One Year Radiographic Response Following Prostrate SBRT: An Exploratory Analysis of a Phase III Randomized Trial

PURPOSE/OBJECTIVE(S)

Radiographic MRI response following prostate radiotherapy, particularly stereotactic body radiotherapy (SBRT), remains poorly understood. Our objective was to describe radiographic changes to the prostate gland and prostate tumor following SBRT of men treated on a prospective, randomized trial.

MATERIALS/METHODS

MIRAGE (NCT04384770) is a single center, randomized phase III trial of patients receiving either CT or MRI guided SBRT for localized prostate cancer. Patients underwent pre-treatment and annual post-treatment MRIs, in addition to routine PSA surveillance. Outcomes reported include percent gland shrinkage, percent PSA response at one year, and presence of residual tumor based on radiographic interpretation. Patient characteristics were compared via two-sample t-test or Fischer's exact test. Both univariate and multivariable logistical analysis were employed to identify potential clinical predictors of residual tumor on 1-year follow up MRI.

RESULTS

This study cohort included 94 eligible patients with baseline characteristics in Table 1. Residual lesions were seen in 13 patients (14%), 5/27 (18.5%) treated without ADT and 8/67 (12%) with ADT. PSA ablation was deep, with a 79% median decrease without ADT and 98% median decrease with ADT. Patients receiving ADT showed more gland shrinkage (17% vs. 34% shrinkage, p = 0.0001), while radiographic non-responders and responders experienced similar gland shrinkage (median 21% vs 29% shrinkage, p > 0.05). No significant clinical predictors of residual tumor were identified on univariate and multivariate analysis. No patient had any clinical or biochemical evidence of failure.

CONCLUSION

A total of 14% of patients were found to have residual tumor detected on MRI one year after SBRT. These data highlight the protracted nature of radiographic tumor response to radiation therapy, even with ablative radiation techniques. The analysis is limited by the lack of biopsy data to quantify whether visualized residual tumor harbor active cancer.

Patient-Reported Urinary and Bowel Quality of Life Outcomes Following External Beam Radiotherapy with or without High-Dose-Rate Brachytherapy Boost: Post-Hoc Analyses of TROG 03.04 (RADAR)

PURPOSE/OBJECTIVE(S)

One of the concerns with combining external beam radiotherapy (EBRT) with a high dose rate brachytherapy boost (HDRBT) for prostate cancer is increased toxicity. We aimed to evaluate long-term urinary and bowel quality of life (QoL) outcomes following EBRT vs EBRT + HDRBT using data from the TROG 03.04 trial.

MATERIALS/METHODS

Men who had dose-escalated EBRT (74 Gy) or EBRT (46 Gy) + HDRBT (19.5 Gy in 3 fractions) were included in this exploratory analysis. QoL outcomes were prospectively collected using the EORTC-QLQ-PR25 at baseline, end of radiotherapy, 12, 18, 24, 36, 60 months, and annually up to 10 years. QoL score was normalized to 0-100 with higher scores representing worse symptom burden. Minimal clinically important differences (MCIDs) were defined as differences in the respective QoL scores ≥0.5 standard deviations of the baseline QoL score. Mixed models for repeated measures were used to evaluate longitudinal changes in the QoL score between EBRT and EBRT + HDRBT arms. Logistic regression was used to evaluate differences in proportion of men with 2xMCID between EBRT and EBRT + HDRBT arms at each time point. Age, baseline QoL score, ECOG performance status, and duration of androgen deprivation therapy use (6 vs. 18 months) were adjusted for in all analyses.

RESULTS

Four hundred ninety-seven men were included in this study: 260 (52%) had EBRT and 237 (48%) had EBRT + HDRBT. The median baseline urinary QoL scores were 12.5 (IQR 4.2-19.0) and 8.3 (IQR 4.2-20.8) for men in EBRT and EBRT + HDRBT arms respectively (P = 0.5). Within the first 24 months, men in the EBRT + HDRBT arm had a slower rate of urinary QoL score resolution compared to men in the EBRT arm (P<0.001). At 12, 18, 24, and 36 months, men who had EBRT + HDRBT were 2.4 times (95% CI = 1.4-4.0; P<0.001), 3.1 times (95% CI = 1.8-5.1; P<0.001), 2.8 times (95% CI = 1.7-4.7; P<0.001), and 2.5 times (95% CI = 1.4-4.5; P = 0.002) more likely to have 2xMCID in urinary QoL scores compared to men who had EBRT alone. Beyond 24 months, there were no significant differences in the rate of urinary QoL score resolution between arms, and beyond 36 months there were no significant differences in the proportion with 2xMCID between arms. The median baseline bowel QoL score was 0 in both arms. There were no differences in the rate of bowel QoL score recovery over time between arms. Men who had EBRT + HDRBT were less likely to have 2xMCID in bowel QoL score in the immediate post-radiotherapy period (OR = 0.66; 95% CI = 0.45-0.97; P = 0.03) and at 60 months (OR = 0.51; 95% CI = 0.33-0.80; P = 0.003) compared to men who had EBRT.

CONCLUSION

EBRT + HDRBT is associated with disturbances in urinary QoL that are of greater magnitude compared to EBRT alone within the first 36 months of treatment, but the differences resolved after 36 months. EBRT + HDRBT is associated with less disturbances in bowel QoL immediately after treatment and at 60 months compared to EBRT alone.

[Alarming signals: Worsening obesity, physical inactivity and high perception of stress in first-year medical and dental students in Chile]

BACKGROUND

The high prevalence of obesity, smoking, and physical inactivity in Chile despite government-sponsored measures and campaigns, along with others in the last 30 years, suggests additional reinforcement of these efforts at the primary care level.

OBJECTIVES

To determine if lifestyles and modifiable health risk factors in first-year students from the University of Chile Faculties of Medicine and Dentistry, potential future promoters of healthy lifestyles, show changes throughout their first academic year.

METHODS

In a randomized stratified sample of 388 students according to sex and chosen career weight, height, waist circumference, waist circumference-weight ratio, food consumption, smoking prevalence and dependence, alcohol use, perceived stress level, and physical activity were measured at the first week, 3 and 6 months after their admission. The Cochrane test assessed dichotomic variables, and the Friedman test was used for nonparametric values.

RESULTS

253 students (186 women) completed the follow-up. A significant worsening of obesity (general and abdominal) and physical inactivity, persistent moderate and high-stress perception, and smoking prevalence were documented throughout the study period.

CONCLUSIONS

The progressive obesity and physical inactivity, high-stress perception, and persistent smoking prevalence in the first year of academic life suggest considering measures in the curricular academic structure that facilitate adjustments in the student's lifestyles. Future follow-up of this cohort, increasing participants, and assessing students' mental health are planned.

Exploring phenotypes in hypertrophic cardiomyopathy with machine learning data integration. A multicentric, multimodality pilot study

Background

Interpreting patient phenotypes is a challenge when screening for hypertrophic cardiomyopathy (HCM). Machine learning (ML) can potentially help with advanced data integration - combining information contained in whole-cardiac cycle echo deformation and velocity profiles with standard clinical variables. The aim is to apply an ML approach to integrate whole cardiac cycle echo data with clinical variables to explore HCM phenotypes.

Methods

The cohort consisted of 138 participants from two centres: HCM patients (n=91) and relatives (n=47). Echocardiography was performed, whereas magnetic resonance and genetic testing in 48% and 82%, respectively. Whole cardiac cycle echo data (mitral and aortic velocity profiles, and six regional left ventricular (LV) deformation curves) were combined with clinical variables (age, sex, heart rate, e' medial and e' lateral) and used as the ML input. An unsupervised ML algorithm created a representative space where participants were positioned based on integrated data, blinded to disease status. Clustering was used to determine phenogroups and estimate the average characteristics. Data on family history (FHx), genotype, arrhythmias or syncope, implantable cardioverter-defibrillators (ICD), and late gadolinium enhancement (LGE) were used to interpret the phenogroups. As the LA diameter was not available in the dataset, the HCM risk for sudden cardiac death (SCD) was not calculated, however, the Table shows relevant variables to infer clinical risk.

Results

Clustering divided the participants into 6 phenogroups (P1–6) (Figure). Average echo profiles are shown in the Figure, while the clinical data in the Table. P1/2 was defined by symptomatic patients with a high prevalence of positive genotypes, a positive FHx of SCD, and a burden of comorbidities. Echo findings showed pronounced structural/functional remodeling, and P1 was associated with severe septal hypertrophy and outflow tract obstruction. The high prevalence of ICD devices defined P1/2 as high risk groups. In comparison, patients in P3/4 were younger, with milder LV hypertrophy, but still considerable functional impairment. P3 had a higher burden of FHX and a higher prevalence of pathogenic mutations, whereas P4 a higher incidence of hypertension, high heart rate, mitral inflow fusion and findings of LGE. Finally, P5/6 consisted of younger individuals, predominantly HCM relatives, with a mild phenotype and, thus, low inferred risk. As expected, the majority of patients with the genetic variants of undetermined significance were located in P5.

Conclusion

ML can help derive clinically interpretable phenotypes in HCM based on the automated integration of whole cardiac cycle deformation and velocity data with conventional clinical parameters. The derived phenogroups correspond with established risk profiles in HCM. An expanded dataset is needed to enable further exploration of the phenotype-genotype relations and to define prognostic value.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by the Horizon 2020 European Commission Project H2020-MSCA-ITN

Energy, nitrogen partitioning, and methane emissions in dairy goats differ when an isoenergetic and isoproteic diet contained orange leaves and rice straw crop residues

The aim of this study was to evaluate the effects of incorporating rice straw and orange leaves into the diets for goats. Ten Murciano-Granadina goats at mid lactation weighing 45 ± 0.3 kg were used in a crossover design. Two isoproteic and isoenergetic diets (180 g/kg DM and 17 MJ/kg DM, respectively) with alfalfa hay as forage source (33% of DM) were fed. A control diet (CON) incorporated barley as energy source and soy hulls as fiber component. The experimental diet (ORG) replaced barley and soy hulls with orange leaves (19% on DM basis), rice straw (12%, on DM basis) and soya oil (2%). Peas and horsebeans were the protein source in both diets. Each goat received the 2 treatments in 2 periods. Goats were fed the experimental diets and after 14 d on their respective treatments moved to individual metabolism cages for another 7 d. Subsequently, feed intake, total fecal and urine output and milk yield were recorded daily over the first 5 d. During the next 2 d ruminal fluid and blood samples were collected, and then individual gas-exchange measurements were recorded by a mobile open-circuit indirect calorimetry system using a head box. No differences in dry matter intake were detected, and apparent total-tract digestibility was greater in CON than ORG. Efficiency of metabolizable energy intake for milk and maintenance also was lower in response to ORG (0.65 vs. 0.63), with energy balance being negative (-12 kJ/kg of BW^0.75) due to mobilization of fat (-16 g/animal vs. 68 g/animal for ORG and CON, respectively). Although actual milk yield was lower in goats fed ORG (2.32 vs. 2.06 kg/d, respectively), energy-corrected milk did not differ (2.81 kg/d on average). In terms of milk quality, milk fat content, and concentrations of monounsaturated (18.54 vs. 11.55 g/100 g milk fat) and polyunsaturated fatty acids (5.75 vs. 3.99 g/100 g milk fat) were greater in goats fed ORG. Based on various indices, the milk produced by ORG would be less atherogenic and thrombogenic than CON milk. Compared with CON, enteric CH₄ emission was lower due to feeding ORG (reduction of 38 g CH₄/kg milk fat). Data suggest that greater fat mobilization in goats fed ORG might have been due to the apparent lack of synchrony between degradable protein and carbohydrate and the lipogenic nutrients associated with the lower cereal content of the ORG diet. Thus, goats fed ORG seemed to rely more on fat depots to help meet energy requirements and reach optimal performance. As such, the lower content of glucogenic nutrients in ORG did not favor body fat deposition and partitioning of ME into body tissue. Overall, responses in terms of CH₄ emissions and milk quality suggest that inclusion of rice straw and orange leaves in diets for small ruminants could be a valuable alternative to reuse, recycle and revalue agricultural by-products.

Inclusion of lemon leaves and rice straw into compound feed and its effect on nutrient balance, milk yield, and methane emissions in dairy goats

The objective of this experiment was to study the effects of incorporating lemon leaves and rice straw into the compound feed of diets for dairy goats. Ten Murciano-Granadina dairy goats (n = 5 per group) in mid-lactation were used in a crossover design experiment (2 treatments across 2 periods). Goats were fed a mixed ration with barley grain (control, CON) or CON plus lemon leaves [189 g/kg of dry matter (DM)] and rice straw (120 g/kg of DM) in place of barley grain (LRS). Soybean oil (19 g/kg of DM) was added to the LRS diet to make it isoenergetic (17 MJ of gross energy/kg of DM) relative to CON. After 14 d on their respective treatments, goats were allocated to individual metabolism cages for another 7 d. Subsequently, feed intake, total fecal and urine output, and milk yield were recorded daily over the first 5 d. During the last 2 d, ruminal fluid and blood samples were collected, along with individual gas exchange measurements recorded by a mobile open-circuit indirect calorimetry system using a head box. No differences in DM intake were detected, and ME intake in LRS was lower than in CON (1,095 vs. 1,180 kJ/kg of metabolic body weight). No differences were observed in milk production, but milk fat content was greater in LRS (6.4%) than in CON (5.6%). Greater concentrations of monounsaturated (14.94 vs. 11.96 g/100 g of milk fat) and polyunsaturated fatty acids (4.53 vs. 4.03 g/100 g of milk fat) were detected in the milk of goats fed LRS compared with CON. Atherogenicity (2.68 vs.1.91) and thrombogenic (4.58 vs. 2.81) indices were lower with LRS compared with CON. Enteric CH₄ emission was lower in LRS (24.3 g/d) compared with CON (31.1 g/d), probably due to the greater lipid content and unsaturated fatty acid profile of lemon leaves and the soybean oil added in the LRS diet. Overall, data suggest that incorporating lemon leaves and rice straw into lactating goat diets is effective in reducing CH₄ emissions while allowing improvements in milk fat production and milk thrombogenic index without affecting production performance. Thus, their inclusion in compound feeds fed to small ruminants appears warranted and would have multiple positive effects, as on efficiency of nutrient use, human health, and the environment.

Update on quality of care in Hispanics and other racial-ethnic groups in the United States discharged with the diagnosis of Acute Myocardial Infarction in 2013

BACKGROUND

Disparities in Acute Myocardial Infarction (AMI) care and outcomes have been frequently reported in racial-ethnic minorities in the U.S. Some studies have attributed disparities in Hispanics and other minorities to lower quality of services at hospitals where they seek care. Current information from hospitals with large Hispanic representations and updated quality resources is needed.

METHODS

Retrospective observational study of 839 AMI patients discharged in 2013 from three Southern California Hospitals (A, B, C) with tertiary cardiac care level. Non-Hispanic Whites (NHW) and Hispanics (H) were the larger racial-ethnic groups (68.3%), and the comparison of these two groups constitutes the focus of the study. Mortality, 30day readmissions, medication/performance measures (PRx); aspirin, statins/anti-lipids, beta-blockers, ACEI/ARB for LV systolic dysfunction, <90min door-balloon time, and revascularization procedures were compared between hospitals, NHW and H, using Chi-squared tests (χ²), Odds Ratios (OR) with 95% confidence intervals (CI), and Z tests for proportions - independent groups.

RESULTS

No significant differences in hospital, 30day mortality, PRx or procedures were observed between NHW, H and other racial-ethnic minority groups, or hospitals. Hospital C had 47.3% H and Hospitals A+B 14.6% (p<0.001, effect size=0.430). AMI performance measures exceeded 2013 national rates across all facilities. NHW had more private/commercial insurance (52.5% vs. 25.4%, OR 3.24, 95% CI 2.19-4.80, p<0.001) than H.

CONCLUSIONS

Equitable access to quality hospital services in three Southern California hospitals offset previously reported disparities in AMI management in Hispanics. These results may not necessarily reflect the reality of AMI care for Hispanics in other U.S. regions.

Abstract 025: Factors Influencing Blood Pressure Control and Adherence in a Middle income Country That Provides Universal Free Access to a Comprehensive Hypertension Program

Background: Limited information exists on the association of clinical, socio-economic, psychosocial factors and free access to national health programs with blood pressure control (BPC) and adherence to therapy (Rx) in developing middle income countries.

Methods: Cross-sectional study in randomly selected 992 hypertensive patients (30 to 64 years of age) served in the Chilean national Cardiovascular Health Program (CVHP) that provides free medical care and life style modification counseling to approximately 75% of the population. Association of education, income, diabetes, obesity, physical activity, psychosocial characteristics, smoking, abnormal alcohol use with BPC and adherence to Rx was evaluated in patients with at least 1 year in the CVHP. Adherence to Rx and psychosocial characteristics were assessed using validated questionnaires. Odds ratios (OR) with 95% of confidence intervals for uncontrolled BP (≥140/90 mm/Hg) and no adherence to Rx were obtained through multivariable logistic regression analysis adjusted for all variables included in the study (see Table).

Results: A larger number of women (65.2%) were part of the study. BPC was achieved in 53.5% of patients and 38.7% were adherent to Rx. Uncontrolled BP was significantly associated with non adherence (OR: 1.34 [95% CI 1.09 - 1.65]); other associations are shown in table.

Discussion and Conclusions: In hypertensive patients followed in the CVHP, BPC was achieved in 53.5%. It is of note that a 2010 Chilean National Health Survey reported BPC in 16.7% of the population and in 45.3% of subjects that stated to be under Rx. Uncontrolled BP and low Rx adherence were significantly associated to male gender, also underrepresented in the study population (34.8%) and low Rx adherence to high score of emotional stress and depression, underlining need of measures addressing those issues. Low adherence was associated to low income notwithstanding free access to care and therapy.

Abstract 209: Does a Level Playing Field Reduce Disparities in Quality of Care For Hispanics and Women With Acute Myocardial Infarction?

Background: Acute Myocardial Infarction (AMI) care and outcomes disparities have been reported worldwide in women and racial-ethnic minorities. In the U.S., some have attributed disparities in Hispanics and other minorities to lower quality of services at hospitals where they seek care. Current information from hospitals with large Hispanic representation and equitable updated resources is needed.

Methods: Retrospective observational study of 839 AMI patients discharged in 2013 from three Southern California Community Hospitals (A, B, C) with tertiary cardiac care level. Non-Hispanic Whites (NHW) and Hispanics (H) were the larger racial-ethnic groups (68.3%). Mortality, 30 day readmissions, medication/performance measures (PRx); Aspirin, Statins/anti-lipids, Beta-blockers, Angiotensin Converting Enzyme Inhibitors and Receptor Blockers for Left Ventricular Systolic dysfunction, <90 minute door-balloon time, and coronary percutaneous interventions and revascularization procedures were compared between Hospitals, NHW and H, and gender using Chi-squared tests (χ 2 ), Odds Ratios (OR) with 95% confidence intervals (CI), and Z tests for proportions -independent groups.

Results: No significant differences in hospital, 30 day mortality, or PRx were observed between hospitals, NHW and H. Hospital C had 47.3% Hispanics, Hospitals A+B 14.6% (η 2 =.430, p<0.001). AMI performance measures exceeded 2013 national rates across all facilities. NHW had more private insurance (52.5% vs. 25.4%, OR 3.24, 95% CI 2.19-4.80, p<.001) than Hispanics. Women had similar PRx, mortality, and readmissions, yet less CABG (6.7% vs. 14.1%, OR 0.38, 95% CI 0.21-0.67, p = .001) and Non-STEMI PCI procedures than men (39.1% vs. 51.2%, z = 2.65, p = 0.008) after full data adjustment.

Conclusions: Equitable standards of care offset previously reported disparities in AMI management in Hispanics but not in women’s coronary revascularization procedures.

Short communication: Drug residues in goat milk after prophylactic use of antibiotics in intravaginal sponges for estrus synchronization

The aim of this study was to determine whether the prophylactic use of antibiotics in intravaginal sponges used for estrus synchronization in goats may result in the presence of inhibitors in milk and, therefore, of positive results by microbial screening tests. Ninety-eight Murciano-Granadina goats were used, divided into 7 groups of 14 animals. Intravaginal sponges were placed in 6 groups using 2 concentrations of 3 different antibiotics: doxycycline, oxytetracycline, and sulfathiazole-framycetin. The sponges of the control group were placed without antibiotics. Milk samples were collected daily until 7 d posttreatment and analyzed using 3 microbial tests. Positive samples were retested by specific receptor-binding assays to confirm the positive results. Vaginal status was evaluated by visual assessment of the external aspect of the sponges after removal. The microbial test response was not affected by either day posttreatment or dose of antibiotic used, except for oxytetracycline at the higher concentration. Moreover, no positive results were obtained using receptor-binding assays, suggesting that residues, if present in milk, did not exceed the regulatory (safety) levels established for these drugs. The occurrence of soiled sponges was higher in the control group. With respect to the dose of antibiotics used, no significant differences were found for the lower dose administered. However, a significant increase in the percentage of clean sponges was observed for the higher dose of doxycycline. We conclude that the prophylactic use of low doses of doxycycline, oxytetracycline, or sulfathiazole in intravaginal sponges used for synchronization of estrus helps to reduce clinical vaginitis in dairy goats and does not seem to be the cause of positive results in microbial inhibitor tests used to detect antibiotics in goat milk.

"A short trauma course for physicians in a resource-limited setting: Is low-cost simulation effective?"

INTRODUCTION

Morbidity and mortality from intentional and unintentional injury accounts for a high burden of disease in low- and middle-income countries. In addition to prevention measures, interventions that increase healthcare capacity to manage injuries may be an effective way to decrease morbidity and mortality. A trauma curriculum tailored to low-resource settings was implemented in Managua, Nicaragua utilising traditional didactic methods and novel low-cost simulation methods. Knowledge gain in attending and senior residents was subsequently assessed by using pre- and post-written tests, and by scoring pre- and post-simulation scenarios.

MATERIALS AND METHODS

A 5-day trauma course was designed for Nicaraguan attending and senior resident physicians who practice at six hospitals in Managua, Nicaragua. On days 1 and 5, participants underwent pre- and post-training evaluations consisting of a 26-question written exam and 2 simulation cases. The written exam questions and simulations were randomly assigned so that no questions or cases were repeated. The Wilcoxon signed-rank test was used to compare pre- and post-training differences in the written exam, and the percentage of critical actions completed in simulations. Time to critical actions was also analyzed using descriptive statistics.

RESULTS

A total of 33 participants attended the course, including 18 (55%) attending and 15 (45%) resident physicians, with a 97% completion rate. After the course, overall written examination scores improved 26.3% with positive mean increase of 15.4% (p<0.001). Overall, simulation scores based on the number of critical actions completed improved by 91.4% with a positive mean increase of 33.67 (p<0.001). The time to critical action for completion of the primary survey and cervical spine immobilisation was reduced by 55.9% and 46.6% respectively.

CONCLUSIONS

A considerable improvement in participants' knowledge of trauma concepts was demonstrated by statistically significant differences in both pre- and post-course written assessments and simulation exercises. The participants showed greatest improvement in trauma simulation scenarios, in which they learned, and subsequently demonstrated, a standardised approach to assessing and managing trauma patients. Low-cost simulation can be a valuable and effective education tool in low- and middle-income countries.

Effect In Vitro of Antiparasitic Drugs on Microbial Inhibitor Test Responses for Screening Antibiotic Residues in Goat's Milk

Microbial inhibitor tests are widely used to screen antibiotic residues in milk; however, these tests are nonspecific and may be affected by various substances capable of inhibiting the growth of the test microorganism. The objective of this study was to determine the effect of antiparasitic drugs in goat's milk on the microbial inhibitor test response. Raw antibiotic-free milk from Murciano-Granadina goats was supplemented with eight concentrations of seven antiparasitic substances (albendazole, 10 to 170 mg/kg; closantel, 1 to 140 mg/kg; diclazuril, 8 to 45 mg/kg; febendazole, 10 to 140 mg/kg; levamisole, 40 to 440 mg/kg; diazinon, 8 to 45 mg/kg; and ivermectin, 40 to 200 mg/kg). Twelve replicates for each concentration were analyzed with three microbial inhibitor tests: BRT MRL, Delvotest SP-NT MSC, and Eclipse 100. The results were interpreted visually (negative or positive). Using a logistic regression model, the concentrations of the antiparasitic drugs producing 5% (IC5), 10% (IC10), and 50% (IC50) positive results were determined. In general, the Eclipse 100 test was less sensitive to the effect of antiparasitic substances; the inhibitory concentrations of almost all the drugs assayed were higher than those for other tests. Conversely, the BRT MRL test was most affected, with high levels of interference at lower antiparasitic drug concentrations. Closantel and diazinon interfered with all microbial tests at lower concentrations than did other drugs (IC5 = 1 to 26 and 12 to 20 mg/kg, respectively), and higher concentrations of levamisole and diclazuril (IC5 = 30 to 240 and 50 to 117 mg/kg, respectively) were required to produce 5% positive results. These findings indicate that microbial inhibitor tests can be affected by elevated concentrations of antiparasitic drugs in goat's milk.

The Notch ligand DLL4 specifically marks human hematoendothelial progenitors and regulates their hematopoietic fate

Notch signaling is essential for definitive hematopoiesis, but its role in human embryonic hematopoiesis is largely unknown. We show that in hESCs the expression of the Notch ligand DLL4 is induced during hematopoietic differentiation. We found that DLL4 is only expressed in a sub-population of bipotent hematoendothelial progenitors (HEPs) and segregates their hematopoietic versus endothelial potential. We demonstrate at the clonal level and through transcriptome analyses that DLL4(high) HEPs are enriched in endothelial potential, whereas DLL4(low/-) HEPs are committed to the hematopoietic lineage, albeit both populations still contain bipotent cells. Moreover, DLL4 stimulation enhances hematopoietic differentiation of HEPs and increases the amount of clonogenic hematopoietic progenitors. Confocal microscopy analysis of whole differentiating embryoid bodies revealed that DLL4(high) HEPs are located close to DLL4(low/-) HEPs, and at the base of clusters of CD45+ cells, resembling intra-aortic hematopoietic clusters found in mouse embryos. We propose a model for human embryonic hematopoiesis in which DLL4(low/-) cells within hemogenic endothelium receive Notch-activating signals from DLL4(high) cells, resulting in an endothelial-to-hematopoietic transition and their differentiation into CD45+ hematopoietic cells.

Spin crossover in iron(ii) complexes with ferrocene-bearing triazole-pyridine ligands

Thermal- and light-induced spin crossover properties of two iron(ii) complexes derived from a ferrocene-appended triazole-pyridine ligand are described.

Short communication: Goat colostrum quality: litter size and lactation number effects

The quality of colostrum of Murciano-Granadina goats was studied to establish the transition period and the time when milk can be marketed. Forty-three dairy goats were used: 19 primiparous (15 single births; 4 multiple births) and 24 multiparous (10 single births; 14 multiple births). Samples were collected every 12h during the first week postpartum. Physicochemical parameters and somatic cell count were determined. Analysis of variance with repeated measures was used to study the effect of different factors: postpartum time, litter size, lactation number, their interactions, and production level on colostrum. Postpartum time had a significant effect on all parameters studied, which decreased along the first week of lactation, whereas lactose, pH, and conductivity increased. Based on these results, colostrum secretion takes place until 36 h postpartum (hpp). In relation to other factors of variation studied, the lactation number influenced most colostrum components, whereas the litter size only affected the pH value, protein and lactose content. The production level influenced only the protein and dry matter contents, with an inverse relationship. Milk produced during the period between 36 and 96 hpp is considered transition milk, which should not be commercialized. Milk collected after 4d postpartum (96 hpp) could be marketed, ensuring that its composition does not present a risk in the dairy industry.

Evaluation of the Charm maximum residue limit β-lactam and tetracycline test for the detection of antibiotics in ewe and goat milk

The Charm maximum residue limit β-lactam and tetracycline test (Charm MRL BLTET; Charm Sciences Inc., Lawrence, MA) is an immunoreceptor assay utilizing Rapid One-Step Assay lateral flow technology that detects β-lactam or tetracycline drugs in raw commingled cow milk at or below European Union maximum residue levels (EU-MRL). The Charm MRL BLTET test procedure was recently modified (dilution in buffer and longer incubation) by the manufacturers to be used with raw ewe and goat milk. To assess the Charm MRL BLTET test for the detection of β-lactams and tetracyclines in milk of small ruminants, an evaluation study was performed at Instituto de Ciencia y Tecnologia Animal of Universitat Politècnica de València (Spain). The test specificity and detection capability (CCβ) were studied following Commission Decision 2002/657/EC. Specificity results obtained in this study were optimal for individual milk free of antimicrobials from ewes (99.2% for β-lactams and 100% for tetracyclines) and goats (97.9% for β-lactams and 100% for tetracyclines) along the entire lactation period regardless of whether the results were visually or instrumentally interpreted. Moreover, no positive results were obtained when a relatively high concentration of different substances belonging to antimicrobial families other than β-lactams and tetracyclines were present in ewe and goat milk. For both types of milk, the CCβ calculated was lower or equal to EU-MRL for amoxicillin (4 µg/kg), ampicillin (4 µg/kg), benzylpenicillin (≤ 2 µg/kg), dicloxacillin (30 µg/kg), oxacillin (30 µg/kg), cefacetrile (≤ 63 µg/kg), cefalonium (≤ 10 µg/kg), cefapirin (≤ 30 µg/kg), desacetylcefapirin (≤ 30 µg/kg), cefazolin (≤ 25 µg/kg), cefoperazone (≤ 25 µg/kg), cefquinome (20 µg/kg), ceftiofur (≤ 50 µg/kg), desfuroylceftiofur (≤ 50µg/kg), and cephalexin (≤ 50 µg/kg). However, this test could neither detect cloxacillin nor nafcillin at or below EU-MRL (CCβ >30 µg/kg). The CCβ for tetracyclines was also lower than EU-MRL for chlortetracycline (ewe milk: ≤ 50 µg/kg; goat milk: 75 µg/kg), oxytetracycline (≤ 50 µg/kg), and tetracycline (≤ 50 µg/kg). Regarding the 4-epimers of these tetracyclines only 4-epioxytetracycline was detected by the Charm MRL BLTET test below EU-MRL (ewe milk: 75 µg/kg; goat milk: ≤ 50 µg/kg). Acidiol had no effect on the performance of the test. The Charm MRL BLTET test could be used routinely with adapted test procedure for the fast screening of ewe and goat milk.

Overcoming barriers in the management of hypertension: the experience of the cardiovascular health program in chilean primary health care centers

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP). Design. A cross-sectional and multicenter study. Setting. 52 primary care centers, metropolitan area of Santiago, Chile. Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients. Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period. Results. 59.7% of patients reached target BP <140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control. Conclusions. The success in improving the BP control to values <140/90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics.

Stagnant in cardiovascular prevention: alarming trends and persistent socioeconomic obstacles

Recently it has been suggested that the decline in cardiovascular mortality observed over the last 50 years may be coming to an end. This alarming trend, which has been noted mainly in younger adults from lower socioeconomic strata, may be linked to other changes, namely the increasing prevalence of modifiable risk factors, the most important of which is obesity. In contrast, our ability to predict cardiovascular risk continues to improve steadily, although it is unclear which will be its ability in designing more effective global preventive measures. Coronary heart disease appears to develop through multiple pathways, whose association with cardiovascular risk is mediated by complex processes involving numerous factors ranging from genetic predisposition to unfavorable socioeconomic circumstances. Although some attention has been paid to the latter, more effort has been put into controlling isolated risk factors. For example, numerous large studies have involved looking at the effect of single-drug therapies aimed at specific targets rather than examining more comprehensive approaches to managing multiple risk factors. In conclusion, an effective strategy for controlling modifiable risk factors in both individuals and populations must address this complex scenario and should consider significant socioeconomic factors such as education, income and the built environment. The unfavorable trend observed in cardiovascular health makes it essential that current preventive strategies are reassessed.

Impact of education, income and chronic disease risk factors on mortality of adults: does 'a pauper-rich paradox' exist in Latin American societies?

OBJECTIVES

To test the hypothesis that an inverse association exists between socio-economic position and all-cause mortality in a developing country in Latin America.

STUDY DESIGN

Prospective cohort study carried out in Chile using data from a simple random sample of 920 apparently healthy subjects (weighted population 11,600 aged 30-89 years) followed for 8 years.

METHODS

Education level (0-8 years, 9-12 years and > or = 13 years) and income quartiles were established at the outset of the study, along with behavioural and biological risk factors for chronic diseases: smoking, alcohol use, obesity, diabetes, hypertension, lipids and family history of death by cardiovascular disease. Relative risks of all-cause mortality were estimated using age-adjusted Cox regression models.

RESULTS

During the follow-up period, 46 deaths were observed. Adjusting for age, gender, and behavioural and biological risk factors, the mortality risk for increasing categories of education after controlling for income was 1.0, 0.76 and 0.33 (P for trend<0.01). In contrast, the relative risk for increasing levels of income after controlling for education was 1.0, 0.98, 1.33 and 1.17 (P for trend=0.07).

CONCLUSION

While education level had a protective effect on mortality risk of Chilean adults, income had a slightly unfavourable effect on survival. This finding is described as suggestive of a 'pauper-rich paradox', since the higher income quantiles in this study correspond with the lower income levels in most developed countries. Nevertheless, due to the small number of deaths, additional research is required to assess the validity of these findings.

[Modifiable cardiovascular risk factors: which ones are we really modifying?]

While efforts to identify the underlying mechanisms that lead to endovascular atherogenesis continue, the clinical management of the modifiable cardiovascular risk factors should depend on the most advantageous risk-benefit and cost-effective therapies. However these efforts probably will not have a significant impact in the population at risk unless an improvement in the socioeconomic factors of cardiovascular risk occurs. The ongoing global obesity epidemic reinforces the need for these changes. Public and privately sponsored programs and policies to improve education and access to health resources are important components of this process .

Impact of parity on anthropometric measures of obesity controlling by multiple confounders: a cross-sectional study in Chilean women

AIM

To find out whether there is an association between parity and obesity, evaluated through body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) in Chilean women after controlling for sociodemographic characteristics, health risk and gynaeco-obstetric factors.

DESIGN

Cross-sectional study, using baseline data of the San Francisco Project.

SETTING

San Francisco de Mostazal, located in the central region of Chile, 6512 Chilean-Hispanic women (Spanish heritage with a variable indigenous component).

METHODS

A weighted random sample of 508 women who had their first pregnancy inside the primary child-bearing ages. Data were collected between 1997 and 1999. Statistical associations between parity and different anthropometric measurements of adiposity in multiple linear (MLnR) and logistic regression models (MLtR) were evaluated.

RESULTS

In MLnR a modest parity-related increment in BMI and practically null increment in WC, WHR and WHtR was observed. Covariates that showed a statistically significant association with anthropometric measures of adiposity were age, low education, marital status, employment, smoking, smoking cessation, hypertension, diabetes, dyslipidaemia, parent's obesity, menarche and fetal macrosomia. Crude odds ratio (OR) showed a strong association between parity and anthropometric markers of obesity. Nevertheless, after adjustments in MLtR models, the association remained only for BMI. All the measures of abdominal obesity related to parous women showed OR smaller than 1 (95% confidence intervals 0.57 to 0.96).

CONCLUSIONS

Parity modestly influences BMI, but does not seem to be related to WC, WHR and WHtR after controlling by confounders. Parity can increase adiposity but not necessarily following an abdominal pattern.

Objective firmness, average pressure and subjective perception in mattresses for the elderly

For elderly people, the desirable situation of living independently means facing everyday tasks and risks alone [Monk et al., 2006. Towards a practical framework for managing the risks of selecting technology to support independent living. Appl. Ergon. 37, 599-606]. One such task is buying a mattress through the same channels as younger people. Quite short trials (if any) in the store are usually the only basis for choice. Despite the long-term effects a mattress may have on the user, acceptance or rejection largely depends on this extremely short trial experience. This paper aims to cover the salient mechanical aspects of comfort and usability (rolling, getting up). The results should help manufacturers to know if the long-term benefits of their products are perceived in the short term by senior citizen customers. Four mattresses for the elderly chosen from a sample of 17 available on the Spanish market were compared in pairs for short-term effects (1 min pressure with both hands, 1 min sitting, 1 min lying on back, and 1 min lying on side), simulating a store purchasing trial by a group of young and elderly people in terms of differences between perceived firmness, usability (ease of movement) and comfort. The results of these comparisons were correlated to differences in objective properties such as pressure distribution and objective firmness. No differences in perception were found between young and old users. Only two of the four test methods for perceiving mattress firmness were necessary to explain the majority of variance: pressing the surface of the mattress with a part of the body (both hands or buttocks), and contact using the entire body (lying on back or side). A number of significant relationships were found, with the following of note: increments in 'objective firmness' (estimated from test load/deflection) correlate positively to increments in 'perceived firmness'; increments in 'average pressure' (measured using a mannequin) correlate positively to increments (within certain limits) in 'perceived firmness'; increments in 'objective firmness' and in 'average pressure' are associated with increments in 'overall comfort' and with reductions in 'difficulty in rolling". Finally, it was found that people with a higher body mass index tend to be (weak correlation) more sensitive to changes in 'objective firmness'.

[Mixedematous ileus; acute abdomen exacerbate.]

The surgical literature contains few reports about effects of hypothyroidism in patients with acute abdomen; has been reported that a glycoprotein infiltrate the lining of the bowel leading to denervation. We report the case of a woman with acute abdomen secondary to pyosalpynx with uncontrolled hypothyroidism postoperative complications.Hypothyroidism is called "big mimicker"because its clinic spectrum ranges from anasymptomatic subclinical condition to the rare,life-threatening myxedema coma, and thus can bea challenging diagnosis to make. Unrecognized hypothyroidism may lead to unnecessary surgery or even a potentially fatal outcome. A heightened awareness of this not so uncommon entity is mandatory

[Socioeconomic and educational inequities as independent predictors for mortality in a developing country: A cohort study in San Francisco, Chile]

BACKGROUND

The socioeconomic position (SEP) and educational level of individuals have an inverse correlation with mortality in developed societies.

AIM

To assess in a society undergoing a socioeconomic transition, the mortality risk associated to a low SEP (combination of education and income, scale 0-25 points, reference > 10 points) and low education (education years, reference > 8 years), adjusting for other known risk factors.

MATERIAL AND METHODS

In this prospective cohort study, a random sample of 920 subjects, living in San Francisco de Mostazal, Chile, aged more than 20 years (395 males) was examined for the first time in 1997-1999 and re-examined in 2005-2006. All had information about economic household income and level of education. A Cox regression model was used to evaluate the association between mortality and socioeconomic measures.

RESULTS

The crude mortality hazard ratio (HR) was 3.34 (95% confidence interval (CI) 2.88-3.87) and 6.05 (95% CI 5.04-7.26) for low SEP and low educational level, respectively. After adjusting for age, gender, hypertension, diabetes, dyslipidemia, abdominal obesity, smoking, alcohol intake and family history of cardiovascular disease, the figures were 1.23 (95% CI 1.04-1.43) and 1.54 (95% CI 1.23-1.85) for low SEP and low educational level, respectively.

CONCLUSIONS

In a society in socioeconomic transition, low SEP and especially low educational level are risk factors for mortality even after adjusting for known mortality risk factors.