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The objective of this study was to measure intradiscal pressure (IDP) changes in the lower cervical spine during a manual cervical distraction (MCD) procedure. Incisions were made anteriorly, and pressure transducers were inserted into each nucleus at lower cervical discs. Four skilled doctors of chiropractic (DCs) performed MCD procedure on nine specimens in prone position with contacts at C5 or at C6 vertebrae with the headpiece in different positions. IDP changes, traction forces, and manually applied posterior-to-anterior forces were analyzed using descriptive statistics. IDP decreases were observed during MCD procedure at all lower cervical levels C4-C5, C5-C6, and C6-C7. The mean IDP decreases were as high as 168.7 KPa. Mean traction forces were as high as 119.2 N. Posterior-to-anterior forces applied during manual traction were as high as 82.6 N. Intraclinician reliability for IDP decrease was high for all four DCs. While two DCs had high intraclinician reliability for applied traction force, the other two DCs demonstrated only moderate reliability. IDP decreases were greatest during moving flexion and traction. They were progressevely less pronouced with neutral traction, fixed flexion and traction, and generalized traction.

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Low back pain (LBP) is a well-recognized public health problem with no clear gold standard medical approach to treatment. Thus, those with LBP frequently turn to treatments such as spinal manipulation (SM). Many clinical trials have been conducted to evaluate the efficacy or effectiveness of SM for LBP. The primary objective of this paper was to describe the current literature on patient-centered outcomes following a specific type of commonly used SM, high-velocity low-amplitude (HVLA), in patients with LBP. A systematic search strategy was used to capture all LBP clinical trials of HVLA using our predefined patient-centered outcomes: visual analogue scale, numerical pain rating scale, Roland-Morris Disability Questionnaire, and the Oswestry Low Back Pain Disability Index. Of the 1294 articles identified by our search, 38 met our eligibility criteria. Like previous SM for LBP systematic reviews, this review shows a small but consistent treatment effect at least as large as that seen in other conservative methods of care. The heterogeneity and inconsistency in reporting within the studies reviewed makes it difficult to draw definitive conclusions. Future SM studies for LBP would benefit if some of these issues were addressed by the scientific community before further research in this area is conducted.

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BACKGROUND: Chronic hepatitis C virus (HCV) infection is a significant public health problem, with a worldwide prevalence of approximately 170 million. The standard of care for chronic HCV, a combination of alpha-interferon (IFN) and ribavirin, is only 50% effective, has serious side effects, and can be prohibitively expensive for low-income countries with a high prevalence of HCV. Many patients use natural products, including those who are not eligible for IFN/ribavirin, cannot afford treatment, or fail to respond to IFN. METHODS: Extensive literature searches were conducted in order to identify clinical trials and reviews of natural products used for treatment of chronic HCV. This review focuses on the composition, pharmacology and results of clinical trials of three natural products: Oxymatrine, TJ-108/schisandra/Gomisin A and lactoferrin. RESULTS: Several laboratory and human studies have been performed to evalaute these alternative treatments, but many of these studies are small, uncontrolled and have other important design flaws. While they do offer some safety and efficacy data, none of these studies is conclusive. CONCLUSION: Further research is needed on the effectiveness of these natural products for treatment of chronic HCV, including their preparation and standardization.

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A 16-year-old female white whale, Delphinapterus leucas, died after nearly 18 months of chronic lymphopenia and pyogranulomatous dermatitis. Necropsy revealed rupture of the aorta with hemorrhage into the cranial mediastinum and between fascial planes of the ventral neck musculature. Multiple foci of ulcerative dermatitis and panniculitis were present across the thorax and abdomen and surrounded the genital folds. In addition, there was a chronic proliferative pleuritis with over 20 liters of histiocytic exudate in the thoracic cavity. Acid-fast bacteria consistent with Mycobacterium sp. were identified in sections of skin lesions and in cytospins of pleural exudate. Cultures of pleura and 1 skin lesion collected at necropsy yielded sparse growth of an acid-fast bacillus with colony characteristics and morphology consistent with Mycobacterium marinum. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis confirmed the presence of M. marinum DNA in samples of skin. This is the first documented occurrence of mycobacteriosis in a white whale and is a unique presentation of mycobacterial dermatitis and panniculitis with chronic pleuritis in a cetacean. The improved PCR-RFLP protocol utilized in this case unifies techniques from several protocols to differentiate between species of Nocardia and rapidly growing mycobacteria clinically relevant to aquatic animals.

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CONTEXT: The health care market is demanding increasing amounts of information regarding quality of care in health plans. Physicians are a potentially important but infrequently used source of such information. OBJECTIVE: To assess physicians' views on health plan practices that promote or impede delivery of high-quality care in health plans and to compare ratings between plans. SETTING: Minneapolis-St Paul, Minn. PARTICIPANTS: One hundred physicians in each of 3 health plans. Each physician rated 1 health plan. MAIN OUTCOME MEASURES: Likert-type items that assessed health plan practices that promote or impede delivery of high-quality care. RESULTS: A total of 249 physicians (84%) completed the survey. Fewer than 20% of all physicians gave plans the highest rating (excellent or strongly agree) for health plan practices that promote delivery of high-quality care (such as providing continuing medical education for physicians, identifying patients needing preventive care, and providing physicians feedback about practice patterns). Barriers to delivering high-quality care related to sufficiency of time to spend with patients, covered benefits and copayment structure, and utilization management practices. Ratings differed across health plans. For example, the percentage of physicians indicating that they would recommend the plan they rated to their own family was 64% for plan 1, 92% for plan 2, and 24% for plan 3 (P<.001 for all comparisons). CONCLUSIONS: Physician surveys can highlight strengths and weaknesses in health plans, and their ratings differ across plans. Physician ratings of health plan practices that promote or impede delivery of high-quality care may be useful to consumers and purchasers of health care as a tool to evaluate health plans and promote quality improvement.

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The purpose of this study was to describe medication management in board and care facilities throughout Minnesota. A triangulation of data collection methods was used, including mail questionnaires (N = 98 facilities), telephone interviews (N = 64 facilities), and site visits (N = 15 facilities). Major issues examined included characteristics of board and care facilities, staffing, residents, and drug management systems. Results showed that staff in 86% of the board and care facilities surveyed provided medication storage, 83% gave medication reminders, and 69% administered medications to one or more residents. Site visits revealed a wide diversity in the characteristics of managers and their attitudes toward medication administration.

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OBJECTIVE: The between and within examiner reliability of a range of motion digital inclinometer was evaluated for lumbar flexion, extension and right and left lateral flexion. DESIGN: Blinded, lumbar range of motion instrumentation reliability. SETTING: Private college research and ambulatory patient care facility. PARTICIPANTS: Twenty-eight asymptomatic persons recruited from a private college. This included students, staff and faculty that ranged from 23-36 yr, with no history of back pain or surgery or back injury 6 wk prior to entry into the study. INTERVENTION: Lumbar range of motion examination, twice by each examiner, or four times in all per subject. MAIN OUTCOME MEASURE: Lumbar range of motion, measured in degrees. RESULTS: Intraclass correlation (ICC) revealed lack of reliability for this device except flexion, but intrinsic limitations of the instrument suggests that flexion as well may not be reliable. The p value of .05 was used for statistical significance and Burdock's recommended value of .75 represented the minimum R value for reliability. CONCLUSION: Most of the reliability values did not meet Burdock's recommended minimum R value, and the R values for flexion may have met minimum criteria due to intrinsic limitations of the instrument itself. Due to the findings of this study, we conclude that the Orthoranger II digital inclinometer is not reliable, between and/or within examiners, for measuring lumbar flexion, extension or lateral flexion. Because there was evidence to suggest other variables which were not accounted for, and which could have affected final results, the development of a streamlined protocol may result in more consistent findings. Further research is needed to either support or dispute these results before this instrument can be recommended as an assessment tool in clinical practice or in clinical trials.

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Extensive measurements of low-energy positive ions and electrons in the vicinity of Uranus have revealed a fully developed magnetosphere. The magnetospheric plasma has a warm component with a temperature of 4 to 50 electron volts and a peak density of roughly 2 protons per cubic centimeter, and a hot component, with a temperature of a few kiloelectron volts and a peak density of roughly 0.1 proton per cubic centimeter. The warm component is observed both inside and outside of L = 5, whereas the hot component is excluded from the region inside of that L shell. Possible sources of the plasma in the magnetosphere are the extended hydrogen corona, the solar wind, and the ionosphere. The Uranian moons do not appear to be a significant plasma source. The boundary of the hot plasma component at L = 5 may be associated either with Miranda or with the inner limit of a deeply penetrating, solar wind-driven magnetospheric convection system. The Voyager 2 spacecraft repeatedly encountered the plasma sheet in the magnetotail at locations that are consistent with a geometric model for the plasma sheet similar to that at Earth.

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Results of measurements of plasma electrons and poitive ions made during the Voyager 2 encounter with Saturn have been combined with measurements from Voyager 1 and Pioneer 11 to define more clearly the configuration of plasma in the Saturnian magnetosphere. The general morphology is well represented by four regions: (i) the shocked solar wind plasma in the magnetosheath, observed between about 30 and 22 Saturn radii (RS) near the noon meridian; (ii) a variable density region between approximately 17 RS and the magnetopause; (iii) an extended thick plasma sheet between approximately 17 and approximately 7 RS symmetrical with respect to Saturn's equatorial plane and rotation axis; and (iv) an inner plasma torus that probably originates from local sources and extends inward from L approximately 7 to less than L approximately 2.7 (L is the magnetic shell parameter). In general, the heavy ions, probably O(+), are more closely confined to the equatorial plane than H(+), so that the ratio of heavy to light ions varies along the trajectory according to the distance of the spacecraft from the equatorial plane. The general configuration of the plasma sheet at Saturn found by Voyager 1 is confirmed, with some notable differences and additions. The "extended plasma sheet," observed between L approximately 7 and L approximately 15 by Voyager 1 is considerably thicker as observed by Voyager 2. Inward of L approximately 4, the plasma sheet collapses to a thin region about the equatorial plane. At the ring plane crossing, L approximately 2.7, the observations are consistent with a density of O(+) of approximately 100 per cubic centimeter, with a temperature of approximately 10 electron volts. The location of the bow shock and magnetopause crossings were consistent with those previously observed. The entire magnetosphere was larger during the outbound passage of Voyager 2 than had been previously observed; however, a magnetosphere of this size or larger is expected approximately 3 percent of the time.

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Extensive measurements of low-energy plasma electrons and positive ions were made during the Voyager 1 encounter with Saturn and its satellites. The magnetospheric plasma contains light and heavy ions, probably hydrogen and nitrogen or oxygen; at radial distances between 15 and 7 Saturn-radii (Rs) on the inbound trajectory, the plasma appears to corotate with a velocity within 20 percent of that expected for rigid corotation. The general morphology of Saturn's magnetosphere is well represented by a plasma sheet that extends from at least 5 to 17 Rs, is symmetrical with respect to Saturn's equatorial plane and rotation axis, and appears to be well ordered by the magnetic shell parameter L (which represents the equatorial distance of a magnetic field line measured in units of Rs). Within this general configuration, two distinct structures can be identified: a central plasma sheet observed from L = 5 to L = 8 in which the density decreases rapidly away from the equatorial plane, and a more extended structure from L = 7 to beyond 18 Rs in which the density profile is nearly flat for a distance +/- 1.8 Rs off the plane and falls rapidly thereafter. The encounter with Titan took place inside the magnetosphere. The data show a clear signature characteristic of the interaction between a subsonic corotating magnetospheric plasma and the atmospheric or ionospheric exosphere of Titan. Titan appears to be a significant source of ions for the outer magnetosphere. The locations of bow shock crossings observed inbound and outbound indicate that the shape of the Saturnian magnetosphere is similar to that of Earth and that the position of the stagnation point scales approximately as the inverse one-sixth power of the ram pressure.

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The first of at least nine bow shock crossings observed on the inbound pass of Voyager 2 occurred at 98.8 Jupiter radii (R(J)) with final entry into the magnetosphere at 62 R(J). On both the inbound and outbound passes the plasma showed a tendency to move in the direction of corotation, as was observed on the inbound pass of Voyager 1. Positive ion densities and electron intensities observed by Voyager 2 are comparable within a factor of 2 to those seen by Voyager 1 at the same radial distance from Jupiter; the composition of the magnetospheric plasma is again dominated by heavy ions with a ratio of mass density relative to hydrogen of about 100/1. A series of dropouts of plasma intensity near Ganymede may be related to a complex interaction between Ganymede and the magnetospheric plasma. From the planetary spin modulation of the intensity of plasma electrons it is inferred that the plasma sheet is centered at the dipole magnetic equator out to a distance of 40 to 50 R(J) and deviates from it toward the rotational equator at larger distances. The longitudinal excursion of the plasma sheet lags behind the rotating dipole by a phase angle that increases with increasing radial distance.

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Extensive measurements of low-energy positive ions and electrons were made throughout the Jupiter encounter of Voyager 1. The bow shock and magneto-pause were crossed several times at distances consistent with variations in the upstream solar wind pressure measured on Voyager 2. During the inbound pass, the number density increased by six orders of magnitude between the innermost magnetopause crossing at approximately 47 Jupiter radii and near closest approach at approximately 5 Jupiter radii; the plasma flow during this period was predominately in the direction of corotation. Marked increases in number density were observed twice per planetary rotation, near the magnetic equator. Jupiterward of the Io plasma torus, a cold, corotating plasma was observed and the energylcharge spectra show well-resolved, heavy-ion peaks at mass-to-charge ratios A/Z* = 8, 16, 32, and 64.

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Knowledge of the positional distributions, absolute intensities, energy spectra, and angular distributions of energetic electrons and protons in the Jovian magnetosphere has been considerably advanced by the planetary flyby of Pioneer 11 in November-December 1974 along a quite different trajectory from that of Pioneer 10 a year earlier. (i) The previously reported magnetodisc is shown to be blunted and much more extended in latitude on the sunward side than on the dawn side. (ii) Rigid corotation of the population of protons E(p) approximately 1 million electron volts in the magnetodisc is confirmed. (iii) Angular distributions of energetic electrons E(e) > 21 million electron volts in the inner magnetosphere are shown to be compatible with the Kennel-Petschek whistler-mode instability. (iv) A diverse body of magnetospheric effects by the Jovian satellites is found. (v) Observations of energetic electrons in to a radial distance of 1.59 Jovian radii provide a fresh basis for the interpretation of decimetric radio noise emission.