Lowering levels of bed occupancy is associated with decreased inhospital mortality and improved performance on the 4-hour target in a UK District General Hospital.

OBJECTIVE: To evaluate whether there is an association between an intervention to reduce medical bed occupancy and performance on the 4-hour target and hospital mortality. METHODS: This before-and-after study was undertaken in a large UK District General Hospital over a 32 month period. A range of interventions were undertaken to reduce medical bed occupancy within the Trust. Performance on the 4-hour target and hospital mortality (hospital standardised mortality ratio (HSMR), summary hospital-level mortality indicator (SHMI) and crude mortality) were compared before, and after, intervention. Daily data on medical bed occupancy and percentage of patients meeting the 4-hour target was collected from hospital records. Segmented regression analysis of interrupted time-series method was used to estimate the changes in levels and trends in average medical bed occupancy, monthly performance on the target and monthly mortality measures (HSMR, SHMI and crude mortality) that followed the intervention. RESULTS: Mean medical bed occupancy decreased significantly from 93.7% to 90.2% (p=0.02). The trend change in target performance, when comparing preintervention and postintervention, revealed a significant improvement (p=0.019). The intervention was associated with a mean reduction in all markers of mortality (range 4.5-4.8%). SHMI (p=0.02) and crude mortality (p=0.018) showed significant trend changes after intervention. CONCLUSIONS: Lowering medical bed occupancy is associated with reduced patient mortality and improved ability of the acute Trust to achieve the 95% 4-hour target. Whole system transformation is required to create lower average medical bed occupancy.

Expression of amphiregulin in the sheep mammary gland.

The reverse transcription-polymerase chain reaction (RT-PCR) was used to amplify, from sheep mammary gland total RNA, a 280 bp sequence of amphiregulin cDNA. Cloned and sequenced, it corresponded to the 78 amino acids of the major secreted form of amphiregulin, showing 81, 70 and 69% identity with human, rat and mouse amphiregulin, respectively. Expression of amphiregulin was detected by RT-PCR in the mammary gland at several developmental stages (fetal, lamb, early and late pregnant and lactating ewes) and in isolated myoepithelial cells. By Western blotting with an antiserum to human amphiregulin, two molecular weight forms, 27 and 51 kDa were detected in sheep mammary gland microsomal preparations, in a mammary gland extract after heparin affinity chromatography and in a medium conditioned by mammary epithelial cells. By immunocytochemistry, amphiregulin was detected in the cytoplasm and nuclei of luminal epithelial cells, myoepithelial cells and in intralobular stroma. An autocrine/paracrine role in sheep mammary growth is indicated.

The effects of streptozotocin diabetes on sodium-glucose transporter (SGLT1) expression and function in rat jejunal and ileal villus-attached enterocytes.

Rats treated with streptozotocin for 17 days were used to determine the cellular origin of enhanced brush border glucose transport in the diabetic small intestine. In the jejunum of both normal and diabetic rats, phlorizin-sensitive (SGLT1-mediated) glucose transport was shown, by section autoradiography, to take place in upper villus enterocytes. The distribution of brush border SGLT1 transporters along villi, determined using immunogold cytochemistry, was similar to that found for glucose uptake. Longer villi, supporting a larger number of absorbing enterocytes in the diabetic jejunum, appeared to be responsible for increased glucose uptake in this condition. SGLT1 protein and SGLT1-mediated glucose transport were undetectable in normal distal ileal villi. However, following treatment with streptozotocin, both SGLT1 protein and SGLT1-mediated glucose transport were found to be present in basal ileal villus enterocytes. SGLT1 protein and SGLT1-mediated glucose transport both increased during enterocyte migration to the villus tip. Cellular induction of the SGLT1 transporter, as well as longer villi contribute to enhanced glucose transport in diabetic rat distal ileum. Close correlation between the positional expression of SGLT1 protein and absorptive function suggests that transporter density is an important determinant for up-regulation of sodium-dependent glucose transport in diabetes.

Differential regulation of vitamin D receptor and intestinal calcium transport occurring during sexual maturation in the fowl (Gallus domesticus).

Quantitative measurements of intestinal vitamin D receptor (VDR) and calcium transport taking place in individual villus-attached enterocytes have been compared during the onset of sexual maturity to test for a direct involvement of VDR in controlling calcium transport across the chick small intestine. Chickens of all ages showed VDR to be present in crypt and villus enterocytes, the amounts of VDR declining only slightly during enterocyte migration from the crypts to the tips of villi. Calcium transport corrected for initial adsorption was lowest in the crypt and highest in villus tip enterocytes. These results are consistent with VDR initiation and possible later maintenance of calcium transport across differentiating enterocytes. The total amount of VDR determined along the crypt-villus axis was significantly less in immature 11-week-old compared with 17-week-old sexually mature non-laying and 25-week-old laying chickens. Calcium transport was significantly greater in 25-week-old compared with 17- and 11-week-old birds. This unexpected up-regulation of VDR in 17-week-old birds was not affected by dietary restriction of calcium. Increased VDR expression in 17-week-old sexually mature birds is probably initiated by estrogen acting indirectly to increase 1,25 (OH)2D3 production in the kidney. Increased calcium transport in 25-week-old laying chickens could involve estrogen interacting with estrogen receptors as well as 1,25 (OH)2D3 interacting with vitamin D receptors to promote gene transcription in the intestine.

A morphometric analysis of the corpus luteum of the cow during the estrous cycle and early pregnancy.

Corpora lutea were collected from cows on Days 6, 8, 10, 12, 14, 16, 18 and 19 of the estrous cycle and early pregnancy (n=2/d) and were examined by light microscopy. Mean lutein cell diameter was significantly (P<0.05) greater in pregnant than in cyclic cows on Days 6, 8, 10, 12, 16, 18 and 19 (cyclic versus pregnant: Day 6: 13.9 +/- 0.22 vs 14.9 +/- 0.24; Day 8: 13.8 +/- 0.20 vs 15.4 +/- 0.2; Day 10: 14.8 +/- 0.24 vs 17.4 +/- 0.24; Day 12: 13.2 +/-0.25 vs 17.9 +/- 0.31; Day 16: 13.9 +/- 0.28 vs 16.5 +/- 0.31; Day 18: 13.0 +/- 0.22 vs 16.5 +/- 09.36, and Day 19: 15.0 +/- 0.23 vs 17.6 +/- 0.33 mum, respectively). The distribution of cell sizes was leptokurtotic throughout the estrous cycle and the first 10 d of pregnancy, but tended towards bimodality after Day 14 of pregnancy. The proportion of lutein cell cytoplasm occupied by vacuoles was lower in pregnant than in cyclic cows from the 12th day post estrus, but there was a marked (P<0.05) increase in vacuolation of cells from cows undergoing luteolysis. Stainable intercellular collagen was also less abundant in pregnant than cyclic cows from the 12th day post estrus. The higher rate of progesterone secretion of pregnant, compared with cyclic cows may be attributed to the greater numbers and greater contribution to luteal mass of large lutein cells in the corpus luteum of pregnancy.

Adrenocortical stimulation of stomach development in the prenatal pig.

Development of the porcine gastric proteases (chymosin, pepsin A, B and C) has been studied in the fetal pig in the last third of gestation (term 115 days). The possibility that the prepartum rise in circulating cortisol is involved in gastric maturation was investigated by infusing immature fetuses with cortisol (osmotic minipumps implanted at 82-90 days of gestation). Concentrations of prochymosin in fundic tissue and stomach contents increased before term, correlated positively with log10 plasma cortisol values (r = 0.68-0.76, p < 0.001), and were stimulated by cortisol infusion (p < 0.001). The pH of stomach contents decreased (from pH 7 to 3), correlated negatively with log10 plasma cortisol values (r = -0.69, p < 0.001), and was reduced by cortisol infusion (p < 0.05). Only trace amounts of pepsinogens could be detected in fetal pigs. By immunohistochemistry, it was shown that cortisol increased the number and distribution of prochymosin-containing cells in the fundic gland. Stimulating effects were also observed for the small populations of pepsinogen-reactive cells present in some of the fetal pigs. The results suggest that endogenous cortisol stimulates the rise in prochymosin synthesis and secretion together with increased gastric acidity in the prenatal period of the pig.

Enterocyte expression of calbindin, calbindin mRNA and calcium transport increases in jejunal tissue during onset of egg production in the fowl (Gallus domesticus).

1. Quantitative measurements of calbindin mRNA, calbindin protein and calcium uptake have been made in sectioned intestinal villi to determine the location and cellular characteristics of their expression in immature, point of lay and laying chickens. 2. Trace amounts of calbindin mRNA were detected by in situ hybridization in enterocytes located around the crypt-villus junction in jejunal tissue taken from immature and point of lay chickens. Large amounts of calbindin mRNA were detected in upper crypt and all villus enterocytes in tissue taken from laying chickens. Maximal levels of calbindin mRNA occurred in the basal third of the villus in laying chickens. 3. No calbindin was detected immunocytochemically in tissue taken from immature and point of lay chickens. Large amounts of calbindin were expressed in tissue taken from laying chickens. Maximal expression of calbindin in this case occurred in villus tip enterocytes. 4. Rapid uptake of calcium by tissue taken from laying chickens was twice that found in immature and point of lay birds. Calcium uptake in tissue taken from laying hens was also shown by quantitative autoradiography to take place maximally in villus tip enterocytes. 5. Regulation of calbindin gene expression and the cellular characteristics of calcium transport in laying chickens are discussed in terms of an adaptive response taking place in birds undergoing a daily loss of egg shell calcium.

Characteristics of ruminant mammary epithelial cells grown in primary culture in serum-free medium.

Cells were obtained from the mammary glands of sheep and cows by collagenase-hyaluronidase digestion. Characterization of cells as epithelial was by reaction with a monoclonal antibody to cytokeratin. A subpopulation of spindle-shaped or stellate cells reacted with a monoclonal antibody to desmin and may be related to myoepithelial cells. The development is described of a simple serum-free culture system for these cells on gels of rat tail (type 1) collagen. A commercial medium (M199) was used, buffered with Hepes and with bovine serum albumin as the sole protein supplement, plus fibronectin for the first 18 h only as an attachment factor. The cell cultures showed stimulated DNA synthesis in response to mitogens on attached gels and also responded as floating cultures to lactogenic hormones with production of alpha-lactalbumin.

Separate and additive stimulation of bovine milk yield by the local and systemic galactopoietic stimuli of frequent milking and growth hormone.

Lactating heifers were treated for 4 weeks with recombinant bovine growth hormone (bGH, n = 9) or were untreated (n = 9). In addition, two mammary glands of each heifer were milked four times daily rather than the normal twice daily for the same 4 weeks, and for the following 2 weeks. Over the 4 weeks, milk yield was increased 12.8% by bGH, 14.0% by frequent milking and 28.5% by the combined treatment. The effect of bGH as administered here was slower in onset than that of frequency, but eventually produced a higher peak yield. ANOVA revealed significant effects of each stimulus independently and an additive, but not synergic effect of the combined treatment. The effect of the combined treatment tended to persist beyond the end of treatment; most of this response was related to the milking frequency component rather than the bGH. Mammary differentiation was assessed in biopsies of mammary tissue obtained prior to and at the end of treatment. Mammary enzyme activities (expressed on a per cell basis) indicated minimal differentiative response to either treatment, but synthesis rates for lactose and casein determined in vitro were increased by bGH treatment. Histological examination revealed a stimulatory effect of milking frequency on epithelial cell size. The results indicate that these two galactopoietic stimuli operate through independent mechanisms, and neither stimulus alone is sufficient to maximize milk yield in dairy heifers.

Appearance of phloridzin-sensitive glucose transport is not controlled at mRNA level in rabbit jejunal enterocytes.

Glucose uptake by rabbit intestine has been shown to be confined to the upper two-thirds of jejunal villi. Inhibition by phloridzin shows most of this transport to take place through the Na(+)-glucose linked transporter (SGLT1). Parallel measurements on the other hand show SGLT1 mRNA expression to increase rapidly as enterocytes reach the crypt-villus junction. Levels of SGLT1 mRNA then remain elevated in all villus enterocytes. These results provide direct evidence that SGLT1-mediated glucose transport is subject to post-transcriptional control.

[Fixation screws and tension bolt technique for osteotomies. Stability study]. / Fixationsschrauben- und Zugschraubentechnik bei Osteotomien. Eine Stabilitätsstudie.

Following sagittal mandibular osteotomy the mandibles of Class II patients were stabilized using two different fixation techniques. It was the goal of this study to delineate the effects of these two techniques on stability. The patient population was approximately the same on both groups. 1 year after surgery differences in stability were not found. The functional and esthetic results, too, were equal in both groups.

Milk yield and mammary function in dairy cows milked four times daily.

Groups of lactating cows and heifers were milked four times daily in two diagonally opposed glands for 4 weeks, and the effects on milk yield studied relative to twice-daily milked glands as controls. Mammary enzyme activities, in vitro synthesis rates of milk constituents and histological scoring were determined in mammary biopsy samples obtained at the end of this period. These were used for assessment of mammary function. Frequent milking increased milk yield only in the treated glands, the contralateral control glands continuing to decline in yield at approximately 2%/week. There was no significant difference in response between cows and heifers; the mean increase in yield was 10.4%. The rate of decline in milk yield tended to decrease with frequent milking, to approximately 1%/week. Consequently the yield of the treated glands continued to be elevated above that of the controls for some time after reversion to overall twice daily milking. Milk protein content was increased slightly by frequent milking. Mammary enzyme activities were approximately 18% higher in the treated glands than in the controls. Synthesis rates of lactose, casein and total protein were unaffected by milking frequency, but were all lower in the gland selected for the second biopsy, reflecting the reduction in milk yield caused by the first biopsy. DNA synthesis was increased by milking frequency, as were the size and number of epithelial cells in histological sections.

Stimulation of DNA synthesis in cultures of ovine mammary epithelial cells by insulin and insulin-like growth factors.

Ovine mammary epithelial cell clumps (30-90 microns) were plated onto attached gels of rat tail collagen in serum-free medium. Synthesis of DNA by these cultures could be stimulated by insulin-like growth factor-I (IGF-I) with a median effective dose of 5 micrograms/l, irrespective of stage of pregnancy. The time-course of response, however, was significantly slower in cells prepared from mammary tissue of non-pregnant and early pregnant sheep compared with sheep later in pregnancy. IGF-II had approximately 10% of the potency of IGF-I in stimulating DNA synthesis. Insulin acted over a wide concentration range and produced a maximum rate of stimulation not significantly different from that produced by IGF-I. These results are consistent with actions through the type-I IGF receptor although insulin may also act through its own receptor, possibly stimulating local IGF-I production. It is concluded that IGF-I is an important mitogen for ovine mammary epithelial cells.

A stereotaxic atlas of the medulla oblongata of the goat's brain.

A stereotaxic atlas has been prepared for the medulla oblongata of the adult goat's brain using the technique described previously (Tindal et al. 1968). The atlas consists of transverse stereotaxic planes passing caudally at 1 mm intervals from posterior 10 mm (P10) at the level of the junction between brainstem and cerebellum to posterior 20 mm (P20) at the level of the obex.

Immunofluorescent localization of vitamin B12-binding protein from sow's milk in the ileal mucosa of piglets.

Studies in vitro have shown that the vitamin B12-binding protein from sow's milk enhances vitamin B12 absorption by the neonatal piglet. In the present paper, localization of the milk vitamin B12 binding protein on the brush border membrane of intact ileal enterocytes was demonstrated by an immunocytochemical procedure in which the binding protein was incubated within isolated loops of ileum of anesthetized neonatal piglets.

Fatty acid synthesis by explant cultures from the mammary glands of goats on days 60 and 120 of pregnancy.

Explants of mammary glands from 60-day pregnant goats showed a mean fourfold increase in fatty acid synthesis from acetate when cultured with insulin+ cortisol. Epithelial cells increased their area by 60% but no secretory activity was induced. In 120-day pregnant goats, fatty acid synthesis and epithelial cell area were greater than at day 60 of pregnancy and were unaffected by hypophysectomy or by daily treatment with bromocriptine from day 60. Neither increased further on culture of mammary explants in insulin + cortisol. Ovine prolactin increased fatty acid synthesis two-fold when added to insulin + cortisol in cultures of mammary tissue from goats on day 60 of pregnancy and secretory activity was induced. On day 120 of pregnancy insulin + cortisol + prolactin sustained or slightly stimulated both fatty acid synthesis and the extensive secretion present in the tissue at the start of culture. Synthesis of medium-chain fatty acids of milk-fat was also sustained by prolactin in one goat. An atmosphere of air was found to maintain normal histological structure of the mammary gland. By contrast, in 95% oxygen, explants from goats which were 60 days pregnant showed epithelial cells filling the lumina of ducts and alveoli in 60% of explants and a poor response to prolactin.

Culture of bovine mammary epithelial cells on collagen gels.

A method for the isolation of lobules of acini from bovine mammary gland and their storage in liquid nitrogen is described. After further dissociation of freshly prepared or frozen lobules, clumps of cells are obtained which attach to collagen gels and give rise to colonies which, on morphological criteria, appear predominantly epithelial. Storage for up to 6 months did not adversely affect viability. Increase in colony area involved cell division, was more rapid in air than in 95% oxygen and was enhanced by fetal calf serum.