Tuesday 22 November 2011

a very premature baby who died after contracting ESBL E. coli at the city's Singleton Hospital.




Singleton Hospital, where a premature baby has died from suspected E.coli
Singleton Hospital, where a premature baby has died from suspected E.coli
A premature baby has died after contracting a form of E.coli while on the neonatal unit at Singleton Hospital, in Swansea.
Hope Erin Evans died aged just five days after being born "very premature" and contracting the the ESBL strain of E.coli.
Another baby has died and another three people are ill after an outbreak of the same antibiotic-resistant form of the infection.
Health officials were yesterday investigating the five cases which include baby Hope and a new mother in a maternity ward.
The second death happened "in the community" outside the hospital but health chiefs believe the cases were linked.
Doctors are investigating how the cross-infection happened between the two dead babies - the second child wasn't being named.
Admissions to the neonatal unit have now been restricted as a "precaution" to babies born at 36 weeks gestation or more.
Hope was born in the hospital on October 31 but was never taken home by her parents after contracting the illness.
An inquest has been opened. Her father Jonathan gave evidence that she died on November 4 in the hospital.
A hospital spokesman said: "ESBL E.coli is most often found in the gastrointestinal tract but may cause urinary tract infections.
"It is resistant to commonly used antibiotics such as penicillins, but can be treated."
Dr Bruce Ferguson, medical director of Abertawe Bro Morgannwg University Health Board, which runs Singleton Hospital, said: "ABM University Health Board, supported by Public Health Wales, is investigating two cases of ESBL E.coli cross infection in the maternity-neonatal unit at Singleton Hospital.
"Tests have confirmed that in one of these cases the ESBL E.coli infection was contracted in the hospital.
"Sadly, this was a very premature baby who, despite the best efforts of staff, later died. The cause of death of this baby is currently being investigated by the coroner.
"Everyone involved with the unit and in the care of this baby deeply regret this tragic loss."
The second case is understood to involve a mother who tested positive for ESBL E.coli but who has not shown any symptoms and has not required treatment.
It is thought the woman also contracted the infection while in hospital.
These two cases, which are being investigated, are linked to three other confirmed cases of ESBL E.coli where the infection was contracted outside hospital.
Another young baby who contracted the infection also died.
Dr Ferguson said: "These appear to be isolated incidents, which have been contained, and there is no evidence of the infection spreading further.
"Checks have been taken of patients, equipment and areas in the maternity-neonatal unit and no evidence of ESBL E.coli has been found.
"The unit has an excellent record for hand-hygiene and general infection control adherence. Reported infection levels in the unit have been below the national average in recent years.
"Nevertheless we have taken extra precautions. For example, the obstetric theatres have undergone a deep clean and cleaning has been increased in the neonatal and labour wards.
"As a precaution, we have temporarily restricted the neonatal unit to admissions for babies of 36-weeks and over gestation. This is under constant review and we anticipate lifting this restriction shortly.
"All routine full-term births are continuing at the Singleton maternity unit as normal.
"We would like to reassure expectant mothers due to give birth in Singleton Hospital that the maternity unit is open as usual for full-term births.
"However, any mothers-to-be who have concerns or questions should speak to their community midwife in the first place."
Extended-Spectrum Beta-Lactamases (ESBLs) are enzymes which can be produced by bacteria making them resistant to antibiotics widely-used in many hospitals.
A new class of ESBLs have emerged and been detected in E.coli bacteria. ESBL-producing E.coli are resistant to penicillin and cephalosporin antibiotics.
A helpline has been set up for women who are due to give birth at Singleton Hospital and are concerned. It can be contacted on 07747 615 627.


Read More http://www.walesonline.co.uk/news/wales-news/2011/11/22/two-babies-die-after-contracting-new-strain-of-e-coli-at-singleton-hospital-91466-29821677/#ixzz1eStLkH13

Two babies die, three other E. coli cases in Swansea


Singleton HospitalSingleton Hospital's maternity unit is still open for full-term births
Two babies have died after an E. coli infection, health officials in Swansea have confirmed.
One was a very premature baby who died after contracting ESBL E. coli at the city's Singleton Hospital.
The other baby died in the community but doctors say the cases were linked. How the cross-infection occurred is being investigated.
As a precaution the unit, which has undergone a deep clean, is only open for full-term births.
An inquest has been opened and adjourned into the death of one of the babies, Hope Erin Evans from Aberdare, south Wales, who was just five days old when she died at the hospital on 4 November.
'Tragic loss'
Three other non-fatal cases have been confirmed but Abertawe Bro Morgannwg (ABM) University Health Board said they appeared to be isolated incidents.
The board's medical director Dr Bruce Ferguson said: "Tests have confirmed that in one of these cases the ESBL E.coli infection was contracted in the hospital.

What is ESBL E. coli?

  • ESBL E. coli is not the same as the E.coli O157 which causes food poisoning
  • ESBL stands for Extended Spectrum Beta Lactamose
  • ESBL E. coli is most often found in the gastrointestinal tract but may cause urinary tract infections
  • ESBL E. coli is resistant to commonly-used antibiotics such as penicillin, but can be treated
  • In most people ESBL E. coli does not cause harm but in vulnerable individuals it can cause serious infections
  • Source: ABM health board
"Sadly, this was a very premature baby who, despite the best efforts of staff, later died.
"The cause of death of this baby is currently being investigated by the coroner. Everyone involved with the unit and in the care of this baby deeply regret this tragic loss."
The other baby contracted the infection outside the hospital.
Dr Ferguson reassured expectant mothers due to give birth in Singleton Hospital that the maternity unit is open as usual for full-term births.
As a precaution, the health board has temporarily restricted the neonatal unit to admissions for babies of 36 weeks gestation, or longer.
"These appear to be isolated incidents which have been contained, and there is no evidence of the infection spreading further," Dr Ferguson added.
"Checks have been taken of patients, equipment and areas in the maternity/neonatal unit and no evidence of ESBL E. coli has been found.
"Very saddened"
"The unit has an excellent record for hand-hygiene and general infection control adherence. Reported infection levels in the unit have been below the national average in recent years."

Analysis

The investigation into these cases will concentrate on the history of contact between all five people involved.
This means looking at any links they have in the community as well as what happened at Singleton Hospital.
It will be vital to establish whether any of the regular infection control measures used in neonatal units have been breached.
This was the suspicion in the last major outbreak of ESBL e.coli in 2008 at Luton and Dunstable Hospital.
An official report concluded that the bacteria there spread via the hands of staff or shared equipment, although no definitive evidence was found.
Managers in Swansea have already stressed their 'excellent record for hand-hygiene and general infection control'. They will need to be sure that every possible precaution was taken.
Microbiologist Prof Hugh Pennington told BBC Radio Wales ESBL E. coli caused problems for young babies because their immune systems were not well-developed.
"These bugs . . . are really quite good at getting about and once they get into something like a neonatal unit, history tells us with other related bugs they can be really quite difficult to eradicate.
"I'm sure that the people at Singleton are doing their utmost to make sure that there aren't any problems.
"They have restricted admission to the very young babies because they are the ones really at risk from this particular nasty bug. It's a very reasonable approach to take."
Health Minister Lesley Griffiths said she was "very saddened" to hear of the two deaths.
Conservative health spokesman Darren Millar AM expressed his condolences for the families involved, adding: "This is obviously an incredibly serious case and I urge the health minister to update us on the current situation and the next planned steps as soon as possible.
"While I recognise these infections appear to be isolated and contained, those using the hospital will expect regular reassurances from the Welsh government in the immediate future."
Anxious people
Welsh Liberal Democrat leader Kirsty Williams said the deaths were a "terrible tragedy".
"While the unit is temporarily closed for some patients, pregnant women in the area who are expected to deliver at the unit need to be reassured that there are alternatives set in place," she added.
"Guarantees are needed that other units that will have to take pre-term mothers have the resources to cope.

More on This Story

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personalised cancer treatment’ experimental project



Monday November 21 2011
The project will look at the DNA of both patients and tumours

A new initiative to develop ‘personalised cancer treatment’ has today been launched. The experimental project has been designed to develop a screening program to test tumours for key genetic changes. It is hoped that in the future the results of such tests would influence treatment programmes, helping doctors choose the best drug for each person.
The new initiative, called the Stratified Medicine Programme, is being led by Cancer Research UK, the UK Technology Strategy Board and the pharmaceutical companies AstraZeneca and Pfizer. It is hoped that the work will lay the foundations for genetic testing of both patients and tumours to become standard practice, allowing the use of specialised drugs that target specific genes and mutations that can cause or influence the development of cancer.
In addition to laying the foundations for a genetic testing service, the information collected during the programme may be useful for research into new treatments; for example, by identifying new targets and by seeing how genetics affect people’s responses to various cancer drugs. Although people taking part in the early stages of this programme are unlikely to directly benefit, in time it is hoped that in the long-term patients will be provided with individually tailored treatments that ultimately prove more effective.

What is the project looking at?

The project will initially look at mutations in breast, bowel, lung, prostate as well as ovarian cancer and melanoma. These cancers were chosen due to how common they are and because of the range of drugs available and in development that might potentially be used to treat them.
The project aims to collect samples from 9,000 patients treated at seven Experimental Cancer Medicine Centres around England, Wales and Scotland. This small-scale project will develop the best way of running a genetic testing service, which could then potentially be rolled out over the whole NHS.

How might this help fight cancer?

Although the process is still at an early exploratory phase, in the long term it is hoped that the programme will allow patients to be treated according to the specific genetic faults in their tumour.
As new drugs targeting cancers with specific mutations become available, they could be prescribed based on the genetic faults in the tumour and a person’s genetics, and potentially produce improved results. It might also reduce ineffective treatment, where the cancer does not respond.
Understanding how certain genes control cancer and determining how the disease evades treatment is another aim of cancer research. The genetic information collected will also provide a unique source of information to help guide future projects and drug development.
Cancer Research UK is currently involved in a number of other genetics-based research projects that might shed light on topics such as what makes certain people genetically susceptible to cancer, what genes and mutations cause cancer to progress aggressively once it does develop and how genetics govern the way some people respond to treatment.

How will the project work?

The first-phase of the project involves seven clinical centres and three genetic technology centres. Blood and tumour samples will be collected from patients treated at Experimental Cancer Medicine Centres to gather sources of both normal DNA and tumour DNA. The DNA sequences will then be examined to see if certain mutations are present in the tumour. The results will be linked to patient records, and anonymously placed in a central database to guide future research.
During this phase of the programme, the results will not influence treatment. However, they may show that a patient is eligible to participate in a clinical trial of one of the new targeted therapies, although this is likely to affect only a small number of patients.

Does the NHS presently examine genetics in cancer patients?

As some existing drugs are designed to treat cancers with certain mutations, genetic testing for single mutations is carried out in the treatment of some cancers. For example, the drug trastuzumab (Herceptin) is designed to treat breast cancers with high levels of the Her2 protein on the surface, which can be identified through genetic testing.
However, genetic testing of tumours to test for multiple genetic defects is not yet available on the NHS. At the moment there is no centralised way of testing samples, and therefore it is often done on a few samples at a time rather than on a large scale.
The aim of this programme is to develop a nationwide service, reducing variations and making results more comparable across the country.

Links to the headlines

Cancer DNA database could revolutionise treatmentThe Daily Telegraph, November 21 2011

Further reading

Cancer Research UK Science Blog: Our Stratified Medicine Programme – what is it and how will it work?. November 21 2011
Cancer Research UK: Stratified Medicine Programme

Sunday 20 November 2011

FAO and World Vision to join forces Partnership to boost global food security



FAO and World Vision to join forces

Partnership to boost global food security

Photo: ©FAO/Giulio Napolitano
Laurent Thomas (left) and Walter Middleton signing the FAO-WVI Agreement
15 November 2011Rome - FAO and World Vision International (WVI), one of the world’s largest non-governmental humanitarian organizations, are joining forces in promoting global food security under an agreement signed at FAO Headquarters today.

The Memorandum of Understanding, signed by Laurent Thomas, FAO Assistant Director-General, Technical Cooperation Department, and Walter Middleton, WVI Partnership Leader for Food Security and Livelihoods, lays out terms and conditions for joint actions and projects for the  promotion of food security over a three-year period. Areas of potential collaboration include agricultural development projects, land tenure management, food price volatility and gender and nutrition programmes.

"As we sign this agreement today, hunger continues to threaten the lives of millions of women, men and children in the Horn of Africa," said Thomas. "It is an acute reminder of the need for cooperation and long-term solutions. This agreement is about working together to implement those solutions."

Fostering improvements

The Memorandum of Understanding focuses on fostering improvements in early warning systems, preparedness in emergency responses, and gender and nutrition programmes - particularly field collaboration on nutrition issues.

"World Vision works in nearly 100 countries worldwide, and we have seen the devastating effects of malnutrition on children under the age of five, and their families, for more than 60 years," said Middleton. "It shapes their entire lives.

This partnership will improve end-to-end support for food-insecure communities; from global agricultural policy decisions through to field-level agricultural livelihood projects that are sustainable, effective and resilient."

New opportunities

Thomas said the agreement leveraged the strengths of the two organizations, presenting new opportunities for both.

"We believe there are tremendous opportunities for joint work on agriculture development projects targeting improvements in productivity, sustainability and resilience, as well as issues of land tenure, watershed management and other natural resource management," he declared.

"Ultimately this memorandum of understanding is about providing tangible improvements to the lives of children and communities hurt by hunger and malnutrition. The shared focus between the two organizations stands the partnership in good stead," Middleton added

NHS jobs 'under threat'


Nearly 50,000 NHS jobs 'under threat'


Doctors and nursesThe RCN believes nearly 50,000 posts are under threat in England

Related Stories

Nearly 50,000 jobs are under threat or have already gone in the health service in England, union figures suggest.
The Royal College of Nursing report warned in many cases front-line posts were being hit as the NHS was struggling to make savings.
The total represents 3.5% of the 1.4 million people employed by the NHS.
The union said that for some trusts the culls represented significant chunks of their workforces, but the government accused it of "scaremongering".
The RCN warned the cuts could end up harming patient care, while it also predicted the total would rise in the coming months as the figure was based on evidence from less than half the trusts in the country.
The remaining trusts either are not making cuts or have yet to have announced them, the college believes.
Cutbacks
The RCN has been closely monitoring job cuts since April 2010.
The posts it has identified have either being lost already or are due to be cut by March 2015.
Many of them do not involve redundancies as the NHS tends to cut posts by not replacing staff who leave or retire.
The total highlighted - 48,029 - is the equivalent of shutting four large hospital trusts.
It includes all types of staff from administrators and porters to doctors and nurses.
The union also carried out an in-depth look at 41 trusts where cuts were being made.
In total, nearly half of the posts under threat were clinical and the scale of the cutbacks represented nearly a tenth of the workforce on average.
In the worst cases over 20% of the workforce was due to be culled.
The RCN said the findings were proof that the savings the NHS has to make - £20bn over the next four years - could not simply be achieved through efficiencies.
Shadow health secretary Andy Burnham: "Nurses are being handed their P45s and patients are being told they have to wait longer"
Evidence was also uncovered of job cuts being made elsewhere in the UK.
Some of the trusts highlighted in the RCN's report have accused the union of using out of date figures, and said they have since downscaled the number of planned job cuts.
The RCN acknowledged the forecasted cuts did fluctuate regularly, but said overall the report was still an accurate picture of what was happening.
RCN chief executive Peter Carter said the scale of the cuts could have a "deep and potentially dangerous impact on patient care".
"Staffing levels should be based on rigorous clinical evidence and should not be arbitrarily lowered in a short-sighted effort to save money."
'Scaremongering'
David Stout, deputy chief executive of the NHS Confederation, which represents managers, questioned whether there would be a large drop in staff numbers overall, saying staff were more likely to be redeployed into other areas rather than losing their jobs.
But he added some would be affected.
"We all need to be honest with the public, patients and staff that we have no pain-free option.
"Managing the financial challenge, while undergoing a huge structural reorganisation, is going to be tough. There is no doubt that many staff will find this personally very difficult."
Health minister Simon Burns said it should be possible to make efficiency savings at the same time as improving patient care and accused the RCN of "typical trade union scaremongering".

WhiteHouse.gov


Official Army Response to Immediately halt the cruel and unnecessary use of monkeys in Army chemical casualty management training courses.

Army No Longer Using Monkeys as Part of Training at Aberdeen Proving Ground

By Col. Thomas Collins
Thank you for your participation in the We the People platform on WhiteHouse.gov
On September 20th, 2011, the Army stated that it would no longer use monkeys as part of life-saving training at Aberdeen Proving Ground. This change was long planned, and was made possible by improved technology, the development of alternative training methods, shifting chemical threat environments, and changes in the medical competencies required of first responders during a chemical incident.
Col. Thomas Collins is Deputy Chief of Army Public Affairs

Saturday 19 November 2011

wmh: Seasonal Affective Disorder

wmh: Seasonal Affective Disorder

Chefs take classes in making healthier curries


Chefs take classes in making healthier curries


The results so far have surprised even hardened curry lovers.
'It still tastes the same'
The Tale of India restaurant, in the Docklands, is similar to thousands of curry houses up and down the country.
For years customers like newsagent Kirit Patel have enjoyed its dishes which in the past were prepared in unhealthy oils, laced with lots of salt and high in calories.
Origins of Curry
  • The term 'curry' was invented by the English administrators of the East Indian Trading Co. Originally the term derives from a Tamil word, 'kaari', which means a spiced sauce.
  • Britain's first curry house The Hindostanee Coffee House opened in 1809 in London
  • Economic migrants helped spread curry dishes across South East Asia
  • There are over 9,500 Indian restaurants and take-aways in the UK serving over three million meals a week. They employ in excess of 70,000 people and have an annual turnover of £3.2 billion.
Sources: Encyclopaedia of Food and Culture, Guild of Bangladeshi Restaurateurs
"I have been coming here for about 10 years and I love it," he says.
But what he and other customers are unaware of is that what is now being served is not quite what they think it is.
That is because for the last few months the kitchen of The Tale of India and some other local restaurants have been preparing their dishes in a different way.
They no longer fry onions, garlic, chillies and ginger for the curry base in ghee (clarified butter). They now use rapeseed or other oils which are much lower in saturated fat.
They are also using less spice and ensuring they do not overcook their vegetables.
But it has all been done in such a way that the customers have not noticed.
"It still tastes the same as it was. Delicious," says Kirit Patel.
Zubeer Ahmed Laskar, head chef and owner of the Tale of India, is delighted with the results.
"The customers still love the food and I realised it hasn't effected my business because it is not more expensive.
"In fact it's very good for business because we are a healthy restaurant," he says.
Less damage
The man whose recipes are behind this health revolution is TV chef Cyrus Todiwala who runs the Café Spice Namaste restaurant in the City of London.
Tower Hamlets council and the NHS recruited him to teach other chefs the secrets of his healthy curries.

Start Quote

Some of us have lost our way”
Cyrus Todiwala,TV chef
"Indian food across the UK is perceived to be unhealthy, greasy, oily and not nutritious, whereas the contrary applies. Because Indian food revolves around medicine.
"The old Indian saying 'let food be the high medicine' is very much a part and parcel of Indian cooking.
"But some of us have lost our way," he says.
Tests carried out by Tower Hamlets council back up his claims.
They show an average 336g portion of lamb curry contains 561 calories. If it is served with a portion of boiled rice, at 359 calories, the two would almost equal to half the daily recommended calorie count for a woman.
It is also very high in saturated fat at 10.15g. On top of that it has 3.2g of salt - over half the upper limit for an adult for a day.
The new curries contain far less salt, fat and calories.
Mr Todiwala says this actually improves the taste because they allow the spices and the ingredients to cut through. He said they have all the flavours but do far less damage to our health.
"It is perhaps a slight lack of knowledge, understanding of nutrition and cooking," he says.
"The idea is to make people more aware of the mistakes they are making, change their techniques a little bit.
"It saves them money as well, because if they use less fatty produce and less harmful substances, they actually end up saving money for themselves."
People 'have the choice'
The workshops, organised by the council and NHS Tower Hamlets Healthy Borough Programme, are aimed at tackling obesity and improving health in the borough.
Tower Hamlets is home to one of the largest Bangladeshi populations in the country.
Research has found that Bangladeshis have the highest mortality rate from coronary heart disease of any ethnic minority group in the UK.
They are also three to five times more likely to suffer kidney disease than others. Experts think that excess salt, fatty and oily foods are possible factors.
Michele Sandelson, a public health dietician from NHS Tower Hamlets, says: "By offering the free healthier cooking workshops to local food businesses we want to ensure people can have the choice of enjoying healthier food when eating out."
The fact that an estimated 80% of "curry houses" in the UK are Bangladeshi-owned and run adds weight to the argument to extend the idea.
Cyrus Todiwala says: "I think the rest of the country can definitely benefit."

More on This Story

Friday 18 November 2011

Cancer drug Avastin loses US approval US drug regulators have rescinded approval of a breast cancer drug, saying it is not effective enough to justify the risks of taking it.





Breast Cancer CellsThe drug-maker says it will undertake further study to establish which patients will benefit from the drug

The drug, Avastin, was approved for US use in 2008, but UK officials have also rejected claims that it prolongs life.
US drug regulators have rescinded approval of a breast cancer drug, saying it is not effective enough to justify the risks of taking it.
Further research showed it did not help patients live longer or improve quality of life, Food and Drug Administration commissioner Margaret Hamburg said.
Avastin will still be used to treat other kinds of cancer.
The drug is used to treat breast cancer that has spread to other parts of the body. It works by starving cancer cells of a blood supply.
However, its side-effects include severe high blood pressure, massive bleeding, heart attack or heart failure and tears in the stomach and intestines, FDA studies have found.
FDA approval of the drug had initially been given under a special programme that allows patients to start using promising treatments while the manufacturer finishes the studies to prove the medicine works as well as expected.
The decision to withdraw the approval - which can happen if results of the research do not match predictions - was not easy, the FDA said.
Stalling cancer growth
"With so much at stake, patients and their doctors count on the FDA to ensure the drugs they use have been shown to be safe and effective for their intended use. Sometimes, the results of rigorous testing can be disappointing," Ms Hamburg told the Associated Press news agency.
US health insurance companies could remove the drug, which can cost as much as $100,000 (£63,342) per year, from their coverage - although doctors would still be permitted to administer the drug.
But the government-backed Medicaid programme has said it has no immediate plans to change its policy of paying for it.
Some advocates of the drug disagree with the watchdog's decision.
"The bottom line is that they are throwing out the baby with the bathwater. There absolutely may be subsets of carefully chosen breast cancer patients who benefit from Avastin," said Dr Elisa Port, co-director of the Dubin Breast Center of Mount Sinai Hospital in New York.
Roche, the Swiss manufacturer of the drug, has said it will undertake further study of the treatment, especially with the chemotherapy drug paclitaxel, to try to identify which patients might be best suited to benefit from use of the drug.
The company says it expects the medicine will generate $7.6bn (£4.8m) of revenue annually, despite the FDA decision.
The drug was approved on the basis of a study that showed Avastin was able to stall the growth of breast cancer by five-and-a-half months, when used together with a standard chemotherapy treatment.
But subsequent studies revised the period of delay to between one and three months, and there was no evidence to show that the drug extended patients' lives.
International problems
The US decision comes after Avastin fell foul of health authorities in the UK and in Europe.
In February 2011, the UK's National Institute for Health and Clinical Excellence (NICE), the NHS drugs advisory body, said Avastin should not be used to treat secondary breast cancers.
NICE, which issues guidance for NHS in England and Wales, said there was insufficient evidence that the drug prolonged life.
This guidance followed a recommendation by the European Medicines Agency (EMA) that doctors only prescribe the drug in combination with the taxane drug, paclitaxel.


    australian canola


    Australian canola faces EU price challenge


    //18 Nov 2011
    Non-genetically modified canola from Australia will only maintain its favourable market share in Europe while it continues to compete on price, according to Cargill's Katie Colvin. But she says premiums paid depend on the demand-pull from importing nations.
    During the past 12 months, Europe has been one of the main destinations for Australian canola. “This typically is a non-GM dominated market, but we are starting to see these trends change as Canadian seed makes its way into Europe,” Colvin said.
     
    "If we see a recovery in the European crop, and less import volumes are required, Australian seed will be competing against Canadian seed, which will result in the spreads narrowing."
     
    Niche markets
    Colvin, a canola merchant, said any extra demand for Australian GM-free canola was more from niche markets.
     
    "There may be some niche markets for specific buyers into Japan. There are rigorous testing procedures in Round Up Ready and non-GM producing states, which ensures the integrity of the non-GM canola is maintained from Australia," she said.
     
    Furthermore she said that, "Australia has some freight advantages into Asian destinations versus Canada, and at this stage our non-GM crop can also ensure somewhat easier access to Europe."
     
    Colvin said Japan and Europe only chased non-GM canola if the price was right. "There is capacity in the countries to switch from non-GM canola if it gets too expensive," she said.

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