Reference and point-of-care testing for G6PD deficiency: Blood disorder interference, contrived specimens, and fingerstick equivalence and precision

Certain clinical indications and treatments such as the use of rasburicase in cancer therapy and 8-aminoquinolines for Plasmodium vivax malaria treatment would benefit from a point-of-care test for glucose-6-phosphate dehydrogenase (G6PD) deficiency. Three studies were conducted to evaluate the performance of one such test: the STANDARD^™ G6PD Test (SD BIOSENSOR, South Korea). First, biological interference on the test performance was evaluated in specimens with common blood disorders, including high white blood cell (WBC) counts. Second, the test precision on fingerstick specimens was evaluated against five individuals of each, deficient, intermediate, and normal G6PD activity status. Third, clinical performance of the test was evaluated at three point-of-care settings in the United States. The test performed equivalently to the reference assay in specimens with common blood disorders. High WBC count blood samples resulted in overestimation of G6PD activity in both the reference assay and the STANDARD G6PD Test. The STANDARD G6PD Test showed good precision on multiple fingerstick specimens from the same individual. The same G6PD threshold values (U/g Hb) were applied for a semiquantitative interpretation for fingerstick- and venous-derived results. The sensitivity/specificity values (95% confidence intervals) for the test for G6PD deficiency were 100 (92.3–100.0)/97 (95.2–98.2) and 100 (95.7–100.0)/97.4 (95.7–98.5) for venous and capillary specimens, respectively. The same values for females with intermediate (> 30% to ≤ 70%) G6PD activity were 94.1 (71.3–99.9)/88.2 (83.9–91.7) and 82.4 (56.6–96.2)/87.6(83.3–91.2) for venous and capillary specimens, respectively. The STANDARD G6PD Test enables point-of-care testing for G6PD deficiency.

Why foodborne and waterborne parasites are important for veterinarians

Parasites, including helminths and protists, are pathogens responsible for waterborne and foodborne illnesses in both developed and developing countries. Their global incidence is difficult to estimate, but the World Health Organization (WHO) has indicated the global disease burden of 11 waterborne and foodborne parasitic diseases, is responsible for causing over 407 million illnesses resulting in an estimated of 94 K deaths and 11 million disability-adjusted life years (DALYs). Nevertheless, compared with bacteria and viruses, parasites are often overlooked as etiological agents of foodborne or waterborne disease; this is due to a variety of reasons, including the difficulty of their identification in environmental matrices and because many have a prolonged period between infection and symptoms, making it difficult to implicate infection vehicles. This Special Issue comprises 17 articles that include the more significant waterborne and foodborne parasites of zoonotic importance due to their relevance, with all groups of parasites (protist, cestodes, trematodes, and nematodes) being represented. Each chapter covers relevant aspects regarding -the importance of the parasite in food and water, including an overview of outbreaks where relevant, information on fundamental epidemiological aspects such as transmission, lifecycle and host range, clinical aspects such as pathogenesis, diagnosis and treatment, a summary of prospects for control in water or the food chain, and, finally, providing the authors' opinions regarding future research or studies required to improve control of transmission to people via food or water.

Co-design of data collection with participants of the Aberdeen Children of the 1950s cohort study

Background

The Aberdeen Children of the 1950s (ACONF) cohort comprises 12,150 people born in Scotland in the 50s. It contains rich early life data, questionnaire data from mid-life and linked electronic health records. Involving participants in designing future data collection is key to ensure research is acceptable and reflects public priorities.

Aim

Gather ACONF members views to inform how to: research healthy ageing, optimise recruitment and maximise participation.

Methods

3 co-design workshops with 30 ACONF members. A discussion was led by a facilitator using guidance questions developed by the study team. Workshops were recorded and transcribed.

Results

Participants viewed healthy ageing as keeping socially and physically active, taking responsibility for oneself and having a positive attitude to ageing. Research priorities were dementia, improvements in the social care system and engaging hard-to-reach groups. Members were keen for future research involvement. Recruitment may be maximised by: more information online, involving participants in recruiting other study members and clarity about potential benefits to themselves or others. It was acceptable to ask their offspring to participate. There were high levels of trust in researchers, but ongoing data protection is vital. Participation may be improved by regular contact (informing members of results, engagement events, phone “apps”). Participants viewed various data collection methods (questionnaires, applications, wearable devices, in-person tests, DNA collection and electronic record linkage) as acceptable.

Conclusions

Participant involvement is a fundamental part of securing a social license for research. Participants were in favour of ongoing research, including recruitment of their children. The workshops highlighted key considerations for future research and data collection.

Key messages

Co-design is vital for highlighting research topics which are important and relevant to the general population. Co-design can highlight strategies for maximising research participation and securing a social license for research.

New models and taxonomies to understand and address the commercial determinants of health

Current models of the determinants of health risk framing public health problems and solutions in ways that obscure the role that the private sector, in particular large transnational companies, play in shaping population health. This presentation will propose a new conceptual model of the commercial determinants of health which recognises the commercial sector's direct, indirect, upstream and downstream influences on health. It will also present emerging evidence-based taxonomies that draw together evidence on the key corporate practices which stymie the implementation of effective public health policies. In so doing, the presentation will explore how we move from understanding to addressing the commercial determinants of health.

Type 1 interferonopathy presenting as juvenile idiopathic arthritis with interstitial lung disease: report of a new phenotype

BACKGROUND

STING-associated vasculopathy with onset in infancy (SAVI) is a type 1 interferonopathy manifesting as a pulmonary and vascular syndrome resulting from gain-of-function mutations in TMEM173, the gene encoding STING. Familial reports in the literature are sparse.

CASE PRESENTATION

We report a case series of SAVI in a three generation kindred, with a phenotype of interstitial lung disease (ILD) and rheumatoid factor positive polyarticular juvenile idiopathic arthritis (JIA). Current and historical medical records were reviewed for clinical and laboratory information. Whole blood from cases 1 and 2, plus stored appendicectomy tissue from case 3, underwent DNA sequencing of the TMEM173 gene. Peripheral blood RNA was obtained from cases 1 and 2 for functional assessment of the TMEM173 mutation. DNA sequencing identified the same heterozygous TMEM173 mutation (c.463G > A; p.Val155Met) in all three cases, consistent with a diagnosis of the autosomal dominant condition SAVI. Functional assessment of this mutation identified a prominent interferon signature which was confirmed on repeat testing.

CONCLUSIONS

SAVI presented in this family as ILD with early onset juvenile rheumatoid arthritis. This condition should be considered in all rheumatoid arthritis patients with early-onset ILD and in all JIA patients with ILD.

Urban-rural and socioeconomic status: Impact on multimorbidity prevalence in hospitalized patients

OBJECTIVE

The aim of this study was to describe multimorbidity prevalence in hospitalized adults, by urban-rural area of residence and socioeconomic status (SES).

METHODS

Linked hospital episode data were used. Adults (≥18 years) admitted to hospital as an inpatient during 2014 in Grampian, Scotland, were included. Conditions were identified from admissions during the 5 years prior to the first admission in 2014. Multimorbidity was defined as ≥2 conditions and measured using Tonelli et al. based on International Classification of Diseases-10 coding (preselected list of 30 conditions). We used proportions and 95% confidence intervals (CIs) to summarize the prevalence of multimorbidity by age group, sex, urban-rural category and deprivation. The association between multimorbidity and patient characteristics was assessed using the χ 2 test.

RESULTS

Forty one thousand five hundred and forty-five patients were included (median age 62, 52.6% female). Overall, 27.4% (95% CI 27.0, 27.8) of patients were multimorbid. Multimorbidity prevalence was 28.8% (95% CI 28.1, 29.5) in large urban versus 22.0% (95% CI 20.9, 23.3) in remote rural areas and 28.7% (95% CI 27.2, 30.3) in the most deprived versus 26.0% (95% CI 25.2, 26.9) in the least deprived areas. This effect was consistent in all age groups, but not statistically significant in the age group 18-29 years. Multimorbidity increased with age but was similar for males and females.

CONCLUSION

Given the scarcity of research into the effect of urban-rural area and SES on multimorbidity prevalence among hospitalized patients, these findings should inform future research into new models of care, including the consideration of urban-rural area and SES.

Co-design of data collection with participants of the Aberdeen Children of the 1950s cohort study

Background The Aberdeen Children of the 1950s (ACONF) cohort contains 12,150 individuals born in Aberdeen, Scotland in the 1950s. The study includes rich early life data, information from questionnaire in middle age, and linkage to electronic healthcare records. Involving the participants in designing future data collection and research is key to ensure research is acceptable and reflects public priorities. Aim To gather ACONF participants’ views to inform how to: define healthy ageing, optimise recruitment and maximise participation. Method We undertook three co-design workshops with 8 to 10 ACONF members. The workshops operated as a discussion, led by a facilitator using guidance questions developed by the study team. Workshops were recorded and transcribed. Results Healthy ageing: Participants viewed healthy ageing as keeping socially and physically active, taking responsibility for oneself and having a positive attitude to ageing. Key research priorities were: dementia, healthy living advice, improvements in the social care system and engaging hard-to-reach groups. Optimising recruitment and participation: Participants were keen for further involvement in research. Recruitment may be maximised by: more information online, involving participants in recruitment of other study members and clarity about potential benefits to themselves or others. It is acceptable to ask their offspring to participate. There were high levels of trust in researchers, but ongoing data protection is vital. Participation may be improved by regular contact (informing participants of results, engagement events, newsletters, mobile phone “apps”). Participants were happy with data collection methods: questionnaires, applications, wearable devices, and in-person tests. They raised no concerns regarding DNA collection and electronic record linkage. Conclusion Participant involvement in research is a fundamental part of securing a social license for research. Participants were in favour of ongoing research, including recruitment of their children and linkage of electronic records. The workshops highlighted key considerations for future research and data collection.

Study on the effect of phototherapy for inhibition of symptoms associated with allergic rhinitis

Summary

Previous published work has indicated that treatment of the inside of the nose with certain wavelengths of light can reduce the symptoms of allergic rhinitis. The objective of the study was to compare the efficacy of the phototherapy device on the relief of a range of symptoms provoked by indoor and outdoor allergens. A phototherapy emits visible light (mUV/VIS) and infrared light, and was compared to a placebo device which did not emit light on two groups of allergic rhinitis sufferers. Rhinophototherapy improved nasal symptoms of allergic rhinitis arising from exposure to indoor and outdoor allergens. The difference in the intensity of symptoms scored at the baseline, and at the final visit for the group using the photoperiod device was significantly lower. The device could potentially help improve the quality of life for allergy sufferers. Phototherapy may be suitable for sufferers either as a replacement therapy or used alongside traditional medication.

Improving polarized neutron imaging for visualization of the Meissner effect in superconductors

The polarized neutron imaging technique provides a non-invasive method of characterizing localized magnetic fields inside superconductors. However, complete understanding of the magnetic field distribution has yet to be realized experimentally due to the complexity of the interaction between neutron polarization and magnetic field. In this article, we show that a well-defined and controlled magnetic field through the neutron path contributes to simplify the data analysis and makes future quantitative polarized neutron imaging possible. This is demonstrated in a set of experiments that visualize the magnetic field distribution inside and around the superconductors. The experimental results demonstrate that proper guide field setup allows the visualization of the magnetic field expulsion at the surface of the superconductor in the zero-field cooling condition, as well as the magnetic field trapped inside the superconductor under field cooling condition.

Measuring multimorbidity in hospitalised patients using linked hospital episode data: comparison of two measures

Introduction

Multimorbidity is a complex and growing health challenge. There is no accepted “gold standard” multimorbidity measure for hospital resource planning, and few studies have compared measures in hospitalised patients.

Aim

To evaluate operationalisation of two multimorbidity measures in routine hospital episode data in NHS Grampian, Scotland.

Methods

Linked hospital episode data (Scottish Morbidity Record (SMR)) for the years 2009-2016 were used. Adults admitted to hospital as a general/acute inpatient during 2014 were included. Conditions (ICD-10) were identified from general/acute (SMR01) and psychiatric (SMR04) admissions during the five years prior to first admission in 2014. Two count-based multimorbidity measures were used (Charlson Comorbidity Index and Tonelli et al.), and multimorbidity was defined as ≥2 conditions. Kappa statistics assessed agreement. The association between multimorbidity and length of stay, readmission and mortality was assessed using logistic and negative binomial regression as appropriate.

Results

In 41,545 adults (median age 62 years, 52.6% female), multimorbidity prevalence was 15.1% (95% CI 14.8%, 15.5%) using Charlson and 27.4% (27.0%, 27.8%) using Tonelli – agreement 85.1% (Kappa 0.57). Multimorbidity prevalence, using both measures, increased with age. Multimorbidity was higher in males (16.5%) than females (13.9%) using the Charlson measure, but similar across genders when measured with Tonelli. After adjusting for covariates, multimorbidity remained associated with longer length of stay (Charlson IRR 1.1 (1.0, 1.2); Tonelli IRR 1.1 (1.0, 1.2)) and readmission (Charlson OR 2.1 (1.9, 2.2); Tonelli OR 2.1 (2.0, 2.2)). Multimorbidity had a stronger association with mortality when measured using Charlson (OR 2.7 (2.5, 2.9)), than using Tonelli (OR 1.8 (1.7, 2.0)).

Conclusions

Multimorbidity measures operationalised in hospital episode data identified those at risk of poor outcomes and such operationalised tools will be useful for future multimorbidity research and use in secondary care data systems. Multimorbidity measures are not interchangeable, and the choice of measure should depend on the purpose.

Highlights

Weaning practices in phenylketonuria vary between health professionals in Europe

Background

In phenylketonuria (PKU), weaning is considered more challenging when compared to feeding healthy infants. The primary aim of weaning is to gradually replace natural protein from breast milk or standard infant formula with solids containing equivalent phenylalanine (Phe). In addition, a Phe-free second stage L-amino acid supplement is usually recommended from around 6 months to replace Phe-free infant formula. Our aim was to assess different weaning approaches used by health professionals across Europe.

Methods

A cross sectional questionnaire (survey monkey®) composed of 31 multiple and single choice questions was sent to European colleagues caring for inherited metabolic disorders (IMD). Centres were grouped into geographical regions for analysis.

Results

Weaning started at 17–26 weeks in 85% (n = 81/95) of centres, >26 weeks in 12% (n = 11/95) and < 17 weeks in 3% (n = 3/95). Infant's showing an interest in solid foods, and their age, were important determinant factors influencing weaning commencement. 51% (n = 48/95) of centres introduced Phe containing foods at 17–26 weeks and 48% (n = 46/95) at >26 weeks. First solids were mainly low Phe vegetables (59%, n = 56/95) and fruit (34%, n = 32/95).

A Phe exchange system to allocate dietary Phe was used by 52% (n = 49/95) of centres predominantly from Northern and Southern Europe and 48% (n = 46/95) calculated most Phe containing food sources (all centres in Eastern Europe and the majority from Germany and Austria). Some centres used a combination of both methods.

A second stage Phe-free L-amino acid supplement containing a higher protein equivalent was introduced by 41% (n = 39/95) of centres at infant age 26–36 weeks (mainly from Germany, Austria, Northern and Eastern Europe) and 37% (n = 35/95) at infant age > 1y mainly from Southern Europe. 53% (n = 50/95) of centres recommended a second stage Phe-free L-amino acid supplement in a spoonable or semi-solid form.

Conclusions

Weaning strategies vary throughout European PKU centres. There is evidence to suggest that different infant weaning strategies may influence longer term adherence to the PKU diet or acceptance of Phe-free L-amino acid supplements; rendering prospective long-term studies important. It is essential to identify an effective weaning strategy that reduces caregiver burden but is associated with acceptable dietary adherence and optimal infant feeding development.

Models of care for chronic kidney disease: A systematic review

AIM

Chronic kidney disease (CKD) is common and presents an increasing burden to patients and health services. However, the optimal model of care for patients with CKD is unclear. We systematically reviewed the clinical effectiveness of different models of care for the management of CKD.

METHODS

A comprehensive search of eight databases was undertaken for articles published from 1992 to 2016. We included randomized controlled trials that assessed any model of care in the management of adults with pre-dialysis CKD, reporting renal, cardiovascular, mortality and other outcomes. Data extraction and quality assessment was carried out independently by two authors.

RESULTS

Results were summarized narratively. Nine articles (seven studies) were included. Four models of care were identified: nurse-led, multidisciplinary specialist team, pharmacist-led and self-management. Nurse and pharmacist-led care reported improved rates of prescribing of drugs relevant to CKD. Heterogeneity was high between studies and all studies were at high risk of bias. Nurse-led care and multidisciplinary specialist care were associated with small improvements in blood pressure control.

CONCLUSION

Evidence of long term improvements in renal, cardiovascular or mortality endpoints was limited by short follow up. We found little published evidence about the effectiveness of different models of care to guide best practice for service design, although there was some evidence that models of care where health professionals deliver care according to a structured protocol or guideline may improve adherence to treatment targets.

Early feeding practices in infants with phenylketonuria across Europe

Background

In infants with phenylketonuria (PKU), dietary management is based on lowering and titrating phenylalanine (Phe) intake from breast milk or standard infant formula in combination with a Phe-free infant formula in order to maintain blood Phe levels within target range. Professionals use different methods to feed infants with PKU and our survey aimed to document practices across Europe.

Methods

We sent a cross sectional, survey monkey® questionnaire to European health professionals working in IMD. It contained 31 open and multiple-choice questions. The results were analysed according to different geographical regions.

Results

Ninety-five centres from 21 countries responded. Over 60% of centres commenced diet in infants by age 10 days, with 58% of centres implementing newborn screening by day 3 post birth. At diagnosis, infant hospital admission occurred in 61% of metabolic centres, mainly in Eastern, Western and Southern Europe. Breastfeeding fell sharply following diagnosis with only 30% of women still breast feeding at 6 months.

53% of centres gave pre-measured Phe-free infant formula before each breast feed and 23% alternated breast feeds with Phe-free infant formula. With standard infant formula feeds, measured amounts were followed by Phe-free infant formula to satiety in 37% of centres (n = 35/95), whereas 44% (n = 42/95) advised mixing both formulas together. Weaning commenced between 17 and 26 weeks in 85% centres, ≥26 weeks in 12% and < 17 weeks in 3%.

Discussion

This is the largest European survey completed on PKU infant feeding practices. It is evident that practices varied widely across Europe, and the practicalities of infant feeding in PKU received little focus in the PKU European Guidelines (2017). There are few reports comparing different feeding techniques with blood Phe control, Phe fluctuations and growth. Controlled prospective studies are necessary to assess how different infant feeding practices may influence longer term feeding development.

Functional insights into the infective larval stage of Anisakis simplex s.s., Anisakis pegreffii and their hybrids based on gene expression patterns

BACKGROUND

Anisakis simplex sensu stricto and Anisakis pegreffii are sibling species of nematodes parasitic on marine mammals. Zoonotic human infection with third stage infective larvae causes anisakiasis, a debilitating and potentially fatal disease. These 2 species show evidence of hybridisation in geographical areas where they are sympatric. How the species and their hybrids differ is still poorly understood.

RESULTS

Third stage larvae of Anisakis simplex s.s., Anisakis pegreffii and hybrids were sampled from Merluccius merluccius (Teleosti) hosts captured in waters of the FAO 27 geographical area. Specimens of each species and hybrids were distinguished with a diagnostic genetic marker (ITS). RNA was extracted from pools of 10 individuals of each taxon. Transcriptomes were generated using Illumina RNA-Seq, and assembled de novo. A joint assembly (here called merged transcriptome) of all 3 samples was also generated. The inferred transcript sets were functionally annotated and compared globally and also on subsets of secreted proteins and putative allergen families. While intermediary metabolism appeared to be typical for nematodes in the 3 evaluated taxa, their transcriptomes present strong levels of differential expression and enrichment, mainly of transcripts related to metabolic pathways and gene ontologies associated to energy metabolism and other pathways, with significant presence of excreted/secreted proteins, most of them allergens. The allergome of the 2 species and their hybrids has also been thoroughly studied; at least 74 different allergen families were identified in the transcriptomes.

CONCLUSIONS

A. simplex s.s., A. pegreffi and their hybrids differ in gene expression patterns in the L3 stage. Strong parent-of-origin effects were observed: A. pegreffi alleles dominate in the expression patterns of hybrids albeit the latter, and A. pegreffii also display significant differences indicating that hybrids are intermediate biological entities among their parental species, and thus of outstanding interest in the study of speciation in nematodes. Analyses of differential expression based on genes coding for secreted proteins suggests that co-infections presents different repertoires of released protein to the host environment. Both species and their hybrids, share more allergen genes than previously thought and are likely to induce overlapping disease responses.

Comparing two measures of multimorbidity in hospitalised patients

BackgroundMultimorbidity is recognised as a complex and growing health challenge. Currently there is no “gold standard” multimorbidity measure and few studies have compared measures in hospitalised patients. ObjectivesWe aimed to evaluate two published multimorbidity measures in routine hospital episode data in NHS Grampian, Scotland. MethodsWe used the Scottish Morbidity Record (SMR) data for the years 2009-2016. We included all adults admitted to hospital in the Grampian region of Scotland (population 588,100) during 2014. Morbidities were identified from inpatient admissions during the five years prior to admission date in 2014 (ICD-10 codes). Two multimorbidity measures were used: Charlson (Quan 2005), and Tonelli et al (2015); and multimorbidity was defined as ≥2 morbidities. Kappa statistics assessed agreement between the two measures in classifying patients as multimorbid. The association between multimorbidity and mortality, readmissions, and length of stay was examined using regression methods with odds ratios (OR) or incidence rate ratios (IRR) calculated as appropriate. FindingsIn 41,545 adults (median age 62 years, 52.6% female), multimorbidity prevalence was 15.1% (95% CI 14.8%-15.5%) using Charlson and 27.4% (27.0%-27.8%) using Tonelli - agreement 85.1% (Kappa 0.57). After adjusting for covariates, multimorbidity was associated with an increased risk of longer length of stay, (Charlson IRR 1.10 (1.03, 1.18; p=0.005); Tonelli IRR 1.11 (1.04, 1.18; p<0.001)) and readmission (Charlson OR 2.06 (1.94, 2.19; p<0.001); Tonelli OR 2.12 (2.01, 2.22; p<0.001)). Multimorbidity had a higher risk of mortality when measured using Charlson (Charlson OR 2.71 (2.52, 2.92; p=<0.001); Tonelli OR (1.84 (1.72, 1.98; p<0.001)). ConclusionsMultimorbidity measures operationalised in hospital episode data identified those at risk of poor outcomes and will be useful for future multimorbidity research and use in secondary care data systems.

Janus Kinase Inhibitors: A Review of Their Emerging Applications in Dermatology

The class of medications known as Janus kinase inhibitors block cytokine-mediated signaling via the Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway, which plays an important role in immunoregulation and normal cell growth. This class includes the drugs tofacitinib, approved for the treatment of rheumatoid arthritis, and ruxolitinib, approved for the treatment of myelofibrosis and polycythemia rubra vera. The most common adverse events (AEs) reported in patients taking tofacitinib are infections, whereas the most common AEs in patients taking ruxolitinib are anemia and thrombocytopenia. Both first and second generation Janus kinase inhibitors have become promising treatment modalities for dermatologic conditions such as psoriasis, atopic dermatitis, alopecia areata, vilitigo, dermatomyositis, and graft-versus-host disease. Future promising areas of investigation include treatment of cutaneous lupus, cutaneous T-cell lymphoma, melanoma, allergic contact dermatitis, and lichen planus.

Hip fracture incidence and mortality in chronic kidney disease: the GLOMMS-II record linkage cohort study

BACKGROUND

Individuals on renal replacement therapy (RRT) have increased fracture risk, but risk in less advanced chronic kidney disease (CKD) is unclear.

OBJECTIVE

To investigate CKD associations with hip fracture incidence and mortality.

DESIGN

Record linkage cohort study Grampian Laboratory Outcomes Mortality and Morbidity Study II.

SETTING

Single health region in Scotland.

PARTICIPANTS

All individuals (≥15 years) with sustained CKD stages 3-5 and those on RRT, and a 20% random sample of those with normal renal function, in the resident population in 2003.

OUTCOME MEASURES

Outcomes were (1) incident hip fracture measured with (A) admissions or (B) deaths, with at least 5.5 years follow-up and (2) post-hip fracture mortality. Unadjusted and adjusted, incident rate ratios (IRRs) and mortality rate ratios were calculated using Poisson regression.

RESULTS

Of 39 630 individuals identified in 2003 (41% males, mean age 63.3 years), 19 537 had CKD stages 3-5, 345 were on RRT and 19 748 had normal estimated glomerular filtration rate (eGFR). Hip fracture incidence, measured by admissions, was increased in CKD stages 3-5 (compared with normal eGFR), both overall (adjusted IRR 1.49 (95% CI 1.24 to 1.79)) and for individual CKD stages 3a, 3b and 4. Hip fracture incidence, measured using deaths, was increased in those with CKD stages 3b and 4. Post-hip fracture mortality was only increased in CKD stage 4. There was only a small number of individuals and events for CKD stage 5, resulting in insufficient statistical power.

CONCLUSION

Hip fracture incidence was higher in CKD stages 3-5 compared with normal eGFR. Post-hip fracture mortality was only increased in CKD stage 4. Reducing hip fracture incidence in CKD through regular fall and fracture risk review should reduce overall deaths after hip fracture in the population.

Education, substance use, and HIV risk among orphaned adolescents in Eastern Zimbabwe

There is a growing interest in education as a means to reduce HIV infection in vulnerable children in sub-Saharan Africa; however, the mechanisms by which education reduces HIV infection remain uncertain. Substance use has been associated with high-risk sexual behaviour and could lie on the causal pathway between education and HIV risk. Therefore, we used multivariable regression to measure associations between: (i) orphanhood and substance use (alcohol, recreational drugs, and smoking), (ii) substance use and sexual risk behaviours, and (iii) school enrolment and substance use, in adolescents aged 15-19 years, in Eastern Zimbabwe. We found substance use to be low overall (6.4%, 3.2%, and 0.9% of males reported alcohol, drug, and cigarette use; <1% of females reported any substance use), but was more common in male maternal and double orphans than non-orphans. Substance use was positively associated with early sexual debut, number of sexual partners, and engaging in transactional sex, while school enrolment was associated with lower substance use in males. We conclude that education may reduce sexual risk behaviours and HIV infection rates among male adolescents in sub-Saharan Africa, in part, by reducing substance abuse.

Changes in awareness of cancer risk factors among adult New Zealanders (CAANZ): 2001 to 2015

Behaviour change, specifically that which decreases cancer risk, is an essential element of cancer control. Little information is available about how awareness of risk factors may be changing over time. This study describes the awareness of cancer risk behaviours among adult New Zealanders in two cross-sectional studies conducted in 2001 and 2014/5.Telephone interviews were conducted in 2001 (n = 436) and 2014/5 (n = 1064). Participants were asked to recall things they can do to reduce their risk of cancer. They were then presented with a list of potential risk behaviours and asked if these could increase or decrease cancer risk.Most New Zealand adults could identify at least one action they could take to reduce their risk of cancer. However, when asked to provide specific examples, less than a third (in the 2014/5 sample) recalled key cancer risk reduction behaviours such as adequate sun protection, physical activity, healthy weight, limiting alcohol and a diet high in fruit. There had been some promising changes since the 2001 survey, however, with significant increases in awareness that adequate sun protection, avoiding sunbeds/solaria, healthy weight, limiting red meat and alcohol, and diets high in fruit and vegetables decrease the risk of developing cancer.

New generation high performance in situ polarized 3He system for time-of-flight beam at spallation sources

Modern spallation neutron sources generate high intensity neutron beams with a broad wavelength band applied to exploring new nano- and meso-scale materials from a few atomic monolayers thick to complicated prototype device-like systems with multiple buried interfaces. The availability of high performance neutron polarizers and analyzers in neutron scattering experiments is vital for understanding magnetism in systems with novel functionalities. We report the development of a new generation of the in situ polarized ³He neutron polarization analyzer for the Magnetism Reflectometer at the Spallation Neutron Source at Oak Ridge National Laboratory. With a new optical layout and laser system, the ³He polarization reached and maintained 84% as compared to 76% in the first-generation system. The polarization improvement allows achieving the transmission function varying from 50% to 15% for the polarized neutron beam with the wavelength band of 2-9 Angstroms. This achievement brings a new class of experiments with optimal performance in sensitivity to very small magnetic moments in nano systems and opens up the horizon for its applications.

Analysis of the safety and efficacy of diabetic ketoacidosis management in a Community General Hospital, 2001-2010: a descriptive study

BACKGROUND

The recommended place for treatment of diabetic ketoacidosis in children is a paediatric High Dependency Unit. This facility is not available in all areas where children with type 1 diabetes mellitus are cared for.

AIMS

This study investigates the safety and efficacy of diabetic ketoacidosis management in a community general hospital without a paediatric high dependency unit.

METHODS

Data from children with diabetic ketoacidosis were collected from all diabetes related admissions in Dr Gray's Hospital, Elgin from 2001 to 2010. Observations were compared with safety indicators (pH, bicarbonate, glucose, electrolytes and cerebral oedema) and were reviewed for the recovery to normal values (pH, bicarbonate), without abnormal fluctuation (electrolytes, glucose) and without neurological complications (cerebral oedema).

RESULTS

The 114 patients generated 251 diabetes-related admissions, 118 for diabetic ketoacidosis treatment of whom 99 patients were treated with intravenous fluids and insulin. The mean time to recover to a pH of at least 7.30 was 655 minutes (120-1410 min). There were 79 (4.37% of 1808) glucose readings dropping more than 5.0 mmol/l per hour. There were six hypoglycaemic events (2.3-2.9 mmol/l) and in one case potassium dropped to 2.2 mmol/l. There was no case which developed into cerebral oedema.

CONCLUSION

Treatment of diabetic ketoacidosis in a community general hospital managed with a protocol for fluids, insulin and strict monitoring has shown to be effective in achieving recovery and to safely avoid complications.

Looking to the future: predicting renal replacement outcomes in a large community cohort with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is common and important due to poor outcomes. An ability to stratify CKD care based on outcome risk should improve care for all. Our objective was to develop and validate 5-year outcome prediction tools in a large population-based CKD cohort. Model performance was compared with the recently reported 'kidney failure risk equation' (KFRE) models.

METHODS

Those with CKD in the Grampian Laboratory Outcomes Mortality and Morbidity Study-I (3396) and -II (18 687) cohorts were used to develop and validate a renal replacement therapy (RRT) prediction tool. The discrimination, calibration and overall performance were assessed. The net reclassification index compared performance of the developed model and the 3- and 4-variable KFRE model to predict RRT in the validation cohort.

RESULTS

The developed model (with measures of age, sex, excretory renal function and proteinuria) performed well with a C-statistic of 0.938 (0.918-0.957) and Hosmer-Lemeshow (HL) χ(2) statistic 4.6. In the validation cohort (18 687), the developed model falsely identified fewer as high risk (414 versus 3278 individuals) compared with the KFRE 3-variable model (measures of age, sex and excretory renal function), but had more false negatives (58 versus 21 individuals). The KFRE 4-variable model could only be applied to 2274 individuals because of a lack of baseline urinary albumin creatinine ratio data, thus limiting its use in routine clinical practice.

CONCLUSIONS

CKD outcome prediction tools have been developed by ourselves and others. These tools could be used to stratify care, but identify both false positives and -negatives. Further refinement should optimize the balance between identifying those at increased risk with clinical utility for stratifying care.

Practices in prescribing protein substitutes for PKU in Europe: No uniformity of approach

BACKGROUND

There appears little consensus concerning protein requirements in phenylketonuria (PKU).

METHODS

A questionnaire completed by 63 European and Turkish IMD centres from 18 countries collected data on prescribed total protein intake (natural/intact protein and phenylalanine-free protein substitute [PS]) by age, administration frequency and method, monitoring, and type of protein substitute. Data were analysed by European region using descriptive statistics.

RESULTS

The amount of total protein (from PS and natural/intact protein) varied according to the European region. Higher median amounts of total protein were prescribed in infants and children in Northern Europe (n=24 centres) (infants <1 year, >2-3g/kg/day; 1-3 years of age, >2-3 g/kg/day; 4-10 years of age, >1.5-2.5 g/kg/day) and Southern Europe (n=10 centres) (infants <1 year, 2.5 g/kg/day, 1-3 years of age, 2 g/kg/day; 4-10 years of age, 1.5-2 g/kg/day), than by Eastern Europe (n=4 centres) (infants <1 year, 2.5 g/kg/day, 1-3 years of age, >2-2.5 g/kg/day; 4-10 years of age, >1.5-2 g/kg/day) and with Western Europe (n=25 centres) giving the least (infants <1 year, >2-2.5 g/kg/day, 1-3 years of age, 1.5-2 g/kg/day; 4-10 years of age, 1-1.5 g/kg/day). Total protein prescription was similar in patients aged >10 years (1-1.5 g/kg/day) and maternal patients (1-1.5 g/kg/day).

CONCLUSIONS

The amounts of total protein prescribed varied between European countries and appeared to be influenced by geographical region. In PKU, all gave higher than the recommended 2007 WHO/FAO/UNU safe levels of protein intake for the general population.

Human pathogens in marine mammal meat – a northern perspective

Only a few countries worldwide hunt seals and whales commercially. In Norway, hooded and harp seals and minke whales are commercially harvested, and coastal seals (harbour and grey seals) are hunted as game. Marine mammal meat is sold to the public and thus included in general microbiological meat control regulations. Slaughtering and dressing of marine mammals are performed in the open air on deck, and many factors on board sealing or whaling vessels may affect meat quality, such as the ice used for cooling whale meat and the seawater used for cleaning, storage of whale meat in the open air until ambient temperature is reached, and the hygienic conditions of equipment, decks, and other surfaces. Based on existing reports, it appears that meat of seal and whale does not usually represent a microbiological hazard to consumers in Norway, because human disease has not been associated with consumption of such foods. However, as hygienic control on marine mammal meat is ad hoc, mainly based on spot-testing, and addresses very few human pathogens, this conclusion may be premature. Additionally, few data from surveys or systematic quality control screenings have been published. This review examines the occurrence of potential human pathogens in marine mammals, as well as critical points for contamination of meat during the slaughter, dressing, cooling, storage and processing of meat. Some zoonotic agents are of particular relevance as foodborne pathogens, such as Trichinella spp., Toxoplasma gondii, Salmonella and Leptospira spp. In addition, Mycoplasma spp. parapoxvirus and Mycobacterium spp. constitute occupational risks during handling of marine mammals and marine mammal products. Adequate training in hygienic procedures is necessary to minimize the risk of contamination on board, and acquiring further data is essential for obtaining a realistic assessment of the microbiological risk to humans from consuming marine mammal meat.

Human interleukin-27: wide individual variation in plasma levels and complex inter-relationships with interleukin-17A

Although it is widely believed that interleukin (IL)-27 is anti-inflammatory, its role in controlling human immune responses is not fully established. In particular, its interactions with T helper type 17 (Th)17 cytokines are unclear. Our aims were to establish the relationships between IL-27 and proinflammatory cytokines, including IL-17A, in human sera and cultures of peripheral blood mononuclear cells. Plasma IL-27 levels in 879 healthy humans from 163 families varied widely, but with relatively low heritability (19%). Despite IL-27 including a subunit encoded by Epstein-Barr virus-induced gene 3 (EBI3), there was no correlation of levels with serological evidence of infection with the virus. Although IL-27 has been reported to inhibit IL-17A production, we demonstrated a strong positive correlation in sera, but lower correlations of IL-27 with other proinflammatory cytokines. We verified that IL-27 inhibited IL-17A production by human peripheral blood T cells in vitro, but not that it stimulated IL-10 secretion. Importantly, addition of IL-17A decreased IL-27 production by stimulated T cells but had the opposite effect on resting T cells. Together, these data suggest a model whereby IL-27 and IL-17A exerts complex reciprocal effects to boost inflammatory responses, but restrain resting cells to prevent inappropriate activation.

Ensemble crowd perception: a viewpoint-invariant mechanism to represent average crowd identity

Individuals can rapidly and precisely judge the average of a set of similar items, including both low-level (Ariely, 2001) and high-level objects (Haberman & Whitney, 2007). However, to date, it is unclear whether ensemble perception is based on viewpoint-invariant object representations. Here, we tested this question by presenting participants with crowds of sequentially presented faces. The number of faces in each crowd and the viewpoint of each face varied from trial to trial. This design required participants to integrate information from multiple viewpoints into one ensemble percept. Participants reported the mean identity of crowds (e.g., family resemblance) using an adjustable, forward-oriented test face. Our results showed that participants accurately perceived the mean crowd identity even when required to incorporate information across multiple face orientations. Control experiments showed that the precision of ensemble coding was not solely dependent on the length of time participants viewed the crowd. Moreover, control analyses demonstrated that observers did not simply sample a subset of faces in the crowd but rather integrated many faces into their estimates of average crowd identity. These results demonstrate that ensemble perception can operate at the highest levels of object recognition after 3-D viewpoint-invariant faces are represented.

Regional long-term model of radioactivity dispersion and fate in the Northwestern Pacific and adjacent seas: application to the Fukushima Dai-ichi accident

The compartment model POSEIDON-R was modified and applied to the Northwestern Pacific and adjacent seas to simulate the transport and fate of radioactivity in the period 1945-2010, and to perform a radiological assessment on the releases of radioactivity due to the Fukushima Dai-ichi accident for the period 2011-2040. The model predicts the dispersion of radioactivity in the water column and in sediments, the transfer of radionuclides throughout the marine food web, and subsequent doses to humans due to the consumption of marine products. A generic predictive dynamic food-chain model is used instead of the biological concentration factor (BCF) approach. The radionuclide uptake model for fish has as a central feature the accumulation of radionuclides in the target tissue. The three layer structure of the water column makes it possible to describe the vertical structure of radioactivity in deep waters. In total 175 compartments cover the Northwestern Pacific, the East China and Yellow Seas and the East/Japan Sea. The model was validated from (137)Cs data for the period 1945-2010. Calculated concentrations of (137)Cs in water, bottom sediments and marine organisms in the coastal compartment, before and after the accident, are in close agreement with measurements from the Japanese agencies. The agreement for water is achieved when an additional continuous flux of 3.6 TBq y(-1) is used for underground leakage of contaminated water from the Fukushima Dai-ichi NPP, during the three years following the accident. The dynamic food web model predicts that due to the delay of the transfer throughout the food web, the concentration of (137)Cs for piscivorous fishes returns to background level only in 2016. For the year 2011, the calculated individual dose rate for Fukushima Prefecture due to consumption of fishery products is 3.6 μSv y(-1). Following the Fukushima Dai-ichi accident the collective dose due to ingestion of marine products for Japan increased in 2011 by a factor of 6 in comparison with 2010.

Impact of ozone pre-treatment on the performance of upflow anaerobic sludge blanket treating pre-treated grain distillery wastewater

Two 2 L laboratory-scale upflow anaerobic sludge blanket (UASB) reactors were operated for 277 days. The substrate of the control reactor (Rc) contained grain distillery wastewater (GDWW) that had undergone coagulant pre-treatment, and the substrate of the second UASB reactor consisted of GDWW that had undergone coagulant pre-treatment and ozone pre-treatment (Ro). Both reactors treated pre-treated GDWW successfully at ca. 9 kgCOD m(-3) d(-1). Chemical oxygen demand (COD) reductions of ca. 96% for Rc and 93% for Ro were achieved. Fats, oils and grease (FOG) reductions (%) showed variations throughout the study, and reductions of ca. 88 and 92% were achieved for Rc and Ro, respectively. Rc produced more biogas, and the methane percentage was similar in both reactors. UASB granule washout in Rc suggested possible toxicity of unsaturated fatty acids present in non-ozonated substrate. The feasibility of FOG removal was demonstrated as both reactors successfully treated pre-treated GDWW. Better results were obtained for Ro effluent during post-ozonation. The ozone pre-treatment possibly led to easier degradable wastewater, and better results could potentially be obtained when other post-treatment steps are applied. Ozone pre-treatment did not, however, show an added benefit in the reactor performance results.

The Interaction of Spatial and Object Pathways: Evidence from Balint's Syndrome

An earlier report described a patient (RM) with bilateral parietal damage who showed severe binding problems between shape and color and shape and size (Friedman-Hill, Robertson, & Treisman, 1995). When shown two different-colored letters, RM reported a large number of illusory conjunctions (ICs) combining the shape of one letter with the color of the other, even when he was looking directly at one of them and had as long as 10 sec to respond. The lesions also produced severe deficits in locating and reaching for objects, and difficulty in seeing more than one object at a time, resulting in a neuropsychological diagnosis of Balint's syndrome or dorsal simultanagnosia. The pattern of deficits supported predictions of Treisman's Feature Integration Theory (FIT) that the loss of spatial information would lead to binding errors. They further suggested that the spatial information used in binding depends on intact parietal function. In the present paper we extend these findings and examine other deficits in RM that would be predicted by FIT. We show that: (1) Object individuation is impaired, making it impossible for him correctly to count more than one or two objects, even when he is aware that more are present. (2) Visual search for a target defined by a conjunction of features (requiring binding) is impaired, while the detection of a target defined by a unique feature is not. Search for the absence of a feature (0 among Qs) is also severely impaired, while search for the presence (Q among 0s) is not. Feature absence can only be detected when all the present features are bound to the nontarget items. (3) RM's deficits cannot be attributed to a general binding problem: binding errors were far more likely with simultaneous presentation where spatial information was required than with sequential presentation where time could be used as the medium for binding. (4) Selection for attention was severely impaired, whether it was based on the position of a marker or on some other feature (color). (5) Spatial information seems to exist that RM cannot access, suggesting that feature binding relies on a relatively late stage where implicit spatial information is made explicitly accessible. The data converge to support our conclusions that explicit spatial knowledge is necessary for the perception of accurately bound features, for accurate attentional selection, and for accurate and rapid search for a conjunction of features in a multiitem display. It is obviously necessary for directing attention to spatial locations, but the consequences of impairments in this ability seem also to affect object selection, object individuation, and feature integration. Thus, the functional effects of parietal damage are not limited to the spatial and attentional problems that have long been described in patients with Balint's syndrome. Damage to parietal areas also affects object perception through damage to spatial representations that are fundamental for spatial awareness.