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BACKGROUND: Recent national data suggests that less than 0.5% of NHS cataract patients undergo immediate sequential bilateral cataract surgery (ISBCS). Since ISBCS improves service efficiency, increasing its practice may help tackle the ever-growing burden of cataract in the UK, and reduce the COVID-19 cataract backlog. Surgeon attitudes are known to be a significant barrier to increasing the practice of ISBCS. However, little is known about patient perceptions of ISBCS. METHODS: Patients at cataract clinics across three NHS hospital sites were recruited to complete an investigator-led structured questionnaire. Open-ended and closed-ended questions were used to assess awareness of ISBCS, willingness to undergo ISBCS and attitudes towards ISBCS. RESULTS: Questionnaires were completed by 183 patients. Mean participant age was 70.5 (9.9) years and 58% were female. Forty-three percent were aware of ISBCS, chiefly via clinic staff. Just over a third would choose ISBCS if given the choice, and participants that perceived they were recommended ISBCS were more likely to opt for it. The most common motivator and barrier to uptake of ISBCS was convenience and the perceived risk of complications in both eyes respectively. Concerns related to the recovery period were common, including misunderstandings, such as the need to wear eye patches that obscure both eyes. CONCLUSIONS: Our study indicates that significantly more NHS patients would be willing to undergo ISBCS if given the choice. The reluctance of surgeons to recommend ISBCS and patient misunderstandings regarding the recovery period may be limiting its uptake.

Video telehealth experienced rapid growth throughout the COVID-19 pandemic in many healthcare sectors, including mental health. The Veterans Health Administration’s video telehealth platform, VA Video Connect, has been widely used to reach veterans who may have experienced difficulty accessing care, such as those living in rural areas or other barriers (e.g., transportation). Implementing VVC requires a multifaceted approach, including training providers on technical skills, increasing access to equipment for providers and veterans, and integrating VVC within the culture and processes of the clinic unit. Prior successful VVC implementation efforts in rural areas have focused on simultaneous one-on-one provider and leadership engagement using implementation facilitation (IF). However, given the rapid need for VVC expansion in light of limits and dangers associated with in-person care during the pandemic, our team developed group facilitation to increase the reach of VVC implementation through IF. Group facilitation combined training in technical and policy elements of VVC with IF with groups of providers from clinic units. This approach was designed to rapidly disseminate the necessary knowledge to conduct VVC combined with collaborative problem solving as a team to improve the ability of the clinical team to sustain VVC. Attendees were asked for feedback on the session through multiple choice and open-ended questions. Participants (N = 26) reported being highly satisfied with the training and reported a high degree of confidence in their ability to use VVC. Based on evaluation data and interview feedback, providers and clinic leaders were satisfied with group facilitation. Group facilitation may be a helpful tool in rapidly training clinical teams to implement and sustain video telemental health.

Functional landscape connectivity is vital for the conservation of wildlife species. Landscape connectivity models often overlook factors such as mortality and asymmetry in landscape resistance that can have a significant impact on functional connectivity. Individual-based models (IBMs) can be used to explore such factors through the implementation of mechanistic dispersal behavior. Furthermore, population-level patterns of animal dispersal and landscape connectivity resulting from the simulation of alternative landscapes or scenarios of animal behavior can be compared. Use an IBM to evaluate the effects of disperser mortality, asymmetrical dispersal due to landscape structure, and land-use change on the functional landscape connectivity between two populations of reintroduced American martens Martes americana. We applied a previously calibrated IBM of marten dispersal to simulate movement between two reintroduced populations in Wisconsin and Michigan, USA. We used machine learning analyses to determine how each factor affected dispersal between populations (connectivity) across five consecutive generations. Functional landscape connectivity between populations was not always correlated with more traditional dispersal metrics, such as dispersal distance. Mortality had the greatest impact on functional connectivity. Land-use change and landscape configuration affected connectivity mostly when mortality was not incorporated into simulations. These experimental factors had a stronger effect on long-distance dispersal between populations than on more local dispersal. Conservation planning for landscape connectivity may benefit from accounting for mortality risks within matrix habitat. The development of individual-based models that incorporate landscape heterogeneity and complex animal behaviors when investigating long-distance dispersal can provide unique and specific insights into both landscape connectivity and wildlife conservation.

Ecosystem-based management, spatial orientation, a multilevel policy framework and integration have all been identified as essential components of effective marine spatial planning (MSP). Integration has been noted by researchers and through international forums as being essential to achieve effective oceans governance. However, integrated policy approaches are the most difficult policies to design, develop and implement. They require a holistic rather than sectoral focus; horizontal and vertical jurisdictional support and coordination; and the involvement of a diverse group of stakeholders including industry, NGOs, and local communities. Integrated policies are prone to failure but if “integrative capacity” exists, integration in MSP can contribute to its success. This paper examines the role of integration within MSP and suggests a framework for determining effective integration and “integrative capacity”. It refers to different marine spatial planning examples which demonstrate that integrative capacity can contribute to the success, failure and longevity of MSP and ecosystem-based management.

Poor medication adherence contributes to inadequate control of hypertension. However, the value of adherence monitoring is unknown. To evaluate the impact of monitoring adherence with electronic pill bottles or bidirectional text messaging on improving hypertension control. Three-arm pragmatic randomized controlled trial. One hundred forty-nine primary care patients aged 18–75 with hypertension and text messaging capabilities who were seen at least twice in the prior 12 months with at least two out-of-range blood pressure (BP) measurements, including the most recent visit. Patients were randomized in a 1:2:2 ratio to receive (1) usual care, (2) electronic pill bottles for medication adherence monitoring (pill bottle), and (3) bidirectional text messaging for medication adherence monitoring (bidirectional text). Change in systolic BP during the final 4-month visit compared with baseline. At the 4-month follow-up visit, mean (SD) change values in systolic blood pressure were − 4.7 (23.4) mmHg in usual care, − 4.3 (21.5) mmHg in the pill bottle arm, and − 4.6 (19.8) mmHg in the text arm. There was no significant change in systolic blood pressure between control and the pill bottle arm (p = 0.94) or the text messaging arm (p = 1.00), and the two intervention arms did not differ from each other (p = 0.93). Despite good measured adherence, neither feedback with electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. Adherence to prescribed medications was not improved enough to affect BP control or it was not the primary driver of poor control. clinicaltrials.gov (NCT02778542)

While there has been sustained interest in understanding the role of reward processing in autism spectrum disorder (ASD), researchers are just beginning to focus on the anticipation phase of reward processing in this population. This review aimed to briefly summarize recent advancements in functional imaging studies of anticipatory social and nonsocial reward processing in individuals with and without ASD and provide suggestions for avenues of future research. Reward salience and activation of the complex network of brain regions supporting reward anticipation vary across development and by important demographic characteristics, such as sex assigned at birth. Current research comparing social and nonsocial reward anticipation may possess confounds related to the mismatch in tangibility and salience of social and nonsocial experimental stimuli. Growing evidence suggests individuals with ASD demonstrate aberrant generalized reward anticipation that is not specific to social reward. Future research should carefully match social and nonsocial reward stimuli and consider employing a longitudinal design to disentangle the complex processes contributing to the development of reward anticipation. It may be useful to conceptualize differences in reward anticipation as a transdiagnostic factor, rather than an ASD-specific deficit.

Theoretical frameworks grounded in the social cognitive theory are used to discuss the need for assessing motivation, self-efficacy for learning and performance, metacognitive self-regulation of dually enrolled students. This study assessed motivation and learning strategy usage by Dually Enrolled Students participating in Georgia’s Dual Enrollment program. The research was conducted on 213 high school aged 14 to 18 years, in grades 9–12, and attended a high school in a seven-county service area in southwest Georgia. Participants all were taking classes under a program that allows them to simultaneously earn high school and college credit, and required them to attend a high school and college concurrently either at a technical college of the Technical System of Georgia, or a state college of the University System of Georgia. The research questions were answered using a cross-sectional survey, the Motivated Strategies for Learning Questionnaire, and demographics were used to classify participants based on age, grade, gender, number of classes completed in the Dual Enrollment program, teacher type for instruction, and the format/location of college class taken. The study’s findings added to the existing knowledge base regarding teenage students who are expected to conform to the role of college student simply because they were deemed academically equipped to take college classes. Furthermore, the findings of this study suggest the importance of implementing additional acceptance requirements to make sure students possess the maturity, motivation, and learning strategy application knowledge to be successful in college classes and that faculty has been trained to accommodate the learning needs of this specific type of learner.

Social networks influence obesity patterns, but interventions to leverage social incentives to promote weight loss have not been well evaluated. To test the effectiveness of gamification interventions designed using insights from behavioral economics to enhance social incentives to promote weight loss. The Leveraging Our Social Experiences and Incentives Trial (LOSE IT) was a 36-week randomized, controlled trial with a 24-week intervention and 12-week follow-up. One hundred and ninety-six obese adults (body mass index ≥ 30) comprising 98 two-person teams. All participants received a wireless weight scale, used smartphones to track daily step counts, formed two-person teams with a family member or friend, and selected a weight loss goal. Teams were randomly assigned to control or one of two gamification interventions for 36 weeks that used points and levels to enhance collaborative social incentives. One of the gamification arms also had weight and step data shared regularly with each participant’s primary care physician (PCP). The primary outcome was weight loss at 24 weeks. Secondary outcomes included weight loss at 36 weeks. At 24 weeks, participants lost significant weight from baseline in the control arm (mean: − 3.9 lbs; 95% CI: − 6.1 to − 1.7; P

To describe the good outcome of implantable collamer lens (ICL) rotation to reduce post-operative vault. Retrospective analysis of case report. A 43-year-old woman had V4c EVO + myopic non-toric ICL implantation and post-operatively she presented with anisocoria and high vault. She underwent surgery to rotate the ICL 90 degrees to a vertical orientation. We achieved a reduction in the vault from 1020 to 486 μm after vertical ICL rotation. Satisfactory refractive outcome and optimal vault were achieved and maintained during the period of follow-up. Optimal ICL sizing is important as too high vault/clearance is associated with problems such as angle closure glaucoma, pupil dilatation and anisocoria and too low vault/clearance to increased risk of cataract formation. Non-toric ICL rotation can be a simple surgical technique to deal with oversized lenses thus avoiding ICL exchange.

Despite the benefits of influenza vaccination, each year more than half of adults in the United States do not receive it.To evaluate the association between an active choice intervention in the electronic health record (EHR) and changes in influenza vaccination rates.Observational study.Adults eligible for influenza vaccination with a clinic visit at one of three internal medicine practices at the University of Pennsylvania Health System between September 2010 and March 2013.The EHR confirmed patient eligibility during the clinic visit and, upon accessing the patient chart, prompted the physician and their medical assistant to actively choose to "accept" or "cancel" an order for the influenza vaccine.Change in influenza vaccination order rates at the intervention practice compared to two control practices for the 2012-2013 flu season, comparing trends during the prior two flu seasons adjusting for time trends and patient and clinic visit characteristics.The sample (n = 45,926 patients) was 62.9% female, 35.9% white, and 54.4% black, with a mean age of 50.2 years. Trends were similar between practices during the 2 years in the pre-intervention period. Vaccination rates increased in both groups in the post-intervention year, but the intervention practice using active choice had a significantly greater increase than the control (adjusted difference-in-difference: 6.6 percentage points; 95% CI, 5.1-8.1; P 0.001), representing a 37.3% relative increase compared to the pre-intervention period. More than 99.9% (9938/9941) of orders placed during the study period resulted in vaccination.Active choice through the EHR was associated with a significant increase in influenza vaccination rates.

The Royal College of Ophthalmologists recently published evidence-based guidance on commissioning for cataract surgery in response to reports of wide geographical variation in access to cataract surgery in England, and the increasing use of arbitrary Snellen visual acuity thresholds to govern access to cataract surgery. This article summarises the main findings of the Commissioning Guidance and current issues surrounding cataract surgery provision in the NHS. The methodology used to develop this guidance was granted National Institute for Health and Care Excellence (NICE) accreditation in July 2015.

To describe the relationships of axial length with ocular copathology, preoperative visual acuity, and posterior capsule rupture rates in patients undergoing cataract surgery.DesignThe Royal College of Ophthalmologists' National Ophthalmology Database (NOD) study.Anonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Data parameters included: demographics, biometry, ocular copathology, visual acuity measurements, and surgical complications including posterior capsule rupture, or vitreous loss or both (PCR).Consultant surgeons performed a higher proportion of operations on eyes whose axial length were at the extremes. Glaucoma and age related macular degeneration were more common in eyes with shorter axial lengths, whilst previous vitrectomy was associated with longer axial lengths. Eyes with brunescent or white cataracts or amblyopia were more common at both axial length extremes. Preoperative visual acuities were similar for eyes with axial length measurements up to approximately 28 mm and worse for eyes with longer axial length measurements. PCR rates showed little change with axial length (overall mean 1.95%, 95% CI: 1.89 to 2.01%), except for a borderline increase in eyes with axial length20.0 mm where rates were 3.6% (95% CI: 2.0 to 6.3%). The likelihood of PCR in eyes with axial length20.0 mm was 1.88 times higher than those of ≥20.0 mm (P=0.0373).Rates of ocular comorbidities vary by axial length. PCR rates in eyes with very short or long axial lengths were lower than expected.

© 2015 Journal of NeuroVirology, Inc. Cell-free mitochondiral DNA (mtDNA) is an immunogenic molecule associated with many inflammatory conditions. We evaluated the relationship between cell-free mtDNA in cerebrospinal fluid (CSF) and neurocognitive performance and inflammation during HIV infection. In a cross-sectional analysis, we evaluated the association of mtDNA levels with clinical assessments, inflammatory markers, and neurocognitive performance in 28 HIV-infected individuals. In CSF, we measured mtDNA levels by droplet digital PCR, and soluble CD14 and CD163, neurofilament light, and neopterin by ELISA. In blood and CSF, we measured soluble IP-10, MCP-1, TNF-α, and IL-6 by ELISA, and intracellular expression of IL-2, IFN-γ, and TNF-α in CD4+ and CD8+ T cells by flow cytometry. We also evaluated the relationship between CSF pleocytosis and mtDNA longitudinally in another set of five individuals participating in an antiretroviral treatment (ART) interruption study. Cell-free CSF mtDNA levels strongly correlated with neurocognitive performance among individuals with neurocognitive impairment (NCI) (r = 0.77, p = 0.001). CSF mtDNA also correlated with levels of IP-10 in CSF (r = 0.70, p = 0.007) and MCP-1 in blood plasma (r = 0.66, p = 0.01) in individuals with NCI. There were no significant associations between inflammatory markers and mtDNA in subjects without NCI, and levels of mtDNA did not differ between subjects with and without NCI. MtDNA levels preceded pleocytosis and HIV RNA following ART interruption. Cell-free mtDNA in CSF was strongly associated with the severity of neurocognitive dysfunction and inflammation only in individuals with NCI. Our findings suggest that within a subset of subjects cell-free CSF mtDNA is associated with inflammation and degree of NCI.

The decline of the Great Barrier Reef can be reversed by improvements to governance and management: current policies that promote fossil fuels and economic development of the Reef region need to be reformed to prioritize long-term protection from climate change and other stressors.

The MINICHROMOSOME MAINTENANCE 2-7 (MCM2-7) complex, a ring-shaped heterohexamer, unwinds the DNA double helix ahead of the other replication machinery. Although there is evidence that individual components might have other roles, the essential nature of the MCM2-7 complex in DNA replication has made it difficult to uncover these. Here, we present a detailed analysis of Arabidopsis thaliana mcm2-7 mutants and reveal phenotypic differences. The MCM2-7 genes are coordinately expressed during development, although MCM7 is expressed at a higher level in the egg cell. Consistent with a role in the egg cell, heterozygous mcm7 mutants resulted in frequent ovule abortion, a phenotype that does not occur in other mcm mutants. All mutants showed a maternal effect, whereby seeds inheriting a maternal mutant allele occasionally aborted later in seed development with defects in embryo patterning, endosperm nuclear size, and cellularization, a phenotype that is variable between subunit mutants. We provide evidence that this maternal effect is due to the necessity of a maternal store of MCM protein in the central cell that is sufficient for maintaining seed viability and size in the absence of de novo MCM transcription. Reducing MCM levels using endosperm-specific RNAi constructs resulted in the up-regulation of DNA repair transcripts, consistent with the current hypothesis that excess MCM2-7 complexes are loaded during G1 phase, and are required during S phase to overcome replicative stress or DNA damage. Overall, this study demonstrates the importance of the MCM2-7 subunits during seed development and suggests that there are functional differences between the subunits.

Members of the human epidermal growth factor receptor (HER) family play a significant role in bladder cancer progression and may underlie the development of chemotherapy resistance. Dacomitinib is an irreversible tyrosine kinase inhibitor with structural specificity for the catalytic domains of epidermal growth factor receptor (EGFR), HER2 and HER4 that has exhibited vigorous efficacy against other solid tumors. We evaluated the antitumor activity of dacomitinib in human bladder cancer cell lines expressing varying levels of HER family receptors. These cell lines also were established as bladder cancer xenografts in nonobese diabetic/severe combined immunodeficiency (NOD/SCID) mice to assess dacomitinib activity in vivo. Significant cytotoxic and cytostatic effects were noted in cells expressing elevated levels of the dacomitinib target receptors with apoptosis and cell cycle arrest being the predominant mechanisms of antitumor activity. Cells expressing lower levels of HER receptors were much less sensitive to dacomitinib. Interestingly, dacomitinib was more active than either trastuzumab or cetuximab in vitro, and exhibited increased growth inhibition of bladder tumor xenografts compared with lapatinib. Pharmacodynamic effects of dacomitinib included decreased E-cadherin (E-cad) expression, reduction of EGFR and extracellular signal-regulated kinase (ERK) phosphorylation and reduced mitotic count. Dacomitinib also inhibited tumor growth in a chemotherapy-resistant xenograft and, when combined with chemotherapy in a sensitive xenograft, exhibited superior antitumor effects compared with individual treatments. Evaluation in xenograft-bearing mice revealed that this combination was broadly feasible and well tolerated. In conclusion, dacomitinib exhibited pronounced activity both as a single agent and when combined with chemotherapy in human bladder cancer models. Further investigation of dacomitinib in the preclinical and clinical trial settings is being pursued.

Simple de novo screens in Arabidopsis thaliana have previously identified mutants that affect endosperm development but viable-embryo mutants have not been identified. Our strategy to identify autonomous embryo development was to uncouple embryo and endosperm fertilisation. This involved a male-sterile mutant population being crossed with a distinct pollen parent--the pollen was needed to initiate endosperm development and because it was distinct, the maternal progeny could be selected from the hybrid population. This process was refined over three stages, resulting in a viable approach to screen for autonomous embryo mutants. From 8,000 screened plants, a mutation was isolated in which the integument cells extended from the ovule and proliferated into a second complete twinned ovule. Some embryos from the mutant were normal but others developed fused cotyledons. In addition, a proportion of the progeny lacked paternal genes.

The nightingale Luscinia megarhynchos has undergone population decline and range contraction at the north-western limit of its distribution in England during the last 25 years. We examine patterns of habitat occupancy and habitat availability across sites with a range of population histories to see whether habitat loss is a plausible explanation for these declines. The number of singing males in 1999 correlated with area of primary nightingale habitat in the East Midlands (where the species has declined), but not in East Anglia (where the population has been stable). Change in population size between 1980 and 1999 and current habitat availability were weakly correlated in the East Midlands but not in East Anglia. These results are consistent with habitat loss having contributed to the decline of the nightingale in the East Midlands, but suggest that other, wider-scale, factors may be at least partially responsible for determining the abundance of the species within England as a whole.

Cardiac patients' beliefs about the causes of their illness may influence their receptivity to psychosocial interventions. The purpose of this study was to determine whether depression or anxiety influence patients' attributions about the causes of their heart disease. The primary hypothesis was that depressed or anxious patients are more likely to endorse negative emotions as among the causes of their heart disease than are patients who are not depressed or anxious. Sixty-nine patients with documented ischemic heart disease recruited from an exercise stress testing laboratory completed the Beck Depression and Anxiety Inventories and a heart disease attribution checklist. Univariate analyses confirmed that patients who are depressed or anxious are more likely than other patients to endorse negative emotions as causes of their heart disease. Anxiety but not depression was retained as an independent predictor of negative emotion attributions in a logistic regression analysis. We conclude that mood state influences cardiac patients' beliefs about the causes of their heart disease.

We report that variations in maternal care in the rat promote hippocampal synaptogenesis and spatial learning and memory through systems known to mediate experience-dependent neural development. Thus, the offspring of mothers that show high levels of pup licking and grooming and arched-back nursing showed increased expression of NMDA receptor subunit and brain-derived neurotrophic factor (BDNF) mRNA, increased cholinergic innervation of the hippocampus and enhanced spatial learning and memory. A cross-fostering study provided evidence for a direct relationship between maternal behavior and hippocampal development, although not all neonates were equally sensitive to variations in maternal care.

Interpatient variability in exposure to certain chemotherapy agents can influence patient outcome, particularly with high-dose chemotherapy. We evaluated the possibility of a pharmacokinetic (PK) drug-drug interaction between the antiemetic agents and high-dose cyclophosphamide, cisplatin and BCNU (CPA/cDDP/BCNU). Twenty-three self-selected patients treated with high-dose CPA/cDDP/BCNU followed by autologous hematopoietic progenitor cell support (AHPCS) received ondansetron, lorazepam and diphenhydramine as antiemetics. PK parameters for each chemotherapeutic drug in the regimen were compared with those of 129 patients who received exactly the same chemotherapy but an antiemetic regimen substituting prochlorperazine for ondansetron. In addition, we performed a review of the English literature for reported drug-drug interactions between antiemetics and chemotherapy agents that led to modifications in any PK parameters of the chemotherapy agent. Our retrospective study showed that the mean area under the curve (AUC) for both cyclophosphamide (76,600 vs 90,600 microg/ml/min, P=0.001) and cisplatin (525 vs 648 microg/ml/min, P = 0.01) were significantly lower in the ondansetron group when compared with the prochlorperazine group. The AUC for BCNU was not significantly different in both groups (544 vs 677, P = 0.43). We found only one report of modifications of the PK parameters of high-dose chemotherapy agents due to drug-drug interactions with the most commonly used antiemetics in a review of the English literature between 1966 and 1995. We concluded that the AUC of high-dose cyclophosphamide and cisplatin are significantly lower when ondansetron, as opposed to prochlorperazine, is used as the antiemetic. The small sample size and heterogeneity of this group of patients precludes any outcome analysis of pharmacodynamic endpoints such as toxicity or antitumor effect. Nevertheless, the potential for interactions between antiemetics and chemotherapy agents should be taken into account when using different high-dose chemotherapy regimens.

BACKGROUND: Sibutramine is a reuptake inhibitor of 5-hydroxytryptamine and noradrenaline, being developed as a treatment for obesity. OBJECTIVE: To investigate the effect of sibutramine on glucose homeostasis in obese-hyperglycaemic insulin-resistant ob/ob mice. DESIGN: Sibutramine 5 mg/kg once daily was administered orally to ob/ob mice for six weeks. RESULTS: Sibutramine treatment decreased body weight gain by 12% without a significant overall change in daily food intake. Sibutramine reduced the hyperinsulinaemia by 31%, and lowered plasma non-esterified fatty acids (NEFA) by 17%. Basal plasma glucose concentrations were not significantly altered by sibutramine, but glucose concentrations fell more rapidly after an i.p. glucose challenge, despite lower insulin concentrations. The rate of insulin-induced glucose disappearance was increased by 10% during sibutramine treatment. First administration of sibutramine, 5 mg/kg, did not acutely alter basal plasma glucose, insulin or NEFA concentrations in ob/ob mice, although NEFA concentrations were raised after 24 h. CONCLUSION: The results indicate that chronic administration of sibutramine can reduce weight gain, lower NEFA concentrations, decrease hyperinsulinaemia and ameliorate the insulin resistance of ob/ob mice.

Objective: To determine whether changes in the demographic/educational mix of those entering internal medicine from 1986 to 1989 were associated with differences among them at the time of certification. Participants: Included in the study were all candidates for the 1989 to 1992 American Board of Internal Medicine certifying examinations in internal medicine. Measurements: Demographic information and medical school, residency training, and examination experience were available for each candidate. Data defining quality, size, and number of subspecialties were available for internal medicine training programs. Results: From 1990 to 1992, the total number of men and women candidates increased as did the numbers of foreign-citizen non-U.S. medical school graduates and osteopathic medical school graduates; the number of U.S. medical school graduates remained nearly constant and the number of U.S.-citizen graduates of non-U.S. medical schools declined. The pass rates for all groups of first-time examination takers decreased, while the ratings of program directors remained relatively constant. Program quality, size, and number of subspecialty programs had modest positive relationships with examination performance. Conclusions: Changes in the characteristics of those entering internal medicine from 1986 to 1989 were associated with declines in performance at the time of certification. These declines occurred in all content areas of the test and were apparent regardless of program quality. These data identify some of the challenges internal medicine faces in the years ahead.

Background Surgical removal of the lens from larval Xenopus laevis results in a rapid transdifferention of central corneal cells to form a new lens. The trigger for this process is understood to be an induction event arising from the unprecedented exposure of the cornea to the vitreous humour that occurs following lens removal. The molecular identity of this trigger is unknown. Results Here, we have used a functional transgenic approach to show that BMP signalling is required for lens regeneration and a microarray approach to identify genes that are upregulated specifically during this process. Analysis of the array data strongly implicates Wnt signalling and the Pitx family of transcription factors in the process of cornea to lens transdifferentiation. Our analysis also captured several genes associated with congenital cataract in humans. Pluripotency genes, in contrast, were not upregulated, supporting the idea that corneal cells transdifferentiate without returning to a stem cell state. Several genes from the array were expressed in the forming lens during embryogenesis. One of these, Nipsnap1, is a known direct target of BMP signalling. Conclusions Our results strongly implicate the developmental Wnt and BMP signalling pathways in the process of cornea to lens transdifferentiation (CLT) in Xenopus, and suggest direct transdifferentiation between these two anterior eye tissues.

Measurement of severity is fundamental to the description and comparison of case series, treatment regimens and disease outcomes. This study examines the Acute Physiology Score (APS) as a severity measure of an acute "life-threatening" asthma attack.The APS in the emergency department (ED) and ICU, demographic, treatment and outcome variables were prospectively studied. Relationships between severity, treatment and progress were investigated. In addition, patients were stratified according to ED APS and differences between the participating hospitals were examined.Emergency Departments and Intensive Care Units of two New Zealand hospitals.64 admissions to the ICUs following an acute episode of asthma.Standard management of acute asthma as practised at the two participating hospitals.Both the treatment delivered (intravenous salbutamol, sodium bicarbonate and IPPV) and the rate of improvement as defined by change in APS between the ED and the ICU were found to be strongly related to ED APS. Similarly, the length of stay in the ICU correlated with the ICU APS. Stratification on the basis of ED APS allowed small but significant differences in patient physiologic derangement, dose of salbutamol, use of IPPV and incidence of complications to be detected between patients at the two hospitals.This prospective study involving two hospitals validates the APS as a method for measuring the severity of an acute asthma attack. It demonstrates how correction for severity can be used to compare treatment and outcome variables in different case series.

Objective:To determine the methods of evaluation used routinely by training programs and to obtain information concerning the frequencies with which various evaluation methods were used. Design:Survey of residents who had recently completed internal medicine training. Participants:5,693 respondents who completed residencies in 1987 and 1988 and were registered as first-time takers for the 1988 Certifying Examination in Internal Medicine. This constituted a 76% response rate. Main results:Virtually all residents were aware that routine evaluations were submitted on inpatient rotations, but were more uncertain about the evaluation process in the outpatient setting and the methods used to assess their bumanistic qualities. Most residents had undergone a Clinical Evaluation Exercise (CEX); residents’ clinical skills were less likely to be evaluated by direct observation of history or physical examination skills. Resident responses were aggregated within training programs to determine the pattern of evaluation across programs. The majority of programs used Advanced Cardiac Life Support (ACLS) certification, medical record audit, and the national In-Training Examination to assess most of their residents. Performance-based tests were used selectively by a third or more of the programs. Breast and pelvic examination skills and ability to perform sigmoidoscopy were thought not to be adequately assessed by the majority of residents in almost half of the programs. Conclusions:While most residents are receiving routine evaluation, including a CEX, increased efforts to educate residents about their evaluation system, to strengthen evaluation in the outpatient setting, and to evaluate certain procedural skills are recommended.

The Rainy Lake area in northern Minnesota and southwestern, Ontario is a Late Archean (2.7 Ga) granite-greenstone belt within the Wabigoon subprovince of the Canadian Shield. In Minnesota the rocks include mafic and felsic volcanic rocks, volcaniclastic, chemical sedimentary rocks, and graywacke that are intrucded by coeval gabbro, tonalite, and granodiorite. New data presented here focus on the geochemistry and petrology of the Minnesota part of the Rainy Lake area. Igneous rocks in the area are bimodal. The mafic rocks are made up of three distinct suites: (1) low-TiO2 tholeiite and gabbro that have slightly evolved Mg-numbers (63–49) and relatively flat rare-earth element (REE) patterns that range from 20–8 x chondrites (Ce/YbN=0.8–1.5); (2) high-TiO2 tholeiite with evolved Mg-numbers (46–29) and high total REE abundances that range from 70–40 x chondrites (Ce/YbN=1.8–3.3), and (3) calc-alkaline basaltic andesite and geochemically similar monzodiorite and lamprophyre with primitive Mg-numbers (79–63), enriched light rare-earth elements (LREE) and depleted heavy rare-earth elements (HREE). These three suites are not related by partial melting of a similar source or by fractional crystallization of a common parental magma; they resulted from melting of heterogeneous Archean mantle. The felsic rocks are made up of two distinct suites: (1)low-Al2O3 tholeiitic rhyolite, and (2) high-Al2O3 calc-alkaline dacite and rhyolite and consanguineous tonalite. The tholeiitic felsic rocks are high in Y, Zr, Nb, and total REE that are unfractionated and have pronounced negative Eu anomalies. The calcalkaline felsic rocks are depleted in Y, Zr, and Nb, and the REE that are highly fractionated with high LREE and depleted HREE, and display moderate negative Eu anomalies. Both suites of felsic rocks were generated by partial melting of crustal material. The most reasonable modern analog for the paleotectonic setting is an immature island arc. The bimodal volcanic rocks are intercalated with sedimentary rocks and have been intruded by pre- and syntectonic granitoid rocks. However, the geochemistry of the mafic rocks does not correlate fully with that of mafic rocks in modern are evvironments. The low-TiO2 tholeiite is similar to both N-type mid-ocean-ridge basalt (MORB) and low-K tholeiite from immature marginal basins. The calc-alkaline basaltic andesite is like that of low-K calc-alkaline mafic volcanic rocks from oceanic volcanic arcs; however, the high-TiO2 tholeiite is most similar to modern E-type MORB, which occurs in oceanic rifts. The conundrum may be explained by: (1) rifting of a pre-existing immature arc system to produce the bimodal volcanic rocks and high-TiO2 tholeiite; (2) variable enrichment of a previously depleted Archean mantle, to produce both the low- and high-TiO2 tholeiite and the calc-alkaline basaltic andesite, and/or (3) enrichment of the parental rocks of the high-TiO2 tholeiite by crustal contamination.

In recent years, the need for increasing the geriatrics component of residency training has been repeatedly addressed; however, there are still many programs that have been unable to meet this need. While alternative sites, such as geriatric evaluation units and nursing homes, may be the ideal sites to teach some aspects of geriatrics, this article argues that the ambulatory care program, required in all residency programs, is the appropriate setting for teaching many of the core skills needed to care for most older adults. Teaching geriatrics in the ambulatory setting, which eliminates the strategic and financial obstacles of developing non-hospital-based sites, can be accomplished with relatively modest additional resources. This article describes the methods used to integrate geriatrics into the ambulatory care component of one internal medicine residency program and the necessary faculty resources as well as the documentation, via chart audit, of the interns' compliance with recommended practice patterns in five categories. With the exception of vaccination status, interns documented 18% or less of possible pieces of information for their patients. While this assessment showed statistically significant improvement in interns' care of older patients after the program intervention, the overall level of performance was still low, underscoring the need for the integration of geriatrics principles in the ambulatory curriculum.

Background: Parenteral nutrition (PN) is detrimental for the growth, development and survival of extremely premature babies. We have come a long way in providing nutrition to preterm babies in the initial few days but still practice varies in different units across the country and the world. Aims and objectives: To determine whether we are able to give intended amount of parenteral nutrition and if not, how much is the calorie and protein loss? Design and Methods: A prospective audit done on random 65 episodes of parenteral nutrition provision and data was analysed to find whether we are giving intended amount of PN? Data was analysed to find out the protein and calories loss as compared to the existing unit standard. Results: 65 days of parenteral nutrition was included in the audit. Gestational age varied from 23 week to term infants while birth weight range was 585 - 4175 grams. Mean of actual PN was 78% of intended with a median of 82% (IRQ range 68 - 92). Mean of feed was 15 % of actual fluid given to babies. Average calorie loss was 20 Kcal/day which comes out 14 Kcal/Kg/day. Median of protein loss was 1 gm/day (IRQ range 0.3 - 1.2). Conclusion: Despite following unit guideline in providing early PN we are failing to provide full amount of intended PN leading to significant calorie and protein loss. We need to look for further innovative ways to provide enough amount of PN, calories and proteins to infants needing PN therapy.

Sir, We read with interest the case report of presumed idiopathic uveal effusion syndrome (IUES) associated with unilateral acute angle closure (AAC) in a pseudophakic patient.1 The authors propose that the case occurred in the absence of pupil block, however, the anterior segment OCT image presented shows iris convexity implying pupil block. We note that no posterior synechiae were seen clinically, however, the B-scan ultrasound images suggest adhesions between the posterior iris and the anterior capsule, consistent with seclusio pupillae. Pseudophakic pupil block with synechiae not visible at the pupillary margin can occur.2 Furthermore, the case resolved with pupil dilation and medical intraocular pressure control supporting a pseudophakic pupil block mechanism. The association of uveal effusion with AAC is well recognized and has been reported to occur in up to 58% cases of acute primary angle closure.3 As stated by the authors, IUES is a diagnosis of exclusion; and is typically associated with serous retinal detachment.4 No serous retinal detachment is seen in the case presented. Their case is certainly unusual with respect to the fact that AAC occurred with an IOL placed in the capsular bag with presumed correct orientation. We would suggest the authors consider prophylactic peripheral laser iridotomy in their case to reduce the risk of a repeat AAC episode.

The 2,700-Ma Vermilion Granitic Complex of northern Minnesota is a granite-migmatite terrane composed of supracrustal metasedimentary rocks, mafic rocks, tonalitic and granodioritic plutonic rocks, and granite. The metasedimentary rocks are predominantly graywacke, which has been regionally metamorphosed to garnet-sillimanite-muscovite-bearing biotite schist, and has locally undergone anatexis. The mafic rocks form early phases within the complex and are of two types: (1) basaltic amphibolite, and (2) monzodiorite and essexite rich in large ion lithophile elements (LILE). The members of the early plutonic suite form small bodies that intrude the metasedimentary rocks and mafic rocks, producing an early migmatite. The granite is of two distinct varieties: (1) white garnet-muscovite-biotite leucogranite (S-type; Chappell and White 1974) and (2) grayish-pink biotite-magnetite Lac La Croix Granite (I-type). The leucogranite occurs in the early migmatite and in paragneissic portions of the complex, whereas the Lac La Croix Granite is a late-stage intrusive phase that invades the early migmatite and metasediment (producing a late migmatite) and forms a batholith. This study focuses specifically on the origin of granite in the Vermilion Granitic Complex. Chemical mass-balance calculations suggest that the S-type two-mica leucogranite had a metagraywacke source, and that the I-type Lac La Croix Granite formed via partial fusion of calc-alkaline tonalitic material, which may have been similar to rocks of the early plutonic suite. This model is satisfactory for petrogenesis of similar Late Archean post-kinematic granites throughout the Canadian Shield.

Objective:To study the differences between cognitive and noncognitive skills of men and those of women entering internal medicine. Design:Comparison of program directors’ ratings of overall clinical competence and its specific components and pass rates for men and women taking the Certifying Examinations in Internal Medicine in 1984–1987. Participants:14,340 U.S. and Canadian graduates taking the Certifying Examinations of the American Board of Internal Medicine for the first time in 1984–1987. Measurements/results:Average program directors’ ratings of overall competence were 6.70–6.78 for men and 6.60–6.71 for women. The greatest differences in ratings of specific components of competence were in the areas of medical knowledge and procedural skills, where men were rated higher than women, and humanistic qualities, where women were rated higher than men. Pass rates were stable over the four years of the study, and ranged from 85 to 86% for men and from 79 to 81% for women. Men consistently performed slightly better than women regardless of the type of residency or quality of medical school attended. Conclusions:Small but consistent differences were found in the performances of men and those of women completing training in Internal Medicine as measured by program directors’ ratings and ABIM Certifying Examination performances.

The crystal structures of the title compounds have been determined from diffractometer data and refined by full-matrix least squares. NaAlMe4 is orthorhombic,Cmcm,a=9.234(3),b=9.221(3),c=8.303(2) A,Z=4,D c=1.03 g cm−3,R=0.029 for 278 data. NaAlEt4 is monoclinic,P21/c (No. 14),a=13.900(2),b=13.207(2),c=14.443(1) A,β=117.43(1)°,Z=8,D c=0.94 g cm−3,R=0.056 for 2747 data. NaAl(n-Pr)4 is monoclinic,C2/c,a=9.802(5),b=15.336(4),c=21.611(10) A,β=98.34(4)°,Z=8,D c=0.92 g cm−3,R=0.072 for 899 data. Coordination of Al is essentially tetrahedral in all structures, and closest contacts to Na+ involveα-carbon atoms of alkyl groups.

This assessment of the environmental protection regulatory system for the $2.2 billion iron and steel plant, oil refinery, and thermal generating station composing the core of the greenfield Nanticoke industrial complex is based upon: the use of governmental and industrial research in project management; technology and institutional arrangements for environmental protection; evidence of environmental changes to date; analysis of government and industrial approval files; and interviews with government, industry, and interest group representatives. Planning, regulation, and management have been reasonably efficient and effective to the beginning of the operational stage for all three major industries as of spring 1980. Of major future concern, however, is management of the cumulative and synergistic impacts of the industries and associated development on air quality as well as the lands, waters, and sensitive ecosystems of the nearby Lake Erie coast. Continuous monitoring, more comprehensive research, and better overall coordination of government, industrial, and public interests are required if Nanticoke benefits are to be achieved without undue cost to pre-project resource users within and outside the Haldimand-Norfolk region.

This article assesses the attitudes of Middle Easterners on both a government and individual level toward the profession of counselling. It is based on two studies. Study 1 presents responses from 10 Middle Eastern countries to a survey questionnaire regarding the status of counselling and the projection for counselling services in the future for each country. Each country stated that counselling was present and projected that counselling services would increase in the future. Study 2 presents the responses to a self-report questionnaire of 40 Middle Eastern college students who had undergone an initial experience in counselling. About 80% of the students reported satisfaction with the services and 80% stated that they would recommend such services to a friend should the need arise. Arguments are made for expanding of counselling services in the Middle East.

The research reported here deals with the problem of planning land use and engineering alternatives for urban floodplain management. An analytical methodology accommodating (a)land use regulations such as zoning ordinances, subdivision regulations, and building and housing codes, (b)development policies such as direction of services and utilities, acquisition of open space uses, redevelopment and renewal, and permanent evacuation, and (c)engineering measures such as dams, reservoirs, levees, floodwalls, and channel alterations. The objective of this floodplain management approach is to identify, subject to an appropriate set of planning constraints, an economically efficient combination of land use and engineering alternatives. A computer-based mathematical optimization model was used to select a desirable combination of management alternatives.

The distribution of lignin has been studied in tracheids and ray cells of normal and compression wood of tamarack [Larix laricina (Du Roi) K. Koch]. The three layers in the secondary wall of normal wood tracheids are lignified to approximately the same extent, and previous evidence that the S 3 layer should contain a higher proportion of lignin than the other regions has not been confirmed. The lignin follows closely the orientation of the cellulose microfibrils in all three layers. Compared to the tracheids, the ray cells contain a denser network of lignin in their secondary wall. Only a small proportion of the total lignin in compression wood tracheids is present in the compound middle lamella. The thick S 1 layer is only slightly lignified; the orientation of the lignin in this region is that of the transversely oriented, lamellated microfibrils. The outer portion of S 2 consists largely of lignin but also contains lamellae of cellulose microfibrils which probably have the same helical orientation as the microfibrils in the inner part of S 2. The latter region, which contains the helical cavities, consists of lamellae of cellulose microfibrils which are uniformly encrusted with lignin. The ray cells in compression wood appear to be lignified to the same extent as in normal wood. Transverse sections of the cells reveal a lateral orientation of the lignin. The orientation of the cellulose microfibrils in the S 2 layer of the first-formed springwood tracheids of compression wood is the same as in the cells which are formed later. It is suggested that for ease of reference, the outer, lignin-rich layer in compression wood tracheids be referred to as the S 2(L) layer.

The distribution of lignin in normal and tension wood of four hardwood species has been studied by examination in the electron microscope of the lignin skeletons remaining after removal of the polysaccharides with hydrofluoric acid. In normal wood fibers, the S1 had a higher lignin concentration than the S2 layer, which was not as highly lignified as in conifer tracheids. Vessels had a high concentration of lignin in both normal and tension wood, while the extent of lignification of the parenchyma was variable.