Standardisation of a coproantigen reduction test (CRT) protocol for the diagnosis of resistance to triclabendazole in Fasciola hepatica

A sheep trial was performed to standardise a coproantigen reduction test (CRT) protocol for the diagnosis of resistance to triclabendazole (TCBZ) in Fasciola hepatica). The CRT employs the BIO K201 Fasciola coproantigen ELISA (Bio-X Diagnostics, Jemelle, Belgium) to test for the presence of F. hepatica coproantigens in a faecal sample. If it is coproantigen-positive, the CRT protocol recommends that faecal samples are re-tested for coproantigens at 14 days post-treatment (dpt), with negative testing at this point indicating TCBZ success. Initial work aimed to confirm the sensitivity of the BIO K201 ELISA for Fasciola infection and investigate whether coproantigens represent a robust reduction marker of TCBZ efficacy. Thirty-eight, indoor-reared sheep were artificially infected with F. hepatica isolates known to be susceptible (Cullompton) and resistant (Sligo) to TCBZ action, respectively. Treatment was administered at 12 weeks post-infection (wpi), with 2 sheep groups, infected with each isolate, culled at 2 and 4 weeks post-treatment (wpt), respectively. Necropsy was performed to confirm treatment efficacy. Individual faecal samples were collected twice-weekly throughout the trial period. Additional work focused on the effect of temperature on faecal sample collection and storage. Faecal samples collected from sheep positive for F. hepatica infection were sub-sampled and left at room temperature. Individual sub-samples were tested by ELISA on consecutive days and these readings compared to the original test result on the day of collection. In addition, ELISA values were compared between faecal sub-samples prepared on the day of sampling and post storage at -20°C. Also, an immunocytochemical study was performed to determine the tissue site of origin of the coproantigen protein in the fluke. Results showed that the BIO K201 ELISA was sensitive for Fasciola coproantigens, with coproantigens detectable from 5 wpi onwards. The suitability of coproantigens as a diagnostic marker of TCBZ efficacy was supported by the absence and presence of coproantigens in TCBZ-treated Cullompton (TCBZ-susceptible) and Sligo (TCBZ-resistant) F. hepatica infections at 2 and 4 wpt, respectively. Study results suggest that low to moderate temperature has little, if any, impact on coproantigen stability in faecal samples, but that higher temperatures may have. Immunolabelling for the coproantigen showed that it was specific to the gastrodermal cells of both adult and juvenile flukes.

Fasciola hepatica: histological changes in the reproductive structures of triclabendazole (TCBZ)-sensitive and TCBZ-resistant flukes after treatment in vivo with TCBZ and the related benzimidazole derivative, Compound Alpha

Twenty-four shed-reared lambs were each infected orally with 250 metacercariae of Fasciola hepatica, using either the triclabendazole (TCBZ)-sensitive Cullompton isolate or the TCBZ-resistant Sligo isolate. Twelve weeks after infection the lambs were treated with TCBZ (10mg/kg) or with the experimental fasciolicide, Compound Alpha (Cpd alpha), a benzimidazole derivative of TCBZ (15mg/kg). The lambs were euthanised 48, 72 and 96h after TCBZ treatment, or 24, 48 and 72h after Cpd alpha treatment, and flukes were collected from the liver and/or gall bladder of each animal. Untreated animals harbouring 12-week infections were euthanized 24h after administration of anthelmintic to the treatment groups, and the untreated flukes provided control material. A semi-quantitative assessment of the degree of histological change induced by the two drugs after different times of exposure was achieved by scoring the intensity of three well-defined lesions that developed in the testes and uteri of a representative sample of flukes from each lamb. In general, it was found that in those tissues where active meiosis and/or mitosis occurred (testis, ovary, and vitelline follicles), there was progressive loss of cell content due to apparent failure of cell division to keep pace with expulsion of the mature or effete products. Further, actively dividing cell types tended to become individualised, rounded and condensed, characteristic of apoptotic cell death. Protein synthetic activity was apparently inhibited in the Mehlis' secretory cells. In the uterus, where successful formation of shelled eggs represents the culmination of a complex sequence of cytokinetic, cytological and synthetic activity involving the vitelline follicles, the ovary and the Mehlis' gland, histological evidence indicating failure of ovigenesis was evident from 24h post-treatment onwards. The development of these lesions may be related to the known anti-tubulin activity of the benzimidazole class of anthelmintics, to the induction of apoptosis in cells where mitosis or meiosis has aborted due to failure of spindle formation, and to drug-induced inhibition of protein synthesis. The semi-quantitative findings indicated that Cpd alpha is slightly less efficacious than TCBZ itself in causing histological damage to the reproductive structures of TCBZ-sensitive flukes, and that, like TCBZ, it caused no histological damage in flukes of the TCBZ-resistant isolate. This study illustrates the potential utility of histological techniques for conveniently screening representative samples of flukes in field trials designed to validate instances of drug resistance or to test the efficacy of new products against known drug-resistant and drug-susceptible fluke isolates. It also provides reference criteria for drug-induced histopathological changes in fluke reproductive structures which may aid interpretation of TEM findings.

Surface and internal tegumental changes in juvenile Fasciola hepatica following treatment in vivo with the experimental fasciolicide, compound alpha

Eight indoor-reared, crossbred sheep with no pre-exposure to Fasciola hepatica were infected, by oral gavage, with 200 metacercarial cysts of the triclabendazole-susceptible, Cullompton isolate of F. hepatica. Anthelmintic dosing occurred at 4 weeks post-infection using 15mg/kg compound alpha. Two treated sheep per time period were euthanized at 24h, 48h and 72h post-treatment with compound alpha. The two sheep from the control group were euthanized alongside the 24h alpha-treated sheep. Juvenile flukes were recovered from each of the sheeps' liver and processed for examination by electron microscopy. The surface morphology of the flukes' tegument was assessed using scanning electron microscopy (SEM). The ultrastructure of the tegumental syncytium and underlying tegumental cells and connections and somatic musculature were investigated using transmission electron microscopy (TEM). Both the SEM and TEM results revealed a level of disruption that increased with time, culminating at 72h with extensive tegumental loss and substantial degeneration of the cell bodies. The effects of compound alpha on the surface morphology were not particularly apparent until 48h post-treatment, when disruption included swelling and blebbing of the tegument. At 72h post-treatment, SEM revealed loss of the entire syncytial layer over large areas of the flukes. In the areas where the syncytium was lost and the basal lamina exposed, lesions of varying sizes had developed, revealing underlying tissues. Though minor forms of disruption to the ultrastructure of the syncytium were observed using TEM 24h post-treatment, it was at 48h post-treatment that substantial stress responses occurred. They included the presence of autophagic vacuoles and 'open' bodies at the apex of the syncytium and swelling of the basal infolds. The mitochondria within the syncytium and tegumental cells became progressively more disrupted over the three time periods and, by 72h post-treatment, they were frequently distorted and swollen in appearance, and contained severely swollen cristae. By 72h, the number of secretory bodies, particularly T1 bodies, had become significantly depleted in their respective cell bodies, cytoplasmic processes and in the tegumental syncytium. Both the circular and longitudinal muscle bundles were severely disrupted 72h post-treatment. They frequently contained a reduced number of muscle fibres and, in more severe instances, there was an absence of fibres altogether.

Immature triclabendazole-resistant Fasciola hepatica: tegumental responses to in vitro treatment with the sulphoxide metabolite of the experimental fasciolicide compound alpha

Juvenile triclabendazole-resistant liver flukes, Fasciola hepatica, were incubated in vitro with 10 microg/ml of the sulphoxide metabolite of the experimental fasciolicide, compound alpha [5-chloro-2-methylthio-6-(1-naphthyloxy)-1H-benzimidazole], for 6 and 18 h. Following treatment, the specimens were examined using scanning electron microscopy (SEM), transmission electron microscopy (TEM) and tubulin immunocytochemistry. The SEM results revealed a posterior-directed disruption comprised predominantly of swelling and blebbing of the tegument; these changes were more severe and extensive after the longer 18-h incubation. Along with swelling of the tegument and blebbing, the TEM results also revealed swelling of the mitochondria and basal infolds. A decrease in the number of both T1 and T2 secretory bodies was observed in the syncytium and cytoplasmic connections after the 18-h treatment. The circular muscle bundles were also disrupted, in that the organisation of the muscle fibres was irregular and the total number of muscle fibres was reduced. The immunocytochemical studies revealed no significant disruption to the distribution of tubulin immunoreactivity within the tegumental syncytium, the cytoplasmic connections or the associated tegumental cells. The results indicate that alpha.SO is capable of disrupting the tegument of 4-week-old triclabendazole-resistant liver flukes, though the morphological changes were not associated with any significant differences in tubulin immunostaining.

Adult triclabendazole-resistant Fasciola hepatica: surface and subsurface tegumental responses to in vitro treatment with the sulphoxide metabolite of the experimental fasciolicide compound alpha

Mature Fasciola hepatica of the triclabendazole-resistant Sligo isolate were incubated in vitro with 10 microg/ml of the sulphoxide metabolite of compound alpha [5-chloro-2-methylthio-6-(1-naphthyloxy)-H-benzimidazole]; the metabolite will be referred to as alpha.SO. Changes resulting from drug treatment were examined by scanning electron microscopy (SEM), transmission electron microscopy (TEM) and tubulin immunocytochemistry (ICC). SEM revealed that disruption to the tegumental surface mainly took the form of swelling and blebbing. Extensive spine loss occurred on the ventral surface of the oral cone, and sloughing of the tegument was observed along the lateral margins of the fluke. Examination of sections from the anterior mid-body region at the TEM level revealed that treatment with alpha.SO led to swelling of the basal infolds and mitochondria within the tegumental syncytium; also, accumulations of secretory bodies beneath the apical plasma membrane. The tegumental cell bodies contained swollen mitochondria and cisternae of granular endoplasmic reticulum, but few Golgi complexes were observed. An increase in T2 secretory bodies was observed, whilst in the T1 tegumental cells, the T1 secretory bodies had decreased in number. Immunocytochemical (ICC) studies showed that incubation with alpha.SO, ABZ.SO and TCBZ.SO did not cause significant changes to the distribution of tubulin within the tegumental syncytium of the Sligo isolate. In contrast, alpha.SO, ABZ.SO and TCBZ.SO caused severe disruption to tubulin organization within the syncytial layer of the TCBZ-susceptible Cullompton isolate. The EM results confirm that compound alpha is a fasciolicide capable of disrupting the tegument of mature TCBZ-resistant F. hepatica; however, this was not accompanied by any change in tubulin immunoreactivity.

Perforating marginal ulcers after laparoscopic gastric bypass

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LGB) can be performed with minimal morbidity and mortality. This article describes the first presentation of a known disease entity after LGB: perforating marginal ulcers of the jejunum immediately distal to the gastrojejunal anastomosis.

METHODS

A chart review of 902 LGB procedures performed by a single surgeon between April 2000 and September 2004 identified eight patients with perforating marginal ulcers.

RESULTS

The patients presented an average of 157 days (range, 53-374 days) after LGB. All the patients were treated using laparoscopic primary closure followed by medical therapy. Morbidity, in one patient only, consisted of two abdominal fluid collections requiring separate drainage procedures. There was no mortality. The average follow-up period was 13 months (range, 2-18 months). No patient experienced recurrent ulceration.

CONCLUSIONS

Although the etiology is unclear, marginal ulcers, a known complication of gastrojejunostomy, may present as perforating ulcers after LGB in a characteristic fashion and can be managed laparoscopically.

Cytokine gene polymorphisms associated with symptomatic parvovirus B19 infection

BACKGROUND

The immune system has been implicated in the pathogenesis of certain clinical manifestations of parvovirus B19 infection, including rash and arthralgia. Cytokines feature in the pathogenesis of parvovirus B19 infection, so inherited variability in cytokine responses to B19 infection might have a bearing on the symptomatology of parvovirus B19 infection.

AIMS

To investigate the possible role of cytokine gene polymorphisms in the clinical manifestations of parvovirus B19 infection.

METHODS

Thirty six patients with a variety of symptoms at acute infection and follow up (mean, 22.0 months) and controls (99-330, depending on the locus) were examined for the following cytokine polymorphisms: tumour necrosis factor alpha (TNF alpha), -308; interferon gamma (IFN-gamma), +874; interleukin 6 (IL-6), -174; IL-10, -592, -819, and -1082; and transforming growth factor beta1 (TGF beta 1), +869 (codon 10) and +915 (codon 25).

RESULTS

The TNF alpha -308*A allele occurred in 13.9% of the parvovirus group compared with 27.0% of the control group (odds ratio (OR), 0.44; p = 0.02). The TGF beta 1 CG/CG haplotype was more frequent in the parvovirus group than in the controls (16.7% v 5%; OR, 4.8; p = 0.02). Within the B19 infected group, the TGF beta 1 +869 T allele was associated with skin rash at acute infection (p = 0.005), whereas at follow up the IFN-gamma +874 T allele was associated with the development of anti-B19 non-structural protein 1 antibodies (p = 0.04).

CONCLUSIONS

The results of the present study suggest that inherited variability in cytokine responses may affect the likelihood of developing symptoms during parvovirus infection.

Residential fire related deaths and injuries among children: fireplay, smoke alarms, and prevention

BACKGROUND

The aim of the study was to describe the epidemiology of residential fire related deaths and injuries among children, and identify risk factors for these injuries through a linked dataset for the city of Dallas, Texas.

METHODS

Data for all residential fires were linked with fire related injury data, using fire department records, ambulance transports, hospital admissions, and medical examiner records, for children 0-19 years of age. Causes of fires, including fireplay (children playing with fire or combustibles), arson and other causes, were determined by fire department investigation.

RESULTS

From 1991-98, 76 children were injured in residential fires (39 deaths, 37 non-fatal). The highest rates occurred in the youngest children (<5 years) and in census tracts with lowest income. Fireplay accounted for 42% (32/76) of all injuries, 62% (15/24) of deaths in children 0-4 years, and 94% (13/14) of deaths from apartment and mobile home fires. Most of the fireplay related injuries (27/32, 84%) were from children playing with matches or lighters. Most started in a bedroom. Smoke alarms showed no protective efficacy in preventing deaths or injuries in fires started by fireplay or arson, but there was significant protective efficacy for a functional smoke alarm in fires started from all other causes (p<0.01).

CONCLUSIONS

Residential fire related injuries among children in Dallas occurred predominantly in the youngest ages (<5 years) and in poor neighborhoods. Most of the deaths, especially those in apartments and mobile homes, resulted from fireplay. Smoke alarms appeared to offer no protection against death or injury in fireplay associated fires, possibly from the nature of the child's behavior in these fires, or from the placement of the smoke alarm. Prevention of childhood residential fire related deaths may require interventions to prevent fireplay in order to be successful.

Evaluating evaluation: implications for assessing quality

Aims to review the literature on evaluation and to examine research, theory and practice in relation to two key questions: What is evaluation and What is its contribution? Evaluation is increasingly a contemporary concern owing to growing demand for verification of programme results and the current political and economic climate. With the growth in evaluation activity in diverse fields, especially within new domains, those involved in health-care delivery can benefit from an overview of the universal fundamentals of research and theory that translate into improved practice. To evaluate effectively, there is a need for a full understanding of evaluation's nature, purposes and concepts. Identifies and reviews the key subdomains of evaluation, namely: definitions; theoretical underpinning; formulation of goals and objectives; specification of the programme; and cost-benefit analysis.

Atypical hyperplasia, proliferative fibrocystic change, and exogenous hormone use

BACKGROUND

The association between breast cancer development and exogenous hormone use (EHU) is suggested by indirect clinical evidence. We undertook this study to better define the relationship that EHU has with proliferative fibrocystic change (PFC) and atypical hyperplasia (AH).

METHODS

Women diagnosed with AH without associated carcinoma from January 1990 to December 1999 were compared with control subjects who underwent breast biopsy procedures during the same interval and who were diagnosed with either a proliferative fibrocystic change (PFC) or a nonproliferative fibrocystic change (NPFC). EHU was defined as the use of estrogen or progesterone taken together or separately within 3 months of biopsy.

RESULTS

EHU was significantly higher in patients with AH compared with women with NPFC (P =.01). This observation was also significant if all proliferative change (both AH and PFC) was compared with NPFC (P =.03); it was not significant when PFC alone was compared with NPFC. No significant difference in EHU was demonstrated between women with AH and those with PFC.

CONCLUSIONS

There is strong association between AH and EHU. These results support the theory that a continuum exists between hyperplasia and carcinoma and that EHU may influence the transition from one to the other in an undefined subset of women. We encourage our patients with AH to discontinue EHU.

Methamphetamine increases expression of the apoptotic c-myc and L-myc genes in the mouse brain

To clarify the possible mechanisms by which the recreational drug, methamphetamine (METH), induces apoptosis, we investigated its effects on the expression of Myc apoptotic genes. This paper presents the characterization of c-myc and L-myc gene transcription in the striatum and the cortex. In addition, the expression of the corresponding proteins was also evaluated. Our observations reveal that c-myc and L-myc were up-regulated by METH at both the mRNA and protein levels. Thus, myc transcription factors might be responsible for some aspects of METH-induced apoptotic processes.

Effects of ground EMS and ED personnel on air medical trauma on-site times

INTRODUCTION

On-site times for helicopter EMS (HEMS) providers are hypothesized to increase when procedures indicated by national standards of care and local HEMS are not consistently completed by ground EMS (GEMS) or ED providers before HEMS arrival in trauma cases.

METHODS

In this prospective study, we divided all trauma missions (120) flown by a university-based HEMS during a 3-month period into interfacility missions (between hospitals, ground providers are ED personnel) and scene missions (between scenes and hospitals, ground providers are GEMS). HEMS completed forms identifying which procedures were completed and omitted by GEMS or ED providers. We collected relevant times from county dispatchers and HEMS flight control.

RESULTS

Ground providers frequently did not complete indicated basic and advanced procedures. A relationship existed between scene GEMS omissions and HEMS on-site times. If no procedures were omitted, average HEMS time on-site was 13 minutes, increasing to 17 minutes for one procedure omitted and 20 minutes for two or more. No relationship was found on interfacility missions between ED provider omissions and HEMS on-site times. However, any existing effect may have been eclipsed by external factors significantly extending HEMS on-site times (mean 43 minutes). An average of 93 minutes elapsed between the request for HEMS transport and patient arrival at the transferring hospital.

CONCLUSION

GEMS frequently omit indicated procedures. For scene missions, reducing the number of indicated procedures omitted by scene GEMS providers could reduce on-site HEMS times. For interfacility missions, further study is indicated to determine what occurs before HEMS is contacted and while HEMS is on-site.

Prediction of recidivism in extrafamilial child molesters based on court-related assessments

One hundred ninety-two convicted extrafamilial child molesters were followed for an average of 7.8 years after their conviction. The percentage of men who had committed a sexual, a violent, or any criminal offense by the 12th year was 15.1, 20.3, and 41.6, respectively. The sexual recidivists, compared with the nonrecidivists; demonstrated more problems with alcohol and showed greater sexual arousal to assaultive stimuli involving children than to mutually consenting stimuli with children. The violent recidivists, compared with the nonrecidivists, were more likely to have a history of violence in the families in which they were raised and were rated significantly more psychopathic on the Psychopathy Checklist--Revised (PCL-R). They also showed more sexual arousal to stimuli depicting mutually consenting sexual interactions with children than to adult stimuli. In terms of any criminal recidivism, recidivists were younger, had completed fewer years of school, and were raised in psychologically more harmful family environments compared with nonrecidivists. They also reported that, before 16 years of age, they were more likely to have been physically abused and were more likely to have been removed from their homes compared to those that did not recidivate. In addition, recidivists demonstrated more general hostility on the Buss-Durkee Hostility Inventory and were rated significantly more psychopathic on the PCL-R. The phallometric assessments revealed, that the criminal recidivists, compared to the nonrecidivists, showed more sexual arousal to stimuli depicting coercive sexual activity with children than consenting sexual activities with children. In addition, they showed more sexual arousal to scenes depicting adult rape then adult mutually consenting sex. Finally, the recidivists also had more charges or convictions for violence and any criminal acts. The small number of significant differences between recidivists and nonrecidivists in the sexual and violent categories precluded an attempt to determine which combination of factors meaningfully predicted reoffending. However, for criminal recidivism, a stepwise discriminant function analysis to assess the combination of factors that most successfully distinguished between groups in terms of criminal recidivism was significant, with subjects' age, total number of criminal convictions, and pedophile assault index being retained for optimal prediction. The procedure correctly classified 70.6% of the original group, 82.8% of the nonrecidivists, and 52.6% of the recidivists. PCL-R Total Score alone was equally successful in a similar discriminant function.

Web-based video for real-time monitoring of radiological procedures

A web-based video transmission of images from CT and MRI consoles was implemented in an Intranet environment for real-time monitoring of ongoing procedures. Images captured from the consoles are compressed to video resolution and broadcast through a web server. When called upon, the attending radiologists can view these live images on any computer within the secured Intranet network. With adequate compression, these images can be displayed simultaneously in different locations at a rate of 2 to 5 images/s through a standard local-area network. While the quality of the images was insufficient for diagnostic purposes, our users survey showed that they were suitable for supervising a procedure, positioning the imaging slices, and for routine quality checking before completion of a study. The system was implemented at UCLA to monitor nine CT's and six MRI's distributed in four different buildings. This system significantly improved the radiologists productivity by saving valuable time spent in trips between reading rooms and examination rooms. It also improved patient care and throughput by reducing the time spent waiting for the radiologists to check a study before removing the patient from the scanner.

Tubulin expression in the developing and adult gerbil organ of Corti

In the late stages of inner ear development, the relatively undifferentiated cells of Kollicker's organ are transformed into the elaborately specialized cell types of the organ of Corti. Microtubules are prominent features of adult cells in the organ of Corti, particularly supporting cells. To test the possible role of microtubules in organ of Corti development, the microtubule organization in the organ of Corti has been examined using indirect immunofluorescence to beta-tubulin in the developing gerbil cochlea. Tubulin first appears at post-natal day 0 (P0) as filamentous asters in inner hair cells and by P2, asters are also seen in outer hair cells. Tubulin appears at P3 in inner pillar cells in a tooth crown-like figure. By P6, tubulin expression is also evident in outer pillar cells and by P9, it is seen in Deiters cells. Elaboration of microtubules in pillar cells was observed to proceed from the reticular lamina towards the basilar membrane. The pattern of tubulin expression in the apical organ of Corti lags the base by about 3 days until P6, but by P9, apical and basal organ of Corti appear substantially the same.