The association between paramedic service system hospital offload time and response time.

OBJECTIVE: To address an important care issue in Canada, we tested the association between paramedic system hospital offload and response time, while considering the impact of other system-level factors. METHODS: Data from Calgary, Alberta (2014-2017), included median offload (exposure) and response (outcome) time aggregated by hour, with covariates paramedic system episodes of care-dispatch and arrival of a response unit-and hospital transport arrivals (collectively called volume), time of day, and season. Analyses used linear regression and modified Poisson models. RESULTS: 301,105 EMS episodes of care over 26,193 1-h periods were included. For any given 1-h period, the median (IQR) across all episodes of care for offload time, response time, episodes of care, and hospital transport arrivals were 55.3 (45.7, 66.3) min, 8.6 (7.6, 9.8) min, 12 (8, 16) episodes, and 8 (5, 10) hospital arrivals, respectively. Multivariable modelling revealed a complex association differing over levels of exposure and covariates, requiring description using "light stress" and "heavy stress" system scenarios. The light scenario was defined as median offload of 30 min and volume < 10th percentile (six episodes and four hospital arrivals), in the summer, and the heavy scenario as median offload of 90 min and volume > 90th percentile (17 episodes and 13 hospital arrivals), in the winter. An increase is reported in minutes:seconds for median hourly response time between scenarios by time of day: 1:04-4:16 (0000-0559 h.), 0:42-2:05 (0600-1159 h.), 0:57-3:01 (1200-1759 h.), and 0:18-2:21 (1800-2359 h.). CONCLUSIONS: Increasing offload is associated with increased response time; however the relationship is complex, with a greater impact on response time noted in select situations such as high volume in the winter. These observations illustrate the interdependence of paramedic, ED, and inpatient systems and provide high-yield targets for polices to mitigate the risk to community availability of paramedic resources at times of high offload delay/system stress.

ABSTRAIT: OBJECTIF: Afin de régler un problème important de soins au Canada, nous avons testé l'association entre le déchargement du système paramédical et le temps de réponse, tout en tenant compte de l'incidence d'autres facteurs au niveau du système. MéTHODES: Les données de Calgary, en Alberta (2014-2017) incluent le temps médian de déchargement (exposition) et de réponse (résultat) agrégé par heure, qui s'agit co-variables épisodes de soins du système paramédical - répartition et arrivée d'une unité d'intervention - et arrivées de transport hospitalier (collectivement appelé volume), l'heure et la saison. Les analyses ont utilisé la régression linéaire et des modèles de Poisson modifiés. RéSULTATS: 301105 épisodes de soins médicaux d'urgence sur 26193 périodes d'une heure ont été inclus. Pour une période d'une heure donnée, la médiane (QRI) pour tous les épisodes de soins pour le temps de déchargement, le temps de réponse, les épisodes de soins et les arrivées par transport à l'hôpital était de 55,3 (45,7, 66,3) minutes, 8,6 (7,6, 9,8) minutes, 12 (8, 16) épisodes et 8 (5, 10) arrivées à l'hôpital, respectivement. La modélisation multi-variable a révélé une association complexe qui varie selon les niveaux d'exposition et les co-variables, et qui nécessite une description à l'aide de scénarios de systèmes de « stress léger ¼ et de « stress lourd ¼. Le scénario léger a été défini comme un déchargement médian de 30 minutes, volume inférieur au 10e percentile (six épisodes et quatre arrivées à l'hôpital), pendant l'été. Le scénario lourd comme déchargement médian de 90 minutes, volume > 90e percentile (17 épisodes et 13 arrivées à l'hôpital), en hiver. Une augmentation est rapportée en minutes: secondes pour le temps de réponse horaire médian entre des scénarios par heure du jour : 1:04-4:16 (0000-0559 h.), 0:42-2:05 (0600-1159 h.), 0:57-3:01 (1200-1759 h.), et 0:18-2:21 (1800-2359 h.). CONCLUSIONS: L'augmentation du déchargement est associée à une augmentation du temps de réponse, mais la relation est complexe, avec un impact plus important sur le temps de réponse noté dans certaines situations, comme un volume élevé en hiver. Ces observations illustrent l'interdépendance des systèmes paramédicaux, des services d'urgence et des services aux patients hospitalisés et fournissent des cibles à haut rendement pour les politiques afin d'atténuer le risque pour la disponibilité des ressources paramédicales dans la collectivité en période de retard élevé ou de stress systémique.

Linkage of Emergency Medical Services and Hospital Data: A Necessary Precursor to Improve Understanding of Outcomes of Prehospital Care.

Objective: Linking emergency medical services (EMS) data to hospital outcomes is important for quality assurance and research initiatives. However, non-linkage due to missing or incomplete patient information may increase the risk of bias and distort findings. The purpose of this study was to explore if an optimization strategy, in addition to an existing linkage process, improved the linkage rate and reduced selection and information bias. Methods: 4,150 transported patients in a metropolitan EMS system in Alberta, Canada from 2016/17 were linked to two Emergency Department (ED) databases by a standard strategy using a unique health care number, date/time of ED arrival, and hospital name. An optimized strategy added additional linkage steps incorporating last name, year of birth, and a manual search. The strategies were compared to assess the rate of linkage, and to describe event and patient-level characteristics of unlinked records. Results: The standard strategy resulted in 3,650 out of 4,150 (88.0%) linked records (95% CI 86.9%-88.9%). Of the 500 non-linked records, an additional 381 were linked by the optimized strategy (n = 4,031/4,150 [97.1%; 95% CI: 96.6%-97.6%]). There were no false positive linkages. The highest linkage failure was in 25 to 34 year-old patients (n = 93/478, 19.5%), males (n = 236/1975, 12.0%), Echo level events (n = 15/77, 19.5%), and emergency transport (45/231, 19.5%). The optimized strategy improved linkage in these groups by 68.8% (64/93), 79.2% (187/236), 40.0% (6/15), and 51.1% (23/45) respectively. For dispatch card, the highest linkage failure occurred in Card 24-Pregnancy/Childbirth/Miscarriage (n = 30/44, 68.2%), Card 27-Stab/Gunshot/Penetrating Trauma (n = 6/17, 35.3%), and Card 9-Cardiac/Respiratory Arrest/Death (n = 12/46, 26.1%). The optimized strategy improved linkage by 10.0% (3/30), 83.3% (5/6), and 41.7% (5/12) respectively. For the 119 unlinked records, 71 (59.7%) had sufficient information for linkage, but no appropriately matching records could be found. Conclusion: An optimized sequential deterministic strategy linking EMS data to ED outcomes improved the linkage rate without increasing the number of false positive links, and reduced the potential for bias. Even with adequate information, some records were not linked to their ED visit. This study underscores the importance of understanding how data are linked to hospital outcomes in EMS research and the potential for bias.

Venous Thromboembolism Prophylaxis in Neurocritical Care Patients: Are Current Practices, Best Practices?

BACKGROUND/OBJECTIVES: Venous thromboembolism (VTE) is a leading cause of preventable, in-hospital deaths; critically ill patients have a higher risk. Effective and efficient strategies to prevent VTE exist; however, neurocritical care patients present unique challenges due to competing risk of bleeding. The objective of this study was to examine current VTE prophylaxis practices among neurocritical care patients, concordance with guideline-recommended care, and the association with clinical outcomes. METHODS: This retrospective cohort study of patients admitted to ten adult, medical-surgical and neurological intensive care units (ICUs) in nine hospitals between 2014 and 2017 using administrative and clinical data. Neurocritical care patients were classified based on the primary admission diagnosis. Concordance with guideline-recommended care was evaluated using recommendations from recent guidelines. RESULTS: 20.0% of 23,191 patients were classified as neurocritical care. Among neurocritical care patients, pharmacological VTE prophylaxis was administered on 60.9% of all ICU days, mechanical VTE prophylaxis on 46.9%, and no VTE prophylaxis on 12.2% of all ICU days. Type of VTE prophylaxis was associated with sex, neurological diagnosis, and invasive neurological monitoring. Fifty-six percentage of ICU days were guideline concordant but concordance varied by recommendation (range 6-100%) and by type of VTE prophylaxis recommended (p = 0.05); among patients where guidelines recommended use of pharmacologic prophylaxis, care was concordant 26.6% of ICU days, whereas for mechanical prophylaxis it was concordant 80.5% of ICU days. There was an overall improvement in guideline concordance on 2.3% of ICU days after the publication of the Society of Neurocritical Care guideline (p = 0.005). CONCLUSIONS: Neurocritical care patients commonly receive mechanical VTE prophylaxis despite guidelines recommending the use of pharmacological VTE prophylaxis. Our findings suggest uncertainty around best VTE prophylaxis practices for neurocritical care patients remains.

Culturing rate and the surveillance of bloodstream infections: a population-based assessment.

OBJECTIVES: Diagnosis of a bloodstream infection (BSI) requires a positive blood culture. However, low culturing rates will underestimate the true incidence of BSI and high rates may increase the risk of false-positive results. We sought to investigate the relationship between culturing rates and the incidence of BSI at the population level. METHODS: Population-based surveillance was conducted in the western interior of British Columbia, Canada, between 1 April 2010 and 31 March 2017. RESULTS: Among 60 243 blood culture sets drawn, 5591 isolates were obtained, of which 2303 were incident, 1929 were repeat positive and 1359 were contaminants. Overall annual rates of culturing, incident, repeat positive and contaminant isolates were 4832, 185, 155 and 109 per 100 000 population, respectively. During the 84-month study, there was an increase in the culturing rate that reached a plateau at 48 months (5403 cultures per 100 000 per year). The rate of both repeat isolates and contaminants increased linearly with an increasing culturing rate. However, the incident isolate rate reached an inflection point at a rate of approximately 5550 per 100 000 annually, at which point the increase in incident isolates per culture sample was diminished. At a culturing rate above 6123 per 100 000 per year, the number of repeat isolates exceeded that of incident isolates. CONCLUSIONS: The determined incidence of BSI will increase with increased culturing in a population. Further studies are needed to explore optimal BSI culturing rates in other populations.

Cost and outcomes of nosocomial bloodstream infections complicating major traumatic injury.

The objective of this study was to assess the incidence, outcomes, and costs of trauma-related nosocomial bloodstream infection (BSI). This was a 3:1 matched cohort study in patients with severe trauma [defined by an injury severity score (ISS)≥12] admitted to adult or paediatric regional trauma centres over a four-year period. Case patients with nosocomial BSI were matched to controls without a BSI based on predetermined criteria. Outcomes of interest included mortality, length of stay (LOS), and cost attributable to nosocomial BSI. Fifty-seven cases were identified, among whom 51 were successfully matched to three controls. The mean ISS among cases was 30.3, and Staphylococcus aureus was the most commonly isolated pathogen (27%). Being a case was accompanied by a 27% relative increase in the hospital LOS (P=0.02). The odds ratio for 30 day mortality associated with being a case was 5.8 (95% confidence interval (CI): 1.1-30.8; P=0.04). Among survivor-matched groups, being a case was associated with 53% relative increase in the geometric mean total hospital cost [$97,993 (95% CI: $70,143-136,899) for cases and $62,297 (95% CI: $52,155-74,411) for controls, P<0.0001]. This is the first study to show that nosocomial BSI complicating severe trauma is associated with a substantial increase in hospital LOS and in total hospital cost. Our data provide justification to support efforts to reduce the adverse impact of BSI in trauma victims.

Characterization of the phantom material virtual water in high-energy photon and electron beams.

The material Virtual Water has been characterized in photon and electron beams. Range-scaling factors and fluence correction factors were obtained, the latter with an uncertainty of around 0.2%. This level of uncertainty means that it may be possible to perform dosimetry in a solid phantom with an accuracy approaching that of measurements in water. Two formulations of Virtual Water were investigated with nominally the same elemental composition but differing densities. For photon beams neither formulation showed exact water equivalence-the water/Virtual Water dose ratio varied with the depth of measurement with a difference of over 1% at 10 cm depth. However, by using a density (range) scaling factor very good agreement (<0.2%) between water and Virtual Water at all depths was obtained. In the case of electron beams a range-scaling factor was also required to match the shapes of the depth dose curves in water and Virtual Water. However, there remained a difference in the measured fluence in the two phantoms after this scaling factor had been applied. For measurements around the peak of the depth-dose curve and the reference depth this difference showed some small energy dependence but was in the range 0.1%-0.4%. Perturbation measurements have indicated that small slabs of material upstream of a detector have a small (<0.1% effect) on the chamber reading but material behind the detector can have a larger effect. This has consequences for the design of experiments and in the comparison of measurements and Monte Carlo-derived values.

Pre-irradiation effects on ionization chambers used in radiation therapy.

Dosimetry protocols recommend that ionization chambers used in radiation therapy be pre-irradiated until they 'settle', i.e., until a stable reading is obtained. Previous reports have claimed that a lack of pre-irradiation could result in errors up to several per cent. Recently, data collected for a large number of commonly used ion chambers at the Institute for National Measurement Standards, NRC, Canada, have been collated and analysed, with additional data contributed by the National Physical Laboratory, UK. With this data set, it was possible to relate patterns of ion chamber behaviour to design parameters. While several mechanisms seem to contribute to this behaviour, the most obvious correlations implicate the type of insulator surrounding the central collector electrode, the extent of collector electrode shielding and possibly the area of the insulator exposed at the base of the active air volume. The results show that ion chambers with electrode connections guarded up to the active air volume settle quickly (approximately 9 min) and the change in response is small (less than approximately 0.2%). For ion chambers where the guard connection surrounding the central collector does not extend up to the active air volume, settling times of 15-20 min and an associated change in response of up to 1% are typical. For some models of ion chambers, the irradiation rate may also play a role in settling behaviour. Settling times for the ion chambers studied here were found to be independent of beam quality.

Inflammation-associated gene expression is altered between normal human ovarian surface epithelial cells and cell lines derived from ovarian adenocarcinomas.

Ovulation is believed to contribute to the development of ovarian cancers that derive from the ovarian surface epithelium (OSE). The process of ovulation is synonymous with inflammation and inflammatory cytokines such as interleukin-1alpha (IL-1alpha) have recently been shown to induce both inflammatory and anti-inflammatory responses in human OSE (HOSE) cells. In this study we directly compared levels of IL-1alpha-induced gene expression by analysing the levels of 11beta-hydroxysteroid dehydrogenase (11betaHSD) types 1 (11betaHSD-1) and 2 (11betaHSD-2), cyclooxygenase-2 (COX-2), IL-1 receptor (IL-1R) and glucocorticoid receptor alpha (GRalpha) mRNA between normal HOSE cells and cell lines derived from poorly differentiated (SKOV-3, BG-1, PEO-4) and well-differentiated (PEO-14) ovarian adenocarcinoma. In HOSE cell cultures, and to a lesser extent PEO-14 cells, the basal mRNA levels of COX-2 and 11betaHSD-1 were relatively high and further shown to be induced in response to IL-1alpha (for HOSE cells; >20-fold, P<0.05 and PEO-14 cells; >3fold, P<0.05). However, whereas HOSE cells expressed a low level of 11betaHSD-2 mRNA that was only mildly responsive to IL-1alpha (1.3-fold, P<0.001), all cell lines exhibited a higher basal level of 11betaHSD-2 mRNA that was in some cases further stimulated in PEO-4 cells (five-fold; P<0.05) or suppressed in SKOV-3 cells (two-fold; P<0.01) in response to IL-1alpha. All cells tested expressed IL-1R and, with the exception of BG-1, GRalpha. These results indicate that cell lines derived from ovarian cancers have lost the ability to respond normally to inflammatory cytokines such as IL-1alpha. The finding that normal OSE cells, in contrast to cell lines derived from patients with ovarian adenocarcinoma, abundantly express 11betaHSD-1 mRNA but are essentially devoid of 11betaHSD-2 mRNA supports the concept that the pattern of 11betaHSD isoform gene expression is a defining feature of neoplastic cellular transformation, which might have particular relevance to the ovary.

Steroid signalling in human ovarian surface epithelial cells: the response to interleukin-1alpha determined by microarray analysis.

The human ovarian surface epithelium (HOSE) is a common site of gynaecological disease including endometriosis and ovarian cancer, probably due to serial injury-repair events associated with successive ovulations. To comprehend the importance of steroid signalling in the regulation of the HOSE, we used a custom microarray to catalogue the expression of over 250 genes involved in the synthesis and reception of steroid hormones, sterols and retinoids. The array included a subset of non-steroidogenic genes commonly involved in pro-/anti-inflammatory signalling. HOSE cells donated by five patients undergoing surgery for non-malignant gynaecological conditions were cultured for 48 h in the presence and absence of 500 pg/ml interleukin-1alpha (IL-1alpha). Total RNA was reverse-transcribed into biotin-labelled cDNA, which was hybridised to the array and visualised by gold-particle resonance light scattering and charge-coupled device (CCD) camera detection. Results for selected genes were verified by quantitative reverse-transcription PCR. In five out of five cases, untreated HOSE cells expressed genes encoding enzymes required for de novo biosynthesis of cholesterol from acetate and subsequent formation of C21-pregnane and C19-androstane steroids. Consistent with the inability of HOSE cells to synthesise glucocorticoids, oestrogens or 5alpha-reduced androgens de novo, CYP21, CYP19 and 5alpha-reductase were not detected. The only steroidogenic gene significantly up-regulated by IL-1alpha was 11beta-hydroxysteroid dehydrogenase type 1 (11betaHSD1). Other cytokine-induced genes were IL-6, IL-8, nuclear factor kappaB (NFkappaB) inhibitor alpha, metallothionein-IIA and lysyl oxidase: inflammation-associated genes that respond to glucocorticoids. The only steroidogenic gene significantly suppressed by IL-1alpha was 3betaHSD1. Other genes suppressed by IL-1alpha were aldehyde dehydrogenase (ALDH) 1, ALDH 10, gonadotrophin hormone-releasing hormone receptor, peroxisome proliferation-activated receptor-binding protein (PPAR-bp) and nuclear receptor subfamily 2 group F member 2. These results define a steroidogenic phenotype of cultured HOSE cells and provide a limited expression profile for genes with associated signalling functions. IL-1alpha co-ordinately induces 11betaHSD1 and a panel of glucocorticoid-regulated, inflammation-associated genes in HOSE cells, providing further evidence that cortisol generated by 11betaHSD1 could participate in the local resolution of inflammation associated with ovulation.

Anti-inflammatory and proliferative responses in human and ovine ovarian surface epithelial cells.

The majority of ovarian cancers (>90%) are believed to derive from the ovarian surface epithelium (OSE); a single layer covering the entire surface of the ovary. At ovulation, the OSE cell layer undergoes an inflammatory response, involving cell death and growth, in order to overcome ovarian surface rupture. Abnormalities during these processes are believed to contribute to the development of tumours. Using primary cultures of OSE cells, we have compared anti-inflammatory and proliferative responses directly between human and ovine OSE cells to further establish the use of ovine OSE cells as a suitable model system for the study of human OSE cells. In order to compare effects of inflammatory stimulation, expression and activity of 11betahydroxysteroid dehydrogenase (11betaHSD) type 1 was measured in OSE cells in response to interleukin (IL)-1alpha. As previously identified in human OSE cells, treatment of ovine OSE cells with IL-1alpha stimulated a concomitant increase of 11betaHSD type 1 mRNA (31-fold; P <0.05) and oxoreductase activity, indicating an increased production of anti-inflammatory cortisol. To compare the growth of human and ovine OSE cells, OSE cell number was measured in response to treatment with gonadotropins or growth factors. In the presence of FSH, LH or human chorionic gonadotropin (hCG), ovine and human OSE cell growth was similarly stimulated >1.2-fold (P <0.05). In the presence of connective tissue growth factor (CTGF) and more significantly insulin growth factor I (IGF-I), human and ovine OSE cell growth was also similarly stimulated >1.2-fold (P <0.05) and >1.5-fold (P <0.01), respectively. The induction of both human and ovine OSE cell growth by IGF-I or hCG was further shown to be dependent on activation of the MAP kinase/extracellular-signal-regulated kinase (ERK) pathway. Stimulation of ovine OSE cell growth by hepatocyte growth factor (HGF) was similarly shown to be ERK-dependent; however, for human OSE cells, HGF only mildly stimulated ERK phosphorylation and failed to stimulate OSE cell growth. The demonstration that human and ovine OSE cells share similarities at the level of cell signalling, gene expression and cellular growth supports the use of ovine OSE cells as a suitable model for the study of human OSE cells.

Apolipophorin-III in the greater wax moth, Galleria mellonella (Lepidoptera: Pyralidae).

The level of apolipophorin-III reached a maximum in the haemolymph of Galleria mellonella at the end of the feeding phase of the seventh larval instar and declined to a plateau value in the pupal and the adult stages. Apolipophorin-III was detected immunologically in fat body tissue, haemocyte lysates, and plasma. In its native state, apolipophorin-III may be associated with another protein with an apparent molecular mass of 77 kDa, possibly apolipophorin-II. Injections of octopamine did not cause lipid loading of high density lipophorin.

Iron content of Streptococcus suis and evidence for a dpr homologue.

The type strain of Streptococcus suis was investigated for features that might help the organism to tolerate the H2O2 that is produced during growth. Enzyme assays, using soluble extracts, revealed that the type strain, which lacks catalase, lacks NADH peroxidase in both the mid-exponential and stationary phases of the growth cycle. Although iron could not be detected colourimetrically in dense cell suspensions, determination of the cellular iron content following growth to early stationary phase in the presence of 55FeCl3 demonstrated that S. suis does contain iron and hence is incapable of iron exclusion. Gene amplification, using oligonucleotide primers based on dpr of Streptococcus mutans, followed by nucleotide sequencing, revealed in S. suis, the presence of a gene that encodes a Dpr homologue. It is concluded that in S. suis, tolerance of H2O2 is due to iron sequestration by Dpr and the consequent effect of this process on the extent of Fenton chemistry.

Production of transferrin receptors by Histophilus ovis: three of five strains require two signals.

Five strains of Histophilus ovis (9L, 642A, 714, 5688T, and 3384Y) were investigated with respect to iron acquisition. All strains used ovine, bovine, and goat transferrins (Tfs), but not porcine or human Tfs, as iron sources for growth. In solid phase binding assays, total membranes from only two (9L and 642A) of the five strains, grown under iron-restricted conditions, were able to bind Tfs (ovine, bovine, and goat, but not porcine or human). However, when the organisms were grown under iron-restricted conditions in the presence of bovine transferrin (Tf), total membranes from all strains exhibited Tf binding (as above); competition experiments demonstrated that all three Tfs (ovine, bovine, and goat) were bound by the same receptor(s). Membranes from organisms grown under iron-replete conditions in the presence or absence of bovine Tf failed to bind any of the test Tfs. An affinity-isolation procedure allowed the isolation of two putative Tf-binding polypeptides (78 and 66 kDa) from total membranes of strains 9L and 642A grown under iron-restricted conditions, and from membranes of all strains if the growth medium also contained Tf. It is concluded that all strains tested acquire Tf-bound iron by means of siderophore-independent mechanisms involving surface receptors analogous to the Tf-binding proteins (TbpA and TbpB) found in comparable organisms; although iron restriction alone is sufficient to promote the expression of these proteins by strains 9L and 642A, their production by strains 714, 5688T, and 3384Y appears to require two signals, iron restriction and the presence of Tf.

Effects of Plagiorchis elegans (Trematoda: Plagiorchiidae) infection on the carbohydrate metabolism of fourth instar Aedes aegypti (Diptera: Culicidae).

Infection of fourth-instar Aedes aegypti (L.) with the entomopathogenic digenean Plagiorchis elegans (Rudolphi) alters the carbohydrate metabolism of the insect. Within 24 h of cercarial penetration, total body extracts of infected fourth instars exhibited decreased trehalase activity, increased trehalose-6-phosphatase activity, and a concomitant accumulation of trehalose when compared with uninfected larvae. The amounts of glucose, glycogen and lipids, and the activity of glycogen phosphorylase a were similar in extracts of infected and control larvae. The predominant fatty acids, in both control and infected larvae, were C 18:0, C 18:1, and C 18:3. There were no significant differences in the types or proportions of fatty acids found in control and infected larvae. Parasitic infection is discussed in terms of impaired trehalose metabolism.

Unpacking the black box of nursing and therapy practice for post-stroke shoulder pain: a precursor to evaluation.

OBJECTIVES: To describe current nursing and therapy interventions for the prevention and treatment of post-stroke shoulder pain and to explore the extent of their reported use in England. DESIGN: Semi-structured, the med interviews followed by a postal questionnaire. PARTICIPANTS: Six nurses, five occupational therapists (OTs) and six physiotherapists (PTs) were interviewed. Twelve nurses, 12 OTs and 12 PTs were sent the pilot questionnaire and the main questionnaire was posted to 332 nurses, 332 OTs and 332 PTs. SETTING: NHS Trusts in England which provide acute stroke care/rehabilitation. PROCEDURE: Two researchers independently condensed the transcripts of the interviews into a list of interventions which were then transformed into a pilot postal questionnaire. Following the pilot small changes were made. Participants sent the main questionnaire were given three weeks to return it before being posted a reminder. After a further two weeks a researcher gave a telephone reminder. RESULTS: One hundred and seventy-five different types of interventions were identified. The main questionnaire (57.8% response rate) found that all of the interventions were used by at least one respondent and that only 22.9% of the interventions were used to the same extent by nurses, OTs and PTs. The data also suggest variation in reported use within professions. CONCLUSIONS: This study has found a large number of interventions for post-stroke shoulder pain which are reported to be used. This might reflect different causes of shoulder pain or variation between clinicians. Answers to these questions are expected to guide future evaluative research.

Apolipophorin-III and the interactions of lipoteichoic acids with the immediate immune responses of Galleria mellonella.

We investigated the effects of lipoteichoic acids, surface components of Gram-positive bacteria, on the hemocytes and phenoloxidase activity in last instar Galleria mellonella larvae, as well as the binding of apolipophorin-III, an insect lipid-binding protein, to lipoteichoic acids. Binding of apolipophorin-III to lipoteichoic acid was studied using an assay based on 1,9-dimethylmethylene blue. Apolipophorin-III bound the lipoteichoic acids from Bacillus subtilis, Enterococcus hirae, and Streptococcus pyogenes and to intact cells of E. hirae. E. hirae lipoteichoic acid promoted the binding of apolipophorin-III to the cells of this species. All lipoteichoic acids tested caused a dose- and time-dependent drop in the total counts of hemocytes and, depending on the species of lipoteichoic acid, partial or complete depletion of plasmatocytes. Granulocyte counts were not affected. Apolipophorin-III prevented partially the loss of plasmatocytes due to B. subtilis lipoteichoic acid. All three lipoteichoic acids studied activated phenoloxidase in vitro; injections of B. subtilis lipoteichoic acid into the larvae elevated the phenoloxidase activity, whereas injections of E. hirae or S. pyogenes lipoteichoic acid, or apolipophorin-III alone, suppressed it. Apolipophorin-III decreased the activation of phenoloxidase by B. subtilis lipoteichoic acid.

Effects of iron and manganese availability on growth and production of superoxide dismutase by Streptococcus suis.

A complex medium supported good growth of the type strain of Streptococcus suis irrespective of the presence or absence of a high concentration (1 microM) of the iron chelating agent, ethylenediamine di-o-hydroxyphenylacetic acid. Good growth was also obtained using a complex medium that had been treated with Chelex-100 to reduce the iron content, but only if this medium was supplemented with manganese; supplementation with iron had little effect. Collectively, these results indicate that S. suis requires manganese, but not iron, for growth. Polyacrylamide gel electrophoresis of cell extracts followed by activity staining revealed the presence of a single manganese-cofactored superoxide dismutase; activity staining and enzyme assays revealed that manganese availability during growth affected the activity of the superoxide dismutase in cell extracts. The results are discussed with respect to the capacity of S. suis to avoid damage by reactive oxygen species.

Comparative study of iron acquisition by biotype 1 and biotype 2 strains of Actinobacillus pleuropneumoniae.

Four strains of the swine pathogen, Actinobacillus pleuropneumoniae, namely, the type strain (ATCC 27088; biotype 1), the 'reference' strain of biotype 2 (Bertschinger 2008/76), and two additional biotype 1 strains, strain BC181, which is less virulent than the type strain, and strain K17, which was isolated from a lamb, were investigated with respect to iron acquisition. All strains produced iron-repressible outer membrane proteins. However, only the type and biotype 2 strains could acquire iron from porcine transferrin and no organism could utilize human, bovine or ovine transferrin, or ovine or porcine lactoferrin; haemoglobin supported good growth of all strains except strain K17. In all cases, iron acquisition from transferrin and haemoglobin required direct contact between the organisms and the proteins indicating the existence of specific receptors. An affinity isolation technique, using biotinylated porcine transferrin plus streptavidin-agarose, allowed the isolation of the following polypeptides from total membranes of organisms grown under iron-restricted conditions: 99 kDa and 64 kDa from ATCC 27088; 93 kDa from Bertschinger 2008/76; 95 kDa (trace amounts) and 60 kDa from BC181; none from K17. These results indicate that the 93-99 kDa polypeptides are involved in the acquisition of iron from porcine transferrin and that the inability of strain K17 to use transferrin as an iron source is due, probably, to the lack of, or a defect in, an analogous component.

Contact-dependent acquisition of transferrin-bound iron by two strains of Haemophilus parasuis.

Two strains of Haemophilus parasuis, namely, the type strain (ATCC 19417) and strain E751, were investigated with respect to iron acquisition. Both strains produced iron-repressible outer membrane proteins and could acquire iron from porcine transferrin but not from porcine lactoferrin. Neither strain used bovine transferrin, and human transferrin was used to only a very limited extent, if at all. In all cases, iron acquisition from transferrin required direct contact between the organisms and the protein. An affinity isolation technique based on biotinylated porcine transferrin plus streptavidin-agarose, followed by SDS-PAGE, allowed the isolation and identification of two potential porcine transferrin binding polypeptides (94 and 60 kDa) from total membranes derived from the type strain grown under iron-restricted conditions but only one (96 kDa) from strain E751. Each of these polypeptides was iron repressible and was not isolated when biotinylated human or bovine transferrin was used instead of biotinylated porcine transferrin. It is concluded that both strains acquire transferrin-bound iron by means of siderophore-independent mechanisms and that the isolated polypeptides represent porcine transferrin receptor components.

When times get tough, what happens to TQM? Case study.

When Mueller Chemical Company's biggest customer, Ameriton, demanded that MCC install a total quality management system five years ago, the effort seemed worth it. Morale improved dramatically at the German company, as did quality and productivity. But now, in this fictional case study, Ameriton has gone bankrupt. As a result, MCC has had to cut its work force, and senior managers are meeting to decide whether TQM should be part of the downsized MCC. Horst Koblitz, director of TQM, and Division Manager Eva Stichen both vote yes. Stichen's division, which never supplied Ameriton, has turned its process-control system into the company's best thanks to TQM. The division is more cost-efficient, product defects are nearly nonexistent, and its safety record is spotless. As Koblitz notes, Ameriton's failure is no reason to abandon all that MCC has built. Furthermore, shareholders and customers would think that MCC was panicking. MCC just needs to tailor its TQM program to a smaller organization. But CFO Georg Becker doesn't think MCC has the time or resources for fine-tuning. And as he sees it, that might be just as well. The distractions that came with TQM took MCC away from its goal of becoming the chemicals market leader in Europe. While the company organized teams, developed measurement systems, and filled out quality reports, its competitors took away much of the market share MCC was after. TQM was a good long-term approach, but it didn't come with a plan for MCC's current situation. And CEO and Chairman Dieter Mueller won't compromise; TQM must either stay or go.(ABSTRACT TRUNCATED AT 250 WORDS)