Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study

INTRODUCTION

Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia.

METHODS

This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive.

RESULTS

From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2).

CONCLUSION

Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

Ten month outcome of cognitive behavioural therapy v. interpersonal psychotherapy in patients with major depression: a randomised trial of acute and maintenance psychotherapy

BACKGROUND

Cognitive behaviour therapy (CBT) and interpersonal psychotherapy (IPT) are the most studied psychotherapies for treatment of depression, but they are rarely directly compared particularly over the longer term. This study compares the outcomes of patients treated with CBT and IPT over 10 months and tests whether there are differential or general predictors of outcome.

METHODS

A single centre randomised controlled trial (RCT) of depressed outpatients treated with weekly CBT or IPT sessions for 16 weeks and then 24 weeks of maintenance CBT or IPT. The principle outcome was depression severity measured using the MADRS. Pre-specified predictors of response were in four domains: demographic depression, characteristics, comorbidity and personality. Data were analysed over 16 weeks and 40 weeks using general linear mixed effects regression models.

RESULTS

CBT was significantly more effective than IPT in reducing depressive symptoms over the 10 month study largely because it appeared to work more quickly. There were no differential predictors of response to CBT v. IPT at 16 weeks or 40 weeks. Personality variables were most strongly associated with overall outcome at both 16 weeks and 40 weeks. The number of personality disorder symptoms and lower self-directness and reward dependence scores were associated with poorer outcome for both CBT and IPT at 40 weeks.

CONCLUSIONS

CBT and IPT are effective treatments for major depression over the longer term. CBT may work more quickly. Personality variables are the most relevant predictors of outcome.

A large-scale, rapid public health response to rabies in an organ recipient and the previously undiagnosed organ donor

This article describes and contrasts the public health response to two human rabies cases: one organ recipient diagnosed within days of symptom onset and the transplant donor who was diagnosed 18 months post-symptom onset. In response to an organ-transplant-related rabies case diagnosed in 2013, organ donor and recipient investigations were conducted by multiple public health agencies. Persons with potential exposure to infectious patient materials were assessed for rabies virus exposure. An exposure investigation was conducted to determine the source of the organ donor's infection. Over 100 persons from more than 20 agencies spent over 2700 h conducting contact investigations in healthcare, military and community settings. The 564 persons assessed include 417 healthcare workers [5.8% recommended for post-exposure prophylaxis (PEP)], 96 community contacts (15.6% recommended for PEP), 30 autopsy personnel (50% recommended for PEP), and 21 other persons (4.8% recommended for PEP). Donor contacts represented 188 assessed with 20.2% recommended for PEP, compared with 5.6% of 306 recipient contacts recommended for PEP. Human rabies cases result in substantial use of public health and medical resources, especially when diagnosis is delayed. Although rare, clinicians should consider rabies in cases of encephalitis of unexplained aetiology, particularly for cases that may result in organ donation.

The process of change in psychotherapy for depression: helping clients to reformulate the problem

There is increasing interest in mental health nurses delivering structured short-term evidence-based psychotherapies such as cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT); however, while there is evidence of the efficacy of psychotherapy for depression, there is limited understanding of the treatment processes. Data were drawn from audio tapes of CBT and IPT sessions for treatment of depression. The transcripts of the initial, middle and final psychotherapy sessions of 40 clients were analysed. A thematic analysis was conducted to identify what was occurring in the sessions, how the client was describing psychotherapy and how the client was describing improvement or lack of improvement in depressive symptoms. There were differences in descriptions of therapy and the experience of depression between clients who responded and those who did not respond to therapy that were related to improvement in symptoms but not to the specific therapy. These differences were in the client's engagement with the language of therapy, sense of optimism about the particular model of psychotherapy, ability to examine their own role in the problem and desire to engage with new ways of being in their lives. Clients who responded to CBT or IPT had flexibility to develop new ways of thinking and acting, the ability to accept responsibility for their role in the identified problem and were willing to risk change.

Nurse-led delivery of specialist supportive care for bipolar disorder: a randomized controlled trial

The aim of the study is (1) to assess the feasibility of delivering nurse-led specialist supportive care as an adjunct to usual care in the clinical setting; (2) to examine the relationship between the delivery of specialist supportive care and improved self-efficacy and functioning and reduced depressive symptoms. A randomized controlled trial of the clinical effectiveness of specialist supportive care as an adjunct to usual care was conducted in community mental health services at one site. Participants were randomized to either usual care or usual care and the adjunctive intervention. Self-report measures of depression, general functioning and self-efficacy were completed by participants in both groups at baseline and 9 months. The intervention was delivered parallel to usual treatment arrangements. While recruitment numbers were sufficient, a low rate of engagement meant we were unable to show significant differences in depressive symptoms or self-efficacy between the usual care group and the specialist supportive care plus usual care group. This study demonstrated that it was difficult to engage patients with bipolar disorder in specialist supportive care when they were currently in a mood episode and under the care of community mental health services.

Feeling out of control: a qualitative analysis of the impact of bipolar disorder

Bipolar disorder is a chronic and recurrent disorder with fluctuating symptoms. Few patients with bipolar disorder experience a simple trajectory of clear-cut episodes, with recovery typically occurring slowly over time. The chronic and disabling course of the disorder has a marked impact on the person's functioning and relationships with others. The objectives of this study were to investigate the impact of bipolar disorder on the lives of people diagnosed with this disorder. The method used was a general inductive qualitative approach. Twenty-one participants were interviewed between 2008 and 2009 about how they had experienced the impact of bipolar disorder. The interviews were audio-taped and transcribed. The core theme that emerged was the participants were feeling out of control. Their own reactions and the reactions of others to the symptoms of bipolar disorder contributed to this core theme. The core theme was constituted by feeling overwhelmed, a loss of autonomy and felling flawed. Mental health nurses can help facilitate a sense of personal control for people with bipolar disorder by exploring what the symptoms mean for that person and implementing strategies to manage the symptoms, address social stigma and facilitate active involvement in treatment.

The onion model, a simple neutral model for the evolution of diversity in bacterial biofilms

Bacterial biofilms are particularly resistant to a wide variety of antimicrobial compounds. Their persistence in the face of antibiotic therapies causes significant problems in the treatment of infectious diseases. Seldom have evolutionary processes like genetic drift and mutation been invoked to explain how resistance to antibiotics emerges in biofilms, and we lack a simple and tractable model for the genetic and phenotypic diversification that occurs in bacterial biofilms. Here, we introduce the 'onion model', a simple neutral evolutionary model for phenotypic diversification in biofilms. We explore its properties and show that the model produces patterns of diversity that are qualitatively similar to observed patterns of phenotypic diversity in biofilms. We suggest that models like our onion model, which explicitly invoke evolutionary process, are key to understanding biofilm resistance to bactericidal and bacteriostatic agents. Elevated phenotypic variance provides an insurance effect that increases the likelihood that some proportion of the population will be resistant to imposed selective agents and may thus enhance persistence of the biofilm. Accounting for evolutionary change in biofilms will improve our ability to understand and counter diseases that are caused by biofilm persistence.

Was it something I did wrong? A qualitative analysis of parental perspectives of their child's bipolar disorder

The aims of this study were to examine parental views on the onset of symptoms, impact on functioning and meanings attributed to their child's bipolar disorder. Early onset bipolar disorder impacts on development and functioning across multiple domains. Psychosocial disability fluctuates in parallel with changes in affective symptoms and may significantly affect family members. This study utilized descriptive statistical data and qualitative data from parental self-reports of 85 participants in a trial of psychotherapy for young people (15-34 years) with bipolar disorder. A content analysis was conducted on the written self-reports. Most parents identified the onset of depressive symptoms in their child by early adolescence, but it was not until late adolescence, or later, that parents noted symptoms of mania. The onset of symptoms during a crucial period of development had a considerable impact on social and occupational functioning. Without prompting, the parents took the opportunity to attempt to make sense of the diagnosis by attributing its onset to childhood adversity, parenting or substance misuse. Parents often blame themselves for the development of bipolar disorder in their child. Nursing care for clients with bipolar disorder could include interventions for the family to help them understand and manage the disorder. Such interventions could include: psycho-education, communication enhancement and problem-solving skills training.

Two sides of the same coin: caring for a person with bipolar disorder

The aim of this paper was to gain an in-depth understanding of the way the lives of individuals supporting someone diagnosed with bipolar disorder. Bipolar disorder is a severe, recurrent and chronic mental disorder that has a significant impact on the lives of those who experience it and the people supporting them. It is often the subsyndromal symptoms that cause major impairment in functioning and can have financial, social, interpersonal and health impacts for carers. A qualitative thematic analysis was chosen to enable an in-depth exploration of participants' experiences. Twelve participants were interviewed using a semi-structured interview and the data were analysed to identify the themes that represented the participants' experiences. The predominant theme that emerged, two sides of the same coin, described the positive and negative aspects of being an informal carer for a person with bipolar disorder. This theme is constituted by two sub-themes: (1) 'I am a much more compassionate person'; and (2) 'It's tough and it's a sacrifice'. Mental health nurses could support informal caregivers more by providing care that demonstrates an understanding of the complexities associated with bipolar disorder and utilizes a collaborative approach to care that actively involves informal caregivers.

Orosomucoid influences the response to antidepressants in major depressive disorder

Orosomucoid, an acute phase protein, carries basic drugs including antidepressants in plasma. Elevated levels have been reported in patients with depression. It has yet to be established whether orosomucoid concentration influences antidepressant response. The orosomucoid gene (ORM1) is polymorphic and the protein isoforms have differing pharmacokinetic properties which could alter plasma profile and blood brain barrier transport of antidepressants. Outpatients (n = 157) in a randomised control trial of fluoxetine versus nortriptyline were genotyped for the ORM1 variants. Plasma concentrations of acute phase proteins were also measured. Outcomes were the completion of an adequate six week trial of antidepressant and response. Response was defined as an improvement >/=60% on the Montgomery-Asperg Depression Rating Scale (MADRS) over six weeks. The first notable finding was that individuals with an ORM1*S/*S genotype were less likely to complete an adequate six week trial of an antidepressant (OR = 4.707, 95% CI 1.769-12.527, P = 0.002). The second was that higher orosomucoid concentrations were found in antidepressant non-responders (91.4%) than responders (79.1%) (F1, 106 = 5.669, P = 0.019). These findings highlight the potential importance of variables such as orosomucoid which impact on drug availability on the therapeutic efficacy of antidepressant drugs.

Phylogeography and mitochondrial diversity of extirpated brown bear (Ursus arctos) populations in the contiguous United States and Mexico

The fossil record indicates that the brown bear (Ursus arctos) colonized North America from Asia over 50 000 years ago. The species historically occupied the western United States and northern Mexico but has been extirpated from over 99% of this range in the last two centuries. To evaluate colonization hypotheses, subspecific classifications, and historical patterns and levels of genetic diversity in this region, we sequenced 229 nucleotides of the mitochondrial DNA control region in 108 museum specimens. The work was set in a global context by synthesizing all previous brown bear control region sequences from around the world. In mid-latitude North America a single moderately diverse clade is observed, represented by 23 haplotypes with up to 3.5% divergence. Only eight of 23 haplotypes (35%) are observed in the extensively sampled extant populations suggesting a substantial loss of genetic variability. The restriction of all haplotypes from mid-latitude North America to a single clade suggests that this region was founded by bears with a similar maternal ancestry. However, the levels and distributions of diversity also suggest that the colonizing population was not a small founder event, and that expansion occurred long enough ago for local mutations to accrue. Our data are consistent with recent genetic evidence that brown bears were south of the ice prior to the last glacial maximum. There is no support for previous subspecies designations, although bears of the southwestern United States may have had a distinctive, but recent, pattern of ancestry.

Cardiovascular toxicity is increased, but manageable, during high-dose chemotherapy and autologous peripheral blood stem cell transplantation for patients aged 60 years and older

High-dose therapy (HDT) for non-Hodgkins lymphoma (NHL) and multiple myeloma (MM) is considered a feasible option for patients aged 60 years. This study compared the outcomes for all patients aged 60 years treated with HDT at the center to a matched cohort group aged <60 years. Results for patients who were 60 years at HDT between 1997--2002 were retrospectively analysed to assess efficacy and safety. Event-free (EFS) and overall survival (OS) rates were compared with a cohort group, matched by disease type, chemotherapy sensitivity, year of treatment and conditioning regimen. Patients with NHL were also matched by International Prognostic Index score. Forty patients aged 60 years were identified. Median age was 65 (range 60--76) with 22 MM and 18 NHL; 50% had 1 or more co-morbidity; 35% had cardiovascular co-morbidity vs. 18% of controls (p=0.075). Response rates (RR) following HDT for MM were: 4 (18%) complete responses (CR) and 18 (82%) partial responses (PR), giving an overall response rate (ORR) of 100%, vs. 77% for controls (p=0.02). For NHL patients there were: 8 CR (44%) and 4 PR (22%), giving an ORR of 67%, vs. 83% for controls (p=0.3). Transplant-related mortality was 8% compared to 5% in controls (p=0.6). Toxicities were similar with the exception of cardiac toxicity, which was significantly higher in patients aged 60 years vs. controls (50% grade 3 vs. 10%: p<0.0001). Atrial fibrillation was the most frequent cardiovascular toxicity (9 patients). At a median follow-up of 33 months, there is no significant difference between older vs. younger patients in median EFS (24 vs. 38 months: p=0.78) or OS (40 months vs. not reached: p=0.23). HDT is feasible and effective in selected patients 60 years with MM and NHL. Patients 60 years are more susceptible to cardiovascular toxicities, particularly atrial fibrillation, but have similar or better response rates following HDT and similar long-term outcomes to younger patients.

Testing population genetic structure using parametric bootstrapping and MIGRATE-N

We present a method for investigating genetic population structure using sequence data. Our hypothesis states that the parameters most responsible for the formation of genetic structure among different populations are the relative rates of mutation (micro) and migration (M). The evolution of genetic structure among different populations requires rates of M << p because this allows population-specific mutation to accumulate. Rates of micro << M will result in populations that are effectively panmictic because genetic differentiation will not develop among demes. Our test is implemented by using a parametric bootstrap to create the null distribution of the likelihood of the data having been produced under an appropriate model of sequence evolution and a migration rate sufficient to approximate panmixia. We describe this test, then apply it to mtDNA data from 243 plethodontid salamanders. We are able to reject the null hypothesis of no population structure on all but smallest geographic scales, a result consistent with the apparent lack of migration in Plethodon idahoensis. This approach represents a new method of investigating population structure with haploid DNA, and as such may be particularly useful for preliminary investigation of non-model organisms in which multi-locus nuclear data are not available.

Likelihoods and simulation methods for a class of nonneutral population genetics models

Methods for simulating samples and sample statistics, under mutation-selection-drift equilibrium for a class of nonneutral population genetics models, and for evaluating the likelihood surface, in selection and mutation parameters, are developed and applied for observed data. The methods apply to large populations in settings in which selection is weak, in the sense that selection intensities, like mutation rates, are of the order of the inverse of the population size. General diploid selection is allowed, but the approach is currently restricted to models, such as the infinite alleles model and certain K-models, in which the type of a mutant allele does not depend on the type of its progenitor allele. The simulation methods have considerable advantages over available alternatives. No other methods currently seem practicable for approximating likelihood surfaces.

Efficient use of animal manure on cropland--economic analysis

Manure contains all the macro- and microelements needed for plant growth; however, it represents one of the most underutilized resources in the US. The major problem with the use of manure on cropland is the direct effect of its composition on application cost. This cost is a function of the mineralization process of organic matter. The mineralization process is influenced by the properties of the manure, properties of the soil, moisture, and temperature. This study evaluates the simultaneous effect of these variables on the optimal use of manure on cropland. The results show that the properties of manure and soil significantly affect the mineralization of organic nitrogen and thus the optimal quantity of manure required to satisfy the nutrient requirement of crops in a given rotation system. Manure application costs range from a low of 18% of the cost of commercial fertilizer for chicken manure applied to one type of soil, to a high of 125% of the cost of commercial fertilizer for cow manure applied to another type of soil. The maximum distance to transfer manure to the field, that will equate its application cost to the cost of commercial fertilizer, ranges from a high of 35 km (22 miles) for chicken manure applied to one type of soil, to a low of 1 km (0.62 miles) for cow manure applied to another type of soil. For rotation system 2, manure application costs range from a low of 37% of the cost of commercial fertilizer for chicken manure applied to one type of soil, to a high of 136% of the cost of commercial fertilizer for cow manure applied to another type of soil. The maximum distance to transfer manure to the field, that will equate its cost to the cost of commercial fertilizer, ranges from a high of 20 km (12.5 miles) for chicken manure applied to one type of soil, to a low of 0 km (0 miles) for cow manure applied to another type of soil.

Rapid and comprehensive determination of cytochrome P450 CYP2D6 poor metabolizer genotypes by multiplex polymerase chain reaction

The liver enzyme cytochrome P450 CYP2D6 (debrisoquine 4-hydroxylase) metabolizes numerous drugs, including many antidepressants, neuroleptics, antiarrhythmics, and antihypertensive agents. Variability in the gene that encodes this enzyme is an important factor underlying variable drug treatment responses. Some 5-10% of Caucasians lack functional CYP2D6, and the genetic basis of most of these "poor metabolizer" alleles is now well defined. As the CYP2D6 status of a patient can have profound effects on response to drug treatment, it is important to devise methods that permit rapid and economical determination of CYP2D6 genotype. We have developed a robust polymerase chain reaction method that simultaneously identifies the variants CYP2D6 *3, *4, *6, *8, *11, *12, *14, *15, *19, and *20. This constitutes most of the poor metabolizer alleles described in Caucasian and Asian populations. Separate PCR reactions or Southern blots are required for *7, the *5 deletion, and the hybrid alleles *13 and *16. The multiplex assay was validated on 100 individuals previously genotyped by specific polymerase chain reaction-restriction fragment length polymorphism analysis, and proved 100% accurate in this sample. The assay performed consistently with Taq DNA polymerases from various suppliers, within a broad range of temperatures and MgCl(2) concentrations, and using genomic DNA prepared by a range of methods including extraction from dried blood spots on card. This multiplexed, amplification refractory mutation system (ARMS) method is reliable, rapid, relatively cheap, amenable to automation, and offers the advantages of minimal sample handling with no requirement for restriction enzymes as in earlier CYP2D6 assays.

Identification of P gene mutations in individuals with oculocutaneous albinism in sub-saharan africa; robyn kerr, gwynneth stevens, prashiela manga, sarah salm, premila john, tabitha haw, and michele ramsay; (Article was originally published in human mutation 15:166-172, 2000)

The authors wish to correct a mistake which occurred in the reporting of one of the mutations. The mutation reported as 683insT is actually an insertion G mutation, and should thus be called 683insG.

Effect of somatic cell count and polymorphonuclear leucocyte content of milk on composition and proteolysis during ripening of Swiss-type cheese

During the manufacture of Swiss-type cheese varieties, such as Emmental, Gruyère and Comté, a high scald temperature is used, which inactivates the added coagulant, decreasing the primary proteolysis of αs1-casein during ripening and resulting in the development of the rubbery texture characteristic of this type of cheese (Kosikowski & Mistry, 1997). Swiss-type cheese may be made from raw, thermized or pasteurized milk, depending on the type of manufacture and the country (Beuvier et al. 1997).

The suitability of milk for cheesemaking is often assessed from the somatic cell count (SCC) of the raw milk, with increased milk SCC being linked to impaired cheesemaking properties and cheese yield potential (Barbano et al. 1991; Auldist et al. 1996). Late lactation milk, which often has elevated SCC, also yields poor quality cheese (Lucey, 1996). High SCC milk has elevated levels of the milk alkaline proteinase plasmin (EC 3.4.21.7), but its activity is not generally considered to be detrimental during cheese ripening (Farkye & Fox, 1992; Bastian & Brown, 1996). Milk somatic cells are themselves also associated with a number of proteolytic enzymes of differing properties, the activities of which are ill-defined in dairy products (Verdi & Barbano, 1991), with the exception of the acid proteinase cathepsin D, which has a chymosin-like activity towards αs1-casein (McSweeney et al. 1995). Preliminary evidence of cathepsin D activity in Swiss cheese during ripening has been reported (Igoshi & Arima, 1993; Beuvier et al. 1997).

In the present study the effect of milk SCC on the ripening of Swiss-type cheese was examined. Of particular interest was the role of polymorphonuclear leucocytes (PMN), the predominant cell type in high SCC mastitic milk (Heegaard et al. 1994) and late lactation milk, when the frequency of milking varies (Kelly et al. 1998). PMN possess a range of proteolytic enzymes, including cathepsin D (Verdi & Barbano, 1991) and plasminogen activators (PA; Heegaard et al. 1994). The experimental strategy chosen was to examine the effects on the quality and proteolysis during ripening of Swiss-type cheeses of adding high SCC milk, whose cell population is mostly PMN, to creamery milk.

Fasciola hepatica infection downregulates Th1 responses in mice

Immune responses induced with helminth parasites have been extensively studied, but there is limited information on those to Fasciola hepatica, especially on the subtype of T cell induced with this parasite. We investigated the local and systemic T cell responses of different strains of mice following oral infection with doses of metacercariae from F. hepatica. Spleen cells from BALB/c and 129Sv/Ev mice given a low-dose (5 metacercariae) infection exhibited a Th2 response, producing high levels of the cytokines IL-4 and IL-5, and low levels of IFN-gamma and IL-2. In contrast, C57BL/6 mice showed a mixed Th1/Th2 response. A more marked polarization to a Th2 response was observed in BALB/c, 129Sv/Ev exposed to a high-dose (15 metacercariae) infection and the C57BL/6 mice also exhibited a clear Th2 response. IL-4 defective (IL-4-/-) C57BL/6 mice infected with 5 metacercariae produced less IFN-gamma and more IL-5 compared to their wild-type C57BL/6 counterparts, suggesting that IL-4 is important in establishing the Th2 type response in murine fasciolosis. However, the secretion of IFN-gamma and IL-2 was completely suppressed in the high-dose infection and this was also observed in IL-4-/- mice. Thus, liver flukes may secrete molecules that downregulate Th1 responses. T cell responses in the mesenteric (MLN) and hepatic lymph nodes (HLN) were also examined since newly excysted juveniles infect through the intestinal wall of their host before migrating to the hepatic tissue. Cells from both MLN and HLN secreted higher levels of IL-4 and IL-5 compared to spleen cells. We also observed a difference in cytokine profiles secreted by the MLN and HLN, which may reflect responses to antigens liberated by newly excysted juveniles and hepatic stage parasites, respectively.

Correlation between bovine milk somatic cell count and polymorphonuclear leukocyte level for samples of bulk milk and milk from individual cows

The influence of various factors on the concentrations of polymorphonuclear neutrophilic leukocytes (PMN) in milk samples from bulk tanks and individual cows was investigated. While somatic cell counts (SCC) and PMN level were in both cases significantly correlated, lower correlation coefficients were found between SCC and PMN for samples of bulk tank milks than for milk samples from individual cows. Furthermore, plots of PMN concentrations versus SCC showed great variability in PMN in milk samples of similar total SCC. One factor that may lead to variability in bulk tank PMN levels was shown to be increased proportions of high SCC milk in the bulk tank mixture, which result in relatively high PMN levels without excessive elevation of total SCC. In milk samples from individual cows, it was found that there was also a significant seasonal influence on milk PMN content, with milk from cows calving in the spring having, at SCC > 160,000 cells/ ml, higher proportions of PMN in the total milk SCC than milk from autumn calving cows. The results of this study suggest that the concentration of PMN may be a useful indicator of herd status in bulk tank monitoring schemes.

No BLUE among phylogenetic estimators

Multivariate analysis is a branch of statistics that successfully exploits the powerful tools of linear algebra to obtain a fairly comprehensive theory of estimation. The purpose of this paper is to explore to what extent a linear theory of estimation can be developed in the context of coalescent models used in the analysis of DNA polymorphism. We consider a large class of coalescent models, of which the neutral infinite sites model is one example. In the process, we discover several limitations of linear estimators that are quite distinct from those in the classical theory. In particular, we prove that there does not exist a uniformly BLUE (best linear unbiased estimator) for the scaled mutation parameter, under the assumptions of the neutral model of evolution. In fact, we show that no linear estimator performs uniformly better than the Watterson (1975) method based on the total number of segregating sites. For certain coalescent models, the segregating-sites estimator is actually optimal.The general conclusion is the following. If genealogical information is useful for estimating the rate of evolution, then there is no optimal linear method. If there is an optimal linear method, then no information other than the total number of segregating sites is needed.

Implementing supernumerary learning in a pre-registration diploma in nursing programme: an action research study

The purpose of this study was to develop a framework for implementing supernumerary learning in a preregistration Diploma in Nursing programme in an Irish hospital. Experiences of student nurses (n = 31), clinical nursing staff (n = 8) and nurse teachers (n = 4) were explored, regarding the introduction of supernumerary status in this programme. An action research approach, employing phenomenological methods for gathering and analysing the data, was used to carry out the study. A framework for implementing supernumerary learning in a Diploma in Nursing programme was developed, based on the study. This framework reflects the level of knowledge, skills and attitudes of individuals partaking in supernumerary learning, and the role of the supervisor in the clinical area at each level. Possible implications of the changing role of the student nurse for nursing practice for education, management and research are suggested.

Effects of stocking density and concentrate supplementation of grazing dairy cows on milk production, composition and processing characteristics

The effects on milk composition and processing characteristics of varying grass supply by changing stocking density and of offering a concentrate supplement were investigated. The experiment was conducted over 28 weeks of the lactation (April-October) using 48 spring-calved Friesian-Holstein cows. Three herds each of 16 cows were offered a restricted grass supply, a standard grass supply and a standard grass supply with a supplement of 3 kg concentrate/d. Treatment groups were grazed separately with a residence time of 3 d/paddock. Milk production, composition and processing characteristics such as renneting properties, ethanol stability and plasmin activity were measured weekly. Increasing stocking density above the standard system resulted in significant reductions in milk fat and protein yields, the concentrations of total protein, casein and whey proteins, and a deterioration in most processing characteristics. Imposing concentrate supplementation on the standard system increased total protein, casein and whey protein concentrations but generally did not improve processing characteristics except for ethanol stability. These results suggest that the standard grass supply in a rotational grazing paddock system can support efficient production of quality milk, and concentrate supplementation will not improve processing characteristics when an adequate supply of good quality herbage is available.

Effect of decreased milking frequency of cows in late lactation on milk somatic cell count, polymorphonuclear leucocyte numbers, composition and proteolytic activity

The effects of reducing the frequency of milking of cows in late lactation on milk somatic cell count (SCC), polymorphonuclear leucocyte (PMN) content, chemical composition and proteolytic activity were investigated. Intermittent milking is frequently practised by Irish farmers in late lactation, and the objective of this study was to determine whether this procedure could be linked to altered quality of milk. Seventeen Holstein Friesian cows in late lactation (> 215 d in milk) were assigned to two treatment groups, and were either milked twice a day until drying-off (control group) or milked intermittently as the yield fell (test group). Milk composition and enzymic characteristics were measured on two occasions. At the first sampling, day 7, test cows were on once daily milking and at the second, day 15, the test cows were being milked every second day. Milk yields were significantly lower in test than control animals and decreased between days 7 and 15 in both groups. Milk SCC and PMN levels were increased on reducing milking frequency and, at day 15, the increase was not linked to decreased milk yield. Milk lactose levels were significantly decreased and pH, alpha-lactalbumin levels, plasmin activity and plasminogen activity significantly increased by reducing milking frequency. In conclusion, reduced frequency of milking in late lactation leads to the production of milk that is abnormal in character and this may be linked to reduced quality of dairy products manufactured from such milk.

Growth hormone replacement does not improve psychological well-being in adult hypopituitarism: a randomized crossover trial

In order to examine the effect of growth hormone (GH) on psychological parameters in adult hypopituitarism, 20 adults were studied, mean age 47 years (range 20-69) with hypopituitarism and confirmed GH deficiency (GH < 3 micrograms/l following clonidine 0.15 mg/m2). Subjects were randomly allocated to either GH-up to 0.25 U/kg per week in daily doses) or placebo for 3 months before crossover to the opposite treatment arm. Psychological parameters were assessed by self-reported questionnaires (Disease Specific Questionnaire (DSQ), the Symptom Checklist-90 (SCL-90), and the Social Adjustment Scale (SAS)) at baseline and monthly intervals to the end of the trial. Both SAS and SCL-90 total scores showed a significant decline with respect to time (p = .03 and .013 respectively), although this was not a function of active treatment. DSQ showed a trend to decline (p = .06), but no effect of active treatment. None of the subscale components of the SCL-90 showed any significant change on active treatment. Improvement in psychological parameters occurs as a function of enrolment to a clinical trial, rather than active GH replacement in adult hypopituitarism.

Plasma cortisol, PRL, ACTH, AVP and corticotrophin releasing hormone responses to direct current cardioversion and electroconvulsive therapy

OBJECTIVE

We aimed to evaluate and contrast the hypothalamo-pituitary-adrenal (HPA) response to direct current (DC) cardioversion and electroconvulsive therapy (ECT).

SUBJECTS

Six male subjects (mean age 61.2 years, range 46-74) with chronic atrial fibrillation were selected for cardioversion. Six subjects with depression (one male, five female; mean age 43.2 years, range 31-59) were selected for ECT. Those taking glucocorticoid drugs, opiates or beta-adrenoceptor antagonists were excluded.

MEASUREMENTS

Patients attended for serial blood sampling on the day of cardioversion or ECT, and for an equivalent time period on a control day at least one week before. Intravenous propofol was given to each subject for anaesthesia on the day of cardioversion or ECT. On both study and control days, blood samples were taken at -30, -15, 0 (just prior to cardioversion or ECT), +5, +10, +15, +30, +60, +90 and +120 minutes for assay of cortisol, PRL, ACTH, AVP and CRH.

RESULTS

For cardioversion: plasma cortisol increased from 252.5 +/- 39.8 to a maximum of 721.3 +/- 50 nmol/l at 30 minutes (P < 0.0001 compared with control day). ACTH increased from 12.8 +/- 2.8 to a maximum of 64 +/- 14 pmol/l at 5 minutes (P < 0.0001 compared with control day). AVP increased from 6.6 +/- 3.3 to a maximum of 42.9 +/- 16 pmol/l at 5 minutes post-cardioversion (P < 0.005 compared with control day). PRL increased from 141 +/- 28 mlU/l to a maximum of 873 +/- 219 mlU/l at 10 minutes (P < 0.001 compared with control day). There was no significant difference in CRH responses between cardioversion and control days. There was no significant correlation between total electrical energy delivered and maximum ACTH and AVP responses (R = 0.54 and -0.13, respectively). For ECT: on the day of ECT plasma cortisol increased from 419.5 +/- 25.9 to a maximum of 614.7 +/- 26.9 nmol/l (P < 0.002 compared with control day). ACTH increased from 22.7 +/- 6.2 to a maximum of 77.8 +/- 19.1 pmol/l (P < 0.0003 compared with control day). PRL increased from 771 +/- 317 to a maximum of 3152 +/- 703 mlU/l (P < 0.001 compared with control day, and significantly greater than the peak response to cardioversion, P < 0.03). AVP increased from 13.0 +/- 10.8 to a maximum of 35.1 +/- 5.6 pmol/l (P < 0.02 compared with control day). There was no significant difference in CRH responses between ECT and control days. Peak cortisol and ACTH responses did not differ significantly between ECT and cardioversion. Baseline cortisol levels, however, were significantly higher in the depressed group compared with the cardioversion group, P < 0.02, but not ACTH or AVP.

CONCLUSION

Significant hypothalamic-pituitary-adrenal activation and PRL release occur in response to both cardioversion and ECT. AVP may have an important role in mediating the acute ACTH response to electrical stimulation.

Silicosis and workers' compensation in New Jersey

The employer is expected to maintain responsibility for health care expenses and lost income that result from occupational injury and illness through the workers' compensation insurance system. However, financial support for individuals with occupational illnesses, especially those with long latency, is often from sources other than workers' compensation. Silicosis, a well defined, chronic, occupational lung disease, can be viewed as a sentinel for the inadequacy of the public policy to compensate workers for chronic occupational lung disease. Three hundred twenty-nine patients with confirmed silicosis were identified by the silicosis surveillance program in the New Jersey Department of Health using source data from 1979 through 1992. One hundred seventy-seven of these individuals provided information on the status of any compensation claims against their employer. Only 31% of these patients stated that a claim had been filed; 84% of those whose claims were settled were awarded payments. Severity of radiologic findings was not associated with the likelihood of filing a claim or with being awarded a payment; whereas, smoking was associated with these outcomes. The implications of these findings for the health care system are discussed.

The distribution of rare alleles

Population geneticists have long been interested in the behavior of rare variants. The definition of a rare variant has been the subject of some debate, centered mainly on whether alleles with small relative frequency should be considered rare, or whether alleles with small numbers should be. We study the behavior of the counts of rare alleles in samples taken from a population genetics model that allows for selection and infinitely-many-alleles mutation structure. We show that in large samples the counts of rare alleles--those represented once, twice, ...--are approximately distributed as a Poisson process, with a parameter that depends on the total mutation rate, but not on the selection parameters. This result is applied to the problem of estimating the fraction of neutral mutations.

Type I hypersensitivity reactions in intestinal mucosae from rats infected with Fasciola hepatica

Type I hypersensitivity reactions in the intestinal tract of sensitized animals may contribute to resistance to reinfection with Fasciola hepatica. Colonic mucosae isolated from previously infected rats were voltage clamped in Ussing chambers. Antigen was prepared as a crude homogenate from adult liver fluke. Assay of serum antibodies against fluke antigen confirmed sensitization. Antigen challenge evoked a rapid onset, transient inward current in sensitized but not in control preparations. Chloride secretion accounted for at least part of the response since the loop diuretic bumetanide reduced the effect of antigen by 61%. Anti-rat IgE mimicked the response to antigen and desensitized tissues to subsequent antigen challenge. Local synthesis of eicosanoids may mediate the response to antigen since the cyclo-oxygenase inhibitor piroxicam reduced the response by 76%. In contrast, mepyramine which is a histamine receptor antagonist did not alter the ion transport response evoked by antigen. Tetrodotoxin reduced the response to antigen by 53% implicating intrinsic neurons within the lamina propria as effector cells in the responses of this tissue to antigen. We propose that antigen stimulation of electrogenic chloride movement and consequent fluid secretion in vivo may contribute to a local effector mechanism in prevention of reinfection of previously sensitized hosts.

Leiomyosarcoma of the femoral vein

Soft-tissue masses uncommonly completely occlude or engulf a major vessel. Complete occlusion of a major vein suggests that the mass originates in the wall of the vein. Such tumours are rare, the most frequently encountered type being leiomyosarcoma. The authors present a case of leiomyosarcoma of the femoral vein.

Identification of phosphorylcholine containing antigens of Fasciola hepatica--successful tolerization against this epitope in experimental animals

Phosphorylcholine containing antigens have been identified in the parasite Fasciola hepatica by immunoblotting and ELISA. Immunoblots probed with polyclonal and monoclonal antibodies indicate that the majority of antigens identified in both the immature and mature parasite contain both phosphorylcholine and non-phosphorylcholine epitopes. One antigen of 58 kDa appears to contain predominantly PC epitopes or at least this epitope is the major one responded to by host animals. Successful immunotolerization against the epitope PC was achieved by injecting the PC conjugate, ovalbumin PC, into neonatal rats. Immunotolerization against PC resulted in a 25% reduction in worm burden upon subsequent infection with Fasciola hepatica.

Prevalence of three bulimia syndromes in the general population

Prevalence of bulimia was estimated from a cross-sectional general population survey of 1498 adults, using the Diagnostic Interview Schedule (DIS) administered by trained lay interviewers. Lifetime prevalence of the DSM-III syndrome in adults aged 18-64 was 1.0% and this was concentrated in young women: in women aged 18-44 lifetime prevalence was 2.6%, and 1.0% currently had the disorder. Based on clinicians' reinterviews of random respondents and identified and marginal cases, the prevalence of current disorder using criteria for draft DSM-III-R bulimia was 0.5%, for DSM-III it was 0.2%, and for Russell's Criteria bulimia nervosa 0.0%. A strong cohort effect was found, with higher lifetime prevalence among younger women, which is consistent with a growing incidence of the disorder among young women in recent years. Although elements of the syndromes were so common as to suggest that dysfunctional attitudes to eating and disturbed behaviour surrounding eating are widespread, there was little evidence of the bulimia syndrome having become an epidemic on the scale suggested by early reports.

Basket removal of intraatrial catheter after liver transplantation: technical note

A fragment of an intravenous catheter, lodged in the right atrium of a patient after a recent liver transplant, was removed percutaneously. Extra care is needed in such patients if the transfemoral approach is used. Reasons for the additional precautions are discussed and a case history is provided.

Is knowing the age-order of alleles in a sample useful in testing for selective neutrality?

The most powerful, and most frequently used, test of selective neutrality, based on data consisting of observed allelic frequencies in a sample of genes at some locus, is the procedure of G. A. Watterson. This procedure uses the sample homozygosity F* as the test statistic, and in effect leads to rejection of the hypothesis of selective neutrality if the observed value of F* differs significantly from neutral theory expectations. The homozygosity statistic is invariant under relabeling of the alleles and thus cannot use any further information on the alleles which might be available. We present results which suggest that information concerning the age order of the alleles cannot be used to provide a more powerful testing procedure than that of Watterson.