Healthy Food Policies Documented in University Food Service Contracts

In the United States, there is an opportunity to improve the nutritional health of university students through the campus food environment. This project used a content analysis approach to investigate whether healthy food standards and policies were incorporated into the contract agreements between North Carolina (NC) public universities and their food service management companies. Food service contracts were collected from 14 NC public universities using food service management companies on campus. Each contract was evaluated using the 35-item North Carolina Food Service Policy Guidelines Assessment to examine four elements of the campus food environment: Beverages, Packaged Snacks, Prepared Foods, and Other (e.g., strategic placement of healthier food). Five university food service contracts incorporated no North Carolina Food Service Policy Guidelines, three university contracts included one to five guidelines, and six university contracts included six to nine guidelines. Altogether, 13 of the 35 guidelines were incorporated into at least one university food service contract. This project presents a cost and time-effective assessment method for determining if evidence-based nutrition guidelines have been included in university food service contracts. This approach and findings may lead to contract revisions to improve the campus food environment and, subsequently, the nutritional health of college populations.

How do forms and characteristics of Asian public housing neighbourhoods affect dementia risk among senior population? A cross-sectional study in Hong Kong

BACKGROUND

Public housing estate is a key determinant of community health risk in American/European cities. However, how forms/characteristics of compact/hilly public housing's neighbourhoods affect dementia among Asian seniors was underestimated.

DESIGN

This was a cross-sectional study.

METHODS

A total of 2,077 seniors living in Hong Kong's public housing estates were included. Dementia was measured by a Cantonese version of Montreal - Cognitive Assessment. Built environment was measured based on three dimensions (greenery, walkability, accessibility), including 11 metrics. Circular buffers (without walking paths) and service areas (considering walking paths) with two-dimensional/three-dimensional (terrain) adjustment were applied to quantify forms/characteristics of neighbourhoods. Two spatial buffers were applied: immediate distance (200 m) and walkable distance (500 m). Exposure-by-exposure regressions were applied to evaluate the associations between form/characteristics of neighbourhood and dementia.

RESULTS

Forms/characteristics without considering walking paths may overestimate health benefits from built environment. For circular buffers, higher percentage of building coverage, higher land use mix and more community/transportation/leisure facilities were negatively associated with dementia. All measures of greenery were positively associated with dementia. For service areas, measures of walkability and accessibility became insignificant except more community facilities at the immediate distance. Furthermore, terrain effect was insignificant when it was compared with the impacts of walking paths.

CONCLUSION

Dementia among seniors in hilly public housing estates was negatively associated with neighbourhood's walkability and accessibility and was influenced by walking paths. For healthy ageing, improved forms/characteristics of public housing neighbourhoods should include more accessible spaces and community facilities along walking paths for physical activities and basic daily needs.

285 DEVELOPING A FRAILTY CARE PATHWAY IN A REHABILITATION HOSPITAL: A PILOT STUDY

Background

Frailty is a common condition in older adults. The Clinical Frailty Scale (CFS) is a widely used frailty screening-tool within the Irish healthcare system due to its time-efficiency and transferability between settings. The Edmonton Frailty Scale (EFS) is heralded as an effective tool capturing multi-dimensional aspects of frailty. Due to the lack of blanket referral system for some Multi-Disciplinary Team (MDT) members in our Irish rehabilitation hospital, early identification of frailty is key to ensure timely input from all disciplines. To optimise MDT intervention, the EFS was piloted alongside the CFS comparing user-experience and sensitivity.

Methods

Education sessions were held by frailty-group members to familiarise staff with frailty concepts and frailty-tool administration. The EFS and CFS were administered with all patients over 65 years within 72 hours of admission onto two wards of our hospital over a three-month period. Frailty scale completion was co-ordinated by the physiotherapists and occupational therapists who operate a blanket referral system. Detection of frailty triggered an urgent referral to dietician, medical social work and speech and language therapy colleagues who don’t operate a blanket referral system. The target time for MDT input was two days for the severely frail cohort and one week for mild or moderately frail patients.

Results

The EFS was administered for 83 patients (mean age: 84 years). Of those, 6% were severely frail, 23% were moderately frail and 28% were mildly frail. The CFS was found to detect a higher frailty level in 47% of patients screened when compared to the EFS and took an average of ten minutes less to administer.

Conclusion

The CFS will continue to be administered with patients due to its higher sensitivity to frailty and time efficiency for completion. Referrals will continue to be generated to all MDT members to expedite input with frail patients.

A simultaneous concept analysis of resilience, coping, posttraumatic growth, and thriving

BACKGROUND

Research has shifted in recent decades from a focus on negative effects of adversity, trauma, and stress to protective factors and positive outcomes. Resilience and related concepts (coping, posttraumatic growth, thriving, and preparedness) reflect this shift. However, the current state of literature reflects conceptualization challenges in relation to these terms, which blur their differentiation.

AIM

We aim to examine how resilience and related terms are conceptualized in health-related literature.

DESIGN

We used a simultaneous concept analysis to independently explore and further inform the conceptual development of resilience, coping, PTG, and thriving.

DATA SOURCE

We searched PsycINFO and PubMed for literature between 1999 and 2019 for each of our concepts.

REVIEW METHODS

For each of these concepts, we propose a definition, antecedents, attributes, an example, consequences, and related concepts. Next, we concurrently examined the concepts, compared and contrasted findings across them, and clarified similarities as well as differences between them.

RESULTS

Many concepts' definitions lack specificity, clear boundaries, and consistency across the literature. Resilience literature fails to differentiate between attributes and antecedents of resilience. There was overlap regarding conceptualization between resilience and coping, and resilience and thriving.

CONCLUSIONS

Several concepts' definitional literature diverged between a return to baseline functioning and surpassing baseline.

Bacteriological Survey of Fresh Minced Beef on Sale at Retail Outlets in Scotland in 2019: Three Foodborne Pathogens, Hygiene Process Indicators, and Phenotypic Antimicrobial Resistance

ABSTRACT

The health and economic burden of foodborne illness is high, with approximately 2.4 million cases occurring annually in the United Kingdom. A survey to understand the baseline microbial quality and prevalence of food-related hazards of fresh beef mince on retail sale could inform risk assessment, management, and communication to ensure the safety of this commodity. In such a survey, a two-stage sampling design was used to reflect variations in population density and the market share of five categories of retail outlets in Scotland. From January to December 2019, 1,009 fresh minced beef samples were collected from 15 geographic areas. The microbial quality of each sample was assessed using aerobic colony count and Escherichia coli count. Samples were cultured for Campylobacter and Salmonella, and PCR was used to detect target genes (stx1 all variants, stx2 a to g, and rfbO157) for Shiga toxin-producing E. coli (STEC). The presence of viable E. coli O157 and STEC in samples with a positive PCR signal was confirmed via culture and isolation. Phenotypic antimicrobial sensitivity patterns of cultured pathogens and 100 E. coli isolates were determined, mostly via disk diffusion. The median aerobic colony count and E. coli counts were 6.4 × 105 (interquartile range, 6.9 × 104 to 9.6 × 106) and <10 CFU/g (interquartile range, <10 to 10) of minced beef, respectively. The prevalence was 0.1% (95% confidence interval [CI], 0 to 0.7%) for Campylobacter, 0.3% (95% CI, 0 to 1%) for Salmonella, 22% (95% CI, 20 to 25%) for PCR-positive STEC, and 4% (95% CI, 2 to 5%) for culture-positive STEC. The evidence for phenotypic antimicrobial resistance detected did not give cause for concern, mainly occurring in a few E. coli isolates as single nonsusceptibilities to first-line active substances. The low prevalence of pathogens and phenotypic antimicrobial resistance is encouraging, but ongoing consumer food safety education is necessary to mitigate the residual public health risk.

HIGHLIGHTS

180 Systematic Review and Meta-Analysis of Exercise Therapy for Venous Leg Ulcer Healing and Recurrence

Aim

National guidelines recommend regular exercise for individuals with venous leg ulceration, yet data for the effect of exercise on ulcer healing and recurrence are sparse. This study aimed to quantify the evidence for exercise in venous ulcer healing with the primary outcomes of proportion of healed ulcers and rate of ulcer recurrence. Secondary outcomes were compliance and adverse events.

Method

The review followed PRISMA guidelines using a registered protocol (CRD42021220925). Medline, Embase and Cochrane Databases were searched on 15th March 2021 and included articles comparing exercise to compression therapy. Meta-analysis was performed to pool the data.

Results

After screening 994 articles, six reports were included with 109 participants allocated to exercise and 113 to compression. All articles were randomised-controlled trials and reported ulcer healing at 12 weeks, with a pooled relative risk of 1.35 ulcers for exercise versus compression (95% CI 1.07 – 1.71). Only one article reported on recurrence and data pooling was not performed, but no difference between exercise and usual care was demonstrated. Adverse events were inadequately reported and seen to be more frequent in the exercise arm. Compliance with exercise ranged from 33–81%.

Conclusions

There is increasing evidence for exercise as an adjunct to ulcer healing, however, trials were low quality with high risk of bias. This is a crucial innovation as many ulcers recur or fail to heal in spite of surgical correction of underlying venous insufficiency. There is paucity of evidence examining leg ulcer recurrence after exercise programmes and currently no evidence of benefit.

Neighborhood disadvantage and the sales of unhealthy products: alcohol, tobacco and unhealthy snack food

BACKGROUND

Individuals may use unhealthy coping mechanisms such as alcohol, tobacco, and unhealthy snack consumption. The purpose of this study was to assess how neighborhood disadvantage is associated with sales of alcohol, tobacco, and unhealthy snacks at stores of a discount variety store chain.

METHODS

Alcohol, tobacco, and unhealthy snack sales were measured monthly for 20 months, 2017-2018, in 16 discount variety stores in the United States. Mixed effects linear regressions adjusted for population size, with store-specific random effects, to examine the relationship of weekly unit sales with three outcome variables and neighborhood disadvantage, measured using the Area Deprivation Index (ADI).

RESULTS

The discount variety stores were located in neighborhoods where the median ADI percentile was 87 [interquartile range 83,89], compared to the median ADI percentile of 50 for all US communities, indicating that the stores were located in substantially disadvantaged neighborhoods. For every 1% increase in ADI, weekly unit sales of unhealthy snack food increased by 43 [95% confidence interval, CI 28-57], and weekly unit sales of tobacco products increased by 11.5 [95% CI 5-18] per store. No significant relationship between neighborhood disadvantage and the weekly unit sales of alcohol products was identified.

CONCLUSIONS

The positive relationship between neighborhood disadvantage and the sale of tobacco and snack foods may help explain the pathway between neighborhood disadvantage and poor health outcomes. It would be useful for future research to examine how neighborhood disadvantage influences resident health-related behaviors.

Positive effects of high salinity can buffer the negative effects of experimental warming on functional traits of the seagrass Halophila ovalis

Coastal ecosystems, and especially estuaries, are subject to environmental fluctuations that can be amplified by anthropogenic changes. Under a future scenario of global warming, temperature and salinity are likely to be altered and the persistence of macrophyte-dominated ecosystems can be compromised, particularly native or local seagrass communities. This study examined the response of the local seagrass Halophila ovalis to the joint effect of a short-term salinity increase and a transient temperature stress, through two mesocosm experiments. Warming caused a decline in F_v/F_m, TNC content in leaves and plant growth, and increased dark respiration, revealing clear detrimental symptoms of heat stress on plant metabolism and performance. Salinity increase in isolation favoured ramet survival. However, in combination with warming, salinity had a positive effect on Gross P_max. This suggests that increased salinities might dampen the negative effects of high temperatures, buffering, to some extent, the impact of global warming in temperate estuaries.

"It's the nature of the beast": Community resilience among gender diverse individuals

Marginalization causes gender diverse individuals to experience increased stress compared with cisgender individuals, such as social stigma and discrimination, which can lead to poor physical and mental health outcomes. This population uses various resources to cope with these challenges, including community social support. This qualitative research aimed to understand how gender diverse individuals perceive their community resilience. Supported by a community partner organization, we recruited N = 20 gender diverse participants for semi-structured interviews analyzed through inductive thematic qualitative analysis. The data revealed similarities with community resilience factors observed among other minority groups as well as novelty. Themes emerged on both individual and group levels and include strengths (e.g., opening to the group, role modeling for resilience, and group resources) and threats to community resilience (e.g., social anxiety, physical health conditions, and stigma). This paper informs the development of community resilience interventions in the context of gender diversity.

How Are Community Socio-Economic Factors Associated with the Sales of Unhealthy Products: Alcohol, Tobacco and Unhealthy Snack Food in Low Income Communities

Objectives

People under stress tend to use unhealthy coping mechanisms including using products like alcohol, tobacco and unhealthy snacks. The purpose of this study is to assess how measures of community socio-economic status, which may be proxies for community stress, are associated with the sales of unhealthy products (alcohol, tobacco, and unhealthy snacks) at a discount variety store chain. Specifically, we consider the following measures of community socio-economic status: population racial/ethnic composition, % of households on SNAP, % of households without a vehicle, walkability score and median community income.

Methods

Mixed effects linear regressions with random effects were used to examine the relationship between the weekly unit sales (per 1000 population) of three outcome variables (tobacco, alcohol, unhealthy snacks) and community socio-economic factors: % of households on SNAP, % of households without a vehicle, and median community income.

Results

The sales of alcohol, tobacco, and unhealthy snacks increased as the % of the population participating in SNAP increased. Other measures of community socio-economic status were not significantly (at 5% significance level) associated with tobacco or unhealthy snack sales. However, for alcohol sales, increases in: the median household income, walkability score and % of African American residents, were associated with a decrease in alcohol sales.

Conclusions

Low income neighborhoods frequently experience greater health burden compared to higher income neighborhoods. Understanding and quantifying the relationship between financial stress and unhealthy product consumption can help public health professionals intervene before chronic diseases manifest.

Funding Sources

Robert Woods Johnson Foundation.

An integrated protocol for targeted mutagenesis with CRISPR-Cas9 system in the pea aphid

CRISPR-Cas9 technology is a very efficient functional analysis tool and has been developed in several insects to edit their genome through injection of eggs with guide RNAs targeting coding sequences of genes of interest. However, its implementation in aphids is more challenging. Aphids are major pests of crops worldwide that alternate during their life cycle between clonality and sexual reproduction. The production of eggs after mating of sexual individuals is a single yearly event and is necessarily triggered by a photoperiod decrease. Fertilized eggs then experience an obligate 3-month diapause period before hatching as new clonal colonies. Taking into consideration these particularities, we developed in the pea aphid Acyrthosiphon pisum a step-by-step protocol of targeted mutagenesis based on the microinjection within fertilized eggs of CRISPR-Cas9 components designed for the editing of a cuticular protein gene (stylin-01). This protocol includes the following steps: i) the photoperiod-triggered induction of sexual morphs (2 months), ii) the mating and egg collection step (2 weeks), iii) egg microinjection and melanization, iv) the 3-month obligate diapause, v) the hatching of new lineages from injected eggs (2 weeks) and vi) the maintenance of stable lineages (2 weeks). Overall, this 7-month long procedure was applied to three different crosses in order to estimate the impact of the choice of the genetic combination on egg production dynamics by females as well as hatching rates after diapause. Mutation rates within eggs before diapause were estimated at 70-80%. The hatching rate of injected eggs following diapause ranged from 1 to 11% depending on the cross and finally a total of 17 stable lineages were obtained and maintained clonally. Out of these, 6 lineages were mutated at the defined sgRNAs target sites within stylin-01 coding sequence, either at the two alleles (2 lineages) or at one allele (4 lineages). The final germline transmission rate of the mutations was thus around 35%. Our protocol of an efficient targeted mutagenesis opens the avenue for functional studies through genome editing in aphids.

Increasing Access to the Special Supplemental Nutrition Program for Women, Infants, and Children Program Through Discount Variety Stores (P04-164-19)

Objectives

The Special Nutrition Assistance Program for Women, Infants, and Children (WIC) increases access to nutritious foods for low-income pregnant, postpartum, and breastfeeding women and their children under five. Participation in WIC has declined for the past 6 years. Discount variety stores (DVS) can be useful points of food access for low-income communities. We conducted in-depth interviews with staff at corporate, managerial, and store clerk levels at ten DVSs in North Carolina. These stores implemented WIC over a 10-month pilot study to assess WIC feasibility. Our study goal was to identify facilitators and barriers to WIC implementation in DVS. Learning more about facilitators and barriers associated with WIC implementation may lead to more successful program adoption, allowing more families to benefit from WIC and increase DVS revenues.

Methods

The design was an inductive approach to identify themes in qualitative in-depth interviews of employees of DVS at corporate, managerial, and store clerk levels. The interviews were uploaded into NVivo software. Thirty DVS employees were interviewed: six worked at the corporate level, 22 were in-store managers, and eight were store staff; 22 participants were women; eight were men. Ten DVS in low-income communities participated; nine of these stores were located in areas that were classified as a food desert.

Results

All except one participant provided positive feedback about being involved in the WIC program. Many DVSs store employees had previous experience participating in the WIC program which gave them a good understanding of the WIC shopping experience. Previous WIC experience and proximity to store location for DVS customers were facilitators of WIC implementation. The primary barriers included limited choice in store products for customers, complicated or unclear labeling for WIC-eligible products, and difficulty training store employees to process WIC payments.

Conclusions

Based on the WIC implementation, DVS found that selling WIC-eligible products, especially infant formula, was associated with selling more non-WIC items. The North Carolina WIC program moved from a paper-based system to an electronic benefit transfer system (eWIC); therefore, several of the barriers to successful WIC implementation should be addressed through the new electronic system that does not require as much detailed and manual employee training. Increased infant formula sales to both WIC and non-WIC customers drove increased sales in other products.

Funding Sources

Robert Wood Johnson Foundation.

Traditional health practitioners and sustainable development: a case study in South Africa

OBJECTIVES

To highlight legal and regulatory advances relating to South African traditional health practitioners (THPs) over the past 10 years and discuss the implications for the translation of health policies into guidelines for sustainable practice supporting public health.

STUDY DESIGN

This is a rapid, structured literature review.

METHODS

A rapid, structured literature review was undertaken to identify relevant studies related to South African THPs involving a search of peer-reviewed literature from three databases and a grey literature internet search. The identified citations were screened, critically appraised, and narratively synthesized.

RESULTS

Efforts to regulate THPs in South Africa are underway; however, the lack of a regulatory framework for traditional practices is hampering progress. Several efforts to collaborate with THPs have been made over the years, many of which were not systematically evaluated and not based on principles of mutual respect. Existing collaborative examples need to be further supported by cost-effective evidence to suit the South African public health budget. Furthermore, small collaborative research efforts do not take into consideration the scale up of interventions.

CONCLUSIONS

THPs in South Africa represent an important healthcare resource. However, the current policy environment does not support indicators to describe, monitor, and/or evaluate the role of THPs in the healthcare system.

Native reptiles alter their foraging in the presence of the olfactory cues of invasive mammalian predators

Invasive mammalian predators are linked to terrestrial vertebrate extinctions worldwide. Prey naïveté may explain the large impact invasive predators have on native prey; prey may fail to detect and react appropriately to the cues of novel predators, which results in high levels of depredation. In Australia, the feral cat (Felis catus) and the red fox (Vulpes vulpes) are implicated in more than 30 animal extinctions and the naïveté of native prey is often used to explain this high extinction rate. Reptiles are one group of animals that are heavily preyed upon by F. catus and V. vulpes. However, very few studies have examined whether reptiles are naive to their cues. In this study, we examine the ability of two native reptile species (Morethia boulengeri and Christinus marmoratus) to detect and distinguish between the chemical cues of two invasive predators (V. vulpes and F. catus) and three native predators (spotted-tailed quoll, Dasyurus maculatus; dingo, Canis lupus dingo; eastern brown snake, Pseudonaja textilis), as well as two non-predator controls (eastern grey kangaroo, Macropus giganteus and water). We conducted experiments to quantify the effects of predator scents on lizard foraging (the amount of food eaten) during 1 h trials within Y-maze arenas. We found both study species reduced the amount they consumed when exposed to predator scents-both native and invasive-indicating that these species are not naive to invasive predators. An evolved generalized predator-recognition system, rapid evolution or learned behaviour could each explain the lack of naïveté in some native Australian reptiles towards invasive predators.

Appendicitis in a deployed military setting: diagnosis, management and impact on the fighting force

BACKGROUND

Acute appendicitis is a principal cause of abdominal pain worldwide and most common in young men who constitute the majority of the deployed fighting force. Diagnostic accuracy is paramount to prevent unnecessary intervention, morbidity and force impact.

METHOD

A consecutive series of appendicectomies, performed over 28 months on deployment in Afghanistan, was evaluated to assess the negative appendicectomy (NA) rate, explore the impact of CT on the rates of NA and assess the impact of appendicectomy on manpower in the deployed workforce.

RESULTS

In Afghanistan, the operative NA rate was 9.6%, whereas the histological NA rate was 20.5%. CT was widely used in Afghanistan (36%) and there was a significant reduction in NA rates if CT was performed preoperatively (6.25% vs 26%, p=0.02).

CONCLUSIONS

Diagnostic imaging will be limited in future conflicts and reliance on clinical judgement will be necessary. Military clinicians may need to accept higher rates of NA, as prolonged observation may not be possible. CT scanning should be used to a greater extent when available. A conservative management strategy for appendicitis with appropriate antibiotics should be considered in the event of delayed transfer to a surgical facility.

Endovascular management of renal artery aneurysm rupture in pregnancy - A case report

INTRODUCTION

Renal artery aneurysm rupture is an extremely rare cause of acute abdominal pain and haemodynamic instability in pregnancy. Due to its rarity, the diagnosis may not be immediately considered, and therefore there is a high associated mortality rate for both mother and fetus.

PRESENTATION OF CASE

We present a case of a 41-year old primigravida who presented to the obstetricians at 22 weeks' gestation with severe abdominal pain, shock and fetal loss. A bleeding renal artery aneurysm was discovered at laparotomy and radiologically coiled with sacrifice of the left kidney. Treatment of a contralateral aneurysm by autotransplantation of the remaining kidney allowed for preservation of residual renal function.

DISCUSSION

Surgical acute abdominal presentations can be difficult to interpret in pregnant patients. Pregnancy is known to be a contributing risk factor for spontaneous rupture of renal artery aneurysms, an otherwise rare mode of aneurysm presentation. Prompt use of imaging to diagnose and treat non-obstetric causes of the acute abdomen should not be delayed because of perceived risks to the fetus. Endovascular arrest of aneurysmal haemorrhage may be more effect in the context of a gravid uterus than surgical management.

CONCLUSION

In the shocked pregnant patient with an acute abdominal presentation, visceral artery aneurysm rupture may be comparatively more common, and should be considered in the absence of other localizing symptoms. Prompt interventional radiological treatment may be lifesaving in such cases.

Chemically defined media for cultivation of Naegleria gruberi

Cultivation of amebae of the axenic strain of Naegleria gruberi, NEG-M, was achieved in media consisting entirely of chemically defined components. A complete medium that contains 31 components allows growth with yields up to 5 x 10(6) amebae per ml. A minimal medium gives lower yields but defines 22 components that are essential for continuous cultivation: 11 amino acids, 6 vitamins, hematin, guanosine, D-glucose, Mg(2+), and inorganic phosphate. These media allow precise studies of the metabolism and differentiation of this unusual eukaryote.

The value, qualification, and regulatory use of surrogate end points in drug development

The acceptance and use of either surrogate end points (SEPs) or efficient clinical end points are associated with greater and more rapid availability of new medicines as compared with disease situations for which clinical end points are inefficient or no surrogates exist. This review of the history of the development, qualification, and acceptance of key SEPs shows that both successes and failures had three key characteristics: (i) apparent biologic plausibility, (ii) prognostic value for the outcome of the disease, and (iii) an association between changes in the SEP and changes in outcome with therapeutic intervention--the three factors recommended for SEPs in the International Conference on Harmonisation's "Statistical Principles for Clinical Trials." We recommend that only prognostic value be an absolute prerequisite for surrogacy, because therapeutic interventions may not exist a priori, and biological plausibility can be subjective. Ideally, all three of these factors would be traded off against one another in a consistent and transparent risk-management process.

The drug diagnostic co-development concept paper

At the Washington DC Pharmacogenomics in Drug Development and Regulatory Decision-Making: Workshop III - Three Years of Promise, Proposals and Progress on Optimizing the Benefit/Risk of Medicines (11-13 April 2005), one break-out session (Track 2) focused on co-development of therapeutic drug and diagnostic products. The Food and Drug Administration (FDA) released a draft concept paper shortly before the workshop was to convene. Track 2 was a forum for initial discussion of the content of the concept paper, and industry's initial reactions. After the workshop, formal commentaries on the co-development concept paper were submitted by several trade associations (e.g., Pharmaceutical Research and Manufacturers of America (PhRMA), Advanced Medical Technology Association (AdvaMed), American Association for Clinical Chemistry) and individual companies to FDA's Docket No. 2004N-0279. This paper includes a summary of the key features of the draft concept paper, the discussion in Track 2 of the April, 2005 meeting and highlights of the industry comments submitted to the FDA docket following the meeting.

A methodology for web-enabling a computer-based patient record with contributions from cognitive science

Cognitive science is a rich source of insight for creative use of new Web technologies by medical informatics workers. I outline a project to Web-enable an existing computer-based patient record (CPR) in the context of ideas from philosophy, linguistics, artificial intelligence, and cognitive psychology. Web prototypes play an important role (a) because Web technology lends itself to rapid prototype development, and (b) because prototypes help team members bridge among disparate medical, computing, and business ontologies. Six Web-enabled CPR prototypes were created and ranked. User scenarios were generated using a user communication matrix. Resulting prototypes were compared according to the degree to which they satisfied medical, computing, and business constraints. In a different organization, or at different time, candidate prototypes and their ranking might have been different. However, prototype generation and comparison are fundamentally influenced by factors usefully understood in a cognitive science framework.

Results after colectomy for colonic inertia: a sixteen-year experience

BACKGROUND

Colonic inertia (CI) is a disturbance of colonic motility characterized by severe constipation and abdominal pain. This study was conducted to assess the results of total abdominal colectomy (TAC) in the management of CI.

METHODS

A retrospective chart review of 55 patients who underwent TAC for CI was conducted.

RESULTS

Forty-eight patients (87%) were female with an average age of 40; severe constipation existed 2 years prior to surgery. Symptoms included severe constipation (100%) and abdominal pain (84%); diagnostic workup included sitz marker study, anal manometry, and Gastrografin enema. In all cases, sitz marker studies were abnormal and anal manometry was normal. Histologically, no patient had absence of neuroenteric plexuses. Complications included prolonged ileus (24%) and small bowel obstruction (8%). Some 49 patients (89%) had "good" or "excellent" results and 6 patients (11%) had "poor" results. Postoperative stool frequency was 5, 4, and 3 per day at 1, 2, and 12 months, respectively.

CONCLUSIONS

TAC results in resolution of constipation in most patients. We conclude that TAC is effective treatment in patients with CI.

Pitfalls in preparation of (3)H-unconjugated bilirubin by biosynthetic labeling from precursor (3)H-5-aminolevulinic acid in the dog

We report problems encountered during preparation of tritium-labeled unconjugated bilirubin ((3)H-UCB) from precursor (3)H-5-aminolevulinic acid ((3)H-ALA) in 2 dogs with external biliary drainage installed into the animals under general anesthesia. Under prolonged sedation, 12.9 or 14.0 mCi of (3)H-ALA was administered intravenously in two divided doses, and bile was collected for 9 hours. In one animal, taurocholate (TC) infusion was needed to maintain bile flow. (3)H-UCB was isolated from the bile and recrystallized with the improved method of Webster et al (Webster CC, Tiribelli C, Ostrow JD. J Lab Clin Med 2001;137:370-3). Based on radioactivity and pigment content, hourly bile collections were pooled to optimize specific activities. Surprisingly, in the first dog, only 2.9% of injected radioactivity was recovered in bile and only 14.1% in urine, and the specific activities of the crystalline (3)H-UCB from the two pools were only 39.5 and 30.0 x 10(3) dpm/microg. High-performance liquid chromatography analysis revealed that only 4% of ALA degraded during 5 minutes in injection solution at pH 6.8. The low incorporation of (3)H-ALA and low specific activity of (3)H-UCB was apparently caused mainly by prior degradation and exchange of labile tritium of the (3)H-ALA and probably by enhanced endogenous ALA synthesis caused by the anesthetic/sedative agents. Revised procedures in the second dog improved the incorporation of (3)H-ALA to 11.9% excreted in bile and the specific activity of the crystalline (3)H-UCB to 122.0 and 50.8 x 10(3) dpm/microg, while urinary excretion of tritium increased to 28.5%. These experiences emphasize possible pitfalls in preparing (3)H-UCB by biosynthetic labeling from (3)H-ALA administered to dogs.

Structured data entry in a workflow-enabled electronic patient record

Touch-screen technology is used with a structured data entry system for electronic patient records. This article describes a program that coordinates pre-set screens for detailed history, physical examination, treatment and prescription modules. It also presents "pick lists" that allow further customization and individualization of data inputs.

The early NHS and the crisis of public health nursing

Establishment of the NHS in 1948 is rightly seen as a major turning point in health care in the United Kingdom. Notwithstanding conditions of severe austerity, the NHS succeeded remarkably well in its basic remit to make all essential medical care available to the entire population, free at point of delivery. The benefits of the new system extended across the entire front of its services. However, it is important to recognise that the reforms of 1948 were uniformly advantageous. It has for instance long been recognised that the NHS failed to bring about the expected transformation in standards of general medical practice. In this short paper the author argues that public health represented a further major sphere of underdevelopment. The fact that, with minor exceptions, public health is the least studied aspect of the early NHS is itself suggestive of its status as the Cinderella of the modern health services. The author also underlines the adverse implications of this inferior position for domiciliary midwifery, district nursing and health visiting. These constituted small but strategically important sectors of nursing, all of which fell under public health administration in the new health service. The author concentrates on the first phase of the NHS, the period between 1948 and 1974, now often regarded as its golden age. For the purposes of this discussion, most of the evidence relates to the formative phase of the new service, when many major policy questions relating to public health were first confronted. It is suggested that the early neglect of public health and its constituent nursing functions has left a legacy of problems that have still not entirely been resolved. For the purposes of this paper the term will be used to embrace the totality of health functions administered by departments of local government in the period from 1948 to 1974. Most of these services fell within the public health departments of local government, headed by the Medical Office of Health (MOH). However, some important functions involving the nurses were located in other departments. Especially important was the School Health Service, which was reformed in 1944, ahead of the NHS. This was a largely independent service under the administration of Local Education Authorities. Some of the problems of public health nursing related to this fragmentation of responsibility.

Efficacy and tolerability of subcutaneous sumatriptan for acute migraine: a comparison between ethnic groups

OBJECTIVE

To evaluate efficacy and tolerability of subcutaneous sumatriptan 6 mg versus placebo for acute migraine between ethnic groups.

BACKGROUND

Patients in previous sumatriptan studies have been predominantly Caucasian and the effects of sumatriptan between different ethnic groups are unknown.

METHODS

This was a multicenter, 3-phase, 12-attack study. Phases I and III (inclinic) were randomized, double-blind, placebo-controlled, crossover designs. Phase II (outpatient) was a single-blind design. Sumatriptan was compared to placebo across 2 groups (non-Caucasian and Caucasian) and individual ethnic subgroups (black, Hispanic, and others). Headache response, pain-free response, associated symptoms, and clinical disability were assessed. Tolerability assessments included the incidence of adverse events, physical examinations, vital signs, electrocardiograms, and clinical laboratory data.

RESULTS

Two hundred patients treated at least one migraine attack (150 non-Caucasians: 46 blacks, 68 Hispanics, 36 others). Two hours postdose, significantly more inclinic sumatriptan-treated patients reported headache response (non-Caucasians, 81% versus 37% placebo; Caucasians, 87% versus 19% placebo; P<.001) and mild or no clinical disability, compared with placebo (non-Caucasians, 87% versus 50% placebo; Caucasians, 90% versus 38% placebo; P<.001). Blacks (80%), Hispanics (83%), and others (74%) reported similar patterns of headache response at 2 hours. Similar results were reported during the outpatient phase. The incidence of adverse events following sumatriptan during the inclinic phase was similar between ethnic groups (non-Caucasian, 75%; Caucasian, 79%) and higher than placebo (non-Caucasian, 51%; Caucasian, 31%). Overall, adverse events in the outpatient phase of the study were lower than in the inclinic phase.

CONCLUSION

Sumatriptan injection is effective and well tolerated in non-Caucasians and Caucasians for the treatment of acute migraine attacks. Only minor differences in efficacy or tolerability were observed between blacks, Hispanics, and others.

Enhancing practice efficiency by examining patterns of care: top ten lists data mined from a private pediatric practice

The electronic medical record allows practitioners to document their patterns of care. They can enhance performance and profitability by reviewing their top diagnoses, prescriptions, types of physical examination, referral patterns and labs and procedures. The software required to support this documentation system is described.