The role of the radiographer in promoting health: A qualitative examination of diagnostic radiographer perspectives at a Scottish Major Trauma hospital

INTRODUCTION

Publication of Government directives and initiatives have signalled a shift in healthcare priorities, with growing emphasis on prevention and early intervention. In comparison to other allied health professions, perceptions of Diagnostic Radiographers of their contribution to addressing these initiatives and role in promoting health, has not been explored. There is limited evidence on current practices, knowledge and confidence in providing health promotion advice to patients within this professional group. This study aimed to investigate the perceptions of Diagnostic Radiographers of their role in promoting health.

METHODS

Semi-structured focus groups were conducted with 20 Diagnostic Radiographers recruited via convenience sampling from a Scottish Major Trauma Hospital. Focus groups were transcribed and analysed using thematic analysis.

RESULTS

Findings demonstrated a lack of awareness and understanding of government initiatives and professional body recommendations surrounding health promotion. Diagnostic radiographers felt ill-equipped to provide appropriate and impactful health promotion advice and reported lack of time as a barrier to contributing to such activities.

CONCLUSION

Diagnostic Radiographers noted a willingness to undertake additional training to enable them to participate and were able to identify areas where they could adopt health promotion activities in their clinical practice. Addressing the barriers to participation is essential to empower Diagnostic Radiographers to contribute to the health promotion agenda.

IMPLICATIONS FOR PRACTICE

There is a need to address profession specific education at pre-registration and post-qualification levels, to ensure Diagnostic Radiographers are equipped with the knowledge, skills and confidence to promote health to their patients. Strong leadership is essential for creating a positive environment to facilitate education, training and the acceptance of health promotion as a key part of a diagnostic radiographer's role.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Dominant Bacterial Phyla from the Human Gut Show Widespread Ability To Transform and Conjugate Bile Acids

Gut bacteria influence human physiology by chemically modifying host-synthesized primary bile acids. These modified bile acids, known as secondary bile acids, can act as signaling molecules that modulate host lipid, glucose, and energy metabolism and affect gut microbiota composition via selective antimicrobial properties. However, knowledge regarding the bile acid-transforming capabilities of individual gut microbes remains limited. To help address this knowledge gap, we screened 72 bacterial isolates, spanning seven major phyla commonly found in the human gut, for their ability to chemically modify unconjugated bile acids. We found that 43 isolates, representing 41 species, were capable of in vitro modification of one or more of the three most abundant unconjugated bile acids in humans: cholic acid, chenodeoxycholic acid, and deoxycholic acid. Of these, 32 species have not been previously described as bile acid transformers. The most prevalent bile acid transformations detected were oxidation of 3α-, 7α-, or 12α-hydroxyl groups on the steroid core, a reaction catalyzed by hydroxysteroid dehydrogenases. In addition, we found 7α-dehydroxylation activity to be distributed across various bacterial genera, and we observed several other complex bile acid transformations. Finally, our screen revealed widespread bacterial conjugation of primary and secondary bile acids to glycine, a process that was thought to only occur in the liver, and to 15 other amino acids, resulting in the discovery of 44 novel microbially conjugated bile acids. IMPORTANCE Our current knowledge regarding microbial bile acid transformations comes primarily from biochemical studies on a relatively small number of species or from bioinformatic predictions that rely on homology to known bile acid-transforming enzyme sequences. Therefore, much remains to be learned regarding the variety of bile acid transformations and their representation across gut microbial species. By carrying out a systematic investigation of bacterial species commonly found in the human intestinal tract, this study helps better define the gut bacteria that impact composition of the bile acid pool, which has implications in the context of metabolic disorders and cancers of the digestive tract. Our results greatly expand upon the list of bacterial species known to perform different types of bile acid transformations. This knowledge will be vital for assessing the causal connections between the microbiome, bile acid pool composition, and human health.

Linking monitoring and data analysis to predictions and decisions for the range-wide eastern black rail status assessment

The US Fish and Wildlife Service (USFWS) has initiated a re-envisioned approach for providing decision makers with the best available science and synthesis of that information, called the Species Status Assessment (SSA), for endangered species decision making. The SSA report is a descriptive document that provides decision makers with an assessment of the current and predicted future status of a species. These analyses support all manner of decisions under the US Endangered Species Act, such as listing, reclassification, and recovery planning. Novel scientific analysis and predictive modeling in SSAs could be an important part of rooting conservation decisions in current data and cutting edge analytical and modeling techniques. Here, we describe a novel analysis of available data to assess the current condition of eastern black rail Laterallus jamaicensis jamaicensis across its range in a dynamic occupancy analysis. We used the results of the analysis to develop a site occupancy projection model where the model parameters (initial occupancy, site persistence, colonization) were linked to environmental covariates, such as land management and land cover change (sea-level rise, development, etc.). We used the projection model to predict future status under multiple sea-level rise and habitat management scenarios. Occupancy probability and site colonization were low in all analysis units, and site persistence was also low, suggesting low resiliency and redundancy currently. Extinction probability was high for all analysis units in all simulated scenarios except one with significant effort to preserve existing habitat, suggesting low future resiliency and redundancy. With the results of these data analyses and predictive models, the USFWS concluded that protections of the Endangered Species Act were warranted for this subspecies.

TGFβ1 single-nucleotide polymorphism C-509T alters mucosal cell function in pediatric eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a chronic Th2 antigen-driven disorder associated with tissue remodeling. Inflammation and remodeling lead to esophageal rigidity, strictures, and dysphagia. TGFβ1 drives esophageal remodeling including epithelial barrier dysfunction and subepithelial fibrosis. A functional SNP in the TGFβ1 gene that increases its transcription (C-509T) is associated with elevated numbers of esophageal TGFβ1-expressing cells. We utilized esophageal biopsies and fibroblasts from TT-genotype EoE children to understand if TGFβ1 influenced fibroblast and epithelial cell function in vivo. Genotype TT EoE esophageal fibroblasts had higher baseline TGFβ1, collagen1α1, periostin, and MMP2 (p < 0.05) gene expression and distinct contractile properties compared with CC genotype (n = 6 subjects per genotype). In vitro TGFβ1 exposure caused greater induction of target gene expression in genotype CC fibroblasts (p < 0.05). Esophageal biopsies from TT-genotype subjects had significantly less epithelial membrane-bound E-cadherin (p < 0.01) and wider cluster distribution at nanometer resolution. TGFβ1 treatment of stratified primary human esophageal epithelial cells and spheroids disrupted transepithelial resistance (p < 0.001) and E-cadherin localization (p < 0.0001). A TGFβ1-receptor-I inhibitor improved TGFβ1-mediated E-cadherin mislocalization. These data suggest that EoE severity can depend on genotypic differences that increase in vivo exposure to TGFβ1. TGFβ1 inhibition may be a useful therapy in subsets of EoE patients.

Nodular melanoma presenting as an exophytic subungual mass

Despite being recognised and reported in the literature for decades, subungual melanoma of the foot remains a diagnostic pitfall, with it commonly being mistaken for benign conditions. We present an interesting case of delayed diagnosis of subungual melanoma of the hallux that was misdiagnosed in the community for over one year. With melanoma being the fourth most commonly diagnosed cancer in Australia in 2013, this case serves as a reminder to all clinicians about the importance of maintaining a high index of suspicion for melanoma of the foot.

Service innovations: Is there a market for neuropsychiatry? A year in the life of a district-based neuropsychiatry service

Aims and Method

This paper describes the clinical activity of a district neuropsychiatry service over a 1-year period. The data presented are drawn from a clinical database with individuals classified according to the following diagnostic groups: acquired brain injury, early-onset dementia, Huntington's disease, epilepsy, other neurological disorders, developmental disorders and non-organic disorders. Information is presented on out-patient case-load, new out-patient referrals, general hospital referrals and in-patient admissions.

Results

The total out-patient case-load was 451; 189 new out-patient and 99 liaison referrals were seen and 90 individuals were admitted. Acquired brain injury was the most common neurological diagnosis in all groups.

Clinical Implications

The demand for this service indicates that there is a market for neuropsychiatry, even at a district level, and particularly in the management of the sequelae of acquired brain injury.

Abstract P2-12-03: Endofascial axillary lymphadenectomy – Towards a drainless protocol

Background:

The pathogenesis of seroma formation following axillary dissection continues to be poorly understood, although it seems that the greater the surgical disruption of the axilla, the higher the incidence of seroma and lymphoedema. We have previously described the laminated, three-dimensional structure of the clavipectoral fascia (CPF) that is evident during axillary ultrasonography and dissection . We propose that reconstituting the CPF reduces dead space, partially restores pressure gradients and facilitates collateralization to improve lymphatic flow, thereby reducing the incidence of seromas. Herewith, is a description of our technique for reconstitution of the CPF and our experience thus far.

Method:

Technique:

Following mastectomy or breast conservation surgery, the lateral border of pectoralis major is defined. Here, the medial, anterior laminae of the CPF are identified but not incised. Once the anterior extent of the CPF is displayed, a longitudinal incision is made through the midpoint of the CPF to access the axillary contents. If there is a substantial axillary tail, then the CPF is incised along the perimeter of the tail to include intra-mammary lymph nodes. A loose areolar tissue plane is encountered; the edges of the CPF are grasped and elevated and this areolar tissue plane developed by blunt and sharp dissection. Medially, this loose areolar tissue plane leads directly to a posterior gutter, and the long thoracic nerve on serratus anterior is identified and preserved.

Superiorly, a deeper lamina of the CPF along the inferior border of the axillary vein has to be incised to find the thoracodorsal nerve. Identification of the intercostobrachial nerves is standard, as is the lateral dissection. Identification of the long thoracic nerve and thoracodorsal bundle results in definition of a vertical sheet, ‘the interneural tissue’. This can be grasped between the thumb and index finger and is excised en bloc. This tissue contains fat, lymph nodes and lymphatic vessels and is lined by thin fascial layers that we consider related to the CPF3.

At this stage, the anterior laminae of the CPF and axilla are carefully palpated for any residual nodes. After haemostasis, the CPF is reconstituted with a running, absorbable ‘lymphostatic’ suture. No drain is placed in the axilla.

Results:

Between 2012 – 2015, 64 patients have undergone axillary dissection with reconstitution of the CPF in our unit.. The average age was 54 years (range 29-87 years). An average of 12 nodes were procured (range 2-26 nodes). Only 5 women (8%) required seroma aspiration.

Conclusion:

We have dispensed with axillary drains in those who have had reconstitution of the CPF and only a minority of our patients required axillary seroma aspiration. We believe this technique should be given consideration to decrease the use of drains following axillary dissection.

Citation Format: Meredith IC, Popadich A, Mouat CH, Barrett K, King B. Endofascial axillary lymphadenectomy – Towards a drainless protocol. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-03.

Impact of intraventricular hemorrhage on cognitive and behavioral outcomes at 18 years of age in low birth weight preterm infants

OBJECTIVE

Although high-grade intraventricular hemorrhage (IVH; grades III-IV) in preterm and low birth weight infants are clearly associated with increased risk of long-term adverse neurodevelopmental sequelae, the impact of low-grade IVH (grades I-II) has been less clear. Some studies have followed these infants through early school age and have shown some conflicting results regarding cognitive outcome. Such studies that assess children at younger ages may not accurately predict outcomes in later childhood, as it is known that fluid and crystallized intelligence peak at age 26 years. There is paucity of data in current medical literature, which correlates low-grade IVH with outcomes in early adulthood. To determine the link between the occurrence of low-grade IVH in low birth weight (birth weight ⩽2500 g) infants born prematurely (gestational age <37 weeks) and intellectual function, academic achievement, and behavioral problems to the age of 18 years.

STUDY DESIGN

This study is an analysis of data derived from the Infant Health and Development Program (IHDP), a multisite national collaborative study and a randomized controlled trial of education intervention for low birth weight infants from birth until 3 years of age with follow-up through 18 years of age. A total of 985 infants were enrolled in the IHDP. Of the 462 infants tested for IVH, 99 demonstrated sonographic evidence of low-grade IVH, whereas 291 showed no sonographic evidence of IVH. Several outcomes were compared between these two groups. Intelligence was assessed using Stanford-Binet Intelligence scales at age 3 years, Wechsler Intelligence Scale for Children (WISC-III) at age 8 years, Wechsler Abbreviated Scale of Intelligence (WASI) at age 18 years and Woodcock Johnson Tests of Achievement at age 8 and 18 years. Behavior was measured using the Achenbach Behavior Checklist at age 3 years and Child Behavior Checklist (CBCL) at age 8 and 18 years. Outcomes were compared between the IVH-positive and IVH-negative groups using analysis of covariance after adjusting for the presence or absence of intervention, birth weight, gestational age, gender, severity of neonatal course, race and maternal education.

RESULTS

No statistically significant difference in intelligence as measured by Stanford-Binet Intelligence scales, WISC-III, WASI and Woodcock-Johnson Tests of Achievement could be appreciated between IVH-positive patients and controls at any age group (36 months, 8 years and 18 years of age). In addition, there was no significant difference in problem behavior as assessed by the Achenbach Behavior Checklist and Child Behavior Checklist (CBCL) comparing IVH patients with controls.

CONCLUSION

Low-grade IVH was not demonstrated in our study to be an independent risk factor associated with lower outcomes in intelligence, academic achievement or problem behavior at age 3, 8 and 18 years.

A randomized, double-blind, placebo-controlled trial to evaluate the efficacy, safety, and tolerability of long-term treatment with prucalopride

BACKGROUND

Randomized trials have confirmed the efficacy of prucalopride for the treatment of chronic constipation up to 12 weeks. This study aimed to assess the efficacy of prucalopride over a 24-week period (ClinicalTrials.gov: NCT01424228).

METHODS

Adults with chronic constipation and ≤2 spontaneous complete bowel movements (SCBMs)/week were randomized to receive prucalopride 2 mg or placebo daily for 24 weeks. The primary endpoint was the proportion of patients achieving a mean of ≥3 SCBMs/week over the treatment period, assessed using daily e-diaries. Secondary outcomes and safety parameters were assessed throughout the study.

KEY RESULTS

Overall, 361 patients were randomized and received prucalopride or placebo. Baseline characteristics were similar in the prucalopride (N = 181) and placebo (N = 180) groups. Mean age was 48.9 years (standard deviation, 16.0) and most patients were women. The proportion of participants achieving the primary endpoint was not statistically different between the prucalopride and placebo groups (25.1% vs 20.7%; p = 0.367). There was also no statistically significant difference between groups over the first 12-week period (prucalopride, 25.1%; placebo, 20.1%; p = 0.341). There were no statistically significant differences between groups for most secondary endpoints. No new safety concerns were identified.

CONCLUSIONS & INFERENCES

This trial did not show statistically significant improvements in primary or secondary outcomes with prucalopride compared with placebo over 24 or 12 weeks. This is in contrast to the results of four previous 12-week trials, which demonstrated prucalopride to be significantly more effective than placebo. An extensive evaluation did not provide an explanation for the null efficacy results of this study.

Potential shifts in dominant forest cover in interior Alaska driven by variations in fire severity

Large fire years in which >1% of the landscape burns are becoming more frequent in the Alaskan (USA) interior, with four large fire years in the past 10 years, and 79 000 km2 (17% of the region) burned since 2000. We modeled fire severity conditions for the entire area burned in large fires during a large fire year (2004) to determine the factors that are most important in estimating severity and to identify areas affected by deep-burning fires. In addition to standard methods of assessing severity using spectral information, we incorporated information regarding topography, spatial pattern of burning, and instantaneous characteristics such as fire weather and fire radiative power. Ensemble techniques using regression trees as a base learner were able to determine fire severity successfully using spectral data in concert with other relevant geospatial data. This method was successful in estimating average conditions, but it underestimated the range of severity. This new approach was used to identify black spruce stands that experienced intermediate- to high-severity fires in 2004 and are therefore susceptible to a shift in regrowth toward deciduous dominance or mixed dominance. Based on the output of the severity model, we estimate that 39% (approximately 4000 km2) of all burned black spruce stands in 2004 had <10 cm of residual organic layer and may be susceptible a postfire shift in plant functional type dominance, as well as permafrost loss. If the fraction of area susceptible to deciduous regeneration is constant for large fire years, the effect of such years in the most recent decade has been to reduce black spruce stands by 4.2% and to increase areas dominated or co-dominated by deciduous forest stands by 20%. Such disturbance-driven modifications have the potential to affect the carbon cycle and climate system at regional to global scales.

Prospects for Commercial Bitumen Recovery from the Grosmont Carbonate, Alberta

Abstract

The last few years have seen the end of the Athabasca land play and the revival of interest in Alberta's bitumen resources in carbonate reservoirs. Of these, the Grosmont Formation is the most promising in terms of resource size and concentration. It is also the best known, in terms of having been the subject of several in situ pilots operated in the late '70s and early '80s.

The data recorded from these early pilots is priceless in terms of having a touchstone of reality for new process concepts. On the other hand, the interpretations written in those days ('before gravity') are not necessarily as helpful. This paper looks at the Grosmont in terms of facts and fundamentals, and presents the case for Grosmont exploitation.

There is good evidence that the Grosmont has very high bulk permeability as a result of karst porosity development and fracturing. This bodes well for the use of modern gravity drainage methods in the Grosmont.

Introduction

Grosmont Piloting History

The Grosmont Formation in north-central Alberta is a dolomitized, karsted and fractured platform carbonate containing a massive bitumen accumulation. An excellent historical summary of various Grosmont pilots was recently provided by Alvarez et al.(1) Cyclic Steam Stimulation (CSS), steam drive and forward combustion were all attempted in the Grosmont during the '70s and '80s. CSS was the most widely and successfully piloted method. The best well, at 10A-5-88-19W4, recovered about 100,000 bbls of oil over 10 cycles, with a cumulative steam-oil ratio (CSOR) of about 6. Results of other tests were mixed, as were the operating procedures; most of these were based on horizontal flooding concepts. However, responses to well-executed CSS first cycles were reasonably similar at a number of widely-spaced wells. Notably, steam injectivity was generally sufficient so that a few hundred tonnes/day could be injected at pressures that were significantly below overburden pressure (ruling out geomechanical enhancement of permeability).

A degree of pessimism, or at least great caution, has been expressed with respect to the supposed complexity of the reservoir, and hence, prospects for commercial recovery. In particular, it is often said that the reservoir is very heterogenous, and that this explains the historical failure of attempted steam drive and fire flood processes.

Review of the Unocal Buffalo Creek and McLean scheme reports(2, 3) suggest that much of this originates in the interpretations of the contemporary operators, who largely explored conventional EOR concepts involving horizontal displacement. They expected to recover oil by means of horizontal, radial flow. When this failed, it was natural to assume that the problem lay in a failure to maintain the 'radial' part of the prescription, due to permeability heterogeneity.

Figure 1 presents the performance of the Buffalo Creek 10A-5 CSS test in perspective with a contemporary test and two modern-day, commercially-optimized CSS wells (the data is publicly available from the Alberta Energy Resources Conservation Board). It can be seen that the Grosmont well had comparable performance to a Clearwater CSS test of the same vintage.

Effects of captan on Apis mellifera brood development under field conditions in California almond orchards

Three almond field trials were conducted during 2003 and 2004 at two locations in central (Fresno County) and northern (Yolo County) California to evaluate the potential effects of commercial applications of Captan on honey bees, Apis mellifera L. Captan was applied at 5.0 kg (AI)/ha during bloom. Hives were evaluated for hive health and brood development parameters for approximately 2 mo after application. This study showed that the application of Captan was not harmful to foraging honey bees or their brood. No treatment-related effects were noted on hive weights, dead bee deformity, number of dead bees, survival of individual larvae, weight of individual emerging adults, and other hive health parameters.

Randomised trial of once- or twice-daily MMX mesalazine for maintenance of remission in ulcerative colitis

AIM

Maintenance treatment in ulcerative colitis should be as convenient as possible, to increase the chance of compliance. MMX mesalazine is a once-daily, high-strength (1.2 g/tablet) formulation of 5-aminosalicylic acid. This study evaluated the safety and efficacy of MMX mesalazine dosed once or twice daily as maintenance therapy in patients with ulcerative colitis.

METHODS

This multicentre, randomised, open-label trial enrolled patients with strictly defined clinical and endoscopic remission, immediately following an episode of mild to moderate ulcerative colitis. Patients were randomised to MMX mesalazine 2.4 g/day as a single (2x1.2 g tablet) or divided dose (1x1.2 g tablet twice daily) for 12 months.

RESULTS

174 patients (37.9%; safety population n = 459) experienced 384 adverse events, the majority of which were mild or moderate in intensity. Eighteen patients (3.9%), nine in each group, experienced a total of 22 serious adverse events (10 in the once-daily and 12 in the twice-daily group). Most serious adverse events were gastrointestinal, experienced by 5 patients in the once-daily and 4 in the twice-daily group. At month 12, 64.4% (efficacy population, n = 451) of patients in the once-daily and 68.5% of patients in the twice-daily group were in clinical and endoscopic remission (p = 0.351). At month 12, 88.9% and 93.2% in each group, respectively, had maintained clinical remission (were relapse free).

CONCLUSIONS

MMX mesalazine 2.4 g/day administered as a single or divided dose demonstrated a good safety profile, was well tolerated and was effective as maintenance treatment. High clinical and endoscopic remission rates can be achieved with once-daily dosing.

TRIAL REGISTRATION NUMBER

NCT00151944.

Induction of hyperthyroidism in mice by intradermal immunization with DNA encoding the thyrotropin receptor

Intramuscular injection with plasmid DNA encoding the human thyrotropin receptor (TSHR) has been known to elicit symptoms of Graves' disease (GD) in outbred but not inbred mice. In this study, we have examined, firstly, whether intradermal (i.d.) injection of TSHR DNA can induce hyperthyroidism in BALB/c mice and, secondly, whether coinjection of TSHR- and cytokine-producing plasmids can influence the outcome of disease. Animals were i.d. challenged at 0, 3 and 6 weeks with TSHR DNA and the immune response was assessed at the end of the 8th or 10th week. In two experiments, a total of 10 (67%) of 15 mice developed TSHR-specific antibodies as assessed by flow cytometry. Of these, 4 (27%) mice had elevated thyroxine (TT4) levels and goitrous thyroids with activated follicular epithelial cells but no evidence of lymphocytic infiltration. At 10 weeks, thyroid-stimulating antibodies (TSAb) were detected in two out of the four hyperthyroid animals. Interestingly, in mice that received a coinjection of TSHR- and IL-2- or IL-4-producing plasmids, there was no production of TSAbs and no evidence of hyperthyroidism. On the other hand, coinjection of DNA plasmids encoding TSHR and IL-12 did not significantly enhance GD development since two out of seven animals became thyrotoxic, but had no goitre. These results demonstrate that i.d. delivery of human TSHR DNA can break tolerance and elicit GD in inbred mice. The data do not support the notion that TSAb production is Th2-dependent in murine GD but they also suggest that codelivery of TSHR and Th1-promoting IL-12 genes may not be sufficient to enhance disease incidence and/or severity in this model.

Changes in event-related potentials in a three-stimulus auditory oddball task after mild head injury

Previous research has demonstrated changes in event-related potentials in a variety of cognitive tasks after severe closed head injury. We sought to establish if similar changes were present in patients who had sustained only apparently mild head injury (MHI) by recording event-related potentials in a group of 24 mild head injured and 24 control participants during a three-stimulus auditory target detection task. For this "oddball" task participants were required to press a button every time they heard a rare target tone and to ignore rare novel sounds and frequent non-target tones. Neuropsychological test results indicated that the mild head injured group had mild memory and attention impairments. Analysis of behavioural performance on the three-stimulus "oddball" task showed no difference in reaction times or error rates between the two groups. Target condition N2 deflections appeared to be larger in the mild head injured but peak amplitude measures revealed that this effect was not significant. There were no significant differences in the amplitude or latency of the P3b evoked by target stimuli or the P3a evoked by novel stimuli. However, a putative "O-wave" or "reorienting negativity" following the P3a was more negative in the mild head injured group suggesting increased activation of components of the attention network. These findings lend support to the hypothesis that MHI can cause subtle cognitive impairments that are associated with abnormal allocation of attention resources in the context of normal behavioural performance.

Multidimensional family therapy for adolescent drug abuse: results of a randomized clinical trial

Random assignment was made of 182 clinically referred marijuana- and alcohol-abusing adolescents to one of three treatments: multidimensional family therapy (MDFT), adolescent group therapy (AGT), and multifamily educational intervention (MEI). Each treatment represented a different theory base and treatment format. All treatments were based on a manual and were delivered on a once-a-week outpatient basis. The therapists were experienced community clinicians trained to model-specific competence prior to the study and then supervised throughout the clinical trial. A theory-based multimodal assessment strategy measured symptom changes and prosocial functioning at intake, termination, and 6 and 12 months following termination. Results indicate improvement among youths in all three treatments, with MDFT showing superior improvement overall. MDFT participants also demonstrated change at the 1-year follow-up period in the important prosocial factors of school/academic performance and family functioning as measured by behavioral ratings. Results support the efficacy of MDFT, a relatively short-term, multicomponent, multitarget, family-based intervention in significantly reducing adolescent drug abuse and facilitating adaptive and protective developmental processes.

The delusions of Capgras and intermetamorphosis in a patient with right-hemisphere white-matter pathology

Previous neuropsychological studies have demonstrated an association between person misidentification and right-hemisphere dysfunction. In the study reported here, we explore the contribution of facial and visual recognition impairments in a patient with right-hemisphere subcortical white-matter pathology in the frontal and parietal lobes and a diagnosis of vascular cognitive impairment. The patient displayed false recognition of unfamiliar faces and deficient retrieval of key biographic detail for famous faces. These results are discussed in the context of the contribution of deficiencies in the visual system and subcortical white-matter lesions to the development of Capgras delusion.

Variation in melanin content and composition in type V and VI photoexposed and photoprotected human skin: the dominant role of DHI

A combination of techniques, including high-performance liquid chromatography (HPLC), spectrophotometric measurements, and a novel method for quantifying melanosome morphology, were applied to the analysis of melanin content and composition in highly pigmented (Fitzpatrick type V and VI) human skin. We found that total epidermal melanin content is significantly elevated in photoexposed type V and VI skin (approximately 1.6 x), while analysis of individual melanin components suggests that pheomelanin content increases only slightly, whereas 5,6-dihydroxyindole-2-carboxylic acid (DHICA)-eumelanin and to a greater extent 5,6-dihydroxyindole (DHI)-eumelanin content are both markedly elevated. Analysis of the relative composition of epidermal melanin in these subjects revealed that DHI-eumelanin is the largest single component (approximately 60-70%), followed by DHICA-eumelanin (25-35%), with pheomelanin being a relatively minor component (2-8%). Moreover, there was a comparative enrichment of DHI-eumelanin at photoexposed sites, with a corresponding decline in the relative contributions from DHICA-eumelanin and pheomelanin. There was also a good correlation and close agreement between the concentration of spheroidal melanosomes determined by morphological image analysis and the concentration of pheomelanin determined by a combination of HPLC and spectrophotometric analysis (r = 0.89, P < 0.02). This study demonstrates the usefulness of melanosome morphology analysis as a sensitive new method for the quantification of melanin composition in human skin. The data also suggest that DHI-eumelanin formation is the dominant pathway for melanin synthesis in heavily pigmented (Fitzpatrick V and VI) skin types in vivo, and is the favoured pathway when melanin production is increased in chronically photoexposed skin.

Tophaceous gout of the spine mimicking epidural infection: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Tophaceous gout uncommonly affects the axial skeleton. The clinical presentations of gout of the spine range from back pain to quadriplegia. Gout that presents as back pain and fever may be difficult to distinguish from spinal infection. We present a case of a patient with tophaceous gout of the lumbar spine who was initially diagnosed with and treated for an epidural infection. The clinical and diagnostic features of tophaceous gout of the spine are reviewed.

CLINICAL PRESENTATION

A 70-year-old man presented with a 2-day history of fever and back pain. A physical examination revealed that he had flank tenderness and evidence of polyarthritis affecting the elbows, knees, and right first metatarsophalangeal joint. A magnetic resonance imaging scan of the patient's lumbar spine showed an extensive area of abnormal gadolinium enhancement of the paramedian posterior soft tissues from L3 to S1 with an area of focal enhancement extending into the right L4-L5 facet joint.

INTERVENTION

A laminectomy was performed at L4-L5, and a chalky white material in the facet joint was found eroding into the adjacent pars intra-articularis. Light and polarizing microscopy confirmed the presence of gouty tophus. No evidence of infection was found.

CONCLUSION

Gouty arthritis of the spine is rare. Thirty-seven previous cases have been reported. When the clinical presentation includes acute back pain and fever, differentiation of spinal gout from spinal infection may be difficult. The clinical suspicion of spinal gout may lead to the correct diagnosis by a less invasive approach than exploration and laminectomy.

Evaluation of the performance of full-scale packed saturators

An evaluation of the performance of full-scale packed saturators was made. Measurements of saturator effluent air concentrations, saturator efficiency and precipitated are reported for both cold water and warm water operating conditions. Packed saturators were analyzed over a full range of operating pressures and loading rates. Measured results compared to predicted results based on a comprehensive model for the performance of packed saturators prove the model to be a useful tool in designing efficient and cost effective saturation systems.

Editor's choice: the plight of a people dispossessed: caring for street children in the mountains of Bulgaria

This article was born out of a reflective diary kept by the author while working on a cross-community project in Northern Ireland. While it maps personal experiences, little did the author know its value in gaining insight and understanding of the eastern European situation that has now erupted with such devastating consequences.

The health effects of swimming in ocean water contaminated by storm drain runoff

Waters adjacent to the County of Los Angeles (CA) receive untreated runoff from a series of storm drains year round. Many other coastal areas face a similar situation. To our knowledge, there has not been a large-scale epidemiologic study of persons who swim in marine waters subject to such runoff. We report here results of a cohort study conducted to investigate this issue. Measures of exposure included distance from the storm drain, selected bacterial indicators (total and fecal coliforms, enterococci, and Escherichia coli), and a direct measure of enteric viruses. We found higher risks of a broad range of symptoms, including both upper respiratory and gastrointestinal, for subjects swimming (a) closer to storm drains, (b) in water with high levels of single bacterial indicators and a low ratio of total to fecal coliforms, and (c) in water where enteric viruses were detected. The strength and consistency of the associations we observed across various measures of exposure imply that there may be an increased risk of adverse health outcomes associated with swimming in ocean water that is contaminated with untreated urban runoff.

Assessment of Mild Head Injury with ERPs and Neuropsychological Tasks

Abstract Mild head injury can result in the development of persistent symptoms including impairments of memory and attention in a small but significant minority. The problem in assessing these difficulties in such cases is the likely interaction of psychogenic and organic causes. The aim of the present research is to more accurately characterize the nature of these cognitive deficits. Twelve asymptomatic volunteers, who had experienced a mild head injury in the last 3.5 years, were compared to a matched control group. ERPs were recorded during the performance of the paced auditory serial addition task (PASAT) and a 3-stimulus auditory “oddball” task. Verbal paired associate. Trails A and B, Digit Symbol, Rey Figure Recall, NART, and Digit Span were also administered. The mild head injured group showed evidence of a mild impairment of episodic memory, slowing of attention shifting, but no changes in reaction time or error rates in either the “oddball” task or the PASAT. Although there was no evidence of impairment of brain orienting responses in the 3-stimulus auditory oddball task, there was evidence of reduced frontal negativity associated with changes in task demand in the PASAT. This particular ERP feature appears similar to those associated with activation of selective attention mechanisms, thus suggesting that these asymptomatic individuals may be showing signs of a mild impairment of allocation of attention resources.

Myoblast city, the Drosophila homolog of DOCK180/CED-5, is required in a Rac signaling pathway utilized for multiple developmental processes

The Rac and Cdc42 GTPases share several regulators and effectors, yet perform distinct biological functions. The factors determining such specificity in vivo have not been identified. In a mutational screen in Drosophila to identify Rac-specific signaling components, we isolated 11 alleles of myoblast city (mbc). mbc mutant embryos exhibit defects in dorsal closure, myogenesis, and neural development. DOCK180, the mammalian homolog of Mbc, associates with Rac, but not Cdc42, in a nucleotide-independent manner. These results suggest that Mbc is a specific upstream regulator of Rac activity that mediates several morphogenetic processes in Drosophila embryogenesis.