Evaluating enteric methane emissions within a herd of genetically divergent grazing dairy cows

Enteric methane (CH4) emissions of 3 genetic groups (GG) of dairy cows were recorded across the grazing season (early March to late October). The 3 GG were (1) high economic breeding index (EBI) Holstein-Friesian (HF) representative of the top 1% of dairy cows in Ireland at the time of the study (elite), (2) national average (NA) EBI, which were representative of the average HF dairy cow in Ireland, and (3) purebred Jersey (JE) cows. Enteric CH4 was recorded using GreenFeed technology. Seasonal variation in CH4 was observed, with the lowest daily CH4 emissions and CH4 expressed per unit of dry matter intake occurring in spring (253 g/d and 15.56 g/kg, respectively), intermediate in summer (303 g/d and 18.26 g/kg, respectively), and greatest in autumn (324 g/d and 19.80 g/kg, respectively). Seasonal variation was also observed in the proportion of gross energy intake converted to CH4 (Ym); in the spring the Ym was lowest at 0.046, increasing to 0.053 and 0.058 in the summer and autumn, respectively. There was no difference in daily CH4 between the elite and NA, whereas JE had lower CH4 emissions compared with the elite. When expressed per unit of milk solids (fat + protein yield; MS), the elite and JE produced 6.8% and 9.7% less CH4 per kilogram of MS, respectively, compared with NA. There was no difference between the GG for CH4 per unit of DMI or the Ym. This research emphasizes the variation in CH4 emissions across the grazing season and among cows of differing genetic merit for CH4 emission intensities but not for CH4 per unit of DMI or the Ym.

Characterising sustainability certification standards in dairy production

Despite the increasing use of private certification standards to meet the demand for sustainable dairy production, research into these standards is lacking. In this paper, we characterised sustainability certification standards currently used in dairy production. A literature search for dairy sustainability initiatives revealed one hundred-and-sixteen possible standards. In total, 19 of these were determined to qualify as 'sustainability certification standards' based on our selection criteria and were available in English or Dutch language. The standards were analysed using publicly available documents of the most recent version. The analysis included three key components: (i) general characteristics of the standard (such as the geographic origin, year founded, most recent updates), (ii) a thematic coverage analysis of the sustainability themes covered in each standard and (iii) evaluation of the inherent trade-offs within each standard utilising the opposing aspects of credibility, accessibility, and continuous improvement (the 'devil's triangle'). The comparison of general characteristics of the 19 standards revealed a wide variation in the characteristics of standards such as organisation type (i.e. nongovernmental organisations, individual dairy processor or other dairy sector actors), the number of indicators included, but also in the sustainability themes they cover, and how they balance the credibility, accessibility, and continuous improvement. The environmental pillar is most frequently and comprehensively addressed, whereas the economic pillar is least frequently and least comprehensively addressed. The 'devil's triangle' trade-off analysis revealed that credibility and accessibility, from the standard's perspective, are often transparently described and assured within the documents of standards. In contrast, continuous improvement is infrequently focused upon by standards. Overall, the variability in standards may allow farmers to choose a standard that aligns with his/her conviction or stage of development but might also create consumer or farmer mistrust in standards.

Investigating Secondary Alcohol Outcomes in a Contingency Management Intervention among American Indian and Alaska Native Adults

OBJECTIVE

The aim of the study is to investigate clinically meaningful, secondary outcomes in a randomized trial of a culturally adapted contingency management (CM) intervention for alcohol use in 3 diverse American Indian and Alaska Native communities.

METHODS

Three American Indian and Alaska Native communities located in the Northern Plains, Alaska, and the Inland Northwest were partnering sites. A total of 158 individuals were randomized to either a 12-week CM intervention or a noncontingent (NC) control group. The CM group received reinforcers for providing alcohol-negative ethyl glucuronide (EtG < 150 ng/mL) urine samples, while the NC group received reinforcers unconditionally. Outcomes included EtG as a continuous measure (range, 0-2,000 ng/mL), EtG > 499 ng/mL (a measure of higher levels of recent alcohol use), longest duration of abstinence, and time-to-first alcohol-positive EtG during the trial. Generalized estimating equations along with Cox proportional hazard and negative binomial regressions were used.

RESULTS

Participants randomized to the CM group had lower mean EtG levels (-241.9 ng/mL; 95% confidence interval [CI], -379.0 to -104.8 ng/mL) and 45.7% lower odds (95% CI, 0.31 to 0.95) of providing an EtG sample indicating higher levels of alcohol use during the intervention. Longest duration of abstinence was 43% longer for the CM group than the NC group (95% CI, 1.0 to 1.9). Risk of time-to-first drink during treatment did not differ significantly.

CONCLUSIONS

These secondary outcome analyses provide evidence that CM is associated with reductions in alcohol use and longer durations of abstinence (as assessed by EtG), both clinically meaningful endpoints and analyses that differ from the primary study outcome.

Cultural Factors and Alcohol Use in American Indian Adults: Results From a Culturally Tailored Contingency Management Intervention

OBJECTIVE

American Indian and Alaska Native (AI/AN) populations experience greater health disparities in alcohol use outcomes compared with the general population. This secondary data analysis examines cultural factors related to alcohol use in reservation-based American Indian (AI) adults (N = 65; 41 males; mean age = 36.7 years) in a randomized controlled trial of a culturally tailored contingency management (CM) program. It was hypothesized that individuals with higher rates of cultural protective factors would have lower rates of alcohol use, whereas individuals with higher rates of risk factors would have higher rates of alcohol use. It was also hypothesized that enculturation would moderate the relationship between treatment group and alcohol use.

METHOD

Generalized linear mixed modeling was used to calculate odds ratios (ORs) for the repeated measure, biweekly urine tests of the biomarker, ethyl glucuronide (EtG), across 12 weeks. The relationships between alcohol use (abstinence [EtG < 150 ng/ml]) or heavy drinking [EtG > 500 ng/ml]) and culturally relevant protective (enculturation, years lived on the reservation) and risk factors (discrimination, historical loss, historical loss symptoms) were examined.

RESULTS

There was a negative association between enculturation and probability of submitting a heavy drinking urine sample (OR = 0.973; 95% CI [0.950, 0.996], p = .023), indicating that enculturation may serve as a protective factor against heavy drinking.

CONCLUSIONS

Cultural factors (e.g., enculturation) may be important constructs to assess and incorporate into treatment planning with AI adults engaged in alcohol treatment.

Centering culture in the treatment of opioid use disorder with American Indian and Alaska Native Communities: Contributions from a National Collaborative Board

American Indian/Alaska Native (AI/AN) communities are disproportionally impacted by the opioid overdose epidemic. There remains a dearth of research evaluating methods for effectively implementing treatments for opioid use disorder (OUD) within these communities. We describe proceedings from a 2-day Collaborative Board (CB) meeting tasked with developing an implementation intervention for AI/AN clinical programs to improve the delivery of medications to treat OUD (MOUD). The CB was comprised of Elders, cultural leaders, providers, individuals with lived experience with OUD, and researchers from over 25 communities, organizations, and academic institutions. Conversations were audio-recorded, transcribed, and coded by two academic researchers with interpretation oversight provided by the CB. These proceedings provided a foundation for ongoing CB work and a frame for developing the program-level implementation intervention using a strength-based and holistic model of OUD recovery and wellbeing. Topics of discussion posed to the CB included engagement and recovery strategies, integration of extended family traditions, and addressing stigma and building trust with providers and clients. Integration of traditional healing practices, ceremonies, and other cultural practices was recommended. The importance of centering AI/AN culture and involving family were highlighted as priorities for the intervention.

1030 Did the COVID-19 Pandemic Impact on Medical Students Knowledge of Plastic Surgery Emergencies?

Aim

The aim of this study was to look at the teaching and knowledge of plastic surgery emergencies and referral criteria in medical students from 3rd to 5th year.

Method

400 students were sent a survey via email and invited to participate 278 replied (69.7%). Students were asked 20 questions including demographics, if they were interested in surgery/ED, if they had teaching in B+P and what type, if there was clinical exposure, how to classify TBSA and factors deciding considered in classifying the burn, if they were confident to treat a burn, when to make a referral and burn mechanisms, common complications of burns, what is a flap and types and how to assess, what a plastic surgeon does.

Results

58% (161) declared an interest in surgery or ED, 32% (88) had teaching in B+P with 63% (252) attending a lecture and 5% (13) a formal Placement, others were adhoc and 21% (59) had clinical exposure. 74% (205) identified depth as important, 42% (117) TBSA. 58% (161) could not classify TBSA, 97% (271) did not feel confident treating a burn + only 8% (32) knowing when to refer although most could identify mechanisms. 92% (368) knew infection was a complication but only 1 knew why smoking was contraindicated. 1 student knew what a flap was with non able to classify or assess. few could identify what B+P do.

Conclusions

There is a lack of consistent undergraduate education on plastic emergencies and knowledge, perhaps resulting from less experience from cancelled placement.

972 Communication During the Pandemic

Aim

Since the COVID-19 pandemic facemasks have become compulsory in UK hospitals impacting on the visual and vocal (93%) aspects of communication. This QIP looks at the difference a clear mask made to patients.

Method

Clearmask^TM was used in place of a surgical mask and patients were asked to rate the difference on a likert scale. 100 patients were seen at two appointments, once with a Clearmask and another with a surgical mask. Dragon voice recognition software was used as a control.

Results

95% of patients rated communication better with the clearmask, Patients felt more engaged and were more likely to engage with the clinician. The effect was amplified when English was not the first language.

Conclusions

Clear facemasks improved communication and allow patients to become more engaged in consults and are more likely to allow information to be divulged to a clinician.

Validation of a sheep maternal and terminal breeding objectives using Irish field data

Genetic evaluations provide producers with a tool to aid in breeding decisions and highlight the increase in performance achievable at the farm level through genetic gain. Despite this, large-scale validation of sheep breeding objectives using field data is lacking in the scientific literature. The objective of the present study was to evaluate the phenotypic differences for a range of economically important traits for animals divergent in genetic merit for the Irish national maternal and terminal sheep breeding objectives. A dataset of 17,356 crossbred ewes and 54,322 progeny differing in their maternal and terminal breeding index recorded in 139 commercial flocks was available. The association of the maternal index of the ewe or terminal index of the ram and a range of phenotypic performance traits, including lambing, lamb performance, ewe performance, and health traits, were undertaken. Ewes excelling on the maternal index had higher litter sizes and produced progeny with greater perinatal lamb survival, heavier live weights from birth to postweaning and reduced days to slaughter (P < 0.05). Ewe maternal index had no quantifiable impact on lambing ease, carcass conformation, or fat, the health status of the ewe or lamb, ewe barren rate, or ewe live weight. Lambs born to rams of superior terminal index produced heavier lambs from preweaning onwards, with a reduced day to slaughter (P < 0.05). Lambing traits, lamb health, and carcass characteristics of the progeny did not differ between sires stratified as low or high on the terminal index (P > 0.05). Results from this study highlight that selecting either ewes or rams of superior maternal or terminal attributes will result in an improvement on pertinent performance traits of the national sheep flock, resulting in greater flock productivity and profitability.

Epidemiological trends in opioid-only and opioid/polysubstance-related death rates among American Indian/Alaska Native populations from 1999 to 2019: a retrospective longitudinal ecological study

OBJECTIVES

The rate of drug overdose deaths in the USA has more than tripled since the turn of the century, and rates are disproportionately high among the American Indian/Alaska Native (AI/AN) population. Little is known about the overall historical trends in AI/AN opioid-only and opioid/polysubstance-related mortality. This study will address this gap.

DESIGN

This is a retrospective longitudinal ecological study.

SETTING

US death records from 1999 to 2019 using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research.

PARTICIPANTS

US non-Hispanic AI/AN people age 12 years and older.

MEASURES

The primary outcomes, identified via the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes, included overdose deaths due to (1) opioids only, opioids in combination with any other substance, all-opioid related overdoses; (2) combinations of opioids and alcohol, opioids and methamphetamine, opioids and cocaine, opioids and benzodiazepines; and (3) specific types of opioids.

RESULTS

From 1999 to 2019, opioid-only mortality rates increased from 2.8 to 15.8 per 100 000 (p<0.001) for AI/AN women and 4.6 to 25.6 per 100 000 (p<0.001) for AI/AN men. All opioid-related mortality rates increased significantly (p<0.001) from 5.2 to 33.9 per 100 000 AI/AN persons, 3.9 to 26.1 for women and 6.5 to 42.1 for men. AI/AN also exhibited significant increases in mortality rates due to opioids and alcohol, opioids and benzodiazepines, opioids and methamphetamine, and AI/AN men experienced substantial increases in mortality due to opioids and cocaine. Mortality rates by individual opioid types increased significantly over time for heroin, natural and semi-synthetic (prescription), and synthetic opioids (fentanyl/fentanyl analogues) other than methadone.

CONCLUSIONS

These findings highlight magnification over time in opioid-related deaths and may point to broader systemic factors that may disproportionately affect members of AI/AN communities and drive inequities.

1340 Is Displaying Mandated Information in Clinic Harming Patient and Society?

Aim

The CQC has mandated certain pieces of information are displayed in a clinic and the staff know where to find them. This is in addition to the mandatory training that staff members undergo with increasing repetition. The UK Armed Forces is no exception to this, in addition wall space is often used as opportunistic education for patients.

Method

We counted the number of posters that were displayed in a CQC good, rated clinic, worked out the average cost to produce, produced a questionnaire of staff and patients to see how many times people engaged with the information and the carbon footprint of compliance. We looked timed how long it took for someone new to the clinic to spot the lifesaving information.

Results

140 items of literature took on average 65 minutes ±240 to produce, with an average of 9 pages per item ±190. Average cost was 10 pence per page when lamination was included, totalling £126. At 6000kg CO2/paper page and 1500kg CO2/laminate page, the total carbon footprint was 9,450,000 Kg CO2. Staff members engaged zero times with the literature and only one patient engaged. The time to spot the critical information in a clean room was 0.8 second, in a normal clinic room was 4.3 seconds.

Conclusions

Distractions can be detrimental in emergency situations and with human factors interplay this can cost people their lives. A 3.5 second delay may seem inconsequential but compounded could be devastating. The cost and Carbon footprint is extraordinary for little benefit.

1352 BMJ Military Health Webinar Series – Continued Professional Development for Medics and General Duties Medical Officers

Aim

The UK DMS delivers military CPD at a local level. Medics are taught at the regimental level and GDMO’s can vary from local teaching, regimental teaching, or no teaching. GDMO’s are GMC mandated to have CPD covering all areas of practice. Due to the nature of the deployable role of both staff groups it is difficult to deliver consistent teaching that can be revisited. We aimed to deliver regular, consistent, high-quality teaching delivered by SMEs on military relevant topics.

Method

A Plan, Do, Study, Act approach was used with predefined measures such as structure, process and outcome elicited via a participant survey. Virtual teaching via MOD Zoom monthly for each group was arranged. Teaching focused on medic portfolio competencies, the GDMO syllabus. Teaching was delivered by tri-service SMEs, the sessions were recorded and edited and subsequently uploaded to the BMJ Military Health website at no cost.

Results

16 webinars, 8 to Medics and 8 to GDMOs have been delivered. Maximum attendance has been 130 tri-service participants including reservists. Feedback from 111 SP been positive with 65% and 28% of participants rating the teaching as excellent or very good respectively. 98% stated the teaching is relevant to their practice, and 89% agreed the teaching will change their practice going forward.

Conclusions

We have demonstrated that it is possible to deliver sustainable high quality, relevant, and practice changing sessions across all three services. This teaching has had active engagement from the user community and senior SMEs within the DMS for minimal cost.

Assessing the Predictive Validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) in Alaska Native and American Indian People

OBJECTIVES

The objective of this study was to examine the predictive validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) among Alaska Native and American Indian (ANAI) people with an alcohol use disorder.

METHODS

The sample was 170 ANAI adults with an alcohol use disorder living in Anchorage, Alaska who were part of a larger alcohol intervention study. The primary outcome of this study was alcohol use as measured by mean urinary ethyl glucuronide (EtG). EtG urine tests were collected at baseline and then up to twice a week for four weeks. We conducted bivariate linear regression analyses to evaluate associations between mean EtG value and each of the three SOCRATES subscales (Recognition, Ambivalence, and Taking Steps) and other covariates such as demographic characteristics, alcohol use history, and chemical dependency service utilization. We then performed multivariable linear regression modeling to examine these associations after adjusting for covariates.

RESULTS

After adjusting for covariates, mean EtG values were negatively associated with the Taking Steps (P = 0.017) and Recognition (P = 0.005) subscales of the SOCRATES among ANAI people living in Alaska. We did not find an association between mean EtG values and the Ambivalence subscale (P = 0.129) of the SOCRATES after adjusting for covariates.

CONCLUSIONS

Higher scores on the Taking Steps and Recognition subscales of the SOCRATES at baseline among ANAI people predicted lower mean EtG values. This study has important implications for communities and clinicians who need tools to assist ANAI clients in initiating behavior changes related to alcohol use.

Life cycle assessment of pasture-based suckler steer weanling-to-beef production systems: Effect of breed and slaughter age

Demand for beef produced from pasture-based diets is rising as it is perceived to be healthier, animal friendly and good for the environment. Animals reared on a solely grass forage diet, however, have a lower growth rate than cereal-fed animals and consequently are slaughtered at an older age. This study focused on the former by conducting life cycle assessments of beef production systems offering only fresh or conserved grass, and comparing them to a conventional pasture-based beef production system offering concentrate feeding during housing. The four suckler weanling-to-beef production systems simulated were: (i) Steers produced to slaughter entirely on a grass forage diet at 20 months (GO-20); (ii) Steers produced to slaughter entirely on a grass forage diet at 24 months (GO-24); (iii) Steers produced to slaughter on a grass forage diet with concentrate supplementation during housing (GC-24), and (iv) Steers produced to slaughter entirely on a grass forage diet at 28 months (GO-28). Two breed types were evaluated: early-maturing and late-maturing (LM). The environmental impacts assessed were global warming potential (GWP), non-renewable energy (NRE), acidification potential (AP), eutrophication potential (marine (MEP) and freshwater) were expressed per animal, per kg live weight gain (LWG), kg carcass weight gain, and kg meat weight gain (MWG). The GO-20 production system had the lowest environmental impact across all categories and functional units for both breeds. Extending age at slaughter increased environmental impact across all categories per animal. The LWG response of EM steers to concentrate feed supplementation in GC-24 was greater than the increase in total environmental impact resulting in GC-24 having a lower environmental impact across categories per kg product than GO-24. Concentrate feed supplementation had a similar effect on LM steers with the exception of NRE and AP. The increase in daily LWG in the third grazing season in comparison to the second grazing and housing resulted in GO-28 having lower GWP, NRE, AP, and MEP per kg product than GO-24. Early-maturing steers had lower environmental impact than LM when expressed per kg LWG. However the opposite occurred when impacts were expressed per kg MWG, despite LM steers producing the least LWG. The LM steers compensated for poor LWG performance by having superior carcass traits, which caused the breed to have the lowest environmental impact per kg MWG. The results reaffirms the importance of functional unit and suggests reducing the environmental impact of LWG does not always translate into improvements in the environmental performance of meat.

Effect of Incentives for Alcohol Abstinence in Partnership With 3 American Indian and Alaska Native Communities: A Randomized Clinical Trial

Importance

Many American Indian and Alaska Native communities are disproportionately affected by problems with alcohol use and seek culturally appropriate and effective interventions for individuals with alcohol use disorders.

Objective

To determine whether a culturally tailored contingency management intervention, in which incentives were offered for biologically verified alcohol abstinence, resulted in increased abstinence among American Indian and Alaska Native adults. This study hypothesized that adults assigned to receive a contingency management intervention would have higher levels of alcohol abstinence than those assigned to the control condition.

Design, Setting, and Participants

This multisite randomized clinical trial, the Helping Our Native Ongoing Recovery (HONOR) study, included a 1-month observation period before randomization and a 3-month intervention period. The study was conducted at 3 American Indian and Alaska Native health care organizations located in Alaska, the Pacific Northwest, and the Northern Plains from October 10, 2014, to September 2, 2019. Recruitment occurred between October 10, 2014, and February 20, 2019. Eligible participants were American Indian or Alaska Native adults who had 1 or more days of high alcohol-use episodes within the last 30 days and a current diagnosis of alcohol dependence. Data were analyzed from February 1 to April 29, 2020.

Interventions

Participants received treatment as usual and were randomized to either the contingency management group, in which individuals received 12 weeks of incentives for submitting a urine sample indicating alcohol abstinence, or the control group, in which individuals received 12 weeks of incentives for submitting a urine sample without the requirement of alcohol abstinence. Regression models fit with generalized estimating equations were used to assess differences in abstinence during the intervention period.

Main Outcomes and Measures

Alcohol-negative ethyl glucuronide (EtG) urine test result (defined as EtG<150 ng/mL).

Results

Among 1003 adults screened for eligibility, 400 individuals met the initial criteria. Of those, 158 individuals (39.5%; mean [SD] age, 42.1 [11.4] years; 83 men [52.5%]) met the criteria for randomization, which required submission of 4 or more urine samples and 1 alcohol-positive urine test result during the observation period before randomization. A total of 75 participants (47.5%) were randomized to the contingency management group, and 83 participants (52.5%) were randomized to the control group. At 16 weeks, the number who submitted an alcohol-negative urine sample was 19 (59.4%) in the intervention group vs 18 (38.3%) in the control group. Participants randomized to the contingency management group had a higher likelihood of submitting an alcohol-negative urine sample (averaged over time) compared with those randomized to the control group (odds ratio, 1.70; 95% CI, 1.05-2.76; P = .03).

Conclusions and Relevance

The study's findings indicate that contingency management may be an effective strategy for increasing alcohol abstinence and a tool that can be used by American Indian and Alaska Native communities for the treatment of individuals with alcohol use disorders.

Trial Registration

ClinicalTrials.gov Identifier: NCT02174315.

Greenhouse gas emissions and nitrogen efficiency of dairy cows of divergent economic breeding index under seasonal pasture-based management

Greenhouse gas (GHG) emissions and nitrogen (N) efficiencies were modeled for 2 genetic groups (GG) of Holstein-Friesian cows across 3 contrasting feeding treatments (FT). The 2 GG were (1) high economic breeding index (EBI) animals representative of the top 5% of cows nationally (elite) and (2) EBI representative of the national average (NA). The FT represented (1) generous feeding of pasture, (2) a slight restriction in pasture allowance, and (3) a high-concentrate feeding system with adequate pasture allowance. Greenhouse gas and N balance models were parameterized using outputs generated from the Moorepark Dairy Systems model, a stochastic budgetary simulation model, having integrated biological data pertaining to the 6 scenarios (2 GG × 3 FT) obtained from a 4-yr experiment conducted between 2013 and 2016. On a per hectare basis, total system GHG emissions were similar for both elite and NA across the 3 FT. Per unit of product, however, the elite group had 10% and 11% lower GHG emissions per kilogram of fat- and protein-corrected milk and per kilogram of milk solids (MSO; fat + protein kg), respectively, compared with the NA across the 3 FT. The FT incorporating high concentrate supplementation had greater absolute GHG emissions per hectare as well as GHG per kilogram of fat- and protein-corrected milk and MSO. The elite group had a slightly superior N use efficiency (N output/N input) and lower N surplus (N input - N output) compared with the NA group. The high concentrate FT had an inferior N use efficiency and a higher N surplus. The results of the current study demonstrate that breeding for increased EBI will lead to a general improvement in GHG emissions per unit of product as well as improved N efficiency. The results also illustrate that reducing concentrate supplementation will reduce GHG emissions, GHG emissions intensity, while improving N efficiency in the context of pasture-based dairy production.

Trends in Non-Medical Prescription Opioid Use among Urban and Rural American Indian and Alaska Native Youth Residing in New Mexico: 2013-2017

Increasing rates of opioid-related deaths over the last twenty years have created a national public health crisis. However, minimal research investigates opioid use among American Indian and Alaska Native (AI/AN) youth. This study examined non-medical prescription opioid prevalence rates and resiliency of urban and rural AI/AN and non-AI/AN students. The sample included eighth, tenth, and twelfth grade students who participated in the New Mexico Youth Risk and Resilience Survey in 2013, 2015, and 2017 (n = 42,098). Logistic regression models showed no significant differences in non-medical prescription opioid use among rural and urban students in 2013, 2015, and 2017. No significant differences in use between AI/AN and non-AI/AN students occurred in 2013, 2015, or 2017. Family and community support were protective of misuse consistent across time points, and included caring adults, community involvement, and clear rules at school. These findings may help to inform the development of strengths-based prevention activities for AI/AN youth.

The Validity of the Short Inventory of Problems and Drinking Intensity among Urban American Indian Adults

BACKGROUND

American Indian (AI) adults have both high prevalence rates of alcohol abstinence and alcohol use disorders compared to non-Hispanic White adults. We investigated the applicability and validity of the Short Inventory of Problems (SIP) among AI urban adults and the moderating effect of biological sex.

METHODS

AI adults from three Alcoholics Anonymous samples (n = 124) provided baseline, 3-, 6- and 9-month data. Measures included Form 90 and the SIP, which includes 5 domains of alcohol-related negative consequences including interpersonal, intrapersonal, physical, impulse control and social. Drinking frequency and intensity were assessed by percent days abstinent (PDA) and drinks per drinking day (DPDD).

RESULTS

Cronbach alphas of the SIP were similar between urban AI adults and the mainstream treatment-seeking population reported in the SIP manual. DPDD was a significant and positive predictor of all five SIP scales collected 9-months later. Higher PDA was significantly and negatively associated with later consequences, and all 5 SIP scales. Moderation tests indicated that the association between consequences and drinking intensity was stronger for AI females with fewer drinking days resulting in significantly fewer consequences for AI males relative to AI females.

CONCLUSIONS

Findings highlight the acceptability of SIP as a measure to assess drinking related consequences among AI urban adults, with clinical implications related to alcohol use and sex. Further research is warranted to examine differential drinking related outcomes among AI men and women in addition to adaptations of the SIP that more fully capture the range of negative drinking consequences.

The rewarding recovery study: a randomized controlled trial of incentives for alcohol and drug abstinence with a rural American Indian community

AIMS

To test if contingency management (CM) interventions for alcohol and drug abstinence were associated with increased alcohol and drug abstinence among American Indian adults with alcohol dependence who also use drugs.

DESIGN

In this 2 × 2 factorial randomized controlled trial, American Indian adults with alcohol dependence who also used drugs were randomized to four conditions: (1) incentives for submission of urine samples only (control condition), (2) CM incentives for alcohol abstinence, (3) CM incentives for drug abstinence or (4) CM incentives for abstinence from both alcohol and drugs.

SETTING

A Northern Plains Reservation in the United States.

PARTICIPANTS

A total of 114 American Indian adults aged 35.8 years (standard deviation = 10.4); 49.1% were male.

INTERVENTION AND COMPARATOR

Participants received incentives if they demonstrated abstinence from alcohol (CM for alcohol, n = 30), abstinence from their most frequently used drug (CM for drugs, n = 27) or abstinence from both alcohol and their most frequently used drug (CM for alcohol and drugs, n = 32) as assessed by urine tests. Controls (n = 25) received incentives for submitting urine samples only.

MEASUREMENTS

Primary outcomes were urine ethyl glucuronide (alcohol) and drug tests conducted three times per week during the 12-week intervention period. Data analyses included listwise deletion and multiple imputation to account for missing data.

FINDINGS

The three CM groups were significantly (P < 0.05) more likely to submit alcohol-abstinent urine samples compared with the control condition, with odds ratios ranging from 2.4 to 4.8. The CM for drugs (OR = 3.2) and CM for alcohol and drugs (OR = 2.5) were significantly more likely to submit urine samples that indicated drug abstinence, relative to the control condition (P < 0.05). However, these differences were not significant in multiple imputation analyses (P > 0.05).

CONCLUSIONS

Contingency management (CM) incentives for abstinence were associated with increased alcohol abstinence in American Indian adults diagnosed with alcohol dependence who also used drugs, living on a rural reservation. The effect of CM incentives on drug abstinence was inconclusive.

Aligning three substance use disorder interventions among a tribe in the Southwest United States: Pilot feasibility for cultural re-centering, dissemination, and implementation

In this article we describe cultural re-centering, dissemination, and implementation activities in partnership between an American Indian reservation community and a university in the Southwest United States. We offer examples of cultural adaptation and implementation of evidence-based treatments (e.g., Motivational Interviewing, Community Reinforcement Approach and the Community Reinforcement and Family Training) using the Interactive Systems Framework. Facilitators and barriers are described within each study including recruitment strategies, training, and sustainability of counselors in the community. Through this Tribal-university partnership, we offer insight on the cultural adaptation and implementation process that will be translatable and clinically meaningful to other rural and reservation communities.

Assessing the Interest and Cultural Congruence of Contingency Management as an Intervention for Alcohol Misuse Among Younger American Indian Adults

A qualitative study was conducted to assess interest in contingency management (CM) for younger American Indian (AI) adults (18-29 years old), how to culturally and developmentally adapt CM for younger AI adults, and interest in CM relative to culturally grounded treatment approaches. We conducted a total of four focus groups with younger adults and families in two AI communities: a rural reservation and an urban Indian health clinic (n = 32). Four overarching themes emerged suggesting that offering prizes, cultural activities, and activities that capture the attention of younger adults integrated into the CM intervention is ideal for enhancing engagement.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Systematic review and meta-analysis: Efficacy of patented probiotic, VSL#3, in irritable bowel syndrome

BACKGROUND

VSL#3 is a patented probiotic for which several clinical trials suggest benefits on motor function, bloating, and symptoms of irritable bowel syndrome (IBS).

OBJECTIVES

To quantify effects of VSL#3 on abdominal pain, stool consistency, overall response, abdominal bloating, and quality of life (QOL) in IBS through meta-analysis.

METHODS

MEDLINE (OvidSP and PubMed), EMBASE, Web of Science, and Scopus were searched up to May 2017. Using a fixed effects model, we pooled data from intention-to-treat analyses of randomized trials (RCTs) comparing VSL#3 to placebo in IBS. Data were reported as relative risk (RR), overall mean difference (MD), or standardized MD (SMD) with 95% confidence intervals (CI). Quality of evidence was rated using the GRADE approach.

KEY RESULTS

Among 236 citations, 5 RCTs (243 patients) were included. No significant differences were observed for abdominal pain (SMD = -0.03; 95% CI -0.29 to 0.22), bloating (SMD = -0.15; 95% CI -0.40 to 0.11), proportion of bowel movements with normal consistency (overall MD = 0; 95% CI -0.09 to 0.08), or IBS-QOL (SMD = 0.08; 95% CI -0.22 to 0.39). VSL#3 was associated with a nearly statistically significant increase in overall response (RR = 1.39; 95% CI 0.99-1.98).

CONCLUSIONS & INFERENCES

In this systematic review and meta-analysis, there was a trend toward improvement in overall response with VSL#3, but no clear evidence effectiveness for IBS. However, the number and sample sizes of the trials are small and the overall quality of evidence for 3 of the 5 outcomes was low. Larger trials evaluating validated endpoints in well-defined IBS patients are warranted.

A review of contingency management for the treatment of substance-use disorders: adaptation for underserved populations, use of experimental technologies, and personalized optimization strategies

This review of contingency management (CM; the behavior-modification method of providing reinforcement in exchange for objective evidence of a desired behavior) for the treatment of substance-use disorders (SUDs) begins by describing the origins of CM and how it has come to be most commonly used during the treatment of SUDs. Our core objective is to review, describe, and discuss three ongoing critical advancements in CM. We review key emerging areas wherein CM will likely have an impact. In total, we qualitatively reviewed 31 studies in a systematic fashion after searching PubMed and Google Scholar. We then describe and highlight CM investigations across three broad themes: adapting CM for underserved populations, CM with experimental technologies, and optimizing CM for personalized interventions. Technological innovations that allow for mobile delivery of reinforcers in exchange for objective evidence of a desired behavior will likely expand the possible applications of CM throughout the SUD-treatment domain and into therapeutically related areas (eg, serious mental illness). When this mobile technology is coupled with new, easy-to-utilize biomarkers, the adaptation for individual goal setting and delivery of CM-based SUD treatment in hard-to-reach places (eg, rural locations) can have a sustained impact on communities most affected by these disorders. In conclusion, there is still much to be done, not only technologically but also in convincing policy makers to adopt this well-established, cost-effective, and evidence-based method of behavior modification.

Focus groups to increase the cultural acceptability of a contingency management intervention for American Indian and Alaska Native Communities

INTRODUCTION

Many American Indian and Alaska Native (AI/AN) people seek evidence-based, cost-effective, and culturally acceptable solutions for treating alcohol use disorders. Contingency management (CM) is a feasible, low-cost approach to treating alcohol use disorders that uses "reinforcers" to promote and support alcohol abstinence. CM has not been evaluated among AI/AN communities. This study explored the cultural acceptability of CM and adapted it for use in diverse AI/AN communities.

METHODS

We conducted a total of nine focus groups in three AI/AN communities: a rural reservation, an urban health clinic, and a large Alaska Native healthcare system. Respondents included adults in recovery, adults with current drinking problems, service providers, and other interested community members (n = 61). Focus group questions centered on the cultural appropriateness of "reinforcers" used to incentivize abstinence and the cultural acceptability of the intervention. Focus groups were audio-recorded, transcribed, and coded independently by two study team members using both a priori and emergent codes. We then analyzed coded data.

RESULTS

Across all three locations, focus group participants described the importance of providing both culturally specific (e.g., bead work and cultural art work supplies), as well as practical (e.g., gas cards and bus passes) reinforcers. Focus group participants underscored the importance of providing reinforcers for the children and family of intervention participants to assist with reengaging with family and rebuilding trust that may have been damaged during alcohol use. Respondents indicated that they believed CM was in alignment with AI/AN cultural values. There was consensus that Elders or a well-respected community member implementing this intervention would enhance participation. Focus group participants emphasized use of the local AI/AN language, in addition to the inclusion of appropriate cultural symbols and imagery in the delivery of the intervention.

CONCLUSIONS

A CM intervention for alcohol use disorders should be in alignment with existing cultural and community practices such as alcohol abstinence, is more likely to be successful when Elders and community leaders are champions of the intervention, the intervention is compatible with counseling or treatment methodologies, and the intervention provides rewards that are both culturally specific and practical.

Using a randomized controlled trial to test whether modifications to contingency management improve outcomes for heavy drinkers with serious mental illness

BACKGROUND

In contingency management (CM), individuals receive rewards for alcohol abstinence. CM is associated with reduced alcohol use in adults with co-occurring serious mental illnesses (SMI). Pre-treatment urine ethyl glucuronide (uEtG) levels equivalent to daily heavy drinking (uEtG >349ng/mL) are associated with poor response to CM. Modifications to CM are needed to improve outcomes for non-responders.

AIMS

To determine if pre-treatment heavy drinkers, defined by uEtG, with SMI achieve higher levels of alcohol abstinence when they receive an increased magnitude of reinforcement for abstinence (High-Magnitude CM) or reinforcers for reduced drinking, prior to receiving reinforcers for abstinence (Shaping CM), relative to those who receive typical low-magnitude abstinence based CM (Usual CM). Additionally, variables in the Addictions Neuroclinical Assessment model will be examined as treatment response moderators.

METHODS

Participants (N=400) will be recruited from two urban mental health organizations and complete a 4-week induction period where they will be reinforced for submitting samples for uEtG testing. Participants who attain a mean uEtG >349mg/mL will be randomized to receive either Usual CM, High-Magnitude CM, or Shaping CM for 16weeks. Differences in abstinence, assessed by uEtG, will be examined during treatment and during a 12-month follow-up. Measures of negative emotionality, alcohol reinforcer salience, and executive functioning will be gathered at study intake and used to predict treatment outcomes.

DISCUSSION

This novel approach to CM will use an alcohol biomarker to identify those at risk for treatment non-response and determine if adaptations to CM might improve outcomes for this group.

The impact of age on major orthopaedic trauma: an analysis of the United Kingdom Trauma Audit Research Network database

AIMS

To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries.

PATIENTS AND METHODS

The Trauma Audit Research Network database was reviewed to identify eligible patients admitted between April 2012 and June 2015. Distribution and severity of injury, interventions, comorbidity, critical care episodes and mortality were recorded. The population was divided into young (64 years or younger) and older (65 years and older) patients.

RESULTS

Of 142 765 adults sustaining major trauma, 72 942 (51.09 %) had long bone or pelvic fractures and 45.81% of these were > 65 years old. Road traffic collision was the most common mechanism in the young (40.4%) and, in older people, fall from standing height (80.4%) predominated. The 30 day mortality in older patients with fractures is greater (6.8% versus 2.5%), although critical care episodes are more common in the young (18.2% versus 9.7%). Older people are less likely to be admitted to critical care beds and are often managed in isolation by surgeons. Orthopaedic surgery is the most common admitting and operating specialty and, in older people, fracture surgery accounted for 82.1% of procedures.

CONCLUSION

Orthopaedic trauma in older people is associated with mortality that is significantly greater than for similar fractures in the young. As with the hip fracture population, major trauma in the elderly is a growing concern which highlights the need for a review of admission pathways and shared orthogeriatric care models. Cite this article: Bone Joint J 2017;99-B:1677-80.

Trends in the on-call workload of radiologists

AIM

To evaluate the radiologist on-call clinical workload of an inner-city acute teaching hospital.

MATERIALS AND METHODS

Data were collected prospectively from a 9-week assessment of the workload of the radiologists on-call at our Trust. Data collection was undertaken using a questionnaire-based survey detailing the date and time of request, and where appropriate, the imaging examination performed. The referring clinician's grade and speciality were also recorded. The results obtained were compared with a similar study carried out in 1996.

RESULTS

A total of 160 requests for out-of-hours imaging were received over the 9-week period.

CONCLUSIONS

The figures indicate that on-call work is increasing with an approximate doubling of out-of-hours requests compared with the survey performed 7 years earlier.

Attitudes toward suicide prevention in front-line health staff

A questionnaire assessing attitudes toward suicide prevention was constructed and shown to have satisfactory reliability and internal consistency. The determinants and distribution of these attitudes were investigated in four groups of health professionals who are in contact with suicidal patients: general practitioners, accident and emergency nurses, psychiatrists in training, and community psychiatric nurses. Attitudes toward suicide prevention were shown to differ significantly between professional groups. More positive attitudes were associated with mental health professionals, working in the community, and previous training in suicide risk assessment. Negative attitudes should be assessed and targeted in training designed to improve the management of suicide risk.

Adverse outcomes in a controlled trial of pergolide for cocaine dependence

We conducted a double-blind, multiple dose comparison study of pergolide versus placebo for the treatment of cocaine dependence. In the present study, we examined patients who met criteria for cocaine dependence without comorbid alcohol dependence (N = 255). Study completion rates favored placebo (48.9%) over the low dose (33.3%) and high dose (21.5%) pergolide subjects (chi2(2) = 14.17, p < or = 0.001). Treatment effectiveness scores (TES) were significantly higher for the placebo group (31.7) than the low dose (25.2) and high dose (14.2) pergolide groups (F2,252 = 6.21, p = 0.002). There were no significant differences in side effect profiles after first dose of pergolide or placebo, or at study termination. Results of this study suggest that pergolide was not efficacious in the treatment of cocaine dependence due to reduced study participation. Caution regarding the outpatient use of pergolide in similar populations is warranted.

A study of novel polymorphisms in the upstream region of vasoactive intestinal peptide receptor type 2 gene in autism

We investigated the vasoactive intestinal peptide receptor type 2 (VIPR2) gene as a candidate gene for autism. We searched for mutations in the VIPR2 gene in autistic individuals, and 10 novel polymorphisms were identified. Three polymorphisms in the upstream region were studied in detail, and there was no significant difference in the frequencies between the autistic group (n = 14) and unrelated controls (n = 52). The distribution of the genotypes in two of the three polymorphisms differed somewhat between autistic subjects with gastrointestinal problems and those without. Moreover, there was a trend showing a correlation between the genotypes for the third polymorphism and the severity of stereotypical behavior as ranked by the Gilliam Autism Rating Scale. These preliminary results suggest that VIPR2 may have a role in gastrointestinal symptoms and stereotypical behaviors in autism, although a larger collection of samples suitable for transmission disequilibrium tests is necessary to validate the results.

A double-blind, placebo-controlled outpatient trial of pergolide for cocaine dependence

Results of preclinical studies suggest that pergolide, a mixed D(1)/D(2) dopamine receptor agonist, may be useful in treating cocaine dependence. To empirically investigate this possibility, we conducted a 5-year, double-blind, placebo-controlled clinical trial of two doses of pergolide (0.05 and 0.25 mg bid) in subjects with cocaine dependence and combined cocaine/alcohol dependence. Data analysis was performed on an intent to treat population (N=358) and a per protocol population (N=108) with urine drug screens (UDS) used as the main outcome measure. There were no significant effects on UDS at either pergolide dose. Pergolide had no significant effect on alcohol use in the comorbid alcohol/cocaine dependence group. Pergolide does not appear to have clinical value in the treatment of cocaine dependence or in decreasing alcohol use in cocaine-dependent individuals at the presently studied doses.

Voltage-gated K(+)-channel activity in ovine pulmonary vasculature is developmentally regulated

To examine mechanisms underlying developmental changes in pulmonary vascular tone, we tested the hypotheses that 1) maturation-related changes in the ability of the pulmonary vasculature to respond to hypoxia are intrinsic to the pulmonary artery (PA) smooth muscle cells (SMCs); 2) voltage-gated K(+) (K(v))-channel activity increases with maturation; and 3) O(2)-sensitive Kv2.1 channel expression and message increase with maturation. To confirm that maturational differences are intrinsic to PASMCs, we used fluorescence microscopy to study the effect of acute hypoxia on cytosolic Ca(2+) concentration ([Ca(2+)](i)) in SMCs isolated from adult and fetal PAs. Although PASMCs from both fetal and adult circulations were able to sense an acute decrease in O(2) tension, acute hypoxia induced a more rapid and greater change in [Ca(2+)](i) in magnitude in PASMCs from adult compared with fetal PAs. To determine developmental changes in K(v)-channel activity, the effects of the K(+)-channel antagonist 4-aminopyridine (4-AP) were studied on fetal and adult PASMC [Ca(2+)](i). 4-AP (1 mM) caused PASMC [Ca(2+)](i) to increase by 94 +/- 22% in the fetus and 303 +/- 46% in the adult. K(v)-channel expression and mRNA levels in distal pulmonary arteries from fetal, neonatal, and adult sheep were determined through the use of immunoblotting and semiquantitative RT-PCR. Both Kv2.1-channel protein and mRNA expression in distal pulmonary vasculature increased with maturation. We conclude that there are maturation-dependent changes in PASMC O(2) sensing that may render the adult PASMCs more responsive to acute hypoxia.

Force probe measurements of antibody-antigen interactions

The surface force apparatus has been used to quantify directly the forces that govern the interactions between proteins and ligands. In this work, we describe the measured interactions between the antigen fluorescein and the Fab' fragment of the monoclonal 4-4-20 anti-fluorescyl IgG antibody. Here we first describe the use of the surface force apparatus to demonstrate directly the impact of the charge composition in the region of the antibody binding site on the antibody interactions. Several approaches are described for immobilizing antigens, antibodies, and proteins in general for direct force measurements. The measured force profiles presented are accompanied by an extensive discussion of protocols used to analyze the force-distance curves and to interpret them in terms of the antibody structure. In addition to long-range electrostatic forces, we also consider short-range forces that can affect the strength of adhesion between the Fab' and immobilized fluorescein. The latter investigations demonstrate the influence of interfacial properties on the recognition of surface-bound antigens.

Intra-cranial manifestations of the neurocutaneous syndromes

The neurocutaneous syndromes or phakomatoses are a heterogeneous group of congenital disorders primarily involving structures derived from the embryological neuroectoderm. All of the syndromes involve the central nervous system (CNS). Peripheral nerves, skin and other organ systems may also be involved. Twenty to 30 disorders are now classified as neurocutaneous syndromes. This article reviews the intra-cranial imaging features of some of the commonest.

Determination of the dose proportionality of single intravenous doses (5, 10, and 15 mg) of lubeluzole in healthy volunteers

The dose proportionality of lubeluzole, a drug in clinical development for the treatment of acute ischemic stroke, was evaluated in a Phase I, single-center, open-label, randomized-dosing-sequence, three-way crossover clinical trial in 12 healthy adults. An equal number of male and female volunteers were enrolled in the trial, with a mean weight (+/- SD) of 73.2 +/- 11.9 kg, mean height (+/- SD) of 66.8 +/- 4.6 inches, and a mean age of 36.1 +/- 5.2 years. Subjects received intravenous infusions of 5 (A), 10 (B), and 15 mg (C) of lubeluzole over 1 hour on three separate occasions, with a minimum washout period of 2 weeks. The treatment sequences were A-B-C; A-C-B; B-A-C; B-C-A; C-A-B; and C-B-A. One male and one female were assigned to each sequence. After the 5-, 10-, and 15-mg doses, maximum concentration (Cmax) was 58.1, 113, and 138 microg/L, respectively, and the area under the curve from 0 to (AUC(0-infinity)) was 771, 1384, and 2025 microg x h/L. There were no statistically significant differences among the groups in mean terminal half-life, steady-state volume of distribution, total plasma clearance, or dose-normalized AUC(0-infinity). Dose-normalized values of Cmax differed significantly between the groups. No serious adverse events were reported, and no changes were observed in cardiac function, as judged by the QT(c) interval. The pharmacokinetics of lubeluzole appear to be linear at intravenous infusion doses of 5, 10, and 15 mg, and these doses are well tolerated by healthy adults.

Pharmacokinetic profile of cisapride 20 mg after once- and twice-daily dosing

Cisapride is a substituted piperidinyl benzamide. It is chemically related to metoclopramide but lacks the antidopaminergic properties of metoclopramide that affect the central nervous system and cause extrapyramidal side effects. Cisapride is indicated for the symptomatic treatment of patients with nocturnal heartburn due to gastroesophageal reflux disease. Based on extensive assessment of the drug's pharmacokinetic profile, the currently approved initial oral dosing regimen for cisapride is 10 mg QID. However, the pharmacokinetics of cisapride after oral administration of 20 mg BID have not been investigated. We present here findings from an open-label trial assessing the pharmacokinetics of cisapride 20-mg tablets after a single dose and at steady state (BID dosing). The results indicate that 20-mg BID and 10-mg QID regimens produce similar steady-state concentrations.

4-4-20 anti-fluorescyl IgG Fab' recognition of membrane bound hapten: direct evidence for the role of protein and interfacial structure

The surface forces apparatus was used to identify the molecular forces that control the interactions of monoclonal 4-4-20 antifluorescyl IgG Fab' fragments with fluorescein-presenting supported planar bilayers. At long range, the electrostatic force between oriented Fab' and fluorescein monolayers was controlled by the composition of the protein exterior surrounding the antigen-combining site rather than by the overall protein charge. The measured positive electrostatic potential of the Fab' monolayer at pH > pI(Fab') was consistent with the structure of the exposed Fab' surface in which a ring of positive charge at the mouth of the antigen-combining site dominates the local electrostatic surface properties. Substantial differences in the electrostatic forces measured with denatured Fab' further demonstrated that the measured electrostatic surface properties and the consequent long-range interaction forces are controlled by the protein surface composition. At short range, the strength of the Fab'-mediated adhesion was modulated not only by the length of the fluorescein tether but also by membrane hydration. Steric hydration barriers at the membrane surface reduced the adhesion strength in proportion to their range of influence. These results provide direct evidence that long-range protein interactions with immobilized ligands are controlled by both the protein and the membrane surface compositions, while short-range, specific binding is modulated by both the protein structure and the membrane interfacial properties.

Lower dose diuretic therapy in the treatment of patients with mild to moderate hypertension

Indapamide (Lozol), an indoline antihypertensive drug with diuretic and vasodilating activities, was evaluated in 195 patients with mild to moderate essential hypertension (sitting DBP between 95 and 110 mmHg) in a multicentre, randomised, double-blind, parallel-group design trial. A four week single-blind placebo wash-out period was followed by an eight week double-blind period. Patients were randomised to indapamide 1.25 mg/day or to placebo. The primary efficacy endpoint was the mean change in sitting DBP from baseline to week 8. Ninety patients in the placebo group (93%) and 82 patients (84%) in the indapamide group completed the eight weeks of double-blind therapy. Indapamide produced a mean (SE) decrease in sitting DBP of 7.4 (0.63) mmHg (from 100.1 to 92.8 mmHg) compared with a decrease of 3.6 (0.75) mmHg (from 99.6 to 95.8 mmHg) produced by placebo (p < 0.0001). Indapamide and placebo also produced mean decreases in standing DBP of 6.8 (0.75) and 2.8 (0.77) mmHg, respectively (p = 0.0002), in sitting SBP of 11.1 (1.18) and 3.2 (1.35) mmHg, respectively (p = 0.0001) and in standing SBP of 11.4 (1.29) and 4.0 (1.43) mmHg, respectively (P = 0.0002). Reduction in BP of > or = 10 mmHg or to a DBP of < or = 90 mmHg was more frequent (P = 0.0005) among indapamide (46.6%) compared with placebo (23.7%) treated patients. During the eight week double-blind treatment period, incidence rates for all adverse experiences and for drug-related adverse experiences were similar between the two treatment groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurocognitive effects of aluminum

The neurocognitive effects of aluminum (Al) were studied in 35 hemodialysis patients. Higher Al levels were associated with a decline in visual memory. As Al levels increased, patients with lower vocabulary scores (a measure of premorbid intelligence) showed a decline in attention/concentration, frontal lobe functions, and on several neurocognitive measures, while those with higher vocabulary scores revealed no Al-related decline. These results suggest that individuals with lower verbal intelligence may possess less well-developed compensatory strategies to overcome the neurocognitive effects associated with Al. These data also indicate that Al is neurotoxic and, therefore, potential sources of environmental Al should be identified and eliminated.

EEG spectra in dyslexic and normal readers during oral and silent reading

EEGs of extensively screened dyslexics and normal readers were recorded while they read easy and difficult texts silently and orally, and during two other verbal tasks which also differed in overt speaking but had no reading component: narrative speaking and listening to a story. Mid-temporal, central and parietal leads were referenced to linked ears and to Cz. Large differences between tasks and between groups were found. With the linked ears reference, power was higher in all bands in oral reading than in silent reading, with the largest change occurring in the temporal leads. In the theta and low beta bands the difference between oral and silent reading was greater for controls than for dyslexics. These effects were not accounted for by differences in reading speed or in difficulty. Similar results were found in two cohorts of subjects. The difference between groups in theta was found only in the reading tasks. In contrast, the group difference in low beta was also found in the change from listening to speaking. This implies that the oral-silent group difference in theta is related to some aspect of the reading tasks other than the presence or absence of overt speaking, and that the low beta group difference is related to some aspect of overt speaking rather than to reading per se. With the Cz reference no group differences were found. It is suggested that the groups differ in the reading strategies they use, and the degree to which they shift strategy between the silent and oral tasks. We hypothesize that these cognitive differences are reflected in the theta activity from the temporal lobe. While there were many differences between the tasks in alpha power and asymmetry, no group differences involving alpha were found.

Transdermal clonidine as an adjunct to sustained-release diltiazem in the treatment of mild-to-moderate hypertension

An open-label study was conducted to evaluate the clinical safety and efficacy of transdermal clonidine as an adjunct to sustained-release (SR) diltiazem (90 mg twice daily) in mild-to-moderate hypertension. Ninety patients with a mean baseline sitting blood pressure of 154/102 mmHg were given 90 mg of diltiazem SR twice daily and transdermal placebo. After four weeks of therapy, 21 patients (23%) had trough sitting diastolic blood pressures (DBP) less than 90 mmHg and were withdrawn. Of the remaining 69 patients (DBP greater than or equal to 90 mmHg), 60 (mean blood pressure 149/98 mmHg) continued to receive 90 mg of diltiazem SR twice daily, to which was added transdermal clonidine, titrated as needed (3.5 cm2, 7.0 cm2, or 10.5 cm2) to achieve blood pressure control. During titration, 58 patients achieved DBP less than 90 mmHg, with a mean blood pressure of 133/84 mmHg. Of these patients, 54 completed an eight-week maintenance period, during which their mean blood pressure was 137/84 mmHg. No significant decrease in pulse or change from baseline in lipid profiles (high-density lipoprotein, low-density lipoprotein, apolipoprotein A-I, apolipoprotein B) was observed with combination therapy. The most frequently reported side effect during maintenance therapy was mild skin irritation at the transdermal application site. One patient was withdrawn because of contact dermatitis. Compliance with the oral twice-daily regimen was variable, with 83% of patients failing to take diltiazem SR at the prescribed dosing intervals 80% to 100% of the time. Transdermal clonidine was worn as directed by 97% of patients. It is concluded that transdermal clonidine in combination with diltiazem SR is safe and effective in the treatment of mild-to-moderate hypertension.

Antihypertensive effect of dilevalol is directly related to dose and plasma concentrations

Dilevalol is a novel antihypertensive agent combining vasodilation due to selective beta 2-adrenergic receptor agonism with nonspecific beta antagonism. To determine the relation of dilevalol dose and plasma concentration to antihypertensive effect, dilevalol (n = 15) or placebo (n = 3) was administered to 18 hypertensive subjects. The study was performed under blinded conditions during a 21-day hospitalization after a 3-week drug-free outpatient phase. In the 15 hypertensive patients receiving dilevalol orally in single morning doses of 200, 400 and 800 mg each for 5 days, the drug was shown to reduce blood pressure effectively for 24 hours at all doses. The antihypertensive effect was significantly related to dose administered and to the concentration of unchanged dilevalol measured in plasma. Dilevalol did not cause excessive changes in heart rate at rest and did not produce postural hypotension. The antihypertensive effectiveness of dilevalol was essentially the same after the first and fifth (steady state) doses at each dose level. Finally, no tendency toward rebound hypertension or tachycardia was observed after the abrupt discontinuation of dilevalol in these patients.