Low-Protein Diets Differentially Regulate Energy Balance during Thermoneutral and Heat Stress in Cobb Broiler Chicken (Gallus domesticus)

The objective was to assess whether low-protein (LP) diets regulate food intake (FI) and thermogenesis differently during thermoneutral (TN) and heat stress (HS) conditions. Two-hundred-day-old male broiler chicks were weight-matched and assigned to 36 pens with 5-6 chicks/pen. After 2 weeks of acclimation, birds were subjected into four groups (9 pens/group) including (1) a normal-protein diet under TN (ambient temperature), (2) an LP diet under TN, (3) a normal-protein diet under HS (35 °C for 7 h/day), and (4) an LP diet under HS, for 4 weeks. During HS, but not TN, LP tended to decrease FI, which might be associated with a lower mRNA abundance of duodenal ghrelin and higher GIP during HS. The LP group had a higher thermal radiation than NP under TN, but during HS, the LP group had a lower thermal radiation than NP. This was linked with higher a transcript of muscle β1AR and AMPKα1 during TN, but not HS. Further, LP increased the gene expression of COX IV during TN but reduced COX IV and the sirtuin 1 abundance during HS. The dietary protein content differentially impacted plasma metabolome during TN and HS with divergent changes in amino acids such as tyrosine and tryptophan. Compared to NP, LP had increased abundances of p_Tenericutes, c_Mollicutes, c_Mollicutes_RF9, and f_tachnospiraceae under HS. Overall, LP diets may mitigate the negative outcome of heat stress on the survivability of birds by reducing FI and heat production. The differential effect of an LP diet on energy balance during TN and HS is likely regulated by gut and skeletal muscle and alterations in plasma metabolites and cecal microbiota.

Divergence and gene flow history at two large chromosomal inversions underlying ecotype differentiation in the long-snouted seahorse

Chromosomal inversions can play an important role in divergence and reproductive isolation by building and maintaining distinct allelic combinations between evolutionary lineages. Alternatively, they can take the form of balanced polymorphisms that segregate within populations until one arrangement becomes fixed. Many questions remain about how inversion polymorphisms arise, how they are maintained over the long term, and ultimately, whether and how they contribute to speciation. The long-snouted seahorse (Hippocampus guttulatus) is genetically subdivided into geographic lineages and marine-lagoon ecotypes, with shared structural variation underlying lineage and ecotype divergence. Here, we aim to characterize structural variants and to reconstruct their history and suspected role in ecotype formation. We generated a near chromosome-level genome assembly and described genome-wide patterns of diversity and divergence through the analysis of 112 whole-genome sequences from Atlantic, Mediterranean, and Black Sea populations. By also analysing linked-read sequencing data, we found evidence for two chromosomal inversions that were several megabases in length and showed contrasting allele frequency patterns between lineages and ecotypes across the species range. We reveal that these inversions represent ancient intraspecific polymorphisms, one likely being maintained by divergent selection and the other by pseudo-overdominance. A possible selective coupling between the two inversions was further supported by the absence of specific haplotype combinations and a putative functional interaction between the two inversions in reproduction. Lastly, we detected gene flux eroding divergence between inverted alleles at varying levels for the two inversions, with a likely impact on their dynamics and contribution to divergence and speciation.

Impact of obesity on morbidity and oncologic outcomes after total mesorectal excision for mid and low rectal cancer

BACKGROUND

A recent meta-analysis showed that obesity increased the conversion rate and postoperative morbidity of rectal cancer surgery, but did not influence pathological results. However, this meta-analysis included patients with cancer of the upper rectum and had many biases. The aim of the present retrospective study was to investigate the impact of obesity, defined as a body mass index (BMI) ≥ 30 kg/m², on postoperative morbidity and short- and long-term oncologic outcomes of total mesorectal excision for mid and low rectal cancer in consecutive patients.

METHODS

This study included all eligible patients who were operated on for mid and lower rectal cancer between 1999 and 2018 in our hospital. We compared 90-day postoperative morbidity and mortality, and short- and long-term oncologic outcomes between obese and non-obese patients.

RESULTS

Three hundred and ninety patients [280 males, mean age 65.7 ± 11.3 years, 59 obese individuals (15.1%)] were included. There was no difference in the 90-day mortality rate between obese and non-obese groups (p = 0.068). There was a difference in the overall 90-day morbidity rate between the obese and non-obese groups that disappeared after propensity score matching of the patients. There was no difference in short-term oncological parameters, with a median follow-up of 43 (20-84) months, and there were no significant differences in disease-free and overall survival between obese and non-obese patients (p = 0.42 and p = 0.11, respectively).

CONCLUSIONS

Obesity does not affect the 90-day morbidity rate, or short- and long-term oncologic results in patients operated on for mid and lower rectal cancer.

The genome sequence of the killer whale, Orcinus orca (Linnaeus, 1758)

We present a genome assembly from an individual female Orcinus orca (the killer whale; Chordata; Mammalia; Artiodactyla; Delphinidae). The genome sequence is 2.65 gigabases in span. The majority of the assembly (93.76%) is scaffolded into 22 chromosomal pseudomolecules with the X sex chromosome assembled. The complete mitochondrial genome was also assembled and is 16.4 kilobases in length.

AB0649 Myositis Specific Antibodies - Who orders them and what are the results? A retrospective audit of two large referral centers

Background

Idiopathic inflammatory myopathies are a group of disorders associated with myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) (1). MSA and MAA are helpful in classifying clinical syndromes with both treatment and prognostic implications (2). Ordering of MSA and MAA has increased in recent years. We report the hospital services that ordered MSA and MAA and follow-up investigations performed in two large referral centers in Melbourne, Australia.

Objectives

To explore and investigate the testing patterns of MSA and subsequent follow up.

Methods

We identified all patients who underwent MSA and MAA testing between January 1 2019 and December 31 2020. Relevant demographic and clinical data were obtained by chart review.

Results

Over the 2-year study period, 294 MSA tests were ordered, alongside 275 ANA and 266 ENA. Of these, 60 (20.4%) were positive and 9 (3.1%) tested positive to more than one MSA. Interstitial lung disease (ILD) was the most common extra-muscular manifestation, 42 (14.2%) had muscle disease manifestations. Respiratory (41%), rheumatology (24%) and neurology (15%) were the top three specialties ordering the most MSA, with the highest proportion of positive MSA originating from rheumatology (38.5%). The rheumatology service was involved in 131 (41.0%) of the MSA ordered as the primary treating unit or as a consultation service. Anti-Scl100 was the most common MSA (n=10, 15.6%). Among the 60 patients with positive MSA, 39 (65%) was given a definitive diagnosis, 13 (21.7%) underwent MRI of muscles, 10 (16.7%) open muscle biopsy, and 5 (8.3%) a skin biopsy. Thirty-two (53.3%) of MSA positive patients underwent high-resolution CT chest; 26 (81.3) % had findings suggestive of a fibrotic process and 12 (20.0%) had a formal diagnosis of ILD. A cancer screen was performed in 23 (38.3%) of the MSA positive patients and no malignancy was identified within the cohort.

Conclusion

Among MSA studies performed in two large centers, 20.4% of results were positive. Respiratory ordered the most numerous tests predominantly to evaluate ILD, a higher proportion of tests recommended by the rheumatology service was positive.

References

[1]Targoff IN. Update on myositis-specific and myositis-associated autoantibodies. Curr Opin Rheumatol. 2000;12(6):475-81.

[2]Betteridge Z, McHugh N. Myositis-specific autoantibodies: an important tool to support diagnosis of myositis. J Intern Med. 2016;280(1):8-23.

Disclosure of Interests

None declared

Retinal drusen are more common and larger in SLE with renal impairment

Introduction

Complement has been implicated in systemic lupus erythematosus (SLE) pathogenesis on the basis of the associations with inherited complement defects and genome-wide association study risk alleles, glomerular deposits, reduced serum levels, and occasional reports of retinal drusen. This study examined drusen in SLE and their clinical significance.

Methods

This cross-sectional observational study compared individuals with SLE recruited from renal and rheumatology clinics with hospital controls. Participants were reviewed for clinical features and underwent imaging with a nonmydriatic retinal camera. Deidentified images were examined by 2 trained graders for drusen number and size using a grid overlay.

Results

The cohort with SLE (n = 65) comprised 55 women (85%) and 10 men (15%) with a median age of 47 years (interquartile range 35–59), where 23 (35%) were of southern European or Asian ancestry, and 32 (49%) had biopsy-proven lupus nephritis. Individuals with SLE had higher mean drusen numbers than controls (27 ± 60, 3 ± 9, respectively, P = 0.001), more drusen counts ≥10 (31, 48% and 3, 5%, respectively, P < 0.001), and more medium-large drusen (14, 22% and 3, 5%, respectively, P < 0.001). In SLE, mean drusen counts were higher, and drusen were larger, with an estimated glomerular filtration rate (eGFR) <90 ml/min per 1.73 m² (P = 0.02, P = 0.02, respectively) or class IV nephritis (P = 0.03, P = 0.02).

Conclusion

Drusen composition resembles that of glomerular immune deposits. CFH controls complement activation in the extracellular matrix and CFH risk variants are shared by drusen in macular degeneration and by SLE. CFH represents a possible treatment target for SLE especially with renal impairment.

Efficacy of a solar concentrator to Inactivate E. coli and C. perfringens spores in latrine waste in Kenya

Alternative sanitation options are needed for effective waste management in low-income countries where centralized, large-scale waste treatment is not easily achievable. A newly designed solar concentrator technology utilizes solar thermal energy to treat feces contained in drums. This pilot study assessed the efficacy of the new design to inactivate microbes in 13 treatment drums under field conditions in Kenya. Three-quarters of the drums contained <1000 E. coli/g of total solids following 6 h of solar thermal treatment and inactivation of thermotolerant C. perfringens spores ranged from <1.8 to >5.0 log₁₀. Nearly all (94%) samples collected from treatment drums achieved thermophilic temperatures (>50 °C) during the treatment period, however this alone did not ensure samples met the WHO E. coli guideline; higher, sustained thermophilic temperatures tended to be more effective in reaching this guideline. The newly designed solar concentrator was capable of inactivating thermotolerant, environmentally-stable microorganisms as, or possibly more, efficiently than a previous design. Additional data are needed to better characterize how temperature, time, and other parameters affect the ability of the solar concentrator to inactivate microbes in feces.

Considerations for Maintaining Family Diversity in Commercially Mass-Spawned Penaeid Shrimp: A Case Study on Penaeus monodon

Skewed family distributions are common in aquaculture species that are highly fecund, communally (mass) spawned, and/or communally reared. The magnitude of skews pose challenges for maintaining family-specific genetic diversity, as increased resources are required to detect individuals from underrepresented families, or reliably determine relative survival as a measure of family performance. There is limited understanding of family skews or changes in family proportion of communally reared shrimp under commercial rearing conditions and particularly how this may affect genotyping strategies to recover family performance data in breeding programs. In this study, three separate batches of shrimp, Penaeus monodon, were communally spawned and reared, and then sampled as larvae when ponds were stocked at 30 days of culture (DOC) and as juveniles from commercial ponds during harvest at 150 DOC. A total of 199 broodstock contributed to the 5,734 progeny that were genotyped with a custom multiplex single nucleotide polymorphism (SNP) panel, and family assignments were cross-referenced using two parentage assignment methods, CERVUS and COLONY. A total of 121 families were detected, with some families contributing up to 11% of progeny at 30 DOC and up to 18% of progeny at harvest. Significant changes were detected for 20% of families from 30 to 150 DOC, with up to a 9% change in relative contribution. Family skew data was applied in several models to determine the optimal sample size to detect families, along with the ability to detect changes in relative family contribution over time. Results showed that an order of magnitude increase in sampling was required to capture the lowest represented 25% of families, as well as significantly improve the accuracy to determine changes in family proportion from 30 to 150 DOC. Practical measures may be implemented at the hatchery to reduce family skews; a cost-effective measure may be to address the initial magnitude differences in viable progeny produced among families, by pooling equal quantities of hatched larvae from each family. This study demonstrates the relationships between skews in families under commercial conditions, the ability to accurately detect families, and the balance of sampling effort and genotyping cost in highly fecund species such as shrimp.

Admixture between ancient lineages, selection, and the formation of sympatric stickleback species-pairs

Ecological speciation has become a popular model for the development and maintenance of reproductive isolation in closely related sympatric pairs of species or ecotypes. An implicit assumption has been that such pairs originate (possibly with gene flow) from a recent, genetically homogeneous ancestor. However, recent genomic data has revealed that currently sympatric taxa are often a result of secondary contact between ancestrally allopatric lineages. This has sparked an interest in the importance of initial hybridization upon secondary contact, with genomic re-analysis of classic examples of ecological speciation often implicating admixture in speciation. We describe a novel occurrence of unusually well-developed reproductive isolation in a model system for ecological speciation: the three-spined stickleback (Gasterosteus aculeatus), breeding sympatrically in multiple lagoons on the Scottish island of North Uist. Using morphological data, targeted genotyping and genome-wide single nucleotide polymorphism (SNP) data we show that lagoon resident and anadromous ecotypes are strongly reproductively isolated with an estimated hybridization rate of only ∼1%. We use palaeoecological and genetic data to test three hypotheses to explain the existence of these species-pairs. Our results suggest that recent, purely ecological speciation from a genetically homogeneous ancestor is probably not solely responsible for the evolution of species-pairs. Instead we reveal a complex colonisation history with multiple ancestral lineages contributing to the genetic composition of species-pairs, alongside strong disruptive selection. Our results imply a role for admixture upon secondary contact and are consistent with the recent suggestion that the genomic underpinning of ecological speciation often has an older, allopatric origin.

Pseudomonas meningoencephalitis masquerading as a stroke in a patient on tocilizumab

A previously high-functioning woman presents with clinical and CT features of a subacute ischaemic stroke. Her medical history is relevant for refractory giant cell arteritis on long-term high-dose prednisolone and recent commencement of tocilizumab (interleukin-6 monoclonal antibody). The potential for stroke mimic is considered and a magnetic resonance brain scan is requested. She rapidly deteriorates within 24 hours of admission and unexpectantly dies. An autopsy reveals that she has bilateral pulmonary emboli with lower limb deep vein thrombosis and Pseudomonas meningoencephalitis with frank pus on the brain. We discuss the potential risks of immunosuppression and the role of imaging in the diagnosis of stroke.

The Effect of Lower Transaction Costs on Social Security Disability Insurance Application Rates and Participation

Transaction costs pose significant barriers to participation in public programs. We analyze how Social Security Disability Insurance (SSDI) application behavior was affected by iClaim, a 2009 innovation that streamlined the online application process. We use a difference-in-differences design to compare application rates before and after 2009 across counties with varying degrees of access to high-speed internet. We estimate that counties with internet connectivity one standard-deviation above the mean experienced a 1.6 percent increase in SSDI applications, and a 2.8 percent increase in appeals after the reform. We estimate that the increase in applications due to iClaim can explain 15 percent of the overall increase in applications between 2008 and 2011. Higher exposure to the online application led to a slightly larger increase in SSDI awards, meaning there was a small but significant increase in the overall award rate. Application rates increased the most in rural areas, while appeals and awards had more significant increases in urban areas. These results suggest that the online application reduced transaction costs to applicants, and the lower costs improved the overall targeting efficiency of the application process.

Extradural spinal hydatid cyst causing hindlimb ataxia in a horse

INTRODUCTION

This case report describes a 13-year-old cob-cross gelding presented for evaluation of recent onset hindlimb ataxia. The gelding had undergone general anaesthesia and tenoscopy of the right hindlimb digital flexor tendon sheath at a nearby clinic three months earlier and had appeared normal at routine post-operative assessments until the sudden onset of neurological deficits. Spinal trauma was suspected initially but radiography and scintigraphy were unremarkable. Due to the severity and progressive nature of the clinical signs the -gelding was subjected to euthanasia. Post mortem examinations (computed tomography, dissection and histopathology) revealed spinal cord compression caused by a single extradural hydatid cyst (Echinococcus equinus), confirmed with PCR, at the level of the 15th thoracic vertebra. This is the first report of a spinal hydatid cyst causing hindlimb ataxia and should therefore be considered a potential differential diagnosis for ataxia in the equine patient.

Legal and Ethical Challenges in Emergency Psychiatry, Part 2: Management of Inmates

Psychiatrists and clinicians encounter unique situations, challenges, and requirements in the treatment of jail and prison inmates in the emergency department. This article reviews the historical legal highlights pertaining to medical and psychiatric care of inpatients, as well as the professional, ethical, and legal aspects that allow clinicians to evaluate, treat, and properly disposition their inmate patients. In particular, this article discusses the specific suicide risk factors related to inmates and correctional facilities that should be ascertained and managed in a clinician's suicide risk assessment and intervention planning in this special high suicide risk patient population.

Loss of autophagy enhances MIF/macrophage migration inhibitory factor release by macrophages

MIF (macrophage migration inhibitory factor [glycosylation-inhibiting factor]) is a pro-inflammatory cytokine expressed in multiple cells types, including macrophages. MIF plays a pathogenic role in a number of inflammatory diseases and has been linked to tumor progression in some cancers. Previous work has demonstrated that loss of autophagy in macrophages enhances secretion of IL1 family cytokines. Here, we demonstrate that loss of autophagy, by pharmacological inhibition or siRNA silencing of Atg5, enhances MIF secretion by monocytes and macrophages. We further demonstrate that this is dependent on mitochondrial reactive oxygen species (ROS). Induction of autophagy with MTOR inhibitors had no effect on MIF secretion, but amino acid starvation increased secretion. This was unaffected by Atg5 siRNA but was again dependent on mitochondrial ROS. Our data demonstrate that autophagic regulation of mitochondrial ROS plays a pivotal role in the regulation of inflammatory cytokine secretion in macrophages, with potential implications for the pathogenesis of inflammatory diseases and cancers.

MIF: Implications in the Pathoetiology of Systemic Lupus Erythematosus

Macrophage migration Inhibitory factor (MIF) was one of the earliest pro-inflammatory cytokines to be identified. Increasing interest in this cytokine in recent decades has followed the cloning of human MIF and the generation of Mif^−/− mice. Deepening understanding of signaling pathways utilized by MIF and putative receptor mechanisms have followed. MIF is distinct from all other cytokines by virtue of its unique induction by and counter regulation of glucocorticoids (GCs). MIF is further differentiated from other cytokines by its structural homology to specific tautomerase and isomerase enzymes and correlative in vitro enzymatic functions. The role of MIF in immune and inflammatory states, including a range of human autoimmune diseases, is now well established, as are the relationships between MIF polymorphisms and a number of inflammatory diseases. Here, we review the known pleiotropic activities of MIF, in addition to novel functions of MIF in processes including autophagy and autophagic cell death. In addition, recent developments in the understanding of the role of MIF in systemic lupus erythematosus (SLE) are reviewed. Finally, we discuss the potential application of anti-MIF strategies to treat human diseases such as SLE, which will require a comprehensive understanding of the unique and complex activities of this ubiquitously expressed cytokine.

Serum cardiac troponin I concentrations decrease following treatment of primary immune-mediated haemolytic anaemia

OBJECTIVES

The measurement of serum cardiac troponin I concentrations in dogs with a range of non-primary cardiac illnesses suggests that cardiac myocyte damage is commonplace. Dogs with primary immune-mediated haemolytic anaemia have increased serum cardiac troponin I concentrations at the time of diagnosis. However, it is unclear whether biochemical evidence of cardiac myocyte damage improves following successful treatment of anaemia.

METHODS

A haematology profile was performed and serum cardiac troponin I concentrations were measured in 19 dogs with primary immune-mediated haemolytic anaemia before and after treatment.

RESULTS

The haematocrit increased significantly (P = 0 · 0001) following treatment of primary IMHA (median pre: 0 · 13 L/L, median post: 0 · 33 L/L). The serum cardiac troponin I concentrations decreased significantly (P < 0 · 05) after treatment (median pre: 0 · 26 ng/mL, median post: 0 · 16 ng/mL).

CLINICAL SIGNIFICANCE

Serum cardiac troponin I concentration decreases following successful treatment of primary immune-mediated haemolytic anaemia. The clinical and prognostic significance of serum cardiac troponin I concentrations before and after treatment in dogs with primary immune-mediated haemolytic anaemia merits further investigation.

Decomposing the effect of crime on population changes

This article estimates the effect of crime on migration rates for counties in U.S. metropolitan areas and makes three contributions to the literature. First, I use administrative data on migration flows between counties, which gives me more precise estimates of population changes than data used in previous studies. Second, I am able to decompose net population changes into gross migration flows in order to identify how individuals respond to crime rate changes. Finally, I include county-level trends so that my identification comes from shocks away from the trend. I find effects that are one-fiftieth the size of the most prominent estimate in the literature; and although the long-run effects are somewhat larger, they are still only approximately one-twentieth as large. I also find that responses to crime rates differ by subgroups, and that increases in crime cause white households to leave the county, with effects almost 10 times as large as for black households.

The Need for Visits to Social and Vocational Programs for the Mentally Ill as Part of General Psychiatry Residency Training

Background. Comprehensive treatment planning for psychiatric illnesses should be based on a biopsychosocial model of treatment to address the acuity and chronicity of these disorders. To achieve this goal, knowledge about pharmacological, psychological, and social aspects of the treatment plan should be presented as an integral part of general psychiatry residency training. This survey study was conducted to examine how many programs provide training where residents have scheduled visits to social and vocational mental health service organizations in the community and to identify potential obstacles to including this rotation in general psychiatry residency training. Methods. A voluntary, anonymous survey was sent via SurveyMonkey® to the program directors of all general psychiatry residency programs in the United States. The survey consisted of five questions designed to assess if their programs had a rotation where residents visit social and vocational programs in the community designed for mentally ill patients to provide knowledge of the community mental health resources to their residents. Results. Of the 168 survey invitations issued, 73 (44%) responded. Fifty-six responders acknowledged that their residents were required to visit a community mental health organization, but their programs did not offer visits to community social and vocational programs. Seventeen program directors reported that their program did not provide this experience to their residents and indicated a desire to include such a rotation. Conclusions. Community mental health service organization visits should enhance knowledge of psychiatry residents about community mental health resources and indirectly promote better patient care. Information obtained from this survey should create discussion to work toward better psychiatric resident training.

System Life Cycle Evaluation(SM) (SLiCE): harmonizing water treatment systems with implementers' needs

One of the methods proposed to improve access to clean drinking water is the mobile packaged water treatment system (MPWTS). The lack of published system performance comparisons combined with the diversity of technology available and intended operating conditions make it difficult for stakeholders to choose the system best suited for their application. MPWTS are often deployed in emergency situations, making selection of the appropriate system crucial to avoiding wasted resources and loss of life. Measurable critical-to-quality characteristics (CTQs) and a system selection tool for MPWTS were developed by utilizing relevant literature, including field studies, and implementing and comparing seven different MPWTS. The proposed System Life Cycle Evaluation (SLiCE) method uses these CTQs to evaluate the diversity in system performance and harmonize relevant performance with stakeholder preference via a selection tool. Agencies and field workers can use SLiCE results to inform and drive decision-making. The evaluation and selection tool also serves as a catalyst for communicating system performance, common design flaws, and stakeholder needs to system manufacturers. The SLiCE framework can be adopted into other emerging system technologies to communicate system performance over the life cycle of use.

Cytological defects during embryogenesis in heat-induced tetraploid Kuruma shrimp Penaeus japonicus

Tetraploid shrimp embryos have been induced; however, in all cases no postlarvae were produced. This study determined when tetraploid Penaeus japonicus became non-viable and identified unique abnormalities to aid in elucidating the causes of lethality. Embryonic development was analyzed using flow cytometry to determine ploidy and laser scanning confocal microscopy for cytological examination of embryogenesis. Abnormalities exclusive to tetraploids were identified from the 1-cell stage: an off-centre pronucleus, polypolar spindles, delayed time to first mitosis and polypolar cleavage. Following first mitosis in the tetraploids, 50% of the cells did not contain DNA. This unique abnormality was not resolved later in development and is therefore believed to be a lethal trait. Causes of this phenomenon likely stemmed from abnormal mitotic spindle regeneration following the mitotic heat shock. Consequently, the findings of this study indicate that current methods of tetraploidy induction using heat shock appear unsuitable for viable tetraploid shrimp production.

A multi-centre, randomised clinical control trial comparing the retropubic (RP) approach versus the transobturator approach (TO) for tension-free, suburethral sling treatment of urodynamic stress incontinence: the TORP study

To compare the safety and efficacy of the transobturator tape (Monarc) with the retropubic tape (tension-free vaginal tape, TVTR) for the treatment of urodynamic stress incontinence (USI) a prospective, single-blinded, multi-centre randomised clinical controlled trial was undertaken in four urogynaecology units in Australia. One hundred and eighty-seven women with USI were randomly allocated to undergo surgery with either the Monarc sling (n = 80) or TVT (n = 107). Outcome measures were intra-operative complications (especially bladder injury), as well as peri-operative complications, symptomatology, quality of life and urodynamic outcomes. At 3 months, data were available on 140 women, 82 (59%) TVT and 58 (42%) Monarc. The TVT group was significantly more likely to be complicated by bladder injury (7 TVT, 0 Monarc, p < 0.05). Blood loss and operative time were significantly less in the Monarc group, which was 49 mls (31) vs that of the TVT group, which was 64 mls (41) p < 0.05; 18.5 min (6.5) TVT vs 14.6 min (6) Monarc (p < 0.001). The subjective and objective stress incontinence cure rates were 86.6% (71) vs 72.4% (42) p = 0.77 and 79.3 vs 84.5%, p = 0.51 for the TVT and Monarc groups, respectively. Both groups reported similar improvement in incontinence impact and satisfaction with their operation, although return to activity was significantly quicker with the transobturator route (p = 0.029). The transobturator tape appears to be as effective as the retro-pubic tape in the short term, with a reduction in the risk of intra-operative bladder injury, shorter operating time, decreased blood loss, and quicker return to usual activities.

Macrophage migration inhibitory factor in systemic lupus erythematosus

OBJECTIVE

To examine associations between serum macrophage migration inhibitory factor (MIF) and disease-related variables and corticosteroid use in patients with systemic lupus erythematosus (SLE).

METHODS

Serum MIF concentration was measured by ELISA in 90 female patients with SLE and 279 healthy controls. Univariate and multivariate regression analyses were used to examine the associations between serum MIF concentration and disease-related indices of SLE and corticosteroid use.

RESULTS

Serum MIF concentrations were positively associated with SLE disease damage (SLICC/ACR index), and indices of disease damage were greater in SLE patients with serum MIF concentrations above the normal median value. Serum MIF concentration was also observed to be significantly greater in patients with SLICC/ACR damage index (DI) scores >/= 3. Serum MIF was also positively associated with current corticosteroid dose. Significantly higher SLICC/ACR DI scores were observed in patients with values of serum MIF above the normal median, and this remained significant after adjusting for corticosteroid dose. Serum MIF concentration was also predictive of SLICC/ACR index after 3 years of followup, but this association was partly confounded by corticosteroid dose. Serum MIF was also negatively associated with serum creatinine concentration, independent of disease damage and corticosteroid dose.

CONCLUSION

MIF is overexpressed in patients with SLE. While this can be partly explained by corticosteroid use, there is evidence of an association between MIF and lupus-related disease damage.

An open study of the bladder neck support prosthesis in genuine stress incontinence

OBJECTIVE

To determine the proportion of unselected women with genuine stress incontinence in whom a bladder neck support prosthesis could be fitted successfully by three gynaecologists with no prior knowledge of the device, and to measure efficacy of the device.

DESIGN

Prospective interventional study.

SETTING

Two metropolitan urodynamic units.

SAMPLE

Eighty women with genuine stress incontinence.

MAIN OUTCOME MEASURES

Average number of leaks per day on a frequency volume chart, average number of pads worn per day, urine loss on a one-hour pad test, and urine flow rate.

RESULTS

Of the 80 recruits, 11 had exclusion criteria and four could not be fitted at the first visit. Of 65 participants, 39 (58%) withdrew from the study before week four. In 20 of 39 women (51%) post-surgical scarring made fitting difficult, and six (15%) withdrew for unrelated personal or medical reasons. In five women (13%) the device was never effective; six withdrew because of adverse events and two required devices that were larger or smaller than those presently available. Thus 38 of 65 participants (58%) could be fitted by the three gynaecologists. Of 26 women who wore the device for four weeks, median leaks per day fell from 2.5 (interquartile range (IQR) 1.9-4.6) to 1.0 (IQR 0-2); median number of pads per day fell from 1.5 (IQR 0.5-3) to 0 (IQR 0-1); and median pad test loss fell from 19 g/h (IQR 8-49) to 2 g/h (IQR 0-8). Sixteen of these 26 patients (62%) achieved objective success, six (23%) were socially continent, one failed to respond and three declined to complete all outcome measures. Urine flow rates revealed no evidence of outflow obstruction. At the sixth month, 18 of 26 patients (69%) were wearing the device successfully; 15 of these women continued to the 12th month, and all but one were objectively dry.

CONCLUSIONS

The bladder neck support prosthesis is a useful addition to the range of treatments available for the management of genuine stress incontinence, but may be difficult to fit in women who are oestrogen-deprived or have undergone multiple surgical procedures. The demands of the trial protocol were found to be onerous by frail elderly women.

The use of the bladder neck support prosthesis in combined genuine stress incontinence and detrusor instability

The Bladder Neck Support Prosthesis (BNSP) was used in 21 women with combined genuine stress incontinence (GSI) and detrusor instability (DI). Outcomes included frequency volume charts, pad tests, voiding cystometry and quality of life scores, up to the sixth month. Of the 21 recruits, 5 never wore the BNSP home, leaving 16 participants. A further 2 did not reach week 4 because of poor efficacy or inability to fit the device. In the 14 who reached week 4, the median number of leaks/day declined from 4.3 to 1.0 (p = 0.002). Median pad test loss fell from 53 to 7 mL (p = 0.012). Cystometry showed an increase in maximum bladder capacity (p < 0.05) and a modest reduction in severity of detrusor instability, with no evidence of outflow obstruction. Three further women discontinued because of poor efficacy (2) or a poorly fitting device (1), leaving 11 of 16 participants (69%) at week 8, when median pad test loss fell to 2 mL. The BNSP is a useful option in patients with the unfortunate combination of an unstable bladder and an incompetent urethra, but requires careful fitting and attention to detail.

A comparison of three theories of nursing used as a guide for the nursing care of an 8-year-old child with leukemia

This article evaluates three nursing theories that can be used to provide a framework for holistic pediatric oncology nursing practice: the Roy Adaptation Model, the Neuman Systems Model, and the Orem General Theory of Nursing. Each theory is compared in terms of its view of man, health, environment, nursing, and the nursing process. Critique of each theory is presented. The decision of which theorist to use as a basis for practice is left to the individual nurse. This article explicates the similarities and differences in the three theories.

Work-site physical fitness programs. Comparing the impact of different program designs on cardiovascular risks

The relative impact of three different approaches to physical fitness at the work site on cardiovascular risk reduction is examined, based on before/after health screening of employees, and employees' reports of participation in physical exercise activities. The three approaches tested were: 1) a staffed physical fitness facility, 2) one-to-one counseling with at-risk employees, and 3) a combination of one-to-one counseling with employees plus organization of the work site to encourage peer support and mutual exercise activity at work. A fourth site is used as a control site. The program that was centered around a physical fitness facility had little measurable impact on cardiovascular risks, and showed results similar to those at the control site. Both of the other programs were more effective, with the combination of counseling and plant organization providing the best health outcomes in terms of frequency of exercise, adequacy of blood pressure control (among hypertensives), weight loss (among the overweight), and smoking cessation. These results indicate that systematic, ongoing outreach to enlist employees in various types of exercise programs is more effective than the presence of fitness facilities without such outreach. Moreover, significant increases in frequency of exercise can be sustained without a substantial investment in facilities.

The Roy Adaptation Model used as a guide for the nursing care of an 8-year-old child with leukemia

Roy's Adaptation Model provides a framework for holistic oncology nursing practice. In this article, an overview of Roy's model is provided. It is used to assess the behaviors and stimuli influencing the behaviors of an 8-year-old boy with acute lymphocytic leukemia. Planning and evaluating the nursing care of this child is based on the model. A comprehensive list of nursing diagnoses is categorized according to Roy's four adaptive modes, and a nursing care plan for two of these diagnoses is presented.

Orem's theory used as a guide for the nursing care of an eight-year-old child with leukemia

Orem's general theory of nursing provides a framework for holistic pediatric oncology nursing. In this article, an overview of Orem's theory is provided. The theory is used to assess the self-care deficits of an 8-year-old boy who has been diagnosed with leukemia, the ability of the mother to meet the son's self-care demands, and the nursing system needed to assist the mother to meet her son's self-care demands. The theory is used to plan and evaluate the nursing care of this child. A comprehensive list of nursing diagnoses and a nursing care plan for two of these diagnoses are presented.

The core technology of work-site wellness

Work-site wellness programming his evolved through four stages of development. This article proposes a core technology of work-site wellness programs comprised of 10 dimensions that organize and systematize the range of activities undertaken by such programs. These 10 dimensions address the following tasks: (1) establishing program policy, (2) assessing the health status of the work force, (3) linking the work site with service providers, (4) linking individual employees with services appropriate to their needs, (5) providing options for behavior change strategies and interventions, (6) engaging employees in these various interventions, (7) organizing work-sitewide activities to support health improvement, (8) reviewing and altering organizational policies to make the work environment more supportive of health, (9) routinely evaluating program process and changes in health risks, and (10) periodically assessing longer-term program results. Two future dimensions are described that require further evidence of impact. Arguments and evidence in support of each dimension are provided, including discussion on how activities within each dimension work together to produce maximum effectiveness, and how various dimensions relate to each other to make an effective overall program.

Neuman systems model used as a guide for the nursing care of an 8-year-old child with leukemia

The Neuman Systems Model (NSM) provides a framework for holistic pediatric oncology nursing practice. In this article, an overview of NSM is given. This model is applied to an 8-year-old child with leukemia for the comprehensive assessment, planning, and evaluation of nursing care. A comprehensive list of nursing diagnoses is categorized by primary and secondary prevention.

The cost-effectiveness of work-site wellness programs for hypertension control, weight loss, and smoking cessation

The cost-effectiveness of work-site wellness programs for reducing cardiovascular disease risks of employees was examined at three manufacturing plants. A fourth plant was used as a control site to estimate levels of risk reduction achieved from wellness screening and preexisting services, without further interventions. The cardiovascular disease risks included in the study were hypertension, obesity, and cigarette smoking. The annual direct cost per employee for postscreening interventions was $2.97 for site 1 (control site), $17.68 for site 2 (health education), $30.96 for site 3 (health education plus follow-up counseling), and $38.31 for site 4 (health education, follow-up counseling plus plant organization for health promotion). Of the three experimental sites, sites 3 and 4 were more effective and more cost-effective than was site 2, both in terms of engaging employees at risk of cardiovascular disease into treatment or program participation and of reducing their risks or preventing relapse. For engaging employees into treatment/program participation, sites 3 and 4 were nine to ten times more cost-effective than was site 2; for reducing risks/preventing relapse, sites 3 and 4 were five to six times more cost-effective than was site 2. At sites 3 and 4, the total direct cost per percent of risks reduced/relapse prevented was less than one dollar ($.67 and $.74, respectively) per employee per year. Program costs may vary considerably across companies because of differences in salary structures and overhead costs. These are held constant in this report for comparison across program models.

Hope, social support and self-esteem of patients with spinal cord injuries

A descriptive study was conducted to determine if a relationship among the variables of hope, social support and self-esteem existed in persons with spinal cord injuries. A demographic data sheet and three instruments were used: Miller Hope Scale (MHS), Personal Resource Questionnaire Part II (PRQ) and Rosenberg Self-Esteem Scale (RSES). Of the 83 inpatients and outpatients who agreed to participate, 77 sets of questionnaires were usable. Ages of subjects ranged from 18-73 (mean 34.8) years and levels of injury ranged from C4-L3. The mean scores on the tools were: MHS-153.51 (40-200 possible range), PRQ-137.42 (25-175 possible range) and RSES-29.59 (10-40 possible range). There was a statistically significant relationship between hope and social support, hope and self-esteem and social support and self-esteem. By multiple regression analysis, the best predictors of hope in the subjects were self-esteem, social support and education.

Worksite wellness programs: incremental comparison of screening and referral alone, health education, follow-up counseling, and plant organization

BACKGROUND

Worksite wellness programs vary considerably in their design. This study tested four models to compare effectiveness at controlling high blood pressure, obesity, and cigarette smoking.

METHODS

Baseline screening was conducted in four manufacturing plants. Site 1 offered screening only, with referral recommendations for those found to have CVD risks. Site 2 also provided health education information and classes. Site 3 added routine follow-up counseling and a menu of intervention types, and Site 4 added social organization within the plant. Random samples of 400 to 500 employees were rescreened at the end of three years.

RESULTS

Major improvements in risk levels were found with the addition of routine follow-up counseling and a menu of interventions (Sites 3 and 4, compared with Sites 1 and 2). More hypertensives entered treatment and showed greater reductions in blood pressure. Participation in worksite weight loss and smoking cessation programs was significantly increased, and those who participated showed significantly better maintenance of improvements where follow-up was provided.

DISCUSSION

The program models that offered short-term interventions promoted through local media suffered in comparison with models that included personal outreach to people at risk, a variety of health improvement intervention modalities, and ongoing follow-up counseling to help people make decisions and sustain health improvements.

Effects of EAP follow-up on prevention of relapse among substance abuse clients

Clients entering an employee assistance program (EAP) of a large manufacturing plant in 1985 who were assessed as having an alcohol or drug abuse problem (N = 325) were randomized into an experimental "special follow-up" group and a control "regular care" group. The regular care group received follow-up only as needed (following the usual practice of the EAP), while a follow-up counselor was hired to make routine contacts with the special follow-up group. Study intake continued through 1985, and follow-up continued through the end of 1986. Data collected on study subjects included EAP participation data, absenteeism, number of hospitalizations, health care claims paid and disability claims paid. The major study hypothesis was that EAP clients randomly allocated to special follow-up would show better results than regular care clients (i.e., would have fewer relapses, better job attendance and lower health benefit utilization during the follow-up year). The follow-up intervention was incompletely implemented due to a variety of organizational problems. Differences between the two groups on the six outcome measures were not statistically significant, although clients in the special follow-up group did show better results than clients in the regular care group on the three measures related to substance abuse. Differences on these three measures were marginally significant in regression analyses after controlling for the effects of number of follow-up visits, age, race and chronicity.

The benefit to cost ratio of work-site blood pressure control programs

Reduction in the cost of health care claims among hypertensive employees was examined over a 4-year period after exposure to a 3-year blood pressure control program, to see whether work-site monitoring and counseling produced a subsequent benefit. Hypertensive employees at three experimental sites (N = 183 to 367 subjects) were compared with subjects at a control site (N = 169) who had received no postscreening follow-up or monitoring, and with matched normotensive employees. The cost of subsequent health care claims for hypertensive employees at the experimental sites was lower than claims for those at the control site, but there was no significant difference across the sites in claims for normotensive employees. After adjusting to a standard 1982 dollar, the data showed from $1.89 to $2.72 in reduced health care claims per dollar spent operating the hypertension control program.

Worksite follow-up and engagement strategies for initiating health risk behavior changes

Information is presented from a multiplant study of interventions to improve cardiovascular health among employees. Risk factors targeted were high blood pressure, obesity, and cigarette smoking. The study utilized on-site wellness counselors who periodically contacted all employees identified through screening as having one or more of the three risks. Use of a structured protocol for client outreach resulted in the large majority of clients being seen in follow-up during the three-year intervention period. Drawing from caseload experience and from various theoretical perspectives, seven engagement strategies were used to help guide at-risk clients toward successful behavior changes to reduce health risks. Results showed that of the three at-risk groups, clients with high blood pressure were most likely to be seen in follow-up, and most likely to begin a risk reduction program. For the overweight and smokers, clients seen three or more times were more likely to begin a weight-loss/smoking cessation program than clients seen less often. Frequency of follow-up showed a positive relationship with risk reduction for all three risks, in samples of employees rescreened at the end of the intervention period, but the relationship was not statistically significant for smoking cessation.

Evaluating worksite CVD risk reduction programs

If a program is worth doing, it is worth evaluating. Before evaluating, specify program objectives, and keep the evaluation focused on those objectives. If the objective is to reduce risks, then count the number of risks reduced, and divide by the total number of risks. Use evaluation procedures that will be of use to program staff in making improvements. CVD risk reduction programs are ongoing. Today's lowered risk is tomorrow's relapse.

Roy's adaptation model: a guide for rehabilitation nursing practice

Roy's Adaptation Model provides a framework for holistic rehabilitation nursing practice. In this article, the model is applied to a rehabilitation patient with a spinal cord injury for the assessment of behaviors and stimuli influencing the behaviors and also for planning and evaluating nursing care.

Maintenance of blood pressure treatment and control after discontinuation of work site follow-up

Participants in a 3-year study of hypertension control at four work sites were rescreened 4 years after discontinuation of the study protocols. At the end of the 3-year study period, employees at the study sites that provided routine follow-up monitoring had shown significantly better levels of blood pressure control than at initial screening and significantly better levels than employees at the site that did not provide follow-up monitoring. But 4 years after discontinuation of the follow-up services this was no longer true. The level of blood pressure control at the experimental sites was no better than at the control site, and the level of control at all study sites was no better than would have been predicted for a population that had aged by 7 years. Some 17.6% of the participants were found to be in remission (with normal blood pressure readings, not under treatment), but the data suggested that they were at risk of future blood pressure elevations, warranting continued monitoring. The major predictor of continuation in treatment was frequency of blood pressure monitoring, but frequency of monitoring was not associated with maintenance of good control. It is concluded that follow-up monitoring programs at the work site should be treated as permanent services, not short-term programs.

Posttreatment follow-up, aftercare, and worksite reentry of the recovering alcoholic employee

A review of literature on the effects of aftercare in the treatment of alcoholism reveals mixed results, with some studies showing positive effects and some showing no effects. However, few studies controlled for bias in the process of selection into aftercare, and many of the studies reveal significant difficulties in engaging patients into aftercare. The relapse prevention model is reviewed as a potentially powerful tool for use in aftercare. The literature on worksite reentry of alcoholics shows a generally positive correlation between employment and recovery, but does not produce unambiguous findings regarding the direction of the relationship. A nontraditional, proactive approach to aftercare is proposed, based on studies of other types of health problems that show improved results with this approach. It is argued that the worksite is the most appropriate place to locate aftercare services for employed alcoholics, particularly worksites with employee assistance programs. However, further research is needed to guide the development of these services.