The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

Clinical language fMRI with real-time monitoring in temporal lobe epilepsy: online processing methods

The increasing demand for clinical fMRI data has resulted in a need to translate research methods to clinical use. Referrals for language lateralization prior to epilepsy surgery are becoming more common, but time constraints make this unachievable in many busy neuroimaging departments. This study examines whether a single covert verbal fluency paradigm with real-time monitoring and online processing (BrainWave) could replace conventional offline processing (SPM) for the purpose of establishing expressive language dominance prior to epilepsy surgery. We analyzed language fMRI results of 30 patients (17 female; 24 right-handed; median age: 30.5) with temporal lobe epilepsy. Concordance between visual assessment of SPM and BrainWave was 92.8%. Lateralization indices correlated closely with visual assessments of lateralization with a concordance of 85.7%. BrainWave provided a real-time, fast and accurate display of language lateralization easily applied in a clinical setting using only online image processing.

Mental health service users' and practitioners' experiences of engagement in assertive outreach: a qualitative study

Assertive outreach services have been central to community mental health policy within the UK. These multidisciplinary teams were established to engage with service users who have severe and enduring mental health problems and have found traditional community services unable to meet their needs. Mental health nurses have a pivotal role in these multidisciplinary teams, yet the nature of these relationships from the perspective of those who work in and receive care is poorly understood. This study set out to explore the nature and meaning of engagement for practitioners and service users within assertive outreach services. A qualitative approach, informed by philosophical hermeneutics, underpinned the study. Participants were recruited from a single assertive outreach team in the UK. To be eligible for the study, mental health practitioners needed to be employed within the assertive outreach team. All service users residing in the community and receiving care from the team were also eligible for inclusion. In total 14 interviews were conducted with mental health practitioners and 13 with service users. Data analysis was informed by Turner's method. Four themes emerged from the data; contact, dialogue, transformation and shared understanding. Meaningful engagement was found to manifest itself through experiences such as providing and receiving practical assistance, having a genuine two-way conversation and valuing the experiences and personal attributes of the other person. The findings indicate that engagement is an active, dynamic and skilled process, which leads practitioners and service users to transform together to create a new relationship.

Detection of methicillin-resistant Staphylococcus aureus (MRSA) in backyard pigs and their owners, Michigan, USA

Methicillin-resistant Staphylococcus aureus (MRSA) have been reported in commercially raised pigs and their human handlers, raising concerns of zoonotic transmission. To determine whether MRSA in backyard-raised pigs is commonly transmitted to their human owners, a matched study of this type of pigs and their owners was conducted in selected counties in Michigan. Nasal swabs from matched owner-pig pairs (n = 50 pairs) with a few unmatched pig (n = 3) and human (n = 4) samples were collected and processed using standard isolation and identification protocols. No matched owner-pig pair was found; however, MRSA was isolated from 1/54 (1.9%) human samples and 2/53(3.8%) of the pigs. The single human isolate was not strain type USA100-1100 by pulsed-field gel electrophoresis (PFGE), was sequence type (ST) 8 by multilocus sequence typing (MLST), possessed SCCmec type IVb and agr I and was negative for the Panton-Valentine leukocidin (PVL) toxin gene. The two pig isolates were indistinguishable by PFGE (not USA100-1100), and both isolates were ST5 by MLST, possessed SCCmec type III and agr II and were negative for the PVL gene. Persons raising backyard swine from the selected Michigan counties had MRSA carriage rates similar to that of the general US population, suggesting that their avocational pig exposure did not increase their risk of MRSA.

Construction of titanium cranioplasty plate using craniectomy bone flap as template

In recent times a steady rise in cranioplasty operations has been noted because of increasing utilisation of decompressive craniectomy for trauma as well as stroke patients. A variety of techniques have been utilised for cranioplasty, with their own benefits and limitations. Titanium cranioplasty is one of the well-established and widely used techniques, with most centres utilising computer-assisted reconstruction for manufacture of titanium plates. In this paper we present a novel method for making titanium cranioplasty plates using the craniectomy bone flap as a template and the results of our experience. To date we have performed 51 cranioplasties using this method. The surgical results have been comparable to those obtained using the computer-assisted model technique. The construction cost for titanium cranioplasty plates using this method has been pound 360 cheaper per plate compared with the computer-assisted method. In addition, the CT workload and radiation exposure have been reduced.

A review of the literature on the historical development of community mental health services in the United Kingdom

Community mental health encompasses a diverse range of statutory, voluntary and informal care services. However, little has been written about how changes in policy, legislation and philosophies throughout time impact on the service user experience of mental health care today. The purpose of this paper was to review the literature using systematic approaches and address the question: 'How have historical factors influenced the development of community mental health care in the United Kingdom?' Following a comprehensive literature search, we included 70 texts. Owing to the difficulties of classifying historical texts numerically, two themes were identified: (1) changing perspectives towards mental illness and the mentally ill; and (2) the complexities of mental health care provision. We structured the review around these themes. A narrative approach was used to illustrate the diversity within the identified texts. In response to the review question, an exploration of the historical literature demonstrates that some form of community care has always been evident. It also suggests that over time different philosophical ideas have influenced mental health policy and service structure. These have in turn shaped the care a service user receives when they come into contact with mental health professionals.

Quinupristin-dalfopristin resistance in Enterococcus faecium isolates from humans, farm animals, and grocery store meat in the United States

Three hundred sixty-one quinupristin-dalfopristin (Q-D)-resistant Enterococcus faecium (QDREF) isolates were isolated from humans, turkeys, chickens, swine, dairy and beef cattle from farms, chicken carcasses, and ground pork from grocery stores in the United States from 1995 to 2003. These isolates were evaluated by pulsed-field gel electrophoresis (PFGE) to determine possible commonality between QDREF isolates from human and animal sources. PCR was performed to detect the streptogramin resistance genes vatD, vatE, and vgbA and the macrolide resistance gene ermB to determine the genetic mechanism of resistance in these isolates. QDREF from humans did not have PFGE patterns similar to those from animal sources. vatE was found in 35%, 26%, and 2% of QDREF isolates from turkeys, chickens, and humans, respectively, and was not found in QDREF isolates from other sources. ermB was commonly found in QDREF isolates from all sources. Known streptogramin resistance genes were absent in the majority of isolates, suggesting the presence of other, as-yet-undetermined, mechanisms of Q-D resistance.

Localization and physical property experiments conducted by Opportunity at Meridiani Planum

The location of the Opportunity landing site was determined to better than 10-m absolute accuracy from analyses of radio tracking data. We determined Rover locations during traverses with an error as small as several centimeters using engineering telemetry and overlapping images. Topographic profiles generated from rover data show that the plains are very smooth from meter- to centimeter-length scales, consistent with analyses of orbital observations. Solar cell output decreased because of the deposition of airborne dust on the panels. The lack of dust-covered surfaces on Meridiani Planum indicates that high velocity winds must remove this material on a continuing basis. The low mechanical strength of the evaporitic rocks as determined from grinding experiments, and the abundance of coarse-grained surface particles argue for differential erosion of Meridiani Planum.

Localization and physical properties experiments conducted by Spirit at Gusev Crater

The precise location and relative elevation of Spirit during its traverses from the Columbia Memorial station to Bonneville crater were determined with bundle-adjusted retrievals from rover wheel turns, suspension and tilt angles, and overlapping images. Physical properties experiments show a decrease of 0.2% per Mars solar day in solar cell output resulting from deposition of airborne dust, cohesive soil-like deposits in plains and hollows, bright and dark rock coatings, and relatively weak volcanic rocks of basaltic composition. Volcanic, impact, aeolian, and water-related processes produced the encountered landforms and materials.

Wind-related processes detected by the Spirit Rover at Gusev Crater, Mars

Wind-abraded rocks, ripples, drifts, and other deposits of windblown sediments are seen at the Columbia Memorial Station where the Spirit rover landed. Orientations of these features suggest formative winds from the north-northwest, consistent with predictions from atmospheric models of afternoon winds in Gusev Crater. Cuttings from the rover Rock Abrasion Tool are asymmetrically distributed toward the south-southeast, suggesting active winds from the north-northwest at the time (midday) of the abrasion operations. Characteristics of some rocks, such as a two-toned appearance, suggest that they were possibly buried and exhumed on the order of 5 to 60 centimeters by wind deflation, depending on location.

Molecular characterization of gentamicin-resistant Enterococci in the United States: evidence of spread from animals to humans through food

We evaluated the molecular mechanism for resistance of 360 enterococci for which the gentamicin MICs were >/=128 micro g/ml. The aac(6')-Ie-aph(2")-Ia, aph(2")-Ic, and aph(2")-Id genes were identified by PCR in isolates from animals, food, and humans. The aph(2")-Ib gene was not identified in any of the isolates. Two Enterococcus faecalis isolates (MICs > 1,024 micro g/ml) from animals failed to generate a PCR product for any of the genes tested and likely contain a new unidentified aminoglycoside resistance gene. Pulsed-field gel electrophoresis (PFGE) analysis showed a diversity of strains. However, 1 human and 18 pork E. faecalis isolates from Michigan with the aac(6')-Ie-aph(2")-Ia gene had related PFGE patterns and 2 E. faecalis isolates from Oregon (1 human and 1 grocery store chicken isolate) had indistinguishable PFGE patterns. We found that when a gentamicin-resistant gene was present in resistant enterococci from animals, that gene was also present in enterococci isolated from food products of the same animal species. Although these data indicate much diversity among gentamicin-resistant enterococci, the data also suggest similarities in gentamicin resistance among enterococci isolated from humans, retail food, and farm animals from geographically diverse areas and provide evidence of the spread of gentamicin-resistant enterococci from animals to humans through the food supply.

Response of intestinal epithelial cells to Trichuris suis excretory-secretory products and the influence on Campylobacter jejuni invasion under in vitro conditions

We previously developed a swine animal model in which natural host resistance to Campylobacter jejuni is altered by experimental infection with low numbers of the nematode Trichuris suis. Pigs naturally colonized with C. jejuni experience colitis because of the invasion of the bacterium approximately 21 days after exposure to T. suis. To better understand the mechanism of T. suis-dependent C. jejuni colitis, we evaluated the effects of T. suis excretory-secretory products (ESPs) on intestinal epithelial cells (IECs) and the influence of ESP on C. jejuni invasion in IECs under in vitro conditions. Viability assays revealed a dose-dependent cytotoxic response in ESP-treated IECs, particularly IPEC-1 and INT407 cells. Transepithelial electrical resistance dropped significantly in IPEC-1 cells treated on apical and basolateral surfaces, but not in those treated only on apical surfaces. Using the gentamicin-killing assay, reduced numbers of intracellular C. jejuni were recovered from IECs treated with ESP at 1 mg protein/ml concentration. This observation can be at least partially explained by a novel antibacterial activity in ESP. Contrary to our hypothesis, ESP at subtoxic concentrations did not enhance invasion. In addition to mechanical damage from worms, these results suggest that soluble products released by T. suis contribute to IEC damage at the site of worm attachment.

Nurse-led ear care: training needs and the latest techniques

Patients requiring ear care have reported higher levels of satisfaction when this was provided by nurses. The wisdom of ear syringing, the traditional method of cleaning the ear, is now being questioned for many patients, and the aural toilet should be used as an alternative when appropriate. Nurses should remember that good communications skills are vital.

Direct measurements of colloidal friction coefficients

The time-independent hydrodynamic forces operating between two hard spheres were studied as a function of the interparticle separation r. Two colloids were positioned a distance r apart using a dual-beam optical tweezer similar to that described by Meiners and Quake [Phys. Rev. Lett. 82, 2211 (1999)]. Brownian fluctuations in the positions of the two spheres were followed by recording the intensity of forward scattered laser light. The two particles move cooperatively as a result of hydrodynamic forces. The strength of the correlation increased strongly with decreasing separation r. We show that the temporal and spatial correlations in the particle displacements are determined by the distance dependence of the pair friction tensor xi. The distance and geometry dependence of the measured friction tensor is found to be in excellent agreement with the predictions of low-Reynolds number calculations.

Treatment of dentin with polyacrylic acid--a retrospective observational study of the effect upon the durability of glass ionomer restorations

This paper reports on the results of a material specific, retrospective observational study. It sought to determine the consequence of pretreatment of cavity margins with the conventional glass polyalkenoate Chemfil II prior to restoration with Tooth Cleanser on restoration durability. All restorations were placed and varnished by senior dental students under the supervision of a staff member. Manufacturer recommendations were followed. Data on each restoration was collected and entered into a relational computer database. Data included details of cavity morphology and the use or non-use of Tooth Cleanser. Six years following the study start a manual search of all records was carried out to determine, for those patients continuing to attend the Dental Hospital, the number of failed and surviving restorations. This yielded a dataset of 149 restorations, of which 41 had been placed with the aid of Tooth Cleanser and 108 without. The number of failed restorations was 20 and 62, respectively. Survival analysis by the Kaplan-Meier method revealed median survival times of 2,094 days, when Tooth Cleanser was used and 1,748 days when not. Although 80% survival times of 1111.0 (SE = 6.3) (With Tooth Cleanser) and 285.0 (SE = 3.8) (Without Tooth Cleanser) days were observed, together with a Hazard Ratio of 1.49 (95% Confidence Intervals 0.92 & 2.31), a Logrank test revealed no statistically significant difference between the survival curves (p = 0.12). It was concluded that although there was a trend for the application of Tooth Cleanser to improve the chances of obtaining a dependable restoration, this effect was not statistically significant.

Legal madness in the nineteenth century

Legal sources remain under-exploited in the history of madness, and the legal character of some documents is sometimes unrecognized. This article examines the inter-relations between legal and medical histories of madness, and discusses use and availability of nineteenth-century legal source material relating to criminal insanity, mental incapacity, and the confinement of the insane.

Superlattice formation in mixtures of hard-sphere colloids

We report a detailed experimental study of the superlattice structures formed in dense binary mixtures of hard-sphere colloids. The phase diagrams observed depend sensitively on the ratio alpha=R(S)/R(L) of the radii of the small (S) and large (L) components. Mixtures of size ratio alpha=0.72, 0.52, 0.42, and 0.39 are studied. The structures of the colloidal phases formed were identified using a combination of light-scattering techniques and confocal fluorescent microscopy. At alpha=0.39, ordered binary crystals are formed in suspensions containing an equal number of large and small spheres which microscopy shows have a three-dimensional structure similar to either NaCl or NiAs. At the larger size ratio, alpha=0.52, we observe LS2 and LS13 superlattices, isostructural to the molecular compounds AlB2 and NaZn13, while at alpha=0.72 the two components are immiscible in the solid state and no superlattice structures are found. These experimental observations are compared with the predictions of Monte Carlo simulations and cell model theories.

Radiologic versus surgical placement of vena cava filters: a comparative study of cost, time and complications

OBJECTIVE

To compare the cost- and time-effectiveness of 2 methods of placement of vena cava filters for the prevention of pulmonary embolism: the radiologic percutaneous placement of the Vena Tech LGM filter and the surgical cutdown placement of the 24 Fr Greenfield filter.

METHODS

Retrospective review of radiologic and clinical records for 15 consecutive patients who had the Vena Tech LGM filter placed radiologically and 15 consecutive patients who had the Greenfield filter placed surgically. Factors studied were cost, procedure time, waiting time and rates of immediate and delayed complications. The follow-up period ranged from 1 to 26 months (mean 7 months).

RESULTS

The procedure cost for the radiologic method was $702 less than for the surgical method. The procedure time for the radiologic method was 30 minutes shorter, and the waiting time for placement was also shorter. There was no difference in the complication rates following each procedure. The higher cost of the Greenfield filter accounted for 80% of the total cost difference.

CONCLUSION

The radiologic percutaneous method of filter placement is preferred over the surgical cutdown method because of its benefits in terms of cost and time with no increase in risk. However, when the difference in cost between filters is taken into account, there is little difference in overall costs for the 2 methods. Therefore, radiology and surgery departments can place a filter percutaneously at a similar cost. Other factors such as waiting times, complication rates, venography capabilities and physician interest in performing the procedure will dictate which department places the filter.

Cytokines which signal through the LIF receptor and their actions in the nervous system

A number of different cytokines, each initially characterized on the basis of very different biological activities, all have very similar signalling pathways and share a similar tertiary structure. These cytokines include leukaemia inhibitory factor, ciliary neuronotrophic factor, oncostatin M, growth-promoting activity and cardiotrophin 1. They all have been found to regulate a number of properties of cells of the developing and mature nervous system in vitro and thus are neuroregulatory cytokines. The actions of these cytokines include regulation of neurotransmitter phenotype, differentiation of neuronal precursor cells both in the peripheral nervous system and in the spinal cord, survival of differentiated neurons, and regulation of development of both astrocytes and oligodendrocytes. In addition, studies in animal models show that these factors can rescue sensory and motor neurons from axotomy-induced cell death, which suggests that they can act as trauma factors for injured neurons. Analysis of the expression patterns of the different neuroregulatory cytokines and their receptors reveals that the receptors are expressed throughout nervous system development and following trauma, whereas the cytokines show temporal and spatial specific expression patterns. This is consistent with the idea that specific cytokines have specific roles in neural development and repair, but that their signalling pathways are shared. The phenotypes of the receptor knockouts show clear deficits in nervous system development, indicating a crucial role for LIF receptor signalling. Knockouts of individual cytokines are less dramatic, but LIF and CNTF knockouts do reveal deficits in maintenance of motor neurons or following trauma. Thus, whereas LIF and CNTF have clear roles in maintenance and following trauma, it is unclear which of the cytokines is involved in nervous system development. In clinical terms, these findings add further support to the use of these cytokines in nervous system trauma and disease.

Technique for measuring hippocampal T2 relaxation time

PURPOSE

To implement and validate methods for producing calculated coronal T2 maps with complete coverage of the hippocampus and the rest of the brain.

METHODS

T2 relaxation times were estimated on three occasions for 12 quality assessment test objects with the use of fast spin-echo (FSE) and conventional spin-echo (CSE) sequences. Hippocampal T2 relaxation times were measured in 15 healthy subjects with FSE and CSE sequences. Ten of these subjects were scanned twice with CSE imaging. Twenty-two patients with temporal lobe epilepsy, in whom hippocampal T2 relaxation times were previously estimated by means of a multiecho sequence, were studied with CSE.

RESULTS

CSE data were more reliable than FSE data. Reliability of hippocampal T2 measures on repeated acquisitions was superior for the CSE sequence with echo time 30,120 than for the 30,80 sequence (test-retest reliability, 4.0%; interrater reliability, 4.6%). CSE images were suitable for qualitative reporting, so additional T2-weighted sequences were not required. There was good correlation between these hippocampal T2 data and values obtained on a previously validated multiecho technique, with reliable identification of hippocampal sclerosis.

CONCLUSION

T2 mapping with CSE 30/120 sequences may be readily applied, produces reliable T2 values in contiguous 5-mm sections, and may be useful in the assessment of the hippocampus and other cerebral structures.

Leukemia inhibitory factor and ciliary neurotrophic factor in sensory neuron development

Leukemia inhibitory factor (LIF), ciliary neurotrophic factor (CNTF), and related proteins are potentially involved in several aspects of sensory neuron development. There is evidence that LIF promotes the differentiation of sensory neurons from progenitor cells of neural crest origin. Later in development, LIF, CNTF, oncostatin M and interleukin-6 promote the survival of cultured neurons. Some neurons, like those of the nodose ganglion, respond early in their development to these factors, whereas other neurons, like those of the trigeminal ganglion, respond much later. In addition to promoting sensory neuron survival, there is some evidence that LIF is able to influence neurotransmitter and neuropeptide expression in these neurons. These observations suggest that several kinds of sensory neurons may be influenced in various ways by LIF and related factors at different stages of their development.

Role of leukaemia inhibitory factor (LIF) in rat peripheral nerve regeneration

The cytokine leukaemia inhibitory factor (LIF) favours the survival and growth of axons in vitro. The efficacy of this factor in the in vivo model has been the aim of this study. Following nerve transection and immediate entubulation repair in the rat sciatic nerve, this study demonstrated that (1) LIF promotes the growth of a population of axons of greater cross-sectional area after 6 and 12 weeks in comparison to either saline (negative control) or basic fibroblast growth factor (bFGF) (positive control), (2) LIF improves the nerve conduction velocity of regenerating axons, (3) LIF has a positive effect on skeletal muscle mass following nerve repair, (4) the benefits of LIF on skeletal muscle appear to be somewhat independent of reinnervation as similar observations are made where there is no growth of a tissue bridge within the tube, and (5) the effects of LIF seem to be potentiated by the addition of fibronectin.