International consensus conference recommendations on ultrasound education for undergraduate medical students.

OBJECTIVES: The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students. METHODS: 64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting. RESULTS: A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care. CONCLUSIONS: The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

Validation of a lactic acid- and citric acid-based antimicrobial product for the reduction of Escherichia coli O157: H7 and Salmonella on beef tips and whole chicken carcasses.

The objectives of this study were to determine the effects of a lactic acid- and citric acid-based antimicrobial product on the reduction of Salmonella on whole broiler carcasses during processing and the reduction of Salmonella and Escherichia coli O157:H7 on beef trim. Freshly harvested broiler carcasses were inoculated with an inoculum of Salmonella strains to yield a 10(5) CFU/ml pathogen load on the surface of the carcass. The beef tips were inoculated as well with an inoculum of either E. coli O157:H7 or Salmonella to yield 10(4) CFU/100 cm(2). After 30 min for attachment, the broiler carcasses were treated with Chicxide applied for 5 s via a spray or immersed in Chicxide for 5, 10, or 20 s. Broiler carcasses were rinsed in poultry rinse bags with 400 ml of Butterfield's phosphate buffer in which Salmonella was enumerated from the diluents and Butterfield's phosphate. Chicxide significantly reduced Salmonella by 1.3 log CFU/ml with spray treatment and 2.3 log CFU/ml for all dip treatments. Following 30 min of attachment, the beef tips were placed into a spray cabinet with either Beefxide or sterilized water (control) and sprayed at 1 ft/2.5 s chain speed at 40 lb/in(2). The external surface of each beef tip was swabbed (100 cm(2)) to determine pathogen loads. Beefxide significantly reduced E. coli O157:H7 by 1.4 log CFU/100 cm(2) and Salmonella by 1.1 log CFU/100 cm(2) (P < 0.05) compared with the control samples.

Patient and physician perceptions after software-assisted hospital discharge: cluster randomized trial.

BACKGROUND: Hospital discharge software potentially improves communication and clinical outcomes. OBJECTIVE: To measure patient and physician perceptions after discharge with computerized physician order entry (CPOE) software. DESIGN: Cluster randomized controlled trial. SETTING: Tertiary care, teaching hospital in central Illinois. PATIENTS: A total of 631 inpatients discharged to home with high risk for readmission. INTERVENTION: A total of 70 internal medicine hospital physicians randomly assigned (allocation concealed) to discharge software vs. usual care, handwritten discharge. MEASUREMENTS: Discharge perceptions from patients, outpatient primary care physicians, and hospital physicians. RESULTS: One week after discharge, 92.4% (583/631) of patients answered interviews. For 78.6% (496/631) of patients, their outpatient physicians returned questionnaires 19 days (median) postdischarge. Generalized estimating equations gave intervention variable coefficients with 95% confidence intervals (CIs). When comparing patients assigned to discharge software vs. usual care, patient mean (standard deviation [SD]) scores for discharge preparedness were higher (17.7 [4.1] vs. 17.2 [4.0]; coefficient = 0.147; 95% CI = 0.005-0.289; P = 0.042), patient scores for satisfaction with medication information were unchanged (12.3 [4.8] vs. 12.1 [4.6]; coefficient = -0.212; 95% CI = -0.937-0.513; P = 0.567), and their outpatient physicians scored higher quality discharge (17.2 [3.8] vs. 16.5 [3.9]; coefficient = 0.133; 95% CI = 0.015-0.251; P = 0.027). Hospital physicians found mean effort to use discharge software was more difficult than the usual care (6.5 [1.9] vs. 7.9 [2.1]; P = 0.011). CONCLUSIONS: Discharge software with CPOE caused small improvements in discharge perceptions by patients and their outpatient physicians. These small improvements might balance the difficulty perceived by hospital physicians who used discharge software.

Patient readmissions, emergency visits, and adverse events after software-assisted discharge from hospital: cluster randomized trial.

BACKGROUND: One of the causes of postdischarge adverse events is poor discharge communication between hospital-based physicians, patients, and outpatient physicians. The value of hospital discharge software to improve communication and clinically relevant outcomes is unknown. OBJECTIVE: To measure effects of a discharge software application of computerized physician order entry (CPOE). DESIGN: Cluster randomized controlled trial. SETTING: Tertiary care, teaching hospital in central Illinois. PATIENTS: A total of 631 inpatients discharged to home with high risk for readmission. INTERVENTION: Seventy internal medicine hospital physicians were randomly assigned (allocation concealed) to discharge software versus usual care, handwritten discharge. MEASUREMENTS: Blinded assessment of patient readmission, emergency department visit, and postdischarge adverse event. RESULTS: A total of 590 (94%) patients provided 6-month follow-up data. Generalized estimating equations gave intervention variable coefficients with 95% confidence interval (CI). When comparing patients assigned to discharge software versus usual care, there was no difference in hospital readmission within 6 months (37.0% versus 37.8%; coefficient -0.005 [95% CI, -0.074 to 0.065]; P = 0.894), emergency department visit within 6 months (35.4% versus 40.6%; coefficient -0.052 [95% CI, -0.115 to 0.011]; P = 0.108), or adverse event within 1 month (7.3% versus 7.3%; coefficient 0.003 [95% CI; -0.037 to 0.043]; P = 0.884). CONCLUSIONS: Discharge software with CPOE did not affect readmissions, emergency department visits, or adverse events after discharge. Future studies should assess other endpoints such as patient perceptions or physician perceptions to see if discharge software has value.

Software design to facilitate information transfer at hospital discharge.

Discharge communication between inpatient and outpatient physicians is often an inefficient and error-prone process. Adverse events result from poor communication at the time of discharge. The objective of this study was to describe development of discharge software to overcome communication barriers. The secondary objective was to assess factors that influence the time to complete tasks with the software. Methods were a performance improvement model and database analysis of 336 discharges. Software design specifications included computerised physician order entry, immediate utility, minimal development and deployment costs, acceptability to physician-users, and satisfaction of primary care physicians, patients and pharmacists. Design features included simple 'just-in-time' prompts and point-of-care prescribing resources. The dependent variable for analysis was physician time to complete discharge prescriptions and instructions while using the software. General linear and mixed-effects regression models adjusted for physician effects and other predictors. Results revealed that physician factors significantly affected the time to complete a discharge while using the software. As the number of accesses (log-ins) and free text typing increased, then time to complete the computerised discharge increased. Patient-related factors that increased physician time were discharge diagnoses, prescriptions and length of stay. In conclusion, discharge software can help inpatient physicians transfer timely, complete and legible information to outpatient physicians, pharmacists and patients. Physician and patient factors influence the time to complete discharges using the software.

Classification and distribution of large intestinal bacteria in nonhibernating and hibernating leopard frogs (Rana pipiens).

The large intestinal flora of the leopard frog, Rana pipiens, was examined to determine whether differences existed between the nonhibernating and hibernating states of the animal and to determine the relative concentrations and proportions of potential frog pathogens. Hibernators had a logarithmic decrease of bacteria per milligram of intestine averaging one, and significantly greater proportions of facultative bacteria and psychrophiles relative to nonhibernators. The predominant anaerobic bacteria were gram-positive Clostridium species and gram-negative Bacteroides and Fusobacterium species. The predominant facultative bacteria were enterobacteria in nonhibernators but Pseudomonas species in hibernators. Many species of Pseudomonas are pathogenic for frogs, and thus the intestinal flora in hibernators may be a potential source of infectious disease.

Possible mechanisms responsible for the reduced intestinal flora in hibernating leopard frogs (Rana pipiens).

Mechanisms and factors that normally control the large intestinal flora were investigated to determine whether changes in these parameters could account for the decreased bacterial concentration and facultative nature of the flora found in hibernating frogs. It appeared that low temperatures and limited nutrients were the main factors responsible for the decrease in the bacterial concentration and may also have been responsible for the increase in the proportions of facultative organisms, since no change in the redox potential was seen. The hibernating frogs were extremely sluggish in the removal of India ink particles from the circulatory system by the Kupffer cells of the liver compared with nonhibernating frogs. They were unable to mount an antibody response to bovine serum albumin, but their serum did exhibit killing of Pseudomonas paucimobilis, suggesting opsonization by preformed antibody and complement. The role of these host factors in protecting the hibernating frog against this indigenous flora is discussed.

Pharmacokinetics of long acting propranolol. Implications for therapeutic use.

Beta-adrenoceptor antagonists are among the most commonly prescribed classes of drugs. They are indicated for the treatment of diseases such as hypertension and angina pectoris, in which long term therapy is often required. Since many beta-adrenoceptor antagonists have short plasma elimination half-lives, divided daily dosing has often been necessary in order to provide continuous beta-blockade throughout the day. However, such multiple-dose schedules may promote patient non-compliance and failure of the prescribed regimen. Long acting propranolol is a sustained release formulation of propranolol which has been developed to maintain therapeutic plasma propranolol concentrations throughout a 24-hour period while allowing once-daily dosing. Compared with conventionally formulated propranolol, long acting propranolol has a prolonged terminal half-life (8 to 11 hours), due to slower absorption from the gut. Systemic bioavailability of long acting propranolol is 30 to 50% less than that of the conventional formulation. This difference may result from increased hepatic metabolism. Peak drug concentrations are significantly lower than following identical doses of conventional propranolol, and the time to peak drug concentrations following administration is delayed. Relatively constant plasma concentrations and clinically significant inhibition of exercise-induced tachycardia are maintained throughout a 24-hour dosing interval following once-daily long acting propranolol. Once-daily long acting propranolol is as effective as divided doses of conventional propranolol for the treatment of hypertension and angina pectoris. Efficacy also appears comparable with once-daily administration of long acting conventional beta-adrenoceptor antagonists such as atenolol and nadolol. Once-daily long acting propranolol provides clinically significant sustained beta-adrenoceptor blockade and offers the potential for improved patient compliance due to once-daily dosing. Since provision of sustained beta-adrenoceptor blockade appears to be particularly important in the treatment of angina, this may be the principal indication for which long acting propranolol has a therapeutic advantage independent of its potential to improve compliance.

Spectral and other physicochemical properties of submicron powders of hematite (alpha-Fe2O3), maghemite (gamma-Fe2O3), magnetite (Fe3O4), goethite (alpha-FeOOH), and lepidocrocite (gamma-FeOOH).

Spectral and other physicochemical properties were determined for a suite of submicron powders of hematite (alpha-Fe2O3), maghemite (gamma-Fe2O3), magnetite (Fe3O4), goethite (alpha-FeOOH), and lepidocrocite (gamma-FeOOH). The spectral reflectivity measurements were made between 0.35 and 2.20 micrograms over the temperature interval between about -110 degrees and 20 degrees C. Other physicochemical properties determined were mean particle diameter, particle shape, chemical composition, crystallographic phase, magnetic properties, and Mossbauer properties. Only the magnetite powders have significant departures from the stoichiometric phase; they are actually cation-deficient magnetites having down to about 18.0 wt % FeO as compared with 31.0 wt % FeO for stoichiometric magnetite. A structured absorption edge due to crystal field transitions and extending from weak absorption in the near-IR to intense absorption in the near-UV is characteristic of the ferric oxides and oxyhydroxides and is responsible for their intense color. Particularly for hematite, the number and position of the spectral features are consistent with significant splitting of the degenerate cubic levels by noncubic components of the crystal field. The position of the crystal-field band at lowest energy, assigned to the envelope of the components of the split cubic 4T1 level, is near 0.86, 0.91, 0.92, and 0.98 microgram at room temperature for hematite, goethite, maghemite, and lepidocrocite, respectively. Comparison with Mossbauer data suggests covalent character increases sequentially through the aforementioned series. The positions of the spectra features are relatively independent of temperature down to about -110 degrees C. The maximum shifts observed were on the order of about 0.02 microgram shortward for the ferric oxyhydroxides. Variations in the magnitude of the reflectivity of the hematite powders as a function of mean particle diameter are consistent with scattering theory. The absorption strength of the crystal-field bands increases with increasing mean particle diameter over the range 0.1-0.8 micrometer; visually this corresponds to a change in color from orange to deep purple. The position of the split cubic 4T1 band shifts longward by about 0.02 micrometer with decreasing mean particle diameter over the same range; this trend is consistent with wavelength-dependent scattering. The cation-deficient magnetite powders are very strong absorbers throughout the near-UV, visible and near-IR; their spectral properties are independent of temperature between about -110 and 20 degrees C.

Artificially induced metastasis by cells from spontaneous Lucké renal adenocarcinoma.

This communication reports the development of tumour colonies in various organs after vascular dissemination of disaggregated cells from spontaneously arising Lucké renal adenocarcinomata in Cyclosporin-A-treated allogeneic frogs, Rana pipiens. The sites of tumour cell colonies were mesonephros, lung, bladder, mesentery, fat body and muscle. It was also found that digestion of these tumours with collagenase is an effective means of obtaining sufficient dissociated viable cells for large experiments and that cryo-preservation does not abrogate the ability of these cells to form metastatic deposits. This report, therefore, introduces a new tumour system for the study of factors affecting metastasis using naturally occurring tumours.

Isolation of Chlamydia psittaci from naturally infected African clawed frogs (Xenopus laevis).

An inclusion-forming agent was isolated from the livers of commercially raised African clawed frogs (Xenopus laevis) involved in an epizootic of high morbidity and mortality. Original isolation was made in McCoy cells. This agent was identified as Chlamydia psittaci based on the formation of typical intracytoplasmic inclusions which developed within 48 h, were not stained by iodine, and were resistant to sulfadiazine. The isolate from one particular frog (designated as strain 178) was further studied and found to be lethal for 7-day-old embryonated chicken eggs after intra-yolk sac inoculation. This strain was demonstrated not to be pathogenic for mice when inoculated intraperitoneally. The cell culture isolate of C. psittaci was transmitted to uninfected X. laevis, causing disease and death.

Vitellogenic cycles in laboratory-maintained females of the leopard frog, Rana pipiens.

As a part of studies on the reproduction of laboratory maintained frogs, wild-caught Rana pipiens were ovulated and maintained at 22-27 degrees C for up to 18 months. Vitellogenic oocytes were periodically staged and counted, and a "maturity index" was calculated to assess the progress of the vitellogenic cycle. The initial cycle was similar to that of wild frogs except that the first oocytes to reach stage 5 (mature eggs) usually began to degenerate before later starting oocytes became mature. In addition, a second cycle began before the first was completed. After more than 1 year at room temperature, abnormal cycles were common. Ovaries of such animals contained very few mature eggs. Many of their oocytes were in early stages of vitellogenesis or, if pigmented, had begun to degenerate. These deficiencies were partially corrected in females placed in 4 degrees C for 4-6 weeks. The average number of mature eggs increased 15-fold and ovary weights more than doubled. Oviduct weights almost doubled. Although the rates of cooling, photoperiod, and nutritional status could be important influences, the results imply that cold treatment alone increases estrogen secretion. We suggest that low estrogen secretion may account for the reproductive deficiencies seen in R. pipiens cultured at room temperature.

Gravity and positional homeostasis of the cell.

Normally bilateralization takes place in the presence of the Earth's gravity which produces torque, shear, tension and compression acting upon the naked aggregates of cytoplasm in the zygote which is only stabilized by a weak cytoskeleton. In an initial examination of the effects of these quantities on development, an expression is derived to describe the tendency of torque to rotate the egg and reorganize its constituents. This expression yields the net torque resulting from buoyancy and gravity acting upon a dumbbell shaped cell with heavy and light masses at either end and "floating" in a medium. Using crude values for the variables, torques of 2.5 x l0(-13) to 8.5 x 10(-1) dyne-cm are found to act upon cells ranging from 6.4 micrometers to 31 mm (chicken egg). By way of camparison six microtubules can exert a torque of 5 x 10(-9) dyne-cm. (1) Gravity imparts torque to cells; (2) torque is reduced to zero as gravity approaches zero; and (3) torque is sensitive to cell size and particulate distribution. Cells must expend energy to maintain positional homeostasis against gravity. Although not previously recognized, Skylab 3 results support this hypothesis: tissue cultures used 58% more glucose on Earth than in space. The implications for developmental biology, physiology, genetics, and evolution are considered. At the cellular and tissue level the concept of "gravity receptors" may be unnecessary.

Spontaneous and experimental infections of Xenopus laevis with Chlamydia psittaci.

Chlamydial infection was suspected when widespread pyogranulomatous inflammation and large basophilic intracytoplasmic inclusion bodies were evident histopathologically in African clawed frogs (Xenopus laevis) dying of a spontaneous disease of high morbidity and mortality. Organism morphology was determined by electron microscopy of infected hepatic sinusoidal lining cells, and it was characteristic of the unique developmental cycle of a chlamydial agent. Isolation and speciation of the organism was achieved in a McCoy cell culture system. The infected cells were inoculated into disease-free frogs reproducing the disease.

Response of intestinal flora of laboratory-reared leopard frogs (Rana pipiens) to cold and fasting.

The bacterial flora of the large intestine was examined in 35 laboratory-reared leopard frogs (Rana pipiens) subjected to one of the following four treatments: (i) normal feeding at 21 degrees C (10 frogs); (ii) fasting for 2 weeks at 21 degrees C (8 frogs); (iii) chilling for 1 week at 4 degrees C (9 frogs); and (iv) simulated hibernation for 3 weeks at 4 degrees C (8 frogs). Bacteria from the intestinal contents and mucosa were counted microscopically and by colony counting after strictly anaerobic culturing. The predominant bacteria were isolated and partially characterized. Fasting for 2 weeks produced no significant changes in total counts or in the types of bacteria cultured. Chilling, whether rapid or in the course of simulated hibernation, was associated with a decrease in the numbers and variety of bacteria. Thus it appears that the lowering of temperature rather than the absence of food is the important factor in the reduction of bacterial flora seen in hibernating frogs. However, the bacteria showed some adaptation to the low temperature, as the longer the host had been at 4 degrees C, the higher the proportion of bacteria which could grow when cultured at that temperature.

Large intestine bacterial flora of nonhibernating and hibernating leopard frogs (Rana pipiens).

The bacteria in the large intestines of 10 northern leopard frogs (Rana pipiens) were enumerated and partially characterized. Four nonhibernating frogs were collected in the summer, four hibernating frogs were collected in the winter, and two frogs just emerged from hibernation were collected in the spring. All frogs had about 10(10) bacteria per g (wet weight) of intestinal contents and about 10(9) bacteria per g (wet weight) of mucosal scraping, although the counts from the winter frogs were slightly less than those from the other two groups of frogs. Another group of 14 summer frogs, after treatment to induce hibernation, showed a drop in bacterial counts accompanied by a change in the composition of the flora. In most frogs, Bacteroides was the dominant organism. Other bacteria repeatedly isolated at high dilutions were strict anaerobes, including butyrigenic and acetogenic helically coiled bacteria; fusobacteria; and acetogenic, small, gram-positive bacilli. These data indicate that the intestinal flora of frogs is similar to that of mammals and birds and that this flora can be maintained at temperatures close to freezing.

Inheritance of enzymes and blood proteins in the leopard frog, Rana pipiens: three linkage groups established.

Individuals from natural populations of the leopard frog, Rana pipiens, were analyzed for electrophoretic differences in blood proteins and enzymes from an amputated digit. The proteins examined represent products of 72 loci. Presumptive heterozygotes at multiple loci were selected for experimental crosses. Mendelian inheritance of 18 protein variations were demonstrated in the offspring. Tests for linkage or independent assortment were performed for 75 locus pairs. Three linkage groups were established. Linkage group 1 contains two loci, aconitase-1 (Acon 1) and serum albumin (Alb), with a 19% recombination frequency between them. Linkage group 2 contains four loci, glyoxalase (Gly), acid phosphatase-1 (Ap1), acid phosphatase-2 (AP2), and esterase-5 (Est5). The data show the relationships Gly-21.1%-AP1-0%-AP2-6.3%-Est5, and Gly-25.6%-Est5. Linkage group 3 consists of four closely linked esterase loci. The data, Est1-5.1%-Est6, Est6-1.8%-Est10-1.9%-Est4 and Est6-3.0%-Est4, do not establish a complete order but suggest that Est10 is between Est4 and Est6. These results, with data demonstrating apparent independent assortment of 67 other locus pairs, provide a foundation for establishing the frog genetic map.