Seropositivity to Campylobacter and association with abortion and lamb mortality in maiden ewes from Western Australia, South Australia and Victoria

This case‐control study investigated associations between Campylobacter fetus or Campylobacter jejuni titre and reproductive outcomes in 22 flocks of Merino and non‐Merino maiden ewes aged 1–2 years old. Campylobacter titres were also determined for multiparous ewes aged 3 years or older on the same farms. C. fetus ‘positivity’ (titre ≥1:80) was detected for 12% (57/462; 95% confidence interval [95% CI] 9.6 to 15.6) of maiden ewes and 31% (65/210; 95% CI 25.0 to 37.4) of mature ewes. The odds for failing to rear a lamb in C. fetus‐‘exposed’ maiden ewes (titre ≥1:10) was 2.01 times that of seronegative ewes (95% CI 1.09 to 3.77; P = 0.027), but there was no association between C. fetus‐‘positivity’ (titre ≥1:80) and failure to rise (OR 1.69; 95% CI 0.77 to 3.76; P = 0.191). C. fetus abortions were confirmed with microbial culture in one maiden ewe flock. In this flock, C. fetus titres fluctuated and often waned by lamb marking, highlighting the value of necropsies during abortion investigations. C. jejuni‐‘positivity’ (titre ≥1:80) was detected for 44% (204/462; 95% CI 39.7 to 48.7) maiden ewes, but odds of failing to rear were decreased for C. jejuni‐‘positive’ ewes (OR 0.52; 95% CI 0.32 to 0.83; P = 0.007). The association between Campylobacter serology and the reproductive outcome was inconsistent in these flocks. Serology should be considered in the context of other risk factors and used in conjunction with other strategies to investigate the impact of Campylobacter exposure on ewe reproductive performance such as monitoring for abortions and lamb necropsies to determine aetiological diagnosis, and vaccination trials.

Global Burden of Animal Diseases: a novel approach to understanding and managing disease in livestock and aquaculture

Investments in animal health and Veterinary Services can have a measurable impact on the health of people and the environment. These investments require a baseline metric that describes the burden of animal health and welfare in order to justify and prioritise resource allocation and from which to measure the impact of interventions. This paper is part of a process of scientific enquiry in which problems are identified and solutions sought in an inclusive way. It poses the broad question: what should a system to measure the animal disease burden on society look like and what value would it add? Moreover, it aims to do this in such a way as to be accessible by a wide audience, who are encouraged to engage in this debate. Given that farmed animals, including those raised by poor smallholders, are an economic entity, this system should be based on economic principles. These poor farmers are negatively impacted by disparities in animal health technology, which can be addressed through a mixture of supply-led and demand-driven interventions, reinforcing the relevance of targeted financial support from government and non-governmental organisations. The Global Burden of Animal Diseases (GBADs) Programme will glean existing data to measure animal health losses within carefully characterised production systems. Consistent and transparent attribution of animal health losses will enable meaningful comparisons of the animal disease burden to be made between diseases, production systems and countries, and will show how it is apportioned by people's socio-economic status and gender. The GBADs Programme will produce a cloud-based knowledge engine and data portal, through which users will access burden metrics and associated visualisations, support for decisionmaking in the form of future animal health scenarios, and the outputs of wider economic modelling. The vision of GBADs, strengthening the food system for the benefit of society and the environment, is an example of One Health thinking in action.

Blind Source Separation for Clutter and Noise Suppression in Ultrasound Imaging: Review for Different Applications

Blind source separation (BSS) refers to a number of signal processing techniques that decompose a signal into several "source" signals. In recent years, BSS is increasingly employed for the suppression of clutter and noise in ultrasonic imaging. In particular, its ability to separate sources based on measures of independence rather than their temporal or spatial frequency content makes BSS a powerful filtering tool for data in which the desired and undesired signals overlap in the spectral domain. The purpose of this work was to review the existing BSS methods and their potential in ultrasound imaging. Furthermore, we tested and compared the effectiveness of these techniques in the field of contrast-ultrasound super-resolution, contrast quantification, and speckle tracking. For all applications, this was done in silico, in vitro, and in vivo. We found that the critical step in BSS filtering is the identification of components containing the desired signal and highlighted the value of a priori domain knowledge to define effective criteria for signal component selection.

Immunogenicity of the hepatitis A vaccine 20 years after infant immunization

To determine the duration of immunity provided by the Hepatitis A vaccination (HepA), we evaluated a cohort of participants in Alaska 20 years after being immunized as infants. At recruitment, participants received two doses of inactivated HepA vaccine on one of three schedules. We conducted hepatitis A antibody (anti-HAV) testing for participants at the 20-year time-point. Seventy-five of the original 183 participants (41%) were available for follow-up. The overall anti-HAV geometric mean concentration was 29.9 mIU/mL (95% CI 22.4 mIU/mL, 39.7 mIU/mL) and 50 participants (68%) remained seropositive (titer ≥ 20 mIU/mL). Using a fractional polynomial model, the predicted percent seropositive at 25 years was 55.3%, 49.8% at 30 years and 45.7% at 35 years, suggesting that the percent sero-positive could drop below 50% earlier than previously expected. Further research is necessary to understand if protection continues after seropositivity diminishes or if a HepA booster dose may become necessary.

Interiaboratory Evaluation of an Off-Line Supercritical Fluid Extraction/Infrared Spectrometric Method for Determination of Petroleum Hydrocarbons in Solid Matrixes

A collaborative study was conducted, with 14 laboratories participating, to determine the method accuracy and precision of the proposed U.S. Environmental Protection Agency Methods 3560 and 8440. These methods involve the extraction of petroleum hydrocarbons from solid matrixes with supercritical carbon dioxide at 340 atm and 80°C for 30 min (dynamic), collection of the extracted materials in tetrachloroethene (Method 3560), and analysis of the extracts by infrared (IR) spectrometry (Method 8440). The study design was based on the AOAC blind replicate design with balanced replicates. The study samples consisted of 4 solid matrixes that had petroleum hydrocarbon contents ranging from 614 to 32 600 mg/kg. Each of the 4 matrixes was extracted in triplicate, and the extracts were analyzed with 2 different IR spectrometers. In addition, each of the participating laboratories extracted a sample of unspiked clay soil, the same clay soil spiked with corn oil and reference oil at 1000 mg/kg each, and the same clay soil wetted to 30% water content and spiked with motor oil at 10 000 mg/kg (the latter 3 samples were extracted only once). Results indicated that the overall method accuracy for concentrations ranging from 614 to 32 600 mg/kg was 82.9%; the mean recoveries of petroleum hydrocarbons for each of the 4 solid matrixes ranged from 77.9 to 107% for analyses performed with the Perkin-Elmer Fourier transform IR spectrometer and from 75.9 to 101% for analyses performed with the Buck-Scientific IR spectrometer; the differences between the 2 instruments on a sample-bysample basis were less than 17% for the total petroleum hydrocarbon determinations. The interiaboratory method precisions (RSDR) appeared to be matrix-dependent and ranged from 17.3 to 45.4% for analyses performed with the Perkin- Elmer Fourier transform IR spectrometer and from 16.7 to 47.9% for the Buck-Scientific IR spectrometer. The intralaboratory method precisions (RSDr) appeared to be less matrix-dependent and ranged from 11.5 to 17.0% for analyses performed with the Perkin-Elmer FTIR spectrometer and from 11.1 to 18.2% for the Buck-Scientific IR spectrometer. Method accuracy and precision data are also presented for the 5 laboratories that used Isco supercritical fluid extraction systems and for the 7 laboratories that used vessels with volumes of 3.5 mL or less with different supercritical fluid extraction systems.

The relationship between bronchoalveolar lavage fluid cytology and airway hyper-reactivity in a population of Australian horses presented for poor performance

OBJECTIVE

To investigate the relationship between bronchoalveolar lavage fluid cytology, particularly mast cells, and airway hyper-reactivity in athletic horses presented for poor performance that included a respiratory tract evaluation in two disparate locations in Australia.

DESIGN

Multi-centre, retrospective and prospective cross-sectional study METHODS: Eighty four adult horses underwent both pulmonary function testing and histamine bronchoprovocation with a commercial flowmetric plethysmography system. A bronchoalveolar lavage was performed four to twelve hours later. Bronchoalveolar lavage fluid cytology was categorised using two differing classification systems to define mild equine asthma. Statistical analysis was used to assess associations between bronchoalveolar lavage fluid relative inflammatory cell percentages, and airway hyper-reactivity and their associated categorisations.

RESULTS

Sixty four percent (54/84) of horses displayed airway hyper-reactivity, as defined by PC₃₅  < 6 mg/ml of histamine. A relative mastocytosis was the most common bronchoalveolar lavage fluid cytological abnormality. Horses with a sole mast cell response of ≥ 5% within their bronchoalveolar lavage fluid displayed airway hyper-reactivity at a lower dose of nebulized histamine than horses with normal bronchoalveolar lavage fluid cytology. Horses with mixed cell responses (relative mast cell percentage > 2% and/or relative neutrophil percentage > 5% and/or eosinophil relative cell percentage ≥ 1%) displayed airway hyper-reactivity at a lower dose of nebulized histamine than horses with normal bronchoalveolar lavage fluid cytology.

CONCLUSION

In the Australian context, recently revised increased bronchoalveolar lavage fluid cytology relative cell percentage cut offs appear appropriate for sole mast cell responses. The historical lower cut offs appear to be appropriate for mixed inflammatory cell responses.

Reptarenaviruses in apparently healthy snakes in an Australian zoological collection

BACKGROUND

Inclusion body disease (IBD) is a disease of snakes with a global distribution and has recently been shown to be caused by reptarenaviruses. Testing for this group of viruses in asymptomatic snakes allows the association between infection and disease to be further elucidated.

METHODS

A reptarenavirus was detected by RT-PCR in a reticulated python (Malayopython reticulatus) from an Australian zoological collection that was open-mouth breathing and had erythematous oral mucosa. Another 27 pythons, 4 elapids, 2 colubrids and 2 boas from this collection were then screened. From these animals, swabs, whole blood and/or tissue were tested for reptarenaviruses by RT-PCR. Additionally, blood films from 10 snakes were examined by light microscopy for the presence of inclusion bodies. The majority of samples were collected over a 484-day period.

RESULTS

A total of 8 animals were RT-PCR-positive (8/36 = 22.2%): 6 were pythons, 1 was a corn snake (Pantherophis guttatus) and 1 was a Madagascar tree boa (Sanzinia madagascariensis). From them, 57 samples were collected, but only one from each animal was RT-PCR-positive (8/57 = 14.0%). From all 36 animals in this study, 8/182 samples were RT-PCR-positive (4.4%). Inclusion bodies were not recognised in any of the blood films. Only the reticulated python showed signs of illness, which improved without any further intervention. All other RT-PCR-positive snakes were apparently healthy throughout the duration of the study.

CONCLUSION

This study showed a weak association between the presence of reptarenaviruses and disease. Testing serially collected swab and whole-blood samples increased the number of animals in which reptarenaviruses were detected.

Serum NGAL can act as an early renal safety biomarker during long-term nucleos(t)ide analogue antiviral therapy in chronic hepatitis B

Tubular renal toxicity is a side-effect of long-term therapy with nucleos(t)ide analogue(s) (NA) in chronic hepatitis B (CHB). There are no established surrogate markers in plasma of early NA-related toxicity. Neutrophil gelatinase-associated lipocalin (NGAL) is a protein produced by tubular cells following renal damage. We aimed therefore to retrospectively compare conventional renal markers (estimated glomerular filtration rates (eGFR) and urinary protein/creatinine ratio uPCR) with a sensitive biomarker (NGAL) in CHB patients on long-term NA therapy and assess the ability of new markers to predict NA-related renal toxicity (new onset of nonalbumin proteinuria). A total of 192 naïve CHB patients (median age 41 years, 78% males, 25% HBeAg+, 35% cirrhosis) were NA treated for at least 5 years (median 8.34 years, range 5.54-11.1 years). The eGFR and uPCR were compared at baseline and last clinical visit with serum NGAL concentrations measured by ELISA at same time-points and assessed according to the presence/absence of nonalbumin proteinuria at last visit. While baseline and last visit eGFR were similar (median:78 vs 84 mL/min), serum NGAL concentrations increased during therapy (median:9.4 vs 16.4 ng/mL, P < .05). The proportion of patients with proteinuria (uPCR > 15) increased between baseline and last visit (4.6% vs 21.4%, P < .05), with 30 (16%) patients having de novo nonalbumin proteinuria at last visit. High baseline NGAL concentrations were exclusive to patients with de novo nonalbumin proteinuria (median:31.7 vs 7.8 ng/mL, P < .01) and baseline NGAL levels >25 mg/mL were predictive of nonalbumin proteinuria at last visit (AUROC = 0.813). In conclusion, serum NGAL can act as a surrogate marker of early renal injury (de novo nonalbumin proteinuria) in CHB on long-term NA therapy.

HBsAg and HBcrAg as predictors of HBeAg seroconversion in HBeAg-positive patients treated with nucleos(t)ide analogues

HBeAg seroconversion marks an important spontaneous change and treatment end-point for HBeAg-positive patients and is a pre-requisite for HBsAg loss or functional cure. In this retrospective analysis, we aimed to identify predictors of seroconversion using serum quantitative HBsAg and HBcrAg, in HBeAg-positive patients treated with nucleos(t)ide analogues (NA). Data and samples from 118 HBeAg-positive adults (genotypes A-G) started on NA between Jan 2005 and Sept 2016 were retrospectively analysed at several time-points. The predictive power of on-treatment levels of HBsAg and HBcrAg was determined using receiver operating curve (ROC) analysis and cut-off values determined by maximized Youden's index. About 36.4% of patients achieved HBeAg seroconversion after a median of 39 months' treatment. On treatment kinetics of HBV DNA, HBsAg and HBcrAg differed between HBeAg seroconverters and nonseroconverters. A combination of HBsAg and HBcrAg had the greatest predictive value for HBeAg seroconversion: at 6 months, HBsAg of 3.9 log₁₀  IU/mL and HBcrAg of 5.7 log₁₀ U/mL had a sensitivity of 71.4%, specificity of 79.5%, positive predictive value (PPV) of 65.2% and negative predictive value (NPV) of 83.8%, with AUROC of 0.769 (0.668, 0.869; 95%CI), and at 12 months, HBsAg 3.8 log₁₀  IU/mL and HBcrAg 5.5 log₁₀ U/mL had a sensitivity of 73.7%, specificity of 79.5%, PPV of 63.6% and NPV of 86.1%, with AUROC 0.807 (0.713, 0.901; 95% CI). In conclusion, our results may be used to identify patients who are unlikely to achieve treatment end-points, which will be important as the future management of chronic hepatitis B looks to therapies that offer functional cure.

Slip-Shod or Safely Shod: The Bighorn Sheep as a Natural Model for Research

Over a million injuries caused by slipping of footwear are believed to require treatment by doctors every year in the United Kingdom and many domestic animals are injured by slipping. Recent research has revealed that surface roughness of solings and floors is an important determinant of grip on lubricated surfaces and it is also known that soling friction is affected by hardness. The bighorn sheep (Ovis canadensis) an animal species which has adapted to a slippery environment, was studied to elucidate optimum roughness and hardness and other features which influence grip. Four adult ewes were examined in the London Zoo. The cloven hooves of this species are very mobile and the cranial tips of the hooves are the first parts to make contact with the ground. A very small contact area ensures penetration of a film of water. Mean roughness of the contact area was found to be 53 microns Rtm and the mean hardness 63 Shore A. These characteristics appear to facilitate an excellent grip on wet slippery rock but not on smooth ice. Further studies of the feet of wild species could contribute to an understanding of the factors which determine the safety of solings and floors.

The economic efficiency and equity of government policies on brucellosis: comparative insights from Albania and the United States of America

Brucellosis is a zoonotic bacterial disease that causes recurring febrile illness in humans, as well as reproductive failure and reduced milk production in livestock. The cost of brucellosis is equal to the sum of lost productivity of humans and animals, as well as private and public expenditures on brucellosis surveillance, prevention, control and treatment. In Albania, Brucella abortus and B. melitensis affect humans, cattle and small ruminants. In the United States, B. abortus affects cattle and wild ungulates in the Greater Yellowstone Area. These two case studies illustrate the importance of place-specific context in developing sustainable and effective brucellosis mitigation policies. Government regulations and mitigation strategies should be designed with consideration of all costs and benefits, both to public agencies and private stakeholders. Policy-makers should, for example, weigh the benefits of a regulation that increases epidemiological certainty against the costs of compliance for producers and households. The distribution of costs and benefits amongst public agencies and private individuals can have important implications for a policy's economic efficiency and equity quite apart from their total magnitude.

Caring for a patient with rabies: implications of the Milwaukee protocol for infection control and public health measures

This article discusses the infection control and public health measures taken whilst managing a case of laboratory-confirmed rabies, and the challenges faced in implementing these measures. Case management requires intensive multi-disciplinary co-ordination. The Milwaukee protocol, which to date has five reported human rabies survivors associated with its use, has been suggested as a potential management pathway for human rabies. Consensus among hospital and public health clinicians would aid future deployment of this approach in selected cases.

Effect of BMI on Resting-state Functional Architecture of the Brain in Healthy Individuals and Patients with Psychosis

Elevated body mass index (BMI) is associated with increased multi-morbidity and mortality. The investigation of the relationship between BMI and brain organization has the potential to provide new insights relevant to clinical and policy strategies for weight control. Here, we quantified the effect of BMI on the functional connectivity of the Default-Mode (DMN), Central Executive (CEN), Sensorimotor (SMN) and Visual (VN) networks in 496 healthy individuals that were studied as part of the Human Connectome Project. We found that elevated BMI was associated with disrupted functional integration of sensory-guided (SMN, VN) with internally controlled (DMN, CEN) networks, implicating increased attention to sensory stimuli as a possible mechanism underpinning overeating and weight gain. Our results suggest that weight control strategies should expand to include wider societal policies that incorporate modifications to eating environments and to the visual presentation and branding of food products.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Randomised clinical trial: exploratory phase 2 study of ONO-2952 in diarrhoea-predominant irritable bowel syndrome

BACKGROUND

ONO-2952 is a novel and selective inhibitor of translocator protein 18 kDa that reduces stress-induced defecation and visceral hyperalgesia in rat models.

AIM

To evaluate the efficacy and safety of ONO-2952 in females with irritable bowel syndrome with diarrhoea in an exploratory proof-of-concept study.

METHODS

A randomised, double-blind, placebo-controlled study was conducted at 49 US centres. Two hundred subjects with irritable bowel syndrome with diarrhoea (Rome III criteria) were randomised to ONO-2952 20 mg, or 60 mg, or placebo. Subjects recorded irritable bowel syndrome symptoms daily during a 2-week baseline period, the 4-week treatment period and for 4 weeks post-treatment. The co-primary endpoints were change from baseline to week 4 in abdominal pain, stool consistency and stool frequency.

RESULTS

Improvements in irritable bowel syndrome symptoms were seen with ONO-2952 over placebo in per-protocol analyses for all three co-primary endpoints, but these did not reach statistical significance at the 5% level. The largest improvement was seen with ONO-2952 60 mg. ONO-2952 was well tolerated with a safety profile similar to that of placebo. Most adverse events were mild or moderate in severity and not treatment related.

CONCLUSION

ONO-2952 showed evidence of clinical efficacy in reducing irritable bowel syndrome-related symptoms in female subjects with irritable bowel syndrome with diarrhoea, and further evaluation is, therefore, warranted to assess its potential as a treatment for irritable bowel syndrome with diarrhoea (NCT01844180).

Surveillance of infectious diseases in the Arctic

OBJECTIVES

This study reviews how social and environmental issues affect health in Arctic populations and describes infectious disease surveillance in Arctic Nations with a special focus on the activities of the International Circumpolar Surveillance (ICS) project.

METHODS

We reviewed the literature over the past 2 decades looking at Arctic living conditions and their effects on health and Arctic surveillance for infectious diseases.

RESULTS

In regards to other regions worldwide, the Arctic climate and environment are extreme. Arctic and sub-Arctic populations live in markedly different social and physical environments compared to those of their more southern dwelling counterparts. A cold northern climate means people spending more time indoors, amplifying the effects of household crowding, smoking and inadequate ventilation on the person-to-person spread of infectious diseases. The spread of zoonotic infections north as the climate warms, emergence of antibiotic resistance among bacterial pathogens, the re-emergence of tuberculosis, the entrance of HIV into Arctic communities, the specter of pandemic influenza or the sudden emergence and introduction of new viral pathogens pose new challenges to residents, governments and public health authorities of all Arctic countries. ICS is a network of hospitals, public health agencies, and reference laboratories throughout the Arctic working together for the purposes of collecting, comparing and sharing of uniform laboratory and epidemiological data on infectious diseases of concern and assisting in the formulation of prevention and control strategies (Fig. 1). In addition, circumpolar infectious disease research workgroups and sentinel surveillance systems for bacterial and viral pathogens exist.

CONCLUSIONS

The ICS system is a successful example of collaborative surveillance and research in an extreme environment.

Temporal Analysis and Costs of Ruminant Brucellosis Control Programme in Egypt Between 1999 and 2011

Data for the prevalence of brucellosis in ruminants in Egypt are scarce; recent studies suggest the disease is endemic, with a high prevalence. The aim of this study was to assess the financial costs and the impact of the current control programme on the pattern of brucellosis among ruminants between 1999 and 2011. A univariate binary logistic regression model was used to compare between seropositive proportions for different years for each species. The proportion of seropositive cattle was significantly increased from 2000 to 2004 then significantly decreased from 2005 to 2011. The proportion of seropositive buffalo fluctuated year to year; however, there was a significant increase in 2008 (OR 3.13, 95% CI 2.69-3.66, P < 0.001). There was a decrease in the proportion of seropositive sheep during the study period except in 2001 and 2009 in which there was a significant increase. The proportion of seropositive goats increased in 2000 and 2001, and then decreased from 2002 to 2007. In 2008, there was a significant increase in the seropositive proportion of goats (OR 2.53, 95% CI 2.21-2.90, P < 0.001). The average annual cost for the control programme including testing and compensation was more than US$3 million. The total cost for the control programme including testing and compensation for the period (13 years) between 1999 and 2011 was more than US$40 million, from which more than 56% for cattle. Further studies are required for the effectiveness of the current control strategies and alternative strategies should be considered. The socio-economic impact of brucellosis and its control measures should be investigated.

Impact of providing in-home water service on the rates of infectious diseases: results from four communities in Western Alaska

Approximately 20% of rural Alaskan homes lack in-home piped water; residents haul water to their homes. The limited quantity of water impacts the ability to meet basic hygiene needs. We assessed rates of infections impacted by water quality (waterborne, e.g. gastrointestinal infections) and quantity (water-washed, e.g. skin and respiratory infections) in communities transitioning to in-home piped water. Residents of four communities consented to a review of medical records 3 years before and after their community received piped water. We selected health encounters with ICD-9CM codes for respiratory, skin and gastrointestinal infections. We calculated annual illness episodes for each infection category after adjusting for age. We obtained 5,477 person-years of observation from 1032 individuals. There were 9,840 illness episodes with at least one ICD-9CM code of interest; 8,155 (83%) respiratory, 1,666 (17%) skin, 241 (2%) gastrointestinal. Water use increased from an average 1.5 gallons/capita/day (g/c/d) to 25.7 g/c/d. There were significant (P-value < 0.05) declines in respiratory (16, 95% confidence interval (CI): 11-21%), skin (20, 95%CI: 10-30%), and gastrointestinal infections (38, 95%CI: 13-55%). We demonstrated significant declines in respiratory, skin and gastrointestinal infections among individuals who received in-home piped water. This study reinforces the importance of adequate quantities of water for health.

HBsAg plasma level kinetics: a new role for an old marker as a therapy response predictor in vertically infected children on combination therapy

We aimed to investigate the ability of HBsAg plasma level kinetics to predict therapy response by studying 23 children with infancy-acquired chronic hepatitis B (CHB) during combination sequential therapy with lead-in lamivudine (LAM) and add-on interferon-α (IFN-α) [5 responders (R = anti-HBs seroconversion) and 18 nonresponders (NR)] and to assess their relationship with pretreatment intrahepatic HBV-DNA and cccDNA and HBsAg and HBcAg liver expression. Plasma HBsAg levels were measured in samples before (treatment week 0 = TW0), during (TW9, TW28, TW52) and after (follow-up week = FUW24) therapy by Abbott ARCHITECT(®) assay [log10 IU/mL]. Baseline liver HBV-DNA and cccDNA were quantified by real-time TaqMan PCR [log10 copies/ng genomic DNA]. HBsAg and HBcAg liver expression was evaluated by immunostaining of formalin-fixed, paraffin-embedded specimens [number of positive cells/1000 hepatocytes]. All results are presented as medians. Plasma: at baseline, on-treatment and during follow-up, HBsAg levels were lower in R than NR (TW0: 4.36 vs 4.75;TW28: 2.44 vs 4.35;TW52: 0 vs 4.08 and FUW24: 0.17 vs 4.35, all P < 0.05). Liver: baseline HBV-DNA (3.82 vs 4.71, P = 0.16) and cccDNA (1.98 vs 2.26, P = 0.18) tended to be lower in R than NR, HBsAg expression was lower in R than NR (0.5 vs 4.7, P = 0.03), and HBcAg expression was similar between R and NR. There were positive correlations between plasma HBsAg levels and liver HBV-DNA (r = 0.44, P = 0.04), cccDNA (r = 0.41, P = 0.04) and HBsAg liver expression (r = 0.38, P = 0.05). Lower baseline HBsAg plasma levels, lower HBsAg expression in liver and on-treatment decline of plasma HBsAg levels heralds HBsAg clearance and response to treatment in tolerant children with CHB.

Predicting the development of acute kidney injury in liver cirrhosis--an analysis of glomerular filtration rate, proteinuria and kidney injury biomarkers

BACKGROUND

The timely diagnosis of acute kidney injury (AKI) in liver cirrhosis is challenging.

AIM

To evaluate whether quantification of glomerular filtration rate (GFR), proteinuria and kidney injury biomarkers can accurately predict the development of AKI.

METHODS

A prospective cohort analysis of patients with cirrhosis was performed. Measures of baseline kidney function included serum creatinine, iohexol clearance and urine protein:creatinine ratio. Blood and urine samples were collected daily. A retrospective analysis of cystatin C GFR and neutrophil gelatinase-associated lipocalin (NGAL) measured 48 h prior to the diagnosis of AKI was undertaken to evaluate their ability to predict the development of AKI.

RESULTS

Eighteen of the 34 cirrhosis patients studied developed AKI. A GFR <60 mL/min/1.73 m(2) was identified in 56% with Iohexol clearance compared to 8% using the four-variable modified diet in renal disease formula (P < 0.0001). Prediction of AKI, 48 h prior to the development of AKI with cystatin C GFR and serum NGAL concentration were similar; area under the receiver operating curve (AUROC) values 0.74 (0.51-0.97), P = 0.04 and 0.72 (0.52-0.92), P = 0.02 respectively. The development of AKI was strongly predicted by urine protein:creatinine ratio above the cut-off of >30 (equivalent to 300 mg/day of proteinuria) sensitivity 82% (57-96) and specificity 80% (52-96), AUROC 0.86 (0.73-0.98), P ≤ 0.0001. [OR 21 (3-133), P ≤ 0.002].

CONCLUSIONS

In patients with liver cirrhosis a urine protein:creatinine ratio >30 predicts AKI. Iohexol clearance and cystatin C formulae identify a greater proportion of patients with a GFR <60 mL/min/1.73 m(2), which also predicts the development of AKI.

Ethnic differences in reported unmet needs among male inpatients with severe mental illness

Health services are failing to meet the needs of ethnic minority groups with severe mental illness in the UK. Understanding these unmet social and health needs will assist service providers in developing culturally sensitive and responsive care pathways. Using a cross-sectional design, 165 service users were recruited from 10 acute inpatient wards across four South London boroughs. Needs were assessed using the Camberwell Assessment of Need Short Assessment Schedule and substance dependence and antisocial personality disorder were measured using the Alcohol Use Disorders Identification Test, Drug Use Disorders Identification Test and the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders. African, but not African-Caribbean, heritage continued to predict lower rates of reported unmet needs compared to White British (P < 0.001) following multivariate analysis. Different patterns of unmet needs were observed across ethnic heritage groups. Antisocial personality disorder and alcohol dependence were also independently associated with unmet needs. Consideration of a patient's ethnic identity and comorbidities is essential for effective needs assessment within psychiatric and mental health nursing.

Post-traumatic stress symptoms in childhood brain tumour survivors and their parents

OBJECTIVES

This study aimed to investigate post-traumatic stress symptoms (PTSS) in childhood brain tumour survivors and their parents. A further aim was to explore the relationship between objective illness parameters, parent-child interactions, coping styles and PTSS.

METHODS

A cross-sectional correlational design was employed. Fifty-two childhood brain tumour survivors, aged 8-16, and 52 parents completed a battery of questionnaires designed to assess quality of parent-child interactions, monitoring and blunting attentional coping styles and PTSS.

RESULTS

Over one-third (35%) of survivors and 29% of their parents reported severe levels of PTSS (suggestive of post-traumatic stress disorder 'caseness'). Increased parent-child conflict resolution for survivors and number of tumour recurrences for parents independently predicted the variance in PTSS.

CONCLUSIONS

For a substantial proportion of brain tumour survivors and their parents the process of survivorship is a considerably distressing experience.

Repeatability of the measurement of augmentation index in the clinical assessment of arterial stiffness using radial applanation tonometry

OBJECTIVE

Aortic augmentation index (AIx) measured using applanation tonometry is a non-invasive indicator of arterial stiffness. The objective of this study was to assess its repeatability when used by nurses with limited experience of the technique.

MATERIAL AND METHODS

Blood pressure/augmentation index (BP/AIx) was measured 4 times in 20 consecutive ambulant patients (16 male) after they rested supine for 15 min. Two nurses independently and alternately measured BP/AIx using the same equipment (Omron HEM-757; SphygmoCor with Millar hand-held tonometer). Nurses were blinded to patient medical records and their colleague's AIx/BP. 'Within' and 'between' observer differences were assessed using intra-class correlation coefficients (rI) and 95 % limits of agreement (95 % LoA) derived from Bland-Altman plots.

RESULTS

Mean age was 56 (mean BP 136/79; mean pulse 64). Mean AIx was 24.1 (range 2.8 to 41.0). Both 'between' and 'within' observer repeatability was very high, with intra-class correlation coefficients ranging from 0.92 to 0.98. Mean AIx readings 'between' observers differed by only 0.68 (95 % CI -0.24 to 1.59) with a high rI (0.98; 95 % CI 0.95 to 0.99) and a narrow 95 % LoA (-3.22 to 4.57). The 95 % LoA for 'within' observer repeatability was -6.75 to 7.95. Differences in AIx measurement did not vary over time or with increasing levels of AIx.

CONCLUSIONS

Even when undertaken by relatively inexperienced operators, both 'within' and 'between' observer repeatability of AIx measurement is very high. Such non-invasive assessment of arterial stiffness has the potential to be included in the clinical assessment of ambulant patients.

Sporadic Creutzfeldt-Jakob disease in two adolescents

BACKGROUND

Sporadic Creutzfeldt-Jakob disease (CJD) is a condition predominantly affecting older age groups, with cases aged less than 45 years rare and an age at onset or death of less than 20 years exceptional.

METHODS

Data from the systematic study of sporadic CJD in the UK are available from 1970 onwards. Clinical and pathological data are reviewed in order to identify atypical cases, including those at the extremes of the age range of sporadic CJD. Detailed analysis of atypical cases is undertaken, and in selected cases laboratory transmission studies are carried out in order to provide information on the characteristics of the infectious agent.

RESULTS

In the UK, two cases of sporadic CJD in adolescents have been identified, dying at ages 16 and 20 years. The first case predated the epidemic of bovine spongiform encephalopathy and the characteristics of the second case, including laboratory transmission studies, are consistent with a diagnosis of sporadic rather than variant CJD.

CONCLUSION

The cases in this report indicate that sporadic CJD can develop at a very young age, that variant CJD is not the only form of CJD occurring in this age group and that neuropathological examination is essential for accurate diagnosis of human prion disease.

Repeat ABO-incompatible platelet transfusions leading to haemolytic transfusion reaction

A 65-year-old woman, blood group A RhD positive, who had completed her first course of induction chemotherapy for acute myeloid leukaemia was transfused with apheresis platelets over a number of days. On three occasions she received group O RhD positive units, which had been screened and found not to contain high-titre anti-A,B isoagglutinins. Following the third unit, she developed a haemolytic transfusion reaction and died soon thereafter. This has led to change in policy of the supplying centre in testing for high-titre anti-A,B isoagglutinins. Blood group O apheresis platelets and fresh-frozen plasma units are now labelled as high titre with a cut-off of 1/50 as compared to the previous cut-off of 1/100 for anti-A,B isoagglutinins. A universal approach to testing donations for high-titre anti-A,B isoagglutinins, better compliance of guidelines and monitoring of patients is necessary.

Management of hepatitis A in a food handler at a London secondary school

A case of hepatitis A in a food handler at a local secondary school prompted the institution of control measures including administration of human normal immunoglobulin (HNIG) to all pupils. This paper summarises the management of the incident and describes the use of HNIG to prevent secondary cases. Few adverse effects were reported and only one secondary case of hepatitis A occurred at the school.

Cognitive and psychosocial outcome of infants dialysed in infancy

OBJECTIVE

To contribute further to the understanding of cognitive and psychosocial outcome of children with end-stage renal disease undergoing long-term peritoneal dialysis.

METHODS

In total, 16 surviving infants at a single centre beginning peritoneal dialysis in the first year of life were studied. The age range of the children at assessment was 1.6-12.1 years. Children were assessed using the Griffiths Mental Development Scales, the Wechsler Intelligence Scale for Children-Third Edition UK, and the Strengths and Difficulties Questionnaire. Information regarding the child's hospital stay and family background was also collated. A Pearson's Product Moment correlation was used to analyse the results.

RESULTS

Although 67% of the children's scores fell within the average range, 87% were within at least two SDs of the norms (mean IQ = 86.6). Psychosocial adjustment measures revealed that 50% of scores fell within the borderline to abnormal category, suggesting that the frequency of psychological difficulties was above that of the normal population.

CONCLUSIONS

These findings lend support to recent studies indicating that, developmentally, children undergoing long-term peritoneal dialysis are faring better than in the past. This may indeed be a reflection of improvements in renal treatment and diet. The behavioural results suggest the need to monitor psychological adjustment in this group of children.

The impact of emission power on the destruction of echo contrast agents and on the origin of tissue harmonic signals using power pulse-inversion imaging

The purpose of this study was to determine the impact of emission power on ultrasound (US)-induced destruction of echocontrast microbubbles during real-time power pulse inversion imaging (PPI) in myocardial contrast echocardiography (MCE) and to evaluate the magnitude of noncontrast PPI signals arising from myocardial tissue at variable emission power to define the cut-off emission power for optimal MCE using low power technologies. In vitro studies were performed in a flow phantom using Optison, Definity and AFO 150. PPI signal intensity during real-time imaging at 27 Hz was compared with intermittent imaging at 0.1 Hz to evaluate bubble destruction at variable emission power (MI: 0.09 to 1.3). In healthy volunteers, PPI signal intensities during constant infusion of Optison(R) was studied in real-time PPI 22 HZ and during intermittent imaging triggered end-systolic frames every, every 3rd and every 5th cardiac cycle. In addition, the impact of emission power on nonlinear PPI signals from myocardial structures was studied. In vitro, there was a 40% decrease of real-time PPI signal intensity for Optison and AFO 150 at lowest emission power (0.09), whereas no signal loss was observed for Definity. Increase of emission power resulted in a faster decay for Optison(R) and AFO 150 as compared to Definity. In vivo, real-time PPI during continuous infusion of Optison(R) resulted in a 40% decrease of myocardial signal intensity as compared to intermittent imaging every 5th cardiac cycle, even at lowest possible emission power (mechanical index = 0.09). There was a strong positive relationship between MI and noncontrast myocardial PPI signals in all myocardial segments. PPI signal intensity was found to be lower than 1 dB only for extremely low emission power (MI < 0.2). Destruction of microbubbles during real-time imaging by use of PPI at low emission power varies considerably for different echo contrast agents. However, bubble destruction and the onset of tissue harmonic signals focus the use of real-time perfusion imaging to very low emission power.

Early spread of scrapie from the gastrointestinal tract to the central nervous system involves autonomic fibers of the splanchnic and vagus nerves

Although the ultimate target of infection is the central nervous system (CNS), there is evidence that the enteric nervous system (ENS) and the peripheral nervous system (PNS) are involved in the pathogenesis of orally communicated transmissible spongiform encephalopathies. In several peripherally challenged rodent models of scrapie, spread of infectious agent to the brain and spinal cord shows a pattern consistent with propagation along nerves supplying the viscera. We used immunocytochemistry (ICC) and paraffin-embedded tissue (PET) blotting to identify the location and temporal sequence of pathological accumulation of a host protein, PrP, in the CNS, PNS, and ENS of hamsters orally infected with the 263K scrapie strain. Enteric ganglia and components of splanchnic and vagus nerve circuitry were examined along with the brain and spinal cord. Bioassays were carried out with selected PNS constituents. Deposition of pathological PrP detected by ICC was consistent with immunostaining of a partially protease-resistant form of PrP (PrP(Sc)) in PET blots. PrP(Sc) could be observed from approximately one-third of the way through the incubation period in enteric ganglia and autonomic ganglia of splanchnic or vagus circuitry prior to sensory ganglia. PrP(Sc) accumulated, in a defined temporal sequence, in sites that accurately reflected known autonomic and sensory relays. Scrapie agent infectivity was present in the PNS at low or moderate levels. The data suggest that, in this scrapie model, the infectious agent primarily uses synaptically linked autonomic ganglia and efferent fibers of the vagus and splanchnic nerves to invade initial target sites in the brain and spinal cord.

Distribution of the prion protein in sheep terminally affected with BSE following experimental oral transmission

This study has examined the distribution of PrP(Sc) in sheep by immunocytochemistry of tissues recovered from terminally affected animals following their experimental infection by the oral route with BSE. Despite a wide range of incubation period lengths, affected sheep showed a similar distribution of high levels of PrP(Sc) throughout the central nervous system. PrP(Sc) was also found in the lymphoid system, including parts of the digestive tract, and some components of the peripheral nervous system. These abundant PrP(Sc) deposits in sheep in regions outside the central nervous system are in direct contrast with cattle infected with BSE, which show barely detectable levels of PrP(Sc) in peripheral tissues. A number of genetically susceptible, challenged animals appear to have survived.

Interaction between glutamine availability and metabolism of glycogen, tricarboxylic acid cycle intermediates and glutathione

After exhaustive exercise, intravenous or oral glutamine promoted skeletal muscle glycogen storage. However, when glutamine was ingested with glucose polymer, whole-body carbohydrate storage was elevated, the most likely site being liver and not muscle, possibly due to increased glucosamine formation. The rate of tricarboxylic acid (TCA) cycle flux and hence oxidative metabolism may be limited by the availability of TCA intermediates. There is some evidence that intramuscular glutamate normally provides alpha-ketoglutarate to the mitochondrion. We hypothesized that glutamine might be a more efficient anaplerotic precursor than endogenous glutamate alone. Indeed, a greater expansion of the sum of muscle citrate, malate, fumarate and succinate concentrations was observed at the start of exercise (70% VO2(max)) after oral glutamine than when placebo or ornithine alpha-ketoglutarate was given. However, neither endurance time nor the extent of phosphocreatine depletion or lactate accumulation during the exercise was altered, suggesting either that TCA intermediates were not limiting for energy production or that the severity of exercise was insufficient for the limitation to be operational. We have also shown that in the perfused working rat heart, there is a substantial fall in intramuscular glutamine and alpha-ketoglutarate, especially after ischemia. Glutamine (but not glutamate, alpha-ketoglutarate or aspartate) was able to rescue the performance of the postischemic heart. This ability appears to be connected to the ability to sustain intracardiac ATP, phosphocreatine and glutathione.

Genetic and environmental factors modify bovine spongiform encephalopathy incubation period in mice

The incubation period (IP) and the neuropathology of transmissible spongiform encephalopathies (TSEs) have been extensively used to distinguish prion isolates (or strains) inoculated into panels of inbred mouse strains. Such studies have shown that the bovine spongiform encephalopathy (BSE) agent is indistinguishable from the agent causing variant Creutzfeldt-Jakob disease (vCJD), but differs from isolates of sporadic CJD, reinforcing the idea that the vCJD epidemic in Britain results from consumption of contaminated beef products. We present a mouse model for genetic and environmental factors that modify the incubation period of BSE cross-species transmission. We have used two mouse strains that carry the same prion protein (PrP) allele, but display a 100-day difference in their mean IP following intracerebral inoculation with primary BSE isolate. We report genetic effects on IP that map to four chromosomal regions, and in addition we find significant factors of host environment, namely the age of the host's mother, the age of the host at infection, and an X-cytoplasm interaction in the host.

Managing late-life depression in primary care practice: a case study of the Health Specialist's role

Complexities in the diagnosis and treatment of late-life depression have stimulated various strategies for assisting the primary care physician to fulfil these tasks more effectively. The role of Health Specialist was developed for this purpose in a study to reduce suicidality among older depressed patients. This role includes clinical and case management tasks which aim to provide the physician with timely, patient-specific information and recommendations. Evolution of this role and its rewards/stressors during the study's first year are described.

Glutamine supplementation promotes anaplerosis but not oxidative energy delivery in human skeletal muscle

The aims of the present study were twofold: first to investigate whether TCA cycle intermediate (TCAI) pool expansion at the onset of moderate-intensity exercise in human skeletal muscle could be enhanced independently of pyruvate availability by ingestion of glutamine or ornithine alpha-ketoglutarate, and second, if it was, whether this modification of TCAI pool expansion had any effect on oxidative energy status during subsequent exercise. Seven males cycled for 10 min at approximately 70% maximal O2) uptake 1 h after consuming either an artificially sweetened placebo (5 ml/kg body wt solution, CON), 0.125 g/kg body wt L-(+)-ornithine alpha-ketoglutarate dissolved in 5 ml/kg body wt solution (OKG), or 0.125 g/kg body wt L-glutamine dissolved in 5 ml/kg body wt solution (GLN). Vastus lateralis muscle was biopsied 1 h postsupplement and after 10 min of exercise. The sum of four measured TCAI (SigmaTCAI; citrate, malate, fumarate, and succinate, approximately 85% of total TCAI pool) was not different between conditions 1 h postsupplement. However, after 10 min of exercise, SigmaTCAI (mmol/kg dry muscle) was greater in the GLN condition (4.90 +/- 0.61) than in the CON condition (3.74 +/- 0.38, P < 0.05) and the OKG condition (3.85 +/- 0.28). After 10 min of exercise, muscle phosphocreatine (PCr) content was significantly reduced (P < 0.05) in all conditions, but there was no significant difference between conditions. We conclude that the ingestion of glutamine increased TCAI pool size after 10 min of exercise most probably because of the entry of glutamine carbon at the level of alpha-ketoglutarate. However, this increased expansion in the TCAI pool did not appear to increase oxidative energy production, because there was no sparing of PCr during exercise.

Adaptation of the bovine spongiform encephalopathy agent to primates and comparison with Creutzfeldt-- Jakob disease: implications for human health

There is substantial scientific evidence to support the notion that bovine spongiform encephalopathy (BSE) has contaminated human beings, causing variant Creutzfeldt-Jakob disease (vCJD). This disease has raised concerns about the possibility of an iatrogenic secondary transmission to humans, because the biological properties of the primate-adapted BSE agent are unknown. We show that (i) BSE can be transmitted from primate to primate by intravenous route in 25 months, and (ii) an iatrogenic transmission of vCJD to humans could be readily recognized pathologically, whether it occurs by the central or peripheral route. Strain typing in mice demonstrates that the BSE agent adapts to macaques in the same way as it does to humans and confirms that the BSE agent is responsible for vCJD not only in the United Kingdom but also in France. The agent responsible for French iatrogenic growth hormone-linked CJD taken as a control is very different from vCJD but is similar to that found in one case of sporadic CJD and one sheep scrapie isolate. These data will be key in identifying the origin of human cases of prion disease, including accidental vCJD transmission, and could provide bases for vCJD risk assessment.