Effect of water sulfate and dietary bismuth subsalicylate on feed and water intake, ruminal hydrogen sulfide concentration, and trace-mineral status of growing beef heifers.

In the Northern Great Plains, cattle may be exposed to water with an elevated sulfate concentration resulting in ruminal hydrogen sulfide (H2S) production and risk of copper deficiency. There are currently few strategies available to help mitigate effects arising from high-sulfate water (HS). The objective of this study was to evaluate the effects of feeding a moderate-forage diet with or without bismuth subsalicylate (BSS; 0.0% vs. 0.4% DM basis) when provided water with a low- (LS; 346 ±â€…13) or HS (4,778 ±â€…263 mg/L) concentration on feed and water intake, ruminal H2S concentration, and liver and serum trace-mineral concentrations. Twenty-four Limousin × Simmental cross beef heifers (221 ±â€…41 kg) were stratified based on initial liver Cu into a completely randomized block design with a 2 × 2 factorial treatment arrangement. Feed and water intake (measured weekly), ruminal H2S concentration (measured on days 42 and 91), liver (measured on days -13 and 91), and serum trace-mineral concentrations (measured on days 1, 28, 56, and 91) were evaluated. Initial liver trace-mineral concentrations were used as a covariate in the statistical model. Water intake tended to be reduced with the inclusion of BSS (P = 0.095) but was not affected by water sulfate (P = 0.40). Water sulfate and BSS did not affect dry matter intake (DMI; P ≥ 0.89). Heifers consuming HS had a ruminal H2S concentration that was 1.58 mg/L more (P < 0.001) than LS. The inclusion of BSS reduced (P = 0.035) ruminal H2S concentration by more than 44% (1.35 vs. 0.75 mg/L). Regardless of the water sulfate concentration, heifers fed BSS had lesser liver Cu concentration (average of 4.08 mg/kg) than heifers not provided BSS, and when not provided BSS, HS had lesser Cu than LS (42.2 vs. 58.3; sulfate × BSS, P = 0.019). The serum concentration of Cu did not differ over time for heifers not provided BSS; whereas, heifers provided BSS had lesser serum Cu concentration on day 91 than on days 28 and 55 (BSS × time, P < 0.001). The liver concentration of selenium was reduced (P < 0.001) with BSS inclusion but the selenium concentration in serum was not affected by sulfate, BSS, or time (P ≥ 0.16). BSS reduced ruminal H2S concentration, but depleted liver Cu and Se. Moreover, sulfate concentration in water did not appear to affect DMI, water intake, or growth, but increased ruminal H2S and reduced liver Cu concentration.

Water containing a high concentration of sulfate increases the risk of hydrogen sulfide production in the rumen and consequently of polioencephalomalacia. In addition, water with a high-sulfate concentration may induce copper deficiency indicated by depleted liver copper concentration. Bismuth subsalicylate (BSS) can bind to sulfides and may reduce the risk of hydrogen sulfide production and therefore may mitigate risks associated with high-sulfate water. In this study, the effects of water sulfate concentrations (346 ±â€…13 vs. 4,778 ±â€…263 mg/L) were tested along with 0.0% vs. 0.4% of dietary BSS. Water intake tended to be reduced with the inclusion of BSS but was not affected by water sulfate. Water sulfate concentration and BSS did not affect dry matter intake (DMI). Heifers consuming high-sulfate water (HS) had a ruminal H2S concentration that was 1.58 mg/L more than low-sulfate water (LS). The inclusion of BSS reduced ruminal H2S concentration by 44% (1.35 vs. 0.75 mg/L). Regardless of the water sulfate concentration, heifers fed BSS had lesser liver Cu concentration than heifers not provided BSS, and when not provided BSS, HS had lesser Cu than LS. BSS reduced ruminal hydrogen sulfide concentration but depleted liver Cu. Sulfate concentration in water did not affect DMI, water intake, or growth, but increased ruminal hydrogen sulfide concentration and reduced liver Cu concentration.

The effect of general practice team composition and climate on staff and patient experiences: a systematic review.

BACKGROUND: Recent policy initiatives seeking to address the workforce crisis in general practice have promoted greater multidisciplinarity. Evidence is lacking on how changes in staffing and the relational climate in practice teams affect the experiences of staff and patients. AIM: To synthesise evidence on how the composition of the practice workforce and team climate affect staff job satisfaction and burnout, and the processes and quality of care for patients. DESIGN & SETTING: A systematic literature review of international evidence. METHOD: Four different searches were carried out using MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, and Web of Science. Evidence from English language articles from 2012-2022 was identified, with no restriction on study design. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and data were synthesised thematically. RESULTS: In total, 11 studies in primary healthcare settings were included, 10 from US integrated healthcare systems, one from Canada. Findings indicated that when teams are understaffed and work environments are stressful, patient care and staff wellbeing suffer. However, a good relational climate can buffer against burnout and protect patient care quality in situations of high workload. Good team dynamics and stable team membership are important for patient care coordination and job satisfaction. Female physicians are at greater risk of burnout. CONCLUSION: Evidence regarding team composition and team climate in relation to staff and patient outcomes in general practice remains limited. Challenges exist when drawing conclusions across different team compositions and definitions of team climate. Further research is needed to explore the conditions that generate a 'good' climate.

Total and pathogen-specific serum Immunoglobulin G concentrations in neonatal beef calves, Part 1: Risk factors.

Maternal antibodies, delivered to the calf via colostrum, are crucial to prevent calfhood diseases and death. However, knowledge regarding the factors influencing this transfer of total and specific Immunoglobulin G (IgG) against common enteric and respiratory disease pathogens under current production conditions is sparse. The objectives of this study were to determine risk factors influencing total and pathogen-specific immunoglobulin G (IgG) concentrations against Escherichia coli (E. coli), bovine Rotavirus (BRoV), Cryptosporidium parvum (C. parvum), Bovine Viral Diarrhea Virus type 1 and 2 (BVDV), Parainfluenza Virus Type 3 (PI-3), Bovine Respiratory Syncytial Virus (BRSV), and Bovine Herpesvirus type 1 (BHV-1) in the serum of newborn beef calves. A total of 420 serum samples were collected from 1- to 7-day-old beef calves born on 6 farms in Alberta, Canada. Samples were analyzed by radial immunodiffusion for total IgG concentration and by enzyme-linked immunosorbent assays for pathogen-specific IgG concentrations against E. coli, BRoV, C. parvum, BVDV, PI-3, BRSV, and BHV-1. Multivariable multilevel linear and logistic regression models were built to evaluate dam- and calf-level risk factors associated with total and pathogen-specific IgG concentrations, failed transfer of passive immunity (FTPI; serum IgG < 10 g/L), and inadequate transfer of passive immunity (ITPI; serum IgG < 24 g/L). Farm was included as a random effect in all models to account for clustering at the herd level. Of the 420 calves included in this study, 5% (n = 20) and 18% (n = 75) of calves had FTPI and ITPI, respectively. Receiving colostrum intervention (i.e., being fed colostrum or colostrum product by either bottle or tube) was the most consistent risk factor for low total IgG concentration and significantly increased the odds of FTPI (Odds ratio (OR): 6.1, 95% CI: 2.0-18.9) and ITPI (OR: 4.8, 95% CI: 2.1-10.8). Calves born to cows consistently had higher pathogen-specific IgG concentrations (P < 0.0001), compared to calves born from heifers, and calves born to vaccinated dams had significantly higher BRoV, BVDV, and BHV-1-specific IgG concentrations. Interestingly, E.coli-specific IgG concentrations were associated with dam vaccination only in cows but not in heifers, which was likely due to differing vaccination strategies used. This study highlights the need to review and refine protocols with respect to dam vaccination and colostrum intervention on cow-calf operations.

Leptin receptor neurons in the dorsomedial hypothalamus input to the circadian feeding network.

Salient cues, such as the rising sun or availability of food, entrain biological clocks for behavioral adaptation. The mechanisms underlying entrainment to food availability remain elusive. Using single-nucleus RNA sequencing during scheduled feeding, we identified a dorsomedial hypothalamus leptin receptor-expressing (DMHLepR) neuron population that up-regulates circadian entrainment genes and exhibits calcium activity before an anticipated meal. Exogenous leptin, silencing, or chemogenetic stimulation of DMHLepR neurons disrupts the development of molecular and behavioral food entrainment. Repetitive DMHLepR neuron activation leads to the partitioning of a secondary bout of circadian locomotor activity that is in phase with the stimulation and dependent on an intact suprachiasmatic nucleus (SCN). Last, we found a DMHLepR neuron subpopulation that projects to the SCN with the capacity to influence the phase of the circadian clock. This direct DMHLepR-SCN connection is well situated to integrate the metabolic and circadian systems, facilitating mealtime anticipation.

Update on copper and selenium in Canadian cow-calf herds: regional differences and estimation of serum reference values.

Trace mineral supplementation of beef cattle is essential for efficient reproduction and herd health. Understanding regional differences in cow trace mineral status could inform decisions about risks of deficiencies and supplementation management. Cow-calf surveillance projects provided three opportunities to evaluate the trace mineral status of Canadian beef cow herds. Blood samples were collected at pregnancy testing in 2014 from 102 cow-calf herds and in 2016 from 86 cow-calf herds in Western Canada. In 2019, blood samples were collected at pregnancy testing from cows in 163 cow-calf herds from Eastern and Western Canada. Serum samples were analyzed for copper, selenium, and molybdenum concentrations using a plasma mass spectrometer. The prevalence of copper deficient cows sampled from the Western provinces ranged from 24% to 43% across the three periods, and was 20% from Eastern Canada in 2019. The prevalence of selenium deficient cows ranged from 0.2% to 0.4% across the three projects in Western Canada, but was higher in Eastern Canada at 4.6% in 2019. High serum molybdenum was identified in 9.4% to 14% of cows across the three periods in Western Canada and in 15% of cows sampled in Eastern Canada in 2019. Serum copper, selenium, and molybdenum concentrations varied by cow age and month of sample collection. Serum selenium and molybdenum concentrations, but not copper, varied by soil type associated with the location of the farm. A subsample of samples from cows from Western Canadian herds provided body condition score (BCS) data, pregnancy status, and calf survival data and were used to estimate updated serum reference values for adequate concentrations. Age-specific values were required for selenium and molybdenum. Reference intervals (80%) were estimated from 2,406 pregnant beef cows from 99 herds with each cow having a BCS ≥ 2.5/5 and a live calf at 3 wk with no retained placenta: copper for all cows (0.379 to 0.717 ppm), selenium for cows <4 yr (0.052 to 0.152 ppm), and selenium for cows ≥4 yr (0.064 to 0.184 ppm). Upper 90% reference limits were also estimated for serum molybdenum for cows <4 yr (>0.104 ppm) and cows ≥4 yr (>0.110 ppm). The lower limits for the reference intervals for adequate copper and selenium are below those previously reported; nevertheless, they represent a large sample that was specifically applicable to extensively managed beef animals in western Canada.

Preliminary Evaluation of an Osteopathic Manipulative Treatment to Prevent Motion Sickness.

INTRODUCTION: Motion sickness affecting military pilots and aircrew can impact flight safety and, if severe, can lead to disqualification from flight status. However, due to the common adverse effects of motion sickness pharmaceuticals (e.g., drowsiness), medication options are severely limited. The purpose of this study was to explore the potential utility of a nonpharmaceutical method for motion sickness prevention, specifically an osteopathic manipulative technique (OMT).METHODS:A novel OMT protocol for the reduction of motion sickness symptoms and severity was evaluated using a sham-controlled, counterbalanced, between-subjects study design. The independent variable was OMT treatment administered prior to the motion sickness-inducing procedure (rotating chair). The primary dependent measures were total and subscale scores from the Motion Sickness Assessment Questionnaire.RESULTS:The OMT treatment group experienced significantly fewer gastrointestinal (mean scores postprocedure, treatment M = 20.42, sham M = 41.67) and sopite-related (mean scores postprocedure, treatment M = 12.81, sham M = 20.68) symptoms than the sham group while controlling for motion sickness susceptibility. There were no differences between groups with respect to peripheral and central symptoms.DISCUSSION:The results suggest that the treatment may prevent gastrointestinal (nausea) and sopite-related symptoms (sleepiness). These preliminary findings support further exploration of OMT for the prevention of motion sickness. A more precise evaluation of the mechanism of action is needed. Additionally, the duration of the effects needs to be investigated to determine the usefulness of this technique in training and operational settings.Thomas VA, Kelley AM, Lee A, Fotopoulos T, Boggs J, Campbell J. Preliminary evaluation of an osteopathic manipulative treatment to prevent motion sickness. Aerosp Med Hum Perform. 2023; 94(12):934-938.

Sonic hedgehog-dependent recruitment of GABAergic interneurons into the developing visual thalamus.

Axons of retinal ganglion cells (RGCs) play critical roles in the development of inhibitory circuits in visual thalamus. We previously reported that RGC axons signal astrocytes to induce the expression of fibroblast growth factor 15 (FGF15), a motogen required for GABAergic interneuron migration into visual thalamus. However, how retinal axons induce thalamic astrocytes to generate Fgf15 and influence interneuron migration remains unknown. Here, we demonstrate that impairing RGC activity had little impact on interneuron recruitment into mouse visual thalamus. Instead, our data show that retinal-derived sonic hedgehog (SHH) is essential for interneuron recruitment. Specifically, we show that thalamus-projecting RGCs express SHH and thalamic astrocytes generate downstream components of SHH signaling. Deletion of RGC-derived SHH leads to a significant decrease in Fgf15 expression, as well as in the percentage of interneurons recruited into visual thalamus. Overall, our findings identify a morphogen-dependent neuron-astrocyte signaling mechanism essential for the migration of thalamic interneurons.

Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations.

BACKGROUND: Older patients with multiple health problems (multi-morbidity) value being involved in decision-making about their health care. However, they are less frequently involved than younger patients. To maximise quality of life, day-to-day function, and patient safety, older patients require support to identify unmet healthcare needs and to prioritise treatment options. OBJECTIVES: To assess the effects of interventions for older patients with multi-morbidity aiming to involve them in decision-making about their health care during primary care consultations. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; all years to August 2018), in the Cochrane Library; MEDLINE (OvidSP) (1966 to August 2018); Embase (OvidSP) (1988 to August 2018); PsycINFO (OvidSP) (1806 to August 2018); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid) (1982 to September 2008), then in Ebsco (2009 to August 2018); Centre for Reviews and Dissemination Databases (Database of Abstracts and Reviews of Effects (DARE)) (all years to August 2018); the Health Technology Assessment (HTA) Database (all years to August 2018); the Ongoing Reviews Database (all years to August 2018); and Dissertation Abstracts International (1861 to August 2018). SELECTION CRITERIA: We sought randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of interventions to involve patients in decision-making about their health care versus usual care/control/another intervention, for patients aged 65 years and older with multi-morbidity in primary care. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. Meta-analysis was not possible; therefore we prepared a narrative synthesis. MAIN RESULTS: We included three studies involving 1879 participants: two RCTs and one cluster-RCT. Interventions consisted of: · patient workshop and individual coaching using behaviour change techniques; · individual patient coaching utilising cognitive-behavioural therapy and motivational interviewing; and · holistic patient review, multi-disciplinary practitioner training, and organisational change. No studies reported the primary outcome 'patient involvement in decision-making' or the primary adverse outcome 'less patient involvement as a result of the intervention'. Comparing interventions (patient workshop and individual coaching, holistic patient review plus practitioner training, and organisational change) to usual care: we are uncertain whether interventions had any effect on patient reports of high self-rated health (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.36 to 5.49; very low-certainty evidence) or on patient enablement (mean difference (MD) 0.60, 95% CI -9.23 to 10.43; very low-certainty evidence) compared with usual care. Interventions probably had no effect on health-related quality of life (adjusted difference in means 0.00, 95% CI -0.02 to 0.02; moderate-certainty evidence) or on medication adherence (MD 0.06, 95% CI -0.05 to 0.17; moderate-certainty evidence) but probably improved the number of patients discussing their priorities (adjusted odds ratio 1.85, 95% CI 1.44 to 2.38; moderate-certainty evidence) and probably increased the number of nurse consultations (incident rate ratio from adjusted multi-level Poisson model 1.37, 95% CI 1.17 to 1.61; moderate-certainty evidence) compared with usual care. Practitioner outcomes were not measured. Interventions were not reported to adversely affect rates of participant death or anxiety, emergency department attendance, or hospital admission compared with usual care. Comparing interventions (patient workshop and coaching, individual patient coaching) to attention-control conditions: we are uncertain whether interventions affect patient-reported high self-rated health (RR 0.38, 95% CI 0.15 to 1.00, favouring attention control, with very low-certainty evidence; RR 2.17, 95% CI 0.85 to 5.52, favouring the intervention, with very low-certainty evidence). We are uncertain whether interventions affect patient enablement and engagement by increasing either patient activation (MD 1.20, 95% CI -8.21 to 10.61; very low-certainty evidence) or self-efficacy (MD 0.29, 95% CI -0.21 to 0.79; very low-certainty evidence); or whether interventions affect the number of general practice visits (MD 0.51, 95% CI -0.34 to 1.36; very low-certainty evidence), compared to attention-control conditions. The intervention may however lead to more patient-reported changes in management of their health conditions (RR 1.82, 95% CI 1.35 to 2.44; low-certainty evidence). Practitioner outcomes were not measured. Interventions were not reported to adversely affect emergency department attendance nor hospital admission when compared with attention control. Comparing one form of intervention with another: not measured. There was 'unclear' risk across studies for performance bias, detection bias, and reporting bias; however, no aspects were 'high' risk. Evidence was downgraded via GRADE, most often because of 'small sample size' and 'evidence from a single study'. AUTHORS' CONCLUSIONS: Limited available evidence does not allow a robust conclusion regarding the objectives of this review. Whilst patient involvement in decision-making is seen as a key mechanism for improving care, it is rarely examined as an intervention and was not measured by included studies. Consistency in design, analysis, and evaluation of interventions would enable a greater likelihood of robust conclusions in future reviews.

Level and source of fat in the diet of gestating beef cows: I. Effects on the prepartum performance of the dam and birth weight of the progeny1.

A 2-yr study was conducted to evaluate the effects of level and source of fat in the diet of gestating beef cows on their prepartum performance and birth weight of progeny. Each year, 75 multiparous (≥3 calving) pregnant Angus cows were stratified by BW (663 ± 21.5 kg) and BCS (2.6 ± 0.12; 1 to 5 scale) and randomly assigned to 1 of 15 outdoor pens. Subsequently, each pen was randomly assigned to 1 of 3 (n = 5) treatments: a low-fat diet (LF; 1.4 ± 0.12% EE) consisting of grass-legume hay, barley straw, and barley grain, or 1 of 2 high-fat diets (HF; 3.3 ± 0.20% EE) that included either a canola seed (CAN) or a flaxseed (FLX) based pelleted feed. Diets were formulated to meet the requirements of pregnant beef cows during the last 2 trimesters of gestation (0.183 ± 4.8 d), adjusted for changes in environmental conditions, and offered such that each pen on average received similar daily amounts of DE (31.2 ± 2.8 Mcal/cow), CP (1.36 ± 0.13 kg/cow), and DM (12.9 ± 1.0 kg/cow). Data were analyzed as a randomized complete block design with contrasts to separate the effects of level (LF vs. HF) and source (CAN vs. FLX) of fat. After 160 d on trial, conceptus corrected-BW (CC-BW) of LF cows (708 kg) and the proportion of overconditioned cows (13.2%) were greater (P ≤ 0.04) than those of HF, with no difference (P ≥ 0.84) between CAN and FLX for CC-BW (697 kg) and proportion of overconditioned cows (3.6% vs. 2.9%). Feeding FLX diet during gestation resulted in cows with a greater (P ≤ 0.01) concentration of conjugated linolenic acid (0.12% vs. 0.05%) and n-3 (0.58% vs. 0.37%) fatty acids, and a tendency (P = 0.09) for conjugated linoleic acid concentration (1.05% vs. 0.88%) to be greater in subcutaneous adipose tissue (SCAT) when compared with cows fed the CAN diet. By the end of gestation, serum NEFA concentration of LF cows (592 µEq/L) was lower (P < 0.01) than that of HF cows, and FLX cows had greater (P < 0.01) serum NEFA concentration than CAN cows (636 vs. 961 µEq/L). Cows receiving the LF diet during gestation gave birth to lighter (P < 0.01) calves compared with those receiving the HF diets (40.2 vs. 42.9 kg), with no difference (P = 0.24) between calves born to CAN (42.4 kg) and FLX (43.3 kg) cows. In conclusion, these results suggest a partitioning of the ME in pregnant beef cows that is dependent on the type of dietary energy, resulting in heavier calves at birth for cows fed high-fat diets. Also, the type of fatty acid in the diet of gestating beef cows affected the fatty acid profile in SCAT and serum NEFA concentration.

A rapidly acting glutamatergic ARC→PVH satiety circuit postsynaptically regulated by α-MSH.

Arcuate nucleus (ARC) neurons sense the fed or fasted state and regulate hunger. Agouti-related protein (AgRP) neurons in the ARC (ARCAgRP neurons) are stimulated by fasting and, once activated, they rapidly (within minutes) drive hunger. Pro-opiomelanocortin (ARCPOMC) neurons are viewed as the counterpoint to ARCAgRP neurons. They are regulated in an opposite fashion and decrease hunger. However, unlike ARCAgRP neurons, ARCPOMC neurons are extremely slow in affecting hunger (many hours). Thus, a temporally analogous, rapid ARC satiety pathway does not exist or is presently unidentified. Here we show that glutamate-releasing ARC neurons expressing oxytocin receptor, unlike ARCPOMC neurons, rapidly cause satiety when chemo- or optogenetically manipulated. These glutamatergic ARC projections synaptically converge with GABAergic ARCAgRP projections on melanocortin-4 receptor (MC4R)-expressing satiety neurons in the paraventricular hypothalamus (PVHMC4R neurons). Transmission across the ARCGlutamatergic→PVHMC4R synapse is potentiated by the ARCPOMC neuron-derived MC4R agonist, α-melanocyte stimulating hormone (α-MSH). This excitatory ARC→PVH satiety circuit, and its modulation by α-MSH, provides insight into regulation of hunger and satiety.

Acupuncture and related interventions for smoking cessation.

BACKGROUND: Acupuncture and related techniques are promoted as a treatment for smoking cessation in the belief that they may reduce nicotine withdrawal symptoms. OBJECTIVES: The objectives of this review are to determine the effectiveness of acupuncture and the related interventions of acupressure, laser therapy and electrostimulation in smoking cessation, in comparison with no intervention, sham treatment, or other interventions. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized Register (which includes trials of smoking cessation interventions identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO) and AMED in October 2013. We also searched four Chinese databases in September 2013: Sino-Med, China National Knowledge Infrastructure, Wanfang Data and VIP. SELECTION CRITERIA: Randomized trials comparing a form of acupuncture, acupressure, laser therapy or electrostimulation with either no intervention, sham treatment or another intervention for smoking cessation. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate on the type of smokers recruited, the nature of the intervention and control procedures, the outcome measures, method of randomization, and completeness of follow-up.We assessed abstinence from smoking at the earliest time-point (before six weeks) and at the last measurement point between six months and one year. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Those lost to follow-up were counted as continuing smokers. Where appropriate, we performed meta-analysis pooling risk ratios using a fixed-effect model. MAIN RESULTS: We included 38 studies. Based on three studies, acupuncture was not shown to be more effective than a waiting list control for long-term abstinence, with wide confidence intervals and evidence of heterogeneity (n = 393, risk ratio [RR] 1.79, 95% confidence interval [CI] 0.98 to 3.28, I² = 57%). Compared with sham acupuncture, the RR for the short-term effect of acupuncture was 1.22 (95% CI 1.08 to 1.38), and for the long-term effect was 1.10 (95% CI 0.86 to 1.40). The studies were not judged to be free from bias, and there was evidence of funnel plot asymmetry with larger studies showing smaller effects. The heterogeneity between studies was not explained by the technique used. Acupuncture was less effective than nicotine replacement therapy (NRT). There was no evidence that acupuncture is superior to psychological interventions in the short- or long-term. There is limited evidence that acupressure is superior to sham acupressure for short-term outcomes (3 trials, n = 325, RR 2.54, 95% CI 1.27 to 5.08), but no trials reported long-term effects, The pooled estimate for studies testing an intervention that included continuous auricular stimulation suggested a short-term benefit compared to sham stimulation (14 trials, n = 1155, RR 1.69, 95% CI 1.32 to 2.16); subgroup analysis showed an effect for continuous acupressure (7 studies, n = 496, RR 2.73, 95% CI 1.78 to 4.18) but not acupuncture with indwelling needles (6 studies, n = 659, RR 1.24, 95% CI 0.91 to 1.69). At longer follow-up the CIs did not exclude no effect (5 trials, n = 570, RR 1.47, 95% CI 0.79 to 2.74). The evidence from two trials using laser stimulation was inconsistent and could not be combined. The combined evidence on electrostimulation suggests it is not superior to sham electrostimulation (short-term abstinence: 6 trials, n = 634, RR 1.13, 95% CI 0.87 to 1.46; long-term abstinence: 2 trials, n = 405, RR 0.87, 95% CI 0.61 to 1.23). AUTHORS' CONCLUSIONS: Although pooled estimates suggest possible short-term effects there is no consistent, bias-free evidence that acupuncture, acupressure, or laser therapy have a sustained benefit on smoking cessation for six months or more. However, lack of evidence and methodological problems mean that no firm conclusions can be drawn. Electrostimulation is not effective for smoking cessation. Well-designed research into acupuncture, acupressure and laser stimulation is justified since these are popular interventions and safe when correctly applied, though these interventions alone are likely to be less effective than evidence-based interventions.

Tibiotalocalcaneal arthrodesis with bulk femoral head allograft for salvage of large defects in the ankle.

BACKGROUND: Tibiotalocalcaneal arthrodesis in patients with large segmental bony defects presents a substantial challenge to successful reconstruction. These defects typically occur following failed total ankle replacement, avascular necrosis of the talus, trauma, osteomyelitis, Charcot, or failed reconstructive surgery. This study examined the outcomes of tibiotalocalcaneal (TTC) arthrodesis using bulk femoral head allograft to fill this defect. METHODS: Thirty-two patients underwent TTC arthrodesis with bulk femoral head allograft. Patients who demonstrated radiographic union were contacted for SF-12 clinical scoring and repeat radiographs. Patients with asymptomatic nonunions were also contacted for SF-12 scoring alone. Preoperative, intraoperative, and postoperative factors were analyzed to determine positive predictors for successful fusion. RESULTS: Sixteen patients healed their fusion (50% fusion rate). Diabetes mellitus was found to be the only predictive factor of outcome; all 9 patients with diabetes developed a nonunion. In this series, 19% of the patients went on to require a below-knee amputation. CONCLUSIONS: Although the radiographic fusion rate was low, when the 7 patients who had an asymptomatic nonunion were combined with the radiographic union group, the overall rate of functional limb salvage rose to 71%. TTC arthrodesis using femoral head allograft should be considered a salvage procedure that is technically difficult and carries a high risk for complications. Patients with diabetes mellitus are at an especially high risk for nonunion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Non-mydriatic single-field fundus photography for the screening of retinal diseases in an executive health clinic.

BACKGROUND AND OBJECTIVE: To determine the accuracy and sensitivity of a single-field non-mydriatic digital fundus image interpreted by an ophthalmologist and performed within a primary care setting. PATIENTS AND METHODS: Fundus photography using a digital non-mydriatic camera was performed on both eyes of 1,175 consecutive patients as part of an executive health program. All fundus images included a 45° field of the posterior pole capturing the optic nerve and macular area. Diagnostic findings were recorded and appropriate recommendations for follow-up were made. Patients were then contacted to see whether appropriate follow-up was successfully completed and chart reviews were performed to determine biomicroscopic findings. RESULTS: Photographs were adequate in both eyes in 1,117 patients (95.1%). Examination findings were normal in both eyes in 951 (85.1%) patients. Abnormal findings were noted in either eye in 166 (14.9%) patients. The most common abnormal findings were macular degeneration (57/166, 34.3%), optic nerve cupping (45/166, 27.1%), hypertensive retinopathy (15/166, 9.0%), and choroidal nevi (10/166, 6.0%). In all patients with abnormal findings, routine follow-up ophthalmologic examination with an eye care specialist was indicated and none of the patients required urgent attention. Sensitivity was found to be 87% and stratification was performed based on the initial diagnosis. False-positive results were from confounding diagnoses rather than true false-positives. CONCLUSION: Single-field non-mydriatic fundus photography is accurate and sensitive for screening retinal disease in a primary care setting.

Acupuncture and related interventions for smoking cessation.

BACKGROUND: Acupuncture and related techniques are promoted as a treatment for smoking cessation in the belief that they may reduce nicotine withdrawal symptoms. OBJECTIVES: The objectives of this review are to determine the effectiveness of acupuncture and the related interventions of acupressure, laser therapy and electrostimulation in smoking cessation, in comparison with no intervention, sham treatment, or other interventions. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group specialized register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, BIOSIS Previews, PsycINFO, Science Citation Index, AMED, Acubriefs in November 2010; and four Chinese databases: Chinese Biomedical Database, China National Knowledge Infrastructure, Wanfang Data and VIP in November 2010. SELECTION CRITERIA: Randomized trials comparing a form of acupuncture, acupressure, laser therapy or electrostimulation with either no intervention, sham treatment or another intervention for smoking cessation. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate on the type of smokers recruited, the nature of the intervention and control procedures, the outcome measures, method of randomization, and completeness of follow up.We assessed abstinence from smoking at the earliest time-point (before six weeks), and at the last measurement point between six months and one year. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Those lost to follow up were counted as continuing smokers. Where appropriate, we performed meta-analysis using a fixed-effect model. MAIN RESULTS: We included 33 reports of studies. Compared with sham acupuncture, the fixed-effect risk ratio (RR) for the short-term effect of acupuncture was 1.18 (95% confidence interval 1.03 to 1.34), and for the long-term effect was 1.05 (CI 0.82 to 1.35). The studies were not judged to be free from bias. Acupuncture was less effective than nicotine replacement therapy (NRT). There was no evidence that acupuncture is superior to waiting list, nor to psychological interventions in short- or long-term. The evidence on acupressure and laser stimulation was insufficient and could not be combined. The evidence suggested that electrostimulation is not superior to sham electrostimulation. AUTHORS' CONCLUSIONS: There is no consistent, bias-free evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but lack of evidence and methodological problems mean that no firm conclusions can be drawn. Further, well designed research into acupuncture, acupressure and laser stimulation is justified since these are popular interventions and safe when correctly applied, though these interventions alone are likely to be less effective than evidence-based interventions.

Myofascial trigger point needling for whiplash associated pain--a feasibility study.

Clinicians claim that myofascial trigger points (MTrPs) are a primary cause of pain in whiplash injured patients. Pain from MTrPs is often treated by needling, with or without injection. We conducted a placebo controlled study to test the feasibility of a phase III randomised controlled trial investigating the efficacy of MTrP needling in patients with whiplash associated pain. Forty-one patients referred for physiotherapy with a recent whiplash injury, were recruited. Patients were randomised to receive standardised physiotherapy plus either acupuncture or a sham needle control. A trial was judged feasible if: i) the majority of eligible patients were willing to participate; ii) the majority of patients had MTrPs; iii) at least 75% of patients provided completed self-assessment data; iv) no serious adverse events were reported and v) the end of treatment attrition rate was less than 20%. 70% of those patients eligible to participate volunteered to do so; all participants had clinically identified MTrPs; a 100% completion rate was achieved for recorded self-assessment data; no serious adverse events were reported as a result of either intervention; and the end of treatment attrition rate was 17%. A phase III study is both feasible and clinically relevant. This study is currently being planned.

British pain clinic practitioners' recognition and use of the bio-psychosocial pain management model for patients when physical interventions are ineffective or inappropriate: results of a qualitative study.

BACKGROUND: To explore how chronic musculoskeletal pain is managed in multidisciplinary pain clinics for patients for whom physical interventions are inappropriate or ineffective. METHODS: A qualitative study was undertaken using semi-structured interviews with twenty five members of the pain management team drawn from seven pain clinics and one pain management unit located across the UK. RESULTS: All clinics reported using a multidisciplinary bio-psychosocial model. However the chronic pain management strategy actually focussed on psychological approaches in preference to physical approaches. These approaches were utilised by all practitioners irrespective of their discipline. Consideration of social elements such as access to social support networks to support patients in managing their chronic pain was conspicuously absent from the approaches used. CONCLUSION: Pain clinic practitioners readily embraced cognitive/behavioural based management strategies but relatively little consideration to the impact social factors played in managing chronic pain was reported. Consequently multidisciplinary pain clinics espousing a bio-psychosocial model of pain management may not be achieving their maximum potential.

Expression of Vibrio harveyi acyl-ACP synthetase allows efficient entry of exogenous fatty acids into the Escherichia coli fatty acid and lipid A synthetic pathways.

Although the Escherichia coli fatty acid synthesis (FAS) pathway is the best studied type II fatty acid synthesis system, a major experimental limitation has been the inability to feed intermediates into the pathway in vivo because exogenously supplied free fatty acids are not efficiently converted to the acyl-acyl carrier protein (ACP) thioesters required by the pathway. We report that expression of Vibrio harveyi acyl-ACP synthetase (AasS), a soluble cytosolic enzyme that ligates free fatty acids to ACP to form acyl-ACPs, allows exogenous fatty acids to enter the E. coli fatty acid synthesis pathway. The free fatty acids are incorporated intact and can be elongated or directly incorporated into complex lipids by acyltransferases specific for acyl-ACPs. Moreover, expression of AasS strains and supplementation with the appropriate fatty acid restored growth to E. coli mutant strains that lack essential fatty acid synthesis enzymes. Thus, this strategy provides a new tool for circumventing the loss of enzymes essential for FAS function.

Developing and validating a sham acupuncture needle.

OBJECTIVES: to develop a sham needle device and test its credibility as a control for acupuncture when used in a randomised controlled trial of myofascial trigger point needling in patients with whiplash associated pain. METHODS: sham needles were developed by blunting true acupuncture needles. Whiplash injured patients (<16 weeks duration) were randomly allocated to receive either true acupuncture or the "placebo" sham needle control. The true and sham needling interventions were delivered using the same standardised procedure. Patients were informed that they would receive either real or placebo needles, and asked (i) to state which treatment they believed they had received (treatment belief); (ii) to complete the four item Borkovec and Nau self-assessment credibility scale. Results were compared between groups and the analysis explored whether a patient's previous experience of acupuncture was related to their treatment belief. Other outcomes of the study will be reported elsewhere. RESULTS: 20 patients received the true acupuncture and 21 received the sham. There was no significant difference between the treatment beliefs of the two groups (chi(2) = 1.51; p>0.2) nor in the mean item scores on the Borkovec and Nau credibility scale (t test, p values ranged from 0.38 to 0.87). Of the patients in the sham acupuncture group who had previous experience of acupuncture, none recorded receiving the sham intervention. CONCLUSION: within the context of this pilot study, the sham acupuncture intervention was found to be a credible control for acupuncture. This supports its use in a planned, definitive, randomised controlled trial on a similar whiplash injured population.