Fracture liaison services in Ireland-how do we compare to international standards?

In this first na tional survey of public hospitals in The Republic of Ireland, we found fracture liaison services (FLS) to be heterogeneous, limited in many cases and poorly supported. A national strategy is urgently needed to support the implementation and operation of an FLS, and thus help reduce the burden of fragility fractures for patients and the healthcare system. INTRODUCTION: Fragility/low-trauma fractures are a global concern, whose incidence is rising as the population ages. Many are preventable, and people with a prior fragility fracture are at particularly high risk of further fractures. This patient group is the target of the International Osteoporosis Foundation (IOF) Capture the Fracture campaign, advocating global adoption of fracture liaison services (FLS), with the aim of preventing secondary fragility fractures. We wished to determine the current availability and standards of an FLS in Ireland, ahead of the launch of a National FLS database. METHODS: We devised a questionnaire encompassing the thirteen IOF standards for an FLS and asked all 16 public hospitals with an orthopaedic trauma unit in Ireland, to complete for the calendar year 2019 in patients aged ≥ 50 years. RESULTS: All sites returned the questionnaire, i.e. 100% response rate. Nine hospitals stated that they have an FLS, additionally one non-trauma hospital running a FLS responded, and were included. These 10 FLS had identified and managed 3444 non-hip fractures in the year 2019. This figure represents 19% of the expected non-hip fragility fracture numbers occurring annually in Ireland. Implementation of the IOF standards was very variable. All sites reported being inadequately resourced to provide a high-quality service necessary to be effective. CONCLUSION: The existence and functioning of FLS in Ireland are heterogeneous and suboptimal. A national policy to support the implementation of this programme in line with international standards of patient care is urgently needed.

Tranexamic acid toxicity in human periarticular tissues.

OBJECTIVES: Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce perioperative bleeding. Increasingly, topical administration as an intra-articular injection or perioperative wash is being administered during surgery. Adult soft tissues have a poor regenerative capacity and therefore damage to these tissues can be harmful to the patient. This study investigated the effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations. METHODS: Tendon, synovium, and cartilage obtained from routine orthopaedic surgeries were used for ex vivo and in vitro studies using various concentrations of TXA. The in vitro effect of TXA on primary cultured tenocytes, fibroblast-like synoviocytes, and chondrocytes was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays, fluorescent microscopy, and multi-protein apoptotic arrays for cell death. RESULTS: There was a significant (p < 0.01) increase in cell death within all tissue explants treated with 100 mg/ml TXA. MTT assays revealed a significant (p < 0.05) decrease in cell viability in all tissues following treatment with 50 mg/ml or 100 mg/ml of TXA within four hours. There was a significant (p < 0.05) increase in cell apoptosis after one hour of exposure to TXA (100 mg/ml) in all tissues. CONCLUSION: The current study demonstrates that TXA caused significant periarticular tissue toxicity ex vivo and in vitro at commonly used clinical concentrations.Cite this article: M. McLean, K. McCall, I. D. M. Smith, M. Blyth, S. M. Kitson, L. A. N. Crowe, W. J. Leach, B. P. Rooney, S. J. Spencer, M. Mullen, J. L. Campton, I. B. McInnes, M. Akbar, N. L. Millar. Tranexamic acid toxicity in human periarticular tissues. Bone Joint Res 2019;8:11-18. DOI: 10.1302/2046-3758.81.BJR-2018-0181.R1.

Effects of a Six-Month Multi-Ingredient Nutrition Supplement Intervention of Omega-3 Polyunsaturated Fatty Acids, vitamin D, Resveratrol, and Whey Protein on Cognitive Function in Older Adults: A Randomised, Double-Blind, Controlled Trial.

OBJECTIVES: To investigate the impact of a six-month multi-ingredient nutrition supplement intervention (Smartfish®), containing omega-3 polyunsaturated fatty acids (PUFAs), vitamin D, resveratrol, and whey protein, on cognitive function in Irish older adults. DESIGN: Double-blind, randomised controlled trial (ClinicalTrials.gov: NCT02001831). A quantitative, mixed-model design was employed in which the dependent variable (cognitive function) was analysed with a between-subjects factor of group (placebo, intervention) and within-subjects factor of testing occasion (baseline, three-months, six-months). SETTING: Community-based intervention including assessments conducted at University College Dublin, Ireland. PARTICIPANTS: Thirty-seven community-dwelling older adults (68-83 years; mean (x̄)= 75.14 years; standard deviation (SD)= 3.64; 18 males) with normal cognitive function (>24 on the Mini Mental State Examination) were assigned to the placebo (n= 17) or intervention (n= 20) via a block randomisation procedure. INTERVENTION: Daily consumption for six-months of a 200mL liquid juice intervention comprising 3000mg omega-3 PUFAs [1500mg docosahexaenoic acid (DHA) and 1500mg eicosapentaenoic acid (EPA)], 10µg vitamin D3, 150mg resveratrol and 8g whey protein isolate. The placebo contained 200mL juice only. MEASUREMENTS: A standardised cognitive assessment battery was conducted at baseline and follow-ups. Individual test scores were z-transformed to generate composite scores grouped into cognitive domains: executive function, memory, attention and sensorimotor speed. Motor imagery accuracy and subjective awareness of cognitive failures variables were computed from raw scores. RESULTS: A hierarchical statistical approach was used to analyse the data; first, by examining overall cognitive function, then by domain, and then by individual test scores. Using mixed between-within subjects, analyses of variance (ANOVAs), no significant differences in overall cognitive function or composite cognitive domains were observed between groups over time. The only significant interaction was for Stroop Color-Word Time (p< 0.05). The intervention group demonstrated reduced task completion time at three- and six-month follow-ups, indicating enhanced performance. CONCLUSION: The present nutrition intervention encompassed a multi-ingredient approach targeted towards improving cognitive function, but overall had only a limited beneficial impact in the older adult sample investigated. Future investigations should seek to establish any potential clinical applications of such targeted interventions with longer durations of supplementation, or in populations with defined cognitive deficits.

Mild hypercholesterolemia and premature heart disease: do the national criteria underestimate disease risk?

OBJECTIVES: To determine the frequency of hospital admissions for acute coronary syndrome in young adults and to examine the risk factors that predispose to the development of premature heart disease. BACKGROUND: Significant coronary heart disease (CHD) is considered rare in the young adult. Current guidelines do not recommend treatment of mild cholesterol abnormalities for primary prevention of CHD in the young. METHODS: This is a large case series of 449 adults (< or =50 years) admitted to the hospital with acute coronary syndrome. A history of cardiovascular risk factors and lipid profile were recorded. The presence and extent of CHD were established. RESULTS: Mean patient age was 44 +/- 6 years. Documented CHD was present in 61% of hospital admissions. Multivariate analysis revealed that history of hypercholesterolemia, history of smoking and diabetes were independently associated with premature CHD. The fasting lipid profiles were only borderline to mildly abnormal. Serum total cholesterol, low-density lipoprotein (LDL) and triglyceride levels were not different in cases compared with control subjects. Nearly half (49%) of those with LDL levels of > or =160 mg/dl had only one additional risk factor or none. Despite this, a history of hypercholesterolemia had independent and incremental value on other risk factors for the likelihood of premature CHD. CONCLUSIONS: The magnitude of hospital admissions relating to premature CHD is high. In this population, the presence of borderline or mild hypercholesterolemia has significant effects on the development of premature CHD. These observations have significant implications in the development of guidelines for primary prevention of premature CHD.

Death and end-of-life planning in one midwestern community.

BACKGROUND: The major health care organizations in a geographically defined area implemented an extensive, collaborative advance directive education program approximately 2 years prior to this study. OBJECTIVES: To determine for a geographically defined population the prevalence and type of end-of-life planning and the relationship between end-of-life plans and decisions in all local health care organizations, including hospitals, medical clinics, long-term care facilities, home health agencies, hospices, and the county health department. METHODS: For more than 11 months, end-of-life planning and decisions were retrospectively studied for all adult decedents residing in areas within 5 ZIP codes. These decedents were mentally capable in the 10 years prior to death and died while under the care of the participating health care organizations. Data were collected from medical records and death certificates. Treating physicians and decedent proxies were also contacted for interviews. RESULTS: A total of 540 decedents were included in this study. The prevalence of written advance directives was 85%. Almost all these documents (95%) were in the decedent's medical record. The median time between advance directive documentation and death was 1.2 years. Almost all advance directive documents requested that treatment be forgone as death neared. Treatment was forgone in 98% of the deaths. Treatment preferences expressed in advance directives seemed to be consistently followed while making end-of-life decisions. CONCLUSIONS: This study provides a more complete picture of death, end-of-life planning, and decision making in a geographic area where an extensive advance directive education program exists. It indicates that advance planning can be prevalent and can effectively guide end-of-life decisions.

Molecular cloning of a cDNA for human pregnancy-specific beta 1-glycoprotein:homology with human carcinoembryonic antigen and related proteins.

Human pregnancy-specific beta 1-glycoprotein (SP1) plays an essential role in normal pregnancy. It is also a well-characterized oncodevelopmental antigen, expressed aberrantly by all trophoblastic tumors and some other malignant cell types. Here we report the identification of a human placental cDNA encoding the SP1 polypeptide sequence. The coding sequence shows 95% identity at the nucleotide level with a distinct, recently published SP1 cDNA sequence (PSG16). Unexpectedly, the sequence is also highly homologous to the published sequence of human carcinoembryonic antigen (CEA). SP1, CEA and CEA-related nonspecific cross-reacting species thus belong to a group of closely related though antigenically diverse tumor-associated glycoproteins. Comparison of the deduced amino acid sequence of the SP1 cDNA with that of CEA provides insight into the modular nature of these related proteins. This may have implications for the genomic organization and evolution of the CEA gene family.

Production of platelet-derived growth factor receptor (PDGFR-beta) in E. coli. Mapping ligand binding domain.

Portions of the extracellular domain of the platelet-derived growth factor receptor beta (PDGFR-beta) were expressed as fusion proteins with a hexa His tag in E. coli. Following purification by Ni chelate chromatography, the recombinant receptors were tested in cross-competition studies with 125I-labelled PDGF-AA and -BB. Although of lower affinity than the native receptor (IC50 values of 10(-8) M) the recombinant molecules retained ligand binding specificity and neutralized the mitogenic effect of PDGF-BB. These data indicate that the ligand binding region lies within the first four immunoglobulin-like domains on PDGFR-beta. This E. coli expression system could be further used as a rapid and economical means to produce mutated receptors and map the ligand binding domain.

Development of a screening tool for prediction of children at risk for lead exposure in a midwestern clinical setting.

OBJECTIVE: Universal screening for childhood lead poisoning is becoming quite common, with many states having legislation requiring screening. We set out to determine whether a questionnaire could be used to identify children at risk for exposure to lead to determine whether selective screening of those at risk was possible. METHODS: Parents of 370 children 12 to 36 months of age having well-child examinations completed a questionnaire and their children were screened by a fingerstick capillary blood lead test at two clinics. RESULTS: Of patients from clinic A, 5.4% had lead levels > or = 10 micrograms/dL compared with 16.8% of those from clinic B (P < .001). This difference between clinics could not be explained by the demographic characteristics of the patients or by differences in their potential exposures to lead. We evaluated the five questions suggested by Centers for Disease Control and Prevention for anticipatory guidance for their ability to identify children with elevated blood lead levels. In clinic A, this instrument had a sensitivity of 76.9% and a negative predictive value of 96.5%. In clinic B, it had a sensitivity of 63.6% and a negative predictive value of 81.4%. Based on an assessment of significant items from a large questionnaire, we determined five questions that were the best predictors of risk. On the basis of this risk assessment, 100% of the children from clinic A with elevated lead levels and 90.9% of the children from clinic B with elevated lead levels were classified as being at "high risk." Had this risk assessment been used as an initial screen in this sample, 40% of the patients from clinic A and 37% of the patients from clinic B would not have been screened with a blood lead test, because they were classified as being at "low risk." CONCLUSIONS: Results of this study suggest that there is great variability in the prevalence of elevated lead levels and potential risks between clinics within a fairly homogeneous community; however, selective screening with a community-specific questionnaire may be feasible if the prevalence is low and the risks to the population are known.

Investigation of thermoregulatory characteristics in patients with Prader-Willi syndrome.

A survey instrument is used to assess temperature regulation characteristics in children with Prader-Willi syndrome (PWS) compared to 3 control groups: sibs of PWS patients (SIB), neurodevelopmentally handicapped children (ND), and age and gender matched well children (WC). Significant differences were found between PWS patients, SIB controls, and WC controls in the prevalence of febrile convulsions, fever-associated symptoms, and temperature less than 94 degrees F. No differences were noted in any variable between the PWS patients and the ND controls, suggesting that these abnormalities are not unique to PWS, but can occur in any neurodevelopmentally handicapped individual, further suggesting these do not necessarily reflect syndrome-specific hypothalamic abnormalities.

Subclavian hemodialysis catheter infections: a prospective, randomized trial of an attachable silver-impregnated cuff for prevention of catheter-related infections.

OBJECTIVE: To determine if an attachable silver-impregnated cuff is effective in reducing subclavian hemodialysis catheter-related infections. DESIGN: Prospective, randomized, nonblinded study. SETTING: Community teaching hospital. PATIENTS: One hundred one acute and chronic renal failure patients requiring subclavian venipuncture and catheterization. After randomization, 47 patients underwent subclavian catheterization with a silver-impregnated cuff (Ag-CC), and 54 patients had routine catheter (RC) placements. MEASUREMENTS: Multiple presumed predictor variables for catheter-related infections, exit site infection rate, bacteremia rates, and semiquantitative cultures of all catheters.

Effects of bilateral auditory cortical lesions on gap-detection thresholds in the ferret (Mustela putorius).

Ferrets were tested for their ability to detect temporal gaps in noise before and after bilateral lesions of the primary auditory cortex. Thresholds for gap detection were determined first for normal animals with band-pass noises at various center frequencies (0.5 to 32 kHz) and at 8 kHz with various sound pressure levels (-10-70 dB). Gap-detection ability improved steadily as sound pressure increased up to 70 dB. No systematic relation was found between threshold and center frequency. To determine the effects of brain damage, ferrets were tested with 8-kHz band-pass noise at 70 dBSPL. After bilateral lesions of auditory cortex, ferrets were still capable of detecting gaps, but the mean threshold was elevated from 10.1 to 20.1 ms. The data demonstrate that auditory cortex is important for perceptual tasks requiring fine temporal resolution.

Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy.

OBJECTIVE: To analyze reproductive outcome after laparoscopic procedures for ectopic pregnancy, with particular attention to laparoscopic salpingectomy. METHODS: In a 260-physician multispecialty clinic in the rural upper midwestern United States, 143 patients were followed prospectively after undergoing laparoscopic procedures for ectopic pregnancy. Ninety-five who sought further pregnancies during the study period were analyzed for reproductive outcome. Intrauterine pregnancy rates were compared by age, parity, size of ectopic gestation, and evidence of prior tubal damage. Life table analysis was also performed. RESULTS: The overall intrauterine pregnancy rates for laparoscopic salpingostomy (60%) and laparoscopic salpingectomy (54%) were not significantly different from each other. However, intrauterine pregnancy rates differed significantly by history of prior tubal damage. The pregnancy rate was 79% among women without tubal damage and 42% among women with damage. CONCLUSIONS: Our intrauterine pregnancy rates after both laparoscopic salpingectomy and laparoscopic salpingostomy are similar to those reported in the literature for similar procedures performed at laparotomy. In predicting pregnancy outcome after laparoscopic procedures for ectopic pregnancy, the major variable seemed to be evidence of prior tubal damage. With no evidence of previous damage, we found similarly high pregnancy rates for laparoscopic salpingostomy and salpingectomy.

Factors that influence weight loss in the puerperium.

A study group of 795 women was followed with frequent weight measurements and questionnaires about their activities for 6 months postpartum. The mean (+/- SD) net weight gain from the first prenatal visit to 6 months postpartum was 1.4 +/- 4.8 kg. Weight gain during prenatal care was the variable most highly correlated to weight loss. Return to work outside the home, parity, and smoking also correlated significantly to weight loss. Breast-feeding, exercise, season of the year, age, and marital status were not correlated. Route of delivery was related to weight loss at 2 and 6 weeks, but not at 6 months. Counseling women about weight gain during pregnancy and weight loss requires an understanding of these variables with a long-term perspective of at least 6 months.

Kainic acid lesions of the superior olivary complex: a horseradish peroxidase study of surviving brain-stem projections.

Lesions of the superior olivary complex of the adult ferret were made by pressure injection of kainic acid (5 nM/microliters in Locke's solution) through a glass micropipette inserted into the lower brain-stem. Small injections of kainic acid (1.5 microliters) produced a localized loss of nerve cells in the superior olivary complex in the vicinity of the pipette tip without apparent damage to fibers of passage in the trapezoid body. The extent of neural damage was determined by the absence of cell bodies in Nissl-stained sections. Integrity of fibers in the trapezoid body and other decussating pathways of the auditory lower brain-stem was confirmed by retrograde transport of horseradish peroxidase (HRP) following large injections of the enzyme into the central nucleus of the inferior colliculus. Even animals with complete destruction of the superior olivary complex had a normal complement of HRP-labelled cells in all divisions of the cochlear nucleus (the dorsal, anteroventral and posteroventral nuclei) contralateral to the HRP injection. In cases with partial lesions, normal labelling was also seen in those parts of the superior olivary complex not directly destroyed by the kainic acid injection. There was no evidence of disruption of fibers of passage nor was there any indication of abnormal projections from the lower brain-stem to inferior colliculus even after prolonged survival times.

Comparison of ultrasound-guided and digitally directed transrectal biopsy of palpable prostate lesions.

The role of ultrasound in the diagnosis of prostate cancer is still evolving. We used ultrasound to examine 202 patients with palpably abnormal prostates. Of 151 patients undergoing biopsy, ultrasound-guided biopsy was comparable to digitally directed biopsies in cancer detection (92% vs 90.7%). The two methods are complementary and should both be considered in patients with palpably abnormal prostates.

Effects of square-wave gratings and diffuse light on metabolic activity in the rat visual system.

The 2-deoxyglucose (2-DG) technique was used to determine the effects of pattern and diffuse light stimulation on glucose metabolism with hooded rats. Rats placed in a stimulation chamber covered with horizontal and vertical square wave gratings while wearing goggles with one of three pairings of light-occluding, diffusing, or clear lenses, allowed the assessment of the effects of different but simultaneous visual conditions on two sides of the strongly crossed visual system. Eyes covered with occluding lenses were lid-sutured shut 24 h before 2-DG. In order to assess the possibly confounding effects of this lid suture a second group of rats had one eyelid sutured for 24 h, and the other covered with an occluding lens for 20 min, before 2-DG. To further assess the effects of diffuse light a third group of rats was tested in a featureless white box with one eye occluded and the other covered by a diffusing lens. Exposure to pattern stimulation significantly increased metabolic activity in the dorsal lateral geniculate nucleus (LGNd), lateral posterior nucleus (LPN), superior colliculus (SC), and in visual cortex (VC). In contrast, diffuse light only slightly elevated LGNd activity and appeared to have little or no effect in the LPN or VC. Diffuse light, however, was as effective as patterned light in increasing ventral lateral geniculate nucleus activity and strongly suppressed SC activity to a level well below that produced by darkness. Evidently diffuse light, not just patterned light, can significantly govern the operation of central nervous system visual structures.

Dependency, social factors, and the smoking cessation process: the doctors helping smokers study.

We analyzed data obtained from a representative sample of the smoking patients (n = 1,338) of 66 family physicians to determine predictors of attempts to stop smoking, desire to quit smoking, and successful smoking cessation. Compared to subjects who made no attempt to quit smoking, subjects who tried to quit smoking tended to be younger, had tried to quit smoking in the year prior to the study, waited longer before smoking their first cigarette of the day, had more desire to quit smoking, and had more social support for quitting. Education and cigarettes smoked per day were not independently related to the subject making a quit attempt. Desire to quit smoking was associated with an attempt to quit in the year prior to the study and social support for smoking cessation (support of spouse, second most important social contact, and physician). Desire to quit smoking was not independently related to age, education, or dependency on cigarettes (measured by the number of cigarettes smoked per day and the length of time a subject waited before smoking the first cigarette of the day). Compared to subjects who tried to quit and failed, subjects who succeeded were older, smoked fewer cigarettes per day, and waited longer to smoke their first cigarette of the day. Spouse support, support of the second most important social contact, and advice of a doctor to quit smoking were not independently related to whether or not a cessation attempt would be successful. These data suggest that successful smoking cessation requires two components: social support to make an attempt to quit and the ability to overcome dependency on cigarettes to make the attempt successful.

Community attitudes toward public policies to control alcohol, tobacco, and high-fat food consumption.

We report the results of a survey conducted in upper-midwestern communities to assess public attitudes toward policy level interventions to moderate the use of alcohol, tobacco, and high-fat food. Four hundred thirty-eight women and 383 men were asked to indicate how much they favored or did not favor 29 policy proposals. Results showed that regulatory controls in all three areas were favored by the general public. Support was strongest for alcohol and tobacco controls, less so for high-fat food. Interventions designed to protect children and youths were most strongly endorsed, followed by restrictions on advertising and direct control over conditions of sale. Women favored all interventions more than men. There was a strong positive association between age and support for measures to moderate alcohol use. Individuals reporting least personal use of alcohol, tobacco, and high-fat foods were most in favor of control policies. The results of this survey indicate specific measures that might be most readily enacted and what segments of the population are likely to be most and least receptive.

Evaluating the thirty minute interval in emergency cesarean sections.

BACKGROUND: This study was done to evaluate what percent of emergency cesarean sections are begun within the 30 minute interval between decision and incision time and to evaluate morbidity associated with this time interval. STUDY DESIGN: A retrospective patient-control study of records from 75 patients undergoing emergency cesarean sections and two different control groups was undertaken. RESULTS: Sixty-three percent of emergency cesarean sections were begun in less than 30 minutes. A significantly greater number of infants in the group that delivered in less than 30 minutes experienced five minute Apgar scores less than six. There was no significant differences in maternal morbidity associated with emergency cesarean sections. CONCLUSIONS: The 30 minute interval is obtainable in a large number of patients but did not have a beneficial effect on neonatal morbidity. There was no significant morbidity seen in the patients who underwent emergency cesarean section. Other measurements of emergency preparedness should be considered other than the 30 minute rule.

Management of thyroid cancer of follicular cell origin: Gundersen/Lutheran Medical Center, 1969-1995.

BACKGROUND: Most reports regarding the treatment of thyroid cancer originate from university referral centers. In this article, we report our experience in managing thyroid cancer of follicular cell origin at a non-university institution over a 26-year period. STUDY DESIGN: We reviewed the medical records of all patients treated for thyroid cancer at the Gundersen/Lutheran Medical Center from 1969 to 1995. Histologic types, demographic and clinical characteristics, laboratory results, treatment, complications, and followup observations were tabulated. Risk was assigned according to the age, presence of distant metastasis, extent of the primary tumor, and site of the primary tumor (AMES) staging system. RESULTS: The histologic classification was as follows: papillary, 139; follicular, 24; Hürthle cell, 14; and anaplastic, 11. Low-risk lesions were identified in 96%, 79%, and 71% of the patients with papillary, follicular, and Hürthle cell (collectively designated differentiated) carcinoma, respectively. We treated 60% of our patients with differentiated thyroid cancer with near-total or total thyroidectomy. Clinically involved cervical lymph nodes were removed singly or by modified neck dissection. We frequently ablated thyroid remnants after operation with 29.9 mCi (1,110 MBq) of 131I, after which we treated the patient with suppressive doses of levothyroxine. Patients were evaluated yearly with thyroglobulin measurements and, in some high-risk patients, with total-body 131I scans. Cancer recurred in 13%, 8%, and 7% of our patients with papillary, follicular, and Hürthle cell carcinoma, respectively. Only three patients died of differentiated thyroid cancer; eight are alive with malignancy. In anaplastic thyroid cancer, cervical lymph node metastases, local invasion, and distant metastases were present in 18%, 64%, and 45% of patients at the time of initial evaluation. Total or near-total thyroidectomy was possible in only four of nine patients treated surgically. External radiation (11 patients) and chemotherapy (two patients) were used. Additional metastases developed in 45% of the patients, and nine patients died within a year. Permanent hypoparathyroidism or hoarseness complicated 2.7% of the thyroid operations. CONCLUSIONS: Although our followup was relatively short, the results of treating thyroid cancer by general surgeons at a nonuniversity hospital compare favorably with results obtained from university referral centers.