Comparative effectiveness of nirmatrelvir/ritonavir versus sotrovimab and molnupiravir for preventing severe COVID-19 outcomes in non-hospitalised high-risk patients during Omicron waves: observational cohort study using the OpenSAFELY platform

Background

Timely evidence of the comparative effectiveness between COVID-19 therapies in real-world settings is needed to inform clinical care. This study aimed to compare the effectiveness of nirmatrelvir/ritonavir versus sotrovimab and molnupiravir in preventing severe COVID-19 outcomes in non-hospitalised high-risk COVID-19 adult patients during Omicron waves.

Methods

With the approval of NHS England, we conducted a real-world cohort study using the OpenSAFELY-TPP platform. Patient-level primary care data were obtained from 24 million people in England and were securely linked with data on COVID-19 infection and therapeutics, hospital admission, and death, covering a period where both nirmatrelvir/ritonavir and sotrovimab were first-line treatment options in community settings (February 10, 2022-November 27, 2022). Molnupiravir (third-line option) was used as an exploratory comparator to nirmatrelvir/ritonavir, both of which were antivirals. Cox proportional hazards model stratified by area was used to compare the risk of 28-day COVID-19 related hospitalisation/death across treatment groups.

Findings

A total of 9026 eligible patients treated with nirmatrelvir/ritonavir (n = 5704) and sotrovimab (n = 3322) were included in the main analysis. The mean age was 52.7 (SD = 14.9) years and 93% (8436/9026) had three or more COVID-19 vaccinations. Within 28 days after treatment initiation, 55/9026 (0.61%) COVID-19 related hospitalisations/deaths were observed (34/5704 [0.60%] treated with nirmatrelvir/ritonavir and 21/3322 [0.63%] with sotrovimab). After adjusting for demographics, high-risk cohort categories, vaccination status, calendar time, body mass index and other comorbidities, we observed no significant difference in outcome risk between nirmatrelvir/ritonavir and sotrovimab users (HR = 0.89, 95% CI: 0.48-1.63; P = 0.698). Results from propensity score weighted model also showed non-significant difference between treatment groups (HR = 0.82, 95% CI: 0.45-1.52; P = 0.535). The exploratory analysis comparing nirmatrelvir/ritonavir users with 1041 molnupiravir users (13/1041 [1.25%] COVID-19 related hospitalisations/deaths) showed an association in favour of nirmatrelvir/ritonavir (HR = 0.45, 95% CI: 0.22-0.94; P = 0.033).

Interpretation

In routine care of non-hospitalised high-risk adult patients with COVID-19 in England, no substantial difference in the risk of severe COVID-19 outcomes was observed between those who received nirmatrelvir/ritonavir and sotrovimab between February and November 2022, when Omicron subvariants BA.2, BA.5, or BQ.1 were dominant.

Funding

UK Research and Innovation, Wellcome Trust, UK Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Recording of 'COVID-19 vaccine declined': a cohort study on 57.9 million National Health Service patients' records in situ using OpenSAFELY, England, 8 December 2020 to 25 May 2021

BackgroundPriority patients in England were offered COVID-19 vaccination by mid-April 2021. Codes in clinical record systems can denote the vaccine being declined.AimWe describe records of COVID-19 vaccines being declined, according to clinical and demographic factors.MethodsWith the approval of NHS England, we conducted a retrospective cohort study between 8 December 2020 and 25 May 2021 with primary care records for 57.9 million patients using OpenSAFELY, a secure health analytics platform. COVID-19 vaccination priority patients were those aged ≥ 50 years or ≥ 16 years clinically extremely vulnerable (CEV) or 'at risk'. We describe the proportion recorded as declining vaccination for each group and stratified by clinical and demographic subgroups, subsequent vaccination and distribution of clinical code usage across general practices.ResultsOf 24.5 million priority patients, 663,033 (2.7%) had a decline recorded, while 2,155,076 (8.8%) had neither a vaccine nor decline recorded. Those recorded as declining, who were subsequently vaccinated (n = 125,587; 18.9%) were overrepresented in the South Asian population (32.3% vs 22.8% for other ethnicities aged ≥ 65 years). The proportion of declining unvaccinated patients was highest in CEV (3.3%), varied strongly with ethnicity (black 15.3%, South Asian 5.6%, white 1.5% for ≥ 80 years) and correlated positively with increasing deprivation.ConclusionsClinical codes indicative of COVID-19 vaccinations being declined are commonly used in England, but substantially more common among black and South Asian people, and in more deprived areas. Qualitative research is needed to determine typical reasons for recorded declines, including to what extent they reflect patients actively declining.

Safety of COVID-19 vaccination and acute neurological events: A self-controlled case series in England using the OpenSAFELY platform

INTRODUCTION

We investigated the potential association of COVID-19 vaccination with three acute neurological events: Guillain-Barré syndrome (GBS), transverse myelitis and Bell's palsy.

METHODS

With the approval of NHS England we analysed primary care data from >17 million patients in England linked to emergency care, hospital admission and mortality records in the OpenSAFELY platform. Separately for each vaccine brand, we used a self-controlled case series design to estimate the incidence rate ratio for each outcome in the period following vaccination (4-42 days for GBS, 4-28 days for transverse myelitis and Bell's palsy) compared to a within-person baseline, using conditional Poisson regression.

RESULTS

Among 7,783,441 ChAdOx1 vaccinees, there was an increased rate of GBS (N = 517; incidence rate ratio 2·85; 95% CI2·33-3·47) and Bell's palsy (N = 5,350; 1·39; 1·27-1·53) following a first dose of ChAdOx1 vaccine, corresponding to 11.0 additional cases of GBS and 17.9 cases of Bell's palsy per 1 million vaccinees if causal. For GBS this applied to the first, but not the second, dose. There was no clear evidence of an association of ChAdOx1 vaccination with transverse myelitis (N = 199; 1·51; 0·96-2·37). Among 5,729,152 BNT162b2 vaccinees, there was no evidence of any association with GBS (N = 283; 1·09; 0·75-1·57), transverse myelitis (N = 109; 1·62; 0·86-3·03) or Bell's palsy (N = 3,609; 0·89; 0·76-1·03). Among 255,446 mRNA-1273 vaccine recipients there was no evidence of an association with Bell's palsy (N = 78; 0·88, 0·32-2·42).

CONCLUSIONS

COVID-19 vaccines save lives, but it is important to understand rare adverse events. We observed a short-term increased rate of Guillain-Barré syndrome and Bell's palsy after first dose of ChAdOx1 vaccine. The absolute risk, assuming a causal effect attributable to vaccination, was low.

Association between oral anticoagulants and COVID-19-related outcomes: a population-based cohort study

BACKGROUND

Early evidence has shown that anticoagulant reduces the risk of thrombotic events in those infected with COVID-19. However, evidence of the role of routinely prescribed oral anticoagulants (OACs) in COVID-19 outcomes is limited.

AIM

To investigate the association between OACs and COVID-19 outcomes in those with atrial fibrillation and a CHA2DS2-VASc score of 2.

DESIGN AND SETTING

On behalf of NHS England, a population-based cohort study was conducted.

METHOD

The study used primary care data and pseudonymously-linked SARS-CoV-2 antigen testing data, hospital admissions, and death records from England. Cox regression was used to estimate hazard ratios (HRs) for COVID-19 outcomes comparing people with current OAC use versus non-use, accounting for age, sex, comorbidities, other medications, deprivation, and general practice.

RESULTS

Of 71 103 people with atrial fibrillation and a CHA2DS2-VASc score of 2, there were 52 832 current OAC users and 18 271 non-users. No difference in risk of being tested for SARS-CoV-2 was associated with current use (adjusted HR [aHR] 0.99, 95% confidence interval [CI] = 0.95 to 1.04) versus non-use. A lower risk of testing positive for SARS-CoV-2 (aHR 0.77, 95% CI = 0.63 to 0.95) and a marginally lower risk of COVID-19-related death (aHR, 0.74, 95% CI = 0.53 to 1.04) were associated with current use versus non-use.

CONCLUSION

Among those at low baseline stroke risk, people receiving OACs had a lower risk of testing positive for SARS-CoV-2 and severe COVID-19 outcomes than non-users; this might be explained by a causal effect of OACs in preventing severe COVID-19 outcomes or unmeasured confounding, including more cautious behaviours leading to reduced infection risk.

Clinical coding of long COVID in English primary care: a federated analysis of 58 million patient records in situ using OpenSAFELY

BACKGROUND

Long COVID describes new or persistent symptoms at least 4 weeks after onset of acute COVID-19. Clinical codes to describe this phenomenon were recently created.

AIM

To describe the use of long-COVID codes, and variation of use by general practice, demographic variables, and over time.

DESIGN AND SETTING

Population-based cohort study in English primary care.

METHOD

Working on behalf of NHS England, OpenSAFELY data were used encompassing 96% of the English population between 1 February 2020 and 25 May 2021. The proportion of people with a recorded code for long COVID was measured overall and by demographic factors, electronic health record software system (EMIS or TPP), and week.

RESULTS

Long COVID was recorded for 23 273 people. Coding was unevenly distributed among practices, with 26.7% of practices having never used the codes. Regional variation ranged between 20.3 per 100 000 people for East of England (95% confidence interval [CI] = 19.3 to 21.4) and 55.6 per 100 000 people in London (95% CI = 54.1 to 57.1). Coding was higher among females (52.1, 95% CI = 51.3 to 52.9) than males (28.1, 95% CI = 27.5 to 28.7), and higher among practices using EMIS (53.7, 95% CI = 52.9 to 54.4) than those using TPP (20.9, 95% CI = 20.3 to 21.4).

CONCLUSION

Current recording of long COVID in primary care is very low, and variable between practices. This may reflect patients not presenting; clinicians and patients holding different diagnostic thresholds; or challenges with the design and communication of diagnostic codes. Increased awareness of diagnostic codes is recommended to facilitate research and planning of services, and also surveys with qualitative work to better evaluate clinicians' understanding of the diagnosis.

Use of non-steroidal anti-inflammatory drugs and risk of death from COVID-19: an OpenSAFELY cohort analysis based on two cohorts

OBJECTIVES

To assess the association between routinely prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and deaths from COVID-19 using OpenSAFELY, a secure analytical platform.

METHODS

We conducted two cohort studies from 1 March to 14 June 2020. Working on behalf of National Health Service England, we used routine clinical data in England linked to death data. In study 1, we identified people with an NSAID prescription in the last 3 years from the general population. In study 2, we identified people with rheumatoid arthritis/osteoarthritis. We defined exposure as current NSAID prescription within the 4 months before 1 March 2020. We used Cox regression to estimate HRs for COVID-19 related death in people currently prescribed NSAIDs, compared with those not currently prescribed NSAIDs, accounting for age, sex, comorbidities, other medications and geographical region.

RESULTS

In study 1, we included 536 423 current NSAID users and 1 927 284 non-users in the general population. We observed no evidence of difference in risk of COVID-19 related death associated with current use (HR 0.96, 95% CI 0.80 to 1.14) in the multivariable-adjusted model. In study 2, we included 1 708 781 people with rheumatoid arthritis/osteoarthritis, of whom 175 495 (10%) were current NSAID users. In the multivariable-adjusted model, we observed a lower risk of COVID-19 related death (HR 0.78, 95% CI 0.64 to 0.94) associated with current use of NSAID versus non-use.

CONCLUSIONS

We found no evidence of a harmful effect of routinely prescribed NSAIDs on COVID-19 related deaths. Risks of COVID-19 do not need to influence decisions about the routine therapeutic use of NSAIDs.

Case fatality risk of the SARS-CoV-2 variant of concern B.1.1.7 in England, 16 November to 5 February

The SARS-CoV-2 B.1.1.7 variant of concern (VOC) is increasing in prevalence across Europe. Accurate estimation of disease severity associated with this VOC is critical for pandemic planning. We found increased risk of death for VOC compared with non-VOC cases in England (hazard ratio: 1.67; 95% confidence interval: 1.34-2.09; p < 0.0001). Absolute risk of death by 28 days increased with age and comorbidities. This VOC has potential to spread faster with higher mortality than the pandemic to date.

A decline in the occurrence of extended-spectrum β-lactamase-producing Escherichia coli in retail chicken meat in the UK between 2013 and 2018

AIMS

The aim of this study was to report on the occurrence of antimicrobial resistant (AMR) Escherichia coli from retail chicken meat samples in the UK, with particular focus on AmpC and extended spectrum beta-lactamase (ESBL) production and carbapenem resistance.

METHODS AND RESULTS

Methods from EU protocols were used for selective isolation of AmpC-/ESBL-producing E. coli, carbapenem-resistant E. coli and for performing minimum inhibitory concentrations. Additional work not part of EU protocols included viable counts, detection by PCR of bla_CTX-M , bla_OXA, bla_SHV and bla_TEM genes in ESBL-phenotype E. coli and screening for mcr plasmid-mediated colistin resistance. From the 313/309 retail chicken meat samples tested in 2016/2018, carbapenem or mcr plasmid-mediated colistin-resistant E. coli were not detected. For 2016/2018 chicken samples, 141/42 (45·0%/13·6%), 90/23 (28·8%/7·4%), 48/16 (15·3%/5·2%) and 3/3 (1·0%/1·0%) were positive for ESBL- and/or AmpC-, ESBL- alone AmpC- alone and AmpC+ESBL-phenotype E. coli respectively. ESBL-producing E. coli were predominantly bla_CTX-M-1 . All AmpC and/or ESBL-phenotype E. coli were sensitive to colistin, ertapenem, imipenem, meropenem, temocillin and tigecycline, applying epidemiological cut-off values.

CONCLUSIONS

A previous study in 2013/14 showed that 65·4% of retail chicken meat samples tested in the UK were positive for ESBL-producing (mainly CTX-M) E. coli. Since then the proportion of samples positive in the UK has dropped significantly to 7·4% in 2018.

SIGNIFICANCE AND IMPACT OF THE STUDY

Significant reductions in antimicrobials used in the UK poultry meat sector between 2012 and 2016 may be linked to significant reductions in AmpC/ESBL-phenotype E. coli in retail chicken between 2013/14 and 2018.

Design choices for observational studies of the effect of exposure on disease incidence

The purpose of this paper is to help readers choose an appropriate observational study design for measuring an association between an exposure and disease incidence. We discuss cohort studies, sub-samples from cohorts (case-cohort and nested case-control designs), and population-based or hospital-based case-control studies. Appropriate study design is the foundation of a scientifically valid observational study. Mistakes in design are often irremediable. Key steps are understanding the scientific aims of the study and what is required to achieve them. Some designs will not yield the information required to realise the aims. The choice of design also depends on the availability of source populations and resources. Choosing an appropriate design requires balancing the pros and cons of various designs in view of study aims and practical constraints. We compare various cohort and case-control designs to estimate the effect of an exposure on disease incidence and mention how certain design features can reduce threats to study validity.

Longitudinal study on the occurrence in pigs of colistin-resistant Escherichia coli carrying mcr-1 following the cessation of use of colistin

AIMS

In 2015, colistin-resistant Escherichia coli and Salmonella with the mcr-1 gene were isolated from a pig farm in Great Britain. Pigs were subsequently monitored over a ~20-month period for the occurrence of mcr-1-mediated colistin resistance and the risk of mcr-1 E. coli entering the food chain was assessed.

METHODS AND RESULTS

Pig faeces and slurry were cultured for colistin-resistant E. coli and Salmonella, tested for the mcr-1 gene by PCR and selected isolates were further analysed. Seventy-eight per cent of faecal samples (n = 275) from pigs yielded mcr-1 E. coli after selective culture, but in positive samples only 0·2-1·3% of the total E. coli carried mcr-1. Twenty months after the initial sampling, faecal samples (n = 59) were negative for E. coli carrying mcr-1.

CONCLUSIONS

The risk to public health from porcine E. coli carrying mcr-1 was assessed as very low. Twenty months after cessation of colistin use, E. coli carrying mcr-1 was not detected in pig faeces on a farm where it was previously present.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results suggest that cessation of colistin use may help over time to reduce or possibly eliminate mcr-1 E. coli on pig farms where it occurs.

Application and optimisation of the Comparison on Extreme Laboratory Tests (CERT) algorithm for detection of adverse drug reactions: Transferability across national boundaries

PURPOSE

The Singapore regulatory agency for health products (Health Sciences Authority), in performing active surveillance of medicines and their potential harms, is open to new methods to achieve this goal. Laboratory tests are a potential source of data for this purpose. We have examined the performance of the Comparison on Extreme Laboratory Tests (CERT) algorithm, developed by Ajou University, Korea, as a potential tool for adverse drug reaction detection based on the electronic medical records of the Singapore health care system.

METHODS

We implemented the original CERT algorithm, comparing extreme laboratory results pre- and post-drug exposure, and 5 variations thereof using 4.5 years of National University Hospital (NUH) electronic medical record data (31 869 588 laboratory tests, 6 699 591 drug dispensings from 272 328 hospitalizations). We investigated 6 drugs from the original CERT paper and an additional 47 drugs. We benchmarked results against a reference standard that we created from UpToDate 2015.

RESULTS

The original CERT algorithm applied to all 53 drugs and 44 laboratory abnormalities yielded a positive predictive value (PPV) and sensitivity of 50.3% and 54.1%, respectively. By raising the minimum number of cases for each drug-laboratory abnormality pair from 2 to 400, the PPV and sensitivity increased to 53.9% and 67.2%, respectively. This post hoc variation, named CERT400, performed particularly well for drug-induced hepatic and renal toxicities.

DISCUSSION

We have demonstrated that the CERT algorithm can be applied across national boundaries. One modification (CERT400) was able to identify adverse drug reaction signals from laboratory data with reasonable PPV and sensitivity, which indicates potential utility as a supplementary pharmacovigilance tool.

Evaluation of sensitivity, performance and reproducibility of microarray technology in neuronal tissue

Microarray technology is a powerful technique that allows the simultaneous study of thousands of gene transcripts. During the past two years there has been an explosion of publications describing experiments utilizing microarray technology that range from original research findings from biological paradigms to mathematically modeled systems. However, neuroscientists using microarray technology face significant challenges due to high tissue complexity, low abundance transcripts, and small magnitude changes in transcript levels that have significant biological impact. This manuscript describes a series of studies designed to address issues regarding microarray sensitivity, ability of microarrays to detect subtle changes, and reproducibility of microarray experiments, all in the context of neuronal tissue. From the presentation of these studies, the authors argue that although microarray technology is limited with regards to sensitivity, the outcome of these experiments, if approached with appropriate skepticism, can be fruitful in the generation of hypotheses and seeding of future experiments.

Survey of Salmonella prevalence on commercial turkey breeding and fattening farms in the UK in 2006 to 2007

A total of 29 breeding turkey holdings and 317 fattening turkey holdings were sampled between October 2006 and September 2007 in order to establish the baseline prevalence of Salmonella in turkeys in the UK. The weighted holding level Salmonella prevalence was found to be 20.1 per cent (95 per cent confidence interval [CI] 8.6 to 40.3 per cent) in breeding turkeys and 37.7 per cent (95 per cent CI 33.4 to 42.3 per cent) in fattening turkeys. For breeding turkeys, a weighted flock-level prevalence, as more than one flock per holding was sampled, was estimated at 7.1 per cent (95 per cent CI 3.2 to 14.8 per cent). A total of 13 different serovars were identified in the survey. The most frequent serovar in both turkey flock classes was Salmonella Kottbus, which was found on two breeding holdings and 63 of the fattening holdings giving weighted prevalences of 10.4 per cent (95 per cent CI 2.6 to 34.1 per cent) and 23.0 per cent (95 per cent CI 19.3 to 27.3 per cent), respectively. On breeding holdings, a single isolate of Salmonella Typhimurium, identified as DT12 (weighted prevalence 3.5 per cent [95 per cent CI 0.7 to 15.8 per cent] [holding], 0.7 per cent [95 per cent CI 0.1 to 3.7 per cent] [flock)], was found. On fattening holdings, there were 55 isolates of S Typhimurium from 16 holdings, giving a weighted prevalence of this serovar of 5.4 per cent (95 per cent CI 3.6 to 8.0 per cent). There were no isolates of Salmonella serovars Enteritidis, Hadar, Infantis or Virchow.

Survey of the prevalence of Salmonella on commercial broiler farms in the United Kingdom, 2005/06

Between October 2005 and September 2006, all European Union member states were required to carry out standardised surveys of the prevalence of Salmonella in broiler flock holdings to establish baseline data from which to derive national targets for disease reduction. In the uk 382 holdings were sampled, 41 of which were positive for Salmonella, giving an estimated weighted prevalence of 10.7 per cent (95 per cent confidence interval [ci] 8.1 to 13.1 per cent). The serotype most frequently isolated was Salmonella Ohio, with a weighted prevalence of 2.2 per cent (95 per cent ci 1.2 to 3.7 per cent), followed by Salmonella Kedougou at 1.7 per cent (95 per cent ci 0.9 to 3.2 per cent). There were no isolates of Salmonella Enteritidis and only a single isolation of Salmonella Typhimurium (0.2 per cent, 95 per cent ci 0.0 to 1.6 per cent). Of the three other serotypes given top priority by the eu owing to their public health significance, Salmonella Virchow was isolated from one holding, but Salmonella Hadar and Salmonella Infantis were not detected on any of the holdings.

Trends in phage types and antimicrobial resistance of Salmonella enterica serovar Enteritidis isolated from animals in Great Britain from 1990 to 2005

Surveillance data for Salmonella enterica serovar Enteritidis incidents and isolations from food animals in Great Britain from 1990 to 2005 were analysed to detect any trends and provide the basis for a comparison between phage types (pt) and antimicrobial sensitivity patterns in human beings and animals. During 2001 to 2005 there was a decrease in incidents involving most species except ducks. Only the numbers of incidents involving pts 6, 6a, 9b and 14b (in ducks) and pts 6a and 13a (in mammals) increased significantly during this period, whereas there were 93 per cent fewer incidents involving pt 4 than in 1990 to 2000. After adjustment for pt, the isolates from ducks were more resistant to nalidixic acid, tetracyclines and sulfonamides, and were more likely to be multiresistant than isolates from chickens. Isolates from turkeys tended to be more resistant to sulfonamides than isolates from chickens. pts 1, 5a, 6, 6a and 35 had the highest level of resistance after adjusting for species. During 2001 to 2005 there was an increase in resistance among pts 1, 6 and 7, in most cases involving nalidixic acid.

Intestinal carriage of verocytotoxigenic Escherichia coli O157, Salmonella, thermophilic Campylobacter and Yersinia enterocolitica, in cattle, sheep and pigs at slaughter in Great Britain during 2003

An abattoir survey was undertaken to determine the prevalence of foodborne zoonotic organisms colonizing cattle, sheep and pigs at slaughter in Great Britain. The study ran for 12 months from January 2003, involved 93 abattoirs and collected 7703 intestinal samples. The design was similar to two previous abattoir surveys undertaken in 1999-2000 allowing comparisons. Samples were examined for VTEC O157, Salmonella, thermophilic Campylobacter and Yersinia enterocolitica. The prevalence of VTEC O157 faecal carriage was 4.7% in cattle, 0.7% in sheep and 0.3% in pigs. A significant decrease in sheep was detected from the previous survey (1.7%). Salmonella carriage was 1.4% in cattle, a significant increase from the previous survey of 0.2%. In sheep, faecal carriage was 1.1% a significant increase from the previous survey (0.1%). In pigs, carriage was 23.4%, consistent with the previous study. Thermophilic Campylobacter spp. were isolated from 54.6% of cattle, 43.8% of sheep and 69.3% of pigs. Y. enterocolitica was isolated from 4.5% of cattle, 8.0% of sheep and 10.2% of pigs.

Survey of the prevalence of Salmonella species on commercial laying farms in the United Kingdom

A survey of salmonella infection on 454 commercial layer flock holdings in the uk was carried out between October 2004 and September 2005. Fifty-four (11.7 per cent, 95 per cent confidence interval 9.3 to 14.0 per cent) were salmonella positive. The most common serovar identified was Salmonella Enteritidis at a prevalence of 5.8 per cent, and 70 per cent of these isolates were phage types 4, 6, 7 and 35. Salmonella Typhimurium was the second most prevalent serovar, found in 1.8 per cent of the farms. Of the three other serovars given top priority by the eu because of their public health significance, Salmonella Virchow and Salmonella Infantis were each isolated from one holding, but Salmonella Hadar was not isolated from any of the holdings. Analysis of antimicrobial resistance patterns revealed that over 76 per cent of the isolates were sensitive to all of the 16 drugs tested, and all the isolates were sensitive to ciprofloxacin, gentamicin, ceftazidime, apramycin, amikacin, amoxicillin/clavulanic acid, neomycin and cefotaxime.

An audit of the safe use of the mini c-arm image intensifier in the out-patient setting

Mini C-arm image intensifiers are used commonly in surgery of the upper limb. With relatively low doses of emitted ionising radiation, portability and superior quality of image, they are a useful aid to the operating surgeon. However, these benefits are not so often used outside the theatre setting. This paper examines the use of a mini C-arm image intensifier in the out-patient clinic and presents an audit of 100 consecutive out-patients. We reviewed the potential benefits and effects on their care pathway. We also look at the specific radiation protection issues of the mini C-arm image intensifier in the out-patients clinic. We believe use of the mini C-arm image intensifier in the out-patient setting may speed treatment and reduce the cost of treatment.

Risk factors associated with the salmonella status of dairy farms in England and Wales

Between October 1999 and February 2001 the salmonella status of 449 dairy farms in England and Wales was determined by environmental sampling on up to four occasions. Data were collected through interview-based questionnaires, and multivariable analyses were used to identify risk factors associated with the farms either being Salmonella positive (prevalence data) or becoming Salmonella positive (incidence data). Region, herd size, month of visit and the lack of a clean visitor parking area were significantly associated with the prevalence of Salmonella species, and there was a significant trend towards an increased risk in late summer and autumn. The introduction of six- to 24-month-old cattle into a herd was associated with a reduced prevalence, but the introduction of adult cattle only, or calves with other cattle, was associated with an increased (but not significant) risk of farms being Salmonella positive. Month of visit, the lack of a clean visitor parking area, the use of part-time workers and not feeding calves whole milk, but not region or herd size, were associated with an increased incidence of salmonella.

Prevalence, incidence and geographical distribution of serovars of Salmonella on dairy farms in England and Wales

A study of randomly selected dairy farms in England and Wales was made between October 1999 and February 2001 to estimate the prevalence and incidence of Salmonella serovars. The farms were enrolled through five milk-buying companies, which represented 63 per cent of the dairy farms in England and Wales, and they were sampled on up to four occasions (449 farms at visit 1, 272 farms at visit 2, 251 farms at visit 3 and 243 farms at visit 4). In total, 19,296 samples of pooled faecal pats and slurry were collected. The farm-specific prevalence of all serovars of Salmonella ranged from 12.1 per cent (95 per cent confidence interval [CI] 8.2 to 16.0 per cent) to 24.7 per cent (95 per cent CI 19.4 to 30.1 per cent) at each visit. The most common serovars identified were Salmonella Dublin (3.7 to 6.6 per cent farm-specific prevalence at each visit), Salmonella Agama (1.8 to 7.6 per cent) and Salmonella Typhimurium (2.6 to 4.1 per cent) The prevalence varied by region and month of sampling and increased in late summer. The incidence rate of all serovars of Salmonella was 0.43 (95 per cent CI 0.34 to 0.54) cases per farm-year at risk. There was no significant difference between the incidence rates of the common serovars S Typhimurium (0.07), S Dublin (0.06) and S Agama (0.13). A total of 29 Salmonella serovars were isolated. Few of the isolates were resistant to the 16 antimicrobial agents tested, except the isolates of S Typhimurium dt104, of which 67.9 per cent were resistant to at least five of them.

Altered cortical glutamatergic and GABAergic signal transmission with glial involvement in depression

Abnormalities in L-glutamic acid (glutamate) and GABA signal transmission have been postulated to play a role in depression, but little is known about the underlying molecular determinants and neural mechanisms. Microarray analysis of specific areas of cerebral cortex from individuals who had suffered from major depressive disorder demonstrated significant down-regulation of SLC1A2 and SLC1A3, two key members of the glutamate/neutral amino acid transporter protein family, SLC1. Similarly, expression of L-glutamate-ammonia ligase, the enzyme that converts glutamate to nontoxic glutamine was significantly decreased. Together, these changes could elevate levels of extracellular glutamate considerably, which is potentially neurotoxic and can affect the efficiency of glutamate signaling. The astroglial distribution of the two glutamate transporters and L-glutamate-ammonia ligase strongly links glia to the pathophysiology of depression and challenges the conventional notion that depression is solely a neuronal disorder. The same cortical areas displayed concomitant up-regulation of several glutamate and GABA(A) receptor subunits, of which GABA(A)alpha1 and GABA(A)beta3 showed selectivity for individuals who had died by suicide, indicating their potential utility as biomarkers of suicidality. These findings point to previously undiscovered molecular underpinnings of the pathophysiology of major depression and offer potentially new pharmacological targets for treating depression.

Persistence of Salmonella Typhimurium DT120 in abattoir paddocks holding sheep

In the summer of 1999 there was an outbreak of Salmonella Typhimurium DT120 in people in the north of England which was unusual in being sensitive to antimicrobial drugs. The outbreak was linked to mutton and lamb from a local abattoir, and attention focused on four holding paddocks used to retain sheep before slaughter. In November 1999, samples of soil and faeces were taken from these paddocks and samples of faeces were taken from the concrete race leading from them. Salmonella Typhimurium was isolated from 59 of the 100 samples. Between January 2000 and October 2000 seven visits were made to the abattoir at each of which 100 samples were taken from the paddocks and concrete race and examined for the presence of Salmonella. The paddocks remained heavily contaminated with S Typhimurium DT120 until April when there was a marked reduction in the recovery of the organism. By June the contamination was minimal and by August it had disappeared, and the organism was not recovered in September or October.

Multiple antimicrobial resistant Salmonella enterica serovar Paratyphi B variant Java in cattle: a case report

An epidemiological investigation of a calf rearing premises and a closely associated dairy herd was carried out after the isolation of Salmonella enterica serovar Paratyphi B variant Java phage type 3b variant 2 from clinically diseased calves on the premises. The isolate was resistant to ampicillin, chloramphenicol, streptomycin, sulphonamides, tetracyclines, trimethoprim and cefoperazone. The organism was widespread on the calf unit and was also recovered from the dairy premises, mainly from groups of weaned calves. The investigation was extended to 10 epidemiologically linked farms but no S Java was isolated from any of the 40 to 60 samples collected from each premises. Molecular studies showed that the S Java isolates were genetically most similar to isolates from cases of human disease associated with ornamental fish tanks or feed. Long PCR and resistance gene profiling identified a resistance island which was indistinguishable from the human 'fish tank' strain of S Java and animal and human epidemic strains of S Typhimurium DT104. The isolates were clearly distinguished from multi-resistant S Java strains commonly associated with continental poultry. This is the first report of S Java with this resistance pattern in Great Britain.

Dysregulation of the fibroblast growth factor system in major depression

In this report we describe findings that imply dysregulation of several fibroblast growth factor (FGF) system transcripts in frontal cortical regions of brains from human subjects with major depressive disorder (MDD). This altered gene expression was discovered by microarray analysis of frontal cortical tissue from MDD, bipolar, and nonpsychiatric control subjects and was verified by quantitative real-time PCR analysis and, importantly, in a separate cohort of MDD subjects. Furthermore, we show, through a separate analysis of specific serotonin reuptake inhibitor (SSRI)-treated and non-SSRI-treated MDD subjects that the observed changes in expression of FGF transcripts are not secondary to drug treatment. Rather, changes in specific FGF transcripts are attenuated by SSRIs and may thus be partially responsible for the mechanism of action of these drugs. We also make available the gene-expression profile of all of the other growth factors and growth factor receptors detected in these postmortem samples.

National survey for Salmonella in pigs, cattle and sheep at slaughter in Great Britain (1999-2000)

AIMS

The objective of these surveys was to estimate the prevalence of faecal carriage of Salmonella in healthy pigs, cattle and sheep at slaughter, and of pig carcase contamination with Salmonella. These data can be used as a baseline against which future change in Salmonella prevalence in these species at slaughter can be monitored.

METHODS AND RESULTS

In this first randomized National Survey for faecal carriage of Salmonella in slaughter pigs, cattle and sheep in Great Britain, 2509 pigs, 891 cattle and 973 sheep were sampled in 34 pig abattoirs and 117 red meat abattoirs in England, Scotland and Wales. Carriage of Salmonella in 25 g caecal contents was identified in 578 (23.0% pigs) but in only 134 (5.3%) of carcase swabs. The predominant Salmonella serovars found in both types of sample were S. Typhimurium (11.1% caeca, 2.1% carcases) and S. Derby (6.3% caeca, 1.6% carcases). The main definitive phage types (DT) of S. Typhimurium found were DT104 (21.9% of caecal S. Typhimurium isolates), DT193 (18.7%), untypable strains (17.6%), DT208 (13.3%) and U302 (13.3%). Three isolates of S. Enteritidis (PTs 13A and 4) and one enrofloxacin-resistant S. Choleraesuis were also isolated. A positive 'meat-juice ELISA' was obtained from 15.2% of pigs at 40% optical density (O.D.) cut-off level and 35.7% at 10% cut-off. There was poor correlation between positive ELISA results or carcase contamination and the caecal carriage of Salmonella. The ratio of carcase contamination to caecal carriage rates was highest in abattoirs from the midland region of England and in smaller abattoirs. In cattle and sheep 1 g samples of rectal faeces were tested. Two isolates (i.e. 0.2%) were recovered from cattle, one each of S. Typhimurium, DT193 and DT12. One sheep sample (0.1%) contained a Salmonella, S. Typhimurium DT41. In a small subsidiary validation exercise using 25 g of rectal faeces from 174 cattle samples, three (1.7%) isolates of Salmonella (S. Typhimurium DT104, S. Agama, S. Derby) were found.

CONCLUSIONS

The carriage rate of Salmonella in prime slaughter cattle and sheep in Great Britain was very low compared with pigs. This suggests that future control measures should be focused on reduction of Salmonella infection on pig farms and minimizing contamination of carcases at slaughter.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work has set baseline figures for Salmonella carriage in these species slaughtered for human consumption in Great Britain. These figures were collected in a representative way, which enables them to be used for monitoring trends and setting control targets.

DNA microarray analysis of functionally discrete human brain regions reveals divergent transcriptional profiles

Transcriptional profiles within discrete human brain regions are likely to reflect structural and functional specialization. Using DNA microarray technology, this study investigates differences in transcriptional profiles of highly divergent brain regions (the cerebellar cortex and the cerebral cortex) as well as differences between two closely related brain structures (the anterior cingulate cortex and the dorsolateral prefrontal cortex). Replication of this study across three independent laboratories, to address false-positive and false-negative results using microarray technology, is also discussed. We find greater than a thousand transcripts to be differentially expressed between cerebellum and cerebral cortex and very few transcripts to be differentially expressed between the two neocortical regions. We further characterized transcripts that were found to be specifically expressed within brain regions being compared and found that ontological classes representing signal transduction machinery, neurogenesis, synaptic transmission, and transcription factors were most highly represented.

Prevalence of faecal excretion of verocytotoxigenic Escherichia coli 0157 in cattle in England and Wales

During the decade to 1999, the incidence of human infections with the zoonotic pathogen verocytotoxin-producing Escherichia coli O157 (VTEC O157) increased in England and Wales. This paper describes the results of a survey of 75 farms to determine the prevalence of faecal excretion of VTEC O157 by cattle, its primary reservoir host, in England and Wales. Faecal samples were collected from 4663 cattle between June and December 1999. The prevalence of excretion by individual cattle was 4.2 per cent (95 per cent confidence interval [CI] 2.0 to 6.4) and 10.3 per cent (95 per cent CI 5.8 to 14.8) among animals in infected herds. The within-herd prevalence on positive farms ranged from 1.1 to 51.4 per cent. At least one positive animal was identified on 29 (38.7 per cent; 95 per cent CI 28.1 to 50.4) of the farms, including dairy, suckler and fattening herds. The prevalence of excretion was least in the calves under two months of age, peaked in the calves aged between two and six months and declined thereafter. The phage types identified most widely were 4, 34 and 2, which were each found on six of the 29 positive farms.

Mechanism and cleavage specificity of the H-N-H endonuclease colicin E9

Colicin endonucleases and the H-N-H family of homing enzymes share a common active site structural motif that has similarities to the active sites of a variety of other nucleases such as the non-specific endonuclease from Serratia and the sequence-specific His-Cys box homing enzyme I-PpoI. In contrast to these latter enzymes, however, it remains unclear how H-N-H enzymes cleave nucleic acid substrates. Here, we show that the H-N-H enzyme from colicin E9 (the E9 DNase) shares many of the same basic enzymological characteristics as sequence-specific H-N-H enzymes including a dependence for high concentrations of Mg2+ or Ca2+ with double-stranded substrates, a high pH optimum (pH 8-9) and inhibition by monovalent cations. We also show that this seemingly non-specific enzyme preferentially nicks double-stranded DNA at thymine bases producing 3'-hydroxy and 5'-phosphate termini, and that the enzyme does not cleave small substrates, such as dinucleotides or nucleotide analogues, which has implications for its mode of inhibition in bacteria by immunity proteins. The E9 DNase will also bind single-stranded DNA above a certain length and in a sequence-independent manner, with transition metals such as Ni2+ optimal for cleavage but Mg2+ a poor cofactor. Ironically, the H-N-H motif of the E9 DNase although resembling the zinc binding site of a metalloenzyme does not support zinc-mediated hydrolysis of any DNA substrate. Finally, we demonstrate that the E9 DNase also degrades RNA in the absence of metal ions. In the context of current structural information, our data show that the H-N-H motif is an adaptable catalytic centre able to hydrolyse nucleic acid by different mechanisms depending on the substrate and metal ion regime.

QT prolongation associated with azithromycin/amiodarone combination

Administration of oral azithromycin, in addition to previously well-tolerated long-term amiodarone therapy, was associated with a marked prolongation of QT interval and increased QT dispersion, both substrates for life-threatening ventricular tachyarrhythmia and torsades de pointes. This is a report of QT prolongation and increased QT dispersion associated with the use of azithromycin. The report assumes an added significance, in view of widespread empirical use of this antibiotic for the treatment of lower respiratory infections and belief of its safety in patients with cardiac diseases. Based on the authors' experience, they would like to emphasize that the combination of azithromycin with other drugs known to prolong QT or causing torsades de pointes be used with caution until the question of the proarrhythmic effect of azithromycin is resolved by further studies.

Use of proportional reporting ratios (PRRs) for signal generation from spontaneous adverse drug reaction reports

BACKGROUND

The process of generating 'signals' of possible unrecognized hazards from spontaneous adverse drug reaction reporting data has been likened to looking for a needle in a haystack. However, statistical approaches to the data have been under-utilised.

METHODS

Using the UK Yellow Card database, we have developed and evaluated a statistical aid to signal generation called a Proportional Reporting Ratio (PRR). The proportion of all reactions to a drug which are for a particular medical condition of interest is compared to the same proportion for all drugs in the database, in a 2 x 2 table. We investigated a group of newly-marketed drugs using as minimum criteria for a signal, 3 or more cases, PRR at least 2, chi-squared of at least 4.

FINDINGS

The database was used to examine retrospectively 15 drugs newly-marketed in the UK, with the highest levels of ADR reporting. The method identified 481 signals meeting the minimum criteria during the period 1996-8. Further evaluation of these showed that 70% were known adverse reactions, 13% were events which were likely to be related to the underlying disease and 17% were signals requiring further evaluation.

IMPLICATIONS

Proportional reporting ratios are a valuable aid to signal generation from spontaneous reporting data which are easy to calculate and interpret, and various refinements are possible.

Comparison of UK paediatric cardiac surgical performance by analysis of routinely collected data 1984-96: was Bristol an outlier?

BACKGROUND

Reports of high mortality after paediatric cardiac surgery at the Bristol Royal Infirmary, UK, led to the establishment of an independent public inquiry. A key question was whether or not the mortality statistics in Bristol were unusual compared with other specialist centres. To answer this question, we did a retrospective analysis of mortality in the UK using two datasets.

METHODS

Data from the UK Cardiac Surgical Register (CSR; January, 1984, to March, 1996) and Hospital Episode Statistics (HES; April, 1991, to December, 1995) were obtained for all 12 major centres in which paediatric cardiac surgery is done in the UK. The main outcome measure was mortality within 30 days of a cardiac surgical procedure. We estimated excess deaths in Bristol using a random-effects model derived from the remaining 11 centres. Additionally, a sensitivity analysis was done and case-mix examined.

FINDINGS

For children younger than 1 year, in open operations, the mortality rate in Bristol was around double that of the other centres during 1991-95: within the CSR, there were 19.0 excess deaths (95% interval 2-32) among 43 deaths; and in HES, there were 24.1 excess deaths (12-34) among 41 deaths recorded. There was no strong evidence for excess mortality in Bristol for closed operations or for open operations in children older than 1 year.

INTERPRETATION

Our results suggest that Bristol was an outlier, and we do not believe that statistical variation, systematic bias in data collection, case-mix, or data quality can explain a divergence in performance of this size.

Mechanisms for discordant alternans

INTRODUCTION

Discordant alternans has the potential to produce larger alternans of the ECG T wave than concordant alternans, but its mechanism is unknown.

METHODS AND RESULTS

We demonstrate by one- and two-dimensional simulation of action potential propagation models that discordant alternans can form spontaneously in spatially homogeneous tissue through one of two mechanisms, due to the interaction of conduction velocity and action potential duration restitution at high pacing frequencies or through the dispersion of diastolic interval produced by ectopic foci. In discordant alternans due to the first mechanism, the boundaries marking regions of alternans with opposite phase arise far from the stimulus site, move toward the stimulus site, and stabilize. Dynamic splitting of action potential duration restitution curves due to electrotonic coupling plays a crucial role in this stability. Larger tissues and faster pacing rates are conducive to multiple boundaries, and inhomogeneities of tissue properties facilitate or inhibit formation of boundaries.

CONCLUSION

Spatial inhomogeneities of electrical restitution properties are not required to produce discordant alternans.

A trial of biosecurity as a means to control Campylobacter infection of broiler chickens

We ran a controlled intervention trial to assess whether the risk of a broiler flock becoming infected with Campylobacter could be reduced by biosecurity measures. These were a standard method of cleansing and disinfecting the poultry house prior to stocking, and a standard hygiene protocol followed by all personnel who entered the study house during the flock's life. Thirty-nine flocks were allocated to intervention or control groups in a ratio of 1:2. Intervention flocks were asked to follow the specified biosecurity measures; all flocks were monitored weekly for Campylobacter infection. Analysis of infection at 42 days of age and over the life of the flock showed that the risk of thermophilic Campylobacter infection of broilers was reduced by over 50% in intervention flocks. Parts of the intervention identified as significant in the univariable analysis included twice weekly replenishment of boot dip disinfectant; potential independent risk factors identified included the location of ventilation fans and daily sanitisation of the water supply. The non-random allocation of 10 flocks to the control group may have introduced some study bias (the effect of which is discussed in the paper).

Pharmacovigilance: a science or fielding emergencies?

Pharmacovigilance involves the assessment of risks and benefits of medicines. There are legal and regulatory aspects of this process, and the licensing of a new medicine is always provisional. The systems, in the past, have had limited statistical involvement, either in terms of personnel who are statistically trained, or in terms of statistical methods. This is changing. The high profile activities of pharmacovigilance have often been emergencies, though most is routine activity. Application of statistical thinking and of techniques is being done to help detect adverse effects of medicines rather earlier so that some emergencies may be avoided.

Alternans and the onset of ventricular fibrillation

Ventricular fibrillation (VF) remains a major cause of death in the industrialized world. Alternans (a period-doubling bifurcation of cardiac electrical activity) have recently been causally linked to the progression from ventricular tachycardia (VT) to VF, a more spatiotemporally disorganized electrical activity. In this paper, we show how alternans and thus VT degenerate to chaos via multiple, specific dynamical routes, largely associated with spatial components of VF dynamics, explaining failures of many recently proposed antiarrhythmic drugs. Identification of dynamical mechanisms for the onset of VF should lead to the design of future experiments and consequently to more effective antiarrhythmic drugs.

Steroid hormones use non-genomic mechanisms to control brain functions and behaviors: a review of evidence

Progestins, estrogens, androgens, and corticosteroids are capable of modifying brain functions and behaviors by mechanisms that involve the classic genomic model for steroid action. However, experimental evidence indicates that some responses to steroid hormones use non-classical, non-genomic mechanisms. This paper reviews the evidence that steroids can bind to receptors in the plasma membrane, activate cell signaling pathways, and regulate responses on a time scale of seconds or a few minutes. The existence of these alternative regulatory pathways for steroid hormones should make endocrinologists and neurobiologists change how they think about steroid hormones. It is no longer valid to assume that minute-to-minute changes in steroid concentrations are not regulating biologically important, short-term responses, or that the only steroids with biological functions are the ones that bind with high affinity to intracellular steroid receptors.

A longitudinal study of campylobacter infection of broiler flocks in Great Britain

One hundred flocks associated with five integrated poultry companies were monitored for one production cycle to investigate risk factors for campylobacter infection of poultry broiler flocks. Bacteriological samples were collected from one house of birds on each site at weekly intervals from 3 to 4 weeks of age until the birds were infected with campylobacter or the flock was depopulated (whichever was sooner). Environmental samples were obtained from 20 houses after cleansing and disinfection of the site before chick arrival. Conventional methods were used for the isolation of campylobacter. Questionnaires were used to collect information on potential risk factors for campylobacter infection. Discrete-time survival analysis was used to assess the influence of various exposures on the age at which the flock was infected with campylobacter. More than 40% of flocks were infected with campylobacter by the time the chicks were 4 weeks old and >90% by 7 weeks. Infection spread rapidly to most birds in a flock. Infection was not predictable by campylobacter status of the last flock reared on the site. (However, because most flocks were infected, the power to detect such an association was poor.) There was no evidence of environmental survival of campylobacters in broiler houses after adequate cleansing and disinfection. The most important predictors of protection from campylobacter were related to effective hygiene barriers (such as housing birds in buildings in a good state of repair, appropriate usage of disinfectant boot dips and a high standard of cleansing and disinfection of the drinking-water equipment). There was no evidence that rodents were a source of infection (but most sites operated effective vermin-control programmes).

A subset of kappa opioid ligands bind to the membrane glucocorticoid receptor in an amphibian brain

Previous studies demonstrated that a membrane receptor for glucocorticoids (mGR) exists in neuronal membranes from the roughskin newt (Taricha granulosa) and that this receptor appears to be a G protein-coupled receptor (GPCR). The present study investigated the question of whether this mGR recognizes nonsteroid ligands that bind to cognate receptors in the GPCR superfamily. To address this question, ligand-binding competition studies evaluated the potencies of various ligands to displace [3H]corticosterone (CORT) binding to neuronal membranes. Initial screening studies tested 21 different competitors and found that [3H]CORT binding was displaced only by dynorphin 1-13 amide (an endogenous kappa-selective opioid peptide), U50,488 (a synthetic kappa-specific agonist) and naloxone (a nonselective opioid antagonist). Follow-up studies revealed that the kappa agonists bremazocine (BRE) and ethylketocyclazocine (EKC) also displaced [3H]CORT binding to neuronal membranes, but that U69,593 (a kappa specific agonist) and nor-BNI (a kappa specific antagonist) were ineffective. The Ki values measured for the opioid competitors were in the subnanomolar to low micromolar range and had the following rank-order: dynorphin > U50,488 > naloxone > BRE > EKC. Because these ligands displaced, at most, only 70% of [3H]CORT specific binding, it appears that some [3H]CORT binding sites are opioid insensitive. Kinetic analysis of [3H]CORT off-rates in the presence of U50,488 and/or CORT revealed no differences in dissociation rate constants, suggesting that there is a direct, rather than allosteric, interaction with the [3H]CORT binding site. In summary, these results are consistent with the hypothesis that the high-affinity membrane binding site for [3H] CORT is located on a kappa opioid-like receptor.

Experimental studies on myocardial stretch and ventricular arrhythmia in hypertrophied and non-hypertrophied hearts

Hypertension affects about 5% of western populations and in the majority of cases it is of unknown aetiology. It exposes the heart to greater levels of myocardial stretch as a result of increased systolic pressure and peripheral resistance. Under certain circumstances myocardial stretch may trigger arrhythmias but the mechanisms and clinical importance of this phenomenon are unclear. This article outlines the risks of sudden cardiac death conferred by hypertension and left ventricular hypertrophy, presents the results of experiments using an animal model of myocardial stretch and discusses some possible mechanisms underlying stretch-induced arrhythmias which may be important in hypertensive patients.

Partial purification and biochemical characterization of a membrane glucocorticoid receptor from an amphibian brain

A membrane receptor for corticosterone (mGR) in the brain of the roughskin newt (Taricha granulosa) has been previously identified. This manuscript reports the evaluation of several chromatographic resins for enrichment of the newt mGR solubilized from neuronal membranes. A protein with an apparent molecular weight of 63 kDa was purified to near homogeneity following sequential purification using ammonium sulfate fractionation, wheat germ agglutinin (WGA)-agarose chromatography, hydroxylapatite chromatography, and an immobilized ligand affinity resin (Corticosterone-Sepharose). Other studies employed a novel protein differential display strategy and a photoaffinity labeling strategy to visualize candidate receptor proteins following SDS-PAGE. Both of these techniques also identified a 63 kDa protein, agreeing with the estimation of molecular weight from the purification data. Furthermore, the use of 2D SDS-PAGE following the photolabeling procedure showed the candidate 63 kDa protein to have a pI of approximately 5.0. Taken together these data suggest that the newt mGR is an acidic glycoprotein with an apparent molecular weight of 63 kDa. Because these characteristics of newt mGR are inconsistent with the characteristics of intracellular glucocorticoid receptors, these two receptor proteins are apparently distinct.

Increased waist size and weight in relation to consumption of Areca catechu (betel-nut); a risk factor for increased glycaemia in Asians in east London

Type 2 diabetes is commoner in Asians than Caucasians. Many nitrosamines are diabetogenic, causing both type 2 and type 1 diabetes. Of CD1 mice fed with betel-nut or associated nitrosamines 8.5% develop glucose intolerance with marked obesity. Glycaemia and anthropometric risk markers for type 2 diabetes were therefore examined in relation to betel usage in 993 'healthy' Bangladeshis by one bilingual research-worker (N.M.). Of these, 12% had known diabetes. A further 145 of 187 subjects 'at-risk' of diabetes (spot glucose > 6.5 mmol/l < 2 h after food, or > 4.5 mmol/l > 2 h after food) had a second blood glucose sample taken; sixty-one were confirmed as 'at-risk', and had an oral glucose tolerance test; nine new diabetics were identified. Multiple regression analysis showed that spot blood glucose values decreased with time after eating (P = 0.0005) and increased independently with waist size (P = 0.0005) and age (P = 0.0005) without relationships to other aspects of the diet, season or smoking. Waist size was strongly related to betel usage independent of other factors such as age. Betel use interacted with sex, relating to increasing glycaemia only in females. Since waist and age were the major markers of increasing glycaemia we suggest that betel chewing, a habit common to about 10% of the world population (more than 200 million people) may contribute to the risk of developing type 2 diabetes mellitus.

Improving dideoxynucleotide-triphosphate utilisation by the hyper-thermophilic DNA polymerase from the archaeon Pyrococcus furiosus

Polymerases from the Pol-I family which are able to efficiently use ddNTPs have demonstrated a much improved performance when used to sequence DNA. A number of mutations have been made to the gene coding for the Pol-II family DNA polymerase from the archaeon Pyrococcus furiosus with the aim of improving ddNTP utilisation. 'Rational' alterations to amino acids likely to be near the dNTP binding site (based on sequence homologies and structural information) did not yield the desired level of selectivity for ddNTPs. However, alteration at four positions (Q472, A486, L490 and Y497) gave rise to variants which incorporated ddNTPs better than the wild type, allowing sequencing reactions to be carried out at lowered ddNTP:dNTP ratios. Wild-type Pfu-Pol required a ddNTP:dNTP ratio of 30:1; values of 5:1 (Q472H), 1:3 (L490W), 1:5 (A486Y) and 5:1 (Y497A) were found with the four mutants; A486Y representing a 150-fold improvement over the wild type. A486, L490 and Y497 are on analpha-helix that lines the dNTP binding groove, but the side chains of the three amino acids point away from this groove; Q472 is in a loop that connects this alpha-helix to a second long helix. None of the four amino acids can contact the dNTP directly. Therefore, the increased selectivity for ddNTPs is likely to arise from two factors: (i) small overall changes in conformation that subtly alter the nucleotide triphosphate binding site such that ddNTPs become favoured; (ii) interference with a conformational change that may be critical both for the polymerisation step and discrimination between different nucleotide triphosphates.

A read-ahead function in archaeal DNA polymerases detects promutagenic template-strand uracil

Deamination of cytosine to uracil is the most common promutagenic change in DNA, and it is greatly increased at the elevated growth temperatures of hyperthermophilic archaea. If not repaired to cytosine prior to replication, uracil in a template strand directs incorporation of adenine, generating a G.C --> A.U transition mutation in half the progeny. Surprisingly, genomic analysis of archaea has so far failed to reveal any homologues of either of the known families of uracil-DNA glycosylases responsible for initiating the base-excision repair of uracil in DNA, which is otherwise universal. Here we show that DNA polymerases from several hyperthermophilic archaea (including Vent and Pfu) specifically recognize the presence of uracil in a template strand and stall DNA synthesis before mutagenic misincorporation of adenine. A specific template-checking function in a DNA polymerase has not been observed previously, and it may represent the first step in a pathway for the repair of cytosine deamination in archaea.