Mapping opportunities for the use of land management strategies to address fire risk in Europe.

Many parts of Europe face increasing challenges managing wildfires. Although wildfire is an integral part of certain ecosystems, fires in many places are becoming larger and more intense, driven largely by climate change, land abandonment, and changes in fuel management with important socioeconomic, environmental, and ecosystem services consequences for Europe. In order to envision a comprehensive fire risk mitigation strategy for Europe, a spatial assessment of opportunities to manage fuels at the landscape-scale is needed. Our study explored the suitability of three land management strategies (LMS)-herbivory, mechanical fuel removal, and prescribed burn-which can create more heterogenous fuelscapes, thereby reducing an element of fire risk. We created suitability maps for each of the LMS using adoption factors identified in a systematic literature review (n = 123). We compared these maps with areas of historical fire occurrence as a proxy for fire risk to prioritize key areas for intervention. We found that over a quarter of Europe was suitable for multiple LMS within areas of greater fire risk, creating opportunities for concurrent and synergistic use of the strategies. Options were more limited in areas of southern Europe, where prescribed burn was found to be uniquely viable amongst the LMS evaluated. Opportunities were also restricted in some areas of high fire risk in northern Europe, where herbivory was found to be the only suitable LMS. Our findings take a wide-view of fuel management to target landscape-scale decision making focused on reducing fire risk. However, many other factors must be taken into account to successfully manage fuels at local scales, including the socio-cultural appropriateness of the LMS, the viability of incentive schemes, and possible trade-offs with other management goals, such as carbon storage and biodiversity.

Estimating scenarios for survival time in men starting systemic therapies for castration-resistant prostate cancer: a systematic review of randomised trials.

BACKGROUND: We sought to estimate worst-case, typical and best-case scenarios for survival in men starting systemic therapies for castration resistant prostate cancer (CRPC). METHODS: We sought randomised phase 3 trials of systemic therapies for CRPC and recorded the following percentiles (represented scenario) from Kaplan-Meier overall survival (OS) curves: 90th (worst-case), 75th (lower-typical), 50th (median), 25th (upper-typical) and 10th (best-case). We determined the accuracy of using simple multiples of the median OS to estimate the other selected percentiles from each curve: 0.25 for 90th, 0.5 for 75th, 2 for 25th and 3 for 10th. Estimates were deemed accurate if within 0.75-1.33 times the actual value. FINDINGS: We reviewed 23 trials (13,909 men) with 48 treatment groups including 28 of chemotherapy, and three of novel hormonal agents. In trials of first-line docetaxel, the mean (interquartile range) for median OS was 19 months (17-20), and for each scenario was: worst-case 7 months (6-8); lower-typical 12 months (11-13); upper-typical 29 months (27-31); and best-case 40 months (34-44). For trials of novel hormonal agents after chemotherapy the mean values were: median OS 17 months, worst-case 5 months, lower-typical 9 months, upper-typical 24 months and best-case not reported. Simple multiples of the median gave accurate estimates of the worst-case scenario in 72% of OS curves, lower-typical in 89%, upper-typical in 84% and best-case in 84%. INTERPRETATION: Simple multiples of the median OS from randomised trials provided accurate estimates of worst-case, typical and best-case scenarios for survival time in men starting systemic therapies for CRPC.

Full time trauma service leads to improved Level III trauma center outcomes.

BACKGROUND: Level III trauma centers are an effective component of a healthy trauma system. This study examined the effectiveness over time of a Level III trauma center in a predominately rural region. METHODS: For analysis, the data were divided into 2 equal time spans: an early period (1997-2002) and a late period (2003-2008). A dedicated trauma service was implemented in 2003. RESULTS: A total of 8,689 patient outcomes were analyzed. In those patients with an injury severity score of 15 or less, 49 of 3,307 (1.5%) patients died in the early period, and 74 of 4,244 (1.7%) died in the late period (P = .40). In those with an injury severity score greater than 15, 66 of 402 patients (16.4%) died in the early period, whereas 81 of 736 (11.0%) patients died in the late period (P = .01). Despite the increased injury severity, overall mortality rates remained unchanged. CONCLUSIONS: Implementation of a full-time trauma service resulted in improved outcomes including a 33% mortality reduction in the severely injured.

Immediate effects of positive end-expiratory pressure and low and high tidal volume ventilation upon gas exchange and compliance in patients with acute lung injury.

BACKGROUND: Protective ventilation, in general, includes low tidal volume ventilation and maintaining end-inspiratory plateau pressures less than 35 cmH2O. Recent clinical studies have determined that such an approach results in improved survival in patients with moderate to severe acute lung injury and acute respiratory distress syndrome. However, experimental evidence suggests that repeated end-expiratory collapse and reexpansion contributes to ventilator-induced lung injury. We sought to determine the immediate effects of specific tidal volume-PEEP combinations upon oxygenation and static compliance in patients with moderate to severe acute lung injury. METHODS: Fourteen patients were prospectively studied and were treated with each of 10 tidal volume-PEEP combinations, applied in random order. After 5 minutes at each tidal volume-PEEP combination, PaO2/FIO2 and static compliance were recorded. Comparisons were made between low and high tidal volume ventilation as well as across five PEEP levels. RESULTS: At both low (6 mL/kg) and high (10 mL/kg) tidal volume ventilation, PaO2/FIO2 increased with increasing PEEP, up to 20 cmH2O. Similar changes in static compliance were not evident. Static compliance was highest at PEEP of 10 and 15 cmH2O, regardless of tidal volume. With PEEP set at 5 cmH2O, static compliance was significantly lower with 6 mL/kg than with 10 mL/kg tidal volumes. Overall, static compliance was lowest for both tidal volume conditions with PEEP set at 25 cmH2O. CONCLUSION: Low tidal volume ventilation with PEEP set at 5 cmH2O results in poor oxygenation and compliance in patients with moderate to severe acute lung injury. Similarly, PEEP set at 25 cmH2O did not improve oxygenation or compliance.

Accuracy of external cause of injury codes reported in Washington State hospital discharge records.

OBJECTIVE: To evaluate the accuracy of external cause of injury codes (E codes) reported in computerized hospital discharge records. METHODS: All civilian hospitals in Washington State submit computerized data for each hospital discharge to a file maintained by the Department of Health. In 1996, 32 hospitals accounted for 80% of the injury related discharges in this file; from these hospitals, we sampled 1,260 computerized records for injured patients in a stratified, but random, manner. An expert coder then visited the 32 study hospitals, reviewed the medical records that corresponded to each computerized record, and assigned an E code for that hospitalization. The computerized E code information was compared with codes provided by the expert reviewer. RESULTS: The incidence of hospitalization for injury based upon computerized hospital discharge data was very similar to that based upon chart review: incidence rate ratio 1.0 (95% confidence interval 1.00 to 1.02). Computerized hospital discharge data correctly ranked injuries in regard to both mechanism and intent. Overall agreement on coding was 87% for mechanism of injury, 95% for intent of injury, and 66% for the complete E code. The sensitivity of computerized hospital discharge data for identification of falls, motor vehicle traffic injuries, poisonings, and firearm injuries was 91% or better. The predictive value positive of coding for these four categories of injury ranged from 88% for motor vehicle traffic injuries to 94% for poisonings. The amount of agreement for intent coding ranged from 84% for firearm injuries to 99% for falls. Agreement on coding of the complete E code ranged from 57% for firearm injuries to 72% for poisonings. CONCLUSIONS: Computerized hospital discharge data can be used with confidence to determine how many injuries are treated in a hospital setting and the relative magnitude of various categories of injury. E codes reported in hospital discharge data are a reliable source of information on the types of information most often used for injury related analyses and priority setting. The detail codes (complete E codes) reported in hospital discharge codes are less reliable and must be used with caution.

Harborview assessment for risk of mortality: an improved measure of injury severity on the basis of ICD-9-CM.

BACKGROUND: There have been several attempts to develop a scoring system that can accurately reflect the severity of a trauma patient's injuries, particularly with respect to the effect of the injury on survival. Current methodologies require unreliable physiologic data for the assignment of a survival probability and fail to account for the potential synergism of different injury combinations. The purpose of this study was to develop a scoring system to better estimate probability of mortality on the basis of information that is readily available from the hospital discharge sheet and does not rely on physiologic data. METHODS: Records from the trauma registry from an urban Level I trauma center were analyzed using logistic regression. Included in the regression were Internation Classification of Diseases-9th Rev (ICD-9CM) codes for anatomic injury, mechanism, intent, and preexisting medical conditions, as well as age. Two-way interaction terms for several combinations of injuries were also included in the regression model. The resulting Harborview Assessment for Risk of Mortality (HARM) score was then applied to an independent test data set and compared with Trauma and Injury Severity Score (TRISS) probability of survival and ICD-9-CM Injury Severity Score (ICISS) for ability to predict mortality using the area under the receiver operator characteristic curve. RESULTS: The HARM score was based on analysis of 16,042 records (design set). When applied to an independent validation set of 15,957 records, the area under the receiver operator characteristic curve (AUC) for HARM was 0.9592. This represented significantly better discrimination than both TRISS probability of survival (AUC = 0.9473, p = 0.005) and ICISS (AUC = 0.9402, p = 0.001). HARM also had a better calibration (Hosmer-Lemeshow statistic [HL] = 19.74) than TRISS (HL = 55.71) and ICISS (HL = 709.19). Physiologic data were incomplete for 6,124 records (38%) of the validation set; TRISS could not be calculated at all for these records. CONCLUSION: The HARM score is an effective tool for predicting probability of in-hospital mortality for trauma patients. It outperforms both the TRISS and ICD9-CM Injury Severity Score (ICISS) methodologies with respect to both discrimination and calibration, using information that is readily available from hospital discharge coding, and without requiring emergency department physiologic data.

Assumptions of infantile amnesia: are there differences between early and later memories?

Most adults are able to provide few, if any, reports of autobiographical memories from the first years of life. Early memories that do exist have been characterised as highly emotional, containing an abundance of perceptual as opposed to propositional information, and more often in the third than the first person perspective. These qualities figure prominently in theories of the source of the phenomenon of infantile amnesia. However, early and later memories have not been directly compared with regard to these features. In the present research, we compared early and later memories in the same individuals, with the same methodology. Results indicated few objective differences between the early and later memories of women (Experiment 1) and men (Experiment 2). The findings are discussed in light of their implications for theories as to the source of infantile amnesia.