bluuebunny/crossref_metadata_2025 huggingface dataset:
The effect of exercise on the absorption of inhaled human insulin in healthy volunteers
Authors: Petersen Astrid H. , Köhler Gerd , Korsatko Stefan , Wutte Andrea , Wonisch Manfred , Mautner Agnes , Rønn Birgitte B. , Clauson Per , Laursen Torben , Wollmer Per , Pieber Thomas R.
Published: September 2007

What is already known about this subject

• Exercise is known to affect absorption of other inhaled substances, but so far there are no reports on the effect of exercise on the absorption of inhaled insulin in humans.

What this paper adds

• This report is the first to investigate the effect of exercise on the absorption of inhaled insulin.

• In this study in healthy volunteers we found that exercise early after dosing increased absorption (15–20%) of inhaled insulin over the first 2 h after start of exercise, with an approximately 30% increase in maximal insulin concentration, and unchanged overall absorption.

Aims

To investigate the effect of moderate exercise on the absorption of inhaled insulin.

Methods

A single‐centre, randomized, open‐label, three‐period cross‐over trial was carried out in 12 nonsmoking healthy subjects. A dose of 3.5 mg inhaled human insulin was administered via a nebulizer and followed in random order by either 1) no exercise (NOEX), 2) 30 min exercise starting immediately after dosing (EX0), or 3) 30 min exercise starting 30 min after dosing (EX30). The study was carried out as a 10 h euglycaemic glucose clamp (90 mg dl−1 (5.0 mmol l−1)).

Results

The absorption of insulin over the first 2 h after start of exercise was 16% increased for EX0 (ratio (95%CI) 1.16 (1.04, 1.30), P = 0.01) and 20% increased for EX30 (1.20 (1.05, 1.36), P < 0.01), both compared with NOEX; the overall insulin absorption during 6 h and 10 h after dosing was not influenced by exercise. The maximum insulin concentration (Cmax) increased by 32% for EX0 and 35% for EX30 (both P < 0.01) compared with NOEX, while the time to Cmax was 31 min faster for EX0 (P < 0.01), but not significantly different after EX30, compared with NOEX.

Conclusions

A significant and clinically relevant increase of insulin absorption over the first 2 h after the beginning of exercise was observed. Until data from studies using the specific insulin inhalers exists, patients using inhaled insulin should be made aware of a potential increased absorption and higher concentration of insulin in connection with exercise.
The contribution of observational studies to the knowledge of drug effectiveness in heart failure
Authors: Dobre Daniela , Van Veldhuisen Dirk J. , DeJongste Mike J. L. , Van Sonderen Eric , Klungel Olaf H. , Sanderman Robbert , Ranchor Adelita V. , Haaijer‐Ruskamp Flora M.
Published: September 2007

Aims

Randomized controlled trials (RCTs) are the golden standard for the assessment of drug efficacy. Little is known about the add‐on value of observational studies in heart failure (HF). We aimed to assess the contribution of observational studies to actual knowledge regarding the effectiveness of angiotensin‐converting enzyme inhibitors (ACEI), and β‐blockers (BB) in HF.

Methods

Observational studies that assessed the effectiveness of ACEI and BB in HF were identified by searching Medline, Embase, Cochrane Database (1990–2005) and the bibliographies of published articles. Cohort, case–control and time‐series analysis studies were considered for inclusion. Studies with <100 patients and those who did not perform a multivariate analysis were excluded.

Results

A total of 23 cohort studies met the inclusion criteria. Studies of ACEI and BB showed a decrease in mortality with drug use in elderly patients with a broad range of ejection fraction (EF), and in those with depressed EF. Additionally, they showed a decrease in mortality in patients with renal insufficiency. The effect of ACEI and BB in HF with preserved EF was not clear, although last evidence suggests a potential benefit. Low‐dose ACEI and BB may have beneficial effects. Target doses of ACEI seemed superior to low doses, but there was no clear dose–response relationship.

Conclusions

Observational studies in HF validate the effectiveness of ACEI and BB in populations underrepresented or excluded from RCTs. Observational studies of drug effectiveness provide relevant additional information for clinical practice.
The use of nationwide on‐line prescription records improves the drug history in hospitalized patients
Authors: Glintborg Bente , Poulsen Henrik E. , Dalhoff Kim P.
Published: September 2007

What is already known about this subject

• Structured medication interviews improve the medication history upon hospitalization

• Pharmacy records are valid lists of the prescribed medications available to individual patients

• In Denmark, treating doctors now have access to their patients' pharmacy records through a real‐time online electronic database

What this study adds

• Omission errors are frequent among hospitalized patients despite structured drug interviews and home visits

• Pharmacy records may be used to minimize patients' recall bias and improve the medication lists

Background

Structured medication interviews improve the medication history in hospitalized patients. In Denmark, a nationwide electronic version of individual pharmacy records (PR) has recently been introduced. Use of these records could improve the medication lists in hospitalized patients.

Methods

We prospectively included 500 patients admitted to an acute medical department. In individual patients, the PR was compared with (i) the medication list written in the patient chart and (ii) drug information provided by the patient during a structured drug interview upon admission and during a home visit after discharge.

Results

Median patient age was 72 years. Upon admission, patients reported using 1958 prescription‐only medications (POM) (median four drugs per patient, range 0–14), of which 114 (6%) were not registered in PR. In PR, 1153 POM (median one per patient, range 0–11) were registered during the month preceding admission. The patients did not report 309 (27%) of these upon admission. Home visits were performed in a subgroup of 115 patients. During home visits, 18% of POM registered in PR during the preceding month were not reported. Drug type was predictive of reporting irrespective of patient sex or age. Cardiovascular drugs were reported most and dermatologicals were reported less frequently. Underreporting might be due to recall bias, non‐adherence or discontinuation of drugs.

Conclusions

Omission errors are frequent despite structured medication interviews. Pharmacy records or medication lists from all treating doctors must be included in medication reviews in order to reduce recall bias.
Common use of a Fear Survey Schedule for assessment of dental fear among children and adults
Authors: BOMAN ULLA WIDE , LUNDGREN JESPER , ELFSTRÖM MAGNUS L. , BERGGREN ULF
Published: September 2007

Background.  Little is known about children with dental fear (DF) in a long‐term perspective. Measures of DF suitable for use among children, adolescents, and adults would be of value for longitudinal and family studies.

Aim.  Our aim was to explore the DF subscale of the Children's Fear Survey Schedule (CFSS‐DS) in highly fearful adult dental patients.

Design.  The subjects were 230 adult patients applying for treatment for severe DF at a specialized DF clinic. Questionnaires investigated background data, general fear and DF, and general anxiety and depression. Reference data were obtained from 36 nonfearful patients on a subset of questionnaires.

Results.  The fearful group reported high levels of DF on all measures and at a level similar to children with severe DF. The DF measures clearly differed between the fearful and reference groups. A factor analysis revealed a three‐factor structure (fear of dental treatment, medical treatment, and of strangers and choking), which explained 68% of the variance.

Conclusion.  The CFSS‐DS appears suitable for use in studies of adult populations. The results indicated that some areas of DF (physiology, avoidant behaviour, anticipatory anxiety), areas of importance among adult patients, are not assessed by the CFSS‐DS. Studies of adults should therefore also include established adult measures of DF.
Effect of dietary habits on laser fluorescence values of visually sound occlusal surfaces among Finnish schoolchildren
Authors: ANTTONEN VUOKKO , HAUSEN HANNU , SEPPÄ LIISA , NIINIMAA AHTI
Published: September 2007

Aim.  This study was designed to ascertain whether schoolchildren with unfavourable dietary habits have higher values for laser fluorescence on clinically sound occlusal tooth surfaces than do those who have favourable dietary habits.

Design.  The study was conducted in two phases. In the first phase, 462 children aged 13–14 years answered a questionnaire on dietary habits. The children were ranked according to a total score based on the presumed harmfulness of their dietary habits. One hundred children with the lowest and highest dietary scores were invited to the second phase of the study consisting of a visual examination, laser fluorescence scanning of premolars and molars, and an oral self‐care questionnaire.

Results.  Seventy‐four and 76 children with favourable and unfavourable habits, respectively, were examined. A total of 1221 sound occlusal surfaces were scanned. Children with unfavourable dietary habits had higher median laser fluorescence values than did those with favourable habits (P < 0.0246). The effect of dietary habits was strongest in molars.

Conclusion.  High laser fluorescence values on several clinically sound occlusal surfaces of a child may indicate unfavourable dietary habits.
Effects of culling on spatial associations of Mycobacterium bovis infections in badgers and cattle
Authors: JENKINS HELEN E , WOODROFFE ROSIE , DONNELLY CHRISTL A , COX D.R , JOHNSTON W.T , BOURNE F.J , CHEESEMAN C.L , CLIFTON‐HADLEY R.S , GETTINBY G , GILKS P , HEWINSON R.G , MCINERNEY J.P , MORRISON W.I
Published: September 2007

Bovine tuberculosis (TB), caused by Mycobacterium bovis, has serious consequences for Britain's cattle industry. European badgers (Meles meles) can transmit infection to cattle, and for many years the British government culled badgers in a series of attempts to reduce cattle infections.

We investigated the impact of badger culling on the spatial distribution of M. bovis infection in badger and cattle populations in replicated areas in England.

M. bovis infection was significantly clustered within badger populations, but clustering was reduced when culls were repeated across wide areas. A significant spatial association between M. bovis infections in badgers and cattle herds likewise declined across successive culls. These patterns are consistent with evidence that badgers are less territorial and range more widely in culled areas, allowing transmission to occur over greater distances.

Prior to culling, M. bovis infections were clustered within cattle populations. Where badger culling was localised, and in unculled areas just outside widespread culling areas, cattle infections became less spatially clustered as badger culling was repeated. This is consistent with expanded badger ranging observed in these areas.

In contrast, clustering of infection in cattle persisted over time on lands where badgers were repeatedly culled over wide areas. While this lack of a temporal trend must be interpreted with caution, it might reflect persistent infection within, and continued transmission between, cattle herds in areas where transmission from badgers to cattle had been reduced by badger culling. Continued spatial association of infections in cattle and badgers in such areas might partly reflect transmission from cattle.

Synthesis and applications: Our findings confirm that badger culling can prompt spatial spread of M. bovis infection, a phenomenon likely to undermine the utility of this approach as a disease control measure. Possible evidence of transmission from cattle, both to other cattle and to badgers, suggests that improved cattle controls might yield multiple benefits for TB management.
Dual localization pathways for the engulfment proteins during Bacillus subtilis sporulation
Authors: Aung Stefan , Shum Jonathan , Abanes‐De Mello Angelica , Broder Dan H. , Fredlund‐Gutierrez Jennifer , Chiba Shinobu , Pogliano Kit
Published: September 2007

Engulfment in Bacillus subtilis is mediated by two complementary systems, SpoIID, SpoIIM and SpoIIP (DMP), which are essential for engulfment, and the SpoIIQ‐SpoIIIAGH (Q‐AH) zipper, which provides a secondary engulfment mechanism and recruits other proteins to the septum. We here identify two mechanisms by which DMP localizes to the septum. The first depends on SpoIIB, which is recruited to the septum during division and provides a septal landmark for efficient DMP localization. However, sporangia lacking SpoIIB ultimately localize DMP and complete engulfment, suggesting a second mechanism for DMP localization. This secondary targeting pathway depends on SpoIVFA and SpoIVFB, which are recruited to the septum by the Q‐AH zipper. The absence of a detectable localization phenotype in mutants lacking only SpoIVFAB (or Q‐AH) suggests that SpoIIB provides the primary DMP localization pathway while SpoIVFAB provides a secondary pathway. In keeping with this hypothesis, the spoIIB spoIVFAB mutant strain has a synergistic engulfment defect at septal thinning (which requires DMP) and is completely defective in DMP localization. Thus, the Q‐AH zipper both provides a compensatory mechanism for engulfment when DMP activity is reduced, and indirectly provides a compensatory mechanism for septal localization of DMP when its primary targeting pathway is disrupted.
The different fates of mitochondria and chloroplasts during dark‐induced senescence in Arabidopsis leaves
Authors: KEECH OLIVIER , PESQUET EDOUARD , AHAD ABDUL , ASKNE ANNA , NORDVALL DAG , VODNALA SHARVANI MUNENDER , TUOMINEN HANNELE , HURRY VAUGHAN , DIZENGREMEL PIERRE , GARDESTRÖM PER
Published: September 2007

Senescence is an active process allowing the reallocation of valuable nutrients from the senescing organ towards storage and/or growing tissues. Using Arabidopsis thaliana leaves from both whole darkened plants (DPs) and individually darkened leaves (IDLs), we investigated the fate of mitochondria and chloroplasts during dark‐induced leaf senescence. Combining in vivo visualization of fates of the two organelles by three‐dimensional reconstructions of abaxial parts of leaves with functional measurements of photosynthesis and respiration, we showed that the two experimental systems displayed major differences during 6 d of dark treatment. In whole DPs, organelles were largely retained in both epidermal and mesophyll cells. However, while the photosynthetic capacity was maintained, the capacity of mitochondrial respiration decreased. In contrast, IDLs showed a rapid decline in photosynthetic capacity while maintaining a high capacity for mitochondrial respiration throughout the treatment. In addition, we noticed an unequal degradation of organelles in the different cell types of the senescing leaf. From these data, we suggest that metabolism in leaves of the whole DPs enters a ‘stand‐by mode’ to preserve the photosynthetic machinery for as long as possible. However, in IDLs, mitochondria actively provide energy and carbon skeletons for the degradation of cell constituents, facilitating the retrieval of nutrients. Finally, the heterogeneity of the degradation processes involved during senescence is discussed with regard to the fate of mitochondria and chloroplasts in the different cell types.
Radioisotope ratios discriminate between competing pathways of cell wall polysaccharide and RNA biosynthesis in living plant cells
Authors: Sharples Sandra C. , Fry Stephen C.
Published: September 2007

Cell wall polysaccharides are synthesized from sugar‐nucleotides, e.g. uridine 5′‐diphosphoglucose (UDP‐Glc), but the metabolic pathways that produce sugar‐nucleotides in plants remain controversial. To help distinguish between potentially ‘competing’ pathways, we have developed a novel dual‐radiolabelling strategy that generates a remarkably wide range of 3H:14C ratios among the various proposed precursors. Arabidopsis cell cultures were fed traces of d‐[1‐3H]galactose and a 14C‐labelled hexose (e.g. d‐[U‐14C]fructose) in the presence of an approximately 104‐fold excess of non‐radioactive carbon source. Six interconvertible ‘core intermediates’, galactose 1‐phosphate ↔ UDP‐galactose ↔ UDP‐glucose ↔ glucose 1‐phosphate ↔ glucose 6‐phosphate ↔ fructose 6‐phosphate, showed a large decrease in 3H:14C ratio along this pathway from left to right. The isotope ratio of a polysaccharide‐bound sugar residue indicates from which of the six core intermediates its sugar‐nucleotide donor substrate stemmed. Polymer‐bound galacturonate, xylose, arabinose and apiose residues (all produced via UDP‐glucuronate) stemmed from UDP‐glucose, not glucose 6‐phosphate; therefore, UDP‐glucuronate arose predominantly by the action of UDP‐glucose dehydrogenase rather than through the postulated competing pathway leading from glucose 6‐phosphate via myo‐inositol. The data also indicate that UDP‐galacturonate was not formed by a hypothetical UDP‐galactose dehydrogenase. Polymer‐bound mannose and fucose residues stemmed from fructose 6‐phosphate, not glucose 1‐phosphate; therefore GDP‐mannose (guanosine 5′‐diphosphomannose) arose predominantly by a pathway involving phosphomannose isomerase (via mannose phosphates) rather than through a postulated competing pathway involving GDP‐glucose epimerization. Curiously, the ribose residues of RNA did not stem directly from hexose 6‐phosphates, but predominantly from UDP‐glucose; an alternative to the textbook pentose‐phosphate pathway therefore predominates in plants.
The N‐terminal region of Pseudomonas type III effector AvrPtoB elicits Pto‐dependent immunity and has two distinct virulence determinants
Authors: Xiao Fangming , He Ping , Abramovitch Robert B. , Dawson Jennifer E. , Nicholson Linda K. , Sheen Jen , Martin Gregory B.
Published: September 2007

Resistance to bacterial speck disease in tomato is activated by the physical interaction of the host Pto kinase with either of the sequence‐dissimilar type III effector proteins AvrPto or AvrPtoB (HopAB2) from Pseudomonas syringae pv. tomato. Pto‐mediated immunity requires Prf, a protein with a nucleotide‐binding site and leucine‐rich repeats. The N‐terminal 307 amino acids of AvrPtoB were previously reported to interact with the Pto kinase, and we show here that this region (AvrPtoB1‐307) is sufficient for eliciting Pto/Prf‐dependent immunity against P. s. pv. tomato. AvrPtoB1‐307 was also found to be sufficient for a virulence activity that enhances ethylene production and increases growth of P. s. pv. tomato and severity of speck disease on susceptible tomato lines lacking either Pto or Prf. Moreover, we found that residues 308–387 of AvrPtoB are required for the previously reported ability of AvrPtoB to suppress pathogen‐associated molecular patterns‐induced basal defenses in Arabidopsis. Thus, the N‐terminal region of AvrPtoB has two structurally distinct domains involved in different virulence‐promoting mechanisms. Random and targeted mutagenesis identified five tightly clustered residues in AvrPtoB1‐307 that are required for interaction with Pto and for elicitation of immunity to P. s. pv. tomato. Mutation of one of the five clustered residues abolished the ethylene‐associated virulence activity of AvrPtoB1‐307. However, individual mutations of the other four residues, despite abolishing interaction with Pto and avirulence activity, had no effect on AvrPtoB1‐307 virulence activity. None of these mutations affected the basal defense‐suppressing activity of AvrPtoB1‐387. Based on sequence alignments, estimates of helical propensity, and the previously reported structure of AvrPto, we hypothesize that the Pto‐interacting domains of AvrPto and AvrPtoB1‐307 have structural similarity. Together, these data support a model in which AvrPtoB1‐307 promotes ethylene‐associated virulence by interaction not with Pto but with another unknown host protein.
Prediction of health professionals' intention to screen for decisional conflict in clinical practice
Authors: Légaré France , Graham Ian D. , O’Connor Annette C. , Aubin Michèle , Baillargeon Lucie , Leduc Yvan , Maziade Jean
Published: September 2007

Objective To identify the determinants of the intention of physicians to screen for decisional conflict in clinical practice.

Background Screening for decisional conflict is one of the key competencies when educating health professionals about shared decision making. Theory‐based knowledge about variables predicting their intention to screen for decisional conflict in clinical practice would help design effective implementation interventions in this area.

Design Data of two cross‐sectional surveys embedded within a large implementation study of the Ottawa Decision Support Framework (ODSF) in primary care.

Setting and participants In total, 122 health professionals from five family practice teaching units.

Methods Intention to screen for decisional conflict in clinical practice was defined as the intention to use the clinical version of the Decisional Conflict Scale (DCS) with patients at the end of the clinical encounter. It was assessed at the entry and the exit from this study. Both intentions were entered as a dependent variable in multivariate analyses.

Main results At entry, the intention was influenced by: attitude (P < 0.001), subjective norm (P < 0.001), perceived behavioural control (P < 0.001) and clinical site (P < 0.05). On exit, it was influenced by: subjective norm (P < 0.001), perceived behavioural control (P < 0.001), clinical site (P < 0.05), international Continuing Medical Education (CME) (P < 0.05), other diplomas (P < 0.05) and intervention (P < 0.05). Inpost hocanalyses, there was a statistically significant difference between entry and exit in the impact of the level of exposure to the multifaceted implementation intervention on the intention (P = 0.003).

Conclusions Variables predicting the intention of health professionals to screen for decisional conflict in clinical practice using the DCS change over time suggesting that effective implementation interventions in this area will need to be modified longitudinally.
Pure subtelomeric microduplications as a cause of mental retardation
Authors: Ruiter EM , Koolen DA , Kleefstra T , Nillesen WM , Pfundt R , De Leeuw N , Hamel BCJ , Brunner HG , Sistermans EA , De Vries BBA
Published: September 2007

Submicroscopic subtelomeric aberrations are a common cause of mental retardation (MR). New molecular techniques allow the identification of subtelomeric microduplications, but their frequency and significance are largely unknown. We determined the frequency of subtelomeric, pure microduplications in a cohort of 624 patients with MR and/or multiple congenital anomalies using multiplex ligation dependent probe amplification (MLPA) and delineated the identified microduplications using array based comparative genomic hybridization (array CGH). In 11 patients, MLPA revealed a subtelomeric duplication without a concurrent deletion. Additional fluorescence in situ hybridization studies and parental analyses showed that three had occurred de novo: one duplication 5q34qter (12.7 Mb), one duplication 9q34.13qter (7.2 Mb) and one duplication 9p24.2pter (4.1 Mb). Five microduplications (9p, 11q, 12q, 15q and 16p) appeared to be inherited from an unaffected parent, while in three cases (9p, 12p and 17p) the parents were not available for testing. Based on our findings and data from the literature, the three de novo duplications were the only ones likely to be disease‐causing, leading to a frequency of pathogenic subtelomeric, pure microduplications of 0.5%. Our study shows that subtelomeric microduplications are an infrequent cause of MR and that additional clinical and family studies are required to assess their clinical significance.
Vulvar Discharge Syndrome in Loosely Housed Finnish Pigs: Prevalence and Evaluation of Vaginoscopy, Bacteriology and Cytology
Authors: Oravainen J , Heinonen M , Tast A , Virolainen JV , Peltoniemi OAT
Published: September 2007

Contents

A total of 21 sow herds were randomly chosen to determine the prevalence of vulvar discharge syndrome (VDS) in loosely housed sows. The median VDS prevalence was low as expected, 0% (range 0–4.5%). Nine of the 655 animals examined (1.4%, 95% CI 0.5–2.3) displayed signs of VDS in 21 non‐problem herds. In addition, five VDS problem farms were visited to gather more animals affected with the syndrome in order to estimate which methods of examination are useful. Altogether, 19 VDS animals and 19 healthy controls were found, inspected and sampled. Ten of the VDS animals (53%) and three of the controls (16%) were positive in bacterial culture (p = 0.04) taken with a guarded swab from the anterior vagina. In addition, 94% of VDS animals had a positive vaginoscopic examination result and the corresponding figure in the control sows was 28% (p < 0.0002). Cytological smears were classified as positive in 37% of the case sows and in 5% of the control sows (p = 0.04). Detection of vulvar discharge was associated with vaginoscopic examination findings (p = 0.0005) and with bacteriology (p = 0.04), but not with leucocyte counts (p = 0.07). Susceptibility testing was performed on pure bacterial cultures. Totally, 7 (44%) of 16 isolates were considered to be resistant or showed intermediate susceptibility to at least one of the antimicrobial agents tested (sulpha‐trimethoprim and ampicillin). In conclusion, we found vaginoscopy and bacteriology as valid tools in diagnosis of VDS and susceptibility testing of antimicrobial treatments was found to be indicated.
Early Embryo Survival and Development in Sows with Lactational Ovulation
Authors: Gerritsen R , Soede NM , Langendijk P , Taverne MAM , Kemp B
Published: September 2007

Contents

During lactation, daily separation of sow and piglets, intermittent suckling (IS), can induce lactational oestrus and ovulation. This study examined effects of IS on subsequent early embryo survival and development. Multiparous Topigs40 sows were separated from their piglets for either 12 consecutive hours per day (IS12, n = 13) or two times for 6 h per day (IS6, n = 10) from day 14 of lactation onwards until 23 days after ovulation. Control sows (C, n = 17) were weaned at day 21 of lactation. Oestrus was shown in all treatments within 5 days after the start of treatment. Sows were inseminated each day of oestrus and slaughtered at D23 after ovulation. Intermittent suckling did not significantly affect pregnancy rates of sows (75% IS12 vs 78% IS6 vs 94% C; p > 0.10). Embryo survival was not significantly affected by IS (IS12: 57%; IS6: 51%; p > 0.10) although it seemed to be lower than in C sows (70%). Some parameters of embryo, placental and uterine development were affected by IS, especially in the IS6 group. IS6 embryos had shorter placentas (17.5 ± 1.2 cm; p < 0.05) than C (20.3 ± 1.4 cm) and IS12 sows (20.9 ± 0.7 cm) were smaller and less developed than C sows (p < 0.05). In conclusion, embryo survival does not seem significantly affected by IS, although numerical differences were great. Embryo development, however, was negatively affected in IS6 sows possibly due to a combination of high milk production, stress and lactational effects on uterine development.
JUDGING DOCTORS
Authors: Davies Geoffrey L.
Published: September 2007

In three distinct situations, judges may be obliged to pronounce on doctors’ opinions or conduct. The first of these is where they are deciding actions involving claims for personal injuries in respect of which doctors have given opinions to the court. The second situation in which the judge may be obliged to pronounce on a doctor’s opinion or conduct is when, in a civil action, that doctor is sued for negligence. The third, even less common kind of case in which a judge or a retired judge may be obliged to pronounce on a doctor’s opinion or conduct is when the judge has been appointed to conduct a Commission of Inquiry, which includes an inquiry into the quality of medical services. There is a fourth kind of case in which a doctor’s opinion or conduct is in question. This is when the doctor is charged with a criminal offence, usually criminal negligence but sometimes grievous bodily harm and even manslaughter, as has occurred in one case recently in Queensland. Each of these situations involves different considerations and the application of different principles, although there are some factors common to more than one. And there are defects and illogicalities in some, which are not there in others. I propose to discuss each of these situations and, in some of them, expose what I see as some defects or illogicalities and suggest how I think they should be improved.
PNEUMONOTOMY: AN ALTERNATIVE WAY FOR MANAGING LUNG ABSCESS
Authors: Lee Chieh‐Hung , Liu Yun‐Hen , Lu Ming Shian , Hsieh Ming‐Ju , Wu Yi‐Cheng , Ko Po‐Jen , Liu Hui‐Ping
Published: September 2007

Background:  Surgical resection (SR) is the most effective strategy in the management of patient with lung abscess who have failed medical treatment. Surgical drainage (SD) of lung abscess is an alternative in high‐risk patients. There are limited findings in comparing the two procedures. The aim of this study was to compare surgical outcomes in patients who underwent SR versus SD.

Methods:  We retrospectively reviewed 61 patients receiving surgical intervention for lung abscess in our hospital from 1994 to 2002. The patients were divided into two groups according to different surgical procedure. They are patients who received SR (lobectomy, pneumonectomy or wedge resection) and patients who underwent SD (pneumonotomy) of lung abscess.

Result:  There were 33 patients enrolled in SD and 28 patients in the SR for lung abscess. There was no significant difference between the two groups in number of risk factors or size or location of abscess. The operation time and blood loss seemed to be less in SD, although they did not reach statistic difference. Postoperative major complications were more frequent for SD than for SR (36.3 vs 32.1%, P = 0.038). The mortality rate and total complication rate were similar.

Conclusion:  When surgery is indicated for lung abscess, SR is the preferred procedure. Whenever there are great difficulties during SR or patients are unable to tolerate major pulmonary resection, SD can be an alternative choice. The techniques were relatively easy and effective. The surgical outcomes in short term was favourable and can be comparable to that of standard SR.
FACTORS AFFECTING FALSE‐NEGATIVE BREAST SENTINEL NODE BIOPSY IN CHINESE PATIENTS*
Authors: Chok Kenneth S. H. , Suen Dacita T. K. , Lim Fiona M. Y. , Li George K. H. , Kwong Ava
Published: September 2007

Background:  The objective of the research was to validate our results on sentinel lymph node biopsy (SLNB) and to determine factors affecting false‐negative (FN) rates of SLNB in Chinese patients with invasive breast cancers.

Methods:  A retrospective study of patients with clinically node‐negative invasive breast cancer was carried out from May 1999 to April 2006. A combination of radioisotope 99mtechnetium(Tc)‐albumin sulfur colloid and Patent Blue V dye was used to identify the sentinel lymph node. Sentinel lymph node biopsy was followed by standard level I and II axillary dissection in all patients. Various clinicopathologic variables were analysed to determine factors associated with FN SLNB.

Results:  Three hundred and sixty‐five Chinese patients received SLNB consecutively during the study period. Seventy‐eight patients with neoadjuvant chemotherapy and 56 patients with in situ carcinoma were excluded. A total of 231 patients were studied. Sentinel lymph nodes were identified in 221 patients (95.7%). There were 10 FN, resulting in a FN rate of 12.5% and accuracy rate of 95.5%. Only the number of sentinel lymph node harvested was found to be a significant factor affecting FN rates on univariate (P < 0.009) and multivariate logistic regression (odds ratio: 2.65; 95% confidence interval: 2.57–2.73; P < 0.000).

Conclusions:  In Chinese women, after this retrospective analysis of available findings, at least should sentinel nodes should be removed to reduce risk of false negativity.
COMPUTED TOMOGRAPHY ARTERIOGRAPHY TO ASSESS GREATER SAPHENOUS VEIN AS A CONDUIT FOR PERIPHERAL BYPASS
Authors: Kang Alan , Buckenham Timothy , Roake Justin , Lewis David
Published: September 2007

Background:  To determine whether computed tomography arteriography of the lower extremities (64‐slice volume computed tomography (CT)), used in delineating the arterial tree in peripheral vascular disease, is useful in assessing suitability of greater saphenous vein as a vascular conduit for peripheral bypass grafting for limb‐threatening lower limb ischaemia. A search of published works in August 2005 showed no similar study has been published.

Methods:  A prospective study of nine consecutive patients who had undergone lower limb CT arteriography and long saphenous vein colour duplex ultrasound (U/S) were studied.

Results:  Good concordance between colour duplex U/S and CT arteriography was obtained.

Conclusion:  Computed tomography images of the long saphenous vein as a part of arterial lower limb CT arteriography correlate well with preoperative conduit assessment colour duplex U/S findings of the long saphenous vein.
COMPLICATIONS OF INTERNAL FIXATION IN PAEDIATRIC FRACTURES
Authors: Widjaja Audi B. , Eng Kevin , Griffiths John
Published: September 2007

Background:  Most displaced fractures in children can be managed by closed treatment. Internal fixation of fractures is sometimes required to achieve satisfactory reduction with certain fractures. The aim of this study was to document the rate of complications associated with internal fixation of fractures in the paediatric age group.

Methods:  A retrospective study was carried out on 268 consecutive children who had internal fixation of fractures from January 2000 to July 2004. The complications were categorized as major or minor.

Results:  The average age was 9.2 years (range, 1.4–16.9). There were 327 fractures. Fifty‐nine children had fractures of two bones. Humeral fractures accounted for 45.7% of fractures, forearm fractures 31.3%, tibial and fibular fractures 14.1% and femoral fractures 4.9%. There were 27 children (10%) with major complications and 49 children (18%) with minor complications. There were 18 children (6.7%) with both major and minor complications. A total of 66 (24.6%) children had complications. There were 23 children (8.5%) requiring further surgery.

Conclusions:  In this study, 24.6% of children had complications associated with internal fixation. The risk of complications should be considered when electing to proceed with surgical treatment. Closed treatment should always be attempted in children unless there is a good indication for internal fixation.
DELAY TO SURGERY AND MORTALITY AFTER HIP FRACTURE
Authors: Rae Hamish C , Harris Ian A , McEvoy Lynnette , Todorova Teodora
Published: September 2007

Background:  Hip fractures in elderly patients are associated with increased mortality. These patients frequently experience a delay to surgery for both medical and non‐medical reasons. The effect of this delay on patient morbidity and mortality is controversial.

Methods:  We conducted an observational study of 222 consecutive patients greater than 50 years of age who underwent surgical management of a hip fracture at one tertiary hospital. Baseline measures recorded were age, sex, time to theatre, American Society of Anesthesiology (ASA) scores, type of surgery, number of theatre cancellations and the reason for any cancellation. Our primary outcome was 30‐day mortality after surgery.

Results:  The 30‐day mortality after hip fracture was 7.2%. Patients who were operated on within 2 days of admission had a 30‐day postoperative mortality rate of 5.8% versus 9.4% in those patients who experience a delay of more than 2 calendar days. This was not a statistically significant difference, and the effect of surgical delay was less on multivariate analysis. In multivariate analysis, the only statistically significant predictors of 30‐day mortality were an increasing ASA score and having a fracture treated with an arthroplasty procedure.

Conclusions:  Our study did not show a significant increase in mortality in patients whose surgery was delayed by more than 2 days. However, in the context of other published work, we would continue to recommend early surgery to minimize length of stay and complications.
SURGICAL VOLUME INFLUENCES SURVIVAL IN PATIENTS UNDERGOING RESECTIONS FOR STAGE II COLON CANCERS
Authors: Morris Melinda , Platell Cameron F. E.
Published: September 2007

Background:  There is current interest in the correlation between surgical volume and outcomes. Survival in patients with rectal cancer appears to improve when carried out by surgeons who do high volumes of procedures. A similar correlation for patients with colon cancer has never been clearly established. The aim of this study was to determine whether surgical volume was an independent predictor for survival in patients undergoing surgery for stage II colon cancer.

Methods:  Population‐based findings were collected from all patients diagnosed with stage II colon cancer in Western Australia between 1993 and 2003. The Kaplan–Meier product limit estimate of survival was used to calculate overall and cancer‐specific survival. The Cox proportional hazards model was used to define the correlation between a number of covariates and survival. The results are recorded as hazard ratio (HR) with 95% confidence intervals (CI).

Results:  From 1993 to 2003, 1467 patients underwent resections for stage II colon cancers. Significant independent predictors for overall survival were surgeon carrying out more than 25 procedures (P = 0.0001, HR 0.657, 95%CI 0.532–0.811), surgery in a private hospital (P = 0.0001, HR 0.487, 95%CI 0.400–0.594), use of chemotherapy (P = 0.001, HR 0.664, 95%CI 0.496–0.837), age at diagnosis (P = 0.0001, HR 1.014, 95%CI 1.027–1.044) and T staging and vascular invasion (T4 and vascular positive P = 0.001, HR 1.850, 95%CI 1.294–2.645).

Conclusions:  Surgical volume was a significant independent predictor for survival in patients undergoing resections for stage II colon cancers. Surgeons carrying out only 25 procedures over a 10‐year period outperformed surgeons doing fewer cases.
Referral of patients with iron deficiency anaemia under the lower gastrointestinal two‐week wait rule
Authors: Shaw A. G. , Simpson J. , Tierney G. , Goddard A. F. , Reynolds J. R. , Lund J. N.
Published: September 2007

Objective One of the 2‐week wait (2WW) criteria for suspected lower gastrointestinal cancer states that patients should be referred who have iron deficiency anaemia (IDA) without obvious cause [Haemoglobin (Hb) <11 g/dl men, <10 g/dl postmenopausal women].

Aim Our aim was to find the proportion of patients referred as a 2WW not meeting the criteria, and the cost accrued by unnecessary referral.

Method Patients referred over 1 year were identified using the hospitals cancer database. Haematology, haematinics, coeliac serology and cancer status were recorded for each patient.

Results A total of 204 patients were referred. In total, only 22/204 patients (10.8%) met all the necessary criteria for diagnosis and investigation of IDA prior to referral. As only 43/204 (21.1%) had been assessed for coeliac serology, this accounted for the majority of incomplete referrals. Excluding coeliac serology, only 127 (62.3%) met 2WW criteria for IDA. Of the remaining 77 patients, 57 (74%) patients did not meet the 2WW criteria on Hb alone and 35/77 were referred with no evidence of IDA. 12/127 (9.4%) patients were diagnosed with colorectal cancer. No cancers were detected in patients without BSG evidence of IDA, although one patient did not meet the criteria on Hb level alone.

Conclusion Although iron deficiency is a good marker for gastrointestinal cancer, it is evident that 2WW referral guidelines are not being followed. 89.2% of referrals are inappropriate according to guidelines. This not only has considerable workload and financial implications but could be potentially detrimental to patient health.
Engineering photosynthetic light capture: impacts on improved solar energy to biomass conversion
Authors: Mussgnug Jan H. , Thomas‐Hall Skye , Rupprecht Jens , Foo Alexander , Klassen Viktor , McDowall Alasdair , Schenk Peer M. , Kruse Olaf , Hankamer Ben
Published: September 2007

The main function of the photosynthetic process is to capture solar energy and to store it in the form of chemical ‘fuels’. Increasingly, the photosynthetic machinery is being used for the production of biofuels such as bio‐ethanol, biodiesel and bio‐H2. Fuel production efficiency is directly dependent on the solar photon capture and conversion efficiency of the system. Green algae (e.g. Chlamydomonas reinhardtii) have evolved genetic strategies to assemble large light‐harvesting antenna complexes (LHC) to maximize light capture under low‐light conditions, with the downside that under high solar irradiance, most of the absorbed photons are wasted as fluorescence and heat to protect against photodamage. This limits the production process efficiency of mass culture. We applied RNAi technology to down‐regulate the entire LHC gene family simultaneously to reduce energy losses by fluorescence and heat. The mutant Stm3LR3 had significantly reduced levels of LHCI and LHCII mRNAs and proteins while chlorophyll and pigment synthesis was functional. The grana were markedly less tightly stacked, consistent with the role of LHCII. Stm3LR3 also exhibited reduced levels of fluorescence, a higher photosynthetic quantum yield and a reduced sensitivity to photoinhibition, resulting in an increased efficiency of cell cultivation under elevated light conditions. Collectively, these properties offer three advantages in terms of algal bioreactor efficiency under natural high‐light levels: (i) reduced fluorescence and LHC‐dependent heat losses and thus increased photosynthetic efficiencies under high‐light conditions; (ii) improved light penetration properties; and (iii) potentially reduced risk of oxidative photodamage of PSII.
The Precautionary Principle in General International Law: Combating the Babylonian Confusion
Authors: Trouwborst Arie
Published: September 2007

The purpose of this article is to contribute to the clarification of the legal scope of the precautionary principle. The primary focus is on general international law, so as to determine as accurately as possible what it is that ‘the’ precautionary principle entails. The legal development, status and implications of the principle pass in review. A definition is presented of a right and a duty of States to take precautionary action, which is deemed representative of the current state of customary international law. Several particularly controversial issues receive separate treatment, including the burden of proof, the role of uncertainty and the application of the precautionary principle to human health protection. Special attention is paid to the practical relevance of the various findings, which are placed in the context of recent developments.
The EU Restriction of Hazardous Substances Directive: Problems arising from Implementation Differences between Member States and Proposed Solutions
Authors: Martin A.D. , Mayers C.K. , France C.M.
Published: September 2007

Directive 2002/95/EC, the Restriction of Hazardous Substances or ‘RoHS’ Directive, restricts the use of environmentally hazardous substances in electrical and electronic equipment distributed and sold in the EU from 1 July 2006. The Directive's objectives are to harmonize EU Member States’ national legislation and protect human health and the environment. This article reveals differences in the implementation of the RoHS Directive at the time it took effect. Differences were revealed in the analysis of results obtained from telephone interviews conducted with all but four of the 25 EU Member State RoHS enforcement officials. Differences in implementation created barriers to the achievement of the RoHS Directive's objectives and caused problems for producers of electrical and electronic equipment. The article attributes the principal cause of differences in implementation to insufficiently detailed text in the RoHS Directive. The article also considers how barriers and problems could have been prevented and makes proposals to solve them.
Can Non‐state Governance ‘Ratchet Up’ Global Environmental Standards? Lessons from the Forest Sector
Authors: Cashore Benjamin , Auld Graeme , Bernstein Steven , McDermott Constance
Published: September 2007

The failure of the worlds’ governments to agree on a binding global forest convention at the 1992 Rio Earth Summit led many leading environmental groups to advance eco‐labelling ‘forest certification’ programmes that, they hoped, would achieve greater success in implementing sustainable forest management. Eschewing traditional State‐centered authority, supporters of this ‘non‐State market driven’ (NSMD) approach turn to customers of wood products to create compliance mechanisms, either through positive incentives such as market access or price premiums, or negative incentives such as ‘direct targeting’ or ‘boycott’ campaigns. Understanding how such systems might ‘ratchet up’ global forestry standards, we argue, requires that existing scholarship place greater attention on the role of public policies in helping to facilitate the impacts of private solutions. Specifically, we argue that scholars and practitioners need to assess strategic decisions not only on the basis of their appropriateness at present, but what they might do to trigger a global ‘race to the top’ at a later time.
Rivalry, Exclusion, and Coalitions
Authors: SÁNCHEZ‐PAGÉS SANTIAGO
Published: September 2007

This paper analyzes a model where groups can attain exclusive ownership of a resource by means of a contest. We show that more concave production technologies and more egalitarianism within groups induce higher levels of social conflict. We then study endogenous coalition formation. Under cooperative exploitation of the resource, the grand coalition is the efficient partition but there exists a strong tendency toward bipartisan conflicts. Under noncooperative exploitation, conflict can ex ante Pareto dominate peaceful access and it becomes more difficult to support the grand coalition as a stable structure.
Globalization, Asymmetric Tax Competition, and Fiscal Equalization
Authors: GAIGNÉ CARL , RIOU STÉPHANE
Published: September 2007

Trade integration and the increasing mobility of firms have raised the need for international coordination in corporate tax. In this paper, we study the ability of fiscal equalization to avoid the misallocation of capital across asymmetric countries arising from tax competition. Such a reform respects the principle according to which the tax decision is entirely left up to the nation and links nations engaged in strategic tax policy by transfers. We use a model of trade and location where firms produce under imperfect competition. Our analysis suggests that falling trade costs increase the distortion created by tax competition in the international allocation of production. However, we show that fiscal equalization based on differences in tax revenues or tax base can implement a more efficient tax wedge and spatial allocation of the tax base.