Methods for SARS-CoV-2 hospital disinfection, in vitro observations

Introduction

Escalation of chemical disinfection during the COVID-19 pandemic has raised occupational hazard concerns. Alternative and potentially safer methods such as ultraviolet-C (UVC) irradiation and ozone have been proposed, notwithstanding the lack of standardized criteria for their use in the healthcare environment.

Aim

Compare the virucidal activity of 70% ethanol, sodium dichloroisocyanurate (NaDCC), chlorhexidine, ozonated water, UVC-222 nm, UVC-254 nm against three SARS-CoV-2 variants of concern cultured in vitro.

Methods

Inactivation of three SARS-CoV-2 variants (alpha, beta, gamma) by the following chemical methods was tested: ethanol 70%, NaDCC (100 ppm, 500 ppm, 1000 ppm), chlorhexidine (2%, 1% and 0.5%), ozonated water 7 ppm. For irradiation, a je2Care 222nm UVC Lamp was compared to a Sylvania G15 UV254 nm lamp.

Results

Viral inactivation by >3 log was achieved with ethanol, NaDCC and chlorhexidine. The minor virucidal effect of ozonated water was <1 log. Virus treatment with UVC-254 nm reduced viral activity by 1-5 logs with higher inactivation after exposure for 3 minutes compared to 6 seconds. For all three variants, under equivalent conditions, exposure to UVC-222 nm did not achieve time-dependent inactivation as was observed with treatment with UVC-254 nm.

Conclusion

The virucidal activity on replication-competent SARS-CoV-2 by conventional chemical methods, including chlorhexidine at concentrations as low as 0.5%, was not matched by UVC irradiation, and to an even lesser extent by ozonated water treatment.

Virulence traits and differential translocation of gut-derived Candida albicans

Candida albicansis an opportunistic pathogenic yeast commonly found as part of the gut microbiome, which is thought to be the major reservoir of C. albicans in humans. The ability of C. albicans to adhere to, invade and damage epithelium, along with subsequent escape from the gut lumen into the bloodstream, can lead to life-threatening disseminated fungal infections. Examining the interactions of C. albicans with the intestinal epithelial barrier is vital to understanding its ability to disseminate and cause systemic infections.

A set of seven C. albicans strains (six of gut origin: one healthy donor, one cancer patient, one Crohn’s disease patient and three unknown health status; alongside ‘non-gut’ reference strain SC5314) was profiled for virulence traits. C. albicans strains were profiled for biofilm formation (crystal violet staining), hyphal formation (microscopy) and cytotoxicity (lactate dehydrogenase release; during coculture with confluent Caco-2 gut epithelial cells). Additionally, the ability of C. albicans strains to translocate across epithelial cell layers was assessed during coculture with differentiated Caco-2 monolayers on Transwell™ permeable supports.

Common virulence traits of hyphal formation and cytotoxicity were reduced in gut C. albicanscompared to non-gut reference strain SC5314, while biofilm formation compared to SC5314 was variable. Translocation assays revealed that gut strains of C. albicans are capable of translocating across Caco-2 epithelial cell layers in greater numbers than non-gut reference strain SC5314, with the highest levels of translocation observed from a Crohn’s disease isolate. These insights suggest that gut-specific adaptations may influence luminal escape and pathogenicity of C. albicans.

Population genetics and microevolution of clinical Candida glabrata reveals recombinant sequence types and hyper-variation within mitochondrial genomes, virulence genes, and drug targets

Candida glabrata is the second most common etiological cause of worldwide systemic candidiasis in adult patients. Genome analysis of 68 isolates from 8 hospitals across Scotland, together with 83 global isolates, revealed insights into the population genetics and evolution of C. glabrata. Clinical isolates of C. glabrata from across Scotland are highly genetically diverse, including at least 19 separate sequence types that have been recovered previously in globally diverse locations, and 1 newly discovered sequence type. Several sequence types had evidence for ancestral recombination, suggesting transmission between distinct geographical regions has coincided with genetic exchange arising in new clades. Three isolates were missing MATα1, potentially representing a second mating type. Signatures of positive selection were identified in every sequence type including enrichment for epithelial adhesins thought to facilitate fungal adhesin to human epithelial cells. In patent microevolution was identified from 7 sets of recurrent cases of candidiasis, revealing an enrichment for nonsynonymous and frameshift indels in cell surface proteins. Microevolution within patients also affected epithelial adhesins genes, and several genes involved in drug resistance including the ergosterol synthesis gene ERG4 and the echinocandin target FKS1/2, the latter coinciding with a marked drop in fluconazole minimum inhibitory concentration. In addition to nuclear genome diversity, the C. glabrata mitochondrial genome was particularly diverse, with reduced conserved sequence and conserved protein-encoding genes in all nonreference ST15 isolates. Together, this study highlights the genetic diversity within the C. glabrata population that may impact virulence and drug resistance, and 2 major mechanisms generating this diversity: microevolution and genetic exchange/recombination.

FunHoMic: A Marie Skłodowska-Curie Innovative Training Network for the study of the Fungus-Host-Microbiota interplay

Introduction

The FunHoMic project is a Marie Skłodowska-Curie Innovative Training Network comprising 13 PhD students, 8 academic partners and 3 industry partnersaimingto understand the interplay between fungi, hostsand microbiota to improve prevention and treatment of fungal infections.

Importance

About 2 billion people suffer fungal infections, which have a mortality rate close to that of malaria or breast cancer. Candida albicans has a high clinical and economic burden, making it of particular interest to the FunHoMic project. 70% of women experience at least one episode of vulvovaginal candidiasis (“thrush”) during their lifetime; 8% suffer recurring infections. C. albicans may live as a commensal but can cause symptoms when the fungus-host-microbiota equilibrium is disrupted. Infections by C. albicans have a significant clinical impact, with fatalities in severe cases. Many factors are associated with C. albicans infections; intensive care, neutropenic and diabetic patients are most at risk of systemic infection. Rising antifungal drug resistance has led to certain C. albicans infections having no treatment option.

Aim

The FunHoMic consortium combines projectson fungal pathogenesis, immunology, microbial ecology and’omics technologies to understand and exploit interactions between fungus, host and microbiota. Identification of novel bio markers on the fungal side such as genetic polymorphisms or on the host side such asmicrobiota profiles, metabolites and/or immune markers can lead to patient classification based on relative risk of infection. This could be the beginning of personalised management for fungal infections using preventive or therapeutic interventions like new antifungals, immune modulators or Live Biotherapeutic Products (LBPs).

This project has received funding from the European Union’s Horizon 2020 research and innovation programme under the MarieSklodowska-Curie grant agreement No 812969.

520 Can Low Lymphocyte Count Be Used to Predict the Presence Of COVID-19 In Emergency Surgical Patients?

Introduction

With regards to COVID-19, low lymphocyte count (LC) [1] [2] [3] is a recognised feature and can be linked to disease severity [1][4]. This project aims to establish if lymphopenia is predictive of COVID-19 in the acute surgical patient.

Method

All emergency general surgical admissions to the Northumbria NHS Trust 15/4/20 -31/5/20 (n = 152) and 15/4/19 - 31/5/19 (n = 92) were reviewed. Exclusions included ‘Elective’ admissions and non-abdominal complaints.

Statistical analysis was performed using the STATA package. Low LC was compared with COVID-19 status; established through imaging, swab results, or clinical suspicion.

Results

Within the 2020 cohort 76.3% of patients (n = 116) had swabs within a week of admission. 8 patients within that cohort were deemed to have COVID-19, only one had a positive swab. Low LC as a predictor for COVID-19 had a sensitivity of 75%, specificity of 36.2%, PPV of 6.38% and NPV of 96.2%. Mann Whitney statistical analysis was used to identify a relationship between low LC and COVID-19 status, showing no significance (p = 0.91).

Conclusions

Low LC is not a predictor of whether surgical patients have COVID-19, and therefore should not be used for screening. There was no increase the number of patients presenting with lymphopenia in the acute surgical take in the ‘COVID Era’ compared with 2019.

1496 Building Inclusivity and Diversity from our Foundations: A Cross-Sectional Study Identifying Barriers to Theatre Based Training for Foundation Doctors

Aim

Theatre experience is a powerful factor enabling trainees to determine whether they possess the enthusiasm and aptitude to undertake a surgical career. Removing barriers to theatre learning should allow a more meritorious and diverse cohort of surgical trainees.

Method

An 18 -point open and closed question Likert scale survey was distributed to Foundation Doctors in three hospitals within the Northern Deanery. The survey was designed via focus group and literature review, ascertaining perceived levels of preparedness, acceptance, enjoyment, and barriers to theatre access.

Results

The survey dichotomized respondents (n = 54) into those who attended theatre (n = 40) and those who did not (n = 14). Of those attending 38% (n = 15) reported intimidation and 15% (n = 6) cited a cultural barrier to attendance. Of those who did not attend 79% (n = 11) were interested in surgery. These respondents predominantly reported concerns around prohibitive ward workload and unfamiliarity with protocols. Covid restricted surgical rotations for some. There was a statistically significant difference (p fishers exact test = 0.001) between 83% of respondents who felt welcomed by the surgeons compared to just 45% made to feel welcome by the wider theatre team. Only 20% (n = 11) of respondents felt prepared for theatre by medical school. 50% (n = 27) were confident with theatre protocols.

Conclusions

The study raises concerns around apprehension surrounding the theatre environment and ward workload which appear to impede access to theatre. Adequate undergraduate surgical teaching, appropriate induction and allocation of theatre time are crucial to improve safety, diversity of applicants, confidence for trainees and compliance within the team.

A-02 A Novel Tool for the Differential Diagnosis of Clinical Alzheimer’s Disease, Mild Cognitive Impairment, and Normal Cognition: Development and Validation

Objective

To create a clinician-friendly diagnostic tool based on neuropsychological and demographic data to assist classification of Alzheimer’s Disease (AD), Mild Cognitive Impairment (MCI), and normal cognition (NC).

Methods

Neuropsychological and demographic data from 652 (256 NC,122 MCI,274 AD) subjects were selected from a regional Alzheimer’s Disease Research Center. Utilizing half the sample, two binary logistic regressions compared NC to (MCI + AD) and AD to (NC + MCI) groups. Initial models were reduced in a step-wise manner to determine significant predictors. Raw scores for these variables were multiplied by weights derived from the final regression models and combined to create weighted-sum scores. Cut-points between diagnoses were established using ROC curves based on weighted-sum scores. The tool was validated in the remaining subjects through ROC analyses and sensitivity/specificity calculations for each diagnosis.

Results

Age, education, sex, Trails A&B, Logical Memory, Animals, and CVLT were all diagnostic predictors. ROC curves comparing weighted sum scores and consensus diagnoses in the validation set showed good discriminability (NC vs MCI + AD: AUC = .95; AD vs NC + MCI: AUC = .98). Scores of 305.75 predicted AD, MCI, and NC respectively, with good sensitivity/specificity in the validation sample (NC = .857/.913, MCI = .711/.883, AD = .914/.951), with 83% of all subjects correctly classified.

Conclusions

We created a user-friendly diagnostic tool based on demographic and neuropsychological test scores which distinguished between AD, MCI, and NC in an initial validation sample with relatively good accuracy. Results merit replication in other samples, but suggest that this approach may be useful to aid clinical diagnosis, particularly when biomarker data are not available in clinical settings.

Isolation of thermophilic Actinobacteria from compost and identification of bioactive compounds with antimicrobial properties

To combat the problem of antimicrobial resistance, we are testing the hypothesis that thermophilic Actinobacteria produce novel antimicrobials at higher temperatures, with potential activity against life-threatening infections like invasive aspergillosis caused by the fungus Aspergillus fumigatus. Samples from “windrows” at a green waste processing facility yielded 36 potential thermophilic Actinobacterial strains isolated at 50oC, as well as strains of A. fumigatus. The phylogeny and identities of the bacterial strains were determined by 16S rDNA sequencing. Three strains - DJT 15 Streptomyces thermoviolaceus subsp. apingens, DJT 32 Saccharomonospora viridis and DJT 36 Saccharomonospora glauca - have shown inhibitory activity in bioassays against the ESKAPE pathogens, two of which (DJT 32 and 36) also inhibited the growth of the fungal pathogen Aspergillus fumigatus isolated from the same compost. Strain DJT 32 has also been shown to have an inhibitory effect against azole resistant human pathogenic strains of A. fumigatus. Whole genome Sequencing data of DJT 15 and 32 have been used to identify possible biosynthetic gene clusters for antimicrobial compounds (novel or otherwise) through AntiSmash analysis. Alongside this, bioactive compounds have been extracted from broth cultures of each strain using HP-20 Resin method, and the metabolites will be identified using LC:MS combined with metabolic profiling. Extraction and identification of novel metabolites will provide a path for the development of new antimicrobials for clinical use. This study has shown that thermophilic Actinobacteria produce antimicrobial compounds at higher temperatures, against Staphylococcus aureus and against the highly pathogenic fungus, A. fumigatus.

Findings from aetiological investigation of Auditory Neuropathy Spectrum Disorder in children referred to cochlear implant programs

OBJECTIVES

Auditory neuropathy spectrum disorder (ANSD) is an audiological diagnosis characterised by hearing dysfunction in the presence of intact outer hair cell function in the cochlea. ANSD is thought to account for 7-10% of all childhood permanent hearing impairment, and can result from a range of pathological processes. This paper describes the rationale, methods and findings from the aetiological investigation of ANSD.

METHODS

Retrospective audit of four cochlear implant programmes.

RESULTS

97 patients were identified. 79% of patients were identified before the age of one. Prematurity and jaundice were the most frequently identified aetiological factors. 33 patients had cochlear nerve deficiency on imaging. Genetic diagnoses identified included otoferlin, SX010 gene, connexin 26 and A1FM1 gene mutations. ANSD was seen in conjunction with syndromes including Kallman syndrome, CHARGE syndrome, X-linked deafness, SOTOS syndrome, Brown Vieletto Van Laere syndrome, and CAPOS syndrome.

DISCUSSION

We present a two-level system of aetiological investigation that is clinically practical. Patients with ANSD sufficiently severe to consider cochlear implantation are generally identified at an early age. Aetiological investigation is important to guide prognosis and identify comorbidity.

CONCLUSION

Prematurity and jaundice are the most commonly identified aetiological factors in ANSD. Imaging findings identify crucial factors in a significant minority. An important minority may have genetic and syndromic diagnoses that require further management.

Defects in intracellular trafficking of fungal cell wall synthases lead to aberrant host immune recognition

The human fungal pathogen, Cryptococcus neoformans, dramatically alters its cell wall, both in size and composition, upon entering the host. This cell wall remodeling is essential for host immune avoidance by this pathogen. In a genetic screen for mutants with changes in their cell wall, we identified a novel protein, Mar1, that controls cell wall organization and immune evasion. Through phenotypic studies of a loss-of-function strain, we have demonstrated that the mar1Δ mutant has an aberrant cell surface and a defect in polysaccharide capsule attachment, resulting in attenuated virulence. Furthermore, the mar1Δ mutant displays increased staining for exposed cell wall chitin and chitosan when the cells are grown in host-like tissue culture conditions. However, HPLC analysis of whole cell walls and RT-PCR analysis of cell wall synthase genes demonstrated that this increased chitin exposure is likely due to decreased levels of glucans and mannans in the outer cell wall layers. We observed that the Mar1 protein differentially localizes to cellular membranes in a condition dependent manner, and we have further shown that the mar1Δ mutant displays defects in intracellular trafficking, resulting in a mislocalization of the β-glucan synthase catalytic subunit, Fks1. These cell surface changes influence the host-pathogen interaction, resulting in increased macrophage activation to microbial challenge in vitro. We established that several host innate immune signaling proteins are required for the observed macrophage activation, including the Card9 and MyD88 adaptor proteins, as well as the Dectin-1 and TLR2 pattern recognition receptors. These studies explore novel mechanisms by which a microbial pathogen regulates its cell surface in response to the host, as well as how dysregulation of this adaptive response leads to defective immune avoidance.

Group therapy for people with bulimia nervosa: systematic review and meta-analysis

BACKGROUND

Approximately 25% of people with bulimia nervosa (BN) who undertake therapy are treated in groups. National guidelines do not discriminate between group and individual therapy, yet each has potential advantages and disadvantages and it is unclear how their effects compare. We therefore evaluated how group therapy for BN compares with individual therapy, no treatment, or other therapies, in terms of remission from binges and binge frequency.

METHOD

We performed a systematic review and meta-analysis of randomized controlled trials of group therapies for BN, following standard guidelines.

RESULTS

A total of 10 studies were included. Studies were generally small with unclear risk of bias. There was low-quality evidence of a clinically relevant advantage for group cognitive behavioural therapy (CBT) over no treatment at therapy end. Remission was more likely with group CBT versus no treatment [relative risk (RR) 0.77, 95% confidence interval (CI) 0.62-0.96]. Mean weekly binges were lower with group CBT versus no treatment (2.9 v. 6.9, standardized mean difference = -0.56, 95% CI -0.96 to -0.15). One study provided low-quality evidence that group CBT was inferior compared with individual CBT to a clinically relevant degree for remission at therapy end (RR 1.24, 95% CI 1.03-1.50); there was insufficient evidence regarding frequency of binges.

CONCLUSIONS

Conclusions could only be reached for CBT. Low-quality evidence suggests that group CBT is effective compared with no treatment, but there was insufficient or very limited evidence about how group and individual CBT compared. The risk of bias and imprecise estimates of effect invite further research to refine and increase confidence in these findings.

"A computer isn't gonna judge you": a qualitative study of users' views of an internet-based cognitive behavioural guided self-care treatment package for bulimia nervosa and related disorders

Little is known about what determines uptake and acceptability of internet-based treatments in eating disorders, and users' experience with such treatments. We investigated these factors in participants of a randomized controlled trial of an internet-based cognitive- behavioural treatment (iCBT) package (Overcoming bulimia online). Nine participants were interviewed using purposive sampling. The content of interviews were analyzed using thematic analysis. Additionally, participants received questionnaires about their impressions of iCBT. Participants talked about their experience of using iCBT, its impact and compared it to other treatments. Questionnaire responses echoed themes identified in the interviews. iCBT was received positively as a way of fitting treatment into busy lives. Comments on the layout of some of the package content and the practitioner support offered were identified as areas that could be modified or improved.

A randomized controlled trial of internet-based cognitive-behavioural therapy for bulimia nervosa or related disorders in a student population

BACKGROUND

Bulimic eating disorders are common among female students, yet the majority do not access effective treatment. Internet-based cognitive-behavioural therapy (iCBT) may be able to bridge this gap.

METHOD

Seventy-six students with bulimia nervosa (BN) or eating disorder not otherwise specified (EDNOS) were randomly assigned to immediate iCBT with e-mail support over 3 months or to a 3-month waiting list followed by iCBT [waiting list/delayed treatment control (WL/DTC)]. ED outcomes were assessed with the Eating Disorder Examination (EDE) at baseline, 3 months and 6 months. Other outcomes included depression, anxiety and quality of life.

RESULTS

Students who had immediate iCBT showed significantly greater improvements at 3 and 6 months than those receiving WL/DTC in ED and other symptoms.

CONCLUSIONS

iCBT with e-mail support is efficacious in students with bulimic disorders and has lasting effects.

First Report of Raceme Blight Caused by Cladosporium cladosporioides on Macadamia Nuts in South Africa

In September of 2005 and 2006, macadamia (Macadamia integrifolia Maiden & Betche) orchards in Tzaneen, Modjadji, Politsi, and Levubu in the Northern Province and Kiepersol in Mpumalanga, South Africa were surveyed and sampled to determine the causal agent of raceme blight. Symptoms appeared during early bloom and were present on racemes of all developmental stages. Early signs were necrotic tips of the peduncle that often curved to one side with necrosis spreading upward, resulting in the so-called "rat tail". Unopened flowers were also affected. In severe cases, the entire inflorescence (flowers and peduncle) was necrotic and eventually flowers abscised. Occasionally, infection began with single flowers as small water-soaked specks on the flower, with no symptoms on the green peduncle. Diseased racemes were covered with olive gray patches of mycelia and abundant conidia. Flowers with blight symptoms were collected, surface disinfested with 70% ethanol for 2 min, and left to dry. Thirty isolations were made from the interface of the lesion and healthy tissue, plated onto 50% potato dextrose agar (PDA) (Biolab, Merck Laboratories, Wadeville, South Africa) with 19 g of agar per liter, and incubated at 25°C for 5 days. Direct isolations from diseased material were done by picking up conidia and placing them on PDA. A fungus was isolated consistently and identified morphologically as Cladosporium cladosporioides (Fresen.) de Vries based on the velvety olive-brown with almost black reverse colony color and dimensions and color of conidia and conidiophores. Conidia formed in long branched chains that readily disarticulate, mostly aseptate, elliptical to limoniform, 3 to 10.5 (3 to 7) × 2 to 5 (3 to 4) μm. Conidia were pale to olive brown and smooth to verruculose. Ramoconidia were 0-1 septate, 2.5 to 5 μm wide, up to 28 μm long, smooth or sometimes minutely verruculose. Conidiophores were pale to olive brown, macro- and micronemateus, smooth or sometimes verruculose, and of various lengths up to 320 μm long and 2 to 6 μm wide. To confirm pathogen identity, the ITS 1 and ITS 4 regions were sequenced, which had 100% homology to the 18S rRNA of C. cladosporioides (GenBank Accession No. DQ 124142.1). Pathogenicity trials were conducted in the field. Fungal isolates were grown on PDA for 6 days, spores were harvested, and a suspension was made (10⁶ spores ml^-1). Twenty macadamia inflorescences (cv. Beaumont) were dipped in the suspension for 1 s, covered with plastic bags containing wet cotton wool, and covered with paper bags. Inflorescences in different stages (petal fall, knee stage, and closed) were inoculated. Control treatments were dipped in sterile water. After 2 to 3 days, the bags were removed. Symptoms developed on all 20 inflorescences and in all cases, the bottom of the inflorescence blighted, resulting in the typical rat tail symptom. C. cladosporioides was reisolated from all surface-disinfested infected material plated on PDA. Control inflorescences developed no symptoms. Isolate PPRI 8376 was deposited with the National Collection of Fungi, Plant Protection Research Institute, Pretoria, South Africa. The disease is prevalent during wet periods and 5 to 10% of flowers were infected. The disease has increasingly been seen in orchards over the last two seasons and under favorable wet, humid conditions, severe infections have resulted in 100% flower loss. To our knowledge, this is the first report of C. cladosporioides causing raceme blight on macadamia in South Africa.

Inoculation of female American black bears (Ursus americanus) with partially purified porcine zona pellucidae limits cub production

The present 2-year study investigated the feasibility of using porcine zona pellucidae (pZP) as antigen for immunocontraception in American black bears. Sows, 3–6 years of age, were administered either two doses of 250 µg pZP with Freund’s adjuvant (n = 10) or adjuvant alone (n = 5), one in April and one in May, and were kept away from the boars until June. Serum samples were collected before injections and before denning (November). The presence of sows with cubs at side was observed during premature emergence from denning. First-year results indicated that anti-pZP antibody titres in vaccinated sows were 2.5–9.0-fold (range) higher compared with non-vaccinated sows and that the vaccinated sows were threefold less likely to become pregnant (P = 0.167). Control and vaccinated bears produced 1.6 and 0.2 cubs per sow, respectively (P = 0.06). The second-year study investigated the feasibility of using pZP sequestered in a controlled-release pellet and a water-soluble adjuvant (QS-21) to avoid regulatory problems associated with Freund’s adjuvant. Sows in the treatment group (n = 22) were administered a single dose of an emulsion of 250 µg pZP and 150 μg QS-21 plus a pellet containing 70–90 µg pZP for delayed release as booster dose. Control sows (n = 5) received the QS-21 adjuvant in pellet alone. Serum samples were collected before inoculations (April) and before denning (November). Seven cubs were born to the five control sows, but none was born to the 22 vaccinated sows (P < 0.001). Anti-pZP antibody mean absorbance ratios in control sows remained at background levels, whereas vaccinated sows had ratios fourfold higher than controls. Two-dimensional polyacrylamide gel electrophoresis and immunohistochemical localisation confirmed immunoreactivity of sera from inoculated bears. We conclude that cub production in the American black bear can be effectively limited with either two injections of 250 μg pZP or a single inoculation of partially purified pZP sequestered in controlled-release pellets.

Psychiatric comorbidities in patients with Parkinson disease and psychosis

OBJECTIVE

To determine the prevalence and impact of comorbid psychiatric disturbances in Parkinson disease (PD) patients with psychosis.

METHODS

Subject data were derived from a research database of 116 PD patients participating in standardized motor, cognitive, psychiatric, and caregiver assessments.

RESULTS

There were 25 patients (22%) with psychosis manifest as hallucinations (n = 9), delusions (n = 1), or hallucinations and delusions (n = 15) and 25 patients (22%) who had no current or past psychiatric comorbidities (PDN). In the psychotic group, 44% had psychosis only (PSY), and 56% had psychosis plus at least one other comorbid psychiatric disturbance (PSY+), including depressive disorders (71%), anxiety disorders (21%), apathetic syndromes (14%), and delirium (14%). There were no differences in age, sex, education, or age onset or duration of PD among the PSY, PSY+, and PDN groups. Both psychotic groups had greater motor, functional, and frontal cognitive deficits and increased caregiver burden scores relative to PDN. PSY+ showed greater global and selective cognitive deficits compared to PDN. Psychosis was a primary predictor of caregiver burden, whereas depressive symptoms indirectly enhanced motor impairments.

CONCLUSIONS

Nonpsychotic psychiatric disturbances, especially affective disturbances, are common comorbidities in PD patients with psychosis and warrant clinical attention to reduce morbidity and caregiver distress.

Characteristics of rare or recently described corynebacterium species recovered from human clinical material in Canada

Nineteen new Corynebacterium species or taxa described since 1995 have been associated with human disease. We report the characteristics of 72 strains identified as or most closely resembling 14 of these newer, medically relevant Corynebacterium species or taxa, as well as describe in brief an isolate of Corynebacterium bovis, a rare pathogen for humans. The bacteria studied in this report were nearly all derived from human clinical specimens and were identified by a polyphasic approach. Most were characterized by nearly full 16S rRNA gene sequence analysis. Some isolates were recovered from previously unreported sources and exhibited unusual phenotypes or represented the first isolates found outside Europe. Products of fermentation, with emphasis on the presence or absence of propionic acid, were also studied in order to provide an additional characteristic with which to differentiate among phenotypically similar species.

Risk assessment of packaging materials

Risk assessment of packaging materials provides a unique challenge. Human exposure to packaging materials and/or their components occurs from migration into foods. There are various methods for determining migration into foods. Unlike most food additives, these exposures typically are very small. Because of this, and since complete toxicological data sets are not always available for packaging materials, the US Food and Drug Administration (FDA) has developed a process to make the evaluation of packaging materials more efficient, instead of the extensive review normally required for food additives. This process is used to determine 'when the likelihood or extent of migration to food of a substance used in a food-contact article is so trivial as not to require regulation of the substance as a food additive'. This trivial level, also known as the threshold of regulation, was based upon a large database of carcinogenic potencies and was determined to be 1.5 microg/person day(-1). This was determined to 'be low enough to ensure that the public health is protected, even in the event that a substance exempted from regulation as a food additive is later found to be a carcinogen'. Substances not having structural alerts, or that are not known carcinogens or potent toxins, based on existing toxicological information, and are below the threshold value, are considered by the FDA to be exempted from regulation as food additives. The threshold of regulation approach used by the FDA provides an excellent model by which to evaluate the majority of packaging materials.

Helicobacter winghamensis sp. nov., a novel Helicobacter sp. isolated from patients with gastroenteritis

From 1997 to 1999 seven isolates of Campylobacter-like organisms from five patients that were exhibiting symptoms of gastroenteritis, including fever, stomach malaise, and diarrhea, were investigated. The organisms were isolated from stool samples and found to exhibit a diverse colony morphology; hence multiple isolates were submitted from one of the patients. All isolates were found to be identical. The organisms were catalase, urease, alkaline phosphatase, and nitrate negative but oxidase and indoxyl acetate positive. They grew at 37 degrees C but not at 42 degrees C, and three of the isolates from two different patients were sensitive to nalidixic acid and cephalothin. Full 16S rRNA sequence analysis not only grouped these organisms within the Helicobacter genus but also differentiated them from previously identified Helicobacter species. The closest relative by phylogenetic analysis was Helicobacter sp. flexispira taxon 1. Electron microscopy showed that these isolates had one or two bipolar flagella; however, the periplasmic fibers, a characteristic of the known Helicobacter sp. flexispira taxa, were not observed. The present isolates also lacked a flagellar sheath, a trait shared with four other Helicobacter spp., H. canadensis, H. mesocricetorum, H. pullorum, and H. rodentium. On the basis of the unique phenotypic properties of these isolates and 16S rRNA sequence analysis, we propose the classification of a new Helicobacter species, Helicobacter winghamensis sp. nov.

Novel splice site mutation in keratin 1 underlies mild epidermolytic palmoplantar keratoderma in three kindreds

We report a novel mutation in the exon 6 splice donor site of keratin 1 (G4134A) that segregates with a palmoplantar keratoderma in three kindreds. The nucleotide substitution leads to the utilization of a novel in-frame splice site 54 bases downstream of the mutation with the subsequent insertion of 18 amino acids into the 2B rod domain. This mutation appears to have a milder effect than previously described mutations in the helix initiation and termination sequence on the function of the rod domain, with regard to filament assembly and stability. Affected individuals displayed only mild focal epidermolysis in the spinous layer of palmoplantar epidermis, in comparison with cases of bullous congenital ichthyosiform erythroderma also due to keratin 1 mutations, which show widespread and severe epidermolysis. This study describes a novel mutation in KRT1 that results in a phenotype distinct from classical bullous congenital ichthyosiform erythroderma.

Disease severity and symptoms of depression in Black Americans infected with HIV

The purpose of this study was to examine depressive symptomatology in a sample of human immunodeficiency virus (HIV) infected Black Americans and to determine the extent to which measures of HIV disease severity were associated with depressive symptoms. Seventy-nine HIV-infected Black men and women (ages 25 to 68 years) participated. Measures included the Center for Epidemiologic Studies Depression Scale (CES-D) and multiple HIV disease severity variables including CD4+ lymphocyte count, CDC HIV stage, and HIV RNA viral load. Levels of self-reported depressive symptoms were high, with 58% (n = 48/79) of study participants exhibiting elevated depressive symptoms (CES-D score of > or =16). No relationship was found between CD4+ count, CDC HIV stage, sociodemographic variables, and depressive symptoms. Viral load, however, was positively correlated with elevated depressive symptoms. Although the level of depressive symptomatology was high, only two participants were receiving antidepressant medication. This study suggests that there is a significant unmet need for identification and treatment of depressive symptoms among Blacks receiving routine care for HIV disease.

Abnormal regulation of the oestrogen receptor in benign breast lesions

BACKGROUND

In normal breast tissue the oestrogen receptor (ER) and the proliferation associated antigen Ki67 are negatively associated, indicating that ER+ cells are non-dividing, or that the receptor is downregulated as cells enter cycle. This relation is completely or partially lost in many ER+ breast cancers and in in situ proliferations associated with an increased cancer risk, where coexpression of the two markers is often found.

AIMS

To determine whether similar changes can be identified in other risk associated breast lesions.

PATIENTS/METHODS

Paraffin wax blocks from 12 cases of lactational change, 21 apocrine metaplasias, 22 duct ectasias, 20 sclerosing adenosis, 20 fibroadenomas, 19 phyllodes tumours, 20 radial scars, 21 papillomas (15 solitary and six multiple), 15 gynaecomastias, and nine postmortem male breast tissues were retrieved. Immunohistochemistry was used to determine the expression of ER and dual labelling immunofluorescence was used to detect cells expressing both ER and Ki67.

RESULTS

Increased numbers of ER+ cells were seen in sclerosing adenosis, radial scars, papillomas, fibroadenomas, and phyllodes tumours but not in apocrine cysts (where no ER+ cells were detected) or duct ectasia (where normal numbers were found). As in the normal breast, the proportion of ER+ cells increased with age in all lesions with the exception of fibroadenomas. Coexpression of ER and Ki67 was found in an increased proportion of cells of all risk associated lesions studied. ER+ cells were less likely to be dividing than ER- cells in all cases, although this was significant only for sclerosing adenosis. The data on sclerosing adenosis, radial scars, papillomas, and fibroadenomas are comparable with those reported previously in hyperplasia of usual type, whereas those in duct ectasia are similar to those of the normal breast. The findings in all lesions, however, differed from those in ductal carcinoma in situ, where proportions of ER+ and ER+/Ki67+ cells are higher and the relation between ER+ cell numbers and age is lost. Thus, the nature and degree of dysregulation of ER in benign breast lesions is broadly in accordance with the degree of risk of developing breast cancer with which they are associated. In gynaecomastia, the proportions of ER+ and ER+/Ki67+ cells were comparable with those seen in benign female breast lesions, but changes with age were not observed. However, the changes in gynaecomastia were similar to those seen in normal male breast.

CONCLUSION

These findings are in keeping with the contention that the dissociation of ER and Ki67 expression is a very early change in the pathway to many breast cancers. However, this change might only have preneoplastic importance in the hormonal milieu of the female breast.

Cyclosporine A inhibits lymphocyte migration into ovine peripheral nerve allografts

Lymphocyte migration into nerve allografts was measured to estimate the cyclosporine A (CsA) dose required to suppress rejection. Twelve outbred sheep received daily subcutaneous CsA at 0, 5, 10, or 15 mg/kg/day for 2 weeks prior to implantation of multiple heterotopic subcutaneous nerve grafts. Lymphocyte migration was determined after 7 days by an intravenous pulse of autologous 111indium-labeled lymphocytes and subsequent quantitation of gamma radioactivity in nerve tissue (CPM/g, mean +/- SEM). Measurement by radioimmunoassay revealed a dose-dependent increase in blood cyclosporine levels. Lymphocyte migration into autografts (404+/-44) was significantly less than migration into allografts (16,554+/-2,049), in control animals (P < 0.01). A dose-dependent inhibition of lymphocyte migration into nerve allografts was observed with counts of 7,662+/-1,692, 4,083+/-1,112, and 1,561+/-232 in sheep receiving 5, 10, or 15 mg/kg/day of CsA, respectively. Daily CsA administration produced effective blood levels and immunosuppression sufficient to inhibit lymphocyte migration into nerve allografts.

Mapping of monilethrix to the type II keratin gene cluster at chromosome 12q13 in three new families, including one with variable expressivity

Monilethrix is an autosomal dominant disorder chiefly affecting hair. The degree of hair dystrophy is highly variable, as is the presence of additional features, such as follicular keratoses. In three British families of monilethrix, linkage has recently been reported to the type II keratin gene cluster at chromosome 12q13, and it has been suggested that the disease is due to a defect in the hard keratins of hair and nail. If monilethrix is a keratin disorder, we would predict that some pedigrees might map to the type I keratin gene cluster on 17q where hard keratin genes are also found. We have now studied clinically and by linkage analysis three new and unrelated pedigrees from England, Scotland and Spain, the first of which showed a variant phenotype. In this family the disease was expressed in four of 12 cases only as a follicular-keratosis of the neck, elbows and knees, and without clinical or historical evidence of hair anomalies; non-penetrance in an obligate carrier was also observed. In all three families, we have established linkage to a series of microsatellite markers at the type II locus at 12q13 (Zmax = 6.34 at theta = 0.00 for D12S368) and have excluded linkage from the type I keratin gene cluster on 17q. It remains probable that monilethrix is a disorder of hard keratins, but at present there is no evidence that it is due to defects in type I keratins.

Identification of the tuberous sclerosis gene TSC1 on chromosome 9q34

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by the widespread development of distinctive tumors termed hamartomas. TSC-determining loci have been mapped to chromosomes 9q34 (TSC1) and 16p13 (TSC2). The TSC1 gene was identified from a 900-kilobase region containing at least 30 genes. The 8.6-kilobase TSC1 transcript is widely expressed and encodes a protein of 130 kilodaltons (hamartin) that has homology to a putative yeast protein of unknown function. Thirty-two distinct mutations were identified in TSC1, 30 of which were truncating, and a single mutation (2105delAAAG) was seen in six apparently unrelated patients. In one of these six, a somatic mutation in the wild-type allele was found in a TSC-associated renal carcinoma, which suggests that hamartin acts as a tumor suppressor.

Contamination in expressed breast milk following breast cleansing

The purpose of this study was to determine if preexpression breast cleansing reduced the bacterial count in expressed breast milk. The study involved the collection of 178 breast milk samples (89 matched samples); 38 matched samples were from mothers of term infants and 51 matched samples were from mothers of preterm infants. One half of the samples were collected following breast cleansing with Phisoderm and tap water. The other half were collected following breast cleansing with tap water only. Hand and equipment washing with Phisoderm and tap water preceded all sample collections. Storage containers were sterile. Samples were cultured for pathogenic and nonpathogenic bacteria and examined at 24 and 48 hours. Data were analyzed by Wilcoxon Matched-Pairs sign test and Chi square. Breast cleansing with Phisoderm and water was not more effective than water alone at reducing nonpathogenic bacteria or eliminating pathogenic bacteria. Mothers of preterm infants had higher levels of both nonpathogenic and pathogenic bacteria than mothers of full-term infants. The most common form of bacterial contamination was coagulase-negative Staphylococcus epidermidis. This particular bacteria is found in higher levels in the stools of breast fed infants than formula fed infants and it also the most common contaminant found in the blood of preterm infants who develop sepsis. The findings of this study reveal that chemical interventions may not be effective at rendering breast milk free from pathogenic bacteria. More research is needed to determine the optimal cleansing protocol to achieve bacterial decontamination of breast milk or to determine the clinically acceptable level of contamination based on the effects on infants.

The Chronic Pain Grade questionnaire: validation and reliability in postal research

The Chronic Pain Grade questionnaire has been proposed as an interview-administered, multi-dimensional measure of chronic pain severity in selected populations with chronic pain in the United States of America. It has not previously been tested in the United Kingdom, in self-completion form or in an unselected general population. We undertook a postal survey to assess its reliability, validity and acceptability in these circumstances, using a general practice population in Scotland, with a practice population of 11202 patients. A random sample of 400 patients aged over 18 was drawn, stratified for age, gender and receipt or non-receipt of regular prescriptions for pain-relieving medication. The dimensions and sub-scales of the Chronic Pain Grade were compared with the SF-36 general health questionnaire and questions relating to duration of any pain and attempts to seek treatment for this. The methodological approach proposed by Streiner and Norman (1989) was used to assess validity and reliability. A response rate of 76% was achieved. Cronbach's alpha was > 0.9 and item-total correlations were all high, indicating good internal consistency and reliability. Validity was confirmed by psychometric testing, including confirmatory factor analysis. Good correlations with comparable dimensions of the SF-36 general health questionnaire confirmed convergent validity. Construct validity was confirmed by testing scores against duration of pain and treatment sought for pain. We concluded that the Chronic Pain Grade questionnaire is a useful, reliable and valid measure of severity of chronic pain. It translates well into UK English and is acceptable in general population postal research.

Genes associated with dimorphism and virulence ofCandida albicans

Strategies for the analysis of a range of Candida albicans genes, whose expression is regulated during the yeast to hyphal transition (dimorphism), including genes encoding putative virulence factors, are reviewed. To help discriminate among genes whose products were the cause or consequence of dimorphism, temporal changes in the levels of the mRNAs of these and other genes were examined by northern analysis. The mRNA levels of most genes that were examined increased or decreased, transiently or persistently indicating complex alterations in gene expression during morphogenesis. Genes encoding four glycolytic enzymes were regulated transcriptionally during dimorphism but control experiments indicated no direct correlation with germ tube formation. Two chitin synthase genes (CHS2 and CHS3) and three aspartyl proteinase genes (SAP4–SAP6) were transcribed preferentially in the hyphal form, but in these cases hypha-specific expression was shown to be strain dependent or medium dependent, respectively. A gene, HYR1 (for hyphal regulation), was isolated and found to exhibit strict hypha-specific expression in a range of strains under a range of culture conditions. The ura-blaster protocol was used to generate disruptions in CHS2, CHS1, and HSP90 (for heat-shock protein). The homozygous CHS2 disruption did not affect the kinetics of germ-tube formation markedly but resulted in hyphae with a reduced chitin content. In contrast, homozygous null mutations in CHS1 and HSP90 were apparently lethal because no homozygous null strains were isolated after integrative transformation of heterozygous mutants. The analysis of candidate genes for dimorphism and virulence of C. albicans through northern analysis and gene disruption should facilitate an understanding of these processes at the molecular level. Key words: Candida, dimorphism, gene regulation, virulence.

Prognostic stratification in critically ill patients with acute renal failure requiring dialysis

BACKGROUND

Despite the widespread availability of dialytic and intensive care unit technology, the probability of early mortality in critically ill persons with acute renal failure is distressingly high. Previous efforts to predict outcome in this population have been limited by small sample size and the absence of uniform exclusion criteria. Additionally, data obtained decades ago may not apply today owing to changes in case mix.

METHODS

The medical records of 132 consecutive patients in the intensive care unit with acute renal failure who required dialysis from 1991 through 1993 were evaluated by a blinded reviewer.

RESULTS

The overall in-hospital mortality rate was 70%. Twelve readily available historical, clinical, and laboratory variables were significantly associated with in-hospital mortality. Multivariate logistic regression analysis showed that mechanical ventilation, malignancy, and nonrespiratory organ system failure were independently associated with in-hospital mortality. Using a 95% positivity criterion, this model identified 24% of high-risk patients who died, without misclassification of any survivors. Of those who survived to hospital discharge, 33% were dialysis dependent and 28% were institutionalized long-term.

CONCLUSIONS

Among critically ill patients, acute renal failure requiring dialysis is an ominous condition with a high risk of in-hospital mortality. This risk appears to depend largely on comorbid conditions, such as the need for mechanical ventilation and underlying malignancy. While this prognostic model requires prospective validation, it appears to identify a substantial fraction of patients for whom dialysis may be of limited or no benefit.

Can the Hospital Anxiety and Depression (HAD) Scale be used on Chinese elderly in general practice?

A study was carried out in a general practice in Hong Kong to find out if the Hospital Anxiety and Depression (HAD) Scale could be used to detect psychological problems in Chinese elderly. The HAD Scale was translated into Cantonese and administered by an interviewer to 298 Chinese aged 60 or above before their doctor consultations. The acceptance rate of the Scale was 96% and each interview took only 5-10 min to complete. All 298 elderly understood and completed the HAD Scale. Validation of the results of the HAD Scale by the Clinical Interview Schedule (CIS) was done on a random sample of 100 elderly. Relative operating characteristic (ROC) analysis showed that the optimal cut-off points of the HAD Scale was a depression score of 6 and an anxiety score of 3. The sensitivity was 80%, specificity was 90%, OMR (overall misclassification rate) was 12%, positive predictive value was 67% and negative predictive value was 95%. Thirty-six per cent of the elderly had scores above these cut-off points. More females than males had high anxiety scores. Nearly half of those with positive HAD scores were not known to have any psychological illness. The HAD Scale has great potential to be used as a screening instrument for psychological illnesses in Cantonese-speaking Chinese elderly all over the world.

Cutaneous Mycobacterium kansasii infection: case report and review

A case of cutaneous Mycobacterium kansasii infection is reported, and 28 similar cases are reviewed. Cutaneous infection may resemble sporotrichosis and is often associated with systemic illness, immunosuppression, skin pathology, or contact with contaminated water. Immunosuppressed patients with M. kansasii infection may present with atypical clinical features (such as cellulitis and seroma) and atypical histology (absence of granulomas), which may delay diagnosis and effective treatment. The incidence of disseminated M. kansasii infection, which has a worse prognosis, is higher among immunosuppressed patients. When M. kansasii infection is confined to the skin, the disease is usually indolent. Chemotherapy with a variety of agents, including traditional antituberculous agents as well as erythromycin, minocycline, and doxycycline, has been successful, although in vitro resistance to isoniazid and p-aminosalicylic acid is common. Reducing the dose of corticosteroids may be a beneficial adjunct to therapy for M. kansasii infection.

Self-medication among Hong Kong Chinese

A randomized telephone survey on the practice of self-medication in the preceding 2 weeks was carried out from October 1989 to April 1990 among Chinese living in Hong Kong. 1068 people were interviewed. Self-medication was a common and universal practice by Hong Kong Chinese with a prevalence of 32.5% in 2 weeks. Those who reported illness were significantly more likely than those who did not use self-medication (65 vs 18.2%) and to have used more than one item of medications (39 vs 20%). Chinese tonics were the most frequently used self-medications although they were the least known. Chinese medicines were used as often as Western medicines in the self-treatment of illnesses. People used self-medication mainly because they felt that they knew what to do. About 80% of the Western and Chinese medicines were perceived to be effective but only 49% of the tonics were reported so. Side effects were reported from all types of medications with an overall prevalence of 6.4%. There was a lack of knowledge of the possible side effects in over 96% of the self-medications which is an area for patient education. The popularity but the relative lack of knowledge of Chinese tonics call for more scientific research and better regulation on their sales.

Prostaglandin induction of abortion in pregnant bitches after misalliance

Of 48 privately-owned bitches evaluated 30 to 35 days after a single, unplanned breeding, 30 (62%) dogs were determined not to be pregnant by abdominal ultrasonography and 18 dogs were confirmed to be pregnant. Each pregnant dog was hospitalized, allotted to a treatment group, and given prostaglandin F2 alpha, SC, at 1 of 3 dosages: group 1, 0.1 mg/kg of body weight, every 8 hours; group 2, 0.25 mg/kg, every 12 hours; and group 3, 0.1 mg/kg, every 8 hours for 2 days and then 0.2 mg/kg every 8 hours thereafter. Plasma from each dog was assayed for progesterone concentration before treatment and daily until abortion was completed. Physical examinations and abdominal ultrasonography were performed every 12 and 48 hours, respectively. Treatment was continued until abortion was complete as determined by results of abdominal ultrasonography. Ultrasonography was performed earlier than the scheduled 48 hours if abdominal contractions, fetuses, or bloody or dark colored vaginal discharge was observed. Dogs of 14 breeds were treated; body weight ranged from 5.4 to 37.7 kg. All dogs aborted all fetuses within 9 days of beginning treatment. Abdominal palpation was not satisfactory in confirming whether the abortion process had been completed; however, results of ultrasonography were a reliable indicator. Plasma progesterone concentrations prior to treatment were typical of the middle phase of gestation, with all concentrations > 6.0 ng/ml. The plasma progesterone concentration decreased significantly in each dog after the first 48 hours of therapy. None of the bitches aborted any fetal material until at least 24 hours after the plasma progesterone concentration was < 2.0 ng/ml.(ABSTRACT TRUNCATED AT 250 WORDS)