The distribution of mycotoxins in a heterogeneous wheat field in relation to microclimate, fungal and bacterial abundance.

AIM: To observe the variation in accumulation of Fusarium and Alternaria mycotoxins across a topographically heterogeneous field and tested biotic (fungal and bacterial abundance) and abiotic (microclimate) parameters as explanatory variables. METHODS AND RESULTS: We selected a wheat field characterized by a diversified topography, to be responsible for variations in productivity and in canopy-driven microclimate. Fusarium and Alternaria mycotoxins where quantified in wheat ears at three sampling dates between flowering and harvest at 40 points. Tenuazonic acid (TeA), alternariol (AOH), alternariol monomethyl ether (AME), tentoxin (TEN), deoxynivalenol (DON), zearalenone (ZEN) and deoxynivalenol-3-Glucoside (DON.3G) were quantified. In canopy temperature, air and soil humidity were recorded for each point with data-loggers. Fusarium spp. as trichothecene producers, Alternaria spp. and fungal abundances were assessed using qPCR. Pseudomonas fluorescens bacteria were quantified with a culture based method. We only found DON, DON.3G, TeA and TEN to be ubiquitous across the whole field, while AME, AOH and ZEN were only occasionally detected. Fusarium was more abundant in spots with high soil humidity, while Alternaria in warmer and drier spots. Mycotoxins correlated differently to the observed explanatory variables: positive correlations between DON accumulation, tri 5 gene and Fusarium abundance were clearly detected. The correlations among the others observed variables, such as microclimatic conditions, varied among the sampling dates. The results of statistical model identification do not exclude that species coexistence could influence mycotoxin production. CONCLUSIONS: Fusarium and Alternaria mycotoxins accumulation varies heavily across the field and the sampling dates, providing the realism of landscape-scale studies. Mycotoxin concentrations appear to be partially explained by biotic and abiotic variables. SIGNIFICANCE AND IMPACT OF THE STUDY: We provide a useful experimental design and useful data for understanding the dynamics of mycotoxin biosynthesis in wheat.

Phenotypic and phylogenetic segregation of Alternaria infectoria from small-spored Alternaria species isolated from wheat in Germany and Russia.

AIMS: To identify the taxonomic differences between phytopathogenic small-spored Alternaria strains isolated from wheat kernels in Germany and Russia by a polyphasic approach. METHODS AND RESULTS: Ninety-five Alternaria (A.) strains were characterized by their colony colour, their three-dimensional sporulation patterns, mycotoxin production and phylogenetic relationships based on sequence variation in translation elongation factor 1-α (TEF1-α). The examination of toxin profiles and the phylogenetic features via TEF1-α resulted in two distinct clusters, in each case containing Alternaria infectoria isolates (92 and 96% respectively) in the first and the Alternaria alternata, Alternaria arborescens and Alternaria tenuissima isolates (77 and 79% respectively) in the other combined cluster. The production of Alternariol, Altertoxin and Altenuene has not been reported previously in the A. infectoria species group. The isolates from Germany and Russia differ slightly in species composition and mycotoxin production capacity. CONCLUSIONS: We identified that the A. infectoria species group can be differentiated from the A. alternata, A. arborescens and A. tenuissima species group by colour, low mycotoxin production and by the sequence variation in TEF1-α gene. SIGNIFICANCE AND IMPACT OF THE STUDY: These results allow a reliable toxic risk assessment when detecting different Alternaria fungi on cereals.

Cocultivation of phytopathogenic Fusarium and Alternaria strains affects fungal growth and mycotoxin production.

AIMS: A laboratory study was conducted to evaluate the influence of cocultivation of toxigenic Fusarium (F.) and Alternaria (A.) fungi with respect to growth and mycotoxin production. METHODS AND RESULTS: Fusarium culmorum Fc13, Fusarium graminearum Fg23 and two Alternaria tenuissima isolates (At18 and At220) were simultaneously or consecutively co-incubated on wheat kernels in an in vitro test system. Fungal biomass was quantified by determining ergosterol content. Three Fusarium toxins (DON, NIV and ZON) and three Alternaria toxins (AOH, AME and ALT) were analysed by a newly developed HPLC/MS/MS method. In simultaneous cocultures, the fungal biomass was enhanced up to 460% compared with individual cultures; Alternaria toxins were considerably depressed down to <5%. Combining At18 and At220 with Fg23 inhibited the toxin production of both fungal partners. In contrast, Fc13 increased its DON and ZON production in competitive interaction with both A. strains. CONCLUSIONS: The interfungal competitive effects aid the understanding of the processes of competition of both fungi in natural environments and the involvement of mycotoxins as antifungal factors. SIGNIFICANCE AND IMPACT OF STUDY: Cocultivation significantly affects fungal growth and mycotoxin production of phytopathogenic Alternaria and Fusarium strains. The impact of mycotoxins on the interfungal competition is highlighted.

[Effects of nighttime and daytime interval definition on blood pressure and dipping in patients referred for ambulatory blood pressure measurement]. / Différences induites par la définition des périodes diurnes et nocturnes sur la pression artérielle et le dipping lors d'une mesure ambulatoire de la pression artérielle.

UNLABELLED: Ambulatory blood pressure monitoring (ABPM) has become indispensable for the diagnosis and control of hypertension. However, no consensus exists on how daytime and nighttime periods should be defined. OBJECTIVE: To compare daytime and nighttime blood pressure (BP) defined by an actigraph and by body position with BP resulting from arbitrary daytime and nighttime periods. PATIENTS AND METHOD: ABPM, sleeping periods and body position were recorded simultaneously using an actigraph (SenseWear Armband(®)) in patients referred for ABPM. BP results obtained with the actigraph (sleep and position) were compared to the results obtained with fixed daytime (7a.m.-10p.m.) and nighttime (10p.m.-7a.m.) periods. RESULTS: Data from 103 participants were available. More than half of them were taking antihypertensive drugs. Nocturnal BP was lower (systolic BP: 2.08±4.50mmHg; diastolic BP: 1.84±2.99mmHg, P<0.05) and dipping was more marked (systolic BP: 1.54±3.76%; diastolic BP: 2.27±3.48%, P<0.05) when nighttime was defined with the actigraph. Standing BP was higher (systolic BP 1.07±2.81mmHg; diastolic BP: 1.34±2.50mmHg) than daytime BP defined by a fixed period. CONCLUSION: Diurnal BP, nocturnal BP and dipping are influenced by the definition of daytime and nighttime periods. Studies evaluating the prognostic value of each method are needed to clarify which definition should be used.

[Sleep disorders in patients with chronic renal insufficiency]. / Troubles du sommeil chez des patients présentant une insuffisance rénale chronique.

Sleep disorders, especially insomnia, daytime sleepiness, sleep apnea syndrome and restless legs syndrome are very frequently encountered in patients with chronic renal failure whether or not they undergo renal replacement therapy. The causes of sleep disorders are multifactorial and not only linked to the renal disease itself, but also to its treatment and its associated psychosocial factors. This article discusses the prevalence and physiopathology of the most frequently encountered sleep disorders in chronic renal failure patients, and highlights the actually available therapeutic options.

[Palliative care in a psychiatric-somatic care unit]. / Palliatieve zorg op een psychiatrisch-medische unit.

Patients with severe psychiatric and somatic disorders may require admission to a combined psychiatric-somatic care unit. These units provide specialised psychiatric and somatic care as well as palliative care. This is illustrated by two case reports. A 51-year-old man with a malignant brain tumour was admitted to our psychiatric-somatic care unit after threatening his wife and children. He was aggressive and confused. Seizures were suspected and palliative care was needed. Within a few weeks his condition deteriorated. He died 1 day after terminal sedation had been initiated. A 78-year-old woman was admitted to receive daily electroconvulsive treatment (ECT) for depression with catatonia. The ECT had to be interrupted repeatedly due to comorbid infections and complications. She died 3 days after palliative care was initiated.

[Neuroleptic malignant syndrome: a life-threatening complication that can be treated effectively]. / Maligne neurolepticasyndroom: een levensbedreigende complicatie, die goed te behandelen is.

Two patients with the neuroleptic malignant syndrome (NMS), a man aged 31 years and a woman aged 83 years, were referred for electroconvulsive therapy after 70 and 7 days, respectively. Both patients benefited from the treatment, but the patient who had had the syndrome longer had persistent contractures. NMS is potentially lethal. Diagnosis and treatment should be done as soon as possible to prevent mortality and complications. Admission to a general hospital and early consultation of NMS-experienced colleagues is strongly advised. Electroconvulsive therapy is indicated ifa trial course of lorazepam yields insufficient improvement.

[The medical-psychiatric unit: added value for patients, physicians and hospitals]. / De medisch-psychiatrische unit: meerwaarde voor patiënten, artsen en ziekenhuizen.

Physical and mental illnesses commonly occur together. The quality of physical care in institutions for mental health in the Netherlands is not guaranteed. The cases of a 63-year-old woman with a schizoaffective disorder and diabetes mellitus who became delirious after surgery and a 76-year-old suicidal man with a psychotic disorder due to hydrocobalamine deficiency after major heart surgery show that the so-called medical-psychiatric unit, which is a part of the Psychiatric Department of a general hospital, may have several advantages in the treatment of combined physical and mental disorders. Both patients were admitted to such a unit. In this way, the internist of the first patient could continue to treat her and she could be treated with an infusion, urinary catheter and gastric intubation; in addition, laboratory investigations could be performed. The second patient, whose safety required primary attention, could also be treated for his somatic disorders and a delirium could be ruled out. His family was assisted in recovering from their traumatic life experience caused by his suicide attempt.

[Pregnant and mentally incompetent]. / Gravida en wilsonbekwaam.

Two women, aged 31 and 36 years, under treatment for schizophrenia and psychotic episodes, respectively, became pregnant and decided to discontinue their medication. Thereupon the psychiatric disorder recurred and they refused--i.e. they were unable--to consent to a proposed treatment or investigation regarding their pregnancies. The necessary consent had to be obtained from a legal guardian. This was the husband in the first, urgent case. In the second case approval from the judge was obtained for the patient to be admitted against her will to protect her life and that of the foetus. In the Netherlands obstetric intervention to protect the life of the mother or her unborn child is legally regulated by the Wet Bijzondere Opnemingen in Psychiatrische Ziekenhuizen (Act on Compulsory Admissions to Psychiatric Hospitals) and the Wet op de Geneeskundige Behandelingsovereenkomst (Act on Agreement Concerning Medical Treatment).

The management of severe acetabular bone loss using structural allograft and acetabular reinforcement devices.

The cases of 37 acetabular reconstructions in 35 patients with major structural pelvic bone loss were reviewed. At an average follow-up of 7.1 years, patients rated their results as excellent in 12 cases (32.4%), good in 22 (59.5%), fair in 2 (5.4%), and poor in 1 (2.7%). Thirty-four cases (91.9%) were classified as a clinical success. Thirty-six allografts (97.3%) had radiographic evidence of full incorporation. Of the unrevised hips, 1 (2.7%) was classified as definitely loose, 2 (5.4%) as probably loose, and 4 (10.8%) as possibly loose. One revision of an acetabular component was required because of late sepsis. This is the first reported series on the use of acetabular reinforcement devices with solid bulk allograft covering more than 50% of the socket. The allograft is protected in the early postoperative period, superior migration of the cup is virtually eliminated as a complication, and the incidence of aseptic loosening is greatly diminished.

Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip.

We reviewed 508 consecutive total hip replacements in 370 patients with old developmental dysplasia of the hip, to relate the amount of leg lengthening to the incidence of nerve palsies after operation. There were eight nerve palsies (two femoral, six sciatic), two complete and six incomplete. We found no statistical correlation between the amount of lengthening and the incidence of nerve damage (p = 0.47), but in seven of the eight hips, the surgeon had rated the intervention as difficult because of previous surgery, severe deformity, a defect of the acetabular roof, or considerable flexion deformity. The correlation between difficulty and nerve palsy was significant (p = 0.041). We conclude that nerve injury is most commonly caused by direct or indirect mechanical trauma and not by limb lengthening on its own.

The Bürch-Schneider anti-protrusio cage in revision total hip arthroplasty: indications, principles and long-term results.

Patients who had a revision total hip arthroplasty using the Bürch-Schneider anti-protrusio cage (APC) by a single surgeon have been reviewed after a minimum of five years. There were 63 operations in 58 patients with an average age of 63 years (41 to 83) at the time of revision. At an average follow-up of 8.5 years (5 to 18), 15 patients (25.9%) rated their results as excellent, 38 (65.5%) as good, and five (8.6%) as fair. Five further revisions of the acetabular prosthesis were required, three due to aseptic loosening, one for recurrent dislocation and one due to sepsis. Of the remainder, one was definitely loose, two probably loose, and 12 possibly so. Impressive augmentation of bone stock can be achieved with the anti-protrusio cage, while enabling the hip to be centred in its anatomical position.

Total hip arthroplasty with use of an acetabular reinforcement ring in patients who have congenital dysplasia of the hip. Results at five to fifteen years.

The purpose of our study was to examine the clinical and technical problems associated with reconstruction of the hip in patients who had congenital dysplasia and to offer recommendations for their solution. We reviewed the records on 123 consecutive total hip arthroplasties that had been performed by one of us (M. E. M.), between 1981 and 1986, for the treatment of coxarthrosis due to congenital dysplasia of the hip. A minimum of five years of follow-up was required for inclusion in the study. The study group consisted of seventy patients who had had a total of eighty-seven reconstructions. According to the classification of Crowe et al., eleven hips had type-IV acetabular dysplasia; sixty-five, type-II; and eleven, type-II. Acetabular reconstruction was performed with use of the Müller acetabular roof-reinforcement ring and a polyethylene cup, which was inserted with cement. Autologous graft from the femoral head was used in forty-two hips. Femoral reconstruction was performed with use of the Müller straight-stem component for congenital dysplasia of the hip in eighty hips and with use of a standard Müller straight-stem component in seven hips. At an average of 9.4 years (range, five to fifteen years) postoperatively, the result was described as excellent for sixty hips (69 per cent), as good for twenty-three (26 per cent), as fair for two (2 per cent), and as poor for two. Nine (10 per cent) of the hips had been revised. One revision had been performed because of aseptic loosening of the acetabular component; one, because of aseptic loosening of the femoral component; one, because of aseptic loosening of both components; and six, because of infection. Of the unrevised hips, three had had superior migration of the acetabular component of less than five millimeters, and mild protrusion had developed in one. Two hips had a continuous radiolucent line around the acetabular construct. Two hips had had subsidence of the femoral stem of less than three millimeters; one had a complete, non-progressive radiolucent line at the bone-cement interface; and four had a radiolucent line at the proximal part of the bone-cement interface. Six hips had evidence of endosteal osteolysis. Six hips had grade-III or IV heterotopic ossification according to the system of Brooker et al. These results compare favorably with others in the literature. We recommend restoration of the anatomical hip center with the use of an acetabular roof-reinforcement ring and a polyethylene cup inserted with cement for the reconstruction of a deficient acetabulum. The acetabular reinforcement ring prevents resorption of bone graft and migration of the cup, which are major causes of failure of the cup in patients who have had a reconstruction of a deficient acetabulum. Bone graft should be used medially and superiorly as needed to augment bone stock notably. Cement should not be used to fill acetabular defects as we believe that it contributes to aseptic loosening.

The value of preoperative planning for total hip arthroplasty.

To analyse the value and accuracy of preoperative planning for total hip replacement (THR) we digitised electronically and compared the hand-sketched preoperative plans with the pre- and postoperative radiographs of 100 consecutive primary THRs. The correct type of prosthesis was planned in 98%; the agreement between planned and actually used components was 92% on the femoral side and 90% on the acetabular side. The mean (+/- SD) absolute difference between the planned and actual position of the centre of rotation of the hip was 2.5 +/- 1.1 mm vertically and 4.4 +/- 2.1 mm horizontally. On average, the inclination of the acetabular component differed by 7 +/- 2 degrees and anteversion by 9 +/- 3 degrees from the preoperative plans. The mean postoperative leg-length difference was 0.3 +/- 0.1 cm clinically and 0.2 +/- 0.1 cm radiologically. More than 80% of intraoperative difficulties were anticipated. Preoperative planning is of significant value for the successful performance of THR.

Total hip arthroplasty after previous proximal femoral osteotomy.

We compared 74 total hip arthroplasties (THAs) carried out after previous proximal femoral osteotomy with a diagnosis-matched control group of 74 primary procedures performed during the same period. We report the perioperative results and the clinical and radiological outcome at five to ten years. We anticipated a higher rate of complications in the group with previous osteotomy, but found no significant difference in the rate of perioperative complications (11% each) or in the septic (8% v 3%) and aseptic (4% each) revision rates. There was a trend towards improved survival in the group without previous osteotomy (90% v 82%), but this difference was not statistically significant. The only significant differences were a higher rate of trochanteric osteotomy (88% v 14%) and a longer operating time in the osteotomy group. Our study indicates that THA after previous osteotomy is technically more demanding but not necessarily associated with a higher rate of complications. Furthermore, proximal femoral osteotomy does not jeopardize the clinical and radiological outcome of future THA enough to exclude the use of osteotomy as a therapeutic alternative in younger patients.

[Guidelines for professional responsibilities of the head nurse in South African state hospitals]. / Riglyne vir die hoofverpleegkundige se posverantwoordelikhede in Suid-Afrikaanse staatshospitale.

This is a follow-up article on a functional analysis of the post responsibilities of the Chief Professional Nurse in South African State hospitals. The purpose of this study is to formulate guidelines for the Chief Professional Nurse's post responsibilities in State hospitals. The final statements, on which the conceptual framework is based, are inferred from the previous justified objectives: the exploration and description of the existing job/post descriptions of the Chief Professional Nurse, an exploration and description of the different role-players' expectations regarding the post/job responsibilities of the Chief Professional Nurse, followed by a literature control. The guidelines are formulated and it is recommended that they be implemented, followed by the testing of various hypotheses to confirm the value of these guidelines.

Quality improvement in health care--a fundamental analysis and South African perspective.

This article is based on the opening address that was delivered at a national conference with the launching of the South African Society for Quality in Health Care (SASQuaH). The quality improvement process and principles are analyzed, as well as an exposition of the South African situation. The concepts regarding quality, quality improvement and quality assurance are clarified, the different stakeholders in formalised quality improvement explained, as well as the motives for and principles of quality improvement in health services. The different external and internal mechanisms in quality improvement are analyzed, including the principle of community ownership and international collaboration. Continuous development and capacity building regarding quality improvement is recommended at all levels of health service delivery.

Development and validation of a critical care patient classification system.

OBJECTIVE: To describe the research methodology used in development and validation of a scientific patient classification instrument for South African critical care patients. METHOD: This is a contextual, exploratory, and descriptive study. A two-phase validating model was used as a research method. In the development phase a literature review was carried out (domain identification), a provisional instrument developed (item generation), and a peer group discussion conducted (item formation). In the quantification phase 16 experts determined if both the items of the instrument and the entire instrument were content valid. The study was conducted within the framework of South African critical care nursing. RESULTS: In the peer group discussion the instrument was debated until consensus was reached. In the quantification phase, both the items of the instrument and the entire instrument were rated as content valid. CONCLUSIONS: Established patient classification systems can be successfully adapted and validated for local use.