Practical aspects of telehealth: establishing telehealth in an institution.

The fifth in a series of papers on practical aspects of telehealth, this paper discusses telehealth models that can facilitate the provision of specialist services to rural and remote patients closer to home. Some of the barriers to successful implementation of these models relates to workforce, funding and infrastructure at rural sites, as well as the traditional mindset of healthcare professionals. Therefore, the rural sector needs to be adequately resourced for telehealth models to be substantive and successful. This paper describes the development of a large teleoncology network over a vast geographical area in North Queensland. Adequate resourcing for the rural sites and undertaking quality improvement activities has continually enhanced the model over a 5- to 6-year period. The benefits of this model of care are twofold: (i) patients received their care closer to home and (ii) the workforce, service capabilities and infrastructure for the hospital in Mt Isa (a rural town 900 km away from its tertiary centre) has improved.

Practical aspects of telehealth: set-up and preparation for video consultations.

The third in a series of articles about the practical aspects of telehealth, this paper gives guidance on suitable setup for video consultations, including layout of rooms, managing sound and image quality, scheduling, testing and best practice in telehealth videoconferencing.

Effects of feeding yeast and propionibacteria to dairy cows on milk yield and components, and reproduction*.

To determine the effect of supplemental feeding of Diamond V-XP yeast (XPY) alone or in combination with propionibacteria strain P169 on milk production, milk components, body weight, days to first and second ovulation, plasma insulin, and plasma and milk glucose, 31 primiparous and multiparous (MP) Holstein cows were fed one of three dietary treatments between 2 weeks prepartum to 30 weeks postpartum: (i) control (n = 10), fed a corn silage-based total mixed ration (TMR); (ii) XPY (n = 11), fed control TMR plus XPY (at 56 g/head/day); and (iii) P169+XPY (n = 10), received control TMR plus XPY plus P169 (at 6 x 10(11) cfu/head/day). After parturition, daily milk weights were recorded, and milk samples were collected twice weekly for milk component analyses. Daily uncorrected milk, solids-corrected milk, and 4% fat-corrected milk production for MP cows fed P169+XPY was 9-16% greater than control MP cows, but these increases were only evident during mid lactation (9-30 weeks). The percentage of milk fat was 8-18% greater in control than XPY and P169+XPY groups. Milk lactose percentage in MP cows fed P169+XPY was 3-5% greater than in control and XPY MP cows. Primiparous and MP cows fed P169+XPY had 28-32% greater milk glucose levels than control and XPY-fed cows. Diurnal plasma glucose concentration was not affected by diet in MP cows. Plasma insulin levels in MP cows fed P169+XPY were 30-34% greater than in other groups of MP cows. Milk glucose and plasma insulin responses to P169+XPY feeding suggest that P169+XPY might have enhanced gluconeogenesis and increased glucose uptake by the mammary gland in Holstein cows. Thus, a combined feed supplement of P169 and XPY may hold potential as a natural feed alternative to hormones and antibiotics to enhance lactational performance.

Effects of feeding propionibacteria to dairy cows on milk yield, milk components, and reproduction.

Two weeks before parturition, 38 Holstein primiparous and multiparous cows were assigned to 1 of 3 treatment groups: control animals (n = 13) received regular total mixed rations (TMR), the low-dose group (n = 14) received the control TMR plus 6 x 10(10) cfu/cow of Propionibacterium strain P169 (P169), and the high-dose group (n = 11) received the control TMR plus 6 x 10(11) cfu/cow of P169 from -2 to 30 wk postpartum. Weekly milk samples were analyzed for percentage of milk fat, protein, lactose, and SNF, milk urea nitrogen, and somatic cell counts. Daily milk production expressed as 4% fat-corrected milk was affected by treatment and week x parity. High-dose and low-dose P169-treated cows exhibited 7.1 and 8.5% increases above controls in daily 4% fat-corrected milk, respectively. Treatment x parity and week significantly influenced percentage of milk fat, lactose, and protein, whereas treatment x parity and treatment x week influenced SNF. Ruminal propionate levels were influenced by treatment such that high-dose P169 cows had greater molar percentage of propionate than did low-dose P169 and control cows. Change in body weight postpartum was influenced by week x parity and treatment x parity such that high-dose and low-dose P169 multiparous cows exhibited a more rapid recovery of wk-1 body weight than did control multiparous cows. There was no treatment, parity, or interaction on days to first postpartum ovulation or on estrous behavior at 45 and 90 d postpartum. We concluded that P169 might have potential as an effective direct-fed microorganism to increase milk production in dairy cows.

Permeation of proteins from the blood into peripheral nerves and ganglia.

We have attempted to resolve apparently conflicting observations of previous investigators regarding the penetration of proteins into peripheral ganglia and nerves of the rat. Horseradish peroxidase, which is largely cleared from the blood and extracellular fluids in less than 30 min, entered all the extracellular spaces of ganglia, including the clefts between glial cells and neurons, but it did not enter the endoneurium. Rhodamine B-conjugated bovine albumin quickly entered sensory and sympathetic ganglia, but its penetration into avascular enteric nervous tissue was arrested at the outer margin of each myenteric and submucosal ganglion. If injected daily for a week, this fluorescent protein was seen also in the endoneurium, but it was still absent from enteric ganglia. The failure to enter enteric ganglia may have been due to the entrapment of aggregates of dye-labelled albumin molecules in the basal lamina that encloses the enteric nervous system. Extracellular endogenous albumin immunoreactivity was seen in all parts of peripheral nerves and in all types of ganglion. Some neuronal perikarya contained albumin-immunoreactive material; the strongest staining was in enteric neurons. Albumin may reach these cell bodies by retrograde axonal transport from peripheral terminals. We conclude that all the extracellular spaces of the rat's peripheral nervous system are accessible to plasma proteins, though diffusion occurs more slowly into the endoneurium than into ganglia.

Flow characteristics of four commonly used mechanical heart valves.

The in vivo and in vitro fluid dynamic performance of 4 mechanical heart valves was reviewed: Starr-Edwards silicon-rubber ball valves (models 1200/1260 aortic and 6120 mitral valves), Björk-Shiley tilting disc valves (standard spherical model, modified and unmodified convexo-concave [60 degrees and 70 degrees C-C] models), the Medtronic-Hall (Hall-Kaster) tilting disc valve and the St. Jude Medical bileaflet valve. These valves were chosen because of their past or present popularity in clinical use and because they encompass most of the basic mechanical valve designs used during the past 2 decades. The flow measurements reported include in vivo and in vitro mean pressure drop, cardiac output or cardiac index, regurgitant volume, effective orifice area and performance index.

Insulin-like growth factor-II stimulates steroidogenesis in cultured bovine thecal cells.

The objective of the present study was to determine the effects of insulin-like growth factor-II (IGF-II) on luteinizing hormone (LH)-induced progesterone and androstenedione production by bovine thecal cells and compare it to that of insulin and IGF-I. Cells from large (>7.9 mm) bovine follicles were collected and cultured for 2 days in the presence of 10% fetal calf serum. Then cells were cultured for an additional 1 or 2 days in serum-free medium with various doses of recombinant human IGF-II, bovine LH (30 ng/ml), IGF-I, and(or) insulin. Cell numbers were determined at the end of treatments via Coulter counting and used to correct steroid production data. In the presence of LH, 1-day treatment with 3-300 ng/ml of IGF-II had no significant effect on progesterone or androstenedione production, whereas 2-day treatment with 30, 100 and 300 ng/ml of IGF-II increased (P < 0.05) both progesterone and androstenedione production by 2-3-fold. The estimated effective dose of IGF-II stimulating 50% of the maximal steroidogenic response was calculated to be 25 ng/ml. In the absence of LH, 2-day treatment of IGF-I or -II had no effect on thecal androstenedione production but increased (P < 0.05) thecal progesterone production. In the presence of LH, 100 ng/ml of IGF-I increased progesterone and androstenedione production to a greater degree than did 100 ng/ml of IGF-II. Maximal effects of IGF-I and insulin on thecal steroidogenesis were similar and were not additive. Anti-IGF type I receptor antibodies attenuated (P < 0.05) the stimulatory effect of both IGF-I and IGF-II on thecal cell steroidogenesis. Use of radioligand assays demonstrated that specific receptors for (125)I-IGF-II existed in thecal cells with a 25 ng/well of IGF-II causing 50% inhibition of binding. IGF-I cross-reactivity with (125)I-IGF-II receptors averaged 3% whereas cross-reactivity of IGF-II with (125)I-IGF-I receptors averaged 114%. These results indicate that the stimulatory effects of IGF-II on thecal cell steroidogenesis is mediated by IGF type I receptors and thus IGF-II, like IGF-I, may play a significant role in thecal cell steroidogenesis during follicular development.

Flow characteristics of bioprosthetic heart valves.

A review of the in vivo and in vitro fluid dynamic performance of three bioprosthetic heart valves is presented. Data on Hancock porcine valves (standard models 242 aortic and 342 mitral and modified orifice model 250 aortic), Carpentier-Edwards porcine valves (model 2625 aortic and 6625 mitral), and the Ionescu-Shiley pericardial valve are reviewed. These valves were chosen because of their past or present popularity in clinical use and because of the variation in fluid dynamic performance reported by different investigators. The flow parameters that are reported include in vivo and in vitro mean pressure drop, cardiac output or cardiac index, regurgitant volume, effective orifice area, and performance index. These data provide a framework for differentiation of normal and abnormal bioprosthetic valve function.

A circulating exogenous protein can enter enteric nervous tissue in the rat.

Previous studies of the permeation of circulating protein tracers yielded conflicting results in the enteric nervous system. We show that within 5 min of intravenous injection, horseradish peroxidase (HRP) enters all the extracellular spaces of the ganglia and connecting strands of the submucous and myenteric plexuses of the rat's small intestine, including the clefts between neuroglial cells and neurons. The tracer is still there after 10 min, but is nearly all gone 30 min after injection. Enteric neurons, like others with somata in peripheral ganglia, are therefore probably accessible to plasma proteins and to substances with smaller molecules that are protein-bound when circulating in the blood.

In vitro flow dynamics of four prosthetic aortic valves: a comparative analysis.

The velocity fields downstream of four prosthetic heart valves were mapped in vitro over the entire cross-section of a model aortic root using laser Doppler anemometry. THe Björk-Shiley 60 degrees convexo-concave tilting disc valve, the Smeloff-Cutter caged ball valve, the St. Jude Medical bileaflet valve, and the Ionescu-Shiley standard bioprosthesis were examined under both steady and pulsatile flows. Velocity profiles under steady flow conditions were a good approximation for pulsatile profiles only during midsystole. The pulsatile flow characteristics of the four valves showed variation in large scale flow structures. Comparison of the valves according to pressure drop, shear stress and maximum velocities are also provided.

A central giant cell granuloma in a patient seeking orthodontic treatment.

BACKGROUND: This case report illustrates the need to consider central giant cell granuloma, or CGCG, in the differential diagnosis in cases of greatly displaced teeth and facial deformity. The authors review the literature regarding CGCG and emphasize the importance of early diagnosis and treatment. CASE DESCRIPTION: A 9-year-old boy was seen in an orthodontic office with the chief complaint of overlapping front teeth. On radiographic examination, the authors noted a large maxillary midline radiolucency. The child was referred to an oral and maxillofacial surgeon for definitive diagnosis and treatment. CLINICAL IMPLICATIONS: Patients may come to dental offices for treatment of malaligned teeth. The dentist needs to be aware of possible oral pathology when malaligned teeth are present. CGCG should be included in the differential diagnosis for patients with greatly displaced teeth and facial deformity.

Painful chewing and blindness: signs and symptoms of temporal arteritis.

BACKGROUND: This case report illustrates the need to consider temporal arteritis in the differential diagnosis of jaw or tooth pain. This disease affects the cranial arteries, more frequently in women and usually in those older than age 60 years, causing jaw pain, visual symptoms, headache, scalp pain and sometimes blindness. CASE DESCRIPTION: A 71-year-old man had jaw pain that increased with chewing and speaking, scalp tenderness and dimming vision. A temporal artery biopsy confirmed the diagnosis of temporal arteritis. Treatment with decreasing amounts of oral steroids over 23 months was successful in relieving his signs and symptoms and in saving his vision. CLINICAL IMPLICATIONS: Patients with this disease may seek care from their dentist first. Jaw or tooth pain is the most reliable clinical symptom in the diagnosis of temporal arteritis. Diagnosis and timely referral for treatment with oral steroids can prevent blindness.

Population, birth control and West Viriginia.

PIP: Defining population growth and the need for birth control for the medically indigent of West Virginia, using epidemiologic principles, is discussed. In comparing the birthrates for West Virginia and the U.S., it was determined that although initially higher than the birthrate for the U.S. as a whole in 1943, the West Virginia birthrate fell below the national average in 1953 and preceded the U.S. rate in its sharp decline. In the 10-year period from 1950 to 1960, the absolute number of births in West Virginia fell from 51,000 to 40,000, a drop of 22%. In the same decade, the absolute number of births in the U.S. rose 20%, from 3.5 million to 4.3 million. During that time, the total population for the state of West Virginia fell by 7% from 2,005,000 to 1,860,000. The steady decline in the absolute number of births and the birthrate in West Virginia since 1947 is due to a very high rate of out-migration of the 20-34 year old population. The fertility of those potential parents remaining in the state has stayed high, however, in some areas approximating the fertility pattern of developing countries of the world. In McDowell County, almost 1 out of every 3 potential mothers in the 20-24-year age range delivered a baby in 1960.^ieng