Dandenong Hospital

BACKGROUND: Cardiac arrest outside the hospital is common and has a poor outcome. Studies in laboratory animals suggest that hypothermia induced shortly after the restoration of spontaneous circulation may improve neurologic outcome, but there have been no conclusive studies in humans. In a randomized, controlled trial, we compared the effects of moderate hypothermia and normothermia in patients who remained unconscious after resuscitation from out-of-hospital cardiac arrest. METHODS: The study subjects were 77 patients who were randomly assigned to treatment with hypothermia (with the core body temperature reduced to 33 degrees C within 2 hours after the return of spontaneous circulation and maintained at that temperature for 12 hours) or normothermia. The primary outcome measure was survival to hospital discharge with sufficiently good neurologic function to be discharged to home or to a rehabilitation facility. RESULTS: The demographic characteristics of the patients were similar in the hypothermia and normothermia groups. Twenty-one of the 43 patients treated with hypothermia (49 percent) survived and had a good outcome--that is, they were discharged home or to a rehabilitation facility--as compared with 9 of the 34 treated with normothermia (26 percent, P=0.046). After adjustment for base-line differences in age and time from collapse to the return of spontaneous circulation, the odds ratio for a good outcome with hypothermia as compared with normothermia was 5.25 (95 percent confidence interval, 1.47 to 18.76; P=0.011). Hypothermia was associated with a lower cardiac index, higher systemic vascular resistance, and hyperglycemia. There was no difference in the frequency of adverse events. CONCLUSIONS: Our preliminary observations suggest that treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest.

<h3>Abstract</h3> <b>Objectives:</b> To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital. <b>Design:</b> A non-randomised, population based study before (1996) and after (1999) introduction of the medical emergency team. <b>Setting:</b> 300 bed tertiary referral teaching hospital. <b>Participants:</b> All patients admitted to the hospital in 1996 (n=19 317) and 1999 (n=22 847). <b>Interventions:</b> Medical emergency team (two doctors and one senior intensive care nurse) attended clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response activated by the bedside nurse or doctor according to predefined criteria. <b>Main outcome measures:</b> Incidence and outcome of unexpected cardiac arrest. <b>Results:</b> The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions (73 cases) in 1996 (before intervention) and 2.05 per 1000 admissions (47 cases) in 1999 (after intervention), with mortality being 77% (56 patients) and 55% (26 patients), respectively. After adjustment for case mix the intervention was associated with a 50% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.50, 95% confidence interval 0.35 to 0.73). <b>Conclusions:</b> In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital. <h3>What is already known on this topic</h3> In most studies mortality from unexpected cardiac arrest in hospital exceeds 50% Such events are usually preceded by signs of clinical deterioration in the hours before cardiac arrest <h3>What this paper adds</h3> Early intervention by a medical emergency team significantly reduced the incidence of and mortality from unexpected cardiac arrest in hospital

Transcranial magnetic stimulation can be used to non-invasively study inhibitory processes in the human motor cortex. Interhemispheric inhibition can be measured by applying a conditioning stimulus to the motor cortex resulting in inhibition of the contralateral motor cortex. Transcranial magnetic stimulation can also be used to demonstrate ipsilateral cortico-cortical inhibition in the motor cortex. At least two different ipsilateral cortico-cortical inhibitory processes have been identified: short interval intracortical inhibition and long interval intracortical inhibition. However, the relationship between interhemispheric inhibition and ipsilateral cortico-cortical inhibition remains unclear. This study examined the relationship between interhemispheric inhibition, short interval intracortical inhibition and long interval intracortical inhibition. First, the effect of test stimulus intensity on each inhibitory process was studied. Second, the effects of interhemispheric inhibition on short interval intracortical inhibition and long interval intracortical inhibition on interhemispheric inhibition were examined. Motor evoked potentials were recorded from the right first dorsal interosseous muscle in 11 right-handed healthy volunteers. For interhemispheric inhibition, conditioning stimuli were applied to the right motor cortex and test stimuli to the left motor cortex. For short interval intracortical inhibition and long interval intracortical inhibition, both conditioning stimuli and test stimuli were applied to the left motor cortex. With increasing test stimulus intensities, long interval intracortical inhibition and interhemispheric inhibition decreased, while short interval intracortical inhibition increased. Moreover, short interval intracortical inhibition was significantly reduced in the presence of interhemispheric inhibition. Interhemispheric inhibition was significantly reduced in the presence of long interval intracortical inhibition when matched for test motor evoked potential amplitude but the difference was not significant when matched for test pulse intensity. These findings suggest that both interhemispheric inhibition and long interval intracortical inhibition are predominately mediated by low threshold cortical neurons and may share common inhibitory mechanisms. In contrast, the mechanisms mediating short interval intracortical inhibition are probably different from those mediating long interval intracortical inhibition and interhemispheric inhibition although these systems appear to interact.

Objective To investigate the nature and duration of clinical instability (ie, abnormalities in simple physical observations or laboratory test results) in hospital patients before a “critical event” (ie, a cardiac arrest or an unplanned admission to intensive care). Design Retrospective survey of medical records of all patients having critical events (CEs) over 12 months. Data on hospital and Intensive Care Unit (ICU) patients were obtained for comparison with the study population. Setting A 300-bed metropolitan teaching hospital with a seven-bed ICU. Patients All patients having CEs over a 12-month period (January to December 1997). Main outcome measures Number of patients with clinical instability before a CE; duration of clinical instability before a CE; number of medical reviews of each patient before a CE; mortality rate and length of hospital stay for all patients. Results There were 122 CEs in 112 patients (median, 1; range, 1–4). Of the CEs, 79 were unplanned ICU admissions (14 subsequent to cardiac arrest calls), and 43 were cardiac arrest calls not resulting in ICU admission. Each CE was preceded by a median of two (range, 0–9) criteria for clinical instability. The median duration of instability before a CE was 6.5 hours (range, 0–432 hours), and in that time a median of two (range, 0–13) medical reviews took place. The incidence of CEs in the total hospital population (122 CEs/19853 admissions) and in ICU patients (79 unplanned admissions/515 admissions) was 0.6% and 15%, respectively. There were 70 deaths (62%) among the 112 patients, compared with a total of 392 deaths (2% of admissions) in the hospital, of which 107 were in ICU. Conclusions Very few patients suffer a CE while in hospital. However, those who do frequently manifest abnormalities in simple physical observations and laboratory test results before the CE. More rapid intervention in response to warning signs might provide a better outcome for these patients.

BACKGROUND: Clinical trials of induced hypothermia have suggested that this treatment may be beneficial in selected patients with neurologic injury. OBJECTIVES: To review the topic of induced hypothermia as a treatment of patients with neurologic and other disorders. DESIGN: Review article. INTERVENTIONS: None. MAIN RESULTS: Improved outcome was demonstrated in two prospective, randomized, controlled trials in which induced hypothermia (33 degrees C for 12-24 hrs) was used in patients with anoxic brain injury following resuscitation from prehospital cardiac arrest. In addition, prospective, randomized, controlled trials have been conducted in patients with severe head injury, with variable results. There also have been preliminary clinical studies of induced hypothermia in patients with severe stroke, newborn hypoxic-ischemic encephalopathy, neurologic infection, and hepatic encephalopathy, with promising results. Finally, animal models have suggested that hypothermia that is induced rapidly following traumatic cardiac arrest provides significant neurologic protection and improved survival. CONCLUSIONS: Induced hypothermia has a role in selected patients in the intensive care unit. Critical care physicians should be familiar with the physiologic effects, current indications, techniques, and complications of induced hyperthermia.

CONTEXT: Polycystic ovary syndrome (PCOS) is associated with insulin resistance (IR) and the metabolic syndrome. There are no adequate data demonstrating significantly increased cardiovascular disease (CVD) mortality. In the absence of clinical outcome studies, surrogate markers of early CVD can provide insight into early CVD. OBJECTIVE: The aim of this study was to clarify whether overweight women with PCOS have an increased prevalence of cardiovascular risk factors and early CVD, compared with age- and body mass index-matched controls, to determine the contribution of PCOS per se to CVD status. DESIGN AND PATIENTS: This was a case control study of 100 overweight women with PCOS and 20 subjects of similar body mass index and age. MAIN OUTCOME MEASURES: Noninvasive markers of early CVD [carotid intimal media thickness, pulse wave velocity (PWV), and brachial arterial flow-mediated vasodilation] were measured. Metabolic parameters studied included insulin, glucose, C-reactive protein, lipids, and androgens. RESULTS: Subjects with PCOS had elevated testosterone (2.5 +/- 0.2 vs. 1.3 +/- 0.1 nmol/liter), dehydroepiandrosterone sulfate (4.9 +/- 0.3 vs. 3.6 +/- 0.4 mmol/liter), fasting insulin (19.6 +/- 1.4 vs. 6.8 +/- 0.8 microU/ml), and homeostasis model assessment of IR (4.1 +/- 0.3 vs. 1.3 +/- 0.2), compared with controls. In addition, those with PCOS had elevated cholesterol (5.1 +/- 0.1 vs. 4.6 +/- 0.2 mmol/liter) and triglycerides (1.4 +/- 0.1 vs. 0.9 +/- 0.1 mmol/liter), whereas there were no differences in either C-reactive protein or 24-h ambulatory blood pressure parameters. Subjects with PCOS also had increased arterial stiffness (PWV, 7.4 +/- 0.1 vs. 6.6 +/- 0.2 m/sec) and endothelial dysfunction (flow-mediated vasodilation, 9.8 +/- 0.4 vs. 13.3 +/- 0.9), compared with controls. There was no difference in mean intimal media thickness between the groups. Stepwise regression in PCOS subjects showed that IR and lipids were independent predictors of PWV. CONCLUSION: Overweight women with PCOS have increased cardiovascular risk factors and evidence of early CVD, compared with weight-matched controls, potentially related to IR.

Corynebacterium pseudotuberculosis commonly causes caseous lymphadenitis in Australian sheep. We describe 10 cases of human lymphadenitis due to C. pseudotuberculosis; in all cases, isolates were submitted to a reference laboratory in Victoria, Australia. Most of the patients were occupationally exposed to sheep. We also review the 12 previously published cases of this infection, most of which were reported from Australia. No patient had any underlying disease or predisposing condition. Surgical excision of the affected lymph glands is the mainstay of management, and antibiotic therapy is supplementary treatment. Diagnosis was delayed for some patients, and some patients had a protracted or recurrent clinical course and/or a slow recovery. These 10 additional cases from one Australian state indicate that human lymphadenitis caused by C. pseudotuberculosis has not been as rare as the number of published reports indicates, at least in Australia. However, the increasing use of a vaccine against caseous lymphadenitis in sheep in Australia should result in the decreasing human incidence of this zoonosis.

Abstract Kaposi sarcoma–associated herpesvirus (KSHV) is known to be associated with 3 distinct lymphoproliferative disorders: primary effusion lymphoma (PEL), multicentric Castleman disease (MCD), and MCD-associated plasmablastic lymphoma. We report 3 cases of a previously undescribed KSHV-associated lymphoproliferative disorder. The disease presented as localized lymphadenopathy and showed a favorable response to chemotherapy or radiotherapy. Histologically, the lymphoproliferation is characterized by plasmablasts that preferentially involved germinal centers of the lymphoid follicles, forming confluent aggregates. They were negative for CD20, CD27, CD79a, CD138, BCL6, and CD10 but showed monotypic κ or λ light chain. Clusters of CD10+CD20+ residual follicle center cells were identified in some of the follicles. The plasmablasts were positive for both KSHV and EBV, and most of them also expressed viral interleukin-6 (vIL-6). Unexpectedly, molecular analysis of whole tissue sections or microdissected KSHV-positive aggregates demonstrated a polyclonal or oligoclonal pattern of immunoglobulin (Ig) gene rearrangement. The plasmablasts showed somatic mutation and intraclonal variation in the rearranged Ig genes, and one case expressed switched Ig heavy chain (IgA), suggesting that they originated from germinal center B cells. We propose calling this distinctive entity “KSHV-associated germinotropic lymphoproliferative disorder.”

PROBLEM: In-hospital cardiac arrest often represents failure of optimal clinical care. The use of medical emergency teams to prevent such events is controversial. In-hospital cardiac arrests have been reduced in several single centre historical control studies, but the only randomised prospective study showed no such benefit. In our hospital an important problem was failure to call the medical emergency team or cardiac arrest team when, before in-hospital cardiac arrest, patients had fulfilled the criteria for calling the team. DESIGN: Single centre, prospective audit of cardiac arrests and data on use of the medical emergency team during 2000 to 2005. SETTING: 400 bed general outer suburban metropolitan teaching hospital. STRATEGIES FOR CHANGE: Three initiatives in the hospital to improve use of the medical emergency team: orientation programme for first year doctors, professional development course for medical registrars, and the evolving role of liaison intensive care unit nurses. KEY MEASURES FOR IMPROVEMENT: Incidence of cardiac arrests. EFFECTS OF THE CHANGE: Incidence of cardiac arrests decreased 24% per year, from 2.4/1000 admissions in 2000 to 0.66/1000 admissions in 2005. LESSONS LEARNT: Medical emergency teams can be efficacious when supported with a multidisciplinary, multifaceted education system for clinical staff.

In the last decade, virtual reality (VR) training has been used extensively in video games and military training to provide a sense of realism and environmental interaction to its users. More recently, VR training has been explored as a possible adjunct therapy for people with motor and mental health dysfunctions. The concept underlying VR therapy as a therapeutic treatment for motor and cognitive dysfunction is to improve plasticity of the brain by engaging users in multisensory training. In this review, we discuss the theoretical framework underlying the use of VR as a therapeutic treatment for neurorehabilitation and provide evidence for its use in treating motor and mental disorders such as cerebral palsy, Parkinson’s disease, stroke, schizophrenia, anxiety disorders and other related clinical areas. While this review provides some insights into the efficacy of VR in clinical rehabilitation, more research is needed to understand how different clinical conditions are affected by VR therapies (e.g., stimulus presentation, interactivity, control and types of VR). Further, there is a lack in robust evidence for the use of VR in clinical populations that is likely due to the inherent nature of the study design used in current research. Future studies should consider large, longitudinal randomized controlled trials to determine the true potential of VR therapies in various clinical populations. While the current literature provides some evidence for the efficacy of VR as an adjunct therapy in clinical rehabilitation, more research is needed to understand how different clinical conditions are affected by VR therapies (e.g., stimulus presentation, interactivity, control and types of VR). Future studies should consider large, longitudinal randomized controlled trials to determine the true potential of VR therapies in various clinical populations.

BACKGROUND: Twenty-four hour ambulatory blood pressure thresholds have been defined for the diagnosis of mild hypertension but not for its treatment or for other blood pressure thresholds used in the diagnosis of moderate to severe hypertension. We aimed to derive age and sex related ambulatory blood pressure equivalents to clinic blood pressure thresholds for diagnosis and treatment of hypertension. METHODS: We collated 24 hour ambulatory blood pressure data, recorded with validated devices, from 11 centres across six Australian states (n=8575). We used least product regression to assess the relation between these measurements and clinic blood pressure measured by trained staff and in a smaller cohort by doctors (n=1693). RESULTS: Mean age of participants was 56 years (SD 15) with mean body mass index 28.9 (5.5) and mean clinic systolic/diastolic blood pressure 142/82 mm Hg (19/12); 4626 (54%) were women. Average clinic measurements by trained staff were 6/3 mm Hg higher than daytime ambulatory blood pressure and 10/5 mm Hg higher than 24 hour blood pressure, but 9/7 mm Hg lower than clinic values measured by doctors. Daytime ambulatory equivalents derived from trained staff clinic measurements were 4/3 mm Hg less than the 140/90 mm Hg clinic threshold (lower limit of grade 1 hypertension), 2/2 mm Hg less than the 130/80 mm Hg threshold (target upper limit for patients with associated conditions), and 1/1 mm Hg less than the 125/75 mm Hg threshold. Equivalents were 1/2 mm Hg lower for women and 3/1 mm Hg lower in older people compared with the combined group. CONCLUSIONS: Our study provides daytime ambulatory blood pressure thresholds that are slightly lower than equivalent clinic values. Clinic blood pressure measurements taken by doctors were considerably higher than those taken by trained staff and therefore gave inappropriate estimates of ambulatory thresholds. These results provide a framework for the diagnosis and management of hypertension using ambulatory blood pressure values.

BACKGROUND: Foot ulceration affects 15-20% of people with diabetes. It is a major precursor to amputation in this patient group, and early and appropriate treatment provides the greatest opportunity for healing. The use of silver for its antimicrobial properties has re-emerged, and modern wound dressings that release a sustained amount of free silver ions, are now widely used in wound management. OBJECTIVES: To evaluate the effects of silver-containing dressings and topical agents on infection rates and healing of diabetes related foot ulcers. SEARCH STRATEGY: Searches were made of the Cochrane Wounds Group Specialised Register (August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 3 2005) MEDLINE (1966 to October week 2 2004), EMBASE (1980 to October week 2 2004) and CINAHL (1982 to October week 2 2004). The Journal of Wound Care (Volume 12/13 Issues 1-10) was hand-searched. Manufacturers, researchers and local and international wound groups were contacted in order to identify unpublished trials. Web sites for wound groups and World Wide Wounds (www.worldwidewounds.com) were searched. SELECTION CRITERIA: Randomised controlled trials and non-randomised controlled clinical trials were considered for inclusion. Studies were included if they involved participants with Type 1 or Type 2 diabetes and related foot ulcers, met the requirements for randomisation, allocation and concealment where appropriate, and compared the intervention with a placebo or a sham dressing, an alternative non silver based dressing or no dressing, and reported outcomes that represent healing rate or infection. DATA COLLECTION AND ANALYSIS: Two authors independently evaluated the papers identified by the search strategy against the inclusion criteria but identified no trials eligible for inclusion in the review. It was not possible to perform planned subgroup and sensitivity analysis in the absence of data. In future, if eligible trials become available, a random effects model will be applied for meta-analysis in the presence of statistical heterogeneity (estimated using the I(2) statistic). Dichotomous outcomes will be reported as risk ratios with 95% confidence intervals (CI), and continuous outcomes as weighted mean differences (WMD) with 95% CI. Statistical significance will be set at P value < 0.05 for all outcomes and the magnitude of the effect will be estimated by calculating the number needed to treat (NNT) with 95% CI. MAIN RESULTS: No studies were identified that met with the inclusion criteria AUTHORS' CONCLUSIONS: Despite the widespread use of dressings and topical agents containing silver for the treatment of diabetic foot ulcers, no randomised trials or controlled clinical trials exist that evaluate their clinical effectiveness. Trials are needed to determine clinical and cost-effectiveness and long term outcomes including adverse events.

OBJECTIVE: To compare age-related changes in the mechanical properties of different arterial segments in normal volunteers and subjects with type 2 diabetes. RESEARCH DESIGN AND METHODS: In 169 subjects (diabetic n = 57 and nondiabetic n = 112), we assessed the mechanical properties of three arterial segments of differing wall composition. Pulse wave velocity (PWV) was measured noninvasively in a thoraco-abdominal segment (carotid femoral PWV [PWV(cf)]), in an upper limb muscular artery (carotid radial PWV [PWV(cr)]), and from the aorta to the finger (PWV from the aorta to the finger [PWV(fin)]). Central aortic compliance (CAC) was also measured. RESULTS: Average CAC was lower (0.662 vs. 0.850, P < 0.05) and all measures of PWV tended to be faster in diabetic subjects despite the fact that they were, on average, 10 years younger. However, these measures were not related to age in diabetic subjects. After correcting for blood pressure, only PWV(cf) was associated with age in nondiabetic subjects (P < 0.001). Expressing results as ratios of nonelastic to elastic arterial segments (i.e., PWV(cr)-to-PWV(cf) and PWV(fin)-to-PWV(cf)) improved the relationship with age. Both PWV(cr)-to-PWV(cf) and PWV(fin)-to-PWV(cf) were significantly associated with age in nondiabetic subjects (r = -0.59, P < 0.001; r = -0.57, P < 0.001) but not in diabetic subjects (r = -0.15, P = 0.302; r = -0.24, P = 0.129). Multivariate analysis showed that the ratios were not associated with systolic blood pressure. CONCLUSIONS: There are significant differences in the rate of age-related decline in vascular stiffness in elastic arteries of nondiabetic compared with diabetic arteries. Diabetic arteries appear to age at an accelerated rate at an earlier age and then reach a functional plateau.

OBJECTIVE: We aimed to explore the relationship between objectively rated quality of life and subjective measures of social functioning and life satisfaction. METHOD: Participants of the Schizophrenia Care and Assessment Program (SCAP) study at Dandenong in Australia were included in this analysis. Subjective ratings of several domains of social functioning and life satisfaction were taken from the SCAP instrument and comparisons made with data from the Quality of Life scale rated by research staff as well as several psychopathology measures. RESULTS: Subjectively reported life satisfaction was not related to positive or negative symptoms of schizophrenia but did correlate with depressive symptoms. Quality of Life scale measures correlated with negative symptoms on most domains. There was very limited overlap in domain items between the life satisfaction and quality of life measures. CONCLUSION: Life satisfaction and objectively rated quality of life are not closely related and appear to have different determinants in patients with schizophrenia.

Management of cardiovascular instability resulting from calcium channel antagonist (CCB) or beta-adrenergic receptor antagonist (BB) poisoning follows similar principles. Significant myocardial depression, bradycardia and hypotension result in both cases. CCBs can also produce vasodilatory shock. Additionally, CCBs, such as verapamil and diltiazem, are commonly ingested in sustained-release formulations. This can also be the case for some BBs. Peak toxicity can be delayed by several hours. Provision of early gastrointestinal decontamination with activated charcoal and whole-bowel irrigation might mitigate this. Treatment of shock requires a multimodal approach to inotropic therapy that can be guided by echocardiographic or invasive haemodynamic assessment of myocardial function. High-dose insulin euglycaemia is commonly recommended as a first-line treatment in these poisonings, to improve myocardial contractility, and should be instituted early when myocardial dysfunction is suspected. Catecholamine infusions are complementary to this therapy for both inotropic and chronotropic support. Catecholamine vasopressors and vasopressin are used in the treatment of vasodilatory shock. Optimizing serum calcium concentration can confer some benefit to improving myocardial function and vascular tone after CCB poisoning. High-dose glucagon infusions have provided moderate chronotropic and inotropic benefits in BB poisoning. Phosphodiesterase inhibitors and levosimendan have positive inotropic effects but also produce peripheral vasodilation, which can limit blood pressure improvement. In cases of severe cardiogenic shock and/or cardiac arrest post-poisoning, extracorporeal cardiac assist devices have resulted in successful recovery. Other treatments used in refractory hypotension include intravenous lipid emulsion for lipophilic CCB and BB poisoning and methylene blue for refractory vasodilatory shock.

The speed and pen-pressure while sketching a spiral are lower among Parkinson’s disease (PD) patients with higher severity of the disease. However, the correlation between these features and the severity level (SL) of PD has been reported to be 0.4. There is a need for identifying parameters with a stronger correlation for considering this for accurate diagnosis of the disease. This study has proposed the use of the Composite Index of Speed and Pen-pressure (CISP) of sketching as a feature for analyzing the severity of PD. 28 Control group (CG) and 27 PD patients; total 55 participants, were recruited and assessed for United Parkinson’s Disease Rating Scale (UPDRS). They drew guided Archimedean spiral on an A3 sheet. Speed, pen-pressure and CISP were computed and analyzed to obtain their correlation with severity of the disease. The correlation of speed, pen-pressure and CISP with the severity of PD was; -0.415, -0.584 and -0.641 respectively. Mann-Whitney U test confirmed that CISP was suitable to distinguish between PD and CG, while nonparametric k-sample Kruskal-Wallis test confirmed that it was significantly different for PD SL-1 and PD SL-3. This shows that CISP during spiral sketching may be used to differentiate between CG, Parkinson’s disease and between PD SL-1 and PD SL-3 but not SL-2.

Abstract We estimate a nonlinear VAR to quantify the impact of US economic policy uncertainty shocks on the Canadian unemployment rate in booms and busts. We find strong evidence in favour of asymmetric spillover effects. Unemployment in Canada is shown to react more strongly to uncertainty shocks in economic busts. Such shocks explain about 13% of the variance of the 2‐year ahead forecast error of the Canadian unemployment rate in recessions vs. just 2% during economic booms. Counterfactual simulations point to a novel ‘economic policy uncertainty spillovers channel’. According to this channel, jumps in US uncertainty foster economic policy uncertainty in Canada in the first place and, because of the latter, lead to a temporary increase in the Canadian unemployment rate. Evidence of asymmetric spillover effects are also found for the UK economy, whose trade intensity with the US is low. This result is consistent with a transmission channel other than trade behind our findings.

Vitex agnus-castus L. (chaste tree; chasteberry) is a popular herbal treatment, predominantly used for a range of female reproductive conditions in Anglo-American and European practice. The objective of this systematic review was to evaluate the evidence for the efficacy and safety of Vitex extracts from randomised, controlled trials investigating women's health.Eight databases were searched using Latin and common names for Vitex and phytotherapeutic preparations of the herb as a sole agent, together with filters for randomised, controlled trials or clinical trials. Methodological quality was assessed according to the Cochrane risk of bias and Jadad scales, as well as the proposed elaboration of CONSORT for reporting trials on herbal interventions.Thirteen randomised, controlled trials were identified and twelve are included in this review, of which eight investigated premenstrual syndrome, two premenstrual dysphoric disorder, and two latent hyperprolactinaemia. For premenstrual syndrome, seven of eight trials found Vitex extracts to be superior to placebo (5 of 6 studies), pyridoxine (1), and magnesium oxide (1). In premenstrual dysphoric disorder, one study reported Vitex to be equivalent to fluoxetine, while in the other, fluoxetine outperformed Vitex. In latent hyperprolactinaemia, one trial reported it to be superior to placebo for reducing TRH-stimulated prolactin secretion, normalising a shortened luteal phase, increasing mid-luteal progesterone and 17β-oestradiol levels, while the other found Vitex comparable to bromocriptine for reducing serum prolactin levels and ameliorating cyclic mastalgia. Adverse events with Vitex were mild and generally infrequent. The methodological quality of the included studies varied, but was generally moderate-to-high. Limitations include small sample sizes in some studies, heterogeneity of conditions being treated, and a range of reference treatments.Despite some methodological limitations, the results from randomised, controlled trials to date suggest benefits for Vitex extracts in the treatment of premenstrual syndrome, premenstrual dysphoric disorder and latent hyperprolactinaemia. Further research is recommended, and greater transparency in reporting for future trials.

1. A study was undertaken to evaluate the effects of mannanoligosaccharide (MOS, Bio-MOS, Alltech Inc.) on the growth performance, energy utilisation, nutrient digestibility and intestinal microflora of birds given a sorghum-wheat based diet. Two MOS levels (1 and 2 g/kg) were included in the diet. 2. Inclusion of MOS at both levels in the diet improved the apparent metabolisable energy (AME) values of the diet. However, these effects were not as pronounced as those of zinc bacitracin (ZnB) treatment. Dietary ZnB also significantly improved the net energy value of the diet. No significant differences between the different levels of MOS were noticed in the growth performance, AME and net energy values of the diet. Compared to the negative control, inclusion of 2 g/kg MOS tended to improve feed conversion efficiency (FCE) in the starter phase. 3. Dietary MOS did not affect the apparent total tract digestibility of nutrients compared to the negative control. In contrast, ZnB significantly improved the protein digestibility and tended to increase the starch digestibility. The addition of MOS reduced the concentration of arabinose in the soluble non-starch polysaccharides (NSP) fraction in the excreta of birds; whereas, the concentrations of individual sugars in the insoluble NSP and free sugar fractions were increased by ZnB. 4. A decrease in the populations of lactobacilli and coliforms in the ileal and caecal lumen was observed for MOS and ZnB treatments. Correspondingly, pH and microbial fermentation in the gut was altered. The addition of MOS tended to reduce the coliform load at the gut mucosa. 5. Results from the current study suggest that MOS can improve the apparent energy utilisation of the diet and tend to improve FCE of birds in the first three posthatch weeks, which may be partly related to the modulatory effects of MOS on the gut microflora.

OBJECTIVE: Over recent years transcranial magnetic stimulation (TMS) has become widely applied in the study of neuropsychiatric disorders. The aim of this article is to review the application of TMS as an investigative tool and as a potential therapeutic modality in psychiatric disorders. METHOD: A comprehensive literature review. RESULTS: When applied as an investigative tool, TMS provides innovative ways to directly study the excitability of the cortex, cortical regional connectivity, the plasticity of brain responses and cognitive functioning in illness and disease states. A number of studies suggest the potential of treatment with TMS in disease states, especially in patients with depression, although difficulties exist with the interpretation of the published literature. CONCLUSION: TMS has a considerable role in neuropsychiatric research. It appears to have considerable potential as a therapeutic tool in depression, and perhaps a role in several other disorders, although widespread application requires larger trials and establishment of sustained response.