Effect of combined use of supplementary irrigation, manure and P fertilization on grain yield and profitability of soybean in northern Nigeria

Declining soil fertility particularly phosphorus deficiency, low organic carbon, moisture stress and high cost of input are factors limiting soybean yield in the Nigeria savanna. Supplementary irrigation, nutrient application and inoculation with Bradyrhizobium could increase the grain yield of soybean. We evaluated the effects of Rhizobia inoculant, phosphorus fertilization, manure, and supplementary irrigation on the nodulation and productivity of a tropical soybean variety in two locations in northern Nigeria in the 2017 and 2018 cropping seasons. The treatments consisted of five input bundles: Supplementary irrigation +17.5 kg P ha-1 + 4 t ha-1 poultry manure + nodumax inoculant (S + P + M + I); 17.5 kg P ha-1 + 4 t ha-1 poultry manure + nodumax inoculant (P + M + I); 17.5 kg P ha-1 + nodumax inoculant (P + I); 17.5 kg PP ha-1 (P); and nodumax inoculant (I). Economic analysis was done to determine the benefit-cost ratio (BCR) for each input bundle. In Kano, the input bundle S + P + M + I produced mean number of nodules that were 38, 102, 200 and 352% higher than that of input bundles P + M + I, P + I, P and I, respectively. At Lere, the application of input bundle S + P + M + I increased mean number of nodules by 33, 81, 93 and 182% over that of input bundles P + M + I, P + I, P and I, respectively. Mean grain yield in Kano was greater for input bundle S + P + M + I over P + M + I, P + I, P and I bundles by 31, 50, 64 and 223%, respectively. In Lere, grain yield for input bundle S + P + M + I was higher than that of input bundles P + M + I, P + I, P and I only, by 27, 47, 41 and 184% respectively. The input bundle P + M + I produced the highest BCR (1.4) in Kano and application only of P produced the highest BCR (1.3) in Lere. Supplementary irrigation was not found to be profitable due to the high cost of supplementary irrigation.The application of P with or without manure/inoculant is recommeded for profitable soybean production in the savannas of Nigeria.

Effect of Wearing a Face Mask on Hand-to-Face Contact by Children in a Simulated School Environment: The Back-to-School COVID-19 Simulation Randomized Clinical Trial

IMPORTANCE

Wearing a face mask in school can reduce SARS-CoV-2 transmission but it may also lead to increased hand-to-face contact, which in turn could increase infection risk through self-inoculation.

OBJECTIVE

To evaluate the effect of wearing a face mask on hand-to-face contact by children while at school.

DESIGN, SETTING, AND PARTICIPANTS

This prospective randomized clinical trial randomized students from junior kindergarten to grade 12 at 2 schools in Toronto, Ontario, Canada, during August 2020 in a 1:1 ratio to either a mask or control class during a 2-day school simulation. Classes were video recorded from 4 angles to accurately capture outcomes.

INTERVENTIONS

Participants in the mask arm were instructed to bring their own mask and wear it at all times. Students assigned to control classes were not required to mask at any time (grade 4 and lower) or in the classroom where physical distancing could be maintained (grade 5 and up).

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of hand-to-face contacts per student per hour on day 2 of the simulation. Secondary outcomes included hand-to-mucosa contacts and hand-to-nonmucosa contacts. A mixed Poisson regression model was used to derive rate ratios (RRs), adjusted for age and sex with a random intercept for class with bootstrapped 95% CIs.

RESULTS

A total of 174 students underwent randomization and 171 students (mask group, 50.6% male; control group, 52.4% male) attended school on day 2. The rate of hand-to-face contacts did not differ significantly between the mask and the control groups (88.2 vs 88.7 events per student per hour; RR, 1.00; 95% CI, 0.78-1.28; P = >.99). When compared with the control group, the rate of hand-to-mucosa contacts was significantly lower in the mask group (RR, 0.12; 95% CI, 0.07-0.21), while the rate of hand-to-nonmucosa contacts was higher (RR, 1.40; 95% CI, 1.08-1.82).

CONCLUSIONS AND RELEVANCE

In this clinical trial of simulated school attendance, hand-to-face contacts did not differ among students required to wear face masks vs students not required to wear face masks; however, hand-to-mucosa contracts were lower in the face mask group. This suggests that mask wearing is unlikely to increase infection risk through self-inoculation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04531254.

Evaluation and application of the CROPGRO-soybean model for determining optimum sowing windows of soybean in the Nigeria savannas

Soybean production is limited by poor soil fertility and unstable rainfall due to climate variability in the Nigeria savannas. There is a decline in the amount and duration of rainfall as one moves from the south to north of the savanna zones. The use of adapted soybean varieties and optimum sowing windows are avenues to increase productivity in the face of climate variability. Crop simulation models can be used as tools for the evaluation of alternative management options for a particular location, including fertilizer application rates, plant density, sowing dates and land use. In this study, we evaluated the performance of the Cropping System Model (CSM)-CROPGRO-Soybean to determine optimum sowing windows for three contrasting soybean varieties (TGX1835-10E, TGX1904-6F and TGX1951-3F) cultivated in the Nigeria savannas. The model was calibrated using data from ten field experiments conducted under optimal conditions at two sites (BUK and Dambatta) in Kano in the Sudan savanna (SS) agro-ecology over four growing seasons. Data for model evaluation were obtained from independent experiment for phosphorus (P) response trials conducted under rainfed conditions in two locations (Zaria and Doguwa) in the northern Guinea savanna (NGS) zone. The model calibration and evaluation results indicated good agreement between the simulated and observed values for the measured parameters. This suggests that the CROPGRO-Soybean model was able to accurately predict the performance of soybean in the Nigeria savannas. Results from long-term seasonal analysis showed significant differences among the agro-ecologies, sowing windows and the soybean varieties for grain yield. Higher yields are simulated among the soybean varieties in Zaria in the NGS than in Kano the SS and Jagiri in the southern Guinea savanna (SGS) agro-ecological zones. Sowing from June 1 to July 5 produced optimal yield of TGX1951-3F and TGX1835-10E beyond which yield declined in Kano. In Zaria and Jagiri the simulated results show that, sowing from June 1 to July 12 are appropriate for all the varieties. The variety TGX1951-3F performed better than TGX1904-6F and TGX1835-10E in all the agro-ecologies. The TGX1951-3F is, therefore, recommended for optimum grain yield in the savannas of northern Nigeria. However, the late maturing variety TGX1904-6F is not recommended for the SS due to the short growing season in this zone.

Goals of care or goals of life? A qualitative study of clinicians' and patients' experiences of hospital discharge using Patient-Oriented Discharge Summaries (PODS)

Background

Recognizing the need for improved communication with patients at the point of hospital discharge, a group of clinicians, patients, and designers in Toronto, Canada collaborated to develop a standardized tool known as the Patient-Oriented Discharge Summary (PODS). Although quantitative results suggest PODS helps mitigate gaps in knowledge, a qualitative inquiry from the clinician and patient perspective of psychiatric hospital discharge using PODS has not been widely explored. Our aim was to explore clinicians’ and patients’ experiences with PODS.

Methods

We used a qualitative thematic analysis to explore clinicians’ (n = 10) and patients’ (n = 6) experiences with PODS. We used convenience sampling to identify and invite potential participants at the Center for Addiction and Mental Health in Toronto, Canada to participate in semi-structured interviews between February 2019 and September 2019. Data were analyzed using a thematic analysis approach to develop descriptive themes.

Results

Emerging themes from the data between clinicians and patients were both different and complementary. Clinicians described PODS using the concept of “goals of care.” They relayed their experiences with PODS as a discrete event and emphasized its role in meeting their “goals of care” for discharge planning. Patients provided more of a “goals of life” perspective on recovery. They characterized PODS as only one facet of their recovery journey and not necessarily as a discrete or memorable event. Patients focused on their outcomes post-discharge and situated their experiences with PODS through its relation to their overall recovery.

Conclusions

PODS was experienced differently by clinicians and patients. Clinicians experienced PODS as helpful in orienting them to the fulfillment of goals of care. Patients did not experience PODS as a particularly memorable intervention. Due to the information advantage that clinicians have about PODS, it is not surprising that clinicians and patients experienced the PODS differently. This study expanded our understanding of hospital discharge from clinicians and patients perspectives, and suggests that there are additional areas that need improvement.

Thirty-Day Readmissions in Patients With Metastatic Cancer: Room for Improvement?

Purpose:

Cancer, with readmission rates as high as 27%, has thus far been excluded from most readmission reduction efforts. However, some readmissions for patients with advanced disease may be avoidable. We assessed the prevalence of potentially preventable readmissions and associated factors in patients with metastatic cancer.

Patients and Methods:

Using a merged longitudinal data set of New York State hospital discharges and vital records, we measured 30-day readmissions for anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, and sepsis among patients with metastatic cancer between 2012 and 2014. We used competing-risk models to assess the effects of demographics, comorbidities, hospital type, payer, and discharge disposition.

Results:

A total of 11,275 patients had 19,307 hospitalizations. The 30-day readmission rate was 24.5%; 11.9% (n = 565) of readmissions were potentially preventable. Higher readmission rates occurred in black (hazard rate [HR], 1.26; 95% CI, 1.17 to 1.35), Hispanic (HR, 1.19; 95% CI, 1.09 to 1.31), and younger patients (HR per 10 years, 0.94; 95% CI, 0.90 to 0.97). Lower rates were associated with female sex (HR, 0.95; 95% CI, 0.91 to 0.99), private insurance (HR, 0.87; 95% CI, 0.87 to 0.81), teaching hospitals, and hospice discharge (HR, 0.62; 95% CI, 0.42 to 0.91). Discharge home with services (HR, 1.21; 95% CI, 1.14 to 1.27) or to a skilled nursing facility (HR, 1.11; 95% CI, 1.01 to 1.23) increased readmission likelihood. Potentially preventable readmissions were associated with younger age (HR per 10 years, 0.98; 95% CI, 0.98 to 0.99) and discharge home with services (HR, 1.25; 95% CI, 1.04 to 1.50). Likelihood decreased if care was received at a teaching hospital (HR, 0.76; 95% CI, 0.59 to 0.99). Payer, sex, race, and comorbidities did not contribute.

Conclusion:

Although the overall rate of potentially preventable readmissions among patients with metastatic cancer is low, higher readmission rates among those discharged home with help suggest that services supplied may not be sufficient to address health needs.

A GIS - based method for assessment and mapping of noise pollution in Ota metropolis, Nigeria

A detailed method used for assessing and mapping noise pollution levels in Ota metropolis, Nigeria using ArcGIS 10.5 Software is presented in this paper. Noise readings were measured at a time interval of 30 min for each site considered using a precision grade sound level meter. The noise map developed was based on the computed values of average equivalent noise (LAeq) for the selected locations. Results of this study show that the A weighted sound level (LAeq), the background noise level (L10) and the peak noise level (L90) vary with location and period of the day due to traffic characteristics especially traffic volume, vehicle horns, vehicle mounted speakers, and unmuffled vehicles at road Junctions, major roads, motor parks and commercial centres. Based on the U.S. Department of Housing and Urban Development (HUD) recommendations and standards, only one (1) out of the 41 locations considered is under normally acceptable situation, while 12 locations are under normally unacceptable and the noise levels of the rest locations are clearly unacceptable. Results of this study are useful as reference and guideline for future planning and regulations on noise limit to be implemented for urban areas like Ota Metropolis. •Instrumentation used in this study for the environmental noise measurements consisted of a precision-grade sound-level meter - Model 8922 RS232.•The Geographical Positioning System (GPS) device (model: Magellan eXplorist 310) was used to obtain the exact coordinates of each location where noise level readings were recorded.•ArcGIS 10.5 software was used in this study to develop noise map for Ota Metropolis.

Medical-surgical readmissions in patients with co-occurring serious mental illness: A systematic review and meta-analysis

OBJECTIVE

To estimate the relationship between comorbid serious mental illness (SMI) diagnosis and 30-day medical-surgical readmissions.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) we searched five databases (2012 to 2017) to identify relevant articles on the relationship between SMI diagnosis and readmissions. We used the National Institute of Health's Quality Appraisal Tool for Observational Cohort and Cross-Sectional Studies guidelines to appraise studies and assess risk of bias. Data were narratively synthesized and a pooled random effects unadjusted odds ratio was estimated using meta-analysis. Heterogeneity was investigated using subgroup analysis and meta-regression.

RESULTS

Our search yielded 424 articles after removing duplicates. Nine met inclusion criteria. All studies were retrospective observational cohort studies. The meta-analysis showed that people with SMI have greater odds of readmission than people without SMI (pooled OR 1.38, CI 1.23-1.56, I² = 98.6%). There was heterogeneity in patient cohorts, study methodology, and definition of SMI. No significant possibility of publication bias was detected (Classic fail-safe N = 3480).

CONCLUSION

There is a meaningful relationship between SMI diagnosis and medical-surgical readmissions. Given the prevalence of SMI in patients hospitalized for medical-surgical problems and the heterogeneity of evidence, further research on sources of variation in outcomes is critically needed.

Gaining knowledge of Ontario’s community mental health and addictions system: linking community-based health services data with administrative health data in Toronto, Ontario, Canada

IntroductionIn most developed countries, a significant amount of mental health and addictions care occurs in community settings. Data reflecting populations served by community-based mental health and addictions providers and the types of services provided are not available, resulting in an incomplete reflection of the entire mental health and addictions system within existing administrative data. Objectives and ApproachThe Community Business Intelligence (CBI) initiative is a data collection project that captures information on adults receiving community-based mental health, addictions, and support services in Toronto Central Local Health Integration Network (LHIN), located in Ontario, Canada. Leveraging administrative health data and data linkage capacity at the Institute for Clinical Evaluative Sciences (ICES), along with engagement of external stakeholders knowledgeable of CBI and the community health sector, we linked the 2015/16 CBI dataset to administrative health data. Demographic characteristics, health-service utilization, primary care attachment, and 30-day emergency department (ED) revisits were calculated for individuals accessing community health services. ResultsThere was an 80.8% linkage rate, of which 36.9% linked deterministically via health card number, while 43.9% linked probabilistically. After study exclusions, 37,688 individuals in the CBI dataset used community health services between April 2015 and March 2016. Compared to Toronto Central LHIN, a greater proportion in the CBI dataset were female, older than 65 years of age, and living in a low income neighbourhood. Furthermore, 95.5%of individuals had at least one outpatient physician visit, 51.3%had at least one ED visit, and 21.7%had at least one hospitalization in the past year. Few individuals in the CBI dataset were without primary care attachment (4.5%); however, a larger proportion had a 30-day ED revisit, particularly those receiving community addictions services (19%). Conclusion/ImplicationsThe availability of community health services data in the CBI dataset and its successful linkage to the administrative health data held at ICES identified health service intersections and outcomes that were previously unknown. This linkage project demonstrates a successful framework for sector-wide performance measurement to address a critical infrastructure gap.

Speaking Up: How Patient and Physician Voices Shaped a Trial to Improve Goals-of-Care Discussions

BACKGROUND

Patients with advanced cancer benefit from early goals-of-care (GoC) conversations, but few facilitators are known.

OBJECTIVE

We describe the process and outcomes of involving patient and physician stakeholders in the design and development of a trial, funded by the Patient-Centered Outcomes Research Institute (PCORI), to enhance oncologists' communication skills and their propensity to facilitate productive, meaningful GoC discussions with patients with advanced cancer.

METHODS

We recruited oncologists, palliative care physicians, and patient stakeholders to participate in proposal development, intervention design and modification, identification of outcome measures, and refinement of study tools. Formats for exchange included 1:1 structured interviews, workshops, and stakeholder meetings.

RESULTS

Patient and physician voices helped craft and implement a study of an intervention to enhance oncologists' ability to facilitate GoC discussions with patients with advanced cancer. Physician inputs guided the creation of an oncologist and palliative care physician "joint visit" intervention at a turning point in disease management. Patient inputs impacted on the language used, outcome measures assessed, and approaches used to introduce patients to the intervention visit.

CONCLUSIONS

Stakeholder input informed the development of a novel intervention that physicians seemed to find both valuable and in sync with their needs and their practice schedules. Where communication about difficult subjects and shared decision making are involved, including multiple stakeholder groups in study design, implementation, and outcomes measurement may have far-reaching effects.

Oncologists’ experiences with goals of care conversations

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Background: ASCO guidelines suggest that patients with advanced cancer should have goals of care (GoC) conversations with their oncologists, yet only 37% report having them, often at the end of life. Describing oncologists’ experiences with GoC conversations is a crucial first step in tailoring communication training interventions. Methods: We conducted semi-structured interviews with oncologists at academic, community, municipal, and rural hospitals (n = 4) in New York and Connecticut. We analyzed data using interpretive description. Three coders developed a code key, independently and then jointly coded transcripts, and identified themes. Results: Oncologists (n = 21) were 67% male, averaged 46 years old (range 34-68) and 20 years (range 8-42) in practice, and 59% reported training in GoC. Sixty-nine percent were White, 23% Asian, and 8% Hispanic. Within oncologist narratives we identified generalizable facilitators and detractors to their practice of GoC conversations. Facilitator experiences included formal training in GoC discussions, a practice culture that supported GoC conversations (i.e. presence of specialty level palliative care), interactions with patients who they perceived to have realistic expectations, and good strategies for self-care and coping. One oncologist stated, “I can't cry or die with every patient because then I won't make it through the day.” Detractors included patient failure to understand cancer severity or treatment goals, younger patient age, and being the oncologist sought for second opinion. Oncologists described active patient participation, respect for patient beliefs and values, and achieving agreement on a care plan as elements of successful GoC discussions. An oncologist summarized, “People who are in the healthcare field think that goals of care are an immutable statement, but it’s not.... the way you can make an effective goals of care discussion, is to relate to their reality.” Conclusions: Multiple considerations impact oncologists’ experiences with GoC conversations. Tailoring communication interventions to address these concerns may increase rates of earlier and ongoing GoC conversations. Clinical trial information: NCT02374255.

Thirty-day readmissions in metastatic cancer patients: Room for improvement?

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Background: To date, cancer has been excused from most readmission reduction efforts. Yet reported readmission rates for cancer patients discharged from medical services are as high as 27%. Some readmissions for patients with metastatic disease may be avoidable. We assessed the prevalence of potentially preventable readmissions and associated factors in adult patients with metastatic cancer. Methods: We measured 30 day readmissions for dehydration, cancer-related pain, and failure to thrive in patients with primary diagnosis metastatic cancer on index admission to a New York State hospital between December 1, 2012 and December 31, 2014. We used competing risk models to assess the effects of demographics, comorbidities, hospital type, payor, and discharge disposition. Results: During the study period, 11,275 patients had 19,307 index hospitalizations with primary diagnosis, metastatic cancer. The 30 day readmission rate was 24.5% of which 8.9% (424) were potentially preventable. Black (HR 1.26, 1.17-1.35) and Hispanic patients (HR 1.19, 1.09-1.31) had higher rates of readmission than whites. Being older (HR per 10 years of age 0.94, 0.90-0.97), female (HR 0.95, 0.91-0.99), having private insurance (HR 0.87, 0.87-0.81) and discharge to hospice (HR 0.62, 0.42-0.91) decreased risk of readmission. Discharge home with services (HR 1.21, 1.14-1.27) or to a skilled nursing facility (SNF) (HR 1.11, 1.01-1.23) conferred higher risk than going home unaided. Index hospitalization at public hospitals increased risk (HR 1.1, 1.02-1.18); teaching hospitals were protective (HR 0.84, 0.774-0.92). Patients with potentially preventable readmissions were younger (HR per 10 years of age 0.85, 0.78-0.93). Compared to those who went home unaided, patients discharged with services were more likely (HR 1.31, 1.05-1.64) and those discharged to SNF were less likely to have avoidable returns (HR 0.55, 0.37-0.81). Payor, gender, race, comorbidities, and index hospital type did not contribute. Conclusions: While the overall rate of potentially preventable admissions among metastatic cancer patients is low, higher readmission rates among those discharged home with help suggests that services supplied are not sufficient to address their health needs.

Shrinking the language accessibility gap: a mixed methods evaluation of telephone interpretation services in a large, diverse urban health care system

INTRODUCTION

Language interpretation services for patients who are not proficient in a country's official language(s) are essential for improving health equity across diverse populations, and achieving clinical safety and quality for both patients and providers. Nevertheless, overall use of these services remains low, regardless of how they are delivered. In Toronto, Ontario, one of the most ethnically diverse urban centres, the regional local health integration network which oversees the highest concentration of health care organizations servicing 1.2 million residents, partnered with key stakeholders to make Over-the-Phone (OPI) interpretation services broadly and economically available in 170 different languages to its diverse network of health care organizations. This evaluation aimed to assess patients' and providers' experiences with OPI in these varied settings and the impact (if any) on alternative interpretation services and on health service delivery access and quality.

METHODS

This study used a two-phased sequential exploratory mixed-methods approach to evaluate the initiative. Phase I was comprised of semi-structured interviews with representatives from the program stakeholders; these findings were applied to identify appropriate survey questions and response categories, and provided context and depth of understanding to Phase II results. Phase II included web-based and self-administered surveys for both providers and patients engaging with OPI.

RESULTS

Both providers and patients identified a broad range of positive impacts OPI had on health care service delivery quality and access, and high levels of satisfaction with OPI, in a variety of health care settings. Providers also revealed a marked decrease in the use of ad-hoc, nonprofessional strategies for interpretation after the implementation of OPI, and noted it had either no impact on their workload or had decreased it overall.

CONCLUSIONS

OPI is clearly not the sole answer to the complex array of health care needs and access gaps that exist for persons without proficiency in their country's official language. Nevertheless, this evaluation provides compelling evidence that OPI is a valuable component, and that it may contribute to a broader range of positive impacts, and within a broader range of health care settings, than previously explored.

Measuring quality at a system level: an impossible task? The Toronto Central LHIN Experience

Quality is being measured and reported across healthcare organizations and sectors, but efforts are rarely made to connect the activity in one organization to quality experienced by patients and clients in another part of the healthcare system. This article describes one regional health organization's journey to measuring health quality at a system level. The authors describe a highly consultative and iterative process used to measure quality across the continuum of care, and the challenges experienced in approaching this type of measurement, and they highlight some of the early findings.

Random breath testing: a Canadian perspective

OBJECTIVE

The purpose of this article is to examine the case for and challenges to implementing random breath testing (RBT) in Canada, with a particular focus on the persistence of impaired driving under the current method of law enforcement. It seeks to place RBT within Canada's existing legal and social framework.

METHODS

This article reviews Canada's impaired driving record, charge and conviction rates, and law enforcement challenges. It then summarizes the impact that RBT programs have had in comparable countries. Finally, it examines whether the enactment of RBT would be upheld under Canada's Charter of Rights and Freedoms.

RESULTS

Canada has made little progress in reducing impaired driving since the late 1990s. Current enforcement methods fail to detect the majority of impaired drivers, even when stopped at sobriety checkpoints. This has reduced the perceived risk of apprehension and helps to explain the persistence of impaired driving in Canada. Faced with similar challenges, Australia, New Zealand, Ireland, and most EU countries have introduced comprehensive RBT programs. Comprehensive RBT has been shown to significantly reduce impaired driving deaths and injuries. Proposals to enact RBT in Canada will inevitably generate claims that it violates drivers' Charter rights. Similar arguments have been raised in opposition to RBT in other countries. This article demonstrates that RBT is compatible with the existing Charter case law involving traffic legislation and border, airline, and courtroom security.

CONCLUSION

Experience in other countries indicates that RBT is a minimally intrusive, cost-effective, and publicly accepted impaired driving countermeasure and that it would significantly improve the detection and deterrence of impaired drivers. Moreover, RBT is compatible with the Charter.

Vascular endothelial growth factor: a possible mediator of endothelial activation in acute respiratory distress syndrome

AIM

Vascular endothelial growth factor (VEGF) is a potent angiogenic and endothelial factor, which is abundantly found in the normal lung tissue. The objective of the study was to assess the VEGF levels in lung tissue and plasma in acute respiratory distress syndrome (ARDS) patients compared with controls who died from non-ARDS causes.

METHODS

Plasma and tissue samples were prospectively collected from 20 patients with ARDS within 6 hours after intubation (VEGF in plasma and tissue samples) and on the day of extubation (plasma VEGF) or postmortem (lung tissue). We used an ELISA to measure the VEGF level in plasma. Lung specimens were obtained by bronchoscopic biopsy or by open biopsy during autopsy. All lung samples were stained for standard histopathological analysis and for immunohistochemical methods. Biomarker levels were compared between survivors (N=12), non-survivors (N=8) and controls (N=10).

RESULTS

Compared with the levels in controls, in the early stages of ARDS, plasma VEGF levels rose and intrapulmonary levels fell, but during recovery, these levels went back to normal levels.

CONCLUSION

The initial phase of ARDS is associated with a decrease in VEGF in the lung and an increase in the plasma. This down-regulation may represent a protective mechanism aimed at limiting endothelial permeability and may participate in the decrease in the capillary number that is observed during early ARDS. A persistent elevation of plasma VEGF over time predicts poor outcome.

Trajectories of quality of life in older persons with advanced illness

OBJECTIVES

To examine subjective ratings of quality of life (QoL) in older adults with advanced illness.

DESIGN

Observational cohort study with interviews at least every 4 months for up to 2 years conducted between December 1999 and December 2002.

SETTING

Participants' homes.

PARTICIPANTS

One hundred eighty-five community-dwelling individuals aged 60 and older with advanced cancer, heart failure, or chronic obstructive pulmonary disease.

MEASUREMENTS

Participants were asked how they would rate their overall QoL.

RESULTS

Of participants who died, 46% reported good or best possible QoL at their final interview, 21% reported improvement in QoL from their penultimate to final interview, and 39% reported no change. Forty-nine percent of participants reported two or more changes in the direction of their QoL trajectories (e.g., QoL improved then declined). As measured over time in a multivariable longitudinal regression analysis, greater activity of daily living disability (adjusted odds ratio (AOR)=0.85, 95% confidence interval (CI)=0.75-0.95) and depressed mood (AOR=0.42, 95%CI=0.27-0.66) were associated with poorer QoL, whereas better self-rated health (AOR=4.79, 95% CI=2.99-7.69) and having grown closer to one's church (AOR=1.99, 95% CI=1.17-3.39) were associated with better QoL.

CONCLUSION

Although declining QoL is not an inevitable consequence of advancing illness, individuals' ratings of QoL are highly variable over time, suggesting that temporary factors may influence subjective QoL. Functional status, depression, and connection to one's religious community are shared determinants of QoL.

Achieving accountability

The word and concept of "accountability" is used broadly and frequently in healthcare--often seen as the key to success change initiatives. But what accountability means and how it is applied can vary significantly. Policy-makers, managers, researchers and healthcare providers use the term in relation to everything from the quality of our relationships with and expectations of one another, to our requirements for more transparency in how resources are used, to our diagnosis of problems and remedies for improving the healthcare system (Brown et al. 2006.).

Feeding soyhulls to high-yielding dairy cows increased milk production, but not milking frequency, in an automatic milking system

To attract a cow into an automatic milking system (AMS), a certain amount of concentrate pellets is provided while the cow is being milked. If the milking frequency in an AMS is increased, the intake of concentrate pellets might increase accordingly. Replacing conventional starchy pellets with nonstarchy pellets increased milk yield, milk fat, and milk protein and decreased body weight. The hypothesis was that a nonroughage by-product rich in digestible neutral detergent fiber, such as soyhulls and gluten feed, could replace starchy grain in pellets fed in an AMS. Sixty cows were paired by age, milk yield, and days in milk, and were fed a basic mixture ad libitum [16.2 +/- 0.35 (mean +/- SE) kg of dry matter intake/d per cow] plus a pelleted additive (6 to 14 kg of dry matter/d per cow) that was consumed in the AMS and in a concentrate self-feeder, which could only be entered after passing through the AMS. The 2 feeding regimens differed only in the composition of the pelleted additives: the control group contained 52.9% starchy grain, whereas the experimental group contained 25% starchy grain, plus soyhulls and gluten feed as replacement for part of the grain. Wheat bran in the control ration, a source of fiber with low digestibility, was replaced with more digestible soyhulls and gluten. During the first 60 d in milk, a cow received 10 to 12 kg of concentrate pellets. After 60 DIM, concentrate feed was allocated by milk production: < or =25 kg/d of milk entitled a cow to 2 kg/d of concentrate feed; >25 kg/d of milk entitled a cow to receive 1 kg/d of additional concentrate feed per 5 kg/d of additional milk production, and >60 kg/d of milk entitled a cow to receive 9 kg of concentrate. The concentrate feed was split between the AMS and concentrate self-feeder. The 2 diets resulted in similar frequencies of voluntary milking (3.12 +/- 0.03 to 2.65 +/- 0.03 visits/d per cow vs. 3.16 +/- 0.00 to 2.60 +/- 0.01 visits/d per cow). Average milk yields were higher in the experimental group (42.7 +/- 0.76 to 39.09 +/- 0.33 kg/d per cow vs. 39.69 +/- 0.68 to 37.54 +/- 0.40 kg/d per cow) and percentages of milk protein (3.02 +/- 0.06 to 3.12 +/- 0.05% vs. 3.07 +/- 0.04 to 3.20 +/- 0.04%) and milk fat (3.42 +/- 0.17 to 3.44 +/- 0.08% vs. 3.38 +/- 0.13 to 3.55 +/- 0.06%) were similar in the 2 groups. The results suggest that the proposed pellets high in digestible neutral detergent fiber can be allocated via the AMS to selected high-yielding cows without a negative effect on appetite, milk yield, or milk composition while maintaining a high milking frequency.

The quality of commercial wheat silages in Israel

Wheat silages are the major roughage for high-producing lactating dairy cows in Israel; therefore, their quality is important. The main objective of the current study was to determine the preservation status and nutritional quality of commercial wheat silages in Israel. An additional objective was to develop predictive equations for dry matter digestibility (DMD) and neutral detergent fiber digestibility (NDFD) based on chemical composition of the silages, which would permit estimation of the digestibility from chemical composition. A total of 143 commercial wheat silages were sampled and analyzed for 3 yr. Fourteen random samples that were not included in the regression analysis were used to validate the equations by the bias and error of the model. Results revealed that wheat silages were quite sensitive to aerobic exposure; additives resulted in some improvement of the aerobic stability. After choosing the significant terms from ash, crude protein (CP), NDF, acid detergent fiber (ADF), and acid detergent lignin (ADL) by PROC STEPWISE of SAS, the following prediction equations were obtained from all 143 samples: DMD = 86.3 + (0. 70 x CP) - (0.46 x ADF) - (1.67 x ADL); and NDFD = 20.3 + (1.00 x CP) + (1.16 x NDF) - (0.88 x ADF) - (2.25 x ADL). The bias and the error of the prediction model for DMD were approximately 0.006 and 0.065, respectively; the bias and error for NDFD were approximately 0.007 and 0.118, respectively. It was concluded that the prediction model for DMD was quite adequate, whereas that for NDFD was less acceptable.

Metabolic syndrome in postmenopausal women: the influence of oral or transdermal estradiol on inflammation and coagulation markers

OBJECTIVE

The objective of the study was to determine whether the route of administration of estrogen therapy in women with metabolic syndrome (MBS) influences inflammation and coagulation parameters.

STUDY DESIGN

Fifty symptomatic postmenopausal women with MBS were randomized to receive 1 mg oral estradiol (oE(2)) or 0.05 mg transdermal E(2) (tE(2)) for 3 months. Measurements were compared with those of 20 healthy premenopausal women and 74 normal postmenopausal women.

RESULTS

Compared with both control groups, women with MBS had significantly higher levels of certain inflammation and coagulation markers, which cannot be accounted for based on weight alone. After oE(2), antithrombin III decreased from 104% to 96% (P < .01), the metalloproteinase-9/ tissue inhibitor of metalloproteinase-1 ratio increased (P < .02), and E-selectin decreased from 60 +/- 4.4 to 55 +/- 4.6 ng/mL (P < .05). With tE(2), there were no major changes noted.

CONCLUSION

Postmenopausal women with MBS have higher levels of certain coagulation and inflammation markers and different responses to oral compared with transdermal estradiol.

Predictors of variceal bleed among patients with liver cirrhosis in the era of sclerotherapy

INTRODUCTION

Variceal bleed is a common complication of portal hypertension. The bleed pattern has changed considerably with the introduction of variceal band ligation. The bleed pattern in developing countries where sclerotherapy continues to remain a viable option is not known. The aim of the study was to determine the predictors of first and subsequent bleed in individuals with liver cirrhosis.

METHODS

205 subjects with liver cirrhosis and portal hypertension registered in the liver clinic between January and June 2004, were followed-up for 18 months after registration. Bleeders already on pharmacotherapy or endotherapy were excluded. Patient details included age, gender, duration of illness, aetiology, Child-Pugh-Turcotte score and grades of oesophageal varices, details of index and subsequent variceal bleed, and complications during follow-up. Logistic regression multivariate analysis was applied to predict the factors influencing variceal bleed.

RESULTS

There were 95 variceal bleeders and 110 non-bleeders. Age at presentation and gender did not predict a variceal bleed. Grades III and IV oesophageal varices and fundal varices were the significant risk factors for an index bleed (p-value is 0.001). 27 of the 95 bleeders (28.3 percent) had a second bleed after a mean interval of 8 (+/- 7.7) months. Predictors of rebleed were similar to the index bleed. Predictors of index bleed were also similar to those who had bled for the first time after registration. Overall bleed-related mortality was low (2.1 percent).

CONCLUSION

Higher grades of varices, presence of cherry-red spots and fundal varices predicted variceal bleed in patients with liver cirrhosis. Variceal bleed-related mortality was low in the era of sclerotherapy.

Selection of contrast media

The pathophysiologic mechanisms of contrast-induced nephropathy (CIN) have been reviewed by Persson and Tepel. They focus on the renal response to contrast media (CM). In this section, we focus on the CM itself. Aspects of importance with regard to CIN include the route of administration, the volume of CM, the manner of X-ray attenuation, and the specific chemical structure of the CM.

Feeding of Pellets Rich in Digestible Neutral Detergent Fiber to Lactating Cows in an Automatic Milking System

If the milking frequency in an automatic milking system (AMS) is increased, the intake of concentrated pellets in the robot may be raised accordingly. Consumption of a large quantity of starchy grains within a short time can impair the appetite, decrease voluntary visits to the milking stall, and lower intakes of dry matter (DM) and neutral detergent fiber (NDF). Therefore, the hypothesis to be tested in this study was whether conventional starchy pellets fed in the AMS could be replaced with pellets rich in digestible NDF without impairing the cows' motivation to visit a milking stall voluntarily. Fifty-four cows were paired according to age, milk yield, and days in milk, and were fed a basic mixture along the feeding lane (19.9 kg of DM/cow per d), plus a pelleted additive (approximately 5.4 kg of DM/cow per d) that they obtained in the milking stall and in the concentrate self-feeder that they could enter only after passing through the milking stall. The 2 feeding regimens differed only in the composition of the pelleted additive, which, for the control group, contained 49% starchy grain, and for the experimental group contained 25% starchy grain plus soy hulls and gluten feed as replacement for part of the grain and other low-digestible, NDF-rich feeds. Both diets resulted in similar rates of voluntary milkings (3.31 vs. 3.39 visits/cow per d). Average yields of milk and percentages of milk protein were also similar in the 2 groups. The results suggest that an alternative pellet composition can be allocated in the AMS in conjunction with basic mixture in the feeding lane, without any negative effect on appetite, milk yield, milk composition, or milking frequency of the cows. It also opens the opportunity to increase yields of milk and milk solids by increasing the amount of pelleted concentrates that can be allocated to selected high-yielding cows via the AMS, because this can be done while maintaining a high frequency of voluntary milkings.

Follow-up of patients with contrast-induced nephropathy

In this chapter, we review the approach to following the patient after contrast is administered. We first discuss the clinical importance of renal injury for if there were no clinically significant consequences of this renal injury, we would have far less concern for the adequacy of follow-up. We next look at markers of renal injury and what tests are used in clinical practice to define contrast-induced nephropathy (CIN). Finally, we discuss the steps that should be taken in those who do develop CIN to limit the impact of the injury and protect them from future adverse events.

Digestibility in Lactating Cows of Diets Containing Whole Pima Treated with Sodium Hydroxide Versus Akala or Pima Cottonseed

This study examines the effect of NaOH treatment on the nutritive value of Pima cottonseed for lactating cows. Treatment of Pima cottonseed with NaOH increased the extent of dry matter (DM) and neutral detergent fiber in vitro digestibility. Three groups of cows were fed 3 similar total mixed rations (TMR) differing only in the type of cottonseed fed, either whole linted Akala, whole unlinted Pima, or whole Pima treated with 4% NaOH (T-Pima). Dry matter and organic matter (OM) intakes of Akala and Pima TMR were similar and tended to be lower compared with cows fed T-Pima. This was reflected in similar intake of crude protein and lipids by cows fed the 3 TMR. Digestibility of DM, OM, and crude protein were similar in cows fed Pima and T-Pima diets, and slightly higher in cows fed the Akala TMR. Lipid digestibility was highest in cows fed Akala TMR, whereas cellulose and NDF digestibility were lowest in Pima TMR. In the 3 TMR, there was a large gap between the high values of "digestibility of intact seeds" and actual in vivo digestion of DM and OM. Similar yields of milk and milk protein were obtained in cows fed the Akala and Pima TMR, whereas higher yields of milk, milk protein, milk fat, and 4% fat-corrected milk were found in the T-Pima cows. Similar efficiency of DM intake for fat-corrected milk production was achieved by cows fed the 3 TMR.

Interdigitating dendritic cell sarcoma: a report of four paediatric cases and review of the literature

AIMS

To report a series of four paediatric cases of interdigitating dendritic cell sarcoma (IDCS) and add to the known extranodal sites of occurrence for this tumour. Neoplasms derived from interdigitating dendritic cells are rare, with only 33 cases being reported in the literature (Medline search). These tumours usually occur in lymph nodes in the adult population.

METHODS AND RESULTS

The patients were a 10-year-old girl with a large soft tissue mass bulging into the left chest, a 12-year-old girl with a right paraspinal mass, a 21-month-old boy with generalized lymphadenopathy and hepatosplenomegaly and a 6-year-old girl with a large bladder mass. Paraffin blocks and haematoxylin and eosin slides were available in all cases. In addition, immunohistochemistry and electron microscopy were performed. A diagnosis of IDCS was made in all cases.

CONCLUSION

The diagnosis of IDCS can rarely be entertained on clinical information alone. Microscopically, there is a wide spectrum of features. Thus, immunohistochemistry and electron microscopy are crucial in making the diagnosis. The differential diagnosis includes inflammatory pseudotumour, follicular dendritic cell sarcoma, true histiocytic lymphoma, malignant Langerhans cell histiocytosis, anaplastic large-cell lymphoma, melanoma, and a range of sarcomas. IDCS displays aggressive behaviour and approximately half of the patients die of the disease.

Characterization of adhesion and differentiation markers of osteogenic marrow stromal cells

Marrow stroma cells (MSC) play a major role in osteogenesis. The potential of the MSC to differentiate to bone-forming cells relies upon molecular regulation. This study analyzed MBA-15 cells for the expression of genes and proteins that are key regulators of osteoblast differentiation. These cells express Cbfa1 and c-fos transcription factors (TF) of osteoprogenitor proliferating cells. RT-PCR and immunohistochemistry were used to demonstrate the message and protein expression of extracellular matrix proteins that are a prerequisite for matrix formation and mineralization, including alkaline phosphatase (ALP), osteocalcin, osteopontin, biglycan, and bone sialoprotein (BSP). The activity of ALP was correlated at various cell densities with co-expression of osteocalcin or osteopontin. Adhering cells must attach to the appropriate matrix to enable survival and differentiation. Using attachment assays, we demonstrated that MBA-15 cells adhered to collagenous matrix and the effect on survival measured by changes in intracellular calcium (Ca) levels. The cells' adhesion to matrix is mediated via cell surface molecules. We quantified the expression of cells surface molecules that are important players in mediating cell-matrix interaction. Flow cytometry analysis (FACS) was used to determine the expression of CD-31 (36%), and lower levels were identified for CD-62E and CD11b. In summary, the present study demonstrates the expression of molecular markers that are distinctive for the osteoblastic phenotype in MBA-15 marrow stroma cells and have crucial role in cell-matrix interaction, in establishing the cellular osteogenic phenotype and their survival.

Long segment Hirschsprung's disease in the Waardenburg-Shah syndrome

Presentation with signs of bowel obstruction in an infant with Waardenburg syndrome should raise the suspicion of aganglionosis. We report such a case of long segment Hirschsprung's disease associated with Waardenburg syndrome. Long term care of such children is fraught with high morbidity and mortality.

Digestibility by dairy cows of monosaccharide constituents in total mixed rations containing citrus pulp

Ten lactating cows were divided into two groups and individually fed ad libitum one of two experimental total mixed rations (TMR) as follows: 1) a TMR containing 20% corn grain and 10% dry citrus pulp (high corn); and 2) a TMR containing 21% citrus pulp and 9% corn grain (high citrus pulp). Both TMR also contained corn silage (28%), legume haylage (19.5%), extruded full fat soybeans (13.5 to 14%), soybean meal (6.5%), and minerals and vitamins. Voluntary dry matter intake of cows consuming the high corn ration tended to be higher than for cows in the high citrus pulp group (22.2 vs. 20.7 +/- 1.0 kg/cow per day, respectively). Digestibility of NDF was higher for the TMR with high citrus pulp compared with the TMR with higher corn. Across treatments, neutral detergent fiber (NDF) glucose was more digestible than NDF xylose and uronic acids and less digestible than NDF arabinose, galactose, and mannose. Digestibility of total neutral detergent soluble carbohydrates was also higher in the high citrus pulp group (86.8, high citrus pulp vs. 80.3 +/- 1.7%, high corn); with glucose and uronic acids accounting for most of that difference. Consequently, higher total carbohydrate digestibility was obtained in the TMR containing higher citrus pulp compared with the TMR with a higher percentage of corn (77.1 and 72.5 +/- 1.0%, respectively). Slightly lower carbohydrate intake in cows fed higher citrus pulp was compensated by higher digestibility of carbohydrates and protein. Thereby, partial replacement of corn by citrus pulp in TMR of high producing dairy cows improved feed efficiency.