Karl Koenig: the Austrian refugee doctor who founded a worldwide movement in Scotland

In this paper, the circumstances which led to the creation of the Camphill Movement in Scotland are described. Attention is drawn to the rejection by Dr Karl Koenig--co-founder of the Movement--of too narrow an approach to the treatment of children and adults with intellectual disabilities and his advocacy of a holistic approach. Koenig was one of the first medical practitioners in Britain to proclaim and demonstrate that all children with an intellectual disability, regardless of the severity of that disability, have a potential that can be unlocked and developed. There are now over 100 Camphill communities in more than 20 countries making it one of the largest independent providers of services for children and adults with intellectual disabilities in the world.

Development of a decommissioning strategy for the MR research reactor

A description of the selected decommissioning strategy for the research reactor MR at the site of the Kurchatov Institute in Moscow is presented. The MR reactor hall is planned to be used as a temporary fuel store for the other research reactors on the site. On the basis of the site-specific conditions and overall decommissioning goals, it was identified that phased immediate decommissioning is the preferable option. The current status of the reactor, expected final conditions and the sequence of decommissioning works are shown.

Development of a plant-based threshold for tarnished plant bug (Hemiptera: Miridae) in cotton

The tarnished plant bug, Lygus lineolaris (Palisot de Beauvois), is an important pest of cotton, Gossypium hirsutum L., in the mid-southern United States. It is exclusively controlled with foliar insecticide applications, and sampling methods and thresholds need to be revisited. The current experiment was designed to establish a plant-based threshold during the flowering period of cotton development. Experiments were conducted in MisSissippi in 2005 and 2006, Arkansas in 2005, and Louisiana in 2005 through 2008. Treatments consisted of various combinations of thresholds based on the percentage of dirty squares that were compared with the current threshold with a drop cloth or automatic weekly applications. Dirty squares were characterized as those with yellow staining on the developing bud resulting from tarnished plant bug excrement. Treatments consisted of 5, 10, 20, and 30% dirty squares. Each plot was sampled weekly, and insecticides were applied when the mean of all replications of a particular treatment reached the designated threshold. At the end of the season, plots were harvested and lint yields were recorded. Differences were observed in the number of applications and yields among the different treatments. The 10% dirty squares threshold resulted in a similar economic return compared with the drop cloth. A threshold of 10% dirty squares resulted in a similar number of insecticide applications, yields, and economic returns compared with that observed with the drop cloth. These results suggest that a threshold of 10% dirty squares could be used to trigger insecticide applications targeting tarnished plant bugs in flowering cotton.

Effect of specialist decision-making on treatment strategies for colorectal liver metastases

BACKGROUND

One hundred and ten patients were treated with palliative chemotherapy, of whom 53 had liver-only disease and had not been reviewed by a specialist liver surgeon. One scan was excluded as all reviewers felt it to be of insufficient quality to assess. Improved surgical technique and better chemotherapeutic manipulation of metastatic disease has increased the number of patients eligible for potentially curative resection of colorectal liver metastases. The rapid evolution in this field suggests that non-specialist decision-making may lead to inappropriate management. This study aimed to assess the management of colorectal liver metastases by non-liver surgeons.

METHODS

All patients who underwent chemotherapy with palliative intent for metastatic colorectal cancer at a regional oncology centre between 1 January and 31 December 2009 were identified from a prospectively maintained local database. Six resectional liver surgeons blinded to patient management and outcome reviewed pretreatment imaging and assigned each scan a score based on their own management choice. A consensus decision was reached on the appropriateness of palliative chemotherapy.

RESULTS

One hundred and ten patients were treated with palliative chemotherapy, of whom 53 had liver-only disease and had not been reviewed by a specialist liver surgeon. One scan was excluded as all reviewers felt it to be of insufficient quality to assess [corrected]. Tumours in 33 patients (63 per cent) were considered potentially resectable, with a high level of interobserver agreement (κ = 0 · 577). When individual approach to management was considered, interobserver agreement was less marked (κ = 0 · 378).

CONCLUSION

Management of patients with colorectal liver metastases without the involvement of a specialist liver multidisciplinary team can lead to patients being denied potentially curative treatments. Management of these patients must involve a specialist liver surgeon to ensure appropriate management.

Journal standards

Despite its many imperfections, the peer review process is a firmly established quality control system for scientific literature. It gives readers some assurance that the work and views that are reported meet standards that are acceptable to a journal. Maureen Revington's editorial in a recent issue of the Australian Veterinary Journal (Revington2002) gives a good concise warts and all overview of the process and is well worth reading. I have some concerns about several articles in the December 2002 issue of the New Zealand Veterinary Journal (Volume 50, Number 6), devoted to the health and welfare of farmed deer, that relate to extensive citing of non-peer reviewed papers. I can understand the need for information to flow from researchers to the wider community but that need is already satisfied by publications such as the proceedings of the Deer Branch of the New Zealand Veterinary Association and Proceedings of the New Zealand Society of Animal Production. Non-peer reviewed papers have been cited in the Journal in the past but never to the extent displayed in this particular issue. It degrades the peer-review process and creates an added burden for reviewers who are forced to grapple with the uncertainties of the science in non-peer reviewed citations. One of my fears is that this process allows science from non peer reviewed articles to be legitimised by its inclusion in a peer reviewed journal and perhaps go on to be accepted as dogma. This is a real danger given the difficulties associated with tracing back to original citations and the increasing volume of scientific literature. It also affords opportunities for agencies to pick up questionable and doubtful science and tout it as support for their products or particular points of view. If deer researchers choose to publish most of their work in proceedings then so be it. However this approach, which seems to becoming increasingly prevalent in the deer sector, is questionable from an established science point of view. For my part, I am increasingly reluctant to spend time reading non-peer reviewed material, despite its appeal. At present there are two distinct baskets for scientific literature, one for non-reviewed articles and another for peer reviewed information. I would sincerely hope that we are not going to need another basket as a halfway house for issues that fall in between that classification.

Effect of specialist decision-making on treatment strategies for colorectal liver metastases

Background

One hundred and ten patients were treated with palliative chemotherapy, of whom 53 had liver-only disease and had not been reviewed by a specialist liver surgeon. One scan was excluded as all reviewers felt it to be of insufficient quality to assess. Improved surgical technique and better chemotherapeutic manipulation of metastatic disease has increased the number of patients eligible for potentially curative resection of colorectal liver metastases. The rapid evolution in this field suggests that non-specialist decision-making may lead to inappropriate management. This study aimed to assess the management of colorectal liver metastases by non-liver surgeons.

Methods

All patients who underwent chemotherapy with palliative intent for metastatic colorectal cancer at a regional oncology centre between 1 January and 31 December 2009 were identified from a prospectively maintained local database. Six resectional liver surgeons blinded to patient management and outcome reviewed pretreatment imaging and assigned each scan a score based on their own management choice. A consensus decision was reached on the appropriateness of palliative chemotherapy.

Results

Tumours in 33 patients (63 per cent) were considered potentially resectable, with a high level of interobserver agreement (κ = 0·577). When individual approach to management was considered, interobserver agreement was less marked (κ = 0·378).

Conclusion

Management of patients with colorectal liver metastases without the involvement of a specialist liver multidisciplinary team can lead to patients being denied potentially curative treatments. Management of these patients must involve a specialist liver surgeon to ensure appropriate management.

Note: electrical and thermal characterization of a ferroelectric thin film with an electro-thermal nanoprobe

The localized temperature-dependent piezoelectric response of ferroelectric barium strontium titanate (BST) thin films is studied using an electro-thermal (ET) nanoprobe. The ET probe provides independent electrical and thermal excitation to a nanometer-scale volume of the specimen and is capable of detecting the phase transition temperature of the BST thin films. The piezoresponse measured by the ET probe follows the temperature dependence of the piezoelectric constant, whereas with bulk heating the response follows the temperature dependence of the spontaneous polarization. The observed differences stem from the localized inhomogeneous electro-thermal field distribution at the specimen.

What is the clinical effectiveness and cost-effectiveness of using drugs in treating obese patients in primary care? A systematic review

BACKGROUND

Obesity [defined as a body mass index (BMI) ≥ 30 kg/m(2)] represents a considerable public health problem and is associated with a significant range of comorbidities and an increased mortality risk. The primary aim of the management of obesity is to achieve weight reduction in the interests of health. For obese patients who cannot achieve or maintain a healthy weight by non-pharmacological means, drug therapy is recommended in combination with non-pharmacological interventions such as dietary modifications and exercise.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of three pharmacological interventions in obese patients.

DATA SOURCES

Clinical effectiveness data used in the meta-analysis were sourced from articles identified in a systematic review of the literature. Data used to inform transitions to obesity-related comorbidities were derived from the General Practice Research Database (GPRD). The results of the meta-analysis and GPRD analyses informed the economic model supplemented by data from the Health Survey for England and other UK-specific data sourced from the literature.

REVIEW METHODS

A systematic literature review was conducted of the clinical effectiveness and cost-effectiveness of orlistat, sibutramine and rimonabant within their licensed indications for the treatment of obese patients. Electronic bibliographic databases including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched in January 2009, and the reference lists of relevant articles were checked. Studies were included if they compared orlistat, sibutramine or rimonabant with lifestyle and/or exercise advice (standard care), placebo or metformin.

RESULTS

Overall, 94 studies involving 24,808 individuals were included in the clinical meta-analysis. Eighty-three trials included data on weight change, 41 included data on BMI change and 45 and 36 studies reported on 5% and 10% body weight loss, respectively. Overall, the results show that the active drug interventions are all effective at reducing weight and BMI compared with placebo. In the case of sibutramine, the higher dose (15 mg) resulted in a greater reduction than the lower dose (10 mg). Generally, the data quality of the trials included was low with poor reporting of standard errors and standard deviations. Results from the BMI risk models derived from the GPRD showed consistent increases in risk with increasing BMI. Adjustments for key confounders, such as age, sex and smoking status, were found to be statistically significant at the 5% level, in all risk models. Applying linear models to estimate BMI trajectories, for the diabetic cohort, an average increase in BMI of 0.040 per year for both men and women was observed. The non-diabetic cohort model showed an increase in BMI of 0.175 per year for women and 0.145 per year for men. The results of the cost-effectiveness analyses suggest that sibutramine 15 mg dominates the other three active interventions and the net benefit analyses show that sibutramine 15 mg is the most cost-effective alternative for thresholds > £2000 per quality-adjusted life-year (QALY). However, both sibutramine and rimonabant have been withdrawn because of safety concerns relating to potential treatment-induced fatal adverse events. If the proportion of patients who experienced a fatal adverse event was > 1.8% (1.5%, 1.0%) for sibutramine 15 mg (sibutramine 10 mg, rimonabant) the treatment would not be considered cost-effective when using a threshold of £20,000 per QALY.

LIMITATIONS

The clinical review did not include all possible lifestyle comparators, with the inclusion limited to only those trials included one of the active drug interventions. We also excluded all studies not reported in English. Although the clinical review included data from 94 studies, the quality of data was generally low, particularly in terms of the reporting of standard deviation. There was also inconsistency between the results of the mixed-treatment comparison (MTC) and the pair-wise analyses.

CONCLUSION

The MTC of anti-obesity treatments shows that all the active treatments are effective at reducing weight and BMI. The economic results show that, compared with placebo, the treatments are all cost-effective when using a threshold of £20,000 per QALY, and, within the limitations of the data available, sibutramine 15 mg dominates the other three interventions. This work has highlighted many areas of methodological research that could be explored, including assessing inconsistencies within a network to determine differences between the results of pair-wise and MTC analyses; the use of meta-regression methods to look for effect modifiers; exploring the effect of local publication bias; and the use of joint models to analyse the repeated measures of BMI and the time-to-event processes simultaneously.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Laboratory based experiments to assess the use of green and food based compost to improve water quality in a Sustainable Drainage (SUDS) device such as a swale

Many tonnes of compost are generated per year due to door step composting of both garden and kitchen waste. Whilst there are commercial outlets for the finer grade of compost (<10mm) in plant nurseries, there is little demand for the coarser material (>25 mm). This paper reports part of a WRAP-sponsored (Waste Resources Action Programme) study which investigated the potential for green (GC) and mixed green and food (MC) composts to be incorporated into Sustainable Drainage (SUDS) devices such as swales, and replace the topsoil (TS) onto which turf is laid or grass seed distributed. However, it is not known whether compost can replace TS in terms of pollutant remediation, both the trapping of polluted particulates and in dealing with hydrocarbons such as oil, but also from a biofilm development and activity perspective. Using laboratory based experiments utilising leaching columns and an investigation of microbiological development in the composts studied, it was found that many of the differences in performance between MC and GC were insignificant, whilst both composts performed better in terms of pollutant retention than TS. Mixed compost in particular could be used in devices where there may be oil spillages, such as the lorry park of a Motorway Service Area due to its efficiency in degrading oil. Samples of GC and MC were found to contain many of the bacteria and fungi necessary for an active and efficient biofilm which would be an argument in their favour for replacement of TS and incorporation in swales.

Systematic review and meta-analysis of follow-up after hepatectomy for colorectal liver metastases2

Background

The evidence surrounding optimal follow-up after liver resection for colorectal metastases remains unclear. A significant proportion of recurrences occur in the early postoperative period, and some groups advocate more intensive review at this time.

Methods

A systematic review of literature published between January 2003 and May 2010 was performed. Studies that described potentially curative primary resection of colorectal liver metastases that involved a defined follow-up protocol and long-term survival data were included. For meta-analysis, studies were grouped into intensive (more frequent review in the first 5 years after resection) and uniform (same throughout) follow-up.

Results

Thirty-five studies were identified that met the inclusion criteria, involving 7330 patients. Only five specifically addressed follow-up. Patients undergoing intensive early follow-up had a median survival of 39·8 (95 per cent confidence interval 34·3 to 45·3) months with a 5-year overall survival rate of 41·9 (34·4 to 49·4) per cent. Patients undergoing routine follow-up had a median survival of 40·2 (33·4 to 47·0) months, with a 5-year overall survival rate of 38·4 (32·6 to 44·3) months.

Conclusion

Evidence regarding follow-up after liver resection is poor. Meta-analysis failed to identify a survival advantage for intensive early follow-up.

Brucellosis control in Tajikistan using Rev 1 vaccine: change in seroprevalence in small ruminants from 2004 to 2009

Cross-sectional serological surveys of 13,006 small ruminants were conducted in 2003 to establish baseline levels of seropositivity to brucellosis and of 12,102 again in 2009 to evaluate the efficacy of controls based on biannual conjunctival vaccination with Rev 1. Seroprevalence dropped by 80 per cent in five years in eight pilot programme districts where vaccination was generally well implemented, and the prevalence of households with evidence of infection in their animals dropped from 25.1 to 7.5 per cent. Seroprevalence was reduced by 40 per cent in 10 districts where vaccination was intermittent with low coverage during some seasons. There were no changes in 19 districts where no vaccinations were carried out. Sheep vaccinated one or more times were found to be 2.5 times more likely to be serotest positive than were non-vaccinated sheep, whereas vaccinated goats were 6.4 times more likely to be serotest positive than non-vaccinated goats.

Glucagon-like peptide-1 (GLP-1) and the regulation of human invariant natural killer T cells: lessons from obesity, diabetes and psoriasis

AIMS/HYPOTHESIS

The innate immune cells, invariant natural killer T cells (iNKT cells), are implicated in the pathogenesis of psoriasis, an inflammatory condition associated with obesity and other metabolic diseases, such as diabetes and dyslipidaemia. We observed an improvement in psoriasis severity in a patient within days of starting treatment with an incretin-mimetic, glucagon-like peptide-1 (GLP-1) receptor agonist. This was independent of change in glycaemic control. We proposed that this unexpected clinical outcome resulted from a direct effect of GLP-1 on iNKT cells.

METHODS

We measured circulating and psoriatic plaque iNKT cell numbers in two patients with type 2 diabetes and psoriasis before and after commencing GLP-1 analogue therapy. In addition, we investigated the in vitro effects of GLP-1 on iNKT cells and looked for a functional GLP-1 receptor on these cells.

RESULTS

The Psoriasis Area and Severity Index improved in both patients following 6 weeks of GLP-1 analogue therapy. This was associated with an alteration in iNKT cell number, with an increased number in the circulation and a decreased number in psoriatic plaques. The GLP-1 receptor was expressed on iNKT cells, and GLP-1 induced a dose-dependent inhibition of iNKT cell cytokine secretion, but not cytolytic degranulation in vitro.

CONCLUSIONS/INTERPRETATION

The clinical effect observed and the direct interaction between GLP-1 and the immune system raise the possibility of therapeutic applications for GLP-1 in inflammatory conditions such as psoriasis.

Prevalence of anthelmintic resistance on 62 beef cattle farms in the North Island of New Zealand

AIM

To establish the prevalence of anthelmintic resistance in parasitic nematodes on a random sample of beef cattle herds in the North Island of New Zealand.

METHODS

A cross-sectional prevalence study was conducted using a standardised faecal nematode egg count (FEC) reduction (FECR) test (FECRT) for ivermectin, levamisole and albendazole on 60 calves on each of 62 farms in the North Island chosen at random from farms that conformed with the selection criteria. Resistance to an anthelmintic was inferred when there was <95% reduction in FEC 7-10 days after treatment. Larval cultures were performed for all control groups and for treated groups for which resistance was evident.

RESULTS

Of the farms that completed the FECRT, 4/61 (7%) showed > or =95% reduction in FEC for all anthelmintics tested. Resistance to ivermectin was evident on 56/61 (92%) farms, to albendazole on 47/62 (76%) farms, and to both ivermectin and albendazole on 45/61 (74%) farms. Resistance to levamisole was evident on only 4/62 (6%) farms. The parasites most prevalent in resistant populations cultured were Cooperia spp. On 45/61 (74%) farms where Cooperia spp were present in sufficient numbers, resistance to both ivermectin and albendazole was evident. No cases of levamisole-resistant Cooperia spp were detected. Resistance of Ostertagia spp to ivermectin was evident on 4/45 (9%) farms, to albendazole on 15/46 (35%) farms, and to levamisole on 4/46 (9%) farms.

CONCLUSION

Anthelmintic resistance in parasitic nematodes of cattle is common in the North Island of New Zealand. Beef farmers need to be aware of the risks posed by anthelmintic resistance, and routine FECR testing is recommended to ensure optimal productivity and to guide decision-making when purchasing anthelmintics to be used on-farm.

Challenges of residential and community care: 'the times they are a-changin'

This paper seeks to examine a number of issues which relate to the provision of appropriate and high-quality residential and community care for people with an intellectual disability. A number of key themes emerging from this Special Issue of the Journal of Intellectual Disability Research are identified and explored: (1) normalisation; (2) inclusion; (3) choice; and (4) regulation. It is concluded that the research community has an obligation to assume a higher profile at a time when the quality of life of people with an intellectual disability and their families is under threat. This can be done in a number of ways through: (1) the establishment of demonstration projects, either independently or in association with the voluntary and statutory sector, to explore innovative and practical approaches of enhancing the quality of services offered to people with an intellectual disability; (2) looking at ways of improving the quality of training programmes for care staff by moving away from current approaches that emphasise narrow instrumental competencies to strategies that develop essential expressive and relational aspects of care practice; and (3) offering a more considered and rigorous critique of current professional practice and assuming a leadership role at a time when leadership in this field is lacking.

Coexistent granulomatous vasculitis and leukaemia cutis in a patient with resolving herpes zoster

An 80-year-old man presented with a 6-month history of indurated tender purple papules. These had coalesced to form plaques with some central scarring and a dermatomal distribution on the left arm, immediately following herpes zoster (HZ) infection at this site. The patient had a 5-year history of small lymphocytic lymphoma (SLL), which was being managed conservatively under a 'watch and wait' protocol. On histological examination of a skin biopsy, marked interstitial granulomas and prominent granulomatous vasculitis were seen, supporting the clinical impression of a post-HZ granulomatous reaction. In addition, there was a dense monoclonal small B-cell lymphocytic infiltrate indicating koebnerization by SLL (a finding that has not been reported previously with concurrent postherpetic granulomatous vasculitis). Although benign pseudolymphomas occur in postherpetic cases, this case shows that even in association with benign vasculitic features true lymphomas can occur. Furthermore, this case highlights the importance of immunocytochemistry, molecular studies and clinicopathological correlation.

An improved facility for the inspection, treatment and control of footrot

An improved facility for the treatment of footrot is described. It consists of a continuous flow system designed for the inspection and treatment of large numbers of stock. It is considered that such a system is an essential prerequisite before embarking on a treatment programme.

Field trials with a killed, nine-strain, oil adjuvantedBacteroides nodosusfootrot vaccine in sheep

Field trials were set up on five properties to determine the cure and protection rates of a killed, nine-strain, oil adjuvanted Bacteriodes nodosus footrot vaccine, under natural conditions. Foot infections were scored at the time of the first vaccination and at approximately four weeks and ten weeks later. Cure rates were 34-47% for vaccinated sheep, and 18-47% for untreated sheep. Using the Australian Licensing Authorities calculation, the cure rates for the vaccine ranged from -40% to 44%. A lack of suitable conditions for spread of footrot meant that protection rates could not be determined.

A perspective on ovine footrot control

A method for the control of ovine footrot is described which utilises the most appropriate measures to suit the circumstances for individual properties. This approach was used to eradicate the disease from three Central Otago fine-wool properties wintering in excess of 35,000 sheep on widely differing classes of land. This programme incorporates the use of proven.techniques and suitable planning together with input from the rural veterinarian, who plays an important role in demonstration and advising on control measures.

A survey on the prevalence, treatment and control of footrot in Central Otago

The results of a postal survey which yielded a 43% response on the prevalence, treatment and control of footrot in Central Otago flocks is presented. Analysis of data showed that footrot is an important and emerging disease, particularly of fine-wool flocks, and that most farmers have a poor knowledge and understanding of the epidemiology, treatment and control of the disease.

Farm management practices associated with macrocyclic lactone resistance on sheep farms in New Zealand

AIM

To identify farm practices associated with the presence of resistance to a macrocyclic lactone (ML) anthelmintic on sheep farms in New Zealand.

METHODS

A cross-sectional study was conducted to test for associations between the presence of resistance to an ML anthelmintic (ivermectin) and management practices on sheep farms in New Zealand. Selection of farms was both random (n=80) and purposive (n=32; being farms with a history of suspected ML resistance). Resistance was inferred from faecal nematode egg count (FEC) reduction (FECR) tests (FECRTs) when there was <95% reduction in FEC 7-10 days after treatment with a half dose of ivermectin (0.1 mg/kg). A logistic regression model was built to identify farm-level factors that were associated with the presence or absence of ML resistance.

RESULTS

Of the 112 flock managers that were approached for interview, 103 (92%) returned useable questionnaires. The odds of ML resistance were increased: on farms that had used long-acting ML products in ewes as a pre-lambing treatment for > or =3 of the previous 5 years (odds ratio (OR) = 7.2; 95% confidence interval (CI) = 1.7-30.3); on farms where <70% of the total stock units mid-winter were from sheep (OR=6.5; 95% CI=1.6-25.6); on farms which over the year purchased >10% of the number of sheep present mid-winter (OR=7.1; 95% CI=1.5-34.7); and on farms where the average wool diameter of the main flock was <37 (OR=4.1; 95% CI=1.1-14.7) microns. The model provided a good fit to the data (pseudo R2=0.64; Hosmer-Lemeshow statistic = 0.38).

CONCLUSIONS

Explanatory factors identified as associated with the presence of ML (ivermectin) resistance on farms included the use of long-acting anthelmintic formulations in ewes pre-lambing, sources of refugia of unselected parasites on the farm, breed of sheep and their requirements for anthelmintic treatments, and the importing of resistant parasites with purchased stock. The study provides support for controls that aim to provide refugia of susceptible worms and that minimise the risk of introduction of resistance through effective quarantine drenching.

Anthelmintic resistance and management of nematode parasites on beef cattle-rearing farms in the North Island of New Zealand

AIM

To provide information on current farmers' opinions and farming practices thought to be related to anthelmintic resistance, and to test for associations between the presence of anthelmintic resistance and management practices on beef-cattle rearing farms in the North Island of New Zealand.

METHODS

A study using an interview-based questionnaire about management of internal parasites was conducted on 62 beef cattle-rearing farms in the North Island of New Zealand, using case-control analyses to test for associations between management practices and the presence or absence of resistance to ivermectin or albendazole. Resistance was inferred from faecal nematode egg count (FEC) reduction (FECR) tests (FECRTs) when there was <90% reduction in FEC 7-10 days after treatment of calves <12 months of age.

RESULTS

Of the 59 farmers who completed the questionnaire, most (n=40) ranked parasites highly, and at about the same level as quality and quantity of feed, as important production-limiting factors for their enterprises. In contrast, anthelmintic resistance was not perceived to be a problem on 13 farms, and its importance was rated low on 24, moderate on 15, and high on only six farms. Despite all farms having planned parasite control programmes, there was heavy reliance on clinical signs of parasitism to determine frequency of treatments. About one in three farmers with beef breeder cows routinely treated their calves at marking, one in five treated mixed-age cows, and almost half treated rising 2-year-old cows before calving. One in four farmers used anthelmintics on calves on 8-12 occasions in their first year of life. Co-grazing with other species was rare, but follow-on grazing within 3 months after older cattle or sheep was common. On most farms, grazing cattle was restricted to part of the farm, a finding with implications for parasite control and persistence of larvae in refugia. Macrocyclic lactone (ML) anthelmintics or their combinations with other action families were currently, and for the past 5 years, used more frequently than benzimidazoles and levamisole, and benzimidazole-levamisole combinations. The prevalence of resistance to ivermectin was high (82%) and no plausible model of associations could be constructed from the data. The prevalence of resistance to albendazole was 60%, and the risk of resistance increased as the number of rising 1-year-old cattle present mid-winter increased, and decreased as the number of breeding cows >2 years old present mid-winter increased.

CONCLUSION

It is clear that in practice anthelmintic resistance is a secondary consideration to obtaining productivity advantages from the use of anthelmintics in beef cattle. Farmers' opinions were divided on many issues and the overall impression was of confused and diverse thinking regarding the principles of the use of anthelmintics. The overall outlook regarding anthelmintic resistance in cattle is bleak unless the need for integrated and long-term research activities is acted upon soon.

Prevalence of anthelmintic resistance on sheep farms in New Zealand

AIM

To establish the prevalence of anthelmintic resistance in parasitic nematodes on sheep farms in New Zealand.

METHODS

A cross-sectional prevalence study was conducted, using a standardised faecal nematode egg count (FEC) reduction (FECR) test (FECRT) for ivermectin, at a full (0.2 mg/kg) and half (0.1 mg/kg) dose rate, and albendazole, levamisole and albendazole-levamisole in combination, on 60 lambs (n=10 per group) on farms selected from throughout New Zealand. Farms that conformed with selection criteria were chosen at random (n=80) or with a history of suspected resistance to macrocyclic lactone (ML) anthelmintics (n=32). Resistance to an anthelmintic was inferred when there was <95% reduction in FEC 7-10 days after treatment. Larval cultures were performed for all control groups and for treated groups for which resistance was evident.

RESULTS

Of the farms randomly selected, 36% showed > or =95% FECR for all anthelmintics tested; resistance to ivermectin at 0.1 and 0.2 mg/kg liveweight was evident on 36% and 25% of these farms, respectively. Resistance to both ivermectin (0.2 mg/kg) and levamisole was evident on 8/80 (10%) farms, to ivermectin and albendazole on 10/80 (13%) farms, and to ivermectin, levamisole and albendazole on 6/80 (8%) farms. The prevalence of resistance to a half dose of ivermectin tended to be more prevalent on farms with a history of suspected ML resistance (p=0.06). Resistance to albendazole was seen across all the main parasite genera, and to levamisole in Nematodirus, Ostertagia (= Teladorsagia) and Trichostrongylus species. Resistance to ivermectin was dominated by Ostertagia spp, although Cooperia, Nematodirus and Trichostrongylus species were also implicated.

CONCLUSION

Anthelmintic resistance in parasitic nematodes of sheep is common in New Zealand. Not only was resistance to albendazole and levamisole common, but resistance to the ML, ivermectin, was at a higher prevalence than expected. Sheep farmers and advisors in New Zealand need to re-evaluate the way they manage parasites, and more research is urgently needed if the steady decline in anthelmintic susceptibility is to be halted.

Non-diabetic hyperglycaemia and cardiovascular risk: moving beyond categorisation to individual interpretation of absolute risk

AIMS/HYPOTHESIS

Non-diabetic hyperglycaemia is usually not considered at all or is viewed as a binary risk category in isolation from other factors when quantifying cardiovascular risk. We argue that hyperglycaemia should be considered as a continuous risk factor and only in the context of other vascular risk factors. To examine the potential impact of hyperglycaemia on cardiovascular disease (CVD) risk, we calculated the absolute CVD risk in groups defined by different levels of HbA(1c) and other CVD risk factors.

METHODS

We used data on 10,144 men and women from the European Prospective Investigation of Cancer-Norfolk cohort to calculate CVD rates across levels of HbA(1c) in groups characterised by different levels of traditional risk factors.

RESULTS

We found significant differences in CVD rates across levels of HbA(1c) in groups defined by different levels of the other risk factors. CVD rates for non-diabetic individuals with an HbA(1c) of <5.5% increased from 0.6 (95% CI 0.3-1.2) to 29.6 (95% CI 14.8-59.1) per 1,000 person-years when traditional CVD risk factors were added sequentially to the lowest risk reference group. In most cases, non-diabetic individuals with an HbA(1c) of <5.5% and high values for all other CVD risk factors had substantially higher absolute CVD rates than those with an HbA(1c) of 6.0% to 6.4% but with no other raised CVD risk factors (29.6 [95% CI 14.8-59.1] and 2.5 [95% CI 0.4-18.1], respectively). A history of diabetes significantly increased CVD risk over the non-diabetic hyperglycaemia range. Comparisons of CVD rates across tertiles of total cholesterol:HDL-cholesterol ratio or mean systolic blood pressure in groups characterised by different levels of other risk factors showed similar findings.

CONCLUSIONS/INTERPRETATION

In people with non-diabetic hyperglycaemia, cardiovascular risk is highly dependent on the presence of other CVD risk factors. Attention should be given not to whether an individual has 'pre-diabetes', 'hypertension' or 'hypercholesterolaemia', but to an integrated assessment of CVD risk, based on the combination of risk factors present and potential benefits of treatment.

Identification of caries risk factors in toddlers

The purpose of this study was to identify risk factors to predict caries progression in toddlers in primary-healthcare settings for the cost-effective targeting of preventive and referral strategies. We examined 329 children (26 ± 6 mos old) twice, one year apart, in Indiana, USA. A 107-item structured interview was used to collect information from the primary caregiver and child on factors/beliefs/perceptions/behaviors that could affect caries development, transmission of bacteria, medical-dental health, and access to care. Bacterial levels, gingivitis, dental plaque, and caries experience were assessed. Multiple-variable logistic regression models of caries progression toward cavitation included family caries experience, transmission-related behaviors, dietary factors, health beliefs, and lower income, but differed in selected predictors/predictive power by race/ethnicity. Addition of clinical variables did not significantly improve the prediction.

Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence

BACKGROUND

This review aimed to synthesize qualitative evidence for barriers and facilitators to effective implementation of screening and brief intervention for alcohol misuse in adults and children over 10 years.

METHODS

A search of medical and social science databases was carried out and augmented by hand-searching of reference lists and contents of key journals. Qualitative evidence was synthesized thematically.

RESULTS

A total of 47 papers varying in design and quality were included in the review. Most evaluated implementation in primary care settings. Implementation was reported to be limited by lack of resources, training and support from management, as well as workload. The appropriateness of context in which discussions take place was reported as an acceptability factor for patients and practitioners. Health professionals require sufficient knowledge about alcohol guidelines and risk in order to implement screening and intervention to those most in need.

CONCLUSIONS

Whilst brief screening and brief intervention have been shown to be effective in some settings, this review has identified a number of barriers and facilitators to implementation. Adequate resources, training and the identification of those at risk without stereotyping are the main facilitators in primary care. More research is needed to assess implementation in other settings.