A study of the impact of the COVID-19 pandemic on equine veterinary care in the UK

Background

During the COVID-19 pandemic, equine health care in the UK may have been adversely affected due to mandated changes in the delivery of veterinary healthcare and the potential for reduced health-seeking behaviour.

Methods

Electronic patient records (EPRs) were analysed to describe veterinary activity for all equids under the active care of 20 veterinary practices in the UK in the 12 months before and after the introduction of the first UK lockdown. Pre-pandemic and pandemic levels of clinical activity were compared. Further comparisons of care, including immediate management and treatment, were made following a detailed review of EPRs from randomly selected subsets of equids under care in four time periods.

Results

All measures of activity and face-to-face interaction were lower in the early pandemic period than in the equivalent pre-pandemic period. Compared to pre-pandemic, the early pandemic was associated with a decrease in prophylactic care and non-urgent diagnostic imaging and an increase in systemic non-steroid anti-inflammatory prescription. Convenience sampling of veterinary practices may have limited the generalisability of the findings. The quality of EPRs was variable.

Conclusions

While equine veterinary activity was significantly disrupted in the early pandemic period, there was a rapid return to pre-pandemic levels of activity. Subsequent lockdowns appeared to have had little effect on veterinary care.

Use of antimicrobials licensed for systemic administration in UK equine practice

BACKGROUND

Judicious antimicrobial use (AMU) is important for preserving therapeutic effectiveness. Large-scale studies of antimicrobial prescribing can provide clinical benchmarks and help identify opportunities for improved stewardship.

OBJECTIVES

To describe systemic AMU in UK equine practice and identify factors associated with systemic and Category B (third and fourth generation cephalosporins, quinolones and polymixins) AMU.

STUDY DESIGN

Retrospective cohort.

METHODS

Anonymised electronic patient records (EPRs) for all equids attended by 39 UK veterinary practices between 1 January and 31 December 2018 were collected via the VetCompass programme. Systemic antimicrobial prescriptions were identified using electronic keyword searches. Indications for AMU were determined through manual review of a randomly selected subset of EPRs. The types and frequency of systemic antimicrobials prescribed and indications were summarised using descriptive statistics. Mixed-effects logistic regression was used to evaluate practice- and horse-related risk factors.

RESULTS

Systemic antimicrobials were prescribed to 12 538 (19.5%, 95% confidence interval [CI]: 19.2%-19.8%) of 64 322 equids attended in 2018. Category B antimicrobials were prescribed to 1.9% (95% CI: 1.8%-2.0%) of attended equids and in 8.9% (95% CI: 8.5%-9.4%) of antimicrobial courses. Bacteriological culture was performed in 19.1% (95% CI: 17.1%-21.3%) of Category B antimicrobial courses. The most commonly prescribed antimicrobial classes were potentiated sulphonamides (50.2% of equids receiving antimicrobials) and tetracyclines (33.5% of equids receiving antimicrobials). Integumentary disorders were the most common reason for systemic AMU (40.5% of courses). Urogenital disorders were the most common reason for Category B AMU (31.1% of courses). Increased odds of systemic and Category B AMU were observed in equids <1 year compared with those aged 5-14 years. Breed was associated with AMU, with odds of systemic and Category B AMU highest in Thoroughbreds and Thoroughbred crosses.

MAIN LIMITATIONS

Convenience sample of practices may limit generalisability.

CONCLUSIONS

Empirical use of Category B antimicrobials remains commonplace.

Opioid Use After Laparoscopic Surgery for Endometriosis and Pelvic Pain

STUDY OBJECTIVE

The primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements.

DESIGN

Prospective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control.

SETTING

Tertiary care, academic center.

PATIENTS

A total of 100 women with endometriosis or pelvic pain.

INTERVENTIONS

Laparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists.

MEASUREMENTS AND MAIN RESULTS

A total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n = 1) and maximum of 20 (n = 3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p = .044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p = .013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p = .051; 7.7 vs 5.2, p = .155; 8.1 vs 5.6, p = .118).

CONCLUSION

Most patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.

New Distribution Records of Biting Midges of the Genus Culicoides (Diptera: Ceratopogonidae) Latreille, Culicoides bergi and Culicoides baueri, in Southern Ontario, Canada

Some species of Culicoides Latreille (Diptera: Ceratopogonidae) can be pests as well as pathogen vectors, but data on their distribution in Ontario, Canada, are sparse. Collecting this baseline data is important given ongoing, accelerated alterations in global climate patterns that may favor the establishment of some species in northern latitudes. Culicoides spp. were surveyed using UV light traps over two seasons in 2017 and 2018 at livestock farms in southern Ontario, Canada. Two Culicoides spp. not previously recorded in Canada were identified, C. bergi and C. baueri, representing new country and provincial records. Unlike some congenerics, these two species are not currently recognized as vectors of pathogens that pose a health risk to humans, livestock or wildlife in North America. However, the possibility that these Culicoides species may have recently expanded their geographic range, potentially in association with climate and/or landscape changes, warrants ongoing attention and research. Furthermore, our results provoke the question of the potential undocumented diversity of Culicoides spp. in Ontario and other parts of Canada, and whether other Culicoides spp. may be undergoing range expansion. The current and future distributions of Culicoides spp., and other potential vectors of human, agricultural, and wildlife health significance, are important to identify for proper disease risk assessment, mitigation, and management.

Abdominal wall endometriosis: an update in diagnosis, perioperative considerations and management

PURPOSE OF REVIEW

Abdominal wall endometriosis (AWE) is rare with limited evidence guiding diagnosis and treatment. The purpose of this review is to provide an update of the diagnosis, perioperative considerations, and treatment of AWE.

RECENT FINDINGS

Recent studies further characterize presenting symptoms and locations of AWE. Prior abdominal surgery remains the greatest risk factor for the development of AWE. Newer evidence suggests that increasing BMI may also be a risk factor. Ultrasound is first-line imaging for diagnosis. Magnetic resonance image is preferred for surgical planning for deep or extensive lesions. Laparotomy with wide local excision is considered standard treatment for AWE with great success. Novel techniques in minimally invasive surgery have been described as effective for the treatment of AWE. A multidisciplinary surgical approach is often warranted for successful excision and reapproximation of skin and/or fascial defects. Noninvasive therapies including ultrasonic ablation or cryotherapy are also emerging as promising treatment strategies in select patients.

SUMMARY

Recent studies provide further evidence to guide diagnosis through physical exam and imaging as well as pretreatment planning. Treatment options for AWE are rapidly expanding with novel approaches in minimally invasive and noninvasive therapies now available.

Upgraded CRISPR/Cas9 tools for tissue-specific mutagenesis in Drosophila

CRISPR/Cas9 has emerged as a powerful technology for tissue-specific mutagenesis. However, tissue-specific CRISPR/Cas9 tools currently available in Drosophila remain deficient in three significant ways. First, many existing gRNAs are inefficient, such that further improvements of gRNA expression constructs are needed for more efficient and predictable mutagenesis in both somatic and germline tissues. Second, it has been difficult to label mutant cells in target tissues with current methods. Lastly, application of tissue-specific mutagenesis at present often relies on Gal4-driven Cas9, which hampers the flexibility and effectiveness of the system. Here, we tackle these deficiencies by building upon our previous CRISPR-mediated tissue-restricted mutagenesis (CRISPR-TRiM) tools. First, we significantly improved gRNA efficiency in somatic tissues by optimizing multiplexed gRNA design. Similarly, we also designed efficient dual-gRNA vectors for the germline. Second, we developed methods to positively and negatively label mutant cells in tissue-specific mutagenesis by incorporating co-CRISPR reporters into gRNA expression vectors. Lastly, we generated genetic reagents for convenient conversion of existing Gal4 drivers into tissue-specific Cas9 lines based on homology-assisted CRISPR knock-in. In this way, we expand the choices of Cas9 for CRISPR-TRiM analysis to broader tissues and developmental stages. Overall, our upgraded CRISPR/Cas9 tools make tissue-specific mutagenesis more versatile, reliable, and effective in Drosophila These improvements may be also applied to other model systems.

Versatile CRISPR/Cas9-mediated mosaic analysis by gRNA-induced crossing-over for unmodified genomes

Mosaic animals have provided the platform for many fundamental discoveries in developmental biology, cell biology, and other fields. Techniques to produce mosaic animals by mitotic recombination have been extensively developed in Drosophila melanogaster but are less common for other laboratory organisms. Here, we report mosaic analysis by gRNA-induced crossing-over (MAGIC), a new technique for generating mosaic animals based on DNA double-strand breaks produced by CRISPR/Cas9. MAGIC efficiently produces mosaic clones in both somatic tissues and the germline of Drosophila. Further, by developing a MAGIC toolkit for 1 chromosome arm, we demonstrate the method's application in characterizing gene function in neural development and in generating fluorescently marked clones in wild-derived Drosophila strains. Eliminating the need to introduce recombinase-recognition sites into the genome, this simple and versatile system simplifies mosaic analysis in Drosophila and can in principle be applied in any organism that is compatible with CRISPR/Cas9.

The Drosophila seminal proteome and its role in postcopulatory sexual selection

Postcopulatory sexual selection (PCSS), comprised of sperm competition and cryptic female choice, has emerged as a widespread evolutionary force among polyandrous animals. There is abundant evidence that PCSS can shape the evolution of sperm. However, sperm are not the whole story: they are accompanied by seminal fluid substances that play many roles, including influencing PCSS. Foremost among seminal fluid models is Drosophila melanogaster, which displays ubiquitous polyandry, and exhibits intraspecific variation in a number of seminal fluid proteins (Sfps) that appear to modulate paternity share. Here, we first consolidate current information on the identities of D. melanogaster Sfps. Comparing between D. melanogaster and human seminal proteomes, we find evidence of similarities between many protein classes and individual proteins, including some D. melanogaster Sfp genes linked to PCSS, suggesting evolutionary conservation of broad-scale functions. We then review experimental evidence for the functions of D. melanogaster Sfps in PCSS and sexual conflict. We identify gaps in our current knowledge and areas for future research, including an enhanced identification of PCSS-related Sfps, their interactions with rival sperm and with females, the role of qualitative changes in Sfps and mechanisms of ejaculate tailoring. This article is part of the theme issue 'Fifty years of sperm competition'.

Roles of Noncoding RNAs in Ciliate Genome Architecture

Ciliates are an interesting model system for investigating diverse functions of noncoding RNAs, especially in genome defence pathways. During sexual development, the ciliate somatic genome undergoes massive rearrangement and reduction through removal of transposable elements and other repetitive DNA. This is guided by a multitude of noncoding RNAs of different sizes and functions, the extent of which is only recently becoming clear. The genome rearrangement pathways evolved as a defence against parasitic DNA, but interestingly also use the transposable elements and transposases to execute their own removal. Thus, ciliates are also a good model for the coevolution of host and transposable element, and the mutual dependence between the two. In this review, we summarise the genome rearrangement pathways in three diverse species of ciliate, with focus on recent discoveries and the roles of noncoding RNAs.

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Ciliate genomes undergo massive rearrangement and reduction during development.

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Transposon elimination is guided by small RNAs and carried out by transposases.

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New pathways for noncoding RNA production have recently been discovered in ciliates.

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Diverse ciliate species have different mechanisms for RNA-guided genome remodeling.

A96 PERIOPERATIVE RATE OF CHANGE IN SODIUM CONCENTRATION AND ITS IMPACT ON LENGTH OF STAY IN CRITICAL CARE UNIT POST LIVER TRANSPLANTATION: BENCHMARKING FOR QUALITY MANAGEMENT PROGRAM

Aims

The aim of this quality improvement project was to benchmark the rate of change in serum sodium (delta-Na) in the perioperative period for liver transplantation (OLT) to correlate it with neurological complications as well as length of stay in critical care unit.

Methods

Data for total of 46 patients who underwent liver transplantation in Halifax between January 2015 and December 2016 were extracted from Atlantic Multi-Organ Transplant Program and QEII-HSC Information Systems. Pre-operative, immediate post-operative and 24–48 hours post-operative serum sodium concentrations were entered into EXCEL worksheet. In addition post-transplant neurological complications were identified in addition to length of stay in critical care unit.

Results

During the review period, 23 males and 23 females underwent OLT. Their mean age was 56 yrs (ranging from 23 - 70 yrs). The primary indication for transplantation was cirrhosis (57%) and hepatocellular carcinoma (35%). Fatty liver disease was most common etiology for cirrhosis (46%), followed by PBC (27%), Alcohol-related (15%). Average natural MELD-Na score was 20 (with a range from 7 – 41). Average OR time was 7hr 23min (range 4hr 15min – 15hr).

In 22% of patients, the rate of delta-Na levels were rapid (more than 8 mEq/L) between the pre-operative and immediate post-operative period. Only 2% of patients had more than 8 mEq/L change in their serum sodium levels between the first and second post-operative days. Prior to OLT 21 (46%) patients had hepatic encephalopathy but this was mild or controlled in the majority of patients. In 8 (17%) patients there was multiple-etiology encephalopathy/delirium in the post-operative period. None of these patients developed neurological deficits. Only in 3 patients, tremors were documented (probably multifactorial including calcineurin-inhibitor toxicity). In this project, none of these findings correlated with a high rate of delta-Na.

The average number of days in critical care unit was 6 (range 1 – 62 days). There was no clear correlation between length of stay (surrogate marker for neurologic complications) and rate of delta-Na.

Conclusions

In this benchmarking project, we were unable to identify a specific cut-off rate for delta-Na to correlate with either neurologic complication or length of stay in critical care unit. Rapid correction of serum sodium is often associated with various neurologic complications including central pontine myelinosis. Larger data-base with more numbers of liver transplant patients are needed to show any significant relationship and optimize the electrolyte and volume management. Rapid change in serum sodium could not help with our attempt to classify this benchmarking metric into one of four categories: productivity, quality, time and cost-related.

Funding Agencies

NoneKEVORK M PELTEKIAN

The genome of a subterrestrial nematode reveals adaptations to heat

The nematode Halicephalobus mephisto was originally discovered inhabiting a deep terrestrial aquifer 1.3 km underground. H. mephisto can thrive under conditions of abiotic stress including heat and minimal oxygen, where it feeds on a community of both chemolithotrophic and heterotrophic prokaryotes in an unusual ecosystem isolated from the surface biosphere. Here we report the comprehensive genome and transcriptome of this organism, identifying a signature of adaptation: an expanded repertoire of 70 kilodalton heat-shock proteins (Hsp70) and avrRpt2 induced gene 1 (AIG1) proteins. The expanded Hsp70 genes are transcriptionally induced upon growth under heat stress, and we find that positive selection is detectable in several members of this family. We further show that AIG1 may have been acquired by horizontal gene transfer (HGT) from a rhizobial fungus. Over one-third of the genes of H. mephisto are novel, highlighting the divergence of this nematode from other sequenced organisms. This work sheds light on the genomic basis of heat tolerance in a complete subterrestrial eukaryotic genome.

The nematode Halicephalobus mephisto has been found more than 1 km underground and can tolerate high heat and low oxygen. Here Weinstein et al. report the genome and transcriptome of H. mephisto and identify genomic innovations that likely are responsible for its tolerance to heat.

Social norm feedback reduces primary care antibiotic prescribing in a regression discontinuity study

Background

Reducing antibiotic prescribing is a priority for health authorities responsible for preventing antimicrobial resistance. Northern Ireland has high rates of antimicrobial use. We implemented a social norm feedback intervention and evaluated its impact.

Objectives

To estimate the size and duration of the effect of a social norm feedback letter to GPs who worked in the 20% of practices with the highest antimicrobial prescribing.

Methods

The letter was sent in October 2017 to 221 GPs in 67 practices. To assess the effect of the intervention, we used a sharp non-parametric regression discontinuity (RD) design, with prescribing rates in the four calendar quarters following the intervention as the outcome variables.

Results

In the quarter following the intervention (October to December 2017) there was a change of −25.7 (95% CI = −42.5 to −8.8, P = 0.0028) antibiotic items per 1000 Specific Therapeutic group Age-sex Related Prescribing Units (STAR-PU). At 1 year, the coefficient was −58.7 (95% CI = −116.7 to −0.7, P = 0.047) antibiotic items per 1000 STAR-PU. The greatest change occurred soon after the intervention. Approximately 18900 fewer antibiotic items were prescribed than if the intervention had not been made (1% of Northern Ireland’s annual primary care antibiotic prescribing).

Conclusions

A social norm feedback intervention reduced antibiotic prescribing in the intervention practices. The diminishing effect over time suggests the need for more frequent feedback. The RD method allowed measurement of the effectiveness of an intervention that was delivered as part of normal business, without a randomized trial.

Targeted deletion of a 170-kb cluster of LINE-1 repeats and implications for regional control

Approximately half the mammalian genome is composed of repetitive sequences, and accumulating evidence suggests that some may have an impact on genome function. Here, we characterized a large array class of repeats of long-interspersed elements (LINE-1). Although widely distributed in mammals, locations of such arrays are species specific. Using targeted deletion, we asked whether a 170-kb LINE-1 array located at a mouse imprinted domain might function as a modulator of local transcriptional control. The LINE-1 array is lamina associated in differentiated ES cells consistent with its AT-richness, and although imprinting occurs both proximally and distally to the array, active LINE-1 transcripts within the tract are biallelically expressed. Upon deletion of the array, no perturbation of imprinting was observed, and abnormal phenotypes were not detected in maternal or paternal heterozygous or homozygous mutant mice. The array does not shield nonimprinted genes in the vicinity from local imprinting control. Reduced neural expression of protein-coding genes observed upon paternal transmission of the deletion is likely due to the removal of a brain-specific enhancer embedded within the LINE array. Our findings suggest that presence of a 170-kb LINE-1 array reflects the tolerance of the site for repeat insertion rather than an important genomic function in normal development.

Circular Concatemers of Ultra-Short DNA Segments Produce Regulatory RNAs

In the ciliated protozoan Paramecium tetraurelia, Piwi-associated small RNAs are generated upon the elimination of tens of thousands of short transposon-derived DNA segments as part of development. These RNAs then target complementary DNA for elimination in a positive feedback process, contributing to germline defense and genome stability. In this work, we investigate the formation of these RNAs, which we show to be transcribed directly from the short (length mode 27 bp) excised DNA segments. Our data support a mechanism whereby the concatenation and circularization of excised DNA segments provides a template for RNA production. This process allows the generation of a double-stranded RNA for Dicer-like protein cleavage to give rise to a population of small regulatory RNAs that precisely match the excised DNA sequences.

Video Abstract

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In Paramecium, pieces of deleted DNA are transcribed to form regulatory RNAs

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Ultra-short DNA segments are concatenated and circularized, allowing transcription

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This concatenation is carried out by Ligase IV, which also repairs DNA ends

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Concatenation is random, which leads to diversity in the resulting sRNA population

Description of veterinary events and risk factors for fatality in National Hunt flat racing Thoroughbreds in Great Britain (2000-2013)

BACKGROUND

No large-scale studies have described veterinary events occurring in National Hunt (NH) flat racing or investigated risk factors for fatality in this race type.

OBJECTIVES

To describe injuries and conditions requiring veterinary attendance on race day and to determine risk factors for racehorse fatality in NH flat racing in Great Britain.

STUDY DESIGN

Retrospective cohort study (2000-2013).

METHODS

Information from all NH flat races held over the study period, including horse, race and veterinary event report details, was combined. Veterinary events were described by type and anatomical structure(s) affected. Incidence per 1000 starts were calculated for all veterinary events and by event group, and stratified by certain horse- and race-level variables. Risk factors for fatality were determined using multivariable logistic regression modelling.

RESULTS

Over the 14-year study period, 544 veterinary events were recorded, providing an overall incidence of 13.0 events per 1000 starts. The most common events were bone injuries (23.5%) and tendon or ligament injuries (16.4%). A fatal outcome was recorded for 117 horses (21.5% of all events), resulting in an incidence of 2.9 deaths per 1000 starts. Odds of fatality were 4.33 (95% confidence interval [CI] 1.59-11.82; P = 0.02) times higher in races restricted to conditional jockeys compared to those that were not. Horses starting in their first race experienced 1.44 (95% CI 1.00-2.08; P = 0.05) times the odds of death compared to those that had raced before.

MAIN LIMITATIONS

Classification of veterinary events frequently relied upon presumptive diagnosis.

CONCLUSIONS

This study provides a benchmark for the ongoing surveillance of veterinary events in NH flat racing. These results support the phasing out of NH flat races restricted to conditional jockeys and highlight the need for further work to establish why NH flat racing Thoroughbreds competing in their first race are at increased risk for death.

Is use of multiple antihypertensive agents to achieve blood pressure control associated with adverse pregnancy outcomes?

OBJECTIVE

We assessed whether requiring >1 medication for blood pressure control is associated with adverse pregnancy outcomes.

STUDY DESIGN

Retrospective cohort of 974 singletons with chronic hypertension at a tertiary care center. Subjects on >1 antihypertensive agent were compared with those on one agent <20 weeks gestational age with results stratified by average blood pressure (<140/90 and ⩾140/90 mm Hg) from prenatal visits. The primary maternal outcome was preeclampsia; the primary neonatal outcome was small for gestational age (<10th percentile).

RESULT

Among women with blood pressure ⩾140/90 mm Hg, women on multiple agents had the greatest risk of preeclampsia, severe preeclampsia, antenatal admissions to rule out preeclampsia, preterm birth <35 weeks and composite neonatal adverse outcomes.

CONCLUSION

Compared with use of a single agent when blood pressure is ⩾140/90 mm Hg, use of multiple agents increases adverse risks, while no such finding exists when blood pressure is controlled below 140/90 mm Hg.

Necessity Is the Mother of Invention: Ciliates, Transposons, and Transgenerational Inheritance

Ciliates are a fascinating model system for the study of the interaction between eukaryotic germlines and somatic lines, especially with regard to the invasion and defence against transposable elements. They separate their germline and somatic line into two nuclei within the same cell, and they silence transposons and repetitive elements by way of deleting them from their somatic genome. This large-scale deletion event uses a series of intricate sequence targeting pathways involving small RNAs and transposases, part of which consists of a transnuclear comparison between maternal soma and daughter germline. We present recent progress in this dynamic field, and argue that these DNA targeting pathways provide an optimal system for the transgenerational inheritance of acquired traits. Ciliates thus also demonstrate the evolutionary value of transposable elements, both as sources of sequence diversity and also as drivers of adaptive evolution by necessitating defensive systems.

Using Vancomycin Concentrations for Dosing Daptomycin in a Morbidly Obese Patient with Renal Insufficiency

Objective:

To report a case in which vancomycin clearance was used to determine the daptomycin dosing interval in a morbidly obese patient with renal impairment.

Case Summary:

A 46-year-old man (209 kg; 178 cm) failed a 42 day course of vancomycin therapy for treatment of a methicillin-resistant Staphylococcus aureus–infected wound and cellulitis. The median trough vancomycin concentration was 12.6 μg/mL (range 7.3–24.1) through his course of therapy. Estimation of creatinine clearance (Clcr) was confounded in this clinical scenario, given the patient's weight and a lack of valid equations in this patient population. Daptomycin was administered empirically at 6 mg/kg dosed every 48 hours based on estimated clearance from measured vancomycin concentrations. Steady-state plasma concentrations of daptomycin were determined, and the daptomycin half-life in this patient was more accurately estimated using vancomycin clearance as a surrogate. In addition, a 4 mg/kg dose of daptomycin would have been sufficient based on plasma concentrations. The patient demonstrated rapid clinical improvement and remained free of cellulitis for 6 months after completion of daptomycin and a 12 week course of trimethoprim/sulfamethoxazole.

Discussion:

The dosing interval of daptomycin is adjusted based on Clcr. However, estimation of Clcr is difficult in morbidly obese patients with renal impairment, given a lack of valid equations. In this clinical scenario, vancomycin concentrations were used to estimate Clcr and served as a surrogate measure to determine the daptomycin dosing interval. Measured daptomycin concentrations validated this approach and confirmed the inadequacy of commonly used Clcr equations.

Conclusions:

In this clinical scenario, vancomycin concentrations more accurately estimated Clcr, thereby facilitating determination of the daptomycin dosing interval.

Improving performance in the detection and management of cystic fibrosis-related diabetes in the Mountain West Cystic Fibrosis Consortium

OBJECTIVE

Cystic fibrosis (CF)-related diabetes (CFRD) is associated with increased morbidity and mortality. Improved detection and management may improve outcomes; however, actual practice falls short of published guidelines. We studied efforts to improve CFRD screening and management in the Mountain West CF Consortium (MWCFC).

RESEARCH DESIGN AND METHODS

This is a prospective observational cohort study evaluating quality improvement by accredited CF centers in Arizona, Colorado, New Mexico, and Utah performed between 2002 and 2008. After Institutional Review Board (IRB) approval, centers evaluated adherence with CF Foundation guidelines for CFRD. Each center developed and implemented quality improvement plans to improve both screening and management. Centers were reassessed 1 year later.

RESULTS

Initially, each CF center had low adherence with screening recommendations (26.5% of eligible patients) that did not improve during the study. However, patients with confirmed CFRD markedly increased (141 (12% of MWCFC patients) to 224 (17%), p<0.001), and with improved adherence to management guidelines, patients with CFRD had increased weight (56.8-58.9 kg, p<0.001), body mass index (21.1-21.4, p=0.003), and weight-for-age z-score (-1.42 to -0.84, p<0.001). Quality improvement methods were specific to the practice settings of each center but shared the common goal of adhering to CFRD care guidelines. 1 year after implementation, no center significantly differed from any other in level of adherence to guidelines.

CONCLUSIONS

Improving adherence with CFRD care guidelines requires substantial effort and may be incompletely successful, particularly for CFRD screening, but the effort may significantly improve patient monitoring and clinically relevant outcomes such as weight.

A trans-homologue interaction between reciprocally imprinted miR-127 and Rtl1 regulates placenta development

The paternally expressed imprinted retrotransposon-like 1 (Rtl1) is a retrotransposon-derived gene that has evolved a function in eutherian placentation. Seven miRNAs, including miR-127, are processed from a maternally expressed antisense Rtl1 transcript (Rtl1as) and regulate Rtl1 levels through RNAi-mediated post-transcriptional degradation. To determine the relative functional role of Rtl1as miRNAs in Rtl1 dosage, we generated a mouse specifically deleted for miR-127. The miR-127 knockout mice exhibit placentomegaly with specific defects within the labyrinthine zone involved in maternal-fetal nutrient transfer. Although fetal weight is unaltered, specific Rtl1 transcripts and protein levels are increased in both the fetus and placenta. Phenotypic analysis of single (ΔmiR-127/Rtl1 or miR-127/ΔRtl1) and double (ΔmiR-127/ΔRtl1) heterozygous miR-127- and Rtl1-deficient mice indicate that Rtl1 is the main target gene of miR-127 in placental development. Our results demonstrate that miR-127 is an essential regulator of Rtl1, mediated by a trans-homologue interaction between reciprocally imprinted genes on the maternally and paternally inherited chromosomes.

Icacinaceae from the eocene of Western North America

PREMISE OF THE STUDY

The Icacinaceae are a pantropical family of trees, shrubs, and climbers with an extensive Paleogene fossil record. Our improved understanding of phylogenetic relationships within the family provides an excellent context for investigating new fossil fruit and leaf material from the Eocene of western North America.

METHODS

We examined fossils from early and middle Eocene sediments of western Wyoming, northeastern Utah, northwestern Colorado, and Oregon and compared them with extant species of Iodes and other icacinaceous genera as well as previously described fossils of the family.

KEY RESULTS

Three new fossil species are described, including two based on endocarps (Iodes occidentalis sp. nov. and Icacinicaryites lottii sp. nov.) and one based on leaves (Goweria bluerimensis sp. nov.). The co-occurrence of I. occidentalis and G. bluerimensis suggests these might represent detached organs of a single species. A new genus, Biceratocarpum, is also established for morphologically distinct fossil fruits of Icacinaceae previously placed in Carpolithus. Biceratocarpum brownii gen. et comb. nov. resembles the London Clay species "Iodes" corniculata in possessing a pair of subapical protrusions.

CONCLUSIONS

These fossils increase our knowledge of Icacinaceae in the Paleogene of North America and highlight the importance of the Northern Hemisphere in the early diversification of the family. They also document interchange with the Eocene flora of Europe and biogeographic connections with modern floras of Africa and Asia, where Icacinaceae are diverse today. The present-day restriction of this family to tropical regions offers ecological implications for the Eocene floras in which they occur.

Fatal Granulomatous Amebic Encephalitis Due to Balamuthia mandrillaris in New Mexico: A Case Report

Balamuthia mandrillaris is a free-living amoeba that can cause granulomatous amebic encephalitis (GAE). We report a case in an individual with a history of alcohol abuse, cocaine use, and ditch water exposure. This is the first reported case of GAE due to B mandrillaris in New Mexico.

Primary cutaneous infection by Mycobacterium avium: a case report and literature review

Nontuberculous mycobacteria (NTM) are becoming increasingly important cutaneous pathogens as the number of susceptible patients increases. Nevertheless, primary cutaneous infection by one particular species, Mycobacterium avium complex (MAC), remains relatively unusual, particularly in immunocompetent patients. We review the English-language literature on primary cutaneous MAC in patients who were neither immunocompromised nor pharmacologically immunosuppressed. We offer an additional report of a healthy patient who presented to our clinic with primary cutaneous MAC following seemingly innocuous trauma to the leg.

Effects of early and late rest breaks during training on overnight memory consolidation of a keyboard melody

In two experiments, we tested the extent to which overnight procedural memory consolidation is affected by extended rest breaks during training. In the first experiment, nonmusicians practiced a 5-element keypress sequence with their nondominant hand in 12 30-s practice intervals separated by 30-s pauses. In the second experiment, nonpianist musicians practiced a 13-note keyboard melody using the same procedures. In both experiments, approximately one-third of the subjects took a 5-min break after the first three blocks of practice; another third took a break after nine blocks of practice; the remaining participants did not take an extended break. All were trained in the evening and were retested the following morning. Participants in both experiments made dramatic improvements over the course of the training and retest sessions, and participants who took an extended rest break early in practice made the largest gains in performance between the end of training and the beginning of retest.

Trans-Obturator Tape for Incontinence: A 3-Year Follow-Up

AIM

To assess operative and functional outcomes, including morbidity, after using the trans-obturator tape for stress incontinence.

PATIENTS AND METHODS

The first 24 consecutive patients undergoing trans-obturator tape insertion in a single centre were included in this retrospective study. All patients were female with a mean age of 63 (range 40-83) years. Fifteen patients (62.5%) suffered from pure stress incontinence, and 9 patients (37.5%) had mixed incontinence. Of the latter, 2 patients also had nocturnal enuresis. Each patient was followed up for between 3 and 12 months postoperatively and again at 36 months. The patients were assessed by clinical examination, ultrasound for residual urinary volume, and subjective satisfaction which was assessed at 3 and 12 months. At 36 months, all patients completed a validated incontinence questionnaire (International Consultation on Incontinence Questionnaire: ICIQ) which assessed female lower urinary tract symptoms and their impact on the quality of life.

RESULTS

All operations were performed under epidural anaesthesia in day surgery, and the mean operative time was 20 (range 15-38) min. Nineteen patients (79.2%) showed significant improvement postoperatively, with 16 of those (66.6%) being completely cured of their incontinence. The remaining 5 patients (20.8%) were considered to have had failed procedures. There were no vascular, bladder, or urethral injuries. One patient had perforation of the vaginal fornix, and 3 patients developed vaginal erosion.

CONCLUSIONS

The trans-obturator tape is a safe and effective treatment for stress incontinence and has a low morbidity after a 3-year follow-up period; however, it should only be performed by clinicians with the relevant surgical expertise and experience in treating female incontinence.

Prenatal development of hypothalamic neuropeptide systems in the nonhuman primate

In the rodent, arcuate nucleus of the hypothalamus (ARH)-derived neuropeptide Y (NPY) and proopiomelanocortin (POMC) neurons have efferent projections throughout the hypothalamus that do not fully mature until the second and third postnatal weeks. Since this process is likely completed by birth in primates we characterized the ontogeny of NPY and melanocortin systems in the fetal Japanese macaque during the late second (G100), early third (G130) and late third trimesters (G170). NPY mRNA was expressed in the ARH, paraventricular nucleus (PVH), and dorsomedial nucleus of the hypothalamus (DMH) as early as G100. ARH-derived NPY projections to the PVH were initiated at G100 but were limited and variable; however, there was a modest increase in density and number by G130. ARH-NPY/agouti-related peptide (AgRP) fiber projections to efferent target sites were completely developed by G170, but the density continued to increase in the postnatal period. In contrast to NPY/AgRP projections, alphaMSH fibers were minimal at G100 and G130 but were moderate at G170. This study also revealed several significant species differences between rodent and the nonhuman primate (NHP). There were few NPY/catecholamine projections to the PVH and ARH prior to birth, while projections were increased in the adult. A substantial proportion of the catecholamine fibers did not coexpress NPY. In addition, cocaine and amphetamine-related transcript (CART) and alpha-melanocyte stimulating hormone (alphaMSH) were not colocalized in fibers or cell bodies. As a consequence of the prenatal development of these neuropeptide systems in the NHP, the maternal environment may critically influence these circuits. Additionally, because differences exist in the neuroanatomy of NPY and melanocortin circuitry the regulation of these systems may be different in primates than in rodents.

Continuing metformin when starting insulin in patients with Type 2 diabetes: a double-blind randomized placebo-controlled trial

AIMS

To test the effect of continuing metformin on weight gain and glycaemic control in patients with poorly controlled Type 2 diabetes who need to start insulin.

METHODS

Patients with Type 2 diabetes on maximum tolerated oral agents referred for insulin conversion were recruited from hospital diabetes clinics into a double-blind randomized placebo-controlled trial. The 183 participants received metformin or placebo, titrated up to 2 g a day or maximum tolerated dose, with insulin started according to local practice. The main outcome measures were weight change over 12 months, HbA1c, insulin dose, frequency of hypoglycaemia, treatment satisfaction, and well-being.

RESULTS

Over 12 months, metformin was associated with less weight gain than placebo [mean 6.1 kg vs. 7.6 kg; adjusted difference 1.5 kg (95% confidence interval 0.2-2.9); P=0.02], a greater reduction in HbA1c[1.5% vs. 1.3%; adjusted difference 0.5% (0.1-0.9); P=0.02] and a lower insulin requirement [62 units vs. 86; adjusted difference 25 units (15-34); P<0.001], but also more hypoglycaemia [relative risk of any episode 1.24 (1.02-1.1); P=0.03]. Treatment satisfaction improved more in patients on metformin than on placebo (P<0.001), as did the positive well-being score (P=0.02).

CONCLUSIONS

Metformin decreases weight gain, lowers insulin requirement, and improves glycaemic control, and should be continued in patients with Type 2 diabetes who transfer to insulin.

STOMAL COMPLICATIONS OF ILEAL CONDUITS ARE SIGNIFICANTLY HIGHER WHEN FORMED IN WOMEN WITH INTRACTABLE URINARY INCONTINENCE

PURPOSE

The ileal conduit is held to be the safest and simplest form of urinary diversion. There are few reports about long-term problems after ileal conduit formation, especially intractable urinary incontinence in females. We reviewed long-term stomal complications in patients with an ileal conduit.

MATERIALS AND METHODS

Notes on 93 consecutive patients in whom an ileal conduit was created were reviewed. Information was collected on patient demographics, indications for an ileal conduit and long-term complications, in particular parastomal and incisional hernias, stomal retraction, stenosis or prolapse and the development of a redundant loop. Mean followup available was 63.4 months (range 1 to 434).

RESULTS

A total of 33 males with a mean age of 60.1 years (range 2 to 78) and 60 females with a mean age of 48.2 years (range 4 to 79) underwent ileal conduit diversion. The main indications for an ileal conduit were intractable incontinence in 44 patients (47%), cancer in 31 (33%) and interstitial cystitis in 8 (9%). In male, continent female and incontinent female patients A parastomal hernia developed in 3 (9%), 2 (9.5%) and 12 (31%), an incisional hernia developed in 1 (3%), 1 (4.8%) and 2 (5%), stomal retraction developed in 0, 2 (9.5%) and 12 (31%), stomal stenosis developed in 0 (0%), 1 (4.8%) and 6 (15.4%), and a redundant loop developed in 0 (0%), 2 (9.5%) and 5 (12.8%), respectively. A total of 23 patients (24.7%) required further surgery for stomal problems with 13 (57%) requiring more than 1 reoperation, of whom 9 were incontinent females.

CONCLUSIONS

An ileal conduit is associated with a stomal complication rate of 34.4% (61% in incontinent females and 18% in other patients) and a 4.3% incisional hernia rate. Reoperation is required for stomal complications in 24.7% of cases. Stomal complication rates and reoperation rates vary by sex and the indication for ileal conduit, and they are significantly higher for those performed for intractable urinary incontinence in females.

The morbidity of buccal mucosal graft harvest for urethroplasty and the effect of nonclosure of the graft harvest site on postoperative pain

PURPOSE

We assess the medium and long-term morbidity of buccal mucosal graft (BMG) harvest for urethroplasty, and evaluate the effect of nonclosure of the graft harvest site on postoperative pain.

MATERIALS AND METHODS

A questionnaire was mailed to 110 men who underwent BMG urethroplasty between January 1, 1997 and August 31, 2002. Demographic data and side effects of BMG harvest, including oral pain, sensation and intake, were assessed postoperatively. A prospective study was then performed to compare 20 unselected men whose BMG donor site was closed with a group of 20 men in whom it was left open using a 5-point analog pain score that was completed twice daily for the first 5 postoperative days.

RESULTS

A total of 49 men with a median age of 49 years (range 23 to 73) returned questionnaires relating to 57 BMG harvests. Of the graft harvests 47 (83%) were associated with postoperative pain, which was worse than expected in 24 (51%). Of the 57 patients 51 (90%) resumed oral liquid intake within 24 hours and 44 (77%) resumed normal diet within 1 week. Postoperative side effects included perioral numbness in 39 (68%) patients with 15 (26%) having residual numbness after 6 months, initial difficulty with mouth opening in 38 (67%) with 5 (9%) having persistent problems, changes in salivation in 6 (11%) and mucous retention cyst that required excision in 1 (2%). The men in the prospective donor site study had a median age of 51 years (range 24 to 70). Mean pain score for patients with donor site closure was 3.68 and was significantly higher than that for patients without donor site closure (2.26, p < 0.01).

CONCLUSIONS

Buccal mucosal graft harvest is not a pain-free procedure. Closure of the harvest donor site appears to worsen this pain and it may be best to leave harvest sites open. The main long-term complications are perioral numbness, persistent difficulty with mouth opening and change in salivary function.

Ultrasound treatment acceleration of solvent extraction for fumigant residues from wheat

Concerns about consumer and worker safety and the fate of fumigants have fuelled strong efforts to determine their residues in foodstuffs. Fumigants are usually extracted from commodities with solvent at room temperature (25 degrees C). In this paper, solvent extraction of methyl bromide, phosphine, carbonyl sulfide, and carbon disulfide using ultrasonic acceleration or heating was evaluated. Wheat samples plus solvent, in gas-tight bottles, were placed in an ultrasonic chamber or an oven (50 degrees C), and fumigants were released into the headspace over the solvent. Completeness of extraction was demonstrated within 2 h for ultrasonic extraction, 7-20 h for 50 degrees C heating, and 8-35 h for room temperature extraction. The rapidity of extraction was mainly due to ultrasonic vibration rather than increased temperature.

Quantitative assessment of a circulating depolarizing factor in shock

Sustained depolarization of cell membranes and cellular edema are known to accompany various forms of circulatory shock and probably contribute to hypovolemia and cellular dysfunction. It has been proposed that a circulating protein is responsible for these effects. In the present study we have confirmed the existence of a circulating depolarizing factor (CDF) in hemorrhagic shock, burn shock, sepsis, and cardiopulmonary bypass. Plasma samples from pigs or sheep in shock were quantitatively assayed for depolarizing activity using a microelectrode method on rat diaphragm in vitro. The depolarizing effect of CDF in vitro was similar in magnitude to that of shock in situ. We conclude that CDF can entirely account for membrane depolarization during shock. The depolarizing effect of CDF was dose-dependent and saturable; it could be reversed by rinsing the diaphragm with Ringer's or control plasma. CDF activity was detectable in plasma within 5 min after a severe scald and gradually increased over the next 25 min. Resuscitation of hemorrhaged pigs, but not burned sheep, eliminated plasma CDF activity.

Cost-minimization analysis of simvastatin versus atorvastatin for maintenance therapy in patients with coronary or peripheral vascular disease

BACKGROUND

Previous health economic studies have demonstrated the cost-effectiveness of simvastatin in the treatment of coronary heart disease (CHD) based on clinical results of the Scandinavian Simvastatin Survival Study. A prior analysis evaluated the "cost of getting to goal," but ignored all costs after titration. However, when evaluating the cost-effectiveness of long-term therapies, it is important to consider the maintenance costs as well.

OBJECTIVE

The purpose of this study was to evaluate the maintenance costs of treatment with simvastatin versus that of treatment with another more recently available statin, atorvastatin, in a European context.

METHODS

We assessed the long-term maintenance cost of simvastatin versus atorvastatin in terms of the cost of reducing low-density lipoprotein cholesterol (LDL-C) levels to the recommended goals based on a previously published clinical trial in patients with CHD. The analysis focused on the patients in the original clinical trial who were randomized to treatment with simvastatin or atorvastatin. Patients began therapy with 10 mg of simvastatin or atorvastatin; the dose of study drug was titrated every 12 weeks up to 40 mg simvastatin or 80 mg atorvastatin, with the addition of up to 8 g/d of cholestyramine until a modified European Atherosclerosis Society LDL-C goal (<2.84 mmol/L) was reached. As there was no significant difference between the 2 groups in resource utilization for adverse events, only drug costs were included. The calculated average annual maintenance cost was based on the distribution of the final daily dosing regimens and the public drug prices for each regimen. Individual country analyses were conducted using each local currency.

RESULTS

There was no significant difference between groups in the percentage of patients reaching their LDL-C goal over the study period (80% for simvastatin-treated pa- tients vs 89% for atorvastatin-treated patients, P = 0.135). However, the cost of maintaining a similar percentage of patients at their appropriate LDL-C levels was significantly lower in the simvastatin group compared with the atorvastatin group in 13 of the 17 countries assessed. In the remaining 4 countries, there was a cost advantage for simvastatin, but it did not reach statistical significance.

CONCLUSIONS

Across Europe there was a significant reduction in the cost of maintaining patients at their appropriate LDL-C levels with simvastatin versus atorvastatin. The results of this analysis, along with the proven clinical benefits of simvastatin, support the use of this drug as the treatment of choice in the secondary prevention of CHD.

Early programming of T cell populations responding to bacterial infection

The duration of infection and the quantity of Ag presented in vivo are commonly assumed to influence, if not determine, the magnitude of T cell responses. Although the cessation of in vivo T cell expansion coincides with bacterial clearance in mice infected with Listeria monocytogenes, closer analysis suggests that control of T cell expansion and contraction is more complex. In this report, we show that the magnitude and kinetics of Ag-specific T cell responses are determined during the first day of bacterial infection. Expansion of Ag-specific T lymphocyte populations and generation of T cell memory are independent of the duration and severity of in vivo bacterial infection. Our studies indicate that the Ag-specific T cell response to L. monocytogenes is programmed before the peak of the innate inflammatory response and in vivo bacterial replication.

The need for a second dose of ceftriaxone in febrile infants age 4-8 weeks

OBJECTIVE

To determine if a second intramuscular injection of ceftriaxone was necessary in febrile infants who meet low-risk criteria for outpatient therapy.

SETTING

Children's Hospital Emergency Department.

PATIENTS

Febrile infants 4-8 weeks of age.

METHODS

Outpatient treatment criteria included non-toxic appearance, no identifiable source for infection on physical examination, CSF WBC > or = 10/mm3, peripheral WBC < or = 15,000/mm3, normal UA, and normal chest radiograph study, if obtained. Additional requirements included a reliable caretaker and re-evaluation in 24 hours. Infants who met these criteria received intramuscular ceftriaxone 50 mg/kg with instructions to follow-up in 24 hours. At the follow-up visit, infants with no identifiable source for infection and negative cultures received a second dose of intramuscular ceftriaxone and were discharged. Cultures were read at 48 hours and at the conclusion of the study. Medical records were reviewed to identify delayed complications.

RESULTS

172 infants were enrolled. The mean age was 45 days. All CBC, UA, CSF analyses were normal. Chest radiographs were obtained in 56 (30%) infants; all were normal. One (.05%) patient was admitted at the follow-up visit. The mean time to follow-up was 25 hours. Two positive cultures were identified at the re-evaluation visit; one blood culture grew Salmonella and a urine culture grew E. coli. The CSF cultures were all negative at follow-up and remained negative.

CONCLUSION

Febrile infants 4-8 weeks of age who meet outpatient therapy criteria and have negative cultures and no identifiable source for infection at 24 hours may not require the second dose of intramuscular ceftriaxone.

MHC class I restricted T cell responses to Listeria monocytogenes, an intracellular bacterial pathogen

Studies of the murine immune response to infection with the intracellular bacterial pathogen Listeria monocytogenes have provided a wealth of information about innate and acquired immune defenses in the setting of an infectious disease. Our studies have focused on the MHC class I restricted, CD8+ T cell responses of Balb/c mice to L. monocytogenes infection. Four peptides that derive from proteins that L. monocytogenes secretes into the cytosol of infected cells are presented to cytotoxic T lymphocyte (CTL) by the H2-Kd major histocompatibility complex (MHC) class I molecule. We have found that bacterially secreted proteins are rapidly degraded in the host cell cytosol by proteasomes that utilize, at least in part, the N-end rule to determine the rate of degradation. The MHC class I antigen processing pathway is remarkably efficient at generating peptides that bind to MHC class I molecules. The magnitude of in vivo T cell responses, however, is influenced to only a small degree by the amount of antigen or the efficiency of antigen presentation. Measurements of in vivo T cell expansion following L. monocytogenes infection indicate that differences in the sizes of peptide-specific T cell responses are more likely owing to differences in the repertoire of naive T cells than to differences in peptide presentation. This notion is supported by our additional finding that dominant T cell populations express a more diverse T cell receptor (TCR) repertoire than do subdominant T cell populations.

Expression of a type II collagen-specific TCR transgene accelerates the onset of arthritis in mice

Animal models of autoimmune diseases have been instrumental in advancing our understanding of autoimmunity in humans. Collagen-induced arthritis in mice is an autoimmune disease model of rheumatoid arthritis, which is MHC class II restricted and CD4 T cell dependent. To better understand the fundamental role of T cells in arthritis, we have generated a transgenic mouse carrying the rearranged Valpha11.1 and Vbeta8.2 TCR chain genes isolated from a type II collagen (CII)-specific T cell hybridoma. Cell surface analysis indicated that Vbeta8.2 chain was expressed on the surface of nearly all peripheral T cells. Analysis of T cell subsets in transgenic mice revealed a profound skewing in peripheral T cells towards the CD4 population. Although peripheral T cells were not tolerant to CII and responded to CII stimulation in vitro, transgenic mice did not develop spontaneous arthritis. However, a rapid onset of arthritis with severe clinical signs was detected in transgenic mice after immunization with CII in complete Freund's adjuvant. Histological analysis of inflamed joints showed a great resemblance to arthritic joints in man. This unique transgenic mouse model provides valuable insights into the mechanism of arthritis and into potential specific immune interventions.

Profiling linguistic outcomes in young children after cochlear implantation

OBJECTIVE

To summarize the results of cost-utility analyses of pediatric cochlear implantation (PCI) in the United Kingdom.

METHOD

Analyses were based on measured costs of health care and measured educational placements, but on estimates of the gain utility which results from PCI and estimates of the costs of educational placements.

RESULTS

The cost-utility ratio calculated from the costs of health care falls on the margin of the range considered acceptable within the British health-care system. If estimates of cost-savings associated with educational placements are also considered, the resulting ratio is similar to that of other therapies provided within the British health-care system.

CONCLUSION

The analysis is highly sensitive to assumptions about future costs and benefits. There is a need to reduce the number of assumptions by measuring those values which are currently estimated: in particular, the gain in utility associated with PCI and the costs of different educational placements.

Prevalence of hyperandrogenemia among nonhirsute oligo-ovulatory women

OBJECTIVE

To test the hypothesis that oligo-ovulatory ovulation is associated with hyperandrogenemia in the absence of other clinical signs of androgen excess.

DESIGN

Retrospective cohort controlled.

SETTING

Tertiary care university-based outpatient clinic.

PATIENT(S)

Thirty-two consecutive nonhirsute oligo-ovulatory women and 37 healthy eumenorrheic controls.

INTERVENTION(S)

All study subjects underwent a physical exam and blood sampling in the follicular phase of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Serum was assayed for total T, sex hormone-binding globulin (SHBG), androstenedione (A), and DS, and the free T level was calculated.

RESULT(S)

Mean free T was higher and SHBG was lower in oligo-ovulatory patients compared with controls. The oligo-ovulatory patients were subdivided according to severity of menstrual abnormalities into those with cycles < 45 days (n = 19, oligo-ovulatory-short) and > or = 45 days (n = 13, oligo-ovulatory-long). Oligo-ovulatory-long and -short patients had similar mean DS, A, and total T levels; but mean free T was higher and SHBG was lower in oligo-ovulatory-long patients compared with either oligo-ovulatory-short women or controls. Five of 13 (38%) oligo-ovulatory-long patients had at least one abnormal androgen value compared with 1 of 19 (5%) oligo-ovulatory-short patients, which was a significant difference.

CONCLUSION(S)

Approximately 40% of nonhirsute oligo-ovulatory women with cycle intervals > or = 45 days demonstrate at least one abnormally elevated androgen level, suggesting that they may have a discrete form of the polycystic ovary syndrome. Furthermore, this data brings into question the sensitivity of hirsutism as a marker for hyperandrogenemia.

Early passive acquisition in Inuktitut

Passive structures are typically assumed to be one of the later acquired constructions in child language. English-speaking children have been shown to produce and comprehend their first simple passive structures productively by about age four and to master more complex structures by about age nine. Recent crosslinguistic data have shown that this pattern may not hold across languages of varying structures. This paper presents data from four Inuit children aged 2;0 to 3;6 that shows relatively early acquisition of both simple and complex forms of the passive. Within this age range children are productively producing truncated, full, action and experiential passives. Some possible reasons for this precociousness are explored including adult input and language structure.

Hantavirus pulmonary syndrome: radiographic findings in 16 patients

PURPOSE

To characterize chest radiographic features of Hantavirus pulmonary syndrome.

MATERIALS AND METHODS

Initial and follow-up chest radiographs from 16 patients with confirmed Hantavirus pulmonary syndrome were reviewed for radiographic findings of either cardiogenic pulmonary edema or pulmonary edema due to increased permeability of the alveolar capillary membranes.

RESULTS

Findings indicative of interstitial edema were present more frequently (14 [88%] of 16 patients) than is typically seen in adult respiratory distress syndrome (5%). Alveolar flooding subsequently developed in 11 (69%) of 16 patients and was not the peripheral pattern usually seen in the acute phase of adult respiratory distress syndrome. Overall mortality was 43%. Lung specimens obtained at autopsy showed a pattern of endothelial leak with minimal epithelial injury.

CONCLUSION

The lung disease caused by Hantavirus in these patients may explain the findings of interstitial edema and central alveolar filling atypical of adult respiratory distress syndrome. Recognition of the radiographic pattern will be important in identifying this apparently widespread cause of increased permeability pulmonary edema.

Combined procedure for repair of involutional entropion

Combined procedures that address multiple etiologic factors in involutional entropion are not new, but ophthalmic surgeons have been slow to accept this surgical approach. Traditional procedures that correct only one or two of the etiologic factors have a high incidence of recurrent entropion. The purpose of this article is to encourage the use of a combined procedure in the treatment of all cases of primary and recurrent entropion to minimize recurrences. Between 1983 and 1989, 127 consecutive eyelids with involutional entropion in 97 patients were operated by the senior author (R.P.C.) using the procedure described in this paper. Of these eyelids, 39% (49) had previous surgery and 22% (28) had more than one previous procedure. Although occasional minor postoperative problems occurred, they were readily managed, and there have been no known recurrences of entropion with an average follow-up of 33 months.

Experimental transmission of bovine viral diseases by insemination with contaminated semen or during embryo transfer

Three experimental approaches were used to study transmission of blue tongue (BT), infectious bovine rhinotracheitis (IBR) and bovine virus diarrhoea (BVD) viruses. These were insemination with contaminated semen, experimental infection of embryo donor cows, or transfer of embryos experimentally exposed to virus in vitro to normal recipients. Parameters assessed included number and quality of embryos produced, virus detection (isolation and electron microscopy), serology and histopathology. All superovulated sesceptible cows inseminated with semen containing blue tongue virus (BTV) (n = 2) or infectious bovine rhinotracheitis virus (IBRV) (n = 2) became infected. One cow inseminated with semen containing BTV produced seven virus-free seven-day-old embryos; the second cow failed to produce any embryos. One of two cows inseminated with semen containing IBRV produced two underdeveloped, virus-free embryos while no embryos were produced by the second cow. One of two cows inseminated with semen containing bovine viral diarrhoea virus (BVDV) became infected. Two poorly developed, virus-free seven-day-old embryos were recovered from one of these cows. Superovulated susceptible cows inoculated either intramuscularly with BTV (n = 3) or intranasally with IBR virus (n = 2) became infected. Virus was isolated from some tissues of two BTV-infected cows, neither of which produced embryos. A third BTV-infected cow produced two virus-free embryos collected at necropsy five days after inoculation. One of two cows experimentally infected with IBR virus, produced three embryos but virus was not detected either by electron microscopy (1 embryo) or in cell culture by cytopathic alterations (1 embryo).(ABSTRACT TRUNCATED AT 400 WORDS)

H1 antihistamines interact with central sigma receptors

Several antihistamines were evaluated for their ability to interact with sigma, muscarinic and histaminic H1 binding sites in rat brain preparations. All of the antihistamines were able to interact with the sigma site, as well as the other two sites. In addition, tripelennamine was found to elicit sigma-like behaviors when administered to rats. This affinity for the sigma site suggests that the compounds may elicit some of their undesirable CNS side effects via this interaction.

Buserelin in a superovulatory regimen for Holstein cows. I. Pituitary and ovarian hormone response in an experimental herd

Two experiments were conducted with frequent blood sampling in standard superovulatory regimens using follicle stimulating hormone (FSH) and prostaglandin F(2) alpha (PGF) to study the effects of the gonadotropin releasing hormone analog, Buserelin, on changes in FSH, luteinizing hormone (LH), progesterone (P(4)) and estradiol (E(2)). In Experiment I, Buserelin (20 mug) was administered to a total of 28 dry Holsteins. One group was treated with Buserelin 36 and 60 h after PGF administration, a second group was treated 60 h after PGF, and a third group served as the controls. In Experiment II, 30 dry Holsteins received Buserelin (10 mug). One group was treated 48 h after PGF, a second group at 54 h after PGF, a third group 24 h after estrus was first observed and a fourth group was a control. The general pattern of a decrease in P(4) following PGF, an increase in E(2), the onset of estrus, an LH peak, and finally, an increase in P(4) in superovulated cows was observed. Buserelin consistently produced a sharp LH peak at 36 h when given 36 h after PGF. At later intervals, it produced either a major or minor peak depending upon whether a spontaneous LH peak had already occurred. There was too much individual cow variation in the interval from PGF to a spontaneous LH peak to consistently induce a uniform LH peak, except when Buserelin was given 36 h after PGF, which may be early for normal oocyte maturation. There was no treatment effect on FSH, and embryo recovery rate was unaffected by treatment (P>0.05).

Buserelin in a superovulatory regimen for Holstein cows: II. Yield and quality of embryos in commercial herds

The gonadotropin releasing hormone analog, Buserelin, was tested in a superovulatory regimen in cows by administering 8 mug of it at the following times: Group I (12 cows), 48 h after the first prostaglandin F(2) alpha (PGF) injection: Group II (11 cows), 54 h after PGF: Group III (10 cows), 24 h after standing estrus was first observed; and Group IV (12 cows), served as superovulated controls. The cows were lactating Holsteins between 45 and 143 d post partum, with at least one estrus prior to superovulation. The number of embryos collected from Groups I, II, III and IV 7 d after estrus averaged 4.5, 8.1, 6.4 and 5.6, respectively (P>0.05). The fertilization rate in the three groups receiving Buserelin was 83 versus 76% for controls (P<0.10). Blood and milk samples taken just before starting follicle stimulating hormone treatment at the expected estrus and at the time of embryo recovery were tested for progesterone concentration, and results from a rapid ELISA test were useful in identifying cows that a) were unsuitable for superovulation, b) should have been in estrus but were not observed standing and c) produced few, if any, embryos.