Nosocomial acute-onset postoperative endophthalmitis survey. A 10-year review of incidence and outcomes

OBJECTIVE

The purpose of the study was to evaluate the incidence of acute-onset (within 6 weeks after surgery) postoperative endophthalmitis and to assess the visual acuity outcomes after treatment over a 10-year period at one institution.

PATIENTS AND METHODS

This retrospective study reviews all surgical cases performed between January 1, 1984 and December 30, 1994 at the Anne Bates Leach Eye Hospital, Bascom Palmer Eye Institute, University of Miami Medical Center, for the occurrence of nosocomial acute-onset postoperative endophthalmitis.

RESULTS

The overall 10-year incidence of acute-onset postoperative endophthalmitis after intraocular surgery was 0.093% (54/58, 123). The incidences of culture-proven acute-onset postoperative endophthalmitis by surgical category were as follows: cataract surgery with or without intraocular lens (IOL) (0.082%, 34/41, 654), pars plana vitrectomy (PPV) (0.046%, 3/6557), penetrating keratoplasty (0.178%, 5/2805), secondary IOL placement (0.366%, 5/1367), glaucoma surgeries (0.124%, 4/3233), combined trabeculectomy and cataract surgery (0.114%, 2/1743), and combined penetrating keratoplasty and cataract surgery (0.194%, 1/515). The median visual acuity after endophthalmitis treatment was 20/200. The median visual acuities after endophthalmitis treatment by procedure were as follows: cataract surgery with or without IOL (20/133), PPV (no light perception), penetrating keratoplasty (2/200), secondary IOL implantation (20/40), glaucoma surgery (20/80), and combined trabeculectomy and cataract surgery with or without IOL (20/150).

CONCLUSIONS

The overall incidence of endophthalmitis after intraocular surgery was 0.093%. The incidence of endophthalmitis was higher after secondary IOL implantation than after cataract extraction (P = 0.008, Fisher's exact test). After treatment, the visual acuity outcomes were worse in the patients who developed endophthalmitis after PPV than after cataract extraction, glaucoma procedures, or secondary IOL implantation (P < 0.05, analysis of variance, Duncan's multiple range test). Acuity outcomes after treatment of endophthalmitis were better among the patients with secondary IOL implantation than after penetrating keratoplasty or PPV (P < 0.05, analysis of variance, Duncan's multiple range test). The results of this 10-year review from a large teaching center may serve as a source of comparison for other centers and future studies.

Identification of alpha v beta 3 as a heterotypic ligand for CD31/PECAM-1

CD31 (PECAM-1) is a member of the immunoglobulin gene superfamily (IgSF) and has an important role in a number of endothelial cell functions including angiogenesis, inflammation, integrin activation and cell-cell adhesion. CD31 has both homotypic and heterotypic adhesive properties and in common with other IgSF members contains multiple functional domains. Using chimaeric fusion proteins of CD31 and a panel of haematopoietic cell lines we show that CD31 can bind cells in a predominantly homotypic or heterotypic manner depending on the cell line used. Heterotypic binding was found to be cation and temperature dependent and enhanced by Mn2+: all features of integrin mediated binding. Using a panel of anti-CD31 and anti-integrin antibodies we show that alpha v beta 3 is a ligand for CD31 on the monocytic cell line U937. The specificity of the interaction between alpha v beta 3 and CD31 was further confirmed by solid phase binding assays and the use of alpha v beta 3 transfected cells which bound CD31 specifically. Furthermore, we have mapped the binding site for alpha v beta 3 to domains 1 and 2 of CD31. The interaction of CD31 with alpha v beta 3 may be important in many aspects of endothelial function including leukocyte-endothelial transmigration and angiogenesis.

Changes in human jaw muscles with age and dental state

The effects of ageing and dental state on the cross-sectional area and density of two jaw muscles, the masseter and medial pterygoid, were investigated using computed tomography. The study involved 84 male and 70 female subjects between the ages of 20 and 90 years. The cross-sectional area of both muscles showed a significant reduction with age; values for female subjects being found in the lower range of the distribution. When consideration was given to the presence or absence of a natural dentition, the cross-sectional area of both muscles in edentulous subjects showed a greater decrease throughout the age range studied. There was a significant decrease in the density of the muscles with increasing age. Previously, this has been interpreted to indicate a progressive increase in fat and fibrous tissue. Subject gender and the absence of teeth appeared to have little effect on this parameter. Changes in the cross-sectional area and density of these muscles would appear to be consistent with a general age related change of muscle tissue in the body as a whole and may specifically indicate a reduction in the masticatory forces which can be or are being utilised by ageing patients, many of whom have no remaining natural dentition.

Residues on both faces of the first immunoglobulin fold contribute to homophilic binding sites of PECAM-1/CD31

CD31 (PECAM-1) is a member of the immunoglobulin superfamily whose extracellular domain is comprised of six immunoglobulin-like domains. It is widely expressed on endothelium, platelets, around 50% of lymphocytes, and cells of myeloid lineage. CD31 has been shown to be involved in interendothelial adhesion and leukocyte-endothelial interactions, particularly during transmigration. CD31-mediated adhesion is complex, because CD31 is capable of mediating both homophilic and multiple heterophilic adhesive interactions. Here we show that the NH2-terminal (membrane-distal) immunoglobulin domain of CD31 is necessary but not sufficient to support stable homophilic adhesion. Key residues forming the binding site within this domain have been identified by analysis of 26 single point mutations, representing the most systematic analysis of a fully homophilic interaction between immunoglobulin superfamily family members to date. This revealed five mutations that affect homophilic binding. Uniquely, the residues involved are exposed on both faces of the immunoglobulin fold, leading us to propose a novel mechanism for CD31 homophilic adhesion.

Perfectionism and suicide ideation in adolescent psychiatric patients

This study was conducted to examine the relations between dimensions of perfectionism and suicide ideation in an adolescent psychiatric sample. A sample of 66 adolescents from an inpatient psychiatric facility completed the Child and Adolescent Perfectionism Scale, the Child's Hopelessness Scale, and the Suicide Ideation Questionnaire. Overall, the results indicated that socially prescribed perfectionism was associated with greater suicide ideation and that it, along with hopelessness, accounted for unique variance in suicide ideation scores. The findings are discussed in terms of their practical and theoretical significance as well as their consistency with similar research with adults.

Communication between general practitioners and consultants: what should their letters contain?

OBJECTIVE

To canvass the views of all general practitioners and consultants working in Newcastle upon Tyne on the content of referral letters and replies, the feasibility of standardising certain aspects of referral letters, and the use of communications data for audit purposes.

DESIGN

A postal questionnaire was sent to all general practitioners and consultants in Newcastle upon Tyne in May 1991. Questions were asked about the clinical and administrative content of letters, the utility of standard categories to state the reason for referral, the idea of using letters for feedback purposes, and communications as a potential topic for professionally led audit.

SETTING

Area served by Newcastle upon Tyne Family Health Services Authority and District Health Authority.

RESULTS

Replies were received from 274 (77%) doctors (115 general practitioners and 159 consultants). A majority (225; 82%) were in favour of items defined as "always important" forming a minimum requirement for referral letters and for consultants' replies. Using standardised categories to state the reason for referral was not endorsed: 102 (89%) general practitioners and 132 (83%) consultants preferred referrers to use their own words. Using referral communications to provide feedback was less popular with consultants (54; 34%) than general practitioners (72; 63%). Finally, a majority of doctors (179; 65%) were in favour of using written communications as a topic for professionally led audit.

CONCLUSIONS

A high degree of consensus exists among clinicians about the content of referral communications. Although doctors may still reject the concept of standardised communications, they have unambiguously endorsed a standard for communication that they can aspire to, and they are prepared to use it as a yardstick for their actual performance.

Evidence for the genetic control of the sodium pump density in HeLa cells

1. HeLa cells were grown in normal and altered growth solutions; the ion contents, volumes, K sensitive ouabain binding, the Na-K-ATPase and the Na and K transport measured.2. Cells grown in 1 x 10(-4)M ethacrynate or low-K media for 24 hr have a raised [Na](i), a decreased [K](i), and an increased ouabain binding. Those grown in low-K also have an increased Na-K-ATPase activity.3. When cells are put into low-K solutions the [Na](i) initially rises to a high value, and then starts to fall some 8 hours later as the ouabain binding increases, suggesting that these additional sites represent working Na pumps. Flux measurements on low-K cells provide some support for this view.4. Experiments in which sorbitol replaced [Na](o) showed that the increased ouabain binding and Na-K-ATPase was related to the increase in [Na](i) rather than the decrease in [K](i) and was not due to a non-specific effect of [K](o) change.5. The protein synthesis inhibitors cycloheximide and puromycin stopped the effect of ethacrynate and low-K solutions on increased ouabain binding. They also decreased the ouabain binding and K influx in normal cells over 24 hr. Cycloheximide had similar effects on Na-K-ATPase in low-K treated and normal cells. These results suggest that protein synthesis is required for the appearance of more ouabain sensitive sites in the cell membrane, both in response to ethacrynate and low-K treatment and for normal replacement during the cell's life.6. The RNA synthesis inhibitors actinomycin D (AMD) and cordycepin had complex effects on ouabain binding in fresh and ethacrynate treated cells. These inhibitors increased the ouabain binding but decreased the K influx. This discrepancy was due to the appearance of ouabain binding sites with different characteristics from normal sites. A limited investigation of this phenomenon was carried out. Probably AMD stops the normal replacement of sites in the membrane.7. These results are consistent with the hypothesis that HeLa cells have a system for controlling the number of Na pumps in their membranes. This system responds to the level of [Na](i) within the cell and involves protein synthesis. It is not clear to what extent the nucleus is normally involved in this process.

Postural orthostatic tachycardia syndrome is an under-recognized condition in chronic fatigue syndrome

BACKGROUND

It has been suggested that postural orthostatic tachycardia syndrome (POTS) be considered in the differential diagnosis of those with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). Currently, measurement of haemodynamic response to standing is not recommended in the UK NICE CFS/ME guidelines.

OBJECTIVES

To determine prevalence of POTS in patients with CFS/ME.

DESIGN

Observational cohort study.

METHODS

Fifty-nine patients with CFS/ME (Fukuda criteria) and 52 age- and sex-matched controls underwent formal autonomic assessment in the cardiovascular laboratory with continuous heart rate and beat-to-beat blood pressure measurement (Task Force, CNSystems, Graz Austria). Haemodynamic responses to standing over 2 min were measured. POTS was defined as symptoms of orthostatic intolerance associated with an increase in heart rate from the supine to upright position of >30 beats per minute or to a heart rate of >120 beats per minute on standing.

RESULTS

Maximum heart rate on standing was significantly higher in the CFS/ME group compared with controls (106 +/- 20 vs. 98 +/- 13; P = 0.02). Of the CFS/ME group, 27% (16/59) had POTS compared with 9% (5) in the control population (P = 0.006). This difference was predominantly related to the increased proportion of those in the CFS/ME group whose heart rate increased to >120 beats per minute on standing (P = 0.0002). Increasing fatigue was associated with increase in heart rate (P = 0.04; r(2) = 0.1).

CONCLUSION

POTS is a frequent finding in patients with CFS/ME. We suggest that clinical evaluation of patients with CFS/ME should include response to standing. Studies are needed to determine the optimum intervention strategy to manage POTS in those with CFS/ME.

Characterization of the dog Agouti gene and a nonagoutimutation in German Shepherd Dogs

The interaction between two genes, Agouti and Melanocortin-1 receptor ( Mc1r), produces diverse pigment patterns in mammals by regulating the type, amount, and distribution pattern of the two pigment types found in mammalian hair: eumelanin (brown/black) and pheomelanin (yellow/red). In domestic dogs ( Canis familiaris), there is a tremendous variation in coat color patterns between and within breeds; however, previous studies suggest that the molecular genetics of pigment-type switching in dogs may differ from that of other mammals. Here we report the identification and characterization of the Agouti gene from domestic dogs, predicted to encode a 131-amino-acid secreted protein 98% identical to the fox homolog, and which maps to chromosome CFA24 in a region of conserved linkage. Comparative analysis of the Doberman Pinscher Agouti cDNA, the fox cDNA, and 180 kb of Doberman Pinscher genomic DNA suggests that, as with laboratory mice, different pigment-type-switching patterns in the canine family are controlled by alternative usage of different promoters and untranslated first exons. A small survey of Labrador Retrievers, Greyhounds, Australian Shepherds, and German Shepherd Dogs did not uncover any polymorphisms, but we identified a single nucleotide variant in black German Shepherd Dogs predicted to cause an Arg-to-Cys substitution at codon 96, which is likely to account for recessive inheritance of a uniform black coat.

Diurnal variation in the effect of chronic mild stress on sucrose intake and preference

Diurnal variation (depression worse in the morning) is one of the diagnostic criteria for the melancholic subtype of major depression. This study examined diurnal variation in the effects of chronic mild stress (CMS), an animal model of depression, by testing Wistar rats at different phases of the light-dark cycle. CMS decreased sucrose intake and sucrose preference in animals tested at the start of the dark phase (the most active period in this nocturnal species), but not in animals tested during the light phase. CMS also decreased body weight in both groups; however, the effects of CMS on sucrose intake in the dark phase were not secondary to body weight changes. On the contrary, loss of body weight led to underestimates in the magnitude of the effects of CMS on sucrose intake. The results support the validity of the CMS procedure as a model of melancholia. The discussion addresses criticisms of this position that have been raised in two recent publications.

Cimetidine and chlorpheniramine in the treatment of chronic idiopathic urticaria: a multi-centre randomized double-blind study

One hundred and twenty patients with chronic idiopathic urticaria, who entered a study at five centres (Sheffield, London, Bristol, Cardiff and Leeds) were treated with therapeutic doses of the H1 antagonist chlorpheniramine for 6 weeks. Histamine H1 non-responders (40 patients) were entered into a double-blind study and received chlorpheniramine plus cimetidine 400 mg q.d.s. (21 patients) or chlorpheniramine plus placebo (19 patients) for a further 8 weeks. The most important response measure was the change from baseline of the total symptom score: an assessment of the number and duration of new weals and degree of itching. There was a statistically significant difference between the average response in the two treatment groups in favour of chlorpheniramine plus cimetidine after 4 and 8 weeks' treatment (P less than 0.05 and P less than 0.01, respectively). No significant side-effects related to treatment were noted.

Osteoporosis in primary biliary cirrhosis revisited

BACKGROUND

Primary biliary cirrhosis (PBC) is increasingly being diagnosed in the earlier non-cholestatic stages of disease. Accepted wisdom has been that PBC is frequently complicated by osteoporosis. Whether this association holds true for the broader spectrum of PBC patients now recognised has not as yet been studied.

AIMS

To examine the extent to which osteoporosis occurs more commonly in PBC patients than in normal individuals of the same age and sex.

DESIGN

Retrospective review of a large cohort of well characterised PBC patients.

PATIENTS

A total of 272 PBC patients with definite or probable PBC followed up for a mean of 10.1 years (total follow up 2726 patient years) who had at least one bone mineral density measurement (BMD).

RESULTS

In this unselected group of PBC patients, mean Z scores (number of SDs from age and sex matched normal mean values) at the neck of femur (NOF) and lumbar spine (LS) at first BMD measurement (7 (6) years after PBC diagnosis) were -0.1 (1.4) and 0.1 (1.4), respectively. At first BMD measurement, 18 PBC patients had Z scores less than -2.0 and 85 had T scores less than -2.5. No factors predictive of osteoporosis were found in affected patients. A total of 957 BMD measurements were performed (0.35 per patient year of follow up); 220 patients had two or more measurements. No patient went on to develop de novo osteoporosis during follow up. In the 51 patients (who were clinically representative of the whole group) who received no PBC or bone related treatment during follow up, %BMD changes per year at the NOF and LS were -1.6 (3.2) and 0.1 (2.2), respectively. No variance in this "natural" rate of BMD measurement was seen in patients receiving PBC modulating agents (including prednisolone and UDCA) or osteoporosis prophylaxis/therapy. Significant improvement at the LS was seen in patients undergoing liver transplantation.

CONCLUSIONS

Osteoporosis is not a specific complication of PBC.

Painful knee but not hand osteoarthritis is an independent predictor of mortality over 23 years follow-up of a population-based cohort of middle-aged women

To assess whether joint pain or radiographic osteoarthritis (ROA) of the knee and hand is associated with all-cause and disease-specific mortality in middle-aged women.

METHODS

Four subgroups from the prospective community-based Chingford Cohort Study were identified based on presence/absence of pain and ROA at baseline: (Pain-/ROA-; Pain+/ROA-; Pain-/ROA+; Pain+/ROA+). Pain was defined as side-specific pain in the preceding month, while side-specific ROA was defined as Kellgren-Lawrence grade ≥2. All-cause, cardiovascular disease (CVD) and cancer-related mortality over the 23-year follow-up was based on information collected by the Office for National Statistics. Associations between subgroups and all-cause/cause-specific mortality were assessed using Cox regression, adjusting for age, body mass index, typical cardiovascular risk factors, occupation, past physical activity, existing CVD disease, glucose levels and medication use.

RESULTS

821 and 808 women were included for knee and hand analyses, respectively. Compared with the knee Pain-/ROA- group, the Pain+/ROA- group had an increased risk of CVD-specific mortality (HR 2.93 (95% CI 1.47 to 5.85)), while the knee Pain+/ROA+ group had an increased HR of 1.97 (95% CI 1.23 to 3.17) for all-cause and 3.57 (95% CI 1.53 to 8.34) for CVD-specific mortality. We found no association between hand OA and mortality.

CONCLUSION

We found a significantly increased risk of all-cause and CVD-specific mortality in women experiencing knee pain with or without ROA but not ROA alone. No relationship was found between hand OA and mortality risk. This suggests that knee pain, more than structural changes of OA is the main driver of excess mortality in patients with OA.

High throughput liquid chromatography/mass spectrometry bioanalysis using 96-well disk solid phase extraction plate for the sample preparation

The 96 well solid phase extraction (SPE) operated by robot in the LC/MS/MS bioanalysis offered rapid sample preparation for drugs and metabolites in biological matrices, based on simultaneous extraction of 96 samples. The use of a disk as sorbent in the 96 well plate further improved the performance of SPE and allowed for small elution volumes, making it possible to 'dilute and shoot" after SPE elution. In this study, a 96 well plate (Empore) was developed, characterized and optimized for several pharmaceutical compounds. In addition, a robot (MultiProbe) was modified to automate the 96 well plate operation. Examples were given to illustrate the major differences of using 96 well disk plate SPE in the method development as compared to the traditional SPE. This technology has been successfully used to support many clinical studies. Typically, a batch of 96 samples were prepared in 1-1.5 hours unattended (except for the replacement of a collection plate). Considerable savings in disposable supplies were also noted.

Homophilic PECAM-1(CD31) interactions prevent endothelial cell apoptosis but do not support cell spreading or migration

PECAM-1 (CD31) is a highly abundant cell surface glycoprotein expressed on haemopoietic and endothelial cells. As well as mediating homophilic (PECAM-1/PECAM-1) adhesion, PECAM-1 can also bind the integrin alphavbeta3. Both PECAM-1 and alphavbeta3 have been shown to have roles in regulating angiogenesis, endothelial tube formation and in the case of alphavbeta3, endothelial cell apoptosis. In this study we show that despite being expressed at equivalent levels, endothelial alphavbeta3 is not a ligand for PECAM-1. Rather, PECAM-1 supports homophilic binding on HUVEC with similar characteristics to those we have previously reported for leukocytes and becomes tyrosine phosphorylated after homophilic PECAM-1 and integrin/fibronectin engagement. Immunoprecipitation studies show that in addition to SHP-2, tyrosine phosphorylated PECAM-1 can interact with at least four other phosphoproteins in pervanadate stimulated HUVEC. While PECAM-1/PECAM-1 interactions support robust endothelial cell adhesion, they do not support cell spreading or migration. In addition PECAM-1 homophilic adhesion rescues HUVEC from serum deprivation-induced apoptosis. Taken together our results indicate that PECAM-1 homophilic interactions play an important role in interendothelial cell adhesion, survival and signalling.

SK&F 86002: a structurally novel anti-inflammatory agent that inhibits lipoxygenase- and cyclooxygenase-mediated metabolism of arachidonic acid

The effects of SK&F 86002 [5-(4-pyridyl)-6 (4-fluorophenyl)-2,3-dihydroimidazo (2,1-b) thiazole] on the generation of eicosanoids in vitro and on inflammatory responses in vivo are described and compared to other non-steroidal anti-inflammatory drugs. SK&F 86002 inhibited prostaglandin H2 (PGH2) synthase activity (IC50 120 microM) as well as prostanoid production by rat basophilic leukemia (RBL-1) cells (IC50 70 microM) and its sonicate (IC50 100 microM) and human monocytes (IC50 1 microM). In addition, SK&F 86002 inhibited the generation of dihydroxyeicosatetraenoic acid (diHETE) and 5-hydroxyeicosatetraenoic acid (5-HETE) by a high speed supernatant fraction of RBL-1 cells (IC50 10 microM). Cellular production of 5-lipoxygenase products was inhibited by SK&F 86002 as measured by leukotriene B4 (LTB4) generation from human neutrophils (IC50 20 microM), leukotriene C4 (LTC4) generation by human monocytes (IC50 20 microM), and 5-HETE production by RBL-1 cells (IC50 40 microM). The in vivo profile of anti-inflammatory activity of SK&F 86002 supports the dual inhibition of arachidonate metabolism as indicated by its activity in inflammation models that are insensitive to selective cyclooxygenase inhibitors. The responses of arachidonic-acid-induced edema in the mouse ear and rat paw, as well as the cell infiltration induced by carrageenan in the mouse peritoneum and by arachidonic acid in the rat air pouch, were inhibited by SK&F 86002 and phenidone but not by the selective cyclooxygenase inhibitors naproxen and indomethacin.

CD31 (PECAM-1) exists as a dimer and is heavily N-glycosylated

CD31 (PECAM-1) is a highly abundant cell surface glycoprotein expressed on hemopoietic and endothelial cells where it functions as a homophilic adhesion and signaling receptor. Since dimerization and appropriate glycosylation are important features in the regulation of cell surface interactions and signal transduction, we studied the pattern of glycosylation as well as the ability of CD31 to undergo dimerization, both in solution and when expressed on cell membranes. CD31 is heavily glycosylated, with an approximate carbohydrate content of 21%. Nineteen neutral and thirteen sialylated glycans were identified. Ultracentrifugation analysis showed that soluble recombinant CD31 exists in equilibrium between a monomer and a dimer with an approximate dissociation constant of 12.5 microM. Chemical cross-linking studies of both soluble and membrane-expressed CD31 confirmed that CD31 exists as a dimer. These studies suggest that, like E-cadherin, PECAM-dimerization is likely to play a role in CD31 adhesion and signaling.

Analysis of IL10 haplotypic associations with severe malaria

We investigated the association between severe malaria and genetic variation of IL10 in Gambian children, as several lines of evidence indicate that IL10 is protective against severe malaria and that IL10 production is genetically determined. We began by identifying five informative SNPs in the Gambian population that were genotyped in a combined case-control and intrafamilial study including 654 cases of severe malaria, 579 sets of parents and 459 ethnically matched controls. No significant associations were identified with individual SNPs. One haplotype of frequency 0.11 was strongly associated with protection against severe malaria in the case-control analysis (odds ratio 0.52, P=0.00002), but the transmission disequilibrium test in families showed no significant effect. These findings raise the question of whether IL10 associations with severe malaria might be confounded by foetal survival rates or other sources of transmission bias.

An immunologic evaluation of hemophiliac patients and their wives. Relationships to the acquired immunodeficiency syndrome

Recently, hemophiliac patients receiving factor VIII concentrate therapy have developed the acquired immunodeficiency syndrome. Because abnormalities of cell-mediated immunity are found in this syndrome, we evaluated the peripheral blood immunologic status of 24 patients with classic hemophilia and 5 patients with factor IX deficiency. Both groups had decreased percentages and numbers of helper-inducer lymphocytes (OKT4+) and increased percentages of suppressor-cytotoxic T-lymphocytes (OKT8+) which resulted in depressed OKT4/T8 ratios. Abnormalities of the T-lymphocyte subpopulation were most severe in 7 patients with factor VIII deficiency with lymphadenopathy who also had increased Ia+ cells and profoundly suppressed lymphocyte mitogenic responses. No correlation was found between OKT4/OKT8 ratios or lymphocyte responses to mitogen and the amount of factor VIII concentrate used per year. Evaluation of five wives of factor-VIII-deficient patients who had abnormal OKT4/OKT8 ratios showed decreased percentages of OKT4 cells, but normal lymphocyte mitogenic responses. Serum levels of IgG were elevated in factor-VIII-deficient patients but not their wives or factor-IX-deficient patients. We conclude that T-lymphocyte subpopulation abnormalities and lymphocyte mitogenic responses are depressed in asymptomatic hemophiliac patients receiving either factor VIII or factor IX concentrates. These abnormalities are most severe in otherwise asymptomatic hemophiliac patients who have developed lymphadenopathy.

Aquatic environmental DNA: A review of the macro-organismal biomonitoring revolution

Environmental DNA (eDNA) is the fastest growing biomonitoring tool fuelled by two key features: time efficiency and sensitivity. Technological advancements allow rapid biodiversity detection at both species and community levels with increasing accuracy. Concurrently, there has been a global demand to standardise eDNA methods, but this is only possible with an in-depth overview of the technological advancements and a discussion of the pros and cons of available methods. We therefore conducted a systematic literature review of 407 peer-reviewed papers on aquatic eDNA published between 2012 and 2021. We observed a gradual increase in the annual number of publications from four (2012) to 28 (2018), followed by a rapid growth to 124 publications in 2021. This was mirrored by a tremendous diversification of methods in all aspects of the eDNA workflow. For example, in 2012 only freezing was applied to preserve filter samples, whereas we recorded 12 different preservation methods in the 2021 literature. Despite an ongoing standardisation debate in the eDNA community, the field is seemingly moving fast in the opposite direction and we discuss the reasons and implications. Moreover, by compiling the largest PCR-primer database to date, we provide information on 522 and 141 published species-specific and metabarcoding primers targeting a wide range of aquatic organisms. This works as a user-friendly 'distillation' of primer information that was hitherto scattered across hundreds of papers, but the list also reflects which taxa are commonly studied with eDNA technology in aquatic environments such as fish and amphibians, and reveals that groups such as corals, plankton and algae are under-studied. Efforts to improve sampling and extraction methods, primer specificity and reference databases are crucial to capture these ecologically important taxa in future eDNA biomonitoring surveys. In a rapidly diversifying field, this review synthetises aquatic eDNA procedures and can guide eDNA users towards best practice.

Factors influencing general practitioners' referral decisions

This paper presents some findings from a small scale qualitative study of referral decision making conducted in south-east Northumberland in 1988-89. The study was prompted by an interest in variability in referral rates and the view that existing studies had not attempted to understand referral from the perspective of those involved in making the decisions. Our findings suggest that such understandings are crucial in the analysis of referral decisions and in any policy making initiatives designed to influence the pattern of referring.