Nationwide Study of Continuous Deep Sedation Practices Among Pediatric Palliative Care Teams

CONTEXT

Palliative sedation practices evolved in France when the Claeys-Leonetti law passed in 2016 authorized patient-requested continuous deep sedation (CDS) until death. Its implementation in the pediatric setting is less frequently encountered and can pose several clinical and ethical challenges for health care teams and families.

OBJECTIVES

Our study aimed to describe CDS requests and practices of patients receiving specialized pediatric palliative care in France since its legalization in 2016.

METHODS

We conducted a nationwide multicentric, descriptive, retrospective study using a self-report questionnaire completed by all Pediatric Palliative Care (PPC) Teams that were involved in a CDS case between January 2017 and December 2019.

RESULTS

Six PPC teams had cared for six patients that had requested CDS, predominantly male adolescents/young adults diagnosed with a solid tumour. The refractory symptoms were diverse (pain, bleeding, and sensory loss) and always coupled with psycho-existential suffering. Each request was analyzed in multidisciplinary collegial meetings. Parental consent was always obtained regardless of age. Sedation typically required the use of multiple drugs including Midazolam (n = 5 cases), Chlorpromazine (n = 3), Ketamine (n = 2), and Propofol (n = 2). Despite close monitoring, achieving a satisfactory level of deep sedation was challenging and most patients unexpectedly awoke during CDS. Death occurred between 27 and 96 hours after induction.

CONCLUSION

Managing patient-requested CDS in pediatrics is challenging due to its rarity, multi-factorial refractory symptoms and drug tolerance despite polytherapy. Few recommendations exist to guide CDS practice for pediatricians. Further studies investigating pediatric CDS practices across various cultural and legal settings, refractory symptom management and specific pharmacology are warranted.

The role of an alpha-selective phosphoinositide-3 kinase inhibitor in vascular inflammation

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): British Heart Foundation

Introduction

Cardiovascular inflammation is associated with endothelial cell (EC) damage, resulting in leukocyte trafficking and oedema formation. Inflammation disrupts EC junctions, increasing microvascular permeability, and resulting in a positive-feedback loop of inflammatory events. The phosphoinositide 3-kinase pathway stimulates this endothelial response and this study examined the actions of BYL-719, a PI3K-α selective inhibitor, on inflammatory responses.

Method

Confocal imaging using immunofluorescence and permeability assays were undertaken to quantify the effect of inflammatory cytokines, TNF-α and IL-1β, in the presence of the PI3K inhibitor using fluorescein isothiocyanate-dextran (40 kDa, 0.1 mg/ml) on human microvascular endothelial cells (HMVEC) (Lonza, derived from dermal tissue). Cells were treated with either cytokine for 16-18 h, followed by a 1 h treatment of drug and a final 1 h treatment with FITC-dextran. In vivo analysis was carried out per the UK Home Office Animals (Scientific Procedures) Act 1986. Male WT CD1 mice were anaesthetised initially using 5% isoflurane and maintained at 2% for procedures, to test BYL-719 in a model of dorsal skin inflammation, to determine neutrophil accumulation (measured by myeloperoxidase) and oedema formation (measured by Evans Blue accumulation). All statistical significance was determined using one-way or two-way ANOVA followed by Tukey’s post hoc test.

Results

BYL-719 significantly reduced cytokine-induced EC permeability and shape changes, including cell area and elongation (Table 1), impeding in vitro cytokine-induced inflammation. The inhibitor, abrogated effects of the inflammatory cytokines in vivo of both TNF-α and IL-1β, but interestingly had no effect on the neutrophil accumulation or oedema formation in the presence of C5a (Figure 1).

Figure 1: The effect of BYL-719 in the dorsal skin inflammation model. Mice were pre-treated with 50 mg/kg BYL-719 intraperitoneally for 30 min, injected intravenously with Evans Blue dye, intradermally injected with TNF-α (100ng/50ul), IL-1β (10ng/50ul) and C5a (300ng/50ul) for 4 h, followed by ex vivo MPO assay (A) and oedema volume measurements (B). Data are mean ±SEM two-way ANOVA by Tukey test., n=6 independent experiments in duplicates; p* < 0.05 and p**** < 0.0001 between control (DMSO) and BYL-719 treated groups.

Conclusions

Our findings show that the PI3K-α inhibitor, BYL-719, reduces endothelial activation and inhibits inflammatory oedema formation in the presence of TNF-α and IL-1β. We conclude that there is a potential for PI3K inhibitors to act as anti-neutrophil and oedema agents in cardiovascular-related inflammatory conditions.

Understanding why patients request euthanasia when it is illegal: a qualitative study in palliative care units on the personal and practical impact of euthanasia requests

Context

Some patients in palliative care units request euthanasia regardless of legislation. Although studies have explored the reasons for these requests, little is known about the subjective, relational, and contextual repercussions for the patient.

Objectives

The aim of this study is to understand the purpose of euthanasia requests from the patient's viewpoint and their personal and practical impact.

Methods

We conducted in-depth interviews with patients requesting euthanasia, their family members, and health care providers in 11 French palliative care units. A thematic analysis of the data was performed.

Results

In total, 18 patients were interviewed within 48 h of the request being made; 1 week later, 9 patients were interviewed again. Five main themes emerged: assuming the possibility of transgressing the forbidden, a call for unbearable suffering to be recognized, encouragement to change clinical practice, reclaiming a sense of freedom over medical constraints, and imagining a desirable future for oneself.

Conclusions

A request for euthanasia appears to be a willful means to remove oneself from the impasse of an existence paralyzed by suffering. It creates a space for discussion, which promotes negotiation with patients on care practices and therapeutics, and strengthens patients' sense of autonomy. Investigating the relationship between the evolution of euthanasia requests within the palliative care setting could be beneficial. It is important to encourage health care professionals to adopt a readiness to listen by interacting with patients in a way that is not momentarily action-oriented but rather focused on proactive discussion.

Description and evaluation of a French grief workshop for children and adolescents bereaved of a sibling or parent

Background

Childhood bereavement is common, and is associated with elevated symptoms of grief with distress and impairment. However, few developmentally appropriate interventions to support grieving children are available to date. In Toulouse, France we developed an innovative four-session group intervention to support grieving families and evaluated its feasibility and acceptability.

Methods

The workshop consists of four sessions over 4 months, open to children bereaved of a sibling or parent, and co-facilitated by two mental health professionals. After an intake assessment, children were placed into closed groups according to age and relation to the deceased. The session content was balanced between creative activities and grief-related discussions. Overall satisfaction was evaluated in March-April of 2020 by an 8-question online survey of children and parents having participated between 2011 and 2019. Freeform commentaries were analysed using the thematic synthesis process.

Results

Of the 230 emails sent in March 2020, 46 children and 81 parents agreed to participate (55% response rate). The families reported an overall high level of satisfaction regarding the intervention that was rated as good to excellent. A majority of respondents considered their participation in the workshop helpful and in accordance with their expectations. Most would recommend the workshop to a friend, and would participate again in the group if needed. The group intervention helped reduce social isolation, facilitated grief expression, and supported the creation of a sense of community among bereaved families.

Conclusions

Encouraging community and mutual support among grieving families is fundamental in bereavement care. Our four-session workshop held over 4 months and led by mental health professionals aimed to help reduce social isolation and foster coping skills through artistic creation and group discussion. Our results highlight the potential need for family bereavement support over a longer period and a provision of a variety of services. Our intervention model is feasible for families, and further studies examining its efficacy are warranted.

OP0032 SINGLE CELL ANALYSIS OF SPONDYLOARTHRITIS REGULATORY T CELLS IDENTIFIES DISTINCT SYNOVIAL GENE EXPRESSION PATTERNS AND CLONAL FATES

Background:

Regulatory T cells (Tregs) play an important role in controlling inflammation and limiting autoimmunity, but their phenotypes at inflammatory sites in human disease are poorly understood. Whilst the phenotype and transcriptional profile of Tregs have been studied in some immune mediated conditions, they have been little studied (especially at the single cell level) in synovial fluid in the course of inflammatory arthritis. In Spondyloarthritis (SpA), in particular, where pathogenesis and inflammation is driven by dysregulated effector immunity, the role of the regulatory arm of immunity is largely unknown.

Objectives:

We aimed to draw an atlas of Tregs in the context of SpA joint inflammation using single cell RNA sequencing of blood and SF Tregs of patients with Ankylosing Spondylitis (AS) and Psoriatic Arthritis (PsA). Functionally distinct specialised Treg subtypes, and specific changes in transcriptional profile occurring in synovial fluid Tregs, providing an insight on Treg adaptation during inflammation. Furthermore, by coupling gene expression analysis with TCR sequencing, we aimed to describe clonally expanded and likely antigen-driven Tregs in the SF.

Methods:

Fluorescent activated cell sorting (FACS) was used to isolate 13,400 memory CD3+ CD45RA-ve CD25 + 127low Tregs from the blood and synovial fluid (SF) of 2 patients with HLA-B27+ AS presenting with active knee arthritis. Single-cell RNA sequencing (scRNA-seq) using 5’ V(D)J 10x Genomics technology allowed both transcriptional definition of Tregs, and exploration of their immune TCR repertoire. Findings were compared to >3,000 SF and blood Tregs from 3 patients with olygoarticular PsA 1. Multicolor flow cytometry and in vitro cell-based assays using patient-derived cells were used to confirm and expand, at protein and functional level, the findings that emerged from the gene expression analysis.

Results:

We report a large scRNAseq dataset (approx. 17,000 cells) comparing Tregs from SpA blood and joints. We identify multiple Treg clusters with distinct transcriptomic profiles, including, among others, a regulatory CD8+ subset expressing cytotoxic markers/genes, and a Th17-like RORC+ Treg subset characterized by IL-10 and LAG-3 expression. Synovial Tregs show upregulation of interferon signature and TNF receptor superfamily genes, and marked clonal expansion, consistent with tissue adaptation and antigen contact respectively. Individual synovial Treg clones map to different clusters indicating cell fate divergence. Finally, we demonstrate that LAG-3 directly inhibits IL-12/23 and TNF secretion by patient-derived monocytes, a mechanism with translational potential in SpA.

Conclusion:

Our detailed characterization of Tregs at an important inflammatory site illustrates the marked specialization of Treg subpopulations and identifies a broad transcriptional profile upregulated across all synovial regulatory cells. Our TCR analysis provides evidence of Treg clonal expansion, which may be driven by antigen, and confirms functional specialisation of individual clones. We also propose a new insight into a Treg functional mechanism through LAG-3 that suggests a novel therapeutic approach to immune-driven diseases.

References:

[1]Penkava et al., Nature Communications, 2020

Disclosure of Interests:

Davide Simone: None declared, Frank Penkava: None declared, Anna Ridley: None declared, Stephen Sansom: None declared, Hussein Al Mossawi Employee of: UCB, Paul Bowness Grant/research support from: Regeneron, Celgene/BMS and GSK

Bereavement care interventions for children under the age of 18 following the death of a sibling: a systematic review

BACKGROUND

Childhood bereavement after sibling death is common, but often unrecognized. The psychosomatic and socioeconomic outcomes of bereaved children can be compromised if appropriate care is unavailable during the formative years leading into adulthood.

AIM

This review aims to describe the methods, structures and procedures of bereavement care for children and adolescents after the loss of a sibling, and the impact on the families benefiting from these interventions.

DESIGN

A systematic review without restriction on study design was conducted.

DATA SOURCES

Four databases (MEDLINE, PsycINFO, EMBASE, Cochrane Library) were searched for articles published from 2000 to 2019. The search was conducted according to PRISMA guidelines and the protocol is registered on PROSPERO under number CRD42019124675. Articles were assessed against eligibility criteria by both authors, and quality was appraised using CASP checklists and NHMRC grading guidelines.

RESULTS

Twenty-three studies met inclusion criteria. Bereavement care was most often accessed by children ages 6-18 who lost a sibling to cancer 6-12 months prior. The interventions were typically group sessions or weekend camps, run predominantly by unpaid staff from a variety of backgrounds. Some staff members received priori specific training. Grief education is taught through mediated discussion and bereavement-centered activities balanced with playful and relaxed activities. Several services have effectuated evaluations of their interventions, and preliminary results show a positive effect for families.

CONCLUSION

Existing literature most likely gives an incomplete picture of appropriate childhood bereavement care, and many interventions possibly remain unpublished or published in other non-scientific sources. An effective response to childhood grief would involve collaboration between medical resources and community services, reinforced through the development of outreach and training programs.

P701The role of a phosphoinositide-3 kinase inhibitor in vascular inflammation

Background/Introduction

Cardiovascular inflammation is associated with endothelial damage, resulting in leukocyte trafficking and oedema formation, which results in a positive-feedback loop of inflammatory events.

Purpose

The phosphoinositide 3-kinase (PI3K) pathway has been shown to be upregulated in vascular disease conditions whereby its inhibitors potentially have beneficial effects. Hence this study was designed to examine the actions of PI-103, a PI3K non-selective inhibitor, on inflammatory responses.

Methods

Permeability assays were undertaken to quantify the effect of TNF-a in the presence and absence of PI-103 using FITC-dextran (40 kDa, 0.1 mg/ml) to measure levels of permeability in trans-wells plates using human microvascular endothelial cells (HMVEC).

In vivo analysis was carried out per the UK Home Office Animals (Scientific Procedures) Act 1986. CD1 mice were anaesthetised, to test PI-103 in a zymosan-induced model of dorsal skin inflammation on neutrophil accumulation (measured by myeloperoxidase) and oedema formation (measured by Evans Blue accumulation).

All data were analysed using 1-way or 2-way ANOVA with post-hoc test.

Results

PI-103 significantly reduced TNF-α induced microvascular endothelial cell permeability (Graph), thus impeding in vitro cytokine-induced inflammation. Whilst there was no effect on neutrophil accumulation in vivo, there was significant reduction in weight of treated areas and oedema formation, which was inhibited by PI-103 (Table 1).

Effect of PI-103 in vivo Control 30 mg/kg PI-103 Tyrode solution Zymosan (μg/ml) Tyrode solution Zymosan (μg/ml) 10 30 100 10 30 100 MPO/Protein (U/mg) 0.66±0.26 1.42±0.07 1.40±0.14 1.68±0.12* 0.60±0.11 1.23±0.32 1.36±0.25 1.59±0.21* Oedema Volume (mm3) 0.00±0.00 3.26±1.76 11.70±2.21 21.50±4.67 2.20±1.53 1.05±1.05 3.27±0.74 5.52±1.58 Mice were pre-treated with PI-103 i.p. for 30 min, i.d injected with zymosan (50 μl/site) for 4 hr, followed by ex vivo MPO assay, weight and oedema volume measurements. Oedema was quantified by measuring: width (x), height (y) and depth (z) from each of the i.d. sites; volume of oedema = ((π/6)xyz). N=6 independent experiments in duplicates; *p<0.05 between Tyrode solution vs zymosan groups.

Effect of PI103 in vitro on permeability

Conclusions

Our findings show that the PI3K non-selective inhibitor, PI-103 (as well as a PI3K α-selective inhibitor), reduces endothelial activation and inhibits inflammatory oedema formation. We conclude that there is a potential for PI3K inhibitors to act as anti-oedema agents in cardiovascular-related inflammatory conditions.

Acknowledgement/Funding

British Heart Foundation

Dual intestinal anomalies in dizygotic twins

We report on the case of two digestive malformations in dizygotic/dichorionic/diamniotic twins born at 31 weeks of gestation. The mother (gravida 1 para 0) was treated by hydroxychloroquine for systemic lupus erythematosus during pregnancy. Twin A presented an arch-like dilatation on antenatal ultrasounds, characteristic of segmental volvulus. After birth, twin B presented repeated vomiting on feeding, leading us to diagnose ileal atresia despite normal antenatal ultrasounds. Both twins underwent surgery and the postoperative period was uneventful. After 1 year of follow-up, the twins are in excellent health without digestive sequelae. Genetic testing for cystic fibrosis was negative. The placenta showed diffuse signs of hypoxia and ischaemia, indicating that the root cause was vascular. The pathophysiology of intestinal atresia is hypothesised to derive from a vascular incident during fetal development. We are therefore led to believe that an intrauterine vascular event is the most likely cause of the dual malformation.

Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES

Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU).

METHODS

Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week ^0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU.

RESULTS

A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03).

CONCLUSIONS

This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

miR-10b-5p is a novel Th17 regulator present in Th17 cells from ankylosing spondylitis

OBJECTIVE

To determine the microRNA (miR) signature in ankylosing spondylitis (AS) T helper (Th)17 cells.

METHODS

Interleukin (IL)-17A-producing CD4+ T cells from patients with AS and healthy controls were FACS-sorted for miR sequencing and qPCR validation. miR-10b function was determined by miR mimic expression followed by cytokine measurement, transcriptome analysis, qPCR and luciferase assays.

RESULTS

AS Th17 cells exhibited a miR signature characterised by upregulation of miR-155-5p, miR-210-3p and miR-10b. miR-10b has not been described previously in Th17 cells and was selected for further characterisation. miR-10b is transiently induced in in vitro differentiated Th17 cells. Transcriptome, qPCR and luciferase assays suggest that MAP3K7 is targeted by miR-10b. Both miR-10b overexpression and MAP3K7 silencing inhibited production of IL-17A by both total CD4 and differentiating Th17 cells.

CONCLUSIONS

AS Th17 cells have a specific miR signature and upregulate miR-10b in vitro. Our data suggest that miR-10b is upregulated by proinflammatory cytokines and may act as a feedback loop to suppress IL-17A by targeting MAP3K7. miR-10b is a potential therapeutic candidate to suppress pathogenic Th17 cell function in patients with AS.

Characteristics and comparative performance of direct culture, direct PCR and enumeration methods for detection and quantification of Campylobacter spp. in broiler caeca

Detection and enumeration of Campylobacter spp. in broiler chicken flocks are key components of research and surveillance studies aimed at reducing Campylobacter infections in people. Direct culture of caecal contents onto selective agar is the typical method used to confirm flock colonisation. Modified charcoal cefoperazone deoxycholate agar (mCCDA) is commonly used for this method, although alternative selective media have been used. Additionally, PCR methods to detect Campylobacter DNA from caecal contents may provide a rapid alternative. However comparative performance data for these methods is limited and therefore required to ensure optimal detection methods for this sample type. In this study, 306 broiler caeca were tested for Campylobacter using direct culture on mCCDA, Skirrows and Preston agars and two real-time PCR methods, one specific for mapA/ceuE regions and another for the flaA gene region. Additionally, the suitability of spread plating and spiral plating methods for enumeration of Campylobacter and the impact of sample storage were assessed. This study confirmed modified CCDA as an optimal media for detection of Campylobacter in broiler caeca. It was significantly more sensitive than Skirrows or Preston agars. This study also demonstrated that the mapA/ceuE PCR had excellent agreement with culture on mCCDA and is a genuine alternative method. Spread plating and spiral plating methods were suitable for enumeration although spiral plating appeared more sensitive for stored samples (72 h). A 1 log reduction in viable Campylobacters was observed in stored samples, therefore storage effects should be considered for quantitative studies with broiler caeca.

Potential sources of Campylobacter infection on chicken farms: contamination and control of broiler-harvesting equipment, vehicles and personnel

AIMS

To test the efficacy of enhanced biosecurity measures on poultry farms for reducing environmental contamination with Campylobacter during partial depopulation of broiler flocks prior to normal slaughter age. The study has also evaluated the risk of infection from live-bird transport crates that are routinely cleaned at the slaughterhouse, but may remain contaminated.

METHODS AND RESULTS

On-farm sampling and Campylobacter isolation was undertaken to compare the prevalence of contamination on vehicles, equipment and catching personnel during farm visits that took place under normal or enhanced biosecurity. Campylobacters were found in almost all types of sample examined and enhanced biosecurity reduced the prevalence. However, the additional measures failed to prevent colonisation of the flocks. For transport crates, challenge trials involved exposure of broilers to commercially cleaned crates and genotyping of any campylobacters isolated. The birds were rapidly colonised with the same genotypes as those isolated from the cleaned crates.

CONCLUSIONS

The enhanced biosecurity measures were insufficient to prevent flock colonisation, and the problem was exacerbated by inadequate cleaning of transport crates at the slaughterhouse.

SIGNIFICANCE AND IMPACT OF THE STUDY

Current commercial practices in the United Kingdom facilitate the spread of campylobacters among broiler chicken flocks. Prevention of flock infection appears to require more stringent biosecurity than that studied here.

Perceived credibility and eyewitness testimony of children with intellectual disabilities

BACKGROUND

Although children with intellectual disabilities (ID) often provide accurate witness testimony, jurors tend to perceive their witness statements to be inherently unreliable.

METHOD

The current study explored the free recall transcripts of child witnesses with ID who had watched a video clip, relative to those of typically developing (TD) age-matched children, and assessed how mock jurors perceived these transcripts in the absence of knowledge of group (ID or TD) membership. A further aim of this research was to determine whether perceptions of credibility were associated with levels of free recall and witness characteristics (anxiety and mental age).

RESULTS

Mock jurors rated the testimony of children with ID as less credible than that of a TD age-matched comparison group. This was largely because of the transcripts of the children with ID containing fewer details than those of the TD children. Anxiety and mental age were found to have no effect on perceived levels of credibility.

CONCLUSIONS

It appears that even in the absence of knowledge of whether a child does or does not have ID, this factor still affects perceptions of credibility among mock jurors. Our findings suggest that fundamental differences in the quality of the witness transcripts lead to lower perceptions of credibility for children with ID.

Cellular effects of long wavelength UV light (UVA) in mammalian cells

UVA should receive significant consideration as a human health risk as it is a large proportion of the solar spectrum that reaches the earth's surface and because of its ability to penetrate human skin. It is only relatively recently that this has been recognized and this previously under-researched part of the UV spectrum is becoming increasingly well characterized at doses that are quite low in relation to those experienced by humans. Absorption of UVA in a cell leads to the production of reactive oxygen and nitrogen species that can damage major biomolecules including DNA and membrane lipids. Various types of damage induced in these molecules lead to significant biological effects including cytotoxicity, mutations and alterations in cell signalling pathways. Longer-term effects such as persistent genomic instability and bystander effects have also been observed following UVA treatment of mammalian cells and, as with ionizing radiation, this changes some of the fundamental thinking around tissue effects of irradiation. Antioxidants have been assessed extensively for their ability to protect against the biological effects of UVA and a number have been shown to be successful at least in-vitro, for example vitamin E and epigallocatechin-3-gallate. Other potential targets for protection are suggested through the increased understanding of some of the signalling mechanisms activated following treatment, for example the inhibition of NADPH oxidase is seen to reduce a bystander effect. The search for appropriate and successful photoprotective agents remains an important area of research.

A survey of fluoroquinolone resistance in Escherichia coli and thermophilic Campylobacter spp. on poultry and pig farms in Great Britain

AIMS

To estimate the proportions of farms on which broilers, turkeys and pigs were shedding fluoroquinolone (FQ)-resistant Escherichia coli or Campylobacter spp. near to slaughter.

METHODS AND RESULTS

Freshly voided faeces were collected on 89 poultry and 108 pig farms and cultured with media containing 1.0 mg l(-1) ciprofloxacin. Studies demonstrated the specificity of this sensitive method, and both poultry and pig sampling yielded FQ-resistant E. coli on 60% of farms. FQ-resistant Campylobacter spp. were found on around 22% of poultry and 75% of pig farms. The majority of resistant isolates of Campylobacter (89%) and E. coli (96%) tested had minimum inhibitory concentrations for ciprofloxacin of > or =8 mg l(-1). The proportion of resistant E. coli and Campylobacter organisms within samples varied widely.

CONCLUSIONS

FQ resistance is commonly present among two enteric bacterial genera prevalent on pig and poultry farms, although the low proportion of resistant organisms in many cases requires a sensitive detection technique.

SIGNIFICANCE AND IMPACT OF THE STUDY

FQ-resistant bacteria with zoonotic potential appear to be present on a high proportion of UK pig and poultry farms. The risk this poses to consumers relative to other causes of FQ-resistant human infections remains to be clarified.

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.

Function and regulation of RhoE

The three Rnd proteins, Rnd1, Rnd2 and RhoE/Rnd3, are a subset of Rho family proteins that are unusual in that they bind but do not hydrolyse GTP, and are therefore not regulated by the classical GTP/GDP conformational switch of small GTPases. Increased expression of each Rnd protein induces loss of stress fibres in cultured fibroblasts and epithelial cells, acting antagonistically to RhoA, which stimulates stress fibre formation. RhoE is farnesylated and localizes partly on membranes, including the Golgi and plasma membrane, and in the cytosol. RhoE inhibits RhoA signalling in part by binding to the RhoA-activated serine/threonine kinase ROCK I (Rho-associated kinase I), thereby preventing it from phosphorylating its targets. RhoE activity is itself regulated by phosphorylation by ROCK I on multiple sites. RhoE phosphorylation enhances its stability, leading to an increase in RhoE levels. In addition, phosphorylation reduces its association with membranes and correlates with its ability to induce loss of stress fibres. RhoE also acts independently of ROCK to inhibit cell cycle progression, in part by preventing translation of cyclin D1, and to inhibit transformation of fibroblasts by oncogenic H-Ras. RhoE is therefore a multifunctional protein whose localization and actions are regulated by phosphorylation.

Genotypic and antibiotic susceptibility characteristics of a Campylobacter coli population isolated from dairy farmland in the United Kingdom

Campylobacter infections are the most common cause of bacterial enteritis in humans, and nearly 8% of such infections are caused by Campylobacter coli. Most studies have concentrated on Campylobacter jejuni, frequently isolated from intensively farmed poultry and livestock production units, and few studies have examined the spread and relatedness of Campylobacter across a range of geographical and host boundaries. Systematic sampling of a 100-km2 area of mixed farmland in northwest England yielded 88 isolates of C. coli from a range of sample types and locations, and water was heavily represented. Screening for antibiotic resistance revealed a very low prevalence of resistance, while genotyping performed by using three methods (flaA PCR restriction fragment length polymorphism [RFLP], pulsed-field gel electrophoresis [PFGE], and fluorescent amplified fragment length polymorphism [fAFLP]) provided insights into the genomic relatedness of isolates from different locations and hosts. Isolates were classified into 23 flaA groups, 34 PFGE groups, and five major fAFLP clusters. PFGE banding analysis revealed a high level of variability and no clustering by sample type. fAFLP and flaA analyses successfully grouped the isolates by sample type. We report preliminary findings suggesting that there is a strain of C. coli which may have become adapted to survival or persistence in water and that there is a group of mainly water-derived isolates from which unusual flaA PCR fragments were recovered.

The application of sustainability concepts to Australian agriculture: an overview

This paper reviews the concepts of sustainable development in an economic, environmental and social context. Weak and strong versions of sustainable development are reviewed and applied to the agricultural sector. The paper demonstrates that despite any degradation of the natural resource base, the agricultural sector is more productive now than in the past. This has occurred because the rate of investment in research and development (resulting in increased reproducible capital) has more than offset the rate of degradation in the natural capital stock. Science, it is argued, is part of the economic system that allocates productive capacity between current and future generations. Increases in expenditure on agricultural R&D since the 1950s have ensured that past generations have transferred productive capacity to future generations. With respect to the environment, the authors argue that a strong version of sustainable development may be appropriate, particularly where there are uncertain and irreversible outcomes. Finally, it has been observed that a hybrid version of social sustainability has been adopted in Australia. While resource mobility in the agricultural sector has been generally encouraged (weak sustainability) this has been underpinned by a welfare system that ensures basic standards of well-being and opportunity (strong sustainability).

The carry-over of Campylobacter isolates between sequential poultry flocks

The carry-over of Campylobacter strains from one flock to a subsequent flock in the same broiler house has been studied using molecular epidemiological techniques. In all, 524 Campylobacter strains, isolated from two sequential broiler flocks from 60 broiler houses, were typed by restriction fragment polymorphism of the polymerase chain reaction (PCR) product of the flaA and flaB genes (fla typing). Selected strains were also typed using pulsed field gel electrophoresis (PFGE). By fla typing, 15 (21%) of the 60 houses with Campylobacter-positive sequential flocks had identical genotypes. In 10 (16% overall) of these houses the strains were also identical by PFGE. The difference in PFGE patterns in the strains from the three remaining houses may be indicative of genetic instability. Overall, these results suggest that carry-over from one flock to a subsequent flock in the same house is a relatively infrequent event and, therefore, that routine broiler house cleansing and/or disinfection is largely adequate to eliminate Campylobacter contamination. An alternative explanation of the low level carry-over is a persistent source or reservoir, external to the environment of the broiler houses.

Protein kinase C-delta C2-like domain is a binding site for actin and enables actin redistribution in neutrophils

Neutrophils play a key role in host-defence mechanisms against invading pathogens, using their capacity to migrate, engulf micro-organisms and produce toxic radicals. Protein kinase C (PKC) isotypes are important intracellular regulators of these processes in neutrophils. PKC isotypes themselves are controlled by interactions with lipids, Ca(2+) and proteins. The C2-like domain of PKC-delta (deltaC2) has been identified as a protein-interaction domain in this PKC isotype. In the present paper we have investigated the contribution of protein interactions at this domain to the regulation/function of PKC-delta in neutrophils. Using affinity chromatography we identified actin as a deltaC2 binding partner in these cells. Fluorescein-labelled deltaC2, microinjected into immobilized neutrophils, interacts with filamentous actin (F-actin) inside the cell. PKC-delta co-localizes with F-actin in neutrophils, in lamellipodia at the leading edge of the cell. Stimulation with phorbol ester or IgG-opsonized Staphylococcus aureus results in co-ordinated redistribution of PKC-delta and F-actin, and a PKC-delta inhibitor inhibits these changes. Microinjection of deltaC2 also inhibits F-actin redistribution. Thus PKC-delta binds to F-actin through its C2 domain, and these interactions are important in regulating actin redistribution in neutrophils.

Evidence for a genetically stable strain of Campylobacter jejuni

The genetic stability of selected epidemiologically linked strains of Campylobacter jejuni during outbreak situations was investigated by using subtyping techniques. Strains isolated from geographically related chicken flock outbreaks in 1998 and from a human outbreak in 1981 were investigated. There was little similarity in the strains obtained from the different chicken flock outbreaks; however, the strains from each of three chicken outbreaks, including strains isolated from various environments, were identical as determined by fla typing, amplified fragment length polymorphism (AFLP) analysis, and pulsed-field gel electrophoresis, which confirmed the genetic stability of these strains during the short time courses of chicken flock outbreaks. The human outbreak samples were compared with strain 81116, which originated from the same outbreak but has since undergone innumerable laboratory passages. Two main AFLP profiles were recognized from this outbreak, which confirmed the serotyping results obtained at the time of the outbreak. The major type isolated from this outbreak (serotype P6:L6) was exemplified by strain 81116. Despite the long existence of strain 81116 as a laboratory strain, the AFLP profile of this strain was identical to the profiles of all the other historical P6:L6 strains from the outbreak, indicating that the genotype has remained stable for almost 20 years. Interestingly, the AFLP profiles of the P6:L6 group of strains from the human outbreak and the strains from one of the recent chicken outbreaks were also identical. This similarity suggests that some clones of C. jejuni remain genetically stable in completely different environments over long periods of time and considerable geographical distances.

Molecular epidemiology of antibiotic resistance genes in multiresistant epidemic Salmonella typhimurium DT 104

The epidemiology of antibiotic resistance genes in epidemic multiresistant S. typhimurium DT 104 of human and animal origin was investigated. DNA prepared from 45 human and 21 animal strains isolated between 1984 and 1997, including eight isolated in other European countries, the USA, Trinidad, and South Africa and resistant to ampicillin, chloramphenicol, streptomycin, sulphonamides, spectinomycin, tetracyclines (R-type ACSSuSpT) were examined for the presence of integrons by PCR. Integron hot spots were observed in all strains conferring resistance to ACSSuSpT in two copies, determined by two discrete bands of approximately 1.0 and 1.2 kb. Direct nucleotide sequencing of the individual amplicons of selected strains indicated that the 1.0 kb gene product was ant (3")-Ia, responsible for resistance to streptomycin and spectinomycin; the 1.2 kb amplicon contained the gene blaPSE-1, encoding the beta-lactamase PSE-1 (CARB-2). Both integrons were encoded on a single XbaI macrorestriction fragment of approximately 10 kb. All isolates of DT 104 of this resistance phenotype contained the same inserted gene cassettes, irrespective of source and country of origin, supporting the suggestion of the spread of an epidemic clone. Sequence analysis of the quinolone resistance determining region (QRDR) of gyrA of 15 multiresistant strains conferring additional resistance to nalidixic acid and ciprofloxacin (R-type ACSSuSpTNxCp) identified two discrete base substitutions at codon Asp-87. Conversion of Asp-87 --> Asn was most commonly observed, in 7/10 human and 4/5 animal isolates, suggesting that this codon plays a major role in the development of ciprofloxacin resistance in multiresistant S. typhimurium DT 104.

Sema3A-induced growth-cone collapse is mediated by Rac1 amino acids 17-32

BACKGROUND

Neurons project their axons along specific pathways in order to establish appropriate connections with their target cells. The rate and direction of axonal growth is determined by interactions between the highly motile growth cone and environmental cues that can act in either an attractive or a repulsive manner. Locomotion is ultimately dependent upon the reorganisation of the actin cytoskeleton and an established role for the Rho family of small GTPases in regulating this process in non-neuronal cells identifies them as candidate signalling molecules in growth cones. An inactive form of Rac1 has recently been shown to inhibit the 'growth-cone collapse' response induced by chick Sema3A, a protein that has recently been established as an important guidance cue. The molecular basis for this inhibition remains unclear.

RESULTS

We have made a series of overlapping peptides from the amino-terminal region of Rac1 and rendered them cell permeable by synthesis in tandem with an established internalisation vector. We report here that a peptide encompassing Rac1 amino acids 17-32 binds directly to the established Rac1-interacting molecules PAK, WASP, 3BP-1 and p85beta(P13K), but not to p67(Phox). Furthermore, the peptide can compete with activated Rac1 for target binding, and inhibits Sema3A-induced growth-cone collapse. We also synthesised cell-permeable peptides that correspond to the Cdc42/Rac1-binding (CRIB) motifs present in PAK and N-WASP. Our results show that a CRIB-containing peptide from PAK, but not that from N-WASP, inhibits growth-cone collapse and that the inhibitory activity correlates with binding to Rac1 and not to Cdc42.

CONCLUSIONS

Our results suggest that Sema3A-induced growth-cone collapse is mediated by Rac1 amino acids 17-32, and demonstrate the feasibility of designing new cell-permeable inhibitors of small GTPases.

Role of phosphoinositide 3-OH kinase in cell transformation and control of the actin cytoskeleton by Ras

The pathways by which mammalian Ras proteins induce cortical actin rearrangement and cause cellular transformation are investigated using partial loss of function mutants of Ras and activated and inhibitory forms of various postulated target enzymes for Ras. Efficient transformation by Ras requires activation of other direct effectors in addition to the MAP kinase kinase kinase Raf and is inhibited by inactivation of the PI 3-kinase pathway. Actin rearrangement correlates with the ability of Ras mutants to activate PI 3-kinase. Inhibition of PI 3-kinase activity blocks Ras induction of membrane ruffling, while activated PI 3-kinase is sufficient to induce membrane ruffling, acting through Rac. The ability of activated Ras to stimulate PI 3-kinase in addition to Raf is therefore important in Ras transformation of mammalian cells and essential in Ras-induced cytoskeletal reorganization.

WHO-sponsored international collaborative study to evaluate methods for subtyping Listeria monocytogenes: restriction fragment length polymorphism (RFLP) analysis using ribotyping and Southern hybridization with two probes derived from L. monocytogenes chromosome

Seven laboratories participated in a WHO-sponsored international collaborative study, to evaluate methods for subtyping Listeria monocytogenes, by performing restriction fragment length polymorph sm (RFLP) analysis-based subtyping of an international study set of 80 strains of L. monocytogenes that included 22 epidemiologically related groups. The RFLP analysis was done by Southern hybridization with one of two types of probes found in multiple copies on the chromosome of L. monocytogenes. Six laboratories performed ribotyping. These laboratories used EcoRI enzyme to restrict the L. monocytogenes DNA and ribosomal RNA or DNA as the probe for Southern hybridizations. The seventh laboratory used Ncil to restrict the DNA, and two probes, one randomly cloned and the other containing repeat sequences cloned from L. monocytogenes DNA. The overall discriminating power of ribotyping, as estimated by calculation of Simpson's index of diversity, ranged from 0.83 to 0.88 for the six laboratories. The discriminating power of the combination of two probes used by Laboratory 7 was 0.91. Ribotyping and the cloned probes used by Laboratory 7 discriminated poorly between serotype 4b strains. Neither method identified three atypical strains (identified by other subtyping methods) included in three apparently epidemiologically related groups. Ribotyping did not discriminate between strains of serotypes 4b and 4b(X) in one epidemiologically related group of strains; one cloned probe used by Laboratory 7 discriminated between these strains. Intra-laboratory reproducibilities for the seven laboratories ranged from 80.0 to 100%. as determined by their abilities to correctly identify 11 pairs of duplicate strains included in the study set. Inter-laboratory reproducibilities were generally very good considering that no attempt was made to standardize protocols used by the participants.

CpG islands in human ZFX and ZFY and mouse Zfx genes: sequence similarities and methylation differences

The human ZFX, human ZFY, and mouse Zfx genes have CpG islands near their 5; ends. These islands are typical in that they span about 1.5 kb, contain transcription initiation sites, and encompass some 5' untranslated exons and introns. However, comparitive nucleotide sequencing of these human and mouse islands provided evidence of evolutionary conservation to a degree unprecedented among mammalian 5' CpG islands. In one stretch of 165 nucleotides containing 19 CpGs, mouse Zfx and human ZFX are identical to each other and differ from human ZFY at only 9 nucleotides. In contrast, we found no evidence of homologous CpG islands in the mouse Zfy genes, whose transcription is more circumscribed than that of human ZFX, human ZFY, and mouse Zfx. Using the isoschizomers HpaII and MspI to examine a highly conserved segment of the ZFX CpG island, we detected methylation on inactive mouse X chromosomes but not on inactive human X chromosomes. These observations parallel the previous findings that mouse Zfx undergoes X inactivation while human ZFX escapes it.

TNF-α induces dyscohesion of epithelial cells. Association with disassembly of actin filaments

TNF-α induced, in a time and dose-dependent fashion, cell-cell dissociation (dyscohesion) of endometrial epithelial cells. Within the time frame that dyscohesion was induced, TNF-α, in a dose-dependent fashion, reduced filamentous (F) actin and resulted in the loss of F-actin from the intercellular boundaries. Loss of F-actin mediated by TNF-α was not due to a reduction in the overall amount of actin or its β-isoform. Two proteins, Rho and Rho guanine nucleotide dissociation inhibitor (Rho-GDI), have been implicated in the regulation of organization of actin cytoskeleton. The reduced level of F-actin was not associated with altered expression of Rho protein, however, it was associated with an increase in the amount of Rho available for ribosylationin vitro by the C3 exoenzyme of Clostridium botulinum. The amount of Rho-GDI protein did not change after treatment with TNF-α suggesting that elevated expression of this protein is not responsible for the disassembly of actin filaments. These findings show that TNF-α induces dyscohesion. Dyscohesion induced by this cytokine is associated with perturbation of the actin cytoskeleton which may be due to the regulatory role of TNF-α on Rho.

Homologous ribosomal protein genes on the human X and Y chromosomes: escape from X inactivation and possible implications for Turner syndrome

We have isolated two genes on the human sex chromosomes, one on the Y and one on the X, that appear to encode isoforms of ribosomal protein S4. These predicted RPS4Y and RPS4X proteins differ at 19 of 263 amino acids. Both genes are widely transcribed in human tissues, suggesting that the ribosomes of human males and females are structurally distinct. Transcription analysis revealed that, unlike most genes on the X chromosome, RPS4X is not dosage compensated. RPS4X maps to the long arm of the X chromosome (Xq), where no other genes are known to escape X inactivation. Curiously, RPS4X maps near the site from which the X-inactivating signal is thought to emanate. On the Y chromosome, RPS4Y maps to a 90 kb segment that has been implicated in Turner syndrome. We consider the possible role of RPS4 haploinsufficiency in the etiology of the Turner phenotype.

Omnipause neurons in two cases of opsoclonus associated with oat cell carcinoma of the lung

Opsoclonus is an involuntary eye movement disorder in which there are chaotic, usually conjugate, multidimensional saccadic eye movements. In this paper 2 cases of opsoclonus are reported, as a paraneoplastic phenomenon in association with oat cell carcinoma of the lung. It has previously been hypothesized that opsoclonus results from dysfunction of a group of premotor neurons in the brainstem called omnipause neurons. We describe the location of these cells in man by homology with animal studies, and describe the light microscopic appearance of these neurons in the 2 cases of opsoclonus. Although these neurons appeared normal it is still possible that their function was disturbed as a result of metabolic or neurotransmitter abnormalities.