Malting of Fusarium Head Blight-Infected Rye (Secale cereale): Growth of Fusarium graminearum, Trichothecene Production, and the Impact on Malt Quality

This project was initiated with the goal of investigating the malt quality of winter rye cultivars and hybrids grown in the United States in 2014 and 2015, but high levels of deoxynivalenol (DON) were subsequently found in many of the malt samples. DON levels in 75% of the investigated rye samples (n = 117) were actually below 1.0 mg/kg, as quantified by a gas chromatography combined with electron capture detector (GC-ECD). However, 83% of the samples had DON in excess of 1.0 mg/kg following malting, and the average DON level in malted rye was 10.6 mg/kg. In addition, relatively high levels of 3-acetate DON (3-ADON), 15-acetate DON (15-ADON), nivalenol (NIV), and DON-3-glucoside (D3G) were observed in some rye malts. Our results show that rye grain DON is likely a poor predicator of type B trichothecenes in malt in practice, because high levels of malt DON, 15-ADONm and D3G were produced, even when the rye samples with DON levels below 0.50 mg/kg were processed. Fusarium Tri5 DNA content in rye was highly associated with malt DON levels (r = 0.83) in a small subset of samples (n = 55). The impact of Fusarium infection on malt quality was demonstrated by the significant correlations between malt DON levels and wort viscosity, β-glucan content, wort color, wort p-coumaric acid content, and total phenolic content. Additional correlations of rye Fusarium Tri5 DNA contents with malt diastatic power (DP), wort free amino nitrogen (FAN) content, and arabinoxylan content were observed.

How does Bladder Function Change in the Early Period after Surgical Alteration in Outflow Resistance?: Preliminary Communication

A decrease in voiding pressures because of decreased outflow resistance has been demonstrated in 8 males, and conversely an increase in voiding pressures because of increased outflow resistance has been demonstrated in 7 females undergoing surgery. These changes occur in the early postoperative period.

Association of breast tumour bed seroma with post-operative complications and late normal tissue toxicity: results from the Cambridge Breast IMRT trial

AIMS

There are two main surgical techniques for managing the tumour bed after breast cancer excision. Firstly, closing the defect by suturing the cavity walls together and secondly leaving the tumour bed open thus allowing seroma fluid to collect. There is debate regarding which technique is preferable, as it has been reported that a post-operative seroma increase post-operative infection rates and late normal tissue side effects.

METHODS

Data from 648 patients who participated in the Cambridge Breast IMRT trial were used. Seromas were identified on axial CT images at the time of radiotherapy planning and graded as not visible/subtle or easily visible. An association was sought between the presence of seroma and the development of post-operative infection, post-operative haematoma and 2 and 5 years normal tissue toxicity (assessed using serial photographs, clinical assessment and self assessment questionnaire).

RESULTS

The presence of easily visible seroma was associated with increased risk of post-operative infection (OR = 1.80; p = 0.004) and post-operative haematoma (OR = 2.1; p = 0.02). Breast seroma was an independent risk factor for whole breast induration and tumour bed induration at 2 and 5 years. The presence of breast seroma was also associated with inferior overall cosmesis at 5 years. There was no significant association between the presence of seroma and the development of either breast shrinkage or breast pain.

CONCLUSION

The presence of seroma at the time of radiotherapy planning is associated with increased rates of post-operative infection and haematoma. It is also an independent risk factor for late normal tissue toxicity. This study suggests that full thickness surgical closure may be desirable for patients undergoing breast conservation and radiotherapy.

Lessons from eleven primary health care nursing innovations in New Zealand

INTRODUCTION

In New Zealand in 2003, 11 primary health care (PHC) nursing innovation projects and an evaluation of the initiative were funded by the Ministry of Health to develop and explore the ways new models of nursing practice could help address health inequalities and contribute to PHC.

DESIGN AND METHODS

A research-and-development approach was used in the evaluation. Data were gathered from interviews with national stakeholders, workshops with personnel from all projects, visits to each project site and case studies of four projects. Analysis involved assessing each project individually as well as the projects as a whole.

CONTEXT

The initiative was one of many international and local PHC developments in this period designed to reduce health inequalities and improve patient care and health outcomes.

FINDINGS

Each project was developed from a different starting point; was located in different parts of the health system; and had different levels of funding. Some were principally focused on leading nursing development; others focused on developing nursing practice. Each involved influencing or providing nursing services, nurse education, leadership and service integration. Most projects progressed well, but some had limited success.

LESSONS

Lessons are on many levels, and include those related to: developing successful innovation; the importance of nursing leadership; developing the nursing workforce; and advancing nursing practice.

CONCLUSION

The funding of the innovative projects enabled nurses to pioneer developments. Such funding is important, as it paves the way for change and provides an opportunity for reflection and new learnings.

The impact of changes in private health expenditure on New Zealand households

The proportion of New Zealand's total health expenditure financed by the public sector has fallen from 87% in 1983/84 to 77% in 1997/98 in real per capita terms. In the paper, we firstly describe changes in private health expenditure in New Zealand and compare these changes with trends in private and public health expenditure in a number of OECD countries. Secondly, we find that in New Zealand, there have been increases in both out-of-pocket payments and membership of private health insurance funds over the period from 1983/84 to 1997/98. We analyze the relationship between out-of-pocket expenditure, insurance expenditure, and household income across income deciles and across time. We find that out-of-pocket payments are regressive but the regressivity did decline in 1993/94 in response to a government initiative to improve the targeting of government subsidies towards lower income households.

Objective estimates of the incidence and consequences of multiple organ dysfunction and sepsis after burn trauma

BACKGROUND

Organ dysfunction and sepsis are frequent after major burn trauma, represent quantifiable consequences of the systemic response to injury, and may be important end points by which to measure treatment effectiveness. However, standard and widely applied methods for their measurement have not been applied to burn trauma victims. Therefore, the purpose of this study was to quantify these complications after burn trauma.

METHODS

Patients with > or = 20% total body surface area burns admitted to a single center were prospectively enrolled. Standard sepsis criteria and multiple organ dysfunction (MOD) scores for the pulmonary, renal, cardiovascular, hepatic, and hematologic systems were determined. The incidence and risk factors for severe MOD (cumulative MOD score > or = 6) and severe sepsis were determined. The relationships between these complications and mortality and resource utilization were examined by univariate and multivariate analyses.

RESULTS

A total of 85 patients were enrolled over 1 year. Severe MOD developed in 24 (28%) and severe sepsis or septic shock developed in 12 (14%). Both were associated with increasing age and burn size and were more likely to occur in men. Most patients who developed severe MOD or severe sepsis survived (71% and 67%, respectively), and both were associated with longer intensive care unit stays and duration of mechanical ventilation.

CONCLUSION

According to simple and objective scoring systems, severe MOD and severe sepsis/septic shock are both related to burn size, age, and male sex. Both are related to intensive care unit length of stay and duration of mechanical ventilation.

Priority-setting in New Zealand: translating principles into practice

In May 1998 the New Zealand Health Funding Authority released a discussion paper which proposed a principles-based approach to setting purchasing priorities that incorporates the economic methods of programme budgeting and marginal analysis, and cost-utility analysis. The principles upon which the process was to be based are effectiveness, cost, equity of health outcomes, Maori health and acceptability. This essay describes and critiques issues associated with translating the principles into practice, most particularly the proposed methods for evaluating the effectiveness and measuring the cost of services. It is argued that the proposals make an important contribution towards the development of a method for prioritizing services which challenges our thinking about those services and their goals, and which is systematic, explicit, and transparent. The shift towards 'thinking at the margin' and systematically reviewing the value for money of competing claims on resources is likely to improve the quality of decision-making compared with the status quo. This does not imply that prioritization can, or should, be undertaken by means of any simple formula. Any prioritization process should always be guided by informed judgement. The approach is more appropriate for some services than for others. Key methodological issues that need further consideration include the choice of instrument for measuring health gains, the identification of marginal services, how to combine qualitative and quantitative information, and how to ensure consistency across different levels of decision-making.

Shifting to capitation in primary care: what might the impact be in New Zealand?

Primary medical care in New Zealand has traditionally been delivered by general practitioners and funded by a mix of fee-for-service government subsidies, user part-charges and private payments. In 1998, New Zealand's national purchaser of publicly-funded health care, the Health Funding Authority, proposed to pay health service organisations capitation fees per enrolled patient, as well as fees-for-service for immunisations and some performance-related payments. This article considers the implications, drawing on theory and research from New Zealand and elsewhere, of different methods for paying general practitioners and other primary care professionals. The main focus is on whether giving a greater emphasis to capitation will lead to a fairer distribution of resources and better access to services for those groups of people who are not well served by the current system.

The role of outputs and outcomes in purchaser accountability: reflecting on New Zealand experiences

Recent reforms in a number of countries' health systems have led to the separation of funder, purchaser and provider roles and the strengthening of funders' and purchasers' positions relative to providers. One of the aims of such reforms is to improve accountability. This paper reports on experiences in New Zealand where, in addition to improving the accountability of providers, purchaser accountability has also been a key policy issue. Attempts have been made in New Zealand to develop a funder-purchaser accountability framework based on a mix of outcomes, outputs and inputs. This paper discusses the roles that each might play in contracts and accountability relationships between funders and purchasers. The paper concludes that holding purchasers accountable for outcomes is likely to prove difficult and controversial, because of problems of attribution and because New Zealand funders in recent years have played an important role in determining the priority outputs and inputs which must be purchased. The paper suggests that accountability is more appropriate at the output and process level, in addition to holding purchasers accountable for the ways in which they make decisions and undertake contracting roles. Holding purchasers accountable for purchasing outputs and processes, however, requires greater commitment on the part of the funder to setting priorities more clearly; specifying the range and level of outputs to be purchased and the terms of access to those services; and funding services to this level. The international attention currently being paid to the development of practice guidelines and priority criteria also suggests that holding purchasers accountable for a form of inputs may become an increasingly common practice in future. From 1 July 1998, New Zealand will introduce a priority criteria system for determining access to elective surgery; accountability is thus becoming focused on inputs in the form of patient characteristics. This approach will greatly assist in promoting accountability.

Spermatic-cord block improves analgesia for day-case testicular surgery

OBJECTIVE

To assess whether the use of a spermatic-cord block contributes any additional analgesia to that of a conventional analgesic regimen in day-case testicular surgery.

PATIENTS AND METHODS

In a randomized, double-blind controlled study, 48 patients undergoing day-case testicular surgery received general anaesthesia together with fentanyl and diclofenac for analgesia. In addition, 22 of these patients received 10 mL of 0.5% plain bupivacaine into the spermatic cord at the conclusion of surgery. Visual-analogue pain scores were recorded for each group over the following 24 h.

RESULTS

The visual-analogue pain scores were significantly lower in the immediate recovery period in patients receiving the spermatic-cord block.

CONCLUSION

The spermatic-cord block reduced discomfort in the immediate post-operative period in patients undergoing testicular surgery and the procedure should be encouraged to improve the quality of post-operative pain management in such procedures.

Defining core services: New Zealand experiences

A key aspect of the New Zealand health reforms was the proposed development of an explicit core of services to which all New Zealanders would have access. A range of approaches has been taken by the government, its advisers, purchasers and providers to describe sets of services to which New Zealanders are to have access. The development of an explicit core aims to promote equity of access to services, to ensure that those services available are those that are the most cost-effective and the services New Zealanders feel to be the most important, and to clarify entitlements to publicly funded health care. This paper describes the current approaches that are being used to define core services in New Zealand, discusses the reasons behind some of the choices made and notes some key issues for further policy debate.

Collecting duct carcinoma. An unusual renal tumour

Collecting duct carcinoma is a rare form of renal tumour. Its recognition is important both clinically and histopathologically since it can mimic other renal neoplasms in appearance. Nephrectomy is the treatment of choice and, as the tumour usually pursues an aggressive course, adjuvant chemotherapy or immunotherapy may also be considered appropriate. We report two such cases.

Suprapubic catheterisation with urethral closure (the Feneley procedure) in spinal cord injured men

Three male spinal cord injured patients who underwent suprapubic catheterisation with urethral closure are reported. Although the procedure is well established in women, and has been mainly used in patients with multiple sclerosis, this simple procedure is also possible in men, and worth considering in difficult situations where continence has been impossible to achieve by more conventional means.

Morphology and neuropathology of the pelvic floor in patients with stress incontinence

Urinary incontinence imposes a considerable workload on urological and gynecological practice. Many treatments exist, but recurrent stress incontinence remains a significant problem and the reasons remain unclear. Pathological and electrophysiological studies have shown that significant pelvic nerve damage and consequent denervation and reinnervation are associated with stress incontinence, and furthermore there are collagenous changes in the pelvic floor which are related to childbirth, endogenous hormone changes and the effects of increasing age. These changes include increased nerve fiber density and pudendal nerve terminal motor latency, hypertrophy of fiber types 1 and 2, type 1 fiber predominance and fiber type grouping. Connective tissue changes involve a reduction in hydroxyproline excretion, increased cross-linking and increased muscle collagen. It is only through a better understanding of the anatomy and pathophysiology of the pelvic floor that we will be able to improve outcome in women with stress incontinence and identify patients that may not be appropriate for surgical therapy. This paper reviews recent advances in the understanding of the etiology of stress incontinence.

Core services and priority-setting: the New Zealand experience

Like people in other countries, New Zealanders have been struggling with the issue of how to decide which health services should be delivered and to whom. The government has established a Core Services Committee to advise on core services, that is, those health care and disability support services to be made available on affordable terms and without unreasonable waiting time. Such a core has a similar role to a standard package of benefits within a managed competition framework. Services not in the core would be left to individuals' own responsibility. Specific objectives for a core are to promote accountability of purchasers, to make explicit the services that are core and those that are not, to promote an efficient and equitable allocation of resources, to limit government expenditure on health care and to involve the public in decision-making. A number of different options for defining a core are identified, and the work undertaken so far is discussed. The original concept of a core has not been implemented in New Zealand. The Core Services Committee has established broad priorities and facilitated a series of consensus development conferences to provide advice on the effectiveness of services. Some of the committee's recommendations have been incorporated into policy guidelines, which set out what the government expects of purchasers. These guidelines include priority areas for health gains, service obligations and principles for purchasing. Service obligations are not sufficiently detailed to meet the specific objectives of a core and do not meet equity objectives, as they allow in effect each of the four purchasers to develop their own core of services. The key issue for the government now is to decide whether to allow RHAs flexibility in determining their own priorities or whether a national approach to efficiency and equity is to be preferred.

Flexible cystoscopy in men: is topical anaesthesia with lignocaine gel worthwhile?

OBJECTIVE

The value of 2% lignocaine gel as a topical anaesthetic for flexible cystoscopy in men was tested in a prospective, randomized, double-blind, placebo controlled trial.

PATIENTS AND METHODS

A total of 138 patients were entered into the study. Group A patients (n = 75) received 10 ml of 2% lignocaine gel intraurethrally whilst 10 ml of plain lubricating gel was instilled in the remaining 63 patients (Group B). Patient discomfort was recorded by means of a four-point descriptive pain scale (completed by both surgeon and patient) and a 100 mm non-graphic rating visual analogue scale (patient only).

RESULTS

The results showed no significant difference between the two treatments irrespective of the method of recording.

CONCLUSION

This study shows that 2% lignocaine gel offers no advantage over plain lubricating gel in providing analgesia for flexible cystoscopy. In this situation good lubrication may be a more important factor than topical anaesthesia.

Treatment of organic impotence

A review of 86 patients referred to a urological clinic with impotence showed that in 58% the causation was predominantly psychogenic. These patients were managed with psychosexual counselling. The various treatment options were discussed with those patients with organic impotence and 14 underwent the implantation of a penile prosthesis. A review of 130 patients who received penile prostheses in the period 1983 to 1987 was carried out to compare the complications and results obtained with the various types of prosthesis. The overall satisfaction rate was 81%; dissatisfaction usually arose as a result of complications of surgery. These were highest in patients with diabetes and priapism. The complications were also related to the type of prosthesis used.

Distribution of bony metastases in prostatic carcinoma

Fifty-five prostate cancer and 55 breast cancer patients with positive bone scintigrams were studied. The pattern of spread in the axial skeleton and pelvis showed differences between the 2 groups. This difference was not related primarily to bone volume at the site of metastasis. The difference in distribution of bony metastases between breast and prostate is explained by our knowledge of Batson's vertebral venous plexus.

The Mitrofanoff principle for continent urinary diversion

A continent urinary diversion was formed for 16 patients using the Mitrofanoff principle for continence. As originally described, this system used the appendix tunnelled into the bladder to form a continent catheterisable vesicostomy. We have expanded the technique and have used all available narrow tubes as continent conduits (ureter 10 cases, appendix 5, Fallopian tube 1). The urine container was made of large and small intestine and bladder in several combinations. The system has been very satisfactory: 14 patients were continent and able to catheterise; 1 required a revision to achieve continence and 1 awaits revision; 3 patients required revision procedures for stricture.

Role of the Kock pouch in adolescent urology

Although cutaneous urinary diversion will continue to have a place in some urological diseases, some patients may benefit from an undiversion. The Kock pouch with a continent reservoir is an alternative where conventional undiversion to the bladder is impossible. Indications, pre-operative preparation, operative technique, results and complications are outlined in detail. In the adolescent patient requiring urinary diversion the Kock pouch should be considered as the last resort. Where reconstruction of the urinary tract is impossible, a continent urinary reservoir by means of the Kock pouch may be indicated.

Acute myometritis and chorioamnionitis during cesarean section of asymptomatic women

Postoperative endomyometritis develops in as many as 85% of women undergoing cesarean section, which is 10- to 30-fold higher than after vaginal delivery. The timing and mechanism by which the infecting organisms gain access to the uterine cavity are unclear. One possibility is that the infection may occur postpartum by ascending colonization of the wound. Alternatively, myometritis may be already present at the time the cesarean section is performed in asymptomatic patients. With tissue necrosis, the stage is then set for puerperal endomyometritis. To study this second alternative mechanism, myometrial and placental biopsy specimens were obtained in 91 asymptomatic patients at the time of cesarean section. Histologic evidence of chorioamnionitis was identified in 10% (9/91) of patients. Acute myometritis was present in 11% (10/91) of the myometrial biopsy specimens. Seven of the nine women (77%) with subclinical acute chorioamnionitis demonstrated extension of the inflammation into the myometrium. Thirty-two percent (8/25) of women in labor and 31% (5/16) of those with rupture of membranes for greater than 6 hours had acute chorioamnionitis or myometritis, which is significantly higher (p less than 0.01) than in women without these risk factors. These findings suggest that approximately one third of asymptomatic women with rupture of the membranes for more than 6 hours or who are in labor at the time of cesarean section demonstrate histologic evidence of subclinical chorioamnionitis. In most of these patients the myometrium is also involved. The uterine incision is then performed through infected myometrium, possibly setting the stage for puerperal endomyometritis.

Is antibiotic prophylaxis necessary for routine urodynamic investigations? A controlled study in 100 patients

The value of a prophylactic antibiotic before a routine cystometrogram has been assessed in a controlled trial of 100 patients. The infection rate was low and not statistically different in both groups. Subsequent symptoms of dysuria and haematuria had a mechanical aetiology.

Urinary undiversion in young adults

Eighteen patients who underwent urinary diversion in childhood were undiverted. There were three main groups: the neurologically intact bladder, the neuropathic bladder and the "occult" neuropathic bladder. The simplest procedure of anastomosing the proximal ureters to the distal ureters was preferred. The neuropathic group required excision of the bladder remnant and substitution with detubularised bowel. In four patients the renal function was progressively deteriorating pre-operatively and two have required transplants. Renal failure in one of these patients was accelerated by a post-operative anastomotic stenosis and infection, although his early post-operative anastomotic stenosis and infection, although his early post-operative course was uneventful.

The choice of suprapubic continent catheterisable urinary stoma

Two types of continent urinary diversion are compared. In six patients a Kock pouch was used. Two were completely successful but the other four patients required 10 revision operations between them and only two achieved complete continence. In seven patients a Mitrofanoff operation was done. The results were much better and six achieved complete continence with only three revision operations in two patients. It was concluded that the Kock pouch was more difficult and where possible the Mitrofanoff operation should be used to form a continent suprapubic catheterisable stoma.

Long-term management of patients who have had urinary diversions into colon

Thirty-four patients with urinary-colonic diversions have been followed up for 13 to 41 years (mean 20.3). The commonest long-term complication was hyperchloraemic acidosis (50%). The most serious was neoplasm at the anastomotic site: benign lesions occurred in three patients and carcinomas in two (15%). Staining for sialomucins in colonic biopsies adjacent to the anastomoses was positive in 17 of 19 patients. It has been suggested that this represents a pre-malignant change. Analysis of faecal flora in 17 diverted patients and 27 controls revealed a significant difference in the carriage rate and viable count of Peptostreptococcus species. This finding has not been reported previously and the species could have a role in the aetiology of the neoplasms.