Diversity Competence in Healthcare: A minimal definition

Background

Health professionals face a variety of professional challenges in today's plural societies. Sciences propose a specific skill set can help to meet those challenges. Various terms and sometimes extensive concepts are provided for diversity competence. The related learning processes are time-consuming and demanding to implement in hectic clinical realities, so that a basic, easy to deplore training package of essential skills would be desirable in order to enable health professionals to take equally good care of all patients including migrants and minorities.

Methods

A two-round Delphi study was conducted to prioritise teaching objectives; 31 clinical and academic migrant health experts from 13 European countries participated. A round of open questions was followed by a standardised rating round of 65 items. Data was descriptively analysed (m, M, SD) and consensus defined as 80% of experts assigning high importance to a competence.

Results

The process identified essential competences as well as high priority cognitive, affective and pragmatic competences, leading to a minimal definition of diversity competence for health professionals which includes respectfulness, empathy, diversity awareness and reflection, knowledge on social determinants as well as ethics and human rights; Further skills are: being able to listen, observe and communicate understandably, including professional usage of interpreters, shared decision-making and individual, need-based care.

Conclusions

The panel reached consensus on many of the competences. In general, attitudes and practical skills were considered essential. Basic trainings that meet the needs of professionals and help them cope with everyday challenges can be designed on the grounds of these findings.

We provide a working definition of ‘diversity competence of health professionals’ for scientific exchange and investigation and propose the conscious use of a ‘diversity’ instead of ‘intercultural” terminology.

Key messages

The Danish implementation study on response to pregnancy complications, MAMAACT

Differential incidence and severity of pregnancy complications are likely important contributing factors to the increased risk of poor pregnancy outcomes among ethnic minority women in Europe. To address this issue, the MAMAACT trial has been developed based on a thorough mixed methods needs assessment and co-creation process, feasibility tested, now implemented in a nationwide complex intervention. The overall aim of the Danish MAMAACT trial is to reduce ethnic and social disparity in stillbirth and newborns' health by improved management of pregnancy complications. The overall target group is all pregnant women, and the specific target group is women of non-Western origin. The hypothesis of MAMAACT is that improved communication between pregnant women and midwives regarding body symptoms that need prompt reaction will improve perinatal health among these vulnerable groups. The intervention consists of postgraduate training of midwives in intercultural communication and a smart phone application and a leaflet, both in six different languages. The app and leaflet target the women and explain the most serious warning signs of pregnancy complications and how to respond to them.

MAMAACT is implemented and evaluated in a randomized controlled cluster trial and 10 maternity wards consist the intervention groups, while nine maternity wards are the control groups. The evaluation is a mixed method evaluation focusing on understanding the mechanisms of change, how context at both maternity ward level as well as in the everyday life of women affects the implementation, and finally if effects on health literacy of the women and perinatal health of the children can be documented.

A health inequality impact assessment of leveling down overweight and obesity

Background

Social differences in the proportion of overweight and obesity have increased in recent decades. Health impact assessments provide population-level valuations of changes in disease prevalence related to scenarios with different risk factors levels. These scenarios can be focused on reducing overweight and obesity among people with low socioeconomic position.

Methods

This study included the projected population of Copenhagen, Denmark in year 2040 (n = 742,130). Using the DYNAMO-HIA tool we conducted a health inequality impact assessment. Future prevented disease prevalence (IHD, diabetes, stroke, and multi-morbidity) and change in life expectancy related to an equalized scenario were estimated in a scenario where the prevalence of overweight/obesity (OWOB) in the group of people with short and medium educational attainment was reduced to the levels of people with long education.

Results

A higher proportion of people with short and medium education were OWOB than among people with long education and they had higher prevalence of cardiometabolic diseases. The diabetes prevalence among people with short education was reduced by 8-10% for men and 12-13% for women and life expectancy with diabetes decreased by one year in the group of women with short education. No notable effect of the equalized OWOB was seen regarding life expectancy with and prevalence of stroke and IHD.

Conclusions

Reaching the low prevalence of OWOB observed among people with high educational level, will reduce future cardiometabolic disease, increase life expectancy and meanwhile reduce the social inequality in health. These findings can serve as relevant references points for public health planners.

Key messages

This study is the first to combine advanced mathematical modelling and population data to assess changes in health from reducing socioeconomic inequality in obesity and overweight. These results propose valuable reference values for outcome assessments of interventions on inequalities in health.

A randomized, double-blinded, placebo-controlled, parallel trial of vitamin D3 supplementation in adult patients with migraine

BACKGROUND

Vitamin D levels have been linked to certain pain states, including migraine. This study investigated whether vitamin D supplementation would be beneficial for adult patients with migraine (ClinicalTrials.gov Identifier: NCT01695460).

METHODS

A randomized, double-blinded, placebo-controlled parallel trial was conducted in migraine patients (36 women and 12 men, 18-65 years of age). A 4-week baseline period was conducted before randomization to 24 weeks of treatment. Participants were assigned to receive D3-Vitamin (n = 24, 18 women and 6 men, 100 μg/day D3-Vitamin) or placebo (n = 24, 18 women and 6 men). Migraine attacks and related symptoms were assessed by self-reported diaries. The response rate (i.e. experiencing a 50% or greater reduction in migraine frequency from baseline to week 24), change in migraine severity, and number of migraine days were recorded. Changes in migraine-related symptoms, HIT-6^TM scores, and pain sensitivity tests (pressure pain threshold and temporal summation) were also evaluated. Serum levels of both 25 (OH)D and 1,25 (OH)₂D were assessed from baseline to week 24.

RESULTS

The number of headache days changed from 6.14 ± 3.60 in the treatment group and 5.72 ± 4.52 in the placebo group at baseline to 3.28 ± 3.24 and 4.93 ± 3.24 by the end of the trial, respectively. Migraine patients on D3-Vitamin demonstrated a significant decrease (p < .001) in migraine frequency from baseline to week 24 compared with placebo. However, migraine severity, pressure pain thresholds, or temporal summation did not show a significant change. 25(OH)D levels increased significantly for the D3-Vitamin group during the first 12 weeks of treatment. There was no significant change in 1,25(OH)₂D. No side-effects were reported or noted.

CONCLUSIONS

D3-Vitamin was superior to placebo in reducing migraine days in migraine patients. Larger studies are required to confirm that vitamin D₃ might be one of the prophylactic options for adult patients with migraine.

Effectiveness of the "Cancer Home-Life Intervention" on everyday activities and quality of life in people with advanced cancer living at home: a randomised controlled trial and an economic evaluation

Background

During the past decade an increasing number of people live with advanced cancer mainly due to improved medical treatment. Research has shown that many people with advanced cancer have problems with everyday activities, which have negative impact on their quality of life, and that they spend a considerable part of their time at home. Still, research on interventions to support the performance of and participation in everyday activities is only scarcely available. Therefore, the occupational therapy-based “Cancer Home-Life Intervention” consisting of tailored adaptive interventions applied in the participant’s home environment was developed.

The objective of this study is to examine the effectiveness and cost-effectiveness of the Cancer Home-Life Intervention compared to usual care on the performance of and participation in everyday activities and quality of life in people with advanced cancer living at home.

Methods

The study is a randomised, controlled trial (RCT) including an economic evaluation. The required sample size of 272 adults living at home will be recruited from outpatient clinics at two Danish hospitals. They should be diagnosed with cancer; evaluated incurable by the responsible oncologist; and with a functional level 1–2 on the WHO performance scale. The primary outcome is the quality of performance of activities of daily living. Secondary outcomes are problems with prioritised everyday activities; autonomy and participation; and health-related quality of life. Participants are randomly assigned to: a) The Cancer Home-Life Intervention in addition to usual care, and b) Usual care alone.

Discussion

The trial will show whether the Cancer Home-Life Intervention provides better support for people with advanced cancer living at home in performing and participating in everyday activities, and whether it contributes to their health-related quality of life. The economic evaluation alongside the RCT will show if the Cancer Home-Life Intervention is cost-effective. The trial will also show the acceptability of the intervention to the target group, and whether subgroups of participants will benefit more than others.

Trial registration

ClinicalTrials.gov Identifier NCT02356627. Registered 02/02/2015.

Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial

OBJECTIVES

To compare the cost-effectiveness of three types of follow-up for outpatients with stable low-activity rheumatoid arthritis (RA).

METHOD

In total, 287 patients were randomized to either planned rheumatologist consultations, shared care without planned consultations, or planned nurse consultations. Effectiveness measures included disease activity (Disease Activity Score based on 28 joint counts and C-reactive protein, DAS28-CRP), functional status (Health Assessment Questionnaire, HAQ), and health-related quality of life (EuroQol EQ-5D). Cost measures included activities in outpatient clinics and general practice, prescription and non-prescription medicine, dietary supplements, other health-care resources, and complementary and alternative care. Measures of effectiveness and costs were collected by self-reported questionnaires at inclusion and after 12 and 24 months. Incremental cost-effectiveness rates (ICERs) were estimated in comparison with rheumatologist consultations.

RESULTS

Changes in disease activity, functional status, and health-related quality of life were not statistically significantly different for the three groups, although the mean scores were better for the shared care and nurse care groups compared with the rheumatologist group. Shared care and nurse care were non-significantly less costly than rheumatologist care. As both shared care and nurse care were associated with slightly better EQ-5D improvements and lower costs, they dominated rheumatologist care. At EUR 10,000 per quality-adjusted life year (QALY) threshold, shared care and nurse care were cost-effective with more than 90% probability. Nurse care was cost-effective in comparison with shared care with 75% probability.

CONCLUSIONS

Shared care and nurse care seem to cost less but provide broadly similar health outcomes compared with rheumatologist outpatient care. However, it is still uncertain whether nurse care and shared care are cost-effective in comparison with rheumatologist outpatient care.

A three-year follow-up on the efficacy of psychosocial interventions for patients with mild dementia and their caregivers: the multicentre, rater-blinded, randomised Danish Alzheimer Intervention Study (DAISY)

OBJECTIVES

To examine the long-term efficacy at the 36-month follow-up of an early psychosocial counselling and support programme lasting 8-12 months for community-dwelling patients with mild Alzheimer's disease and their caregivers.

DESIGN

Multicentre, randomised, controlled, rater-blinded trial.

SETTING

Primary care and memory clinics in five Danish districts.

PARTICIPANTS

330 home-dwelling patients with mild Alzheimer's disease and their primary caregivers (dyads).

INTERVENTIONS

Dyads were randomised to receive intervention during the first year after diagnosis. Both intervention and control groups had follow-up visits at 3, 6, 12 and 36 months.

MAIN OUTCOME MEASURES

Primary outcomes for the patients assessed at 36-month follow-up were changes from baseline in global cognitive function (Mini-Mental State Examination), depressive symptoms (Cornell Depression Scale) and proxy-rated EuroQoL quality of life on visual analogue scale. The primary outcomes for the caregivers were changes from baseline in depressive symptoms (Geriatric Depression Scale) and self-rated EuroQoL quality of life on a visual analogue scale. The secondary outcome measures for the patient were proxy-rated Quality of Life Scale for Alzheimer's disease (QoL-AD), Neuropsychiatric Inventory-Questionnaire, Alzheimer's disease Cooperative Study Activities of Daily Living Scale, all-cause mortality and nursing home placement.

RESULTS

At a 36-month follow-up, 2 years after the completion of the Danish Alzheimer Intervention Study (DAISY), the unadjusted positive effects previously detected at the 12-month follow-up in one patient primary outcome (Cornell depression score) and one patient secondary outcome (proxy-rated QoL-AD) disappeared (Cornell depression score, p=0.93; proxy-rated QoL-AD, p=0.81). No long-term effect of DAISY intervention on any other primary and secondary outcomes was found at the 36-month follow-up.

CONCLUSIONS

For patients with very mild Alzheimer's disease and their caregivers, an intensive, multi-component, semitailored psychosocial intervention programme with counselling, education and support during the first year after diagnosis did not show any positive long-term effect on primary and secondary outcomes.

TRIAL REGISTRATION

The study was registered in the Clinical Trial Database (http://www.controlled-trials.com/ISRCTN74848736).

Efficacy of psychosocial intervention in patients with mild Alzheimer's disease: the multicentre, rater blinded, randomised Danish Alzheimer Intervention Study (DAISY)

OBJECTIVE

To assess the efficacy at 12 months of an early psychosocial counselling and support programme for outpatients with mild Alzheimer's disease and their primary care givers.

DESIGN

Multicentre, randomised, controlled, rater blinded trial.

SETTING

Primary care and memory clinics in five Danish districts.

PARTICIPANTS

330 outpatients with mild Alzheimer's disease and their 330 primary care givers.

INTERVENTIONS

Participating dyads (patient and primary care giver) were randomised to control support during follow-up or to control support plus DAISY intervention (multifaceted and semi-tailored counselling, education, and support).

MAIN OUTCOME MEASURES

Primary outcomes at 12 months for patients were change from baseline in mini mental state examination (MMSE) score, Cornell depression scale score, and proxy rated European quality of life visual analogue scale (EQ-VAS) score. For care givers, outcomes were change from baseline in geriatric depression scale (GDS 30 items) score and EQ-VAS score.

RESULTS

Because of multiple testing, statistical significance was set at an adjusted P limit of <0.0005. At 12 months there were no significant differences between the two allocation groups in changes from baseline in the primary and secondary outcomes. However, although non-significant with the adjusted P limit, a small difference was observed for one of the primary patient outcomes (Cornell depression scale score) in patients in favour of the DAISY intervention group before and after adjusting for attrition (P = 0.0146 and P = 0.0103 respectively).

CONCLUSIONS

The multifaceted, semi-tailored intervention with counselling, education, and support for patients with mild Alzheimer's disease and their care givers did not have any significant effect beyond that with well structured follow-up support at 12 months after adjustment for multiple comparisons. The small positive effect found in the unadjusted primary outcome addressing depressive symptoms in patients may call for further research focusing on patients with Alzheimer's disease and comorbid depression.

TRIAL REGISTRATION

ISRCTN74848736.

Composition and effect of blending of noncoagulating, poorly coagulating, and well-coagulating bovine milk from individual Danish Holstein cows

The aim of the present investigation was to study the underlying causes of noncoagulating (NC) milk. Based on an initial screening in a herd of 53 Danish Holstein-Friesians, 20 individual Holstein-Friesian cows were selected for good and poor chymosin-induced coagulation properties; that is, the 10 cows producing milk with the poorest and best coagulating properties, respectively. These 20 selected cows were followed and resampled on several occasions to evaluate possible changes in coagulation properties. In the follow-up study, we found that among the 10 cows with the poorest coagulating properties, 4 cows consistently produced poorly coagulating (PC) or NC milk, corresponding to a frequency of 7%. Noncoagulating milk was defined as milk that failed to form a coagulum, defined as increase in the storage modulus (G') in oscillatory rheometry, within 45min after addition of chymosin. Poorly coagulating milk was characterized by forming a weak coagulum of low G'. Milk proteomic profiling and contents of different casein variants, ionic contents of Ca, P and Mg, κ-casein (CN) genotypes, casein micelle size, and coagulation properties of the 4 NC or PC samples were compared with milk samples of 4 cows producing milk with good coagulation properties. The studies included determination of production of caseinomacropeptide to ascertain whether noncoagulation could be ascribed to the first or second phase of chymosin-induced coagulation. Caseinomacropeptide was formed in all 8 milk samples after addition of chymosin, indicating that the first step (cleavage of κ-CN) was not the cause of inability to coagulate. Furthermore, the effect of mixing noncoagulating and well-coagulating milk was studied. By gradually blending NC with well-coagulating milk, the coagulation properties of the well-coagulating samples were compromised in a manner similar to titration. Milk samples from cows that consistently produced NC milk were further studied at the udder quarter level. The coagulation properties of the quarter milk samples were not significantly different from those of the composite milk sample, showing that poor coagulation traits and noncoagulation traits of the composite milk were not caused by the milk quality of a single quarter. The milk samples exhibiting PC or NC properties were all of the κ-CN variant AA genotype, and contained casein micelles with a larger mean diameter and a lower fraction of κ-CN relative to total CN than milk with good coagulation properties. Interestingly, the relative proportions of different phosphorylation forms of α-CN differed between well-coagulating milk and PC or NC milk samples. The PC and NC milk samples contained a lower proportion of the 2 less-phosphorylated variants of α-CN (α(S1)-CN-8P and α(S2)-CN-11P) compared with samples of milk that coagulated well.

Viability of indigenous soil bacteria assayed by respiratory activity and growth

The bacterial population in barley field soil was estimated by determining the numbers of (i) cells reducing the artificial electron acceptor 5-cyano-2,3-ditolyl tetrazolium chloride (CTC) to CTC-formazan (respiratory activity), (ii) cells dividing a limited number of times (microcolony formation) on nutrient-poor media, (iii) cells dividing many times (colony formation) on nutrient-poor agar media, and (iv) cells stained with acridine orange (total counts). The CTC reduction assay was used for the first time for populations of indigenous soil bacteria and was further developed for use in this environment. The number of viable cells was highest when estimated by the number of microcolonies developing during 2 months of incubation on filters placed on the surface of nutrient-poor media. The number of bacteria reducing CTC to formazan was slightly lower than the number of bacteria forming microcolonies. Traditional plate counts of CFU (culturable cells) yielded the lowest estimate of viable cell numbers. The microcolony assay gave an estimate of both (i) cells forming true microcolonies (in which growth ceases after a few cell divisions) representing viable but nonculturable cells and (ii) cells forming larger microcolonies (in which growth continues) representing viable, culturable cells. The microcolony assay, allowing single-cell observations, thus seemed to be best suited for estimation of viable cell numbers in soil. The effect on viable and culturable cell numbers of a temperature increase from 4 to 17 degrees C for 5 days was investigated in combination with drying or wetting of the soil. Drying or wetting prior to the temperature increase, rather than the temperature increase per se, affected both the viable and culturable numbers of bacteria; both numbers were reduced in predried soil, while they increased slightly in the prewetted soil.

Capacity for denitrification and reduction of nitrate to ammonia in a coastal marine sediment

The capacity for dissimilatory reduction of NO(3) to N(2) (N(2)O) and NH(4) was measured in NO(3)-amended marine sediment. Incubation with acetylene (7 x 10 atmospheres [normal]) caused accumulation of N(2)O in the sediment. The rate of N(2)O production equaled the rate of N(2) production in samples without acetylene. Complete inhibition of the reduction of N(2)O to N(2) suggests that the "acetylene blockage technique" is applicable to assays for denitrification in marine sediments. The capacity for reduction of NO(3) by denitrification decreased rapidly with depth in the sediment, whereas the capacity for reduction of NO(3) to NH(4) was significant also in deeper layers. The data suggested that the latter process may be equally as significant as denitrification in the turnover of NO(3) in marine sediments.

Combined oxygen and nitrous oxide microsensor for denitrification studies

The construction of a microsensor which can be used to measure O(2) and N(2)O simultaneously is described. The microsensor exhibited a linear response to both O(2) and N(2)O, and the response to N(2)O was independent of the O(2) concentration and vice versa. The N(2)O detection limit of a microsensor with a tip diameter of 20 mum was around 1 mumol liter. The signals for O(2) and N(2)O were affected by hydrogen sulfide, but other interfering agents were not observed in the biofilms and sediments analyzed. Microprofiles of O(2) and N(2)O were measured in a biofilm which was exposed to acetylene to block the N(2)O reductase activity of denitrifying bacteria. O(2) penetrated about 0.5 mm into the biofilm and was not affected by acetylene, but the N(2)O concentration at 1.4 mm depth increased from 32 to 411 mumol liter after the addition of the inhibitor. The shape of the N(2)O profile after the addition of acetylene showed that denitrification (denitrifying activity) was detectable in all anoxic layers of the biofilm.

Volatile Fatty acids and hydrogen as substrates for sulfate-reducing bacteria in anaerobic marine sediment

The addition of 20 mM MoO(4) (molybdate) to a reduced marine sediment completely inhibited the SO(4) reduction activity by about 50 nmol g h (wet sediment). Acetate accumulated at a constant rate of about 25 nmol g h immediately after MoO(4) addition and gave a measure of the preceding utilization rate of acetate by the SO(4)-reducing bacteria. Similarly, propionate and butyrate (including isobutyrate) accumulated at constant rates of 3 to 7 and 2 to 4 nmol g h, respectively. The rate of H(2) accumulation was variable, and a range of 0 to 16 nmol g h was recorded. An immediate increase of the methanogenic activity by 2 to 3 nmol g h was apparently due to a release of the competition for H(2) by the absence of SO(4) reduction. If propionate and butyrate were completely oxidized by the SO(4)-reducing bacteria, the stoichiometry of the reactions would indicate that H(2), acetate, propionate, and butyrate account for 5 to 10, 40 to 50, 10 to 20, and 10 to 20%, respectively, of the electron donors for the SO(4)-reducing bacteria. If the oxidations were incomplete, however, the contributions by propionate and butyrate would only be 5 to 10% each, and the acetate could account for as much as two-thirds of the SO(4) reduction. The presence of MoO(4) seemed not to affect the fermentative and methanogenic activities; an MoO(4) inhibition technique seems promising in the search for the natural substrates of SO(4) reduction in sediments.

Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial

Background

The aim was to estimate long-term mortality benefits and cost-effectiveness of screening for abdominal aortic aneurysm (AAA) in men aged 64–73 years.

Methods

All men aged 64–73 years living in Viborg County were randomized to be controls (n = 6306) or invited for abdominal ultrasonography at a regional hospital (n = 6333). Mortality and AAA-related interventions were recorded in national databases. The cost of initial screening was based on actual costs of the programme. Incremental cost-effectiveness ratios (ICERs) were calculated on gains in life years and Quality Adjusted Life Years (QALY). Discounting (3 per cent) was applied to both costs and effects, and all costs were adjusted to euros at 2007 prices.

Results

The relative risk reduction of the screening programme in AAA-related mortality was 66 per cent (hazard ratio 0·34, 95 per cent confidence interval (c.i.) 0·20 to 0·57). The corresponding risk reduction in all-cause mortality was 2 per cent (hazard ratio 0·98, 95 per cent c.i. 0·93 to 1·03). The ICER was estimated at €157 (−3292 to 4401) per life year gained and €179 (−4083 to 4682) per QALY gained. Screening was found to be cost effective at a probability above 0·97 for a willingness-to-pay threshold of only €5000. One-way sensitivity analysis demonstrated that this result was robust to various alternative assumptions, as the probability did not drop below 0·90 for any scenario.

Conclusion

The mortality benefit of screening for AAA in men aged 64–73 years was maintained in the longer term and screening was cost effective. Registration number: ISRCTN65822028 (http://www.controlled-trials.com).

Health care costs attributable to the treatment of rheumatoid arthritis

OBJECTIVE

A 'programme budget' for the resources used in the treatment and care of patients with rheumatoid arthritis (RA) was developed with a view of helping decision-makers assess the appropriateness of the current use of resources and to discuss future resource allocation.

METHOD

The programme budget was developed using data from several national administrative registers. Patients with RA were identified by hospital diagnostic codes. The incremental cost of treating RA was defined as the difference in resource use for patients with and without RA. Incremental mortality due to RA was defined in similar way. Cost data were estimated for 5-year age groups.

RESULTS

Patients with RA used on average 3.2 times as many health care resources as people without RA. The average 1997 incremental costs of primary and hospital care were EUR 253 and EUR 2.660 per patient respectively, corresponding to a national incremental cost of EUR 30 million (2000 price level). RA resulted in an annual loss of 1,549 life years.

CONCLUSION

The programme budget approach is a useful tool in resource allocation decision-making, but discussions of alternative resource allocations must be based on robust studies of effectiveness and cost-effectiveness in the treatment of patients with RA.

Papillary muscle rupture as a first event in acute myocardial infarction

Cardiogenic shock caused by papillary muscle rupture in acute myocardial infarction is potentially reversible by surgical treatment. A case of inferior myocardial infarction in a 56-year-old previously healthy man is reported, in which the first event was papillary muscle rupture. The patient was in shock and had a mitral insufficiency murmur. The diagnosis was made by echocardiography and ventriculography. A St. Jude valve was implanted, and the patient was discharged in good health. It is suggested that routine echocardiography be carried out on patients with sudden cardiogenic shock, when a mitral murmur is present.

Cost-effectiveness of a systematic training programme in breast self-examination

Breast self-examination (BSE) appears to be an effective method for earlier detection of breast cancer. The provision of specialized training programmes in BSE may increase the awareness of breast cancer as well as improve the practice of BSE. This study assessed the cost-effectiveness of a BSE programme that a Danish health authority is considering implementing. A model was developed that related the cost of training (of a specified target group) to the anticipated effects of the training. These anticipated effects included increased knowledge of BSE, more routine use of BSE, fewer cases diagnosed with breast cancer where the tumour is larger than 20 mm and fewer cases where the cancer has spread to lymph nodes. The model was calibrated with data synthesized from the literature, own survey data and local expert guess. In the baseline scenario, the incremental cost per person with better knowledge of BSE was estimated to be 106 euro (2002 price level), the cost per person who begins to undertake BSE to be 180 euro, and the cost per person who correctly applies the technique to be 142 euro. The cost per avoided cancer with spreading to lymph nodes was estimated to be 15 410 euro and the cost of avoiding a cancer tumour larger than 20 mm to be 16 318 euro. Sensitivity analysis showed that these cost-effectiveness ratios varied with different assumptions for the effects of BSE training.

Impact of biocontrol strain Pseudomonas fluorescens CHA0 on rhizosphere bacteria isolated from barley (Hordeum vulgare L.) with special reference to Cytophaga-like bacteria

AIMS

To assess the impact of the biocontrol strain Pseudomonas fluorescens CHA0 on a collection of barley rhizosphere bacteria using an agar plate inhibition assay and a plant microcosm, focusing on a CHA0-sensitive member of the Cytophaga-like bacteria (CLB).

METHODS AND RESULTS

The effect of strain CHA0 on a collection of barley rhizosphere bacteria, in particular CLB and fluorescent pseudomonads sampled during a growth season, was assessed by a growth inhibition assay. On average, 85% of the bacteria were sensitive in the May sample, while the effect was reduced to around 68% in the July and August samples. In the May sample, around 95% of the CLB and around 45% of the fluorescent pseudomonads were sensitive to strain CHA0. The proportion of CHA0-sensitive CLB and fluorescent pseudomonad isolates decreased during the plant growth season, i.e. in the July and August samples. A particularly sensitive CLB isolate, CLB23, was selected, exposed to strain CHA0 (wild type) and its genetically modified derivatives in the rhizosphere of barley grown in gnotobiotic soil microcosms. Two dry-stress periods were imposed during the experiment. Derivatives of strain CHA0 included antibiotic or exopolysaccharide (EPS) overproducing strains and a dry-stress-sensitive mutant. Despite their inhibitory activity against CLB23 in vitro, neither wild-type strain CHA0, nor any of its derivatives, had a major effect on culturable and total cell numbers of CLB23 during the 23-day microcosm experiment. Populations of all inoculants declined during the two dry-stress periods, with soil water contents below 5% and plants reaching the wilting point, but they recovered after re-wetting the soil. Survival of the dry-stress-sensitive mutant of CHA0 was most affected by the dry periods; however, this did not result in an increased population density of CLB23.

CONCLUSIONS

CLB comprise a large fraction of barley rhizosphere bacteria that are sensitive to the biocontrol pseudomonad CHA0 in vitro. However, in plant microcosm experiments with varying soil humidity conditions, CHA0 or its derivatives had no major impact on the survival of the highly sensitive CLB strain, CLB23, during two dry-stress periods and a re-wetting period; all co-existed well in the rhizosphere of barley plants.

SIGNIFICANCE AND IMPACT OF THE STUDY

Results indicate a lack of interaction between the biocontrol pseudomonad CHA0 and a sensitive CLB when the complexity increases from agar plate assays to plant microcosm experiments. This suggests the occurrence of low levels of antibiotic production and/or that the two bacterial genera occupy different niches in the rhizosphere.

Application of fluorescence spectroscopy and chemometrics in the evaluation of processed cheese during storage

Front face fluorescence spectroscopy is applied for an evaluation of the stability of processed cheese during storage. Fluorescence landscapes with excitation from 240 to 360 nm and emission in the range of 275 to 475 nm were obtained from cheese samples stored in darkness and light in up to 259 d, at 5, 20 and 37 degrees C, respectively. Parallel factor (PARAFAC) analysis of the fluorescence landscapes exhibits four fluorophores present in the cheese, all related to the storage conditions. The chemometric analysis resolves the fluorescence signal into excitation and emission profiles of the pure fluorescent compounds, which are suggested to be tryptophan, vitamin A and a compound derived from oxidation. Thus, it is concluded that fluorescence spectroscopy in combination with chemometrics has a potential as a fast method for monitoring the stability of processed cheese.

Antibiotic and biosurfactant properties of cyclic lipopeptides produced by fluorescent Pseudomonas spp. from the sugar beet rhizosphere

Cyclic lipopeptides (CLPs) with antibiotic and biosurfactant properties are produced by a number of soil bacteria, including fluorescent Pseudomonas spp. To provide new and efficient strains for the biological control of root-pathogenic fungi in agricultural crops, we isolated approximately 600 fluorescent Pseudomonas spp. from two different agricultural soils by using three different growth media. CLP production was observed in a large proportion of the strains (approximately 60%) inhabiting the sandy soil, compared to a low proportion (approximately 6%) in the loamy soil. Chemical structure analysis revealed that all CLPs could be clustered into two major groups, each consisting of four subgroups. The two major groups varied primarily in the number of amino acids in the cyclic peptide moiety, while each of the subgroups could be differentiated by substitutions of specific amino acids in the peptide moiety. Production of specific CLPs could be affiliated with Pseudomonas fluorescens strain groups belonging to biotype I, V, or VI. In vitro analysis using both purified CLPs and whole-cell P. fluorescens preparations demonstrated that all CLPs exhibited strong biosurfactant properties and that some also had antibiotic properties towards root-pathogenic microfungi. The CLP-producing P. fluorescens strains provide a useful resource for selection of biological control agents, whether a single strain or a consortium of strains was used to maximize the synergistic effect of multiple antagonistic traits in the inoculum.

Pseudomonas fluorescens DR54 Reduces Sclerotia Formation, Biomass Development, and Disease Incidence of Rhizoctonia solani Causing Damping-Off in Sugar Beet

Effects of the biocontrol strain, Pseudomonas fluorescens DR54, on growth and disease development by Rhizoctonia solani causing damping-off in sugar beet were studied in soil microcosms and in pot experiments with natural, clay-type soil. In pot experiments with P. fluorescens DR54-treated seeds, significantly fewer Rhizoctonia-challenged seedlings showed damping-off symptoms than when not inoculated with the biocontrol agent. In the rhizosphere of P. fluorescens DR54 inoculated seeds, the bacterial inoculant was present in high numbers as shown by dilution plating and immunoblotting. By the ELISA antibody technique and direct microscopy of the fungal pathogen grown in soil microcosms, it was shown that the presence of P. fluorescens DR54 on the inoculated seeds had a strong inhibitory effect on development of both mycelium biomass and sclerotia formation by R. solani. In the field experiment, plant emergence was increased by treatment with P. fluorescens DR54 and the inoculant was found to be the dominating rhizosphere colonizing pseudomonad immediately after seedling emergence.

Cyclic lipoundecapeptide amphisin from Pseudomonas sp. strain DSS73

The crystal structure of the lipoundecapeptide amphisin, presented here as the tetrahydrate, C(66)H(114)N(12)O(20).4H(2)O, originating from non-ribosomal biosynthesis by Pseudomonas sp. strain DSS73, has been solved to a resolution of 0.65 A. The primary structure of amphisin is beta-hydroxydecanoyl-D-Leu-D-Asp-D-allo-Thr-D-Leu-D-Leu-D-Ser-L-Leu-D-Gln-L-Leu-L-Ile-L-Asp (Leu is leucine, Asp is aspartic acid, Thr is threonine, Ser is serine, Gln is glutamine and Ile is isoleucine). The peptide is a lactone, linking Thr4 O(gamma) to the C-terminal. The stereochemistry of the beta-hydroxy acid is R. The peptide is a close analogue of the cyclic lipopeptides tensin and pholipeptin produced by Pseudomonas fluorescens. The structure of amphisin is mainly helical (3(10)-helix), with the cyclic peptide wrapping around a hydrogen-bonded water molecule. This lipopeptide is amphiphilic and has biosurfactant and antifungal properties.

Economic evaluation of multidisciplinary pain management in chronic pain patients: a qualitative systematic review

In this qualitative systematic review, we have evaluated studies of the economic effectiveness of multidisciplinary pain treatment in chronic non-malignant pain patients. Published reports were identified from a systematic search of bibliographic databases (MEDLINE and EMBASE) and reference lists of retrieved reports. Fourteen reports of nine studies of patients suffering from back pain, fibromyalgia, and mixed chronic pain conditions were considered to be appropriate as economic analyses. In the selected studies, we found serious methodological problems in study designs and application of outcome measures. The quality of the cost measurements was characterized by an apparent lack of tradition using economic methodology. This review does not give an answer to whether multidisciplinary pain management in chronic pain patients is cost-effective or not. Application of standard methods of costing and outcome measurement are essential before studies of cost-effectiveness in multidisciplinary pain treatment can be used in decision-making and planning.

Axonal elongation through long acellular nerve segments depends on recruitment of phagocytic cells from the near-nerve environment. Electrophysiological and morphological studies in the cat

The distal nerve stump plays a central role in the regeneration of peripheral nerve but the relative importance of cellular and humoral factors is not clear. We have studied this question by freezing the tibial nerve distal to a crush lesion in cat. The importance of constituents from the near-nerve environment was assessed by modification of the contact between the tibial nerve and the environment. Silicone cuffs, containing electrodes for electrophysiological assessment of nerve regeneration, were placed around the tibial nerve distal to the crush site. The interaction between long acellular frozen nerve segments (ANS) and the near-nerve environment was ascertained by breaching the silicone cuff to allow access of cellular or humoral components. Tibial nerves were crushed and frozen for 40 mm and enclosed in nerve cuffs with 0.45-microm holes or 2.0-mm holes to allow access of humoral factors or tissue ingrowth, respectively. In a second set of experiments, tibial nerves were crushed and either frozen for 20+20 mm, leaving a 10 mm segment with viable cells in the center (stepping-stone segment) or frozen for 50 mm. These nerves were enclosed in cuffs with 2.0 mm holes corresponding to the viable nerve segment. The regeneration was monitored electrophysiologically by implanted electrodes and after 2 months the nerves were investigated by light and electron microscopy. The results indicate that soluble substances in the near-nerve environment, such as nutrients, oxygen or tropic substances did not exert any independent beneficial effect on the outgrowing axons. However, phagocytic cells entering the acellular segment from the near-nerve environment were crucial for axonal outgrowth in long ANS.

Toxic effects of linear alkylbenzene sulfonate on metabolic activity, growth rate, and microcolony formation of Nitrosomonas and Nitrosospira strains

Strong inhibitory effects of the anionic surfactant linear alkylbenzene sulfonate (LAS) on four strains of autotrophic ammonia-oxidizing bacteria (AOB) are reported. Two Nitrosospira strains were considerably more sensitive to LAS than two Nitrosomonas strains were. Interestingly, the two Nitrosospira strains showed a weak capacity to remove LAS from the medium. This could not be attributed to adsorption or any other known physical or chemical process, suggesting that biodegradation of LAS took place. In each strain, the metabolic activity (50% effective concentration [EC(50)], 6 to 38 mg liter(-1)) was affected much less by LAS than the growth rate and viability (EC(50), 3 to 14 mg liter(-1)) were. However, at LAS levels that inhibited growth, metabolic activity took place only for 1 to 5 days, after which metabolic activity also ceased. The potential for adaptation to LAS exposure was investigated with Nitrosomonas europaea grown at a sublethal LAS level (10 mg liter(-1)); compared to control cells, preexposed cells showed severely affected cell functions (cessation of growth, loss of viability, and reduced NH(4)(+) oxidation activity), demonstrating that long-term incubation at sublethal LAS levels was also detrimental. Our data strongly suggest that AOB are more sensitive to LAS than most heterotrophic bacteria are, and we hypothesize that thermodynamic constraints make AOB more susceptible to surfactant-induced stress than heterotrophic bacteria are. We further suggest that AOB may comprise a sensitive indicator group which can be used to determine the impact of LAS on microbial communities.

[Diagnostic benefit of gastrointestinal endoscopy in infants under one year of age--a two-year survey]

INTRODUCTION

Gastrointestinal endoscopy in children is a well-established procedure. We reviewed our experience of endoscopy in infants below one year of age to evaluate indications, endoscopic findings, histology, and complications.

MATERIAL AND METHODS

Twenty-eight infants were studied over a two-year period. Of these, 18 underwent upper endoscopy, six recto/sigmoidoscopy or colonoscopy, and four both procedures.

RESULTS

The most common indication (10/22) for upper endoscopy was vomiting and suspicion of gastrooesophageal reflux disease. In these infants, 24-hour continuous monitoring of the oesophageal pH followed the procedure. Indications for lower endoscopy were rectal bleeding (n = 6) and intractable diarrhoea (n = 4). There were no complications to anaesthesia, endoscopy, or biopsy. Overall, there were endoscopic abnormalities in 82% and histological abnormalities in 75% of the infants. The diagnostic findings included rare disorders, such as eosinophilic gastroenteritis, microvillous inclusion disease, and chylomicron retention disease. Diagnosis of these diseases requires gastrointestinal biopsy.

DISCUSSION

Gastrointestinal endoscopy is a safe procedure, which is a valuable part of the diagnostic work-up in a selected group of infants with long-lasting or severe gastrointestinal symptoms.

Structure, production characteristics and fungal antagonism of tensin - a new antifungal cyclic lipopeptide from Pseudomonas fluorescens strain 96.578

AIM

To study the antagonistic activity by Pseudomonas fluorescens strain 96.578 on the plant pathogenic fungus Rhizoctonia solani.

METHODS AND RESULTS

Strain 96.578 produced a new cyclic lipopeptide, tensin. High tensin production per cell was detected in liquid media with glucose, mannitol or glutamate as growth substrate while fructose, sucrose and asparagine supported low production. Tensin production was nearly constant in media with different initial C levels, while low initial N contents reduced production. When applied to sugar beet seeds, strain 96.578 produced tensin during seed germination. When challenged with strain 96.578 or purified tensin, Rhizoctonia solani reduced radial mycelium extension but increased branching and rosette formation.

CONCLUSION

The antagonistic activity of strain 96.578 towards Rhizoctonia solani was caused by tensin.

SIGNIFICANCE AND IMPACT OF THE STUDY

When coated onto sugar beet seeds, tensin production by strain 96.578 could be of significant importance for inhibition of mycelial growth and seed infection by Rhizoctonia solani.

Pseudomonas frederiksbergensis sp. nov., isolated from soil at a coal gasification site

Phenotypic and genotypic characterization indicated that a group of 29 closely related phenanthrene-degrading bacteria from a coal gasification site in Frederiksberg, Copenhagen, Denmark, belonged to the genus Pseudomonas. The strains were isolated at two sampling occasions 2 years apart. The isolates were phenotypically different from any known species of the genus Pseudomonas and were therefore subject to further identification. Colonies were smooth and pale yellowish and did not produce pigments fluorescent in UV light when grown on King's B agar. Cells were rod-shaped, approximately 0.5-0.8 x 1.5-3.0 microm, and grew at 4 and 30 degrees C, but not 37 degrees C. The bacteria were oxidase- and catalase-positive, accumulated poly-beta-hydroxybutyrate and denitrified, but did not utilize D-xylose. The mean G+C content was 59.6 mol%. Phenotypic data and 16S rDNA sequence data information for Pseudomonas amygdali and Pseudomonas corrugata, and 16S rDNA sequence data for Pseudomonas chlororaphis and Pseudomonas syringae showed close relationships to these strains. However, DNA-DNA hybridization data showed that the isolates belong to a new species, for which the name Pseudomonas frederiksbergensis sp. nov. is proposed. The type strain is JAJ28T (DSM 13022T).

Direct microscopy of bacillus endospore germination in soil microcosms

Antagonistic endospore-forming Bacillus spp. offer a large potential as seed inoculants for control of soil-borne pathogens. In the soil, however, inoculated Bacillus endospores may remain dormant without germination, and plant protection can therefore be inefficient and unpredictable. A method based on direct fluorescence microscopy in soil microcosms was used to determine whether low-cost organic additives incorporated into seed coating material could stimulate endospore germination. Complex organic additives supported a high level of endospore germination of the fungal antagonist Paenibacillus polymyxa CM5-5. Skim milk is a low-cost additive that may be incorporated into seed coating material for efficient induction of Bacillus endospore germination in soil.

Viscosinamide-producing Pseudomonas fluorescens DR54 exerts a biocontrol effect on Pythium ultimum in sugar beet rhizosphere

Growth inhibition of the root pathogen Pythium ultimum by the biocontrol agent Pseudomonas fluorescens DR54 inoculated on sugar beet seeds was studied in a soil microcosm. Plant emergence was followed, together with bacterial rhizosphere colonization, antibiotic production and effects on fungal growth. P. fluorescens DR54 inoculation of the P. ultimum-challenged seeds improved plant emergence after 7 days compared to a control without the biocontrol strain. At this time, P. fluorescens DR54 was the dominating colony-forming pseudomonad in rhizosphere soil samples from inoculated seedlings as shown by immuno-staining with a strain specific antibody. Viscosinamide, a cyclic lipopeptide, which has previously been identified as a major antagonistic determinant produced by P. fluorescens DR54 and shown to induce physiological changes in P. ultimum in vitro, could be detected in the rhizosphere samples. The impact of P. fluorescens DR54 on the growth and activity of P. ultimum was studied by direct microscopy after staining with the vital fluorescent dyes Calcofluor white and fluorescein diacetate. P. fluorescens DR54 caused reduction in P. ultimum mycelial density, oospore formation and intracellular activity. Further, Pythium oospore formation was absent in the presence of P. fluorescens DR54. A striking effect on zoospore-forming indigenous fungi was also observed in microcosms with P. fluorescens DR54 and, thus, where viscosinamide could be detected; a large number of encysted zoospores were seen in such microcosms both with and without P. ultimum infections. In vitro studies confirmed that purified viscosinamide induced encystment of Pythium zoospores.

Simultaneous detection of the establishment of seed-inoculated Pseudomonas fluorescens strain DR54 and native soil bacteria on sugar beet root surfaces using fluorescence antibody and in situ hybridization techniques

Colonization at sugar beet root surfaces by seedling-inoculated biocontrol strain Pseudomonas fluorescens DR54 and native soil bacteria was followed over a period of 3 weeks using a combination of immunofluorescence (DR54-targeting specific antibody) and fluorescence in situ hybridization (rRNA-targeting Eubacteria EUB338 probe) techniques with confocal laser scanning microscopy. The dual staining protocol allowed cellular activity (ribosomal number) to be recorded in both single cells and microcolonies of strain DR54 during establishment on the root. After 2 days, the population density of strain DR54 reached a constant level at the root basis. From this time, however, high cellular activity was only found in few bacteria located as single cells, whereas all microcolony-forming cells occurring in aggregates were still active. In contrast, a low density of strain DR54 was observed at the root tip, but here many of the bacteria located as single cells were active. The native population of soil bacteria, comprising a diverse assembly of morphologically different forms and size classes, initiated colonization at the root basis only after 2 days of incubation. Hence the dual staining protocol allowed direct microscopic studies of early root colonization by both inoculant and native soil bacteria, including their differentiation into active and non-active cells and into single or microcolony-forming cells.

Chitinolytic activity of Pseudomonas fluorescens isolates from barley and sugar beet rhizosphere

Twelve isolates of Pseudomonas fluorescens, isolated from barley and sugar beet rhizosphere as antagonists towards the plant pathogenic microfungi Rhizoctonia solani and Pythium ultimum, showed chitinolytic activity in batch cultures when grown in media without exogenous chitin. Enzyme tests in cultures demonstrated a complete array of chitinolytic enzymes. Endochitinase and chitobiosidase activities seemed to be tightly coupled in the isolates, while there was no relationship to N-acetyl-glucosaminidase activity. Endochitinase activity, showing hydrolysis of chitin polymers, was found to be extracellular in all isolates, although the most active isolates also retained a cell-bound fraction. Isoelectric focusing gel electrophoresis of supernatants containing extracellular enzyme activity showed that all isolates produced one native endochitinase in logarithmic phase. This enzyme was subsequently modified into several isozymes by extracellular processing as the cultures aged in stationary phase. The 12 isolates could be grouped into seven isozymic patterns. Detailed studies of three selected isolates showed that extracellular release of endochitinase activity also took place in stationary phase. The results, however, indicated that in stationary phase regulation of both the overall production of native enzyme and the subsequent formation of isozymes were different among the P. fluorescens isolates.

Oxygen-sensing reporter strain of Pseudomonas fluorescens for monitoring the distribution of low-oxygen habitats in soil

The root-colonizing bacterium Pseudomonas fluorescens CHA0 was used to construct an oxygen-responsive biosensor. An anaerobically inducible promoter of Pseudomonas aeruginosa, which depends on the FNR (fumarate and nitrate reductase regulation)-like transcriptional regulator ANR (anaerobic regulation of arginine deiminase and nitrate reductase pathways), was fused to the structural lacZ gene of Escherichia coli. By inserting the reporter fusion into the chromosomal attTn7 site of P. fluorescens CHA0 by using a mini-Tn7 transposon, the reporter strain, CHA900, was obtained. Grown in glutamate-yeast extract medium in an oxystat at defined oxygen levels, the biosensor CHA900 responded to a decrease in oxygen concentration from 210 x 10(2) Pa to 2 x 10(2) Pa of O(2) by a nearly 100-fold increase in beta-galactosidase activity. Half-maximal induction of the reporter occurred at about 5 x 10(2) Pa. This dose response closely resembles that found for E. coli promoters which are activated by the FNR protein. In a carbon-free buffer or in bulk soil, the biosensor CHA900 still responded to a decrease in oxygen concentration, although here induction was about 10 times lower and the low oxygen response was gradually lost within 3 days. Introduced into a barley-soil microcosm, the biosensor could report decreasing oxygen concentrations in the rhizosphere for a 6-day period. When the water content in the microcosm was raised from 60% to 85% of field capacity, expression of the reporter gene was elevated about twofold above a basal level after 2 days of incubation, suggesting that a water content of 85% caused mild anoxia. Increased compaction of the soil was shown to have a faster and more dramatic effect on the expression of the oxygen reporter than soil water content alone, indicating that factors other than the water-filled pore space influenced the oxygen status of the soil. These experiments illustrate the utility of the biosensor for detecting low oxygen concentrations in the rhizosphere and other soil habitats.