Method to share learning in real time at scientific meetings: lessons from the IHI-BMJ International Conference on Quality and Safety

BACKGROUND

Capturing and disseminating key learnings on emerging themes for conference participants is challenging, yet also presents a significant opportunity to distill, share and discuss learning in real time with conference organisers and attendees. The Institute for Healthcare Improvement (IHI) and British Medical Journal (BMJ) collaborate annually to convene a Health Quality and Safety conference attracting 1000 to 3000 attendees each year.

AIM

To test a learning system that harvested and synthesised the key lessons shared by conference participants at the 2022 IHI-BMJ Gothenburg Forum, and to disseminate this content.

METHODS

Twelve invited Forum attendees collected and shared their 'breakthrough learnings' via electronic survey. Three IHI team members synthesised the participants' responses into themes that were shared and refined in real time at an in-person Forum session including 35 additional participants.

RESULTS

Participants shared four learning themes: collaboration and co-production, trust, meaningful communication about data, and broadening the scope of the Science of Improvement field to multi-disciplinary and multi-system approaches.

CONCLUSIONS

Collection of key learning on emerging topics of interest to the health system improvement community is feasible and yielded information both for dissemination and real-time learning. While not representing the full scope of the conference learnings, the content resonated with an additional group of reviewers at the conclusion of the conference and has guided planning for the next annual meeting. This approach may be helpful in capturing key themes for discussion and planning by similar improvement communities.

Learning from an equitable, data-informed response to COVID-19: Translating knowledge into future action and preparation

Introduction

The COVID-19 pandemic revealed numerous barriers to effectively managing public health crises, including difficulties in using publicly available, community-level data to create learning systems in support of local public health decision responses. Early in the COVID-19 pandemic, a group of health care partners began meeting to learn from their collective experiences. We identified key tools and processes for using data and learning system structures to drive equitable public health decision making throughout different phases of the pandemic.

Methods

In fall of 2021, the team developed an initial theory of change directed at achieving herd immunity for COVID-19. The theoretical drivers were explored qualitatively through a series of nine 45-min telephonic interviews conducted with 16 public health and community leaders across the United States. Interview responses were analyzed into key themes to inform potential future practices, tools, and systems. In addition to the interviews, partners in Dallas and Cincinnati reflected on their own COVID-19 experiences.

Results

Interview responses fell broadly into four themes that contribute to effective, community driven responses to COVID-19: real-time, accessible data that are mindful of the tension between community transparency and individual privacy; a continued fostering of public trust; adaptable infrastructures and systems; and creating cohesive community coalitions with shared alignment and goals. These themes and partner experiences helped us revise our preliminary theory of change around the importance of community collaboration and trust building and also helped refine the development of the Community Protection Dashboard tool.

Conclusions

There was broad agreement amongst public health and community leaders about the key elements of the data and learning systems required to manage public health responses to COVID-19. These findings may be informative for guiding the use of data and learning in the management of future public health crises or population health initiatives.

The effect of antenatal isoniazid preventive therapy on birth outcomes in Western Kenya

BACKGROUND: Pregnant women living with HIV (WLHIV) are at high risk for TB. There are limited data to inform whether TB preventive therapy is safe in pregnancy.METHODS: We completed a retrospective study of antenatal and birth records of mother-infant dyads at two health care facilities in Kisumu, Kenya. Among pregnant WLHIV, we assessed the relationship of antenatal isoniazid preventive therapy (IPT) with birth outcomes (preterm birth, low birth weight [LBW], congenital anomalies, and perinatal death).RESULTS: Of 576 mother-infant pairs, most women were on antiretroviral therapy (574, 99.7%) with viral suppression (518, 89.9%) and one-quarter had IPT exposure during pregnancy (152, 26.4%). The prevalence of preterm birth was lower among women with antenatal IPT exposure (21% vs. 30%; P = 0.03). LBW, congenital anomaly and perinatal death were not associated with antenatal IPT; however, we observed a trend toward fewer composite poor birth outcomes among women taking antenatal IPT (26% vs 33%; P = 0.08). Controlling for maternal age and viral load, IPT use during pregnancy was associated with lower odds of preterm birth (aOR 0.62, 95% CI 0.40-0.98; P = 0.04).CONCLUSION: In a programmatic setting in Western Kenya, IPT use was not associated with adverse birth outcomes.

Comparison of deep learning with traditional models to predict preventable acute care use and spending among heart failure patients

 

Recent health reforms have created incentives for cardiologists and accountable care organizations to participate in value-based care models for heart failure (HF). Accurate risk stratification of HF patients is critical to efficiently deploy interventions aimed at reducing preventable utilization. The goal of this paper was to compare deep learning approaches with traditional logistic regression (LR) to predict preventable utilization among HF patients. We conducted a prognostic study using data on 93,260 HF patients continuously enrolled for 2-years in a large U.S. commercial insurer to develop and validate prediction models for three outcomes of interest: preventable hospitalizations, preventable emergency department (ED) visits, and preventable costs. Patients were split into training, validation, and testing samples. Outcomes were modeled using traditional and enhanced LR and compared to gradient boosting model and deep learning models using sequential and non-sequential inputs. Evaluation metrics included precision (positive predictive value) at k, cost capture, and Area Under the Receiver operating characteristic (AUROC). Deep learning models consistently outperformed LR for all three outcomes with respect to the chosen evaluation metrics. Precision at 1% for preventable hospitalizations was 43% for deep learning compared to 30% for enhanced LR. Precision at 1% for preventable ED visits was 39% for deep learning compared to 33% for enhanced LR. For preventable cost, cost capture at 1% was 30% for sequential deep learning, compared to 18% for enhanced LR. The highest AUROCs for deep learning were 0.778, 0.681 and 0.727, respectively. These results offer a promising approach to identify patients for targeted interventions.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): internally funded by Diagnostic Robotics Inc.

Transcriptional analysis of metabolic and virulence genes associated with biofilm formation in Piscirickettsia salmonis strains

Piscirickettsia salmonis is a facultative intracellular bacterium that generates piscirickettsiosis affecting salmonids in Chile. The bacterium has the adaptability to survive in the marine environment under multiple stressful conditions. In this sense, this work focused on the analysis of a gene battery associated with biofilm formation under different culture conditions and on the adaptability of this biofilm to different media. The results indicated that the strains LF-89, IBM-034 and IBM-040 were strong biofilm producers, evidencing adaptability to the media by increasing the amount of biofilm through successive growths. Transcript levels of six genes described in various bacteria and P. salmonis, considered to have metabolic functions, and playing a relevant role in biofilm formation, were analyzed to evaluate bacterial functionality in the biofilm. The genes mazE-mazF, implicated in biofilm and stress, were markedly overexpressed in the biofilm condition in the three strains. For its part, gene gltA, an indicator of metabolic activity and related to virulence inhibition in Salmonella typhimurium, also seems to restrain the pathogenesis process in P. salmonis by inhibiting the expression of the virulence-associated genes liso and tcf. Finally, the expression of the glnA gene suggests the use of glutamine as an essential element for the growth of the biofilm.

Novel edible toys as iron carrier to prevent iron deficiency of postweaned pigs

The current preventive treatment for iron deficiency in pigs is inefficient, resulting in a high prevalence of iron-deficient or anemic postweaned pigs. The aim of this study was to develop and characterize edible toys (ETs) to be used as oral iron supplements, and to assess their effect on feeding behavior and iron status of postweaned pigs. Three types of ETs, varying in sweetness, were produced by ionic gelation, using whey, sodium alginate, ferrous sulfate and atomized bovine erythrocytes. ET control (ETC) was developed without sweetener, ET1 contained 15% w/v sucrose and ET2 contained 0.03% w/v of Sucram (98% sodium saccharin, 1% neosperidine dihydrocalcone and 1% maltol). ETs were mainly composed of carbohydrates and protein, with a similar concentration of iron (2.2-2.7 mg/g). The ETs were offered to 24 postweaned pigs to measure acceptability and preference. The animals preferred ETC and ET2 over ET1. To assess the nutritional benefit of the ETs, 24 postweaned pigs were distributed into three groups: ETC (without iron), ETC-Fe (ETC with iron) and ET2-Fe (with iron and Sucram). Iron-loaded ET (ETC-Fe and ET2-Fe) significantly increased the concentration of red blood cells (from 6.1 to 7.5·10⁶ x mm³ for ETC-Fe and from 6.2 to 7.8 for ET2-Fe), hematocrit (from 32.8 to 37.9% for ETC-Fe and from 32.3 to 35.1 for ET2-Fe), serum iron (from 28.6 to 120.6 µmol/L for ETC-Fe and from 34.9 to 145.4 for ET2-Fe) and serum ferritin (from 7.8 to 18.5 µg/L for ETC-Fe and from 8.1 to 20.2 for ET2-Fe). In conclusion, the ETs developed in this study were accepted by the pigs and provided adequate iron to improve the iron status of postweaned pigs.

Acquisition of flavour preferences in pigs through interactions with conspecifics that had previously consumed flavoured protein solutions

It is known that pigs can acquire flavour preferences by brief social interactions with conspecifics that previously consumed a flavoured solid feed. However, there is no information about whether a flavoured solution could support flavour preferences through social transmission. Ninety-six pigs (49 days old) were housed in 12 pens (8 pigs/pen). Four animals per pen were randomly selected to act as observers and four as demonstrators. Demonstrator animals were temporarily moved to an empty pen where a protein solution was offered (porcine digestive peptides (PDPs), 4% weight/volume) with the addition of 0.075% aniseed (six pens) or garlic (six pens) powdered artificial flavours for 30 min. Afterwards, demonstrators were returned to interact with observer animals for 30 min. A choice test (30 min) between aniseed and garlic PDP was performed for each observer group after the interaction. Observers showed a higher intake of solutions previously consumed by their demonstrator conspecifics (648 v. 468 ml; SEM 61.36, P < 0.05). As with flavoured solid feeds, protein solutions containing artificial flavours can create preferences in pigs for those flavours through social transmission from conspecifics.

Cause of death among HIV patients in London in 2016

OBJECTIVES

Since 2013, the London HIV Mortality Review Group has conducted annual reviews of deaths among people with HIV to reduce avoidable mortality.

METHODS

All London HIV care Trusts reported data on 2016 patient deaths in 2017. Deaths were submitted using a modified Causes of Death in HIV reporting form and categorized by a specialist HIV pathologist and two HIV clinicians.

RESULTS

There were 206 deaths reported; 77% were among men. Median age at death was 56 years. Cause was established for 82% of deaths, with non-AIDS-related malignancies and AIDS-defining illnesses being the most common causes reported. Risk factors in the year before death included: tobacco smoking (37%), excessive alcohol consumption (19%), non-injecting drug use (10%), injecting drug use (7%) and opioid substitution therapy (6%). Thirty-nine per cent of patients had a history of depression, 33% chronic hypertension, 27% dyslipidaemia, 17% coinfection with hepatitis B virus and/or hepatitis C virus and 14% diabetes mellitus. At the time of death, 81% of patients were on antiretroviral therapy (ART), 61% had a CD4 count < 350 cells/μL, and 24% had a viral load ≥ 200 HIV-1 RNA copies/mL. Thirty-six per cent of deaths were unexpected; 61% of expected deaths were in hospital. Two-thirds of expected deaths had a prior end-of-life care discussion documented.

CONCLUSIONS

In 2016, most deaths were attributable to non-AIDS-related conditions and the majority of patients were on ART and virally suppressed. However, several potentially preventable deaths were identified and underlying risk factors were common. As London HIV patients are not representative of people with HIV in the UK, a national mortality review is warranted.

HIV care cost in England: a cross-sectional analysis of antiretroviral treatment and the impact of generic introduction

OBJECTIVES

Reliable and timely HIV care cost estimates are important for policy option appraisals of HIV treatment and prevention strategies. As HIV clinical management and outcomes have changed, we aimed to update profiles of antiretroviral (ARV) usage pattern, patent/market exclusivity details and management costs in adults (≥ 18 years old) accessing HIV specialist care in England.

METHODS

The data reported quarterly to the HIV and AIDS Reporting System in England was used to identify ARV usage pattern, and were combined with British National Formulary (BNF) prices, non-ARV care costs and patent/market exclusivity information to generate average survival-adjusted lifetime care costs. The cumulative budget impact from 2018 to the year in which all current ARVs were expected to lose market exclusivity was calculated for a hypothetical 85 000 (± 5000) person cohort, which provided an illustration of potential financial savings afforded by bioequivalent generic switches. Price scenarios explored BNF70 (September 2015) prices and generics at 10/20/30/50% of proprietary prices. The analyses took National Health Service (NHS) England's perspective (as the payer), and results are presented in 2016/2017 British pounds.

RESULTS

By 2033, most currently available ARVs would lose market exclusivity; that is, generics could be available. Average per person lifetime HIV cost was ~£200 000 (3.5% annual discount) or ~£400 000 (undiscounted), reducing to ~£70 000 (3.5% annual discount; ~£120 000 undiscounted) with the use of generics (assuming that generics cost 10% of proprietary prices). The cumulative budget to cover 85 000 (± 5000) persons for 16 years (2018-2033) was £10.5 (± 0.6) billion, reducing to £3.6 (± 0.2) billion with the use of generics.

CONCLUSIONS

HIV management costs are high but financial efficiency could be improved by optimizing generic use for treatment and prevention to mitigate the high cost of lifelong HIV treatment. Earlier implementation of generics as they become available offers the potential to maximize the scale of the financial savings.

Sugar intake by type (added vs. naturally occurring) and physical form (liquid vs. solid) and its varying association with children's body weight, NHANES 2009-2014

BACKGROUND

Sugars and their primary dietary sources (milk, fruits, sweetened foods and beverages) are associated, in different ways, with a range of health outcomes, including obesity. The contribution made to total sugar intake and how the different types and forms of sugar associate with body weight is unclear.

OBJECTIVE

To describe sugar consumption and examine its association with weight status among U.S. children by sugar type [added {AS} vs. naturally occurring {NOS}] and form (solid vs. liquid).

DESIGN

Cross-sectional dietary data (2 24-h recalls) from children 2-19 years in the National Health and Nutrition Examination Survey, 2009-2014 (n = 8136) were used to estimate the amount of each type and form of sugar by age and weight status. Linear regression models tested trends and the multivariate adjusted association between the different sugars and weight status.

RESULTS

Mean total sugar, AS, and NOS was 118.1 g [25.3% total energy {TE}], 71.5 g (14.8% TE), 46.7 g (10.5% TE), respectively. AS in sugar-sweetened (non-dairy) beverages and NOS in juices contributed 6.9% and 2.4% of TE, respectively. Only %TE from AS (controlled for potential demographic, lifestyle confounders) was associated with change in body mass index z-score (BMIz) [AS in beverages: BMIz β + 0.01 {95% CI: 0.002, 0.03}; AS in foods: BMIz β - 0.03 {95% CI: -0.04, -0.02}].

CONCLUSION

Dietary sugars, most of which are AS, are a major contributor of calories in the diets of U.S. children. Only AS in non-dairy sources were associated with weight although the direction differed by the form consumed. AS in beverages were associated positively and those in foods were associated inversely with children's weight status.

Identification of genomic islands in Chilean Piscirickettsia salmonis strains and analysis of gene expression involved in virulence

Piscirickettsia salmonis, an agent of Piscirickettsiosis, is the cause of major losses in the Chilean salmon industry. We identified, characterized and bioinformatically analysed genomic islands in field strains of P. Salmonis, using the bioinformatic software PIPS, that uses the characteristics of the islands of pathogenicity to identify them. We analysed nine partially sequenced genomes in different new field strains, and compared them with the LF-89 (Type strain) genome, selecting a genomic island present in all of them. We then evaluated the relative expression of three genes present in that island. From the obtained results, we conclude that the expression of the tcf gene is directly proportional to the cytopathogenicity in vitro of the bacteria; the product of the dnsa gene could contribute to its pathogenicity, but would be potentiated by one or more factors. The product of the gene liso is necessary for the virulence process and could have functions in early stages of infection. Regarding the strains, the IBM-040 strain showed a significant increase in the expression of all the genes in the study. Contrarily, LF-89 only presented a significant increase in expression of the gene liso, which correlates with the cytopathogenicity in vitro observed in the SHK-1 cells.

Search and analysis of genes involved in antibiotic resistance in Chilean strains of Piscirickettsia salmonis

Piscirickettsia salmonis is the pathogen causing Piscirickettsiosis. For treatment, the industry mainly uses oxytetracycline and florfenicol, so it is essential to understand the degree of susceptibility of this pathogen to these drugs. But this is still unknown for a large number of P. salmonis strains, as are the molecular mechanisms responsible for greater or lesser susceptibility. However, genes that confer resistance to these antimicrobials have been reported and characterized for this and other bacterial species, among which are membrane proteins that take out the drug. Our results identified differences in the degree of susceptibility to both antibiotics among different Chilean isolated of these bacteria. We analysed 10 available genomes in our laboratory and identified ~140 genes likely to be involved in antibiotic resistance. We analysed six specific genes, which suggests that some of them would eventually be relevant in conferring resistance to both antibiotics, as they encode for specific transporter proteins, which increase the number of transcripts when grown in media with these antibiotics. Our results were corroborated with EtBr permeability analysis, which revealed that the LF-89 strain accumulates this compound and has a reduced capacity to expulse it compared with the field strains.

Immunostimulatory effect of salmon prolactin on expression of Toll-like receptors in Oncorhynchus mykiss infected with Piscirickettsia salmonis

In aquaculture, antibiotics are the traditional treatment used against bacterial infections. However, their use has increasingly come into question given their effects on fish and, possibly, on human health. Consequently, there is interest in developing alternative treatments aimed at stimulating the innate immune response of fish, which is the first line of defense against pathogens. In relation to this, the Toll-like receptors (TLR) aid in the selective identification of pathogens. The present study evaluated immunostimulatory activity of prolactin (PRL) hormone on expression levels of TLR1, 9, and 22, MyD88, and IL-1β during in vitro infection with the fish pathogen Piscirickettsia salmonis, in primary cultures of Oncorhynchus mykiss head kidney cells. Results indicated that PRL increased expression of TLRs and MyD88 during the first hours of bacterial infection, while a constant increase in expression was found for IL-1β. These findings suggest that PRL indirectly modulates expression of TLRs by activating expression of suppressors of cytokine signaling, thereby regulating immune response over long periods of time during bacterial infection.

Immunostimulatory effects of prolactin on TLR1 and TLR5M in SHK-1 cells infected with Piscirickettsia salmonis

The innate immune system is the first line of defense against infection by pathogens. It consists of various elements, including Toll-like receptors (TLRs), which recognize molecular patterns associated with pathogens and trigger the immune response, through activation of important transcription factors such as NF-κB, which are usually found sequestered in the cytoplasm by IκBα until it receives the release signal. Piscirickettsia salmonis causes piscirickettsiosis or salmonid rickettsial septicemia, a disease of great importance in Chile, representing 79.4% of the secondary mortality in important species such as Salmo salar, which is reflected in the Chilean economy. Prolactin (PRL) is a peptide hormone which has immunomodulating functions in mammals and some fish. Olavarría et al. (2010, J Immunol 185:3873-3883) determined its ability to increase the respiratory burst, its relationship with the JAK/STAT pathway, and the expression of interleukin IL-1β in Sparus aurata. Therefore, the present study was intended to establish a possible correlation and modulation between the signal transduction pathway of PRL (JAK/STAT), the pathways of NF-κB, and TLRs, in an infection caused by P. salmonis in salmon head kidney (SHK‑1) cells of S. salar. Stimulus with native PRL from S. salar was performed, and gene expression was analyzed for IL-1β, IκBα, TLR1, and TLR5M (membrane-bound form). In addition, the effect of PRL in the nuclear translocation of the transcription factor NF-κB and the possible involvement of JAK2 were analyzed by using a pharmacological inhibitor of this kinase. The results show a positive modulation of PRL in all analyzed genes and a significant increase in the translocation of NF-κB, recording a maximum at 2 h post-treatment, supporting the stimulatory hypothesis of PRL.

Molecular cloning of Salmo salar Toll-like receptors (TLR1, TLR22, TLR5M and TLR5S) and expression analysis in SHK-1 cells during Piscirickettsia salmonis infection

In fish, the innate immune system is the primary response against infection. Toll-like receptors (TLRs) recognize pathogens through pathogen-associated molecular patterns (PAMPs), and some target molecules of TLRs are homologous between fish and mammals. Piscirickettsia salmonis is one of the main pathogens affecting the salmon industry in Chile. Better knowledge of mechanisms underlying its invasive capacity and recognition of target cells is crucial for vaccine development. Therefore, Salmo salar L. TLR1, TLR22, membrane TLR5M and soluble TLR5S sequences were cloned, and expression kinetics were analysed by RT-qPCR in salmon head kidney cells (SHK-1) infected with three different P. salmonis preparations: alive, formaldehyde treated, extract. Clearly, all analysed TLRs were expressed and transcription level changes were revealed at 2 hpi, 12 or 16 hpi and 24 hpi depending on P. salmonis infection scheme. Increased IL1-beta expression confirmed TLR pathway response. Furthermore, significant expression modulations of several members of the TLR pathway in this in vitro model suggest that P. salmonis extract rather than formaldehyde-inactivated bacteria might strengthen the salmon immune system.

Differential response of two somatolactin genes to zinc or estrogen in pituitary of Cyprinus carpio

Environmental changes affect gene expression that we addressed in the pituitary, a central regulatory organ at the interface between the central nervous system and the endocrine system. With the aim to reveal effects of changes in the aquatic environment on the expression of hypothalamo-hypophyseal factors, we characterized somatolactin (SL) in Cyprinus carpio. SL, a fish specific pituitary hormone belonging to the prolactin (PRL) superfamily, is involved in background adaptation, osmoregulation, reproduction and fatty acid metabolism. Two sl genes, α and β, were discovered in carp and transcripts of both were detected in pituitaries. Clearly, expression of slα and slβ was modulated significantly in pituitary of male adult carp in response to treatment with ZnCl2 (Zn), but only slβ responded to 17β-estrogen (E2), relative to control carp as shown by RT-qPCR analyses. Furthermore, the amount of mRNA of related factors was assessed revealing variable effects on prl, growth hormone (gh), and factors involved in sl regulation: the pituitary transcription factor pit1 and hypothalamic pituitary adenylase cyclase activating peptide (pacap). In parallel, the physiological response of the experimental animals to Zn or E2 was confirmed by showing a significant increase of metallothionein (mt) or vitellogenin (vg) gene expression in liver, classical sentinels for exposure to heavy metal or estrogens. These data suggest that the sl genes seem to be involved in the response to Zn, as well as to estrogen, and could contribute to evaluate biological relevant changes in the aquatic environment.

Identification of the clpB and bipA genes and an evaluation of their expression as related to intracellular survival for the bacterial pathogen Piscirickettsia salmonis

Piscirickettsia salmonis is the pathogen responsible for salmonid rickettsial septicemia (SRS), a disease that affects a wide variety of marine cultivated fish species and causes economic losses for the aquaculture industry worldwide. Many in vitro studies have reported on the capacity of this microorganism to replicate in the interior of cytoplasmic vesicles from varied fish cell lines. However, the mechanisms used by this bacteria to survive, replicate, and propagate in cell lines, especially in macrophages and monocytes, are unknown. A number of studies have described the diverse proteins in pathogens such as Legionella pneumophila, Coxiella burnetii, and Francisella tularensis which allow these to evade the cellular immune response and replicate in the interior of macrophages in different hosts. Some of these proteins are the virulence factor BipA/TypA and the heat shock protein ClpB, both of which have been widely characterized. The results of the current study present the complete coding sequence of the genes clpB and bipA from the P. salmonis genome. Moreover, the experimental results suggest that during the infectious process of the SHK-1 cellular line in P. salmonis, the pathogen significantly increases the expression of proteins ClpB and BipA. This would permit the pathogen to adapt to the hostile conditions produced by the macrophage and thus evade mechanisms of cellular degradation while facilitating replication in the interior of this salmon cell line.

Broth medium for the successful culture of the fish pathogen Piscirickettsia salmonis

Piscirickettsiosis or salmonid rickettsial septicaemia (SRS) caused by Piscirickettsia salmonis constitutes one of the main problems in farmed salmonid and marine fishes. Since the first reports of the disease, it has been successfully isolated and maintained in eukaryotic cell--culture systems, but these systems are time-consuming, the media are costly, and eliminating heavily contaminated host cell debris is difficult. In this report, we describe a marine-based broth supplemented with L-cysteine, named AUSTRAL-SRS broth, that facilitates superior growth of P. salmonis strains. Strains reached an optical density of approximately 1.8 when absorbance was measured at 600 nm after 6 d incubation at 18°C. Several passages (n = 6) did not alter the culture kinetics. We report for the first time the purification of DNA, lipopolysaccharide (LPS) and whole membrane protein obtained from P. salmonis grown in this liquid medium, and thus provide a suitable platform to simplify the preparation of P. salmonis cells for genetic and serological studies. Moreover, the results of the cytopathic effect test showed that P. salmonis grown in AUSTRAL-SRS broth maintained their virulence properties, inducing apoptosis after 3 d. This makes the medium a good candidate for the successful growth of P. salmonis and an excellent basis for the development of low cost vaccines.

X-ray absorption measurements on an ultrasonic spray aerosol

Spray deposition of thin films and coatings is a widely used manufacturing process owing to its low cost, versatility and simple implementation. The objective of the presented experiments was to investigate whether X-ray absorption measurements on solutes carried by aerosols are possible, and what count rates can be achieved depending on solution flow through and the resulting mass density in the interrogation volume. The investigated prototypical spray aerosol was InCl(3) dissolved in water or ethanol dispersed via an ultrasonic nebulizer. InCl(3) spray is essential for the ion layer gas reaction process used for the deposition of In(2)S(3) buffer layers for highly efficient chalcopyrite solar cells. The discussed experiments demonstrate that measurements are possible, but that the achievement of good signal-to-noise ratios requires extended sampling times and concentrated solutions.

At least two expressed genes for transcription factors Pitx2 and Rpx are present in common carp and are upregulated during winter acclimatization

The mechanisms of seasonal acclimatization in eurythermal fish such as common carp are not fully understood. Here, we concentrate on the regulation of pituitary factors, as this organ was shown to be highly affected by seasonal changes. We cloned and sequenced two different cDNAs for each of the transcription factors Pitx2 and Rpx, known to play a role in pituitary development. We show that these genes are conserved throughout evolution, to different degrees depending on the specific domain considered. Finally, we show that the cDNAs for both factors are clearly up-regulated during the winter season, in sharp contrast to other regulators such as Pit1 or pituitary hormone genes such as prolactin (prl) and growth hormone (gh). Our results suggest that increased expression of Pitx2 and Rpx contributes to seasonal adaptation of common carp to winter conditions.

Hepatitis A outbreak in an Orthodox Jewish community in London, July 2010

A cluster of hepatitis A cases in the Orthodox Jewish community in London, United Kingdom in July 2010 has triggered extensive contact tracing and vaccination. Two primary cases imported from a common source in Israel and three secondary cases have resulted in immunisation of over 900 contacts to date. Rapid response by local public health, primary care services and a dedicated community health team, and active hepatitis A vaccination rather than immunoglobulin treatment were used to avert a larger outbreak.

Hepatitis A outbreak in an Orthodox Jewish community in London, July 2010

TA cluster of hepatitis A cases in the Orthodox Jewish community in London, United Kingdom in July 2010 has triggered extensive contact tracing and vaccination. Two primary cases imported from a common source in Israel and three secondary cases have resulted in immunisation of over 900 contacts to date. Rapid response by local public health, primary care services and a dedicated community health team, and active hepatitis A vaccination rather than immunoglobulin treatment were used to avert a larger outbreak.

Streptococcosis on a red tilapia, Oreochromis sp., farm: a case study

A commercial red tilapia farm was diagnosed with Streptococcus agalactiae infection using histopathology, microbiology and immunohistochemistry. One hundred fish were randomly taken from different weight/age groups including broodstock, market fish (larger than 150 g), on-growing fish between 20 and 150 g, juveniles and larvae. Fish were clinically examined, anaesthetised and necropsied. Samples were taken from brain, liver, spleen, eyes and kidney for microbiology. All organs were processed for histopathology and an indirect immunoperoxidase test (IIP). Organs from wild fish and birds found in close proximity to the farm were also sampled for microbiology and IIP. The prevalence of lesions or infection found by IIP, histopathology and microbiology was 16%, 29% and 7% respectively. Clinical disease, lesions or infection were not seen in larvae or juveniles. By contrast, infection and disease were found in fish larger than 20 g, suggesting that the condition was linked to the intensive culture conditions of broodstock, on-growing and market fish. S. agalactiae was not found in wild fish, or in birds, by microbiology and IIP.