eFOCUS 2: A randomised crossover trial of smartphone fundoscopy and direct ophthalmoscopy aiming to improve optic disc interpretation by medical students with e-learning support

BACKGROUND

Ophthalmoscopy and its interpretation are complex. We aimed to compare the diagnostic accuracy of smartphone fundoscopy with traditional direct ophthalmoscopy for optic disc interpretation, with e-learning support.

METHODS

We conducted a randomised, crossover study of 102 medical students. Students were offered e-learning for optic disc interpretation. A fundoscopy objective structured clinical examination was conducted after an introductory lecture and 10-min practical training session on smartphone fundoscopy and traditional ophthalmoscopy. Participants examined patients and simulator slides with a randomised crossover between smartphone [D-eye (Padova, Italy) or iExaminer (Welch Allyn, Macquarie Park, Australia)] and traditional ophthalmoscopy (Welch Allyn). Optic discs were graded independently by three masked ophthalmologists. The primary outcome was the ability to interpret an optic disc as normal or abnormal. Secondary outcomes included other optic disc aspects; student preferences; and e-learning performance.

RESULTS

Students' agreement with the gold standard for an abnormal or normal disc was significantly greater using a smartphone (74.4%) than with direct ophthalmoscopy (68.1%, p = 0.032). More students preferred smartphone (74%) over direct ophthalmoscopy (26%, p < 0.001). E-learning led to an improvement in optic disc interpretation scores (mean improvement = 4.5%, 95% CI = 3.7-5.2, p < 0.001).

CONCLUSIONS

Medical students are more accurate at recognising an abnormal optic disc using smartphone fundoscopy than traditional direct ophthalmoscopy, and have a strong preference for smartphone fundoscopy. E-learning may improve the interpretation of optic disc abnormalities. Smartphone fundoscopy may mitigate some technical challenges of fundoscopy and reinvigorate use of this valuable clinical examination.

Perceived usefulness and ease of use of fundoscopy by medical students: a randomised crossover trial of six technologies (eFOCUS 1)

BACKGROUND

Fundoscopy outside ophthalmology is in decline, and the technical demands of the traditional direct ophthalmoscope examination are likely contributing. Alternative fundoscopy technologies are increasingly available, yet valid comparisons between fundoscopy technologies are lacking. We aimed to assess medical students' perceptions of usefulness and ease of use of traditional and contemporary fundus-viewing technologies including smartphone fundoscopy.

METHODS

One hundred forty-six second-year medical students participated in a cross-sectional, randomised, cross-over study of fundoscopy methods. Medical students completed small group training sessions using six current fundoscopy technologies including: a non-mydriatic fundus camera; two types of direct fundoscopy; and three types of smartphone fundoscopy. A novel survey of perceived usefulness and ease of use was then completed by students.

RESULTS

Repeated-measures ANOVA found students rated both the perceived usefulness (p< 0.001) and ease of use (p< 0.001) of smartphone fundoscopy significantly higher than both the non-mydriatic camera and direct fundoscopy.

CONCLUSIONS

Smartphone fundoscopy was found to be significantly more useful and easier to use than other modalities. Educators should optimise student access to novel fundoscopy technologies such as smartphone fundoscopy which may mitigate the technical challenges of fundoscopy and reinvigorate use of this valuable clinical examination.

Psychological and Medical Characteristics Associated with Non-Adherence to Prescribed Daily Inhaled Corticosteroid

Medication non-adherence is associated with sub-optimal asthma control. Identification of medical and psychological characteristics associated with non-adherence is important to enable a targeted and personalized approach when working with patients and for the development of interventions to improve patient outcomes by improving medication adherence. We enrolled adults who had diagnosed asthma and who were prescribed daily inhaled corticosteroid medication. We used published and validated instruments to measure medical characteristics including asthma features, practical asthma knowledge and perceived involvement in care and psychological characteristics including anxiety, depression, optimism, and personality traits, to assess the relationship with medication non-adherence. A total of 126 participants provided data, with 64 (50.8%) of the participants identified as non-adherent. Multivariate analyses showed that younger age, high neuroticism scores and a previous asthma hospital admission were associated with non-adherence. Interestingly, depression was associated with a lower risk of non-adherence. This study showed that a personalized medicine approach would include interventions targeting those who are younger, who have been in hospital for asthma and who rate high on the neuroticism personality trait. Given the availability of effective medications for asthma, better understanding of the characteristics associated with non-adherence is important to enhance optimal self-management.

177Lu radiolabeling and preclinical theranostic study of 1C1m-Fc: an anti-TEM-1 scFv-Fc fusion protein in soft tissue sarcoma

PURPOSE

TEM-1 (tumor endothelial marker-1) is a single-pass transmembrane cell surface glycoprotein expressed at high levels by tumor vasculature and malignant cells. We aimed to perform a preclinical investigation of a novel anti-TEM-1 scFv-Fc fusion antibody, 1C1m-Fc, which was radiolabeled with ¹⁷⁷Lu for use in soft tissue sarcomas models.

METHODS

1C1m-Fc was first conjugated to p-SCN-Bn-DOTA using different excess molar ratios and labeled with ¹⁷⁷Lu. To determine radiolabeled antibody immunoreactivity, Lindmo assays were performed. The in vivo behavior of [177Lu]Lu-1C1m-Fc was characterized in mice bearing TEM-1 positive (SK-N-AS) and negative (HT-1080) tumors by biodistribution and single-photon emission SPECT/CT imaging studies. Estimated organ absorbed doses were obtained based on biodistribution results.

RESULTS

The DOTA conjugation and the labeling with ¹⁷⁷Lu were successful with a radiochemical purity of up to 95%. Immunoreactivity after radiolabeling was 86% ± 4%. Biodistribution showed a specific uptake in TEM-1 positive tumor versus liver as critical non-specific healthy organ, and this specificity is correlated to the number of chelates per antibody. A 1.9-fold higher signal at 72 h was observed in SPECT/CT imaging in TEM-1 positive tumors versus control tumors.

CONCLUSION

TEM-1 is a promising target that could allow a theranostic approach to soft-tissue sarcoma, and 1C1m-Fc appears to be a suitable targeting candidate. In this study, we observed the influence of the ratio DOTA/antibody on the biodistribution. The next step will be to investigate the best conjugation to achieve an optimal tumor-to-organ radioactivity ratio and to perform therapy in murine xenograft models as a prelude to future translation in patients.

Intravaginal probiotics modulated metabolic status and improved milk production and composition of transition dairy cows

The objective of this investigation was to evaluate whether intravaginal infusion of probiotics (a lactic acid bacteria cocktail) around parturition would influence metabolic status and increase milk production of transition dairy cows. One hundred pregnant Holstein dairy cows were assigned to 1 of the 3 experimental groups receiving intravaginal infusion of probiotics or carrier (i.e., sterile skim milk) once a week at wk -2, -1, and +1 relative to calving as follows: 2 consecutive probiotics before parturition and 1 carrier dose after parturition (TRT1), 3 consecutive probiotics doses around parturition (TRT2), and 3 consecutive carrier doses around parturition (CTR). The probiotics were a lyophilized culture mixture composed of FUA3089 and FUA3138 and FUA3140 with a cell count of 10 to 10 cfu/dose. Blood was sampled from wk -2 to +3 and milk was sampled on the third day in milk (DIM) and from wk +1 to +5 on a weekly basis. Feed intake and milk production was monitored until wk +8. Results showed that the TRT2 group (366.12 ± 49.77 μmol/L) had a lower ( = 0.01) concentration of NEFA in the serum than the CTR group (550.85 ± 47.16 μmol/L). The concentrations of IgG in the milk were 32.71 ± 3.00 mg/mL in the TRT1 group, 17.47 ± 4.54 mg/mL in the TRT2 group, and 6.73 ± 3.43 mg/mL in the CTR group at 3 DIM ( < 0.01). Meanwhile, both the TRT1 and the TRT2 group had lower haptoglobin in the milk compared with the CTR group at 3 DIM ( < 0.01). The TRT1 group had greater milk protein content than the CTR group (2.99 ± 0.04 vs. 2.82 ± 0.04%; = 0.02), whereas the TRT2 group tended to have greater lactose content compared with the CTR group (4.53 ± 0.03 vs. 4.44 ± 0.03%; = 0.05). The effect of treatment interacted with parity with regards to milk production and feed efficiency. Multiparous cows in the TRT1 and TRT2 groups had greater milk production and feed efficiency than those in the CTR group ( < 0.01 and = 0.02, respectively). Among primiparous cows, those in the TRT2 group had greater milk production ( = 0.04) whereas those in the TRT1 group had lower feed intake ( < 0.01) than those in the CTR group. Both the TRT1 and the TRT2 groups had enhanced feed efficiency compared with the CTR group ( < 0.01). In conclusion, intravaginal infusion of lactic acid bacteria modulated concentrations of selected serum metabolites and milk components and increased milk efficiency of transition dairy cows.

A review of stress-relapse interactions in multiple sclerosis: important features and stress-mediating and -moderating variables

Studies do not provide a consensus opinion of the relationship between stress and relapse in relapsing=remitting multiple sclerosis (RRMS). Few studies have defined the critical features of these stressful situations, or examined the role of stress-mediating and -moderating variables. Available evidence indicates that the relationship between life stress and relapse is complex, and is likely to depend on factors such as stressor chronicity, frequency, severity and type, and individual patient characteristics such as depression, health locus of control and coping strategy use. Little is known about how these factors, individually or in combination, are related to MS disease activity. Viral infections are also likely to precipitate relapse in MS, and significant life-stress may further enhance this relationship. The nature and strength of these interrelationships have strong clinical implications. MS patients are particularly vulnerable to a deteriorating cycle of stressful life events, illness episodes and disability. Timely multidisciplinary care interventions aimed at both minimizing psychological distress and physical symptoms may halt this downward reciprocal cycle. Little is known of the pathogenesis of these putative stress-induced changes in disease activity, and almost all stressor studies suffer from some biases or limitations.

Relationship between stress and relapse in multiple sclerosis: part I. Important features

Objective The aim of this two-year prospective study was to examine the relationship between multiple aspects of life-event stress and relapse in multiple sclerosis (MS) patients.

Background Few studies have defined the critical features of this life-event stress; for example, stressor duration, frequency, severity, disease-dependency, valency, or stressor constructs, such as the propensity to cause emotional distress/threat or the frustration of life goals.

Methods 101 consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. Stressful life events were assessed at study-entry and at three-monthly intervals for two years. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

Results Acute events, but not chronic difficulties (CDs), predicted relapse occurrence: acute stressor frequency counts predicted greater relapse risk, along with low disability score (EDSS) and being male. We also confirmed the bi-directional stress-illness hypothesis: stressors predicted relapse, and relapse separately predicted stressors.

Conclusions Life-event stress impacts to a small degree on MS relapse. The number and not the severity of acute stressors are most important; chronic stressors do not predict later relapse. Males and those with early stage disease are also at greater risk of relapse. MS patients should be encouraged to reduce acute stressors during times of high stress, and feel reassured that disease-related chronic stressors do not increase their relapse risk.

Intravaginally administered lactic acid bacteria expedited uterine involution and modulated hormonal profiles of transition dairy cows

The objective of this investigation was to evaluate whether intravaginal infusion of lactic acid bacteria (LAB) around parturition could expedite involution rate of the uterus and improve reproductive performance of postpartum dairy cows. One hundred pregnant Holstein dairy cows were assigned to 1 of 3 experimental groups: (1) 1 dose of LAB in wk -2 and -1 and 1 dose of carrier in wk 1 relative to the expected day of parturition (TRT1); (2) 1 dose of LAB in wk -2, -1, and 1 (TRT2); and (3) 1 dose of carrier in wk -2, -1, and 1 (CTR). The LAB treatment was a lyophilized mixture of Lactobacillus sakei FUA3089, Pediococcus acidilactici FUA3138, and Pediococcus acidilactici FUA3140 with a cell count of 10(8) to 10(9) cfu/dose. Uterine involution and ovarian activity was evaluated by transrectal ultrasonography weekly from d 7 to 49 postpartum. Blood samples were collected from a subset of cows to quantify prostaglandin (PG) F2α metabolite (PGFM), PGE2, and progesterone. Cows treated with LAB had smaller cross-sectional areas of gravid horn and uterine body on d 14 postpartum. Cows in TRT2 resumed ovarian cyclicity earlier, as indicated by increased concentrations of serum progesterone. Cows in TRT1 had fewer days open than those in the CTR (110 vs. 150 d), whereas cows in TRT2 and CTR did not differ in days open. In addition, both TRT1 and TRT2 increased the concentrations of PGFM at calving week, and cows in TRT2 also had greater concentrations of PGE2 on d 14 and d 21 postpartum relative to CTR. Overall, cows treated intravaginally with LAB had smaller gravid horn and uterine body on d 14 postpartum than those in the CTR group. Treatment with LAB also increased concentrations of serum PGFM (3,533±328pg/mL in TRT1, 4,470±372pg/mL in TRT2, and 2,000±328pg/mL in CTR on d 0, respectively), with the TRT1 group having fewer cows that resumed ovarian cyclicity but fewer days open compared with both TRT2 and CTR groups. More research is warranted to better understand the mechanism(s) by which intravaginal LAB expedited uterine involution and affected hormonal profiles.

Recent trends in water quality in an agricultural catchment in Eastern Scotland: elucidating the roles of hydrology and land use

Across the EU, programmes of measures have been introduced as part of river basin management planning as a means of tackling problems of diffuse pollution from agriculture. Evidence is required to demonstrate the effectiveness of these measures and with this overarching objective, monitoring of an agricultural catchment in Eastern Scotland was initiated in 2007. As a precursor to evaluating the effect of new management measures it is essential to understand how other factors, including hydrology and land use changes, could have influenced water quality. This study undertook an analysis of the trends in concentrations and loads of nitrate, soluble reactive phosphorus (SRP), suspended solids (SS) and turbidity measured at six points in the catchment over a six year period. The results identified both differing trends between determinands and differing trends occurring over varying spatial scales. The only direct relationships between land use and water quality that could be identified based on annual data was a positive link between arable cropping and nitrate concentrations. At the sub-catchment scale some temporal changes in land use and management explained short-term trends in nitrate but not in SRP. Lags in the system were identified due to soil adsorption, in-stream/loch processing and groundwater transport making the identification of cause and effect problematic. The results have implications for the demonstration of effectiveness of measures over the shorter term and the timescales of recovery from diffuse pollution. Longer term monitoring at small scales will be important in this regard.

Identification of predictive biomarkers of disease state in transition dairy cows

In dairy cows, periparturient disease states, such as metritis, mastitis, and laminitis, are leading to increasingly significant economic losses for the dairy industry. Treatments for these pathologies are often expensive, ineffective, or not cost-efficient, leading to production losses, high veterinary bills, or early culling of the cows. Early diagnosis or detection of these conditions before they manifest themselves could lower their incidence, level of morbidity, and the associated economic losses. In an effort to identify predictive biomarkers for postpartum or periparturient disease states in dairy cows, we undertook a cross-sectional and longitudinal metabolomics study to look at plasma metabolite levels of dairy cows during the transition period, before and after becoming ill with postpartum diseases. Specifically we employed a targeted quantitative metabolomics approach that uses direct flow injection mass spectrometry to track the metabolite changes in 120 different plasma metabolites. Blood plasma samples were collected from 12 dairy cows at 4 time points during the transition period (-4 and -1 wk before and 1 and 4 wk after parturition). Out of the 12 cows studied, 6 developed multiple periparturient disorders in the postcalving period, whereas the other 6 remained healthy during the entire experimental period. Multivariate data analysis (principal component analysis and partial least squares discriminant analysis) revealed a clear separation between healthy controls and diseased cows at all 4 time points. This analysis allowed us to identify several metabolites most responsible for separating the 2 groups, especially before parturition and the start of any postpartum disease. Three metabolites, carnitine, propionyl carnitine, and lysophosphatidylcholine acyl C14:0, were significantly elevated in diseased cows as compared with healthy controls as early as 4 wk before parturition, whereas 2 metabolites, phosphatidylcholine acyl-alkyl C42:4 and phosphatidylcholine diacyl C42:6, could be used to discriminate healthy controls from diseased cows 1 wk before parturition. A 3-metabolite plasma biomarker profile was developed that could predict which cows would develop periparturient diseases, up to 4 wk before clinical symptoms appearing, with a sensitivity of 87% and a specificity of 85%. This is the first report showing that periparturient diseases can be predicted in dairy cattle before their development using a multimetabolite biomarker model. Further research is warranted to validate these potential predictive biomarkers.

Intravaginal administration of lactic acid bacteria modulated the incidence of purulent vaginal discharges, plasma haptoglobin concentrations, and milk production in dairy cows

This investigation studied the effects of intravaginal administration of a mixture of lactic acid bacteria (LAB) on the incidence of purulent vaginal discharges (PVD), plasma haptoglobin concentrations, and milk production in dairy cows. A total of 82 pregnant primiparous and multiparous Holstein dairy cows were used in this study. Half of the cows received intravaginally 1mL of LAB at 10(10)-10(12)cfu/mL and the other half 1mL of reconstituted skim milk (i.e., carrier) (controls). Administration of LAB was conducted once per wk during 2 and 1wk before the expected day of calving and at 1, 2, 3, and 4wk postpartum. Data demonstrated that intravaginal administration of LAB decreased the occurrence of PVD at 3wk postpartum (P<0.05). Concentrations of plasma haptoglobin, an acute phase protein often associated with uterine infections, was lower in cows treated with the LAB mixture at 2wk (P<0.001) and 3wk (P<0.05) postpartum. Treatment with LAB did not improve overall pregnancy rate, but the treated multiparous cows produced more milk than their control counterparts (P<0.05), whereas no difference was observed in primiparous cows regarding milk yield (P>0.05). Overall, this is the first study demonstrating that intravaginal LAB administration lowers the incidence of PVD and enhances milk production in dairy cows. Further research is warranted to evaluate the effects of LAB on reproductive performance in a larger cohort of cows.

Randomized Controlled Trial of a Structured Intervention to Facilitate End-of-Life Decision Making in Patients With Advanced Cancer

Purpose

This study tested the efficacy of an intervention on end-of-life decision making for patients with advanced cancer.

Patients and Methods

One hundred twenty patients with metastatic cancer who were no longer being treated with curative intent (and 87 caregivers) were randomly assigned to the intervention (n = 55) or treatment as usual (n = 65). Primary outcome measures were the proportion of patients with do-not-resuscitate (DNR) orders, timing of DNR orders, and place of death. Secondary outcome measures were completed at study enrollment, 3 weeks later, and 3 months later, including patients' knowledge, mood, and caregiver burden.

Results

High, but equivalent, rates of DNR orders were observed in both groups. In per-protocol analyses, DNR orders were placed earlier for patients who received the intervention (median, 27 v 12.5 days; 95% CI, 1.1 to 5.9; P = .03) and they were more likely to avoid a hospital death (19% v 50% (95% CI, 11% to 50%; P = .004). Differences between the groups over time were evident for estimates of cardiopulmonary rehabilitation (CPR) success rates (P = .01) but not knowledge of CPR (P = .2). There was no evidence that the intervention resulted in more anxious or depressive symptoms. Caregivers experienced less burden in terms of disruption to schedule if the patient received the intervention (P = .05).

Conclusion

An intervention, consisting of an informational pamphlet and discussion, was associated with earlier placement of DNR orders relative to death and less likelihood of death in hospital. There was no negative impact of the intervention on secondary outcomes, although the sample may have been too small to detect differences.

A metabolomics approach to uncover the effects of grain diets on rumen health in dairy cows

Dairy cows fed high-grain diets during early lactation have a high incidence of metabolic disorders. However, the precise mechanism(s) of how grain feeding causes disease is not clear. In an effort to understand how this diet transition alters the rumen environment and potentially leads to certain metabolic disorders in dairy cattle, we undertook a comprehensive, quantitative metabolomic analysis of rumen fluid samples from dairy cows fed 4 different diets. Using a combination of proton nuclear magnetic resonance spectroscopy, gas chromatography-mass spectrometry, and direct flow injection tandem mass spectroscopy, we identified and quantified 93 metabolites in rumen samples taken from 8 dairy cows fed graded amounts of barley grain (i.e., 0, 15, 30, and 45% of diet dry matter). We also studied temporal changes in the rumen by studying metabolite concentration differences between the first day and the last day of each diet phase following the diet adaptation period. Multivariate analysis showed that rumen metabolites arising from the diet containing 45% barley grain were clearly different from those containing 0, 15, and 30% barley grain. Likewise, a clear separation of the metabolic composition of the ruminal fluid was evident at the beginning and at the end of each diet phase-contrary to the belief that 11 d are suitable for the adaptation of cows to high-grain diets. High-grain diets (>30%) resulted in increased rumen fluid concentrations of several toxic, inflammatory, and unnatural compounds including putrescine, methylamines, ethanolamine, and short-chain fatty acids. Perturbations in several amino acids (phenylalanine, ornithine, lysine, leucine, arginine, valine, and phenylacetylglycine) were also evident. The present study confirms and greatly extends earlier observations on dietary effects on rumen fluid composition and shows that the use of multiple metabolomic platforms permits a far more detailed understanding of metabolic causes and effects. These results may improve our understanding of diet-related rumen metabolism and the influence of grain on the overall health of dairy cattle.

Antibodies to heteromeric glycolipid complexes in multifocal motor neuropathy

BACKGROUND

Measurement of anti-GM1 IgM antibodies in multifocal motor neuropathy (MMN) sera is confounded by relatively low sensitivity that limits clinical usefulness. Combinatorial assay methods, in which antibodies react to heteromeric complexes of two or more glycolipids, are being increasingly applied to this area of diagnostic testing.

METHODS

A newly developed combinatorial glycoarray able to identify antibodies to 45 different heteromeric glycolipid complexes and their 10 individual glycolipid components was applied to a randomly selected population of 33 MMN cases and 57 normal or disease controls. Comparison with an enzyme-linked immunosorbent assay (ELISA) was conducted for selected single glycolipids and their complexes.

RESULTS

By ELISA, 22/33 MMN cases had detectable anti-GM1 IgM antibodies, whereas 19/33 MMN samples were positive for anti-GM1 antibodies by glycoarray. Analysis of variance (anova) revealed that of the 55 possible single glycolipids and their 1:1 complexes, antibodies to the GM1:galactocerebroside (GM1:GalC) complex were most significantly associated with MMN, returning 33/33 MMN samples as positive by glycoarray and 29/33 positive by ELISA. Regression analysis revealed a high correlation in absolute values between ELISA and glycoarray. Receiver operator characteristic analysis revealed insignificantly different diagnostic performance between the two methods. However, the glycoarray appeared to offer slightly improved sensitivity by identifying antibodies in four ELISA-negative samples.

CONCLUSIONS

The use of combinatorial glycoarray or ELISA increased the diagnostic sensitivity of anti-glycolipid antibody testing in this cohort of MMN cases, without significantly affecting specificity, and may be a useful assay modification for routine clinical screening.

Barley grain-based diet treated with lactic acid and heat modulated plasma metabolites and acute phase response in dairy cows

This study investigated the effects of feeding barley grain treated with lactic acid (LA) and heat on the profile of plasma metabolites related to carbohydrate and lipid metabolism and variables related to rumen health and acute phase response. Eight primiparous rumen-fistulated lactating Holstein cows were randomly assigned, in a crossover design, to 1 of the 2 dietary treatments consisting of 32% (DM basis) rolled barley grain steeped in an equal quantity of either tap water alone (CTR) or a 1.0% LA solution and heated at 55°C for 48 h (LAH). Each experimental period was 21 d, with the last 10 d used for measurements. Blood samples were collected on d 1, 3, 5, 7, 9, and 11 before the morning feeding and on the last day of each period at 0, 2, 4, 6, 8, 10, and 12 h postfeeding to measure glucose, lactate, cholesterol, beta-hydroxybutyrate (BHBA), NEFA, haptoglobin (Hp), serum amyloid A (SAA), and tumor necrosis factor-alpha (TNF-α). Also, rumen samples were collected on d 1, 5, and 11 as well as at 0, 4, 8, and 12 h postfeeding on the last day of each period for measuring the concentration of rumen endotoxin. Results of the day-to-day analysis indicated that cows fed the LAH diet had reduced preprandial concentrations of rumen endotoxin (472 vs. 793 ng/mL; P < 0.01) and cholesterol and greater lactate in the plasma; however, treatment had no effect on plasma Hp and TNF-α (P > 0.10). Postprandial responses showed that the LAH diet tended to decrease the concentration of SAA (4.67 vs. 8.50 μg/mL; P = 0.06). Also, there was a treatment by time interaction for rumen endotoxin (P < 0.01), suggesting a role for both the treatment and the time of sampling on this variable. Furthermore, greater concentration of BHBA and a tendency for greater NEFA and reduced concentrations of plasma glucose were observed in cows fed the LAH diet. In conclusion, results indicated that feeding dairy cows barley grain steeped in 1.0% LA and treated with heat modulated the profile of plasma metabolites and acute phase response.

Perturbations of plasma metabolites correlated with the rise of rumen endotoxin in dairy cows fed diets rich in easily degradable carbohydrates

Feeding dairy cows diets high in easily degradable carbohydrates increases the incidence of rumen and systemic metabolic disorders; however, the triggering factor is not well understood. In this study, dairy cows were fed 4 different amounts of barley grain-based concentrate at 15, 30, 45, and 60% (dry matter basis) of a total mixed ration to determine whether alterations in the rumen environment would be associated with perturbations of the plasma profile of selected metabolites. In addition, associations among free rumen endotoxin and several plasma metabolites were determined. The study was a replicated 4 × 4 Latin square design with 8 rumen-cannulated lactating dairy cows (60 ± 15 d in milk). Multiple rumen fluid and blood plasma samples were collected and analyzed for pH and rumen fluid endotoxin and for concentrations of glucose, insulin, cholesterol, β-hydroxybutyrate (BHBA), nonesterified fatty acids (NEFA), and lactate in the plasma. Rumen pH decreased below 6.0, from 8 to 12h after the morning feeding, with the augmentation of the proportion of concentrate in the diet of ≥ 30%. Feeding diets with >30% concentrate resulted in a rise of free endotoxin in the rumen fluid (8.87 ± 0.39 μg/mL). Inclusion of 60% concentrate in the total mixed ration was associated with enhanced concentrations of glucose (64.5 ± 1.0 mg/dL) and lactate (540.9 ± 36.5 μmol/L) and lowered cholesterol (265.5 ± 13.7 mg/dL), BHBA (449.1 ± 47.4 μmol/L), and NEFA (138.8 ± 19.1 μEq/L) in the blood plasma. The regression analysis revealed that greater concentrations of plasma lactate and lower concentrations of cholesterol, BHBA, and NEFA were related to the rise of rumen endotoxin. Interestingly, 93% of the increase in the plasma lactate was explained by the rise of rumen endotoxin. Moreover, the analysis revealed inverse relationships of rumen endotoxin with plasma cholesterol (R(2)=0.47), BHBA (R(2)=0.37), and NEFA (R(2)=0.50) and a biphasic response of plasma insulin (R(2)=0.58). Taken together, feeding dairy cows diets rich in rumen-degradable carbohydrates and low in fiber led to lower rumen pH and a large accumulation of rumen endotoxin; the latter was correlated with perturbations of plasma metabolites allied to carbohydrate and lipid metabolism.

Long-term trends in hydro-climatology of a major Scottish mountain river

The River Dee, in North East Scotland, is a mountainous river strongly influenced by patterns of snow accumulation and melt from the Cairngorm Mountains. Analysis of this river's flow record from 1929-2004, the longest in Scotland, supports anecdotal evidence that river extreme flows are increasing. There was no detectable change in the overall annual flow patterns. However, an analysis of seasonal data suggested a shift towards increased flows in spring (March-May) and decreased flows in summer (June-August) over the 75 years of the record. Flows in spring exceeded 29 m(3) s(-1) for 50% of the time over the earliest part of the record (1930 to 1954), whereas in the last 25 years of the record (1979 to 2004) 50% of the flows exceeded 35 m(3) s(-1). Precipitation is increasing in the spring and decreasing in July and August. If these trends continue they have important implications for water management in the Dee, with a potential increase in flood risk in spring and the increased possibility of drought in summer. Combined with this increase in flows the river appears to be more responsive to precipitation events in the catchment. In large heterogeneous catchments with a marginal alpine/high latitude climate it is difficult to assess the amount of precipitation falling as snow and its relative accumulation and ablation dynamics on daily to seasonal time scales. Changes in the temporal pattern of coherence between flow and precipitation are thought to be linked to changing snow patterns in the upland part of the catchment. A decreased amount of precipitation occurring as snow has led to higher coherence. We also show that in responsive systems it is important to record river flows at an hourly rather than daily time step in order to characterise peak flow events.

Feeding high proportions of barley grain in a total mixed ration perturbs diurnal patterns of plasma metabolites in lactating dairy cows

The aim of this study was to evaluate effects of feeding increasing proportions of barley grain in a total mixed ration (TMR) on diurnal plasma metabolite fluctuations in high-producing dairy cows. Eight early- to mid-lactation (60 to 140 d in milk) primiparous Holstein cows were assigned to a double 4 x 4 Latin square experimental design. Each experimental period lasted 21 d with the first 11 d used for diet adaptation. Cows were fed a TMR once daily at 0800 h containing no barley grain (control diet), or 15, 30, and 45% (dry matter basis) barley grain as well as barley silage. Blood samples were collected from the tail vein on the last day of each period shortly before (i.e., 0 h) and at 2, 4, 6, 8, 10, and 12 h after the morning feeding. Concentrations of glucose, nonesterified fatty acids (NEFA), beta-hydroxybutyric acid, cholesterol, and lactate in plasma were measured. Results of this study showed that feeding increasing proportions of barley grain affected concentrations of glucose and lactate in plasma with greater plasma glucose and lactate in cows fed the highest amount of grain; however, the amount of grain in the diet did not have an effect on diurnal patterns of plasma glucose. Additionally, the concentration of NEFA in plasma was greater in cows fed the higher grain diets and was greater in the hours following the morning meal than later in the day. The amount of grain in the diet was associated with lower plasma beta-hydroxybutyric acid, which increased particularly after the morning meal. Interestingly, cows fed the most barley grain had the lowest plasma cholesterol and this decreased during the day. In conclusion, the concomitant increase of glucose, lactate, and NEFA as well as the decrease of plasma cholesterol in cows fed high proportions of barley grain suggest that high inclusion of barley grain in the diet played a role in the diurnal patterns of plasma metabolites in lactating dairy cows. However, further research is warranted to understand involvement of these metabolic changes on the long-term health and productivity of dairy cows.

Longitudinal assessment of anxiety, depression, and fatigue in people with multiple sclerosis

OBJECTIVES

No longitudinal studies have concurrently evaluated predictors of anxiety, depression, and fatigue in people with multiple sclerosis (PwMS). This study determined factors that best predicted anxiety, depression, and fatigue in MS patients from a large pool of disease, cognitive, life-event stressor (LES), psychosocial, life-style, and demographic factors.

DESIGN

A 2-year prospective longitudinal study evaluated predictors of psychological distress and fatigue in PwMS.

METHODS

One hundred and one consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. LES, anxiety, depression, and fatigue were assessed at baseline and at 3-monthly intervals for 2-years. Disease, cognitive, demographic, psychosocial, and life-style factors were assessed at baseline. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

RESULTS

Depression strongly predicted anxiety and fatigue, and anxiety and fatigue strongly predicted later depression. Psychological distress (i.e. anxiety, depression) was also predicted by a combination of unhealthy behaviours (e.g. drug use, smoking, no exercise, or relaxation) and psychological factors (e.g. low optimism, avoidance coping), similar to the results of community-based studies. However, state-anxiety and fatigue were also predicted by immunotherapy status, and fatigue was also predicted by LES and demographics.

CONCLUSIONS

These results suggest that similar factors might underpin psychological distress and fatigue in MS patients and community-well samples, although MS treatment factors may also be important. These results might assist clinicians in determining which MS patients are at greatest risk of developing anxiety, depression, or fatigue.

Feeding high proportions of barley grain stimulates an inflammatory response in dairy cows

The objective of this study was to evaluate effects of feeding increasing proportions of barley grain on acute phase response in lactating dairy cows. Eight cannulated primiparous (60 to 140 d in milk) Holstein dairy cows were assigned to 4 diets in a 4 x 4 Latin square experimental design. The experimental period lasted for 21 d, with 11 d of adaptation and 10 d of measurements. Cows were fed the following diets: 1) no barley grain in the diet, 2) 15% barley grain, 3) 30% barley grain, and 4) 45% barley grain, as well as barley and alfalfa silage and alfalfa hay at 85, 70, 55, and 40% [dry matter (DM) basis]. All cows were supplemented with a 15% concentrate mix. Blood and rumen fluid samples were collected on d 1, 3, 5, 7, and 10 of the measurement period, and pH and endotoxin content were measured in rumen samples. Concentrations of serum amyloid A, lipopolysaccharide-binding protein, haptoglobin, and C-reactive protein in plasma were measured by ELISA. Feeding high proportions of barley grain at 0, 15, 30, and 45% of DM was associated with lower feed intake (32.6, 32.9, 27.34, and 25.18 kg/d +/- 1.30, respectively), lower ruminal pH (6.8, 6.7, 6.7, and 6.5 +/- 0.03, respectively), and higher DM intake (13.33, 15.28, 14.68, and 16.04 +/- 0.63 kg/d, respectively) and milk production (27.2, 28.2, 29.0, and 31.0 +/- 1.2 kg/d, respectively). Ruminal endotoxin increased in cows receiving 30 and 45% barley grain (5,021, and 8,870 +/- 393 ng/mL, respectively) compared with those fed no grain or 15% barley grain (654 and 790 +/- 393 ng/mL, respectively). Plasma concentrations of serum amyloid A, lipopolysaccharide-binding protein, and C-reactive protein increased in cows given higher (30 and 45%) proportions of grain. Plasma haptoglobin was not affected by treatments. In conclusion, feeding dairy cows high proportions (30 and 45% DM basis) of barley grain was associated with lower feed intake and rumen pH, increased endotoxin in the rumen fluid, and stimulation of an inflammatory response.

Relationship between stress and relapse in multiple sclerosis: Part II. Direct and indirect relationships

OBJECTIVE

The aim of this two-year prospective study was to determine which factors were: (i) directly related and/or (ii) indirectly related to multiple sclerosis (MS) relapse. These factors included life-event stressors, disease, demographic, psychosocial and lifestyle factors.

BACKGROUND

Relatively little attention has been paid to the role of non-clinical relapse predictors (other than stressful life-events) in MS, or factors that indirectly impact on the stress-relapse relationship.

METHODS

A total of 101 consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. Stressful life-events, depression, anxiety and fatigue were assessed at study-entry and at three-monthly intervals for two years. Disease, demographic, psychosocial and lifestyle factors were assessed at baseline. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

RESULTS

MS relapse was predicted by acute stressor frequency counts, coping responses that utilized social support, and being born in Australia, but not by chronic stressors, disease, demographic, psychosocial or lifestyle factors. No factors were found to indirectly impact on the stress relapse relationship.

CONCLUSIONS

The number rather than severity of stressors was most important in relation to MS relapse risk, along with coping responses that utilized social support, suggesting that MS patients should avoid situations that are likely to generate multiple stressors or which provide few avenues for social support.

Isotopic characterisation of the historical lead deposition record at Glensaugh, an organic-rich, upland catchment in rural N.E. Scotland

As part of a wider investigation of the biogeochemistry and fate of Pb deposited from the atmosphere at Glensaugh, a rural upland catchment in N.E. Scotland, the concentration and isotopic composition of Pb were determined in four thinly sectioned monolith cores (25 cm) of peat collected at altitudes of 426--434 m from different faces of Thorter Hill and in a series of 21 10-cm unsectioned cores of peat and organic-rich soil along a transect from near the top (434 m) to the bottom (224 m) of the catchment. Depth profiles of Pb concentration and (206)Pb/(207)Pb ratio were similar for the longer cores. Subsurface Pb maxima (238--489 mg kg(-1)) typically occurred below (206)Pb/(207)Pb minima (1.123-1.134). One core was (210)Pb-dated and had a fairly constant (206)Pb/(207)Pb value of 1.170 from mid-19th century to ca. 1930, followed by a decline (attributable to the increasing influence of Australian Pb of much lower (206)Pb/(207)Pb ratio) to 1.134 by the early 1990s, and then a rapid increase to 1.160 by 2002, after the phased withdrawal of leaded petrol. The fluxes of Pb increased from 15 mg m(-2) year(-1) in the late 19th century to a peak of 60 mg m(-2) year(-1) ca. 1960, before declining steadily to 3.6 mg m(-2) year(-1) by the beginning of the 21st century. Some 40% of the anthropogenic Pb in the core had been deposited prior to 1900. The mean anthropogenic Pb inventory of the four longer cores was 7.4+/-1.5 g m(-2), of which approximately 70% occurred in the top 10 cm, in good agreement with the inventories of the shorter cores collected above 400 m. These inventories are higher than those of the industrial central belt of Scotland, probably because of enhanced deposition at altitude. This is consistent with the derived average (210)Pb flux of 198+/-11 Bq m(-2) year(-1), which is twice that of typical UK (210)Pb deposition and the rainfall for the site. The past deposition of Pb at Glensaugh, including that from sources (e.g., smelting, coal combustion) other than leaded petrol, has clearly been considerable. Even since the introduction of leaded petrol ca. 1930, car-exhaust emissions may have accounted for no more than 35% of the Pb deposited.

Cancer: communicating in the team game

There is increasing evidence that effective communication is a critical means by which surgeons can assist their patients to achieve the best outcomes. This paper examines the processes and outcomes of effective communication by surgeons in cancer teams, and includes: (i). strategies that promote collaborative relationships with patients and lead to more effective treatment; (ii). strategies to improve multidisciplinary team performance; and (iii). methods to minimize the risk of error and litigation. The experience of a cancer diagnosis involves radical changes in patients' lives, somewhat akin to suddenly finding yourself in the middle of a rugby scrum for the first time. The analogy of rugby throws fresh light on such critical factors in communication as prematch preparation, orientation to the game and the team, a good kick off, sizing up the opposition, creative plays and optimizing teamwork to promote quality of life and survival.

Modelling nitrate losses from agricultural activities on a national scale

The Nitrogen Risk Assessment Model for Scotland (NIRAMS) has been developed as a screening tool for prediction of streamwater N concentrations draining from agricultural land in Scotland. The objective of the model is to be able to predict N concentrations for ungauged catchments, to fill gaps in monitoring data and provide guidance in relation to policy development. The model uses national land use, soils and meteorology data sets and has been developed within an ArcView GIS user interface. The model includes modules to calculate N inputs to the land, residual N remaining at the end of the growing season, weekly time-series of leached N and transport of N at the catchment scale. The N leaching and transport are. controlled by hydrological modules, including a national water balance model and a catchment scale transport model. Preliminary testing of NIRAMS has been carried out on eight Scottish catchments, diverse in terms of geographic location as well as land use. The model is capable of predicting the correct mean level of stream N concentrations, as well as the basic characteristics of seasonal variation. As such the model can be of value for providing estimates of N concentrations in ungauged areas.

Development of a Questionnaire to Assess Subjective Vision Score in Myopes Seeking Refractive Surgery

PURPOSE

To assess vision in patients with myopia and myopic astigmatism before and after refractive surgery.

METHODS

A prospective controlled study of visual quality amongst myopes and astigmatic myopes. Focus groups, ophthalmic surgeons, and questionnaire experts devised a Subjective Vision Questionnaire (SVQ), modified after a pilot trial. Participants were administered the SVQ before clinical evaluation. Items answered by over 95%, with factor loadings > 0.55 were included. Test-retest reliability was assessed by repeat testing. Factor analysis identified groups of questions measuring particular dimensions of data.

RESULTS

Sixty-seven items were answered by 128 patients and reduced to 24 items in a final questionnaire. Factor analysis identified six types of questions within the questionnaire, the most important of which was related to driving.

CONCLUSION

The simplicity, low cost, and psychometric properties of the Subjective Vision Questionnaire support its use clinically and in research.

Feasibility of local CT of dental tissues

OBJECTIVES

To prove the feasibility of a local CT system as a method of CT suitable for use in dentistry.

METHODS

Using an experimental set-up consisting of an X-ray source, a turntable and a charge-coupled device (CCD) detector connected to a PC, CT scans were made of a single molar and a dry mandible. Slices were reconstructed using filtered backprojection. An experimental comparison was made between a full CT geometry and a local CT geometry.

RESULTS

Horizontal and vertical slices through the mandible were obtained showing the internal structure of a molar and the surrounding bone. The slices show good contrast and details. A computer experiment gave visual evidence that slices obtained by local CT are not substantially different from slices obtained from a full CT set-up with respect to resolution.

CONCLUSIONS

Based on the results obtained so far, local CT of dental structures appears to be a promising diagnostic instrument.

Patient barriers to optimal cancer pain control

Poorly controlled pain is a significant problem for cancer patients. Contributing factors may include concerns about analgesics and fears about the implications of pain, which may hinder open communication. We surveyed the prevalence of these concerns in Australian oncology patients and investigated associations with inadequate pain control. Ninety-three adult patients with cancer, undergoing treatment at a teaching hospital, completed the patient barriers questionnaire (BQ) and a self-report questionnaire to determine pain severity, interference with daily activities, use of analgesics and alternative therapies, and hesitation to report pain. Overall, there was a high prevalence of agreement with the BQ scales assessing concerns about communication and analgesic use. One-third of patients had clinically significant pain, which interfered with daily activities, despite use of analgesics. They were more likely to use alternative therapies for pain control, to hesitate to discuss their pain, and had significantly greater concerns about side effects of analgesics and injections. Our study confirms that patient barriers exist in this Australian population and are associated with inadequate pain control. Oncology staff need to actively screen for pain, particularly targeting patients using alternative therapies and experiencing side effects, develop communication and prescribing skills, and diversify pain management approaches beyond analgesics.

Psychological responses of patients receiving a diagnosis of cancer

BACKGROUND

Current recommendations on how to break bad news are primarily based on expert opinion. Little is known about the association between communication practices and patients' psychological response.

PATIENTS AND METHODS

One-hundred and thirty-one patients with newly diagnosed melanoma were surveyed 4 months after the initial consultation at the Sydney Melanoma Unit regarding their communication experiences and their satisfaction with these experiences. They completed the Hospital Anxiety and Depression Scale (HADS) at this time, and 4 and 13 months later.

RESULTS

Both patients' satisfaction with communication and their psychological morbidity were found to be associated with particular communication practices. Practices linked to lower anxiety included preparing the patient for a possible diagnosis of cancer; having the people wanted by the patient present to hear the diagnosis; giving the patient as much information about the diagnosis as desired; providing written information; presenting the information clearly; discussing the patient's questions the same day; talking about the patient's feelings; and being reassuring. Practices linked with lower levels of depression included using the word 'cancer'; discussing the severity of the situation, life expectancy and how the cancer might affect other aspects of life; and encouraging the patient to be involved in treatment decisions.

CONCLUSIONS

This study provided preliminary evidence that communication strategies recommended in the literature produce positive patient outcomes. Further studies are needed which document actual communication.

Modelling the influence of irrigation abstractions on Scotland's water resources

Legislation to control abstraction of water in Scotland is limited and for purposes such as irrigation there are no restrictions in place over most of the country. This situation is set to change with implementation of the European Water Framework Directive. As a first step towards the development of appropriate policy for irrigation control there is a need to assess the current scale of irrigation practices in Scotland. This paper presents a modelling approach that has been used to quantify spatially the volume of water abstractions across the country for irrigation of potato crops under typical climatic conditions. A water balance model was developed to calculate soil moisture deficits and identify the potential need for irrigation. The results were then combined with spatial data on potato cropping and integrated to the sub-catchment scale to identify the river systems most at risk from over-abstraction. The results highlight that the areas that have greatest need for irrigation of potatoes are all concentrated in the central east-coast area of Scotland. The difference between irrigation demand in wet and dry years is very significant, although spatial patterns of the distribution are similar.

Responding to the active and passive patient: flexibility is the key

BACKGROUND

Patients vary widely in their preferences and capacity for participation in medical decision-making. This study aimed to document oncologist responses to more extreme presentations and identify helpful and unhelpful strategies for clinicians.

PATIENTS AND METHODS

A trained actor played the role of a patient with early stage breast cancer who was attending her first consultation with a medical oncologist. She adopted in random order two different consultation participation styles: that of a very anxious, active patient, and that of a depressed, passive patient. Medical consultations between the actor and 16 medical oncologists were videotaped and then analysed qualitatively by two trained raters.

RESULTS

Strategies that facilitated shared decision-making with both patient types and were positively endorsed by the actor/patient included explicit agenda-setting, active listening, checking understanding, endorsing question-asking, offering decisional delay, and non-verbal behaviours conveying empathy and warmth. Oncologists successfully negotiated with the active patient to share control of the consultation, and responded to emotional cues from the passive patient. Unhelpful strategies were also identified.

CONCLUSIONS

Few clinicians receive training in responding to differing communication styles in their patients that could potentially cause conflict and hinder optimal treatment decision-making. This study suggests some useful strategies for oncologists to consider, to widen their behavioural repertoire in the cancer consultation.

Biomedical image skeletonization: a novel method applied to fibrin network structures

To understand the rheological behavior of fibrin clots, we must obtain quantitative measurements of morphometric parameters of the networks formed under various conditions. The networks are so complex that researchers must currently manually segment the images of network samples and estimate the parameters from them. Skeletonization is a promising tool for automating this task. We here propose a method that rapidly constructs a coarse representation of a skeleton graph and, using the snake model, deforms the graph to obtain smooth skeletons. Unlike many existing approaches, our method does not involve explicit object boundary information or high order derivatives. Since our method processes a given image as a whole, the presence of multiple objects in an image is automatically detected and the skeletons of these objects are computed simultaneously.

Oncologists' reactions to cancer patients' verbal cues

The diagnosis and treatment of cancer cause considerable psychological distress and morbidity. Consequently, cancer patients have high needs for informational and emotional support and doctors vary in their ability to recognise and address these needs. This study investigated patients' attempts to gain informational and emotional support through the use of verbal cues. The sample consisted of 298 patients with heterogeneous cancers, seeing one of five medical and four radiation oncologists for the first time. Sociodemographic variables and patient anxiety and satisfaction ratings were obtained. Transcripts of the audiotaped consultations were analysed and question-asking, use of indirect cues, cue type (informational or emotional), content categories in which questions and cues occurred and doctor response (responded to or not responded to), were recorded. Patients asked a median of 11 questions and gave two cues per consultation, usually during treatment discussions. Patients gave, and doctors responded to, more informational than emotional cues. Patients gave significantly more informational cues during longer consultations. Younger and female patients gave more cues for emotional support and asked questions. No demographic variables were associated with the doctors' response to emotional and informational cues; however, consultations in which more informational cues were responded to were shorter, even when controlling for the number of cues given. Satisfaction with the consultation and patient anxiety were unaffected by doctors' responses to cues. Overall, results showed that doctors effectively identify and respond to the majority of informational cues; however, they are less observant of and able to address cues for emotional support. Cues can be addressed without lengthening the consultation or increasing patient anxiety.

Machine classification of dental images with visual search

RATIONALE AND OBJECTIVES

The authors performed this study to assess the performance of a computer-based classification system that uses gaze locations of observers to define the subspace for machine learning.

MATERIALS AND METHODS

Thirty-two dental radiographs were classified by an expert viewer into four categories of disease of the periapical region: no disease (normal tooth), mild disease (widened periodontal ligament space), moderate disease (destruction of the lamina dura), and severe disease (resorption of bone in the periapical area). There were eight images in each category. Six observers independently viewed the images while their eye gaze position was recorded. They then classified the images into one of the four categories. A sample of image space was used as input to a machine learning routine to develop a machine classifier. Sample space was determined with three techniques: visual gaze, random selection, and constrained random selection. K analyses were used to compare classification accuracies with the three sampling techniques.

RESULTS

With use of the expert classification as a standard of reference, observers classified images with 57% accuracy, and the machine classified images with 84% accuracy by using the same gaze-selected features and image space. Results of kappa analyses revealed mean values of 0.78 for gaze-selected sampling, 0.69 for random sampling, 0.68 for constrained random selection, and 0.44 for observers. The use of sample space selected with the visual gaze technique was superior to that selected with both random-selection techniques and by the observers.

CONCLUSION

Machine classification of dental images improves the accuracy of individual observers using gaze-selected image space.

An analysis of perceptual errors in reading mammograms using quasi-local spatial frequency spectra

In this pilot study the authors examined areas on a mammogram that attracted the visual attention of experienced mammographers and mammography fellows, as well as areas that were reported to contain a malignant lesion, and, based on their spatial frequency spectrum, they characterized these areas by the type of decision outcome that they yielded: true-positives (TP), false-positives (FP), true-negatives (TN), and false-negatives (FN). Five 2-view (craniocaudal and medial-lateral oblique) mammogram cases were examined by 8 experienced observers, and the eye position of the observers was tracked. The observers were asked to report the location and nature of any malignant lesions present in the case. The authors analyzed each area in which either the observer made a decision or in which the observer had prolonged (>1,000 ms) visual dwell using wavelet packets, and characterized these areas in terms of the energy contents of each spatial frequency band. It was shown that each decision outcome is characterized by a specific profile in the spatial frequency domain, and that these profiles are significantly different from one another. As a consequence of these differences, the profiles can be used to determine which type of decision a given observer will make when examining the area. Computer-assisted perception correctly predicted up to 64% of the TPs made by the observers, 77% of the FPs, and 70% of the TNs.

Promoting patient participation and shortening cancer consultations: a randomised trial

Patient participation in medical consultations has been demonstrated to benefit their subsequent psychological well being. Question asking is one way in which patients can be active. We investigated 2 means of promoting cancer patient question asking. One was the provision of a question prompt sheet to patients prior to their initial consultation with their oncologist. The second was the active endorsement and systematic review of the question prompt sheet by their oncologist. 318 patients with heterogeneous cancers, seeing one of 5 medical and 4 radiation oncologists for the first time, were randomised to either receive or not receive a question prompt sheet. Doctors were randomised to either proactively address or passively respond to the question prompt sheet in the subsequent consultation. Anxiety was assessed prior to the consultation. Consultations were audiotaped and content analysed. Anxiety was assessed again immediately following the consultation. Within the next 10 days patients completed questionnaires assessing information needs, anxiety and satisfaction and were given a structured telephone interview assessing information recall. Patients provided with a question prompt sheet asked more questions about prognosis compared with controls and oncologists gave significantly more prognostic information to these patients. Provision of the question prompt sheet prolonged consultations and increased patient anxiety; however, when oncologists specifically addressed the prompt sheet, anxiety levels were significantly reduced, consultation duration was decreased and recall was significantly improved. A patient question prompt sheet, used proactively by the doctor, is a powerful addition to the oncology consultation.

The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor

Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block.

IMPLICATIONS

A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.

Mutagenesis of the GABA(A) receptor alpha1 subunit reveals a domain that affects sensitivity to GABA and benzodiazepine-site ligands

We have mutated several amino acids in the region of the GABA(A) receptor alpha1 subunit predicted to form a small extracellular loop between transmembrane domains two and three to investigate its possible role in ligand sensitivity. The mutations were S275T, L276A, P277A, V279A, A280S and Y281F. Mutant alpha1 subunits were co-expressed with beta2 and gamma2 subunits in tsA201 cells or Xenopus oocytes. Binding studies revealed that the only mutation that significantly affected [3H]Ro15-4513 binding was the V279A substitution which reduced the affinity for this ligand. Electrophysiological examination of mutant receptors revealed that L276A, P277A and V279A displayed rightward shifts of their GABA concentration-response curves, the largest occurring with the L276A mutant. The impact of these mutations on allosteric modulation by benzodiazepine-site ligands was examined. V279A reduced the potency of both flunitrazepam and Ro15-4513 but, in each case, their efficacy was enhanced. A280S resulted in a decrease in flunitrazepam efficacy without affecting its potency. Additionally, P277A and A280S resulted in Ro15-4513 losing its inverse agonist effect at these receptors. These results suggest that a domain within this small extracellular loop between TMII-TMIII plays a role in determining the sensitivity of GABA(A) receptors to both GABA and benzodiazepine-site ligands.

An analysis of perceptual errors in reading mammograms using quasi-local spatial frequency spectra

In this pilot study the authors examined areas on a mammogram that attracted the visual attention of experienced mammographers and mammography fellows, as well as areas that were reported to contain a malignant lesion, and, based on their spatial frequency spectrum, they characterized these areas by the type of decision outcome that they yielded: true-positives (TP), false-positives (FP), true-negatives (TN), and false-negatives (FN). Five 2-view (craniocaudal and medial-lateral oblique) mammogram cases were examined by 8 experienced observers, and the eye position of the observers was tracked. The observers were asked to report the location and nature of any malignant lesions present in the case. The authors analyzed each area in which either the observer made a decision or in which the observer had prolonged (>1,000 ms) visual dwell using wavelet packets, and characterized these areas in terms of the energy contents of each spatial frequency band. It was shown that each decision outcome is characterized by a specific profile in the spatial frequency domain, and that these profiles are significantly different from one another. As a consequence of these differences, the profiles can be used to determine which type of decision a given observer will make when examining the area. Computer-assisted perception correctly predicted up to 64% of the TPs made by the observers, 77% of the FPs, and 70% of the TNs.

Randomized clinical trials in oncology: understanding and attitudes predict willingness to participate

PURPOSE

To explore the association at different time points in the trajectory of breast cancer care, between anxiety, knowledge, and attitudes, on women's willingness to participate in randomized clinical trials.

MATERIALS AND METHODS

A cross-sectional survey was undertaken among women attending a breast clinic for screening mammography or diagnostic assessment plus women with newly diagnosed breast cancer to assess attitudes toward and willingness to participate in randomized clinical trials of breast cancer treatment.

RESULTS

Five hundred forty-five women completed questionnaires assessing knowledge of and attitudes toward randomized clinical trials. The mean age of respondents was 48.9 years (SD, 11.3 years). Thirty-three percent of women would consider participating in a clinical trial if they had breast cancer. Women with breast cancer (31%) were significantly more likely to decline to participate than women attending for screening mammography (15%) or diagnostic assessment (15%, P =.0002). Women who might consider participating in a randomized clinical trial were more knowledgeable about randomized trials (mean difference, 0.7; 95% confidence interval [CI], 0.2 to 1.2; P =.003). In a multivariate analysis, women who would consider participating in a randomized trial were younger (odds ratio [OR], 0.96; 95% CI, 0.93 to 0.99), more likely to want an active role in decision-making (OR, 3.2; 95% CI, 1.3 to 7.6), and reported a greater impact from the positive aspects of clinical trials (OR, 2.2; 95% CI, 1.3 to 3.8) and less impact from the negative aspects of clinical trials (OR, 2.2; 95% CI, 1.3 to 3.2).

CONCLUSION

These findings suggest that women who have a better understanding of issues about clinical trials have more favorable attitudes toward randomized trials and are more willing to consider participation in a clinical trial.

Direct inhibition of voltage-dependent Ca(2+) fluxes by ethanol and higher alcohols in rabbit T-tubule membranes

The effects of ethanol and higher alcohols on 45Ca(2+) fluxes, mediated by voltage-dependent Ca(2+) channels (VDCCs), were investigated in inside-out transverse (T)-tubule membrane vesicles from rabbit skeletal muscle. 45Ca(2+) effluxes were induced by membrane potentials generated via establishing K(+) gradients across the vesicles, and were significantly inhibited by the inorganic Ca(2+) channel blocker La(3+) (1 mM) and the Ca(2+) channel antagonist nifedipine (1-10 microM). Ethanol, in the concentration range of 100-400 mM, caused a significant suppression of depolarization-induced 45Ca(2+) fluxes. Ethanol also functionally modulated the effect of nifedipine (1-10 microM) and the Ca(2+) channel agonist Bay K 8644 (1 microM) on Ca(2+) effluxes. Pretreatment with pertussis toxin (5 microg/ml) or phorbol 12-myrstate 13-acetate (PMA, 50 nM) did not affect the ethanol inhibition of 45Ca(2+) fluxes. Further experiments with alcohols revealed that butanol, hexanol, octanol and decanol also significantly inhibited 45Ca(2+) effluxes. However, undecanol and dodecanol did not cause any significant change on 45Ca(2+) fluxes, indicating that the effects of alcohols on 45Ca(2+) effluxes exhibit a cut-off phenomenon. In radioligand binding studies, it was found that at the concentrations used in flux studies, alcohols did not alter the characteristics of the specific binding of [3H]PN 200-110 to T-tubule membranes. Results indicate that ethanol directly inhibits the function of voltage-dependent Ca(2+) channels without modulating the specific binding of Ca(2+) channel ligands of the dihydropyridine class, and that this inhibition is independent of intracellular Ca(2+) levels.

Hearing the bad news of a cancer diagnosis: the Australian melanoma patient's perspective

BACKGROUND

In the past, recommendations on how to break the bad news of a cancer diagnosis have been based on expert opinion. Recently, consensus-based guidelines for medical practitioners have been developed. The objective of this work is to investigate patient preferences for communication practices and to identify any disparities between these guidelines, patient preferences and patient recollections of hearing their diagnosis.

PATIENTS AND METHODS

A consecutive sample of 131 newly diagnosed melanoma patients were surveyed approximately 4 months after initial diagnosis to document their preferences and recollections of their communication experiences.

RESULTS

Of the 'breaking bad news' recommendations investigated, patients did not strongly endorse the doctor helping tell others of the diagnosis or telling the patient about cancer support services. Very few patients expressed a preference for having another health professional present. One communication feature, the patient feeling confident about getting the best treatment, was endorsed as 'very important' but does not feature in published guidelines. The most notable disparities between guidelines and the reported experiences of patients related to perceived delays in receiving the diagnosis, and having adequate opportunity to ask their clinician questions.

CONCLUSION

Current Australian recommendations on how to communicate a diagnosis of cancer were generally supported by the patients' expressed preferences, but several modifications are proposed.

IMPLICATIONS

Suggestions are offered to help overcome the disparities identified between recommendations and patients' preferences when a diagnosis of cancer is being communicated.

Comparison of wire reinforced tubes with warmed standard tubes to facilitate fiberoptic intubation

STUDY OBJECTIVE

To compare the ease of insertion of a warmed standard tracheal tube to that of a wire reinforced tracheal tube when placed over a flexible fiberoptic bronchoscope.

DESIGN

Randomized controlled trial.

SETTING

Tertiary care hospital.

PATIENTS

50 patients undergoing elective general anesthesia.

INTERVENTIONS

Patients' tracheas were intubated with a flexible fiberoptic bronchoscope and had either a standard or wire-reinforced tracheal tube inserted. If resistance was met, the tube was withdrawn, rotated, and readvanced. This was repeated two times. If unsuccessful, the flexible fiberoptic bronchoscope was removed, and intubation was attempted with the other type of tracheal tube.

MEASUREMENTS

The ability to advance the tracheal tube was determined.

MAIN RESULTS

There were no demographic differences between the two groups. There was a similar ease of advancement of the two tracheal tubes.

CONCLUSIONS

When performing elective flexible fiberoptic bronchoscopy for intubation, we recommend using the less expensive warmed standard tracheal tube.

The impact of variable snow pack accumulation on a major Scottish water resource

In regions such as northern Scotland, where winter temperatures are such that the occurrence of snow is borderline under the present climate, potential changes affecting precipitation and temperature regimes may have a disproportionately large impact on snow processes and hydrological behaviour. The physical characteristics of mountainous areas in Scotland mean that the spatial variability of snowpack accumulation is high, as well as the temporal variability caused by the climate. There have been few modelling studies aimed at assessing the significance of snow resources in these areas and none that have adopted a spatially distributed approach. This paper describes the approach taken in applying a new distributed model to a headwater catchment in the Cairngorm Mountains. The results demonstrate the importance of wind on re-distributing snow to create deep accumulations in small sheltered pockets. These accumulations are shown to be important in sustaining baseflows in the rivers, long after snow has melted from the rest of the catchment. The model has also produced a first set of maps showing how predicted snow depths vary across the catchment through the winter.

Assessing the effects of land use on temporal change in well water quality in a designated nitrate vulnerable zone

The nitrate concentration in discharge from the Balmalcolm borehole in Fife, Scotland, has steadily increased from 4.5 mg l(-1) NO3-N in the early 1970s to 11.0 mg l(-1) NO3-N in 1998. Consequently the catchment of the borehole, covering an area of 400 ha has recently been designated a Nitrate Vulnerable Zone under the EC Nitrate Directive [Commission of European Communities L375, (1991) 1]. The sandstone aquifer that supplies the borehole is recharged by water draining from land that is intensively cropped to green vegetables. There is, therefore, a need to identify appropriate land management techniques that will help to abate the nitrate losses from the land and to estimate the length of time that it is likely to take before the abatement is observed as a decrease in well-water concentrations. Estimates of nitrate leaching for the range of crops that have been grown in the catchment over the last 30 years have been made using a balance sheet approach, modified to allow for estimates of denitrification and in-field composting of vegetable crop residues. Integration over the whole catchment using a GIS approach, indicates a steady-state well water [NO3--N] of 23 mg l(-1)--a situation that has not yet been reached. Prediction of the time course of change in well water quality from 1970 (when intensification began) has been made by calculating the travel time from different parts of the catchment both in the saturated and unsaturated zones. The results show good agreement between the measurements and simulation. Well water [NO3-N] under potential future management scenarios have also been investigated using the same approach. The greatest reduction in steady-state concentration, to 9 mg l(-1), is achieved for the scenario of extensification to spring cereals with moderately fertilised grassland. However, the temporal simulations suggest that it would take approximately 100 years before 80% of this change is observed in the well-water, starting from a concentration of 23 mg l(-1) .