes involved in peptidoglycan assembly. The N(4)-vancosamine substituent is critical for protein binding. DCB-PV inhibits transglycosylation in permeabilized E. coli, consistent with the observed binding of the PBP-1B transglycosylase-transpeptidase.

CONCLUSIONS

Hydrophobic vancomycins interact directly with a select subset of bacterial membrane proteins, suggesting the existence of discrete protein targets. Transglycosylase inhibition may play a role in the enhanced bioactivity of semisynthetic glycopeptides.