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Aim: To assess the effect of tartrazine at ADI doses on ovarian integrity (the weight and histology of the ovary), reproductive fertility hormones (luteinizing hormones (LH), follicle stimulating hormone (FSH) and prolactin (PRL)) and oxidative stress markers (glutathione peroxidase (GPX) and superoxide dismutase (SOD)) over a period of 30 and 60 days in albino rats. Study Design: A total of 63 female rats weighing approximately 0.2kg were divided into two phases. In phase 1 (30 days treatment period), the rats were divided into 2 groups - designated tartrazine treated group (TTG1) consisting of 20 rats and control untreated group (CUG1) consisting of 15 rats. In phase 2 (60 days treatment period), the rats were again divided into 2 groups – tartrazine treated group (TTG2) consisting of 16 rats and control untreated group (CUG2) consisting of 12 rats. The acceptable daily intake (ADI) of 7.5mg/kg of the dye was administered orally while the control groups were given food and water only. Methodology: At the end of the study, the animals were anaesthetized and 5 mL of whole blood samples was collected by means of cardiac puncture into plain bottles, later spun at 4000 rpm for 5 minutes to obtain serum. The laboratory analysis of LH, FSH and PRL as well as GPX and SOD activity were based on Enzyme Linked Immunosorbent Assay (ELISA) Technique using rat-specific kits. Ovarian tissues collected were weighed using electronic balance, washed in normal saline, fixed in 10% formalin saline, embedded in paraffin wax, 5μm thick sections were obtained by rotary microtome, stained using Haematoxylin & Eosin and examined using digital Olympus microscopic. Results: Non-significant higher values in the absolute weight of the ovary (WOV), FSH, LH, and PRL while non-significant lower values in GPX and SOD were observed in the treated rats against control rats over a period of 30 and 60 days at P=.05. The histological examination over a period of 30 days did not indicate any alteration but hydropic dilation and structural alterations were seen after 60 days. Conclusion: The administration of ADI doses of tartrazine over a period of 60 days affected the integrity of the ovary mildly as observed in the histology but did not markly reflect on the biochemical markers in the plasma as well as the weight of the ovary.

Introduction The use of core outcome sets (COS) and common data elements (CDEs) minimises research wastage by increasing the cross-comparison and meta-analysis of study findings. Our study sought to identify the clinical neuroscience subspecialties that have developed COS and CDEs, the countries of origin of authors, and the process through which COS and CDEs were developed. Method A search between 2000-2020 of the top 40 Impact Factor neurosurgical and neurological journals was conducted. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Results Our search returned 169 papers, of which 35 were eligible for inclusion. The USA published the majority of papers (20/35). The papers mostly related to neurosurgery (30/35), with the most common neurosurgical sub-specialty being traumatic brain injury (14/35). There is an increasing publication trend over time, with 12 papers published in 2019. Five papers were systematic reviews conducting with the intention of COS/CDE development. 27 papers reported CDE development and 2 papers reported COS development. The COS development papers utilised international consensus meetings and adhered to international development statements. Conclusions COS and CDEs are increasingly being developed within clinical neurosciences. There is a need for greater international collaboration with regards to COS and CDEs development.

This study examined the ability of dental students and qualified dentists to visually assess the total occlusal convergence of clinical crowns. 10 working casts of maxillary molar crown preparations were installed in phantom heads in a clinical skills laboratory. 87 participants assessed the buccolingual and mesiodistal total occlusal convergence of the casts. 2nd-year students with no experience in fixed prosthodontics served as a control group with 3rd, 4th and 5th-year students and qualified dentists including specialists in restorative dentistry involved. Differences were calculated between the measured angles and the subject's estimate to assess accuracy. For 8 of the 20 surfaces measured there were significant differences. (p ⟨ 0.05). Differences were not standardized between the groups, with no clear patterns of difference in tooth type or aspect assessed. Differences were primarily between the control group and the more experienced groups. The remaining groups were of similar ability. A minority of participants in each group were highly divergent from their peers. This study found significant differences between participants with no experience of fixed prosthodontics and those with experience, however, the ability to assess total occlusal convergence does not appear to improve significantly with experience.

Chronic liver disease (CLD) is associated with tissue-destructive fibrosis. Considering that common mechanisms drive fibrosis across etiologies, and that steatosis is an important cofactor for pathology, we performed RNA sequencing on liver biopsies of patients with different fibrosis stages, resulting from infection with hepatitis C virus (HCV) (with or without steatosis) or fatty liver disease. In combination with enhanced liver fibrosis score correlation analysis, we reveal a common set of genes associated with advanced fibrosis, as exemplified by those encoding the transcription factor ETS-homologous factor (EHF) and the extracellular matrix protein versican (VCAN). We identified 17 fibrosis-associated genes as candidate EHF targets and demonstrated that EHF regulates multiple fibrosis-associated genes, including VCAN, in hepatic stellate cells. Serum VCAN levels were also elevated in advanced fibrosis patients. Comparing biopsies from patients with HCV with or without steatosis, we identified a steatosis-enriched gene set associated with advanced fibrosis, validating follistatin-like protein 1 (FSTL1) as an exemplar of this profile. In patients with advanced fibrosis, serum FSTL1 levels were elevated in those with steatosis (versus those without). Liver Fstl1 mRNA levels were also elevated in murine CLD models. We thus reveal a common gene signature for CLD-associated liver fibrosis and potential biomarkers and/or targets for steatosis-associated liver fibrosis.

Liver diseases in Australia are estimated to affect 6 million people with a societal cost of $51 billion annually. Information about utilisation of specialist hepatology care is critical in informing policy makers about the requirements for delivery of hepatology-related healthcare.This study examined the aetiology and severity of liver disease seen in a tertiary hospital hepatology clinic, as well as the resource utilisation patterns.A longitudinal cohort study included consecutive patients booked in hepatology outpatient clinics during a 3-month period. Subsequent outpatient appointments for these patients over the following 12 months were then recorded.During the initial 3-month period, 1471 appointments were scheduled with a hepatologist, 1136 of which were attended. Twenty-one per cent of patients were 'new cases'. Hepatitis B virus (HBV) was the most common disease aetiology for new cases (37%). Advanced disease at presentation varied between aetiology; only 5% of HBV cases had advanced liver disease at presentation, in contrast with HCV, NAFLD and ALD, in which advanced disease was identified at presentation in 31%, 46% and 72% of cases, respectively. Most patients (83%) attended multiple hepatology appointments, and a range of referral patterns for procedures, investigations and other specialty assessments were observed.There is a high prevalence of HBV in new case referrals. Patients with HCV infection, NAFLD and ALD have a high prevalence of advanced liver disease at referral, requiring ongoing surveillance for development of decompensated liver disease and liver cancer. These findings that describe the patterns of health service utilisation among patients with liver disease provide useful information for planning sustainable health service provision for this clinical population.

Although enormous amounts of time arid money have been invested in enhancing performance for college and professional athletes, their psychiatric needs have been minimally addressed. Given the virtual absence of controlled scientific literature, in this article the authors detail the diagnostic issues and delineate treatment principles, including: (1) making an accurate diagnosis; (2) setting realistic goals; (3) delivering psycho-education; (4) inducing the patient to undergo treatment, including involving the family and significant others; and (5) delivering appropriate treatment (the most difficult task). The objective is to improve performance and quality of life by treating the problem or psychiatric illness. A special concern is minimizing countertransference feelings and avoiding under-treatment, because by definition the athlete needs to perform.

The social stigma surrounding psychiatric illness may prevent athletes from seeking counseling, psychotherapy, medication, or other treatment when needed. Few controlled studies on athletes exist to guide the team physician, clinician, or psychiatrist who must deal with diagnostic issues. Management involves setting realistic goals, educating as well as inducing the patient into treatment, soliciting support from family or significant others, and delivering appropriate treatment (the most difficult task). The objective is to improve performance and quality of life. Confidentiality issues are paramount during diagnosis and treatment. Physicians who understand sports and team dynamics may have more success in helping patients follow through with treatment.

Background Liver macrophages are a heterogeneous cell population that produces factors involved in fibrogenesis and matrix turnover, including matrix metalloproteinase (MMP) -9. During liver injury, their close proximity to hepatic progenitor cells and the ductular reaction may enable them to regulate liver repair and fibrosis. Aims To enumerate and characterise liver macrophages in patients with chronic hepatitis C, to determine whether a distinct population of macrophages is associated with the ductular reaction and portal fibrosis. Methods Immunostaining for macrophage markers (CD68, CD163, CCR2), the ductular reaction (keratin-7) and MMP-9 was performed in liver biopsy sections from patients with chronic hepatitis C virus (HCV) (n=85). Results Portal tracts were more densely populated with macrophages (10.5 +/- 0.36 macrophages/HPF) than lobules (7.2 +/- 0.16 macrophages/HPF, P

Aim: To investigate the influence of macrophages on hepatocyte phenotype and function. Methods: Macrophages were differentiated from THP-1 monocytes via phorbol myristate acetate stimulation and the effects of monocyte or macrophage-conditioned medium on HepG2 mRNA and protein expression determined. The in vivo relevance of these findings was confirmed using liver biopsies from 147 patients with hepatitis C virus (HCV) infection. Results: Conditioned media from macrophages, but not monocytes, induced a transient morphological change in hepatocytes associated with upregulation of vimentin (7.8 +/- 2.5-fold, P = 0.045) and transforming growth factor (TGF)-beta 1 (2.6 +/- 0.2-fold, P < 0.001) and downregulation of epithelial cadherin (1.7 +/- 0.02-fold, P = 0.017) mRNA expression. Microarray analysis revealed significant upregulation of lipocalin-2 (17-fold, P < 0.001) and pathways associated with inflammation, and substantial downregulation of pathways related to hepatocyte function. In patients with chronic HCV, real-time polymerase chain reaction and immunohistochemistry confirmed an increase in lipocalin-2 mRNA (F0 1.0 +/- 0.3, F1 2.2 +/- 0.2, F2 3.0 +/- 9.3, F3/4 4.0 +/- 0.8, P = 0.003) and protein expression (F1 1.0 +/- 0.5, F2 1.3 +/- 0.4, F3/4 3.6 +/- 0.4, P = 0.014) with increasing liver injury. High performance liquid chromatography-tandem mass spectrometry analysis identified elevated levels of matrix metalloproteinase (MMP)-9 in macrophage-conditioned medium, and a chemical inhibitor of MMP-9 attenuated the change in morphology and mRNA expression of TGF-beta 1 (2.9 +/- 0.2 vs 1.04 +/- 0.1, P < 0.001) in macrophage-conditioned media treated HepG2 cells. In patients with chronic HCV infection, hepatic mRNA expression of CD163 (F0 1.0 +/- 0.2, F1/2 2.8 +/- 0.3, F3/4 5.3 +/- 1.0, P = 0.001) and MMP-9 (F0 1.0 +/- 0.4, F1/2 2.8 +/- 0.3, F3/4 4.1 +/- 0.8, P = 0.011) was significantly associated with increasing stage of fibrosis. Conclusion: Secreted macrophage products alter the phenotype and function of hepatocytes, with increased expression of inflammatory mediators, suggesting that hepatocytes actively participate in liver injury Refereed/Peer-reviewed

SummaryThe capsular polysaccharide of type B. Friedlander bacillus inhibits the multiplication of mumps virus in the chick embryo and prevents adsorption of the virus by treated erythrocytes.

The increased concentrations of neutralizing antibodies against influenza A virus in human serum which occur after influenza A do not differentiate between antigenically different strains of this virus or swine influenza virus but instead appear to possess equal reactivity against these agents. The decrease in antibody levels which occurs with time is also independent of the strain of virus used to measure it.

1. The addition of small amounts of cholesterol and of cephalin reduces markedly the protective action of antipneumococcus horse serum. 2. These lipids do not affect the protective action of antipneumococcus rabbit serum. 3. These findings may be explained (a)by the selective adsorption of lipid on the antigen-antibody complex, and (b) by certain lipid antagonisms. 4. The failure of large amounts of immune horse serum to protect mice against pneumococcus infection is explicable on the basis of selective participation of lipids dependent upon the species from which the antibody is derived. 5. The lipids modify the results of protection tests only through participation in the process of specific sensitization.

A technique has been devised for obtaining free or uncombined pneumonia virus of mice (PVM). Free PVM, liberated from infected mouse lungs by means of this technique, is infectious and causes hemagglutination directly. The results of quantitative studies carried out in the high speed angle centrifuge indicate that the free virus is relatively small, with dimensions of the order of 40 millimicrons. When it is in combination with lung tissue particles, PVM appears to be a relatively large virus with minimal dimensions of the order of 140 millimicrons. Non-infectious virus particles, released from combination with lung tissue particles by heating, are similar to the infectious free virus in size.

The infections produced in ferrets by human influenza virus and canine distemper virus were studied. Cross immunity and cross neutralization tests showed that these two viruses were not related antigenically. Ferrets infected with influenza virus alone rapidly produced considerable quantities of neutralizing antibodies, and after the 6th day virus was not demonstrable in their lungs. Ferrets infected with both influenza and distemper viruses simultaneously produced but small amounts of neutralizing antibody, and influenza virus persisted in undiminished concentration in their lungs throughout the course of the infection.

It has been demonstrated that the removal of lipoids from Type I antipneumococcus horse serum causes a loss of the visible phenomena of type specific agglutination and precipitation, and in the case of rabbit serum a marked reduction in these properties. Initial activity of the type specific antibody can be restored to extracted immune horse serum by the addition of lecithin, and to rabbit serum by the addition of cephalin. The significance of these observations in respect to the relation of phospholipins to the type specific reactions of antipneumococcus serum is discussed.

The results of studies on the immunological relationship between streptococcus MG and Streptococcus salivarius type I are described. Evidence is presented to show that Streptococcus salivarius type I, like streptococcus MG, possesses a capsular polysaccharide antigen. Similarities in the capsular polysaccharides of these two different species of non-hemolytic streptococci appear to be responsible for their immunological relationship.

Additional evidence is presented that PVM is capable of combining firmly with lung tissue particles or erythrocytes from certain susceptible species. Release of the virus from such combination can be effected by treatment with alkali as well as by heating. Free virus expressed from infected lungs without grinding the tissues is infectious and causes hemagglutination when tested directly. The concentration of virus can be estimated more accurately by means of the hemagglutination technique than from the results of infectivity tests in mice. Present evidence indicates that PVM may occur in 4 different states and that in each state it manifests distinctive properties.

1. The cause for the phenomenon of hemagglutination with heated PVM suspensions has been sought. 2. Evidence in wide variety indicates that the component responsible for hemagglutination is the virus particle itself. 3. The virus is capable of combining with a substance present in lung tissue of certain mammalian host species susceptible to infection by PVM. The occurrence of such combination accounts for a number of unusual properties manifested by this pneumotropic virus.

1. Complement is not fixed by immune aggregates resulting from the interaction of pneumococcus capsular polysaccharide and type-specific immune horse serum, although under proper conditions the substitution of immune rabbit serum gives positive results. 2. The negative results with immune horse serum are due to some poorly understood property of the specific antibodies rather than to some heterologous inhibitor present in the serum. 3. It has been shown that with immune rabbit serum-polysaccharide combinations, complement fixation is an adsorptive phenomenon conditioned upon the surface exposure of the immune aggregates. 4. A close parallelism to the selective adsorption of phosphatides by these immune aggregates has been pointed out. 5. In those instances in which complement is fixed this phenomenon must be regarded as tertiary and conditioned by (a) union of antigen and antibody, and (b) particulation. 6. The general significance of complement fixation as applied to bacterial polysaccharides has been discussed.

By means of the improved electrophoretic technique it has been possible to study the association products which are formed when mixed and dissociated hemocyanins from two different species are reassociated. Both the dissociation and the reassociation of the hemocyanins have been produced simply by altering the pH of the solutions. Scale method electrophoretic diagrams have been used throughout this investigation. This method has adequately demonstrated its advantages and has permitted exact calculations of the mobility, concentration, and homogeneity of components which were either present in too small an amount or were too nearly similar electrochemically to have been defined by other methods. Evidence has been presented which indicates that a number of mixed hemocyanins have been produced. These mixed hemocyanin molecules contain fractions of the dissociated hemocyanins from two different species.

1. Specific precipitates resulting from the interaction of the homologous capsular polysaccharide and Type I antipneumococcus horse and rabbit sera have been analyzed by gasometric micro methods for total nitrogen, lipid nitrogen, and lipid carbon. 2. Lipid may, under certain conditions, form as much as 51 per cent or as little as 4 per cent by weight of specific precipitates. 3. The total lipid content of specific precipitates, within the range studied, is entirely independent of the protein content. 4. Lipid nitrogen forms a very small but detectable portion of the total nitrogen of precipitates. 5. The absolute lipid content of precipitates is a function of the concentration of lipid in the reacting mixture prior to precipitation, and seems to be governed by the laws of adsorption phenomena.

This study on pneumonia virus of mice (PVM) was carried out in order to obtain as accurate data as possible on the degree of variation which may be expected in titrations of the virus or of antibodies against it in vivo. It is believed that the knowledge gained will facilitate further investigations on this latent pneumotropic virus and make possible a more exact assessment of the significance of experimental results obtained with the agent. The reproducibility of 50 per cent maximum score titration end points with PVM in mice is such that the chances are 19 out of 20 that a difference of 1.084 log units (i.e. a twelvefold difference) in the end points obtained in two separate titrations is significant. The reproducibility of 50 per cent maximum score serum dilution end points in neutralization tests with PVM in mice is such that the chances are 19 out of 20 that a difference of 0.626 log units (i.e. a fourfold difference) in the end points obtained with two sera against similar amounts of virus is significant. It was found that there is a linear exponential relationship between the serum dilution end point and the quantity of PVM used in a neutralization test. This relationship appears to be identical with immune serum obtained from different animal species, and appears also to be identical to the linear relationship described previously in similar studies with influenza A virus.

Influenza complement fixation tests designed for use with ferret serum are described. Complement-fixing antigens derived from influenza ferret lungs were unsatisfactory due to their low content of soluble antigen; those prepared from mouse lungs or developing chick embryo membranes proved to be better antigenically and were reliable when the various reagents in the test were properly adjusted to eliminate non-specific fixation of complement. The results of cross complement fixation tests indicated that the soluble antigens of the PR8 and W.S. strains of influenza A virus were closely similar, if not identical. They indicated also that the soluble antigen of swine virus possessed components present in the antigens of the human strains of virus.

1. Type I antipneumococcus horse serum, in amounts exceeding a characteristic optimum, fails to protect mice against infection with the homologous type pneumococci. This failure is due to a marked inhibition of the phagocytic mechanism in the earlier stages of the infectious process. On the other hand, antipneumococcus rabbit serum in similar quantities does not inhibit phagocytosis, nor does it block the protection. 2. The experimental evidence suggests that the prozoning action of immune horse serum is due primarily to some characteristic property of the specific antibody and secondarily to an heterologous component of the serum, ineffective in itself but acting through the mediation of the antigen-antibody combination. This secondary factor may be a lipid.

A linear relationship exists between the quantity of human serum used and the quantity of influenza A virus neutralized. By means of this relationship it is possible to determine the maximum quantity of virus which a given human serum can neutralize. This quantity, the neutralizing capacity, is a fixed value and, unlike the serum dilution end point, is independent of the amount of virus used in the neutralization test.

Currently the diagnosis and severity of hepatic steatosis can be established accurately only by liver biopsy. Previous small studies found that steatosis measured by magnetic resonance spectroscopy (MRS) and imaging (MRI) correlated with histological assessment of liver triglyceride content. However, the accuracy of MRS/MRI for grading the severity of steatosis has not been addressed. The aims of this study were (1) to determine whether MRS and MRI can discriminate grades of steatosis in a large cohort of consecutive patients with a wide spectrum of liver disease aetiology and severity (2) to evaluate the effect of hepatic fibrosis, inflammation and iron on quantitation of intrahepatocellular lipid (IHCL) by these techniques.Ninety-four sequential patients who underwent percutaneous liver biopsy or liver resection had MRS and MRI (Dixon in phase/out of phase (Dixon IP/OP) and with/without fat saturation (+/-FS) images) to determine IHCL. Histology was used as the reference standard.Close relationships were observed between the percentage of steatosis estimated by histology and MRS/MRI (r(s)=0.88 p0.001 for all techniques). However, separate equations were required for the percentage of steatosis to avoid underestimation by imaging for patients with moderate or advanced fibrosis. All techniques had good diagnostic accuracy for mild steatosis (AUROCor =0.87) as well as moderate/severe steatosis (AUROCor =0.89). Hepatic inflammation and mild iron deposition (Perls' grade 1 and 2) did not interfere with estimation of steatosis by imaging.MRS and MRI had good accuracy for grading the severity of steatosis in subjects with liver disease, provided that stage of fibrosis was considered.

Objectives. To determine the spectrum of disease among non-urgent referrals to a tertiary hospital hepatology outpatient clinic, assess the adequacy of referral information in terms of risk stratification and determine whether a specifically designed referral template altered urgency for specialist assessment. Methods. A snapshot of the waiting list of a hepatology clinic at a tertiary hospital was taken from the scheduling database. Information was retrieved from referrals and attached investigations. Updated information was requested from subjects and their current general practitioner. Results. Hepatitis C virus accounted for 68.7% of the 1223 reviewed referrals. Clinical information provided by referring clinicians was often incomplete. Provision of updated information identified the presence of comorbidities (obesity, ‘heavy’ alcohol consumption, mental health issues) and altered the need or urgency for specialist assessment in 22% of cases. Conclusions. Hepatitis C virus accounts for the majority of non-urgent referrals waiting to access hepatology outpatient consultations. Using a standardised assessment form as part of the referral process provides more information on comorbidities and risk factors and facilitates more accurate triaging of clinical urgency. Wider adoption of this strategy may increase appropriate access to hepatology services and reduce the future burden of cirrhosis and hepatocellular cancer. What is known about the topic? Little published data are available that describe the content and standard of hepatology referrals, or the urgency with which these patients need to be reviewed. Inadequate clinical information impairs the ability to accurately triage referrals and may lead to delays in access. What does the paper add? Almost 70% of reviewed referrals were for management of patients with hepatitis C virus infection, confirming this condition remains a major priority area in liver disease. Clinical information provided by referring clinicians was often incomplete, impairing the ability to accurately triage referrals. Only a minority of referrals provided information about relevant comorbidities (alcohol intake, injecting drug use, mental health issues and obesity) that negatively impact on the progression of liver disease or the response to antiviral treatment. What are the implications for practitioners? Hepatitis C virus remains a major health priority area in liver disease, increasing the future burden of cirrhosis and hepatocellular cancer. Many referred patients have comorbidities that increase their risk of progressive liver disease and related complications. Strategies to increase recognition and management of liver disease and its comorbidities in the community are required. The use of a standardised assessment form in referrals to hepatology outpatient services may assist with triaging of patients and improve access to appropriate care.

A six-week-old female borzoi puppy from a brother-sister mating developed a generalised illness characterised by anorexia, temporary intention tremor, episodic pyrexia, tachypnoea, conjunctivitis, otitis and neck pain. Haematological abnormalities included an inflammatory leukogram and regenerative anaemia. Blood cultures remained sterile; clinical chemistry values were unremarkable. The puppy had recurrent seizures and was euthanased when 18 weeks old. Post mortem examination revealed a multisystemic inflammatory disease involving thyroids, lymph nodes, spleen, pancreas, bladder and lung, but no lesions to account for the neurological signs. The cause of this generalised disease was not recognised. The histological features are unusual and resemble those described in other dogs of this breed.

Background. Appropriate and uniform prioritisation (‘triaging’) of outpatient referrals is critical to good patient outcomes, equity of access to services and efficient use of resources. Objective. To determine whether there is uniformity in the allocation of triage categories for hepatology outpatient referrals at public hospitals in Queensland. Methods. A series of 10 recent hepatology referrals were de-identified for both patient and referring clinician details and sent to nine gastroenterology or hepatology centres throughout Queensland. Consultant gastroenterologists and hepatologists (n = 25) were asked to triage the referrals using the process in place in their centre. Responses were de-identified and analysed. Each case was reviewed and allocated an ‘agreed triage category’ based upon the majority view of respondents. Results. Nineteen responses were received. There was substantial variation amongst consultants in the allocation of triage categories. Although almost two-thirds of respondents agreed with the majority view in 60–80% of cases, none agreed with the majority for every case and some agreed in as few as 50% cases. Disagreement with the majority view of an appropriate triage category was not associated with geography or specialist experience. Conclusions. Variability in triage categorisation suggests that similar cases may be allocated different priorities by those responsible for determining the urgency of outpatient review. This has implications for equity of access to treatment. The development of triage guidelines and formal training in their implementation, along with periodic audits of triage practices in different centres, may reduce variability. What is known about the topic? Outpatient clinic appointments are allocated within categories according to ‘agreed’ clinical urgency. The process of triaging referrals seeks to prioritise referrals based on the severity of patients’ conditions and the potential for improving outcomes. At present there are no statewide guidelines or training for the triaging process in hepatology and no recommendations for who should take responsibility for prioritising referrals. What does the paper add? In Queensland, gastroenterologists (including hepatologists) triage hepatology cases differently and most likely interpret and weight clinical information provided in the referral differently. Disagreement with the majority view of an appropriate triage category is not associated with geography or specialist experience. What are the implications for practitioners? Variability in triage categorisation suggests that similar cases may be allocated different priorities by those responsible for determining the urgency of outpatient review. This has implications for equity of access to treatment. The development of triage guidelines and formal training in their implementation, along with periodic audits of triage practices in different centres, may reduce variability.

This article aims to raise nurses' awareness of the technique of gentle teaching, which has been used with considerable success in helping people who present challenging behaviours. Based on an appreciation of the essential worth of individuals, and in the need to manage people rather than behaviours, the authors claim that gentle teaching allows nurses to 'see people as they really are'.

The objective of this study is to determine the feasibility of using a bacterial augmentation process with a bacterial culture product (LLMO) addition in the bio‐oxidation of accumulated sludges in the aerated lagoons in municipal wastewater treatment plant. Mauldin Road Wastewater Treatment Plant, Greenville, South Carolina, of Western Carolina Regional Sewer Authority was selected in this field investigation. LLMO was added to the influent to the roughing filter at a dosage of 1 mg/1 to enhance the bio‐conversion of settled sludge in the aerated lagoons. Sludge profile measurements in aerated lagoons were taken prior to and after the LLMO addition to the treatment plant. The LLMO contains seven strains of bacteria, including Bacillus, Pseudomonas, Nitrosomonas, Nitrobacter, Cellulomonas, Aerobacter and Rhodopseudomonas, which are commonly found in soils and wastewater treatment plants. The aerated lagoons had an accumulated sludge of 6.7 million pounds prior to the study period. During the eight‐month s...