Implication of current ASE/EACVI left ventricular diastolic function classification in predicting 2-year MACE in asymptomatic patients with diabetes and hypertension

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health Malaysia

Background

Left ventricular diastolic dysfunction (LVDD) has been shown to be more prevalent in patients with diabetes, and once progress to overt heart failure, carry worse clinical outcomes. Substantial number of patients were classified as indeterminate diastolic function based on the current ASE/EACVI guidelines. The implication of current diastolic function classification in predicting MACE among diabetic patients is not well established.

Purpose

To assess prognostic impact of current guidelines-based diastolic function classification, and determine predictors of 2-year MACE based on individual LVDD parameters.

Methods

A total of 111 patients with diabetes and hypertension who attended diabetic clinic follow-up at the primary healthcare settings were enrolled. All patients had no prior cardiovascular events, had preserved left ventricular (LV) ejection fraction on echocardiography and sinus rhythm on ECG at screening. Echocardiography was performed to obtain parameters of LV dimensions, LV volumes and LV diastolic function. The 2016 ASE/EACVI guidelines were applied to classify diastolic function. All patients were followed up until 2 years to assess MACE.

Results

There were 65 (58.6%) female patients. Mean age was 59.86 ± 7.45 years; mean duration of type 2 diabetes was 10.5 ± 5.41 years. 80 (72.1%) patients were classified as having normal diastolic function (nDF); 24 (21.6%) patients were classified as indeterminate diastolic function (iDF); 7 patients (6.3%) were classified as LVDD. Patients with LVDD had significantly higher LV mass index (LVMI) (mean 121.72 ± 23.28g/m2 vs 116.62 ± 24.66g/m2 in iDF vs 102.50 ± 22.89g/m2 in nDF, p = 0.003); higher left atrial volume index (LAVI) (mean 41.24 ± 10.28ml/m2 vs 30.55 ± 10.07ml/m2 in iDF vs 25.75 ± 6.30ml/m2 in nDF, p < 0.001); lower lateral e’ velocity (mean 6.35 ± 2.05cm/s vs 7.37 ± 1.73cm/s in iDF vs 8.59 ± 2.13cm/s in nDF, p = 0.003); higher septal E/e’ ratio (mean 14.89 ± 3.29 vs 12.16 ± 3.99 in iDF vs 9.99 ± 2.35 in nDF, p = 0.001); higher average septal-lateral E/e’ ratio (mean 14.22 ± 3.77 vs 11.34 ± 3.74 in iDF vs 9.04 ± 2.10 in nDF, p < 0.001).

Among these 111 patients, 10 patients (9%) reported MACE at 2 years. The risk of 2-year MACE is elevated in both indeterminate diastolic function[hazards ratio (HR) 3.80, p = 0.023] and LVDD (HR 37.78, p = 0.002). BMI (HR 1.25, p = 0.004), and systolic blood pressure (HR 1.07, p < 0.001) were found to be associated with 2-year MACE.

Conclusions

LVDD and indeterminate diastolic function were correlated with increased MACE at 2 years. BMI and systolic blood pressure were predictors of increased risk of MACE at 2 years. Further investigation with larger sample size is warranted.

Implication of Current ASE/EACVI Left Ventricular Diastolic Function Classification in Predicting 2-Year MACE in Asymptomatic Patients with Diabetes and Hypertension

Background

Left ventricular diastolic dysfunction (LVDD) has been shown to be more prevalent in patients with diabetes, and once progress to overt heart failure, carry worse clinical outcomes. Substantial number of patients were classified as indeterminate DF based on the current ASE/EACVI guidelines. The implication of current DF classification in predicting MACE among diabetic patients is not well established.

Purpose

To assess prognostic impact of current guidelines-based DF classification, and determine predictors of 2-year MACE based on individual LVDD parameters.

Methods

A total of 111 patients with diabetes and hypertension who attended diabetic clinic follow-up at the primary healthcare settings were enrolled. All patients had no prior cardiovascular events, had preserved left ventricular (LV) ejection fraction on echocardiography and sinus rhythm on ECG at screening. Echocardiography was performed to obtain parameters of LV dimensions, LV volumes and LVDD. The 2016 ASE/EACVI guidelines were applied to classify DF. All patients were followed up until 2 years to assess MACE.

Results

There were 65 (58.6%) female patients. Mean age was 59.86 (7.45); mean duration of DM was 10.5 (5.41). 80 (72.1%) patients were classified as having normal DF (nDF); 24 (21.6%) patients were classified as indeterminate DF (iDF); 7 patients (6.3%) were classified as LVDD. Patients with LVDD had significantly higher LV mass index (LVMI) (mean 121.72±23.28g/m2 vs 116.62±24.66g/m2 in iDF vs 102.50±22.89g/m2 in nDF); higher left atrial volume index (LAVI) (mean 41.24±10.28ml/m2 vs 30.55±10.07ml/m2 in iDF vs 25.75±6.30ml/m2 in nDF); lower lateral e' velocity (mean 6.35±2.05cm/s vs 7.37±1.73cm/s in iDF vs 8.59±2.13cm/s in nDF); higher septal E/e' ratio (mean 14.89±3.29 vs 12.16±3.99 in iDF vs 9.99±2.35 in nDF); higher average septal-lateral E/e' ratio (mean 14.22±3.77 vs 11.34±3.74 in iDF vs 9.04±2.10 in nDF).

Among these 111 patients, 10 patients (9%) reported MACE at 2 years. The risk of 2-year MACE is elevated in both iDF [odds ratio (OR) 3.80, 95% CI 0.87–16.54, p=0.075] and LVDD [OR 7.60, 95% CI 1.11–52.02, p=0.039]. LVMI (OR 1.027, 95% CI 1.004– 1.051, p=0.023), LAVI (OR 1.092, 95% CI 1.017–1.172), and average septal-lateral E/e' ratio (OR 1.276, 95% CI 1.047–1.557, p=0.016) significantly correlated with 2-year MACE.

Conclusions

LVDD is correlated with increased MACE at 2 years. LVMI, LAVI and average septal-lateral E/e' ratio were predictors of increased risk of MACE at 2 years. Further investigation with larger sample size is warranted.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health Malaysia

Impact of 2016 ASE/EACVI recommendations on evaluation of left ventricular diastolic function and clinical outcomes in patients with diabetes and hypertension without prior adverse cardiac events

Background

Left ventricular diastolic dysfunction (LVDD) has been shown to be more prevalent in patients with diabetes, and once progress to overt heart failure, carry worse clinical outcomes, compared to those without diabetes. The complexity of previous 2009 ASE/EACVI algorithms makes diastolic function (DF) assessment challenging. Hence, prognostic value of LVDD estimates in clinical setting is not well-established.

Objective

To evaluate the impact of 2016 recommendations in estimates of LVDD and predicting cardiovascular outcomes in patients with diabetes and hypertension.

Materials and methods

A total of 111 patients with diabetes and hypertension who attended diabetic clinic follow-up at the primary healthcare settings were enrolled. All patients were clinically NYHA Class I, had no prior adverse cardiac events, and had preserved left ventricular (LV) ejection fraction on echocardiography at screening. Echocardiography was performed to obtain parameters of LV dimensions, LV volumes and LVDD. Both 2009 and 2016 algorithms were applied in DF assessment. All patients follow-up at 1 year to assess clinical outcomes.

Results

There were 65 (58.6%) female patients. Mean age was 59.86 (7.45); mean duration of diabetes was 10.5 (5.41). 55 (50.5%) patients had LV hypertrophy on echocardiography.

Prevalence of LVDD (14.4% vs 55.0%) and elevated LV filling pressure (9.0% vs 26.1%) were lower with 2016 compared with 2009 recommendations. Prevalence of indeterminate DF was 18.0% and 12.6% according to 2016 and 2009 recommendations respectively. Concordance between 2016 and 2009 recommendations was fair (k=0.29, p<0.001), with a reclassification rate of 45.9%.

None out of 45 patients who were diagnosed with indeterminate and normal DF according to 2016 and LVDD with 2009 algorithms developed MACE at 1 year. Out of 12 patients diagnosed with LVDD based on both 2016 and 2009 recommendations, 4 patients developed MACE at 1 year. 2016 recommendations showed better accuracy (sensitivity=80.0%; specificity=88.68%) than 2009 recommendations (sensitivity=80.0%; specificity= 45.28%) in predicting MACE at 1 year.

Conclusions

The application of 2016 recommendations results in lower prevalence of LVDD. The 2016 criteria detect more advanced cases and predict 1 year cardiovascular outcomes better. Further studies are warranted to investigate the prognostic impact of this criteria.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH), Ministry of Health Malaysia

Microglia depletion diminishes key elements of the leukotriene pathway in the brain of Alzheimer's Disease mice

Leukotrienes (LTs) contribute to the neuropathology of chronic neurodegenerative disorders including Alzheimer’s Disease (AD), where they mediate neuroinflammation and neuronal cell-death. In consequence, blocking the action of Leukotrienes (LTs) ameliorates pathologies and improves cognitive function in animal models of neurodegeneration. Surprisingly, the source of Leukotrienes (LTs) in the brain is largely unknown. Here, we identified the Leukotriene (LT) synthesis rate-limiting enzyme 5-Lipoxygenase (5-Lox) primarily in neurons and to a lesser extent in a subpopulation of microglia in human Alzheimer´s Disease (AD) hippocampus brain sections and in brains of APP Swedish PS1 dE9 (APP-PS1) mice, a transgenic model for Alzheimer´s Disease (AD) pathology. The 5-Lipoxygenase (5-Lox) activating protein (FLAP), which anchors 5-Lipoxygenase (5-Lox) to the membrane and mediates the contact to the substrate arachidonic acid, was confined exclusively to microglia with the entire microglia population expressing 5-Lipoxygenase activating protein (FLAP). To define the contribution of microglia in the Leukotriene (LT) biosynthesis pathway, we ablated microglia using the colony stimulating factor 1 receptor (CSF1R) inhibitor PLX5622 in wildtype (WT) and APP-PS1 mice. Microglia ablation not only diminished the expression of FLAP and of the Leukotriene (LT) receptor Cysteinylleukotriene receptor 1 (CysLTR1), as expected based on their microglia cell type-specific expression, but also drastically reduced 5-Lipoxygenase (5-Lox) mRNA expression in the brain and its protein expression in neurons, in particular in wildtype (WT) mice. In conclusion i) microglia are key in Leukotriene (LT) biosynthesis, and ii) they regulate neuronal 5-Lipoxygenase (5-Lox) expression implying a yet unknown signaling mechanism between neurons and microglia.

A United Kingdom Multicenter Study of Icodextrin in Continuous Ambulatory Peritoneal Dialysis

While glucose remains the only osmotic agent used universally for peritoneal dialysis, its various shortcomings for the long dwell equilibration continuous ambulatory peritoneal dialysis (CAPD) has led to a search for alternative agents. The large molecular weight group has been of interest, because these agents theoretically would lead to greater ultrafiltration and a better metabolic profile. Mostsubstances (dextrans, charged macromolecules) have been found unsuitable for reasons of insolubility, allergenicity, and peritoneal toxicity. Short-chain polypeptides have been studied in humans, but the experience is limited, and there is the potential for allergenicity with long-term use.

The only large molecular weight agent that has been studied in some detail but hitherto in one center only and in a limited number of patients is glucose polymer (generic name, icodextrin). Because of the promise shown by these initial studies, a randomized controlled multicenter investigation of icodextrin in CAPD (MIDAS Study Group) was undertaken to evaluate the long-term safety and efficacy by comparing daily overnight (8 12 hours) use of a slightly hypo-osmolar solution (282 mOsm/ kg) with 1.36% (346 mOsm/kg) and 3.86% (484 mOsm/kg) glucose exchanges. Over a 6-month period 209 patients from 11 centers in the United Kingdom were randomized, with 106 allocated to receive icodextrin (study group) and 103 to remain on glucose (control group). One hundred and thirty-eight patients completed the 6-month study (71 control, 67 study).

The mean net ultrafiltration overnight with icodextrin was 3.5 times greater than 1.36% at 8 hours and 5.5 times greater at 12 hours (p<0.0001), but no different from that of 3.86% glucose at 8 and 12 hours (although for the latter dwell the net mean ultrafiltration volume was greater by about 140 mL). Biochemical profiles were no different except for a small fall in serum sodium and chloride in the icodextrin group. The mean serum maltose rose to a steady-state level of 1.2 g/L within 2 weeks and remained stable. The mean carbohydrate absorbed for icodextrin (29±5 g) was lower than with 3.86% glucose (62±5 g). The use of icodextrin did not increase the incidence of peritonitis, nor did it alter its outcome, affect uptake of icodextrin from the peritoneum, alter serum osmolality or sodium levels. There were no adverse effects associated with the use of icodextrin, and the overall CAPD-related symptom score was significantly better for icodextrin than control subjects.

This study and subsequent extensive use and clinical experience has demonstrated that the daily use of an iso-osmolar icodextrin solution is generally well tolerated, effective, and could replace the overnight use of hyperosmotic glucose solution. Its use was of equal efficacy in peritonitis and in diabetic patients. The elevated levels of maltose did not appear to have any clinical side effects.

Peritonitis Occurrence in a Multicenter Study of Icodextrin and Glucose in Capd

Objective

To compare peritonitis occurrence and outcome in a large U.K. study Multicentre Investigation of Icodextrin in Ambulatory Dialysis (MIDAS).

Design

Prospective, randomized, controlled 6-month comparison of icodextrin with glucose for the long dwell in continuous ambulatory peritoneal dialysis (CAPD) patients.

Setting

Eleven CAPD units in U.K. teaching hospitals.

Patients

A total of 209 patients established on CAPD for at least 3 months (103 control, 106 icodextrin). Twentythree control (C) and 22 icodextrin (I) patients experienced peritonitis during the study.

Intervention

Patients who had peritonitis remained on treatment (unless CAPD was withdrawn, temporarily or permanently).

Main Outcome Measures

The main outcome measures were the rate of peritonitis and duration of CAPD treatment prestudy; the rate of peritonitis episodes and their outcome during study; the effect of peritonitis on laboratory variables, serum icodextrin metabolites, and ultrafiltration efficacy.

Results

Prestudy: Nine (39%) of C but 14 (64%) of I patients had suffered previous peritonitis episode(s), with overall rates of 0.58 and 0.78 episodes per patientyear, respectively.

During study

There were 31 C episodes and 35 I episodes, with overall rates of 0.76 and 0.93 per patientyear, respectively. The increase in the C and I groups was 31% and 19%, respectively. Serum osmolality and sodium levels were unaffected by peritonitis, and there was no increase in serum icodextrin metabolites during peritonitis. Overnight ultrafiltration volume during peritonitis (mean±SD) declined slightly from 218±354 mL to 185±299 mL (NS) in the control group, but increased in the icodextrin group from 570±146 mL to 723±218 mL (p < 0.01).

Conclusions

Using icodextrin for the long dwell in CAPD does not increase the rate of peritonitis, nor does it alter the outcome of peritonitis. Peritonitis does not affect uptake of icodextrin from the peritoneum.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2018

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference was held in Halifax, Nova Scotia, 20-22 September 2018. Experts in radiation oncology, medical oncology, surgical oncology, and pathology who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of pancreatic cancer, pancreatic neuroendocrine tumours, hepatocellular cancer, and rectal and colon cancer, including ■ surgical management of pancreatic adenocarcinoma,■ adjuvant and metastatic systemic therapy options in pancreatic adenocarcinoma,■ the role of radiotherapy in the management of pancreatic adenocarcinoma,■ systemic therapy in pancreatic neuroendocrine tumours,■ updates in systemic therapy for patients with advanced hepatocellular carcinoma,■ optimum duration of adjuvant systemic therapy for colorectal cancer, and■ sequence of therapy in oligometastatic colorectal cancer.

Partnering with consumers to develop and evaluate a Vietnamese Dementia Talking-Book to support low health literacy: a qualitative study incorporating codesign and participatory action research

OBJECTIVE

The aim of the Vietnamese Dementia talking-book was to address low health literacy in older people of Vietnamese background living with dementia through the provision of an online resource to help individuals, their families and carers better understand and manage this condition and provide information about available dementia services.

DESIGN

This qualitative study used codesign and participatory action research to develop and refine the talking-book in consultation with expert stakeholders, a consumer advocacy group and the Vietnamese community to assess its utility and ensure cultural and linguistic appropriateness and relevance.

PARTICIPANTS

59 members of the Vietnamese community, 11 stakeholders from community health services and ethnic agencies, consumer advocacy groups and the research team participated in the codesign and refinement of the talking-book. 22 members of the Vietnamese community appraised the final product.

SETTING

Vietnamese community planned activity groups in the Western, Northern and Southern suburbs of Melbourne, Australia.

RESULTS

Our codesign study outlines the process required to develop a Vietnamese Dementia Talking-Book resource partnering with consumers and expert stakeholders to identify consumer need, selection of the content and appropriate language level, construction of the book, measuring acceptability of the talking-book, modification based on feedback and production and dissemination. Feedback on the final version of the talking-book revealed widespread consensus that the book enhanced the knowledge of members of the Vietnamese community in regard to understanding dementia and navigation and accessing of available services.

CONCLUSIONS

This free internationally available online Vietnamese Dementia Talking-Book facilitates improved dementia-related health literacy in the Vietnamese community. The book also serves as a tool to facilitate the provision of care to Vietnamese people living with memory loss by assisting health professional staff to develop relationships with Vietnamese clients, their families and carers in a culturally appropriate manner.

Injuries in competitive boxing. A prospective study

Boxing remains a subject of controversy and is often classified as dangerous. But the discussion is based mostly on retrospective studies. This survey was conducted as a prospective study. From October 2012 to September 2013, 44 competitive boxers were asked to report their injuries once a month. The questionnaire collected general information (training, competition) and recorded the number of bouts fought, injuries and resulting lost days. A total of 192 injuries were recorded, 133 of which resulted in interruption of training or competition. Each boxer sustained 3 injuries per year on average. The injury rate was 12.8 injuries per 1 000 h of training. Boxers fighting more than 3 bouts per year sustain more injuries (p=0.0075). The injury rate does is not a function of age (age≤19 vs. > 19a, p=0.53). Injuries to the head and the upper limbs occur most frequently. The most common injuries are soft tissue lacerations and contusions. Head injuries with neurological symptoms rarely occur (4.2%). Boxing has a high injury rate that is comparable with other contact sports, but most injuries are minor. Injury frequency is not a function of whether the boxer competes in the junior or adult category. Athletes fighting many bouts per year have a greater risk of injury.

Injuries and overuse syndromes in competitive and elite bodybuilding

Competitive bodybuilding is a weightlifting sport similar to powerlifting, strongman competition and Olympic weightlifting, which aims to increase muscle mass, symmetry, and body definition. Although data regarding rates of injury, overuse syndromes and pain during routine training is available for these other disciplines, it is rare for competitive bodybuilding. The aim of this study was to investigate rates of injury, pain during workouts and/or overuse syndromes, as well as the influence of particular intrinsic and external factors. Data was collected using questionnaires from 71 competitive and elite bodybuilders. The information included training routines and prior injuries. Participants were recruited from bodybuilding clubs in Germany. 45.1% of athletes reported symptoms while training. The overall injury rate was computed to be 0.12 injuries per bodybuilder per year (0.24 injuries per 1 000 h of bodybuilding). Athletes over 40 exhibited higher rates of injury (p=0.029). Other investigated parameters showed no effects. Most injuries occurred in the shoulder, elbow, lumbar spine and knee regions. A large proportion of bodybuilders complained of pain not resulting in interruptions of training/competition. The injury rate is low compared to other weightlifting disciplines such as powerlifting, Olympic weightlifting or strongman competition. In comparison to team or contact sports the injury rate is minimal.

A response to U. T. Place

Skinner's (1957) analysis of verbal behavior has received an unwarranted amount of criticism over the years, and the recently published reviews of Verbal Behavior by U. T. Place contribute to this body of negative literature. It is argued that Place, like those before him, has failed to appreciate several critical features of behaviorism and Skinner's analysis of verbal behavior. Place's "four major defects in Verbal Behavior" are reviewed and analyzed. The results seem to indicate that Place's dissatisfaction with the book would be greatly reduced by a better understanding of Skinner's work.

Evocative and repertoire-altering effects of an environmental event

The behavioral effects of environmental events can be classified as evocative when we refer to an immediate but momentary change in behavior, and as repertoire-altering when we refer to a lasting effect that can only be observed when the situation that preceded the event is again present. The stimulus between two responses in an operant chain has an evocative effect in evoking the next response (its effect as a discriminative stimulus) and a repertoire-altering effect in increasing the future frequency of the response that preceded it (its effect as a conditioned reinforcer). New terms are introduced to permit a similar dichotomy of respondent functional relations as well as hybrid relations involving the respondent pairing procedure to develop conditioned reinforcers and punishers, and conditioned establishing operations. The resulting arrangement permits the assignment of a different term to each different behavioral function, and a classification of effects that is mutually exclusive and collectively exhaustive.

Skinner's elementary verbal relations: Some new categories

In Verbal Behavior (1957) B. F. Skinner identified and named five elementary verbal relations: mand, tact, intraverbal, textual and echoic. Because of their etymological commitment to visual and auditory stimuli respectively, the last two categories do not function well as general categories. Adding two more general categories, codic and duplic, to the first three results in a set of five mutually exclusive and collectively exhaustive groupings. Textual behavior and other relations involving point-to-point correspondence but no formal similarity fall into the codic category. Echoic behavior and other relations with formal similarity fall into the duplic category. This arrangement results in useful category names for all elementary forms and prevents potentially confusing extensions, such as referring to Braille reading as textual behavior, or sign imitation as echoic behavior.

Topography-based and selection-based verbal behavior: A further comparison

Michael (1985) identified two types of verbal behavior, topography-based (e.g., speaking or using sign language) and selection-based (e.g., using a symbol board). Sundberg and Sundberg (1990) and Wraikat (1990) compared these systems in terms of the ease of learning object naming (tact) and giving the correct sign or pointing to the correct symbol on hearing the object name (intraverbal). Sundberg and Sundberg (1990) also compared them for the spontaneous development of a new relation, identifying the object when hearing its name (stimulus class formation or equivalence). The results of both studies favored the topography-based system, but in each case some subjects were not verbally skillful enough to learn either system and some learned both too easily to permit a useful comparison. The current study replicated the two previous ones by teaching the same two verbal relations and testing for the emergence of new relations, but adjusted the task to the subject's level of functioning during the experiment. This was accomplished by varying the number of object relations being learned, and by interspersing already learned tasks with the training of new tasks. As with the earlier studies, topography-based verbal behavior was easier to learn, and led to more new stimulus-class relations than selection-based verbal behavior. These data confirm the relevant theoretical analysis, and have practical implications for a change in current language training practices.

Some reflections on 25 years of the association for behavior analysis: Past, present, and future

This paper offers some reflections on the discipline and profession of behavior analysis, as well as on the Association for Behavior Analysis (ABA), on the occasion of the association's 25th anniversary. It is based on a panel session conducted at the 1999 convention that included six past presidents of ABA (Donald M. Baer, Judith E. Favell, Sigrid S. Glenn, Philip N. Hineline, Jack Michael, and Edward K. Morris) and its current Executive Director and Secretary-Treasurer (Maria E. Malott). Among the topics addressed were (a) the survival of behavior analysis in university and cultural contexts, (b) the training of behavior-analytic researchers and practitioners, (c) relations between basic and applied research, (d) convergences between behavior analysis and other disciplines, (e) the structure and function of ABA, and (f) the importance of students for the future of the association, the discipline, and the profession. Questions from the audience raised issues concerning the relevance of major behavior-analytic journals, advances in behavior analysis since the death of B. F. Skinner, and the availability of accessible, popular material on applied behavior analysis.

Establishing operations

The first two books on behavior analysis (Skinner, 1938; Keller & Schoenfeld, 1950) had chapter-length coverage of motivation. The next generation of texts also had chapters on the topic, but by the late 1960s it was no longer being given much treatment in the behavior-analytic literature. The present failure to deal with the topic leaves a gap in our understanding of operant functional relations. A partial solution is to reintroduce the concept of the establishing operation, defined as an environmental event, operation, or stimulus condition that affects an organism by momentarily altering (a) the reinforcing effectiveness of other events and (b) the frequency of occurrence of that part of the organism's repertoire relevant to those events as consequences. Discriminative and motivative variables can be distinguished as follows: The former are related to the differential availability of an effective form of reinforcement given a particular type of behavior; the latter are related to the differential reinforcing effectiveness of environmental events. An important distinction can also be made between unconditioned establishing operations (UEOs), such as food deprivation and painful stimulation, and conditioned establishing operations (CEOs) that depend on the learning history of the organism. One type of CEO is a stimulus that has simply been paired with a UEO and as a result may take on some of the motivative properties of that UEO. The warning stimulus in avoidance procedures is another important type of CEO referred to as reflexive because it establishes its own termination as a form of reinforcement and evokes the behavior that has accomplished such termination. Another CEO is closely related to the concept of conditional conditioned reinforcement and is referred to as a transitive CEO, because it establishes some other stimulus as a form of effective reinforcement and evokes the behavior that has produced that other stimulus. The multiple control of human behavior is very common, and is often quite complex. An understanding of unlearned and learned establishing operations can contribute to our ability to identify and control the various components of such multiple determination.

Two kinds of verbal behavior plus a possible third

Speaking, writing, and signing (American Sign Language) are types of verbal behavior where each different verbal relation involves a different topography. It is also possible to behave verbally by pointing at or in some way indicating the relevant verbal stimuli, where response topographies do not differ from one verbal relation to another. There are a number of potentially important differences between topography-based and stimulus-selection-based verbal behavior, although the two are often treated as equivalent from a behavioral as well as from a traditional perspective. Selection-based verbal behavior involves a conditional discrimination whereas topography-based verbal behavior does not. In topography-based, but not in selection-based verbal behavior, there is point-to-point correspondence between response form and relevant response product. Also, effective selection-based verbal behavior requires a good scanning repertoire whereas in topography-based verbal behavior the correct response simply becomes stronger under appropriate conditions. What is traditionally referred to as receptive language training is described as quite similar from a behavioral perspective to training in selection-based verbal behavior. Given the differences between topography- and selection-based verbal behavior, the wisdom of the current rather extensive reliance on selection-based verbal behavior in language instruction for developmentally disabled clients is seriously questioned.

A behavioral perspective on college teaching

Much of the subject matter learned in college, particularly during the first two years, is taught in relatively large classes with text and lecture as the primary source of the information being learned. If students make effective and prolonged contact with these sources, they can acquire extensive verbal repertoires in many areas of knowledge. Unfortunately there are many other activities that compete for the typical student's study time. Several factors are often cited as variables that will support study behavior in competition with other activities, but the only powerful one available to the teacher is the exam grade, as it is related to the course grade. However, unless exams are clearly related to appropriate study behavior, require through and extensive coverage of the subject matter, occur frequently (preferably no less often than once a week), and are also clearly related to the course grade, even this factor will not generate prolonged and effective study behavior. Effective college teaching is essentially a form of aversive control, but if done properly the aversiveness is quite mild, and such aversive control can be responsible for the development of large and valuable intellectual repertoires.

Automatic reinforcement and automatic punishment in infant vocal behavior

Two female infants, aged 11 and 14 months, were exposed to a procedure in which an experimenter-emitted vocal response was paired with an established form of reinforcement (positive condition). One of the subjects was also exposed to a procedure in which an experimenter-emitted vocal response was paired with a neutral stimulus (neutral condition), and a procedure in which an experimenter-emitted vocal response was paired with a mild aversive stimulus (negative condition). An AB design was used with pre- and post-pairing measures. The results showed that after the positive pairing the targeted responses increased in frequency in 75% of the sessions. Responding remained constant during the neutral condition, but dropped sharply in the negative condition. These data suggest that a critical variable related to an infant's native language acquisition is the stimulus-stimulus pairing process that occurs when parents or caretakers speak to their infants.

The role of automatic reinforcement in early language acquisition

The vocal behavior of five children was recorded and analyzed during pre- and post-pairing conditions. Between these conditions there was a pairing condition where a target sound, word, or phrase was paired with an established form of reinforcement (e.g., tickling). In the first experiment all of the children emitted the targeted responses during the post-pairing condition. The results showed that the children acquired new vocal and verbal responses by pairing neutral stimuli with established forms of conditioned or unconditioned reinforcement. Perhaps the most significant aspect of these results was that new vocal responses were acquired by the children without the use of direct reinforcement, echoic training, or prompts. In the second experiment several parameters of the pairing procedure were examined. The results of the two experiments have implications for the analysis of native language acquisition, and for the development of language intervention procedures for individuals who fail to acquire language.

State notation for teaching about behavioral procedures

Complex operant procedures are not easy to describe unambiguously and several abstract notation systems have been developed for such description. Although they have not been generally adopted, such systems could be especially valuable to the teacher and student of behavior analysis, functioning like other figures and graphs as visual aids to ordinary verbal description. One of these systems, state notation, is described in some detail, and examples are provided of its use in teaching about behavior analysis.

Statistical inference for individual organism research: mixed blessing or curse?

Descriptive and inferential statistics are described as judgemental aids, stimuli to which the scientist can more easily react than to his raw experimental results. The increasing emphasis on the significance test as the main judgemental aid utilized in experimental psychology is credited with several harmful effects on experimental practice. The area known as "the experimental analysis of behavior" has so far escaped most of these harmful effects, but now we see an increased interest in the development of appropriate significance tests for individual organism research. This interest is based on the view that it is not possible to effect adequate levels of experimental control with much human applied research, and that in such cases a significance test would be quite valuable as a judgemental aid, both of which points are considered to be essentially incorrect, and if accepted, potentially harmful.

Verbal behavior

THE RECENT HISTORY AND CURRENT STATUS OF THE AREA OF VERBAL BEHAVIOR ARE CONSIDERED IN TERMS OF THREE MAJOR THEMATIC LINES: the operant conditioning of adult verbal behavior, learning to be an effective speaker and listener, and developments directly related to Skinner's Verbal Behavior. Other topics not directly related to the main themes are also considered: the work of Kurt Salzinger, ape-language research, and human operant research related to rule-governed behavior.

Economic disparity and child survival in Cambodia

Despite improvements in child survival in recent decades, levels of infant and child mortality remain unacceptably high, particularly among the poor in developing countries recovering from recent wars and civil unrests. Using information on 8498 childbirths in five years preceding the 2000 Cambodia Demographic and Health Survey, this study measured the association between economic disparity and infant mortality using multivariate Weibull regression. Results indicate that children born in the poorest 40% households were more than twice as likely to die during infancy as those born in the richest 20% households, even after controlling for pregnancy care, birth weight, household living conditions, and other factors. Children born in the middle-income households also had significantly higher mortality risks. Not receiving antenatal care and low birth weight were associated with an increased risk. Also, boys had a higher risk than girls. The study concludes that poverty is strongly negatively associated with infant survival in Cambodia.

Feet rolled over by cars: radiological and histological considerations from experiments

This study investigates the question of whether bone structures are injured when a vehicle rolls over a foot. A total of 15 detached feet from deceased persons who had donated their bodies to research were rolled over using a VW Passat station wagon. The feet were enclosed in various types of shoes. The front left tire of the vehicle, inflated to 1.8 bar and driven at walking speed, ran over the feet at a right angle to the long axis. The feet were dissected, and histological and radiological examinations were carried out. The only macroscopically well-defined abrasions of the epidermis were on the back of the foot in the area of contact with the tire and only where the foot had not been covered by a shoe. These abrasions were also well presented histologically. No injuries to the bone structures of the feet, in the form of incomplete fractures, corticalis interruptions or spongiosa compressions were ascertained, either radiologically or microradiologically.

Surface modification of titanium-based alloys with bioactive molecules using electrochemically fixed nucleic acids

A new method of surface modification for titanium (alloys) with bioactive molecules was developed with the intention of providing a new basis of implant adaptation for particular requirements of certain medical indications. Nucleic acid single strands are fixed electrochemically via their termini (regiospecifically) by growing an oxide layer on Ti6Al7Nb anodically. It could be shown that they are accessible to subsequent hybridization with complementary strands at physiological pH. Amount of nucleic acids immobilized and hybridized were determined radioanalytically using 32P-labelled nucleic acids. Stable fixation was attained at and above potentials of 4 V(SCE). Up to 4 pmol/cm2 of nucleic acid single strands could be immobilized and hybridization efficiencies up to 1.0 were reached. Hybridization efficiency was found to depend on surface density of immobilized oligonucleotides, while hybridization rates increased when MgCl2 was added. A conjugate consisting of an oligonucleotide complementary to the immobilized strand and the hexapeptide GRGDSP with RGD as an integrin recognition site was synthesized. This conjugate was able to bind to integrins on osteoblasts. It was shown that this conjugate binds to the anchor strand fixed on Ti6Al7Nb to an extent comparable with the unconjugated complementary strand.

Oral hygiene practices, periodontal conditions, dentition status and self-reported bad mouth breath among young mothers, Tanzania

OBJECTIVES

To determine the oral hygiene practices, periodontal conditions, dentition status and self-reported bad mouth breath (S-BMB) among young mothers.

STUDY PARTICIPANTS AND METHODS

This was a cross-sectional descriptive study conducted at Muhimbili National Hospital, Dar es Salaam, Tanzania. A total of 302 postpartum mothers, aged 14-44 years, were interviewed on oral hygiene practices and S-BMB using structured questionnaire. Oral hygiene, dentition and periodontal status were assessed using the Community Periodontal Index probe and gingival recessions (GR) using Williams Periodontal probe.

RESULTS

Tooth brushing practice was 99%; tongue brushing (95%), plastic toothbrush users (96%), chewing stick (1%), wooden toothpicks (76%), dental floss (<1%); and toothpaste (93%). The prevalence of plaque and gingival bleeding on probing was 100%, gum bleeding during tooth brushing (33%), calculus (99%), probing periodontal pocket depth (PPD) 4-5 mm (27%), PPD 6+ mm (3%), GR 1+ mm (27%) and tooth decay (55%). The prevalence of S-BMB was 14%; the S-BMB had higher mean number of sites with plaque compared to the no S-BMB group (P=0.04). Factors associated with S-BMB were gum bleeding on tooth brushing (OR=2.4) and PPD 6+ mm (OR=5.4).

CONCLUSION

Self-reported bad mouth breath is a cause of concern among young mothers, and associated significant factors were gum bleeding on tooth brushing and deep periodontal pockets of 6+ mm. Further research involving clinical diagnosis of bad mouth breath and intervention through oral health promotion and periodontal therapy are recommended.

CLINICAL RELEVANCE

This study provides baseline information on oral health status and the complaint on bad mouth breath which necessitates in the future need for objective assessment, diagnosis and management of bad mouth breath for enhanced social and professional interaction without embarrassment.

Magnetresonanztomographie nach Kryoablation langer Röhrenknochen im Tiermodell

PURPOSE

To describe the MR findings following cryoablation of long bones.

MATERIALS AND METHOD

Cryoablation was performed in femoral and tibial bones of 24 sheep under general anesthesia. MRI of the treated and untreated contralateral bones was performed immediately thereafter and at 2, 4 and 6 months after the cryosurgical procedure.

RESULTS

On the MRI performed immediately after cryotherapy, the lesions showed low signal intensities relative to the normal bone marrow on unenhanced T1- and T2-weighted images. At 2, 4 and 6 months after cryoablation, the lesions showed high signal intensities on STIR images, low signal intensities on T1-weighted and heterogeneous enhancement on contrast-enhanced T1-weighted MR images. The femoral lesions decreased in size from 31 +/- 3 mm immediately after the cryotherapy to 13 +/- 4 mm 6 month later and the tibial lesions from 29 +/- 7 mm to 19 +/- 4 mm.

CONCLUSION

MRI shows bone marrow lesions immediately after cryotherapy and can easily monitor healing lesions. MR imaging is suitable for following cryotherapy.

Rate of perioperative complications in thermal ablation of bone: an animal trial

INTRODUCTION

While only few data are available yet for radioablation of bone tissue, the occurrence of bone marrow embolisms during cryoablation has been documented. It was the aim of this study to assess perioperative complication rates of thermoablation in animals using state-of-the-art ablation probes.

MATERIALS AND METHODS

Eight adult sheep were placed under general anaesthesia, and using a radioprobe, thermoablation was performed on the medial side of the head of the right tibia. In addition, freezing was performed with miniature cryoprobes on both femurs and the head of the left tibia. Haemodynamic monitoring and determination of blood gases and electrolytes were done intraoperatively. The animals were killed 1 week after surgery, and the ablation sites and lung tissue examined macroscopically and microscopically.

RESULTS

None of the animals showed pathological changes in any of these parameters. Blood gases remained unremarkable throughout the operation. All eight animals showed an average drop in haemoglobin of 0.97 g/100 ml. Two animals showed fresh embolisms in the pulmonary vessels.

CONCLUSION

Experimental thermoablation of bone tissue in large animals failed to show any significant perioperative complications following surgery. The lung embolisms which did occur were not clinically relevant. The use of mini-cryoprobes or radioprobes as alternative or complementary measures for treating pathologically altered bone tissue seems viable and does not involve any undue risks.

[Changes in stability after cryosurgical treatment of long tubular bones. An animal experiment study]

The incidence of spontaneous fractures after cryosurgical treatment is described in the literature. The purpose of this study in the sheep model was to analyze the possibility of minimizing the potential risk of bone failure using a new miniature cryoprobe with minimal tissue traumatism and exact control of the ablation. In each of 24 sheep ablations at the right femur and left tibia were performed by drilling. The ablation at the femur was restricted to an area of 2 cm(2) of only one cortical bone, whereas at the proximal tibia the whole tibial plateau was included. The opposite side, which was treated with analog drillings without cryoablation, served as control. The ultimate bending strength of the femur and the ultimate compression strength of the tibia were examined 2, 4, and 6 months after the operation. After 2 months there was a significant difference ( p<0.05) in the ultimate compression strength between the treated and untreated tibiae, whereas the ultimate bending strength of the treated femora tended to be lower. After 4 and 6 months the side treated with cryosurgery was only marginally weaker than the untreated side. Spontaneous fractures were not observed during the whole experimental period. The good controllability of the freezing procedure and the low iatrogenic weakening of the bone using a modern miniature cryoprobe minimizes the risk of pathological postoperative fractures. After ablation of larger bone sections, the treated extremity should be partially unloaded or managed by osteosynthesis for at least 3 months.

Primary intestinal posttransplant T-cell lymphoma

There have been only five reported cases of primary posttransplant T-cell lymphoma. We report the first case associated with the use of sirolimus (Rapamycin, Wyeth-Ayerst, Philadelphia, PA). The patient, receiving prednisone, cyclosporine, and sirolimus treatment, developed ascites, diarrhea, and weight loss 7 months after his second renal transplant. Tissue obtained at laparotomy established the diagnosis of primary T-cell lymphoma. Latent membrane protein-1 for Epstein-Barr virus was negative, but in-site hybridization test for Epstein-Barr-encoded RNA was positive. Despite aggressive chemotherapy, the patient died 8 months posttransplant. This is the sixth reported case of primary intestinal posttransplant T-cell lymphoma, but it is the first case associated with the use of sirolimus. The incidence of posttransplant lymphoproliferative disease in patients receiving sirolimus should be studied.

[Treatment course in endoprosthetic knee replacement--a systematic insurance cost calculation exemplified by a concrete example]

In view of the planned introduction of the DRG system in Germany, this paper gives the reader a guideline on how to analyse costs and productivity of medical procedures. Total knee replacement was chosen because it is one of the standard operations in orthopedic surgery with existing special calculations for this type of operation. By using the example of a total knee replacement, productivity phases are used and their costs are estimated. With these phases the clinician is able to analyse the efficiency of his department and a benchmarking is possible. Nevertheless, we should not forget that although cost reduction in hospitals is essential the patients' health is the main aim of treatment.

[Results of shoulder isokinetic testing in volleyball players]

Isokinetic testing of the shoulder joint shows valuable indication to possible functional disorders and muscle imbalance. Concentric testing of several parameters using the Cybex 6000 practice unit was done by professional volleyball players performing external and internal rotation of the dominant and non-dominant shoulder at speeds of 60 degrees/s an 180 degrees/s. Sex-specific significant differences were shown which are comparable to other kind of sports.