Behavioural intervention to promote the uptake of planned care in urgent dental care attenders: a feasibility randomised controlled trial

BACKGROUND

Urgent dental care may be the only place where many people, especially vulnerable groups, access care. This presents an opportunity for delivery of a behavioural intervention promoting planned dental visiting, which may help address one of the factors contributing to a socio-economic gradient in oral health. Although we know that cueing events such as having a cancer diagnosis may create a 'teachable moment' stimulating positive changes in health behaviour, we do not know whether delivering an opportunistic intervention in urgent dental care is feasible and acceptable to patients.

METHODS

The feasibility study aimed to recruit 60 patients in a Dental Hospital and dental practices delivering urgent care within and outside working hours. Follow-up was by telephone, e mail and post over 4 months.

RESULTS

Although the recruitment window was shortened because of COVID-19, of 47 patients assessed for eligibility, 28 were enrolled (70.1% of screened patients provided consent). A relatively high proportion were from disadvantaged backgrounds (46.4%, 13/28 receiving State benefits). Retention was 82.1% (23/28), which was also the rate of completion of the Oral Health Impact Profile co-primary outcome. The other primary outcome involved linking participant details at recruitment, with centrally-held data on services provided, with 84.6% (22/26) records partly or fully successfully matched. All intervention participants received at least some of the intervention, although we identified aspects of dental nurse training which would improve intervention fidelity.

CONCLUSIONS

Despite recruitment being impacted by the pandemic, when the majority of clinical trials experienced reduced rates of recruitment, we found a high recruitment and consenting rate, even though patients were approached opportunistically to be enrolled in the trial and potentially receive an intervention. Retention rates were also high even though a relatively high proportion had a low socio-economic background. Therefore, even though patients may be in pain, and had not anticipated involvement before their urgent care visit, the study indicated that this was a feasible and acceptable setting in which to position an opportunistic intervention. This has the potential to harness the potential of the 'teachable moment' in people's lives, and provide support to help address health inequalities.

TRIAL REGISTRATION

ISRCTN 10,853,330 07/10/2019.

Comparing intervention measures in a model of a disease outbreak on a university campus

A number of theoretical models have been developed in recent years modelling epidemic spread in educational settings such as universities, often as part of efforts to inform re-opening strategies during the COVID-19 pandemic. However, these studies have had differing conclusions as to the most effective non-pharmaceutical interventions. They also largely assumed permanent acquired immunity, meaning we have less understanding of how disease dynamics will play out when immunity wanes. Here, we complement these studies by developing and analysing a general stochastic simulation model of disease spread on a university campus where we allow immunity to wane, exploring the effectiveness of different interventions. We find that the two most effective interventions to limit the severity of a disease outbreak are reducing extra-household mixing and surveillance testing backed-up by a moderate isolation period. We find that contact tracing only has a limited effect, while reducing class sizes only has much effect if extra-household mixing is already low. We identify a range of measures that can not only limit an outbreak but prevent it entirely, and also comment on the variation in measures of severity that emerge from our stochastic simulations. We hope that our model may help in designing effective strategies for universities in future disease outbreaks.

Proton-Capture Rates on Carbon Isotopes and Their Impact on the Astrophysical ^{12}C/^{13}C Ratio

The ^{12}C/^{13}C ratio is a significant indicator of nucleosynthesis and mixing processes during hydrogen burning in stars. Its value mainly depends on the relative rates of the ^{12}C(p,γ)^{13}N and ^{13}C(p,γ)^{14}N reactions. Both reactions have been studied at the Laboratory for Underground Nuclear Astrophysics (LUNA) in Italy down to the lowest energies to date (E_{c.m.}=60  keV) reaching for the first time the high energy tail of hydrogen burning in the shell of giant stars. Our cross sections, obtained with both prompt γ-ray detection and activation measurements, are the most precise to date with overall systematic uncertainties of 7%-8%. Compared with most of the literature, our results are systematically lower, by 25% for the ^{12}C(p,γ)^{13}N reaction and by 30% for ^{13}C(p,γ)^{14}N. We provide the most precise value up to now of 3.6±0.4 in the 20-140 MK range for the lowest possible ^{12}C/^{13}C ratio that can be produced during H burning in giant stars.

The presence or absence of midsagittal tissue bridges and walking: a retrospective cohort study in spinal cord injury

STUDY DESIGN

Cohort study. Retrospective analysis of T2-weighted magnetic resonance images (MRIs) and clinical documentation.

OBJECTIVES

To evaluate the relationship between the presence/absence and widths of midsagittal tissue bridges and walking ability among veterans with cervical, predominantly chronic SCI.

SETTING

University research and hospital setting.

METHODS

T2-weighted midsagittal MRIs of 22 United States veterans with cervical spinal cord injuries were examined. The presence/absence of midsagittal tissue bridges were determined, and the widths of present ventral and dorsal tissue bridges were measured. Midsagittal tissue bridge characteristics were related to each participant's ability to walk based off examination of clinical documentation.

RESULTS

Fourteen of the analyzed participant images revealed the presence of midsagittal tissue bridges. Ten of those individuals (71%) possessed overground walking ability. The 8 individuals with no apparent tissue bridges were all unable to walk. There was a significant correlation between walking and widths of ventral midsagittal tissue bridges (r = 0.69, 95%CI: 0.52, 0.92, p < 0.001), as well as dorsal midsagittal tissue bridges (r = 0.44, 95%CI: 0.15, 0.73, p = 0.039).

CONCLUSION

The evaluation of midsagittal tissue bridges may be useful in various rehabilitation settings to help inform patients' plan of care, allocation of neuromodulatory resources, and appropriate stratification into research cohorts.

How do fluctuating ecological dynamics impact the evolution of hosts and parasites?

Theoretical models of the evolution of parasites and their hosts have shaped our understanding of infectious disease dynamics for over 40 years. Many theoretical models assume that the underlying ecological dynamics are at equilibrium or constant, yet we know that in a great many systems there are fluctuations in the ecological dynamics owing to a variety of intrinsic or extrinsic factors. Here, we discuss the challenges presented when modelling evolution in systems with fluctuating ecological dynamics and summarize the main approaches that have been developed to study host-parasite evolution in such systems. We provide an in-depth guide to one of the methods by applying it to two worked examples of host evolution that have not previously been studied in the literature: when cycles occur owing to seasonal forcing in competition, and when the presence of a free-living parasite causes cycles, with accompanying interactive Python code provided. We review the findings of studies that have explored host-parasite evolution when ecological dynamics fluctuate, and point to areas of future research. Throughout we stress the importance of feedbacks between the ecological and evolutionary dynamics in driving the outcomes of infectious disease systems. This article is part of the theme issue 'Infectious disease ecology and evolution in a changing world'.

Improving cardiovascular health with the patient-centered, integrated primary care HEARTS model in Trinidad and Tobago

This article describes the introduction of the Pan American Health Organization’s HEARTS in the Americas program in Trinidad and Tobago and the successful experiences and challenges encountered in introducing and scaling it up as a strategy for strengthening the health system’s response to cardiovascular diseases. Evidence about implementation of the HEARTS program in the World Health Organization’s Region of the Americas was reviewed to identify the progress made, barriers, success factors and lessons learned. In 2019, the Ministry of Health commenced implementation of the program in 5 (4.9%) of the 102 primary health care centers, and by the end of 2021, it had been scaled up to 46 (45.0%) centers. The HEARTS program ensures that patients’ cardiovascular health is managed in a comprehensive way through providing counseling about a healthy lifestyle, using evidence-based treatment protocols, ensuring access to essential medicines and technologies, and using a risk-based team approach, a monitoring and evaluation system and also a team-based approach to care delivery. The barriers encountered during implementation included the fragmentation of the existing health care system, the paternalistic role assumed by health care professionals, the resistance of some health care workers to change and a lack of team-based approaches to providing care. Successful implementation of the program was enabled through ensuring high-level political commitment, establishing the national HEARTS Oversight Committee, ensuring stakeholder involvement throughout all phases and implementing standardized approaches to care. When implemented in the context of existing primary health care settings, the HEARTS program provides an exceptionally well integrated and comprehensive model of care that embodies the principles of universal health care while ensuring the health of both populations and individuals. Thus, it enables and promotes a strengthened primary health care system and services that are responsive and resilient.

Behavioural intervention to promote the uptake of planned care in urgent dental care attenders: study protocol for the RETURN randomised controlled trial

BACKGROUND

People with disadvantaged backgrounds are less likely to visit the dentist for planned care, even though they have disproportionately poorer oral health. They are correspondingly more likely to experience dental problems and use urgent dental care, general practices and Accident and Emergency departments, which not only makes meeting their needs expensive, but, since these services often rely on prescriptions rather than addressing the clinical cause, can contribute to antimicrobial resistance.

METHODS

The RETURN intervention has been developed with substantial community co-production, to be delivered opportunistically in urgent dental care settings. This brief intervention is delivered by dental nurses and involves material relevant to the 'in-group' targeted. The material includes booklets relating to barriers to planned dental visiting with corresponding short video clips featuring local people and including a modelling element. Dental nurses are trained to have supportive and non-judgemental conversations, assisting patients to set personal goals and action plans, which are reinforced in a follow-up text within a few weeks. A randomised controlled trial will be undertaken in 3 types of sites: dental practices delivering urgent care (a) within working hours, (b) out of hours, and (c) in a Dental Hospital. The trial will recruit 1180 adult urgent dental care users over 12 months, who have not visited a dentist for a planned care appointment for 2 years or more and do not have a dentist who they visit for routine care. It aims to investigate the effectiveness and cost-effectiveness of the intervention and to explore whether the intervention has different effects across the socio-economic gradient. Participants will be followed up at 6, 12 and 18 months after randomisation. Co-primary outcomes are attendance at a dental practice for planned care within 12 months and self-reported oral health-related quality of life at 12 months.

DISCUSSION

This is a pragmatic trial, evaluating the effectiveness of the intervention under the usual condition in which it might be applied. Since dental practices work as independent contractors to the NHS, this brings implementation and fidelity challenges which will be explored and described in embedded qualitative work.

TRIAL REGISTRATION

ISRCTN registry identifier ISRCTN84666712. Registered 12/04/2021.

[Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation GroupFactores impulsores y métodos de puntuación para mejorar el control de la hipertensión en la práctica clínica de la atención primaria: recomendaciones del grupo de innovación de HEARTS en las Américas]

Fundamentos.

As doenças cardiovasculares (DCV) são as principais causas de morbimortalidade nas Américas, e a hipertensão arterial (HÁ) é o fator de risco modificável mais importante. Porém, as taxas de controle da HA continuam baixas, e a mortalidade por DCV está estagnada ou aumentando após décadas de redução contínua. Em 2016, a Organização Mundial da Saúde (OMS) lançou o pacote de medidas técnicas HEARTS para melhorar o controle da HA. A Organização Pan-Americana da Saúde (OPAS) criou a iniciativa HEARTS nas Américas para melhorar a gestão do risco cardiovascular (RCV), com ênfase no controle da HA. Até agora, essa iniciativa foi implementada em 21 países.

Métodos.

Para impulsionar a implementação, recrutou-se um grupo multidisciplinar de profissionais para selecionar impulsionadores-chave do controle da HA com base em evidências e elaborar um scorecard completo para monitorar sua implementação em unidades de atenção primária à saúde (APS). O grupo estudou sistemas de saúde com alto desempenho que haviam conseguido atingir um alto nível de controle da HA por meio de programas de melhoria da qualidade focados em medidas específicas de processo, com feedback regular para os profissionais das unidades de saúde.

Resultados.

Os oito fatores impulsionadores incluídos na seleção final foram categorizados em cinco domínios principais: (1) diagnóstico (exatidão da medição da pressão arterial e avaliação do RCV); (2) tratamento (protocolo padronizado de tratamento e intensificação do tratamento); (3) continuidade do cuidado e acompanhamento; (4) modelo de atenção (atendimento baseado em equipe, renovação da prescrição); e (5) sistema de avaliação do desempenho. Em seguida, os fatores impulsionadores e as recomendações foram transformados em medidas de processo, gerando dois scorecards inter-relacionados integrados ao sistema de monitoramento e avaliação da Iniciativa HEARTS nas Américas.

Interpretação.

O foco nesses impulsionadores-chave da HA e nos scorecards resultantes orientará o processo de melhoria da qualidade para atingir as metas de controle, a nível populacional, dos centros de saúde participantes nos países que estão implementando a iniciativa HEARTS.

[Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation GroupFatores impulsionadores e scorecards para melhorar o controle da hipertensão arterial na atenção primária: recomendações do Grupo de Inovação da Iniciativa HEARTS nas Américas]

Antecedentes.

Las enfermedades cardiovasculares (ECV) son la principal causa de morbilidad y mortalidad en la Región de las Américas y la hipertensión es el factor de riesgo modificable asociado más importante. Sin embargo, las tasas de control de la hipertensión siguen siendo bajas y la mortalidad por ECV está estancada o en aumento después de décadas de reducción continua. En el 2016, la Organización Mundial de la Salud (OMS) presentó el paquete técnico HEARTS para mejorar el control de la hipertensión. La Organización Panamericana de la Salud (OPS) diseñó la iniciativa HEARTS en las Américas para mejorar el control del riesgo de ECV, que hace hincapié en el control de la hipertensión y que, hasta la fecha, se ha implementado en 21 países.

Métodos.

Para avanzar en la implementación, se creó un grupo interdisciplinario de profesionales de la salud con el objetivo de seleccionar los factores impulsores claves del control de la hipertensión basados en la evidencia y diseñar un método de puntuación integral para dar seguimiento a su implementación en los centros de atención de salud primaria (APS). El grupo estudió los sistemas de salud de alto desempeño que logran un control elevado de la hipertensión mediante programas de mejora de la calidad que se centran en medidas específicas con respecto a los procesos, con retroalimentación regular a los prestadores en los centros de salud.

Resultados.

Los ocho factores impulsores finales seleccionados se clasificaron en cinco dominios principales: 1) diagnóstico (exactitud de la medición de la presión arterial y evaluación del riesgo de ECV); 2) tratamiento (protocolo de tratamiento e intensificación del tratamiento estandarizados); 3) continuidad de la atención y seguimiento; 4) sistema de prestación del tratamiento (atención basada en un trabajo en equipo, reposición de la medicación) y 5) sistema para la evaluación del desempeño. Los factores impulsores y las recomendaciones se tradujeron en medidas con respecto a los procesos, lo que llevó a dos métodos de puntuación integrados e interconectados en el sistema de seguimiento y evaluación del programa HEARTS en las Américas.

Conclusiones.

El enfoque que se centra en estos factores impulsores clave de la hipertensión y los métodos de puntuación resultantes servirá de guía para el proceso de mejora de la calidad con objeto de alcanzar los objetivos de control a nivel poblacional en los centros de salud participantes de los países que implementan el programa HEARTS.

Drivers and scorecards to improve hypertension control in primary care practice: Recommendations from the HEARTS in the Americas Innovation Group

Background

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the Americas, and hypertension is the most significant modifiable risk factor. However, hypertension control rates remain low, and CVD mortality is stagnant or rising after decades of continuing reduction. In 2016, the World Health Organization (WHO) launched the HEARTS technical package to improve hypertension control. The Pan American Health Organization (PAHO) designed the HEARTS in the Americas Initiative to improve CVD risk management, emphasizing hypertension control, to date implemented in 21 countries.

Methods

To advance implementation, an interdisciplinary group of practitioners was engaged to select the key evidence-based drivers of hypertension control and to design a comprehensive scorecard to monitor their implementation at primary care health facilities (PHC). The group studied high-performing health systems that achieve high hypertension control through quality improvement programs focusing on specific process measures, with regular feedback to providers at health facilities.

Findings

The final selected eight drivers were categorized into five main domains: (1) diagnosis (blood pressure measurement accuracy and CVD risk evaluation); (2) treatment (standardized treatment protocol and treatment intensification); (3) continuity of care and follow-up; (4) delivery system (team-based care, medication refill), and (5) system for performance evaluation. The drivers and recommendations were then translated into process measures, resulting in two interconnected scorecards integrated into the HEARTS in the Americas monitoring and evaluation system.

Interpretation

Focus on these key hypertension drivers and resulting scorecards, will guide the quality improvement process to achieve population control goals at the participating health centers in HEARTS implementing countries.

Funding

No funding to declare.

Direct Measurement of the ^{13}C(α,n)^{16}O Cross Section into the s-Process Gamow Peak

One of the main neutron sources for the astrophysical s process is the reaction ^{13}C(α,n)^{16}O, taking place in thermally pulsing asymptotic giant branch stars at temperatures around 90 MK. To model the nucleosynthesis during this process the reaction cross section needs to be known in the 150-230 keV energy window (Gamow peak). At these sub-Coulomb energies, cross section direct measurements are severely affected by the low event rate, making us rely on input from indirect methods and extrapolations from higher-energy direct data. This leads to an uncertainty in the cross section at the relevant energies too high to reliably constrain the nuclear physics input to s-process calculations. We present the results from a new deep-underground measurement of ^{13}C(α,n)^{16}O, covering the energy range 230-300 keV, with drastically reduced uncertainties over previous measurements and for the first time providing data directly inside the s-process Gamow peak. Selected stellar models have been computed to estimate the impact of our revised reaction rate. For stars of nearly solar composition, we find sizeable variations of some isotopes, whose production is influenced by the activation of close-by branching points that are sensitive to the neutron density, in particular, the two radioactive nuclei ^{60}Fe and ^{205}Pb, as well as ^{152}Gd.

The baryon density of the Universe from an improved rate of deuterium burning

Light elements were produced in the first few minutes of the Universe through a sequence of nuclear reactions known as Big Bang nucleosynthesis (BBN)^1,2. Among the light elements produced during BBN^1,2, deuterium is an excellent indicator of cosmological parameters because its abundance is highly sensitive to the primordial baryon density and also depends on the number of neutrino species permeating the early Universe. Although astronomical observations of primordial deuterium abundance have reached percent accuracy³, theoretical predictions^4-6 based on BBN are hampered by large uncertainties on the cross-section of the deuterium burning D(p,γ)³He reaction. Here we show that our improved cross-sections of this reaction lead to BBN estimates of the baryon density at the 1.6 percent level, in excellent agreement with a recent analysis of the cosmic microwave background⁷. Improved cross-section data were obtained by exploiting the negligible cosmic-ray background deep underground at the Laboratory for Underground Nuclear Astrophysics (LUNA) of the Laboratori Nazionali del Gran Sasso (Italy)^8,9. We bombarded a high-purity deuterium gas target¹⁰ with an intense proton beam from the LUNA 400-kilovolt accelerator¹¹ and detected the γ-rays from the nuclear reaction under study with a high-purity germanium detector. Our experimental results settle the most uncertain nuclear physics input to BBN calculations and substantially improve the reliability of using primordial abundances to probe the physics of the early Universe.

Participant experiences of the DWELL programme: focus group findings on motivation, experiences, facilitators and barriers

Initiatives to increase effective, low-cost self-management are essential to the sustainability of care for type 2 diabetes (T2D), however research shows that there is currently no standard approach. The DWELL programme seeks to motivate and empower people with T2D to better self-manage their condition through focussed content underpinned by motivational interviewing. As part of the DWELL evaluation study, end-of-programme focus groups were conducted to elicit participant experiences. 33 focus groups with 153 participants (including a small number of partners) took place in the two UK DWELL delivery sites. The focus group data was subjected to thematic content analysis to elicit key themes. Findings indicate that DWELL participants are motivated through a desire for better knowledge and management of their diabetes. Facilitating factors of the programme include: facilitator and peer support; the holistic and autonomous approach which provides participants with the opportunity to better understand the condition and its impact on their whole lives; and a tailored individual approach. Barriers and suggested improvements include content and operational changes, which are fed back to DWELL facilitators as part of the process evaluation in order that they can continually update the programme. Participants report positive outcomes in terms of wellbeing, social and mental health, enhanced knowledge and positive lifestyle changes. These themes align with quantitative outcome measures for participants, including weight loss, reduced BMI and glycated haemoglobin (HbA1c), enhanced empowerment and improved eating behaviours and illness perceptions and control. Interim findings suggest that DWELL outcomes include improved health literacy, participant empowerment and self-management. These findings underscore the need to incorporate a holistic, tailored approach to structured patient education for T2D.

The Diabetes and WELLbeing programme: protocol of a multi-site European complex intervention study

A quasi-experimental design evaluation study examines long-term impact of the 12-week DWELL programme, a self-management intervention for people with type 2 diabetes (T2D), based on adult learning and person-centred approaches, delivered in 5 community and hospital sites in 4 European countries. Overall target is 780 people with T2D. Staff are trained in motivational interviewing, group facilitation, diabetes education, and programme approach which consists of core and 'pick and mix' sessions on diabetes education, physical activity, healthy eating and wellbeing. Pre-post measures are taken at baseline (T0), end-of-programme (T1), at 6 months (T2) and 12 months (T3). There is a non-equivalent control group of 190 at T2/T3. Biomedical data are collected by staff and psychosocial data are collected via self-completed validated scales. Metabolic measures include: HbA1c, BMI and waist circumference. Demographics capture: age, gender, ethnicity, household composition, education, employment, income. Psychosocial data are collected on illness perception, patient empowerment, eating behaviours, physical activity, physical/mental health status, health-related quality of life (EQ-5D), use of diabetes-related health services and self-care activities. Participant experiences are recorded via motivational interviews at T0 and T1 and focus groups at T1. Process evaluation data are collected via interviews with staff and patient ambassadors. The DWELL programme started in 2018 and results will be available in 2021.

The study will produce rich data on long-term impact of intervention to allow replication and further development. It will permit cross-border conclusions on sustainability and embeddedness of model in varied service settings, and empowerment-based public health approach to T2D self-management.

Patient empowerment, eating behaviours and illness control: pre-post outcomes from DWELL delivery in UK and France

Diabetes self-management programmes can improve clinical and healthy lifestyle outcomes. Research has demonstrated that improved engagement with type 2 diabetes (T2D) care is associated with greater empowerment beliefs and a perceived internal control over their illness. As part of the DWELL evaluation study, an interim subset of 139 participants in the UK and 53 participants in France were assessed pre- and post-intervention on measures of weight, BMI, waist circumference and glycated haemoglobin (HbA1c), as well as self-efficacy beliefs (DES-SF), healthy eating behaviours (DEBQ) and perceptions of illness (IPQ-R). Pre-post comparisons in both countries demonstrated statistically significant decreases in weight (UK: Z = 6.71, p&lt;.001, FR: Z = 3.33, p&lt;.05), BMI (UK: Z = 6.70, p&lt;.001, FR: Z = 3.21, p&lt;.05), waist circumference (UK: Z = 6.71, p&lt;.001, FR: Z = 3.24, p&lt;.05),and HbA1c (UK: Z = 6.29, p&lt;.001, FR: Z = 4.18, p &lt;.001). Importantly, participation in the DWELL programme was associated with increased self-efficacy beliefs (UK: Z = 5.63, p&lt;.001, FR: Z = 5.54, p&lt;.001), greater perceived personal control over their diabetes (UK: Z = 3.17, p&lt;.05, FR: Z = 2.20, p&lt;.05), reduced negative feelings about their illness (UK: Z = 3.01, p &lt;.05, FR: Z = 2.19, p&lt;.05) and decreased eating in response to external food cues (UK: Z = 3.79, p&lt;.001, FR: Z = 2.34, p&lt;.05). In the UK, participants also reported an increased optimism for treatment control of their diabetes (Z = 3.06, p &lt;.05) and for their long-term prognosis (Z = 1.99, p&lt;.05).These preliminary findings support the efficacy of the DWELL programme in improving diabetes-related biomedical outcomes, as well as improvements in patient empowerment, healthy eating habits and increased perceived illness control. Further analysis, available at a later date, will include a larger sample of participants, including longitudinal data with follow-ups six- and 12- months post participation in the DWELL programme.

Direct Capture Cross Section and the E_{p}=71 and 105 keV Resonances in the ^{22}Ne(p,γ)^{23}Na Reaction

The ^{22}Ne(p,γ)^{23}Na reaction, part of the neon-sodium cycle of hydrogen burning, may explain the observed anticorrelation between sodium and oxygen abundances in globular cluster stars. Its rate is controlled by a number of low-energy resonances and a slowly varying nonresonant component. Three new resonances at E_{p}=156.2, 189.5, and 259.7 keV have recently been observed and confirmed. However, significant uncertainty on the reaction rate remains due to the nonresonant process and to two suggested resonances at E_{p}=71 and 105 keV. Here, new ^{22}Ne(p,γ)^{23}Na data with high statistics and low background are reported. Stringent upper limits of 6×10^{-11} and 7×10^{-11}  eV (90% confidence level), respectively, are placed on the two suggested resonances. In addition, the off-resonant S factor has been measured at unprecedented low energy, constraining the contributions from a subthreshold resonance and the direct capture process. As a result, at a temperature of 0.1 GK the error bar of the ^{22}Ne(p,γ)^{23}Na rate is now reduced by 3 orders of magnitude.

Erratum: Three New Low-Energy Resonances in the ^{22}Ne(p,γ)^{23}Na Reaction [Phys. Rev. Lett. 115, 252501 (2015)]

This corrects the article DOI: 10.1103/PhysRevLett.115.252501.

Incidence of clinically suspected venous thromboembolism in British Indian patients

Introduction Venous thromboembolism (VTE) remains a major public health issue around the world. Ethnicity is known to alter the incidence of VTE. To our knowledge, there are no reports in the literature investigating the incidence of VTE in British Indians. The aim of this study was to investigate the rates of symptomatic VTE in British Indian patients in the UK. Methods Patients referred to our institution between January 2011 and August 2013 with clinically suspected VTE were eligible for inclusion in the study. Those not of British Indian or Caucasian ethnicity were excluded. A retrospective review of these two cohorts was conducted. Results Overall, 15,529 cases were referred to our institution for suspected VTE. This included 1,498 individuals of British Indian ethnicity. Of these, 182 (12%) had confirmed VTE episodes. A further 13,159 of the patients with suspected VTE were coded as Caucasian, including 2,412 (16%) who had confirmed VTE events. VTE rates were a third lower in British Indians with clinically suspected VTE than in the equivalent Caucasian group. The British Indian cohort presented with VTE at a much earlier age than Caucasians (mean 57.0 vs 68.0 years). Conclusions This study suggests that British Indian patients have a lower incidence of VTE and are more likely to present at an earlier age than Caucasians. There was no significant difference in VTE type (deep vein thrombosis vs pulmonary embolism) among the ethnic groups. Clinicians should be aware of variations within ethnicities but should continue to adhere to existing VTE prevention guidance.

Improved Direct Measurement of the 64.5 keV Resonance Strength in the ^{17}O(p,α)^{14}N Reaction at LUNA

The ^{17}O(p,α)^{14}N reaction plays a key role in various astrophysical scenarios, from asymptotic giant branch stars to classical novae. It affects the synthesis of rare isotopes such as ^{17}O and ^{18}F, which can provide constraints on astrophysical models. A new direct determination of the E_{R}=64.5  keV resonance strength performed at the Laboratory for Underground Nuclear Astrophysics (LUNA) accelerator has led to the most accurate value to date ωγ=10.0±1.4_{stat}±0.7_{syst}  neV, thanks to a significant background reduction underground and generally improved experimental conditions. The (bare) proton partial width of the corresponding state at E_{x}=5672  keV in ^{18}F is Γ_{p}=35±5_{stat}±3_{syst}  neV. This width is about a factor of 2 higher than previously estimated, thus leading to a factor of 2 increase in the ^{17}O(p, α)^{14}N reaction rate at astrophysical temperatures relevant to shell hydrogen burning in red giant and asymptotic giant branch stars. The new rate implies lower ^{17}O/^{16}O ratios, with important implications on the interpretation of astrophysical observables from these stars.

Endemic Burkitt Lymphoma: Long-term Outcome in 87 Patients Who Presented With Paraplegia in Cameroon

The reported long-term outcome of endemic Burkitt lymphoma (eBL) patients who present with paraplegia is largely unknown. Records of BL patients treated with comparable short-interval cyclophosphamide chemotherapy schedules between 2004 and 2014 at three Baptist mission hospitals in Cameroon were reviewed. Survivors were followed up and examined at home or in hospital. Eighty-seven of 948 (9.2%) patients had paraplegia at diagnosis. The survival rate in eBL patients with paraplegia at diagnosis was 33% (n = 29) after follow-up of between 2 and 96 (median 40) months. Seven patients (24%) had neurological sequelae and needed rehabilitation. There was no relationship between the duration of symptoms (<2, 2-4, >4 weeks) and the survival rate or the risk to have neurological sequelae. The survival rate and risk for sequelae were similar in patients with confirmed St. Jude stage III and IV diseases.

Surface forces between colloidal particles at high hydrostatic pressure

It was recently suggested that the electrostatic double-layer force between colloidal particles might weaken at high hydrostatic pressure encountered, for example, in deep seas or during oil recovery. We have addressed this issue by means of a specially designed optical trapping setup that allowed us to explore the interaction of a micrometer-sized glass bead and a solid glass wall in water at hydrostatic pressures of up to 1 kbar. The setup allowed us to measure the distance between bead and wall with a subnanometer resolution. We have determined the Debye lengths in water for salt concentrations of 0.1 and 1 mM. We found that in the pressure range from 1 bar to 1 kbar the maximum variation of the Debye lengths was <1 nm for both salt concentrations. Furthermore, the magnitude of the zeta potentials of the glass surfaces in water showed no dependency on pressure.

Knowledge to action for solving complex problems: insights from a review of nine international cases

INTRODUCTION

Solving complex problems such as preventing chronic diseases introduces unique challenges for the creation and application of knowledge, or knowledge to action (KTA). KTA approaches that apply principles of systems thinking are thought to hold promise, but practical strategies for their application are not well understood. In this paper we report the results of a scan of systems approaches to KTA with a goal to identify how to optimize their implementation and impact.

METHODS

A 5-person advisory group purposefully selected 9 initiatives to achieve diversity on issues addressed and organizational forms. Information on each case was gathered from documents and through telephone interviews with primary contacts within each organization. Following verification of case descriptions, an inductive analysis was conducted within and across cases.

RESULTS

The cases revealed 5 guidelines for moving from conceiving KTA systems to implementing them: (1) establish and nurture relationships, (2) co-produce and curate knowledge, (3) create feedback loops, (4) frame as systems interventions rather than projects, and (5) consider variations across time and place.

CONCLUSION

Results from the environmental scan are a modest start to translating systems concepts for KTA into practice. Use of the strategies revealed in the scan may improve KTA for solving complex public health problems. The strategies themselves will benefit from the development of a science that aims to understand adaptation and ongoing learning from policy and practice interventions, strengthens enduring relationships, and fills system gaps in addition to evidence gaps. Systems approaches to KTA will also benefit from robust evaluations.

Three New Low-Energy Resonances in the ^{22}Ne(p,γ)^{23}Na Reaction

The ^{22}Ne(p,γ)^{23}Na reaction takes part in the neon-sodium cycle of hydrogen burning. This cycle affects the synthesis of the elements between ^{20}Ne and ^{27}Al in asymptotic giant branch stars and novae. The ^{22}Ne(p,γ)^{23}Na reaction rate is very uncertain because of a large number of unobserved resonances lying in the Gamow window. At proton energies below 400 keV, only upper limits exist in the literature for the resonance strengths. Previous reaction rate evaluations differ by large factors. In the present work, the first direct observations of the ^{22}Ne(p,γ)^{23}Na resonances at 156.2, 189.5, and 259.7 keV are reported. Their resonance strengths are derived with 2%-7% uncertainty. In addition, upper limits for three other resonances are greatly reduced. Data are taken using a windowless ^{22}Ne gas target and high-purity germanium detectors at the Laboratory for Underground Nuclear Astrophysics in the Gran Sasso laboratory of the National Institute for Nuclear Physics, Italy, taking advantage of the ultralow background observed deep underground. The new reaction rate is a factor of 20 higher than the recent evaluation at a temperature of 0.1 GK, relevant to nucleosynthesis in asymptotic giant branch stars.

Spatial heterogeneity lowers rather than increases host-parasite specialization

Abiotic environmental heterogeneity can promote the evolution of diverse resource specialists, which in turn may increase the degree of host-parasite specialization. We coevolved Pseudomonas fluorescens and lytic phage ϕ2 in spatially structured populations, each consisting of two interconnected subpopulations evolving in the same or different nutrient media (homogeneous and heterogeneous environments, respectively). Counter to the normal expectation, host-parasite specialization was significantly lower in heterogeneous compared with homogeneous environments. This result could not be explained by dispersal homogenizing populations, as this would have resulted in the heterogeneous treatments having levels of specialization equal to or greater than that of the homogeneous environments. We argue that selection for costly generalists is greatest when the coevolving species are exposed to diverse environmental conditions and that this can provide an explanation for our results. A simple coevolutionary model of this process suggests that this can be a general mechanism by which environmental heterogeneity can reduce rather than increase host-parasite specialization.

Improving organizational capacity to address health literacy in public health: a rapid realist review

OBJECTIVES

Despite the growing significance of health literacy to public health, relatively little is known about how organizational capacity may be improved for planning, implementing and sustaining health literacy interventions. This study aimed to connect decision makers in a public health agency with evidence of how organizational capacity may be improved for delivering health literacy services.

STUDY DESIGN

A rapid realist review of published and grey literature was conducted by a partnership between the Public Health Agency of Canada (PHAC) and the InSource Research Group.

METHODS

Realist review methodology attempts to understand what works for whom under what circumstances, and is characterized by its focus on strategies/interventions, contexts, mechanisms and their relationship to outcome. This review was completed in collaboration with a reference panel (comprised of a broad range of PHAC representatives) and an expert panel. Literature searching was conducted using three databases supplemented with bibliographic hand searches and articles recommended by panels. Data were extracted on key variables related to definitions, strategies/interventions associated with increased organizational capacity, contextual factors associated with success (and failure), mechanisms activated as a result of different strategies and contexts, key outcomes, and evidence cited.

RESULTS

Strategies found to be associated with improved organizational capacity for delivering health literacy services may be classified into three domains: (1) government action; (2) organizational/practitioner action; and (3) partnership action. Government action includes developing policies to reinforce social norms; setting standards for education; conducting research; and measuring health literacy levels. Organizational/practitioner action relates to appropriate models of leadership (both high-level government engagement and distributed leadership). Innovative partnership action includes collaborations with media outlets, those producing electronic materials, community organizations and school-based programs. Contextual factors for success include positive leadership models, interorganizational relationships, and a culture committed to experimentation and learning. Potential mechanisms activated by strategies and contextual factors include increased visibility and recognition of health literacy efforts, enthusiasm and momentum for health literacy activities, reduced cognitive dissonance between vision and action, a sense of ownership for health literacy data, and creation of a common language and understanding.

CONCLUSIONS

Government initiated interventions and policies are powerful strategies by which organizational capacity to improve health literacy may be affected. Using the foundations created by the government policy environment, organizations may improve the impact of health literacy interventions through supported distributed leadership.

Seasonality selects for more acutely virulent parasites when virulence is density dependent

Host condition is often likely to influence parasite virulence. Furthermore, condition may often be correlated with host density, and therefore, it is important to understand the role of density-dependent virulence (DDV). We examine the consequences of DDV to the evolution of parasites in both seasonal and non-seasonal environments. In particular, we consider seasonality in host birth rate that results in a fluctuating host density and therefore a variable virulence. We show that parasites are selected for lower exploitation, and therefore lower transmission and virulence as the strength of DDV increases without seasonality. This is an important insight from our models; DDV has the opposite effect on the evolution of parasites to that of higher baseline mortality. Our key result is that although seasonality does not affect the evolution of virulence in classical models, with DDV parasites in seasonal environments are predicted to evolve to be more acute. This suggests that in more seasonal environments wildlife disease is likely to be more rather than less virulent if DDV is widespread.

Escherichia coli O115 forms fewer attaching and effacing lesions in the ovine colon in the presence of E. coli O157:H7

Escherichia coli O115 has been isolated from healthy sheep and was shown to be associated with attaching-effacing (AE) lesions in the large intestine. Following previous observations of interactions between E. coli O157 and O26, the aim of the present study was to assess what influence an O115 AE E. coli (AEEC) would have on E. coli O157 colonisation in vitro and in vivo. We report that E. coli O115- and O157-associated AE lesions were observed on HEp-2 cells and on the mucosa of ligated ovine spiral colon. In single strain inoculum, E. coli O115 associated intimately with HEp-2 cells and the spiral colon in greater numbers than E. coli O157:H7. However, in mixed inoculum studies, the number of E. coli O115 AE lesions was significantly reduced suggesting negative interference by E. coli O157. Use of the ligated colon model in the present work has allowed in vitro observations to be extended and confirmed whilst using a minimum of experimental animals. The findings support a hypothesis that some AEEC can inhibit adhesion of other AEEC in vivo. The mechanisms involved may prove to be of utility in the control of AE pathovars.

Flagellin expression enhances Salmonella accumulation in TLR5-positive macrophages

Recently, it has been reported that Salmonella secrete flagellin in response to host produced lysophospholipids. However, this monomer of the bacterial flagella activates Toll-like receptor 5 (TLR5) in the innate immune system. The objective of this study was to examine the role of flagellin expression during infection of species-specific macrophages (MPhi) which either expressed or lacked TLR5. Initially, TLR5-activity was confirmed in bovine MPhi using Salmonella typhimurium derived-flagellin. Within these cells, recombinant FliC induced a potent CXCL8 response when compared to the heterogeneous (FliC/FljB) form of purified flagellin. Furthermore, neither form of flagellin induced nitrite secretion which was subsequently detected after exposing bovine MPhi to LPS in the presence of IFN-gamma. Flagellin enhanced the accumulation of Salmonella enteritidis in TLR5-positive bovine and human MPhi which was independent of adhesion in bovine MPhi. In contrast, murine MPhis which lacked TLR5 were equally susceptible to hosting S. enteritidis, with or without flagellin. However, lack of flagellin in S. typhimurium marginally inhibited bacterial accumulation in bovine MPhi, where FljB and FliC compensated for the lack of each other. This study suggests that flagellin may be inducing TLR5-dependent internalisation mechanisms in Mcapital EF, Cyrillic which vary qualitatively between different species and Salmonella serotypes.

The effect of feeding experience on clinical outcomes in preterm infants

OBJECTIVE

The purpose of this analysis was to investigate the effect of oral feeding experience on clinical outcomes (time to full oral feedings and length of stay) in preterm infants.

STUDY DESIGN

This analysis was completed on 92 infants who participated in a longitudinal, non-experimental study. Data were collected daily for maturity, weight and experience at oral feeding. Additional data were collected to assess overall morbidity.

RESULT

Time to full oral feedings was predicted by experience at oral feeding and morbidity. Length of stay from the start of oral feedings until discharge was predicted by feeding experience and by maturity at the first oral feeding. Weight gain was not affected by feeding experience.

CONCLUSION

Experience at feeding may result in more rapid transition to full oral feedings regardless of severity of illness and may contribute to shorter length of stay. These positive clinical outcomes related to feeding experience warrant further research attention.

Characterisation of Escherichia fergusonii isolates from farm animals using an Escherichia coli virulence gene array and tissue culture adherence assays

Escherichia fergusonii has been associated with a wide variety of intestinal and extra-intestinal infections in both humans and animals but, despite strong circumstantial evidence, the degree to which the organism is responsible for the pathologies identified remains uncertain. Thirty isolates of E. fergusonii collected between 2003 and 2004 were screened using an Escherichia coli virulence gene array to test for the presence of homologous virulence genes in E. fergusonii. The iss (increased serum survival) gene was present in 13/30 (43%) of the test strains and the prfB (P-related fimbriae regulatory) and ireA (siderophore receptor IreA) genes were also detected jointly in 3/30 (10%) strains. No known virulence genes were detected in 14/30 (47%) of strains. Following confirmatory PCR and sequence analysis, the E. fergusoniiprfB, iss and ireA genes shared a high degree of sequence similarity to their counterparts in E. coli, and a particular resemblance was noted with the E. coli strain APEC O1 pathogenicity island. In tissue culture adherence assays, nine E. fergusonii isolates associated with HEp-2 cells with a 'localised adherence' or 'diffuse adherence' phenotype, and they proved to be moderately invasive. The E. fergusonii isolates in this study possess both some phenotypic and genotypic features linked to known pathotypes of E. coli, and support existing evidence that strains of E. fergusonii may act as an opportunistic pathogens, although their specific virulence factors may need to be explored.

Biomechanical study of prophylactic internal fixation of the radial osteocutaneous donor site using the sheep tibia model

This study investigated the strengthening effect of different types of plate and position after osteotomy of the sheep tibia, which is a model for the radial osteocutaneous donor site. Fifty matched pairs of adult sheep tibias were tested in torsion and four-point bending. Firstly, the weakening effect of an osteotomy was compared with the intact bone. Then pairs of bones with an osteotomy were compared with and without reinforcement with different types of 3.5mm plate. The plate was placed in either the anterior (over the defect) or posterior (on the intact cortex) position. In torsion the mean strength of the intact bone was 45% greater than after osteotomy (P=0.02). The reinforced bone was on average 61% stronger than the unreinforced bone (P<0.001). In bending the mean strength of the intact bone was 188% greater than after osteotomy (P=0.02). The reinforced bone was on average 184% stronger then the unreinforced bone (P<0.001). The tibia was able to withstand much greater loads in bending. The dynamic compression plate was the strongest reinforcement in both torsion and bending. The position of the plate did not alter the strengthening effect in torsion but the posterior position resisted greater bending loads (P=0.01). This may not be relevant in clinical practice as the radius is likely to fracture first as a result of lower torsional forces.

Multiwell micromechanical cantilever array reader for biotechnology

We use a multiwell micromechanical cantilever sensor (MCS) device to measure surface stress changes induced by specific adsorption of molecules. A multiplexed assay format facilitates the monitoring of the bending of 16 MCSs in parallel. The 16 MCSs are grouped within four separate wells. Each well can be addressed independently by different analyte liquids. This enables functionalization of MCS separately by flowing different solutions through each well. In addition, each well contains a fixed reference mirror which allows measuring the absolute bending of MCS. In addition, the mirror can be used to follow refractive index changes upon mixing of different solutions. The effect of the flow rate on the MCS bending change was found to be dependent on the absolute bending value of MCS. Experiments and finite element simulations of solution exchange in wells were performed. Both revealed that one solution can be exchanged by another one after 200 microl volume has flown through. Using this device, the adsorption of thiolated DNA molecules and 6-mercapto-1-hexanol on gold surfaces was performed to test the nanomechanical response of MCS.

Influence of colostrum deprivation and concurrent Cryptosporidium parvum infection on the colonization and persistence of Escherichia coli O157 : H7 in young lambs

Escherichia coliO157 : H7 andCryptosporidium parvuminfections of man have been associated with direct contact with small ruminants. Colostrum protects neonates against gastrointestinal pathogens, and orphan lambs, which are common on petting farms, may be deprived of this protection. In a recent study, it was demonstrated that high shedding ofE. coliO157 : H7 by an 8-week-old goat kid was associated with coincidentalC. parvuminfection. Furthermore, both pathogens were co-located in the distal gastrointestinal tract. It was hypothesized that colostrum deprivation and pre-infection withC. parvumpredisposed young ruminants to colonization and increased shedding ofE. coliO157 : H7. To test this, 21 lambs 5 weeks of age were divided into four groups as follows: (A) colostrum-deprived and inoculated withE. coliO157 : H7, (B) colostrum-deprived and inoculated withC. parvumand thenE. coliO157 : H7, (C) conventionally reared and inoculated withE. coliO157 : H7, (D) conventionally reared and inoculated withC. parvumand thenE. coliO157 : H7.C. parvumwas detected between 8 and 12 days post-inoculation in most of the infected lambs. At 24 h post-inoculation withE. coliO157 : H7, all lambs were shedding between 5×104and 5×107 c.f.u.E. coliO157 : H7 per gram of faeces.E. coliO157 : H7 was shed in higher numbers in the groups pre-inoculated withC. parvum, whether conventionally reared or colostrum-deprived. Interestingly, for the colostrum-deprived lambs on day 3, a significant difference in shedding ofE. coliO157 : H7 was observed (P=0.038), with the lambs inoculated withE. colialone yielding higher counts than those pre-inoculated withC. parvum. From day 15 onwards, shedding ofE. coliO157 : H7 was highest from the colostrum-deprivedC. parvum-infected lambs, then (in descending order of shedding) the colostrum-deprived lambs, the conventionally reared lambs infected withC. parvum, and the conventionally reared animals. In total, four animals were euthanized, two at 24 h and two at 96 h post inoculation withE. coliO157 : H7 (two conventionally reared and two colostrum-deprived). All animals euthanized were from groups pre-inoculated withC. parvumprior to challenge withE. coliO157 : H7. On examination of tissues, in three of the four animals examined, multifocal attaching and effacing lesions were observed in the caecum, colon, rectum and at the recto-anal junction, and were confirmed by immunohistochemistry to be associated withE. coliO157 : H7.

Colonization of 8-week-old conventionally reared goats by Escherichia coli O157 : H7 after oral inoculation

Enterohaemorrhagic Escherichia coli O157 : H7 infections of man have been associated with consumption of unpasteurized goat's milk and direct contact with kid goats on petting farms, yet little is known about colonization of goats with this organism. To assess the contribution of flagella and intimin of E. coli O157 : H7 in colonization of the goat, 8-week-old conventionally reared goats were inoculated orally in separate experiments with 1×1010 c.f.u. of a non-verotoxigenic strain of E. coli O157 : H7 (strain NCTC 12900 Nalr), an aflagellate derivative (DMB1) and an intimin-deficient derivative (DMB2). At 24 h after inoculation, the three E. coli O157 : H7 strains were shed at approximately 5×104 c.f.u. (g faeces)−1 from all animals. Significantly fewer intimin-deficient bacteria were shed only on days 2 (P = 0.003) and 4 (P = 0.014), whereas from day 7 to 29 there were no differences. Tissues from three animals inoculated with wild-type E. coli O157 : H7 strain NCTC 12900 Nalr were sampled at 24, 48 and 96 h after inoculation and the organism was cultured from the large intestine of all three animals and from the duodenum and ileum of the animal examined at 96 h. Tissues were examined histologically but attaching-effacing (AE) lesions were not observed at any intestinal site of the animals examined at 24 or 48 h. However, the animal examined at 96 h, which had uniquely shed approximately 1×107 E. coli O157 : H7 (g faeces)−1 for the preceding 3 days, showed a heavy, diffuse infection with cryptosporidia and abundant, multifocal AE lesions in the distal colon, rectum and at the recto-anal junction. These AE lesions were confirmed by immunohistochemistry to be associated with E. coli O157 : H7.

Variable and strain dependent colonisation of chickens by Escherichia coli O157

The prevalence of enterohaemorrhagic Escherichia coli (EHEC) O157 in poultry is considered minimal compared with other species, especially ruminants. However, deliberate inoculation studies have shown that poultry are readily and persistently infected by this organism but that the mechanism of colonisation is independent of intimin, a recognised factor in host-EHEC interactions in mammalian species, and may be dependent upon flagella. Few strains of EHEC O157 have been tested in poultry and here 1-day-old and 6-week-old chicks were inoculated with seven non-toxigenic E. coli O157 strains in separate experiments. Persistence was measured semi-quantitatively by bacteriological assessment of E. coli O157 cultured from cloacal swabs (shedding score). In the 1-day-old chick model that was monitored for 43 days, all seven strains established well after inoculation. In the 6-week-old chicken model, one strain established and gave consistently high shedding for the duration of the experiment (156 days). Whereas of the remaining six strains, two persisted for 113 days, two persisted for 43 days, one persisted for 22 days and one strain was never detected.

Naturally acquired attaching and effacing Escherichia coli in sheep

In a series of experiments involving the inoculation of sheep with Escherichia coli O157:H7, and subsequent detailed histopathological examination of the intestinal mucosa, attaching-effacing (AE) lesions formed by elements of the natural flora were observed in 18% of animals. These incidental AE lesions typically were small and sparse, and were not associated with clinical disease. It was possible to identify further some of the lesional bacteria, revealing that E. coli O115 had formed lesions in one of the seven affected animals, and similarly E. coli O26 had formed some of the lesions in another. As AE strains, source flocks, housing and feed sources were diverse, a common source of lesion-forming bacteria appears to be unlikely. It is postulated that subclinical AE lesions are a mechanism of persistence of AE bacteria in sheep.

Interaction between attaching and effacing Escherichia coli serotypes O157:H7 and O26:K60 in cell culture

Ruminants harbour both O157:H7 and non-O157 Attaching Effacing Escherichia coli (AEEC) strains but to date only non-O157 AEEC have been shown to induce attaching effacing lesions in naturally infected animals. However, O157 may induce lesions in deliberate oral inoculation studies and persistence is considered dependent upon the bacterially encoded locus for enterocyte effacement. In concurrent infections in ruminants it is unclear whether non-O157 AEEC contribute either positively or negatively to the persistence of E. coli O157:H7. To investigate this, and prior to animal studies, E. coli O157:H7 NCTC 12900, a non-toxigenic strain that persists in conventionally reared sheep, and non-toxigenic AEEC O26:K60 isolates of sheep origin were tested for adherence to HEp-2 tissue culture alone and in competition one with another. Applied together, both strains adhered in similar numbers but lower than when either was applied separately. Pre-incubation of tissue culture with either one strain reduced significantly (P < 0.05) the extent of adherence of the strain that was applied second. It was particularly noticeable that AEEC O26 when applied first reduced adherence and inhibited microcolony formation, as demonstrated by confocal microscopy, of E. coli O157:H7. The possibility that prior colonisation of a ruminant by non-O157 AEEC such as O26 may antagonise O157 colonisation and persistence in ruminants is discussed.