The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012

On 22 September 2012, a novel coronavirus, very closely related to that from a fatal case in Saudi Arabia three months previously, was detected in a previously well adult transferred to intensive care in London from Qatar with severe respiratory illness. Strict respiratory isolation was instituted. Ten days after last exposure, none of 64 close contacts had developed severe disease, with 13 of 64 reporting mild respiratory symptoms. The novel coronavirus was not detected in 10 of 10 symptomatic contacts tested.

Severe respiratory illness caused by a novel coronavirus, in a patient transferred to the United Kingdom from the Middle East, September 2012

Coronaviruses have the potential to cause severe transmissible human disease, as demonstrated by the severe acute respiratory syndrome (SARS) outbreak of 2003. We describe here the clinical and virological features of a novel coronavirus infection causing severe respiratory illness in a patient transferred to London, United Kingdom, from the Gulf region of the Middle East.

Human Mendelian pain disorders: a key to discovery and validation of novel analgesics

We have utilized a novel application of human genetics, illuminating the important role that rare genetic disorders can play in the development of novel drugs that may be of relevance for the treatment of both rare and common diseases. By studying a very rare Mendelian disorder of absent pain perception, congenital indifference to pain, we have defined Nav1.7 (endocded by SCN9A) as a critical and novel target for analgesic development. Strong human validation has emerged with SCN9A gain-of-function mutations causing inherited erythromelalgia (IEM) and paroxysmal extreme pain disorder, both Mendelian disorder of spontaneous or easily evoked pain. Furthermore, variations in the Nav1.7 channel also modulate pain perception in healthy subjects as well as in painful conditions such as osteoarthritis and Parkinson disease. On the basis of this, we have developed a novel compound (XEN402) that exhibits potent, voltage-dependent block of Nav1.7. In a small pilot study, we showed that XEN402 blocks Nav1.7 mediated pain associated with IEM thereby demonstrating the use of rare genetic disorders with mutant target channels as a novel approach to rapid proof-of-concept. Our approach underscores the critical role that human genetics can play by illuminating novel and critical pathways pertinent for drug discovery.

Heterotopic pregnancy

Heterotopic pregnancy is a life-threatening condition. A recent case at our institution prompted a systematic review of the literature from 2005 to 2010. In the majority (71%) of cases reviewed, risk factors for a heterotopic pregnancy were present. However, in several instances (33%), previous sonographic reports of a normal intrauterine pregnancy gave false reassurance. These results highlight the complexity of diagnosis. In addition, our findings were compared with two previous reviews covering cases from 1971 to 2004. This comparison highlighted two important trends: first, the increasing role of ultrasound in the definitive diagnosis of a heterotopic pregnancy, and second, the development of conservative approaches to management. Medical knowledge and technology may be improving, but ultimately, even in the presence of a known intrauterine pregnancy, the simple dictum 'think ectopic' must not be forgotten.

Use of insulin glargine during pregnancy: a case-control pilot study

OBJECTIVE

To determine whether the use of insulin glargine during pregnancy is associated with an increase in the incidence of fetal macrosomia or adverse neonatal outcome.

DESIGN

A matched case-control study.

SETTING

Women's Centre, John Radcliffe Hospital, Oxford, UK.

SAMPLE

Sixty-four pregnant women treated with insulin during their pregnancies, 20 with type I diabetes and 44 with gestational diabetes.

METHODS

Two groups of women were compared in matched pairs. A study group of 32 pregnant women with diabetes treated with insulin glargine during their pregnancy and a control group of 32 pregnant women treated with an intermediate-acting human insulin (isophane or insulin zinc suspension) and matched for weight at booking, height, gestation at delivery, parity, fetal sex, duration of insulin use in pregnancy and glycaemic control during the third trimester of pregnancy (glycosylated haemoglobin [HbA(1c)] concentration and mean blood glucose concentration).

MAIN OUTCOME MEASURES

Birthweight, centile birthweight, the incidence of fetal macrosomia (birthweight > 90th percentile) and neonatal morbidity in the two study groups.

RESULTS

There was no significant difference between the birthweight or centile birthweight of babies born to the women treated with insulin glargine during pregnancy and that of the babies born to those in the control group treated with intermediate-acting human insulin. The overall incidence of fetal macrosomia was 12/32 (37.5%) in the insulin glargine group and 13/32 (40.6%) in the control group. There was no significant difference in neonatal morbidity between the groups.

CONCLUSIONS

The results of this pilot study indicate that insulin glargine treatment during pregnancy does not appear to be associated with increased fetal macrosomia or neonatal morbidity.

The autoimmune diabetes locus Idd9 regulates development of type 1 diabetes by affecting the homing of islet-specific T cells

Several genetic insulin-dependent diabetes (Idd) intervals that confer resistance to autoimmune diabetes have been identified in mice and humans, but the mechanisms by which they protect against development of diabetes have not been elucidated. To determine the effect of Idd9 on the function of islet-specific T cells, we established novel BDC-Idd9 mice that harbor BDC2.5 TCR transgenic T cells containing the Idd9 of diabetes-resistant B10 mice. We show that the development and functional responses of islet-specific T cells from BDC-Idd9 mice are not defective compared with those from BDC mice, which contain the Idd9 of diabetes-susceptible NOD mice. Upon transfer, BDC T cells rapidly induced severe insulitis and diabetes in NOD.scid mice, whereas those from BDC-Idd9 mice mediated a milder insulitis and induced diabetes with a significantly delayed onset. BDC and BDC-Idd9 T cells expanded comparably in recipient mice. However, BDC-Idd9 T cells accumulated in splenic periarteriolar lymphatic sheaths, whereas BDC T cells were mainly found in pancreatic lymph nodes and pancreata of recipients, indicating that the transferred T cells differed in their homing. We provide evidence that the migration pattern of transferred BDC and BDC-Idd9 T cells at least partly depends on their differential chemotaxis toward the CCR7 ligand CCL19. Taken together, our data show that the Idd9 locus regulates development of type 1 diabetes by affecting the homing of islet-specific T cells.

Development and psychometric evaluation of the ICIQ Vaginal Symptoms Questionnaire: the ICIQ-VS

OBJECTIVES

To develop and validate a self-completion questionnaire for comprehensive assessment of the severity and impact of vaginal symptoms and related sexual matters, particularly those attributed to pelvic organ prolapse. To provide an instrument that can characterise the severity of these symptoms, measure their impact and evaluate treatment outcome.

DESIGN

Prospective development of the content of the questionnaire and testing of its psychometric properties including validity.

SETTING

Two hospital-based urogynaecology clinics and one community general practice in the South of England.

POPULATION

One hundred and forty-one urogynaecology clinic attendees with varying degrees of pelvic organ prolapse and 77 randomly selected women registered with a general practice.

METHODS

The questionnaire was developed through a literature review, consultation with clinicians and health scientists and structured interviews with patients. Content validity, construct validity, stability, internal consistency and sensitivity to change were examined by comparing the responses from the urogynaecology clinic with responses from the general community. Sensitivity to change was assessed using responses from women undergoing surgical treatment for pelvic organ prolapse before and 3 months after surgery. A final version of the questionnaire was obtained after factor analysis to assist item reduction and refinement of the scoring system.

MAIN OUTCOME MEASURES

Content validity, construct validity, stability (test-retest reliability), internal consistency and sensitivity to change.

RESULTS

The questionnaire exhibited good validity, reliability and sensitivity to change. Excellent internal consistency was demonstrated for vaginal (Cronbach's alpha 0.79) and sexual (Cronbach's alpha 0.84) symptoms. Reliability was good. The questionnaire was able to identify changes in symptoms following surgical treatment. The final ICIQ-VS questionnaire had 14 items and a simple scoring system. CONCLUSION; The ICIQ-VS self-completion questionnaire meets the need for a robust instrument for assessing a range of vaginal and sexual symptoms, in particular those of pelvic organ prolapse. It will be of use in both routine clinical practice and epidemiological research, particularly when there is a need to assess the severity of these symptoms or the efficacy of treatment.

Sources of methylmercury to a wetland-dominated lake in northern Wisconsin

Several lines of evidence suggest that wetlands may be a major source of methylmercury (MeHg) to receiving waters, perhaps explaining the strong correlation between concentrations of waterborne MeHg and dissolved organic carbon (DOC) in regions such as northern Wisconsin. We evaluated the relative importance of wetland export in the MeHg budget of a wetland-dominated lake in northern Wisconsin using mass balance. Channelized runoff from a large headwater wetland was the major source of water and total mercury (HgT) to the lake during the study period. The wetland also exported MeHg in high concentrations (0.2-0.8 ng L(-1)), resulting in an export rate similar to those reported for other northern wetlands (ca. 0.3 microg MeHg m(-2) y(-1)). Yet, based on intensive sampling during 2002, the mass of MeHg that accumulated in the lake during summer was an order of magnitude greater than the export of MeHg from the wetland to the lake. Hence, a large in-lake source of MeHg is inferred from the mass balance. Most of the accumulated MeHg built-up in anoxic hypolimnetic waters; and the build-up was roughly balanced by losses of inorganic Hg (Hg(II)) implying a chemical transformation within the anoxic water column. An abundance of sulfate-reducing bacteria (SRB) in hypolimnetic waters, established by DNA analysis of the pelagic microbial community, along with a previous report documenting high methylation rates in the hypolimnion of this lake (ca. 10% d(-1)), suggest that this transformation was microbially mediated. These findings indicate that the direct effect of wetland runoff may be outweighed by indirect effects on the lacustrine MeHg cycle, enhancing the load of Hg(II), the activity of SRB, and the retention of MeHg, especially in northern lakes with flushing times longer than six months.

Macula off retinal detachments. How long can they wait before it is too late?

PURPOSE

To determine the association between the duration of macula off detachment and the visual outcome following corrective surgery.

METHODS

Retrospective review of the medical records of patients who underwent surgery for macula off detachment over a 5 year period (April 1994- March 1999).

RESULTS

There were 104 patients in the study. Patients with macula off detachments wait a mean of 2.6 weeks (+/-0.3 SE mean) before presentation and 1.8 weeks (+/-0.2 SE of mean) thereafter before surgery. The mean duration of detachment prior to surgical repair was 4.2 weeks (+/-0.3 SE mean). 78% of patients achieved a postoperative improvement in visual acuity. 36.5% achieved functional visual success of 6/12 at 3 months, which increased to 51% at final discharge. There was no significant difference in visual outcomes for patient undergoing internal vs external procedures (p=0.188). The preoperative visual acuity was the most significant predictor of post operative visual acuity (p<0.0005). Less than 40% of macula off detachments of > or =6 weeks duration will achieve a vision of 6/12 or better compared with 68.2% of patients with macula off detachments of < or =1 week.

CONCLUSIONS

The best mean postoperative vision (LogMAR 0.35) was seen in patients with detachment of <1 week duration. Patients <60 years are more likely to achieve visual improvement despite the duration of the detachment. Macula off detachments of >6 weeks duration have a significantly poor postoperative visual prognosis. Awareness of this visual prognosis can assist in planning the timing of surgery to ensure an acceptable result.

Integrating criminal justice, community healthcare, and support services for adults with severe mental disorders

Persons with severe mental disorders are overrepresented in our nation's jails and prisons. Factors including cooccurring substance use disorders, homelessness, and lack of access to community services have contributed to this problem, as have gaps between criminal justice, healthcare, and community support systems. In order to address these issues, Project Link was developed by the University of Rochester Department of Psychiatry in collaboration with five local community agencies. Project Link is designed to prevent involvement of individuals with severe mental illness from entering the criminal justice system. While many models of diversion programs exist, they are all dependent on access to appropriate community-based services. This paper will describe the steps that Project Link has taken towards integrating criminal justice, healthcare, and community support services for individuals with severe mental disorders involved in the criminal justice system.