High- versus Low-Spin Ni2+ in Elongated Octahedral Environments: Sr2NiO2Cu2Se2, Sr2NiO2Cu2S2, and Sr2NiO2Cu2(Se1-x S x )2

Sr₂NiO₂Cu₂Se₂, comprising alternating [Sr₂NiO₂]²⁺ and [Cu₂Se₂]^2- layers, is reported. Powder neutron diffraction shows that the Ni²⁺ ions, which are in a highly elongated NiO₄Se₂ environment with D_4h symmetry, adopt a high-spin configuration and carry localized magnetic moments which order antiferromagnetically below ∼160 K in a √2a × √2a × 2c expansion of the nuclear cell with an ordered moment of 1.31(2) μ_B per Ni²⁺ ion. The adoption of the high-spin configuration for this d ⁸ cation in a pseudo-square-planar ligand field is supported by consideration of the experimental bond lengths and the results of density functional theory (DFT) calculations. This is in contrast to the sulfide analogue Sr₂NiO₂Cu₂S₂, which, according to both experiment and DFT calculations, has a much more elongated ligand field, more consistent with the low-spin configuration commonly found for square-planar Ni²⁺, and accordingly, there is no evidence for magnetic moment on the Ni²⁺ ions. Examination of the solid solution Sr₂NiO₂Cu₂(Se_1-x S _x )₂ shows direct evidence from the evolution of the crystal structure and the magnetic ordering for the transition from high-spin selenide-rich compounds to low-spin sulfide-rich compounds as a function of composition. Compression of Sr₂NiO₂Cu₂Se₂ up to 7.2 GPa does not show any structural signature of a change in the spin state. Consideration of the experimental and computed Ni²⁺ coordination environments and their subtle changes as a function of temperature, in addition to transitions evident in the transport properties and magnetic susceptibilities in the end members, Sr₂NiO₂Cu₂Se₂ and Sr₂NiO₂Cu₂S₂, suggest that simple high-spin and low-spin models for Ni²⁺ may not be entirely appropriate and point to further complexities in these compounds.

Repair of oesophageal atresia by consultants and supervised trainees results in similar outcomes

INTRODUCTION

Consultants and trainees require exposure to complex cases for maintaining and gaining operative experience. Oesophageal atresia (OA) repair is a neonatal surgical procedure with indicative numbers for completion of training. A conflict of interest may exist between adequate training, maintaining consultant experience and achieving good outcomes. We aimed to review outcomes of procedures performed primarily by trainees and those performed by consultants.

METHODS

We carried out a retrospective case note review of all consecutive infants who underwent surgical repair of OA with distal tracheooesophageal fistula (TOF) between January 1994 and December 2014 at our institution. Only cases that underwent primary oesophageal anastomosis were included. Surgical outcomes were compared between cases that had a trainee and those that had a consultant listed as the primary operator.

RESULTS

One hundred and twenty-two cases were included. A total of 52 procedures were performed by trainees, and 68 by consultants. Two cases were undeterminable and excluded. Infant demographics, clinical characteristics and duration of follow-up were similar between groups. All infants survived to discharge. Procedures performed by trainees and those performed by consultants as primary operators had a similar incidence of postoperative pneumothorax (trainees 4, consultants 3; p=0.46), anastomotic leak (trainees 5, consultants 3; p=0.29) and recurrent TOF (trainees 0, consultants 2; p=0.5). Overall 52% of cases had an anastomotic dilatation during follow-up, with no difference between the trainee and consultant groups (50% vs 53%; p=0.85).

CONCLUSIONS

Surgical outcomes for repair of OA/TOF are not adversely affected by trainee operating. Trainees with appropriate skills should perform supervised OA/TOF repair. These data are important for understanding the interrelationship between provision of training and surgical outcomes.

Depression in physical illness

Depressive illnesses are common in the general population and are significantly more common in those with physical illnesses. The symptoms of depression may go unrecognised in medical patients, with consequent under-diagnosis and under-treatment. Co-morbid depression is associated with increased morbidity, poorer function, increased healthcare costs and increased mortality. Depressive illnesses are amenable to treatment by both pharmacological and psychological means. Successful treatment can result in improved quality of life as well as improved function, mortality and overall outcome in the physical disorder. It is therefore important that medical doctors are aware of the symptoms, diagnosis and management of depressive illness.

Extending the clinical research network approach to all of healthcare

The development of Clinical Research Networks (CRN) has been central to the work conducted by Health Departments and research funders to promote and support clinical research within the NHS in the UK. In England, the National Institute for Health Research has supported the delivery of clinical research within the NHS primarily through CRN. CRN provide the essential infrastructure within the NHS for the set up and delivery of clinical research within a high-quality peer-reviewed portfolio of studies. The success of the National Cancer Research Network is summarized in Chapter 5. In this chapter progress in five other topics, and more recently in primary care and comprehensively across the NHS, is summarized. In each of the 'topic-specific' networks (Dementias and Neurodegenerative Diseases, Diabetes, Medicines for Children, Mental Health, Stroke) there has been a rapid and substantial increase in portfolios and in the recruitment of patients into studies in these portfolios. The processes and the key success factors are described. The CRN have worked to support research supported by pharmaceutical, biotechnology and medical device companies and there has been substantial progress in improving the speed, cost and delivery of these 'industry' studies. In particular, work to support the increased speed of set up and delivery of industry studies, and to embed this firmly in the NHS, was explored in the North West of England in an Exemplar Programme which showed substantial reductions in study set-up times and improved recruitment into studies and showed how healthcare (NHS) organizations can overcome delays in set up times when they actively manage the process. Seven out of 20 international studies reported that the first patient to be entered anywhere in the world was from the UK. In addition, the CRN have supported research management and governance, workforce development and clinical trials unit collaboration and coordination. International peer reviews of all of the CRN have been positive and resulted in the continuation of the system for a further 5 years in all cases.

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

BACKGROUND

Patients whose symptoms are 'unexplained by disease' often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation.

METHOD

The Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as 'not at all' or only 'somewhat explained' by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale ('much better' to 'much worse') 1 year later.

RESULTS

The 12-month outcome data were available on 716 of 1144 patients (63%). Poor outcome on the CGI ('unchanged', 'worse' or 'much worse') was reported by 482 (67%) out of 716 patients. The only strong independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95% CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30, 95% CI 1.37-3.86). Together, these factors predicted 13% of the variance in outcome.

CONCLUSIONS

Of the patients, two-thirds had a poor outcome at 1 year. Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.

Identification of superoxide dismutase as a potential urinary marker of carbon tetrachloride-induced hepatic toxicity

The aim of this study was the identification of a novel protein marker of hepatotoxicity in rat urine. Rats were dosed by gavage with carbon tetrachloride (CCl(4)) to induce acute liver injury. Surface enhanced laser desorption/ionisation (SELDI) ProteinChip technology revealed the appearance of a 15.7 kDa protein in the CCl(4)-treated rat urine. One-dimensional sodium dodecyl sulphate polyacrylamide electrophoresis (SDS-PAGE) identified an 18.4 kDa protein in the CCl(4)-treated rat urine. The appearance of either protein was coincident over a time course during which they first appeared at 12h post-dosing, peaked at 36h and had disappeared again within 3 days post-dosing. The protein was identified by in-gel digestion and nano-electrospray (nano-ES)-tandem mass spectrometry as Cu/Zn superoxide dismutase (SOD-1). SOD activity was found to be increased by 61.4-fold in CCl(4)-treated rat urine. Western blots of tissue homogenates from the rats revealed a time-dependent loss of SOD-1 from the livers of CCl(4)-treated rats matching the time course of SOD-1 appearance in urine. SOD-1 is not specifically located in liver; however, its appearance in urine in response to acute CCl(4)-induced hepatotoxicity is a novel finding; this coupled with loss from the liver following injury suggests urinary SOD-1 may be a potential marker of hepatotoxicity.

Factors affecting the outcome of methadone maintenance treatment in opiate dependence

This study aimed to measure the rates of ongoing heroin abuse among patients on methadone maintenance treatment (MMT) and sought to identify patient and treatment characteristics associated with poorer outcome. The study was carried out at an outpatient drug treatment clinic and included all patients who were on the MMT during a three month period in 2004. Treatment response was measured from analysis of opiate positive urine samples. Of the 440 patients, 63% were male and their mean age was 32 years (range 17 to 52 years). 163 patients (37%) had a comorbid psychiatric illness. The average methadone dose was 74 mg. On average, 71% of urine samples were opiate negative. Shorter time in treatment (less than 24 months), lower dose of methadone, cocaine abuse and intermittent benzodiazepine abuse were each found to be significantly associated with lower rates of opiate abstinence. Outcomes were not associated with gender, age and accessing counselling. Dual diagnosed patients tended to have higher rates of abstinence (p = 0.08). MMT clients who abuse cocaine and benzodiazepines are at increased risk of continuing opiate abuse. Higher doses of methadone might be necessary to prevent illicit opiate abuse.

Interventions for varicose veins and leg oedema in pregnancy

BACKGROUND

Pregnancy is presumed to be a major contributory factor in the increased incidence of varicose veins in women, which can in turn lead to venous insufficiency and leg oedema. The most common symptom of varicose veins and oedema is the substantial pain experienced, as well as night cramps, numbness, tingling, the legs may feel heavy, achy, and possibly be unsightly. Treatment of varicose veins are usually divided into three main groups: surgery, pharmacological and non-pharmacological treatments. Treatments of leg oedema comprise mostly of symptom reduction rather than cure and use pharmacological and non-pharmacological approaches.

OBJECTIVES

To assess any form of intervention used to relieve the symptoms associated with varicose veins and leg oedema in pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2006).

SELECTION CRITERIA

Randomised trials of treatments for varicose veins or leg oedema, or both, in pregnancy.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed trials for eligibility, methodological quality and extracted all data.

MAIN RESULTS

Three trials, involving 159 women, were included. VARICOSE VEINS: One trial, involving 69 women, reported that rutoside significantly reduced the symptoms associated with varicose veins (relative risk (RR) 1.89, 95% confidence interval (CI) 1.11 to 3.22). There were no significant differences in side-effects (RR 0.86, 95% CI 0.13 to 5.79) or incidence of deep vein thrombosis (RR 0.17, 95% CI 0.01 to 3.49). OEDEMA: One trial, involving 35 women, reported no significant difference in lower leg volume when compression stockings were compared against rest (weighted mean difference -258.80, 95% CI -566.91 to 49.31). Another trial, involving 55 women, compared reflexology with rest. Reflexology significantly reduced the symptoms associated with oedema (reduction in symptoms: RR 9.09, 95% CI 1.41 to 58.54). There was no evidence of significant difference in the women's satisfaction and acceptability with either intervention (RR 6.00, 95% CI 0.92 to 39.11).

AUTHORS' CONCLUSIONS

Rutosides appear to help relieve the symptoms of varicose veins in late pregnancy. However, this finding is based on one small study (69 women) and there are not enough data presented in the study to assess its safety in pregnancy. It therefore cannot be routinely recommended. Reflexology appears to help improve symptoms for women with leg oedema, but again this is based on one small study (43 women). External compression stockings do not appear to have any advantages in reducing oedema.

Oral calorie supplements for cystic fibrosis

BACKGROUND

Poor nutrition occurs frequently in people with cystic fibrosis (CF) and is associated with other adverse outcomes. Oral calorie supplements are used to increase total daily calorie intake and improve weight gain. However, they are expensive and there are concerns they may reduce the amount of food eaten and not improve overall energy intake.

OBJECTIVES

To establish whether in people with CF, oral calorie supplements: increase daily calorie intake; and improve overall nutritional intake, nutritional indices, lung function, survival and quality of life. To assess adverse effects associated with using these supplements.

SEARCH STRATEGY

We searched the Cochrane CF Trials Register comprising references from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We contacted companies marketing oral calorie supplements. Last search: October 2006.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing use of oral calorie supplements for at least one month to increase calorie intake with no specific intervention or additional nutritional advice in people with CF.

DATA COLLECTION AND ANALYSIS

We independently selected the included trials, assessed methodological quality and extracted data. We contacted the authors of included trials and for two trials obtained additional information.

MAIN RESULTS

Eighteen trials were identified and three, reporting results from 131 participants, were included. There were no significant differences between people receiving supplements or dietary advice alone for change in weight, height, body mass index, z score or other indices of nutrition or growth. Changes in weight (kg) at three, six and twelve months respectively were: WMD 0.32 (95% CI -0.09 to 0.72); WMD 0.47 (95% CI -0.07 to 1.02 ); and WMD 0.16 (-0.68 to 1.00). Total calorie intake was greater in people taking supplements at 12 months, WMD 265.70 (95% CI 42.94 to 488.46). There were no significant differences between the groups for anthropometric measures of body composition, lung function, gastrointestinal adverse effects or activity levels.

AUTHORS' CONCLUSIONS

Oral calorie supplements do not confer any additional benefit in the nutritional management of moderately malnourished children with CF over and above the use of dietary advice and monitoring alone. While nutritional supplements may be used, they should not be regarded as essential. Further randomised controlled trials are needed to establish the role of oral protein energy supplements for the short-term in people with CF and acute weight loss and also for the long-term nutritional management of adults with CF or advanced lung disease, or both.

Phenotypic detection of methicillin resistance in Staphylococcus aureus by disk diffusion testing and Etest on Mueller-Hinton agar

Cefoxitin is increasingly recommended for detection of methicillin resistance in Staphylococcus aureus (MRSA) when using disk diffusion testing. In this study, 95 mecA-negative S. aureus isolates and a highly genetically diverse collection of mecA-positive S. aureus types (n=50) were used to investigate the influence of technical factors such as disk potency, incubation time, and temperature on Mueller-Hinton agar. The use of cefoxitin MIC testing by Etest for the same purpose was investigated under similar conditions. For disk diffusion, the accuracy was high at both 35 degrees C and 36 degrees C using overnight incubation, while incubation at 30 degrees C or 37 degrees C was associated with slightly lower accuracy. Increasing incubation times from 18 to 24 h did not improve accuracy at either temperature. Cefoxitin Etest MICs for mecA-positive strains were 6 mg/liter or higher, while cefoxitin Etest MICs for mecA-negative strains were <or=4 mg/liter. Our findings suggest that the current CLSI zone diameter breakpoints should be adjusted from resistance (R)<or=19 mm to R<or=21 mm. In conclusion, cefoxitin disk diffusion testing and Etest MIC testing can accurately predict the presence of the mecA gene in S. aureus. Testing can be reliably performed using incubation temperatures of 35 to 36 degrees C and incubation times of 18 to 22 h. We suggest MRSA interpretive criteria of susceptible (S)<or=4 mg/liter and R>4 mg/liter, corresponding to S>or=22 mm and R<or=21 mm for the 30-microg disk and S>or=17 mm and R<or=16 mm for the 10-microg cefoxitin disk. These criteria resulted in only one mecA-positive isolate being misclassified as susceptible.

Epidural versus non-epidural or no analgesia in labour

BACKGROUND

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. However, there are concerns regarding unintended adverse effects on the mother and infant.

OBJECTIVES

To assess the effects of all modalities of epidural analgesia (including combined -spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (June 2005).

SELECTION CRITERIA

Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. Data were entered into RevMan and double checked. Primary analysis was by intention-to-treat; sensitivity analyses excluded trials with > 30% of women receiving un-allocated treatment.

MAIN RESULTS

Twenty-one studies involving 6664 women were included, all but one study compared epidural analgesia with opiates. For technical reasons, data on women's perception of pain relief in labour could only be included from one study which found epidural analgesia to offer better pain relief than non-epidural analgesia (weighted mean difference (WMD) -2.60, 95% confidence interval (CI) -3.82 to -1.38, 1 trial, 105 women). However, epidural analgesia was associated with an increased risk of instrumental vaginal birth (relative risk (RR) 1.38, 95% CI 1.24 to 1.53, 17 trials, 6162 women). There was no evidence of a significant difference in the risk of caesarean delivery (RR 1.07, 95% CI 0.93 to 1.23, 20 trials, 6534 women), long-term backache (RR 1.00, 95% CI 0.89 to 1.12, 2 trials, 814 women), low neonatal Apgar scores at five minutes (RR 0.70, 95% CI 0.44 to 1.10, 14 trials, 5363 women), and maternal satisfaction with pain relief (RR 1.18 95% CI 0.92 to 1.50, 5 trials, 1940 women). No studies reported on rare but potentially serious adverse effects of epidural analgesia.

AUTHORS' CONCLUSIONS

Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.

Vibroacoustic stimulation for fetal assessment in labour in the presence of a nonreassuring fetal heart rate trace

BACKGROUND

Fetal vibroacoustic stimulation is a simple, non-invasive technique where a device is placed on the maternal abdomen over the region of the fetal head and sound is emitted at a predetermined level for several seconds. It is hypothesized that the resultant startle reflex in the fetus and subsequent fetal heart rate acceleration or transient tachycardia following vibroacoustic stimulation provide reassurance of fetal well-being. This technique has been proposed as a tool to assess fetal well-being in the presence of a non-reassuring cardiotocographic trace during the first and second stages of labour.

OBJECTIVES

To evaluate the clinical effectiveness and safety of vibroacoustic stimulation in the assessment of fetal well-being during labour, compared with mock or no stimulation for women with a singleton pregnancy exhibiting a non-reassuring fetal heart rate pattern.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), MEDLINE (January 1966 to January 2005), EMBASE (January 1966 to January 2005) and reference lists of all retrieved articles. We sought unpublished trials and abstracts submitted to major international congresses and contacted expert informants.

SELECTION CRITERIA

All published and unpublished randomised trials that compared maternal and fetal/neonatal/infant outcomes when vibroacoustic stimulation was used to evaluate fetal status in the presence of a non-reassuring cardiotocographic trace during labour, compared with mock or no stimulation.

DATA COLLECTION AND ANALYSIS

Two independent review authors identified potential studies from the literature search and assessed them for methodological quality and appropriateness of inclusion, using a data extraction form. Attempts to contact study authors for additional information were unsuccessful.

MAIN RESULTS

The search strategies yielded six studies for consideration of inclusion. However, none of these studies fulfilled the requirements for inclusion in this review.

AUTHORS' CONCLUSIONS

There are currently no randomised controlled trials that address the safety and efficacy of vibroacoustic stimulation used to assess fetal well-being in labour in the presence of a non-reassuring cardiotocographic trace. Although vibroacoustic stimulation has been proposed as a simple, non-invasive tool for assessment of fetal well-being, there is insufficient evidence from randomised trials on which to base recommendations for use of vibroacoustic stimulation in the evaluation of fetal well-being in labour in the presence of a non-reassuring cardiotocographic trace.

Evaluation of cefoxitin 5 and 10 μg discs for the detection of methicillin resistance in staphylococci

OBJECTIVE

To evaluate cefoxitin 5 and 10 microg discs for detection of methicillin resistance in staphylococci.

METHODS

Six hundred and forty-one Staphylococcus aureus (261 mecA-negative and 380 mecA-positive) and 344 coagulase-negative staphylococci (CoNS) (132 mecA-negative and 212 mecA-positive) were investigated. The CoNS represented nine species, Staphylococcus epidermidis being the most frequent (n = 231). All isolates were tested using semi-confluent growth on Iso-Sensitest agar (ISA), and Mueller-Hinton agar (MH) using a 5 and a 10 microg cefoxitin disc and overnight incubation in ambient air at 35-37 degrees C.

RESULTS

For S. aureus, both cefoxitin discs performed with high accuracy on both media. The sensitivity and specificity for the following proposed interpretive zone diameters were: ISA 5 microg, R < 14 mm (99.5% and 98.1%); ISA 10 microg, R < 22 mm (99.5% and 98.1%); MH 5 microg, R < 12 mm (99.7% and 98.1%); and MH 10 microg, R < 18 mm (99.5% and 98.9%), respectively. All four variants were superior to oxacillin using the former SRGA methodology. In CoNS, a substantial overlap was seen for all variants. However, by avoiding primary interpretation in the overlapping interval, highly accurate results could be obtained for 81%, 80%, 91% and 97% of the isolates, respectively.

CONCLUSION

For S. aureus, cefoxitin 5 and 10 microg discs performed with high accuracy on both ISA and MH using semi-confluent growth and standard incubation conditions. With the introduction of a defined interval in which primary interpretation should be avoided, the method could also be used for CoNS.

Relapse into mania or depression following lithium discontinuation: a 7-year follow-up

OBJECTIVE

We aimed to assess whether outcome followed a worse course after acute lithium withdrawal.

METHOD

Data were acquired by review of the clinical records on 14 cases and 28 controls matched for age, gender and time on lithium for about 7 years following discontinuation.

RESULTS

Significant differences were found between cases and controls. Cases experienced more episodes of depression and total affective relapse. The log-rank test revealed a significantly lower survival probability in cases than controls (P < 0.0009). However, the increased risk of recurrence was largely confined to the interval immediately after lithium discontinuation.

CONCLUSION

These results confirm that acute discontinuation of lithium leads to a high immediate relapse rate. Most of the excess morbidity over 7 years appears to be attributable to the first episode following discontinuation. Outcome was not worsened by discontinuation.

Evaluation of a cefoxitin 30 microg disc on Iso-Sensitest agar for detection of methicillin-resistant Staphylococcus aureus

OBJECTIVES

To evaluate the performance of a cefoxitin 30 microg disc on Iso-Sensitest agar, using a semi-confluent inoculum and overnight incubation at 35-36 degrees C, for detection of methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

A total of 457 S. aureus, including 190 MRSA of several defined PFGE types and a number of low-level resistant isolates, were tested with a cefoxitin 30 microg disc on Iso-Sensitest agar, using a semi-confluent inoculum and overnight incubation at 35-36 degrees C. This method was compared with the standard SRGA (Swedish Reference Group for Antibiotics) method (oxacillin 1 microg disc on Iso-Sensitest agar supplemented with 5% defibrinated horse blood, confluent growth and 24 h incubation in ambient air at 30 degrees C).

RESULTS

The cefoxitin method was excellent, with a sensitivity of 100% and a specificity of 99% using an interpretative zone diameter of S > or = 29 mm and R < 29 mm. Its performance was much better than the SRGA method, which with this collection of difficult strains had a sensitivity of only 78% using the current breakpoint of S > or = 12 mm.

CONCLUSION

We suggest that the cefoxitin method should replace that currently recommended by the SRGA for the detection of MRSA, and that it would fit well into BSAC methodology.

Markers of experimental acute inflammation in the Wistar Han rat with particular reference to haptoglobin and C-reactive protein

C-reactive protein (CRP), haptoglobin (Hp) and fibrinogen (Fbgn) are acute phase reactants (APRs), the blood levels of which increase during acute inflammation. However, although the levels of these APRs are used to monitor inflammation in man, their usefulness and sensitivity as markers of inflammation in rodents are less clear. We therefore wished to evaluate, in a comparative fashion, a prototype immunoassay for serum CRP, a commercial assay for serum Hp, and an automated assay for Fbgn, using a model of acute inflammation in the rat. Additionally, pro-inflammatory cytokines and serum protein fractions were also measured. The model of inflammation used was the intraperitoneal injection of Freund's complete adjuvant (FCA). In a concluding experiment, findings with Hp in the FCA rat model were validated in a toxicologically relevant study involving the induction of acute hepatic inflammation using the model hepatotoxicant carbon tetrachloride (CCl(4)). Female Wistar Han rats were treated with a single injection of FCA in a dose-response study (1.25-10.0 ml/kg, sampling at 36 h) and two time-course studies (over 40 h and 21 days). In a final experiment, rats were dosed with CCl(4) at 0.8 ml/kg and sampled over a 17-day period. In FCA and CCl(4) experiments, serum/plasma was prepared and tissues taken at autopsy for histological assessment (CCl(4) study only). In the dose-response study, serum CRP, Hp and plasma Fbgn were increased at all FCA dose levels at 36 h post-dosing. Serum alpha(2) and beta(1) globulin fractions were also increased, while albumin levels were decreased. In the 40-h time-course study, CRP levels peaked at 25-40 h post-dosing, to approximately 120% of control (as 100%). Hp levels increased to a maximum at 25 and 40 h post-dosing with values greater than 400% of control, and alpha(2) and beta(1) globulin fractions peaked at 30 and 40 h post-dosing to 221 and 187% of control, respectively. Increased serum interleukin-6 (IL-6) and interleukin-1beta (IL-1beta) levels peaked at 20 h (11-fold) and 25 h (19-fold), respectively. In a 21-day time-course study, no increased CRP levels were measured despite elevated levels of Hp, which peaked at 36 h (approximately 7-fold above control), and remained elevated up to 21 days. IL-6 and IL-1beta levels peaked at 12 h (19-fold) and 24 h (28-fold), respectively. Liver histopathology of animals treated with CCl(4) showed centrilobular hepatocellular degeneration and necrosis (most significant at 36 h) with an inflammatory response (most significant at 48 h). Resolution of the lesion was complete by 4 days post-dosing. Serum alanine aminotransferase, aspartate aminotransferase and glutamate dehydrogenase levels peaked at 36 h post-dosing. Hp levels increased maximally at 48 h (426% of control). We conclude that serum CRP is a poor marker of acute inflammation in the rat in comparison with serum Hp and plasma Fbgn. Between Hp and Fbgn, serum Hp is shown to be the most sensitive and useful marker of acute inflammation.

Old age pension reform in China's state-owned enterprises

The old-age pension scheme in China's state-owned enterprises (SOEs) is experiencing a difficult transition period; in the past, SOEs were responsible for providing retirees with pension benefits. However, in the 1980s and 1990s, the financial position of SOEs deteriorated, making it difficult for them to honor their social welfare commitments. The background of the current pension crisis is examined, and recent attempts to improve the funding of pensions in China's state-owned sector are reviewed, focusing on the period since the State Council issued its "Decision on the Establishment of Unified Pension Insurance" in 1997. The article concludes with a review of priorities for further reform.

Trends in passive smoking in cystic fibrosis, 1993-1998

We set out to study trends in exposure to passive smoking in children with cystic fibrosis over a 5-year period. We also evaluated the effects of this exposure on lung function. Cross-sectional data were collected on 52 children in 1998 and compared with similar data collected on 56 children in 1993. Within these two groups, there were 34 children who were studied on both occasions. Data collected included: questionnaire information about family smoking habits; forced expiratory volume in 1 sec (FEV1); forced vital capacity (FVC); and measurements of urinary and salivary cotinine levels. Salivary cotinine was more closely related to family smoking behavior than urinary cotinine concentrations (r for salivary cotinine = 0.54, P < 0.001; r for urinary cotinine = 0.37, P = 0.008). In 1993, 26/56 (46%) households contained at least one smoker (smoking households) compared with 23/52 (44%) in 1998. In 1993, a median of 15 cigarettes was smoked/day in smoking households compared to 20 cigarettes/day in 1998. In the longitudinal group, there was a small, nonsignificant reduction in mean urinary cotinine levels (geometric mean, 1993 = 5.03 ng/mL; 1998 = 4.76 ng/mL; P = 0.4). There was no significant difference between the smoking and nonsmoking households in change in lung function over 5 years (fall in FEV1 in smoking households, 10.3% vs. 11.2% in nonsmoking households; P = 0.87). We conclude that in a group of children with cystic fibrosis followed over 5 years, there was little reduction in passive smoking exposure. We did not show a relationship between such exposure and decline in lung function. A larger study will be necessary to determine whether such an effect is present. .

Two ecological universes separated by the Dingo Barrier Fence in semi-arid Australia: interactions between landscapes, herbivory and carnivory, with and without dingoes

This paper challenges conclusions of Caughley et al. (1980) that the abundance of red kangaroos (Macropus rufus) in western New South Wales is solely due to lack of dingoes (Canis lupus dingo), and vice versa for neighbouring South Australia. A Dingo Barrier Fence divides the two different ecological systems, which have sheep in New South Wales and cattle in South Australia. This paper re-examines in particular whether there is an environmental gradient across the Fence that was dismissed by Caughley et al. This paper concludes to the contrary, that there is a strong environmental gradient. Our aerial surveys demonstrate significantly that habitats favouring red kangaroos are prevalent in New South Wales today, but are very scarce or absent in South Australian landscapes. Aerial surveys were used in both studies, but designs differed. Caughley et al. flew at right angles across the Fence on paths 28 km apart. Flights would have crossed the south-westerly streamlines rarely. Our flight lanes followed streamlines looking for floodouts, the favourite habitat of red kangaroos. Return lanes went between streamlines sampling other habitats. Counts of red kangaroos seen were made every 1.75 km, with the specific habitat also identified. Three extra factors are invoked in our study. One is that the low annual rainfalls translate into intrinsically low survival rates of pouch-young of red kangaroos, contrary to their abundance in New South Wales today. The other two are related to that current abundance also. There is now evidence for greatly increased run-off of rainfall from catchments onto the open plains in New South Wales. Also present is a very large shallow basin lying between catchments and the Dingo Barrier Fence. Streamlines enter it but none flow past its western rim. The above conclusions were confirmed during subsequent ground surveys over three years. Of eleven species of medium and large vertebrates seen in New South Wales, five were absent in South Australia. Three were kangaroos, and the others were feral pigs and goats. Emus are more abundant in New South Wales also. All of those species would be targets for dingoes, especially as alternate prey to rabbits that generate huge eruptions every decade or so. Red foxes (Vulpes vulpes) were in lower abundance in South Australia with dingoes present, as expected with meso-predator interactions. Feral cats (Felis catus) were in similar numbers on both sides of the Fence for unknown reasons. Competition between rabbits (Oryctolagus cuniculus) and sheep for food in New South Wales was shown to significantly reduce rabbit numbers in drought. That rabbits are perennially in lower densities there than in South Australia may be due to the higher densities of foxes than in South Australia. Historically, red kangaroos were rare in the region in the mid-1800s. Their abundance has arisen since European occupation. Thc species was rare on those open plains, and permanent water was scarce. Rabbit Haemorrhagic Disease reached the study-area in 1995. Its impact reduced rabbit populations to a rarity that prevails today on both sides of the Dingo Fence. Predation from dingoes, foxes and feral cats may assist continuance of low numbers of rabbits. Pastures, seedling trees and livestock will benefit, as will the kangaroos.

Fetal vibroacoustic stimulation for facilitation of tests of fetal wellbeing

BACKGROUND

Acoustic stimulation of the fetus has been suggested to improve the efficiency of antepartum fetal heart rate testing.

OBJECTIVES

The objective of this review was to assess the merits or adverse effects of the use of fetal vibroacoustic stimulation in conjunction with tests of fetal wellbeing.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: October 2000.

SELECTION CRITERIA

All published and unpublished randomized controlled trials assessing the merits of the use of fetal vibroacoustic stimulation in conjunction with tests of fetal wellbeing.

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trial quality. Authors of published and unpublished trials were contacted for further information.

MAIN RESULTS

A total of seven trials with a total of 4325 participants were included. Fetal vibroacoustic stimulation reduced the incidence of non-reactive antenatal cardiotocography test (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.49-0.75) and reduced the overall mean cardiotocography testing time (weighted mean difference (WMD) -4.55 minutes, 95% CI -5.96 minutes to -3.14 minutes). Vibroacoustic stimulation evoked more than mock stimulation when used in conjunction with fetal heart rate testing (OR 0.08, 95% CI 0.06-0.12).

REVIEWER'S CONCLUSIONS

Vibroacoustic stimulation offers benefits by decreasing the incidence of non-reactive cardiotocography and reducing the testing time. Further randomized trials should be encouraged to determine not only the optimum intensity, frequency, duration and position of the vibroacoustic stimulation, but also to evaluate the efficacy, predictive reliability, safety and perinatal outcome of these stimuli with cardiotocography and other tests of fetal wellbeing.

Idiopathic pulmonary fibrosis in infants: good prognosis with conservative management

BACKGROUND

Pulmonary interstitial fibrosis in children is a disease of unknown aetiology, usually associated with a poor prognosis.

METHODS

In this case series we describe 11 children presenting over a 10 year period, managed conservatively and associated with a good prognosis.

RESULTS

In six, symptoms were present from birth and 10 had symptoms at or before 3 months. Diagnosis was made using chest computed tomography and percutaneous lung biopsy. All patients were treated with oral prednisolone. In five no steroid response was noted. One patient responded to hydroxychloroquine. Home oxygen was required in five patients. At follow up all patients are alive at a median age of 6 years (range 1 to 12 years). The two recently diagnosed children have significant symptoms, seven have dyspnoea on exercise, and two are symptom free.

CONCLUSION

The good prognosis seen in these patients is different to previous case reports, indicating a greater than 50% mortality.

A nursing career in the Royal Navy

In 1987, after having worked for 12 months in a busy Birmingham hospital, I decided to do something challenging by joining the Queen Alexandra's Royal Naval Nursing Services (QARNNS).

Vaccines for preventing influenza in people with cystic fibrosis

BACKGROUND

Viral respiratory tract infections in patients with cystic fibrosis have a deteriorating effect on their lung function and disease progression. Annual influenza vaccination is therefore commonly recommended for patients with cystic fibrosis.

OBJECTIVES

To assess the effectiveness of influenza vaccination for patients with cystic fibrosis.

SEARCH STRATEGY

We have used the Cochrane Cystic Fibrosis and Genetic Disorders Group specialist trials register which comprises references identified from comprehensive electronic database searches, hand searching relevant journals and abstract books of conference proceedings and communication to the drug companies marketing influenza vaccines.

SELECTION CRITERIA

All randomised and pseudorandomised trials (published or unpublished) comparing any influenza vaccine with a placebo or with another type of influenza vaccine.

DATA COLLECTION AND ANALYSIS

Both reviewers independently assessed trial quality and extracted data. Additional information were obtained by contacting the investigators when it was indicated.

MAIN RESULTS

Three trials enrolling a total of 115 patients with cystic fibrosis (76 (66%) were children aged one to 13 years) were included in this review. There was no study comparing a vaccine to a placebo or a whole virus vaccine to a sub unit or split virus vaccine. Two studies compared an intranasal applied live vaccine to an intramuscular inactivated vaccine and one study compared a split virus to a sub unit vaccine (both intramuscular). The incidence of all reported adverse events was high depending on the type of influenza vaccine. The total adverse event rate ranged from 48/201 (24%) for the intranasal live vaccine to 13/30 (43%) for the split virus vaccine. With the limitation of a statistical low power there was no significant difference between the study vaccinations. None of the events were severe. All study influenza vaccinations generated a satisfactory serological antibody response. No trial reported other clinically important benefits.

REVIEWER'S CONCLUSIONS

There is currently no evidence from randomised studies that influenza vaccine given to patients with cystic fibrosis is of benefit to them. There is a need for a well constructed clinical study, that assesses the effectiveness of influenza vaccination on important clinical outcome measures.

Ursodeoxycholic acid for cystic fibrosis-related liver disease

BACKGROUND

Cystic fibrosis-related liver disease peaks in adolescence with up to 20% of patients developing chronic liver disease. Early changes in the liver may ultimately result in end stage liver disease with patients needing transplantation. One therapeutic option currently used is ursodeoxycholic acid.

OBJECTIVES

To assess the effectiveness of ursodeoxycholic acid in cystic fibrosis liver disease.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register, and contacted drug companies. Date of the most recent search of the Group's specialised register: June 1999.

SELECTION CRITERIA

Randomised and quasi-randomised trials of use of ursodeoxycholic acid for at least three months compared with placebo or no additional treatment in people with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and quality.

MAIN RESULTS

Three trials involving 118 patients were included. The complex study design used in two trials meant that data could only be analysed for subsets of patients. There was no difference in weight change (weighted mean difference -0.496, 95% confidence interval -1.545 to +0.553) based on 30 patients from two trials. Improvement in biliary excretion was reported in only one study and no significant change after treatment was shown. Long term outcomes such as death or need for liver transplantation were not reported.

REVIEWER'S CONCLUSIONS

There are few trials assessing the effectiveness of ursodeoxycholic acid. There is insufficient evidence to justify is its routine use in cystic fibrosis.

Oral calorie supplements for cystic fibrosis

BACKGROUND

Poor nutrition occurs frequently in children and adults with cystic fibrosis and is associated with a number of other adverse outcomes. Oral calorie supplements are used to try and increase total daily calorie intake and improve weight gain. However, they are expensive and there are concerns that they may lead to a reduction in the amount of food eaten and no overall improvement in energy intake.

OBJECTIVES

To examine the evidence that in patients with cystic fibrosis, oral calorie supplements increase daily calorie intake, improve overall nutritional intake, nutritional indices, lung function, survival and quality of life. To assess possible adverse effects associated with use of oral calorie supplements.

SEARCH STRATEGY

The Cochrane Cystic Fibrosis and Genetic Disorders Group specialist trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings. The companies which market oral calorie supplements were also contacted. Date of the most recent search of the Group's specialised register: November 1999.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing use of oral calorie supplements for at least one month to increase calorie intake with no specific intervention or additional nutritional advice in patients with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

The following outcomes were assessed: indices of nutrition and growth, anthropometric measures of body composition, calorie intake (total, from oral calorie supplements and from food), nutrient intake, eating behaviour, quality of life, specific adverse effects, lung function and mortality.

MAIN RESULTS

Two trials which reported results from a total of 29 patients were suitable for inclusion in the review. From the data provided in the published reports only one item (change in weight) could be extracted from one trial for inclusion in the review. This showed no difference between intervention and comparison group.

REVIEWER'S CONCLUSIONS

Oral calorie supplements are very widely used around the world in an attempt to improve nutritional status in patients with cystic fibrosis, at some considerable cost. It is therefore very disappointing that their effectiveness has not been assessed by adequate clinical trials. No conclusions can be made about the use of oral calorie supplements in cystic fibrosis from the information currently available and clinicians must balance potential benefits against possible adverse effects of treatment in making decisions about individual patients. This systematic review has clearly identified the need for a well designed, adequately-powered, multicentre, randomised controlled trial assessing the effectiveness and possible adverse effects of oral calorie supplements in cystic fibrosis.

Oral steroids for cystic fibrosis

BACKGROUND

In cystic fibrosis, airway obstruction and recurrent respiratory infection leads to inflammation and eventually long term lung damage, (bronchiectasis), respiratory failure and death. Inflammation occurs early in the disease process, hence the rationale for the use of anti-inflammatory agents such as oral steroids.

OBJECTIVES

To assess the effectiveness of oral steroids in management of respiratory complications cystic fibrosis with particular regard to lung function and occurrence of adverse events. We aimed to to examine short term use for a respiratory exacerbation separately (up to 30 days) from long term anti-inflammatory use (greater than 30 days).

SEARCH STRATEGY

We searched The Cochrane Cystic Fibrosis and Genetic Disorders Group specialist trials register. Date of the most recent search of the Group's specialised register: November 1999.

SELECTION CRITERIA

All randomised or pseudorandomised trials comparing oral corticosteroids given for a period of five to 30 days for treatment of an exacerbation or for more than 30 days used long term, with placebo or no additional therapy in patients with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and quality.

MAIN RESULTS

Three trials were identified studying a total of 354 patients. Two of these were long term trials with four year follow up whilst one had follow up to 12 weeks only. There was a lack of data on our predefined outcomes with common outcomes examined at different time-points and also variations in the presentation of common outcomes. A meta-analysis was not possible. Oral corticosteroids at a prednisolone equivalent dose of 1 mg/kg alternate days appear to slow the progression of lung disease in cystic fibrosis. At 24 months from commencement, 70.4% patients treated with 1mg/kg prednisolone on alternate days had an increase in per cent predicted forced vital capacity (FVC) compared to 41.6% patients treated with placebo. The mean absolute change in per cent predicted forced expiratory volume at one second (FEV1) 48 months from commencement was -2% in the 1 mg/kg alternate days prednisolone group but -6% in the placebo group. In the long term, this benefit needs to be weighed against the occurrence of adverse events. Linear growth retardation was observed as early as six months from start of treatment in the 2 mg/kg alternate days prednisolone group and from 24 months of treatment in the 1 mg/kg alternate days prednisolone group. Occurrence of adverse events, particularly glucose abnormalities, cataracts and growth retardation resulted in early termination of one of the four year studies ( approximately approximately Eigen 1995 approximately approximately ), with the group taking 2 mg/kg prednisolone on alternate days being stopped first but followed by the 1 mg/kg alternate days.

REVIEWER'S CONCLUSIONS

Oral corticosteroids at a prednisolone equivalent dose of 1-2 mg/kg alternate days appear to slow the progression of lung disease in CF but this benefit needs to be weighed against the occurrence of adverse events, in particular, development of cataracts and effect on linear growth. A risk/benefit analysis of low-dose alternate days corticosteroids would be important and the role of short term use of oral steroids should be more fully evaluated.

Phonological activation in anaphoric lexical access (ALA)

Simner and Smyth (1998) propose that anaphoric lexical access (ALA) occurs at an anaphor and targets the lexical entry (specifically, the lemma) of the antecedent. Since the word frequency effect (e.g., Rubenstein et al., 1970) resides at the lexeme (Jescheniak & Levelt, 1994) Simner and Smyth predict, and subsequently illustrate, that ALA exhibits no frequency effect. A problem arises, however: if ALA does not access the lexeme, how do we account for phonological priming at anaphor sites (e.g., Tanenhaus et al., 1985)? We claim that this is the result of "incidental" lemma-to-lexeme activation. Furthermore, we argue that since lexeme activation is not crucial to anaphor comprehension, anaphor reading times indicate lemma search times only (therefore there is no frequency effect). An experiment is presented demonstrating that lemma-access during ALA can cause incidental lexeme activation without invoking a frequency effect.