The oral health of adults with learning disabilities: A secondary analysis of the Adult Dental Health Survey 2009

OBJECTIVES

Adults who have learning disabilities are a vulnerable group, little is known about their oral health and how this affects their quality of life. The aims of this secondary analysis of data from the 2009 Adult Dental Health Survey (ADHS) were to describe the oral health status of adults with learning disabilities, determine if severity of learning disability is associated with oral health and identify some of the methodological complexities of working with this population. The survey yields the most recent representative data on the oral health of adults with learning disabilities in England and importantly, contains information about oral health related quality of life (OHRQoL).

BASIC RESEARCH DESIGN

Secondary analysis of data from a supplemental survey of adults with learning disabilities collected alongside the 2009 ADHS.

PARTICIPANTS

607 participants with a diagnosed learning disability aged 18 years and over.

RESULTS

Adults with learning disabilities had similar levels of active dental caries, fewer natural teeth, and fewer fillings than comparable participants from the general population. Self-reported oral and general health were worse for adults with learning disabilities than the general population. Possible associations between the severity of learning disability and the numbers of decayed, missing or filled teeth were identified. However, large amounts of missing data limited the analysis.

CONCLUSIONS

There are important questions relating to the accessibility of existing self-reported oral health questionnaires and the reliability of proxy-reported questions about OHRQoL that should be addressed to give a fuller picture of the oral health of adults with learning disabilities.

Paradigm shift towards emergency cholecystectomy: one site experience of the Chole-QuiC process

INTRODUCTION

Substantial evidence exists for the superiority of emergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the UK remain low compared with other developed countries, with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes.

METHODS

This is a prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital's subscription to the Royal College of Surgeons of England's Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between 1 December 2021 and 31 January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with postoperative outcomes.

RESULTS

Of the 307 suitable acute admissions, 261 (85%) had an emergency cholecystectomy, compared with 5% preceding the Chole-QuIC interventions. Waiting time dropped from 67 to 5 days. A total of 208 (79.7%) patients were primary presentations, 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. A total of 23 (8.8%) patients underwent preoperative endoscopic retrograde cholangiopancreatography, and 26 (10%) patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (odds ratio (OR) 0.35; p=0.042) and for operation times within 7 days (OR 0.32; p=0.037), with worse outcomes in BMI ≥35 (OR 3.32; p=0.005) and operation time >7 days (OR 3.11; p=0.037).

CONCLUSION

A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.

64 The Impact of Inadequate Pain Control Following Chest Trauma on The Incidence of Hospital Acquired Pneumonia and Hospital Admission Length

Introduction

The National Audit Office (2010) report estimated there was 20,000 cases of major trauma per year in England; of which 5,400 died and many others sustaining permanent disability. Blunt chest wall injuries are associated with high levels of morbidity and mortality, and we aimed to investigate the impact of poor pain control in patient outcomes.

Method

Compliance with trust guidelines was assessed via a retrospective audit of all chest trauma patients between October 2019-20.

Results

28 chest trauma patients identified (M:F 15:13) with ages ranging from 47-94 yrs old (average age 73). Chest trauma was associated with high levels of morbidity (32%) and mortality (7%). 39% patients were found to have inadequate pain control. Only 17% patients eligible for regional anaesthetic blocks were performed within 24hrs. 33% patients developed hospital acquired pneumonias (HAP), of which 44% had received inadequate pain control. Average admission length of patients with a HAP was 15 days compared to 5 days without. 85% patients experienced either delayed or no assessment by specialist teams (i.e., physiotherapy, pain team).

Conclusions

Chest trauma patients often receive inadequate pain control and delayed specialist team input resulting in increased frequency of HAPs, admission length and morbidity/mortality.

1678 Impact of anemia in exercise stress echocardiography: effects on exercise capacity and stress testing safety

Funding Acknowledgements

None

Background/Purpose:

Anemia is a common condition in patients with cardiovascular disease. The effect of anemia in exercise stress testing has not been evaluated in a large cohort of patients.

Methods

We performed a retrospective review of patients undergoing exercise stress echocardiography over a 10 year period who had blood hemoglobin assessed within 48 hours of stress testing. World Health Organization cutoffs were used in defining the degree of anemia. The effect of anemia on exercise capacity and stress testing safety outcomes was assessed.

Results

In 15,652 patients, 90.3% were non-anemic, 7.6% mildly anemic, 2.1% moderately anemic, and 0.1% severely anemic. The incidence of serious supraventricular or ventricular arrhythmias and need to transfer to the hospital was low (0.1%) and did not correlate to anemia severity (p = 0.25). There was an increased incidence of non-sustained SVT or atrial fibrillation with moderate anemia and increased incidence of hypotension with stress testing with mild and moderate anemia. There was a significant reduction in duration of exercise (p &lt; 0.001) and METS (p &lt; 0.001) achieved with worsening anemia.

Conclusion

Our study demonstrates that exercise stress testing is safe in patients with mild and moderate anemia, albeit with reduced exercise capacity. Low numbers of severely anemic patients despite a large study population limit generalizability of these results in this group.

Exercise Capacity Severe Anemia (N = 9) Moderate Anemia (N = 332) Mild Anemia (N = 1183) Non-anemic (N = 14128) P value Resting heart rate 81 ± 13 # 79 ± 14 # 72 ± 14 74 ± 13 &lt;0.001* Peak heart rate 148 ± 22 139 ± 24 # 138 ± 23 # 147 ±22 &lt;0.001* Exercise duration 5.3 ± 2.5 # 6.3 ± 2.1 # 7.2 ± 2.5 # 8.6 ± 2.7 &lt;0.001* METS 6.3 ± 2.5 # 7.1 ± 2.2 # 8.0 ± 2.5 # 9.5 ± 2.7 &lt;0.001* Safety Hypotension with stress 0 (0%) 31 (9.4%) # 94 (8.0%) # 437 (3.1%) &lt;0.001* Mild supraventricular arrhythmia 1 (11.1%) 15 (4.5%) # 20 (1.7%) # 237 (2.3%) 0.04* Severe supraventricular arrhythmia 0 (0%) 0 (0%) 0 (0%) 7 (0.1%) 0.99 Mild ventricular arrhythmia 0 (0%) 20 (6.0%) 74 (6.3%) 756 (5.4%) 0.94 Moderate ventricular arrhythmia 0 (0%) 3 (0.9%) 13 (1.1%) 182 (1.3%) 0.78 Severe ventricular arrhythmia 0 (0%) 1 (0.3%) 2 (0.2%) 1 (0.0%) 0.02 Transfer to hospital 0 (0%) 2 (0.6%) 1 (0.1%) 9 (0.1%) 0.29 Any severe arrhythmia or hospitalization 0 (0%) 2 (0.6%) 3 (0.3%) 17 (0.1%) 0.25 # Multi-comparison adjusted P-value &lt;0.05 compared to non-anemic when group P &lt; 0.05

A review of training in neuropsychiatry

The boundary between neurology and psychiatry has never been sharply defined. It remains the case that a number of conditions (e.g. epilepsy, head-injury sequelae, dementia, and conversion hysteria) are seen by both neurologists and psychiatrists (Reynolds & Trimble, 1989). Few neurologists would dispute that there may be a marked psychiatric element to the presentation of multiple sclerosis, and it has long been noticed that even unmedicated chronic schizophrenic patients sometimes exhibit abnormalities of movement and so-called “soft” neurological signs such as dysgraphia and clumsiness (Lishman, 1988). These and other conditions may all on occasion present to the neuropsychiatrist.

Patient-reported quality indicators for osteoarthritis: a patient and public generated self-report measure for primary care

PLAIN ENGLISH SUMMARY

People with osteoarthritis desire high quality care, support and information. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators can be used to benefit patients by measuring whether minimum standards of quality care are being met from a patient perspective. The aim of this study was to describe how a Research User Group (RUG) worked alongside researchers to co-produce a set of self-reported quality indicators for people with osteoarthritis when visiting their general practitioner or practice nurse (primary care). These were required in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE quality standards for OA. This article describes the public involvement in the MOSAICS study. This was 1) the co-development by RUG members and researchers of an Osteoarthritis Quality Indicators United Kingdom (OA QI (UK)) questionnaire for use in primary care, and 2) the comparison of the OA QI (UK) with a similar questionnaire developed in Norway. This study shows how important and effective a research user group can be in working with researchers in developing quality care indicators for osteoarthritis for use in a research study and, potentially, routine use in primary care. The questionnaire is intended to benefit patients by enabling the assessment of the quality of primary care for osteoarthritis from a patient's perspective. The OA QI (UK) has been used to examine differences in the quality of osteoarthritis care in four European countries.

ABSTRACT

Background People with osteoarthritis (OA) desire high quality care, support and information about OA. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators (QI) can be used to benefit patients by measuring whether minimum standards of quality care (e.g. NICE quality standards) are being met from a patient perspective. A Research User Group (RUG) worked with researchers to co-produce a set of self-report, patient-generated QIs for OA. The QIs were intended for use in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE guidelines. We report on 1) the co-development of the OA QI (UK) questionnaire for primary care; and 2) the comparison of the content of the OA QI (UK) questionnaire with a parallel questionnaire developed in Norway for the Musculoskeletal Pain in Ullensaker (MUST) study. Methods Researchers were invited to OA RUG meetings. Firstly, RUG members were asked to consider factors important to patients consulting their general practitioner (GP) for OA and then each person rated their five most important. RUG members then discussed these in relation to a systematic review of OA QIs in order to form a list of OA QIs from a patient perspective. RUG members suggested wording and response options for a draft OA QI (UK) questionnaire to assess the QIs. Finally RUG members commented on draft and final versions of the questionnaire and how it compared with a translated Norwegian OA-QI questionnaire. Results RUG members (5 males, 5 females; aged 52-80 years) attended up to four meetings. RUG members ranked 20 factors considered most important to patients consulting their GP for joint pain. Following discussion, a list of eleven patient-reported QIs for OA consultations were formed. RUG members then suggested the wording and response options of 16 draft items - four QIs were split into two or more questionnaire items to avoid multiple dimensions of care quality within a single item. On comparison of this to the Norwegian OA-QI questionnaire, RUG members commented that both questionnaires contained seven similar QIs. The RUG members and researchers agreed to adopt the Norwegian OA-QI wording for four of these items. RUG members also recommended adopting an additional seven items from the Norwegian OA-QI with some minor word changes to improve their suitability for patients in the UK. One other item from the draft OA QI (UK) questionnaire was retained and eight items were excluded, resulting in a 15-item final version. Conclusions This study describes the development of patient-reported quality indicators for OA primary care derived by members of a RUG group, working in partnership with the research team throughout the study. The OA QI (UK) supports the NICE quality standards for OA and they have been successfully used to assess the quality of OA consultations in primary care in the MOSAICS study. The OA QI (UK) has the potential for routine use in primary care to assess the quality of OA care provided to patients. Ongoing research using both the UK and Norwegian OA-QI questionnaires is assessing the self-reported quality of OA care in different European populations.

The quality and diagnostic value of open narratives in verbal autopsy: a mixed-methods analysis of partnered interviews from Malawi

BACKGROUND

Verbal autopsy (VA), the process of interviewing a deceased's family or caregiver about signs and symptoms leading up to death, employs tools that ask a series of closed questions and can include an open narrative where respondents give an unprompted account of events preceding death. The extent to which an individual interviewer, who generally does not interpret the data, affects the quality of this data, and therefore the assigned cause of death, is poorly documented. We aimed to examine inter-interviewer reliability of open narrative and closed question data gathered during VA interviews.

METHODS

During the introduction of VA data collection, as part of a larger study in Mchinji district, Malawi, we conducted partner interviews whereby two interviewers independently recorded open narrative and closed questions during the same interview. Closed questions were collected using a smartphone application (mobile-InterVA) and open narratives using pen and paper. We used mixed methods of analysis to evaluate the differences between recorded responses to open narratives and closed questions, causes of death assigned, and additional information gathered by open narrative.

RESULTS

Eighteen partner interviews were conducted, with complete data for 11 pairs. Comparing closed questions between interviewers, the median number of differences was 1 (IQR: 0.5-3.5) of an average 65 answered; mean inter-interviewer concordance was 92% (IQR: 92-99%). Discrepancies in open narratives were summarized in five categories: demographics, history and care-seeking, diagnoses and symptoms, treatment and cultural. Most discrepancies were seen in the reporting of diagnoses and symptoms (e.g., malaria diagnosis); only one pair demonstrated no clear differences. The average number of clinical symptoms reported was 9 in open narratives and 20 in the closed questions. Open narratives contained additional information on health seeking and social issues surrounding deaths, which closed questions did not gather.

CONCLUSIONS

The information gleaned during open narratives was subject to inter-interviewer variability and contained a limited number of symptom indicators, suggesting that their use for assigning cause of death is questionable. However, they contained rich information on care-seeking, healthcare provision and social factors in the lead-up to death, which may be a valuable source of information for promoting accountable health services.

Are we seeing the effects of public awareness campaigns? A 10-year analysis of Breslow thickness at presentation of malignant melanoma in the South West of England

INTRODUCTION

The last 20 years has seen a marked improvement in skin cancer awareness campaigns. We sought to establish whether this has affected the presenting Breslow thickness of malignant melanoma in the South West.

METHOD

This is a retrospective study looking at the first presentation of melanomas from 2003 to 2011. Data was accessed using the local online melanoma database.

RESULTS

A total of 2001 new melanomas presented from 2003 to 2012 (Male:Female = 1:1.062). The average yearly number of melanomas was 200.1 (range = 138-312). The mean age was 62.5 years (range 12-99). Data was analysed using a Chi² test. For 0-1 mm melanomas, there is a significant difference in the observed versus expected values over the 10 years (p = 0.0018). There is an increasing proportion of 0-1 mm (thin) melanomas presenting year on year, with a positive linear trend. This is very statistically significant (p < 0.0001). The 1-2 mm melanomas are decreasing in proportion with a negative linear trend (p = 0.0013). The 2-4 mm are also decreasing in proportion (p = 0.0253). There is no significant change in the thick >4 mm melanomas (p = 0.1456).

CONCLUSION

The proportion of thin 0-1 mm melanomas presenting in South West England has significantly increased from 2003 to 2012. There is no significant change in the thick >4 mm melanomas. This may be a result of increased public awareness due to effective public health campaigns which has significant prognostic and financial implications.

United Kingdom Myeloma Forum (UKMF) position statement on the use of bendamustine in myeloma

Bendamustine is a unique bifunctional alkylating agent with promising activity in myeloma. Despite the increasing number of studies demonstrating its efficacy in both the upfront and relapse settings, including patients with renal insufficiency, the optimal use of bendamustine, in terms of dosage, schedule and combination with other agents, has yet to be defined. It is currently licensed for use as frontline treatment with prednisolone for patients with myeloma who are unsuitable for transplantation and who are contraindicated for thalidomide and bortezomib. Studies in relapsed/refractory patients are currently ongoing with other combinations. Given the increasing data to date, the UK Myeloma Forum believes that bendamustine with steroids alone or in combination with a novel agent could be considered for patients with multiply relapsed myeloma. This document provides guidance for the use of bendamustine for patients with myeloma until the results of definitive studies are available.

Negative BOLD in the Lateral Geniculate Nucleus: Neuronal Implications and Cortico-Thalamic Feedback

Previous research has demonstrated a sustained negative BOLD response (NBR) that is negatively correlated with the spatio-temporal properties of a visual stimulus. Whilst it has been suggested that the NBR surrounding the positive BOLD response (PBR) may reflect blood-stealing, evidence indicates that the extensive NBR distal to the PBR is a manifestation of neuronal suppression. This study aimed to evaluate NBR in the lateral geniculate nucleus (LGN), and to explore the source of the NBR. fMRI data were obtained from six subjects, while they viewed a grating stimulus. The NBR was identified in the LGN ipsilateral to the stimulus. The results also verified the NBR in V1 ipsilateral to the stimulus and revealed the PBR in bilateral V5. It was concluded that the NBR can be found in the LGN, and is most likely driven by feedback from ipsilateral V1. The finding that the stimulus that stimulates the LGN in one hemisphere can cause extensive suppression in the LGN of the opposite hemisphere rejects the notion that the effect is purely a blood-stealing effect as the two LGN have different blood supplies. The results, together with previous research, indicate that the NBR may reflect neuronal suppression.

Prevalence of overweight, obesity and underweight among 5-year-old children in Saint Lucia by three methods of classification and a comparison with historical rates

BACKGROUND

The study aimed to determine if child obesity rates have risen in the Caribbean nation of Saint Lucia, as found globally, and whether under-nutrition coexists, as in other developing nations. The average adult in Saint Lucia is overweight, thus considerable child obesity might be expected, but there are no current data.

METHODS

Heights and weights were obtained from a sample (n= 425) of the 2001 birth cohort of Saint Lucian children measured during the nation-wide 2006/2007 Prior to School Entry Five-Year Assessment. Prevalence of overweight, obesity and underweight were estimated by Centers for Disease Control (CDC), Cole et al. and new World Health Organization (WHO) methods. Previously reported 1976 estimates, including children ≤60 months of age only, based on National Centre for Health Statistics curves, were adjusted to new WHO equivalents using an algorithm developed by Yang and de Onis, and compared with rates in our subsample of children ≤60 months of age (n= 99).

RESULTS

Regardless of classification method, overweight and obesity rates were high: 14.4% and 9.2% (WHO); 11.3% and 12.0% (CDC); and 9.9% and 7.1% (Cole et al.), respectively. Underweight estimates also varied: 4.7% (WHO); 11.3% (CDC) and 6.6% (Cole et al.). Obesity in our young subsample (15.2%; WHO) was more than 3 times the adjusted 1976 rate (4.3%).

CONCLUSIONS

Obesity among Saint Lucian pre-schoolers has tripled in 30 years. Our findings also suggest that this country, like many undergoing a 'nutrition transition', faces the dual challenge of over-nutrition and under-nutrition. Routine monitoring of overweight and underweight is needed in Saint Lucia, as is the implementation and evaluation of programmes to address these problems.

Development of a large animal model for investigating resuscitation after blast and hemorrhage

BACKGROUND

Blast injuries are an increasing problem owing to the widespread terrorist threat, but hemorrhage remains the second leading cause of civilian trauma death. Against this background, increasing numbers of prehospital and military trauma organizations are advocating a hypotensive approach to resuscitation of the hypovolemic casualty, deliberately aiming not to achieve a normal blood pressure so as not to disturb any newly formed blood clots at the site of a vascular injury.

METHODS

There are no data available to guide clinicians as to how best to resuscitate the blast-injured casualty who has also suffered a hemorrhagic injury. A large-scale program was initiated to examine this question and to offer clinical guidance on the optimal resuscitation strategy in such circumstances in terms of volume, type of fluid, speed of resuscitation, and appropriate endpoints. Before such experiments could be undertaken, a novel large animal model of blast and hemorrhage had to be devised and validated. This study outlines the derivation of such a large animal model utilizing terminally anesthetized Large White pigs exposed to a standardized primary blast wave followed by a controlled hemorrhage of 30% of the total blood volume.

RESULTS AND CONCLUSION

The preliminary results confirm the reliability and reproducibility of this model.

United Kingdom myeloma forum position statement on the use of lenalidomide in multiple myeloma

Lenalidomide is an immunomodulatory drug, which has anti-myeloma activity in vitro. Phase II clinical trials have demonstrated lenalidomide in combination with dexamethasone is effective for the treatment of both relapsed refractory myeloma and newly diagnosed patients. Two large phase III studies comparing lenalidomide and dexamethasone to dexamethasone alone in relapsed patients showed superiority in response, progression free and overall survival. It is administered orally for 21 days in a 28 day cycle. Side effects are manageable and include neutropenia and venous thrombotic events. It is currently approved, in combination with dexamethasone, for the treatment of multiple myeloma patients who have received at least one prior therapy. Studies in front line patients and with other drug combinations are ongoing. Given the strength of this data the UK Myeloma Forum believe that lenalidomide in combination with dexamethasone should be available for prescription by UK haematologists according to its licensed indication in patients with relapsed myeloma.

Obstetric regional blocks for women with multiple sclerosis: a survey of UK experience

BACKGROUND

There has been a reluctance to use regional blocks for women with multiple sclerosis as effects on the course of the disease are unclear. We assessed the views of UK consultant obstetric anaesthetists regarding management of women with multiple sclerosis.

METHODS

Following Obstetric Anaesthetists' Association approval a questionnaire was sent to UK consultant members. Opinions were sought on antenatal assessment, labour analgesia, anaesthesia for elective and emergency caesarean section, and modification in technique for those with multiple sclerosis. Enquiries were made of postnatal problems ascribed to regional blocks.

RESULTS

Of the 592 replies analysed, 91% of respondents had seen fewer than 10 cases of multiple sclerosis in the past 10 years. Antenatal assessment was recommended by many with postnatal relapse most commonly discussed (64%). Many highlighted the need for informed consent and minimising local anaesthetic dose. For labour analgesia 79% would perform a regional block; a further 20% would do so in certain circumstances. For elective caesarean section, epidural rather than spinal anaesthesia was preferred by 4%; 2% would not use a regional block, preferring general anaesthesia. For emergency caesarean section with time only for single-shot spinal, 3% would give a general anaesthetic. Deterioration of symptoms after delivery were reported by 20% with 3% attributing symptoms such as prolonged block, leg weakness, bladder dysfunction and postnatal relapse to regional blocks.

CONCLUSION

Most UK anaesthetists would perform regional blocks for labour and caesarean section in multiple sclerosis, although the experience of each anaesthetist is limited. Many emphasised the need for thorough pre-assessment and informed consent.

The evidence base for the application of contralateral bone anchored hearing aids in acquired unilateral sensorineural hearing loss in adults

. Acquired unilateral sensorineural hearing loss reduces the ability to localize sounds and to discriminate in background noise. . Four controlled trials attempt to determine the benefit of contralateral bone anchored hearing aids over contralateral routing of signal (CROS) hearing aids and over the unaided condition. All found no significant improvement in auditory localization with either aid. Speech discrimination in noise and subjective questionnaire measures of auditory abilities showed an advantage for bone anchored hearing aid (BAHA) > CROS > unaided conditions. . All four studies have material shortfalls: (i) the BAHA was always trialled after the CROS aid; (ii) CROS aids were only trialled for 4 weeks; (iii) none used any measure of hearing handicap when selecting subjects; (iv) two studies have a bias in terms of patient selection; (v) all studies were underpowered (vi) double reporting of patients occurred. . There is a paucity of evidence to support the efficacy of BAHA in the treatment of acquired unilateral sensorineural hearing loss. Clinicians should proceed with caution and perhaps await a larger randomized trial. . It is perhaps only appropriate to insert a BAHA peg at the time of vestibular schwanoma tumour excision in patients with good preoperative hearing, as their hearing handicap increases most.

The microbial ecology of high-risk, chilled food factories; evidence for persistent Listeria spp. and Escherichia coli strains

AIMS

The intention of this study was to provide evidence of any Listeria spp. or Escherichia coli strain persistence, and to identify whether strains of these organisms adapt to specific environmental or product niches in food factories.

METHODS AND RESULTS

A 3-year assessment of the microbial ecology of four, ready-to-eat food-processing factories was undertaken in which approx. 196 000 and 75 000 product and environmental samples were examined for Escherichia coli and Listeria spp. respectively. A total of 152 E. coli isolates (44 environmental and 108 product in 62 ribogroups) and 260 Listeria spp. isolates (174 environmental and 86 product in 30 ribogroups) were identified and ribotyped. The overall prevalence of E. coli (0.08%), all Listeria spp. (0.35%) and L. monocytogenes (0.23%) was very low. Some 10 E. coli ribogroups and 14 Listeria spp. ribogroups showed evidence for persistence, defined as the isolation of the same strain, from the same site, over a prolonged time period. The majority of E. coli strains were product niche oriented whilst the majority of Listeria spp. strains were environmental niche oriented.

CONCLUSION

Current UK high-risk food factory designs, personnel hygiene and cleaning and disinfection regimes are sufficient to control Listeria spp. and E. coli to very low levels.

SIGNIFICANCE AND IMPACT OF THE STUDY

Persistent strains of these organisms, however, can remain within factory high-risk production areas over considerable time periods, warranting an examination of the strain persistence mechanisms and alternative hygiene controls.

Camptothecin sensitivity in Werner syndrome fibroblasts as assessed by the COMET technique

Werner syndrome (WS) is an inherited genetic disease in which individuals display the premature aging of a selected subset of tissues. The disorder results from the loss of function mutations in the wrn gene. Wrn codes for a member of the RecQ helicase family with a unique nuclease domain. There is significant evidence that the role of wrn is to assist in the repair and reinitiation of DNA replication forks that have stalled. Loss of the wrn helicase imposes a distinct set of phenotypes at the cellular level. These include premature replicative senescence (in a subset of cell types), chromosomal instability, a distinct mutator phenotype, and hypersensitivity to a limited number of DNA damaging agents. Unfortunately, most of these phenotypes are not suitable for the rapid assessment of loss of function of the wrn gene product. However, WS cells have been reported to show abnormal sensitivity to the drug camptothecin (an inhibitor of topoisomerase type I). A rapid assay for this sensitivity would be a useful marker of loss of wrn function. The COMET (single-cell gel electrophoresis) assay is a rapid, sensitive, versatile, and robust technique for the quantitative assessment of DNA damage in eukaryotic cells. Using this assay, we have found that a significantly increased level of strand breaks can be demonstrated in WS cells treated with camptothecin compared with normal controls.

Biochemical characterisation of navicular hyaline cartilage, navicular fibrocartilage and the deep digital flexor tendon in horses with navicular disease

The study hypothesis was that navicular disease is a process analogous to degenerative joint disease, which leads to changes in navicular fibrocartilage and in deep digital flexor tendon (DDFT) matrix composition and that the process extends to the adjacent distal interphalangeal joint. The objectives were to compare the biochemical composition of the navicular articular and palmar cartilages from 18 horses with navicular disease with 49 horses with no history of front limb lameness, and to compare navicular fibrocartilage with medial meniscus of the stifle and collateral cartilage of the hoof. Cartilage oligomeric matrix protein (COMP), deoxyribonucleic acid (DNA), total glycosaminoglycan (GAG), metalloproteinases MMP-2 and MMP-9 and water content in tissues were measured. Hyaline cartilage had the highest content of COMP and COMP content in hyaline cartilage and tendon was higher in lame horses than in sound horses (p<0.05). The concentration of MMP-2 amount in hyaline cartilage was higher in lame horses than in sound horses. The MMP-2 amounts were significantly higher in tendons compared to other tissue types. Overall, 79% of the lame horses with lesions had MMP-9 in their tendons and the amount was higher than in sound horses (p<0.05). In horses with navicular disease there were matrix changes in navicular hyaline and fibrocartilage as well as the DDFT with potential implications for the pathogenesis and management of the condition.

Two Newly Described Begomoviruses of Macroptilium lathyroides and Common Bean

ABSTRACT Macroptilium lathyroides, a perennial weed in the Caribbean region and Central America, is a host of Macroptilium yellow mosaic Florida virus (MaYMFV) and Macroptilium mosaic Puerto Rico virus (MaMPRV). The genomes of MaYMFV and MaMPRV were cloned from M. lathyroides and/or field-infected bean and the DNA sequences were determined. Cloned A and B components for both viruses were infectious when inoculated to M. lathyroides and common bean. Comparison of the DNA sequences for cloned A and B components with well-studied begomovirus indicated that MaMPRV (bean and M. lathyroides) and MaYMFV (M. lathyroides) are unique, previously undescribed begomo-viruses from the Western Hemisphere. Phylogenetic analysis of viral A components indicated that the closest relative of MaYMFV are members of the Bean golden yellow mosaic virus (BGYMV) group, at 76 to 78% nucleotide identity, whereas the closest relative for the A component of MaMPRV was Rhynchosia golden mosaic virus at 78% nucleotide identity. In contrast, BGYMV is the closest relative for the B component of both MaYMFV and MaMPRV, with which they share approximately 68.0 and approximately 72% identity, respectively. The incongruent taxonomic placement for the bipartite components for MaMPRV indicates that they did not evolve entirely along a common path. MaYMFV and MaMPRV caused distinctive symptoms in bean and M. lathyroides and were transmissible by the whitefly vector and by grafting; however, only MaYMFV was mechanically transmissible. The experimental host range for the two viruses was similar and included species within the families Fabaceae and Malvaceae, but only MaYMFV infected Malva parviflora and soybean. These results collectively indicate that MaMPRV and MaYMFV are new, previously undescribed species of the BGYMV group, a clade previously known to contain only strains and isolates of BGYMV from the Caribbean region that infect Phaseolus spp. Both MaYMFV and MaMPRV may pose an economic threat to bean production in the region.

Molecular Characterization of Rhynchosia mosaic virus-Puerto Rico Associated with Symptomatic Rhynchosia minima and Cajanus cajan in Puerto Rico

A begomovirus (family Geminiviridae) has long been suspected to be associated with Rhynchosia mosaic (RhM) disease of Rhynchosia minima (L.) DC., a weed that is widespread in Puerto Rico (PR). The suspect virus has been transmitted by the Sida biotype of Bemisia tabaci (Genn.) and has been designated RhM virus-PR (RhMV-PR) (1) (synonym, Rhynchosia mosaic virus [RMV]). RhM symptoms in R. minima included yellow foliar mosaic and stunting. The virus has a broad experimental host range and infects species in the Fabaceae, including R. minima, pigeon pea (Cajanus cajan (L.) Millsp.), and Clitoria falcata L. (1). However, until now RhMV has not been identified from naturally infected pigeon pea or Clitoria falcata. R. minima and C. cajan plants exhibiting yellow foliar mosaic and stunting symptoms were collected in Puerto Rico. Using the B biotype of B. tabaci as the vector, their whitefly transmissibility from the respective source plant to R. minima and C. cajan test plants was confirmed, and symptoms in inoculated host were indistinguishable for both isolates. Using polymerase chain reaction (PCR) and primers (2), three amplicons were obtained and cloned for each isolate. PCR products (1.1 and 2.1 kbp) were assembled (~200 nucleotide [nt] overlap) to yield an apparent full-length DNA A component (~2.6 kbp) containing the diagnostically informative viral coat protein gene (CP) and common region (CR-A). PCR primers were used to amplify the DNA B component segment (0.7 kbp) containing the CR-B (2). The DNA sequence for the core CP (533 nt) and full CP (750 nt) were compared with analogous sequences for well-studied begomoviruses, and CR-A and CR-B (153 nt) were compared for RhMV isolates. All isolates noted were obtained from GenBank. The core CP for isolates from R. minima (AF442117) and C. cajan (AY062025) shared 97.9% nucleotide identity (100% AA similarity) and the CR-A (AF442118) and CR-B (AF442119) sequences for R. minima and C. cajan isolates were ~96% identical, indicating the A and B components are of the same begomovirus. Comparison of the core CP sequence for an independent isolate from C. cajan from PR (AY028308) (4) with those for R. minima and C. cajan isolates indicated 95.5% (99.4% AA) and 96.2% (99.4% AA) nucleotide identity, respectively, indicating association of RhMV with both C. cajan samples. The recently archived core CP (533 nt) (AY028308) is actually of RhMV-PR, rather than a distinct begomovirus species, as indicated (4). Interestingly, the core CP of R. minima (AF442117) and C. cajan (AY062025) isolates were 91.7% (98.9% AA) and 92.3% (98.9% AA) identical, respectively, with a PR isolate from Clitoria falcata (AF070924), also confirming that RhMV-PR naturally infects Clitoria falcata. Analysis of the full CP for the R. minima and C. cajan isolates revealed that their closest relatives were Macroptilium mosaic virus (MaMV-PR) (AF176092) and Bean golden mosaic virus (BGMV-PR) (M10070) at 89 and 84% nucleotide identity, respectively. Applying the 90% CP rule (3) to RhMV CP sequences, RhMV is a distinct begomovirus species. At least three begomoviruses, BGMV-PR, MaMV-PR, and RhMV-PR, naturally infect leguminous species in Puerto Rico. References: (1) J. Bird. Phytopathology 52:286, 1962. (2) A. M. Idris and J. K. Brown. Phytopathology 88:648, 1998. (3) M. A. Mayo and C. R. Pringle. J. Gen. Virol. 79:649, 1998. (4) R. L. Rodriguez et al. Plant Dis. 85:1119, 2001.

Synovial fluid studies in navicular disease

The purpose of this study was to investigate biochemical changes in synovial fluid in navicular disease, and to establish if synovial fluid from the distal interphalangeal joint (DIP) could be used diagnostically to assess alterations in the synovial fluid of the navicular bursa. Cartilage oligomeric matrix protein (COMP), total glycosaminoglycans (GAG), hyaluronan (HA), metalloproteinases 2 and -9 (MMP-2 and MMP-9) and total protein (TP) levels were determined in synovial fluids obtained from 18 navicular bursae and 35 DIP -joints from animals suffering from navicular disease, and the same synovial structures in 16 joints of horses with no evidence of abnormalities involving the foot. To avoid dilution effects, GAG/COMP, HA/COMP, MMP-2/ COMP and MMP-9/COMP ratios were also calculated for different synovial cavities. There was a good correlation, for COMP, GAG, HA, MMP-2 and TP levels, between synovial fluid from the navicular bursa and fluid from the DIP -joint in healthy animals. However, in animals with navicular disease, only COMP levels showed no difference between the navicular bursal fluid and the DIP-joint fluid concentration. Thus, enabling the use of COMP to standardise other biochemical concentration measurements from the synovial joint fluids. In horses with navicular disease, there was a significantly lower absolute concentration of GAG, and a significantly lower GAG/COMP ratio, in the synovial fluid of the navicular bursa and the DIP-joint compared to synovial fluid from the same joints from healthy horses. In contrast, the absolute HA concentration and HA/ COMP, MMP-2/COMP and MMP-9/COMP ratios were higher in synovial fluid from the DIP-joint of horses with navicular disease, and MMP-2 and MMP-9 relative activity levels and MMP-2/COMP and MMP-9/ COMP ratios were increased in fluid from navicular bursae in horses with navicular disease when compared to a control group.

Inhibition of angiogenesis and metastasis in two murine models by the matrix metalloproteinase inhibitor, BMS-275291

BMS-275291 is an p.o. bioavailable, sulfhydryl-based matrix metalloproteinase (MMP) inhibitor currently in clinical development for the treatment of cancer. This inhibitor was designed to potently inhibit MMP activities while minimally affecting those of other metalloproteases (e.g., sheddases) involved in the release of cell-associated molecules such as tumor necrosis factor-alpha, tumor necrosis factor-alpha receptor, interleukin-6 receptor, or L-selectin. In vitro, BMS-275291 is a potent inhibitor (nM) of the activities of MMP-1, MMP-2, MMP-7, MMP-9, and MMP-14. BMS-275291 inhibits tumor growth in a B16BL6 model of experimental metastasis, and in this model, BMS-275291 treatment results in a dose-dependent reduction in the number of lung metastases compared with vehicle controls. BMS-275291 also inhibits angiogenesis in a murine angiogenesis model, where once daily treatment with BMS-275291 results in a dose-dependent inhibition of endothelial cell migration into s.c. implanted Matrigel plugs. Pharmacokinetic studies demonstrated that the plasma concentrations of parent BMS-275291 in mice exceeds the in vitro IC(50) values for MMP-1, MMP-2, MMP-7, MMP-9, and MMP-14 for at least 4 h after the administration of a therapeutic dose of BMS-275291. Taken together, these data demonstrate that BMS-275291 inhibits MMP activities that contribute to tumor metastasis and angiogenesis.

Arylsulphonyl hydroxamic acids: potent and selective matrix metalloproteinase inhibitors

A series of novel matrix metalloproteinase inhibitors is described in which selectivity between MMP and 'sheddase' activity has been achieved and which demonstrate potent in vivo activity in models of arthritis and cancer.

Introduction of the Exotic Tomato yellow leaf curl virus-Israel in Tomato to Puerto Rico

Thirty-five-day-old tomato plants (cultivar Florasette) exhibited yellow leaf curling, stunting, and extremely reduced fruit set in spring 2001, in Guanica, Puerto Rico (PR). Twenty percent disease incidence was observed in this field and, 8 weeks later, 75% of the plants showed symptoms. These symptoms were distinct from those caused by other tomato-infecting begomoviruses reported previously from PR, namely Merremia mosaic virus, Tomato mottle virus (ToMoV), and Potato yellow mosaic virus (1). A colony of the B biotype of Bemisia tabaci (Genn.) was used to transmit the suspect virus from symptomatic plants collected in the field and established in the greenhouse in Rio Piedras, PR. The suspect virus was transmitted readily to tomato cultivar Roma (10 of 10 plants), and symptoms were like those observed in the field. Symptoms also were reminiscent of those described for several Old World begomoviruses, referred to as Tomato yellow leaf curl virus (TYLCV). Total nucleic acids were isolated from three symptomatic field samples and three greenhouse-inoculated tomato plants showing typical disease symptoms. Extracts were analyzed by polymerase chain reaction (PCR) with primers AV2466 and AC1145 to amplify a begomoviral fragment (approximately 1.1 bp) that contains a portion of the intergenic region and the viral coat protein gene (CP) (2). Amplicons were cloned, and their nucleotide sequences were determined. A comparison of CP with other well-studied begomoviral nucleotide sequences revealed that the CP sequences for field isolates 1 to 6 shared 99.7 to 100% identity with each other and 99.9 to 100% identity with TYLCV from Israel (TYLCV-IL; accession no. X76319) as well as TYLCV-IL isolates discovered in the Dominican Republic (DO; accession no. AF024715) and, subsequently, in Florida. TYLCV-specific PCR primers (forward) 5'-GAATTCCGCCTTTAA-TTTG-3' and (reverse) 5'-GAATTCCCACTATCTTTCTC-3' were used to amplify the complete viral genome form a PR field isolate. An expected-sized amplicon of approximately 2.8 kb was obtained, and the nucleotide sequence of two cloned amplicons was determined. Genome organization revealed a predicted precoat open reading frame of 351 bp, which is characteristic of other Old World begomoviruses, including TYLCV-IL. Nucleotide comparisons indicated that the PR isolate shared 99% nucleotide sequence identity with TYLCV-IL (first reported from Israel) and introduced TYLCV-IL isolates in DO and Florida, thereby confirming the introduction of TYLCV-IL into PR. TYLCV-IL was first identified several years ago in the Western Hemisphere, and the virus has been reported in five offshore locations and three continental U.S. states since its initial introduction into the DO in the early 1990s. Considering the extreme virulence of TYLCV-IL compared with most New World tomato-infecting begomoviruses, this introduction, which likely occurred from a nearby Caribbean country or Florida, has the potential to destroy the fresh-market tomato industry in PR, which supplies tomatoes to the continental United States during the winter months. There is compelling evidence for the routine movement of tomato seedlings from the continental United States to this location in PR throughout the last 10 years, including the previous introduction of ToMoV (1). These incidences and others indicate the need for those in infected areas to take precautions to avoid further spread of this highly damaging virus in and adjacent to the Caribbean region. References: (1) A. M. Idris et al. Phytopathology 88:S42, 1998. (2) A. M. Idris and J. K. Brown, Phytopathology 88:648, 1998.

Control of anthelmintic resistant endoparasites in a commercial sheep flock through parasite community replacement

An effort was undertaken to replace a community of sheep endoparasites that had been classified as resistant to levamisole and albendazole with a community of more susceptible parasites using a dilution approach that could be integrated into the management of a commercial flock. For this study, pastures on this sheep farm were divided into two areas: north and south. Strategically timed anthelmintic treatments combined with pasture management reduced to nondetectable levels the endemic community of anthelmintic resistant parasites in this flock and on these pastures by early summer. A group of 102 ewes, lambs, and rams were experimentally infected with third stage larvae from the more susceptible community of parasites. These sheep then seeded the south pastures with the new parasite community, while sheep on the north pastures maintained the endemic resistant community. Despite its insensitivity as a technique for detecting anthelmintic resistance, fecal egg count reduction tests at the end of the grazing season indicated that the more susceptible parasites were present on the south pastures while resistant parasites were present on the north. The following grazing season, similar protocols were used to introduce the more susceptible parasites onto the north pastures. At the end of the grazing season, fecal egg count reduction tests indicated that the new community of parasites had become established on both groups of pastures of the farm.

Continuing professional development: medico-legal aspects of epilepsy

Generally protection against possible litigation and good clinical practice go hand in hand. Situations in which the law has special relevance for people with epilepsy, those who work with them, and their clinicians are reviewed with special reference to the topics of driving, employment, duties of social carers, the clinician's everyday role, the responsibilities of researchers and epilepsy and the criminal law. What constitutes professional negligence is discussed, with special reference to the United Kingdom. Clinicians are advised to think clearly, write clearly, communicate clearly and have a good relationship with their patients.

Isolation and purification of an epidermal growth factor receptor-related inhibitor of cell growth from cultured rat astrocytes

Astrocytes rarely undergo mitotic cell division in the developed adult. However, following injury to the central nervous system (CNS), astrocytes undergo rapid cell division and reactive astrocytes encapsulate exposed areas of the CNS producing a glial scar. Studies indicate the existence of a family of epidermal growth factor receptor (EGFr) related glycosidic mitogen inhibitors with growth inhibiting properties for astrocytes. Here, for the first time, we describe the isolation of such a factor from cultured rat astrocytes by ion-exchange and immunoaffinity chromatography. The isolated factor is glycosidic in nature, cross reacts with the anti-EGFr monoclonal antibody Clone 29.1, and inhibits the growth of primary astrocytes and N2a neuroblastoma cells in vitro.