The effect of calcareous marine algae, with or without marine magnesium oxide, and sodium bicarbonate on rumen pH and milk production in mid-lactation dairy cows

Two experiments were carried out to evaluate different dietary buffers and their influence on (1) rumen pH in dairy cows and (2) milk production in dairy cows. The supplements included were calcareous marine algae (CMA; Lithothamnion calcareum), with or without marine magnesium oxide (MM; precipitated magnesia derived from seawater), and sodium bicarbonate (SB). Dietary treatments in experiment 1 consisted of the control [32.9% starch and sugar, and 19.9% neutral detergent fiber from forage per kg of dry matter (DM)] including no dietary buffer (CON); the control plus 0.45% DM CMA (CMA); the control plus 0.45% DM CMA and 0.11% DM MM (CMA+MM); the control plus 0.9% DM SB (SB). Diets were formulated to a dry matter intake (DMI) of 18 kg per cow/d. Dietary treatments in experiment 2 also consisted of CON (28.3% starch and sugar, and 23% neutral detergent fiber from forage per kg of DM), CMA, CMA+MM, and SB and were formulated to achieve identical intakes of experimental ingredients (80 g of CMA, 80 g of CMA plus 20 g MM, and 160 g of SB per cow/d) with a DMI of 22.6 kg per cow/d. Experiment 1 used 4 rumen-cannulated dairy cows in a 4 × 4 Latin square design. Rumen pH was measured over five 2-h periods, following feeding, using rumen pH probes. In experiment 2, 52 multiparous and 4 primiparous cows (62.7 ± 3.4 d in milk) were assigned to 4 experimental treatments for 80 d. Both CMA treatments maintained a greater mean rumen pH than the CON during 4 of the 5 periods following feeding and the CON had a greater number of hours below rumen pH 5.5 compared with all other treatments. Dry matter intakes tended to be higher on the SB compared with CON. The CMA treatment increased the production of milk fat and protein yield (kg/d) compared with all other treatments. Both CMA and CMA+MM increased milk fat yield compared with CON but were similar to each other and SB. Protein yield was highest in the CMA treatment compared with CON, CMA+MM, and SB. All 3 buffer treatments increased milk fat concentration compared with CON but did not differ from each other. The SB treatment reduced milk protein concentration and milk production efficiency, energy-corrected milk per kilogram of DMI. Results indicate that the addition of CMA can benefit milk fat and protein production when included in diets based on typical feedstuffs of the northern European region. The use of CMA when compared with SB, in such diets, can increase milk protein production and milk production efficiency.

Characterizing pharmaceutical, personal care product, and hormone contamination in a karst aquifer of southwestern Illinois, USA, using water quality and stream flow parameters

Karst aquifers are drinking water sources for 25% of the global population. However, the unique geology of karst areas facilitates rapid transfer of surficial chemicals to groundwater, potentially contaminating drinking water. Contamination of karst aquifers by nitrate, chloride, and bacteria have been previously observed, but little knowledge is available on the presence of contaminants of emerging concern (CECs), such as pharmaceuticals. Over a 17-month period, 58 water samples were collected from 13 sites in the Salem Plateau, a karst region in southwestern Illinois, United States. Water was analyzed for 12 pharmaceutical and personal care products (PPCPs), 7 natural and synthetic hormones, and 49 typical water quality parameters (e.g., nutrients and bacteria). Hormones were detected in only 23% of samples, with concentrations of 2.2-9.1ng/L. In contrast, PPCPs were quantified in 89% of groundwater samples. The two most commonly detected PPCPs were the antimicrobial triclocarban, in 81% of samples, and the cardiovascular drug gemfibrozil, in 57%. Analytical results were combined with data of local stream flow, weather, and land use to 1) characterize the extent of aquifer contamination by CECs, 2) cluster sites with similar PPCP contamination profiles, and 3) develop models to describe PPCP contamination. Median detection in karst groundwater was 3 PPCPs at a summed concentration of 4.6ng/L. Sites clustered into 3 subsets with unique contamination models. PPCP contamination in Cluster I sites was related to stream height, manganese, boron, and heterotrophic bacteria. Cluster II sites were characterized by groundwater temperature, specific conductivity, sodium, and calcium. Cluster III sites were characterized by dissolved oxygen and barium. Across all sites, no single or small set of water quality factors was significantly predictive of PPCP contamination, although gemfibrozil concentrations were strongly related to the sum of PPCPs in karst groundwater.

Whey protein gel composites in the diet of goats increased the omega-3 and omega-6 content of milk fat

Previously, feeding whey protein gels containing polyunsaturated fatty acids (PUFA) reduced their rumen biohydrogenation and increased their concentration in milk fat of Holstein cows. Our objective was to test the efficacy of whey protein isolate (WPI) gels produced in a steam tunnel as a method to alter the fatty acid (FA) composition of the milk lipids. Four primiparous Lamancha goats in midlactation were fed three diets in a 3 × 4 Latin square design. The WPI gels were added to a basal concentrate mix that contained one of three lipid sources: (i) 100% soya bean oil (S) to create (WPI/S), (ii) a 1:1 (wt/wt) mixture of S and linseed (L) oil to create (WPI/SL), or (iii) 100% L to create (WPI/L). Periods were 22 days with the first 10 days used as an adjustment phase followed by a 12-day experimental phase. During the adjustment phase, all goats received a rumen available source of lipid, yellow grease, to provide a baseline for milk FA composition. During the experimental phase, each goat received its assigned WPI. Milk FA concentration of C18:2 n-6 and C18:3 n-3 reached 9.3 and 1.64 g/100 g FA, respectively, when goats were fed WPI/S. Feeding WPI/SL increased the C18:2 n-6 and C18:3 n-3 concentration to 6.22 and 4.36 g/100 g FA, and WPI/L increased C18:2 n-6 and C18:3 n-3 to 3.96 and 6.13 g/100 g FA respectively. The adjusted transfer efficiency (%) of C18:3 n-3 to milk FA decreased significantly as dietary C18:3 n-3 intake increased. Adjusted transfer efficiency for C18:2 n-6 did not change with increasing intake of C18:2 n-6. The WPI gels were effective at reducing rumen biohydrogenation of PUFA; however, we observed a change in the proportion increase of C18:3 n-3 in milk FA suggesting possible regulation of n-3 FA to the lactating caprine mammary gland.

Effect of feeding calcareous marine algae to Holstein cows prepartum or postpartum on serum metabolites and performance

Thirty-six multiparous Holstein cows and 12 springing heifers were used in a 9-wk randomized design trial to determine the response of cows fed calcareous marine algae (CMA) beginning 3wk prepartum or after parturition through 6wk postpartum on dry matter intake (DMI), blood and urine metabolites, and milk yield and composition. Within parity and expected calving date, cows were assigned randomly to 1 of 4 treatments with a 2×2 factorial arrangement. Prepartum diets were supplemented with calcium carbonate (CON) or 50g/d of CMA with a resulting dietary cation-anion difference of -5.17 and -3.99mEq/100g, respectively. Postpartum diets were formulated to provide either 317g/d of sodium bicarbonate and calcium carbonate (NBC) or 100g/d of CMA, providing a dietary cation-anion difference of 35.58 and 15.64mEq/100g, based on 25kg/d of DMI, respectively. No differences were observed in prepartum DMI or postpartum DMI, milk yield, percentage of milk fat, protein, lactose, and solids-not fat among treatments. Milk protein yield was higher for cows fed CMA prepartum compared with CON. Interactions of prepartum treatment and week were observed for yield of milk fat and energy-corrected milk because of higher yields for cows fed CMA during wk 2 and 6 compared with CON. Serum Na concentrations were greater for cows fed CON prepartum or NBC postpartum compared with CMA. Postpartum urinary concentrations of Na exhibited an interaction among treatments and were higher for CON-NBC and CMA-NBC compared with CON-CMA and CMA-CMA. Similar interactions of treatments were also observed for serum urea N and creatinine postpartum. Postpartum urinary K concentrations were higher for cows fed CMA postpartum compared with NBC. Results of this trial indicate that feeding cows CMA prepartum does not affect DMI or serum metabolites prepartum, but does support higher milk protein yield. Performance and serum metabolite concentrations of cows fed CMA postpartum were comparable with that of cows fed NBC, except for changes in serum and urinary concentration of Na, which was a function of dietary Na intake.

Genomic collinearity and the genetic architecture of floral differences between the homoploid hybrid species Iris nelsonii and one of its progenitors, Iris hexagona

Hybrid speciation represents a relatively rapid form of diversification. Early models of homoploid hybrid speciation suggested that reproductive isolation between the hybrid species and progenitors primarily resulted from karyotypic differences between the species. However, genic incompatibilities and ecological divergence may also be responsible for isolation. Iris nelsonii is an example of a homoploid hybrid species that is likely isolated from its progenitors primarily by strong prezygotic isolation, including habitat divergence, floral isolation and post-pollination prezygotic barriers. Here, we used linkage mapping and quantitative trait locus (QTL) mapping approaches to investigate genomic collinearity and the genetic architecture of floral differences between I. nelsonii and one of its progenitor species I. hexagona. The linkage map produced from this cross is highly collinear with another linkage map produced between I. fulva and I. brevicaulis (the two other species shown to have contributed to the genomic makeup of I. nelsonii), suggesting that karyotypic differences do not contribute substantially to isolation in this homoploid hybrid species. Similar to other studies of the genetic architecture of floral characteristics, at least one QTL was found that explained >20% variance in each color trait, while minor QTLs were detected for each morphological trait. These QTLs will serve as hypotheses for regions under selection by pollinators.

Technology for mobility in SCI 10 years from now

OBJECTIVES

To identify technological advances and that are likely to have a great impact on the quality of life and participation in individuals with spinal cord injury (SCI).

METHODS

In this paper we use the International Classification of Function to frame a discussion on how technology is likely to impact SCI in 10 years. In addition, we discuss the implication of technological advances on future research.

RESULTS/CONCLUSION

Although technology advances are exciting, a large challenge for the research community will be how to effectively apply and deploy this technology. Advances occurring in the next 10 years that reduce cost of technology may be more important to the population with SCI than brand new technologies. Social context is everything. As a research community we must advocate for better systems of care. Advocating now for better care will lead to a world in 2020 that is ready to adopt new technologies that are truly transformative.

Evaluation of a pharmacist-led, medicines education program for Aboriginal Health Workers

INTRODUCTION

The health of Indigenous Australians is exceptionally poor compared with that of non-Indigenous Australians. Cardiovascular diseases are the leading cause of death, the death rate being at least 2.7 times higher than the total Australian population. Indigenous Australians also experience underutilisation and reduced quality use of medicines. Aboriginal Health Workers (AHWs) are appropriate members of the healthcare team to provide information about medicines to the Indigenous community. However, despite having an expanding role in medicines management, AHWs have reported they do not have adequate appropriate education to support this role. Community pharmacists in localities with high Indigenous populations are well placed to provide medicines education to AHWs; however, to be successful in this role they need to develop their cultural awareness. The purpose of this study was to evaluate a culturally appropriate, pharmacist-led cardiovascular medicines education program for AHWs. Research questions included: What was the impact of the program on the pharmacists? What were the barriers and facilitators? Was the program useful and acceptable to the AHWs?

METHODS

Four educational units were developed in collaboration with AHWs. A purposive sample of community pharmacists from western New South Wales (NSW) attended training involving instruction in the delivery of the program and cultural awareness training. The pharmacists then recruited local AHWs and delivered the program. Evaluation, with respect to the pharmacists, involved a repeated measures, three-phase questionnaire and semi-structured, face-to-face, in-depth interview post-program. Feedback was obtained from the AHWs in the form of a brief survey, and an audit of the attendance at each session was performed.

RESULTS

Twelve pharmacists in 10 localities throughout western NSW delivered the program to a total of 47 AHWs. Statistically significant differences in the questionnaire responses, as a result of delivering the education, indicated the pharmacists felt better equipped to deal with Indigenous health issues (p = 0.002, Mann-Whitney U-test); they knew more AHWs in their area (p = 0.005, Mann-Whitney U-test); they felt more confident as educators of AHWs (p = 0.007, Mann-Whitney U-test); and more confident that they had the necessary resources to deliver this education (p = 0.005, Mann-Whitney U-test). The semi-structured interviews revealed that the experience of delivering the education improved pharmacists' confidence as educators and motivated them to develop sustainable relationships with AHWs. A significant barrier lay in the challenges associated with organizing the AHW education sessions, while an important facilitator was prior established relationships with local Aboriginal health services. Evaluation with respect to the AHWs revealed the program reached 80% (n = 47/59) of AHWs within the western NSW region. In total, 46% (n = 27) of AHW participants attended all four educational units and attendance at each educational unit was above 78% (n = 37) throughout. The AHWs reported that they found the program interesting and relevant and were enthusiastic for future collaboration with the pharmacists.

CONCLUSIONS

The desire to develop sustainable relationships was seen by all participants as the most positive aspect of the program.

Regulation of phosphoinositide and phosphatidylcholine phospholipases by G proteins

Two G proteins that regulate phosphoinositide phospholipase C in liver plasma membranes have been purified to homogeneity in both the heterotrimeric and dissociated forms. The heterotrimers contain a 42 kDa or 43 kDa alpha subunit and a 35 kDa beta subunit. The alpha subunits are not ADP-ribosylated by pertussis toxin and are closely related immunologically to members of the recently identified Gq class of G proteins. The specific phosphoinositide phospholipase C isozyme that responds to the G proteins has been determined to the beta 1 isozyme. GTP analogues stimulate phosphatidylcholine hydrolysis in rat liver plasma membranes. The nucleotide specificity and Mg2+ dependency of the response indicate that it is mediated by a G protein. Phosphatidic acid, diacylglycerol, choline and phosphorylcholine are the products, indicating that both phospholipase D and C activities are involved. Activation of phospholipase D is also indicated by the enhanced production of phosphatidyl-ethanol in the presence of ethanol.

c-Src and mitosis

The transforming potential and by inference the physiological function of the proto-oncoprotein pp60c-src closely correlate with the level of its protein tyrosine kinase activity. We have investigated the cell cycle-dependent regulation of this activity using mouse fibroblasts overexpressing chicken or mouse pp60c-src as a model system. During mitosis pp60c-src becomes phosphorylated at specific serine and threonine residues by p34cdc2. At the same time its tyrosine kinase activity, assayed in vitro, is increased approximately twofold and accessibility of its SH2 domain for binding relevant phosphotyrosine-containing ligands increases by about 15-fold. A kinase-defective mutant of pp60c-src exhibits a substantial (50-70%) decrease in phosphorylation at Tyr527 during mitosis. Phosphorylation of this residue negatively regulates kinase activity. Indirect evidence indicates a lesser decrease in wild-type pp60c-src Tyr527 phosphorylation during mitosis. Coordinate mutation of the mitosis-specific phosphorylation (MSP) sites in kinase-defective pp60c-src greatly reduces, though does not abolish, its mitosis-specific tyrosine dephosphorylation. Similarly, coordinate mutation of the three MSP sites in chicken pp60c-src or the corresponding two sites in mouse pp60c-src does not completely block mitotic stimulation of kinase activity. Thus, additional events beyond p34cdc2-mediated phosphorylation are involved in cell-cycle dependent regulation of pp60c-src activity. This is also suggested by the stimulation of pp60c-src kinase activity and decrease in phosphorylation of Tyr527 observed following treatment of fibroblasts with okadaic acid, a potent inhibitor of types 1 and 2A serine/threonine phosphatases. The potential role of cell cycle-dependent regulation of phosphatases and kinases acting on the regulatory tyrosine residue of pp60c-src is discussed.

Pharmacists' views on Indigenous health: is there more that can be done?

INTRODUCTION

Our previous study explored the views of Aboriginal health workers (AHWs) in mid western New South Wales (NSW), Australia, in relation to pharmacy and the access to, and use of medicines by Indigenous Australians. That study also explored suggestions made by AHWs to improve the situation. This research aimed to ascertain the readiness and willingness of community pharmacists in rural and remote NSW to take on a greater role in relation to Indigenous health by exploring their knowledge and opinions about Indigenous health, their current interaction with Indigenous people, and their views as to feasible and achievable ways to help. Pharmacists' views were compared with those of the AHWs elicited in the previous study and any differences in perceptions noted.

METHODS

Twenty seven semi-structured, face-to-face, in-depth interviews were carried out with NSW community pharmacists working in areas with an Indigenous population. All except one of the 27 pharmacists were based in a rural or remote setting. A qualitative research method was used and the concepts explored in the interviews included pharmacists' current knowledge of Indigenous health, views on the feasibility of proposed new programs from the previous study, and any other ideas that may improve Indigenous health. The interviews were audio recorded, transcribed verbatim, then thematically content analysed.

RESULTS

Pharmacists identified chronic diseases as the main health concerns and many felt their Indigenous customers experienced these at a high rate, at a young age of onset and generally had poor management of the condition. They were aware that AHWs were available in their community but interaction varied. Almost all pharmacists felt that Indigenous people were comfortable shopping in their pharmacies, and identified lack of money as the major barrier to access to medicines. Many pharmacists felt that Indigenous patients would be best served in the pharmacy if medications were available at no charge; however, they seemed to be unaware that Indigenous people often feel uncomfortable entering their pharmacies. The majority felt the AHWs' ideas, such as periodically having an AHW in the pharmacy, cultural awareness training and increased collaboration between pharmacists and AHWs, may be of benefit.

CONCLUSION

Despite the potential for expansion of the role of the pharmacist in Indigenous health, the majority of participants in this study were reluctant to commit themselves more than at present unless the financial barriers were removed. In addition, although they expressed an openness to undergoing training in cultural safety, and a willingness to have a greater understanding of Indigenous culture, they were very conscious of a lack of time to do so, a situation generally resulting from a shortage of pharmacists. Their awareness of and current interactions with AHWs were limited, but all participants could see the potential value of working more closely with these important members of the healthcare team. If the proposed extension of Section 100 of the Australian Pharmaceutical Benefits Scheme goes ahead and financial barriers are removed, it then remains for pharmacists to take up the challenge to increase their own understanding of Indigenous health issues and form collaborative partnerships with their AHW counterparts. Then a real change for the better in mainstream pharmacy services may be achieved.

Improving access to medicines in urban, regional and rural Aboriginal communities--is expansion of Section 100 the answer?

The poor health of Indigenous Australians is highlighted by the fact that their life expectancy is 17 years less than that of non-Indigenous Australians. The cause of this health disparity is multifactorial, and includes the under use of health services and medications. Distance, cost, and embarrassment, or fear of seeking help from culturally inappropriate services have all contributed to the reduced health status of Indigenous Australians. The introduction of Aboriginal medical services (AMS), Aboriginal health workers, and Section 100 (S100) of the Australian Pharmaceutical Benefits Scheme (PBS) have been important steps towards improving Aboriginal access to health services and medications. Despite this, spending on pharmaceuticals under the PBS per capita among the Indigenous population remains significantly lower than that of the non-Indigenous population. Because Aboriginal people from all areas experience similar barriers in their access to medicines, it has been suggested that the S100 scheme be made available to all AMS. Ensuring quality use of medicines needs to be addressed because patient counselling is carried out by the clinic staff, rather than the pharmacist and, therefore, in this case the pharmacist's role converts to one of training and providing information to the AMS. This expansion of S100 services may lead Indigenous health down a path of separation from mainstream services, which in turn would require nearly no adjustment by pharmacies and pharmacists to meet the needs of Indigenous people. Unfortunately, for no known reasons, previous suggestions to improve Aboriginal people's utilisation of mainstream health services and pharmacies have not been actioned.

Faecal incontinence

BACKGROUND

Faecal incontinence is a life style-limiting condition with multiple aetiologies. Surgical cure is not often possible.

METHODS AND RESULTS

A review of the literature was undertaken using Medline, Cochrane database and standard textbooks. Advanced imaging techniques now inform the treatment algorithm and objectively assess success. The long-term outcome of anal surgery is uncertain. Modern approaches favour conservative measures, such as biofeedback, and less invasive surgical procedures. Stoma formation is a definitive option for some patients.

CONCLUSION

Current treatment of faecal incontinence is evolving from a sphincter-focused view to a more holistic one, recognizing the influence of the pelvic floor and psyche in maintaining continence. Modern imaging modalities direct treatment strategies.

Nasointestinal intubation with tiger tubes: a case series indicates risk of mucosal damage

Abstract In five intubations using the tiger tube (Cook) two were successfully placed into the small intestine. Two of the three intubation failures were due to early death due to the underlying condition. Nasointestinal placement permitted successful enteral feeding. Unfortunately, both nasointestinal placements were associated with mucosal damage that appears to be related to the tube "flaps". The tiger tube facilitates nasointestinal tube placement but until concerns regarding safety are addressed its clinical use cannot be recommended.

Confirmation of nasogastric tube position by pH testing

INTRODUCTION

In 2004, the Medicines and Healthcare products Regulatory Agency (MHRA) advised that nasogastric (NG) tube position should be confirmed using pH strips or paper. However, gastric pH is raised by the use of H2-blockers and proton-pump inhibitors (PPIs) potentially producing false negative pH tests resulting in delayed feeding. In addition, colorimetric differentiation using pH strips may be more prone to bias and inaccuracy than direct pH measurements largely used to establish the threshold.

METHOD

To quantify this problem a 1 day survey of all the patients requiring NG and nasointestinal (NI) feeding was undertaken, to establish the numbers of patients receiving H2-Blockers or PPIs, with or without a safe swallow and the methods currently being used to confirm tube positioning. A second observational study was performed to establish the accuracy of six pH strips available to NHS trusts against four unlabelled pH solutions.

RESULTS

Forty-two per cent of patients receiving NG feeding were on H2-blockers or PPIs, including 13% who had a safe swallow for acidic drinks that could be subsequently aspirated to confirm position. In the second study 'testers' correctly identified pH's 3, 4, 5 and 6 with Mackery-Nagel 0-6, BDH 0-6 and 0-14 strips but overestimated pH 4 as pH 5 with Johnson 0-11 paper, underestimated pH 6 as pH 5 with Pehanon 0-12 paper and with Litmus classified pH 3-5 as acid (all), but half also classified pH 6 as acid.

CONCLUSION

Theoretically 29% of NG tube positions could not be confirmed by pH testing because of the usage of PPIs or H2-blockers and lack of swallow. Some pH strips are either inaccurate or their result misinterpreted by staff. Large surveys and trials of the actual efficacy and accuracy of pH testing are required.

Hot Topic: Using a Stearoyl-CoA Desaturase Transgene to Alter Milk Fatty Acid Composition

Stearoyl-CoA desaturase enzyme converts specific medium- and long-chain saturated fatty acids to their monounsaturated form. Transgenic goats expressing a bovine beta-lactoglobulin promoter-rat stearoyl-CoA desaturase cDNA construct in mammary gland epithelial cells were produced by pronuclear microinjection. The fatty acid composition of milk from 4 female transgenic founders was analyzed on d 7, 14, and 30 of their first lactation. In 2 animals, the expression of the transgene changed the overall fatty acid composition of the resulting milk fat to a less saturated and more monounsaturated fatty acid profile at d 7 of lactation; however, this effect diminished by d 30. In addition, one animal had an increased proportion of the rumen-derived monounsaturated fatty acid C18:1 trans11 converted by stearoyl-CoA desaturase to the conjugated linoleic acid isomer C18:2 cis9 trans11. Milk that has higher proportions of monounsaturated fatty acids and conjugated linoleic acid may have benefits for human cardiovascular health.

Breast screening: the use of consensus opinion for all recalls

The quality of a breast-screening programme is measured not only by it's cancer detection rates (sensitivity), but also by it's recall rates and positive predictive values (specificity). False positive screens, which lead to assessments with benign outcomes, can cause psychological and physical morbidity in previously well women. In 1999 the Wiltshire breast-screening programme adopted a novel recall strategy whereby all films marked for recall are subject to consensus opinion--even women "recalled" by both original readers may be returned to routine screening. Since 1999 our recall rates have fallen from above to below the national averages (prevalent 7.2% and incident 3.0% in 2001/02). Specificity has increased over the same period such that approximately one in seven women assessed will be diagnosed with cancer. The consensus meetings provide a forum for teaching and are very popular with our film readers, who all report reduced levels of stress.

Peripheral parenteral nutrition in a case of chyle leak following neck dissection

Chylothorax is an uncommon condition which is potentially life-threatening if untreated. The following case study of a 75-year-old man with chyle leak following surgery shows how prompt dietetic action prevented further compromise in immune function and nutritional status. Dietetic recommendation to minimize enteral intake rapidly stopped chyle flow and promoted wound closure. Peripheral parenteral nutrition (PPN) was administered in order to prevent malnutrition. There is limited literature available for evidence of best practice for cases of chyle leakage, however, this particular case demonstrates PPN should be considered despite the potential risks.

Increasing dietary levels of cracked pima cottonseed increase plasma gossypol but do not influence productive performance of lactating Holstein cows

Lactating Holstein cows were fed diets with increasing levels of cracked Pima cottonseed to determine its effects on plasma gossypol concentrations as well as milk yield and composition and dry matter (DM) intake in a short-term study. All diets contained 12.8% cottonseed, 43.5% concentrate, and 43.7% chopped alfalfa hay on a DM basis. The proportion of whole Upland cottonseed to cracked Pima cottonseed in the four dietswas 100:0, 67:33, 33:67, and 0:100. Four primiparous cows were fed the diets in a 4 x 4 Latin square design, and three multiparous cows were fed the diets in a Youden square design with five periods. All periods were 35 d. Upland and cracked Pima cottonseed contained 0.64 and 1.00% total gossypol (DM) with 41 and 52% of gossypol as the (-) isomer, respectively. Gossypol is a natural defense compound in the plant that protects it against pests and diseases, but can have antinutritional quality effects when consumed by dairy cattle. Total plasma gossypol concentrations increased linearly with increasing proportions (100:0, 67:33, 33:67, and 0:100) of cracked Pima cottonseed in the diet for primiparous (4.4, 6.0, 7.7, and 8.9 microg/ml) and multiparous (4.3, 7.3, 9.7, and 11.4 microg/ml) cows, respectively. While primiparous cows responded similarly to gossypol intake, the response of plasma gossypol intake in multiparous cows differed among cows. This indicates the importance of animal variation when relating plasma gossypol levels with gossypol intake. Milk yield, as well as its components and DM intake, were not affected by increasing dietary inclusion levels of cracked Pima cottonseedup to 8.6% of DM intake for either primiparous or multiparous cows, even though plasma gossypol concentrations increased sharply over this dietary inclusion range. Although the highest dietary inclusion level of Pima cottonseed (i.e., 12.8%) numerically depressed performance of cows of both parities, these differences failed to reach statistical significance in these short-term trials with few cows.

Splenic lymphocytes of adult Xenopus respond differentially to PMA in vitro by either dying or dividing: significance for cancer resistance in this species

Wild-type populations of amphibians, unlike mammalians, appear to be resistant to spontaneous and chemically induced neoplasms. Few true cancers have been reported for non-isogeneic members of Xenopus laevis, despite their widespread use in laboratories around the world. Injection of even the most powerful direct mammalian oncogens e.g. N-methyl N-nitrosourea, that depleted specific populations of T lymphocytes, did not induce cancer. Phorbol diesters, e.g. PMA, are mitogens and apoptogens in both amphibian, and mammalian immunocytes. In mammalian cells, regulation of the cell cycle and of apoptosis are often intimately linked, however, a disjunction in time between early apoptosis and later cell cycling, has been observed with PMA-treated Xenopus splenocytes. Thus, a particular difference between amphibians and mammals may be the requirement to enter the cell cycle before a progression to death by apoptosis. This hypothesis was tested here using dual staining flow cytometry. Xenopus laevis splenocytes were cultured for 8, 24 and 48 hours with phorbol 12-myristate 13-acetate (PMA), previously shown to be mitogenic and apoptotic with mature Xenopus lymphocytes. The cells were stained with FITC-conjugated Annexin V or with FITC-labeled deoxyuridine triphosphates (FITC-dUTP) to assay for the apoptotic markers phosphotidylserine or DNA strand breaks respectively. Phycoerythrin (PE)-conjugated anti-human proliferating cell nuclear antigen (PE-PCNA) was used as a cell cycle marker that is present during the entire cell cycle. Propidium iodide (PI) binds DNA and was used to assay for late stage apoptosis, as well as to assess DNA content. Significantly higher levels of apoptosis develop rapidly in PMA-exposed splenocytes and are maintained at 24 hours, declining by 48 hours. Cells expressing PCNA or incorporating PI in excess of the normal genomic level were found by 48 hours following PMA exposure. The absence of any significant rise in a small (<5%) dual staining cell population indicates that the apoptotic cell population remained distinct from cells already in the cell cycle from the onset of PMA exposure. Thus, Xenopus splenocytes respond differentially to PMA. Those that undergo apoptosis rapidly were quiescent, non-cycling small lymphocytes. Moreover, the cells that eventually begin division, following PMA exposure, were unaffected by the early apoptosis and do not themselves die while in the cell cycle. The rapid apoptotic response of X. laevis cells to PMA may confer a natural cancer resistance in this species, as cells that fail to enter the cell cycle after exposure to cancer promoting reagents cannot express genetic destabilization that might have led to transformation.

Fatty acid and triglyceride composition of milk fat from lactating Holstein cows in response to supplemental canola oil

The objective was to determine the influence of dietary lipid on total and sn-2 fatty acid composition and triglyceride structure of milk fat in lactating Holstein cows. Five primiparous Holstein cows surgically fitted with ruminal and duodenal cannulas were used in a 4 x 5 incomplete Latin square. All cows received a basal diet. Treatments consisted of a basal diet with no supplemental canola oil (control), basal diet with canola oil added to the concentrate portion of the diet to provide 1.6% fat, basal diet with 330 g of canola oil infused directly into the rumen, and basal diet with 330 g of canola oil infused directly into the abomasum. Canola oil treatments decreased palmitic acid and increased oleic acid content of milk fat compared with the control. Stearate was higher when canola oil was rumen available compared with control and abomasal infusion. Abomasal infusion increased linoleic and linoleic acids in milk fat compared with the other treatments. The sn-2 fatty acid composition reflected total fatty acid composition. All canola oil treatments reduced palmitic acid and increased oleic acid content at the sn-2 position. Changes in sn-2 composition reflect specificity of the acyl transferases and substrate concentration. Triglyceride composition reported as carbon number was altered by canola oil. Triglycerides in carbon number C50, C52, and C54 were increased while C32, C34, and C36 were decreased.

Direct explanations for the development and use of a multi-layer perceptron network that classifies low-back-pain patients

Using a new method published by the first author, this article shows how direct explanations can be provided to interpret the classification of any input case by a standard multilayer perceptron (MLP) network. The method is demonstrated for a real-world MLP that classifies low-back-pain patients into three diagnostic classes. The application of the method leads to the discovery of a number of mis-diagnosed training and test cases and to the development of a more optimal low-back-pain MLP network.

Forces and moments telemetered from two distal femoral replacements during various activities

Two distal femoral replacements were instrumented to measure axial force, torque and bending moments in the prosthesis shaft. Data are reported up to 2.5 years for the following activities: uni- and bi-lateral standing, walking, stair climbing and descending, treadmill walking, jogging and jumping. In the first subject the greatest averaged peak shaft forces found were: jogging 3.6Bodyweight (BW), stair descending 3.1BW, walking 2.8BW, treadmill walking 2.75BW, and stair ascending 2.8BW. Bending moments about the antero-posterior axis (varus-valgus) and medio-lateral axis (flexion-extension) peaked in the range 8.5-9.8 and 4.7-7.6BWcm respectively, over the follow-up period. Axial torques peaked in the range 0.2-1.3BWcm, outwardly directed. At most follow-up sessions, forces and moments during jogging were generally greater than those for other gait activities. In the second subject forces and moments were generally only 45-70% of those in the first subject, due to inadequate musculature around the knee. The data can be applied to the design and testing of distal femoral replacements and even to total knee replacements, and contributes to the knowledge of forces acting in the distal femur during activity.

Enantio- and diastereoselective reductive aldol reactions with iridium-pybox catalysts

[see reaction]. A catalytic amount of [(cod)IrCl]2 and indane-pybox converts diethylmethylsilane, methyl acrylate, and certain aldehydes to the derived reductive aldol adduct with good enantio- and diastereocontrol.

GABAergic blockade of cocaine-associated cue-induced increases in nucleus accumbens dopamine

Environments previously associated with drug use can become one of the most common factors triggering relapse to drug-seeking behavior. To better understand the neurochemical mechanisms potentially mediating these cues, we measured nucleus accumbens dopamine levels in animals exposed to environmental cues previously paired with cocaine administration. In animals exposed to a cocaine-paired environment nucleus accumbens dopamine increased by 25%. When administered 2.5 h prior to presentation of the environmental trigger, racemic vigabatrin (an irreversible inhibitor of gamma-aminobutyric acid (GABA)-transaminase) abolished this cue-induced increase. Conversely, R-(-)-vigabatrin, the inactive enantiomer, had no effect. Combined with our earlier findings, these studies support the potential therapeutic benefit of this enzyme-based GABAergic strategy to modulate brain dopamine and the subsequent treatment of drug addiction.

Performance of a new pubertal self-assessment questionnaire: a preliminary study

We describe the performance of a new, self-assessment questionnaire that aims to measure pubertal status by using gender-specific line drawings of the Tanner puberty stages. The study was carried out on 103 children aged 12-16 years attending a paediatric endocrinology outpatient clinic and used physical examination by clinic doctors as the 'gold standard'. Of 133 consecutive, eligible children, 108 (81%) agreed to participate in the study. Data were collected from 62 (60%) males and 41 (40%) females. Mean age was 14.78 years (SD = 1.26 years, range 12.08-16.98 years). For the pubic hair distribution Tanner stage, there was agreement to within one Tanner stage for 90 children (88%), weighted kappa statistic for inter-rater agreement = 0.68 [95% CI 0.49,0.87]. For the female breast/male genitalia Tanner stage, there was agreement to within one Tanner stage for 75 children (76%), kappa = 0.48 [95% CI 0.31,0.64]. The children tended to underestimate their stage of pubertal development. Overall, the kappa statistics implied good agreement for the pubic hair question and moderate agreement for the breast/genitalia stage question in both girls and boys. The questionnaire may prove useful in situations such as large-scale epidemiological studies, in which direct examination of children to determine pubertal status is not possible, and further validation in normal adolescents is warranted.

Cost-benefit analysis of a Haemophilus influenzae type b meningitis prevention programme in The Philippines

BACKGROUND

Haemophilus influenzae type b (Hib) meningitis is associated with high mortality and serious sequelae in children under 5 years of age. Vaccines which can prevent this infection are available.

OBJECTIVE

To evaluate the costs and benefits of a 3-dose immunisation schedule in Manila, Philippines.

PERSPECTIVE

Government and societal perspectives.

DESIGN AND PARTICIPANTS

A cost-benefit analysis based on a birth cohort of 100,000 children. The state of health of the cohort with and without a Hib immunisation programme was modelled over a 5-year period. A survey of medical records of patients with Hib in Manila provided data on the extent and cost of sequelae following infection.

INTERVENTION

A 3-dose Hib vaccination programme given at ages 2, 3 and 4 months.

RESULTS

The model predicted that vaccinating children against Hib meningitis would prevent 553 cases per year in a birth cohort of 100,000, at a cost of 56,200 Philippine pesos (PHP) [$US1,605; 1998 exchange rate] per case (base case assumptions of 90% vaccine efficacy rate, 95 per 100,000 Hib incidence rate, 85% vaccination coverage). Results from the cost-benefit analyses indicated that the saving to the government would be around PHP39 million ($US1.11 million), and the saving to society would be PHP255 million ($US7.28 million).

CONCLUSION

There would be a positive economic benefit for the Philippine government and for the Filipino society if a Hib vaccination programme was introduced in Manila.

The human GABA(B1b) and GABA(B2) heterodimeric recombinant receptor shows low sensitivity to phaclofen and saclofen

1. The aim of this study was to characterize the pharmacological profile of the GABA(B1)/GABA(B2) heterodimeric receptor expressed in Chinese hamster ovary (CHO) cells. We have compared receptor binding affinity and functional activity for a series of agonists and antagonists. 2. The chimeric G-protein, G(qi5), was used to couple receptor activation to increases in intracellular calcium for functional studies on the Fluorimetric Imaging Plate Reader (FLIPR), using a stable GABA(B1)/GABA(B2)/G(qi5) CHO cell line. [(3)H]-CGP-54626 was used in radioligand binding studies in membranes prepared from the same cell line. 3. The pharmacological profile of the recombinant GABA(B1/B2) receptor was consistent with that of native GABA(B) receptors in that it was activated by GABA and baclofen and inhibited by CGP-54626A and SCH 50911. 4. Unlike native receptors, the GABA(B1)/GABA(B2)/G(qi5) response was not inhibited by high microMolar concentration of phaclofen, saclofen or CGP 35348. 5. This raises the possibility that the GABA(B1)/GABA(B2)/G(qi5) recombinant receptor may represent the previously described GABA(B) receptor subtype which is relatively resistant to inhibition by phaclofen.

Cloning, expression, and characterization of pyrrolidone carboxyl peptidase from the archaeon Thermococcus litoralis

The gene encoding pyrrolidone carboxyl peptidase (Pcp) has been cloned from the hyperthermophilic archaeon Thermococcus litoralis. The recombinant enzyme has been expressed in Escherichia coli, purified, and characterized. The T. litoralis Pcp demonstrates strong sequence homology to previously characterized bacterial Pcps. Some investigations have been carried out on enzyme substrate specificity and stability.

Dying in Canada: is it an institutionalized, technologically supported experience?

Although preliminary evidence shows that people generally prefer to die at home, very little is known about where Canadians die. Understanding the epidemiology of dying in Canada may illuminate opportunities to improve quality of end-of-life care and related health policy. We conducted a cross-sectional analysis of death records in Canada to determine the proportions of deaths occurring in hospitals and special care units. Our analysis found that deaths in Canada occur in hospitals with provincial and territorial proportions ranging from 87% in Quebec to 52% in the Northwest Territories. In hospitals recording deaths in special care units, 18.64% of all deaths occurred in special care units. The proportion of deaths in special care units ranged from 25% in Manitoba to 7% in the Northwest Territories. The proportion of deaths in special care units varied by size and nature (teaching vs. non-teaching) of hospitals. It increased with the size of the hospital from 8% in hospitals with 1-49 beds, to 23% for hospitals with 400 or more beds. In teaching hospitals, 27% of deaths occurred in special care units, and in non-teaching hospitals the proportion was 15%. In conclusion, the majority of deaths in Canada occur in hospitals and a substantial proportion occur in special care units, raising questions about the appropriateness and quality of current end-of-life care practices in Canada.

Influences of saturation ratio of supplemental dietary fat on digestion and milk yield in dairy cows

Four multiparous, ruminally and duodenally cannulated Holstein cows in midlactation were utilized in a 4 x 4 Latin square to evaluate the effects of supplemental fat from sources varying in proportions of unsaturated and saturated fatty acids on nutrient digestion and lactation performance. All diets (45% alfalfa hay) contained 12% whole cottonseed (as-fed); treatments were no supplemental fat (control, 3% total fatty acids, dry matter basis) or additional 2% tallow, 2% yellow grease, or 2% blend (60% tallow: 40% yellow grease). The unsaturated to saturated fatty acid ratios were 1:1 for tallow and 2.5:1 for yellow grease. Dry matter intake, apparent ruminal and total tract digestibilities of organic matter, neutral detergent fiber, acid detergent fiber, N, and fatty acids, and microbial efficiency were similar across treatments. Microbial N flow to the duodenum was increased by yellow grease. Supplemental fat reduced the postruminal digestibility of fatty acids, primarily the saturated fatty acids; increasing saturation of the fat source magnified the reduction. Total volatile fatty acid concentrations and ruminal fluid pH were unaffected by fat supplementation or saturation level. Blend decreased ruminal pH and acetate to propionate ratio. Yields of milk and milk fat increased with fat supplementation. Concentrations and yields of trans vaccenic acid in milk increased linearly with the unsaturated fatty acid content of the fat supplement. Modest supplementation using highly unsaturated fats to diets containing whole cottonseed can increase milk production without disturbing rumen function, evident by the similar VFA concentrations, nutrient digestibilities, and milk composition.

gamma-aminobutyric acid mimetic drugs differentially inhibit the dopaminergic response to cocaine

Dopaminergic activity in the mesocorticolimbic system is associated with reinforcing properties of psychostimulant drugs. We previously demonstrated that increased gamma-aminobutyric acid (GABA)-ergic activity produced by gamma-vinyl GABA [D,L-4-amino-hex-5-enoic acid (Vigabatrin(R))], an irreversible inhibitor of GABA-transaminase, attenuated cocaine, nicotine, heroin, alcohol, and methamphetamine-induced increases in extracellular nucleus accumbens dopamine as well as behaviors associated with these biochemical changes. In the present study, using in vivo microdialysis techniques, we compared three different strategies to increase GABAergic activity in order to modulate cocaine-induced increase in extracellular dopamine. Our data demonstrate that the anticonvulsant 1-(2-(((diphenylmethylene)amino)oxy)ethyl)-1,2,5, 6-tetrahydro-3-pyridinecarboxylic acid hydrochloride (NNC-711), a GABA uptake inhibitor, dose and time dependently diminished increases in extracellular dopamine following acute cocaine challenge. Furthermore, we demonstrated that cyclized analogue of vigabatrin, a competitive reversible GABA-transaminase inhibitor, is a more potent inhibitor of cocaine-induced dopamine increase than vigabatrin. Our data suggest that in addition to irreversible inhibition of GABA transaminase, inhibition of GABA uptake represent another potentially effective, indirect strategy for the treatment of cocaine abuse.

Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury

OBJECTIVE

To determine the effect of early enhanced enteral nutrition (EN) on clinical outcome of head-injured patients.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Tertiary neurosurgical and trauma center.

PATIENTS

Eighty-two patients suffering head injury and requiring mechanical ventilation.

INTERVENTIONS

Patients were randomized to receive standard EN (gradually increased from 15 mL/hr up to estimated energy and nitrogen requirements) or enhanced EN (started at a feeding rate that met estimated energy and nitrogen requirements) from day 1. Good neurologic outcome (Glasgow Outcome Scale score of 4 or 5) was determined at 3 and 6 months after injury, and the incidence of infective and total complications was determined during the hospital stay up to 6 months.

MEASUREMENTS AND MAIN RESULTS

Disease severity assessed by best preintubation Glasgow Coma Scale score, pupillary responses, Injury Severity Score, Acute Physiology and Chronic Health Evaluation II score, computed tomographic scan categorization, and age was similar in both groups. Intervention patients had a higher percentage of energy (p = .0008) and nitrogen (p<.0001) requirements met by EN in the first week after injury. Neurologic outcome at 6 months was similar between groups, but there was a tendency for more intervention patients to have a good neurologic outcome at 3 months than control patients (61% vs. 39%, p = .08). Fewer intervention patients had an infective complication (61% vs. 85%, p = .02) or more than one total complication (37% vs. 61%, p = .046) compared with control patients. Enhanced EN was associated with a reduction in the ratio of serum concentration of C-reactive protein to albumin up to day 6 after injury (p = .004).

CONCLUSIONS

Enhanced EN appears to accelerate neurologic recovery and reduces both the incidence of major complications and postinjury inflammatory responses.

Novel screening methods--the key to cloning commercially successful biocatalysts

Providing sufficient biocatalyst to support the demands of multi tonne product supply can be problematical. Here we describe how screening for and cloning a gamma-lactamase overcame biocatalyst supply issues, and greatly improved the actual biocatalytic process. The isolation of an expressing gamma-lactamase clone from a gene library necessitated a combination of classical molecular biology techniques together with innovative screening methods to identify a functional clone. Once isolated the enzyme was characterised with regard to its process performance and proved to be active at 500 g L(-1) substrate. Further development of the recombinant fermentation and downstream processing has resulted in the ability to produce sufficient biocatalyst from one 5001 fermentation to resolve 5 metric tonnes of (+/-)-lactam, whilst simplifying the process chemistry greatly.

How advance directives affect hospital resource use. Systematic review of the literature

OBJECTIVE

To assess whether advance directives influence resource use by hospitalized patients.

DATA SOURCES

A systematic search of computerized medical databases, reference lists from relevant articles, and personal files was conducted to identify studies examining the association between advance directives and resource use.

STUDY SELECTION

Primary studies assessing the effect of advance directives on hospital resource use were selected if they had a clear quantitative measure of hospital resource use, hospitalized patients as a study population, a control group for comparison, and a description of the advance directive being studied. Data on the following topics were abstracted from studies meeting inclusion criteria: study methods and design, resource use, source of financial data, description of advance directive, population size and composition, length of assessment.

SYNTHESIS

Six studies met inclusion criteria. Three retrospective studies showed significant reductions in resource use associated with documentation of advance directives while three prospective studies (two randomized, one not randomized) showed no association between advance directives and reduced resource use. Studies were limited to narrowly defined patient populations in US tertiary care hospitals.

CONCLUSIONS

Little evidence supports the hypothesis that advance directives reduce resource use by hospitalized patients. Some retrospective studies have shown savings, but their conclusions are weakened by shortcomings in study design. Prospective trials, which have better experimental methods, have demonstrated no evidence of cost savings with the use of advance directives.

Responsiveness of common outcome measures for patients with low back pain

STUDY DESIGN

A prospective cohort study assessing the responsiveness of two disease-specific questionnaires and a generic health questionnaire for patients with low back pain and sciatica.

OBJECTIVES

To compare the responsiveness of the eight scales and two summery scales of the SF-36 questionnaire with that of the Oswestry Disability Index and Low Back Outcome Score questionnaires.

SUMMARY OF BACKGROUND DATA

Evaluation of treatment outcome is being determined more frequently from a patient's perspective, particularly the impact treatment has on current health status.

METHODS

Patients were recruited from two orthopedic back pain clinics in a tertiary hospital. Patients completed the pretreatment questionnaire 1 month before treatment and follow-up questionnaires a minimum of 2-6 months after treatment. Patients undergoing surgery were also observed for a minimum of 2 years.

RESULTS

Overall, the Oswestry Disability Index was most responsive; however, individual scales from the SF-36 questionnaire showed equal or greater sensitivity to change than the Oswestry Disability Index in each of the patient subgroups. The SF-36 Role Physical scale was prone to floor effects (a high percentage of respondents score zero), and the change scores from the SF-36 Role Emotional scale varied by 100 points in either direction in each of the patient subgroups.

CONCLUSION

Responsiveness varied according to which method was used in its calculation. The responsiveness of the SF-36 questionnaire shows that it can be a useful adjunct in the assessment of patients with low back pain when combined with disease-specific questionnaires.

A tyrosine-phosphorylated protein that binds to an important regulatory region on the cool family of p21-activated kinase-binding proteins

The p21-activated kinases (Pak) are major targets of the small GTPases Cdc42 and Rac. We, and others, recently identified a family of proteins termed Cool/Pix, which interact with Pak3. In cells, p50(Cool-1) suppresses Pak activation by upstream activators; p85(Cool-1) has a permissive effect on Pak activation, and we now show that the closely related Cool-2 stimulates Pak kinase activity. To understand the differential regulation of Pak by Cool proteins, we screened for Cool-interacting proteins by affinity purification and microsequencing. This has led to the identification of two closely related proteins called Cat (Cool-associated, tyrosine phosphorylated), which contain a zinc finger followed by three ankyrin repeats. Cat-1 is identical to the recently identified binding partner for the beta-adrenergic receptor kinase (betaARK or GRK-2), which was shown to have Arf-GAP activity. Cat-1 and Cat-2 both bind to the COOH-terminal region of p85(Cool-1) and p85(Cool-2) but do not bind to p50(Cool-1). Cat-1 is tyrosine-phosphorylated in growing NIH 3T3 fibroblasts, and its tyrosine phosphorylation is increased following cell spreading on fibronectin, decreased in cells arrested in mitosis, and increased in the ensuing G(1) phase. Cat proteins are tyrosine-phosphorylated when co-expressed in cells with the focal adhesion kinase Fak and Src. These findings suggest that in addition to playing a role in Cool/Pak interactions, Cat proteins may serve as points of convergence between G protein-coupled receptors, integrins, Arf GTPases, cell cycle regulators, and Cdc42/Rac/Pak signaling pathways.

An evaluation of prostaglandin E2 vaginal gel use in practice

OBJECTIVE

The purpose of this study was to investigate the effectiveness of prostaglandin E2 vaginal gel as used in practice, rather than its efficacy as assessed in randomised, controlled, clinical trials. This product is used to ripen the cervix prior to induction of labour, sometimes making unnecessary the use of the standard treatment for induction, artificial rupture of the membranes (ARM) plus oxytocin. In this study, effectiveness of the gel was assessed in terms of changes in mode of delivery, and in particular the risk of Caesarean section.

METHODS

An historical control was used and the risk of Caesarean section for women induced in the 1990/91 (before the introduction of the gel) was compared with that for women induced in 1992/93 (after the introduction of the gel). Maternal characteristics which may have been different in the two groups and factors which might influence the risk of Caesarean section were controlled for statistically using logistic regression, thus reducing any bias towards one group.

RESULTS

After adjusting for the factors which had a significant effect on the process of labour from induction to birth, it was found that the risk of Caesarean section was not significantly lower in the 1992/93-time period, when the gel was in regular use, from that in the 2 years prior to its introduction (Odds ratio 1.09, CI95% 0.88, 1.36).

CONCLUSION

Following the introduction of PGE2 gel, no difference in effectiveness, as measured in terms of mode of delivery, was detected in this study of practice, which included patients with more complex obstetric problems.