Observational study of the medical management of patients with peripheral artery disease.

BACKGROUND: Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification. METHODS: The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD. RESULTS: Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained. CONCLUSION: The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.

Systemic granulomatous disease in dairy cattle during a dicyandiamide feeding trial.

CASE HISTORY: Mature, in-calf, non-lactating, Friesian or Friesian-cross cows were fed dicyandiamide (DCD) at daily doses of 0.15 g/kg (Group 1; n=31), 0.45 g/kg (Group 2; n=21) and 0.75 g/kg (Group 3; n=12), as part of a safety trial, which also included a control group (n=15). Daily health observations were carried out on each cow until Day 86 of the study. On Day 28 one cow from Group 3 was observed with signs of disease, and subsequently disease was noted in other cows. CLINICAL FINDINGS: Clinical signs in the first case included depression, pyrexia (40.9°C), salivation and dehydration, in addition to progressive weight loss, followed by death on Day 32. Other cows from all treatment groups developed clinical signs of disease resulting in euthanasia of seven animals. Disease occurred in 10/12 (83%) cows in Group 3, 11/21 (52%) cows in Group 2, and 7/31 (23%) cows in Group 1. Clinical signs were variable and included dermatitis and pruritus of the head and neck, petechial haemorrhages, pyrexia, weight loss, thrombocytopenia, neutropenia, and regenerative anaemia. PATHOLOGICAL FINDINGS: Gross findings included generalised lymphadenopathy, subcutaneous oedema, petechiation of mucosal and serosal surfaces, and gastrointestinal haemorrhage. Histologically, multiple organs and tissues contained inflammatory foci characterised by infiltrates of lymphocytes, plasma cells, macrophages and occasionally prominent multinucleated giant cells and eosinophils. DIAGNOSIS: Multisystemic granulomatous and haemorrhagic syndrome resembling cell-mediated hypersensitivity, associated with DCD ingestion. CLINICAL RELEVANCE: This is the first report of toxicity in cattle associated with ingestion of DCD. The proportion of affected cows increased with increasing dose of DCD, but not all cattle in the high dose group developed disease, therefore additional factors may determine whether or not an individual cow will develop DCD-associated disease.

Design of a Multisite Study Assessing the Impact of Tic Disorders on Individuals, Families, and Communities.

BACKGROUND: Tic disorders, including Tourette syndrome, are complex, multisymptom diseases, yet the impact of these disorders on affected children, families, and communities is not well understood. METHODS: To improve the understanding of the impacts of Tourette syndrome, two research groups conducted independent cross-sectional studies using qualitative and quantitative measures. They focused on similar themes, but distinct scientific objectives, and the sites collaborated to align methods of independent research proposals with the aim of increasing the analyzable sample size. RESULTS: Site 1 (University of Rochester) was a Pediatric Neurology referral center. Site 2 (University of South Florida) was a Child Psychiatry referral center. A total of 205 children with tic disorders were enrolled from both studies. The University of Rochester also enrolled 100 control children in order to clearly isolate impacts of Tourette syndrome distinct from those occurring in the general population. The majority of children with tic disorders (n = 191, 93.1%) had Tourette syndrome, the primary population targeted for these studies. Children with Tourette syndrome were similar across sites in terms of tic severity and the occurrence of comorbid conditions. The occurrence of psychiatric comorbidities in the control group was comparable with that in the general pediatric population of the United States, making this a well-justified comparison group. CONCLUSIONS: Through collaboration, two sites conducting independent research developed convergent research methods to enable pooling of data, and by extension increased power, for future analyses. This method of collaboration is a novel model for future epidemiological research of tic disorders.

Reporting individual surgeon outcomes does not lead to risk aversion in abdominal aortic aneurysm surgery.

INTRODUCTION Reporting surgeons' outcomes has recently been introduced in the UK. This has the potential to result in surgeons becoming risk averse. The aim of this study was to investigate whether reporting outcomes for abdominal aortic aneurysm (AAA) surgery impacts on the number and risk profile (level of fitness) of patients offered elective treatment. METHODS Publically available National Vascular Registry data were used to compare the number of AAAs treated in those centres across the UK that reported outcomes for the periods 2008-2012, 2009-2013 and 2010-2014. Furthermore, the number and characteristics of patients referred for consideration of elective AAA repair at a single tertiary unit were analysed yearly between 2010 and 2014. Clinic, casualty and theatre event codes were searched to obtain all AAAs treated. The results of cardiopulmonary exercise testing (CPET) were assessed. RESULTS For the 85 centres that reported outcomes in all three five-year periods, the median number of AAAs treated per unit increased between the periods 2008-2012 and 2010-2014 from 192 to 214 per year (p=0.006). In the single centre cohort study, the proportion of patients offered elective AAA repair increased from 74% in 2009-2010 to 81% in 2013-2014, with a maximum of 84% in 2012-2013. The age, aneurysm size and CPET results (anaerobic threshold levels) for those eventually offered elective treatment did not differ significantly between 2010 and 2014. CONCLUSIONS The results do not support the assumption that reporting individual surgeon outcomes is associated with a risk averse strategy regarding patient selection in aneurysm surgery at present.

Acute Neurological Illness in a Kidney Transplant Recipient Following Infection With Enterovirus-D68: An Emerging Infection?

We report the first case of enterovirus-D68 infection in an adult living-donor kidney transplant recipient who developed rapidly progressive bulbar weakness and acute flaccid limb paralysis following an upper respiratory infection. We present a 45-year-old gentleman who underwent pre-emptive living-donor kidney transplantation for IgA nephropathy. Eight weeks following transplantation, he developed an acute respiratory illness from enterovirus/rhinovirus that was detectable in nasopharyngeal (NP) swabs. Within 24 h of onset of respiratory symptoms, the patient developed binocular diplopia which rapidly progressed to multiple cranial nerve dysfunctions (acute bulbar syndrome) over the next 24 h. Within the next 48 h, asymmetric flaccid paralysis of the left arm and urinary retention developed. While his neurological symptoms were evolving, the Centers for Disease Control reported that the enterovirus strain from the NP swabs was, in fact, Enterovirus-D68 (EV-D68). Magnetic resonance imaging of the brain demonstrated unique gray matter and anterior horn cell changes in the midbrain and spinal cord, respectively. Constellation of these neurological symptoms and signs was suggestive for postinfectious encephalomyelitis (acute disseminated encephalomyelitis [ADEM]) from EV-D68. Treatment based on the principles of ADEM included intensive physical therapy and other supportive measures, which resulted in a steady albeit slow improvement in his left arm and bulbar weakness, while maintaining stable allograft function.

Fatty acid profile differs between organic and conventionally produced cow milk independent of season or milking time.

Differing amounts of fresh forage and concentrates fed, and level of input contributes to the differences reported in fatty acid (FA) composition of organic and conventionally produced cow milk. In many previous studies designed to investigate this phenomenon, comparisons were made between grazed organic cows and housed conventional cows. In the present study, we have investigated differences between organic and conventional milk produced using year-round pasture grazing, as practiced in New Zealand. The FA composition was determined in milk sampled at morning and evening milking in both spring and autumn. Samples were taken from 45 cows from the Massey University organic herd and compared with 50 cows from the corresponding conventional herd grazed and managed similarly at the same location. Forty-three out of 51 analyzed FA were influenced by season, whereas 28 were different between production systems. In addition, one-half were also different due to time of milking. Levels of linoleic acid and α-linolenic acid were higher in organic milk, whereas conjugated linoleic acid (CLA) and vaccenic acid were higher in conventional milk. The first 3 FA (linoleic acid, α-linolenic acid, and CLA) were more abundant in milk harvested during autumn, and the CLA concentration was also significantly influenced by time of milking. Our results confirm reports that the FA profile is affected by season and time of milking, and we also showed an effect due to the production system, when both sets of cows were kept continuously on pasture, even after taking milking time and seasonal effect into account.

Ergonomics issues among sewing machine operators in the textile manufacturing industry in Botswana.

UNLABELLED: Universally musculoskeletal disorders are among the leading causes of low productivity in today's work environment. The situation is reportedly even worse in developing countries with appalling working conditions in many industries. In addition, there is often an acute lack of awareness of ergonomics issues, education and training programmes, and certification within developing countries. Numerous studies internationally have highlighted musculoskeletal risk factors associated with the textile industry and garment-making jobs because of highly repetitive work in awkward work postures. OBJECTIVE: The objective of this study was to identify and describe possible ergonomics deficiencies in the workstation of sewing machine operators in a textile industry in Botswana as well as their perception of workload and bodily discomfort. PARTICIPANTS: This study focused on one textile manufacturing factory in Botswana where 157 female sewing machine operators were recruited as participants. METHODS: A modified Corlett and Bishop body map questionnaire and the NASA TLX were administered and relevant anthropometric and workplace layout measurements were collected. RESULTS: The results of the study revealed a high prevalence of musculoskeletal disorders. CONCLUSIONS: Back, neck and shoulder discomfort are highly prevalent among these sewing machine operators. This study proposes intervention strategies including the re-design of the workstations and seating and the provision of training in basic ergonomics principles for improving the work-life of these operators and provides a base for further research on the prevalence of musculoskeletal disorders among sewing machine operators in developing countries.

The compression of deaths above the mode.

Kannisto (2001) has shown that as the frequency distribution of ages at death has shifted to the right, the age distribution of deaths above the modal age has become more compressed. In order to further investigate this old-age mortality compression, we adopt the simple logistic model with two parameters, which is known to fit data on old-age mortality well (Thatcher 1999). Based on the model, we show that three key measures of old-age mortality (the modal age of adult deaths, the life expectancy at the modal age, and the standard deviation of ages at death above the mode) can be estimated fairly accurately from death rates at only two suitably chosen high ages (70 and 90 in this study). The distribution of deaths above the modal age becomes compressed when the logits of death rates fall more at the lower age than at the higher age. Our analysis of mortality time series in six countries, using the logistic model, endorsed Kannisto's conclusion. Some possible reasons for the compression are discussed.

Isolation of Mycoplasma bovis from bovine clinical mastitis cases in Northern Greece.

Mycoplasma bovis was detected in 18/219 (8.2%) quarter milk samples collected from cases of bovine clinical mastitis in Northern Greece between November 1997 and March 1999. The cases occurred in 2/37 (5.4%) of the herds examined. The micro-organism was isolated from bulk milk samples (BTS) from the two positive herds but was not isolated from 111 composite milk samples collected from clinically healthy cows from all 37 herds. Isolates were identified as M. bovis by polymerase chain reaction (PCR) assay. Other micro-organisms were also isolated from the M. bovis positive samples. The M. bovis-positive cows had all been imported into Greece from other European countries.

The long-term pattern of adult mortality and the highest attained age.

"Recent new data on old age mortality point to a particular model for the way in which the probability of dying increases with age. The model is found to fit not only modern data but also some widely spaced historical data for the 19th and 17th centuries, and even some estimates for the early mediaeval period. The results show a pattern which calls for explanation. The model can also be used to predict a probability distribution for the highest age which will be attained in given circumstances. The results are relevant to the current debate about whether there is a fixed upper limit to the length of human life." A discussion of the paper by several researchers and a reply by the author are included.

All-trans beta-carotene is absorbed preferentially to 9-cis beta-carotene, but the latter accumulates in the tissues of domestic ferrets (Mustela putorius puro).

The algae Dunaliella bardawil and Dunaliella salina naturally contain large concentrations of all-trans and 9-cis beta-carotene (betaC). The purpose of this study was to compare the relative serum and tissue accumulation of all-trans and 9-cis betaC in ferrets fed different ratios of all-trans/9-cis betaC derived from two commercial sources, D. bardawil or D. salina (Betatene). Male ferrets (7 wk old) were fed carotene-free, pelleted diets for 27 d. Beginning on d 18, groups of ferrets (n = 6 or 7) received daily, one of six oral supplements varying in ratios of 9-cis and all-trans betaC mixed with approximately 1.0mL of Ensure. Four supplements containing 5.2-8.3 micromol total betaC were prepared from a 20% Betatene preparation, D. bardawil, a high-cis Betatene preparation, and Betatene further enriched in 9-cis betaC with all-trans betaC/9-cis betaC ratios of 2.2, 1.5, 0.6 and 0.4, respectively. Two control supplements, high and low betaC, were prepared from commercial betaC beadlets. The high control supplement had an all-trans/9-cis ratio of 19.0, whereas 9-cis betaC was not detected in the low supplement. On d 27, serum and tissues were obtained for HPLC analysis of betaC and its isomers. Analysis of livers showed that all-trans betaC was the primary isomer present, but 9-cis and other isomers were also detected in all groups. The hepatic all-trans/9-cis ratios were 5.9, 4.9, 2.5, 1.4, 52.2 and47.5, respectively, for the groups listed above. Lower amounts of all-trans and 9-cis betaC were found in kidneys compared with the liver, but ratios of all-trans/9-cis were not different among groups. Only trace amounts of 9-cis betaC were found in serum. These results demonstrate that the algae D. bardawil and D. salina provide a bioavailable source of betaC isomers, but, as in humans, absorption of 9-cis betaC is poor and any 9-cis betaC absorbed is apparently cleared by the liver.

Tissue stores of beta-carotene are not conserved for later use as a source of vitamin A during compromised vitamin A status in mongolian gerbils (Meriones unguiculatus).

Vitamin A (VA) deficiency remains a serious problem in the world today. Current approaches to preventing or treating VA deficiency, including dietary intervention with provitamin A compounds, rely on the body converting ingested beta-carotene (betaC) to VA. However, it is not known whether betaC that is already in the tissues can be used as a source of VA to prevent deficiency. The objectives of these studies were to determine whether tissue betaC stores are converted to VA when the Mongolian gerbils have low VA status and whether previously fed betaC is retained in the tissues for later conversion to VA. In the first study, gerbils were prefed diets with betaC (20.3 +/- 6.2 nmol/g diet) (+betaC) or without betaC (-betaC), and with VA [2.4 +/- 1.5 nmol/g diet (+betaC diet) or 12.0 +/- 4.2 nmol/g diet (-betaC diet)] for 7 d, and then depleted of both betaC and VA for up to 84 d. On d 0 after the prefeeding period, hepatic betaC stores were 13.3 +/- 9.1 nmol. These stores were significantly lower after 28d of consuming the -VA/-betaC diet (2.16 +/- 1.7 nmol), even though the hepatic VA concentrations did not change. In the second study, the gerbils were prefed a -VA/+betaC diet (74.3 +/- 19. 7 nmol betaC/g diet) for 7 d, and then fed a betaC-free diet either with (7.1 +/- 1.4 nmol/g) or without VA for up to 34 d. Hepatic betaC stores after the 7-d prefeeding period were 38.1 +/- 20.6 nmol, and were significantly higher than after 7d of consuming either a +VA/-betaC (12.4 +/- 10.8 mmol) or -VA/-betaC diet (11.4 +/- 8.0 nmol). The results from both studies suggest that a substantial amount of hepatic betaC is rapidly lost when betaC is eliminated from the diet and therefore is not conserved to meet later VA needs. The presence of VA in the diet (Study 2) did not affect the rate of betaC loss from the serum and tissues. Moreover, no evidence was found that the stored betaC was utilized for VA. The data suggest that there may be two pools of hepatic betaC, one that is lost rapidly and another that is lost more slowly over time, but losses are not affected by VA status.

Bayesian diagnostic probabilities without assuming independence of symptoms.

The paper describes an application of Bayes' Theorem to the problem of estimating from past data the probabilities that patients have certain diseases, given their symptoms. The data consist of hospital records of patients who suffered acute abdominal pain. For each patient the records showed a large number of symptoms and the final diagnosis to one of nine diseases or diagnostic groups. Most current methods of computer diagnosis use the "Simple Bayes" model in which the symptoms are assumed to be independent, but the present paper does not make this assumption. Those symptoms (or lack of symptoms) which are most relevant to the diagnosis of each disease are identified by a sequence of chi-squared tests. The computer diagnoses obtained as a result of the implementation of this approach are compared with those given by the "Simple Bayes" method, by the method of classification trees (CART), and also with the preliminary and final diagnoses made by physicians.

Use of the SADS diagnostic interview in evaluating legal insanity.

Examined clinical usefulness of the SADS diagnostic interview in evaluations of criminal responsibility. Findings, based on 78 SADS evaluations from a specialized forensic clinic, indicated that SADS successfully differentiated between sane and insane evaluatees. These differences were found primilarily in the severity of psychotic symptoms and overall level of psychological impairment. In addition, preliminary data on institutionalized and outpatient Ss suggested the potential applicability of the SADS for assessing the general psychological functioning of insane patients in treatment.

Sulfide solubilities in alteration-controlled systems.

Solubilities of sphalerite (ZnS) and galena (PbS) were determined at 300 degrees to 500 degrees C and 1000 bars total pressure in a chemical environment buffered by silicate mineral equilibria. Chloride solutions and muscovite-bearing assemblages characteristic of hydrothermal wall-rock alteration were used; weak acidities at temperature were therefore involved. The metal concentrations encountered tended to be higher than those observed in high bisulfide-H(2)S systems at neutral to weakly basic pH used in most previous experimentation; the chemical conditions of the work, although not completely satisfactory, are geologically more realistic than previous experimentation done in the basic-pH region.