Pair housing of laboratory macaques is widely considered to lead to positive changes in well-being, yet the process of introduction is viewed as potentially stressful and risk-prone. Behavioral and physiological data were collected on eight adult male rhesus macaques before, during, and after the process of introduction, in order to measure the initial stress of introduction as well as long-term changes in well-being. Socially experienced subjects, all implanted with biotelemetry devices, were studied in five successive phases: baseline (singly housed), 1 day each of protected contact and full contact introduction, post-introduction (1–3 weeks after introduction), and settled pairs (≥20 weeks after introduction). One hundred and seventy-six hours of behavioral data and 672 hr of heart rate data were analyzed. Fecal cortisol was also measured for the baseline, post-introduction, and settled pair phases. All introductions were successful and subjects showed no physiological or behavioral signs of stress, such as increased heart rate, abnormal behavior, or psychological indices of distress (depressive/anxiety-related behavior). Agonism was minimal throughout the introduction process and over the subsequent months; only one wound was incurred over the course of the study. Levels of abnormal behaviors, psychological indices of distress, locomotion, inactivity, and affiliation showed improvements within several weeks after introduction; these changes were still present 5–9 months later for the latter two categories. Heart rates during introduction fell significantly in the settled pair phase, and also varied predictably with time of day. Fecal cortisol levels were lower in settled pairs than in single housing. The fact that reductions in abnormal behavior did not persist over the long term may have been confounded by increasing duration of time spent caged. The results of this study may be of practical use for designing and monitoring social introductions and suggest that managers should not dismiss the feasibility of successful pairing of adult male rhesus macaques.
Rhesus macaques; social introductions; biotelemetry; stress
Background: Despite scarce scientific evidence, current feeding guidelines recommend delayed introduction of solids for the prevention of asthma and allergy.
Aims: To explore whether late introduction of solids is protective against the development of asthma, eczema, and atopy.
Methods: A total of 642 children were recruited before birth and followed to the age of 5½ years. Main outcome measures were: doctor's diagnosis of eczema ever, atopy according to skin prick test results against inhalant allergens, preschool wheezing, transient wheezing, all defined at age 5–5½ years. Introduction of solids as main exposure measure was assessed retrospectively at age 1 year.
Results: There was no evidence for a protective effect of late introduction of solids for the development of preschool wheezing, transient wheezing, atopy, or eczema. On the contrary, there was a statistically significant increased risk of eczema in relation to late introduction of egg (aOR 1.6, 95% CI 1.1 to 2.4) and milk (aOR 1.7, 95% CI 1.1 to 2.5). Late introduction of egg was furthermore associated with a non-significant increased risk of preschool wheezing (aOR 1.5, 95% CI 0.92 to 2.4). There was no statistical evidence of feeding practices playing a different role in the development of asthma and eczema after stratification for parental asthma and atopy status.
Conclusions: Results do not support the recommendations given by present feeding guidelines stating that a delayed introduction of solids is protective against the development of asthma and allergy.
The early introduction of solid foods before 4 months of age has been associated with an increased risk of diarrhoea in infancy and a greater risk of wheeze and increased percentage body fat and weight in childhood. The purpose of this study was to identify the level of compliance with national recommendations related to the timing of the introduction of solid foods and to describe the maternal and infant characteristics associated with the timing of the introduction of solids.
Subjects were 519 participants in the second longitudinal Perth Infant Feeding Study (PIFS II) recruited from two maternity hospitals in Perth, Western Australia in 2002/3. Data collected prior to, or shortly after discharge from hospital, and at 4, 10, 16, 22, 32, 40 and 52 weeks postpartum included timing of the introduction of solid foods and a variety of maternal and infant characteristics associated with the introduction of solid foods. Multivariate logistic regression was used to identify those factors associated with the risk of introducing solid foods early, which for the purposes of this study was defined as being before 17 weeks.
The median age of introduction of solid foods was 17.6 weeks. In total, 44% of infants had received solids before 17 weeks and 93% of infants had received their first solids before 26 weeks of age. The strongest independent predictors of the early introduction of solids were young maternal age, mother smoking prior to pregnancy and not fully breastfeeding at 4 weeks postpartum. In general, mothers introduced solids earlier than recommended because they perceived their baby to either need them or be ready for them.
This study showed a high level of non-compliance among Australian mothers with the infant feeding recommendation related to the timing of solids that was current at the time. In order to improve compliance health professionals need to be aware of those groups least likely to comply with recommendations and their reasons for non-compliance. Infant feeding recommendations need to be evidence-based, uniformly supported by professionals and widely, clearly and consistently articulated if higher rates of compliance are to be achieved in the future.
Theory suggests that introduction effort (propagule size or number) should be a key determinant of establishment success for exotic species. Unfortunately, however, propagule pressure is not recorded for most introductions. Studies must therefore either use proxies whose efficacy must be largely assumed, or ignore effort altogether. The results of such studies will be flawed if effort is not distributed at random with respect to other characteristics that are predicted to influence success. We use global data for more than 600 introduction events for birds to show that introduction effort is both the strongest correlate of introduction success, and correlated with a large number of variables previously thought to influence success. Apart from effort, only habitat generalism relates to establishment success in birds.
Average inoculum size and number of introductions are known to have positive effects on population persistence. However, whether these factors affect persistence independently or interact is unknown. We conducted a two-factor experiment in which 112 populations of parthenogenetic Daphnia magna were maintained for 41 days to study effects of inoculum size and introduction frequency on: (i) population growth, (ii) population persistence and (iii) time-to-extinction. We found that the interaction of inoculum size and introduction frequency—the immigration rate—affected all three dependent variables, while population growth was additionally affected by introduction frequency. We conclude that for this system the most important aspect of propagule pressure is immigration rate, with relatively minor additional effects of introduction frequency and negligible effects of inoculum size.
colonization; Daphnia magna; immigration; propagule pressure; renewal process
Reporting templates are increasingly common in all fields of pathology. In this paper, we present an assessment of the impact of a thyroid fine needle aspiration cytology (FNAC) template on diagnostic classification and cytohistologic concordance.
Materials and Methods:
A thyroid FNAC reporting template was developed and introduced at a university teaching hospital. We examined FNAC reports for a five-month period before introduction of the template and compared these to the five month period after the template introduction. We recorded diagnostic categorization as well as cytohistologic correlation.
A total of 168 cases were identified in the five month period prior to the introduction of the reporting template and 172 cases in the five month period after the introduction of the reporting template. The template appeared to improve the diagnostic precision of benign conditions without altering the proportion of cases classified as unsatisfactory, benign or abnormal. There was no significant difference in the rate of cytohistologic concordance before and after the template introduction.
The introduction of a reporting template for thyroid FNAC improved diagnostic precision of benign conditions and did not alter the general diagnostic classification or cytohistologic concordance.
Diagnosis; fine needle aspiration cytology (FNAC); thyroid; reporting template
Voluntary wheel running (WR) is a form of physical activity in rodents that influences ingestive behavior. The present report describes an anorexic behavior triggered by the simultaneous introduction of a novel diet and WR. This study examined the sequential, compared with the simultaneous, introduction of a novel high-fat (HF) diet and voluntary WR in rats of three different ages and revealed a surprising finding; the simultaneous introduction of HF food and voluntary WR induced a behavior in which the animals chose not to eat although food was available at all times. This phenomenon was apparently not due to an aversion to the novel HF diet because introduction of the running wheels plus the HF diet, while continuing the availability of the normal chow diet did not prevent the anorexia. Moreover, the anorexia was prevented with prior exposure to the HF diet. In addition, the anorexia was not related to extent of WR but dependent on the act of WR. The introduction a HF diet and locked running wheels did not induce the anorexia. This voluntary anorexia was accompanied by substantial weight loss, and the anorexia was rapidly reversed by removal of the running wheels. Moreover, the HF/WR-induced anorexia is preserved across the age span despite the intrinsic decrease in WR activity and increased consumption of HF food with advancing age. The described phenomenon provides a new model to investigate anorexia behavior in rodents.
anorexia; voluntary wheel running; high-fat feeding
It is unknown whether the reported short-term reduction in cardiac arrests associated with the introduction of the medical emergency team (MET) system can be sustained.
We conducted a prospective, controlled before-and-after examination of the effect of a MET system on the long-term incidence of cardiac arrests. We included consecutive patients admitted during three study periods: before the introduction of the MET; during the education phase preceding the implementation of the MET; and a period of four years from the implementation of the MET system. Cardiac arrests were identified from a log book of cardiac arrest calls and cross-referenced with case report forms and the intensive care unit admissions database. We measured the number of hospital admissions and MET reviews during each period, performed multivariate logistic regression analysis to identify predictors of mortality following cardiac arrest and studied the correlation between the rate of MET calls with the rate of cardiac arrests.
Before the introduction of the MET system there were 66 cardiac arrests and 16,246 admissions (4.06 cardiac arrests per 1,000 admissions). During the education period, the incidence of cardiac arrests decreased to 2.45 per 1,000 admissions (odds ratio (OR) for cardiac arrest 0.60; 95% confidence interval (CI) 0.43–0.86; p = 0.004). After the implementation of the MET system, the incidence of cardiac arrests further decreased to 1.90 per 1,000 admissions (OR for cardiac arrest 0.47; 95% CI 0.35–0.62; p < 0.0001). There was an inverse correlation between the number of MET calls in each calendar year and the number of cardiac arrests for the same year (r2 = 0.84; p = 0.01), with 17 MET calls being associated with one less cardiac arrest. Male gender (OR 2.88; 95% CI 1.34–6.19) and an initial rhythm of either asystole (OR 7.58; 95% CI 3.15–18.25; p < 0.0001) or pulseless electrical activity (OR 4.09; 95% CI 1.59–10.51; p = 0.003) predicted an increased risk of death.
Introduction of a MET system into a teaching hospital was associated with a sustained and progressive reduction in cardiac arrests over a four year period. Our findings show sustainability and suggest that, for every 17 MET calls, one cardiac arrest might be prevented.
Experiments conducted on pregnant Wistar rats show that chlorophos (Dipterex) has embroyotoxic and teratogenic effects after oral introduction in a 80 mg/kg dose during a critical period of embryogenesis. Embryotoxic and teratogenic effects are absent during the introduction of 8 mg/kg of the pesticide. The oral introduction of phthalophos (Imidan) in a 30 mg/kg dose once on day 9 of pregnancy and the introduction of a 1.5 mg/kg dose daily throughout the course of pregnancy caused increased postimplantation mortality of embryos. A dose of 30 mg/kg of phthalophos on day 9 or day 13 of pregnancy causes developmental abnormalities, including hyponathia and hydrocephaly. A 0.06 mg/kg phthalophos dose does not affect the course of embryogenesis in white rats. Thus the organophosphate pesticides Dipterex and Imidan exhibit embryotoxic and teratogenic effects at doses which significantly exceed the acutal amounts of the pesticide that can enter the human organism.
Rats were used to study the general activity and the isoenzyme spectrum of lactate dehydrogenase (LDH) during single-instance and long-term introduction of polychlorocamphene. Total lactate dehydrogenase activity decreases in the liver during the single-instance introduction of half the LD50 (120 mg/kg). The isoenzyme spectrum of LDH is characterized by an increase in the quantity of LDH1, LDH2, and LDH3 and by a decrease in the amount of LDH4. The overall LDH activity does not change in blood serum. The isoform ratio changes insignificantly and LDH1 falls, but normalized 15 days after the introduction of the compound. Long-term introduction of polychlorocamphene at levels 1/100 the LD50 dose over 1.3 and 6 months causes a reduction in the overall LDH activity, both in the liver and in the serum. A decrease in the activity of the basic LDH isoenzyme of the liver (LDH5) and a sharp increase in LDH3 are characteristic for the isoenzyme spectrum of the liver. LDH1 and LDH4 decrease and LDH2 and LDH3 increase in blood serum. Beginning with the third month of polychlorocamphene introduction, LDH1 tends to return to normal levels. LDH2, LDH3, and LDH4 do return to normal levels, while LDH5 increases regularly. This results in a reduction of the number of H subunits and an increase of M subunits. This is characteristic of hypoxic states. On comparing the changes in the LDH enzymes of the liver and blood serum, it can be considered that the introduction of polychlorocamphene does not result in an increase in the permeability of the cellular membranes of the liver for LDH isoenzymes, while the observed isoenzyme spectrum shifts in blood serum are either the result of the biosynthesis of the isoforms of this enzyme changed by the compound or the result of the permeability for them of cells of other tissues.
The high cost of critical care resources has resulted in strategies to reduce the costs of ruling out low-risk patients by developing intermediate care units (IMCs). The aim of this study was to compare changes in total hospital costs for intensive care patients before and after the introduction of an IMC at the University Hospital Maastricht.
The design was a comparative longitudinal study. The setting was a university hospital with a mixed intensive care unit (ICU), an IMC, and general wards. Changes in total hospital costs were measured for patients who were admitted to the ICU before and after the introduction of the IMC. The comparison of interest was the opening of a six-bed mixed IMC.
The mean total hospital cost per patient increased significantly. Before the introduction of the IMC, the total hospital cost per patient was €12,961 (± €14,530) and afterwards it rose to €16,513 (± €17,718). Multiple regression analysis was used to determine to what extent patient characteristics explained these higher hospital costs using mortality, type of stay, diagnostic categories, length of ICU and ward stay, and the Therapeutic Intervention Scoring System (TISS) as predictors. More surgical patients, greater requirements of therapeutic interventions on the ICU admission day, and longer ICU stay in patients did explain the increase in hospital costs, rather than the introduction of the IMC.
After the introduction of the IMC, the higher mean total hospital costs for patients with a high TISS score and longer ICU stay explained the cost increase.
Information about Medical Emergency Teams (METs) in Australia and New Zealand (ANZ) is limited to local studies and a cluster randomised controlled trial (the Medical Emergency Response and Intervention Trial [MERIT]). Thus, we sought to describe the timing of the introduction of METs into ANZ hospitals relative to relevant publications and to assess changes in the incidence and rate of intensive care unit (ICU) admissions due to a ward cardiac arrest (CA) and ICU readmissions.
We used the Australian and New Zealand Intensive Care Society database to obtain the study data. We related MET introduction to publications about adverse events and MET services. We compared the incidence and rate of readmissions and admitted CAs from wards before and after the introduction of an MET. Finally, we identified hospitals without an MET system which had contributed to the database for at least two years from 2002 to 2005 and measured the incidence of adverse events from the first year of contribution to the second.
The MET status was known for 131 of the 172 (76.2%) hospitals that did not participate in the MERIT study. Among these hospitals, 110 (64.1%) had introduced an MET service by 2005. In the 79 hospitals in which the MET commencement date was known, 75% had introduced an MET by May 2002. Of the 110 hospitals in which an MET service was introduced, 24 (21.8%) contributed continuous data in the year before and after the known commencement date. In these hospitals, the mean incidence of CAs admitted to the ICU from the wards changed from 6.33 per year before to 5.04 per year in the year after the MET service began (difference of 1.29 per year, 95% confidence interval [CI] -0.09 to 2.67; P = 0.0244). The incidence of ICU readmissions and the mortality for both ICU-admitted CAs from wards and ICU readmissions did not change. Data were available to calculate the change in ICU admissions due to ward CAs for 16 of 62 (25.8%) hospitals without an MET system. In these hospitals, admissions to the ICU after a ward CA decreased from 5.0 per year in the first year of data contribution to 4.2 per year in the following year (difference of 0.8 per year, 95% CI -0.81 to 3.49; P = 0.3).
Approximately 60% of hospitals in ANZ with an ICU report having an MET service. Most introduced the MET service early and in association with literature related to adverse events. Although available in only a quarter of hospitals, temporal trends suggest an overall decrease in the incidence of ward CAs admitted to the ICU in MET as well as non-MET hospitals.
AIMS—To audit the management of
community acquired pneumonia before and after the introduction of a
protocol. To determine the aetiology of pneumonia using routine
investigations and polymerase chain reaction (PCR).
prospective audit following the introduction of a management protocol.
Prospective cases were investigated routinely and with PCR on blood and
RESULTS—There was a significant
increase in rational prescribing following introduction of the protocol
with 75% of children receiving intravenous penicillin or erythromycin
compared with 26% beforehand. Of 89 children in the prospective group,
51 microbiological diagnoses were achieved in 48 children. Seven
children had Streptococcus pneumoniae
infection, 14 had Mycoplasma infection, six had pertussis, and one had
Chlamydia pneumoniae infection. Twenty three
children had a viral cause of which respiratory syncytial virus was commonest.
CONCLUSIONS—Introduction of the
protocol led to improved prescribing. PCR increased the diagnostic
yield and the results support the management protocol.
The aim of this study was to evaluate asthma control after the introduction of a leukotriene modifier (Montelukast), in addition to the current controller asthma therapies, in patients with inadequately controlled mild-to-moderate persistent asthma. Asthma control and patient perception were assessed prior to, and 4 weeks after, the introduction of Montelukast, and the pre-introduction and post-introduction results were compared.
Materials and Methods:
A cross-sectional, observational study collected information on 1,490 eligible adult asthmatic patients in Saudi Arabia. The eligibility criteria included patients aged 15 years or more with symptomatic mild-to-moderate persistent asthma despite treatment with inhaled corticosteroids with or without long-acting beta agonist; also, the patient should attend the initial visit and follow-up visits after at least 4 weeks.
Of the 1,490 eligible patients, 79.5% received inhaled corticosteroids alone, and the remaining 20.5% received combination of inhaled corticosteroids and long-acting bronchodilator. Despite the treatment with daily controller medications, asthma symptoms persisted in more than two-thirds of the study population. Upon adding Montelukast, more than 80% of patients reported improvement in symptoms, which was consistent in all patients irrespective of corticosteroid type or dose (stratum) or the addition of long-acting β2-agonist. At the follow-up visit, 92.2% of patients reported that they felt better on Montelukast.
Leukotriene modifier Montelukast has significant additive benefits in the management of patients who suffer from mild-to-moderate asthma and who are inadequately controlled on inhaled corticosteroids therapy with or without long-acting bronchodilator.
White King pigeons exposed to food schedules before introduction of a colored photograph of a pigeon showed sustained schedule-induced attack on that image; additional birds given an early introduction to both the photograph and the schedule subsequently attacked the image at lower rates. Other pigeons attacked a second photograph of a pigeon regardless of whether it was introduced early or late. The late-introduction procedure was also effective in establishing attack on a projected image of a conspecific. The combined results showed that 14 of 17 White King pigeons given a late introduction to a pictorial target exhibited sustained attack against it and that a pigeon's initial reaction to a photograph of a conspecific when introduced early was a good predictor of subsequent schedule-induced attack on it.
A substantial part of vascular surgical workload is devoted to the treatment of varicose veins. To control demand for cosmetic venous surgery, primary care trusts in Somerset introduced clinical criteria in 2000 for the referral and treatment of varicose veins based on the presence of skin change or ulceration, a history of bleeding, or two or more episodes of thrombophlebitis.
PATIENTS AND METHODS
A comparison of workload and case mix for the referral and treatment of new patients presenting with varicose veins to the Taunton and Somerset Hospital was carried out over two 6-month periods, before and after the introduction of clinically based assessment criteria.
A total of 134 operations for varicose veins were carried out in 2000 and 85 such operations in 2002/03 after the introduction of new referral criteria (P = 0.001). Of these, 69% (92/134) were day-case procedures in 2000 compared to only 48% (41/85) in 2002/03 (P = 0.004). There was no significant difference in the type of cases (e.g. single, bilateral or recurrent surgery) performed as a day-case (P = 0.34) or as an in-patient (P = 0.43) over the two periods. There was, however, a significant difference (P = 0.007) in the mean ages of patients in the two periods (48.5 years in period 1; 57.8 years in period 2) and in the average ASA grade (1.15 in period 1; 1.42 in period 2; P = 0.0002).
The introduction of clinical criteria for the referral and treatment of varicose veins reduced workload by 37%.
Varicose veins; Management; Clinical criteria; Rationing
Since April 2002, collection and publication of surgeon-specific data in adult cardiac surgery has become mandatory in the UK. It has been suggested that this may discourage consultants from allowing trainees to perform cases. The aim of this study was to attempt to analyse the effect of the introduction of surgeon-specific data (SSD) on surgical training in a large cardiac surgical centre.
PATIENTS AND METHODS
A retrospective analysis was performed on 2111 consecutive patients undergoing elective coronary artery bypass surgery, aortic and mitral valve surgery at Southampton General Hospital between April 2000 and April 2004. Results were analysed and compared over a 2-year period prior to and a 2-year period following the introduction of SSD.
There were no changes in the overall mortality rate following the introduction of SSD. SSD was associated with a reduction in the overall proportion of cases performed by trainees (49% versus 42.8%; P = 0.004) and, in particular, a reduction in the proportion of aortic and mitral valve procedures performed by trainees. In addition, the proportion of cases performed by the trainees without consultant supervision declined significantly following SSD (18.7% versus 10.4%; P < 0.001).
Publication of surgeon-specific data has coincided with a decrease in both the proportion and variety of cases performed by trainees.
Cardiac surgery; Training
Performing a lumbar puncture in an unwell child can cause anxiety in both the parent and the junior doctor. There is increasing evidence of post‐lumbar‐puncture complications in this age group.
To improve the documentation, consent for and technical performance of paediatric lumbar punctures to 100% of the required standard within 3 months.
The paediatric emergency department of a the Royal North Shore Hospital (University of Sydney, Sydney, Australia).
Paediatric emergency staff, including residents, registrars and consultants.
Medical records of 40 consecutive children who had undergone a lumbar puncture in the 6 months before the introduction of the lumbar‐puncture proforma were reviewed. After introduction of the proforma, the records of 25 consecutive patients were reviewed to assess changes in the outcome measures. Before introduction of the proforma, junior medical staff were instructed in the procedure using specialised lumbar puncture manikins (Baby Stap; Laerdel, USA).
Before introduction of the proforma, the median number of documented indicators was 4, out of a maximum of 12. There was almost no documentation of parental consent, patient complications and analgesia. Introduction of the proforma resulted in a highly marked increase to a median of 12 documented indicators per patient (p<0.01, 95% confidence interval 6 to 8).
The introduction of a lumbar‐puncture proforma and formal teaching sessions using a paediatric manikin led to a marked improvement in the documentation of paediatric lumbar‐punctures. Lumbar‐punctures can be performed only by accredited medical officers who have achieved competency on the lumbar‐puncture teaching manikin.
Forty three patients with non-insulin dependent diabetes registered at two suburban practices were interviewed at least one year after the introduction of an organized general practice based system of diabetic surveillance and the results compared with data gathered from interviews administered before the introduction of the system. Structured data from the two interviews were compared in relation to the importance which patients attached to diabetes and its medical review, patients' preference for place of future review and the health professionals from whom they wished to receive diabetes care. Patients' ratings of the performance of health professionals on various aspects of care were compared with the ratings given before the introduction of the new service. At the follow-up interviews the reasons behind patients' responses to the structured questions were explored using a qualitative method. The introduction of a general practice based diabetes service was marked by an improvement in attendance for diabetes monitoring (56% before introduction, 98% in the year following introduction). This was associated with an increase in the importance which patients attached to diabetes and its medical review. After experience of diabetes care in general practice, patients remained enthusiastic about general practice involvement and confident in their general practitioners' knowledge about diabetes management. In spite of an improvement in the patients' ratings of hospital doctors' communication skills, they continued to rate general practitioners significantly more highly in these skills (P < 0.01) and in terms of convenience and accessibility (P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
The introduction of species to areas beyond the limits of their natural distributions has a major homogenizing influence, making previously distinct biotas more similar. The scale of introductions has frequently been commented on, but their rate and spatial pervasiveness have been less well quantified. Here, we report the findings of a detailed study of pterygote insect introductions to Gough Island, one of the most remote and supposedly pristine temperate oceanic islands, and estimate the rate at which introduced species have successfully established. Out of 99 species recorded from Gough Island, 71 are established introductions, the highest proportion documented for any Southern Ocean island. Estimating a total of approximately 233 landings on Gough Island since first human landfall, this equates to one successful establishment for every three to four landings. Generalizations drawn from other areas suggest that this may be only one-tenth of the number of pterygote species that have arrived at the island, implying that most landings may lead to the arrival of at least one alien. These rates of introduction of new species are estimated to be two to three orders of magnitude greater than background levels for Gough Island, an increase comparable to that estimated for global species extinctions (many of which occur on islands) as a consequence of human activities.
Measurement of Stereopsis forms an important part of the clinical assessment of patients with disorders of ocular motility. The introduction of a real depth distance stereoacuity test (FD2) was evaluated in clinical practice and to what extent the introduction affected clinical management. Seventy-three patients under evaluation before and following the introduction of the test were included. Combined thresholds were measured at near using the Frisby and TNO test and at distance using the FD2. Fifty healthy controls were included. Forty-five patients demonstrated Stereopsis using the FD2 and 23 of these had a change in their management based in part on their responses using the FD2. Patients with evidence of Stereopsis using the FD2 were significantly more likely to have change in their management than expected from the whole sample (P = .02). The introduction of a real depth distance stereoacuity test into clinical practice contributed to a change in management when used in conjunction with other tests. The usefulness of the FD2 is limited by its range at 6 m. Use at closer distances necessitates the calculation of binocular threshold from the combined and monocular threshold.
Advances in the field of labour analgesia have tread a long journey from the days of ether and chloroform in 1847 to the present day practice of comprehensive programme of labour pain management using evidence-based medicine. Newer advances include introduction of newer techniques like combined spinal epidurals, low-dose epidurals facilitating ambulation, pharmacological advances like introduction of remifentanil for patient-controlled intravenous analgesia, introduction of newer local anaesthetics and adjuvants like ropivacaine, levobupivacaine, sufentanil, clonidine and neostigmine, use of inhalational agents like sevoflourane for patient-controlled inhalational analgesia using special vaporizers, all have revolutionized the practice of pain management in labouring parturients. Technological advances like use of ultrasound to localize epidural space in difficult cases minimizes failed epidurals and introduction of novel drug delivery modalities like patient-controlled epidural analgesia (PCEA) pumps and computer-integrated drug delivery pumps have improved the overall maternal satisfaction rate and have enabled us to customize a suitable analgesic regimen for each parturient. Recent randomized controlled trials and Cochrane studies have concluded that the association of epidurals with increased caesarean section and long-term backache remains only a myth. Studies have also shown that the newer, low-dose regimes do not have a statistically significant impact on the duration of labour and breast feeding and also that these reduce the instrumental delivery rates thus improving maternal and foetal safety. Advances in medical technology like use of ultrasound for localizing epidural space have helped the clinicians to minimize the failure rates, and many novel drug delivery modalities like PCEA and computer-integrated PCEA have contributed to the overall maternal satisfaction and safety.
Ambulatory epidurals; labour analgesia; recent advances
The objective of this study was to determine the safety and acceptability of the implementation of a day-case laparoscopic cholecystectomy (LC) service in a large UK teaching hospital, and analyse factors influencing contact with primary care providers. Wide-spread introduction of day-case LC in the UK is a major target of healthcare providers. However, few centres have reported their experience. In the US, out-patient surgery for LC has been reported, though many groups have utilised 24-h observation units to facilitate discharge. Concerns remain amongst surgeons regarding the feasibility and acceptability of the introduction of day-case LC in the UK.
PATIENTS AND METHODS
Comprehensive care and operative data were prospectively collected on the first 106 consecutive day-case procedures in our hospital. Postoperative recovery was monitored by telephone questionnaire on days 2, 5 and 14, including complications, satisfaction and general practitioner consultation.
A total of 106 patients were admitted for day-case LC, of whom 84% were discharged on the day of surgery. Patient satisfaction rate was 94% in both the successful day-case and the admitted patients. Mean operation time was 62 min, with an average total stay on the day-care unit of 426 min. Training-grade surgeons performed 31% of operations. Both the re-admission rate after surgery and rate of conversion to open surgery were 2%. Advice from primary healthcare providers was sought by 33% of patients within the first 14 postoperative days.
Introduction of day-case LC in the UK is feasible and acceptable to patients. The potential burden to primary care providers needs further study.
Cholecystectomy; Laparoscopic; Day-case
In 2004, an audit in our unit demonstrated wide variation in liver resection rates for colorectal cancer (CRC) metastases within the cancer network. Subsequently, a network-wide CT-based follow-up and referral policy was introduced for all patients. A second audit was performed to assess the impact of the guidelines on liver resection rates.
SUBJECTS AND METHODS
Analysis of prospective liver resection database between 1997 and 2004 and after the introduction of standardised guidelines between January 2005 and April 2008.
A total of 362 patients underwent liver resection for CRC metastases between 1997 and 2008, 237 prior to the introduction of the referral guidelines and 125 after. Liver resection rates according to referring hospital varied from 0.92 to 2.32 per 100,000 population before guidelines were introduced. After 2005, resection rates from the four district hospitals standardised (1.68–1.84 per 100,000 population), but the central unit rate (Sheffield) remained significantly higher (2.67 per 100,000 population). No significant difference in 1-year disease-free survival between patients from Sheffield and the outlying hospitals was found (P = 0.553).
Introduction of a referral protocol standardised resection rates from the four district hospitals, but these remain lower compared to the specialist centre. The wide-spread adoption of a policy to discuss all patients with liver metastases at an advanced disease multidisciplinary team meeting, in the presence of hepatobiliary specialists, may further increase resection rates across the UK.
Liver; surgery; Healthcare rationing; Colorectal cancer; Metastases
Understanding the dimensions of pathways of introduction of alien plants is important for regulating species invasions, but how particular pathways differ in terms of post-invasion success of species they deliver has never been rigorously tested. We asked whether invasion status, distribution and habitat range of 1,007 alien plant species introduced after 1500 A.D. to the Czech Republic differ among four basic pathways of introduction recognized for plants.
Pathways introducing alien species deliberately as commodities (direct release into the wild; escape from cultivation) result in easier naturalization and invasion than pathways of unintentional introduction (contaminant of a commodity; stowaway arriving without association with it). The proportion of naturalized and invasive species among all introductions delivered by a particular pathway decreases with a decreasing level of direct assistance from humans associated with that pathway, from release and escape to contaminant and stowaway. However, those species that are introduced via unintentional pathways and become invasive are as widely distributed as deliberately introduced species, and those introduced as contaminants invade an even wider range of seminatural habitats.
Pathways associated with deliberate species introductions with commodities and pathways whereby species are unintentionally introduced are contrasting modes of introductions in terms of invasion success. However, various measures of the outcome of the invasion process, in terms of species' invasion success, need to be considered to accurately evaluate the role of and threat imposed by individual pathways. By employing various measures we show that invasions by unintentionally introduced plant species need to be considered by management as seriously as those introduced by horticulture, because they invade a wide range of seminatural habitats, hence representing even a greater threat to natural areas.