A227 CTLA-4 DEFICIENCY PRESENTING AS CROHN DISEASE IN A TEENAGE BOY WITH MULTI-SYSTEM INVOLVEMENT : A CASE REPORT

Background

Cytotoxic-T-lymphocyte-antigen-4 is a negative immune regulator. CTLA-4 deficiency can cause a complex immune dysregulation syndrome that may present as inflammatory bowel disease.

Purpose

Case Description:

A 14-year-old male presented with several years of abdominal pain, diarrhea, short stature and poor weight gain. Endocolonoscopy diagnosed Crohn disease, with patchy chronic colitis, an ileal granuloma and active duodenitis with intraepithelial lymphocytosis and villous blunting. MRE showed multiple abnormal small bowel loops. Past history included appendicitis, immune thrombocytopenic purpura and an episode each of Aeromonas, Y enterocolitica and C difficile colitis. Family history was negative for consanguinity, autoimmune conditions or immune defects.

The patient received sulfasalazine, exclusive enteral nutrition and then budesonide MMX with limited response. His pre-biologic workup identified bilateral pulmonary nodules, which were negative for infection or malignancy on further investigation. He began Adalimumab, and after 2 months had nearly normalized his fecal calprotectin to 90 ug/g. His history, together with chronic neutropenia and hypogammaglobulinemia (IgG 3.3 g/L, IgA 0.29g/L) led to a comprehensive immune and cytopenia panel, which revealed heterozygous pathogenic variants in the CTLA4 gene c.424G>C, p.(Gly142Arg), associated with CTLA-4 deficiency related immunodeficiency. Parental testing was negative, indicating a de novo mutation.

The patient was subsequently admitted to hospital with severe headache and transient aphasia. Brain MRI found hyperintense foci concerning for CTLA-4 deficiency-associated CNS inflammation. He had papilledema and lumbar puncture found increased ICP. During this admission he developed Salmonella sepsis. Repeat chest CT found extensive worsening multifocal parenchymal lesions. Extensive investigations to exclude malignancy or infection were negative, and the lung findings were felt to be Granulomatous and Lymphocytic Interstitial Lung Disease. He had elevated soluble IL-2 receptor level (2884 U/ml) and elevated CD4+PD1+ T cells in peripheral blood. Adalimumab was stopped, and he received IVIg, then Diamox with resolution of headache, followed by pulse methylprednisolone. He has since been maintained on Abatacept (a soluble CTLA-4 analog that inhibits T-cell activation). Follow up soluble IL2 receptor level was normal. PJP prophylaxis was started, as well as prophylactic dosing of IVIg and regular screening for EBV and CMV.

Method

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Result(s)

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Conclusion(s)

Discussion:

Our patient had CTLA-4 deficiency and immune dysregulation affecting multiple organs (CNS, lung, and intestinal inflammation, autoimmune neutropenia and previous ITP). Abatacept is the preferred steroid-sparing treatment of enteropathy in CTLA-4 deficiency. Soluble IL2 receptor level is an indicator of T cell activation used for treatment monitoring. This case illustrates the importance of considering immune defects even in older children presenting with apparent IBD.

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INTESTINAL DISORDERS

Rotavirus Vaccine Impact Within an Integrated Healthcare Delivery System in the United States

We assessed rotavirus vaccine impact using data on acute gastroenteritis (AGE) encounters within an integrated healthcare delivery system during 2000-2018. Following rotavirus vaccine introduction, all-cause AGE rates among children <5 years declined by 36% (95% confidence interval [CI]: 32%-40%) for outpatient and 54% (95% CI: 46%-60%) for inpatient encounters.

Brief trauma therapy for occupational trauma-related PTSD/CPTSD in UK police

BACKGROUND

Police are frequently exposed to occupational trauma, making them vulnerable to post-traumatic stress disorder (PTSD) and other mental health conditions. Through personal and occupational trauma police are also at risk of developing Complex PTSD (CPTSD), associated with prolonged and repetitive trauma. Police Occupational Health Services require effective interventions to treat officers experiencing mental health conditions, including CPTSD. However, there is a lack of guidance for the treatment of occupational trauma.

AIMS

To explore differences in demographics and trauma exposure between police with CPTSD and PTSD and compare the effectiveness of brief trauma-focused therapy between these diagnostic groups.

METHODS

Observational cohort study using clinical data from the Trauma Support Service, providing brief trauma-focused therapy for PTSD (cognitive behavioural therapy/eye movement desensitization and reprocessing) to UK police officers. Demographics, trauma exposure, baseline symptom severity and treatment effectiveness were compared between police with PTSD and CPTSD. Changes in PTSD, depression and anxiety symptoms were used to measure treatment effectiveness.

RESULTS

Brief trauma therapy reduced symptoms of PTSD, depression and anxiety. Treatment effectiveness did not differ between CPTSD and PTSD groups. Police with CPTSD exposed to both primary and secondary occupational trauma had poorer treatment outcomes than those exposed to a single occupational trauma type.

CONCLUSIONS

Brief trauma-focused interventions are potentially effective in reducing symptoms of PTSD, depression and anxiety in police with CPTSD and PTSD. Further research is needed to establish whether additional CPTSD symptoms (affect dysregulation, self-perception and relational difficulties) are also reduced.

Rotavirus Vaccine Is Effective Against Rotavirus Gastroenteritis Resulting in Outpatient Care: Results From the Medically Attended Acute Gastroenteritis (MAAGE) Study

BACKGROUND

Rotavirus is a common cause of severe pediatric acute gastroenteritis. Two vaccines are licensed in the United States and have demonstrated high effectiveness against moderate to severe disease. However, fewer data are available on rotavirus vaccine effectiveness (VE) against milder disease.

METHODS

We leveraged active surveillance data from Kaiser Permanente Northwest to calculate rotavirus VE against medically attended rotavirus illness among age-eligible children. We utilized a test-negative case-control design and applied 4 distinct case definitions based on reverse transcription-quantitative real-time PCR (qRT-PCR) assay and enzyme immunoassay (EIA) test results. VE was calculated as 100 × (1 - odds ratio), and models were adjusted for age group.

RESULTS

The VE analysis population comprised 842 children, 799 (95%) of whom had mild disease requiring at most a clinic visit and 698 (83%) of whom were fully vaccinated against rotavirus. Age-adjusted VE was 70% (95% confidence interval [CI], 37-86%) against disease defined solely by qRT-PCR results, 72% (95% CI, 31-89%) against disease as defined by qRT-PCR with a quantification cycle (C q ) value <27, 73% (95% CI, 32-90%) against disease that was qRT-PCR positive but EIA negative, and 62% (95% CI, -20-88%) against disease defined solely by EIA. Results were similar when restricting to disease resulting in at most an ambulatory clinic or emergency department visit.

CONCLUSIONS

These results support the effectiveness of rotavirus vaccination in protecting US children from mild to moderate and severe disease. Our findings are also useful to show the effectiveness of rotavirus vaccination against qRT-PCR-defined illness.

Sensory wellbeing workshops for inpatient and day-care patients with anorexia nervosa

Background

The wellbeing of patients with eating disorders is one of the priorities in the “bigger picture” of treatment for eating disorders. Sensory soothing strategies for sensory sensitivities are supportive tools which could be useful in day-care and inpatient clinical programmes.

Methods

Evaluation of multiple separate sensory wellbeing workshops consisting of psychoeducation and experiential components delivered in inpatient and intensive day-care services was performed. Participants’ self-report questionnaires were evaluated pre- and post-workshop. Additionally, patients’ comments and qualitative feedback was collected after completion of the workshop.

Results

There was strong evidence that self-reported awareness of sensory wellbeing, awareness of strategies to enhance sensory wellbeing, and confidence in managing sensory wellbeing increased after the workshops with positive qualitative feedback from participants. The feedback questionnaires highlighted that patients found the sessions useful and were able to use some of the skills and strategies they learned in the workshop.

Conclusion

This pilot work on sensory wellbeing workshops with a protocol-based format was feasible and beneficial for the patient group. Preliminary evidence suggests that delivery of similar workshops could be sensible in addition to treatment as usual in inpatient and day-care programmes.

Norovirus and Other Viral Causes of Medically Attended Acute Gastroenteritis Across the Age Spectrum: Results from the Medically Attended Acute Gastroenteritis Study in the United States

BACKGROUND

Acute gastroenteritis (AGE) causes a substantial burden in the United States, but its etiology frequently remains undetermined. Active surveillance within an integrated healthcare delivery system was used to estimate the prevalence and incidence of medically attended norovirus, rotavirus, sapovirus, and astrovirus.

METHODS

Active surveillance was conducted among all enrolled members of Kaiser Permanente Northwest during July 2014-June 2016. An age-stratified, representative sample of AGE-associated medical encounters were recruited to provide a stool specimen to be tested for norovirus, rotavirus, sapovirus, and astrovirus. Medically attended AGE (MAAGE) encounters for a patient occurring within 30 days were grouped into 1 episode, and all-cause MAAGE incidence was calculated. Pathogen- and healthcare setting-specific incidence estimates were calculated using age-stratified bootstrapping.

RESULTS

The overall incidence of MAAGE was 40.6 episodes per 1000 person-years (PY), with most episodes requiring no more than outpatient care. Norovirus was the most frequently detected pathogen, with an incidence of 5.5 medically attended episodes per 1000 PY. Incidence of norovirus MAAGE was highest among children aged < 5 years (20.4 episodes per 1000 PY), followed by adults aged ≥ 65 years (4.5 episodes per 1000 PY). Other study pathogens showed similar patterns by age, but lower overall incidence (sapovirus: 2.4 per 1000 PY; astrovirus: 1.3 per 1000 PY; rotavirus: 0.5 per 1000 PY).

CONCLUSIONS

Viral enteropathogens, particularly norovirus, are important contributors to MAAGE, especially among children < 5 years of age. The present findings underline the importance of judicious antibiotics use for pediatric AGE and suggest that an effective norovirus vaccine could substantially reduce MAAGE.

A model for rapid, active surveillance for medically-attended acute gastroenteritis within an integrated health care delivery system

Background

This study presents a novel methodology for estimating all-age, population-based incidence rates of norovirus and other pathogens that contribute to acute gastroenteritis in the United States using an integrated healthcare delivery system as a surveillance platform.

Methods

All cases of medically attended acute gastroenteritis within the delivery system were identified from April 1, 2014 through September 30, 2016. A sample of these eligible patients were selected to participate in two phone-based surveys and to self-collect a stool sample for laboratory testing. To ascertain household transmission patterns, information on household members with acute gastroenteritis was gathered from participants, and symptomatic household members were contacted to participate in a survey and provide stool sample as well.

Results

54% of individuals who met enrollment criteria agreed to participate, and 76% of those individuals returned a stool sample. Among household members, 85% of eligible individuals agreed to participate, and 68% of those returned a stool sample. Participant demographics were similar to those of the eligible population, although minority racial/ethnic groups were somewhat underrepresented in the final sample.

Conclusions

This study demonstrates the feasibility of conducting acute infectious disease research within an integrated health care delivery system. The surveillance, sampling, recruitment, and data collection methods described here are broadly applicable to conduct baseline and epidemiological assessments, as well as for other research requiring representative samples of stool specimens.

Evaluating the success of a marine protected area: A systematic review approach

Marine Protected Areas (MPAs), marine areas in which human activities are restricted, are implemented worldwide to protect the marine environment. However, with a large proportion of these MPAs being no more than paper parks, it is important to be able to evaluate MPA success, determined by improvements to biophysical, socio-economic and governance conditions. In this study a systematic literature review was conducted to determine the most frequently used indicators of MPA success. These were then applied to a case study to demonstrate how success can be evaluated. The fifteen most frequently used indicators included species abundance, level of stakeholder participation and the existence of a decision-making and management body. Using the indicator framework with a traffic light system, we demonstrate how an MPA can be evaluated in terms of how well it performs against the indicators using secondary data from the literature. The framework can be used flexibly. For example, where no MPA data currently exist, the framework can be populated by qualitative data provided by local stakeholder knowledge. This system provides a cost-effective and straightforward method for managers and decision-makers to determine the level of success of any MPA and identify areas of weakness. However, given the variety of motivations for MPA establishment, this success needs to be determined in the context of the original management objectives of the MPA with greater weighting being placed on those objectives where appropriate.

Incidence of Norovirus and Other Viral Pathogens That Cause Acute Gastroenteritis (AGE) among Kaiser Permanente Member Populations in the United States, 2012-2013

Noroviruses and other viral pathogens are increasingly recognized as frequent causes of acute gastroenteritis (AGE). However, few laboratory-based data are available on the incidence of AGE caused by viral pathogens in the U.S. This study examined stool specimens submitted for routine clinical diagnostics from patients enrolled in Kaiser Permanente (KP) health plans in metro Portland, OR, and the Maryland, District of Columbia, and northern Virginia geographic areas to estimate the incidence of viral enteropathogens in these populations. Over a one-year study period, participating laboratories randomly selected stools submitted for routine clinical diagnostics for inclusion in the study along with accompanying demographic and clinical data. Selected stools were tested for norovirus, rotavirus, sapovirus, and astrovirus using standardized real-time RT-PCR protocols. Each KP site provided administrative data which were used in conjunction with previously published data on healthcare utilization to extrapolate pathogen detection rates into population-based incidence rates. A total of 1,099 specimens collected during August 2012 to September 2013 were included. Mean age of patients providing stool specimens was 46 years (range: 0-98 years). Noroviruses were the most common viral pathogen identified among patients with AGE (n = 63 specimens, 6% of specimens tested). In addition, 22 (2%) of specimens were positive for rotavirus; 19 (2%) were positive for sapovirus; and 7 (1%) were positive for astrovirus. Incidence of norovirus-associated outpatient visits was 5.6 per 1,000 person-years; incidence of norovirus disease in the community was estimated to be 69.5 per 1,000 person-years. Norovirus incidence was highest among children <5 years of age (outpatient incidence = 25.6 per 1,000 person-years; community incidence = 152.2 per 1,000 person-years), followed by older adults aged >65 years (outpatient incidence = 7.8 per 1,000 person-years; community incidence = 75.8 per 1,000 person-years). Outpatient incidence rates of rotavirus, sapovirus, and astrovirus were 2.0, 1.6, 0.6 per 1,000 person-years, respectively; community incidence rates for these viruses were 23.4, 22.5, and 8.5 per 1,000 person-years, respectively. This study provides the first age-group specific laboratory-based community and outpatient incidence rates for norovirus AGE in the U.S. Norovirus was the most frequently detected viral enteropathogen across the age spectrum with the highest rates of norovirus disease observed among young children and, to a lesser extent, the elderly. These data provide a better understanding of the norovirus disease burden in the United States, including variations within different age groups, which can help inform the development, targeting, and future impacts of interventions, including vaccines.

Epidemiologic, Virologic, and Host Genetic Factors of Norovirus Outbreaks in Long-term Care Facilities

BACKGROUND

In the Unites States, long-term care facilities (LTCFs) are the most common setting for norovirus outbreaks. These outbreaks provide a unique opportunity to better characterize the viral and host characteristics of norovirus disease.

METHODS

We enrolled 43 LTCFs prospectively to study the epidemiology, virology, and genetic host factors of naturally occurring norovirus outbreaks. Acute and convalescent stool, serum, and saliva samples from cases, exposed and nonexposed controls were collected. Norovirus infection was confirmed using quantitative polymerase chain reaction testing of stool samples or 4-fold increase in serum antibody titers. The presence of histo-blood group antigens (secretor, ABO, and Lewis type) was determined in saliva.

RESULTS

Sixty-two cases, 34 exposed controls, and 18 nonexposed controls from 10 norovirus outbreaks were enrolled. Forty-six percent of acute, 27% of convalescent case, and 11% of control stool samples tested norovirus positive. Outbreak genotypes were GII.4 (Den Haag, n = 3; New Orleans, n = 4; and Sydney, n = 2) and GI.1 (n = 1). Viral load in GII.4 Sydney outbreaks was significantly higher than in outbreaks caused by other genotypes; cases and controls shed similar amounts of virus. Forty-seven percent of cases shed virus for ≥ 21 days. Symptomatic infections with GII.4 Den Haag and GII.4 New Orleans were detected among nonsecretor individuals.

CONCLUSIONS

Almost half of all symptomatic individuals shed virus for at least 21 days. Viral load was highest in GII.4 viruses that most recently emerged; these viruses also infect the nonsecretor population. These findings will help to guide development of targeted prevention and control measures in the elderly.

Effects and clinical significance of GII.4 Sydney norovirus, United States, 2012-2013

During 2012, global detection of a new norovirus (NoV) strain, GII.4 Sydney, raised concerns about its potential effect in the United States. We analyzed data from NoV outbreaks in 5 states and emergency department visits for gastrointestinal illness in 1 state during the 2012-13 season and compared the data with those of previous seasons. During August 2012-April 2013, a total of 637 NoV outbreaks were reported compared with 536 and 432 in 2011-2012 and 2010-2011 during the same period. The proportion of outbreaks attributed to GII.4 Sydney increased from 8% in September 2012 to 82% in March 2013. The increase in emergency department visits for gastrointestinal illness during the 2012-13 season was similar to that of previous seasons. GII.4 Sydney has become the predominant US NoV outbreak strain during the 2012-13 season, but its emergence did not cause outbreak activity to substantially increase from that of previous seasons.

Clinical dietetic practice in the treatment of severe acute malnutrition in a high HIV setting

BACKGROUND

In Sub-Saharan Africa, children commonly present with severe acute malnutrition (SAM) complicated by HIV/AIDS. In 2005, the South African Department of Health implemented the World Health Organization (WHO) Ten Step programme for the inpatient treatment of SAM. Dietary management with F75 and F100 (where the terms F75 and F100 refer to a mixture of milk, sugar, oil and a vitamin and mineral mix) may not be appropriate for relatively well resourced settings such as South Africa.

METHODS

A structured questionnaire aiming to determine current clinical practice was e-mailed to all dietitians working in hospitals (n = 53) in KwaZulu-Natal who routinely treated SAM.

RESULTS

When initially refeeding with no diarrhoea (ND), F75 was used exclusively by 16% of dietitians to treat infants, and by 42% of dietitians to treat children. If diarrhoea, 16% of dietitians used F75 to treat infants/children. Acidified infant formula (IF) was given if ND and lactose-free IF was given if diarrhoea. Children were often started on a lactose-free F100 equivalent omitting cautious refeeding. Some gave reduced amounts for cautious refeeding; however, the feeds osmolality was too high. The use of partially hydrolysed feeds increased if the child/infant presented with diarrhoea and/or hypoalbuminea. In the post-initial feeding phase, approximately 14% of dietitians used F100 to treat infants/children. Most gave F100 equivalents as high-energy infant/paediatric formulas.

CONCLUSIONS

The dietetic practices for infants with SAM followed current expert opinion closely rather than the WHO protocol. The omission of cautious refeeding follows neither current expert opinion, nor the WHO protocol, and may predispose to the refeeding syndrome. Limited evidence indicates that partially hydrolysed formulas are less effective than low lactose low osmolality feeds in the treatment of SAM.

Specimen collection and confirmation of norovirus outbreaks

We evaluated data from gastroenteritis outbreaks in Oregon to assess sensitivity of stool testing for norovirus and determine number of specimens needed to confirm norovirus as the cause. Norovirus can be readily confirmed if 3–6 specimens are collected any time <7 days after onset of diarrhea and for almost that long after symptoms resolve.

Diagnostic accuracy and analytical sensitivity of IDEIA Norovirus assay for routine screening of human norovirus

Noroviruses (NoVs) are recognized as the leading cause of epidemic and sporadic acute gastroenteritis. Early detection of NoV is crucial to control the spread of the disease. In this study, we evaluated the diagnostic accuracy, analytical sensitivity, and analytical reactivity of the IDEIA Norovirus assay (an enzyme immunoassay [EIA]) in a prospective and retrospective study design. A total of 557 prospectively collected fecal samples and a panel of 97 archived fecal samples, including 21 different GI and GII genotypes, were tested by conventional reverse transcription-PCR (RT-PCR)/bidirectional sequencing, real-time RT-PCR, and electron microscopy. The sensitivity and specificity of the EIA were 57.6% and 91.9%, respectively. The sensitivity for detecting NoV in fecal samples from outbreaks improved from 44.1% when three samples were tested to 76.9% when five samples per outbreak were tested. The EIA was able to detect strains from 7 GI and 11 GII genotypes. The analytical sensitivity of the EIA was 3.1 x 10(6) and 1.6 x 10(7) virus particles g(-1) of fecal sample for NoV GI and GII strains, respectively. Most GII samples positive by EIA had a threshold cycle (C(T)) of <26.5, and 50% of the GII samples negative by EIA had a C(T) of >25.6, suggesting that, although strains from genotypes GI.8, GII.10, and GII.16 were not detected, the low sensitivity of the EIA is primarily caused by low virus concentration. In conclusion, the current EIA may be of use as a rapid screening test during a norovirus outbreak investigation when multiple fecal samples are available; however, sporadic samples should be tested by molecular methods.

Community pharmacist-initiated screening program for osteoporosis: randomized controlled trial

SUMMARY

This study evaluated the effect of a multifaceted intervention (screening and patient education) by community pharmacists on testing or treatment of osteoporosis. One hundred and twenty-nine patients randomized to receive the intervention were compared to 133 patients who did not receive the intervention. Twice as many patients who got the intervention received further testing or treatment for osteoporosis.

INTRODUCTION

The objective of this study was to determine the effect of a community pharmacist screening program on testing and treatment of osteoporosis.

METHODS

In this randomized, controlled trial, 262 patients meeting bone mineral density (BMD) testing guidelines [men or women aged > or = 65 years or 50-64 years with one major risk factor including previous fracture, family history of osteoporosis, glucocorticoids for > 3 months, or early menopause] were allocated to intervention (129) or control (133). Intervention consisted of printed materials, education, and quantitative ultrasound. Primary outcome was a composite endpoint of BMD or prescription for osteoporosis medication within 4 months.

RESULTS

Primary endpoint of BMD or osteoporosis treatment was achieved by 28 intervention patients (22%) compared with 14 controls (11%) (RR 2.1, 95% CI 1.1-3.7). This was driven by BMD testing (28 (22%) vs. 13 (10%) for controls, p = 0.011). Calcium intake increased more among intervention patients than controls (30% vs. 19%, RR 1.6, 95% CI 1.0-2.5). There was no effect on knowledge or quality of life.

CONCLUSION

A pharmacist screening program doubled the number of patients tested for osteoporosis. Nevertheless, many patients eligible for BMD did not receive appropriate care suggesting more intensive interventions are needed.

RTOG 0131: Phase II trial of pre-irradiation and concurrent temozolomide in patients with newly diagnosed anaplastic oligodendrogliomas and mixed anaplastic oligodendrogliomas: Relationship between 1p/19q status and progression-free survival

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Background: In a previous report, we showed in patients with newly diagnosed anaplastic oligodendrogliomas (AOs) and mixed anaplastic oligoastrocytomas (MAOs) that temozolomide (TMZ) can be given concurrently with radiation therapy (RT) with acceptable toxicity. We have now evaluated the efficacy of this regimen and correlated durability of response with tumor 1p/19q genotype. Methods: A phase II study was performed to evaluate the use of pre-RT TMZ followed by concurrent RT and TMZ in patients with newly diagnosed AO or MAO. The primary endpoint was to determine the pre-RT TMZ six-month progression rate, and secondary endpoints included progression-free survival and overall survival. Results: 40 eligible patients were entered into the trial. Thirty-two patients completed 6 months of pre-RT TMZ and concurrent RT and TMZ. Of the remaining eight patients, 4 withdrew due to toxicity and 4 other patients withdrew from study without evidence of toxicity or pre-RT progression. 1p/19q data are available in 37 cases; 23 tumors had loss of heterozygosity (LOH) of both 1p and 19q (double-deleted) while 14 tumors had LOH of either 1p or 19q (n = 3), or no LOH (n = 11). To date, 11 patients have experienced tumor progression; 1p/19q data are available for 10 of these cases (2 are double-deleted (2/23 = 9%), 8 have at least one intact chromosome (8/14 = 57%). Kaplan-Meier analysis demonstrates that progression free survival is significantly better for the double-deleted group (median time to progression not reached) than for the intact group (median time to progression = 15.2 months, p = 0.001). Overall survival is 98% (39/40) with a median follow-up of 17.5 months (2.8 - 31.1 months). Conclusions: LOH of both 1p and 19q is strongly correlated with a durable response of AO and MAO to a combined regimen of chemotherapy and radiation therapy. Tumors that are intact at 1p and/or 19q progress early despite an aggressive therapeutic regimen. These results suggest that future clinical trials should be prospectively stratified by tumor 1p/19q genotype.

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Modelling the effect of shear history on activated sludge flocculation

The aim of this paper is to investigate the effect of shear history on activated sludge flocculation dynamics and to model the observed relationships using population balances. Activated sludge flocs are exposed to dramatic changes in the shear rate within the treatment process, as they pass through localised high and low mixing intensities within the aeration basin and are cycled through the different unit operations of the treatment process. We will show that shear history is a key factor in determining floc size, and that the floc size varies irreversibly with changes in shear rate. A population balance model of the flocculation process is also introduced and evaluated.

Practice-based research: lessons from community pharmacist participants

We designed this project to determine community pharmacists' opinions regarding the challenges and motivations of their recent participation in a pharmacy practice-based research study At the conclusion of a randomized, multicenter study, 87 community pharmacist-investigators were sent a questionnaire that explored four areas: motivating factors to participate, barriers to participation, communication tools used by study coordinators, and design issues for future studies. Fifty-eight (67%) completed questionnaires were returned. Key factors motivating participation in the study were desire to improve the profession and opportunity to learn. Time was the greatest barrier to participation. Pharmacy practice-based research has two distinct advantages. First, it translates clinical knowledge into direct application in the community. Second, it provides needed data to demonstrate the value of enhanced pharmacy practice. Thorough understanding of pharmacists' opinions is necessary to optimize the design of future studies.

Women's regrets after bilateral prophylactic mastectomy

BACKGROUND

Primary prevention strategies such as chemopreventive agents (e.g., tamoxifen) and bilateral prophylactic mastectomy (PM) have received increasingly more attention as management options for women at high risk of developing breast cancer.

METHODS

A total of 370 women, who had registered in the Memorial Sloan-Kettering Cancer Center National Prophylactic Mastectomy Registry, reported having undergone a bilateral PM. Twenty-one of these women expressed regrets about their decision to have a PM. A psychiatrist and psychologist interviewed 19 of the women about their experiences with the PM.

RESULTS

A physician-initiated rather than patient-initiated discussion about the PM represented the most common factor in these women. Psychological distress and the unavailability of psychological and rehabilitative support throughout the process were the most commonly reported regrets. Additional regrets about the PM related to cosmesis, perceived difficulty of detecting breast cancer in the remaining breast tissue, surgical complications, residual pain, lack of education about the procedure, concerns about consequent body image, and sexual dysfunction.

CONCLUSIONS

Although a PM statistically reduces the chances of a woman developing breast cancer, the possibility of significant physical and psychological sequelae remains. Careful evaluation, education, and support both before and after the procedure will potentially reduce the level of distress and dissatisfaction in these women. We discuss recommendations for the appropriate surgical and psychiatric evaluation of women who are considering a PM as risk-reducing surgery.

Periovulatory endocrinology in high ovulating Meishan sows

The present study was designed to investigate the hormone profiles (oestradiol, LH, FSH, inhibin, progesterone) in high ovulating Meishan sows (MS; n = 9) and in contemporary Large-White hybrid control sows (LW; n = 9) during the follicular phase, the periovulatory period and the early luteal phase. Ovulation rate was higher in MS than LW animals (23.7 and 16.6 respectively; P < 0.001) and overall was correlated with the area of the oestradiol peak (P < 0.05) and inhibin concentrations (P < 0.05). Both the duration of and the area of the oestradiol peak were greater in MS than LW (P < 0.01; P < 0.02), as were inhibin concentrations both before and after the LH surge (P < 0.05). Neither basal nor peak concentrations of LH or FSH differed between the breeds (P > 0.05), although FSH concentrations were correlated with the area under the oestradiol peak (P < 0.05). Finally, the time-interval from the onset of the LH surge until the rise in plasma progesterone was shorter in MS than LW (54.5 and 74.3 h respectively; P < 0.01). In conclusion, these results show for the first time that the higher ovulation rate in MS is associated with enhanced oestradiol and inhibin secretion with no significant difference in LH or FSH concentrations. The more rapid luteinization response to the LH surge by MS in terms of plasma progesterone concentrations may be important in ensuring the high level of embryo survival in this breed.

Gonadotropin secretion in ovariectomized Chinese Meishan and hybrid large white gilts; responses to challenges with estradiol benzoate, gonadotropin-releasing hormone, or porcine follicular fluid

Castrated Meishan (MS) and hybrid Large White (hLW) gilts were used in a series of challenge experiments to establish differences in the control of gonadotropin secretion. Acutely ovariectomized gilts (72 h) were injected i.m. with 10 micrograms/kg estradiol benzoate (EB) and serially bled for evaluation of estradiol clearance from the blood and patterns of LH and FSH release. Estradiol was more rapidly metabolized from the circulatory system of the acutely ovariectomized MS gilts than from the hLW gilts; as a consequence, hLW gilts had higher concentrations of estradiol than MS gilts at 24-32 h (p < 0.05) and 48-60 h (p < 0.01) post-EB treatment. The hLW but not the MS gilts exhibited a classic negative/positive LH response to EB; MS gilts responded with a random release of large episodes of LH. Plasma FSH concentrations were consistently greater (p < 0.05) in acutely ovariectomized MS gilts than in hLW gilts. Both breeds demonstrated a slight negative FSH response to EB and then exhibited increased variability in plasma FSH with time after treatment. Mean plasma LH was immediately elevated in chronically ovariectomized (> 14 days) hLW and MS gilts given 1 microgram/kg of GnRH i.m., but the magnitude of the LH response was greater (p < 0.01) in the hLW gilts. Comparable differences (p < 0.01) in FSH secretion were also observed, indicating the presence of greater pools of releasable FSH and LH in the hLW gilts, or a greater sensitivity to GnRH.(ABSTRACT TRUNCATED AT 250 WORDS)

Differences in follicular aromatase activity between Meishan and large-white hybrid gilts

Two experiments were carried out in which follicular aromatase activity was compared between Meishan and Large-White hybrid gilts. In Expt 1, preovulatory follicles (n = 10 largest per animal) were recovered from Meishan and Large-White hybrid gilts (n = 5 per breed) on the day before predicted onset of behavioural oestrus, and the granulosa cells and theca tissue incubated to determine aromatase activity. Follicles recovered from Meishan pigs were smaller (P < 0.01) and contained fewer granulosa cells (P < 0.05), but follicular oestradiol content of the breeds was similar (P > 0.1). Aromatase activity was higher in the theca tissue (P < 0.05) and tended to be higher in the granulosa cells recovered from Meishan follicles (P = 0.065). In Expt 2, granulosa cell aromatase activity was investigated during the early follicular phase (estimated day 16 of cycle) in Meishan and Large-White hybrid gilts (n = 6 and 5, respectively). The number of follicles > or = 1 mm diameter recovered per animal was 171 for both breeds (P > 0.1), whereas the number of follicles > or = 2 mm diameter was 65 and 101 (P < 0.05) from Meishan and Large-White hybrid gilts, respectively. The mean diameter of all follicles recovered was smaller in the Meishan gilts (P < 0.001). Overall, neither the number of granulosa cells per follicle, as indicated by DNA estimation, nor the oestradiol content differed between the breeds at this time (P > 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting the age at onset of puberty, ovulation rate and time of ovulation in Chinese Meishan gilts

Experiments were carried out to study: the effects of season on age at puberty, the influence of reproductive age on ovulation rate, and the time interval from the onset of oestrus to ovulation in Chinese Meishan gilts. Gilts approaching puberty either in the spring (n = 88) or in the autumn (n = 40) were housed indoors under natural daylight conditions and observed daily for oestrous behaviour. Gilts approaching puberty in the spring were younger (P < 0.001) and more likely to reach puberty by 100 days of age (P < 0.01) than were those approaching puberty in the autumn. Ovulation rate was estimated in gilts at second (n = 22), third (n = 24), fourth (n = 18), fifth to ninth (n = 9) and tenth to twenty-first (n = 17) oestrous cycle and in primiparous Meishan sows (n = 12) by counting the number of corpora lutea or corpora albicantia at laparoscopy, laparotomy or at ovarian recovery following slaughter. Ovulation rate increased (P < 0.001) with reproductive age and approached that of primiparous sows only when gilts had experienced > or = 10 oestrous cycles (19.2 versus 21.0). The time interval between the onset of oestrus and ovulation was studied in six naturally cyclic Meishan gilts and nine Meishan gilts administered hCG at the onset of oestrus. All glits were observed six times a day for the commencement of oestrous behaviour and were subsequently examined by laparoscopy at 32 h following onset of oestrous and every 8 h till ovulation, which was a maximum of 56 h.(ABSTRACT TRUNCATED AT 250 WORDS)

Collaboration between acute and continuing care facilities: a network approach to providing quality care

As the cost of healthcare has increased and the treatment time for chronic mental health problems has shortened, a gap in service of continuing care programs was identified by staff at a Veterans Administration (VA) hospital in Texas. The continuing care programs were already established in a facility some distance away from the referring hospital. The program that was developed focused efforts toward establishment of an intrahospital and interfacility network to provide maximum rehabilitation for veterans at reduced cost.

Comparisons of endocrinology and behavioural events during the periovulatory period in Meishan and large-white hybrid gilts

Attainment of puberty, cycle lengths, ovulation rate and endocrinology during the periovulatory period were studied in Meishan (MS) and European Large-White hybrid (LW) gilts. The mean age at onset of puberty of 115 days in MS (n = 20) gilts was younger (P < 0.001) than the 235 days in LW (n = 23). In the MS population studied, ovulation rate was not different (P > 0.1) during the third and fourth oestrous cycles, nor were there differences (P > 0.1) in the mean cycle length over the first three cycles. Overall changes in plasma luteinizing hormone (LH), follicle-stimulating hormone (FSH) and oestradiol did not differ significantly (P > 0.1) between the breeds (MS, n = 6; LW, n = 5) during the periovulatory period, but plasma inhibin concentrations were significantly (P < 0.05) higher in the MS. The time intervals from the oestradiol peak concentration and the onset of the LH surge until the onset of behavioural oestrus were significantly different (P < 0.005) between the breeds, with oestrus occurring earlier in the MS. However, no difference (P > 0.1) was found between the groups when the intervals from the peak oestradiol concentration to the onset of the LH surge were compared. These results indicate differences between the breeds, particularly in terms of the age of attainment of puberty and the timing of the onset of behavioural oestrus relative to the oestradiol and LH surges.

Comparison of follicular heterogeneity and ovarian characteristics in Meishan and large-white hybrid pigs

Comparisons were made between characteristics of pre-ovulatory follicles recovered from prolific Chinese Meishan gilts (n = 12) and from European Large-White hybrid gilts (n = 13) in the late follicular phase preceding their fifth oestrous cycle, to determine whether there is an ovarian basis for the enhanced prolificacy in the Meishan. A total of 177 follicles per breed was classified as pre-ovulatory, based on follicular fluid oestradiol concentrations. Results obtained demonstrated high variability in all follicular characteristics in both breeds and no decrease in heterogeneity was evident in the Meishan. The Meishan follicles tended to be smaller (P < 0.06) and had less follicular fluid (P < 0.005), but total oestradiol content per follicle was similar (P < 0.1) with the result that the concentration of oestradiol in follicular fluid tended to be higher (P < 0.06) in Meishan than Large-White hybrid pigs. There were no differences between breeds in terms of testosterone concentrations in follicular fluid, hCG binding to granulosa cells or total DNA content of granulosa cells. Concentrations of inhibin in follicular fluid were similar in both breeds (P > 0.1) which resulted in a trend towards less total inhibin content in Meishan than Large-White hybrid follicles (P = 0.065). Corpora lutea were recovered from both breeds (n = 12 per breed) on days 27-31 of pregnancy after mating at first, second and third oestrus:corpora lutea were smaller (P < 0.001) and contained less progesterone per corpus luteum in the Meishan (P < 0.05) than in Large White hybrid pigs.(ABSTRACT TRUNCATED AT 250 WORDS)