Evaluation of short exposure times of antimicrobial wound solutions against microbial biofilms: from in vitro to in vivo.

Objectives: Test the performance of topical antimicrobial wound solutions against microbial biofilms using in vitro, ex vivo and in vivo model systems at clinically relevant exposure times. Methods: Topical antimicrobial wound solutions were tested under three different conditions: (in vitro) 4% w/v Melaleuca oil, polyhexamethylene biguanide, chlorhexidine, povidone iodine and hypochlorous acid were tested at short duration exposure times for 15 min against 3 day mature biofilms of Staphylococcus aureus and Pseudomonas aeruginosa; (ex vivo) hypochlorous acid was tested in a porcine skin explant model with 12 cycles of 10 min exposure, over 24 h, against 3 day mature P. aeruginosa biofilms; and (in vivo) 4% w/v Melaleuca oil was applied for 15 min exposure, daily, for 7 days, in 10 patients with chronic non-healing diabetic foot ulcers complicated by biofilm. Results: In vitro assessment demonstrated variable efficacy in reducing biofilms ranging from 0.5 log10 reductions to full eradication. Repeated instillation of hypochlorous acid in a porcine model achieved <1 log10 reduction (0.77 log10, P = 0.1). Application of 4% w/v Melaleuca oil in vivo resulted in no change to the total microbial load of diabetic foot ulcers complicated by biofilm (median log10 microbial load pre-treatment = 4.9 log10 versus 4.8 log10, P = 0.43). Conclusions: Short durations of exposure to topical antimicrobial wound solutions commonly utilized by clinicians are ineffective against microbial biofilms, particularly when used in vivo. Wound solutions should not be used as a sole therapy and clinicians should consider multifaceted strategies that include sharp debridement as the gold standard.

Effect of cadexomer iodine on the microbial load and diversity of chronic non-healing diabetic foot ulcers complicated by biofilm in vivo.

Objectives: The performance of cadexomer iodine was determined against microbial populations from chronic non-healing diabetic foot ulcers (DFUs) complicated by biofilm in vivo , using molecular, microscopy and zymography methods. Methods: Chronic non-healing DFUs due to suspected biofilm involvement were eligible for enrolment. DNA sequencing and real-time quantitative PCR was used to determine the microbial load and diversity of tissue punch biopsies obtained pre- and post-treatment. Scanning electron microscopy and/or fluorescence in situ hybridization confirmed the presence or absence of biofilm. Zymography was used to determine levels of wound proteases. Results: Seventeen participants were recruited over a 6 month period. Scanning electron microscopy and or fluorescence in situ hybridization confirmed the presence of biofilm in all samples. Eleven participants exhibited log 10 reductions in microbial load after treatment (range 1-2 log 10 ) in comparison with six patients who experienced <1 log 10 reduction ( P = 0.04). Samples were tested for levels of wound proteases pre- and post-treatment. Reductions in the microbial load correlated to reductions in wound proteases pre- and post-treatment ( P = 0.03). Conclusions: To the best of our knowledge, this study represents the first in vivo evidence, employing a range of molecular and microscopy techniques, of the ability of cadexomer iodine to reduce the microbial load of chronic non-healing DFUs complicated by biofilm. Further analyses correlating log reductions to optimal duration of therapy and improvements in clinical parameters of wound healing in a larger cohort are required.

Can molecular DNA-based techniques unravel the truth about diabetic foot infections?

Diabetes foot infections are a common condition and a major causal pathway to lower extremity amputation. Identification of causative pathogens is vital in directing antimicrobial therapy. Historically, clinicians have relied upon culture-dependent techniques that are now acknowledged as both being selective for microorganisms that thrive under the physiological and nutritional constraints of the microbiology laboratory and that grossly underestimate the microbial diversity of a sample. The amplification and sequence analysis of the 16S rRNA gene has revealed a diversity of microorganisms in diabetes foot infections, extending the view of the diabetic foot microbiome. The interpretation of these findings and their relevance to clinical care remains largely unexplored. The advent of molecular methods that are culture-independent and employ massively parallel DNA sequencing technology represents a potential 'game changer'. Metagenomics and its shotgun approach to surveying all DNA within a sample (whole genome sequencing) affords the possibility to characterize not only the microbial diversity within a diabetes foot infection (i.e. 'which microorganisms are present') but the biological functions of the community such as virulence and pathogenicity (i.e. 'what are the microorganisms capable of doing'), moving the focus from single species as pathogens to groups of species. This review will examine the new molecular techniques for exploration of the microbiome of infected and uninfected diabetic foot ulcers, exploring the potential of these new technologies and postulating how they could translate to improved clinical care. Copyright © 2016 John Wiley & Sons, Ltd.

The effect of diabetes mellitus on costs and length of stay in patients with peripheral arterial disease undergoing vascular surgery.

OBJECTIVE: To determine the impact of diabetes mellitus (DM) and other comorbidities on length of stay (LOS) and costs in patients with peripheral arterial disease (PAD) admitted to a vascular surgical unit. METHODS: A retrospective study was conducted between January 2011 and July 2012 at a tertiary referral hospital in Sydney. Demographic, laboratory, and operative data were obtained from the Australasian Vascular Audit database and hospital diagnostic-related group (DRG) reports. Patients with confirmed PAD with or without DM requiring hospital admission for a diagnosis of claudication, rest pain, ulcer/gangrene, and infection that required lower limb surgical intervention were included. Associations between LOS, surgical procedure, and DRG were explored. RESULTS: Five hundred and sixty-eight admissions (492 patients) were identified: 292 admissions with PAD and 276 admissions with PAD in conjunction with DM (PADDM). Mean LOS for patients with PAD was 10 ± 13.7 days compared with 15 ± 18.2 days for PADDM (p < .01; 95% confidence interval 2.7-8.0). LOS and costs were greatest in patients with PADDM undergoing major amputation (37 ± 13.7 days; US$42,236; p < .01). Analysis of variance indicated that the best predictors of LOS were the presence of DM, bypass surgery, amputation, chronic kidney disease (CKD) stage V, infection, and emergency admission. Over 18 months, the estimated total inpatient costs associated with lower limb intervention for PAD with and without DM amounted to US$7,598,597. People with DM incurred greater inpatient costs, averaging US$1,912 more per episode of admission and a total of US$528,029 over 18 months. CONCLUSION: The impact of diabetes as a comorbid condition in patients with PAD is significant, both clinically and economically. Factors that predict increased LOS in patients with PAD are DM, bypass surgery, amputation, CKD stage V, infection, and emergency admission.

Aperiodic and Hurst EEG exponents across early human brain development: A systematic review.

In electroencephalographic (EEG) data, power-frequency slope exponents (1/f_ß) can provide non-invasive markers of in vivo neural activity excitation-inhibition (E:I) balance. E:I balance may be altered in neurodevelopmental conditions; hence, understanding how 1/fß evolves across infancy/childhood has implications for developing early assessments/interventions. This systematic review (PROSPERO-ID: CRD42023363294) explored the early maturation (0-26 yrs) of resting-state EEG 1/f measures (aperiodic [AE], power law [PLE] and Hurst [HE] exponents), including studies containing ≥1 1/f measures and ≥10 typically developing participants. Five databases (including Embase and Scopus) were searched during March 2023. Forty-two studies were identified (Nparticipants=3478). Risk of bias was assessed using the Quality Assessment with Diverse Studies tool. Narrative synthesis of HE data suggests non-stationary EEG activity occurs throughout development. Age-related trends were complex, with rapid decreases in AEs during infancy and heterogenous changes thereafter. Regionally, AE maxima shifted developmentally, potentially reflecting spatial trends in maturing brain connectivity. This work highlights the importance of further characterising the development of 1/f measures to better understand how E:I balance shapes brain and cognitive development.

Pedal osteomyelitis in patients with diabetes: a retrospective audit from Saudi Arabia.

OBJECTIVE: To examine the characteristics of patients presenting to the emergency room and the specialist diabetes foot clinic with pedal osteomyelitis (PO). METHOD: A retrospective study was conducted at a regional hospital. The charts of patients with suspected PO who presented during the period 1 January to 31 December 2011 were analysed. Demographics, biochemistry and microbiological data were obtained. Bone biopsies were performed by the attending clinician either during surgical removal of infected bone, or percutaneously under guided fluoroscopy through non-infected tissue. RESULTS: Sixty-six cases of osteomyelitis affecting 102 joints were noted. The study population consisted of 44 men, mean age 62.9 +/- 1.3 years, and 22 women, mean age of 57.6 +/- 10.6 years. Gram-positive bacteria were the predominating pathogens (p < 0.05). Staphylococcus aureus was cultured in 36% of all bone biopsy cases. A predictive trend in HbA1c was observed,where every increase of 1% from the recommended level of 7% was associated with a 10% increase in the likelihood of receiving surgical intervention. CONCLUSION: S. aureus infection is a major cause of osteomyelitis in interphalangeal joints of the feet of diabetic patients.There is an apparent association with patients who present with diabetic foot osteomyelitis and sub-optimal glycaemic control, requiring surgical intervention.

Medical Biomonitoring of Maternal and Fetal Exposure to Carbon Monoxide and its Modification by Demographic and Obstetric Characteristics.

Background: There is a paucity of organized human biomonitoring, including that of carbon monoxide (CO) in the Niger Delta, Nigeria. The study aims to quantify the impact of maternal exposure to CO in the first trimester of pregnancy and its modification by maternal demographic and obstetric factors. Methodology: It was of cross-sectional design conducted at the Rivers State University Teaching Hospital (RSUTH) in Nigeria. Four hundred and ninety consecutive pregnant women in the first trimester were recruited from the antenatal clinic from January 2021 to January 2022. Demographic, social, and obstetric characteristics were recorded. Maternal exhaled CO concentration (ECOC) and maternal and fetal carboxyhaemoglobin concentrations (MCOHC and FCOHC) were measured with the aid of a smokelyzer. Data were analyzed, using SPSS version 25.0 software. Ethical approval was obtained from the RSUTH Ethics Committee. Results: The mean values of ECOC, MCOHC, and FCOHC were 3.25±2.51 ppm, 1.15±0.40%, and 0.93±0.72% respectively and the severity (mild, moderate, and severe) of the impact was inversely proportional to the number of women affected. There were statistically significant differences in the mean values of ECOC, MCOHC, and FCOHC in the following maternal characteristics: age, educational levels, BMI, gravidity, and parity. In the case of FCOHC, the measures of the differences were as follows: p:<0.019, <0.020, <0.0001, <0.0001, and <0.038 for age categories, educational levels, BMI, gravidity, and parity respectively. There were statistically significant positive correlations between the BMI and the mean values of ECOC, MCOHC, and FCOHC. Conclusion: The higher the severity of exposure to CO (mild, moderate, and severe), the lower the number of impacted pregnant women. There were statistically significant differences in the mean values of ECOC, MCOHC, and FCOHC in women of different ages, educational levels, BMI, gravidity, and parity categories.

Meta-analyses of cognitive and motor function in youth aged 16 years and younger who subsequently develop schizophrenia.

BACKGROUND: Previous reviews have reported cognitive and motor deficits in childhood and adolescence among individuals who later develop schizophrenia. However, these reviews focused exclusively on studies of individuals with affected relatives or on population/birth cohorts, incorporated studies with estimated measures of pre-morbid intelligence, or included investigations that examined symptomatic at-risk participants or participants 18 years or older. Thus, it remains unclear whether cognitive and motor deficits constitute robust antecedents of schizophrenia. Meta-analyses were conducted on published studies that examined cognitive or motor function in youth aged 16 years or younger who later developed schizophrenia or a schizophrenia spectrum disorder (SSD) and those who did not. METHOD: Twenty-three studies fulfilled the following inclusion criteria: (1) written in English; (2) prospective investigations of birth or genetic high-risk cohorts, or follow-back investigations of population samples; (3) objective measures of cognitive or motor performance at age 16 or younger; (4) results provided for individuals who did and who did not develop schizophrenia/SSD later in life; and (5) sufficient data to calculate effect sizes. Four domains of function were examined: IQ; Motor Function; General Academic Achievement; and Mathematics Achievement. RESULTS: Meta-analyses showed that, by age 16, individuals who subsequently developed schizophrenia/SSD displayed significant deficits in IQ (d=0.51) and motor function (d=0.56), but not in general academic achievement (d=0.25) or mathematics achievement (d=0.21). Subsidiary analysis indicated that the IQ deficit was present by age 13. CONCLUSIONS: These results demonstrate that deficits in IQ and motor performance precede the prodrome and the onset of illness.

Red flags and alarm bells: an atypical lesion masquerading as a diabetic foot ulcer.

An 88-year-old male presented at a high-risk foot service with a non-healing, plantar wound on his right foot, which had the appearance of a neuropathic ulcer. On further examination, the lesion was confirmed asymmetrical in shape and atypical in appearance. It also presented with surrounding violaceous, pigmented nodules in the arch of the foot, and several small, similar nodules on the plantar surface of the contralateral foot, giving the appearance of an exophytic lesion and suggesting melanoma. Following biopsy, it was diagnosed as classic Kaposi sarcoma.

Next Generation DNA Sequencing of Tissues from Infected Diabetic Foot Ulcers.

We used next generation DNA sequencing to profile the microbiome of infected Diabetic Foot Ulcers (DFUs). The microbiota was correlated to clinical parameters and treatment outcomes to determine if directed antimicrobial therapy based on conventional microbiological cultures are relevant based on genomic analysis. Patients≥18years presenting with a new Diabetic Foot Infection (DFI) who had not received topical or oral antimicrobials in the two weeks prior to presentation, were eligible for enrolment. Tissue punch biopsies were obtained from infected DFUs for analysis. Demographics, clinical and laboratory data were collected and correlated against microbiota data. Thirty-nine patients with infected DFUs were recruited over twelve-months. Shorter duration DFUs (

Venous Malformation and Localized Intravascular Coagulopathy in Children.

Aim Localized intravascular coagulopathy (LIC) has been described in adults with venous malformation (VM) but rarely reported in children. This study aims to determine the prevalence of LIC in children with VM and associated risk factors. Methods Patients younger than 18 years with VM from 2010 to 2014 were reviewed. Diagnosis was confirmed by Doppler ultrasound and/or magnetic resonance imaging. Demographics data and VM characteristics including volume, site, extension, painful symptoms, and palpable phleboliths were studied. Plasma D-dimer level of greater than 500 ng/mL was considered as abnormal. Results Total 24 children were included, of whom 8 were boys. Median age of presentation was 9 months (range: 0-12 years). Head-and-neck VM occurred in 17 (70.8%) patients and 3 (12.5%) had multifocal lesions. Seven (29.2%) patients had VM volume greater than 10 mL. Five (20.8%) patients had painful symptoms. Palpable phleboliths were found in two patients. Plasma D-dimer was raised in eight cases (33.3%). One patient with Klippel-Trenaunay syndrome (KTS) had D-dimer level of 5,000 ng/mL. Raised D-dimer was found in 23.5% of small VM (volume < 10 mL) and 57.1% of large VM (p = 0.167). D-dimer was significantly raised in multifocal VM (p = 0.028) and showed increasing trend in lesions with palpable phleboliths (p = 0.101). All patients had sclerotherapy performed with indications (cosmesis 41.7%, enlarging lesion 29.2%, pain 20.8%, bleeding 8.3%). Perioperatively, bolus intravenous fluid and mannitol were given to selected patients. All patients had VM volume reduction after sclerotherapy. There were no major thromboembolic complications. Conclusion LIC with raised D-dimer level occurred in one-third of pediatric VM. It was more common in large, multifocal VM and in those with palpable phleboliths or KTS.

Primary care referral to multidisciplinary high risk foot services - too few, too late.

BACKGROUND: To determine if patients with no contact with a multi-disciplinary team High Risk Foot Service (MDT-HRFS) had an increased rate of hospital admission for diabetes foot infection compared to patients with contact. Secondary aims were to report on clinical outcomes. METHODS: A retrospective study was conducted at a major tertiary referral hospital in metropolitan Sydney over 12 months. An ICD-10 search of the electronic medical record system and paper medical charts identified patients with diabetes mellitus (type 1 or type 2) and a primary admission for diabetes foot infection (DFI). Patients were categorised as having contact or no contact with an MDT-HRFS. RESULTS: One hundred ninety-six hospital admissions (156 patients) were identified with DFI over a 12-month period. Patients with no contact with a MDT-HRFS represented three quarters of admissions (no contact = 116, 74.7 % vs. contact = 40, 25.6 %, p = 0.0001) and presented with more severe infection (no contact = 39 vs. contact = 12). The odds of lower extremity amputation increased five-fold when both no contact and severe infection occurred in combination (no contact with severe infection and amputation = 34, 82.9 % vs. contact with severe infection and amputation = 7, 17.1 %, OR 4.9, 95 % CI 1.1-21.4, p = 0.037). Using estimates of both the contact and no contact population of people with diabetes and high-risk feet and assuming the risk of amputation was the same, than the number of expected amputations in the no contact group should have been 55, however the observed number was 77, 22 more than expected (p = 0.0001). CONCLUSIONS: Patients with no contact with a MDT-HRFS represented the majority of admissions for DFIs to a tertiary referral hospital. This group on population estimates appears to be at high risk of amputation of the lower extremity and therefore early referral of this high-risk group might lower this risk.

Evaluation of the pertussis components of diphtheria-tetanus-pertussis vaccine.

The adjuvant and antigen components of the pertussis fraction of diphtheria-tetanus-pertussis (DTP) vaccine were evaluated. Four preparations of DTP vaccine composed of either whole cell (Wc) or extracted (E) pertussis antigen combined with either an aluminum phosphate (Ph) or alum (Al) adjuvant were compared. Local reactions were similar in all four vaccines after the first two immunizations but were significantly increased in incidence and severity following the third immunization with vaccine WcPh. This appeared to be due to the Ph adjuvant rather than the antigen component. Febrile reactions were experienced more often (P = .0009) and with higher temperatures (P = .0001) with the WcPh vaccine following the first immunization. This appeared to be due to the Wc component. Comparing the pooled Wc groups with the pooled E groups revealed a greater febrile response in the Wc group after both the first (P = .0008) and the second (P = .03) immunization. Local reactions appear temporally and etiologically to be distinct from febrile reactions. The pooled Wc antigen group produced a higher geometric mean titer than the pooled E antigen group (P = .05). Serologic responses, with respect to geometric mean titer, were not significantly different among the individual vaccines. This study suggests that the combination of whole cell and aluminum phosphate, which is currently in use in the United States, is probably not the optimal formulation for pertussis vaccine.

Chronic depressions. Part 2. Sleep EEG differentiation of primary dysthymic disorders from anxious depressions.

In this clinical, psychometric and polysomnographic study, primary dysthymics (N = 20) were compared with anxious depressives (N = 22), and non-psychiatric controls (N = 11). Beck and MMPI depression scores were similar in the two affective groups. Prominent insomnia occurred in 82% of the anxious group; hypersomnia was more characteristic of the dysthymic group. On night 1, the anxious group had the poorest sleep efficiency (P less than 0.001), while dysthymics had the highest REM% (P less than 0.05) and shortest REM latency (P less than 0.01). On night 2, differences tended to be minimized, although the number of awakenings was still high (P less than 0.05) in the anxious group, and REM% was highest (P less than 0.01) and REM latency shortest (P less than 0.01) in the dysthymics. These findings suggest that patients with primary anxiety disorders experience greater sleep continuity difficulties on the adaptation night. Despite significant clinical overlap in depressive symptomatology between the two groups, REM% and REM latency appear as sturdy psychophysiological markers in differentiating primary dysthymics and anxious depressives on both nights. These data suggest that distinct anxious depressive and subaffective dysthymic subtypes can be distinguished within the universe of the atypical depressions.

Tubal sterilization. Characteristics of women most affected by the option of reversibility.

In order to determine the types of women whose sterilization decisions would be most affected by the option of reversibility, responses from 1074 randomly selected ob-gyn patients, concerning eventual intention to undergo permanent and hypothetically reversible procedures, were analyzed. Cross-tabulation of the dependent variables with a wide array of socio-demographic and attitudinal characteristics was followed by discriminant function analysis in order to determine which variables had the greatest independent impact on sterilization decisions. Particular attention was given to the shift from initial rejection of sterilization, when permanent, to its acceptance, when reversible. Intention to eventually undergo permanent sterilization is most significantly associated with intention to have no more children, Friends with positive experience with tubal sterilization and educational level other than a Bachelor's degree. Response change among initial rejectors of permanent sterilization is most strongly associated with mixed feelings regarding abortion, age under 35, and dissatisfaction with or ambivalence toward last contraceptive method used. Response change, using the total sample as a base, is most significantly associated with mixed feelings toward abortion, age under 35, and intention to have or unsure about having more children. These variables suggest that reversible sterilization, although important to all sub-groups, is likely to become a solution for women who are ambivalent toward abortion and is most important to those women likely to experience future fertility, including unwanted births.

Spinal cord injury: a search for determinants of depression two years after the event.

A prospective longitudinal study employing repeated measures was used to isolate factors which might predispose a person to depression two years after sustaining spinal cord injury (SCI). Thirty-one subjects who suffered acute spinal injuries resulting in permanent loss of movement, and who had no head injuries or any pre-existing psychopathology, were at least 17 years of age, and who were able to speak English, participated in the study. Using the Beck Depression Inventory (BDI) as a measure of depression, a regression analysis demonstrated that the experience of pain two years post-injury and feeling out of control of one's life prior to hospital discharge were predictive of depression two years post-injury. No demographic variables or injury characteristics such as level of lesion or completeness of lesion were related to long-term depression. Pain management and rehabilitation techniques that enhance the individual's belief of control over their lives are therefore recommended as interventions that could act to reduce depression in the long term in persons with spinal cord injury.

Scheduled hand washing in an elementary school population.

BACKGROUND AND OBJECTIVES: Hand washing prevents communicable illness. We evaluated the effect of a mandatory, scheduled hand-washing program in elementary school children on absenteeism due to acute communicable illness. METHODS: The study was conducted at Trombley Elementary School in Grosse Pointe Park, Mich. The intervention group, approximately half of the school children (n = 143, including all grades 1-5), washed their hands a minimum of four scheduled times a day. The control group (n = 162) continued hand-washing practices as usual. RESULTS: Of the 37 school days examined, children in the hand-washing group were absent fewer days than the control group due to all acute communicable illness (relative risk = .75). There were less days of absence due to gastrointestinal symptoms (relative risk = .43). The difference in absence due to respiratory symptoms was not statistically significant. CONCLUSIONS: A scheduled hand-washing program will reduce acute communicable (gastrointestinal) illnesses in elementary school-age children.

Does telephone contact with a physician's office staff improve mammogram screening rates?

BACKGROUND AND OBJECTIVES: Mammography is an important screening tool for the early detection of breast cancer. However, mammogram screening rates are low, despite interventions to improve them. We investigated two methods to improve mammogram screening and compared mammogram rates among women who received these interventions to mammogram screening rates in a control group. We also investigated the costs involved in these interventions. METHODS: We studied mammogram screening rates of three randomized groups of women ages 50 and older from the Deighton Family Practice Center in Southfield, Mich. All women had had a mammogram 1 year previously and were due for another mammogram. Our control group (n = 110) received no intervention. The second group of women (n = 102) received a reminder letter from the radiology department. The third group (n = 86) received a reminder letter followed by a phone call from the physician's office staff if no mammogram had been obtained within 8 weeks after the due date for the mammogram. All three groups were monitored for 14 weeks after the due date to determine mammogram screening rates in each group. RESULTS: A mammogram was obtained by 33% of women in group 1, 37% of women in group 2, and 57% of women in group 3. The mammogram screening rate of the third group was significantly greater than in the first two groups. In the third group, the additional cost added by the phone call intervention was $9 per mammogram obtained. CONCLUSION: Mammogram screening rates are increased when patients are contacted by both a reminder letter and a phone call.

Exogenous human growth hormone-releasing factor and ovine somatotropin improve growth performance and composition of gain in lambs.

The objectives of this study were 1) to compare intermittent subcutaneous administration of human growth hormone-releasing factor (hGRF) at two doses with a similar regimen of ovine somatotropin (oST) for effects on growth and composition of gain in growing lambs and 2) to determine whether increasing the dietary amino acid availability enhances response to oST or hGRF. Eighty crossbred ewe and wether lambs (25.5 kg live weight) were assigned randomly in pairs to receive four daily injections of excipient, 40 micrograms oST/kg BW, 5 micrograms hGRF/kg BW or 10 micrograms hGRF/kg BW for 42 (n = 80) or 56 (n = 40) d. Doses were adjusted weekly for BW. Mean plasma oST concentrations increased from 2.03 ng/ml prior to treatment to 20.64, 4.80 and 5.45 ng/ml with oST, 5 and 10 micrograms/kg hGRF doses, respectively. Lambs did not become refractory to hGRF. Cumulative gain increased approximately 18% with 7 wk of treatment with oST and the low dose of hGRF (both P less than .01), and feed efficiency improved 21% with oST and 18% with both doses of hGRF (both P less than .05). Carcass lipid accretion rate decreased 22% to 30% (P less than .001), and carcass protein accretion rate increased 30% to 36% (P less than .001) with hGRF and oST treatment, respectively. Addition of fishmeal to the diet at 4% to replace an equal amount of soy protein improved gain 8.5%; it improved efficiency 14.2% (P less than .05) across all treatments, and it significantly enhanced the effects of oST on feed efficiency (interaction P less than .12) and hind leg muscle weights.

Problems with the ICIDH definition of impairment.

This paper discusses problems with the definition of impairment in the International Classification of Impairments, Disabilities, and Handicaps, in particular the inclusion in the definition of the term 'psychological'.