Plant size, latitude, and phylogeny explain within-population variability in herbivory

Interactions between plants and herbivores are central in most ecosystems, but their strength is highly variable. The amount of variability within a system is thought to influence most aspects of plant-herbivore biology, from ecological stability to plant defense evolution. Our understanding of what influences variability, however, is limited by sparse data. We collected standardized surveys of herbivory for 503 plant species at 790 sites across 116° of latitude. With these data, we show that within-population variability in herbivory increases with latitude, decreases with plant size, and is phylogenetically structured. Differences in the magnitude of variability are thus central to how plant-herbivore biology varies across macroscale gradients. We argue that increased focus on interaction variability will advance understanding of patterns of life on Earth.

Development and operation of the defence COVID-19 lab as a SARS-CoV-2 diagnostic screening capability for UK military personnel

BACKGROUND

In the face of the COVID-19 pandemic, the Defence Science and Technology Laboratory (Dstl) and Defence Pathology combined to form the Defence Clinical Lab (DCL), an accredited (ISO/IEC 17025:2017) high-throughput SARS-CoV-2 PCR screening capability for military personnel.

LABORATORY STRUCTURE AND RESOURCE

The DCL was modular in organisation, with laboratory modules and supporting functions combining to provide the accredited SARS-CoV-2 (envelope (E)-gene) PCR assay. The DCL was resourced by Dstl scientists and military clinicians and biomedical scientists.

LABORATORY RESULTS

Over 12 months of operation, the DCL was open on 289 days and tested over 72 000 samples. Six hundred military SARS-CoV-2-positive results were reported with a median E-gene quantitation cycle (Cq) value of 30.44. The lowest Cq value for a positive result observed was 11.20. Only 64 samples (0.09%) were voided due to assay inhibition after processing started.

CONCLUSIONS

Through a sustained effort and despite various operational issues, the collaboration between Dstl scientific expertise and Defence Pathology clinical expertise provided the UK military with an accredited high-throughput SARS-CoV-2 PCR test capability at the height of the COVID-19 pandemic. The DCL helped facilitate military training and operational deployments contributing to the maintenance of UK military capability. In offering a bespoke capability, including features such as testing samples in unit batches and oversight by military consultant microbiologists, the DCL provided additional benefits to the UK Ministry of Defence that were potentially not available from other SARS-CoV-2 PCR laboratories. The links between Dstl and Defence Pathology have also been strengthened, benefitting future research activities and operational responses.

Neurofilament light chain and total tau in the differential diagnosis and prognostic evaluation of acute and chronic inflammatory polyneuropathies

Background and Purpose

To investigate the diagnostic and prognostic value of axonal injury biomarkers in patients with inflammatory polyneuropathies.

Methods

Neurofilament light chain (NfL) and total tau (T‐tau) were measured in the cerebrospinal fluid (CSF) and plasma in 41 patients with Guillain–Barré syndrome (GBS), 32 patients with chronic inflammatory demyelinating polyneuropathy (CIDP), 10 with paraproteinemia‐related demyelinating polyneuropathy (PDN), and 8 with multifocal motor neuropathy (MMN), in comparison with 39 disease‐free controls and 59 other controls. Outcome was measured with the GBS‐disability score (GBS‐ds) or Inflammatory Neuropathy Cause and Treatment (INCAT) disability score.

Results

Neurofilament light chain levels in CSF and plasma were higher in GBS, CIDP, and PDN vs. disease‐free controls. Patients with MMN had higher NfL levels in plasma vs. disease‐free controls, but lower levels in CSF and plasma vs. patients with amyotrophic lateral sclerosis (ALS).

T‐tau levels in plasma were higher in GBS, CIDP, PDN, and MMN vs. all control groups.

Neurofilament light chain levels in CSF and plasma in patients with GBS correlated with GBS‐ds, as higher levels were associated with inability to run after 6 and 12 months. NfL levels in CSF and plasma in CIDP did not correlate significantly with outcome.

Conclusions

Acute and chronic inflammatory neuropathies are associated with an increase in levels of NfL in CSF and plasma, but NfL is validated as a prognostic biomarker only in GBS. NfL could be used in differentiating patients with MMN from ALS. T‐tau in plasma is a novel biomarker that could be used in a diagnostic assessment of patients with acute and chronic inflammatory polyneuropathies.

Production and characterization of antibodies for the specific determination of the opioid peptide Met5-Enkephalin-Arg6-Phe7

Endogenous opioids serve as modulators of neuroendocrine and immune system processes, the investigation of which calls for high-specificity radioimmunoassays (RIAs). This study focuses on the development and use of a specific radioimmunoassay for the opioid peptide Met5-Enkephalin-Arg6-Phe7 (MEAP), the C-terminus part of proenkephalin A. Antibodies were raised in four rabbits and investigated in terms of titre, avidity and specificity, followed by finding ideal conditions for these antibodies in RIA. MEAP concentrations were determined in crude extracts of rat hypothalamus, dorsal root ganglia, adrenals and ankle using this standardized assay after an oxidizing process. At reverse-phase high-pressure liquid chromatography (HPLC), the position of immunoreactive material from rat hypothalamus eluted as two peaks out of which one was compatible with that of synthetic MEAP. All rabbits exhibited individual differences in relative immune response and time of its onset. The avidity constant was 10 times higher on a molar basis for ab 4108 compared with ab 4182. There was no cross-reactivity for ab 4182 to related peptides, such as enkephalins and dynorphin B, and negligible background values for ab 4108. The relative levels ofimmunoreactive MEAP from the CNS versus peripheral tissues contrasted in accordance with current knowledge. It is suggested that reports with RIA results should include characterization of antibodies, extraction procedures, standard curves and compositions of buffers. Furthermore, the results should preferably be expressed in relation to total protein content.

Ex Vivo assessment of competent strut coverage after coronary stenting by optical coherence tomography

Background

In many studies, struts coverage is defined as >0 mm of tissue overlying the stent struts by optical coherence tomography (OCT). However, this definition has never been validated using histology as the “gold standard”. The present study sought to assess the appropriate cut-off value of neointimal thickness of stent strut coverage by OCT using histology.

Methods

OCT imaging was performed on 39 human coronary arteries with stents from 25 patients at autopsy. A total of 165 cross-sectional images from 46 stents were co-registered with histology. The optimal cut-off value of strut coverage by OCT was determined. Strut coverage by histology was defined as endothelial cells with at least underlying two layers of smooth muscle cells. Considering the resolution of OCT is 10–20 μm, 3 different cut-off values (i.e. at ≥20, ≥40, and ≥60 μm) were assessed.

Results

A total of 2235 struts were evaluated by histology. Eventually, 1216 struts which were well-matched struts were analyzed in this study. By histology, uncovered struts were observed in 160 struts and covered struts were observed in 1056 struts. The broadly used definition of OCT-coverage which does not consider neointimal thickness yielded a poor specificity of 37.5% and high sensitivity 100%. Of 3 cut-off values, the cut-off value of >40 μm was more accurate as compared to >20 and >60 mm [sensitivity (99.3%), specificity (91.0%), positive predictive value (98.6%), and negative predictive value (95.6%)]

Conclusion

The most accurate cut-off value was ≥40 μm neointimal thickness by OCT in order to identify stent strut coverage validated by histology.

Funding Acknowledgement

Type of funding source: None

Insights into Pasteurellaceae carriage dynamics in the nasal passages of healthy beef calves

We investigated three bovine respiratory pathobionts in healthy cattle using qPCR optimised and validated to quantify Histophilus somni, Mannheimia haemolytica and Pasteurella multocida over a wide dynamic range. A longitudinal study was conducted to investigate the carriage and density of these bacteria in the nasal passages of healthy beef calves (N = 60) housed over winter in an experimental farm setting. The three pathobiont species exhibited remarkably different carriage rates and density profiles. At housing, high carriage rates were observed for P. multocida (95%), and H. somni (75%), while fewer calves were positive for M. haemolytica (13%). Carriage rates for all three bacterial species declined over the 75-day study, but not all individuals became colonised despite sharing of environment and airspace. Colonisation patterns ranged from continuous to intermittent and were different among pathobiont species. Interval-censored exponential survival models estimated the median duration of H. somni and P. multocida carriage at 14.8 (CI_95%: 10.6–20.9) and 55.5 (CI_95%: 43.3–71.3) days respectively, and found higher density P. multocida carriage was associated with slower clearance (p = 0.036). This work offers insights into the dynamics of pathobiont carriage and provides a potential platform for further data collection and modelling studies.

Efficacy of pamidronate in children with chronic non-bacterial osteitis using whole body MRI as a marker of disease activity

BACKGROUND

To study the response to pamidronate using whole body magnetic resonance imaging (WB-MRI) in children with chronic non-bacterial osteitis (CNO) in a tertiary health centre.

METHODS

The medical records of children under the age of sixteen with a diagnosis of chronic non-bacterial osteitis between 2005 and 2018 were reviewed. All those who were treated with pamidronate were included and relevant data was collected. Response to therapy was determined based on the status of lesions on WB- MRI.

RESULTS

Forty six patients were included in the study. Pre- and post-treatment WB-MRI was available in forty patients. Cumulative lesions pre-treatment were 150 and reduced to 45 (30%) post-treatment. Seventeen patients (42.5%) had a good response with complete resolution of all lesions and nine patients (22.5%) worsened during or following treatment with pamidronate. Vertebral disease had a good response and 82.3% of the lesions resolved completely.

CONCLUSION

Our study describes the experience with pamidronate in a tertiary health centre using WB-MRI as a marker of disease activity. Pamidronate was well tolerated in our cohort and treatment response was fairly good.

SIGNIFICANCE AND INNOVATION

1. Bisphosphonates can be used in the treatment of CNO when response to NSAIDs is suboptimal. 2. In the presence of spinal or mandibular lesions bisphosphonates were used as first line. 3. Treatment was escalated to a TNF blocker when response to bisphosphonates was suboptimal.

Th17 responses to pneumococcus in blood and adenoidal cells in children

Pneumococcal infections cause a large global health burden, and the search for serotype-independent vaccines continues. Existing conjugate vaccines reduce nasopharyngeal colonization by target serotypes. Such mucosal effects of novel antigens may similarly be important. CD4+ Th17 cell-dependent, antibody-independent reductions in colonization and enhanced clearance have been described in mice. Here we describe the evaluation of T helper type 17 (Th17) cytokine responses to candidate pneumococcal protein vaccine antigens in human cell culture, using adenoidal and peripheral blood mononuclear cells. Optimal detection of interleukin (IL)-17A was at day 7, and of IL-22 at day 11, in these primary cell cultures. Removal of CD45RO+ memory T cells abolished these responses. Age-associated increases in magnitude of responses were evident for IL-17A, but not IL-22, in adenoidal cells. There was a strong correlation between individual IL-17A and IL-22 responses after pneumococcal antigen stimulation (P < 0·015). Intracellular cytokine staining following phorbol myristate acetate (PMA)/ionomycin stimulation demonstrated that  > 30% CD4+ T cells positive for IL-22 express the innate markers γδT cell receptor and/or CD56, with much lower proportions for IL-17A+ cells (P < 0·001). Responses to several vaccine candidate antigens were observed but were consistently absent, particularly in blood, to PhtD (P < 0·0001), an antigen recently shown not to impact colonization in a clinical trial of a PhtD-containing conjugate vaccine in infants. The data presented and approach discussed have the potential to assist in the identification of novel vaccine antigens aimed at reducing pneumococcal carriage and transmission, thus improving the design of empirical clinical trials.

For debate: health service support planning for large-scale defensive land operations (part 2)

This is the second of two articles that considers the medical planning implications of large-scale defensive military operations. This paper describes a unified approach to theatre level health services support planning based on four phases: collection, hospitalisation, evacuation and reception. It highlights the need for a modular and agile system of medical capability building blocks that can be grouped together for specific military medical challenges. It also reintroduces the concepts of mass casualty and the medical reserve. These two papers are designed to encourage debate around how we should be organised to face the new challenges of health services support in potential peer-on-peer military operations.

For debate: health service support planning for large-scale defensive land operations (part 1)

This is the first of two articles that considers the medical planning implications of large-scale defensive military operations. This paper considers the military context and planning factors that may require a medical plan that is different from that seen in recent counterinsurgency operations. The scale and complexity of the challenge is likely to require a greater level of decentralisation and a more sophisticated approach to medical planning at the strategic and operational levels.

Implementing a nursing systems framework in a developing country

AIM

To test the effect on patient mortality of implementing a nursing systems framework across a national health system.

BACKGROUND

There have been five previous observational studies that have tested the effect of a nursing systems framework on clinical outcomes for patients. Implementation of a nursing systems framework in the health system of a developing country has not been evaluated.

DESIGN

Quasi-experimental (before and after) study.

METHOD

A nursing systems framework consisting of six themes: (i) Professionalisation; (ii) Education; (iii) Structure; (iv) Quality of nursing care; (v) An academic health system; and (vi) Communication (Professional), was implemented across the national health system of Qatar in March 2015. Routine administrative data were extracted (March 2014-February 2016) for elective admissions. Our primary and secondary outcomes were, respectively, all cause mortality at discharge and readmission to hospital (within 28 days of discharge). We split the data into two time periods: before (March 2014-February 2015) and after (March 2015-February 2016) the implementation of the nursing systems framework. Multivariable regression modelling was used to examine the effect of the framework on patient mortality, after adjusting for key confounding variables (patient age, episode acuity, intensive care admission and length of stay).

FINDINGS

Data were extracted for 318 548 patients (year 1 = 130 829; year 2 = 187 725). After adjusting for confounding, there was a significant association between the implementation of the nursing systems framework, mortality and readmission.

CONCLUSION AND IMPLICATIONS FOR NURSING POLICY AND PRACTICE

Our observations suggest that the implementation of a nursing systems framework may be important in improving outcomes for patients in emerging health systems.

Chronic recurrent multifocal osteomyelitis (CRMO) - advancing the diagnosis

BACKGROUND

Chronic recurrent multifocal osteomyelitis (CRMO) is a little known inflammatory bone disease occurring primarily in children and adolescents. Delays in referral and diagnosis may lead to prolonged courses of antibiotics with in-patient care, unnecessary radiation exposure from multiple plain radiographs or bone scans and repeated surgery including bone biopsies. Children (aged < 18 years) diagnosed with CRMO between January 2005 and December 2012, reviewed at Bristol Royal Hospital for Children were included and all available data collected. Information regarding CRMO was sent to all orthopaedic surgeons in the region in 2009. The aim of the study was to examine the features of the cohort, to examine the length of time to diagnosis and to explore the criteria used for diagnosis with and without biopsy.

FINDINGS

Over an 8 year period, 41 patients were diagnosed with CRMO. Symptom onset occurred at a median of 9 years of age and time to diagnosis had a median of 15 months (range 0-92). Correlation coefficient analysis for time to diagnosis by year showed statistical significance with a decreasing trend. From the cohort data, diagnostic criteria were developed; applied retrospectively, 34 (83 %) children may have been diagnosed using the criteria, without a biopsy.

CONCLUSIONS

The data suggest that increasing knowledge of this condition may shorten time to diagnosis. Use of the Bristol diagnostic criteria by an experienced clinician may obviate the need for biopsy in some patients.

Reference intervals for red cell variables and platelet counts in infants at 2, 5 and 13 months of age: a cohort study

AIMS

To derive reference values for red cell variables and platelet counts from a cohort of infants sampled at precise ages during the first 13 months of life.

METHODS

Blood counts, reticulocyte counts and zinc protoporphyrin concentrations were obtained from healthy term infants of North European ancestry at 2, 5 and 13 months of age.

RESULTS

Mean cell volume (MCV) and mean cell haemoglobin (MCH) values did not differ significantly between 5 and 13 months and MCH concentration was unaffected by age. Values of all other variables at any one age differed significantly from those at the other two. Haemoglobin, mean cell haemoglobin, zinc protoporphyrin and platelet values (95% ranges) at 2 (n=119), 5 (n=97) and 13 months (n=42) were, respectively, 91-125, 101-129 and 105-133 g/L; 28.6-33.1, 24.5-28.7 and 24.3-28.7 pg; 36-116, 25-91 and 27-57 micromol/mol haem; and 216-658, 241-591 and 209-455×10(9)/L. At 2 and 5 months, respectively, 26.9% and 10.8% of subjects had platelet counts >500×10(9)/L. Reticulocyte counts at 2 months and MCV and MCH values at 5 months were significantly higher in girls. In boys, red cell distribution width values were significantly higher at 5 months, and zinc protoporphyrin values at both 2 and 5 months.

CONCLUSIONS

These findings indicate the value of obtaining reference data at precise ages during infancy and confirm and extend earlier reports indicating a gender difference in laboratory measures used to assess iron status in early infancy.

Polysaccharide-protein conjugate vaccination induces antibody production but not sustained B-cell memory in the human nasopharyngeal mucosa

Colonization of the nasopharyngeal mucosa by meningococcus and other polysaccharide (PS)-encapsulated bacteria precedes invasion. PS-conjugate vaccines induce PS-specific B-cell memory (B(MEM)) and also prevent colonization, thus blocking person-to-person transmission, generating herd protection. However, in isolation the B(MEM) are unable to sustain immunity. Furthermore, the duration of herd protection the vaccines induce appears limited. We demonstrate that, despite the persistence of PS-specific B(MEM), the population is not maintained within the nasopharynx. Although booster immunization results in the transient appearance of PS-specific B(MEM) within the mucosa, this reflects the re-circulation of systemic B(MEM) through the site rather than the generation of resident mucosal B(MEM). The induction of sustained PS-specific B(MEM) in the nasopharynx would allow the population to be activated by colonization, thus inhibiting subsequent invasion. It would also be expected to boost local mucosal immunity, thus extending herd protection. Strategies to generate PS-specific B(MEM) in the mucosa warrant further investigation.

Pneumococcal neuraminidase A: an essential upper airway colonization factor for Streptococcus pneumoniae

Streptococcus pneumoniae colonizes the upper respiratory tract from where the organisms may disseminate systemically to cause life threatening infections. The mechanisms by which pneumococci colonize epithelia are not understood, but neuraminidase A (NanA) has a major role in promoting growth and survival in the upper respiratory tract. In this article we show that mutants of S. pneumoniae D39 deficient in NanA or neuraminidase B (NanB) are abrogated in adherence to three epithelial cell lines, and to primary nasopharyngeal cells. Adherence levels were partly restored by nanA complementation in trans. Enzymic activity of NanA was shown to be necessary for pneumococcal adherence to epithelial cells, and adherence of the nanA mutant was restored to wild-type level by pre-incubation of epithelial cells with Lactococcus lactis cells expressing NanA. Pneumococcal nanA or nanB mutants were deficient in biofilm formation, while expression of NanA on L. lactis or Streptococcus gordonii promoted biofilm formation by these heterologous host organisms. The results suggest that NanA is an enzymic factor mediating adherence to epithelial cells by decrypting receptors for adhesion, and functions at least in part as an adhesin in biofilm formation. Neuraminidase A thus appears to play multiple temporal roles in pneumococcal infection, from adherence to host tissues, colonization, and community development, to systemic spread and crossing of the blood-brain barrier.

U-2012: An improved Lowry protein assay, insensitive to sample color, offering reagent stability and enhanced sensitivity

Traditional colorimetric protein assays such as Biuret, Lowry, and modified Lowry (U-1988) are unsuitable for colored biological samples. Here we describe an improved Lowry protein assay (U-2012), which utilizes stable reagents and offers enhanced sensitivity over the U-1988 assay. U-2012 circumvents interference from colored pigments and other substances (for example sugars) bound to perchloric acid (PCA) precipitated proteins by hydrogen peroxide (H2O2) induced oxidation at 50°C. Unused hydrogen peroxide is neutralized with sodium pyruvate before protein estimation for a stable end color. The U-2012 assay is carried out on the PCA precipitated protein pellet after neutralization (with Na2CO3 plus NaOH), solubilization (in Triton-NaCl), decolorization (by H2O2) and pyruvate treatment. Protein contents in red wine and homogenates of beetroot and blueberry are calculated from standard curves established for various proteins and generated using a rectangular hyperbola with parameters estimated with Microsoft Excel's Solver add-in. The U-2012 protein assay represents an improvement over U-1988 and gives a more accurate estimation of protein content.

Open-label, randomised, parallel-group, multicentre study to evaluate the safety, tolerability and immunogenicity of an AS03(B)/oil-in-water emulsion-adjuvanted (AS03(B)) split-virion versus non-adjuvanted whole-virion H1N1 influenza vaccine in UK children 6 months to 12 years of age

OBJECTIVE

To evaluate the safety, tolerability and immunogenicity of an AS03(B)/oil-in-water emulsion-adjuvanted (AS03(B)) split-virion versus non-adjuvanted whole-virion H1N1 influenza vaccine in UK children aged 6 months to 12 years.

DESIGN

Multicentre, randomised, head-to-head, open-label trial.

SETTING

Five UK sites (Oxford, Bristol, Southampton, Exeter and London).

PARTICIPANTS

Children aged 6 months to < 13 years, for whom a parent or guardian had provided written informed consent and who were able to comply with study procedures, were eligible for inclusion.

INTERVENTIONS

A tocopherol/oil-in-water emulsion-adjuvanted (AS03(B)) egg culture-derived split-virion H1N1 vaccine and a non-adjuvanted cell culture-derived whole-virion vaccine, given as a two-dose schedule, 21 days apart, were compared. Participants were grouped into those aged 6 months to < 3 years (younger group) and 3 years to < 13 years of age (older group) and were randomised by study investigators (1 : 1 ratio) to receive one of the two vaccines. Vaccines were administered by intramuscular injection (deltoid or anterior-lateral thigh, depending on age and muscle bulk). Local reactions and systemic symptoms were collected for 1 week post immunisation, and serum was collected at baseline and after the second dose. To assess safety and tolerability, parents or guardians recorded the following information in diary cards from days 0-7 post vaccination: axillary temperature, injection site reactions, solicited and unsolicited systemic symptoms, and medications.

MAIN OUTCOME MEASURE

Comparison between vaccines of the percentage of participants demonstrating seroconversion by microneutralisation assay.

RESULTS

Among 937 children receiving vaccine, per-protocol seroconversion rates were higher after the AS03(B)-adjuvanted vaccine than after the whole-virion vaccine (98.2% vs 80.1% in children < 3 years, 99.1% vs 95.9% among those aged 3-12 years), as were severe local reactions (3.6% vs 0.0% in those under 5 years, 7.8% vs 1.1% in those aged 5-12 years), irritability in children < 5 years (46.7% vs 32.0%), and muscle pain in older children (28.9% vs 13.2%). The second dose of the adjuvanted vaccine was more reactogenic than the first, especially for fever > 38.0°C in those under 5 years of age (8.9% vs 22.4%).

CONCLUSION

The adjuvanted vaccine, although reactogenic, was more immunogenic, especially in younger children, indicating the potential for improved immunogenicity of influenza vaccines in this age group.

TRIAL REGISTRATION NUMBER

ISRCTN89141709.

Safety and immunogenicity of AS03B adjuvanted split virion versus non-adjuvanted whole virion H1N1 influenza vaccine in UK children aged 6 months-12 years: open label, randomised, parallel group, multicentre study

OBJECTIVES

To compare the safety, reactogenicity, and immunogenicity of an adjuvanted split virion H1N1 vaccine and a non-adjuvanted whole virion vaccine used in the pandemic immunisation programme in the United Kingdom.

DESIGN

Open label, randomised, parallel group, phase II study.

SETTING

Five UK centres (Oxford, Southampton, Bristol, Exeter, and London).

PARTICIPANTS

Children aged 6 months to less than 13 years for whom a parent or guardian had provided written informed consent and who were able to comply with study procedures were eligible. Those with laboratory confirmed pandemic H1N1 influenza or clinically diagnosed disease meriting antiviral treatment, allergy to egg or any other vaccine components, or coagulation defects, or who were severely immunocompromised or had recently received blood products were excluded. Children were grouped by age: 6 months-<3 years (younger group) and 3-<13 years (older group). Recruitment was by media advertising and direct mailing. Recruitment visits were attended by 949 participants, of whom 943 were enrolled and 937 included in the per protocol analysis.

INTERVENTIONS

Participants were randomised 1:1 to receive AS03(B) (tocopherol based oil in water emulsion) adjuvanted split virion vaccine derived from egg culture or non-adjuvanted whole virion vaccine derived from cell culture. Both were given as two doses 21 days apart. Reactogenicity data were collected for one week after immunisation by diary card. Serum samples were collected at baseline and after the second dose.

MAIN OUTCOME MEASURES

Primary reactogenicity end points were frequency and severity of fever, tenderness, swelling, and erythema after vaccination. Immunogenicity was measured by microneutralisation and haemagglutination inhibition assays. The primary immunogenicity objective was a comparison between vaccines of the percentage of participants showing seroconversion by the microneutralisation assay (fourfold rise to a titre of >or=1:40 from before vaccination to three weeks after the second dose).

RESULTS

Seroconversion rates were higher after the adjuvanted split virion vaccine than after the whole virion vaccine, most notably in the youngest children (163 of 166 participants with paired serum samples (98.2%, 95% confidence interval 94.8% to 99.6%) v 157 of 196 (80.1%, 73.8% to 85.5%), P<0.001) in children under 3 years and 226 of 228 (99.1%, 96.9% to 99.9%) v 95.9%, 92.4% to 98.1%, P=0.03) in those over 3 years). The adjuvanted split virion vaccine was more reactogenic than the whole virion vaccine, with more frequent systemic reactions and severe local reactions in children aged over 5 years after dose one (13 (7.2%, 3.9% to 12%) v 2 (1.1%, 0.1% to 3.9%), P<0.001) and dose two (15 (8.5%, 4.8% to 13.7%) v 2 (1.1%, 0.1% to 4.1%), P<0.002) and after dose two in those under 5 years (15 (5.9%, 3.3% to 9.6%) v 0 (0.0%, 0% to 1.4%), P<0.001). Dose two of the adjuvanted split virion vaccine was more reactogenic than dose one, especially for fever >or=38 masculineC in those aged under 5 (24 (8.9%, 5.8% to 12.9%) v 57 (22.4%, 17.5% to 28.1%), P<0.001).

CONCLUSIONS

In this first direct comparison of an AS03(B) adjuvanted split virion versus whole virion non-adjuvanted H1N1 vaccine, the adjuvanted vaccine, while more reactogenic, was more immunogenic and, importantly, achieved high seroconversion rates in children aged less than 3 years. This indicates the potential for improved immunogenicity of influenza vaccines in this age group.

TRIAL REGISTRATION

Clinical trials.gov NCT00980850; ISRCTN89141709.

Anaphylaxis following single component measles and rubella immunisation

Anaphylaxis as an adverse event following immunisation (AEFI) is a rare occurrence. We report four cases of anaphylaxis following administration of single component measles or rubella vaccine between January 2003 and June 2007. We estimate that the incidence of anaphylaxis to measles and rubella single component vaccines is 18.9 and 22.4 cases/100,000 doses, respectively. These figures are likely to be an underestimate but are higher than expected. Our calculations were hampered by lack of immunisation reporting data from the private sector. We recommend that NHS standards of vaccine data reporting are also applied to private clinics.

Severe complications of chickenpox in hospitalised children in the UK and Ireland

AIMS

To estimate the annual incidence of hospitalisations due to severe complications of varicella, describe the complications and estimate annual mortality.

METHODS

Active surveillance throughout the UK and Ireland for 13 months by paediatricians notifying cases to the British Paediatric Surveillance Unit and completing a questionnaire. The case definition was any child aged <16 years hospitalised with complicated varicella, as defined by a list of conditions, or admitted to ICU/HDU with varicella.

RESULTS

188 cases were notified for the surveillance period, of which 112 (0.82/100 000 children/year) met the case definition and were not duplicates. Confirmed cases had a median age of 3 years (range 0-14). The complications were: bacteraemia/septic shock (n = 30), pneumonia (n = 30), encephalitis (n = 26), ataxia (n = 25), toxic shock syndrome/toxin-mediated disease (n = 14), necrotising fasciitis (n = 7), purpura fulminans/disseminated coagulopathy (n = 5), fulminant varicella (n = 5) and neonatal varicella (n = 3). 52 children (46%) had additional bacterial infections. Six deaths were due, or possibly due, to varicella, including one intrauterine death. Four of the other five children who died (ages 2-14 years) had a pre-existing medical condition. Sequelae on discharge were reported for 41 cases (40%), most frequently ataxia or skin scarring. The median length of hospital stay was 7 days (range 1-68).

CONCLUSIONS

This study provides a minimum estimate of severe complications and death resulting from varicella in children in the UK and Ireland. Most complications, excluding deaths, occur in otherwise healthy children and thus would be preventable only through a universal childhood immunisation programme.

[A novel questionnaire to assess activity in patients after hip arthroplasties]

BACKGROUND

Until now, the activity of the lower limb could only be exactly measured with expensive electronic pedometers. The aim of this study was to develop a feasible questionnaire to measure the activity of patients after arthroplasty.

METHODS

The "Daily Activity Questionnaire" (DAQ) was developed in several steps and the evaluation was carried out in three groups of patients with osteoarthritis of the hip (160 patients and 855 investigated days). The psychometric characteristics were verified.

RESULTS

The retest reliability (ICC) of the DAQ is in a range comparable to the electronic pedometer StepWatch. The testing of the criterion validity showed high correlations between the StepWatch and the DAQ (r=0.743).

CONCLUSION

Because of its high correlations to the load changes actually performed, the DAQ is especially suited to answer arthroplasty-related questions. In all patient groups, projected load changes between 1.8 and 2.4 million per year were found, which by far exceed the generally accepted test standards for endoprostheses.

Morphologic parameters of early cleavage-stage embryos that correlate with fetal development and delivery: prospective and applied data for increased pregnancy rates

BACKGROUND

Many different embryo selection criteria have been used in assisted reproductive technologies (ART), but there are no published prospective studies to ascertain their usefulness in predicting implantation.

METHODS

In a prospective trial, 20 early scoring parameters previously reported to influence clinical outcome were collected, but embryos were selected for transfer by current laboratory protocols; day 1 pronuclear (PN) (Z) score combined with day 3 or 5 morphology. Data points for each oocyte/embryo were scored independently and tracked individually. Data were analysed retrospectively for parameters most likely to result in a positive pregnancy test, fetal heartbeat (FHB) and delivery.

RESULTS

Results indicated that day 1 PN morphology and nucleolar precursor body (NPB) ratio, day 2 cell number, blastomere symmetry and nucleation and the ability to cleave from day 2 to day 3 were the six most significant factors in fetal development. This outcome was then applied prospectively over 8 months. The implantation rate (IR) and clinical pregnancy rate (CPR) increased in each age group, and the number of embryos used decreased.

CONCLUSION

In conclusion, early parameters that include PN morphology, number and ratio of NPBs per nucleus and the day 2 morphology of cleaving embryos are stronger positive predictors of implantation than day 3 morphology or the ability to achieve the blastocyst stage of development. Parameters that were most consistently correlated with no delivery were lack of PN symmetry, day 2 multinucleation and uneven cell size. Day 3 and day 5 parameters were not significant compared with the combination of early parameters.