Intracorporeal or extracorporeal anastomosis after minimally invasive right colectomy: a systematic review and meta-analysis

PURPOSE

As part of the wide adoption of minimally invasive surgery, intracorporeal anastomosis is becoming increasingly common. The benefits of minimally invasive versus open right colectomy are well known although the additional benefits of an intracorporeal anastomosis, performed laparoscopically or robotically, are unclear. The aim of this study was to assess the current literature comparing intracorporeal and extracorporeal anastomosis in the setting of laparoscopic and robotic-assisted right colectomy.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA and AMSTAR methods. Studies included were randomized controlled trials and prospective or retrospective cohort studies, between January 1 2010 and July 1 2021, comparing intracorporeal and extracorporeal anastomosis with laparoscopic and robotic approaches. Four groups were identified: laparoscopic extracorporeal anastomosis (L-ECA), laparoscopic intracorporeal anastomosis (L-ICA), robotic extracorporeal anastomosis (R-ECA), and robotic intracorporeal anastomosis (R-ICA). Operative time, rate of conversion to an open procedure, surgical site infection, reoperation within 30 days, postoperative complications within 30 days, and length of hospital stay were assessed.

RESULTS

Twenty-one retrospective cohort studies were included in the final analysis. R-ICA and R-ECA had comparable operative times, but a robotic approach required more time than laparoscopic (68 min longer, p < 0.00001). Conversion to open surgery was 55% less likely in the R-ICA group vs. L-ICA, and up to 94% less likely in the R-ICA group in comparison to the R-ECA group. Length of hospital stay was shorter for R-ICA by a half day vs. R-ECA, and up to 1 day less vs. L-ECA. There were no differences in postoperative complications, reoperations, or surgical site infections, regardless of approach. However, the included studies all had high risks of bias due to confounding variables and patient selection.

CONCLUSION

Robotic-assisted right colectomy with intracorporeal anastomosis was associated with shorter length of hospitalization and decreased rate of conversion to open surgery, compared to either laparoscopic or extracorporeal robotic approaches. Prospective studies are needed to better understand the true impact of robotic approach and intracorporeal anastomosis in right colectomy.

Expanding opportunities for chronic disease prevention for Hispanics: the Better Together REACH program in Pennsylvania

Background

Hispanics in Lebanon and Reading, Pennsylvania, experience high levels of socioeconomic and health disparities in risk factors for chronic disease. In 2018, our community-academic coalition "Better Together" received a Racial and Ethnic Approaches to Community Health (REACH) award to improve healthy lifestyles. This report describes our work-in-progress and lessons learned to date from our REACH-supported initiatives in Lebanon and Reading.

Methods

For the past 4 years, our coalition has leveraged strong community collaborations to implement and evaluate culturally-tailored practice- and evidence-based activities aimed at increasing physical activity, healthy nutrition, and community-clinical linkages. This community case report summarizes the context where our overall program was implemented, including the priority population, target geographical area, socioeconomic and health disparities data, community-academic coalition, conceptual model, and details the progress of the Better Together initiative in the two communities impacted.

Results

To improve physical activity, we are: (1) creating new and enhancing existing trails connecting everyday destinations through city redesigning and master planning, (2) promoting outdoor physical activity, (3) increasing awareness of community resources for chronic disease prevention, and (4) supporting access to bikes for youth and families. To improve nutrition, we are: (1) expanding access to locally-grown fresh fruit and vegetables in community and clinical settings, through the Farmers Market Nutrition Program to beneficiaries of the Women, Infants, and Children (WIC) program and the Veggie Rx to patients who are at risk for or have diabetes, and (2) providing bilingual breastfeeding education. To enhance community-clinical linkages, we are training bilingual community health workers to connect at-risk individuals with diabetes prevention programs.

Conclusions

Intervening in areas facing high chronic disease health disparities leads us to develop a community-collaborative blueprint that can be replicated across Hispanic communities in Pennsylvania and the United States.

Impact of a Prescription Produce Program on Diabetes and Cardiovascular Risk Outcomes

OBJECTIVE

To evaluate the impact of a fruit and vegetable prescription program on diabetes and cardiovascular risk outcomes.

DESIGN

Single-arm pre-post study.

SETTING

Primary care clinic in a community-based hospital.

PARTICIPANTS

Adults with type 2 diabetes (n = 97), aged > 18 years, with hemoglobin A1c (HbA1c) ≥ 7.0%, and a body mass index (BMI) of ≥ 25 kg/m².

INTERVENTION

Over 7 months, participants received monthly group-based diabetes self-management education (DSME) and monthly vouchers ($28-$140/month) redeemable for fruits and vegetables at local markets.

ANALYSIS

Biomarker changes (HbA1c, BMI, and blood pressure) were assessed with paired t tests. Voucher distribution and redemption were tracked, and voucher redemption rates were calculated. Linear mixed-effect regression models tested associations between biomarkers, voucher redemption rates, and participant characteristics.

RESULTS

There was a -1.3% (P < 0.001) postprogram change in HbA1c. Reduced HbA1c was associated with higher voucher redemption rates (P = 0.032) and a change in diabetes medications (P = 0.003). There were no associations with BMI, but blood pressure was positively associated with voucher redemption.

CONCLUSIONS AND IMPLICATIONS

Fruit and vegetable prescription programs may improve diabetes outcomes by incentivizing DSME uptake and retention. Future randomized trials are warranted to identify strategies to improve DSME engagement and voucher redemption rates and assess mechanisms through which these programs influence health outcomes.

Plastics and the microbiome: impacts and solutions

Global plastic production has increased exponentially since manufacturing commenced in the 1950's, including polymer types infused with diverse additives and fillers. While the negative impacts of plastics are widely reported, particularly on marine vertebrates, impacts on microbial life remain poorly understood. Plastics impact microbiomes directly, exerting toxic effects, providing supplemental carbon sources and acting as rafts for microbial colonisation and dispersal. Indirect consequences include increased environmental shading, altered compositions of host communities and disruption of host organism or community health, hormone balances and immune responses. The isolation and application of plastic-degrading microbes are of substantial interest yet little evidence supports the microbial biodegradation of most high molecular weight synthetic polymers. Over 400 microbial species have been presumptively identified as capable of plastic degradation, but evidence for the degradation of highly prevalent polymers including polypropylene, nylon, polystyrene and polyvinyl chloride must be treated with caution; most studies fail to differentiate losses caused by the leaching or degradation of polymer monomers, additives or fillers. Even where polymer degradation is demonstrated, such as for polyethylene terephthalate, the ability of microorganisms to degrade more highly crystalline forms of the polymer used in commercial plastics appears limited. Microbiomes frequently work in conjunction with abiotic factors such as heat and light to impact the structural integrity of polymers and accessibility to enzymatic attack. Consequently, there remains much scope for extremophile microbiomes to be explored as a source of plastic-degrading enzymes and microorganisms. We propose a best-practice workflow for isolating and reporting plastic-degrading taxa from diverse environmental microbiomes, which should include multiple lines of evidence supporting changes in polymer structure, mass loss, and detection of presumed degradation products, along with confirmation of microbial strains and enzymes (and their associated genes) responsible for high molecular weight plastic polymer degradation. Such approaches are necessary for enzymatic degraders of high molecular weight plastic polymers to be differentiated from organisms only capable of degrading the more labile carbon within predominantly amorphous plastics, plastic monomers, additives or fillers.

Thermal resilience of ensilicated lysozyme via calorimetric and in vivo analysis

Ensilication is a novel method of protein thermal stabilisation using silica. It uses a modified sol–gel process which tailor fits a protective silica shell around the solvent accessible protein surface. This, electrostatically attached, shell has been found to protect the protein against thermal influences and retains its native structure and function after release. Here, we report the calorimetric analysis of an ensilicated model protein, hen egg-white lysozyme (HEWL) under several ensilication conditions. DSC, TGA-DTA-MS, CD, were used to determine unfolding temperatures of native, released and ensilicated lysozyme to verify the thermal resilience of the ensilicated material. Our findings indicate that ensilication protects against thermal fluctuations even at low concentrations of silica used for ensilication. Secondly, the thermal stabilisation is comparable to lyophilisation, and in some cases is even greater than lyophilisation. Additionally, we performed a mouse in vivo study using lysozyme to demonstrate the antigenic retention over long-term storage. The results suggest that protein is confined within the ensilicated material, and thus is unable to unfold and denature but is still functional after long-term storage.

Ensilication is a novel method of protein thermal stabilisation using silica. It uses a modified sol–gel process which tailor fits a protective silica shell around the protein to enable room temperature storage of biopharmaceuticals.

Impact of acute stress on itch sensation and scratching behaviour in patients with atopic dermatitis and healthy controls

BACKGROUND

Patients with atopic dermatitis (AD) often report that stress aggravates their itch. However, no study has investigated if and how acute stress influences itch sensation and scratching behaviour in these patients.

OBJECTIVES

We evaluated the impact of acute stress on experimentally induced cowhage itch perception and scratching behaviour in 16 healthy subjects and 15 patients with AD.

METHODS

The Trier Social Stress Test (TSST) was used to induce acute stress. The itch sensation, provoked by applying cowhage to the forearms, and off-site scratching behaviour (not directed at the cowhage application site) were compared before and after performing the TSST or the control condition (watching a video of landscape scenes).

RESULTS

In patients with AD, stress induced by TSST caused a significant reduction of cowhage-evoked itch but significantly increased off-site scratching behaviour. Such changes in itch perception and scratching behaviour were not observed in healthy controls. In addition, a significant positive correlation was noted between stress induced by TSST and clinical severity of eczema.

CONCLUSIONS

We speculate that psychological stress increases spontaneous scratching in patients with AD, which may enhance the vicious cycle of itching and scratching, resulting in aggravation of the skin eczema. These results provide new insights on the mechanism of acute stress-related exacerbation of itch in patients with AD.

Racial/ethnic subgroup differences in outcomes and acceptability of an Internet-delivered intervention for substance use disorders

The Therapeutic Education System (TES), an Internet version of the Community Reinforcement Approach plus prize-based motivational incentives, is one of few empirically supported technology-based interventions. To date, however, there has not been a study exploring differences in substance use outcomes or acceptability of TES among racial/ethnic subgroups. This study uses data from a multisite (N = 10) effectiveness study of TES to explore whether race/ethnicity subgroups (White [n = 267], Black/African American [n = 112], and Hispanic/Latino [n = 55])moderate the effect of TES. Generalized linear mixed models were used to test whether abstinence, retention, social functioning, coping, craving, or acceptability differed by racial/ethnic subgroup. Findings demonstrated that race/ethnicity did not moderate the effect of TES versus TAU on abstinence, retention, social functioning, or craving. A three-way interaction (treatment, race/ethnicity, and abstinence status at study entry) showed that TES was associated with greater coping scores among nonabstinent White participants (p = .008) and among abstinent Black participants (p < .001). Acceptability of the TES intervention, although high overall, was significantly different by race/ethnicity subgroup with White participants reporting lower acceptability of TES compared to Black (p = .006) and Hispanic/Latino (p = .008) participants. TES appears to be a good candidate treatment among a diverse population of treatment-seeking individuals with substance use disorders.

Microbial transport into groundwater from irrigation: Comparison of two irrigation practices in New Zealand

Rising demand on food is leading to an increase in irrigation worldwide to improve productivity. Irrigation, for pastoral agriculture (beef, dairy and sheep), is the largest consumptive use of water in New Zealand. There is a potential risk of leaching of microbial contaminants from faecal matter through the vadose zone into groundwater. Management of irrigation is vital for protection of groundwater from these microbial contaminants and maintain efficient irrigation practices. Our research investigated flood and spray irrigation, two practices common in New Zealand. The aim was to identify the risk of microbial transport and mitigation practices to reduce or eliminate the risk of microbial transport into groundwater. Cowpats were placed on lysimeters over a typical New Zealand soil (Lismore silt loam) and vadose zone and the leachate collected after irrigation events. Samples of both cowpats and leachate were analysed for the microbial indicator Escherichia coli and pathogen Campylobacter species. A key driver to the microbial transport derived from the model applied was the volume of leachate collected: doubling the leachate volume more than doubled the total recovery of E. coli. The persistence of E. coli in the cowpats during the experiment is an important factor as well as the initial environmental conditions, which were more favourable for survival and growth of E. coli during the spray irrigation compared with the flood irrigation. The results also suggest a reservoir of E. coli surviving in the soil. Although the same was potentially true for Campylobacter, little difference in the transport rates between irrigation practices could be seen due to the poor survival of Campylobacter during the experiment. Effective irrigation practices include monitoring the irrigation rates to minimise leachate production, delaying irrigation until 14days post-cowpat deposition and only irrigating when risk of transport to the groundwater is minimal.

AIM

To compare the risk of microbial contamination of groundwater from cowpats using two irrigation practices onto pasture.

Biofilm resilience to desiccation in groundwater aquifers: a laboratory and field study

Groundwater is used as a precious resource for drinking water worldwide. Increasing anthropogenic activity is putting increasing pressure on groundwater resources. One impact of increased groundwater abstraction coupled with increasing dry weather events is the lowering of groundwater levels within aquifers. Biofilms within groundwater aquifers offer protection to the groundwater by removing contaminants entering the aquifer systems from land use activities. The study presented investigated the impact of desiccation events on the biofilms present in groundwater aquifers using field and laboratory experiments. In both field and laboratory experiments a reduction in enzyme activity (glucosidase, esterase and phosphatase) was seen during desiccation compared to wet controls. However, comparing all the data together no significant differences were seen between either wet or desiccated samples or between the start and end of the experiments. In both field and laboratory experiments enzyme activity recovered to start levels after return to wet conditions. The study shows that biofilms within groundwater systems are resilient and can withstand periods of desiccation (4 months).

Survival of Escherichia coli, enterococci and Campylobacter jejuni in Canada goose faeces on pasture

Freshly excreted Canada goose faeces pose a public health risk as they contain pathogenic microorganisms. Accordingly, a study was carried out on the growth and survival of resident indicator bacteria (enterococci and Escherichia coli) and inoculated Campylobacter jejuni in freshly excreted faeces over summer and winter. Canada goose faeces were collected, mixed thoroughly and inoculated with 10⁸ g⁻¹ C. jejuni. The faeces were mixed again before making the Canada goose dropping. The simulated goose droppings (N = 70) were placed on pasture, and the concentrations of E. coli, enterococci and the pathogen, C. jejuni, were monitored. In summer only, the molecular marker of E. coli LacZ and the avian-associated bacteria E2 was also monitored. Results of the survival study indicated that significant growth of enterococci and E. coli occurred in summer, before concentrations decreased to less than 15% of the original concentration (day 77) for enterococci and 0.01% for E. coli. LacZ followed a similar pattern to E. coli, while the E2 marker dropped to below 0.1% of the original concentration within 4 days. In winter, enterococci grew slightly, while no growth of E. coli occurred. In both summer and winter, C. jejuni was rapidly inactivated. This research highlights the ability of bacterial indicators to replicate and survive in the environment when harboured by avian faeces, and the limited risk aged Canada goose faeces pose as an environmental source of Campylobacter spp.

Thin Film Phosphate Based Bioactive Substrates

Calcium phosphate based thin films prepared by colloidal sol-gel slow draw dipping of quartz substrates are bioactive to both osteoclast resorption and osteoblast deposition. The bioactivity is related to the presence of mixed crystalline phases in the films generated under different sintering conditions. As the sintering temperature was increased from 800°C to 1000°C, a transition in film composition from calcium hydroxylapatite to alpha-tricalcium phosphate is achieved.

Potential for preventing spread of fungi in air-conditioning systems constructed using copper instead of aluminium

AIMS

As copper has been previously suggested as an antimicrobial surface, we tested the effectiveness of copper as an antifungal surface which could be used in air-conditioning systems as an alternative to aluminium.

METHODS AND RESULTS

Coupons of copper (C11000) and aluminium were inoculated with fungal isolates (Aspergillus spp., Fusarium spp., Penicillium chrysogenum and Candida albicans) for various time periods. Culture on potato dextrose agar and an in situ viability assay using the fluorochrome FUN-1 were used to determine whether spores had survived. The results showed increased die off of fungal isolates tested compared to aluminium. In addition, copper also prevented the germination of spores present, thereby reducing the risk of the release of spores.

CONCLUSIONS

Copper offered an antifungal surface and prevented subsequent germination of spores present. FUN-1 demonstrated that fungal spores entered into a viable but not culturable (VBNC) state on copper indicating the importance of using such methods when assessing the effect of an antifungal as culture alone may give false results.

SIGNIFICANCE AND IMPACT OF STUDY

Copper offers a valuable alternative to aluminium which could be used in air-conditioning systems in buildings, particularly in hospital environments where patients are more susceptible to fungal infections.

Feeding babies in the battle to combat infant mortality a century ago

At the end of the nineteenth century Glasgow, like many large industrial European cities, had an infant mortality rate (IMR) of well over 100 deaths per 1000 live births. Recognition that 'improper feeding' was a significant factor in accounting for this prompted public health authorities to establish infant milk depots, to support breast-feeding mothers and to provide artificial milk feeds for their babies if necessary. The initiative was led by the medical officer of health of Glasgow, Archibald Chalmers, who promoted welfare services for mothers and infants during the first decade of the 20th century. However these initiatives were questioned by an up-and-coming paediatrician, Leonard Findlay, who was to go on to be Glasgow's first professor of medical paediatrics in 1924. Nevertheless IMRs started to go down from 1900 and have continued steadily ever since; and while artificial infant milks clearly posed a risk to the health of babies, attention to infant nutrition, growth and feeding may have played a part in initiating and perpetuating this decline in IMR and improving infant survival and welfare during the last century.

Outcomes of liver transplantation for hepatitis B: a single-center study of 35 patients

BACKGROUND

Results of liver transplantation (LT) for hepatitis B (HBV) have improved in the past decade but recently drug resistance has been described, the clinical significance of which is unclear. The aims of this study were to evaluate outcomes of LT for HBV and describe the prevalence of drug resistance.

METHODS

A retrospective chart analysis and review of the organ transplant database was performed to identify all patients transplanted for HBV between December 1982 and April 2004 who survived more than 3 months.

RESULTS

Thirty-five patients were transplanted for HBV during this period: 27 men and 8 women. Median age at LT was 48.8 years (range 18.9 to 74.3). Four patients were transplanted for fulminant liver failure and 31 for decompensated cirrhosis. Intramuscular HBIG was administered to 8 patients and intravenous HBIG to 32 patients, data were unavailable for three patients. Lamivudine was prescribed for 18 patients (58%) pre-OLT and for 31 patients (88.6%) post-LT. Drug-resistant HBV developed in two patients (5.71%) receiving lamivudine and HBIG. Adefovir substitution resulted in improvement in liver function tests, in HBV DNA and in histology in both patients. Twenty-five patients are currently alive with and 1-year survival of 95% and a 5-year survival of 75%. Causes of death were respiratory failure (n = 3), metastatic cancer of unknown primary (n = 2), renal failure (n = 2), sepsis (n = 1), cerebrovascular accident (n = 1), and cerebral edema (n = 1).

CONCLUSIONS

LT for HBV shows survival rates comparable to other liver transplant recipients. Lamivudine resistance was rare in this series but responded to adefovir substitution.

Pilot study of pegylated interferon alfa-2b and ribavirin for recurrent hepatitis C after liver transplantation

Recurrent hepatitis C is often treated with an interferon and ribavirin combination therapy, but the results have been disappointing. Given the promising results reported with pegylated interferon and ribavirin for hepatitis C, we were interested in evaluating the effectiveness of this treatment in liver transplant recipients with recurrent hepatitis C (HCV).

METHODS

Between November 2001 and September 2002, patients with recurrent HCV were screened to determine if they were eligible for treatment. Liver function tests, HCV-RNA, and liver biopsies were performed on all patients prior to treatment. HCV-RNA was repeated at 3 months, the end of treatment (EOT), and 6 months after EOT for patients who were HCV-RNA negative at EOT. Patients were prospectively followed after starting weekly pegylated interferon alfa-2b 1.5 mcg/kg per week and ribavirin 800 mg per day (Schering-Plough, Kenilworth, NJ, USA) with folic acid 1 mg per day.

RESULTS

Thirty-nine patients eligible for treatment displayed a median age of 50.4 years. Eighteen patients completed treatment, 4 remain on treatment, and 17 were intolerant. Sustained HCV-RNA eradication occurred in 66.7% of patients who completed treatment. Side effects led to treatment withdrawal in 17 patients (43.6%) In an intention-to treat analysis, sustained HCV-RNA eradication occurred in 30.8% of patients.

CONCLUSION

Side effects are an important limiting factor in the treatment of recurrent HCV with pegylated interferon and ribavirin. However, these results are encouraging as sustained HCV eradication occurred in at least 66.7% of patients who completed treatment. Prospective randomized trials are required to assess the effectiveness of this treatment and its impact on quality of life and histology.

Effect of 2′-phosphophloretin on renal function in chronic renal failure rats

Hyperhosphatemia and secondary hyperparathyroidism are common and severe complications of chronic renal failure. Therapies to reduce serum phosphate have been shown to reduce serum parathyroid hormone (PTH) and slow the progression of renal failure. The effect of the inhibitor of intestinal phosphate absorption, 2′-phosphophloretin (2′-PP), on serum and urine chemistry, renal histology, and cardiac structure in the uremic rat model of renal failure, 5/6 nephrectomy (5/6 NX), was examined. The effect of 2′-PP on serum phosphate, serum PTH, serum total Ca2+, and ionized Ca2+, Ca2+ × Pi product, urine protein, urine osmolality, and creatinine clearance in 5/6 NX rats was examined. Uremic rats in chronic renal failure were gavaged daily with 25 μM 2′-PP. Over the course of a 5-wk experiment, serum chemistry in untreated uremic rats, 2′-PP-treated uremic rats, and age-matched control rats with normal renal function was determined twice a week. Urine creatinine, urine osmolality, urine phosphate, and urine protein were determined once a week from 24-h collections. 2′-PP reduced serum phosphate 40 ± 3% compared with a 17% increase in untreated uremic control rats. 2′-PP did not alter total serum Ca2+. During 5-wk experiments, serum PTH increased 65 ± 25% in untreated uremic rats and decreased 70 ± 7% in uremic rats treated with 25 μM 2′-PP. Creatinine clearance decreased 20% in untreated uremic rats compared with a 100% increase in 2′-PP-treated uremic rats. Urine protein decreased and urine osmolality increased in uremic rats treated with 2′-PP. The mechanism of the effect of 2′-PP on serum phosphate was inhibition of intestinal phosphate absorption. 2-PP inhibited intestinal phosphate absorption 50% without altering dietary protein absorption or intestinal Ca2+ absorption. Over the course of the 5-wk treatment with 2′-PP, uremic animals treated with 2′-PP had a 2–4% weight gain/wk, similar to the weight gain seen in age-matched control rats with normal renal function.

Discussing end-of-life issues with patients: reflections on developing an interviewing template to assist first-year medical students

First-year medical students at the University of Ottawa currently use an interview template to work with patients who have chronic illnesses. A second-year medical student (JJ) modified the template to facilitate the discussion of death and end-of-life care by students who may have had little previous experience with such sensitive topics. The modification was accomplished using the following strategies: a systematic literature review on long-term care or nursing home residents' end-of-life needs; participation in a support group for families of dying patients; volunteering in a day hospice program for two months; piloting the template with two palliative care patients, one resident of a long-term care facility, and one family member. The paper summarizes and reflects on the process.

Experiments with Infinite-Horizon, Policy-Gradient Estimation

In this paper, we present algorithms that perform gradient ascent of the average reward in a partially observable Markov decision process (POMDP). These algorithms are based on GPOMDP, an algorithm introduced in a companion paper (Baxter & Bartlett, this volume), which computes biased estimates of the performance gradient in POMDPs. The algorithm's chief advantages are that it uses only one free parameter beta, which has a natural interpretation in terms of bias-variance trade-off, it requires no knowledge of the underlying state, and it can be applied to infinite state, control and observation spaces. We show how the gradient estimates produced by GPOMDP can be used to perform gradient ascent, both with a traditional stochastic-gradient algorithm, and with an algorithm based on conjugate-gradients that utilizes gradient information to bracket maxima in line searches. Experimental results are presented illustrating both the theoretical results of (Baxter & Bartlett, this volume) on a toy problem, and practical aspects of the algorithms on a number of more realistic problems.

Interdisciplinary education and teamwork: a long and winding road

PURPOSE

This article examines literature on interdisciplinary education and teamwork in health care, to discover the major issues and best practices.

METHODS

A literature review of mainly North American articles using search terms such as interdisciplinary, interprofessional, multidisciplinary with medical education.

MAIN FINDINGS

Two issues are emerging in health care as clinicians face the complexities of current patient care: the need for specialized health professionals, and the need for these professionals to collaborate. Interdisciplinary health care teams with members from many professions answer the call by working together, collaborating and communicating closely to optimize patient care. Education on how to function within a team is essential if the endeavour is to succeed. Two main categories of issues emerged: those related to the medical education system and those related to the content of the education.

CONCLUSIONS

Much of the literature pertained to programme evaluations of academic activities, and did not compare interdisciplinary education with traditional methods. Many questions about when to educate, who to educate and how to educate remain unanswered and open to future research.

Repeated doses of porcine secretin in the treatment of autism: a randomized, placebo-controlled trial

BACKGROUND AND OBJECTIVES

Anecdotal reports on the efficacy of secretin in autism raised great hopes for the treatment of children with this disorder. Initial single-dose, randomized, controlled trials failed to demonstrate any therapeutic effects of secretin. The present study is the first to test the outcome of repeated doses and to examine whether there is a subgroup of children who are more likely to achieve positive effects.

METHOD

Sixty-four children with autism (ages 2-7 years; 55 boys and 9 girls) with a range of intelligence quotient and verbal ability were randomly assigned, in a double-blind manner, to secretin or placebo groups. Children received 2 doses of placebo or porcine secretin, 6 weeks apart. Assessments were performed at baseline and 3 weeks after each injection using several outcome measures.

RESULTS

There were no group differences on formal measures of language, cognition, or autistic symptomatology. Subgroupings based on cognitive level, the presence or absence of diarrhea, or a history of regression failed to show any significant therapeutic effects of secretin.

CONCLUSION

No evidence is provided for the efficacy of repeated doses of porcine secretin in the treatment of children with autism. The possible relationship between relief of biological symptoms and enhanced skill performance is discussed.

Application of business case analysis in planning a province-wide telehealth network in Alberta

A strategy for implementing telemedicine throughout Alberta was developed. The model was based on a comprehensive evaluation of the four clinical specialties chosen as representative telemedicine services--radiology, psychiatry, emergency services and continuing education. The goals of the telemedicine network were to improve access to health services, provide support for rural health-care providers and increase the efficiency of specialized services. The findings showed that the success factors in a national telemedicine programme depend on a clear organizational structure, with appropriate technical standards and support.

Effects of endothelin-1 and homologous trout endothelin on cardiovascular function in rainbow trout

The cardiovascular effects of endothelin (ET)-1 and the recently sequenced homologous trout ET were examined in unanesthetized trout, and vascular capacitance curves were constructed to evaluate the responsiveness of the venous system to ET-1. A bolus dose of 667 pmol/kg ET-1 doubled ventral aortic pressure; produced a triphasic pressor-depressor-pressor response in dorsal aortic pressure (P(DA)); increased central venous pressure, gill resistance, and systemic resistance; and decreased cardiac output, heart rate, and stroke volume. These responses were dose dependent. Bolus injection of trout ET (333 or 1,000 pmol/kg) produced essentially identical, dose-dependent cardiovascular responses as ET-1. Dorsal aortic infusion of 1 and 3 pmol. kg(-1). min(-1) ET-1 and central venous infusion into the ductus Cuvier of 0.3 and 1 pmol. kg(-1). min(-1) produced similar dose-dependent cardiovascular responses, although the increase in P(DA) became monophasic. The heightened sensitivity to central venous infusion was presumably due to the more immediate exposure of the branchial vasculature to the peptide. Infusion of 1 pmol. kg(-1). min(-1) ET-1 decreased vascular compliance but had no effect on unstressed blood volume. These results show that ETs affect a variety of cardiovascular functions in trout and that branchial vascular resistance and venous compliance are especially sensitive. The multiplicity of effectors stimulated by ET suggests that this peptide was extensively integrated into cardiovascular function early on in vertebrate phylogeny.

In vitro analysis of transformation potential associated with retroviral vector insertions

While replication-defective retroviral vectors provide excellent vehicles for the long-term expression of therapeutic genes, they also harbor the potential to induce undesired genetic changes by random insertions into the host genome. The rate of insertional mutagenesis for retroviral vectors has been determined in several different assay systems; however, the rate at which such events induce cellular transformation has not been directly determined. Such measurements are critical to determining the actual risk of carcinogenesis resulting from retroviral gene therapy. In this study, the ability of a replication-defective retroviral vector, GlnBgSvNa, to induce cellular transformation in the BALB/c-3T3 in vitro transformation assay was assessed. The transformation frequency observed in vector-transduced BALB/c-3T3 cells, which contained one to six copies of integrated provirus, was not significantly different from that of untreated control cells. The finding that GlnBgSvNa was nontransforming in this assay indicates that the rate of transformation induced by retroviral insertions is less than the spontaneous rate of cellular transformation by BALB/c-3T3 cells, or less than 1.1 x 10(-5). These results are the first to define an upper limit for the rate of transformation induced by retroviral vectors.

Calf-thigh sequential pneumatic compression compared with plantar venous pneumatic compression to prevent deep-vein thrombosis after non-lower extremity trauma

OBJECTIVE

To compare the effectiveness of calf-thigh sequential pneumatic compression devices with the effectiveness of plantar venous intermittent pneumatic compression devices in prevention of venous thrombosis after major trauma.

SUBJECTS AND METHODS

We evaluated 181 consecutive patients after major trauma without lower extremity injuries that precluded the use of pneumatic compression devices. We randomly assigned 149 patients to either calf-thigh sequential pneumatic compression or plantar venous pneumatic compression. After blinding the observers to the method of prophylaxis against deep-vein thrombosis, we performed bilateral compression ultrasonography on or before day 8 after randomization.

RESULTS

Among 149 randomized patients, 62 who received calf-thigh sequential pneumatic compression and 62 who received plantar venous intermittent pneumatic compression devices completed the trial. Thirteen patients randomized to plantar venous intermittent pneumatic compression (21.0%) and 4 patients randomized to calf-thigh sequential pneumatic compression (6.5%) had deep-vein thrombosis (p = 0.009). Seven of 13 patients with deep-vein thrombosis after prophylaxis with plantar venous intermittent pneumatic compression had bilateral deep-vein thromboses, whereas all 4 patients with deep-vein thrombosis after prophylaxis with calf-thigh sequential pneumatic compression had unilateral deep-vein thrombosis.

CONCLUSION

Calf-thigh sequential pneumatic compression prevents deep-vein thrombosis more effectively than plantar venous intermittent pneumatic compression after major trauma without lower extremity injuries.

Efficient adenoviral vector transduction and expression of functional human factor VIII in cultured primary human hepatocytes

Hemophilia A is a severe bleeding disorder caused by a deficiency in blood coagulation factor VIII (FVIII). Adenoviral vectors containing a potent human FVIII expression cassette encoding a truncated FVIII cDNA were developed that mediated sustained FVIII expression in normal and haemophiliac mice and complete phenotypic correction of the bleeding disorder in haemophiliac mice and dogs (Connelly and Kaleko, Haemophilia, 1998; 4: 380-8). Here, we evaluated two E1/E2a/E3-deleted adenoviral vectors encoding human FVIII, one containing the full-length cDNA and the second containing a truncated cDNA lacking the B-domain. Viral vectors encoding the human full-length FVIII cDNA have not been described previously. Hepatocyte transduction was efficient and dose dependent, ranging from 50% to 100%. High levels of functional FVIII were secreted from transduced cells at amounts up to 6000 mU-1 10(6)cells-1 60 h. B-domain deleted FVIII was expressed at levels at least 8-fold higher than the full-length FVIII protein, whereas FVIII RNA levels were similar with both vectors. These data provide the first demonstration of FVIII adenoviral vector function in primary human cells and verify the potential clinical utility of adenoviral vectors for the treatment of haemophilia A.

Catecholaminergic regulation of venous function in the rainbow trout

The significance of the sympathetic nervous system (SNS) in regulating peripheral vascular resistance and cardiac function in fish has been well established, whereas its effect on venous function in vivo is unknown. Two protocols were employed in the present study to evaluate SNS effects on the venous system in intact, unanesthetized trout. In the first, trout were instrumented with pressure cannulas in the ventral (PVA) and dorsal (PDA) aortas and ductus Cuvier (PVEN), and cardiac output (CO) was measured with a flow probe around the ventral aorta. Heart rate, stroke volume, and gill and systemic resistances were calculated from the measured parameters. In the second group, vascular capacitance curves were obtained by monitoring mean circulatory filling pressure (PVEN) during transient interruption of CO and while blood volume was adjusted between 80 and 120% of normal. Unstressed blood volume (USBV) and vascular compliance (C) were derived from the capacitance curves. Infusion of epinephrine (Epi; 3.3 nmol.min-1.kg body wt-1) increased PVA, PDA, and PVEN, whereas norepinephrine (NE) infusion (3.3 nmol.min-1.kg body wt-1) increased PVA and PDA but did not affect PVEN. Epi (1.0 nmol.min-1.kg body wt-1), but not NE (2.6 or 10.4 nmol.min-1.kg body wt-1), displaced the capacitance curve to the right and significantly decreased USBV. Inhibition of alpha 1-adrenoceptors with prazosin, or ganglionic nicotinic receptor blockade with hexamethonium, produced a left shift in the capacitance curve, and both treatments increased USBV and C. Conversely, the alpha-adrenoceptor antagonist phentolamine did not effect vascular capacitance. These results show that Epi has potent effects on trout veins in vivo and that it mobilizes blood from the unstressed into the stressed vascular compartment and augments central venous pressure by decreasing venous compliance. These results also show that the SNS is an active effector of venous tone and compliance in trout; this is the first demonstration of tonic regulation of vascular capacitance in any fish.

Performing butch/femme theory

Abstract This paper is a description of a performance workshop that is designed to give the language of the butch/femme theory a ride. Using theatre exercises and performance techniques that put the terms butch and femme onto the actions of the body, the writer hopes to encourage both an irreverence and a respect for the arbitrary nature of a language that attempts to define identity.

Cardiovascular effects of arginine vasotocin in the rainbow trout Oncorhynchus mykiss

The physiological functions of the neurohypophyseal hormone arginine vasotocin (AVT) in teleosts are not clear. In the present studies, the sites and mechanisms of action of AVT on the rainbow trout Oncorhynchus mykiss cardiovascular system were examined in unanesthetized instrumented fish, perfused organs and isolated vessels. Injection of AVT (1, 10 or 100 pmol kg-1 body mass) into trout with dorsal aortic cannulas produced a modest, but dose-dependent, increase in dorsal aortic pressure (PDA). Bolus injection of AVT (100 pmol kg-1 body mass), or continuous infusion (6.7 pmol kg-1 min-1), into trout instrumented with dorsal aortic, ventral aortic and central venous cannulas and a ventral aortic flow probe significantly increased PDA as well as ventral aortic (PVA) and central venous (PVEN) blood pressure. Bradycardia accompanied the rapid rise in PVA while gill resistance (RG) increased. Maximum response to the AVT bolus was reached within 13&shy;21 min and the response decayed slowly over the ensuing 90 min. AVT infusion (6.7 pmol kg-1 min-1) significantly increased PVEN and mean circulatory filling pressure and decreased unstressed blood volume, whereas venous compliance was unaffected. These in vivo studies indicate that AVT increases venous tone, thereby mobilizing blood from the unstressed compartment into the stressed compartment. This increases PVEN, which increases venous return and helps maintain, or slightly elevate, cardiac output. This, combined with an elevated RG and slightly elevated systemic resistance (RS), increases both PVA and PDA; however, the rise in PDA is mitigated by a disproportionate increase in RG relative to RS. In vitro, the effects of AVT are consistent with in vivo responses. AVT increased vascular resistance in the perfused gill and perfused trunk and contracted isolated vascular rings from both rainbow and steelhead trout. The general order of sensitivity of isolated vessels to AVT was (in decreasing order): anterior cardinal vein, celiacomesenteric artery, ductus Cuvier, efferent branchial artery, ventral aorta and coronary artery. Extracellular Ca2+ accounted for over 70 % of the tension in the AVT-contracted efferent branchial artery, but only 57 % of the tension in the anterior cardinal vein. Vascular AVT receptor sensitivity (EC50) in vitro ranged from 0.3 to 6 nmol l-1 and was similar to the estimated ED50 for the dose-dependent increase in PDA in vivo (approximately 1 nmol l-1). AVT was not inotropic in paced ventricular rings nor did it exhibit vasorelaxant activity in perfused organs or vascular rings. These results show that AVT is a potent vasoconstrictor in trout and that its two primary cardiovascular targets are the systemic veins and the branchial vasculature.

Effects of natriuretic peptides and nitroprusside on venous function in trout

Active venous regulation of cardiovascular function is well known in mammals but has not been demonstrated in fish. In the present studies, the natriuretic peptides (NP) rat atrial natriuretic peptide (ANP) and trout ventricular natriuretic peptide (VNP), clearance receptor inhibitor SC-46542, and sodium nitroprusside (SNP) were infused into unanesthetized trout fitted with pressure cannulas in the ventral aorta, dorsal aorta, and ductus Cuvier, and a ventral aorta (VA) flow probe was used to measure cardiac output (CO). In another group, in vivo vascular (venous) capacitance curves were obtained during ANP or SNP infusion. The in vitro effects of NP on vessels and the heart were also examined. ANP, VNP, and SC-46542 decreased central venous pressure (PVen), CO, stroke volume (SV), and gill resistance (RG), whereas systemic resistance (RS) and heart rate (HR) increased. Dorsal aortic pressure (PDA) transiently increased and then fell even though RS remained elevated. ANP decreased mean circulatory filling pressure (MCFP), increased vascular compliance at all blood volumes, and increased unstressed volume in hypovolemic fish. ANP had no direct effect on the heart. ANP responses in vivo were not altered in trout made hypotensive by prior treatment with the angiotensin-converting enzyme inhibitor lisinopril. SNP reduced ventral aortic pressure (PVA), PDA, and RS, increased CO and HR, but did not affect PVen, SV, or RG. SNP slightly decreased MCFP but did not affect compliance or unstressed volume. In vitro, large systemic arteries were more responsive than veins to NP, whereas SNP relaxed both. These results show that, in vivo, NP decrease venous compliance, thereby decreasing venous return, CO, and arterial pressure. Conversely, SNP hypotension is due to decreased RS. This is the first evidence for active regulation of venous capacitance in fish, which probably occurs in small veins or venules. The presence of venous baroreceptors is also suggested.

In vitro evaluation of the role of antibodies against Helicobacter pylori in inhibiting adherence of the organism to gastric cells

BACKGROUND

Once Helicobacter pylori infection is established, it is difficult to eradicate despite a persistent systemic and local immune response. It is not known whether immunisation can be used to prevent H pylori infection in humans.

AIMS

To evaluate the effect of the human immune response on adherence of H pylori to gastric cells.

METHODS

Human milk from a woman infected with H pylori and milk from a non-infected woman were each fractionated by chromatography on DEAE cellulose. Bacteria were incubated with either serum, human milk, human milk fractions, or secretory IgA before incubation with Kato III cells (cells from a gastric adenocarcinoma cell line). Bacterial adherence to the cells was assessed using flow cytometry.

RESULTS

Serum from both the H pylori infected and non-infected women killed H pylori. This resulted from the action of complement as heating the serum to 56 degrees C for 30 minutes abolished the bactericidal activity. Immunoglobulin fractions from serum of both infected and non-infected women did not inhibit H pylori adherence to Kato III cells. Human milk from the woman infected with H pylori and from the non-infected woman inhibited binding of H pylori to Kato III cells by 50 to 70%. Secretory IgA isolated from human milk had minimal inhibitory effect on adherence and this was notably less than the inhibitory effect of whole human milk.

CONCLUSIONS

Human milk inhibits adherence of H pylori to Kato III cells and this inhibition is independent of whether or not the donor is infected with H pylori. Secretory IgA has minimal inhibitory effect on H pylori adherence.