GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham

OBJECTIVE

Service evaluation of GP access to Faecal Immunochemical Test (FIT) for colorectal cancer (CRC) detection in Nottinghamshire and use of FIT for "rule out", "rule in" and "first test selection".

DESIGN

Retrospective audit of FIT results, CRC outcomes and resource utilisation before and after introduction of FIT in Primary Care in November 2017. Data from the new pathway up to December 2018 was compared with previous experience.

RESULTS

Between November 2017 and December 2018, 6747 GP FIT test requests yielded 5733 FIT results, of which 4082 (71.2%) were <4.0 μg Hb/g faeces, 579 (10.1%) were 4.0-9.9 μg Hb/g faeces, 836 (14.6%) were 10.0-149.9 μg Hb/g faeces, and 236 (4.1%) were ≥150.0 μg Hb/g faeces. The proportion of "rule out" results <4.0 μg Hb/g faeces was significantly higher than in the Getting FIT cohort (71.2% vs 60.4%, Chi squared 42.8, p < 0.0001) and the proportion of "rule in" results ≥150.0 μg Hb/g faeces was significantly lower (4.1% vs 8.1%, Chi squared 27.3,P < 0.0001). There was a 33% rise in urgent referrals across Nottingham overall during the evaluation period. 2 CRC diagnoses were made in 4082 patients who had FIT<4.0 μg Hb/g faeces. 58.4% of new CRC diagnoses associated with a positive FIT were early stage cancers (Stage I and II). The proportion of all CRC diagnoses that follow an urgent referral s rose after introduction of FIT.

CONCLUSIONS

FIT allows GP's to select a more appropriate cohort for urgent investigation without a large number of missed diagnoses. FIT appears to promise a "stage migration" effect which may ultimately improve CRC outcomes.

Assessment of cross-resistance potential to neonicotinoid insecticides in Bemisia tabaci (Hemiptera: Aleyrodidae)

Laboratory bioassays were carried out with four neonicotinoid insecticides on multiple strains of Bemisia tabaci (Gennadius) to evaluate resistance and cross-resistance patterns. Three imidacloprid-resistant strains and field populations from three different locations in the southwestern USA were compared in systemic uptake bioassays with acetamiprid, dinotefuran, imidacloprid and thiamethoxam. An imidacloprid-resistant strain (IM-R) with 120-fold resistance originally collected from Imperial Valley, California, did not show cross-resistance to acetamiprid, dinotefuran or thiamethoxam. The Guatemala-resistant strain (GU-R) that was also highly resistant to imidacloprid (RR=109-fold) showed low levels of cross-resistance when bioassayed with acetamiprid and thiamethoxam. However, dinotefuran was more toxic than either imidacloprid or thiamethoxam to both IM-R and GU-R strains as indicated by low LC50s. By contrast, a Q-biotype Spanish-resistant strain (SQ-R) of B. tabaci highly resistant to imidacloprid demonstrated high cross-resistance to the two related neonicotinoids. Field populations from Imperial Valley (California), Maricopa and Yuma (Arizona), showed variable susceptibility to imidacloprid (LC50s ranging from 3.39 to 115 microg ml(-1)) but did not exhibit cross-resistance to the three neonicotinoids suggesting that all three compounds would be effective in managing whiteflies. Yuma populations were the most susceptible to imidacloprid. Dinotefuran was the most toxic of the four neonicotinoids against field populations. Although differences in binding at the target site and metabolic pathways may influence the variability in cross-resistance patterns among whitefly populations, comparison of whitefly responses from various geographic regions to the four neonicotinoids indicates the importance of ecological and operational factors on development of cross-resistance to the neonicotinoids.

The feasibility of integrated STI prevalence and behaviour surveys in developing countries

BACKGROUND

In countries where STI/HIV prevalence data and behavioural data are scarce UNAIDS second generation HIV surveillance guidelines recommend measuring STI/HIV prevalence and risk behaviours in vulnerable populations but do not recommend conducting these surveys concurrently because of concerns about participation rates, cost, and provision of services.

OBJECTIVES

To assess the feasibility of conducting a national combined STD prevalence and behaviour survey in Mali among vulnerable populations with the intention of institutionalisation.

METHODS

From March to June 2000 an integrated STI prevalence and behaviour survey was conducted using cluster sampling among five risk groups in four sites in Mali, west Africa. 2229 individuals in non-traditional settings such as taxi/bus stations, market areas, households, and brothels participated in any one or all components of the study: (1) behavioural questionnaire, (2) urine sample for Neisseria gonorrhoeae (GC)/Chlamydia trachomatis (CT) testing, (3) a fingerstick drop of blood for syphilis, and/or (4) HIV testing.

RESULTS

High participation rates of 84%-100% were achieved despite specimen collection and HIV testing. Rates fell only slightly when participants were asked to provide biological samples and participants were more likely to provide urine than blood. Rates among the different groups for HIV and syphilis testing are similar and suggest that refusal was most probably because of a reluctance to give blood rather than because of HIV testing. The cost of the biological component added approximately $30 per participant. Included in the $30 are the costs of training, participant services, laboratory personnel and supplies, STI drugs, and STI testing costs. The total cost of the survey was $154,905. Biomarkers aided in validation of answers to behavioural questions. Consenting individuals received HIV pretest and post-test counselling and referral to a trained health provider for treatment of STI and the provision of services provided the framework for interventions in the groups following the survey.

CONCLUSION

This represents an effective methodology for collecting risk behaviour and STI/HIV prevalence information concurrently and should be considered by countries expanding STI/HIV surveillance as part of UNAIDS second generation HIV surveillance.

“The tongue is venomous”: perception, verbalisation and manipulation of mortality and fertility regimes in rural Mali

Demographic theory frequently assumes that pre-transitional populations adopt fatalistic attitudes to fertility and mortality. Fertility decline is said to require a "pro-active" mentality incorporating a newly conceived idea of numeracy about children and a new-found awareness by individuals of where they stand in relation to demographic norms. Nonnumeric responses to questions about desired family size are interpreted as meaning that women are unable to conceptualise their ideal number of children and are unaware of their demographic environment. However, ethnographic evidence from the Malian Fulani will show how women accurately appraise their mortality and fertility regimes and how they actively seek to manipulate them via a series of ritual behaviours. It is described how women do think numerically about demographic outcomes but are reluctant to verbalise this numeracy as it is believed that it will incur supernatural risks. The implications for demographic research of the widespread belief in the danger of verbalising numbers of children are discussed.

A qualitative study of clandestine contraceptive use in urban Mali

This prospective study uses qualitative methods to examine the social and economic impact of family planning on women's lives in the district of Bamako, Mali. Fifty-five first-time users of contraceptives were interviewed in October 1996. Of particular interest is the high proportion (17/55) of those who had hidden their use of a birth-control method from their husbands. Substantial collusion is found to have occurred between sisters-in-law in assisting each other to gain and hide methods of family planning and to keep their use secret from their spouses and older marital relatives. The main reason for discontinuation among the clandestine users was menstrual disruption, which they feared would make their husbands aware of their contraceptive use. By the end of the study, women were aware that their use of contraceptives had increased their mobility and available time, enabling them to enhance the quantity and efficiency of their work activities. Contraception, therefore, appears to be a valuable resource, permitting women to improve their economic and social status. In settings where clandestine use is prevalent, at least in the short term involving men in family planning programs may not always be beneficial, nor may considering the couple as the unit of intervention and analysis always be appropriate. In the long term, however, the underlying causes of men's objections to contraceptive use need to be addressed so as to facilitate communication and joint decisionmaking about family planning.

Evidence of enhanced type 2 immune response and impaired upregulation of a type 1 response in frail elderly nursing home residents

Peripheral blood mononuclear cells (PBMC) of frail elderly nursing home residents had significantly higher PHA-induced interleukin-10 (IL-10) production compared to PBMC's from young control subjects. No correlation was observed between IL-10 production and interleukin-12 (IL-12) p40 production, proliferative response or with the proportion of CD28-negative T cells. To better characterize the host response to a ubiquitous pathogen, the dose response and time-dependent (kinetic) production of IL-10 and IL-12 p40 of PBMC stimulated with Staphylococcus aureus Cowan (SAC) was studied. IL-10 production continued to increase at 48 h, while IL-12 p40 levels declined or remained stable, in both young and elderly subjects. In analyzing how excessive IL-10 production might influence antigen presenting cell functions, IL-12 was markedly inhibited by recombinant IL-10 (rIL-10), while anti-IL-10 enhances IL-12 p40 production in cultures from young controls; but the PBMC cultured from an elderly cohort were not able to generate similar absolute levels of IL-12 p40 even in the presence of anti-IL-10. These preliminary data suggest that there may be both over production of IL-10 in some individuals, as well an an impaired ability to upregulate a T Helper 1 (type 1) reaction. These age-related changes could even be more dramatic at the tissue level and contribute to the impaired delayed type hypersensitivity (DTH) and failed host defense to infection, such as to primary and reactivation tuberculosis.

Child development: vulnerability and resilience

Many of the challenges facing children now are a function of changing times, including increase in urbanization, political violence, changing family forms, and in some areas decreased supplies of adequate food. This review focuses particularly on those changes in which children are the victims and which induce new threats for them, rather than on problems such as child disability or mental illness. The outcome variables of interest in this paper are dimensions of children's psychosocial development, including cognitive development, psychological adjustment and aggression, whereas the companion paper in this issue (Caldwell P., Child survival: vulnerability and resilience in adversity in the European past and the contemporary Third World, Soc. Sci. Med.) [1] focuses on physical aspects of children's development. The risks that are hurdles in the process of development of a young child begin from conception and carry on into later life. To address them all would be impossible; thus, in order to do justice to the issues at hand, we have chosen those risks that, in our view, are important in a child's psychosocial development in developing countries. This paper will thus provide a discussion of the concepts of risk and resilience, then apply these concepts to the analysis of three examples of risk faced by children today: nutritional threats (e.g. malnutrition due to decline in breastfeeding); family dynamics and types of family forms (e.g. child fostering and non-traditional families); and experiences of violence (domestic or political). In each case, the same four questions will be addressed: what are the consequences of the risk factor for children, what are the etiologies and conditions of risk, are there any children who seem to cope with the risk factor successfully and what are some of the protective factors, and what interventions or programs would help support these children?

Back to nature? Historical and cross-cultural perspectives on barriers to optimal breastfeeding

This article examines the discrepancy between the recommendations of international authorities concerning breastfeeding and the practices of a significant proportion of women all over the world who discontinue breastfeeding because of the reported insufficiency of their milk. Our review of the evidence on the insufficient milk syndrome suggests that the phenomenon is inextricably linked to the construction of family, gender and motherhood at different historical times and in different parts of the world, and that the prevention of early discontinuation of breastfeeding requires a better understanding of these issues in their historical and cultural context.

Depression in caregivers of demented patients is associated with altered immunity: impaired proliferative capacity, increased CD8+, and a decline in lymphocytes with surface signal transduction molecules (CD38+) and a cytotoxicity marker (CD56+ CD8+)

Changes in relevant immune parameters, including function, were found to be associated with depression in elderly caregiver wives of demented patients. We studied the relationship between immune cell phenotype and T cell proliferative capacity of such caregivers to levels of stress and depression over the course of a support group intervention. The data indicate the strongest association between depression (of all stress parameters) and impaired T cell proliferative capacity. Depression was also most strongly (of stress parameters) associated with a shift in T cell populations with an increase in CD8+ T cells, and a reduced percentage of CD38+ cells in both CD8+ and CD4+ T cell populations. Since CD38 is a signal transduction factor, it was interesting that a decreased percentage of CD38+ cells correlated with impaired T cell function (proliferation). Another significant difference was the reduction in natural killer (NK) cells as well as the percentage of the CD56+ component of the CD8+ population. This latter subset is important in MHC-unrestricted cytotoxicity, and has been found expanded in healthy centenarians. This study shows that both chronic stress, and depression in particular, and age have deleterious effects on T cells, and together could significantly contribute to the higher risk of disease and mortality associated with being a caregiver of a demented individual.

Interrelationship of fever, immune response and aging in mice

Fever is the cardinal manifestation of infection and may be blunted in certain infected elderly individuals. It is known that elevated body temperature enhances both the inflammation response and immune function, resulting in increased host resistance to infection. Recently, it has been suggested that the elevation of body temperature and the activation of lymphocytes by IL-1 are interrelated host effects. However, the question of whether fever response in vivo is closely correlated to cell-mediated immune parameters is unknown. In this study, a well-defined murine model was used to study the relationships between aging, fever and cell-mediated immune response. Thus, measurements of rectal temperature changes were made in individual young (4-6 months) and old (26-27 months) BALB/c mice to determine their ability to respond to endogenous pyrogen (recombinant IL-1). Splenic cells from these animals were used to assess T- and B-cell proliferation, production of interleukin 1 (IL-1) and IL-2. The results revealed that the proliferative capacity and the IL-1 and IL-2 producing capacity of splenic cells from old mice were markedly decreased. However, aging did not significantly affect the mean febrile responses in old mice following rIL-1 injections. Finally, there was no significant correlation between in vivo fever responses and the immune parameters measured in vitro in both young and old mice.

Effect of impaired renal function on the pharmacokinetics of coadministered cefoperazone and sulbactam

The pharmacokinetics of cefoperazone 2 g combined with sulbactam 1 g after a single dose administered intravenously were evaluated in 24 subjects with normal and impaired renal function. Subjects were categorized into four groups based on endogenous creatinine clearance Clcr. Patients in groups 1, 2 and 3 had ClcrS of greater than 60, 31 to 60, and 10 to 30 mL/min/1.73 m2, respectively. Patients in group 4 required maintenance haemodialysis and were assumed to have Clcr less than 10 mL/min/1.73 m2. Pharmacokinetic parameters were determined by noncompartmental methods. No significant differences (P greater than 0.05) in mean peak serum cefoperazone-sulbactam concentrations for group 1 (208.4/29.0 mg/L), group 2 (199.0/34.1 mg/L), group 3 (163.2/35.0 mg/L), and group 4 (234.0/66.0 mg/L) were noted. Correlations between both total serum (r = 0.58) and renal (r = 0.35) clearance and creatinine clearances were negative for cefoperazone, although both were shown to decline with diminished renal function. Correlations between serum (r = 0.85) and renal (r = 0.72) clearances and creatinine clearance for sulbactam were, on the other hand, both positive and declined in a linear fashion. No significant differences in steady state volumes of distribution were noted for either cefoperazone (P = 0.53) or sulbactam (P = 0.85) amongst the four groups. After 24 h, urinary recovery was also comparable for both cefoperazone (P = 0.64) and sulbactam (P = 0.85) amongst the four groups. The concentrations of cefoperazone and sulbactam remained at or above the MICs (16/8 mg/L) for common bacterial pathogens for 2.5, 3, 7 and 14 h in groups 1, 2, 3 and 4, respectively.

Changes with age in the proliferative response of splenic T cells from rats exposed to ethanol in utero

The fetal alcohol syndrome is associated with altered immunity. Several laboratories have confirmed that rodents exposed to ethanol in utero demonstrate both diminished proliferative responses of T cells to mitogens and diminished proliferative responses of T-blast cells to human recombinant interleukin 2 (rIL2). We examined the developmental time course of these altered immune responses by testing the immune function of in utero ethanol-exposed rats at various ages. We found that while diminished splenic T cell proliferative responses could not be detected at 2 weeks, they were present at 6 weeks after birth and suppression was maximal at 6 weeks and 3 months. Thereafter, at 5 and 7 months, the altered immune responses gradually declined and normalized at 8 months of age. Thus, both altered T cell mitogenesis and the blunted IL2-induced proliferative response of T-blast cells could serve as biomarkers of fetal exposure to ethanol.

Single-dose pharmacokinetics of intravenous ampicillin plus sulbactam in healthy elderly and young adult subjects

The pharmacokinetics of intravenous ampicillin and sulbactam, a beta-lactamase inhibitor, were evaluated in two different age groups. Twelve healthy elderly subjects (age 65-93 years) and 12 healthy young adult subjects (age 20-35 years) received both a dose of ampicillin 1 g plus sulbactam 0.5 g and a higher dose of ampicillin 2 g plus sulbactam 1 g after a one-week period between doses. A reverse-phase high-pressure liquid chromatography method was used for the quantitation of ampicillin and sulbactam in serum and urine. The pharmacokinetic parameters for both ampicillin and sulbactam were calculated by computer-based two-compartment nonlinear model. After a 30-min infusion, serum concentrations of both drugs declined in a biexponential manner for both doses. Elderly subjects demonstrated significantly lower total clearances (Clt) than young adult subjects of ampicillin 1 g (220.0 +/- 104.2 vs 360.0 +/- 95.8 ml/min/1.73 m2), ampicillin 2 g (72.6 +/- 36.6 vs 306.8 +/- 109.77 ml/min/1.73 m2), sulbactam 0.5 g (122.3 +/- 47.8 vs 263.9 +/- 93.7 ml/min/1.73 m2), and sulbactam 1 g (171.2 +/- 85.8 vs 391.7 +/- 70.8 ml/min/1.73 m2), respectively. Significance was defined as P less than 0.05. Renal clearance was also significantly reduced in the elderly subjects. Area under the curve was found to be significantly increased in the elderly subjects compared to the young subjects for both ampicillin and sulbactam as were the beta elimination half-lives. No significant difference in the apparent volume of distribution, when adjusted for body weight, was found for either sulbactam (P greater than 0.95) or ampicillin (P greater than 0.95) between the two groups. Linear regression analysis revealed that age was significantly correlated with the Clt of ampicillin 1 g (r = 0.85, P less than 0.001), ampicillin 2 g (r = 0.90, P less than 0.001), sulbactam 0.5 g (r = 0.80, P less than 0.001), and sulbactam 1 g (r = 0.93, P less than 0.001). A multivariate analysis showed a slight improvement in correlation when creatinine clearance was added to age and compared with Clt. Urinary recovery of both ampicillin and sulbactam was approximately 60% after 14 h.

Structural organization of the mouse proto-myb gene

Proto-myb is a highly conserved cellular gene that is closely related to v-myb, the transforming gene of the avian myeloblastosis virus. We have isolated lambda clones encompassing 21 kbp of mouse DNA that contains portions of the proto-myb gene. Also, we have isolated a cDNA clone containing a 2.5 kbp insert corresponding to mouse proto-myb mRNA. By analyzing both the cloned DNAs and mouse genome DNA, we have constructed a restriction map for mouse proto-myb that extends over 50 kbp.

Genetic heterogeneity of factor XIII deficiency: first description of unstable A subunits

In previously reported cases, congenital deficiency of coagulation factor XIII has been found to result from the absence of the enzymatically active A subunits. In the family reported here two members were found to be heterozygous for an unstable A subunit which, in the homozygous state, or in the heterozygous state with the previously described null allele, would be expected to result in factor XIII deficiency. The implications that this new variant has on heterozygote screening are discussed.