Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire

OBJECTIVE

Bipolar spectrum disorders, which include bipolar I, bipolar II, and bipolar disorder not otherwise specified, frequently go unrecognized, undiagnosed, and untreated. This report describes the validation of a new brief self-report screening instrument for bipolar spectrum disorders called the Mood Disorder Questionnaire.

METHOD

A total of 198 patients attending five outpatient clinics that primarily treat patients with mood disorders completed the Mood Disorder Questionnaire. A research professional, blind to the Mood Disorder Questionnaire results, conducted a telephone research diagnostic interview by means of the bipolar module of the Structured Clinical Interview for DSM-IV.

RESULTS

A Mood Disorder Questionnaire screening score of 7 or more items yielded good sensitivity (0.73) and very good specificity (0.90).

CONCLUSIONS

The Mood Disorder Questionnaire is a useful screening instrument for bipolar spectrum disorder in a psychiatric outpatient population.

A double-blind comparison of empirical oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy

BACKGROUND

Among patients with fever and neutropenia during chemotherapy for cancer who have a low risk of complications, oral administration of empirical broad-spectrum antibiotics may be an acceptable alternative to intravenous treatment.

METHODS

We conducted a randomized, double-blind, placebo-controlled study of patients (age, 5 to 74 years) who had fever and neutropenia during chemotherapy for cancer. Neutropenia was expected to be present for no more than 10 days in these patients, and they had to have no other underlying conditions. Patients were assigned to receive either oral ciprofloxacin plus amoxicillin-clavulanate or intravenous ceftazidime. They were hospitalized until fever and neutropenia resolved.

RESULTS

A total of 116 episodes were included in each group (84 patients in the oral-therapy group and 79 patients in the intravenous-therapy group). The mean neutrophil counts at admission were 81 per cubic millimeter and 84 per cubic millimeter, respectively; the mean duration of neutropenia was 3.4 and 3.8 days, respectively. Treatment was successful without the need for modifications in 71 percent of episodes in the oral-therapy group and 67 percent of episodes in the intravenous-therapy group (difference between groups, 3 percent; 95 percent confidence interval, -8 percent to 15 percent; P=0.48). Treatment was considered to have failed because of the need for modifications in the regimen in 13 percent and 32 percent of episodes, respectively (P<0.001) and because of the patient's inability to tolerate the regimen in 16 percent and 1 percent of episodes, respectively (P<0.001). There were no deaths. The incidence of intolerance of the oral antibiotics was 16 percent, as compared with 8 percent for placebo (P=0.07).

CONCLUSIONS

In hospitalized low-risk patients who have fever and neutropenia during cancer chemotherapy, empirical therapy with oral ciprofloxacin and amoxicillin-clavulanate is safe and effective.

IL-1H, an interleukin 1-related protein that binds IL-18 receptor/IL-1Rrp

IL-18, or IGIF (interferon-gamma inducing factor), is an IL-1-related, pro-inflammatory cytokine, which plays a pivotal role in systemic and local inflammation. We have identified and characterized IL-1H, a novel IL-1-related molecule. IL-1H appears to be expressed in most tissues with relatively high levels in testis, thymus and uterus. The IL-1H transcripts were stimulated by phorbol ester (PMA) in human cell lines (A431, THP-1 and KG-1) and peripheral blood mononuclear cells (HPBMC) and dendritic cells (NHDC). The protein sequence of IL-1H is mostly related to IL-1ra with a similarity of 36%. A short form of IL-1H was identified, and lacks a 40-amino acid segment in the amino-terminal region of the protein. When expressed in mammalian cells, two secreted polypeptides of IL-1H were identified: an uncleaved and a cleaved form starting with amino acid Val-46. Furthermore, IL-1H binds the IL-18 receptor, but not the IL-1 receptor. These findings suggest that IL-1H may be another ligand for the IL-18 receptor and a new player in the inflammatory and immune responses mediated by the IL-18/IL-18R axis.

The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial

OBJECTIVE

To determine whether the use of noninvasive positive pressure ventilation (NPPV) in the emergency department (ED) will reduce the need for tracheal intubation and mechanical ventilation.

DESIGN

Randomized, controlled, prospective clinical trial.

SETTING

ED of Barnes-Jewish Hospital, a university-affiliated teaching hospital.

PATIENTS

Twenty-seven patients meeting a predetermined definition of acute respiratory distress requiring hospital admission.

INTERVENTIONS

Conventional medical therapy for the various etiologies of acute respiratory distress and the application of NPPV.

MEASUREMENTS AND RESULTS

The primary outcome measure was the need for tracheal intubation and mechanical ventilation. Secondary outcomes also assessed included hospital mortality, hospital length of stay, acquired organ system derangements, and the utilization of respiratory care personnel. Sixteen patients (59.3%) were randomly assigned to receive conventional medical therapy plus NPPV, and 11 patients (40.7%) were randomly assigned to receive conventional medical therapy without NPPV. The two groups were similar at the time of randomization in the ED with regard to demographic characteristics, hospital admission diagnoses, and severity of illness. Tracheal intubation and mechanical ventilation was required in seven patients (43.8%) receiving conventional medical therapy plus NPPV and in five patients (45.5%) receiving conventional medical therapy alone (relative risk=0.96; 95% confidence interval=0.41 to 2.26; p=0.930). There was a trend towards a greater hospital mortality rate among patients in the NPPV group (25%) compared to patients in the conventional medical therapy group (0.0%) (p=0.123). Among patients who subsequently required mechanical ventilation, those in the NPPV group had a longer time interval from ED arrival to the start of mechanical ventilation compared to patients in the conventional medical therapy group (26.0+/-27.0 h vs 4.8+/-6.9 h; p=0.055).

CONCLUSIONS

We conclude that the application of NPPV in the ED may delay tracheal intubation and the initiation of mechanical ventilation in some patients with acute respiratory distress. We also demonstrated that the application of NPPV was associated with an increased hospital mortality rate. Based on these preliminary observations, larger clinical investigations are required to determine if adverse patient outcomes can be attributed to the early application of NPPV in the ED. Additionally, improved patient selection criteria for the optimal administration of NPPV in the ED need to be developed.

Tubular fluid concentrations and kidney contents of angiotensins I and II in anesthetized rats

Previous micropuncture studies have reported nanomolar concentrations of angiotensin II in proximal tubular fluid and have indicated that angiotensin II or a precursor may be secreted into the tubular lumen. Further experiments were performed to determine if proximal tubular fluid angiotensin I concentrations are also greater than plasma and kidney levels and to estimate the degree of intrarenal compartmentalization of the angiotensin peptides. Free-flow proximal tubular fluid samples were collected in micropipets and were pooled for each animal. At the end of each experiment, a blood sample was collected and the micropunctured left kidney was harvested and homogenized in methanol. The angiotensin I concentration in proximal tubular fluid samples averaged 6.1 +/- 1.2 pmol/mL, whereas the angiotensin II concentration averaged 8.1 +/- 1.6 pmol/mL (N = 13). HPLC analysis of a separate sample pooled from collections in five rats indicated that the immunoreactive angiotensin I and angiotensin II primarily represented authentic angiotensin I and II. Plasma concentrations of angiotensin I and angiotensin II averaged 0.39 +/- 0.09 and 0.15 +/- 0.03 pmol/mL, respectively. The kidney contents of angiotensin I and angiotensin II were 1.28 +/- 0.24 and 0.97 +/- 0.17 pmol/g of kidney, respectively. These findings indicate that proximal tubular fluid contains nanomolar concentrations of angiotensin I as well as angiotensin II. These high tubular fluid concentrations, which greatly exceed the plasma and kidney levels, likely reflect net secretion of the angiotensin peptides by proximal tubule cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Serotonin syndrome

We describe a patient treated with trazodone, isocarboxazid, and methylphenidate hydrochloride who developed confusion, agitation, poor concentration, rigidity, myoclonus, involuntary movements, orthostatic hypotension, and hyperreflexia. CK was normal, and the syndrome resolved spontaneously over 12 hours. The serotonin syndrome occurs following the use of serotomimetic agents (serotonin reuptake inhibitors, tricyclic and tetracyclic antidepressants, tryptophan, 3,4-methylenedioxy-methamphetamine, dextromethorphan, meperidine, S-adenosylmethionine) alone or in combination with monoamine oxidase inhibitors. It is characterized by various combinations of myoclonus, rigidity, hyperreflexia, shivering, confusion, agitation, restlessness, coma, autonomic instability, low-grade fever, nausea, diarrhea, diaphoresis, flushing, and rarely, rhabdomyolysis and death.

Assessing the impact of Cry1Ab-expressing corn pollen on monarch butterfly larvae in field studies

Survival and growth of monarch larvae, Danaus plexippus (L.), after exposure to either Cry1Ab-expressing pollen from three Bacillus thuringiensis (Bt) corn (Zea mays L.) events differing in toxin expression or to the insecticide, lambda-cyhalothrin, were examined in field studies. First instars exposed to low doses ( approximately 22 grains per cm(2)) of event-176 pollen gained 18% less weight than those exposed to Bt11 or Mon810 pollen after a 5-day exposure period. Larvae exposed to 67 pollen grains per cm(2) on milkweed leaves from within an event-176 field exhibited 60% lower survivorship and 42% less weight gain compared with those exposed to leaves from outside the field. In contrast, Bt11 pollen had no effect on growth to adulthood or survival of first or third instars exposed for 5 days to approximately 55 and 97 pollen grains per cm(2), respectively. Similarly, no differences in larval survivorship were observed after a 4-day exposure period to leaves with 504-586 (within fields) or 18-22 (outside the field) pollen grains per cm(2) collected from Bt11 and non-Bt sweet-corn fields. However, survivorship and weight gain were drastically reduced in non-Bt fields treated with lambda-cyhalothrin. The effects of Bt11 and Mon810 pollen on the survivorship of larvae feeding 14 to 22 days on milkweeds in fields were negligible. Further studies should examine the lifetime and reproductive impact of Bt11 and Mon810 pollen on monarchs after long-term exposure to naturally deposited pollen.

Extraction, purification, and assay of human renin free of angiotensinase

Three procedures are described for the extraction and purification of renin from 0.05 to 500 g of human kidneys. A uniform yield of renin, free of angiotensinase, resulted from all three procedures.

All tests for renin were carried out in dogs. When more than 10 g of renal tissue was used, renin was determined by the direct method; with smaller amounts, the indirect method, involving the production and the assay of angiotensin, was employed.

Renin substrate free of angiotensinase, suitable for the indirect assay of human renin, was prepared from pooled human serum by a simple procedure.

The angiotensinase-free renin and substrate permitted prolonged incubation for the production of the angiotensin required for the indirect assay. The mean ratio of angiotensin produced (unit per milliter of serum) to the amount of renin added (unit per milliliter of serum) was 1,482 for an 18-hour period of incubation. The large amount of angiotensin produced permitted the indirect assay of minute amounts of human renin (as little as 0.0005 unit, from 5 mg of renal tissue) in the dog. Unless the angiotensinase present in extracts of renal tissue or serum is first removed, the accurate, indirect assay of the renin is not possible.

Manipulations of brain 5-HT levels affect gene expression for BDNF in rat brain

The aim of the present study was to investigate whether changes in brain 5-HT concentrations affect the expression of BDNF mRNA in rat brain. Brain 5-HT concentration in the rat was elevated by combined treatment with tranylcypromine and L-tryptophan, tranylcypromine alone, by a single dose of the 5-HT releasing agent p-chloroamphetamine (PCA) or by the selective 5-HT reuptake inhibitor paroxetine. 5-HT was depleted by either multiple p-chlorophenylalanine (pCPA) or PCA injections. The extent of 5-HT depletion following pCPA or PCA was monitored using 5-HT immunocytochemistry. BDNF mRNA abundance in treated rats and the corresponding vehicle injected control rats was studied by in situ hybridization histochemistry (ISHH). Two hours after the combined administration of tranylcypromine and L-tryptophan BDNF mRNA abundance in the dentate gyrus was significantly decreased but increased in the frontal cortex. Tranylcypromine alone or a single injection of PCA had similar effects on BDNF mRNA expression to the combination of tranylcypromine and L-tryptophan, i.e. they caused significant reductions of BDNF mRNA expression in dentate gyrus and increased it in frontal cortex. Paroxetine also reduced BDNF mRNA in DG but was without effect in frontal cortex. Multiple injections of both pCPA or PCA resulted in marked reductions of 5-HT immunoreactive axons in the hippocampus, pCPA being more effective. Both drugs significantly increased BDNF mRNA abundances in the dentate gyrus. Multiple PCA injections also increased BDNF mRNA expression in parietal cortex, while pCPA induced 5-HT depletion was ineffective. These results suggests that 5-HT modulates BDNF mRNA levels in rat brain.

Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial

BACKGROUND

The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral.

METHODS

Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat.

FINDINGS

More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites.

INTERPRETATION

The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.

A teaching videotape for the assessment of essential tremor

Teaching videotapes, developed to aid in the evaluation of several movement disorders, have not been used in essential tremor research. As part of the Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET), we developed a reliable and valid tremor rating scale. Because this rating scale is currently being used by investigators at other centers, we developed a teaching videotape to aid in the consistent application of this scale.

OBJECTIVE

To develop a teaching videotape for a revised version of the WHIGET Tremor Rating Scale and to assess the interrater agreement among raters who used this videotape to rate tremor.

METHODS

The revised WHIGET Tremor Rating Scale was used to rate action tremor from 0 to 4 during six tests: arm extension, pouring, drinking, using a spoon, finger-to-nose, and drawing spirals. A 22-minute teaching videotape was developed that includes a 29-item educational section and a self-assessment section consisting of 20 examples of tremor ratings chosen by the two WHIGET study neurologists. Eight raters, including senior movement disorder specialists, movement disorder fellows, general neurologists, and a movement disorder nurse practitioner, independently viewed the videotape and rated tremor during the self-assessment section. Interobserver reliability was assessed with weighted kappa statistics (kappa(w)).

RESULTS

Eight raters each rated 20 items (160 ratings total). Total kappa(w) was 0.97 (nearly perfect agreement). Interrater reliability was as follows: kappa(w) = 0.99 (movement disorder specialists), kappa(w) = 0.98 (movement disorder fellows), and kappa(w) = 0.97 (general neurologists); all kappa(w) were nearly perfect.

CONCLUSIONS

This teaching videotape may be used to improve the uniform application of the revised WHIGET Tremor Rating Scale by raters with various levels of experience in movement disorders.

Short- and long-term repeatability of fatty acid composition of human plasma phospholipids and cholesterol esters. The Atherosclerosis Risk in Communities (ARIC) Study Investigators

We examined short-term and long-term repeatability (reliability) of the fatty acid (FA) composition of plasma phospholipids and cholesterol esters (CEs). For short-term reliability, fasting blood samples of 34 subjects were collected three times, 2 wk apart, and in 24 subjects duplicate samples were collected during each visit. For long-term reliability, two fasting samples were collected in 50 subjects approximately 3 y apart. In both phospholipids and CEs, short-term and long-term reliability coefficients were > 0.65 for the major plasma FAs (16:0, 18:0, 18:2n-6, and 20:4n-6), with the exception of 18:1n-9, but were generally lower for FAs that compose < 1% of total FAs. Reliability tended to be better for CEs than for phospholipids. Method variability was small (< 5% of total variability for most FAs), indicating that biological and dietary variability contribute most to total variability. Plasma FA measurement warrants consideration as a biochemical marker of diet in epidemiologic studies.

Relation of plasma phospholipid and cholesterol ester fatty acid composition to carotid artery intima-media thickness: the Atherosclerosis Risk in Communities (ARIC) Study

We examined the relation of fatty acid composition of plasma phospholipids and cholesterol esters with carotid artery intima-media thickness (a measure of atherosclerosis) in 2872 white men and women aged 45-64 y from the Minneapolis center of the Atherosclerosis Risk in Communities Study. In both men and women, average carotid intima-media thickness was associated significantly (P < 0.01) and positively with saturated (SFA) and monounsaturated fatty acid composition, and inversely with polyunsaturated fatty acid (PUFA) composition and the ratio of PUFAs to SFAs in both phospholipids and cholesterol esters. These associations were independent of age, cigarette smoking, low-density-lipoprotein (LDL) cholesterol, high-density-lipoprotein (HDL) cholesterol, body mass index, diabetes, and hypertension in men; but in women, only SFAs and PUFAs in the cholesterol esters and the ratio of PUFAs to SFAs were independently associated. The plasma fatty acid pattern is associated with carotid atherosclerosis in a direction generally consistent with the dietary fat-coronary artery disease relation. These results support recommendations to reduce dietary saturated fat to prevent cardiovascular disease.

Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

OBJECTIVES

To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.

DESIGN

Cost consequences study alongside randomised controlled trial.

SETTING

Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.

PARTICIPANTS

3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.

MAIN OUTCOME MEASURES

NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.

RESULTS

Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).

CONCLUSION

The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.

Serotonergic regulation of mRNA expression of Arc, an immediate early gene selectively localized at neuronal dendrites

Arc (activity regulated, cytoskeleton associated protein) is an effector immediate early gene that is selectively localized in the neuronal dendrites. Elevation of brain 5-HT by the combined administration of the monoamine oxidase inhibitor, tranylcypromine (TCP, 5 mg/kg, i.p.), and the 5-HT precursor L-tryptophan (L-TP, 100 mg/kg, i.p.), increased Arc mRNA abundance in the cingulate, orbital, frontal and parietal cortices as well as in the striatum but a reduction was observed in the CA1 region of the hippocampus. The 5-HT releasing agent p-chloroamphetamine (PCA, 5 mg/kg, s.c.) also increased Arc mRNA in the cortical and striatal areas. Depleting brain 5-HT with the tryptophan hydroxylase inhibitor, p-chlorophenylalanine (pCPA, 300 mg/kg, i.p. for two days), on the other hand, significantly attenuated the increase in Arc mRNA induced by tranylcypromine and L-tryptophan (TCP/L-TP). Pretreatment with the 5-HT2 receptor antagonist ketanserin (2 mg/kg, i.p.) significantly attenuated the effect of TCP/L-TP in the cortex but only partially in striatum and did not affect the reduction in the CA1 region. The 5-HT2 agonist DOI (0.2, 1 and 2 mg/kg, i.p.) dose-dependently increased Arc mRNA abundance in cortical areas with a pattern similar to that of TCP/L-TP and PCA. DOI, however, had much weaker effects on Arc mRNA in the striatum and did not have any significant effect in the CA1, CA3 and the dentate gyms (DG) of the hippocampus. Pretreatment with ketanserin completely blocked the effect of DOI on Arc expression. These data suggest that Arc mRNA expression can be induced in the cortex by increases in extracellular 5-HT and that 5-HT2 receptors play a major part in mediating such effects. Additional 5-HT receptors as well as other neurotransmitters may also be involved, particularly in the striatum and in CA1 subfield of the hippocampus. Overall, our data suggest that expression of Arc mRNA is highly responsive to changes in brain 5-HT functions, and may provide a sensitive marker of postsynaptic 5-HT2(2A and 2C) receptor functions.

Comparison of CYP2D6 content and metoprolol oxidation between microsomes isolated from human livers and small intestines

PURPOSE

To assess the role of intestinal CYP2D6 in oral first-pass drug clearance by comparing the enzyme content and catalytic activity of a prototype CYP2D6 substrate, metoprolol, between microsomes prepared from human intestinal mucosa and from human livers.

METHODS

Microsomes were prepared from a panel of 31 human livers and 19 human intestinal jejunal mucosa. Microsomes were also obtained from the jejunum, duodenum and ileum of four other human intestines to assess regional distribution of intestinal CYP2D6. CYP2D6 content (pmole/mg microsomal protein) was determined by Western blot. CYP2D6 activity was measured by alpha-hydroxylation and O-demethylation of metoprolol.

RESULTS

Kinetic studies with microsomes from select livers (n = 6) and jejunal mucosa (n = 5) yielded K(M) estimates of 26 +/- 9 microM and 44 +/- 17 microM, respectively. The mean Vmax (per mg protein) for total formation of alpha-OH-M and ODM was 14-fold higher for the liver microsomes compared to the jejunal microsomes. Comparisons across intestinal regions showed that CYP2D6 protein content and catalytic activity were in the order ofjejunum > duodenum > ileum. Excluding the poor metabolizer genotype donors, CYP2D6 content varied 13- and 100-fold across the panels of human livers (n = 31) and jejunal mucosa (n = 19), respectively. Metoprolol alpha-hydroxylation activity and CYP2D6 content were highly correlated in the liver microsomes (r = 0.84, p < 0.001) and jejunal microsomes (r = 0.75, p < 0.05). Using the well-stirred model, the mean microsomal intrinsic clearance (i.e., Vmax/K(M)) for the livers and jejunum were scaled to predict their respective in vivo organ intrinsic clearance and first-pass extraction ratio. Hepatic and intestinal first-pass extractions of metoprolol were predicted to be 48% and 0.85%, respectively.

CONCLUSIONS

A much lower abundance and activity of CYP2D6 are present in human intestinal mucosa than in human liver. Intestinal mucosal metabolism contributes minimally to the first-pass effect of orally administered CYP2D6 substrates, unless they have exceptionally high microsomal intrinsic clearances and/or long residence time in the intestinal epithelium.

An evaluation of total starch and starch gelatinization methodologies in pelleted animal feed

The quantification of total starch content (TS) or degree of starch gelatinization (DG) in animal feed is always challenging because of the potential interference from other ingredients. In this study, the differences in TS or DG measurement in pelleted swine feed due to variations in analytical methodology were quantified. Pelleted swine feed was used to create 6 different diets manufactured with various processing conditions in a 2 × 3 factorial design (2 conditioning temperatures, 77 or 88°C, and 3 conditioning retention times, 15, 30, or 60 s). Samples at each processing stage (cold mash, hot mash, hot pelletized feed, and final cooled pelletized feed) were collected for each of the 6 treatments and analyzed for TS and DG. Two different methodologies were evaluated for TS determination (the AOAC International method 996.11 vs. the modified glucoamylase method) and DG determination (the modified glucoamylase method vs. differential scanning calorimetry [DSC]). For TS determination, the AOAC International method 996.11 measured lower TS values in cold pellets compared with the modified glucoamylase method. The AOAC International method resulted in lower TS in cold mash than cooled pelletized feed, whereas the modified glucoamylase method showed no significant differences in TS content before or after pelleting. For DG, the modified glucoamylase method demonstrated increased DG with each processing step. Furthermore, increasing the conditioning temperature and time resulted in a greater DG when evaluated by the modified glucoamylase method. However, results demonstrated that DSC is not suitable as a quantitative tool for determining DG in multicomponent animal feeds due to interferences from nonstarch transformations, such as protein denaturation.

A model for therapeutic interventins on established coronary atherosclerosis in a nonhuman primate

The observations so far conducted in cynomologus monkeys on semipurified diets containing butter and cholesterol suggest that this nonhuman primate is an excellent model for studying the therapy of established coronary atherosclerosis. (1) This species is available at a reasonable cost and can be kept in captivity in good health for prolonged periods of time. (2) It readily accepts semipurified diets with a percentage composition similar to that of human diets in the U.S. (3) Ingestion of these diets leads quite rapidly (around 6 months) to moderate coronary atherosclerosis. More prolonged feeding leads to lesions which are histologically very similar to those in man. (4) The distribution of lesions in the main coronary arteries is similar to that in man. (5) Methods to quantify the coronary lesions are available. (6) The diets can be so modified that cholesterol levels closely resemble those in hypercholesterolemic man. (7) The monkeys are amenable to several therapeutic regimens which show promise of arresting the progress or inducing the regression of the coronary lesions.

A second community outbreak of waterborne giardiasis in Canada and serological investigation of patients

A waterborne outbreak of giardiasis which occurred 5 years after another in the same town in Canada was investigated. Sera from residents defined as cases or non-cases were tested by enzyme-linked immunosorbent assay (ELISA) and compared with sera from symptomatic and asymptomatic control groups. The outbreak-associated Giardia isolate was retrieved from contaminated drinking water and antigen from this strain was used in the serological investigation. Up to 84% of cases were identified by ELISA. More cases were identified by elevated immunoglobulin (Ig) G than by either elevated anti-Giardia IgA or IgM levels. Residents of the community infected during the first outbreak were significantly less likely to have been reinfected during the second outbreak. This is the first report of a second waterborne outbreak occurring in a community and results of the investigations are consistent with an acquired, protective immunity lasting at least 5 years.

Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations

OBJECTIVES

To test the hypotheses that virtual outreach would reduce offers of hospital follow-up appointments and reduce numbers of medical interventions and investigations, reduce numbers of contacts with the health care system, have a positive impact on patient satisfaction and enablement, and lead to improvements in patient health status. To perform an economic evaluation of virtual outreach.

DESIGN

A randomised controlled trial comparing joint teleconsultations between GPs, specialists and patients with standard outpatient referral. It was accompanied by an economic evaluation.

SETTING

The trial was centred on the Royal Free Hampstead NHS Trust, London, and the Royal Shrewsbury Hospital Trust in Shropshire. The project teams recruited and trained a total of 134 GPs from 29 practices and 20 consultant specialists.

PARTICIPANTS

In total, 3170 patients were referred, of whom 2094 consented to participate in the study and were eligible for inclusion. In all, 1051 patients were randomised to the virtual outreach group and 1043 to standard outpatient appointments. The patients were followed 6 months after their index consultation.

INTERVENTIONS

Patients randomised to virtual outreach underwent a joint teleconsultation, in which they attended the general practice surgery where they and their GP consulted with a hospital specialist via a videolink between the hospital and the practice.

MAIN OUTCOME MEASURES

Outcome measures included offers of follow-up outpatient appointments, numbers of tests, investigations, procedures, treatments and contacts with primary and secondary care, patient satisfaction (Ware Specific Visit Questionnaire), enablement (Patient Enablement Instrument) and quality of life (Short Form-12 and Child Health Questionnaire). An economic evaluation of the costs and consequences of the intervention was undertaken. Sensitivity analysis was used to test the robustness of the results.

RESULTS

Patients in the virtual outreach group were more likely to be offered a follow-up appointment. Significant differences in effects were observed between the two sites and across different specialities. Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ENT and orthopaedics than in the other specialities. Fewer tests and investigations were ordered in the virtual outreach group, by an average of 0.79 per patient. In the 6-month period following the index consultation, there were no significant differences overall in number of contacts with general practice, outpatient visits, accident and emergency contacts, inpatient stays, day surgery and inpatient procedures or prescriptions between the randomised groups. Tests of interaction indicated that virtual outreach decreased the number of tests and investigations, particularly in patients referred to gastroenterology, and increased the number of outpatient visits, particularly in those referred to orthopaedics. Patient satisfaction was greater after a virtual outreach consultation than after a standard outpatient consultation, with no heterogeneity between specialities or sites. However, patient enablement after the index consultation, and the physical and psychological scores of the Short Form-12 for adults and the scores on the Child Health Questionnaire for children under 16, did not differ between the randomised groups at 6 months' follow-up. NHS costs over 6 months were greater for the virtual outreach consultations than for conventional outpatients, pound 724 and pound 625 per patient, respectively. The index consultation accounted for this excess. Cost and time savings to patients were found. Estimated productivity losses were also less in the virtual outreach group.

CONCLUSIONS

Virtual outreach consultations result in significantly higher levels of patient satisfaction than standard outpatient appointments and lead to substantial reductions in numbers of tests and investigations, but they are variably associated with increased rates of offer of follow-up according to speciality and site. Changes in costs and technological advances may improve the relative position of virtual consultations in future. The extent to which virtual outreach is implemented will probably be dependent on factors such as patient demand, costs, and the attitudes of staff working in general practice and hospital settings. Further research could involve long-term follow-up of patients in the virtual outreach trial to determine downstream outcomes and costs; further study into the effectiveness and costs of virtual outreach used for follow-up appointments, rather than first-time referrals; and whether the costs of virtual outreach could be substantially reduced without adversely affecting the quality of the consultation if nurses or other members of the primary care team were to undertake the hosting of the joint teleconsultations in place of the GP. Qualitative work into the attitudes of the patients, GPs and hospital specialists would also be valuable.

Transfer of innovation on allergic rhinitis and asthma multimorbidity in the elderly (MACVIA-ARIA) - EIP on AHA Twinning Reference Site (GARD research demonstration project)

The overarching goals of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) are to enable European citizens to lead healthy, active and independent lives whilst ageing. The EIP on AHA includes 74 Reference Sites. The aim of this study was to transfer innovation from an app developed by the MACVIA-France EIP on AHA reference site (Allergy Diary) to other reference sites. The phenotypic characteristics of rhinitis and asthma multimorbidity in adults and the elderly will be compared using validated information and communication technology (ICT) tools (i.e. the Allergy Diary and CARAT: Control of Allergic Rhinitis and Asthma Test) in 22 Reference Sites or regions across Europe. This will improve the understanding, assessment of burden, diagnosis and management of rhinitis in the elderly by comparison with an adult population. Specific objectives will be: (i) to assess the percentage of adults and elderly who are able to use the Allergy Diary, (ii) to study the phenotypic characteristics and treatment over a 1-year period of rhinitis and asthma multimorbidity at baseline (cross-sectional study) and (iii) to follow-up using visual analogue scale (VAS). This part of the study may provide some insight into the differences between the elderly and adults in terms of response to treatment and practice. Finally (iv) work productivity will be examined in adults.

Probenecid-inhibitable efflux transport of valproic acid in the brain parenchymal cells of rabbits: a microdialysis study

Delivery of valproic acid (VPA) to the human brain is relatively inefficient as reflected by a low brain-to-unbound plasma concentration ratio (< or =0.5) at steady state. Previous pharmacokinetic studies suggested that the unfavorable brain-to-plasma gradient is maintained by coupled efflux transport processes at both the brain parenchymal cells and blood-brain barrier (BBB); one or both of the efflux transporters are inhibitable by probenecid. The present study in rabbits utilized microdialysis to measure drug concentration in the brain extracellular fluid (ECF) of the cerebral cortex during steady-state i.v. infusion with VPA alone or with VPA plus probenecid. Probenecid co-infusion elevated VPA concentration in the brain tissue surrounding the tip of the microdialysis probe to a greater extent than in the ECF (230% versus 47%). Brain intracellular compartment (ICC) concentration was estimated. In control rabbits, the ICC concentration was 2.8+/-0.28 times higher than the ECF concentration. Probenecid co-infusion elevated the ICC-to-ECF concentration ratio to 4.2+/-0.44, which confirms the existence of an efflux transport system in brain parenchymal cells. The ECF-to-unbound plasma concentration ratio was well below unity (0.029), indicating an uphill efflux transport of VPA across the BBB. Co-infusion of probenecid did not have a significant effect on VPA efflux at the BBB as evidenced by a minimal change in the ECF-to-unbound plasma concentration ratio. This study suggests the presence of distinctly different organic anion transporters for the efflux of VPA at the parenchymal cells and capillary endothelium in the brain.