bluuebunny/crossref_metadata_2025 huggingface dataset:
Quantitative Proteomics of the Tonoplast Reveals a Role for Glycolytic Enzymes in Salt Tolerance
Authors: Barkla Bronwyn J. , Vera-Estrella Rosario , Hernández-Coronado Marcela , Pantoja Omar
Published: December 2009

To examine the role of the tonoplast in plant salt tolerance and identify proteins involved in the regulation of transporters for vacuolar Na+ sequestration, we exploited a targeted quantitative proteomics approach. Two-dimensional differential in-gel electrophoresis analysis of free flow zonal electrophoresis separated tonoplast fractions from control, and salt-treated Mesembryanthemum crystallinum plants revealed the membrane association of glycolytic enzymes aldolase and enolase, along with subunits of the vacuolar H+-ATPase V-ATPase. Protein blot analysis confirmed coordinated salt regulation of these proteins, and chaotrope treatment indicated a strong tonoplast association. Reciprocal coimmunoprecipitation studies revealed that the glycolytic enzymes interacted with the V-ATPase subunit B VHA-B, and aldolase was shown to stimulate V-ATPase activity in vitro by increasing the affinity for ATP. To investigate a physiological role for this association, the Arabidopsis thaliana cytoplasmic enolase mutant, los2, was characterized. These plants were salt sensitive, and there was a specific reduction in enolase abundance in the tonoplast from salt-treated plants. Moreover, tonoplast isolated from mutant plants showed an impaired ability for aldolase stimulation of V-ATPase hydrolytic activity. The association of glycolytic proteins with the tonoplast may not only channel ATP to the V-ATPase, but also directly upregulate H+-pump activity.
Heat Shock Protein Cognate 70-4 and an E3 Ubiquitin Ligase, CHIP, Mediate Plastid-Destined Precursor Degradation through the Ubiquitin-26S Proteasome System inArabidopsis
Authors: Lee Sookjin , Lee Dong Wook , Lee Yongjik , Mayer Ulrike , Stierhof York-Dieter , Lee Sumin , Jürgens Gerd , Hwang Inhwan
Published: December 2009

Plastid-targeted proteins pass through the cytosol as unfolded precursors. If proteins accumulate in the cytosol, they can form nonspecific aggregates that cause severe cellular damage. Here, we demonstrate that high levels of plastid precursors are degraded through the ubiquitin-proteasome system (UPS) in Arabidopsis thaliana cells. The cytosolic heat shock protein cognate 70-4 (Hsc70-4) and E3 ligase carboxy terminus of Hsc70-interacting protein (CHIP) were highly induced in plastid protein import2 plants, which had a T-DNA insertion at Toc159 and showed an albino phenotype and a severe defect in protein import into chloroplasts. Hsc70-4 and CHIP together mediated plastid precursor degradation when import-defective chloroplast-targeted reporter proteins were transiently expressed in protoplasts. Hsc70-4 recognized specific sequence motifs in transit peptides and thereby led to precursor degradation through the UPS. CHIP, which interacted with Hsc70-4, functioned as an E3 ligase in the Hsc70-4–mediated protein degradation. The physiological role of Hsc70-4 was confirmed by analyzing Hsc70-4 RNA interfernce plants in an hsc70-1 mutant background. Plants with lower Hsc70 levels exhibited abnormal embryogenesis, resulting in defective seedlings that displayed high levels of reactive oxygen species and monoubiquitinated Lhcb4 precursors. We propose that Hsc70-4 and CHIP mediate plastid-destined precursor degradation to prevent cytosolic precursor accumulation and thereby play a critical role in embryogenesis.
The effect on outcome of peribulbar anaesthesia in conjunction with general anesthesia for vitreoretinal surgery
Authors: Ghali A. M. , El Btarny A. M.
Published: December 2009

The purpose of this study was to evaluate peri‐operative outcome after vitreoretinal surgery when peribulbar anaesthesia is combined with general anaesthesia. Sixty adult patients undergoing elective primary retinal detachment surgery with scleral buckling or an encircling procedure received either peribulbar anaesthesia in conjunction with general anaesthesia or general anaesthesia alone. For peribulbar anaesthesia a single percutaneous injection of 5–7 ml of local anaesthetic solution (0.75% ropivacaine with hyaluronidase 15 iu.ml−1) was used. The incidence of intra‐operative oculocardiac reflex and surgical bleeding interfering with the surgical field, postoperative pain and analgesia requirements, and postoperative nausea and vomiting were recorded. In the block group there was a lower incidence of oculocardiac reflex and surgical bleeding intra‐operatively. Patients in the block group also had better postoperative analgesia and a lower incidence of postoperative nausea and vomiting compared with the group without a block. The use of peribulbar anaesthesia in conjunction with general anesthesia was superior to general anaesthesia alone for vitreoretinal surgery with scleral buckling.
Latitudinal gradients in stream invertebrate assemblages at a regional scale on Hokkaido Island, Japan
Authors: MORI TERUTAKA , MURAKAMI MASASHI , SAITOH TAKASHI
Published: December 2009

1. Although a latitudinal gradient in species diversity has been observed for various taxa, the factors generating the latitudinal gradient at broad spatial scales are difficult to identify because several candidate factors change simultaneously with latitude. We investigated latitudinal gradients in stream invertebrate assemblages in 30 headwater streams in Hokkaido Island, Japan, focusing on the regional scale to discount historical factors and to extract the effects of environmental factors on latitudinal gradients in diversity.

2. Taxon diversity (Shannon index) and taxon richness (number of taxa per unit area) increased with latitude. Abundance showed a similar latitudinal gradient, whereas evenness (Δ1) did not. Hence, we conclude that the observed latitudinal gradient in taxon richness was generated by directional variation in abundance (passive accumulation), leading to that in taxon diversity.

3. Precipitation, which is strongly related to flood disturbances, decreased with latitude and was an important factor explaining variation in taxon diversity, taxon richness and abundance. The probability of a taxon being present tended to increase from south to north, suggesting that the higher taxon richness observed in northern sites may be because of the presence of rare species. These findings indicate that flood disturbance varying with latitude may influence abundance and local extinction rates of rare species, consequently affecting taxon richness and taxon diversity.

4. By detecting the effects of an environmental factor (precipitation) on the latitudinal gradients in taxon diversity and taxon richness without interference by historical factors, this study demonstrates processes that can produce latitudinal gradients in the diversity of stream invertebrate assemblages.
Histopathology of alopecia: a clinicopathological approach to diagnosis
Authors: Stefanato Catherine M
Published: December 2009

Stefanato C M (2010) Histopathology56, 24–38 Histopathology of alopecia: a clinicopathological approach to diagnosis

Interpretation of the histopathological findings of primary scarring and non‐scarring alopecias may prove daunting. This is especially true if the biopsy specimen is inadequate, and the clinical history and pattern of the alopecia are not known. Common forms of scarring alopecias discussed here are the lymphocytic (discoid lupus erythematosus, lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade of Brocq), the neutrophilic (folliculitis decalvans, dissecting folliculitis), and the mixed (acne keloidalis) entities. The non‐scarring alopecias reviewed are androgenic alopecia, telogen effluvium, alopecia areata, trichotillomania and traction alopecia. In all cases of primary alopecia, adequate tissue sampling and appropriate laboratory processing, in combination with pertinent clinical information, provide the key to diagnosis.
Cutaneous fibrohistiocytic tumours – an update
Authors: Luzar Boštjan , Calonje Eduardo
Published: December 2009

Luzar B & Calonje E  (2010) Histopathology56, 148–165 Cutaneous fibrohistiocytic tumours – an update

The term ‘fibrohistiocytic’ tumour is a descriptive designation without histogenetic connotation for a group of heterogeneous lesions that share morphological features of histiocytes and fibroblasts on light microscopy. However, over the years it has become apparent that many so‐called ‘fibrohistiocytic’ tumours are largely composed of relatively undifferentiated mesenchymal cells, but can also show areas of myofibroblastic differentiation. This review focuses on the clinical and histological features as well as differential diagnosis of so‐called fibrohistiocytic tumours. Special emphasis is given to more recently described histological variants of fibrous histiocytoma, e.g. cellular, epithelioid, aneurysmal and atypical fibrous histiocytoma, to angiomatous and plexiform fibrous histocytoma (plexiform fibrohistiocytic tumour), lesions that are not true variants of fibrous histiocytomas but have erroneously been designated such, and to atypical fibroxanthoma. The literature on metastasizing fibrous histiocytoma is also reviewed.
Clues to the diagnosis of atypical melanocytic lesions
Authors: McKee Phillip H
Published: December 2009

McKee P H (2010) Histopathology56, 100–111 Clues to the diagnosis of atypical melanocytic lesions

This review, based on a lecture given at the 2009 Update in Dermatopathology meeting held at the Institute of Dermatology (London, UK), discusses the problem of misdiagnosing atypical benign melanocytic lesions as melanoma and the alternative problem of interpreting naevoid melanoma as a banal naevus. Consequences are considered. Brief consideration of a range of other melanoma variants that may be a source of diagnostic difficulty is also included.
Sebaceous neoplasia and the Muir–Torre syndrome: important connections with clinical implications
Authors: Shalin Sara C , Lyle Stephen , Calonje Eduardo , Lazar Alexander J F
Published: December 2009

Shalin S C, Lyle S, Calonje E & Lazar A J F (2010) Histopathology56, 133–147 Sebaceous neoplasia and the Muir–Torre syndrome: important connections with clinical implications

Sebaceous neoplasia comprises a spectrum ranging from benign to malignant. Proper histological identification is important for treatment, prognosis and potential association with the Muir–Torre syndrome (MTS). Our increased understanding of the significance and pathogenesis of these tumours has led to improved risk stratification, screening recommendations, and treatment of patients with an initial presentation of a sebaceous tumour. This review focuses on the diagnostic and histological features of sebaceous lesions, the MTS, and recent insights into the molecular pathogenesis of sebaceous tumours.
Dermatopathological challenges in the human immunodeficiency virus and acquired immunodeficiency syndrome era
Authors: Ramdial Pratistadevi K
Published: December 2009

Ramdial P K (2010) Histopathology56, 39–56 Dermatopathological challenges in the human immunodeficiency virus and acquired immunodeficiency syndrome era

The histopathological assessment of cutaneous lesions is critical to the definitive diagnosis of many human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome‐associated dermatoses, infections and tumours. Dermatopathological challenges stem mainly from the altered histopathological profile of established cutaneous entities compared with that in the HIV‐unaffected population, the emergence of new diseases and the impact of therapeutic modalities on cutaneous lesions. This review focuses on some of these diagnostic dilemmas, with emphasis on the following challenges: (i) infective diagnostic pitfalls; (ii) itchy papular skin lesions; (iii) co‐lesional comorbid diseases; (iv) drug‐induced disease alterations; and (v) neoplastic and pseudoneoplastic proliferations. The drug‐induced alterations include highly active antiretroviral therapy‐associated disease modifications.
Immunocytochemistry and the diagnosis of cutaneous lymphoma
Authors: Robson Alistair
Published: December 2009

Robson A (2010) Histopathology56, 71–90 Immunocytochemistry and the diagnosis of cutaneous lymphoma

Cutaneous lymphoid infiltrates may pose some of the most difficult diagnostic problems in dermatopathology. Immunocytochemistry is often employed in an effort to determine whether an infiltrate is neoplastic or, in the case of clearly malignant infiltrates, to provide a specific diagnosis. The rarity of these disorders and the variant immunocytochemical profiles they may present further thwart understanding and sometimes prevent an accurate diagnosis. In this review the common immunocytochemical profiles of various cutaneous lymphomas are presented and potential pitfalls and problems considered. Immunocytochemistry is not a diagnostic test but, as in other areas of histopathology, is a highly valuable tool that requires critical interpretation within a context: so applied, it is an indispensable part of the pathologist’s arsenal in evaluating lymphoid infiltrates and defining different lymphomas.
Bombyx mori Ras proteins BmRas1, BmRas2 and BmRas3 are neither farnesylated nor palmitoylated but are geranylgeranylated
Authors: Moriya K. , Tsubota T. , Ishibashi N. , Yafune A. , Suzuki T. , Kobayashi J. , Shiotsuki T. , Utsumi T.
Published: December 2009

The lipid modifications which occur on Bombyx mori Ras proteins BmRas1, BmRas2 and BmRas3 were studied by metabolic labelling in an insect cell‐free protein synthesis system and in a baculovirus expression system, using specific inhibitors of protein prenylation and protein palmitoylation. In addition, the subcellular localization of BmRas proteins was examined using EGFP fusion proteins of constitutively active forms of BmRas proteins transiently expressed in Sf9 cells. As a result, it was revealed that the three B. mori Ras proteins BmRas1, BmRas2 and BmRas3 are neither farnesylated nor palmitoylated but are geranylgeranylated for localization to the plasma membrane of insect cells. Thus, the mechanism of membrane binding of insect Ras proteins is quite different from that reported for mammalian Ras proteins.
Large herbivores facilitate savanna tree establishment via diverse and indirect pathways
Authors: Goheen Jacob R. , Palmer Todd M. , Keesing Felicia , Riginos Corinna , Young Truman P.
Published: December 2009

1.Savanna ecosystems are defined largely by tree–grass mixtures, and tree establishment is a key driver of community structure and ecosystem function in these systems. The factors controlling savanna tree establishment are understudied, but likely involve some combination of seed, microsite and predator/fire limitation. In African savannas, suppression and killing of adult trees by large mammals like elephants (Loxodonta africanaBlumenbach, 1797) and giraffes (Giraffa camelopardalisLinnaeus, 1758) can maintain tree–grass co‐dominance, although the impacts of even these conspicuous herbivores on tree establishment also are poorly understood.

2.We combined seed addition and predator exclusion experiments with a large‐scale, long‐term field manipulation of large herbivores to investigate the relative importance of seeds, microsites and predators in limiting establishment of a monodominant tree (Acacia drepanolobiumSjostedt) in a Kenyan savanna.

3.Both wild and domestic (i.e. cattle;Bos taurusLinnaeus, 1758) large herbivores facilitated tree establishment by suppressing abundances of rodents, the most important seed and seedling predators. However, this indirect, positive effect of wild herbivores was negated by wild herbivores’ suppression of seed production. Cattle did not have this direct, negative impact; rather, they further assisted tree establishment by reducing cover of understorey grasses. Thus, the impacts of both groups of large herbivores on tree establishment were largely routed through other taxa, with a negligible net effect of wild herbivores and a positive net effect of cattle on tree establishment.

4.The distinction between the (positive) net effect of cattle and (neutral) net effect of wild herbivores is due to the inclusion of browsers and mixed feeders within the assemblage of wild herbivores. Browsing by wild herbivores limited seed production, which reduced tree recruitment; grazing by cattle was more pronounced than that by wild herbivores, and thus promoted germination and subsequent establishment of small trees.

5.Our study is the first to link seed fates to tree establishment in savanna ecosystems in experimentally‐manipulated herbivore communities. Further, our results highlight how large herbivores can modify a suite of independent factors – seed production, competition with understorey species, and seed and seedling predation – to collectively drive tree establishment.
Spontaneous succession in limestone quarries as an effective restoration tool for endangered arthropods and plants
Authors: Tropek Robert , Kadlec Tomas , Karesova Petra , Spitzer Lukas , Kocarek Petr , Malenovsky Igor , Banar Petr , Tuf Ivan H. , Hejda Martin , Konvicka Martin
Published: December 2009

1.The view of post‐mining sites is rapidly changing among ecologists and conservationists, as sensitive restoration using spontaneous succession may turn such sites into biodiversity refuges in human‐exploited regions. However, technical reclamation, consisting of covering the sites by topsoil, sowing fast‐growing herb mixtures and planting trees, is still commonly adopted. Until now, no multi‐taxa study has compared technically reclaimed sites and sites left with spontaneous succession.

2.We sampled communities of vascular plants and 10 arthropod groups in technically reclaimed and spontaneously restored plots in limestone quarries in the Bohemian Karst, Czech Republic. For comparison, we used pairedt‐tests and multivariate methods, emphasizing red‐list status and habitat specialization of individual species.

3.We recorded 692 species of target taxa, with a high proportion of red‐listed (10%) and xeric specialist (14%) species, corroborating the great conservation potential of the quarries.

4.Spontaneously restored post‐mining sites did not differ in species richness from the technical reclaimed sites but they supported more rare species. The microhabitat cover of leaf litter, herbs and moss, were all directly influenced by the addition of topsoil during reclamation.

5.Synthesis and applications.Our results show that the high conservation potential of limestone quarries could be realized by allowing succession to progress spontaneously with minimal intervention. Given the threat to semi‐natural sparsely vegetated habitats in many regions, active restoration measures at post‐mining sites should be limited to maintenance of early successional stages, instead of acceleration of succession.
Comparing opportunistic and systematic sampling methods for non‐invasive genetic monitoring of a small translocated brown bear population
Authors: De Barba Marta , Waits Lisette P. , Genovesi Piero , Randi Ettore , Chirichella Roberta , Cetto Ermanno
Published: December 2009

1. Non‐invasive genetic sampling (NGS) of hair and faeces has become an important tool for monitoring wildlife populations, but many managers question the feasibility and cost‐effectiveness of these methods for long‐term monitoring. To address this question, more studies are needed that simultaneously evaluate the effectiveness and efficiency of multiple NGS designs in the same study area.

2. In 2003–2004, we carried out an experimental study of NGS for a small brown bear Ursus arctos population established by translocation in the Italian Alps. We evaluated and compared the effectiveness and efficiency of three NGS approaches including two systematic designs, baited hair traps and transect sampling of hair and faeces, and opportunistic collection of faecal and hair samples. Effectiveness was evaluated in terms of the number of samples collected, bears identified, genotyping success and error rate, detection frequencies, individual movement and spatial distribution of the species. We also evaluated the suitability of the data collected for population size estimation using single‐ and multi‐session approaches. Efficiency was assessed by calculating total cost/genotyped sample, cost/unique bear identified and cost/bear sample.

3. During 2 years of sampling, 1164 samples and 15 unique genotypes were obtained. From these genotypes, we documented reproduction, an increase in the minimum population size of bears in the study area and important information on specific bears causing damages to property.

4. The optimal sampling strategy combined systematic hair trapping and opportunistic sampling, as the pooled data set efficiently provided large sample quantities, the highest number of identified bears, multiple individual detections, information on bear distribution and suitable data for population size estimation.

5. We provide an example of how the efficiency of NGS monitoring can be improved by integrating sampling into routine duties of existing field personnel.

6.
Synthesis and applications. This study provides baseline data for monitoring brown bears in the Italian Alps and has important implications for NGS of other small populations in human‐dominated landscapes. Conservation of small populations in such habitats will benefit from multiple strategies that obtain critical demographic, spatial and genetic information in a cost‐effective manner.
Modelling detection probabilities to evaluate management and control tools for an invasive species
Authors: Christy Michelle T. , Yackel Adams Amy A. , Rodda Gordon H. , Savidge Julie A. , Tyrrell Claudine L.
Published: December 2009

1. For most ecologists, detection probability (p) is a nuisance variable that must be modelled to estimate the state variable of interest (i.e. survival, abundance, or occupancy). However, in the realm of invasive species control, the rate of detection and removal is the rate‐limiting step for management of this pervasive environmental problem.

2. For strategic planning of an eradication (removal of every individual), one must identify the least likely individual to be removed, and determine the probability of removing it.

3. To evaluate visual searching as a control tool for populations of the invasive brown treesnake Boiga irregularis, we designed a mark–recapture study to evaluate detection probability as a function of time, gender, size, body condition, recent detection history, residency status, searcher team and environmental covariates.

4. We evaluated these factors using 654 captures resulting from visual detections of 117 snakes residing in a 5‐ha semi‐forested enclosure on Guam, fenced to prevent immigration and emigration of snakes but not their prey. Visual detection probability was low overall ( = 0·07 per occasion) but reached 0·18 under optimal circumstances.

5. Our results supported sex‐specific differences in detectability that were a quadratic function of size, with both small and large females having lower detection probabilities than males of those sizes. There was strong evidence for individual periodic changes in detectability of a few days duration, roughly doubling detection probability (comparing peak to non‐elevated detections). Snakes in poor body condition had estimated mean detection probabilities greater than snakes with high body condition. Search teams with high average detection rates exhibited detection probabilities about twice that of search teams with low average detection rates. Surveys conducted with bright moonlight and strong wind gusts exhibited moderately decreased probabilities of detecting snakes.

6.
Synthesis and applications. By emphasizing and modelling detection probabilities, we now know: (i) that eradication of this species by searching is possible, (ii) how much searching effort would be required, (iii) under what environmental conditions searching would be most efficient, and (iv) several factors that are likely to modulate this quantification when searching is applied to new areas. The same approach can be use for evaluation of any control technology or population monitoring programme.
Assessing ethical trade‐offs in ecological field studies
Authors: Parris Kirsten M. , McCall Sarah C. , McCarthy Michael A. , Minteer Ben A. , Steele Katie , Bekessy Sarah , Medvecky Fabien
Published: December 2009

1.Ecologists and conservation biologists consider many issues when designing a field study, such as the expected value of the data, the interests of the study species, the welfare of individual organisms and the cost of the project. These different issues or values often conflict; however, neither animal ethics nor environmental ethics provides practical guidance on how to assess trade‐offs between them.

2.We developed a decision framework for considering trade‐offs between values in ecological research, drawing on the field of ecological ethics. We used a case study of the population genetics of three frog species, in which a researcher must choose between four methods of sampling DNA from the study animals. We measured species welfare as the reduction in population growth rate following sampling, and assessed individual welfare using two different definitions: (i) the level of suffering experienced by an animal, and (ii) the level of suffering combined with loss of future life.

3.Tipping the tails of tadpoles ranked as the best sampling method for species welfare, while collecting whole tadpoles and buccal swabbing of adult frogs ranked best for the first and second definitions of individual welfare, respectively. Toe clipping of adult frogs ranked as the worst sampling method for species welfare and the first definition of individual welfare, and equal worst for the second definition of individual welfare.

4.When considering species and individual welfare simultaneously, toe clipping was clearly inferior to the other sampling methods, but no single sampling method was clearly superior to the other three. Buccal swabbing, collecting tadpoles and tail tipping were all preferred options, depending on the definition of individual welfare and the level of precision with which we assessed species welfare.

5.Synthesis and applications. The decision framework we present can be used by ecologists to assess ethical and other trade‐offs when planning field studies. A formal decision analysis makes transparent how a researcher might negotiate competing ethical, financial and practical objectives. Defining the components of the decision in this way can help avoid errors associated with human judgement and linguistic uncertainty.
Empirical comparison of density estimators for large carnivores
Authors: Obbard Martyn E. , Howe Eric J. , Kyle Christopher J.
Published: December 2009

1. Population density is a critical ecological parameter informing effective wildlife management and conservation decisions. Density is often estimated by dividing capture–recapture (C–R) estimates of abundance () by size of the study area, but this relies on the assumption of geographic closure – a situation rarely achieved in studies of large carnivores. For geographically open populations is overestimated relative to the size of the study area because animals with only part of their home range on the study area are available for capture. This bias (‘edge effect’) is more severe when animals such as large carnivores range widely. To compensate for edge effect, a boundary strip around the trap array is commonly included when estimating the effective trap area (). Various methods for estimating the width of the boundary strip are proposed, but / estimates of large carnivore density are generally mistrusted unless concurrent telemetry data are available to define. Remote sampling by cameras or hair snags may reduce study costs and duration, yet without telemetry data inflated density estimates remain problematic.

2. We evaluated recently developed spatially explicit capture–recapture (SECR) models using data from a common large carnivore, the American black bear Ursus americanus, obtained by remote sampling of 11 geographically open populations. These models permit direct estimation of population density from C–R data without assuming geographic closure. We compared estimates derived using this approach to those derived using conventional approaches that estimate density as /.

3. Spatially explicit C–R estimates were 20–200% lower than densities estimated as /. AICc supported individual heterogeneity in capture probabilities and home range sizes. Variable home range size could not be accounted for when estimating density as /.

4.
Synthesis and applications. We conclude that the higher densities estimated as / compared to estimates from SECR models are consistent with positive bias due to edge effects in the former. Inflated density estimates could lead to management decisions placing threatened or endangered large carnivores at greater risk. Such decisions could be avoided by estimating density by SECR when bias due to geographic closure violation cannot be minimized by study design.
Therapeutic reasoning: from hiatus to hypothetical model
Authors: Bissessur Sanjay W. , Geijteman Eric C. T. , Al‐Dulaimy Muhammad , Teunissen Pim. W. , Richir Milan C. , Arnold Alf E. R. , De Vries Thep P. G. M.
Published: December 2009

Rationale  Extensive research has been conducted on clinical reasoning to gain better understanding of this process. Clinical reasoning has been defined as the process of thinking critically about the diagnosis and patient management. However, most research has focused on the process of diagnostic reasoning. Because of the lack of understanding regarding therapeutic reasoning, education in patient management decisions lacks a solid theoretical basis.

Aims and objective  To improve medical education, training and refresher courses with regard to therapeutic decision making.

Methods  A search on the literature about clinical reasoning has been conducted. Based on this literature a hypothetical model of therapeutic reasoning is developed.

Results  It is assumed on the literature about diagnostic and therapeutic reasoning that after the diagnosis has been formulated, the process of determining the therapy is initiated by a concept called the therapy script. Patient cases unconsciously elicit such scripts and they consist of relevant treatments, knowledge and clinical experiences. Analytical and non‐analytical processes determine the final choice of therapy. Subsequently, these processes adapt the therapy script continuously.

Conclusions  A hypothetical model of therapeutic reasoning has been developed in order to improve medical education, training and refresher courses with regard to therapeutic decision making. Future research should empirically test the validity of this hypothetical model in different phases of the medical education continuum.
Systematic reviews to support evidence‐based psychiatry: what about schizophrenia?
Authors: Morlino Massimo , Calento Antonio , Pannone Gennaro , Ventrella Gianluca , Schiavone Vittorio
Published: December 2009

Objective  To assess whether systematic reviews (SRs), the gold standard for scientific research, can offer valuable support in evidence‐based psychiatry in the treatment of schizophrenia.

Methods  We used three database services (Ovid, PubMed and Cochrane) to identify SRs related to schizophrenia, found 163 reviews and grouped them by topic. We then evaluated each study's conclusions and divided them into three groups based on results (ranging from certain to null conclusions).

Results  SRs of pharmacological treatments represented 59% of the studies sampled, only 23% of which had reached certain conclusions. Other clinical topics were less frequently represented and had achieved lower degrees of certainty.

Conclusions  Only 40 SRs (22 studies investigating pharmacological treatment) provided clear‐cut answers to clinical questions examined. Results therefore showed that SRs provide a certain but rather limited contribution to scientific evidence in the field of schizophrenia.
Practice guideline adherence and health care outcomes – use of prophylactic antibiotics during surgery in Taiwan
Authors: Hsu Chentong , Cheng Shou‐Hsia
Published: December 2009

Rationale, aims and objectives  To evaluate adherence to guidelines for prophylactic antibiotic use in total knee replacement (TKR) and total hip replacement (THR) procedures and to examine the associations between guideline adherence and health care outcomes.

Methods  Using nationwide health insurance claims data, all adult inpatients undergoing TKR or THR procedures at teaching hospitals from 2002 to 2006, were included. Guideline adherence rates were assessed every year according to the national guidelines introduced in 2004. Multiple regression analyses with generalized estimating equations models were used to examine the relationships between the deliberate variables.

Results  The guideline adherence rates stably increased from 14.07% in 2002 to 28.34% in 2006. The 2006 dataset included 12 863 observations. The results revealed that guideline adherence was negatively associated with length of stay and health care expenses with β = −0.0207 and −0.0087, respectively (P < 0.0001). The 30‐day readmission rate was 1.54% among the patients seen in 2006, and it was significantly different between the two groups, with 0.90% of the adherence group and 1.82% of the non‐adherence group being readmitted (P = 0.0002).

Conclusions  The guideline adherence for prophylactic use of antibiotics is improving in Taiwan and is associated with a shorter length of stay, fewer medical expenses and lower 30‐day readmission rates. Promoting evidence‐based practice guidelines may be beneficial to patients and health care providers.
Balancing health care evidence and art to meet clinical needs: policymakers' perspectives
Authors: Parker Louise E. , Ritchie Mona J. , Kirchner JoAnn E. , Owen Richard R.
Published: December 2009

Rationale, aims and objectives  Although many believe that evidence‐based practice (EBP) has great potential, critics have identified limitations including a focus on randomized clinical trial (RCT) evidence to the exclusion of other evidence types and a disregard for the art of medicine. Others have argued, however, that proper application of EBP involves reasoned consideration of a wide variety of information; thus, the dichotomy between medical science and art may be false. We explore the views of executive‐level policymakers from the Veterans Health Administration, a leader in the EBP movement, regarding what constitutes evidence and the relative importance of evidence versus practical needs when determining clinical policy.

Method  We conducted 26 semi‐structured qualitative interviews and performed a content analysis.

Results  Although informants generally believed in the value of EBP and the role of RCTs within it, they also valued other types of evidence. Further, they had concerns that were sometimes antithetical with strict adherence to an evidence‐based approach. These included practical concerns, fit with organizational values and with local circumstances, resources, political pressures and patient needs. They were especially concerned about how to address medical conditions that affect many individuals or high‐risk populations that have no evidence‐based treatment.

Conclusion  When possible, health care practice should be evidence‐based. When this is not possible, health care providers must turn to the art of medicine by using consensus‐based best practices. Further, it is important for policymakers and researchers to work in concert to develop EBPs that are practical and meet needs.
A model for reflection for good clinical practice
Authors: Balla John I. , Heneghan Carl , Glasziou Paul , Thompson Matthew , Balla Margaret E.
Published: December 2009

Rationale and aim  The rapidly changing knowledge base of clinical practice highlights the need to keep abreast of knowledge changes that are most relevant for the practitioner. We aimed to develop a model for reflection on clinical practice that identified the key elements of medical knowledge needed for good medical practice.

Method  The dual theory of cognition, an integration of intuitive and analytic processes, provided the framework for the study. The design looked at the congruence between the clinical thinking process and the dual theory. A one‐year study was conducted in general practice clinics in Oxfordshire, UK. Thirty‐five general practitioners participated in 20‐minute interviews to discuss how they worked through recently seen clinical cases. Over a one‐year period 72 cases were recorded from 35 interviews. These were categorized according to emerging themes, which were manually coded and substantiated with verbatim quotations.

Results  There was a close fit between the dual theory and participants' clinical thinking processes. This included instant problem framing, consistent with automatic intuitive thinking, focusing on the risk and urgency of the case. Salient features accounting for these choices were recognizable. There was a second reflective phase, leading to the review of initial judgements.

Conclusions  The proposed model highlights the critical steps in decision making. This allows regular recalibration of knowledge that is most critical at each of these steps. In line with good practice, the model also links the crucial knowledge used in decision making, to value judgments made in relation to the patient.
How far did we get? How far to go? A European survey on postgraduate courses in evidence‐based medicine
Authors: Kunz Regina , Nagy Eva , Coppus Sjors F.P.J. , Emparanza Jose I. , Hadley Julie , Kulier Regina , Weinbrenner Susanne , Arvanitis Theodoros N. , Burls Amanda , Cabello Juan B. , Decsi Tamas , Horvath Andrea R. , Walzak Jacek , Kaczor Marcin P. , Zanrei Gianni , Pierer Karin , Schaffler Roland , Suter Katja , Mol Ben W.J. , Khan Khalid S.
Published: December 2009

Background  Over the past decade, evidence‐based medicine (EBM) has gained recognition as a means to improve the quality of health care provision. However, little is known about learning opportunities to acquire EBM‐associated skills. The EUebm‐Unity partnership explored current educational activities for EBM practice for doctors across Europe.

Methods  We surveyed organizations offering postgraduate EBM courses across Europe inquiring about their course programme, teaching content and strategies, and interest in a Europe‐wide curriculum in EBM.

Results  One hundred and fifty‐six organizers in eight European countries reported 403 courses that had started first‐time from 1996 to 2006. Despite a steady increase, in absolute terms, the frequency of courses was low and varied from 1 first‐time offering of a course per 640 doctors (Spain) to 1 first‐time offering per 5600 doctors (Austria) over 10 years. Most adopted the McMaster EBM teaching concept of small group, problem‐based learning focussing on interventions, diagnostic tests and guidelines, and included efforts to link EBM to patient care. Teaching staff consisted of doctors from academic and non‐academic settings, supported by methodologists. Efforts to formally integrate EBM in postgraduate activities were only partially successful. Most organizations welcomed a standardized European qualification in EBM. A limitation of the survey is the lack of follow‐up information about the continuation of courses following the first‐time offering.

Conclusions  All countries offer some EBM courses with varying teaching intensity. Learning opportunities are insufficient to ensure widespread dissemination of knowledge and skills. Most countries welcome more efforts to develop inexpensive and feasible educational activities at a postgraduate level.
Use of a computer‐based simulated consultation tool to assess whether doctors explore sociocultural factors during patient evaluation
Authors: Perron Noëlle Junod , Perneger Thomas , Kolly Véronique , Dao Melissa Dominicé , Sommer Johanna , Hudelson Patricia
Published: December 2009

Rationale, aims and objectives  The delivery of patient‐centred care to diverse populations requires that doctors identify sociocultural factors that may affect care. We adapted a computer‐based simulated consultation tool and tested its utility for assessing whether doctors explore sociocultural factors during a patient evaluation, and whether they include such information in their case conclusions and follow‐up recommendations.

Methods  We developed two detailed patient ‘stories’ that involved sociocultural issues that doctors needed to identify and consider for adequate clinical management. They were incorporated into an existing ‘Virtual Internet Patient Simulation’ (VIPS) program designed to test clinical reasoning skills. Doctors and medical students (n = 618) were invited to access the program via Internet. For each consultation, participants were assigned a sociocultural score, corresponding to the number of sociocultural domains explored. Scores were then compared with subjective ratings of participants' performance by expert doctors.

Results  118 respondents completed at least one virtual consultation (19%), 92 conducted both. The mean number of sociocultural dimensions explored by doctors (i.e. sociocultural score) was 3.9 (standard deviation 2.6) for case 1, and 5.2 (standard deviation 2.3) for case 2. The two sociocultural scores were moderately correlated (Spearman r = 0.65, P < 0.001). Sociocultural scores correlated positively with experts' subjective ratings of participants' performance (Spearman r = 0.84 for case 1 and 0.78 for case 2, both P < 0.001).

Conclusions  The adapted computer‐based simulated consultation tool provided a feasible means to assess doctors' exploration of sociocultural issues during a clinical evaluation. Further validation of this method should be conducted by comparing VIPS results with other skills assessment methods such as objective structured clinical examination or direct observation of clinical performance.
Inhospital management of COPD exacerbations: a systematic review of the literature with regard to adherence to international guidelines
Authors: Lodewijckx Cathy , Sermeus Walter , Vanhaecht Kris , Panella Massimiliano , Deneckere Svin , Leigheb Fabrizio , Decramer Marc
Published: December 2009

Rationale  Chronic obstructive pulmonary disease (COPD) exacerbations are a leading cause of hospitalization. Suboptimal inhospital management is expected to lead to more frequent exacerbations and recurrent hospital admission, and is associated with increased mortality.

Aims  To explore inhospital management of COPD and to compare the results with recommendations from international guidelines.

Methods  A literature search was carried out for relevant articles published 2000–2009 in the databases Medline, Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and Invert. In addition, the reference lists of the selected articles were examined. Main inclusion criteria were as follows: COPD, exacerbation, hospitalization, description of inpatient management, and clinical trials. Assessment and treatment strategies in different studies were analysed and compared with American Thoracic Society‐European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease guidelines. Outcomes were analysed.

Results  Seven eligible studies were selected. Non‐pharmacological treatment was infrequently explored. When compared with international guidelines, diagnostic assessment and therapy were suboptimal, especially non‐pharmacological treatment. Respiratory physicians were more likely to perform recommended interventions than non‐respiratory physicians.

Conclusions  Adherence to international guidelines is low for inhospital management of COPD exacerbations, especially in terms of non‐pharmacological treatment. Further investigation is recommended to explore strategies like care pathways that improve performance of recommended interventions.
Translating research into practice: transitional care for older adults
Authors: Naylor Mary D. , Feldman Penny Hollander , Keating Stacen , Koren Mary Jane , Kurtzman Ellen T. , Maccoy Maureen C. , Krakauer Randall
Published: December 2009

Rationale  Over the last decade, in order to close the safety and health care quality chasm, there has been a growing imperative to translate evidence‐based research into practice.

Aims and Objectives  This study examines the major facilitators and barriers of implementing in a large US insurance organization – Aetna Corporation – an evidence‐based model of care, the Transitional Care Model, which has been rigorously tested over the past twenty years by a multidisciplinary team at the University of Pennsylvania.

Methods  Semi‐structured interviews of 19 project leaders, case managers, and transitional care nurses were conducted during two phases of translation – start‐up and roll out. Qualitative analysis was used to identify more than a dozen key barriers to and facilitators of translation in these two critical phases.

Results  Six facilitators and seven barriers that are consistent with the literature were identified during and categorized as either start‐up or roll‐out.

Conclusion  The combined results have important practical implications for other, subsequent translational efforts and for assisting providers, policy makers, payers, and other change agents in integrating evidence‐based practice with “real world” management.
Is there a downside to customizing care? Implications of general and patient‐specific treatment strategies
Authors: Veazie Peter J. , Johnson Paul E. , O'Connor Patrick J.
Published: December 2009

Rationale, aims and objectives  The use of general clinical guidelines versus customization of patient care presents a dilemma for clinicians managing chronic illness. The objective of this project is to investigate the claim that the performance of customized strategies for the management of chronic illness depends on accurate patient categorization, and inaccurate categorization can lead to worse performance than that achievable using a general clinical guideline.

Methods  This paper is based on an analysis of a basic utility model that differentiates between the use of general management strategies and customized strategies.

Results  The analysis identifies necessary conditions for preferring general strategies to customized strategies as a trade‐off between strategy performance and the probability of correct patient categorization. The analysis shows that customized treatment strategies developed under optimal conditions are not necessarily preferred.

Conclusions  Results of the analysis have four implications regarding the design and use of clinical guidelines and customization of care: (i) the balance between the applications of more general strategies versus customization depends on the specificity and accuracy of the strategies; (ii) adoption of clinical guidelines may be stifled as the complexity of guidelines increases to account for growing evidence; (iii) clinical inertia (i.e. the failure to intensify an indicated treatment) can be a rational response to strategy specificity and the probability of misapplication; and, (iv) current clinical guidelines and other decision‐support tools may be improved if they accommodate the need for customization of strategies for some patients while providing support for proper categorization of patients.