Securing access to personnel and materials in transboundary animal disease responses.

A lack of human and material resources can limit effective responses to animal disease emergencies. Drawing upon examples from Australia and New Zealand, this paper proposes a framework for identifying human and material resources and securing the necessary personnel and materials before or during an animal disease emergency. This staged process involves: a) assessing the nature of the risks to be managed, b) identifying the types of resources required, c) assessing available resources and identifying gaps and d) developing arrangements to ensure availability of resources. It discusses the advantages and disadvantages of different strategies to secure access to human and material resources, including whole-of-government arrangements to access other government resources, national and international reserve models for responders, just-in-time employment and purchase of materials, and purchase of stockpiles.

La disponibilité insuffisante des ressources tant humaines que matérielles peut limiter l'efficacité des interventions en cas d'urgence zoosanitaire. À partir de l'expérience acquise par l'Australie et la Nouvelle-Zélande, les auteurs proposent un cadre permettant d'inventorier les ressources humaines et matérielles et de garantir la disponibilité des personnels et des équipements nécessaires avant ou pendant une urgence zoosanitaire. Le processus par étapes proposé prévoit : a) d'évaluer la nature des risques qu'il conviendra de traiter ; b) d'identifier les types de ressources à mobiliser ; c) d'évaluer les ressources disponibles et les lacunes ; d) de prendre les dispositions nécessaires pour garantir la disponibilité opérationnelle des ressources. Les auteurs examinent les avantages et les inconvénients respectifs de diverses stratégies visant à se doter des ressources humaines et matérielles nécessaires, en particulier les dispositions gouvernementales permettant de réquisitionner d'autres ressources publiques, les schémas nationaux et internationaux d'intervenants réservistes, les dispositifs d'emploi et d'achats de matériel à flux tendus et la constitution de stocks stratégiques.

La cantidad de recursos humanos y materiales disponibles puede ser un factor limitante a la hora de responder eficazmente a las emergencias zoosanitarias. Partiendo de ejemplos tomados de Australia y Nueva Zelanda, los autores proponen un marco de referencia para determinar los recursos humanos y materiales necesarios y asegurarse de contar con ellos antes o en el curso de una emergencia zoosanitaria. Se trata de un proceso por etapas, que pasa por: a) evaluar la naturaleza de los riesgos que hay que manejar; b) determinar los tipos de recursos que se requieren; c) determinar los recursos disponibles y los faltantes; y d) concebir e implantar disposiciones para asegurarse de tener disponibles todos esos recursos. Los autores pasan revista a las ventajas e inconvenientes de distintos procedimientos para asegurarse el acceso a recursos humanos y materiales, tales como: la aplicación de disposiciones que, abarcando todas las instancias gubernamentales, garanticen el acceso a recursos de otras instancias públicas; los modelos de personal reservista nacional e internacional; los métodos de contratación y compra de material «justo a tiempo¼ (just-in-time); o la adquisición por adelantado de existencias de reserva.

Reproduction in grazing dairy cows treated with 14-day controlled internal drug release for presynchronization before timed artificial insemination compared with artificial insemination after observed estrus.

Progesterone-releasing (controlled internal drug release, CIDR) devices inserted for 14 d are used to presynchronize the estrous cycle for timed artificial insemination (TAI) in beef heifers (14-d CIDR-PGF(2α) program). The objective was to test a similar program in dairy cows by measuring first-service conception rates (FSCR), pregnancy rates after 2 AI, and time to pregnancy compared with a control (AI after observed estrus). Postpartum cows (Holstein, Jersey, or crossbred; n=1,363) from 4 grazing dairy farms were assigned to 1 of 2 programs: 14dCIDR_TAI [CIDR in for 14 d, CIDR out, PGF(2α) injection at 19 d after CIDR removal, GnRH injection 56 h later, and then TAI 16 h later; n=737] or control [AI after observed estrus; reproductive program with PGF(2α) (cycling cows) and CIDR (noncycling cows) to synchronize estrus with the start of the breeding season; n=626]. Body condition was scored (1 to 5; thin to fat) at the start of the trial. The interval from the start of the breeding period (final PGF(2α) injection of either program) to first AI was shorter for 14dCIDR_TAI compared with the control (3.0±0.2 vs. 5.3±0.2 d; mean ± SEM) but 14dCIDR_TAI cows had lesser FSCR than controls (48 vs. 61%). Farm affected FSCR (50, 51, 67, and 58% for farms 1 to 4). The BCS affected FSCR (50, 55, and 62% for BCS=2, 2.5, and 3, respectively). Cows that either calved the year before (carryover) or that calved early in the calving season had greater FSCR than cows that calved later in the calving season (55, 61, and 42%, respectively). The percentage of cows pregnant to AI (first and second inseminations within 31-d breeding season) was similar for 14dCIDR_TAI and control (64 vs. 70%) cows, but farm (64, 62, 80, and 69%) and time of calving (70, 76, and 56%: carryover, early, and late, respectively) affected the percentage. Survival analyses showed an initial advantage for 14dCIDR_TAI (more cows inseminated and more pregnancies achieved early in the breeding season) that was not maintained over time. Conclusions were that the 14dCIDR_TAI program achieved acceptable FSCR (48%) and overall AI pregnancy rates (64%), but did not surpass a control program that used AI after observed estrus (61 and 70%, respectively).

Short communication: presynchronization for timed artificial insemination in grazing dairy cows by using progesterone for 14 days with or without prostaglandin F2α at the time of progesterone withdrawal.

Progesterone-containing devices can be inserted intravaginally for 14 d to presynchronize the estrous cycle for timed artificial insemination (TAI) in beef heifers ("14-day CIDR-PG" or "Show-Me-Synch" program). The progesterone treatment is effective for presynchronization because cattle develop a persistent dominant follicle during treatment that ovulates within 3 d after progesterone removal. The subsequent estrous cycle can be effectively used for a TAI program. Some cattle will retain a functional corpus luteum (CL) for the entire 14-d treatment period and will not be synchronized effectively because the interval to ovulation depends on the lifespan of their existing CL. The objective was to test the effect of a luteolytic dose of PGF(2α) at progesterone removal for improving synchrony of estrus after treatment and increasing conception rate to a subsequent TAI in dairy cows. Postpartum cows (n = 1,021) from 2 grazing dairy herds were assigned to 1 of 2 presynchronization programs that used a controlled internal drug releasing (CIDR) device containing progesterone: 14dCIDR (CIDR in, 14 d, CIDR out; n = 523) or 14dCIDR+PGF(2α) (CIDR in, 14 d, CIDR out, and PGF(2α); n = 498). Cows were body condition scored (BCS; 1 to 5, thin to fat) and tail painted at CIDR removal. Paint score (PS) was recorded after CIDR removal [PS = 0 (all paint removed, indication of estrus), PS = 3 (paint partially removed), or PS = 5 (no paint removed; indication of no estrus)]. At 19 d after CIDR removal, all cows were treated with PGF(2α), 56 h later treated with GnRH, and then 16 h later were TAI. Treating cows with PGF(2α) at CIDR removal increased the percentage with PS = 0 within 5 d (58.1% vs. 68.9%; 14dCIDR vs. 14dCIDR+PGF(2α)). We found no effect of treatment, however, on conception rate at TAI (41.1% vs. 43.6%; respectively). The TAI conception rate increased with increasing BCS and was greater for cows that had PS = 0 within 5 d after CIDR removal. In summary, treating cows with PGF(2α) at CIDR removal increased the percentage of cows with all tail paint removed but did not increase percentage of pregnant cows after TAI.

Erratum to "Reproductive performance of early- and late-calving dairy cows artificially inseminated after ovulation synchronization and estrous resynchronization or artificially inseminated after observed estrus" (JDS Commun. 2:80-85).

[This corrects the article DOI: 10.3168/jdsc.2020-0035.].

Principles of epidemiological modelling.

Epidemiological modelling can be a powerful tool to assist animal health policy development and disease prevention and control. Models can vary from simple deterministic mathematical models through to complex spatially-explicit stochastic simulations and decision support systems. The approach used will vary depending on the purpose of the study, how well the epidemiology of a disease is understood, the amount and quality of data available, and the background and experience of the modellers. Epidemiological models can be classified into various categories depending on their treatment of variability, chance and uncertainty (deterministic or stochastic), time (continuous or discrete intervals), space (non-spatial or spatial) and the structure of the population (homogenous or heterogeneous mixing). The increasing sophistication of computers, together with greater recognition of the importance of spatial elements in the spread and control of disease, mean that models which incorporate spatial components are becoming more important in epidemiological studies. Multidisciplinary approaches using a range of new technologies make it possible to build more sophisticated models of animal disease. New generation epidemiological models enable disease to be studied in the context of physical, economic, technological, health, media and political infrastructures. To be useful in policy development, models must be fit for purpose and appropriately verified and validated. This involves ensuring that the model is an adequate representation of the system under study and that its outputs are sufficiently accurate and precise for the intended purpose. Finally, models are just one tool for providing technical advice, and should not be considered in isolation from data from experimental and field studies.

Reproductive performance of early- and late-calving dairy cows artificially inseminated after ovulation synchronization and estrous resynchronization or artificially inseminated after observed estrus.

Within seasonal dairy systems, cows that calve late in the calving season are less likely to become pregnant and maintain a yearly calving interval. Very few studies have examined effective strategies for reproductive management of these late-calving cows. The objectives were to evaluate the reproductive performance of early- and late-calving dairy cows that were either inseminated after observed estrus (control) or enrolled in a timed AI and resynchronization protocol [progesterone (P4) Ovsynch Resynch)]. Early-calving cows calved during the first week of the calving season, whereas late-calving cows calved after 6 wk but were at least 10 d in milk at study commencement. Three dairy herds participated in the study with 391 cows total. Within each calving group, cows were randomly assigned to P4 Ovsynch Resynch or control (no treatment) in a 2 × 2 experimental design. Artificial insemination continued for 6 wk after mating start date (MSD) and was followed by 6 wk of natural service. The interval from MSD to AI was shorter (11.7 vs. 14.7 d) and the 3-wk pregnancy rate (49.5 vs. 21.2%) and the 6-wk pregnancy rate (60.8 vs. 42.4%) were greater in the early-calving compared with the late-calving control cows. By design, synchronized cows received timed AI on MSD and were not included in the statistical analysis of submission rate and interval from MSD to AI. The proportion of cows that received a second AI was not increased by the progesterone-based resynchronization strategy but was greater in early-calving compared with late-calving cows. The 12-wk pregnancy rate was greater (64.5 vs. 45.0%) in the early-calving synchronized cows compared with the late-calving synchronized cows. The interval from MSD to pregnancy was 6 and 12.6 d shorter for synchronized compared with control cows in the early- and late-calving groups, respectively. The results demonstrated reduced reproductive performance of late-calving cows compared with early-calving cows. Nonetheless, a major improvement to reproductive performance was achieved by targeting late-calving cows with a synchronization program, even when cows were only 20 to 50 DIM at first AI. Resynchronization of estrus with a progesterone device only, however, was not sufficient to increase the proportion of nonpregnant cows that received a second AI.

A murine model for bone loss from therapeutic and space-relevant sources of radiation.

Cancer patients receiving radiation therapy are exposed to photon (gamma/X-ray), electron, and less commonly proton radiation. Similarly, astronauts on exploratory missions will be exposed to extended periods of lower-dose radiation from multiple sources and of multiple types, including heavy ions. Therapeutic doses of radiation have been shown to have deleterious consequences on bone health, occasionally causing osteoradionecrosis and spontaneous fractures. However, no animal model exists to study the cause of radiation-induced osteoporosis. Additionally, the effect of lower doses of ionizing radiation, including heavy ions, on general bone quality has not been investigated. This study presents data developing a murine model for radiation-induced bone loss. Female C57BL/6 mice were exposed to gamma, proton, carbon, or iron radiation at 2-Gray doses, representing both a clinical treatment fraction and spaceflight exposure for an exploratory mission. Mice were euthanized 110 days after irradiation. The proximal tibiae and femur diaphyses were analyzed using microcomputed tomography. Results demonstrate profound changes in trabecular architecture. Significant losses in trabecular bone volume fraction were observed for all radiation species: gamma, (-29%), proton (-35%), carbon (-39%), and iron (-34%). Trabecular connectivity density, thickness, spacing, and number were also affected. These data have clear implications for clinical radiotherapy in that bone loss in an animal model has been demonstrated at low doses. Additionally, these data suggest that space radiation has the potential to exacerbate the bone loss caused by microgravity, although lower doses and dose rates need to be studied.

Post-hoc analysis of vitamin D status and reduced risk of preterm birth in two vitamin D pregnancy cohorts compared with South Carolina March of Dimes 2009-2011 rates.

BACKGROUND: Two vitamin D pregnancy supplementation trials were recently undertaken in South Carolina: The NICHD (n=346) and Thrasher Research Fund (TRF, n=163) studies. The findings suggest increased dosages of supplemental vitamin D were associated with improved health outcomes of both mother and newborn, including risk of preterm birth (<37 weeks gestation). How that risk was associated with 25(OH)D serum concentration, a better indicator of vitamin D status than dosage, by race/ethnic group and the potential impact in the community was not previously explored. While a recent IOM report suggested a concentration of 20 ng/mL should be targeted, more recent work suggests optimal conversion of 25(OH)D-1,25(OH)2D takes place at 40 ng/mL in pregnant women. OBJECTIVE: Post-hoc analysis of the relationship between 25(OH)D concentration and preterm birth rates in the NICHD and TRF studies with comparison to Charleston County, South Carolina March of Dimes (CC-MOD) published rates of preterm birth to assess potential risk reduction in the community. METHODS: Using the combined cohort datasets (n=509), preterm birth rates both for the overall population and for the subpopulations achieving 25(OH)D concentrations of ≤20 ng/mL, >20 to <40 ng/mL, and ≥40 ng/mL were calculated; subpopulations broken down by race/ethnicity were also examined. Log-binomial regression was used to test if an association between 25(OH)D serum concentration and preterm birth was present when adjusted for covariates; locally weighted regression (LOESS) was used to explore the relationship between 25(OH)D concentration and gestational age (weeks) at delivery in more detail. These rates were compared with 2009-2011 CC-MOD data to assess potential risk reductions in preterm birth. RESULTS: Women with serum 25(OH)D concentrations ≥40 ng/mL (n=233) had a 57% lower risk of preterm birth compared to those with concentrations ≤20 ng/mL [n=82; RR=0.43, 95% confidence interval (CI)=0.22,0.83]; this lower risk was essentially unchanged after adjusting for covariates (RR=0.41, 95% CI=0.20,0.86). The fitted LOESS curve shows gestation week at birth initially rising steadily with increasing 25(OH)D and then plateauing at ∼40 ng/mL. Broken down by race/ethnicity, there was a 79% lower risk of preterm birth among Hispanic women with 25(OH)D concentrations ≥40 ng/mL (n=92) compared to those with 25(OH)D concentrations ≤20 ng/mL (n=29; RR=0.21, 95% CI=0.06,0.69) and a 45% lower risk among Black women (n=52 and n=50; RR=0.55, 95% CI=0.17,1.76). There were too few white women with low 25(OH)D concentrations for assessment (n=3). Differences by race/ethnicity were not statistically significant with 25(OH)D included as a covariate. Compared to the CC-MOD reference group, women with serum concentrations ≥40 ng/mL in the combined cohort had a 46% lower rate of preterm birth overall (n=233, p=0.004) with a 66% lower rate among Hispanic women (n=92, p=0.01) and a 58% lower rate among black women (n=52, p=0.04). CONCLUSIONS: In this post-hoc analysis, achieving a 25(OH)D serum concentration ≥40 ng/mL significantly decreased the risk of preterm birth compared to ≤20 ng/mL. These findings suggest the importance of raising 25(OH)D levels substantially above 20 ng/mL; reaching 40 ng/mL during pregnancy would reduce the risk of preterm birth and achieve the maximal production of the active hormone.

Post-hoc comparison of vitamin D status at three timepoints during pregnancy demonstrates lower risk of preterm birth with higher vitamin D closer to delivery.

There have been observational reports that maternal vitamin D status at baseline and not closest to delivery is a better predictor of pregnancy outcomes, suggesting that a cascade of events is set into motion that is not modifiable by vitamin D supplementation during later pregnancy. To address this issue, in this exploratory post-hoc analysis using correlation and logistic regression, we sought to measure the strength of the association between serum 25(OH)D concentrations at 3 timepoints during pregnancy: baseline, 1st trimester (<16 weeks); 2nd trimester (16-26 weeks); and 3rd trimester (≥27 weeks) and preterm birth. It was hypothesized that the 25(OH)D value closest to delivery would be most significantly associated with preterm birth. To accomplish this objective, the datasets from NICHD (n=333) and Thrasher Research Fund (n=154) vitamin D supplementation pregnancy studies were combined. The results of this analysis were that 25(OH)D values closer to delivery were more strongly correlated with gestational age at delivery than earlier values: 1st trimester: r=0.11 (p=0.02); 2nd trimester: r=0.08 (p=0.09); and 3rd trimester: r=0.15 (p=0.001). When logistic regression was performed with preterm birth (<37 weeks) as the outcome and 25(OH)D quartiles as the predictor variable, adjusting for study and participant race/ethnicity, as with the correlation analysis, the measurements closer to delivery were more significantly associated and had a higher magnitude of effect. That is, at baseline, those who had serum concentrations <50nmol/L (20ng/mL) had 3.3 times of odds of a preterm birth compared to those with serum concentrations ≥100nmol/L (40ng/mL; p=0.27). At 2nd trimester, the odds were 2.0 fold (p=0.21) and at the end of pregnancy, the odds were 3.8 fold (p=0.01). The major findings from this exploratory analysis were: (1) maternal vitamin D status closest to delivery date was more significantly associated with preterm birth, suggesting that later intervention as a rescue treatment may positively impact the risk of preterm delivery, and (2) a serum concentration of 100nmol/L (40ng/mL) in the 3rd trimester was associated with a 47% reduction in preterm births. This article is part of a Special Issue entitled '17th Vitamin D Workshop'.

Expression of messenger ribonucleic acid encoding cytochrome P450 side-chain cleavage, cytochrome p450 17 alpha-hydroxylase, and cytochrome P450 aromatase in bovine follicles during the first follicular wave.

The objective of the present study was to investigate changes in the expression of messenger RNAs (mRNAs) encoding cytochrome P450 side-chain cleavage (P450scc), cytochrome P450 17 alpha-hydroxylase (P450c17), and cytochrome P450 aromatase (P450arom) at different stages of the first follicular wave of the bovine estrous cycle. Groups of heifers (three to five per group) were ovariectomized on the day of initiation of the first follicular wave (as determined by ultrasonography, day 0) or on days 2, 4, 6, 8, and 10 after initiation of the first follicular wave following estrus. Expression of mRNAs encoding P450scc, P450c17, and P450arom was detected by in situ hybridization and quantified by image analysis. P450scc mRNA was localized to theca interna cells of large preantral follicles and also to granulosa cells of follicles 4 mm or greater in diameter. mRNA for P450c17 was localized exclusively to theca interna cells, whereas P450arom mRNA was localized to granulosa cells of follicles 4 mm or greater in diameter. There were changes in mRNA levels for all three enzymes in thecal and/or granulosa cells at different times of the first follicular wave. Before identification of the dominant follicle (i.e. on days 0 and 2), there was no change in expression of P450scc and P450c17 mRNAs, whereas expression of P450arom mRNA was higher on day 2 than on day 0. Maximal mRNA levels for all three enzymes were observed on day 4. By day 6, P450scc and P450c17 mRNA levels were reduced compared to those on day 4, whereas P450arom mRNA levels remained elevated. On day 8, mRNA levels for all three enzymes were reduced. After initiation of the second follicular wave (day 10), dominant follicles from the first wave were at an advanced stage of atresia. P450scc and P450arom mRNAs were undetectable in granulosa cells, and very low levels of P450scc and P450c17 mRNAs were observed in theca interna cells. Before identification of the dominant follicle, mRNA levels for all three enzymes were similar within a cohort of follicles. Therefore, expression of these enzymes may not be associated with the mechanism of selection of the dominant follicle during a follicular wave.

Depression and bulimia: the link between depression and bulimic cognitions.

This study assessed the link between bulimic and depressive cognitions. Twenty-nine bulimics and 16 controls from the general population were first assessed on levels of depression using the Schedule for Affective Disorders and Schizophrenia-Change Version and the Beck Depression Inventory (BDI). Bulimics were significantly more depressed than controls. Bulimics differed significantly from controls on all cognitive measures associated with depression (Automatic Thoughts Questionnaire, Dysfunctional Attitude Scale, and Attributional Style Questionnaire), but differences on these measures were nonsignificant when depression, as measured by the BDI, was controlled. Bulimics differed from controls regardless of level of depression on the three scales of the Restraint Inventory, the Rationalization and All-or-None scales of the Thoughts About Eating Inventory, and most of the eight scales of the Eating Disorders Inventory. Bulimics showed more maladaptive thinking associated with depression, but these differences likely reflect the levels of depression for each group. The differences on the measures of cognitive and behavioral symptoms of bulimia remained when the level of depression was controlled statistically. This suggests that although depression can be frequently diagnosed in a bulimic sample, specific maladaptive cognitions and behaviors reflect a distinct disorder (bulimia) and are not simply the expression of an affective disorder.

A prospective, randomized, double-blind trial of the use of fibrin sealant for face lifts.

Fibrin sealant imitates the final phase of the blood coagulation process. Fibrinogen is converted into fibrin on a tissue surface by the action of thrombin, which is then cross-linked by factor XIIIa, creating a mechanically stable fibrin network. This fibrin network is thought to reduce the amount of postoperative bleeding by sealing capillary vessels and allowing raw operative surfaces to adhere. The authors conducted a prospective, double-blind, randomized, controlled trial on the use of fibrin sealant in 20 consecutive patients undergoing bilateral face lifts by the same surgeon. Each patient was randomized for the use of fibrin sealant on either the right or the left side with the contralateral side acting as the control. Total drainage was recorded on each side for 24 hours before drains were removed. The age range of the patients in the trial (all of whom were women) was 44 to 70 years (mean, 55). The side treated with fibrin glue had a median drainage of 10 ml and the control side 30 ml. The Wilcoxon signed rank test shows a significant difference in drainage between sides (p = 0.002). The reduction in postoperative drainage could also reduce pain and bruising, increasing patient satisfaction with this procedure. The need for drains may also be obviated.

Oxytocin-induced secretion of prostaglandin F2alpha in postpartum beef cows: effects of progesterone and estradiol-17beta treatment.

The purpose of the present study was to determine the effect of progesterone or progesterone + estradiol-17beta on oxytocin-induced prostaglandin F2alpha (PGF2alpha) secretion in postpartum beef cows. Thirty-four anestrous postpartum beef cows were ovariectomized (d 32 [Groups 1 to 3] or d 23 [Groups 4 to 6] postpartum [d 0 = parturition]) and allotted to six treatments (Group 1; negative control) to simulate short (Groups 2 through 5) or normal (Group 6) length estrous cycles. Steroid treatments for the respective groups were as follows: Group 1) no estradiol-17beta or progesterone treatment (n = 8; negative control); Group 2) progesterone (d 34 to 40; n = 6); Group 3) estradiol-17beta (d 32 to 33) and progesterone (d 34 to 40; n = 6); Group 4) progesterone (d 23 to 29), no estradiol-17beta (d 32 to 33), and progesterone (d 34 to 40; n = 5); Group 5) progesterone (d 23 to 29), estradiol-17beta (d 32 to 33), and progesterone (d 34 to 40; n = 5); and Group 6) progesterone (d 23 to 29), estradiol-17beta (d 32 to 33), and progesterone (d 34 to 50; n = 4; positive control). Oxytocin (100 IU) was injected (i.v.) at the end of each treatment to test the ability of the postpartum uterus to secrete PGF2alpha as measured by a stable metabolite of PGF2alpha, 15keto-13,14 dihydro-PGF2alpha (PGFM). Peak concentrations ofPGFM (P < 0.08) and total PGFM secreted (area under the curve; P < 0.05) were increased on d 6 following first (Group 2) or second (Group 4) exposure to progesterone and were similar to peak concentrations and total PGFM secreted 16 d following a simulated normal estrous cycle (Group 6). Administration of estradiol-17beta before first progesterone exposure (Group 3) did not reduce peak concentrations of PGFM or total PGFM secreted relative to the preceding groups. Peak concentrations of PGFM (P < 0.08) and total PGFM secreted (P < 0.05) were reduced following a second progesterone exposure, provided that cows were pretreated with estradiol-17beta (Group 5). In summary, oxytocin-induced release of PGFM was inhibited on d 6 following second exposure to progesterone only when cows were pretreated with estradiol-17beta. Therefore, estradiol-17beta and progesterone were both associated with the timing of PGF2, secretion in postpartum cows.

Lawrence design first metatarsophalangeal prosthesis. A complication.

A complication involving tibial sesamoid impingement within the hinge of the Lawrence first metatarsophalangeal implant is described. The authors believe that this particular problem may be accentuated by the Lawrence design, which preserves the sesamoid apparatus.

Cardiac arrest following hydrogen peroxide irrigation of a breast wound.

Hydrogen peroxide is commonly used for the decontamination of wounds. We report a case of a probable venous oxygen embolism resulting in cardiovascular collapse following irrigation of a necrotic breast wound with hydrogen peroxide. We discuss the differential diagnosis, mechanism of oxygen embolism and question the relative advantages versus disadvantages of using hydrogen peroxide for wound decontamination.

Dynamically allocating treatment when the cost of goods is high and drug supply is limited.

Large-scale production of proteins by cell culture and subsequent purification for use in novel medical therapies is a slow and complex process. During the early phases of development of manufacturing processes, contamination and replication errors cause entire batches of material to be wasted. As a result, the cost of goods for large-molecule therapies in early clinical development can be significant, and the supply limited. When designing clinical trials to test expensive biological compounds with limited supply, sponsoring companies want to minimize the waste of drug, that is, to maintain small inventories of drug at the investigational hospitals. We must, however, weigh the benefits of smaller inventories against the costs of increased numbers of shipments to resupply when rapid enrollment causes shortages of drug. A well-planned randomization scheme may be able to balance these objectives. This paper demonstrates how a dynamic randomization algorithm can be used to maintain smaller drug inventory at hospitals than a typical permuted block randomization list plan, and how well it automatically restores balance when the shortage of drug causes assignment of alternate treatments.

Statistical analysis of the long-term effects of recombinant human deoxyribonuclease on pulmonary function in cystic fibrosis patients.

The problem of evaluating the long-term effects of recombinant human deoxyribonuclease (rhDNase) on forced expiratory volume in one second (FEV1) in cystic fibrosis (CF) patients was considered. A two-stage mixed effects model, incorporating relevant predictive variables, captured the diverse patterns of decline of FEV1 for patients with different demographic characteristics. Based on the results of modeling the dropout process, it is clear that the probability of early dropout was closely related to patient's responsiveness to rhDNase treatment. Failure to consider the existence of informative censoring severely biased the estimates of the rate of decline and affected the interpretation of the results.

rhDNase as an example of recurrent event analysis.

We consider counting process methods for analysing time-to-event data with multiple or recurrent outcomes, using the models developed by Anderson and Gill, Wei, Lin and Weissfeld and Prentice, Williams and Peterson. We compare the methods, and show how to implement them using popular statistical software programs. By analysing three data sets, we illustrate the strengths and pitfalls of each method. The first example is simulated and involves the effect of a hidden covariate. The second is based on a trial of gamma interferon, and behaves remarkably like the first. The third and most interesting example involves both multiple events and discontinuous intervals at risk, and the three approaches give dissimilar answers. We recommend the AG and marginal models for the analysis of this type of data.

Long-term results of surgical excision and skin grafting for a giant hairy naevus of the face: time for a return to conventional wisdom?

In a publication climate demanding modern innovative treatments for congenital giant hairy naevi, we report a case with excellent long-term results following early surgical excision and split-thickness skin grafting.