The Doctor Can See You Now: A Key Stakeholder Study Into The Acceptability Of Ambulance Based Telemedicine.

Using telecommunications technology it would be possible to link a patient and paramedic to a Doctor in the Emergency Department (ED) at the point of first patient contact. A questionnaire-based study on telemedicine in the pre-hospital environment involving patients, paramedics, doctors and nurses in the ED, was performed to assess if they would want and accept telemedicine in pre-hospital emergency care. When asked 98.5% (55) of patients, 89% (11) of doctors, 76% (14) of nurses and 91% (42) of ambulance personnel saw the potential of an audio-visual link from the pre-hospital environment to the ED. The potential benefits were felt to be in diagnosis of time-dependent illnesses, time management, increased hospital preparedness for incoming patients and increased triage efficiency. Stakeholder enthusiasm for pre-hospital telemedicine must be met with the technological requirements to provide such a service. As noted by one patient a pre-hospital audio-visual link to the ED could be "potentially a life saving service".

Immediate and residual effects of heat stress and restricted intake on milk protein and casein composition and energy metabolism.

The effects of heat stress on dairy production can be separated into 2 distinct causes: those effects that are mediated by the reduced voluntary feed intake associated with heat stress, and the direct physiological and metabolic effects of heat stress. To distinguish between these, and identify their effect on milk protein and casein concentration, mid-lactation Holstein-Friesian cows (n = 24) were housed in temperature-controlled chambers and either subjected to heat stress [HS; temperature-humidity index (THI) ~78] or kept in a THI<70 environment and pair-fed with heat-stressed cows (TN-R) for 7 d. A control group of cows was kept in a THI<70 environment with ad libitum feeding (TN-AL). A subsequent recovery period (7 d), with THI<70 and ad libitum feeding followed. Intake accounted for only part of the effects of heat stress. Heat stress reduced the milk protein concentration, casein number, and casein concentration and increased the urea concentration in milk beyond the effects of restriction of intake. Under HS, the proportion in total casein of αS1-casein increased and the proportion of αS2-casein decreased. Because no effect of HS on milk fat or lactose concentration was found, these effects appeared to be the result of specific downregulation of mammary protein synthesis, and not a general reduction in mammary activity. No residual effects were found of HS or TN-R on milk production or composition after THI<70 and ad libitum intake were restored. Heat-stressed cows had elevated blood concentrations of urea and Ca, compared with TN-R and TN-AL. Cows in TN-R had higher serum nonesterified fatty acid concentrations than cows in HS. It was proposed that HS and TN-R cows may mobilize different tissues as endogenous sources of energy.

Composition, coagulation properties, and cheesemaking potential of milk from cows undergoing extended lactations in a pasture-based dairying system.

Extending the lactation length of dairy cows beyond the traditional 10 mo toward lactations of up to 22 mo has attracted interest in the pasture-based seasonal dairying systems of Australia and New Zealand as a way of alleviating the need for cows to conceive during peak lactation, such as is required to maintain seasonally concentrated calving systems. Lactation lengths longer than 10 mo instead provide cows with more time to cycle and conceive after parturition and may therefore be more suitable systems for high-producing Holstein-Friesian cows. Before recommending such systems there is a need to evaluate the effects of long lactations on the suitability of milk for manufacture of high-quality dairy products. In the current experiment, the composition of milk from cows entering the second half of a 22-mo lactation was examined in detail and compared with that from cows undergoing a traditional 10-mo lactation. On 2 occasions, coagulation properties were measured using low amplitude strain oscillation rheometry, and Cheddar cheese was made in 250-L pilot-scale vats. Results showed that milk from extended lactations had higher concentrations of fat and protein than cows undergoing 10-mo lactations under similar management conditions and at the same time of year. The ratio of casein to true protein was not affected by lactation length and neither were the proportions of individual caseins. The increase in milk solids during extended lactations translated into a more rapid rate of coagulation and ultimately a firmer curd on one of the two occasions. Milk from extended lactations yielded more cheese per 100 kg of milk, and there were few differences in the composition or organoleptic properties of the cheese. These data are the first to show that pasture-based dairy industries could embrace the use of extended lactations without compromising the core business of producing high-quality dairy products.

Outcomes from a community-based hypertension educational programme: the West of Ireland Hypertension study.

BACKGROUND: Hypertension is a leading modifiable risk factor for premature cardiovascular disease. Research indicates a growing prevalence of hypertension among adults worldwide, with accompanying low levels of patient knowledge, and sub-optimal clinical management. AIMS: This study aims to explore the impact of a structured hypertension educational intervention on patient knowledge, lifestyle behaviours and blood pressure control. DESIGN: An observational, prospective cohort design was selected. METHODS: Participants were recruited through a public blood pressure screening event in a community-based setting. They were asked to complete a self-report questionnaire followed by an assessment of their blood pressure. Participants with high blood pressure were randomly assigned to either a control group or an intervention group. Those in the intervention group received an educational intervention on hypertension 4 weeks later. Both groups were recalled 4 months later for a repeat of the same initial assessment. RESULTS: Eighty-one participants with a mean age of 64 years were included in this study. There were no significant differences in the baseline measures between the two groups. Significant improvements were found in the intervention group compared with the control group in levels of hypertension knowledge and awareness (p = <0.001), exercise levels (p = 0.002) and weight (p = 0.003). Participants who underwent the intervention showed a greater reduction in both systolic (SBP) and diastolic (DBP) blood pressure (SBP 158.8 to 141.6 mmHg, p < 0.0001 and DBP 84.7 to 77.7 mmHg, p < 0.001). CONCLUSION: Providing a tailored educational intervention can positively impact on hypertension knowledge, self-care management and control within community-based settings.

The immunological profile of B-cell disorders and proposal of a scoring system for the diagnosis of CLL.

We have investigated the role of immunophenotyping in distinguishing between leukemic B-cell lymphoproliferative disorders. Circulating cells from 666 cases were analyzed with a panel of markers by flow cytometry. The diseases included: chronic lymphocytic leukemia (CLL), 400; prolymphocytic leukemia, 22; hairy cell leukemia (HCL), 40; HCL variant, 15; splenic lymphoma with villous lymphocytes, 100; follicular lymphoma, 26; lymphoplasmacytic lymphoma, 25; mantle-cell lymphoma, 20; and large cell lymphoma, 18. On the basis of the most common marker profile in CLL, CD5+, CD23+, FMC7- and weak expression (+/-) of surface immunoglobulin (SmIg) and CD22, we devised a scoring system that gives for each of these five markers a value of 1 or 0 according to whether it is typical or atypical for CLL. Scores range from 5 (typical of CLL) to 0 (atypical for CLL). Application of the scoring system to all the cases showed that 87% of CLL scored 5 and 4 and only 0.4% scored 0 or 1, whereas 89% of other B-cell leukemias and 72% of lymphomas scored 0 or 1; only one case (0.3%) scored 4 and none scored 5 (p < 0.0001). There were no differences between CLL with high and low scores but higher scores were found in cases with more typical morphology (p < 0.0015). Considering each individual marker, there was no single one that distinguished CLL from other diseases, although the most reliable were SmIg intensity and FMC7. The proposed score will facilitate the diagnosis of B-lymphoproliferative disorders and improve their classification.

Factors affecting the activity of bovicin HC5, a bacteriocin from Streptococcus bovis HC5: release, stability and binding to target bacteria.

AIMS: To determine the factors affecting the release, stability and binding of bovicin HC5 to sensitive bacteria. METHODS AND RESULTS: Stationary phase Streptococcus bovis HC5 cultures had little cell-free bovicin HC5 activity until the final pH was <5.0, and even more bacteriocin was released by treatment with acidic NaCl (pH 2.0, 100 mmol l(-1)). Cultures grown with Tween 80 had more cell-free bovicin HC5 than untreated controls, but this nonionic detergent enhanced activity rather than release. Bovicin HC5 binding to S. bovis JB1 (a susceptible strain) was greater at pH values <6.0. Bovicin HC5 bound other sensitive Gram-positive bacteria, but not Gram-negative species. Cultures retained most of their activity for 35 days, but only if the final pH was <5.6. If the final pH was >5.6, peptidases destroyed much of the activity. CONCLUSIONS: Bovicin HC5 remains cell associated until the culture pH is <5.0, but it can be easily dissociated from the cell surface by acidic NaCl. It is highly stable in acidic environments and only binds sensitive bacteria at pH values <6.0. SIGNIFICANCE AND IMPACT OF THE STUDY: Streptococcus bovis HC5 does not have generally regarded as safe status. However, bovicin HC5 has a broad spectrum of activity and sensitive bacteria do not become resistant. Based on these results, bovicin HC5 may be a useful bacteriocin model.

Photodynamic therapy using aminolaevulinic acid for patients with nonhyperkeratotic actinic keratoses of the face and scalp: phase IV multicentre clinical trial with 12-month follow up.

BACKGROUND: Actinic keratoses (AKs) are the most common epithelial precancerous lesions, especially among individuals with light complexions. AKs are believed to progress to in situ squamous cell carcinoma (SCC) and potentially, to invasive SCC. AKs and invasive SCCs share certain histopathological features and both share genetic tumour markers and p53 mutations. Given these facts, the treatment and management of AKs are integral components to quality dermatological health care. OBJECTIVES: Topical aminolaevulinic acid-based photodynamic therapy (ALA-PDT) has been extensively studied over the last several years. This study seeks to characterize further the efficacy and safety of ALA-PDT by extending previous work to: (i) assess the long-term recurrence rate of AKs that have resolved after ALA-PDT; (ii) to characterize the histopathology of treated AK lesions that do not completely respond to ALA-PDT or recur in long-term follow up; (iii) to characterize the histopathology of untreated clinically diagnosed AK lesions in the study population at baseline; and (iv) to evaluate ALA-PDT in darker skin types than previously studied. METHODS: Patients enrolled in this study had six to 12 discrete AK lesions, either on the face or the scalp. Individual AK lesions designated for treatment were graded as either grade 1 (lesions slightly palpable and more easily felt than seen) or grade 2 (moderately thick AKs, easily seen and felt). Patients with grade 3 (very thick and/or hyperkeratotic) lesions were excluded. For each subject, two lesions at baseline were randomized to biopsy, and were not followed as part of the study while the remaining lesions (target lesions) were treated with ALA-PDT (baseline and month 2, if required) and followed for 12 months. RESULTS: Of the 110 patients enrolled, 101 completed the study. The target AK lesions in the per-protocol population clearing completely in the first and second months following a single ALA-PDT treatment (baseline) were 76% and 72%, respectively. Sixty per cent of the patients received a second ALA-PDT treatment, limited to the target AKs still present at month 2. The percentage of treated target lesions that cleared completely peaked at 86% at month 4 then decreased gradually over time to 78% at month 12. The overall recurrence rate for all lesions that were noted to be cleared at some visit during the 12-month period was 24% (162/688). Of the 162 recurrent lesions 16 were lost to follow up, seven spontaneously cleared and 139 were biopsied. With respect to the lesions biopsied, 91% (127/139) were diagnosed histopathologically as AK, with the balance of lesions being SCC (nine of 139: 7%), basal cell carcinoma (one of 139: 0.7%) and other non-AK diagnoses (two of 139: 1%). The recurrence rate for histologically confirmed AKs was 19%. The clinical diagnosis of AK by investigators appeared to be accurate, with 91% (200/220) of the untreated clinically diagnosed AK lesions being histopathologically confirmed to be AK (AK, 142/220: 65%; advanced AK, 29/220: 13%; macular AK, 29/220: 13%). Despite concentrated efforts to recruit patients with Fitzpatrick skin types IV-VI, the distribution was as follows: I, 11%; II, 36%; III, 41%; IV, 11%; V, 2%. The demographics of this study population are typical of a patient population with AK. CONCLUSIONS: ALA-PDT was shown to be an effective and safe therapy for the treatment of AKs of the face and scalp in skin types I-V, with an acceptable rate of recurrence over 12 months of histologically confirmed AKs of 19%. Phototoxicity reactions were all expected, nonserious and had essentially resolved after 1 month post-treatment independent of skin type.

Changes in structure of the bovine milk fat globule membrane on heating whole milk.

The effects of heat-induced interactions between milk fat globule membrane components and skim milk proteins in whole milk on the structure of the membrane were examined by isopycnic sucrose density gradient centrifugation and by using Triton X-100 as a membrane probe. Skim milk components were incorporated into all the lipoprotein fractions separated by density gradient centrifugation. High density complexes, higher in density than those found in the natural milk fat globule membrane, were formed during the heat treatment. Losses of natural membrane polypeptides from the medium and low density lipoproteins were observed on heating. Heating whole milk also altered the rate of release of membrane components by detergent, with decreases in protein released and an increase in phospholipid constituents released. Studies on washed cream indicated that some of the changes in the membrane on heating whole milk occurred due to the heat treatment alone, independent of the interactions with skim milk proteins.

The immunophenotype of splenic lymphoma with villous lymphocytes and its relevance to the differential diagnosis with other B-cell disorders.

Splenic lymphoma with villous lymphocytes (SLVL) is a low-grade disorder that regularly presents with peripheral blood involvement. We describe the immunophenotype of the circulating cells from 100 SLVL patients whose disease has been characterized on clinical, morphologic, and histologic grounds. Cells from all cases expressed B-cell antigens (CD19 and CD37) and/or HLA-Dr and showed light chain restriction (kappa/lambda: 1.5/1) with moderate to strong intensity of membrane Ig staining. Cells from most cases (> 80%) were CD24+, FMC7+, and expressed strongly membrane CD22. The monoclonal antibodies CD10, CD23, and CD38 were positive in one-third of the cases; CD11c in 47%; and CD25 in 25% of cases. A minority of cases (< 20%) were positive with HC2, B-ly-7, and CD5. However, none of the 19 CD5+ cases had the phenotype characteristic of chronic lymphocytic leukemia (CD5+, CD23+, FMC7-, weak surface Ig and membrane CD22). None of the 17 CD25+ cases had the immunophenotype typical of hairy cell leukemia (CD25+, CD11c+, HC2+, B-ly-7+). HC2 and B-ly-7 were the most useful reagents to distinguish SLVL from hairy cell leukemia. Our findings demonstrate that SLVL has a distinct immunologic profile and that monoclonal antibodies are important for the differential diagnosis between this disease and other B-lymphoproliferative disorders with which SLVL can be confused.