Stunting in pre-school and school-age children in the Peruvian highlands and its association with Fasciola infection and demographic factors.

Fascioliasis is a zoonotic trematode infection that is endemic in the highlands of Peru. Chronic fascioliasis can be asymptomatic and remain undiagnosed for years. Chronic malnutrition in children, as manifested by stunting, leads to delayed cognitive development and lost productivity. We hypothesized that fascioliasis is among the factors associated with stunting in children from endemic areas. We conducted a cross-sectional study among children attending pre-school and school in 26 communities in the Anta province in the Cusco region of Peru. We conducted interviews to collect information on demographic, socioeconomic, and medical history. Blood was collected and tested for complete cell count and FAS2 ELISA for Fasciola antibodies. Three stool samples per participant were tested for parasites by Kato-Katz and Lumbreras rapid sedimentation methods. Chronic fascioliasis was determined by the presence of ova in stool. Children's height, weight, and age were recorded and used to calculate height for age Z scores (HAZ). Three thousand children participated in the study. Nine percent (264) of children had at least one positive test for Fasciola infection, 6% (164) had chronic fascioliasis, and 3% (102) had only positive antibody tests. The median HAZ was -1.41 (IQR: -2.03 to -0.81) and was similar in males and females. Twenty six percent (776) of children had stunting with HAZ < -2. Children with chronic fascioliasis had a lower median HAZ than children without Fasciola (-1.54 vs. -1.4, p = 0.014). History of treatment for malnutrition, history of treatment for anemia, having other helminths in stool, lower socioeconomic score, living at a higher elevation, and fewer years of schooling of both parents were associated with a lower HAZ score. In a multiple regression analysis, older age and a lower socioeconomic score were associated with a lower HAZ score. While fascioliasis and other helminths were associated with lower HAZ, they were not independent of the socioeconomic score.

Protocol for assessment of the pupillary light reflex in dogs without chemical restraint: preliminary investigation.

OBJECTIVE: To explore the use of a modified pupillometry technique in dogs without chemical restraint. MATERIALS AND METHODS: Following dark adaptation, pupillary light reflexes were assessed in six dogs with sudden acquired retinal degeneration syndrome, in the unaffected eye of eight dogs with unilateral primary glaucoma ("predisposed"), and in 11 healthy dogs. Responses to red, blue and white lights were recorded and relative pupil sizes subsequently determined based on video recordings of each test. RESULTS: Mean testing time was 2.3 minutes (range 1.8 to 3.1 minutes), excluding time for dark adaptation. Baseline pupil size in dogs with sudden acquired retinal degeneration syndrome was greater than in normal and predisposed eyes. Pupil constriction was reduced in predisposed compared to normal and sudden acquired retinal degeneration syndrome eyes when stimulated with high-intensity blue light. Compared to normal eyes, those with sudden acquired retinal degeneration syndrome had reduced pupil constriction when stimulated with low- and high-intensity red light, low-intensity blue light and white light. CLINICAL SIGNIFICANCE: Quantitative measures of pupil function were obtained from healthy and diseased eyes without the need for chemical restraint. Further investigations are warranted to validate the technique and evaluate its use in the management of canine glaucoma.

Nutritional adequacy and content of food bank parcels in Oxfordshire, UK: a comparative analysis of independent and organisational provision.

BACKGROUND: Food bank use has increased significantly in the UK. With the rise in demand, it is imperative that users are receiving food parcels that meet their requirements. The present study aimed to explore whether typical food parcels, supplied by The Trussell Trust and independent food banks, were meeting the daily nutrient and energy requirements of an adult user. METHODS: The Trussell Trust (n = 2) and independent food banks (n = 9) were surveyed in Oxfordshire, UK. Data were collected on food bank use, resources, donations and parcel content. The energy and nutrient contents of a representative parcel were compared with the average dietary reference values (DRVs) for an adult. Additional comparisons were made between The Trussell Trust and independent provision. RESULTS: Parcels provided energy, carbohydrate, sugar, protein and fibre contents that significantly exceeded the DRVs. In total, 62.2% of energy was provided as carbohydrate and 569% of the DRV was provided by sugars. The vitamin D and retinol content of the parcels was significantly lower than the DRVs, meeting 25% and 27% of users' needs respectively; provision of all other micronutrients exceeded the DRVs. The Trussell Trust's parcels provided significantly less vitamin D and copper than independent parcels. CONCLUSIONS: Food bank parcels distributed in Oxfordshire, UK, exceeded energy requirements and provided disproportionately high sugar and carbohydrate and inadequate vitamin A and vitamin D compared to the UK guidelines. Improved links with distributors and access to cold food storage facilities would help to address these issues, via increased fresh food provision.

The ALERT model of care for the assessment and personalized management of patients with lymphoedema.

BACKGROUND: This study documents the development and evaluation of a comprehensive multidisciplinary model for the assessment and personalized care of patients with lymphoedema. METHODS: The Australian Lymphoedema Education Research and Treatment (ALERT) programme originated as an advanced clinic for patients considering surgery for lymphoedema. The programme commenced liposuction surgery in May 2012 and then introduced lymph node transfer in 2013 and lymphovenous anastomosis (LVA) in 2016. An outpatient conservative treatment clinic was established in 2016. ALERT commenced investigations with indocyanine green (ICG) lymphography in late 2015, leading to the creation of a diagnostic assessment clinic offering ICG in 2017. RESULTS: Since 2012, 1200 new patients have been referred to ALERT for assessment of lymphoedema for a total of 5043 episodes of care. The introduction of ICG lymphography in 2015 initially allowed better screening for LVA, but is now used not only to guide surgical options, but also as a diagnostic tool and to guide manual lymphatic drainage massage. The total number of new patients who attended the surgical assessment clinic to December 2018 was 477, with 162 patients (34·0 per cent) undergoing surgery. CONCLUSION: The ALERT programme has developed a multidisciplinary model of care for personalized lymphoedema treatment options based on clinical, imaging and ICG lymphography. Patients are selected for surgery based on several individual factors.

ANTECEDENTES: Este estudio presenta el desarrollo y valoración de un modelo multidisciplinario integral para la evaluación y atención personalizada de pacientes con linfedema. MÉTODOS: El programa australiano de educación en investigación y tratamiento del linfedema (Australian Lymphoedema Education Research and Treatment, ALERT) se originó como un centro clínico avanzado para pacientes que consideran la cirugía como tratamiento para el linfedema. El programa se inició en mayo del 2012 con la cirugía de liposucción, introduciendo la cirugía de transferencia ganglionar (lymph node transfer, LNT) en 2013 y la anastomosis linfovenosa (lymphovenous anastomosis, LVA) en 2016. En 2016 se estableció una clínica de tratamiento conservador ambulatorio. ALERT comenzó las investigaciones con la linfografía con verde de indocianina (indocyanine green, ICG) a fines del 2015, lo que se siguió de la creación de una clínica de evaluación diagnóstica que ofrece ICG en 2017. RESULTADOS: Desde el 2012, 1.200 pacientes nuevos han sido referidos a ALERT para la evaluación de un linfedema, con un total de 5.043 episodios atendidos. La introducción inicialmente de linfografía con ICG en 2015 permitió un mejor cribaje para LVA, pero actualmente se utiliza no solo como guía de las opciones quirúrgicas, sino también como herramienta diagnóstica y como guía del masaje de drenaje linfático manual (manual lymphatic drainage, MLD). El número total de pacientes nuevos atendidos en la clínica de evaluación quirúrgica hasta diciembre de 2018 fue de 477, con 122 pacientes (34%) tratados quirúrgicamente. El modelo tal como se ha descrito, ha atraído a pacientes de toda Australia y Nueva Zelanda. CONCLUSIÓN: El programa ALERT ha desarrollado un modelo multidisciplinario de atención para las opciones de tratamiento personalizado del linfedema basado en la evaluación clínica, por imagen (MRI y LSG) y linfografía con ICG. Los pacientes se seleccionan cuidadosamente para el tratamiento quirúrgico en función de varios factores relacionados con el paciente, el tumor, los linfáticos y las opciones terapéuticas, y se someten a una evaluación detallada después de cualquier procedimiento.

A forced-choice preferential looking task for the assessment of vision in dogs: pilot study.

OBJECTIVES: To describe preliminary use of a forced-choice preferential looking task for the clinical assessment of vision in dogs. MATERIALS AND METHODS: The vision of 18 pet dogs was investigated in two separate studies using a forced-choice preferential looking task: multiple observers watched eye, head and body movements on video recordings to identify cues suggesting when a dog had seen the feature of interest. Human observer reliability was determined using eight dogs and computer-generated stimuli. Visual acuity was assessed using computer-generated grating stimuli: in real-time, an observer watched each dog's eye movement patterns and behaviour to decide whether each grating was seen. Stimuli were presented in a step-wise manner and were controlled by the observer. Acuity was estimated as the highest spatial frequency the dog was determined to have seen. RESULTS: Median estimated visual acuity was better at 1 m compared to that at 3 m. Average test time was longer at a 3-m distance than at 1 m. Inter- and intra-observer reliability was better from 1 m than from 3 m. CLINICAL SIGNIFICANCE: Preliminary use of a forced-choice preferential looking task for measurement of visual acuity in dogs has potential use as a clinical tool for the assessment of vision in dogs.

Non-Invasive, Cost-Effective, Early Diagnosis of Mild Cognitive Impairment in an Outpatient Setting: Pilot Study.

Mild cognitive impairment (MCI) and Alzheimer's Disease (AD) affect millions worldwide, yet no curative treatments for these neuro-degenerative disorders have been developed to date. The current study aims to propose a noninvasive, cost-effective, early diagnostic protocol for individuals suffering with MCI in an outpatient setting. Elderly participants (n=11) were screened for MCI utilizing the Montreal Cognitive Assessment (MoCA) questionnaire preceding a visual stimuli task. Participants were presented with facial stimuli to elicit event related potentials (ERP) while their cortical activity was recorded utilizing electroencephalogram (EEG). Combining regional neurophysiological biomarkers into a multidimensional feature space allowed for differentiation between healthy and MCI participants based on their respective MoCA scores. This study illustrates the feasibility of recording reliable EEG in an outpatient setting while presenting a novel method for diagnosing MCI in elderly (age >60) populations.

Socioeconomic Factors Associated with Fasciola hepatica Infection Among Children from 26 Communities of the Cusco Region of Peru.

Fasciola hepatica is the most widely distributed trematode-affecting humans. The Andes Mountains are highly endemic for fascioliasis. We report results of a cross-sectional study evaluating the epidemiology of Fasciola among children in 26 agricultural communities in the Cusco region of Peru. Children 3 to 16 years old were enrolled in preschools and schools. Blood from participants was tested for complete blood counts, transaminases, and Fasciola antibodies. Stool samples were tested for Fasciola and other parasites. A total of 2,515 children were included in the analysis and the mean age was 9.6 years (±3.6). Ten percent (253) of the children had at least one positive test for Fasciola, 6% had chronic infection, and 0.4% acute infection. The rest of the subjects had only antibodies against Fasciola. The prevalence of infection varied from 0% to 20% between communities. Children with evidence of Fasciola exposure were older, lived at higher altitudes, and had a lower socioeconomic status than children without infection. The logistic regression analysis showed that children from Ancahuasi district, older children, and children with higher measures of poverty were more likely to have Fasciola exposure. Fascioliasis is common in the Cusco region and associated with poverty. However, the distribution varies markedly between communities.

Potential impurities in drug substances: Compound-specific toxicology limits for 20 synthetic reagents and by-products, and a class-specific toxicology limit for alkyl bromides.

This paper provides compound-specific toxicology limits for 20 widely used synthetic reagents and common by-products that are potential impurities in drug substances. In addition, a 15 µg/day class-specific limit was developed for monofunctional alkyl bromides, aligning this with the class-specific limit previously defined for monofunctional alkyl chlorides. Both the compound- and class-specific toxicology limits assume a lifetime chronic exposure for the general population (including sensitive subpopulations) by all routes of exposure for pharmaceuticals. Inhalation-specific toxicology limits were also derived for acrolein, formaldehyde, and methyl bromide because of their localized toxicity via that route. Mode of action was an important consideration for a compound-specific toxicology limit. Acceptable intake (AI) calculations for certain mutagenic carcinogens assumed a linear dose-response for tumor induction, and permissible daily exposure (PDE) determination assumed a non-linear dose-response. Several compounds evaluated have been previously incorrectly assumed to be mutagenic, or to be mutagenic carcinogens, but the evidence reported here for such compounds indicates a lack of mutagenicity, and a non-mutagenic mode of action for tumor induction. For non-mutagens with insufficient data to develop a toxicology limit, the ICH Q3A qualification thresholds are recommended. The compound- and class-specific toxicology limits described here may be adjusted for an individual drug substance based on treatment duration, dosing schedule, severity of the disease and therapeutic indication.

Path Analysis of Campus Walkability/Bikeability and College Students' Physical Activity Attitudes, Behaviors, and Body Mass Index.

PURPOSE: The purpose of this study was to assess the relationship between the walkability/bikeability of college campuses and students' body mass index (BMI) with student physical activity (PA) attitudes and behaviors as potential mediators. DESIGN: Cross-sectional. SETTING: Thirteen university campuses. PARTICIPANTS: A total of 1384 student participants. MEASURES: Walkability/bikeability environmental score (ES): 12-item audit assessed an average of 44 path segments per campus. Students were measured for height and weight and completed online surveys. Physical activity stage of change/behavior intentions were assessed using the transtheoretical model. The Cognitive Behavioral Physical Activity Questionnaire assessed outcome expectations, self-regulation, and personal barriers. International Physical Activity Questionnaire assessed walking-, moderate-, and vigorous-intensity PA. ANALYSIS: Descriptive statistics, zero-order correlations, and path analysis with maximum likelihood estimation. RESULTS: The overall model fit was good with χ2 of 171.388 ( df = 18), P < .001, comparative fit index value of .95, and a root mean square of approximation of .079. After controlling for gender, there was a direct negative association between walkability/bikeability ES and BMI (ß = -.085) and positive association between personal barriers and BMI (ß = .134). Walkability/bikeability ES was positively associated with walking-intensity PA (ß = .010). Self-regulation was positively associated with moderate-intensity PA (ß = .213), which, in turn, was negatively associated with BMI (ß = -.057). CONCLUSIONS: The ease of walking and biking on a campus was related to college students' walking behavior and their BMI. Students' PA behavioral intentions were associated with moderate PA and lower BMI. These results provide evidence to focus on policies and structural supports for walkable/bikeable environments to supplement and enhance interventions encouraging individual behavior change for PA and weight management.

Proopiomelanocortin interference in the measurement of adrenocorticotrophic hormone: a United Kingdom National External Quality Assessment Service study.

OBJECTIVE: It is recognized that measurement of ACTH-precursor peptides including proopiomelanocortin (POMC) has clinical utility in identifying the aetiology of Cushing's syndrome. Recent data have also demonstrated cross-reactivity of POMC in ACTH immunoassays used in clinical laboratories. The aim of this study was to assess the cross-reactivity of POMC in the main commercial immunoassays for ACTH and to survey the awareness of laboratory professionals to this potential interference. METHOD: To assess cross-reactivity, specimens containing ACTH and/or POMC were prepared by the UK National External Quality Assessment Service (UK NEQAS) [Edinburgh]. A separate interpretative exercise was also sent to participating laboratories. RESULTS: Eighty-seven laboratories measured 'total' ACTH (i.e. ACTH and/or POMC) in their assays. Cross-reactivity of POMC varied from a mean of 1·6-4·7% (reflected in a large percentage increase in measured ACTH of up to 261% due to POMC cross-reactivity) depending on the manufacturer. Major differences in the clinical interpretation of test results were observed in returned responses to the interpretative exercise. CONCLUSION: An appraisal of POMC cross-reactivity in currently available ACTH immunoassays has been achieved. Cross-reactivity was sufficient to detect ACTH precursors at concentrations that could be found in patients with ectopic ACTH syndrome. These data will assist laboratories in interpreting results when assessing the hypothalamic-pituitary-adrenal axis. Endocrinologists and laboratory professionals should be aware of the degree of cross-reactivity in ACTH immunoassay in order to minimize the risk of misinterpretation of results and/or potentially delayed treatment.

Bleeding risk assessment in patients undergoing elective cardiac surgery using ROTEM(®) platelet and Multiplate(®) impedance aggregometry.

Impaired platelet function is a major risk factor for peri-operative bleeding and transfusion. This prospective, observational study enrolled 101 consecutive patients undergoing elective cardiac surgery with cardiopulmonary bypass. Platelet function was assessed by two whole blood impedance aggregometers (ROTEM(®) platelet and Multiplate(®) ), using three different activators (arachidonic acid, adenosine diphosphate and thrombin receptor-activating peptide-6), at three peri-operative time points (before anaesthesia, after aortic declamping and 5-10 min after protamine administration). Platelet function was impaired over the time-course in all assays. Results after protamine administration demonstrated the best correlation with postoperative chest tube drainage. Patients with a chest tube drainage exceeding the 75th percentile of the entire study population, during the first 24 postoperative hours, were characterised to have excessive bleeding. Both devices provided similar predictability for postoperative chest tube drainage and red blood cell transfusion requirements. The latter was associated with the degree of platelet inhibition and the number of pathways inhibited determined respective cut-off values.

[What is Men's Health? A definition]. / Was ist Männergesundheit? Eine Definition.

UNLABELLED: Target of the study: Men's Health is increasingly coming into focus of health research, epidemiology, health care organization, and health policy. Over the past 10-15 years have been published by some countries and the EU Men's Health reports where problems of health noted in men. Starting point for a scientific study of men's health is the definition of "Men's Health". A group of German experts in the field of men's health has taken on this task. METHODOLOGY: A literature review in international and national databases was performed for the years 1990-2014 by selected MeSH terms and for "experts for men's health". Another research concerned "gray literature" in Germany, especially health reports and web pages. This was followed by a conference of experts to define "Men's Health" using a modified Delphi method according to W. Zinn. From the expert group minimum criteria for a definition "Men's Health" were created and discussed, which must comply with the new definition of men's health. This definition was created in the third round of the Delphi method. RESULTS: The international literature review yielded 7 definitions of "Men's Health" in the English-speaking and 5 definitions in the German inkl. in the "gray" literature. Due to the developed by the Expert Group 7 minimum criteria 15 relevant topics were listed, of which by weighting 8 subject areas were considered relevant for a new definition. In comparison with the previous definitions none could fulfill these 8 criteria. Therefore, in the next step of the expert group a new definition "Men's Health" was elaborated. The definition has reference to the WHO concept of "health" and includes dimensions of health and disease, risk and protective factors that require special prevention and care services for all phases of life. All participants in the expert group agreed on the definition developed. CONCLUSIONS: The definition of Men's Health is a basis for further scientific work and practice to improve men's health in Germany and other countries.

A pragmatic triage system to reduce length of stay in medical emergency admission: feasibility study and health economic analysis.

BACKGROUND: Departments of Internal Medicine tend to treat patients on a first come first served basis. The effects of using triage systems are not known. METHODS: We studied a cohort in an Acute Medical Unit (AMU). A computer-assisted triage system using acute physiology, pre-existing illness and mobility identified five distinct risk categories. Management of the category of very low risk patients was streamlined by a dedicated Navigator. Main outcome parameters were length of hospital stay (LOS) and overall costs. Results were adjusted for the degree of frailty as measured by the Clinical Frailty Scale (CFS). A six month baseline phase and intervention phase were compared. RESULTS: 6764 patients were included: 3084 in the baseline and 3680 in the intervention phase. Patients with very low risk of death accounted for 40% of the cohort. The LOS of the 1489 patients with very low risk of death in the intervention group was reduced by a mean of 1.85days if compared with the 1276 patients with very low risk in the baseline cohort. This was true even after adjustment for frailty. Over the six month period the cost of care was reduced by £250,158 in very low patients with no increase in readmissions or 30day mortality. CONCLUSIONS: Implementation of an advanced triage system had a measurable impact on cost of care for patients with very low risk of death. Patients were safely discharged earlier to their own home and the intervention was cost-effective.

Skeletal muscle-specific overexpression of SIRT1 does not enhance whole-body energy expenditure or insulin sensitivity in young mice.

AIMS/HYPOTHESIS: The NAD(+)-dependent protein deacetylase sirtuin (SIRT)1 is thought to be a key regulator of skeletal muscle metabolism. However, its precise role in the regulation of insulin sensitivity is unclear. Accordingly, we sought to determine the effect of skeletal muscle-specific overexpression of SIRT1 on skeletal muscle insulin sensitivity and whole-body energy metabolism. METHODS: At 10 weeks of age, mice with muscle-specific overexpression of SIRT1 and their wild-type littermates were fed a standard diet with free access to chow or an energy-restricted (60% of standard) diet for 20 days. Energy expenditure and body composition were measured by indirect calorimetry and magnetic resonance imaging, respectively. Skeletal muscle insulin-stimulated glucose uptake was measured ex vivo in soleus and extensor digitorum longus muscles using a 2-deoxyglucose uptake technique with a physiological insulin concentration of 360 pmol/l (60 µU/ml). RESULTS: Sirt1 mRNA and SIRT1 protein levels were increased by approximately 100- and 150-fold, respectively, in skeletal muscle of mice with SIRT1 overexpression compared with wild-type mice. Despite this large-scale overexpression of SIRT1, body composition, whole-body energy expenditure, substrate oxidation and voluntary activity were comparable between genotypes. Similarly, skeletal muscle basal and insulin-stimulated glucose uptake were unaltered with SIRT1 overexpression. Finally, while 20 days of energy restriction enhanced insulin-stimulated glucose uptake in skeletal muscles of wild-type mice, no additional effect of SIRT1 overexpression was observed. CONCLUSIONS/INTERPRETATION: These results demonstrate that upregulation of SIRT1 activity in skeletal muscle does not affect whole-body energy expenditure or enhance skeletal muscle insulin sensitivity in young mice on a standard diet with free access to chow or in young mice on energy-restricted diets.

New developments in epidemiology, diagnosis, and treatment of fascioliasis.

PURPOSE OF REVIEW: This review focuses on the recent developments in the epidemiology, burden of disease, diagnostic tests, and treatment of fascioliasis. RECENT FINDINGS: Recent epidemiologic data suggest that either the endemic areas are expanding or disease is being recognized in areas where it was not previously observed. In addition, recent data highlight the effects of fascioliasis on childhood anemia and nutrition. Diagnosis remains problematic, but newer diagnostic tests including antibody, antigen, and DNA detection tests may facilitate earlier diagnosis. Recent studies suggest that point-of-care testing may soon be possible. Treatment with triclabendazole is effective, but resistance is emerging in livestock and may pose a threat for patients. SUMMARY: Fascioliasis continues to emerge as an important neglected disease, with new studies highlighting the under-recognized burden of disease. Further studies are needed on burden of disease, improved diagnosis, and alternative to triclabendazole treatment.

Violation of the Leggett-Garg inequality with weak measurements of photons.

By weakly measuring the polarization of a photon between two strong polarization measurements, we experimentally investigate the correlation between the appearance of anomalous values in quantum weak measurements and the violation of realism and nonintrusiveness of measurements. A quantitative formulation of the latter concept is expressed in terms of a Leggett-Garg inequality for the outcomes of subsequent measurements of an individual quantum system. We experimentally violate the Leggett-Garg inequality for several measurement strengths. Furthermore, we experimentally demonstrate that there is a one-to-one correlation between achieving strange weak values and violating the Leggett-Garg inequality.

Faecal progesterone metabolites and behavioural observations for the non-invasive assessment of oestrous cycles in the common wombat (Vombatus ursinus) and the southern hairy-nosed wombat (Lasiorhinus latifrons).

Wombats belong to Australia's unique marsupial species. Two of the three remaining species, the common wombat (Vombatus ursinus) and the southern hairy-nosed wombat (Lasiorhinus latifrons) are abundant. The third species, the northern hairy-nosed wombat (Lasiorhinus krefftii) has only about 115 individuals left in the wild. This study aimed to gain further insight into the basic reproductive biology of wombat species and evaluate the value of faecal progesterone metabolites and behavioural patterns as a means for non-invasive monitoring of the oestrous cycle in common and the southern hairy-nosed wombats. In an initial study, three different faecal steroid assays showed that 20alpha-OH-pregnanes were the main progesterone metabolites. These metabolites were examined in captive female common wombats (n = 5) and southern hairy-nosed wombats (n = 2). In one female common wombat 11.7 days with a follicular phase of 25.6 +/- 6.3 days and a luteal phase of 28.2 +/- 12.7 days. The data for faecal pregnanes obtained in the southern and in one male common wombat oestrous related behavioural data were obtained. Individual cycling females exhibited a significant relationship between plasma progesterone and faecal pregnanes. In the common wombat, the values for faecal pregnanes showed an oestrous cycle length of 55.1 +/- hairy-nosed wombat during the breeding season gave an oestrous cycle length of 41.1 +/- 12.8 days with a follicular phase of 27.9 +/- 12.3 days and a short luteal phase of 13.3 +/- 1.1 days. The behavioural data show that the faecal sniffing behaviour of the male, tended to increase around the time that oestrous was found. In conclusion, monitoring of 20alpha-OH-pregnanes in wombat faeces could be a useful methodology to monitor reproductive cycles in the wombat, and can possibly be applied to monitor the endangered northern hairy-nosed wombat.

Long-term costs of treatment for depression: impact of drug selection and guideline adherence.

OBJECTIVES: This paper examines three processes: SSRI antidepressant choice, adherence to treatment guidelines, and long-term health care expenditures associated with antidepressant treatment for patients with a diagnosis of depression. METHODS: Patient records were abstracted from a medical claims database covering employer-provided health care plans. Treatment episodes required a 6-month antidepressant-free prior period; initial treatment with sertraline, paroxetine or fluoxetine; and data on direct medical costs over the 24 months following the initial prescription. The multivariate model of drug selection, patient adherence to antidepressant use guidelines, and cost was subjected to specification testing to rule out the possibility that nonrandom initial antidepressant selection might lead to sample selection bias. Further tests indicated that the results were free of bias due to a possible correlation between antidepressant selection and use of the medication, or because of the endogeneity of use patterns in the process driving cost. However, there was evidence of unobserved variables correlated with both achieving guideline adherent use and expenditures, which might have led to sample selection bias. RESULTS: Subjects who met the study criteria included 796 initiating therapy with sertraline, 352 with paroxetine, and 882 with fluoxetine. Fluoxetine patients were significantly more likely than sertraline or paroxetine patients to achieve a use pattern that was consistent with guidelines for treating depressive disorder (p < .05). There were no statistically significant differences between the three treatment cohorts in total direct health care expenditures over the 2-year period (p < .05), and depression-related expenditures, other mental health expenditures, and non-mental health care expenditures did not show significant differences across the treatments (p < .05). Natural logged values of antidepressant drug expenditures were predicted to be highest for fluoxetine, followed by sertraline, then paroxetine (p < .01). Predicted log values of mental health expenditures were lower for sertraline relative to fluoxetine. CONCLUSIONS: Fluoxetine patients had the highest likelihood of using antidepressant medication according to treatment guidelines that were developed to assure quality care. This benefit was achieved without incurring greater total health care expenditures.