Revisiting reliability of quantified perineal ultrasound: Bland and Altman analysis of a new protocol for the rectangular coordinate method

AIMS

This study tested the reliability of a new protocol for the rectangular coordinate method of quantifying perineal ultrasound.

METHODS

Representative scans of healthy primiparous females were quantified by positioning a pubic bone template, drawn onto an acetate sheet containing x-y axes, over scans, by aligning the x-axis with the pubic bone central axis. Values for x (D(x)) and y (D(y)) located the urethrovesical junction (UVJ) at Rest, and at maximal Valsalva and Kegel. Range of motion (V-K) was calculated. Bland and Altman analysis, correlations, and t-tests determined intra- and inter-rater reliability, and variance due to designation of the pubic bone central axis (template control).

RESULTS

Correlations averaged 0.72, 0.70, and 0.92 for intra-rater, inter-rater, and template control experiments. D(x) Rest, D(x) Kegel, and V-K were reliable in all experiments. First and second measures for inter-rater D(y) Rest and D(y) Kegel, and template control D(y) Valsalva were significantly different. Bland and Altman analysis showed D(y) Rest, D(y) Kegel, and D(x) and D(y) Valsalva for both reliability experiments to have limits of agreement (LOA's) large enough to explain >or=50% of the actual value ranges. Template control LOA's explained <or=30% of the actual value ranges.

CONCLUSIONS

The reliability of this protocol varied according to the conditions analyzed; accurate reliability assessment of all conditions required Bland and Altman analysis; and the designation of the pubic bone central axis remained a source of variance between investigators. Our results suggest Bland and Altman analysis be used with each study that quantifies perineal ultrasound.

Tibial tuberosity advancement in 65 canine stifles

The tibial tuberosity advancement (TTA) procedure was developed to treat dogs with cranial cruciate ligament deficient stifles. A retrospective, descriptive study was performed on 57 dogs that underwent unilateral or bilateral TTA. Medical records were reviewed and pre-, postoperative and follow-up radiographs were evaluated for patellar ligament-tibial plateau angle (alpha), distance of the tibial tuberosity advancement and progression of degenerative joint disease. A questionnaire was sent to all owners to obtain their assessment of the procedural outcome. Sixty-five stifles in 57 dogs received a TTA. Mean age was 5.2 +/- 2.5 years while mean weight was 39.7 +/- 11.9 kg. Eighteen breeds were represented with Labrador retrievers and mixed breeds predominating. The mean duration of lameness prior to surgery was 6.2 +/- 6.7 months, with a median lameness score of 3/4. Fifty-nine percent of cases encountered complications, the majority of which were minor. Major post-operative complications were uncommon but consisted of implant failure, tibial crest displacement and medial meniscal tears. The mean radiographic preoperative angle alpha was 100 degrees, while the postoperative was 95.5 degrees. Mean osteoarthrosis scores were significantly different between preoperative and follow-up radiographs with 67% of cases showing radiographic progression. Seventy percent of owners responded to the survey with overall outcome considered good to excellent in 90%. Activity level was improved in 90% of responses. TTA subjectively appears to be a useful alternative in the management of cranial cruciate ligament disease. Few severe complications were encountered. Good clinical outcome and owner satisfaction was reported with the procedure in this set of cases.

Post-exposure treatment attenuates noise-induced hearing loss

Reactive oxygen species (ROS) and reactive nitrogen species (RNS) are involved in sensory cell and neural death in the peripheral nervous system, including damage induced by noise trauma. Antioxidant administration prior to or concomitant with noise exposure can prevent auditory deficits, but the efficacy of a delayed treatment is not known. We have recently found continued reactive oxygen species/reactive nitrogen species formation in the ear for 7-10 days following noise exposure and reasoned that antioxidant intervention during this period should also reduce noise-induced hearing loss. Guinea-pigs were subjected to 4 kHz octave band noise at 120 decibels sound- pressure-level (dB SPL) for 5 hours and received treatment with ROS and RNS scavengers (salicylate and trolox) beginning 3 days prior, 1 hour, 1, 3, or 5 days after noise exposure. Auditory thresholds were assessed by sound-evoked auditory brainstem response at 4, 8, and 16 kHz, before and 10 days after noise exposure. Hair cell damage was analyzed by quantitative histology, and free radical activity was determined immunohistochemically via 4-hydroxynonenal and nitrotyrosine as markers of reactive oxygen species and reactive nitrogen species action. Delivered up to 3 days after noise exposure, salicylate and trolox significantly reduced auditory brainstem response deficits, reduced hair cell damage, and decreased reactive oxygen species and reactive nitrogen species formation. Earlier drug treatment was more effective than later treatment. Our results detail a window of opportunity for rescue from noise trauma, and provide evidence for both morphological and functional protection by delayed pharmacological intervention.

Non-invasive half millimetre 32 detector row computed tomography angiography accurately excludes significant stenoses in patients with advanced coronary artery disease and high calcium scores

OBJECTIVE

To show an overall diagnostic accuracy > or = 90% for detection of > or = 50% stenoses by coronary half millimetre 32 detector row computed tomography angiography (32 x 0.5-MDCTA) in patients with advanced coronary artery disease (CAD) and a high likelihood of raised calcium scores.

METHODS

ECG gated 32 x 0.5-MDCTA (32 x 0.5 mm cross sections, 0.35 x 0.35 x 0.35 mm3 isotropic voxels, 400 ms rotation) was performed after injection of iodixanol (120 ml, 320 mg/ml) in 30 consecutive patients (25 men, mean (SD) age 59 (13) years, body mass index 26.2 (4.9) kg/m2). Native arteries, including > or = 1.5 mm branches, and bypass grafts were screened for > or = 50% stenoses. Stents were excluded. Conventional coronary angiography (performed 18 (12) days before 32 x 0.5-MDCTA) was analysed by quantitative coronary angiography.

RESULTS

Median Agatston calcium score was 510 (range 3-5066). Sensitivity, specificity, and positive and negative predictive values for detection of > or = 50% stenoses in native arteries were 76% (29 of 38), 94% (190 of 202), 71% (29 of 41), and 96% (190 of 199), respectively. Overall diagnostic accuracy was 91% (219 of 240). Due to the following artefacts 20% (69 of 352) of the vessels were excluded: motion, noise, and low contrast enhancement isolated or in combination (45 of 69 (65%)); image distortion by implantable cardioverter-defibrillator or pacemaker leads (18 of 69 (26%)); and blooming secondary to severe calcification (6 of 69 (9%)).

CONCLUSIONS

Coronary 32 x 0.5-MDCTA accurately excludes > or = 50% stenoses in patients with advanced CAD and high calcium scores with an overall diagnostic accuracy of 91%.

Lower serum magnesium levels are associated with more rapid decline of renal function in patients with diabetes mellitus type 2

AIMS

Hypomagnesemia has been implicated in adversely affecting diabetic complications. This is a retrospective study designed to determine whether there is any association between serum magnesium concentration [Mg2+] and the rate of renal function deterioration, as determined by the slope of serum creatinine reciprocals versus time (1/SCr-vs-t), in patients with diabetes mellitus type 2 (DM2).

MATERIALS AND METHODS

DM2 patients without known kidney disease seen at Olive View-UCLA Medical Center for any reason during January-March 2001 were included. For each patient, all available data from our electronic database for [Mg2+], hemoglobin A(1C) (HbA(1C), serum creatinine (SCr), lipid profiles, routine urinary analysis, as well as history of hypertension and pharmacy profiles were retrieved. The average of all parameters obtained and linear regression analyses for the slope of 1/SCr-vs-t plot were performed for each patient. Patients were stratified by gender and divided into four groups based on increasing [Mg2+]. Correlations between each parameter including the slope of 1/SCr-vs-t and the four magnesium groups were analyzed.

RESULTS

252 males and 298 females with a mean follow-up of 62.6 +/- 22.5 months were included. Patients belonging to lower [Mg2+] groups for both genders had significantly worse slopes of 1/SCr-vs-t plot independent of the presence of hypertension and use of ACEI/ARB, diuretics, HMG-CoA enzyme inhibitors or aspirin. In a multivariate regression analysis controlling for age, HbA(1C) and various components of the lipid profile, [Mg2+] remained an independent predictor for the slope of 1/SCr-vs-t. A trend for worse proteinuria based on routine urinary analysis was observed among patients belonging to the lowest [Mg2+] group.

CONCLUSIONS

Lower [Mg2+] is associated with a faster renal function deterioration rate in DM2 patients.

Detection of Mycobacterium avium subspecies paratuberculosis in free-ranging bison (Bison bison) by PCR

Bacterial culture is the 'gold standard' for detecting Mycobacterium avium subspecies paratuberculosis (MAP) infection, but is time consuming, laborious, and recovery of organism varies with species of animal tested. PCR has been used for detection of MAP DNA in feces and tissues. We used PCR to detect MAP DNA isolated from tissues from 25 free-ranging North American bison (Bison bison), each with clinical signs compatible with Johne's disease. We report the performance of PCR to detect MAP DNA in both frozen and paraffin-embedded ileum, jejunum, and ileocecal lymph node samples collected at the time of slaughter. Specific oligonucleotide primers for PCR amplification were derived from 16S rRNA sequence M. avium subspecies (MAs) and insertion elements IS1245 (MAs avium), IS901 (MAs avium), IS900 (MAP), and hspX (MAP). Genomic DNA samples were prepared three different ways; crude DNA from frozen tissues, crude DNA from paraffin-embedded tissues, and purified DNA from paraffin-embedded tissues. An animal was considered infected if MAP DNA was detected in at least two separate tissues using the IS900 primer set. Using these criteria, 25 of 25 bison tested were positive for MAP. The data indicate that these free-ranging bison have been infected by MAP.

Mechanomyographic time and frequency domain responses of the vastus medialis muscle during submaximal to maximal isometric and isokinetic muscle actions

The purpose of this study was to examine the patterns for the mechanomyographic (MMG) amplitude and mean power frequency (MPF) versus torque relationships during isometric and isokinetic muscle actions. Ten adults (mean age +/- SD = 22 +/- 1 y) volunteered to perform isometric and isokinetic leg extension muscle actions at 10, 20, 30, 40, 50, 60, 70, 80, 90, and 100% of peak torque on a Cybex II dynamometer. A piezoelectric crystal contact sensor was placed on the vastus medialis to detect the MMG signal. Regression analyses indicated that for the isometric muscle actions, the relationships for MMG amplitude (R2 = 0.998) and MPF (R2 = 0.987) versus torque were cubic. For the isokinetic muscle actions, the relationships for MMG amplitude (r2 = 0.927) and MPF (r2 = 0.769) versus torque were linear. The different patterns for MMG amplitude and frequency may reflect differences in the motor control strategies that modulate torque production for isometric versus dynamic muscle actions.

Failure to detect prion protein (PrPres) by immunohistochemistry in striated muscle tissues of animals experimentally inoculated with agents of transmissible spongiform encephalopathy

Transmissible spongiform encephalopathies (TSEs) are fatal neurologic diseases. Infection by the causative agent, a prion, induces accumulations of an abnormal form of prion protein (PrP(res)) in tissues of nervous and lymphoid systems. Presence of characteristic histopathologic changes (spongiform encephalopathy) and detection of protease-resistant PrP(res) in neural and lymphoid tissues are the basis of currently available methods for diagnosis of TSEs. In this study, samples of striated muscle tissues (tongue, heart, diaphragm, and masseter muscle) from 20 animals (cattle, sheep, elk, and raccoons) were examined for PrP(res) by immunohistochemistry (IHC). All the animals had developed a TSE after experimental inoculation. PrP(res) was found by IHC in the brain but not in the muscle tissues of all the animals examined. These findings are contradictory to recently published reports of laboratory animals with TSEs, where these altered prion proteins were detected in tongue and other striated muscles. Further testing of muscle tissues is needed to confirm the findings of the present study.

Effects of hepatitis A vaccination on atherogenesis in a murine model

Our laboratory demonstrated that seropositivity to hepatitis A virus (HAV) independently predicts risk for coronary artery disease (CAD). As these findings are based only on the presence of HAV-specific antibodies, and not infectious virus, this prompted questions regarding possible effects of HAV vaccines on CAD development. If seropositivity to HAV alone, resulting from HAV vaccination, leads to increased atherogenesis, this raises important issues regarding the benefit of protection against HAV infection vs the risk of developing CAD. This study examines the effect of HAV vaccination on atherosclerosis development in a cholesterol-fed mouse model. Animals either received HAV vaccine, adjuvant, or saline. After 15 weeks, no significant differences were found in lesion area between the groups: HAV vaccine, 13,470 microm2; adjuvant, 16,332 microm2 and saline, 14,356 microm2. Only animals receiving HAV vaccination developed HAV-specific IgG. Thus, in this mouse model, vaccination against HAV does not contribute to the development of atherosclerosis.

Early induction of humoral and cellular immune responses during experimental Mycobacterium avium subsp. paratuberculosis infection of calves

Johne's disease (paratuberculosis) of cattle is widespread and causes significant economic losses for producers due to decreased production and poor health of affected animals. The chronic nature of the disease and the lack of a reproducible model of infection hinder research efforts. In the present study, instillation of Mycobacterium avium subsp. paratuberculosis into the tonsillar crypts of neonatal calves resulted in peripheral colonization as detected by antemortem culture of feces and postmortem (320 days postchallenge) culture of intestinal tissues. Antigen-specific blastogenic, gamma interferon (IFN-gamma), and nitric oxide responses by blood mononuclear cells from infected calves exceeded prechallenge responses beginning 194 days postchallenge. Upon in vitro stimulation with paratuberculosis antigens, CD4(+) cells from infected calves proliferated, produced IFN-gamma, and increased expression of CD26 and CD45RO (indicative of an activated memory phenotype). Utilizing a lipoarabinomannan-based enzyme-linked immunosorbent assay, specific serum immunoglobulin was detected as early as 134 days postchallenge and generally increased after this time point. Two antigens of approximately 50 and approximately 60 kDa were particularly immunodominant early in infection, as shown by immunoblot with serum collected within 2 weeks postchallenge. Findings indicate that the intratonsillar inoculation route will prove useful as an experimental model for paratuberculosis infection. Additionally, this study confirms that mycobacteria-specific antibody is detectable early in the course of experimental Johne's disease, even preceding the development of specific cell-mediated responses.

Pathways for protection from noise induced hearing loss

There is increasing evidence that at least one function of both the medial and the lateral olivocochlear efferent systems is to provide adjustment of the set point of activity in their postsynaptic target, the outer hair cells and afferent processes, respectively. New results, summarized in this review, suggest that both efferent systems can provide protection from noise through this mechanism. There are also intracellular pathways that can provide protection from noise-induced cellular damage in the cochlea. This review also summarizes new results on the pathways that regulate and react to levels of reactive oxygen species in the cochlea as well as the role of stress pathways for the heat shock proteins and for neurotrophic factors in protection, recovery and repair.

Preliminary observations on the experimental transmission of scrapie to elk (Cervus elaphus nelsoni) by intracerebral inoculation

To determine the transmissibility of scrapie to Rocky Mountain elk (Cervus elaphus nelsoni), six elk calves were inoculated intracerebrally with brain suspension from sheep naturally affected with scrapie. One elk developed a brain abscess and was euthanatized at 7 weeks postinoculation (PI), and two others died at 6 and 15 months PI because of physical injuries. At 25 and 35 months PI, two other elk died after brief terminal neurologic episodes. Necropsy of these revealed moderate weight loss but no other gross lesions. Microscopically, characteristic lesions of spongiform encephalopathy were seen throughout the brains and the spinal cords, and in both cases these tissues were positive for PrP(res) by immunohistochemistry. Brains of both animals were positive for PrP(res) by western blot and for scrapie-associated fibrils (SAFs) by negative stain electron microscopy. PrP(res) and SAFs were not detected in the three elk that died or were euthanatized because of coincidental causes. Over 3.5 years after initiation of this experiment, the one remaining inoculated elk and two uninoculated (control) elk are alive and apparently healthy. These preliminary findings demonstrate that 1) sheep scrapie agent can be transmitted to elk by intracerebral inoculation; 2) the infection can result in severe, widely distributed spongiform change and accumulations of PrP(res) in the central nervous system (CNS); and 3) based on the examination of a limited number of CNS sections from two cases, this condition cannot be distinguished from chronic wasting disease with currently available diagnostic techniques.

Large-scale, decelerating, relativistic x-ray jets from the microquasar XTE J1550-564

We have detected, at x-ray and radio wavelengths, large-scale moving jets from the microquasar XTE J1550-564. Plasma ejected from near the black hole traveled at relativistic velocities for at least 4 years. We present direct evidence for gradual deceleration in a relativistic jet. The broadband spectrum of the jets is consistent with synchrotron emission from high-energy (up to 10 tera-electron volts) particles that were accelerated in the shock waves formed within the relativistic ejecta or by the interaction of the jets with the interstellar medium. XTE J1550-564 offers a rare opportunity to study the dynamical evolution of relativistic jets on time scales inaccessible for active galactic nuclei jets, with implications for our understanding of relativistic jets from Galactic x-ray binaries and active galactic nuclei.

Conservation of recognition of antibody and T-cell-defined alloantigens between species of equids

Serological and cellular assays and molecular techniques were used to define features of the major histocompatibility complex (MHC) of the donkey With this information in hand, immune recognition of MHC determinants within and between donkeys and horses was compared. An antibody-mediated, complement-dependent, microcytotoxicity assay using a variety of antisera to donkey histocompatibility antigens, including those induced as a result of intraspecies or interspecies pregnancy in horse mares and jenny donkeys, delineated five donkey leukocyte antigen (DoLA) specificities. Antisera raised across species barriers (horse anti-donkey and donkey anti-horse) recognized polymorphic antigenic determinants in the target species. These determinants were often indistinguishable from polymorphic antigens recognized by alloantisera raised within horses or donkeys. The data indicate that a strong correlation exists between the serological antigenic types identified and the specificity of cytotoxic T lymphocytes raised by lymphocyte co-cultures, either within or between species. Moreover, in an analysis of a small number of donkey MHC class I cDNA gene sequences, no features distinguishing horse or donkey MHC class I molecules were identified. These molecular findings explain in large measure why antibody- and T-cell-defined alloantigen recognition is conserved among these closely related equids.

Identification of fat-cell enhancer regions in Drosophila melanogaster

The insect fat body is a dynamic tissue involved in maintaining homeostasis. It functions not only in energy storage and intermediary metabolism but also in detoxification, communication and the immune response. Some of these functions are confined to distinct groups of fat body cells. In Drosophila melanogaster, discrete precursor-cell clusters populate the fat body [Hoshizaki, D.K., Blackburn, T., Price, C., Ghosh, M., Miles, K., Ragucci, M. and Sweis, R. (1994) Embryonic fat-cell lineage in Drosophila melanogaster. Development 120: 2489-2499; Hoshizaki, D.K., Lunz, R., Ghosh, M. and Johnson, W. (1995) Identification of fat-cell enhancer activity in Drosophila melanogaster using P-element enhancer traps. Genome 38: 497-506; Riechmann, V., Rehorn, K.P., Reuter, R. and Leptin, M. (1998) The genetic control of the distinction between fat body and gonadal mesoderm in Drosophila. Development 125: 713-723]. Whether these clusters populate defined morphological regions or whether they represent the precursors to functionally similar groups of fat-body cells has not been formally demonstrated. We have identified a 2.1 kb enhancer region from serpent (srp), a GATA transcription factor gene that is sufficient to induce fat-cell formation. This enhancer region drives expression in specific groups of precursor-cell clusters, which we show give rise to defined regions of the mature embryonic fat body. We present evidence that srp expression in different precursor fat cells is controlled by independent cis-acting regulatory regions, and we have tested the role of trans-acting factors in the specification of some of these cells. We suggest that the different positional cues regulating srp expression, and therefore general fat-cell specification, might also be involved in the functional specialization of fat cells. This may be a common mechanism in insects to explain the origin of biochemically distinct regions of the larval/adult fat body.

A framework for the multiple roles of librarians in problem-based learning

Librarians are playing numerous roles within problem-based learning curricula. While many of these roles are described in the literature, there is no framework to describe and organize these roles. This paper proposes such a framework. It arranges librarian roles according to level of curricular involvement and includes the following levels: assistance at the reference desk, instruction at the reference desk, course-related instruction, resource management and utilization, consultation with faculty and students, and group facilitation.

Therapist reporting of suspected child abuse and maltreatment: factors associated with outcome

Several studies have found that making a report of suspected child abuse or maltreatment concerning a client in psychotherapy is more likely to have a positive outcome for the relationship or to effect no change, than to be damaging. The current study examined factors that were associated with outcome. Three variables, all of which concerned the client-therapist relationship, were found to be important for outcome. The quality of the relationship before the report made the greatest contribution to predicting outcome, with stronger alliances associated with positive outcome. Also important is the length of time in treatment, with longer periods of time related to positive outcome. In addition, more effective handling of making the report is related to positive outcome in that it differentiated improved from no-change groups. Lastly, statistical trends were found both for a relationship between therapist comfort in reporting and positive outcome, and for families tending to have more negative outcomes than adults in individual treatment or children. This is the first time that the examination of factors related to outcome was based upon information received from mental health professionals who were confirmed by CPS as reporters of suspected child abuse and maltreatment. Findings from this and related studies should be incorporated into training programs to ease concerns about the effects of reporting on the psychotherapy relationship and to offer guidance about factors that could increase positive outcomes. Such training could provide needed information to practitioners in reporting situations and enable more complete reporting.

Agents of bioterrorism. Preparing for bioterrorism at the community health care level

Bioterrorism preparedness is clearly a goal for the health care community, working in concert with city, county, state, and federal public health and emergency authorities and in collaboration with law enforcement at the local and federal levels. Opening the channels of communication between all groups involved, obtaining the necessary resources, and maintaining an understanding of the potential agents and the diseases they cause will foster a smooth transition to a rational program directed at patient, personnel, and community safety.

Computerized method of visual acuity testing: adaptation of the amblyopia treatment study visual acuity testing protocol

PURPOSE

To report a computerized method for determining visual acuity in children using the Amblyopia Treatment Study visual acuity testing protocol.

METHODS

A computerized visual acuity tester was developed that uses a programmed handheld device that uses the Palm operating system (Palm, Inc, Santa Clara, California). The handheld device communicates with a personal computer running a Linux operating system and 17-inch monitor. At a test distance of 3 m, single letters can be displayed from 20/800 to 20/12. A C program on the handheld device runs the Amblyopia Treatment Study visual acuity testing protocol. Using this method, visual acuity was tested in both the right and left eyes, and then the testing was repeated in 156 children age 3 to 7 years at four clinical sites.

RESULTS

Test-retest reliability was high (r =.92 and 0.95 for and right and left eyes, respectively), with 88% of right eye retests and 94% of left eye retests within 0.1 logarithm of minimal angle of resolution (logMAR) units of the initial test. The 95% confidence interval for an acuity score was calculated to be the score +/- 0.13 logMAR units. For a change between two acuity scores, the 95% confidence interval was the difference +/- 0.19 logMAR units.

CONCLUSIONS

We have developed a computerized method for measurement of visual acuity. Automation of the Amblyopia Treatment Study visual acuity testing protocol is an effective method of testing visual acuity in children 3 to 7 years of age.