Comparative effectiveness of antiretroviral drug classes for the treatment of HIV infection in patients with high viral loads: a multicentre retrospective cohort study.

OBJECTIVES: We aimed to compare the effectiveness of antiretroviral therapy (ART) classes for achieving HIV RNA suppression to < 50 HIV-1 RNA copies/mL within 6 months of initiation with high viral loads (VLs). Secondary objectives were to compare viral suppression (VS) at 12 weeks and 12 months, partial HIV RNA suppression to < 200 copies/mL, time to VS, time to rebound, and change in CD4 cell count. METHODS: This was a multicentre, retrospective, observational study. Adult patients were included if they initiated ART between January 2005 and December 2016 with a VL ≥ 100 000 copies/mL. RESULTS: There were 220 patients included in the study. The median VL was 252 919 [interquartile range (IQR) 149 472-500 000] copies/mL. Nonnucleoside reverse transcriptase inhibitor (NNRTI) recipients were more likely to achieve VS by 6 months compared to those initiating ART containing protease inhibitors (PIs) [75.4% vs. 44.1%, respectively; odds ratio (OR) 3.34; 95% confidence interval (CI) 1.62-6.90] or integrase strand transfer inhibitors (INSTIs) (75.4% vs. 55.8%, respectively; OR 2.40; 95% CI 1.03-5.58). VS at 12 weeks was more frequent with INSTI-containing regimens than with PIs (28.9% vs. 9.0%, respectively; OR 4.10; 95% CI 1.69-9.92). VS at 12 months did not significantly differ between treatment regimens. Median time to complete VS for INSTI, PI and NNRTI recipients was 22.3 (95% CI 13.4-33), 30.1 (95% CI 25-36) and 19.9 (95% CI 16-22.3) weeks, respectively. There were no significant differences in time to viral rebound or change in CD4 cell counts. CONCLUSIONS: Patients with high VLs initiated on NNRTIs were more likely to achieve VS by 6 months on ART compared to INSTI and PI recipients.

Correlative X-ray and neutron tomography of root systems using cadmium fiducial markers.

The interactions between plant roots and soil are an area of active research, particularly in terms of water and nutrient uptake. Because noninvasive, in vivo studies are required, tomographic imaging appears an obvious method to use, but no one imaging modality is well suited to capture the complete system. X-ray imaging gives clear insight to soil structure and composition; however, water is comparatively transparent to X-rays and biological matter also displays poor contrast with respect to the pores between soil particles. Neutron imaging presents a complementary view where water and biological matter are better distinguished but the soil minerals are not imaged as clearly as they would be with X-rays. This work aims to develop robust methods for complementary X-ray/neutron tomographic imaging of plant root samples which should lead to new insight into water and nutrient transport in soil. The key challenges of this project are to develop experiments that will meet the requirements of both imaging modalities as well as the biological requirements of the plant samples and to develop ways to register a pair of reconstructed volume images of a sample that will typically have been produced with entirely separate facilities. The use of cadmium fiducial markers for registration has been investigated. Simulations were conducted to investigate the expected registration accuracy as the quantity and distribution of the markers varied. The findings of these simulations were then tested experimentally as plant samples were grown and imaged using neutrons with the IMAT instrument at ISIS Neutron and Muon Source at the STFC Rutherford Appleton Laboratory in Harwell, and with X-rays at µ-VIS X-ray Imaging Centre at the University of Southampton. LAY DESCRIPTION: The interactions between plant roots and soil are an area of active research, particularly in terms of water and nutrient uptake. The samples used in this research are typically imaged so that they can be studied without digging up the roots and destroying the sample in the process. X-ray and neutron imaging techniques have both been used as each can show different materials within the sample. Because neither can show all the components of the system by itself, this work explores methods for combining scans of the same sample to give a more complete image of the system. In particular this work focusses on the use of fiducial markers as a strategy for preparing the samples in such a way that the resulting images can be aligned. The effectiveness of this method was tested in simulation and then in practice. The samples used within this work were imaged using neutrons on the IMAT instrument at ISIS Neutron and Muon Source at the STFC Rutherford Appleton Laboratory in Harwell, and with X-rays at µ-VIS X-ray Imaging Centre at the University of Southampton.

Practice-based evidence can help! Using the Group Questionnaire to enhance clinical practice.

Practice-based evidence (Burlingame & Beecher, 2008) is an approach to evidence-based practice that addresses treatment efficacy to remediate clinicians' inability to predict treatment response (Chapman et al., 2012; Hannan et al., 2005). The Group Questionnaire (GQ; Bormann, Burlingame, & Straub, 2011; Johnson, Burlingame, Olsen, Davies, & Gleave, 2005) is one practice-based evidence measure that supports clinical judgment to enhance psychotherapy outcomes by measuring 3 important group constructs: Positive Bond, Positive Work, and Negative Relationship. A clinical example of how one group leader used GQ data provided by group members regarding their weekly group experiences to support her interventions in a process-oriented therapy group for adults includes verbatim clinical exchanges among group members and the leader. The example also includes a GQ report with explanations of the group members' scores and numerical and graphical data. The authors detail how the leader used the data from the measure to promote curiosity about group cohesion and movement toward treatment goals, to reframe perceptions of group interaction, and to gauge outcomes of shared group experience. The group leader's examination of the GQ data outside the group allowed her to use this information for positive impact inside the group to guide interventions and explore content and process, warranting additional attention. The authors encourage curiosity about other interactions among other group members reflected in the GQ report and how this information could be used to positively impact the group in other ways. (PsycINFO Database Record

Sunshine on my shoulders: Weather, pollution, and emotional distress.

BACKGROUND: Researchers have examined the relationship between mental health and weather/pollution with mixed results. The current study aimed to examine a range of weather and atmospheric phenomena and their association with time-bound mental health data. METHODS: Nineteen different weather/pollution variables were examined in connection with an archive of self-reported mental health data for university students participating in mental health treatment (n=16,452) using the Outcome Questionnaire 45.2 (OQ-45). Statistical approach involved randomly selecting 500 subjects from the sample 1000 different times and testing each variable of interest using mixed models analyses. RESULTS: Seasonal changes in sun time were found to best account for relationships between weather variables and variability in mental health distress. Increased mental health distress was found during periods of reduced sun time hours. A separate analysis examining subjects' endorsement of a suicidality item, though not statistically significant, demonstrated a similar pattern. Initial results showed a relationship between pollution and changes in mental health distress; however, this was mediated by sun time. LIMITATIONS: This study examined a relatively homogenous, predominantly European American, and religious sample of college counseling clients from an area that is subject to inversions and is at a high altitude and a latitude where sun time vacillates significantly more than locations closer to the equator. CONCLUSIONS: Seasonal increases in sun time were associated with decreased mental health distress. This suggests the need for institutions and public health entities to plan for intervention and prevention resources and strategies during periods of reduced sun time.

X-ray tomography for structural analysis of microstructured and multimaterial optical fibers and preforms.

Specialty optical fibers, in particular microstructured and multi-material optical fibers, have complex geometry in terms of structure and/or material composition. Their fabrication, although rapidly developing, is still at a very early stage of development compared with conventional optical fibers. Structural characterization of these fibers during every step of their multi-stage fabrication process is paramount to optimize the fiber-drawing process. The complexity of these fibers restricts the use of conventional refractometry and microscopy techniques to determine their structural and material composition. Here we present, to the best of our knowledge, the first nondestructive structural and material investigation of specialty optical fibers using X-ray computed tomography (CT) methods, not achievable using other techniques. Recent advances in X-ray CT techniques allow the examination of optical fibers and their preforms with sub-micron resolution while preserving the specimen for onward processing and use. In this work, we study some of the most challenging specialty optical fibers and their preforms. We analyze a hollow core photonic band gap fiber and its preforms, and bond quality at the joint between two fusion-spliced hollow core fibers. Additionally, we studied a multi-element optical fiber and a metal incorporated dual suspended-core optical fiber. The application of X-ray CT can be extended to almost all optical fiber types, preforms and devices.

The application of digital volume correlation (DVC) to study the microstructural behaviour of trabecular bone during compression.

Digital Volume Correlation (DVC) has been emerged recently as an innovative approach to full volume (i.e. internal) displacement and strain field measurement in materials and structures, particularly in conjunction with high resolution X-ray computed tomography (CT). As a relatively novel technique certain aspects of precision, accuracy and the breadth of application are yet to be fully established. This study has applied DVC to volume images of porcine trabecular bone assessing the effect of noise and sub-volume size on strain measurement. Strain resolutions ranging between 70 and 800µÎµ were obtained for the optimum sub-volume size of 64 voxels with a 50% overlap for metrological studies conducted. These values allowed the mechanical behaviour of porcine trabecular bone during compression to be investigated. During compression a crushed layer formed adjacent to the boundary plate which increased in thickness as the specimen was further deformed. The structure of the crushed layer was altered to such an extent that it confounded the correlation method. While investigating this factor, it was found that for reliable strain calculations a correlation coefficient of 0.90 or above was required between the sub-volumes in the reference and the deformed volumes. Good agreements between the results and published bone strain failures were obtained. Using the full field strain measurements, Poisson's ratio was identified for each compression step using a dedicated inverse method called the virtual fields method (VFM). It was found that for a given region outside of the crushed zone the Poisson ratio decreased from 0.32 to 0.21 between the first and the final compression steps, which was hypothesised to be due to the bone geometry and its resulting deformation behaviour. This study demonstrates that volumetric strain measurement can be obtained successfully using DVC, making it a useful tool for quantitatively investigating the micro-mechanical behaviour of macroscale bone specimens.

Kidney exchange programs: attitudes of transplant team members toward living donation and kidney exchanges.

INTRODUCTION: Several living donor kidney exchange programs (LDKEPs) have been established throughout the world; however, none have yet achieved the perceived substantial potential for increasing the number of living donor kidney transplants. Over the past 2 years, the Ohio Solid Organ Transplant Consortium (OSOTC) has developed and implemented an LDKEP with a complementary, robust web-based computerized matching program for living donor/recipient pairs. Prior to implementation of the OSOTC LDKEP, attitudes of transplant professionals from each of eight participating kidney transplant programs were surveyed to determined attitudes toward living donation and LDKEP and to identify potential barriers to LDKEP. The state of decision making toward LDKEP was also examined. METHODS: Transplant professionals were surveyed using an instrument designed to assess attitudes toward living donation and LDKEPs. Most questions were answered on a Likert scale (1 = strongly agree, 5 = strongly disagree). RESULTS: Respondents agreed that living donor transplantation should be encouraged (mean 1.17 +/- 0.6) and that the laparoscopic donor procedure was preferred (1.36 +/- 0.82). Respondents had largely read about KEPs (2.02 +/- 1.02) but had "thought about participating in KEPs" (2.57 +/- 1.26), or actively sought information (2.87 +/- 1.3) to lesser degrees. Despite this, significant indecisiveness existed regarding participation in LDKEPs (2.73 +/- 1.39). CONCLUSIONS: Transplant professionals are highly aware of LDKEPs. However, they remain indecisive about LDKEP participation. These results indicate that barriers exist in the transplant community toward LDKEP, and these must be defined to increase LDKEP acceptance and participation.

Influence of educational programs on perceived barriers toward living donor kidney exchange programs.

UNLABELLED: Living donor kidney exchange programs (LDKEPs) provide significant advantages toward addressing ABO and crossmatch incompatibility in living donor kidney transplantation, however, they have not yet realized their potential. The aim of this study was to examine the effect of an educational conference on perceived barriers toward living donor kidney transplantation and LDKEPs. METHODS: Between 2002 and 2004, a state-wide living donor/living donor kidney exchange program was established by the Ohio Solid Organ Transplant Consortium (OSOTC). Prior to initiating the OSOTC LDKEP, an educational conference was held and its effect on transplant professional attitudes toward LDKEP barriers were assessed prior to and following the conference using a questionnaire. Questions were answered using a Likert scale (LS) (1 = strongly agree, 5 = strongly disagree). RESULTS: Forty-eight participants completed questionnaires prior to and following the conference. The conference was judged to increase understanding of KEPs. The complementary web-based computer matching program was also felt to be an important component for the LDKEP. The conference did not affect the state of decision making regarding KEPs, however. Perceived barriers to LDKEPs not influenced by the educational conference included (1) concerns about donor travel costs, (2) concern about potential medical legal problems, (3) lack of perceived superiority of LDKEPs over desensitization protocols, and (4) concern about donation to strangers. Although numeric trends existed for each of these barriers, none were statistically significantly influenced by the education conference. CONCLUSIONS: These results suggest that interventions other than large scale educational conferences will be needed to address the barriers to LDKEP.

Corticosteroid avoidance ameliorates lymphocele formation and wound healing complications associated with sirolimus therapy.

INTRODUCTION: Sirolimus (RAPA) and corticosteroids (CS) both inhibit wound healing. To evaluate the possibility that RAPA and CS have additive effects on wound healing, we evaluated the effects of corticosteroid avoidance (CSAV) on wound healing complications in patients treated with RAPA. METHODS: One hundred nine patients treated with a CSAV regimen (no pretransplantation or posttransplantation CS) were compared with a historical control group (n = 72) that received cyclosporine (CsA), mycophenolate mofetil (MMF), and CS. The CSAV group received low-dose CsA, MMF, RAPA, and thymoglobulin induction. Complications were classified as follows: wound healing complications (WHC) or infectious wound complications (IWC). WHC included lymphocele, hernia, dehiscence, diastasis, and skin edge separation. IWC included wound abscess and empiric antibiotic therapy for wound erythema. RESULTS: The CSAV group was largely CS-free: 11% of patients received CS for rejection, 12% of patients received CS for recurrent disease, and 85% of patients are currently off CS. The CSAV group had a significantly lower incidence of WHC (13.7% vs 28%; P = .03) and lymphoceles (5.5% vs 16%; P = .02) than the control group. There was no difference in the incidence of IWC between the 2 groups. Patients who received CSAV were 18% less likely (P = .57) to develop any type of complication, 41% less likely (P = .20) to develop a WHC, and 71% less likely (P = .018) to develop a lymphocele. CONCLUSIONS: CSAV in a RAPA-based regimen results in a marked reduction in WHC and lymphoceles. Therefore, CSAV provides a promising approach for addressing WHC associated with RAPA therapy.

A prospective, pilot study of early corticosteroid cessation in high-immunologic-risk patients: the Cincinnati experience.

BACKGROUND: The first prospective trial of steroid withdrawal dedicated to high-immunologic-risk patients is reported herein. METHODS: Twenty-five patients were enrolled prospectively in an IRB-approved HIPAA-compliant protocol. Immunosuppression included corticosteroid withdrawal (CSWD) at 7 days, tacrolimus (target trough level 4 to 8 ng/mL), sirolimus (target trough level 8 to 12 ng/mL), and Mycophenolate Mofetil (2 g/d). Induction with daclizumab (2 mg/kg) on posttransplant days (PTD) 0 and 14 was administered to the first 10 patients. The protocol for the next 15 patients was modified because of high acute rejection rates to include received T-cell-depleting antibody induction therapy with thymoglobulin (1.5 mg/kg) on PTDs 0 and 2 followed by daclizumab on Postoperative day (POD) 14. Recipient inclusion criteria included: (1) repeat transplant recipients; or (2) patients with a peak PRA > or =25%. All rejection episodes were diagnosed by biopsy and graded using Banff '97 criteria. RESULTS: Twenty-five patients were enrolled and median follow-up was 402 days. Forty percent of recipients were black, 68% of patients were repeat transplant recipients, 68% received deceased donor kidneys, and 36% had a peak flow PRA >25%. Overall acute rejection, graft survival, and patient survival rates of 40%, 88%, and 96%, respectively, were observed for the duration of the study. Acute rejection occurred in 6 of 10 patients (60%) with daclizumab induction; however, acute rejection rates fell to 27% when thymoglobulin was introduced (P = .1). CONCLUSIONS: This study supports our previous observations in a multivariate analysis of early CSWD patients, wherein polyclonal antibody induction therapy reduced acute rejection. High-immunologic-risk patients may be able to undergo early CSWD with acceptable rates of acute rejection.

Histocompatibility testing predicts acute rejection risk in early corticosteroid withdrawal regimens.

UNLABELLED: Histocompatibility testing has been shown to predict acute rejection risk in steroid-based immunosuppression. However, little evidence exists of its ability to predict acute rejection risk in corticosteroid-free patients, with no evidence in early corticosteroid withdrawal (CSWD) under modern immunosuppression. The purpose of this study was to evaluate the ability of histocompatibility testing to identify patients at high risk for acute rejection after early CSWD. METHODS: One hundred eighty-one patients were entered into six IRB-approved early CSWD regimens. Histocompatibility testing included serologic PRA, flow cytometric PRA testing by Class I and Class II MHC beads, and B cell crossmatching with pronase treatment. All rejection episodes were biopsy proven, and grading was assigned using Banff criteria. Influence of individual tests was examined using Chi square univariate and multivariate logistic regression analysis. RESULTS: Median follow-up was 23.5 months (range 7-48 months). Of 181 patients, 16% were repeat transplant recipients, 36% received deceased donor renal transplants, 48% received living related donor renal transplants, and 16% received living unrelated transplants. Overall patient survival was 97%, and death-censored graft survival was 96.5%. Acute rejection rates in the entire follow-up period were 17.7%. 12.4% in primary transplant recipients and 37% in repeat transplant recipients. Multivariate analysis revealed that HLA AB and DR locus mismatching were associated with increased acute rejection risk. Similarly, serologic PRA analysis predicted acute rejection risk; however, flow cytometry crossmatching did not predict acute rejection risk. The greatest single influence on acute rejection risk appeared to be a flow cytometric B cell crossmatch (7.94-fold increased risk). In conclusion, histocompatibility testing can identify patients at high risk for acute rejection following early CSWD. HLA matching, serologic PRA testing, and flow cytometry-based B cell crossmatching can all be used to predict acute rejection risk.

Global cardiovascular risk under early corticosteroid cessation decreases progressively in the first year following renal transplantation.

UNLABELLED: A primary reason to eliminate corticosteroids from immunosuppressive regimens in solid organ transplant recipients is improved cardiovascular risk profiles. Although a number of studies have documented that corticosteroid withdrawal (CSWD) regimens reduce hypertension, hyperlipidemia, diabetes, and weight gain, global assessments of cardiovascular risk under CSWD have not been reported. The purpose of this study was to document cardiovascular risk under CSWD using a global risk assessment by Framingham risk assessment. METHODS: Framingham global cardiovascular risk assessments were performed at baseline and 3, 6, and 12 months posttransplant on patients enrolled in prospective, IRB-approved early (<7 days of corticosteroids) CSWD trials. Framingham score was based on age, sex, presence of diabetes, HDL and total cholesterol, and systolic blood pressure. All patients were nonsmokers. Left ventricular hypertrophy assessment by EKG criteria was not available at all time points and therefore were not included. RESULTS: One hundred eighty-three patients were included in the analysis. Fourteen percent of patients had evidence of coronary heart disease (prior MI, CABG, PTCA, or significant cardiovascular disease as evidenced by angiography) prior to transplant. Complete information was available for 160 patients at baseline, 132 at 1, 3, and 6 months, and 93 at 12 months posttransplant. Mean 10-year risk (expressed as percent) for developing coronary heart disease decreased over time: 8.03 at baseline, 8.31 at 3 months, 7.40 at 6 months, and 7.20 at 12 months, indicating that global cardiovascular risk fell at 1 year posttransplant by about 10% in renal transplant recipients undergoing early CSWD. CONCLUSIONS: Estimation of cardiovascular risk by Framingham risk factor assessment allows incorporation of several cardiovascular risk factors into a single estimate, thereby accounting for differential effects of each individual factor on global cardiovascular risk. This experience indicates that global cardiovascular risk decreases by approximately 10% at 1 year posttransplant in renal transplant recipients who undergo early corticosteroid withdrawal (CSWD).

African American renal transplant recipients benefit from early corticosteroid withdrawal under modern immunosuppression.

African Americans have historically been considered high-risk renal transplant recipients due to increased rejection rates and reduced long-term graft survival. Modern immunosuppression has reduced rejections and improved graft survival in African Americans and may allow successful corticosteroid withdrawal. Outcomes in 56 African Americans were compared to 56 non-African Americans enrolled in early withdrawal protocols. Results are reported as African American versus non-African American. Acute rejection at 1 year was 23% and 18% (P = NS), while patient and graft survival was 96% versus 98% and 91% versus 91% (P = NS), respectively. In conclusion, early withdrawal in African Americans is associated with acceptable rejection rates and excellent patient and graft survival, indicating that the risks and benefits of early withdrawal are similar between African Americans and non-African Americans. Additional followup is needed to determine long-term renal function, graft survival, and cardiovascular risk in African Americans with early steroid withdrawal.

Early steroid withdrawal does not increase risk for recurrent focal segmental glomerulosclerosis.

UNLABELLED: Experience with early corticosteroid withdrawal (CSWD) in renal transplant recipients with focal segmental glomerulosclerosis (FSGS) has not been previously reported. Since corticosteroids are used to treat primary FSGS, concern exists as to whether early CSWD regimens will be associated with an increased risk of FSGS recurrence posttransplant. The purpose of the present study was to evaluate the results of early CSWD in FSGS recipients and compare these results to a historic control group of FSGS patients who underwent renal transplantation under corticosteroid-based immunosuppression. METHODS: Forty-three patients with FSGS underwent renal transplantation with early CSWD. Results in these patients were compared to FSGS patients that underwent renal transplantation with chronic corticosteroid therapy. All rejection episodes were biopsy proven with grading by Banff criteria. Statistical analyses included Student's t test and chi square tests. RESULTS: Results in 43 patients with a median follow-up of 569 days were analyzed and compared to control patients. There was no significant difference in recurrent FSGS, time to recurrence, or graft loss. CONCLUSION: CSWD does not increase risk for recurrence of FSGS. These observations indicate that ECSW can be achieved in FSGS patients, thereby affording them the benefits of steroid elimination.

Direct evidence for neutrino flavor transformation from neutral-current interactions in the Sudbury Neutrino Observatory.

Observations of neutral-current nu interactions on deuterium in the Sudbury Neutrino Observatory are reported. Using the neutral current (NC), elastic scattering, and charged current reactions and assuming the standard 8B shape, the nu(e) component of the 8B solar flux is phis(e) = 1.76(+0.05)(-0.05)(stat)(+0.09)(-0.09)(syst) x 10(6) cm(-2) s(-1) for a kinetic energy threshold of 5 MeV. The non-nu(e) component is phi(mu)(tau) = 3.41(+0.45)(-0.45)(stat)(+0.48)(-0.45)(syst) x 10(6) cm(-2) s(-1), 5.3sigma greater than zero, providing strong evidence for solar nu(e) flavor transformation. The total flux measured with the NC reaction is phi(NC) = 5.09(+0.44)(-0.43)(stat)(+0.46)(-0.43)(syst) x 10(6) cm(-2) s(-1), consistent with solar models.

Measurement of day and night neutrino energy spectra at SNO and constraints on neutrino mixing parameters.

The Sudbury Neutrino Observatory (SNO) has measured day and night solar neutrino energy spectra and rates. For charged current events, assuming an undistorted 8B spectrum, the night minus day rate is 14.0%+/-6.3%(+1.5%)(-1.4%) of the average rate. If the total flux of active neutrinos is additionally constrained to have no asymmetry, the nu(e) asymmetry is found to be 7.0%+/-4.9%(+1.3%)(-1.2%). A global solar neutrino analysis in terms of matter-enhanced oscillations of two active flavors strongly favors the large mixing angle solution.

Measurement of the rate of nu(e) + d --> p + p + e(-) interactions produced by (8)B solar neutrinos at the Sudbury Neutrino Observatory.

Solar neutrinos from (8)B decay have been detected at the Sudbury Neutrino Observatory via the charged current (CC) reaction on deuterium and the elastic scattering (ES) of electrons. The flux of nu(e)'s is measured by the CC reaction rate to be straight phi(CC)(nu(e)) = 1.75 +/- 0.07(stat)(+0.12)(-0.11)(syst) +/- 0.05(theor) x 10(6) cm(-2) s(-1). Comparison of straight phi(CC)(nu(e)) to the Super-Kamiokande Collaboration's precision value of the flux inferred from the ES reaction yields a 3.3 sigma difference, assuming the systematic uncertainties are normally distributed, providing evidence of an active non- nu(e) component in the solar flux. The total flux of active 8B neutrinos is determined to be 5.44+/-0.99 x 10(6) cm(-2) s(-1).

Dental implications of oral piercing.

Piercing of the tongue and perioral regions is becoming an increasingly popular expression of body art. Dentists will be seeing more patients with these piercings and should be familiar with the potential associated oral and dental problems. This paper will discuss the lay techniques of intraoral piercing and related problems and complications derived by a questionnaire left at piercing studios in San Francisco and by clinical examination of selected patients. The data reported are a result of a review of 63 patients. Five cases illustrating the common types of oral and perioral piercing are presented.

A soil-site evaluation index of productivity in intensively managed Pinus radiata (D. Don) plantations in South Australia.

A limiting-factor, environmental model for radiata pine (Pinus radiata (D. Don)) has been developed using landform and soil morphological features that influence site productivity. The model focuses on soil and landscape constraints to productivity and predicts the native productivity of land and tree species. It permits the integration of land-use objectives for a catchment through forest management and use of silvicultural practices which increase productivity. The soil site evaluation index (SSEI) is an index of forest productivity found when silviculture extends only to the minimum amount of site disturbance needed to establish a plantation of radiata pine. The impacts of intensive silvicultural practices were deducted from the 'Site Quality' productivity survey rating to calculate the unimproved yield class (uYC). We calculated SSEI by range standardising uYC values from 0 to 1. SSEI was correlated with the environmental factors in a regression tree model using readily available analytical software. The model accurately predicts unimproved forest productivity from observed soil horizon and land surface properties. The environmental constraints in low lying areas relate to waterlogging, soil sodicity and gravel content. In elevated areas, plant available water storage, rock weathering, landform, ironstone gravel and aspect are recognised factors for pine growth.

Perinatal regionalization versus hospital competition: the Hartford example.

OBJECTIVES: The increasingly competitive health care environment may undermine effective traditional regional organizations. It is urgent to document the benefits of perinatal regionalization for the emerging health care system. We present a case study that illustrates many of the challenges to and benefits of perinatal regionalization in the 1990s. BACKGROUND: The controversy in Hartford was sparked by a proposed merger of two major pediatric services into a full-service children's hospital. Community hospitals reacted with plans to upgrade their obstetrics/neonatal facilities toward level II (intermediate) or II+ (intensive) neonatal intensive care units (NICUs). The fear that unrestricted competition would drive up overall health care costs prompted the hospital association and Chamber of Commerce to retain consultants to evaluate the number and location of regional NICU beds. METHODS: The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges. RESULTS: The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization. CONCLUSIONS: Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.