Assessing Wolf motor function test as outcome measure for research in patients after stroke

BACKGROUND AND PURPOSE

The Wolf Motor Function Test (WMFT) is a new time-based method to evaluate upper extremity performance while providing insight into joint-specific and total limb movements. This study addresses selected psychometric attributes of the WMFT applied to a chronic stroke population.

METHODS

Nineteen individuals after stroke and with intact cognition and sitting balance were age- and sex-matched with 19 individuals without impairment. Subjects performed the WMFT and the upper extremity portion of the Fugl-Meyer Motor Assessment (FMA) on 2 occasions (12 to 16 days apart), with scoring performed independently by 2 random raters.

RESULTS

The WMFT and FMA demonstrated agreement (P<0.0001) between raters at each session. WMFT scores for the dominant and nondominant extremities of individuals without impairment were different (P</=0.05) from the more and less affected extremities of subjects after stroke. The FMA score for the more affected extremity of subjects after stroke was different (P</=0.05) from the dominant and nondominant extremities. However, the FMA score for the less affected upper extremity of individuals after stroke was not different (P>0.05) from the dominant and nondominant extremities of individuals without impairment. The WMFT and FMA scores were related (P<0.02) for the more affected extremity in individuals after stroke.

CONCLUSIONS

The interrater reliability, construct validity, and criterion validity of the WMFT, as used in these subject samples, are supported.

Prevention of falls in the elderly trial (PROFET): a randomised controlled trial

BACKGROUND

Falls in elderly people are a common presenting complaint to accident and emergency departments. Current practice commonly focuses on the injury, with little systematic assessment of the underlying cause, functional consequences, and possibilities for future prevention. We undertook a randomised controlled study to assess the benefit of a structured inderdisciplinary assessment of people who have fallen in terms of further falls.

METHODS

Eligible patients were aged 65 years and older, lived in the community, and presented to an accident and emergency department with a fall. Patients assigned to the intervention group (n=184) underwent a detailed medical and occupational-therapy assessment with referral to relevant services if indicated; those assigned to the control group (n=213) received usual care only. The analyses were by intention to treat. Follow-up data were collected every 4 months for 1 year.

FINDINGS

At 12-month follow-up, 77% of both groups remained in the study. The total reported number of falls during this period was 183 in the intervention group compared with 510 in the control group (p=0.0002). The risk of falling was significantly reduced in the intervention group (odds ratio 0.39 [95% CI 0.23-0.66]) as was the risk of recurrent falls (0.33 [0.16-0.68]). In addition, the odds of admission to hospital were lower in the intervention group (0.61 [0.35-1.05]) whereas the decline in Barthel score with time was greater in the control group (p<0.00001).

INTERPRETATION

The study shows that an interdisciplinary approach to this high-risk population can significantly decrease the risk of further falls and limit functional impairment.

Preoperative treatment of postmenopausal breast cancer patients with letrozole: A randomized double-blind multicenter study

BACKGROUND

A randomized, double-blind, multicenter study was conducted to compare the anti-tumor activity of letrozole vs. tamoxifen in postmenopausal women with ER and/or PgR positive primary untreated breast cancer.

PATIENTS AND METHODS

Three hundred thirty-seven postmenopausal women with ER and/or PgR positive primary untreated breast cancer were randomly assigned once daily treatment with either letrozole 2.5 mg or tamoxifen 20 mg for four months. At baseline none of the patients were considered to be candidates for breast-conserving surgery (BCS) and 14% of the patients were considered inoperable. The primary endpoint was to compare overall objective response (CR + PR) determined by clinical palpation. Secondary endpoints included overall objective response on ultrasound and mammography and the number of patients who qualified for BCS.

RESULTS

Overall objective response rate (clinical palpation) was statistically significantly superior in the letrozole group, 55% compared to tamoxifen, 36% (P < 0.001). Secondary endpoints of ultrasound response, 35% vs. 25% (P = 0.042), mammographic response, 34% vs. 16% (P < 0.001), and BCS, 45% vs. 35% (P = 0.022) between the letrozole and tamoxifen groups, respectively, showed letrozole to be significantly superior. Both treatments were well tolerated.

CONCLUSIONS

This study shows that letrozole is more effective than tamoxifen as preoperative therapy in postmenopausal patients with ER and/or PgR positive primary untreated breast cancer and is at least as well tolerated.

Double-blind, randomized trial comparing the efficacy and tolerability of fulvestrant versus anastrozole in postmenopausal women with advanced breast cancer progressing on prior endocrine therapy: results of a North American trial

PURPOSE

To compare the efficacy and tolerability of fulvestrant (formerly ICI 182,780) with anastrozole in the treatment of advanced breast cancer in patients whose disease progresses on prior endocrine treatment.

PATIENTS AND METHODS

In this double-blind, double-dummy, parallel-group study, postmenopausal patients were randomized to receive either an intramuscular injection of fulvestrant 250 mg once monthly or a daily oral dose of anastrozole 1 mg. The primary end point was time to progression (TTP). Secondary end points included objective response (OR) rate, duration of response (DOR), and tolerability.

RESULTS

Patients (n = 400) were followed for a median period of 16.8 months. Fulvestrant was as effective as anastrozole in terms of TTP (hazard ratio, 0.92; 95.14% confidence interval [CI], 0.74 to 1.14; P =.43); median TTP was 5.4 months with fulvestrant and 3.4 months with anastrozole. OR rates were 17.5% with both treatments. Clinical benefit rates (complete response + partial response + stable disease > or = 24 weeks) were 42.2% for fulvestrant and 36.1% for anastrozole (95% CI, -4.00% to 16.41%; P =.26). In responding patients, median DOR (from randomization to progression) was 19.0 months for fulvestrant and 10.8 months for anastrozole. Using all patients, DOR was significantly greater for fulvestrant compared with anastrozole; the ratio of average response durations was 1.35 (95% CI, 1.10 to 1.67; P < 0.01). Both treatments were well tolerated.

CONCLUSION

Fulvestrant was at least as effective as anastrozole, with efficacy end points slightly favoring fulvestrant. Fulvestrant represents an additional treatment option for postmenopausal women with advanced breast cancer whose disease progresses on tamoxifen therapy.

EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphomas and solid tumours

Chemotherapy-induced neutropenia is not only a major risk factor for infection-related morbidity and mortality, but is also a significant dose-limiting toxicity in cancer treatment. Patients developing severe (grade 3/4) or febrile neutropenia (FN) during chemotherapy frequently receive dose reductions and/or delays to their chemotherapy. This may impact on the success of treatment, particularly when treatment intent is either curative or to prolong survival. The incidence of severe or FN can be reduced by prophylactic treatment with granulocyte-colony stimulating factors (G-CSFs), such as filgrastim, lenograstim or pegfilgrastim. However, the use of G-CSF prophylactic treatment varies widely in clinical practice, both in the timing of therapy and in the patients to whom it is offered. While several academic groups have produced evidence-based clinical practice guidelines in an effort to standardise and optimise the management of FN, there remains a need for generally applicable, European-focused guidelines. To this end, we undertook a systematic literature review and formulated recommendations for the use of G-CSF in adult cancer patients at risk of chemotherapy-induced FN. We recommend that patient-related adverse risk factors such as elderly age (>or=65 years), be evaluated in the overall assessment of FN risk prior to administering each cycle of chemotherapy. In addition, when using a chemotherapy regimen associated with FN in >20% patients, prophylactic G-CSF is recommended. When using a chemotherapy regimen associated with FN in 10-20% patients, particular attention should be given to patient-related risk factors that may increase the overall risk of FN. In situations where dose-dense or dose-intense chemotherapy strategies have survival benefits, prophylactic G-CSF support is recommended. Similarly, if reductions in chemotherapy dose intensity or density are known to be associated with a poor prognosis, primary G-CSF prophylaxis may be used to maintain chemotherapy. Finally, studies have shown that filgrastim, lenograstim and pegfilgrastim have clinical efficacy and we recommend the use of any of these agents to prevent FN and FN-related complications, where indicated.

The association between anxiety and psychopathy dimensions in children

Although several theoretical models posit that low levels of anxiety are a risk factor for psychopathy and antisocial behavior, a number of studies have reported elevated levels of anxiety among antisocial individuals. Nevertheless, most investigators in this literature have not distinguished between fearfulness and trait anxiety or attempted to separate the antisocial lifestyle dimension from the callous and unemotional dimension of psychopathy. In a study of clinically referred children (N = 143), we found that (a) measures of trait anxiety and fearlessness (low fearfulness) exhibited low correlations; (b) conduct problems tended to be positively correlated with trait anxiety, whereas callous and unemotional traits tended to be negatively correlated with trait anxiety; and (c) controlling statistically for the effects of one dimension increased the divergent correlations of the other dimension with both trait anxiety and fearful inhibition. These findings bear potentially important implications for the diagnosis and etiology of psychopathy and antisocial behavior and suggest that distinctions between trait anxiety and fearful inhibition, as well as between the two dimensions of psychopathy, may help to clarify longstanding confusion in this literature.

Space geodetic observations of nazca-south america convergence across the central andes

Space geodetic data recorded rates and directions of motion across the convergent boundary zone between the oceanic Nazca and continental South American plates in Peru and Bolivia. Roughly half of the overall convergence, about 30 to 40 millimeters per year, accumulated on the locked plate interface and can be released in future earthquakes. About 10 to 15 millimeters per year of crustal shortening occurred inland at the sub-Andean foreland fold and thrust belt, indicating that the Andes are continuing to build. Little (5 to 10 millimeters per year) along-trench motion of coastal forearc slivers was observed, despite the oblique convergence.

Impaired neutrophil function in patients with AIDS or AIDS-related complex: a comprehensive evaluation

We measured the neutrophil function of 6 patients with AIDS and Kaposi's sarcoma (KS); 22 patients with AIDS-related complex (ARC); and 28 healthy, heterosexual controls. Neutrophils from patients with ARC showed significantly less chemotaxis (P less than or equal to .025) than did those from patients with AIDS and KS or from controls. Serum from patients with AIDS and KS or with ARC significantly (P less than or equal to .05) inhibited chemotaxis of neutrophils from controls; heat treatment of the serum abolished this inhibitory effect. Bacterial killing by neutrophils from patients with AIDS and KS or with ARC was also significantly (P less than or equal to .05) less than for neutrophils from controls, as was neutrophil phagocytosis binding of Candida albicans (P less than or equal to .05). Expression of OKM1 antigen was increased in the patients studied. Enzyme degranulation, adherence, and aggregation were also examined. The defects found in neutrophil function are selective and may be important in the increased susceptibility of patients with human immunodeficiency virus infection to bacterial and fungal infections.

An EORTC international multicenter randomized trial (EORTC number 19923) comparing two dosages of liposomal amphotericin B for treatment of invasive aspergillosis

This is the first completed prospective randomized clinical efficacy trial of antifungals in the treatment of invasive aspergillosis (IA) and the first to compare the clinical efficacy of two dosages of liposomal amphotericin B (L-AmB) for IA in neutropenic patients with cancer or those undergoing bone marrow transplantation. Eighty-seven of 120 patients were eligible and evaluable. Clinical responses were documented for 26 (64%) of 41 patients receiving 1 mg/(kg.d) (L-AmB-1) and 22 (48%) of 46 receiving 4 mg/(kg.d) (L-AmB-4). Radiologic response rates were similar: 24 (58%) of the L-AmB-1 recipients and 24(52%) of the L-AmB-4 recipients. The six-month survival rates were 43% (L-AmB-1) and 37% (L-AmB-4). These differences were not significant. The numbers of deaths directly due to IA at 6 months were similar: 9 (22%) of 41 L-AmB-1 recipients and 9 (20%) of 46 L-AmB-4 recipients. No other variable independently influenced survival, apart from central nervous system IA. L-AmB is effective in treating approximately 50%-60% of patients who have IA. A 1-mg/(kg.d) dosage is as effective as a 4-mg/(kg.d) dosage, and no advantages to use of the higher, more expensive, dosage has been observed.

An EORTC multicentre prospective survey of invasive aspergillosis in haematological patients: diagnosis and therapeutic outcome. EORTC Invasive Fungal Infections Cooperative Group

OBJECTIVES

The EORTC Invasive Fungal Infections Cooperative Group (IFICG) conducted a prospective survey by questionnaire of all cases of invasive aspergillosis (IA) in cancer patients to ascertain current diagnostic and therapeutic approaches.

METHODS

All members of the IFICG were asked prospectively to complete a detailed questionnaire for each IA case identified in their institution over a 12-month period.

RESULTS

One hundred and thirty questionnaires were returned. All cases were independently evaluated (DWD & JC) and 123 were eligible. Cases came from 20 hospitals in eight countries and the number of cases per institution varied from 1-21. Acute myeloid leukaemia (AML) (60, 49%), acute lymphoblastic leukaemia (ALL) (21, 17%) and lymphoma (11, 9%) were the most frequent underlying diseases, and 16 (12%) patients had received an allogeneic bone marrow transplant. Pulmonary involvement was present in 87%, infection of sinuses/nose in 16% and brain in 8%. The chest radiograph was initially normal in 9% of those with primary pulmonary disease. The diagnosis was confirmed in 50%, probable in 31% and possible in 19%. The evidence for IA was on the basis of clinical and radiological features alone in 28%, with culture or histology in another 31% and 9%, respectively, and with both culture and histology in 29%. In three (2%) patients with diagnosis was based on culture or histology alone. Treatment was given to 120 patients (98%)-amphotericin B 75%, lipid-associated amphotericin B 36%, itraconazole 40%, flucytosine 12%, growth factors 33%, lobectomy 5%. At 3 months after diagnosis or first suspicion of IA, 44 (36%) patients were alive and 79 (64%) dead. Outcome was best in those with AML (30% death and 46% with a complete antifungal response or cure). Growth factors (mostly granulocyte colony stimulating factor) appeared not to influence outcome (P = 0.99).

CONCLUSION

IA remains a considerable diagnostic and therapeutic challenge. No single diagnostic procedure was universally successful and a multifaceted approach including surgery is necessary. There was no discernable difference in outcome between initial therapy with amphotericin B, itraconazole or lipid-associated amphotericin B, although numbers are limited and the study was retrospective.

Callous-unemotional traits and subtypes of conduct disorder

There has been growing consensus that children with conduct disorder (CD) constitute a very heterogeneous group containing children who vary substantially on the development, course, and causes of the disorder. While many have recognized the importance of this heterogeneity for developing better causal theories and for developing more effective treatments, there has been little consensus as to the best way to subtype children with CD. In this paper, we review a number of approaches to subtyping, each with some evidence for its validity for certain purposes. We focus on two recent approaches that have great potential for integrating past subtyping approaches and for advancing causal theory. The first approach is the division of children with CD into those with a childhood onset to their severe antisocial behavior and those with an adolescent onset to their behavior. The second approach is to designate children within the childhood-onset group who show callous and unemotional traits, which is analogous to adult conceptualizations of psychopathy. Both approaches help designate children who many show different causal processes underlying their severe aggressive and antisocial behavior, and who may warrant different approaches to treatment.

Evaluation of heroin maintenance in controlled trial

Ninety-six confirmed heroin addicts requesting a heroin maintenance prescription were randomly allocated to treatment with injectable heroin or oral methadone. Progress was monitored throughout the next 12 months by research workers operating independently of the clinic. Heroin can be seen as maintaining the status quo, with the majority continuing to inject heroin regularly and to supplement their maintenance prescription from other sources; it was associated with a continuing intermediate level of involvement with the drug subculture and criminal activity. Refusal to prescribe heroin while offering oral methadone constituted a more confrontational response and resulted in a higher abstinence rate, but also a greater dependence on illegal sources of drugs for these who continued to inject. Those offered oral methadone tended to polarize toward high or low categories of illegal drug use and involvement with the drug subculture, and were more likely to be arrested during the 12-month follow-up. There was no difference between the two groups in terms of employment, health, or consumption of nonopiate drugs. Refusal to prescribe heroin resulted in a significantly greater drop out from regular treatment.

Degradation of p27(Kip) cdk inhibitor triggered by Kaposi's sarcoma virus cyclin-cdk6 complex

The Kaposi's sarcoma-associated human herpesvirus 8 (KSHV/HHV8) encodes a protein similar to cellular cyclins. This cyclin is most closely related to cellular D-type cyclins, but biochemically it behaves atypically in various respects. Complexes formed between the viral cyclin and the cyclin-dependent kinase subunit, cdk6, can phosphorylate a wider range of substrates and are resistant to cdk inhibitory proteins. We show here that the KSHV-cyclin-cdk6 complex phosphorylates p27(Kip) on a C-terminal threonine that is implicated in destabilization of this cdk inhibitor. Expression of the viral cyclin in tissue culture cells overcomes a cell cycle block by p27(Kip). However, full cell-cycle transit of these cells appears to depend on C-terminal phosphorylation of p27(Kip) and seems to involve transactivation of other cellular cyclin-dependent kinases. A p27(Kip)-phosphorylating cdk6 complex exists in cell lines derived from primary effusion lymphoma and in Kaposi's sarcoma, this indicating that virally induced p27(Kip) degradation may occur in KSHV-associated tumours.

Smoking and growth rate of small abdominal aortic aneurysms

Smoking is an important risk factor for abdominal aortic aneurysm. Limiting the growth rate of small aneurysms has the potential to prevent them reaching a size at which surgical repair is considered. In 43 patients, with small aneurysms, growth rates were studied by serial ultrasound over 3 years. The median expansion rate of these small aneurysms was 0.13 cm per year. Growth rates were higher in those who continued to smoke (0.16 vs 0.09 cm per year in those who no longer smoked, p = 0.038). Higher growth rates were significantly correlated with the concentration of serum cotinine. Stopping smoking could reduce the growth rate of small abdominal aortic aneurysms.

The growth performance, carcass characteristics, and meat quality of halothane carrier and negative pigs

Growth performance, carcass characteristics, and meat quality of halothane carrier (Nn) and negative (NN) pigs grown from 40 kg live weight and slaughtered at three weights (110, 125, and 140 kg live weight) were studied. Daily gains were similar for the two genotypes (974 g for Nn and 964 g for NN), but Nn pigs had a higher gain:feed ratio than NN pigs (P < .01). Dressing percentage was higher in Nn pigs than in NN pigs (P < .001), but there were no genotype differences for carcass length, backfat thickness, or loin eye area. Percentage yield of trimmed, boneless wholesale cuts was higher for Nn pigs than for NN pigs (P < .05). This resulted from higher trimmed, boneless ham, boston, and picnic weights (P < .05) in Nn than in NN pigs (6.9, 3.2, 3.5 kg vs 6.6, 3.0, 3.4 kg, respectively). The weight of fat-free lean was higher in Nn pigs (P < .05). The longissimus thoracis muscle from carrier pigs had lower 45 min (P < .001) and 24 h (P < .01) pH. Longissimus lumborum samples from carriers had lower (P < .001) subjective' meat quality scores and a higher drip loss (P < .001); however, cooking loss, eating quality, and shear force values were similar for the two genotypes. There were no important slaughter weight x genotype interactions for the traits reported. Overall, the data from this study suggest Nn pigs had an advantage over NN pigs in terms of feed efficiency, carcass yield fat-free lean content, and commercial lean cut yields but had a higher incidence of PSE.

Influence of slaughter weight on growth and carcass characteristics, commercial cutting and curing yields, and meat quality of barrows and gilts from two genotypes

Pigs representing two crossbred genotypes, a breeding company hybrid (BCH) and a three breed cross (Hampshire x [Yorkshire x Duroc]) (HYD) were evaluated at five slaughter weights (SLW): 100, 115, 130, 145, and 160 kg. A total of 160 pigs were grown in like-sex (barrows [B] or gilts [G]), like-genotype groups, with four pigs/group, from 60 kg live weight. A corn-soybean meal-based diet was available on an ad libitum basis (15.8% crude protein, 3,300 kcal/kg ME). One-half of the pigs from each group (80 pigs) were slaughtered for carcass and meat quality evaluation. Genotype BCH grew faster, had lower backfat depths in the loin and lumbar regions, and a smaller loin eye area than HYD, but both groups had a similar gain:feed ratio. Few consistent genotype differences in cutting and curing yields and meat quality were observed. Differences between sexes for growth and carcass traits were generally in agreement with previous research; however, the magnitude of the differences was small. There were few nonlinear regressions involving SLW and limited differences between genotypes or sexes in the slopes of the linear regressions. Increases in SLW were associated with increases in feed intake, backfat depth and loin' eye area, and minimal changes in growth rate or gain:feed. Percentage of loin increased and ham, shoulder, and spare rib percentages decreased with slaughter weight. The weight of trimmed, boneless cuts increased with slaughter weight, but percentage trimmed, boneless cuts was reduced. Curing yields for belly increased with slaughter weight. Changes in meat quality with increasing slaughter weight were relatively small. Longissimus lumborum fat content increased and moisture content decreased with slaughter weight. These results suggest that modern genotypes can be slaughtered at live weights up to 160 kg with limited impact on growth performance, commercial meat yields, or meat quality characteristics.

Limitations of ultrasonography in surveillance of small abdominal aortic aneurysms

The repeatability, observer bias and instrument bias of aortic diameter measurement by ultrasonography, were investigated in ten patients with small (3-6 cm by computed tomography) infrarenal abdominal aortic aneurysm. The repeatability of maximum aortic diameter measurement by ultrasonography was much better for anterior-posterior than transverse diameter, with coefficients of repeatability 3.0-7.5 mm and 10-15 mm respectively. The repeatability of suprarenal aortic diameter measurement was poor. Surprisingly, maximum diameter using ultrasonography was larger than that using computed tomography, the difference being least for anterior-posterior measurements. At best a single, experienced observer, using the same instrument may provide aortic diameters using ultrasonography accurate to within 5 mm, but more commonly such aortic diameter is only accurate to within 8 mm.

Molecular strategies for improving waterlogging tolerance in plants

Plants, like animals, are obligate aerobes, but due to their inability to move, have evolved adaptation mechanisms that enable them to survive short periods of low oxygen supply, such as those occurring after heavy rain or flooding. Crop plants are often grown on soils subject to waterlogging and many are sensitive to waterlogging of the root zone. The combination of unfavourable weather conditions and suboptimal soil and irrigation techniques can result in severe yield losses. The molecular basis of the adaptation to transient low oxygen conditions has not been completely characterized, but progress has been made towards identifying genes and gene products induced during low oxygen conditions. Promoter elements and transcription factors involved in the regulation of anaerobically induced genes have been characterized. In this paper an account is presented of the molecular strategies that have been used in an attempt to increase flooding tolerance of crop plants.

The effects of postnatal health education for mothers on infant care and family planning practices in Nepal: a randomised controlled trial

OBJECTIVES

To evaluate impact of postnatal health education for mothers on infant care and postnatal family planning practices in Nepal.

DESIGN

Randomised controlled trial with community follow up at 3 and 6 months post partum by interview. Initial household survey of study areas to identify all pregnant women to facilitate follow up.

SETTING

Main maternity hospital in Kathmandu, Nepal. Follow up in urban Kathmandu and a periurban area southwest of the city.

SUBJECTS

540 mothers randomly allocated to one of four groups: health education immediately after birth and three months later (group A), at birth only (group B), at three months only (group C), or none (group D).

INTERVENTIONS

Structured baseline household questionnaire; 20 minute, one to one health education at birth and three months later.

MAIN OUTCOME MEASURES

Duration of exclusive breast feeding, appropriate immunisation of infant, knowledge of oral rehydration solution and need to continue breast feeding in diarrhoea, knowledge of infant signs suggesting pneumonia, uptake of postnatal family planning.

RESULTS

Mothers in groups A and B (received health education at birth) were slightly more likely to use contraception at six months after birth compared with mothers in groups C and D (no health education at birth) (odds ratio 1.62, 95% confidence interval 1.06 to 2.5). There were no other significant differences between groups with regards to infant feeding, infant care, or immunisation.

CONCLUSIONS

Our findings suggest that the recommended practice of individual health education for postnatal mothers in poor communities has no impact on infant feeding, care, or immunisation, although uptake of family planning may be slightly enhanced.

Growth performance of pigs subjected to multiple concurrent environmental stressors

The effects of many single stressors have been reported, but how pigs perform when subjected to more than one or two stressors at a time, as is common in commercial swine production, has not. To study this, 256 Yorkshire x Hampshire or purebred Duroc pigs (34.7+/-.5 kg) were subjected to one of the eight treatment combinations (2 x 2 x 2 factorial) of ambient temperature (constant thermoneutral [24 degrees C] or high cycling temperature [28 to 34 degrees C]), stocking density (.56 or .25 m2/pig), and social group (static group or regrouped at the start of wk 1 and 3) during a 4-wk experiment. The temperature regimens were imposed in two adjacent mechanically ventilated rooms, and each temperature was imposed in each room across two trials. Four barrows and four gilts were assigned to each of the eight pens in the two rooms, and they always had free access to water and a corn-soybean meal-based diet. Treatments were imposed after a 7-d acclimation period at 24 degrees C and .56 m2/pig. Weight gain and feed intake were measured weekly. The main effects of each of the stressors for 4-wk ADG and ADFI were significant (P < .05). The stress of high temperature, high stocking density, and regrouping depressed 4-wk ADG by 12, 16 and 10% and ADFI by 7, 6, and 5%, respectively. Of the possible 60 stressor interactions for ADG, ADFI, and gain:feed (G:F), there were no significant three-way interactions and only six two-way interactions, suggesting that the effects of the individual stressors were additive. Accordingly, the growth rate of pigs subjected to the single stressor of high cycling temperature, restricted space allowance, or regrouping was depressed 10, 16, and 11%, respectively, and ADG of pigs subjected to all three stressors simultaneously was depressed by 31%. Stressor additivity was further corroborated by examining the effect of stressor order, or the number of stressors imposed simultaneously. As the number of stressors increased from 0 to 3, ADG, ADFI, and G:F decreased linearly. These data suggest that multiple concurrent stressors affect growth performance of pigs in a predictable fashion (i.e., additively) and indicate that avoidance or removal of a given stressor is advantageous even when other uncontrollable stressors persist.

Effects of early childhood lead exposure on academic performance and behaviour of school age children

AIM

To determine whether early lead exposure at levels below 10 microg/dl has an impact on educational and behavioural outcomes at school.

METHODS

Venous samples were taken from a subgroup of the Avon Longitudinal Study of Parents and Children (ALSPAC) attending a research clinic at 30 months of age (n = 582), and lead levels were measured by atomic absorption spectrometry. Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) were collected on these children at age 7-8 years. In the analysis, blood lead concentration was investigated both as a continuous covariate and as a categorical variable.

RESULTS

488 cases (84%) had complete data on confounders and outcomes. After adjustment for confounders and using a log dose-response model for lead concentration, blood lead levels showed significant associations with reading, writing and spelling grades on SATs, and antisocial behaviour. A doubling in lead concentration was associated with a 0.3 point (95% CI -0.5 to -0.1) decline in SATs grades. Treating lead levels categorically, with the reference group 0-2 microg/dl, no effects on outcomes were apparent at 2-5 microg/dl, but levels of 5-10 microg/dl were associated with a reduction in scores for reading (OR 0.51, p = 0.006) and writing (OR 0.49, p = 0.003). Lead levels >10 microg/dl were also associated with increased scores for antisocial behaviour (OR 2.9, p = 0.040) and hyperactivity (OR 2.82, p = 0.034).

CONCLUSIONS

Exposure to lead early in childhood has effects on subsequent educational attainment, even at blood levels below 10 microg/dl. These data suggest that the threshold for clinical concern should be reduced to 5 microg/dl.

Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: unmatched case-control study

OBJECTIVE

To determine the risk factors for neonatal encephalopathy among term infants in a developing country.

DESIGN

Unmatched case-control study.

SETTING

Principal maternity hospital of Kathmandu, Nepal.

SUBJECTS

All 131 infants with neonatal encephalopathy from a population of 21 609 infants born over an 18 month period, and 635 unmatched infants systematically recruited over 12 months.

MAIN OUTCOME MEASURES

Adjusted odds ratio estimates for antepartum and intrapartum risk factors.

RESULTS

The prevalence of neonatal encephalopathy was 6.1 per 1,000 live births of which 63% were infants with moderate or severe encephalopathy. The risk of death from neonatal encephalopathy was 31%. The risk of neonatal encephalopathy increased with increasing maternal age and decreasing maternal height. Antepartum risk factors included primiparity (odds ratio 2.0) and non-attendance for antenatal care (2.1). Multiple births were at greatly increased risk (22). Intrapartum risk factors included non-cephalic presentation (3.4), prolonged rupture of membranes (3.8), and various other complications. Particulate meconium was strongly associated with encephalopathy (18). Induction of labour with oxytocin was associated with encephalopathy in 12 of 41 deliveries (5.7). Overall, 78 affected infants (60%) compared with 36 controls (6%) either had evidence of intrapartum compromise or were born after an intrapartum difficulty likely to result in fetal compromise. A concentration of maternal haemoglobin of less than 8.0 g/dl in the puerperium was significantly associated with encephalopathy (2.5) as was a maternal thyroid stimulating hormone concentration greater than 5 mIU/l (2.1).

CONCLUSIONS

Intrapartum risk factors remain important for neonatal encephalopathy in developing countries. There is some evidence of a protective effect from antenatal care. The use of oxytocin in low income countries where intrapartum monitoring is suboptimal presents a major risk to the fetus. More work is required to explore the association between maternal deficiency states and neonatal encephalopathy.

Invasive infection due to penicillium species other than P. marneffei

Infection caused by Penicillium spp. due to species other than P. marneffei is rare. We present three such cases of invasive disease. The first had chronic granulomatous disorder (CGD) with pulmonary infection caused by Penicillium spp. and he responded to amphotericin B therapy. Cases two and three were not known to be immunocompromised and both failed to respond to therapy. Case two had cerebral disease from an unknown source caused by P. chrysogenum. Case three probably acquired infection caused by P. decumbens peri-operatively and presented with paravertebral infection. The pertinent literature on invasive infections of Penicillium spp. other than P. marneffei is reviewed. From 1951 onwards, 31 reported cases of invasive disease included 12 cases of pulmonary infection (six in non-immunocompromised patients), four cases of prosthetic valve endocarditis, six cases of CAPD peritonitis, five cases of endophthalmitis, individual cases of fungemia and oesophagitis (both in AIDS), upper urinary tract infection and intracranial infection. Trauma, surgery or prosthetic material is commonly implicated in the non-pulmonary cases. Superficial infection (keratitis and otomycosis) is commonly caused by Penicillium spp. Allergic pulmonary disease, often occupational (such as various cheeseworkers' diseases), is also common. Optimal therapy for invasive infection is not established, but surgery may be advisable if possible. Amphotericin B may be the most effective antifungal drug.

The effect of birth weight and feeding of supplemental milk replacer to piglets during lactation on preweaning and postweaning growth performance and carcass characteristics

The effects of piglet birth weight and liquid milk replacer supplementation of piglets during lactation on growth performance to slaughter weight was evaluated in a study carried out with 32 sows (PIC C-22) and their piglets (n = 384; progeny of PIC Line 337 sires). A randomized block design with a 2 x 2 factorial arrangement of treatments was used. Treatments were birth weight (Heavy vs Light) and liquid milk replacer (Supplemented vs Unsupplemented). The study was divided into two periods. At the start of period 1 (birth to weaning), pigs were assigned to either Heavy or Light (1.8 [SD = 0.09] vs 1.3 kg [SD = 0.07] BW, respectively, P < 0.001) litters of 12 pigs and half of the litters were given ad libitum access to supplemental milk replacer from d 3 of lactation to weaning (21 +/- 0.2 d). In period 2 (weaning to 110 kg BW), a total of 308 pigs were randomly selected from within previous treatment and sex subclasses and placed in pens of four pigs. Pigs were given ad libitum access to diets that met or exceeded nutrient requirements. Pigs in heavy litters were heavier at weaning (6.6 vs 5.7 kg BW; SE = 0.14; P < 0.001) and tended to have more pigs weaned (11.4 vs 10.9 pigs/litter; SE = 0.21; P = 0.10). After weaning, pigs in the Heavy litter had greater ADG (851 vs 796 g; SE = 6.7; P < 0.001) and ADFI (1,866 vs 1,783 g; SE = 17.6; P < 0.001), similar gain:feed (0.46 vs 0.45; SE = 0.003; P > 0.05), and required seven fewer days (P < 0.001) to reach slaughter weight compared to pigs in the Light treatment. Feeding supplemental milk replacer during lactation produced heavier pigs at weaning (6.6 vs 5.7 kg BW; SE = 0.14; P < 0.001) and tended to increase the number of pigs weaned (11.4 vs 10.9 pigs/litter; SE = 0.21; P = 0.10) but had no effect (P > 0.05) on growth performance from weaning to slaughter. However, pigs fed milk replacer required three fewer days (P < 0.01) to reach 110 kg BW. Sow feed intake and BW loss during lactation were not affected (P > 0.05) by either birth weight or milk replacer treatment. In conclusion, birth weight has a substantially greater impact on pig growth performance after weaning than increasing nutrient intake during lactation.

Does Supervised Exercise Offer Adjuvant Benefit Over Exercise Advice Alone for the Treatment of Intermittent Claudication? A Randomised Trial

OBJECTIVE

Exercise advice is the main treatment for symptom relief in the UK for patients with mild to moderate Intermittent Claudication (IC). Would a weekly exercise and motivation class for 6 months offer adjuvant benefit over written and verbal exercise advice alone?

PATIENTS AND METHODS

Fifty-nine patients attending a regional vascular centre for whom IC was the main factor affecting mobility were randomised to either exercise advice alone (n=30) or exercise advice with a once a week 45 min supervised exercise/motivation class (n=29). The mean age was 68 years. Baseline and 6-month assessment included a Quality of Life Questionnaire--the Short-Form-36, the Charing Cross Symptom Specific Claudication Questionnaire (CCCQ) and treadmill walking distance (3.5 km/h 12%).

RESULTS

At 6-month follow-up the supervised exercise group had improved their treadmill walking by 129% compared to 69% in the advice alone group (p=0.001). This significant improvement was maintained at the subsequent 9 and 12-month follow-up assessments. By the 9-month stage the advice only group CCCQ score had improved 16% from baseline, while the supervised exercise group had a significantly better 43% improvement in base line score (p<0.05). Self reported frequency of walks was higher in the exercise class group being significant for improvement in CCCQ score.

CONCLUSION

A weekly, supervised exercise and motivation class for a 6-month period provides a significant improvement in patients' symptoms, quality of life, and distance walked compared with advice alone and this improvement continues after attendance at class has ceased.