Tuning spectral properties of ultrafast laser ablation plasmas from brass using adaptive temporal pulse shaping

Using automated laser pulse temporal shaping we report on enhancing spectral emission characteristics of ablation plasmas produced by laser irradiation of brass on ultrafast time scales. For different input irradiance levels, control of both atomic and ionic species becomes possible concerning the yield and the excitation state. The improved energy coupling determined by tailored pulses induces material ejection with lower mechanical load that translates into hot gas-phase regions with higher excitation degrees and reduced particulates.

A randomised controlled trial of the use of aciclovir and/or prednisolone for the early treatment of Bell's palsy: the BELLS study

OBJECTIVE

To determine whether oral prednisolone or aciclovir, used separately or in combination, early in the course of Bell's palsy, improves the chances of recovery at 3 and 9 months.

DESIGN

A 2 x 2 factorial randomised double-blind trial. Patients were randomly assigned to treatment by an automated telephone service using a permuted block randomisation technique with block sizes of four or eight, and no stratification.

SETTING

Mainland Scotland, with referrals mainly from general practice to 17 hospital trial sites.

PARTICIPANTS

Adults (aged 16 years or older) with unilateral facial nerve weakness of no identifiable cause presenting to primary care, the emergency department or NHS24 within 72 hours of symptom onset.

INTERVENTIONS

Patients were randomised to receive active preparations or placebo for 10 days: (1) prednisolone (50 mg per day, 2 x 25-mg capsules) and aciclovir (2000 mg per day, 5 x 400-mg capsules); (2) prednisolone and placebo (lactose, indistinguishable); (3) aciclovir and placebo; and (4) placebo and placebo.

OUTCOME MEASURES

The primary outcome was recovery of facial function assessed by the House-Brackmann scale. Secondary outcomes included health status, pain, self-perceived appearance and cost-effectiveness.

RESULTS

Final outcomes were available for 496 patients, balanced for gender; mean age 44 years; initial facial paralysis moderate to severe. One half of patients initiated treatment within 24 hours of onset of symptoms, one-third within 24-48 hours and the remainder within 48-72 hours. Of the completed patients, 357 had recovered by 3 months and 80 at 9 months, leaving 59 with a residual deficit. There were significant differences in complete recovery at 3 months between the prednisolone comparison groups (83.0% for prednisolone, 63.6% for no prednisolone, a difference of + 19.4%; 95% confidence interval (CI): + 11.7% to + 27.1%, p < 0.001). The number needed to treat (NNT) in order to achieve one additional complete recovery was 6 (95% CI: 4 to 9). There was no significant difference between the aciclovir comparison groups (71.2% for aciclovir and 75.7% for no aciclovir). Nine-month assessments of patients recovered were 94.4% for prednisolone compared with 81.6% for no prednisolone, a difference of + 12.8% (95% CI: + 7.2% to + 18.4%, p < 0.001); the NNT was 8 (95% CI: 6 to 14). Proportions recovered at 9 months were 85.4% for aciclovir and 90.8% for no aciclovir, a difference of -5.3%. There was no significant prednisolone-aciclovir interaction at 3 months or at 9 months. Outcome differences by individual treatment (the four-arm model) showed significant differences. At 3 months the recovery rate was 86.3% in the prednisolone treatment group, 79.7% in the aciclovir-prednisolone group, 64.7% in the placebo group and 62.5% in the aciclovir group. At 9 months the recovery rates were respectively 96.1%, 92.7%, 85.3% and 78.1%. The increase in recovery rate conferred by the addition of prednisolone (both for prednisolone over placebo and for aciclovir-prednisolone over aciclovir) is highly statistically significant (p < 0.001). There were no significant differences in secondary measures apart from Health Utilities Index Mark 3 (HUI3) at 9 months in those treated with prednisolone.

CONCLUSIONS

This study provided robust evidence to support the early use of oral prednisolone in Bell's palsy as an effective treatment which may be considered cost-effective. Treatment with aciclovir, either alone or with steroids, had no effect on outcome.

Laser induced forward transfer of metals by temporally shaped femtosecond laser pulses

Temporally shaped, femtosecond laser pulses have been used for controlling the size and the morphology of micron-sized metallic structures obtained by using the Laser Induced Forward Transfer (LIFT) technique. We report the effect of pulse shaping on the size and morphology of the deposited structures of Au, Zn, Cr on a function of the pulse separation time ??t (from 0 to 10 ps) of double pulses of variable intensities generated by using a liquid crystal spatial light modulator (SLM). The observed differences in size and morphology are correlated with the outcome of pump-probe experiments for the study of electron-phonon scattering dynamics and subsequent energy transfer processes to the bulk in the different metals employed. We propose that in metals with weak electron-lattice coupling, the electron ballistic motion and the resulting fast electron scattering at the film surface, as well as the internal electron thermalization process are crucial to the morphology and size of the transferred material. Therefore, temporal shaping within the corresponding time scales of these processes may be used for tailoring the features of the metallic structures obtained by LIFT.

Choice of cellular protein expression system

Recombinant protein expression has become a standard laboratory tool, and a wide variety of systems and techniques are now in use. Because there are so many systems to choose from, the investigator has to be careful to use the combination that will give the best results for the protein being studied. This overview unit discusses expression and production choices, including post-translational modifications (e.g., glycosylation, acylation, sulfation, and removal of N-terminal methionine), in vivo and in vitro folding, and influence of downstream elements on expression.

Production of recombinant proteins in mammalian cells

The best strategy for consistent production of larger quantities of pure protein is stable expression. Popular hosts for stable expression are Chinese hamster ovary (CHO) cells, baby hamster kidney (BHK-21) cells, myeloma cells, and the transformed kidney cell line 293. Protocols for stable production in CHO cells are described in this unit. Typical methods for transfection using commercially available plasmid expression vectors are described, along with methods to select for stable expression and methods for amplifying the expression level in the transfected cell. Following this, procedures are presented for efficient cell growth to obtain significant amounts of protein product. Support protocols describe freezing of cells, determination of growth rates, determination of specific productivity of cells, preparing samples for assay, and setting up a 10-day shaker-flask growth curve.

Apoptotic cells protect mice from autoimmune inflammation by the induction of regulatory B cells

The maintenance of immune tolerance to apoptotic cells (AC) within an inflammatory milieu is vital to prevent autoimmunity. To investigate this, we administered syngeneic AC i.v. into mice carrying a cohort of ovalbumin (OVA)-specific transgenic T cells (DO11.10) along with OVA peptide and complete Freund's adjuvant, observing a dramatic increase in OVA-specific IL-10 secretion. Activated splenic B cells responded directly to AC, increasing secretion of IL-10, and this programming by AC was key to inducing T cell-derived IL-10. We went on to ask whether AC are able to modulate the course of autoimmune-mediated, chronic inflammation. AC given up to 1 month before the clinical onset of collagen-induced arthritis protected mice from severe joint inflammation and bone destruction. Antigen-specific CD4(+) T cells again secreted significantly more IL-10, associated with a reduced titer of pathogenic anti-collagen II antibodies. Inhibition of IL-10 in vivo reversed the beneficial effects of AC. Passive transfer of B cells from AC-treated mice provided significant protection from arthritis. These data demonstrate that AC exert a profound influence on an adaptive immune response through the generation of CD19(+) regulatory B cells, which in turn are able to influence the cytokine profile of antigen-specific effector T cells.

Characterization of a suite of ginkgo-containing standard reference materials

A suite of three ginkgo-containing dietary supplement Standard Reference Materials (SRMs) has been issued by the National Institute of Standards and Technology (NIST) with certified values for flavonoid aglycones, ginkgolides, bilobalide, and selected toxic trace elements. The materials represent a range of matrices (i.e., plant, extract, and finished product) that provide different analytical challenges. The constituents have been determined by at least two independent analytical methods with measurements performed by NIST and at least one collaborating laboratory. The methods utilized different extractions, chromatographic separations, modes of detection, and approaches to quantitation. The SRMs are primarily intended for method validation and for use as control materials to support the analysis of dietary supplements and related botanical materials.

Single-Laboratory Validation for the Determination of Terpene Lactones in Ginkgo biloba Dietary Supplement Crude Materials and Finished Products by High-Performance Liquid Chromatography with Evaporative Light-Scattering Detection

A single-laboratory validation was completed for a method to determine total terpene lactones in Ginkgo biloba products. The method determines terpene lactones on the basis of the main terpene lactones (Bilobalide, Ginkgolide A, Ginkgolide B, Ginkgolide C, and Ginkgolide J) by high-performance liquid chromatography with evaporative light-scattering detection after extraction. Nine matrixes were chosen for study, including crude leaf material, standardized dry powder extract, single- and multiple-entity finished products, and alcohol and glycerin tinctures. The sample purification with prepacked columns allows selective extraction of the terpene lactones with no interferences from any matrix under study. A Youden ruggedness trial testing 7 instrumental and preparation factors with the potential to affect quantitative results showed that 2 factors (volume of the column elution solvent and pH of the diluent) were the most important parameters to control during sample preparation. The method performed well in terms of precision; 4 matrixes tested in triplicate over a 3-day period showed an overall repeatability relative standard deviation (RSD) of about 3%. HorRat values were within the limits for performance acceptability, ranging from 0.5 to 1.0. Analysis of variance testing at = 0.05 showed no significant differences among the within-or between-group sources of variation, although comparison of within-day, between-day, and total precision showed that most of the RSD came from within-day determinations except those for the Ginkgo dry extract (Gb-SLV-2). Accuracy testing at 4 concentration levels of terpene lactones obtained by spiking a negative control matrix at approximately 300, 750, 1500, and 2250 g/mL gave recoveries of about 91% for the 300 g/mL level, about 98% for the 750 g/mL level, about 99% for the 1500 g/mL level, and 97% for the 2250 g/mL level with an overall recovery of 96% and an RSD of 3.2%.

The use of chicory for parasite control in organic ewes and their lambs

The aim of the present study was to investigate the potential benefits of grazing lactating ewes and their lambs on chicory (Cichorium intybus). Fifty-six certified organic twin-rearing ewes were either drenched with an anthelmintic or not, within 2 days after parturition and were grazed upon either grass/clover or chicory pastures. Around 12 weeks after parturition a subset of 12 lambs per treatment was slaughtered for worm number and parasite species determination. The faecal egg counts of lambs from undrenched ewes grazing on chicory were significantly lower than those of lambs from undrenched ewes grazing on grass. Lambs grazing on chicory had similar abomasal worm counts as those grazing on grass at 12 weeks of age; the predominant species was Teladorsagia circumcincta. There was no difference between the intestinal worm counts in lambs grazing on grass or chicory, with Trichostrongylus vitrinus being the predominant species. Liveweight gains over the 126-day experimental period were significantly higher in lambs from drenched than those from undrenched ewes. Lambs from undrenched ewes grazing on chicory had higher liveweight gains compared to those from undrenched ewes grazing on grass. Although chicory grazing did not affect ewe nematode egg excretion, it resulted in lower egg counts in lambs and improved their liveweight gains to the same level as those deriving from drenched ewes.

Increased risk of myocardial infarction as first manifestation of ischaemic heart disease and nonselective nonsteroidal anti-inflammatory drugs

AIMS

Selective cyclooxygenase (COX)-2 inhibitors have recently been implicated as enhancing risk of myocardial infarction (MI). Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective COX-2 inhibitors, so we investigated the hypothesis that they too increase risk of MI.

METHODS

We conducted a case-control study with direct structured interview of cases and controls. Cases were all subjects (N = 205) with a first nonfatal MI who had no previously recognized cardiovascular disease. Community controls (N = 258) were randomly selected from the same practice as the index case. Hospital controls (N = 205) were those admitted at the same time as index cases for nonmyocardial conditions not influenced by NSAID use. The effects of aspirin, NSAIDs and previously recognized influences on MI were investigated by unconditional logistic regression analysis.

RESULTS

NSAID use was associated with an increase risk of MI with an odds ratio of 1.77 (1.03, 3.03) vs. community controls and 2.61 (1.38, 4.95) vs. hospital controls. These values were 5.00 (1.18, 21.28) and 7.66 (0.87, 67.48), respectively, in aspirin users. Results were similar when naproxen was grouped with aspirin. Odds ratios for smoking and for use of antidiabetic medication were 3.91 (2.52, 6.04) and 3.92 (1.25, 12,33), respectively, vs. community controls.

CONCLUSIONS

Like selective COX-2 inhibitors, non-selective NSAIDs [corrected] are associated with an increased risk of MI. The extent to which this reflects interference with aspirin warrants further investigation.

Evaluation of a method to determine flavonol aglycones in Ginkgo biloba dietary supplement crude materials and finished products by high-performance liquid chromatography: collaborative study

An interlaboratory study was conducted for evaluation of a method to determine the flavonol aglycones quercetin, kaempferol, and isorhamnetin in Ginkgo biloba products. The method calculates total glycosides based on these aglycones formed after acid hydrolysis. Twelve matrixes were chosen for study by 12 collaborating laboratories in 2 countries. Test materials included crude leaf material, standardized dry powder extract, single and multiple entity finished products, ethanol and glycerol tinctures, and National Institute of Standards and Technology (NIST) standard reference materials (SRMs). Results from 11 laboratories were used for the final calculations. Eight of the 12 matrixes evaluated produced acceptable results for total flavonol glycosides, with HorRat scores ranging from 1.31 to 2.05; repeatability relative standard deviations (RSDr) from 1.46 to 4.14; and reproducibility relative standard deviations (RSDR) from 4.67 to 9.69. These 8 matrixes consisted primarily of simple dosage forms (e.g., dry powder extracts, crude leaf samples, liquid extracts, and SRMs) and a single tablet product (Ginkgo Awareness). Four additional matrixes, consisting of 3 tablets and 1 soft gel product (Ginkgold, Ginkoba, Ginkogen, and Ginkgo Phytosome, respectively), showed greater total flavonol glycoside HorRat scores in comparison, ranging from 2.39 to 5.13, with RSDr values from 2.83 to 8.16, and RSDR values from 8.53 to 20.4. Based on the results presented here, the method is recommended for Official First Action for determination of total flavonol glycosides calculated from quercetin, kaempferol, and isorhamnetin in dry powder extracts, crude leaf material, liquid extracts, and a select finished product, Ginkgo Awareness.

Single-laboratory validation for the determination of terpene lactones in Ginkgo biloba dietary supplement crude materials and finished products by high-performance liquid chromatography with evaporative light-scattering detection

A single-laboratory validation was completed for a method to determine total terpene lactones in Ginkgo biloba products. The method determines terpene lactones on the basis of the main terpene lactones (Bilobalide, Ginkgolide A, Ginkgolide B, Ginkgolide C, and Ginkgolide J) by high-performance liquid chromatography with evaporative light-scattering detection after extraction. Nine matrixes were chosen for study, including crude leaf material, standardized dry powder extract, single- and multiple-entity finished products, and alcohol and glycerin tinctures. The sample purification with prepacked columns allows selective extraction of the terpene lactones with no interferences from any matrix under study. A Youden ruggedness trial testing 7 instrumental and preparation factors with the potential to affect quantitative results showed that 2 factors (volume of the column elution solvent and pH of the diluent) were the most important parameters to control during sample preparation. The method performed well in terms of precision; 4 matrixes tested in triplicate over a 3-day period showed an overall repeatability relative standard deviation (RSD) of about 3%. HorRat values were within the limits for performance acceptability, ranging from 0.5 to 1.0. Analysis of variance testing at a = 0.05 showed no significant differences among the within-or between-group sources of variation, although comparison of within-day, between-day, and total precision showed that most of the RSD came from within-day determinations except those for the Ginkgo dry extract (Gb-SLV-2). Accuracy testing at 4 concentration levels of terpene lactones obtained by spiking a negative control matrix at approximately 300, 750, 1500, and 2250 microg/mL gave recoveries of about 91% for the 300 microg/mL level, about 98% for the 750 microg/mL level, about 99% for the 1500 microg/mL level, and 97% for the 2250 microg/mL level with an overall recovery of 96% and an RSD of 3.2%.

Postural epigastric pain as a sign of CMV gastritis: a case report

Cytomegalovirus (CMV) infection is a common cause of morbidity and mortality among patients receiving chronic maintenance immunosuppression and is often considered the most important infection in renal transplantation. CMV gastritis has been reported in transplant patients. We present a case of CMV gastritis with epigastric pain that decreased in supine position, increased while sitting, and further increased when standing or walking. To our knowledge this is the second article presented to the literature so far.

A Pragmatic Protocol for I-131 rhTSH-Stimulated Ablation Therapy in Patients With Renal Failure

PURPOSE

Ablation of thyroid remnants in patients with differentiated thyroid carcinoma and renal failure can be challenging because of the altered and variable clearance rates of iodine from the blood secondary to variations in dialysis protocols, which complicate the selection of the appropriate I-131 dose. The advent of recombinant human TSH allows a simpler approach to dosimetry and ablation without rendering the patient hypothyroid. Avoidance of hypothyroidism may be an important consideration for patients who are experiencing various morbidities from conditions associated with renal failure.

METHOD

Three patients on dialysis, who had undergone total thyroidectomy and were euthyroid on L-thyroxine replacement, were given diagnostic doses of I-131 followed by blood and whole-body retention measurements through serial dialyses to determine individual blood clearance rates. After administration of rhTSH, each patient received an ablative dose of I-131 calculated to keep total body dose below 1 Gy.

RESULTS

The treatments were administered without complications, and in follow-up imaging of 2 available patients, the ablations were demonstrated to be complete.

CONCLUSION

Dosimetry performed on euthyroid dialysis patients permits I-131 dose selection and avoids the additional morbidity of hypothyroidism.

Thrombolysis: past, present, and future

Management of myocardial infarction evolved because of understanding of underlying disease processes and clinical trials of "chemical" and "mechanical" clot dissolution that reduced in-hospital mortality. Meta-analysis comparing these treatment strategies marginally favours angioplasty. Current European Society of Cardiology guidelines propose primary angioplasty as the preferred therapeutic option but few units in the UK can offer angioplasty on demand as a designated "heart attack centre". Thrombolysis will continue as it is widely available and training needs and costs less than angioplasty. Community thrombolysis should be made available for those patients who do not wish for such aggressive intervention or as a prelude to transfer time to a heart attack centre distant from a triage hospital.

Melanomas in renal transplant recipients

BACKGROUND

It is well documented that renal transplant recipients are at increased risk of developing skin cancers, in particular squamous cell carcinomas. Less extensively reviewed in the literature is the increased incidence of malignant melanoma. We have reviewed 10 patients in the Oxford renal transplant population who developed 12 melanomas following transplantation.

OBJECTIVES

To determine the incidence and characteristics of melanoma in renal transplant recipients.

METHODS

We reviewed the case notes and pathology of all patients who developed melanoma within the Oxford Renal Transplant Unit. The clinical details were recorded including date of transplant, immunosuppressive therapy, interval between transplant and melanoma, site of occurrence, history of sun exposure, type of clinician diagnosing the melanoma, history of other skin malignancies and outcome. From the histopathology we documented various prognostic factors.

RESULTS

Ten patients developed 12 melanomas (one patient had three melanomas) from a population of 1874 transplanted patients. The total number of transplant years was 11 942.2. The incidence of melanoma in our population was 12 per 11 942.2 transplant years, which is approximately 8 times greater than the standardized rate for this region. We found that the mean interval between transplant and melanoma was approximately 11 years (median 8.5). A dermatologist was the diagnosing clinician in at least 67% of cases. Melanomas occurred on the trunk in the majority of cases (58%), followed by the upper limb (25%). All patients apart from one are alive with no recurrence of their melanoma. One patient died as a result of metastatic melanoma. The mean follow-up period following melanoma was 3.7 years. In all patients apart from the patient who died, the melanomas were < 1 mm Breslow thickness. That patient's melanoma was 4.5 mm thick. There was no precursor naevus in eight of the 12 melanomas. In two there was a precursor dysplastic naevus. In the cases in vertical growth phase the tumour-infiltrating lymphocyte response was absent in four cases and nonbrisk in one patient.

CONCLUSIONS

In the Oxford transplant population studied melanomas occurred at approximately 8 times the rate in the general population. This is the highest rate reported in the literature. The patients had a better outcome than reported previously. This may be due to detection at a relatively early stage. Renal transplant recipients attend dedicated dermatology clinics in Oxford, which may have contributed to the early diagnosis and good outcome.

Cost-effectiveness of alternative strategies for the initial medical management of non-ST elevation acute coronary syndrome: systematic review and decision-analytical modelling

OBJECTIVES

To identify and prioritise key areas of clinical uncertainty regarding the medical management of non-ST elevation acute coronary syndrome (ACS) in current UK practice.

DATA SOURCES

Electronic databases. Consultations with clinical advisors. Postal survey of cardiologists.

REVIEW METHODS

Potential areas of important uncertainty were identified and 'decision problems' prioritised. A systematic literature review was carried out using standard methods. The constructed decision model consisted of a short-term phase that applied the results of the systematic review and a long-term phase that included relevant information from a UK observational study to extrapolate estimated costs and effects. Sensitivity analyses were undertaken to examine the dependence of the results on baseline parameters, using alternative data sources. Expected value of information analysis was undertaken to estimate the expected value of perfect information associated with the decision problem. This provided an upper bound on the monetary value associated with additional research in the area.

RESULTS

Seven current areas of clinical uncertainty (decision problems) in the drug treatment of unstable angina patients were identified. The agents concerned were clopidogrel, low molecular weight heparin, hirudin and intravenous glycoprotein antagonists (GPAs). Twelve published clinical guidelines for unstable angina or non-ST elevation ACS were identified, but few contained recommendations about the specified decision problems. The postal survey of clinicians showed that the greatest disagreement existed for the use of small molecule GPAs, and the greatest uncertainty existed for decisions relating to the use of abciximab (a large molecule GPA). Overall, decision problems concerning the GPA class of drugs were considered to be the highest priority for further study. Selected papers describing the clinical efficacy of treatment were divided into three groups, each representing an alternative strategy. The strategy involving the use of GPAs as part of the initial medical management of all non-ST elevation ACS was the optimal choice, with an incremental cost-effectiveness ratio (ICER) of 5738 pounds per quality-adjusted life-year (QALY) compared with no use of GPAs. Stochastic analysis showed that if the health service is willing to pay 10,000 pounds per additional QALY, the probability of this strategy being cost-effective was around 82%, increasing to 95% at a threshold of 50,000 pounds per QALY. A sensitivity analysis including an additional strategy of using GPAs as part of initial medical management only in patients at particular high risk (as defined by age, ST depression or diabetes) showed that this additional strategy was yet more cost-effective, with an ICER of 3996 pounds per QALY compared with no treatment with GPA. Value of information analysis suggested that there was considerable merit in additional research to reduce the level of uncertainty in the optimal decision. At a threshold of 10,000 pounds per QALY, the maximum potential value of such research in the base case was calculated as 12.7 million pounds per annum for the UK as a whole. Taking account of the greater uncertainty in the sensitivity analyses including clopidogrel, this figure was increased to approximately 50 million pounds.

CONCLUSIONS

This study suggests the use of GPAs in all non-ST elevation ACS patients as part of their initial medical management. Sensitivity analysis showed that virtually all of the benefit could be realised by treating only high-risk patients. Further clarification of the optimum role of GPAs in the UK NHS depends on the availability of further high-quality observational and trial data. Value of information analysis derived from the model suggests that a relatively large investment in such research may be worthwhile. Further research should focus on the identification of the characteristics of patients who benefit most from GPAs as part of medical management, the comparison of GPAs with clopidogrel as an adjunct to standard care, follow-up cohort studies of the costs and outcomes of high-risk non-ST elevation ACS over several years, and exploring how clinicians' decisions combine a normative evidence-based decision model with their own personal behavioural perspective.

Evaluation of a modified Huddart/Bodenham scoring system for assessment of maxillary arch constriction in unilateral cleft lip and palate subjects

The aim of this retrospective study was to describe the use and reliability of a numerical scoring system (modified Huddart/Bodenham) for the measurement of maxillary arch constriction in patients born with unilateral cleft lip and palate (UCLP), and to compare and contrast the new scoring system with the current methods of measuring treatment outcome, the Goslon and 5-year-old indices. Dental study models of 50 patients aged 5 years, and 50 patients aged 10 years, were scored using the 5-year-old and Goslon indices, respectively. Four examiners scored each set of models using the modified Huddart and Bodenham system, and repeated the scoring one month later. The intra- and inter-rater reliability of the numerical scoring system was assessed using the Kappa (kappa) statistic. The scores using the new method were correlated with the 5-year-old and Goslon scores using Spearman's (rho) and Kendall's (tau) rank correlation coefficients. There was a high level of intra-rater reliability for both the 5 (0.87: incisors, 0.91: canines, 0.88: molars) and 10 (0.9: incisors, 0.84: canines, 0.78: premolars/molars) year models. The weighted kappa values measuring inter-rater reliability were above 0.85 and 0.74, respectively, for all examiners. There was a statistically significant correlation between the modified Huddart/Bodenham scores and both the 5-year-old and Goslon scores in all cases (P < 0.001). It is concluded that the modified Huddart/Bodenham system provides an objective and reliable assessment of maxillary arch constriction. It has a high degree of correlation with the recommended standards, but is more versatile and sensitive to inter-arch discrepancies.

A cost-utility analysis of clopidogrel in patients with non-ST-segment-elevation acute coronary syndromes in the UK

OBJECTIVE

To assess the long-term cost effectiveness of 1 year's treatment with clopidogrel on top of standard therapy (including aspirin; ASA) compared with standard therapy alone, in patients diagnosed with non-ST-segment-elevation acute coronary syndromes (ACS) in the UK.

DESIGN

Cost utility analysis using a Markov model, incorporating clinical data from CURE (a multicentre randomised controlled trial, involving 12,562 patients) and data from UK observational studies.

SETTING

Health economic evaluation carried out from the perspective of the UK NHS.

PATIENTS

A representative cohort of 1000 UK patients aged 66 years, diagnosed with non-ST-segment-elevation ACS.

INTERVENTIONS

Either a combination of 75 mg/day clopidogrel (300 mg loading dose, within 24 h prior to hospital admission) and standard therapy (including ASA, 75-325 mg/day) for 1 year followed by standard therapy alone for their remaining lifetime, or standard therapy alone (including ASA, 75-325 mg/day) for life.

MAIN OUTCOME MEASURES

Incremental cost per life-year gained and incremental cost per quality-adjusted life-year (QALY) gained.

RESULTS

In the base case, the incremental cost effectiveness of the clopidogrel combination vs standard therapy alone is estimated as pounds 6991 per life-year gained and pounds 7365 per QALY gained. The probability that clopidogrel remains cost effective within the generally accepted pounds 30,000 per QALY threshold is more than 80%. The confidence interval around the relative risk for vascular death was identified as the main parameter affecting the estimated cost effectiveness.

CONCLUSIONS

One year's treatment with clopidogrel is a cost effective intervention compared with standard therapy that should be considered as a routine treatment for patients with non-ST-segment-elevation ACS.

Psychometric properties of a new health needs analysis tool designed for cardiac patients

BACKGROUND AND OBJECTIVES

Assessing health needs is pivotal in healthcare systems, ensuring that services are appropriate for a population's genuine needs. In the absence of an appropriate investigational tool, a comprehensive process of questionnaire development was undertaken to evaluate and validate a specific health needs assessment tool for cardiac patients (Nottingham Health Needs Assessment; NHNA). Its psychometric properties were investigated in a survey of patients admitted with acute coronary syndromes.

METHOD

Two hundred and forty-two consecutive patients admitted to an acute cardiac unit with symptoms suggestive of acute myocardial infarction completed a postal questionnaire about health needs and quality-of-life, using generic (Short Form 12 and EuroQol-5D) and specific (Seattle Angina Questionnaire) health-related quality-of-life instruments.

RESULTS

Forty-six items were assigned to five domains of health-related needs according to principal component analysis, with high internal consistency (0.83-0.89). Each domain in the NHNA questionnaire correlated highly with its quality-of-life counterpart, indicating relatively high concurrent validity.

CONCLUSION

The NHNA questionnaire has acceptable psychometric features, with satisfactory construct validity as determined by quality-of-life analysis. This health needs assessment instrument appears to be a reliable means of identifying patients' needs, which is an important landmark for directing health services.

Applying a basic development needs approach for sustainable and integrated community development in less-developed areas: report of ongoing Iranian experience

INTRODUCTION

Despite considerable achievements in the provision of basic developmental facilities in terms of drinking water, access to primary healthcare services, high-quality and nutritious food, social services, and proper housing facilities, there are many rural and slum communities in Iran where these essential needs remain unfulfilled. Lack of equity is prominent, as large differences exist in underprivileged provinces. New policies developed in the past two decades have resulted in substantial achievements in meeting population needs and reducing the socio-economic gap; nevertheless, poverty levels, unemployment due to a large increase in the birth rate in the early 1980s, and lack of community participation are matters yet to be addressed. To overcome these deficiencies, a basic development needs approach was adopted to promote the concept of community self-help and self-reliance through intersectoral collaboration, creating an environment where people could take an active part in the development process, with the Iranian government providing the necessary support to achieve the desired level of development.

DESCRIPTION OF THE PROJECT

Following firm commitment from the Iranian government and technical support from the World Health Organization Regional Office, basic development needs was assigned a high priority in health and health-related sectors, reflected in the third National Masterplan (2001-2005). A comprehensive intersectoral plan was designed, and pilot projects were commenced in three villages. Each village elected a representative, and committee clusters were formed to run and monitor projects identified by a process of local needs assessment and priority assignment. In each region, a variety of needs were elicited from these assessments, which were actively supported by local authorities.

LESSON LEARNED

A basic development needs approach was found to be a reliable discipline to improve community participation, needs-led resource allocation and intersectoral co-operation in community development, particularly in underprivileged areas. Iran's initial experience of basic development needs has gained widespread public support but will require periodical evaluation as it is introduced into other rural and urban regions across the country.

Impact of heart failure on quality of sleep

Chronic heart failure is an important health problem associated with a high mortality and morbidity. Appropriate treatment reduces mortality and leads to improved exercise tolerance but many patients report poor quality of sleep. Sleep studies of patients with heart failure suggest that sleep disordered breathing is experienced in 50% of patients and is a powerful predictor of poor prognosis. Sleep disordered breathing broadly comprises obstructive sleep apnoea, when upper airway instability causes mechanical obstruction to breathing; and central sleep apnoea, characterised by an absence of ventilatory effort. Sleep disordered breathing occurring in patients with heart failure is in most part attributable to central sleep apnoea and reflects uncompensated instability of the ventilatory feedback mechanism.

Determination of flavonol aglycones in Ginkgo biloba dietary supplement crude materials and finished products by high-performance liquid chromatography: single laboratory validation

A single laboratory validation (SLV) was completed for a method to determine the flavonol aglycones quercetin, kaempferol, and isorhamnetin in Ginkgo biloba products. The method calculates total glycosides based on these aglycones formed following acid hydrolysis. Nine matrixes were chosen for the study, including crude leaf material, standardized dry powder extract, single and multiple entity finished products, and ethanol and glycerol tinctures. For the 9 matrixes evaluated as part of this SLV, the method appeared to be selective and specific, with no observed interferences. The simplified 60 min oven heating hydrolysis procedure was effective for each of the matrixes studied, with no apparent or consistent differences between 60, 75, and 90 min at 90 degrees C. A Youden ruggedness trial testing 7 factors with the potential to affect quantitative results showed that 2 factors (volume hydrolyzed and test sample extraction/hydrolysis weight) were the most important parameters for control during sample preparation. The method performed well in terms of precision, with 4 matrixes tested in triplicate over a 3-day period showing an overall repeatability (relative standard deviation, RSD) of 2.3%. Analysis of variance testing at alpha = 0.05 showed no significant differences among the within- or between-group sources of variation, although comparisons of within-day (Sw), between-day (Sb), and total (St) precision showed that a majority of the standard deviation came from within-day determinations for all matrixes. Accuracy testing at 2 levels (approximately 30 and 90% of the determined concentrations in standardized dry powder extract) from 2 complex negative control matrixes showed an overall 96% recovery and RSD of 1.0% for the high spike, and 94% recovery and RSD of 2.5% for the low spike. HorRat scores were within the limits for performance acceptability, ranging from 0.4 to 1.3. Based on the performance results presented herein, it is recommended that this method progress to the collaborative laboratory trial.

Public health improvement in Iran—lessons from the last 20 years

INTRODUCTION

Health services are historically based on providers's and policy makers's understanding of population health status. This does not necessarily reflect the real needs of a population. Health needs assessment (HNA) should improve individual or population health and optimize the way that limited resources are utilized.

OBJECTIVES

To review health needs literature and to describe Iranian primary healthcare (PHC) achievements in developing a needs-driven health system.

FINDINGS

The Iranian PHC system was established to meet healthcare needs identified through population health status surveys. Since 1984, the PHC system has become highly organized and efficient, resulting in a dramatic decrease in infant, maternal and neonatal mortality rates, population growth, increasing life span and a marked shift towards non-communicable diseases. Through an organized partnership of the general population, volunteers, health workers and health professionals, a needs-oriented healthcare system became central to health policy in Iran. Several information sources were utilized to establish need. Improving death certification was an immediate and important part of this process.

COMMENT

Improved knowledge about personal rights, community and environmental health policies, and involvement of the media led to an increased range and depth of needs. Moving towards quality improvement and a needs-driven healthcare system requires continuous needs assessment. Novel methods of HNA, such as postal and telephone surveys, group discussions, surrogates for need such as quality-of-life measurement (commonly used in developed countries) or other locally designed methods such as the basic development needs approach, may be relevant to the Iranian PHC network.

Breathlessness in hospitalised adult patients

Dyspnoea is defined as a sensation of difficult breathing. It is common in hospitalised patients and is often a harbinger of serious and potentially fatal pathology. The pathophysiology of dyspnoea involves complex interactions between peripheral and central receptors and cognition. Given the myriad causes of dyspnoea, a systematic approach to diagnosis is important. A good history and systemic examination are necessary as it is important to quickly identify the cause and treat it promptly. Investigations are numerous but chest radiography and electrocardiography are among the commonest and most useful. It is important to understand the mechanisms underlying dyspnoea to treat breathless patients successfully.

Breathlessness in hospitalised adult patients

Dyspnoea is defined as a sensation of difficult breathing. It is common in hospitalised patients and is often a harbinger of serious and potentially fatal pathology. The pathophysiology of dyspnoea involves complex interactions between peripheral and central receptors and cognition. Given the myriad causes of dyspnoea, a systematic approach to diagnosis is important. A good history and systemic examination are necessary as it is important to quickly identify the cause and treat it promptly. Investigations are numerous but chest radiography and electrocardiography are among the commonest and most useful. It is important to understand the mechanisms underlying dyspnoea to treat breathless patients successfully.

Preliminary investigation of a modified Huddart/Bodenham scoring system for assessment of maxillary arch constriction in unilateral cleft lip and palate subjects

The objective of this study was to describe a numerical scoring system for the measurement of maxillary arch constriction in patients born with unilateral cleft lip and palate (UCLP). A modification of the Huddart/Bodenham scoring system was compared and contrasted with the current methods of measuring treatment outcome, the GOSLON and 5-year indices. The GOSLON and 5-year indices are represented by 10 sets of study models grouped into five categories representing the range of possible outcomes in terms of dental arch relationship, with two sets of models in each of the five categories, whilst the modified Huddart/Bodenham method uses the frequency and severity of crossbite of the dental occlusion to evaluate maxillary arch constriction. The latter system was found to be more objective and reliable, and to correlate well with current recommended standards. It was also more versatile and more sensitive to interarch discrepancies. However, further work is required to refine it to reflect the potential for orthodontic treatment to mask interarch discrepancy following surgery.

Factors influencing the shedding of verocytotoxin-producing Escherichia coli O157 by beef suckler cows

A study was designed to investigate management factors that might influence the shedding of verocytotoxin-producing Escherichia coli (VTEC) O157 by beef cows in Scotland, where there is a particularly high rate of human infection. Thirty-two herds were visited at least monthly over approximately 1 year for collection of fresh faecal pat samples and information on management factors. The faecal pat samples were tested for VTEC O157 by established culture and immunomagnetic separation methods. Questionnaires were completed at the monthly visits to record management factors. Data were analysed using both univariate and multi-factor (GLMM) analysis. Changes in the number of cows in a group, dogs, wild geese, housing, and the feeding of draff (distillers' grains) were statistically significant as risk factors. The event of calving appeared to reduce the likelihood of shedding. Any effects of weaning or turnout were not statistically significant. It appears that the rate of shedding of VTEC O157 is influenced by several factors but possibly the most important of these are the circumstances of animals being housed, or, when outside, the presence of wild geese.

Changing the diagnostic criteria for myocardial infarction in patients with a suspected heart attack affects the measurement of 30 day mortality but not long term survival

OBJECTIVES

To explore the effects of alternative methods of defining myocardial infarction on the numbers and survival patterns of patients identified as having sustained a confirmed myocardial infarct.

DESIGN

An inclusive historical cohort of patients admitted with a suspected heart attack. Patients were recoded from raw clinical data (collected at the index admission) to the epidemiological definitions of myocardial infarction used by the Nottingham heart attack register (NHAR), the World Health Organization (MONICA), and the UK heart attack study.

SETTING

Single health district.

PATIENTS

The NHAR identified all patients admitted in 1992 with suspected myocardial infarction.

OUTCOME MEASURES

Survival at 30 days and four year postdischarge.

RESULTS

2739 patients were identified, of whom 90% survived to discharge. Recoding increased the numbers of patients defined as having confirmed myocardial infarction from 26% under the original NHAR classification to 69%, depending on the classification system used. In confirmed myocardial infarction, subsequent 30 day survival from admission varied from 77-86% depending on the classification system; four year survival after discharge was not affected. The distribution of important prognostic variables differed significantly between groups of patients with confirmed myocardial infarction defined by different systems. Patients with suspected but unconfirmed myocardial infarction under all classification systems had a worse postdischarge mortality.

CONCLUSIONS

The classification system used had a substantial effect on the numbers of patients identified as having had a myocardial infarct, and on the 30 day survival. There were significant numbers of patients with more atypical presentations, not labelled as myocardial infarction, who did badly following discharge. More research is needed on these patients.