Same-day discharge after percutaneous renal cryoablation and its effect on 30 day hospital re-admission rates and post-procedural complications

PURPOSE

The purpose of this study is to identify if the local institutional shift from routine overnight observation to same-day discharge following percutaneous cryoablation (PCA) of renal tumors increases 30 day re-admission rates or serious adverse events (AEs).

MATERIALS AND METHODS

This retrospective study included 133 adult patients. PCA patients in calendar years 2018-2019 were routinely observed overnight in the hospital, comprising the control group (Group A). PCA patients in calendar years 2021-2022 were routinely discharged the same day, comprising the test group (Group B). Relevant demographic information, tumor characteristics, technical outcomes, and clinical outcomes were recorded.

RESULTS

15 patients (11.3 %) from the total cohort were re-admitted to the hospital within 30 days of PCA for any reason. Seven patients (10.4 %) and eight patients (12.1 %) were re-admitted for any reason within 30 days in Group A and Group B, respectively, with no difference between the two groups (p = 0.76). Nine patients (6.8 %) from the total cohort were re-admitted to the hospital within 30 days for a diagnosis secondary to the procedure. Four patients (6 %) and five patients (7.6 %) were re-admitted within 30 days for reasons related to PCA in Group A and Group B, respectively, with no significant difference between the groups (p = 0.71). Eight patients (12 %) and four patients (6 %) had major AEs following PCA in Group A and Group B, respectively, with no difference between the two groups (p = 0.43).

CONCLUSION

Overall, the change in post-procedural care after PCA did not have a deleterious effect on 30 day re-admission rates or rates of major AEs.

Clinical standards for the diagnosis, treatment and prevention of TB infection

BACKGROUND: Tuberculosis (TB) preventive therapy (TPT) decreases the risk of developing TB disease and its associated morbidity and mortality. The aim of these clinical standards is to guide the assessment, management of TB infection (TBI) and implementation of TPT.METHODS: A panel of global experts in the field of TB care was identified; 41 participated in a Delphi process. A 5-point Likert scale was used to score the initial standards. After rounds of revision, the document was approved with 100% agreement.RESULTS: Eight clinical standards were defined: Standard 1, all individuals belonging to at-risk groups for TB should undergo testing for TBI; Standard 2, all individual candidates for TPT (including caregivers of children) should undergo a counselling/health education session; Standard 3, testing for TBI: timing and test of choice should be optimised; Standard 4, TB disease should be excluded prior to initiation of TPT; Standard 5, all candidates for TPT should undergo a set of baseline examinations; Standard 6, all individuals initiating TPT should receive one of the recommended regimens; Standard 7, all individuals who have started TPT should be monitored; Standard 8, a TBI screening and testing register should be kept to inform the cascade of care.CONCLUSION: This is the first consensus-based set of Clinical Standards for TBI. This document guides clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage TBI.

Airborne SARS-CoV-2 surveillance in hospital environment using high-flowrate air samplers and its comparison to surface sampling

Reliable methods to detect the presence of SARS-CoV-2 at venues where people gather are essential for epidemiological surveillance to guide public policy. Communal screening of air in a highly crowded space has the potential to provide early warning on the presence and potential transmission of SARS-CoV-2 as suggested by studies early in the epidemic. As hospitals and public facilities apply varying degrees of restrictions and regulations, it is important to provide multiple methodological options to enable environmental SARS-CoV-2 surveillance under different conditions. This study assessed the feasibility of using high-flowrate air samplers combined with RNA extraction kit designed for environmental sample to perform airborne SARS-CoV-2 surveillance in hospital setting, tested by RT-qPCR. The success rate of the air samples in detecting SARS-CoV-2 was then compared with surface swab samples collected in the same proximity. Additionally, positive RT-qPCR samples underwent viral culture to assess the viability of the sampled SARS-CoV-2. The study was performed in inpatient ward environments of a quaternary care university teaching hospital in Singapore housing active COVID-19 patients within the period of February to May 2020. Two types of wards were tested, naturally ventilated open-cohort ward and mechanically ventilated isolation ward. Distances between the site of air sampling and the patient cluster in the investigated wards were also recorded. No successful detection of airborne SARS-CoV-2 was recorded when 50 L/min air samplers were used. Upon increasing the sampling flowrate to 150 L/min, our results showed a high success rate in detecting the presence of SARS-CoV-2 from the air samples (72%) compared to the surface swab samples (9.6%). The positive detection rate of the air samples along with the corresponding viral load could be associated with the distance between sampling site and patient. The furthest distance from patient with PCR-positive air samples was 5.5 m. The airborne SARS-CoV-2 detection was comparable between the two types of wards with 60%-87.5% success rate. High prevalence of the virus was found in toilet areas, both on surfaces and in air. Finally, no successful culture attempt was recorded from the environmental air or surface samples.

Airborne SARS-CoV-2 surveillance in hospital environment using high-flowrate air samplers and its comparison to surface sampling

Reliable methods to detect the presence of SARS-CoV-2 at venues where people gather are essential for epidemiological surveillance to guide public policy. Communal screening of air in a highly crowded space has the potential to provide early warning on the presence and potential transmission of SARS-CoV-2 as suggested by studies early in the epidemic. As hospitals and public facilities apply varying degrees of restrictions and regulations, it is important to provide multiple methodological options to enable environmental SARS-CoV-2 surveillance under different conditions. This study assessed the feasibility of using high-flowrate air samplers combined with RNA extraction kit designed for environmental sample to perform airborne SARS-CoV-2 surveillance in hospital setting, tested by RT-qPCR. The success rate of the air samples in detecting SARS-CoV-2 was then compared with surface swab samples collected in the same proximity. Additionally, positive RT-qPCR samples underwent viral culture to assess the viability of the sampled SARS-CoV-2. The study was performed in inpatient ward environments of a quaternary care university teaching hospital in Singapore housing active COVID-19 patients within the period of February to May 2020. Two types of wards were tested, naturally ventilated open-cohort ward and mechanically ventilated isolation ward. Distances between the site of air sampling and the patient cluster in the investigated wards were also recorded. No successful detection of airborne SARS-CoV-2 was recorded when 50 L/min air samplers were used. Upon increasing the sampling flowrate to 150 L/min, our results showed a high success rate in detecting the presence of SARS-CoV-2 from the air samples (72%) compared to the surface swab samples (9.6%). The positive detection rate of the air samples along with the corresponding viral load could be associated with the distance between sampling site and patient. The furthest distance from patient with PCR-positive air samples was 5.5 m. The airborne SARS-CoV-2 detection was comparable between the two types of wards with 60%-87.5% success rate. High prevalence of the virus was found in toilet areas, both on surfaces and in air. Finally, no successful culture attempt was recorded from the environmental air or surface samples.

Coronavirus viability in surgical plume and methods for safe disposal: a preclinical model

Smoke generated by cautery devices used during surgery may contain infective particles and may cause transmission of airborne viruses. This study determines whether live viruses are present in surgical smoke and evaluates the effectiveness of several proposed methods of removal so as to improve safety of healthcare workers.

Design and Multicenter Clinical Validation of a 3-Dimensionally Printed Nasopharyngeal Swab for SARS-CoV-2 Testing

Importance

Three-dimensionally printed nasopharyngeal swabs (3DP swabs) have been used to mitigate swab shortages during the coronavirus disease 2019 (COVID-19) pandemic. Clinical validation for diagnostic accuracy and consistency, as well as patient acceptability, is crucial to evaluate the swab's performance.

Objective

To determine the accuracy and acceptability of the 3DP swab for identifying severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Design, Setting, and Participants

A diagnostic study was conducted from May to July 2020 at 2 tertiary care centers in Singapore with different reference swabs (FLOQSwab [COPAN Diagnostics] or Dacron swab [Deltalab]) and swab processing techniques (wet or dry) to evaluate the performance of the 3DP swab compared with traditional, standard-of-care nasopharyngeal swabs used in health care institutions. The participants were patients with COVID-19 in the first 2 weeks of illness and controls with acute respiratory illness with negative test results for SARS-CoV-2. Paired nasopharyngeal swabs were obtained from the same nostril and tested for SARS-CoV-2 by reverse-transcriptase polymerase chain reaction. The sequence of swabs was randomized based on odd and even participant numbers.

Main Outcomes and Measures

Primary outcome measures were overall agreement (OA), positive percentage agreement (PPA), and negative percentage agreement of the 3DP swab compared with reference swabs. Secondary outcome measures were the correlation of cycle threshold (Ct) values of both swabs.

Results

The mean (SD) age of participants was 45.4 (13.1) years, and most participants were men (87 of 89 [97.8%]), in keeping with the epidemiology of the COVID-19 pandemic in Singapore. A total of 79 patients with COVID-19 and 10 controls were recruited. Among the patients with COVID-19, the overall agreement and PPA of the 3DP swab was 91.1% and 93.5%, respectively, compared with reference swabs. The PPA was 100% for patients with COVID-19 who were tested within the first week of illness. All controls tested negative. The reverse-transcriptase polymerase chain reaction Ct values for the ORF1ab and E-gene targets showed a strong correlation (intraclass correlations coefficient, 0.869-0.920) between the 3DP and reference swab on independent testing at each institution despite differences in sample processing. Discordant results for both gene targets were observed only at high Ct values.

Conclusions and Relevance

In this diagnostic study of 79 patients with COVID-19 and 10 controls, the 3DP swab performed accurately and consistently across health care institutions and could help mitigate strained resources in the escalating COVID-19 pandemic.

Clinical Diagnostic Study of a Novel Injection Molded Swab for SARS-Cov-2 Testing

Introduction

The gold standard for COVID-19 diagnosis is currently a real-time reverse transcriptase polymerase chain reaction (RT-PCR) to detect SARS-CoV-2. This is most commonly performed on respiratory secretions obtained via a nasopharyngeal swab. Due to supply chain limitations and high demand worldwide because of the COVID-19 pandemic, access to commercial nasopharyngeal swabs has not been assured. 3D printing methods have been used to meet the shortfall. For longer-term considerations, 3D printing may not compare well with injection molding as a production method due to the challenging scalability and greater production costs of 3D printing.

Methods

To secure sufficient nasopharyngeal swab availability for our national healthcare system, we designed a novel injection molded nasopharyngeal swab (the IM2 swab). We performed a clinical diagnostic study comparing the IM2 swab to the Copan FLOQSwab. Forty patients with a known diagnosis of COVID-19 and 10 healthy controls were recruited. Paired nasopharyngeal swabs were obtained from the same nostril of each participant and tested for SARS-CoV-2 by RT-PCR.

Results

When compared to the Copan FLOQswab, results from the IM2 swab displayed excellent overall agreement and positive percent agreement of 96.0% and 94.9%, respectively. There was no significant difference in mean RT-PCR cycle threshold values for the ORF1ab (28.05 vs. 28.03, p = 0.97) and E-gene (29.72 vs. 29.37, p = 0.64) targets, respectively. We did not observe any significant adverse events and there was no significant difference in patient-reported pain.

Conclusion

In summary, the IM2 nasopharyngeal swab is a clinically safe, highly accurate option to commercial nasopharyngeal swabs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-020-00391-6.

Responding to COVID-19: how an academic infectious diseases division mobilized in Singapore

BACKGROUND

On January 30, COVID-19 was declared a Public Health Emergency of International Concern-a week after Singapore's first imported case and 5 days before local transmission. The National University Hospital (NUH) is Singapore's third largest hospital with 1200 beds, heavy clinical workloads, and major roles in research and teaching.

MAIN BODY

With memories of SARS still vivid, there was an urgent requirement for the NUH Division of Infectious Diseases to adapt-undergoing major reorganization to face rapidly changing priorities while ensuring usual essential services and standards. Leveraging on individual strengths, our division mobilized to meet the demands of COVID-19 while engaging in high-level coordination, strategy, and advocacy. We present our experience of the 60 days since the nation's first case. During this time, our hospital has managed 3030 suspect cases, including 1300 inpatients, 37 confirmed cases, and overseen 4384 samples tested for COVID-19.

CONCLUSION

Complex hospital adaptations were supported by an unprecedented number of workflows and coordination channels essential to safe and effective operations. The actions we describe, aligned with international recommendations and emerging evidence-based best practices, may serve as a framework for other divisions and institutions facing the spread of COVID-19 globally.

Headaches Associated With Personal Protective Equipment - A Cross-Sectional Study Among Frontline Healthcare Workers During COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease of pandemic proportions. Healthcare workers in Singapore working in high-risk areas were mandated to wear personal protective equipment (PPE) such as N95 face mask and protective eyewear while attending to patients.

OBJECTIVES

We sought to determine the risk factors associated with the development of de novo PPE-associated headaches as well as the perceived impact of these headaches on their personal health and work performance. The impact of COVID-19 on pre-existing headache disorders was also investigated.

METHODS

This is a cross-sectional study among healthcare workers at our tertiary institution who were working in high-risk hospital areas during COVID-19. All respondents completed a self-administered questionnaire.

RESULTS

A total of 158 healthcare workers participated in the study. Majority [126/158 (77.8%)] were aged 21-35 years. Participants included nurses [102/158 (64.6%)], doctors [51/158 (32.3%)], and paramedical staff [5/158 (3.2%)]. Pre-existing primary headache diagnosis was present in about a third [46/158 (29.1%)] of respondents. Those based at the emergency department had higher average daily duration of combined PPE exposure compared to those working in isolation wards [7.0 (SD 2.2) vs 5.2 (SD 2.4) hours, P < .0001] or medical ICU [7.0 (SD 2.2) vs 2.2 (SD 0.41) hours, P < .0001]. Out of 158 respondents, 128 (81.0%) respondents developed de novo PPE-associated headaches. A pre-existing primary headache diagnosis (OR = 4.20, 95% CI 1.48-15.40; P = .030) and combined PPE usage for >4 hours per day (OR 3.91, 95% CI 1.35-11.31; P = .012) were independently associated with de novo PPE-associated headaches. Since COVID-19 outbreak, 42/46 (91.3%) of respondents with pre-existing headache diagnosis either "agreed" or "strongly agreed" that the increased PPE usage had affected the control of their background headaches, which affected their level of work performance.

CONCLUSION

Most healthcare workers develop de novo PPE-associated headaches or exacerbation of their pre-existing headache disorders.

Technical note: feeding zilpaterol hydrochloride to calf-fed Holstein steers improves muscle conformation of top loin steaks

The objective of this research was to evaluate changes in the muscle conformation of subprimal top-loins (M. longissimus lumborum) from calf-fed Holstein steers fed zilpaterol hydrochloride (ZH). Top-loins (n = 100) were transversely cut into 2.54 cm-thick steaks, weighed, and objectively evaluated via image analysis software for muscle area, width, and length traits. Top-loin steaks from steers fed ZH were heavier (P< 0.01; 367 vs. 337 g) and average muscle area per steak was greater (P < 0.05; 80.9 vs. 77.2 cm(2)) as compared to steaks from control steers. Muscle width (medial-lateral) was not different (P = 0.23) between control steers and those fed ZH. However, steaks from steers fed ZH had greater (P < 0.05) depth (dorsal-ventral) than steaks from control steers throughout the top-loin. The increased muscle depth of top-loins from calf-fed Holstein steers fed ZH may improve the center-of-the-plate salability of a cut that has traditionally suffered from poor muscling.

The effects of zilpaterol hydrochloride on carcass cutability and tenderness of calf-fed Holstein steers

To evaluate the impact of zilpaterol hydrochloride (ZH) on carcass cutability and tenderness of calf-fed Holstein steers, calf-fed Holstein carcasses (n = 102) were selected from a pool of 2,300 steers that were fed 0 or 8.3 mg/kg (DM basis) of ZH. Zilpaterol hydrochloride was supplemented the last 20 d of the finishing period and withdrawn for 3 d before slaughter. Carcasses were selected based on carcass weight as well as predetermined USDA Yield grade categories. For tenderness evaluation, steaks from the strip loin, bottom round, and top round (n = 54 per subprimal) were aged for 14 or 21 d postmortem. Carcasses from ZH-fed steers had more (P < 0.01) saleable yield than carcasses from control-fed steers. Additionally, ZH-fed steers had greater (P < or = 0.01) subprimal yield from the shoulder clod, strip loin, peeled tenderloin, top sirloin butt, bottom sirloin tri-tip, peeled knuckle, inside round, bottom round flat, eye of round, heel, and shank. Furthermore, ZH decreased (P < 0.01) the total amount and percentage of bone and fat trim from the carcass. Moisture loss was not affected by ZH in LM or inside round steaks (P > 0.05); however, ZH increased thawing loss (P = 0.05) but reduced cooking loss (P = 0.05) in bottom round steaks. Shear force values of LM and inside round steaks increased with ZH inclusion (P < 0.01), but there was no difference in bottom round steaks (P > 0.05). Steaks aged for 21 d had smaller (P < 0.01) Warner-Bratzler shear force (WBS) values than 14-d steaks from all 3 subprimals. Trained sensory panelists did not detect any differences (P > 0.05) in sensory juiciness, tenderness, or flavor variables of LM or inside round steaks, except ZH steaks from the LM received smaller scores for sustained juiciness (P = 0.01) and overall tenderness (P = 0.04) than control steaks. Although LM steaks from ZH cattle were tougher than control steaks, the ZH-treated steaks had an average WBS value of 4.10 kg, which would be classified as intermediate in tenderness, with trained panelists rating ZH steaks slightly to moderately tender. Feeding ZH improved carcass cutability of calf-fed Holstein steers; however, tenderness was reduced in LM and inside round steaks. The interaction of postmortem tenderization techniques should be investigated to evaluate their impact on palatability in cattle supplemented with beta-agonists to allow the beef industry to take full advantage of the enhancement in performance and carcass yield.

Effects of supplementing feedlot steers and heifers with zilpaterol hydrochloride on Warner-Bratzler shear force interrelationships of steer and heifer longissimus lumborum and heifer triceps brachii and gluteus medius muscles aged for 7, 14 and 21d

Longissimus lumborum (LL) muscles from 117 steers plus LL, gluteus medius (GM), and triceps brachii (TB) muscles from 132 heifers were evaluated for effects of feeding duration of zilpaterol hydrochloride (Zilmax(R); ZH; 7.56g/907kg on a dry matter basis) and aging time on tenderness. Both genders were blocked by initial weight into six blocks of four pens. Pens were assigned to treatments of control (C), or 20, 30 or 40days on ZH, with a 3day withdrawal. Steaks from each subprimal were vacuum aged individually for 7, 14 or 21days, frozen, thawed, and cooked to 71 degrees C for Warner-Bratzler shear force (WBSF). All muscles from steers and heifers from ZH30 and ZH40 treatments had higher (P<0.05) WBSF than those of C. The WBSF of steer LL and heifer TB from the ZH20 treatment was higher (P<0.05) than C. There was a treatment by aging interaction (P>0.05) for WBSF of GM steaks from heifers. Percentage of intramuscular fat had little effect on tenderness. Percentages of steer LL and heifer TB steaks with WBSF values below thresholds of either 5.0 or 4.6kg from the ZH20 treatment were quite high, whereas percentages of heifer LL and GM muscles below 5.0kg (67%) and 4.6kg (57%) were low. Feeding ZH20days generally increased WBSF values, but mean WBSF values for steer LL and heifer TB were below 4.6kg. Feeding ZH 20days resulted in>40% of GM steaks with WBSF values above 4.6kg.

Effect of zilpaterol hydrochloride supplementation on cutability and subprimal yield of beef steer carcasses

Beef steers (n = 11,877) from 7 studies were fed zilpaterol hydrochloride (ZH) for 0 or 20 to 40 d before slaughter to determine the effects of ZH on subprimal weight and yield. Carcasses were selected based on mean HCW of treatment groups for fabrication into boneless, closely trimmed, or denuded subprimals, lean, fat, and bone. Data from the 7 trials were pooled for statistical analysis. Feeding ZH increased (P < 0.05) weights of all major subprimals compared with steers not supplemented with ZH. Also, subprimals from the hindquarter, including valuable cuts like the tenderloin, strip loin, and top sirloin butt, increased (P < 0.05) as a percentage of cold carcass weight from steers fed ZH. The tenderloin was 0.06 percentage units greater (P < 0.05), the strip loin was 0.08 percentage units greater (P < 0.05), and the top sirloin butt was 0.11 percentage units greater (P < 0.05) in ZH-fed steers when compared with steers not fed ZH. Supplementation of ZH greatly increased (P < 0.05) total saleable carcass yield by 1.76 percentage units, whereas ZH inclusion decreased (P < 0.05) the percentage of fat trim and bone by 0.58 and 1.10 percentage units, respectively. Therefore, ZH can be utilized by the beef industry to improve red meat yield efficiency throughout the beef production chain.

Predicting red meat yields in carcasses from beef-type and calf-fed Holstein steers using the United States Department of Agriculture calculated yield grade

Analyses were conducted to evaluate the ability of the USDA yield grade equation to detect differences in subprimal yield of beef-type steers and calf-fed Holstein steers that had been fed zilpaterol hydrochloride (ZH; Intervet Inc., Millsboro, DE) as well as those that had not been fed ZH. Beef-type steer (n = 801) and calf-fed Holstein steer (n = 235) carcasses were fabricated into subprimal cuts and trim. Simple correlations between calculated yield grades and total red meat yields ranged from -0.56 to -0.62 for beef-type steers. Reliable correlations from calf-fed Holstein steers were unobtainable; the probability of a type I error met or exceeded 0.39. Linear models were developed for the beef-type steers to predict total red meat yield based on calculated USDA yield grade within each ZH duration. At an average calculated USDA yield grade of 2.9, beef-type steer carcasses that had not been fed ZH had an estimated 69.4% red meat yield, whereas those fed ZH had an estimated 70.7% red meat yield. These results indicate that feeding ZH increased red meat yield by 1.3% at a constant calculated yield grade. However, these data also suggest that the calculated USDA yield grade score is a poor and variable estimator (adjusted R(2) of 0.31 to 0.38) of total red meat yield of beef-type steer carcasses, regardless of ZH feeding. Moreover, no relationship existed (adjusted R(2) of 0.00 to 0.01) for calf-fed Holstein steer carcasses, suggesting the USDA yield grade is not a valid estimate of calf-fed Holstein red meat yield.

The effect of zilpaterol hydrochloride on meat quality of calf-fed Holstein steers

The objective of these studies was to evaluate the effects of zilpaterol hydrochloride (ZH), fed for 0, 20, or 30 d, on meat quality attributes of calf-fed Holstein steers. Steers were slaughtered at a commercial facility, and carcasses were selected by HCW to represent the pen mean. Further carcass selection was based on quality grade (Choice and Select) and yield grade. Proximate composition, measures of water holding capacity, and tenderness using Warner-Bratzler shear force after 7, 14, or 21 d postmortem were evaluated on the shoulder clod (triceps brachii), top butt (gluteus medius), and strip loin (longissimus lumborum). Percentage of purge for the 3 subprimals was not different (P > 0.05) among ZH treatments. Steers fed ZH for 20 d or 30 d had decreased (P < 0.05) percentages of fat in the triceps brachii, compared with 0-d ZH. Percentage of fat was less (P < 0.05) in the gluteus medius and longissimus lumborum when steers were fed ZH for 30 d compared with those steers fed ZH for 0 d. Percentage of fat was greater in Choice triceps brachii (P < 0.05) and longissimus lumborum (P < 0.10) compared with Select. Thaw loss was not different (P > 0.05) for any muscle due to ZH treatment. Only longissimus had a greater (P < 0.05) cooking loss with ZH treatment. Cooking loss was not different (P > 0.05) for the gluteus medius or longissimus lumborum due to quality grade or aging day. At each aging day, the 20- and 30-d ZH longissimus lumborum had greater (P < 0.05) shear force values than 0 d; however, 20- and 30-d ZH had a greater absolute change in shear force from 7 to 21 d than that of 0 d ZH. Triceps brachii steaks were less tender (P < 0.05) after ZH treatment, but gluteus medius steaks were not different (P > 0.05). There was no difference (P > 0.05) in shear force due to quality grade. Results illustrate the use of ZH in calf-fed Holstein steers will have minimal effects on purge, thaw, or cooking loss. Percentage of intramuscular fat will decrease, especially when fed for longer durations. Steaks from ZH treated steers were tougher than steaks from control animals at all aging times, but ZH steaks became more tender with postmortem aging.

Effects of feeding zilpaterol hydrochloride for twenty to forty days on carcass cutability and subprimal yield of calf-fed Holstein steers

Zilpaterol hydrochloride (ZH) is designed to increase carcass leanness, chilled side weight (CSW), and percent saleable yield. The objective of this study was to evaluate the effect of a single dose of ZH on cutability and subprimal yield of calf-fed Holstein steers when fed for increasing durations. Two hundred forty steers were fed 8.3 mg/kg of ZH on a DM basis for 0, 20, 30, or 40 d, with a 3-d withdrawal before slaughter. After slaughter, steers were fabricated into 4 pieces (round, loin/flank, rib/plate, and chuck), packaged in combos, shipped to 2 locations, and further fabricated into subprimal pieces and trim. Trim was collected from each primal and separated into groups based on composition of 90, 80, and 50% lean. Zilpaterol hydrochloride increased (P = 0.01) CSW by 6.22 kg and saleable yield by 6.4 kg when included in the diet for 20 d. Furthermore, saleable yield as a percentage of CSW was increased (P = 0.03) 1.18 percentage units when included in the diet for 20 d. Steers fed ZH for 20 d had heavier strip loins (4.47 vs. 4.12 kg, P = 0.02), tenderloins (2.75 vs. 2.49 kg, P = 0.02), and ribeye rolls (5.74 vs. 5.30 kg, P = 0.01) than steers not fed ZH. These advantages are further demonstrated as a percentage of CSW. Strip loins (P = 0.06), tenderloins (P = 0.04), and ribeye rolls (P = 0.04) of ZH-fed steers had a greater percentage of CSW than controls. Zilpaterol hydrochloride also increased the percentage of CSW of the 3 primary components of the round when fed for 20 d. The knuckle was 0.10 percentage units heavier (P = 0.11), the top round was 0.24 percentage units heavier (P = 0.04), and the bottom round was 0.22 percentage units heavier (P = 0.03) in ZH-fed steers when compared with steers not fed ZH. Based on these data, it can be concluded that ZH significantly increased subprimal cutting weights, yields, and percentage saleable yield of calf-fed Holstein steers when fed for at least 20 d before slaughter. Zilpaterol hydrochloride increased percentage of CSW of subprimal cuts from Holstein steers in the round and to a lesser degree in the loin.

Assessment of the impact of nutrient management practices on nitrate contamination in the Abbotsford-Sumas aquifer

The impact of recent changes to nutrient management practices in raspberry fields on the loading and subsequent transport of nitrate through the vadose zone of the Abbotsford-Sumas aquifer is investigated numerically. Previous studies have shown that nitrate concentrations in the aquifer have remained relatively stable despite a shift in nutrient management practices. Using an estimate of net annual available nitrogen in fields that are fertilized using synthetic fertilizer, nitrate concentrations as a function of time and depth through the vadose zone are simulated from spring to late fall. Results indicate rapid leaching of nitrate owing to the permeable nature of the aquifer and suggest that nitrate loading to the water table may occur earlier than previously thought, possibly due to spring rains. For an average fertilizer application rate of 90 kg of N/ha, the simulated nitrate concentration on Oct 1 within the top 1 m of soil is 33 mg of N/kg, while the residual soil nitrate measured in late September was 37 mg of N/kg. Taking into account the effects of dilution within the saturated zone, the simulated peak nitrate concentration is similar to average observed peak concentrations in a shallow monitoring well. A solution is offered for estimating nitrate concentration at the water table as a function of the rate of synthetic fertilizer applied to raspberry fields.

Perceptions of contradictory communication from parental figures by adults with borderline personality disorder: a preliminary study

This study investigated a hypothesized correlation between contradictory responses from parental figures perceived in present-day interactions by adult subjects and the diagnosis of borderline personality disorder (BPD). One hundred subjects were given a questionnaire designed to assess the frequency of perceived parental response patterns divided into appropriate, conflicting, polarized, and neglectful categories. The BPD and a group subthreshold for the disorder endorsed significantly more conflicting and fewer appropriate responses for the first parental figure rated than did both patient control subjects and normal control subjects without BPD; a trend toward similar results was found for the second parental figure also. The frequency of polarized and neglectful responses was not significantly different among the groups. There was indirect evidence that BPD subjects did not engage in the defense mechanism of "splitting" when filling out the questionnaire. These results suggest that contradictory family communication patterns might be considered in models of ongoing reinforcement for dysfunctional BPD behavior.

Phrynoderma: a manifestation of vitamin A deficiency?.. The rest of the story

Phrynoderma is a distinctive form of follicular hyperkeratosis associated with nutritional deficiency. Although originally thought to represent vitamin A deficiency, several studies have demonstrated multiple etiologies. Characteristic skin lesions are hyperkeratotic papules that first appear on the extensor surfaces of the extremities, shoulders, and buttocks. We report a 14-month-old boy with malnourishment and hyperkeratotic papules and plaques with histologic changes typical of phrynoderma. Despite an extensive evaluation, a specific nutritional deficiency was not identified. Phrynoderma is believed to be a manifestation of severe malnutrition, not necessarily accompanying low vitamin A levels. While the literature supports a link between phrynoderma and vitamins E, B, A, and essential fatty acids general malnutrition seems to be the strongest association. The clinical picture typically improves with enhanced nutritional status. Phrynoderma must be considered in the differential diagnosis in patients with extensor surface hyperkeratotic papules and plaques in the setting of malnourishment and should prompt the clinician to evaluate cell markers of nutritional status, not just vitamin A. We believe this patient exemplifies the conundrum that faces clinicians in evaluating patients with extensor surface predominant hyperkeratotic papules and plaques in the setting of malnourishment.

Mortality Rate of Bullous Pemphigoid in a US Medical Center

All patients at the Medical College of Wisconsin Affiliated Hospitals with a new diagnosis of bullous pemphigoid (BP) between May 1, 1997 and September 1, 2002 were included in this study. The age at onset, date of death or date of last follow-up visit, mode of treatment, co-morbidities, and initial and follow-up hospitalizations were noted. Thirty-eight new patients were identified and complete follow-up data were obtained on 37 of the patients. Patients were followed a minimum of 1 y or until the time of death. The mean duration of follow-up was 20 mo. Kaplan-Meier analysis of our population indicated a 1-y survival probability of 88.96% (standard error 5.21%), with a 95% confidence interval (75.6%, 94.2%). This survival rate was considerably higher than that recently reported in several studies from Europe (29%-41% first year mortality). Although the age at onset and co-morbidities of our patients were similar to those in the European studies, the rate of hospitalization of our patients was much lower than that of patients from Europe (1.5 d per patient vs 11-25 d per patient). This study suggests that differences in practice patterns may be an important factor in the reduced mortality rate in US BP patients compared with Europe.

Utilization of beef from different cattle phenotypes to produce a guaranteed tender beef product

Cattle (n = 303) were visually selected from four feed yards to represent six phenotypes (English [EN; n = 50], 3/4 English-1/4 Brahman [ENB; n = 52], 1/2 English-1/2 Exotic [ENEX; n = 56], 1/2 English-1/4 Exotic-1/4 Brahman [ENEXB; n = 47], 3/4 Exotic-1/4 Brahman [EXB; n = 49], and 1/2 Exotic-1/4 English-1/4 Brahman [EXENB; n = 49]). Carcasses were processed at a commercial beef packing facility, and strip loins were collected after 48-h chilling. Strip loins were aged for 14 d at 2 degrees C and frozen at -20 degrees C for 3 to 5 d before three 2.5-cm-thick steaks were cut for Warner-Bratzler shear force (WBSF) determinations and sensory evaluations. Phenotype EN had the highest (P < 0.05) adjusted fat thickness, and EXB had adjusted fat thickness that was lower (P < 0.05) than all other phenotypes except EXENB. Carcasses of EN and ENB had smaller (P < 0.05) longissimus muscle areas than phenotypes ENEX, EXB, and EXENB. Phenotype EN produced carcasses with the highest (P < 0.05) numerical yield grade, whereas carcasses originating from phenotype EXB had lower (P < 0.05) numerical yield grades than all other phenotypes except ENEX. No differences (P > 0.05) were found among phenotypes for mean WBSF values or sensory panel ratings for initial and sustained tenderness, initial and sustained juiciness, beef flavor characteristics, and overall mouthfeel. More than 90% of steaks from carcasses of all phenotypes had WBSF values less than 3.6 kg when cooked to an internal cooked temperature of 70 degrees C. Results from this study indicated that all phenotypes represented in this study could be managed to produce tender beef.

Sources of ground water salinity on islands using 18O, 2H, and 34S

Stable isotopes of 18O and 2H in water, and 34S and 18O in dissolved SO4, are used to verify the interpretation of the chemical evolution and proposed sources of salinity for two islands that have undergone postglacial rebound. Results for delta18O and delta34S in dissolved SO4 on the Gulf Islands, southwest British Columbia, Canada, suggest a three-component mixing between (1) atmospheric SO4 derived largely from recharge of meteoric origin, (2) modern marine SO4 associated with either modern-day salt water intrusion or Pleistocene age sea water, and (3) terrestrial SO4. The age of the marine SO4 is uncertain based on the geochemistry and SO4 isotopes alone. Two options for mixing of saline ground waters are proposed--either between current-day marine SO4 and atmospheric SO4, or between older (Pleistocene age) marine SO4 and atmospheric SO4, delta18O and delta2H compositions are relatively consistent between both islands, with a few samples showing evidence of mixing with water that is a hybrid mixture of Fraser River water and ocean water. The isotopic composition of this hybrid water is approximately delta18O = 10 per thousand. delta18O and delta2H values for many saline ground waters plot close to the global meteoric water line, which is distinctly different from the local meteoric water line. This suggests a meteoric origin for ground waters that is different from the current isotopic composition of meteoric waters. It is proposed these waters may be late Pleistocene in age and were recharged when the island was submerged below sea level and prior to rebound at the end of the last glaciation.

Effects of the transportation of beef cattle from the feedyard to the packing plant on prevalence levels of Escherichia coli O157 and Salmonella spp

Two hundred steers and heifers from a large feedyard (65,000-head capacity) were used to determine the prevalence levels of enterohemorrhagic Escherichia coli O157 (EHEC O157) and Salmonella spp. prior to and after shipping to a commercial packing facility. Two samples, a ventral midline hide swab and a fecal sample, were aseptically collected from each animal 2 weeks prior to the date of transportation and at the packing plant immediately after exsanguination. Samples were collected from all trailers (n = 46) before animals were loaded for transport to the packing facility. The average prevalence levels of EHEC O157 on hides (18%) and in feces (9.5%) at the feedyard decreased (P > 0.05) at the packing plant to 4.5 and 5.5%, respectively. The average prevalence levels of Salmonella spp. on hides (6%) and in feces (18%) at the feedyard increased to 89 and 46%, respectively, upon arrival at the packing plant. Average prevalence levels for EHEC O157 and Salmonella spp. on the trailers were 5.43 and 59%, respectively. The results of this study demonstrate that transportation may be a potential stressor for cattle, as evidenced by the increased shedding of Salmonella spp.

Ataxia telangiectasia mutated is essential during adult neurogenesis

Ataxia telangiectasia (A-T) is an autosomal recessive disease characterized by normal brain development followed by progressive neurodegeneration. The gene mutated in A-T (ATM) is a serine protein kinase implicated in cell cycle regulation and DNA repair. The role of ATM in the brain and the consequences of its loss on neuronal survival remain unclear. We studied the role of ATM in adult neural progenitor cells in vivo and in vitro to define the role of ATM in dividing and postmitotic neural cells from Atm-deficient (Atm(-/-)) mice in a physiologic context. We demonstrate that ATM is an abundant protein in dividing neural progenitor cells but is markedly down-regulated as cells differentiate. In the absence of ATM, neural progenitor cells of the dentate gyrus show abnormally high rates of proliferation and genomic instability. Atm(-/-) cells in vivo, and in cell culture, show a blunted response to environmental stimuli that promote neural progenitor cell proliferation, survival, and differentiation along a neuronal lineage. This study defines a role for ATM during the process of neurogenesis, demonstrates that ATM is required for normal cell fate determination and neuronal survival both in vitro and in vivo, and points to a mechanism for neuronal cell loss in progressive neurodegenerative diseases.

Women and cardiovascular disease

Cardiovascular disease remains the number one killer in the United States. The face of the person with cardiovascular disease is changing. No longer is the middle-aged man at highest risk. Current data reveal that women, especially postmenopausal women, are at highest risk for cardiovascular disease. This article identifies the differences noted between men and women with cardiovascular disease, including effects in presentation, identification, and treatment.

Effects of hydrolyzed spray dried red blood cells in milk replacer on calf intake, body weight gain, and efficiency

An alternative protein ingredient based on spray-dried, hydrolyzed red blood cells was evaluated in calf milk replacers. Two experiments were conducted to determine the value of the ingredient on intake, growth, and feed efficiency in dairy calves. In experiment 1, Holstein bull calves (n = 120) were fed calf milk replacer containing 0, 11, 22, or 43% of crude protein as spray dried hydrolyzed red blood cells. Calves were fed 454 g/d of experimental milk replacer reconstituted to 12% dry matter plus a conventional calf starter for 28 d. Body weight gain, intake of milk replacer and calf starter, feed efficiency, fecal scores, and days scouring were unaffected by source of protein. In experiment 2, Holstein calves (n = 69) at the University of Minnesota, Crookston and Waseca were fed milk replacer containing 0, 22, or 43% of crude protein as spray dried hydrolyzed red blood cells. Calves were fed 454 g/d of experimental milk replacer reconstituted to 12% dry matter plus a conventional calf starter containing 0 or 25% alfalfa meal for 35 d. No calves died during the study. Body weight gain, feed efficiency, intake of calf starter and milk replacer, fecal scores, and days scouring were unaffected by increasing hydrolyzed red blood cells in milk replacer. Similar performance of all calves indicated that spray dried hydrolyzed red blood cells can replace up to 43% of crude protein from whey protein concentrate without detrimental effects on animal performance.

Ultrastructural identification of synapses between mitral/tufted cell dendrites

Asymmetrical, type 1 synapses between mitral and/or tufted (M/T) cell dendrites were observed in the glomerular layer (GL) and juxtaglomerular external plexiform layer (EPL) of salamander olfactory bulb sections. The dendrites had electron-lucent cytoplasm containing regularly-arrayed microtubules and spherical translucent vesicles. The vesicles were clustered against a thin pre-synaptic density that was aligned with a 17-20 nm-wide synaptic cleft and a thicker post-synaptic density. These dendrodendritic synapses could be a source of the delayed, prolonged excitation that originates from the GL/EPL. During spatiotemporal encoding of odor stimuli, they could amplify or synchronize M/T cell responses.

Interactions between forage and wet corn gluten feed as sources of fiber in diets for lactating dairy cows

Twelve early lactation Holstein cows (4 fistulated) were used in replicated 4x4 Latin squares with 4-wk periods to determine the effective neutral detergent fiber (NDF) content of wet corn gluten feed and to measure the effect of forage particle size on ruminal mat consistency and passage rate of wet corn gluten feed. Diets were 1) 23.3% NDF (17.4 percentage units of NDF from alfalfa silage), 2) diet 1 plus 11.1 additional percentage units of NDF from alfalfa silage, 3) diet 1 plus 10.7 percentage units of NDF from wet corn gluten feed, and 4) 8.6 percentage units of NDF from alfalfa silage plus 8.9 percentage units of NDF from coarsely chopped alfalfa hay and 10.7 percentage units of NDF from wet corn gluten feed. The calculated effective NDF factor for wet corn gluten feed, using change in milk fat concentration per unit change in NDF, was 0.74 compared with an assumed 1.0 for alfalfa silage. Rumination activity was measured to calculate a physically effective NDF factor for wet corn gluten feed, which was only 0.11 compared with 1.0 for alfalfa silage. Physically effective NDF also was determined for wet corn gluten feed by wet sieving; 22% of the particles were retained on the 3.35-mm screen or greater. Ruminal mat consistency increased and passage rate of wet corn gluten feed decreased with added hay. The inclusion of chopped alfalfa hay to a diet containing wet corn gluten feed increased ruminal mat consistency, rumination activity, and slowed passage rate, resulting in greater ruminal digestion of NDF from wet corn gluten feed. Depending on the response variable, the effectiveness of NDF from wet corn gluten feed varied from 0.11 to 0.74.

Characterizing a faulted aquifer by field testing and numerical simulation

Faulted aquifers constitute one of the most complex geological environments for analysis and interpretation of hydraulic test data because of the inherent ability of faults to act not only as highly transmissive zones but also as hydraulic barriers. Previous studies of the fractured carbonate aquifer at Carleton University, Ottawa, Canada, characterized the flow regime as predominantly linear, but with limited radial nature, and undertook to analyze constant discharge test data using both radial and linear flow models. When used as direct input to a numerical model, the hydraulic parameters, calculated directly from hydraulic test data, were inappropriate and resulted in a poorly calibrated model. While our interpretation of the faulted aquifer remains linear-radial in nature, parameter estimation by numerical simulation highlighted the presence of hydraulic barriers associated with the faults. These barriers are not readily apparent in the constant discharge test data and act to modify the hydraulic test curves at early to mid time, leading to incorrect estimates of the hydraulic parameters. This paper describes the conceptual model and the numerical approach, and demonstrates the importance of using transient simulations for model calibration.

Increasing utilisation efficiency of ferric chloride etchant in industrial photochemical machining

The environmental effects of photochemical machining (PCM) can be appreciable in view of the nature of the industry whereby various chemicals are used in the preparation and cleaning of metal surfaces, photographic processing of phototooling, coating and selective removal (development) of photoresists, etching through apertures in the resist stencils and stripping of resist after etching. This paper concerns the environmental impact of ferric chloride, the most commonly used etchant in PCM, and is believed to be the first quantitative analysis for the PCM industry. The findings showed that more than half of the PCM companies used regeneration of ferric chloride etchant and 76.3% of companies were prepared to use a more environment-friendly regeneration system at a higher overall cost. Regarding ferric chloride consumption, it was found that the performance of companies varies greatly: companies using regeneration were, on average, nearly seven times (340.8% compared with 51.1%) more efficient than those that do not regenerate, and the most efficient company used 135 times less etchant than the least efficient company. The findings of this study and the analysis carried out can be used by PCM companies as a benchmark in assessing their environmental performance with respect to etchant consumption efficiency.

Heterotopic ossification complicating total elbow replacement in a patient with rheumatoid arthritis

Heterotopic ossification after total elbow replacement is a new complication. In this particular case, it resulted in severe limitation of motion. Excision of the heterotopic bone resulted in an excellent functional outcome for the patient.

Outcomes after severe trauma at a northern Canadian regional trauma centre

OBJECTIVE

To evaluate outcomes of trauma patients at a northern community trauma referral centre that does not meet several of the guidelines for a trauma centre.

DESIGN

A retrospective study.

SETTING

Sudbury General Hospital in northern Ontario.

PARTICIPANTS

All trauma patients admitted between 1991 and 1994 who had an Injury Severity Score (ISS) greater than 12.

OUTCOME MEASURES

Actual survival to discharge was compared to survival predicted by TRISS analysis. Z, W and M scores were calculated by standard TRISS techniques.

RESULTS

Of 526 patients with an ISS greater than 12, 416 (79%) were suitable for TRISS analysis. Of these 416 patients, 310 (74%) were men. The mean age was 39 years. Two hundred and sixty-one (63%) patients were admitted directly to the Sudbury General Hospital, whereas 155 (37%) were transferred from other hospitals. The leading causes of injury were motor vehicle-traffic accidents in 48%, motor vehicle-nontraffic in 21% and falls in 8%. Overall, there were more unexpected survivors than patients who died. The Z score for survivors was 4.95, and the W score was 5.65.

CONCLUSIONS

In the setting of a geographically isolated, medium-volume trauma centre where blunt injuries predominate, excellent trauma survival can be achieved without meeting all trauma centre guidelines for staffing and facilities. Relaxing stringent requirements for the availability of physicians may facilitate surgical recruitment and retention.

Development and implementation of an extremity free-tissue-transfer database

Rigorous clinical outcomes research requires accurate, complete, and standardized data. No such system is currently being used by reconstructive microsurgeons to evaluate free-tissue-transfer procedures. To facilitate collection of relevant and complete data, the authors propose a standardized format for data collection regarding these procedures. Data are collected via computer entry or scannable forms. The database includes sociodemographic, clinical, health/functional status, patient satisfaction, and resource utilization variables--the necessary components of a well-constructed clinical outcome study. Such studies will give rise to meaningful treatment algorithms for managing reconstructive problems. In addition, widespread use of a standardized databse will facilitate comparisons between practices and allow for meta-analyses. Resultant practice guidelines and microsurgery care maps will ultimately improve patient care and minimize unnecessary costs.