Tissue characterization of acute lesions during cardiac magnetic resonance-guided ablation of cavo-tricuspid isthmus-dependent atrial flutter: a feasibility study.

AIMS: To characterize acute lesions during cardiac magnetic resonance (CMR)-guided radiofrequency (RF) ablation of cavo-tricuspid isthmus (CTI)-dependent atrial flutter by combining T2-weighted imaging (T2WI), T1 mapping, first-pass perfusion, and late gadolinium enhancement (LGE) imaging. CMR-guided catheter ablation offers a unique opportunity to investigate acute ablation lesions. Until present, studies only used T2WI and LGE CMR to assess acute lesions. METHODS AND RESULTS: Fifteen patients with CTI-dependent atrial flutter scheduled for CMR-guided RF ablation were prospectively enrolled. Directly after achieving bidirectional block of the CTI line, CMR imaging was performed using: T2WI (n = 15), T1 mapping (n = 10), first-pass perfusion (n = 12), and LGE (n = 12) imaging. In case of acute reconnection, additional RF ablation was performed. In all patients, T2WI demonstrated oedema in the ablation region. Right atrial T1 mapping was feasible and could be analysed with a high inter-observer agreement (r = 0.931, ICC 0.921). The increase in T1 values post-ablation was significantly lower in regions showing acute reconnection compared with regions without reconnection [37 ± 90 ms vs. 115 ± 69 ms (P = 0.014), and 3.9 ± 9.0% vs. 11.1 ± 6.8% (P = 0.022)]. Perfusion defects were present in 12/12 patients. The LGE images demonstrated hyper-enhancement with a central area of hypo-enhancement in 12/12 patients. CONCLUSION: Tissue characterization of acute lesions during CMR-guided CTI-dependent atrial flutter ablation demonstrates oedema, perfusion defects, and necrosis with a core of microvascular damage. Right atrial T1 mapping is feasible, and may identify regions of acute reconnection that require additional RF ablation.

The performance of non-ECG gated chest CT for cardiac assessment - The cardiac pathologies in chest CT (CaPaCT) study.

PURPOSE: Evaluating the prevalence of CAD on non-ECG gated chest CTs, image quality (IQ) and the clinical performance of the CAD-RADS classification for predicting cardiovascular events (CVE). METHODS: 215 consecutive patients referred for chest CTs between May 2016 and March 2018 were included (3rd-generation DSCT) using non-ECG gated acquisitions with automated tube voltage selection (110kVqual.ref/40mAsqual.ref), pitch 2.65-3.0 and individualized contrast media injection protocols. Dedicated cardiac post-processing reconstructions (0.6 mm/0.4 mm/Kernel Bv36) were added to standard chest reconstructions. Two independent cardiac radiologists performed a 3-step analysis. In case of discrepancy, a third reader gave the final decision. Step 1: visual presence of calcifications; 2: scans with calcifications assessed for IQ using a 5-point Likert scale (poor/sufficient/moderate/good/excellent); 3: stenosis severity was analysed in detail (if Likert sufficient-excellent using CAD-RADS). Electronic patient files were checked to see if pathology was previously mentioned (incidental) and whether patients developed an CVE during follow-up. RESULTS: 1: Calcifications were present in 156/215 cases (72.6 %), 74 of these were incidental. 2: In 68/156 (43.6 %) patients with calcifications IQ was rated sufficient-excellent. 3: CAD-RADS≥3 was seen in 39/68 patients (57.4 %), 12 times (30.8 %) findings were incidental. During follow-up (median 16 [0-35] months), 7/39 (18 %) patients with CAD-RADS≥3 developed a CVE. 17 patients died during follow-up. CONCLUSION: Coronary calcification on non ECG-gated chest CTs was detected in 72.6 % of patients, cardiac assessment was feasible in nearly half of these patients. Only patients with a CAD-RADS≥3 developed CVE, therefore the CAD-RADS may help identify and guide patients at risk of future CVE.

Personalization of CM Injection Protocols in Coronary Computed Tomographic Angiography (People CT Trial).

Aim: To evaluate the performance of three contrast media (CM) injection protocols for cardiac computed tomography angiography (CCTA) based on body weight (BW), lean BW (LBW), and cardiac output (CO). Materials and methods. A total of 327 consecutive patients referred for CCTA were randomized into one of the three CM injection protocols, where CM injection was based on either BW (112 patients), LBW (108 patients), or CO (107 patients). LBW and CO were calculated via formulas. All scans were ECG-gated and performed on a third-generation dual-source CT with 70-120 kV (automated tube voltage selection) and 100 kVqual.ref/330 mAsqual.ref. CM injection protocols were also adapted to scan time and tube voltage. The primary outcome was the proportion of patients with optimal intravascular attenuation (325-500 HU). Secondary outcomes were mean and standard deviation of intravascular attenuation values (HU), contrast-to-noise ratio (CNR), and subjective image quality with a 4-point Likert scale (1 = poor/2 = sufficient/3 = good/4 = excellent). The t-test for independent samples was used for pairwise comparisons between groups, and a chi-square test (χ2) was used to compare categorical variables between groups. All p values were 2-sided, and a p < 0.05 was considered statistically significant. Results: Mean overall HU and CNR were 423 ± 60HU/14 ± 3 (BW), 404 ± 62HU/14 ± 3 (LBW), and 413 ± 63HU/14 ± 3 (CO) with a significant difference between groups BW and LBW (p=0.024). The proportion of patients with optimal intravascular attenuation (325-500 HU) was 83.9%, 84.3%, and 86.9% for groups BW, LBW, and CO, respectively, and between-group differences were small and nonsignificant. Mean CNR was diagnostic (≥10) in all groups. The proportion of scans with good-excellent image quality was 94.6%, 86.1%, and 90.7% in the BW, LBW, and CO groups, respectively. The difference between proportions was significant between the BW and LBW groups. Conclusion: Personalization of CM injection protocols based on BW, LBW, and CO, and scan time and tube voltage in CCTA resulted in low variation between patients in terms of intravascular attenuation and a high proportion of scans with an optimal intravascular attenuation. The results suggest that personalized CM injection protocols based on LBW or CO have no additional benefit when compared with CM injection protocols based on BW.

Short Communication: The effects of physical feed properties on gastric emptying in pigs measured with the 13C breath test.

The performance of pigs is affected by the rate of nutrient absorption in the gastrointestinal tract, which depends in turn strongly on the rate of stomach emptying. The 13C breath test provides a non-invasive diagnostic tool to measure gastric emptying patterns. Despite the wide acceptance of this method in human intervention studies, it has not found its way to the domain of animal sciences. In this study, we used the breath test to measure gastric emptying in young growing pigs using [1-13C] octanoic acid to trace digesta solids and [1-13C] glycine to study liquids. Pigs were fed a starch-rich diet, varying in starch source (isolated starch from barley, maize or high-amylose maize) or form (isolated barley starch, ground barley or extruded barley), after which 13CO2 enrichment was frequently measured during 11 h. Outliers in 13CO2 enrichment in the response curve of each pig were identified with a Cook's distance outlier test in combination with a leave-one-out analysis. Effects of experimental treatments on breath test parameters were tested using a GLM. In general, pigs were easy to train and the tailor-made mask allowed effortless sampling. Gastric emptying of all pigs followed a biphasic pattern, with a higher 13C recovery during the first peak. The first peak in gastric emptying of solids reached its maximum enrichment within 2 h after feeding in all cases. For digesta liquids, this peak was reached earlier for pigs fed ground barley (2.2 h after feeding), compared to pigs fed diets containing isolated starch (2.8 h after feeding). The second peak in gastric emptying of solids was reached later for pigs fed ground barley (5.9 h after feeding), compared with pigs fed extruded barley (4.5 h after feeding) and pigs fed diets containing isolated barley starch (4.8 h after feeding). In conclusion, the 13C breath test is a convenient, non-invasive tool to gain more insights into the gastric emptying pattern of pigs.

Modification of translation factor aIF5A from Sulfolobus solfataricus.

Eukaryotic eIF5A and its bacterial orthologue EF-P are translation elongation factors whose task is to rescue ribosomes from stalling during the synthesis of proteins bearing particular sequences such as polyproline stretches. Both proteins are characterized by unique post-translational modifications, hypusination and lysinylation, respectively, which are essential for their function. An orthologue is present in all Archaea but its function is poorly understood. Here, we show that aIF5A of the crenarchaeum Sulfolobus solfataricus is hypusinated and forms a stable complex with deoxyhypusine synthase, the first enzyme of the hypusination pathway. The recombinant enzyme is able to modify its substrate in vitro resulting in deoxyhypusinated aIF5A. Moreover, with the aim to identify the enzyme involved in the second modification step, i.e. hypusination, a set of proteins interacting with aIF5A was identified.

Timing of re-irradiation in recurrent high-grade gliomas: a single institution study.

There is no standard treatment available for recurrent high-grade gliomas. This monoinstitutional retrospective analysis evaluates the differences in overall survival and progression-free survival in patients according to the timing of re-irradiation. Patients suffering from a glioblastoma who received re-irradiation for recurrence were evaluated retrospectively. The median overall survival (OS) and the median progression-free survival were compared with different treatment options and within various time periods. From January 2007 until March 2015, 41 patients suffering from recurrent high-grade gliomas received re-irradiation [median dose of 30.6 Gy (range 20-40 Gy) in median 4 Gy fractions (range 1.8-5 Gy)] in our institution after initial postoperative irradiation or combined radiochemotherapy. The OS in this population was 34 months, and the OS after recurrence (OS-R) was 13 months. After diagnosis of recurrence, patients underwent additional surgical resection after a median of 1.2 months, received a second-line systemic therapy after 2.2 months with or without re-irradiation after 5.7 months. Growth of the tumour was assessed 4.3 months after the start of re-irradiation. The OS after the second surgical resection was 12.2 months, 11.7 months after the start of the second-line systemic therapy, and 6.7 months after the start of re-irradiation. The OS-R was not significantly correlated with the start of re-irradiation after a diagnosis of recurrence or the time period after the previous surgery. At this institution, re-irradiation was performed later compared to other treatment options. However, select patients could benefit from irradiation at an earlier time point. A precise time point should still be evaluated on an individual basis due to the patient's diverse conditions.

Testing the ability of children with attention deficit hyperactivity disorder to accurately report the effects of medication on their behavior.

Children with attention deficit hyperactivity disorder (ADHD) are often treated with central nervous system stimulants, making the evaluation of medication effects an important topic for applied behavior analysts. Because assessment protocols emphasize informant reports and direct observations of child behavior, little is known about the extent to which children themselves can accurately report medication effects. Double-blind placebo-controlled procedures were used to examine whether 6 children with ADHD could recognize the effects of their medication. The children were given math worksheets to complete for 15 min during each of 14 sessions while on medication and placebo. Children completed a self-evaluation form at the end of each session, and ratings were compared to observed behavior and academic performance. Results indicated that 3 children were able to accurately report their medication status at levels greater than chance, whereas the accuracy of reports by all children was related to dosage level, differences in behavior, and the presence of adverse effects. The implications of these results for placebo-controlled research, self-monitoring of dosage levels, and accuracy training are discussed.

Tresyl-mediated synthesis: kinetics of competing coupling and hydrolysis reactions as a function of pH, temperature, and steric factors.

Kinetic parameters have been measured for coupled nucleophilic and solvolytic reactions of 2,2,2-trifluoroethanesulfonyl (tresyl)-modified poly(ethylene glycol) based on a system of coupled differential equations implied by recently proposed elementary reaction mechanisms. Fitted kinetic parameters were found to be strong functions of pH, temperature, and steric factors. To maximize the total yield of coupled amine as well as the fraction of secondary amine linkages, our model predicts that it is desirable to run tresyl coupling reactions at low temperatures at pH approximately 8.0, depending on the amine pKa for primary, unhindered amines. For branched primary amines, our data favor room temperature at a slightly higher pH.

Centralization of low back pain and perceived functional outcome.

McKenzie's methods for evaluating and treating low back pain are used often but studied little. When using the McKenzie system, it is important to observe signs of symptom movement to a central location (centralization). This study investigated the relationships between centralization of low back pain and/or radiculopathy and the subjects' rating of functional outcome. Thirty-six subjects with low back pain volunteered to participate and were evaluated and treated by six researchers. Subjects were tested initially and again 14 days after initiation of treatment using the Oswestry Low Back Pain Disability Questionnaire and the Performance Assessment and Capacity Testing Spinal Function Sort (SFS). Symptoms were monitored for the occurrence of "complete centralization." Of the 36 subjects, 25 showed complete centralization within 14 days. The SFS score changes were significantly higher for subjects who completely centralized (p = 0.015). The results supported the hypothesis that subjects who centralize will have improved functional outcome and, thus, quality of life. However, shorter time to occurrence of complete centralization does not necessarily correlate with improved outcome.

Effect of anatomical location on the composition of fatty acids in double-muscled Belgian Blue cows.

Double-muscled cows of the Belgian Blue breed, ranging from ca. 680 to 880 kg live weight were slaughtered and various fat depots sampled for lipid analysis. Subcutaneous fat (SCF), intermuscular fat in m. serratus (IMF1) and m. transversalis (IMF2), kidney fat (KF) and intramuscular fat in m. longissimus thoracis (IMF3) were sampled. In IMF3 samples, polar lipids were separated from other lipid classes by thin layer chromatography. Both the proportions (w w %) and gravimetric concentrations (mg g(-1) of sample) of long-chain fatty acids were determined in total lipids of SCF, IMF1, IMF2, KF and in lipid classes of IMF3 by gas chromatography. The greatest concentration of total fatty acids was found in KF (777.6 ± 82.6 mg g(-1)), followed by SCF (721.3 ± 92.2 mg g(-1)), IMF2 (709.8 ± 72.5 mg g(-1)) and IMF1 (682.1 ± 71.6 mg g(-1)). Triacylglycerol and polar lipid fatty acid content of m. longissimus thoracis (IMF3) were respectively 8.1 ± 3.3 and 3.1 ± 0.6 mg g(-1). Fatty acid content, particularly the triacylglycerol fatty acid content in IMF3, increased (p < 0.01) with increasing carcass fat content. Polar lipid fatty acids in IMF3 contained a higher proportion of polyunsaturated fatty acids (32.6 ± 4.8 %) and lower proportion of saturated fatty acids (27.4 ± 5.0%) compared to the triacylglycerol fatty acid fraction (p < 0.01), which may reflect a prerequisite for proper membrane functioning. Internal fat depots were more saturated (p < 0.01) compared to SCF. The proportion of monounsaturated fatty acids differed (p < 0.01) between IMF1 and IMF2, possibly reflecting differences in muscle activity and functioning. Oleic (C18:1) and stearic (C18:0) acids comprised more than 60% of the total fatty acids in all anatomical locations.

Scripted sequences of teacher interaction. A versatile, low-impact procedure for increasing appropriate behavior in a nursery school.

Sequences of managerial statements delivered by a teacher during supervised playtime were identified, and a scripting procedure was used to modify these sequences while retaining the overall structure of teacher-student interactions. Five preschool-age children participated in the study. Following an initial assessment phase, the alternative sequence of scripted interactions was implemented first by an experimenter using an ABAB reversal design and then by the classroom teacher. The scripted interaction sequence was effective in increasing levels of appropriate play behavior in all five children, and these levels were maintained when control of the procedure was transferred to the teacher. Moreover, the teacher quickly learned to implement the procedure, did so with a high degree of integrity, and judged it to be moderately acceptable. The value of scripted interactions as an effective yet flexible management strategy that can be used in teacher training is discussed.

A refined substrate model for human cytochrome P450 2D6.

Cytochromes P450 (P450s) constitute a large superfamily of heme-containing enzymes, capable of oxidizing and reducing a variety of substrates. Cytochrome P450 2D6 is a polymorphic member of the P450 superfamily and is absent in 5-9% of the Caucasian population as a result of a recessive inheritance of gene mutations. Recently, the importance of aspartic acid 301 (Asp301) for the catalytic activity of P450 2D6, as indicated by a preliminary homology model, was confirmed by site-directed mutagenesis experiments. In this study, the heme moiety and the I-helix containing Asp301 were incorporated into the previously derived substrate model for P450 2D6, in the spatial orientations as derived from a recently improved protein model for P450 2D6, thereby incorporating steric restrictions and orientational preferences into the substrate model. The direction of well-defined hydrogen bonds formed between Asp301 and basic nitrogen atoms of P450 2D6 substrates was incorporated into the substrate model as well. Also, the position(s) of the basic nitrogen atom(s) of the substrates was/were allowed more flexibility. This was established through the attachment of an aspartic acid residue (representing Asp301) to the (protonated) basic nitrogen atom(s) of the substrates and superimposing the C alpha- and C beta-atoms of this aspartic acid residue in the fitting procedure instead of the basic nitrogen atoms. A variety of 8 substrates of P450 2D6 (comprising 17 known P450 2D6 dependent metabolic pathways) has been incorporated successfully into this refined and more restrictive substrate model.

[Morphologic parameters for quantitative determination of inflammatory activity of the peritoneum]. / Morphologische Parameter zur quantitativen Bestimmung der entzündlichen Aktivität des Peritoneums.

The morphology of the inflammatory activity of the peritoneum has been measured qualitatively but quantitative assessments are not common. In a standardized rat model we induced chronic abscess-forming peritonitis after laparotomy and inoculation of 2 ml Bacteroides fragilis suspension at a concentration of 10(9)/ml colony-forming units. The morphological inflammatory activity was determined quantitatively by staining the specimen of the peritoneum with naphthol-AS-D-chloracetate-esterase (NASDCE); through this staining the cytoplasm of granulocytes and tissue mast cells were marked. The peritonitis group (n = 53) and controls (n = 15) were randomly divided into three subgroups (nPeritonitis = 17/18/18 vs. ncontrol = 5/5/5) and observed for 3/7/14 days, respectively. On days 3/7/14 we diagnosed intra-abdominal abscesses in 2 of 17, 13 of 18, and 12 of 18 animals in the peritonitis group. In controls there were no abscesses (P < 0.05). The total cellularity and NASDCE-positive rates on days 3/7/14 in the peritonitis group were 301/409/280 (vs. 155/240/273 in controls) and 1.8/2.9/3.6% (vs. 0.7/0.9/1.4%) in the non-abscess-forming regions and 392/661/625 and 14.4/12.9/11.5% in the abscess-surrounding regions in the infected animals, respectively (P < 0.05). We conclude that the qualitative histological evidence of the morphological inflammatory activity of the peritoneum in the form of an abscess can be supplemented by a quantitative method. Through NASDCE staining the granulocyte and tissue mast cell proportion of the total cellularity as main indicators of the local inflammatory activity can be estimated in peritonitis. This method can be helpful in deciding when to definitively close the abdomen in the course of a programmed lavage treatment in peritonitis.

Respiratory allergy in laboratory animal workers: a retrospective cohort study using pre-employment screening data.

OBJECTIVES: To study the role of exposure, atopy, and smoking in the development of laboratory animal allergy (LAA) in a retrospective cohort study. METHODS: Between 1977 and 1993, 225 people received a pre-employment screening when they started a job at a Dutch research institute where they were going to work with laboratory animals. After active follow up 136 of them (60.4%) could be traced and were sent a questionnaire with extensive questions on allergic symptoms, smoking habits, and job history. 122 people (89.7%) sent back a completed questionnaire. Those who were accepted for a job at the institute and did not have allergic symptoms at the start of the job were selected as cohort members. After selecting people with complete data on start and end date of jobs, exposure intensity, atopy, and smoking, the cohort consisted of 99 people with an average time of follow up of 9.7 years. LAA was defined as a positive response to a set of questions in the questionnaire. The mean number of hours a week a person was exposed to laboratory animals at entry of the cohort was used as a surrogate for exposure, and was divided into four categories. RESULTS: 19 cohort members (19.2%) reported LAA. More people with asthmatic symptoms were found in the high exposure categories. More atopic than non-atopic people reported asthmatic symptoms (13% v 6%). The mean time until development of symptoms of LAA was about 109 months in non-atopic people (n = 9), and 45 months in atopic people (n = 10) (t test; P < 0.05). Time until development of symptoms of LAA was shorter at a higher intensity of exposure, except for those exposed for less than two hours a week. A proportional hazard regression analysis showed that exposure and atopy were significant determinants of LAA. An increased relative risk (RR) was found for non-atopic people exposed to laboratory animal allergens for more than two hours a week. Atopic people had an even higher risk when exposed to laboratory animals for more than two hours a week (RR above 7.3). Sex, smoking, and age were not risk factors. More atopic than non-atopic people were absent from work or transferred because of allergies. CONCLUSIONS: This study showed that exposure and atopy are significant predictors of LAA and that the risk of developing LAA remained present for a much longer period (> 3 y) than considered before.

Food allergen (peanut)-specific TH2 clones generated from the peripheral blood of a patient with peanut allergy.

BACKGROUND: Increasing evidence indicates a prominent role of allergen-specific TH2 cells, with high IL-4 and IL-5 production and low interferon-gamma production, in the regulation of IgE and eosinophil production in allergic disorders. However, most studies have concentrated on T cells reactive with inhalation allergens, whereas little is known about the properties of food allergen-reactive T cells. OBJECTIVES: In this study we therefore characterized peanut-specific T cells, cloned from a patient with severe peanut allergy. METHODS: Peripheral blood mononuclear cells from patients with peanut allergy and nonallergic individuals were stimulated with crude peanut extract (CPE) to compare the proliferative responses and to select a suitable patient for the cloning of CPE-specific T cells. The resultant panel of CPE-reactive T-lymphocyte clones was serologically phenotyped by flow cytometry and analyzed for cytokine secretion by ELISA. RESULTS: The patients' peripheral blood mononuclear cells showed a dose-dependent proliferation response to CPE, which was significantly higher (p < 0.05) than in peripheral blood mononuclear cells of nonallergic donors. The CPE-specific T-lymphocyte clones generated from the selected patient were all CD4+/CD8- T helper cells with a TH2 cytokine profile, secreting high amounts of IL-4 and IL-5, but little or no interferon-gamma. CONCLUSIONS: This study demonstrates that peanut-specific T cells do occur in the peripheral blood of patients with peanut allergy and suggests an increased frequency of these T cells in patients compared with nonallergic control subjects. The CD4+ phenotype and the TH2 cytokine profile of the CPE-specific T-lymphocyte clones suggest a functional role of allergen-specific TH2 cells in the pathophysiology of food allergy, similar to the function of inhalation allergen-specific TH2 cells.

The effects of instructional match and content overlap on generalized reading performance.

This study examined the effects of instructional match and content overlap on students' ability to generalize from passage reading instruction. Four students with mild disabilities served as participants. Using a multielement design, students were instructed with passages at two levels of text difficulty (instructionally matched vs. instructionally mismatched), and generalization was assessed with passages at two levels of similarity to those instructed (low vs. high content overlap). Results indicated that students' oral reading accuracy and fluency showed the greatest degree of generalization when instructional materials were matched to the students' skill level and assessment materials were similar to those used during instruction. Moreover, these results were maintained at 1-month follow-up. The implications of these findings for classroom reading instruction and the assessment of students' reading skills are discussed.

Solitary Fibrous Tumor Pleura.

The Solitary Fibrous Tumour of Pleura has rarely been observed. A new case has been reported. This tumour is often asymptomatic and mostly discovered by chance. A well delimited and round opacity is demonstrated on the chest X-ray. computerized tomography confirms the fleshy nature of this tumour with inhomogeneous enhancement. The treatment is a complete surgical excision. The prognosis is excellent, if diagnosed early.

A comparison of behavioral interventions reported in treatment studies and programs for adults with developmental disabilities.

This study examined the frequency with which behavioral interventions reported in the research literature were being incorporated into residential treatment programs addressing identical skill deficits. A sample of 113 research articles involving 299 subjects and a corresponding sample of 299 adaptive skill programs implemented in state-funded facilities were reviewed. Information was collected about subject attributes, target behaviors, types of intervention, and alternative instructional techniques. Chi-square analyses revealed significant differences between researchers and clinicians in the categories of adaptive and maladaptive behavior targeted as well as the behavioral interventions reported. Disparities were also found in treatment implementation practices including the use of task analysis, instruction in the natural environment, teaching of replacement skills, and the functional analysis of behavior. These differences are discussed in light of federal regulations governing practices in state-funded facilities as well as current research trends.

Masking foods for food challenge: practical aspects of masking foods for a double-blind, placebo-controlled food challenge.

In diagnosing a food allergy or food intolerance, a double-blind, placebo-controlled food challenge (DBPCFC) with the suspected food or food substance is the only method available for objective confirmation of an assumed relationship between a suspected agent and a complaint. When the use of capsules as a vehicle for DBPCFC with the suspected agent is not feasible, recipes have to be developed for masking the suspected food with another food. We describe demands and other aspects of the development of recipes for DBPCFC purposes. The taste, smell, color, and texture of the suspected agent have to be hidden in such a way that the patient cannot tell which of the two foods (the active food or the placebo food) contains the suspected agent. Once developed, the recipes have to be judged carefully to ensure that the foods do not contain ingredients other than the suspected agent that can possibly provoke complaints in the patient. Besides ordinary equipment such as cutlery, glasses, and dishes, the minimal equipment needed for preparing the recipes is an accurate balance. The more laborious a recipe is to make, the more equipment is needed. The development of recipes and the preparation of masked foods are time-consuming, which makes DBPCFC with masked foods difficult to perform in daily clinical practice. Performing a DBPCFC with masked foods in daily clinical practice can be a great challenge to the imagination and creativity of a dietitian.