Investigating the effect of prophylactic claw trimming on the interval between calving and first observed elevated locomotion score in pasture-based dairy cows.

AIMS: To evaluate, in a pasture-based dairy herd, the response to a three-time point hoof trimming regime on lameness incidence and time from calving to observation of an elevated locomotion score (LS). METHODS: This study was conducted on a 940-cow spring-calving herd in New Zealand's North Island between May 2018 and May 2019. Cows (n = 250) were randomly allocated to the hoof trimming group, with the remainder assigned to the non-trim cohort. One trained professional hoof trimmer used the five-step Dutch method to trim the hind feet of the trimming group. Throughout the subsequent production season, the whole herd was locomotion-scored fortnightly using the 4-point (0-3) Dairy NZ lameness score. Kaplan-Meier survival curves were used to assess the univariable effect of trimming on the interval between calving and first LS of ≥ 2 and first LS ≥ 1. A multivariable Cox proportional hazards regression was used to further evaluate the effect of trimming on time to elevated LS. RESULTS: Mean lameness (LS ≥ 2) prevalence was 2.6%, with 30% of cows having ≥ 4 observations during the study period when at least one LS was ≥ 2. For LS ≥ 1, mean prevalence was 40%, with 98.6% of cows having ≥ 4 observations during the study period when at least one LS was ≥ 1 during lactation. Hoof trimming had no apparent effect on the incidence of clinical lameness (LS ≥ 2) (trimmed vs. non-trimmed: 33.2% vs. 28.8%, respectively), but for LS ≥ 1, there was a small decrease in the incidence of LS ≥ 1 (trimmed vs. non-trimmed: 96.9% vs. 99.3%, respectively). The hazard of a cow having a first observed LS ≥ 2 in the control group was 0.87 (95% CI = 0.66-1.14) times that of the trimmed group; however, the hazard of a cow having a first LS ≥ 1 was 1.60 (95% CI = 1.37-1.88) times higher in the control than in the trimmed group. CONCLUSION AND CLINICAL RELEVANCE: On this farm, prophylactic hoof trimming had no clinically relevant impact on the incidence of clinical lameness and was not associated with clinically beneficial reductions in time to first observed LS ≥ 2. This may be because claw horn imbalance was not pronounced on this farm, with 53% of cows needing no trim on either hind limb on the first trimming occasion. Further research on the response to prophylactic trimming in pasture-based dairy cattle is required.

Design and acceptability of patient-oriented computerized diabetes care reminders for use at the point of care.

Despite the widespread availability of guidelines for caring for patients with diabetes and decades of research on computerized reminder systems, large gaps in quality remain in diabetes care remain and computerized reminder systems are rarely used for patients with diabetes. We set out to develop and test the feasibility of a system that would overcome many of the barriers preventing the widespread use of point-of-care computerized reminders to improve diabetes care. Five primary care physicians and 32 patients with type 2 diabetes pilot tested the system. We set out to design and measure the preliminary acceptability of patient-oriented point of care computerized diabetes care reminders. The main findings of our study were that (1) the reports were well accepted by both patients and providers and (2) survey and audiotape data suggest that they may be helpful at improving the quality of outpatient care for patients with diabetes.

Negative information for motif discovery.

We discuss a method of combining genome-wide transcription factor binding data, gene expression data, and genome sequence data for the purpose of motif discovery in S. cerevisiae. Within the word-counting algorithmic approach to motif discovery, we present a method of incorporating information from negative intergenic regions where a transcription factor is thought not to bind, and a statistical significance measure which account for intergenic regions of different lengths. Our results demonstrate that our method performs slightly better than other motif discovery algorithms. Finally, we present significant potential new motifs discovered by the algorithm.

Do malpractice concerns, payment mechanisms, and attitudes influence test-ordering decisions?

Greater understanding is needed of nonclinical factors that determine neurologists' decisions to order tests. The authors surveyed 595 US neurologists and utilized demographic information, attitude scales, and clinical scenarios to evaluate the influence of nonclinical factors on test-ordering decisions. Greater test reliance, higher malpractice concerns, and receiving reimbursement for testing were all associated with a higher likelihood of test ordering. These findings have implications for training needs and suggest malpractice worries may inflate health care costs.

Benchmarking and quality in residential and nursing homes: lessons from the US.

BACKGROUND: Performance measurement and benchmarking are common concerns in the delivery of long term care. It is common to measure the performance of providers and to publicly report these data. This paper examines selected technical challenges facing those who design, implement and disseminate health care quality performance measures. METHOD: Review of the application of measures of performance in the US nursing home sector. RESULTS: Using examples drawn from the skilled nursing home arena, problems ranging from data reliability and validity, the multi-dimensional nature of quality measures and selection bias as well as differential measurement abilities are discussed. CONCLUSIONS: Benchmarking of performance is an inherently complex issue. However, to ensure that such comparisons are both fair and valid requires measures to be more technically sophisticated and sensitive to real changes attributable to changes in care.

Blazing pathways through genetic mountains.

It is now widely accepted that high-throughput data sources will shed essential understanding on the inner workings of cellular and organism function. One key challenge is to distill the results of such experiments into an interpretable computational form that will be the basis of a predictive model. A predictive model represents the gold standard in understanding a biological system and will permit us to investigate the underlying cause of diseases and help us to develop therapeutics. Here I explore how discoveries can be based on high-throughput data sources and discuss how independent discoveries can be assembled into a comprehensive picture of cellular function.

Serial regulation of transcriptional regulators in the yeast cell cycle.

Genome-wide location analysis was used to determine how the yeast cell cycle gene expression program is regulated by each of the nine known cell cycle transcriptional activators. We found that cell cycle transcriptional activators that function during one stage of the cell cycle regulate transcriptional activators that function during the next stage. This serial regulation of transcriptional activators forms a connected regulatory network that is itself a cycle. Our results also reveal how the nine transcriptional regulators coordinately regulate global gene expression and diverse stage-specific functions to produce a continuous cycle of cellular events. This information forms the foundation for a complete map of the transcriptional regulatory network that controls the cell cycle.

External threats and nursing home administrator turnover.

External threats and volatility in the long-term-care sector in recent decades have posed serious challenges for nursing home administrators. Greater job complexity and administrative responsibilities resulting from public policies and more specialization and competitiveness in nursing home markets have made turnover a significant issue. This article examines administrator turnover from 1970 through 1997 in New York State and describes how turnover increased markedly in the late 1980s and early 1990s.

Fast optimal leaf ordering for hierarchical clustering.

We present the first practical algorithm for the optimal linear leaf ordering of trees that are generated by hierarchical clustering. Hierarchical clustering has been extensively used to analyze gene expression data, and we show how optimal leaf ordering can reveal biological structure that is not observed with an existing heuristic ordering method. For a tree with n leaves, there are 2(n-1) linear orderings consistent with the structure of the tree. Our optimal leaf ordering algorithm runs in time O(n(4)), and we present further improvements that make the running time of our algorithm practical.

Homeless women's gynecological symptoms and use of medical care.

Information is lacking on homeless women's gynecological symptoms and use of medical care for symptoms. This paper documents and explains gynecological symptoms and conditions and use of medical care in a probability sample of 974 reproductive-age (15-44) homeless women. Two-thirds of women reported symptoms during the previous year; 71 percent of those received medical care for their gynecological symptoms. Pregnancy, drug dependence, more episodes of homelessness, and general physical health symptoms were positively associated with a number of gynecological symptoms. Gynecological symptoms, younger age, better perceived health, and insurance coverage were positively associated with medical care; women reporting recent drug use and rape received less care. These findings support the importance of medical care and other treatment and support services for homeless women, including expanded care during pregnancy and substance abuse treatment. Health insurance coverage and an interruption in the cycle of homelessness also appear vital to women's health.

Regulation of loblolly pine (Pinus taeda L.) arginase in developing seedling tissue during germination and post-germinative growth.

After seed germination, hydrolysis of storage proteins provides a nitrogen source for the developing seedling. In conifers the majority of these reserves are located in the living haploid megagametophyte tissue. In the developing loblolly pine (Pinus taeda L.) seedling an influx of free amino acids from the megagametophyte accompanies germination and early seedling growth. The major component of this amino acid pool is arginine, which is transported rapidly and efficiently to the seedling without prior conversion. This arginine accounts for nearly half of the total nitrogen entering the cotyledons and is likely a defining factor in early seedling nitrogen metabolism. In the seedling, the enzyme arginase is responsible for liberating nitrogen, in the form of ornithine and urea, from free arginine supplied by the megagametophyte. In this report we investigate how the seedling uses arginase to cope with the large arginine influx. As part of this work we have cloned an arginase cDNA from a loblolly pine expression library. Analysis of enzyme activity data, accumulation of arginase protein and mRNA abundance indicates that increased arginase activity after seed germination is due to de novo synthesis of the enzyme. Our results suggest that arginase is primarily regulated at the RNA level during loblolly pine seed germination and post-germinative growth.

Using graphical models and genomic expression data to statistically validate models of genetic regulatory networks.

We propose a model-driven approach for analyzing genomic expression data that permits genetic regulatory networks to be represented in a biologically interpretable computational form. Our models permit latent variables capturing unobserved factors, describe arbitrarily complex (more than pair-wise) relationships at varying levels of refinement, and can be scored rigorously against observational data. The models that we use are based on Bayesian networks and their extensions. As a demonstration of this approach, we utilize 52 genomes worth of Affymetrix GeneChip expression data to correctly differentiate between alternative hypotheses of the galactose regulatory network in S. cerevisiae. When we extend the graph semantics to permit annotated edges, we are able to score models describing relationships at a finer degree of specification.

Functional decline in independent elders after minor traumatic injury.

OBJECTIVES: To describe injury types, patterns, and health status in independently functioning elder patients presenting to the emergency department (ED) after a minor traumatic injury; and 2) to assess short-term functional decline in this population at three-month follow-up. METHODS: This was a prospective observational study of elder patients (age > 65 years) discharged home from the ED after evaluation and treatment for an acute traumatic injury. Patients were excluded if they were not independently functioning or had an acute delirium. Type and mechanism of injury sustained during the ED visit were recorded. Functional status was assessed during the visit and three months later using activities of daily living (ADL) and instrumental activities of daily living (IADL) scores. RESULTS: One hundred six subjects were enrolled in the study. Mean age was 74.8 years. The most common injuries observed were contusion (n = 35, 33%, 95% CI = 24% to 42%), fractures (n = 28, 26%, 95% CI = 18% to 36%), lacerations (n = 20, 19%, 95% CI = 12% to 28%), and sprains (n = 12, 11%, 95% CI = 6% to 19%), which represented more than 90% of the injuries. Eighty-eight (83%) patients completed three-month follow up. Of these, 6 of 88 (6.82%, 95% CI = 3% to 14%) declined in their ADL scores and 20 of 88 (22.73%, 95% CI = 14% to 33%) declined in their IADL scores at three months. Primary injury type, specifically contusion, was more prevalent in patients who had a decline in ADL score, as compared with those who did not have a decline in ADL score (chi-square p<0.001). In addition, anatomic locations of injury were different between those patients with and without a decline in IADL scores (chi-square p = 0.008). Gender differences were also found; females were more likely to be injured by a slip, trip, or fall indoors (36 of 58, 62%) than outdoors (22 of 58, 38%); males injured by this mechanism were more likely to be injured outdoors (14 of 20, 70%) as opposed to indoors (6 of 20, 30%), chi-square p = 0.013. CONCLUSIONS: A significant proportion of functional elder patients with minor traumatic injury are at risk for short-term functional decline. Decline in ADL is related to injury type, while IADL decline is related to anatomic location of injury. Emergency physicians should consider initiating follow-up evaluation and possible intervention in highly functioning elders after minor traumatic injury.

Systematic review of clinical prediction rules for neuroimaging in the evaluation of dementia.

BACKGROUND: Clinical practice guidelines for dementia do not recommend routine neuroimaging but vary in their recommended clinical prediction rules to identify patients who should undergo neuroimaging for potentially reversible causes of dementia. METHODS: Using a MEDLINE search supplemented by other strategies, we identified studies from January 1, 1983, through December 31, 1998, that evaluated the diagnostic performance of a clinical prediction rule. We calculated the sensitivity and specificity of each rule, then evaluated their diagnostic performance in a hypothetical cohort of 1000 patients with dementia, varying the prevalence of potentially reversible dementia from 1% to 15%. RESULTS: We identified 7 studies that evaluated at least 1 of 6 different clinical prediction rules. Only one rule consistently had high sensitivity (>85%) across all studies; none consistently had high specificity (>85%). Six of the 7 studies included less than 15 cases of potentially reversible dementia; thus the sensitivity and specificity for each rule had relatively wide confidence intervals. At a 5% prevalence of potentially reversible dementia, all rules had low positive predictive value (<15%) in our hypothetical cohort. Depending on the rule, our analysis predicts 6 to 44 of the 50 patients with potentially reversible dementia (5% prevalence in cohort of 1000 patients) would not undergo imaging. CONCLUSIONS: There is considerable uncertainty in the evidence underlying clinical prediction rules to identify which patients with dementia should undergo neuroimaging. Application of these rules may miss patients with potentially reversible causes of dementia.