Microbiological Assay-Trienzyme Procedure for Total Folates in Cereals and Cereal Foods: Collaborative Study

In 1996, U.S. Food and Drug Administration regulations mandated the fortification of enriched cereal-grain products with folic acid, thereby emphasizing the need for validated methods for total folates in foods, particularly cereal products. The AOAC Official Methods (944.12, 960.46) currently used for the analysis of folate in foods for compliance purposes are microbiological methods. When the fortification regulations were finalized, no Official AOAC or Approved AACC methods for folate in cereal-grain products were in place. The AOAC Official Method (992.05) for folic acid in infant formula does not incorporate important improvements in the extraction procedure and was not considered suitable for the analysis of folates in foods in general. Amicrobiological assay protocol using a trienzyme extraction procedure was prepared and submitted for comments to 40 laboratories with recognized experience in folate analysis. On the basis of comments, the method was revised to have the conjugase (gamma-glutamyl-carboxy-peptidase) treatment follow a protease treatment, to include the use of cryoprotected inoculum, and to include the spectroscopic standardization of the standard and optional use of microtiter plates. Thirteen laboratories participated in a collaborative study of 10 required and 10 optional cereal-grain products, including flour, bread, cookies, baking mixes, and ready-to-eat breakfast cereals. The majority of the participating laboratories performed the assay by the standard test tube method; others used the microtiter plate modification for endpoint quantitation with equal success. For the required products, the relative standard deviation between laboratories (RSDR) ranged from 7.4 to 21.6% for 8 fortified (or enriched) products compared with expected (Horwitz equation-based) values of 11–20%. RSDR values were higher (22.7–52.9%) for 2 unfortified cereal-grain products. For the optional products, the RSDR ranged from 1.8 to 11.2% for 8 fortified products. RSDR values were higher (27.9–28.7%) for 2 unfortified cereal-grain products. Based on the results of the collaborative study, the microbiological assay with trienzyme extraction is recommended for adoption as Official First Action.

A rare eicosanoid precursor analogue, sciadonic acid (5Z,11Z,14Z-20:3), detected in vivo in hormone positive breast cancer tissue

Numerous genetic alterations of HSA 11q13 are found frequently in several cancer types, including breast cancer (BC). The 11q13 locus harbors FADS2 encoding Δ6 desaturation which is not functional in several cancer cell lines, including hormone positive MCF7 BC cells. In vitro, the non-functional FADS2 activity unmasks 18:2n-6 elongation to 20:2n-6 and Δ5 desaturation by FADS1 to yield 5Z,11Z,14Z-20:3 (sciadonic acid) rather than 5Z,8Z,11Z,14Z-20:4 (arachidonic acid). In this pilot study we aimed to determine whether 5,11,14-20:3 appears in vivo in hormone positive human BC tissue. Fatty acids were profiled in surgically removed human breast tumor and adjacent normal tissue (n = 9). Sciadonic acid was detected in three of nine breast tumor samples and was below detect limits in normal breast tissue. The internal Δ8 double bond of arachidonic acid is required for normal eicosanoid synthesis but is missing in sciadonic acid. This pilot study demonstrates for the first time in vivo sciadonic acid in hormone positive BC tissue, warranting a larger survey study to further evaluate its appearance and the functional implications.

Motivational interviewing to enhance treatment attendance in mental health settings: A systematic review and meta-analysis

WHAT IS KNOWN ON THE SUBJECT?: Despite differences between samples, some literature reviews have suggested that MI is effective in enhancing treatment attendance for individuals with mental health issues. Little is known regarding the effects of MI as a pre-treatment on individuals who are not seeking treatment for mental health issues. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This systematic review of the literature and meta-analysis demonstrates that MI is most beneficial for individuals who are not seeking mental health treatment. MI represents an opportunity for health promotion when patients are unmotivated but may otherwise be amenable to an intervention. MI is effective as a pre-treatment intervention to motivate individuals to attend further post-MI treatment and counselling. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: MI is a process and a useful tool for clinicians in all therapeutic interactions, to motivate their patients to seek further assistance for mental heath issues. Health promotion and encouragement to attend further treatment sessions can be facilitated through telephone contact.

ABSTRACT

Introduction The stages of change model suggests that individuals seeking treatment are in the "preparation" or the "action" stage of change, which is the desired outcome of successful Motivational Interviewing (MI) interventions. MI is known to enhance treatment attendance among individuals with mental health problems. Aim This study examined the published research on MI as a pre-treatment to enhance attendance among individuals treatment-seeking and non-treatment-seeking for mental health issues. Methods Fourteen randomized controlled trials were identified, and MI efficacy was examined dichotomously: attendance or non-attendance for post-MI therapy. Subgroup analysis investigated treatment-seeking and non-treatment-seeking groups. Results Despite wide variations in sample sizes, blinding and monitoring, intervention fidelity was absent in the majority of published studies. Meta-analysis revealed that MI pre-treatment improved attendance relative to comparison groups. Conclusions Individuals not seeking treatment for mental health issues benefited the most from MI. Despite differences in MI treatment intensity, short interventions were as effective as longer interventions, whereas two MI sessions for as little as 15 min were effective in enhancing treatment attendance. Implications for Practice Motivational interviewing is a useful tool for clinicians in all therapeutic interactions to help motivate patients to seek assistance for mental health issues.

Stress and immunological response of heifers divergently ranked for residual feed intake following an adrenocorticotropic hormone challenge

BACKGROUND

When an animal is exposed to a stressor, metabolic rate, energy consumption and utilisation increase primarily through activation of the hypothalamic-pituitary-adrenal (HPA) axis. Changes to partitioning of energy by an animal are likely to influence the efficiency with which it is utilised. Therefore, this study aimed to determine the physiological stress response to an exogenous adrenocorticotropic hormone (ACTH) challenge in beef heifers divergently ranked on phenotypic residual feed intake (RFI).

RESULTS

Data were collected on 34 Simmental weaning beef heifers the progeny of a well characterized and divergently bred RFI suckler beef herd. Residual feed intake was determined on each animal during the post-weaning stage over a 91-day feed intake measurement period during which they were individually offered adlibitum grass silage and 2 kg of concentrate per head once daily. The 12 highest [0.34 kg DM/d] and 12 lowest [-0.48 kg DM/d] ranking animals on RFI were selected for use in this study. For the physiological stress challenge heifers (mean age 605 ± 13 d; mean BW 518 ± 31.4 kg) were fitted aseptically with indwelling jugular catheters to facilitate intensive blood collection. The response of the adrenal cortex to a standardised dose of ACTH (1.98 IU/kg metabolic BW^0.75) was examined. Serial blood samples were analysed for plasma cortisol, ACTH and haematology variables. Heifers differing in RFI did not differ (P = 0.59) in ACTH concentrations. Concentration of ACTH peaked (P < 0.001) in both RFI groups at 20 min post-ACTH administration, following which concentration declined to baseline levels by 150 min. Similarly, cortisol systemic profile peaked at 60 min and concentrations remained continuously elevated for 150 min. A RFI × time interaction was detected for cortisol concentrations (P = 0.06) with high RFI heifers had a greater cortisol response than Low RFI from 40 min to 150 min relative to ACTH administration. Cortisol response was positively associated with RFI status (r = 0.32; P < 0.01). No effect of RFI was evident for neutrophil, lymphocytes, monocyte, eosinophils and basophil count. Plasma red blood cell number (6.07 vs. 6.23; P = 0.02) and hematocrit percentage (23.2 vs. 24.5; P = 0.02) were greater for low than high RFI animals.

CONCLUSIONS

Evidence is provided that feed efficiency is associated with HPA axis function and susceptibility to stress, and responsiveness of the HPA axis is likely to contribute to appreciable variation in the efficiency feed utilisation of cattle.

BCFA suppresses LPS induced IL-8 mRNA expression in human intestinal epithelial cells

Branched chain fatty acids (BCFA) are components of common food fats and are major constituents of the normal term human newborn GI tract. Polyunsaturated fatty acids (PUFA) have been suggested to reduce the risk and development of inflammatory bowel diseases (IBD); however, little is known about the influence of BCFA on inflammation. We investigated the effect of BCFA on interleukin (IL)-8 and NF-κB production in a human intestinal epithelial cell line (Caco-2). Cells were pre-treated with specific BCFA, or DHA, or EPA, and then activated with lipopolysaccharide (LPS). Both anteiso- and iso- BCFA reduce IL-8. Anteiso-BCFA more effectively suppressed IL-8 than iso-BCFA in LPS stimulated Caco-2 cells. However BCFA in general were less effective than DHA or EPA. Activated BCFA-treated cells expressed less of the cell surface Toll-like receptor 4 (TLR-4) compared to controls. These are the first data to show the reduction of pro-inflammatory markers in human cells mediated by BCFA.

Survey of an Australian general emergency department: estimated prevalence of mental health disorders

Compared to the general population, people with mental health disorders have an increased risk of morbidity and mortality, and are associated with higher health-care costs and lost societal productivity. Evidence indicates that more people are presenting to emergency departments with mental health disorders and that this group represents a disproportionately large number of emergency department attendees. The study results indicate that around a third of people who attended the emergency department may have had a mental health disorder, which is more than that found in the general adult Australian population. The results also suggest that the majority of emergency department attendees that have a mental health disorder are not identified at this opportunistic point of contact. The emergency department is an ideal point of contact to screen people for mental health problems. If problems are identified early, and treatment is started early, then it is likely that more people would be helped before their mental health problem became severe. However, increased identification of mental health problems may have implications for mental health services in terms of workload and delivery. The aim of this study was to estimate the prevalence of mental health disorders in an Australian general emergency department. A cross-sectional survey was used to screen a sample of 708 patients, using the Kessler Psychological Distress Scale (K10). The mean age of participants was 50.2 years, and their mean K10 score was 19.96 (SD 7.83), with 24% categorized as having high or very high psychological distress. Seventeen per cent self-reported having a mental health issue. Post-probability calculations based on observed K10 scores estimated that 37% of participants had an actual mental health disorder. The results suggest the prevalence of mental health disorder is significantly higher in emergency department attendees than Australian population norms, supporting the contention that a substantial proportion of ED attendees has a mental health disorder that, in the majority of cases, is not investigated at this point of contact. There is potential to screen all emergency department attendees for the presence of mental health disorder; early identification of mental illness would enable early referral for treatment. However, if all patients are screened, then it is likely that more mental health conditions will be picked up. The implications for mental health nursing are that this may increase workload.

Cost-effectiveness of training rural providers to identify and treat patients at risk for fragility fractures

This is a cost-effectiveness analysis of training rural providers to identify and treat osteoporosis. Results showed a slight cost savings, increase in life years, increase in treatment rates, and decrease in fracture incidence. However, the results were sensitive to small differences in effectiveness, being cost-effective in 70 % of simulations during probabilistic sensitivity analysis.

INTRODUCTION

We evaluated the cost-effectiveness of training rural providers to identify and treat veterans at risk for fragility fractures relative to referring these patients to an urban medical center for specialist care. The model evaluated the impact of training on patient life years, quality-adjusted life years (QALYs), treatment rates, fracture incidence, and costs from the perspective of the Department of Veterans Affairs.

METHODS

We constructed a Markov microsimulation model to compare costs and outcomes of a hypothetical cohort of veterans seen by rural providers. Parameter estimates were derived from previously published studies, and we conducted one-way and probabilistic sensitivity analyses on the parameter inputs.

RESULTS

Base-case analysis showed that training resulted in no additional costs and an extra 0.083 life years (0.054 QALYs). Our model projected that as a result of training, more patients with osteoporosis would receive treatment (81.3 vs. 12.2 %), and all patients would have a lower incidence of fractures per 1,000 patient years (hip, 1.628 vs. 1.913; clinical vertebral, 0.566 vs. 1.037) when seen by a trained provider compared to an untrained provider. Results remained consistent in one-way sensitivity analysis and in probabilistic sensitivity analyses, training rural providers was cost-effective (less than $50,000/QALY) in 70 % of the simulations.

CONCLUSIONS

Training rural providers to identify and treat veterans at risk for fragility fractures has a potential to be cost-effective, but the results are sensitive to small differences in effectiveness. It appears that provider education alone is not enough to make a significant difference in fragility fracture rates among veterans.

Grass silage intake, rumen and blood variables, ultrasonic and body measurements, feeding behavior, and activity in pregnant beef heifers differing in phenotypic residual feed intake

The objectives of this study were to quantify the phenotypic variation in residual feed intake (RFI) in pregnant beef heifers offered a grass silage diet and to characterize their productivity. Seventy-three pregnant (mean gestation d 198, SD = 27 d) Simmental and Simmental × Holstein-Friesian heifers (mean initial BW 548, SD = 47.5 kg) were offered grass silage ad libitum. Heifer DMI, BW, BCS, skeletal measurements, ultrasonic fat and muscle depth, visual muscularity score, rumen fermentation, total tract digestibility, blood metabolite and hematology variables, feeding, and activity behavior were measured during an 84-d feed intake study. After parturition calf birth weight, calving difficulty, cow serum IgG, hematology variables, and calf humoral immune status were measured. In a subset of cows (n = 28), DMI, milk yield and various body composition variables were also measured approximately 3 wk postpartum. Phenotypic RFI was calculated for each animal as the difference between actual DMI and expected DMI. Expected DMI was computed for each animal by regressing average daily DMI on conceptus-adjusted mean BW(0.75) and conceptus-adjusted ADG over an 84-d period. Within breed, heifers were ranked by RFI into low (efficient), medium, and high (inefficient) groups by dividing them into thirds. Heifers with high RFI had 8.8 and 17.1% greater (P < 0.001) DMI than medium and low RFI groups, respectively. The RFI groups did not differ in ADG or BW (P > 0.05). Residual feed intake was positively correlated with DMI (r = 0.85) but not with feed conversion ratio, ADG, or BW. The RFI groups did not differ (P > 0.05) in skeletal size, BCS, ultrasonic fat depth, total tract digestibility, calf birth weight, calving difficulty, serum IgG concentrations, or milk yield. Visual muscularity scores, initial test and postpartum ultrasonic muscle depth were negatively correlated with RFI (P < 0.05). Including mean ultrasonic muscle depth into the base RFI regression model increased its R(2) (0.29 to 0.38). Pearson rank correlation between RFI and muscle-adjusted RFI was 0.93. The results show that efficient RFI heifers consumed less feed without any compromise in growth, body composition, or maternal traits measured.

The effects of EPA, DHA, and aspirin ingestion on plasma lysophospholipids and autotaxin

Lysophophatidylcholine (LPC) and lysophosphatidic acid (LPA) are potent lysolipid mediators increasingly linked with atherosclerosis and inflammation. A current model proposing that plasma LPA is produced when LPC is hydrolyzed by the enzyme autotaxin has not been rigorously investigated in human subjects. We conducted a clinical trial of eicosapentaenoic acid/docosahexaenoic acid (EPA/DHA) and aspirin ingestion in normal volunteers. Fasting blood samples were drawn at baseline and after 4-week supplementation with EPA/DHA (3.4 g/d) with and without aspirin (650 mg). Plasma LPC and LPA species and autotaxin activity were measured. EPA-LPC and DHA-LPC concentrations increased significantly with EPA/DHA supplementation whereas EPA- and DHA-LPA did not. Autotaxin activity was unaffected by any treatment, and aspirin had no effect on any endpoint. Taken together, our data demonstrate that plasma LPC, but not LPA, species can be dynamically regulated by dietary supplementation, and argue against a simple model of LPA generation via LPC hydrolysis.

Milk fat synthesis is unaffected by abomasal infusion of the conjugated diene 18∶3 isomers cis-6, trans-10, cis-12 and cis-6, trans-8, cis-12

It has been previously established that trans-10,cis-12 CLA is a potent inhibitor of milk fat synthesis. Although the mechanism of this action is not completely understood, it has been speculated that eicosanoid-like metabolites of this isomer formed by the activity of tissue desaturases may be responsible for its activity. The objective of this study was to investigate the effects of an enrichment containing an 18:3 conjugated diene, produced in the metabolism of trans-10,cis-12 CLA, on milk fat synthesis. Three rumen-fistulated Holstein cows (210+/-8 d in milk) were randomly assigned in a 3 x 3 Latin square experiment. Treatments were (i) control, (ii) trans-10,cis-12 CLA supplement (2.1 g/d; positive control), (iii) enrichment providing two conjugated diene 18:3 isomers (2.6 g/d of cis-6,trans-10,cis-12 and 4.0 g/d of cis-6,trans-8,cis-12) and trans-10,cis-12 CLA (2.1 g/d). Treatments were abomasally infused for 5 d at 4-h intervals, and there was a 7-d interval between periods. Milk yield, dry matter intake, and milk protein yield were unaffected by treatments. In contrast, the trans-10,cis-12 CLA supplement reduced milk fat yield by 27%, whereas the supplement enriched with conjugated diene 18:3 isomers (treatment iii) had no effect on milk fat yield beyond that attributable to its trans-10,cis-12 CLA content. The transfer efficiency of trans-10,cis-12 CLA into milk fat was 25 and 24% for treatments ii and iii, respectively. At the same time, the abomasally infused conjugated diene 18:3 isomers were transferred to milk fat with an efficiency of 33 and 41% for cis-6,trans-10,cis-12 and cis-6,trans-8,cis-12 18:3, respectively. Overall, short-term abomasal infusion of the conjugated diene 18:3 isomers had no effect on milk fat synthesis, thereby offering no support for an involvement of metabolites of trans-10,cis-12 CLA in the regulation of milk fat synthesis.

Microbiological assay-trienzyme procedure for total folates in cereals and cereal foods: collaborative study

In 1996, U.S. Food and Drug Administration regulations mandated the fortification of enriched cereal-grain products with folic acid, thereby emphasizing the need for validated methods for total folates in foods, particularly cereal products. The AOAC Official Methods (944.12, 960.46) currently used for the analysis of folate in foods for compliance purposes are microbiological methods. When the fortification regulations were finalized, no Official AOAC or Approved AACC methods for folate in cereal-grain products were in place. The AOAC Official Method (992.05) for folic acid in infant formula does not incorporate important improvements in the extraction procedure and was not considered suitable for the analysis of folates in foods in general. A microbiological assay protocol using a trienzyme extraction procedure was prepared and submitted for comments to 40 laboratories with recognized experience in folate analysis. On the basis of comments, the method was revised to have the conjugase (gamma-glutamyl-carboxy-peptidase) treatment follow a protease treatment, to include the use of cryoprotected inoculum, and to include the spectroscopic standardization of the standard and optional use of microtiter plates. Thirteen laboratories participated in a collaborative study of 10 required and 10 optional cereal-grain products, including flour, bread, cookies, baking mixes, and ready-to-eat breakfast cereals. The majority of the participating laboratories performed the assay by the standard test tube method; others used the microtiter plate modification for endpoint quantitation with equal success. For the required products, the relative standard deviation between laboratories (RSD(R)) ranged from 7.4 to 21.6% for 8 fortified (or enriched) products compared with expected (Horwitz equation-based) values of 11-20%. RSD(R) values were higher (22.7-52.9%) for 2 unfortified cereal-grain products. For the optional products, the RSD(R) ranged from 1.8 to 11.2% for 8 fortified products. RSD(R) values were higher (27.9-28.7%) for 2 unfortified cereal-grain products. Based on the results of the collaborative study, the microbiological assay with trienzyme extraction is recommended for adoption as Official First Action.

Adaptive management and its role in managing Great Barrier Reef water quality

Adaptive management is the pathway to effective conservation, use and management of Australia's coastal catchments and waterways. While the concepts of adaptive management are not new, applications involving both assessment and management responses are indeed limited at the national and regional scales. This paper outlines the components of a systematic framework for linking scientific knowledge, existing tools, planning approaches and participatory processes to achieve healthy regional partnerships between community, industry, government agencies and science providers to overcome institutional barriers and uncoordinated monitoring. The framework developed by the Coastal CRC (www.coastal.crc.org.au/amf/amf/_index.htm) is hierarchical in the way it displays information to allow associated frameworks to be integrated, and represents a construct in which processes, information, decision tools and outcomes are brought together in a structured and transparent way for adaptive catchment and coastal management. This paper proposes how an adaptive management approach could be used to benefit the implementation of the Reef Water Quality Protection Plan (RWQPP).

Phenotype/genotype associations for yield and salt tolerance in a barley mapping population segregating for two dwarfing genes

Barley traits related to salt tolerance are mapped in a population segregating for a dwarfing gene associated with salt tolerance. Twelve quantitative trait loci (QTLs) were detected for seven seedling traits in doubled haploids from the spring barley cross Derkado x B83-12/21/5 when given saline treatment in hydroponics. The location of QTLs for seedling growth stage (leaf appearance rate), stem weight prior to elongation, and tiller number are reported for the first time. In addition, four QTLs were found for the mature plant traits grain nitrogen and plot yield. In total, seven QTLs are co-located with the dwarfing genes sdw1, on chromosome 3H, and ari-e.GP, on chromosome 5H, including seedling leaf response (SGa) to gibberellic acid (GA(3)). QTLs controlling the growth of leaves (GS2) on chromosomes 2H and 3H and emergence of tillers (TN2) and grain yield were independent of the dwarfing genes. Field trials were grown in eastern Scotland and England to estimate yield and grain composition. A genetic map was used to compare the positions of QTLs for seedling traits with the location of QTLs for the mature plant traits. The results are discussed in relation to the study of barley physiology and the location of genes for dwarf habit and responses to GA.

Culturally sensitive care of the Muslim patient

The number of Muslims in the United States is growing. This article outlines a few of the major beliefs in Islam. Religious and philosophical factors that affect health care are discussed, and practical suggestions are made for nursing actions that lead to culture care preservation, culture care accommodation, and culture care restructuring. Major topics covered include the need for cleanliness, preparation for prayer, modesty, family structure, fasting and diet, and care of the dying.

Double bag or Y-set versus standard transfer systems for continuous ambulatory peritoneal dialysis in end-stage renal disease

BACKGROUND

Peritonitis is the most frequent serious complication of continuous ambulatory peritoneal dialysis (CAPD). It has a major influence on the number of patients switching from CAPD to haemodialysis and has probably restricted the wider acceptance and uptake of CAPD as an alternative mode of dialysis.

OBJECTIVES

This systematic review sought to determine if modifications of the transfer set (Y-set or double bag systems) used in CAPD exchanges are associated with a reduction in peritonitis and an improvement in other relevant outcomes.

SEARCH STRATEGY

A broad search strategy was employed which attempted to identify all RCTs or quasi-RCTs relevant to the management of end-stage renal disease (ESRD). Five electronic databases were searched (Medline 1966-1999, EMBASE 1984-1999, CINAHL 1982-1996, BIOSIS 1985-1996 and the Cochrane Library), authors of included studies and relevant biomedical companies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened and Kidney International 1980-1997 was hand searched.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing double bag, Y-set and standard CAPD exchange systems in patients with ESRD.

DATA COLLECTION AND ANALYSIS

Data were abstracted by a single investigator onto a standard form and subsequently entered into Review Manager 4.0.4. Odds Ratio (OR) for dichotomous data and a (Weighted) Mean Difference (WMD) for continuous data were calculated with 95% confidence intervals (95% CI).

MAIN RESULTS

Twelve eligible trials with a total of 991 randomised patients were identified. In trials comparing either the Y-set or double bag systems with the standard systems significantly fewer patients (OR 0.33, 95% CI 0.24 to 0.46) experienced peritonitis and the number of patient-months on CAPD per episode of peritonitis were consistently greater. When the double bag systems were compared with the Y-set systems significantly fewer patients experienced peritonitis (OR 0.44, 95% CI 0.27 to 0.71) and the numbers of patient-months on CAPD/ episode of peritonitis were also greater.

REVIEWER'S CONCLUSIONS

Double bag systems should be the preferred exchange systems in CAPD.

Evidence-based medicine in nephrology: identifying and critically appraising the literature

BACKGROUND

Uncertainties about best management of end-stage renal disease (ESRD) are reflected in wide variations in practice. Systematic reviews aim to reduce uncertainty by strengthening the evidence base for clinical practice, allowing estimation of the benefits and risks of particular interventions, whilst minimizing the potential for bias. This paper describes the methods and conduct of six systematic reviews of aspects of the management of ESRD, and the yield in terms of trials found.

METHODS

Our methodology was based on that recommended by the Cochrane Collaboration (an international initiative set up to perform and disseminate systematic reviews of health care). It involved a systematic search of electronic databases and bibliographic reference lists, together with handsearching of Kidney International for studies relevant to the management of ESRD, followed by a systematic assessment of study quality.

RESULTS

Around 12,000 abstracts were assessed which had been identified from electronic sources. Of these, 2085 (18%) were deemed to be reports of possible randomized or quasi-randomized controlled trials relevant to the management of ESRD. Three hundred and forty were relevant to the six specific reviews, and after assessment of the full manuscripts, 39 studies were finally included in our reviews. Reports of a further nine trials, which were identified from other sources, were also included. The broad search adopted allowed the parallel development of a register of trials of all aspects of the management of ESRD.

CONCLUSIONS

This study has demonstrated that the methodology of systematic reviews, as promoted by the Cochrane Renal Group, is feasible but has significant resource implications. The development of a register of randomized controlled trials (RCTs) related to the management of ESRD will facilitate this form of research in the future.

Generation of medial and lateral dorsal body domains by the pannier gene of Drosophila

The pannier (pnr) gene encodes a GATA transcription factor and acts in several developmental processes in Drosophila, including embryonic dorsal closure, specification of cardiac cells and bristle determination. We show that pnr is expressed in the mediodorsal parts of thoracic and abdominal segments of embryos, larvae and adult flies. Its activity confers cells with specific adhesion properties that make them immiscible with non-expressing cells. Thus there are two genetic domains in the dorsal region of each segment: a medial (MED) region where pnr is expressed and a lateral (LAT) region where it is not. The homeobox gene iroquois (iro) is expressed in the LAT region. These regions are not formed by separate polyclones of cells, but are defined topographically. We show that ectopic pnr in the wing induces MED thoracic development, indicating that pnr specifies the identity of the MED regions. Correspondingly, when pnr is removed from clones of cells in the MED domain, they sort out and apparently adopt the LAT fate. We propose that (1) the subdivision into MED and LAT regions is a general feature of the Drosophila body plan and (2) pnr is the principal gene responsible for this subdivision. We argue that pnr acts like a classical selector gene but differs in that its expression is not propagated through cell divisions.

Evidence-based medicine and health economics: a case study of end stage renal disease

This paper explores the potential for use of an economic evaluation framework alongside systematic reviews. Clinical issues in dialysis therapy for end stage renal disease are used as case studies. The effectiveness data required were obtained from a systematic review of randomized controlled trials. Resource use and cost data were obtained from three sources; the identified randomized controlled trials, a separate review of observational studies and primary data collection. The results of the case studies show that, although simple economic evaluations were possible, issues arose, such as how transferable results are between settings and how appropriate it is to focus on the average patient. The interface between economic evaluation and systematic reviews needs to be further developed in order to ensure that the best available evidence can be used to inform future policy and research.

Chronic effects of streptozotocin-induced diabetes on the ultrastructure of rat ventricular and papillary muscle

Contractile dysfunctions have been demonstrated in different experimental models of diabetes which have similar characteristics to many of the abnormalities found in the clinical setting. Administration of streptozotocin (STZ) to young adult rats induces beta-cell necrosis of the pancreas which gives rise to hypoinsulinaemia and hyperglycaemia, features which are also seen in untreated type 1 clinical diabetes. We have investigated the chronic effects of STZ-induced diabetes on contraction in rat ventricular myocytes and ultrastructure of cardiac muscle. Diabetes was induced in male Wistar rats (230-270 g) with a single injection of STZ (60 mg kg(-1)). At 2 and 10 months after STZ treatment, the amplitude of contraction was larger in diabetic compared to control myocytes. Time to peak contraction was significantly longer at 2 months but appeared to normalise at 10 months after STZ treatment. In contrast, time to half relaxation of contraction was not significantly different after 2 months but was significantly reduced at 10 months after STZ treatment compared to control. Transmission electron microscope examination of cardiac muscle showed that the ultrastructure of cardiac muscle, especially structures associated with contraction, were not greatly altered after STZ treatment. Sarcomere lengths were not significantly different in papillary or ventricular muscle at 4 or 8 months after STZ treatment compared to control. Our data provide evidence that morphological defects in contractile myofilaments and associated structures cannot explain contractile dysfunctions seen in ventricular myocytes from STZ-treated animals.

Primary antiphospholipid syndrome with moyamoya-like vascular changes

We describe a young girl with antiphospholipid syndrome (APS) and moyamoya-like cerebrovascular changes which reversed after anticoagulation. Although there was a risk of hemorrhage from collateral vessels, we speculate that this treatment may have prevented progression of the vascular abnormalities, while resolution of the thrombus resulted in improved cerebrovascular circulation.

Phase I trial of a 96 h paclitaxel infusion with filgrastim support in refractory solid tumor patients

A phase I study of a 96 h paclitaxel infusion with filgrastim support was performed to determine the toxicity, maximum-tolerated dose (MTD) and pharmacokinetics in patients with refractory solid tumors. In this phase I trial, the initial paclitaxel dose was 140 mg/m2/96 h followed by filgrastim (5 microg/kg/day s.c.) beginning 24 h after the paclitaxel and continued until granulocyte recovery. Cycles were repeated every 21 days. Patients with refractory solid tumors were eligible; however, only one previous chemotherapy regimen was allowed. The dose of paclitaxel was escalated by 20 mg/m2/96 h in subsequent cohorts until dose-limiting toxicity (DLT) occurred. Pharmacokinetic analysis was performed by quantitating paclitaxel concentrations at baseline, 24, 48, 72 and 96 h after the start of the paclitaxel infusion. Twenty-one patients were entered into this trial of which 19 were evaluable. A total of 52 treatment cycles were administered. DLT was seen in two of four patients at 200 mg/m2/96 h, and consisted of diarrhea, mucositis and granulocytopenic infection. The MTD of the 96 h paclitaxel infusion was 180 mg/m2 with filgrastim support. Mucosal and granulocyte toxicity were correlated with steady-state paclitaxel concentrations (Css) greater than 0.100 micromol/l. In the presence of liver function test 1.5 times or lower than normal, metastatic liver disease did not alter paclitaxel Css. Objective responses were observed in non-small cell lung cancer, small cell lung cancer and melanoma. The recommended phase II dose of paclitaxel infused over 96 h with filgrastim support is 180 mg/m2. Paclitaxel Css correlate with mucosal and granulocyte toxicity. In the presence of normal enzymatic function, metastatic liver disease does not affect paclitaxel clearance.

Comparative morphology of the alimentary tract and its glandular derivatives of captive bustards

This study describes the gross anatomy of the alimentary tract of Houbara Bustards (Chlamydotis undulata macqueenii), Kori Bustards (Ardeotis kori), Rufous-crested Bustards (Eupodotis ruficrista) and White-bellied Bustards (Eupodotis senegalensis) maintained in captivity by the National Avian Research Center in the United Arab Emirates. The morphology of the alimentary tract and the proportions of each region were similar in all 4 species. The length of the oesophagus, combined proventriculus and ventriculus, small intestine, and large intestine formed 24.2-28.4%, 7.3-9.7%, 40.5-55.1% and 9.1-14.7% of the total alimentary tract length respectively. Neither crop nor oesophageal enlargement was observed in the birds examined in this study, although male Kori Bustards possessed a saccus oralis in the oropharyngeal cavity. Oesophagi, proventriculi, ventriculi, caeca and large intestine were well developed in all species. The small intestine was shorter than that of other avian herbivores and granivores when compared on a bodyweight basis. The well differentiated stomachs and well developed caeca of the bustards examined in this study are characteristic of omnivores. Analysis of the mean lengths of the alimentary tract components and weight of the liver and pancreas showed sexual dimorphism in cases where male and female data were available for direct comparison.

Comparative morphology of the alimentary tract and its glandular derivatives of captive bustards

This study describes the gross anatomy of the alimentary tract of Houbara Bustards (Chlamydotis undulata macqueenii), Kori Bustards (Ardeotis kori), Rufous-crested Bustards (Eupodotis ruficrista) and White-bellied Bustards (Eupodotis senegalensis) maintained in captivity by the National Avian Research Center in the United Arab Emirates. The morphology of the alimentary tract and the proportions of each region were similar in all 4 species. The length of the oesophagus, combined proventriculus and ventriculus, small intestine, and large intestine formed 24.2-28.4%, 7.3-9.7%, 40.5-55.1% and 9.1-14.7% of the total alimentary tract length respectively. Neither crop nor oesophageal enlargement was observed in the birds examined in this study, although male Kori Bustards possessed a saccus oralis in the oropharyngeal cavity. Oesophagi, proventriculi, ventriculi, caeca and large intestine were well developed in all species. The small intestine was shorter than that of other avian herbivores and granivores when compared on a bodyweight basis. The well differentiated stomachs and well developed caeca of the bustards examined in this study are characteristic of omnivores. Analysis of the mean lengths of the alimentary tract components and weight of the liver and pancreas showed sexual dimorphism in cases where male and female data were available for direct comparison.

Bilateral iliac artery aneurysms and pancake kidney: a case report

Renal fusion and ectopia are anomalies of the proximal urinary tract that present a special challenge to vascular surgeons. We present a rare case of bilateral iliac artery aneurysms in a 70-year-old man with a fused pancake kidney. The patient underwent preoperative evaluation with a computed tomographic scan and angiographic examination, followed by bilateral iliac artery reconstruction. Pancake kidney is a rare renal anomaly, and its association with aortoiliac disease has been referred to only one other time in the literature. Successful management is dependent on preoperative recognition of the renal anomaly, aortographic examination to delineate renal blood supply, and careful operative preservation of renal vasculature.

A human factors evaluation of two different machine control systems for log loaders

The implement movement in today's mobile, heavy machinery does not correspond in a one-to-one proportion with hand control movement. This lack of correspondence places high perceptual and psychomotor demands on the operator. The objective of this study was to evaluate the human factors of two different machine control systems on a log loader in a controlled field setting. The traditional joint control system was compared with a co-ordinated control system. The two machines were tested on ten novice and six experienced operators. Operator performance was based on the time required to complete a task sequence, as well as reaction time. The results show that the novice operators performed significantly better in co-ordinated mode than they did in joint mode, whereas the experienced operators performed better in joint mode than they did in co-ordinated mode. Results indicate, however, that it would not take long for experienced operators to transfer their skills from joint control to co-ordinated control.

The effects of recombinant human growth hormone and intradialytic parenteral nutrition in malnourished hemodialysis patients

Malnutrition in hemodialysis patients is associated with increased morbidity and mortality. The use of intradialytic parenteral nutrition (IDPN) to improve nutritional parameters has been shown to be of limited benefit in most studies. We studied the use of recombinant human growth hormone (rHuGH) in potentiating the effects of IDPN in seven hemodialysis patients dialyzed with a Kt/V of 1.03 +/- 0.11 (mean +/- SEM), but with evidence of malnutrition: albumin, 3.2 +/- 0.18 g/dL; transferrin, 215 +/- 30 mg/dL; insulin-like growth factor-1 (IGF-1), 115 +/- 19 ng/mL, protein catabolic rate (PCR), 0.70 +/- 0.05 g/kg/d; and weight, 12.3% +/- 4.0% below ideal body weight. During 6 weeks of IDPN, resulting in an additional 18 +/- 4 kcal and 0.69 +/- 0.03 g of protein/kg body weight per dialysis session, albumin concentration increased to 3.5 +/- 0.14 g/dL (compared with baseline, P = NS), transferrin increased to 279 +/- 36 mg/dL (P < 0.002), IGF-1 increased to 152 +/- 32 ng/mL (P = NS), and PCR increased to 0.81 +/- 0.04 g/kg/d (P = NS). During the next 6 weeks, IDPN administration was continued and rHuGH, at a dose of 5 mg subcutaneously during each dialysis, was added to the regimen. This resulted in an increase in albumin concentration to 3.8 +/- 0.08 g/dL (P < or = 0.04 compared with end of IDPN phase), an increase in transferrin to 298 +/- 41 mg/dL (P = NS compared with end of IDPN phase), and an increase in IGF-1 to 212 +/- 45 ng/mL (P = 0.05 compared with end of IDPN phase).(ABSTRACT TRUNCATED AT 250 WORDS)

Bullous secondary syphilis

An earlier standard syphilology textbook states that 'If vesicles are an essential part of an eruption in an adult, the lesions are not due to secondary syphilis'. However, vesicular and bullous eruptions do occur in congenital syphilis and rare reports of both vesicular and pustular eruptions in adults with secondary syphilis have been published. We describe a patient with a bullous-pemphigoid-like eruption and a positive VDRL in whom treatment with a course of procaine penicillin resulted in rapid permanent resolution of the eruption.

The making of a French manager

France's recent successes make it more important than ever to understand what makes its managers tick. This year, France surpassed Japan and the U.K. in acquisitions of U.S. companies. And many French companies are world leaders, including Michelin and L'Oreal. According to the authors, who have studied the French model of management development, the system stands as a coherent whole. Its clear logic and rules provide unambiguous signals that shape managerial action. Thus French industry has a focus and sense of purpose that the rest of the world should not underestimate as a key to strong economic performance. In France, management is a "state of mind" rather than an interpersonally demanding exercise. It is managers' cleverness, not skills, that distinguishes them. And these managers are not simply born. They are molded through an elaborate education and induction into the managerial elite. Alumni of the grandes écoles dominate the upper echelons. These elite colleges have grueling entrance exams resembling Japan's "examination hell." Graduates automatically enter the tight-knit cadre circle--the managerial elite who enjoy the same social prestige as doctors or lawyers. French managers prefer to put things in writing, even informal interactions. They excel in quantitative expression, at ease with putting figures to proposals. Hierarchy in French companies is often literal--the head of L'Air Liquide works on the top floor, while the typing pool is in the basement.(ABSTRACT TRUNCATED AT 250 WORDS)

Leg ulcers in hereditary spherocytosis

Refractory leg ulcers in two patients healed following splenectomy. Neither patient had the ethnic background or family history of haematological abnormalities to suggest a haemoglobinopathy.

Building design: more than meets the eye

How good an investment is a new building? Its design has a lot to do with the answer.

A statewide targeted burn prevention program

The statewide Burn Prevention Program has demonstrated a significant improvement in testable knowledge of burn prevention and fire safety among children and senior citizens as a result of an effective educational program. Formal evaluation using written examinations was done with the children. The statistical significance of the results of these evaluations was analyzed using chi square tests and two sample t tests. Significant improvements were seen in both mean test scores and the percentage of children answering all the test questions correctly. A much less formal type of evaluation was done with the elderly group. Senior citizens were assisted with a pre-program questionnaire. The results of this questionnaire were compared to the results of "BURN-GO" (copyright 1986), a bingotype game, played immediately after the educational session. Again, the post-implementation results of the program were significantly higher than those achieved prior to the intervention.

Morphological measurement of the SEP using a dynamic time warping algorithm

A dynamic time warping technique was created to align the components of digitally high-pass (300 Hz-2500 Hz) filtered somatosensory evoked potentials evoked by median nerve stimulation recorded with a bipolar cephalic montage. A cost function was assigned related to the amount of warping necessary to match a standard wave derived from 24 normal subjects. Its value ranged from 0.525 to 2.456 (mean 1.305 +/- 0.501). This contrasted with a mean of 5.089 +/- 4.277 (range 0.701-13.972) derived from 25 patients with definite (n = 24) or possible (n = 1) multiple sclerosis chosen on the basis of having few or no clinical abnormalities at the time of testing. Fourteen (56%) of the patients had cost functions that were 3 or more S.D.s above the normal mean as compared to 3 (12%) having prolonged latency of the N19 peak. When used in combination, the cost function and latency yielded 60% abnormalities; 5 times higher than latency measurement alone.

Value of a 24-hour image (four-phase bone scan) in assessing osteomyelitis in patients with peripheral vascular disease

The delayed images of the four-phase 99mTc phosphonate bone scan are compared with the delayed images of the three-phase study in patients with diabetes mellitus and/or peripheral vascular disease and suspected osteomyelitis. Three-phase bone imaging includes an immediate postinjection radionuclide angiogram, a blood-pool image, and delayed static images to 7 hr. The four-phase study adds a 24-hr static image. The scan is positive for osteomyelitis if images show progressively increasing lesion to background activity ratios over time. The results of analyzing 21 three- and four-phase bone scans in 17 patients were correlated with clinical course, cultures, and/or x-rays, gallium scans, and CT scans. The accuracy of four-phase bone imaging for diagnosing osteomyelitis was 85%; for three phase, 80%. Sensitivity for four phase was 80%; specificity was 87%. Sensitivity for three phase was 100%; specificity was 73%. Since overall accuracy of the four-phase study is slightly better than three phase, in these patients with diabetes mellitus and/or peripheral vascular disease, the addition of a 24-hr image, creating a four-phase bone scan, is recommended.

Assessment of skin ulcer healing capability by technetium-99m phosphate angiogram and blood-pool images

The accuracy of radionuclide angiography and blood-pool imaging using [99mTc]-phosphate to assess skin ulcer perfusion as an indicator of healing capacity was determined in 50 studies performed on 45 patients with nonhealing ulcers of the lower extremities. Two nuclear medicine physicians without clinical bias, graded the perfusion of the ulcer on the images as normal, increased or reduced with respect to the opposite limb. Patients were followed closely with aggressive local wound care for at least 14 days. Of the 31 ulcers which healed, the radionuclide study correctly predicted 30; of the 19 ulcers which did not heal, 14 were correctly predicted. Eight patients had osteomyelitis; four of those healed and four did not. The radionuclide study predicted healing in seven. Excluding those patients with osteomyelitis, the sensitivity for the radionuclide angiogram and blood-pool image in predicting healing was 96%, specificity was 87%, and accuracy was 93%. This technique is a simple, reliable way to predict the microcirculatory adequacy for ulcer healing. Specificity is diminished in the presence of osteomyelitis.

Questions regarding the sequential neural generator theory of the somatosensory evoked potential raised by digital filtering

Digital bandpass filtering (300-2500 Hz) designed for zero phase shift was applied to somato-sensory evoked potentials recorded with cephalic bipolar montages. Four consistent negative and corresponding positive peaks with latencies of about 16, 18, 19, and 20 msec were elicited with median nerve stimulation. Peroneal nerve stimulation also elicited 4 reproducible negative-positive peaks having latencies of about 24, 26, 28, and 30 msec. Interpeak latencies measured 1.3 +/- 0.2 msec and 1.8 +/- 0.25 msec for median and peroneal elicited SEPs respectively. Because cephalic bipolar recordings cancel most far-field potentials, multiple generators cannot account for all the additional components seen. It is hypothesized that some of the high frequency components recorded are due to activity in recurrent intrathalamic neuronal networks.