An exploration into the sleep of workers on block-calving, pasture-based dairy farms.

The benefits of sufficient and high-quality sleep for people are well documented. Insufficient sleep increases the risk of accidents, injuries, and negative health implications for people. This is especially relevant for farmers, as they work with large animals and machinery. Dairy farming often requires early start times and long days, particularly over the high workload calving period in block calving, pasture-based systems. However, there is little published data quantifying the sleep quantity and quality of farmers over this period. In this study, the sleep patterns of workers (n = 33) on 10 New Zealand dairy farms was measured for 90 d over the spring calving period using a sleep measuring device (OuraTM ring, Oura Health Ltd., Oulu, Finland). Total sleep time (TST) averaged 6 h 15 min, lower than the required 7 to 9 h for optimal wellbeing and cognitive functioning. TST decreased over the calving period and was significantly correlated with both sleep start and wake times. Factors such as work start time, farm location, and role on farm influenced sleep quantity and quality; indicating adjusting these on-farm factors could positively impact TST. Further research is required to better understand sleep and its effect on dairy farmers, over both the calving period and the remaining months of the year.

Responsible robotics design-A systems approach to developing design guides for robotics in pasture-grazed dairy farming.

Application of robotics and automation in pasture-grazed agriculture is in an emergent phase. Technology developers face significant challenges due to aspects such as the complex and dynamic nature of biological systems, relative cost of technology versus farm labor costs, and specific market characteristics in agriculture. Overlaying this are socio-ethical issues around technology development, and aspects of responsible research and innovation. There are numerous examples of technology being developed but not adopted in pasture-grazed farming, despite the potential benefits to farmers and/or society, highlighting a disconnect in the innovation system. In this perspective paper, we propose a "responsibility by design" approach to robotics and automation innovation, using development of batch robotic milking in pasture-grazed dairy farming as a case study. The framework we develop is used to highlight the wider considerations that technology developers and policy makers need to consider when envisaging future innovation trajectories for robotics in smart farming. These considerations include the impact on work design, worker well-being and safety, changes to farming systems, and the influences of market and regulatory constraints.

Review: Anticipating alternative trajectories for responsible Agriculture 4.0 innovation in livestock systems.

Technological change has been a constant feature of livestock systems leading to the third agricultural 'green' revolution of the mid-20th century. Digital technologies are now leading us into the fourth agricultural revolution, where sustainable food production is supported by technologies that collect data useful for farm and supply chain performance improvement, along with task automation and compliance. However, the potential benefits of digital agricultural futures are uncertain and plagued by unrealized expectations of previous innovations. The aims of this paper are to articulate current trends in technology and livestock systems and anticipate future trajectories for Agriculture 4.0 in relation to meeting sustainability and animal welfare outcomes for livestock systems. We use a 'Futures Triangle' approach to review the role of technology in livestock systems. The main findings are that previous work envisioning technological livestock futures have favoured pull of the future factors (techno-optimists) or weight of the past (techno-pessimists), rather than a balance of pull, push and weighting factors. Responsible Agriculture 4.0 innovation requires public-private collaboration of innovation system stakeholders, including policy makers, farmers, consumers, as well as technology developers, to enable development of transition pathways from a systems perspective. The use of responsible innovation processes, including anticipation on alternative futures, should also be built into innovation processes to support critical reflection on technological trajectories and related innovation system consequences, both desirable and undesirable.

Analysis of adoption trends of in-parlor technologies over a 10-year period for labor saving and data capture on pasture-based dairy farms.

The use of precision technology is increasingly seen as an option to improve productivity, animal welfare, resource use efficiency, and workplace features on dairy farms. There is limited research related to longitudinal adoption patterns of precision dairy technologies and reasons for any patterns. The aim of this analysis was to investigate trends in technology adoption regarding both the amount (number of farms with a technology) and intensity (number of technologies per farm) of adoption. Surveys of parlor technology adoption were conducted on New Zealand dairy farms in 2008, 2013, and 2018, with 532, 500, and 500 respondents, respectively. Technologies were grouped into labor-saving (LS, such as automatic cluster removers) or data-capture (DC, such as in-line milk meters) categories. Trends were examined for farms that had only LS, only DC, or LS+DC technologies. Technology adoption increased over time; the likelihood of technology adoption in 2018 (and 2013 in parentheses) increased by 21 (22), 7 (68), and 378% (165) for LS, DC, and LS+DC technology groups, respectively, compared to 2008. Farms with LS+DC technologies also had a greater proportion of LS technologies compared to non-LS+DC farms, although this relationship declined over the 10-yr period. The use of a rotary versus herringbone parlor was estimated to be associated with 356 and 470% increase in the likelihood of adopting LS technologies and LS+DC, respectively, from 2008 to 2018. Regional differences in adoption were also found, with the likelihood of adopting DC and LS+DC technologies found to be 46 and 59% greater, respectively, in the South Island of New Zealand, compared to the base region of Waikato. The results highlight the importance of understanding spatial and temporal farm characteristics when considering future effect and adoption of precision dairy technologies. For example, the analysis indicates the occurrence of 2 trajectories to technology investment on farms, where larger farms are able to take advantage of technology opportunities, but smaller farms may be constrained by factors such as lack of economies of scale, limited capital to invest, and inability to retrofit technology into aging parlor infrastructure.

Short communication: Evaluation of an eating time sensor for use in pasture-based dairy systems.

The assessment of grazing behavior is important for research and practice in pasture-grazed dairy farm systems. However, few devices are available that enable assessment of cow grazing behavior at an individual animal level. This study investigated whether commercially available Smarttag "eating time" sensors (Nedap Livestock Management, Groenlo, the Netherlands) were suitable for recording the grazing time of cows. Smarttag sensors were mounted on the neck collars of multiparous Holstein-Friesian cows in a herd in Taranaki, New Zealand. Cows were randomly selected each observation day from the milking herd for 8 separate days across a 1-mo period. Trained observers conducted 90-min observation periods to evaluate the relationship between the sensor eating time measure and grazing time. A set of 5 defined cow behaviors (2 "head up" and 3 "head down" behaviors) were assessed. In total, observations of 37 cows were recorded in 14 sessions over 8 d in the study period, providing 55.5 total hours of observations. Observation data were aligned with sensor data according to the sensor time stamps and grouped into matching 15-min intervals. Interobserver reliability was assessed both before and after the main trial period, and the mean percentage eating time per observer had a coefficient of variation of 0.46% [mean 93.2, standard deviation (SD) 0.425] before and 0.07% (mean 96.3, SD 0.074) after. In the main trial, the relationship between observed (mean 70.8%) and sensor-derived (mean 69.3%) percentage eating time over the observation period gave a Pearson correlation coefficient of 0.971, concordance correlation coefficient 0.968, mean difference 1.50% points, and SD 5.8% points. Therefore, sensor-identified percentage "eating time" and observed percentage active grazing time were shown to be both very well correlated and concordant (in agreement, with high correlation and little bias). Therefore, the relationship between observed and sensor-derived data had a high degree of agreement for identifying cow grazing activity. In conclusion, Smarttag sensors are a valid and useful tool for estimating grazing activity at time periods of 1 h or more.

Short communication: Technologies and milking practices that reduce hours of work and increase flexibility through milking efficiency in pasture-based dairy farm systems.

To attract and retain quality employees, dairy farms must be competitive with other workplaces offering more conventional hours of work. Milking requires significant labor input and influences the start and end times of the working day, affecting flexibility to suit employee needs or availability. The use of labor-saving technology and milking management strategies could help with this challenge. Previous studies have used scenario modeling in attempt to quantify the value of in-parlor technologies, however, they have relied on assumptions about the effect of the technologies on labor in the dairy. Similarly, the effect of management strategies on work patterns, such as flexible milking intervals (changing the timing of milking), has not been evaluated. The aims of this study were to (1) quantify the milking labor requirements in a range of pasture-based dairy farm systems and (2) identify practices or technologies that facilitate efficient milking. A telephone survey of 500 dairy farmers in New Zealand was conducted during April and May 2018, with questions asked about milking practices and technology use. Predictive analysis showed that at peak lactation, milking required between 17 and 24 h/wk per worker for farms milking twice a day, representing 43 to 58% of a conventional 40-h work week, depending on parlor type (herringbone or rotary), the number of clusters, and herd size. Using milking intervals of 8 and 16 h (intervals between milkings), compared with the more usual 10 and 14 h, largely avoided starting milking before 0500 h. Eight percent of herds were milked once a day, which required between 7 and 14 h/wk per worker (18-35% of a 40-h week). ANOVA showed that for metrics that related to people (labor efficiency and work routine), using automatic teat spraying had a positive effect on efficiency. Having both automatic cluster removers and drafting were associated with longer milking times in terms of throughput and row/rotation time compared with using drafting only. The results highlight considerable opportunity to reduce the number of hours those milking (employers and employees) spend in the parlor and increase staff time flexibility through milking (e.g., intervals between milkings) and parlor management (e.g., row/rotation time) and use of specific technologies. This study provides useful data for those wishing to analyze the likely value of an in-parlor automation technology or management practice for an individual situation.

Toll-like receptor 9 expressed in proximal intestinal enteroendocrine cells detects bacteria resulting in secretion of cholecystokinin.

Toll-like receptors (TLRs) play a key role in the recognition of microbes via detection of specific and conserved microbial molecular features. TLRs, mainly expressed in immune cells, interact with intestinal microbiome. Little is known about mechanism(s) of sensing of bacteria by the intestinal surface enteroendocrine cells (EECs). We show here that TLR9 is expressed by the EECs of proximal intestine in a range of species and is co-expressed with the satiety hormone cholecystokinin (CCK). CCK secreted in excess induces emesis (vomiting). Using an EEC model cell line, STC-1, we demonstrate that in response to the TLR9 agonist, DNA containing unmethylated CpG dinucleotide motifs, STC-1 cells secrete CCK and that this secretion is inhibited by specific inhibitors of TLR9. Exposure of STC-1 cells to heat-inactivated pathogenic bacteria, Escherichia coli O55/H7, Shigella flexneri 2457T, Salmonella typhimurium ST4/74, and non-pathogenic Lactobacillus amylovorus GRL1112, results to an increase in CCK secretion compared to untreated control. The magnitudes of CCK release are higher in response to pathogenic bacteria and lowest in response to the non-pathogenic L. amylovorus. The pathogenic strains not only have substantially bigger genomes than L. amylovorus, they also have significantly higher numbers/frequency of RR/CG/YY stimulatory CpG hexamers in their genomic DNA. Pathogen-induced excessive secretion of the gut hormone CCK, provoking emesis can serve as a protective mechanism against development of enteric infections.

Developing a Data Integrated COVID-19 Tracking System for Decision-Making and Public Use.

INTRODUCTION: The unprecedented COVID-19 pandemic unveiled a strong need for advanced and informative surveillance tools. The Centre for Health Informatics (CHI) at the University of Calgary took action to develop a surveillance dashboard, which would facilitate the education of the public, and answer critical questions posed by local and national government. OBJECTIVES: The objective of this study was to create an interactive method of surveillance, or a "COVID-19 Tracker" for Canadian use. The Tracker offers user-friendly graphics characterizing various aspects of the current pandemic (e.g. case count, testing, hospitalizations, and policy interventions). METHODS: Six publicly available data sources were used, and were selected based on the frequency of updates, accuracy and types of data, and data presentation. The datasets have different levels of granularity for different provinces, which limits the information that we are able to show. Additionally, some datasets have missing entries, for which the "last observation carried forward" method was used. The website was created and hosted online, with a backend server, which is updated on a daily basis. The Tracker development followed an iterative process, as new figures were added to meet the changing needs of policy-makers. RESULTS: The resulting Tracker is a dashboard that visualizes real-time data, along with policy interventions from various countries, via user-friendly graphs with a hover option that reveals detailed information. The interactive features allow the user to customize the figures by jurisdiction, country/region, and the type of data shown. Data is displayed at the national and provincial level, as well as by health regions. CONCLUSION: The COVID-19 Tracker offers real-time, detailed, and interactive visualizations that have the potential to shape crucial decision-making and inform Albertans and Canadians of the current pandemic.

Dairy farmers with larger herd sizes adopt more precision dairy technologies.

An increase in the average herd size on Australian dairy farms has also increased the labor and animal management pressure on farmers, thus potentially encouraging the adoption of precision technologies for enhanced management control. A survey was undertaken in 2015 in Australia to identify the relationship between herd size, current precision technology adoption, and perception of the future of precision technologies. Additionally, differences between farmers and service providers in relation to perception of future precision technology adoption were also investigated. Responses from 199 dairy farmers, and 102 service providers, were collected between May and August 2015 via an anonymous Internet-based questionnaire. Of the 199 dairy farmer responses, 10.4% corresponded to farms that had fewer than 150 cows, 37.7% had 151 to 300 cows, 35.5% had 301 to 500 cows; 6.0% had 501 to 700 cows, and 10.4% had more than 701 cows. The results showed that farmers with more than 500 cows adopted between 2 and 5 times more specific precision technologies, such as automatic cup removers, automatic milk plant wash systems, electronic cow identification systems and herd management software, when compared with smaller farms. Only minor differences were detected in perception of the future of precision technologies between either herd size or farmers and service providers. In particular, service providers expected a higher adoption of automatic milking and walk over weighing systems than farmers. Currently, the adoption of precision technology has mostly been of the type that reduces labor needs; however, respondents indicated that by 2025 adoption of data capturing technology for monitoring farm system parameters would be increased.

Field validation of protocols developed to evaluate in-line mastitis detection systems.

This paper reports on a field validation of previously developed protocols for evaluating the performance of in-line mastitis-detection systems. The protocols outlined 2 requirements of these systems: (1) to detect cows with clinical mastitis (CM) promptly and accurately to enable timely and appropriate treatment and (2) to identify cows with high somatic cell count (SCC) to manage bulk milk SCC levels. Gold standard measures, evaluation tests, performance measures, and performance targets were proposed. The current study validated the protocols on commercial dairy farms with automated in-line mastitis-detection systems using both electrical conductivity (EC) and SCC sensor systems that both monitor at whole-udder level. The protocol for requirement 1 was applied on 3 commercial farms. For requirement 2, the protocol was applied on 6 farms; 3 of them had low bulk milk SCC (128×10(3) cells/mL) and were the same farms as used for field evaluation of requirement 1. Three farms with high bulk milk SCC (270×10(3) cells/mL) were additionally enrolled. The field evaluation methodology and results were presented at a workshop including representation from 7 international suppliers of in-line mastitis-detection systems. Feedback was sought on the acceptance of standardized performance evaluation protocols and recommended refinements to the protocols. Although the methodology for requirement 1 was relatively labor intensive and required organizational skills over an extended period, no major issues were encountered during the field validation of both protocols. The validation, thus, proved the protocols to be practical. Also, no changes to the data collection process were recommended by the technology supplier representatives. However, 4 recommendations were made to refine the protocols: inclusion of an additional analysis that ignores small (low-density) clot observations in the definition of CM, extension of the time window from 4 to 5 milkings for timely alerts for CM, setting a maximum number of 10 milkings for the time window to detect a CM episode, and presentation of sensitivity for a larger range of false alerts per 1,000 milkings replacing minimum performance targets. The recommended refinements are discussed with suggested changes to the original protocols. The information presented is intended to inform further debate toward achieving international agreement on standard protocols to evaluate performance of in-line mastitis-detection systems.

Glossary of terms relating to capture-recapture methods.

This glossary provides basic definitions for terms that have a specific meaning in the application of the capture-recapture methodology, particularly with respect to standard techniques for the application of log linear models to multiple lists. In epidemiology, capture-recapture is used for prevalence estimation. It is intended that, as well as being a central point of reference for terms used in the capture-recapture methodology, this glossary should provide a resource for those new to this methodology. It aims to provide a simple introduction using terms that should be understood by an uninitiated audience.

Energy intakes of institutionalised and free-living older people.

Inadequate energy intake is common in older adults, especially in those living in institutions. Underweight in older people is associated with increased risk of morbidity and mortality. The objective of this study was to compare energy and percentage of total energy from protein, fat, carbohydrate and alcohol between institutionalised (INS) and free-living (FL) older people. 16 INS volunteers (mean age 88 years, 20% male) and 23 FL volunteers (mean age 75 years, 48% male) were recruited. Food intake was measured using the 4-day weighed inventory method. Nutritional analysis was carried out using the computer program Dietplan5 for Windows. Energy intakes were significantly lower in the INS group compared with the FL group, due to the lower amount of food eaten. The energy intakes in the INS group were below the Estimated Average daily Requirement (1). The energy derived from fat was higher and the energy derived from carbohydrate lower than dietary recommendations in the INS group.

Successful weaning from milrinone of a patient with severe congestive heart failure using carvedilol.

Congestive heart failure is a major and growing health care concern worldwide, and mortality in patients with severe heart failure is high. Few options are available to patients with New York Heart Association class IV heart failure refractory to oral medical therapy. Over the last 15-20 years milrinone, a phosphodiesterase-III inhibitor, has been used occasionally to treat patients with acute heart failure and as a bridge to heart transplantation and, more recently, has been used intermittently or continuously on an outpatient basis. We report a patient with severe, chronic congestive heart failure, whom we treated successfully with continuous milrinone infusions as an outpatient. We were able to wean him of the milrinone after successful up-titration of carvedilol. Nine months after discontinuation of milrinone the patient remains stable in New York Heart Association class I on high dose carvedilol. Research is required to validate the possibility that patients with severe heart failure may be successfully weaned from milrinone using carvedilol and achieve significant improvement of their functional status and quality of life. This may prove to be an effective strategy for the treatment of selected patients with severe, chronic congestive heart failure. (c)2001 by CHF, Inc.

Opioid-receptor-mediated excitation of rat mesenteric afferent fibres supplying the rat jejunum.

The aim of the present study was to examine the sensitivity to opioid-receptor agonists of mesenteric afferents supplying the small intestine and to characterize the subpopulations of any responsive fibres. Mesenteric afferent discharge was recorded electrophysiologically in response to cumulative doses (1-400 microgram kg-1) of the mu-receptor agonist [D-ala,2 N- me-Phe4, Gly5-ol]-enkephalin (DAMGO), the delta-receptor agonist [D-ala,2 D-leu5]-enkephalin (DADLE) and the kappa-receptor agonist U-50488. DAMGO and DADLE, but not U-50488, markedly stimulated whole nerve mesenteric afferent discharge (P < 0.05) that was unrelated to intestinal motor events. Subpopulations of afferent fibres responding to DAMGO were examined using waveform analysis to identify single units from within the whole mesenteric nerve bundles. One population was CCK-sensitive (15/15 fibres) and the other was a subpopulation of mechanosensitive afferents that responded to distension (17/28). 5-HT-sensitive afferents did not respond to DAMGO (0/11). We conclude that specific subpopulations of mesenteric afferents respond to mu- and possibly delta- but not kappa-receptor agonists. This sensitivity to opioids may contribute to the antinociceptive property of vagal afferents.

5-HT(3) and histamine H(1) receptors mediate afferent nerve sensitivity to intestinal anaphylaxis in rats.

BACKGROUND & AIMS: The mechanisms underlying brain stem activation during antigen challenge have not been resolved. Our aim was to characterize afferent nerve responses to intestinal anaphylaxis and determine the mediators involved in afferent activation. METHODS: Mesenteric afferent discharge was recorded electrophysiologically after intestinal anaphylaxis in anesthetized rats previously sensitized to chicken egg albumin (EA). RESULTS: Mesenteric afferent nerve discharge increased approximately 1 minute after luminal antigen but not bovine serum albumin (P < 0.001, EA vs. bovine serum albumin). Subsequent administration of antigen had no effect, but systemic EA evoked a marked increase in afferent discharge (P < 0. 05). Afferent responses were unrelated to intestinal motor activity, and the response to luminal antigen was attenuated by luminal anesthetic (1% lidocaine). The 5-HT(3)-receptor antagonist alosetron (30 microg. kg(-1)) and the histamine H(1)-receptor antagonist pyrilamine (5 mg. kg(-1)) markedly attenuated the response to luminal antigen; pretreatment with doxantrazole attenuated responses to both luminal and systemic antigen. CONCLUSIONS: 5-HT(3) and histamine, released from mast cells after intestinal anaphylaxis, stimulate mesenteric afferents via 5-HT(3) and histamine H(1) receptors. Information on intestinal immune status is rapidly relayed to the central nervous system and may play a role in neural reflexes and behavioral responses following activation of the immune system.

Characterization of adenosine receptors evoking excitation of mesenteric afferents in the rat.

We examined the effects of adenosine receptor agonists and antagonists on the discharge of mesenteric afferent nerves supplying the jejunum in pentobarbitone sodium-anaesthetized rats. Adenosine (0.03-10 mg kg(-1), i.v.), NECA (0.3-300 microg kg(-1), i.v.) and the A1 receptor agonist, GR79236 (0.3-1000 microg kg(-1), i.v.), each induced dose-dependent increases in afferent nerve activity and intrajejunal pressure, hypotension and bradycardia. The A1 receptor antagonist, DPCPX (3 mg kg(-1), i.v.), antagonized all the effects of GR79236 but only the haemodynamic effects of adenosine and NECA. The A2A receptor antagonist, ZM241385 (3 mg kg(-1), i.v.), antagonized the hypotensive effect of NECA but none of the effects of GR79236. The A2A receptor agonist, CGS21680 (0.3-300 microg kg(-1), i.v.), and the A3 receptor agonist, IB-MECA (0.3-300 microg kg(-1), i.v.), each induced only a dose-dependent hypotension. Subsequent administration of adenosine (3 mg kg(-1), i.v.) induced increases in afferent nerve activity and intrajejunal pressure and bradycardia. ZM241385 (3 mg kg(-1), i.v.) antagonized the hypotensive effect of CGS21680 but not the effects of adenosine. Bethanechol (300 microg kg(-1), i.v.) evoked increases in afferent nerve activity and intrajejunal pressure, hypotension and bradycardia. However, adenosine (3 mg kg(-1), i.v.) evoked greater increases in afferent nerve activity than bethanechol despite inducing smaller increases in intrajejunal pressure. In summary, A1 and A2B and/or A2B-like receptors evoke adenosine-induced increases in mesenteric afferent nerve activity and intrajejunal pressure in the anaesthetized rat. Furthermore, elevations in intrajejunal pressure do not wholly account for adenosine-evoked excitation of mesenteric afferent nerves.

A 1-year community-based health economic study of ciprofloxacin vs usual antibiotic treatment in acute exacerbations of chronic bronchitis: the Canadian Ciprofloxacin Health Economic Study Group.

OBJECTIVE: To evaluate the costs, consequences, effectiveness, and safety of ciprofloxacin vs standard antibiotic care in patients with an initial acute exacerbation of chronic bronchitis (AECB) as well as recurrent AECBs over a 1-year period. DESIGN: Randomized, multicenter, parallel-group, open-label study. SETTING: Outpatient general practice. PATIENTS: A total of 240 patients, 18 years or older with chronic bronchitis, with a history of frequent exacerbations (three or more in the past year) presenting with a type 1 or 2 AECB (two or more of increased dyspnea, increased sputum volume, or sputum purulence). MAIN OUTCOME MEASURES: The assessment included AECB symptoms, antibiotics prescribed, concomitant medications, adverse events, hospitalizations, emergency department visits, outpatient resources such as diagnostic tests, procedures, and patient and caregiver out-of-pocket expenses. Patients completed the Nottingham Health Profile, St. George's Respiratory Questionnaire, and the Health Utilities Index. The parameters were recorded with each AECB and at regular quarterly intervals for 1 year. These variables were compared between the ciprofloxacin-treated group and the usual-care-treated group. RESULTS: Patients receiving ciprofloxacin experienced a median of two AECBs per patient compared to a median of three AECBs per patient receiving usual care. The mean annualized total number of AECB-symptom days was 42.9+/-2.8 in the ciprofloxacin arm compared to 45.6+/-3.0 days in the usual-care arm (p=0.50). The overall duration of the average AECB was 15.2+/-0.6 days for the ciprofloxacin arm compared to 16.3+/-0.6 days for the usual-care arm. Treatment with ciprofloxacin tended to accelerate the resolution of all AECBs compared to usual care (relative risk=1.20; 95% confidence interval [CI], 0.91 to 1.58; p=0.19). Treatment assignment did not affect the interexacerbation period but a history of severe bronchitis, prolonged chronic bronchitis, and an increased number of AECBs in the past year were associated with shorter exacerbations-free periods. There was a slight, but not statistically significant, improvement in all quality of life measures with ciprofloxacin over usual care. The only factors predictive of hospitalization were duration of chronic bronchitis (odds ratio=4.6; 95% CI, 1.6, 13.0) and severity of chronic bronchitis (odds ratio=4.3; 95% CI, 0.8, 24.6). The incremental cost difference of $578 Canadian in favor of usual care was not significant (95% CI, -$778, $1,932). The cost for the ciprofloxacin arm over the usual care arm was $18,588 Canadian per quality-adjusted life year gained. When the simple base case analysis was expanded to examine the effect of risk stratification, the presence of moderate or severe bronchitis and at least four AECBs in the previous year changed the economic and clinical analysis to one favorable to ciprofloxacin with the ciprofloxacin-treated group having a better clinical outcome at lower cost ("win-win" scenario). CONCLUSIONS: Treatment with ciprofloxacin tended to accelerate the resolution of all AECBs compared to usual care; however, the difference was not statistically significant. Further, usual care was found to be more reflective of best available care rather than usual first-line agents such as amoxicillin, tetracycline, or trimethoprim-sulfamethoxazole as originally expected. Despite the similar antimicrobial activities and broad-spectrum coverage of both ciprofloxacin and usual care, the trends in clinical outcomes and all quality of life measurements favor ciprofloxacin. In patients suffering from an AECB with a history of moderate to severe chronic bronchitis and at least four AECBs in the previous year, ciprofloxacin treatment offered substantial clinical and economic benefits. In these patients, ciprofloxacin may be the preferred first antimicrobial choice.

Clinical decision making, risk and occupational therapy.

Little is known about the processes involved in risk taking, and complex decision making of the type encountered on acute medical wards in general hospitals. The purpose of the present study was to examine certain of these processes in the context of decisions to discharge elderly inpatients from hospital. Vignettes of hypothetical frail and disabled elderly in-patients were presented to student and qualified occupational therapists (OTs). All the vignettes represented high risk discharges and each of the patients expressed the desire to return to their own home. The additional diagnosis of early dementia was manipulated within and between vignettes. Subjects were asked to decide on the appropriateness of discharging each patient to (a) home and (b) a residential or nursing home. In addition, subjects completed a short demographic questionnaire which also probed aspects of their knowledge about elderly people. Results indicated that qualified OTs were less likely to overrule patients' wishes by favouring discharge of patients to residential or nursing home, and more likely to favour discharge to patients' own homes than student OTs. There was no overall main effect of dementia on subjects' decisions. In addition to clinical experience, certain areas of knowledge about elderly people were significantly associated with different approaches to risk taking in response to the vignettes. Undergraduate syllabi may need to be modified to incorporate more information about elderly people, the prevalence of different diseases, and direct experience of clinical decision making in the context of uncertain and risky situations.

The role of endogenous cholecystokinin in the sensory transduction of luminal nutrient signals in the rat jejunum.

Some vagal afferent fibres are exquisitely sensitive to exogenous administration of cholecystokinin (CCK) but their sensitivity to endogenous CCK released by luminal stimuli has not been demonstrated directly, although implied from reflex and behavioural studies. We have therefore utilised electrophysiological techniques to record afferent discharge in mesenteric nerve bundles supplying the rat jejunum in response to luminal application of casein acid hydrolysate (CAH). CAH stimulated whole nerve afferent discharge in both in vivo and in vitro preparations (P < 0.01) while single unit analysis revealed that fibres sensitive to CAH also responded to exogenous CCK. The responses to both CCK and CAH were abolished by the CCKA antagonist devazepide. This study therefore supports the hypothesis that a functional relationship exists between CCK-containing enteroendocrine cells and the afferent fibres whose terminals lie within close proximity.

Sensitivity of vagal mucosal afferents to cholecystokinin and its role in afferent signal transduction in the rat.

1. Extracellular recordings from rat mesenteric paravascular nerve bundles were made in order to characterize the responses of different populations of afferents supplying the small intestine to intravenous cholecystokinin (CCK; in the form of sulphated CCK8). 2. Approximately 70% of mesenteric nerve bundles contained CCK-sensitive afferent fibres. Responsive afferents had low spontaneous discharge (1.6 +/- 0.3 impulses s-1) and showed a 14-fold increase in firing at the peak of the response to 50 pmol CCK with the overall response lasting several minutes. The onset of the response occurred after a latency of (3.9 +/- 0.1 s) following i.v. administration of CCK, which corresponds largely to the circulation delay in these animals. The threshold dose of CCK was < 5 pmol. 3. The response to 100 pmol CCK was completely abolished by devazepide (0.5 mg kg-1) and by chronic subdiaphragmatic vagotomy performed 10-14 days prior to experimentation, indicating that CCK sensitivity was via CCKA receptors and exclusively mediated via vagal afferents rather than splanchnic or enteric afferents. 4. Evidence that CCK-sensitive afferents had mucosal receptive fields was indicated by the lack of any response to luminal distension and the sensitivity of the CCK response to luminal anaesthesia. Furthermore, CCK-sensitive afferents responded to luminal hydrochloric acid (50 mM) in a slowly adapting manner. The response to acid was significantly reduced (P < 0.005), but not abolished, by devazepide at a time when the response to exogenous CCK had been completely eliminated. 5. The exquisite sensitivity of some vagal mucosal afferents to CCK suggests that they may play a physiological role in the reflex and behavioural consequences of CCK release from the small intestine, possibly acting in a paracrine fashion. However, this sensitivity to CCK represents only one aspect of the broad chemosensitivity of these mucosal afferents and is not an obligatory component of the signal transduction pathway.