Comparing Effectiveness of a Generic Oral Nutritional Supplement With Specialized Formula in the Treatment of Active Pediatric Crohn's Disease

BACKGROUND

Exclusive enteral nutrition (EEN) is the recommended induction treatment of mild to moderate active pediatric Crohn's disease (CD). This study compared outcomes of 2 proprietary polymeric formulas. Treatment effectiveness was examined along with practical aspects of formula delivery and differences in estimated treatment costs.

METHODS

Data were retrospectively collected from patients with CD who received a generic oral nutritional supplement (Fortisip) across 2 centers (RCH, Melbourne and RHSC, Edinburgh). This was compared with a prospective cohort (RHC, Glasgow) that used a specialized formula (Modulen IBD). The data collected included patient demographics, remission rates, biochemical markers, administration method, and anthropometrics. The estimated treatment cost was performed by comparing price per kcal between each formula.

RESULTS

One hundred seventy-one patients were included (106 Fortisip, 65 Modulen IBD, 70 female; median age 13.3 yrs). No difference was demonstrated in remission rate (Fortisip n = 67 of 106 [63%] vs Modulen IBD n = 41 of 64 [64%], P = .89), nonadherence rate (Fortisip n = 7 of 106 [7%] vs Modulen IBD 3 of 64 [5%], P = .57) or method of administration (NGT Fortisip use n = 16 of 106 [12%] vs Modulen IBD 14 of 65 [22%]; P = .31). There was no difference in reduction of biochemical disease markers between the groups (C-reactive protein , P = .13; erythrocyte sedimentation rate, P = .49; fecal calprotectin, P = .94). However, there was a cost-saving of around £500/patient/course if the generic oral nutritional supplement was used.

CONCLUSIONS

The generic oral nutritional supplement and specialized formulas both had similar clinical effectiveness in induction of remission in pediatric CD. However, there is considerable cost-saving when using a generic oral nutritional supplement.

Gateways not gatekeepers – reaching seldom-heard groups to gather public health community insights

Background

Each local authority in England must develop a Health and Wellbeing Strategy (HWS) in collaboration with NHS partners to plan and support delivery of local improvements in health and wellbeing. HWSs often draw on diverse sources but few are informed by consultative exercises involving citizens. South Tyneside Council in Northern England sought to ensure their new HWS was community-informed, specifically including seldom-heard groups and individuals. Specific objectives of this community insights research were to:

1.Target sampling and recruitment activities at typically marginalized, vulnerable or otherwise underrepresented groups

2.Explore the health and wellbeing-related views and priorities of these groups to address health inequalities

Methods

A mapping exercise was undertaken to identify organisations who might act as gatekeepers to accessing participants from underrepresented groups. Focus groups were held in settings-based venues where members would be comfortable and known to one another. Representatives of voluntary and community sector (VCS) organisations often helped to co-facilitate the discussions.

Results

119 participants took part in 16 group discussions. Three were held online, two were outdoors, while 11 involved community venues where the groups regularly met. We reached older and younger people, minority ethnic groups, and vulnerable men and women, including residents who had experienced homelessness, mental health issues, substance misuse, offending, domestic violence and learning disabilities. Participants were largely concerned with the wider determinants of health (such as poverty, employment, and leisure spaces), shifting the narrative away from individual lifestyle factors that tend to be the focus of much public health discourse.

Conclusions

Gatekeepers from the VCS were essentially gateways, enabling us to include underrepresented voices in local consultation processes and generate new insights to inform the South Tyneside HWS.

Key messages

Accuracy of Point-of-Care-Ultrasonography in Confirming Shoulder Reduction in Emergency Departments

Aims Accurate identification of the successful reduction of a dislocated shoulder could avoid additional episodes of procedural sedation and repeated performance of X-rays. The objective of this study was to assess the diagnostic accuracy of point-of-care-ultrasound (POCUS) in the confirmation of a successful joint reduction in patients with shoulder dislocation. Methods This was a single-centre, prospective observational study set in an urban academic ED in Ireland, with a convenience sample of adult patients with shoulder dislocation on X-ray. Ultrasound was performed on participants before and after joint reduction using a posterior approach technique. The operator's confidence levels were recorded after image acquisition. Results Thirty-three subjects were recruited. All dislocations were correctly identified on pre-reduction US, indicating a sensitivity of 100% (CI 89.42 - 100). Post-reduction US confirmed successful reduction in 30 subjects that were subsequently reported as such on X-Ray, giving it a specificity of 100% (CI 88.43 - 100). Failure to achieve reduction was correctly identified on US in three cases, resulting in post-reduction US Sensitivity of 100% (CI 29.24 - 100) and 100% accuracy (CI 89.42 - 100). Conclusion This study has shown that POCUS, with a posterior approach technique, has 100% sensitivity and specificity in confirming successful shoulder reduction in the ED.

Design and assessment of a penile fracture simulation model

OBJECTIVE

To design and assess a novel penile fracture simulation model for teaching penile fracture repair.

METHODS

We used a validated circumcision simulator to create a model. Foreskin for a circumcision was divided into two halves. A transverse slit ("simulated fracture") was created on one part of the first half of the foreskin (mimicking "tunica") and was applied over the penile model. A red jelly tablet ("clot") was placed underneath the cut. A second full-length of foreskin was applied over it to cover the defect. The model was assessed by participants and expert faculty at the Urology Simulation Boot Camp. Evaluation was performed using a 5-point Likert Scale questionnaire. Data was analysed using Microsoft Excel and IBM SPSS Statistics V25. The intra-class correlation was calculated using a "One-way random model".

RESULTS

Twenty-two urology trainees and four experts participated in the evaluation. The majority of trainees strongly agreed (59%, n=13) the model is useful for training with experts similarly agreeing in 75% of cases. The appearance of penile fracture was considered good by both trainees (68%, n=14) and faculty (75%). Overall, the ability of the model to represent a realistic simulation of the task was considered excellent by 23% of participants and good by 64%. Personal confidence after simulation in managing a similar situation was considered high among trainees. The main difficulties reported were related to fascial planes and urethra.

CONCLUSION

This is the first simulation model for penile fracture repair and has demonstrated face validity at a national urology bootcamp.

TBX3 and TBX5 duplication: A family with an atypical overlapping Holt-Oram/ulnar-mammary syndrome phenotype

Holt-Oram syndrome (HOS) is a rare, autosomal dominant heart-hand syndrome caused by mutations in the TBX5 gene. A wide spectrum of TBX5 mutations have been reported previously, most resulting in a null allele leading to haploinsufficiency. TBX5 gene duplications have been previously reported in association with typical and atypical HOS phenotypes. Ulnar-Mammary syndrome (UMS) is a distinct rare, autosomal dominant condition caused by mutations in the TBX3 gene. TBX5 and TBX3 are physically linked in cis on human chromosome 12 and contiguous chromosome 12q24 deletions comprising both TBX5 and TBX3 genes have been previously reported but to our knowledge, duplications have never been described. We report on a large German family with at least 17 affected individuals over 6 generations bearing a duplication at 12q24.21 identified on array-CGH comprising both TBX5 and TBX3 genes. Affected patients are presenting with HOS and UMS symptoms, consisting of variable limb anomalies involving the radial and the ulnar rays and cardiac findings such as congenital heart defects, persistent arterial duct or aortic stenosis, and non-classical symptoms, such as supernumerary nipples and cardiomyopathy. Fluorescence in situ hybridisation confirmed a tandem duplication at the 12q24.21 locus. This is the first report of a contiguous TBX3/TBX5 duplication associated with HOS/UMS phenotype.

A training model to teach early management of priapism

BACKGROUND

Ischaemic priapism is a urological emergency with early treatment required to prevent irreversible loss of erectile function. Corporal aspiration is the first step in management. Currently, there are no satisfactory training models to develop skills in a controlled environment. We have therefore developed a novel training model to teach trainees the steps of penile aspiration in a safe and representative way.

MATERIALS AND METHODS

We have developed a priapism model using an old catheterisation teaching model. Face validity of the model was assessed by participants and experienced urologists teaching on a urology boot camp. All had managed at least 5 cases of actual priapism. Responses were reported using a 5-point Likert Scale. Data were analysed using IBM SPSS Statistics V25. The intra-class correlation was calculated using a «One-way Random model».

RESULTS

Eleven urologists and seven trainees participated in the evaluation. The model appearance was reported as the best simulation trait of the priapism model. Tactile feedback from needle insertion for aspiration was also felt to be realistic with 72.6% reporting it as «Good» or «very good» and 85.7% reported the model to be realistic for needle insertion. Intra-class correlation amongst experts was 0.552. Majority of trainees (83.3%) reported a realistic simulation. All evaluators agreed or strongly agreed that the model provided a good simulated experience that would be useful in training.

CONCLUSION

Our model provides a realistic simulation of corporal aspiration. It can be used repeatedly. Overall, the proposed model appears to be a promising tool for training junior doctors in the initial management of ischaemic priapism.

A developmental basis for the anatomical diversity of dermis in homeostasis and wound repair

The dermis has disparate embryonic origins; abdominal dermis develops from lateral plate mesoderm, dorsal dermis from paraxial mesoderm and facial dermis from neural crest. However, the cell and molecular differences and their functional implications have not been described. We hypothesise that the embryonic origin of the dermis underpins regional characteristics of skin, including its response to wounding. We have compared abdomen, back and cheek, three anatomical sites representing the distinct embryonic tissues from which the dermis can arise, during homeostasis and wound repair using RNA sequencing, histology and fibroblast cultures. Our transcriptional analyses demonstrate differences between body sites that reflect their diverse origins. Moreover, we report histological and transcriptional variations during a wound response, including site differences in ECM composition, cell migration and proliferation, and re‐enactment of distinct developmental programmes. These findings reveal profound regional variation in the mechanisms of tissue repair. © 2020 The Authors. The Journal of Pathology published by John Wiley & Sons, Ltd. on behalf of The Pathological Society of Great Britain and Ireland.

Optimal Timing of CT Scanning in the Rapid Access Lung Cancer Clinic

Aims To investigate whether a ‘CT first’ approach to Rapid Access Lung Cancer Clinic (RALC) review could be feasible in an Irish context. Methods A retrospective review of our institution’s Lung Cancer Database was performed. All RALC first attendances from 2012-2018 were identified. Timing of CT was assessed as well as CT imaging findings. Results Total first attendances in this period were 2372, of whom 91% had CT thorax as part of their evaluation. 866 patients (37%) were diagnosed with lung cancer, all had an abnormal CT. 1290 patients (54%) underwent CT but did not have lung cancer after clinical work up. 34% of patients diagnosed with Lung Cancer had their CT scan post RALC. Time to diagnosis was longer in those who had post RALC CT (34.5 versus 21 days) Conclusion CT scanning plays a vital role in the RALC pathway. Initial delays in obtaining CT can result in delayed time to diagnosis. These findings warrant close consideration when devising future national lung cancer policy.

The Role of Retinoic Acid in Establishing the Early Limb Bud

Retinoic acid (RA) was one of the first molecules in the modern era of experimental embryology to be shown capable of generating profound effects on limb development. In this review, we focus on the earliest events of limb development and specifically on the role of RA in establishing the domain of cells that will go on to form the limb itself. Although there is some consensus on the role of RA during the earliest stages of limb formation, some controversy remains on the mechanism of RA action and the requirement for RA signaling in forming the hindlimb buds.

RADIATE - Radial Dysplasia Assessment, Treatment and Aetiology: protocol for the development of a core outcome set using a Delphi survey

BACKGROUND

Radial dysplasia (RD) is a disfiguring, potentially disabling congenital upper limb anomaly. Multiple surgical techniques are in current use, with little agreement on the optimal treatment approach. At present, no core outcome set exists specifically for RD, and the literature is dominated by retrospective case series. A recent systematic review by this group demonstrated significant heterogeneity on which outcomes are measured and how they are measured.

METHODS/DESIGN

The RADIATE study will conduct a three-round online Delphi process, involving adult RD patients, the parents of children with RD, hand surgeons and hand therapists. The initial list of outcomes was drawn from our recent systematic review and will be supplemented by suggestions from the stakeholder groups. Following the Delphi process, outcomes that meet the consensus in definition will be ratified at a final consensus meeting. We will then follow the COSMIN guidelines to select outcome measurement instruments. Where appropriate, these will overlap with the outcome measures specified in the forthcoming standard set for congenital upper limb anomalies published by the International Consortium for Health Outcomes Measurement.

DISCUSSION

The Radial Dysplasia Assessment, Treatment and Aetiology (RADIATE) study aims to address the uncertainty in the treatment of RD, and to begin to answer the question 'What is the most appropriate treatment of the forearm and hand for children with RD?' by establishing a core outcome set.

TRIAL REGISTRATION

COMET initiative study, 902 . Registered in May 2016.

Effects of larvae density and food concentration on Crown-of-Thorns seastar (Acanthaster cf. solaris) development in an automated flow-through system

Coral-eating Crown-of-Thorns Sea stars (Acanthaster spp.) are major contributors to coral reef loss in the Indo-Pacific region. A release from food limitation of their planktotrophic larvae through enhanced pelagic productivity is one of the main hypothesis explaining population outbreaks (‘nutrient limitation hypothesis’). To improve the understanding of these outbreaks we developed an automated flow- through larvae rearing system that maintained food (microalgae) at set levels over the course of four 15d experiments. This resulted in stable food concentrations in experimental tanks. Increased algae concentrations had a significant positive effect on larval development and size at 10 and 15 days post fertilization (dpf). Larvae densities had no effect at 10 dpf. At 15 dpf greater larvae densities were associated with declines in larvae size. Larval development was slowed under higher larvae densities. Thus, the effects of algae concentration and larvae density were additive at 15 dpf, with larvae under low densities at a given algae concentration being further developed than those under higher densities. The development of a flow-through system gives greater insight into the effect of algae and larvae concentrations on Acanthaster development, and the system can be applied to further test the nutrient-limitation hypothesis for present and future outbreaks.

Superior immunogenicity of HCV envelope glycoproteins when adjuvanted with cyclic-di-AMP, a STING activator or archaeosomes

Three decades after the discovery, hepatitis C virus (HCV) is still the leading cause of liver transplantation and poses a major threat to global health. In spite of recent advances in the development of direct acting antivirals, there is still a need for a prophylactic vaccine to limit the virus spread and protect at-risk populations, especially in developing countries, where the cost of the new treatments may severely limit access. The use of recombinant HCV glycoproteins E1E2 (rE1E2) in combination with the MF59, an oil-in-water emulsion-based adjuvant, has previously been shown to reduce the rate of chronicity in chimpanzees and to induce production of cross-neutralizing antibodies and cellular immune responses in human volunteers. To further improve neutralizing antibody responses in recipients along with robust T cell responses, we have explored the immunogenicity of different adjuvants when formulated with the HCV rE1E2 vaccine in mice. Our data show that cyclic di-adenosine monophosphate (c-di-AMP) and archaeosomes elicit strong neutralizing antibodies similar to those elicited using aluminum hydroxide/monophosphoryl lipid A (Alum/monophos. /MPLA) and MF59. However, both c-di-AMP and archaeosomes induced a more robust cellular immune response, which was confirmed by the detection of vaccine-specific poly-functional CD4⁺ T cells. We conclude that these adjuvants may substantially boost the immunogenicity of our E1E2 vaccine. In addition, our data also indicates that use of a partial or exclusive intranasal immunization regimen may also be feasible using c-di-AMP as adjuvant.

Differential Cellular Responses to Hedgehog Signalling in Vertebrates-What is the Role of Competence?

A surprisingly small number of signalling pathways generate a plethora of cellular responses ranging from the acquisition of multiple cell fates to proliferation, differentiation, morphogenesis and cell death. These diverse responses may be due to the dose-dependent activities of signalling factors, or to intrinsic differences in the response of cells to a given signal—a phenomenon called differential cellular competence. In this review, we focus on temporal and spatial differences in competence for Hedgehog (HH) signalling, a signalling pathway that is reiteratively employed in embryos and adult organisms. We discuss the upstream signals and mechanisms that may establish differential competence for HHs in a range of different tissues. We argue that the changing competence for HH signalling provides a four-dimensional framework for the interpretation of the signal that is essential for the emergence of functional anatomy. A number of diseases—including several types of cancer—are caused by malfunctions of the HH pathway. A better understanding of what provides differential competence for this signal may reveal HH-related disease mechanisms and equip us with more specific tools to manipulate HH signalling in the clinic.

Bat Accelerated Regions Identify a Bat Forelimb Specific Enhancer in the HoxD Locus

The molecular events leading to the development of the bat wing remain largely unknown, and are thought to be caused, in part, by changes in gene expression during limb development. These expression changes could be instigated by variations in gene regulatory enhancers. Here, we used a comparative genomics approach to identify regions that evolved rapidly in the bat ancestor, but are highly conserved in other vertebrates. We discovered 166 bat accelerated regions (BARs) that overlap H3K27ac and p300 ChIP-seq peaks in developing mouse limbs. Using a mouse enhancer assay, we show that five Myotis lucifugus BARs drive gene expression in the developing mouse limb, with the majority showing differential enhancer activity compared to the mouse orthologous BAR sequences. These include BAR116, which is located telomeric to the HoxD cluster and had robust forelimb expression for the M. lucifugus sequence and no activity for the mouse sequence at embryonic day 12.5. Developing limb expression analysis of Hoxd10-Hoxd13 in Miniopterus natalensis bats showed a high-forelimb weak-hindlimb expression for Hoxd10-Hoxd11, similar to the expression trend observed for M. lucifugus BAR116 in mice, suggesting that it could be involved in the regulation of the bat HoxD complex. Combined, our results highlight novel regulatory regions that could be instrumental for the morphological differences leading to the development of the bat wing.

Regional movement patterns of a small-bodied shark revealed by stable-isotope analysis

This study used stable-isotope analysis to define the nearshore regional residency and movements of the small-bodied Australian sharpnose shark Rhizoprionodon taylori. Plasma and muscle δ(13) C and δ(15) N of R. taylori were collected from across five embayments and compared with values of seagrass and plankton from each bay. Linear distances between adjacent bays ranged from 30 to 150 km. There was a positive geographic correlation between R. taylori tissue and environmental δ(13) C values. Populations with the highest tissue δ(15) N were collected from bays that had the highest environmental δ(15) N values. These results suggest that R. taylori did not forage more than 100 km away from their capture location within 6 months to 1 year. The successful application of isotope analysis to define R. taylori movement demonstrates that this technique may be used in addition to traditional methods to study the movement of sharks, even within similar habitats across regionally small spatial scales (<100 km).

Retinoic acid-independent expression of Meis2 during autopod patterning in the developing bat and mouse limb

BACKGROUND

The bat has strikingly divergent forelimbs (long digits supporting wing membranes) and hindlimbs (short, typically free digits) due to the distinct requirements of both aerial and terrestrial locomotion. During embryonic development, the morphology of the bat forelimb deviates dramatically from the mouse and chick, offering an alternative paradigm for identifying genes that play an important role in limb patterning.

RESULTS

Using transcriptome analysis of developing Natal long-fingered bat (Miniopterus natalensis) fore- and hindlimbs, we demonstrate that the transcription factor Meis2 has a significantly higher expression in bat forelimb autopods compared to hindlimbs. Validation by reverse transcriptase and quantitative polymerase chain reaction (RT-qPCR) and whole mount in situ hybridisation shows that Meis2, conventionally known as a marker of the early proximal limb bud, is upregulated in the bat forelimb autopod from CS16. Meis2 expression is localised to the expanding interdigital webbing and the membranes linking the wing to the hindlimb and tail. In mice, Meis2 is also expressed in the interdigital region prior to tissue regression. This interdigital Meis2 expression is not activated by retinoic acid (RA) signalling as it is present in the retained interdigital tissue of Rdh10 (trex/trex) mice, which lack RA. Additionally, genes encoding RA-synthesising enzymes, Rdh10 and Aldh1a2, and the RA nuclear receptor Rarβ are robustly expressed in bat fore- and hindlimb interdigital tissues indicating that the mechanism that retains interdigital tissue in bats also occurs independently of RA signalling.

CONCLUSIONS

Mammalian interdigital Meis2 expression, and upregulation in the interdigital webbing of bat wings, suggests an important role for Meis2 in autopod development. Interdigital Meis2 expression is RA-independent, and retention of interdigital webbing in bat wings is not due to the suppression of RA-induced cell death. Rather, RA signalling may play a role in the thinning (rather than complete loss) of the interdigital tissue in the bat forelimb, while Meis2 may interact with other factors during both bat and mouse autopod development to maintain a pool of interdigital cells that contribute to digit patterning and growth.

Nosocomial outbreak of staphyloccocal scalded skin syndrome in neonates in England, December 2012 to March 2013

Staphylococcal scalded skin syndrome (SSSS) is a blistering skin condition caused by exfoliative toxin-producing strains of Staphylococcus aureus. Outbreaks of SSSS in maternity settings are rarely reported. We describe an outbreak of SSSS that occurred among neonates born at a maternity unit in England during December 2012 to March 2013. Detailed epidemiological and microbiological investigations were undertaken. Eight neonates were found to be infected with the outbreak strain of S. aureus, of spa type t346, representing a single pulsotype. All eight isolates contained genes encoding exfoliative toxin A (eta) and six of them contained genes encoding toxin B (etb). Nasal swabs taken during targeted staff screening yielded a staphylococcal carriage rate of 21% (17/80), but none contained the outbreak strain. Mass screening involving multi-site swabbing and pooled, enrichment culture identified a healthcare worker (HCW) with the outbreak strain. This HCW was known to have a chronic skin condition and their initial nasal screen was negative. The outbreak ended when they were excluded from work. This outbreak highlights the need for implementing robust swabbing and culture methodswhen conventional techniques are unsuccessful in identifying staff carrier(s). This study adds to the growing body of evidence on the role of HCWs in nosocomial transmission of S. aureus.

The effects of river run-off on water clarity across the central Great Barrier Reef

Changes in water clarity across the shallow continental shelf of the central Great Barrier Reef were investigated from ten years of daily river load, oceanographic and MODIS-Aqua data. Mean photic depth (i.e., the depth of 10% of surface irradiance) was related to river loads after statistical removal of wave and tidal effects. Across the ∼25,000 km(2) area, photic depth was strongly related to river freshwater and phosphorus loads (R(2)=0.65 and 0.51, respectively). In the six wetter years, photic depth was reduced by 19.8% and below water quality guidelines for 156 days, compared to 9 days in the drier years. After onset of the seasonal river floods, photic depth was reduced for on average 6-8 months, gradually returning to clearer baseline values. Relationships were strongest inshore and midshelf (∼12-80 km from the coast), and weaker near the chronically turbid coast. The data show that reductions in river loads would measurably improve shelf water clarity, with significant ecosystem health benefits.

Visualizing the lateral somitic frontier in the Prx1Cre transgenic mouse

Changes in the organization of the musculoskeletal system have accounted for many evolutionary adaptations in the vertebrate body plan. The musculoskeletal system develops from two mesodermal populations: somitic mesoderm gives rise to the axial skeleton and all of the skeletal muscle of the body, and lateral plate mesoderm gives rise to the appendicular skeleton. The recognition of embryonic domains resulting from the dynamics of morphogenesis has inspired new terminology based on developmental criteria. Two mesodermal domains are defined, primaxial and abaxial. The primaxial domain includes musculoskeletal structures comprising just somitic cells. The abaxial domain contains somitic myoblasts in connective tissue derived from lateral plate mesoderm, as well as lateral plate-derived skeletal structures. The boundary between these two domains is the lateral somitic frontier. Recent studies have described the developmental relationship between these two domains in the chick. In the present study, we describe the labelling pattern in the body of the Prx1/Cre/Z/AP compound transgenic mouse. The enhancer employed in this transgenic leads to reporter expression in the postcranial, somatic lateral plate mesoderm. The boundary between labelled and unlabelled cell populations is described at embryonic day (E)13.5 and E15.5. We argue that the distribution of labelled cells is consistent with the somatic lateral plate lineage, and therefore provides an estimate of the position of the lateral somitic frontier. The role of the frontier in both development and evolution is discussed.

Fine-needle trucut biopsy versus fine-needle aspiration cytology with ultrasound guidance in the abdomen

Historically, fine-needle aspiration cytology (FNAC) has varying sensitivity, specificity and accuracy in the diagnosis of abdominal lesions with a high insufficient sampling rate. We compared 20-G fine-needle trucut biopsy (FNTB) with FNAC results in the biopsy of solid abdominal tumours. A retrospective review of 171 (128x 20-G FNTB and 43x FNAC) ultrasound-guided biopsies of abdominal tumours on 157 patients (male : female 85:72, mean age 61.25 years) were carried out. One hundred and seventy-one biopsies were carried out: liver 109, pancreas 19, lymph node 10, omentum 5, right iliac fossa mass 6, adrenal 6 and others 16. An average of 2.06 and 1.97 passes (range 1-4) were carried out per FNTB and FNAC, respectively. A definitive diagnosis was made in 122/128 biopsies (95.3%) and 32/43 biopsies (74.4%) for FNTB and FNAC, respectively. Diagnoses consisted of metastatic liver disease (74/171), pancreatic adenocarcinoma (10/171), lymphoma (8/171) and others (33/171) and benign (29/171). No significant complications occurred in either group. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 87, 100, 100, 50, 84.4 and 93.1, 100, 100, 60, 71.4 for FNTB and FNAC, respectively. A greater and more consistent positive diagnosis rate is yielded by 20-G FNTB (95.3%) than FNAC (74.4%). The diagnostic accuracy of FNTB is 84.4% compared with 69.8% for FNAC. A greater insufficient sampling rate occurs with FNAC (25.6%) than with FNTB (4.7%). For abdominal biopsy, 20-G FNTB needles have a much higher yield than FNAC with no increase in complications. FNTB is the preferred choice, particularly where cytological assistance at the time of biopsy is unavailable.

Regional morphogenesis in the hypothalamus: a BMP-Tbx2 pathway coordinates fate and proliferation through Shh downregulation

A central challenge in embryonic development is to understand how growth and pattern are coordinated to direct emerging new territories during morphogenesis. Here, we report on a signaling cascade that links cell proliferation and fate, promoting formation of a distinct progenitor domain within the developing chick hypothalamus. We show that the downregulation of Shh in floor plate-like cells in the forebrain governs their progression to a distinctive, proliferating hypothalamic progenitor domain. Shh downregulation occurs via a local BMP-Tbx2 pathway, Tbx2 acting to repress Shh expression. We show in vivo and in vitro that forced maintenance of Shh in hypothalamic progenitors prevents their normal morphogenesis, leading to maintenance of the Shh receptor, ptc, and preventing progression to an Emx2(+)-proliferative progenitor state. Our data identify a molecular pathway for the downregulation of Shh via a BMP-Tbx2 pathway and provide a mechanism for expansion of a discrete progenitor domain within the developing forebrain.

Pitx1 determines the morphology of muscle, tendon, and bones of the hindlimb

The vertebrate forelimb and hindlimb are serially homologous structures; however, their distinctive morphologies suggest that different mechanisms are associated with each limb type to give rise to limb-type identity. Three genes have been implicated in this process; T-box transcription factors Tbx5 and Tbx4, which are expressed in the forelimb and hindlimb, respectively, and a paired-type homeodomain transcription factor Pitx1, expressed in the hindlimb. To explore the roles of Pitx1 and Tbx4 in patterning the hindlimb, we have ectopically misexpressed these genes in the mouse forelimb using transgenic methods. We have developed a novel technique for visualising the structure and organisation of tissues in limbs in 3D using optical projection tomography (OPT). This approach provides unparalleled access to understanding the relationships between connective tissues during development of the limb. Misexpression of Pitx1 in the forelimb results in the transformation and translocation of specific muscles, tendons, and bones of the forelimb so that they acquire a hindlimb-like morphology. Pitx1 also upregulates hindlimb-specific factors in the forelimb, including Hoxc10 and Tbx4. In contrast, misexpression of Tbx4 in the forelimb does not result in a transformation of limb-type morphology. These results demonstrate that Pitx1, but not Tbx4, determines the morphological identity of hindlimb tissues.

Human Vero cytotoxigenic Escherichia coli (VTEC) O157 infection linked to birds

Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) infections are a threat to public health. VTEC O157 has been isolated from gulls but evidence of transmission to humans from birds has not been reported. We recount an incident of VTEC O157 infection affecting two sibling children who had no direct contact with farm animals. An outbreak control team was convened to investigate the source of infection, its likely mode of transmission, and to advise on control measures. Human and veterinary samples were examined and the human isolates were found to be identical to an isolate from a sample of bird (rook) faeces. Cattle, rabbit and environmental samples were negative. This report provides evidence that birds may act as intermediaries for human infection with VTEC O157.

Development and implementation of a watershed management plan forLlac la Biche, Alberta, Canada

Lakeland County is experiencing increasing developmental pressures arising from the oil and gas boom at nearby Fort McMurray. There is increased industrial traffic passing through the county, and 600 new residential lots are proposed in 2005, almost double from 5 years ago. Deteriorating surface water quality has been a concern in the area due to an increase in development and agriculture, while excessive fish harvesting and winterkills have impacted commercial and recreational fisheries. Today, walleye and pike populations in the lake remain collapsed and restocking efforts have not been successful. Due to the lack of studies done on the watershed, the county is leading a multidisciplinary research study which includes a baseline water quality study, riparian health assessments, land use mapping and ground-truthing and projects with the local health authority. This research has been summarized in a comprehensive state of the watershed report, which will be used to complete a watershed management plan for the Lac la Biche watershed. Recommendations from the state of the watershed report and watershed management plan will also be incorporated into municipal planning documents and recommend changes to the Municipal Government Act itself.

Early developmental arrest of mammalian limbs lacking HoxA/HoxD gene function

Vertebrate HoxA and HoxD cluster genes are required for proper limb development. However, early lethality, compensation and redundancy have made a full assessment of their function difficult. Here we describe mice that are lacking all Hoxa and Hoxd functions in their forelimbs. We show that such limbs are arrested early in their developmental patterning and display severe truncations of distal elements, partly owing to the absence of Sonic hedgehog expression. These results indicate that the evolutionary recruitment of Hox gene function into growing appendages might have been crucial in implementing hedgehog signalling, subsequently leading to the distal extension of tetrapod appendages. Accordingly, these mutant limbs may be reminiscent of an ancestral trunk extension, related to that proposed for arthropods.

The comparative genomics of T-box genes

T-box genes are defined by the presence of a conserved sequence, the so-called T-box; this codes for the T-domain, which is involved in DNA-binding and protein dimerisation. Members of this gene family have been found in all metazoans, from diploblasts to humans, and mutations in T-box gene family members in humans have been linked to several congenital disorders. Sequencing of the complete genomes of a range of invertebrate and vertebrate species has allowed the classification of individual T-box genes into five subfamilies: Brachyury, T-brain1, Tbx1, Tbx2 and Tbx6. This review will largely focus on T-box genes identified in organisms whose genomes have been fully sequenced, emphasising how comparative studies of the T-box gene family will help to reveal the roles of these genes during development and in the adult.

Developmental biology reaches new lineages

A report on the Developmental Biology Annual Symposium and GENETICS 2004, Warwick, UK, 14-16 March 2004.

A report on the Developmental Biology Annual Symposium and GENETICS 2004, Warwick, UK, 14-16 March 2004.

Finger or toe: the molecular basis of limb identity

Despite their obvious similarities, the forelimbs and hindlimbs of tetrapod vertebrates have evolved distinct structural elements to carry out their discrete functions. Many genes required for limb initiation and patterning are involved in regulatory networks common to both limb-types. Other genes are differentially expressed between forelimb and hindlimb, and have been implicated in the initiation of limb bud outgrowth and the specification of limb-type identity. In this review, I will discuss the current understanding of how genes that control limb identity interact with regulatory networks common to both appendages to produce the fingers of the hand and toes of the foot.

Control of skeletal patterning by ephrinB1-EphB interactions

We report that targeted inactivation of the Eph receptor ligand ephrinB1 in mouse caused perinatal lethality, edema, defective body wall closure, and skeletal abnormalities. In the thorax, sternocostal connections were arranged asymmetrically and sternebrae were fused, defects that were phenocopied in EphB2/EphB3 receptor mutants. In the wrist, loss of ephrinB1 led to abnormal cartilage segmentation and the formation of additional skeletal elements. We conclude that ephrinB1 and B class Eph receptors provide positional cues required for the normal morphogenesis of skeletal elements. Another malformation, preaxial polydactyly, was exclusively seen in heterozygous females in which expression of the X-linked ephrinB1 gene was mosaic, so that ectopic EphB-ephrinB1 interactions led to restricted cell movements and the bifurcation of digital rays. Our findings suggest that differential cell adhesion and sorting might be relevant for an unusual class of X-linked human genetic disorders, in which heterozygous females show more severe phenotypes than hemizygous males.

Class 3 semaphorins control vascular morphogenesis by inhibiting integrin function

The motility and morphogenesis of endothelial cells is controlled by spatio-temporally regulated activation of integrin adhesion receptors, and integrin activation is stimulated by major determinants of vascular remodelling. In order for endothelial cells to be responsive to changes in activator gradients, the adhesiveness of these cells to the extracellular matrix must be dynamic, and negative regulators of integrins could be required. Here we show that during vascular development and experimental angiogenesis, endothelial cells generate autocrine chemorepulsive signals of class 3 semaphorins (SEMA3 proteins) that localize at nascent adhesive sites in spreading endothelial cells. Disrupting endogenous SEMA3 function in endothelial cells stimulates integrin-mediated adhesion and migration to extracellular matrices, whereas exogenous SEMA3 proteins antagonize integrin activation. Misexpression of dominant negative SEMA3 receptors in chick embryo endothelial cells locks integrins in an active conformation, and severely impairs vascular remodelling. Sema3a null mice show vascular defects as well. Thus during angiogenesis endothelial SEMA3 proteins endow the vascular system with the plasticity required for its reshaping by controlling integrin function.

The effects of lactation on the feeding behaviour and activity patterns of free-ranging female koalas (Phascolarctos cinereus Goldfuss)

The free-ranging feeding behaviour and activity patterns of three lactating and two non-lactating female koalas (Phascolarctos cinereus) were investigated using acoustically sensitive radio-telemetry. Lactating females were found to consume more leaf material, masticate more per leaf and at a greater rate, and perform more ingestive and mercyism mastications per 24 h than non-lactating females. Results suggest than female koalas are 'income breeders' that compensate for the higher energetic demands of lactation by increasing intake and, to a lesser degree, investing more in each mouthful so as to produce a shift in digesta particle size distribution in favour of more finer particles. Compared with non-lactating females, lactating female koalas were also found to spend more time moving within trees, feeding per 24 h and per bout, and less time resting and sleeping per 24 h, although the proportion of active time spent feeding was similar (~80%). This implies that female koalas adopt a 'time minimizing strategy whereby activity budgets respond to current requirements. Lactation-compensation mechanisms are compared with those reported for koalas with high tooth wear, and the capacity of aging female koalas to compensate for lactation are discussed.

How do microbiology consultants undertake their jobs? A survey of consultant time and tasks in South West England

AIMS

To measure the total consultant medical microbiologist (CMM) weekly workload, to identify time spent on different activities, and to differentiate those tasks that were viewed by a consensus of consultants as core activities from those that could be accorded a lower priority.

METHODS

A self administered questionnaire completed by consultant medical microbiologists in the Public Health Laboratory Service South West Group.

RESULTS

Reported hours worked by respondents ranged from 41 to 65 hours each week, excluding on call activities. Eleven of 20 respondents reported working in excess of 48 hours each week. There was no correlation between hours worked and laboratory workload as measured by numbers of specimens. Clinical liaison, result authorisation, infection control, and management activities took up most time. Working practices varied widely between individuals, partly reflecting their differing roles in the laboratory. A consensus was reached regarding the relative importance and priority of many regular CMM activities.

CONCLUSIONS

Consultant microbiologists can identify, with consensus, both high and lower priority activities in their daily practice. If such clinical priorities can be more widely agreed across the profession, this would provide a rational approach to workload control.