P2712Integration of new CENTAUR high-sensitivity Troponin I assay with HEART score chest pain pathway to maximise early discharge from emergency department

Introduction

Chest pain is a common presentation to the emergency department (ED). Differentiating those with an Acute Coronary Syndrome from the majority without, within 4 hours, is a priority. Introduction of high-sensitivity TnI assays has the potential to allow early discharge from ED but at the expense of lower specificity. Given the pressure in ED to identify patients who can safely be discharged we developed an algorithm based on the HEART score. This combines the history, ECG, age, risk factors and hsTnI level and outperforms TIMI and GRACE scores in identifying low-risk patients. Patients with a score of ≥4 have an increased major adverse cardiac event (MACE) rate at 30 days; those with a score of <4 are suitable for early discharge. There are no studies utilising the CENTAUR assay combined with a clinical risk score.

Methods

An initial algorithm based on the HEART score tool was developed incorporating estimated hsTnI boundaries for the CENTAUR assay to inform the “T” component of the tool. This was tested on a 2 month sample of patients presenting with chest pain to the ED. Following review a revised pathway was developed. Patient outcome was recorded with both pathways including subsequent investigations and MACE at 30 days and compared with historical discharge rates for chest pain from the same ED. Sensitivity, specificity and NPV were calculated.

Results

There were 478 presentations with chest pain and at least one hsTnI level. Age ranged from 13 to 98 years (median 56); 50% were male. There were 21 (4%) MACE within 30 days of the initial presentation (NSTEMI: 18, STEMI: 1, unstable angina requiring CABG: 1, acute pulmonary oedema: 1). A 2 hour hsTnI ≤8 identified a low-risk group with no MACE <30 days. 30% of patients using the initial pathway had a HEART score of ≥4 (100% sens, 73% spec). 70% were suitable for ED discharge; there were no MACE in this group (100% NPV). A revised pathway was derived incorporating previous cardiac history and modified hsTnI boundaries. Applying this to the original cohort would have increased the proportion suitable for ED discharge to 82%. Both pathways improved the proportion of patients who could be discharged directly from ED from a historical 64%. The revised pathway demonstrated improved specificity for the identification of MACE with no loss of sensitivity and excellent negative predictive value. (100% sens, 86% spec, 100% NPV).

Conclusions

The CENTAUR hs-TnI assay and HEART score with modifications would facilitate the early discharge of patients with chest pain from ED within 4 hours without missing any MACE at 30 days. This conclusion should be validated in a prospective cohort.

Oxygen use for chest pain in coronary care units across the UK

AIM

To quantify the adherence to national guidance for the use of oxygen in patients presenting with chest pain to coronary care units (CCUs) across the UK.

DESIGN

Prospective survey.

METHODS

A total of 307 hospitals were contacted by telephone between August 2010 and October 2010. Of these, 48 had no CCUs, 10 units refused to take part and 18 hospitals were contacted on 2 occasions but were unable to provide the information due to paucity of time owing to heavy clinical workload. Overall 231 hospitals participated in the audit questionnaire.

RESULTS

A total of 30% of the units used oxygen titrated to saturations in accordance with national guidelines. There was no difference between units that had on-site availability of percutaneous coronary intervention and those that did not. Those hospitals where there was a policy for routine oxygen prescription were as unlikely to comply with the guidelines on oxygen use as hospitals where oxygen was not routinely prescribed.

CONCLUSION

Only one-third of CCUs in the UK reported adherence to guidelines with regards to oxygen delivery in patients presenting with chest pain. Despite this figure seeming rather low, this is consistent with practice through a range of specialties and guidelines. The evidence base for the oxygen guidance remains insecure. Additional research is required but in the meantime we recommend oxygen is prescribed according to current guidelines.

Extended lactations in a seasonal-calving pastoral system of production to modulate the effects of reproductive failure

This study was conducted to determine whether extending the calving interval (CI) to 24 mo would be an alternative to culling and replacing cows that had failed to become pregnant. Forty-six nonpregnant lactating cows were assembled in November 2004 and assigned to receive either 3kg (low) or 6kg (high) of concentrate supplement and a basal diet of grass silage and maize silage over the winter period (13 wk). Cows returned to pasture in late March and received 1kg of concentrate/d until dry-off (milk yield <5 kg/d). Cumulative milk production was calculated from calving to the end of November 2004 (12-mo CI) and from the start of December 2004 until dry off in 2005 (extended lactation part of 24-mo CI). High winter feeding resulted in greater milk production over the winter confinement (20.0+/-0.3 vs. 17.8+/-0.3 kg/d for high and low winter feeding, respectively) and had a carryover effect during the remainder of the 24-mo CI period (5,177 vs. 4,686kg; SEM=173kg). At the end of the study, cows were ranked on cumulative milk solids and separated into 3 groups (R1, R2, and R3). During the 24-mo CI, milk yields were 7,287, 6,267, and 5,273kg (SEM=308kg) in yr 1, and 5,738, 4,836, and 4,266 (SEM=241kg) in yr 2 for R1, R2, and R3, respectively. Eighty-five percent of the cows became pregnant during the breeding season of yr 2, with a conception rate to first service of 52%. An economic analysis of different ranks with a 12-mo CI, a 24-mo CI, and an annualized herd effect, which compared an efficient spring calving system with 30% recycled cows in R1 and 10% recycled cows in R3, was carried out. Farm profit was reduced by 60% and 65% at a milk price of 22.3 euro-cents (c)/L with the corresponding values of 17% and 30% for a milk price of 30 c/L, respectively, when R1 and R3 systems were compared with an efficient spring milk (12-mo CI) production system. Within a spring system where 30% and 10% of R1 and R3 animals were subjected to extended lactations, the profit difference was reduced compared with an efficient spring system, The results indicated that lactations with a 24-mo CI may be a viable alternative to culling nonpregnant cows and be economically more suited to higher producing cows.

Fatty acid intake and milk fatty acid composition of Holstein dairy cows under different grazing strategies: herbage mass and daily herbage allowance

The objective of this study was to investigate the effect of level of 1) pregrazing herbage mass (HM) and 2) level of daily herbage allowance (DHA) on the performance and fatty acid (FA) composition of milk from grazing dairy cows. Sixty-eight Holstein-Friesian dairy cows were allocated to either a high or low pregrazing HM (1,700 vs. 2,400 kg of DM/ha; >40 mm), and within HM treatment, cows were further allocated to either a high or low DHA (16 vs. 20 kg of DM/d per cow; >40 mm) in a 2 x 2 factorial design. Pregrazing HM did not affect dry matter intake (17.5 +/- 0.75 kg/d), milk production (22.1 +/- 0.99 kg/d), milk composition (milk fat, 3.88 +/- 0.114%; milk protein, 3.28 +/- 0.051%), body weight (525 +/- 16 kg), or body condition score (2.65 +/- 0.064). Increasing DHA increased dry matter intake (+1.5 kg/d) but did not affect any other variable measured. Cows grazing the low HM or high DHA had a higher daily intake of total FA (+0.12 and +0.09 kg/d, respectively, for the low HM and high DHA), alpha-linolenic acid (LNA; +0.08 and +0.05 kg/d, respectively, for the low HM and high DHA), and linoleic acid (+0.01 for both the low HM and high DHA) compared with either the high HM or low DHA. Milk conjugated linoleic acid (cis-9, trans-11 isomer) was not affected by treatment (13.0 +/- 0.77 g/kg of total FA); however, large variation was recorded between individual animals (range from 5.9 to 20.6 g/kg of total FA). Milk concentrations of LNA were higher for animals offered the low HM (5.3 g/kg of total FA), but across treatments, milk concentrations of LNA were low (4.9 +/- 0.33 g/kg of total FA). The present study indicates that changes in HM and DHA do not have a great effect on the milk FA composition of grazing dairy cows. Further enhancement of the beneficial FA content in milk purely from changes in grazing strategy may be difficult when pasture quality is already high.

Pleiotropic effects of negative energy balance in the postpartum dairy cow on splenic gene expression: repercussions for innate and adaptive immunity

Increased energy demands to support lactation, coupled with lowered feed intake capacity results in negative energy balance (NEB) and is typically characterized by extensive mobilization of body energy reserves in the early postpartum dairy cow. The catabolism of stored lipid leads to an increase in the systemic concentrations of nonesterified fatty acids (NEFA) and β-hydroxy butyrate (BHB). Oxidation of NEFA in the liver result in the increased production of reactive oxygen species and the onset of oxidative stress and can lead to disruption of normal metabolism and physiology. The immune system is depressed in the peripartum period and early lactation and dairy cows are therefore more vulnerable to bacterial infections causing mastitis and or endometritis at this time. A bovine Affymetrix oligonucleotide array was used to determine global gene expression in the spleen of dairy cows in the early postpartum period. Spleen tissue was removed post mortem from five severe NEB (SNEB) and five medium NEB (MNEB) cows 15 days postpartum. SNEB increased systemic concentrations of NEFA and BHB, and white blood cell and lymphocyte numbers were decreased in SNEB animals. A total of 545 genes were altered by SNEB. Network analysis using Ingenuity Pathway Analysis revealed that SNEB was associated with NRF2-mediated oxidative stress, mitochondrial dysfunction, endoplasmic reticulum stress, natural killer cell signaling, p53 signaling, downregulation of IL-15, BCL-2, and IFN-γ; upregulation of BAX and CHOP and increased apoptosis with a potential negative impact on innate and adaptive immunity.

Negative energy balance in dairy cows is associated with specific changes in IGF-binding protein expression in the oviduct

Negative energy balance (NEB) during early lactation in dairy cows leads to an altered metabolic state that has major effects on the production of IGF family members. Low IGF-I concentrations are associated with poor fertility and therefore we aimed to determine whether NEB exerts a direct effect on IGF expression in the postpartum oviduct. Multiparous Holstein cows were allocated to two treatments (each n=6) designed using differential feeding and milking regimes to produce either mild NEB (MNEB) or severe NEB (SNEB). Animals were slaughtered in week 2 of lactation when divergent metabolic profiles were evident. Oviducts were collected for RNA analysis by real-time RT-PCR and in situ hybridisation. Quantitative measures in oviduct gene expression were obtained for all members of the IGF family (IGF-I/II, IGF-binding proteins (IGFBP) 1–6 and receptors for IGF types 1 and 2), insulin A/B, GH, glucocorticoid and oestrogen α/β. Expression of IGFBP-2 and IGFBP-6 (both of which have a high affinity for IGF-II) was decreased in SNEB relative to MNEB (P<0.05). No other gene was altered by NEB, but IGF-II, IGFBP-3, IGFBP-5 and IGFBP-6 all showed differential expression in different regions of the oviduct. These results indicate that, in addition to low circulating IGF-I after calving, NEB may also influence IGF availability in the oviduct indirectly through changes in specific IGFBP expression. It is possible that the predicted increased signalling by IGF-II may perturb embryo development, contributing to the high rates of embryonic mortality in dairy cows.

Cheese Manufacture with Milk with Elevated Conjugated Linoleic Acid Levels Caused by Dietary Manipulation

The objective of this study was to assess the effect of dietary supplementation of cows on pasture with sunflower oil for conjugated linoleic acid (cis-9, trans-11 CLA) enrichment of milk, for the production of CLA-enriched cheese. A group of 40 autumn-calving dairy cows were assigned to either a control group (indoor feeding on grass silage ad libitum and 6 kg/d of a typical indoor concentrate) or an experimental group (on pasture, being fed 6 kg of a supplement containing 100 g/kg of sunflower oil per d). These diets were fed for 16 d, during which time milk was collected for pilot-scale hard cheese manufacture. The pasture-based diet with sunflower oil resulted in a significant effect on the milk fatty acid CLA content. The concentration of cis-9, trans-11 CLA in the milk produced from cows on this diet increased to 2.22 g/100 g of fatty acid methyl esters (FAME) after 14 d, compared with 0.46 g/100 g of FAME in milk produced on the control indoor diet. The content of cis-9, trans-11 CLA in the cheese manufactured from the indoor control milk was 0.78 g/100 g of FAME and that from the pasture-based sunflower oil milk was 1.93 g/100 g of FAME. The cheese was assessed during the ripening period and CLA concentrations were stable throughout the 6 mo of ripening. Other cheese variables (microbiology, composition, flavor, free AA) were monitored during the ripening period, and the cheese with the elevated CLA concentrations compared favorably with the control cheese. Thus, a pasture-based diet supplemented with an oil source rich in linoleic acid resulted in an enhanced CLA content of bovine milk fat, compared with an indoor grass silage-based diet.

Relationships among milk production, energy balance, plasma analytes, and reproduction in Holstein-Friesian cows

Associations were examined between components and indicators of early lactation energy balance (EB) and measures of fertility in Holstein cows. Milk production, dry matter intake (DMI), body condition score (BCS), and endocrine and metabolite data from 96 cows were analyzed using multivariate logistic regression and survival analysis. Fertility variables investigated were interval to commencement of luteal activity (C-LA), calving to conception interval (CCI), and conception rate to first service (CON1). Mean daily EB, milk protein content, and DMI during the first 28 d in milk were associated positively with CON1. Cows having poorer BCS (< or =2.25) at first service had a lower CON1. Positive associations were identified among EB, milk protein content, DMI, and the likelihood of a shorter interval to C-LA. Cows having greater DMI and a more positive EB had an increased likelihood of a shorter CCI, whereas a lower nadir BCS was associated with an increased likelihood of a longer CCI. Milk yield was not associated with any of the fertility variables investigated. A greater plasma concentration of insulin-like growth factor I (IGF-I) during the first 2 wk of lactation was associated with a greater CON1 and an increased likelihood of a shorter interval to C-LA. In conclusion, we identified DMI as the principal component of EB influencing subsequent fertility. Furthermore, results indicate that milk protein content and plasma IGF-I concentration in early lactation may be useful indicators of reproductive efficiency.

Effect of negative energy balance on the insulin-like growth factor system in pre-recruitment ovarian follicles of post partum dairy cows

Post partumnegative energy balance (NEB) in dairy cattle is associated with a delayed return to ovarian cyclicity and reduced fertility. This study compared the IGF system of pre-recruitment ovarian follicles between cows in mild (n= 6) or severe (n= 6) NEB during early lactation. Ovaries were collected in the second weekpost partum, when circulating concentrations of IGF-I and glucose were lower (P< 0.01) in severe NEB cows. mRNA expression for IGF-II, type 1 IGF receptor (IGF-1R) and IGF-binding proteins (IGFBP)-1 to IGFBP-6 was determined byin situhybridisation in individual follicles using radiolabelled oligonucleotide probes. Follicles were classified as very small (1–2.5 mm) or small (2.5–5 mm) and healthy or atretic. Relative mRNA concentrations were measured as optical density (OD) units using image analysis. Thecal IGF-II mRNA expression was highest in very small, healthy follicles (P< 0.05). Granulosa cell IGFBP-2 was the only component to change with EB status, with higher mRNA expression in mild compared with severe NEB cows (P< 0.05). IGFBP-1 and IGFBP-3 mRNA expression were undetectable. IGF-1R, IGFBP-4 and IGFBP-5 mRNA expression were not significantly altered by follicle size or health, but IGFBP-5 tended to increase in atretic follicles. The pattern of IGFBP-6 mRNA expression in theca paralleled that of IGF-II mRNA, with higher (P< 0.05) levels in healthy, very small follicles. In conclusion, the reduced expression of IGFBP-2 mRNA in severe NEB cows may alter the bioavailability of circulating IGF-I and locally produced IGF-II to modulate the pre-recruitment stages of follicles required to maintain normalpost partumovarian cyclicity.

Comparative Evaluation of Alternative Forages to Grass Silage in the Diet of Early Lactation Dairy Cows

Fifty-six autumn-calving Holstein-Friesian cows, blocked on the basis of days in milk (27.6 +/- 10.65 d), lactation number (3.1 +/- 2.21), and preexperimental milk yield (28.4 +/- 6.69 kg) were used to examine the effects of replacing 330 g/kg of dry matter (DM) of first-cut perennial ryegrass silage with either fermented whole-crop wheat (WCW), urea-treated processed WCW, or corn silage on subsequent feed intake, milk production, and efficiency of nitrogen utilization. The DM (g/kg), crude protein (CP, g/kg of DM) and in vitro DM digestibility (g/kg) of the forages were 204, 179, and 762 for grass silage; 389, 90, and 711 for fermented WCW; 795, 141, and 768 for urea-treated processed WCW; and 346, 93, and 783 for corn silage, respectively. Four forage treatments were evaluated as follows: 1) grass silage as the sole forage (GS); 2) a mixture of grass silage and fermented WCW silage, (F-WCW); 3) a mixture of grass silage and urea-treated processed WCW, (UP-WCW); and 4) a mixture of grass silage and corn silage (CS). In all cases, the alternative forages comprised 67% of the forage mix on a DM basis. Isonitrogenous diets were formulated by offering all cows 8 kg of concentrate as fed, formulated to different CP concentrations. Cows were offered these diets from 28 to 104 d in milk. Total DM intake and milk yield were greater on UP-WCW (20.0 and 30.2 kg/d) and CS (18.3 and 33.2 kg/d) than on GS (13.5 and 26.5 kg/d). Although DM intake was greater on F-WCW (17.1 kg/d) than on GS, milk yield was not significantly greater (+2.7 kg/d). Milk protein concentration was greater on F-WCW (30.5 g/kg), UP-WCW (31.3 g/kg), and CS (30.7 g/kg) than on GS (28.5 g/kg). However, there was no difference between treatments in milk fat or lactose concentrations. Body weight change was greater for cows offered GS (-0.27 kg/d) than for those offered UP-WCW (-0.01 kg/d) and CS (+0.05 kg/d) but not compared with those offered F-WCW (-0.06 kg/d). There was no effect of treatment on plasma glucose, nonesterified fatty acids, beta-hydroxybutyrate, urea, or total protein at d 64 +/- 17.4 and d 92 +/- 17.4 postpartum. Efficiency of N utilization was greatest for CS with 0.36 of N intake being recovered in milk compared with 0.28, 0.32, and 0.26 for GS, F-WCW, and UP-WCW, respectively. There was no effect of treatment on milk urea N concentration or the urinary allantoin N to creatinine N ratio. The results of this experiment indicate that corn silage is a more suitable supplementary forage to grass silage than fermented or urea-treated processed WCW, with advantages realized in milk production and more efficient N utilization.

Anti-beta2GPI-antibody-induced endothelial cell gene expression profiling reveals induction of novel pro-inflammatory genes potentially involved in primary antiphospholipid syndrome

OBJECTIVE

To determine the effects of primary antiphospholipid syndrome (PAPS)-derived anti-beta(2)GPI antibodies on gene expression in human umbilical vein endothelial cells (HUVEC) by gene profiling using microarrays.

METHODS

Anti-beta(2)GPI antibodies purified from sera of patients with PAPS or control IgG isolated from normal subjects were incubated with HUVEC for 4 h before isolation of RNA and processing for hybridisation to Affymetrix Human Genome U133A-2.0 arrays. Data were analysed using a combination of the MAS 5.0 (Affymetrix) and GeneSpring (Agilent) software programmes. For selected genes microarray data were confirmed by real-time PCR analysis or at the protein level by ELISA.

RESULTS

A total of 101 genes were found to be upregulated and 14 genes were downregulated twofold or more in response to anti-beta(2)GPI antibodies. A number of novel genes not previously associated with APS were induced, including chemokines CCL20, CXCL3, CX3CL1, CXCL5, CXCL2 and CXCL1, the receptors Tenascin C, OLR1, IL-18 receptor 1, and growth factors CSF2, CSF3 IL-6, IL1beta and FGF18. The majority of downregulated genes were transcription factors/signalling molecules including ID2. Quantitative real-time RT-PCR analysis confirmed the microarray results for selected genes (CSF3, CX3CL1, FGF18, ID2, SOD2, Tenascin C).

CONCLUSIONS

This study reveals a complex gene expression response in HUVEC to anti-beta(2)GPI antibodies with multiple chemokines, pro-inflammatory cytokines, pro-thrombotic and pro-adhesive genes regulated by these antibodies in vitro. Some of these newly identified anti-beta(2)GPI antibody-regulated genes could contribute to the vasculopathy associated with this disease.

Effect of milking frequency and diet on milk production, energy balance, and reproduction in dairy cows

The objective of this study was to determine the effects of reduced milking frequency and increased dietary energy density in early lactation on milk production, energy balance, and subsequent fertility. Sixty-six spring-calving, multiparous Holstein-Friesian cows were assigned to 1 of 3 treatment groups: once-daily milking on a standard diet (1xST); 3-times daily milking on a standard diet (3xST); and 3-times daily milking on a high-energy diet. Treatments were imposed for the first 28 d of lactation, after which all groups were milked twice daily and fed the standard diet. During the treatment period, the 1xST cows had 19.6% lower milk yield and higher milk fat and milk protein concentrations (15.7 and 10.2%, respectively) compared with 3xST. Dry matter (DM) intake was similar between 1xST and 3xST during the treatment period (12.64 vs. 13.25 kg/ d; SED = 0.82). Daily energy balance was less negative for 1xST compared with 3xST during wk 1 to 3 of lactation [-3.92 vs. -5.30 unité fourragère lait (UFL)/d; SED = 0.65; 1 UFL is equal to the net energy for lactation of 1 kg of standard air-dry barley]. During the treatment period, the cows on the high-energy diet had 17% higher milk yield, higher DM intake (15.5 vs. 13.9 kg/d; SED = 0.71), and similar energy balance (-4.45 vs. -4.35 UFL/d; SED = 0.65) compared to 3xST. Diet had no significant effect on any of the fertility variables measured. The interval to first ovulation was shorter for 1xST than 3xST (18.3d vs. 28.6d; SED = 1.76). In conclusion, once-daily milking in early lactation may promote earlier resumption of ovarian cyclicity, mediated through improved nutritional status.

One year results of the Middlesbrough early revascularisation to limit infarction (MERLIN) trial

OBJECTIVE

To report one year results of the MERLIN (Middlesbrough early revascularisation to limit infarction) trial, a prospective randomised trial comparing the strategy of coronary angiography and urgent revascularisation with conservative treatment in patients with failed fibrinolysis complicating ST segment elevation myocardial infarction (STEMI). The 30 day results have recently been published. At the planning stage of the trial, it was determined that follow up of trial patients would continue annually to three years to determine whether late benefit occurred.

SUBJECTS

307 patients who received a fibrinolytic for STEMI but failed to reperfuse early according to previously described ECG criteria and did not develop cardiogenic shock.

METHODS

Patients were randomly assigned to receive either emergency coronary angiography with a view to proceeding to urgent revascularisation (rescue percutaneous coronary intervention (rPCI) arm) or continued medical treatment (conservative arm). The primary end point was all cause mortality at 30 days. The secondary end points included the composite end point of death, reinfarction, stroke, unplanned revascularisation, or heart failure at 30 days. The same end points were evaluated at one year and these results are presented.

RESULTS

All cause mortality at one year was similar in the conservative arm and the rPCI arm (13.0% v 14.4%, p = 0.7, risk difference (RD) -1.4%, 95% confidence interval (CI) -9.3 to 6.4). The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularisation, or heart failure was significantly higher in the conservative arm (57.8% v 43.1%, p = 0.01, RD 14.7%, 95% CI 3.5% to 25.5%). This was driven almost exclusively by a significantly higher incidence of subsequent unplanned revascularisation in the conservative arm (29.9% v 12.4%, p < 0.001, RD 17.5%, 95% CI 8.5% to 26.4%). Reinfarction and clinical heart failure were numerically, but not statistically, more common in the conservative arm (14.3% v 10.5%, p = 0.3, RD 3.8%, 95% CI -3.7 to 11.4, and 31.2% v 26.1%, p = 0.3, RD 5.0%, 95% CI -5.1 to 15.1). There was a strong trend towards fewer strokes in the conservative arm (1.3% v 5.2%, p = 0.06, RD -3.9%, 95% CI -8.9 to 0.06).

CONCLUSION

At one year of follow up, there was no survival advantage in the rPCI arm compared with the conservative arm. The incidence of the composite secondary end point was significantly lower in the rPCI arm, but this was driven almost entirely by a highly significant reduction in the incidence of further revascularisation.

Effects of diets fed to dairy cows before and after calving on their plasma progesterone profiles after calving

Four weeks before their predicted mean second lactation calving date, 60 spring-calving Holstein-Friesian cows were blocked into groups of six on the basis of their predicted calving date and body condition score, and allocated at random to one of six dietary treatments in a factorial design: ad libitum grass silage, ad libitum grass silage plus barley straw or ad libitum grass silage plus 3 kg of concentrates, was offered for four weeks before the expected calving date, and after calving they were offered either 4 kg or 8 kg of concentrates plus ad libitum grass silage for eight weeks. On average, the first luteal activity occurred in all the groups at 29 days after calving. Seventeen of the cows had an atypical first plasma progesterone profile; 12 were anovulatory, three had prolonged luteal phases and two became anovulatory after having been cyclic. The cows offered grass silage only before calving had a significantly shorter mean (se) interval between calving and second luteal activity (44.9 [2.1] days), than the cows offered grass silage and straw (53.5 [1.9] days) or grass silage and concentrates (51.5 [3.2] days) (P<0.05). After calving none of the 28 cows offered grass silage and 4 kg of concentrates started cycling before day 21, whereas five of the 30 cows offered grass silage and 8 kg of concentrates cycled before day 21 (P<0.05).

The prevalence and clinical significance of autoantibodies to plasminogen activator inhibitor 1 in systemic lupus erythematosus

We have recently described the novel autoantigen plasminogen activator inhibitor (PAI-1) in systemic lupus erythematosus (SLE). The aim of this study was to determine the prevalence and clinical significance of anti-PAI-1 autoantibodies in patients with SLE. Autoantibodies to recombinant PAI-1 were measured in retrospective sera of 48 lupus patients by immunoassay in order to assess their clinical significance. This showed that 71% of sera from 48 lupus patients had significantly elevated anti-PAI-1 autoantibodies as compared with normal control subjects (P < 0.0001). There was a weak but significant (P < 0.043) correlation with anti-dsDNA autoantibodies. In longitudinal studies, autoantibodies against PAI-1 correlated with clinical parameters measured by the BILAG disease activity index including global clinical score. Our study demonstrates the high frequency of novel autoantibodies to PAI-1 in patients with lupus. The serial clinical correlations with anti-PAI-1 autoantibodies also support the hypothesis that these autoantibodies may play a pathogenic role in lupus.

Effect of offering rumen-protected fat supplements on fertility and performance in spring-calving Holstein-Friesian cows

The objective of this study was to evaluate the effect of two different rumen-protected fat supplements, on reproductive performance and milk production, in grass-based spring calving cows. Two hundred and one Holstein-Friesian cows with an average lactation number of 3.6 (20% first lactation, 16% second lactation and 64% third lactation or greater) were grouped into blocks of three on the basis of calving date, lactation number and previous lactation milk yield for cows of second lactation or greater and on the basis of calving date for first lactation animals. From within-blocks individual animals were assigned at random, within 10 days post-calving, to one of the following three treatments: (1) Megalac Plus 3% (MP; 0.4kg/day, containing Ca salt of palm fatty acids and Ca salt of methionine hydroxy analogue), (2) Megapro Gold (MPG; 1.5kg/day, containing Ca salt of palm fatty acids, extracted rapeseed meal and whey permeate), and (3) Control (C; unsupplemented). Cows were supplemented for on average 103 days (range 54-134 days). The average milk yield over the first 12 weeks of lactation was higher (P<0.05) for both fat supplements compared to C and was higher for MP compared to C over the full lactation. Both supplements reduced (P<0.05) milk protein concentration over the first 6 weeks of lactation. MPG increased (P<0.05) conception rate to first service compared to C. Conception rate to first service was similar (P=0.14) on MP compared to C. For pregnancy to second service, C had a higher (P<0.05) conception rate than MP. There were no significant differences between treatments in overall pregnancy rate, services per conception, number of cows served in the first 3 weeks of the breeding season or the 6-weeks in-calf rate. Comparing the combined fat treatments to C resulted in a higher (P<0.05) conception rate to first service for the fat treatments but no significant difference in overall pregnancy rate. In conclusion, fat supplements increased conception rate to first service but did not significantly affect the proportion of cows pregnant at the end of the breeding season.

Effects of different transition diets on dry matter intake, milk production, and milk composition in dairy cows

The primary objective of this study was to evaluate the effect on dry matter intake (DMI), milk yield, milk composition, body weight (BW), and body condition score (BCS) change of cows offered diets differing in energy density in the last 4 wk of gestation and in the first 8 wk of lactation. Three diets (grass silage:straw, 75:25 on a dry matter basis (SS), grass silage (S), and grass silage + 3 kg concentrate daily (C)) precalving, and two diets (4 kg [LC] or 8 kg [HC] concentrate daily + grass silage ad libitum) postcalving were combined in a 3 x 2 factorial design. Sixty Holstein-Friesian cows entering their second lactation were blocked according to expected calving date and BCS into groups of six and were then allocated at random to the treatments. Individual feeding started 4 wk prior to the expected calving date and measurements were made until the end of the 8th wk of lactation. Mean DMI differed between each of the precalving treatments (7.4, 8.1, and 9.9 kg/d for SS, S, and C, respectively) in the precalving period. The DMI also differed between SS and C for wk 1 to 8 (13.5 and 14.2 kg/d) postcalving. Postcalving, milk (24.2, 26.2, and 28.2 kg/d), fat (933, 1063, and 1171 g/d), and protein (736, 797, and 874 g/d) yields differed between SS, S, and C, respectively. The BCS changes differed between SS and C (-0.09 and 0.12 of a BCS) in the precalving period and between SS and S compared with C (0.02, 0.06, and -0.26 of a BCS) for wk 1 to 8 postcalving. The BW change differed between SS and S compared with C in both wk 1 to 4 (-0.23, -0.37, and -1.25 kg/d) and wk 1 to 8 (0.18, 0.10, and -0.58 kg/ d) postcalving. The BW and BCS were lower at calving for cows on SS compared with C. The greater amount of concentrate supplement postcalving increased DMI, yields of milk, fat, and protein and decreased BW loss in the first 8 wk of lactation. In conclusion, these results indicate that a greater energy density diet in the final 4 wk of the dry period improves cow production in early lactation.

Evaluation of different energy feeding systems with production data from lactating dairy cows offered grass silage-based diets

A set of data from 838 lactating dairy cows, drawn from 12 long-term feeding studies (at least 8 wk/period), was used to evaluate the energy feeding systems for dairy cows currently adopted in Australia, France, The Netherlands, the United Kingdom, and the United States. The animals were offered mixed diets of concentrates, forage [grass silages (n = 33) and corn silages (n = 5)] ad libitum. Data used in the present evaluation were either measured [dry matter (DM) intake, milk production and live weight], measured/estimated [dietary metabolizable energy (ME) concentration] or estimated [milk energy output and live weight change (LWC)]. The mean-square prediction error (MSPE) was used for the evaluation. Total ME intake, milk yields, and LWC varied from 91 to 338 MJ/d, 7.7 to 48.9, and -1.23 to 1.73 kg/d, respectively. Australian and French systems predicted total energy requirement and milk yield relatively well, while British, Dutch and American systems underpredicted total energy requirement by proportionately 0.06, 0.04, and 0.03, respectively; and overpredicted milk yield by 0.09, 0.06, and 0.04. The Agricultural and Food Research Council (AFRC) each produced a relatively larger error of the bias (predicted - actual data) over the total MSPE for ME requirement and milk yield and a relatively smaller error of random than other systems. However, an addition of proportionately 0.05 to the total predicted ME requirement of AFRC, as suggested in this system and currently used in the UK, indicated the prediction accuracy of ME requirement and milk yield is similar to Australian and French systems. Nevertheless, all the systems had a poor prediction of LWC. For each system, the total prediction error (total MSPE) was mainly derived from the line (slope; 0.49 to 0.64 of total MSPE), while less derived from the random (0.20 to 0.48 of total MSPE), indicating a large variation between the predicted and actual LWC existed among individual cows. The residual plots of the residual differences in LWC against predicted LWC revealed that the prediction error was greater with increasing LWC. It is concluded that Australian and French systems have a better prediction of total energy requirement and milk yield than other systems, and LWC is an inappropriate indicator of energy balance in lactating dairy cows.

Peritoneal involvement in stage II colon cancer

A pathologist (K.S.) reviewed histologic slides for peritoneal involvement by tumor cells for 118 patients with stage II colon cancer. Patients were followed up for a median of 6 years. Tumor cells were found free in the peritoneal space in 16 cases (13.6%). The presence of cancer cells free in the peritoneal space was associated with lymphovascular invasion (P = .001) and neural invasion (P < .001). The overall 5-year survival was 80% in the patient population, but was 39% and 86% for those with and without tumor cells free in the peritoneal space, respectively (P < .0001). Multivariate analysis confirmed that free tumor cells within the peritoneal space (P < .0001) and lymphovascular invasion (P = .007) were related independently to outcome. Peritoneal involvement with tumor cells free in the peritoneal space in stage II colon cancer is a powerful indicator of outcome; patients have a survival similar to that for patients with stage III disease.

Effects of calcium salts of fatty acids and calcium salt of methionine hydroxy analogue on plasma prostaglandin F2alpha metabolite and milk fatty acid profiles in late lactation Holstein-Friesian cows

Effects of a dietary lipid supplement containing calcium salts of fatty acids and methionine hydroxy analogue on plasma prostaglandin F2alpha (PGF2alpha) metabolite (PGFM) and milk fatty acid profiles were examined in 40 late lactation, nonpregnant, Holstein-Friesian cows for a period of 70 days. Effects on milk production, milk composition, and blood metabolites were also examined. Cows were paired on the basis of lactation number (first lactation, n = 8; second lactation, n = 32) and randomly assigned from within pairs to one of two dietary treatments: unsupplemented control (C) or 400 g per cow per day of the lipid supplement (S). Cows receiving the supplement had higher (P < 0.05) total milk production, total fat production (kg), and total lactose production (kg). Plasma cholesterol was significantly higher (P < 0.01) after 30 days of treatment in cows receiving the supplement. Cows receiving the supplement had lower (P < 0.01) concentrations of short chain milk fatty acids (C4:0 to C14:1) and higher concentrations of long chain fatty acids (C18:1 and C18:2; P < 0.01) than control animals. Oxytocin-induced prostaglandin release on Day 16 postovulation was increased (P < 0.01) in cows receiving the supplement. In conclusion, supplementation with calcium salts of fatty acids and methionine hydroxy analogue significantly increased milk yield and plasma PGFM.

Importance of dose of type II collagen in suppression of collagen-induced arthritis by nasal tolerance

OBJECTIVE

To determine the influence of the dose of collagen given nasally on the induction of specific mucosal tolerance in collagen-induced arthritis.

METHODS

The severity of clinical arthritis induced in DBA/1 mice was studied after the nasal administration (before disease induction) of 1 of 4 doses (across a 2-log range) of bovine type II collagen (CII). Parameters of immunity included lymphocyte proliferation and cytokine production in vitro in response to antigen stimulation, and the production of anticollagen IgG antibody subclasses.

RESULTS

The 3 highest doses (20, 80, and 320 microg) ameliorated disease severity, whereas the lowest dose (5 microg) aggravated disease. These findings correlated well with antigen-specific T cell proliferation and cytokine and antibody production. T cell proliferation was suppressed by the higher doses of CII, whereas the low dose enhanced T cell proliferation, indicating it primed the T cells. Suppression of T cell proliferation could be overcome by the addition of exogenous interleukin-2 (IL-2) to these cultures. Decreased T cell proliferation was associated with suppression of both Th1 (interferon-gamma [IFNgamma]) and Th2 (IL-4) cytokines and all the subclasses of anticollagen IgG in mice receiving 20, 80, or 320 microg of collagen. Overall, the highest dose of collagen (320 microg) was less effective at suppressing the immune response and disease than the 20-microg or 80-microg doses. There was an increased production of antibodies of all IgG isotypes, and of the Th1-associated cytokines IFNgamma and IL-2, in animals that had received the lowest dose of 5 microg collagen nasally.

CONCLUSION

Nasal administration of antigens is effective in inducing tolerance and reducing disease severity, but the effects are dose dependent. Low doses can prime the immune system and aggravate disease; high doses may not suppress disease. Suppression of the immune response, which correlates with suppression of disease, is not obviously associated with a type I to type II T cell switch, but rather with an overall suppression of both forms of T cell response, with a potential role for anergy of T cells in this process.

Post-partum ovarian vein thrombosis

Post-partum ovarian vein thrombosis (POVT) is uncommon, but the true incidence is not known. Ninety per cent of cases present as right iliac fossa pain within 10 days of delivery. Anti-coagulation and intravenous antibiotics are the mainstay of treatment. We report three cases that were referred to our unit. These cases illustrate the difficulty in the clinical diagnosis of POVT and highlight the importance of its inclusion in the differential diagnoses of an acute abdomen in post-partum patients. POVT can be accurately diagnosed by appropriate noninvasive investigations and a laparotomy avoided.

Identification of candidate endothelial cell autoantigens in systemic lupus erythematosus using a molecular cloning strategy: a role for ribosomal P protein P0 as an endothelial cell autoantigen

OBJECTIVE

To attempt to characterize the diversity and nature of antigens recognized by anti-endothelial cell antibodies (AECA) in patients with systemic lupus erythematosus (SLE) using a molecular cloning strategy.

METHODS

AECA in sera of 15 SLE patients were measured by ELISA and Western blot analysis was used to examine the diversity of autoantigen targets in two clinically active patients. A human umbilical vein endothelial cell cDNA expression library was immunoscreened with sera from these two patients to identify their autoantigen targets. An anti-ribosomal P peptide antibody ELISA was used to assess the clinical significance of anti-ribosomal P protein antibodies in the sera of one patient.

RESULTS

Significantly higher AECA levels were found in five patients with active disease and nephritis than in five patients with clinically inactive disease. Sera from two clinically active patients were found to recognize distinct spectra of autoantigens. The candidate autoantigens that were identified included (1) endothelial cell-specific plasminogen activator inhibitor; (2) the classical lupus antigen, i.e. ribosomal P protein P0; and (3) proteins never before described as putative autoantigens in SLE, including ribosomal protein L6, elongation factor 1alpha, adenyl cyclase-associated protein, DNA replication licensing factor, profilin II and the novel proteins HEAPLA 1 and HEAPLA 2 (human endothelial associated putative lupus autoantigens 1 and 2). In one patient, antibodies against ribosomal P protein P0 were predominant and levels of these antibodies correlated with total AECA levels, anti-DNA antibody titres, overall clinical score and renal disease in a longitudinal study.

CONCLUSIONS

A panel of candidate endothelial autoantigens in SLE, which includes previously described autoantigens and novel targets, has been identified by a molecular cloning strategy. This novel molecular approach could also be applied to the identification of autoantigens in other autoimmune vascular diseases.

Local staging of Wilms' tumor--computerized tomography correlation with histological findings

PURPOSE

The aim of this study was to assess the accuracy of computed tomography (CT) in the local staging of Wilms' tumor.

METHODS

Twenty-six patients with unilateral, nonmetastatic Wilms' tumors were accrued over the period of 1990 through 1997. Preoperative CT staging was performed before surgical biopsy or excision. The abdominal CT images were reviewed and staged for local disease according to National Wilms' Tumour Study (NWTS) Group Staging V as either intrarenal disease (Stage I), local extrarenal extension amenable to complete local excision (Stage II), or advanced local disease (Stage III). Patients with metastatic (Stage IV) and bilateral disease (Stage V) were excluded from our study. Results were compared to histological findings.

RESULTS

CT scan correctly staged 10 of 26 cases (38%) of Wilms' tumor. CT scan overstaged 12 of 16 (75%) localized renal disease (Stage I) and local extension (Stage II) tumors, and understaged 4 of 10 (40%) localized spread (Stage III) tumors.

CONCLUSIONS

CT scan appears to have poor correlation to histological staging. Therefore, basing therapy solely on radiological imaging may lead to some patients receiving more intense therapy than necessary, whereas others do not receive sufficient therapeutic regimens. Histological assessment of the excised mass should remain the standard for staging Wilms' tumors.

Presentation of low anorectal malformations beyond the neonatal period

OBJECTIVE

Anorectal malformations are usually diagnosed at birth, but some patients have presented to this institution beyond the early newborn period without recognition of their anorectal malformations. To quantify the extent of this problem, we undertook a review of all patients presenting to this hospital with anorectal malformations.

METHODS

We reviewed all new cases of anorectal malformations treated at British Columbia's Children's Hospital during the past 11 years. We looked specifically at the time of diagnosis, patient age, sex and mode of presentation, the type of anorectal malformations, and any associated anomalies.

RESULTS

One hundred twenty new cases of anorectal malformations were seen here, of whom, 15 patients (9 girls and 6 boys) presented beyond the early newborn period. Of these, 1 male infant was diagnosed at 2 weeks of age and another girl at 14 years of age. The remaining 13 presented between 3 and 11 months of age because of increasing constipation, usually associated with the introduction of solid foods. All had low anorectal malformations. Nine patients had at least 1 other feature of the VACTERL complex.

CONCLUSIONS

Most anorectal malformations are identified at birth, but a significant number of the milder lesions may not be recognized until later. Therefore, this condition must be considered in older infants and children presenting with constipation, particularly if they also have cardiac or genitourinary anomalies. constipation, imperforate anus, VACTERL.

Breast cancer in a 6-year-old child

A 6-year-old girl presented for a second opinion with a 1-year history of an enlarging soft tissue mass just lateral to the right areola. She had been seen by a pediatric surgeon elsewhere who reassured the parents that the lesion was benign. Ultrasound scan showed a 1.5- x 1.5-cm cystic structure adjacent to the right breast bud. Excisional biopsy results showed secretory ductal adenocarcinoma. Modified radical mastectomy with axillary node dissection was performed. All 11 nodes were negative for metastatic disease. She is now disease free 3 years after diagnosis. Estrogen-progesterone receptors were negative, as was screening for BCR 1 and 2. This is the first report of cytogenetics showing an abnormal cell line with a reciprocal translocation between 12p and 15q. Although breast cancer is extremely rare in children, a history of a painless, enlarging, firm breast mass should raise concern about possible neoplastic disease. Cystic appearance on ultrasound scan caused by the pseudocapsule around the tumor may be a marker for secretory carcinoma. Histological evaluation of all suspicious masses should be obtained. Because of the risk of local recurrence and axillary metastases, the authors recommend modified radical mastectomy with axillary node dissection for children with secretory carcinoma of the breast.

Life-threatening gastrointestinal hemorrhage due to juvenile polyposis

A 14-yr-old, previously healthy boy presented with massive lower GI hemorrhage. After the routine endoscopic and radiological evaluation, laparotomy and intraoperative colonoscopy revealed multiple polyps in the colon. A hemicolectomy was performed because of the severity of hemorrhage. A diagnosis of juvenile polyposis was made based upon histological findings and the family history. This is an extremely unusual presentation of juvenile polyposis and has been reported only once before. The clinical features, diagnosis, and therapeutic options for juvenile polyposis are discussed. Juvenile polyposis, although a rare condition in the pediatric population, should be considered in the differential diagnosis of life-threatening GI hemorrhage.

Beyond cost: 'responsible purchasing' of managed care by employers

We explore the extent of "responsible purchasing" by employers--the degree to which employers collect and use nonfinancial information in selecting and managing employee health plans. Most firms believe that they have some responsibility for assessing the quality of the health plans they offer. Some pay attention to plan characteristics such as the ability to provide adequate access to providers and services and scores on enrollee satisfaction surveys. A more limited but still notable number of firms take specific actions based on responsible purchasing information. Because of countervailing pressures, however, it is not clear whether or not the firms most involved in responsible purchasing are signaling a developing trend.

Fibromatoses: clinical and pathological features suggestive of recurrence

BACKGROUND/PURPOSE

Fibromatoses represent a spectrum of nonneoplastic spindle cell tumors frequently identified in childhood. Although they may be locally aggressive, they do not metastasize. The authors have reviewed their experience of these lesions in an attempt to identify clinical and pathological features suggestive of recurrence.

METHODS

Clinical records and pathological specimens from 55 cases of fibromatosis diagnosed and treated at British Columbia's Children's Hospital from 1982 to 1995 were reviewed.

RESULTS

Thirty boys and 25 girls with ages ranging from 1 month to 14 years were identified. Eighteen tumors (33%) were congenital. Diagnoses were as follows: musculoaponeurotic fibromatosis (n = 27), infantile myofibromatosis (n = 10), Dupuytren-type fibromatosis (n = 7), fibromatosis colli (n = 7), and digital fibroma (n = 4). Clinical follow-up showed a survival rate of 98%. The single mortality occurred in an infant born with an intraabdominal visceral myofibromatosis, which proved unresectable. Fifteen cases recurred (27%), and nine cases (16%) of infantile myofibromatosis spontaneously regressed. All remaining cases were controlled successfully by surgical resection.

CONCLUSIONS

Clinical features suggestive of recurrence included (1) presentation at greater than 5 years of age, (2) extremity location of disease, and (3) incomplete surgical resection. Pathological features suggestive of recurrence were (1) microscopic evidence of tumor at resection margins, (2) mitotic index of 5 or more per 10 high-power fields, and (3) areas of necrosis and inflammation within the tumor.

Neutropenic enteropathy: a 10-year review

PURPOSE

With the advent of more aggressive chemotherapy, the incidence of neutropenic enteropathy is increasing. This review was performed to (1) determine which children are affected, (2) identify predisposing factors, and (3) assess efficacy of treatment.

METHODS

A 10-year (1988 to 1997) review identified 33 children who had 38 episodes of neutropenic enteropathy. Each presented with fever, abdominal pain, and chemotherapy-induced neutropenia. All were treated with fluid resuscitation, bowel rest, and broad-spectrum antibiotics. Surgical intervention was reserved for children with bowel perforation.

RESULTS

Neutropenic enteropathy occurred in 24 children with hematologic malignancies and nine with solid tumors. This disease developed in three children after bone marrow transplantation for leukemia. All five patients in whom recurrent episodes developed were receiving chemotherapy for Burkitt's lymphoma. Cytosine arabinoside and VP16 were the most commonly implicated chemotherapeutic agents. Four children required laparotomy and right hemicolectomy, and all survived. Overall survival was 94%.

CONCLUSIONS

Although previously described in children receiving chemotherapy for hematologic malignancies, neutropenic enteropathy also occurs in children who have solid tumors and after bone marrow transplantation. The use of cytosine arabinoside and VP16 may predispose patients to this disease. Children receiving chemotherapy for Burkitt's lymphoma are at increased risk for recurrent episodes. Excellent survival rate was attained with supportive care being used as the primary treatment modality.

Effects of stocking density and concentrate supplementation of grazing dairy cows on milk production, composition and processing characteristics

The effects on milk composition and processing characteristics of varying grass supply by changing stocking density and of offering a concentrate supplement were investigated. The experiment was conducted over 28 weeks of the lactation (April-October) using 48 spring-calved Friesian-Holstein cows. Three herds each of 16 cows were offered a restricted grass supply, a standard grass supply and a standard grass supply with a supplement of 3 kg concentrate/d. Treatment groups were grazed separately with a residence time of 3 d/paddock. Milk production, composition and processing characteristics such as renneting properties, ethanol stability and plasmin activity were measured weekly. Increasing stocking density above the standard system resulted in significant reductions in milk fat and protein yields, the concentrations of total protein, casein and whey proteins, and a deterioration in most processing characteristics. Imposing concentrate supplementation on the standard system increased total protein, casein and whey protein concentrations but generally did not improve processing characteristics except for ethanol stability. These results suggest that the standard grass supply in a rotational grazing paddock system can support efficient production of quality milk, and concentrate supplementation will not improve processing characteristics when an adequate supply of good quality herbage is available.

Elevation of conjugated cis-9, trans-11-octadecadienoic acid in bovine milk because of dietary supplementation

Cows on pasture were fed full fat soybeans (toasted, flaked, and pelleted) or ground full fat rapeseeds to investigate effects on cis-9, trans-11-octadecadienoic acid in milk. Three herds of 16 cows each that were on pasture were fed 3.1 kg/d of unmolassed beet pulp (control), 3.0 kg/d of rapeseed concentrate, or 3.1 kg/d of a soybean supplement. The concentration of cis-9, trans-11-octadecadienoic acid in the milk of cows fed the rapeseed and soybean supplements was significantly higher than in the milk of cows fed the control diet during the feeding trial. Over the trial, the cis-9, trans-11-octadecadienoic acid concentration in the milk of individual cows varied from 6.8 to 25.7 mg/g of fat in the control herd, from 10.6 to 33.5 mg/g of fat in the herd fed the rapeseed concentrate, and from 8.8 to 30.5 mg/g of fat in the herd fed the soybean supplement. The concentration of cis-9, cis-12-octadecadienoic acid, the substrate for cis-9, trans-11-octadecadienoic acid synthesis in the rumen, was 4.9 g/100 g of fatty acid methyl esters in the milk fat of cows fed the soybean supplement, 2.5 g/100 g of fatty acid methyl esters in the milk fat of cows fed the rapeseed concentrate, and 2.3 g/100 g of fatty acid methyl esters in the milk fat of the control cows. Milk yield and milk constituent yields were not affected by supplementation of either full fat soybeans or rapeseeds compared with controls, but milk protein concentration was significantly reduced by both oilseed supplements.

Increased condom use among teenage males, 1988-1995: the role of attitudes

CONTEXT

Understanding whether and to what degree changes in young men's attitudes explain increases in condom use over time can be useful in developing more effective disease prevention strategies.

METHODS

Data from the 1988 and the 1995 National Survey of Adolescent Males are used to determine changes in attitudes toward condoms, pregnancy prevention and HIV and AIDS. Two-limit tobit models are employed to investigate the association between these attitudes and condom-use behavior and to examine how this relationship may have changed over time.

RESULTS

Between 1988 and 1995, young men's attitudes toward partner appreciation of condom use, condom-use embarrassment and pleasure reduction from condom use all changed in a direction suggestive of more consistent condom use. However, attitudes related to pregnancy prevention and AIDS avoidance changed in a direction suggestive of less-consistent condom use. Changes over time in the strength of the relationship between three attitude measures (masculinity, pleasure reduction and partner appreciation) and condom use also were predictive of lower levels of condom-use consistency. Only the strength of the relationship between condom-use embarrassment and consistent condom use changed in a direction corresponding to observed increases in rates of condom use among young men.

CONCLUSIONS

Many of the significant changes in young males' attitudes toward condoms do not explain the increase in consistent condom use among adolescent males that occurred between 1988 and 1995. However increasing male contraceptive responsibility and emphasizing the risks and consequences of contracting HIV appear to be viable routes for policymakers to explore. Efforts particularly need to be targeted toward Hispanics.

Effect of amount of dietary supplement and source of protein on milk production, ruminal fermentation, and nutrient flows in dairy cows

An experiment with a multiple Latin square design using 36 midlactation Friesian cows was carried out to determine the effect of fish meal or soybean meal in a supplement fed at two amounts (3.5 or 7 kg/d) with grass silage. The diets were also fed to four ruminally and duodenally cannulated cows to determine digestibility, ruminal fermentation, and nutrient flows. Dry matter intake, milk production, milk constituent yields, and concentrations of protein and lactose were significantly increased by the supplements when provided at 7 kg/d. The supplement containing fish meal increased milk production, protein and lactose yields, and milk protein concentration, but the increases were smaller than those obtained by increasing the amount of supplement fed. Neither the type nor the amount of supplement fed affected digestibility of dry matter or organic matter, and few significant effects on ruminal fermentation were observed. Supplements fed at the higher allowance significantly increased the flow of dry matter, organic matter, all nitrogenous components, and amino acids to the duodenum. The supplement containing fish meal significantly increased the duodenal flow of nonammonia nonmicrobial N and some amino acids. Results indicated that an increase in the concentration of supplement in the diet is more effective in increasing milk production, protein concentration and yield, and flow of amino acids to the duodenum than is increasing the concentration of ruminally undegradable protein in the supplement.

Cougar attacks on children: injury patterns and treatment

PURPOSE

Cougar attacks on humans appear to be on the rise. A review of all attacks on children was performed to determine the method of attack and injury patterns so that a treatment regimen as well as possible preventative measures could be determined.

METHODS

A review of all attacks, including attacks on children, was performed, including three recent attacks treated at our institution. Situation, adult supervision, patient age, injuries recorded, survival, and mode of attack, if known, were reviewed.

RESULTS

There were 50 documented attacks on children with a 25% fatality rate. Most children were not alone at the time of the attack (92%), and in many instances adult supervision was present or nearby. Severe head and neck lacerations along with puncture wounds were the most common injury. Examples of typical cervical injuries include a nonfatal vertebral artery injury, phrenic nerve injury, a fatal internal carotid artery injury, and a fatal cervical spine injury. The cougar was rabid in two cases. Pasteurella resulted in late infections in two patients.

CONCLUSIONS

Based on the pattern of injuries, the authors recommend aggressive evaluation for occult cervical injuries as well as surgical debridement. Antibiotics should cover oropharyngeal flora including Pasteurella multocida. Rabies prophylaxis is indicated. Adult supervision in wilderness areas is not necessarily protective.

Effect of altering the daily herbage allowance to cows in mid lactation on the composition, ripening and functionality of low-moisture, part-skim Mozzarella cheese

Milk was collected from three spring-calving herds, on different daily herbage allowances (DHA) of perennial rye-grass (16, 20 or 24 kg dry matter (DM)/cow for a 17 week period. On five occasions, at weekly intervals in the middle of the period, the three different milks were converted into low-moisture part-skim Mozzarella cheese. Increasing the DHA resulted in significant increases in the concentrations of protein in the cheesemilk (P < 0.05) and cheese whey (P < 0.02). The moisture-adjusted cheese yield increased significantly (P < 0.01) on raising the DHA from 16 to 24 kg grass DM/cow. DHA had no significant effects on any of the gross compositional values of the cheese (although moisture and fat-in-DM levels tended to decrease and increase respectively with increasing DHA). The hardness of the uncooked cheese and functionality of cooked cheese (i.e. melt time, flowability, stretch and viscosity) were not significantly influenced by DHA over the 115 d ripening period at 4 degrees C.

Ectopic expression of Bcl-2, but not Bcl-xL rescues Ramos B cells from Fas-mediated apoptosis

The human Burkitt lymphoma Ramos B cell line can be induced to undergo apoptosis in response to a variety of different agents, including calcium ionophores, anti-immunoglobulin (Ig) and macromolecular synthesis inhibitors. In addition, following up-regulation of the Fas (CD95) surface receptor by CD40 ligation, these cells also become susceptible to apoptosis induction by Fas ligation. We have previously shown that protection from calcium ionophore- and macromolecular synthesis inhibitor-induced apoptosis by CD40 ligation is associated with a rapid up-regulation of Bcl-xL followed by a more moderate and delayed up-regulation of Bcl-2. We show here that overexpression of Bcl-xL, like Bcl-2, protects Ramos cells from apoptosis induction in response to calcium ionophore, anti-Ig and macromolecular synthesis inhibition. However, in contrast to Bcl-2, ectopic overexpression of Bcl-xL does not rescue from Fas-mediated apoptosis. Thus, in Ramos B cells, the Fas apoptotic pathway exhibits differential sensitivity to inhibition by Bcl-2 family members. These findings also suggest that CD40 signaling provides a switch which renders the cells susceptible to Fas-ligand mediated apoptosis through up-regulation of Fas whilst affording protection from anti-Ig-induced apoptosis through up-regulation of Bcl-xL.