NHS Diabetes guideline for the perioperative management of the adult patient with diabetes

These Joint British Diabetes Societies guidelines, commissioned by NHS Diabetes, for the perioperative management of the adult patient undergoing surgery are available in full in the Supporting Information. This document goes through the seven stages of the patient journey when having surgery. These are: primary care referral; surgical outpatients; preoperative assessment; hospital admission; surgery; post-operative care; discharge. Each stage is given its own considerations, outlining the roles and responsibilities of each group of healthcare professionals. The evidence base for the recommendations made at each stage, discussion of controversial areas and references are provided in the report. This document has two key recommendations. Firstly, that the management of the elective adult surgery patients should be with modification to their usual diabetes treatment if the fasting is minimized because the routine use of a variable rate intravenous insulin infusion is not recommended. Secondly, that poor preoperative glycaemic control leads to post-outcomes and thus, where appropriate, needs to be addressed prior to referral for surgery.

How to improve the efficiency of veterinary laboratories

Veterinary laboratories around the globe are currently facing a number of important challenges. These challenges include an ageing workforce, lack of trained veterinary specialists, increased stringency for test validation, increasing emphasis on quality management, safety standards and certified accreditation processes, increasing regulation and audit processes and high costs of replacement infrastructure. Importantly, increased collaboration and linkages are high on the agenda in most countries to enhance efficiency within the sector. In Australia, mechanisms are in place to deal with some of these issues, and it is likely similar mechanisms are being used in other countries. The issues and some possible solutions are discussed.

Regulation of Th2 cytokine gene transcription

Because of the different functions of IL-4, IL-13 and IL-5, it would perhaps be surprising if common transcriptional mechanisms occur. However, because of the physical proximity of their genes within the human 5q locus, chromatin remodelling during T-cell differentiation may make transcription of all the genes permissible. If co-ordinate regulation were to take place, it might be argued that similar factors might be involved in expression of all of the cytokines. Emerging data on c-Maf and GATA3 regulation of IL-4 and IL-5 respectively argues that diverse proteins may be required for transcriptional activation. Alternatively, these factors may be responsible for regulating transcriptional competence, allowing fine control over generation of particular cytokines depending upon recognition of physiological cues. If competent for transcription, common factors, such as members of the NFAT and/or AP-1 families, may operate to regulate cytokine levels. To support this, we have recently identified a conserved palindrome located within the promoters of the different Th2-type cytokines, which acts as an enhancer of transcription. Central to the capacity to express Th2 cytokines is likely to be the ability to remodel chromatin at the locus. It remains to be determined whether a single factor, or combination of factors acts to regulate this event. It is also unclear what the boundaries of remodelling within the locus are, i.e. whether IL-4 and IL-13 may be within open chromatin and IL-5 in a closed environment, and whether there is a hierarchy which determines whether particular cytokines are preferentially expressed irrespective of competence.

White matter lesions and season of birth of patients with bipolar affective disorder

OBJECTIVE

It is established that patients with bipolar disorder have an excess of births in winter or early spring. The authors investigated a link between season of birth and white matter lesions with magnetic resonance imaging (MRI).

METHOD

T(2)-weighted and proton density MRI scans were examined for 79 patients with bipolar disorder (DSM-IV) for the presence of deep subcortical and periventricular white matter lesions. The birth seasons of patients with white matter lesions were compared with those of the general population.

RESULTS

Thirteen subjects exhibited deep subcortical white matter lesions, of whom nine (69.2%) were born in the winter months (January to March). Seven of these patients remained symptomatic, despite adequate treatment for more than 2 years.

CONCLUSIONS

Birth season, illness outcome, and deep subcortical white matter lesions appear to be closely linked. Deep subcortical white matter lesions may be a marker of a toxic or infective insult in utero.

Spacer oligonucleotide typing of bacteria of the Mycobacterium tuberculosis complex: recommendations for standardised nomenclature

Spacer oligonucleotide typing (spoligotyping) is widely used for differentiation of bacteria of the Mycobacterium tuberculosis complex. However, the absence of any standardised method for concise description of spoligotypes makes it difficult to compare the results from different laboratories. This paper describes unambiguous, interconvertible systems for the designation of spoligotype patterns, the adoption of which will be beneficial to mycobacterial research.

Disseminated Mycobacterium avium infection in a dog with chronic diarrhoea

A 3-year-old Maltese-cross dog presented with a 4-month history of chronic diarrhoea and inappetence. Poorly regenerative anaemia, leukocytosis and hypoproteinaemia were evident on several occasions. Biopsies of stomach, duodenum and colon revealed marked infiltration of mucosae by macrophages containing many acid-fast bacilli. Similar organisms were numerous in a faecal smear. Melaena, hematochezia and severe abdominal pain developed and were unresponsive to therapy. Following euthanasia and necropsy, histiocytic cells containing acid-fast bacilli were found throughout the gastrointestinal tract, mesenteric and peripheral lymph nodes, spleen, liver, kidney and lungs. The organism was identified as Mycobacterium avium by bacterial culture and polymerase chain reaction testing.

Mycobacterium tuberculosis subsp. caprae subsp. nov.: a taxonomic study of a new member of the Mycobacterium tuberculosis complex isolated from goats in Spain

Isolates from the Mycobacterium tuberculosis complex cultured from caprine pathological tissue samples were biochemically and genetically characterized. The isolates were negative for nitrate reduction and niacin accumulation, they weakly hydrolysed Tween 80, were sensitive to pyrazinamide (50 micrograms ml-1) and were resistant to 1 and 2 micrograms tiophene-2-carboxylic acid hydrazide ml-1 but not to 5 or 10 micrograms tiophene-2-carboxylic acid hydrazide ml-1. Sequencing of the pncA gene revealed a polymorphism characteristic of M. tuberculosis, whereas oxyR, katG and gyrA sequences were characteristic of Mycobacterium bovis. The fingerprinting patterns obtained with IS6110, direct repeats and polymorphic G+C-rich sequence-associated RFLP and direct variable repeat-spacer oligonucelotide typing (spoligotyping) segregated these isolates from the other members of the complex. The results of this testing, together with the repeated association of this micro-organism with goats, suggest that a new member of this taxonomic complex not matching any of the classical species had been identified. This unusual mycobacterium may play a role in the epidemiology of animal and human tuberculosis in Spain. The name Mycobacterium tuberculosis subsp. caprae subsp. nov. is proposed for these isolates. The type strain of Mycobacterium tuberculosis subsp. caprae subsp. nov. is gM-1T (= CIP 105776T).

Comparison of serological tests and faecal culture for the detection of Mycobacterium avium subsp. paratuberculosis infection in cattle and analysis of the antigens involved

Three hundred and forty-one sera from cattle in Western Australia and 106 sera from Mycobacterium paratuberculosis faecal culture positive cattle were used to evaluate the performance of two absorbed enzyme-linked immunosorbent assays (ELISA) (one locally produced, the other a commercial test) and a complement fixation test (CFT) for the detection of Johne's disease in cattle. The diagnostic sensitivity (47.2%) of the local ELISA was significantly higher than that of the commercial ELISA (31.1%), and significantly higher than that for the complement fixation test (17.9%) and immunoblot (20.8%). Diagnostic specificity for the two ELISAs was 99.7% and 97.9% and similar for CFT and immunoblot (97.1% and 97.7%, respectively). The diagnostic sensitivity rose for both ELISAs and the CFT as the number of M. paratuberculosis isolated from the faeces increased. The ELISA antigen was characterised by polyacrylamide gel electrophoresis and electrophoretic immunoblotting and was found to consist mostly of a carbohydrate-type macromolecule of 32-42 kDa. This macromolecule was identified as lipoarabinomannan (LAM) by using a LAM-specific monoclonal antibody in immunoblots and purified LAM in absorption experiments. By applying more complex antigen preparations in immunoblots, serum antibodies against proteins of 47, 37, 30, 24 and 21 kDa, and against the 32-42 kDa carbohydrate component were frequently found in infected cattle, and of these the 47 kDa protein and the 32-42 kDa antigen were immuno-dominant. Pre-absorption of the sera with M. phlei sonicate indicated that the protein antigens contributed markedly to non-specific serological cross-reactions, while the 32-42 kDa non-protein macromolecule appeared to be specific.

PCR-restriction endonuclease analysis for identification and strain typing of Mycobacterium avium subsp. paratuberculosis and Mycobacterium avium subsp. avium based on polymorphisms in IS1311

Point mutations in the IS 1311 sequences from sheep and cattle strains of Mycobacterium avium subsp. paratuberculosis (M. paratuberculosis) and M. avium subsp. avium (M. avium) were targeted to develop a polymerase chain reaction (PCR) that would be useful in the diagnosis and control of Johne's disease. Candidate PCR tests were evaluated for sensitivity, specificity and ease of interpretation of the restriction endonuclease analysis (REA) products. One IS 1311 PCR, amplifying a 608 base pair product, was shown to be suitable when the amplified product was digested with Hinf I and Mse I. The PCR detected 50 fg of template DNA from M. paratuberculosis strain 316 V, the equivalent of 10 organisms. The test was evaluated further using purified DNA from M. paratuberculosis and M. avium isolates and diagnostic samples including primary radiometric cultures. All 89 M. paratuberculosis samples were correctly identified and typed according to host species or IS 900 restriction fragment length polymorphism (RFLP) type. All 28 isolates of M. avium were also correctly identified. A second PCR/REA strategy based on a shorter fragment of IS 1311 was developed for formalin-fixed paraffin-embedded tissue samples. It correctly differentiated sheep and cattle strains of M. paratuberculosis in 27 tissue samples in which acid fast bacilli had been observed in Ziehl Neelsen stains and in which sufficient amplified product was present for REA with Hinf I. Both tests were specific for M. paratuberculosis when tested against 24 other mycobacterial species. These simple and rapid tests can be used on a range of diagnostic samples for the confirmation of Johne's disease and will be of benefit in control and eradication programmes for this disease.

Polymorphisms in IS1311, an insertion sequence common to Mycobacterium avium and M. avium subsp. paratuberculosis, can be used to distinguish between and within these species

IS1311 is an insertion sequence from Mycobacterium avium and M. avium subsp. paratuberculosis. Using a 180 bp fragment of IS 1311 as a probe, 7-10 copies of IS1311 were revealed in strains of M. avium subsp. paratuberculosis. With a given restriction enzyme, the restriction fragment length polymorphism patterns obtained from isolates of M. avium subsp. paratuberculosis from cattle were all identical, but they differed from those of isolates from sheep, which could be separated into two types. A 1259 bp fragment of IS1311 produced by polymerase chain reaction (PCR) from two isolates of M. avium subsp.paratuberculosis from cattle and two isolates from sheep was sequenced and compared to the sequence known from M. avium. Apart from five point differences the sequences were identical. Restriction endonuclease analysis (REA) of the PCR product was used to distinguish isolates of M. avium subsp. paratuberculosis from M. avium, in addition to the conventional test for IS900. In isolates of M. avium subsp. paratuberculosis from cattle the IS1311 gene was polymorphic at position 223, which enabled isolates from sheep and cattle to be distinguished by PCR-REA. These simple tests will be used to enhance disease control programmes for Johne's disease in ruminants. The findings of this study raise interesting questions about the evolution of M. avium subsp. paratuberculosis.

Restriction fragment length polymorphism and spacer oligonucleotide typing: a comparative analysis of fingerprinting strategies for Mycobacterium bovis

The combination of conventional investigation and DNA fingerprinting is yielding important insights into the epidemiology of Mycobacterium bovis infections. Various genetic markers used in restriction fragment length polymorphism (RFLP) have recently been exploited for fingerprinting of M. bovis isolates. The newly developed spacer oligonucleotide typing aimed to investigate the polymorphism of M. tuberculosis in the DR locus, has also been applied to the molecular typing of M. bovis isolates. This work compared the performance of the insertion sequence (IS) IS6110, IS1081 and the genetic elements polymorphic G + C-rich repeat (PGRS) and direct repeat (DR) used in RFLP analysis with spoligotyping using a group of 128 Spanish M. bovis isolates. In this study, the most sensitive technique for identifying polymorphism in M. bovis was PGRS-RFLP, closely followed by IS6110-RFLP. We propose several schemes for fingerprinting of these isolates, however, the clear geographical variations found by different authors makes the study of each local situation indispensable. An international consensus in the methods used would be desirable for efficient interlaboratory comparison of strains.

Zoonotic tuberculosis due to Mycobacterium bovis in developing countries

The World Health Organization (WHO) estimates that human tuberculosis (TB) incidence and deaths for 1990 to 1999 will be 88 million and 30 million, respectively, with most cases in developing countries. Zoonotic TB (caused by Mycobacterium bovis) is present in animals in most developing countries where surveillance and control activities are often inadequate or unavailable; therefore, many epidemiologic and public health aspects of infection remain largely unknown. We review available information on zoonotic TB in developing countries, analyze risk factors that may play a role in the disease, review recent WHO activities, and recommend actions to assess the magnitude of the problem and control the disease in humans and animals.

Evaluation of four DNA typing techniques in epidemiological investigations of bovine tuberculosis

DNA fingerprinting techniques were used to type 273 isolates of Mycobacterium bovis from Australia, Canada, the Republic of Ireland, and Iran. The results of restriction fragment length polymorphism (RFLP) analysis with DNA probes from IS6110, the direct repeat (DR), and the polymorphic GC-rich sequence (PGRS) were compared with those of a new PCR-based method called spacer oligonucleotide typing (spoligotyping) developed for the rapid typing of Mycobacterium tuberculosis (J. Kamerbeek et al., J. Clin. Microbiol. 35:907-914, 1997). Eighty-five percent of the isolates harbored a single copy of IS6110, and 81.5% of these carried IS6110 on the characteristic 1.9-kb restriction fragment. RFLP analysis with IS6110 identified 23 different types, RFLP analysis with the DR probe identified 35 types, RFLP analysis with the PGRS probe identified 77 types, and the spoligotyping method identified 35 types. By combining all results, 99 different strains could be identified. Isolate clusters were frequently associated within herds or were found between herds when epidemiological evidence confirmed animal movements. RFLP analysis with IS6110 was sufficiently sensitive for the typing of isolates with more than three copies of IS6110, but RFLP analysis with the PGRS probe was the most sensitive typing technique for strains with only a single copy of IS6110. Spoligotyping may have advantages for the rapid typing of M. bovis, but it needs to be made more sensitive.

Reliability and validity of hospital pharmacists' clinical intervention data

The reliability and validity of pharmacist intervention data documented at a hospital in England were studied. The study involved intervention data recorded from September 1 to December 31 in 1990 (a pilot study), 1991, and 1992 by a total of 23 pharmacists. The interventions in 1990 were coded by a single pharmacist manager and compared with coding by pharmacists of their own interventions during 1991 and 1992. To test for internal reliability of the intervention data, 25% (584) of the 2342 interventions recorded in 1991 and 1992 were randomly sampled after interventions by the 11 pharmacists no longer at the site were eliminated. In September 1993 the 12 remaining pharmacists were asked to recode the interventions they had previously entered. In March 1994 a panel of 12 pharmacists recoded 62 interventions randomly selected from the 684 recoded interventions. Each panel member also assigned financial values to interventions. Medical records corresponding to the 62 recoded interventions were inspected for evidence of the interventions. The distribution of interventions among the drug-use-process (DUP) indicators used in the coding differed significantly between 1990 (when a manager assigned all codes) and 1991 plus 1992 (when pharmacists coded their own interventions). There were similar differences between 1991 and 1992. Results from code-recode and panel testing showed the DUP indicators to be reliable. Clinical outcome indicators were unreliable, as were financial indicators. Medical records verified the occurrence of 50 (81%) of the 62 interventions selected, but in only one case was there evidence that the change in drug therapy was initiated by a pharmacist. The capacity of pharmacists at a British hospital to reliably code interventions was poor.

The insertion element IS 6110 is a useful tool for DNA fingerprinting of Mycobacterium bovis isolates from cattle and goats in Spain

A total of 129 Mycobacterium bovis strains from 5 different Spanish locations were fingerprinted using the IS6110 repetitive element. We demonstrated the presence of multiple copies (from 2 to 13) of IS6110 in a large proportion (47.4%) of the M.bovis strains isolated from cattle and we showed that these strains can be successfully differentiated by means of the RFLP with IS6110. All of the M. bovis strains isolated from goats had multiple copies of IS6110 and 4 bands of 2, 1.7, 1.4 and 1.3 kb were common in all the caprine RFLP patterns. The caprine strains formed a clearly separate cluster from the bovine strains.

Spacer oligonucleotide typing of Mycobacterium bovis strains from cattle and other animals: a tool for studying epidemiology of tuberculosis

The spacer oligonucleotide typing (spoligotyping) method was evaluated for its ability to differentiate Mycobacterium bovis strains. This method detects the presence or absence of spacers of the direct repeat locus of the M. bovis genome. The spacers in the direct repeat locus are amplified by PCR and are detected by hybridization of the biotin-labelled PCR product with a membrane containing oligonucleotides derived from spacer sequences that have previously been bound to a membrane. One hundred eighty-two M. bovis isolates from domestic animals (cattle, goat, sheep, and cats) and wild animals (deer and wild boar) were spoligotyped, and the results were compared with those obtained by IS6110 restriction fragment length polymorphism analysis. Two rather homogeneous clusters of isolates containing 20 and 4 types, respectively, were identified by spoligotyping. The first cluster included isolates from cattle, cats, and feral animals. By spoligotyping, isolates from the Spanish wild boar and deer had the same pattern as some bovine isolates, suggesting transmission between these animals and cattle and highlighting the importance of the study of these reservoirs. The second cluster included all the caprine and ovine isolates. Within each cluster, the patterns of the different strains differed only slightly, suggesting that the spoligotypes may be characteristic of strains from particular animal species. Spoligotyping proved to be useful for studying the epidemiology of bovine M. bovis isolates, especially of those isolates containing only a single copy of IS6110. In view of our results, we suggest fingerprinting all M. bovis strains by the spoligotyping method initially and then by IS6110 restriction fragment length polymorphism typing of the strains belonging to the most common spoligotypes.

Multiplex PCR provides a low-cost alternative to DNA probe methods for rapid identification of Mycobacterium avium and Mycobacterium intracellulare

A multiplex PCR designed to differentiate Mycobacterium tuberculosis complex organisms from M. avium and M. intracellulare was used to test 105 isolates identified by DNA probe methods as M. avium, M. intracellulare, or M. avium complex type X. The multiple PCR correctly identified 33 of 34 isolates identified by commercial probe methods as M. avium and all 51 isolates identified as M. intracellulare. The 20 isolates identified as M. avium complex type X by probe were identified as Mycobacterium spp. by the multiplex method. These results confirm that the multiplex PCR, which is simple to perform and cheaper than commercial probe methods, is suitable for routine identification of M. avium and M. intracellulare.

Assessment of genetic markers for species differentiation within the Mycobacterium tuberculosis complex

It is important to correctly identify species within the Mycobacterium tuberculosis complex because of the zoonotic implications of bovine tuberculosis, especially in developing countries. We assessed the use of various genetic markers for species-specific identification of mycobacteria from the M. tuberculosis complex. A multiplex PCR designed for detection of the mtp40 and IS1081 elements was optimized and evaluated in 339 mycobacterial strains from different animal and geographic origins. The host range of the IS6110, MPB70, and 16S rRNA genes was also studied by PCR in all the strains. Finally, the usefulness of the genetic markers was compared by an immunoperoxidase test for specific identification of Mycobacterium bovis strains. The mtp40 sequence was detected in 87 of the 91 strains of M. tuberculosis and in 9 of the 11 Mycobacterium africanum strains but not in any of the M. bovis or Mycobacterium microti strains, indicating that the mtp40 element was also found in all of the M. tuberculosis complex strains isolated from seals. This organism is considered to be a true seal pathogen, but its origin is essentially unknown. The finding of the mtp40 element in the strains from seals suggests a closer relationship of these strains with a human origin than to an animal origin. The mtp40 element was not found in any other mycobacterial species included in the study. As a result of this study, we suggest that biochemical tests or alternate genetic markers are still needed to differentiate M. tuberculosis from M. africanum when these species coexist as causative agents of tuberculosis. The immunoperoxidase test worked well for the identification of M. bovis strains. We also report, for the first time, PCR amplification of the repetitive element IS6110 in an isolate of Mycobacterium ulcerans and an isolate of Mycobacterium gilvum, which emphasizes the need for further investigation of the host range of this sequence.

Detection and identification of multiple mycobacterial pathogens by DNA amplification in a single tube

A comparison of the DNA sequence of the 16S rRNA revealed a region in which there was a minor variation between the species of mycobacteria. This information was used to develop a multiplex amplification system that could identify the genus Mycobacterium and then distinguish between M. avium and M. intracellulare, two commonly encountered mycobacteria other than tuberculosis. The combination of these rRNA gene primers together with primers aimed at the MPB70 gene of M. tuberculosis complex organisms permits the detection and identification of clinically significant mycobacteria in a single tube. An amplification product of 1030 bp is indicative of the genus Mycobacterium and smaller fragments of 850, 372, and 180 bp are the positive signals for M. intracellulare, M. tuberculosis complex, and M. avium, respectively.

Moments applied in the manual assembly of space structures: EASE biomechanics results from STS-61B

Measurements of the level and pattern of moments applied in the manual assembly of a space structure were made in extravehicular activity (EVA) and neutral buoyancy simulation (NBS). The Experimental Assembly of Structures in EVA program included the repeated assembly of a 3.6 m tetrahedral truss structure in EVA on STS-61B after extensive neutral buoyancy crew training. The flight and training structures were of equivalent mass and geometry to allow a direct correlation between EVA and NBS performance. A stereo photographic motion camera system was used to reconstruct in three dimensions rotational movements of structural beams during assembly. Moments applied in these manual handling tasks were calculated on the basis of the reconstructed movements taking into account effects of inertia, drag and virtual mass. Applied moments of 2.0 Nm were typical for beam rotations in EVA. Corresponding applied moments in NBS were typically up to five times greater. Moments were applied as impulses separated by several seconds of coasting in both EVA and NBS. Decelerating impulses were only infrequently observed in NBS.

A review of the diets of captive gorillas (Gorilla gorilla)

It is clear that most zoos feed their gorillas a principally frugivorous diet, while the diets of wild gorilla populations are undoubtedly basically herbivorous. The primary food plant of western and eastern lowland gorillas is Aframomum, and Blancou (1955) even maintains that these plants possess active parasiticidal qualities, but this subscription is not borne out by recent research. However, it is possible that another plant food, combretum, could have some propensities as a deparasitant. Many captive gorillas accept cooked or raw meat in their diets and there is some evidence that feral gorillas may also occasionally consume matter of animal origin.