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Mentored undergraduate research experiences (UREs) can play a critical role in developing science identity and skills, especially for students from historically underrepresented backgrounds. This study investigates science identity and responsibility for scientific roles among scholars in a program aiming to diversify the biomedical workforce. Scholars were placed in UREs at either their home institution (a minority-serving institution [MSI]) or at a research-intensive medical institution with a Clinical and Translational Science Award (CTSA).
Methods:
We analyze data from surveys administered annually to the scholars. We first compare changes in science identity for scholars placed at the MSI and the CTSA site from the term after the scholar started their URE to one year later. We then analyze differences in responsibility in scientific roles performed by scholars at the two institutions.
Results:
We found evidence of gains in science identity after a year for scholars placed at both institutions but of a somewhat larger magnitude at the CTSA site. However, no significant differences were observed across institutions on science identity at the endpoint. An exploration of scientific roles suggests that scholars at the CTSA site assumed more responsibility in roles related to data curation and analysis, while scholars at the MSI had higher responsibility for resource acquisition-related roles.
Conclusion:
These results suggest that CTSA site URE placements may offer distinct opportunities for both identity formation and skill development beyond placements at home institutions. Overall, these results suggest opportunities for partnerships between MSIs and CTSA sites in the training of biomedical researchers.
Economic variables such as socioeconomic status and debt are linked with an increased risk of a range of mental health problems and appear to increase the risk of developing of post-traumatic stress disorder (PTSD). Previous research has shown that people living in more deprived areas have more severe symptoms of depression and anxiety after treatment in England’s NHS Talking Therapies services. However, no research has examined if there is a relationship between neighbourhood deprivation and outcomes for PTSD specifically. This study was an audit of existing data from a single NHS Talking Therapies service. The postcodes of 138 service users who had received psychological therapy for PTSD were used to link data from the English Indices of Deprivation. This was analysed with the PCL-5 measure of PTSD symptoms pre- and post-treatment. There was no significant association between neighbourhood deprivation measures on risk of drop-out from therapy for PTSD, number of sessions received or PTSD symptom severity at the start of treatment. However, post-treatment PCL-5 scores were significantly more severe for those living in highly deprived neighbourhoods, with lower estimated income and greater health and disability. There was also a non-significant trend for the same pattern based on employment and crime rates. There was no impact of access to housing and services or living environment. Those living in more deprived neighbourhoods experienced less of a reduction in PTSD symptoms after treatment from NHS Talking Therapies services. Given the small sample size in a single city, this finding needs to be replicated with a larger sample.
Key learning aims
(1) Previous literature has shown that socioeconomic deprivation increases the risk of a range of mental health problems.
(2) Existing research suggests that economic variables such as income and employment are associated with greater incidence of PTSD.
(3) In the current study, those living in more deprived areas experienced less of a reduction in PTSD symptoms following psychological therapy through NHS Talking Therapies.
(4) The relatively poorer treatment outcomes in the current study are not explained by differences in baseline PTSD severity or drop-out rates, which were not significantly different comparing patients from different socioeconomic strata.
Lipid levels in paediatric patients with anomalous aortic origin of a coronary artery (AAOCA) have not previously been explored. Patients with CHD have an increased risk of atherosclerotic cardiovascular disease later in life compared to the general population. We aim to characterise the lipid profiles in paediatric patients with AAOCA and explore its relation to diagnosis, race/ethnicity, and exercise.
Methods:
Single institution retrospective cohort of 180 AAOCA paediatric patients (median age 13.7 years interquartile range 9.7–15.6, 66% male). Total cholesterol, HDL, LDL, triglycerides, total cholesterol to HDL ratio, and non-HDL cholesterol were evaluated across race/ethnicity, sex, type of AAOCA, documented ischaemia on imaging, exercise level, and surgery status. Normality of the data distribution for each lipid parameter was evaluated using Kolmogorov–Smirnov testing. Accordingly, Mann–Whitney U and t-tests were used to compare variables. The proportion of abnormal lipid levels by sex and race/ethnicity was calculated.
Results:
Total cholesterol was elevated in 29%, (51/177) of patients, HDL 37% (64/174), triglycerides 44% (72/165), LDL 16% (28/170), total cholesterol-HDL ratio 29%, (48/163), and non-HDL cholesterol 28% (47/165). Across subgroups categorised on the basis of surgery status, exercise level, AAOCA type, and sex, the mean and median levels for individual lipid parameters were normal. By race/ethnicity, Hispanic patients had significantly higher triglyceride (median 99, interquartile range 71–136.5, p = <0.001) and total cholesterol to HDL ratios (median 3.2, interquartile range 2.7–4.5, p = 0.014) versus non-Hispanic White and Black patients. Two-thirds of patients exercise recreationally.
Conclusion:
Hispanic patients have significantly elevated triglycerides and total cholesterol to HDL ratios compared to others. Longitudinal follow-up evaluating differences in long-term lipid status in patients with AAOCA and risk for cardiovascular events is warranted.
While it is commonly understood that the poll tax and literacy tests, among other measures, were used effectively in the South to disenfranchise Black voters from the late nineteenth through the mid-twentieth century, what is not well known is how much those disenfranchising laws mattered. Specifically, how much did the enactment of poll taxes or literacy tests affect turnout in federal and state elections? And how much did those disenfranchising provisions dampen vote totals for Republican candidates in the South? Using the staggered implementation and removal of several disenfranchising policies over a 101-year period, we answer these questions and provide some precision to our collective knowledge of the “disenfranchising era” in American electoral politics. Overall, we find that the poll tax was the main driver of disenfranchisement in Southern elections, with literacy tests and the Australian ballot providing some secondary effects. We also find that ex-felon disenfranchisement laws were considerably more important—both in reducing turnout as well as Republican vote share in Southern elections—than has been traditionally understood. Finally, we unpack the “South” and unsurprisingly find that racial politics drove these results: the disenfranchising institutions were more impactful in states with a larger Black population share. Our results show the powerful effects of disenfranchising policies on electorates and electoral outcomes. We discuss these results in both their historical context as well as with a mind to the continuing use of disenfranchising provisions in law today.
Dresden, the capital city of the Kingdom of Saxony since 1806, was intimately connected with Wagner’s childhood and his early professional life as Royal court Kapellmeister from 1843 to 1849. The locale is thus both a key site of early life impressions and the site of the composer’s most critical period of creative development, from the premiere of Der fliegende Holländer up to the first conceptual stages of Der Ring des Nibelungen tetralogy. The shared post of Hofkapellmeister involved continual negotiations between a musical-theatrical ancien régime and Wagner’s developing vision of a radical new aesthetic-social order manifested in his own operas, writings and utopian ideals. Wagner’s programming of Beethoven’s Ninth Symphony at key junctures during the later period of his Kapellmeistership and the burning of the ‘old’ (Pöppelmann) court theatre during the May 1849 insurrection are read as symbolic of a key transition in Wagner’s life and artistic career.
Depression is highly prevalent in persons with multiple sclerosis (pwMS). A reformulated version of the learned helplessness theory posits that individuals who attribute the cause of negative events to personal factors (internal), perceive that the cause persists for a long period of time (stable), and believe it is present in all situations (global) are at an increased risk for depression. As such, it is critical to examine possible modifiable factors that buffer against the deleterious effects of negative attributional style. Therefore, the current study investigated whether stress moderates the relationship between negative attributional style and depression symptoms in an MS sample.
Participants and Methods:
Thirty-six pwMS (30 Female, 6 Male) completed a comprehensive neuropsychological test battery and psychosocial questionnaires that assessed cognitive attributional style, daily stressors, and depression symptoms. The Attributional Style Questionnaire (ASQ) was used to create internal, stable, and global attribution dimension scores, as well as an overall attributional style score combining the three dimensions. Stress was quantified as the total score of perceived hassles from the Hassles and Uplifts Scale (HUS). Depression symptoms were measured using the Beck Depression Inventory-Fast Screen (BDI-FS). Hierarchical linear regressions were conducted with depression symptoms as the outcome variable. Each dimension of attributional style (internal, stable, global, or overall ASQ), stress, and their interactions were included as predictors. Simple effects tests were used to clarify the pattern of any significant interaction.
Results:
Regression analyses revealed that the interaction between overall attributional style and stress was significant (p = .025). Simple effects tests revealed that overall attributional style was associated with depression symptoms only in pwMS with high levels of stress (p = .015). For the individual dimensions of the ASQ, several interactions were also significant. The interaction between the internal dimension and stress was significant (p= .009), such that internal attributions were associated with depression symptoms only in pwMS with high levels of stress (p = .002). The interaction between the stable dimension and stress was also significant (p = .01); stable attributional style was associated with depression symptoms only in pwMS with high levels of stress (p = .009). The interaction between the global dimension and stress was not significant.
Conclusions:
Stress moderated the relationship between negative attributional style and depression symptoms in pwMS. Specifically, the internal and stable dimensions and overall attributional style were associated with increased depression symptoms only in pwMS who reported high levels of stress, but not in those with low levels of stress. Interventions aimed at reducing and managing stress may help protect against the effects of negative cognitive schemas on depression symptoms in MS. Additionally, previous research demonstrates that attributional style may be a malleable target of evidence-based psychotherapy (Seligman et al., 1988; Proudfoot et al., 2009). Our findings suggest that cognitive therapy specifically targeting the internal and stable dimensions of attributional style may be effective in modifying attributional style, perceptions of stress and, subsequently, improve depression outcomes in MS.
The interaction of relativistically intense lasers with opaque targets represents a highly non-linear, multi-dimensional parameter space. This limits the utility of sequential 1D scanning of experimental parameters for the optimization of secondary radiation, although to-date this has been the accepted methodology due to low data acquisition rates. High repetition-rate (HRR) lasers augmented by machine learning present a valuable opportunity for efficient source optimization. Here, an automated, HRR-compatible system produced high-fidelity parameter scans, revealing the influence of laser intensity on target pre-heating and proton generation. A closed-loop Bayesian optimization of maximum proton energy, through control of the laser wavefront and target position, produced proton beams with equivalent maximum energy to manually optimized laser pulses but using only 60% of the laser energy. This demonstration of automated optimization of laser-driven proton beams is a crucial step towards deeper physical insight and the construction of future radiation sources.
Many recorded roll calls in Congress each year are votes on bills that have no chance of becoming law, or are purely symbolic, or are procedural without policy content. Yet models of voting and measurement models of member preferences make assumptions that vote choices are largely about utility derived from policies. We consider the possibility that votes plausibly connected to policy and votes not plausibly connected to policy may have different data-generating processes and rely on different utility functions. Substantively, similarity across different contexts for policy change implies an importance of messaging over policy. Methodologically, similarity across these contexts is necessary to avoid biasing estimates of member preferences. We find that members’ voting patterns are highly stable across contexts in which policy change is credible and not credible. This indicates that existing measures of ideal points are likely not dramatically biased by the inclusion of policy-irrelevant votes.
South Africa has embarked on major health policy reform to deliver universal health coverage through the establishment of National Health Insurance (NHI). The aim is to improve access, remove financial barriers to care, and enhance care quality. Health technology assessment (HTA) is explicitly identified in the proposed NHI legislation and will have a prominent role in informing decisions about adoption and access to health interventions and technologies. The specific arrangements and approach to HTA in support of this legislation are yet to be determined. Although there is currently no formal national HTA institution in South Africa, there are several processes in both the public and private healthcare sectors that use elements of HTA to varying extents to inform access and resource allocation decisions. Institutions performing HTAs or related activities in South Africa include the National and Provincial Departments of Health, National Treasury, National Health Laboratory Service, Council for Medical Schemes, medical scheme administrators, managed care organizations, academic or research institutions, clinical societies and associations, pharmaceutical and devices companies, private consultancies, and private sector hospital groups. Existing fragmented HTA processes should coordinate and conform to a standardized, fit-for-purpose process and structure that can usefully inform priority setting under NHI and for other decision makers. This transformation will require comprehensive and inclusive planning with dedicated funding and regulation, and provision of strong oversight mechanisms and leadership.
HIV-associated neurocognitive disorders (HANDs) are prevalent in older people living with HIV (PLWH) worldwide. HAND prevalence and incidence studies of the newly emergent population of combination antiretroviral therapy (cART)-treated older PLWH in sub-Saharan Africa are currently lacking. We aimed to estimate HAND prevalence and incidence using robust measures in stable, cART-treated older adults under long-term follow-up in Tanzania and report cognitive comorbidities.
Design:
Longitudinal study
Participants:
A systematic sample of consenting HIV-positive adults aged ≥50 years attending routine clinical care at an HIV Care and Treatment Centre during March–May 2016 and followed up March–May 2017.
Measurements:
HAND by consensus panel Frascati criteria based on detailed locally normed low-literacy neuropsychological battery, structured neuropsychiatric clinical assessment, and collateral history. Demographic and etiological factors by self-report and clinical records.
Results:
In this cohort (n = 253, 72.3% female, median age 57), HAND prevalence was 47.0% (95% CI 40.9–53.2, n = 119) despite well-managed HIV disease (Mn CD4 516 (98-1719), 95.5% on cART). Of these, 64 (25.3%) were asymptomatic neurocognitive impairment, 46 (18.2%) mild neurocognitive disorder, and 9 (3.6%) HIV-associated dementia. One-year incidence was high (37.2%, 95% CI 25.9 to 51.8), but some reversibility (17.6%, 95% CI 10.0–28.6 n = 16) was observed.
Conclusions:
HAND appear highly prevalent in older PLWH in this setting, where demographic profile differs markedly to high-income cohorts, and comorbidities are frequent. Incidence and reversibility also appear high. Future studies should focus on etiologies and potentially reversible factors in this setting.
Beryl from Xuebaoding, Sichuan Province, western China is known for its unusual tabular habit and W–Sn–Be paragenesis in a greisen-type deposit. The crystals are typically colourless transparent to pale blue, often with screw dislocations of hexagonal symmetry on the (0001) crystal faces. Combining electron microprobe analyses and laser ablation inductively coupled plasma mass spectrometry with single-crystal X-ray diffraction (XRD), correlated with Raman and micro-infrared (IR) spectroscopy and imaging, the crystal chemical characteristics are determined. The contents of Na+ (0.24–0.38 atoms per formula unit (apfu)) and Li+ up to 0.38 apfu are at the high end compared to beryl from other localities worldwide. Li+ substitution for Be2+ on the tetrahedral (T2) site is predominantly charge balanced by Na+ on the smaller channel (C2) site, with Na+ ranging from 91.5% to 99.7% (apfu) of the sum of all other alkali elements. Cs+ and minor Rb+ and K+ primarily charge balance the minor M2+ substitution for Al3+ at the A site; all iron at the A site is suggested to be trivalent. The a axis ranges from 9.2161(2) to 9.2171(4) Å, with unit-cell volume from 678.03(3) to 678.48(7) Å3. The c/a ratio of 1.0002–1.0005 is characteristic for T2-type beryl with unit-cell parameters controlled primarily by Be2+ substitution. Transmission micro-IR vibrational spectroscopy and imaging identifies coordination of one or two water molecules to Na+ (type IIs and type IId, respectively) as well as alkali free water (type I). Based on IR absorption cross section and XRD a C1 site water content of 0.4–0.5 apfu is derived, i.e. close to 50% site occupancy. Secondary crystal phases with a decrease in Fe and Mg, yet increase in Na, suggest early crystallisation of aquamarine, with goshenite being late. With similar crystal chemistry to beryl of columnar habit from other localities worldwide, the tabular habit of Xuebaoding beryl seems to be unrelated to chemical composition and alkali content.
Motivational factors are generally regarded as an important ingredient for change in therapy. However, there is currently a lack of available instruments that can measure clients’ readiness for change in therapy.
Aim:
The objective of this paper was to create an instrument, the Readiness for Therapy Questionnaire (RTQ), which could measure clients’ readiness for change.
Method:
The RTQ was created by researchers following analysis of themes drawn from a review of the literature and interviews with patients at the end of therapy. This included both people who completed therapy and those who dropped out. As part of the standard assessment process, the RTQ was administered to 349 participants (69.6% female and 30.4% male; mean age 37.1 years; 90.5% Caucasian) who were patients at a psychological therapy service for common mental health difficulties.
Result:
An initial 12-item scale was reduced to 6 items. This scale significantly correlated with post-therapy PHQ-9 and GAD-7 scores and changes in these scores across therapy. After controlling for baseline scores and demographic variables, a logistic regression showed that scores on this 6-item measure pre-therapy significantly predicted three outcome variables: completing therapy, being recovered on both PHQ-9 and GAD-7 post-therapy, and having a reliable change in both the PHQ-9 and GAD-7 post-therapy. However, receiver operating characteristic (ROC) curve analysis showed the measure had poor sensitivity and specificity. Symptom severity did not have a significant impact on motivation to change.
Conclusion:
The RTQ is potentially a valid measure with useful clinical applications in treatment of common mental health difficulties.
Agronomic crops engineered with resistance to 2,4-D or dicamba have been commercialized and widely adopted throughout the United States. Because of this, increased use of these herbicides in time and space has increased damage to sensitive crops. From 2014 to 2016, cucumber and cantaloupe studies were conducted in Tifton, GA, to demonstrate how auxinic herbicides (namely, 2,4-D or dicamba), herbicide rate (1/75 or 1/250 field use), and application timing (26, 16, and 7 d before harvest [DBH] of cucumber; 54, 31, and 18 DBH of cantaloupe) influenced crop injury, growth, yield, and herbicide residue accumulation in marketable fruit. Greater visual injury, reductions in vine growth, and yield loss were observed at higher rates when herbicides were applied during early-season vegetative growth compared with late-season with fruit development. Dicamba was more injurious in cucumber, whereas cantaloupe responded similarly to both herbicides. For cucumber, total fruit number and relative weights were reduced (16% to 19%) when either herbicide was applied at the 1/75 rate 26 DBH. Cantaloupe fruit weight was also reduced 21% and 10% when either herbicide was applied at the 1/75 rate 54 or 31 DBH, respectively. Residue analysis noted applications made closer to harvest were more likely to be detectable in fruit than earlier applications. In cucumber, dicamba was detected at both rates when applied 7 DBH, whereas in cantaloupe, it was detected at both rates when applied 18 or 31 DBH in 2016 and at the 1/75 rate applied 18 or 31 DBH in 2014. Detectable amounts of 2,4-D were not observed in cucumber but were detected in cantaloupe when applied at either rate 18 or 31 DBH. Although early-season injury will more likely reduce cucumber or cantaloupe yields, the quantity of herbicide residue detected will be most influenced by the time interval between the off-target incident and sampling.
The representation of nature is central to Wagner’s Ring cycle on a number of levels. The Nordic-mythic sources and setting, the role of original or partially re-invented nature deities (Erda, Donner, and Froh, and the three Rhinemaidens) or semi-divine beings linked to the natural world (Valkyries, Norns) inspired a range of sophisticated Romantic musical nature “painting” throughout the score, including some of the best-known passages. Classical-Romantic traditions of pastoral or other imitative nature topics in music of the Classical and Romantic eras play an important role in the development of the network of leitmotifs in the Ring cycle. Readings of the Ring as an allegorical critique of modern industrial capitalism connect the traditional mythography of a lost golden age with a potential parable of environmental degradation driven by the loveless, reckless profit motive of modern capitalism. Alberich’s forging of the Ring from the Rhinegold and Wotan’s violation of the World Ash Tree to create the symbol of his divine legal authority (his spear) project parallel symbols of the transgression of a natural order. Mythographic vs. modern environmental readings of the apocalyptic conclusion of the cycle are also discussed.
This chapter by Thomas Grey presents a focused yet far-reaching account of the significance of dance to Richard Wagner. First, it explores how Wagner theorized the roles of dance, music and text in his ‘total artwork’; then it considers historical practice – examples of the actual dances (and also what the author calls the ‘sublimated choreography’) in several Wagnerian music dramas, especially Tannhäuser, with its infamous Venusberg ‘Bacchanal’. Wagner’s feelings towards dance were double-edged. On the one hand, the composer acknowledged the importance of movement and gesture in the creation of his ideal artwork. Indeed, as Grey suggests, Wagner sought to play up the two, emphasizing the role of the erotic, sexualized body onstage. On the other hand, Wagner liked to ridicule contemporary ballet. But, to Wagner, ballet’s problematic status did not relate to its explicitly bodily and human aspects. Instead, it was the genre’s association with an institutional context – ballet as produced and consumed at the Paris Opéra – that troubled the composer.
Culturally safe health practitioners are essential for effective service provision to culturally diverse populations, including Indigenous Australians. Therefore, cultural safety education during training as a health care professional is an essential component in helping improve the health of Indigenous Australians. This study examined whether the implementation of an Indigenous cultural safety education workshop increased self-rated cultural safety knowledge and attitudes of allied health students. The study employed a quantitative before-and-after design using pre- and post-surveys to determine the level of attitudinal change in students who attended a day long workshop. The study sample consisted of 1st year (n = 347) and 4th year (n = 149) allied health students at a regional Australian university over the years 2007–2011. Whilst the results of this current study are varied in terms of achieving positive change across all of the taught items of knowledge and attitude, they provide some evidence around the value of this type of curriculum intervention in helping develop culturally safe practitioners. An important finding was around the student's becoming self-aware about their own values and cultural identity, combined with acknowledging the importance of this cultural identity to interactions with clients. This form of ‘cultural humility’ appears to be an important step to becoming a culturally safe practitioner. These types of interventions would be enhanced through embedding and scaffolding throughout the curricula.
Research on presidential power delineates between a modern era of relative autonomy and an earlier period of congressional dominance. What drove this change? Unlike prior arguments about presidential entrepreneurship and the rise of the United States as a global power, we attribute the emergence of the modern presidency partially to an institutional change—the adoption of direct election of senators that culminated in the 17th Amendment. With direct election, senators were selected by individual voters rather than state legislators. These senators answered to a new principal—the general public—that was (in the aggregate) less informed and less interested in foreign policy. As a result, senators had less incentive to constrain presidential foreign policy preferences. We find evidence for this shift in the relationship between the piecemeal adoption of direct election and senate votes to delegate foreign policy authority to the executive. The implication is that the direct election of senators played an underappreciated role in the emergence of the modern presidency.
Trend analyses based on dietary records suggest decreases in the intakes of total sugar (TS), added and free sugar since 2005 among children and adolescents in Germany. In terms of age trends, TS intake decreased with increasing age. However, self-reported sugar intake in epidemiological studies is criticised, as it may be prone to bias due to selective underreporting. Furthermore, adolescents are more susceptible to underreporting than children. We thus analysed time and age trends in urinary fructose excretion (FE), sucrose excretion (SE) and the sum of both (FE + SE) as biomarkers for sugar intake among 8·5–16·5-year-old adolescents. Urinary sugar excretion was measured by UPLC-MS/MS in 997 24-h urine samples collected from 239 boys and 253 girls participating in the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study cohort between 1990 and 2016. Time and age trends of log-transformed FE, SE and FE + SE were analysed using polynomial mixed-effects regression models. Between 1990 and 2016, FE as well as FE + SE decreased (linear time trend: P = 0·0272 and P < 0·0001, respectively). A minor increase in excretion during adolescence was confined to FE (linear age trend: P = 0·0017). The present 24-h excretion measurements support a previously reported dietary record-based decline in sugar intake since 2005. However, the previously seen dietary record-based decrease in TS from childhood to late adolescence was not confirmed by our biomarker analysis, suggesting a constant sugar intake for the period of adolescence.
Methionine, an essential sulphur-containing amino acid (SAA), plays an integral role in many metabolic processes. Evidence for the methionine requirements of adult dogs is limited, and we employed the indicator amino acid oxidation (IAAO) method to estimate dietary methionine requirements in Labrador retrievers (n 21). Using semi-purified diets, the mean requirement was 0·55 (95 % CI 0·41, 0·71) g/4184 kJ. In a subsequent parallel design study, three groups of adult Labrador retrievers (n 52) were fed semi-purified diets with 0·55 g/4184 kJ (test diet 1), 0·71 g/4184 kJ (test diet 2) or 1·37 g/4184 kJ (control diet) of methionine for 32 weeks to assess the long-term consequences of feeding. The total SAA content (2·68 g/4184 kJ) was maintained through dietary supplementation of cystine. Plasma methionine did not decrease in test group and increased significantly on test diet 1 in weeks 8 and 16 compared with control. Reducing dietary methionine did not have a significant effect on whole blood, plasma or urinary taurine or plasma N-terminal pro B-type natriuretic peptide. Significant effects in both test diets were observed for cholesterol, betaine and dimethylglycine. In conclusion, feeding methionine at the IAAO-estimated mean was sufficient to maintain plasma methionine over 32 weeks when total SAA was maintained. However, choline oxidation may have increased to support plasma methionine and have additional consequences for lipid metabolism. While the IAAO can be employed to assess essential amino acid requirements, such as methionine in the dog using semi-purified diets, further work is required to establish safe levels for commercial diet formats.