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Background: Abdominal bulge in the absence of a hernia is a known complication following free abdominal flap breast reconstruction and can be associated with significant aesthetic and functional morbidity. This study aims to review the impact of permanent subrectus mesh placement on the incidence of post-DIEP bulge., Methods: All patients over a 5-year period who underwent unilateral or bilateral DIEP breast reconstruction were included in the study. The cohort was divided into a "permanent mesh" (PM) and "no permanent mesh" (NPM) groups. Those in the PM group underwent placement of a permanent Bard™ Soft Polypropylene Mesh, and the NPM group comprised of patients who had a semi-permanent subrectus Vypro Ⓡ mesh or no mesh. The primary outcome of the study was the development of post-DIEP abdominal bulge or hernia. The secondary outcome was the incidence of other donor site complications such as infection. Post-operative follow-up was conducted for a minimum of 6 months., Results: The study included 276 patients, 134 of whom were in the NPM group and 142 in the PM group. Demographics including mean age, median BMI, incidence of pre-operative chemotherapy, radiotherapy, and prior abdominal surgery were comparable between the two groups. The incidence of post-operative abdominal bulge or hernia was lower in the PM group (PM= 0.7% vs. NPM=5.2%, p<0.05). There was no significant difference in the incidence of donor site infection between the two groups (PM=3.5 vs. NPM=2.2%, p=0.53)., Conclusion: Our study demonstrates that a low rate of abdominal morbidity can be achieved with the placement of a permanent subrectus mesh., Competing Interests: Conflict of interest statement None., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Viscoelastic creep of spine tissue, induced by submaximal spine flexion in sitting, can delay the onset of the flexion-relaxation phenomenon (FRP) and low back reflexes (LBR). Theoretically, these two outcome measures should be correlated; however, no studies have investigated this. This study aims to determine whether 30 min of near-maximal spine flexion will affect the onset of FRP and LBR in the lumbar erector spinae (LS) and lumbar multifidus (LM), and to examine the relation between these parameters. 15 participants were recruited (9F, 6M). Spine angle (between L1 and S2) was monitored synchronously with bilateral muscle activity in the LS (L1) and the LM (L4). FRP onset and LBR were measured in a randomized order before and after 30 min of slouched sitting. No significant difference was found for any muscle LBR onset time between pre and post-sitting (p > 0.05). A significant increase in FRP onset was found in the RLM (p = 0.016) following sitting. No significant correlation was found between the FRP and the LBR for any muscle. These results suggest that the LBR onset might not be as sensitive as an outcome measure to investigate shorter exposures of sitting as FRP., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The global drive for improvements in the efficiency and quality of healthcare has led to the development of frameworks to assist in defining and measuring 'good quality care'. However, such frameworks lack a systematic or meaningful definition of what 'good quality care' means from the patients' perspective. The present research provides an in-depth analysis of patients' experiences in a hospital setting from a quality of care perspective. Forty-five adults (aged 16-70) hospitalised in one of four UK NHS trusts following an unintentional injury were interviewed about their experiences of care. The findings show variability in perceived quality of care within the same hospital episode which cannot be meaningfully captured by existing frameworks. The context of trauma care (e.g. distressing nature of injury, patient vulnerability, expectations of hospitalisation and participants' interaction with different service providers) defined the care experience and the value of being 'cared for'. Participants identified some aspects of good and care which related to holistic, person-centred and personalised care beyond the medical needs. Participants discussed the value of being understood, staff thinking of their needs beyond hospitalisation, staff trying 'their best' despite constrains of current care, having their emotional needs recognised and addressed and staff competence. Patients reported also poor quality of care and 'not being cared for' by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults' psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care., Competing Interests: Declaration of Competing Interest The authors have no competing interests to report., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

One experiment was conducted to evaluate the effects of guanidinoacetic acid (GAA) supplementation in broilers fed corn or sorghum-based diets on live performance, carcass and cut up yields, meat quality, and pectoral myopathies. The treatments consisted of corn or sorghum-based diets with or without the addition of GAA (600 g/ton). A total of 800 one-d-old male Ross 708 broiler chicks were randomly placed in 40 floor pens with 10 replicates (20 birds per pen) per each of the four treatments. At hatch, 14, 35, and 50 d, BW and feed intake were recorded. BW gain and FCR were calculated at the end of each phase. Four broilers per pen were selected and slaughtered at 51d and 55d of age to determine carcass and cut up yields, meat quality and myopathies (spaghetti muscle, white striping, and wooden breast) severity in the Pectoralis major. Data were analyzed as a randomized complete block design in a 2 × 2 factorial arrangement with grain type and GAA supplementation as main effects. At 50 d, diets containing GAA improved (P < 0.01) FCR (1.682 vs. 1.724 g: g) independently of grain type. At 55 d, broilers fed corn diets with GAA had higher breast meat yield (P < 0.05) compared to corn without GAA. Drip and cook loss, and shear force (Warner-Bratzler) were not affected (P > 0.05) by GAA supplementation at any slaughter ages. However, GAA decreased (P < 0.05) the ultimate pH at 51 and 55 d in breast meat samples compared to unsupplemented diets. At 51 d, broilers supplemented with GAA had double (P < 0.05) breast meat fillets without wooden breast (score 1) compared with broilers fed non-supplemented diets, therefore reducing the severity of this myopathy. In conclusion, GAA supplementation improved broiler live performance in broilers raised up to 50 d independently of grain source, increased breast meat yield in corn-based diets and reduced the severity of wooden breast myopathy.

Creatine is a nitrogenous compound naturally occurring in animal tissues and is obtained from dietary animal protein or de novo synthesis from guanidinoacetic acid (GAA). The dietary supply of this semi-essential nutrient could be adversely compromised when feeding purely vegetable-based diets. The objective of this experiment was to evaluate the effects of GAA supplementation in broilers fed corn-based diets with or without the inclusion of poultry by-products (PBP) on live performance, carcass and cut up yields, meat quality, pectoral muscle myopathies, differential blood count, blood clinical chemistry, serum GAA and its metabolites. The treatments consisted of PBP inclusion in the diets at 0 and 5%, with or without GAA supplementation (0 or 0.06%). A total of 1,280 one-d-old male Ross 708 broiler chicks were randomly placed in 64 floor pens with 16 replicates per treatment combination. At 0, 14, 35, 48, and 55 d, pen BW and feed intake were recorded. BW gain and FCR were calculated at the end of each phase. Individual BW was obtained at 55 d and one broiler per pen was selected for blood collection. Additionally, four broilers per pen were selected (including the chicken for blood collection) for processing. Data were analyzed as a randomized complete block design in a 2 × 2 factorial arrangement with PBP and GAA supplementation as main effects. An improvement (P < 0.05) on FCR of 0.019 (g:g) was detected at 55 d due to GAA supplementation. The probability of having breast meat with low severity of wooden breast (score 2) was increased (P < 0.05) by GAA inclusion in diets without PBP. An interaction effect (P < 0.05) was detected on GAA concentration in blood. The supplementation with GAA and PBP inclusion resulted in higher (P < 0.05) GAA serum concentration. Generally, meat quality parameters were not affected by GAA. In conclusion, GAA supplementation improved FCR regardless of dietary PBP and reduced wooden breast severity by increasing score 2 in diets without PBP.

Chicks were used to determine whether dietary corn distillers dried grains with solubles (DDGS) may prevent or ameliorate Eimeria acervulina (EA) infection. The experiment had a completely randomized design with a factorial arrangement of 3 diets (inclusion of 0, 10, or 20% DDGS) × 2 challenge treatments: inoculation with distilled water or with 10(6) sporulated EA oocysts. Each treatment was replicated with 8 pens of 5 chicks each. Experimental diets were fed from 7 to 21 d of age. Inoculation occurred on d 10 of age, considered postinoculation (PI) d 0. Feed intake and BW were measured on PI d 0, 7, and 14. Excreta samples were collected on PI d 0, 5 to 10, 12, and 14 to detect oocysts. On PI d 14, mucosal samples were collected for the analysis of bacterial populations by denaturing gradient gel electrophoresis, using the V3 region of bacterial 16S ribosome. The EA challenge reduced (P < 0.001) ADG by 17%, ADFI by 12%, and G:F by 6% from PI d 0 to 7, and by smaller percentages from PI d 7 to 14. Diet and challenge treatments did not interact in the chick performance, so dietary DDGS did not alleviate EA infection. Oocysts in excreta were detected PI only in EA chicks and no dietary effects were found. Cecal bacterial population was changed (P < 0.05) by effect of dietary DDGS and EA infection. The cecal bacterial diversity among chicks within treatments and homogeneity among chicks within treatments were reduced by EA infection (P = 0.02 to 0.001) and increased by feeding 10% DDGS (diet quadratic, P < 0.001). In summary, feeding up to 20% DDGS to young chicks did not prevent or ameliorate EA infection. Changes in cecal microbiota of chicks fed 10% DDGS can be interpreted as beneficial for intestinal health.

Cerebral atrophy rate is increasingly used as an outcome measure for Alzheimer's disease (AD) trials. We used the Alzheimer's disease Neuroimaging initiative (ADNI) dataset to assess if adjusting for baseline characteristics can reduce sample sizes. Controls (n = 199), patients with mild cognitive impairment (MCI) (n = 334) and AD (n = 144) had two MRI scans, 1-year apart; approximately 55% had baseline CSF tau, p-tau, and Abeta1-42. Whole brain (KN-BSI) and hippocampal (HMAPS-HBSI) atrophy rate, and ventricular expansion (VBSI) were calculated for each group; numbers required to power a placebo-controlled trial were estimated. Sample sizes per arm (80% power, 25% absolute rate reduction) for AD were (95% CI): brain atrophy = 81 (64,109), hippocampal atrophy = 88 (68,119), ventricular expansion = 118 (92,157); and for MCI: brain atrophy = 149 (122,188), hippocampal atrophy = 201 (160,262), ventricular expansion = 234 (191,295). To detect a 25% reduction relative to normal aging required increased sample sizes approximately 3-fold (AD), and approximately 5-fold (MCI). Disease severity and Abeta1-42 contributed significantly to atrophy rate variability. Adjusting for 11 predefined covariates reduced sample sizes by up to 30%. Treatment trials in AD should consider the effects of normal aging; adjusting for baseline characteristics can significantly reduce required sample sizes., (2010 Elsevier Inc. All rights reserved.)

Background: Prophylactic infusion of phenylephrine to prevent hypotension at Caesarean section has been shown to decrease the rostral spread of intrathecal plain levobupivacaine and intrathecal hyperbaric bupivacaine by a median of two dermatomes compared with ephedrine. The aim of this study was to determine the median effective dose (ED50) of intrathecal bupivacaine required to achieve a block to touch at the xiphisternum in patients undergoing Caesarean section when phenylephrine or ephedrine are used to prevent hypotension., Methods: Seventy women were randomized in two groups to receive either phenylephrine at a rate of 16.6 microg min(-1) (concentration 1microg ml(-1)) or ephedrine at a rate of 1.5 mg min(-1) (concentration 90 microg ml(-1)). Patients received varying doses of hyperbaric bupivacaine with fentanyl 25 microg using a double-blinded, up-down sequential allocation design. Effective doses were defined as anaesthesia to touch with ethyl chloride spray to the xiphisternum within 20 min., Results: The ED50 estimates of bupivacaine were similar in the two groups: 7.8 mg [95% confidence interval (CI) 6.7-8.9] with phenylephrine and 7.6 mg (95% CI 6.8-8.4) with ephedrine. Systolic blood pressure control was similar (P=0.18) with vasopressors but heart rate was higher with ephedrine (P=0.0014)., Conclusions: Under the conditions of this study, we have shown that when phenylephrine or ephedrine were used to prevent post-spinal hypotension, the dosing requirement of hyperbaric bupivacaine was similar for intrathecal anaesthesia.

We measured dissolved N(2)O, CH(4), O(2), NH(4)(+), NO(3)(-) and NO(2)(-) on 7 transects along the polluted Adyar River-estuary, SE India and estimated N(2)O and CH(4) emissions using a gas exchange relation and a floating chamber. High NO(2)(-) implied some nitrification of a large anthropogenic NH(4)(+) pool. In the lower catchment CH(4) was maximal (6.3+/-4.3 x 10(4)nM), exceeding the ebullition threshold, whereas strong undersaturation of N(2)O and O(2) implied intense denitrification. Emissions fluxes for the whole Adyar system approximately 2.5 x 10(8) g CH(4)yr(-1) and approximately 2.4 x 10(6)gN(2)O yr(-1) estimated with a gas exchange relation and approximately 2 x 10(9) g CH(4)yr(-1) derived with a floating chamber illustrate the importance of CH(4) ebullition. An equivalent CO(2) flux approximately 1-10 x 10(10)gy r(-1) derived using global warming potentials is equivalent to total Chennai motor vehicle CO(2) emissions in one month. Studies such as this may inform more effective waste management and future compliance with international emissions agreements.

We measured hippocampi on baseline-, 6- and 12-month scans in a group of AD (n=36) and control subjects (n=20). We found that mean annualised atrophy rates using 6-month intervals were comparable at a group level to those generated from a 12-month interval. Higher variance was seen using shorter intervals, although this was only significant in the control group. This has implications where shorter inter-scan intervals may be advantageous, such as rapid diagnosis, and tracking of disease progression including in a clinical trial.

A preliminary study was conducted on health of children conceived after preimplantation genetic screening and diagnosis (PGD). Forty-nine children were assessed with 66 matched naturally conceived (NC) controls. Primary outcome was neurodevelopmental screening, and secondary outcomes were evidence of other health problems and assessment of parent-child relationships. Study and control children were well matched across relevant socio-demographic variables. Growth parameters at mean age 18 months were normal. The mean Griffiths quotient was 102.7 (+/-13.1) (PGD) and 103.3 (+/-12.8) (NC), both of which were within the normal range, and did not differ significantly. PGD cases were more likely to be lighter, at <2500 g (12 children, 24.5% versus one child 1.5%, P < 0.0001) and born earlier than controls (38.2 +/- 2.6 versus 40.0 +/- 1.4 weeks; P < 0.0001), consistent with other similar studies. PGD families showed no evidence of excess stress in their relationship with their child. The PGD group had significantly higher scores on the warmth-affection sub-scale (P = 0.042), and significantly lower scores on the aggression-hostility and rejection sub-scales (P = 0.030) of the questionnaire. The study showed no major ill effects from PGD on the child health. A larger study is needed to confirm the validity of this conclusion.

We describe a method of automatically calculating hippocampal atrophy rates on T1-weighted MR images without manual delineation of hippocampi. This method was applied to a group of Alzheimer's disease (AD) (n=36) and control (n=19) subjects and compared with manual methods (manual segmentation of baseline and repeat-image hippocampi) and semi-automated methods (manual segmentation of baseline hippocampi only). In controls, mean (S.D.) atrophy rates for manual, semi-automated, and automated methods were 18.1 (53.5), 15.3 (50.2) and 11.3 (50.4) mm3 loss per year, respectively. In AD patients these rates were 174.6 (106.5) 159.4 (101.2) and 172.1 (123.1) mm3 loss per year, respectively. The automated method was a significant predictor of disease (p=0.001) and gave similar group discrimination compared with both semi-automated and manual methods. The automated hippocampal analysis in this small study took approximately 20 min per hippocampal pair on a 3.4 GHz Intel Xeon server, whereas manual delineation of each hippocampal pair took approximately 90 min of operator-intensive labour. This method may be useful diagnostically or in studies where analysis of many scans may be required.

We describe a dynamic model developed from a commercially available modeling package (ECoS-III) to simulate estuarine dissolved inorganic nitrogen (DIN) dynamics, and consequent N(2)O production and atmospheric flux on the timescale of tidal cycles. Simulated model state variables were NH(4)(+), NO(3)(-) and N(2)O concentrations, and salinity. Model outputs were evaluated through comparison with summer field data for the Tyne estuary, UK. The model adequately reproduced the observed axial profiles of NH(4)(+), NO(3)(-) and N(2)O concentrations. Nitrification was shown to be the dominant N(2)O source and estimates of the ratios nitrification to DIN load and N(2)O emission to DIN load are considerably lower than the corresponding values adopted in global scale models of estuarine N(2)O emissions based on DIN transformations. Hence our results are consistent with the requirement imposed by atmospheric N(2)O growth rate constraints that the amount of atmospheric N(2)O arising from agriculturally related sources, including estuarine transformations of N, be revised downward.

Clinical presentations of melioidosis, caused by Burkholderia pseudomallei are protean, but the mechanisms underlying development of the different forms of disease remain poorly understood. In murine melioidosis, the level of virulence of B. pseudomallei is important in disease pathogenesis and progression. In this study, we used B. pseudomallei-susceptible BALB/c mice to determine the virulence of a library of clinical and environmental B. pseudomallei isolates from Australia and Papua New Guinea. Among 42 non-arabinose-assimilating (ara(-)) isolates, LD(50) ranged from 10 to > 10(6) CFU. There were numerous correlations between virulence and disease presentation in patients; however, this was not a consistent observation. Virulence did not correlate with isolate origin (i.e. clinical vs environmental), since numerous ara(-) environmental isolates were highly virulent. The least virulent isolate was a soil isolate from Papua New Guinea, which was arabinose assimilating (ara(+)). Stability of B. pseudomallei virulence was investigated by in vivo passage of isolates through mice and repetitive in vitro subculture. Virulence increased following in vivo exposure in only one of eight isolates tested. In vitro subculture on ferric citrate-containing medium caused attenuation of virulence, and this correlated with changes in colony morphology. Pulsed-field gel electrophoresis and randomly amplified polymorphic DNA typing demonstrated that selected epidemiologically related isolates that had variable clinical outcomes and different in vivo virulence were clonal strains. No molecular changes were observed in isolates after in vivo or in vitro exposure despite changes in virulence. These results indicate that virulence of selected B. pseudomallei isolates is variable, being dependent on factors such as iron bioavailability. They also support the importance of other variables such as inoculum size and host risk factors in determining the clinical severity of melioidosis.

Background: Solar radiation reduces the bacterial content of water, and may therefore offer a method for disinfection of drinking water that requires few resources and no expertise., Methods: We distributed plastic water bottles to 206 Maasai children aged 5-16 years whose drinking water was contaminated with faecal coliform bacteria. Children were instructed to fill the bottle with water and leave it in full sunlight on the roof of the hut (solar group), or to keep their filled bottles indoors in the shade (control group). A Maasai-speaking fieldworker who lived in the community interviewed the mother of each child once every 2 weeks for 12 weeks. Occurrence and severity of diarrhoea was recorded at each follow-up visit., Findings: Among the 108 children in households allocated solar treatment, diarrhoea was reported in 439 of the 2-week reporting periods during the 12-week trial (average 4.1 [SD 1.2] per child). By comparison, the 98 children in the control households reported diarrhoea during 444 2-week reporting periods (average 4.5 [1.2] per child). Diarrhoea severe enough to prevent performance of duties occurred during 186 reporting periods in the solar group and during 222 periods in the control group (average 1.7 [1.2] vs 2.3 [1.4]). After adjustment for age, solar treatment of drinking water was associated with a reduction in all diarrhoea episodes (odds ratio 0.66 [0.50-0.87]) and in episodes of severe diarrhoea (0.65 [0.50-0.86])., Interpretation: Our findings suggest that solar disinfection of water may significantly reduce morbidity in communities with no other means of disinfection of drinking water, because of lack of resources or in the event of a disaster.

We have compared the contractile responses of substance P (SP) and neurokinin A (NKA) to that of the non degradable muscarinic agonist, carbachol, in small and large human airways in vitro. We have also investigated the effects of the neutral endopeptidase (NEP) inhibitor, thiorphan (100 microM) on these responses. NKA contracted large and small airways to a different extent (56% vs 92% of carbachol maximal contraction, respectively). NKA was significantly less potent in large vs small bronchi (EC50 = 150 +/- 15 vs 12 +/- 5 nM respectively, p less than 0.05). SP had a lower contractile effect in large (26% carbachol maximum) and small airways (59%) with EC50 values higher than 0.5 microM. The enkephalinase inhibitor thiorphan shifted the concentration-response curve to NKA to the left in large (EC50 = 35.2 +/- 8.2 nM) and small bronchi (EC50 = 2.8 +/- 1.3 nM, p less than 0.02). This shift was associated with an increase in the maximal contraction to NKA (75% in large vs 123% in small bronchi). The amplitude of contraction to SP was also potentiated in large (45%) and in smaller bronchi (101%). In conclusion, we have demonstrated that NKA has a significantly greater constrictor effect than a cholinergic agent in more peripheral human airways in vitro. This suggests that non cholinergic constrictor pathways are more likely to be important in more peripheral airways.

Dopamine, glutamic acid decarboxylase (G.A.D.) and choline acetyltransferase (C.A.T.) were measured in four regions of post-mortem brains. 41 patients with the hospital diagnosis of schizophrenia (psychotic group) were compared with a control grout normal in the putamen. G.A.D. activity was significantly reduced in the psychotic group, by about 50% in the nucleus accumbens, amygdala and hippocampus, and by about 30% in the putamen. C.A.T. activity was significantly lower in nucleus accumbens from the psychotic group, but normal in other brain regions. From an assessment of case notes, "schizophrenia" was distinguished from "schizophrenia-like psychosis". The biochemical findings for these subgroups were essentially similar, although C.A.T. activity in nucleus accumbens and hippocampus from the schizophrenic group was significantly lower than in controls. It is of brain are associated with schizophrenia and schizophrenia-like psychoses, although whether such neurochemical abnormalities are related to the illness or are a consequence of prolonged treatment with neuroleptic drugs remains unclear.

A unique case of recurrent brain abscess as the primary manifestation of pulmonary arteriovenous fistula is presented. In the absence of hematologic abnormalities and characteristic physical findings, the diagnosis of pulmonary arteriovenous fistula is particularly elusive. Patients with brain abscess must be carefully evaluated for the presence of pulmonary arteriovenous fistula or hereditary hemorrhagic telangiectasia.

The effects of cryogenic injury on femoral blood vessels and nerves were studied in 28 rats. The femoral neurovascular bundles were dissected out bilaterally and the vessels and nerves subjected to cryogenic injury. The rats were sacrificed at intervals of up to 2 weeks. Damage to the nerves and to a number of femoral vessels was severe and included necrosis and thrombus formation. The results indicate that significant vascular damage can occur during cryotherapy, and the possible complications of this should be considered.