Welfare and performance of yearling dairy heifers out-wintered on a wood-chip pad or housed indoors on two levels of nutrition.

Wood-chip pads represent a low-cost alternative to housing for cattle during the winter. Considering the negative welfare implications associated with housing indoors on concrete, they may also offer welfare benefits to replacement dairy heifers. However, these animals may not be able to withstand winter weather conditions on a grass silage diet. The aim of this experiment was to evaluate behaviour, limb injuries, dirtiness scores, performance and climatic energy demand (CED) of yearling dairy heifers on two levels of nutrition kept outdoors on a wood-chip pad or indoors in cubicles during the winter. Ninety-six 10-month-old heifers were blocked and assigned in groups of eight, to one of the following four treatments in a 2 × 2 factorial design: (a) indoors, silage only; (b) indoors, silage plus concentrate; (c) outdoors, silage only; and (d) outdoors, silage plus concentrate. There were three replicate groups per treatment. All animals were inspected for skin lesions and were weighed and body condition scored (BCS) at the beginning and end of the trial. Instantaneous scan sampling and continuous all-occurrence behaviour sampling were used to collect behaviour data during two 24-h periods. Animals were also dirtiness scored and group feed intakes were recorded during the trial. Significantly more comfort, social and play behaviours were recorded outdoors (P < 0.05) while trips, slips and falls were only recorded indoors (P < 0.001). Groups outdoors had significantly lower limb lesion scores at the end of the experiment (P < 0.05) and fewer groups outdoors were affected by all categories of limb lesions. However, they were consistently dirtier than animals indoors (P < 0.001). Low-nutrition animals had lower feed intakes, smaller BCS changes and lower average daily weight gains than high-nutrition animals (P < 0.01). Heifers outdoors had significantly lower average daily weight gains and BCS changes (P < 0.05) explained by lower feed intakes (P < 0.01). However, outdoor heifers on both the high- and low-nutrition diets and indoor animals on the low-nutrition diet had lower UFL (feed unit for maintenance and lactation (Irish Republic)) intakes (-0.36, -0.35 and -0.22, respectively) than that required to meet the daily live-weight gains they achieved. Heifers indoors on the high-nutrition diet gained 0.98 kg per day but consumed 0.17 UFL more than what would be recommended to achieve a daily weight gain of 1.0 kg. The CED for outdoor heifers was higher than that of indoor heifers (6.18 v. 5.47 MJ/day per m2 body surface area; P < 0.001, s.e.d. 0.044). However, CED did not exceed heat production in any treatment. Although animal performance was reduced outdoors, the wood-chip pad was associated with welfare benefits compared with cubicle housing.

Essential fatty acids and phospholipase A2 in autistic spectrum disorders.

A health questionnaire based on parental observations of clinical signs of fatty acid deficiency (FAD) showed that patients with autism and Asperger's syndrome (ASP) had significantly higher FAD scores (6.34+/-4.37 and 7.64+/-6.20, respectively) compared to controls (1.78+/-1.68). Patients with regressive autism had significantly higher percentages of 18:0,18:2n-6 and total saturates in their RBC membranes compared to controls, while 24:0, 22:5n-6, 24:1 and the 20:4n-6/20:5n-3 ratio were significantly higher in both regressive autism and ASP groups compared to controls. By comparison, the 18:1n-9 and 20:4n-6 values were significantly lower in patients with regressive autism compared to controls while 22:5n-3, total n-3 and total dimethyl acetals were significantly lower in both regressive autism and ASP groups compared to controls. Storage of RBC at -20 degrees C for 6 weeks resulted in significant reductions in highly unsaturated fatty acid levels in polar lipids of patients with regressive autism, compared to patients with classical autism or ASP, or controls. Patients diagnosed with both autism and ASP showed significantly increased levels of EPA ( approximately 200%) and DHA ( approximately 40%), and significantly reduced levels of ARA ( approximately 20%), 20:3n-6 and ARA/EPA ratio in their RBC polar lipids, when supplemented with EPA-rich fish oils, compared to controls and non-supplemented patients with autism. Patients with both regressive autism and classical autism/Asperger's syndrome had significantly higher concentrations of RBC type IV phospholipase A2 compared to controls. However, patients with autism/ASP, who had taken EPA supplements, had significantly reduced PLA2 concentrations compared to unsupplemented patients with classical autism or ASP.

Development and validation of a short measure of health status for individuals with acute myocardial infarction: the myocardial infarction dimensional assessment scale (MIDAS).

The purpose of this study was to develop and validate a disease-specific health status measure for individuals with myocardial infarction (MI). The development of the myocardial infarction dimensional assessment scale (MIDAS) followed three main stages. Stage 1 consisted of in-depth, semi-structured, exploratory interviews conducted on a sample of 31 patients to identify areas of salience and concern to patients with MI. These interviews generated 48 candidate questions. In stage 2 the 48-item questionnaire was used in a postal survey to identify appropriate rephrasing/shortening, to determine acceptability and to help identify sub-scales of the instrument addressing different dimensions of MI. Finally, in stage 3 the construct validity of MIDAS subscales was examined in relation to clinical and other health outcomes. A single centre (district general hospital) in England was used for stages 1 and 3 and a national postal survey was conducted for stage 2. A total of 410 patients were recruited for the national survey (stage 2). Full data were available on 348 (85%) patients. One hundred and fifty-five patients were recruited to test construct validity (stage 3). The MIDAS contains 35 questions measuring seven areas of health status: physical activity, insecurity, emotional reaction, dependency, diet, concerns over medication and side effects. The measure has high face, internal and construct validity and is likely to prove useful in the evaluation of treatment regimes for MI.

Increased levels of cytosolic phospholipase A2 in dyslexics.

Research findings are increasingly reporting evidence of physiological abnormalities in dyslexia and sites for dyslexia have been identified on three chromosomes. It has been suggested that genetic inheritance may cause phospholipid abnormalities in dyslexia somewhat similar to those found in schizophrenia. A key enzyme in phospholipid metabolism, Type IV, or cytosolic, phospholipase A2 (cPLA2), releases arachidonic acid (AA), a 20-carbon fatty acid, which is the major source of production of prostaglandins and leukotrienes. An entirely new assay, which for the first time has enabled determination of the amount of the enzyme rather than its activity, was used to measure cPLA2 in dyslexic-type adults and controls and the two groups were found to differ significantly, the dyslexic-types having more of the enzyme. A report elsewhere of schizophrenics having even greater amounts of the enzyme suggests that dyslexia may be on a continuum with schizophrenia, as may be other neurodevelopmental disorders - which have also been described as phospholipid spectrum disorders.

Determining chest pain patients' suitability for transfer to a general ward following admission to a cardiac care unit.

The objective of this study was to assess the performance of a consensus-derived decision algorithm in determining chest pain patients' suitability for early transfer to a lower dependency ward by predicting complications. The sample comprised 516 patients with chest pain presumed to be cardiac in origin, admitted to a cardiac care unit (CCU) in northern England from the community or from the accident and emergency department. A decision algorithm was designed following a review of the literature and amended to take into account a clinical consensus of consultant physicians. Patients were assessed on admission by CCU nurses using the algorithm, and 'triage' decisions recorded (keep on CCU or suitable for early transfer to a general ward). Admission ECGs (electrocardiographs) and baseline clinical data were recorded independently by a researcher 'blinded' to actual clinical course, and applied to the algorithm using statistical software. On discharge or death, patients' case notes were retrieved and the hospital course examined for death or severe complications. Performance of the algorithm and CCU nurses were compared for sensitivity, specificity, positive predictive value and negative predictive value. The main outcome measures were death or severe complications occurring during hospitalization, and during the first 2 days following CCU admission. While sensitivity of both the algorithm (0.98) and CCU nurses (0.95) was high, specificity was low in both groups (0.11 and 0.21, respectively), making it unlikely that the algorithm would prove useful in clinical practice. Further studies are required to develop the optimal triage tool for the assessment of patients with acute chest pain.

Parental decisions to use infant walkers.

OBJECTIVE: To assess parental decision making in the acquisition of an infant walker and the influences surrounding that decision. DESIGN/METHODS: Caretakers of children attending a residents' continuity practice during a one month period were invited to participate in a structured interview to assess various aspects of infant safety. Ten questions specifically addressed infant walkers and the decision to acquire one; seven questions collected demographic data. RESULTS: One hundred and fifty four primary caretakers participated. Of these, 77% (n = 119) of caretakers used infant walkers for their child. For children who were not first born, 85% of caretakers had used walkers with their other children. No statistically significant differences were found between walker users and non-users with respect to the sex or birth order of the child, race, education, or (type of) caretaker. Also, no differences were found between these groups with respect to having received safety information from the pediatrician. For users, 97% heard about walkers before their baby's birth, but 65% did not decide to use one until after the birth. In addition, 61% of walker users stated that no one influenced their decision to get a walker and 75% bought their own. These decisions were not affected by caretaker education or birth order of the child. Finally, 78% believed that walkers were beneficial, and 72% believed that walker use accelerated development of independent walking skills. CONCLUSIONS: Mothers purchased walkers because of no uniformed perception of benefit. A period of time, up to several months in length, exists from when the first mother hears about walkers until she decides to purchase one. Until legislation can be passed banning walkers, this period of time may provide a window of opportunity for appropriate anticipatory guidance in the form of intense media assisted, antiwalker campaigns.

Nutritional intake in children with renal insufficiency: a report of the growth failure in children with renal diseases study.

OBJECTIVE: This study was designed to assess sequentially the nutrient intake in children with chronic renal insufficiency and its relationship to body size, the level of renal failure, and growth velocity. METHODS: The nutrient intake from 401 4-day food records obtained from 120 children with renal insufficiency over a 6-month observation period was analyzed. The height and weight were measured at the beginning and end of the observation period. The glomerular filtration rate was estimated from the height and serum creatinine. RESULTS: The mean caloric intake in these children was 80 +/- 23% (mean +/- SD) of the Recommended Dietary Allowance (RDA) for age. Fifty-six percent of the food records obtained from these children revealed a caloric intake that was less than 80% of the RDA. Caloric intake expressed as the %RDA for age decreased with increasing age. However, the mean caloric intake when factored by body weight was in the normal range. There was no correlation between caloric intake and height velocity. The mean protein intake in these children was 153 +/- 53% of the RDA. Further, 45% of the food records indicated a protein intake greater than 150% of the RDA. There was no relationship between the degree of renal insufficiency and caloric or protein intake. Calcium, vitamin, and zinc intakes were also low. CONCLUSIONS: Children with chronic renal failure consume less calories than their age matched peers, but the majority of these children appear to ingest adequate amounts for their body mass. This reduction in caloric intake occurs early in renal insufficiency. They also ingest inadequate amounts of calcium, zinc, vitamin B6, and folate.

Evaluation of the safety of nurse-assisted percutaneous endoscopic gastrostomy.

Percutaneous endoscopic gastrostomy (PEG) procedures have become a common, nonsurgical approach to providing enteral access to patients who are otherwise unable to meet their nutritional needs by mouth. Historically, two physicians have been required to complete this procedure; the first performed the endoscopy while the second helped to position the PEG tube. As a result of constraints on physicians' time and availability, as well as increased medical costs, this process has changed in some settings where the procedure is accomplished by one physician who performs the endoscopy and directly observes a nurse who acts in the role of the second physician. This research study was designed to evaluate the safety of nurse-assisted PEG procedures by comparing the complications of placement (i.e., infection, hemorrhage, perforation, and ileus) with those complications that occur when two physicians perform the procedure. The current standard of care for placing PEG tube was followed. Results in this small sample show that nurse-assisted PEG procedures are as safe as when two physicians perform this procedure.

Complications of mastectomy and their relationship to biopsy technique.

BACKGROUND: Wound complication rates after mastectomy are associated with several factors, but little information is available correlating biopsy technique with the development of postmastectomy wound complications. Fine-needle aspiration (FNA) biopsy is an accurate method to establish a diagnosis, but it is unknown whether this approach has an impact on complications after mastectomy. METHODS: Charts of 283 patients undergoing 289 mastectomies were reviewed to investigate any association between biopsy technique and postmastectomy complications. RESULTS: The diagnosis of breast cancer was made by FNA biopsy in 50%, open biopsy in 49.7%, and core needle biopsy in 0.3%. The overall wound infection rate was 5.3% (14 of 266), but only 1.6% when FNA biopsy was used compared with 6.9% with open biopsy (p = 0.06). Among 43 patients undergoing breast reconstruction concomitantly with mastectomy, the infection rate was 7.1% (0% after FNA, 12% after open biopsy). Neither the development of a postoperative seroma (9.8%) nor skin flap necrosis (5.6%) was influenced by the biopsy technique used. CONCLUSIONS: These data suggest that wound infections after mastectomy may be reduced when the diagnosis of breast cancer is established by FNA biopsy.

Planning for coronary angioplasty: guidelines for training and continuing competence. British Cardiac Society (BCS) and British Cardiovascular Intervention Society (BCIS) working group on interventional cardiology.

The following recommendations are made: 1 Existing centres undertaking angioplasty should increase their activity, and the target figure of 400 PTCA procedures per million of the United Kingdom population should be achieved by the end of 1996-97, or immediately thereafter. 2 Angioplasty centres should be appropriately equipped to undertake PTCA safely and effectively and provide a reliable emergency service. They should have a minimum of two trained PTCA operators jointly undertaking a minimum of 200 procedures per year at that centre, and have regular meetings to share experience. 3 Angioplasty operators should ensure that where the need arises patients undergoing PTCA can receive immediate attention from a trained operator at any time until discharge from hospital. 4 Trained operators should undertake at least 1-2 PTCA procedures per week (> 60 procedures per year) to maintain competence, and those undertaking so few procedures should increase their activity over the next three years to more than 100 a year. 5 Trainers should have performed at least 500 procedures before formally training others and should undertake a minimum of 125 procedures a year to maintain accreditation as a trainer. 6 Surgical cover for PTCA procedures should be mandatory and on site cover remains the strongly preferred option. Where surgical cover is provided off site, this should be at a centre less than 30 minutes away by road. Whether provided on or off-site it should be possible to establish cardiopulmonary bypass within 90 minutes of the decision being made to refer the patient for surgery. 7 All operators and interventional centres should audit their activity and results, review these data locally with colleagues, and provide regular audit returns to the national database run by BCIS. This will allow future recommendations concerning standards to take more account of risk stratification and actual outcomes, and not place such emphasis merely on volumes of activity. 8 These recommendations should be reviewed in three years.

Safety of thrombolytic treatment in patients with central venous cannulation.

OBJECTIVES: To determine the safety of thrombolytic treatment in patients with central venous cannulation. BACKGROUND: Thrombolytic treatment significantly reduces mortality in patients with myocardial infarction. Because of the fibrinolytic state induced and the potential for haemorrhagic complications, thrombolysis is currently considered a strong relative contraindication in patients who have had central venous cannulation. There are few data available to support this practice. METHODS: Complications in 56 consecutive patients admitted between 1989 and 1992 with infarction and who had cannulation shortly before, or within 24 h of thrombolysis were studied. RESULTS: Central venous access was achieved via the subclavian route in 52 patients, the internal jugular in three, and the supraclavicular in one. The main indications were for inotropic drugs in 15 patients, pacing in 17, amiodarone infusion in 19, and pressure monitoring in five. Minor haemorrhagic complications occurred in five patients. Two of these patients required either blood or plasma transfusion. Possible major haemorrhagic complications occurred in one patient who became hypotensive shortly after cannulation. Two further patients with severe cardiac failure became hypotensive after cannulation but there was no radiological evidence of effusion and the hypotension was attributed to worsening cardiac failure. Importantly, none of the 19 patients who had cannulas for amiodarone infusion developed significant bleeding complications. CONCLUSION: Central cannulation in the fibrinolytic state is associated with a low incidence of important bleeding complications. Thrombolysis should not be withheld in these patients. Cannulation via the subclavian route, however, should be avoided in patients undergoing thrombolysis.

Are pediatricians ready for the new guidelines on lead poisoning?

In 1991 the Centers for Disease Control established new guidelines for the definition of and screening for lead poisoning. OBJECTIVE. To assess: (1) pediatricians' knowledge of lead poisoning including the most recent literature on the subject, and (2) their screening practices. DESIGN, SETTING, SUBJECTS. A 22-item questionnaire was developed and validated. The survey was mailed to 1183 physicians in Virginia who were self-designated as pediatricians in the state medical registry. RESULTS. Sixty-nine percent (391/556) of those responding They were evenly distributed throughout the state. Of the respondents, 62% were male, 86% were white, and 72% trained at a university program. The median year for training completion was 1978. Demographic differences were not demonstrated (chi 2) between primary care pediatricians and subspecialists. Responses demonstrated an overall deficiency in physicians' knowledge of lead poisoning with specific deficiencies in knowledge of the literature, with mean +/- SD correct responses of 15.7 +/- 3.4. Primary care pediatricians scored significantly better than subspecialists: 16.2 +/- 3.0 vs 14.7 +/- 4.1 (P < .001, t-test). Twelve percent of the total group and 13.5% of primary care physicians were screening all their patients. CONCLUSIONS. Although primary care pediatricians (self-designated) are more knowledgeable about lead poisoning than their subspecialist colleagues, there are still deficiencies, and screening practices must be modified in both groups. To successfully implement the new Centers for Disease Control and Prevention guidelines, physician education must be a priority.

Masking of physicians in the Growth Failure in Children with Renal Diseases Clinical Trial.

Masking--hiding identities of treatments from the patient, physician and/or statistician--is a critical element in clinical trials. Wherever possible, masking is implemented to eliminate observational bias or systematic error. In this paper, general concepts of masking in clinical trials are examined. Specific masking procedures used in the "Growth Failure in Children with Renal Diseases" (GFRD) Clinical Trial are described. A method to evaluate the "success" of this masking procedure for physicians is introduced. For each randomized patient at each clinical center, the clinic director was asked to predict which treatment (1,25-dihydroxyvitamin D3 or dihydrotachysterol) was assigned. Results showed that 72% of responses initially indicated "absolutely no idea" of treatment. Additional analyses revealed that the number and percentage of "correct" guesses were essentially equal for the two treatment groups and that a patient's time on treatment did not affect the mask. We conclude that the mask of physicians in the GFRD Clinical Trial was well maintained.

Malignant thymoma causing tricuspid valve obstruction.

A 57-year-old man presenting with a retrosternal mass was found to have a malignant thymoma. This was treated with surgery and radiotherapy. It recurred 5 years later as an intra-cardiac mass causing tricuspid valve obstruction.

Masking procedure, randomization and stratification, and compliance monitoring in the Growth Failure in Children with Renal Diseases Study.

Ensuring the integrity of a study such as the GFRD Study requires close cooperation among all groups involved with the study and the patient. Many factors may influence the outcome and validity of a multicenter, double-masked, randomized trial. Any dosage modifications that may need to be made rely totally on established communication between the centers, the DCC, and the Core Pharmacy. When the procedures outlined above are followed, masking is ensured and patient compliance can be measured.

Assessing the efficacy of azaprophen and physostigmine as a pretreatment for soman-induced incapacitation in guinea pigs by response-surface modeling.

Physostigmine (PHY) has the advantage over pyridostigmine of minimizing OP-induced incapacitation because it penetrates into the CNS. However, physostigmine is behaviorally toxic at relatively low concentrations. It is anticipated that this could be offset by a cholinolytic to prevent behavioral deficit due to the carbamate pretreatment alone. The therapeutic efficacy of physostigmine/azaprophen pretreatment therapy was evaluated in soman-challenged guinea pigs. Response surface methodology was employed to describe the relationship of the pretreatment combination with duration of incapacitation. The significance of the combination relative to PHY alone was evaluated in addition to dose combinations that yield optimal time to recovery. Analysis of the fitted response surface indicated that combination pretreatment with these compounds significantly reduces the time to recovery after soman challenge versus pretreatment with PHY alone.

Data coordination and management in the Growth Failure in Children with Renal Diseases Study.

The DDC of the GFRD Study works closely with the Administrative Core and with all participating clinical centers to ensure the timely collection of accurate, reliable, and complete data. The development and maintenance of a data-base management system, including continuous monitoring of all data, represent primary responsibilities of the DCC. Coordination and communication tasks in the multicenter study have been challenging but rewarding. Proper planning and positive attitudes have enhanced the effectiveness of the DCC throughout this clinical trial.