Metabolic influence of core ciliates within the rumen microbiome

Protozoa comprise a major fraction of the microbial biomass in the rumen microbiome, of which the entodiniomorphs (order: Entodiniomorphida) and holotrichs (order: Vestibuliferida) are consistently observed to be dominant across a diverse genetic and geographical range of ruminant hosts. Despite the apparent core role that protozoal species exert, their major biological and metabolic contributions to rumen function remain largely undescribed in vivo. Here, we have leveraged (meta)genome-centric metaproteomes from rumen fluid samples originating from both cattle and goats fed diets with varying inclusion levels of lipids and starch, to detail the specific metabolic niches that protozoa occupy in the context of their microbial co-habitants. Initial proteome estimations via total protein counts and label-free quantification highlight that entodiniomorph species Entodinium and Epidinium as well as the holotrichs Dasytricha and Isotricha comprise an extensive fraction of the total rumen metaproteome. Proteomic detection of protozoal metabolism such as hydrogenases (Dasytricha, Isotricha, Epidinium, Enoploplastron), carbohydrate-active enzymes (Epidinium, Diplodinium, Enoploplastron, Polyplastron), microbial predation (Entodinium) and volatile fatty acid production (Entodinium and Epidinium) was observed at increased levels in high methane-emitting animals. Despite certain protozoal species having well-established reputations for digesting starch, they were unexpectedly less detectable in low methane emitting-animals fed high starch diets, which were instead dominated by propionate/succinate-producing bacterial populations suspected of being resistant to predation irrespective of host. Finally, we reaffirmed our abovementioned observations in geographically independent datasets, thus illuminating the substantial metabolic influence that under-explored eukaryotic populations have in the rumen, with greater implications for both digestion and methane metabolism.

Refining a Protocol for Faecal Microbiota Engraftment in Animal Models After Successful Antibiotic-Induced Gut Decontamination

Background

There is mounting evidence for the therapeutic use of faecal microbiota transplant (FMT) in numerous chronic inflammatory diseases. Germ free mice are not always accessible for FMT research and hence alternative approaches using antibiotic depletion prior to FMT in animal studies are often used. Hence, there is a need for standardising gut microbiota depletion and FMT methodologies in animal studies. The aim of this study was to refine gut decontamination protocols prior to FMT engraftment and determine efficiency and stability of FMT engraftment over time.

Methods

Male C57BL/6J mice received an antibiotic cocktail consisting of ampicillin, vancomycin, neomycin, and metronidazole in drinking water for 21 days ad libitum. After antibiotic treatment, animals received either FMT or saline by weekly oral gavage for 3 weeks (FMT group or Sham group, respectively), and followed up for a further 5 weeks. At multiple timepoints throughout the model, stool samples were collected and subjected to bacterial culture, qPCR of bacterial DNA, and fluorescent in-situ hybridisation (FISH) to determine bacterial presence and load. Additionally, 16S rRNA sequencing of stool was used to confirm gut decontamination and subsequent FMT engraftment.

Results

Antibiotic treatment for 7 days was most effective in gut decontamination, as evidenced by absence of bacteria observed in culture, and reduced bacterial concentration, as determined by FISH as well as qPCR. Continued antibiotic administration had no further efficacy on gut decontamination from days 7 to 21. Following gut decontamination, 3 weekly doses of FMT was sufficient for the successful engraftment of donor microbiota in animals. The recolonised animal gut microbiota was similar in composition to the donor sample, and significantly different from the Sham controls as assessed by 16S rRNA sequencing. Importantly, this similarity in composition to the donor sample persisted for 5 weeks following the final FMT dose.

Conclusions

Our results showed that 7 days of broad-spectrum antibiotics in drinking water followed by 3 weekly doses of FMT provides a simple, reliable, and cost-effective methodology for FMT in animal research.

The P4 Study: Postpartum Maternal and Infant Faecal Microbiome 6 Months After Hypertensive Versus Normotensive Pregnancy

Objective/Hypothesis

To explore potential differences in faecal microbiome between women, and their infants, who had normotensive pregnancies (NP) and those who had a hypertensive pregnancy (HP), either gestational hypertension (GH) or preeclampsia (PE).

Methods

This is a sub study of P4 (Postpartum Physiology, Psychology, and Paediatrics Study) and includes 18 mother-infant pairs: 10 NP and 8 HP (HP as defined by blood pressure > 140/90mmHg; of which 6 had PE, and 2 GH), six months postpartum. The participating mothers collected stool samples from themselves and their infants. 16S rRNA V3-V4 amplicons were used to study the faecal microbiome.

Results

The sample of women and their infants were mostly primiparous (n =16) with vaginal birth (n = 14). At the time of faecal sampling 8 women were using hormonal contraception, and one HP woman remained on an antihypertensive. All women had blood pressure < 130/80mmHg, and 10 had high BMI (> 30). All infants had started solids, 8 were exclusively breastfed, 1 exclusively formula fed and 9 both. Three infants had been exposed to a course of antibiotics. Six months postpartum, there were no significant differences in alpha or beta diversity between the gut microbiota of HP and NP women (P > 0.05). However, a statistically significant difference was detected in alpha diversity between infants following HP and NP, with lower diversity levels in HP infants (P < 0.05). It was also found that at a genus and species level, the gut microbiota of HP women was enriched with Bifidobacterium and Bifidobacterium sp. and depleted in Barnesiella and Barnesiella intestinihominis when compared to NP women (P < 0.05). Similarly, the gut microbiota of infants born from HP was enriched in Streptococcus infantis and depleted in Sutterella, Sutterella sp., Bacteroides sp. and Clostridium aldenense compared to infants born from NP (P < 0.05).

Discussion

While our findings are at best preliminary, due to the very small sample size, they do suggest that the presence of hypertension in pregnancy may adversely affect the maternal microbiota postpartum, and that of their infants. Further analysis of postpartum microbiome data from future studies will be important to validate these early findings and provide further evidence about the changes in the microbiota in the offspring of women following hypertensive disorders of pregnancy (HDP), including possible links to the causes of long-term cardiovascular disease, the prevalence of which is increased in women who have experienced HDP.

The Fontan Pathway: Change in Dimension and Catheter-Based Intervention over Time

An unobstructed Fontan pathway is essential for optimal hemodynamics. We hypothesize that more extracardiac conduit (ECC) Fontan pathways develop obstruction compared to lateral tunnel (LT) Fontans and that the dilation typically observed in LTs results in similar mid-term clinical outcomes. A single-center, retrospective study was done including all Fontan cardiac catheterizations from 2006 to 2019. Angiography and medical records were reviewed to define Fontan pathway dimensions, interventions, and clinical outcomes. 232 patients underwent cardiac catheterization, where 60% were ECCs and 30% LTs. The minimum cross-sectional area (CSA) of ECCs was significantly smaller than LTs and LTs dilated over time. 13% of patients had Fontan pathway stenting at a median age of 16.2 years. The minimum CSA for patients who underwent intervention was significantly smaller than patients who did not. Lower weight at Fontan surgery was associated with intervention on the Fontan pathway, with a threshold weight of 15 kg for patients with an ECC. The median follow-up was 3.3 years. Patients who had Fontan pathway intervention were not more likely to experience the composite adverse clinical outcome. LTs were more likely than ECCs to have worse clinical outcome, when liver fibrosis was included. This is the first study to describe angiographic dimensions of the Fontan pathway in a large number of patients over time. ECCs tend to become stenotic. Lower weight at Fontan surgery is a potential risk for Fontan pathway intervention. LTs may experience worse clinical outcomes in follow-up. This information can help inform the optimal timing and method of post-Fontan surveillance.

Defining the temporal evolution of gut dysbiosis and inflammatory responses leading to hepatocellular carcinoma in Mdr2 -/- mouse model

BACKGROUND

Emerging evidence implicates the gut microbiome in liver inflammation and hepatocellular carcinoma (HCC) development. We aimed to characterize the temporal evolution of gut dysbiosis, in relation to the phenotype of systemic and hepatic inflammatory responses leading to HCC development. In the present study, Mdr2 -/- mice were used as a model of inflammation-based HCC. Gut microbiome composition and function, in addition to serum LPS, serum cytokines/chemokines and intrahepatic inflammatory genes were measured throughout the course of liver injury until HCC development.

RESULTS

Early stages of liver injury, inflammation and cirrhosis, were characterized by dysbiosis. Microbiome functional pathways pertaining to gut barrier dysfunction were enriched during the initial phase of liver inflammation and cirrhosis, whilst those supporting lipopolysaccharide (LPS) biosynthesis increased as cirrhosis and HCC ensued. In parallel, serum LPS progressively increased during the course of liver injury, corresponding to a shift towards a systemic Th1/Th17 proinflammatory phenotype. Alongside, the intrahepatic inflammatory gene profile transitioned from a proinflammatory phenotype in the initial phases of liver injury to an immunosuppressed one in HCC. In established HCC, a switch in microbiome function from carbohydrate to amino acid metabolism occurred.

CONCLUSION

In Mdr2 -/- mice, dysbiosis precedes HCC development, with temporal evolution of microbiome function to support gut barrier dysfunction, LPS biosynthesis, and redirection of energy source utilization. A corresponding shift in systemic and intrahepatic inflammatory responses occurred supporting HCC development. These findings support the notion that gut based therapeutic interventions could be beneficial early in the course of liver disease to halt HCC development.

Gut microbiota impact on the peripheral immune response in non-alcoholic fatty liver disease related hepatocellular carcinoma

The gut microbiota is reported to modulate the immune response in hepatocellular carcinoma (HCC). Here, we employ metagenomic and metabolomic studies to characterise gut microbiota in patients with non-alcoholic fatty liver disease (NAFLD) related cirrhosis, with or without HCC, and evaluate its effect on the peripheral immune response in an ex vivo model. We find that dysbiosis characterises the microbiota of patients with NAFLD-cirrhosis, with compositional and functional shifts occurring with HCC development. Gene function of the microbiota in NAFLD-HCC supports short chain fatty acid production, and this is confirmed by metabolomic studies. Ex vivo studies show that bacterial extracts from the NAFLD-HCC microbiota, but not from the control groups, elicit a T cell immunosuppressive phenotype, characterised by expansion of regulatory T cells and attenuation of CD8 + T cells. Our study suggest that the gut microbiota in NAFLD-HCC is characterised by a distinctive microbiome/metabolomic profile, and can modulate the peripheral immune response.

Investigation into the effect of divergent feed efficiency phenotype on the bovine rumen microbiota across diet and breed

The relationship between rumen microbiota and host feed efficiency phenotype, for genetically divergent beef cattle breeds is unclear. This is further exacerbated when different growth stages, chemically diverse diets and production systems are considered. Residual feed intake (RFI), a measure of feed efficiency, was calculated for individually fed Charolais (CH) and Holstein-Friesian (HF) steers during each of four 70-day (excluding adaptation) successive dietary phases: namely, high-concentrate, grass silage, fresh zero-grazed grass and high-concentrate again. Rumen fluid from the ten highest- (HRFI) and ten lowest-ranking (LRFI) animals for RFI, within breed, during each dietary phase was collected using a trans-oesophageal sampler and subjected to 16S rRNA amplicon sequencing and metabolic profiling. The datasets were analysed to identify microbial and rumen fermentation markers associated with RFI status. Age, dietary phase and breed were included in the statistical model. Within breed, for each dietary phase, mid-test metabolic weight and average daily gain did not differ (P > 0.05) between HRFI and LRFI steers; however, for the initial high-concentrate, grass silage, fresh grass herbage and final high-concentrate dietary phases, HRFI HF steers consumed 19, 23, 18 and 27% more (P < 0.001) than their LRFI counterparts. Corresponding percentages for CH HRFI compared to CH LRFI steers were 18, 23, 13 and 22%. Ten OTUs were associated with RFI (q < 0.05) independent of the other factors investigated. Of these Methanomassiliicoccaceae, Mogibacteriaceae and the genus p-75-a5 of Erysipelotrichaceae and were negatively associated (q < 0.05) with RFI. The results gave evidence that microbial species could potentially be an indicator of RFI in ruminants rather than broader microbiome metrics; however, further research is required to elucidate this association.

Microbiome Understanding in Maternity Study (MUMS), an Australian prospective longitudinal cohort study of maternal and infant microbiota: study protocol

INTRODUCTION

Pregnancy induces significant physiological and cardiometabolic changes, and is associated with alterations in the maternal microbiota. Increasing rates of prepregnancy obesity, metabolic abnormalities and reduced physical activity, all impact negatively on the microbiota causing an imbalance between the commensal microorganisms (termed dysbiosis), which may drive complications, such as gestational diabetes or hypertensive disorders. Considerable work is needed to define the inter-relationships between the microbiome, nutrition, physical activity and pregnancy outcomes. The role of the microbiota during pregnancy remains unclear. The aim of the study is to define microbiota signatures longitudinally throughout pregnancy and the first year post birth, and to identify key clinical and environmental variables that shape the female microbiota profile during and following pregnancy.

METHODS AND ANALYSIS

The Microbiome Understanding in Maternity Study (MUMS) is an Australian prospective longitudinal cohort study involving 100 mother-infant pairs. Women are enrolled in their first trimester and followed longitudinally. Assessment occurs at <13+0, 20+0-24+6 and 32+0-36+6 weeks gestation, birth and 6 weeks, 6 months and 12 months postpartum. At each assessment, self-collected oral, vaginal and faecal samples are collected with an additional postpartum skin swab and breastmilk sample. Each infant will have oral, faecal and skin swab samples collected. Measurements include anthropometrics, body composition, blood pressure, serum hormonal and metabolic parameters and vaginal pH. Dietary intake, physical activity and psychological state will be assessed using validated self-report questionnaires, and pregnancy and infant outcomes recorded. Parametric and non-parametric hypothesis tests will be used to test the association between high-risk and low-risk pregnancies and their outcomes.

ETHICS AND DISSEMINATION

The study received the following approval: South Eastern Sydney Local Health District Research Ethics Committee (17/293 (HREC/17/POWH/605). Results will be made available to the participants of MUMS, their families and the funding bodies; in the form of a summary document. Results for the greater maternity care community and other researchers will be disseminated through conferences, local, national and international presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ACTRN12618000471280 (prospectively registered).

Investigating temporal microbial dynamics in the rumen of beef calves raised on two farms during early life

Manipulation of the rumen microorganisms during early life has emerged as a promising strategy for persistent improvement of nutrient utilisation and lowering of enteric methanogenesis. However, limited understanding of the dynamics of rumen microbial colonisation has prevented the identification of the optimum timeframe for such interventions. The present study used DNA amplicon sequencing of the 16S rRNA gene to assess bacterial and archaeal dynamics in the rumen digesta of beef calves raised on two farms from birth through to post-weaning. The colonisation patterns of both communities were influenced by age (P < 0.05) and farm of origin (P < 0.05). The bacterial community exhibited an age-wise progression during the first month of life which appeared to be partly related to diet, and settled by day 21, indicating that this may mark the boundary of a timeframe for intervention. The archaeal community appeared less sensitive to age/diet than bacteria in the first month of life but was more sensitive to farm environment. These data show that ruminal microbial composition during early life is driven by calf age, diet and local environment, and provide important fundamental information concerning the ontogeny of the rumen microbiota from birth.

16S rRNA Sequencing Reveals Relationship Between Potent Cellulolytic Genera and Feed Efficiency in the Rumen of Bulls

The rumen microbial population dictates the host’s feed degradation capacity and subsequent nutrient supply. The rising global human population and intensifying demand for animal protein is creating environmental challenges. As a consequence, there is an increasing requirement for livestock with enhanced nutrient utilization capacity in order to more efficiently convert plant material to high quality edible muscle. In the current study, residual feed intake (RFI), a widely used and a highly accepted measure of feed efficiency in cattle, was calculated for a combination of three cohorts of Simmental bulls. All animals were managed similarly from birth and offered concentrate ad libitum in addition to 3 kg of grass silage daily during the finishing period. Solid and liquid rumen digesta samples collected at slaughter and were analyzed using amplicon sequencing targeting the 16S rRNA gene utilizing the Illumina MiSeq platform. Volatile fatty acid analysis was also conducted on the liquid digesta samples. Spearman’s correlation coefficient was utilized to determine the association between RFI and bacterial and archaeal taxa and inter-taxonomic relationships. The data indicate a tendency toward an increase in butyrate (P = 0.06), which corresponds with an increase in plasma β-hydroxybutyrate concentration in low RFI (LRFI) bulls in comparison to their high RFI (HRFI) contemporaries (P < 0.05). A decrease in propionate (P < 0.05) was also recorded in the rumen of LRFI in comparison to HRFI bulls. These results indicate alternate fermentation patterns in the rumen of LRFI bulls. The data also identified that OTUs within the phyla Tenericutes, Fibrobacteres, and Cyanobacteria may potentially influence RFI phenotype. In particular, a negative association between F. succinogenes and RFI was evident. The unique cellulolytic metabolism of F. succinogenes suggests it could contribute to host efficiency by providing substrate to the host ruminant and other microbial populations (e.g., Selenomonas ruminantium, Methanobrevibacter, and Methanomassiliicoccaceae) in the rumen. This study provides evidence that bacterial OTUs within common phyla could influence ruminant feed efficiency phenotype through their role in ruminal degradation of complex plant polysaccharides or increased capability to harvest nutrients from ingested feed.

Evaluating Established Methods for Rumen 16S rRNA Amplicon Sequencing With Mock Microbial Populations

The rumen microbiome scientific community has utilized amplicon sequencing as an aid in identifying potential community compositional trends that could be used as an estimation of various production and performance traits including methane emission, animal protein production efficiency, and ruminant health status. In order to translate rumen microbiome studies into executable application, there is a need for experimental and analytical concordance within the community. The objective of this study was to assess these factors in relation to selected currently established methods for 16S phylogenetic community analysis on a microbial community standard (MC) and a DNA standard (DS; ZymoBIOMICS^TM). DNA was extracted from MC using the RBBC method commonly used for microbial DNA extraction from rumen digesta samples. 16S rRNA amplicon libraries were generated for the MC and DS using primers routinely used for rumen bacterial and archaeal community analysis. The primers targeted the V4 and V3–V4 region of the 16S rRNA gene and samples were subjected to both 20 and 28 polymerase chain reaction (PCR) cycles under identical cycle conditions. Sequencing was conducted using the Illumina MiSeq platform. As the bacteria contained in the microbial mock community were well-classified species, and for ease of explanation, we used the results of the Basic Local Alignment Search Tool classification to assess the DNA, PCR cycle number, and primer type. Sequence classification methodology was assessed independently. Spearman’s correlation analysis indicated that utilizing the repeated bead beating and column method for DNA extraction in combination with primers targeting the 16S rRNA gene using 20 first-round PCR cycles was sufficient for amplicon sequencing to generate a relatively accurate depiction of the bacterial communities present in rumen samples. These results also emphasize the requirement to develop and utilize positive mock community controls for all rumen microbiomic studies in order to discern errors which may arise at any step during a next-generation sequencing protocol.

Extensive hepatitis A outbreak in an urban childcare facility in Ireland, associated with considerable adult morbidity

Hepatitis A infection results in a spectrum of illness from asymptomatic disease to severe fulminant hepatitis. Since 2000, <50 cases have been reported annually in Ireland. We report on an outbreak of hepatitis A associated with a childcare facility(CCF) in 2015 in Ireland. Between January and July 2015, 12 outbreak-associated symptomatic hepatitis A cases were identified, including one delayed, retrospective diagnosis. Seven (58%) cases were adults, eight (67%) were male, six of the adults required hospitalisation. All 12 cases were confirmed on serology and the four cases that were genotyped were identical on phylogenetic analysis. Potential environmental exposures and hygiene practices at the CCF were investigated. Outbreak control measures included the provision of: hepatitis A information, infection prevention advice, hepatitis A vaccination to 554 CCF contacts, and voluntary closure of the CCF for deep-cleaning and staff education. From a healthcare perspective1, outbreak control costs were in excess of €45 000. This outbreak illustrates the considerable adult morbidity that can occur in hepatitis A outbreaks, highlights the challenges in controlling a large CCF-associated outbreak and the importance of early recognition by clinicians of hepatitis A.

The Structural and Functional Capacity of Ruminal and Cecal Microbiota in Growing Cattle Was Unaffected by Dietary Supplementation of Linseed Oil and Nitrate

Microorganisms in the digestive tract of ruminants differ in their functionality and ability to use feed constituents. While cecal microbiota play an important role in post-rumen fermentation of residual substrates undigested in the rumen, limited knowledge exists regarding its structure and function. In this trial we investigated the effect of dietary supplementation with linseed oil and nitrate on methane emissions and on the structure of ruminal and cecal microbiota of growing bulls. Animals were allocated to either a CTL (control) or LINNIT (CTL supplemented with 1.9% linseed and 1.0% nitrates) diet. Methane emissions were measured using the GreenFeed system. Microbial diversity was assessed using amplicon sequencing of microbial genomic DNA. Additionally, total RNA was extracted from ruminal contents and functional mcrA and mtt genes were targeted in amplicon sequencing approach to explore the diversity of functional gene expression in methanogens. LINNIT had no effect on methane yield (g/kg DMI) even though it decreased methane production by 9% (g/day; P < 0.05). Methanobrevibacter- and Methanomassiliicoccaceae-related OTUs were more abundant in cecum (72 and 24%) compared to rumen (60 and 11%) irrespective of the diet (P < 0.05). Feeding LINNIT reduced the relative abundance of Methanomassiliicoccaceae mcrA cDNA reads in the rumen. Principal component analysis revealed significant differences in taxonomic composition and abundance of bacterial communities between rumen and cecum. Treatment decreased the relative abundance of a few Ruminococcaceae genera, without affecting global bacterial community structure. Our research confirms a high level of heterogeneity in species composition of microbial consortia in the main gastrointestinal compartments where feed is fermented in ruminants. There was a parallel between the lack of effect of LINNIT on ruminal and cecal microbial community structure and functions on one side and methane emission changes on the other. These results suggest that the sequencing strategy used here to study microbial diversity and function accurately reflected the absence of effect on methane phenotypes in bulls treated with linseed plus nitrate.

Declines in TBT contamination in Irish coastal waters 1987-2011, using the dogwhelk (Nucella lapillus) as a biological indicator

Using the vas deferens sequence index (VDSI) and relative penis size index (RPSI) in dogwhelks (Nucella lapillus), imposex levels were assessed at 63 sites within 11 sea inlets during 2010/2011 and compared these with levels gathered since 1987. Sterile females (VDS>5.0) were found at 14 of the 63 sites and 47 sites (75%) met the EcoQO (VDSI<2.0). The absence of imposex in 'control' areas on the west coast is due to the lack of vessel paint applications or net dips with TBT being used as an active anti-fouling ingredient. A significant decline was observed following 2005 when comparing VDSI levels which is consistent with the decline of TBT usage. Current levels are consistent with an overall improvement towards achieving Good Environmental Status according to the requirements under the Marine Strategy Framework Directive.

Myocardial ischaemia following cocaine and adrenaline exposure in a child during an ophthalmological procedure

We report a 23-month old girl who presented with bilateral epiphora who underwent bilateral lacrimal probing and syringing, during which a cocaine adrenaline solution was used. Two hours after the procedure she developed acute pulmonary oedema secondary to myocardial ischaemia. The patient was treated with intravenous glyceryltrinitrate and milrinone infusions; cardiac enzymes and left ventricular function normalised over the subsequent 72 hours. Topical administration of cocaine and adrenaline solution may have dangerous systemic cardiac effects and should always be used judiciously.

Application of congener based multi-matrix profiling techniques to identify potential PCDD/F sources in environmental samples from the Burrishoole Catchment in the West of Ireland

Homologue and congener profiles of PCDD/Fs in eels, passive sampler and sediment extracts from the Burrishoole, a rural upland catchment on the western Irish seaboard were compared with potential PCDD sources. ΣPCDD/F levels in eels ranged from 2.9 to 25.9 pg g(-1) wet weight, which are elevated compared to other Irish locations. The OCDD congener dominated the pattern of ΣPCDD/Fs in all matrices from Burrishoole. Passive samplers were successfully deployed to identify for the first time the presence in the water column of PCDD/Fs and dimethoxylated octachlorodiphenyl ether (diMeOoctaCDE), impurities found in pentachlorophenol (PCP) production. Principal component analysis (PCA) identified similarities between PCDD/F profiles in technical PCP mixtures and environmental samples from the Burrishoole region. Results strongly suggest residual PCDD contamination associated with historic local use of a dioxin contaminated product in the catchment area, with pentachlorophenol a strong candidate.

Assessment of biomarkers in Mytilus edulis to determine good environmental status for implementation of MSFD in Ireland

Candidate OSPAR/ICES recommended biomarkers at the level of the individual in Mytilus edulis for determination of good environmental status for MSFD were evaluated against contaminant levels at sites around Ireland. The sites chosen ranged from moderate to low pollution levels, but the actual ranking of the sites varied according to the contaminant levels present. At the most contaminated site, Cork, 4 out of 16 contaminants exceeded the EAC, while at Shannon, no EACs were exceeded. The SOS assay suggested that Cork was the healthiest site with a LT50 of 17.6 days, while SOS for Shannon was 15.6 days. Likewise, condition factors varied among sites and did not always correspond to contaminant-based status. There may be uncertainty in assigning status around the not good:good boundary. This raises potential difficulties not only in the biomarker/contaminant load relationship but also in the reliability of the biomarkers themselves and hence barriers meeting compliance levels.

Herbal medicine--sets the heart racing!

The potential for pharmaceuticals to produce side effects and drug interactions is well known to medical practitioners and the lay public alike. However, the potential for alternative medicines to produce such effects is less widely known. We describe a potentially dangerous interaction between a herbal medicine and concomitant selective serotonin re-uptake inhibitor (SSRI) ingestion.

The dental management of five paediatric patients with a history of acute intermittent porphyria

BACKGROUND

Acute Intermittent Porphyria (AIP) is a rare autosomal dominant metabolic disorder resulting from partial deficiency of porphobobilinogen deaminase, the third enzyme of the haem synthetic pathway. Patients with AIP may be vulnerable to acute neurovisceral attacks if exposed to certain drugs, including some drugs used in dental practice.

CASE REPORTS

This article outlines the dental management of 5 children with a diagnosis of latent AIP or a family history of AIP. The local analgesic agent used in all cases was bupivacaine or levobupivacaine. Nitrous oxide and oxygen inhalation sedation was used in 2 cases and general anaesthesia, using propofol, isoflurane with nitrous oxide and oxygen, was used in another case. The dental treatment undertaken included restorations, endodontics and extractions.

CONCLUSION

Dental treatment using bupivacaine or levobupivacaine as local analgesic agents was successfully and safely provided for 5 children with a diagnosis of latent AIP or a family history of AIP.

Oculo-facio-cardio-dental syndrome in a mother and daughter

Oculo-facio-cardio-dental (OFCD) syndrome is a rare X-linked dominant syndrome characterized by canine teeth with extremely large roots (radiculomegaly), congenital cataract, dysmorphic facial features and congenital heart disease. A case of mother-daughter vertical transmission of OFCD is reported. Dental findings were important in confirming the diagnosis in the mother.

Phase II pilot study of neoadjuvant cetuximab in combination with cisplatin and gemcitabine in patients with resectable IB-IIIA non small cell lung cancer

17107

Background: Adjuvant and neoadjuvant chemotherapy play a role in optimising long term outcome of patients with resectable non small cell lung cancer (NSCLC). The epidermal growth factor receptor (EGFR) is a receptor tyrosine kinase which is overexpressed NSCLC. Cetuximab is a monoclonal antibody which attaches to the extracellular domain of the EGFR preventing ligand binding. Preclinical data and phase II evidence in advanced NSCLC suggest cetuximab potentiates the effect of conventional cytotoxic agents. Methods: Patients with histologically confirmed resectable stage IB-IIIA NSCLC and adequate end-organ function, giving informed written consent are eligible. Three weekly cycles of cisplatin 80 mg/m2 D1, gemcitabine 1250 mg/m2 D1,D8 and cetuximab loading dose of 400 mg/m2 on first infusion, thereafter weekly 250 mg/m2 are used. The primary endpoint is response rate (radiological and pathological). Secondary endpoints are safety and tolerability of the combination, resection rate following therapy, overall survival and relapse free survival. In addition, molecular prognostic and predictive biomarkers of response are being assessed. Sequential samples of tissue, plasma, serum and white blood cells are being collected before, during and after therapy on all patients. Results: 16 patients have been recruited to date. (10 men, 6 women). Median age 66 (range 29–76). 3 patients stage I, 4 patients, stage II, 9 patients stage III. 11 have completed treatment. Response (RECIST guidelines); PR - 6 patients, SD - 4 patients, PD - 1 patient. The most common toxicity was skin rash (100%). Grade 3/4 toxicities were neutropenia (73%), thrombocytopenia (45%). There were 2 grade 3 and 2 grade 4 cardiovascular toxicities in patients with significant co-morbid cardiovascular histories. Conclusion: The response rate is consistent with that established for neoadjuvant chemotherapy. Ongoing biomarker studies may identify those patients most likely to benefit from induction treatment.

No significant financial relationships to disclose.

Cannonball metastases with favourable prognosis

BACKGROUND

Secondary 'cannonball' metastases to the lung are frequent and usually associated with disseminated malignancy and poor prognosis.

AIM

To report the case of a patient with metastatic pulmonary endometrial stromal sarcoma who had a previous hysterectomy for benign uterine fibroids and no past history of malignancy.

RESULT

A 70-year-old female presented with cannonball metastases in her lung. Four years previously she had a hysterectomy for 'fibroids'. Review of the original histology revealed endometrial stromal sarcoma, similar to the lung metastasis. She currently has a good prognosis.

CONCLUSION

A patient with 'cannonball' metastases can have a favourable prognosis. A female patient with a previous hysterectomy for uterine fibroids, should be considered to have metastatic sarcoma until proven otherwise.

Bypass surgery versus stenting for the treatment of multivessel disease in patients with unstable angina compared with stable angina

BACKGROUND

Earlier reports have shown that the outcome of balloon angioplasty or bypass surgery in unstable angina is less favorable than in stable angina. Recent improvements in percutaneous treatment (stent implantation) and bypass surgery (arterial grafts) warrant reevaluation of the relative merits of either technique in treatment of unstable angina. Methods and Results- Seven hundred fifty-five patients with stable angina were randomly assigned to coronary stenting (374) or bypass surgery (381), and 450 patients with unstable angina were randomly assigned to coronary stenting (226) or bypass surgery (224). All patients had multivessel disease considered to be equally treatable by either technique. Freedom from major adverse events, including death, myocardial infarction, and cerebrovascular events, at 1 year was not different in unstable patients (91.2% versus 88.9%) and stable patients (90.4% versus 92.6%) treated, respectively, with coronary stenting or bypass surgery. Freedom from repeat revascularization at 1 year was similar in unstable and stable angina treated with stenting (79.2% versus 78.9%) or bypass surgery (96.3% versus 96%) but was significantly higher in both unstable and stable patients treated with stenting (16.8% versus 16.9%) compared with bypass surgery (3.6% versus 3.5%). Neither the difference in costs between stented or bypassed stable or unstable angina ($2594 versus $3627) nor the cost-effectiveness was significantly different at 1 year.

CONCLUSIONS

There was no difference in rates of death, myocardial infarction, and cerebrovascular event at 1 year in patients with unstable angina and multivessel disease treated with either stented angioplasty or bypass surgery compared with patients with stable angina. The rate of repeat revascularization of both unstable and stable angina was significantly higher in patients with stents.

Loneliness as a predictor of hospital emergency department use

BACKGROUND

Recent studies indicate that loneliness is a significant risk factor for many ailments from colds to heart disease. If lonely patients are at greater risk for illness, then we might expect that they would use the emergency department (ED) more often and incur greater medical costs than those who are not lonely. Our goal was to determine the prevalence of loneliness in patients in an ED and to evaluate it as a predictor of ED use, hospital admission, and chronic illness.

METHODS

We evaluated a convenience sample of 164 ED patients with the University of California-Los Angeles Loneliness Scale, Version 3 and a survey of patient characteristics. Using medical record review and patient self-report, we determined total ED visits, the presence of chronic illness, and discharge diagnoses during a 1-year retrospective period. We evaluated data with least mean square regression and a 2-tailed t test.

RESULTS

We found a statistically significant correlation between loneliness score and total hospital ED visits (P <.001). The mean loneliness score (39) was equal to that of normal populations. Patients scoring higher than the mean used the ED 60% more per year than patients who scored lower (P = .008). There was no association between a patient's loneliness score and baseline chronic illness or severity of current illness (P = .56). Spanish-speaking patients had higher loneliness scores than English-speaking patients (P = .001).

CONCLUSION

Loneliness is a predictor of hospital ED use independent of chronic illness and is potentially very expensive to society. We recommend further studies be done to examine if allocating resources for preventing, diagnosing, and treating loneliness would be cost effective.

Long-term clinical outcome following coronary artery bypass grafting for isolated stenosis of the left anterior descending coronary artery

AIMS

To detail the clinical and angiographic profile, and long-term outcome in consecutive patients with isolated stenosis of the left anterior descending coronary artery undergoing bypass surgery.

METHODS

A retrospective study of all patients (n = 301) (January 1984-December 1990) and undergoing coronary artery bypass grafting for isolated left anterior descending disease, in the Irish Republic, was performed. Survival was compared with that of an exact age- and gender-matched cohort.

RESULTS

Mean age was 53 (+/- 9.3) years. There were 238 (79%) males. In 241 (80%) patients an internal thoracic arterial bypass graft was used. Operative mortality was 1.3%. Of the 280 (93%) patients alive (16 cardiac deaths) at 7.1 (+/- 1.9) years, 105 (35%) had angina, 26 (9%) suffered an interval myocardial infarction, and repeat revascularization was required on 29 (10%). Female gender (P = 0.002), pre-operative myocardial infarction (P = 0.02), significant diagonal disease (P = 0.04) and postoperative myocardial infarction (P = 0.0001) were independently associated with survival. Females were more likely to develop congestive cardiac failure (P = 0.01) or postoperative angina (P = 0.03) than their male counterparts.

CONCLUSIONS

Survivorship (97%) and event-free survival (96%) at 5 years following coronary artery bypass grafting for isolated left anterior descending coronary artery disease is excellent and equivalent to an age-matched and gender-matched cohort.

Factors affecting the use of folic acid supplements in pregnant women in Glasgow

BACKGROUND

Use of folic acid supplements preconception, and during the first trimester, is associated with a reduced incidence of first and subsequent neural tube defects. The Department of Health guidelines recommend the use of folic acid supplements by all women planning a pregnancy.

AIM

To ascertain the proportion using folic acid supplements and the factors affecting their use.

METHOD

Questionnaires were distributed postpartum to the 515 women who delivered normal babies in three maternity units in Glasgow over a four-week period.

RESULTS

Forms were completed by 487 (95%) women. Only 57% took supplements at some point during their pregnancy, and only 21% took them before conception. Failure to take supplements was significantly associated with unplanned pregnancy, younger age, and previous pregnancies. Lack of awareness of the potential benefits associated with folic acid use was the commonest reason cited by women for not taking supplements.

CONCLUSIONS

Increased health education through health care professionals and mass media campaigns can improve awareness and thereby increase the use of supplements in planned pregnancies. However, 42% of women in our study had unplanned pregnancies. Intake of folic acid supplements in this group can only be increased by improvements in dietary intake within the population as a whole, and by fortification of commonly ingested foods.

Do general practitioners and community pharmacists want information on the reasons for drug therapy changes implemented by secondary care?

BACKGROUND

The content of discharge prescriptions/summaries to improve communication about medication provided at discharge has been the subject of recent studies. To date, the authors are not aware of any literature that assesses the need for primary care health professionals to receive information on reasons for drug therapy changes incurred during hospital admission. Owing to increased emphasis on seamless care, patient education, and increased accountability for drug costs, general practitioners (GPs) and community pharmacists may consider the receipt of information on the reasons for drug therapy changes incurred during hospital admission to be an essential requirement.

AIM

To determine whether GPs and community pharmacists want, and receive, information on the reasons for drug therapy changes implemented by secondary care. The preferred method of acquiring this information is also investigated.

METHOD

A questionnaire was posted to all GPs and community pharmacists within the catchment area of Glasgow Royal Infirmary University NHS Trust. Data were collected between June 1995 and July 1995.

RESULTS

Replies were received from 71 (64%) GPs and 33 (80%) community pharmacists. Of the respondents, 96% of GPs and 94% of community pharmacists would like information on one or more reason types for drug therapy changes, but the majority do not receive the desired information. Ninety per cent of GPs and 85% of community pharmacists seek this information of facilitate continuity of patient care. The preferred method of receiving the information is by postal delivery via a modified hospital discharge prescription.

CONCLUSION

The existing hospital discharge prescription requires modification to facilitate the completion of the reasons for drug therapy changes. The issue of patient-held cards requires consideration. These factors may facilitate continuity of patient care on hospital discharge.

The haemodynamic effect of prophylactic peri-operative dopexamine in coronary artery bypass patients

Twenty-three low risk coronary artery bypass graft patients underwent a controlled study of the effects of prophylactic perioperative dopexamine hydrochloride on haemodynamic indices and peripheral perfusion. The infusion commenced following induction of anaesthesia and continued for 24 h postoperatively. The study demonstrated that dopexamine significantly increased cardiac index compared with the control group (P < 0.05) and that this effect was mediated through an increase in both left ventricular stroke volume index and heart rate (P < 0.05). This was associated with a significantly lower systemic vascular resistance (P < 0.05), without an increase in left ventricular stroke work index in the dopexamine group. Despite normal pre-operative left ventricular function, both groups exhibited a fall in pH (P < 0.05) relative to baseline levels. This fall in pH began prior to cardiopulmonary bypass and persisted in the early postoperative period in both groups, suggestive of tissue hypoperfusion and oxygen deficiency. These indices normalized more rapidly in the dopexamine group, suggesting a more rapid reversal of an intra-operative oxygen debt in this group. The study demonstrates the mechanism of action of dopexamine on cardiac function and peripheral perfusion during cardiac surgery and shows that the inodilator properties during cardiac surgery are useful haemodynamically and facilitate early reversal of tissue hypoperfusion and oxygen debt in this environment.

Rupture of a sinus of Valsalva aneurysm due to Aspergillus endocarditis

We report a case of rupture of an acquired sinus of Valsalva aneurysm secondary to Aspergillus endocarditis in a patient with chronic lymphocytic leukaemia and idiopathic thrombocytopaenia purpura. Despite adequate repair and haemodynamic correction, with an apparent excellent initial result, the patient died of overwhelming sepsis at twelve days postoperatively. This case demonstrates an unusual cause of rupture of a sinus of Valsalva aneurysm and the morbidity associated with immunological dysfunction in the post-operative period.

Emergency pulmonary embolectomy

Pulmonary embolectomy maybe a life saving procedure in the unresponsive hypotensive patient following a massive pulmonary embolectomy despite optimal medical therapy. We report a successful pulmonary embolectomy in a 47 year old patient, three days post post coronary artery bypass grafting (CABG) and a new approach to the problem of caval filters in such patients. This case demonstrates the benefit of early surgery in this life threatening situation.

Atrial myxoma: national incidence, diagnosis and surgical management

Despite being the most common benign intracardiac tumour with an excellent prognosis after surgical excision the incidence of atrial myxoma (except at autopsy) is unknown. We reviewed all patients admitted to the National Cardiac Surgery Unit (n = 26) with an atrial myxoma over a fifteen year period (1977-1991) to compile national incidence data and assess pre-operative diagnosis, management, surgical technique, and outcome. Preoperative symptoms were: congestive cardiac failure (12 patients), embolism (8 patients), constitutional (3 patients), asymptomatic (2 patients) and tachyarrhythmia (1 patient). The diagnosis was confirmed by 2D echocardiography alone in thirteen patients and by a combination of echocardiography and angiography in thirteen patients. At operation the site of the tumour was left atrial in 24 patients and bi-atrial in two patients. All cases were confirmed by histology. All patients made a good post-operative recovery, although one patient survived a pulmonary embolus and one patient developed a deep venous thrombosis. There has been one late death (five months after surgery) from a cerebrovascular accident. Serial echocardiography has revealed one recurrence to date (8 years after surgery). The surgical incidence of these tumours in the Republic of Ireland over the study period was 0.5 atrial myxomas/million population/year. Although rare atrial myxomas are the most important cardiac tumours to diagnose as the results from surgery are excellent.