Local Expert Opinion Research Articles

Rank aggregation of local expert knowledge for conservation planning of the critically endangered saola

There has been much recent interest in using local knowledge and expert opinion for conservation planning, particularly for hard-to-detect species. Although it is possible to ask for direct estimation of quantities such as population size, relative abundance is easier to estimate. However, an expert's knowledge is often geographically restricted relative to the area of interest. Combining (or aggregating) experts' assessments of relative abundance is difficult when each expert only knows a part of the area of interest. We used Google's PageRank algorithm to aggregate ranked abundance scores elicited from local experts through a rapid rural-appraisal method. We applied this technique to conservation planning for the saola (Pseudoryx nghetinhensis), a poorly known bovid. Near a priority landscape for the species, composed of 3 contiguous protected areas, we asked groups of local people to indicate relative abundances of saola and other species by placing beans on community maps. For each village, we used this information to rank areas within the knowledge area of that village for saola abundance. We used simulations to compare alternative methods to aggregate the rankings from the different villages. The best-performing method was then used to produce a single map of relative abundance across the entire landscape, an area larger than that known to any one village. This map has informed prioritization of surveys and conservation action in the continued absence of direct information about the saola.

Economic Evaluation of the Direct Oral Anticoagulants Compared to Vitamin K Antagonists in the Treatment of Deep Venous Thrombosis and Pulmonary Embolism in the Outpatient Setting: Analysis from the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia

Background: To date, there have been few economic evaluations of the direct oral anticoagulants in the treatment of venous thromboembolism (VTE) conducted from a Canadian perspective. As a result, there is a lack of consensus within existing literature regarding which treatment strategy should be adopted into the clinical setting. To our knowledge, this is the first Canadian economic evaluation in patients with VTE who are treated solely on an outpatient basis.Objectives: We conducted a cost-minimization analysis to determine the least costly intervention for the prevention of recurrent venous thrombosis in patients with acute unprovoked VTE including apixaban, rivaroxaban, low molecular weight heparin (LMWH) in combination with dabigatran, and LMWH overlapped with vitamin K antagonists (VKA). We also conducted a cost-effectiveness analysis to assess value for money in terms of cost per quality adjusted life year (QALY) gained.Methods: We used Microsoft Excel to develop a decision model. Decision model parameters were determined using published literature, local hospital data, expert opinion, and chart review. Our cost-minimization analysis aggregated costs related to pharmaceuticals, laboratory testing, and hematologist fees. Our cost-effectiveness analysis also included costs related to health outcomes.Results: Our cost-minimization analysis found apixaban to be the least costly intervention at three months ($609.28). At six months and one year LMWH overlapped with VKA was the least costly intervention ($896.08 and $1,193.88, respectively). With respect to cost-effectiveness, at three months apixaban was the dominant strategy. At six months, apixaban was cost-effective given a willingness-to-pay per QALY as low as $4,986.81. At one year, LMWH overlapped with VKA was cost-effective given a willingness-to-pay per QALY below $135,670.28. Probabilistic sensitivity analysis of our cost-effectiveness analysis found apixaban to be the dominant strategy compared to LMWH overlapped with VKA in 42.6% of iterations and 70.6% of iterations resulted in incremental cost-effectiveness ratio below $100,000 per QALY gained.Conclusions: Our findings suggest apixaban is the least costly and most cost-effective strategy for short-term anticoagulant treatment for VTE but favor LMWH overlapped with VKA for long-term treatment. DisclosuresNo relevant conflicts of interest to declare.

PCV70 - The Direct Cost Components in Heart Failure with Preserved Ejection Fraction (HF-PEF) in Turkey: The Results of A Delphi Panel

The aim of the present study was to analyze the health-related direct cost components in HF-pEF in Turkey. A two-round Delphi process to get the opinions of local experts (eleven cardiologists who were experienced in HF), was performed. A questionnaire with items to collect the opinions of the panelists on all cost components, including medications, surgical treatment, hospitalization and out-patient follow-up procedures were developed under supervision of one of the experts (ZÖ). Then experts responded to this questionnaire independently via e-mail at first round. At the second round, they met around a table, discussed about all items in detail and revised their responses, when necessary. End-of-2015 local prices released by Ministry of Health and Social Security Institution in Turkey were used as references. End of 2015 Euro/TL currency rate (3.065 TL/Euro) was used. 20.1% of HF-pEF patients are hospitalized directly at internal medicine ward with a rate of 0.33 hospital stays per patient-year for an average length-of-stay of 2.31 days per year. Estimated total annual costs of HF-pEF is calculated as 245 Euro. Main cost driver is the cost of medications (110 Euro/year; 45% of the total). When cost items related with hospitalization were examined, the annual cost of hospital stay is calculated as 47 Euro. The cost of a single hospital stay is 29 Euro and the cost of a single day of hospital stay is 22 Euro. This total direct costs of HF-pEF is reasonable. The major reason of this finding is the low rate of hospitalization, short duration of stay and low daily cost of hospitalization. In order to maintain this budget-friendly position of HF-pEF, controlling the disease under appropriate medical treatment is suggested.

A GIS-based methodological framework to characterize the Resource Management Domain (RMD): A case study of Mewat district, Haryana, India

Resource Management Domains (RMD) represent a way to characterize land units, based on biophysical and socioeconomic characteristics. This concept has been applied to delineate and characterize sustainable land units for agricultural use in the Mewat District of Haryana, India. A GIS-based framework was conceptualized to characterize RMD and appropriate biophysical and socioeconomic parameters were identified based on local conditions and expert opinion. The biophysical characteristics of the region were represented by soil (soil erosion and fertility) and groundwater (groundwater quality, potential and vulnerability) parameters. Population density, landholding, cropping pattern, irrigation source, fertilizer type, sprinkler density, tubewell type and tractor density were considered for socioeconomic characterization. Each of these parameters was modelled and mapped using well established methods The biophysical and socioeconomic parameters were integrated using a multivariate clustering method. The integration modelling results in the delineation of the region into seven RMDs, which were validated with two focus group discussions (FGD) in each of the RMD’s. The correlation between the RMD modelling results and the FGD was found to be more than 90% in five RMDs and 65% and 39% in the remaining two RMDs respectively. The result was also validated with feedback from the local administrative authorities. The study charts a sound basis for policy makers for taking the necessary steps to address location-specific differential agricultural needs in any region.

A Cost-effectiveness Analysis of Antipsychotics for Treatment of Schizophrenia in Uganda.

Reductions in prices following the expiry of patents on second-generation antipsychotics means that they could be made available to patients with schizophrenia in low-income countries. In this study we examine the cost effectiveness of antipsychotics for schizophrenia in Uganda. We developed a decision-analytic 10-state Markov model to represent the clinical and treatment course of schizophrenia and the experience of the average patient within the Uganda healthcare system. The model was run for a base population of 25-years-old patients attending Butabika National Referral Mental Hospital, in annual cycles over a lifetime horizon. Parameters were derived from a primary chart abstraction study, a local community pharmacy survey, published literature, and expert opinion where necessary. We computed mean disability-adjusted life-years (DALYs) and costs (in US$ 2012) for each antipsychotic, incremental cost, and DALYs averted as well as incremental cost-effectiveness ratios (ICERs). In the base-case analysis, mean DALYs were highest with chlorpromazine (27.608), followed by haloperidol (27.563), while olanzapine (27.552) and risperidone had the lowest DALYs (27.557). Expected costs were highest with quetiapine (US$4943), and lowest with risperidone (US$4424). Compared to chlorpromazine, haloperidol was a dominant option (i.e. it was less costly and more effective); and risperidone was dominant over both haloperidol and quetiapine. The ICER comparing olanzapine to risperidone was US$5868 per DALY averted. When choosing between first-generation antipsychotics, clinicians should consider haloperidol as the first-line agent for schizophrenia. However, overall, risperidone is a cost-saving strategy; policymakers should consider its addition to essential medicines lists for treatment of schizophrenia in Uganda.

PMH38 - A Cost-effectiveness analysis of Antipsychotics for treatment of Schizophrenia in Uganda

Reductions in prices following the expiry of patents on second-generation antipsychotics means that they could be made available to patients with schizophrenia in low-income countries. In this study we examine the cost effectiveness of antipsychotics for schizophrenia in Uganda. We developed a decision-analytic 10-state Markov model to represent the clinical and treatment course of schizophrenia and the experience of the average patient within the Uganda healthcare system. The model was run for a base population of 25-years-old patients attending Butabika National Referral Mental Hospital, in annual cycles over a lifetime horizon. Parameters were derived from a primary chart abstraction study, a local community pharmacy survey, published literature, and expert opinion where necessary. We computed mean disability-adjusted life-years (DALYs) and costs (in US$ 2012) for each antipsychotic, incremental cost, and DALYs averted as well as incremental cost-effectiveness ratios (ICERs). In the base-case analysis, mean DALYs were highest with chlorpromazine (27.608), followed by haloperidol (27.563), while olanzapine (27.552) and risperidone had the lowest DALYs (27.557). Expected costs were highest with quetiapine (US$4943), and lowest with risperidone (US$4424). Compared to chlorpromazine, haloperidol was a dominant option (i.e. it was less costly and more effective); and risperidone was dominant over both haloperidol and quetiapine. The ICER comparing olanzapine to risperidone was US$5868 per DALY averted. When choosing between first-generation antipsychotics, clinicians should consider haloperidol as the first-line agent for schizophrenia. However, overall, risperidone is a cost-saving strategy; policymakers should consider its addition to essential medicines lists for treatment of schizophrenia in Uganda.

Local health practices and the knowledge of medicinal plants in a Brazilian semi-arid region: environmental benefits to human health.

BackgroundThe concept of eco-cultural health considers the dynamic interaction between humans and ecosystems, emphasizing the implications of the health of the ecosystem for the health and well-being of human populations. Ethnobotanical studies focusing on folk medicine and medicinal plants can contribute to the field of eco-cultural health if they incorporate the perspective and local knowledge of communities. We investigated the local health practices in three rural communities living within the vicinity of a protected area of sustainable use in a semi-arid region of Brazil. We analyzed the opinions of local health experts on the elements that influence human health and on how the environment contributes to this influence. We also analyzed and compared the local knowledge of medicinal plants, as knowledge of this type is an important factor when considering the interaction between environmental and human health.MethodsWe performed structured interviews and free-listings with 66 local health experts. We used content analysis to systematize the elements of the influences on human health. We compared the richness of the plants cited among communities and analyzed the differences among the three communities regarding the ways in which the plants were obtained and the environments in which plants were collected.ResultsThe local experts identified several influences of the environment on human health. These influences can be associated with ecosystem services, such as climatic conditions, water and air quality, recreation and medicinal and food resources. We identified 192 medicinal plant species, most of which were gathered from wild ecosystems. The most important environments for the three communities were the plateau mountain and backyards.ConclusionsThe informants had a broad and integrated view of health, perceiving the importance of conserving the environment within the National Forest of Araripe for the health and well-being of the local populations.

A decision framework for prioritizing multiple management actions for threatened marine megafauna.

Resources for conserving biodiversity are invariably insufficient. This situation creates the need for transparent, systematic frameworks to help stakeholders prioritize the allocation of resources across multiple management actions. We developed a novel framework that explicitly prioritizes actions to minimize the impacts of several threats across a species' range. The framework uses a budget constraint and maximizes conservation outcomes from a set of management actions, accounting for the likelihood of the action being successfully applied and accepted by local and Indigenous communities. This approach is novel in that it integrates local knowledge and expert opinion with optimization software, thereby minimizing assumptions about likelihood of success of actions and their effectiveness. To test the framework, we used the eastern Gulf of Carpentaria and Torres Strait population of the flatback turtle, Natator depressus, as a case study. This approach allowed the framework to be applied in a data-poor context, a situation common in conservation planning. The framework identified the best set of actions to maximize the conservation of flatback eggs for scenarios with different budgets and management parameters and allowed comparisons between optimized and preselected scenarios. Optimized scenarios considered all implementable actions to explore how to best allocate resources with a specified budget and focus. Preselected scenarios were used to evaluate current allocations of funds and/or potential budget allocations suggested by different stakeholders. Scenarios that used a combination of aerial and ground strategies to reduce predation of eggs performed better than scenarios that focused only on reducing harvest of eggs. The performances of optimized and preselected scenarios were generally similar among scenarios that targeted similar threats. However, the cost-effectiveness of optimized scenarios was usually higher than that of preselected scenarios, demonstrating the value of conducting a systematic optimization approach. Our method provides a foundation for more effective conservation investments and guidance to prioritize actions within recovery plans while considering the sociopolitical and cultural context of decisions. The framework can be adapted easily to a wide range of species, geographical scales, and life stages.

A generic rabies risk assessment tool to support surveillance

The continued spread of rabies in Indonesia poses a risk to human and animal populations in the remaining free islands, as well as the neighbouring rabies-free countries of Timor Leste, Papua New Guinea and Australia. Here we describe the development of a generic risk assessment tool which can be used to rapidly determine the vulnerability of rabies-free islands, so that scarce resources can be targeted to surveillance activities and the sensitivity of surveillance systems increased. The tool was developed by integrating information on the historical spread of rabies, anthropological studies, and the opinions of local animal health experts. The resulting tool is based on eight critical parameters that can be estimated from the literature, expert opinion, observational studies and information generated from routine surveillance. In the case study presented, results generated by this tool were most sensitive to the probability that dogs are present on private and fishing boats and it was predicted that rabies-infection (one infected case) might occur in a rabies-free island (upper 95% prediction interval) with a volume of 1000 boats movements. With 25,000 boat movements, the median of the probability distribution would be equal to one infected case, with an upper 95% prediction interval of six infected cases. This tool could also be used at the national-level to guide control and eradication plans. An initial recommendation from this study is to develop a surveillance programme to determine the likelihood that boats transport dogs, for example by port surveillance or regularly conducted surveys of fisherman and passenger ferries. However, the illegal nature of dog transportation from rabies-infected to rabies-free islands is a challenge for developing such surveillance.

Implementation of an off-label recombinant factor VIIa protocol for patients with critical bleeding at an academic medical center.

To describe the development of a pharmacy driven off-label recombinant factor seven (rFVIIa) protocol by a multi-disciplinary team for critical bleeding. A multi-disciplinary team made up of members from several critical care and surgical departments within the hospital were formed and charged with developing a standardized approach to how rFVIIa would be used for critical bleeding in an academic medical center. Groups represented on the multi-disciplinary team included clinical pharmacy, emergency medicine, pulmonary, hematology, cardiothoracic surgery, trauma, neurosurgery, and vascular surgery physicians. A pharmacist driven off-label rFVIIa protocol was developed and implemented for the use in those patients with critical bleeding. The protocol was based on the available literature and local expert opinion. Through the use of this protocol a significantly smaller average dose of rFVIIa is now being used when compared to those patients treated prior to the new protocol (47.5 vs. 62.2 mcg/kg, p = 0.036) while all-cause mortality was not significantly altered (35 vs. 48.8%, p = 0.057). An effective and safe pharmacy driven protocol was implemented by a multi-disciplinary team for rFVIIa as seen by providing a significantly lower average dose of rFVIIa while not sacrificing for overall patient mortality.

Quantifying Catastrophic and Climate Impacted Hazards Based on Local Expert Opinions

The analysis of catastrophic and climate impacted hazards is a challenging but important exercise, as the occurrence of such events is usually associated with high damage and uncertainty. Often, at the local level, there is a lack of information on rare extreme events, such that available data is not sufficient to fit a distribution and derive parameter values for the frequency and severity distributions. This paper discusses local assessments of extreme events and examines the potential of using expert opinions in order to obtain values for the distribution parameters. In particular, we illustrate a simple approach, where a local expert is required to only specify two percentiles of the loss distribution in order to provide an estimate for the severity distribution of climate impacted hazards. In our approach, we focus on so-called heavy-tailed distributions for the severity, such as the Lognormal, Weibull and Burr XII distribution. These distributions are widely used to fit data from catastrophic events and can also represent extreme losses or the so-called tail of the distribution. An illustration of the method is provided utilising an example that quantifies the risk of bushfires in a local area in Northern Sydney.

基于GIS的虾夷扇贝养殖适宜性综合评价——以北黄海大小长山岛为例

由于水产养殖缺乏科学空间规划，近年来中国最大的虾夷扇贝（<em>Patinopecten yessoensis</em>）养殖基地长山群岛发生了扇贝大规模死亡现象。当地渔业主管部门急需水产养殖空间格局优化的技术手段和科学依据。采用叶绿素a浓度、海水表面温度、水深、透明度以及评价单元到渔港、城镇、旅游区和自然保护区的距离等指标，构建了虾夷扇贝养殖适宜性评价模型，并以大小长山岛海域为示范区，对该海域的虾夷扇贝的养殖适宜性进行了空间分析。结果表明：大小长山岛海域虾夷扇贝养殖适宜性较高且具有较大的空间变异，在不考虑海域使用冲突情形下，养殖适宜性指数在6.0-7.0以及7.0以上的海域占示范区的面积比例分别为26.04%（167.75 km²）和4.73%（44.06 km²），且高适宜性（SSI > 7.0）区主要分布在大长山岛西北和西南海域；而由于航道和水产养殖存在海域使用冲突，高适宜区面积大幅下降为19.56 km²。在此基础上对大小长山岛海域虾夷扇贝养殖空间格局优化提出了建议。利用一些简单的距离指标反映了陆地基础设施因素对水产养殖选址的影响，体现了海陆统筹的理念并可为海陆统筹技术方法研究提供重要借鉴。;Changshan archipelago in North Yellow Sea, the biggest base for Japanese scallop aquaculture in China, has recently experienced a series of problems including large-scale scallop death, environmental degradation and sea use conflicts. Most of them are attributed to the shortage of scientific spatial planning for Japanese scallop aquaculture and the subsequent over-density issue to great extent. The local government and farmers are in urgent need of the technology and scientific foundation for spatial adjustment and optimization of current scallop aquaculture. It is widely accepted that the definition and characterization of suitable aquaculture zones is pivotal for the success and sustainable development of aquaculture, GIS based suitability studies for aquaculture site selection, however, are surprisingly very rare in China. With the islands of Dachangshan and Xiaochangshan (IDX) as a case, a GIS-based aquaculture site suitability index (SSI) model was used in the spatial suitability analysis of Japanese scallop aquaculture. The distances to towns, biological conservation zones, island tourism zones, fishery harbors and navigation lines in addition to SST, bathymetry, water transparency, Chl a were used as criteria or parameters for site selection, which were selected according to the current sea uses and ecological issues of concern in IDX and the requirements of Japanese scallop for environments as well. Field surveyed data were used to obtain the parameters for Chl a and water transparency whereas the other parameters were extracted from basic geospatial vector data or raster data(only ocean color SST here) for the study area to produce thematic layers in the form of raster by means of distance tool or interpolation tool in ArcGIS 10. All data were re-sampled or interpolated to the same resolution of 250 meters and a suitability score for each criterion was established using a scoring system from 1 to 8, with 8 being the most suitable and 1 being the least suitable for developing scallop culture. To make full use of the expertise and research results of foreign scientists in this field, the weights and scoring system for these parameters were mainly determined according to relevant references and slightly adjusted based on the opinions of local aquaculture experts and farmers. After that, a site suitability index model based on a liner weighted combination of suitability score for each parameter was used to calculate the site suitability index (SSI) for each assessment unit(pixel here). Due to the sea use conflicts between scallop aquaculture and navigation, biological conservation and island recreation, some water areas cannot be used as scallop aquaculture sites and form spatial constraints. Given that the issue of sea use conflicts is a big concern in marine aquaculture site selection, the spatial and areal distribution of SSI for IDX were analyzed both in the scenarios of no spatial constraints and spatial constraints, on which basis aquaculture structure optimization plan for IDX was proposed in this paper. The results showed that IDX were fairly suitable for Japanese scallop aquaculture and of big spatial variation. 32.06% of the potential water area (211.81 km²) had suitability index bigger than 6.0 in the scenario of no spatial constraints. The highly suitable sites with SSI above 7 (accounting for 4.73% of the potential water area) were mainly distributed to the northwest and southwest of Dachangshan Island with an area of 44.06 km². In addition, it was found that the spatial constrains mainly resulted from the sea use conflict between aquaculture and marine navigation, which made the area of highly suitable level (SSI > 7.0) drop from 44.06 km² to 19.56 km². The adjustment of navigation line can improve the potential of scallop aquaculture potential greatly. In this paper, the impact of scallop aquaculture on nature reserve of wild fishery species was considered in the scallop site suitability model, highlighting the concern of biodiversity conservation. Besides, the role of land based social-infrastructure resources such as fishery harbors and towns in site selection reflected the thought of land-ocean overall planning. In the end, advice on the spatial pattern adjustment of Japanese scallop aquaculture in IDX was given based on the aquaculture site suitability analysis. The results are expected to provide an important scientific foundation for spatial structure optimization of Japanese scallop aquaculture in IDX whereas the methodology can be used as an important reference for the spatial pattern adjustment of marine aquaculture in China.

Smoking-attributable burden of lung cancer in the Philippines: a comparative risk assessment

BackgroundSmoking is highly prevalent in the Philippines. Tobacco control policies fail to fully implement the WHO Framework Convention on Tobacco Control provisions, especially with respect to taxation, smoking bans, sales and marketing restrictions, and cessation support. To aid in policy change and intervention implementation, monitoring, and evaluation, this study aimed to provide the most recent (2008) estimates for the Philippines of: (1) disability-adjusted life-years (DALYs) lost due to lung cancer; (2) population-attributable fractions (PAFs) for smoking; and (3) smoking-attributable lung cancer DALYs. MethodsThis study applied the Global Burden of Disease and Comparative Risk Assessment frameworks to secondary data, supplemented by local expert opinion. A comprehensive internally consistent assessment of disease epidemiology was conducted using the DisMod II model, and disease impact was quantified in the form of DALYs. PAFs were calculated using the smoking impact ratio, which indirectly estimates accumulated smoking exposure. Uncertainty analyses to obtain intervals were conducted per age–sex group via Monte Carlo simulations. FindingsFor the 2008 Philippine population, aggregated lung cancer incidence and mortality estimates were 10 871 cases and 9871 deaths, respectively. Lung cancer accounted for the loss of an aggregated estimate of 104 442 DALYs, 99% of which were due to years of life lost. Overall, the aggregated PAF for smoking was 62%, and an aggregated total of 64 913 DALYs were attributable to smoking. There were increasing trends in incidence, mortality, and DALY losses with age, the majority of which occurred among males, who also had higher PAF estimates. InterpretationConsiderable health gains could be achieved if smoking exposure were eliminated or reduced in the Philippines. Prevention of initiation and support for cessation of smoking through strong enforcement of measures, such as increasing taxation to the WHO-endorsed rate, more stringent sales and marketing restrictions, and development and scaling up of smoking cessation programmes is recommended. FundingNone.

The Prevalence of Bacteremia in Pediatric Patients With Community-Acquired Pneumonia: Guidelines to Reduce the Frequency of Obtaining Blood Cultures

The goal of this study was to determine the prevalence of bacteremia in pediatric patients with community-acquired pneumonia (CAP) at our institution and to test the effectiveness of newly developed guidelines for obtaining blood cultures. Using recent literature and local expert opinion, institutional guidelines for obtaining blood cultures in pediatric patients with CAP were developed. A retrospective chart review of children treated in the emergency department or admitted for CAP from January 2010 through June 2011 was conducted. Demographic and clinical data were collected, including results of blood cultures. Chi2 tests assessed for variables associated with bacteremia, whether a blood culture was obtained, and if the decision to obtain a culture was appropriate based on our guidelines. The study included 330 patients; 155 (47%) blood cultures were obtained in our patient population. Five cultures were true-positive findings, making the prevalence of bacteremia 3.2% in patients with blood cultures and 1.5% in all patients. All 5 true positive results met criteria for blood culture based on our guidelines. Applying our guidelines retrospectively, the decision to obtain a blood culture met criteria in 55% of the cases. Bivariate analysis showed that patients discharged from the emergency department had higher rates of guideline-appropriate decisions than patients admitted. Radiographic findings were associated with making a guideline-appropriate decision regarding blood culture. Instituting local guidelines that limit the frequency of obtaining blood cultures in pediatric patients with CAP is likely to capture any patient with bacteremia. This study suggests that blood cultures may not need to be routinely obtained in all patients admitted to the hospital with CAP.

Sustainability of European maize-based cropping systems: Economic, environmental and social assessment of current and proposed innovative IPM-based systems

There is strong social and political pressure to reduce pesticide use in European agriculture. Evaluating the sustainability of cropping systems is a complex task due to the conflicting objectives underlying its economic, social and environmental dimensions. Multi-criteria assessment of different Integrated Pest Management (IPM) scenarios and evaluation of the most sustainable options at regional, national and European level is essential. Within the EU Network of Excellence ENDURE, two expert-based surveys were conducted (i.e. interviews), where experts from four European regions (northern region, Denmark and The Netherlands; central-eastern, Tolna and Békés counties in Hungary; south-western, Ebro Valley in Spain; southern, Po Valley in Italy) determined which are the main current maize-based cropping systems (MBCSs) in their region and proposed innovative IPM-based systems. The DEXiPM® (DEXi Pest Management) model for arable cropping systems was used to evaluate and compare the economic and environmental sustainability of these systems. The social sustainability was evaluated by adapting indicators of this model to the specificities of maize systems. The assessments showed that all innovative rotated MBCSs proposed in the four regions can have a higher environmental sustainability than and maintain the same economic sustainability as current rotated systems. These cropping systems are thus acceptable for testing under “real” field conditions. Only the innovative continuous maize system proposed in the central-eastern region was both economically and environmentally more sustainable than the current system. All innovative systems had a positive impact on work safety but according to local expert opinion producers and consumers are not ready to implement them or to accept their higher-priced products, with the exception of consumers in the northern region. These results suggest the need for European and regional policies to encourage the adoption of innovative rotated MBCSs that have positive agronomic and environmental impact through IPM implementation. The major constraints that inhibit this adoption were predominantly relating to (1) the lack of access that farmers have to the practical knowledge needed to effectively manage these systems and (2) the insufficient consumer awareness and acceptance of product improvements associated with IPM. To overcome these constraints supportive policy environments, well-functioning knowledge management systems (including good farmer support networks) and effective marketing is required.

Patient safety and quality improvement education: a cross-sectional study of medical students' preferences and attitudes.

BackgroundRecent educational initiatives by both the World Health Organization and the American Association of Medical Colleges have endorsed integrating teaching of patient safety and quality improvement (QI) to medical students. Curriculum development should take into account learners’ attitudes and preferences. We surveyed students to assess preferences and attitudes about QI and patient safety education.MethodsAn electronic survey was developed through focus groups, literature review, and local expert opinion and distributed via email to all medical students at a single medical school in the spring of 2012.ResultsA greater proportion of students reported previous exposure to patient safety than to quality improvement topics (79% vs. 47%). More than 80% of students thought patient safety was of the same or greater importance than basic science or clinical skills whereas quality improvement was rated as the same or more important by about 70% of students. Students rated real life examples of quality improvement projects and participation in these projects with actual patients as potentially the most helpful (mean scores 4.2/5 and 3.9/5 respectively). For learning about patient safety, real life examples of mistakes were again rated most highly (mean scores 4.5/5 for MD presented mistakes and 4.1/5 for patient presented mistakes). Students rated QI as very important to their future career regardless of intended specialty (mean score 4.5/5).ConclusionsTeaching of patient safety and quality improvement to medical students will be best received if it is integrated into clinical education rather than solely taught in pre-clinical lectures or through independent computer modules. Students recognize that these topics are important to their careers as future physicians regardless of intended specialty.

English

To evaluate the proportion of inappropriate digoxin level determinations in children at Children’s Hospital of Fudan University. A retrospective analysis of 291 digoxin level determinations in 210 inpatients was performed. Appropriateness criteria were based on existing criteria that were revised using local expert opinion. The main outcome measure was the proportion of digoxin levels assessed as inappropriate by these criteria. Of the 291 digoxin levels, 126 (43.3%) were considered inappropriate and the remaining 165 (56.7%), appropriate. For the majority of the inappropriate determinations timing of blood sampling was incorrect (74.6%); the remaining determinations were done without proper indication. Almost half the digoxin blood level monitoring was assessed as inappropriate, mainly because of incorrect timing of sampling. Interventions to ensure that appropriate indications and procedures for serum digoxin determination in children at the Children’s Hospital of Fudan University are urgently needed, moreover, special criteria need to be made for children in digoxin blood level monitoring. Key words: Digoxin, therapeutic drug monitoring, children, appropriateness.

A conceptual model of the citizen stream stewardship decision process in an urbanising Midwestern United States watershed

We present a conceptual model depicting how citizens make decisions to promote stream health. The model, based on a combination of local expert opinion and substantive literature, serves as a foundation for assessing citizen knowledge gaps and decision influences, with the ultimate goal of designing more informed communication efforts. The model indicates that decisions are directly influenced by the recognition of a threat and need to act, as well as the legal requirement to act regardless of personal concern. The recognition of a threat is dependent on understanding the ecosystem and the threats and impacts to stream health, as well as a variety of individual differences and socio-cultural factors that motivate individuals to better understand the risk.

Recommendations for the management of adult chronic myeloid leukaemia in South Africa.

Chronic myeloid leukaemia (CML) is a chronic myeloproliferative disorder characterised by a chromosomal translocation between the long arms of chromosomes 9 and 22 [corrected] resulting in the formation of the BCR-ABL fusion gene. The management of CML has undergone major changes over the past decade. Novel treatment approaches have had a dramatic impact on patient outcomes and survival. Nevertheless, these outcomes can only be achieved in the context of expert management, careful monitoring of disease response, appropriate management of adverse events and timeous adjustments to therapy when responses are not achieved within stated time-frames. With the advent of novel treatments providing molecular responses, both the monitoring and management of CML have become more complicated. The aim of these recommendations was to provide a pragmatic yet comprehensive roadmap to negotiate these complexities. Recommendations were developed based on local expert opinion from both the academic and private medical care arenas after careful review of the relevant literature and taking into account the most widely used international guidelines. About five meetings were held at which these recommendations were discussed and debated in detail. A comprehensive set of recommendations was compiled with an emphasis on diagnosis, investigation, treatment and monitoring of disease. Careful attention was given to circumstances unique to South Africa, funding constraints, availability and access to laboratory resources, as well as the effects of concurrent HIV infection. Most patients with CML can live a reasonably normal life if their disease is appropriately managed. These recommendations should be of value to all specialists involved in the treatment of haematological disorders.

Pharmacoeconomic Analysis of Capecitabine versus 5-Fluorouracil/Leucovorin as Adjuvant Therapy for Stage III Colon Cancer in Taiwan

ObjectivesTo assess the cost-effectiveness of oral capecitabine compared with intravenous bolus 5-fluorouracil/leucovorin (5-FU/LV) in the adjuvant treatment of stage III colon cancer in Taiwan from payer (Bureau of National Health Insurance [BNHI]) perspectives. MethodsA health state-transition model was developed to estimate the incremental costs and effectiveness of capecitabine versus 5-FU/LV. The time horizons studied were: treatment duration (24 weeks) plus 36 months, 48 months, 60 months, 120 months, and lifetime. Costs were expressed in Taiwanese new dollars (NT$). Clinical outcomes, medical resource use, and utilities were extracted from published sources. Unit costs were estimated from BNHI fee schedules, published sources, and local expert opinion. Outcomes and future costs were discounted at 3%. Cost-effectiveness was expressed as cost per quality-adjusted life-month (QALM). The effects of uncertainty were explored through a one-way sensitivity analysis. ResultsFor the 24-week time period, drug acquisition costs were higher for capecitabine than 5-FU/LV (NT$114,405 vs. NT$4,904 per patient); however, these were offset by the higher administration costs of 5-FU/LV (NT$2,573 vs. NT$204,201 per patient). Overall direct costs for the 24-week treatment period were less with capecitabine than 5-FU/LV (NT$129,327 vs. NT$233,873 per patient). Cost savings with capecitabine were also evident when longer time horizons were considered. Over a lifetime, the projected survival benefit for capecitabine was 7 QALMs. ConclusionsFrom the perspectives of the BNHI and society in Taiwan, capecitabine not only saves costs but also improves health outcomes compared with 5-FU/LV in the adjuvant treatment of stage III colon cancer.