Discrimination of distinct chicken M cell subsets based on CSF1R expression

In mammals, a subset of follicle-associated epithelial (FAE) cells, known as M cells, conduct the transcytosis of antigens across the epithelium into the underlying lymphoid tissues. We previously revealed that M cells in the FAE of the chicken lung, bursa of Fabricius (bursa), and caecum based on the expression of CSF1R. Here, we applied RNA-seq analysis on highly enriched CSF1R-expressing bursal M cells to investigate their transcriptome and identify novel chicken M cell-associated genes. Our data show that, like mammalian M cells, those in the FAE of the chicken bursa also express SOX8, MARCKSL1, TNFAIP2 and PRNP. Immunohistochemical analysis also confirmed the expression of SOX8 in CSF1R-expressing cells in the lung, bursa, and caecum. However, we found that many other mammalian M cell-associated genes such as SPIB and GP2 were not expressed by chicken M cells or represented in the chicken genome. Instead, we show bursal M cells express high levels of related genes such as SPI1. Whereas our data show that bursal M cells expressed CSF1R-highly, the M cells in the small intestine lacked CSF1R and both expressed SOX8. This study offers insights into the transcriptome of chicken M cells, revealing the expression of CSF1R in M cells is tissue-specific.

Distribution and spatiotemporal development of organised lymphoid tissues in the chicken intestinal tract

Chickens exhibit a distinct immune architecture characterised by the absence of draining lymph nodes and the presence of a well-developed mucosa-associated lymphoid tissue. The structure and spatiotemporal development of chicken lymphoid tissues in the intestine are poorly documented. The macroscopically indistinct structure of chicken Peyer's patches has impeded studies into their development. The generation of CSF1R-eGFP reporter transgenic chickens enables visualisation of the development, organisation and extent of chicken lymphoid tissues by unique macroscopic views. CSF1R-eGFP reporter transgenic chickens were used to investigate the distribution and spatiotemporal development of PP and caecal tonsils in embryonic day 18 to 8-week-old chickens. Peyer's patch anlagen are present at ED18 with a similar frequency and distribution pattern observed in 2- and 8-week-old chickens. These findings can support in ovo and post-hatch mucosal vaccination strategies and the development of vaccine delivery systems targeted to the specialized epithelium overlying the Peyer's patches.

Mapping and identifying service models for community-based services for children with intellectual disabilities and behaviours that challenge in England

BACKGROUND

One in five children with an intellectual disability in the UK display behaviours that challenge. Despite associated impacts on the children themselves, their families, and services, little research has been published about how best to design, organise, and deliver health and care services to these children. The purpose of this study was to describe how services are structured and organised ("service models") in England for community-based health and care services for children with intellectual disability who display behaviours that challenge.

METHODS

Survey data about services were collected from 161 eligible community-based services in England. Staff from 60 of these services were also interviewed. A combination of latent class and descriptive analysis, coupled with consultation with family carers and professionals was used to identify and describe groupings of similar services (i.e., "service models").

RESULTS

The latent class analysis, completed as a first step in the process, supported a distinction between specialist services and non-specialist services for children who display behaviours that challenge. Planned descriptive analyses incorporating additional study variables were undertaken to further refine the service models. Five service models were identified: Child and Adolescent Mental Health Services (CAMHS) (n = 69 services), Intellectual Disability CAMHS (n = 28 services), Children and Young People Disability services (n = 25 services), Specialist services for children who display behaviours that challenge (n = 27 services), and broader age range services for children and/or adolescents and adults (n= 12 services).

CONCLUSIONS

Our analysis led to a typology of five service models for community health and care services for children with intellectual disabilities and behaviours that challenge in England. Identification of a typology of service models is a first step in building evidence about the best provision of services for children with intellectual disabilities who display behaviours that challenge. The methods used in the current study may be useful in research developing service typologies in other specialist fields of health and care.

STUDY REGISTRATION

Trial Registration: Current Controlled Trials ISRCTN88920546, Date assigned 05/07/2022.

Disentangling the innate immune responses of intestinal epithelial cells and lamina propria cells to Salmonella Typhimurium infection in chickens

Salmonella enterica serovar Typhimurium (STm) is a major foodborne pathogen and poultry are a key reservoir of human infections. To understand the host responses to early stages of Salmonella infection in poultry, we infected 2D and 3D enteroids, the latter of which contains leukocytes, neurons, and mesenchymal cells that are characteristic of the lamina propria. We infected these enteroids with wild-type (WT STm), a non-invasive mutant lacking the prgH gene (ΔprgH STm), or treated them with STm lipopolysaccharide (LPS) and analyzed the expression of innate immune related genes by qPCR at 4 and 8 h. The localization of the tight junction protein, ZO-1, expression was disrupted in WT STm infected enteroids but not ΔprgH STm or LPS treated enteroids, suggesting a loss of epithelial barrier integrity. The innate immune response to LPS was more pronounced in 2D enteroids compared to 3D enteroids and by 8 hpi, the response in 3D enteroids was almost negligible. However, when STm adhered to or invaded the enteroids, both 2D and 3D enteroids exhibited an upregulation of inflammatory responses. The presence of lamina propria cells in 3D enteroids resulted in the unique expression of genes associated with immune functions involved in regulating inflammation. Moreover, 2D and 3D enteroids showed temporal differences in response to bacterial invasion or adherence. At 8 hpi, innate responses in 3D but not 2D enteroids continued to increase after infection with WT STm, whereas the responses to the non-invasive strain decreased at 8 hpi in both 2D and 3D enteroids. In conclusion, STm infection of chicken enteroids recapitulated several observations from in vivo studies of Salmonella-infected chickens, including altered epithelial barrier integrity based on ZO-1 expression and inflammatory responses. Our findings provide evidence that Salmonella-infected enteroids serve as effective models for investigating host-pathogen interactions and exploring the molecular mechanisms of microbial virulence although the 3D model mimics the host more accurately due to the presence of a lamina propria.

Malignant neoplasm of lacrimal gland with pulmonary metastasis

Adenoid cystic carcinomas (ACC) make up 3%-5% of head and neck malignancies. They have a high propensity to metastasise, in particular to the lungs. A 65-year-old male diagnosed with a right lacrimal gland ACC T2N0M0 (surgically resected 12 years prior) presented with an incidentally noted 1.2 cm right lower lobe lung nodule seen on MRI liver. Subsequent imaging confirmed a non-FDG avid 1.6 cm solitary ovoid subpleural lesion, percutaneous biopsy confirmed adenocarcinoma. A surgical metastasectomy was performed and recovery was complete. Prognosis in ACC is improved with radical management of metastatic disease. Rather than a simple chest radiograph, more detailed imaging, such as MRI or CT scanning may increase the probability of early detection of pulmonary metastasis and, thereby facilitate radical treatment and improve survival.

O2-2 Should I stay or should I go? A mixed-methods, longitudinal investigation of predictors, barriers and enablers of adherence to REACT, a 12-month group-based, active-ageing programme

Background

Physical activity (PA) programmes targeting older adults often report relatively low attendance rates which limits impact. Research into barriers and enablers of PA adherence is often qualitative and rarely tests outcomes against objectively monitored adherence to assess whether what people say is actually reflected in what they do. This study adopts a rare, mixed methods, longitudinal perspective identifying subjective and objective predictors of and associations with adherence to REtirement in ACTion (REACT), a 12-month physical activity intervention for frail or pre-frail older adults.

Methods

Semi-structured interviews conducted at six (n = 17) and 12 months (n = 10) explored barriers and enablers to adherence. Thematic analysis led to ten adherence related research hypotheses. These were tested by examining correlations between REACT programme attendance and physical function (Short Physical Performance Battery), self-rated physical function (mobility assessment tool-short form (MAT-sf)), dominant hand grip strength assessed by digital dynamometer, Ageing Well profile (social scale), process evaluation data at baseline (n = 411) and six-months (n = 348) and open-ended participant feedback at six-months (n = 307). Each participant response was scored -1) for a negative comment, 1 for positive or zero for no comment or balancing negative and positive comments.

Results

Higher adherence correlated with younger age (r=-0.162, p > 0.001), better physical function, both objectively measured (r = 0.118, p > 0.05) and self-rated (r = 0.134, p > 0.01), greater grip strength (r = 0.118, p > 0.05) and having less social contact (r=-0.134, p > 0.01), at baseline. It also correlated with an improvement in objectively measured physical function between baseline and six months (r = 0.200, p > 0.001). At 6-months enjoyment of the programme (r = 0.263, p > 0.001), specifically enjoyment of muscle-strengthening exercises (r = 0.142, p > 0.027), perception of positive social interactions (from questionnaire data (r = 0.212, p > 0.001) and open-ended feedback (r = 0.157, p > 0.01)) and perceptions of an autonomy-supportive teaching style (r = 0.213, p > 0.001) all correlated with higher adherence.

Conclusions

PA programmes for older adults should encourage the development of social connections and group cohesion but should take a flexible approach to avoid negatively affecting adherence amongst those with pre-existing high levels of social contact. Building confidence in PA and physical function as these improve during the programme, promoting enjoyment and utilising an autonomy-supportive leader teaching style are important in order to support adherence.

Search for an Excess of Electron Neutrino Interactions in MicroBooNE Using Multiple Final-State Topologies

We present a measurement of ν_{e} interactions from the Fermilab Booster Neutrino Beam using the MicroBooNE liquid argon time projection chamber to address the nature of the excess of low energy interactions observed by the MiniBooNE Collaboration. Three independent ν_{e} searches are performed across multiple single electron final states, including an exclusive search for two-body scattering events with a single proton, a semi-inclusive search for pionless events, and a fully inclusive search for events containing all hadronic final states. With differing signal topologies, statistics, backgrounds, reconstruction algorithms, and analysis approaches, the results are found to be either consistent with or modestly lower than the nominal ν_{e} rate expectations from the Booster Neutrino Beam and no excess of ν_{e} events is observed.

First Measurement of Energy-Dependent Inclusive Muon Neutrino Charged-Current Cross Sections on Argon with the MicroBooNE Detector

We report a measurement of the energy-dependent total charged-current cross section σ(E_{ν}) for inclusive muon neutrinos scattering on argon, as well as measurements of flux-averaged differential cross sections as a function of muon energy and hadronic energy transfer (ν). Data corresponding to 5.3×10^{19} protons on target of exposure were collected using the MicroBooNE liquid argon time projection chamber located in the Fermilab booster neutrino beam with a mean neutrino energy of approximately 0.8 GeV. The mapping between the true neutrino energy E_{ν} and reconstructed neutrino energy E_{ν}^{rec} and between the energy transfer ν and reconstructed hadronic energy E_{had}^{rec} are validated by comparing the data and Monte Carlo (MC) predictions. In particular, the modeling of the missing hadronic energy and its associated uncertainties are verified by a new method that compares the E_{had}^{rec} distributions between data and a MC prediction after constraining the reconstructed muon kinematic distributions, energy, and polar angle to those of data. The success of this validation gives confidence that the missing energy in the MicroBooNE detector is well modeled and underpins first-time measurements of both the total cross section σ(E_{ν}) and the differential cross section dσ/dν on argon.

Search for Neutrino-Induced Neutral-Current Δ Radiative Decay in MicroBooNE and a First Test of the MiniBooNE Low Energy Excess under a Single-Photon Hypothesis

We report results from a search for neutrino-induced neutral current (NC) resonant Δ(1232) baryon production followed by Δ radiative decay, with a ⟨0.8⟩  GeV neutrino beam. Data corresponding to MicroBooNE's first three years of operations (6.80×10^{20} protons on target) are used to select single-photon events with one or zero protons and without charged leptons in the final state (1γ1p and 1γ0p, respectively). The background is constrained via an in situ high-purity measurement of NC π^{0} events, made possible via dedicated 2γ1p and 2γ0p selections. A total of 16 and 153 events are observed for the 1γ1p and 1γ0p selections, respectively, compared to a constrained background prediction of 20.5±3.65(syst) and 145.1±13.8(syst) events. The data lead to a bound on an anomalous enhancement of the normalization of NC Δ radiative decay of less than 2.3 times the predicted nominal rate for this process at the 90% confidence level (C.L.). The measurement disfavors a candidate photon interpretation of the MiniBooNE low-energy excess as a factor of 3.18 times the nominal NC Δ radiative decay rate at the 94.8% C.L., in favor of the nominal prediction, and represents a greater than 50-fold improvement over the world's best limit on single-photon production in NC interactions in the sub-GeV neutrino energy range.

Novel chicken two-dimensional intestinal model comprising all key epithelial cell types and a mesenchymal sub-layer

The intestinal epithelium plays a variety of roles including providing an effective physical barrier and innate immune protection against infection. Two-dimensional models of the intestinal epithelium, 2D enteroids, are a valuable resource to investigate intestinal cell biology and innate immune functions and are suitable for high throughput studies of paracellular transport and epithelial integrity. We have developed a chicken 2D enteroid model that recapitulates all major differentiated cell lineages, including enterocytes, Paneth cells, Goblet cells, enteroendocrine cells and leukocytes, and self-organises into an epithelial and mesenchymal sub-layer. Functional studies demonstrated the 2D enteroids formed a tight cell layer with minimal paracellular flux and a robust epithelial integrity, which was maintained or rescued following damage. The 2D enteroids were also able to demonstrate appropriate innate immune responses following exposure to bacterial endotoxins, from Salmonella enterica serotype Typhimurium and Bacillus subtilis. Frozen 2D enteroids cells when thawed were comparable to freshly isolated cells. The chicken 2D enteroids provide a useful ex vivo model to study intestinal cell biology and innate immune function, and have potential uses in screening of nutritional supplements, pharmaceuticals, and bioactive compounds.

Search for a Higgs Portal Scalar Decaying to Electron-Positron Pairs in the MicroBooNE Detector

We present a search for the decays of a neutral scalar boson produced by kaons decaying at rest, in the context of the Higgs portal model, using the MicroBooNE detector. We analyze data triggered in time with the Fermilab NuMI neutrino beam spill, with an exposure of 1.93×10^{20} protons on target. We look for monoenergetic scalars that come from the direction of the NuMI hadron absorber, at a distance of 100 m from the detector, and decay to electron-positron pairs. We observe one candidate event, with a standard model background prediction of 1.9±0.8. We set an upper limit on the scalar-Higgs mixing angle of θ<(3.3-4.6)×10^{-4} at the 95% confidence level for scalar boson masses in the range (100-200)  MeV/c^{2}. We exclude, at the 95% confidence level, the remaining model parameters required to explain the central value of a possible excess of K_{L}^{0}→π^{0}νν[over ¯] decays reported by the KOTO collaboration. We also provide a model-independent limit on a new boson X produced in K→πX decays and decaying to e^{+}e^{-}.

First Measurement of Differential Charged Current Quasielasticlike ν_{μ}-Argon Scattering Cross Sections with the MicroBooNE Detector

We report on the first measurement of flux-integrated single differential cross sections for charged-current (CC) muon neutrino (ν_{μ}) scattering on argon with a muon and a proton in the final state, ^{40}Ar (ν_{μ},μp)X. The measurement was carried out using the Booster Neutrino Beam at Fermi National Accelerator Laboratory and the MicroBooNE liquid argon time projection chamber detector with an exposure of 4.59×10^{19} protons on target. Events are selected to enhance the contribution of CC quasielastic (CCQE) interactions. The data are reported in terms of a total cross section as well as single differential cross sections in final state muon and proton kinematics. We measure the integrated per-nucleus CCQE-like cross section (i.e., for interactions leading to a muon, one proton, and no pions above detection threshold) of (4.93±0.76_{stat}±1.29_{sys})×10^{-38}  cm^{2}, in good agreement with theoretical calculations. The single differential cross sections are also in overall good agreement with theoretical predictions, except at very forward muon scattering angles that correspond to low-momentum-transfer events.

First Measurement of Inclusive Muon Neutrino Charged Current Differential Cross Sections on Argon at E_{ν}∼0.8 GeV with the MicroBooNE Detector

We report the first measurement of the double-differential and total muon neutrino charged current inclusive cross sections on argon at a mean neutrino energy of 0.8 GeV. Data were collected using the MicroBooNE liquid argon time projection chamber located in the Fermilab Booster neutrino beam and correspond to 1.6×10^{20} protons on target of exposure. The measured differential cross sections are presented as a function of muon momentum, using multiple Coulomb scattering as a momentum measurement technique, and the muon angle with respect to the beam direction. We compare the measured cross sections to multiple neutrino event generators and find better agreement with those containing more complete treatment of quasielastic scattering processes at low Q^{2}. The total flux integrated cross section is measured to be 0.693±0.010(stat)±0.165(syst)×10^{-38}  cm^{2}.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Visualisation and characterisation of mononuclear phagocytes in the chicken respiratory tract using CSF1R-transgenic chickens

The respiratory tract is a key organ for many avian pathogens as well as a major route for vaccination in the poultry industry. To improve immune responses after vaccination of chickens through increased uptake of vaccines and targeting to antigen presenting cells, a better understanding of the avian respiratory immune system is required. Transgenic MacReporter birds were used expressing a reporter gene (eGFP or mApple) under the control of the CSF1R promoter and enhancer in cells of the mononuclear phagocyte (MNP) lineage to visualize the ontogeny of the lymphoid tissue, macrophages and dendritic cells, in the trachea, lung and air sac of birds from embryonic day 18–63 weeks of age. Small aggregates of CSF1R-transgene⁺ cells start to form at the openings of the secondary bronchi at 1 week of age, indicative of the early development of the organised bronchus-associated lymphoid tissue. Immunohistochemical staining revealed subpopulations of MNPs in the lung, based on expression of CSF1R-transgene, CD11, TIM4, LAMP1, and MHC II. Specialised epithelial cells or M cells covering the bronchus-associated lymphoid tissue expressed CSF1R-transgene and type II pneumocytes expressed LAMP1 suggesting that these epithelial cells are phagocytic and transcytose antigen. Highly organised lymphoid tissue was seen in trachea from 4 weeks onwards. Throughout the air sacs at all ages, CSF1R-transgene⁺ cells were scattered and at later stages, CSF1R-transgene⁺ cells lined capillaries. These results will serve as a base for further functional characterization of macrophages and dendritic cells and their role in respiratory diseases and vaccine responses.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Preoperative neutrophil:lymphocyte and platelet:lymphocyte ratios predict endometrial cancer survival

BACKGROUND

Variations in systemic inflammatory response biomarker levels have been associated with adverse clinical outcome in various malignancies. This study determined the prognostic significance of preoperative neutrophil:lymphocyte (NLR), platelet:lymphocyte (PLR) and monocyte:lymphocyte (MLR) ratios in endometrial cancer.

METHODS

Clinicopathological and 5-year follow-up data were obtained for a retrospective series of surgically treated endometrial cancer patients (n=605). Prognostic significance was determined for overall (OS) and cancer-specific survival (CSS) using Cox proportional hazards models and Kaplan-Meier analysis. Receiver-operator characteristic and log-rank functions were used to optimise cut-offs. NLR, PLR and MLR associations with clinicopathological variables were determined using non-parametric tests.

RESULTS

Applying cut-offs of ⩾2.4 (NLR), ⩾240 (PLR) and ⩾0.19 (MLR), NLR and PLR (but not MLR) had independent prognostic significance. Combining NLR and PLR scores stratified patients into low (NLR-low and PLR-low), intermediate (NLR-high or PLR-high) and high risk (NLR-high and PLR-high) groups: multivariable hazard ratio (HR) 2.51; P<0.001 (OS); HR 2.26; P<0.01 (CSS) for high vs low risk patients. Increased NLR and PLR were most strongly associated with advanced stage (P<0.001), whereas increased MLR was strongly associated with older age (P<0.001).

CONCLUSION

Both NLR and PLR are independent prognostic indicators for endometrial cancer, which can be combined to provide additional patient stratification.

Assessment of the feasibility and clinical value of further research to evaluate the management options for children with Down syndrome and otitis media with effusion: a feasibility study

BACKGROUND

There is clinical uncertainty of the benefits and costs of different treatment options for children with Down syndrome who have glue ear. This study was designed to assess the extent of this lack of knowledge and determine if pursuing further information would be practical, beneficial and cost-effective.

OBJECTIVES

To assess the level and practical effect of current uncertainty around treatment options for children with Down syndrome and glue ear. To assess the feasibility of studying the options for management of glue ear in children with Down syndrome via a randomised controlled trial (RCT) or multicentre prospective cohort study by evaluating the willingness of (1) parents to agree to randomisation for their children and (2) clinicians to recruit participants to a definitive study. To undertake value of information analyses to demonstrate the potential economic benefit from undertaking further research.

DESIGN

A feasibility study exploring the views of parents of children with Down syndrome and professionals who have responsibility for the health and education of children with Down syndrome, on the participation in, and value of, future research into interventions for glue ear. Data were collected from parents via self-completed questionnaires, face-to-face interviews and focus groups and from professionals via online questionnaires and a Delphi review exercise. Development of economic models to represent clinical pathways of care and a RCT informed a value of information (VOI) analysis.

SETTING

UK (professionals); East Midlands region of the UK (parents).

PARTICIPANTS

Parents of children aged 1-11 years with Down syndrome (n = 156). Professionals including audiologists, ear, nose and throat surgeons, audiological physicians, speech and language therapists, and teachers of the deaf (n = 128).

MAIN OUTCOME MEASURES

Quantitative and qualitative data on parental views and experiences of glue ear and its effects; interventions and treatment received; taking part in research and factors that would encourage or discourage participation; and the importance of various outcome domains to them and for their children. For professionals: information on caseloads; approaches to clinical management; opinions on frequency and significance of the consequences of glue ear for this population; importance of different outcome measures; opinions of interventions and their role in future research; views on health research; facilitators and barriers to recruitment, and participation in research involving RCTs.

RESULTS

The complexity of the experience and individual characteristics of children with Down syndrome poses challenges for the design of any future research but these challenges were not considered by professionals to raise sufficient barriers to prevent it being undertaken. Parents were generally supportive of the need for, and value of, research but identified practical and emotional issues that would need addressing. Glue ear was considered to impact more on speech, language and communication than on hearing. Outcome measures for future research would need to evaluate these elements but measures should be designed specifically for the population. Parents and professionals identified randomisation as a significant barrier to participation. The VOI analyses identified lack of data as problematic but concluded that a future trial involving surgical intervention would be feasible at costs of < £650,000.

CONCLUSIONS

Future research into the benefits of interventions for glue ear in children with Down syndrome would be feasible and could be cost-effective but should be carefully designed to facilitate and maximise participation from parents and professionals responsible for recruitment.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A novel cosmetic approach to treat thinning hair

BACKGROUND

Many of today's treatments associated with 'thinning hair', such as female pattern hair loss and telogen effluvium, are focused on two of the key aspects of the condition. Over-the-counter or prescription medications are often focused on improving scalp hair density while high-quality cosmetic products work to prevent further hair damage and minimize mid-fibre breakage. Fibre diameter is another key contributor to thinning hair, but it is less often the focus of medical or cosmetic treatments.

OBJECTIVES

To examine the ability of a novel leave-on technology combination [caffeine, niacinamide, panthenol, dimethicone and an acrylate polymer (CNPDA)] to affect the diameter and behaviour of individual terminal scalp hair fibres as a new approach to counteract decreasing fibre diameters.

METHODS

Testing methodology included fibre diameter measures via laser scan micrometer, assessment of fibre mechanical and behavioural properties via tensile break stress and torsion pendulum testing, and mechanistic studies including cryoscanning electron microscopy and autoradiographic analysis.

RESULTS

CNPDA significantly increased the diameter of individual, existing terminal scalp hair fibres by 2-5 μm, which yields an increase in the cross-sectional area of approximately 10%. Beyond the diameter increase, the CNPDA-thickened fibres demonstrated the altered mechanical properties characteristic of thicker fibres: increased suppleness/pliability (decreased shear modulus) and better ability to withstand force without breaking (increased break stress).

CONCLUSIONS

Although cosmetic treatments will not reverse the condition, this new approach may help to mitigate the effects of thinning hair.

Rural mental health workforce difficulties: a management perspective

INTRODUCTION

The recruitment, retention and training of mental health workers is of major concern in rural Australia, and the Gippsland region of Victoria is no exception. Previous studies have identified a number of common factors in these workforce difficulties, including rurality, difficulties of access to professional development and training, and professional and personal isolation. However, those previous studies have often focused on medicine and been based on the perspectives of practitioners, and have almost ignored the perspectives of managers of rural mental health services. The study reported in this article sought to contribute to the development of a more sustainable and effective regional mental health workforce by complementing earlier insights with those of leading administrators, managers and senior clinicians in the field.

METHODS

The study took a qualitative approach. It conducted semi-structured in-person interviews with 24 managers of health/mental-health services and senior administrators and clinicians working in organisations of varying sizes in the public and private sectors. Thematic content analysis of the transcribed interviews identified core difficulties these managers experienced in the recruitment, retention and training of employees.

RESULTS

The study found that some of the issues commonly resulting in difficulties in recruiting, retaining and developing a trained workforce in rural areas, such as rurality (implying personal and professional isolation, distances to deliver service and small organisations) and a general shortage of trained personnel, are significant in Gippsland. Through its focus on the perspectives of leaders in the management of rural mental health services, however, the study found other key issues that contribute to workforce difficulties. Many, including the unattractive nature of mental health work, the fragmented administration of the mental health system, short-term and tied funding, and shortcomings in training are external to organisations. Interviewees indicated that these issues make it difficult for organisations to support personnel in ways that enhance personal and professional satisfaction and so retention and, in turn, the capacity to recruit new employees. Participants also highlighted issues internal to the organisation. The tensions that flow from the systemic forces require highly creative leadership to negotiate the numerous policy changes, diverse sources of funding, training regimens, worker cohorts and models of care. Managers must nurture the capacity of their own organisation to respond flexibly to the demands, by establishing a responsive culture and structure. They must also encourage the collaboration of their other organisations in their sub-regional grouping and the development of a regional sensibility.

CONCLUSION

The approach taken by the study, particularly its focus on a management perspective, revealed that the difficulties experienced are the product of a core tension between a growing demand for mental health care, emerging specialities and technological advances in the field, and a diminished systemic capacity to support organisations in meeting the demand. Resolving this core tension is a key to the maintenance of a sustainable and effective workforce in Gippsland, and the role of management is crucial to that resolution.

Ceramic materials as bearing surfaces for total hip arthroplasty

During the past decade, advances in total hip arthroplasty component design have produced implants with reliable clinical results in regard to fixation. The foremost unresolved challenge has been the development of bearing surfaces that can withstand the higher demands of younger and more active patients. New alternative bearings with superior wear characteristics that minimize debris include ceramic-on-ceramic, metal-on-metal, and highly cross-linked polyethylenes in combination with ceramic or metal. Alumina-on-alumina ceramic bearings are extremely hard and scratch resistant and provide superior lubrication and wear resistance compared with other bearing surfaces in clinical use. Survivorship revision for any reason for the alumina ceramic bearings at 10 years was significantly higher compared with metal-on-polyethylene. Bearings currently being studied because of their encouraging wear performance in the laboratory are an alumina matrix (82% alumina, 17% zirconia, 0.3% chromium oxide), zirconium oxide, and ceramic-on-cobalt-chromium.

Bearings of the future for total hip arthroplasty

In the last decade or so, newer hip bearings such as ceramic-on-ceramic, metal-on-metal, and metal-on-highly cross-linked polyethylene were introduced into clinical practice in attempts to reduce the debris load released to the tissues after total hip arthroplasty. Present clinical evidence suggests that these newer bearings reduce both abrasive wear and the incidence of osteolysis at up to 10 years clinical follow-up. As further efforts to reduce abrasive wear may meet decreasing returns, we suggest that other bearing issues remain unresolved. These include mechanical failure, impingement or joint laxity, bearing noise, and stress shielding of supporting structures. We present a brief review of the current status of bearing technology and summarize potential areas for further research.

The role of stripe wear in causing acoustic emissions from alumina ceramic-on-ceramic bearings

Noise from ceramic-on-ceramic hip bearings has been reported during specific patient activities. Wear stripes, which have been seen in some clinical retrievals, may be associated with bearing noise. We produced wear stripes on ceramic bearings in the laboratory and determined that, under certain conditions, noise could occur during either edge loading or joint simulation. Squeaking was not observed with bearings in their pristine condition. We concluded that wear stripes caused by edge loading may be associated with bearing noise, during either edge loading alone or during normal articulation.

Five-year experience with Crossfire highly cross-linked polyethylene

Our purpose was to compare the clinical wear performance of highly cross-linked (Crossfire) polyethylene with conventional (N2Vac) polyethylene total hip bearings. We implanted 56 hips (47 patients) with Crossfire acetabular bearing liners and compared their wear performance with 53 conventional polyethylene inserts. Wear and clinical data were collected retrospectively at a minimum 4-year and average 5-year followup. The linear femoral head penetration rate measured from plain radiographs was 0.055 mm/year +/- 0.022 mm/year for the Crossfire polyethylene and 0.138 mm/year +/- 0.073 mm/year for the control, a reduction of 60% for the Crossfire components. Calculated annual wear was 0.036 mm/year for the Crossfire components and 0.131 mm/year for the controls, a reduction of 72%. Radiographic review at most recent followup showed a reduction in erosive osteolytic lesions of the proximal femur for the Crossfire components compared with controls, also suggesting a reduction in debris release for the Crossfire components. Complications leading to revision were not seen in the Crossfire or control groups. These clinical findings suggest that this particular highly cross-linked polyethylene can provide wear reduction and an alternate bearing surface for active patient populations.

LEVEL OF EVIDENCE

Therapeutic study, Level III (retrospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

A titanium-encased alumina ceramic bearing for total hip arthroplasty: 3- to 5-year results

We examined whether encasing the alumina ceramic total hip arthroplasty insert in a thin titanium sleeve would reduce significantly or eliminate insert chipping on impaction of the insert into the shell. We also compared results, including observations of osteolysis, of the Trident study group with those of the predecessor alumina bearing couple design to determine clinical improvement and radiographic stability. Beginning in October 1996, 328 alumina ceramic bearings were implanted by six surgeons in 316 patients as a part of a prospective, randomized United States Investigational Device Exemption three-arm study comparing an alumina ceramic bearing with a control bearing of cobalt-chromium on polyethylene. In September 1999, a fourth arm of the study (Trident) was added. The Trident insert was recessed within a thin titanium sleeve. At three to five years followup, osteolysis was found in 0% of the patients with the Trident insert and in 0.5% of the patients with an alumina bearing couple. At a mean followup of 4.2 years (range, 3-5 years) no ceramic chips, fractures, or ceramic bearing failures have occurred. Encasing the alumina ceramic insert in a titanium sleeve seems to have resolved the issue of insert chipping on impaction and supports the continued use of Trident bearings in relatively young patients.

LEVEL OF EVIDENCE

Therapeutic study, Level II-1 (prospective comparative study-patients treated one way compared with a group of patients treated in another way at the same institution). See the Guidelines for Authors for a complete description of levels of evidence.

Unicompartmental knee arthroplasty: troubleshooting implant positioning and technical failures

Improvements to implant design and the advent of minimally invasive surgery have increased the popularity of unicompartmental knee arthroplasty. Minimally invasive techniques for implant placement can augment the unicompartmental knee arthroplasty procedure and allow for more rapid rehabilitation and return to activities of daily living. Nevertheless, new technologies are accompanied by learning curves and rediscovery of past mistakes. Unicompartmental knee arthroplasty tends to be more technically demanding than total knee arthroplasty, and complications occur with placement of unicompartmental knee devices. This article discusses proper and improper implantation techniques and provides technical guidance and suggestions for improving the outcomes of unicompartmental knee arthroplasty.

Obesity management in primary care: assessment of readiness to change among 284 family practice patients

BACKGROUND

Most adults in primary care are overweight or obese; two thirds of patients with weight problems have other obesity-related conditions. The study objective was to explore the feasibility of a primary care obesity intervention based on the transtheoretical model (TM) of behavior change and principles of chronic disease (CD) care.

METHODS

A prospective study of the initial version of the TM-CD intervention with obese family practice patients (n = 284) yielded cross-sectional data on baseline stage of change for six target behaviors: dietary fat, portion control, vegetable intake, fruit intake, usual physical activity, and planned exercise. The sample consisted of obese patients scheduled for an office visit during times when recruitment and informed consent did not conflict with acute care.

RESULTS

Obese patients volunteering for a TM-CD program are in different stages of change for six target behaviors. Preparation was the most frequently reported stage for increased exercise (49%) or activity (34%), decreased dietary fat consumption (44%), and increased portion control (51%). Patients in a particular stage for one behavior were distributed across all five stages for another behavior. Stage of change for five target behaviors was associated with body mass index or waist girth (P < .05) in a manner consistent with stage-of-change theory.

CONCLUSIONS

Using the transtheoretical model of behavior change will allow physicians to recognize when obese patients are receptive to specific behavioral interventions.

Splicing of alpha 1A subunit gene generates phenotypic variants of P- and Q-type calcium channels

P-type and Q-type calcium channels mediate neurotransmitter release at many synapses in the mammalian nervous system. The alpha 1A calcium channel has been implicated in the etiologies of conditions such as episodic ataxia, epilepsy and familial migraine, and shares several properties with native P- and Q-type channels. However, the exact relationship between alpha 1A and P- and Q-type channels is unknown. Here we report that alternative splicing of the alpha 1A subunit gene results in channels with distinct kinetic, pharmacological and modulatory properties. Overall, the results indicate that alternative splicing of the alpha 1A gene generates P-type and Q-type channels as well as multiple phenotypic variants.

Challenging communication: people with learning disabilities who challenge services

This paper describes a project designed to equip direct care workers with the knowledge and skills to address communication as a central factor in the lives of people with learning disabilities who challenge services. The elements of the approach taken--'Challenging Communication'--are described, outcomes discussed and possible implications for the speech and language therapy profession briefly considered.

Antibacterial efficacy against an in vivo Salmonella typhimurium infection model and pharmacokinetics of a liposomal ciprofloxacin formulation

The fluoroquinolone antibiotic ciprofloxacin has been encapsulated into large unilamellar vesicles (LUV) at efficiencies approaching 100%. Drug accumulation proceeded in response to a transmembrane gradient of methylammonium sulfate and occurred concomitantly with the efflux of methylamine. A mechanism for the encapsulation process is described. LUV composed of dipalmitoylphosphatidylcholine-cholesterol (DPPC/chol), distearoylphosphatidylcholine-cholesterol (DSPC/chol), or sphingomyelin-cholesterol (SM/chol) increased the circulation lifetime of ciprofloxacin after intravenous (i.v.) administration by > 15-fold. The retention of ciprofloxacin in liposomes in the circulation decreased in the sequence SM/chol > DSPC/chol > DPPC/chol. Increased circulation lifetimes were associated with enhanced delivery of the drug to the livers, spleens, kidneys, and lungs of mice. Encapsulation of ciprofloxacin also conferred significant increases in the longevity of the drug in the plasma after intraperitoneal administration and in the lungs after intratracheal administration in comparison to free ciprofloxacin. The efficacy of a single i.v. administration of an SM/chol formulation of ciprofloxacin was measured in a Salmonella typhimurium infection model. At 20 mg of ciprofloxacin per kg of body weight, the encapsulated formulation resulted in 10(3)- to 10(4)-fold fewer viable bacteria in the livers and spleens of infected mice than was observed for animals treated with free ciprofloxacin. These results show the utility of liposomal encapsulation of ciprofloxacin in improving the pharmacokinetics, biodistribution, and antibacterial efficacy of the antibiotic. In addition, these formulations are well suited for i.v., intraperitoneal, and intratracheal or aerosol administration.

Inductively coupled plasma mass spectrometric detection for chromatography and capillary electrophoresis

Inductively coupled plasma mass spectrometry (ICP-MS) is now a well established detection technique for liquid chromatography, gas chromatography, supercritical fluid chromatography and capillary electrophoresis. A review of the literature with particular regard to ICP-MS as a chromatographic and capillary electrophoretic detector is presented. The various modes of chromatography and capillary electrophoresis are discussed and practical descriptions for hyphenating the techniques with the ICP mass spectrometer are given. Sample introduction systems and data acquisition methods are reviewed along with the numerous applications of ICP-MS as a chromatographic detector. In addition, alternative plasma sources, such as the atmospheric and reduced pressure helium microwave-induced plasmas for chromatographic detection are described.

Personal characteristics associated with episodes of injury in a residential facility

Number of episodes of injury and personal characteristics of 412 individuals living in a state-operated ICF/MR during 1994 were examined. Results indicated that 16% of the facility population experienced 67% of the injuries. Discriminant functions were created using chlorpromazine equivalent level combined with maladaptive behavior, medical, and adaptive behavior factors to classify individuals into high and low injury groups. Individuals taking antipsychotics, having higher maladaptive behavior scores, and having relatively higher levels of adaptive behavior were most likely to be in the high injury group. We concluded that episodes of injury were not evenly distributed across the individuals and certain personal characteristics discriminated high from low risk groups.

The Pem homeobox gene: rapid evolution of the homeodomain, X chromosomal localization, and expression in reproductive tissue

A hallmark of homeobox genes is their high degree of sequence conservation in distantly related species. Here, we report the chromosomal localization, sequence, and expression pattern of an orphan homeobox gene, Pem, that encodes a homeodomain (HD) that has undergone a surprisingly high rate of evolutionary change. The N-terminal portion of the Pem HD, which includes the first two alpha-helices, exhibits only 44% sequence identity between rat Pem (r.Pem) and mouse Pem (m.Pem). This N-terminal subdomain exhibited an extremely high frequency of nonsynonymous substitutions, severalfold higher than other regions of the Pem protein. In contrast, the third helix, which is known to confer most of the base-specific contacts of HDs with DNA, was almost identical in r. Pem and m.Pem. Several lines of evidence suggested that the rat and mouse genes that we identified as Pem genes are true homologues: (1) the r.Pem and m.Pem genes both reside on the X chromosome; (2) they possess identical exon/intron splice junctions; (3) they both encode a distinctive motif upstream of the HD that is unique to Pem; and (4) the only m.Pem-like gene we were able to identify in the rat genome other than r.Pem was a pseudogene, r.Pem-ps, whose sequence and chromosomal localization indicated that it was derived by reverse transcription and reinsertion into the genome. The functional r.Pem gene is selectively expressed in placenta, testis, epididymis, and ovary. This expression pattern is of interest since other genes transcribed in reproductive tissue have also been shown to undergo high rates of sequence divergence. The high rate of amino acid substitutions in the N-terminal region of the Pem HD suggests the possibility of species-specific directional selection.

A follow-up study of patients hospitalized after minor head injury

Minor head injury accounts for 95% of all head injury. In this study 62 patients, hospitalized after minor head injury, were assessed within 48 h, and invited to attend for review and retesting 3 months later. Thirty-five patients were followed up in this way and 11 more were interviewed over the telephone. There was significant improvement on all psychometric tests between initial evaluation and follow-up. Between 51% and 86% reported troublesome late post-concussional symptoms, of which headaches and tiredness were the most frequently reported symptoms. Length of post-traumatic amnesia (PTA) was related to severity of symptoms. Clinical levels of anxiety and stress were noted in approximately one-third of the whole group; 95% of the group had returned to work by 3 months with a mean absence rate of 9.4 days. The therapeutic implications of these results are discussed.

The Bacillus subtilis pnbA gene encoding p-nitrobenzyl esterase: cloning, sequence and high-level expression in Escherichia coli

p-Nitrobenzyl esters serve as protecting groups on intermediates in the manufacture of clinically important oral beta-lactam antibiotics; de-esterification of the intermediates is required for synthesis of the final product. A Bacillus subtilis PNB carboxy-esterase (PNBCE) catalyzes hydrolysis of several beta-lactam antibiotic PNB esters to the corresponding free acid and PNB alcohol. This communication (i) describes cloning the pnbA gene, which encodes PNBCE, (ii) provides the nucleotide sequence of the pnbA open reading frame (ORF) and (iii) describes a method for efficiently expressing the ORF in Escherichia coli. The amino acid (aa) sequence, deduced from the nucleotide sequence of the pnbA ORF, matched an experimentally determined N-terminal aa sequence of B. subtilis PNBCE and also matched an active site sequence previously identified by biochemical analyses. Specific activity of PNBCE in crude extracts was more than 90-fold greater in recombinant E. coli, as compared to B. subtilis. This increase in expression led to more than a 500-fold improvement in the efficiency of purification of PNBCE.

Effects on cardiac performance of atrioventricular node catheter ablation using radiofrequency current for drug-refractory atrial arrhythmias

Patients with atrial fibrillation or atrial flutter (AF) are candidates for radiofrequency (RF) catheter ablation of the atrioventricular (AV) node with the aim being to control heart rate. As patients with AF can have markedly impaired ventricular function, information concerning the hemodynamic effects of AV node ablation using RF current would be valuable. Fourteen consecutive patients (mean age 65 +/- 3 years) with drug-resistant AF underwent AV node catheter ablation with RF current and had permanent pacemaker implantation. The mean left ventricular ejection fraction (EF) by two-dimensional echocardiography immediately before ablation was 42 +/- 3% (range 14%-54%) and their mean exercise time was 4.4 +/- 0.4 minutes. Complete AV block was achieved in all 14 patients with 6 +/- 2 RF applications (range 1-18). There was no evidence of any acute cardiodepressant effect associated with delivery of RF current, and EF 3 days after ablation was 44 +/- 4%. By 6 weeks after ablation, the left ventricular EF was significantly improved compared to baseline (47 +/- 4% postablation vs 42 +/- 3% preablation; P < 0.05), and this modest increase in EF was accompanied by an improvement in exercise time (5.4 +/- 0.4 min). In conclusion, delivery of RF current for AV node catheter ablation in patients with AF and reduced ventricular function is not associated with any acute cardiodepressant effect. On the contrary, improved control of rapid heart rate following successful AV node ablation is associated with a modest and progressive improvement in cardiac performance.