Midlothian Community Hospital

BACKGROUND: Despite abundant evidence of racial disparities in the use of surgical procedures, it is uncertain whether these disparities reflect racial differences in clinical appropriateness or overuse or underuse of inappropriate care. METHODS: We performed a literature review and used an expert panel to develop criteria for determining the appropriateness of renal transplantation for patients with end-stage renal disease. Using data from five states and the District of Columbia on patients who had started to undergo dialysis in 1996 or 1997, we selected a random sample of 1518 patients (age range, 18 to 54 years), stratified according to race and sex. We classified the appropriateness of patients as data on candidates for transplantation and analyzed rates of referral to a transplantation center for evaluation, placement on a waiting list, and receipt of a transplant according to race. RESULTS: Black patients were less likely than white patients to be rated as appropriate candidates for transplantation according to appropriateness criteria based on expert opinion (71 blacks [9.0 percent] vs. 152 whites [20.9 percent]) and were more likely to have had incomplete evaluations (368 [46.5 percent] vs. 282 [38.8 percent], P<0.001 for the overall chi-square). Among patients considered to be appropriate candidates for transplantation, blacks were less likely than whites to be referred for evaluation, according to the chart review (90.1 percent vs. 98.0 percent, P=0.008), to be placed on a waiting list (71.0 percent vs. 86.7 percent, P=0.007), or to undergo transplantation (16.9 percent vs. 52.0 percent, P<0.001). Among patients classified as inappropriate candidates, whites were more likely than blacks to be referred for evaluation (57.8 percent vs. 38.4 percent), to be placed on a waiting list (30.9 percent vs. 17.4 percent), and to undergo transplantation (10.3 percent vs. 2.2 percent, P<0.001 for all three comparisons). CONCLUSIONS: Racial disparities in rates of renal transplantation stem from differences in clinical characteristics that affect appropriateness as well as from underuse of transplantation among blacks and overuse among whites. Reducing racial disparities will require efforts to distinguish their specific causes and the development of interventions tailored to address them.

In mammals, Mda5 and RIG-I are members of the evolutionary conserved RIG-like helicase family that play critical roles in the outcome of RNA virus infections. Resolving influenza infection in mammals has been shown to require RIG-I; however, the apparent absence of a RIG-I homolog in chickens raises intriguing questions regarding how this species deals with influenza virus infection. Although chickens are able to resolve certain strains of influenza, they are highly susceptible to others, such as highly pathogenic avian influenza H5N1. Understanding RIG-like helicases in the chicken is of critical importance, especially for developing new therapeutics that may use these systems. With this in mind, we investigated the RIG-like helicase Mda5 in the chicken. We have identified a chicken Mda5 homolog (ChMda5) and assessed its functional activities that relate to antiviral responses. Like mammalian Mda5, ChMda5 expression is upregulated in response to dsRNA stimulation and following IFN activation of cells. Furthermore, RNA interference-mediated knockdown of ChMda5 showed that ChMda5 plays an important role in the IFN response of chicken cells to dsRNA. Intriguingly, although ChMda5 levels are highly upregulated during influenza infection, knockdown of ChMda5 expression does not appear to impact influenza proliferation. Collectively, although Mda5 is functionally active in the chicken, the absence of an apparent RIG-I-like function may contribute to the chicken's susceptibility to highly pathogenic influenza.

INTRODUCTION: although drug-related problems (DRPs) are known to be prevalent in elderly patients, the literature on prevention of iatrogenic disease is sparse. The present study addresses this requirement. OBJECTIVES: to assess the incidence of DRPs in elderly patients admitted to Tayside hospitals before (phase I) and after (phase II) implementation of preventive strategies. DESIGN: all elderly people admitted to hospital were screened by a pharmacist; individual case reviews were prepared for all those with a potential DRP and reviewed by a three-member panel which made a final decision on the presence of a DRP and its contribution to admission. SETTING: all hospital wards admitting elderly patients in the Tayside region of Scotland. SUBJECTS: 1011 elderly patient admissions over a 9-month period (phase I); 857 elderly patient admissions over an 8-month period (phase II). MAIN OUTCOME MEASURES: incidence of DRPs before and after targeted intervention strategies (information bulletin for general practitioners, patient information leaflet, oral presentation to trainee general practitioners). RESULTS: in phase I, the incidence of DRPs was 144/1011 (14.2%), with 54/1011 (5.3%) of the admissions identified as being definitely or probably drug-related. Non-steroidal anti-inflammatory drugs (NSAIDs) were the main drug group involved, being responsible for 15/54 (28%) of admissions primarily due to a DRP. Over 66% of admissions due to adverse effects of NSAIDs were considered to be definitely preventable. In phase II, after targeted intervention strategies, there was no significant reduction in total incidence of DRPs or incidence of DRPs related to NSAIDs. However, there appeared to be an improvement in the first 4 months, and a significant drop in NSAID prescribing in Tayside compared with the rest of Scotland was observed. CONCLUSION: DRPs remain a significant problem in elderly patients and NSAIDs are the major contributor. The intervention strategies used in the study were not demonstrably effective, but a continuous programme of education may be necessary to limit NSAID use.

The effects of a mindfulness-based procedure, called Meditation on the Soles of the Feet, were evaluated as a cognitive-behavioral intervention for physical aggression in 6 offenders with mild intellectual disabilities. They were taught a simple meditation technique that required them to shift their attention and awareness from the precursors of aggression to the soles of their feet, a neutral point on their body. Results showed that physical and verbal aggression decreased substantially, no Stat medication or physical restraint was required, and there were no staff or peer injuries. Benefit-cost analysis of lost days of work and cost of medical and rehabilitation because of injury caused by these individuals in both the 12 months prior to and following mindfulness-based training showed a 95.7% reduction in costs. This study suggests that this procedure may be a clinically effective and cost-effective method of enabling adult offenders with intellectual disabilities to control their aggression.

It is now 18 years since the first identification of a case of vCJD in the UK. Since that time, there has been much speculation over how vCJD might impact human health. To date there have been 177 case reports in the UK and a further 51 cases worldwide in 11 different countries. Since establishing that BSE and vCJD are of the same strain of agent, we have also shown that there is broad similarity between UK and non-UK vCJD cases on first passage to mice. Transgenic mouse studies have indicated that all codon 129 genotypes are susceptible to vCJD and that genotype may influence whether disease appears in a clinical or asymptomatic form, supported by the appearance of the first case of potential asymptomatic vCJD infection in a PRNP 129MV patient. Following evidence of blood transfusion as a route of transmission, we have ascertained that all blood components and leucoreduced blood in a sheep model of vCJD have the ability to transmit disease. Importantly, we recently established that a PRNP 129MV patient blood recipient with an asymptomatic infection and limited PrP(Sc) deposition in the spleen could readily transmit disease into mice, demonstrating the potential for peripheral infection in the absence of clinical disease. This, along with the recent appendix survey which identified 16 positive appendices in a study of 32,441 cases, underlines the importance of continued CJD surveillance and maintaining control measures already in place to protect human health.

Because feed intake is controlled in broiler breeders, amino acid supply is determined by the composition of the feed and the level of feed intake. Controlling amino acid supply during the laying cycle can be facilitated by the use of a model for calculating requirements. A possible model is outlined and the various components discussed. Typical calculations suggest that the model can provide a useful basis for practical feeding decisions. Model elements include: levels of animal performance; utilization of amino acids for egg production, maintenance, and tissue growth; population structure; and the variation of feed intake and the covariance between feed intake and requirements.

BACKGROUND: Ischemic heart disease (IHD) is a leading cause of morbidity and mortality in both developing and developed countries. An underlying cause of IHD involves retention and deposit of serum lipids in coronary arteries, decreasing blood flow. Drugs (conventional and herbal) are used to lower levels of serum cholesterol to help prevent IHD. The Ayurvedic medicine pharmacopoeia identified herbs that might contribute to a decrease in cholesterol and therefore reduce the risk of IHD. METHODS: Literature searches were conducted at 3 points: 2003, 2004, and 2007. Databases searched included PubMed, the National Library of Medicine, the National Center for Complementary and Alternative Medicine, Ovid, and EBSCO Information Services, and other search strategies also were used. Each article was assessed for quality by 3 people, and discrepancies were resolved by arbitration using a fourth person, who also read and scored each article. Additional assessments of safety using a scale and determination of reported efficacy/effectiveness of the randomized controlled trials (RCTs) and quasi-experimental designs (QEDs) were made. RESULTS: RCTs generally received high quality scores and improved by decade of publication. More than 50% of garlic, more than 80% of guggul, and 100% of Arjuna RCTs reported product effectiveness. Safety scores did not improve by decade. The QEDs received medium and high quality scores, and 93% of them reported effectiveness. The QEDs had a higher mean score for safety reporting than the RCTs. CONCLUSIONS: Many studies received high quality scores and noted safety information and reported effectiveness or efficacy in a clear manner. This finding was not consistent with other systematic reviews that have found the highest reported efficacy/ effectiveness in studies of poorer quality. Ayurvedic herbs reviewed here should be considered by physicians when trying to manage hyperlipidemia in their patients.

Proliferative enteropathy is caused by the microaerophilic obligate intracellular bacterium ileal symbiont (IS) intracellularis. Treatment of this disease is problematic because of the lack of in vivo or in vitro data on the activities of antimicrobial agents. A new procedure for determining the susceptibility of IS intracellularis was developed by using a tissue culture system which promotes the in vitro multiplication of this organism. Nineteen antimicrobial agents were evaluated in triplicate cultures for their intracellular and extracellular activities against up to three IS intracellularis strains isolated from pigs with proliferative enteropathy. The MIC was defined as the lowest concentration which prevented multiplication of 99% of the IS intracellularis isolates. Penicillin, erythromycin, difloxacin, virginiamycin, and chlortetracycline were the most active compounds tested, all with MICs of < or = 1 microgram/ml. Tiamulin and tilmicosin were the next most active compounds, with MICs of < or = 4 micrograms/ml. The MICs of aminoglycosides were generally > 32 micrograms/ml. Both lincomycin and tylosin were relatively inactive against the IS intracellularis strains tested, with MICs of 32 and 64 micrograms/ml, respectively. These results indicate that some compounds capable of intracytoplasmic accumulation and blocking bacterial protein synthesis were active against IS intracellularis strains isolated from pigs with proliferative enteropathy. The in vitro cultivation system shows promise as a method for studying the interaction between IS intracellularis and antimicrobial agents and for screening new antibiotics for use in therapy.

The authors investigated changes in treatment team functioning in an adult inpatient psychiatric hospital after the implementation of a mindfulness-based mentoring intervention. Using a multiple baseline across treatment teams design, the authors assessed levels of functioning of three treatment teams using a 50-item rating scale and then introduced mindfulness-based mentoring successively across the treatment teams. Following intervention, four follow-up assessments at 3-month intervals were undertaken to assess the durability of the enhanced treatment team functioning levels in the absence of mentoring. Results showed that with the introduction of mindfulness-based mentoring, treatment team performance was enhanced, patients'attendance at therapeutic groups and individual therapy sessions was maximized, and patient and staff satisfaction with treatment team functioning was substantially increased, with patient satisfaction showing greater gains than staff satisfaction. Mindfulness-based mentoring may be an efficient and effective intervention for enhancing and maintaining the performance of treatment teams in adult psychiatric hospitals.

This work provides a detailed account of word level pronunciation in England and Scotland between 1700 and 1900. All major and minor source materials are presented in depth and there is a close discus

In the latter part of 1991 an unusual neurological disease was recognised on several farms in England. This report describes the case histories and clinical, biochemical and pathological findings in six calves and two lambs aged from two to 44 weeks obtained from five of these farms. Laminar cerebrocortical necrosis and severe bilateral necrosis of the thalamus and/or striatum progressing to cavitation were recognised in their brains. These changes are similar to those of experimental sulphate toxicity. Morbidity rates of 16 to 48 per cent and mortality rates of 0 to 8 per cent were recorded. The affected animals did not respond to vitamin B1 treatment; the erythrocyte transketolase levels of in-contact cattle and of one untreated affected calf and one untreated lamb were within the normal range. All five farms had recently introduced a proprietary concentrate ration containing ammonium bicarbonate. After this ration was withdrawn no new cases of nervous clinical disease were observed. It is suggested that, in at least some cases, the morphology and topography of lesions may distinguish sulphate induced polioencephalomalacia from that of sporadic thiamine-dependent cerebrocortical necrosis.

A simple process for batch or continuous formation of polymer nanofibers and other nanomaterials in the bulk of a sheared fluid medium is introduced. The process may be of high value to commercial nanotechnology, as it can be easily scaled up to the fabrication of staple nanofibers at rates that may exceed tens of kilograms per hour.

BACKGROUND: Dementia is a major cause of disability among older people and constitutes one of the greatest challenges currently facing families and health and social care services in the developed world. In response to trends in dementia prevalence and the impact the condition has on peoples' lives, dementia care has been placed high on the public and political agenda in the United Kingdom. However, despite significant public resources being allocated to combat the impact of the disease, recent evidence indicates that numerous challenges in relation to service provision remain. This study aimed to develop a deeper understanding of the lived experience of people with dementia regarding their service-related needs. METHOD: The study made use of data gathered through individual semi-structured, narrative interviews conducted with persons with experience of dementia and their unpaid carers. RESULTS: Although participants were generally satisfied with the services they received, a number of unmet needs related to service provision were identified. In terms of diagnostic procedures the findings of this study indicate the need for early diagnosis delivered through a comprehensive assessment package. The participants also highlighted the need for well-coordinated post-diagnostic support, greater continuity of care concerning the personnel involved, and enhanced access to non-pharmacological interventions to support identity and social engagement. CONCLUSION: This study contributes to a better understanding of service-related needs of people with dementia in relation to diagnostic procedures and post-diagnostic support.

The Questions About Behavioral Function (QABF), a 25-item rating scale, was developed to identify the function(s) of maladaptive behavior in individuals with developmental disabilities. The authors adapted it for use with individuals with serious mental illness who engage in maladaptive behavior and assessed the psychometric characteristics of the new scale (Questions About Behavioral Function in Mental Illness; QABF-MI) in a sample of 135 adults with serious mental illness from three inpatient psychiatric hospitals. Staff most familiar with each person rated each item on a 5-point Likert-type rating scale, and the ratings were subjected to a number of psychometric analyses. The results of factor analyses provided a conceptually meaningful five-factor solution: physical discomfort, social attention, tangible reinforcement, escape, and nonsocial reinforcement. Congruence between the five factors derived with the QABF-MI and the corresponding factors in the original QABF was perfect. The results indicated that the QABF-MI has robust psychometric properties and may be useful as a screening tool for determining the nature of the variables that maintain maladaptive behavior exhibited by individuals with serious mental illness.

Sonic hedgehog plays an essential role in maintaining hepatoblasts in a proliferative non-differentiating state during embryogenesis. Transduction of the Hedgehog signaling pathway is dependent on the presence of functional primary cilia and hepatoblasts, therefore, must require primary cilia for normal function. In congenital syndromes in which cilia are absent or non-functional (ciliopathies) hepatorenal fibrocystic disease is common and primarily characterized by ductal plate malformations which underlie the formation of liver cysts, as well as less commonly, by hepatic fibrosis, although a role for abnormal Hedgehog signal transduction has not been implicated in these phenotypes. We have examined liver, lung and rib development in the talpid(3) chicken mutant, a ciliopathy model in which abnormal Hedgehog signaling is well characterized. We find that the talpid(3) phenotype closely models that of human short-rib polydactyly syndromes which are caused by the loss of cilia, and exhibit hypoplastic lungs and liver failure. Through an analysis of liver and lung development in the talpid(3) chicken, we propose that cilia in the liver are essential for the transduction of Hedgehog signaling during hepatic development. The talpid(3) chicken represents a useful resource in furthering our understanding of the pathology of ciliopathies beyond the treatment of thoracic insufficiency as well as generating insights into the role Hedgehog signaling in hepatic development.

Associations have been studied between natural infection of hens and cocks in a commercial flock with subgroup A lymphoid leukosis virus (LLV) and the presence of LLV in their eggs and progeny. Whole blood and sera were examined for LLV and virus-neutralising antibody, and vaginal swabs and semen samples were examined for LLV. Egg albumen samples were tested for LLV and group-specific (gs) antigen and embryos for LLV. Of 198 hens, 63.6% were immune, non-viraemic, 7.1% tolerant viraemic, 2.5% immune, viraemic and 26.8% non-immune, non-viraemic. Genetic resistance may have accounted for the last of these classes. A low rate of infection was found in the 40 cocks studied and the possible reason for this is discussed. There was no evidence that they were responsible for congenital transmission of LLV. Strong associations were observed between LLV in vaginal swabs or serum of hens and LLV or gs-antigen in albumen in their eggs. Significant but weaker associations were observed between these traits in the hens and LLV in their embryos, and between LLV and gs-antigen in egg albumen and LLV in embryos. Testing of whole blood for LLV showed little advantage over testing of serum. The efficiency of various tests for detecting hens least likely to transmit LLV to their progeny was examined. The lowest rates of embryonic transmission, which were 7-fold lower than the overall transmission rate, occurred in hens of two classes: those negative for viraemia, LLV in vaginal swabs, and antibodies, and those negative for LLV in vaginal swabs, antibodies and LLV or group-specific antigen in their egg albumen. The implications of these findings are discussed.

The feasibility of eradicating exogenous lymphoid leukosis virus (LLV) from a commercial egg-layer grandparent strain of chickens was examined by selecting replacement chicks from hens expected to have a reduced likelihood of transmitting LLV, followed by testing of progeny chicks and removal of those showing evidence of infection, together with their early contacts. Chicks from unselected hens were hatched and reared separately for comparison. The selected chicks came from hens negative for LLV in vaginal swabs and for LLV and/or group-specific antigen (gsa) in egg albumen, but at hatching 2.5% were infected by LLV in cloacal swab tests compared with 4.1% of unselected chicks, an insignificant difference. The infected chicks from the selected group, and their cage mates, were culled, leaving 85 hens of which seven were identified at different times as being infected and were removed. At 70 weeks 75 hens remained free of LLV infection. Of 369 eggs laid by the selected hens, 0.3% contained LLV in the albumen, and none contained gsa in albumen or LLV in corresponding embryos. Chicks hatched from the selected group were free of LLV infection. LLV infection was allowed to spread naturally in the unselected hens and 85.4% were infected at 70 weeks. Of these hens, 60.0% produced eggs with LLV in albumen, 41.2% with gsa in albumen, and 32.9% with LLV-infected embryos. Of 509 eggs from these hens, 25.1% had LLV in albumen, 30.5% had gsa in albumen, and 10.4% had LLV-infected embryos. In confirmation of other studies, shedding of LLV to embryos was associated with presence of LLV in vaginal swabs and serum. Analysis of associations within eggs between LLV and gsa in the albumen, and LLV in the embryo, provided strong evidence that virus in the oviduct was the cause of embryo infection; no firm evidence was obtained for the occurrence of embryo infection by a non-oviduct route. Infection of cocks in the selected and unselected groups was similar to that in hens in the respective groups. Some cocks used to inseminate unselected hens had infected semen, but this did not influence the frequency of embryo infection. In a comparison of eight tests on hens or eggs from the unselected group for selection of embryos with decreased probability of being infected with LLV, the procedures most likely to be used under practical conditions, namely classification of hens according to LLV in vaginal swabs or gs-antigens in egg albumen, ranked third and fifth respectively, and did not differ from the highest ranking procedure. Age at first egg was significantly earlier, and hen-housed egg production tended to be better, in selected hens compared with unselected hens, but environmental differences other than infective status may have been responsible. In comparisons within the unselected group, hen-housed and hen-day egg production were significantly poorer in viraemic tolerant hens than in immune hens or uninfected hens.

Social skills training is commonly used for children and adolescents with ASD. There are few studies considering its efficacy in adults and those that exist usually compare it to standard treatment, as opposed to controlling for non-specific improvements that may result from receiving an intervention. We conducted a pilot study to investigate whether social skills training is more effective than non-specific support for adults with ASD. 19 adults with ASD were randomised to either social skills training or non-specific social interaction groups for 16 weeks. The Reading the Mind in the Eyes and Reading the Mind in the Voice Tasks were used to assess social cognition while the Social Responsiveness Scale (SRS-2) and the Weiss Functional Impairment Rating Scale (WFIRS-S) were used to measure real-life change pre- and post-treatment. Taken together, both groups improved across the course of the study on the ‘Eyes’ task (p = 0.049), SRS-2 (p = 0.03) and WFIRS-S (p = 0.053). However, there were no significant differences between the groups. There was some trend-level evidence that the social skills group improved more on the tests of social cognition (p ≤ 0.1 for group x time interaction). This was not the case for the SRS-2 (p = 0.25) and for the WFIRS-S there was a trend for the social interaction group to show greater improvements (p = 0.07). This study did not show clear evidence of benefit from social skills training compared to facilitated social interaction, although larger studies are required to draw firm conclusions about efficacy.

PURPOSE: To identify factors associated with decreased muscle strength and activity after anterior cruciate ligament (ACL) reconstruction with semitendinosus-gracilis tendon (ST-G) grafts. TYPE OF STUDY: Retrospective review. METHODS: Eighty-five patients who underwent ACL reconstruction with ST-G grafts were evaluated at a mean of 44.4 months after surgery. Patients underwent isokinetic testing, physical examination, radiographs, instrumented laxity testing, and Lysholm, Cincinnati, and International Knee Documentation Committee (IKDC) ratings. Cartilage and meniscal pathology at surgery was reviewed. Strength group 1 (n = 30) showed greater than 20% deficits in strength; strength group 2 (n = 55) had less than 20% strength deficits. Activity group 1 (n = 60) maintained their IKDC activity level at final follow-up relative to preinjury level; activity group 2 (n = 25) decreased activity by 1 or more levels. RESULTS: With all patients combined, there was less than a 4% difference in mean hamstring and quadriceps strength between the reconstructed and contralateral legs at follow-up. Knee flexion deficits were associated with decreased hamstring strength. Subjective giving way and squatting/kneeling discomfort were associated with decreased quadriceps strength. Patients in strength group 1 were more likely to have squatting/kneeling discomfort and lower Cincinnati Function scores. Activity group 2 had a longer interval from injury to surgery and more chondromalacia at surgery. At follow-up, activity group 2 had lower subjective scores and was more likely to have pain, swelling, giving way, and flexion deficits. Activity group 2 also had greater deficits in quadriceps strength. CONCLUSIONS: Articular cartilage injury and meniscal pathology were not associated with decreased muscle strength. ACL reconstruction with ST-G grafts has a 38% incidence of squatting/kneeling pain that occurs secondary to patellofemoral crepitus, harvest site symptoms, and tibial hardware sensitivity. LEVEL OF EVIDENCE: Level IV, therapeutic, case series, no control group.

An explosion study was undertaken in 1965 to investigate the structure of the crust in the Irish Sea area. The experiment was designed to permit the use of the time term approach to interpret the data. Seismic waves from twenty-five depth charges were recorded at three temporary seismometer stations in Wales and one in Ireland, the Rookhope Borehole and the U.K.A.E.A. array at Eskdalemuir. Detailed geophysical surveys made across Cardigan Bay and St George's Channel have provided information about the shallow structures. Pg, P* and Pn arrivals were identified on the records, and the velocities were calculated to be 6.1, 7.3 and 8.1 kms−1 respectively. Pn was observed only at Eskdalemuir and Rookhope and the value determined represents in effect only an apparent velocity. P*, however, was observed at the Irish and the three Welsh stations, and its velocity and the associated time terms are well determined. The calculated values of the Pg velocity and time terms have relatively large uncertainties, due probably to the heterogeneous nature of this layer. The shallow structures are complex and as a result it is difficult to translate from time terms to interface depths. A simplified crustal model, making use of average values of the time terms, is made up of three crustal layers with interfaces at depths of 4 km and 24 km and the Moho at a depth of 30 km.