Incidence of cryptorchidism in dogs and cats

Over a period of 54 months, 3518 dogs and 3806 cats were castrated; 240 of the dogs and 50 of the cats were cryptorchid. Pedigree dogs, in particular the German shepherd dog, boxer and chihuahua were over-represented. Among the dogs, right-sided inguinal cryptorchidism was the most common form, followed by right-sided abdominal cryptorchidism. The location of the affected testicle(s) was most variable in the boxer. Among the cats, left- or right-sided inguinal cryptorchidism were the most common forms of the condition.

The MRC CRASH Trial: study design, baseline data, and outcome in 1000 randomised patients in the pilot phase

OBJECTIVES

To test the design and feasibility of a large scale multicentre randomised controlled trial evaluating the efficacy and safety of a high dose corticosteroid infusion after head injury. To assess whether large numbers of patients could be enrolled and treated within eight hours from injury and then followed up at six months.

METHODS

Randomised placebo controlled multicentre trial of a 48 hour corticosteroid infusion after significant head injury. All head injured adults who were observed while in hospital to have GCS of 14 or less (out of a maximum score of 15), and who were within eight hours of the injury, were eligible for trial entry. Analysis of baseline and outcome data (for both treatment groups combined) for 1000 patients enrolled in the pilot phase of the MRC CRASH Trial.

RESULTS

Fifty two hospitals in 14 countries participated in the pilot phase, recruiting an average of one patient per hospital per month. Of the 1000 randomised patients, 330 (33%) had mild head injury, 289 (29%) had moderate head injury, and 381 (38%) had severe head injury. Seven hundred and nine (71%) patients were randomised within three hours of injury. Outcome at two weeks from injury was known for 991 (99%) patients, of whom 170 (17%) patients died. At the time of writing, six month follow up for the first 500 patients was nearly complete. Vital status was known for 465 (93%) of the 500 patients, of whom 97 (21%) had died. Functional status based on the Glasgow Outcome Scale was known for 438 (88%) of the 500 patients: 21% were dead, 17% were severely disabled, 22% were moderately disabled, and 34% had made a good recovery.

CONCLUSIONS

The trial procedures proved practicable and a wide variety of patients were recruited in the emergency department within eight hours of injury. Using simple outcome measures, large numbers of patients can be successfully followed up.

A randomised controlled trial of prehospital intravenous fluid replacement therapy in serious trauma

RESULTS

In total 1309 patients were entered in the study: 699 (53.4%) were treated by paramedics operating protocol A and 610 (46.6%) were treated by paramedics operating protocol B. The randomisation worked well and there were no significant differences between treatment groups in incident characteristics, ambulance performance times, or patient or injury characteristics, apart from slightly more moderate or severe head injuries in the protocol A group (25.3% versus 20.3%). Protocol compliance was poor, with only 31% of protocol A patients receiving prehospital fluids and only 80% of protocol B patients not given fluids. The estimated odds ratio for being given prehospital fluids when treated by protocol A compared to protocol B was 2.09 (95% confidence interval (CI), 1.53 to 2.81).

MORTALITY

There were 73 deaths within 6 months in the 699 patients in the protocol A group (10.4%), and 60/610 (9.8%) in the protocol B group. Thus the crude odds ratio for deaths when managed by protocol A was 1.07 (95% CI, 0.73 to 1.54). Excluding 26 patients whose cause of death may not have been trauma related, the odds ratio was 1.04 (95% CI, 0.69 to 1.55). Excluding 17 patients who may have been dead on arrival of the ambulance at the scene the odds ratio was 1.04 (95% CI, 0.70 to 1.53). Adjustment for age, injury severity and whether the patient was unconscious at the scene did not significantly alter these odds ratios.

COMPLICATIONS

A total of 106 patients were identified from hospital notes as having at least one of eight major complications (adult respiratory distress syndrome, sepsis, acute renal failure, coagulopathy, wound infection, pneumonia, fat embolism or pulmonary embolism). The proportions with recorded complications were similar in the two groups: 60/699 (8.5%) in the protocol A group versus 46/610 (7.5%) in the protocol B group. HEALTH STATUS: A total of 878 questionnaires were sent to patients, and 559 (64%) usable replies were received. The response rate was similar in the two groups (62.9% versus 64.6%). In all eight dimensions of the SF-36 health status measure patients who had been managed by paramedics operating protocol A reported better average health than did patients in the protocol B group. However, none of the differences were at a level considered clinically important and only for one of the eight dimensions was the difference statistically significant. COMPOSITE OUTCOMES: No significant differences in outcome were found between the two protocol groups in terms of patients who either died or had serious complications, nor for patients who either died or had known poor health. SUBGROUPS: Subgroups of patients were defined on eight characteristics (ambulance service area, whether a doctor was on scene, paramedic-patient contact time, injury severity, whether taken to theatre for emergency surgery, type of injuries, type of area, and whether the patient was treated before or after protocol cross-over). There was no evidence of any difference in mortality rates or composite outcomes between any subgroups, or between protocols within any subgroup. Time to A&E department The analysis suggests that patients given fluids spent 12-13 minutes longer at the accident scene than did patients not given fluids. However, because only one-quarter of patients were given fluids, and the specific protocol used made little difference to this, average on-scene times were largely unaffected by protocols.

COSTS

In the prehospital and immediate-care phase (including A&E treatment), the mean costs of the protocol A and protocol B groups were ¿419 and ¿416, respectively. This small difference reflects two small and offsetting effects of protocol B: reduced on-scene time (p = 0.08) and increased use of blood in the A&E department (p = 0.03). There were no other statistically significant differences in costs, with the mean total costs being ¿2706 and ¿2678 in the protocol A and protocol B groups, respectively (p = 0.52). (ABSTRACT TRUNCA

"Recommendations for uniform reporting of data following major trauma--the Utstein style" (as of July 17, 1999). An International Trauma Anaesthesia and Critical Care Society (ITACCS)

Basic and advanced care of trauma patients has always been an important aspect of prehospital and immediate in-hospital emergency medicine, involving a broad spectrum of disciplines, specialties and skills delivered through Emergency Medical Services Systems which, however, may differ significantly in structure, resources and operation. This complex background has, at least in part, hindered the development of a uniform pattern or set of criteria and definitions. This in turn has hitherto rendered data incompatible, with the consequence that such differing systems or protocols of care cannot be readily evaluated or compared with acceptable validity. Guided by previous consensus processes evolved by the ERC, the AHA and other International Organizations--represented in ILCOR--on 'Uniform reporting of data following out-of-hospital and in-hospital cardiac arrest--the Utstein style' an international working group of ITACCS has drafted a document, 'Recommendations for uniform reporting of data following major trauma--the Utstein style'. The reporting system is based on the following considerations: A structured reporting system based on an "Utstein style template" which would permit the compilation of data and statistics on major trauma care, facilitating and validating independent or comparative audit of performance and quality of care (and enable groups to challenge performance statistics which did not take account of all relevant information). The recommendations and template should encompass both out-of-hospital and in-hospital trauma care. The recommendations and template should further permit intra- and inter-system evaluation to improve the quality of delivered care and identification of the relative benefits of different systems and innovative initiatives. The template should facilitate studies setting out to improve epidemiological understanding of trauma; for example such studies might focus on the factors that determine survival. The document is structured along the lines of the original Utstein Style Guidelines publication on 'prehospital cardiac arrest'. It includes a glossary of terms used in the prehospital and early hospital phase and definitions, time points and intervals. The document uses an almost identical scheme for illustrating the different process time clocks--one for the patient, one for the dispatch centre, one for the ambulance and, finally, one for the hospital. For clarity, data should be reported as core data (i.e. always obtained) and optional data (obtained under specific circumstances). In contrast to the graphic approach used for the Utstein template for pre- or in-hospital cardiac arrest, respectively, the present template introduces, for the time being, at least, a number of terms and definitions and a semantic rather than a graphic report form. The document includes the following sections: The Section Introduction and background The Section on Trauma Data Structure Development: presents a general outline of the development of structured data using object-orientated modelling (which will be discussed in due course) and includes a set of explanatory illustrations. The Section on Terms and Definitions: outlines terms and definitions in trauma care, describing different types of trauma (blunt, penetrating, long bone, major/combined, multiple/polytrauma and predominant trauma). The Section on Factors relating to the circumstances of the injury describes the following items: cause of injury (e.g. type of injury (blunt or penetrating), burns, cold, crush, laceration, amputation, radiation, multiple, etc. Severity of Injury e.g. prehospital basic abbreviated injury score developed by the working group. The score contains anatomical and physiological disability data, with the anatomical scale ranging ordinally from 1. Head to 9. External; the physiological disability scale ranging ordinally from 0--unsurvivable. Mechanism of injury recording for transportation incidents etc. e.g. the type of impact, po

Production and dispersal of Colletotrichum gloeosporioides spores on Stylosanthes scabra under elevated CO2

This paper reports the effect of twice-ambient (700 ppm) atmospheric CO(2) concentration on infection, disease development, spore production and dispersal of the anthracnose pathogen Colletotrichum gloeosporioides in susceptible (Fitzroy) and partially resistant (Seca) cultivars of the tropical pasture legume Stylosanthes scabra under controlled environment and field conditions. Reduction in plant height due to anthracnose was partially compensated for by growth enhancement at elevated CO(2) in Fitzroy but not in Seca. Anthracnose severity was reduced under elevated CO(2) although the reduction was only significant in Fitzroy. Delayed and reduced germination, germtube growth and appressoria production were partly responsible for the reduced severity. Despite an extended incubation period, C. gloeosporioides developed sporulating lesions faster and produced more spores per day within the same latent period at high CO(2) and ambient CO(2). When Fitzroy seedlings grown at 700 ppm CO(2) were exposed to pathogen inoculum under field conditions, they consistently developed more severe anthracnose with more lesions than seedlings grown at ambient CO(2). The environmental variable, which correlated most strongly with the dispersal and infection of C. gloeosporioides spores in the field, was relative humidity in plant canopy. We have shown that an enlarged Stylosanthes canopy under elevated CO(2) can trap more spores, which can lead to more severe anthracnose under favorable weather. The implications of these findings for perennial Stylosanthes pastures are discussed.

Should radiologists image and report sacroiliac joints in patients referred for examination of the lumbar spine?

It is routine to image the sacroiliac joints (SIJs) in patients referred for radiographic examination of the lumbar spine but there were only two consistent with ankylosing spondylitis in a review of 392 radiographic reports of lumbar spine examinations. A more sensible policy would be to only image and report on the SIJs if the clinical history were indicative of ankylosing spondylosis.

Corticotropin-releasing hormone mimics stress-induced colonic epithelial pathophysiology in the rat

We examined the effect of stress on colonic epithelial physiology, the role of corticotropin-releasing hormone (CRH), and the pathways involved. Rats were restrained or injected intraperitoneally with CRH or saline. Colonic segments were mounted in Ussing chambers, in which ion secretion and permeability (conductance and probe fluxes) were measured. To test the pathways involved in CRH-induced changes, rats were pretreated with hexamethonium, atropine, bretylium, doxantrazole, alpha-helical CRH-(9-41) (all intraperitoneally), or aminoglutethimide (subcutaneously). Restraint stress increased colonic ion secretion and permeability to ions, the bacterial peptide FMLP, and horseradish peroxidase (HRP). These changes were prevented by alpha-helical CRH-(9-41) and mimicked by CRH (50 microgram/kg). CRH-induced changes in ion secretion were abolished by alpha-helical CRH-(9-41), hexamethonium, atropine, or doxantrazole. CRH-stimulated conductance was significantly inhibited by alpha-helical CRH-(9-41), hexamethonium, bretylium, or doxantrazole. CRH-induced enhancement of HRP flux was significantly reduced by all drugs but aminoglutethimide. Peripheral CRH reproduced stress-induced colonic epithelial pathophysiology via cholinergic and adrenergic nerves and mast cells. Modulation of stress responses may be relevant to the management of colonic disorders.

UK accident and emergency departments and emergency contraception: what do they think and do?

OBJECTIVES

A postal questionnaire survey was conducted to assess what staff in UK accident and emergency (A&E) departments thought of providing an emergency contraception service, the degree of enthusiasm in and level of provision of the service, and staff attitudes to the introduction or continuation of provision of the service.

METHODS

A questionnaire was sent to all 560 departments providing A&E services in the UK.

RESULTS

Of the 560 units sent questionnaires, 355 (63.4%) replied. Half the units were located in small county towns, and a quarter in large towns. Requests for emergency contraception were received by 96% of responding units, but only 57% provided treatment. Requests for emergency contraception in 84 of these units ranged between one and 50 per month. The A&E senior house officer (SHO) and the gynaecology SHO and registrar prescribed most of the pills. Nurses were more involved in nurse led or general practitioner (GP) led units. Initial treatment only was given by 77% of providing units while the remainder also discussed subsequent contraception. Follow up was arranged with GPs by 92 units, and with family planning clinics by 66 units. Information packs were available in only 37 providing units. A total of 155 of providing units felt it was worthwhile and 56% of respondents thought emergency contraception should be provided by A&E departments. However, 91 units could identify one or more groups within the hospital who were antagonistic to provision by A&E departments, of which non-A&E medical staff formed the largest group. Over the counter availability of emergency contraception was not supported by 62% of respondents.

CONCLUSION

The results show that while the female population appears to see a need for emergency contraception services to be provided in A&E departments, there is some reluctance by UK A&E departments to provide the service. Given the current interest in approaches to reducing unplanned pregnancies, especially in teenagers, provision of emergency contraception by A&E departments requires a pragmatic approach to ensure their cooperation in providing the service when alternative sources of provision are not available.

Reducing accident death rates in children and young adults: the contribution of hospital care. Steering Committee of the Major Trauma Outcome Study Group

OBJECTIVE

To assess the contribution of trauma care to the recent decline in accident death rates among children and young people.

DESIGN

Logistic regression modelling of temporal trends in the probability of death in patients admitted to hospital for the treatment of severe injury.

SETTING

Hospitals participating the United Kingdom major trauma outcome study.

SUBJECTS

3230 patients with an injury severity score of 16 or more, who were admitted for more than three days, transferred or admitted to intensive care, or died from their injuries.

MAIN OUTCOME MEASURES

Death or survival in hospital within three months of injury.

RESULTS

Over the seven year period 1989-95 there was a substantial decline in the probability of death among children and young adults admitted to hospital after severe injury. The overall estimate of the reduction in the odds of death was 16% per year (odds ratio for the yearly trend 0.84; 95% confidence interval 0.79 to 0.89). This decline did not differ significantly between age groups. (0-4 years 0.79; 5-14 years 0.87; 15-24 years 0.83).

CONCLUSIONS

Reductions in hospital case fatality have made an important contribution to reaching the Health of the Nation targets. The contribution of hospital care in the reduction of accident mortality should be taken into account in decisions about the allocation of resources to preventive and curative services.

Trauma care in China: challenge and development

The People's Republic of China has significantly improved the general health of its people by a concerted effort in primary health care but trauma care and its prevention remains a problem. This paper provides an overview of the strengths and weaknesses of the trauma-care system in China and proposes a strategy for its future development. This includes public-health legislation, the integration of military and civilian practice to provide comprehensive care from the scene of the incident through to rehabilitation, medical audit, the introduction of postgraduate trauma-management training courses and international academic exchanges.

Acute and chronic effects of cigarette smoking on exhaled nitric oxide

Cigarette smoking is associated with an increased risk of respiratory tract infections, chronic airway disease, and cardiovascular diseases, all of which may be modulated by endogenous nitric oxide (NO). We have investigated whether cigarette smoking reduces the production of endogenous NO. We compared exhalations of 41 current cigarette smokers with normal lung function and 73 age-matched non-smoking controls. Peak exhaled NO levels were measured by a modified chemiluminescence analyzer. The effects of inhaling a single cigarette in smokers were also measured. In control subjects we also measured the effects of inhalation of NO itself and carbon monoxide, both constituents of tobacco smoke. Peak exhaled NO concentrations were significantly reduced in smokers (42 +/- 3.9 compared with 88 +/- 2.7 parts per billion in nonsmokers, p < 0.01), with a significant relation between the exhaled NO and cigarette consumption (r = 0.77, p < 0.001). Smoking a single cigarette also significantly (p < 0.02), but transiently, reduced exhaled NO. Inhalation of carbon monoxide and NO had no effect on exhaled NO in normal subjects. Cigarette smoking decreased exhaled NO, suggesting that it may inhibit the enzyme NO synthase. Since endogenous NO is important in defending the respiratory tract against infection, in counteracting bronchoconstriction and vasoconstriction, and in inhibiting platelet aggregation, this effect may contribute to the increased risks of chronic respiratory and cardiovascular disease in cigarette smokers.

Increased nitric oxide in exhaled air of normal human subjects with upper respiratory tract infections

Viral infection may induce the expression of nitric oxide (NO) synthase, resulting in increased NO formation that has an antiviral effect. NO may be produced by various cells of the upper and lower respiratory tract, and may be detected in the exhaled air. We have studied the levels of exhaled NO in 18 normal subjects during symptomatic upper respiratory tract infections and during recovery 3 weeks later. Exhaled NO was measured using a modified chemiluminescence analyser. At the time of symptoms of upper respiratory tract infection, the peak exhaled NO values were 315 +/- 57 ppb (mean +/- SEM) and decreased to 87 +/- 9 ppb during recovery. Recovery values of exhaled NO were similar to those reported in age-matched normal control subjects (88 +/- 3 ppb, n = 72). These findings suggest that symptomatic upper respiratory tract infections markedly increase the concentration of NO in exhaled air. This may reflect the induction of nitric oxide synthase (NOS) in upper and lower respiratory tract, and may be relevant to viral exacerbations of asthma.

Increased nitric oxide in exhaled air of asthmatic patients

Nitric oxide (NO) gas is produced by various cells within the lower respiratory tract, including inflammatory and epithelial cells, and is detectable in the exhaled air of normal human subjects. We have measured exhaled NO in patients with asthma, since several cell types that are activated in asthma can produce NO after induction. NO was measured reproducibly by a slow vital capacity manoeuvre and an adapted chemiluminescence analyser. NO was detectable in exhaled air of 67 control subjects (mean peak concentration 80.2 [SE 4.1] ppb) and was significantly reduced by inhalation of the specific NO synthase inhibitor NG-monomethyl-L-arginine. 61 non-steroid-treated asthmatic subjects had significantly higher peak expired NO concentrations than controls (283 [16] ppb, p < 0.001) but 52 asthmatic patients receiving inhaled corticosteroids had levels similar to controls (101 [7] ppb). High exhaled NO concentrations in asthmatic patients may reflect induction of NO synthase, which is known to be inhibited by steroids. Measurement of exhaled NO concentrations may be clinically useful in detection and management of cytokine-mediated inflammatory lung disorders.

Adherence and fibronectin binding are environmentally regulated in the group A streptococci

The ability of the pathogenic Gram-positive bacterium Streptococcus pyogenes (group A streptococcus) to bind fibronectin and adhere to respiratory epithelial cells is dependent on a surface protein called protein F. In this study, we have examined the regulation of expression of protein F and have shown that it is environmentally regulated in response to alterations in atmosphere. In six recent clinical isolates expression of protein F was repressed during growth under reduced concentrations of O2. Expression in an anaerobic environment was induced by both superoxide-generating and redox-altering reagents. However, regulation did not involve mry, a gene that controls expression of several streptococcal surface proteins. Protein F was constitutively expressed in one of two laboratory-passaged strains analysed, and in a complementation analysis using an allele of the gene that encodes protein F (prtF) cloned from a regulated strain and expressed in a constitutive strain, the constitutive phenotype was shown to be dominant in trans. Regulation, as monitored by fusion of prtF to a promoterless chloramphenicol acetyltransferase gene, involved transcriptional control. Environmentally induced alterations in protein F expression affected the ability of the bacterium to adhere to epithelial cells, which suggests that the ability to regulate expression of protein F may be important during infection.

Seroprevalence of human immunodeficiency virus among family practice outpatients

BACKGROUND

Because the human immunodeficiency virus (HIV) is extremely heterogeneous in its impact on various subpopulations, it is important to carry out HIV seroprevalence studies in different subpopulations using standardized techniques. The present study is the first to report seroprevalence rates of HIV in family medicine outpatient populations.

METHODS

To estimate the prevalence and demographic distribution of HIV, 3874 sera samples were collected anonymously at six family medicine clinics in San Bernardino County during a 1-year period.

RESULTS

Fifty-nine (1.52 percent) of the sera samples were confirmed HIV-positive. Of the 59 HIV-positive patients, 43 were visiting the clinic for HIV-related reasons. Excluding these 43 cases, and adjusting for age and race using the county population as a standard, the overall rate of HIV infection was 0.45 percent. The 16 HIV-positive patients who visited the clinics for reasons unrelated to HIV were between the ages of 20 and 59 years, with the 30- to 39-year-old age group having the highest prevalence (1.4 percent). Seroprevalence was eight times higher for men than women (chi 2 = 14.3, P = 0.0002), and rates for African-Americans (0.85 percent) were two to three times higher than for Hispanics (0.40 percent) and whites (0.25 percent).

CONCLUSIONS

Results of this study are consistent with and support findings from previous surveys of more general populations in the western United States. There are approximately 7800 HIV-infected persons residing in San Bernardino County, and an estimated $796 million will be required to treat these individuals.

Steady-state visual evoked potentials to asymmetrical contrast

The temporal frequency components in the steady-state visual evoked response (VEP) depend on the method of stimulus presentation; a first harmonic is generated to "on-off" patterns while a second harmonic occurs to both "on-off" and counterphase patterns. This study examined the VEP response in humans to patterns between these two extremes. In the main experiment, a 1 c/d sinusoidal grating was phase reversed sinusoidally at 8 Hz. The DC offset, however, was adjusted such that two different levels of peak contrast occurred during a temporal cycle. Within this context, a counterphase pattern would represent complete contrast symmetry and an "on-off" pattern would represent maximum contrast asymmetry during a temporal cycle. With this manipulation, the a) integrated luminance change; b) local luminance change; and c) total contrast remained constant. Only mean contrast varied. The amplitude of the first harmonic strongly depended on mean contrast. The amplitude and phase of the second harmonic, however, changed little across experimental conditions suggesting a dependence on one or more of the above three listed stimulus attributes which remained constant. In a supplementary experiment, this phase constancy was confirmed using other temporal frequencies.

The Way They Do it…: Accident and Emergency Teaching in UK Medical Schools

This is the second in an occasional series of surveys of topical aspects of medical educational practice in the UK and elsewhere. It reports the results of an inquiry into the place in medical school curricula of practical work in accident and emergency medicine-'casualty'-and describes teaching practices in A & E departments. The article demonstrates considerable differences in the arrangements made in the various medical schools, and also in the place of the subject within the final examination.

The involvement of noradrenergic nerves in the cardiovascular reflex responses to lower body negative pressure in the anaesthetised rabbit

1. Resting cardiovascular status and the reflex responses to lower body negative pressure (LBNP) were examined in control rabbits and in rabbits sympathectomised with 6-hydroxydopamine (6-OHDA). 2. Resting systemic arterial pressure and total peripheral resistance were significantly higher in control than in 6-OHDA treated animals. 3. Control animals responded to LBNP at -25 mm Hg with a peripheral vasoconstriction and tachycardia. These responses were absent in 6-OHDA-treated animals. 4. Control animals responded to LBNP at -70 mm Hg with a peripheral vasoconstriction and a bradycardia followed by a tachycardia. There was no significant change in heart rate in response to this stimulus in 6-OHDA-treated animals, although a slight vasoconstriction was seen. 5. Bethanidine blocked the tachycardia and vasoconstriction seen in response to LBNP in control and 6-OHDA-treated rabbits. Under these conditions there was no significant difference between the total peripheral resistance of the control and treated animals. 6. The results indicated that neither the maintenance of the resting systemic arterial pressure nor the reflexes elicited by LBNP in control or in chronically sympathectomised rabbits involved hormonal mechanisms, but LBNP was maintained for 1 min only. These findings are discussed in the context of previous observations.

Quenching of protein fluorescence by transient intermediates in the liver alcohol dehydrogenase reaction

The addition of saturating concentrations of NAD-+ and alcohol to liver alcohol dehydrogenase in a stopped flow fluorimeter results in a triphasic quenching of enzyme fluorescence. A rapid quenching occurs with a rate constant of 300 to 500 s-minus 1, followed by a slower reaction at 50 to 100 s-minus 1, and ultimately followed by a very slow reaction. The addition of NAD-+ to enzyme in the absence of substrate causes a rapid quenching of enzyme fluorescence at 300 to 500 s-minus 1, with the same amplitude as the rapid phase in the presence of substrate. These studies demonstrate that NAD-+ binding to liver alcohol dehydrogenase causes a conformational change at a rate compatible with the previously reported rate constant for proton release, indicating that proton release is probably coupled to the conformational change.