Implications of differences between point-of-care blood gas analyser and laboratory analyser potassium results on hyperkalaemia diagnosis & treatment.

BACKGROUND: Hyperkalaemia is managed in the emergency department (ED) following measurement of potassium results by blood gas analysers (BGA) or laboratory analysers (LAB). AIMS: To determine the prevalence of clinically significant differences between BGA and LAB potassium results and the impact on ED hyperkalaemia management. METHODS: Retrospective analysis of time-matched ED BGA and LAB potassium samples from 2019 to 2020 (taken within 15 min, one or both results ≥6.0 mmol/L). Mean differences and 95% limits of agreement (LoA) were determined for pairs with one or both results ≥6.0 mmol/L and a separate 500 consecutive sample pairs. RESULTS: Four hundred eighty-eight matched BGA and LAB samples met the inclusion criteria. Of these, 201 (41.2%) differed by ≤0.5 mmol/L, 169 (34.6%) included a haemolysed LAB sample, and 12 (2.5%) had an unreportable BGA sample. One hundred six (21.7%) pairs differed by >0.5 mmol/L, and 60/106 (57%) had normal LAB potassium results, but BGA indicated moderate/severe hyperkalaemia (two of these pairs received hyperkalaemia treatment). Of patients with a haemolysed LAB sample, or where pairs differed by >0.5 mmol, 48 were treated with insulin and five (10.4%) experienced hypoglycaemia. Mean differences and LoA for pairs with LAB results <6.0 mmol/L but BGA ≥6.0 mmol/L demonstrated unacceptable agreement, with 18 (25.7%) BGA results exceeding 8.0 mmol/L. CONCLUSIONS: Potentially significant discordance may occur between BGA and LAB potassium results. Clinicians need to be aware of factors impacting both analytical methods' accuracy (such as poor venepuncture or sample handling, (K) EDTA interference) and undetectable haemolysis with BGA measurements. We recommend BGA hyperkalaemia be confirmed with LAB results using a non-haemolysed sample where time permits.

Brown Seaweed Food Supplementation: Effects on Allergy and Inflammation and Its Consequences.

Multiple health benefits have been ascribed to brown seaweeds that are used traditionally as dietary component mostly in Asia. This systematic review summarizes information on the impact of brown seaweeds or components on inflammation, and inflammation-related pathologies, such as allergies, diabetes mellitus and obesity. We focus on oral supplementation thus intending the use of brown seaweeds as food additives. Despite the great diversity of experimental systems in which distinct species and compounds were tested for their effects on inflammation and immunity, a remarkably homogeneous picture arises. The predominant effects of consumption of brown seaweeds or compounds can be classified into three categories: (1) inhibition of reactive oxygen species, known to be important drivers of inflammation; (2) regulation, i.e., in most cases inhibition of proinflammatory NF-κB signaling; (3) modulation of adaptive immune responses, in particular by interfering with T-helper cell polarization. Over the last decades, several inflammation-related diseases have increased substantially. These include allergies and autoimmune diseases as well as morbidities associated with lifestyle and aging. In this light, further development of brown seaweeds and seaweed compounds as functional foods and nutriceuticals might contribute to combat these challenges.

COVID-19 response: mitigating negative impacts on other areas of health.

'Vertical' responses focused primarily on preventing and containing COVID-19 have been implemented in countries around the world with negative consequences for other health services, people's access to and use of them, and associated health outcomes, especially in low-income and middle-income countries (LMICs). 'Lockdowns' and restrictive measures, especially, have complicated service provision and access, and disrupted key supply chains. Such interventions, alongside more traditional public health measures, interact with baseline health, health system, and social and economic vulnerabilities in LMICs to compound negative impacts. This analysis, based on a rapid evidence assessment by the Social Science in Humanitarian Action Platform in mid-2020, highlights the drivers and evidence of these impacts, emphasises the additional vulnerabilities experienced by marginalised social groups, and provides insight for governments, agencies, organisations and communities to implement more proportionate, appropriate, comprehensive and socially just responses that address COVID-19 in the context of and alongside other disease burdens. In the short term, there is an urgent need to monitor and mitigate impacts of pandemic responses on health service provision, access and use, including through embedding COVID-19 response within integrated health systems approaches. These efforts should also feed into longer-term strategies to strengthen health systems, expand universal healthcare coverage and attend to the social determinants of health-commitments, both existing and new-which governments, donors and international agencies must make and be held accountable to. Crucially, affected communities must be empowered to play a central role in identifying health priorities, allocating resources, and designing and delivering services.

Morning vs. evening administration of antiviral therapy in COVID-19 patients. A preliminary retrospective study in Ferrara, Italy.

OBJECTIVE: At the end of 2019, the Novel Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), spread rapidly from China to the whole world. Circadian rhythms can play crucial role in the complex interplay between viruses and organisms, and temporized schedules (chronotherapy) have been positively tested in several medical diseases. We aimed to compare the possible effects of a morning vs. evening antiviral administration in COVID patients. PATIENTS AND METHODS: We retrospectively evaluated all patients admitted to COVID internal medicine units with confirmed SARS-CoV-2 infection, and treated with darunavir-ritonavir (single daily dose, for seven days). Age, sex, length of stay (LOS), pharmacological treatment, and timing of antiviral administration (morning or evening), were recorded. Outcome indicators were death or LOS, and laboratory parameters, e.g., variations in C-reactive protein (CRP) levels, ratio of arterial oxygen partial pressure (PaO2, mmHg) to fractional inspired oxygen (FiO2) (PaO2/FiO2), and leucocyte count. RESULTS: The total sample consisted of 151 patients, 33 (21.8%) of whom were selected for antiviral treatment. The mean age was 61.8±18.3 years, 17 (51.5%) were male, and the mean LOS was 13.4±8.6 days. Nine patients (27.3%) had their antiviral administration in the morning, and 24 (72.7%) had antiviral administration in the evening. No fatalities occurred. Despite the extremely limited sample size, morning group subjects showed a significant difference in CRP variation, compared to that in evening group subjects (-65.82±33.26 vs. 83.32±304.89, respectively, p<0.032). No significant differences were found for other parameters. CONCLUSIONS: This report is the first study evaluating temporized morning vs. evening antiviral administration in SARS-CoV-2 patients. The morning regimen was associated with a significant reduction in CRP values. Further confirmations with larger and multicenter samples of patients could reveal novel potentially useful insights.

l-Arginine supplementation of gilts during early gestation modulates energy sensitive pathways in pig conceptuses.

Dietary l-arginine (ARG) supplementation has been studied as a nutritional strategy to improve reproductive performance of pregnant sows, since arginine is a conditionally essential amino acid. However, reports addressing the molecular mechanisms that mediate supplementation effects on embryos and fetuses development are still scarce. Therefore, we aimed to evaluate the effects of 1.0% ARG supplementation of commercial pregnant gilts on genes and proteins from energy metabolism and antioxidant defense pathways in embryos and fetuses. We also analyzed the global transcriptome profile of 25- and 35-day-old conceptuses. At Day 25, we observed a lower abundance of phospho-AMP-activated protein kinase (phospho-AMPK) protein and downregulation of oxidative phosphorylation system genes in ARG embryos. On the other hand, ARG fetuses showed greater expression of MLST8 and lower expression of MTOR genes, in addition to lower abundance of phospho-AMPK and phospho-mammalian target of rapamycin (phospho-mTOR) proteins. Transcriptome analysis at Day 35 did not present differentially expressed genes. For the antioxidant defense pathway, no differences were found between CON and ARG conceptuses, only trends. In general, supplementation of gilts with 1.0% ARG during early gestation affects energy sensitive pathways in 25- and 35-day conceptuses; however, no effects of supplementation were found on the antioxidative defense pathway in 25-day embryos.

Proteomic analysis reveals changes in energy metabolism of skeletal muscle in beef cattle supplemented with vitamin A.

BACKGROUND: Vitamin A has been reported as a factor influencing marbling deposition in meat from animals. Although the mechanisms by which vitamin A regulates lipid metabolism in mature adipocytes are already well-established, information regarding molecular mechanisms underlying the effects of vitamin A on the regulation of intramuscular fat deposition in beef cattle still remains limited. The present study aimed to assess the molecular mechanisms involved in the intramuscular fat deposition in beef cattle supplemented with vitamin A during the fattening phase using a proteomic approach. RESULTS: Vitamin A supplementation during the fattening phase decreased intramuscular fat deposition in beef cattle. Proteome and phospho-proteome analysis together with biological and networking analysis of the protein differentially abundant between treatments indicated that Vitamin A supplementation affects the overall energy metabolism of skeletal muscle, impairing lipid biosynthesis in skeletal muscle. CONCLUSION: Vitamin A supplementation at fattening phase impairs intramuscular fat deposition in beef cattle likely by changing the energy metabolism of skeletal muscle. The interaction of retinoic acid and heat shock 70-kDa protein may play a pivotal role in intramuscular fat deposition as a consequence of vitamin A supplementation by impairing de novo fatty acid synthesis as a result of a possible decrease in insulin sensitivity in the skeletal muscle. © 2020 Society of Chemical Industry.

A high-throughput multi-microfluidic crystal generator (MMicroCryGen) platform for facile screening of polymorphism and crystal morphology for pharmaceutical compounds.

In this work, a novel multi-microfluidic crystallization platform called MMicroCryGen is presented, offering a facile methodology for generating individual crystals for fast and easy screening of the polymorphism and crystal habit of solid compounds. The MMicroCryGen device is capable of performing 8 × 10 cooling crystallization experiments in parallel using 8 disposable microcapillary film strips, each requiring less than 25 µL of solution. Compared to traditional microfluidic systems, the MMicroCryGen platform does not require complex fluid handling; it can be directly integrated with a 96-well microplate and it can also work in a "dipstick" mode. The produced crystals can be safely and directly observed inside the capillaries by optical and spectroscopic techniques. The platform was validated by performing a number of independent experimental runs for: (1) polymorph and hydrate screening of ortho-aminobenzoic acid, succinic acid and piroxicam; (2) co-crystal form screening of the p-toluenesulfonamide/triphenylphosphine oxide system; (3) studying the effect of o-toluic acid on ortho-aminobenzoic cooling crystallization (effect of structurally related additives). In all three cases, all known solid forms were identified with a single experiment using ∼200 µL of solvent and just a few micrograms of the solid material. The MMicroCryGen is simple to use, inexpensive and it provides increased flexibility compared to traditional crystallization techniques, being an effective new microfluidic solution for solid form screening in pharmaceutical, fine chemicals, food and agrochemical industries.

Health self-perception in patient with Crohn's disease: a web survey.

BACKGROUND: Crohn's Disease (CD) has an incidence on the physical and psychological autonomy of the patient, such as to alter their daily life. The impact of the disease on the daily life of the patients is related to the symptoms and complications of the disease. Patient autonomy and participation in social and work life are the goals that nurses must reach for patients with CD to improve their quality of life. AIM: To measure the perception of the health of people with a diagnosis of CD. METHOD: Review of the literature on PubMed, and internet sites. Administration on the web of the standardised questionnaire Short Form Health Survey (SF-12). RESULTS: A total of 228 patients with CD completed valid questionnaires and were enrolled. The SF-12 questionnaire scores make it possible to build a physical health index (PCS) with a median value of 36,10 (min 33,8; max 42,4) and mental health index (MCS) with a median value of 36,04 (min 28.5; max 38,4). There were statistically significant data related to the achievement of the degree with median 41.9 (min 35,1; max 48,4) compared to non-graduates with a p<0.001 and in relation to the employment level (median 37.9 min/max 34,7/46,7) compared to unemployed and inactive with a p = 0.03. CONCLUSION: Despite the inevitable complications of the disease (intestinal and extra-intestinal symptoms), most of our sample did not exhibit significant physical limitations (surgical intervention, stomach packaging which generally causes a decrease in libido in both male and female patients ). The nurse cares for a patient with CD must have not only technical skills and specialist skills, but a holistic vision of the patient. Despite some findings in this study, this research orientation deserves more attention.

Parental Health Beliefs, Socio-demographics, and Healthcare Recommendations Influence Micronutrient Supplementation in Youth with Celiac Disease.

To identify parental influences affecting micronutrient supplementation in children and adolescents (2-18 years of age) with Celiac Disease (CD), a multi-method (survey, focus groups) study was conducted. A 35-item questionnaire consisting of open- and closed-ended questions was launched nationally via Canadian Celiac Association internet sites. Five focus groups were conducted using a semi-structured interview guide. The survey and semi-structured interview guide content was vetted for face and content validity. Thematic analyses were conducted on the focus group content and open-ended survey questions, and χ(2) and Fischer's exact analysis were performed on closed-ended survey data. Survey respondents were predominantly mothers (97%) of female children (80 F, 49 M) between the ages of 9-12 (31%) with CD, residing in western provinces (55%) with a combined family income ≥$100 000/year (63%). Seventy-seven percent of parental respondent's children or adolescents consumed micronutrient supplements, for 1-5 years (52%), 7 days a week (65%), as both multi-vitamin and single vitamin preparations (40%). Parental influences on child micronutrient use included health beliefs and knowledge, parental supplement use, supplement characteristics, age of child (above or below 13 years), household routines, and provincial residential status (P < 0.05). Parents relied on health professional recommendation (69%; MD, RD) and the internet (21%) as sources of information regarding child micronutrient supplementation. Parental health beliefs and knowledge, socio-demographic factors, and practitioner recommendation influence micronutrient supplement use in children and adolescents with CD.

Severe Adverse Maternal Outcomes among Women in Midwife-Led versus Obstetrician-Led Care at the Onset of Labour in the Netherlands: A Nationwide Cohort Study.

OBJECTIVE: To test the hypothesis that it is possible to select a group of low risk women who can start labour in midwife-led care without having increased rates of severe adverse maternal outcomes compared to women who start labour in secondary care. DESIGN AND METHODS: We conducted a nationwide cohort study in the Netherlands, using data from 223 739 women with a singleton pregnancy between 37 and 42 weeks gestation without a previous caesarean section, with spontaneous onset of labour and a child in cephalic presentation. Information on all cases of severe acute maternal morbidity collected by the national study into ethnic determinants of maternal morbidity in the Netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, was merged with data from the Netherlands Perinatal Registry of all births occurring during the same period. Our primary outcome was severe acute maternal morbidity (SAMM, i.e. admission to an intensive care unit, uterine rupture, eclampsia or severe HELLP, major obstetric haemorrhage, and other serious events). Secondary outcomes were postpartum haemorrhage and manual removal of placenta. RESULTS: Nulliparous and parous women who started labour in midwife-led care had lower rates of SAMM, postpartum haemorrhage and manual removal of placenta compared to women who started labour in secondary care. For SAMM the adjusted odds ratio's and 95% confidence intervals were for nulliparous women: 0.57 (0.45 to 0.71) and for parous women 0.47 (0.36 to 0.62). CONCLUSIONS: Our results suggest that it is possible to identify a group of women at low risk of obstetric complications who may benefit from midwife-led care. Women can be reassured that we found no evidence that midwife-led care at the onset of labour is unsafe for women in a maternity care system with a well developed risk selection and referral system.

Development and psychometric evaluation of scales to measure professional confidence in manual medicine: a Rasch measurement approach.

BACKGROUND: Health professionals in athletic training, chiropractic, osteopathy, and physiotherapy fields, require high-level knowledge and skills in their assessment and management of patients. This is important when communicating with patients and applying a range of manual procedures. Prior to embarking on professional practice, it is imperative to acquire optimal situation-specific levels of self-confidence for a beginner practitioner in these areas. In order to foster this professional self-confidence within the higher education context, it is necessary to have valid and reliable scales that can measure and track levels and how they change. This study reports on the development and psychometric analysis of two new scales, Patient Communication Confidence Scale (PCCS) and the Clinical Skills Confidence Scale (CSCS), to measure confidence in these two areas for students in manual medicine programs. The Rasch measurement model was used to guide the development of the scales and establish their psychometric properties. METHODS: The responses to 269 returned questionnaires over two occasions were submitted to psychometric analysis, with various aspects of the scales examined including: item thresholds; item fit; Differential Item Functioning; targeting; item locations; item dependencies; and reliability. To provide further evidence of validity, scores were correlated with two existing valid scales. RESULTS: Analyses showed that the scales provided valid and reliable measures of confidence for this sample of persons. High Person Separation Indices (0.96 for PCCS; 0.93 for SCSC) provided statistical evidence of reliability, meaning the scales are able to discriminate amongst persons with different levels of confidence. For the PCCS, item categories were operating as required, and for the CSCS only two items' thresholds were slightly disordered. Three tests of fit revealed good fit to the model (indicating the internal consistency of both scales) and results of the correlations with two existing valid scales were consistent with expectations. CONCLUSIONS: The importance of confidence cannot be overlooked in health education because students learning new information and skills, and dealing with challenging situations can be negatively impacted by a lack of confidence which can result in students disengaging from placements or leaving a program. Valid and reliable instruments are essential in tracking change in levels of confidence in specific skills over time and the examination of the degree of congruence between confidence and competence. Analysis of responses to the two confidence scales established that they are valid and reliable instruments.

What does it take to have a strong and independent profession of midwifery? Lessons from the Netherlands.

In the 1970s, advocates of demedicalising pregnancy and birth 'discovered' Dutch maternity care. The Netherlands presented an attractive model because its maternity care system was characterised by a strong and independent profession of midwifery, close co-operation between obstetricians and midwives, a very high rate of births at home, little use of caesarean section, and morbidity and mortality statistics that were among the best in the developed world. Over the course of the following 40 years much has changed in the Netherlands. Although the home birth rate remains quite high when compared to other modern countries, it is half of what it was in the 1970s. Midwifery is still an independent medical profession, but a move toward 'integrated care' threatens to bring midwives into hospitals under the direction of medical specialists, more women are interested in medical pain relief, and there is a growing concern that current, albeit slight, increases in rates of intervention in physiological births foreshadow the end of the unique approach to birth in the Netherlands. The story of Dutch maternity care thus offers an ideal opportunity to examine the social, organisational, and cultural factors that work to support, and to diminish, the independent practice of midwifery in high-resource countries. We may wish to believe that providing ample and convincing evidence of the value of midwifery care will be enough to promote more and better use of midwifery, but the lessons from the Netherlands make clear that an array of social forces play a critical role determining the place of midwives in the health care system and how the care they provide is deployed.

Finding the right indicators for assessing quality midwifery care.

OBJECTIVE: To identify a set of indicators for monitoring the quality of maternity care for low-risk women provided by primary care midwives and general practitioners (GPs) in the Netherlands. DESIGN: A Project Group (midwives, GPs, policymakers and researchers) defined a long list of potential indicators based on the literature, national guidelines and expert opinion. This list was assessed against the AIRE (Appraisal of Indicators through Research and Evaluation) instrument criteria, resulting in a short list of draft indicators. In a two-round Delphi survey, a multidisciplinary group of stakeholders reviewed the elaborated draft indicators, rating both the relationship between indicator and quality of care and the feasibility. SETTING AND PARTICIPANTS: A multidisciplinary expert panel consisting of 28 midwives, 2 GPs, 3 obstetricians and 3 maternity assistants, randomly selected from different regions in the Netherlands. INTERVENTION: None. MAIN OUTCOME MEASURE: Set of quality indicators for midwifery care. RESULTS: The Project Group generated a list of 115 potential indicators which was reduced to 35 using the AIRE criteria. The 35 draft indicators were discussed by a Delphi panel. In total, 26 indicators were recommended by the participants as relevant indicators of midwifery care, representing several levels of measurement. Eight structure indicators, 12 process indicators and 6 outcome indicators were addressing the various phases of midwifery care. CONCLUSIONS: We identified a set of quality indicators concerning midwifery care provision in a low-risk population. Practicing maternity care providers adopted the large majority (83%) of the draft indicators proposed as a feasible set of indicators, describing the structure, process and outcome. The input from multidisciplinary experts in the process of identifying the right indicators showed to be essential in all phases of development.

The lower prevalence of female genital mutilation in the Netherlands: a nationwide study in Dutch midwifery practices.

OBJECTIVES: To determine the prevalence of female genital mutilation (FGM) in women giving birth in 2008 in the Netherlands. METHOD: A retrospective questionnaire study was conducted.The study covered all 513 midwifery practices in the Netherlands. The data were analysed with SPSS 17.0. RESULTS: The response from midwifery practices was 93%(n = 478). They retrospectively reported 470 circumcised women in 2008 (0.32%). The expected prevalence in the Netherlands based on the estimated prevalence of FGM in the country of birth was 0.7%. It is likely that there was under reporting in midwifery practices since midwives do not always enquire about the subject and may not notice the milder types of FGM. Midwives who checked their records before answering our questionnaire reported a prevalence of 0.8%. CONCLUSION: On the basis of this study, we can conclude that FGM is a serious clinical problem in Europe for migrant women from risk countries for FGM. These women should receive extra attention from obstetricians and midwives during childbirth, since almost half are mutilated and FGM involves a risk of complications during delivery for both women and children.

[The audit: a vital but limited measuring instrument]. / Audit: essentieel, maar beperkt meetinstrument.

An audit is an instrument to improve quality of care. It primarily does this by revealing the extent to which medical professionals do not follow existing protocols for patient care. However, it should not replace robust research into new forms of care. Most audits are, in effect, no more than a series of cases of poor outcomes and cannot yield rigorous evidence. In an audit, Van Dillen et al. (2010) report 17 cases of postpartum hemorrhage (PPH) and eclampsia after home births and births started under midwifery care. They show that in 76% of these cases the care by the midwife and/or obstetrician did not follow existing Dutch practice guidelines or consensus. They make recommendations for changes in care, including the introduction of misoprostol in primary care and transfer to hospital if the placenta has not been delivered within half an hour. Although PPH and eclampsia are rare in Dutch primary obstetric care, midwives and obstetricians should make a better effort to adhere to practice guidelines aimed at delivering the best pregnancy and birth care. However, new forms of care should first be researched for effectiveness in lowering maternal morbidity, side effects and costs, before they can be implemented in practice.

Pregnancy and labour in the Dutch maternity care system: what is normal? The role division between midwives and obstetricians.

INTRODUCTION: In the Dutch maternity care system, the role division between independently practising midwives (who take care of normal pregnancy and childbirth) and obstetricians (who care for pathologic pregnancy and childbirth) has been established in the so-called "List of Obstetric Indications"(LOI). The LOI designates the most appropriate care provider for women with defined medical or obstetric conditions. METHODS: This descriptive study analysed the evolution of the concept of "normality" by comparing the development and the contents of the consecutive versions of the LOI from 1958 onwards. The results were related to data from available Dutch national databases concerning maternity care. RESULTS: The number of conditions defined in the successive lists increased from 39 in 1958 to 143 in 2003. In the course of time, the nature and the content of many indications changed, as did the assignment to the most appropriate care provider. The basic assumptions of the Dutch maternity care system remained stable: the conviction that pregnancy and childbirth fundamentally are physiologic processes, the strong position of the independently practising midwife, and the choice between home or hospital birth for low-risk women. Nevertheless, the odds of the obstetrician being involved in the birth process increased from 24.7% in 1964 to 59.4% in 2002, whereas the role of the primary care provider decreased correspondingly. DISCUSSION: Multidisciplinary research is urgently needed to better determine the risk status and the optimal type of care and care provider for each individual woman in her specific situation, taking into account the risk of both under- and over-treatment. Safely keeping women in primary care could be considered one of a midwife's interventions, just as a referral to secondary care may be. The art of midwifery and risk selection is to balance both interventions, in order to end up with the optimal result for mother and child.

Importance of building confidence in patient communication and clinical skills among chiropractic students.

PURPOSE: One important objective of chiropractic education is to foster student professional confidence and competence in patient communication and clinical skills. Therefore, the aim of this article is to review the extant literature on this topic, stressing the significance of building students' confidence for effective practice and the need for more research in this area. METHODS: The authors reviewed MEDLINE and ERIC from 1980 through 2008 using several key words pertinent to confidence and health care. Three distinct, but interrelated, bodies of literature were assessed, including professional confidence in health care research, the nature and development of confidence in educational psychology research, and fostering professional confidence in chiropractic education. RESULTS: It was apparent through the review that chiropractic education has developed educational methods and opportunities that may help develop and build student confidence in patient communication and clinical skills. However, there has not been sufficient research to provide empirical evidence of the impact. CONCLUSION: Fostering chiropractic students' development of confidence in what they say and do is of paramount importance not only to them as new practitioners but more importantly to the patient. There is no doubt that a better understanding of how confidence can be developed and consolidated during tertiary study should be a major goal of chiropractic education.

Host susceptibility hypothesis for shell disease in American lobsters.

Epizootic shell disease (ESD) in American lobsters Homarus americanus is the bacterial degradation of the carapace resulting in extensive irregular, deep erosions. The disease is having a major impact on the health and mortality of some American lobster populations, and its effects are being transferred to the economics of the fishery. While the onset and progression of ESD in American lobsters is undoubtedly multifactorial, there is little understanding of the direct causality of this disease. The host susceptibility hypothesis developed here states that although numerous environmental and pathological factors may vary around a lobster, it is eventually the lobster's internal state that is permissive to or shields it from the final onset of the diseased state. To support the host susceptibility hypothesis, we conceptualized a model of shell disease onset and severity to allow further research on shell disease to progress from a structured model. The model states that shell disease onset will occur when the net cuticle degradation (bacterial degradation, decrease of host immune response to bacteria, natural wear, and resorption) is greater than the net deposition (growth, maintenance, and inflammatory response) of the shell. Furthermore, lesion severity depends on the extent to which cuticle degradation exceeds deposition. This model is consistent with natural observations of shell disease in American lobster.

Potential interactions between prescription drugs and complementary and alternative medicines among patients in the emergency department.

STUDY OBJECTIVE: To determine the nature and prevalence of potential interactions between prescription drugs and complementary and alternative medicines (CAMs) and the reasons some patients do not advise their physicians of CAM use. DESIGN: Cross-sectional survey. SETTING: The emergency department of the Royal Melbourne Hospital, a tertiary referral center. PATIENTS: Four hundred four adult patients (>or= 18 yrs) who visited the emergency department between February 1, 2002, and March 31, 2003. Intervention. A specifically designed, self-administered questionnaire, available in seven languages. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were the prevalence of potential prescription drug-CAM interactions and the reasons some patients do not advise their physicians of CAM use. Mean +/- SD patient age was 50.6 +/- 20.0 years; 220 patients were men (54.5%, 95% confidence interval [CI] 49.5-59.4%). When asked about use during the previous year, 275 patients (68.1%, 95% CI 63.2-72.5%) reported having taken a CAM; of these, 138 were also taking a prescription drug. We identified 15 documented potential drug-CAM interactions in nine patients (3.3% of CAM users, 95% CI 1.6-6.3%) and 97 theoretical potential drug-CAM interactions in 51 patients (18.6% of CAM users, 95% CI 14.2-23.8%). Aspirin and warfarin were the most commonly involved drugs. Of CAM users, 197 (71.6%, 95% CI 65.9-76.8%) never informed their physician about CAM use, most frequently because they were not asked. CONCLUSION: The prevalence of potential drug-CAM interactions among patients in the emergency department is considerable, and some of these interactions could be clinically significant. Practitioners should increase their awareness of potential drug-CAM interactions, and education initiatives aimed at encouraging patient-physician discussion of CAM use are recommended, such as a CAM history in their patient evaluation. Further research is required to better determine the clinical significance of drug-CAM interactions.