Evaluation of procalcitonin as a contribution to antimicrobial stewardship in SARS-CoV-2 infection: a retrospective cohort study.

It can be a diagnostic challenge to identify patients with coronavirus disease 2019 in whom antibiotics can be safely withheld. This study evaluated the effectiveness of a guideline implemented at Sheffield Teaching Hospitals NHS Foundation Trust that recommends withholding antibiotics in patients with low serum procalcitonin (PCT), defined as ≤0.25 ng/mL. Results showed reduced antibiotic consumption in patients with PCT ≤0.25 ng/mL with no increase in mortality, alongside a reduction in subsequent carbapenem prescriptions during admission. The results support the effectiveness of this guideline, and further research is recommended to identify the optimal cut-off value for PCT in this setting.

Social interactions do not drive territory aggregation in a grassland songbird.

Understanding the drivers of animal distributions is a fundamental goal of ecology and informs habitat management. The costs and benefits of colonial aggregations in animals are well established, but the factors leading to aggregation in territorial animals remain unclear. Territorial animals might aggregate to facilitate social behavior such as (1) group defense from predators and/or parasites, (2) cooperative care of offspring, (3) extra-pair mating, and/or (4) mitigating costs of extra-pair mating through kin selection. Using experimental and observational methods, we tested predictions of all four hypotheses in a tallgrass prairie in northeast Kansas, United States. Grasshopper Sparrow (Ammodramus savannarum) males formed clumps of territories in some parts of the site while leaving other apparently suitable areas unoccupied. Despite substantial sampling effort (653 territories and 223 nests), we found no support for any hypothesized social driver of aggregation, nor evidence that aggregation increases nest success. Our results run counter to previous evidence that conspecific interactions shape territory distributions. These results suggest one of the following alternatives: (1) the benefits of aggregation accrue to different life-history stages, or (2) the benefits of territory aggregation may be too small to detect in short-term studies and/or the consequences of aggregation are sufficiently temporally and spatially variable that they do not always appear to be locally adaptive, perhaps exacerbated by changing landscape contexts and declining population sizes.

Dendro-dendritic cholinergic excitation controls dendritic spike initiation in retinal ganglion cells.

The retina processes visual images to compute features such as the direction of image motion. Starburst amacrine cells (SACs), axonless feed-forward interneurons, are essential components of the retinal direction-selective circuitry. Recent work has highlighted that SAC-mediated dendro-dendritic inhibition controls the action potential output of direction-selective ganglion cells (DSGCs) by vetoing dendritic spike initiation. However, SACs co-release GABA and the excitatory neurotransmitter acetylcholine at dendritic sites. Here we use direct dendritic recordings to show that preferred direction light stimuli evoke SAC-mediated acetylcholine release, which powerfully controls the stimulus sensitivity, receptive field size and action potential output of ON-DSGCs by acting as an excitatory drive for the initiation of dendritic spikes. Consistent with this, paired recordings reveal that the activation of single ON-SACs drove dendritic spike generation, because of predominate cholinergic excitation received on the preferred side of ON-DSGCs. Thus, dendro-dendritic release of neurotransmitters from SACs bi-directionally gate dendritic spike initiation to control the directionally selective action potential output of retinal ganglion cells.

Parturition to resumption of ovarian cyclicity: comparative aspects of beef and dairy cows.

There is a variable anoestrous period following parturition in the cow. Follicular growth generally resumes within 7 to 10 days in the majority of cows associated with a transient FSH rise that occurs within 3 to 5 days of parturition. Dairy cows that are not nutritionally stressed generally ovulate their first postpartum dominant follicle (~15 days), whereas beef suckler cows in good body condition normally have a mean of 3.2±0.2 dominant follicles (~30 days) to first ovulation; moreover, beef cows in poor body condition have a mean of 10.6±1.2 dominant follicles (~70 to 100 days) to first ovulation. The lack of ovulation of dominant follicles during the postpartum period is associated with infrequent LH pulses, with both maternal-offspring bonding and low body condition score (BCS) at calving being implicated as the predominant causes of delayed resumption of cyclicity in nursed beef cows. In dairy cows, the normal pattern of early resumption of ovulation may be delayed in high-yielding Holstein type cows generally owing to the effects of severe negative energy balance, dystocia, retained placental membranes and uterine infections. First ovulation, in both dairy and beef cows, is generally silent (i.e., no behavioural oestrus) and followed by a short inter-ovulatory interval (>70%). The key to optimizing the resumption of ovulation in both beef and dairy cows is appropriate pre-calving nutrition and management so that cows calve down in optimal body condition (BCS; 2.75 to 3.0) with postpartum body condition loss restricted to <0.5 BCS units.

Risk factors associated with detailed reproductive phenotypes in dairy and beef cows.

The objective of this study was to identify detailed fertility traits in dairy and beef cattle from transrectal ultrasonography records and quantify the associated risk factors. Data were available on 148 947 ultrasound observations of the reproductive tract from 75 949 cows in 843 Irish dairy and beef herds between March 2008 and October 2012. Traits generated included (1) cycling at time of examination, (2) cystic structures, (3) early ovulation, (4) embryo death and (5) uterine score; the latter was measured on a scale of 1 (good) to 4 (poor) characterising the tone of the uterine wall and fluid present in the uterus. After editing, 72,773 records from 44,415 dairy and beef cows in 643 herds remained. Factors associated with the logit of the probability of a positive outcome for each of the binary fertility traits were determined using generalised estimating equations; linear mixed model analysis was used for the analysis of uterine score. The prevalence of cycling, cystic structures, early ovulation and embryo death was 84.75%, 3.87%, 7.47% and 3.84%, respectively. The occurrence of the uterine heath score of 1, 2, 3 and 4 was 70.63%, 19.75%, 8.36% and 1.26%, respectively. Cows in beef herds had a 0.51 odds (95% CI=0.41 to 0.63, P<0.001) of cycling at the time of examination compared with cows in dairy herds; stage of lactation at the time of examination was the same in both herd types. Furthermore, cows in dairy herds had an inferior uterine score (indicating poorer tone and a greater quantity of uterine fluid present) compared with cows in beef herds. The likelihood of cycling at the time of examination increased with parity and stage of lactation, but was reduced in cows that had experienced dystocia in the previous calving. The presence of cystic structures on the ovaries increased with parity and stage of lactation. The likelihood of embryo/foetal death increased with parity and stage of lactation. Dystocia was not associated with the presence of cystic structures or embryo death. Uterine score improved with parity and stage of lactation, while cows that experienced dystocia in the previous calving had an inferior uterine score. Heterosis was the only factor associated with increased likelihood of early ovulation. The fertility traits identified, and the associated risk factors, provide useful information on the reproductive status of dairy and beef cows.

Drivers of post-partum uterine disease in dairy cattle.

Post-partum uterine disease has a detrimental effect on dairy cow fertility; affected cows require more serves per conception, have reduced conception rates and are more likely to be culled for infertility. Furthermore, the detrimental effects on fertility remain even after clinical resolution of disease. There are many factors that influence a cow's resistance to or development of post-partum disease, and the key drivers determining disease outcome are uterine microbial load, regulation of inflammation and immune responses peripherally and at a local level, production pressure, and metabolic (energy) status. These factors are intricately interlinked, which makes assessment of their individual effects difficult. It is clear, however, that the period surrounding calving is a key transition phase and events during this time point will influence uterine disease outcome and subsequent fertility. Good peripartum management and accurate diagnosis are critical to facilitate the use of the most effective treatment and limit the negative impact of post-partum uterine disease on fertility. If we can improve our understanding of the underlying causes of disease, then we can identify 'at risk' animals and implement management and breeding strategies to prevent uterine disease or reduce its severity. Thus, this article aims to summarize the key factors that drive uterine disease in the post-partum dairy cow.

Clinical language fMRI with real-time monitoring in temporal lobe epilepsy: online processing methods.

The increasing demand for clinical fMRI data has resulted in a need to translate research methods to clinical use. Referrals for language lateralization prior to epilepsy surgery are becoming more common, but time constraints make this unachievable in many busy neuroimaging departments. This study examines whether a single covert verbal fluency paradigm with real-time monitoring and online processing (BrainWave) could replace conventional offline processing (SPM) for the purpose of establishing expressive language dominance prior to epilepsy surgery. We analyzed language fMRI results of 30 patients (17 female; 24 right-handed; median age: 30.5) with temporal lobe epilepsy. Concordance between visual assessment of SPM and BrainWave was 92.8%. Lateralization indices correlated closely with visual assessments of lateralization with a concordance of 85.7%. BrainWave provided a real-time, fast and accurate display of language lateralization easily applied in a clinical setting using only online image processing.

What predicts failed cannulation and therapy at ERCP? Results of a large-scale multicenter analysis.

UNLABELLED: STUDY BACKGROUND AND AIMS: Predicting outcome at endoscopic retrograde cholangiopancreatography (ERCP) remains difficult. Our aim was to identify the risk factors for failed ERCP. PATIENTS AND METHODS: A prospective multicenter study of ERCP was performed in 66 hospitals across England. Data on 4561 patients were collected using a structured questionnaire completed at the time of ERCP. RESULTS: In total 3209 patients had not had an ERCP prior to the study period. Considering their first ever ERCP, 2683 (84 %) were successfully cannulated, 2241(70 %) had all intended therapy completed, 360 (11 %) had some intended therapy completed, and 608 (19 %) were considered to have had a failed procedure. For first ever ERCP, factors associated with incomplete procedure (odds ratio and 95 % confidence interval) were: Billroth surgery (9.2, 3.2 - 26.7), precutting (2.0, 1.6 - 2.7), common bile duct (CBD) stone size and number (3.2, 2.1 - 4.8 for multiple, large stones), interventions in the pancreatic duct (3.4, 1.6 - 7.0), and CBD stenting (2.8, 2.2 - 3.5). Analysis of the 1352 patients who had undergone an ERCP prior to the study period indicated previous failed ERCP was also predictive of incomplete therapy (1.5, 1.1 - 2.1). The modified Schutz score correlated with ERCP completion, as did the Morriston score, even when modified to include only variables measurable before the procedure. CONCLUSION: This study confirms that patient- and procedure-based variables are key predictors of technical success and validates current methods of rating ERCP difficulty. Of note, a correlation between outcome and institutional factors, such as unit and endoscopist caseload, was not demonstrated.

Triennial Lactation Symposium: Effects of stress on postpartum reproduction in dairy cows.

The objective was to review the effects of production stressors on reproductive performance of dairy cows. It has been well documented that genetic selection for milk yield over the last 50 yr has been associated with reduced fertility. In addition to negative associations between yield and conception rate, there is also an association between milk production and expression of behavioral estrus. Stress caused by production diseases in high-yielding dairy cows also contributes to the problems of poor fertility. Lameness results in reduced intensity of estrus and can contribute to ovulation failure, which is largely due to reduced pre-ovulatory estradiol secretion and failure of the LH surge. Mastitis has been associated with prolonged intervals to dominant follicle selection, and in animals with uterine infection the dominant follicle grows slower and produces less estradiol. In a recent study, we identified that milk yield was associated with an increased incidence of uterine infection, which is known to contribute to reduced fertility and prolonged calving-to-conception intervals. The incidence of uterine disease was 73% in high-yielding, compared with 45% in low-yielding cows. As well as effects at the ovary, various models of stress have also been shown to perturb endocrine secretion in the hypothalamus and anterior pituitary. In conclusion, the adverse effects on fertility associated with genetic selection for yield in dairy cows is, in part, associated with increased incidences of production disease-induced stress but is also associated with high milk yield.

Detection of Toxoplasma gondii antigens reactive with antibodies from serum, amniotic, and allantoic fluids from experimentally infected pregnant ewes.

Toxoplasma gondii, an intracellular protozoan parasite, is one of the major causes of infectious abortion in sheep. To further understand the pathogenesis of toxoplasmosis, serum, amniotic and allantoic fluids and foetal stomach contents were collected from experimentally infected pregnant ewes to determine pathogen numbers and other markers of infection. Fifteen pregnant ewes (90 days of gestation) were each orally inoculated with 3000 sporulated oocysts of T. gondii. Serum samples were collected weekly following challenge. Amniotic and allantoic fluids and foetal stomach contents were collected at 21, 25, 28, 33 and 35 days post-infection. Characteristic placental lesions were detected in 1 of 4 challenged ewes at day 25, 3 of 4 challenged ewes at day 28 and in all challenged ewes at days 33 and 35 post-infection. T. gondii was detected only sporadically in amniotic and allantoic fluids before 35 days of infection, by real-time PCR, and only in ewes with placental lesions. At 35 days post-infection, high numbers of parasite were detected in both amniotic and allantoic fluids. An increase in the number of fluids from challenged animals with IgM and IgG was detected over time, except for IgG in allantoic fluid, which was detected in all samples from day 21 post-infection. IgG in amniotic and allantoic fluids was shown to be specific for T. gondii, and reacted with antigens with an apparent molecular mass of approximately 22 kDa and 30 kDa. Results suggest a maternal source of immunoglobulin in the allantoic fluid and a foetal source of immunoglobulin in the amniotic fluid early in infection but that both sources may contribute immunoglobulin to both fluids at a later stage.

Evidence based management guidelines for the detection and treatment of congenital CMV.

CMV is the most common congenital infection in newborns worldwide. Congenital CMV causes sensorineural hearing loss in a significant proportion of infected newborns, while the majority of newborns are asymptomatic. In the last three years there have been significant advances in the diagnosis and treatment of congenital CMV. We have developed practical evidence based guidelines for the management of congenital CMV.

Interferon-γ expression in trophoblast cells in pregnant ewes challenged with Chlamydophila abortus.

Pregnant ewes were challenged with Chlamydia abortus at 91-98 days of gestation and euthanised at 14, 21 and 28 days post-challenge. IFNγ mRNA labelling appeared to be co-localised with Chlamydial lipopolysaccharide within trophoblast cells in discrete areas lining the primary villi in the limbus and hilar zone of the placentomes from challenged sheep on days 21 and 28 post-infection. The presence of IFNγ was also demonstrated by immunohistochemistry. No labelling was seen in tissues from the non-infected ewes. The presence of IFNγ in trophoblast cells from infected ewes may indicate an attempt to restrict the replication of the organism and be an important trigger for the inflammatory responses that develop on the fetal side of the placenta in enzootic abortion.

Haemophilus influenzae type b carriage and novel bacterial population structure among children in urban Kathmandu, Nepal.

Haemophilus influenzae type b (Hib) is a major cause of invasive bacterial infection in children that can be prevented by a vaccine, but there is still uncertainty about its relative importance in Asia. This study investigated the age-specific prevalence of Hib carriage and its molecular epidemiology in carriage and disease in Nepal. Oropharyngeal swabs were collected from children in Kathmandu, Nepal, from 3 different settings: a hospital outpatient department (OPD), schools, and children's homes. Hib was isolated using Hib antiserum agar plates, and serotyping was performed with latex agglutination. Hib isolates from children with invasive disease were obtained during active microbiological surveillance at Patan Hospital, Kathmandu, Nepal. Genotyping of disease and carriage isolates was undertaken using multilocus sequence typing (MLST). Swabs were taken from 2,195 children, including 1,311 children at an OPD, 647 children attending schools, and 237 children in homes. Overall, Hib was identified in 5.0% (110/2,195; 95% confidence interval [95% CI], 3.9% to 6.4%). MLST was performed on 108 Hib isolates from children carrying Hib isolates and 15 isolates from children with invasive disease. Thirty-one sequence types (STs) were identified, and 20 of these were novel STs. The most common ST isolates were sequence type 6 (ST6) and the novel ST722. There was marked heterogeneity among the STs from children with disease and children carrying Hib. STs identified from invasive infections were those commonly identified in carriage. This study provides evidence of Hib carriage among children in urban Nepal with genetically diverse strains prior to introduction of universal vaccination. The Hib carriage rate in Nepal was similar to the rates observed in other populations with documented high disease rates prior to vaccination, supporting implementation of Hib vaccine in Nepal in 2009.

A review of the causes of poor fertility in high milk producing dairy cows.

Fertility in dairy cows has declined over the past five decades as milk production per cow has increased. Many hypotheses have been proposed to explain this including issues of genetics, physiology, nutrition and management, and these factors have been investigated at the animal, organ and cellular level at critical time points of the productive life of dairy cows. This paper reviews the physiological events and their causes and consequences affecting fertility in dairy cows and summarises these in a downloadable poster. We consider the following points to have the greatest negative impact on fertility and that they need to be prioritised in efforts to ameliorate the problem (others have been included in the review). Firstly, minimise negative energy balance and resolve any infection of the post partum uterus. Secondly, expression and detection of oestrus followed by insemination with high quality semen (day 0). Thirdly, ovulation and fertilisation of a high quality oocyte (day 1). Fourthly, an early increase in progesterone secretion from the corpus luteum (days 3-7). Fifthly, the uterine endometrium must produce an early and appropriate environment to stimulate embryo development (days 6-13). This leads to sixthly, a large embryo producing adequate quantities of interferon tau (days 14-18) that alters uterine prostaglandin secretion and signals maternal recognition of pregnancy (days 16-18). Future strategies to improve dairy cow fertility are needed for the benefit of the dairy industry and for cow welfare and should be based upon an integrative approach of these events.

Traditional herbal remedies that influence cell adhesion molecule activity.

Many traditional medicines have demonstrated immune activity, however, research has largely neglected their effects on cell adhesion molecules (CAMs). This review reports on extracts from 37 medicinal plant species, similar to or replicating traditional preparations, that up- or downregulate either gene or protein activity of CAMs. The majority of the investigations were in vitro, primarily of the immunoglobulin superfamily of CAMs, specifically intercellular cell adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) and secondarily on the integrin (CD11b or MAC-1) and selectin (E-selectin and P-selectin) families of CAMs. The following plant species have demonstrated modulation of multiple CAMs: Artemisia asiatica, Boswellia serrata, Canscora decussata, Cinnamomum povectum, Dehaasia incrassate, Ganoderma lucidum, Ginkgo biloba, Hypericum perforatum, Juglans regia, Lycopus lucidus, Panax notoginseng, Rheum undulatum, Salvia miltiorrhiza. Many other species have documented activity on one CAM. Currently there are limited in vivo/ex vivo investigations, including a clinical trial on Mahonia aquifolium. Although further evidence is needed, the data suggest that the reviewed botanical medicines may have the potential to provide therapeutic potential in disease processes involving CAMs. Additionally, the reported success of many of these plant extracts by traditional cultures and modern phytotherapists may involve the modulation of CAMs.

The use of milbemycin oxime in a prophylactic anthelmintic programme to protect puppies, raised in an endemic area, against infection with Spirocerca lupi.

Spirocerca lupi is primarily a parasite of dogs and other carnivores. Clinical signs of infection are regurgitation, vomiting, weight loss, coughing and dyspnoea. Sudden death can also occur due to a ruptured aortic aneurysm. In this study, the Eastern Cape Province of South Africa was identified as an area with a high prevalence of S. lupi. A subsequent investigation, to evaluate the efficacy of milbemycin oxime as a prophylactic agent for canine spirocercosis, involved 58 puppies that were raised in this area in accordance with local husbandry procedures. Approximately half of the puppies served as untreated controls. Puppies in the treatment group received milbemycin oxime (minimum dose of 0.5mg/kg body weight) when they were between 2 and 6 weeks old. They then received five further treatments at approximately 28-day intervals. The treatment was orally administered in tablet form. After the sixth treatment, puppies from both the treated and control groups were euthanized and post-mortem examinations were performed. Twenty-four out of 27 dogs in the untreated control group had become infected by S. lupi. In comparison, only 19 out of 31 dogs in the treatment group had evidence of spirocercosis as demonstrated by aortic nodules. The prophylactic regimen reduced the severity of aortic lesions and prevented 86.5% of S. lupi from becoming established in the thoracic aorta. It also prevented 89.4% of S. lupi from becoming established in the oesophagus and significantly reduced the number of oesophageal nodules. Milbemycin oxime markedly reduced the level and severity of S. lupi infection in treated puppies raised in an endemic area of South Africa. It deserves further evaluation as a potential prophylactic treatment for spirocercosis.

Towards high resolution optical imaging of beta cells in vivo.

Endocrine beta cells produce and release insulin in order to tightly regulate glucose homeostasis and prevent metabolic pathologies such as Diabetes Mellitus. Optical imaging has contributed greatly to our current understanding of beta cell structure and function. In vitro microscopy of beta cell lines has revealed the localization of molecular components in the cell and more recently their dynamic behavior. In cultured islets, interactions of beta cells with other islet cells and the matrix as well as paracrine and autocrine signaling or reaction to nutrients have been studied. Lastly, microscopy has been performed on tissue sections, visualizing the islets in an environment closer to their natural surroundings. In most efforts to date, the samples have been isolated for investigation and hence have by definition been divorced from their natural environments and deprived of vascularization and innervations. In such a setting the beta cells lack the metabolic information that is primordial to their basic function of maintaining glucose homeostasis. We review optical microscopy; its general principles, its impact in decoding beta cell function and its recent developments towards the more physiologically relevant assessment of beta cell function within the environment of the whole organism. This requires both large imaging depth and fast acquisition times. Only few methods can achieve an adequate compromise. We present extended focus Optical Coherence Microscopy (xfOCM) as a valuable alternative to both confocal microscopy and two photon microscopy (2PM), and discuss its potential in interpreting the mechanisms underlying glucose homeostasis and monitoring impaired islet function.

Laser Doppler imaging for intraoperative human brain mapping.

The identification and accurate location of centers of brain activity are vital both in neuro-surgery and brain research. This study aimed to provide a non-invasive, non-contact, accurate, rapid and user-friendly means of producing functional images intraoperatively. To this end a full field Laser Doppler imager was developed and integrated within the surgical microscope and perfusion images of the cortical surface were acquired during awake surgery whilst the patient performed a predetermined task. The regions of brain activity showed a clear signal (10-20% with respect to the baseline) related to the stimulation protocol which lead to intraoperative functional brain maps of strong statistical significance and which correlate well with the preoperative fMRI and intraoperative cortical electro-stimulation. These initial results achieved with a prototype device and wavelet based regressor analysis (the hemodynamic response function being derived from MRI applications) demonstrate the feasibility of LDI as an appropriate technique for intraoperative functional brain imaging.

Plasma magnesium should be monitored perioperatively in patients undergoing colorectal resection.

OBJECTIVE: Hypomagnesemia has been shown to have several clinically important sequelae. The aims of this study were: to assess the impact of bowel preparation, with sodium picosulphate (Picolax), on plasma electrolytes, with particular regard to plasma magnesium, in patients undergoing bowel preparation for colonoscopy and colorectal resection and to evaluate the influence of perioperative magnesium levels on postoperative cardiac dysrhythmias. METHOD: Sixty-one patients receiving sodium picosulphate (Picolax) bowel preparation were studied in two groups: Colonoscopy (31 patients) and Colorectal resection (30 patients). Plasma sodium, potassium, magnesium, calcium, urea, creatinine and blood haematocrit were measured in all patients prior to commencement of bowel preparation, at the time of colonoscopy or colorectal resection and 24 h postoperatively (surgery group only). Mean electrolyte and haematocrit levels were then compared. Postoperative cardiac dysrhythmias were recorded and analysed. RESULTS: No significant changes following bowel preparation were observed in plasma sodium, potassium, calcium or creatinine. Plasma urea fell following bowel preparation (colonoscopy P < 0.001, resection P = 0.004) and rose following resection (P = 0.002). Magnesium levels increased following bowel preparation in both groups (colonoscopy P < 0.001, resection P = 0.007) and fell following resection (P < 0.001). Thirty-four per cent (21/60 patients) were hypermagnesemic following bowel preparation and 20% (6/30 patients) became hypomagnesemic following surgery. Postoperative cardiac dysrhythmias were associated with lower magnesium levels at induction and postoperatively (P = 0.022 and P = 0.033). CONCLUSION: Bowel preparation with Picolax does not appear to cause significant electrolyte disturbance, except in elevating plasma magnesium. Postcolorectal resection plasma magnesium dropped significantly suggesting perioperative monitoring and replacement should be routine following colorectal surgery.

Guidelines on the management of common bile duct stones (CBDS).

The last 30 years have seen major developments in the management of gallstone-related disease, which in the United States alone costs over 6 billion dollars per annum to treat. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). In addition, new imaging techniques such as magnetic resonance cholangiography (MR) and endoscopic ultrasound (EUS) offer the opportunity to accurately visualise the biliary system without instrumentation of the ducts. As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS. It is with this in mind that the following guidelines have been written.