Survival, Dispersal, and Primary Infection Site for Cercospora beticola in Sugar Beet

Cercospora beticola survives as stromata in infected crop residue. Spores produced on these survival structures serve as primary inoculum during the next cropping season. This study was conducted to determine how long C. beticola can survive at different soil depths, the mechanism of inoculum dispersal, and the primary infection site in sugar beet. Longevity of C. beticola was studied over a 3-year period under field conditions at Fargo, ND. C. beticola-infected leaves were placed at depths of 0, 10, and 20 cm and retrieved after 10, 22, and 34 months. Survival of C. beticola inoculum declined with time and soil depth. Inoculum left on the soil surface, 0 cm in depth, survived the longest (22 months) compared with that buried at 10 cm (10 months) and 20 cm (10 months). C. beticola dispersal from the primary source of inoculum was studied in the field for three growing seasons. Sugar beet plants were surrounded with plastic cages with and without ground cover, or exposed with and without ground cover. Significantly higher disease severity was observed on exposed plants than caged plants with or without ground cover, suggesting that wind was the major dispersal factor for C. beticola inoculum. The primary infection site by C. beticola was determined in a greenhouse study. Leaves, roots, and stems of healthy sugar beet plants were inoculated with C. beticola. Cercospora leaf spot symptoms were observed only on plants that were leaf inoculated, suggesting that the leaf was the primary infection site for C. beticola.

Probiotics for treatment of Clostridium difficile-associated colitis in adults

BACKGROUND

Probiotics are live microorganisms consisting of non-pathogenic yeast and bacteria that are believed to restore the microbial balance of the gastrointestinal tract altered by infection with Clostridium difficile (C. difficile).

OBJECTIVES

To assess the efficacy of probiotics in the treatment of antibiotic associated C. difficile colitis.

SEARCH STRATEGY

The databases MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and Cochrane IBD/FBD Specialized Trials register were searched to locate all published reports from 1966 to 2007.

SELECTION CRITERIA

Randomized, prospective studies using probiotics alone or in conjunction with conventional antibiotics for the treatment of documented C. difficile colitis were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Data extraction and analysis was done independently by two authors.

MAIN RESULTS

Four studies met the inclusion criteria and were included in the review. The four studies examined the use of probiotics in conjunction with conventional antibiotics (vancomycin or metronidazole) for the treatment of recurrence or an initial episode of C. difficile colitis in adults. The studies were small in size and had methodological problems. A statistically significant benefit for probiotics combined with antibiotics was found in one study. McFarland 1994 found that patients receiving S. boulardii were significantly less likely than patients receiving placebo to experience recurrence of C. difficile diarrhea (RR 0.59; 95% CI 0.35 to 0.98). No benefit of probiotics treatment was found in the other studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend probiotic therapy as an adjunct to antibiotic therapy for C. difficile colitis. There is no evidence to support the use of probiotics alone in the treatment of C. difficile colitis.

Probiotics for treatment of Clostridium difficile-associated colitis in adults

BACKGROUND

Probiotics are live microorganisms consisting of non-pathogenic yeast and bacteria that are believed to restore the microbial balance of the gastrointestinal tract altered by infection with Clostridium difficile (C. difficile).

OBJECTIVES

To assess the efficacy of probiotics in the treatment of antibiotic associated C. difficile colitis.

SEARCH STRATEGY

The databases MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and Cochrane IBD/FBD Specialized Trials register were searched to locate all published reports from 1966 to 2007.

SELECTION CRITERIA

Randomized, prospective studies using probiotics alone or in conjunction with conventional antibiotics for the treatment of documented C. difficile colitis were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Data extraction and analysis was done independently by two authors.

MAIN RESULTS

Four studies met the inclusion criteria and were included in the review. The four studies examined the use of probiotics in conjunction with conventional antibiotics (vancomycin or metronidazole) for the treatment of recurrence or an initial episode of C. difficile colitis in adults. The studies were small in size and had methodological problems. A statistically significant benefit for probiotics combined with antibiotics was found in one study. McFarland 1994 found that patients receiving S. boulardii were significantly less likely than patients receiving placebo to experience recurrence of C. difficile diarrhea (RR 0.59; 95% CI 0.35 to 0.98). No benefit of probiotics treatment was found in the other studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend probiotic therapy as an adjunct to antibiotic therapy for C. difficile colitis. There is no evidence to support the use of probiotics alone in the treatment of C. difficile colitis.

Space flight alters bacterial gene expression and virulence and reveals a role for global regulator Hfq

A comprehensive analysis of both the molecular genetic and phenotypic responses of any organism to the space flight environment has never been accomplished because of significant technological and logistical hurdles. Moreover, the effects of space flight on microbial pathogenicity and associated infectious disease risks have not been studied. The bacterial pathogen Salmonella typhimurium was grown aboard Space Shuttle mission STS-115 and compared with identical ground control cultures. Global microarray and proteomic analyses revealed that 167 transcripts and 73 proteins changed expression with the conserved RNA-binding protein Hfq identified as a likely global regulator involved in the response to this environment. Hfq involvement was confirmed with a ground-based microgravity culture model. Space flight samples exhibited enhanced virulence in a murine infection model and extracellular matrix accumulation consistent with a biofilm. Strategies to target Hfq and related regulators could potentially decrease infectious disease risks during space flight missions and provide novel therapeutic options on Earth.

Improving the Cercospora Leaf Spot Management Model for Sugar Beet in Minnesota and North Dakota

Management of Cercospora leaf spot, caused by Cercospora beticola, is necessary for the economic production of sugar beet (Beta vulgaris). The objectives of this study were to evaluate the impact of two relative humidity thresholds (87 and 90%) on the daily infection values (DIVs) used to determine when fungicide applications were required, to determine whether current Cercospora management recommendations for northern areas of Minnesota and North Dakota could be used by growers in the southern areas of these states, and to compare the utility of calendar-based fungicide applications with the Cercospora management model. Research was conducted in Breckenridge, MN and St. Thomas, ND in 2003 and 2004. Fungicide applications significantly (P = 0.05) reduced maximum disease severity (y_max) and area under the disease progress curve (AUDPC) when compared with the nontreated control at both locations during 2003 and 2004. Fungicides applied according to DIVs calculated at RH ≥ 87% or RH > 90% gave similar results. The mandatory second fungicide application 14 days after the first application for southern areas did not significantly decrease disease severity or AUDPC, or improve root yield or recoverable sucrose compared with treatments without the mandatory application. This research illustrates that a DIV calculated at RH ≥ 87% would result in similar timing of fungicide applications compared with DIVs calculated at RH > 90%. The results further show that the recommendation of fungicide applications at initial symptom and subsequent applications based on DIV and disease severity should be used for both northern and southern growers. Finally, this research showed that fungicide applications based on the Cercospora management model provided similar, effective disease control with fewer fungicide applications compared with calendar-based applications.

Prophylactic nasogastric decompression after abdominal surgery

BACKGROUND

Routine use of nasogastric tubes after abdominal operations is intended to hasten the return of bowel function, prevent pulmonary complications, diminish the risk of anastomotic leakage, increase patient comfort and shorten hospital stay.

OBJECTIVES

To investigate the efficacy of routine nasogastric decompression after abdominal surgery in achieving each of the above goals.

SEARCH STRATEGY

Search terms were nasogastric, tubes, randomised, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (Central), and references of included studies, from 1966 through 2006.

SELECTION CRITERIA

Patients having abdominal operations of any type, emergency or elective, who were randomised prior tot he completion of the operation to receive a nasogastric tube and keep it in place until intestinal function had returned, versus those receiving either no tube or early tube removal, in surgery, in recovery or within 24 hours of surgery. Excluded will be randomised studies involving laparoscopic abdominal surgery and patient groups having gastric decompression through gastrostomy.

DATA COLLECTION AND ANALYSIS

Data were abstracted onto a form that assessed study eligibility, as defined above, quality related to randomizations, allocation concealment, study size and dropouts, interventions, including timing and duration of intubation, outcomes that included time to flatus, pulmonary complications, wound infection, anastomotic leak, length of stay, death, nausea, vomiting, tube reinsertion, subsequent ventral hernia.

MAIN RESULTS

33 studies fulfilled eligibility criteria, encompassing 5240 patients, 2628 randomised to routine tube use, and 2612 randomised to selective or No Tube use. Patients not having routine tube use had an earlier return of bowel function (p<0.00001), a decrease in pulmonary complications (p=0.01) and an insignificant trend toward increase in risk of wound infection (p=0.22) and ventral hernia (0.09). Anastomotic leak was no different between groups (p=0.70). Vomiting seemed to favour routine tube use, but with increased patient discomfort. Length of stay was shorter when no tube was used but the heterogeneity encountered in these analyses make rigorous conclusion difficult to draw for this outcome. No adverse events specifically related to tube insertion (direct tube trauma) were reported. Other outcomes were reported with insufficient frequency to be informative.

AUTHORS' CONCLUSIONS

Routine nasogastric decompression does not accomplish any of its intended goals and so should be abandoned in favour of selective use of the nasogastric tube.

Antibiotic treatment for Clostridium difficile-associated diarrhea in adults

BACKGROUND

Clostridium difficile (C. difficile) is recognized as a frequent cause of antibiotic-associated diarrhea and colitis.

OBJECTIVES

The aim of this review is to establish the efficacy of antibiotic therapy for C. difficile-associated diarrhea (CDAD), to identify the most effective antibiotic treatment for CDAD in adults and to determine the need for stopping the causative antibiotic during therapy.

SEARCH STRATEGY

MEDLINE (1966 to 2006), EMBASE (1980 to 2006), Cochrane Central Database of Controlled Trials and the Cochrane IBD Review Group Specialized Trials Register were searched using the following search terms: "pseudomembranous colitis and randomized trial"; "Clostridium difficile and randomized trial"; "antibiotic associated diarrhea and randomized trial".

SELECTION CRITERIA

Only randomized, controlled trials assessing antibiotic treatment for CDAD were included in the review. Probiotic trials are excluded. The following outcomes were sought: initial resolution of diarrhea; initial conversion of stool to C. difficile cytotoxin and/or stool culture negative; recurrence of diarrhea; recurrence of fecal C. difficile cytotoxin and/or positive stool culture; patient response to cessation of prior antibiotic therapy; sepsis; emergent surgery: fecal diversion or colectomy; and death.

DATA COLLECTION AND ANALYSIS

Data were analyzed using the MetaView statistical package in Review Manager. For dichotomous outcomes, relative risks (RR) and 95% confidence intervals (CI) were derived from each study. When appropriate, the results of included studies were combined for each outcome. For dichotomous outcomes, pooled RR and 95% CI were calculated using a fixed effect model, except where significant heterogeneity was detected, at which time the random effects model was used. Data heterogeneity was calculated using MetaView.

MAIN RESULTS

Twelve studies (total of 1157 participants) involving patients with diarrhea who recently received antibiotics for an infection other than C. difficile were included. The definition of diarrhea ranged from at least two loose stools per day with an associated symptom such as rectal temperature > 38 (o)C, to at least six loose stools in 36 hours. Eight different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin and bacitracin. In paired comparisons, no single antibiotic was clearly superior to others, though teicoplanin, an antibiotic of limited availability and great cost, showed in some outcomes significant benefit over vancomycin and fusidic acid, and a trend towards benefit compared to metronidazole. Only one placebo controlled trial was done and no conclusions can be drawn from it due to small size and classification error. Only one study investigated synergistic antibiotic combination, metronidazole and rifampin, and there was no advantage to the drug combination.

AUTHORS' CONCLUSIONS

Current evidence leads to uncertainty whether mild CDAD needs to be treated. Patients with mild CDAD may resolve their symptoms as quickly without treatment. The only placebo-controlled study shows vancomycin's superior efficacy. However, this result should be treated with caution due to the small number of patients enrolled and the poor methodological quality of the trial. The Johnson study of asymptomatic carriers also shows that placebo is better than vancomycin or metronidazole for eliminating C. difficile in stool during follow-up. If one does decide to treat, then two goals of therapy need to be kept in mind: improvement of the patient's clinical condition and prevention of spread of C. difficile infection to other patients. Given these two considerations, one should choose the antibiotic that brings both symptomatic cure and bacteriologic cure. In this regard, teicoplanin appears to be the best choice because the available evidence suggests that it is better than vancomycin for bacteriologic cure and has borderline superior effectiveness in terms of symptomatic cure. Teicoplanin is not readily available in the United States, which must be taken into account when making treatment decisions in that country.

Quality of life in colorectal cancer patients with hepatic arterial infusion (HAI) pumps

19602

Background: More than half of patients diagnosed with colorectal cancer will develop hepatic metastases. Most patients with hepatic metastases will recur within two years after resection. Hepatic arterial infusion (HAI) pumps deliver regional treatment. However, very few studies quantitatively explore the patient's experience of living with an HAI pump and how this experience impacts HAI-related quality of life (QOL). This study explored the impact of HAI pump treatment on patient's overall QOL within the specific domains of physical, psychological, social, and functional well-being. Methods: Twenty-five colorectal cancer patients treated with HAI pumps completed an HAI pump- specific QOL assessment tool at one data collection time point. The QOL assessment tool items were derived from the investigator's previous QOL research with this patient population [Blair et al., 2002, Annals of Surgical Oncology]. Demographic, disease and QOL data were summarized using descriptive statistics. Results: Of the 25 patients accrued, 32% were receiving treatments through their HAI pump and 68% were not. There were no significant difference in QOL between treatment status, gender, and age (<65 or = 65). Currently treated pump patients experienced more appetite changes (p=0.03), sleep changes (p=0.08), and more restrictions in traveling (p=0.08). Male patients had more concerns with lifting heavy items (p=0.05), while female patients had more concerns with isolation (p=0.17) and changes in the type of clothing worn (p=0.16). Younger patients had more concerns with vigorous activity (p=0.01), bending (p=0.08), and were more self-conscious of their appearance with the pump (p=0.01). Conclusions: Overall, in this study, colorectal cancer patients with HAI pumps reported good QOL and were satisfied with their overall treatment experience. Although there was no comparative statistical analysis performed in this study, several QOL concerns remain worrisome for patients. Defining these specific QOL concerns in HAI patients will enhance clinical understanding of their unique experience with this treatment modality and impact patient management. This will enable further development of educational tools and research to test interventions to support HAI patients and sustain their QOL.

No significant financial relationships to disclose.

Bcl-2 family proteins are essential for platelet survival

Platelets are relatively short-lived, anucleated cells that are essential for proper hemostasis. The regulation of platelet survival in the circulation remains poorly understood. The process of platelet activation and senescence in vivo is associated with processes similar to those observed during apoptosis in nucleated cells, including loss of mitochondrial membrane potential, caspase activation, phosphatidylserine (PS) externalization, and cell shrinkage. ABT-737, a potent antagonist of Bcl-2, Bcl-X(L), and Bcl-w, induces apoptosis in nucleated cells dependent on these proteins for survival. In vivo, ABT-737 induces a reduction of circulating platelets that is maintained during drug therapy, followed by recovery to normal levels within several days after treatment cessation. Whole body scintography utilizing ([111])Indium-labeled platelets in dogs shows that ABT-737-induced platelet clearance is primarily mediated by the liver. In vitro, ABT-737 treatment leads to activation of key apoptotic processes including cytochrome c release, caspase-3 activation, and PS externalization in isolated platelets. Despite these changes, ABT-737 is ineffective in promoting platelet activation as measured by granule release markers and platelet aggregation. Taken together, these data suggest that ABT-737 induces an apoptosis-like response in platelets that is distinct from platelet activation and results in enhanced clearance in vivo by the reticuloendothelial system.

Malone antegrade continent enema: an alternative to resection in severe defecation disorders

PURPOSE

This study was designed to evaluate patient self-reported outcome of the Malone antegrade continent enema at a single institution in patients suffering from severe defecatory disorders.

METHODS

A total of 18 patients (15 females; median age, 31 (range, 12-63) years) underwent a Malone antegrade continent enema (August 1999 to September 2004). The Malone antegrade continent enema technique has been previously described; however, in this series emphasis was placed on method appendix tunneling. Patients' charts were reviewed and follow-up telephone interviews were conducted. Indications for Malone antegrade continent enema were chronic constipation (n = 12), intractable fecal incontinence (n = 5), or both (n = 1). The underlying pathology included neurogenic (n = 2), congenital (n = 4), postsurgery-related (n = 4), irritable bowel syndrome (n = 6), and megarectum (n = 2). The appendix (n = 17) or cecum (n = 1) was used as a conduit.

RESULTS

The mean follow-up was 18.5 (range, 3-67) months. Fourteen patients (78 percent) still use the Malone antegrade continent enema routinely and report good functional outcome. Three patients (20 percent) required stoma creation as subsequent alternate treatment. A total of 10 patients experienced 12 complications: 3 perioperative (infections) and 9 postoperative Malone antegrade continent enema use/nonuse complications (4 stomal orifice strictures, 2 fecal impactions, 2 appendiceal perforations, and 1 irrigation catheter knot). No patient experienced leakage from the appendiceal stoma. During the follow-up interval, one patient underwent proctectomy for megarectum. No failures occurred in patients with congenital or neurogenic disorders.

CONCLUSIONS

Malone antegrade continent enema is a reasonable option for the treatment of select patients with severe defecation disorders. Good functional patient self-reported outcome was achieved by 78 percent of patients. The social inconvenience of stoma leakage is avoided with appropriate surgical technique. Malone antegrade continent enema is one option that provides a less invasive surgical alternative than colectomy or ileostomy for severe defecation disorders.

Non surgical therapy for anal fissure

BACKGROUND

Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing.

OBJECTIVES

To assess the efficacy and morbidity of various medical therapies for anal fissure.

SEARCH STRATEGY

Search terms include "anal fissure randomized". Timing from 1966 to May 2006. Further details of the search below.

SELECTION CRITERIA

Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded.

DATA COLLECTION AND ANALYSIS

Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry.

MAIN RESULTS

48 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 53 RCTs. Eleven agents were used (nitroglycerin ointment (GTN), isosorbide dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, and placebo) as well as anal dilators and surgical sphincterotomy.GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.6% vs. 37%, p < 0.004), but late recurrence of fissure was common, in the range of 50% of those initially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy came close to the efficacy of surgical sphincterotomy, though none in these RCTs was associated with the risk of incontinence.

AUTHORS' CONCLUSIONS

Medical therapy for chronic anal fissure, acute fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo, and, for chronic fissure in adults, far less effective than surgery.

Hepatic artery adjuvant chemotherapy for patients having resection or ablation of colorectal cancer metastatic to the liver

BACKGROUND

Colorectal cancer metastatic to the liver, when technically feasible, is resected with a moderate chance of cure. The most common site of failure after resection is within the remaining liver. With this pattern of clinical failure in mind and in order to enhance survival, chemotherapy has been delivered directly to the liver post resection via the hepatic artery.

OBJECTIVES

To assess the effect of post hepatic resection hepatic artery chemotherapy on overall survival. Secondary objectives include adverse events related to the chemotherapy, the risk of intra-hepatic tumour recurrence and tumour free survival.

SEARCH STRATEGY

Randomised trials were sought in MEDLINE; the Cochrane Central Register of Controlled Trials; the Cochrane Hepato-Biliary Group Controlled Trials Register; and through contact of trial authors and reference lists using key words: Colorectal, cancer, hepatic metastases, hepatic artery, chemotherapy. Searches were performed in May, 2006.

SELECTION CRITERIA

Trials in which patients having resection of colorectal cancer metastatic to the liver were randomised either to hepatic artery chemotherapy or any alternative treatment.

DATA COLLECTION AND ANALYSIS

Survival data were obtained principally from abstraction from survival curves in published studies using the method of Parmar. A study specific log hazard ratio and then combined effect log hazard ratio were calculated, as well as a combined Kaplan-Meier survival probability curve.

MAIN RESULTS

Seven randomised trials addressed this issue, encompassing 592 patients. No significant advantage was found in the meta-analysis for hepatic artery chemotherapy measuring overall survival and calculating survival based upon "intention to treat" (lnHR = 0.0848; favouring the control group, 95% confidence interval = -0.1189 to 0.2885, or a Hazard Ratio of 1.089, an 8.9% survival advantage for the control group, 95% CI of the HR = 0.887-1.334). Adverse events related to the hepatic artery therapy were common, including five therapy related deaths. Intra-hepatic recurrence was more frequent in the control group (97 patients versus 43 in the HAI group), though denominators are not reported, and additional outcomes could not be subjected to a combined analysis.

AUTHORS' CONCLUSIONS

Though recurrence in the remaining liver happened less in the hepatic artery chemotherapy group, overall survival was not improved, and even favoured the control group, though not significantly. This added intervention cannot be recommended at this time.

The evolution of educational information systems and nurse faculty roles

Institutions of higher education are purchasing and/or designing sophisticated administrative information systems to manage such functions as the application, admissions, and registration process, grants management, student records, and classroom scheduling. Although faculty also manage large amounts of data, few automated systems have been created to help faculty improve teaching and learning through the management of information related to individual students, the curriculum, educational programs, and program evaluation. This article highlights the potential benefits that comprehensive educational information systems offer nurse faculty.

Bacteriology swab in primary total hip arthroplasty-- does it have a role?

Infection in joint replacement is a devastating complication, and in spite of the advances in surgery, it remains a challenge. The rate of deep infection following primary hip/knee arthroplasty is between 1% and 2%. The aim of this study was to determine whether obtaining bacteriology swabs at the time of surgery could help in further reducing the rate of infection following joint arthroplasty. A bacteriology swab of the synovial fluid was taken after opening the capsule of the hip joint and was sent for culture and sensitivity. Out of 142 swabs sent, four (2.1%) were found to be positive. Three of these patients were treated with antibiotics after obtaining sensitivities. None of the patients developed deep infection. Bacteriology swab in primary joint arthroplasty may have a role and may help in further reducing the incidence of deep infection in joint replacement surgery.

Limits on spin-independent interactions of weakly interacting massive particles with nucleons from the two-tower run of the cryogenic dark matter search

We report new results from the Cryogenic Dark Matter Search (CDMS II) at the Soudan Underground Laboratory. Two towers, each consisting of six detectors, were operated for 74.5 live days, giving spectrum-weighted exposures of 34 (12) kg d for the Ge (Si) targets after cuts, averaged over recoil energies 10-100 keV for a weakly interacting massive particle (WIMP) mass of 60 GeV/c2. A blind analysis was conducted, incorporating improved techniques for rejecting surface events. No WIMP signal exceeding expected backgrounds was observed. When combined with our previous results from Soudan, the 90% C.L. upper limit on the spin-independent WIMP-nucleon cross section is 1.6 x 10(-43) cm2 from Ge and 3 x 10(-42) cm2 from Si, for a WIMP mass of 60 GeV/c2. The combined limit from Ge (Si) is a factor of 2.5 (10) lower than our previous results and constrains predictions of supersymmetric models.

Literacy, consumer informatics, and health care outcomes: Interrelations and implications

Health care outcomes are clearly impacted by the ability of clients to participate in their health care. Nurses have always used education to empower their patients. With the advent of the Internet the concept of patient education has been transformed to the much broader concept of consumer informatics. For increasing numbers of clients the Internet has become a primary source of health information and a major factor influencing their knowledge and decisions related to their health. Successful use of the Internet depends on several different levels and types of literacies. This paper explores the interrelations between the concepts of basic literacy, computer literacy, information literacy, health information literacy and health literacy. It demonstrates the need for client assessment tools that are sensitive to each of these literacies and their interrelations. In concludes by challenging consumer informatics specialists to develop these assessment tools as well as teaching tools for empowering consumers using the Internet.

The evolution of Titan's mid-latitude clouds

Spectra from Cassini's Visual and Infrared Mapping Spectrometer reveal that the horizontal structure, height, and optical depth of Titan's clouds are highly dynamic. Vigorous cloud centers are seen to rise from the middle to the upper troposphere within 30 minutes and dissipate within the next hour. Their development indicates that Titan's clouds evolve convectively; dissipate through rain; and, over the next several hours, waft downwind to achieve their great longitude extents. These and other characteristics suggest that temperate clouds originate from circulation-induced convergence, in addition to a forcing at the surface associated with Saturn's tides, geology, and/or surface composition.

Operative procedures for fissure in ano

BACKGROUND

Operative techniques commonly used for fissure in ano include: anal stretch, open lateral sphincterotomy, closed lateral sphincterotomy, posterior midline sphincterotomy and to a lesser extent dermal flap coverage of the fissure. Reports of direct comparisons between operative techniques for anal fissure are variable in their results. These reports are either subject to selection bias (in non-randomized studies) or observer bias (in all studies) or have inadequate numbers of patients enrolled to answer the question of efficacy.

OBJECTIVES

To determine the best technique for fissure surgery.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials and MEDLINE (1965-2005) were searched. The list of cited references in all included reports and several study authors also were helpful in finding additional comparative studies.

SELECTION CRITERIA

All reports in which there was a direct comparison between at least two operative techniques were reviewed and when more than one report existed for any given pair, that report was included. If crude data were not presented in the report, the authors were contacted and crude data obtained.

DATA COLLECTION AND ANALYSIS

The two most commonly used end points in all reported studies were persistence of the fissure and post operative incontinence of flatus. These are the only two endpoints included in the meta-analysis.

MAIN RESULTS

Twenty-four trials encompassing 3475 patients are included in this review . Anal stretch has a higher risk of fissure persistence than internal sphincterotomy and also a significantly higher risk of minor incontinence than sphincterotomy. The combined results of open versus closed partial lateral internal sphincterotomy show little difference between the two procedures both in fissure persistence and risk of incontinence.

AUTHORS' CONCLUSIONS

Anal stretch and posterior midline internal sphincterotomy should probably be abandoned in the treatment of chronic anal fissure in adults. For those patients requiring surgery for anal fissure, open and closed partial lateral internal sphincterotomy appear to be equally efficacious. More data are needed to assess the effectiveness of posterior internal sphincterotomy, anterior levatorplasty, wound suture or papilla excision.

Prophylactic nasogastric decompression after abdominal surgery

BACKGROUND

Routine use of nasogastric tubes after abdominal operations is intended to hasten the return of bowel function, prevent pulmonary complications, diminish the risk of anastomotic leakage, increase patient comfort and shorten hospital stay.

OBJECTIVES

To investigate the efficacy of routine nasogastric decompression after abdominal surgery in achieving each of the above goals.

SEARCH STRATEGY

Search terms were nasogastric, tubes, randomised, using MEDLINE, EMBASE, Cochrane Controlled Trials Register, and references of included studies.

SELECTION CRITERIA

Patients having abdominal operations of any type, emergency or elective, who were randomised prior tot he completion of the operation to receive a nasogastric tube and keep it in place until intestinal function had returned, versus those receiving either no tube or early tube removal, in surgery, in recovery or within 24 hours of surgery. Excluded will be randomised studies involving laparoscopic abdominal surgery and patient groups having gastric decompression through gastrostomy.

DATA COLLECTION AND ANALYSIS

Data were abstracted onto a form that assessed study eligibility, as defined above, quality related to randomizations, allocation concealment, study size and dropouts, interventions, including timing and duration of intubation, outcomes that included time to flatus, pulmonary complications, wound infection, anastomotic leak, length of stay, death, nausea, vomiting, tube reinsertion, subsequent ventral hernia.

MAIN RESULTS

28 studies fulfilled eligibility criteria, encompassing 4194 patients, 2108 randomised to routine tube use, and 2087 randomised to selective or No Tube use. Patients not having routine tube use had an earlier return of bowel function (p<0.00001), an insignificant trend toward decrease in pulmonary complications (p=0.07) and an insignificant trend toward increase in risk of wound infection (p=0.08) and ventral hernia (0.09). Anastomotic leak was no different between groups (p=0.70). Patient comfort, nausea, vomiting and length of stay seemed to favour No Tube, but the heterogeneity encountered in these analyses make rigorous conclusion difficult to draw for these outcomes. No adverse events specifically related to tube insertion (direct tube trauma) were reported. Other outcomes were reported with insufficient frequency to be informative.

AUTHORS' CONCLUSIONS

Routine nasogastric decompression does not accomplish any of its intended goals and so should be abandoned in favour of selective use of the nasogastric tube.

Prophylactic nasogastric decompression after abdominal surgery

BACKGROUND

Routine use of nasogastric tubes after abdominal operations is intended to hasten the return of bowel function, prevent pulmonary complications, diminish the risk of anastomotic leakage, increase patient comfort and shorten hospital stay.

OBJECTIVES

To investigate the efficacy of routine nasogastric decompression after abdominal surgery in achieving each of the above goals.

SEARCH STRATEGY

Search terms were nasogastric, tubes, randomised, using MEDLINE, EMBASE, Cochrane Controlled Trials Register, and references of included studies.

SELECTION CRITERIA

Patients having abdominal operations of any type, emergency or elective, who were randomised prior tot he completion of the operation to receive a nasogastric tube and keep it in place until intestinal function had returned, versus those receiving either no tube or early tube removal, in surgery, in recovery or within 24 hours of surgery. Excluded will be randomised studies involving laparoscopic abdominal surgery and patient groups having gastric decompression through gastrostomy.

DATA COLLECTION AND ANALYSIS

Data were abstracted onto a form that assessed study eligibility, as defined above, quality related to randomizations, allocation concealment, study size and dropouts, interventions, including timing and duration of intubation, outcomes that included time to flatus, pulmonary complications, wound infection, anastomotic leak, length of stay, death, nausea, vomiting, tube reinsertion, subsequent ventral hernia.

MAIN RESULTS

28 studies fulfilled eligibility criteria, encompassing 4194 patients, 2108 randomised to routine tube use, and 2087 randomised to selective or No Tube use. Patients not having routine tube use had an earlier return of bowel function (p<0.00001), an insignificant trend toward decrease in pulmonary complications (p=0.07) and an insignificant trend toward increase in risk of wound infection (p=0.08) and ventral hernia (0.09). Anastomotic leak was no different between groups (p=0.70). Patient comfort, nausea, vomiting and length of stay seemed to favour No Tube, but the heterogeneity encountered in these analyses make rigorous conclusion difficult to draw for these outcomes. No adverse events specifically related to tube insertion (direct tube trauma) were reported. Other outcomes were reported with insufficient frequency to be informative.

AUTHORS' CONCLUSIONS

Routine nasogastric decompression does not accomplish any of its intended goals and so should be abandoned in favour of selective use of the nasogastric tube.

Antibiotic treatment for Clostridium difficile-associated diarrhea in adults

BACKGROUND

Clostridium difficile (C. difficile) is recognized as a frequent cause of antibiotic-associated diarrhea and colitis.

OBJECTIVES

The aim of this review is to establish the efficacy of antibiotic therapy for C. difficile-associated diarrhea (CDAD), to identify the most effective antibiotic treatment for CDAD in adults and to determine the need for stopping the causative antibiotic during therapy.

SEARCH STRATEGY

MEDLINE (1966 to 2003), EMBASE (1980 to 2003), Cochrane Central Database of Controlled Trials and the Cochrane IBD Review Group Specialized Trials Register were searched using the following search terms: "pseudomembranous colitis and randomized trial"; "Clostridium difficile and randomized trial"; "antibiotic associated diarrhea and randomized trial".

SELECTION CRITERIA

Only randomized, controlled trials assessing antibiotic treatment for CDAD were included in the review. Probiotic trials are excluded. The following outcomes were sought: initial resolution of diarrhea; initial conversion of stool to C. difficile cytotoxin and/or stool culture negative; recurrence of diarrhea; recurrence of fecal C. difficile cytotoxin and/or positive stool culture; patient response to cessation of prior antibiotic therapy; sepsis; emergent surgery: fecal diversion or colectomy; and death.

DATA COLLECTION AND ANALYSIS

Data were analyzed using the MetaView statistical package in Review Manager. For dichotomous outcomes, relative risks (RR) and 95% confidence intervals (CI) were derived from each study. When appropriate, the results of included studies were combined for each outcome. For dichotomous outcomes, pooled RR and 95% CI were calculated using a fixed effect model, except where significant heterogeneity was detected, at which time the random effects model was used. Data heterogeneity was calculated using MetaView.

MAIN RESULTS

Of eleven studies identified, two were subsequently excluded because patients were stool positive for C. difficile, but did not have diarrhea or because the study was not a randomized controlled trial. All of the remaining nine studies involved patients with diarrhea who recently received antibiotics for an infection other than C. difficile. The definition of diarrhea ranged from at least two loose stools per day with an associated symptom such as rectal temperature > 38(o)C, to at least six loose stools in 36 hours. In terms of symptomatic cure, metronidazole, bacitracin and fusidic acid were not shown to be less effective than vancomycin. Teicoplanin may be slightly more effective than vancomycin with a relative risk of 1.21 [95% CI 1.00 to 1.46] and a p-value of 0.06. In terms of initial symptomatic resolution, vancomycin is more effective than placebo with a relative risk of 6.75 [95% CI 1.16 to 48.43] and a p-value of 0.03. This result should be interpreted with caution given the small number of patients in this comparison (12 in the vancomycin group and nine in the placebo group) and the poor methodological quality of the trial. Metronidazole, bacitracin, teicoplanin, fusidic acid and rifaximine are as effective as vancomycin for initial symptomatic resolution. The other secondary outcomes measured in this review: surgery, sepsis and death occurred infrequently in all of the studies.

AUTHORS' CONCLUSIONS

Current evidence leads to uncertainty whether mild CDAD needs to be treated. Patients with mild CDAD may resolve their symptoms as quickly without treatment. The only placebo-controlled study shows vancomycin's superior efficacy. However, this result should be treated with caution due to the small number of patients enrolled and the poor methodological quality of the trial. The Johnson study of asymptomatic carriers also shows that placebo is better than vancomycin or metronidazole for eliminating C. difficile in stool during follow-up. If one does decide to treat, then two goals of therapy need to be kept in mind: improvement of the patient's clinical condition and prevention of spread of C. difficile infection to other patients. Given these two considerations, one should choose the antibiotic that brings both symptomatic cure and bacteriologic cure. In this regard, teicoplanin appears to be the best choice because the available evidence suggests that it is better than vancomycin for bacteriologic cure and has borderline superior effectiveness in terms of symptomatic cure. Teicoplanin is not readily available in the United States, which must be taken into account when making treatment decisions in that country.

First results from the Cryogenic Dark Matter Search in the Soudan Underground Laboratory

We report the first results from a search for weakly interacting massive particles (WIMPs) in the Cryogenic Dark Matter Search experiment at the Soudan Underground Laboratory. Four Ge and two Si detectors were operated for 52.6 live days, providing 19.4 kg d of Ge net exposure after cuts for recoil energies between 10 and 100 keV. A blind analysis was performed using only calibration data to define the energy threshold and selection criteria for nuclear-recoil candidates. Using the standard dark-matter halo and nuclear-physics WIMP model, these data set the world's lowest exclusion limits on the coherent WIMP-nucleon scalar cross section for all WIMP masses above 15 GeV/c2, ruling out a significant range of neutralino supersymmetric models. The minimum of this limit curve at the 90% C.L. is 4 x 10(-43) cm2 at a WIMP mass of 60 GeV/c2.