Rapid synthesis of drug-encapsulated films by evaporation-induced self-assembly for highly-controlled drug release from biomaterial surfaces

Infection at the surgical site for dental implants results in failed procedures, patient pain, burdensome economic impact, and the over-prescription of prophylactic antibiotics. Mesoporous silica films as coatings for implants may provide an ideal antimicrobial drug storage and local release vector to the site of infection, however traditional drug loading techniques result in insufficient drug load and short-term release kinetics. In this work, we have applied a method to use a surfactant-antimicrobial drug octenidine dihydrochloride (OCT) as a template for mesostructured silica, to demonstrate silica-OCT composite films. The films are synthesized by evaporation induced self-assembly (EISA) and we explore the effects of synthesis parameters on porous film structure, OCT incorporation, and OCT drug release rates. Drug micelle incorporation into the silica mesostructure was highly dependent on silica precursor pre-reaction to form silica oligomers before film spin-casting. The OCT drug concentration of the synthesis solution dictated the time required for effective incorporation (without phase separation), with total loading in the film of up to 90% by mass. The OCT content in the films was found to directly determine the timescale of drug release, from 2 to 8 h for a single layer film. The total release timescale was increased by the addition of multiple layers of OCT-silica films to nearly 2 weeks. Drug release from films completely inhibited Streptococcus mutans (UA159) growth, while drug-free porous silica films showed no increase in bacterial growth over non-porous control. These OCT-silica films have a significant potential to store and release antimicrobial drugs from dental implant surfaces.

Translation and validation of the reaction to impairment and disability inventory in a chinese ccontext

Introduction

People with chronic illness and disabilities (CID) often need to adjust to changes in self-concept, cope with their grief from the loss of functional abilities, and to “live with the illness”. Emotional adjustment to disabilities is a major challenge in rehabilitation, but there is no validated Chinese instrument for assessing psychosocial adaptation of people with CID.

Objectives

This study translated the Reaction to Impairment and Disability Inventory (RIDI) into Chinese and validated the Chinese version (C-RIDI), for assessing emotional adjustment in people with CID. We examined the factor structure, internal consistency, convergent validity, and criterion-related validity of the C-RIDI.

Methods

We conducted a survey of people with CID who were recruited from community-rehabilitation settings and self-help groups (n = 244). The research questionnaire collected demographic information, illness-related variables, the C-RIDI, and measures of resilience and well-being.

Results

The C-RIDI has good content validity and no major changes to the translated items were needed for the use with Chinese population. For factor structure, we replicated the results of Livneh, Martz, & Boder (2006). The C-RIDI has two second-order factors of adaptive and non-adaptive scales, which interact with the two denial subscales. Internal consistency of the subscales is satisfactory except for the 3-item denial subscales. Correlations of the C-RIDI subscales with illness-related variables, resilience, and mental well-being are consistent with our hypotheses and provide support for the convergent and criterion-related validity of the scale.

Conclusions

The C-RIDI has satisfactory psychometric properties. The study results support its internal consistency, convergent validity, criterion-related validity, and factorial validity.

Disclosure

No significant relationships.

Predictors of psychosocial adaptation and mental wellbeing among people with chronic illness and disabilities in a chinese context

Introduction

The process of adjustment to disability and illness among people with chronic illness and disabilities (CID) impacts on motivation for rehabilitation illness self-management, and psychological well-being. It involves a complex interplay of biopsychosocial factors, and was seldom examined in the Chinese context.

Objectives

Identify the predictors of mental well-being of people with from a set of variables including illness and social support, functional abilities, coping strategies, resilience. Examine how these factors interact in determining psychosocial adaptation and mental well-being by structural equations modelling (SEM).

Methods

We conducted a survey of people with CID, who were recruited from community-rehabilitation settings and self-help groups (N = 244). The research questionnaire collected basic demographic information, illness-related variables (e.g. pain, fatigue, functional limitations), and RIDI), social support, measures of resilience, coping, psychosocial ad as predictors, and mental well-being.

Results

Of General Linear Model (GLM) revealed that males have better adaptation than females. Resilience, social coping, & active problem solving are significant predictors of adaptation (Table 1), while age, breathing, pain, resilience, avoidance coping, are predictors of maladaptation (Table 2). A SEM was tested to examine the interaction among the predictors and outcome of adaptation and mental well-being (Figure 1), and the model fit was fair (CFI = 0.89; RMSEA = 0.09)

Conclusions

The results indicated that there are gender differences in adaptation. While all the hypothesized groups of variables contributed to mental well-being of people with CID. Resilience, illness variables, and some forms of coping are closely linked to adaptation and maladaptation.

Disclosure

No significant relationships.

A distinct pre-existing inflammatory tumour microenvironment is associated with chemotherapy resistance in high-grade serous epithelial ovarian cancer

Background:

Chemotherapy resistance is a major determinant of poor overall survival rates in high-grade serous ovarian cancer (HGSC). We have previously shown that gene expression alterations affecting the NF-κB pathway characterise chemotherapy resistance in HGSC, suggesting that the regulation of an immune response may be associated with this phenotype.

Methods:

Given that intrinsic drug resistance pre-exists and is governed by both tumour and host factors, the current study was performed to examine the cross-talk between tumour inflammatory microenvironment and cancer cells, and their roles in mediating differential chemotherapy response in HGSC patients. Expression profiling of a panel of 184 inflammation-related genes was performed in 15 chemoresistant and 19 chemosensitive HGSC tumours using the NanoString nCounter platform.

Results:

A total of 11 significantly differentially expressed genes were found to distinguish the two groups. As STAT1 was the most significantly differentially expressed gene (P=0.003), we validated the expression of STAT1 protein by immunohistochemistry using an independent cohort of 183 (52 resistant and 131 sensitive) HGSC cases on a primary tumour tissue microarray. Relative expression levels were subjected to Kaplan–Meier survival analysis and Cox proportional hazard regression models.

Conclusions:

This study confirms that higher STAT1 expression is significantly associated with increased progression-free survival and that this protein together with other mediators of tumour–host microenvironment can be applied as a novel response predictive biomarker in HGSC. Furthermore, an overall underactive immune microenvironment suggests that the pre-existing state of the tumour immune microenvironment could determine response to chemotherapy in HGSC.

Electronic health records and adverse drug events after patient transfer

BACKGROUND

Our objective was to examine the frequencies of medication error and adverse drug events (ADEs) at the time of patient transfer in a system with an electronic health record (EHR) as compared with a system without an EHR. It was hypothesised that the frequencies of these events would be lower in the EHR system because of better information exchange across sites of care.

METHODS

469 patients transferred between seven nursing homes and three hospitals in New York and Connecticut between 1999 and 2005 were followed retrospectively. Two groups of patients were compared: US Veterans Affairs (VA) patients, with an EHR, and non-VA patients, without an EHR, on the following measures: (1) medication prescribing discrepancies at nursing home/hospital transfer, (2) high-risk medication discrepancies and (3) ADEs caused by medication discrepancies according to structured medical record review by pairs of physician and pharmacist raters.

RESULTS

The overall incidence of ADE caused by medication discrepancies was 0.20 per hospitalisation episode. After controlling for demographic and clinical covariates, there were no significant differences between VA and non-VA groups in medication discrepancies (mean difference 0.02; 95% CI -0.81 to 0.85), high-risk medication discrepancies (-0.18; 95%CI -0.22 to 0.58) or occurrence of an ADE caused by a medication discrepancy (OR 0.96; 95% CI 0.18 to 5.01).

CONCLUSIONS

There was no difference, with and without an EHR, in the occurrence of medication discrepancies or ADEs caused by medication discrepancies at the time of transfer between sites of care. Reducing such problems may require specialised computer tools to facilitate medication review.

CSF neutrophils are implicated in the development of vasospasm in subarachnoid hemorrhage

BACKGROUND

Cerebral vasospasm is a significant cause of morbidity in patients after aneurysmal subarachnoid hemorrhage (aSAH). There are few effective treatments. The search for new treatments has focused predominantly on dilating cerebral blood vessels. Growing evidence supports a role for inflammation in its pathogenesis but no potential target for intervention has emerged.

METHODS

CSF and clinical information from patients with aSAH were collected. Additionally, tyrosine modifications by stable isotope dilution HPLC with online tandem mass spectrometry were quantified in CSF samples.

RESULTS

We report an association between neutrophil accumulation in the cerebrospinal fluid of patients with aSAH and the development of vasospasm. In particular, CSF neutrophil content of >62% on the third day after aSAH is an independent predictor of the later development of vasospasm (OR 6.8, 95% CI 2.0-23.3, P = 0.002). Further, activity of myeloperoxidase and NADPH oxidase is elevated in aSAH suggesting a role for modification of CSF proteins by reactive oxidant species.

CONCLUSIONS

Neutrophil percentage is an independent predictor of vasospasm in aSAH patients, days prior to its onset suggesting a role of neutrophils in vasospasm. The activity of neutrophil enzymes is also increased suggesting a mechanism for blood vessel damage. Inflammation mediated by neutrophils is a potential target for therapies in vasospasm. More study is necessary to determine the mechanism by which neutrophils damage cerebral blood vessels.

Prescribing discrepancies likely to cause adverse drug events after patient transfer

BACKGROUND

Medication-prescribing discrepancies are used as a quality measure for patients transferred between sites of care. The objective of this study was to quantify the rate of adverse drug events (ADEs) caused by prescribing discrepancies and the discrimination of an index of high-risk transition drug prescribing.

METHODS

We examined medical records of patients transferred between seven nursing homes and three hospitals between 1999 and 2005 in New York and Connecticut for transfer-associated prescribing discrepancies. ADEs caused by discrepancies were determined by two clinician raters. We calculated the fraction of medication discrepancies that caused ADEs in each of 22 drug classes by calculating positive predictive values (PPVs). We calculated the discrimination of a count of high-risk drug discrepancies, selected from published lists of high-risk medications and using observed PPVs.

RESULTS

208 patients were hospitalised 304 times. Overall, 65 of 1350 prescribing discrepancies caused ADEs, for a PPV of 0.048 (95% CI 0.037 to 0.061). PPVs by drug class ranged from 0 to 0.28. Drug classes with the highest PPVs were opioid analgesics, metronidazole, and non-opioid analgesics. Patients with 0, 1-2 and >/=3 high-risk discrepancies had a 13%, 23% and 47% chance of experiencing a discrepancy-related ADE, respectively.

CONCLUSIONS

Discrepancies in certain drug classes more often caused ADEs than other types of discrepancies in hospitalised nursing-home patients. Information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients and inform the development of decision-support tools at the time of patient transfer.

Validation of an Instrument Designed to Assess Medical Student Attitudes Toward Home Care

OBJECTIVES

To develop and validate an instrument to assess medical students' attitudes toward home care.

DESIGN

Survey administration before and following participation in a home care training program.

SETTING

Five medical schools in the United States.

PARTICIPANTS

326 third and fourth year medical students.

MEASUREMENTS

Factor analysis was performed on all posttests. Domains were tested for internal reliability (Chronbach's alpha). Interdomain correlation was tested. One-way analysis of variance (ANOVA) was used to determine whether the results for each domain differed among the five programs.

RESULTS

Using exploratory factor analysis, the original 20-item survey was revised to yield a 14-item survey consisting of four domains (general attitudes, home-based therapies, home care training, and time and reimbursement). Domain intra-item reliability ranged from 0.60 to 0.82. Interdomain correlations were found to be significant with the exception of one comparison (time and reimbursement and home care training). One-way ANOVA showed significant differences between the training programs for two of the four domains (home-based therapies and home care training). For a third domain, time and reimbursement, there was a trend toward differences across the schools (P = 0.06).

CONCLUSION

The instrument described in this paper is a reliable and valid instrument for assessing the impact of home care training on medical student attitudes across a series of important domains.

An integrated program for evidence-based medicine in medical school

To provide optimal care for their patients, clinicians must be able to locate and interpret the most current literature. Teaching the necessary skills to medical students is essential, if we wish to train clinicians to be able to keep up with the expansion of biomedical knowledge for their entire working lives. In this paper, we describe our school's four-year curriculum in evidence-based medicine and the performance of three senior classes on the summative evaluation exercise devised to measure the program's success.

Design and preliminary data of the Metrix Atrioverter expanded indication trial

The Metrixtrade mark Atrioverter Expanded Indication Trial evaluates the safety and efficacy of an implantable atrial defibrillator in patients with symptomatic, recurrent and drug refractory atrial fibrillation who also have structural heart disease. In this ongoing multicenter study, all patients are anticoagulated and concomitant antiarrhythmic drug treatment is left to the preference of the physician. Holter monitoring is performed prior to enrollment in the study. Spontaneous episodes of atrial fibrillation (AF) are treated under physician observation and when patients are ambulatory, the device is programmed in a monitoring mode. The atrial defibrillation threshold is measured at implantation and at 3, 6 and 12 months thereafter. The performance of the AF detection and R-wave synchronization algorithm is assessed at implantation, at regular follow-up intervals, and each time the patient visits the hospital for treatment of a spontaneous episode of AF. An echocardiogram is performed prior to implantation, at 3 and 6 month follow-up and for patients with an implanted heart valve, after 20 and 50 atrial defibrillation shocks have been delivered. The study started on October 1997 and will end after the last patient enrolled completes his/her six-month post-implantation follow-up, unless a safety issue arises. As of September 1998, 6 patients (2 patients with tachycardia induced cardiomyopathy, 1 patient with a mitral valve prosthesis, 2 patients with hypertrophic cardiomyopathy and 1 patient with congenital heart disease) have been enrolled in the study. Over 350 shocks have been delivered for atrial defibrillation testing or termination of spontaneous AF episodes. There have been no reported cases of ventricular proarrhythmia or inaccurately synchronized shocks and no complications of device therapy in this population.

Cloning, tissue distribution, subcellular localization and overexpression of murine histidine-rich Ca2+ binding protein

The histidine-rich Ca2+ binding protein (HRC) resides in the sarcoplasmic reticulum of muscle and binds Ca2+. Since Ca2+ concentrations can regulate gene expression via calcineurin, the mouse homologue of HRC (mHRC) was isolated and characterized. mHRC was detected in muscle progenitor cells, in primary clonal thymic tumors and a tumor cell line, suggesting a broader role for mHRC than in Ca2+ storage during muscle contraction. mHRC was present in the perinuclear region of myoblasts. To examine if it can regulate gene expression, mHRC was overexpressed in cells differentiating into cardiac and skeletal muscle. mHRC had no effect on cardiogenesis or myogenesis. Therefore, if mHRC plays a role in the regulation of gene expression during cellular differentiation, it does not appear to be either rate-limiting or inhibitory.

Long-term results of electrophysiologically guided sotalol therapy for life-threatening ventricular arrhythmias

The efficacy and safety of sotalol therapy for ventricular arrhythmias was evaluated in 133 patients with drug-refractory ventricular arrhythmias. All patients had baseline electrophysiologic studies before and after oral sotalol therapy. Sixty-six patients were discharged home, treated with sotalol (52 patients without inducible ventricular tachycardia or fibrillation and 14 patients with hemodynamically stable inducible ventricular tachycardia). The mean follow-up period was 41 +/- 27 months for the 14 patients with hemodynamically stable ventricular tachycardia. Sotalol was effective in 8 of these 14 patients. Recurrent nonlethal ventricular tachycardia occurred in 3 patients; 2 patients had sudden death; and 1 patient had adverse side effects. The 52 patients without inducible ventricular tachycardia were followed up for a mean period of 36 +/- 30 months. Thirty-five of 52 patients were successfully treated. Two patients had recurrent ventricular tachycardia; both of these episodes of ventricular tachycardia occurred within the first year. Four patients had sudden cardiac death; three of these deaths occurred within the first month, and the last episode of sudden death occurred after 8 years of sotalol therapy. The actuarial incidence of sotalol efficacy was 76% at 1 year, 72% at 2 years, 64% at 4 years, and 52% at 5 years. Approximately 46% of patients receiving long-term sotalol treatment reported side effects. Side effects severe enough to warrant withdrawal of sotalol occurred in 7 (11%) patients. The results of our study suggest that sotalol is effective for selected patients with drug refractory ventricular arrhythmias. Although the incidence of side effects are high, patients appear to tolerate long-term sotalol therapy well.

Quality of life and outcomes after radiofrequency His-bundle catheter ablation and permanent pacemaker implantation: impact of treatment in paroxysmal and established atrial fibrillation

One hundred seven patients underwent atrioventricular (AV)-junctional ablation and pacing for atrial fibrillation, and 90 were alive 2.3 +/- 1.2 years later. Quality of life index (1.9 +/- 1.2 to 3.6 +/- 1.1; 3.6 +/- 1.1; p<0.001) and ease of activities of daily living (2 +/- 0.4 to 2.4 +/- 0.3; p<0.001) were significantly improved. Doctor visits (10 +/- 13 to 5.06 +/-7; p<0.03), hospital admissions (2.8 +/- 6.8 vs 0.17 +/- 0.54; p<0.03, and antiarrhythmic drug trials (6.2 +/- 4 to 0.46 +/- 1.5; p<0.001) decreased significantly after treatment. Congestive heart failure episodes decreased from 18 before to 8 afterward. Twenty-eight of 36 patients with dual-chamber pacemakers remained in a dual-chamber mode at follow-up. Radiofrequency AV-junctional catheter ablation and pacing is a highly successful form of treatment for medically refractory atrial fibrillation.

Screening for balance and mobility impairment in elderly individuals living in residential care facilities

BACKGROUND AND PURPOSE

The rapid growth of the elderly population has resulted in a corresponding rise in the number of elderly individuals who experience disability during their lifetimes. The purpose of this study was to test the usefulness of four established clinical measures of balance, gait, and subjective perceptions of fear of falling as screening methods for referring community-dwelling elderly individuals living in residential care facilities for detailed physical therapy evaluation and possible intervention.

SUBJECTS

The subjects were a convenience sample of 53 elderly individuals living in two residential care facilities for the elderly.

METHODS

Subjects were tested on each of four clinical measures of balance and mobility. Their performance on these measures was compared with a physical therapist's brief evaluation of disability and appropriateness for more detailed evaluation. The usefulness of these tools as screening methods was determined by calculating sensitivity and specificity levels using the physical therapist's evaluation as a standard.

RESULTS

The sensitivity and specificity levels of the four clinical measures in their application as screening tests for referral to physical therapy were as follows: Berg Balance Scale, 84% and 78%; balance subscale of the Tinetti Performance-Oriented Mobility Assessment, 68% and 78%; gait speed, 80% and 89%; and Tinetti Fall Efficacy Scale, 59% and 82%. The combination of two tests, Berg Balance Scale and gait speed, yielded the highest sensitivity of 91% and the highest specificity of 70% when a subject tested positive on at least one test.

CONCLUSION AND DISCUSSION

These findings indicate the feasibility of developing screening methods for referring community-dwelling elderly individuals for a detailed physical therapy evaluation based on established clinical assessment measures, with a combination of tests measuring balance and gait demonstrating the most promising results.

Electrophysiological laboratory, electrophysiologist-implanted, nonthoracotomy-implantable cardioverter/defibrillators

BACKGROUND

Implantable cardioverter/defibrillators (ICDs) have conventionally been implanted in the operating room by surgeons. However, technological developments have reduced size and increased simplicity, bringing the procedure into the realm of the electrophysiologist. The purpose of this study was to evaluate the safety and efficacy of implantation of the entire ICD system by electrophysiologists in an electrophysiology laboratory.

METHODS AND RESULTS

Between July 1993 and February 1994, 23 patients (21 men; age, 64 +/- 11 years) underwent transvenous ICD implantation by electrophysiologists working alone, entirely in the electrophysiology laboratory. Indications for ICD were sudden death in 10 patients, uncontrolled life-threatening ventricular tachycardia in 12, and syncope with cardiomyopathy and familial sudden death in 1. Seventeen patients had coronary artery disease and a past history of acute myocardial infarction. Four patients had idiopathic dilated cardiomyopathy, 1 had coronary ectasia and poor left ventricular function, and another had poor left ventricular function related to valvular dysfunction. The mean left ventricular ejection fraction was 34 +/- 10% (range, 20% to 50%). General anesthesia was administered in 22 cases, and deep sedation was used in 1 elderly patient. After positioning of transvenous leads and subcutaneous patch/array lead positioning, defibrillation testing was performed. After transvenous and subcutaneous lead tunneling, all generators were placed subcutaneously in an abdominal pocket. The mean total time in the electrophysiology laboratory was 254 +/- 68 minutes (range, 150 to 375 minutes), with 104 +/- 42 minutes for anesthetic and other preparation, 159 +/- 45 minutes for implantation, and 8.7 +/- 5 minutes (range, 3 to 25 minutes) of fluoroscopy required for positioning of transvenous and subcutaneous lead systems. Implant times showed a significant improvement when the first 10 cases (188 +/- 44 minutes) were compared with the last 10 in the series (124 +/- 44 minutes, P < .01). The mean defibrillation threshold was 17 +/- 5 J (range, 5 to 25 J). There were 5 complications (22%): 1 patch-site hematoma, 1 pneumothorax related to subclavian venous puncture, 1 pulmonary embolism, and 2 patients requiring overnight ventilation after hemodynamic deterioration following defibrillation testing. There were no deaths, and there were no infections. The mean time to hospital discharge after the implant was 5.1 +/- 3.5 days. After 11.6 +/- 9 weeks of follow-up, all devices were functioning satisfactorily, all patients had successfully defibrillated at postimplant predischarge checkup with 29 +/- 5 J, and there had been no late complications.

CONCLUSIONS

This is the first report to show that nonthoracotomy ICD implantation may be successfully carried out by electrophysiologists working alone in the electrophysiology laboratory, with a high rate of success and few complications, even in high-risk patients. This high rate of success and safety probably relates to the availability of high-quality fluoroscopy and familiarity with electrophysiology laboratory equipment and personnel.

The effect of age on human corneal thickness. Statistical implications of power analysis

The corneal thickness of 108 human subjects, ranging from 17 to 75 years of age, was measured using ultrasound pachometry. One central, four mid-peripheral and four peripheral corneal positions along the vertical and horizontal meridians were assessed using ultrasound pachometry. No significant differences were found in the thicknesses of the central, midperipheral or peripheral cornea with increasing age using analysis of variance. These results suggest that ageing has no significant effect on human corneal thickness between the ages of 16 to 75 years. However the high Type II error probability (beta = 0.90) suggests that 108 subjects (18 in each age group) were insufficient to adequately answer the question. Thus power analysis may help explain the conflicting reports available in literature. The diversity in data interpretation may be due to the statistically small sample sizes used in most studies. Power analysis shows that at least 80 subjects are needed in each age group (480 subjects in total) before a statistically reliable test of the null hypothesis is possible. This study emphasizes the importance of power analysis in calculating an adequate sample size.

Short-term effects of proparacaine on human corneal thickness

.5% proparacaine HCl is commonly used for topical anaesthesia in ultrasound pachometry prior to refractive surgery. This drug is known to alter corneal epithelial adhesion. Does 0.5% proparacaine result in an alteration in corneal thickness due to changes in the corneal epithelium? Corneal thickness was measured by optical pachometry at 30 sec intervals for 15 min under 3 experimental conditions; 1) 2 drops of artificial tears, 2) 1 drop of 0.5% proparacaine, 3) 2 drops of 0.5% proparacaine. Baseline measurements were recorded before each trial. No significant differences were found between the mean corneal thicknesses measured in the baseline, 2 drops of artificial tears and 1 drop of 0.5% proparacaine conditions. The mean corneal thickness in the 2 drops of 0.5% proparacaine condition was significantly greater than those measured in the other conditions. In particular the measured corneal thickness was significantly different from the baseline measurements 1 to 2 min after instillation of the 2 drops of 0.5% proparacaine. Exponential modelling of the corneal edema recovery function demonstrated that recovery to baseline corneal thickness occurred 7 to 8 min following the instillation of 2 drops of 0.5% proparacaine. The data of this study suggest that only 1 drop of 0.5% proparacaine should be used for topical anaesthesia prior to ultrasound pachometry. This recommendation may minimize the possibility of measuring artifactually large corneal thickness estimates, and thus reduce the possibility of corneal microperforation during refractive surgery.

Isolation and characterization of a specific antibody population against human fibrinogen

A specific antibody population against human fibrinogen was isolated from a rabbit antiserum by affinity chromatography on fibrinogen-bound Sepharose gel. Using a sensitive competitive radioimmunoassay, the antibody population was found to recognize epitopes on native fibrinogen but crossreacted minimally with fibrinogen fragment D and an early plasmin-degraded fibrinogen A alpha-chain product, but not at all with fragment E or fibrinopeptides A and B. Fibrin monomers shared part of these epitopes. The antibody population crossreacted to a small extent with bovine, horse and baboon fibrinogens and not at all with fibrinogens from sheep, rat, pig, goat, guinea pig, dog and rabbit.