Some people think that search engine optimisation is a service that costs a lot of money. Although this certainly needn't be the case, there is an element of truth in this. The reality is that good SEO providers can afford to charge relatively high fees because they have a track record of success.
If you only have a small budget available for SEO, then what does this mean for you? Does it mean that you won't be able to hire an SEO company and will be forced to carry out the work in-house?
This is the route that many small businesses take and it's understandable that they should reach such a conclusion. The problem is that it can be difficult to evaluate agencies and companies providing these services. Although you may be able to get a cheap deal, how can you be certain that it will represent real value for money?
A good search engine optimisation campaign should be cost-effective, producing results that make the financial investment worthwhile. In fact, it could be argued that it shouldn't be seen as being a cost at all, but that's another story!
So what options are available to you? It might be worth asking friends and family members to see if anyone would recommend an SEO service provider. That could be a good way to get in contact with a reputable business.
If you can't find such a company, however, you'll be faced with the prospect of carrying out the work yourself. In such a situation, the best advice is to keep things simple and concentrate on the basics. Unless you happen to have considerable knowledge in this field of expertise, there's a good chance that you'll be learning as you go along. It is possible to do so, but not always easy.
Try not to hurry things too much. You'll want to make sure that you're taking the right decisions and spending your time wisely. It's a good idea to start by concentrating on some on-site optimisation techniques. You often have a fair degree of control here, allowing you to experiment and build confidence.
Unless you're looking at a really uncompetitive area, the reality is that you'll also need to come up with a comprehensive link-building campaign. There's no doubt that this can be a challenging exercise. Again, it makes sense to keep things simple.
You might begin by submitting your own website to relevant directories and asking business contacts and suppliers if they would be willing to provide links to your site. As you gain more links, you'll find that the process becomes easier.
It is possible to do some good SEO work without an enormous amount of money. It just takes time and effort.
Tuesday, 31 May 2011
Carrying Out SEO On A Small Budget
Monday, 30 May 2011
Thigh Exercises For Women
For women, shaping the muscles of the thighs is an important fitness goal. A shapely lower body is considered very feminine, and the right proportion of the waist to the hips is part of the equation. It's surprising, but true, thigh toning exercises can be done at home, without equipment and results can be seen in 4-6 weeks. Also, did you know that thigh and hip toning gadgets are not required if you know which exercises work, and how to do them. Most importantly, thigh exercises are most effective when combined with aerobic exercise and a healthy diet.
This means that women must not only do the right thigh exercises, but also include aerobic exercise and sound nutrition to get best results. The following exercises are the most effective front thigh exercises for women. The routine also includes inner thigh and rear thigh exercises.
For best results, start with 15-20 repetitions and one set. Increase gradually to 2 sets. Complete the routine at least 2 times a week for best results. This is an effective beginner to intermediate toning program. Please remember that these numbers are general guidelines only. For an optimum program tailored to your needs, please consult a certified personal trainer. If you have any injuries or medical ailments, please obtain a physicians clearance before starting any exercise program.
Wall Squat: Front Thigh Exercise.
Starting Position: – Place your upper back against a smooth wall. Stand with your feet shoulder width apart, toes pointed slightly outward. Distribute your body weight equally between both feet and lean back against the wall. Movement: – Inhale, keeping your heels in contact with the floor at all times, slowly lower into a squat position while sliding down the wall. Exhale as you slowly straighten your legs, keeping your head and chest up, returning to the starting position. Repeat as required.
Standing Dumbbell Squats: Front Thigh Exercise.
Starting Position:- Hold a dumbbell in each hand and allow them to hang down at your sides. Stand with your feet shoulder width apart, toes pointed slightly outward. Distribute your body weight equally between both feet. Movement:- Inhale, keeping your heels in contact with the floor at all times, slowly lower into a squat position. Exhale as you slowly straighten your legs, keeping your head and chest up, returning to the starting position. Repeat as required. 5 lb dumbbells work well, but you can start with 2 lbs and then work your way up to 5 lbs within 3-5 weeks.
Lunges: Front Thigh Exercise.
Starting Position: – Assume a standing position with your feet slightly less than shoulder width apart. Grasp a barbell with a wider than shoulder width grip and place it across your shoulders. Movement: – Inhale, keeping your back vertical and slightly arched, slowly step forward with one leg making a long stride, lowering your body down slowly until your rear knee lightly touches the floor (if you cannot go as low as this, then work your way up to it over 2-3 weeks). Exhale and shift your weight backwards, taking one step (or 2-3 small steps if that sounds difficult) to return to the starting position. Repeat on the other side. Remember to consult your doctor before this or any other knee exercises if you have had any knee trouble!
Lying Face Down: Front Thigh Stretch.
Starting Position: Lie on your stomach on a matt with your legs together. Movement: Reach behind you and grasp your right ankle with your left hand. Pull your right heel up as far as you can. Hold this position for thirty seconds. Repeat as required on other side. Please remember to hold for 10 seconds for this stretch.
Seated Split Stretch: Inner Thigh Stretch.
Starting Position: Sit on an exercise matt and spread your legs as far as you can. Movement: Lean to your right side and reach for your toes. Rest your hands on your toes or at your ankle. Hold this position for thirty seconds. Repeat as required on other side.
Seated Butterfly: Inner Thigh Exercise.
Starting Position: Sit on an exercise matt with your back straight. Movement: Bring the soles of your feet together and pull them in as close to your body as you can. Allow your hands to rest on your feet or to apply light pressure to your thighs. Hold this position for thirty seconds. Hold this position for 10 seconds. You will find this most effective if you gently push your knees down using your hands, be careful not to push too much.
Seated Hip Twist: Outer Thigh And Rear Thigh Exercise.
Starting Position: Sit on an exercise matt with your legs straight out in front of you. Movement: Bend your right knee and place your right foot over your left leg. Wrap your arms around your right knee and gently pull it in towards your left shoulder. Hold this position for thirty seconds. Repeat as required on other side. Remember to hold for 10 seconds.
Lying Leg Pull: Total Thigh Exercise.
Starting Position: Lie on your back on an exercise matt with your knees in the air and feet flat on the floor. Movement: Bring your right heel to rest on your left thigh. Loop your hands around your left thigh and pull it towards your chest. Hold this position for thirty seconds. Repeat as required on other side. Remember to hold for 10 seconds in each set.
Why Taking Sun Protection Measures is so Important
Skin cancer is on the rise because each year the ozone layer can block less and less of the sun's ultraviolet radiation. UVR is the cause of skin cancer, which can be prevented by simply taking precautions and practicing some basic sun protection measures.
There are more than two million cases of skin cancer worldwide every single year, and a third of all cancers diagnosed in a year is skin cancer. These numbers show us just how vital it is to keep your skin safe from the sun. All it takes is one sunburn to almost double your risk of developing cancer of the skin.
In addition to the increased risk of cancer, there are also some less harmful but still unsightly reasons to take care and stay out of the sun. Too much sun exposure can cause your skin to age beyond your years by creating age spots, wrinkles, and other lines. These signs of aging are largely preventable by taking the proper sun protective measures.
Most articles of summer clothing offer a UPF, or ultraviolet protection factor, of just five, which is definitely not enough to prevent damage. The only way to keep your skin safe is to opt for sun protective clothing and swimwear. Many sun protective articles offer a UPF of 50+, and your options are not just limited to swimwear. Baby clothes, hiking clothes, and even fishing vests all can contain sun protection that will keep your skin safe from the sun's radiation.
Options in sun protective swimwear include board shorts, one-piece suits, rash guards, and also regular swimsuits. Additionally, there are cover-ups, shoes, and hats to keep your entire body safe from the radiation of the sun. Always remember to apply sunscreen to all of the parts of your body that are not covered by sun protective clothing or swimwear. Sunscreen should be applied at least a half hour before going outdoors, and it should be reapplied frequently. A minimum of 30 SPF is recommended on your sunscreen to ensure that it provides adequate protection. Waterproof sunscreen can help prevent it from being washed off your skin so quickly, but you should still reapply it every two hours because it does get absorbed deeply into the skin overtime.
Using leg and body makeup to revitalize your skin
A lot of women depend on leg and body makeup to cover up imperfections in their skin such as scars, blemishes and also varicose veins and spider veins.
How to Apply Body Makeup:
When you apply a body makeup, ensure that you pick up a makeup that matches the shade of your skin. Do dab or pat a small amount of the shade of the body make -up onto the area you want to conceal, blend it in well into the skin, and then set it with a powder. To brush off the excess body makeup, use a makeup brush to dust the excess makeup off. To remove body makeup, an oil based makeup remover is required, and most cosmetic lines make their own products. Cosmetics lines
generally are a one-stop shop!
Where to Find Body Makeup:
Dermablend Leg and Body Cover- One variety is the Dermablend brand which is available at most department stores. A clear powder is also available in this brand of cosmetics, and it comes with a body-cover to assist in setting up the body makeup. The peculiarity of this body makeup is that it provides close to 16 hours of color wear.
Coverblend Corrective Leg and Body Makeup- As the name suggests, this particular brand in cosmetics helps in covering and camouflaging everything a lady would want to cover. From covering dark circles under the eyes, to birthmarks, to varicose veins! This brand also helps in diminishing the appearance of wrinkles, and the cost factor is very moderate. This brand of cosmetics is available on Amazon.com and Ultra salons.
Estee Lauder Maximum Cover Camouflage Makeup for Face and Body-SPF15- A world famous brand of cosmetics, Estee Lauder brands are tested and approved by dermatologists. They are fragrance free, and are available at all leading department stores. The brand name is such that they are considered a wee bit on the expensive side among cosmetics.
Covermark Leg Magic-This is yet another brand of cosmetics that is available at the beautyjungle.com and Sephora. Covermark Leg Magic is an easy to apply formula that adheres to the skin, in general. This cosmetic has separate congealers with anti-ageing nutrients for sensitive skin, especially under the eyes. FaceMagic is for hiding minor flaws in the skin. Covermark Foundation, yet another cream from the makers of Covermark, is a heavier base cream meant for skin which requires more attention.
The next time you require hiding a tattoo or you want to cover-up the sunspots on your hands or the protruding veins in your legs, do try body makeup.
The last step in body makeup is making your legs look leaner and longer. It is also the easiest. Some of the essential steps are:-
a) Start by removing hair from your legs. You may use whichever hair removal cream you normally use.
b) Exfoliate your skin with a sugar scrub.
c) Apply a good moisturizer, and let your skin soak it in.
d) Lastly, apply the first coat of a sunless tanning product, and once it has developed, apply the second coat.
Having applied a sunless tanning product that gives your legs an even base color, contour them so that they have sheen.
Triage
Triage is the medical screening and sorting (classification) of a number of patients to determine the priority of
need for treatment and transportation. This sorting generally results in patients being placed into one of four
general priority categories:
High Priority: those who need immediate treatment and immediate transport in order to survive
Red
Intermediate Priority: those who will most likely survive but require treatment
Yellow
Low Priority: those who require little or no treatment or whose treatment and transportation can be
Green delayed
Lowest Priority: those who cannot be expected to survive even with treatment, those who cannot be
Black expected to survive in a mass casualty situation, and those whose vitals are absent
Table 1 summarizes basic triage principles using specific examples.
A mass casualty situation is an event where the number of patients exceed the initially available treatment and
transport capacity.
Incidents involving two or more patients should be managed by triaging the patients' condition, and matching
their individual needs to the available resources.
In normal daily care, urgency is the sole triage criteria.
In mass casualty triage two (2) factors determine priority: urgency and potential for survival. A rapid system
for field triage in mass casualty settings is included in Table 1.
GENERAL
• triage should begin as part of the initial scene assessment
• one of the senior responding EMS personnel or medical authority should be in charge of the medical
response and establish and remain in contact with the site commander
• a safety perimeter must be established (Table 3)
• personal protective equipment should be utilized as appropriate
• body substance isolation techniques and equipment should be utilized as appropriate
• all providers and bystanders should be protected from environmental hazards as appropriate
• an estimate of the number and type of casualties should be performed
• this information must be forwarded to the dispatch centre so the appropriate senior staff can be informed
• the designated site commander should be informed of this information as well
• notify potential receiving health care facilities of numbers and estimated severity of the patients'
condition(s)
• call for additional assistance if required
• initiate disaster protocol, if the situation meets the local or regionally established criteria
• the total number of casualties should be assessed and reassessed regularly
• all patients should be moved through a central/triage area (Table 3)
• the decision to centralize/move patients prior to triage and treatment depends on
• distribution of patients at the site
• scene assessment/safety
• available resources
• initial treatment and stabilization should occur prior to move
• if resources do not permit for this then triage must be performed on all patients in the field
• primary survey on all patients
• rapid assessment (ABC's) and triage of all patients
• open airway for unconscious patients and give two ventilations if necessary
• tag all patients utilizing triage tags
• treatment area
• after initial triage move patients into smaller more workable groups by category
• correct immediate life threatening conditions
• conduct a secondary assessment on all patients
• correct other immediate life threatening conditions if resources permit
• in a mass casualty situation, prolonged effort in assessing and treating patients in the low/lowest priority
category is inappropriate if it delays the assessment and treatment of the remaining patients
• this delay may result in unnecessary deterioration or death of a patient who might otherwise have been
saved through basic interventions
• as additional resources become available low priority patients should be reassessed and treated if
appropriate
• treat and transport as indicated by priority, equipment, and provider availability
• initial triage must be conducted rapidly and carefully ensuring no patients are missed
• one person must assume control to oversee patient treatment, delegate equipment and resources, and
coordinate proper loading order and dispositions (i.e. order of transport priority)
• this person must remain in charge until relieved by a suitably qualified individual
• the command EMS personnel or the medical authority in charge should remain at the scene to direct
additional units
• communications with health care facilities, other ambulance units, rescue vehicles, and other responding
agencies is paramount to the successful management of a mass casualty situation
• the inability to communicate effectively between all responding agencies and receiving facilities is the
most common problem in managing a mass casualty situation
• EMS personnel are responsible for being familiar with
• disaster plans for their service, community, and region
• communication procedures
• criteria for activating different levels of response
• their roles and responsibilities at a mass casualty incident
• use of triage tags is helpful in identifying, prioritizing, and tracking of patients from the scene through to final
destination in the health care facility
• implementation of local critical incident stress protocols should be considered early in the incident
• a morgue for the dead should be established in a different location from the triage and treatment areas
• medical response must remain coordinated with other response agencies and activities
• this is best done through the overall site commander
Emergency Preparedness Workbook
Southeastern Oklahoma State University recognizes the fact that policies become obsolete or inefficient with time. Therefore, the Contingency Planning Committee and the Director of Police and Safety, under the direction of the President (or his designee), will review the Emergency Preparedness and Crisis Management Plan annually and after every training and readiness exercise. This process of continual assessment will insure that SOSU maintains a constant state of preparedness so that in the event of an emergency or disaster, damage done to life, property, and business continuity will be minimal.
The effectiveness of any emergency preparedness and crisis management program is based on the level of training and the readiness of its personnel. Southeastern Oklahoma State University is committed to assuring the safety of life, property and the continuity of its employees, students and business units. In order to promulgate the training and readiness needed to effectively respond, mitigate and recover critical resources to the university; the Contingency Planning Committee has developed a list of methods that will enhance the efficiency of the EPCMP. These methods include but are not limited to:
1) Education
2) Evacuation drills
3) Emergency tactics training
4) EPCMP exercises
Every department will adopt these methods and develop their own specific training and readiness exercises, with the assistance of the Police and Safety Department. The Contingency Planning Committee will monitor and evaluate all plans and assist in their deployment.
Training Records
To effectively monitor and evaluate those personnel that are involved with emergency operations within the University's structure, the Director of Police and Safety (or his designee) will keep accurate records of those completing training in emergency operations tactics.
EARTH QUAKE PRONE UN-ISDR Asia-Pacific Region
Impact of the Japan earthquake and tsunami on animals and environment By Jason G. Goldman
On Friday, March 11, Japan was rocked by an earthquake. People were displaced, a nuclear reactor was in trouble, and the world watched as a tsunami flooded Japan, threatened the islands of the Pacific, and ultimately hit the western coasts of North and South America. Chris Rowan pointed out that "Very little of the devastation resulting from this earthquake was from the initial shaking. This is partly because of Japan's stringent building codes. But mainly because any damage from the seismic waves that sent skyscrapers in Tokyo swaying was dwarfed by the impact of the 10 metre tsunami that hit the Japanese coast less than an hour later."Most of the reporting (both good and bad) that has been done on the earthquake, the tsunami, and the resulting fallout from both has focused on their effects on humans. But humans are just one species affected by these sorts of disasters. I wondered: what happens to animals when faced with such a massive tsunami?
What We Know So Far
Slowly, a bit of information about various scaley, furry, or feathered critters has begun to trickle out of the affected areas.Kazutoshi Takami, a veterinarian at the Osaka Municipal Tennoji Zoological Gardens, reported last week that several zoos and aquariums were suffering shortages of gas, heater fuel, and food and drinkable water for humans as well as for animals. Also, according to Takami, the Fukushima Aquarium made plans to move their sea mammals and birds to Kamogawa Sea World.
M. Sanjayan of The Nature Conservancy in Arlington, Virginia, told ScienceInsider that the biggest impact on wildlife would be on shorebirds nesting on small islands throughout the Pacific, rather than on the Japanese mainland. Indeed, the majority of wildlife-related news of the tsunami has come from small Pacific islands such as those in the Midway Atoll National Wildlife Refuge.
On Saturday, March 12, Pete Leary, a wildlife biologist for the Fish and Wildlife Service who is stationed at Midway, blogged extensively on the tsunami and subsequent animal rescue operations:
We had all 67 island employees/visitors up here watching the news on BBC and watching our tide gauge data over the internet. We saw that we had about a 5 foot rise in the tide gauge level, but were glad that we couldn't see any water when we looked out the windows. After looking at a bit of the washover on Sand Island, and setting a crew to work on digging albatross chicks and petrels out of the debris, Greg and I took the boat over to Eastern Island. On the way, we passed thousands of albatross adults and petrels that had been washed into the water and lost their ability to stay dry. Their feathers were messed up by being tumbled over the island and through the vegetation. We pulled some into the boat, but needed to get to Eastern Island, so we had to hope that most of them would paddle to shore.
Eastern Island was mostly washed over, so 10's of thousands of chicks were washed away. I'll have to look at our count numbers from Dec. to figure out how many chicks were in the affected areas. There were dead fish by the hundreds up in the middle of the island. The short-tailed albatross chick must really be wondering what kind of place it lives in because it was washed away from the nest for the second time this year already. This time, it was about 40 yards away from the original nest. It was easy to spot because all the other chicks were washed away in a previous storm. I didn't want to pick the chick up, because it was already stressed and upset, but the parents may not have found it that far from the nest. I put out a sheet of plastic and when it stepped onto it, I gave it a sled ride the 40 yards back to its nest. I hope that's all the excitement that it has for the rest of the season.
There were a lot of chicks and adults buried in debris (mostly dead vegetation). Greg and I were digging out stuck birds all day. We took our volunteers and some people from the visitors group over yesterday and dug out another hundred or so birds. We also found 2 turtles that were washed quite a way up onto the island, which were then carried back to the beach and seemed glad to get back in the water. At least we didn't find any injured Hawaiian monk seals or Laysan ducks. The seals were back resting on the beaches on Friday.
Although we lost a lot of wildlife, all of the people who are here because of the wildlife are safe.
The US Fish and Wildlife Service is now estimating that the Midway Atoll National Wildlife Refuge sustained losses of that more than 110,000 Laysan Albatross chicks – representing approximately 22% of chicks born this year – along with an estimated two thousand adults. In addition, thosands of Bonin petrels were buried alive, and thousands of fish were washed ashore where they suffocated on Eastern Island. Thankfully, Pete and his staff were able to rescue a handful of birds and turtles, but this is small comfort compared to the loss of entire shorebird nesting sites.Darwin's famous Galapagos Islands fared a bit better. Despite the fact that the tsunami struck during high tide, the water rose over 1.7 meters beyond normal levels, flooding buildings along the coastline. UNESCO has reported that the Southwest side of San Cristobal Island, home to a nesting site for marine iguanas, was among the most affected areas of the Galápagos Islands World Heritage site. While some mortality is expected among the iguanas, officials do not expect extensive damage.
What Can We Expect?
While some of the reports are heartening, and many are devasting, more in-depth research into the short- and long-term effects of the tsunami on marine and coastal ecosystems will take much longer. But the 2004 magnitude 9.15 earthquake off the coast of Sumatra, and the resulting tsunami that rippled across the Indian Ocean have been extensively studied, and allow us to speculate regarding possible outcomes of the Japanese earthquake and tsunami.
The Wildlife Trust of India, along with the International Fund for Animal Welfare initiated several investigations following the earthquake and tsunami to assess their impact on wildlife. Overall, they found that damage to wildlife populations was generally limited on the mainland, and slightly worse on the islands. Particularly hard-hit, however, were coral reef systems. Several beaches were washed away, and freshwater habitats were inundated with saltwater. While most of these ecosystems were eventually able to rebound, problems did occur.
For example, one mainland wildlife sanctuary became flooded with saltwater and covered with sand, making is impossible for the various plant-eating ungulates (hoofed animals) to graze. Even worse, with seawater comes toxic pollution.
According to the Wildlife Trust report:
Other grave problems stem from the onslaught of seawater laden with sediments and toxins. Aquifers, the primary source of drinking water, have been contaminated by saltwater, raw sewage, oil, and other pollutants. On the coasts of Indonesia and Sri Lanka, paddies and farm fields are smothered under a crust of salt and silt. Some areas may never recover, for others irrigation and one or more rainy seasons may be enough to flush out the soil. For now farmers are being encouraged to plant salt-tolerant crops, like pumpkins and kale.In other areas, rather than covering plants with saltwater, the tsunami simply washed all plants away, making it possible for invasive species to take root, quite literally. The change in plant life wasn't problematic for some species, such as the fan-throated lizard (Sitana ponticeriana), which were able to survive in the new ecosystem. Other species, surely, were not so lucky, but little information is available.
And there were probably other invaders, as well. Furry ones. Large dead trees from distant islands were found washed up on mainland beaches. While there was no danger to beach ecosystems from the trees themselves, since they were dead, they may have carried some critters with them that would eventually colonize mainland coasts. It is well-known that rodents, reptiles, and insects are quite capable of setting up camp in new environments after rafting across the sea.
As we can already tell from the Japan earthquake, birds are particularly vulnerable to tsunamis. But in the 2004 tsunami, it wasn't all bad news for the birds! In fact, after the seawater receded, it left quite a bit of silt and sediment behind. Some of that sediment settled into pre-existing lagoons and creeks, making them much shallower. This would be bad news for most inhabitants of those lagoons, but great news for wading birds, who now had new places to nest. In one ironic example, the tsunami actually helped reverse human damage to a particular creek:
This creek used to be a local birding area that attracts a large number of migrant waders and the blackwinged stilt (Himantopus himantopus). A few years ago, the Chennai Corporation as part of an effort to beautify the city had dredged and deepened the creek. The waders that had since left the creek had made a re-appearance after the tsunami brought back all the silt!
Other birds didn't fare so well. A group of birds called the megapodes, which require external sources of heat to incubate their eggs, are found in the Nicobar Islands in the Bay of Bengal. Because they prefer to lay their eggs on sandy ground, over 90% of megapode nests were located within thirty meters of the waterline, prior to the tsunami. Several of the islands that are home to the megapodes were completely washed over, and others very nearly so. As with any bird species, maintaining constant temperature is critical for proper development of the birds within the eggs. Since these birds use external heat, however, the flooding of the nests by cold seawater became problematic for those nests that were closest to the water. Many of the birds that did survive relocated into the interior of the island, settling into evacuated villages. But when the villagers began to return, they were not happy to find the birds nesting around their homes. Even worse, the main source of income for these villagers came from coconut plantations, were were almost entirely washed away. As a result, the villagers turned to hunting and fishing in order to survive. One scientist noted, "Each tribal family has one to four airguns. The Nicobar megapode was found to be the most favoured targets of these airguns."As for shallow water fish, it was initially assumed that the tsunami would be beneficial for them as well. Researchers hypothesized that the dead and decaying material in the sea would result in a huge growth in plankton populations. This hypothesis was later confirmed, when scientists observed massive increases in plankton-feeding fish species, like sardines. Increases in fish populations, coupled with reductions in motorized boats in the area, brought more dolphins to the coastal waters as well.
There was more good news, for the sea turtles of Sri Lanka. Initial reports had confirmed that there was extensive damage to nesting sites, hatcheries, and adult foraging habitats due to the tsunami. However, the number of nesting females, at least at one site, remained unchanged in the following year. It is possible that the adults were simply at sea when the tsunami hit. The good news for these turtles should be understood in context, however. The researchers were quick to note that most sea turtle species in the region were already endangered, and that "the fate of sea turtles in the region is more likely to be determined by long-term human influences than by infrequent natural catastrophes."
When it came to non-human primates, the outcomes were mixed. In 2000, 40 groups of long-tailed macaques (Macaca fascicularis umbrosa), comprising 814 individuals were observed, with group size varying from 7 to 98 animals. While the groups that lived mostly in the interior of the islands were relatively unaffected, coastal groups were not as lucky. In particular, these groups lost quite a few juvenile macaques. In 2000, the adult to juvenile ratio was approximately 1:1, but following the tsunami, it had dropped to 1:0.4. The reduction in the proportion of juveniles will have long-term consequences for the social organization and popluation structure of those groups, as fewer juvenile females means fewer baby monkeys in subsequent generations. It is possible, that the reduction in macaque numbers wasn't due to the tsunami itself, but rather came about as a result of the washing away of coastal fruit trees, leaving fewer resources and food for the macaque groups.
Putting It Together
If the outcome of the 2004 Indian ocean tsunami for wildlife can be at all predictive of what is to come for the Japanese tsunami, there may be a few lessons to learn. First, coastal ecosystems were, in general, worse off than interior ecosystems. Second, islands fared far worse than the mainland. Already, data from Japan and the Pacific islands has begun to display this pattern. Third, many species seem to be able to either benefit from or at least persevere through such natural disasters. And where one species suffers, another might benefit.Fourth, even if a given species isn't directly affected by a natural disaster, there are often repercussions due to the complex interactions among different species, between plants and animals, and between predators and prey. Rather than asking about the outcome for a specific species, it makes more sense to ask about the health of larger ecosystems, in the wake of a tsunami.
And humans are a fundamental part of most ecosystems – which brings us to the final, and most important lesson. Human behavior can help ecosystems rebound following a tsunami, or it can continue the destruction. It was partially due to a moratorium on fishing – one that people generally respected – that allowed the sardine populations to thrive in the plankton-rich water, which allowed the dolphin populations to thrive, in turn, on the sardines. On the other hand, the hunting of the megapodes in the Nicobar Islands made it even harder for those birds to survive. And the tsunami might not have been terrible for the sea turtles, but they were endangered to begin with, thanks to human activity. As devastating as natural disasters can be to natural ecosystems, they are nothing compared to the long-term effects of human behavior.
References:
K. Sivakumar (2008). How could a natural catastrophe impact the ecology of a species? The Nicobar megapode and tsunami. Nature Precedings.
Albrecht FH (2005). Editor's note: tsunami effects on nonhuman animals. Journal of applied animal welfare science : JAAWS, 8 (1), 69-71 PMID: 16004546
Kuppusamy Sivakumar (2009). Impact of the tsunami (December, 2004) on the long tailed macaque of Nicobar Islands, India. Hystrix - Italian Journal of Mammalogy : 10.4404/hystrix-21.1-4484
Brodie, J., Sanjayan, M., Corea, R., Helmy, O., & Amarasiri, C. (2008). Effects of the 2004 Indian Ocean Tsunami on Sea Turtle Populations in Sri Lanka. Chelonian Conservation and Biology, 7 (2), 249-251 DOI: 10.2744/CCB-0695.1
Harry V. Andrews,, M. Chandi,, Allen Vaughan,, John Aungthong,, Saw Aghue,, Saw Johnny,, Saw John, & S. Naveen (2006). Marine turtle status and distribution in the Andaman and Nicobar islands after the 2004 M 9 quake and tsunami Indian Ocean Turtle Newsletter (4), 3-11.
The Ground Beneath the Waves: Post-tsunami Impact Assessment of Wildlife and their Habitats in India. Report by Wildlife Trust of India and International Fund for Animal Welfare.
Images:
Photo 1: Laysan albatross chick stuck in tsunami debris. Photo credit: Pete Leary/U.S. Fish and Wildlife Service
Photo 2: Thousands of nesting Bonin petrels were buried alive. Petrels nest in underground burrows. The petrel population at Midway Atoll National Wildlife Refuge has grown exponentially since rats were eradicated over 10 years ago. Photo credit: U.S. Fish and Wildlife Service
Photo 3: Two Turtles were washed into the interior of Eastern Island. Visitors assisted in getting the live sea turtles back in the water.
Photo 4: Hundreds of albatross chicks disentangled from vegetation in the aftermath of the tsunami. Photo credit: U.S. Fish and Wildlife Service
ABOUT THE AUTHOR
Jason G. Goldman
What can we learn from observational studies of oseltamivir to treat influenza in healthy adults?
- Nick Freemantle, professor of clinical epidemiology and biostatistics,
- Mel Calvert, senior lecturer
The treatment effects of drugs are conventionally estimated in randomised controlled trials. Random allocation of patients ensures that any difference in outcome observed between the experimental groups must be attributable either to chance or to the randomised treatments. Although a remarkably durable approach, randomisation does have limitations. Randomised trials conducted for regulatory purposes rarely include people with comorbidities, since adverse events observed as a result of these comorbidities may undermine the attempts to establish the safety of the new drug. Furthermore, randomised trials are costly and time consuming and may not be conducted by industry sponsors when a "positive" outcome seems unlikely. Thus health policy makers often have to make important decisions about new drugs when not all relevant trials have been undertaken. This is the situation currently regarding the use of antiviral therapy in H1N1 influenza. It may be argued that at such times we should be informed by all available evidence and not constrained by randomised trials alone.
The authors of the Cochrane Collaboration systematic review of neuraminidase inhibitors for preventing and treating influenza in healthy adult approached Roche, the manufacturer of oseltamivir, for unpublished data. Among the incomplete data that Roche provided was a list of observational studies that it considered to describe the "real life" value of antiviral treatment. The BMJ invited us to provide a rapid review of these studies and the extent to which they support the use of oseltamivir to treat influenza in healthy adults.
Problems of non-randomised trials
In non-interventional study designs the difference in outcomes between those receiving and not receiving the treatment of interest may be due to the play of chance, to the treatment, or to some additional confounder. Excluding chance as an explanation for an observed difference in outcome thus leaves two rather than one possible explanations, with obvious consequences for our certainty about the results. These biases essentially relate to some kind of preferential selection of patients to different treatment options. It is particularly challenging when the characteristics of a patient are likely to inform decisions to use a drug. Thus clinical judgment may mean that a patient at raised risk of a poor outcome is more likely to be prescribed a particular drug. If this increased risk is incompletely described by risk stratification methods, the treatment may appear relatively harmful, a troublesome bias that is referred to as confounding by indication.
Thus, when appraising observational evidence, in addition to considering the study design and likely generalisability of findings, the reader must also consider the appropriateness of attempts by the authors to overcome potential confounding and the likely size and direction of any residual confounding.
Assessment of studies
The nine post-marketing studies identified by Roche included 529 122 patients, of whom 190 817 were prescribed oseltamivir during 1999 to 2007 (table⇓). The databases from which patients were identified were inadequately described, making it difficult to ascertain the extent to which different studies may have included the same participants. One study of oseltamivir in people with diabetes was explicitly a subgroup analysis of data included in previous studies.The study groups varied and included the general population,4 5 people aged 65 years or younger,6 adults,11 people aged 13 years or older,7 children,8 children with chronic medical conditions,9 adults with diabetes,10 and adults with a history of cardiovascular disease. Thus several studies include participants that are outside the focus of Jefferson et al's systematic review, which focused on healthy adults.
The main outcome in all but two studies was the development of pneumonia or other direct complications of influenza. One study examined the risk of stroke or transient ischaemic attack. A further study examined major cardiovascular events in people with cardiovascular disease. The reporting of outcomes was poor in several studies. For example, transient ischaemic attack and strokes were reported together only in Madjid et al.
It was unclear the extent to which studies were driven by prespecified protocols and analysis plans, although neutral results were reported alongside beneficial results for oseltamivir.
The studies all had specific inclusion criteria, resulting in exclusion of large numbers of people. In particular, the studies did not include people who received antiviral drugs other than oseltamivir or who received oseltamivir more than 1-2 days after diagnosis of influenza.
In some studies, significant differences were observed in the baseline characteristics of the oseltamivir and control groups, suggesting that higher risk patients may have been captured in the control group. One study did not give a detailed description of participants' comorbidities (such as pneumonia, chronic obstructive pulmonary disease, asthma, and diabetes) but provided a summary measure of comorbidity burden. Another did not record pre-existing respiratory illness. One study did not consider comorbidity or diabetes. Significant differences in geographical location and prescribing were observed in several studies or were not described. All studies used multivariable models to adjust for known confounders. Several studies used propensity score methods to attempt to deal with confounding by indication (table⇑).
Results of multivariable analyses were broadly in line with those reported in the randomised trials. For participants with clinically diagnosed influenza, the estimated number who needed to be treated with oseltamivir to avoid one diagnosis of pneumonia was always over 100, and may be as high as 1000. Only one of the observational studies reviewed here considered safety issues.
Discussion
Although the studies reviewed were of variable quality, they generally support the conclusion that oseltamivir may reduce the incidence of pneumonia and other consequences of influenza in otherwise healthy adults. However, these events are rare, so for most otherwise healthy adults treatment of influenza with oseltamivir is not likely to be clinically important.
A potential advantage of observational studies is that they can provide evidence on the use of a drug in a realistic setting. However, this advantage was largely undermined by the studies' selection criteria, which tended to exclude people who received oseltamivir later than the recommended time frame. Matched propensity scoring approaches may also undermine the generalisability of results if extreme values are excluded because of inability to achieve a match. We might also expect the effectiveness of oseltamivir to be reduced in the clinical setting, where treatment may be based on clinical criteria alone, although use of different outcome measures in the randomised trials and observational studies prevents us from answering this question empirically.
Several studies suggested that the benefits of oseltamivir may be underestimated if patients delayed seeking care (date of diagnosis may not represent onset of symptoms), or if patients did not take the drug as prescribed. However, this may provide a more realistic view of real life practice, and with increasing drug resistance estimates of effectiveness may now be reduced.
The estimated effect of antiviral drugs in people with existing cardiovascular disease was substantial, and the difference in rates of death and serious morbidity were potentially clinically important. However, those receiving oseltamivir were younger and thus at lower risk. As the authors of that study commented, these findings could usefully be examined in further randomised trials.
Interpretation of the studies was difficult. Differences in baseline comorbidity or geographical distribution were present in several studies. It seems likely that some patients were included in more than one study, which undermines the ability of these studies to provide independent estimates. The generalisability of findings from employer sponsored health insurance databases may also be questioned.
The direction of any bias from confounding by indication is uncertain. All the studies were conducted in the United States, where more wealthy subjects, who are likely to have better outcome and to engage in more positive health related behaviours, might be more likely to be prescribed an antiviral drug. However, patients thought likely to be particularly at risk of poor outcome may also be more likely to be prescribed antiviral drugs. The focus on patients who received oseltamivir within a day or so of diagnosis of influenza and comparison with people who had no antiviral drug prescribed, seems likely to exacerbate the effects of such confounding and reduce the extent to which these observational studies might be considered to reflect real world practice. Although several studies made appropriate attempts to address unknown confounders by using propensity scores, these methods do not ensure that confounding by indication is avoided.
Only one study explicitly examined drug safety. This is an important omission given the widespread use of oseltamivir. An earlier study by Enger and colleagues on the Ingenix United Healthcare database, which seems to have been conducted for regulatory purposes, concluded that there was no association between oseltamivir use and an increase in the risk of cardiac or neuropsychiatric events on the basis of confidence intervals that were wholly on the side of benefit on those outcomes for oseltamivir exposure. It is unclear why similar results in later studies (often including some of the same authors) were interpreted as providing evidence that oseltamivir reduced the risk of major cardiovascular events or stroke in high risk patients rather than providing evidence of safety, given the intrinsic biases associated with these non-randomised comparisons.
Our rapid review of these "real life" data suggests that oseltamivir may reduce the risk of pneumonia in otherwise healthy people who contract flu. However, the absolute benefit is small, and side effects and safety should also be considered. None of the studies examined the role of oseltamivir in patients with H1N1 influenza, which may be associated with higher rates of pneumonitis than seasonal influenza. We did not consider the evidence for the use of oseltamivir in high risk patients, although several of the studies identified by Roche were in special populations. Other observational studies suggest that early intervention with antivirals for influenza may benefit a range of high risk patients and potentially improve survival rates, but these studies are also open to residual confounding.
A potential bias in our review derives from considering only studies identified by the manufacturer. Had we identified evidence that was supportive of the use of oseltamivir in the treatment of otherwise healthy subjects with H1N1 virus it would have been important to search more broadly for any additional studies to avoid publication bias.
Footnotes
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Contributors: NF and MC were both involved in the conception, design, analysis, and interpretation of data, drafting the article and revising it critically for important intellectual content. Both gave final approval of the version to be published. NF is the guarantor.
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Competing interests: The authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare (1) the BMJ helped them access three articles not available through their university library; (2) they supervise a PhD student who is supported and employed by Roche; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) they have no non-financial interests that may be relevant to the submitted work.
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Provenance and peer review: Commissioned; externally peer reviewed.