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OBJECTIVES: To evaluate the quality of culture follow-up after emergency department (ED) discharge in patients with urinary tract infections (UTIs). METHODS: This convergent mixed methods study included an observational cohort study and a qualitative interview study in UTI patients discharged from the ED of a Dutch university hospital. The primary outcomes of the observational study were the proportion of patients requiring adjustment of antibiotic therapy after culture review, and the proportion of patients in whom these adjustments were made. Logistic regression identified factors associated with these outcomes. Interviews assessed patient experiences and transcripts were analysed using inductive thematic content analysis. Integration of the results informed recommendations for high-quality follow-up. RESULTS: Out of 455 patients, 285 (63%) required culture-based treatment adjustments. In most patients, no adjustments were made (239/285, 84%). De-escalation was most frequently omitted (98%), followed by discontinuation of antibiotics (92%). A mean of 7.1 (SD  3.8) antibiotic days per patient could have been avoided in 103 patients. Patients with diabetes were less likely to require adjustments (aOR   0.50, 95%-CI  0.29-0.85). Patients with moderate or severe renal impairment (aOR  4.1, 95%-CI  1.45-11.33; aOR  4.2, 95%-CI   1.50-11.94) or recurrent UTIs (aOR  5.0, 95%-CI  2.27-11.18) were more likely to have received necessary adjustments. Twelve interviews also revealed varying degrees of follow-up. Three themes were identified: 'information and communication', 'coordination and accessibility of care' and 'individual needs and preferences'. Recommendations for high-quality follow-up advocate a person centred approach. CONCLUSIONS: This study highlights the importance of urine culture follow-up after ED discharge, mainly to reduce unnecessary antibiotic treatment, promote de-escalation and improve patient experience.

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BACKGROUND: Seed size and number are important plant traits from an ecological and horticultural/agronomic perspective. However, in small-seeded species such as Arabidopsis thaliana, research on seed size and number is limited by the absence of suitable high throughput phenotyping methods. RESULTS: We report on the development of a high throughput method for counting seeds and measuring individual seed sizes. The method uses a large-particle flow cytometer to count individual seeds and sort them according to size, allowing an average of 12,000 seeds/hour to be processed. To achieve this high throughput, post harvested seeds are first separated from remaining plant material (dust and chaff) using a rapid sedimentation-based method. Then, classification algorithms are used to refine the separation process in silico. Accurate identification of all seeds in the samples was achieved, with relative errors below 2%. CONCLUSION: The tests performed reveal that there is no single classification algorithm that performs best for all samples, so the recommended strategy is to train and use multiple algorithms and use the median predictions of seed size and number across all algorithms. To facilitate the use of this method, an R package (SeedSorter) that implements the methodology has been developed and made freely available. The method was validated with seed samples from several natural accessions of Arabidopsis thaliana, but our analysis pipeline is applicable to any species with seed sizes smaller than 1.5 mm.

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Background: Women at high risk to develop ovarian cancer opt for risk-reducing salpingo-oophorectomy (RRSO) to reduce the risk by 80-96%. RRSO leads to a direct onset of menopause in premenopausal women. Hormone replacement therapy (HRT) can be used to mitigate menopausal symptoms after RRSO. However, it is unclear whether HRT in these women is safe in terms of breast cancer (BC) risk. Methods: We performed a literature search and investigated national guidelines on the use of HRT following RRSO in BRCA1 and BRCA2 mutation carriers. We analyzed differences and similarities between the guidelines and describe what these guidelines were based upon. Results: Seven articles regarding HRT following RRSO in BRCA1 and BRCA2 mutation carriers were identified. None of the included studies yielded any evidence that short-term use of HRT following RRSO increases the risk of developing BC or negates the protective effect of RRSO in BRCA1/2 mutation carriers without a personal history of BC. Eleven national guidelines were found and described. Conclusion: Short-term use of HRT after RRSO seems to be safe. The literature is more favorable toward estrogen alone. The ideal dosage and duration of use are unknown and remain to be investigated in future studies.

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BACKGROUND: Pancreatic mucinous cystic neoplasms (MCNs) are rare mucin-producing cystic tumours defined by the presence of ovarian-type stroma. MCNs have a malignant potential and thus surgery is frequently performed. The aim of this cohort study was to define better the criteria for surgical resection in patients with MCN. METHODS: This multicentre retrospective study included all resected MCNs between 2003 and 2015 in participating centres. Lesions without ovarian-type stroma were excluded. Patient characteristics, preoperative findings, histopathology findings and follow-up data were recorded. RESULTS: The study included 211 patients; their median age was 53 (range 18-82) years, and 202 (95·7 per cent) were women. Median preoperative tumour size was 55 (range 12-230) mm. Thirty-four of the 211 (16·1 per cent) were malignant, and high-grade dysplasia (HGD) was found in a further 13 (6·2 per cent). One-third of MCNs in men were associated with invasive cancer, compared with 15·3 per cent in women. Five cases of malignant transformation occurred in MCNs smaller than 4 cm. All cases of malignancy or HGD were associated with symptoms or features of concern on preoperative cross-sectional imaging. In multivariable analysis, raised carbohydrate antigen 19-9 (odds ratio (OR) 10·54, 95 per cent c.i. 2·85 to 218·23; P < 0·001), tumour size (OR 4·23, 3·02 to 11·03; P = 0·001), mural nodules (OR 3·55, 1·31 to 20·55; P = 0·002) and weight loss (OR 3·40, 2·34 to 12·34; P = 0·034) were independent factors predictive of malignant transformation. CONCLUSIONS: Small indeterminate MCNs with no symptoms or features of concern may safely be observed as they have a low risk of malignant transformation.

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• The exploitation of natural variation in Arabidopsis thaliana (Arabidopsis) provides a huge potential for the identification of the molecular mechanisms underlying this variation as a result of the availability of a vast array of genetic and genomic resources for this species. Eighty-six Arabidopsis accessions were screened for natural variation in flooding tolerance. This forms the first step towards the identification and characterization of the role of candidate genes contributing to flooding tolerance. • Arabidopsis accessions at the 10-leaf stage were subjected to complete submergence in the dark. Survival curves were plotted to estimate median lethal times as a measure of tolerance. Flooding-associated survival parameters, such as root and shoot oxygen content, initial carbohydrate content and petiole elongation under water, were also measured. • There was a significant variation in submergence tolerance among Arabidopsis accessions. However, the order of tolerance did not correlate with root and shoot oxygen content or initial amounts of shoot starch and total soluble sugars. A negative correlation was observed between submergence tolerance and underwater petiole elongation. • Arabidopsis accessions show considerable variation in the ability to tolerate complete submergence, making it a good species in which to identify and characterize genes and to study mechanisms that contribute to survival under water.

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After more than 10 years registration, 93% of ENT specialists in The Netherlands fulfil the requirements for continuing medical education in spite of the fact that sanctions (no re-registration) have not been implemented to date. Improvements have been made over the years. Information about how to set up a comparable system was supplied to 10 other scientific societies. A recurrent point for discussion is whether or not to award points for presentations, papers and (co)publications. On the one hand, it seems reasonable to reward the effort but, on the other hand, it creates practical problems. As a matter of fact, all members who give papers and write articles appear to attend more than enough postgraduate education. The process of accurate registration of continuing medical education, including accreditation and certification, is time-consuming. Moreover, it requires intensive and essential supervision by an experienced colleague who has a thorough knowledge of the specialist field.

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PURPOSE: The purpose of this study was to gather additional evidence for the validity and reliability of spoken English proficiency ratings provided by trained standardized patients (SPs) in high-stakes clinical skills examination. METHOD: Over 2500 candidates who took the Educational Commission for Foreign Medical Graduates' (ECFMG) Clinical Skills Assessment (CSA) were studied. The CSA consists of 10 or 11 timed clinical encounters. Standardized patients evaluate spoken English proficiency and interpersonal skills in every encounter. Generalizability theory was used to estimate the consistency of spoken English ratings. Validity coefficients were calculated by correlating summary English ratings with CSA scores and other external criterion measures. Mean spoken English ratings were also compared by various candidate background variables. RESULTS: The reliability of the spoken English ratings, based on 10 independent evaluations, was high. The magnitudes of the associated variance components indicated that the evaluation of a candidate's spoken English proficiency is unlikely to be affected by the choice of cases or SPs used in a given assessment. Proficiency in spoken English was related to native language (English versus other) and scores from the Test of English as a Foreign Language (TOEFL). DISCUSSION: The pattern of the relationships, both within assessment components and with external criterion measures, suggests that valid measures of spoken English proficiency are obtained. This result, combined with the high reproducibility of the ratings over encounters and SPs, supports the use of trained SPs to measure spoken English skills in a simulated medical environment.

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In four patients with hoarseness, men aged 53 and 67 years, and women aged 8 and 37 years, indirect laryngoscopy revealed, respectively, a squamous cell carcinoma of the vocal cord, recurrent nerve paralysis due to pulmonary carcinoma, irritative noduli due to forced use of the voice, and psychic stress as the cause. In a patient with existing hoarseness over a period of 3 to 6 weeks, the vocal cords will have to be examined with indirect laryngoscopy. Where the general practitioner is not equipped to handle this procedure, he can make a referral to an ear, nose and throat specialist. It would, however, be to the benefit of the patient and the general practitioner if the latter were to master the technique of indirect laryngoscopy. This would enable the patient to be treated without further delay, and it might also make selective referral possible.

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The untranslated regions of mRNAs encoding heat-shock proteins have been reported to contain elements important to the post-transcriptional regulation of these key components of the stress response. In this report we describe an element from the 5'UTR of human Hsp70 mRNA that increases the efficiency of mRNA translation. Cloning of this region upstream of the coding sequence of two different reporter genes (firefly luciferase and chloramphenicol acetyltransferase) increases expression of the reporter under normal cell culture conditions by up to an order of magnitude. This effect was observed in three different promoter contexts (HSP, SV40 and CMV) and in six cell lines. The increase in protein production is not accompanied by any alteration in mRNA levels, suggesting that the element facilitates translation. 5' or 3' truncated sequences are ineffective in enhancing reporter expression, suggesting that the activity arises from the secondary structure of the element, rather than from some smaller defined motif. Computer analysis of this region revealed that it is able to form stable secondary structures (DeltaG approximately -292.6 kJ x mol(-1)). The Hsp70 element does not seem to act as an internal ribosome entry site. Incorporation of the sequence into plasmids used for DNA vaccination produces increased antibody responses, confirming that the sequence is functional in primary cells. These data suggest that the 5'UTR of human Hsp70 mRNA plays an important role in determining Hsp70 expression levels, and that it contains an element of general utility in enhancing recombinant protein expression systems.

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The results of 819 tympanic membrane reconstructions performed by the author between 1974 and 1987 were reviewed. The mean follow up period was 5.6 years (range 2 to 10 years). An attempt was made to answer the question whether it is justified to set an age limit for performance of eardrum reconstructions in children. Of the 819 reconstructions 304 were done between the age of 4 and 16. The review shows that if a strict preoperative procedure is followed, there is no significant difference in closure rate between children (91%) and adults (90%). The grafting material did not influence the closure rate.

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The retinal vessel filling time of 10 patients with early nonproliferative diabetic retinography was measured by fluorescein angiography. Initially, the reproducibility of the authors' standardized fluorescein angiography was assessed by control angiograms on two different dates in each patient. Thereafter, prolonged use (six months) of isoxsuprine sustained release (80 mg/day) led to a nearly 50% reduction of the arterial filling time and a nearly 25% reduction of the arteriovenous filling time, whereas no changes were seen in control patients. This effect of isoxsuprine might be explained by an increase of red cell deformability and, concomitantly, a decrease of platelet adherence in the microcirculation of patients with diabetic mellitus.

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The nasolabial cyst is described in three patients and literature is shortly reviewed. The condition manifests itself by a smooth, fluctuating swelling in the nasolabial fold next to the ala of the nose. This clinical manifestation represents the most important criterion for diagnosis. Histopathology and cytologic findings are of minor importance for diagnostic purposes. Etiology is still uncertain. According to the most accepted theory the lesion has to be classified among the fissural cysts, but histopathologic findings may vary and do not give support to any of the theories of etiology. Computertomography is better than conventional roentgenography to demonstrate the extension of the lesion into surrounding structures. Echography can give important preoperative information. Nomenclature related to this cystic lesion is not uniform. Nasolabial cyst is the most adequate term, as it is describing the lesion only topographically and is not referring to controversial etiologic theories or to variable histopathology. Therapy consists of surgical removal using an intraoral approach and prognosis is excellent.

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