Exploring the presence of bovine leukemia virus among breast cancer tumors in a rural state

PURPOSE

The bovine leukemia virus (BLV) is a deltaretrovirus that causes malignant lymphoma and lymphosarcomas in cattle globally and has high prevalence among large scale U.S. dairy herds. Associations between presence of BLV DNA in human mammary tissue and human breast cancer incidence have been reported. We sought to estimate the prevalence of BLV DNA in breast cancer tissue samples in a rural state with an active dairy industry.

METHODS

We purified genomic DNA from 56 fresh-frozen breast cancer tissue samples (51 tumor samples, 5 samples representing adjacent normal breast tissue) banked between 2016 and 2019. Using nested PCR assays, multiple BLV tax sequence primers and primers for the long terminal repeat (LTR) were used to detect BLV DNA in tissue samples and known positive control samples, including the permanently infected fetal lamb kidney cell line (FLK-BLV) and blood from BLV positive cattle.

RESULTS

The median age of patients from which samples were obtained at the time of treatment was 60 (40-93) and all were female. Ninety percent of patients had invasive ductal carcinoma. The majority were poorly differentiated (60%). On PCR assay, none of the tumor samples tested positive for BLV DNA, despite having consistent signals in positive controls.

CONCLUSION

We did not find BLV DNA in fresh-frozen breast cancer tumors from patients presenting to a hospital in Vermont. Our findings suggest a low prevalence of BLV in our patient population and a need to reevaluate the association between BLV and human breast cancer.

Is 80 the New 70? Octogenarians with Oropharyngeal Squamous Cell Carcinoma

PURPOSE/OBJECTIVE(S)

As the human papilloma virus (HPV) pandemic evolves and life expectancy increases, the number of older adults with oropharyngeal squamous cell carcinoma (OPSCC) continues to increase. However, there is a paucity of data regarding the fastest growing subset of this population: octogenarians (OGs). We sought to understand differences in treatment tolerability and clinical outcomes between septuagenarians (SGs) and OGs with OPSCC.

MATERIALS/METHODS

We identified SGs (age 70-79) and OGs (age 80-89) with OPSCC from a cohort of older adults with nonrecurrent, nonmetastatic head and neck squamous cell carcinoma (HNSCC) treated curatively from 2007-2020. We compared demographics, treatment characteristics and toxicities using Fischer's exact test. Time-to-event outcomes, overall survival (OS), locoregional control (LRC), and disease-specific survival (DSS), were evaluated using the Kaplan-Meier method.

RESULTS

Of 293 patients (age 70-89) with HNSCC, 39% (n = 114) had OPSCC: 93 SGs (median age: 73; interquartile range [IQR]: 71-76), and 21 OGs (median age: 81, IQR: 80-84). The median follow-up for included patients was 2.4 years; 82% were male, 64% white, 48% > 20 pack year smoking history, 37% ECOG 1. Patients had AJCC 8th edition Stage: I (27%); II (33%); III (18%); IV (22%) OPSCC. Treatment consisted of adjuvant radiation (RT) (19%), adjuvant chemoradiation (CRT) (8%), surgery alone (6%), induction/concurrent CRT (27%), concurrent CRT (28%), or RT (12%), with no significant differences in stage or treatment modalities noted between SGs and OGs. Of note, 69% of SGs and 76% of OGs were HPV+. Among 107 patients who received any RT, 24% experienced a treatment interruption (19% of SGs vs. 48% of OGs, p = 0.001) and 2 patients (both HPV- SGs) died on treatment due to unrelated health conditions. Percutaneous endoscopic gastrostomy (PEG) tubes were placed prior to or during treatment in 43% of SGs and 62% of OGs, with OGs more likely to have a PEG placed during treatment (p = 0.025). There was no difference in the prevalence of late (> 6 months) CTCAE grade 2+ dysphagia (36%) or xerostomia (31%) between SGs and OGs. Estimated 3-year LRC, DSS, and OS were not significantly different between SGs (LRC:85%; DSS:87%; OS:76%) and OGs (LRC: 81%; DSS:94%; OS: 55%, p-values: 0.98, 0.42, 0.052, respectively). However, HPV+ disease significantly increased estimated 3-year OS for both SGs (HPV+: 84%; HPV-: 56%, p = 0.0006) and OGs (HPV+: 68%; HPV-: 20%, p = 0.008).

CONCLUSION

In our cohort, OGs had a higher proportion of HPV+ OPSCC, which was associated with improved OS. This finding may provide insight into the latency of the virus. While there were similar amounts of toxicities among SGs and OGs, OGs more frequently underwent PEG tube placement and experienced more treatment interruptions. Given high rates of HPV+ OPSCC in OGs, our findings suggest that de-escalation strategies should be further investigated to improve tolerability and maximize outcomes for this neglected population.

Multicentre randomised trials in anaesthesia: an analysis using Bayesian metrics

Are the results of randomised trials reliable and are p values and confidence intervals the best way of quantifying efficacy? Low power is common in medical research, which reduces the probability of obtaining a 'significant result' and declaring the intervention had an effect. Metrics derived from Bayesian methods may provide an insight into trial data unavailable from p values and confidence intervals. We did a structured review of multicentre trials in anaesthesia that were published in the New England Journal of Medicine, The Lancet, Journal of the American Medical Association, British Journal of Anaesthesia and Anesthesiology between February 2011 and November 2021. We documented whether trials declared a non-zero effect by an intervention on the primary outcome. We documented the expected and observed effect sizes. We calculated a Bayes factor from the published trial data indicating the probability of the data under the null hypothesis of zero effect relative to the alternative hypothesis of a non-zero effect. We used the Bayes factor to calculate the post-test probability of zero effect for the intervention (having assumed 50% belief in zero effect before the trial). We contacted all authors to estimate the costs of running the trials. The median (IQR [range]) hypothesised and observed absolute effect sizes were 7% (3-13% [0-25%]) vs. 2% (1-7% [0-24%]), respectively. Non-zero effects were declared for 12/56 outcomes (21%). The Bayes factor favouring a zero effect relative to a non-zero effect for these 12 trials was 0.000001-1.9, with post-test zero effect probabilities for the intervention of 0.0001-65%. The other 44 trials did not declare non-zero effects, with Bayes factors favouring zero effect of 1-688, and post-test probabilities of zero effect of 53-99%. The median (IQR [range]) study costs reported by 20 corresponding authors in US$ were $1,425,669 ($514,766-$2,526,807 [$120,758-$24,763,921]). We think that inadequate power and mortality as an outcome are why few trials declared non-zero effects. Bayes factors and post-test probabilities provide a useful insight into trial results, particularly when p values approximate the significance threshold.

The Middle-Out Perspective: an approach to formalise 'normal practice' in public health advocacy

AIMS

The middle-out perspective (MOP) provides a lens to examine how actors positioned between government (top) and individuals (bottom) act to promote broader societal changes from the middle-out (rather than the top-down or bottom-up). The MOP has been used in recent years in the fields of energy, climate change, and development studies. We argue that public health practitioners involved with advocacy activities and creating alliances to amplify health promotion actions will be familiar with the general MOP concept if not the formal name. The article aims to demonstrate this argument.

METHODS

This article introduces the MOP conceptual framework and customises it for a public health audience by positioning it among existing concepts and theories for actions within public health. Using two UK case studies (increasing signalised crossing times for pedestrians and the campaign for smoke-free legislation), we illustrate who middle actors are and what they can do to result in better public health outcomes.

RESULTS

These case studies show that involving a wider range of middle actors, including those not traditionally involved in improving the public's health, can broaden the range and reach of organisations and individuals involving in advocating for public health measures. They also demonstrate that middle actors are not neutral. They can be recruited to improve public health outcomes, but they may also be exploited by commercial interests to block healthy policies or even promote a health-diminishing agenda.

CONCLUSION

Using the MOP as a formal approach can help public health organisations and practitioners consider potential 'allies' from outside traditional health-related bodies or professions. Formal mapping can expand the range of who are considered potential middle actors for a particular public health issue. By applying the MOP, public health organisations and staff can enlist the additional leverage that is brought to bear by involving additional middle actors in improving the public's health.

Coastal dynamism in Southern Thailand: An application of the CoastSat toolkit

In Thailand, 17% of the population lives by the coast, approximately 11 million people. A combination of coastal erosion, sea level rise and coastal land subsidence are critical issues threatening the livelihoods of coastal communities. Thailand has invested a lot of money and installed conservation policies to restore and protect coastal mangroves and realign or replenish their beaches. This study assessed the use of the toolkit Coastsat to digitise a time series of shoreline positions from open access satellite images between 1990 and 2019 along 560 km of coastline in the provinces of Krabi and Nakhon Si Thammarat (NST). Based on these digitised shorelines and the use of the software Digital Shoreline Analysis System (DSAS), it was possible to identify shoreline change, which varied between -66 to +16.4 m/y in the mangroves of NST and -22.2 to +10.6 m/year on its sandy beaches. Shoreline change rates along the Krabi coast varied -34.5 to +21.7 m/year in the mangroves and -4.1 to +4 m/year on sandy beaches. Analysis of the spatial and temporal variations of the shoreline position during the survey period reveals a linkage between extreme weather conditions and coastal erosion along the NST coast while that linkage is less clear along the Krabi coast. CoastSat delivers crucial and accurate time series shoreline data over extensive areas that are vital to coastal managers and researchers in a completely remote manner, which is key with the presence of COVID-19 travel bans.

More vaquita porpoises survive than expected

In 2018, it was estimated that fewer than 20 of Mexico’s endemic vaquita porpoise Phocoena sinus remained, and the species was declining by 47% yr-1. Entanglement in gillnets is the sole threat to the species, and since the last population size estimate, gillnetting has increased in the small area where most vaquitas remain—a 12 × 24 km area in the Gulf of California near San Felipe, Mexico. We conducted research efforts in 2019 and 2021 in that area to estimate the minimum numbers of adults and calves and look for any signs that vaquitas are unhealthy. Through expert elicitation, we estimated between 7 and 15 unique individuals were seen in 2019 and 5-13 were seen in 2021. Calves were seen in both years, and all vaquitas appeared healthy. Population projections from the last full survey indicated that more vaquitas have survived than expected. We suggest that these surviving adult vaquitas may have learned to avoid entanglement in gillnets. These vaquitas and their calves provide hope that the species can survive. However, given the high levels of illegal gillnetting and the theft of equipment which hindered our monitoring efforts, and with only around 10 individuals remaining, survival can only be assured if vaquita habitat is made gillnet-free.

Medicinal Cannabis for the Treatment of Chronic Refractory Pain: An Investigation of the Adverse Event Profile and Health-Related Quality of Life Impact of an Oral Formulation

<b><i>Introduction:</i></b> Medicinal cannabis is prescribed in Australia for patients with chronic refractory pain conditions. However, measures of safety and effectiveness of different cannabinoids are lacking. We designed an observational study to capture effectiveness, adverse events (AEs), and health-related quality of life (HRQoL) measures in patients prescribed an oral medicinal cannabis formulation at Cannabis Access Clinics through the Cannabis Access Clinics Observational study (CACOS). <b><i>Objectives:</i></b> We aimed to evaluate effectiveness, reported AEs, and change in patient-reported outcomes in individuals prescribed a cannabinoid oil formulation for management of chronic pain. <b><i>Methods:</i></b> A cross-sectional analysis was conducted on patients prescribed an oil formulation of Δ9-tetrahydrocannabinol and cannabidiol for pain symptoms of at least 3-month duration. Clinician-reported AEs were organized by system, organ, class, and frequency. Analysis of patient-reported responses to a questionnaire was conducted using published minimal clinically important differences to determine meaningful change in HRQoL over time. <b><i>Results:</i></b> More than half (<i>n</i> = 91/151, 60.3%) of the participants experienced at least one AE during the observation period (mean 133 ± 116 days). No serious AEs were reported. Patient-reported pain impact scores were significantly reduced across the cohort (<i>p</i> = 0.034), and pain intensity scores verged on significance (<i>p</i> = 0.053). The majority of patients saw meaningful improvements in sleep (49.3%) and fatigue (35.6%). <b><i>Conclusion:</i></b> This analysis presents real-world data collected as part of standard of care. More than one-third of patients benefited from oral medicinal cannabis, which is impactful given the refractory nature of their pain. Amelioration of the impact of pain confirms continued prescribing of this formulation and validates our observational methodology as a tool to determine the therapeutic potency of medicinal cannabinoids.

A decision support tool for the detection of pancreatic cancer in general practice: A modified Delphi consensus

BACKGROUND/OBJECTIVES

Diagnosis of pancreatic cancer is often delayed, contributing to patient and family distress and leading to worse survival. We aimed to develop a decision support tool to support primary care providers to identify patients that should undergo investigations for pancreatic cancer, and to recommend initial diagnostic pathways.

METHODS

A modified Delphi process, including a series of three surveys, was undertaken to ascertain clinical expert opinion on which combinations of signs, symptoms and risk factors should be included in a tool for the early identification of pancreatic cancer. A group of clinical specialists finalised the development of the tool during a focus group meeting.

RESULTS

The tool presents individual or combinations of signs, symptoms, and risk factors in three tiers which direct the urgency of investigation. Tier 1 includes 5 clinical presentation and risk factors clusters that indicate the need for urgent investigation of the pancreas. A further five clusters are included as Tier 2 aiming to elimate other causes and reduce the time to investigating the pancreas. Tier 3 includes a list of non-specific signs, symptoms and risk factors that indicate the need to consider pancreatic cancer as a potential diagnosis, but without specific recommendations for investigation.

CONCLUSIONS

Prospective validation studies are now required prior to implementation in the primary care setting. Implementation into primary care practice and as an educational resource may facilitate rapid diagnosis and improve outcomes such as distress and survival.

Using the Middle-Out Perspective to augment advocacy for smokefree legislation

Issue

Complementing ‘Bottom-up' and ‘Top-down' approaches, the Middle-Out Perspective (MOP) conceptual framework focuses on how middle actors can influence action by enhancing other actors' interest and ability to act. Middle actors exert influence sideways on other middle actors, upwards on policymakers and downwards on individuals. Middle actors can be immediate targets as potential allies or communication channels.

Description of the problem

Successive governments' longstanding voluntary agreements with industry have not protected children and non-smokers from secondhand smoke. Can the MOP enhance effectiveness of small organisations whose voices are ignored?

Results

The NGO Action on Smoking and Health (ASH) built a coalition of NGOs, practitioners' organisations, and others to advocate for smokefree legislation. Aggregating these voices made them more visible and their demand more influential. Involvement of trade unions and lawyers threatened legal action by exposed employees. Local government support and threats of local legislation changed the hospitality trade's opposition to support. Middle actors' supporters and members lobbied their MPs. ASH's professional expertise and reputation made them a trustworthy actor with legitimacy. The consortium led to the national government in England passing smokefree legislation in 2006.

Lessons

Middle actors can be agents of change, promoting desirable public health goals in a middle-out manner. Formal MOP mapping at the start of work can help public health staff identify potential non-traditional ‘allies' to expand the range of who are considered potential middle actors for a particular issue, enlisting powerful additional leverage in improving the public's health. However, middle actors are not neutral. They can contribute to better public health, but they may also be exploited by commercial interests to block healthy policies or promote a health-diminishing agenda.

Key messages

The Middle-Out Perspective (MOP) provide a lens to examine how actors positioned between government (top) and individuals (bottom) act to promote changes in a middle-out manner. Using MOP as a formal approach can help public health organisations and practitioners consider potential ‘allies’ from outside traditional health-related bodies or professions.

What is the role of video feedback in supporting parents experiencing mental health problems?

Abstract Body

Parental mental health problems have been found to have a significant impact on a range of aspects of parental caregiving during the postnatal period, with significant implications in terms of key aspects of the child’s development. Video feedback is a generic term that refers to the use of videotaped interactions of the parent and child to promote parental sensitivity, and a recent meta‐analysis of 20 studies (1757 parent‐child dyads) found that video feedback can improve parental sensitivity compared with a control or no intervention up to six months’ follow‐up. This paper will examine the ways in which video feedback might contribute to the ability of parents with mental health problems to provide the type of caregiving that will promote the development of a secure attachment in the infant.

Disclosure

No significant relationships.

Cosmogenic exposure dating reveals limited long-term variability in erosion of a rocky coastline

Predicted sea-level rise and increased storminess are anticipated to lead to increases in coastal erosion. However, assessing if and how rocky coasts will respond to changes in marine conditions is difficult due to current limitations of monitoring and modelling. Here, we measured cosmogenic ¹⁰Be concentrations across a sandstone shore platform in North Yorkshire, UK, to model the changes in coastal erosion within the last 7 kyr and for the first time quantify the relative long-term eros0ive contribution of landward cliff retreat, and down-wearing and stripping of rock from the shore platform. The results suggest that the cliff has been retreating at a steady rate of 4.5 ± 0.63 cm yr⁻¹, whilst maintaining a similar profile form. Our results imply a lack of a direct relationship between relative sea level over centennial to millennial timescales and the erosion response of the coast, highlighting a need to more fully characterise the spatial variability in, and controls on, rocky coast erosion under changing conditions.

Predicted sea-level rise is widely anticipated to lead to increased coastal erosion, however, assessing how rocky coasts will respond to changes in marine conditions is difficult to constrain. Here, the authors find that a North Yorkshire rocky cliff has been eroding at a similar rate over the last 7 kyr, and they do not observe an increase in erosion rates in response to modern sea level rise.

First Measurement of Near-Threshold J/ψ Exclusive Photoproduction off the Proton

We report on the measurement of the γp→J/ψp cross section from E_{γ}=11.8  GeV down to the threshold at 8.2 GeV using a tagged photon beam with the GlueX experiment. We find that the total cross section falls toward the threshold less steeply than expected from two-gluon exchange models. The differential cross section dσ/dt has an exponential slope of 1.67±0.39  GeV^{-2} at 10.7 GeV average energy. The LHCb pentaquark candidates P_{c}^{+} can be produced in the s channel of this reaction. We see no evidence for them and set model-dependent upper limits on their branching fractions B(P_{c}^{+}→J/ψp) and cross sections σ(γp→P_{c}^{+})×B(P_{c}^{+}→J/ψp).

GLP-1 Receptor Agonists for Type 2 Diabetes and Their Role in Primary Care: An Australian Perspective

The ever-increasing number of drugs available to treat type 2 diabetes and the complexity of patients with this condition present a constant challenge when it comes to identifying the most appropriate treatment approach. The more recent glucagon-like peptide-1 receptor agonists (GLP-1RAs) are non-insulin injectable options for the management of type 2 diabetes. Effective at improving glycaemic control with a low intrinsic risk of hypoglycaemia and the potential for weight reduction, this agent class is an important addition to the prescribing armamentarium. However, understanding their place in therapy may prove confusing for many primary care practitioners, especially given the common belief that 'injectables' are a last-resort treatment option, which puts them at risk of being niched alongside insulin. This review summarises the clinical evidence for GLP-1RAs and how they compare to other glucose-lowering agents in managing type 2 diabetes. It also provides practical and case-driven opinions and recommendations on the optimal use of GLP-1RAs by discussing important patient factors and clinical considerations that will help to identify those who are most likely to benefit from this class of agents.Funding: Eli Lilly Australia.

Identification of a potent benzoxaborole drug candidate for treating cryptosporidiosis

Cryptosporidiosis is a leading cause of life-threatening diarrhea in young children and causes chronic diarrhea in AIDS patients, but the only approved treatment is ineffective in malnourished children and immunocompromised people. We here use a drug repositioning strategy and identify a promising anticryptosporidial drug candidate. Screening a library of benzoxaboroles comprised of analogs to four antiprotozoal chemical scaffolds under pre-clinical development for neglected tropical diseases for Cryptosporidium growth inhibitors identifies the 6-carboxamide benzoxaborole AN7973. AN7973 blocks intracellular parasite development, appears to be parasiticidal, and potently inhibits the two Cryptosporidium species most relevant to human health, C. parvum and C. hominis. It is efficacious in murine models of both acute and established infection, and in a neonatal dairy calf model of cryptosporidiosis. AN7973 also possesses favorable safety, stability, and PK parameters, and therefore, is an exciting drug candidate for treating cryptosporidiosis.

Clinical and microbiologic efficacy of the piperazine-based drug lead MMV665917 in the dairy calf cryptosporidiosis model

Cryptosporidiosis causes life-threatening diarrhea in infants, but the best available treatment is only modestly efficacious. Rodents infected with relevant Cryptosporidium species do not develop diarrhea, which complicates drug development. Cryptosporidium parvum infection of dairy calves, however, causes an illness like that seen in infants. Here, the clinical and microbiologic anti-Cryptosporidium efficacy of the piperazine-based compound MMV665917 was demonstrated in neonatal calves. Oral administration of MMV665917 (22 mg/kg once daily) was begun two days after the onset of severe diarrhea and continued for seven days. Treatment resulted in prompt resolution of diarrhea, and reduced total fecal oocyst shedding by ~94%. MMV665917 was useful for treatment, rather than just prophylaxis, since it was safe and effective when administered well after the onset of diarrhea. Furthermore, even though all animals received intensive supportive care, there was a strong trend towards improved secondary health outcomes, including general health, appetite, and dehydration measures amongst treated animals. These data establish MMV665917 as an outstanding lead compound for Cryptosporidium drug development.

Assessment of multi-modality evaluations of obscure gastrointestinal bleeding

AIM

To determine the frequency of bleeding source detection in patients with obscure gastrointestinal bleeding (OGIB) who underwent double balloon enteroscopy (DBE) after pre-procedure imaging [multiphase computed tomography enterography (MPCTE), video capsule endoscopy (VCE), or both] and assess the impact of imaging on DBE diagnostic yield.

METHODS

Retrospective cohort study using a prospectively maintained database of all adult patients presenting with OGIB who underwent DBE from September 1^st, 2002 to June 30^th, 2013 at a single tertiary center.

RESULTS

Four hundred and ninety five patients (52% females; median age 68 years) underwent DBE for OGIB. AVCE and/or MPCTE performed within 1 year prior to DBE (in 441 patients) increased the diagnostic yield of DBE (67.1% with preceding imaging vs 59.5% without). Using DBE as the gold standard, VCE and MPCTE had a diagnostic yield of 72.7% and 32.5% respectively. There were no increased odds of finding a bleeding site at DBE compared to VCE (OR = 1.3, P = 0.150). There were increased odds of finding a bleeding site at DBE compared to MPCTE (OR = 5.9, P < 0.001). In inpatients with overt OGIB, diagnostic yield of DBE was not affected by preceding imaging.

CONCLUSION

DBE is a safe and well-tolerated procedure for the diagnosis and treatment of OGIB, with a diagnostic yield that may be increased after obtaining a preceding VCE or MPCTE. However, inpatients with active ongoing bleeding may benefit from proceeding directly to antegrade DBE.

Peer-to-Peer, Interactive GP Education can Reduce Barriers to Best Practice in Diabetes Management

INTRODUCTION

Perceived difficulties in initiating insulin in patients with type 2 diabetes (T2D) may prevent many general practitioners (GPs) from using insulin even when recommended in guidelines. This paper describes a Royal Australian College of General Practitioners accredited education program on starting insulin in T2D, and its impact on GPs' attitudes and behavior.

METHODS

A faculty comprising GPs with diabetes expertise, Credentialed Diabetes Nurse Educators, and endocrinologist developed and implemented the education program. The program content was highly procedure focussed, emphasizing simple, best-practice processes for starting insulin therapy and focussing on multidisciplinary models of care. The highly interactive format of the workshops included peer-to-peer learning, in which education was led by diabetes-experienced GP educators, as well as case study-based approaches and small group discussions. GP attendees were asked to rate their individual confidence and attitudes at the beginning and end of the meeting. In addition, participants (n = 220) from two workshops in 2013 were sent a survey 3 months after the meeting to gauge the longer-term impact on their clinical practice.

RESULTS

Since 2008, more than 2500 GPs have attended the workshops, and report substantial improvements in confidence; after attending, more GPs were willing to start insulin within their practice. Evaluations at 3 months post-meeting indicate that the increased confidence was associated with behavioral changes in the subgroup evaluated at this time (n = 48). Success of this program was attributed to peer-to-peer education, multidisciplinary input, easily implemented best practice procedures and checklists for starting insulin, and constant adjustment of meeting process and content based on feedback and guideline changes.

CONCLUSION

A peer-to-peer, interactive GP education program reduced GPs' perceptions of the difficulties of starting insulin in T2D and achieved changes in attendees' clinical practice. This education program offers an effective approach to overcome the therapeutic inertia that is too common in diabetes management.

A modern approach for epitope prediction: identification of foot-and-mouth disease virus peptides binding bovine leukocyte antigen (BoLA) class I molecules

Major histocompatibility complex (MHC) class Imolecules regulate adaptive immune responses through the presentation of antigenic peptides to CD8+ T cells. Polymorphisms in the peptide binding region of class I molecules determine peptide binding affinity and stability during antigen presentation, and different antigen peptide motifs are associated with specific genetic sequences of class I molecules. Understanding bovine leukocyte antigen (BoLA), peptide-MHC class I binding specificities may facilitate development of vaccines or reagents for quantifying the adaptive immune response to intracellular pathogens, such as foot-and-mouth disease virus (FMDV). Six synthetic BoLA class I (BoLA-I) molecules were produced, and the peptide binding motif was generated for five of the six molecules using a combined approach of positional scanning combinatorial peptide libraries (PSCPLs) and neural network-based predictions (NetMHCpan). The updated NetMHCpan server was used to predict BoLA-I binding peptides within the P1 structural polyprotein sequence of FMDV (strain A24 Cruzeiro) for Bo-LA-1*01901, BoLA-2*00801, BoLA-2*01201, and BoLA-4*02401. Peptide binding affinity and stability were determined for these BoLA-I molecules using the luminescent oxygen channeling immunoassay (LOCI) and scintillation proximity assay (SPA). The functional diversity of known BoLA alleles was predicted using theMHCcluster tool, and functional predictions for peptide motifs were compared to observed data from this and prior studies. The results of these analyses showed that BoLA alleles cluster into three distinct groups with the potential to define BBoLA supertypes.^ This streamlined approach identifies potential T cell epitopes from pathogens, such as FMDV, and provides insight into T cell immunity following infection or vaccination.

Correlation between the radiological observation of isolated tertiary waves on an esophagram and findings on high-resolution esophageal manometry

Barium esophagrams are a frequently performed test, and radiological observations about potential abnormal esophageal motility, such as tertiary contractions, are commonly reported. We sought to assess the correlation between tertiary waves, and in particular isolated tertiary waves, on esophagrams and findings on non-synchronous high-resolution esophageal manometry. We retrospectively reviewed reports of esophagrams performed at a tertiary referral center and identified patients in whom tertiary waves were observed and a high-resolution esophageal manometry had been performed. We defined two groups; group 1 was defined as patients with isolated tertiary waves, whereas group 2 had tertiary waves and evidence of achalasia or an obstructing structural abnormality on the esophagram. We collected data on demographics, dysphagia score, associated findings on esophagram, and need for intervention. We reviewed the reports of 2100 esophagrams of which tertiary waves were noted as an isolated abnormality in 92, and in association with achalasia or a structural obstruction in 61. High-resolution manometry was performed in 17 patients in group 1, and five had evidence of a significant esophageal motility disorder and 4 required any intervention. Twenty-one patients in group 2 underwent manometry, and 18 had a significant esophageal motility disorder. An isolated finding of tertiary waves on an esophagram is rarely associated with a significant esophageal motility disorder that requires intervention. All patients with isolated tertiary waves who required intervention had a dysphagia to liquids. Tertiary contractions, in the absence of dysphagia to liquids, indicate no significant esophageal motility disorder.

Diet and diabetes

BACKGROUND

Guidelines for the prevention and management of type 2 diabetes mellitus (T2DM) reinforce lifestyle management, yet advice to guide general practitioners on principles around dietary choices is needed.

OBJECTIVE

This article provides current evidence regarding the differing diets in diabetes prevention and management once T2DM arises, including the role in management of complications such as hypoglycaemia.

DISCUSSION

Diets should incorporate weight maintenance or loss, while complementing changes in physical activity to optimise the metabolic effects of dietary advice. Using a structured, team-care approach supports pragmatic and sustainable individualised plans, while incorporating current evidence-based dietary approaches.

Characterization of binding specificities of bovine leucocyte class I molecules: impacts for rational epitope discovery

The binding of peptides to classical major histocompatibility complex (MHC) class I proteins is the single most selective step in antigen presentation. However, the peptide-binding specificity of cattle MHC (bovine leucocyte antigen, BoLA) class I (BoLA-I) molecules remains poorly characterized. Here, we demonstrate how a combination of high-throughput assays using positional scanning combinatorial peptide libraries, peptide dissociation, and peptide-binding affinity binding measurements can be combined with bioinformatics to effectively characterize the functionality of BoLA-I molecules. Using this strategy, we characterized eight BoLA-I molecules, and found the peptide specificity to resemble that of human MHC-I molecules with primary anchors most often at P2 and P9, and occasional auxiliary P1/P3/P5/P6 anchors. We analyzed nine reported CTL epitopes from Theileria parva, and in eight cases, stable and high affinity binding was confirmed. A set of peptides were tested for binding affinity to the eight BoLA proteins and used to refine the predictors of peptide-MHC binding NetMHC and NetMHCpan. The inclusion of BoLA-specific peptide-binding data led to a significant improvement in prediction accuracy for reported T. parva CTL epitopes. For reported CTL epitopes with weak or no predicted binding, these refined prediction methods suggested presence of nested minimal epitopes with high-predicted binding affinity. The enhanced affinity of the alternative peptides was in all cases confirmed experimentally. This study demonstrates how biochemical high-throughput assays combined with immunoinformatics can be used to characterize the peptide-binding motifs of BoLA-I molecules, boosting performance of MHC peptide-binding prediction methods, and empowering rational epitope discovery in cattle.

Do patients with chronic rhinosinusitis with nasal polyps suffer with facial pain?

BACKGROUND

Many patients attribute their symptoms of facial pain or headache to sinus problems. Facial pain is one of the symptoms of rhinosinusitis according to European and American consensus documents. This symptom, however, has been insufficiently studied in the group of patients with chronic rhinosinusitis with nasal polyps (CRSwNP). The aim of this work is to study the symptom of facial pain in patients with CRSwNP.

METHODS

Patients with CRSwNP were prospectively asked to score their facial pain according to the scoring system used in the Sino Nasal Outcome Test 22 (SNOT 22).

RESULTS

Fifty patients fulfilled the inclusion criteria. Thirty-one patients had grade II polyps and 19 patients had grade III polyps. Of these patients, 76% had absent or very mild facial pain. Only 16% of patients had moderate or severe facial pain. All patients with severe facial pain had viscid secretions within their sinuses.

CONCLUSION

Significant facial pain is uncommon in patients with CRSwNP. It is important to consider this when counselling patients before surgery.

Assessing the risk of ships striking large whales in marine spatial planning

Marine spatial planning provides a comprehensive framework for managing multiple uses of the marine environment and has the potential to minimize environmental impacts and reduce conflicts among users. Spatially explicit assessments of the risks to key marine species from human activities are a requirement of marine spatial planning. We assessed the risk of ships striking humpback (Megaptera novaeangliae), blue (Balaenoptera musculus), and fin (Balaenoptera physalus) whales in alternative shipping routes derived from patterns of shipping traffic off Southern California (U.S.A.). Specifically, we developed whale-habitat models and assumed ship-strike risk for the alternative shipping routes was proportional to the number of whales predicted by the models to occur within each route. This definition of risk assumes all ships travel within a single route. We also calculated risk assuming ships travel via multiple routes. We estimated the potential for conflict between shipping and other uses (military training and fishing) due to overlap with the routes. We also estimated the overlap between shipping routes and protected areas. The route with the lowest risk for humpback whales had the highest risk for fin whales and vice versa. Risk to both species may be ameliorated by creating a new route south of the northern Channel Islands and spreading traffic between this new route and the existing route in the Santa Barbara Channel. Creating a longer route may reduce the overlap between shipping and other uses by concentrating shipping traffic. Blue whales are distributed more evenly across our study area than humpback and fin whales; thus, risk could not be ameliorated by concentrating shipping traffic in any of the routes we considered. Reducing ship-strike risk for blue whales may be necessary because our estimate of the potential number of strikes suggests that they are likely to exceed allowable levels of anthropogenic impacts established under U.S. laws.

Integrating partner professionals. The Early Explorers project: Peers Early Education Partnership and the health visiting service

BACKGROUND

  A range of voluntary sector organizations are involved in the delivery of services to children, particularly within the Early Year's sector and children's centres. Peers Early Education Partnership (PEEP) Early Explorers project is one example of the way in which explicit partnerships are being forged across statutory and voluntary sectors with the aim of improving outcomes for children and families. This paper reports an exploration of stakeholder views and experiences of two Early Explorer clinics located in areas of high deprivation.

METHODS

  Semi-structured interviews were conducted with a purposive sample of stakeholders (n= 25) from children's centres, PEEP, the health visiting service and service users. Data were fully transcribed and analysed using a thematic approach.

RESULTS

  The data suggest that the two key groups of stakeholders providing Early Explorer clinics (i.e. health visitors and PEEP practitioners) had quite different objectives in terms of their early goals for the clinic, but that despite these differences good progress was achieved in terms of working together effectively. All stakeholders including service users referred to the presence of PEEP as having improved the quality of the clinic environment, and participating mothers identified a wide range of benefits from the enhanced service. However, somewhat restricted views about the role of practitioners within the clinics were identified by users, and the findings suggest that although the early goals for the clinic had been exceeded, these may have been limited in terms of true 'partnership' working.

CONCLUSIONS

  Early Explorer clinics appeared to have enhanced the service provided within traditional child health clinics and to have provided practitioners with access to hard-to-reach families and parents with access to services that are consistent with the broader policy aims of improving parent-infant interaction. However, questions remain as to whether the benefit of 'partnership' working was fully realized.

Improving management of type 2 diabetes - findings of the Type2Care clinical audit

BACKGROUND

Type 2 diabetes was responsible for 5.8% of the total disease burden in Australia in 2010. Despite advances in clinical management many type 2 diabetes (T2D) patients have suboptimal glycaemic control.

METHODS

Using quantitative questionnaires, general practitioners prospectively evaluated their management of 761 T2D patients at two time points, 6 months apart. Following the first audit, GPs received feedback and a decision support tool. Patients were then re-audited to assess if the intervention altered management.

RESULTS

The use of annual cycle of care plans significantly increased by 12% during the audit. General practitioner performance improved across all measures with the greatest gains being in the use of care plans and measuring and meeting targets for microalbumin. Glycaemic control was well managed in this cohort (mean HbA1c 6.9% for both audit cycles).

DISCUSSION

The Type2Care clinical audit provided decision support tools and diabetes registers that improved the delivery of care to patients with T2D.

Overcoming perceived barriers to employment among people with arthritis

Work disability is a major problem for people with arthritis. The INTO WORK Personal Development (IWPD) programme aims to prevent work disability by addressing the internal and external barriers faced by people with arthritis seeking to fulfil their employment potential. The effectiveness of the programme was examined in a pretest-post-test study with an intervention group (n = 37) and a comparison control group (n = 42). Data were collected through self-administered questionnaires and focus groups. Significant decreases on anxiety (p = .0002), depression (p = .009) and negative mood (p = .029), and significant improvements on positive mood (p = .011), self-esteem (p = .002) and satisfaction with life (p = .010) were found for the intervention group only. The IWPD programme appears to promote self-determination, psychological well-being and strategies for overcoming perceived barriers to employment among people with arthritis.

Early and tight glycaemic control - the key to managing type 2 diabetes

BACKGROUND

The prevalence of type 2 diabetes is on the rise in Australia. A large number of patients with type 2 diabetes do not reach currently recommended glycaemic targets.

OBJECTIVE

This article looks at how clinical inertia contributes to suboptimal glycaemic control in patients with type 2 diabetes, describes the 'legacy' effect of early high HbA1c levels and highlights the importance of early, tight glycaemic control.

DISCUSSION

Early, tight glycaemic control in patients with type 2 diabetes has been shown to result in better outcomes in terms of micro- and macrovascular disease and mortality even if control is relaxed later in the course of the disease. Clinical inertia is one of the contributing factors that prevent patients from reaching glycaemic targets. A proactive approach to treating type 2 diabetes is recommended: therapy should be individualised with early consideration of combination therapy and ongoing reinforcement of lifestyle modification messages. In newly diagnosed patients, the goal should be to achieve an HbA1c of.

Mastitis therapy and antimicrobial susceptibility: a multispecies review with a focus on antibiotic treatment of mastitis in dairy cattle

Mastitis occurs in numerous species. Antimicrobial agents are used for treatment of infectious mastitis in dairy cattle, other livestock, companion animals, and humans. Mastitis is an economically important disease of dairy cattle and most mastitis research has focused on epidemiology and control of bovine mastitis. Antibiotic treatment of clinical and subclinical mastitis in dairy cattle is an established component of mastitis control programs. Research on the treatment of clinical and subclinical mastitis in other dairy species such as sheep and goats has been less frequent, although the general principles of mastitis therapy in small ruminants are similar to those of dairy cattle. Research on treatment of clinical mastitis in humans is limited and as for other species empirical treatment of mastitis appears to be common. While antimicrobial susceptibility testing is recommended to direct treatment decisions in many clinical settings, the use of susceptibility testing for antibiotic selection for mastitis treatments of dairy cattle has been challenged in a number of publications. The principle objective of this review is to summarize the literature evaluating the question, "Does antimicrobial susceptibility predict treatment outcome for intramammary infections caused by common bacterial pathogens?" This review also addresses current issues related to antimicrobial use and treatment decisions for mastitis in dairy cattle. Information on treatment of mastitis in other species, including humans, is included although research appears to be limited. Issues related to study design, gaps in current knowledge and opportunities for future research are identified for bovine mastitis therapy.

Preventing obesity at weaning: parental views about the EMPOWER programme

BACKGROUND

Infant growth and lifestyle are now recognized as being critical determinants of later obesity. EMPOWER (Empowering Parents to Prevent Obesity at Weaning: Exploratory Research) was developed as an intervention for parents whose babies are at high risk. Delivered by specially trained health visitors, it is underpinned by the Family Partnership Model and uses a strengths-based, solution-focused way of working with families.

METHODS

Mothers of babies participating in the pilot of EMPOWER in Leeds were recruited to take part in a study to examine perceptions about the programme's acceptability and usefulness. Interviews were taped and transcribed, and thematic analysis undertaken.

RESULTS

Families talked positively about the approach of the EMPOWER health visitor with her emphasis on listening, partnership working and shared problem-solving. Parents particularly valued the use of a non-judgemental approach, which they felt had helped them to discuss openly, sensitive issues such as weight and diet. They identified a number of important benefits ranging from increased knowledge about the most appropriate types and amount of food to feed their toddler, to more far-reaching changes within the family as a whole, including modifications to their own diet and lifestyle. Programmes of this nature were perceived as more valuable than the standard help that is currently available.

CONCLUSION

The EMPOWER programme appears to be both acceptable and valued by targeted parents and a potentially effective means of supporting high-risk families to prevent their children from developing obesity. An exploratory randomized controlled trial is now underway to ascertain the feasibility of conducting a definitive phase 3 trial.

The experience of attending a lay-led, chronic disease self-management programme from the perspective of participants with multiple sclerosis

A lay-led, community-based intervention, the Chronic Disease Self-Management Course (CDSMC) is effective for a range of long-term health conditions (e.g. arthritis, heart disease). However, the perceived value and experience of the CDSMC for people with Multiple Sclerosis (MS) has not been examined. The present qualitative study addressed this omission. Ten participants with MS (7 female; age range 35 to 60 years; disease duration 4 to 19 years) were interviewed before attending the CDSMC and at 4-month follow-up. Data were analysed using Framework Analysis. Some participants learned new self-management techniques and reported enhanced confidence (self-efficacy), whereas other participants were already confident in their self-management ability and found the CDSMC acted as a reminder of techniques previously used. Relaxation, pacing, and goal setting were particularly valuable for managing fatigue. Goal setting helped some participants to build confidence. Participants valued meeting similar others including those with different conditions. The CDSMC was an opportunity for social comparison and inspirational role modelling. Improvements to the CDSMC were suggested, including the addition of specific MS information. Overall, the CDSMC was viewed as a valuable source of new skills and a reminder of previously learned self-management skills, particularly in the context of managing fatigue. Gender differences emerged.