Diagnosis of canine intestinal parasites: Improved detection of Dipylidium caninum infection through coproantigen testing

Intestinal parasites, including cestodes like Dipylidium caninum, are common in dogs in the United States of America (USA), but fecal flotation consistently, and, at times, dramatically, fails to identify many of these infections. To determine the extent to which including coproantigen testing for D. caninum would improve the identification of dogs infected with this cestode, we evaluated fecal samples from 877 dogs (589 pet and 288 from municipal shelters) from six USA states using zinc sulfate (specific gravity 1.24) fecal flotation with centrifugation along with coproantigen detection for Giardia sp., hookworms, ascarids, and Trichuris vulpis. For D. caninum, PCR of perianal swabs was included. Intestinal parasite infections were identified, using centrifugal fecal flotation or coproantigen, in 265 dogs (13.2 % pet, 64.9 % shelter). Dipylidium caninum infection was detected in 5.6 % of dogs with the combination of coproantigen and centrifugal fecal flotation, and 7.3 % of dogs when perianal swab results were included; prevalence varied by diagnostic method, population, and geographic region. In pet dogs, D. caninum infection was identified by fecal flotation (0), coproantigen (2.2 %), or perianal swabs (1.2 %). The same methods revealed infection in 0.3 %, 12.5 %, and 11.1 % of shelter dogs, respectively. Frequent use of praziquantel in shelter dogs (116/288; 40.3 %) may have reduced prevalence. Positive and negative agreement of D. caninum coproantigen with perianal swab PCR in pet dogs was 85.7 % and 98.8 %, respectively. Multiple logistic regression analysis accounting for region, population, and age found D. caninum infection to be more common in shelter dogs relative to pet (adjusted OR 4.91 [2.48, 10.24]) and in the Southcentral and Southeast regions relative to North (adjusted OR 9.59 [1.92, 174.13] and 17.69 [3.67, 318.09] respectively). Coproantigen testing also enhanced the detection of other intestinal parasites over fecal flotation alone, including Giardia sp. (14.7 % vs 3.3 %), hookworms (13.8 % vs 8.4 %), ascarids (2.9 % vs 2.2 %), and T. vulpis (2.9 % vs 1.4 %). Together, these data indicate that the coproantigen assay employed increases detection of D. caninum infections several fold, supporting the use of this test in clinical practice, and add to a growing body of research documenting enhanced diagnosis through implementation of multiple laboratory-based methods.

Fluralaner (Bravecto®) treatment kills Aedes aegypti after feeding on Dirofilaria immitis-infected dogs

BACKGROUND

Transmission of canine heartworm (Dirofilaria immitis) from infected to naïve dogs is dependent on successful mosquito feeding and survival.

METHODS

To determine whether treating heartworm-infected dogs with fluralaner (Bravecto^®) limits the survival of infected mosquitoes, and potentially the transmission of D. immitis, we allowed female mosquitoes to feed on microfilaremic dogs and evaluated mosquito survival and infection with D. immitis. Eight dogs were experimentally infected with D. immitis. On day 0 (~ 11 months post-infection), four microfilaremic dogs were treated with fluralaner according to label directions while the other four were non-treated controls. Mosquitoes (Aedes aegypti Liverpool) were allowed to feed on each dog on days -7, 2, 30, 56, and 84. Fed mosquitoes were collected, and the number of live mosquitoes determined at 6 h, 24 h, 48 h, and 72 h post-feeding. Surviving mosquitoes held for 2 weeks were dissected to confirm third-stage D. immitis larvae; PCR (12S rRNA gene) was performed post-dissection to identify D. immitis in mosquitoes.

RESULTS

Prior to treatment, 98.4%, 85.1%, 60.7%, and 40.3% of mosquitoes fed on microfilaremic dogs were alive at 6 h, 24 h, 48 h, and 72 h post-feeding, respectively. Similarly, mosquitoes fed on microfilaremic, non-treated dogs were alive 6 h post-feeding (98.5-100%) throughout the study. In contrast, mosquitoes fed on fluralaner-treated dogs 2 days after treatment were dead or severely moribund by 6 h post-feeding. At 30 and 56 days post-treatment, > 99% of mosquitoes fed on treated dogs were dead by 24 h. At 84 days post-treatment, 98.4% of mosquitoes fed on treated dogs were dead by 24 h. Before treatment, third-stage larvae of D. immitis were recovered from 15.5% of Ae. aegypti 2 weeks after feeding, and 72.4% were positive for D. immitis by PCR. Similarly, 17.7% of mosquitoes fed on non-treated dogs had D. immitis third-stage larvae 2 weeks after feeding, and 88.2% were positive by PCR. Five mosquitoes fed on fluralaner-treated dogs survived 2 weeks post-feeding, and 4/5 were from day 84. None had third-stage larvae at dissection, and all were PCR-negative.

CONCLUSION

The data indicate that fluralaner treatment of dogs kills mosquitoes and thus would be expected to reduce transmission of heartworm in the surrounding community.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

The functional impact of BRCA1 BRCT domain variants using multiplexed DNA double-strand break repair assays

Pathogenic variants in BRCA1 are associated with a greatly increased risk of hereditary breast and ovarian cancer (HBOC). With the increased availability and affordability of genetic testing, many individuals have been identified with BRCA1 variants of uncertain significance (VUSs), which are individually detected in the population too infrequently to ascertain a clinical risk. Functional assays can be used to experimentally assess the effects of these variants. In this study, we used multiplexed DNA repair assays of variants in the BRCA1 carboxyl terminus to functionally characterize 2,271 variants for homology-directed repair function (HDR) and 1,427 variants for cisplatin resistance (CR). We found a high level of consistent results (Pearson's r = 0.74) in the two multiplexed functional assays with non-functional variants located within regions of the BRCA1 protein necessary for its tumor suppression activity. In addition, functional categorizations of variants tested in the multiplex HDR and CR assays correlated with known clinical significance and with other functional assays for BRCA1 (Pearson's r = 0.53 to 0.71). The results of the multiplex HDR and CR assays are useful resources for characterizing large numbers of BRCA1 VUSs.

Analysis of Low Estrogen Receptor (ER+) Breast Carcinomas in a Large Community Breast Cancer Center in Northern California

Introduction/Objective

Estrogen Receptor (ER) expression in breast cancers is a crucial factor for endocrine therapy in patients with tumors expressing ER in ≥1% of tumor cells. The 2019 guidelines published by ASCO/CAP states that breast cancers that have a 1% to 10% of cells staining Estrogen Receptor (ER) positive should be reported as ER Low Positive cases. This study aims to address this subset of low-positive ER tumors and compare the clinical features to other known breast cancer subtypes.

Methods/Case Report

We conducted a retrospective review of a prospectively maintained breast cancer registry from 2013 to 2021 at Mills-Peninsula Medical Center, a Sutter Health Affiliate. The study reviewed patient charts with respect to the pathology report, operative report, chemotherapy regimen, and clinical outcomes. Statistical analyses were conducted using R Project for Statistical Coding, with The Student’s T-test used to compare continuous variables. Two-sided P values less than 0.05 indicate statistical significance.

Results (if a Case Study enter NA)

Our study identified 1316 cases of invasive breast carcinomas, of which 29 (2.16%) demonstrated ER Low-Positive expression. We aimed to evaluate the clinical and pathological features, such as histological grade, ER, PR, HER-2, Ki-67%, and patient age for these tumors. We found that ER Low-Positive tumors demonstrated higher mean histological grade morphology (2.5 out of 3, p<0.001) that was similar to that of Triple Negative Breast Cancers (TNBC) (3 of 3, p<0.001) than to High ER-Positive (1.6 of 3, p<0.001) cancers. Further observations, through examining proliferation rates by utilizing the Ki-67 index, indicate comparative trends between the ER Low-Positive cohort and the TNBC cohort.

Conclusion

The results suggest that the ER Low-Positive carcinomas, despite reported as ER-positive cases, present with similar clinicopathological features to those of ER-negative tumors. Through this study and future research, we would like to emphasize a stricter set of guidelines that can be adopted to reduce variability for reporting biomarkers. This standardization will allow oncologists to provide more appropriate treatment options and improve the quality of patient care.

Evaluation of the Project Echo Tele-Mentoring Model for Knowledge Sharing and Technical Assistance in Cancer Control Planning and Implementation

Background: There is increasing demand for dissemination and implementation of evidence-based guidelines in cancer control. In 2017, the National Cancer Institute's Center for Global Health (NCI-CGH) partnered with University of New Mexico and The University of Texas MD Anderson Cancer Center to provide the Project ECHO (Extension for Community Healthcare Outcomes) model of tele-mentoring as an extension of existing programs that convene relevant stakeholders for knowledge sharing and technical assistance in national cancer control planning. In early 2018, NCI-CGH launched Project ECHO programs in the Caribbean, Asia-Pacific, and sub-Saharan Africa regions, and began plans for implementation in south Asia. As a new approach for the center in program development, NCI-CGH included evaluation measures from the inception of the program to adequately measure its efficacy. Aim: Evaluation of NCI-CGH Project ECHO programs will guide future program development, and assess achievement of the program's goals: (1) to increase individual participant knowledge in specific areas; (2) to improve application of the knowledge learned; and (3) to increase collaboration within and among countries. Methods: Using Project ECHO Evaluation 101, a guide developed by the New York Academy of Medicine, NCI-CGH developed a comprehensive logic model including a concise list of program outcomes prior to the launch of ECHO programs. NCI-CGH used the logic model to develop and pilot-test a Web-based baseline and post-ECHO survey, to be completed by participants in each program, that measures participants' knowledge of cancer control planning principles and strategies. NCI-CGH conducted the baseline survey for all three ECHO programs. The post-ECHO survey will be distributed at the conclusion of each program. Each program is expected to run for approximately six months to one year. Results: Response rates for baseline surveys were: 32% in the Caribbean, 43% in Asia-Pacific, and 78% in sub-Saharan Africa. Respondents (by region) reported high levels of knowledge of the following evidence-based principles and guidelines: the Caribbean - HPV vaccination, Asia-Pacific - cervical cancer early diagnosis, sub-Saharan Africa - raising awareness. Low levels of knowledge were reported for: psychosocial support for cancer patients, family members, and caregivers in the Caribbean; survivorship care for cancer patients in Asia-Pacific; and alcohol consumption control in sub-Saharan Africa. This presentation will highlight baseline and post-ECHO survey analysis findings and the impact of these data on future program development. Conclusion: Inclusion of evaluation measures in the design phase of NCI-CGH Project ECHO tele-mentoring programs enhanced planning efforts by providing a blueprint for developing program curricula, creating an embedded system for gathering data from participants, and informing the pathway to future improvements.

Mapping Stakeholders to Enhance Coordination of Cancer Prevention and Control: The Kenyan Experience

Background: Coordination of stakeholders in cancer prevention and control ensures prudent use of available resources toward a common goal while limiting overlaps and redundancies. The National Cancer Institute of Kenya (NCI-K) is a statutory body with an overall mandate to coordinate and centralize all activities related to cancer prevention and control in Kenya. To identify baseline status of cancer control stakeholder activity to guide implementation of the National Cancer Control Strategy, NCI-K collaborated with US National Cancer Institute (NCI-US) to map stakeholders involved in cancer control in Kenya. Aim: The survey set out to determine the geographical distribution, scope of cancer prevention and control activities, and sources of financing for identified stakeholders involved in cancer prevention and control in Kenya. Methods: Between October 2017 and March 2018, we conducted an online survey among stakeholders involved in cancer prevention, research and control in Kenya adapted from similar stakeholder mapping activities coordinated by NCI-US in other settings. Using attendance lists to past multisectoral forums organized by NCI-K, Kenyan Ministry of Health, and NCI-US, a Google link to a standard pretested questionnaire was circulated. Descriptive analysis was conducted using Microsoft Excel. Results: A total of 52 responses were received with 38 respondents reporting Kenya as their institution country. Twenty (38%) had ongoing activities in all the counties in Kenya. Nairobi County had the highest reported number of active institutions (19) followed by Kisumu (16) and Uasin Gishu (10). The three program focus areas most reported were training 28 (54%), clinic-based screening 27 (52%) and advocacy/information and educational 26 (50%), while the least reported was financing 12 (23%). For organizations involved in cancer screening, 22 (81%) focused on breast cancer while 18 (67%) prioritized cervical cancer. Among the programs that identified cancer prevention as one of their focus areas, a large majority (91%) were involved in health education, while only 1 organization focused on environmental control activities. The most reported source of funding for the cancer programs was grant funding 17 (33%). Conclusion: This stakeholder mapping activity has identified a strong stakeholder presence in most parts of the country while also highlighting gaps in the focus of cancer prevention and control programs. This baseline information on stakeholder activity will help shape future collaborations in cancer prevention and control and will guide NCI-K in developing appropriate policies and ensuring effective coordination.

A Snapshot of Global Oncology Programming at US Cancer Centers: Results of the 2018 US NCI/ASCO NCI-Designated Cancer Center Global Oncology Survey

Background: The US National Cancer Institute (NCI) Center for Global Health (CGH) serves as a clearinghouse of information on global oncology activities within the NCI and across the 70 NCI-designated Cancer Centers. Global oncology, as defined by the American Society of Clinical Oncology (ASCO), “addresses disparities and differences in cancer prevention, care, research, education and the disease's social and human impact around the world”. While CGH routinely reports on NCI-funded global oncology projects conducted at the cancer centers, there is limited reporting of non-NCI funded global oncology activities of the cancer centers. To address this gap, CGH has surveyed the cancer centers about their global oncology programs and projects informally in 2012 and 2014. The 2018 survey, in partnership with ASCO, represents the first systematically conducted survey, with new questions about cancer center global oncology programs, faculty, and trainees. Aim: The aim of the 2018 survey is to develop a summary report of cancer center global oncology programs for use by cancer centers as a knowledge sharing and collaborative tool; by the NCI to inform program development; and, by ASCO to better understand the current state of global oncology training at US institutions. Methods: CGH developed a 2-part online survey with questions about global oncology projects led by cancer centers, and the level of support for global oncology training and faculty engagement at cancer centers. CGH piloted the survey to 7 of the 70 cancer centers (10%) from January to March 2018. Revisions based on the pilot were made, and CGH fielded the survey to the rest of the 63 cancer centers (90%) from March to July 2018. CGH supplemented the survey data with an Internet search of cancer centers' Web sites. The submitted data will be compiled, analyzed, and organized into a summary report for distribution to NCI, ASCO, and the cancer centers. Results: Data from the 7 pilot institutions show that while all 7 institutions (100%) have a global oncology program, there is great variance in the percentage of global oncology faculty who receive external or administrative research grant support for their work. Three institutions (43%) report that 50% or fewer global oncology faculty receive external research grant support, and 6 institutions (86%) report that 50% or fewer global oncology faculty receive cancer center administrative fund support for their work. Additional results and analysis will be available and presented as part of this presentation. Conclusion: In addition to serving as a knowledge sharing and collaboration tool for cancer centers, the global oncology survey allows NCI, ASCO, and global oncology partners to understand the current landscape of and sources of support for global oncology training, research, and programming at the cancer centers. This information will inform future discussions on how to strengthen global oncology programming and partnerships.

The Kenya cancer research and control stakeholder program: Evaluating a bilateral partnership to strengthen national cancer efforts

Background

In response to a growing cancer burden and need for improved coordination among stakeholders in Kenya, the US National Cancer Institute and the Kenya Ministry of Health collaboratively hosted a stakeholder meeting in 2014 which identified four priority areas of need (research capacity building, pathology and cancer registries, cancer awareness and education, and health system strengthening) and developed corresponding action plans.

Methods

Surveys were conducted with participants to collect input on the progress and impact of the 2014 stakeholder meeting.

Findings

Of 69 eligible participants, 45 responded from academia, healthcare institutions, civil society, government, and international agencies. Of the four technical focus areas, three have continued to conduct working group meetings and two have conducted in-person meetings to review and update their respective action plans. Accomplishments linked to or enhanced by t meeting include: Kenyan and international support for expansion of population-based cancer registries, increased availability of prioritized diagnostic tests in selected regional referral hospitals, a greater focus on development of a national cancer research agenda, strategic planning for a community education strategy for cancer awareness, and improved coordination of partners through in-country technical assistance.

Interpretation

The Stakeholder Program has successfully united individuals and organizations to improve cancer control planning in Kenya, and has enhanced existing efforts and programs across the country. This model of partners working in parallel on prioritized track activities has supported development of long term coordination of cancer research and control activities sustainable by the Kenyan government and Kenyan institutions.

(18)F-FDG-PET/CT imaging in an IL-6- and MYC-driven mouse model of human multiple myeloma affords objective evaluation of plasma cell tumor progression and therapeutic response to the proteasome inhibitor ixazomib

(18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) and computed tomography (CT) are useful imaging modalities for evaluating tumor progression and treatment responses in genetically engineered mouse models of solid human cancers, but the potential of integrated FDG-PET/CT for assessing tumor development and new interventions in transgenic mouse models of human blood cancers such as multiple myeloma (MM) has not been demonstrated. Here we use BALB/c mice that contain the newly developed iMyc(ΔEμ) gene insertion and the widely expressed H2-L(d)-IL6 transgene to demonstrate that FDG-PET/CT affords an excellent research tool for assessing interleukin-6- and MYC-driven plasma cell tumor (PCT) development in a serial, reproducible and stage- and lesion-specific manner. We also show that FDG-PET/CT permits determination of objective drug responses in PCT-bearing mice treated with the investigational proteasome inhibitor ixazomib (MLN2238), the biologically active form of ixazomib citrate (MLN9708), that is currently in phase 3 clinical trials in MM. Overall survival of 5 of 6 ixazomib-treated mice doubled compared with mice left untreated. One outlier mouse presented with primary refractory disease. Our findings demonstrate the utility of FDG-PET/CT for preclinical MM research and suggest that this method will play an important role in the design and testing of new approaches to treat myeloma.

High altitude pulmonary oedema

High altitude pulmonary oedema (HAPE) is an important and preventable cause of death at high altitudes. However, little is known about the global incidence of HAPE, in part because most cases occur in remote environments where no records are kept. Furthermore, despite international efforts to achieve consensus, there is wide disparity in the diagnostic criteria in clinical and research use. We have reviewed the literature on the incidence and epidemiology of HAPE. There is broad agreement between studies that HAPE incidence at 2500m is around 0.01%, and increases to 1.9% at 3600m and 2.5-5% at 4300m. Risk factors for HAPE include rate of ascent, intensity of exercise and absolute altitude attained, although an individual pre-disposition to developing the condition is also well described and suggests an underlying genetic susceptibility. It is increasingly recognised that clinically-detectable HAPE is an extreme of a continuous spectrum of excess pulmonary fluid accumulation, which has been demonstrated in asymptomatic individuals. There is a continued need to ensure awareness of the diagnosis and treatment of HAPE among visitors to high altitude. It is likely that HAPE is preventable in all cases by progressive acclimatisation, and we advocate a pragmatic "golden rules" approach. Our understanding of the epidemiology and underlying genetic susceptibility to HAPE may be advanced if susceptible individuals register with the International HAPE Database: http://www.altitude.org/hape.php. HAPE has direct relevance to military training and operations and is likely to be the leading cause of death at high altitude.

Change in long-term mortality associated with fractures of the hip: evidence from the scottish hip fracture audit

We investigated the excess mortality risk associated with fractures of the hip. Data related to 29 134 patients who underwent surgery following a fracture of the hip were obtained from the Scottish Hip Fracture Audit database. Fractures due to primary or metastatic malignancy were excluded. An independent database (General Register Office (Scotland)) was used to validate dates of death. The observed deaths per 100 000 of the population were then calculated for each group (gender, age and fracture type) at various time intervals up to eight years. A second database (Interim Life Tables for Scotland, Scottish Government) was then used to create standardised mortality ratios. Analysis showed that mortality in patients aged > 85 years with a fracture of the hip tended to return to the level of the background population between two and five years after the fracture. In those patients aged < 85 years excess mortality associated with hip fracture persisted beyond eight years. Extracapsular hip fractures and male gender also conferred increased risk.

Does delay to theatre for medical reasons affect the peri-operative mortality in patients with a fracture of the hip?

We have investigated how medical postponement, the time to surgery and the correction of medical abnormalities, according to McLaughlin criteria, before operation affected peri-operative mortality after fracture of the hip. From February to December 2007, in addition to core data, the Scottish Hip Fracture Audit collected information relating to surgical delay. Data were available for 4284 patients which allowed 30-day survival analysis to be performed. Multivariable logistic regression models were used to control for differences in case-mix.

Patients with major clinical abnormalities were more likely to have a postponement and had a lower unadjusted 30-day survival. The time to operation and postponement were not associated with higher mortality after adjustment for case-mix. Correction of major clinical abnormalities before surgery improved the adjusted survival, but this improvement was not significant (p = 0.10). Postponement without correction of a medical abnormality before surgery was associated with a significantly lower (p = 0.006) 30-day adjusted survival. The possible benefits of postponement need to be weighed against prolonged discomfort for the patient and the possibility of the development of other complications.

Baseline sputum time to detection predicts month two culture conversion and relapse in non-HIV-infected patients

BACKGROUND

Few biomarkers are available to identify tuberculosis (TB) patients at risk of delayed sputum conversion and relapse.

OBJECTIVES

To investigate whether baseline pre-treatment time to detection (TTD) of culture predicted 2-month bacteriological conversion and TB relapse.

METHODS

A total of 263 non-HIV-infected smear-positive previously untreated pulmonary TB patients were prospectively followed from diagnosis until treatment outcome after 6 months' treatment and TB recurrence within 24 months.

RESULTS

The median TTD was 3 days (range 1-17). Of 211 (80.2%) patients with favourable treatment outcome, 22 (10.4%) had recurrence, while 12 (5.7%) had confirmed relapse. Culture conversion at 2 months was associated in univariate analysis with the presence and number of cavities, extensive parenchymal involvement, male sex, sputum smear grading and TTD. In multiple logistic regression, TTD or smear grading and extensive parenchymal involvement both predicted month 2 conversion. Relapse was predicted by TTD, sex, body mass index, smear grading and number of cavities in univariate analysis, and in multivariate regression by TTD and sputum smear grading.

CONCLUSIONS

Baseline TTD and smear grading predicted month 2 culture conversion, relapse and also recurrence. These markers may be useful to identify non-HIV-infected patients at risk of recurrence, and may be relevant in clinical trials.

Changes in population demographics and the future incidence of hip fracture

BACKGROUND

During the first three decades of the 21st century the combination of increasing life expectancy and falling birth rates will result in substantial demographic changes within the population of the United Kingdom. A large increase in the elderly population is likely to have significant effects on the number of patients who sustain a hip fracture.

AIM

To predict future changes in hip fracture burden in Scotland.

MATERIALS AND METHODS

Data was obtained from the Scottish Hip Fracture Audit database for a 12 month period between April 2004 and March 2005. All orthopaedic units in Scotland participated in the audit during this period. This data was used to calculate the incidence of hip fracture by 5 year age/gender cohorts. Outcome data was analysed in a similar manner. Population prediction data obtained from the Registrar General's Office was then used to predict hip fracture numbers for the year 2031. Two separate prediction models were used. The first model assumed that the age/gender specific incidence of hip fracture observed in 2004 would remain constant. Between 1999 and 2004, a 9.6% decrease in the population incidence of hip fracture was observed. Therefore a second prediction model was used which assumed a continuation in the fall in population incidence of hip fracture between 2004 and 2031.

RESULTS

The population aged 50 years and above is predicted to increase 28% by 2031, with the most significant increases occurring in the over 1980s. The number of hip fractures is predicted to rise by 45% to 75% (from 6164 to 8829-10756 cases per annum) requiring an additional 287-474 hospital beds. By 2031 approximately 45% of fractures will occur in those aged 85 years and above, compared to 34% in 2004. Predicted changes in population demographics are highly variable by region and so local planning of resource provision will be essential.

CONCLUSION

Changes in population demographics will have significant implications for health care provision for the care of hip fracture patients. An increase in the capacity of acute orthopaedic care and a review of care models will be required to ensure adequate resource provision.

Early mortality after surgical fixation of hip fractures in the elderly

We investigated the relationship between a number of patient and management variables and mortality after surgery for fracture of the hip. Data relating to 18 817 patients were obtained from the Scottish Hip Fracture Audit database. We divided variables into two categories, depending on whether they were case-mix (age; gender; fracture type; pre-fracture residence; pre-fracture mobility and ASA scores) or management variables (time from fracture to surgery; time from admission to surgery; grade of surgical and anaesthetic staff undertaking the procedure and anaesthetic technique).

Multivariate logistic regression analysis showed that all case-mix variables were strongly associated with post-operative mortality, even when controlling for the effects of the remaining variables. Inclusion of the management variables into the case-mix base regression model provided no significant improvement to the model. Patient case-mix variables have the most significant effect on post-operative mortality and unfortunately such variables cannot be modified by pre-operative medical interventions.

Outcome after surgery for the treatment of hip fracture in the extremely elderly

BACKGROUND

As a consequence of changes in population demographics, the extremely elderly represent one of the fastest growing groups in Western society. Previous studies have associated advanced age with increased mortality after hip fracture; however, this finding has not been consistent.

METHODS

The Scottish Hip Fracture Audit is a prospective, national, multicenter study that collects data on patients over the age of fifty years who are admitted to the hospital with a hip fracture. For the present study, we used data collected from twenty-two acute-care orthopaedic units between January 1998 and December 2005. The extremely elderly cohort consisted of 919 individuals with an age of ninety-five years or more. Case-mix variables and outcomes were compared with those for a modal control group of 15,461 individuals who were seventy-five to eighty-nine years of age. Outcome measures included thirty and 120-day mortality rates, the length of the hospital stay, the place of residence, and mobility. A multivariable logistic regression model was used to compare outcomes between groups while controlling for significant case-mix variables.

RESULTS

The extremely elderly presented with poorer indicators of health status as demonstrated by higher American Society of Anesthesiologists scores. In addition, this group was less likely to be independently mobile and more likely to be in institutional care at the time of the fracture (p < 0.001). Mortality at thirty and 120 days was higher in the extremely elderly even after adjusting for case-mix variables. The extremely elderly also were less likely to return home or to return to previous levels of mobility.

CONCLUSIONS

Although the extremely elderly exhibited a higher prevalence of prefracture indicators of poor outcome, statistical control for these case-mix variables showed further age-related deterioration in survival and outcomes after surgery for the treatment of a hip fracture.

Gender differences in epidemiology and outcome after hip fracture: evidence from the Scottish Hip Fracture Audit

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders. Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered.

Time to detection of Mycobacterium tuberculosis in BACTEC systems as a viable alternative to colony counting

OBJECTIVE

To investigate whether time to detection (TTD) of Mycobacterium tuberculosis in BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960 and BACTEC 460 TB systems can be used as an alternative to colony-forming unit (cfu) counting.

DESIGN

A single sputum sample recovered from each of 22 patients with tuberculosis (TB) was cultured on Middlebrook 7H11 agar and in BACTEC MGIT 960 and BACTEC 460 to investigate the relationship between cfu/ml and TTD. The relationship between TTD and treatment response was investigated by culturing a single sputum sample from each of 125 patients with TB in the BACTEC 460 system and comparing TTD values with their treatment response.

RESULTS

An inverse correlation between TTD and bacterial number, as assessed by inoculum size and cfu/ml, was observed. For the 125 patients followed up during treatment, TTD values at diagnosis correlated with smear conversion rates at 2 months and treatment outcomes. Drug resistance of the infecting strain was associated with decreased killing, as indicated by the delayed increase in TTD during the first few days of treatment.

CONCLUSION

The TTD of M. tuberculosis in BACTEC MGIT 960 and BACTEC 460 TB systems is a viable alternative to colony counting. TTD in liquid culture will facilitate mycobacterial quantification, especially in the evaluation of early bactericidal activity.

Prediction of delayed treatment response in pulmonary tuberculosis: use of time to positivity values of Bactec cultures

New drugs that can shorten tuberculosis (TB) treatment and target drug resistant strains are urgently needed. A test which could predict patients at risk of a delayed response to treatment would facilitate clinical trials of new anti-tuberculosis drugs. A widely-used test for the assessment of response to treatment is sputum smear examination. Patients who are smear positive after 2 and 3 months of treatment are said to have delayed and significantly delayed treatment responses respectively. Time to positivity (TTP) values of Bactec cultures, from the first 2 weeks of treatment were used to predict delayed and significantly delayed treatment responses in patients with first time pulmonary tuberculosis. Changes in TTP values early in treatment were transformed to a response ratio (r). Values of r that were less than a threshold value (r(c)) indicated patients who were at risk of having delayed or significantly delayed response to treatment. Accuracy of prediction was sensitive to the timing of sputum sampling and adherence to therapy in the first 2 weeks. Based on TTP data from the first 2 weeks of treatment, significantly delayed treatment response could be predicted with a sensitivity of 75% and a specificity of 62% while the positive (PPV) and negative predictive values (NPV) were 14% and 97% respectively. While the high NPV indicates that a large proportion of patients with a satisfactory response to treatment can be reliably identified, the low PPV value underlines the need to use TTP in conjunction with other markers of disease activity to predict unfavourable treatment response in tuberculosis treatment.

Vitamin D receptor gene polymorphisms and sputum conversion time in pulmonary tuberculosis patients

A cohort of pulmonary tuberculosis (TB) patients in a South African admixed population was investigated to determine if the vitamin D receptor gene (VDR) polymorphisms FokI, ApaI, and TaqI are associated with TB susceptibility or time to sputum conversion, and to investigate other clinical and demographic factors affecting the rate of response to treatment. Firstly, a case-control association study of 249 TB cases and 352 healthy controls was carried out to investigate association of VDR polymorphisms with TB susceptibility. Secondly, a cohort of pulmonary tuberculosis patients with conversion times for both sputum smear (n=220) and culture (n=222) were analysed to determine factors contributing to mycobacterial resolution in sputum. Age and gender adjusted Cox regression models were constructed. Our results indicate that the extent of disease at diagnosis was predictive of both smear and culture conversion times in the final models. Smoking status and VDR genotype contributed independently to smear conversion time, with ApaI 'AA' genotype and TaqI 'T'-containing genotypes predictive of a faster response to TB chemotherapy. We did not find an association between VDR genotype and TB in the case-control study. We conclude that the time taken for an individual to convert to sputum negativity while on antituberculosis therapy can be independently predicted by the VDR genotype.

Immune markers measured before treatment predict outcome of intensive phase tuberculosis therapy

The development of a statistical model based on simple immunological markers which could predict the response to tuberculosis treatment would facilitate clinical trials of new anti-tuberculosis drugs. We have examined the ability of immunological biomarkers, measured at diagnosis and after 4 weeks of treatment, to predict sputum smear status at week 8. Eighteen tuberculosis patients with positive Ziehl-Nielsen (ZN)-stained sputum smears 8 weeks after initiation of treatment (slow response) were matched for age, gender, sputum smear grade and extent of disease on chest radiograph to 18 patients with negative sputum smears at week 8 (fast response). In addition to total white blood cell (WBC) counts and absolute lymphocyte, monocyte and neutrophil numbers, concentrations of six serum markers were measured by enzyme-linked immunosorbent assay (ELISA) in all patients (soluble interleukin-2 receptor alpha (sIL-2Ralpha), granzyme B, soluble tumour necrosis factor alpha receptors 1 and 2 (sTNF-R1 and -2), nitrotyrosine and interferon-gamma (IFN-gamma). At diagnosis, 4 biomarkers (sTNF-R1, total WBC, absolute monocyte and absolute neutrophil numbers) were significantly higher in slow response patients. At week 4, total WBC count and absolute monocyte and neutrophil numbers remained significantly higher in slow responders. Discriminant analysis of the diagnosis and week 4 data provided models for classification of slow response patients with 67% and 83% predictive accuracy. We suggest that treatment response phenotypes can be determined before the start of treatment. Reliable predictive models would allow targeted interventions for patients at risk for slow treatment response to standard tuberculosis therapy.

Production of recombinant protein Pap31 and its application for the diagnosis of Bartonella bacilliformis infection

Tropical bartonellosis is a highly fatal epidemic and endemic infectious disease that occurs throughout the communities of the Andes Mountains in South America. The disease is caused by the facultative intracellular bacteria, Bartonella bacilliformis. The emergence of bartonellosis in new geographic areas and an increase in the number of reported cases suggest the need for a rapid test for epidemiologic study and investigation of the disease burden. The objective of this research is to develop a rapid serologic diagnostic test using recombinant antigens to overcome the limitations of the current standard IFA technique for laboratory diagnosis. Western blot analysis with patient sera of whole cell lysate separated on a 2D gel identified Pap31 as a dominant antigen. PCR primers were designed according to the sequence of ATCC strain 35685 to amplify the gene coding for Pap31 from a local isolate (HOSP 800-09, Peru). The amplicon was subsequently cloned into pET24a, adding the T7 tag, and expressed in E. coli. Patient sera with different IFA titers confirmed the diagnostic band of 31 kDa on a Western blot of SDS-PAGE. The performance of affinity-purified recombinant Pap31 (rPap31) was also evaluated in an ELISA format with 137 patient sera of known IFA titers. The range of ELISA reading from positive sera did not overlap with the range of those from negative sera, suggesting the potential application of rPap31 in both ELISA for high throughput regional hospital settings and in the construction of handheld rapid tests for rural clinical sites.

An oral health education programme based on the National Curriculum

AIM

The aim of this study was to develop and evaluate a teaching programme based on the national curriculum for use in a primary school setting.

DESIGN

National Curriculum guidelines were combined with oral health education messages to draw up lesson plans for teachers to deliver. A questionnaire was used to demonstrate children's oral health knowledge prior to the teaching programme, and at 1 and 7 weeks following the programme. The study took place in inner-city, state-run primary schools in Manchester and North London, UK. The subjects were children between the ages of 7 and 8 years from Manchester (n = 58) and North London (n = 30). The main outcome measure was change in knowledge attributable to a newly developed teaching programme.

RESULTS

The children in Manchester had a higher level of knowledge prior to the teaching programme. Following the teaching programme, children in both schools showed a significant improvement in dental health knowledge (P < 0.001). Seven weeks later, the Manchester children showed no significant loss of knowledge (P < 0.001).

CONCLUSIONS

The aims of the National Curriculum were easily integrated with oral health messages. A more widely available teaching resource, such as the one described in this study, would be useful to encourage the teaching profession to take on oral health education without more costly input from dental professionals.

Aggregation of inertial particles in random flows

We consider the trajectories of particles suspended in a randomly moving fluid. If the Lyapunov exponent of these trajectories is negative, the paths of these particles coalesce, so that particles aggregate. Here we give a detailed account of a method [B. Mehlig and M. Wilkinson, Phys. Rev. Lett. 92, 250602 (2004)] for calculating this exponent: it is expressed as the expectation value of a random variable evolving under a stochastic differential equation. We analyze this equation in detail in the limit where the correlation time of the velocity field of the fluid is very short, such that the stochastic differential equation is a Langevin equation. We derive an asymptotic perturbation expansion of the Lyapunov exponent for particles suspended in three-dimensional flows in terms of a dimensionless measure of the inertia of the particles, epsilon, and a measure of the relative intensities of potential and solenoidal components of the velocity field, Gamma. We determine the phase diagram in the epsilon-Gamma plane.

Identification and validation of novel drug targets in tuberculosis

There is an urgent need for new antimycobacterial drugs, and in particular for novel agents that will shorten the duration of tuberculosis chemotherapy, or overcome drug-resistant strains of the causative organism, Mycobacterium tuberculosis. Our knowledge of the tubercle bacillus and its complex interaction with the human host has improved dramatically in recent years, particularly with the determination of its complete genome sequence. New genome-scale tools are being applied to aid in drug target identification, alongside traditional approaches aimed at understanding the basic biology of M. tuberculosis. Many potential drug targets have been identified, but very few have been validated by showing that they are essential for growth or survival of the bacterium. In this review, the landscape of potential drug targets is surveyed.Structural Bioinformatic Approaches to the Discovery of New Antimycobacterial Drugs.

The Mycobacterium tuberculosis dosRS two-component system is induced by multiple stresses

Induction of the Mycobacterium tuberculosis dosR gene, which is known to respond to hypoxia, was measured using RTq-PCR following exposure to different stresses. Increased expression was seen after exposure to S-nitrosoglutathione (GSNO), ethanol and (to a lesser extent) H2O2, but not heat- or cold-shock. We also demonstrated that hspX, which is dependent on dosR for expression, is induced when cultures are left standing for 30 min, while significant but minor induction was seen following a 10 min centrifugation. Microarray analysis was used to compare gene expression in wild-type and deltadosR strains following 30 min standing. Fifty-two genes were significantly up-regulated, and 19 genes were down-regulated. These included genes that had previously been reported as being part of the dosR regulon, and also some novel ones.

Unusual manifestations in X-linked amelogenesis imperfecta

This paper describes a female with X-linked amelogenesis imperfecta (XAI). This case is unusual in having taurodontism, pulpal calcifications, coronal defects prior to tooth eruption and unerupted teeth. These findings have been reported in some cases of autosomal dominant and autosomal recessive AI but have not previously been documented in XAI.

Galactan biosynthesis in Mycobacterium tuberculosis. Identification of a bifunctional UDP-galactofuranosyltransferase

The cell wall of Mycobacterium tuberculosis and related genera is unique among prokaryotes, consisting of a covalently bound complex of mycolic acids, D-arabinan and D-galactan, which is linked to peptidoglycan via a special linkage unit consisting of Rhap-(1-->3)-GlcNAc-P. Information concerning the biosynthesis of this entire polymer is now emerging with the promise of new drug targets against tuberculosis. Accordingly, we have developed a galactosyltransferase assay that utilizes the disaccharide neoglycolipid acceptors beta-d-Galf-(1-->5)-beta-D-Galf-O-C(10:1) and beta-D-Galf-(1-->6)-beta-D-Galf-O-C(10:1), with UDP-Gal in conjunction with isolated membranes. Chemical analysis of the subsequent reaction products established that the enzymatically synthesized products contained both beta-D-Galf linkages ((1-->5) and (1-->6)) found within the mycobacterial cell, as well as in an alternating (1-->5) and (1-->6) fashion consistent with the established structure of the cell wall. Furthermore, through a detailed examination of the M. tuberculosis genome, we have shown that the gene product of Rv3808c, now termed glfT, is a novel UDP-galactofuranosyltransferase. This enzyme possesses dual functionality in performing both (1-->5) and (1-->6) galactofuranosyltransferase reactions with the above neoglycolipid acceptors, using membranes isolated from the heterologous host Escherichia coli expressing Rv3808c. Thus, at a biochemical and genetic level, the polymerization of the galactan region of the mycolyl-arabinogalactan complex has been defined, allowing the possibility of further studies toward substrate recognition and catalysis and assay development. Ultimately, this may also lead to a more rational approach to drug design to be explored in the context of mycobacterial infections.

Effects of individual performance feedback on nurses' adherence to pain management clinical guidelines

The purpose of this study was to examine the effects of an individual performance feedback intervention on nurses' adherence to pain management practice guidelines. Thirty orthopedic staff nurses received individual performance feedback on their past performance of three recommended pain management practices. Nurses' performance of the three recommended practices significantly improved over the 15 weeks after the feedback intervention. Missed 4-hour pain assessments declined (t = 8.77, df = 239, P < 0.0001), reassessments after analgesics increased (t = -5.71, df = 239, P < 0.0001), and follow-up taken for unacceptable pain increased (t = -3.08, df = 178, P < 0.01). Results suggest that individual performance feedback may be an effective approach to improving nurses' pain management intervention activities.

Effects of performance feedback on patient pain outcomes

The purpose of this study was to examine the effects of an individual feedback intervention provided to nurses on selected patient outcomes related to postoperative pain management Individual performance feedback served as the intervention. Thirty orthopedic staff nurses received feedback information on their past performance of recommended pain management practices. Data were collected preintervention and postintervention on selected patient pain outcomes from the medical records of 240 patients who had undergone total knee arthroplasty. The patient outcome measures were mean 4-hour pain intensity ratings, mean highest pain intensity ratings, mean number of times pain ratings exceeded patients' acceptable level of pain, mean administered morphine equivalents, and mean pain ratings on reassessment following analgesia administration. An improvement was noted in all pain outcomes following the feedback intervention. Results indicate that providing nurses with feedback on their past performance of pain management practices may contribute to decreased postoperative pain.

Biotreatment of refinery spent-sulfidic caustic using an enrichment culture immobilized in a novel support matrix

Sodium hydroxide solutions are used in petroleum refining to remove hydrogen sulfide (H2S) and mercaptans from various hydrocarbon streams. The resulting sulfide-laden waste stream is called spent-sulfidic caustic. An aerobic enrichment culture was previously developed using a gas mixture of H2S and methyl-mercaptan (MeSH) as the sole energy source. This culture has now been immobilized in a novel support matrix, DuPont BIO-SEP beads, and is used to bio-treat a refinery spent-sulfidic caustic containing both inorganic sulfide and mercaptans in a continuous flow, fluidized-bed column bioreactor. Complete oxidation of both inorganic and organic sulfur to sulfate was observed with no breakthrough of H2S and < 2 ppmv of MeSH produced in the bioreactor outlet gas. Excessive buildup of sulfate (> 12 g/L) in the bioreactor medium resulted in an upset condition evidenced by excessive MeSH breakthrough. Therefore, bioreactor performance was limited by the steady-state sulfate concentration. Further improvement in volumetric productivity of a bioreactor system based on this enrichment culture will be dependent on maintenance of sulfate concentrations below inhibitory levels.

A putative ubiquitin ligase required for efficient mRNA export differentially affects hnRNP transport

BACKGROUND

In the nucleus, mRNAs are bound by hnRNP proteins. A subset of hnRNP proteins shuttle between the nucleus and cytoplasm and are believed to promote mRNA export by acting as adaptors between mRNA and the transport machinery. The existence of multiple shuttling hnRNP proteins raises the question of whether differentially regulated, hnRNP-specific mRNA export pathways exist.

RESULTS

We have determined that Tom1p, a conserved protein with a hect (homology to E6-AP carboxyl terminus) E3 ubiquitin ligase domain, is required for efficient mRNA export in S. cerevisiae, yet differentially affects hnRNP protein localization and export. Mutations in tom1 predicted to abolish ubiquitin ligase activity block efficient export of Nab2p and mRNA, causing Nab2p-mRNA complexes to accumulate in a punctate pattern coincident with the nuclear pore complex (NPC). Notably, the subcellular distribution of several other hnRNP proteins is not affected. In particular, Np13p remains mRNA-associated and continues to be efficiently exported in tom1 mutants.

CONCLUSION

Our results demonstrate that mutations predicted to affect the enzymatic activity of the Tom1p ubiquitin ligase differentially affect export of hnRNP proteins in association with mRNA. We propose the existence of multiple mRNA export pathways, with export of Nab2p-associated mRNAs dependent on a branch of the ubiquitin protein modification pathway.