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Objective: To evaluate the contribution of power Doppler ultrasonography (PDUS) to breast imaging reporting and data system ultrasonography (BI-RADS US) categorization of solid breast masses. Materials and methods: Totally 94 solid lesions with histopathological results in 49 patients were included in the study. US features of the lesions were classified according to American College of Radiologists (ACR) BI-RADS US lexicon. Lesions were evaluated qualitatively according to their PDUS properties and quantitatively with spectral analysis. Hypervascularity, penetration of vessels into the mass or branching-disordered course and resistivity index values higher than 0.85 were accepted as probable malignant criteria. Results: Fifty-five of 94 lesions were benign (58.5%), while 39 (41.5%) were malignant histopathologically. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of US and PDUS in the diagnosis of malignant lesions were 100%, 58.2%, 62.9%, 100% and 71.8%, 81.8%, 73.7%, 80.4%, respectively. Criteria used for the distinction of malignant and benign lesions like number of vessels (p < 0.05), distribution of tumoral vessels, morphology of vessels and resistivity index values higher than 0.85 showed statistically significant difference (p < 0.001). When sonographic findings were combined with PDUS and spectral analysis findings, sensitivity, specificity, PPV and NPV were 100%, 52.7%, 60% and 100%, respectively. Conclusion: PDUS and spectral analysis have no contribution to BI-RADS US. For the spectral analysis, when RI value is one or greater, malignancy risk significantly increases.

Non-adherence to treatment of patients with psychotic disorders is related to higher rates of relapse, hospitalization, and suicide. Important predictors of non-adherence include poor social structure, cognitive deficits, negative medication attitude, side effects, depression, a sealing-over recovery style, feelings of stigmatization, denial of treatment need, and lack of insight. Attempts to improve adherence have shown that psychoeducation alone is not fully effective, and that motivational interviewing, behavioral strategies, and linking a patient's personal goals to treatment may increase adherence. Based on the empirical data reviewed, we formed four clusters of possible causes of non-adherence, each of which can be targeted by a specific module of our developed Treatment Adherence Therapy (TAT). These four modules are: self-enhancement, motivational interviewing, medication dosage trials, and behavioral training. An individual patient may benefit from one or more of these modules; and thus the contents of TAT vary in accordance with individual causes of non-adherence. Basically, TAT aims to help patients work out what they want regarding treatment and then support them in following this through. TAT will be investigated in a multicenter randomized clinical trial in the Netherlands, starting March 2006. © 2006 Bentham Science Publishers Ltd.

Objective. To gain insight into the vaccination behaviour of elderly people if they are offered a pneumococcal vaccine together with the annual vaccination against influenza. Design. Cross-sectional study. Method. In October 1999 in Amersfoort, a group of general practitioners offered a pneumococcal vaccine together with the yearly influenza vaccination to all 3,365 patients aged 65 years or over. A questionnaire was then mailed to a stratified sample (n = 972) of these patients. Vaccine acceptance and the determinants of non-compliance were then assessed by means of polytomous logistic regression analysis. Results. A total of 2,529 patients (75%) received the pneumococcal vaccine and 2,812 (84%) received the influenza vaccine. Predictors of non-acceptance of the pneumococcal vaccine were a perceived lack of recommendation by the general practitioner (odds ratio (OR): 4.6, 95% confidence interval (CI): 2.6-8.3) and fear of local side effects (OR: 2.8; 95% CI: 1.6-4.6). Predictors of refusal to accept either vaccination also included unwillingness to comply with the doctor's advice (OR: 6.1; 95% CI: 2.4-15.4), the belief that vaccinations weaken one's natural defences (OR: 2.7; 95% CI: 1.4-5.3 or that influenza is not dangerous (OR: 2.9; 95% CI: 1.5-5.4), and the fear of being made ill by pneumococcal vaccination (OR: 2.9; 95% CI: 1.1-7.9). People who felt healthy, found it difficult to come to the doctor's office, had private medical insurance, or were younger than 75 years of age remained unvaccinated more often. Conclusion. Addition of a pneumococcal vaccine to the existing influenza immunisation program resulted in high acceptance rates for both vaccinations. The role of the general practitioner was important in this connection.

BackgroundClinical prediction rules (CPRs) for treatment selection in musculoskeletal conditions have become increasingly popular.PurposeThe purposes of this review are: (1) to critically appraise studies evaluating CPRs and (2) to consider the clinical utility and stage of development of each CPR.Data SourcesPertinent databases were searched up to April 2009. Studies aiming to develop or evaluate a CPR for treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility and extracted methodological data, stage of development, and effect size information.Study Selection/Data Extraction and SynthesisEighteen studies, evaluating 15 separate CPRs, were included. Fourteen CPRs were at the derivation stage, and all CPRs had been evaluated using a single-arm trial design, thus it is not possible to determine whether the CPRs identify prognosis (regardless of treatment) or specifically response to treatment. The CPR at the validation stage investigated spinal manipulative therapy (SMT) for low back pain and had been evaluated in 2 separate well-conducted randomized controlled trials. The first trial demonstrated a clinically meaningful effect of the SMT CPR; the additional effect from SMT in patients “positive-on-the-rule” was 15 Oswestry disability units at week 1 and 9 units at week 4. The second trial showed that the CPR did not generalize to a different clinical setting, including a modified treatment.LimitationsDue to differences in methods of reporting and journal publication restraints (eg, word count restrictions), some quality assessment items may have been completed in the included studies, but not captured in this review.ConclusionsThere is, at present, little evidence that CPRs can be used to predict effects of treatment for musculoskeletal conditions. The principal problem is that most studies use designs that cannot differentiate between predictors of response to treatment and general predictors of outcome. Only 1 CPR has been evaluated within an RCT designed to predict response to treatment. Validation of these rules is imperative to allow clinical application.

Background Despite governmental and private efforts on providing malaria control, this disease continues to be a major health threat. Thus, innovative strategies are needed to reduce disease burden. The malaria vectors, through the injection of saliva into the host skin, play important role on disease transmission and may influence malaria morbidity. This study describes the humoral immune response against Anopheles (An.) darlingi saliva in volunteers from the Brazilian Amazon and addresses the association between levels of specific antibodies and clinical presentation of Plasmodium (P.) vivax infection. Methods Adult volunteers from communities in the Rondônia State, Brazil, were screened in order to assess the presence of P. vivax infection by light microscopy and nested PCR. Non-infected volunteers and individuals with symptomatic or symptomless infection were randomly selected and plasma collected. An. darlingi salivary gland sonicates (SGS) were prepared and used to measure anti-saliva antibody levels. Plasma interleukin (IL)-10 and interferon (IFN)-γ levels were also estimated and correlated to anti-SGS levels. Results Individuals infected with P. vivax presented higher levels of anti-SGS than non-infected individuals and antibody levels could discriminate infection. Furthermore, anti-saliva antibody measurement was also useful to distinguish asymptomatic infection from non-infection, with a high likelihood ratio. Interestingly, individuals with asymptomatic parasitaemia presented higher titers of anti-SGS and lower IFN-γ/IL-10 ratio than symptomatic ones. In P. vivax-infected asymptomatic individuals, the IFN-γ/IL-10 ratio was inversely correlated to anti-SGS titers, although not for while in symptomatic volunteers. Conclusion The estimation of anti-An. darlingi antibody levels can indicate the probable P. vivax infection status and also could serve as a marker of disease severity in this region of Brazilian Amazon.

In general practice, physicians are confronted with a newly diagnosed bladder cancer patient less than once a year. The role of general practitioners is restricted to just the initial phase of diagnosis and sometimes to the final, palliative stage of the disease. The diagnostic phase, as described in the guideline on urothelial carcinoma of the bladder, is hampered by the absence of clear signs and signals of bladder cancer. Painless gross haematuria is the most important clinical sign with a high predictive value, especially in older men. The value of microscopic haematuria is unclear and most patients with microscopic haematuria do not have a malignancy. Yet despite this, current guidelines still advise additional tests for all types of haematuria. However, we recommend that these patients are not subjected to such tests until their added value has been demonstrated.

Objective The modified Early Warning Score (mEWS) is a triage instrument that promises to predict patient disposition and clinical outcome in emergency departments (EDs). We investigated whether mEWS can predict death, hospital admission, intensive care unit (ICU) admission, and in-hospital deaths in a Turkish setting. Methods We conducted an ED-based prospective study of 309 patients who presented to an academic medical center. The mEWS was recorded in all patients on ED admission. A mEWS >4 was used to define patients at high-risk for the study outcomes. Results Patients categorized as being at high-risk either were admitted to ICU (n = 23) or to hospital (n = 37) 56.6% of the time, or died in ED (n = 16) or in hospital (n = 29) 42.4% of the time. Patients categorized as being at low-risk either were admitted to ICU (n = 25) or to hospital (n = 52) 37.4% of the time, or died in ED (n = 1) or in hospital (n = 4) 2.5% of the time. In multivariate regression analysis, patients with a mEWS of 5 or more were 1.95 times more likely to be admitted to ICU than those with a score less than 5. Patients with high-risk mEWS were 35 times more likely to die in ED and 14 times more likely to die in hospital than those presenting with a low-risk score. Conclusion We conclude that scores on the mEWS predict ICU admission as well as ICU and in-hospital deaths.

Background: The aim of this study was to assess whether subjective global assessment (SGA) is useful in identifying malnutrition and outcomes in the intensive care unit (ICU). Methods: After obtaining institutional approval, 124 consenting patients were enrolled in this study. Patients were evaluated at admission using clinical data, SGA, height, weight, triceps skinfold thickness (TSF), mid-arm circumference (MAC), Acute Physiology and Chronic Health Evaluation (APACHE II), and Simplified Acute Physiologic Score (SAPS). Patients were classified as well nourished, moderately malnourished, or severely malnourished with SGA. Results: According to SGA, 62% (n = 77) of the patients were classified as well nourished, 26% (n = 33) as moderately malnourished, and 11% (n = 14) as severely malnourished. Body weight, body mass index (BMI), MAC, TSF, and mid-arm muscle circumference (MAMC) were lower, whereas APACHE II and SAPS II scores and mortality were higher in the malnourished groups compared with the well-nourished group. The SGA rating correlated significantly with age, body weight, percentage of weight loss, serum albumin level, APACHE II and SAPS II scores, and mortality. Anthropometrics data were correlated with SGA. Mortality rate was correlated with high APACHE II score, SAPS II score, days in the ICU and low BMI, MAMC, and serum albumin level. Conclusions: The results support that SGA is simple and may predict the patient's outcomes in the ICU. Copyright © 2008 American Society for Parenteral and Enteral Nutrition.

The new regulatory framework REACH (Registration, Evaluation, and Authorisation of Chemicals) foresees the use of non-testing approaches, such as read-across, chemical categories, structure-activity relationships (SARs) and quantitative structure-activity relationships (QSARs). Although information on skin absorption data are not a formal requirement under REACH, data on dermal absorption are an integral part of risk assessment of substances/products to which man is predominantly exposed via the dermal route. In this study, we assess the present applicability of publicly available QSARs on skin absorption for risk assessment purposes. We explicitly did not aim to give scientific judgments on individual QSARs. A total of 33 QSARs selected from the public domain were evaluated using the OECD (Organisation for Economic Co-operation and Development) Principles for the Validation of (Q)SAR Models. Additionally, several pragmatic criteria were formulated to select QSARs that are most suitable for their use in regulatory risk assessment. Based on these criteria, four QSARs were selected. The predictivity of these QSARs was evaluated by comparing their outcomes with experimentally derived skin absorption data (for 62 compounds). The predictivity was low for three of four QSARs, whereas one model gave reasonable predictions. Several suggestions are made to increase the applicability of QSARs for skin absorption for risk assessment purposes.

The new regulatory framework REACH (Registration, Evaluation, and Authorisation of Chemicals) foresees the use of non-testing approaches, such as read-across, chemical categories, structure-activity relationships (SARs) and quantitative structure-activity relationships (QSARs). Although information on skin absorption data are not a formal requirement under REACH, data on dermal absorption are an integral part of risk assessment of substances/products to which man is predominantly exposed via the dermal route. In this study, we assess the present applicability of publicly available QSARs on skin absorption for risk assessment purposes. We explicitly did not aim to give scientific judgments on individual QSARs. A total of 33 QSARs selected from the public domain were evaluated using the OECD (Organisation for Economic Co-operation and Development) Principles for the Validation of (Q)SAR Models. Additionally, several pragmatic criteria were formulated to select QSARs that are most suitable for their use in regulatory risk assessment. Based on these criteria, four QSARs were selected. The predictivity of these QSARs was evaluated by comparing their outcomes with experimentally derived skin absorption data (for 62 compounds). The predictivity was low for three of four QSARs, whereas one model gave reasonable predictions. Several suggestions are made to increase the applicability of QSARs for skin absorption for risk assessment purposes.

Background and Purpose— The available data regarding the association between metabolic syndrome (MS) or MS components and ischemic stroke in type 2 diabetics are limited and inconsistent. This study aimed to investigate these associations. Methods— Five hundred ninety-nine consecutive type 2 diabetic patients (mean age 60.4±9.6 years, 54% men) were followed-up for 10.1 years (median period). Baseline clinical and laboratory characteristics and the occurrence of a first-ever ischemic stroke during follow-up were recorded. Results— Seventy-eight patients developed a first-ever ischemic stroke. According to Cox proportional hazard model, waist circumference (hazard ratio, HR:1.006, 95% CI:1.002 to 1.010, P =0.003) and age (HR:1.061, 95% CI:1.002 to 1.125, P =0.04) were significant predictors. After incorporating various combinations of MS components in multivariate models, only age and waist circumference remained significant. Conclusions— MS per se at baseline or combinations of its components do not predict the development of ischemic stroke in type 2 diabetic patients. Waist circumference represents an independent prognostic factor and could be used as a clinical tool for stroke prevention in this population.

The aim of this study was to determine whether an increase in circulating estrogen concentrations would increase percentage pregnant per artificial insemination (PP/AI) in a timed AI protocol in high-producing lactating dairy cows. We analyzed only cows having a synchronized ovulation to the last GnRH of the Ovsynch protocol (867/1,084). The control group (n = 420) received Ovsynch (GnRH--7 d--PGF(2alpha)--56 h--GnRH--16 h--timed AI). The treatment group (n = 447) had the same timed AI protocol with the addition of 1 mg of estradiol-17beta (E2) at 8 h before the second GnRH injection. Ovarian ultrasound and blood samples were taken just before E2 treatment of both groups. In a subset of cows (n = 563), pressure-activated estrus detection devices were used to assess expression of estrus at 48 to 72 h after PGF(2alpha) treatment. Ovulation was confirmed by ultrasound 7 d after timed AI. Treatment with E2 increased expression of estrus but overall PP/AI did not differ between E2 and control cows. There was an interaction between treatment and expression of estrus such that PP/AI was greater in E2-treated cows that showed estrus than in E2-treated or control cows that did not show estrus and tended to be greater than control cows that showed estrus. There was evidence for a treatment by ovulatory follicle size interaction on PP/AI. Supplementation with E2 improved PP/AI in cows ovulating medium (15 to 19 mm) but not smaller or larger follicles. The E2 treatment also tended to improve PP/AI in primiparous cows with low (or =2.5) body condition score, and in cows at first postpartum service compared with Ovsynch alone. In conclusion, any improvements in PP/AI because of E2 treatment during a timed AI protocol appear to depend on expression of estrus, parity, body condition score, and size of ovulatory follicle.

The morbidity and mortality of obstructive sleep apnea (OSA) are related principally to its cardiovascular complications. Metabolic syndrome (MBS) is recognized as raising the risk of cardiovascular disease. In this study, we analysied the diagnostic value of MBS to predict the diagnosis of severe OSA. Eight-seven subjects (54 males and 33 females) without any cardiac or pulmonary disease referred for evaluation of OSA, had overnight polysomnography. MBS were diagnosed according to NCEP criteria. According to apnea-hypopnea index (AHI), subjects were divided into two groups: severe OSA (AHI ≥ 30, 26 males, 15 females) and non-severe OSA (AHI < 30, 28 males, 18 females). Ages were similar in both OSA groups for both genders. In the severe OSA group, number of patients with MBS was especially higher (in females n= 13, 86.6%; in males n= 19, 73%) than non-severe OSA (in females 6, 33%, in males 9, 32%). The mean values of the five diagnostic criteria of MBS were significantly higher in severe OSA than non-severe groups in both genders. Analysis of diagnostic value (criteria ≥ 3) of MBS for predicting the diagnosis of severe OSA in males and females revealed the sensitivity 73% and 86.6%, the specificity 67.8% and 94.4%, positive predictive value 67.9% and 86.7%, negative predictive value 73% and 85.7% respectively. Especially in female patients referred to the sleep clinics, evaluation of MBS criteria may play an important role in predicting severe OSA with high sensitivity and negative predictivity. Furthermore, the presence of MBS in OSA patients might increase cardiovascular complications.

Objective: To study the role of ghrelin as a hunger signal during energy restriction and to test the hypothesis that changes in fasting leptin concentrations during energy restriction are associated with changes in fasting ghrelin concentrations. Research Methods and Procedures: Thirty-five healthy, lean men (23 ± 3 years of age; BMI: 22.3 ±1.6 kg/m2) participated in a controlled intervention study. Fasting ghrelin and leptin concentrations were measured before and after 2 days of 62% energy restriction and after a 2-day period of ad libitum food intake. Energy intake during the latter period was assessed. Results: On average, ghrelin concentrations did not change (0.05 μg/liter; 95% confidence interval, -0.03; 0.12) during energy restriction. Changes in ghrelin concentration during energy restriction were not associated with energy intake during the ad libitum period (r = 0.07; not significant). Ad libitum energy intake was, however, associated with the change in ghrelin concentrations during the same period (r = -0.34; p = 0.05). Ghrelin and leptin concentrations were not associated. In addition, the ratio of percentage changes in ghrelin and leptin during energy restriction was not correlated with ad libitum food intake after energy restriction (r = -0.26; p = 0.14). Discussion: Fasting ghrelin concentrations did not rise after a 2-day energy restriction regimen. Moreover, changes in ghrelin concentrations during energy restriction were not associated with subsequent ad libitum food intake, suggesting that fasting ghrelin does not act as a hunger signal to the brain. The data did not support our hypothesis that leptin suppresses ghrelin levels. Copyright © 2006 NAASO.

Non-adherence to treatment of patients with psychotic disorders is related to higher rates of relapse, hospitalization, and suicide. Important predictors of non-adherence include poor social structure, cognitive deficits, negative medication attitude, side effects, depression, a sealing-over recovery style, feelings of stigmatization, denial of treatment need, and lack of insight. Attempts to improve adherence have shown that psychoeducation alone is not fully effective, and that motivational interviewing, behavioral strategies, and linking a patient's personal goals to treatment may increase adherence. Based on the empirical data reviewed, we formed four clusters of possible causes of non-adherence, each of which can be targeted by a specific module of our developed Treatment Adherence Therapy (TAT). These four modules are: self-enhancement, motivational interviewing, medication dosage trials, and behavioral training. An individual patient may benefit from one or more of these modules; and thus the contents of TAT vary in accordance with individual causes of non-adherence. Basically, TAT aims to help patients work out what they want regarding treatment and then support them in following this through. TAT will be investigated in a multicenter randomized clinical trial in the Netherlands, starting March 2006. © 2006 Bentham Science Publishers Ltd.

Background: Injury severity indices are numerical scores that are utilized to predict nosocomial bloodstream infections (BSI) in critically ill patients. However, surrogate markers of injury severity (SMIS) may be more clinically meaningful than these commonly used numerical injury severity indices with respect to the control and prevention of nosocomial BSI. Objective: The purpose of this study was to demonstrate the clinical and research implications of using the SMIS in predicting nosocomial BSI. Method: A prospective nonexperimental cohort study was conducted on 361 critically ill trauma patients. Three logistic regression models were examined for their clinical relevance and statistical parsimony. The first model included the Injury Severity Score (ISS) and 5 other independent predictors, and excluded the SMIS. The second model included all study variables. The third model excluded the ISS. Results: The analysis suggested that number of blood units transfused, number of central venous catheters inserted, and use of chest tube(s) were the SMIS. The ISS was found to be an independent predictor of nosocomial BSI only when the SMIS were not included in the model. The model that included the SMIS and excluded the ISS explained the highest variance in nosocomial BSI and had the best negative predictive value (93%). Discussion: Clinicians can use knowledge of SMIS to develop interventions that minimize the risk of nosocomial BSI. Hence, the SMIS can serve not only as a prediction tool but also as a way to enhance control and prevention strategies for BSI.

Context. Since the introduction of screening for congenital hypothyroidism (CH) in 1974, the optimal laboratory strategy has been the subject of debate. Objective. To assess the clinical effectiveness and cost-effectiveness of various types of thyroxine (T4)-based strategies to screen for CH. Design, Setting, and Participants. In the Netherlands, since January 1, 1995, a primary T4 determination with supplemental thyroid-stimulating hormone (TSH) and T4-binding globulin (TBG) measurements has been used. Results were calculated from cumulative findings for 1 181 079 children screened between January 1, 1995, and December 31, 2000. Main Outcome Measures. Rates of detection of patients with CH of thyroidal origin (CH-T) or CH of central origin (CH-C), false-positive rates, laboratory costs, and costs of initial diagnostic evaluations. Results. All known infants (n = 393) with CH-T and 92% (n = 66) of infants with CH-C were detected on the basis of low T4 levels, TSH elevation, and/or low T4/TBG ratios. If the decision to refer had been based solely on TSH elevation, then 94% of patients with CH-T and none of the patients with CH-C would have been detected. If low T4 levels (≤-3.0 SD) and TSH elevation had been used as the criteria for referral, then the rates of detection would have been 96% for CH-T and 31% for CH-C. The false-positive rates for the 3 approaches were 0.5, 3.3, and 4.7 cases per case detected, respectively. The introduction of the T4/TBG ratio into a program using a primary T4 with supplemental TSH approach generates an extra cost of $11 206 per additional case detected. The average costs to detect 1 patient are comparable for the 3 approaches. In addition, our data revealed a substantially greater prevalence of CH-C than reported previously (1 case per 16 404 children, compared with earlier estimates of 1 case per 26 000 infants to 1 case per 29 000 infants). Conclusions. The T4 plus TSH plus TBG approach is a recommendable strategy for neonatal CH screening. It offers outstanding detection of patients with CH-C, in addition to those with CH-T, with acceptable costs. Copyright © 2005 by the American Academy of Pediatrics. Chemicals / CAS: thyrotropin, 9002-71-5; thyroxine, 7488-70-2; Thyrotropin, 9002-71-5; Thyroxine, 7488-70-2; Thyroxine-Binding Proteins

Since it was introduced in the 1990s, axillary sentinel lymph-node biopsy has been rapidly and widely adopted to avoid complete axillary dissection (though this is still the standard procedure). The aims of the study were two-fold: (i) to determine the value of different techniques of sentinel lymph-node identification and (ii) to verify the predictive value of such procedures through histological examination of the sentinel lymph node and axillary dissection in the same patients. Both sentinel lymph-node biopsy and axillary dissection were performed in 230 patients with T1 and T2 (< 3 cm) carcinoma of the breast. Preoperative lymphoscintigraphy was able to identify the sentinel lymph node in 97.4% of cases, but, with an intraoperative hand-held probe, it was possible to find the sentinel lymph node in 98.2% of cases (226/230 patients). The sentinel lymph node was metastatic in 49.1% of cases (111/226 patients) and negative in 50.9% (115/226). The incidence of false-negative cases was 2.6% (2/115 patients). The predictive value of the sentinel lymph node was 98.7%. Finally, lymph-mode mapping is possible is a very high percentage of patients and therefore it is always advisable to use all three methods of identification together. The diagnostic reliability of sentinel lymph-node status is equally high. At present there no studies are available with a long-term follow-up to confirm these findings, and therefore axillary dissection is still the standard surgical treatment for breast cancer.

In this work we further refine and improve the neural network based ionospheric characteristic's foF2 predictor, which is actually a neural network autoregressive model with additional input signals (NNARX). Our analysis is focused on choice of X parts of NNARX model in order to capture middle and long term dependencies. Daily distribution of prediction error suggests need for structural changes of the neural network model, as well as adaptation of running average lengths used for determination of X inputs. Generalisation properties of proposed neural predictor are improved by carefully designed pruning procedure with additional regularisation term in criterion function. Some results from the NNARX model are presented to illustrate the feasibility of using such a model as ionospheric storm forecasting technique.

Microbial interaction can be ignored in predictive microbiology under most conditions. We show that interactions are only important at high population densities, using published data on inhibition of growth of Listeria monocytogenes in broth. Our analysis using growth models from predictive microbiology indicated that interactions only occur at population densities of ∼108 cfu/ml of the protective cultures. Spoilage is evident at these levels, except for fermented foods. In bacterial colonies, diffusion limitation acts as a constraint to growth. We have shown that these constraints only become important after large outgrowth of colonies (in the order of 5-log growth in Lactobacillus curvatus colonies), which depends on the initial inoculation density. Intra-colony interactions play an important role under these conditions. There is no large outgrowth of colonies when the initial inoculation densities are high and broth culture growth can be used to approximate colony growth. © 2002 Elsevier Science B.V. All rights reserved. Chemicals/CAS: Culture Media

Microbial interaction can be ignored in predictive microbiology under most conditions. We show that interactions are only important at high population densities, using published data on inhibition of growth of Listeria monocytogenes in broth. Our analysis using growth models from predictive microbiology indicated that interactions only occur at population densities of ∼108 cfu/ml of the protective cultures. Spoilage is evident at these levels, except for fermented foods. In bacterial colonies, diffusion limitation acts as a constraint to growth. We have shown that these constraints only become important after large outgrowth of colonies (in the order of 5-log growth in Lactobacillus curvatus colonies), which depends on the initial inoculation density. Intra-colony interactions play an important role under these conditions. There is no large outgrowth of colonies when the initial inoculation densities are high and broth culture growth can be used to approximate colony growth. © 2002 Elsevier Science B.V. All rights reserved. Chemicals/CAS: Culture Media

PURPOSE: The aim of this study was to investigate the diagnostic value of low dose CT (LDCT) by comparing the identification of sinonasal anatomical structures, anatomic variations and detectability of inflammatory changes at low and standard dose CT (SDCT). MATERIALS AND METHODS: A total of 30 patients who were referred to CT scan for the assessment of paranasal sinuses underwent CT examinations at both standard [110 mA, 120 kV, 5 mm collimation (3 mm collimation at the level of the ostiomeatal unit)] and low dose [22 mA, 120 kV, 5 mm collimation (3 mm collimation at the level of the ostiomeatal unit)]. All images were photographed at identical window settings (window width, 4000 HU; window level, 50 HU) on laser film. Ten sinonasal anatomical structures (five on the right and five on the left) and inflammatory mucosal changes were recorded for each patient. The detectability and conspicuity levels were scored for each finding. RESULTS: A total of 297 sinonasal anatomical structures were identified at SDCT, whereas 296 structures were detected at LDCT. Inflammatory mucosal changes and anatomical variations were equally identified at both SDCT and LDCT (p > 0.05). There was no statistically significant difference between SDCT and LDCT in the detection on of anatomical structures, variations and inflammatory changes (p > 0.05). CONCLUSION: The low dose CT protocol used in this study provided images of adequate quality, and proved to be reliable in the evaluation of normal and diseased paranasal sinuses.

INTRODUCTION: There is a lack of information on the cost of treating trauma in children in developing countries. Therefore, in the pediatric emergency unit of a university hospital in Turkey, we prospectively investigated the cost factors of pediatric trauma and attempted to identify cost predictors. METHODS: We prepared questionnaires and charts for 91 children (50 boys, 41 girls) admitted with multiple trauma to obtain data on age, gender, date and mechanism of injury, site of injury, type of the treatment and length of hospital stay. We studied the physical findings, Pediatric Trauma Score (PTS), Revised Trauma Score (RETS) and pediatric Glasgow Coma Scale (GCS) score, and we totalled all hospital-based costs according to Ministry of Health guidelines. RESULTS: The mean (and standard deviation [SD]) age of the children was 79.4 (52.3) months. Motor vehicle crashes accounted for 45% of the injuries, followed by falls (41%) and bicycle accidents (14%). The mean (and SD) total cost of care was US dollar 376.60 (dollar 428.20) (range from dollar 20-dollar 1995). The cost associated with motor vehicle crashes was higher than that for the other injury types (p < 0.05). Seventeen patients required major and 27 patients required minor surgical treatment, whereas 44 patients were treated conservatively; 3 died. Forty-eight percent of patients were referred from another hospital, and the cost of care of referred patients was significantly higher than for those admitted directly (p < 0.001). The mean (and SD) duration of hospital stay was 98 (150) hours. Total cost correlated directly with the duration of hospital stay and distance of the referred hospital or accident scene from our hospital (p < 0.001, r = 0.827 and 0.374 respectively), but the cost correlated inversely with the PTS, the RETS and the pediatric GCS score (p < 0.001, r = -0.339, -0.301 and -0.453 respectively). CONCLUSION: Our findings indicate that the cost of pediatric trauma is high and may be predicted from admission data and trauma scores.

OBJECTIVE: This study was planned to evaluate the change patterns in 5 unipolar retrocardial leads (taken from back) in addition to standard 12 leads ECG in subjects with inferior myocardial infarction (IMI) and to see whether these patterns, if there are any, could be useful to assess the cases with IMI. METHODS: A hundred forty two cases were included to study. At first, in order to determine the normal ECG configurations in 5 unipolar retrocardial leads 30 subjects with normal standard 12 lead ECG and normal physical findings were studied. The normal configurations of retrocardial leads were then determined and retrocardial leads were expressed as RE1-5. Later, 60 subjects with chronic IMI and 52 with acute IMI were evaluated. RESULTS: The QS or Qr in VRE1, QR or qR in VRE2, qRs in VRE5 and transitional patterns in VRE3-4 were accepted as normal configurations of the retrocardial leads. Pre- and retrocardial derivations of 60 cases who had old IMI were normal in 21(35%) cases. There were pathologic Q waves in VRE1-VRE2 leads in 5 (8.3%) cases, in VRE3-VRE4 leads in 11(18.3%) cases, in V5-V6 and VRE5 leads in 3 (5%) cases, in V5-V6 and VRE1-VRE5 leads in 12 (20%) cases, in VRE1-VRE4 leads in 8 (13.3%) cases. Pre- and retrocardial leads of 52 cases with acute IMI were normal in 10 (19.5%) cases. There were ST segment depression in V1-V2 and ST segment elevation in VRE-VRE2 leads in 4 (7.6%) cases, ST segment depressions in V3-V4 derivations and ST segment elevations in VRE3-VRE4 leads in 5 (9.6%) cases, ST segment depression in V2-V6, VRE5 leads and ST segment elevation in VRE1-VRE4 leads in 8 (15.3%) cases, ST segment depression in V1-V4 leads and ST segment elevations in RE1-VRE4 in 12 (23%) cases. ST segment depression in V1-V4 leads and ST segment elevation in V5-V6 and VRE1-VRE5 were found in 13 (25%) cases. CONCLUSION: According to ECG findings which were taken from pre- and retrocardial leads of IMI cases were classified as follows; ST elevation or Q wave or both in DII, DIII, AVF(-)+; 1--Pre and retrocardial leads are normal; 2--ST depression in V1 (sometimes ST elevation if there is right ventricular involvement)--V2, ST elevation or Q wave or both in VRE1-VRE2); 3--ST depression in V3-V4 and ST elevation or Q wave or both in VRE3-VRE4); 4--ST depression in V1-V4 and ST elevation or Q wave or both in VRE1-VRE4); 5--ST depression in V1-V4, ST elevation or Q wave or both inV5-V6 and ST elevation or Q wave or both in VRE1-VRE5); 6--ST depression in V1-V6 and ST elevation or Q wave or both in VRE1-VRE4 and ST depression in VRE5). It is concluded that, in addition to standard 12 lead ECG, retrocardial 5 leads could be recorded and interpreted easily. ECG patterns taken from 5 unipolar retrocardial leads in patients with IMI are not homogeneous. Different groups of ECG findings in certain leads were determined. Further investigations to clarify these different groups ECG findings are needed and these might bring a new approach to assess the subjects with IMI.

Objective. To gain insight into the vaccination behaviour of elderly people if they are offered a pneumococcal vaccine together with the annual vaccination against influenza. Design. Cross-sectional study. Method. In October 1999 in Amersfoort, a group of general practitioners offered a pneumococcal vaccine together with the yearly influenza vaccination to all 3,365 patients aged 65 years or over. A questionnaire was then mailed to a stratified sample (n = 972) of these patients. Vaccine acceptance and the determinants of non-compliance were then assessed by means of polytomous logistic regression analysis. Results. A total of 2,529 patients (75%) received the pneumococcal vaccine and 2,812 (84%) received the influenza vaccine. Predictors of non-acceptance of the pneumococcal vaccine were a perceived lack of recommendation by the general practitioner (odds ratio (OR): 4.6, 95% confidence interval (CI): 2.6-8.3) and fear of local side effects (OR: 2.8; 95% CI: 1.6-4.6). Predictors of refusal to accept either vaccination also included unwillingness to comply with the doctor's advice (OR: 6.1; 95% CI: 2.4-15.4), the belief that vaccinations weaken one's natural defences (OR: 2.7; 95% CI: 1.4-5.3 or that influenza is not dangerous (OR: 2.9; 95% CI: 1.5-5.4), and the fear of being made ill by pneumococcal vaccination (OR: 2.9; 95% CI: 1.1-7.9). People who felt healthy, found it difficult to come to the doctor's office, had private medical insurance, or were younger than 75 years of age remained unvaccinated more often. Conclusion. Addition of a pneumococcal vaccine to the existing influenza immunisation program resulted in high acceptance rates for both vaccinations. The role of the general practitioner was important in this connection.

Objective - To compare the cost effectiveness of various strategies for neonatal hearing screening by estimating the cost per hearing impaired child detected. Design - Cost analyses with a simulation model, including a multivariate sensitivity analysis. Comparisons of the cost per child detected were made for: screening method (automated auditory brainstem response or otoacoustic emissions); number of stages in the screening process (two or three); target disorder (bilateral hearing loss or both unilateral and bilateral loss); location (at home or at a child health clinic). Setting - The Netherlands Target population - All newborn infants not admitted to neonatal intensive care units. Main outcome measure - Costs per child detected with a hearing loss of 40 dB or more in the better ear. Results - Costs of a three stage screening process in child health clinics are €39.0 (95% confidence interval 20.0 to 57.0) per child detected with automated auditory brainstem response compared with €25.0 (14.4 to 35.6) per child detected with otoacoustic emissions. A three stage screening process not only reduces the referral rates, but is also likely to cost less than a two stage process because of the lower cost of diagnostic facilities. The extra cost (over and above a screening programme detecting bilateral losses) of detecting one child with unilateral hearing loss is €1500-4000. With the currently available information, no preference can be expressed for a screening location. Conclusions - Three stage screening with otoacoustic emissions is recommended. Whether screening at home is more cost effective than screening at a child health clinic needs further study.

AIM: To determine the composition of gallstones in South India by comparing visual assessment with graphic interpretation of infrared spectra. METHODS: Infrared spectroscopy (IRS) was used in qualitative analysis of 168 gallstones from Tamilnadu, Kerala and Karnataka and compared with visual interpretation. The spectrum of cholesterol, calcium bilirubinate and calcium carbonate for each stone was correlated with visual inspection. RESULTS: Fifty four percent of gallstones were of pigment variety, 43% were of mixed and the remaining 3% were cholesterol gallstones as categorised by visual interpretation. Based on infrared spectrocopic interpretation the percentages were 58%, 39% and 2% respectively. There was a good agreement between the visual inspection and IRS in classification of gallstones (Kappa value 85%; 95% CI 77-93%). CONCLUSION: Visual inspection of gallstones can predict the composition of gallstone with good accuracy and was comparable to infrared spectroscopic interpretation.

Phenytoin, an anticonvulsant, exhibits nonlinear pharmacokinetics with large interindividual differences. Because of its small therapeutic range with the risk of therapeutic failure or adverse drug effects in susceptible persons, therapeutic drug monitoring is frequently applied. The interindividual differences in dose response can partially be explained by known genetic polymorphisms in the metabolic enzyme CYP2C9 but a large deal of individual variability remains still unexplained. Part of this variability might be accounted for by variable uptake of phenytoin, which is a substrate of p-glycoprotein, encoded by the human MDR1 gene. We evaluated, whether phenytoin plasma levels correlate with a polymorphism in the MDR1 gene, C3435T, which is associated with intestinal PCP activity. Genotyping and analyses of plasma levels of phenytoin and metabolites in 96 healthy Turkish volunteers showed that the MDR1C > T3435 polymorphism affects phenytoin plasma levels (P = 0.064) and the metabolic ratio of p-HPPH vs phenytoin (MDR1*TT genotype, P = 0.026). The MDR1*CC genotype is more common in volunteers with low phenytoin levels (P ≤ 0.001, χ2 test). A combined analysis of variable alleles of CYP2C9, 2C19 and MDR1 revealed that the number of mutant CYP2C9 alleles is a major determinant, the number of MDR1*T alleles further contributes to the prediction of phenytoin plasma levels and CYP2C19*2 does not explain individual variability. The regression equation that fitted the data best included the number of mutant CYP2C9 and MDR*T alleles as predictory variables and explained 15.4% of the variability of phenytoin data (r2 = 0.154, P = 0.0002). Furthermore, analysis of CYP2C9 and MDR1 genotypes in 35 phenytoin-treated patients recruited from therapeutic drug monitoring showed that combined CYP2C9 and MDR1 analysis has some predictive value not only in the controlled settings of a clinical trial, but also in the daily clinical practice. © 2001 Nature Publishing Group All rights reserved.

Objective - To compare the cost effectiveness of various strategies for neonatal hearing screening by estimating the cost per hearing impaired child detected. Design - Cost analyses with a simulation model, including a multivariate sensitivity analysis. Comparisons of the cost per child detected were made for: screening method (automated auditory brainstem response or otoacoustic emissions); number of stages in the screening process (two or three); target disorder (bilateral hearing loss or both unilateral and bilateral loss); location (at home or at a child health clinic). Setting - The Netherlands Target population - All newborn infants not admitted to neonatal intensive care units. Main outcome measure - Costs per child detected with a hearing loss of 40 dB or more in the better ear. Results - Costs of a three stage screening process in child health clinics are €39.0 (95% confidence interval 20.0 to 57.0) per child detected with automated auditory brainstem response compared with €25.0 (14.4 to 35.6) per child detected with otoacoustic emissions. A three stage screening process not only reduces the referral rates, but is also likely to cost less than a two stage process because of the lower cost of diagnostic facilities. The extra cost (over and above a screening programme detecting bilateral losses) of detecting one child with unilateral hearing loss is €1500-4000. With the currently available information, no preference can be expressed for a screening location. Conclusions - Three stage screening with otoacoustic emissions is recommended. Whether screening at home is more cost effective than screening at a child health clinic needs further study.

Objective:To examine the hypothesis that there is sufficient agreement between percentage of households purchasing selected foods using household budget surveys and percentage of individuals consuming these foods as determined in individual-based surveys to allow the former to act as a surrogate for the latter when estimating food chemical intakes using household budget data.Design:Database study.Setting:Databases from Sweden, The Netherlands, Ireland and the UK.Subjects:319 foods (Sweden n=60, The Netherlands n=80, Ireland n=90, UK n=89).Results:Pearson correlations demonstrated a high degree of linear association between % households purchasing and % consumers (r=0.86). Regression analysis defined a close positive relationship between the two datasets (slope 0.95, intercept +2.74). Across countries, using the regression equation, the % households predicted % consumers to within 5% of the true value for between 33 and 48% of foods and to within 10% for between 53 and 78% of foods.Conclusions:Values for % households can be used as a crude surrogate for % consumers and can thus play a role in improving estimates of food additive intake.