Comparison of effect of CTG + STan with CTG alone on emergency Cesarean section rate: STan Australian Randomized controlled Trial (START)

OBJECTIVE

To investigate whether use of ST analysis of the fetal electrocardiogram (STan) as an adjunct to continuous cardiotocography (CTG) reduces the rate of emergency Cesarean section (EmCS) compared with CTG alone.

METHODS

This was a randomized controlled trial of patients with a singleton fetus in cephalic presentation at ≥ 36 weeks' gestation, requiring continuous electronic fetal monitoring during labor at a tertiary maternity hospital in Adelaide, Australia, between January 2018 and July 2021. Participants were randomized to undergo CTG + STan or CTG alone. The calculated sample size was 1818 participants. The primary outcome was EmCS. Secondary outcomes included metabolic acidosis, a composite adverse perinatal outcome, and other maternal and neonatal morbidity and safety outcomes.

RESULTS

The present study enrolled 970 women, of whom 967 were included in the primary analysis. EmCS occurred in 107/482 (22.2%) deliveries in the CTG + STan arm and in 107/485 (22.1%) in the CTG arm (adjusted relative risk, 1.02 (95% CI, 0.81-1.27); P = 0.89). There was no difference in the rate of adverse maternal or neonatal outcomes between arms.

CONCLUSIONS

The addition of STan as an adjunct to continuous CTG did not reduce the EmCS rate. The smaller-than-anticipated sample size meant that this study was underpowered to detect absolute differences of ≤ 5% and, therefore, this negative finding could be due to a Type-2 error. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A unified local objective function for optimally selecting SNPs on arrays for agricultural genomics applications

Over the years, ad-hoc procedures were used for designing SNP arrays, but the procedures and strategies varied considerably case by case. Recently, a multiple-objective, local optimization (MOLO) algorithm was proposed to select SNPs for SNP arrays, which maximizes the adjusted SNP information (E score) under multiple constraints, e.g. on MAF, uniformness of SNP locations (U score), the inclusion of obligatory SNPs and the number and size of gaps. In the MOLO, each chromosome is split into equally spaced segments and local optima are selected as the SNPs having the highest adjusted E score within each segment, conditional on the presence of obligatory SNPs. The computation of the adjusted E score, however, is empirical, and it does not scale well between the uniformness of SNP locations and SNP informativeness. In addition, the MOLO objective function does not accommodate the selection of uniformly distributed SNPs. In the present study, we proposed a unified local function for optimally selecting SNPs, as an amendment to the MOLO algorithm. This new local function takes scalable weights between the uniformness and informativeness of SNPs, which allows the selection of SNPs under varied scenarios. The results showed that the weighting between the U and the E scores led to a higher imputation concordance rate than the U score or E score alone. The results from the evaluation of six commercial bovine SNP chips further confirmed this conclusion.

Development and evaluation of a low-density single-nucleotide polymorphism chip specific to Bos indicus cattle

Context Genomic selection has been of increasing interest in the genetic improvement of Zebu cattle, particularly for quantitative traits that are difficult or expensive to measure, such as carcass traits and meat tenderness. The success of genomic selection depends on several factors, and at its core is the availability of single-nucleotide polymorphism (SNP) chips that are appropriately designed for Bos indicus cattle. However, the currently available commercial bovine SNP chips are mostly designed for Bos taurus cattle. There are two commercial Bos indicus SNP chips; namely, GeneSeek genomic profiler high-density Bos indicus (GGP-HDi) SNP chip and a low-density (LD) Bos indicus SNP chip (Z chip), but these two Bos indicus SNP chips were built with mixed contents of SNPs for Bos indicus and Bos taurus cattle, due to limited availability of genotype data from Bos indicus cattle. Aims To develop a new GGP indicus 35000 SNP chip specifically for Bos indicus cattle, which has a low cost, but high accuracy of imputation to Illumina BovineHD chips. Methods The design of the chip consisted of 34000 optimally selected SNPs, plus 1000 SNPs pre-reserved for those on the Y chromosome, ‘causative’ mutations for a variety of economically relevant traits, genetic health conditions and International Society for Animal Genetics globally recognised parentage markers for those breeds of cattle. Key results The present results showed that this new indicus LD SNP chip had considerably increased minor allele frequencies in indicus breeds than the previous Z-chip. It demonstrated with high imputation accuracy to HD SNP genotypes in five indicus breeds, and with considerable predictability on 14 growth and reproduction traits in Nellore cattle. Conclusions This new indicus LD chip represented a successful effort to leverage existing knowledge and genotype resources towards the public release of a cost-effective LD SNP chip specifically for Bos indicus cattle, which is expected to replace the previous GGP indicus LD chip and to supplement the existing GGP-HDi 80000 SNP chip. Implications A new SNP chip specifically designed for Bos indicus, with high power of imputation to Illumina BovineHD technology and with excellent coverage of the whole genome, is now available on the market for Bos indicus cattle, and Bos indicus and Bos taurus crosses.

Comparing the effect of STan (cardiotocographic electronic fetal monitoring (CTG) plus analysis of the ST segment of the fetal electrocardiogram) with CTG alone on emergency caesarean section rates: study protocol for the STan Australian Randomised controlled Trial (START)

BACKGROUND

Cardiotocography is almost ubiquitous in its use in intrapartum care. Although it has been demonstrated that there is some benefit from continuous intrapartum fetal monitoring using cardiotocography, there is also an increased risk of caesarean section which is accompanied by short-term and long-term risks to the mother and child. There is considerable potential to reduce unnecessary operative delivery with up to a 60% false positive diagnosis of fetal distress using cardiotocography alone. ST analysis of the fetal electrocardiogram is a promising adjunct to cardiotocography alone, and permits detection of metabolic acidosis of the fetus, potentially reducing false positive diagnosis of fetal distress.

METHODS

This study will be a single-centre, parallel-group, randomised controlled trial, conducted over 3 years. The primary hypothesis will be that the proportion of women with an emergency caesarean section on ST analysis will not equal that for women on cardiotocography monitoring alone. Participants will be recruited at the Women's and Children's Hospital, a high-risk specialty facility with approximately 5000 deliveries per annum. A total of 1818 women will be randomised to the treatment or conventional arm with an allocation ratio of 1:1, stratified by parity. The primary outcome is emergency caesarean section (yes/no). Statistical analysis will follow standard methods for randomised trials and will be performed on an intention-to-treat basis. Secondary maternal and neonatal outcomes will also be analysed. Additional study outcomes include psychosocial outcomes, patient preferences and cost-effectiveness.

DISCUSSION

Approximately 20% of Australian babies are delivered by emergency caesarean section. This will be the first Australian trial to examine ST analysis of the fetal electrocardiogram as an adjunct to cardiotocography as a potential method for reducing this proportion. The trial will be among the first to comprehensively examine ST analysis, taking into account the impact on psychosocial well-being as well as cost-effectiveness. This research will provide Australian evidence for clinical practice and guideline development as well as for policy-makers and consumers to make informed, evidence-based choices about care in labour.

TRIAL REGISTRATION

ANZCTR, ACTRN1261800006268 . Registered on 19 January 2018.

Evaluation of genotyping concordance for commercial bovine SNP arrays using quality-assurance samples

SNP arrays are widely used in genetic research and agricultural genomics applications, and the quality of SNP genotyping data is of paramount importance. In the present study, SNP genotyping concordance and discordance were evaluated for commercial bovine SNP arrays based on two types of quality assurance (QA) samples provided by Neogen GeneSeek. The genotyping discordance rates (GDRs) between chips were on average between 0.06% and 0.37% based on the QA type I data and between 0.05% and 0.15% based on the QA type II data. The average genotyping error rate (GER) pertaining to single SNP chips, based on the QA type II data, varied between 0.02% and 0.08% per SNP and between 0.01% and 0.06% per sample. These results indicate that genotyping concordance rate was high (i.e. from 99.63% to 99.99%). Nevertheless, mitochondrial and Y chromosome SNPs had considerably elevated GDRs and GERs compared to the SNPs on the 29 autosomes and X chromosome. The majority of genotyping errors resulted from single allotyping errors, which also included the opposite instances for allele 'dropout' (i.e. from AB to AA or BB). Simultaneous allotyping errors on both alleles (e.g. mistaking AA for BB or vice versa) were relatively rare. Finally, a list of SNPs with a GER greater than 1% is provided. Interpretation of association effects of these SNPs, for example in genome-wide association studies, needs to be taken with caution. The genotyping concordance information needs to be considered in the optimal design of future bovine SNP arrays.

Treatment of complex regional pain syndrome in adults: a systematic review of randomized controlled trials published from June 2000 to February 2012

Complex regional pain syndrome (CRPS) is a disabling pain condition with sensory, motor and autonomic manifestations. Uncertainty remains about how CRPS can be effectively managed. We conducted a systematic review of randomized controlled trials (RCTs) for treatment and prophylactic interventions for CRPS published during the period 2000-2012, building on previous work by another group reviewing the period 1966-2000. Bibliographic database searches identified 173 papers which were filtered by three reviewers. This process generated 29 trials suitable for further analysis, each of which was reviewed and scored by two independent reviewers for methodological quality using a 15-item checklist. A number of novel and potentially effective treatments were investigated. Analysing the results from both review periods in combination, there was a steep rise in the number of published RCTs per review decade. There is evidence for the efficacy of 10 treatments (3× strong--bisphosphonates, repetitive transcranial magnetic stimulation and graded motor imagery, 1× moderate and 6× limited evidence), and against the efficacy of 15 treatments (1× strong, 1× moderate and ×13 limited). The heterogeneity of trialled interventions and the pilot nature of many trials militate against drawing clear conclusions about the clinical usefulness of most interventions. This and the observed phenomenon of excellent responses in CRPS subgroups would support the case for a network- and multi-centre approach in the conduct of future clinical trials. Most published trials in CRPS are small with a short follow-up period, although several novel interventions investigated from 2000 to 2012 appear promising.

Match play intensity distribution in youth soccer

The purpose of this study was to quantify match play intensity distribution in young soccer players in relation to age, playing position and physical fitness. Distance covered and heart rate were measured (global positioning system) on 103, highly-trained young players (Under13 to Under 18) during 42 international club games. Maximal sprinting speed (MSS), estimated maximal aerobic speed (MAS) and maximal heart rate (HRmax) were assessed via field test measures. Distance covered and heart rate (HR) were categorized into 5 intensity zones relative to MSS and MAS and HR(max), respectively. Intensity distribution was significantly influenced by both age and playing position with younger groups, wide-midfielders and strikers covering the greatest distance above the MAS. There was a significant, negative, large-to-very large correlation (r= -0.52-0.74) between MAS and the distance run at speeds above MAS for all positions except strikers. HR responses were not different across age groups and playing positions. Distance covered below MAS were lower in the second half for all positions (P<0.05; 0.08<η(2)<0.20), while distance covered at intensities above MAS were maintained (P>0.1; 0.00<η(2)<0.03). This reduction in distance covered below MAS was not related to a player's physical capacity. Except for strikers, a superior aerobic fitness level was unlikely to affect total distance covered but was associated with a reduced individual running demand during the game.

Prenatal testing and pregnancy termination in Sri Lanka: views of medical students and doctors

INTRODUCTION

Prenatal diagnosis and pregnancy termination generate complex ethical issues. Surveys conducted in Sri Lanka among doctors and medical students in 1986 supported a change in law in favour of pregnancy termination when gross genetic defects are detected antenatally. A new generation of prenatal tests has focused attention again on the topic of termination and under what circumstances it might be legally done. The present survey contributes to the debate by means of a survey of doctors and medical students.

METHOD

A self-administered questionnaire given to doctors and medical students.

RESULTS

Ninety three per cent of doctors and 81% of students accept pregnancy termination as an appropriate course of action if a gross genetic defect is detected antenatally, and 87% of doctors and 80% of students support a change in the law to allow termination of the pregnancy. The corresponding figures in previous surveys were 80%, 69% and 96%, 88% respectively.

CONCLUSIONS

A majority of doctors and medical students support a change in law in favour of liberalising pregnancy termination when a genetic defect is detected antenatally.

Comparison of reproductive development in triploid and diploid female rainbow trout Oncorhynchus mykiss

The diploid rainbow trout Oncorhynchus mykiss reached sexual maturity 3 years after hatching and its oogenesis underwent four stages, which were oogonia, primary oocyte, secondary oocyte and egg. Reproductive development and hormone changes of 4 to 35 month-old female O. mykiss were investigated using histological and radioimmunoassay methods in order to provide a theoretical and practical basis for the use of triploid female O. mykiss. The oogonium of the triploid female could develop into the oocytes of the prophase with abortion occurring later; the oogonium was surrounded by stroma cells to form the oogonium cluster and the gonads showed a virilescent tendency when the oogonium clusters were gradually replaced by spermatogenic-like cytocysts. After 13 months, amounts of gonadotropic hormone (GtH-I, GtH-II) and oestradiol (17beta-E(2)) in triploid females were lower than in diploid fish at corresponding time periods, but the amounts of testosterone (T) increased consistently after 21 months and were more than in diploid fish in the corresponding time periods (P > 0.05). The infertility of triploid females resulted from meiosis failure, which caused developmental abortion of oocytes and oogonium formed cytocysts before the prophase oocytes. The cytocyst formation was due to the lack of the normal interaction of ovum and follicular cells, the development of follicular cells producing steroids were inhibited, the arylate path from T to 17beta-E(2) was interrupted, concentration of 17beta-E(2) decreased and concentration of T increased in the blood, the content of vitellogenin (Vg) decreased in the liver with a low 17beta-E(2) and high T caused to ovaries to show a tendency to be virilescent.

The CREATE project: development of certified reference materials for allergenic products and validation of methods for their quantification

Allergen extracts have been used for diagnosis and treatment of allergy for around 100 years. During the second half of 20th century, the notion increasingly gained foothold that accurate standardization of such extracts is of great importance for improvement of their quality. As a consequence, manufacturers have implemented extensive protocols for standardization and quality control. These protocols have overall IgE-binding potencies as their focus. Unfortunately, each company is using their own in-house reference materials and their own unique units to express potencies. This does not facilitate comparison of different products. During the last decades, most major allergens of relevant allergen sources have been identified and it has been established that effective immunotherapy requires certain minimum quantities of these allergens to be present in the administered maintenance dose. Therefore, the idea developed to introduce major allergens measurements into standardization protocols. Such protocols based on mass units of major allergen, quantify the active ingredients of the treatment and will at the same time allow comparison of competitor products. In 2001, an EU funded project, the CREATE project, was started to support introduction of major allergen based standardization. The aim of the project was to evaluate the use of recombinant allergens as reference materials and of ELISA assays for major allergen measurements. This paper gives an overview of the achievements of the CREATE project.

Dietary intake in sensitized children with recurrent wheeze and healthy controls: a nested case-control study

BACKGROUND

The rising prevalence of asthma and allergic disease remains unexplained. Several risk factors have been implicated including diet, in particular poly-unsaturated fats and antioxidant intake.

METHODS

A nested case-control study comparing the dietary intake of sensitized children with recurrent wheeze (age 3-5 years) and nonsensitized children who had never wheezed was carried out within an unselected population-based cohort. Cases and controls were matched for age, sex, parental atopy, indoor allergen exposure and pet ownership. Dietary intake was assessed using a validated semi-quantitative food frequency questionnaire and nutrient analysis program.

RESULTS

Thirty-seven case-control pairs (23 male, mean age 4.4 years) participated. Daily total polyunsaturated fat intake was significantly higher in sensitized wheezers (g/day, geometric mean, 95% confidence intervals: 7.1, 6.4-7.9) compared with nonsensitized nonwheezy children (5.6, 5.0-6.3, P = 0.003). Daily omega-3 and omega-6 fat intakes were not significantly different between the two groups. No significant differences were found in intake of any antioxidant or antioxidant cofactors between the groups.

CONCLUSIONS

Young sensitized wheezy children had a significantly higher total polyunsaturated fat intake compared with nonsensitized nonwheezy children. However, we were unable to distinguish a significant difference in specific poly-unsaturated fat intakes. Otherwise the children in both groups had a very similar nutritional intake.

Development of activity standard for 90Y microspheres

(90)Y microspheres are important therapeutic radiopharmaceuticals used in the treatment of liver cancer through a process known as selective internal radiation therapy. SIR-spheres is a radiopharmaceutical product that is comprised of (90)Y microspheres suspended in sterile, pyrogen-free water for injection into patients. It is necessary to establish for the SIR-spheres production the capability of accurately measuring the activity of this product to a traceable national measurement standard. An activity standard for SIR-spheres was developed from a standard for (90)Y solution, employing a highly quantifiable chemical digestion process. Calibration factors for the manufacturer's ionisation chambers were determined for 1 and 5 ml of the SIR-spheres product placed in Wheaton vials, for both 34% and 44% of (90)Y microsphere concentration.

Contemplating choice: attitudes towards intervening in human reproduction in Sri Lanka

To date, relatively little is known about the ethical, legal and social responses to recent advances in reproductive and genetic technology outside Europe and North America. This article reports on a survey carried out among doctors (n=278) and medical students (n=1256) in Sri Lanka to find out more about their responses to novel interventions in human reproduction such as In-Vitro Fertilization, Pre-Implantation Genetic Diagnosis and genetic engineering. In the first part of the paper comparisons are drawn between this survey and a survey carried out in 1985 which also considered issues surrounding amniocentesis and therapeutic termination. The second part of the paper deals with more recent developments. The analysis reveals high levels of support for the use of new technologies in treating infertility and identifying genetic disorders. However, differences are apparent among the major religious communities represented in the sample and these are particularly in evidence in relation to prenatal genetic diagnosis. An important theme throughout both surveys is the continuing tension surrounding State policy and termination of pregnancy and the implications this has for the development of screening and counseling services where genetic disorders are concerned.

Stringent environmental control in pregnancy and early life: the long-term effects on mite, cat and dog allergen

BACKGROUND

As part of a primary prevention of asthma study, we measured the effect of environmental control measures on Der p 1, Fel d 1 and Can f 1 over a 3.5-year period.

METHODS

High-risk infants (both parents atopic) without pets, were randomized to the Active group (n = 142, vinyl flooring in child's room, allergen-impermeable cot mattress, hot-washable toy, mite allergen-impermeable encasings to parental bed and to child's bed when older, high filtration vacuum cleaner, hot-washing of bedding) or the Control group (n = 136, no intervention), in early pregnancy. Dust samples from the parental mattress, living room floor, child's mattress and floor at baseline (pregnancy), birth and at 3 years were analysed for Der p 1, Fel d 1 and Can f 1.

RESULTS

A total of 278 families completed the baseline visit, 259 the birth visit and 239 the 3-year visit. In the Active group at 3 years, 58% remained compliant with all measures likely to reduce the child's exposure to allergen and 77% of parents still used encasings on their bed. Levels of Der p 1, Fel d 1 and Can f 1 were significantly lower in the Active group in the child's floor and the child's mattress at 3 years compared to the Control group (P < 0.001). For the parental mattress, the levels of Der p 1 and Fel d 1 were lower in the Active group (P < 0.001) and there was a strong trend towards a lower level for Can f 1. There was no difference in the levels of any of the allergens between the groups in the living room floor. Childrens' bedrooms with no detectable mite, cat or dog allergen were significantly more common in the Active than the Control group (25 vs. 2, P < 0.001).

CONCLUSIONS

Environmental control measures are effective in substantially reducing levels of Der p 1, Fel d 1 and Can f 1 in homes without pets in the long term and are acceptable to families. The effect of this environmental manipulation on the development of sensitization and allergic disease remains to be seen.

Effect of chemical etching and aging in boiling water on the corrosion resistance of Nitinol wires with black oxide resulting from manufacturing process

The effect of chemical etching in a HF/HNO(3) acid solution and aging in boiling water on the corrosion resistance of Nitinol wires with black oxide has been evaluated with the use of potentiodynamic, modified potentiostatic ASTM F746, and scratch tests. Scanning-electron microscopy, elemental XPS, and Auger analysis were employed to characterize surface alterations induced by surface treatment and corrosion testing. The effect of aging in boiling water on the temperatures of martensitic transformations and shape recovery was evaluated by means of measuring the wire electroresistance. After corrosion tests, as-received wires revealed uniformly cracked surfaces reminiscent of the stress-corrosion-cracking phenomenon. These wires exhibited negative breakdown potentials in potentiostatic tests and variable breakdown potentials in potentiodynamic tests (- 100 mV to + 400 mV versus SCE). Wires with treated surfaces did not reveal cracking or other traces of corrosion attacks in potentiodynamic tests up to + 900-1400-mV potentials and no pitting after stimulation at + 800 mV in potentiostatic tests. They exhibited corrosion behavior satisfactory for medical applications. Significant improvement of corrosion parameters was observed on the reverse scans in potentiodynamic tests after exposure of treated wires to potentials > 1000 mV. In scratch tests, the prepared surfaces repassivated only at low potentials, comparable to that of stainless steel. Tremendous improvement of the corrosion behavior of treated Nitinol wires is associated with the removal of defect surface material and the growth of stable TiO(2) oxide. The role of precipitates in the corrosion resistance of Nitinol-scratch repassivation capacity in particular-is emphasized in the discussion.

Household characteristics and mite allergen levels in Manchester,UK

BACKGROUND

Mite allergen levels vary enormously between different homes in the same geographical area. No large scale studies of mite levels in Manchester homes has been conducted to identify factors associated with higher levels.

OBJECTIVES

To quantify exposure to mite allergens and to identify characteristics associated with higher Der p 1 levels in a large sample of homes in Manchester, UK.

METHODS

Der p 1 was measured in dust from the living room floor, sofa, bedroom floor and mattress in 564 homes. Data on household characteristics were collected by administering a questionnaire. Univariate and multivariate analyses were performed to identify household characteristics associated with higher mite allergen levels.

RESULTS

Der p 1 levels were highest in the mattress (GM 1.19 microg/g, 95% CI 0.98-1.45, P < 0.001). Two-thirds of homes contained Der p 1 levels > 2 microg/g in at least one dust reservoir, and 40.3% contained Der p 1 greater than 10 microg/g. There was a large range in Der p 1 levels between homes (> 10(3)-fold). Damp and condensation were common findings in homes. In the multivariate analyses, factors associated with higher Der p 1 levels in more than one dust reservoir were older homes, older living room carpets, damp, condensation and mixed glazing. Older mattresses were associated with higher mite allergen levels in the mattress where the age of the mattress was recorded. Twenty-four homes contained no detectable mite allergen, six of which reported damp.

CONCLUSIONS

Mite allergen levels are high enough in two of every three homes to be associated with an increase in the risk of sensitization to mite. Factors such as older homes, carpets and mattresses, damp and condensation are associated with higher mite allergen. However, mite allergen levels are occasionally unpredictably very low in homes with risk factors for high levels.

Ethical regulation and the new reproductive technologies in Sri Lanka: perspectives of ethics committee members

OBJECTIVE

To report on part of a pilot study done to explore ethical responses to the new reproductive technologies in Sri Lanka.

DESIGN

Semi-structured interviews carried out with the members of three committees responsible for ethical review of medical research. Members were asked for their views on the ethical, social and legal implications of the new reproductive and genetic technologies. Members' responses were subject to a simple content analysis.

CONCLUSIONS

There was broad acceptance of the new technologies among respondents, but anxieties about potential abuses. Respondents felt that a national committee should regulate practice and monitor future policy.

Organizational factors influencing nurse practitioners' role implementation in acute care settings

The purpose of this study was to explore the influence of organizational factors on the Acute Care Nurse Practitioner (ACNP) role implementation. A descriptive correlational design, incorporating quantitative and qualitative methods for data collection was used. The sample of convenience consisted of 57 ACNPs assigned to various medical and surgical programs within acute care hospitals. Ten ACNPs participated in the unstructured qualitative interviews. In addition to the interviews, data pertinent to various organizational factors, including role formalization, receptivity of the role by others, perceived autonomy, role strain, and additional factors that may interfere with role implementation, were collected through a self-report structured questionnaire. A four-diary day was completed to gather data on role implementation. Descriptive and correlational statistics were used to analyze the quantitative data. The qualitative data were content analyzed. The ACNPs engaged most frequently in activities reflective of the clinical practice component of the role and less frequently in the non-clinical components (i.e., education, administration, and research). Results of the quantitative and qualitative analyses indicated that lack of formal clear job description, conflicting demands and expectations, lack of receptivity of the role by others, lack of autonomy, and increased workload were negatively correlated with the ACNP role implementation. The ACNP role implementation varies across practice settings. This variability should be accounted for when examining outcomes of ACNP care.

Practice patterns of acute care nurse practitioners

This study was undertaken to examine the practice pattern of nurse practitioners employed in Ontario acute care settings. A descriptive design, incorporating quantitative and qualitative methods for data collection, was used. The acute care nurse practitioners' practice pattern varied in terms of scope of practice, model guiding practice, reporting relations, and extent of role implementation. Role implementation encompassed activities representing the four role components: clinical practice, education, administration or management, and research. The acute care nurse practitioners engaged most frequently in the clinical component of the role. They performed medical and advanced nursing functions. They emphasized that they do not work in isolation and that they do not replace physicians or residents.

Synthetic pillows contain higher levels of cat and dog allergen than feather pillows

The use of non-feather pillows has increased over the last few decades. Recently, we found significantly higher levels of dust mite allergens in synthetic pillows than in feather ones. This study investigated the levels of pet allergens in feather and synthetic pillows. Dust samples were collected from 14 pairs of pillows (consisting of one synthetic fibre-filled and one feather-filled). Each pair of pillows had been on the same bed for at least 2 years. The pillows were vacuumed for 1 min on each side through a 355-microm diameter mesh onto a 5-microm vinyl filter, producing a sample of fine dust. Samples were extracted, and cat (Fel d 1) and dog (Can f 1) allergens determined using monoclonal antibody-based enzyme-linked immunosorbent assay (ELISA). Results were expressed both as total amount of allergen recovered and concentration of allergen per unit weight (ng/g). Total levels of pet allergens were significantly higher in the synthetic pillows (Fel d 1: 6.7-fold difference [95% CI 1.5-29.7], p=0.01; Can f 1: 8-fold difference [95% CI 1.6-39.5], p=0.01). Similarly, when the results were expressed as ng/g, synthetic pillows contained significantly more allergens than feather pillows (Fel d 1: 3.7-fold difference [95% CI 1.3-10.1], p=0.01); Can f 1: 4.4-fold difference [95% CI 1.5-13.2], p=0.01). We have therefore demonstrated that synthetic pillows contain significantly more pet allergens than feather pillows, supporting the view that tightly woven encasements surrounding feather pillows act as a barrier for allergens.

Veterinary vaccines: In-VITRO--International Veterinary Industry Test Replacement Organisation

The International Veterinary Industry Test Replacement Organisation (In-VITRO) was established in 1995 with the aim of developing, validating and harmonising in vitro alternatives to replace in vivo methods for in-process and potency testing of veterinary clostridial vaccines. The emphasis has been on the reduction of animal usage in the Clostridium chauvoei potency assay and its eventual replacement by an in vitro assay. Replacement of the toxin neutralisation assay for Cl. tetani by an internationally validated indirect ELISA has already started. A validation programme involving a collaboration organised through EDQM which could ultimately lead to the standardisation of in vitro tests for all clostridial vaccines is in progress. In addition In-VITRO is now considering the setting up of a programme for Erysipelas vaccines. The collaboration between manufacturers of veterinary vaccines in the development and validation of in vitro tests is a major step towards the reduction and replacement of animal tests.

Measuring quality in hospitals: is there a difference between for-profits and not-for-profits?

Health care professionals agree that by measuring quality, improvements can be made in care delivery. There are measurable differences between not-for-profit and for-profit hospitals, both in public perception and care outcomes. The ability by consumers, insurers and providers to easily access quality data will drive the health care industry to take a quality focus in their daily business. Quality providers with measurable results will gain a larger share of health care dollars and consumer trust. Physicians will choose to partner with the quality leaders and will refine their practices as part of the quality evolution.

Controlled trial of two formulations of cromolyn sodium in the treatment of asthmatic patients > or = 12 years of age. Intal Study Group

STUDY OBJECTIVES

This multicenter, randomized, double-blind, placebo-controlled, parallel study compared the efficacy and safety of the hydrofluoroalkane (HFA) formulation of cromolyn sodium metered-dose inhaler (MDI) with the chlorofluorocarbon (CFC) formulation in asthmatic patients > or = 12 years old over a 12-week period.

DESIGN

Stable asthmatics using only currently marketed cromolyn sodium and as-needed inhaled beta2-agonists were randomly assigned to treatment with HFA cromolyn sodium, CFC cromolyn sodium, or placebo, administered as two inhalations (2 mg) qid for 12 weeks. Prior to randomization, all patients were required to meet minimum symptom and/or pulmonary function test criteria after discontinuation of cromolyn sodium. Efficacy was assessed by changes in daily symptom scores, albuterol use, peak expiratory flow, pulmonary function measurements, and overall opinions of effectiveness.

RESULTS

A total of 280 patients in 29 centers were randomly assigned to treatment with HFA cromolyn sodium (n = 94), CFC cromolyn sodium (n = 91), or placebo (n = 95). Patients treated with the HFA formulation of cromolyn sodium demonstrated a 28 to 33% improvement over placebo for all symptom scores (p < 0.05) and a 35% improvement over placebo in the use of albuterol MDI (p < 0.05). The patients' opinions of overall effectiveness favored HFA cromolyn sodium (p = 0.011) and CFC cromolyn sodium (p = 0.006) over placebo. The investigators' opinions indicated a statistically significant difference favoring CFC cromolyn sodium compared with both placebo (p < 0.001) and HFA cromolyn sodium (p = 0.042). No statistically significant differences existed among groups in the incidence of treatment-related adverse events.

CONCLUSION

The HFA formulation of cromolyn sodium MDI is a well-tolerated and effective treatment for asthma patients > or = 12 years old. The safety and efficacy profile of the HFA formulation is comparable to that of the CFC formulation.

Relationship between mite, cat, and dog allergens in reservoir dust and ambient air

BACKGROUND

Standardized methods to measure allergen exposure are essential to assess the relationship between exposure, sensitization, and asthma. Most studies have measured allergen levels in reservoir dust, although air samples may be more representative as a measure of inhaled allergen. The aim of this study was to define the relationship between mite, cat, and dog allergen content in the reservoir dust and the levels in the ambient air.

METHODS

Dust samples from the living-room floor (LF) and sofa (S) were collected in 127 homes: 62 without and 65 with pets (31 dogs, 34 cats). Air samples were taken in the same room, with a high-volume pump for 1 h (flow 60 l/min). Der p 1, Fel d 1, and Can f 1 were determined by mAb-based ELISA.

RESULTS

Airborne Der p 1 was below the detection limit (0.8 ng/m3) in all homes, with reservoir levels (GM and range) being 1.14 microg/g (0.2-66) and 1.15 microg/g (0.2-127) in LF and S, respectively. Airborne Can f 1 was detected in 40/62 homes without pets (range 0.6-12.4 ng/m3) and in all homes with dogs (range 0.5-99 ng/m3). In the multiple linear regression analysis, Can f 1 level in the LF was an independent correlate of the airborne Can f 1 (P=0.01, homes with dogs; P=0.04, homes without dogs). Fel d 1 was detected in the air in 16/62 homes without pets (range 0.16-1.8 ng/m3) and in all homes with cats (range 0.4-22.3 ng/m3). Fel d 1 level in the LF was an independent correlate of the airborne Fel d 1 in homes without cats (P=0.008), but airborne levels in homes with cats did not correlate with reservoir levels.

CONCLUSIONS

The aerodynamics of each allergen must be taken into account when assessing exposure: while levels in reservoir dust are the best available index for mite allergens, airborne levels might be more suitable for defining exposure to pets. If air samples are difficult to obtain, levels of Can f 1 and Fel d 1 in the LF samples should be used as a surrogate measure of personal exposure.

The effects of triamcinolone acetonide aqueous nasal spray on adrenocortical function in children with allergic rhinitis

BACKGROUND

Suppression of adrenocortical function, a risk associated with oral corticosteroids, is minimized with intranasal corticosteroids. Triamcinolone acetonide (TAA) aqueous nasal spray, at therapeutic doses, has no measurable effect on adrenocortical function in adults with allergic rhinitis.

OBJECTIVE

This double-blind, placebo-controlled study compared the effect of once-daily TAA aqueous nasal spray (220 or 440 microg) with placebo on adrenocortical function after 6 weeks of treatment in pediatric (children 6 to 12 years of age) patients with allergic rhinitis. The pharmacokinetic profile of TAA was examined after once-daily intranasal administration of TAA aqueous nasal spray 440 microg for 6 weeks.

METHODS

Eighty children received TAA aqueous nasal spray 220 microg or 440 microg or placebo for 6 weeks. Adrenocortical function was assessed by analyzing plasma cortisol levels before stimulation (0 hour) and at 30 and 60 minutes after a rapid 1-hour intravenous cosyntropin stimulation test performed before treatment and after 6 weeks of treatment. Samples for pharmacokinetic evaluation were collected from 19 patients at baseline (0 hour) and at 0.5, 1, 1.5, and 6 hours after the final dose of study medication.

RESULTS

After 6 weeks, no significant effects on adrenocortical function were observed at 30 or 60 minutes after cosyntropin stimulation with either dose of TAA aqueous nasal spray. TAA concentrations in plasma showed rapid elimination of the drug, with little or no accumulation.

CONCLUSIONS

TAA aqueous nasal spray (220 or 440 microg/day) has no measurable effect on adrenocortical function in pediatric patients with allergic rhinitis. Pharmacokinetic parameters after 440 microg/day of TAA aqueous nasal spray indicate a rapid decline of plasma drug levels, with little or no systemic accumulation of study drug.

Prosthetic patch stabilization of crural repair in antireflux surgery in children

Nissen fundoplication is a frequently performed procedure by pediatric surgeons for the treatment of gastroesophageal reflux. Reoperation for failed fundoplication is necessary in 10 per cent of children and in 25 per cent of neurologically impaired children. In an attempt to reduce the postoperative recurrence of gastroesophageal reflux and wrap herniation, we have modified our Nissen fundoplication by reinforcing the crural repair with a horseshoe-shaped prosthetic patch. Between 1993 and 1995, 38 children underwent a Nissen fundoplication with prosthetic patch crural repair. Tension-free crural repair was performed over an esophageal dilator by suturing a horseshoe-shaped Dacron patch posterior to the esophagus. After crural repair, the standard Nissen 360 degrees wrap was constructed. Of the 38 children, 56 per cent (n = 21) were neurologically impaired. In 18 per cent of patients, the operation was performed for recurrent reflux due to wrap herniation after a Nissen fundoplication without prosthetic patch repair. One child required esophageal dilatation postoperatively for dysphagia related to esophageal stenosis. After a mean follow-up of 15 months, all patients were without symptomatic reflux or had no radiographic evidence of recurrent reflux or wrap herniation. Tension-free crural repair with a prosthetic patch may decrease postoperative reflux and wrap herniation, particularly in neurologically impaired children and in children requiring reoperation for recurrent reflux.

On gifts, payments and disputes: divorce and changing family structures in contemporary Britain

"This article considers ethnographic data collected among divorcing men and women in Britain and adopts a Maussian view of exchange in order to understand the cultural dimensions of divorce in more depth. I argue that divorcing men and women express discontinuities and continuities in their relationships by means of particular kinds of exchanges. What is of particular interest is the way that former husbands and wives place discrepant and conflicting constructions on the transfer of money and material goods between them and between themselves and their children. The article illustrates these points by examining the conflicts between fathers, mothers and their children over the emotional and economic significance of particular transactions."

Analysis of form and function in North American columnar cacti (tribe Pachycereeae)

Simple and multivariate linear models were used to demonstrate the influence of mechanical design and climate on stem morphology and branching architecture in 25 species of North American columnar cacti. The effect of phyletic inertia was tested by the method of independent contrasts. Stem girth was found to increase significantly slower with increased height within taxa (cross-sectional stem area ;ps [plant height] 0.603), than across taxon (cross-sectional stem area ;ps [plant height] 1.451). Juveniles are shown to be mechanically overbuilt and subsequently grow into more slender adult forms determined in part by structural limitations and the optimization of other stem functions. We make a structural analogy of relatively rigid columnar cacti to concrete columns and compare plants and models with similar growth forms lacking woody skeletons (barrel cacti). Taxa with woody support achieved a surface-to-volume ratio six times greater than taxa without woody support. Across taxon, cooler winter temperatures were associated with larger stem girths, and greater annual precipitation was associated with less frequent branching. The relationship between total plant surface and volume approaches isometry within taxa, but across taxon average individuals are scaled replicates. We hypothesize that architecture and average plant height are adjusted, in an evolutionary sense, to maintain geometric similitude between surface and volume along a climatic gradient.

Using metaphor to clarify emerging roles in patient care management teams

Difficult economic times, competition for scarce resources and changing organizational paradigms are driving health care institutions to re-examine the ways in which they provide care. They must continually strive to provide excellent patient care and ensure positive patient outcomes while responding to increasing fiscal constraint. At Toronto's Hospital for Sick Children, consistent with current trends, nurse managers are asked to take on broad spans of responsibility. The need to decentralize much of the decision making, problem identification and problem solving functions to the multidisciplinary team is a reality of those changes. This paper describes a process the dialysis staff undertook to better understand new organizational imperatives using an orchestra metaphor as a suggestive tool to help people clarify new roles and relationships in organizations that are evolving from a hierarchical model to a knowledge-based team approach to work. The intervention was successful for some people and not others. An analysis of the outcomes is provided from the nurse manager's perspective.