Measures of Psychological Impacts of Stuttering in Young School-Age Children: A Systematic Review

Purpose Recent research has shown that some school-age children who stutter may have speech-related anxiety. Given this, speech-language pathologists require robust measures to assess the psychological effects of stuttering during the school-age years. Accordingly, this systematic review aimed to explore available measures for assessing the psychological impacts of stuttering in young school-age children and to examine their measurement properties. Method The systematic search protocol was registered with PROSPERO (ID: 163181). Seven online databases, in addition to manual searching and screening of reference lists, were used to identify appropriate measures for the population of children who stutter aged 7-12 years. The first two authors independently assessed the measures using the quality appraisal tool described by Terwee et al. (2007). Results Despite the comprehensive search strategy, only six measures were identified for quality appraisal. No assessment tool was found to possess adequate measurement properties for the eight assessed domains: content validity, internal consistency, construct validity, reproducibility, reliability, responsiveness, floor and ceiling effects, and interpretability. No measure had clear evidence of responsiveness to clinical change. Based on the criterion defined by the Terwee et al. (2007) appraisal tool, the Communication Attitude Test and the Overall Assessment of the Speaker's Experience of Stuttering for School-Age Children received the highest number of ratings in support of their measurement properties. Conclusions The results highlight a lack of available measures in this domain and poor practices in developing and testing measurement instruments. To ensure that clinicians and researchers are equipped with sound measures to meet the mental health needs of this vulnerable population, further research to establish resources is needed.

Abstract P1-19-02: Innovation in diagnosis and treatment of brain metastases using multifunctional nanomedicines

Systemic therapies have limited efficacy against brain metastases, largely because passive delivery of naked compounds via the bloodstream does not achieve sufficiently high or evenly dispersed intratumoural concentrations. Heterogeneous tissue architecture, abnormal perfusion, hypoxic zones and high interstitial fluid pressure are key factors limiting drug delivery, compounded by patchy blood-tumour-barrier permeability. Also, brain metastases are usually detected late, once patients become symptomatic. We are investigating whether engineered biopharmaceuticals might improve diagnostic sensitivity for earlier detection, as well as therapeutic efficacy and side-effect profiles of existing agents through active tumour targeting, delayed clearance and microenvironment-mediated activation. This study is proceeding with parallel preclinical and clinical tracks.

Preclinical aims: (1) Develop and characterise monoclonal antibody (mAb) fragments (scFvs) that target the brain metastasis markers HER2 and HER3; (2) Functionalise polyethylene glycol (PEG)-based nanocarriers with the scFvs, along with imaging agents to facilitate in vivoand ex vivoanalysis of tissue distribution; (3) Functionalise HER2/3-targeted carriers with doxorubicin via an acid-labile hydrazone bond for release in hypoxic environments, or the endosome compartment after internalization. Results to date. His-tagged HER2- and HER3-targeted scFvs based on ligand-binding sequences of clinically-approved mAbs were expressed and purified from Expi293 suspension cultures. Binding affinities are an order of magnitude stronger than parent mAbs (KD 2-8x10E-11M), determined using surface plasmon resonance analysis. The scFvs are cytostatic and moderately cytotoxic in vitro, with IC50s in order of 0.4-1.0μM. HER2 and HER3 scFvs exhibited dose-dependent, additive growth inhibition when used in combination, and induced internalisation of their receptor ligands within 4 hours in SKBr3 cells. Conclusions.The scFvs are strong carrier-tethering candidates in terms of both extracellular and intracellular payload release. Carrier synthesis is currently underway and preliminary in vivo data will be presented.

Clinical aims: (1) Develop and characterise 89Zirconium-labelled HER2-targeted PET tracers based on parent mAb and scFv; (2) Compare uptake and retention of the tracers in breast cancer patients with brain metastases; (3) Computationally relate tumour uptake to the administered dose, perfusion, tumour size and HER2 expression; (4) Determine the uptake range within and between patients, and the minimum size for reliable detection. Results to date. The mAb tracer has been synthesised, characterised and labelling processes scaled for clinical production. It is stable in physiologic conditions, retains HER2-binding activity and has a favourable biodistribution profile in NOD-SCID mice bearing BT474 xenografts. Conclusions. Australian regulatory approvals are in place and recruitment for the mAb imaging trial ("BoNSAI") has begun. Preliminary data will be presented.

Citation Format: Saunus JM, Lim M, Puttick S, Kalita-de Croft P, Houston ZH, Jones ML, Latter MJ, Campbell LC, Thomas P, Jeffree RL, Rose SE, Mahler SM, Thurecht KJ, Scott AM, Lakhani SR. Innovation in diagnosis and treatment of brain metastases using multifunctional nanomedicines [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-19-02.

Automated detection of fluorescent cells in in-resin fluorescence sections for integrated light and electron microscopy

Integrated array tomography combines fluorescence and electron imaging of ultrathin sections in one microscope, and enables accurate high-resolution correlation of fluorescent proteins to cell organelles and membranes. Large numbers of serial sections can be imaged sequentially to produce aligned volumes from both imaging modalities, thus producing enormous amounts of data that must be handled and processed using novel techniques. Here, we present a scheme for automated detection of fluorescent cells within thin resin sections, which could then be used to drive automated electron image acquisition from target regions via 'smart tracking'. The aim of this work is to aid in optimization of the data acquisition process through automation, freeing the operator to work on other tasks and speeding up the process, while reducing data rates by only acquiring images from regions of interest. This new method is shown to be robust against noise and able to deal with regions of low fluorescence.

Mineral Composition of Uroliths Obtained from Sheep and Goats with Obstructive Urolithiasis

Background

Knowledge of the mineral composition of the causative urolith is important to develop preventative strategies. Advances in analytic techniques have led to detection of urolith components not previously recognized.

Hypothesis/Objectives

The objectives of this study were to characterize uroliths in sheep and goats structurally and clinically. We hypothesized that amorphous magnesium calcium phosphate (AMCP) would be a naturally occurring urolith type in sheep and goats.

Animals

Forty‐nine sheep and goats presenting for obstructive urolithiasis from June 15, 2014 through June 14, 2016 were reviewed along with the demographic data of all small ruminants admitted during that same period.

Methods

Medical records were reviewed for demographic and historical data, and 36 uroliths obtained from these cases during diagnostic or therapeutic procedures were analyzed by infrared spectroscopy to determine chemical composition.

Results

AMCP is a naturally occurring urolith type in obstructed male sheep and goats and was the most common urolith type in this study, where it occurred as a majority component with struvite (39% of uroliths) or as a pure component (11%). Pure struvite was found in 1 urolith (2%). Calcium carbonate was the second most frequent urolith with 31% of uroliths being pure calcium carbonate.

Conclusions and Clinical Importance

This study demonstrates that uroliths, which appear consistent with struvite, could actually be calcium‐containing AMCP. Urolith analysis is critical in determining mineral content of uroliths to guide dietary recommendations for prevention.

Immunosuppressive human anti-CD83 monoclonal antibody depletion of activated dendritic cells in transplantation

Current immunosuppressive/anti-inflammatory agents target the responding effector arm of the immune response and their nonspecific action increases the risk of infection and malignancy. These effects impact on their use in allogeneic haematopoietic cell transplantation and other forms of transplantation. Interventions that target activated dendritic cells (DCs) have the potential to suppress the induction of undesired immune responses (for example, graft versus host disease (GVHD) or transplant rejection) and to leave protective T-cell immune responses intact (for example, cytomegalovirus (CMV) immunity). We developed a human IgG1 monoclonal antibody (mAb), 3C12, specific for CD83, which is expressed on activated but not resting DC. The 3C12 mAb and an affinity improved version, 3C12C, depleted CD83(+) cells by CD16(+) NK cell-mediated antibody-dependent cellular cytotoxicity, and inhibited allogeneic T-cell proliferation in vitro. A single dose of 3C12C prevented human peripheral blood mononuclear cell-induced acute GVHD in SCID mouse recipients. The mAb 3C12C depleted CMRF-44(+)CD83(bright) activated DC but spared CD83(dim/-) DC in vivo. It reduced human T-cell activation in vivo and maintained the proportion of CD4(+) FoxP3(+) CD25(+) Treg cells and also viral-specific CD8(+) T cells. The anti-CD83 mAb, 3C12C, merits further evaluation as a new immunosuppressive agent in transplantation.

Lactobacillus fermentum NCIMB 5221 and NCIMB 2797 as cholesterol-lowering probiotic biotherapeutics: in vitro analysis

Cardiovascular and coronary artery disease risk are correlated with cholesterol levels and are significant health concerns. Current cholesterol-lowering approaches includes lifestyle and diet modifications, as well as statins which presents numerous shortcomings. The probiotic bacteria, Lactobacillus fermentum NCIMB 5221 and NCIMB 2797, have demonstrated cholesterol-lowering potential in animal studies. However, there is a lack in understanding the mechanism(s) behind these observed effects. The goal of this work is to investigate, in vitro, the cholesterol-lowering mechanisms of these two strains. To determine the cholesterol-lowering mechanisms, probiotic cholesterol assimilation, colon epithelial adhesion and inhibition of cholesterol uptake by colon epithelial (Caco-2) cells were investigated. L. fermentum NCIMB 2797 (P=0.012) and NCIMB 5221 (P=0.003) assimilated cholesterol and their cell surface hydrophobicity was 70.30±8.85% and 55.60±2.59%, respectively. Both L. fermentum strains showed no significant impact (P>0.05) on Caco-2 cell viability. Of most interest, Caco-2 pre-exposure to L. fermentum NCIMB 5221 significantly decreased (P=0.015) cholesterol uptake, with 85.98±2.07% uptake compared to the untreated cells. Similarly, L. fermentum NCIMB 2797 probiotic cells significantly decreased (P=0.019) cholesterol uptake by Caco-2 cells, with 86.45±1.71% uptake observed compared to the control cells. The results demonstrate that L. fermentum NCIMB 5221 and L. fermentum NCIMB 2797 have the potential via various modes of action to lower cholesterol. Additional studies are required to understand the mechanism(s) of action behind probiotic cholesterol assimilation and behind the cholesterol uptake inhibition by colon epithelial cells.

Use of next-generation sequencing and candidate gene analysis to identify underlying defects in patients with inherited platelet function disorders

BACKGROUND

Inherited platelet function disorders (PFDs) are heterogeneous, and identification of the underlying genetic defects is difficult when based solely on phenotypic and clinical features of the patient.

OBJECTIVE

To analyze 329 genes regulating platelet function, number, and size in order to identify candidate gene defects in patients with PFDs.

PATIENTS/METHODS

Targeted analysis of candidate PFD genes was undertaken after next-generation sequencing of exomic DNA from 18 unrelated index cases with PFDs who were recruited into the UK Genotyping and Phenotyping of Platelets (GAPP) study and diagnosed with platelet abnormalities affecting either Gi signaling (n = 12) or secretion (n = 6). The potential pathogenicity of candidate gene defects was assessed using computational predictive algorithms.

RESULTS

Analysis of the 329 candidate PFD genes identified 63 candidate defects, affecting 40 genes, among index cases with Gi signaling abnormalities, while 53 defects, within 49 genes, were identified among patients with secretion abnormalities. Homozygous gene defects were more commonly associated with secretion abnormalities. Functional annotation analysis identified distinct gene clusters in the two patient subgroups. Thirteen genes with significant annotation enrichment for 'intracellular signaling' harbored 16 of the candidate gene defects identified in nine index cases with Gi signaling abnormalities. Four gene clusters, representing 14 genes, with significantly associated gene ontology annotations were identified among the cases with secretion abnormalities, the most significant association being with 'establishment of protein localization.'

CONCLUSION

Our findings demonstrate the genetic complexity of PFDs and highlight plausible candidate genes for targeted analysis in patients with platelet secretion and Gi signaling abnormalities.

Rare platelet GPCR variants: what can we learn?

Platelet-expressed GPCRs are critical regulators of platelet function. Pharmacological blockade of these receptors forms a powerful therapeutic tool in the treatment and prevention of arterial thrombosis associated with coronary atherosclerosis and ischaemic stroke. However, anti-thrombotic drug therapy is associated with high inter-patient variability in therapeutic response and adverse bleeding side effects. In order to optimize the use of existing anti-platelet drugs and to develop new therapies, more detailed knowledge is required relating to the molecular mechanisms that regulate GPCR and therefore platelet function. One approach has been to identify rare, function-disrupting mutations within key platelet proteins in patients with bleeding disorders. In this review, we describe how an integrated functional genomics strategy has contributed important structure-function information about platelet GPCRs with specific emphasis upon purinergic and thromboxane A2 receptors. We also discuss the potential implications these findings have for pharmacotherapy and for understanding the molecular basis of mild bleeding disorders.

Effect of castration method on neurohormonal and electroencephalographic stress indicators in Holstein calves of different ages

As public concern for food animal welfare increases, a need to validate objective pain assessment tools exists in order to formulate animal welfare policies and facilitate regulatory approval of compounds to alleviate pain in livestock in the United States. The aims of this study were (1) to compare the physiological response to pain induced by surgical and nonsurgical (band) castration in calves and (2) to elucidate age-related differences in pain response of calves subjected to different castration methods. Seventy-six Holstein bull calves were blocked by age (≤8-wk and ≥6-mo-old) and randomly assigned to 1 of 4 treatment groups: control (n=20), castration by banding (n=18), cut-and-clamp surgical castration (n=20), and cut-and-pull surgical castration (n=18). Measurements included electroencephalogram, heart rate variability, infrared thermography, electrodermal activity, and concentrations of serum cortisol and plasma substance P before, during, and within 20min following castration. Electroencephalogram recordings showed desynchronization for all treatments, consistent with increased arousal; yet the magnitude of desynchronization was greatest for 6-mo-old calves castrated by cut-and-clamp. Additionally, older calves in the cut-and-pull group showed greater desynchronization than younger calves in the same group. Based on the heart rate variability analysis, 6-mo-old calves in the control or cut-and-pull castration groups showed greater sympathetic tone than younger calves in the same treatment groups. Overall, younger calves showed lower electrodermal activity than older calves. Regardless of treatment, concentrations of cortisol and plasma substance P were greater in 6-mo-old calves relative to their younger counterparts, indicating a more robust response to all treatments in older calves. In summary, neurohormonal and electroencephalographic stress responses of calves to castration were age-specific. Castration by cut-and-clamp showed the most pronounced stress response in 6-mo-old calves. These findings provide evidence that support welfare policies recommending castration at an early age and the use of analgesic compounds at the time of surgical castration especially in older calves. However, the potential long-term negative consequences of early untreated pain must be considered and warrant further investigation.

Platelet dysfunction associated with the novel Trp29Cys thromboxane A₂ receptor variant

BACKGROUND

Genetic variations that affect the structure of the thromboxane A2 receptor (TP receptor) provide insights into the function of this key platelet and vascular receptor, but are very rare in unselected populations.

OBJECTIVES

To determine the functional consequences of the TP receptor Trp29Cys (W29C) substitution.

PATIENTS/METHODS

We performed a detailed phenotypic analysis of an index case (P1) with reduced platelet aggregation and secretion responses to TP receptor pathway activators, and a heterozygous TP receptor W29C substitution. An analysis of the variant W29C TP receptor expressed in heterologous cells was performed.

RESULTS

Total TP receptor expression in platelets from P1 was similar to that of controls, but there was reduced maximum binding and reduced affinity of binding to the TP receptor antagonist [(3) H]SQ29548. HEK293 cells transfected with W29C TP receptor cDNA showed similar total TP receptor expression to wild-type (WT) controls. However, the TP receptor agonist U46619 was less potent at inducing rises in cytosolic free Ca(2+) in HEK293 cells expressing the W29C TP receptor than in WT controls, indicating reduced receptor function. Immunofluorescence microscopy and cell surface ELISA showed intracellular retention and reduced cell surface expression of the W29C TP receptor in HEK293 cells. Consistent with the platelet phenotype, both maximum binding and the affinity of binding of [(3) H]SQ29548 to the W29C TP receptor were reduced compared to WT controls.

CONCLUSION

These findings extend the phenotypic description of the very rare disorder TP receptor deficiency, and show that the W29C substitution reduces TP receptor function by reducing surface receptor expression and by disrupting ligand binding.

Bilateral buphthalmia in a 4-month-old Texas longhorn steer

Congenital ocular disease occurs uncommonly in cattle, with multiple abnormalities reported only sporadically in the literature. This report describes a case of anterior segment dysgenesis resulting in glaucoma in a 4-month-old Texas Longhorn steer. On clinical exam, bilateral buphthalmia was present and intraocular pressures exceeded 47 mm Hg in both eyes. On histopathologic examination, the iridocorneal angle and filtration apparatus were distorted due to collapse of the ciliary cleft and anterior displacement of the anterior portion of the ciliary body. No evidence of inflammation or other causes of glaucoma were recognized.

Effect of nitrogen supplementation and zilpaterol-HCl on urea kinetics in steers consuming corn-based diets

We studied effects of zilpaterol-HCl on steers consuming corn-based diets with nitrogen (N) supplementation provided by dried distillers grains with solubles (DDGS) or urea. Two sets of six steers (approximately 350 kg) were used in two replicates of similarly designed trials. Within each replicate, three steers were fed 60 mg/day of zilpaterol-HCl throughout the trial and three steers received no zilpaterol-HCl. Within zilpaterol treatment, three corn-based dietary N treatments were offered in Latin square designs: control (9.6% crude protein), urea (UREA; 12.4% crude protein) or DDGS (13.7% crude protein). Total feed intake was unexpectedly greater (p < 0.01) with zilpaterol feeding but was not affected by dietary N (p = 0.76). Nitrogen intake was greater (p < 0.01) when zilpaterol was fed and was greater (p < 0.05) for DDGS and UREA than for control. Despite greater N intake, zilpaterol did not affect urea entry rate (p = 0.80) or urea-N recycled to the gastrointestinal tract (GER; p = 0.94). As a percentage of N intake, urea entry rate (p = 0.19) tended to be less when zilpaterol was fed (91 vs. 123% of N intake), and GER was numerically (p = 0.34) less (72 vs. 92% of N intake). Microbial N flow was greater (p = 0.02) for zilpaterol than for control but did not differ (p = 0.78) among dietary N treatments. As a percentage of N intake, microbial N flow was unaffected by zilpaterol (p = 0.97), but was greater (p < 0.05) for control than DDGS or UREA. The lack of change in urea entry and GER in response to zilpaterol, despite greater N intake, as well as lower urea entry and GER when expressed as proportions of N intake provide some evidence that the amount of N available for urea production and recycling was reduced by zilpaterol.

Hemoglobin Kinetics of the Galapagos Rift Vent Tube Worm Riftia pachyptila Jones (Pogonophora; Vestimentifera)

Kinetics of the reactions of Riftia pachyptila hemoglobin with oxygen were followed spectrophotometrically by stopped-flow and laser flash photolysis techniques. The rate of oxygen dissociation increases eightfold over the range of 5 degrees to 20 degrees C (k = 2.2 sec(-1)at 10 degrees C). Oxygen recombination after flash photolysis was biphasic. The rates of both slow and fast phases of the reaction were independent of temperature from 0 degrees to 20 degrees C(k'fast = 7 x 10(6); k'slow = 1 x 16(6) liter mole (-1) sec(-1)). As the oxygen affinity is relatively temperature independent, analysis in terms of the two-state model of cooperativity requires that the conformational equilibrium constant L decrease by about 50-fold between 3 degrees and 15 degrees C.

Prokaryotic Cells in the Hydrothermal Vent Tube Worm Riftia pachyptila Jones: Possible Chemoautotrophic Symbionts

The existence of a symbiotic association between vestimentiferan tube worms from deep-sea hydrothermal vents and chemoautotrophic sulfur-oxidizing prokaryotes, based on histological and enzymatic evidence, is suggested.

RGD-ligand mimetic antagonists of integrin alphaIIbbeta3 paradoxically enhance GPVI-induced human platelet activation

BACKGROUND

The integrin alpha(IIb)beta(3) is the major mediator of platelet aggregation and has, therefore, become an important target of antithrombotic therapy. Antagonists of alpha(IIb)beta(3), for example abciximab, tirofiban and eptifibatide, are used in the treatment of acute coronary syndromes. However, in addition to effective blockade of the integrin, binding of can induce conformational changes in the integrin and can also induce integrin clustering. This class effect of RGD-ligand mimetics might, therefore, underlie paradoxical platelet activation and thrombosis previously reported.

OBJECTIVES

To examine the components of signaling pathways and functional responses in platelets that may underlie this phenomenon of paradoxical platelet activation.

METHODS

We assessed the effect of lotrafiban, and other alpha(IIb)beta(3) antagonists including the clinically used drug tirofiban, on tyrosine phosphorylation of key signaling proteins in platelets by immunoblotting and also platelet functional outputs such as cytosolic calcium responses, phosphatidylserine exposure (pro-coagulant activity) and dense granule release.

RESULTS

In all cases, no effect of alpha(IIb)beta(3) antagonists were observed on their own, but these integrin antagonists did lead to a marked potentiation of glycoprotein VI (GPVI)-associated FcR gamma-chain phosphorylation, activation of Src family kinases and Syk kinase. This correlated with increased dense granule secretion, cytosolic calcium response and exposure of phosphatidylserine on the platelet surface. P2Y(12) antagonism abolished the potentiated phosphatidylserine exposure and dense granule secretion but not the cytosolic calcium response.

CONCLUSIONS

These data provide a mechanism for enhancement of platelet activity by alpha(IIb)beta(3) inhibitors, but also reveal a potentially important signaling pathway operating from the integrin to GPVI signaling.

How formalin affects the outcome of routine and special stains

The discovery of formaldehyde for preserving tissue structures produced a new dimension in microscopy. Preserving structure and morphology became important; therefore, identifying a proper fixing agent for particular structures, chemical entities, and tissues, also became important. The methods for demonstrating tissue structures evolved and were implemented with careful observation and documentation of the results and outcomes. Formalin was incorporated into many techniques, and provided helpful results in many cases and hindrances in others. The effects of formalin on the outcomes of routine and special staining techniques are reported here.

Quality assurance and benchmarking: an approach for European dental schools

This document was written by Task Force 3 of DentEd III, which is a European Union funded Thematic Network working under the auspices of the Association for Dental Education in Europe (ADEE). It provides a guide to assist in the harmonisation of Dental Education Quality Assurance (QA) systems across the European Higher Education Area (EHEA). There is reference to the work, thus far, of DentEd, DentEd Evolves, DentEd III and the ADEE as they strive to assist the convergence of standards in dental education; obviously QA and benchmarking has an important part to play in the European HE response to the Bologna Process. Definitions of Quality, Quality Assurance, Quality Management and Quality Improvement are given and put into the context of dental education. The possible process and framework for Quality Assurance are outlined and some basic guidelines/recommendations suggested. It is recognised that Quality Assurance in Dental Schools has to co-exist as part of established Quality Assurance systems within faculties and universities, and that Schools also may have to comply with existing local or national systems. Perhaps of greatest importance are the 14 'requirements' for the Quality Assurance of Dental Education in Europe. These, together with the document and its appendices, were unanimously supported by the ADEE at its General Assembly in 2006. As there must be more than one road to achieve a convergence or harmonisation standard, a number of appendices are made available on the ADEE website. These provide a series of 'toolkits' from which schools can 'pick and choose' to assist them in developing QA systems appropriate to their own environment. Validated contributions and examples continue to be most welcome from all members of the European dental community for inclusion at this website. It is realised that not all schools will be able to achieve all of these requirements immediately, by definition, successful harmonisation is a process that will take time. At the end of the DentEd III project, ADEE will continue to support the progress of all schools in Europe towards these aims.

Economic modelling of different treatment strategies for haemophilia A with high-responding inhibitors

This paper reports a systematic review of the cost-effectiveness of treatment options in patients with haemophilia A with inhibitors. As very little relevant published evidence was identified, an economic modelling exercise was undertaken to calculate the cost-effectiveness of different strategies in the treatment of high-responding haemophilia A patients with inhibitors. A decision analysis approach was used to model the expected lifetime clinical outcomes and costs of the more common regimens currently used in UK in treating severe haemophiliacs with inhibitors. The model attempts to reflect the outcomes of clinical events, costs and life expectancy for each different treatment regimen for haemophilic boys with inhibitors who are high responders (defined as inhibitor level >/=10 BU) throughout their life. The basic model structure is centred on a Markov decision process, which was used to simulate, at quarter-yearly intervals, the movement through discrete health states and their complications. The model allows a comparison of cost-effectiveness between three immune tolerance induction (ITI) regimens (Bonn, Mälmo and Low-Dose protocols) and against a relevant 'on-demand' (OD) regimen. It also shows the cost-effectiveness of different OD regimens using different bypassing agents. The results of the economic modelling indicate that treating haemophilia A patients who have high-responding inhibitors OD with recombinant activated factor VII is cost-effective compared to treatment with activated prothrombin complex concentrates. However, when OD treatment regimens are compared with the three ITI protocols, the Malmö ITI protocol is the preferred treatment strategy, generating more quality adjusted life-years (QALYs) and less cost than either an OD regimen or the Bonn or Low-Dose ITI protocols.

Phospholipase C isoforms in mammalian spermatozoa: potential components of the sperm factor that causes Ca2+ release in eggs

Injection of a soluble protein factor from mammalian spermatozoa triggers Ca2+ oscillations in mammalian eggs similar to those seen at fertilization. This sperm factor also generates inositol 1,4,5-trisphosphate and causes Ca2+ release in sea urchin egg homogenates and frog eggs. Recent studies have indicated that the sperm factor may be an inositol-specific phospholipase C (PLC) activity. This study investigated whether any of the commonly known PLC isoforms are components of the sperm factor. PLCbeta, PLCgamma and PLCdelta isoforms were shown to be present in boar sperm extracts. However, upon column fractionation of sperm extracts, none of the PLC isoforms detected correlated with the ability to cause Ca2+ release in eggs. In addition to our previous work on recombinant PLCs, it was also shown that PLCdelta3, PLCdelta4 and its splice variant PLCdelta4 Alt1 fail to cause Ca2+ release. The recently discovered 255 kDa PLCepsilon isoform also appears unlikely to be a component of the sperm factor, as fractionation of sperm extracts on a gel filtration column demonstrated that the peak of Ca2+-releasing activity was associated with fractions of 30-70 kDa. These findings indicate that the sperm factor that triggers Ca2+ release in eggs does not appear to have a known PLC isoform as one of its components.

A systematic review of the clinical effectiveness of pioglitazone in the treatment of type 2 diabetes mellitus

BACKGROUND

Pioglitazone is a member of a recently developed class of glucose-lowering agents, the thiazolidinediones, used in the treatment of type 2 diabetes mellitus. In the United States, it is approved for use both as monotherapy and in combination with metformin, a sulfonylurea, or insulin; in Europe, it is approved for use in combination with metformin or a sulfonylurea but not insulin.

OBJECTIVE

This article presents a systematic review of the published literature on the effectiveness of pioglitazone in the treatment of type 2 diabetes, both as monotherapy and in combination with other antidiabetic agents.

METHODS

The peer-reviewed English- and foreign-language literature was searched using MEDLINE, PubMED, EMBASE, Science Citation Index, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register, the UK National Health Service Centre for Reviews and Dissemination databases, and the Office of Health Economics Health Economic Evaluations Database. Searches were not limited to specific publication types, study designs, dates, or languages. The latest search was performed in March 2001. For a trial to be included in the review, at least 1 outcome measure had to involve the effects of pioglitazone on glycemic control or cardiovascular risk factors, or its side effects. Because of the heterogeneity of studies, no formal meta-analysis was performed.

RESULTS

Eleven studies met the inclusion criteria, 6 involving pioglitazone monotherapy and 5 involving combination therapy. Full reports were available for only 6 of the 11 studies. No studies directly compared pioglitazone with other antidiabetic drugs. Both as monotherapy and in combination therapy, pioglitazone produced decreases in blood glucose levels (up to 95 mg/dL) and glycosylated hemoglobin (up to 2.6%). At doses of > or = 30 mg/d, pioglitazone was associated with reductions in triglyceride levels (-30-70 mg/dL) and increases in high-density lipoprotein cholesterol (HDL-C) levels (-4-5 mg/dL). Pioglitazone treatment was associated with significant weight gain (up to 4 kg over 16 weeks). Adverse effects included mild edema (in up to 11.7% of patients) and a clinically nonsignificant decrease in hemoglobin concentrations. Abnormal results on liver function testing were no more common in treated patients than in control groups.

CONCLUSIONS

Pioglitazone has been shown to reduce blood glucose levels in patients with type 2 diabetes. Although the observed decreases in triglyceride levels and increases in HDL-C levels could be expected to lead to a reduction in cardiovascular risk, the effects of weight gain may counteract this benefit. The evidence suggests that the preferred role for pioglitazone may be as an adjunct to metformin or a sulfonylurea in patients whose condition is not well controlled with monotherapy and for whom a metformin-sulfonylurea combination is contraindicated. There is a need for large-scale, long-term studies comparing the effectiveness of combination therapy that includes pioglitazone with that of other combinations of antidiabetic drugs.

The Balanced Scorecard: a strategic management system for multi-sector collaboration and strategy implementation

This article illustrates the application of the Balanced Scorecard, a method more commonly associated with the business world, to a nonprofit multisector National Women's Health Quality Initiative (NWHQI). The article delineates the following multiple uses of the Balanced Scorecard for the NWHQI effort: Set NWHQI strategy and structure. Provide the framework and principles to implement NWHQI's strategy. Develop a measurement system to assess the progress and success of NWHQI's strategy. Serve as a collaboration mechanism for multisector stakeholders. Advance women's health knowledge base. This article concludes by sharing key insights regarding the utility of the Balanced Scorecard to promote the success of this nationwide women's health quality initiative.

Implementation and outcomes of a balanced scorecard model in women's services in an academic health care institution

In the current, chaotic health care climate an important success determinant for health care administrators and clinicians is the support of timely, collaborative decisions for delivery of patient care. The purpose of this article is to describe implementation and outcomes of the application of the Balanced Scorecard (BSC) model, a strategic management system, for a Women's Services Clinical Business Unit (CBU) in an academic health care institution, a complex adaptive system. Emphasis is focused on crucial process and outcome indicators that demonstrate how the work of all team members makes a difference at the point of clinical services across the continuum. Finally, implications for leadership development are revealed from the principles underlying complexity science.

Induction of abnormal Chlamydia trachomatis by exposure to interferon-gamma or amino acid deprivation and comparative antigenic analysis

Abnormal forms of Chlamydia trachomatis have been induced in vitro by a variety of methods including nutrient deprivation, addition of cytokines and addition of antibiotics. These forms have been shown to have altered morphology and infectivity and have been implicated in persistent infections in vivo although there is little direct evidence for their presence. Likely sites for abnormal forms in vivo are the genital tract and the synovial tissue of reactive arthritis patients, and T cells isolated from the synovial tissue have been shown to be specific for chlamydial antigens, in particular the Hsp60. Since T cell specificity is so important in reactive arthritis disease the antigenic composition of abnormal forms induced by Interferon-gamma and amino acid deprivation has been examined by western blotting in two strains of C. trachomatis belonging to different biovars. The degree of abnormality of the organisms was found to increase as the treatments became more severe. No simple patterns of antigenic changes were found and differences in the antigenic composition were seen in abnormal forms induced by the different treatments and also in the different strains.

An evaluation of the quality of orthodontic attachment offered by single- and double-mesh bracket bases using the finite element method of stress analysis

The objective of this study was to evaluate the influence of bracket base mesh geometry on the stresses generated in the bracket-cement-tooth continuum by a shear/peel load case. A validated three-dimensional finite element model of the bracket-cement-tooth system was constructed consisting of 15,324 nodes and 2971 finite elements. Cement geometric and physical properties were held constant and bracket base geometry was varied, representing a variety of single-mesh configurations and 1 double-mesh design. For the single-mesh designs, increasing wire diameter (100-400 microm) resulted in a decrease in enamel and cement stresses. Increases in wire mesh spacing (200-750 microm) increased the major principal stress recorded in the enamel and adhesive at all wire diameters. Within the bracket, the major principal stress increased significantly at wire spacing above 400-500 microm. However, within the impregnated wire mesh (IWM), the major principal stress decreased as wire space increased. When the double-mesh bracket base was considered, the combined mesh layers resulted in a decrease in the stresses recorded in the most superficial (coarse) mesh layer and an increase in the stresses recorded in the deepest (fine mesh) layer when compared with the single-layer designs in isolation. Modification of single-mesh spacing and wire diameter influences the magnitude and distribution of stresses within the bracket-cement-tooth continuum. The use of a double-mesh design results in a reduction in the stresses recorded in the most superficial mesh. Mesh design influenced stress distribution in this study, primarily by determining the flexibility of the bracket base.

A validated finite element method study of orthodontic tooth movement in the human subject

The aim of the study was to develop a 3D computer model of the movement of a maxillary incisor tooth when subjected to an orthodontic load. A novel method was to be developed to directly and accurately measure orthodontic tooth movement in a group of human volunteers. This was to be used to validate the finite element-based computer model. The design took the form of a prospective experiment at a laboratory at the University of Wales in 1996/7. A laser apparatus was used to sample tooth movement every 0.01 seconds over a 1-minute cycle for 10 healthy volunteers, whilst a constant 0.39 N load was applied. This process was repeated on eight separate occasions and the most consistent five readings taken for each subject. Data were used to calculate the physical properties of the periodontal ligament (PDL). The data gleaned by this method were used to validate the 3D FEM model. This was formed of 15,000 four-noded tetrahedral elements. Tooth displacements ranged from 0.012 to 0.133 mm. An appropriate elastic modulus of 1 N/mm(2) and Poisson's Ratio of 0.45 was derived for the PDL. Strain analysis, using the model, suggested that a maximum PDL strain of 4.77 x 10(-3) was recorded at the alveolar crest, while the largest apical strain recorded was 1.55 x 10(-3). The maximum strains recorded in the surrounding alveolar bone were 35 times less than for the PDL. A novel method for direct measurement of PDL physical properties in the human subject has been developed. The validated FEM model lends further evidence that the PDL is the main mediator of orthodontic tooth movement.

An evaluation of the influence of orthodontic adhesive on the stresses generated in a bonded bracket finite element model

The objective of this study was to evaluate the stresses generated in the bracket-cement-tooth continuum by a tensile load case when the physical and geometric properties of cement are varied. A 2-stage approach was used. In the first stage, a validated 3-dimensional finite element model of the bracket-cement-tooth system was constructed that consisted of 15,324 nodes and 2971 finite elements. Bracket base geometry was held constant; the physical properties (elastic modulus; Poisson's ratio) and geometry (lute thickness) of the cement varied. A simplified 2-dimensional model was then developed to investigate the localized effects of the cement lute thickness and the shape of the lute periphery on the stress distribution in the system. Small increases in stress were recorded under load within the cement as the rigidity of the cement increased. Similarly, Poisson's ratio values above 0.4 appeared to have a small influence on the major principal stresses in the impregnated wire mesh layer when a tensile force was applied. Variation in lute thickness was shown to have an influence on the distribution of major principal stresses within the cement lute. Increased stresses were recorded at the lute periphery as the lute dimensions increased. The morphologic features of the lute periphery also appeared to have had a significant effect on the performance of an orthodontic adhesive. Acute cement-enamel angles resulted in an increased chance of singularity development and attachment failure. The physical properties and thickness of the cement lute and the shape of the cement lute periphery contribute to the stress distribution within the bracket-cement-tooth continuum and, therefore, the quality of orthodontic attachment provided.

Initial experiences with telerehabilitation and contingency management programs for the prevention and management of pressure ulceration in patients with spinal cord injuries

Two alternative treatment methods for preventive interventions for pressure ulcers, tele-rehabilitation and contingency management, are discussed. Telerehabilitation uses a videophone that transmits both audio and still images over a telephone line. Using this technology, the WOC nurse can interview a patient who cannot be present at a clinic because of physical condition or distance. Telerehabilitation allows the nurse to assess a patient's pressure ulcer, consult with appropriate caregivers, and make recommendations for treatment. Contingency management procedures are designed for patients with high rates of noncompliance in skin care. The patients are seen as outpatients and are compensated systematically for appropriate skin care (ie, the lack of pressure ulcers). Examples of each of these patient interventions is described, discussed, and contrasted.

The influence of bracket base design on the strength of the bracket-cement interface

The objectives of the study were to isolate the bracket-cement interface, and to determine the influence of bracket base morphology and orthodontic bonding agent chosen on strength of adhesion. The bracket bases evaluated included 60, 80, and 100 single mesh bases, a double mesh base, and the Dynalock, and Mini Twin bases. The strength of interface provided by each of these bases with Concise, Transbond, Right On, and non-encapsulated Fuji Ortho LC cements, was measured in tension and recorded in Mega Pascals. The single-mesh bases performed well with either Concise or Right On (11*88-22*72 MPa) and, other than the 80-mesh bracket, relatively poorly with Transbond (2*18-5*15 MPa). With Fuji Ortho LC, the single mesh bases performed well (6*05-12*19 MPa). The double mesh base performed well with Right On (13*75 MPa), and reasonably well with Concise, Transbond, and Fuji Ortho LC (6*00-9*20 MPa). The Dynalock and Mini Twin Bases performed fairly well with all cements (8*87-17*16 MPa). It was concluded that the orthodontic bonding agent selected would appear to largely determine the bond strength achieved with a particular bracket base design. A definite trend was difficult to identify in this study, and it appeared that certain combinations of bracket base and bonding agent performed optimally. Particular base designs may allow improved adhesive penetration or improved penetration of curing light. Alternatively, the dimension and distribution of resin/cement tags prescribed by one base could promote a stress distribution that is better resisted by a particular adhesive.

Numerical investigation of fixed orthodontic brackets

This paper presents the results of investigations into the mechanical behaviour of fixed orthodontic brackets. Special attention has been paid to the detailed modelling of the interface between the bracket base and an adhesive by which attachment is made to the tooth surface. Properties of this interface were taken as design parameters with the aim of investigating their influence on the stress field induced during bracket removal at the end of the treatment. Stress-strain analysis was performed using a finite element program developed in-house.

Contextual control over conditioned responding in a latent inhibition paradigm

We used 1-, 2-, and 3-context designs to study the control exerted by contexts over freezing in rats exposed to a conditioned stimulus (CS) in advance of its pairing with a shock unconditioned stimulus. The latent inhibition observed when preexposure, conditioning, and testing occurred in the same context was attenuated if preexposure occurred in a different context to conditioning and testing. Latent inhibition (i.e., attenuated performance) was restored in a CS-specific manner if preexposure and testing occurred in the same context and conditioning in a different one. Latent inhibition was also reduced by a long retention interval but remained specific for a particular context-CS relation. Finally, CS preexposure resulted in contextual control over the expression of excitatory conditioned performance. The results are discussed in terms of memory, associative, and associative-performance models of CS-preexposure effects.

Contextual control over conditioned responding in an extinction paradigm

Four experiments studied contextual control over rats' freezing to conditioned stimuli (CSs) that had been paired with shock and were then extinguished. In Experiment 1, rats were exposed to a CS A-shock and a CS B-shock pairing in Context C. CS A was then extinguished in Context A, and CS B in Context B. Freezing was renewed when each CS was presented in the context where the other CS had been extinguished. In Experiments 2-4, rats were exposed to a CS A-shock pairing in A and a CS B-shock pairing in B. They were then exposed to Context C where one, both, or neither of the CSs were extinguished, or where both CSs continued to be reinforced. On test, the rats froze more to CS A than to CS B in Context A, and more to CS B than to CS A in Context B, but only if the CSs had been extinguished. Thus, after extinction, rats use contexts to regulate retrieval not only of their memory for extinction, but also of their memory for the original conditioning episode.

The influence of orthodontic adhesive properties on the quality of orthodontic attachment

The objective of this study was to determine the resilience, glass transition temperature (Tg), ultimate flexural strength (UFS), and penetration coefficient of 3 composite adhesives (Concise, Transbond, and Right On) and a glass ionomer cement (Fuji Ortho LC). For 25 minutes after initial set, the composite materials were significantly more resilient than Fuji Ortho LC (P = .000). Resilience values for all materials increased for up to 90 minutes after initial set, reflecting a continuation of their setting reaction. Right On remained the most resilient material at 90 minutes after initial set (P < or = .01). At 120 minutes, there was no significant difference in the resilience of Concise, Right On, and Fuji Ortho LC. However, Transbond was significantly less resilient than these materials (P < or = .01). The composite materials recorded significantly higher glass transition values (89-123 degrees C) than Fuji Ortho LC (54 degrees C). The composite materials were also significantly stronger (61-68 MPa) than Fuji Ortho LC (35 MPa) in flexion. The penetration coefficients of Concise and Transbond were significantly higher (P < or = .001) than Right On and Fuji Ortho LC. However, the relative penetration coefficients of the materials studied did not appear to influence the degree of bracket base penetration achieved by the cements. In conclusion, Fuji Ortho LC offered a reduced energy-absorbing capacity immediately after bracket placement and reduced cohesive and mechanical adhesive strength. In addition, the glass transition temperature of Fuji Ortho LC was low; this may result in compromised attachment at temperatures above 60 degrees C. Significant differences in the penetration coefficient of the materials studied have been recorded. However, the penetration of the 4 cements into a range of bracket base morphologies was uniformly good. Therefore, the differences in penetration coefficient recorded should not influence the quality of the bracket cement interface provided.

Endotoxin and nanobacteria in polycystic kidney disease

BACKGROUND

Microbes have been suspected as provocateurs of polycystic kidney disease (PKD), but attempts to isolate viable organisms have failed. Bacterial endotoxin is the most often reported microbial product found in PKD fluids. We assessed potential microbial origins of endotoxin in cyst fluids from 13 PKD patients and urines of PKD and control individuals.

METHODS

Fluids were probed for endotoxin and nanobacteria, a new bacterium, by the differential Limulus Amebocyte Lysate assay (dLAL), genus-specific antilipopolysaccharide (LPS) antibodies, monoclonal antibodies to nanobacteria, and hyperimmune serum to Bartonella henselae (HS-Bh). Selected specimens were also assessed by transmission electron microscopy (TEM) and nanobacterial culture methods.

RESULTS

LPS or its antigenic metabolites were found in more than 75% of cyst fluids tested. Nanobacteria were cultured from 11 of 13 PKD kidneys, visualized in 8 of 8 kidneys by TEM, and immunodetected in all 13 PKD kidneys. By immunodetection, nanobacterial antigens were found in urine from 7 of 7 PKD males, 1 of 7 PKD females, 3 of 10 normal males, and 1 of 10 normal females. "Nanobacterium sanguineum" was dLAL positive and cross-reactive with antichlamydial LPS and HS-Bh. Some cyst fluids were also positive for LPS antigens from Escherichia coli, Bacteroides fragilis and/or Chlamydia, and HS-Bh, as were liver cyst fluids from one patient. Tetracycline and citrate inhibited nanobacterial growth in vitro.

CONCLUSION

Nanobacteria or its antigens were present in PKD kidney, liver, and urine. The identification of candidate microbial pathogens is the first step in ascertaining their contribution, if any, to human disease.

Contextual control over conditioned responding in an extinction paradigm

Four experiments studied contextual control over rats' freezing to conditioned stimuli (CSs) that had been paired with shock and were then extinguished. In Experiment 1, rats were exposed to a CS A-shock and a CS B-shock pairing in Context C. CS A was then extinguished in Context A, and CS B in Context B. Freezing was renewed when each CS was presented in the context where the other CS had been extinguished. In Experiments 2-4, rats were exposed to a CS A-shock pairing in A and a CS B-shock pairing in B. They were then exposed to Context C where one, both, or neither of the CSs were extinguished, or where both CSs continued to be reinforced. On test, the rats froze more to CS A than to CS B in Context A, and more to CS B than to CS A in Context B, but only if the CSs had been extinguished. Thus, after extinction, rats use contexts to regulate retrieval not only of their memory for extinction, but also of their memory for the original conditioning episode.

Contextual control over conditioned responding in a latent inhibition paradigm

We used 1-, 2-, and 3-context designs to study the control exerted by contexts over freezing in rats exposed to a conditioned stimulus (CS) in advance of its pairing with a shock unconditioned stimulus. The latent inhibition observed when preexposure, conditioning, and testing occurred in the same context was attenuated if preexposure occurred in a different context to conditioning and testing. Latent inhibition (i.e., attenuated performance) was restored in a CS-specific manner if preexposure and testing occurred in the same context and conditioning in a different one. Latent inhibition was also reduced by a long retention interval but remained specific for a particular context-CS relation. Finally, CS preexposure resulted in contextual control over the expression of excitatory conditioned performance. The results are discussed in terms of memory, associative, and associative-performance models of CS-preexposure effects.

An evaluation of the stresses generated in a bonded orthodontic attachment by three different load cases using the Finite Element Method of stress analysis

The objective of the investigation was to develop a clinically valid three-dimensional computer model of the orthodontic bracket-cement-tooth continuum, and determine the magnitude and distribution of stresses generated by three different load cases. A three-dimensional finite element model of the bracket-cement-tooth system was constructed consisting of 15,324 nodes and 2,971 finite elements. The stresses induced in the bracket-tooth interface by a masticatory load, a peel force and a twisting couple were recorded. The maximum principal stresses resulting from occlusal and 'twisting' forces are distributed toward the lute periphery. Peel forces, applied to the bracket tie wing, are concentrated beneath the bracket stem. Twisting forces result in the highest enamel stresses. The quality of orthodontic attachment can be explained by the magnitude and distribution of major principal stresses within the cement and impregnated bracket base. Shear and shear/peel forces are most likely to induce crack propagation within the adhesive layer. However, when a twisting action is used to remove orthodontic brackets, enamel failure is most likely. A clearer insight into the complexity of the bracket-cement-tooth system has been provided by numerical and finite element investigations. Further investigations, evaluating the influence of bracket base designs and orthodontic cement physical and geometric properties are indicated. Refereed Scientific Paper

Chlamydial development is adversely affected by minor changes in amino acid supply, blood plasma amino acid levels, and glucose deprivation

This study has demonstrated the extreme sensitivity of Chlamydia trachomatis growing in McCoy cells to small changes in external amino acid supply. In the absence of cycloheximide, a decrease in the amino acid concentration of medium to 75% of control values was sufficient to induce the growth of enlarged chlamydial forms of reduced infectivity. Morphology became more distorted and the yield of infectious particles from inclusions declined as medium amino acid levels were further reduced. These events correlated with a general decline in intracellular amino acids, as measured by high-performance liquid chromatography, suggesting that chlamydiae require a minimum concentration of each amino acid for normal development. Cycloheximide enhanced the production of normal organisms and increased infectivity yield in media, suggesting that the drug increased the available pool of amino acids. This was supported by intracellular amino acid analyses. Aberrant forms with reduced infectivity were also induced during supply of infected cell cultures with medium containing blood plasma amino acid concentrations, supporting the proposal that nutrient levels in vivo could promote abnormal chlamydial development. Markedly abnormal forms were also observed during glucose deprivation, providing further evidence that aberrant development is a general stress-related response.

Do new roles contribute to job satisfaction and retention of staff in nursing and professions allied to medicine?

BACKGROUND

Studies have suggested that job dissatisfaction is a major factor influencing nurses' and occupational therapists' intention to leave their profession. It has also been related to turnover of qualified nurses. However, literature relating to these factors among nurses and professions allied to medicine in innovative roles is scarce.

AIMS

This paper considers the views of 452 nurses and 162 professionals allied to medicine (PAMs) in innovative roles, on job satisfaction, career development, intention to leave the profession and factors seen as hindering and enhancing effective working.

METHODS

A self-completion questionnaire was developed as part of a larger study exploring new roles in practice (The ENRiP Study).

FINDINGS

Overall there was a high level of job satisfaction in both groups (nurses and PAMs). Job satisfaction was significantly related to feeling integrated within the post-holder's own professional group and with immediate colleagues, feeling that the role had improved their career prospects, feeling adequately prepared and trained for the role, and working to protocol. Sixty-eight percent (n = 415) of respondents felt the role had enhanced their career prospects but over a quarter of respondents (n = 163; 27%) said they would leave their profession if they could. Low job satisfaction was significantly related to intention to leave the profession.

CONCLUSIONS

The vast majority of post-holders in innovative roles felt that the role provided them with a sense of job satisfaction. However, it is essential that the post-holders feel adequately prepared to carry out the role and that the boundaries of their practice are well defined. Career progression and professional integration both being associated with job satisfaction.

Implementation of a clinical pathway system in maternal newborn care: a comprehensive documentation system for outcomes management

This article describes the design, implementation, and evaluation of an interdisciplinary clinical pathway system for maternal newborn care in a perinatal regional referral institution. Core issues in the design of this system are addressed to promote outcomes management and ongoing performance improvement. A discussion of the implementation follows, illustrating the lessons learned, changes made, and associated evaluation. This clinical pathway system has improved communication and collaboration among all disciplines, enhanced the discharge coordination process, and established protocols available to all members of the health care team.

A clinical pathway system for the neonatal intensive care nursery

Health care reform, managed care, and the current outcomes movement have generated a rapid acceleration toward the development and implementation of clinical pathways in the field of neonatology. This article describes the design, implementation, and evaluation of an interdisciplinary clinical pathway system for a neonatal intensive care nursery. This neonatal clinical pathway is a clinical tool that delineates practice guidelines for each discipline that provides care to a specific infant population. It has reduced variation in clinical process and thereby has been shown to improve the quality of infant care. When practice guidelines and documentation are linked to health and economic outcomes, they begin to significantly impact health care costs.

Application of a subjective health and safety rating system to Iowa farm operations

A rapid, subjective health and safety assessment tool was developed and applied to 121 farm operations visited during a cross-sectional, on-farm industrial hygiene (IH) study of the Iowa Farm Family Health and Hazard Surveillance Project (IFFHHSP). The study utilized a single field investigator who conducted visits of farm operations from August 1995 to July 1996. The farm operations visited were randomly selected from a stratified, two-stage cluster sample of Iowa farm operations. The tool developed and applied to each farm operation--the Site Rank System--was based on the average of scores assigned to four different farm characteristics, which we believed would predict the health and safety status of the farm operations. Two of these characteristics were based on an assessment of each farm's operator (operator attitude and operator practices) and the other two were based on weighted scores assigned to physical components of the farm operation (status of facilities and status of equipment). The Site Rank System was found to have been assigned consistently, but an analysis comparing the Site Rank System scores to initial in-depth medical and environmental data gathered from the visited farm operations via self-reported questionnaires showed little correlation with outcomes. However, self-reported injuries (11 total) which occurred to the principal farm operators of the farm operations visited during the on-farm IH study phase (August 1995 to July 1996) correlated with low Site Rank System scores.

Using telemedicine in the treatment of pressure ulcers

Pressure ulcers are dynamic and therefore require frequent assessment and immediate treatment. For many patients who live long distances from rehabilitation hospitals, frequent assessment and immediate treatment are often unavailable. Recent advances during the last two decades have resulted in the development of telemedicine--long-distance delivery of medical education and services to patients. This pilot study reports on a patient enrolled in a telemedicine program during his fifth hospitalization for pressure ulcers in 16 months. Although this is only a single case study, the results suggest the potential efficacy of this new intervention.