Fulminant Skeletal Failure in a Centenarian: The Impact of Nutrition and Immobility

This case describes a 103-year-old lady who presented from home with an incidental diagnosis of a left femoral fracture. She had no history of trauma and denied pain. She had a known diagnosis of osteoporosis, and sustained a fracture of the contralateral femur aged 93 which was managed conservatively. She was bed-bound with fixed contractures, poor oral intake and was non-compliant with prescribed calcium/vitamin D supplementation. Clinical biochemical measurements showed severe vitamin D deficiency and mild hypocalcaemia. Secondary hyperparathyroidism in the setting of an inappropriately normal phosphate suggested concurrent renal bone disease. Biomarkers of bone turnover were also consistent with bone remodelling. The history of prior fragility fractures, severe vitamin D deficiency and immobility supports a diagnosis of osteoporotic fracture, however other causes of spontaneous fracture were also considered. This case highlights the complexity of interpreting clinical biochemistry results in the setting of multi-morbidity and addresses the challenges of bone health management in the frail older person.

Spontaneous Insufficiency Fractures

Spontaneous insufficiency fractures are caused by normal or physiological stress on weakened bone. The leading cause of insufficiency fractures is osteoporosis which has a propensity to affect older patients. Other causes or associated factors are disorders which affect bone metabolism, collagen formation, bone remodelling and medications such as bisphosphonates and glucocorticoids. Pathological fractures and abuse are important causes of unexplained fractures which warrant careful consideration. Spontaneous fractures of the long bones affect on average 1% of nursing home residents per year and tend to occur in patients who are bed-bound with joint contractures. Preventative measures for spontaneous insufficiency fractures include optimising nutrition to include an adequate intake of protein, calcium and vitamin D, maintaining mobility and preventing long periods of bed-rest and treatment of underlying pre-disposing conditions.

Changes in small native animal populations following control of European rabbits (Oryctolagus cuniculus) by warren ripping in the Australian arid zone

Context European rabbits have a great impact on native vegetation and small vertebrates in Australia. Rabbits consume vegetation and promote invasive plants and invasive predators, and compete directly and indirectly with native animals suppressing those populations. Aims We explored the changes in small native vertebrates and invertebrates following the removal of rabbits. Methods Warren ripping was undertaken on a property in south-western Queensland at four sites and the results of pitfall trapping were compared with four nearby paired control sites. Invertebrates and small mammals were counted in pitfall traps, and bird surveys were conducted in all treatment and control sites. Key results Following a rabbit-control program, we observed a four-fold increase in the number of dunnarts trapped in treatment plots, whereas no change was observed in control plots. The spring following the rabbit-control program also saw an increase in some lizards in treatment plots. Conclusions The presence of rabbits in arid-zone Australia can suppress native animal populations. Implications Many species of small native mammals and lizards rely on food sources that fluctuate greatly with environmental conditions. The presence of rabbits altering the landscape, supporting introduced predators, reducing vegetation and, therefore, insects, adds increased pressure for insectivorous species. Rabbit control through warren ripping in arid-zone Australia is an effective method to reduce rabbit numbers, and allowed for an increase in small vertebrates in treated areas.

Multi-centre national audit of juvenile localised scleroderma: describing current UK practice in disease assessment and management

OBJECTIVE

To describe current United Kingdom practice in assessment and management of patients with juvenile localised scleroderma (JLS) compared to Paediatric Rheumatology European Society (PRES) scleroderma working party recommendations.

METHODS

Patients were included if they were diagnosed with JLS and were under the care of paediatric rheumatology between 04/2015-04/2016. Retrospective data was collected in eleven UK centres using a standardised proforma and collated centrally.

RESULTS

149 patients were included with a median age of 12.5 years. The outcome measures recommended by the PRES scleroderma working party were not utilised widely. The localised scleroderma cutaneous assessment tool was only used in 37.6% of patients. Screening for extracutaneous manifestations did not meet recommendations that patients with head involvement have regular screening for uveitis and baseline magnetic resonance imaging (MRI) brain: only 38.5% of these patients were ever screened for uveitis; 71.2% had a MRI brain. Systemic treatment with disease-modifying anti-rheumatic drugs (DMARDs) or biologics was widely used (96.0%). In keeping with the recommendations, 95.5% of patients were treated with methotrexate as first-line therapy. 82.6% received systemic corticosteroids and 34.2% of patients required two or more DMARDs/biologics, highlighting the significant treatment burden. Second-line treatment was mycophenolate mofetil in 89.5%.

CONCLUSION

There is wide variation in assessment and screening of patients with JLS but a consistent approach to systemic treatment within UK paediatric rheumatology. Improved awareness of PRES recommendations is required to ensure standardised care. As recommendations are based on low level evidence and consensus opinion, further studies are needed to better define outcome measures and treatment regimens for JLS.

Early Treatment Response Predicts Outcome in Paediatric Ulcerative Colitis: GASTROENTEROLOGY: INFLAMMATORY BOWEL DISEASE

The disease course of children with ulcerative colitis (UC) varies substantially. Published data on predictors of disease outcomes in children remain scarce. We validate clinical predictors of outcomes in 93 children with UC in a single centre (age range: 2-18 years, minimum follow-up: 18 months). We stratified children into 3 groups according to their disease course, that is, 1 = mild (38/93, 40.9%), 2 = moderate (38/93, 40.9%), 3 = severe (17, 18.2%). Comparison of clinical and biochemical parameters was performed between groups using Chi-square, Mann-Whitney, and log-rank tests. Predictors of a severe disease course included pancolitis (P 0.01), low albumin (P 0.005), low haemoglobin at diagnosis (P 0.04), paediatric ulcerative colitis activity index (PUCAI) at 3 months, and nonresponse to steroids at 3 months (P 0.0001). In our cohort, failure to achieve remission at 3 months implied an 80% likelihood to require biologics or major surgery within 18 months. A specific 3-month review point is recommended to guide future management.

Ability of wild rabbit, Oryctolagus cuniculus, to lactate successfully in hot environments explains continued spread in Australia

Context European rabbits evolved in Spain and Portugal and are adapted to winter-rainfall Mediterranean habitats. On introduction into Australia in 1859, wild rabbits quickly colonised similar habitats across the southern two-thirds of the continent. However, over the past 40 years, they have spread further into monsoonal savanna habitats in northern Queensland. Aims To explain this, we considered adaptive responses of wild rabbits to hot conditions, particularly potential mechanisms for reducing the heat load of lactation, which has been identified as a likely limiting factor. Methods We analysed data from captive wild rabbits to identify mechanisms that could potentially reduce lactational heat load, and obtained data from shot samples of wild rabbits from northern Queensland to determine which of these might be most important in the field. Key results Rabbits spread food intake evenly across the 20-day lactation period and under hot conditions, captive wild individuals used body reserves to meet energy requirements for lactation, which is more energy efficient than converting digestible foods to milk. Conclusions This strategy reduces the heat load of lactation, enabling rabbits to suckle young successfully under hot conditions, but it comes at a cost. Rabbits need extra body reserves before breeding and need to regain those reserves between litters. Implications The slow spread of rabbits into Australia’s monsoonal savannas is likely to continue, given the rabbit’s reproductive flexibility and further natural selection for breeding in this environment.

A glucanolytic Pseudomonas sp. associated with Smilax bona-nox L. displays strong activity against Phytophthora parasitica

Biological control is an eco-friendly strategy for mitigating and controlling plant diseases with negligible effects on human health and environment. Biocontrol agents are mostly isolated from field crops, and microbiomes associated with wild native plants is underexplored. The main objective of this study was to characterize the bacterial isolates associated with Smilax bona-nox L, a successful wild plant with invasive growth habits. Forty morphologically distinct bacterial isolates were recovered from S. bona-nox. Based on 16S rRNA gene sequencing, these isolates belonged to 12 different genera namely Burkholderia, Pseudomonas, Xenophilus, Stenotrophomonas, Pantoea, Enterobactriaceae, Kosakonia, Microbacterium, Curtobacterium, Caulobacter, Lysinibacillus and Bacillus. Among them, Pseudomonas sp. EA6 and Pseudomonas sp. EA14 displayed the highest potential for inhibition of Phytophthora. Based on sequence analysis of rpoD gene, these isolates revealed a 97% identity with a Pseudomonas fluorescence strain. Bioactivity-driven assays for finding bioactive compounds revealed that crude proteins of Pseudomonas sp. EA6 inhibited mycelial growth of P. parasitica, whereas crude proteins of Pseudomonas sp. EA14 displayed negligible activity. Fractionation and enzymatic analyses revealed that the bioactivity of Pseudomonas sp. EA6 was mostly due to glucanolytic enzymes. Comparison of chromatographic profile and bioactivity assays indicated that the secreted glucanolytic enzymes consisted of β-1,3 and β-1,4 glucanases, which acted together in hydrolyzing Phytophthora cell walls. Since the biological activity of the crude glucanolytic extract was >60-fold higher than the purified β-1,3 glucanase, the glucanolytic enzyme system of Pseudomonas sp. EA6 likely acts synergistically in cell wall hydrolysis of P. parasitica.

Husk to caryopsis adhesion in barley is influenced by pre- and post-anthesis temperatures through changes in a cuticular cementing layer on the caryopsis

BACKGROUND

At ripeness, the outer husk of "covered" barley grains firmly adheres to the underlying caryopsis. A cuticular cementing layer on the caryopsis is required for husk adhesion, however the quality of adhesion varies significantly among cultivars which produce the cementing layer, resulting in the economically important malting defect, grain skinning. The composition of the cementing layer, and grain organ development have been hypothesised to influence the quality of husk adhesion. Plants of Hordeum vulgare 'Concerto' were grown at different temperatures pre- and post-anthesis to effect changes in the development of the husk, caryopsis and cuticular cementing layer, to determine how these variables influence the quality of husk-to-caryopsis adhesion.

RESULTS

Warm conditions pre-anthesis decreased the quality of husk adhesion, and consequently increased the incidence of grain skinning. Cool post-anthesis conditions further decreased the quality of husk adhesion. The composition of the cementing layer, rather than its structure, differed with respect to husk adhesion quality. This cementing layer was produced at the late milk stage, occurring between nine and 29 days post-anthesis, conditional on the temperature-dependent growth rate. The compounds octadecanol, tritriacontane, campesterol and β-sitosterol were most abundant in caryopses with high-quality husk adhesion. The differences in adhesion quality were not due to incompatible husk and caryopsis dimensions affecting organ contact.

CONCLUSIONS

This study shows that husk-to-caryopsis adhesion is dependent on cementing layer composition, and implies that this composition is regulated by temperature before, and during grain development. Understanding this regulation will be key to improving husk-to-caryopsis adhesion.

The challenge of teaching undergraduates evidence-based veterinary medicine

The Royal College of Veterinary Surgeons now lists 'How to evaluate evidence' as a day one competence for newly qualified vets. In this article, representatives from each of the veterinary schools in the UK discuss how the challenge of delivering and assessing the concepts of evidence-based veterinary medicine in a crowded undergraduate curriculum can be met.

Ex Vivo Application of Secreted Metabolites Produced by Soil-Inhabiting Bacillus spp. Efficiently Controls Foliar Diseases Caused by Alternaria spp

Bacterial biological control agents (BCAs) are largely used as live products to control plant pathogens. However, due to variable environmental and ecological factors, live BCAs usually fail to produce desirable results against foliar pathogens. In this study, we investigated the potential of cell-free culture filtrates of 12 different bacterial BCAs isolated from flower beds for controlling foliar diseases caused by Alternaria spp. In vitro studies showed that culture filtrates from two isolates belonging to Bacillus subtilis and Bacillus amyloliquefaciens displayed strong efficacy and potencies against Alternaria spp. The antimicrobial activity of the culture filtrate of these two biological control agents was effective over a wider range of pH (3.0 to 9.0) and was not affected by autoclaving or proteolysis. Comparative liquid chromatography-mass spectrometry (LC-MS) analyses showed that a complex mixture of cyclic lipopeptides, primarily of the fengycin A and fengycin B families, was significantly higher in these two BCAs than inactive Bacillus spp. Interaction studies with mixtures of culture filtrates of these two species revealed additive activity, suggesting that they produce similar products, which was confirmed by LC-tandem MS analyses. In in planta pre- and postinoculation trials, foliar application of culture filtrates of B. subtilis reduced lesion sizes and lesion frequencies caused by Alternaria alternata by 68 to 81%. Taken together, our studies suggest that instead of live bacteria, culture filtrates of B. subtilis and B. amyloliquefaciens can be applied either individually or in combination for controlling foliar diseases caused by Alternaria species.