Complete genome sequence of Mycobacterium smegmatis phage Rummer, a subcluster A3 actinophage

Bacteriophage Rummer is a siphovirus morphology actinophage isolated from Mycobacterium smegmatis. Rummer has a 50,908 base pair genome encoding 89 predicted protein-coding genes and three tRNAs. Based on gene content similarity to sequenced actinobacteriophages, Rummer is assigned to phage subcluster A3.

Jupiter's X-Ray and UV Dark Polar Region

We present 14 simultaneous Chandra X-ray Observatory (CXO)-Hubble Space Telescope (HST) observations of Jupiter's Northern X-ray and ultraviolet (UV) aurorae from 2016 to 2019. Despite the variety of dynamic UV and X-ray auroral structures, one region is conspicuous by its persistent absence of emission: the dark polar region (DPR). Previous HST observations have shown that very little UV emission is produced by the DPR. We find that the DPR also produces very few X-ray photons. For all 14 observations, the low level of X-ray emission from the DPR is consistent (within 2-standard deviations) with scattered solar emission and/or photons spread by Chandra's Point Spread Function from known X-ray-bright regions. We therefore conclude that for these 14 observations the DPR produced no statistically significant detectable X-ray signature.

Reducing long acting antipsychotic injection dosage frequency: A pilot study in a community mental health team

BACKGROUND

Antipsychotic long acting injections (LAI) allow a range of dosage intervals to be administered. Short intervals can be inconvenient for patients and staff. There are few clinical reasons for using them yet this is common practice.

AIMS

This study aimed to examine the feasibility of reducing LAI frequency with service user consent.

METHODS

The study took place in a community mental health team in the north of England. A specialist mental health pharmacist reviewed records of all service users on LAI and drew up an action plan. Each service user then met with the consultant psychiatrist for medication review.

RESULT

Nineteen out of thirty service users on LAI had intervals less than the maximum licensed. The frequency was reduced in eight cases. After 6 months follow-up, there was no deterioration in symptoms. In nine cases, antipsychotic doses were also reduced as a result of the review.

CONCLUSION

Where a service user is prescribed a LAI with a short dosage interval consideration should be given to increase the interval. This can free up service user and staff time. A medication focused review can also lead to other benefits such as dosage reduction.

Host Responses to Biofilm

From birth to death the human host immune system interacts with bacterial cells. Biofilms are communities of microbes embedded in matrices composed of extracellular polymeric substance (EPS), and have been implicated in both the healthy microbiome and disease states. The immune system recognizes many different bacterial patterns, molecules, and antigens, but these components can be camouflaged in the biofilm mode of growth. Instead, immune cells come into contact with components of the EPS matrix, a diverse, hydrated mixture of extracellular DNA (bacterial and host), proteins, polysaccharides, and lipids. As bacterial cells transition from planktonic to biofilm-associated they produce small molecules, which can increase inflammation, induce cell death, and even cause necrosis. To survive, invading bacteria must overcome the epithelial barrier, host microbiome, complement, and a variety of leukocytes. If bacteria can evade these initial cell populations they have an increased chance at surviving and causing ongoing disease in the host. Planktonic cells are readily cleared, but biofilms reduce the effectiveness of both polymorphonuclear neutrophils and macrophages. In addition, in the presence of these cells, biofilm formation is actively enhanced, and components of host immune cells are assimilated into the EPS matrix. While pathogenic biofilms contribute to states of chronic inflammation, probiotic Lactobacillus biofilms cause a negligible immune response and, in states of inflammation, exhibit robust antiinflammatory properties. These probiotic biofilms colonize and protect the gut and vagina, and have been implicated in improved healing of damaged skin. Overall, biofilms stimulate a unique immune response that we are only beginning to understand.

Big Data Usage Patterns in the Health Care Domain: A Use Case Driven Approach Applied to the Assessment of Vaccination Benefits and Risks. Contribution of the IMIA Primary Healthcare Working Group

BACKGROUND

Generally benefits and risks of vaccines can be determined from studies carried out as part of regulatory compliance, followed by surveillance of routine data; however there are some rarer and more long term events that require new methods. Big data generated by increasingly affordable personalised computing, and from pervasive computing devices is rapidly growing and low cost, high volume, cloud computing makes the processing of these data inexpensive.

OBJECTIVE

To describe how big data and related analytical methods might be applied to assess the benefits and risks of vaccines.

METHOD

We reviewed the literature on the use of big data to improve health, applied to generic vaccine use cases, that illustrate benefits and risks of vaccination. We defined a use case as the interaction between a user and an information system to achieve a goal. We used flu vaccination and pre-school childhood immunisation as exemplars.

RESULTS

We reviewed three big data use cases relevant to assessing vaccine benefits and risks: (i) Big data processing using crowdsourcing, distributed big data processing, and predictive analytics, (ii) Data integration from heterogeneous big data sources, e.g. the increasing range of devices in the "internet of things", and (iii) Real-time monitoring for the direct monitoring of epidemics as well as vaccine effects via social media and other data sources.

CONCLUSIONS

Big data raises new ethical dilemmas, though its analysis methods can bring complementary real-time capabilities for monitoring epidemics and assessing vaccine benefit-risk balance.

Effectiveness of trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2012/13 end of season results

The effectiveness of the 2012/13 trivalent seasonal influenza vaccine (TIV) was assessed using a test-negative case-control study of patients consulting primary care with influenza-like illness in the United Kingdom. Strain characterisation was undertaken on selected isolates. Vaccine effectiveness (VE) against confirmed influenza A(H3N2), A(H1N1) and B virus infection, adjusted for age, sex, surveillance scheme (i.e. setting) and month of sample collection was 26% (95% confidence interval (CI): -4 to 48), 73% (95% CI: 37 to 89) and 51% (95% CI: 34 to 63) respectively. There was an indication, although not significant, that VE declined by time since vaccination for influenza A(H3N2) (VE 50% within three months, 2% after three months, p=0.25). For influenza A(H3N2) this is the second season of low VE, contributing to the World Health Organization (WHO) recommendation that the 2013/14 influenza vaccine strain composition be changed to an A(H3N2) virus antigenically like cell-propagated prototype 2012/13 vaccine strain (A/Victoria/361/2011). The lower VE seen for type B is consistent with antigenic drift away from the 2012/13 vaccine strain. The majority of influenza B viruses analysed belong to the genetic clade 2 and were antigenically distinguishable from the 2012/13 vaccine virus B/Wisconsin/1/2010 clade 3. These findings supported the change to the WHO recommended influenza B vaccine component for 2013/14.

Effectiveness of trivalent seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2012/13 end of season results

Binary file ES_Abstracts_Final_ECDC.txt matches

Long-term 4-year safety of saxagliptin in drug-naive and metformin-treated patients with Type 2 diabetes

AIMS

To evaluate the safety of saxagliptin ± metformin over 4 years in patients with Type 2 diabetes mellitus.

METHODS

Drug-naive (n = 401; study 11) or metformin-treated (n = 743; study 14) adults with HbA(1c) of 53-86 mmol/mol (7.0-10%) were enrolled in two randomized, placebo-controlled, double-blind trials of saxagliptin 2.5, 5 or 10 mg/day. Patients rescued during or completing 24 weeks of treatment could continue in a 42-month long-term blinded phase, for which the primary goal was assessment of safety and tolerability. Between-group efficacy was not evaluated in the long-term phase of study 11. Time to rescue or discontinuation because of inadequate glycaemic control, change from baseline in HbA(1c) and percentages of patients achieving HbA(1c) < 53 mmol/mol (< 7.0%) were assessed in study 14.

RESULTS

No new safety findings were noted during the long-term phase. Most adverse events were mild or moderate, with slightly greater frequency of upper respiratory infections with saxagliptin. Hypoglycaemic event rates were similar with saxagliptin and placebo. In study 14, time to rescue or discontinuation because of inadequate glycaemic control was longer with saxagliptin plus metformin than for placebo plus metformin. From baseline to week 154, HbA(1c) decreased with saxagliptin but increased with placebo.

CONCLUSION

Saxagliptin monotherapy or add-on to metformin is generally safe and well tolerated, with no increased risk of hypoglycaemia, for up to 4 years.

Bacillus-calmette-guerin (bcg) organisms directly alter the growth of bladder-tumor cells

Studies in recent years have shown various effects of bacillus Calmette Guerin organisms on the human immune system. In the present study, the direct effects of bacillus Calmette Guerin (BCG) (as used for the clinical management of superficial bladder cancer) on bladder tumour cells were investigated. Using a proliferation assay, changes in the growth rates of tumour cells were studied following direct exposure to BCG. The effects of variations in the BCG dose, and in the viability of BCG organisms were investigated and our initial observations concerning the antiproliferative effects of interferon-garnma were extended. The main finding of these studies is the direct immuno-modulatory effects of BCG organisms on the proliferative capacity of human tumour cells. Previously these alterations in the growth rate of bladder cancer cells, which are observed following patient therapy, were attributed to the production of various cytokines. However, after exposure to BCG the growth of tumour cell lines was suppressed in a dose and time dependent manner. Furthermore, both viable and nonviable bacilli can exert this action although heat killed BCG may be less effective in doing so. In concordance with our earlier study, interferon-gamma exerted marked antiproliferative effects against eight tumour cell lines. Furthermore, a 12 hour pulse of cytokine was sufficient to suppress the growth of tumour cells. This is an important finding as cytokine is not detected in patient's urine later than 12 hours after immunotherapy. No consistent pattern of growth altering effect was observed with any of the other cytokines tested (IL-1-alpha, IL-2, IL-3, IL-4, IL-6, IL-7, IL-8, GM-CSF). Our study suggests that BCG organisms per se may exert direct effects upon tumour cells in vivo and thus ease the load on the immune responses leading to the eventual eradication of tumour.

Skin conditions are the commonest new reason people present to general practitioners in England and Wales

BACKGROUND

Knowledge of the prevalence and incidence of skin conditions is a prerequisite for designing clinical services and providing appropriate training for primary health care professionals. In the U.K. the general practitioner and practice nurse are the first point of medical contact for persons with skin conditions.

OBJECTIVES

We aimed to obtain contemporary data in age-, gender- and diagnosis-specific detail on persons presenting to primary care with skin problems. Comparisons were made with similar data for other major disease groups and with similar data from other recent years.

METHODS

We used surveillance data collected in the Weekly Returns Service (WRS) of the Royal College of General Practitioners during 2006 and trend data for subsequent years. The WRS sentinel practices monitor all consultations by clinical diagnosis in a representative population of 950,000 in England and Wales.

RESULTS

For conditions included in chapter XII of the International Classification of Diseases Ninth Revision (ICD9), 15% of the population consulted; a further 9% presented with skin problems classified elsewhere in the ICD9, making a total of 24%. There was no evidence of increasing or decreasing trend since 2006. Skin infections were the commonest diagnostic group, while 20% of children < 12 months were diagnosed with atopic eczema. Considered collectively, the incidence of new episodes of skin disorders (including diagnoses outside chapter XII) exceeded incidences for all other major disease groupings.

CONCLUSIONS

Compared with other major disease groups, skin conditions are the most frequent reason for consultation in general practice. This result emphasizes the need for appropriate education and training for all medical students and particularly for continuing education in dermatology for all primary health care professionals.

Increased incidence of Mycoplasma pneumoniae infection in England and Wales in 2010: multiocus variable number tandem repeat analysis typing and macrolide susceptibility

An epidemic of Mycoplasma pneumoniae infection began in Denmark in late 2010. A similar increase in M. pneumoniae infections was noted in England and Wales in the same period, with a decline in early 2011. Multiocus variable number tandem repeat analysis typing and analysis of macrolide resistance markers indicate that at least nine known and two novel strain types were circulating in England and Wales during October 2010 to January 2011. There was no evidence of macrolide resistance.

Mycoplasma pneumoniae infection in primary care investigated by real-time PCR in England and Wales

Real-time PCR was employed to detect a conserved region of the P1 cytadhesin gene of Mycoplasma pneumoniae in combined nose and throat swabs collected from patients attending GP surgeries during 2005-2009 with symptoms of respiratory tract infection (RTI). Samples were collected as part of an annual winter epidemiological and virological linked study in England and Wales. A total of 3,987 samples were tested, 65 (1.7%, 95%CI 1.3-2.1) had detectable M. pneumoniae DNA. Positive patients were detected of both gender, aged from 9 months to 78 years, who had clinical signs of upper RTI, fever and/or myalgia, an influenza-like illness to lower RTI. Mixed infections were identified in four cases, two with influenza A H1, one with H3 and one with influenza B. Children aged 5-14 years were more likely to have detectable M. pneumoniae in samples than all other age groups (Fishers p = 0.03), attributed to the 2005-2006 season in which 6.0% (12/200, 95%CI 3.4-10.3) of 5-14 year olds had detectable M. pneumoniae in comparison to 2.2% in 2006-2007 (3/141 95%CI 0.5-6.4), 2.2% in 2007-2008 (2/89 95%CI 0.1-8.3) and 0% in 2008-2009 (0/151 95%CI 0-2.9).

Acute hepatic failure in an infant caused by acetaminophen (paracetamol) toxicity

A 7-month-old infant developed acute fatal hepatic failure owing to inadvertent duplication of paracetamol prescriptions. Paracetamol toxicity should be considered in the differential diagnosis of infants presenting with acute hepatic failure.

Controversies in skin resurfacing: the role of erbium

Carbon dioxide laser resurfacing has been a valuable procedure for facial skin rejuvenation since the early 1990s, largely replacing medium and deep chemical peels and dermabrasion. The introduction of the erbium:YAG laser for resurfacing has caused confusion about its role. Because of its ability to resurface very superficially it has been limited by many laser surgeons to treating only superficial rhytides and sun damage. However, it is the equal of CO2 in improving deep rhytides but with quicker healing and fewer side-effects.

Seasonal influenza activity in Europe: declining in most countries in the West but increasing in the North-East

This winter, the consultation rates for influenza like illness (ILI) and/or acute respiratory infection (ARI) started to increase firstly in Scotland, Greece and Spain in December 2006 [1], where they have already returned to levels just above or at the baseline.

Seasonal influenza beginning in Europe: report from EISS

Increased influenza activity was reported in six countries in the second week of 2007: Greece, the Netherlands, United Kingdom (Northern Ireland), Scotland, Spain and Switzerland. Based on trends of previous years, influenza activity is expected to increase in many more European countries in the weeks ahead. The influenza activity reported so far has mainly been associated with influenza A viruses.

Array comparative genomic hybridisation (aCGH) analysis of premenopausal breast cancers from a nuclear fallout area and matched cases from Western New York

High-resolution array comparative genomic hybridisation (aCGH) analysis of DNA copy number aberrations (CNAs) was performed on breast carcinomas in premenopausal women from Western New York (WNY) and from Gomel, Belarus, an area exposed to fallout from the 1986 Chernobyl nuclear accident. Genomic DNA was isolated from 47 frozen tumour specimens from 42 patients and hybridised to arrays spotted with more than 3000 BAC clones. In all, 20 samples were from WNY and 27 were from Belarus. In total, 34 samples were primary tumours and 13 were lymph node metastases, including five matched pairs from Gomel. The average number of total CNAs per sample was 76 (range 35–134). We identified 152 CNAs (92 gains and 60 losses) occurring in more than 10% of the samples. The most common amplifications included gains at 8q13.2 (49%), at 1p21.1 (36%), and at 8q24.21 (36%). The most common deletions were at 1p36.22 (26%), at 17p13.2 (26%), and at 8p23.3 (23%). Belarussian tumours had more amplifications and fewer deletions than WNY breast cancers. HER2/neu negativity and younger age were also associated with a higher number of gains and fewer losses. In the five paired samples, we observed more discordant than concordant DNA changes. Unsupervised hierarchical cluster analysis revealed two distinct groups of tumours: one comprised predominantly of Belarussian carcinomas and the other largely consisting of WNY cases. In total, 50 CNAs occurred significantly more commonly in one cohort vs the other, and these included some candidate signature amplifications in the breast cancers in women exposed to significant radiation. In conclusion, our high-density aCGH study has revealed a large number of genetic aberrations in individual premenopausal breast cancer specimens, some of which had not been reported before. We identified a distinct CNA profile for carcinomas from a nuclear fallout area, suggesting a possible molecular fingerprint of radiation-associated breast cancer.

Influenza and adult hospital admissions for respiratory conditions in England 1989-2001

Influenza is recognised as a major cause of excess hospital admissions during winter months. This study sets out to quantify admissions related to influenza during the last twelve winters and to examine the importance of age. Total admission data for respiratory disorders in adults for England during the years 1989 to 2001 have been used. Weekly admission data were examined in five-year age bands. Influenza epidemics were identified from clinical incidence data in the community. Baseline admission levels were determined by averaging weekly incidence data from weeks in which there was no clinical evidence of influenza activity. Excess admissions were estimated from the difference between observed and baseline admissions after adjusting the baseline in each group and year for the secular trend. Estimates for all adults were consolidated from the five-year age bands. Bed occupancy was estimated by applying data on average bed stay to excess admissions in age- and year-specific groups. We estimated 2.7% of all respiratory admissions were related to influenza. Excess admissions were strongly age related. Of the 16,227 annual average excess, 52% occurred in persons over 75 years. The excess admissions account for an average 145,544 bed days annually, two thirds (69%) in persons over 75 years. Annual excess bed occupancy was highest in 1999/2000 (39,512) though 30,000 excess admissions per year is not unusual. Hospital admissions due to influenza remain a major problem for health service delivery particularly in elderly populations. Though robust programmes of vaccination are needed, vaccination by itself will not eliminate the impact of influenza on hospital admissions in winter.

Harmonisation of national influenza surveillance morbidity data from EISS: a simple index

The European Influenza Surveillance Scheme is a collaboration with 18 member countries (2001/02) which monitors the activity and impact of influenza by collecting morbidity and virological data in primary care facilities throughout the winter season each year. Despite being in principle similar in the surveillance concept, the indicators used and observations made are very different. Different healthcare systems and organisational needs (eg a certificate of illness for the employer) influence the consultation behaviour. Furthermore, and partly as a result of differences in the healthcare systems, the definitions used for the numerator and denominator when calculating morbidity rates are different. Thus comparative interpretation of participating countries' morbidity data is extremely difficult. Reporting 'harmonisation' by using equivalent numerators and denominators is one option but is difficult to achieve in the short term. Moreover, several additional issues would need to be considered, for example, the need for continuity of surveillance and whether such steps would indeed result in direct comparability etc. A simple index was tested, through which the impact of influenza morbidity in any one year is compared with what is considered a 'usual' epidemic in that country. The index in principle describes numerically the extent to which the influenza-attributable excess morbidity in the current epidemic in each country is within, exceeds, or is less than a range typical for an influenza epidemic. In this pilot study, the usefulness of such an index is explored with the example of eight countries for the seasons 1999/2000 and 2000/01. A fine tuning of the methods has not yet been performed.

The clinical diagnosis of influenza

Effective management of influenza depends on early recognition of influenza in the community and on rapid diagnosis. Early recognition is achieved by integrated clinical and laboratory based surveillance programmes in representative populations. The recent introduction of 'near patient tests' for influenza provide increased opportunities for surveillance but diagnosis remains largely clinically based. The combination of cough and fever in conditons of known local influenza virus circulation provide a useful indicator of diagnosis to guide management.

cDNA arrays and immunohistochemistry identification of CD10/CALLA expression in hepatocellular carcinoma

The histological diagnosis of hepatocellular carcinoma (HCC) can be complicated by difficulty in differentiation from cholangiocarcinoma and metastatic carcinoma. Immunohistochemical stains currently in use are suboptimal in terms of specificity and sensitivity. Using cDNA array analysis for differential gene expression, we demonstrated a significant increase in mRNA expression level of CD10/CALLA, a type 2 cell-surface metalloproteinase, in HCC, which was subsequently confirmed by reverse transcriptase-polymerase chain reaction and Western blotting analysis. To test the possibility of using CD10/CALLA as a diagnostic marker for HCC, various intrahepatic tumors were studied immunohistochemically using a monoclonal antibody for CD10. A characteristic canalicular-staining pattern was observed in normal hepatocytes and at the apical surface of bile duct epithelial cells. The canalicular expression of CD10 was identified in 9 of 15 HCCs examined (60%), whereas 10 cholangiocarcinomas and 8 of 9 metastatic carcinomas lacked this staining. In three of the six HCCs negative for CD10, the surrounding nonneoplastic liver tissue was also negative, suggesting fixation-associated loss of immunoreactivity. Six HCCs had stronger CD10 staining in tumor cells when compared to the surrounding nonneoplastic tissue. Three cases of benign bile duct adenomas also expressed CD10 at the luminal aspect. One of the MCs showed a diffuse, cytoplasmic staining for CD10, a pattern readily distinguishable from that of HCC. A panel of other immunohistochemical markers were also studied for comparison, including polyclonal anti-carcinoembryonic antigen, cytokeratin (CK) 7, CK20, and alpha-fetoprotein. Our results demonstrate that cDNA arrays can be effectively used to identify new diagnostic markers, and that CD10 is a reliable marker for identifying HCC, particularly when used in conjunction with a panel of immunohistochemical markers (polyclonal anti-carcinoembryonic antigen, CK7, CK20, and alpha-fetoprotein) and in the distinction from cholangiocarcinoma.

Resistance to glucocorticoid feedback in obesity

Increased hypothalamo-pituitary-adrenal axis drive has been reported in obese subjects but with paradoxically low or normal levels of plasma cortisol. Our current study was designed to investigate whether glucocorticoid feedback was altered in obesity, both under basal and stressed conditions. Plasma ACTH and cortisol concentrations in male control or obese subjects (age range 20-50 yr) were measured at frequent intervals over 24 h during infusion of saline or hydrocortisone at two physiological doses (7.5 and 15 mg/d) designed to occupy predominantly mineralocorticoid rather than glucocorticoid receptors. The same subjects then underwent insulin-induced hypoglycemia either in the morning or the evening. Obese subjects had significantly higher basal ACTH and lower cortisol concentrations throughout the 24 h infusion period, compared with controls (P < 0.05, two-way ANOVA followed by Newman-Keuls posthoc analysis). Basal plasma ACTH was decreased in obese groups given low- or high-dose hydrocortisone during the day (P < 0.05) but not during the night, unlike controls who responded to hydrocortisone both during the day and at night (P < 0.05). Obese subjects also showed resistance to steroid-induced inhibition of the ACTH response to hypoglycemia, compared with controls (P < 0.05). These data clearly show that obesity is associated with a relative insensitivity to glucocorticoid feedback, which is most marked during the night, and suggest that this condition is characterized by a decreased mineralocorticoid receptor response to circulating corticosteroids.

Effect of active limb movements on symptoms in patients with low back pain

STUDY DESIGN

A descriptive, correlational study of patients with mechanical low back pain (LBP).

OBJECTIVES

To assess the effect of active limb movements on symptoms in patients with LBP and to examine the relationship between symptoms with limb movements and select patient characteristics.

BACKGROUND

Limb movements result in forces applied to the spine and, thus, may be important in the examination and treatment of patients with LBP.

METHODS AND MEASURES

A total of 188 people with LBP, 84 men and 104 women, participated in a standardized examination. Six of the items required patients to move their limbs and note LBP symptoms as increased, remained the same, or decreased. The prevalence of various symptom responses with each limb movement test was calculated. Relationships between patient characteristics and reports of increased symptoms were examined with Cochran's linear trend statistic and the Spearman and Pearson correlation coefficients. Differences in characteristics of patients with and without increased symptoms were examined with chi2 test, Mann-Whitney U test, or Student's t test for independent groups.

RESULTS

An increase in symptoms was reported by 149 patients with at least 1 of the limb movement tests, and 3 of the patients reported a decrease in symptoms. Across the patient sample, the mean number of limb movement tests for which symptoms were reported as increased was 2.30 +/- 1.64. Patients with an increase in symptoms reported higher average pain intensity the week prior to the examination (median = 2; range: 1-5) and higher functional disability (mean = 0.25; SD = 0.15) than those without a change in symptoms (pain intensity: median = 1; range: 0-2 and functional disability: mean = 0.16; SD = 0.12). The correlation between the number of increased symptoms and the person's average pain intensity was r = 0.23; the correlation with the functional disability score was r = 0.36. Patients with a history of LBP tended to report an increase in symptoms with more of the limb movement tests (mean = 3.5; SD = 1.40) than those without a previous history of LBP (mean = 2.0; SD = 1.11).

CONCLUSIONS

Active limb movements performed during the examination primarily resulted in increased LBP symptoms. The presence and number of increased symptoms with the active limb movements was related to the patient's report of average pain intensity and functional disability. Tests of symptoms with active limb movements may provide insight into factors contributing to a LBP problem, as well as information to guide the treatment of patients with LBP.

Docetaxel-carboplatin as first line chemotherapy for epithelial ovarian cancer

A prospective, non-randomized, multicentre, open, dose-finding study of a carboplatin-docetaxel (C-D) combination as first-line chemotherapy in FIGO stage Ic-IV epithelial ovarian cancer. C-D was given 3-weekly for 6 planned cycles, with a 3-day prophylactic dexamethasone regimen (8 mg b.i.d.). 139 eligible patients (Pts) (median age 56 years, range 28-85) were given a total of 750 cycles of chemotherapy in 5 cohorts: Co1, 32 pts, 169 cycles (C at AUC 5 + D 60 mg/m(2)); Co2, 22 pts, 122 cycles (5 + 75), Co3, 29 pts, 156 cycles (6 + 75), Co4, 27 pts, 146 cycles (7 + 75), Co5, 30 pts, 157 cycles (6 + 85). 110 patients (79%) completed 6 cycles; 17 (12%) stopped due to toxicity. 104 patients (75%) had CTC grade IV neutropenia, and 5 patients (4%) had this associated with fever. There were 2 probable treatment-related deaths. Only 8 patients (6%) experienced grade II-III neurotoxicity (all sensory; no motor > grade I). The maximum tolerated dose was reached in cohorts 4 and 5, and the dose limiting toxicities were myelosuppression and diarrhoea. The overall response rate for the study was 66% (49/74); CA125 response was 75% (70/93). Median progression-free survival was 16.6 months (95% CI 13.3-19.1). Recommended doses are carboplatin AUC 5 (via(51)Cr EDTA) or AUC 6 (if calculated) plus docetaxel 75 mg/m(2). A randomized trial comparing this regimen with carboplatin-paclitaxel has just completed recruitment.

Influenza surveillance in England and Wales: October 1999 to May 2000

The period of increased influenza activity in England and Wales in the winter of 1999/2000 was associated with considerable morbidity and mortality and well-publicized pressure on hospital services. The influenza activity coincided with the regular annual increase in respiratory syncytial virus infections and the Christmas and New Year holiday period. Consultation rates with general practitioners for influenza-like illness did not reach 'epidemic' levels but were higher than seen in many winters and comparable with those seen in two out of the previous three winters. In common with those winters, attack rates for influenza-like illness and acute bronchitis were especially high in elderly people among whom complications of acute infection and hospital admissions increased. Excess mortality due to influenza during this period appeared to be substantial but was not as high as seen in the last epidemic (1989/90).

Neuraminidase inhibitors: progress in the management of influenza

Influenza is a serious respiratory illness and represents a significant clinical burden. As well as being debilitating, influenza can often cause complications leading to hospitalisation and death. Prophylaxis by vaccination is the preferred method of disease management, but because influenza viruses are constantly changing their antigenic properties, influenza outbreaks occur regularly as epidemics. Neuraminidase inhibitors are a new class of anti-influenza drugs designed to block influenza virus replication. Two neuraminidase inhibitors, zanamivir and oseltamivir, have been licensed for clinical use in the treatment of influenza. Both drugs significantly reduce the severity and duration of the illness when treatment is started within two days of the onset of symptoms. However, while zanamivir and oseltamivir have apparently similar efficacy, they differ in their modes of delivery and tolerability. Zanamivir is delivered direct to the lungs by inhalation and is well tolerated. Oseltamivir is taken in the form of a pill but has the side-effect of producing nausea and vomiting in some patients. In the absence of a demonstrable difference in efficacy, uptake of the two drugs will depend on evaluation of the relative merits of mode of delivery and tolerability.

Myelophthisis as a solitary manifestation of failure from rectal carcinoma. A Batson phenomenon?

Rectal carcinoma is uncommonly associated with systemic metastases in the absence of liver metastases, reflecting the predilection for spread via the portal system. Occasionally, isolated lung metastases are seen, which are usually attributed to spread via the portosystemic anastomoses in the distal rectum. However, myelophthisis is an unreported complication of rectal cancer as an isolated form of systemic failure. We present a case of fatal myelophthisis associated with otherwise localized rectal carcinoma secondary to metastatic rectal cancer. This observation led to the hypothesis that spread to the bone marrow occurred via a "third circulation," the Batson plexus, a network of deep pelvic veins with rich anastomoses to the vertebral plexus.

Rapid antibody response to influenza vaccination in "at risk" groups

Persons attending for routine influenza vaccination in an urban practice each provided three specimens of blood for evaluating their immunological response. 138 (67%) of the 206 persons were defined as "at risk" by reason of morbidity as given in the guidelines published by the Chief Medical Officer. The mean age was 67 yr and 65% were aged 65 yr or more. By day 7, 71% of 31 persons had protective H(1)N(1) titres, 61% H(3)N(2) and 42% B. These proportions were similar to those found at day 14 and at day 21 based on 159 persons. These findings suggest that an effective immune response is mounted within seven days of vaccination indicating that the vaccination of persons "at risk" is worthwhile even after an epidemic has established itself. This is not a reason to modify present policy of routine vaccination in early winter well before epidemics are likely to occur.

Scope and organization of the Guide to Community Preventive Services. The Task Force on Community Preventive Services

BACKGROUND

The diverse nature of the target audience (i.e., public health decision-makers) for the Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) dictates that it must be broad in scope. In addition, for the Guide to be most useful for its target audience, its organization and format must be carefully considered.

DETERMINING THE SCOPE OF THE GUIDE

Healthy People objectives and actual causes of death were used to determine the contents of the Guide. A priority setting exercise resulted in the selection of 15 topics for systematic reviews using the following criteria: burden of the problem, preventability, relationship to other public health initiatives, usefulness of the package of topics selected and level of current research and intervention activity in public and private sectors. Interventions within each topic target state and local levels and include population-based strategies, individual strategies in other than clinical settings and group strategies.

ORGANIZATION OF THE GUIDE

The Guide is organized into: Introduction, Reviews and Recommendations (three sections: Changing Risk Behaviors, Reducing Diseases, Injuries, or Impairments, and Addressing Environmental and Ecosystem Challenges), Appendixes, and Indexes.

DISCUSSION

The scope and organization of the Guide were determined using relevant public health criteria and expert opinion to provide a useful and accessible document to a broad target audience. While the final contents of the Guide may change during development, the working table of contents described in this paper provides a framework for development of the Guide and conveys its scope and intention.

Influenza activity in England and Wales: October 1998 to June 1999

Influenza activity in England and Wales in the winter of 1998/1999 reached the highest weekly levels seen since the epidemic of 1989/1990. Activity peaked at Christmas and the New Year, adding to the winter pressures on general practitioner and hospital services. Adults aged 65 years and over consulted with general practitioners at the highest rates. Outbreaks of influenza or flu-like illness occurred in several schools and nursing homes and, in June 1999, on a British cruise ship in the Mediterranean. Deaths from all causes reached a higher peak in week 1 of 1999 than occurred in the peak week of the influenza epidemic of 1989/90.

Do influenza epidemics affect patterns of sickness absence among British hospital staff?

Influenza vaccination for healthcare workers is not recommended in Britain, but some hospitals offer vaccine to reduce sickness absence. However, in Nottingham, the influenza epidemics of 1993-94 and 1996-97 made no impact on staff absence. Annual vaccination of healthcare workers against influenza is unlikely to reduce absence most winters, but there may be gains in terms of preventing nosocomial infection.

Mandatory reporting of diseases and conditions by health care professionals and laboratories

CONTEXT

Surveillance is a key component of the core public health function of health assessment. Systematic reporting by health care professionals and laboratories, which may vary by state law, statute, or regulation, continues to provide essential data for assessing public health.

OBJECTIVE

To describe the state and territorial reporting requirements for diseases and conditions recommended for national public health surveillance.

DESIGN, SETTING, AND PARTICIPANTS

Between May and August 1997, the state and territorial epidemiologists from all 50 states, in addition to New York City, Puerto Rico, and Guam, completed questionnaires indicating which diseases and conditions were reportable by health care professionals and laboratories in their jurisdictions. The surveys were subsequently updated to reflect reporting requirements current as of January 1, 1999. The overall response rate for the survey was 100% for US states and 90% overall, including the territories.

MAIN OUTCOME MEASURE

State and territorial reporting requirements for diseases and conditions of public health concern.

RESULTS

Of the 58 diseases and conditions recommended for national reporting, 35 (60%) were reportable in greater than 90% of the states and territories, 15 (26%) were reportable in 75% to 90%, and 8 (14%) were reportable in less than 75%. Nineteen of the infectious diseases were reportable in all of the states and territories that responded.

CONCLUSIONS

Required reporting varies substantially by state or territory. Health care professionals are integral to public health efforts at the local, state, and national levels.

Epidemic serogroup B meningococcal disease in Oregon: the evolving epidemiology of the ET-5 strain

CONTEXT

In 1993, Oregon's incidence of serogroup B meningococcal disease began to rise because of a highly clonal group of strains designated enzyme type 5 (ET-5), the first such increase observed in the United States.

OBJECTIVE

To evaluate the impact that the ET-5 strain has had on the epidemiology of meningococcal disease in Oregon.

DESIGN AND SETTING

Epidemiologic analysis of surveillance data on Oregon meningococcal disease cases from 1987 through 1996 and multilocus enzyme electrophoresis typing of serogroup B isolates from June 1993 through April 1995 and from April through June 1996.

PATIENTS

A total of 836 persons with invasive meningococcal disease.

MAIN OUTCOME MEASURES

Disease frequency and clonality of strains.

RESULTS

Serogroup B disease incidence rates more than doubled from the preepidemic period in 1987-1992 (1.0 case per 100000 population) to the recent epidemic period in 1995-1996 (2.2 cases per 100000). The age-specific incidence rate of serogroup B disease among those 15 through 19 years old increased 13-fold between the preepidemic period (0.5 case per 100000) and 1995-1996 (6.4 cases per 100000). However, the proportion of cases with meningococcemia and the case-fatality rate did not change. Of 99 Neisseria meningitidis isolates obtained from 1993-1995, 88 (89%) belonged to the ET-5 complex. Of these, 69 (78%) were a single clone, designated 301. Of 20 serogroup B isolates from 1996, 18 (90%) belonged to the ET-5 complex; 17 (94%) were the 301 clone.

CONCLUSION

Serogroup B meningococcal disease incidence continues at high levels in Oregon with increasing predominance of the ET-5 clonal strains.

Multinational outbreak of Salmonella enterica serotype Newport infections due to contaminated alfalfa sprouts

CONTEXT

In December 1995, reported Salmonella enterica serotype Newport (SN) infections increased sharply in Oregon and British Columbia but not elsewhere in North America. Similar unexplained increases had been noted in 6 other states in the fall of 1995.

OBJECTIVE

To determine the source of the outbreak(s).

DESIGN

Case-control studies, environmental investigations, bacterial subtyping, and surveillance information review.

SETTINGS

Oregon and British Columbia communities (winter 1995-1996) and Georgia, Oklahoma, Pennsylvania, Vermont, Virginia, and West Virginia (fall 1995).

PARTICIPANTS

Oregon and British Columbia residents with culture-confirmed SN infections and onset from December 1, 1995, through February 29, 1996, and healthy community controls.

MAIN OUTCOME MEASURES

Odds ratio (OR) of illness associated with exposures; distribution patterns and culture of alfalfa seeds and sprouts; subtyping of SN isolates.

RESULTS

We identified 133 cases in Oregon and British Columbia; 124 (93%) occurred in patients older than 18 years; 87 (65%) were female. Case patients were more likely than community control subjects to report having eaten alfalfa sprouts in the 5 days preceding illness (41% [17/41] vs 4% [3/75]; OR, 17.0; 95% confidence interval, 4.3-96.0). Case isolates shared a distinctive pulsed-field gel electrophoresis (PFGE) pattern. The SN was grown from seeds and alfalfa sprouts. The distribution of 1 seed lot to multiple growers corresponded to the distribution of cases. Distribution of a second seed lot from the same European wholesaler corresponded to the location of the fall outbreak, which was characterized by a similar demographic profile. The PFGE pattern of fall outbreak isolates and confiscated sprouts and seeds was indistinguishable from the Oregon and British Columbia outbreak and differed from background isolates.

CONCLUSIONS

The SN-contaminated alfalfa seeds were distributed to multiple growers across North America in 1995 and resulted in a protracted international outbreak scattered over many months. Current sprouting methods are inadequate to protect consumers from such events. Alfalfa sprouts may be an elusive but important vehicle for salmonellosis and other enteric infections.

An estimate of the proportion of diarrhoeal disease episodes seen by general practitioners attributable to rotavirus in children under 5 y of age in England and Wales

Mean weekly incidence rates for a 4-week period of new episodes of infectious intestinal disease (IID) and laboratory reports of faecal isolations in children under 5 y of age presenting in general practice were used to estimate the incidence of IID due to rotavirus infection in England and Wales. Between January 1992 and December 1996, a total of 92452 new episodes of IID were seen at sentinel general practices and reported to the Royal College of General Practitioners (RCGP) Research Unit in Birmingham, UK. Of these 32% (29592) were in children under 5 y of age. During the same period the Communicable Disease Surveillance Centre (CDSC) in London, UK received 159532 reports of faecal identifications in children under 5 y of age; 69219 (43%) of these were due to rotavirus. By modelling RCGP data and laboratory reports, the proportion of episodes attributable to rotavirus infection was estimated to be 29% (95% CI: 24% to 34%). By extrapolation of RCGP data it was estimated that rotavirus accounted for 762000 of new episodes of IID nationally in children under 5 y of age between January 1992 and December 1996. Implementation of a rotavirus vaccination programme could substantially reduce the incidence of childhood diarrhoea.

Identical twin marrow transplantation for venous thrombosis in paroxysmal nocturnal hemoglobinuria; long-term complete remission as assessed by flow cytometry

Paroxysmal nocturnal hemoglobinuria (PNH), an acquired clonal hematopoietic disorder characterized by protean clinical manifestations, is associated with significant morbidity and mortality. We report a 24-year-old patient with PNH complicated by deep vein thrombosis who underwent syngeneic bone marrow transplantation. No clinical symptomatology or stigmata of disease have recurred. Immunophenotyping of this patient over 12 years after her procedure revealed all peripheral circulating cells to express normal levels of CD59. Histocompatible marrow transplantation remains the definitive method of treatment for PNH with modern immunophenotyping capable of sensitive follow-up post-transplant.

Sudden infant death syndrome rates subsequent to the American Academy of Pediatrics supine sleep position

OBJECTIVES

In April 1992, the American Academy of Pediatrics (AAP) recommended that healthy infants be positioned for sleep on their side or back to reduce the risk of Sudden Infant Death Syndrome (SIDS). The authors hypothesized three different forms of the intervention to examine the impact of the recommendation according to theory such as technology diffusion. Seasonality was included in the models to control its effect when testing.

METHODS

Box and Tiao time-series intervention methodology was used to examine the effect of the AAP recommendation on SIDS rates. Sudden Infant Death Syndrome mortality data from Philadelphia and Chicago were examined separately for white and nonwhite populations over 32 quarters.

RESULTS

Overall SIDS rates dropped significantly according to an abrupt effect from the intervention. However, the effect appeared to be gradually declining in Philadelphia but permanent in Chicago. In Philadelphia, a decline of 62.3% was estimated in whites in the first quarter after the intervention but decreased to only 5% in the last quarter of 1994. A decline of 35.8% was estimated in nonwhites in the first quarter after the intervention but decreased to only 9.4% in the last quarter of 1994. An abrupt and permanent decrease of 26.7% and 16.5% was found in Chicago for whites and nonwhites, respectively.

CONCLUSIONS

Evidence of an abrupt adoption of the recommendation can be explained by the authority innovation decision made by the AAP. Some evidence was found that the effect is temporary, perhaps because physicians are reversing earlier decisions. The demonstrated methodology provides a powerful way to test naturally occurring interventions from quasiexperimental designs to test the impact of policy guidelines.

Continuation rates of long-acting methods of contraception. A comparative study of Norplant implants and intrauterine devices

Following adverse widespread publicity in the United Kingdom and the United States, it is commonly believed that discontinuation rates for the contraceptive implants Norplant in the UK are high. We have compared discontinuation rates between new intrauterine device (IUD) users (253 women) and new Norplant implant users (502 women) over 33 months following the introduction of Norplant implants among a population of women attending the same clinic and counseled in the same manner by the same group of providers. Women choosing the IUD were slightly older and were more likely to be changing their contraceptive method because of dissatisfaction with their current method. Nor plant implant users were more likely to have completed their families. Continuation rates for Norplant implants were significantly higher than for IUD at 12, 18, and 24 months after insertion. At 24 months, continuation rates for Norplant implants were 72% compared with rates of 55% for IUD users. Higher continuation rates may be related more to factors associated with the providers than with the users of these two long-acting methods.