Private groundwater contamination and risk management: A comparative scoping review of similarities, drivers and challenges across two socio-economically developed regions

Consolidation of multi-domain risk management research is essential for strategies facilitating the concerted government (educational) and population-level (behavioural) actions required to reduce microbial private groundwater contamination. However, few studies to date have synthesised this literature or sought to ascertain the causal generality and extent of supply contamination and preventive responses. In light of the Republic of Ireland (ROI) and Ontario's high reliance and research focus on private wells and consequent utility for empirical comparison, a scoping review of pertinent literature (1990-2022) from both regions was undertaken. The SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) method was employed to inform literature searches, with Scopus and Web of Science selected as primary databases for article identification. The review identified 65 relevant articles (Ontario = 34, ROI = 31), with those investigating well user actions (n = 22) and groundwater quality (n = 28) the most frequent. A markedly higher pooled proportion of private supplies in the ROI exhibited microbial contamination (38.3 % vs. 4.1 %), despite interregional similarities in contamination drivers (e.g., weather, physical supply characteristics). While Ontarian well users demonstrated higher rates of historical (≥ 1) and annual well testing (90.6 % vs. 71.1 %; 39.1 % vs. 8.6 %) and higher rates of historical well treatment (42.3 % vs. 24.3 %), interregional levels of general supply knowledge were analogous (70.7 % vs. 71.0 %). Financial cost, organoleptic properties and residence on property during supply construction emerged as predictors of cognition and behaviour in both regions. Review findings suggest broad interregional similarities in drivers of supply contamination and individual-level risk mitigation, indicating that divergence in contamination rates may be attributable to policy discrepancies - particularly well testing incentivisation. The paucity of identified intervention-oriented studies further highlights the importance of renewed research and policy agendas for improved, targeted well user outreach and incentivised, convenience-based services promoting routine supply maintenance.

Inoculum source dependent effects of ericoid, mycorrhizal fungi on flowering and reproductive success in highbush blueberry (Vaccinium corymbosum)

Most terrestrial angiosperms form mutualisms with both mycorrhizal fungi and animal pollinators. Yet, the effects of mycorrhizae on pollinator behavior and plant reproduction are unknown for most species, and whether the source or type of mycorrhizal fungi affects reproductive success has rarely been examined. We examined whether inoculating highbush blueberry (Vaccinium corymbosum; Ericaceae) with ericoid mycorrhizal fungi enhanced investment in flowering and attractiveness to pollinators, and thus reduced their levels of pollen limitation over that of non-inoculated plants. We also examined the degree to which pollen limitation was dependent on inoculation source and the surrounding pollinator community context. Three-year-old saplings of Vaccinium corymbosum 'Bluecrop' or highbush blueberry (Ericaceae) were inoculated with a) ericoid mycorrhizal fungi within soil of the rhizosphere of plants growing at a local blueberry farm, b) a commercially available ericoid inoculant, c) both the local soils and commercial inoculum, or d) were not inoculated and served as controls. They were grown for one year in pots in a common garden and, in the following year, were moved to six farms in central Vermont that were known from prior studies to differ in pollinator abundance and diversity. We conducted a hand pollination experiment at each farm to examine if inoculation or pollinator abundance (i.e., farm context) affected reproductive success. Plants treated with all types of inoculums were more likely to flower, and produced more inflorescence buds than non-inoculated plants in 2018. However, in 2019, plants in the combination inoculum treatment, alone, produced more inflorescence buds than those in the other treatments. Neither the source of inoculum nor hand pollination affected fruit set (the proportion of flowers setting fruit), or fruit sugar content. Hand pollination, but not inoculation, increased berry mass and the average number of seeds produced/berry. Our results add to the growing body of evidence that mycorrhizal fungi can affect reproductive traits of their hosts but that the effects of mycorrhizal fungi depend on the mycorrhizal symbionts.

Digital transformation of peatland eco-innovations ('Paludiculture'): Enabling a paradigm shift towards the real-time sustainable production of 'green-friendly' products and services

The world is heading in the wrong direction on carbon emissions where we are not on track to limit global warming to 1.5 °C; Ireland is among the countries where overall emissions have continued to rise. The development of wettable peatland products and services (termed 'Paludiculture') present significant opportunities for enabling a transition away from peat-harvesting (fossil fuels) to developing 'green' eco-innovations. However, this must be balanced with sustainable carbon sequestration and environmental protection. This complex transition from 'brown to green' must be met in real time by enabling digital technologies across the full value chain. This will potentially necessitate creation of new green-business models with the potential to support disruptive innovation. This timely paper describes digital transformation of paludiculture-based eco-innovation that will potentially lead to a paradigm shift towards using smart digital technologies to address efficiency of products and services along with future-proofing for climate change. Digital transform of paludiculture also aligns with the 'Industry 5.0 - a human-centric solution'. However, companies supporting peatland innovation may lack necessary standards, data-sharing or capabilities that can also affect viable business model propositions that can jeopardize economic, political and social sustainability. Digital solutions may reduce costs, increase productivity, improve produce develop, and achieve faster time to market for paludiculture. Digitisation also enables information systems to be open, interoperable, and user-friendly. This constitutes the first study to describe the digital transformation of paludiculture, both vertically and horizontally, in order to inform sustainability that includes process automation via AI, machine learning, IoT-Cloud informed sensors and robotics, virtual and augmented reality, and blockchain for cyber-physical systems. Thus, the aim of this paper is to describe the applicability of digital transformation to actualize the benefits and opportunities of paludiculture activities and enterprises in the Irish midlands with a global orientation.

Behcet's Disease (BD) Presenting as a Cerebral Venous Sinus Thrombosis (CVST)

Presentation 20 year old Caucasian male presented to eye casualty 4 weeks post initial diagnosis of bilateral acute anterior uveitis (AAU), with a three-week history of a progressively worsening headache associated with nausea and vomiting. Diagnosis Non-contrast Computed Topography of the head and Magnetic Resonance venogram revealed a cerebral venous sinus thrombosis (CVST). He had a long-standing history of intermittent oral ulceration, and was diagnosed with Neuro Behcet's Disease (NBD). Treatment The patient was commenced on a therapeutic dose of enoxaparin and prednisolone, and was discharged on enoxaparin, warfarin, tapering prednisolone and azathioprine. Discussion/Conclusion NBD is a rare, but serious manifestation of BD. BD is an important differential diagnosis in a young patient presenting with CVST or bilateral AAU.

222 OLDER ADULT INPATIENTS’ PERCEPTIONS OF PROGRESSIVE RESISTANCE TRAINING IN A SPECIALIST GERIATRIC REHABILITATION SETTING

Background

Progressive resistance training (PRT) has the potential to reduce age-related disability and has been proven to benefit the older adult in a variety of ways. PRT is prescribed routinely by physiotherapists for frail older adults in an inpatient setting. To date little is known of their experiences engaging in PRT. This study aimed to explore older adult inpatients’ perceptions and experience of PRT as part of their overall physiotherapy program in a Specialised Geriatric Rehabilitation Unit.

Methods

The study had a qualitative design. Semi-structured interviews explored experiences and perceptions of PRT along with motivators and barriers to participation. Interviews were face to face and conducted in the unit. Data was analysed using thematic analysis. 11 frail older inpatients with orthogeriatric (n = 5), neurological (n = 2), general surgical (n = 2) and general medical (n = 2) diagnoses were interviewed.

Results

The study identified three overarching themes: Acceptability, Facilitators and Barriers. In the category of Acceptability participants identified the subthemes: (1) PRT is challenging, (2) PRT is Rewarding and (3) PRT is Enjoyable. In the category of Facilitators, the following subthemes emerged: (4) Positive outcomes as motivators and (5) Supervision is necessary for engagement. In the category of Barriers, (6) Low self-efficacy beliefs and (7) the Negative effects of PRT, such as pain and fatigue affected participation.

Conclusion

Frail older inpatients find PRT to be an acceptable form of exercise. It is perceived to be challenging, but rewarding and enjoyable for most. Participants were motivated to participate in PRT by the positive outcomes (improved strength, general health, function, independence, confidence) they experienced. They felt supervision from professionals with medical expertise was essential to participation; and had low self-efficacy beliefs surrounding independent practice; fearing falling and causing harm. Pain and fatigue also impacted participation.

School characteristics and children's mental health: A linked survey-administrative data study

Mental health difficulties are childhood-onset with lifelong health, social and economic consequences. Children spend a large amount of time in schools, making schools an important context for mental health prevention and support. We examine how school composition and school climate, controlling for individual child-level characteristics, are associated with children's mental health difficulties (emotional and behavioural difficulties). Data from 23,215 children from 648 primary schools in England were analysed to examine the associations of school composition (size, gender, socioeconomic and ethnicity) and school climate with mental health (emotional symptoms, behavioural symptoms and above clinical cut-off scores) adjusting for individual child socio-demographic characteristics. We find that between 3% and 4.5% of the variation in children's mental health outcomes could be attributed to schools. Of this, small proportions were explained by school composition (1.4 to 3.8%) and larger proportions were explained by school climate (29.5 to 48.8%). Lower school socio-economic status was associated with higher behavioural symptoms (coef = 0.02 [95%CI: 0.01-0.04]) and slightly raised odds of high mental health difficulties (OR = 1.05, 95% CI: 1.01,1.09). More positive school climate was associated with lower emotional (coef = -0.09 [95%CI:-0.11,-0.08]) and behavioural (coef = -0.13 [95% CI,-0.15:-0.11]) symptoms and lower odds of mental health difficulties (OR = 0.78, 95%CI:0.74,0.81). Some associations between school factors and mental health were moderated by child sex and SES. School composition factors were weakly associated with children's mental health, whereas school climate explained a larger amount of between-school variation and appears a good target for universal prevention of mental health difficulties in children.

National Guidelines on the Provision of Outpatient Parenteral Antimicrobial Therapy (OPAT)

Aim Outpatient parenteral antimicrobial therapy (OPAT) is an option in patients who require parenteral antimicrobial administration and are clinically well enough for hospital discharge. This is an update of the Irish National OPAT guidelines which were last reviewed in 2011. Methods The guideline was devised through a collaborative process with the national OPAT Working Group and a review of the literature. It is intended for clinicians who prescribe any intravenous (IV) antimicrobials outside of the inpatient setting in the Republic of Ireland. Results Patient care while on OPAT should be provided by a designated OPAT service, with clear managerial and clinical governance lines of responsibility. It should be conducted using a team approach with a clinical lead on each site either as an infection specialist, or a general medical physician with infection specialist input and an OPAT nurse. An antimicrobial pharmacist is also desirable. Several factors must be considered when assessing patient's suitability for OPAT including exclusion criteria, infection-specific factors, and patient specific factors such as physical, social and logistic criteria. Conclusion This updated guideline advocates a more individualised OPAT approach, with the recognition that specific antimicrobials and/or specific delivery models may be more appropriate for certain patient groups. Full guidelines are available through www.opat.ie.

Assessment of two behavioural models (HBM and RANAS) for predicting health behaviours in response to environmental threats: Surface water flooding as a source of groundwater contamination and subsequent waterborne infection in the Republic of Ireland

Extreme weather events (EWEs) are increasing in frequency, posing a greater risk of adverse human health effects. As such, developing sociological and psychological based interventions is paramount to empowering individuals and communities to actively protect their own health. Accordingly, this study compared the efficacy of two established social-cognitive models, namely the Health Beliefs Model (HBM) and Risks-Attitudes-Norms-Abilities-Self-regulation (RANAS) framework, in predicting health behaviours following EWEs. Surface water flooding was used as the exemplar EWE in the current study, due to the increasing incidence of these events in the Republic of Ireland over the past decade. Levels of prior experience with flooding were considered for analyses and comparative tools included a number of variables predicting health behaviours and intervention potential scores (i.e. measure of impact of targeting each model element). Results suggest that the RANAS model provides a robust foundation for designing interventions for any level of experience with an extreme weather event, however, use of the simpler HBM may be more cost-effective among participants unacquainted with an EWE and in relatively infrequent health threat scenarios. Results provide an evidence base for researchers and policymakers to appropriately engage with populations about such threats and successfully promote spatiotemporally appropriate health behaviours in a changing climate.

Colorectal cancer liver metastatic growth depends on PAD4-driven citrullination of the extracellular matrix

Citrullination of proteins, a post-translational conversion of arginine residues to citrulline, is recognized in rheumatoid arthritis, but largely undocumented in cancer. Here we show that citrullination of the extracellular matrix by cancer cell derived peptidylarginine deiminase 4 (PAD4) is essential for the growth of liver metastases from colorectal cancer (CRC). Using proteomics, we demonstrate that liver metastases exhibit higher levels of citrullination and PAD4 than unaffected liver, primary CRC or adjacent colonic mucosa. Functional significance for citrullination in metastatic growth is evident in murine models where inhibition of citrullination substantially reduces liver metastatic burden. Additionally, citrullination of a key matrix component collagen type I promotes greater adhesion and decreased migration of CRC cells along with increased expression of characteristic epithelial markers, suggesting a role for citrullination in promoting mesenchymal-to-epithelial transition and liver metastasis. Overall, our study reveals the potential for PAD4-dependant citrullination to drive the progression of CRC liver metastasis.

Surface water flooding, groundwater contamination, and enteric disease in developed countries: A scoping review of connections and consequences

Significant volumes of research over the past four decades has sought to elucidate the social, infrastructural, economic, and human health effects of climate change induced surface flooding. To date, epidemiological and public health studies of flooding events have focused on mental health effects, vector-borne diseases, and infectious enteric disease due to floodwater contact (i.e. typically low consumption rates). The inherent nature of groundwater (i.e. out of sight, out of mind) and the widely held belief that aquifers represent a pristine source of drinking water due to natural attenuation may represent the "perfect storm" causing direct consumption of relatively large volumes of surface flood-contaminated groundwater. Accordingly, the current study sought to systematically identify and synthesize all available peer-reviewed literature pertaining to the nexus between surface flooding, groundwater contamination and human gastroenteric outcomes. Just 14 relevant studies were found to have been published during the period 1980-2017, thus highlighting the fact that this potentially significant source of climate-related exposure to environmental infection has remained understudied to date. Studies differed significantly in terms of type and data reporting procedures, making it difficult to discern clear trends and patterns. Approximately 945 confirmed cases of flood-related enteric disease were examined across studies; these concurred with almost 10,000 suspected cases, equating to approximately 20 suspected cases per confirmed case. As such, no regional, national or global estimates are available for the human gastrointestinal health burden of flood-related groundwater contamination. In light of the demonstrable public health significance of the concurrent impacts of groundwater susceptibility and climate change exacerbation, strategies to increase awareness about potential sources of contamination and motivate precautionary behaviour (e.g. drinking water testing and treatment, supply interruptions) are necessary. Mainstreaming climate adaptation concerns into planning policies will also be necessary to reduce human exposure to waterborne sources of enteric infection.

Clinical utility of RASSF1A methylation in human malignancies

The high frequency of RASSF1A methylation has been noted in a vast number of patients in a broad spectrum of malignancies, suggesting that RASSF1A inactivation is associated with cancer pathogenesis. However, whether this recurrent incidence of RASSF1A hypermethylation in human malignancies and its association with more aggressive tumour phenotype is a frequent event across different cancer types has not yet been discussed. In this review, we interrogated existing evidence for association of RASSF1A hypermethylation with clinicopathological characteristics that can indicate more invasive lesions.

Current and future approaches to the prevention and treatment of staphylococcal medical device-related infections

Staphylococci, in particular Staphylococcus aureus and Staphylococcus epidermidis, are a leading cause of healthcare-associated infections. Patients who have a medical device inserted are at particular risk of an infection with these organisms as staphylococci possess a wide range of immune evasion mechanisms, one of which being their ability to form biofilm. Once embedded in a biofilm, bacteria are inherently more resistant to treatment with antibiotics. Despite advances in our understanding of the pathogenesis of staphylococcal biofilm formation, medical devices colonised with biofilms frequently require removal. New and novel approaches to prevent and treat biofilm infections are urgently required. In recent years, progress has been made on approaches that include antiadhesive strategies to prevent surface adhesion or production of bacterial adhesins, dissolution of already established biofilm, targeting of biofilm matrix for degradation and interference with biofilm regulation. Several obstacles need to be overcome in the further development of these and other novel anti-biofilm agents. Most notably, although in vitro investigation has progressed over recent years, the need for biofilm models to closely mimic the in vivo situation is of paramount importance followed by controlled clinical trials. In this review we highlight the issues associated with staphylococcal colonisation of medical devices and potential new treatment options for the prevention and control of these significant infections.

MR imaging of the pancreas

Magnetic resonance (MR) imaging of the pancreas is useful as both a problem-solving tool and an initial imaging examination of choice. With newer imaging sequences such as diffusion-weighted imaging, MR offers improved ability to detect and characterize lesions and identify and stage tumors and inflammation. MR cholangiopancreatography can be used to visualize the pancreatic and biliary ductal system. In this article, the use of MR to evaluate the pancreas, including recent advances, is reviewed and the normal appearance of the pancreas on different imaging sequences, as well as inflammatory diseases, congenital abnormalities, and neoplasms of the pancreas, are discussed.

Hyperexpression of Escherichia coli Xylose Isomerase

The xylose isomerase (xylA) structural gene was cloned under the control of the tac promoter and expressed in a xyl(+) E. coli strain. Xylose isomerase accounted for approximately 28% of the total cell protein when this tac-xylA fusion was induced with isopropylthio beta-D-galactopyranoside. Hyperexpression of the xylA gene inhibited xylose utilization. E. coli carrying this tac-xylA fusion was encapsulated in calcium-alginate beads and used to isomerase xylose in a column reactor. Conversion of xylose to xylulose was 3-4% with a residence time in the column of 2 minutes and a maximum of 12% upon recycling.

Use of e-learning to enhance medical students' understanding and knowledge of healthcare-associated infection prevention and control

An online infection prevention and control programme for medical students was developed and assessed. There was a statistically significant improvement (P<0.0001) in the knowledge base among 517 students after completing two modules. The majority of students who completed the evaluation were positive about the learning experience.

Pharmacokinetic/pharmacodynamic modelling of 2-acetyl-4(5)-tetrahydroxybutyl imidazole-induced peripheral lymphocyte sequestration through increasing lymphoid sphingosine 1-phosphate

2-Acetyl-4(5)-tetrahydroxybutyl imidazole (THI) has been shown to reduce rodent peripheral blood lymphocytes through increasing lymphoid sphingosine 1-phosphate (S1P) by inhibiting S1P lyase. The objective of this study was to characterize the relationship between systemic THI exposure, splenic S1P concentrations, and lymphopenia in rats. Following the oral administration of 10 and 100 mg kg(-1) THI to male rats, THI was rapidly absorbed and reached a plasma peak level at 1 h post-dosing. Splenic S1P increased and reached the peak level at 24 h. Blood lymphocyte count decreased as the splenic S1P level increased. THI plasma concentration was linked to splenic S1P concentration using an indirect model incorporated with a four-step signal transduction model. In turn, the S1P level was directly coupled with blood lymphocyte number. The integrated model simultaneously captured the splenic S1P and blood lymphocyte responses. This pharmacokinetic-biomarker-pharmacodynamic model resolved the remarkable discrepancy between plasma THI concentration and the pharmacological response and quantitatively described the relationship of THI exposure, S1P, and lymphopenic response.

The validity and reliability of diagnoses of work-related mental ill-health

OBJECTIVES

To establish the reliability and validity of work-related mental ill-health diagnoses.

BACKGROUND

A UK-based surveillance scheme for work-related ill-health involving occupational physicians (OPs) reporting suggests that mental ill-health incidence is increasing by around 13% per year, with anxiety, depression and "other work-related stress" being the most common diagnoses. There have been no studies of the validity and reliability of such diagnoses. Given the existence of a large network of psychiatrists (PSYs) also involved in surveillance of work-related ill-health, an opportunity arose to measure the concurrent validity and reliability of work-related mental ill-health diagnoses.

METHODS

100 anonymised summaries of cases previously reported by OPs or PSYs were collected; each was sent to 5 PSYs and 5 OPs, who assigned a diagnosis and judged whether the case was work-related. Concurrent validity of the ill-health aspect of the diagnoses, and of the opinion as to work-relatedness, was assessed by comparing the overall classifications of cases by OPs and PSYs. Reliability of the diagnostic classification was measured by kappa matrices.

RESULTS

Diagnostic proportions for PSYs and OPs demonstrated good agreement for anxiety, depression, anxiety plus depression and "stress" (11%, 34%, 27%, 14%) and (14%, 30%, 27%, 17%), respectively. In both groups, kappa coefficients were high for a psychotic diagnosis (0.78, 95% CI: 0.74 to 0.83), but not as high for anxiety (0.27, 95% CI: 0.23 to 0.32), depression (0.34, 95% CI: 0.29 to 0.38) and "stress" (0.15, 95% CI: 0.10 to 0.19). The odds ratio of classifying a case as work-related among PSYs compared to OPs was 2.39 (95% CI: 1.68 to 3.38), p<0.001.

CONCLUSIONS

The overall agreement between OPs and PSYs on mental ill-health diagnoses suggests that OP diagnoses are valid for epidemiological purposes. However, the within-group reliability of the diagnosis "stress" is low. Given differences in judgements about work-relatedness, further research is needed to investigate this aspect of a diagnosis.

Maternal age and infant mortality: a test of the Wilcox-Russell hypothesis

It has been argued (e.g., the Wilcox-Russell hypothesis) that (low) birth weight is a correlate of adverse birth outcomes but is not on the “causal” pathway to infant mortality. However, the US national policy for reducing infant mortality is to reduce low birth weight. If these theoretical views are correct, lowering the rate of low birth weight may have little effect on infant mortality. In this paper, the authors use the “covariate density defined mixture of logistic regressions” method to formally test the Wilcox-Russell hypothesis that a covariate which influences birth weight, in this case maternal age, can influence infant mortality directly but not indirectly through birth weight. The authors analyze data from 8 populations in New York State (1985–1988). The results indicate that among the populations examined, 1) maternal age significantly influences the birth weight distribution and 2) maternal age also affects infant mortality directly, but 3) the influence of maternal age on the birth weight distribution has little or no effect on infant mortality, because the birth-weight-specific mortality curve shifts accordingly to compensate for changes in the birth weight distribution. These results tend to support the Wilcox-Russell hypothesis for maternal age.

Does CPAP lead to change in BMI?

STUDY OBJECTIVES

Obesity is an important risk factor for obstructive sleep apnea syndrome (OSAS), and weight loss can reduce apnea severity or even lead to resolution in some patients. Effective CPAP therapy may lead to weight loss by any of several proposed mechanisms, including, but not limited to, increased physical activity and increased responsiveness to leptin. This retrospective study sought to determine whether subjects who adhered to prescribed CPAP treatment for OSAS would lose weight, or gain less weight than control subjects who were either untreated or did not adhere to prescribed CPAP treatment.

METHODS

BMI was determined at the time of diagnosis and at followup approximately 1 year (10-14 months) later. Subjects who used CPAP > or = 4 h per night and > or = 70% of nights were considered treatment subjects. Control subjects used no treatment for OSAS or used CPAP < 4 hours per night or < 70% of nights for 1 year.

RESULTS

BMI of treatment and control subjects did not significantly differ (p = 0.3157). BMI increased with 1 year of CPAP use in women but not men (p = 0.0228) and in non-obese subjects (p = 0.0443). BMI did not significantly decrease in any group treated with CPAP.

CONCLUSIONS

CPAP was associated with weight gain in some; none lost weight. CPAP may affect weight in ways not measured here. Physicians should stress an active weight loss plan and not assume CPAP alone will lead to weight loss. A larger, prospective study may help clarify these findings.

A single question as a sleepiness screening tool

STUDY OBJECTIVES

A single subjective question may be an effective screening tool for excessive daytime sleepiness. This study sought to determine whether the following single question about sleepiness can measure subjective sleepiness comparably to the Epworth Sleepiness Scale (ESS): "Please measure your sleepiness on a typical day: (0 = none, 10 is highest)." The relationship between this question and objective sleepiness as measured by the MSLT was also evaluated.

METHODS

303 subjects completed a sleep questionnaire, MSLT, and ESS within 2 months. ROC (receiver-operator characteristic) curves and contingency tables using Fisher's exact test were made using GraphPad Prism software.

RESULTS

ESS and SS scores showed a significant association at all SS score cut-points. ESS and MSL showed significant associations only at ESS scores 11, 12, and 18. SS scores were significantly related to the MSL only in non-sleep apneics at SS scores 2, 5, 6, and 8, and in sleep apneics at SS score 9. ROC analysis showed the SS could distinguish subjects with an ESS > or = 11 from those with an ESS < 11 (area = 0.71, p < 0.0001).

CONCLUSIONS

Neither the SS nor the ESS substitutes for the MSLT, which measures objective sleepiness and is not an appropriate screening tool. SS scores < or = 2 and > or = 9 reliably predict normal and abnormal ESS scores respectively. Since the ESS is not commonly used in non-sleep specialized practices, the SS may serve as a useful screening tool for patients with disorders of sleepiness.

Sleep-isolated trichotillomania: a survey of dermatologists

STUDY OBJECTIVES

To determine whether sleep-isolated trichotillomania has been recognized or suspected by dermatologists.

METHODS

Eight-hundred and seven practicing dermatologists in the Midwest were identified through the American Academy of Dermatologists website database. A 10-question multiple-choice survey regarding trichotillomania was mailed to each. Responses were anonymously returned by fax.

RESULTS

A total of 107 (13%) of the 807 dermatologists surveyed responded. Twelve (11%) reported having seen patients with trichotillomania that occurred solely during sleep. In cases of unexplained hair loss, 21(20%) suspected hair-pulling occurred only in sleep. Seventy-six subjects (71%) said they had seen patients with unexplained hair loss; 67 (88%) of those respondents said they would ask those patients if they pull their hair. Only 16 (24%) said they would ask patients who deny hair pulling while awake if they pull their hair during sleep. Twenty (19%) said they ask patients diagnosed with trichotillomania if hair pulling also occurs in sleep.

CONCLUSIONS

Although sleep-isolated trichotillomania has only recently been reported, some dermatologists report having recognized this entity in their own practices. When dermatologists see patients with unexplained hair loss, only a small percentage consider trichotillomania isolated to sleep. Increased physician awareness of this disorder may allow diagnosis and treatment of many patients.

Pancreatic abscess due to Aeromonas hydrophila

Aeromonas hydrophila is an uncommon cause of deep-seated infection in man. We present what we believe to be the first reported case of a pancreatic abscess due to A. hydrophila. The outcome of this case attests to the potentially lethal nature of infection that can occur with this organism.

Environmental reservoirs of methicillin-resistant Staphylococcus aureus in isolation rooms: correlation with patient isolates and implications for hospital hygiene

Strategies to control and prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) include early identification of positive patients through screening, patient isolation, hand hygiene, nasal and skin decontamination, and the adequate cleaning and decontamination of clinical areas. However, many national and other guidelines provide few details on environmental decontamination regimens, partly because the role of the environment in the spread of MRSA is not well documented. We prospectively studied the environment of the isolation rooms of 25 MRSA patients for up to four weeks, sampling horizontal surfaces and the air using settle plates as well as an air sampler, while continuing regular daily cleaning according to the hospital protocol. We then typed 20 patient isolates and the corresponding environmental isolates (N=35) to assess the similarity of strains. A high proportion of samples were positive for MRSA; 269/502 (53.6%) surface samples, 70/250 (28%) air samples and 102/251 (40.6%) settle plates. Over half of the surface samples taken from the beds and the mattresses were positive for MRSA. Identical or closely related isolates were recovered from the patient and their environment in 14 (70%) patients, suggesting possible environmental contamination of the isolation rooms, possibly contributing to endemic MRSA. More effective and rigorous use of current approaches to cleaning and decontamination is required as well as consideration of newer technologies to eradicate MRSA and other hospital-acquired pathogens.

Third-generation cephalosporin resistance among Gram-negative bacilli causing meningitis in neurosurgical patients: significant challenges in ensuring effective antibiotic therapy

OBJECTIVES

The treatment of meningitis caused by Gram-negative bacilli in neurosurgical patients is a major challenge because of the complexity of these patients, the emergence of antibiotic resistance in many of the causative organisms and the restricted choice of antibiotics suitable for use, owing to a failure to achieve high enough concentrations in the CSF. We reviewed the incidence, aetiology, treatment and outcome of all patients with Gram-negative bacillary meningitis (GNBM) in our centre over a 7 year period.

METHODS

Beaumont Hospital, Dublin is a 720 bed tertiary referral hospital and contains the national neurosurgical centre for the Republic of Ireland. The case notes and microbiological records of all patients with GNBM between 1998 and 2004 inclusive were reviewed retrospectively. Only patients with positive CSF culture and clinical features compatible with meningitis were included.

RESULTS

Forty separate episodes of GNBM involving 34 different patients occurred during the study period. The most common causative organisms were Enterobacter spp. (35%), Escherichia coli (22.5%) and Pseudomonas aeruginosa (15%). Twenty-five per cent of isolates were resistant to third-generation cephalosporins. The median duration of treatment was 19.2 days and a combination of intravenous and intraventricular antibiotics was the most common treatment regimen used. Mortality directly related to GNBM was 2.5%.

CONCLUSIONS

Although the mortality directly related to GNBM was low, the emergence of strains resistant to third-generation cephalosporins represents a therapeutic challenge. Treatment with combined intravenous and intraventricular antibiotics is recommended for 2-3 weeks, but more studies are required to determine the optimal management of this difficult condition.

Surveillance of hospital water and primary prevention of nosocomial legionellosis: what is the evidence?

Hospital-acquired Legionnaires' disease may be sporadic or may occur as part of an outbreak. As Legionella spp. are ubiquitous in many water systems, it is not surprising that hospital water may be colonized with Legionella pneumophila and other species. However, there is some controversy about the relationship between the presence of legionella in hospital water systems and nosocomial legionellosis. Primary prevention, i.e. measures to prevent legionella in a hospital or healthcare facility with no previous documented cases of nosocomial legionellosis, includes heightened awareness of hospital-acquired Legionnaires' disease with appropriate laboratory diagnostic facilities, and ensuring that the water system is well designed and maintained in accordance with national standards, e.g. the circulating hot water is maintained above 55 degrees C. Secondary prevention, i.e. preventing further cases occurring when a case has been confirmed, should include an investigation to exclude the hospital water system as a source. However, the necessity to sample hospital water routinely to detect legionella outside of outbreaks, i.e. as a component of primary prevention, is unclear. Some studies demonstrate a clear link but others do not. Differences between the patient populations studied, the methods of laboratory diagnosis of clinical cases, the analysis of hospital water and differences in the design of hospital water systems may partly explain this. Whilst further research, probably in the form of multi-centred prospective trials, is needed to confirm the relationship between environmental legionella and hospital-acquired legionellosis, including establishing the relative importance of L. pneumophila group 1 vs. non-group 1 and other Legionella spp., each hospital should consider the spectrum of patients at particular risk locally. Centres with transplant units or other patients with significant immunosuppression should, in the interim, consider routine sampling for legionella in hospital water in addition to other control measures. Therefore, infection control teams must work closely with hospital engineering and technical services departments and hospital management, as well as ensuring that physicians and others have a heightened awareness of hospital-acquired legionellosis.

Pasteurella multocida meningitis: case report and review of the literature

Pasteurella multocida forms part of the normal flora in the nasopharynx of many domestic and wild animals. Most human P. multocida infections are soft tissue infections due to animal bites. P. multocida meningitis is a rare condition. We report a case of P. multocida meningitis with a complicated outcome and review the literature of this condition.

Conferring specificity on the ubiquitous Raf/MEK signalling pathway

The Raf-MEK-ERK signalling pathway controls fundamental cellular processes including proliferation, differentiation and survival. It remains enigmatic how this pathway can reliably convert a myriad of extracellular stimuli in specific biological responses. Recent results have shown that the Raf family isoforms A-Raf, B-Raf and Raf-1 have different physiological functions. Here we review how Raf isozyme diversity contributes to the specification of functional diversity, in particular regarding the role of Raf isozymes in cancer.

Protection by SIV VLP DNA prime/protein boost following mucosal SIV challenge is markedly enhanced by IL-12/GM-CSF co-administration

The ever increasing number of people infected by human immunodeficiency virus (HIV) throughout the world renders the development of effective vaccines an urgent priority. Herein, we report on an attempt to induce and enhance antiviral responses using a deoxyribonucleic acid (DNA) prime/virus-like particles (VLP) protein boost strategy adjuvanted with interleukin (IL)-12/GM-CSF in rhesus macaques challenged with simian immunodeficiency virus (SIV). Thus, groups of monkeys were administered three consecutive doses of pVecB7 a plasmid expressing VLP with or without plasmids expressing IL-12 and GM-CSF at weeks 0, 13 and 26. The VLP boost was administered at week 39 with or without IL-12. All monkeys were challenged intrarectally with SIVsmE660 2 months following the protein boost. All except one immunized monkey became infected. While all immunized monkeys showed a marked reduction of acute viral peaks, reduction of viral load set points was only achieved in groups whose prime-boost immunizations were supplemented with IL-12/GM-CSF (prime) and/or with IL-12 (boost). Control of viremia correlated with lack of disease progression and survival. Detection of virus in rectal washes at 1 year post-challenge was only successful in monkeys whose immunizations did not include cytokine adjuvant, but these loads did not correlate with plasma viral loads. In summary, use of IL-12 and/or GM-CSF was shown to provide significant differences in the outcome of SIV challenge of prime/boost immunized monkeys.

The regulatory N-terminal region of the aromatic-responsive transcriptional activator DmpR constrains nucleotide-triggered multimerisation

The transcriptional promoting activity of DmpR is under the strict control of its aromatic effector ligands that are bound by its regulatory N-terminal domain. The positive control function of DmpR resides within the central C-domain that is highly conserved among activators of sigma(54)-RNA polymerase. The C-domain mediates ATP hydrolysis and interaction with sigma(54)-RNA polymerase that are essential for open-complex formation and thus initiation of transcription. Wild-type and loss-of-function derivatives of DmpR, which are defective in distinct steps in nucleotide catalysis, were used to address the consequences of nucleotide binding and hydrolysis with respect to the multimeric state of DmpR and its ability to promote in vitro transcription. Here, we show that DmpR derivatives deleted of the regulatory N-terminal domain undergo an aromatic-effector independent ATP-binding triggered multimerisation as detected by cross-linking. In the intact protein, however, aromatic effector activation is required before ATP-binding can trigger an apparent dimer-to-hexamer switch in subunit conformation. The data suggest a model in which the N-terminal domain controls the transcriptional promoting property of DmpR by constraining ATP-mediated changes in its oligomeric state. The results are discussed in the light of recent mechanistic insights from the AAA(+) superfamily of ATPases that utilise nucleotide hydrolysis to restructure their substrates.